- Email: [email protected]
Feasibility and clinical impact of re-biopsy in advanced non small-cell lung cancer: A prospective multicenter study in a real-world setting (GFPC study 12-01)
Lung Cancer 86 (2014) 170–173
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Feasibility and clinical impact of re-biopsy in advanced non small-cell lung cancer: A prospective multicenter study in a real-world setting (GFPC study 12-01) Christos Chouaid a , Cecile Dujon b , Pascal Do c , Isabelle Monnet d , Anne Madroszyk e , Herve Le Caer f , Jean Bernard Auliac g , Henri Berard h , Pascal Thomas i , Herve Lena j , Gilles Robinet k , Nathalie Baize l , Acya Bizieux-Thaminy m , Gislaine Fraboulet n , Chrystele Locher o , Jacques Le Treut p , Stephane Hominal q , Alain Vergnenegre r,∗ a
Service de pneumologie APHP, Saint Antoine, Paris, France CH Le Chesnay, France CAC, Caen, France d CHI Creteil, France e CAC Marseille, France f CH Draguignan, France g CH Mantes la Jolie, France h HIA Toulon, France i CH Gap, France j CHU Rennes, France k CHU Brest, France l CHU Angers, France m CH La Roche sur Yon, France n CH Cercy Pontoise, France o CH Meaux, France p CH Aix en Provence, France q CH Annecy-Genevois, Pringy, France r CHU Limoges, France b c
a r t i c l e
i n f o
Article history: Received 16 June 2014 Received in revised form 20 August 2014 Accepted 22 August 2014 Keywords: Non small cell lung cancer Re-biopsy Clinical management Guidelines Biomarkers
a b s t r a c t Objectives: When advanced non-small-cell lung cancer (NSCLC) progresses during first-line treatment, re-biopsy may be indicated to detect a possible new biological profile (comparison to initial status, emergence of resistance biomarkers, or assessment of new biomarkers). The aim of this pragmatic prospective multicenter study was to assess the feasibility and clinical utility of re-biopsy in advanced NSCLC in a real-world setting. Methods: The main inclusion criteria were advanced NSCLC with an indication for repeat biopsy identified by the patient’s clinician. The primary outcome was the percentage of successful procedures. Secondary outcomes were the type of procedure, new biological status, tolerability of the procedure, and clinical utility (treatment modification). Results: From May 2012 to May 2013, 18 centers enrolled 100 patients (males: 44%; median age: 64.8 years; PS 0/1: 88%; adenocarcinoma: 89%; EGFR mutated: 50%; no initial biological profile: 16.4%). Rebiopsy was not possible in 19.5% of cases and provided no or too few tumor cells in 25.6% of cases. Repeat biopsy was useful for guiding treatment in 30.4% (25/82) of cases. Complications were infrequent (2 cases of moderate bleeding and 1 case of pneumothorax). Conclusion: Re-biopsy of advanced NSCLC is feasible in the real-world setting, with acceptable adverse events. Guidelines are needed on the indications of re-biopsy, the choice of procedure, the sampling site, and laboratory analysis. © 2014 Elsevier Ireland Ltd. All rights reserved.
∗ Corresponding author at: Service de l’Unité d’Oncologie Thoracique et Cutanée (UOTC), CHU de LIMOGES, France. E-mail address: [email protected] (A. Vergnenegre). http://dx.doi.org/10.1016/j.lungcan.2014.08.016 0169-5002/© 2014 Elsevier Ireland Ltd. All rights reserved.
C. Chouaid et al. / Lung Cancer 86 (2014) 170–173
1. Introduction Non small-cell lung cancer (NSCLC) represents 80% of lung cancers and most patients have advanced or metastatic disease at diagnosis. NSCLC is now considered as a heterogeneous collection of diseases with diverse molecular characteristics [1]. In today’s era of personalized medicine, histo-cytologic diagnosis remains a necessary priority, but sufficient tissue is also required for molecular analysis to help to predict outcome and guide therapy [1]. Treatment is increasingly based on the matching of drug profiles with specific mutations in a patient’s primary tumor [2,3]. For example, the availability of targeted drugs has made the assessment of EGFR mutation and ALK rearrangement critical for choosing the optimal treatment for patients with non small cell lung cancer (NSCLC) [4–9]. Testing for EGFR mutations and ALK rearrangements in non squamous tumors is recommended before first-line treatment decisions [3]. When no driver mutations are found or not enough material is obtained for biological profiling, cisplatin combination chemotherapy is recommended for patients with good performance status. Unfortunately, most patients will progress after first-line therapy, and second-line chemotherapy is recommended for those whose performance status remains acceptable. Metastatic tumors often carry different genetic clones. Therefore, when tumors recur, further analysis of molecular markers is warranted, as treatment may be driven by the metastatic disease process and its molecular profile. For example, in patients with EGFR mutations, resistance to EGFR tyrosine kinase inhibitors (TKIs) may be due to the emergence of the EGFR T790M mutation [10], amplification of the hepatocyte growth factor receptor proto-oncogene, or a change from NSCLC to a small-cell lung histology, etc. As new treatment options emerge, it might require more frequent and possibly higher-volume re-biopsies, particularly for patients with a driver mutation who progress on targeted therapy, but also for patients without enough material for initial biological profiling and who remain in good condition after a first or second line of treatment [9]. Despite close collaboration between oncologists, pathologists and pulmonologists to ensure that adequate material is available for cytological and histological studies and to standardize specimen handling and processing, several factors limit the feasibility of re-biopsy and molecular analysis, particularly the amount of material that can be recovered during bronchial endoscopy, difficult access to some tumor sites, and the sometimes invasive nature of sampling methods. However, few data have been published on the feasibility of re-biopsy and its clinical impact in the real-world setting. The primary objective of this pragmatic prospective multicenter study in a population of patients with advanced NSCLC was to determine the rate of successful re-biopsy. Secondary objectives were to describe the safety of the procedure and its clinical impact.
