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Kidane B, Bott M, Spicer J, Backhus L, Chaft J, Chudgar N, Colson Y, D'Amico TA, David E, Lee J, Najmeh S, Sepesi B, Shu C, Yang J, Swanson S, Stiles B. The American Association for Thoracic Surgery (AATS) 2023 Expert Consensus Document: Staging and multidisciplinary management of patients with early-stage non-small cell lung cancer. J Thorac Cardiovasc Surg 2023; 166:637-654. [PMID: 37306641 DOI: 10.1016/j.jtcvs.2023.04.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 04/27/2023] [Indexed: 06/13/2023]
Abstract
Novel targeted therapy and immunotherapy drugs have recently been approved for use in patients with surgically resectable lung cancer. Accurate staging, early molecular testing, and knowledge of recent trials are critical to optimize oncologic outcomes in these patients.
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Affiliation(s)
| | - Matthew Bott
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Jamie Chaft
- Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | | | | | - Jay Lee
- University of California, Los Angeles, Los Angeles, Calif
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Gosney JR, Paz-Ares L, Jänne P, Kerr KM, Leighl NB, Lozano MD, Malapelle U, Mok T, Sheffield BS, Tufman A, Wistuba II, Peters S. Pathologist-initiated reflex testing for biomarkers in non-small-cell lung cancer: expert consensus on the rationale and considerations for implementation. ESMO Open 2023; 8:101587. [PMID: 37356358 PMCID: PMC10485396 DOI: 10.1016/j.esmoop.2023.101587] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/18/2023] [Accepted: 05/18/2023] [Indexed: 06/27/2023] Open
Abstract
Biomarker tests in lung cancer have been traditionally ordered by the treating oncologist upon confirmation of an appropriate pathological diagnosis. The delay this introduces prolongs yet further what is already a complex, multi-stage, pre-treatment pathway and delays the start of first-line systemic treatment, which is crucially informed by the results of such analysis. Reflex testing, in which the responsibility for testing for an agreed range of biomarkers lies with the pathologist, has been shown to standardise and expedite the process. Twelve experts discussed the rationale and considerations for implementing reflex testing as standard clinical practice.
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Affiliation(s)
- J R Gosney
- Department of Cellular Pathology, Royal Liverpool University Hospital, Liverpool, UK
| | - L Paz-Ares
- Hospital Universitario 12 de Octubre, H12O-CNIO Lung Cancer Unit, Ciberonc and Complutense University, Madrid, Spain
| | - P Jänne
- Lowe Center for Thoracic Oncology, Dana-Farber Cancer Institute, Boston, USA
| | - K M Kerr
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, UK
| | - N B Leighl
- Princess Margaret Cancer Centre, Toronto, Canada
| | - M D Lozano
- Pathology, Universidad de Navarra-Clínica Universidad de Navarra, Pamplona, Spain
| | - U Malapelle
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - T Mok
- Department of Clinical Oncology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - B S Sheffield
- Department of Pathology and Laboratory Medicine, William Osler Health System, Brampton, Canada
| | - A Tufman
- Department of Internal Medicine V, Thoracic Oncology Centre Munich, Ludwig Maximilian University, Munich; Comprehensive Pneumology Center Munich (CPC-M), Munich; German Center for Lung Research (DZL), Munich, Germany
| | - I I Wistuba
- Departments of Thoracic/Head and Neck Medical Oncology; Translational Molecular Pathology, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - S Peters
- Department of Oncology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.
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Consensus Recommendations to Optimize Testing for New Targetable Alterations in Non-Small Cell Lung Cancer. Curr Oncol 2022; 29:4981-4997. [PMID: 35877256 PMCID: PMC9318743 DOI: 10.3390/curroncol29070396] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/06/2022] [Accepted: 07/12/2022] [Indexed: 12/03/2022] Open
Abstract
Non-small cell lung cancer (NSCLC) has historically been associated with a poor prognosis and low 5-year survival, but the use of targeted therapies in NSCLC has improved patient outcomes over the past 10 years. The pace of development of new targeted therapies is accelerating, with the associated need for molecular testing of new targetable alterations. As the complexity of biomarker testing in NSCLC increases, there is a need for guidance on how to manage the fluid standard-of-care in NSCLC, identify pragmatic molecular testing requirements, and optimize result reporting. An expert multidisciplinary working group with representation from medical oncology, pathology, and clinical genetics convened via virtual meetings to create consensus recommendations for testing of new targetable alterations in NSCLC. The importance of accurate and timely testing of all targetable alterations to optimize disease management using targeted therapies was emphasized by the working group. Therefore, the panel of experts recommends that all targetable alterations be tested reflexively at NSCLC diagnosis as part of a comprehensive panel, using methods that can detect all relevant targetable alterations. In addition, comprehensive biomarker testing should be performed at the request of the treating clinician upon development of resistance to targeted therapy. The expert multidisciplinary working group also made recommendations for reporting to improve clarity and ease of interpretation of results by treating clinicians and to accommodate the rapid evolution in clinical actionability of these alterations. Molecular testing of all targetable alterations in NSCLC is the key for treatment decision-making and access to new therapies. These consensus recommendations are intended as a guide to further optimize molecular testing of new targetable alterations.
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Aggarwal C, Bubendorf L, Cooper WA, Illei P, Borralho Nunes P, Ong BH, Tsao MS, Yatabe Y, Kerr KM. Molecular testing in stage I-III non-small cell lung cancer: Approaches and challenges. Lung Cancer 2021; 162:42-53. [PMID: 34739853 DOI: 10.1016/j.lungcan.2021.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/02/2021] [Accepted: 09/08/2021] [Indexed: 02/08/2023]
Abstract
Precision medicine in non-small cell lung cancer (NSCLC) is a rapidly evolving area, with the development of targeted therapies for advanced disease and concomitant molecular testing to inform clinical decision-making. In contrast, routine molecular testing in stage I-III disease has not been required, where standard of care comprises surgery with or without adjuvant or neoadjuvant chemotherapy, or concurrent chemoradiotherapy for unresectable stage III disease, without the integration of targeted therapy. However, the phase 3 ADAURA trial has recently shown that the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), osimertinib, reduces the risk of disease recurrence by 80% versus placebo in the adjuvant setting for patients with stage IB-IIIA EGFR mutation-positive NSCLC following complete tumor resection with or without adjuvant chemotherapy, according to physician and patient choice. Treatment with adjuvant osimertinib requires selection of patients based on the presence of an EGFR-TKI sensitizing mutation. Other targeted agents are currently being evaluated in the adjuvant and neoadjuvant settings. Approval of at least some of these other agents is highly likely in the coming years, bringing with it in parallel, a requirement for comprehensive molecular testing for stage I-III disease. In this review, we consider the implications of integrating molecular testing into practice when managing patients with stage I-III non-squamous NSCLC. We discuss best practices, approaches and challenges from pathology, surgical and oncology perspectives.
