Correlation between EGFR mutation status and response to first-line platinum-based chemotherapy in patients with advanced non-small cell lung cancer

Association between epidermal growth factor receptor gene mutation status and short‑term efficacy of first‑line platinum‑containing chemotherapy in advanced non‑small cell lung cancer

It remains undetermined whether there is an explicit association between the epidermal growth factor receptor (EGFR) gene mutation status and chemotherapy efficacy in non-small cell lung cancer (NSCLC) patients with advanced stages. Thus, the aim of the present retrospective study was to investigate the possible association between EGFR gene mutation status and the efficacy of first-line chemotherapy in patients with advanced NSCLC. In total, 52 patients who were diagnosed with NSCLC at Changzhou Tumor Hospital (Changzhou, China) from January 2015 to December 2018 were enrolled. All 52 patients received pemetrexed combined with platinum chemotherapy, for 21 days per cycle. After two cycles of treatment, the short-term clinical efficacy was assessed according to the Response Evaluation Criteria in Solid Tumours 1.1 guidelines. The objective response rate (ORR), disease control rate (DCR) and progression-free survival (PFS) rate were calculated at the end of the study (December 31, 2019). These patients also underwent second-generation gene sequencing before the potential association between mutations in the EGFR gene and chemotherapy efficacy was analyzed. In this group of patients, 25 cases (48.1%) were found to be harboring EGFR gene mutation, whilst 27 cases (51.9%) expressed wild-type EGFR. After receiving the first-line chemotherapy regimen, the ORR was determined to be 36.5%, the DCR was 71.2%, whereas the PFS period was 207 days. Following first-line chemotherapy, the DCR of patients with EGFR mutations (52%) was higher compared with those in patients harboring the wild-type EGFR (22%). By contrast, the PFS (260 days) of patients with EGFR mutations was longer compared with those in patients harboring wild-type EGFR (100 days). These differences were statistically significant (P<0.05). Multivariate analysis revealed that EGFR gene mutation was an independent predictor of PFS in patients with advanced NSCLC (P<0.05). To conclude, data from the present study suggest that EGFR gene mutation has independent predictive value for the efficacy of first-line chemotherapy in patients with advanced NSCLC.

Worldwide Prevalence of Epidermal Growth Factor Receptor Mutations in Non-Small Cell Lung Cancer: A Meta-Analysis

Background

Identification of variable epidermal growth factor receptor (EGFR) gene mutations in non-small cell lung cancer (NSCLC) is important for the selection of appropriate targeted therapies. This meta-analysis was conducted to provide a worldwide overview of EGFR mutation and submutation (specifically exon 19 deletions, exon 21 L858R substitutions, and others) prevalence, and identify important covariates that influence EGFR mutation status in patients with advanced NSCLC to address this clinical data gap.

Methods

Embase^® and MEDLINE^® in Ovid were searched for studies published between 2004 and 2019 with cohorts of ≥ 50 adults with EGFR mutations, focusing on stage III/IV NSCLC (≤ 20% of patients with stage I/II NSCLC). Linear mixed-effects models were fitted to EGFR mutation endpoints using logistic transformation (logit), assuming a binomial distribution. The model included terms for an intercept reflecting European studies and further additive terms for other continents. EGFR submutations examined were exon 19 deletions, exon 21 L858R substitutions, and others.

Results

Of 3969 abstracts screened, 57 studies were included in the overall EGFR mutation analysis and 74 were included in the submutation analysis relative to the overall EGFR mutation population (Europe, n = 12; Asia, n = 51; North America, n = 5; Central America, n = 1; South America, n = 1; Oceania, n = 1; Global, n = 3). The final overall EGFR mutations model estimated Asian and European prevalence of 49.1% and 12.8%, respectively, and included an additive covariate for the proportion of male patients in a study. There were no significant covariates in the submutation analyses. Most submutations were actionable: exon 19 deletions (49.2% [Asia]; 48.4% [Europe]); exon 21 L858R substitutions (41.1% [Asia]; 29.9% [Europe]).

