Mechanisms of primary/secondary resistance to EGFR inhibitors
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1 UNIVERSITY OF OF TORINO DEPARTMENT OF ONCOLOGY Mechanisms of primary/secondary resistance to EGFR inhibitors Silvia Novello University of Torino Italy Department of Oncology
2 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
3 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
4 Some considerations for patients who progress on targeted therapy The definition of disease progression in the context of EGFR inhibition may differ from RECIST criteria and requires further refinement. Ou S H I, Drug Design, Development and Therapy 2011
5 Define Resistance by RECIST 5cm 0m 6m 12m 18m
6 Define Resistance by RECIST 5cm PR at 2cm 0m 6m 12m 18m
7 Define Resistance by RECIST 5cm PR at 2cm Symptomatic PD at 4cm 0m 6m 12m 18m
8 Define Resistance by RECIST 5cm PR at 2cm Symptomatic PD at 4cm 0m 6m 12m 18m
9 Define Resistance by RECIST 5cm PR at 2cm Symptomatic PD at 4cm 0m 6m 12m 18m
10 Cessation of EGFR TKI upon progression Riely et al Clin Can Res 13:5150, 2007
11 Cessation of EGFR TKI upon progression Last day of TKI Off EGFR TKI Resumed TKI Day 0 Day 21 Day 42 Riely et al Clin Can Res 13:5150, 2007
12 UNIVERSITY OF OF TORINO DEPARTMENT OF ONCOLOGY Defining resistance by RECIST may lead to premature termination of TKI
13 ASPIRATION: To optimize treatment duration Advance stage NSCLC with EGFR Mutation EGFR TKI PD By RECIST EGFR TKI PD By doctor Discretion* *Doctor Discretion: Symptomatic progression, multiple progression Threat to major organ etc PI: K Park
14 ASPIRATION: To optimize treatment duration Advance stage NSCLC with EGFR Mutation EGFR TKI PFS 1 PD By RECIST EGFR TKI PD By doctor Discretion* *Doctor Discretion: Symptomatic progression, multiple progression Threat to major organ etc PI: K Park
15 ASPIRATION: To optimize treatment duration Advance stage NSCLC with EGFR Mutation EGFR TKI PFS 1 PD By RECIST PFS 2 EGFR TKI PD By doctor Discretion* *Doctor Discretion: Symptomatic progression, multiple progression Threat to major organ etc PI: K Park
16 Diagnosis (and tests) do not end at the time of diagnosis
17 Diagnosis (and tests) do not end at the time of diagnosis
18 UNIVERSITY OF OF TORINO DEPARTMENT OF ONCOLOGY BRONCHIAL BIOPSY, NOVEMBER 2010 Adenocarcinoma, acinar BRONCHIAL ASPIRATE, NOVEMBER 2010 adenocarcinoma
19 TTF 1 BRONCHIAL BIOPSY, JANUARY 2012 small cell carcinoma UNIVERSITY OF OF TORINO DEPARTMENT OF ONCOLOGY synaptophysin
20 Sequist L et al, Sci Transl Med 2011 Zakowski MF et al NEJM 2006 Morinaga R et al, Lung Cancer 2007 Emergence of EGFR&ALK Resistance Mechanisms: Rebiopsy of EGFRm&ALK+ tumors at progression ALK-dependent ALK-independent Doebele et al, CCR 2012
