Abstract
Compound EGFR mutations, defined as double or multiple mutations in the EGFR tyrosine kinase domain, are frequently detected with advances in sequencing technology but its clinical significance is unclear. This study analyzed 61 cases of EGFR mutation positive lung adenocarcinoma using next-generation sequencing (NGS) based repeated deep sequencing panel of 16 genes that contain actionable mutations and investigated clinical implication of compound EGFR mutations. Compound EGFR mutation was detected in 15 (24.6%) of 61 cases of EGFR mutation-positive lung adenocarcinoma. The majority (12/15) of compound mutations are combination of the atypical mutation and typical mutations such as exon19 deletion, L858R or G719X substitutions, or exon 20 insertion whereas 3 were combinations of rare atypical mutations. The patients with compound mutation showed shorter overall survival than those with simple mutations (83.7 vs. 72.8 mo; P = 0.020, Breslow test). Among the 115 missense mutations discovered in the tested genes, a few number of actionable mutations were detected irrelevant to the subtype of EGFR mutations, including ALK rearrangement, BCL2L11 intron 2 deletion, KRAS c.35G>A, PIK3CA c.1633G>A which are possible target of crizotinib, BH3 mimetics, MEK inhibitors, and PI3K-tyrosine kinase inhibitors, respectively. 31 missense mutations were detected in the cases with simple mutations whereas 84 in those with compound mutation, showing that the cases with compound missense mutation have higher burden of missense mutations (P = 0.001, independent sample t-test). Compound EGFR mutations are detected at a high frequency using NGS-based repeated deep sequencing. Because patients with compound EGFR mutations showed poor clinical outcomes, they should be closely monitored during follow-up.
Keywords: Compound EGFR mutation, co-mutation, EGFR, lung adenocarcinoma, NGS, repeated deep sequencing, simple EGFR mutation
Abbreviations
- DFS
disease-free survival
- NGS
next-generation sequencing
- NSCLC
non-small cell lung cancer
- OS
overall survival
- PFS
progression-free survival
- TKD
tyrosine kinase domain
- TKI
tyrosine kinase inhibitors.
Introduction
Despite relentless efforts to decrease the mortality of lung cancer, it remains a common and leading cause of cancer-related death worldwide. In the year 2012, 1,824,701 new cases were identified and 1,590,000 patients died of lung cancer worldwide (WHO annual report). During the same period, 21,753 new Korean cases were diagnosed and 16,654 Korean patients died of this devastating disease.1
Oncogenic driver mutations include multiple types of genomic changes that are critical for cancer development and maintenance. The identification of actionable oncogenic driver mutations that guide selection of appropriate target agents has improved clinical outcomes of lung cancer patients by incorporating tumor genotyping into therapeutic decision making.2
Activating EGFR mutations are more frequently identified in lung adenocarcinoma in East Asian patients than in other populations, and advances in tumor genotyping facilitate discovery of such mutations in small population samples.3-6 The most common type of EGFR mutation is in-frame deletion of exon 19 (E19del) around the LREA motif (amino acid residues 747 to 750; ∼45% of EGFR mutations), followed by L858R point mutation of exon 21 (∼40% of EGFR mutations).7-9 Tumors with these activating EGFR mutations or less frequent mutations, such as point mutations in exon 18 at position G719 (∼3% of EGFR mutations) and the exon 21 L861Q mutant (∼2% of EGFR mutations), show sensitivity to EGFR-tyrosine kinase inhibitors (TKIs).10-12 On the other hand, in-frame insertion mutations within exon 20 of EGFR, which account for 4∼10% of all EGFR mutations, and other rare mutations including L747S, D761Y, T790M, and T854A confer resistance to EGFR-TKIs.11,13-15
With the clinical application of more sensitive and precise tumor genotyping systems, rare EGFR mutations of unknown biological and clinical significance are frequently encountered in routine clinical practice.14,15 Different responses to EGFR-TKI are reported even for mutations at the same approximate location within the genomic DNA. For example, among the in-frame insertions within EGFR exon 20, which were originally considered EGFR-TKI resistance mutations with a low response rate (<5%) and short interval of disease control, A763_Y764insFQEA is now reported to be a sensitizing mutation to EGFR-TKI.14,15 These findings indicate that more attention and collaborative efforts are required to elucidate the biological and clinical significance of these rare compound mutations.
Compound EGFR mutations are defined as double or multiple independent mutations of the EGFR tyrosine kinase domain (TKD), in which an EGFR-TKI-sensitizing or other mutation is identified together with a mutation of unclarified clinical significance.16 Recent advances in tumor genotyping techniques provide not only accurate data, but also a higher probability of identifying atypical and multiple mutations in the EGFR-TKD in a single sample. Kobayashi et al. reported compound EGFR mutations in which an EGFR-TKI-sensitizing mutation (such as G719X, E19del, L858R, or L861Q) coexists with uncommon mutations involving other residues of the EGFR-TKD and show some sensitivity to EGFR-TKI. In EGFR mutant non-small cell lung cancer (NSCLC), double mutations in EGFR were detected in 14∼18% of cases using Sanger method based sequencing techniques, but their biologic behavior and clinical significance have not been well characterized.16,17
In this study, we identified EGFR compound mutations in lung adenocarcinomas from patients who underwent surgical curative resection using next-generation sequencing (NGS)-based repeated deep sequencing of EGFR together with 15 other genes containing actionable oncogenic mutations. This study shows that the compound EGFR mutation is common in lung adenocarcinoma and imparts a new meaning of compound EGFR mutation.
