Biomarker Consortium

Lung Cancer

Non–Small Cell Lung Cancer

 exon 20 mutations are generally a heterogeneous group, some of which are responsive to targeted therapy, requiring a detailed knowledge of the specific alteration.

 Most alterations are a diverse group of in-frame insertion (ex20ins) mutations. More than 60 unique variants of 

ex20ins have been identified, representing up to 12% of all 

 mutations in NSCLC and 0.1% to 4% of all mutations in NSCLC.

-activating mutation, following exon 19 deletion and L858R.

ex20ins mutations induce structural changes that lead to activation of the kinase domain.

 However, these mutations often show resistance to first- and second-generation EGFR tyrosine kinase inhibitors (EGFRi).

ex20 mutations may be sensitive to first- and third-generation inhibitors, the specific sequence of 

ex20 insertion mutations remains important. Targeted PCR-based approaches for detection of EGFR variants may under-detect 

ex20ins events; therefore, NGS-based strategies are preferred.

ex20ins in NSCLC has been elusive. The most commonly represented EGFRex20 insertions/duplications in clinical studies evaluating specific targets have been insASV, insSVD, and insNPH, although a wide spectrum of other alterations were included. No evidence currently exists that the specific alteration type impacts the likelihood of responsiveness to this class of targeted therapy.

 Presently, amivantamab, a monoclonal antibody, is the only FDA-approved treatment for 

ex20ins NSCLC on the market. In 2021, mobocertinib, an EGFRi, was granted accelerated approval by the FDA but was voluntarily withdrawn by the manufacturer in October 2023 as the confirmatory trial did not meet its primary end point.

 In November 2022, the FDA issued a complete response letter to the manufacturer of poziotinib, another EGFRi. Clinical trials have revealed differences in EGFRi sensitivity for distinct types of exon 20 insertions, demonstrating the heterogeneity of these mutations.

ex20ins result in a relatively small drug binding pocket which has prevented first generation EGFRi binding.

ex20ins will depend upon being able to fit into this binding pocket.

1. NCCN. Clinical Practice Guidelines in Oncology. Non-small cell lung cancer, version 4.2024. Accessed May 17, 2024. 

https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf

2. Reiss JW, Gandara DR, Frampton GM, Madison R, et al. Diverse EGFR exon 20 insertions and co-occurring molecular alterations indentified by comprehensive genomic profiling of NSCLC. 

. 2018;13(10):1560-1568. doi:10.1016/j.tho.2018.06.019

3. Harrison PT, Vyse S, Huang PH. Rare epidermal growth factor receptor (EGFR) mutations in non-small cell lung cancer. 

. 2020;61:167-179. doi:10.1016/j.semcancer.2019.09.015

4. Takeda provides update on EXKIVITY (mobocertinib). News release. Takeda. October 2, 2023. Accessed April 22, 2024. 

https://www.takeda.com/newsroom/newsreleases/2023/Takeda-Provides-Update-on-EXKIVITY-mobocertinib/

EGFR Exon 20

Mesenchymal-epithelial transition proto-oncogene (MET)

 gene, located on chromosome 7q21-q31, encodes the tyrosine kinase receptor c-MET.

 Under normal physiological conditions, hepatocyte growth factor binds to the c-MET receptor initiating activation of the MET signaling pathway. This pathway is involved in cell proliferation, survival, and growth, and plays an important role in embryonic development, wound healing, and tissue regeneration. 

mutations, gene amplification, and protein overexpression, can drive oncogenic MET

signaling, thereby contributing to carcinogenesis and tumor progression.

 In non–small cell lung cancer (NSCLC), 

 alterations and generally occur independently of other driver mutations.

ex14 may coincide with MET amplification, with a co-occurrence rate of 0% to 40.5%.

 gene copy numbers, is a known resistance mechanism in 

ex14 varies by histology with approximate rates of 2% in adenocarcinoma, 1% in squamous cell carcinoma, 6% in adenosquamous cell carcinoma, and 13% in pulmonary sarcomatoid carcinoma (PSC).

ex14 mutations are typically older, predominantly female, and less likely to be smokers compared with those without such mutations.