Conclusions

Although EGFR mutation prevalence was higher in Asian than Western countries, data support worldwide testing for EGFR overall and submutations to inform appropriate targeted treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40291-021-00563-1.

The impact of epidermal growth factor receptor mutations on the prognosis of resected non-small cell lung cancer: a meta-analysis of literatures

BACKGROUND

Epidermal growth factor receptor (EGFR) mutation represents a good response to EGFR-tyrosine kinase inhibitor and an advantageous prognostic factor in advanced-stage non-small cell lung cancer (NSCLC). However, the predictive value of EGFR mutation for prognosis in NSCLC patients after complete surgery, which more reflective of natural process, remains controversial. We sought to examine the predictive value of EGFR mutation in NSCLC. Several studies with small sample sizes have been reported but small studies bring bias especially in a postoperative setting. Therefore, we sought to pool all current evidence to show the true effects.

METHODS

Electronic databases were used to search the relevant articles. Disease-free survival (DFS), which will be less effected by subsequent treatments after recurrence, was the primary endpoint. The DFS between EGFR mutated and wild-type patients were compared focus on stage I patients who are rarely received adjuvant therapy. Besides, the DFS of patients with 19 exon deletion (19del) and 21 exon L858R mutation (L858R) were compared. A random effects model was used.

RESULTS

A total of 19 relevant studies which involved 4,872 cases were enrolled and 2,086 patients were EGFR-mutated. The majority of studies used PCR-based methods to detect EGFR mutations. Through meta-analysis, we observed the DFS of EGFR-mutated patients were similar to wild type patients in overall population (HR 0.93, 95% CI: 0.74 to 1.17). Similar results were observed in stage I subgroup (HR 0.82, 95% CI: 0.50 to 1.33). DFS of 19 del patients were potentially inferior to L858R patients but the difference was not significant (HR 1.38, 95% CI: 0.76 to 2.52).

CONCLUSIONS

There was no significant difference in postoperative DFS between EGFR-mutant patients and wild-type with resected NSCLC. In addition, there is still insufficient evidence to support different postoperative treatment strategies (especially for stage I) for both mutated and wild-type patients. However, 19 del may be a negative factor, which may require more strict management. Thus, we strongly encourage reporting specific prognostic impacts of different mutation types.

KRAS mutation and DNA repair and synthesis genes in non-small-cell lung cancer

The aim of the present study was to assess the expression of select DNA repair and synthesis genes in non-small-cell lung cancer (NSCLC) according to KRAS mutation status. ERCC1, TS, RRM1, and BRCA1 mRNA expression levels were assessed from either primary or metastatic tumor specimens of patients diagnosed with epidermal growth factor receptor (EGFR) wild-type (WT) advanced NSCLC. Total RNA was isolated from paraffin-embedded tumor specimens using the RNeasy FFPE kit and automatically purified using a QiaCube instrument. Quantification levels were analyzed by real-time one-step RT-PCR using QuantiFast technology, and the results were compared considering β-actin as the internal reference gene. One hundred and eighty-four patients with advanced NSCLC were evaluated for the analysis, of which 92 were KRAS-mutants. Nearly all patients had adenocarcinoma histology (96.7%). Among KRAS-mutants, the majority had a KRAS codon 12 mutation (88%), the most common being G12C (44.4% of cases). Mean ERCC1 levels were indicated to be significantly higher in KRAS-mutants when compared with KRAS WT patients (3,234±6.63 vs. 184±1.24; P=0.05). However, mean TS levels were significantly lower in the KRAS-mutant subgroup compared with the KRAS WT subgroup (4,481±3.756 vs. 5,941±6.4; P=0.039). KRAS-mutant NSCLCs are more likely to express high ERCC1 and low TS levels. This finding may suggest different sensitivity to cytotoxic chemotherapy according to KRAS mutation status.

