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Trastuzumab Emtansine (T-DM1) in Patients with Previously Treated HER2-
Overexpressing Metastatic Non-Small Cell Lung Cancer: Efficacy, Safety and
Biomarkers
Solange Peters1, Rolf Stahel2, Lukas Bubendorf3, Philip Bonomi4, Augusto Villegas5,
Dariusz M. Kowalski6, Christina S. Baik7, Dolores Isla8, Javier De Castro Carpeno9, Pilar
Garrido10, Achim Rittmeyer11, Marcello Tiseo12, Christoph Meyenberg13, Sanne de
Haas14, Lisa H. Lam15, Michael W. Lu15, and Thomas E. Stinchcombe16
1Oncology Department, Lausanne University Hospital, Lausanne, Switzerland; 2Cancer
Center Zürich, University Hospital of Zürich, Zürich, Switzerland; 3Institute of Pathology,
University Hospital Basel, Basel, Switzerland; 4Section of Medical Oncology, Rush
University Medical Center, Chicago, IL, USA; 5Florida Cancer Specialists and Research
Institute, Fleming Island, FL, USA; 6Center of Oncology, Maria Skłodowska Curie
Memorial Cancer Centre, Warsaw, Poland; 7Seattle Cancer Center Alliance, University
of Washington, Seattle, WA, USA; 8Medical Oncology Section, Hospital Clinico
Universitario Lozano Blesa, Zaragoza, Spain; 9Medical Oncology Section, Hospital
Universitario La Paz, Madrid, Spain; 10Medical Oncology Department, Hospital
Universitario Ramon y Cajal, Madrid, Spain; 11Department of Thoracic Oncology,
Fachklinik für Lungenerkrankungen, Immenhausen, Germany; 12Medical Oncology Unit,
Azienda Ospedaliero-Universitaria di Parma, Italy; 13Biostatistics, F. Hoffmann-La
Roche, Basel, Switzerland; 14Oncology Biomarker Development, F. Hoffmann-La
Roche, Basel, Switzerland; 15Product Development Oncology, Genentech, Inc, South
San Francisco, CA, USA; 16Duke Cancer Institute, Duke University School of Medicine,
Durham, NC, USA
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Running title: T-DM1 in HER2-overexpressing metastatic NSCLC
Abbreviations: AE, adverse event; ALK, anaplastic lymphoma kinase; C, treatment
cycle; CBR, clinical benefit rate; CI, confidence interval; CNA, copy number alteration;
CR, complete response; DoR, duration of response; ECOG, Eastern Cooperative
Oncology Group; EGFR, epidermal growth factor receptor; FISH, fluorescence in situ
hybridization; FMI, Foundation Medicine, Inc.; HER, human epidermal growth factor
receptor; IHC, immunohistochemistry; ISH, in situ hybridization; T-DM1, trastuzumab
emtansine; TKI, tyrosine kinase inhibitor; NCI CTCAE, National Cancer Institute
Common Terminology Criteria for Adverse Events; ND, not done; NE, not evaluable;
NGS, next-generation sequencing; NSCLC, non-small cell lung cancer; OS, overall
survival; ORR, overall response rate; PD, progressive disease; PFS, progression-free
survival; PR, partial response; RA, rearrangement; RECIST, Response Evaluation
Criteria in Solid Tumors; SD, stable disease; SV, short variant; U, unknown HER2
amplification; UNK, unknown.
Corresponding author: Dr Solange Peters, Oncology Department, Centre Hospitalier
Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011 Lausanne, Switzerland,
Telephone: +41795560192, E-mail: [email protected]
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Disclosures
SP has received honoraria from and served as a consultant for F. Hoffmann-La
Roche/Genentech, Inc., Bristol-Myers Squibb, Novartis, Pfizer, MSD, Janssen, Amgen,
Merck Serono, Eli Lilly, Regeneron, and AstraZeneca, and she has received funding for
travel from F. Hoffmann-La Roche and Bristol-Myers Squibb.
RS has received honoraria from Astellas, AstraZeneca, Lilly, MSD, Novartis, and F.
Hoffmann-La Roche, and has served as a consultant for AbbVie, AstraZeneca, BMS,
Boehringer Ingelheim, Eli Lilly, MSD, Pfizer, and F. Hoffmann-La Roche.
LB has received honoraria from and served as a consultant for F. Hoffmann-La
Roche/Genentech, Inc., Bristol-Myers Squibb, Novartis, Pfizer, MSD, and AstraZeneca,
and he has received research support from and owns stock in F. Hoffmann-La Roche.
PB has served as a consultant for and received honoraria from F. Hoffmann-La
Roche/Genentech, Inc., AstraZeneca, Biodesix, Helsinn, Merck, and Pfizer, and his
institution has received research funding from F. Hoffmann-La Roche/Genentech, Inc.,
AstraZeneca, Biodesix, and Merck.
AV has served on speakers’ bureaus and received honoraria and funding for travel from
BMS, Celgene, and Alexion, and has served as a consultant for BMS.
CSB has served as a consultant for Novartis and received research funding from
Celgene, AstraZeneca, Novartis, Clovis, Loxo, Pfizer, and Genentech, Inc.
JDCC has served as a consultant for AstraZeneca, F. Hoffmann-La Roche, Lilly,
Boehringer Ingelheim, and MSD.
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PG has served as a consultant for F. Hoffmann-La Roche, Pfizer, Novartis, and BMS;
has served on speakers’ bureaus for MSD, BMS, and Boehringer Ingelheim; and has
received funding for travel from F. Hoffmann-La Roche, AstraZeneca, and Boehringer
Ingelheim.
AR has served as a consultant for AstraZeneca, Lilly, F. Hoffmann-La
Roche/Genentech, Inc., Boehringer Ingelheim, MSD, Pfizer, and Bristol-Myers Squibb.