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Affiliation(s)
- Charu Aggarwal
- Abramson Cancer Center and Division of Hematology/Oncology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Lukas Bubendorf
- Institute of Medical Genetics and Pathology, University Hospital Basel, University of Basel, Switzerland
| | - Wendy A Cooper
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred Hospital and NSW Health Pathology, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia; Western Sydney University, Campbelltown, NSW, Australia
| | - Peter Illei
- Department of Pathology and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paula Borralho Nunes
- Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; Hospital CUF Descobertas, Lisbon, Portugal
| | - Boon-Hean Ong
- Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore
| | - Ming-Sound Tsao
- Department of Pathology, University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
| | - Yasushi Yatabe
- Department of Diagnostic Pathology, National Cancer Center, Tokyo, Japan
| | - Keith M Kerr
- Department of Pathology, Aberdeen University, Medical School and Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK.
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Utilisation and Determinants of Epidermal Growth Factor Receptor Mutation Testing in Patients with Non-small Cell Lung Cancer in Routine Clinical Practice: A Global Systematic Review. Target Oncol 2021; 15:279-299. [PMID: 32445082 DOI: 10.1007/s11523-020-00718-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR) mutation testing is recommended for selecting patients with non-squamous non-small cell lung cancer (NSCLC) for EGFR tyrosine kinase inhibitor drug treatment. OBJECTIVE The objective of this article was to systematically review available evidence on the utilisation and determinants of EGFR mutation testing of patients with NSCLC in routine clinical practice. PATIENTS AND METHODS Searches were made of five electronic databases (Web of Science, MEDLINE [Ovid], Science Direct, EMBASE and Scopus), bibliographies of relevant articles, studies that cited included studies and relevant cancer websites. Studies were included if they: (1) reported the rate of uptake of EGFR testing in patients with NSCLC; (2) were conducted in routine clinical practice settings; (3) were published in English prior to July 2017; and (4) had full text available. Studies were appraised using the STROBE and the National Institutes of Health (National Heart, Lung and Blood Institute) checklists. RESULTS Eighteen eligible studies were identified for this systematic review, published between 2011 and 2017, from the USA (n = 7), Canada (n = 2), Republic of Korea (n = 2), Norway (n = 1), Sweden (n = 1), Germany (n = 1), Spain (n = 1), New Zealand (n = 1), China (n = 1) and multiple countries from the Asia-Pacific region (n = 1). Overall, testing for EGFR mutations was undertaken in 16,146 of 52,257 study patients (31%), although testing rates varied widely between different studies (from 7.8% to 78.3%). Single institution retrospective audits reported higher rates of testing (median 65.7%, range 31.3-78.3%) than population-based retrospective cohort analyses (median 23%, range 11-69%) and multi-institutional cross-sectional practitioner surveys (median 19.8%, range 7.8-31.8%). Nine studies reported increasing rates of testing over the study period but maximum testing rates remained less than 75% in most studies. Factors associated with higher testing uptake rates included: female sex; younger age; former/no smoking; advanced stage of lung cancer; adenocarcinoma histology; better mobility; radiation therapy; available tissue specimen; and private insurance. Among 16,146 tested patients, EGFR mutations were detected in 4328 patients (26.8%). However, estimates of mutation prevalence were biased by incomplete and selective testing in many studies. CONCLUSIONS The uptake of EGFR mutation testing of patients with NSCLC is suboptimal in many parts of the world. Incomplete uptake of testing is fuelled by selective testing referral practices, sample limitations, and funding constraints.
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Nelson DB, Antonoff MB. Commentary: The prognostic value of Kirsten rat sarcoma viral oncogene mutation for non-small cell lung cancer: One size does not always fit all. J Thorac Cardiovasc Surg 2020; 163:e91-e92. [PMID: 32741631 DOI: 10.1016/j.jtcvs.2020.06.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 06/15/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Affiliation(s)
- David B Nelson
- Department of Surgery, Loma Linda University Health, Loma Linda, Calif
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex.
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Smith SA, van Berkel VH. Commentary: Every detail matters-Understanding the impact of KRAS mutations. J Thorac Cardiovasc Surg 2020; 163:e88-e89. [PMID: 32680644 DOI: 10.1016/j.jtcvs.2020.06.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/05/2020] [Accepted: 06/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Susan A Smith
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Ky
| | - Victor H van Berkel
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Ky.
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Lung Carcinoma. Genomic Med 2020. [DOI: 10.1007/978-3-030-22922-1_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Patel SH, Rimner A, Foster A, Zhang Z, Woo KM, Yu HA, Riely GJ, Wu AJ. Patterns of initial and intracranial failure in metastatic EGFR-mutant non-small cell lung cancer treated with erlotinib. Lung Cancer 2017; 108:109-114. [PMID: 28625621 PMCID: PMC5477661 DOI: 10.1016/j.lungcan.2017.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Patients with metastatic EGFR-mutant (mEGFRmt) NSCLC have favorable survival when treated with erlotinib. We hypothesized that treatment failure in most patients is limited to initial sites of disease, in which case incorporating local therapy such as radiation might further delay progression. We therefore analyzed patterns and predictors of failure in a large cohort of such patients. MATERIALS AND METHODS We reviewed 189 patients treated with erlotinib for mEGFRmt NSCLC. We classified first pattern of failure as involving initial sites only (ISF), new sites only (NSF), or the combination (CSF), and used competing-risks regression to identify factors associated with ISF, progression and overall survival (OS). We also separately analyzed intracranial and intrathoracic failure. RESULTS Of 171 patients who progressed, 103 (60.2%) had ISF, 30 (17.5%) had NSF, and 38 (22.2%) had CSF. Younger age and lack of initial CNS involvement independently correlated with ISF, with a trend for higher T and N stage. Higher T and N stage was also a significant predictor of progression. Factors predicting shorter OS were female gender, weight loss, initial intracranial involvement, and ≥4 extracranial metastases. Intrathoracic progression was a component of first failure in 61%, and three-year cumulative incidence of brain metastasis was 30%. CONCLUSION The main pattern of progression in mEGFRmt NSCLC on erlotinib is in the initial sites of disease. Younger patients and those without brain involvement are particularly likely to develop ISF. This suggests a role for incorporating local therapy into treatment of selected patients with mEGFRmt NSCLC.
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Affiliation(s)
- Suchit H Patel
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Andreas Rimner
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Amanda Foster
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Zhigang Zhang
- Departments of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Kaitlin M Woo
- Departments of Biostatistics, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Helena A Yu
- Departments of Thoracic Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Gregory J Riely
- Departments of Thoracic Oncology, Memorial Sloan Kettering Cancer Center, New York, United States
| | - Abraham J Wu
- Departments of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, United States.