Epidermal Growth Factor Receptor Mutations and Their Prognostic Value with Carcinoembryonic Antigen in Pathological T1 Lung Adenocarcinoma

Aims

The prognostic value of epidermal growth factor receptor (EGFR) mutations in the context of serum carcinoembryonic antigen levels remains controversial in T1 lung adenocarcinoma.

Methods

Clinical and pathological characteristics, preoperational carcinoembryonic antigen levels, EGFR mutations, and disease-free and overall survival were analysed retrospectively in 573 pathological T1 patients in East China.

Results

EGFR mutations were detected in 220 of 573 patients (38.4%). Patients with serum carcinoembryonic antigen levels ≥ 2.12 ng/mL had worse disease-free (P < 0.001) and overall survival (P < 0.001) than had others, although survival was comparable between patients with and without EGFR mutations. However, patients with exon 21 mutations in EGFR had significantly better overall survival than had patients with exon 19 mutations (P = 0.016), although disease-free survival was comparable (P = 0.424). Among patients with serum carcinoembryonic antigen levels ≥ 2.12 ng/mL, disease-free (P = 0.019) and overall survival (P < 0.001) was also better than that in those with exon 21 mutations. Finally, the exon 19 deletion was found to be an independent predictor of unfavourable overall survival (P = 0.037).

Conclusions

EGFR mutations were associated with preoperational serum carcinoembryonic antigen levels ≥ 2.12 ng/mL. In patients with levels above this threshold, those with the exon 19 deletion have less favourable prognosis than have those with the exon 21 mutation.

Predictive and prognostic value of preoperative serum tumor markers is EGFR mutation-specific in resectable non-small-cell lung cancer

Background

The predictive and prognostic value of carcinoembryonic antigen (CEA), cytokeratin-19 fragments (Cyfra21-1), squamous cell carcinoma antigen (SCCA) and neuron-specific enolase (NSE) has been investigated in non-small-cell lung cancer (NSCLC) patients. However, few studies have directly focused on the association between these markers and epidermal growth factor receptor (EGFR) mutation status or mutation subtypes.

Patients and methods

We retrospectively analyzed 1016 patients with stage I-IIIA NSCLC who underwent complete resection between 2008 and 2012. Correlations between serum tumor marker levels and EGFR mutations and survival parameters were analyzed and prognostic factors were identified.

Results

Cyfra21-1 levels (P = 0.032 for disease-free survival [DFS]; P < 0.001 for overall survival [OS]) and clinical stage were identified as independent predictive and prognostic factors in EGFR-mutated adenocarcinoma patients. CEA levels (P < 0.001 for DFS; P = 0.002 for OS) and clinical stage were independently predictive and prognostic in EGFR wild-type adenocarcinoma patients. Further stratification analysis revealed that in EGFR exon 19 deletion adenocarcinomas, elevated Cyfra21-1 was an independent prognostic factor (P = 0.002). Within the Leu858Arg substitution subgroup, increased CEA (P = 0.005) and clinical stage were predictive factors of DFS, while elevated CEA (P = 0.005) and Cyfra21-1 (P = 0.027) were independent prognostic factors.

Conclusion

Cyfra21-1 and CEA exhibit different predictive and prognostic values between EGFR-mutated and wild-type adenocarcinomas, as well as between EGFR mutation subtypes. The prognostic impact of preoperative serum tumor markers should be evaluated together with EGFR mutation status.

