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MEETING SUMMARY

Consensus for EGFR Mutation Testing in Non-small Cell


Lung Cancer
Results from a European Workshop
Robert Pirker, MD,* Felix J. F. Herth, MD, PhD, FCCP,† Keith M. Kerr, MD, FRCPath,‡
Martin Filipits, PhD,* Miquel Taron, PhD,§储 David Gandara, MD,¶ Fred R. Hirsch, MD,#
Dominique Grunenwald, MD,** Helmut Popper, MD,†† Egbert Smit, MD, PhD,‡‡
Manfred Dietel, MD,§§ Antonio Marchetti, MD, PhD,储储 Christian Manegold, MD,¶¶
Peter Schirmacher, MD,## Michael Thomas, MD, PhD,† Rafael Rosell, MD, PhD,§储
Federico Cappuzzo, MD,*** and Rolf Stahel, MD†††; on Behalf of the European EGFR Workshop Group

cell lung cancer (NSCLC). Patients harboring these mutations in


Introduction: Activating somatic mutations of the tyrosine kinase
their tumors show excellent response to EGFR tyrosine kinase
domain of epidermal growth factor receptor (EGFR) have recently inhibitors (EGFR-TKIs). The EGFR-TKI gefitinib has been ap-
been characterized in a subset of patients with advanced non-small proved in Europe for the treatment of adult patients with locally
advanced or metastatic NSCLC with activating mutations of the
*Medical University of Vienna, Vienna, Austria; †Thoraxklinik University of EGFR TK. Because EGFR mutation testing is not yet well estab-
Heidelberg, Heidelberg, Germany; ‡Aberdeen Royal Infirmary, Aberdeen, lished across Europe, biomarker-directed therapy only slowly
United Kingdom; §Catalan Institute of Oncology, Badalona, Spain; 储Pan-
gaea Biotech, USP Institut Universitari Dexeus, Barcelona, Spain; ¶Univer- emerges for the subset of NSCLC patients most likely to benefit:
sity of California Davis Cancer Center, Sacramento, California; #University those with EGFR mutations.
of Colorado Health Sciences Center, Aurora, Colorado; **Hopital Tenon, Methods: The “EGFR testing in NSCLC: from biology to clinical
University of Paris VI, Paris, France; ††Medical University of Graz, Graz, practice” International Association for the Study of Lung Cancer-
Austria; ‡‡Vrije Universiteit Medical Centre, Amsterdam, The Netherlands;
§§Institute of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Ger- European Thoracic Oncology Platform multidisciplinary workshop
many; 储储Clinical Research Center, Center of Excellence on Aging, Univer- aimed at facilitating the implementation of EGFR mutation testing.
sity-Foundation, Chiety, Italy; ¶¶Medical Center Mannheim, Heidelberg Recommendations for high-quality EGFR mutation testing were
University, Mannheim, Germany; ##Institute of Pathology, University Hos- formulated based on the opinion of the workshop expert group.
pital Heidelberg, Heidelberg, Germany; ***Livorno Hospital, Livorno, Italy;
and †††University Hospital Zurich, Zurich, Switzerland. Results: Co-operation and communication flow between the various
Disclosure: Robert Pirker, MD, has received speaker’s fees and honorari for disciplines was considered to be of most importance. Participants
consulting from AstraZeneca, Boehringer Ingelheim, Merck Serono, and agreed that the decision to request EGFR mutation testing should be
Roche. Keith M. Kerr, MD, FRCPath, has received consulting fees and made by the treating physician, and results should be available
honoraria from AstraZeneca and Roche. Martin Filipitis, PhD, has received
speaker’s feed and honoraria for advisory boards from AstraZeneca. Miquel within 7 working days. There was agreement on the importance of
Taron, PhD, has received honoraria for advisory boards and speaker’s fees appropriate sampling techniques and the necessity for the standard-
from AstraZeneca. David Gandara, MD, has received consulting fees from ization of tumor specimen handling including fixation. Although
Amgen, AstraZeneca, Biodesix, Boehringer Ingelheim, BMS/Imclone, there was no consensus on which laboratory test should be preferred
GlaxoSmithKline, Genentech, Merck, Novartis, and Sanofi-Aventis, as well
as research grants from Abbott, BMS/Imclone, Genentech, Eli Lilly, Merck,
for clinical decision making, all stressed the importance of standard-
Novartis, and Pfizer. Fred R. Hirsch, MD, has received honoraria for ization and validation of these tests.
advisory boards from AstraZeneca, OSI, Roche, Genentech, and Boehringer Conclusion: The recommendations of the workshop will help im-
Ingelheim; research grants from AstraZeneca, OSI, and Genentehc; and is an plement EGFR mutation testing in Europe and, thereby, optimize the
inventor of a University of Colorado-owned patent (EGFR FISH predictive
marker for EGFR inhibitors). Helmut Popper, MD, has received honoraria
use of EGFR-TKIs in clinical practice.
for advisory boards from AstraZeneca and Roche. Manfred Dietel, MD, has Key Words: Epidermal growth factor receptor, EGFR mutation,
received honoraria for scientific advisory boards from AstraZeneca. Peter
Schirmacher, MD, had received honoraria fror advisory boards from Astra- EGFR testing recommendations, Gefitinib, Erlotinib, Non-small cell
Zeneca and Roche, as well as research grants from AstraZeneca. Rolf Stahel, lung cancer, Tyrosine kinase inhibitors.
MD, has received honoraria for scientific advisory boards from AstraZeneca
and merck Serono. The other authors declare no conflicts of interest. (J Thorac Oncol. 2010;5: 1706–1713)
Address correspondence to: Robert Pirker, Medical University of Vienna,
Waehringer Guertel 18 –20, 1090 Vienna, Austria. E-mail: robert.
pirker@meduniwien.ac.at
Copyright © 2010 by the International Association for the Study of Lung
Cancer
ISSN: 1556-0864/10/0510-1706
E pidermal growth factor receptor-tyrosine kinase inhibitors
(EGFR-TKIs) such as gefitinib and erlotinib have demon-
strated efficacy in the treatment of advanced non-small cell