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Cheema PK, Menjak IB, Winterton-Perks Z, Raphael S, Cheng SY, Verma S, Muinuddin A, Freedman R, Toor N, Perera J, Anaka M, Victor JC. Impact of Reflex EGFR/ALK Testing on Time to Treatment of Patients With Advanced Nonsquamous Non–Small-Cell Lung Cancer. J Oncol Pract 2017; 13:e130-e138. [DOI: 10.1200/jop.2016.014019] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: Optimal first-line systemic therapy for patients with advanced nonsquamous (nonsq) non–small-cell lung cancer (NSCLC) requires confirmation of EGFR/ ALK status, which can delay treatment. We evaluated the impact of reflex testing, defined as pathologists initiating EGFR/ ALK testing at the time of diagnosis of nonsq NSCLC, on time to treatment (TTT). Methods: We conducted a retrospective review of patients with nonsq NSCLC with medical oncology consultation at Sunnybrook Odette Cancer Centre between March 18, 2010 and April 30, 2014. Data were compared during routine and reflex testing. TTT was defined as the interval between the first medical oncology visit with advanced NSCLC and the initiation of systemic therapy. Results: A total of 306 patients were included (n = 232 for routine testing, n = 74 for reflex testing). There was a trend to improvement in median TTT with reflex testing (36 days [interquartile range {IQR}, 16 to 71 days v 26 days [IQR, 8 to 41 days], P = .071). Omitting patients with intentional delays in systemic therapy for low-volume disease, poor performance status, comorbidity management, and/or radiation therapy, median TTT improved (34 days [IQR, 15 to 67 days] v 22 days [IQR, 8 to 42 days], P = .049). Time to optimal first-line systemic therapy according to published guidelines improved (median, 36 days [IQR, 16 to 91 days] v 24 days [IQR, 8 to 43 days], P = .036). There was no impact on receipt of any first-line systemic therapy (55% v 59%, P = .66). The quality of biomarker testing improved, with fewer unsuccessful tests ( EGFR, 14% v 4%, P = .039; and ALK, 17% v 3%, P = .037). Conclusion: Reflex testing of EGFR/ ALK improved the time to optimal systemic therapy and the quality of biomarker testing for patients with advanced nonsq NSCLC.
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Affiliation(s)
- Parneet K. Cheema
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ines B. Menjak
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Zoe Winterton-Perks
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Simon Raphael
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Susanna Y. Cheng
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Sunil Verma
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ahmad Muinuddin
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Ryan Freedman
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Nevkeet Toor
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Joseph Perera
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Matthew Anaka
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - J. Charles Victor
- Sunnybrook Odette Cancer Centre; North York General Hospital, Toronto; Trillium Health Partners, Mississauga, Ontario; and Tom Baker Cancer Centre, Calgary, Alberta, Canada
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Abstract
INTRODUCTION Mutant BRAF is a driver oncogene found in 2% of lung adenocarcinomas and represents a target for therapy. We examined the clinical characteristics and course of patients with lung adenocarcinomas harboring BRAF mutations. METHODS We identified patients with lung adenocarcinomas harboring BRAF mutations between 2009 and 2013 detected using a mass spectrometry-based polymerase chain reaction genotyping assay of hot-spot mutations involving codons corresponding to amino acids V600, D594, and G469 of BRAF. Patient characteristics and treatment outcomes were analyzed. Overall survival (OS) was compared with stage-matched patients with KRAS and EGFR mutant lung adenocarcinomas. RESULTS Sixty-three patients were diagnosed with BRAF mutant lung adenocarcinomas between 2009 and 2013 (V600, 36; non-V600, 27). The majority of patients with BRAF mutations were smokers (92%), although patients with V600 mutations were more likely to be light/never-smokers compared with patients with non-V600 mutations (42% versus 11%; p = 0.007). Of the 32 patients with early-stage disease, six (19%; 95% confidence interval 7%-36%) developed second primary lung cancers harboring KRAS mutations. Patients with advanced V600 mutant lung adenocarcinomas had a better survival from diagnosis compared with those with non-V600 mutant lung adenocarcinomas (3-year OS: 24% versus 0%; p < 0.001). CONCLUSIONS This is the largest series of patients with BRAF mutant lung cancers described. Most patients were heavy smokers. Nineteen percent of patients with early-stage BRAF mutant lung cancers developed second primary lung cancers harboring KRAS mutations. Patients with advanced lung adenocarcinomas harboring V600 mutations have an improved OS compared with those with non-V600 mutations.
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Jotte RM, Spigel DR. Advances in molecular-based personalized non-small-cell lung cancer therapy: targeting epidermal growth factor receptor and mechanisms of resistance. Cancer Med 2015; 4:1621-32. [PMID: 26310719 PMCID: PMC4673988 DOI: 10.1002/cam4.506] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 07/10/2015] [Accepted: 07/14/2015] [Indexed: 01/15/2023] Open
Abstract
Molecularly targeted therapies, directed against the features of a given tumor, have allowed for a personalized approach to the treatment of advanced non-small-cell lung cancer (NSCLC). The reversible epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) gefitinib and erlotinib had undergone turbulent clinical development until it was discovered that these agents have preferential activity in patients with NSCLC harboring activating EGFR mutations. Since then, a number of phase 3 clinical trials have collectively shown that EGFR-TKI monotherapy is more effective than combination chemotherapy as first-line therapy for EGFR mutation-positive advanced NSCLC. The next generation of EGFR-directed agents for EGFR mutation-positive advanced NSCLC is irreversible TKIs against EGFR and other ErbB family members, including afatinib, which was recently approved, and dacomitinib, which is currently being tested in phase 3 trials. As research efforts continue to explore the various proposed mechanisms of acquired resistance to EGFR-TKI therapy, agents that target signaling pathways downstream of EGFR are being studied in combination with EGFR TKIs in molecularly selected advanced NSCLC. Overall, the results of numerous ongoing phase 3 trials involving the EGFR TKIs will be instrumental in determining whether further gains in personalized therapy for advanced NSCLC are attainable with newer agents and combinations. This article reviews key clinical trial data for personalized NSCLC therapy with agents that target the EGFR and related pathways, specifically based on molecular characteristics of individual tumors, and mechanisms of resistance.
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Liu J, Zhao R, Zhang J, Zhang J. ARMS for EGFR mutation analysis of cytologic and corresponding lung adenocarcinoma histologic specimens. J Cancer Res Clin Oncol 2014; 141:221-7. [DOI: 10.1007/s00432-014-1807-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/15/2014] [Indexed: 11/30/2022]
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Fisher KE, Pillai RN, Kudchadkar RR, Rossi MR. Section IV: non-small cell lung cancer and malignant melanoma. Curr Probl Cancer 2014; 38:180-98. [PMID: 25281457 DOI: 10.1016/j.currproblcancer.2014.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Chaft JE, Litvak A, Arcila ME, Patel P, D'Angelo SP, Krug LM, Rusch V, Mattson A, Coeshott C, Park B, Apelian DM, Kris MG, Azzoli CG. Phase II study of the GI-4000 KRAS vaccine after curative therapy in patients with stage I-III lung adenocarcinoma harboring a KRAS G12C, G12D, or G12V mutation. Clin Lung Cancer 2014; 15:405-10. [PMID: 25044103 DOI: 10.1016/j.cllc.2014.06.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 05/30/2014] [Accepted: 06/17/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Patients with early-stage lung cancer have a high risk of recurrence despite multimodality therapy. KRAS-mutant lung adenocarcinomas are the largest genetically defined subgroup, representing 25% of patients. GI-4000 is a heat-killed recombinant Saccharomyces cerevisiae yeast-derived vaccine expressing mutant KRAS proteins. The present phase II study assessed the feasibility, immunogenicity, and safety of the GI-4000 vaccine in patients with early-stage, KRAS-mutant lung cancer. MATERIALS AND METHODS Patients with stage I-III KRAS-mutant lung cancer who completed curative therapy were enrolled. The patients received the genotype matched GI-4000 vaccine for ≤ 3 years or until intolerance, disease recurrence, or death. The KRAS antigen T-cell response was assessed using the interferon-gamma enzyme-linked immunospot assay in peripheral blood mononuclear cells. The study was powered to detect an immune response in ≥ 25% of patients. RESULTS A total of 24 patients were enrolled over 28 months. No vaccine-related serious adverse events occurred. One patient withdrew consent because of pain at the injection site. The study met its primary endpoint, with 50% of patients developing an immune response to mutant KRAS. The median number of vaccinations received was 15 (range, 1-19). Ten patients experienced disease recurrence, and 6 died. Compared with the genotypically matched historical controls, the recurrence rates were equivalent but overall survival showed a favorable trend. CONCLUSION GI-4000 was well tolerated and immunogenic when used as consolidation therapy in patients with stage I-III KRAS-mutant lung cancer. The patterns of recurrence and death observed in the present study can be used to design a randomized study of GI-4000 with overall survival as the primary endpoint.
