Predominance of EGFR mutations responsible for resistance to tyrosine kinase inhibitors among tumor DNAs assessed by picoliter droplet digital PCR analysis of cell-free plasma DNAs Yoshitaka Seki1,2, Yutaka Fujiwara3, Takashi Kohno1, Erina Takai4, Kuniko Sunami3, Hidehito Horinouchi3, Shintaro Kanda3, Hiroshi Nokihara3, Shun-ichi Watanabe5, Noboru Yamamoto3, Kazuyoshi Kuwano2, Yuichiro Ohe3. 1Division of Genome Biology and 4Division of Cancer Genomics, National Cancer Center Research Institute, Tokyo, Japan 3Department of Thoracic Oncology and 5Department of Thoracic Surgery, National Cancer Center Hospital, Tokyo, Japan Introduction & Objectives Detecting mutations by two TaqMan probes Exon 19 DEL mutations Study cohort consisting of 8 LADC patients who received EGFR-TKI therapy Eight patients with advanced LADCs were subjected to the cfDNA analysis(Table). Tumor tissues from all patients were diagnosed as positive for TKI-sensitive EGFR mutations. cfDNA was obtained after the cancers acquired resistance to EGFR-TKIs Assessment of the predominance of T790M+ tumor cells among tumor cells. Two ddPCR assays for a cfDNA sample Wild-type Del mut L858R or T790M mutations M Wild-type probe Mutation probe Reference probe Wild-type probe Fractions obtained RainDrop® Digital PCR System PCR mixture C T790M DNA /all EGFR DNA 19DEL or L858R DNA /all EGFR DNA 1000 Exon 19 DEL T790M Analysis of cell line genome DNA Negative droplet FAM+ droplet VIC+ droplet 69 60 60 0 -500 1500 19DEL : 228 500 0 Wild type : 887 0 1000 2000 3000 -500 1500 Wild type : 1322 1000 500 Wild type : 599 0 1000 Wild type : 501 1000 0 T790M : 2 1000 2000 3000 0 T790M : 99 0 1000 ●NSCLC with common EGFR mutation (exon 19 deletion, L858R) ●Systemic disease progression on EGFR-TKI within 30 days ●Patients without HBV/HCV infection cfDNAs from eight LADC patients acquiring resistance to EGFR-TKIs were subjected to picoliter-ddPCR assay that enables us to assess fractions of EGFR DNAs with T790M, L858R and representative exon 19 deletion mutations among all EGFR DNAs. 2000 3000 cfDNAs from 4 patients was consistent with those of their re-biopsied tissues from the lesion acquiring resistance. T790M mutation was deduced to have occurred in a variety of fractions (7-97%) of tumor DNAs. Table. Plasma cell-free DNAs subjected to picoliter-ddPCR Patient Age Sex no. cfDNA before acquiring resistance cfDNA after acquiring T790M mutation in resistance rebiopsied Sensitive T790M Sensitive T790M T790M tissues mut (%) mut (%) mut (%) mut (%) fraction Duration EGFR of Smoking EGFR-TKI Modes of disease mutation Stage (pack years) (Best response) therapy progression in tumor (months) 1 62 Female Never 19DEL IV Erlotinib (PR) 6.6 Malignant pericarditis 5.8 Negative Positive 30.7* 15.0* 0.49 2 74 Female Never 19DEL IV Erlotinib (PR) 12.4 Brain metastasis - - Positive 24.7* 9.5* 0.39 3 67 Female Never L858R IV Gefitinib (PR) 12.0 Primary diseases and liver metastasis - Positive 4.0* 0.86* 0.22 4 65 Male Never 19DEL IV Erlotinib (PR) 10.0 Malignant pleuritis 3.0 Negative - 5 68 Male Never 19DEL IV Erlotinib (SD) 8.6 Malignant pleuritis - - - 1.1* Negative - 6 65 Female Never L858R IV Gefitinib (PR) & 6.4 & Erlotinib (SD) 5.3 Liver and spinal metastases - - - 5.8 5.6 0.97 7 53 Female Never 19DEL IV Gefitinib (PR) Bone metastases - - - 16.0 1.2 0.074 8 51 Female Never 19DEL IV Erlotinib (SD) & 31.5 & Gefitinib (SD) 3.2 Primary diseases and spinal metastasis - - - 10.8 Negative - 2000 3000 500 0 69 12.3 Negative Negative Negative 20 0.0 