171
Table 1 Patient characteristics. Age: median (range)
64 (39–91)
Sex Female Male
56 (56.0%) 44 (44.0%)
Performance status 0/1 2 >2
86 (86.0%) 12 (12.0%) 2 (2.0%)
Smoking status Current smoker Quit <1 year Former smoker Non smoker
7 (7.0%) 9 (9.0%) 38 (38.0%) 46 (46.0%)
Histology Adenocarcinoma Bronchiolo-alveolar Large cell carcinoma Epidermoid Undifferentiated
89 (89.0%) 2 (2.0%) 2 (2.0%) 5 (5.0%) 2 (2.0%)
Initial biological profile EGFR mutated KRAS mutated EGFR-KRAS wildtype No biological profile
50 (50.0%) 7 (7.0%) 25 (25.0%) 18 (18.0%)
Table 2 Re-biopsy methods. n = 82 Surgery Adrenalectomie Lung surgery Node surgery Biopsy Bronchial + E-BUS Pulmonary under CT Liver Bone Skin Cytology Nodes Pleura
1 3 1 43 19 2 6 2 3 2
study, each center used its usual laboratory methods. There were no imposed biological tests and no centralized analysis. The analysis was descriptive. Data were processed in Excel (Microsoft Office 2010). The protocol was approved by the Limoges Ethics Committees. 3. Results
2. Patients and methods This study included patients with advanced NSCLC over 18 years old with RECIST-defined progression after first-line targeted therapy or chemotherapy and a clinical indication for re-biopsy. To avoid a selection bias we ask each participating center to include 6 to 7 consecutive patients who meet the inclusion criteria’s. Clinical indication of re-biopsy was decided by each center after multidisciplinary meeting. Protocol was systematically proposed to all eligible patients. Non-inclusion criteria’s were a non lung-cancer histology and detainee status. The analysis focused on demographic characteristics, initial biological results of biopsy, the feasibility of re-biopsy (and the reasons for non completion), the sampling site, the type of procedure, complications, and the results of re-biopsy. As this was an observational
Between 1 March 2012 and 28 February 2013, 18 centers enrolled 100 patients (Table 1). The patients were relatively young (median 64 years) and in good general condition. Women were over-represented (56%), as was adenocarcinoma (89%) and non smokers/former smokers (84%). Initial biopsy failed to yield a molecular profile in 18% of patients, while respectively 50% and 25% of patients were EGFR-mutated and KRAS-EGFR wild type. There is no patient with ALK translocation. Re-biopsy could not be done in 18% of cases, mainly because of anticoagulation, which the patient’s physician considered to be a contraindication. One patient refused re-biopsy. Among the 82 patients who underwent re-biopsy, the sample could be analysed histologically in 94% of cases. Cytological samples represented only 6% of cases. The main procedure was pulmonary endoscopic (52%) (Table 2). Histological examination showed that respectively 18.3%
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Table 3 Initial molecular profile and results of re-biopsy. Initial molecular profile (n = 100)
Re-biopsy molecular profile (n = 82)
EGFR mutated Re-biopsy done:
n = 50 n = 40
KRAS mutated Re-biopsy done:
n=7 n=5
EGFR- KRAS wild type Re-biopsy done:
n = 25 n = 22
No biological profile Re-biopsy done:
n = 18 n = 15
EGFR mutated: KRAS mutated: New histology:
16 1
Not enough material:
4
KRAS mutated: No tumor detectable: EGFR-KRAS wild type EML4ALK: Ros1: Not enough material: EGFR mutated: New histology: No tumor detectable:
3 1 12 1 1 3 1 3 4
and 7.3% of samples contained no or too few tumor cells for molecular analysis (Table 3). Among the EGFR-mutated patients 80% had a rebiopsy, the initial mutation was again found in 45% of cases, while the T790M mutation was found in 5% of cases. In 2 cases the initial EGFR mutation was no longer found, and in one case the analysis showed a KRAS mutation suggestive of two concomitant pulmonary malignancies. Finally, histological transformation was found in 3 cases (Table 3). In KRAS-EGFR wild type patients, 88% had a re biopsy which detected a driver mutation in four cases (EGFR mutation: 1, ALK translocation: 1, ROS translocation: 1, HER2 mutation: 1) and a new histology in one case (Table 3). Among patients with no initial molecular profile, re-biopsy, done in 83% of cases showed a driver mutation in one case. Thus, re-biopsy had a clinical impact in 30.4% (25/82) of patients (shown in bold type in Table 3). Complications consisted of one case of pneumothorax requiring chest drainage, and two cases of hemoptysis requiring minor prolongation of the hospital stay. 4. Discussion This multicenter, prospective, pragmatic study examined the feasibility of re-biopsy in NSCLC patients. All but one of the patients accepted the procedure, which was feasible in 82% of cases; however, in one-quarter of cases, no or too few tumor cells were recovered for molecular profiling. Re-biopsy had clinical repercussions in 30.4% of cases, in terms of the treatment choice. There are few studies on the feasibility of re-biopsy or its impact on the management of NSCLC. The first published data, for EGFRmutated patients progressing on TKI therapy, helped to understand the mechanisms of progression [11]. However, most studies have been performed in a single center with centralized laboratory analysis; in addition, they were oriented towards basic and translational research and thus took place in conditions different from those of routine clinical practice. In an Asian cohort of 124 patients with advanced NSCLC treated for more than six months with an EGFRTKI between July 2010 and November 2012 [12], only 90 patients (72.5%) consented to the re-biopsy protocol but adequate tissue was obtained in 89.4% of cases, a rate markedly higher than in our study (76.4%). This study was limited to an analysis of EGFR mutations in a central laboratory. The prevalence of the T490M mutation in this population was 36%, compared to only 5% in our population, possibly because each center participating in our study used its local laboratory. Another study [13] evaluated the feasibility and safety of chest computed tomography (CT) guided procedures for repeat biopsy for mutational analysis in NSCLC patients with a history of resistance to previous chemotherapy or to EGFR-TKI therapy; 32/126
