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Danilo Rocco
Pneumologia ad indirizzo Oncologico
La terapia del paziente EGFR
mutato
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885
EGFR mut+ patients
L858R exon 21 Del exon 19 uncommon
Afatinib Erlotinib Gefitinib
exon 20 Exon 18
clinically relevant endpoints:
tolerability
quality of life
comorbidities
drug interaction
life expectancy
Consider TKI
CTx
Algorithm in A-NSCLC EGFR +
patients
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Study TKI CTx N # PFS mos HR 95% CI OS mos OS HR 95%
CI
IPASS GEFITINIB Cb/Pac 261 9.5 vs. 6.3 0.48 0.36 - 0.64
21.6 vs. 21.9 1.00 0.76 – 1.33
NEJ002 GEFITINIB Cb/Pac 194 10.8 vs. 5.4 0.32 0.22 – 0.41
27.7 vs. 26.6 0.89 0.63 – 1.24
WJTOG 3405 GEFITINIB Cis/Doc 172 8.4 vs. 5.3 0.33 0.21 – 0.54
36.0 vs 39.0 1.19 0.73 – 1.83
OPTIMAL ERLOTINIB Cis/Gem 164 13.1 vs.4.6 0.16 0.10 – 0.26
22.7 vs. 28.9 1.04 0.69 – 1.58
EURTAC ERLOTINIB P/Doc or
Gem 174 10.4 vs 5.4 0.47
0.28 – 0.78 19.3 vs. 19.5 1.04
0.65 – 1.68
ENSURE ERLOTINIB P/Gem 217 11.0 vs 5.6 0.34 0.22- 0.51
26.3 vs. 25.5 0.91 0.62 – 1.31
LUX-LUNG 3 AFATINIB Cis/Pem 308 11.1 vs.6.9 0.49 0.37 – 0.65
31.6 vs 28.3 0.78 0.58 – 1.06
LUX-LUNG 6 AFATINIB Cis/Gem 364 11.0 vs. 5.6 0.28 0.20 – 0.39
23.6 vs. 23.5 0.83 0.62 – 1.09
ARCHER 1050 DACOMITINIB Gef 452 14.7 vs 9.2 0.59
0.47-0.74 - -
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Mechanisms of therapeutic
resistance to kinase
Target modification
Patient-specific factors
Tumor-intrinsic factors
Other mechanisms
Histologic transformation
Bypass signaling
Target gene amplification
Plasma drug levels
Coexistent genetic
alterations in the drug target
Increased growth factor production
Epithelial-to-mesenchymal
transition
Activation of ‘compensatory
loops’ to circumvent the
inhibited target
‘Second site’ mutation within the target gene
Drug–drug interactions Coexistent
mutations in other signaling
genes
Phenotypic change from
NSCLC to SCLC
Inactivation of proapoptotic
pathways
Alternative splicing of the
target gene
Examples of strategies to overcome acquired resistance
Alternative dose or schedule
Next-generation inhibitors
Drug combinations
Dual-target blockade
Therapeutic resistance
Primary resistance
Acquired resistance
Lovly and Shaw. Clin Cancer Res 2014; Ohashi et al. J Clin Oncol 2013
Acquired resistance to EGFR
inhibition
± Pharmacokinet
ic failure
± Exogenous factors eg, HGF, IL-
6
~30–40%
Activation of other receptor tyrosine kinases? (eg, ERBB2 amplification) FAS / NFχB activation?
~60% second-site EGFR mutations (mostly T790M)
~1% BRAF mutations
~5% small-cell cancer
transformation ~5% PIK3CA
mutations 5–10% MET
amplification
Epithelial-mesenchymal transition? (AXL, Slug activation?) Loss or spliced variant of BIM? Other? (eg, CRKL or ERK amplification)
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Potenziale meccanismo attraverso il quale la mutazione T790M provoca
resistenza ad EGFR-TKIs
Ipotesi 1: Prevenzione del legame di EGFR-TKIs La mutazione T790M EGFR-TKI resistente, derivante dalla sostituzione di treonina con metionina nell’amminoacido “gatekeeper” 790, determina una catena laterale più ingombrante1,2
Questo causa ingombro sterico, che riduce il legame degli EGFR-TKIs, erlotinib e gefitinib, a EGFR1,2
1. Kobayashi S, et al. N Engl J Med 2005;352:786–792; 2. Cross DA, et al. Cancer Discov 2014;4:1046–1061
Il legame di erlotinib a EGFR-WT determinato mediante cristallografia (Fig. A) è impedito dall’ingombro sterico, dovuto alla presenza della catena laterale della metionina nella mutazione T790M (Fig. B mostrata in arancione) nella tasca di legame dell’ATP.
• La Fig. C mostra l’ingombro sterico del complesso di gefitinib
e EGFR con la mutazione T790M.
• La Fig. D mostra il legame di un altro inibitore EGFR non
correlato (CL-387,785) a EGFR con la mutazione T790M (il
cambiamento strutturale introdotto dalla mutazione T790M è
mostrato in arancione).