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Affiliation(s)
- Jamie E Chaft
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY.
| | - Anya Litvak
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Maria E Arcila
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Payal Patel
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Sandra P D'Angelo
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Lee M Krug
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Valerie Rusch
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | | | - Bernard Park
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Mark G Kris
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | - Christopher G Azzoli
- Thoracic Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
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Gerber NK, Yamada Y, Rimner A, Shi W, Riely GJ, Beal K, Yu HA, Chan TA, Zhang Z, Wu AJ. Erlotinib versus radiation therapy for brain metastases in patients with EGFR-mutant lung adenocarcinoma. Int J Radiat Oncol Biol Phys 2014; 89:322-9. [PMID: 24679729 DOI: 10.1016/j.ijrobp.2014.02.022] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 02/12/2014] [Accepted: 02/13/2014] [Indexed: 12/13/2022]
Abstract
PURPOSE/OBJECTIVES Radiation therapy (RT) is the principal modality in the treatment of patients with brain metastases (BM). However, given the activity of EGFR tyrosine kinase inhibitors in the central nervous system, it is uncertain whether upfront brain RT is necessary for patients with EGFR-mutant lung adenocarcinoma with BM. METHODS AND MATERIALS Patients with EGFR-mutant lung adenocarcinoma and newly diagnosed BM were identified. RESULTS 222 patients were identified. Exclusion criteria included prior erlotinib use, presence of a de novo erlotinib resistance mutation, or incomplete data. Of the remaining 110 patients, 63 were treated with erlotinib, 32 with whole brain RT (WBRT), and 15 with stereotactic radiosurgery (SRS). The median overall survival (OS) for the whole cohort was 33 months. There was no significant difference in OS between the WBRT and erlotinib groups (median, 35 vs 26 months; P=.62), whereas patients treated with SRS had a longer OS than did those in the erlotinib group (median, 64 months; P=.004). The median time to intracranial progression was 17 months. There was a longer time to intracranial progression in patients who received WBRT than in those who received erlotinib upfront (median, 24 vs 16 months, P=.04). Patients in the erlotinib or SRS group were more likely to experience intracranial failure as a component of first failure, whereas WBRT patients were more likely to experience failure outside the brain (P=.004). CONCLUSIONS The survival of patients with EGFR-mutant adenocarcinoma with BM is notably long, whether they receive upfront erlotinib or brain RT. We observed longer intracranial control with WBRT, even though the WBRT patients had a higher burden of intracranial disease. Despite the equivalent survival between the WBRT and erlotinib group, this study underscores the role of WBRT in producing durable intracranial control in comparison with a targeted biologic agent with known central nervous system activity.
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Affiliation(s)
- Naamit K Gerber
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yoshiya Yamada
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andreas Rimner
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Weiji Shi
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Gregory J Riely
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kathryn Beal
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Helena A Yu
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Timothy A Chan
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Abraham J Wu
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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Abstract
ROS1 gene rearrangements are reported in 1% to 2% of lung adenocarcinomas (ACAs) and are associated with response to the multitargeted tyrosine kinase inhibitor crizotinib. ROS1 rearrangements can be detected using fluorescence in situ hybridization (FISH); however, immunohistochemistry (IHC) for ROS1 protein is a promising alternate screening modality. In this study, we examine the correlation between ROS1 IHC and FISH and describe the clinicopathologic characteristics of ROS1-rearranged lung tumors. ROS1 IHC was performed using clone D4D6 on whole-tissue sections. In a validation cohort, IHC was compared with ROS1 break-apart FISH in 53 cases of lung ACA enriched for an absence of known genetic alterations and never-smoking status. In a screening cohort, we performed ROS1 IHC on 167 consecutive cases of lung ACA from a routine molecular diagnostic practice and confirmed positive results by FISH. In the validation cohort, 6 cases (11%) were both FISH and IHC positive. One FISH-negative case was strongly ROS1 IHC positive. All IHC-negative cases were FISH negative. In the screening cohort, 2 of 167 (1.2%) had strong, diffuse ROS1 protein expression; a rearrangement was confirmed by FISH in both. ROS1-translocated tumors were wild type for EGFR, KRAS, and ALK and commonly had solid growth with mucinous/cribriform features and psammomatous calcification. ROS1 protein expression in tumor cells is 100% sensitive and 92% specific for ROS1 rearrangements by FISH. ROS1 IHC is an effective screening tool for this rare but clinically important subset of lung ACAs.
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Bar J, Damianovich M, Hout Siloni G, Dar E, Cohen Y, Perelman M, Ben Nun A, Simansky D, Yellin A, Urban D, Onn A. Genetic mutation screen in early non--small-cell lung cancer (NSCLC) specimens. Clin Lung Cancer 2013; 15:159-65. [PMID: 24370118 DOI: 10.1016/j.cllc.2013.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 10/19/2013] [Accepted: 11/08/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Testing for genetic abnormalities in epithelial growth factor receptor (EGFR), anaplastic lymphoma receptor tyrosine kinase (ALK), and potentially additional genes is a critical tool in the care of advanced NSCLC. There is conflicting evidence for the role of such tests in early NSCLC. We report a single-institute Sequenom testing for a wide range of mutations and their clinical correlations in early-resected NSCLC specimens. MATERIALS AND METHODS Early NSCLC paraffin-embedded, formalin-fixed (FFPE) specimens were collected, DNA extracted, and using Sequenom-based matrix-assisted laser desorption/ionization-time of flight analysis, mutations in 22 oncogenes and tumor suppressor genes were evaluated. Clinical data was collected retrospectively. RESULTS The technique was found to be feasible. Thirty-six of 96 patients (37.5%) had any genetic abnormality identified, and 8 (8.3%) had 2 or more mutations. Kirsten rat sarcoma viral oncogene homolog (KRAS) and EGFR were the most common genes to appear mutated (15.6%); phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha (PIK3CA) was the gene to be found most commonly in tumors with co-mutations. Transversions were found mostly in KRAS gene mutations and to be nonprognostic. No difference in the spectrum of mutations was found between squamous-cell and non-squamous-cell lung cancers. Ever-smokers showed a trend for worse prognosis, with a similar spectrum of mutations. CONCLUSION Sequenom-based mutation screen is feasible using FFPE samples. More than a third of the patients were found to harbor some genetic abnormality, and 8% were found to have more than a single mutated gene. Wide-range gene screens using large sample depositories are required for further insight into the important genes at play in early NSCLC.