MT has served as a consultant for AstraZeneca, Pfizer, Eli-Lilly, BMS, Novartis, Roche,
MSD, Boehringer Ingelheim, Otsuka, and Pierre Fabre.
CM is an employee of CRO KOEHLER-eClinical, Freiburg, Germany, which was
contracted to work on behalf of F. Hoffmann-La Roche.
SdH is a salaried employee of F. Hoffmann-La Roche.
LHL and ML are salaried employees of Genentech, Inc. and own stock in F. Hoffmann-
La Roche.
TES has served as a consultant for AstraZeneca, Takeda, and Novartis, and has
received research funding from BMS, AstraZeneca, Merck, Takeda, and Genentech,
Inc.
DMK and DI have declared no conflicts of interest.
Key words: HER2 amplification, HER2 overexpression, non-small cell lung cancer
(NSCLC), trastuzumab emtansine (T-DM1), human epidermal growth factor receptor 2
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Funding Support: This study was funded by F. Hoffmann–La Roche, Ltd.
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Translational relevance There are no standard therapies targeting human epidermal growth factor receptor 2
(HER2) in non-small cell lung cancer (NSCLC); however, HER2-targeted therapies are
standard in breast and gastric cancer. Results from this phase II study indicate a signal
of activity of the HER2-targeted antibody-drug conjugate trastuzumab emtansine (T-
DM1) in patients with immunohistochemistry 3+ HER2–positive NSCLC. T-DM1 was
tolerable in NSCLC and safety was similar to findings from prior trials. An exploratory
biomarker analysis showed that, of the four responding patients, three had HER2
amplified tumors and two had HER2 mutations. Additional investigation into HER2
oncogenic modifications, including HER2 overexpression, amplification or mutation may
help refine a patient population likely to benefit from treatment with T-DM1. Of
importance, HER2 IHC as a single parameter was an insufficient predictive biomarker to
select patients with most benefit from T-DM1. Further trials should refine the target
population for HER-2 targeted therapies in NSCLC.
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ABSTRACT
Background
HER2-targeted therapy is not standard of care for human epidermal growth factor
receptor 2 (HER2)–positive non-small cell lung cancer (NSCLC). This phase II study
investigated efficacy and safety of the HER2-targeted antibody-drug conjugate
trastuzumab emtansine (T-DM1) in patients with previously treated advanced HER2-
overexpressing NSCLC.
Methods
Eligible patients had HER2-overexpressing NSCLC (centrally-tested
immunohistochemistry [IHC]), and received previous platinum-based chemotherapy and
targeted therapy in the case of EGFR mutation or ALK gene rearrangement. Patients
were divided into cohorts based on HER2 IHC (2+, 3+). All patients received T-DM1 3.6
mg/kg intravenously every 3 weeks until disease progression or unacceptable toxicity.
The primary endpoint was investigator-determined overall response rate (ORR) using
Response Evaluation Criteria in Solid Tumors v1.1.
Results
Forty-nine patients received T-DM1 (29 IHC 2+, 20 IHC 3+). No treatment responses
were observed in the IHC 2+ cohort. Four partial responses were observed in the IHC
3+ cohort (ORR 20%; 95% confidence interval 5.7–43.7%). Clinical benefit rates were
7% and 30% in the IHC 2+ and 3+ cohorts, respectively. Response duration for the
responders was 2.9, 7.3, 8.3, and 10.8 months. Median progression-free and overall
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survival were similar between cohorts. Three of four responders had HER2 gene
amplification. No new safety signals were observed.
Discussion
T-DM1 showed a signal of activity in patients with HER2-overexpressing (IHC 3+)
advanced NSCLC. Additional investigation into HER2 pathway alterations is needed to
refine the target population for T-DM1 in NSCLC; however, HER2 IHC as a single
parameter was an insufficient predictive biomarker.
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Introduction
The development of targeted therapy for non-small cell lung cancer (NSCLC) with
specific molecular alterations such as anaplastic lymphoma kinase (ALK)
rearrangements or epidermal growth factor receptor (EGFR) mutations represents a
tremendous advance (1,2). Current research is focused on the identification and
development of targeted therapy for additional molecular subtypes. Human epidermal
growth factor receptor 2 (HER2) is overexpressed on the surface of multiple tumor cell
types, including NSCLC (35). Survival data meta-analyses show HER2 overexpression
is associated with poor prognosis in lung cancer (3,6). There are currently no standard
therapies targeting the HER2 pathway in NSCLC, whereas HER2-targeted therapies
are standard for breast and gastric cancer. In breast and gastric cancer, HER2
overexpression generally occurs in the context of gene amplification while discordance
between immunohistochemistry (IHC) overexpression and gene amplification is
observed in NSCLC (710). Instead, increased HER2 expression in NSCLC may result
from upregulated transcriptional/post-transcriptional mechanisms (7,9).
The reported prevalence of “HER2-positive” NSCLC varies since previous studies have
used different definitions and testing methods (in situ hybridization [ISH] and IHC), with
HER2 positivity defined by IHC 2+/3+ staining reported in 13–20%, IHC 3+ staining in
2–6%, and HER2 gene amplification by ISH in 2–4% (8). HER2 gene mutation, another
HER2 alteration in NSCLC, has a frequency of 1%–4% (8). HER2 gene mutations and
amplifications show limited co-occurrence in NSCLC (8,10). The absence of correlation
between HER2 overexpression, amplification, or mutation suggests three biologically
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distinct NSCLC subtypes, leaving the question of which subtypes will be most effectively
treated with HER2-targeted therapy.