EGFR wildtype: T790M mutation: -small-cell LC: -other: No tumor detectable:
2 2 1 2 12
KRAS wildtype:
1
EGFR mutated: Her2: New histology: No tumor detectable: KRAS mutated: Not enough material:
1 1 1 2 5 2
(25.4%) of the patients were excluded after strict review of the CT images. Percutaneous transthoracic lung biopsy was performed in all the patients and the specimens were adequate for at least partial mutational analysis in 75/94 (80%) cases (37.2% for EGFR, 36.3% for ALK rearrangement, and 26.5% for both). Post-procedural complications occurred in 14% of cases (pneumothorax in 10 patients, hemothorax in one patient and pulmonary haemorrhage in two patients), a rate much higher than in our study. In a prospective biopsy protocol [14] involving a selected population (adenocarcinoma and acquired resistance to an EGFR-TKI), 175 patients were enrolled from August 2004 to January 2012. The vast majority (92.6%) was able to have a new biopsy, and sufficient material suitable for biological analysis was obtained in 80.6% of cases. The sampling sites were mainly lung/chest, liver and lymph nodes. Contrary to our study, fibroscopy was rarely used for biopsy [14]. Despite the use of different methods and populations, these studies reveal the difficulties of repeat biopsy for therapeutic management of advanced NSCLC. However, with progress in the processing of small-volume specimens and the increasing collaboration between oncologists, pathologists, pulmonologists and interventional radiologists, re-biopsy will become increasingly frequent in this setting. This will notably concern EGFR-mutated patients who progress on second-line EGFR TKIs (to identify the mechanism of progression), and also patients with an absent or incomplete molecular profile after initial biopsy. Re-biopsy can also be envisaged according to the clinical phenotype (non-smoker, young patient, adenocarcinoma, etc.) or when a patient progresses despite appropriate chemotherapy, in order to identify a driver mutation. Re-biopsy will also become more of an issue during front-line treatment as new drugs are developed, with the same difficulties as in the second-line setting. In a prospective phase II trial in patients with advanced NSCLC, focusing on feasibility and on molecular analysis-directed individualized therapy, 75 of 85 (88%) patients underwent the required biopsy, permitting gene analysis in only 55/75 (73.3%)of cases [15]. In a phase III trial in which firstline cisplatin-based chemotherapy was customized according to quantitative excision repair cross-complementing 1 mRNA expression, 78/444 (17.6%) patients went off-study because insufficient tumor tissue was obtained for ERCC1 mRNA assessment [16]. In another randomized phase III international trial in which first-line chemotherapy was chosen according to in situ RRM1 and ERCC1 protein levels in patients with advanced NSCLC, tumor re-biopsy for specific gene expression analysis was necessary in 17% of patients, 35% of whom refused. No complications occurred in the patients who accepted re-biopsy [17]. Our study has a number of limitations. Re-biopsy was decided on clinical grounds alone, the only constraint being that each center
C. Chouaid et al. / Lung Cancer 86 (2014) 170–173
included all consecutive patients with an indication. This explains some characteristics of the population, and notably the high proportion (50%) of patients with mutated EGFR, and of patients with an absent or incomplete molecular profile after initial biopsy. The second limitation is the lack of relevant clinical practice guidelines in France. Yet, ensuring equal access to personalized cancer treatment is a public health requirement in France and a nationwide network offers easy access to molecular tests. Since early 2011, lung tumor samples sent to a center for EGFR mutation screening have also been screened for BRAF, KRAS, PI3KCA and HER2 mutations, as well as for the ALK gene translocation. This program enables centers to deal with the increasing complexity of testing several biomarkers in the same tumor sample and to implement these tests in their daily practice [18]. However, there are no guidelines on the indications for re-biopsy, the sampling site or the type of genetic tests to be performed, resulting in marked variability. Similarly, the lack of centralized laboratory resulted in some heterogeneity in the molecular techniques used, which may partly explain the low rate of T790M mutation found in this study (5%), compared to rates of 50–68% reported elsewhere [19]. In this pragmatic study each center use his regional platform. As we want to be in «real word setting» it’s not seems relevant to use a central lab. Another limitation is the possibility that certain changes were found, not because of dedifferentiation, but because the molecular analysis was changed in time or because different laboratory performed the first and second biopsy. 5. Conclusion This study, conducted in real-world conditions, shows that re-biopsy of NSCLC patients after first-line treatment is feasible, acceptable, and useful for therapeutic decision-making in more than one-third of cases. Guidelines are needed to clarify the indications, the sampling site, the optimal procedure, and the cost effectiveness of re-biopsy in NSCLC. Author contributions Christos Chouaid and Alain Vergnenegre had full control of the study design, data analysis and interpretation, and manuscript preparation. Cecile Dujon, Christos Chouaid and Alain Vergnenegre conceived and performed the statistical analysis, participated in the design and coordination and helped to draft the manuscript. The final draft manuscript was approved by all the authors. Presentation This study has been presented in part at the 2013 WLCC meeting in Sydney. Conflicts of interest There are no conflicts of interest.