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Affiliation(s)
- Jair Bar
- Institute of Oncology, Sheba Medical Center, Tel-Hashomer, Israel; Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel.
| | - Maya Damianovich
- Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
| | - Goni Hout Siloni
- Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
| | - Erel Dar
- Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yoram Cohen
- Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
| | - Marina Perelman
- Institute of Pathology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Alon Ben Nun
- Thoracic Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - David Simansky
- Thoracic Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Alon Yellin
- Thoracic Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Damien Urban
- Peter MacCallum Cancer Center, East Melbourne, Victoria, Australia
| | - Amir Onn
- Institute of Oncology, Sheba Medical Center, Tel-Hashomer, Israel; Cancer Research Center, Sheba Medical Center, Tel-Hashomer, Israel
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Distinct clinical course of EGFR-mutant resected lung cancers: results of testing of 1118 surgical specimens and effects of adjuvant gefitinib and erlotinib. J Thorac Oncol 2013; 7:1815-1822. [PMID: 23154553 DOI: 10.1097/jto.0b013e31826bb7b2] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND EGFR and KRAS mutations are mutually exclusive and predict outcomes with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) treatment in patients with stage IV lung cancers. The clinical significance of these mutations in patients with resected stage I-III lung cancers is unclear. METHODS At our institution, resection specimens from patients with stage I-III lung adenocarcinomas are tested for the presence of EGFR or KRAS mutations during routine pathology analysis such that the results are available before consideration of adjuvant therapy. In a cohort of 1118 patients tested over 8 years, overall survival was analyzed using multivariate analysis to control for potential confounders, including age, sex, stage, and smoking history. The impact of adjuvant erlotinib or gefitinib was examined in an independent data set of patients exclusively with EGFR mutation, in which date of recurrence was recorded. RESULTS In the overall population, we identified 227 KRAS (25%) and 222 EGFR (20%) mutations. Patients with EGFR-mutant lung cancers had a lower risk of death compared with those without EGFR mutations, overall survival (OS) HR 0.51 (95% confidence interval [CI]: 0.34-0.76, p < 0.001). Patients with KRAS-mutant lung cancers had similar outcomes compared with individuals with KRAS wild-type tumors, OS HR 1.17 (95% CI: 0.87-1.57, p = 0.30). A separate data set includes only patients with EGFR-mutant lung cancers identified over 10 years (n = 286). In patients with resected lung cancers and EGFR mutation, treatment with adjuvant erlotinib or gefitinib was associated with a lower risk of recurrence or death, disease-free survival HR 0.43 (95% CI: 0.26-0.72, p = 0.001), and a trend toward improved OS. CONCLUSIONS Patients with resected stage I-III lung cancers and EGFR mutation have a lower risk of death compared with patients without EGFR mutation. This may be because of treatment with EGFR TKIs. Patients with, and without KRAS mutation have similar OS. These data support reflex testing of resected lung adenocarcinomas for EGFR mutation to provide prognostic information and identify patients for enrollment on prospective clinical trials of adjuvant EGFR TKIs.
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20
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Lam DC. Counterpoint: Should Epidermal Growth Factor Receptor Mutations Be Routinely Tested for in Patients With Lung Cancer? No. Chest 2013; 143:600-602. [DOI: 10.1378/chest.12-2548] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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21
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Cagle PT, Allen TC. Lung cancer genotype-based therapy and predictive biomarkers: present and future. Arch Pathol Lab Med 2013. [PMID: 23194040 DOI: 10.5858/arpa.2012-0508-ra] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The advent of genotype-based therapy and predictive biomarkers for lung cancer has thrust the pathologist into the front lines of precision medicine for this deadly disease. OBJECTIVE To provide the clinical background, current status, and future perspectives of molecular targeted therapy for lung cancer patients, including the pivotal participation of the pathologist. DATA SOURCES Data were obtained from review of the pertinent peer-reviewed literature. CONCLUSIONS First-generation tyrosine kinase inhibitors have produced clinical response in a limited number of non-small cell lung cancers demonstrated to have activating mutations of epidermal growth factor receptor or anaplastic lymphoma kinase rearrangements with fusion partners. Patients treated with first-generation tyrosine kinase inhibitors develop acquired resistance to their therapy. Ongoing investigations of second-generation tyrosine kinase inhibitors and new druggable targets as well as the development of next-generation genotyping and new antibodies for immunohistochemistry promise to significantly expand the pathologist's already crucial role in precision medicine of lung cancer.
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Affiliation(s)
- Philip T Cagle
- Department of Pathology & Genomic Medicine, The Methodist Hospital, Houston, Texas, USA.
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22
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Arcila ME, Nafa K, Chaft JE, Rekhtman N, Lau C, Reva BA, Zakowski MF, Kris MG, Ladanyi M. EGFR exon 20 insertion mutations in lung adenocarcinomas: prevalence, molecular heterogeneity, and clinicopathologic characteristics. Mol Cancer Ther 2013; 12:220-9. [PMID: 23371856 DOI: 10.1158/1535-7163.mct-12-0620] [Citation(s) in RCA: 344] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In contrast to other primary epidermal growth factor receptor (EGFR) mutations in lung adenocarcinomas, insertions in exon 20 of EGFR have been generally associated with resistance to EGFR-tyrosine kinase inhibitors. Their molecular spectrum, clinicopathologic characteristics, and prevalence are not well established. Tumors harboring EGFR exon 20 insertions were identified through an algorithmic screen of 1,500 lung adenocarcinomas. Cases were first tested for common mutations in EGFR (exons 19 and 21) and KRAS (exon 2) and, if negative, further analyzed for EGFR exon 20 insertions. All samples underwent extended genotyping for other driver mutations in EGFR, KRAS, BRAF, ERBB2/HER2, NRAS, PIK3CA, MEK1, and AKT by mass spectrometry; a subset was evaluated for ALK rearrangements. We identified 33 EGFR exon 20 insertion cases [2.2%, 95% confidence interval (CI), 1.6-3.1], all mutually exclusive with mutations in the other genes tested (except PIK3CA). They were more common among never-smokers (P < 0.0001). There was no association with age, sex, race, or stage. Morphologically, tumors were similar to those with common EGFR mutations but with frequent solid histology. Insertions were highly variable in position and size, ranging from 3 to 12 bp, resulting in 13 different insertions, which, by molecular modeling, are predicted to have potentially different effects on erlotinib binding. EGFR exon 20 insertion testing identifies a distinct subset of lung adenocarcinomas, accounting for at least 9% of all EGFR-mutated cases, representing the third most common type of EGFR mutation after exon 19 deletions and L858R. Insertions are structurally heterogeneous with potential implications for response to EGFR inhibitors.