Materials and methods
Patient characteristics and tumor DNA samples
A total of 143 patients with a pathologically confirmed diagnosis of pStage IB∼IIIA lung adenocarcinoma who underwent curative surgical resection and platinum-based adjuvant chemotherapy and provided informed consent for tissue collection were randomly selected from tissue archives of affiliated hospitals of Yonsei University Medical Center. Among them, 61 patients with EGFR mutations who had not received EGFR-TKI before tumor genotyping were enrolled in this study. All paraffin-embedded samples were loaded onto silanated slides as 4-μm-thick sections. One slide of every block was stained with H&E and re-examined for the presence of cancer cells. The enriched area was marked by an independent lung pathologist to validate the presence of tumor cells. These cancer cell-enriched areas were microdissected, and DNA was extracted using a QIAamp DNA FFPE Tissue Kit (Qiagen, Valencia, CA, USA). Institutional Review Board (IRB) approval was obtained for this study (IRB #3-2013-0298).
Library preparation, NGS with IonTorrent, and variant calling
Ten micrograms of genomic DNA were amplified by the Ion AmpliSeq™Custom Panel (Life Technologies, Carlsbad, CA). This panel contains 16 genes that contain actionable mutations; AKT1, ALK, BCL2L11, BRAF, DDR2, EGFR, ERBB2, FGFR1, KRAS, MAP2K1, MET, NRAS, PIK3CA, PTEN, ROS1, and RET. ALK fusion was detected by FISH using Abbott Vysis ALK break apart FISH probe kit (Abbott, Abbott Park, Il). Multiplex pools were purified with Agencourt AMPure XP beads (Beckman Coulter Inc.) and ligated with Ion Xpress barcode adapters (Life Technologies). The fragment size and quantity of each library were analyzed by a BioAnalyzer using a High Sensitivity Chip (Agilent, Santa Clara, CA). The library was diluted, and emulsion PCR was performed with the Onetouch™ reagent kit (Life Technologies). The emulsion PCR product was enriched using Dynabeads® MyOne™ Streptavidin C1 beads (Life Technologies). The final enriched ion spheres were mixed with a sequencing primer and polymerase and loaded onto 5 318v2 chips. The libraries were sequenced with the Ion Torrent PGM sequencer at deep coverage (aiming for 1,000×) using the Ion OneTouch 200 Template Kit v2 DL and Ion PGM Sequencing 200 Kit v2 with the 318 v2 chip kits (all from Life Technologies). The sequencing reads were aligned to the human reference GRCh37 genome, and base calling was performed using the Ion Torrent Suite V3.4.2 using tmap-f3 on the Ion Torrent server. The Ion Torrent Variant Caller (ITVC) v3.4 was used for the detection of mutations, requiring a frequency greater than 5% for a variant to be called. Bam (Binary sequence Alignment/Map format) and FASTQ files (alignment) were generated based on the base calling results and were used to report the variant calling, including single nucleotide polymorphisms (SNPs) and insertions/deletions (INDELs).
Statistical analysis
Categorical variables are expressed as percentages and compared using χ2-tests. Differences in distribution of continuous variables between 2 independent samples were assessed by Mann–Whitney U test, and the Kaplan–Meier estimator was used for survival analysis. All analyses were performed with IBM SPSS Statistics version 20 (IBM Corp). All statistical tests were 2-sided, and a P value <0.05 was considered to indicate statistical significance.
Results
Demographic characteristics of the study population
The 61 patients with mutations in EGFR-TKD had a mean age of 59 ± 9.9 years (range; 34∼78 years); 17 (27.9%) were male and 44 (72.1%) were female. The difference in age at the time of diagnosis between male and female patients was not significant. The majority of patients (50; 82%) did not have a smoking history, 6 (9.8%) were current smokers, and 5 (8.2%) were ex-smokers; the ever-smokers had a pack-year average of 43 ± 48.2 years. These demographic characteristics are comparable to previous findings of EGFR mutation-positive Korean patients with lung adenocarcinoma.3,4,18
Compound EGFR mutations
Determination of the entire sequence of EGFR exons 18∼21 constituting EGFR-TKD revealed that simple mutations were the more frequent (46 of 61, 75.4%). These were predominantly E19del (24 of 61, 39.3%), followed by L858R point mutation (17 of 61, 27.9%), and EGFR exon 20 insertion mutations (2 out of 61, 3.2%). Point mutations involving exon 20, exon 19 insertions, and L861R were less frequent (Table 1). The remaining 15 cases (24.6%) had compound EGFR mutations, which is composed of double or multiple independent mutations in the EGFR-TKD (Table 1). Most of the compound mutations, (10 of 15, 66.7%) were composed of a rare atypical mutation with EGFR-TKI sensitizing mutations such as G719X (n = 3), L858R (n = 6), and E19del (n = 1). Interestingly, one case had a compound mutation composed of L858R and E19del. Two compound mutations involved exon 20 insertion plus H773Y and rare cases of E749Q plus A750P, L688F plus G824S, and multiple point mutations scattered throughout exon 20 and exon 21 were also detected. The partner mutations were atypical mutations in exon 18 (V689L, I706T, and E709K), those in exon 20 (H773Y and R776H), or those in exon 21 (L833V, H870R, and A871G). Table 1 summarizes the combinations of specific mutations detected in this study. Taken together, EGFR compound mutations are common in EGFR mutation-positive lung adenocarcinoma.
Table 1.
