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.
- Robinson LA, Ruckdeschel JC, Wagner HJ, Stevens CW. Treatment of non-small cell lung cancer-stage IIIA: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:243S–65S.PubMedView ArticleGoogle Scholar
- Dong S, Guo AL, Chen ZH, Wang Z, Zhang XC, Huang Y, et al. RRM1 single nucleotide polymorphism -37C → A correlates with progression-free survival in NSCLC patients after gemcitabine-based chemotherapy. J Hematol Oncol. 2010;3:10.PubMed CentralPubMedView ArticleGoogle Scholar
- NSCLC Meta-analysis Collaborative Group. Preoperative chemotherapy for non-small-cell lung cancer: a systematic review and meta-analysis of individual participant data. Lancet. 2014;383:1561–71.PubMed CentralView ArticleGoogle Scholar
- Xu C, Zhou Q, Wu YL. Can EGFR-TKIs be used in first line treatment for advanced non-small cell lung cancer based on selection according to clinical factors? - A literature-based meta-analysis. J Hematol Oncol. 2012;5:62.PubMed CentralPubMedView ArticleGoogle Scholar
- Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med. 2009;361:947–57.PubMedView ArticleGoogle Scholar
- Rosell R, Moran T, Queralt C, Porta R, Cardenal F, Camps C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. N Engl J Med. 2009;361:958–67.PubMedView ArticleGoogle Scholar
- Wu YL, Zhou C, Hu CP, Feng J, Lu S, Huang Y, et al. Afatinib versus cisplatin plus gemcitabine for first-line treatment of Asian patients with advanced non-small-cell lung cancer harbouring EGFR mutations (LUX-Lung 6): an open-label, randomised phase 3 trial. Lancet Oncol. 2014;15:213–22.PubMedView ArticleGoogle Scholar
- Zhou C, Wu YL, Chen G, Feng J, Liu XQ, Wang C, et al. Erlotinib versus chemotherapy as first-line treatment for patients with advanced EGFR mutation-positive non-small-cell lung cancer (OPTIMAL, CTONG-0802): a multicentre, open-label, randomised, phase 3 study. Lancet Oncol. 2011;12:735–42.PubMedView ArticleGoogle Scholar
- Hishida T, Nagai K, Mitsudomi T, Yokoi K, Kondo H, Horinouchi H, et al. Salvage surgery for advanced non-small cell lung cancer after response to gefitinib. J Thorac Cardiovasc Surg. 2010;140:e69–71.PubMedView ArticleGoogle Scholar
- Kappers I, Klomp HM, Burgers JA, Van Zandwijk N, Haas RL, van Pel R. Neoadjuvant (induction) erlotinib response in stage IIIA non-small-cell lung cancer. J Clin Oncol. 2008;26:4205–7.PubMedView ArticleGoogle Scholar
- Takamochi K, Suzuki K, Sugimura H, Funai K, Mori H, Bashar AH, et al. Surgical resection after gefitinib treatment in patients with lung adenocarcinoma harboring epidermal growth factor receptor gene mutation. Lung Cancer. 2007;58:149–55.PubMedView ArticleGoogle Scholar
- Wang Q, Wang H, Li P, Zhu H, He C, Wei B, et al. Erlotinib-based perioperative adjuvant therapy for a case of unresectable stage IIIA (N2) nonsmall cell lung cancer. Am J Med Sci. 2010;340:321–5.PubMedView ArticleGoogle Scholar
- Lara-Guerra H, Waddell TK, Salvarrey MA, Joshua AM, Chung CT, Paul N, et al. Phase II study of preoperative gefitinib in clinical stage I non-small-cell lung cancer. J Clin Oncol. 2009;27:6229–36.PubMedView ArticleGoogle Scholar
- Schaake EE, Kappers I, Codrington HE, Valdes OR, Teertstra HJ, van Pel R, et al. Tumor response and toxicity of neoadjuvant erlotinib in patients with early-stage non-small-cell lung cancer. J Clin Oncol. 2012;30:2731–8.PubMedView ArticleGoogle Scholar
- Wislez M, Barlesi F, Besse B, Mazieres J, Merle P, Cadranel J, et al. Customized adjuvant phase II trial in patients with non-small-cell lung cancer: IFCT-0801 TASTE. J Clin Oncol. 2014;32:1256–61.PubMedView ArticleGoogle Scholar
- Yang J, Chen H, Yan H, Zhang X, Zhou Q, Su J, et al. Clinical modes of EGFR tyrosine kinase inhibitor failure and subsequent management in advanced non-small cell lung cancer. 2013. p. 33–9.Google Scholar
- Goss GD, O’Callaghan C, Lorimer I, Tsao MS, Masters GA, Jett J, et al. Gefitinib versus placebo in completely resected non-small-cell lung cancer: results of the NCIC CTG BR19 study. J Clin Oncol. 2013;31:3320–6.PubMed CentralPubMedView ArticleGoogle Scholar
