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target cell tropism, restricted capacity for packaging nucleic acids, and difculties in the production process [36, 37]. Novel gene therapy vectors that are not depen­dent on viral mechanisms have been created with the aim of addressing or surpass­ing these constraints. Non-viral vectors refer to articially created carriers that are specically intended for the transportation of nucleic acids and genes. In a broad sense, these vectors possess the capacity to transport bigger genetic payloads and encounter less signicant obstacles in terms of production compared to viral vec­tors. Furthermore, it should be noted that they exhibit decreased immunogenicity, resulting in a considerable reduction in the likelihood of adverse effects [36]. Despite the persistent challenges afliated with the effective delivery of payloads to specic target cells, the use of non-viral vectors in cancer therapy has been a subject of considerable investigation. Preliminary investigations using these gene therapy methods in the treatment of PCa have provided fundamental insights that have laid the groundwork for further advancements in this area of research.
In a study conducted in 2007, it was shown that the introduction of a degradable polymer (poly (butane diol diacrylate co amino pentanol) (C32)) combined with a diphtheria toxin suicide gene controlled by prostate-specic antigen expression directly into the prostates of mice with tumors led to a decrease in size by 33% or complete elimination by 13% of the injected prostatic lobes. This outcome was compared to the results of injecting naked diphtheria toxin gene DNA, which resulted in a reduction of 17% and no complete elimination in a TRAMP mouse model [38]. It is worth mentioning that the introduction of naked DNA through injection did not lead to apoptosis. In contrast, when the vector was combined with the diphtheria toxin suicide gene and injected at the initial site, tumor death was observed in 80% of cells. On the other hand, the administration of naked diphtheria toxin gene DNA resulted in less than 5% apoptotic cell death [38]. It is substantial to note that this vector is currently not utilized.
Lipid-based non-viral vectors have been widely recognized and utilized as a viable approach for facilitating gene transfer. In a research conducted in 1987, lipo­plexes, which are lipid complexes used for the encapsulation of DNA, were recog­nized as promising non-viral vectors for transferring genes [39]. Previous investigations have revealed the effectiveness of lipid-based cationic particles in delivering DNA to human PCa cell lines and a nasopharyngeal cancer cell line [40]. Additionally, in vitro experiments using folate-linked lipid-based nanoparticles have shown a signicant increase in transfection efciency (~100-fold) compared to the commercially available vector Tfx20 in luciferase gene transfer assays. The study established the efcacy of using a folate-linked nanoparticle for the delivery of herpes simplex virus thymidine kinase (HSV-TK) by direct tumor injections, fol­lowed by the administration of ganciclovir (GCV). This treatment approach caused a signicant decrease (>50%) in tumor volume, indicating the successful suppres­sion of prostate cancer xenograft development [41]. In an alternative methodology, the implementation of systemic therapy with a cationic liposome-p53 gene complex targeted by human transferrin, in conjunction with radiation, resulted in the total regression of PCa xenograft tumors. Notably, no indications of tumor reversion were seen during the six-month treatment period, with statistical signicance proven
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(P < 0.001) [42]. Various lipid formulations and targeting strategies have been explored in the laboratory for the delivery of macromolecules, such as DNA, to cancer cells using liposomes. These strategies include the use of pH-sensitive poly­mers like N-isopropylacrylamide copolymers and succinylated PEG, as well as fusogenic peptides and proteins like GALA peptide [41, 43, 44]. Nevertheless, there is a lack of clinical investigation about the usage of these techniques in PCa. In contrast, the utilization of a plasmid DNA expression vector harboring IL2 com­plexed with a cationic lipid vector known as leuvectin has been observed to facili­tate invivo transfection in phase I/II clinical trials conducted on patients with renal cell carcinoma. However, the clinical response to this approach has been varied, suggesting that its efcacy in treating kidney cancer or its translation to patients with prostate cancer is improbable [45]. Lipid-based non-viral vectors are now undergoing active development and continuous improvement in the realm of small­molecule medication delivery for cancer-related purposes. The ongoing progress in this eld of study is likely to generate heightened attention toward the application of these delivery methods based on the idea of gene therapy applications for PCa.
