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.

 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).

All patients with advanced or metastatic lung adenocarcinoma should undergo broad molecular profiling at diagnosis.

Broad molecular profiling should also be considered for those with advanced or metastatic lung squamous cell carcinoma at diagnosis.

In early-stage disease, testing at diagnosis should include assessment of PD-L1, EGFR, and ALK.

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 EGFR.

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

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

To optimize tissue use and minimize waste, the National Comprehensive Cancer Network advises broad molecular profiling through a validated test. 

In patients with advanced or metastatic NSCLC, testing should include, at a minimum, the following biomarkers: ALK, BRAF, EGFR, ERBB2 (HER2), KRAS, METex14, NTRK, RET, ROS1, and PD-L1. Liquid biopsy may also be considered in conjunction with tissue NGS testing. 

For patients with early-stage NSCLC, testing should assess PD-L1 status, EGFR mutations, and ALK rearrangements.

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 

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.

Amivantamab is a bispecific antibody targeting the extracellular domains of EGFR and MET.

In vitro and in vivo studies show it disrupts EGFR and MET signaling in models with exon 19 deletions, exon 21 L858R substitutions, and exon 20 insertions by blocking ligand binding or promoting degradation. Its binding to EGFR and MET on tumor cells also enables immune-mediated cell destruction via antibody-dependent cellular cytotoxicity (ADCC) and trogocytosis.

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

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

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

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/

RYBREVANT (amivantimab). Prescribing information. Janssen Biotech, Inc.;2024. Accessed October 2, 2024. 

https://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/RYBREVANT-pi.pdf

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.

All patients with advanced or metastatic lung adenocarcinoma should undergo broad molecular profiling at diagnosis. 

Broad molecular profiling should also be considered for those with advanced or metastatic lung squamous cell carcinoma at diagnosis. 

In early-stage disease, testing at diagnosis should include assessment of PD-L1, EGFR, and ALK

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 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.

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

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.

Capmatinib and tepotinib are MET kinase inhibitors that act by inhibiting hepatocyte growth factor (HGF)-dependent and -independent MET phosphorylation and MET-dependent downstream signaling pathways.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

Tabrecta (Capmatinib). Prescribing information. Novartis; 2024. 

https://www.novartis.com/us-en/sites/novartis_us/files/tabrecta.pdf

Tepmetko (tepotinib). Prescribing information. Merck KGaA; 2024. Accessed December 3, 2024. 

https://www.emdserono.com/us-en/pi/tepmetko-pi.pdf 

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

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

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

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%

mutations in NSCLC, there are several relevant mutations including 

Broad molecular profiling should also be considered for those with advanced or metastatic lung squamous cell carcinoma at diagnosis. In early-stage disease, testing at diagnosis should include assessment of PD-L1, EGFR, and ALK.

 alteration relevant in NSCLC is mutation vs amplification or expression. 

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 National Comprehensive Cancer Network (NCCN).

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

, testing should include, at a minimum, the following biomarkers: ALK, BRAF, EGFR, ERBB2 (HER2), KRAS, METex14, NTRK, RET, ROS1, and PD-L1. 

Liquid biopsy may also be considered in conjunction with tissue NGS testing. 

, testing should assess PD-L1 status, EGFR mutations, and ALK rearrangements.

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

 G12C-mutated locally advanced or metastatic NSCLC: sotorasib in 2021 and adagrasib in 2022. 

Both of these 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.

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

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

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

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

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

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

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

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

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

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

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

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. 

 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. 

 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.

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).

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

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When Should Patients With NSCLC be Referred to Thoracic Surgeons in Specialized Centers of Care?