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Phase II study of biomarker-guided neoadjuvant treatment strategy for IIIA-N2 non-small cell lung cancer based on epidermal growth factor receptor mutation status
- Wenzhao Zhong†1,
- Xuening Yang†1,
- Honghong Yan1,
- Xuchao Zhang1,
- Jian Su1,
- Zhihong Chen1,
- Riqiang Liao1,
- Qiang Nie1,
- Song Dong1,
- Qing Zhou1,
- Jinji Yang1,
- Haiyan Tu1 and
- Yi-Long Wu1Email author
© Zhong et al. 2015
Received: 2 March 2015
Accepted: 7 May 2015
Published: 17 May 2015
Neoadjuvant erlotinib and customized adjuvant therapy are appealing but controversial. The purpose of this study was to evaluate the role of biomarker-guided neoadjuvant treatment strategy in patients with IIIA-N2 non-small cell lung cancer (NSCLC) stratified by epidermal growth factor receptor (EGFR) mutation status.
Patients with resectable histologically documented stage IIIA-N2 NSCLC were assigned to a neoadjuvant erlotinib arm or a gemcitabine/carboplatin (GC) arm based on EGFR mutation status. The primary endpoint was response rate (RR). Secondary endpoints were progression-free survival (PFS) and overall survival (OS).
Twenty-four patients with IIIA-N2 NSCLC were enrolled in the trial from January 2008 until May 2011. The overall response rate was 41.7 % and the PFS and OS were 7.9 and 23.2 months, respectively, in overall population. The RR was 58.3 % (7/12) for the erlotinib arm with mutant EGFR and 25.0 % (3/12) for the GC arm with wild type EGFR (P = 0.18). Median PFS was 6.9 months versus 9.0 months, respectively (P = 0.071). Median OS was 14.5 months for the erlotinib arm and 28.1 months for the GC arm (P = 0.201). No unexpected toxicities were observed.
The primary endpoint was met and biomarker-guided neoadjuvant treatment strategy in patients with IIIA-N2 NSCLC is feasible. Erlotinib alone in neoadjuvant setting of EGFR mutant population showed an improved response but without survival benefits.
ClinicalTrials.gov NCT00600587 https://www.clinicaltrials.gov/ct2/show/NCT00600587?term=NCT00600587&rank=1
Patients with stage IIIA non-small cell lung cancer (NSCLC) represent a relatively heterogeneity with ipsilateral mediastinal lymph nodes (N2) involved, and relative roles of treatment modalities are not clearly defined. Chemoradiotherapy is an important treatment for stage IIIA disease but limited by treatment-related life-threatening toxicities . And previous work showed that status of gene expression was related to different degrees of how much gemcitabine improved survival of patients with advanced NSCLC . Recently, an individual participant data meta-analysis  found that neoadjuvant chemotherapy improves an absolute 5-year survival of 5 % and may be preferable for patients with poorer prognosis or larger tumors. However, chemotherapy has reached a therapeutic plateau in NSCLC. A literature-based meta-analysis reported  that tyrosine kinase inhibitors (TKIs) could provide more survival benefits for patients with advanced epidermal growth factor receptor (EGFR) mutant NSCLC, indicating the importance of selected patients with specific mutations when exploring efficacy of targeted therapy. In patients with EGFR mutation positive NSCLC, an EGFR-TKI may provide a dramatic response in a metastatic setting [5–7]. The primary analysis in the OPTIMAL study, comparing first-line erlotinib with gemcitabine/carboplatin (GC) in patients with advanced NSCLC with EGFR mutations, showed relatively higher response rate of 82.9 % (68/82) and significantly longer progression-free survival (PFS) with erlotinib than with GC therapy . Since 2007, several case reports and retrospective studies with small sample sizes have shown that neoadjuvant EGFR-TKI therapy results in N2 downstaging in patients with stage IIIA-N2 NSCLC harboring EGFR mutation [9–12]. In two phase II studies, neoadjuvant EGFR-TKI showed low toxicity and sufficient activity in an enriched population [13, 14]. However, no survival data in neoadjuvant TKI therapy were obtained.
In the near future, lung cancer treatment will likely become more patient-tailored by a molecular-based strategy. Neoadjuvant EGFR-TKI therapy and customized adjuvant therapy (IFCT-0801, TASTE trial) are appealing but controversial strategies in patients with IIIA-N2 NSCLC . The aim of this study was to investigate the efficacy of biomarker-guided neoadjuvant treatment strategy with erlotinib versus GC regimen in patients with stage IIIA-N2 NSCLC stratified by EGFR activating mutations and explore a new treatment strategy for this subset of patients.
