Chris Karlovich

Abstract B136: Plasma EGFR mutation detection using a combined exosomal RNA and circulating tumor DNA approach in patients with acquired resistance to first-generation EGFR-TKIs

Background: After initial responses to tyrosine kinase inhibitors (TKIs), NSCLC patients (pts) harboring EGFR activating mutations inevitably progress, with the “gatekeeper” EGFR T790M resistance mutation accounting for approximately 60% of cases of acquired resistance (AR) to TKIs. EGFR activating and T790M resistance mutations can be found in plasma on both circulating free tumor DNA (ctDNA) and on RNA contained within exosomes. While ctDNA is thought to be primarily released by dying cells, exosome RNA is actively released by many living cells (Jahr et al. Cancer Res 2001; Thery et al. Nat Rev Immunol 2009). Some pts, particularly those with either early stage or intra-thoracic disease, do not seem to release mutations on ctDNA into circulation that is detectable by any current method. Here we present data demonstrating the detection of activating and AR EGFR mutations using a combined single-step exosomal RNA (exoRNA) and ctDNA approach to maximize sensitivity and demonstrate the ability to detect mutations using exosomal RNA on pts previously described as negative by ctDNA methods alone. Methods: Matched pretreatment tumor tissue and plasma were collected from 81 NSCLC pts enrolled in TIGER-X, a Ph1/2 study of rociletinib in previously treated mutant EGFR pts with advanced NSCLC. Among the 81 pts (all enrolled before Dec 2014), 56 cases were randomly chosen from the clinical patient population (including 35 cases ≥10 mutant copies/mL and 21 cases Results: For the 56 cases randomly chosen from the clinical patient population, 54 had valid tumor tissue results. The positive percent agreement (PPA) between plasma and tumor was 96% (52/54) for activating mutations and 86% (42/49) for T790M with tumor as the reference method. For most cases analyzed, the combined mutation signal from exoRNA and ctDNA was greater than the signal from ctDNA alone. Furthermore, we detect mutations in the circulation of some pts who were previously called negative by analysis of ctDNA alone, suggesting improved sensitivity from addition of exoRNA to the analysis. In the subset of pts with low or undetectable levels of ctDNA and valid tumor results (N = 45), we detect activating mutations in 38 of 45 cases (PPA 84%) compared to 27 of 45 (PPA 60%) by ctDNA alone, as well as T790M in 22 of 35 evaluable cases (PPA 63%) compared to 19 of 35 in ctDNA alone (PPA 54%). Conclusions: Our data demonstrate the ability to detect low copy numbers of activating and AR mutations in plasma of lung cancer pts by combining the mutation signal from exoRNA and ctDNA isolated by EXO52 and using the EXO1000 targeted NGS gene panel. By combining these two analytes, a higher sensitivity of mutation detection may be possible compared to analysis by ctDNA alone. Citation Format: Anne K. Krug, Chris Karlovich, Tina Koestler, Kay Brinkmann, Alexandra Spiel, Jennifer Emenegger, Mikkel Noerholm, Vince O9Neill, Lecia V. Sequist, Jean-Charles Soria, Jonathan W. Goldman, D. Ross Camidge, Heather A. Wakelee, Shirish M. Gadgeel, Elaina Mann, Shannon Matheny, Lindsey Rolfe, Mitch Raponi, Daniel Enderle, Johan Skog. Plasma EGFR mutation detection using a combined exosomal RNA and circulating tumor DNA approach in patients with acquired resistance to first-generation EGFR-TKIs. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr B136.

EGFR Genotyping of Matched Urine, Plasma, and Tumor Tissue in Patients With Non–Small-Cell Lung Cancer Treated With Rociletinib, an EGFR Tyrosine Kinase Inhibitor

PurposeLiquid biopsies represent an attractive alternative to tissue biopsies, particularly rebiopsies, in determining patient eligibility for targeted therapies. Clinical utility of urine genotyping, however, has not been explored extensively. We evaluated epidermal growth factor receptor (EGFR) T790M detection in matched urine, plasma, and tissue and the clinical outcomes of patients with advanced non–small-cell lung cancer treated with rociletinib.MethodsTissue (n = 540), plasma (n = 482), and urine (n = 213) were collected from evaluable patients enrolled in TIGER-X, a phase I/II study. Genotyping was performed by therascreen EGFR testing in tissue, BEAMing in plasma, and a quantitative short footprint assay (Trovera) in urine, which was used to further examine discordant samples.ResultsPositive percent agreement with tissue T790M results was similar for urine (82%; 142 of 173) and plasma (81%; 313 of 387) genotyping. Urine and plasma together identified more patients who were T790M positive (92%) tha...