1706 Journal of Thoracic Oncology • Volume 5, Number 10, October 2010


Journal of Thoracic Oncology • Volume 5, Number 10, October 2010 Consensus for EGFR Mutation Testing in NSCLC

FIGURE 1. EGFR mutations in NSCLC. (Reproduced from reference 10 with permission from the publisher.)

lung cancer (NSCLC), particularly in females, never-smok- lower objective response rates with gefitinib compared with
ers, and those with adenocarcinoma histology.1–3 In 2004, carboplatin/paclitaxel (1.1% versus 23.5%; p ⫽ 0.001).
specific mutations in the EGFR TK domain were identified, Results similar to the Phase III IRESSA Pan-ASia
which confer sensitivity to EGFR TKIs.4 – 6 These activating Study have also been seen in several other studies including
somatic mutations of the EGFR gene were more prevalent in other prospective studies of first-line gefitinib,14 –21 and three
patients who derived greater clinical benefit from EGFR- further randomized phase III studies that compared first-line
TKIs.4 –9 The most common EGFR sensitizing mutations are gefitinib with doublet chemotherapy.22–24 In one of these
exon 19 microdeletions, which remove a leucine-arginine- phase III studies (NEJ002; n ⫽ 198), gefitinib compared with
glutamic acid-alanine motif, and the exon 21 L858R point carboplatin/paclitaxel resulted in a higher response rate
mutation, which produces a leucine-to-arginine substitution (74.5% versus 29.0%) and longer PFS (HR 0.357; 95% CI
(Figure 1). Together, these two types of mutations comprise 0.252– 0.507; p ⬍ 0.001) in patients with EGFR mutation-
up to approximately 85 to 90% of known EGFR activating positive tumors.24
mutations in NSCLC.8 –11 Some mutations, particularly in Activating EGFR mutations also seem to be associated
exon 20, are associated with resistance to EGFR TKIs.10,12 with response to erlotinib. A large-scale screening study
The Phase III IRESSA Pan-ASia Study compared ge- identified EGFR mutations in patients with NSCLC, who
fitinib with carboplatin/paclitaxel in previously untreated, were then considered for first- or second-line therapy with
never-smokers/light ex-smokers with advanced pulmonary erlotinib.25 From 2105 screened patients, EGFR mutations
adenocarcinoma in East Asia and confirmed the predictive were detected in 350 patients, and of these, 217 patients
value of EGFR mutations. Patients with EGFR mutation- received erlotinib. In those patients with EGFR mutation-
positive tumors (n ⫽ 261) had significantly longer progres- positive tumors, erlotinib resulted in an objective response
sion-free survival (PFS) with gefitinib (hazard ratio [HR, rate of 70.6%. The exon 19 deletion mutation was associated
gefitinib:carboplatin/paclitaxel] 0.48; 95% confidence inter- with a higher probability of response (odds ratio 3.08; 95%
val [CI] 0.36 – 0.64; p ⬍ 0.001), whereas those in the muta- CI 1.63–5.81; p ⫽ 0.001). This study also demonstrated that
tion-negative subgroup (n ⫽ 176) had significantly shorter large-scale screening of patients for EGFR mutations is
PFS with gefitinib (HR 2.85; 95% CI 2.05–3.98; p ⬍ feasible and results in improved clinical outcome.
0.001).13 Patients with EGFR mutation-positive tumors also Gefitinib has received European approval for the treat-
had higher objective response rates with gefitinib versus ment of adult patients with locally advanced or metastatic
carboplatin/paclitaxel (71.2% versus 47.3%; p ⬍ 0.001), NSCLC with activating mutations of the EGFR-TK. Al-
whereas those with EGFR mutation-negative tumors had though American Society of Clinical Oncology guidelines