Despite observation of these three alterations in NSCLC, the role of these abnormalities
as therapeutic biomarkers remains undefined. Few data sets report on the use of
HER2-targeted therapies in patients with HER2-positive (11,12) or –mutated (13–16)
NSCLC. These studies were small and some included patients treated concurrently with
chemotherapy and a HER2 targeting agent. Of note, most trials do not assess presence
of all three types of HER2 alterations, and tend to use significantly divergent definitions,
which impairs the interpretation of the predictive value of specific HER2 alterations in
NSCLC.
Trastuzumab emtansine (T-DM1) is an antibody–drug conjugate composed of
trastuzumab joined via a stable linker to DM1, a cytotoxic microtubule-inhibitory agent
(17). T-DM1 targets the delivery of DM1 to HER2-positive cancer cells, maximizing the
therapeutic index of DM1 and minimizing off-target effects. T-DM1 has been approved
for the treatment of previously-treated HER2-positive metastatic breast cancer. In
preclinical studies, T-DM1 demonstrated potent in vitro growth inhibition of HER2 IHC
3+ (Calu-3, H2170) and IHC 1+ (H1781) NSCLC cells (18). T-DM1 also showed robust
antitumor activity in Calu-3 HER2 IHC 3+ and H1781 HER2 IHC 1+ mouse xenograft
tumor models.
Altogether, this evidence provided rationale to conduct this first phase II study of T-DM1
in patients with HER2-overexpressing advanced NSCLC prior to considering a more
definitive trial and to investigate potential predictive biomarkers. Given the T-DM1
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mechanism of action, we selected patients with moderate-to-high HER2
overexpression, defined as IHC 2+ or 3+ only. Specifically, HER2 overexpression can
occur due to increased HER2 transcription, independent of HER2 gene amplification or
mutation (710). To date, there are no clinical data suggesting T-DM1, in contrast to
trastuzumab or a HER2 tyrosine kinase inhibitor (TKI), would have a stronger effect in
HER2-mutated or HER2-amplified NSCLC. While amplification and mutations are
considered potential driver oncogenes, we hypothesize that targeting HER2
overexpression will address a potentially larger patient population that may be more
relevant taking into account the mechanism of action of T-DM1, targeting the HER2
extracellular component.
Methods
Study design and patients
In this multicenter, single-arm, clinical trial (trial registration NCT02289833), eligible
patients were aged ≥18 years with HER2-positive (IHC 2+ or 3+) locally advanced or
metastatic NSCLC previously treated with ≥1 prior platinum-based chemotherapeutic
regimen. Patients with EGFR mutated or ALK gene rearranged NSCLC were eligible if
they had also experienced disease progression following treatment with prior targeted
therapy or if they were intolerant to such treatment.
Archived tumor specimens from previously collected tissue were centrally and
prospectively tested for HER2 status (Ventana Pathway HER2 (4B5) IHC assay;
Ventana Medical Systems, Inc., Tucson, AZ, USA). HER2 overexpression was
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evaluated by IHC, the gold standard for HER2 assessment in breast and gastric cancer.
If archival tissue was unavailable for HER2 testing, patients could have a newly
collected biopsy specimen tested. Based on results from central testing, patients with a
HER2 status of IHC 2+ (defined as weak-to-moderate complete, basolateral, or lateral
membranous reactivity in ≥10% of tumor cells) or IHC 3+ (defined as strong complete,
basolateral, or lateral membranous reactivity in ≥10% of tumor cells) were eligible.
A retrospective exploratory biomarker analysis was conducted if sufficient tissue was
available following IHC testing. In this analysis, HER2 gene amplification (HER2/CEP17
gene ratio ≥2) was also assessed by ISH (similar to breast and gastric cancers). HER2
mRNA expression levels were measured by quantitative reverse transcriptase
polymerase chain reaction (Roche Molecular Diagnostics, Pleasanton, CA, USA) and
evaluated in subgroups defined using the median mRNA expression distribution values
(>median versus ≤median). Pending tissue availability, HER2 mutation status and
amplification was also assessed using next-generation sequencing (NGS; Foundation
Medicine Inc., Cambridge, MA, USA), where amplification was defined by copy number
≥5 in a diploid model.
Eligible patients also had an Eastern Cooperative Oncology Group (ECOG)
performance status of 0 or 1, measurable disease (per Response Evaluation Criteria in
Solid Tumours [RECIST] v1.1), adequate organ function, and left ventricular ejection
fraction ≥50% (echocardiogram or multiple-gated acquisition scan). Patients with
untreated or symptomatic brain metastases (baseline brain imaging required but repeat
imaging was not required), or who had received anticancer or investigational therapy
within 21 days of the start of study treatment were excluded.
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Procedures
Patients were able to enroll in the screening portion of the trial and underwent IHC
testing prior to disease progression on current therapy to determine if they were
potentially eligible for the trial. Eligible patients were subdivided according to HER2 IHC
status (2+ or 3+). Over-enrollment was allowed to the IHC 2+ cohort to accommodate
patients who had initiated the screening process and met the eligibility criteria. All
patients received T-DM1 (3.6 mg/kg intravenously every 3 weeks) until investigator-
assessed disease progression, unmanageable toxicity, or study termination. Survival
status was assessed every 3 months following discontinuation due to disease
progression. Tumor assessments by radiographic evaluation were performed every 6
weeks.
The trial protocol was approved by the institutional review boards at each participating
center. The study was conducted in accordance with the Declaration of Helsinki, Good
Clinical Practice guidelines, and applicable local laws. All patients provided written
informed consent.
Outcomes
The primary efficacy endpoint was confirmed investigator-assessed objective response
rate (ORR) using RECIST v1.1, defined as a complete response (CR) or partial
response (PR) determined on two consecutive assessments ≥4 weeks apart (19).