Abstract 927: Pretreatment and serial plasma assessments of EGFR mutations in NSCLC patients treated with rociletinib (CO-1686)

Background: EGFR mutation testing is required to identify patients who may respond to TKI therapy. However, tumor biopsies from NSCLC patients can pose challenges for molecular analyses due to inadequate sample material, the inability to biopsy patients due to poor health status or inaccessible lesions, and tumor heterogeneity. We examined the detection of EGFR mutations in circulating cell-free DNA (cfDNA) from plasma and the concordance of EGFR mutation status with contemporaneously matched tumor tissue in TIGER-X, a Phase 1/2 clinical study of rociletinib (CO-1686) in previously treated advanced NSCLC patients harboring EGFR mutations in their tumors. Rociletinib is an oral, potent, small-molecule irreversible tyrosine kinase inhibitor that selectively targets mutant forms of EGFR, including T790M, L858R and Del(19), while sparing wild-type EGFR. Methods: Pretreatment matched tumor tissue and plasma from 139 Stage IIIB/IV NSCLC patients enrolled in TIGER-X were evaluated for EGFR status. Tumor tissue was processed as FFPE and tested by allele-specific PCR. Plasma was tested as a two mL aliquot using BEAMing, a quantitative and sensitive detection technology based on digital PCR. Results: Using tissue as the reference, the positive percent agreement between tumor and BEAMing plasma test results was 86% (102/119) for activating mutations and 77% (78/101) for T790M. Four plasma samples of the 23 tumor T790M+/plasma T790M- cases were also tested by three independent plasma testing platforms with claimed analytical sensitivities of Conclusions: The BEAMing plasma test identified EGFR mutations detected in tumor with high sensitivity. In addition, plasma testing identified T790M+ patients that were determined T790M- by the tumor test, which may be in part explained by tumor heterogeneity and/or inadequate biopsy. These findings demonstrate that BEAMing can be a useful tool for the non-invasive assessment of EGFR mutations in NSCLC. Citation Format: Jonathan W. Goldman, Chris Karlovich, Elaina Mann, Lindsey Rolfe, Shannon Matheny, Darrin Despain, Philipp Angenendt, Claudia Stamm, Heather A. Wakelee, Jean-Charles Soria, Benjamin Solomon, D. R. Camidge, Rafal Dziadziuszko, Leora Horn, Shirish Gadgeel, Mitch Raponi, Andrew R. Allen, Lecia V. Sequist. Pretreatment and serial plasma assessments of EGFR mutations in NSCLC patients treated with rociletinib (CO-1686). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 927. doi:10.1158/1538-7445.AM2015-927

Cell-Free DNA Next-Generation Sequencing Prediction of Response and Resistance to Third-Generation EGFR Inhibitor

&NA; We profiled 77 non–small‐cell lung cancer patients with paired baseline and progression blood samples treated with the third‐generation EGFR tyrosine kinase inhibitor (TKI) rociletinib using a broad cell‐free circulating DNA (cfDNA) next‐generation sequencing (NGS) gene panel. We demonstrated a utility of cfDNA NGS to detect EGFR T790M and predict response comparable to tissue‐based tests, even at low allele fractions, and we identified resistance mechanisms. Our findings highlight the genomic heterogeneity observed in disease after progression while receiving therapy with a third‐generation EGFR TKI. Introduction: The genomic alterations driving resistance to third‐generation EGFR tyrosine kinase inhibitors (TKIs) are not well established, and collecting tissue biopsy samples poses potential complications from invasive procedures. Cell‐free circulating DNA (cfDNA) testing provides a noninvasive approach to identify potentially targetable mechanisms of resistance. Here we utilized a 70‐gene cfDNA next‐generation sequencing test to interrogate pretreatment and progression samples from 77 EGFR‐mutated non‐small cell lung cancer (NSCLC) patients treated with a third‐generation EGFR TKI. Patients and Methods: Rociletinib was evaluated in advanced or metastatic (second line or higher) disease with EGFR T790M‐positive NSCLC in the TIGER‐X (NCT01526928) and TIGER‐2 (NCT02147990) studies. Plasma samples were collected at baseline and at the time of systemic progression while receiving rociletinib. The critical exons in 70 genes were sequenced in cfDNA isolated from plasma samples to elucidate a comprehensive genomic profile of alterations for each patient. Results: Plasma‐based cfDNA analysis identified 93% of the initial EGFR activating and 85% of the EGFR T790M resistance mutations in pretreatment samples with detectable tumor DNA. Profiling of progression samples revealed significant heterogeneity, with different variant types (eg, mutations, amplifications, and fusions) detected in multiple genes (EGFR, MET, RB1) that may be driving resistance in patients. Novel alterations not previously described in association with resistance to third‐generation TKIs were also detected, such as an NTRK1 fusion. Conclusion: cfDNA next‐generation sequencing identified initial EGFR activating and secondary T790M resistance mutations in NSCLC patients with high sensitivity, predicted treatment response equivalent to tissue analysis, and identified multiple novel and established resistance alterations.