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Acknowledgments This trial was an academic trial conducted by Groupe Franc¸ais de Pneumo-Cancérologie. This study was sponsored by an unrestricted grant from F. Hoffmann-La Roche Ltd and Boeringher Ingelheim France. References [1] Travis WD, Brambilla E, Riely GJ. New pathologic classification of lung cancer: relevance for clinical practice and clinical trials. J Clin Oncol 2013: 992–1001. [2] Ellis PM, Blais N, Soulieres D, et al. A systematic review and Canadian consensus recommendations on the use of biomarkers in the treatment of non-small cell lung cancer. J Thorac Oncol 2011;6:1379–91. [3] Peters S, Adjei AA, Gridelli C, et al. ESMO Guidelines Working Group. Metastatic non-small-cell lung cancer (NSCLC): ESMOClinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23:7:vii56-64. [4] Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;361:947–57. [5] Rosell R, Carcereny E, Gervais R, et al. Erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFR mutationpositive non-small-cell lung cancer (EURTAC): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol 2012;13:239–46. [6] Sequist LV, Yang JC, Yamamoto N, et al. Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations. J Clin Oncol 2013;31:3327–34. [7] Awad MM, Katayama R, McTigue M, et al. Acquired resistance to crizotinib from a mutation in CD74-ROS1. N Engl J Med 2013;368:2395–401. [8] Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med 2013;368: 2385–94. [9] Shaw AT, Kim DW, Mehra R, et al. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med 2014;370:1189–97. [10] Sun JF, Ahn MJ, Choi YL, et al. Clinical implications of T790M mutation in patients with acquired resistance to EGFR tyrosine kinase inhibitors. Lung Cancer 2013;82:294–8. [11] Sequist LV, Waltman BA, Dias-Santagata D, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med 2011;3:75ra26. [12] Sun JM, Ahn MJ, Choi YL, et al. Clinical implications of T790M mutation in patients with acquired resistance to EGFR tyrosine kinase inhibitors. Lung Cancer 2013;82:294–8. [13] Yoon HJ, Lee HY, Lee KS, et al. Repeat biopsy for mutational analysis of nonsmall cell lung cancers resistant to previous chemotherapy: adequacy and complications. Radiology 2012;265:939–48. [14] Yu HA, Arcila ME, Rekhtman N, et al. 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 2013;19:2240–7. [15] Simon G, Sharma A, Li X, et al. Feasibility and efficacy of molecular analysisdirected individualized therapy in advanced non-small-cell lung cancer. J Clin Oncol 2007;25:2741–6. [16] Cobo M, Isla D, Massuti B, et al. Customizing cisplatin based on quantitative excision repair cross-complementing 1 mRNA expression: a phase III trial in non-small-cell lung cancer. J Clin Oncol 2007;25:2747–54. [17] Bepler G, Williams C, Schell MJ, et al. Randomized international phase III trial of ERCC1 and RRM1 expression-based chemotherapy versus gemcitabine/carboplatin in advanced non-small-cell lung cancer. J Clin Oncol 2013;31:2404–12. [18] Barlesi F BH, Beau-Faller M, et al. Biomarkers (BM) France: Results of routine EGFR, HER2, KRAS, BRAF, PI3KCA mutations detection and EML4-ALK gene fusion assessment on the first 10,000 non-small cell lung cancer (NSCLC) patients (pts). J Clin Oncol 2013;31:abstr 8000. [19] Oxnard GR, Arcila ME, Sima CS, et al. Acquired resistance to EGFR tyrosine kinase inhibitors in EGFR-mutant lung cancer: distinct natural history of patients with tumors harboring the T790M mutation. Clin Cancer Res 2011;17: 1616–22.