- Kim ES, Herbst RS, Wistuba II, Lee JJ, Blumenschein GJ, Tsao A, et al. The BATTLE trial: personalizing therapy for lung cancer. Cancer Discov. 2011;1:44–53.PubMed CentralPubMedView ArticleGoogle Scholar
- Scagliotti GV, Pastorino U, Vansteenkiste JF, Spaggiari L, Facciolo F, Orlowski TM, et al. Randomized phase III study of surgery alone or surgery plus preoperative cisplatin and gemcitabine in stages IB to IIIA non-small-cell lung cancer. J Clin Oncol. 2012;30:172–8.PubMedView ArticleGoogle Scholar
- Rosell R, Gomez-Codina J, Camps C, Maestre J, Padille J, Canto A, et al. A randomized trial comparing preoperative chemotherapy plus surgery with surgery alone in patients with non-small-cell lung cancer. N Engl J Med. 1994;330:153–8.PubMedView ArticleGoogle Scholar
- Roth JA, Fossella F, Komaki R, Ryan MB, Putnam JJ, Lee JS, et al. A randomized trial comparing perioperative chemotherapy and surgery with surgery alone in resectable stage IIIA non-small-cell lung cancer. J Natl Cancer Inst. 1994;86:673–80.PubMedView ArticleGoogle Scholar
- Lu S, Jiang G, Chen Z. A single arm, multi-center, Phase II study of intercalated erlotinib with gemcitabine/cisplatin as neoadjuvant treatment in Stage IIIA non-small cell lung cancer (CTONG 1101, NCT01297101): preliminary result. WCLC Abstract #P1.09-016. In: the 15th World Conference on Lung Cancer; October 27–30, 2013. Sydney, Australia; 2013.Google Scholar
- Albain KS, Swann RS, Rusch VW, Turrisi AR, Shepherd FA, Smith C, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet. 2009;374:379–86.PubMed CentralPubMedView ArticleGoogle Scholar
- Chaft JE, Oxnard GR, Sima CS, Kris MG, Miller VA, Riely GJ. Disease flare after tyrosine kinase inhibitor discontinuation in patients with EGFR-mutant lung cancer and acquired resistance to erlotinib or gefitinib: implications for clinical trial design. Clin Cancer Res. 2011;17:6298–303.PubMed CentralPubMedView ArticleGoogle Scholar
- Zhou Q, Cheng Y, Yang JJ, Zhao MF, Zhang L, Zhang XC, et al. Pemetrexed versus gefitinib as a second-line treatment in advanced nonsquamous nonsmall-cell lung cancer patients harboring wild-type EGFR (CTONG0806): a multicenter randomized trial. Ann Oncol. 2014;25:2385–91.PubMedView ArticleGoogle Scholar
- Chin TM, Quinlan MP, Singh A, Sequist LV, Lynch TJ, Haber DA, et al. Reduced erlotinib sensitivity of epidermal growth factor receptor-mutant non-small cell lung cancer following cisplatin exposure: a cell culture model of second-line erlotinib treatment. Clin Cancer Res. 2008;14:6867–76.PubMed CentralPubMedView ArticleGoogle Scholar
- Bai H, Wang Z, Chen K, Zhao J, Lee JJ, Wang S, et al. Influence of chemotherapy on EGFR mutation status among patients with non-small-cell lung cancer. J Clin Oncol. 2012;30:3077–83.PubMedView ArticleGoogle Scholar
- Zhou Q, Zhang XC, Chen ZH, Yin XL, Yang JJ, Xu CR, et al. Relative abundance of EGFR mutations predicts benefit from gefitinib treatment for advanced non-small-cell lung cancer. J Clin Oncol. 2011;29:3316–21.PubMedView ArticleGoogle Scholar
- Yi S, Zhuang Y, Zhou J, Ma H, Huang J, Wang L, et al. A comparison of epidermal growth factor receptor mutation testing methods in different tissue types in non-small cell lung cancer. Int J Mol Med. 2014;34:464–74.PubMedGoogle Scholar
- Mitsudomi T, Suda K, Yatabe Y. Surgery for NSCLC in the era of personalized medicine. Nat Rev Clin Oncol. 2013;10:235–44.PubMedView ArticleGoogle Scholar
- An SJ, Chen ZH, Su J, Zhang XC, Zhong WZ, Yang JJ, et al. Identification of enriched driver gene alterations in subgroups of non-small cell lung cancer patients based on histology and smoking status. PLoS One. 2012;7:e40109.PubMed CentralPubMedView ArticleGoogle Scholar
- Costa DB, Halmos B, Kumar A, Schumer ST, Huberman MS, Boggon TJ, et al. BIM mediates EGFR tyrosine kinase inhibitor-induced apoptosis in lung cancers with oncogenic EGFR mutations. PLoS Med. 2007;4:1669–79.PubMedView ArticleGoogle Scholar
- Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. 3rd ed. New York: John Wiley & Sons; 2003.View ArticleGoogle Scholar