Abstract 1039: PDX models generated from a patient with metastatic colon adenocarcinoma display both spatial and temporal tumor heterogeneity

Background: Patient-derived Xenograft (PDX) models are being widely used in preclinical studies to identify biomarkers of drug response and to enhance our understanding of cancer biology. Since patients with metastatic cancer have both intra-tumor and inter-site heterogeneity, PDX models generated from different tumor sites may provide a way to study tumor heterogeneity. Characterization of the genomic landscape in these models may also provide better insights into treatment response or resistance. It is rare to have multiple PDX models generated from a single patient over multiple time points during a treatment trajectory. Here, we report the genomic profiles of PDX models generated from 4 distinct tissue specimens over a 7-month period from a patient with metastatic colon adenocarcinoma. The first 2 PDX models were generated from circulating tumor cells (CTCs) and a liver biopsy prior to treatment with a combination pan-AKT + MEK inhibitor regimen. A third PDX model was generated from a liver biopsy while on-treatment and a fourth from an adrenal gland resection at progression. Clinically, all reported metastatic sites, except the adrenal gland, responded to the combination therapy. Results: Genomic characterization of the specimens obtained from these 4 PDX models led to the following observations: 1) PIK3CA E545K and KRAS G12D are present in all the specimens tested for all 4 models and are likely truncal driver mutations; 2) exclusive inter-model SNVs (single nucleotide variants) were identified, and may be model-specific variants representing inter-site heterogeneity in the patient; 3) variants involved in known resistance mechanisms to MEK inhibition were not present in any specimens; 4) overexpression of AKT3 has been reported as a resistance mechanism to a pan-AKT inhibitor and was observed in the adrenal tissue from the patient but not in any other PDX model derived from this patient; 5) intra-model and inter-model heterogeneity in whole genome CNV (copy number variant) profiles was observed between individual PDXs obtained from the pre-treatment CTC-derived model and the on-treatment liver biopsy model. Interestingly, one of the PDXs from the CTC-derived model presented a sub-clonal tumor fraction closely related to the on-treatment liver biopsy model. The multiple inter-model CNV profiles in the liver biopsy derived PDX models represent temporal heterogeneity within a tissue. Conclusions: We observed genomic heterogeneity in PDXs generated from specimens from a patient with metastatic colon adenocarcinoma. Both truncal and sub-clonal variants were identified representing various tumor fractions in these models. This case study illustrates how genomic profiling of multiple tumor sites at different times during course of treatment can provide insight into the complexity of tumor heterogeneity and tumor evolution in patients with metastatic disease. Citation Format: Biswajit Das, Chris Karlovich, Corrine E. Camalier, Rajesh Patidar, Li Chen, Vivekananda Datta, William D. Walsh, Sean P. McDermott, Tomas Vilimas, Palmer Fliss, Justine N. McCutcheon, Amanda Peach, Michelle Ahalt-Gottholm, Carrie Bonomi, Kelly Dougherty, John Carter, Shivaani Kummar, Yvonne A. Evrard, Melinda G. Hollingshead, Paul M. Williams, James H. Doroshow. PDX models generated from a patient with metastatic colon adenocarcinoma display both spatial and temporal tumor heterogeneity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1039.

Abstract 3840: The National Cancer Institute’s patient-derived models repository (PDMR)