Contents lists available at ScienceDirect
Lung Cancer journal homepage: www.elsevier.com/locate/lungcan
Feasibility and clinical impact of re-biopsy in advanced non small-cell lung cancer: A prospective multicenter study in a real-world setting (GFPC study 12-01) Christos Chouaid a , Cecile Dujon b , Pascal Do c , Isabelle Monnet d , Anne Madroszyk e , Herve Le Caer f , Jean Bernard Auliac g , Henri Berard h , Pascal Thomas i , Herve Lena j , Gilles Robinet k , Nathalie Baize l , Acya Bizieux-Thaminy m , Gislaine Fraboulet n , Chrystele Locher o , Jacques Le Treut p , Stephane Hominal q , Alain Vergnenegre r,∗ a
Service de pneumologie APHP, Saint Antoine, Paris, France CH Le Chesnay, France CAC, Caen, France d CHI Creteil, France e CAC Marseille, France f CH Draguignan, France g CH Mantes la Jolie, France h HIA Toulon, France i CH Gap, France j CHU Rennes, France k CHU Brest, France l CHU Angers, France m CH La Roche sur Yon, France n CH Cercy Pontoise, France o CH Meaux, France p CH Aix en Provence, France q CH Annecy-Genevois, Pringy, France r CHU Limoges, France b c
a r t i c l e
i n f o
Article history: Received 16 June 2014 Received in revised form 20 August 2014 Accepted 22 August 2014 Keywords: Non small cell lung cancer Re-biopsy Clinical management Guidelines Biomarkers
a b s t r a c t Objectives: When advanced non-small-cell lung cancer (NSCLC) progresses during first-line treatment, re-biopsy may be indicated to detect a possible new biological profile (comparison to initial status, emergence of resistance biomarkers, or assessment of new biomarkers). The aim of this pragmatic prospective multicenter study was to assess the feasibility and clinical utility of re-biopsy in advanced NSCLC in a real-world setting. Methods: The main inclusion criteria were advanced NSCLC with an indication for repeat biopsy identified by the patient’s clinician. The primary outcome was the percentage of successful procedures. Secondary outcomes were the type of procedure, new biological status, tolerability of the procedure, and clinical utility (treatment modification). Results: From May 2012 to May 2013, 18 centers enrolled 100 patients (males: 44%; median age: 64.8 years; PS 0/1: 88%; adenocarcinoma: 89%; EGFR mutated: 50%; no initial biological profile: 16.4%). Rebiopsy was not possible in 19.5% of cases and provided no or too few tumor cells in 25.6% of cases. Repeat biopsy was useful for guiding treatment in 30.4% (25/82) of cases. Complications were infrequent (2 cases of moderate bleeding and 1 case of pneumothorax). Conclusion: Re-biopsy of advanced NSCLC is feasible in the real-world setting, with acceptable adverse events. Guidelines are needed on the indications of re-biopsy, the choice of procedure, the sampling site, and laboratory analysis. © 2014 Elsevier Ireland Ltd. All rights reserved.
∗ Corresponding author at: Service de l’Unité d’Oncologie Thoracique et Cutanée (UOTC), CHU de LIMOGES, France. E-mail address: [email protected] (A. Vergnenegre). http://dx.doi.org/10.1016/j.lungcan.2014.08.016 0169-5002/© 2014 Elsevier Ireland Ltd. All rights reserved.
C. Chouaid et al. / Lung Cancer 86 (2014) 170–173
1. Introduction Non small-cell lung cancer (NSCLC) represents 80% of lung cancers and most patients have advanced or metastatic disease at diagnosis. NSCLC is now considered as a heterogeneous collection of diseases with diverse molecular characteristics [1]. In today’s era of personalized medicine, histo-cytologic diagnosis remains a necessary priority, but sufficient tissue is also required for molecular analysis to help to predict outcome and guide therapy [1]. Treatment is increasingly based on the matching of drug profiles with specific mutations in a patient’s primary tumor [2,3]. For example, the availability of targeted drugs has made the assessment of EGFR mutation and ALK rearrangement critical for choosing the optimal treatment for patients with non small cell lung cancer (NSCLC) [4–9]. Testing for EGFR mutations and ALK rearrangements in non squamous tumors is recommended before first-line treatment decisions [3]. When no driver mutations are found or not enough material is obtained for biological profiling, cisplatin combination chemotherapy is recommended for patients with good performance status. Unfortunately, most patients will progress after first-line therapy, and second-line chemotherapy is recommended for those whose performance status remains acceptable. Metastatic tumors often carry different genetic clones. Therefore, when tumors recur, further analysis of molecular markers is warranted, as treatment may be driven by the metastatic disease process and its molecular profile. For example, in patients with EGFR mutations, resistance to EGFR tyrosine kinase inhibitors (TKIs) may be due to the emergence of the EGFR T790M mutation [10], amplification of the hepatocyte growth factor receptor proto-oncogene, or a change from NSCLC to a small-cell lung histology, etc. As new treatment options emerge, it might require more frequent and possibly higher-volume re-biopsies, particularly for patients with a driver mutation who progress on targeted therapy, but also for patients without enough material for initial biological profiling and who remain in good condition after a first or second line of treatment [9]. Despite close collaboration between oncologists, pathologists and pulmonologists to ensure that adequate material is available for cytological and histological studies and to standardize specimen handling and processing, several factors limit the feasibility of re-biopsy and molecular analysis, particularly the amount of material that can be recovered during bronchial endoscopy, difficult access to some tumor sites, and the sometimes invasive nature of sampling methods. However, few data have been published on the feasibility of re-biopsy and its clinical impact in the real-world setting. The primary objective of this pragmatic prospective multicenter study in a population of patients with advanced NSCLC was to determine the rate of successful re-biopsy. Secondary objectives were to describe the safety of the procedure and its clinical impact.