21 Is there a room for rechallenge?
22 Is there a room for rechallenge?
23 Is there a room for rechallenge? EGFRm+ pts receiving 1 st line treatment with gefitinib with a documented complete (CR) or partial response (PR) or stable disease (SD) >12 weeks as the best response Ph II trial; PI: F De Marinis PD Chemotherapy (P based or docetaxel or pemetrexed monochemo) PD RECHALLENGE with gefitinib 250 mg/die
24 EGFR TKI Re treatment after Acquired Resistance: DFCI/MGH Experience Retrospective, 24 pts (over 9.5 yrs) with activating EGFR mutation after AR to gefitinib (30%) or erlotinib (70%) RR 4%, SD 63% Median interval off EGFR TKI 5 mo (range 2 46 mo) Greater benefit w/longer interval of EGFR TKI (PFS 4.4 vs. 1.9 mo for 6 mo interval off EGFR TKI) Heon, ASCO 2012, Abst#7525
25 Re challenge with EGFR TKI after Acquired Resistance N = 73 pts with acquired resistance OS post PD better for 56 who had EGFR TKI re treatment vs. 17 who did not No correlation of benefit w/interval off EGFR TKI seen Hata, ASCO 2012, A#7528
26 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
27 Chemo/Erlotinib vs. Chemo Alone at Progression after Acquired Resistance N = 78 retrospective review of outcomes chemo alone (N = 44) or chemo/erlotinib (N = 34) RR 18% (chemo) vs. 41% with chemo/erlotinib) No differences in PFS or OS between these two strategies Goldberg, ASCO 2012, Abst#7524
28 IMPRESS: Chemotherapy with or with Advance stage NSCLC with EGFR Mutation gefitinib at progression Gefintinib PD By RECIST Gefitinib + Alimta/Platinum Primary endpoint: PFS Alimta/Platinum Co PI: Soria J; Mok T
29 Chemotherapy +/ Ongoing EGFR TKI for Acquired Resistance, with Retreatment PI: Leora Horn (Vanderbilt) Advanced NSCLC Activating EGFR TKI Resp to EGFR TKI>4 mo No prior chemotherapy PS 0/1 N= 120 Stratification by: EGFR mut n exon 19 vs. exon 21 Time to progression on EGFR TKI <1 yr vs. >1 yr PS 0 vs. 1 Primary endpoint: progression free survival R A N D Cis or Carbo/Pemetrexed + ongoing erlotinib Cis or Carbo/Pemetrexed Erlotinib re treatment
30 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
31 Treatment of TKI Resistance Oligo Progression Local therapy + continuation of TKI Oncogenic driven cancer with tumor response to TKI Targeting the resistant gene Systemic Progression Systemic therapy Chemotherapy Chemotherapy + TKI
32 Treatment of TKI Resistance Oligo Progression Local therapy + continuation of TKI Oncogenic driven cancer with tumor response to TKI Targeting the resistant gene Systemic Progression Systemic therapy Chemotherapy Chemotherapy + TKI
33 Local Therapy in Acquired Resistance: MSKCC 18/184 pts/7+ yrs underwent local therapy for extracranial PD CNS PD excluded From time of local therapy Median TTP: 10 months Median time to new systemic Rx: 22 months Median OS: 41 months Yu, ASCO 2012, Abst#7527
34 Local treatment to oligo progression plus continuation of TKI Colorado University collection of 65 patients with oncogenic driven cancer (EGFR mutation or ALK positive) All received EGFR TKI or Crizotinib PFS 1 defined as <4 sites of progression Local ablative therapy offered to all sites of involvement and continue TKI PFS 2 defined as from time of local therapy to second progression Weickhardt A et al, Proc ASCO 2012 # 7526