EGFR mutation type | No. | % of total | |
---|---|---|---|
Simple mutations | |||
Exon 19 deletions | 24 | 39.3 | |
Exon 19 insertions | V738_K739insKIPVAI | 1 | 1.6 |
Exon 20 insertions | |||
M766_A767insASV | 1 | 1.6 | |
D770_N771insG+N771T | 1 | 1.6 | |
Exon 20 mutations | |||
N771F | 1 | 1.6 | |
Exon 21 mutations | |||
L858R | 17 | 27.9 | |
L861R | 1 | 1.6 | |
Compound mutations | |||
L858R + V689L | 1 | 1.6 | |
L858R + L833V | 1 | 1.6 | |
L858R + H870R | 1 | 1.6 | |
L858R + A871G | 1 | 1.6 | |
L858R + R776H | 1 | 1.6 | |
L858R + E19del | 1 | 1.6 | |
G719A + I706T | 1 | 1.6 | |
G719S + E709K | 1 | 1.6 | |
G719S + R776H | 1 | 1.6 | |
E19del + I706T | 1 | 1.6 | |
D770_N771insNPY +H773Y | 2 | 3.3 | |
L688F + G824S | 1 | 1.6 | |
E749Q + A750P | 1 | 1.6 | |
T785I + Y813H + V845M + V851I + G857R | 1 | 1.6 | |
Total | 61 | 100 |
Clinical characteristics of cases with compound EGFR mutation
Next, we questioned whether the cases with compound EGFR mutation showed discernible clinical and pathologic characteristics (Table 2). There was no difference in age or gender distribution between patients with simple mutation and those with compound mutation. Smoking status and pStage at the time of diagnosis were not associated with the type of EGFR mutation. We also investigated whether the histologic subtype of adenocarcinoma was different according to the type of mutation. Compound EGFR mutation was not detected in the lepidic predominant types. The subtypes that are associated with poor clinical outcomes, such as papillary/micropapillary predominant types and solid with mucin production type, were more frequently detected in cases with compound mutations (21.7% vs. 33.3%) but this did not reach clinical significance. The diameter of the tumor mass at the time of operation was larger in the tumors with compound mutation but also did not reach statistical significance (2.9 ± 0.96 vs. 3.4 ± 1.01 cm).
Table 2.
Simple mutation (n = 46) | Compound mutation (n = 15) | P-value | ||
---|---|---|---|---|
Age (mean ± SD); yrs | 59.6 ± 10.52 | 58.9 ± 7.93 | 0.778* | |
Gender | ||||
Male | 10 | 7 | 0.061** | |
Female | 36 | 8 | ||
Smoking status | ||||
Non-smoker | 39 | 11 | 0.488** | |
Current smoker | 4 | 2 | ||
Ex-smoker | 3 | 2 | ||
Stage | ||||
IB | 4 | 1 | 0.970** | |
IIA | 16 | 5 | ||
IIB | 2 | 1 | ||
IIIA | 24 | 8 | ||
Maximum tumor diameter | 2.9 ± 0.96 | 3.4 ± 1.01 | 0.075* | |
Histologic subtype | ||||
Lepidic predominant | 3 | 0 | 0.732** | |
Acinar predominant | 31 | 9 | ||
Papillary and micropapillary predominant | 7 | 4 | ||
Solid with mucin production | 3 | 1 | ||
Others† | 2 | 1 |
P-value was obtained from t-test
P-value was obtained from Pearson's Chi-square test
Includes invasive mucinous adenocarcinoma and adenosquamous carcinoma
Lung adenocarcinoma with compound EGFR mutation shows poor clinical outcome
Because the cases with compound EGFR mutation had properties which might be related to poor clinical outcome, we compared the disease-free survival (DFS) and overall survival (OS) of cases with simple and compound mutations (Fig. 1). The median follow-up duration of the study population was 81.9 months (95% confidence interval (CI): 65.7∼98.1 months). Of 61 patients, 33 (54.1%) experienced recurrence of the disease and 15 (24.6%) died of same disease during follow-up period. There was no difference in DFS between the groups, but OS was significantly poorer in the cases with compound mutation (simple mutation, 83.7 months vs. compound mutation, 72.8 months, P = 0.020, Breslow test) (Fig. 1A). A multivariate analysis including age, smoking status, EGFR mutation subtypes, stage, and histologic subtypes revealed that smoking history (HR, 11.47; 95% CI, 2.510∼54.404; P = 0.002), compound EGFR mutation (HR, 4.030; 95% CI, 1.305∼12.446; P = 0.015) were significantly associated with a shorter OS (Table 3). Based on these findings, we hypothesized that cases with compound mutation have a poor response to EGFR-TKI. Among 33 patients that experienced recurrence of lung cancer after curative resection, 24 had taken EGFR-TKI for management of the recurrence. However, when the duration of disease control with EGFR-TKI was analyzed, there was no difference between groups with compound or simple mutations (data not shown).
Table 3.