Secondary endpoints were investigator-assessed progression-free survival (PFS),
duration of response (DoR; time from initial documented response to documented
disease progression or death from any cause), clinical benefit rate (CBR; proportion of
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patients with CR or PR or stable disease [SD] determined by the investigator at 6
months), overall survival (OS), and safety. Patients were monitored continuously for
adverse events (AEs).
Statistical analysis
The primary efficacy objective was investigator-assessed ORR. Given the exploratory
nature of this study, a sample size of 20 patients per cohort was selected to estimate
two-sided 95% Clopper-Pearson confidence intervals (CIs) for ORR in each cohort and
overall. The data cutoff for the ORR analysis occurred when all enrolled patients were
expected to have completed ≥ 4.5 months of follow-up (when three post-baseline tumor
assessments were expected to be performed). Efficacy and safety were evaluated in
patients who received ≥1 dose of T-DM1. DoR and Kaplan–Meier estimates of PFS and
OS are reported for all evaluable patients and separately for the two IHC cohorts. For
PFS and DoR, data for patients without disease progression or death were censored at
the time of the last tumor assessment. For OS, data from patients without a death event
were censored on the date last known to be alive. Exploratory biomarker data were
analyzed using descriptive statistics.
Safety was assessed through summaries of AEs, deaths, and changes in laboratory
results. All AEs occurring on or after first study treatment were summarized by mapped
term, appropriate thesaurus levels, and National Cancer Institute Common Terminology
Criteria for Adverse Events (NCI CTCAE) v4.0 toxicity grade. Serious AEs were listed
separately and summarized.
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Results
Study population
Of 370 screened patients, 133 had IHC 2+ or 3+ tumors (Figure S1). Of these, 49
patients from five centers in the USA and 13 European centers were eligible and
enrolled between December 15, 2014 and June 21, 2016; the remaining 84 patients did
not meet eligibility criteria or elected for alternative treatment. Of the 49 enrolled
patients, HER2 status was based on archival samples for 41 patients and freshly
obtained samples (collected within 8 weeks before start of study treatment) for 6
patients; the sample collection date was unknown for 2 patients. Median age was 61
years (range, 36–80), and the majority of patients were male, previous smokers, and
had adenocarcinoma (Table 1). All but one patient previously received platinum-based
chemotherapy (98%; 48/49); information on prior and follow-up treatments is shown in
Table S1. The IHC 2+ cohort was over-enrolled and included 29 patients and the IHC
3+ cohort included 20 patients.
At the cutoff date (May 29, 2017), 15/49 (31%) patients remained on study for survival
follow-up and one in the IHC 3+ cohort remained on treatment; three were lost to follow-
up, 30 died (29 due to disease progression; one died of an unknown cause as reported
in death registry records), and one discontinued the study due to clinical progression.
Efficacy
Median follow-up was 23.1 months (range, 0.9–26.7) and 18.4 months (1.0–25.1) in the
IHC 2+ and 3+ cohorts, respectively. In the IHC 2+ cohort, there were no treatment
responses; 8/29 (28%) patients had SD, 16/29 (55%) had progressive disease (PD),
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and response was not evaluable for 5/29 (17%) (Figure 1A and 1B). In the IHC 3+
cohort, ORR was 20% (95% CI 5.7–43.7%); 4/20 (20%) patients had a PR, 4/20 (20%)
had SD, 11/20 (55%) had PD, and one (5%) died prior to first scheduled tumor
assessment (response missing) (Figure 1C). CBR was 7% (2/29, 95% CI 1–23%) and
30% (6/20; 95% CI 12–54%) in the IHC 2+ and 3+ cohorts, respectively. DoR for the
four IHC 3+ responders was 2.9, 7.3, 8.3, and 10.8 months (censored for one patient
still on treatment; Figure 1D).
In the IHC 2+ and 3+ cohorts, median PFS was 2.6 months (95% CI 1.4–2.8) and 2.7
months (95% CI 1.4–8.3), respectively; median OS was 12.2 months (95% CI 3.8–23.3)
and 15.3 months (95% CI 4.1–NE), respectively (Figure 2).
Safety
Median duration of T-DM1 treatment was 3.6 months (range, 0–24.8 months) (Figure
S2). AEs, regardless of causality or attribution, are reported (Table 2). Forty-five
patients (92%) reported an AE (any grade). Ten patients reported Grade 3 AEs
(regardless of relationship to treatment), and fatigue (n=2) was the only Grade 3 AE
reported in more than one patient. One Grade 4 seizure was reported in a patient with
prior history of brain metastases receiving concurrent treatment for seizures. There
were no deaths due to AEs. Two patients withdrew from study treatment due to AEs
(Grade 2 infusion-related reaction and Grade 3 influenza). Of AEs of particular interest
in T-DM1-treated patients, one event each of Grade 3 thrombocytopenia and infusion-
related reaction/hypersensitivity occurred.
Exploratory biomarker analysis
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All responding patients were in the IHC 3+ cohort (Table 3). A higher proportion of IHC
3+ patients had HER2-amplified tumors, higher HER2 gene copy number, and HER2
mRNA expression >median compared with the IHC 2+ cohort.
Biomarker characteristics of the responders and those with SD >6 months are shown in
Table 4. Of four responding patients, three had HER2 amplified tumors (ISH,
HER2/CEP17 gene ratio ≥2). Three responders had central NGS data; two of these
patients had HER2 amplification (NGS, copy number ≥5; Tables 3 and 4). The other
responder had locally-determined NGS results (same platform used for central
assessment) showing an equivocal test result for HER2 amplification. Two responders
had HER2 mutations including one HER2 gene rearrangement (unknown functional
status).
A heatmap of the top 20 genetic alterations found across all patients was prepared for
those with central NGS results (n=24, Figure S3). Of these 24 patients, HER2 mutations
were detected in four patients (no responders) and HER2 amplification was detected in
five patients (2 responders).