Peptide-based vectors used for the delivery of gene consequences contain poly­arginine, a cationic cell-penetrating peptide that has revealed effective transportation of plasmid DNA to PCa cell lines [46]. The transfection efcacy of the nal plasmid DNA complex was enhanced fourfold with the incorporation of poly- arginine, as compared to the control samples. Moreover, the synergistic use of aspartic acid and poly-arginine shows promising prospects for selective afnity toward hydroxyapa­tite, the predominant constituent of rigid connective tissue. This combination has promise as a viable bone-targeting vector [46]. Given the potential therapeutic ben­et of delivering prostate transmembrane protein androgen induced 1 (PMEPA1), which has been linked to reduced tumor invasion and bone metastasis, making use of this vector in the context of metastasis is worth considering [46]. While the poten­tial of poly-arginine is encouraging, it is considerable to note that alternative pep­tide-based vectors have not shown any discernible benets in prostate cancer models, as far as our current understanding is concerned.
TA-MCs are truncated versions of plasmids that do not include prokaryotic ele­ments and, if preferred, do not include antibiotic-resistance genes, resulting in the retention of only eukaryotic machinery [47]. In the year 2019, it was shown that a transcription activator-mediator complex has the capability to induce the expression of a reporter gene that is not naturally occurring inside an organism. This reporter gene has the potential to serve as a biomarker when detected in plasma samples [48]. The transfection effectiveness of TA-MCs is enhanced in comparison to plas­mids, mostly due to decreased transcriptional silencing and their smaller size [49,
50]. Subsequent investigations employed the promoter region of survivin, a protein
that exhibits heightened expression in various types of cancer (such as lung, pros­tate, and breast). This protein demonstrates low expression in normal prostate tissue but expands with the grade of PCa tumors. To induce the expression of embryonic alkaline phosphatase, a synthetically modied variant of human placental phospha­tase, the aforementioned promoter region was utilized. The successful transfection of TA-MCs into various PCa cell lines resulted in the induction of detectable
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alkaline phosphatase expression in the blood of mouse models with subcutaneous PCa tumors. This expression was discovered to be correlated positively with sur­vivin expression, recommending that alkaline phosphatase could serve as a poten­tial marker for assessing the aggressiveness of PCa [48]. Despite being in its rst phases of research, this technique has the potential to provide innovative approaches for estimating disease aggressiveness and may nd use in screening for prostate cancer or other conditions characterized by high survivin expression. In conclusion, the administration of oligonucleotide antisense compounds by systemic injection represents a promising strategy for the control of gene products. Specically, inves­tigation attempts have been directed at suppressing the expression of STAT3, which has revealed potential in altering immunosuppressive myeloid cells in the context of PCa [51, 52].
13.5 CRISPR–Cas9 andCAR T inPCa Gene Therapy
The use of CRISPR and the CRISPR–Cas9 technology has signicantly trans­formed the eld of biological research [53]. In summary, this method allows accu­rate modications of certain DNA sequences at any location inside the target DNA by inducing double-strand breaks [53]. The binding of a guide RNA to Cas9 facili­tates its targeting to a complementary target sequence, resulting in the formation of a double-strand break [54]. Therefore, this technique facilitates genetic alteration by introducing single-stranded or double-stranded nucleotides into specic sites. The eld of prostate cancer disease biology, along with other types of malignancies, has seen a signicant transformation due to the advent of CRISPR–Cas9 technology. This breakthrough has paved the way for the emergence of a revolutionary thera­peutic approach known as CAR T cell therapy.