Univariate analysis |
Multivariate analysis |
||||||
---|---|---|---|---|---|---|---|
Variables | HR | 95% CI | P-value | HR | 95% CI | P-value | |
Age | < 65 | 1 | reference | – | 1 | reference | – |
≥ 65 | 0.777 | 0.482-1.251 | 0.299 | 1.824 | 0.628-15.299 | 0.269 | |
Smoking status | None | 1 | reference | – | 1 | reference | – |
Current and ex-smoker | 3.151 | 1.087-9.135 | 0.035 | 11.47 | 2.510-52.404 | 0.002 | |
EGFR subtypes | Simple | 1 | reference | – | 1 | reference | – |
Compound | 2.489 | 0.925-6.695 | 0.071 | 4.030 | 1.305-12.446 | 0.015 | |
Stage | IB | 1 | reference | – | 1 | reference | – |
IIA-IIB | 1.717 | 0.211-13.988 | 0.614 | 3.985 | 0.313-50.713 | 0.287 | |
IIIA | 2.300 | 0.287-18.41 | 0.433 | 9.078 | 0.743-110.883 | 0.084 | |
Histologic subtypes | Acinar | 1 | reference | – | 1 | reference | – |
Papillary and micropapillary | 1.229 | 0.387-3.898 | 0.726 | 0.590 | 0.175-1.985 | 0.394 | |
Lepidic | 1.575 | 0.357-6.943 | 0.548 | 0.890 | 0.161-4.928 | 0.894 | |
Solid | 0.256 | 0.012-5.344 | 0.380 | 0 | – | 0.981 | |
Others | 0.591 | 0.028-12.390 | 0.735 | 0 | – | 0.988 |
To further investigate the reason for the poor clinical outcome in the cases with compound mutation, we examined co-mutations in the AKT1, BRAF, DDR2, ERBB2, FGFR, KRAS, MAPK2K1, MET1, NRAS, PIK3CA, PTEN, RET, and ROS1 genes, ALK gene rearrangement, and BCL2L11 intron 2 deletion. A total 115 missense mutations were discovered in the tested genes (Table 4). 31 missense mutations were discovered in the cases with simple EGFR mutations whereas 84 were discovered in those with compound EGFR mutation, showing that the cases with compound EGFR mutation have higher chance of harboring multiple missense mutations in the clinically important genes (Table 7) (0.66 mutations / case vs. 6.0 mutations / case, P = 0.001, independent sample t-test). Similarity the cases with compound EGFR mutations have higher chance of co-alteration in the other genes than those with simple EGFR mutations (0.61 vs. 2.2 genes/case). Interestingly, there are a few number of actionable mutations irrelevant to the subtype of EGFR mutations, including ALK rearrangement, BCL2L11 intron 2 deletion, KRAS c.35G>A, PIK3CA c.1633G>A which is possible target mutation of crizotinib, BH3 mimetics, MEK inhibitors, and PI3K-TKIs, respectively (Tables 5 and 6).19,20 Taken together, the cases with compound EGFR mutation shows poor OS, which may attribute to the higher burden of missense mutations in the clinically important genes.
Table 4.
Substitution | Simple EGFR mutation (n = 46) | Compound EGFR mutation (n = 15) |
---|---|---|
C>T | 6 | 29 |
A>G | 3 | 0 |
G>A | 17 | 51 |
C>G | 1 | 0 |
G>C | 4 | 2 |
A>T | 0 | 1 |
A>C | 0 | 1 |
Total | 31 | 84 |
Table 7.
Type of EGFR mutation | Average of co-mutations in other genes | |
---|---|---|
Simple mutation | E19del (n = 24) | 0.7 |
V738_K739insKIPVAI (n = 1) | 0 | |
M766_A767insASV (n = 1) | 0 | |
D770_N771insG+N771T (n = 1) | 1 | |
N771F (n = 1) | 0 | |
L858R (n = 17) | 0.5 | |
L861R (n = 1) | 0 | |
Compound mutation | L858R + V689L (n = 1) | 1 |
L858R + L833V (n = 1) | 0 | |
L858R + H870R (n = 1) | 0 | |
L858R + A871G (n = 1) | 10 | |
L858R+ R776H (n = 1) | 19 | |
L858R + E19del (n = 1) | 0 | |
G719A + I706T (n = 1) | 0 | |
G719S + E709K (n = 1) | 0 | |
G719S + R776H (n = 1) | 0 | |
E19del + I706T (n = 1) | 0 | |
D770_N771insNPY + H773Y (n = 2) | 1 | |
L688F + G824S (n = 1) | 34 | |
E749Q + A750P (n = 1) | 0 | |
T785I + Y813H + V845M + V851I + G857R (n = 1) | 19 |
Table 5.
Rand No. | ALK | BCL2L11 | BRAF | FGFR1 | KRAS | MET | NRAS | PIK3CA | ROS1 | RET |
---|---|---|---|---|---|---|---|---|---|---|
E0006 | ||||||||||
E0010 | ||||||||||
E0016 | c.2143A>G | |||||||||
E0017 | Rearrangement* | c.3437G>A | c.2071G>A | |||||||
E0019 | ||||||||||
E0023 | c.2071G>A | |||||||||
E0024 | ||||||||||
E0033 | c.5326G>C | c.2071G>A | ||||||||
E0043 | Int 2 del** | |||||||||
E0051 | ||||||||||
E0059 | Int 2 del** | |||||||||
E0081 | ||||||||||
E0098 | c.2071G>A | |||||||||
E0108 | Rearrangement* | Int 2 del** | ||||||||
E0110 | Int 2 del** | c.3637C>T | ||||||||
E0116 | ||||||||||
E0120 | ||||||||||
E0123 | Int 2 del** | c.1750C>T | c.1456C>T | c.109G>A | c.2379G>A | c.91G>A | c.1633G>A* | c.2071G>A | ||
E0124 | c.5326G>C | |||||||||
E0126 | ||||||||||
E0130 | ||||||||||
E0138 | Int 2 del** | c.5326G>C | ||||||||
E0149 | ||||||||||
E0152 | c.2071G>A | |||||||||
E0157 | ||||||||||
E0168 | ||||||||||
E0174 | c.35G>A* | |||||||||
E0182 | ||||||||||
E0187 | ||||||||||
E0191 | ||||||||||
E0195 | ||||||||||
E0197 | c.3496C>T, c.3503A>G | |||||||||
E0201 | ||||||||||
E0203 | c.1766C>T | c.3503A>G | ||||||||
E0210 | c.3836C>T | c.2071G>A | ||||||||
E0222 | ||||||||||
E0224 | ||||||||||
E0226 | ||||||||||
E0233 | c.2071G>A | |||||||||
E0242 | ||||||||||
E0250 | c.1255G>A | |||||||||
E0252 | c.2208C>G | |||||||||
E0256 | Int 2 del** | c.5704G>A, c.5326G>C | ||||||||
E0260 | c.2071G>A | |||||||||
E0269 | ||||||||||
E0272 |
Actionable mutations (19).
