G Model LUNG-4988; No. of Pages 2
ARTICLE IN PRESS Lung Cancer xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Correspondence Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation To the Editors, We read with great interest the review article written by Jiang et al. [1] on the role of circulating-tumor DNA (ctDNA) analysis in non-small cell lung cancer (NSCLC). They discussed the clinical applications of ctDNA in patient management. It is now clear that EGFR alterations can be detected in patients’ ctDNA before [2–4] and during [5–7] tyrosine kinase inhibitor (TKI) treatment. Detection of the T790M resistance mutation, a common molecular mechanism of acquired resistance to first- and second-generation TKIs [8,9], is of particular interest since third-generation TKIs have shown favorable results in patients presenting this mutation
[10,11]. In this context, ctDNA analysis could be most convenient for the selection of T790M positive patients and for follow-up of treatment. A 70-year-old Caucasian female with history of smoking (20 pack-year, stopped 10 years ago) was diagnosed with cT3N3M1b (stage IV) adenocarcinoma in July 2010 (lower left lung). The patient was treated with cisplatin-pemetrexed resulting in a partial response. Molecular analysis of the bronchial biopsies revealed the presence of an activating alteration of the EGFR gene (exon 19 deletion). In March 2011 the tumor relapsed and treatment with gefitinib was started, resulting in a partial response lasting 4 years. A computed tomography (CT) scan then demonstrated the presence of brain metastases and the patient received whole brain irradiation and corticoids. A positron emission tomography-CT scan showed multifocal lung relapse,
Fig. 1. (A) Detection of EGFR alterations in the patient’s plasma. DNA was extracted from plasma (2 ml) using the QIAmp circulating nucleic acid kit (Qiagen). EGFR alterations (exon 19 deletion 䊏; p.T790M 䊐) were detected by allele-specific amplification using the Therascreen RGQ EGFR kit (Qiagen). Standard curves (for both Del19 and T790M) were generated with serial 2-fold dilutions of a plasma sample in which the number of mutated copies was determined by digital PCR. The number of mutated DNA copies was calculated from these standard curves using the RotorGene software. nd; not detected. CT scans at baseline (B) and after 6 weeks of AZD9291 treatment (C).
http://dx.doi.org/10.1016/j.lungcan.2015.11.008 0169-5002/© 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: A. Vallée, et al., Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation, Lung Cancer (2015), http://dx.doi.org/10.1016/j.lungcan.2015.11.008
G Model LUNG-4988; No. of Pages 2
ARTICLE IN PRESS Correspondence / Lung Cancer xxx (2015) xxx–xxx
2
but it was not possible to obtain biopsies. Blood was collected, and the ctDNA analysis revealed the presence of the T790M mutation in addition to the initial activating EGFR alteration (exon 19 deletion: c.2240-2257del) (Fig. 1A). Based on this information, the patient was treated with AZD9291 (expanded access program), and the molecular analyses were repeated during treatment. The level of mutated EGFR (both exon 19 deletion and T790M) was increased at day 3, followed by a significant decrease in both alterations the next day (Fig. 1A). These alterations were barely detectable after 6 days of treatment, and have not been detected since then. The patient rapidly showed benefit from the treatment, and corticoids were stopped after 10 days. The CT scan performed after 6 weeks clearly demonstrated a reduction in tumor size (Fig. 1C). Since then, the patient has been doing well (performance status 0) with no side effects and no additional medication. The last CT scan and clinical evaluation confirmed a stable disease after 5 months of AZD9291. Clinical trials have demonstrated the efficacy of AZD9291 in patients when the T790M resistance mutation was detected in tumor tissue collected on relapse [10]. This is the first report of a patient being treated with a third-generation TKI