171
Table 1 Patient characteristics. Age: median (range)
64 (39–91)
Sex Female Male
56 (56.0%) 44 (44.0%)
Performance status 0/1 2 >2
86 (86.0%) 12 (12.0%) 2 (2.0%)
Smoking status Current smoker Quit <1 year Former smoker Non smoker
7 (7.0%) 9 (9.0%) 38 (38.0%) 46 (46.0%)
Histology Adenocarcinoma Bronchiolo-alveolar Large cell carcinoma Epidermoid Undifferentiated
89 (89.0%) 2 (2.0%) 2 (2.0%) 5 (5.0%) 2 (2.0%)
Initial biological profile EGFR mutated KRAS mutated EGFR-KRAS wildtype No biological profile
50 (50.0%) 7 (7.0%) 25 (25.0%) 18 (18.0%)
Table 2 Re-biopsy methods. n = 82 Surgery Adrenalectomie Lung surgery Node surgery Biopsy Bronchial + E-BUS Pulmonary under CT Liver Bone Skin Cytology Nodes Pleura
1 3 1 43 19 2 6 2 3 2
study, each center used its usual laboratory methods. There were no imposed biological tests and no centralized analysis. The analysis was descriptive. Data were processed in Excel (Microsoft Office 2010). The protocol was approved by the Limoges Ethics Committees. 3. Results
2. Patients and methods This study included patients with advanced NSCLC over 18 years old with RECIST-defined progression after first-line targeted therapy or chemotherapy and a clinical indication for re-biopsy. To avoid a selection bias we ask each participating center to include 6 to 7 consecutive patients who meet the inclusion criteria’s. Clinical indication of re-biopsy was decided by each center after multidisciplinary meeting. Protocol was systematically proposed to all eligible patients. Non-inclusion criteria’s were a non lung-cancer histology and detainee status. The analysis focused on demographic characteristics, initial biological results of biopsy, the feasibility of re-biopsy (and the reasons for non completion), the sampling site, the type of procedure, complications, and the results of re-biopsy. As this was an observational
Between 1 March 2012 and 28 February 2013, 18 centers enrolled 100 patients (Table 1). The patients were relatively young (median 64 years) and in good general condition. Women were over-represented (56%), as was adenocarcinoma (89%) and non smokers/former smokers (84%). Initial biopsy failed to yield a molecular profile in 18% of patients, while respectively 50% and 25% of patients were EGFR-mutated and KRAS-EGFR wild type. There is no patient with ALK translocation. Re-biopsy could not be done in 18% of cases, mainly because of anticoagulation, which the patient’s physician considered to be a contraindication. One patient refused re-biopsy. Among the 82 patients who underwent re-biopsy, the sample could be analysed histologically in 94% of cases. Cytological samples represented only 6% of cases. The main procedure was pulmonary endoscopic (52%) (Table 2). Histological examination showed that respectively 18.3%
172
C. Chouaid et al. / Lung Cancer 86 (2014) 170–173
Table 3 Initial molecular profile and results of re-biopsy. Initial molecular profile (n = 100)
Re-biopsy molecular profile (n = 82)
EGFR mutated Re-biopsy done:
n = 50 n = 40
KRAS mutated Re-biopsy done:
n=7 n=5
EGFR- KRAS wild type Re-biopsy done:
n = 25 n = 22
No biological profile Re-biopsy done:
n = 18 n = 15
EGFR mutated: KRAS mutated: New histology:
16 1
Not enough material:
4
KRAS mutated: No tumor detectable: EGFR-KRAS wild type EML4ALK: Ros1: Not enough material: EGFR mutated: New histology: No tumor detectable:
3 1 12 1 1 3 1 3 4
and 7.3% of samples contained no or too few tumor cells for molecular analysis (Table 3). Among the EGFR-mutated patients 80% had a rebiopsy, the initial mutation was again found in 45% of cases, while the T790M mutation was found in 5% of cases. In 2 cases the initial EGFR mutation was no longer found, and in one case the analysis showed a KRAS mutation suggestive of two concomitant pulmonary malignancies. Finally, histological transformation was found in 3 cases (Table 3). In KRAS-EGFR wild type patients, 88% had a re biopsy which detected a driver mutation in four cases (EGFR mutation: 1, ALK translocation: 1, ROS translocation: 1, HER2 mutation: 1) and a new histology in one case (Table 3). Among patients with no initial molecular profile, re-biopsy, done in 83% of cases showed a driver mutation in one case. Thus, re-biopsy had a clinical impact in 30.4% (25/82) of patients (shown in bold type in Table 3). Complications consisted of one case of pneumothorax requiring chest drainage, and two cases of hemoptysis requiring minor prolongation of the hospital stay. 4. Discussion This multicenter, prospective, pragmatic study examined the feasibility of re-biopsy in NSCLC patients. All but one of the patients accepted the procedure, which was feasible in 82% of cases; however, in one-quarter of cases, no or too few tumor cells were recovered for molecular profiling. Re-biopsy had clinical repercussions in 30.4% of cases, in terms of the treatment choice. There are few studies on the feasibility of re-biopsy or its impact on the management of NSCLC. The first published data, for EGFRmutated patients progressing on TKI therapy, helped to understand the mechanisms of progression [11]. However, most studies have been performed in a single center with centralized laboratory analysis; in addition, they were oriented towards basic and translational research and thus took place in conditions different from those of routine clinical practice. In an Asian cohort of 124 patients with advanced NSCLC treated for more than six months with an EGFRTKI between July 2010 and November 2012 [12], only 90 patients (72.5%) consented to the re-biopsy protocol but adequate tissue was obtained in 89.4% of cases, a rate markedly higher than in our study (76.4%). This study was limited to an analysis of EGFR mutations in a central laboratory. The prevalence of the T490M mutation in this population was 36%, compared to only 5% in our population, possibly because each center participating in our study used its local laboratory. Another study [13] evaluated the feasibility and safety of chest computed tomography (CT) guided procedures for repeat biopsy for mutational analysis in NSCLC patients with a history of resistance to previous chemotherapy or to EGFR-TKI therapy; 32/126