0 PC9 (n=4) II-18 (n=4) Exon 19 deletion H1975 (n=4) L858R H1975 (n=4) PC9 (n=9) T790M Analysis of cfDNA from two patients with LADC harboring the EML4-ALK fusion 10 5.8 5 EGFR cfDNA profile of eight patients who acquired resistance Quantitative analysis using serially diluted DNA 40 Droplet measurement 19DEL : 55 Results: All eight patients examined after acquiring resistance to EGFR-TKIs showed positivity for TKI-sensitive mutations, and five of them (62.5%) also for T790M mutations. The mutation status of Patients eligibility: FAM intensity (Arb. units) 80 ddPCR assay 1000 500 89 No. of droplets positive for EGFR mutations B 19DEL or L858R After TKI resistance acquisition Before EGFR-TKI therapy Droplet creation 100 Thermal cycling T790M Fraction: T790M DNA/19DEL or L858R DNA || T790M tumor cells/ all tumor cells (i.e., fraction of TKI-resistant tumor cells) Mutant DNA (%) A Analysis of cfDNA from LADC patients Validation of analysis method Genomic DNA extracted from cell lines was used to assess the accuracy and reproducibility of picoliter-ddPCR. The quantitative nature of the analysis was validated using serially diluted DNA (R2 = 0.96), and the limit of detection was defined as more than 0.75% mutant alleles. To set the threshold for calling EGFR mutations in patient cfDNA, we subjected cfDNA from two patients with LADC harboring the EML4-ALK fusion to picoliter-ddPCR. These results revealed that only a few droplets among millions were positive for EGFR mutations (mean = 2.5, standard error, SE = 1.4); the threshold for a positive call was tentatively set to 10 droplets, based on the equation: mean + 5 × SE = 9.5. Using this threshold, the rate of false-positive droplet detection was predicted to be less than 0.0002%. T790M DNA detected (%) Wild-type of Respiratory Diseases, Department of Internal Medicine, Jikei University School of Medicine, Japan Experimental Design VIC intensity (Arb. units) The new generation EGFR-tyrosine kinase inhibitors (TKIs), which suppress the kinase activity of EGFR proteins with secondary T790M resistant mutation, are being developed to overcome resistance to therapy using current EGFR-TKI. Non-invasive monitoring of EGFR gene mutations conferring sensitive (L858R and ex. 19 deletion mutations) and T790M as resistant mutations to TKIs are inevitable for efficient therapy of lung adenocarcinoma (LADC) using new generation EGFR-TKIs. We aimed to evaluate the utility of picoliter droplet digital PCR (pdPCR)-based cell-free plasma DNA (cfDNA) examination to assess the tumor progression status of LADC patients against EGFR-TKI treatments. 2Division 100 Circle size: Tumor cfDNA fraction in total cfDNA R² = 0.96 % of T790M positive % of T790M negative 1 0.3 1 19DEL L858R T790M all (n=3) (n=5) (n=6) (n=14) 10 H1975 DNA mixed (%) 100 ? ? 12 m Erlotinib 7 m #4 30.7% #2 #5 ? Erlotinib 12 m 24.7% Gefitinib 6m Erlotinib 5 m Erlotinib 1.1% 9 m Conclusion 97% 5.8% #7 ? 0% Erlotinib 3.0% 10 m ? 0 0 5.8% #6 22% Erlotinib 4.0% (-) 10 2.5 0.8 #1 #3 #8 ? Gefitinib 12 m 7.4% 16.0% Erlotinib 32 m Gefitinib 10.8% 3m + another TKI Picoliter-ddPCR-based examination of cfDNAs present a robust noninvasive assessment of tumor resistant status against EGFR-TKI treatments. Information of the predominance of T790M mutated DNAs among tumor DNAs might be helpful for T790M targeted therapy. A prospective study to validate the utility of the picoliter-ddPCR assay is on-going on patients receiving EGFR-TKI therapy.
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