Discussion
In NSCLC, activation of HER2 occurs through various mechanisms including protein
overexpression, gene amplification, or mutation, and is considered an oncogenic driver.
In our study of T-DM1 in patients with HER2-overexpressing advanced NSCLC,
objective responses were observed in patients with IHC 3+ tumors. No responses were
observed in the IHC 2+ cohort, regardless of HER2 amplification status. However, four
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additional patients achieved SD >6 months, resulting in CBRs of 7% and 30% in the
IHC 2+ and 3+ cohorts, respectively.
Several small studies have also investigated the use of HER2-targeted therapies in lung
cancer (Table S2). A phase II trial investigated treatment with T-DM1 in NSCLC
characterized by overexpressed, amplified or mutated HER2 and was stopped early due
to limited efficacy (20). Among 15 patients with HER2-positive NSCLC treated with T-
DM1 (five IHC 3+, three IHC 2+/FISH positive, seven with HER2 mutations), there was
only one partial response in a patient with HER2 mutation (ORR 6.7%; 90% CI 0.2–
32.0%). The small number of patients enrolled in the trial, and in the various molecular
subsets limits the interpretation of these results. Analyses from the NCT02675829
basket trial further support the potential role of TDM-1 in advanced NSCLC
characterized by HER2 oncogenic alterations. This trial investigates efficacy of T-DM1
in various HER2-amplified solid tumors and HER2 mutant lung cancers (21,22). In the
cohort of patients with advanced HER2-mutant lung adenocarcinoma, ORR was 44%
(8/18; 95% CI 22–69%), median PFS was 5 months (95% CI 3 to 9 months), and
median DoR was 4 months (95% CI 2 to 9 months). In the cohort of patients with HER2-
amplified advanced lung cancer ORR was 50% (3/6) (22).
Other limited datasets have reported activity of HER2-targeted therapy in NSCLC. In a
retrospective analysis of patients with a HER2-mutation who received 22 individual anti-
HER2 treatments, there were 11 partial responses, leading to an ORR of 50% (11/22)
(13). The MyPathway basket trial (NCT02091141) is evaluating dual inhibition of the
HER2 pathway with pertuzumab plus trastuzumab in patients with HER2-
overexpressing, -amplified, or -mutated tumors, including lung cancer (23). Based on
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interim data for NSCLC, ORR was 13% (2/16; 95% CI 2–38%) in the HER2-amplified
cohort and 21% (3/14; 95% CI 5–51%) in the HER2-mutated cohort.
In a phase II study, patients with HER2-mutant or HER2-amplified lung cancer received
treatment with dacomitinib, a pan-HER TKI, and the ORR was 12% (3/26; 95% CI, 2–
30%) for HER2-mutant disease and 0% (0/4; 95% CI, 0–60%) for HER2-amplified
disease (14). Neratinib, another pan-HER TKI, has been investigated in HER2 mutated
lung cancer. In a cohort of 26 lung cancer patients with HER2 or HER3 mutations from
the phase II SUMMIT basket trial, only 1 patient with a HER2 exon 20 mutation (L755S)
achieved a response (ORR 3.8% at 8 weeks)(24). Median progression-free survival was
5.5 months. A phase I study of neratinib plus temsirolimus, a mammalian target of
rapamycin inhibitor, observed responses in 2 of 7 patients with HER2 mutated NSCLC;
however, this was at the cost of significant treatment-related toxicity (25). Pyrotinib, a
TKI targeting HER1 and HER2 receptors, has also been studied, and preliminary results
from a phase II study found on ORR of 55% (6/11) among patients with previously-
treated HER2 mutant advanced NSCLC (26). Studies of afatinib, an ErbB family
blocker, have showed varied results. In a phase II study of patients with heavily
pretreated lung adenocarcinoma, a cohort of 7 patients with HER2 mutation received
afatinib monotherapy and none experienced an objective response (27). Another phase
II study of afatinib demonstrated an ORR of 7.7% (1/13) among pretreated patients with
NSCLC harboring HER2 exon 20 mutations (28). Finally, a retrospective review of
patients with metastatic HER2-mutant lung cancer treated with afatinib from 7
institutions found an ORR of 11% (3/27) (29). Of note, a study investigating response to
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immune checkpoint blockade (ICB) in HER2 mutated advanced lung cancer found an
ORR of 12% (3/26) and a median PFS of 1.9 months (95% CI 1.5-4.0) (30).
Whereas data suggest a potential role for HER2-targeted therapy in NSCLC, further
investigation of HER2 as a biological target in NSCLC is needed. The relationship
between the distinct, and probably independent, features of HER2 activation, related
biomarkers, and response to treatment needs further elucidation. For example, in our
study, all responders had IHC 3+ tumors, three had HER2 amplification (by ISH and
NGS), and two had HER2 gene mutations. By contrast, none of the eight responders to
T-DM1 in the HER2-mutant cohort of the NCT02675829 basket trial had HER2 levels
beyond IHC 2+, but one patient had HER2 amplification (21). Activity of T-DM1 in the
context of HER2 mutations remains to be biologically elucidated (21) and, given co-
occurring HER2 amplification and mutation in the majority of responders and the small
number of responders in our trial, we do not have sufficient sample size to assess for a
potential interaction between the molecular alterations. We used IHC to identify patients
with intermediate to high HER2 protein levels, as IHC is the standard assay used in
indications where HER2 targeted therapy is established. HER2 mRNA levels were
assessed as part of the exploratory biomarker evaluation, however, this did not identify
a cutoff to identify patients who responded to T-DM1. Of the 4 responders, only 1
patient had HER2 mRNA levels above the median HER2 mRNA level (Table 3). . HER2
IHC alone is insufficient as a predictive biomarker and identification of additional
biomarkers is required.