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Affiliation(s)
- Maria E Arcila
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA.
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23
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Khode R, Larsen DA, Culbreath BC, Parrish S, Walker KL, Sayage-Rabie L, Beissner RS, Rao A. Comparative study of epidermal growth factor receptor mutation analysis on cytology smears and surgical pathology specimens from primary and metastatic lung carcinomas. Cancer Cytopathol 2013; 121:361-9. [PMID: 23364874 DOI: 10.1002/cncy.21273] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/09/2012] [Accepted: 11/29/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND The detection of epidermal growth factor receptor (EGFR) mutations on small biopsy or fine-needle aspiration samples is required to guide therapy in nonsmall cell lung cancer (NSCLC). In this study, the authors compared results from EGFR mutation testing on both cytologic smears and surgical specimens and also compared the performance of platforms using 2 different technologies (pyrosequencing and real-time polymerase chain reaction) for both specimen types. METHODS Specimens from 114 patients were divided into 2 subsets. The first subset had 60 paired cytology smears and surgical specimens, including 37 paired specimens from the same site and 23 paired specimens from different sites. The second subset consisted of nonpaired cytology smears and formalin-fixed, paraffin-embedded (FFPE) tissues (including 8 cell blocks), which were compared on the pyrosequencing and real-time polymerase chain reaction platforms. Laser-capture microscopy was used to enrich tumor in the FFPE specimens before DNA extraction. RESULTS All cytology smears that were used in the study were adequate for analysis on both platforms. Comparison between smears and concurrent FFPE tissues from the same anatomic site had a concordance rate of 97%. The concordance rate between the pyrosequencing platform and the real-time polymerase chain reaction platform was 84% and 85% for FFPE tissues and cytology smears, respectively. CONCLUSIONS The current results indicated that direct extraction and analysis of EGFR mutations from cytology smears can be performed successfully on both a pyrosequencing platform and a real-time polymerase chain reaction platform with results comparable to those achieved in matched surgical specimens. In fine-needle aspiration/endobronchial ultrasound samples with limited tissue, cytology smears can be important for molecular analysis. Cancer (Cancer Cytopathol) 2013;121:361-369. © 2012 American Cancer Society.
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Affiliation(s)
- Renu Khode
- Department of Pathology, Scott & White Memorial Hospital and Texas A&M University Health Science Center, Temple, Texas 76504, USA
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Cagle PT, Olsen RJ. Verifying the role of surgical pathologists in the precision medicine of lung cancer. Arch Pathol Lab Med 2013; 137:1176-8. [PMID: 23276149 DOI: 10.5858/arpa.2012-0659-ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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25
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Gazdar AF. The evolving role of the pathologist in the management of lung cancer. Lung Cancer Manag 2012; 1:273-281. [PMID: 26279685 DOI: 10.2217/lmt.12.43] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Major advances in pathology, molecular biology, patient diagnosis and care, as well as the advent of personalized therapy, have resulted in a greatly increased role for the pathologist, who has emerged as a key member of the lung cancer management team. A new multidisciplinary, clinically relevant classification of pulmonary adenocarcinoma has resulted in a paradigm shift in how we view and practice lung cancer pathology. In the future, the role of the pathologist will continue to grow and become fully integrated with clinical care.
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Affiliation(s)
- Adi F Gazdar
- Hamon Center for Therapeutic Oncology Research & Department of Pathology, UT Southwestern Medical Center, Bld NB8-206, 6000 Harry Hines Blvd, TX 75390-8593, USA; Tel.: +1 214 648 4921; ;
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26
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Dogan S, Shen R, Ang DC, Johnson ML, D’Angelo SP, Paik PK, Brzostowski EB, Riely GJ, Kris MG, Zakowski MF, Ladanyi M. Molecular epidemiology of EGFR and KRAS mutations in 3,026 lung adenocarcinomas: higher susceptibility of women to smoking-related KRAS-mutant cancers. Clin Cancer Res 2012; 18:6169-77. [PMID: 23014527 PMCID: PMC3500422 DOI: 10.1158/1078-0432.ccr-11-3265] [Citation(s) in RCA: 437] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The molecular epidemiology of most EGFR and KRAS mutations in lung cancer remains unclear. EXPERIMENTAL DESIGN We genotyped 3,026 lung adenocarcinomas for the major EGFR (exon 19 deletions and L858R) and KRAS (G12, G13) mutations and examined correlations with demographic, clinical, and smoking history data. RESULTS EGFR mutations were found in 43% of never smokers and in 11% of smokers. KRAS mutations occurred in 34% of smokers and in 6% of never smokers. In patients with smoking histories up to 10 pack-years, EGFR predominated over KRAS. Among former smokers with lung cancer, multivariate analysis showed that, independent of pack-years, increasing smoking-free years raise the likelihood of EGFR mutation. Never smokers were more likely than smokers to have KRAS G > A transition mutation (mostly G12D; 58% vs. 20%, P = 0.0001). KRAS G12C, the most common G > T transversion mutation in smokers, was more frequent in women (P = 0.007) and these women were younger than men with the same mutation (median 65 vs. 69, P = 0.0008) and had smoked less. CONCLUSIONS The distinct types of KRAS mutations in smokers versus never smokers suggest that most KRAS-mutant lung cancers in never smokers are not due to second-hand smoke exposure. The higher frequency of KRAS G12C in women, their younger age, and lesser smoking history together support a heightened susceptibility to tobacco carcinogens.
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Affiliation(s)
- Snjezana Dogan
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ronglai Shen
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Daphne C Ang
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Melissa L Johnson
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Sandra P D’Angelo
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Paul K Paik
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Edyta B Brzostowski
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Gregory J Riely
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark G Kris
- Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Maureen F Zakowski
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Marc Ladanyi
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY
- Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, New York, NY
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27
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Suehara Y, Arcila M, Wang L, Hasanovic A, Ang D, Ito T, Kimura Y, Drilon A, Guha U, Rusch V, Kris MG, Zakowski MF, Rizvi N, Khanin R, Ladanyi M. Identification of KIF5B-RET and GOPC-ROS1 fusions in lung adenocarcinomas through a comprehensive mRNA-based screen for tyrosine kinase fusions. Clin Cancer Res 2012; 18:6599-608. [PMID: 23052255 DOI: 10.1158/1078-0432.ccr-12-0838] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mutually exclusive pattern of the major driver oncogenes in lung cancer suggests that other mutually exclusive oncogenes exist. We conducted a systematic search for tyrosine kinase fusions by screening all tyrosine kinases for aberrantly high RNA expression levels of the 3' kinase domain (KD) exons relative to more 5' exons. METHODS We studied 69 patients (including five never smokers and 64 current or former smokers) with lung adenocarcinoma negative for all major mutations in KRAS, EGFR, BRAF, MEK1, HER2, and for ALK fusions (termed "pan-negative"). A NanoString-based assay was designed to query the transcripts of 90 tyrosine kinases at two points: 5' to the KD and within the KD or 3' to it. Tumor RNAs were hybridized to the NanoString probes and analyzed for outlier 3' to 5' expression ratios. Presumed novel fusion events were studied by rapid amplification of cDNA ends (RACE) and confirmatory reverse transcriptase PCR (RT-PCR) and FISH. RESULTS We identified one case each of aberrant 3' to 5' ratios in ROS1 and RET. RACE isolated a GOPC-ROS1 (FIG-ROS1) fusion in the former and a KIF5B-RET fusion in the latter, both confirmed by RT-PCR. The RET rearrangement was also confirmed by FISH. The KIF5B-RET patient was one of only five never smokers in this cohort. CONCLUSION The KIF5B-RET fusion defines an additional subset of lung cancer with a potentially targetable driver oncogene enriched in never smokers with "pan-negative" lung adenocarcinomas. We also report in lung cancer the GOPC-ROS1 fusion originally discovered and characterized in a glioma cell line.