The usage of CRISPR–Cas9 technology enables the expeditious and effective execution of many scientic procedures. The generation of activating and detrimen­tal mutations in less time when compared to transgenic mice enables the production of novel genetic models for cancer. In previous studies, the targeted removal of phospholipase receptor A2 receptor 1 [55], the androgen receptor [56], and meta­bolically signicant kinases [57] has been successfully achieved by the use of CRISPR–Cas9 technology in both PCa cell lines and xenograft models. The use of CRISPR–Cas9 technology allows for the generation of mouse models via the pro­cess of deletions, as shown by the production of a PTEN-knockout mouse [58]. Furthermore, the use of CRISPR technology has enabled the targeted removal of single-nucleotide polymorphisms linked to the risk of prostate cancer. This has pro­vided valuable knowledge on the possible functional impacts of mutations in these specic risk alleles [59, 60]. The induction of phenotypes may be achieved by the use of a modied Cas9 protein in conjunction with a transcription-activating domain. This approach has been shown in research where the expression of RNA target genes, including DKK3, was raised in cell lines associated with prostate can­cer [61]. In recent studies, researchers have successfully integrated CRISPR–Cas9
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with other delivery mechanisms, including liposomes paired with an RNA aptamer targeting PSMA.This innovative approach enables the targeted delivery of precise genome-editing tools specically to cancerous PCa cells in laboratory settings (in vitro) [62]. This work effectively demonstrated the specic targeting of PSMA­expressing PCa cell lines and xenograft models by the method. Furthermore, the editing of PLK1 mRNA levels resulted in disrupted proliferation of both cell lines and tumors.
The use of CRISPR–Cas9 may also facilitate the conduction of high-throughput screenings targeting biological components that play a crucial role in the prolifera­tion of cancer cells [63]. From a methodological perspective, the construction of a gene library consisting of single-guide sequences facilitates the targeted suppres­sion of a substantial number of genes within a single experimental setup. The gene library was subjected to incubation together with the required equipment, leading to the integration of the single-guide sequences into the cells and the targeted suppres­sion of a signicant percentage of them. After a phase of expansion, the procedure of DNA sequencing is carried out for the purpose of ascertaining the proportional occurrence of sequences that match those present in the sequence library. In contrast to the baseline controls, a reduction in the abundance of a certain gene sequence signies genes that have undergone negative selection and are hence crucial for the survival of cells [63]. Numerous research endeavors using this technological approach have explored a wide range of gene-associated results, including medica­tion resistance [64], cancer metastasis [65], and immune response [66]. A compre­hensive screening of the LNCaP cell line has been conducted in the context of prostate cancer, using a single-guide RNA library that specically targets over 19,000 genes. The ndings from this study, in conjunction with further mechanistic investigations, have shown that a cluster of genes encoding RNA-binding proteins, including those involved in alternative splicing and the regulation of the androgen receptor, plays a crucial role in the proliferation of LNCaP PCa cells [67]. In addi­tion, a recent study using a CRISPR screen identied novel pathways of resistance to inhibition of PARP, which may have implications for the therapy of metastatic PCa [68].
CAR T cells are a kind of genetically modied receptors that have the ability to attach to particular antigens and also activate T cells [69]. Over the course of many generations, CAR T cells have undergone engineering that incorporates double or multiple costimulatory signals. These modications have been aimed at enhancing the immune response by promoting the activation of cytotoxic T cells [69]. CAR T cells are created by the manipulation of T cells obtained from patients, wherein a virus, often lentiviral in nature, is used as a means of introducing the desired genetic information. Signicantly, CAR T cell technology exhibits independence from the major histocompatibility complex, hence allowing CAR T cells to recognize anti­gens in individuals with any human leukocyte antigen (HLA) lineage or in tumors where the major histocompatibility complex has been downregulated [69]. The ef­cacy of CAR T cell technology has been proven for the management of hematologi­cal malignancies [70], but its effectiveness in solid tumors has yet to be established. Several potential antigen targets for CAR T cell therapy in PCa have been
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discovered, including PSA, PAP, PSMA, and PSCA [71]. The research conducted in 2014 examined the effectiveness of several generations of anti-PSMA CAR T cells in an invivo model that expressed PSMA [72]. One of the generations used CD28 as a costimulatory molecule, and it exhibited signicant activity. A further investi­gation has shown that the manipulation of PD1, together with CD28 co-stimulation, successfully eradicates cancerous cells in animal models exhibiting various malig­nancies, such as prostate cancer [73]. In addition, a further investigation utilizing PCa cell lines and mouse models of PCa demonstrated that the inclusion of an intracellular 4-1BB costimulatory domain resulted in enhanced specicity toward PSCA+ tumor cells when compared to CAR T cells including a CD28 costimula­tory domain [74]. Recent research conducted on patient-derived mCRPC cells has provided evidence suggesting that chimeric antigen receptor (CAR) T cells directed against PSMA might potentially exhibit efcacy when used in conjunction with the dominant-negative transforming growth factor beta (TGF-β) type II receptor. The aforementioned combination elicited a response in CD8+ T cells, causing them to exhibit reactivity toward PSMA and insensitivity toward TGF-β, which is a recog­nized consequence of resistance to CAR T cell treatment. To ensure safety, the T cell construct was engineered to be regulated by HSV-1-TK, enabling the elimina­tion of cells with the administration of GCV.The invitro use of GCV injection led to the successful eradication of castration-resistant cell lines [75].