Results and discussion
Baseline patient demographics and clinical characteristics
Median age at diagnosis (years)
60.17 ± 13.31
58.75 ± 12.12
Gender, n (%)
6 (6/12, 50.00 %)
8 (8/12, 66.67 %)
6 (6/12, 50.00 %)
4 (4/12, 33.33 %)
6.25 ± 11.89
20.83 ± 21.09
Daily cigarette consumption, n
7.92 ± 14.99
17.92 ± 18.27
Pathology, n (%)
11 (11/12, 91.67 %)
11 (11/12, 91.67 %)
0 (0.00 %)
1 (1/12, 8.33 %)
Adenoid cystic carcinoma
1 (1/12, 8.33 %)
0 (0.00 %)
Mutation status, n (%)
EGFR/KRAS wild type
Exon 19 deletion
EGFR mutation with KRAS codon
EGFR mutation with EML4-ALK*
Deletion in BIM
Postoperative radiotherapy, n
Median follow-up (months)
Evaluation of neoadjuvant therapy efficacy
Erlotinib arm n = 12, (%)
GC arm n = 12, (%)
Clinical N2 downstaging
Pathological N2 downstaging
Survival and failure models 
Treatment toxicity and feasibility
Overall, neoadjuvant therapies were well tolerated. The most common side effects in the erlotinib arm were rash (100 %; 16.7 % as grade 3–4) and diarrhea (41.6 %). Only one case had postoperative bleeding. Another case in the erlotinib arm suffered from acute radiotherapy-induced pneumonitis related to death. Three cases in the GC arm exhibited grade 4 thrombocytopenia, two of which received blood transfusion.
The second median PFS, after the first progression, was 8.0 months (95 % CI, 4.0–12.0) for the erlotinib arm and 4.0 months (95 % CI, 1.2–6.8) for the GC arm (P = 0.880) (Fig. 2f). In addition, all six cases undergoing R0/R1 resection in the erlotinib arm achieved PR to TKI retreatment at progression, with a median PFS of 9.4 months.
Genetic profiles in two arms are summarized in Additional file 1, indicating rare genetic heterogeneity between initial specimens and surgical samples after neoadjuvant therapy. There was only one patient in each arm whose gene mutation status transferred from mutant type to wild type or contrariwise. The BIM deletion polymorphism had no correlation with TKI efficacy (Additional file 1). Immunohistochemistry (IHC) was conducted to detect protein expressions on resected samples after induced elotinib therapy. In all six cases, pEGFR (Tyr1068) has been deregulated. Two cases with L858R mutation enjoyed the longest PFS, among which the p44/42MAPK (Erk1/2) (137 F5) was deregulated and the pAkt (Thr308) (244 F9) was most activated compared with other five cases. (Additional file 2).
Several randomized controlled trials (RCTs) have established the foundation of EGFR-TKI as first-line therapy in advanced NSCLC with EGFR mutation [5–8]. Indications for EGFR-TKIs have been transferred from second-line to first-line in targeted populations. However, NSCLC is a heterogeneous disease between early and advanced stages and between wild and mutant EGFR lung cancer. Therefore, principles for TKI therapy might be different between first-line, neoadjuvant, and adjuvant treatment . The use of EGFR-TKI in neoadjuvant treatment of NSCLC has been evaluated in limited numbers of phase II studies without survival data. Furthermore, customized NSCLC adjuvant therapy (IFCT-0801, TASTE trial)  and systematic therapy (BATTLE)  had validated its feasibility. Thus, biomarker-guided neoadjuvant treatment should be further evaluated in neoadjuvant settings for locally advanced but operable diseases.
Comparison of neoadjuvant trials in lung cancer
Roth 1994 
Rosell 1994 
Scagliotti 2012  (CHEST)
Lara-Guerra 2009 
Schaake 2012 
Lu 2013  (CTONG 1101)
E + GC
Zhong 2014 (CSLC 0702)
E or GC
Overall, the PFS and OS were 7.9 and 23.2 months, respectively, similar to the INT 0139 trial in radiotherapy plus chemotherapy with/without surgical resection for stage IIIA NSCLC . Therefore, biomarker-guided neoadjuvant treatment strategy in patients with IIIA-N2 NSCLC based on EGFR mutation status is feasible.
To our knowledge, CSLC 0702 is the first phase II study of biomarker-guided neoadjuvant treatment strategy for IIIA-N2 NSCLC based on EGFR mutation status with PFS and OS data. The trial met its primary outcome and validated the feasibility of this strategy. Nevertheless, erlotinib alone in neoadjuvant setting tended to show an improved response but without better PFS or OS. Brain and lung metastases were most common failure models. The role of TKIs in first-line setting of advanced NSCLC should not be simply extrapolated to neoadjuvant therapy. More RCTs combining neoadjuvant with adjuvant EGFR-TKI therapy in a larger population are warranted to validate the role of perioperative TKI therapy. We look forward to results of these trials to provide convincing evidences for customized therapy for patients with resectable NSCLC .