Copyright © 2010 by the International Association for the Study of Lung Cancer 1707
Pirker et al. Journal of Thoracic Oncology • Volume 5, Number 10, October 2010

FIGURE 2. Sample preparation, pathology, and


EGFR mutation analysis.

recommend EGFR mutation testing in patients with Which Patients Should Be Tested?
NSCLC,26 this procedure has yet to be broadly established in The decision to test for EGFR mutations should be
Europe as it has been for KRAS mutation testing in colorectal made by the treating physician at the time of diagnosis. This
cancer.27–29 decision may depend on the availability of sufficient tissue;
The “EGFR testing in NSCLC: from biology to clinical therefore, it is vital that biopsy methods are optimized, and
practice” workshop was held on 27–28 November 2009, that tissue is conserved at initial diagnosis and whenever
Vienna, Austria, under the auspices of the International As- possible thereafter. Although all patients with NSCLC may
sociation for the Study of Lung Cancer and the European eventually be tested, the primary focus could be on patients
Thoracic Oncology Platform. This European multidisci- with adenocarcinoma and/or patients with a negative smoking
plinary workshop, which was attended by clinical and scien- history because the frequencies of mutations are particularly
tific experts involved in the management of advanced high in these patients.
NSCLC, aimed to develop recommendations to facilitate the Potential prescreening strategies were discussed. These
implementation of EGFR mutation testing in clinical practice. included the issue of whether focus should be on specific
The 122 participants included molecular biologists, patholo- patient populations such as never-smokers and/or patients
gists, surgeons, chest physicians, and medical oncologists. with adenocarcinoma. Molecular prescreening techniques
Breakout groups addressed the identification and preparation such as high-resolution melting analysis were of some inter-
of suitable biopsy/sample material and optimal methods for est for prescreening.30 –32 Immunohistochemistry could be a
high-quality EGFR mutation testing. The key conclusions of useful prescreening test because it detects the most common
the breakouts were reviewed and discussed in plenary ses- and relevant mutations at the protein level (e.g., exon 19
sions among the entire workshop group. Here, we summarize deletions), but does not detect all mutations.33,34 Circulating
consensus recommendations for biopsy methods and EGFR tumor cell DNA testing could also provide an initial screen.
mutation testing and provide a flowchart of the overall pro- However, circulating tumor cells are limited by numbers and
cess (Figure 2). difficult to extract. Some participants suggested KRAS muta-
tion testing as a prescreen method but currently, its use is not
standard for excluding EGFR mutations in clinical practice.
GENERAL CONSIDERATIONS FOR EGFR Although some of these assays may prove useful as pre-
MUTATION TESTING screening methods in the future, there was no consensus
A key conclusion was that close collaboration, commu- agreement on current prescreening algorithms.
nication flow, and coordination between the departments
involved in the management of lung cancer is essential to
implement EGFR mutation testing in routine practice. This Are There Minimum Requirements for a
process involves clinicians, pathologists, molecular biolo- Laboratory to Undertake EGFR Mutation
gists, and radiologists. Awareness of the need for tumor Testing?
material for routine EGFR mutation testing has to be EGFR mutation testing should only be done in a qual-
raised. This is a key step in allowing all patients with ity-assured setting. There should be accreditation for EGFR
EGFR sensitizing mutations to benefit from treatment with mutation testing in Europe, at a national or even European
an EGFR TKI. level. The establishment of reference laboratories in Europe