Our study has a few limitations. We did not test a predetermined response rate since
this was an exploratory study to obtain preliminary efficacy data and investigate
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potential biomarkers for further rationale for development in this rare subset of NSCLC.
Higher patient numbers might be needed to provide clarity on potential relationships
between different HER2 biomarkers and response. Additionally, only 49 of 133
prescreened patients with IHC 2+ or 3+ tumors were enrolled and started treatment with
T-DM. Prescreening was allowed while patients were still on other therapy, and, at the
time of disease progression, patients may have no longer met all eligibility criteria or
may have elected for alternative treatment. As some sites screened patients for HER2
status prior to the central laboratory assessment, the prevalence of IHC 2+ and IHC 3+
NSCLC is likely higher than an actual population-based prevalence of HER2 IHC
overexpression. In our study, most tissue came from the archival specimen (41/49;
84%). The absence of mandatory re-biopsy at study entry is a weakness – adopted for
practical reasons – given that HER2 status at diagnosis and study entry may
theoretically vary under selective pressure of treatments and tumor evolution, while the
majority of patient tumor samples came from primary tumors. HER2 amplification has
been hypothesized as a resistance mechanism with EGFR TKIs (31,32), indicating
potential changes in HER2 status following treatment with EGFR TKIs. While data from
NSCLC showing loss of HER2 overexpression are not available, this cannot be
excluded. Sufficient tissue was available for evaluation of all mandatory biomarkers,
however, our biomarker analyses were limited by sample availability. Where possible,
we collected data on EGFR and ALK based on local testing; while broader NGS testing
for other molecular alterations is not routinely performed and was available for selected
patients (Figure S3). Finally, further dedicated studies would be strengthened by
independent radiologic review.
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In summary, our study indicates activity of T-DM1 in selected patients with IHC 3+
HER2-positive metastatic NSCLC. The safety profile of T-DM1 was similar to findings
from prior T-DM1 clinical trials and showed that T-DM1 was also tolerable in NSCLC.
Additional investigation into HER2 signaling pathway oncogenic modifications, including
HER2 overexpression, amplification or mutation, may help to refine a patient population
more likely to benefit from treatment with T-DM1. Of importance, HER2 IHC – used as a
single parameter – was an insufficient predictive biomarker for T-DM1 activity. Further
trials are needed to refine the target population for T-DM1 as well as for other HER2
directed therapies in NSCLC.
Acknowledgements
The authors would like to thank all the patients who participated in the trial and their
families, as well as the participating study sites.
The authors are grateful for the assistance of Sven Stanzel of F. Hoffmann-La Roche,
Ltd., Yvonne G. Lin, Alan Sandler, and David Chen of Genentech, Inc.
This study was funded by F. Hoffmann La-Roche, Ltd., Basel, Switzerland. Support for
third-party writing assistance was provided by Meredith Kalish, MD, of CodonMedical,
an Ashfield Company, part of UDG Healthcare plc, and was funded by F. Hoffmann-La
Roche.
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Tables
Table 1. Patient baseline and exploratory biomarker characteristics
IHC 2+
(n=29)
IHC 3+
(n=20)
All patients
(N=49)
Baseline characteristics
Median age, years (range) 61 (36–80) 61 (40–75) 61 (36–80)
Sex, n
Male
Female
16
13
13
7
29
20
Smoking status, n
Current
Previous
Never
6
16
7
4
13
3
10
29
10
ECOG performance status, n
0
1
7
22
5
15
12
37
Stage of disease, n
Metastatic disease
Locally advanced
29
0
19
1
48
1
Histology, n
Squamous 2 1 3
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Adenocarcinomaa 20 17 37
Undifferentiated/poorly
differentiated
3 2 5
Unknown 4 0 4
Prior lines of therapy, n
Any
1
2
≥3
Neoadjuvant/adjuvant
29
7
10
11
1
20
6
7
6
1
49
13
17
17
2
CNS metastases at baseline, n
Yes 3 1 4
No 26 19 45
ALK rearrangement, nb
Present
Not present/not done/not
evaluable
0
29
1
19
1
48
EGFR status, nb
Exon 19 deletion
Exon 20 T790M mutation
Exon 20 insertion
Other (including wild type/not
done/not evaluable)
0
1
3
25
1
0
1
18
1
1
4
43
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HER2 mutation status, nb
A775_G776insYVMA
G776_V777>VCV
Not done/not evaluable/not
reported
2
0
27
0
1
19
2
1
46
Exploratory biomarker
characteristics
ISH HER2 amplification status, n
Non-amplified, gene ratio <2c
Amplified, gene ratio ≥2c
Missingd
17
5
7
9
11
0
26
16
7
HER2 gene copy number, n
<4
4 to <6
≥6
Missingd
12
8
2
7
6
5
9
0
18
13
11
7
HER2 mRNA expression, ne
≤Median
>Median
Missingd
14
9
6
8
12
0
22
21
6
ECOG, Eastern Cooperative Oncology Group; HER, human epidermal growth factors
receptor; IHC, immunohistochemistry.
aIncludes one patient from the IHC 2+ group with lepidic predominant adenocarcinoma.
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bEGFR, ALK, and HER2 mutations are derived from local assessment.
cHER2 gene ratio represents the HER2 gene/centromere 17 ratio. HER2 amplification
(ISH) defined as HER2/CEP17 gene ratio ≥2.
dMissing values due to lack of sufficient sample, sample quality, and/or assay failure.
eMedian HER mRNA level was 7.26.