based on ctDNA analysis. Since ctDNA collection is much less invasive than a biopsy, it may become the preferred option in this setting, possibly as pre-screening before attempting to obtain a tissue sample. Furthermore, ctDNA samples might be less prone to heterogeneity and provide a better way of determining overall tumor mutation status than a small biopsy. Another potential advantage for ctDNA is that it allows repeated sampling and thus monitoring over time. This case demonstrated a rapid increase in mutated ctDNA after treatment was initiated, probably indicating tumor lysis, followed by a rapid decrease. This decrease is probably associated with response to treatment, as recently demonstrated for first-generation TKIs [7]. Further studies are required to determine whether analysis of a plasma sample as early as 3 days after treatment initiation could be used to determine whether the patient is responding or not. References [1] T. Jiang, S. Ren, C. Zhou, Role of circulating-tumor DNA analysis in non-small cell lung cancer, Lung Cancer 90 (2015) 128–134. [2] J.Y. Douillard, G. Ostoros, M. Cobo, T. Ciuleanu, R. Cole, G. McWalter, J. Walker, S. Dearden, A. Webster, T. Milenkova, R. McCormack, Gefitinib treatment in EGFR mutated caucasian NSCLC: circulating-free tumor DNA as a surrogate for determination of EGFR status, J. Thorac. Oncol. 9 (2014) 1345–1353. [3] A. Vallee, M. Marcq, A. Bizieux, K. El, C. ouri, H. Lacroix, J. Bennouna, J.Y. Douillard, M.G. Denis, Plasma is a better source of tumor-derived circulating cell-free DNA than serum for the detection of EGFR alterations in lung tumor patients, Lung Cancer 82 (2013) 373–374. [4] J. Luo, L. Shen, D. Zheng, Diagnostic value of circulating free DNA for the detection of EGFR mutation status in NSCLC: a systematic review and meta-analysis, Sci. Rep. 4 (2014) 6269. [5] M. Marcq, A. Vallee, A. Bizieux, M.G. Denis, Detection of EGFR mutations in the plasma of patients with lung adenocarcinoma for real-time monitoring of therapeutic response to tyrosine kinase inhibitors? J. Thorac. Oncol. 9 (2014) e49–e50. [6] G.R. Oxnard, C.P. Paweletz, Y. Kuang, S.L. Mach, A. O’Connell, M.M. Messineo, J.J. Luke, M. Butaney, P. Kirschmeier, D.M. Jackman, P.A. Janne, Noninvasive detection of response and resistance in EGFR-mutant lung cancer using
[7]
[8]
[9] [10]
[11]
quantitative next-generation genotyping of cell-free plasma DNA, Clin. Cancer Res. 20 (2014) 1698–1705. A. Marchetti, J.F. Palma, L. Felicioni, T.M. De Pas, R. Chiari, M. Del Grammastro, G. Filice, V. Ludovini, A.A. Brandes, A. Chella, F. Malorgio, F. Guglielmi, M. De Tursi, A. Santoro, L. Crino, F. Buttitta, early prediction of response to tyrosine kinase inhibitors by quantification of EGFR mutations in plasma of NSCLC patients, J. Thorac. Oncol. 10 (2015) 1437–1443. H.A. Yu, M.E. Arcila, N. Rekhtman, C.S. Sima, M.F. Zakowski, W. Pao, M.G. Kris, V.A. Miller, M. Ladanyi, G.J. Riely, Analysis of tumor specimens at the time of acquired resistance to EGFR-TKI therapy in 155 patients with EGFR-mutant lung cancers, Clin. Cancer. Res. 19 (2013) 2240–2247. M.G. Denis, A. Vallee, S. Theoleyre, EGFR T790M resistance mutation in non small-cell lung carcinoma, Clin. Chim. Acta 444 (2015) 81–85. P.A. Janne, J.C. Yang, D.W. Kim, D. Planchard, Y. Ohe, S.S. Ramalingam, M.J. Ahn, S.W. Kim, W.C. Su, L. Horn, D. Haggstrom, E. Felip, J.H. Kim, P. Frewer, M. Cantarini, K.H. Brown, P.A. Dickinson, S. Ghiorghiu, M. Ranson, AZD9291 in EGFR inhibitor-resistant non-small-cell lung cancer, N. Engl. J. Med. 372 (2015) 1689–1699. L.V. Sequist, J.C. Soria, J.W. Goldman, H.A. Wakelee, S.M. Gadgeel, A. Varga, V. Papadimitrakopoulou, B.J. Solomon, G.R. Oxnard, R. Dziadziuszko, D.L. Aisner, R.C. Doebele, C. Galasso, E.B. Garon, R.S. Heist, J. Logan, J.W. Neal, M.A. Mendenhall, S. Nichols, Z. Piotrowska, A.J. Wozniak, M. Raponi, C.A. Karlovich, S. Jaw-Tsai, J. Isaacson, D. Despain, S.L. Matheny, L. Rolfe, A.R. Allen, D.R. Camidge, Rociletinib in EGFR-mutated non-small-cell lung cancer, N. Engl. J. Med. 372 (2015) 1700–1709.