The National Comprehensive Cancer Network (NCCN) NSCLC Panel recommends screening eligible patients with metastatic NSCLC for 

ex14 skipping mutations, guided by the efficacy of several agents and FDA approvals for capmatinib and tepotinib.

 Next-generation sequencing (NGS) is the preferred method for detecting 

ex14 skipping mutations, with RNA-based NGS possibly offering enhanced detection.

 Liquid biopsy may be employed when tissue biopsy is challenging, but negative results should be followed up with tissue-based testing. Amplicon-based NGS methods, though widely used, may have low detection rates for 

ex14 mutations due to allele dropout, leading to false negatives.

 Hybrid capture-based NGS methods offer better detection rates but may have increased off-target sequencing.

The US Food & Drug Administration (FDA) has approved 2 oral medications for treating 

ex14-positive metastatic NSCLC. Both approved agents are MET kinase inhibitors that act by inhibiting hepatocyte growth factor (HGF)-dependent and -independent MET phosphorylation and MET-dependent downstream signaling pathways.

 Capmatinib received accelerated approval in 2020 for use in adult patients with 

ex14-positve metastatic NSCLC, as detected by an FDA-approved test.

 The FoundationOne CDx assay (Foundation Medicine, Inc.) received concurrent approval as a companion diagnostic. Full FDA approval for capmatinib was subsequently granted in August of 2022.

 More recently in February 2024, tepotinib received full approval for treating adult patients with 

ex14-positve metastatic NSCLC, following its initial accelerated approval in 2021.

1. Smyth EC, Sclafani F, Cunningham D. Emerging molecular targets in oncology: clinical potential of MET/hepatocyte growth-factor inhibitors. 

. 2014;7:1001-1014. doi:10.2147/OTT.S44941

2. Spitaleri G, Trillo Aliaga P, Attili I, et al. MET in non-small-cell lung cancer (NSCLC): cross 'a long and winding road' looking for a target. 

. 2023;15(19):4779. doi:10.3390/cancers15194779

3. Frampton GM, Ali SM, Rosenzweig M, et al. Activation of MET via diverse exon 14 splicing alterations occurs in multiple tumor types and confers clinical sensitivity to MET inhibitors. 

. 2015;5(8):850-859. doi:10.1158/2159-8290.CD-15-0285

4. Sadiq AA, Salgia R. MET as a possible target for non-small-cell lung cancer. 

. 2013;31(8):1089-1096. doi:10.1200/JCO.2012.43.9422

5. Tong JH, Yeung SF, Chan AW, et al. MET amplification and exon 14 splice site mutation define unique molecular subgroups of non-small cell lung carcinoma with poor prognosis. 

. 2016;22(12):3048-3056. doi:10.1158/1078-0432.CCR-15-2061

6. Awad MM, Lee JK, Madison R, et al. Characterization of 1,387 NSCLCs with MET exon 14 (METex14) skipping alterations (SA) and potential acquired resistance (AR) mechanisms. 

. 2020;38(15):9511. doi: 10.1016/j.jtocrr.2022.100381

7. Reungwetwattana T, Ou SH. MET exon 14 deletion (METex14): finally, a frequent-enough actionable oncogenic driver mutation in non-small cell lung cancer to lead MET inhibitors out of "40 years of wilderness" and into a clear path of regulatory approval. 

. 2015;4(6):820-824. doi:10.3978/j.issn.2218-6751.2015.12.03

8. Schrock AB, Frampton GM, Suh J, et al. Characterization of 298 patients with lung cancer harboring MET exon 14 skipping alterations. 

. 2016;11(9):1493-1502. doi:10.1016/j.jtho.2016.06.004

9. Mignard X, Ruppert A, Antoine M, et al: c-MET overexpression as a poor predictor of MET amplifications or exon 14 mutations in lung sarcomatoid carcinomas.

. 2020;13(12):1962-1967. doi:10.1016/j.jtho.2018.08.008

10. Baldacci S, Figeac M, Antoine M, et al. High MET overexpression does not predict the presence of MET exon 14 splice mutations in NSCLC: Results from the IFCT PREDICT.amm study. 