The National Cancer Institute (NCI) has developed a Patient-Derived Models Repository (PDMR) comprised of quality-controlled, early-passage, clinically-annotated patient-derived xenografts (PDXs) to serve as a resource for public-private partnerships and academic drug discovery efforts. These models are offered to the extramural community for research use (https://pdmr.cancer.gov/), along with clinical annotation and molecular information (whole exome sequence, RNASeq), which is available in a publicly accessible database. The PDMR was established by NCI at the Frederick National Laboratory for Cancer Research (FNLCR) in direct response to discussions with academia and industry; the oncology community9s highest priority need was preclinical models that more faithfully reflect the patient9s tumor and are associated with the patient9s treatment history. NCI has focused on generating models to complement existing PDX collections and address unmet needs in the preclinical model space. The PDMR generates the majority of its PDXs by subcutaneous implantation except for those histologies having better success rates in either orthotopic or alternate implant sites. All SOPs and quality-control standards developed by the PDMR as well as those shared by collaborators are posted to a public web site that houses the PDMR database. In May 2017, the public website (https://pdmr.cancer.gov/) went live with its first 100 models from histologies including pancreatic, colorectal, renal, head and neck, and lung squamous cell cancers as well as melanoma and adult soft tissue sarcomas. In early 2018, the PDMR will begin releasing models from gynecological cancers, small cell lung cancer, chondro/osteo sarcomas, lung adenocarcinoma, and squamous cell skin and Merkel cell carcinomas. In addition, wherever available germline sequence and somatic variant calls will be added to the existing molecular characterization data for each model. NCI has also increased its focus on creating PDXs from racial and ethnic minorities through several funding opportunities. The overall goal of NCI is to create a long-term home for at least 1000 models such that sufficient biological and clinical diversity is represented to allow researchers to ask questions regarding the impact of tumor heterogeneity on target qualification or clinical response, whether PDXs more faithfully represent the human tumor for pharmacodynamic assay and predictive marker development, or if adequately powered preclinical PDX clinical trials can lead to better evaluation of therapies for future clinical use. Moving forward the PDMR plans to distribute in vitro, early-passage tumor cell cultures and cancer-associated fibroblasts as well as releasing PDX drug response data for a panel of FNA-approved therapeutic agents. Funded by NCI Contract No. HHSN261200800001E Citation Format: Yvonne A. Evrard, Michelle M. Gottholm Ahalt, Sergio . Y. Alcoser, Kaitlyn Arthur, Mariah Baldwin, Linda L. Blumenauer, Carrie Bonomi, Suzanne Borgel, Elizabeth Bradtke, Corinne Camalier, John Carter, Tiffanie Chase, Alice Chen, Lily Chen, Donna W. Coakley, Nicole E. Craig, Biswajit Das, Vivekananda Datta, Jordyn Davidson, Margaret R. DeFreytas, Emily Delaney, Michelle A. Eugeni, Raymond Divelbiss, Palmer Fliss, Thomas Forbes, Marion Gibson, Tara Grinnage-Pulley, Sierra Hoffman, Lilia Ileva, Paula Jacobs, Franklyn Jimenez, Joseph Kalen, Catherine Karangwa, Chris Karlovich, Candace Mallow, Chelsea McGlynn, Jenna E. Moyer, Michael Mullendore, Dianne L. Newton, Nimit Patel, Rajesh Patidar, Kevin Plater, Marianne Radzyminski, Lisa Riffle, Larry Rubinstein, Luke H. Stockwin, Mickey Williams, Melinda G. Hollingshead, James H. Doroshow. The National Cancer Institute9s patient-derived models repository (PDMR) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 986.

Abstract 1009: Comprehensive ctDNA sequencing reveals mechanisms of resistance to rociletinib in EGFR T790M-mutated NSCLC