1708 Copyright © 2010 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 5, Number 10, October 2010 Consensus for EGFR Mutation Testing in NSCLC

may also be helpful: such laboratories exist for KRAS muta- TABLE 1. Biopsy Techniques
tion testing in colorectal cancer.27–29
21-g 19-g CT-Guided
Needle Needle Transbronchial Needle
What Are Acceptable Timelines for the Aspiration Aspiration Biopsy Biopsy
Different Stages in the Process? Total no. of cells ⱖ100 ⱖ150 ⱖ300 ⱖ500
Timelines are a key consideration in the management of per biopsy/
aspiration
patients with advanced NSCLC. Results from mutation test-
No. of biopsies 4 4 4–5 2–3
ing should become available to the treating physician as soon
as possible. After tumor biopsy and its transport to the
pathologist within 24 hours, the pathology report (except
immunohistochemistry) should be completed within 1 to 2 How Can Complications Be Prevented and
working days. The EGFR mutation testing should then be Minimized?
completed within another 5 to 7 working days. The overall Every precaution should be taken to prevent and min-
process from sampling (or ordering of the test) to availability imize complications. Additional biopsies have little adverse
of the mutation results should not take more than 10 working effect on the complication rate.
days (Figure 2).
What Tumor Content Should the Biopsy
Material Have for Successful EGFR Mutation
BIOPSY AND TISSUE SAMPLING METHODS Analysis?
Before molecular analysis, the tumor cell content of the
When Should Tissue Collection Occur? tissue sample should be determined to assess the reliability of
Tissue collection specifically for EGFR mutation test- subsequent test results. There was agreement that the ratio of
ing is unlikely to occur. Therefore, samples used for tumor malignant to normal cells within the sample is crucial for the
diagnosis will also be used for mutation analysis. Rebiopsy, detection of tumor-specific mutations. In this regard, deter-
specifically for EGFR mutation testing could be considered at mination of the relative proportion of tumor (cellularity) in
the time of recurrence or disease progression, or even during the sample being tested, as a percentage of all cells, is
initial patient work-up, if diagnostic samples are inadequate recommended. Tumor cell enrichment by manual dissection
for mutation analysis. The benefits of obtaining as much may be required to improve accuracy of the test results in
tumor tissue as possible during any biopsy procedure and case of sequencing. Laser capture microdissection can also be
storage of this tissue after initial pathologic diagnosis were used but is not required.
emphasized. The minimum number of tumor cells required for
It might be good to also obtain a plasma or blood adequate mutation testing is ill-defined, although the clear
sample that can be tested if the tumor analysis fails, but this consensus was that as much material as possible should be
approach is currently considered experimental. obtained. Ideally, a sample should contain at least 200 to 400
tumor cells, but this is rarely achieved in routine. For DNA
sequencing, the percentage of tumor cells should ideally be at
From Which Tumor Site Should the Biopsy Be least 50% although with good technical procedures reliable
Taken? results can be obtained with tumor percentage as low as 10 to
The biopsy site should be selected by the clinician who 20%. Several methods with higher detection sensitivity can
will perform the biopsy. In general, the biopsy should be detect mutations present at very low levels (1–5% of EGFR
taken from the most easily accessible tumor. Although pa- gene copies mutated), allowing the possibility of mutation
thologists had no preference with regard to the disease site, detection when tumor cell proportion is less than 10% of the
e.g., primary tumor, lymph node, or distant metastases, all test sample.
participants agreed that further research into the potential
mutation discordance between the primary and different met-
How Should the Biopsy Material Be Prepared
astatic sites is clearly indicated.35 for Subsequent Pathology and EGFR Mutation
Testing?
Handling of tumor specimens has yet to be standard-
Which Biopsy Techniques Should Be Used to ized. There was agreement that 10% neutral-buffered forma-
Ensure High-Quality Tissue Samples and What lin is the optimum fixative, whereas Bouin’s fluid should not
Volume of Sample Is Needed? be used and other fixatives have yet to be validated against
Several well-established biopsy techniques can be used formalin. The fixation time should be as short as possible, yet
to obtain high-quality tissue samples: needle core biopsy, sufficient to permit diagnosis. For example, it has been shown
transbronchial biopsy, endobronchial biopsy, computed to- that fixation times of 6 to 12 hours for small biopsy samples
mography-guided needle biopsy, mediastinoscopy, video-as- and 8 to 18 hours for larger surgical specimens generally give
sisted thoracic surgery, and thoracotomy. Number of biopsies best results. For other techniques, such as DNA extraction
and cells obtained by the various techniques are summarized and polymerase chain reaction (PCR), the optimal fixation
in Table 1. times have yet to be established. Because tissue samples are