. 2020;12020;15(1):120-124. doi:10.1016/j.jtho.2019.09.196

11. Noonan SA, Berry L, Lu X, et al. Identifying the appropriate FISH criteria for defining MET copy number-driven lung adenocarcinoma through oncogene overlap analysis. 

. 2016;11(8):1293-1304. doi:10.1016/j.jtho.2016.04.033

12. Wolf J, Seto T, Han JY, et al. Capmatinib in MET exon 14-mutated or MET-amplified non-small-cell lung cancer. 

. 2020;383(10):944-957. doi:10.1056/NEJMoa2002787

13. Le X, Kowalski D, Cho BC, et al. Liquid biopsy to detect MET exon 14 skipping (METex14) and MET amplification in patients with advanced NSCLC: Biomarker analysis from VISION study. 

. 2020;80(suppl 16):3385 doi:10.1158/1538-7445.AM2020-3385

14. Yu HA, Arcila ME, Rekhtman N, et al. Analysis of tumor specimens at the time of acquired resistance to EGFR-TKI therapy in 155 patients with EGFR-mutant lung cancers. 

. 2013;19(8):2240-2247. doi:10.1158/1078-0432.CCR-12-2246

15. Engelman JA, Zejnullahu K, Mitsudomi T, et al. MET amplification leads to gefitinib resistance in lung cancer by activating ERBB3 signaling. 

16. Bean J, Brennan C, Shih JY, et al. MET amplification occurs with or without T790M mutations in EGFR mutant lung tumors with acquired resistance to gefitinib or erlotinib. 

. 2007;104(52):20932-20937. doi:10.1073/pnas.0710370104

17. Socinski MA, Pennell NA, Davies KD. MET Exon 14 skipping mutations in non-small-cell lung cancer: an overview of biology, clinical outcomes, and testing considerations. 

. 2021;5:PO.20.00516. doi:10.1200/PO.20.00516

18. National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology. Non-small cell lung cancer, version 3.2024. Accessed March 13, 2024. 

19. Wolf J, Neal J, Mansfield A, et al. Comparison of clinical outcomes of patients with METΔex14 NSCLC treated with first-line capmatinib in the GEOMETRY mono-1 study with those of a cohort of real-world patients. Poster presented at: The European Society for Medical Oncology Virtual Meeting, September 19-21, 2020. Poster 1246P.

20. Drilon A, Clark JW, Weiss J, et al. Antitumor activity of crizotinib in lung cancers harboring a MET exon 14 alteration. 

. 2020;26(1):47-51. doi:10.1038/s41591-019-0716-8

21. Poirot B, Doucet L, Benhenda S, et al. MET exon 14 alterations and new resistance mutations to tyrosine kinase inhibitors: Risk of inadequate detection with current amplicon-based NGS panels. 

. 2017;12(10):1582-1587. doi:10.1016/j.jtho.2017.07.026

22. Jennings LJ, Arcila ME, Corless C, et al. Guidelines for validation of next-generation sequencing-based oncology panels: a joint consensus recommendation of the Association for Molecular Pathology and College of American Pathologists. 

. 2017;19(3):341-365. doi:10.1016/j.jmoldx.2017.01.011

23. TABRECTA (capmatinib). Package insert. East Hanover, NJ,USA: Novartis Pharmaceuticals Corporation; 03/2023.

24. TEPMETKO (tepotinib). Package insert. Darmstadt, Germany.Merck KGaA; 02/2024.

25. FDA grants accelerated approval to capmatinib formetastatic non-small cell lung cancer. US FDA. Updated May 6, 2020.Accessed March 13, 2024.

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-capmatinib-metastatic-non-small-cell-lung-cancer

26. FDA approves capmatinib for metastatic non-small cell lung cancer. US FDA. Updated August 11, 2022. Accessed March 13, 2024. 

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-capmatinib-metastatic-non-small-cell-lung-cancer

27. FDA grant accelerated approval to tepotinib for metastatic non-small cell lung cancer. US FDA. Updated February 3, 2021. Accessed March 13, 2024. 