EGFR wildtype: T790M mutation: -small-cell LC: -other: No tumor detectable:
2 2 1 2 12
KRAS wildtype:
1
EGFR mutated: Her2: New histology: No tumor detectable: KRAS mutated: Not enough material:
1 1 1 2 5 2
(25.4%) of the patients were excluded after strict review of the CT images. Percutaneous transthoracic lung biopsy was performed in all the patients and the specimens were adequate for at least partial mutational analysis in 75/94 (80%) cases (37.2% for EGFR, 36.3% for ALK rearrangement, and 26.5% for both). Post-procedural complications occurred in 14% of cases (pneumothorax in 10 patients, hemothorax in one patient and pulmonary haemorrhage in two patients), a rate much higher than in our study. In a prospective biopsy protocol [14] involving a selected population (adenocarcinoma and acquired resistance to an EGFR-TKI), 175 patients were enrolled from August 2004 to January 2012. The vast majority (92.6%) was able to have a new biopsy, and sufficient material suitable for biological analysis was obtained in 80.6% of cases. The sampling sites were mainly lung/chest, liver and lymph nodes. Contrary to our study, fibroscopy was rarely used for biopsy [14]. Despite the use of different methods and populations, these studies reveal the difficulties of repeat biopsy for therapeutic management of advanced NSCLC. However, with progress in the processing of small-volume specimens and the increasing collaboration between oncologists, pathologists, pulmonologists and interventional radiologists, re-biopsy will become increasingly frequent in this setting. This will notably concern EGFR-mutated patients who progress on second-line EGFR TKIs (to identify the mechanism of progression), and also patients with an absent or incomplete molecular profile after initial biopsy. Re-biopsy can also be envisaged according to the clinical phenotype (non-smoker, young patient, adenocarcinoma, etc.) or when a patient progresses despite appropriate chemotherapy, in order to identify a driver mutation. Re-biopsy will also become more of an issue during front-line treatment as new drugs are developed, with the same difficulties as in the second-line setting. In a prospective phase II trial in patients with advanced NSCLC, focusing on feasibility and on molecular analysis-directed individualized therapy, 75 of 85 (88%) patients underwent the required biopsy, permitting gene analysis in only 55/75 (73.3%)of cases [15]. In a phase III trial in which firstline cisplatin-based chemotherapy was customized according to quantitative excision repair cross-complementing 1 mRNA expression, 78/444 (17.6%) patients went off-study because insufficient tumor tissue was obtained for ERCC1 mRNA assessment [16]. In another randomized phase III international trial in which first-line chemotherapy was chosen according to in situ RRM1 and ERCC1 protein levels in patients with advanced NSCLC, tumor re-biopsy for specific gene expression analysis was necessary in 17% of patients, 35% of whom refused. No complications occurred in the patients who accepted re-biopsy [17]. Our study has a number of limitations. Re-biopsy was decided on clinical grounds alone, the only constraint being that each center
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included all consecutive patients with an indication. This explains some characteristics of the population, and notably the high proportion (50%) of patients with mutated EGFR, and of patients with an absent or incomplete molecular profile after initial biopsy. The second limitation is the lack of relevant clinical practice guidelines in France. Yet, ensuring equal access to personalized cancer treatment is a public health requirement in France and a nationwide network offers easy access to molecular tests. Since early 2011, lung tumor samples sent to a center for EGFR mutation screening have also been screened for BRAF, KRAS, PI3KCA and HER2 mutations, as well as for the ALK gene translocation. This program enables centers to deal with the increasing complexity of testing several biomarkers in the same tumor sample and to implement these tests in their daily practice [18]. However, there are no guidelines on the indications for re-biopsy, the sampling site or the type of genetic tests to be performed, resulting in marked variability. Similarly, the lack of centralized laboratory resulted in some heterogeneity in the molecular techniques used, which may partly explain the low rate of T790M mutation found in this study (5%), compared to rates of 50–68% reported elsewhere [19]. In this pragmatic study each center use his regional platform. As we want to be in «real word setting» it’s not seems relevant to use a central lab. Another limitation is the possibility that certain changes were found, not because of dedifferentiation, but because the molecular analysis was changed in time or because different laboratory performed the first and second biopsy. 5. Conclusion This study, conducted in real-world conditions, shows that re-biopsy of NSCLC patients after first-line treatment is feasible, acceptable, and useful for therapeutic decision-making in more than one-third of cases. Guidelines are needed to clarify the indications, the sampling site, the optimal procedure, and the cost effectiveness of re-biopsy in NSCLC. Author contributions Christos Chouaid and Alain Vergnenegre had full control of the study design, data analysis and interpretation, and manuscript preparation. Cecile Dujon, Christos Chouaid and Alain Vergnenegre conceived and performed the statistical analysis, participated in the design and coordination and helped to draft the manuscript. The final draft manuscript was approved by all the authors. Presentation This study has been presented in part at the 2013 WLCC meeting in Sydney. Conflicts of interest There are no conflicts of interest.