35 PFS of patients treated with local therapy and continuation of TKI therapy Site of first progression Number of patients CNS 10 *ecns Ϯ 15 All patients 25 * bone, lung, lymph node, adrenal, liver PFS1 (months)(95% CI) PFS2 (months)(95% CI) Site of 2 nd progression 2 (20%) no prog 3 (30%) CNS 5 (50%) ecns 4 (27%) no prog 3 (20%) CNS 8 (53%) ecns 6 (24%) no prog 7 (28%) CNS 12 (48%) ecns Ϯ Includes 3 patients who progressed systemically (ecns) and simultaneously within the CNS Weickhardt A et al, JTO Dec 2012
36 PFS of patients treated with local therapy and continuation of TKI therapy Site of first progression Number of patients CNS 10 *ecns Ϯ 15 All patients 25 * bone, lung, lymph node, adrenal, liver PFS1 (months)(95% CI) PFS2 (months)(95% CI) Site of 2 nd progression 2 (20%) no prog 3 (30%) CNS 5 (50%) ecns 4 (27%) no prog 3 (20%) CNS 8 (53%) ecns 6 (24%) no prog 7 (28%) CNS 12 (48%) ecns Ϯ Includes 3 patients who progressed systemically (ecns) and simultaneously within the CNS Weickhardt A et al, JTO Dec 2012
37 Future Prospective Study? Primary endpoint: PFS Secondary endpoint: OS, RR, QOL Weickhardt A et al, JTO Dec 2012
38 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
39 Primary Resistance Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
40 Primary Resistance Mutational activation of targets immediately downstream of EGFR can induce resistance to EGFR Tki: one clear example is Ras which can bypass the inhibitionof the upstream EGFR signal Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
41 Primary Resistance It is postulated that the loss of PTEN is associated with increased signaling via the PI3K Akt pathway and thereby enhancing the survival of NSCLC cells, causing resistance to both erlotinib and gefitinib with resultant poor prognosis in NSCLC patients Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
42 Primary Resistance The mechanism of primary resistance includes in frame insertion mutations in EGFR exon 20, accounting for about 5% of NSCLC patients. de novo resistant T790M mutation on exon 20 has also been reported Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
43 Primary Resistance The presence of c MET amplification, a transmembrane TK receptor, or its overexpression has also been demonstrated in a subset of patients who had not been treated with EGFR TKIs and this was also thought to represent a form of primary resistance to EGFR TKI Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
44 Incidence of De Novo T790M
45 Acquired Resistance Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
46 Acquired Resistance The cells develop resistance mechanisms that reactivate EGFR despite the inhibitor: this is exaclty what occurrs when cell acquire the second site mutation called T790M Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
47 Acquired Resistance D761Y L747S T854A The cells develop resistance mechanisms that reactivate EGFR despite the inhibitor: this is exaclty what occurrs when cell acquire the second site mutation called T790M Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
48 Acquired Resistance MET seems to provide a bypass signaling pathway, even in the presence of EGFR inhibition, through MET amplification (5 20%) and overexpression of HGF (10 20%) Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
49 Acquired Resistance IGF seems to be involved in some cases of resistance (probably a reversible mechanism). In NSCLC cell lines that have been continuously exposed to a first generation TKI, an increased activation of the IGF 1R has led to cell growth Ayoola A et al Cancer Invest 2012; Nakata A& N Gotoh, Expert Opinion 2012