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-tepotinib-metastatic-non-small-cell-lung-cancer

28. FDA approves tepotinib for metastatic non-small cell lung cancer. US FDA. Updated February 16, 2024. Accessed March 13, 2024. 

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-tepotinib-metastatic-non-small-cell-lung-cancer

Liang H, Wang M. MET oncogene in non-small cell lung cancer: mechanism of MET dysregulation and agents targeting the HGF/c-Met Axis. 

. 2020;13:2491-2510. doi:10.2147/OTT.S231257

Salgia R. Role of c-Met in cancer: emphasis on lung cancer. 

. 2009;36(2 suppl 1):S52-S58. doi:10.1053/j.seminoncol.2009.02.008

Titmarsh HF, O'Connor R, Dhaliwal K, Akram AR. The emerging role of the c-MET-HGF axis in non-small cell lung cancer tumor immunology and immunotherapy. 

. 2020;10:54. doi:10.3389/fonc.2020.00054

Zucali PA, Ruiz MG, Giovannetti E, et al. Role of cMET expression in non-small-cell lung cancer patients treated with EGFR tyrosine kinase inhibitors. 

. 2008;19(9):1605-1612. doi:10.1093/annonc/mdn240

METex14

Kirsten rat sarcoma viral oncogene homologue (

 was first detected in 1982 in lung cancer cells, located on the short arm of chromosome 12 (12p11.1–12p12.1).

 KRAS is a member of the RAS family of GTPase signal transducer proteins which include Harvey rat sarcoma viral oncogene (

) and neuroblastoma rat sarcoma oncogene (

). These proteins hydrolyze guanosine triphosphate (GTP) to guanosine diphosphate (GDP) and serve as molecular switches that cycle between the inactive GDP-bound state and the active GTP-bound state under normal conditions. When active, KRAS activates the MAPK and PI3K signaling pathways that promote cell proliferation, growth, and survival.

 is a commonly occurring oncogene with the highest mutation rate among all cancers, and mutated forms of 

 (more frequent in patients with a smoking history) are present in approximately 25% of lung adenocarcinomas.

 are an early event in lung tumorigenesis. They are associated with a history of smoking

, a high mutation burden, and elevated markers of immune evasion (PD-L1 and PD-L2).

 Most mutations occur in exons 2 or 3, resulting in impaired GTPase activity. Approximately 42% of mutations result in substitution of cysteine for glycine at codon 12 (G12C; in exon 2).

 These alterations result in an isoform that inhibits GTP hydrolysis and locks G12C-mutant 

 in its active state. This, in turn, causes constitutive activation of the MAPK and PI3K pathways, thereby promoting tumorigenesis.

 G12C mutations are the most common, accounting for 40% of 

mutations in NSCLC, there are several relevant mutations including 

 alteration relevant in NSCLC is mutation vs amplification or expression. As the majority of lung cancers are detected at an advanced stage, biomarker testing should be performed as soon as possible. Next-generation sequencing (NGS), real-time polymerase chain reaction (PCR), and Sanger sequencing (ideally paired with tumor enrichment) are the most commonly deployed methodologies for examining alterations in 

. When feasible, a broad, panel-based approach, most typically performed by NGS, is recommended by the NCCN.

 mutation is important as the currently available agents are designed specifically for 

Two oral medications have been approved by the US Food & Drug Administration (FDA) for treatment of 

 G12C-mutated locally advanced or metastatic NSCLC: 

 in 2022. Both drugs have the similar mechanism of action, namely that they selectively and irreversibly bind to cysteine 12 in KRAS and lock it in its inactive state.

1. Chang EH, Gonda MA, Ellis RW, et al. Human genome contains four genes homologous to transforming genes of Harvey and Kirsten murine sarcoma viruses. 

 1982; 79:4848–4852. doi:10.1073/pnas.79.16.4848

2. O’Sullivan É, Keogh A, Henderson B, et al. Treatment strategies for 

. 2023; 15(6):1635. doi:10.3390/cancers15061635

3. Tsao AS, Scagliotti GV, Bunn PA Jr, et al. Scientific advances in lung cancer 2015. 

. 2016; 11:613-638. doi:10.1016/j.jtho.2016.03.012

4. Westra WH, Baas IO, Hruban RH, et al. K-ras oncogene activation in atypical alveolar hyperplasias of the human lung. 

5. Riely GJ, Kris MG, Rosenbaum D, et al. Frequency and distinctive spectrum of KRAS mutations in never smokers with lung adenocarcinoma. 