Copyright © 2010 by the International Association for the Study of Lung Cancer 1709
Pirker et al. Journal of Thoracic Oncology • Volume 5, Number 10, October 2010

only fixed once, immediately after the biopsy procedure, What Are the Best EGFR Mutation Testing
variations in fixation time according to analytical technique Techniques?
are not practical, and techniques are best adapted to these A variety of methods are used to detect EGFR muta-
standard fixation times. Sections cut from the formalin-fixed tions. These methods include direct sequencing, the Ampli-
paraffin-embedded tissue block are the standard resource fication Refractory Mutation System (ARMS), length analy-
used for DNA extraction. Between 1 and 6 sections of 5- to sis, and denaturing high-performance liquid chromatography.
10-␮m thickness should be used. Laboratories that use laser These methods have different advantages and disadvantages
capture microdissection will require thinner sections. Tissue (Table 2), and there was no consensus agreement on which
fixation and processing have the potential to denature DNA, was the best method. Some tests only detect the most com-
especially when using automated processes. mon activating mutations, whereas other tests can detect all
Can Cytology Samples Be Used? mutations. DNA sequencing is widely used. It can detect all
mutations, but is usually more time-consuming. However,
Cytology samples may be suitable for analysis but
with sequencing there is no need for batching of samples and
further research is needed to fully understand the clinical
it provides better contamination control as the exact, specific
reliability of mutational data obtained from these samples.
mutation in the sample can be determined. ARMS is more
Until then, clinicians should be encouraged to provide tissue
sensitive than sequencing, but detects fewer mutations. In
biopsy samples whenever possible.
cases in which available DNA template is limited, the most
common sensitizing mutations found within exons 19 and 21
STANDARD METHODS FOR EGFR MUTATION should be assessed as a priority.
TESTING
What Are the Best DNA Extraction Methods? Under What Circumstances Should the EGFR
A range of extraction methods may be used. There was Mutation Test Be Repeated?
no consensus on which was the best method. Simple column- Several criteria for the test to be repeated have been
free methods, e.g., Gentra Puregene Blood kit (QIAGEN recommended. The test should be repeated if a new (unre-
GmbH, Germany), were recommended in cases in which ported) mutation is found because of the possibility of a false
sample material is limited, whereas other methods, e.g., positive result.36 The test should also be repeated in case of
QIAGEN FFPET kit (Formalin-Fixed Paraffin-Embedded poor sequence data (with primary PCR and sequencing), if
Tissue kit; QIAGEN GmbH, Germany) can be used when the cycle threshold is close to the defined cut-off limit (with
material is more abundant. Alternative, simple purification the ARMS-based kits) or if other quality assessment criteria
steps may be appropriate for all samples. Further research to are not met.
define the optimal DNA extraction method is needed. In case of failed tests, the following options exist:
There was general agreement that the quality of ampli- repeat PCR; fragment analysis for exon 19, which is very
fiable DNA is more important than its quantity. Mutation sensitive; TaqMan for exon 20 and 21; DNA extraction from
testing should only proceed when the PCR-amplified DNA new tissue sections; repeating the test using different sam-
has been judged to be sufficient. To improve results, quality ples, if available; and discussing other options with the
assurance (QA) procedures have been recommended, based pathology team. Networking for second opinions with differ-
on defined criteria for the quality of the sample. The QA ent methodologies might also be useful. In all cases, it is best
results should also be reported to the clinician. If a sample to start again from tissue if available and to discuss difficult
that does not meet these QA criteria is EGFR mutation samples with the individual clinician or team managing the
positive, and a standard EGFR mutation test has been carried patient.
out, the result can be reported as it is rare to have false
positives. However, if a sample that does not meet these QA How Should the Results Be Reported?
criteria is EGFR mutation negative, it should be reported that The report on the mutation status should be submitted
a mutation was not found but that the presence of a mutation by the pathologist or the molecular biologist in close collab-
cannot be excluded due to the poor quality of the sample. oration with the pathologist. The report should contain the