Background: First and second-generation EGFR tyrosine kinase inhibitors (TKIs) have benefited patients with EGFR-mutated non-small cell lung cancer (NSCLC), but resistance invariably develops after a median of 9-16 months. In ~60% of patients, resistance is mediated by a second mutation in EGFR, namely T790M. Hence, third-generation EGFR TKIs such as osimertinib and rociletinib were developed to target both activating EGFR mutations as well as T790M. Unfortunately, patients also develop resistance to these therapies through mechanisms that have not yet been thoroughly explored. Since repeat tissue biopsies pose potential complications from invasive procedures, circulating tumor DNA (ctDNA) testing is increasingly used in the clinical setting to identify potentially targetable mechanisms of resistance. Methods: Matched pre-treatment and progression plasma from 57 patients with EGFR-mutated NSCLC treated with rociletinib were profiled using a 70-gene ctDNA targeted next-generation sequencing panel (Guardant360) that detects somatic single nucleotide variants, short insertions and deletions, fusions, and copy number variants. Pre-treatment EGFR ctDNA allele fractions were also determined by BEAMing, a technique based on droplet digital PCR followed by flow cytometry. Pre-treatment tumor EGFR status was assessed by the therascreen EGFR test. Results: In all 57 pre-treatment samples profiled, plasma-based ctDNA analysis detected the initial EGFR driver and T790M resistance mutations that were identified in the matched tumor. Interestingly, we found that 12% (7/57) of patients had evidence of compound EGFR driver mutations at baseline, including E709A-L858R, K860I-L858R, and L718V-L858R. EGFR T790M mutations in plasma were observed subclonally (present on average at 40% of the allele fraction of the driver mutation), suggesting tumor heterogeneity at baseline. The correlation coefficients (r) between Guardant360 and BEAMing for EGFR L858R, Exon19Del, and T790M were 0.90, 0.92, 0.95, respectively. Upon progression on rociletinib, 5% of patients (3/57) developed the EGFR C797S resistance mutation, 5% (3/57) developed focal MET amplification, and 2% (1/57) developed a NTRK1 fusion that were not present in the matched baseline plasma. Additionally, 4 deleterious BRCA1/2 alterations (2 germline and 2 somatic) were identified, with the somatic alterations emerging at progression. In 14% (8/57) of the patients, mutations in genes involved in the RAS/RAF signaling pathway, including KRAS Q61H, KRAS K117N and NF1 Q1822*, emerged or increased at progression. Conclusions: Plasma ctDNA revealed heterogeneity and multiple mechanisms of resistance in rociletinib treated patients. Thus comprehensive ctDNA sequencing allows for the identification of potentially actionable alterations and may help inform the choice of next therapy for patients progressing on a third-generation EGFR TKI. Citation Format: Elena Helman, Andrew D. Simmons, Chris A. Karlovich, Thomas C. Harding, Mitch Raponi, Darya I. Chudova, Daniel A. Simon, Richard B. Lanman, AmirAli Talasaz. Comprehensive ctDNA sequencing reveals mechanisms of resistance to rociletinib in EGFR T790M-mutated NSCLC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1009. doi:10.1158/1538-7445.AM2017-1009

Abstract A31: Assessment of EGFR mutations in matched urine, plasma and tumor tissue in NSCLC patients treated with rociletinib (CO-1686)

Background: The acquisition of suitable tumor tissue is a challenge for a significant fraction of late-stage NSCLC patients who require EGFR testing to inform choice of therapy. An alternative for these patients could be the assessment of EGFR mutations in circulating tumor DNA (ctDNA). In this study, we examined the detection of EGFR T790M mutation in ctDNA from urine, assessed urine sample requirements, and compared the results with contemporaneously matched tumor tissue and plasma in TIGER-X (NCT01526928), a Phase 1/2 clinical study of rociletinib in previously treated mutant EGFR patients with advanced NSCLC. Rociletinib is an oral, potent, small-molecule irreversible tyrosine kinase inhibitor that selectively targets mutant forms of EGFR, including T790M, L858R and Del(19), while sparing wild-type EGFR. Methods: 63 Stage IIIB/IV NSCLC patients enrolled in either Phase 1 or 2 components of TIGER-X and representing all therapeutic dose groups consented to optional urine collection. Maximum sample volumes were 100 mL for urine and 2 mL for plasma. To maximize assay sensitivity in urine, samples containing the recommended sample volume of ≥90 mL (≥ 90% of maximum in this study) were evaluated; all samples received were processed to assess this recommendation. Urinary and plasma ctDNA were tested for mutations by the same EGFR assays using a sensitive and quantitative short footprint assay method that employs a mutation enrichment step followed by next generation sequencing. Results: Urine volumes ranged from 8-100 mL with a median DNA yield of 313 ng (N = 63). The median DNA yield was 299 ng for urine specimens with volume Conclusions: The analysis of ctDNA from urine identified a similar proportion of T790M+ patients as tissue-based testing with highest PPA amongst patients with urine volumes ≥90 mL. Discordant samples between urine and tissue that were not identified by the tumor test may be explained by tumor heterogeneity and/or inadequate biopsy. EGFR mutation detection from urine increases with urine volume and DNA yields and should be considered as a viable approach, particularly when tumor tissue is not available. Lastly, monitoring urine ctDNA T790M mutations longitudinally with baseline and post-therapy sampling could be clinically useful to determine benefit from therapy. Citation Format: Shirish Gadgeel, Chris Karlovich, Vlada Melnikova, Lecia V. Sequist, D. Ross Camidge, Heather Wakelee, Maurice Perol, Geoffrey R. Oxnard, Karena Kosco, Cecile Rose T. Vibat, Elaina Mann, Shannon Matheny, Lindsey Rolfe, Mitch Raponi, Mark G. Erlander, Karen Reckamp. Assessment of EGFR mutations in matched urine, plasma and tumor tissue in NSCLC patients treated with rociletinib (CO-1686). [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2015 Nov 5-9; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(12 Suppl 2):Abstract nr A31.