Audrey Vallée Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France Clarisse Audigier-Valette Service de Pneumologie, CHITS Toulon Sainte Musse, France Guillaume Herbreteau Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France Julien Merrien Service de Pneumologie, CHITS Toulon Sainte Musse, France Laurent Tessonnier Service de Médecine Nucléaire, CHITS Toulon Sainte Musse, France Sandrine Théoleyre Marc G. Denis ∗ Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France ∗ Corresponding
author. Fax: +33 240083991. E-mail address: [email protected] (M.G. Denis) 31 October 2015 4 November 2015
Please cite this article in press as: A. Vallée, et al., Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation, Lung Cancer (2015), http://dx.doi.org/10.1016/j.lungcan.2015.11.008
ARTICLE IN PRESS Lung Cancer xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Correspondence Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation To the Editors, We read with great interest the review article written by Jiang et al. [1] on the role of circulating-tumor DNA (ctDNA) analysis in non-small cell lung cancer (NSCLC). They discussed the clinical applications of ctDNA in patient management. It is now clear that EGFR alterations can be detected in patients’ ctDNA before [2–4] and during [5–7] tyrosine kinase inhibitor (TKI) treatment. Detection of the T790M resistance mutation, a common molecular mechanism of acquired resistance to first- and second-generation TKIs [8,9], is of particular interest since third-generation TKIs have shown favorable results in patients presenting this mutation
[10,11]. In this context, ctDNA analysis could be most convenient for the selection of T790M positive patients and for follow-up of treatment. A 70-year-old Caucasian female with history of smoking (20 pack-year, stopped 10 years ago) was diagnosed with cT3N3M1b (stage IV) adenocarcinoma in July 2010 (lower left lung). The patient was treated with cisplatin-pemetrexed resulting in a partial response. Molecular analysis of the bronchial biopsies revealed the presence of an activating alteration of the EGFR gene (exon 19 deletion). In March 2011 the tumor relapsed and treatment with gefitinib was started, resulting in a partial response lasting 4 years. A computed tomography (CT) scan then demonstrated the presence of brain metastases and the patient received whole brain irradiation and corticoids. A positron emission tomography-CT scan showed multifocal lung relapse,
Fig. 1. (A) Detection of EGFR alterations in the patient’s plasma. DNA was extracted from plasma (2 ml) using the QIAmp circulating nucleic acid kit (Qiagen). EGFR alterations (exon 19 deletion 䊏; p.T790M 䊐) were detected by allele-specific amplification using the Therascreen RGQ EGFR kit (Qiagen). Standard curves (for both Del19 and T790M) were generated with serial 2-fold dilutions of a plasma sample in which the number of mutated copies was determined by digital PCR. The number of mutated DNA copies was calculated from these standard curves using the RotorGene software. nd; not detected. CT scans at baseline (B) and after 6 weeks of AZD9291 treatment (C).
http://dx.doi.org/10.1016/j.lungcan.2015.11.008 0169-5002/© 2015 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: A. Vallée, et al., Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation, Lung Cancer (2015), http://dx.doi.org/10.1016/j.lungcan.2015.11.008
G Model LUNG-4988; No. of Pages 2
ARTICLE IN PRESS Correspondence / Lung Cancer xxx (2015) xxx–xxx
2
but it was not possible to obtain biopsies. Blood was collected, and the ctDNA analysis revealed the presence of the T790M mutation in addition to the initial activating EGFR alteration (exon 19 deletion: c.2240-2257del) (Fig. 1A). Based on this information, the patient was treated with AZD9291 (expanded access program), and the molecular analyses were repeated during treatment. The level of mutated EGFR (both exon 19 deletion and T790M) was increased at day 3, followed by a significant decrease in both alterations the next day (Fig. 1A). These alterations were barely detectable after 6 days of treatment, and have not been detected since then. The patient rapidly showed benefit from the treatment, and corticoids were stopped after 10 days. The CT scan performed after 6 weeks clearly demonstrated a reduction in tumor size (Fig. 1C). Since then, the patient has been doing well (performance status 0) with no side effects and no additional medication. The last CT scan and clinical evaluation confirmed a stable disease after 5 months of AZD9291. Clinical trials have demonstrated the efficacy of AZD9291 in patients when the T790M resistance mutation was detected in tumor tissue collected on relapse [10]. This is the first report of a patient being treated with a third-generation TKI based on ctDNA analysis. Since ctDNA collection is much less invasive than a