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Table 2. Safety summary
Summary of adverse
events
na
Any grade adverse event 45
Grade 3b 10
Grade 4c 1
Grade 5 0
Adverse events leading to
withdrawald
2
Selected adverse events
in patients with at least
one adverse evente
Grade 1–2, na Grade 3–5, na
Hemorrhage 7 0
Infusion-related reaction/
hypersensitivity
6 1
Peripheral neuropathy 7 0
Thrombocytopenia 4 1
Hepatotoxicity 5 0
Cardiac dysfunction 2 0
Pulmonary toxicity 0 0
an represents the number of patients with an adverse event, patients may have
experienced more than one adverse event.
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bThe only Grade 3 adverse events occurring in more than one patient was fatigue (n=2).
The other Grade 3 adverse events observed were: abdominal pain, anemia, bronchitis,
confusional state, decreased appetite, diarrhea, dyspnea, hyperglycemia, hypertension,
infusion-related reaction, lung infection, nausea, platelet count decreased, pneumonia,
pulmonary embolism, tumor pain (each Grade 3 adverse events reported in one
patient).
cGrade 4 adverse event was a seizure.
dWithdrawal due to adverse events was due to a Grade 2 infusion-related reaction and
Grade 3 influenza.
eEvents for selected adverse events are consistent with the United States Prescribing
Information for trastuzumab emtansine. Adverse events classified by National Cancer
Institute Common Terminology Criteria for Adverse Events grade for safety-evaluable
patients (all patients who received ≥1 dose of T-DM1). Multiple occurrences of the same
adverse event in one individual are counted once at the highest grade for this patient.
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Table 3. Responders categorized by HER2 ISH, NGS, and HER2 mRNA results
IHC 2+
responder/total
(n/N)
IHC 3+
responder/total
(n/N)
All patients
responder/total
(n/N)
Responders 0/29 4/20 4/49
ISH result, na 0/22 4/20 4/42
HER2 not amplified 0/17 1/9 1/26
HER2 amplified 0/5 3/11 3/16
Missingb 7 0 7
NGS resultc
HER2 not amplified
HER2 amplified
Missing
0/12
0/12
0/0
17
3/12
1/7
2/5
8
3/24
1/19
2/5
25
HER2 mRNAd
≤Median
>Median
Missing
0/23
0/14
0/9
6
4/20
3/8
1/12
0
4/43
3/22
1/21
6
IHC, immunohistochemistry; ISH, in situ hybridization; NGS, next generation
sequencing (Foundation Medicine).
aHER2 gene amplification was defined as HER2/CEP17 gene ratio ≥2.
bMissing data due to lack of sufficient sample, sample quality, and/or unreadable assay.
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cOnly 24 samples available for Foundation Medicine analysis due to insufficient sample
and/or sample quality. HER2 amplification was defined by copy number ≥5 in a diploid
model.
dHER2 mRNA values are missing for six patients, due to insufficient sample or assay
failure. HER2 mRNA expression levels were evaluated in subgroups defined using the
median distribution values for mRNA expression (>median versus ≤median). Median
HER2 mRNA level was 7.26.
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Table 4. Exploratory biomarker characteristics for patients with a clinical benefit: Clinical response (CR or PR) or
prolonged SD (>6 months)
Patients with clinical response (CR or PR) Patients with SD >6 months
Demography 67 years, male,
white, 87 kg,
ECOG 1
56 years, female,
white, 79.5 kg,
ECOG 1
66 years, female,
white, 60 kg,
ECOG 0
60 years, male,
white, 71 kg,
ECOG 0
74 years, female,
white, 65 kg,
ECOG 0
36 years, male,
Black or African
American, 122 kg,
ECOG 1
52 years, male,
white, 99 kg,
ECOG 1
56 years, female,
white, 65 kg,
ECOG 1
NSCLC
histology
Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma Adenocarcinoma
Sample
source
Archival Fresha Archival Archival Archival Archival Archival Archival
Biomarkers
HER2
IHC 3+
(15% staining)
3+
(75% staining)
3+
(100% staining)
3+
(60% staining)
2+
(30% staining)
2+
(40% staining)
3+
(90% staining)
3+
(35% staining)
ISH status
(ratio)b
Negative (<2) Positive (≥2 and
<4)
Positive (≥4) Positive (≥2
and <4)
Unknown Unknown Positive (≥4) Negative (<2)
ISH gene
copy number
3.55 4.45 20.0 6.53 Unknown Unknown 20.50 4.95
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NGS (HER2)
HER2
amplification
by central
FMIc (copy
number)
Nonamplified ND Amplified (145) Amplified (8) ND
ND Amplified (59)
ND
HER2
mutation by
central FMI
None ND HER2 gene
rearrangement
(unknown
functional
status)
None ND
ND None ND
HER2
mutation by
local NGS
ND G776_V777>VC ND ND ND A775_G776insYVMA ND ND
ALK No RA No RA No RA No RA No RA No RA No RA ND
EGFR ND Negative ND Exon 19 deletion ND Negative Negative Exon 20 insertion
DoR
(months)
2.9 7.3 10.8+ 8.3 NA NA NA NA
PFS
(months)
8.3 8.5 12.2+ 9.6 27.5 9.5 11.2 18.7
OS (months) 18.4+ 20.2+ 12.9+ 21.6+ 27.5+ 18.4 17.1+ 25.1+
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Date of
confirmed
response
C11 C5 C5 C5 N/A N/A N/A N/A
Prior cancer
treatments
Carboplatin +
pemetrexed +
vinorelbine
Cisplatin +
pemetrexed
Bevacizumab
+ carboplatin
+ paclitaxel
Bevacizumab
Afatinib
Carboplatin +
vinorelbine
Carboplatin
Erlotinibd Cisplatin/
vinorelbine
Bevacizumab +
carboplatin +
onartuzumab/
placebo
(blinded) +
paclitaxel
Bevacizumab +
onartuzumab/
placebo
(blinded)
Docetaxel +
selumetinib/
placebo
(blinded)
Erlotinib
Bevacizumab +
carboplatin +
pemetrexed
Docetaxel
Paclitaxel
Carboplatin +
pemetrexed
AMP-514 +
durvalumab
Carboplatin +
vinorelbine
Docetaxel
Follow-up
treatments
Nivolumab Nivolumab Still on treatment
(finished C19 in
May 2017)
Unknown Unknown Afatinib,
ipilimumab,
nivolumab,
vinorelbine
Cyclophosphamide,
fludarabine,
investigational
CAR-T cell therapy
Cisplatin +
vinorelbine
C, treatment cycle; CR, complete response; DoR, duration of response; ECOG, Eastern Cooperative Oncology Group;
FMI, Foundation Medicine, Inc; NGS, next generation sequencing (Foundation Medicine): NSCLC, non-small cell lung
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cancer; OS, overall survival; PFS, progression-free survival; PR, partial response; RA, rearrangement; N/A, not
applicable; ND, not done; SD, stable disease.