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Acknowledgments This trial was an academic trial conducted by Groupe Franc¸ais de Pneumo-Cancérologie. This study was sponsored by an unrestricted grant from F. Hoffmann-La Roche Ltd and Boeringher Ingelheim France. References [1] Travis WD, Brambilla E, Riely GJ. New pathologic classification of lung cancer: relevance for clinical practice and clinical trials. J Clin Oncol 2013: 992–1001. [2] Ellis PM, Blais N, Soulieres D, et al. A systematic review and Canadian consensus recommendations on the use of biomarkers in the treatment of non-small cell lung cancer. J Thorac Oncol 2011;6:1379–91. [3] Peters S, Adjei AA, Gridelli C, et al. ESMO Guidelines Working Group. Metastatic non-small-cell lung cancer (NSCLC): ESMOClinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23:7:vii56-64. [4] Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;361:947–57. [5] Rosell R, Carcereny E, Gervais R, et al. Erlotinib versus standard chemotherapy as first-line treatment for European patients with advanced EGFR mutationpositive non-small-cell lung cancer (EURTAC): a multicentre, open-label, randomised phase 3 trial. Lancet Oncol 2012;13:239–46. [6] Sequist LV, Yang JC, Yamamoto N, et al. Phase III study of afatinib or cisplatin plus pemetrexed in patients with metastatic lung adenocarcinoma with EGFR mutations. J Clin Oncol 2013;31:3327–34. [7] Awad MM, Katayama R, McTigue M, et al. Acquired resistance to crizotinib from a mutation in CD74-ROS1. N Engl J Med 2013;368:2395–401. [8] Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med 2013;368: 2385–94. [9] Shaw AT, Kim DW, Mehra R, et al. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med 2014;370:1189–97. [10] Sun JF, Ahn MJ, Choi YL, et al. Clinical implications of T790M mutation in patients with acquired resistance to EGFR tyrosine kinase inhibitors. Lung Cancer 2013;82:294–8. [11] Sequist LV, Waltman BA, Dias-Santagata D, et al. Genotypic and histological evolution of lung cancers acquiring resistance to EGFR inhibitors. Sci Transl Med 2011;3:75ra26. [12] Sun JM, Ahn MJ, Choi YL, et al. Clinical implications of T790M mutation in patients with acquired resistance to EGFR tyrosine kinase inhibitors. Lung Cancer 2013;82:294–8. [13] Yoon HJ, Lee HY, Lee KS, et al. Repeat biopsy for mutational analysis of nonsmall cell lung cancers resistant to previous chemotherapy: adequacy and complications. Radiology 2012;265:939–48. [14] Yu HA, Arcila ME, Rekhtman N, et al. 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 2013;19:2240–7. [15] Simon G, Sharma A, Li X, et al. Feasibility and efficacy of molecular analysisdirected individualized therapy in advanced non-small-cell lung cancer. J Clin Oncol 2007;25:2741–6. [16] Cobo M, Isla D, Massuti B, et al. Customizing cisplatin based on quantitative excision repair cross-complementing 1 mRNA expression: a phase III trial in non-small-cell lung cancer. J Clin Oncol 2007;25:2747–54. [17] Bepler G, Williams C, Schell MJ, et al. Randomized international phase III trial of ERCC1 and RRM1 expression-based chemotherapy versus gemcitabine/carboplatin in advanced non-small-cell lung cancer. J Clin Oncol 2013;31:2404–12. [18] Barlesi F BH, Beau-Faller M, et al. Biomarkers (BM) France: Results of routine EGFR, HER2, KRAS, BRAF, PI3KCA mutations detection and EML4-ALK gene fusion assessment on the first 10,000 non-small cell lung cancer (NSCLC) patients (pts). J Clin Oncol 2013;31:abstr 8000. [19] Oxnard GR, Arcila ME, Sima CS, et al. Acquired resistance to EGFR tyrosine kinase inhibitors in EGFR-mutant lung cancer: distinct natural history of patients with tumors harboring the T790M mutation. Clin Cancer Res 2011;17: 1616–22.