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Affiliation(s)
- Yoshiyuki Suehara
- Departments of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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28
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Serracino HS, Franklin WA, Aisner DL. Molecular Pathology of Non-Small Cell Lung Cancer. Surg Pathol Clin 2012; 5:903-18. [PMID: 26838508 DOI: 10.1016/j.path.2012.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This review offers an overview of the molecular pathology of lung cancer, with a focus on analyses that are most commonly part of the current clinical testing paradigm. Molecular testing of lung cancer has proved integral to the success of new targeted therapies, and their use is now commonplace in treatment selection. Traditional pathologic evaluation, however, plays a major role in these advances and serves an equally critical role to aid in determining optimal therapy.
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Affiliation(s)
- Hilary S Serracino
- Department of Pathology, University of Colorado Denver, 12631 E. 17th Avenue, Mail Stop B216, Aurora, CO 80045, USA
| | - Wilbur A Franklin
- Department of Pathology, University of Colorado Denver, 12631 E. 17th Avenue, Mail Stop B216, Aurora, CO 80045, USA
| | - Dara L Aisner
- Department of Pathology, University of Colorado Denver, 12631 E. 17th Avenue, Mail Stop B216, Aurora, CO 80045, USA.
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29
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Aisner DL, Marshall CB. Molecular pathology of non-small cell lung cancer: a practical guide. Am J Clin Pathol 2012; 138:332-46. [PMID: 22912349 DOI: 10.1309/ajcpfr12wjkceezz] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The traditional distinction between small cell lung cancer and non-small cell lung cancer (NSCLC) is no longer sufficient for treatment planning. It is advised to handle small diagnostic specimens prudently because they are often the only specimen available for molecular analysis. Pathologists are experiencing pressure to subclassify lung carcinoma based on extremely small tumor samples, because NSCLC tumor subtyping is now essential to determine molecular testing strategies. Evaluation for EGFR mutations and ALK rearrangements are now considered to be the standard of care in advanced-stage pulmonary adenocarcinomas. Immunohistochemical stains can aid in subclassifying NSCLC, but performing these ancillary studies can significantly reduce the quantity of tissue available for molecular tests, requiring careful balancing of these 2 needs. The pathologist plays a pivotal role in facilitating clear and timely communication between the clinical oncology care team and the molecular laboratory to ensure that the appropriate tests are ordered and optimal material is submitted for testing.
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30
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Hasanovic A, Ang D, Moreira AL, Zakowski MF. Use of mutation specific antibodies to detect EGFR status in small biopsy and cytology specimens of lung adenocarcinoma. Lung Cancer 2012; 77:299-305. [PMID: 22542171 DOI: 10.1016/j.lungcan.2012.04.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 01/13/2012] [Accepted: 04/01/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND EGFR mutation status is the best predictor of response to tyrosine kinase inhibitors (TKIS) in primary lung adenocarcinoma. Approximately 70% of lung cancers are diagnosed in advanced stages where small biopsies and cytological specimens are the only source of material for both diagnosis and mutation testing. Specific antibodies that can detect mutant EGFR protein were evaluated for the detection of EGFR mutation by immunohistochemistry (IHC) in cytology and small biopsy specimens. METHODS Assessment of EGFR mutation status was performed by using antibodies specific to the two major forms of mutant EGFR, exon 21 L858R and exon 19 deletion (15bp). The study was performed in 145 lung adenocarcinomas, including cytology material, core biopsy, and decalcified bone biopsy. Stains were scored as negative (0), 1+ (weak and focal), 2+ (moderate intensity and focal), and 3+ (strong and diffuse). The result of the IHC stains was correlated with mutations status determined by standard molecular methods. RESULTS Validation using clinical material showed deletions in exon 19 were detected in 35% and L858R mutation in 17.6% of all cases by standard molecular methods. A cutoff value of 2+ was used as positive by IHC. No wild type cases were immunoreactive. The positive predictive value (PPV) and specificity for both antibodies was 100%. The antibodies performed well in cytology, core biopsies and decalcified bone biopsies. CONCLUSION Immunostaining to detect specific mutant EGFR shows a good correlation with mutation analysis and can be used as a screening method to identify patients for TKI therapy. IHC methodology is potentially useful when molecular analysis is not available and for use in small biopsies when material is too scant for molecular tests. Importantly mutation specific antibodies are useful in determining EGFR status in tissues obtained from bone biopsy as decalcification processes used in molecular based studies often result in DNA degradation hindering mutation detection.
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Affiliation(s)
- Adnan Hasanovic
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Looyenga BD, Hutchings D, Cherni I, Kingsley C, Weiss GJ, MacKeigan JP. STAT3 is activated by JAK2 independent of key oncogenic driver mutations in non-small cell lung carcinoma. PLoS One 2012; 7:e30820. [PMID: 22319590 PMCID: PMC3271110 DOI: 10.1371/journal.pone.0030820] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 12/27/2011] [Indexed: 12/22/2022] Open
Abstract
Constitutive activation of STAT3 is a common feature in many solid tumors including non-small cell lung carcinoma (NSCLC). While activation of STAT3 is commonly achieved by somatic mutations to JAK2 in hematologic malignancies, similar mutations are not often found in solid tumors. Previous work has instead suggested that STAT3 activation in solid tumors is more commonly induced by hyperactive growth factor receptors or autocrine cytokine signaling. The interplay between STAT3 activation and other well-characterized oncogenic “driver” mutations in NSCLC has not been fully characterized, though constitutive STAT3 activation has been proposed to play an important role in resistance to various small-molecule therapies that target these oncogenes. In this study we demonstrate that STAT3 is constitutively activated in human NSCLC samples and in a variety of NSCLC lines independent of activating KRAS or tyrosine kinase mutations. We further show that genetic or pharmacologic inhibition of the gp130/JAK2 signaling pathway disrupts activation of STAT3. Interestingly, treatment of NSCLC cells with the JAK1/2 inhibitor ruxolitinib has no effect on cell proliferation and viability in two-dimensional culture, but inhibits growth in soft agar and xenograft assays. These data demonstrate that JAK2/STAT3 signaling operates independent of known driver mutations in NSCLC and plays critical roles in tumor cell behavior that may not be effectively inhibited by drugs that selectively target these driver mutations.