EGFR kinase domain mutation positive lung cancers are sensitive to intrapleural perfusion with hyperthermic chemotherapy (IPHC) complete treatment

Lung cancer is the global leading cause of cancer-related deaths. A significant portion of lung cancer patients harbor kinase domain mutations in the epidermal growth factor receptor (EGFR). While EGFR tyrosine kinase inhibitors (TKI) effectively shrink tumors harboring mutant EGFR, clinical efficacy is limited by the development of TKI resistance. Effective alternatives are desperately needed in clinic for treating EGFR kinase domain mutation positive lung cancer. In our clinic in treating M1a lung cancer patients through intrapleural perfusion with hyperthermic chemotherapy (IPHC) followed by cycles of systemic chemotherapy (we termed this procedure IPHC complete treatment, IPHC-CT), we found dramatic tumor shrinkage in mutant EGFR-positive patients. We further confirmed the sensitivity of EGFR mutation-positive lung cancer cell lines derived from patients to HC (hyperthermic chemotherapy) treatment. We found that hyperthermia promoted accumulation of cisplatin in lung cancer cells. Hyperthermia and cisplatin synergistically downregulated the EGFR protein level, leading to quenching of signal from EGFR and induction of apoptosis. Our work therefore showed IPHC-CT is an effective treatment for EGFR kinase domain mutation positive lung cancer patients.

Economic Evaluation of Companion Diagnostic Testing for EGFR Mutations and First-Line Targeted Therapy in Advanced Non-Small Cell Lung Cancer Patients in South Korea

Background

As targeted therapy becomes increasingly important, diagnostic techniques for identifying targeted biomarkers have also become an emerging issue. The study aims to evaluate the cost-effectiveness of treating patients as guided by epidermal growth factor receptor (EGFR) mutation status compared with a no-testing strategy that is the current clinical practice in South Korea.

Methods

A cost-utility analysis was conducted to compare an EGFR mutation testing strategy with a no-testing strategy from the Korean healthcare payer’s perspective. The study population consisted of patients with stage 3b and 4 lung adenocarcinoma. A decision tree model was employed to select the appropriate treatment regimen according to the results of EGFR mutation testing and a Markov model was constructed to simulate disease progression of advanced non-small cell lung cancer. The length of a Markov cycle was one month, and the time horizon was five years (60 cycles).

Results

In the base case analysis, the testing strategy was a dominant option. Quality-adjusted life-years gained (QALYs) were 0.556 and 0.635, and total costs were $23,952 USD and $23,334 USD in the no-testing and testing strategy respectively. The sensitivity analyses showed overall robust results. The incremental cost-effectiveness ratios (ICERs) increased when the number of patients to be treated with erlotinib increased, due to the high cost of erlotinib.

Conclusion

Treating advanced adenocarcinoma based on EGFR mutation status has beneficial effects and saves the cost compared to no testing strategy in South Korea. However, the cost-effectiveness of EGFR mutation testing was heavily affected by the cost-effectiveness of the targeted therapy.

Clinical correlation of extensive-stage small-cell lung cancer genomics

BACKGROUND

Genomic studies in small-cell lung cancer (SCLC) lag far behind those carried out in nonsmall-cell lung cancer (NSCLC). To date, most SCLC studies have evaluated patients with surgically resectable disease. Here we sought to evaluate the genomic mutation spectrum of 'every-day' SCLC patient tumors with extensive stage disease (ES-SCLC) and to correlate mutations with the main clinical outcomes of response to chemotherapy, progression-free (PFS) and overall (OS) survival.

PATIENTS AND METHODS

A total of 50 SCLC patient tumors were examined in this study; targeted exome sequencing was obtained on 42 patients and whole-exome sequencing on 8 patients. Mutated genes were correlated with clinical outcomes using Kaplan-Meier methods (PFS, OS) and logistic regression (chemo-response). RB1 protein expression was detected by either western blotting of cultured cell lysates or immunohistochemistry of tumor specimens.