BCL2L11 intron 2 deletion mutant (20).
No mutation was detected in AKT1, DDR2, ERBB2, MAP2K1, and PTEN.
Table 6.
Rand No. | ALK | BCL2L11 | BRAF | ERBB2 | FGFR1 | KRAS | MET | NRAS | PIK3CA | PTEN | ROS1 | RET |
---|---|---|---|---|---|---|---|---|---|---|---|---|
E0001 | c.2071G>A | |||||||||||
E0012 | ||||||||||||
E0048 | ||||||||||||
E0092 | c.5704G>A | |||||||||||
E0113 | Rearrangement*, c.3755C>T | c.1760A>T | c.2275G>A, c.1417C>T, c.1391C>T, c.1382C>T, | c.2610G>A, c.2612G>A, c.3670G>A | c.235C>T, c.38G>A, c.31G>A, c.29G>A, c.28G>A, | c.5770G>A, c.5741C>T, c.5587A>C, c.5572C>T | ||||||
E0140 | c.1766C>T | c.2293C>T, c.1490C>T, c.487G>A | c.85G>A | c.2327G>A, c.2389G>A | c.203G>A, c.38G>A | c.2071G>A | ||||||
E0154 | c.5704G>A | |||||||||||
E0170 | ||||||||||||
E0176 | ||||||||||||
E0214 | Int 2 del** | |||||||||||
E0217 | c.3808G>A, c.3781G>A | c.1822C>T, c.1793C>T | c.2209G>C, c.1505G>A, c.1495G>A, c.1489C>T, c.1426C>T, c.1346C>T | c.160G>A, c.91G>A, c.35G>A* | c.1231G>A, c.1268C>T, c.1492C>T, c.2119C>T, c.2161G>A, c.2336C>T, c.2395G>A, c.3512C>T, c.3584C>T, c.3683G>A, c.3745G>A | c.201G>A, c.169G>A, c.50G>A, c.25G>A | c.1656G>A | c.724G>A, c.754G>A | c.5572C>T, c.5291G>A | c.2143C>T | ||
E0228 | ||||||||||||
E0231 | ||||||||||||
E0235 | c.3821C>T, | c.1798G>A, c.1753C>T | c.2499G>A | c.2191C>T, c.2324G>A, c.2339G>A, c.3322G>A, c.3395G>A, c.3687G>A | c.239G>A, c.176C>T, c.32C>T | c.3104C>T | c.653G>A | c.5770G>A, c.5602G>A, c.5333G>A, c.5326G>C | ||||
E0254 |
Actionable mutations (19).
BCL2L11 intron 2 deletion mutant (20).
No mutation was detected in AKT1, DDR2, and MAP2K1.
Discussion
The definition of a compound EGFR mutation remains as ambiguous as its clinical significance. A compound mutation is defined as a combination of 2 or more independent mutations in EGFR-TKD. In the case of E19del, approximately half of the mutations are accompanied by a continuous, in-frame point mutation or insertion around the deleted motif. In this study, these cases were considered simple mutations.
The detection rate of compound EGFR mutations has gradually increased from 4% in 2004 to 14% in 2013.16,17,21 In a report from the early era of EGFR sequencing, cDNA of EGFR exon 18∼21 was generated by RT-PCR and used as a template for sequencing. In that study of Japanese cohorts, 111 of 277 lung adenocarcinomas showed EGFR mutations, and 4 of 111 EGFR mutation-positive cases (4%) were compound EGFR mutations.21 A study that applied the direct sequencing of gDNA showed that the frequency of compound mutation in 443 EGFR mutation positive NSCLC is 4.97%.22 Another EGFR study of a large East Asian cohort sequenced 2 types of specimen, gDNA from paraffin blocks and total RNA from frozen tissues. Those studies revealed that, among 627 EGFR mutation-positive cases, 78 (12.4%) were uncommon EGFR mutations and approximately half of these, 32 cases, were compound EGFR mutations.17 A report that adapted bidirectional direct DNA sequencing showed that the detection rate of compound EGFR mutation was 14% of total EGFR mutations.16 These differences in the frequency of compound EGFR mutations may be attributed to the progress of sequencing technology and the source of sequencing templates. Recent extensive clinical application of PNA clamping-based EGFR mutation detection techniques that focus on detection of the G719X, E19del, T790M, S768I, E20ins3dup, E20ins3, and L858R, or L861Q mutations showed an increased detection rate of EGFR mutations. However, compound EGFR mutations were very rarely encountered in daily practice. This study adopted NGS-based repeated deep sequencing at exon 18∼21 of EGFR, and the detection rate of compound EGFR mutations was 24.6%. These technical advances in sequencing provide a higher probability of encountering EGFR compound mutations.