. 2008; 14:5731–5734. doi:10.1158/1078-0432.CCR-08-0646

6. Calles A, Liao X, Sholl LM, et al. Expression of PD-1 and its ligands, PD-L1 and PD-L2, in smokers and never smokers with KRAS-mutant lung cancer. 

. 2015; 10:1726–1735. doi:10.1097/JTO.0000000000000687

7. Karachaliou N, Mayo C, Costa C, et al. KRAS mutations in lung cancer. 

. 2013; 14:205-214. doi:10.1016/j.cllc.2012.09.007

8. Judd J, Abdel Karim N, Khan H, Naqash AR, et al. Characterization of 

mutation subtypes in non-small cell lung cancer. 

 2021;20(12):2577-2584. doi:10.1158/1535-7163.MCT-21-0201

9. National Comprehensive Cancer Network. NCCN guidelines version 2.2024: Non-Small Cell Lung Cancer. Accessed May 17, 2024.

10. Shim HS, Kenudson M, Zheng Z, et al. Unique genetic and survival characteristics of invasive mucinous adenocarcinoma of the lung. 

. 2015; 10:1156–1162. doi:10.1097/JTO.0000000000000579

11. Veluswamy R, Mack PC, Houldsworth J, et al. KRAS G12C-mutant non-small cell lung cancer: biology, developmental therapeutics, and molecular testing. 

. 2021; 23:507–520. doi:10.1016/j.jmoldx.2021.02.002

Amanam I, Mambetsariev I, Gupta R, Achuthan S, Wang Y, Pharaon R, Massarelli E, Koczywas M, Reckamp K, Salgia R. Role of immunotherapy and co-mutations on KRAS-mutant non-small cell lung cancer survival. 

. 2020; 12(9):5086–5095. doi:10.21037/jtd.2020.04.18

Lim TKH, Skoulidis F, Kerr KM, et al. KRAS G12C in advanced NSCLC: Prevalence, co-mutations, and testing. 

. 2023; 184:107293. doi:10.1016/j.lungcan.2023.107293

Salgia R, Pharaon R, Mambetsariev I, et al. The improbable targeted therapy: KRAS as an emerging target in non-small cell lung cancer (NSCLC). 

. 2021; 2(1):100186. doi:10.1016/j.xcrm.2020.100186

KRAS G12C

Human epidermal growth factor receptor 2 (

); erb-b2 avian erythroblastic leukemia viral oncogene homolog 2 (

 oncogene is located on chromosome 17q12 and encodes a transmembrane tyrosine kinase receptor that is part of the epidermal growth factor receptor family.

 mutations and amplifications have been identified in 2% to 4% of NSCLC.

-mutant NSCLC represents a heterogenous disease group, found in both smokers and nonsmokers. Patients with 

 mutations typically exhibit a worse prognosis than do patients with 

 mutations, partially because their disease cannot yet be treated with a highly selective, targeted therapy. De novo 

 mutations are usually mutually exclusive with other driver genes, and predominantly occur in the kinase domain.

 mutations primarily involve insertion or duplication events in exon 20 and other activating mutations, and they are associated with responsiveness to anti-HER2 targeted therapy.

-mutated NSCLC demonstrates a propensity for brain metastases during treatment, with subtype 

 YVMA insertion showing a particularly higher estimated 12-month brain metastasis incidence when compared with the group not having this insertion.

In the 2023 update to the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in NSCLC, new testing recommendations for 

 NGS-based testing is considered the most effective method for detecting a wide range of genomic 

) alterations; however, Sanger sequencing and targeted PCR approaches are also options. Based on clinical trial data and FDA approval of fam-trastuzumab deruxtecan-nxki (T-DXd), the NCCN NSCLC Panel advises testing for 

 mutations in all patients with metastatic nonsquamous NSCLC or NSCLC not otherwise specified (NOS). Testing for 

 mutations may also be considered for patients with metastatic squamous cell carcinoma.