TABLE 2. Advantages and Disadvantages of Sequencing and ARMS


DNA Sequencing ARMS
Advantages Commonly used and widely available Increased sensitivity compared with sequencing technologies
Can detect all mutations, including novel variants Less time consuming than sequencing
No need for batching of samples Requires fewer tumor cells
Identifies the exact mutation
Disadvantages More time consuming Mutations not assayed for are missed
Lower sensitivity than targeted methods Requirement for batching of samples
Requires experienced operators Possibly more expensive
ARMS, Amplification Refractory Mutation System.

1710 Copyright © 2010 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 5, Number 10, October 2010 Consensus for EGFR Mutation Testing in NSCLC

following information: details of the tissue block tested, TABLE 3. Recommendations for EGFR Mutation Testing
sample source, biopsy method used, sample size and quality, in NSCLC
tumor content of the sample extracted for DNA, methodology
used, exons tested, and mutation present/absent. Details of Which patient? NSCLC patientsa
the specific mutation found and their relevance with regard to Time point At diagnosis
response to EGFR-directed TKIs should be documented, e.g., When possible at disease progression
whether they are sensitizing mutations to TKIs, TKI-resistant Sample source Most easily accessible
mutations (T790M) or mutations with unknown relevance Biopsy preferred over cytology
with regard to response to EGFR-directed TKIs. New muta- Fixation 10% neutral-buffered formalin
tions should be checked against the Greek mutations data- Bouin’s fluid should not be used
base37 regarding their clinical implication and a recommen- Tumor cell content ⱖ50% Tumor cells for DNA
sequencing
dation should be made accordingly, noting that it is a new or
Lower % acceptable with higher
minority mutation. Other relevant comments should be re- sensitivity techniques
corded to assist interpretation of the test, such as the analyt- EGFR mutation analysis method No gold standard yet
ical sensitivity of the test (in the context of the percentage of Report to include Detail of biopsy sample and tissue
tumor cells in the extracted sample). Quantitative data on extracted
mutations may also be valuable. Type of mutation analysis
Mutation present/absent
PERSPECTIVES Interpretation
Further evaluation of the significance of some EGFR a
Local policy may determine which patients are tested. In European studies, the
mutations is needed, including assessment of the func- prevalence of EGFR mutation in definitively diagnosed squamous cell carcinoma,
neuroendocrine carcinomas, and mucinous bronchioloalveolar-pattern adenocarcinomas
tional importance (clinical and/or predictive significance) is effectively zero.45 A pragmatic approach could be to exclude from testing those
of the less-common activating mutations. The results of the patients with a confident diagnosis of the above tumor types, but to test all those with
other NSCLC subtypes, and all “never smokers,” regardless of tumor type. In cases in
Greek mutations database have been published.37 A con- which subtype is unclear, testing is indicated.
tinuously up-dated international database of mutation vari- NSCLC, non-small cell lung cancer.
ants and patients’ response to treatment is required. In
some patients, the T790M mutation in exon 20 has been
associated with acquired resistance to gefitinib.10,38 How-
ever, the clinical implications of the T790M mutation also TKIs in NSCLC, e.g., female gender, never-smokers, and
needs further investigation; this mutation has also been adenocarcinoma histology. However, recent findings suggest
found additionally in patients who have an activating that tumor molecular profiling may soon supersede these
EGFR mutation.17 Other areas requiring further investiga- selection factors in individualizing NSCLC treatment.44 The
tion include the reasons for nonresponse to TKIs in some most striking biomarker results have been the identification of
patients with EGFR activating mutations, the heterogene- activating EGFR mutations within NSCLC tumors, which
ity in mutation expression within the primary tumor and have conferred superior patient outcomes with gefitinib com-
mutation discordance between the primary tumor and metas- pared with chemotherapy.13 In this dawning era of personal-
tases, and the significant association that has been observed ized care in advanced NSCLC, EGFR mutations have
between tumor histologic phenotype and EGFR mutations.39 emerged as a key predictive biomarker for EGFR-TKI treat-
The relationship between new imaging technologies and ment and should be the primary standard for selection of
EGFR mutation testing should also be investigated, as imag- patients for first-line treatment with an EGFR-TKI. These
ing may provide a way of assessing changes in tissue during recommendations from a multidisciplinary International As-
treatment.40 sociation for the Study of Lung Cancer-European Thoracic
Additional mutation testing techniques are being devel- Oncology Platform workshop will help to optimize routine
oped, such as the peptide nucleic acid-locked nucleic acid EGFR mutation testing in NSCLC for the use of EGFR-TKIs
PCR clamp assay,11,41– 43 and may be useful in the future. in Europe (Table 3). These early recommendations will help
However, it should be noted that any methodology that has to facilitate the implementation of EGFR mutation testing,
not been used in the main clinical trials require validation and but further research to identify the best techniques is required,
accreditation to ensure that they provide comparable results. both within clinical studies and as the guidelines are validated
With this in mind, simple standardized techniques as vali- in clinical practice.
dated in trials may be optimal. Advanced techniques with
increased sensitivity are being developed, but with these, ACKNOWLEDGMENTS
comes the increased risk of false-positive results. These must The “EGFR Testing in NSCLC: from biology to clinical
be avoided, so that patients do not receive treatment from practice” workshop that was held on November 27–28, 2009
which they are unlikely to benefit. in Vienna, Austria, was made possible by unrestricted edu-
cational grants from AstraZeneca (principal sponsor) and
SUMMARY Merck Serono (secondary sponsor).
Clinical characteristics and histology have previously The authors thank all the participants. A list of
been documented as predictive factors for response to EGFR- participants is included in the Appendix.