This study, conducted in Guangdong General Hospital, China, was designed as an open-label, single-center, non-randomized, phase II clinical trial. It was approved by a local independent ethics committee and designed in accordance with Good Clinical Practice Guidelines. Written informed consents were obtained from patients before the start of treatment. Patients with resectable stage IIIA-N2 NSCLC diagnosed by mediastinoscopy or EBUS were assigned at a ratio of 1:1 to the neoadjuvant erlotinib arm or the GC arm based on EGFR mutation status. This study was sponsored by Chinese Society of Lung Cancer (CSLC 0702), the predecessor of Chinese Thoracic Oncology Group (CTONG), and was registered at ClinicalTrials.gov as NCT00600587.
Patients with newly diagnosed resectable stage IIIA-N2 NSCLC and confirmed by mediastinoscopy or EBUS (i.e., clinical T1-3 N2) were enrolled. All patients were evaluated in a multidisciplinary tumor board discussion. The diagnosis had to be histologically or cytologically confirmed with sufficient tissue samples to perform gene analysis. Candidates, having ECOG performance status of 0–1, adequate hematological and hepatic-renal functions, and qualified lung function, were required to tolerate neoadjuvant therapy and a lobectomy and radical lymph node dissection. No pregnant or breast feeding patients were included. In addition, patients with a small cell lung cancer component, any unstable systemic disease, or exposure to investigational drug therapy or other concurrent anticancer therapies outside of this trial were excluded.
Tumor specimens and imaging data were reviewed and analyzed by the Guangdong Lung Cancer Institute. The CT or FDG-PET/CT scans were performed after study treatments were compared with baseline scans. Radiological tumor response after neoadjuvant therapy was assessed according to the Response Evaluation Criteria in Solid Tumors measurement criteria, version 1.1.
DNA was extracted from formalin-fixed paraffin-embedded (FFPE) samples or frozen resection samples with macroscopically viable tumor tissue. Mutation testing was performed at the certified laboratory of Guangdong Lung Cancer Institute. EGFR and KRAS mutations in the initial biopsy, postoperative material, and recurrent tumor tissue were determined by Sanger sequencing, and EGFR mutations in plasma were tested using ARMS according to the protocol of the DxS EGFR mutation test kit (DxS). EML4-ALK translocation was analyzed by FISH using Vysis ALK Break Apart FISH Probe Kit according to the manufacturer’s instruction. In addition, the deletion polymorphism of the Bcl-2-interacting mediator of cell death (BIM) gene in intron 2 was retrospectively examined by Sanger sequencing to validate its predictive role for TKI efficacy. IHC was conducted to detect the protein expressions of mutant EGFR and downstream molecules using rabbit mAbs from Cell Signaling Technology according to the protocols recommended by the manufacturer [31, 32].
Power analysis of one proportion non-inferiority was applied to provide 95 % power to declare the treatment sufficiently active for a response rate ≥42.5 % (the average of 50 % of TKI in EGFR mutant lung cancer and 35 % of GC regimen in neoadjuvant setting) in the biomarker-guided neoadjuvant treatment strategy and 11 % for the history reference of neoadjuvant TKI therapy [13, 19]. A sample size of 22 achieves 96 % power to detect a difference of −0.01 using a one-sided binomial test. The target significance level is 0.05. The actual significance level achieved is 0.0344. These results assume a baseline proportion of 0.12 and that the actual proportion is 0.417 .
Response rates were analyzed by use of the Fisher’s Exact Test. Survival was estimated with Kaplan-Meier methodology and was summarized as a median value with range and a two-sided 95 % CI. A Cox proportional hazards model was utilized to estimate hazard ratios (HR) and 95 % CI. SPSS version 21 was used for statistical analyses. All analyses were exploratory only.
We would like to thank all patients who took part in and contributed to this research. We thank the investigators (Binchao Wang, She-Juan An, Congrui Xu, Huajun Chen, Benjiang Yuan, Yisheng Huang, Zhiyong Chen, Ying Huang, Hong-Yan Tang, Zhi Xie, and Shi-Lang Chen) and study nurses (Sufen Luo, Bin Gan) who participated in this study.
This work was supported by grants from the National Natural Science Foundation of China [81001031 to W.Z. Zhong, 81372285 to W.Z. Zhong] and the grant S2013010016354 from the Natural Science Foundation of Guangdong, Guangdong Provincial Key Laboratory of Lung Cancer Translational Medicine (Grant No. 2012A061400006), Special Fund for Research in the Public Interest from National Health and Family Planning Commission of PRC (Grant No. 201402031), and Research Fund from Guangzhou Science and Technology Bureau (Grant No. 2011Y2-00014).
This study was presented in part at the World Conference on Lung Cancer (WCLC) (e-poster on July 31st–August 4th, 2009; San Francisco, California, USA), the American Society of Clinical Oncology (ASCO) (poster on June 4th–8th, 2010; Chicago, Illinois, USA) (poster on June 1st–5th, 2012; Chicago, Illinois, USA) (poster on May 30th–June 3rd, 2014; Chicago, Illinois, USA), and the Japanese Society of Medical Oncology (JSMO) (oral presentation on July 26th–28th, 2012; Osakasayama City, Osaka, Japan). What is more, our team has won CAHON’s 2014 ASCO YIA awards for this trial.
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