On August 11, 2022, the US Food & Drug Administration (FDA) granted accelerated approval to T-DXd for the treatment of adult patients with unresectable or metastatic NSCLC whose tumors have activating 

 mutations, as detected by an FDA-approved test, and who have received a prior systemic therapy.

 T-DXd is a HER2-directed antibody-drug conjugate (ADC) consisting of a humanized anti-HER2 IgG1 antibody linked to the topoisomerase I inhibitor payload, deruxtecan, via a cleavable tetrapeptide linker.

 Upon binding of HER2 on tumor cells, T-DXd undergoes internalization and intracellular linker cleavage, thereby releasing the DXd payload and subsequently causing DNA damage and apoptotic cell death. Accelerated approval was granted based on findings from DESTINY-Lung02, marking the first approval for 

 Alongside this approval, the FDA also sanctioned Life Technologies Corporation’s Oncomine™ Dx Target Test (tissue) and Guardant Health, Inc.’s Guardant360

 CDx (plasma) as Enhertu's companion diagnostics, stipulating that tumor tissue testing is recommended if no mutation is detected with plasma-based testing. 

In April of 2023, T-DXd was granted accelerated approval for previously treated unresectable or metastatic HER2+ (IHC 3+) solid tumors with no satisfactory alternative treatment options, marking it as the first tumor-agnostic approved ADC. Accelerated approval was based on findings from three clinical trials: DESTINY-PanTumor02 (NCT04482309), DESTINY-Lung01 (NCT03505710), and DESTINY-CRC02 (NCT04744831).

Learn more about Fam-Trastuzumab Deruxtecan-nxki (T-DXd) >

1. Rubin I and Yarden, Y. The basic biology of HER2. 

 2001;12(supp1):S3-S8. doi:10.1093/annonc/12.suppl_1.s3

2. Schechter AL, Stern DF, Vaidyanathan L, 

. The neu oncogene: an erb-B-related gene encoding a 185,000-Mr tumour antigen. 

. 1984;312(5994):513‐516. doi:10.1038/312513a0

3. Yu X, Ji X, Su C. HER2-altered non-small cell lung cancer: biology, clinicopathologic features, and emerging therapies. 

 2022;12:860313. doi:10.3389/ fonc.2022.860313

4. Pillai RN, Behera M, Berry LD, et al. HER2 mutations in lung adenocarcinomas: a report from the Lung Cancer Mutation Consortium. 

 2017;123(21):4099-4105. doi:10.1002/cncr.30869

5. Yang S, Wang Y, Zhao C, et al. Exon 20 YVMA insertion is associated with high incidence of brain metastasis and inferior outcome of chemotherapy in advanced non-small cell lung cancer patients with HER2 kinase domain mutations. 

 2021;10(2):753-765. doi:10.21037/tlcr-20-559

6. National Comprehensive Cancer Network. Clinical Practice Guidelines in Non-small cell lung cancer, version 3.2024. Accessed March 18, 2024. 

7. FDA. FDA grant accelerated approval to fam-trastuzumab deruxtecan-nxki for HER2-mutant non-small cell lung cancer. US FDA. Updated August 16, 2022. Accessed March 18, 2024. 

https://www.fda.gov/drugs/resources-information-approved-drugs/fda-grants-accelerated-approval-fam-trastuzumab-deruxtecan-nxki-her2-mutant-non-small-cell-lung

8. Enhertu (fam-trastuzumab deruxtecan-nxki). Package insert. Daiichi Sankyo Inc; February 2024.

9. FDA.gov. FDA grant accelerated approval to fam-trastuzumab deruxtecan-nxki for unresectable or metastatic HER2-positive solid tumors. Updated April 5, 2024. Accessed April 22, 2024. 

Non–Small Cell Lung Cancer

Afatinib

Initial US Approval

Indications

Recommended Dose/Route

Dose Reductions for Adverse Reactions

Pivotal Study

Treatment

Safety

References