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Mechanisms and clinical activity of an EGFR and HER2 exon 20-selective kinase inhibitor in non-small cell lung cancer.

ABSTRACT: Although most activating mutations of epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancers (NSCLCs) are sensitive to available EGFR tyrosine kinase inhibitors (TKIs), a subset with alterations in exon 20 of EGFR and HER2 are intrinsically resistant and lack an effective therapy. We used in silico, in vitro, and in vivo testing to model structural alterations induced by exon 20 mutations and to identify effective inhibitors. 3D modeling indicated alterations restricted the size of the drug-binding pocket, limiting the binding of large, rigid inhibitors. We found that poziotinib, owing to its small size and flexibility, can circumvent these steric changes and is a potent inhibitor of the most common EGFR and HER2 exon 20 mutants. Poziotinib demonstrated greater activity than approved EGFR TKIs in vitro and in patient-derived xenograft models of EGFR or HER2 exon 20 mutant NSCLC and in genetically engineered mouse models of NSCLC. In a phase 2 trial, the first 11 patients with NSCLC with EGFR exon 20 mutations receiving poziotinib had a confirmed objective response rate of 64%. These data identify poziotinib as a potent, clinically active inhibitor of EGFR and HER2 exon 20 mutations and illuminate the molecular features of TKIs that may circumvent steric changes induced by these mutations.

SUBMITTER: Robichaux JP

PROVIDER: S-EPMC5964608 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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Mechanisms and clinical activity of an EGFR and HER2 exon 20-selective kinase inhibitor in non-small cell lung cancer.

Robichaux Jacqulyne P JP Elamin Yasir Y YY Tan Zhi Z Carter Brett W BW Zhang Shuxing S Liu Shengwu S Li Shuai S Chen Ting T Chen Ting T Poteete Alissa A Estrada-Bernal Adriana A Le Anh T AT Truini Anna A Nilsson Monique B MB Sun Huiying H Roarty Emily E Goldberg Sarah B SB Brahmer Julie R JR Altan Mehmet M Lu Charles C Papadimitrakopoulou Vassiliki V Politi Katerina K Doebele Robert C RC Wong Kwok-Kin KK Heymach John V JV

Nature medicine 20180423 5

Although most activating mutations of epidermal growth factor receptor (EGFR)-mutant non-small cell lung cancers (NSCLCs) are sensitive to available EGFR tyrosine kinase inhibitors (TKIs), a subset with alterations in exon 20 of EGFR and HER2 are intrinsically resistant and lack an effective therapy. We used in silico, in vitro, and in vivo testing to model structural alterations induced by exon 20 mutations and to identify effective inhibitors. 3D modeling indicated alterations restricted the s ...[more]

PMID: 29686424

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Project description:BackgroundDue to less sensitivity to classic tyrosine kinase inhibitors, effective first-line treatment is limited in non-small cell lung cancer (NSCLC) patients with epidermal growth factor receptor (EGFR) or human epidermal growth factor receptor 2 (HER2) exon 20 insertion (ex20ins) mutations. Meanwhile, the impact of driver genes on the efficacy of PD-1 inhibitors is discrepant. Our study aimed to assess the clinical response to immunotherapy in NSCLC patients with EGFR or HER2 ex20ins mutations. In parallel, patients treated with chemotherapy but without immunotherapy were included as controls.MethodsWe retrospectively reviewed patients harboring ex20ins mutations treated with immune checkpoint inhibitors (ICIs) and/or chemotherapy in the real world. The clinical response was assessed by progression-free survival (PFS) and the objective response rate (ORR). Propensity score matching (PSM) was performed to control for confounding factors between immunotherapy and chemotherapy.ResultsOf 72 patients enrolled, 38 had been treated with one line of single-agent immunotherapy or combined therapy including immunotherapy, and 34 had received conventional chemotherapy without immunotherapy. Among patients treated with immunotherapy, the median PFS was 10.7 months [95% confidence interval (CI): 8.2-13.2 months] in the first-line setting, with an ORR of 50% (8/16). The median PFS was significantly longer in the first-line immunotherapy group than in the chemotherapy group (10.7 vs. 4.6 months, P<0.001). A trend of an increased ORR in patients who received ICIs was observed compared with chemotherapy, but there was no statistical difference (50% vs. 21.9%, P=0.096). After PSM, the median PFS with first-line immunotherapy was still longer than that with chemotherapy (10.7 vs. 4.6 months, P=0.028). Grade 3-4 adverse events (AEs) were observed in 13.2% (5/38) of patients, with the majority developing granulocytopenia (40%, 2/5). One patient discontinued treatment due to a grade 3 rash after three cycles of ICI plus anlotinib treatment.ConclusionsThe results showed that immunotherapy combined with chemotherapy may play a role in the first-line treatment of NSCLC patients with ex20ins mutations. This finding requires further investigation for application.

Project description:No targeted treatments are currently approved for HER2 exon 20 insertion-mutant lung adenocarcinoma patients. Mobocertinib (TAK-788) is a potent irreversible tyrosine kinase inhibitor (TKI) designed to target human epidermal growth factor receptor 2 (HER2/ERBB2) exon 20 insertion mutations. However, the function of mobocertinib on HER2 exon 20 insertion-mutant lung cancer is still unclear. Here we conducted systematic characterization of preclinical models to understand the activity profile of mobocertinib against HER2 exon 20 insertions. In HER2 exon 20 insertion-mutant cell lines, the IC50 of mobocertinib was higher than poziotinib and comparable with or slightly lower than afatinib, neratinib, and pyrotinib. Mobocertinib had the lowest HER2 exon 20 insertion IC50/wild-type (WT) EGFR IC50 ratio, indicating that mobocertinib displayed the best selectivity profile in these models. Also, mobocertinib showed strong inhibitory activity in HER2 exon 20YVMA allograft and patient-derived xenograft models. In genetically engineered mouse models, HER2 exon 20G776>VC lung tumors exhibited a sustained complete response to mobocertinib, whereas HER2 exon 20YVMA tumors showed only partial and transient response. Combined treatment with a second antibody-drug conjugate (ADC) against HER2, ado-trastuzumab emtansine (T-DM1), synergized with mobocertinib in HER2 exon 20YVMA tumors. In addition to the tumor cell autonomous effect, sustained tumor growth control derived from M1 macrophage infiltration and CD4+ T-cell activation. These findings support the ongoing clinical development of mobocertinib (NCT02716116) and provide a rationale for future clinical evaluation of T-DM1 combinational therapy in HER2 exon 20YVMA insertion-mutant lung adenocarcinoma patients. SIGNIFICANCE: This study elucidates the potent inhibitory activity of mobocertinib against HER2 exon 20 insertion-mutant lung cancer and the synergic effect of combined mobocertinib and T-DM1, providing a strong rationale for clinical investigation.

Dataset Information

Mechanisms and clinical activity of an EGFR and HER2 exon 20-selective kinase inhibitor in non-small cell lung cancer.

Publications

Mechanisms and clinical activity of an EGFR and HER2 exon 20-selective kinase inhibitor in non-small cell lung cancer.

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