+ denoted a censored observation.
aSample was considered fresh if obtained within 8 weeks before start of study treatment.
bHER2 gene amplification was defined as positive based on HER2/CEP17 gene ratio ≥2.
cHER2 amplification defined as positive based on a copy number ≥5 in a diploid model by NGS.
dPatient was not treated with prior platinum therapy (protocol violation).
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Figure Legends
Figure 1. Investigator-assessed treatment response and change from baseline
tumor size over time
Best treatment response and change from baseline in tumor size for the IHC 2+ cohort
(A, B); best treatment response and change from baseline in tumor size for the IHC 3+
cohort (C, D).
CI, confidence interval; IHC, immunohistochemistry; NE, not evaluable/missing; ORR,
objective response rate; PD, progressive disease; PR, partial response; SD, stable
disease; U, unknown HER2 amplification.
*Indicates positive HER2 amplification. The ISH status of all other patients is negative.
Figure 2. Kaplan–Meier analysis of investigator-assessed PFS (A) and OS (B)
(A) Final descriptive Kaplan–Meier estimates of progression-free survival (PFS) in all
patients as well as stratified by IHC 2+ and IHC 3+. All patients were treated with
trastuzumab emtansine (T-DM1). PFS was defined as the time from first study
treatment to first documented disease progression or death from any cause. PFS data
for patients without disease progression or death was censored at the time of last tumor
assessment.
(B) Descriptive Kaplan–Meier estimates of overall survival (OS) by all patients as well
as categorized by IHC 2+ and IHC 3+. OS was defined as the time from first study
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treatment to death from any cause. Patients without a death event were censored on
the date the patient was last known to be alive.
IHC, immunohistochemistry; NE, not estimable.
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D.150
100
50
0
Chan
ge fr
om b
asel
ine
tum
or s
ize
(%)
–50
–1000 3 96 12 15
Study month of tumor measurement 18
IHC 3+
PRSDPDNE
100
75
50
25
0
Chan
ge in
dia
met
er fr
om b
asel
ine
(%)
–25
–50
–75
–100
Patient
IHC 3+ORR=20% (95% CI 5.7–43.7)
1 2 3
*
4 5
*
6 7 8
*
9
*
10
*
11
*
12
*
13
*
14 15 16
*
17
*
18*
19
C.
B.150
100
50
0
Chan
ge fr
om b
asel
ine
tum
or s
ize
(%)
–50
–1000 3 6 9 12
Study month of tumor measurement 15 18 21 24 27
IHC 2+
* U
PRSDPDNE
100
75
50
25
0
Chan
ge in
dia
met
er fr
om b
asel
ine
(%)
–25
–50
–75
–100
*
PRSDPDNE
PRSDPDNE
* U U U * U
Patient
IHC 2+ORR=0% (95% CI 0.0–11.9)
A.
Figure 1
* * UU
1 3 5 7 9 11 13 15 17 19 21 23 23 27 29
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100
IHC 2+ (n=29)IHC 3+ (n=20)All patients (N=49)Censored
Median time to Patients with OS event, IHC status OS event, n (%) months (95% CI)IHC 2+ 20 (69) 12.2 (3.8–23.3)IHC 3+ 10 (50) 15.3 (4.1–NE)All patients 30 (61) 12.2 (4.7–23.6)
80
60
40
Ove
rall
surv
ival
(%)
20
00 3 6 9 12 15 18 21 24
Time (months)27
292049
IHC 2+IHC 3+All patients
No. patients at risk211637
281947
251742
161430
191534
171431
151227
161430
151328
141024
151126
141024
128
20
128
20
128
20
106
16
127
19
117
18
639
84
12
84
12
325
628
628
1
1
112
1
1
100
IHC 2+ (n=29)IHC 3+ (n=20)All patients (N=49)Censored
Median time to Patients with PFS event, IHC status PFS event, n (%) months (95% CI)IHC 2+ 29 (100) 2.6 (1.4–2.8)IHC 3+ 19 (95) 2.7 (1.4–8.3)All patients 48 (98) 2.6 (1.4–2.8)
80
60
40
Prog
ress
ion-
free
sur
viva
l (%
)
20
00 3 6 9 12 15 18 21 24
Time (months)27
292049
IHC 2+IHC 3+All patients
No. patients at risk68
14
271946
161228
46
10
68
14
68
14
246
369
268
123
134
134
112
112
112
112
112
112
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
A.Figure 2
B.
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Published OnlineFirst September 11, 2018.Clin Cancer Res Solange Peters, Rolf A. Stahel, Lukas Bubendorf, et al. Cancer: Efficacy, Safety and BiomarkersTreated HER2-Overexpressing Metastatic Non-Small Cell Lung Trastuzumab Emtansine (T-DM1) in Patients with Previously
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