The majority of compound EGFR mutations are composed of one typical EGFR mutation and an atypical partner mutation. Point mutations have a higher chance of harboring an atypical partner mutation. This may be related to the definition of a compound EGFR mutation, in which consecutive mutation around the E19del is defined as a simple mutation. The atypical partner mutations are quite heterogeneous with respect to location in the EGFR gene, and it is difficult to generalize their effects on EGFR-TKI. A report by Peng et al. showed that among the 22 cases of the multiple EGFR mutation 20 (90.1%) had L858R or exon 19 in-frame deletion EGFR mutation.23 The type of compound EGFR mutation is more homogenous than our findings, which showed 7 (46.7%) out of 15 cases accompanied with L858R or exon 19 in frame deletion. In a report by Kosaka et al., one tumor with a mutation at codon 719 and 3 tumors with mutations at codon 858 contained another mutation at E709H, S768I, R776C, or T790M, respectively.21 This finding is similar to that of Wu et al., who showed that all multiple mutations contained one sensitizing mutation such as G719X, L858R, L861Q, or E19del and one or more rare atypical partner mutations. However, the findings of Kobayashi et al. and the current study indicate that 20∼27% of compound EGFR mutations consist of rare atypical mutations.16
The concept that one cancer has single driver mutation is being challenged by the advancement of techniques which are capable of sequencing multiple genes at a time. When the frequency of the co-alteration of EGFR and ALK rearrangement was evaluated by EGFR direct sequencing and ALK FISH, it is 0.27%.24 When the EGFR mutations status was re-inspected in ALK rearrangement positive and EGFR mutation negative cases with the mutant enriched NGS, the co-mutation rate was increased up to 15.4%.24 Another study that investigated mutation of PIK3CA exon 9 and 20 in 1,117 NSCLC showed that it was detected in 3.9% of squamous cell cancer and 2.7% of adenocarcinoma.25 Among 34 NSCLC cases that have PIK3CA mutation, 17 cases had co-mutation in the EGFR exon 18∼21 and 4 cases in the KRAS exon 2∼3 showing PIK3CA mutation is frequently accompanied with EGFR/KRAS mutation.25 In our study, ALK rearrangement and PIK3CA was observed in 3 cases respectively, suggesting that the representative driver mutations are not completely mutually exclusive and can occasionally be found at lower frequently. It is worthy of notice that MET had highest mutational burden among the genes tested in this panel. However, no mutation was detected in the exon14 and exon skipping could not be detected by the applied technique.26,27 Mutations in the MET kinase domain (c.3166-c.4068; Exon 15∼21) were detected in the 8 cases, but their biologic significance is not confirmed yet.
A few papers have reported that there are differences in the responses to the EGFR-TKIs among compound EGFR mutations. Peng et al. revealed that when the clinical outcome between NSCLC patients with L858 single mutation and those with L858 and other co-mutation in EGFR exon 18∼21 was compared, there was no significant differences in OS and PFS.22 Another study addressed the clinical significance of compound EGFR mutations, showing a poorer outcome for patients with rare atypical mutations combined with E19del or L858R (progression-free survival (PFS) 5.3 months, OS 18.8 months) compared with those with single classic mutations (PFS 8.5, OS 19.6 months).17 Compound mutations that contain sensitizing mutations such as G719X or L858R seem to have good responses to EGFR-TKIs. On the other hands, those comprised of rare atypical mutations have poor response to EGFR-TKI.17,28 In our study, a homogenous cohort was selected to identify the clinical meaning of compound mutations, and we found that patients with compound EGFR mutations had poorer OS than those with simple EGFR mutations. It is of note that there was no difference in the DFS. These findings suggest that mutation status may be related to the response to drug administered after confirmation of recurrence. The unproved supposition that tumors with a compound EGFR mutation do not respond to EGFR-TKI might cause clinicians to hesitate in positioning EGFR-TKI at the early line of therapy, which may have complicated evaluation of the response to EGFR-TKI in this study cohort. Several other factors such as male predominance, larger tumor size at the time of detection, and aggressive histologic subtype might have acted in combination to influence the poor OS of patients with the compound EGFR mutation.
The biologic significance of co-alteration of EGFR and other genes need to be investigated. In a study that evaluated the response to TKIs in the 14 NSCLC which had EGFR and ALK co-alteration, 3 treated with EGFR-TKI showed poor responses to gefitinib but 8 treated with ALK inhibitors revealed favorable responses, suggesting that signaling from ALK rearrangement override EGFR.24 Others addressed the importance of PIK3CA mutation test by showing that the patients with PIK3CA single mutation showed poorer prognosis than those with co-mutation of PIK3CA and EGFR/KRAS.25
A few mutations in the BCL2L11, ALK, PIK3CA, and KRAS are key driver mutations that can be potentially targeted, while those in the other genes need further validation. It would be interesting to see if the NSCLC patients with EGFR compound mutation or co-alteration with other genes may be benefit from 3rd generation EGFR-TKIs when compared to 1st and 2nd generation EGFR-TKIs.29,30
In conclusion, compound EGFR mutation is frequently detected in EGFR-mutant tumors and is related to poor overall survival of patients with lung adenocarcinoma. Because it is expected that such mutations may be more frequently detected with wider adoption of NGS-based tests, more dedicated efforts are needed to clarify their biologic effects on disease course and drug responsiveness.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Funding
This study was supported by an NSCR grant (HI10C2020) awarded to YS Chang.