Therefore, CAR T cells have potential in the management of metastatic PCa and, perhaps, non-metastatic PCa. Nevertheless, the presence of an immunosuppressive tumor microenvironment and the difculty associated with directing cells to bone metastases are obstacles that still need to be addressed [76]. Patients with hemato­logical malignancies who have undergone CAR T cell treatment have had adverse effects, including cytokine release syndrome and neurotoxicity [77]. Additionally, studies conducted on solid malignancies have shown modest response rates so far. The safety, practicality, and effectiveness of this intriguing technique will be deter­mined via ongoing experiments.
13.6 Perspective ofGene Therapy inPCa
While gene therapy has demonstrated promise as an emerging modality for address­ing PCa, the limited number of therapies available in clinical settings may be attrib­uted to the underwhelming outcomes seen in early clinical studies with vector-based systems. The absence of achievement may be attributed to several factors. In inves­tigations pertaining to direct injection therapies, it has been regularly shown that both replication-incompetent and replication-competent vectors have not been suc­cessful in achieving comprehensive eradication of tumors. Despite the promising substantiation of tumor cell death and immune response, the overarching objective of preventing cancer has yet to be achieved. Similar to previous endeavors in focal therapy utilizing ablation devices, which have persistently demonstrated a high recurrence rate beyond the targeted treatment area [78], direct injection therapy is
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additionally hindered by the prevalent heterogeneity observed inlocalized prostate cancer [79]. This heterogeneity poses a challenge to direct oncolytic injection treat­ments, as they are vulnerable to potential inadequacy beyond the intended treatment zone, particularly when the objective is the complete eradication of cancer.
The emergence of the CRISPR–Cas9 system, CAR T cell treatment, and advance­ments in laboratory research have stimulated a renewed enthusiasm for the function of gene therapy in the management of PCa. The promise of gene editing in the context of PCa treatment seems to be vast, and the enthusiasm around the clinical implementation of these strategies is well-founded. Nevertheless, despite the increasing impetus, the development of new or enhanced treatments will encounter similar challenges as those encountered in the past when attempting to translate promising oncolytic and vaccine-based ndings into outcomes that are clinically signicant. The efcacy of presently promising medicines in signicantly amelio­rating the trajectory of disease development in males diagnosed with prostate cancer has to be determined and will be revealed over time [13].

13.7 Conclusion

Prostate cancer possesses favorable characteristics for the application of gene ther­apy as a treatment modality. These include its physiological availability for biopsy and treatment, the relatively protracted disease progression observed in men with both localized and metastatic forms of the disease, and the extensive prior research conducted on therapies using both immune-incompetent and immune-competent models. Nevertheless, regardless of the promising outcomes shown in preclinical studies including immune material administration by direct injection and vaccine­based approaches, gene therapy has not yet been included in the therapy protocol for individuals diagnosed with PCa. Future research endeavors exploring the potential of gene therapy-based approaches, in conjunction with other therapeutic modalities, as well as innovative strategies for gene delivery and immune activation, hold prom­ise in enhancing the longevity and overall well-being of those aficted with PCa [13].

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