50 How we define PD/resistance in a patient treated with EGFRTki Is there a role for chemotherapy? Do we accept a different approach for OLIGO and SYSTEMIC PD? Primary and Acquired resistance: quick overview Target the Resistance
51 Sequist L et al, Sci Transl Med 2011
52 Sequist L et al, Sci Transl Med 2011 MET activates PI3K/Akt signaling in the presence of EGFR TKI Engelman Science 2007, Bean PNAS 2007 Concomitant inhibition of both EGFR and MET is required to kill resistant cells Targeting of Both the c Met and EGFR Pathways Results in Additive Inhibition of Lung Tumorigenesis in Transgenic Mice Stabile L et al, Cancer 2010 MET amplification: 4 22% of NSCLC with acquired EGFR TKI resistance Engelman Science 2007, Bean PNAS 2007, Sequist Sci Transl Med 2011, Oxnard Clin Ca Res 2011
53 Tivantinib: Phase II data Median PFS (95% CI), months n/n Tivantinib/Erlotinib Placebo/Erlotinib Squamous cell 26/ ( ) 2.0 ( ) Non squamous cell 58/ ( ) 2.3 ( ) c MET FISH > 4 19/ ( ) 3.6 ( ) c MET FISH > 5 8/ (3.8 NE) 3.6 ( ) EGFR mutant 6/ ( ) 4.9 ( ) EGFR wt 51/ ( ) 1.9 ( ) KRAS mutant 10/5 2.3 (1.8 NE) 1.0 ( ) KRAS wt 49/ ( ) 2.3 ( ) A PFS benefit associated with tivantinib plus erlotinib was observed in patients with tumors harboring amplified c-met, wild-type EGFR, or mutant KRAS Unadjusted HR Favors tivantinib/erlot. Favors placebo/erlotinib Cox proportional hazard ratio analysis of median progression-free survival by patient subgroup. Abbreviations: CI, confidence interval; FISH, fluorescence in situ hybridization; HR, hazard ratio; PFS, progression-free survival; wt, wild type Sequist L, Shiller J et al, JCO 2011
54 Tivantinib: Phase II data EGFR wt Median PFS (95% CI), months n/n Tivantinib/Erlotinib Placebo/Erlotinib Squamous cell 26/ ( ) 2.0 ( ) Non squamous cell 58/ ( ) 2.3 ( ) c MET FISH > 4 19/ ( ) 3.6 ( ) c MET FISH > 5 8/ (3.8 NE) 3.6 ( ) EGFR mutant 6/ ( ) 4.9 ( ) EGFR wt 51/ ( ) 1.9 ( ) KRAS mutant 10/5 2.3 (1.8 NE) 1.0 ( ) KRAS wt 49/ ( ) 2.3 ( ) A PFS benefit associated with tivantinib plus erlotinib was observed in patients with tumors harboring amplified c-met, wild-type EGFR, or mutant KRAS Kras mutated Unadjusted HR Favors tivantinib/erlot. Favors placebo/erlotinib Cox proportional hazard ratio analysis of median progression-free survival by patient subgroup. Abbreviations: CI, confidence interval; FISH, fluorescence in situ hybridization; HR, hazard ratio; PFS, progression-free survival; wt, wild type Sequist L, Shiller J et al, JCO 2011
55 Onartuzumab: Phase II data Spigel et al: WCLC 2011
56 T790M Sequist L et al, Sci Transl Med 2011 Ohashi K et al, JCO 2013
57 Second and Third generation EGFR TKIs Drug Name Generic Name Target Recommended dose EKB 569 Pelitinib EGFR 50 mg once per day CI 1033 Canertinib EGFR/ERBB2/E RBB4 150 mg once per day HKI 272 Neratinib EGFR/ERBB2 320 mg once per day (than 240 within trial) BIBW2992 Afatinib EGFR/ERBB2/E RBB4 PF Dacomitinib EGFR/ERBB2/E RBB4 50 mg once per day 45 mg once per day Status Phase I* Phase II* Phase II* Phase III Phase III CO 1686 NA EGFR T790M NA Phase I/II WZ4002 NA EGFR T790M NA Preclinical *no additional trials planned in lung cancer Ohashi K et al, JCO 2013
58 Irreversible EGFR TKIs WT Activated Resistance Mutation: wild type H1666 L858R H3255 L858R+T790M NCI1975 Target Binding mode BIBW EGFR/HER2 Irreversible Gefitinib >4000 EGFR Reversible Erlotinib >4000 EGFR Reversible Lapatinib >4000 EGFR/HER2 Reversible CP 724,714 2 > >4000 HER2 Reversible IC50 values (nm) for the inhibitory activities of different compounds on the proliferation of NSCLC cells with EGFR mutations