Copyright © 2010 by the International Association for the Study of Lung Cancer 1711
Pirker et al. Journal of Thoracic Oncology • Volume 5, Number 10, October 2010

APPENDIX: PARTICIPANTS OF THE “EGFR Sweden: Johan Botling, Daniel Brattström, Simon Ekman,
TESTING IN NSCLC” WORKSHOP Göran Elmberger, Leif Johansson, Hirsch Koyi, Jeanette
Spinnars, Karin Sundqvist.
Steering Committee Switzerland: Mico Frattini, Sonja Jehle, Rolf Stahel.
Robert Pirker, Martin Filipits, Helmut Popper (Aus- The Netherlands: Anne-Marie Dingemans, Manfred Marang,
tria); Dominique Grunenwald (France); Felix Herth (Ger- Petra Nederlof, Egbert Smit, Erik Thunnissen.
many); Federico Cappuzzo (Italy); Egbert Smit (The Nether- Turkey: Havva Didem Akpir Soydan, Adnan Aydiner, E
lands); Rafael Rosell (Spain); Rolf Stahel (Switzerland); Dilek Yilmazbayhen.
Keith Kerr (UK). United Kingdom: Rachel Butler, Caroline Clark, Ian Cook,
Ian Cree, David Gonzalez De Castro, Alison Horsfield,
Keith Kerr, Gael McWalter, Philippe Taniere, Jane
Breakout Session Chairs and Cochairs Theaker, Graham Walker.
USA: David Gandara, Fred Hirsch.
Biopsy and sampling session: Felix Herth (Germany); Do-
minique Grunenwald (France); Robert Pirker (Austria).
Pathology session: Keith Kerr (UK); Egbert Smit (The Neth- REFERENCES
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