RESULTS

In all, 39 patients had ES-SCLC; 15 patients had either primary refractory/resistant disease and 21 patients had sensitive disease. The two most frequently mutated genes were TP53 (86%) and RB1 (58%); other frequently mutated genes (>10% patients) were involved in epigenetic regulation as well as the mTOR pathway. We identified a number of low-frequency, targetable mutations, including RICTOR, FGFR1, KIT, PTCH1 and RET. Using multivariate analysis, RB1 was the only significant factor (P = 0.038) in predicting response to first-line chemotherapy, with an odds ratio of 5.58 comparing mutant RB1 with wild-type. Patients with mutant RB1 had both better OS (11.7 versus 9.1 months P = 0.04) and PFS (11.2 versus 8.6 months, P = 0.06) compared with patients with wild-type RB1. Interestingly, ∼25% of SCLC cell lines and tumor specimens expressed RB1 protein, possibly representing the subgroup with wild-type RB1.

CONCLUSIONS

We found that SCLC tumors harboring no mutation in RB1 had a poor response to chemotherapy.

Reactivation of hepatitis B virus after withdrawal of erlotinib

Reactivation of hepatitis B virus (hbv) is a reported complication for patients undergoing chemotherapy, particularly immunochemotherapy with anti-CD20 agents such as rituximab. However, as the use of molecularly targeted agents increases, the risk of viral reactivation is less clearly defined. Here, we present the case of a 62-year-old woman with newly diagnosed EGFR mutation-positive metastatic non-small-cell lung cancer (nsclc). Per interview, our patient had a remote history of hbv infection. She was started on erlotinib and developed profound diarrhea leading to renal failure that required hospital admission and temporary discontinuation of erlotinib. At 8 days after erlotinib cessation, she had a marked spike in her liver function tests, with viral serologies that were consistent with hbv reactivation. Although erlotinib and other tyrosine kinase inhibitors (tkis) are not classically associated with hbv reactivation, hbv reactivation can occur even in the setting of tki withdrawal. Before tki initiation, careful patient screening in those at risk for hbv should be performed to attenuate preventable hepatotoxicity and to differentiate between other causes of hepatotoxicity (for example, drug-induced toxicity).

[Association between the epidermal growth receptor status and the efficacy of first-line chemotherapy in patients with advanced non-small cell lung cancer]

背景与目的

表皮生长因子受体（epidermal growth factor receptor, EGFR）基因状态是表皮生长因子受体酪氨酸激酶抑制剂（epidermal growth factor receptor tyrosine kinase inhibitor, EGFR-TKI）疗效的预测因素，但其对化疗疗效的预测作用尚不明确。本研究旨在探讨对晚期非小细胞肺癌（non-small cell lung cancer, NSCLC）患者一线化疗疗效的预测意义。

方法

收集首都医科大学附属北京胸科医院自2006年1月10日-2013年12月20日经组织病理学证实的181例Ⅲb期/Ⅳ期的NSCLC患者。分析EGFR基因状态、临床特征与化疗疗效及无疾病进展生存期（progression-free survival, PFS）之间的关系。

结果

181例患者均进行了EGFR基因检测，EGFR突变患者75例（41.4%），野生型为106例（58.6%）。全部患者均接受一线化疗，客观缓解率（objective response rate, ORR）为26.0%，疾病控制率（disease control rate, DCR）为70.2%。EGFR突变患者的DCR显著高于EGFR野生型患者高（84.0% vs 60.4%, P=0.001）。亚组分析显示，19外显子缺失突变患者化疗的ORR、DCR均高于EGFR野生型患者（P值分别为0.049，0.002）。21外显子L858R突变患者的DCR高于EGFR野生型患者（P=0.010）。全部患者中，168例患者可评价PFS，中位PFS为4.3个月，其中腺癌患者PFS较鳞癌患者延长（4.7个月 vs 3.0个月，P=0.036）；突变患者PFS长于野生型患者（6.3个月 vs 3.0个月，P=0.002）；体力状况评分（performance status, PS）0-1分组患者PFS较评分为2分延长（4.4个月 vs 0.7个月，P=0.016）。Cox多因素分析显示，EGFR突变是影响PFS的独立因素（HR=0.654, 95%CI: 0.470-0.909, P=0.012）。

结论

EGFR突变是晚期NSCLC患者一线化疗PFS的预测因素。