59 Dual Targeting of EGFR Regales L et al, J Clin Invest 2009
60 Horn L et al, IASLC 2011 Phase IB Afatinib and Cetuximab
61 Horn L et al, IASLC 2011 Phase IB Afatinib and Cetuximab
62 Other targets
63 FGFR Autocrine/Paracrine Loop EGF TGFα Gefitinib Erlotinib EGF TGFα EGFR FGFR2/3 Growth and Transformation FGF2 FGF9 TME (fibroblasts) FGF2 FGF9 Courtesy P. Bunn
64 Three of nine EGFR mutant NSCLC cell lines acquire EGFR TKIresistance through induction of FGF2 and FGFR1 Cell Line EGFR genotype Resistance Resistance Mechanism H1650 E746-A750 del Gefitinib FGF2 and resistant FGFR1 induction H1975 L858R, T790M BIBW2992 IGF1R? resistant H3255 L858R Gefitinib Multi-clonal resistant HCC827 E746-A750 del Gefitinib resistant HCC2279 E746-A750 del Gefitinib resistant HCC2935 HCC4006 E746-S752 del, I insert L747-A750 del, P insert In process Gefitinib resistant HCC4011 L858R In process PC9 E746-A750 del Gefitinib resistant MET amplification FGF2 and FGFR1 induction FGF2 and FGFR1 induction T790M Courtesy P. Bunn
65 Phase I Study of FGFR TKI + Erlotinib Part 1: MTD determination Patients: Clinically selected Advanced solid malignancies Refractory to SoC or no SoC available PK data collected Escalating doses of erlotinib (50 150mg/day po) and FGFR TKI up to RP2D 1 cycle = 4 weeks Scans every 2 cycles Study sites are Univ. Colorado, one or more sites in Asia and one or more other SPORE sites. Study: Design Part 2: Patients: advanced stage adenocarcinoma Molecularly defined No limit on prior regimens Efficacy and single /multi dose PK data collected EGFR activating mutations EGFR wt (excluding KRAS mut and ALK+)
66 Rationale for Hsp90 inhibition in NSCLC NSCLC with activating mutations in EGFR Mutated EGFR is a sensitive client protein of Hsp90 Both T790M and Met amplification are susceptible to Hsp90 inhibition (Park et al, Abstract 2450 AACR Annual Meeting 2008) NSCLC containing wild type EGFR Many NSCLC cell lines are sensitive to Hsp90 inhibitors in vitro Multiple proteins important in the progression of NSCLC are client proteins of Hsp90 HER2 p AKT EML4 ALK c RAF 66
67 Study Design NCT AUY mg/m 2 KRAS-activating mutation n=28 Phase II Study Population Previously treated stage IIIb or IV NSCLC 2 lines of chemotherapy Prior EGFR TKI therapy if EGFR is mutated WHO PS 2 AUY mg/m 2 EGFR-activating mutation n=35 AUY mg/m 2 EGFR/KRAS/ALK wild type n=33 AUY mg/m 2 ALK+ n=22 Bayesian design: Primary endpoint efficacy classified as 3 categories (mutually exclusive): 1. Response (CR or PR) or 2. SD at 18 weeks or 3. No clinical benefit (NCB) Secondary endpoints efficacy (OS, or PFS) and PK, safety/tolerability Null hypothesis (no efficacy): response 5%, and NCB 85% Alternative hypothesis (efficacious): response 10% ( 20% for ALK+ arm), or NCB 60% ( 40% for ALK+ arm) CR, complete response; OS, overall survival; PFS, progression free survival; PK, pharmacokinetics; PR, partial response; SD, stable disease; TKI, tyrosine kinase inhibitor; WHO PS, World Health Organization performance status. Shaw A et al, ESMO 2012