biopsy, it may become the preferred option in this setting, possibly as pre-screening before attempting to obtain a tissue sample. Furthermore, ctDNA samples might be less prone to heterogeneity and provide a better way of determining overall tumor mutation status than a small biopsy. Another potential advantage for ctDNA is that it allows repeated sampling and thus monitoring over time. This case demonstrated a rapid increase in mutated ctDNA after treatment was initiated, probably indicating tumor lysis, followed by a rapid decrease. This decrease is probably associated with response to treatment, as recently demonstrated for first-generation TKIs [7]. Further studies are required to determine whether analysis of a plasma sample as early as 3 days after treatment initiation could be used to determine whether the patient is responding or not. References [1] T. Jiang, S. Ren, C. Zhou, Role of circulating-tumor DNA analysis in non-small cell lung cancer, Lung Cancer 90 (2015) 128–134. [2] J.Y. Douillard, G. Ostoros, M. Cobo, T. Ciuleanu, R. Cole, G. McWalter, J. Walker, S. Dearden, A. Webster, T. Milenkova, R. McCormack, Gefitinib treatment in EGFR mutated caucasian NSCLC: circulating-free tumor DNA as a surrogate for determination of EGFR status, J. Thorac. Oncol. 9 (2014) 1345–1353. [3] A. Vallee, M. Marcq, A. Bizieux, K. El, C. ouri, H. Lacroix, J. Bennouna, J.Y. Douillard, M.G. Denis, Plasma is a better source of tumor-derived circulating cell-free DNA than serum for the detection of EGFR alterations in lung tumor patients, Lung Cancer 82 (2013) 373–374. [4] J. Luo, L. Shen, D. Zheng, Diagnostic value of circulating free DNA for the detection of EGFR mutation status in NSCLC: a systematic review and meta-analysis, Sci. Rep. 4 (2014) 6269. [5] M. Marcq, A. Vallee, A. Bizieux, M.G. Denis, Detection of EGFR mutations in the plasma of patients with lung adenocarcinoma for real-time monitoring of therapeutic response to tyrosine kinase inhibitors? J. Thorac. Oncol. 9 (2014) e49–e50. [6] G.R. Oxnard, C.P. Paweletz, Y. Kuang, S.L. Mach, A. O’Connell, M.M. Messineo, J.J. Luke, M. Butaney, P. Kirschmeier, D.M. Jackman, P.A. Janne, Noninvasive detection of response and resistance in EGFR-mutant lung cancer using
[7]
[8]
[9] [10]
[11]
quantitative next-generation genotyping of cell-free plasma DNA, Clin. Cancer Res. 20 (2014) 1698–1705. A. Marchetti, J.F. Palma, L. Felicioni, T.M. De Pas, R. Chiari, M. Del Grammastro, G. Filice, V. Ludovini, A.A. Brandes, A. Chella, F. Malorgio, F. Guglielmi, M. De Tursi, A. Santoro, L. Crino, F. Buttitta, early prediction of response to tyrosine kinase inhibitors by quantification of EGFR mutations in plasma of NSCLC patients, J. Thorac. Oncol. 10 (2015) 1437–1443. H.A. Yu, M.E. Arcila, N. Rekhtman, C.S. Sima, M.F. Zakowski, W. Pao, M.G. Kris, V.A. Miller, M. Ladanyi, G.J. Riely, Analysis of tumor specimens at the time of acquired resistance to EGFR-TKI therapy in 155 patients with EGFR-mutant lung cancers, Clin. Cancer. Res. 19 (2013) 2240–2247. M.G. Denis, A. Vallee, S. Theoleyre, EGFR T790M resistance mutation in non small-cell lung carcinoma, Clin. Chim. Acta 444 (2015) 81–85. P.A. Janne, J.C. Yang, D.W. Kim, D. Planchard, Y. Ohe, S.S. Ramalingam, M.J. Ahn, S.W. Kim, W.C. Su, L. Horn, D. Haggstrom, E. Felip, J.H. Kim, P. Frewer, M. Cantarini, K.H. Brown, P.A. Dickinson, S. Ghiorghiu, M. Ranson, AZD9291 in EGFR inhibitor-resistant non-small-cell lung cancer, N. Engl. J. Med. 372 (2015) 1689–1699. L.V. Sequist, J.C. Soria, J.W. Goldman, H.A. Wakelee, S.M. Gadgeel, A. Varga, V. Papadimitrakopoulou, B.J. Solomon, G.R. Oxnard, R. Dziadziuszko, D.L. Aisner, R.C. Doebele, C. Galasso, E.B. Garon, R.S. Heist, J. Logan, J.W. Neal, M.A. Mendenhall, S. Nichols, Z. Piotrowska, A.J. Wozniak, M. Raponi, C.A. Karlovich, S. Jaw-Tsai, J. Isaacson, D. Despain, S.L. Matheny, L. Rolfe, A.R. Allen, D.R. Camidge, Rociletinib in EGFR-mutated non-small-cell lung cancer, N. Engl. J. Med. 372 (2015) 1700–1709.
Audrey Vallée Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France Clarisse Audigier-Valette Service de Pneumologie, CHITS Toulon Sainte Musse, France Guillaume Herbreteau Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France Julien Merrien Service de Pneumologie, CHITS Toulon Sainte Musse, France Laurent Tessonnier Service de Médecine Nucléaire, CHITS Toulon Sainte Musse, France Sandrine Théoleyre Marc G. Denis ∗ Laboratoire de Biochimie, Plateforme de Génétique Moléculaire des Cancers, CHU de Nantes, France ∗ Corresponding
author. Fax: +33 240083991. E-mail address: [email protected] (M.G. Denis) 31 October 2015 4 November 2015
Please cite this article in press as: A. Vallée, et al., Rapid clearance of circulating tumor DNA during treatment with AZD9291 of a lung cancer patient presenting the resistance EGFR T790M mutation, Lung Cancer (2015), http://dx.doi.org/10.1016/j.lungcan.2015.11.008