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Affiliation(s)
- Brendan D. Looyenga
- Systems Biology, Van Andel Research Institute, Grand Rapids, Michigan, United States of America
- * E-mail: (BDL); (JPM)
| | - Danielle Hutchings
- Systems Biology, Van Andel Research Institute, Grand Rapids, Michigan, United States of America
| | - Irene Cherni
- Lung Cancer Unit, Cancer & Cell Biology Division, The Translational Genomics Research Institute (TGen), Phoenix, Arizona, United States of America
| | - Chris Kingsley
- Diabetes, Cardiovascular & Metabolic Diseases Division, TGen, Phoenix, Arizona, United States of America
| | - Glen J. Weiss
- Lung Cancer Unit, Cancer & Cell Biology Division, The Translational Genomics Research Institute (TGen), Phoenix, Arizona, United States of America
- Virginia G. Piper Cancer Center Clinical Trials, Scottsdale Healthcare, Scottsdale, Arizona, United States of America
| | - Jeffrey P. MacKeigan
- Systems Biology, Van Andel Research Institute, Grand Rapids, Michigan, United States of America
- * E-mail: (BDL); (JPM)
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Rekhtman N, Paik PK, Arcila ME, Tafe LJ, Oxnard GR, Moreira AL, Travis WD, Zakowski MF, Kris MG, Ladanyi M. Clarifying the spectrum of driver oncogene mutations in biomarker-verified squamous carcinoma of lung: lack of EGFR/KRAS and presence of PIK3CA/AKT1 mutations. Clin Cancer Res 2012; 18:1167-76. [PMID: 22228640 DOI: 10.1158/1078-0432.ccr-11-2109] [Citation(s) in RCA: 306] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE There is persistent controversy as to whether EGFR and KRAS mutations occur in pulmonary squamous cell carcinoma (SQCC). We hypothesized that the reported variability may reflect difficulties in the pathologic distinction of true SQCC from adenosquamous carcinoma (AD-SQC) and poorly differentiated adenocarcinoma due to incomplete sampling or morphologic overlap. The recent development of a robust immunohistochemical approach for distinguishing squamous versus glandular differentiation provides an opportunity to reassess EGFR/KRAS and other targetable kinase mutation frequencies in a pathologically homogeneous series of SQCC. EXPERIMENTAL DESIGN Ninety-five resected SQCCs, verified by immunohistochemistry as ΔNp63(+)/TTF-1(-), were tested for activating mutations in EGFR, KRAS, BRAF, PIK3CA, NRAS, AKT1, ERBB2/HER2, and MAP2K1/MEK1. In addition, all tissue samples from rare patients with the diagnosis of EGFR/KRAS-mutant "SQCC" encountered during 5 years of routine clinical genotyping were reassessed pathologically. RESULTS The screen of 95 biomarker-verified SQCCs revealed no EGFR/KRAS [0%; 95% confidence interval (CI), 0%-3.8%], four PIK3CA (4%; 95% CI, 1%-10%), and one AKT1 (1%; 95% CI, 0%-5.7%) mutations. Detailed morphologic and immunohistochemical reevaluation of EGFR/KRAS-mutant "SQCC" identified during clinical genotyping (n = 16) resulted in reclassification of 10 (63%) cases as AD-SQC and five (31%) cases as poorly differentiated adenocarcinoma morphologically mimicking SQCC (i.e., adenocarcinoma with "squamoid" morphology). One (6%) case had no follow-up. CONCLUSIONS Our findings suggest that EGFR/KRAS mutations do not occur in pure pulmonary SQCC, and occasional detection of these mutations in samples diagnosed as "SQCC" is due to challenges with the diagnosis of AD-SQC and adenocarcinoma, which can be largely resolved by comprehensive pathologic assessment incorporating immunohistochemical biomarkers.
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Affiliation(s)
- Natasha Rekhtman
- Department of Pathology, Thoracic Oncology Service, Department of Medicine, and Human Oncology and Pathogenesis Program, Memorial Sloan-Kettering Cancer Center, NY 10065, USA.
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Dimou A, Harrington K, Syrigos KN. From the bench to bedside: biological and methodology considerations for the future of companion diagnostics in nonsmall cell lung cancer. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2011:312346. [PMID: 21785682 PMCID: PMC3140218 DOI: 10.4061/2011/312346] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 05/09/2011] [Accepted: 06/14/2011] [Indexed: 01/02/2023]
Abstract
Companion diagnostics are an emerging and exciting field in the care of oncology patients. These tests accompany standard diagnostic investigations in cancer patients and function as an aid in treatment decision making. A great number of new compounds are under clinical and laboratory testing in nonsmall cell lung cancer (NSCLC). As the variety of therapeutic options expands in the various settings of the disease, it becomes apparent that specific and sensitive molecular tests are necessary to define the subsets of patients who are going to derive clinical benefit. Testing for epidermal growth factor receptor (EGFR) somatic mutations for the appropriate administration of tyrosine kinase inhibitors is just the beginning. Anaplastic lymphoma kinase (ALK) fusion protein detection and molecular histology classification are promising candidate predictors for clinical benefit from crizotinib and pemetrexed, respectively. This paper summarizes such diagnostics and discusses unanswered questions concerning underlying biology and standardization issues.
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Affiliation(s)
- Anastasios Dimou
- Department of Pathology, Yale University School of Medicine, New Haven, CT 06520-8023, USA
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Mino-Kenudson M, Mark EJ. Reflex Testing for Epidermal Growth Factor Receptor Mutation and Anaplastic Lymphoma Kinase Fluorescence In Situ Hybridization in Non–Small Cell Lung Cancer. Arch Pathol Lab Med 2011; 135:655-64. [DOI: 10.5858/2011-0029-rai.1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Context.—Non–small cell lung cancer (NSCLC) is a poor-prognosis malignancy for which more effective treatments are needed, with accumulating clinical experiences supporting benefits of receptor tyrosine kinase inhibitors for patients with tumors harboring an epidermal growth factor receptor (EGFR) mutation or anaplastic lymphoma kinase (ALK) rearrangement.
Objective.—To review completed and ongoing clinical trials of EGFR tyrosine kinase inhibitors for EGFR mutation–positive NSCLC and an ALK inhibitor for those with ALK rearrangement, while also exploring practical issues surrounding the implementation of molecular testing as a routine component of the diagnostic workup of NSCLC in the United States.
Data Sources.—Published biomedical literature, abstracts presented at recent major oncology meetings, and ClinicalTrials.gov.
Conclusions.—Continually evolving evidence indicates the possible efficacy of molecularly targeted agents for the treatment of advanced NSCLC, especially adenocarcinoma. To identify patients who will most likely benefit from the targeted therapy, routine determination of the corresponding genetic alterations after histologic diagnosis of NSCLC (reflex molecular testing for EGFR mutations and ALK rearrangement) should be considered.
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