68 Study Design NCT AUY mg/m 2 KRAS-activating mutation n=28 Phase II Study Population Previously treated stage IIIb or IV NSCLC 2 lines of chemotherapy Prior EGFR TKI therapy if EGFR is mutated WHO PS 2 AUY mg/m 2 EGFR-activating mutation n=35 AUY mg/m 2 EGFR/KRAS/ALK wild type n=33 AUY mg/m 2 ALK+ n=22 Bayesian design: Primary endpoint efficacy classified as 3 categories (mutually exclusive): 1. Response (CR or PR) or 2. SD at 18 weeks or 3. No clinical benefit (NCB) Secondary endpoints efficacy (OS, or PFS) and PK, safety/tolerability Null hypothesis (no efficacy): response 5%, and NCB 85% Alternative hypothesis (efficacious): response 10% ( 20% for ALK+ arm), or NCB 60% ( 40% for ALK+ arm) CR, complete response; OS, overall survival; PFS, progression free survival; PK, pharmacokinetics; PR, partial response; SD, stable disease; TKI, tyrosine kinase inhibitor; WHO PS, World Health Organization performance status. Shaw A et al, ESMO 2012
69 Results: Patient Demographics and Disease Characteristics Demographic or characteristic KRAS mut (n=28) EGFR mut (n=35) EGFR/KRAS/ ALK wt (n=33) ALK+ (n=22) All* (N=121) Age (median), years Sex (male), % 17 (61) 10 (29) 15 (45) 7 (32) 52 (43) WHO PS Histology Adenocarcinoma Squamous cell carcinoma Other Prior regimens (36) 18 (64) 0 (0) 23 (82) 1 (4) 4 (14) 1 (4) 8 (29) 14 (50) 5 (18) 13 (37) 19 (54) 3 (9) 32 (91) 0 (0) 3 (9) 3 (9) 13 (37) 11 (31) 8 (23) 10 (30) 20 (61) 3 (9) 27 (82) 2 (6) 4 (12) 0 (0) 16 (48) 4 (12) 13 (39) 9 (41) 11 (50) 2 (9) 20 (91) 0 (0) 2 (9) 1 (5) 5 (23) 7 (32) 9 (41) 43 (36) 70 (58) 8 (7) 105 (87) 3 (2) 13 (11) Prior ALK inhibitor (crizotinib) NA NA NA 14 (64) NA Prior EGFR TKI Erlotinib Gefitinib None NA 34 (97) 30 (86) 4 (11) 1 (3) 5 (4) 42 (35) 38 (31) 36 (30) NA NA NA Shaw A et al, ESMO 2012 *Includes unknown genotype patients (n=3; stratum not listed); NA, not applicable; wt, wild type.
70 Results: Patient Demographics and Disease Characteristics Demographic or characteristic KRAS mut (n=28) EGFR mut (n=35) EGFR/KRAS/ ALK wt (n=33) ALK+ (n=22) All* (N=121) Age (median), years Sex (male), % 17 (61) 10 (29) 15 (45) 7 (32) 52 (43) WHO PS Histology Adenocarcinoma Squamous cell carcinoma Other Prior regimens (36) 18 (64) 0 (0) 23 (82) 1 (4) 4 (14) 1 (4) 8 (29) 14 (50) 5 (18) 13 (37) 19 (54) 3 (9) 32 (91) 0 (0) 3 (9) 3 (9) 13 (37) 11 (31) 8 (23) 10 (30) 20 (61) 3 (9) 27 (82) 2 (6) 4 (12) 0 (0) 16 (48) 4 (12) 13 (39) 9 (41) 11 (50) 2 (9) 20 (91) 0 (0) 2 (9) 1 (5) 5 (23) 7 (32) 9 (41) 43 (36) 70 (58) 8 (7) 105 (87) 3 (2) 13 (11) Prior ALK inhibitor (crizotinib) NA NA NA 14 (64) NA Prior EGFR TKI Erlotinib Gefitinib None NA 34 (97) 30 (86) 4 (11) 1 (3) 5 (4) 42 (35) 38 (31) 36 (30) NA NA NA Shaw A et al, ESMO 2012 *Includes unknown genotype patients (n=3; stratum not listed); NA, not applicable; wt, wild type.
71 Best % change in target lesions Best CT Response: EGFR mutant Patients (n=25 /35) EGFR mutant (n=35) ORR (any PR) 7 (20%) DCR (CR/PR or SD) 20 (57%) PFS (18 weeks [95% CI]), % 35.2 (18.7, 52.2) *Confirmed responses; Patients with at least one post baseline scan; Including one PR not confirmed. * * * * * * Shaw A et al, ESMO 2012
72 Best CT Response: EGFR mutant Patients with EGFR TKI as Part of Their Last Regimen (n= 16 /19) Best % change in target lesions EGFR mutant with TKI as part of last regimen (n=19) ORR (any PR) 5 (26%) DCR (CR/PR or SD) 13 (68%) PFS (18 weeks [95% CI]), % 46.6 (21.6, 68.4) *Confirmed responses; Patients with at least one post baseline scan. * * * * * Shaw A et al, ESMO 2012
73 Conclusion More information and details are needed about this issue Unfortunately, at the present time, only chemotherapy is approved in this setting Whenever is possible, please contribute to implement knownledge increasing re biopsies at the time of resistance and including pts in dedicated trials
74 UNIVERSITY OF OF TORINO DEPARTMENT OF ONCOLOGY Save the date! October 27-31, 2013
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