References
- 1.Jung KW, Won YJ, Kong HJ, Oh CM, Lee DH, Lee JS. Prediction of cancer incidence and mortality in Korea, 2014. Cancer Res Treat 2014; 46:124-30; PMID:24851103; http://dx.doi.org/ 10.4143/crt.2014.46.2.124 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kris MG, Johnson BE, Berry LD, Kwiatkowski DJ, Iafrate AJ, Wistuba II, Varella-Garcia M, Franklin WA, Aronson SL, Su PF, et al.. Using multiplexed assays of oncogenic drivers in lung cancers to select targeted drugs. JAMA 2014; 311:1998-2006; PMID:24846037; http://dx.doi.org/ 10.1001/jama.2014.3741 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Han SW, Kim TY, Hwang PG, Jeong S, Kim J, Choi IS, Oh DY, Kim JH, Kim DW, Chung DH, et al.. Predictive and prognostic impact of epidermal growth factor receptor mutation in non-small-cell lung cancer patients treated with gefitinib. J Clin Oncol 2005; 23:2493-501; PMID:15710947; http://dx.doi.org/ 10.1200/JCO.2005.01.388 [DOI] [PubMed] [Google Scholar]
- 4.Kim YT, Kim TY, Lee DS, Park SJ, Park JY, Seo SJ, Choi HS, Kang HJ, Hahn S, Kang CH, et al.. Molecular changes of epidermal growth factor receptor (EGFR) and KRAS and their impact on the clinical outcomes in surgically resected adenocarcinoma of the lung Lung Cancer (Amsterdam, Netherlands) 2008; 59:111-8. [DOI] [PubMed] [Google Scholar]
- 5.Soung YH, Lee JW, Kim SY, Seo SH, Park WS, Nam SW, Song SY, Han JH, Park CK, Lee JY, et al.. Mutational analysis of EGFR and K-RAS genes in lung adenocarcinomas. Virchows Archiv : an international journal of pathology 2005; 446:483-8; PMID:15815931; http://dx.doi.org/ 10.1007/s00428-005-1254-y [DOI] [PubMed] [Google Scholar]
- 6.Kim HS, Sung JS, Yang SJ, Kwon NJ, Jin L, Kim ST, Park KH, Shin SW, Kim HK, Kang JH, et al.. Predictive efficacy of low burden EGFR mutation detected by next-generation sequencing on response to EGFR tyrosine kinase inhibitors in non-small-cell lung carcinoma. PloS one 2013; 8:e81975; PMID:24376508; http://dx.doi.org/ 10.1371/journal.pone.0081975 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Shigematsu H, Lin L, Takahashi T, Nomura M, Suzuki M, Wistuba II, Fong KM, Lee H, Toyooka S, Shimizu N, et al.. Clinical and biological features associated with epidermal growth factor receptor gene mutations in lung cancers. J Natil Cancer Instit 2005; 97:339-46; PMID:15741570; http://dx.doi.org/ 10.1093/jnci/dji055 [DOI] [PubMed] [Google Scholar]
- 8.Sequist LV, Bell DW, Lynch TJ, Haber DA. Molecular predictors of response to epidermal growth factor receptor antagonists in non-small-cell lung cancer. J Clin Oncol 2007; 25:587-95; PMID:17290067; http://dx.doi.org/ 10.1200/JCO.2006.07.3585 [DOI] [PubMed] [Google Scholar]
- 9.Tokumo M, Toyooka S, Kiura K, Shigematsu H, Tomii K, Aoe M, Ichimura K, Tsuda T, Yano M, Tsukuda K, et al.. The relationship between epidermal growth factor receptor mutations and clinicopathologic features in non-small cell lung cancers. Clin Cancer Res 2005; 11:1167-73; PMID:15709185 [PubMed] [Google Scholar]
- 10.Mitsudomi T, Yatabe Y. Epidermal growth factor receptor in relation to tumor development: EGFR gene and cancer. FEBS J 2010; 277:301-8; PMID:19922469; http://dx.doi.org/ 10.1111/j.1742-4658.2009.07448.x [DOI] [PubMed] [Google Scholar]
- 11.Mitsudomi T, Yatabe Y. Mutations of the epidermal growth factor receptor gene and related genes as determinants of epidermal growth factor receptor tyrosine kinase inhibitors sensitivity in lung cancer. Cancer Sci 2007; 98:1817-24; PMID:17888036; http://dx.doi.org/ 10.1111/j.1349-7006.2007.00607.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Yeh P, Chen H, Andrews J, Naser R, Pao W, Horn L. DNA-Mutation Inventory to Refine and Enhance Cancer Treatment (DIRECT): a catalog of clinically relevant cancer mutations to enable genome-directed anticancer therapy. Clin Cancer Res 2013; 19:1894-901; PMID:23344264; http://dx.doi.org/ 10.1158/1078-0432.CCR-12-1894 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Pao W, Chmielecki J. Rational, biologically based treatment of EGFR-mutant non-small-cell lung cancer. Nat Rev Cancer 2010; 10:760-74; PMID:20966921; http://dx.doi.org/ 10.1038/nrc2947 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Yasuda H, Kobayashi S, Costa DB. EGFR exon 20 insertion mutations in non-small-cell lung cancer: preclinical data and clinical implications. Lancet Oncol 2012; 13:e23-31; PMID:21764376; http://dx.doi.org/ 10.1016/S1470-2045(11)70129-2 [DOI] [PubMed] [Google Scholar]
- 15.Yasuda H, Park E, Yun CH, Sng NJ, Lucena-Araujo AR, Yeo WL, Huberman MS, Cohen DW, Nakayama S, Ishioka K, et al.. Structural, biochemical, and clinical characterization of epidermal growth factor receptor (EGFR) exon 20 insertion mutations in lung cancer. Sci Translat Med 2013; 5:216ra177; PMID:24353160; http://dx.doi.org/ 10.1126/scitranslmed.3007205 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Kobayashi S, Canepa HM, Bailey AS, Nakayama S, Yamaguchi N, Goldstein MA, Huberman MS, Costa DB. Compound EGFR mutations and response to EGFR tyrosine kinase inhibitors. J Thor Oncol 2013; 8:45-51; PMID:23242437; http://dx.doi.org/ 10.1097/JTO.0b013e3182781e35 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wu JY, Yu CJ, Chang YC, Yang CH, Shih JY, Yang PC. Effectiveness of tyrosine kinase inhibitors on “uncommon” epidermal growth factor receptor mutations of unknown clinical significance in non-small cell lung cancer. Clin Cancer Res 2011; 17:3812-21; PMID:21531810; http://dx.doi.org/ 10.1158/1078-0432.CCR-10-3408 [DOI] [PubMed] [Google Scholar]
- 18.Bae NC, Chae MH, Lee MH, Kim KM, Lee EB, Kim CH, Park TI, Han SB, Jheon S, Jung TH, et al.. EGFR, ERBB2, and KRAS mutations in Korean non-small cell lung cancer patients. Cancer Gen Cytogenet 2007; 173:107-13; PMID:17321325; http://dx.doi.org/ 10.1016/j.cancergencyto.2006.10.007 [DOI] [PubMed] [Google Scholar]
- 19.Meador CB, Micheel CM, Levy MA, Lovly CM, Horn L, Warner JL, Johnson DB, Zhao Z, Anderson IA, Sosman JA, et al.. Beyond histology: translating tumor genotypes into clinically effective targeted therapies. Clin Cancer Res 2014; 20:2264-75; PMID:24599935; http://dx.doi.org/ 10.1158/1078-0432.CCR-13-1591 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Ng KP, Hillmer AM, Chuah CT, Juan WC, Ko TK, Teo AS, Ariyaratne PN, Takahashi N, Sawada K, Fei Y, et al.. A common BIM deletion polymorphism mediates intrinsic resistance and inferior responses to tyrosine kinase inhibitors in cancer. Nat Med 2012; 18:521-8; PMID:22426421; http://dx.doi.org/ 10.1038/nm.2713 [DOI] [PubMed] [Google Scholar]
- 21.Kosaka T, Yatabe Y, Endoh H, Kuwano H, Takahashi T, Mitsudomi T. Mutations of the epidermal growth factor receptor gene in lung cancer: biological and clinical implications. Cancer Res 2004; 64:8919-23; PMID:15604253; http://dx.doi.org/ 10.1158/0008-5472.CAN-04-2818 [DOI] [PubMed] [Google Scholar]
- 22.Peng L, Song Z, Jiao S. Comparison of uncommon EGFR exon 21 L858R compound mutations with single mutation. OncoTarget Ther 2015; 8:905-10; PMID:25960661; http://dx.doi.org/ 10.2147/ott.s78984 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Peng LS Z., Jioo S. Efficacy analysis of tyrosine kinase inhibitors on rare non-small cell lung cancer patients harboring complex EGFR mutations. Sci Rep 2014; 4:e6104; PMID:25130612; http://dx.doi.org/ 10.1038/srep06104. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Won JK, Keam B, Koh J, Cho HJ, Jeon YK, Kim TM, Lee SH, Lee DS, Kim DW, Chung DH. Concomitant ALK translocation and EGFR mutation in lung cancer: a comparison of direct sequencing and sensitive assays and the impact on responsiveness to tyrosine kinase inhibitor. Annal Oncol 2015; 26:348-54; PMID:25403583; http://dx.doi.org/ 10.1093/annonc/mdu530 [DOI] [PubMed] [Google Scholar]
- 25.Wang L, Hu H, Pan Y, Wang R, Li Y, Shen L, Yu Y, Li H, Cai D, Sun Y, et al.. PIK3CA mutations frequently coexist with EGFR/KRAS mutations in non-small cell lung cancer and suggest poor prognosis in EGFR/KRAS wildtype subgroup. PloS One 2014; 9:e88291; PMID:24533074; http://dx.doi.org/ 10.1371/journal.pone.0088291 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Frampton GM, Ali SM, Rosenzweig M, Chmielecki J, Lu X, Bauer TM, Akimov M, Bufill JA, Lee C, Jentz D, et al.. Activation of MET via diverse exon 14 splicing alterations occurs in multiple tumor types and confers clinical sensitivity to MET inhibitors. Cancer Dis 2015; 5:850-9; PMID:25971938; http://dx.doi.org/ 10.1158/2159-8290.CD-15-0285 [DOI] [PubMed] [Google Scholar]
- 27.Paik PK, Drilon A, Fan PD, Yu H, Rekhtman N, Ginsberg MS, Borsu L, Schultz N, Berger MF, Rudin CM, et al.. Response to MET inhibitors in patients with stage IV lung adenocarcinomas harboring MET mutations causing exon 14 skipping. Cancer Dis 2015; 5:842-9; PMID:25971939; http://dx.doi.org/ 10.1158/2159-8290.CD-14-1467 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Berge EM, Aisner DL, Doebele RC. Erlotinib response in an NSCLC patient with a novel compound G719D+L861R mutation in EGFR. J Thor Oncol 2013; 8:e83-4; PMID:23945392; http://dx.doi.org/ 10.1097/JTO.0b013e31829ceb8d [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Liao BC, Lin CC, Yang JC. Second and third-generation epidermal growth factor receptor tyrosine kinase inhibitors in advanced nonsmall cell lung cancer. Curr Opin Oncol 2015; 27:94-101; PMID:25611025; http://dx.doi.org/ 10.1097/CCO.0000000000000164 [DOI] [PubMed] [Google Scholar]
- 30.Steuer CE, Khuri FR, Ramalingam SS. The next generation of epidermal growth factor receptor tyrosine kinase inhibitors in the treatment of lung cancer. Cancer 2015; 121:E1-6; PMID:25521095; http://dx.doi.org/ 10.1002/cncr.29139 [DOI] [PubMed] [Google Scholar]