A B
C D
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Potenziale meccanismo attraverso il quale la mutazione T790M provoca
resistenza ad EGFR-TKIs
T790M aumenta l’affinità di legame di EGFR per l’ATP
Poichè gefitinib e erlotinib sono ligandi reversibili che competono con l’ATP al sito di legame
chinasico di EGFR, una maggiore affinità per l’ATP significa una riduzione nella potenza di questi
EGFR-TKIs
Ipotesi 2: Aumetata affinità di legame per l’ATP
Modificate da: Yun C-H, et al. Proc Natl Acad Sci U S A 2008;105:2070–2075. Copyright (2008) National Academy of Sciences, U.S.A.
1.0
1.1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
-0.1
Fra
ctio
na
l ve
locity*
-0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
EGFR-sensitising mutation L858R:
Even at cellular ATP concentrations (~1 mM), EGFR remains sensitive to EGFR-TKI
binding
L858R plus T790M mutation:
At cellular concentrations of ATP
(~1 mM), EGFR-TKI binding is reduced
L858R
0.01 mM ATP
1.00 mM ATP
[Gefitinib] µM
1.0
1.1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
-0.1
Fra
ctio
na
l ve
locity*
-0.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5
L858R/T790M
0.01 mM ATP
1.00 mM ATP
[Gefitinib] µM
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3rd generation EGFR-TKIs targeting T790M
Drug Company Clinical Stage ORR DCR PFS
(month)
AZD9291 Astra
Zeneca
Phase III
(Approved) 61% 95% 9.6
CO-1686 Clovis Phase II/III
(stopped) 59% 93% 13.1
HM61713 Hanmi/BI Phase II/III
(stopped) 43% 86% -
ASP8273 Astellas Phase II 30% - 6.8
EGF816 Novartis Phase I 47% 87% 9.7
AC0010 Acea Bio Phase I 39% 78% -
PF-
06747775 Pfizer Phase I/II NR NR NR
Chee-Seng Tan et al. Lung Cancer 2016;
Pasi Janne et al. NEJM 2015; Sequist LV. NEJM 2015;
Zhang Li et al. ESMO 2016; Daniel Shao-Weng Tan. ASCO 2016 Abs 9044. #6009: Novel Tyrosine Kinase Inhibitors in Lung Cancer –Caicun Zhou
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I tre studi del Programma AURA
Gli Studi AURA
Programma di studi clinici per valutare sicurezza e attività di osimertinib, un EGFR-TKI
orale, potente, irreversibile, selettivo per mutazioni sensibilizzanti e di resistenza T790M
in pazienti con NSCLC avanzato EGFRm+ in progressione dopo terapia con un farmaco
EGFR-TKI.
1. Janne PA, et al. NEJM 2015; 2. Mitsudomi T, et al. Lancet Oncol 2016; 3. Mok T.S. et al, NEJM 2016.
Aumento della dose ed espansione (fase I) ed estensione (fase II)
Studio di fase I/II, open-label,
multicentrico per valutare
sicurezza, tollerabilità,
farmacocinetica ed attività
antitumorale di dosi crescenti
di osimertinib in pazienti con
NSCLC avanzato in
progressione dopo una
precedente terapia con un
farmaco EGFR-TKI
AURA
Studio di fase II
Studio di fase II, open-label,
con braccio singolo per
valutare sicurezza ed
efficacia di osimertinib in
pazienti con NSCLC
localmente avanzato o
metastatico in progressione
dopo una precedente terapia
con un farmaco EGFR-TKI e i
cui tumori sono EGFRm+ e
T790M+
AURA2
Studio confirmatorio di fase III
Studio di fase III, open-label,
randomizzato per valutare
sicurezza ed efficacia di
osimertinib vs doppietta
chemioterapica a base di
platino in pazienti con
NSCLC localmente avanzato
o metastatico,
EGFRm+/T790M+ in
progressione dopo una
precedente terapia con un
farmaco EGFR-TKI
AURA3
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Disegno dello Studio1
AURA 3
1. Mok T.S. et al, NEJM 2016
T790M+
(n=610)
T790M-
Platinum-based doublet chemotherapyb
every 3 weeks (n=203)
osimertinib
(80 mg orally once daily; n=407)
Central testinga
of biopsy sample
Not eligible for enrollment
acobas® EGFR Mutation Test (Roche Molecular Systems).
Tissue and plasma samples will be collected so as to understand: a) the utility of multiple sample types for the identification of T790M+ tumors; b) the molecular evolution of the disease. b Pemetrexed 500 mg/m2 + carboplatin AUC5 or pemetrexed 500 mg/m2 + cisplatin 75 mg/m2 – to be confirmed from feasibility.
AUC5 = area under the plasma concentration-time curve 5 mg/mL-1 per minute.
Randomization 2:1
Studio di fase III, open-label, randomizzato per valutare sicurezza ed efficacia di osimertinib vs doppietta chemioterapica a base di platino in 2a linea, in pazienti con NSCLC localmente avanzato/metastatico, EGFRm+/T790M+ in progressione dopo una precedente terapia con un farmaco EGFR-TKI.
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AURA 3
PFS secondo valutazione dello sperimentatore1
1. Mok T.S. et al, NEJM 2016
Median
No. of Progression-free
Patients Survival
mo (95% CI)
Osimertinib 279 10.1 (8.3-12.3)
Platinum-pemetrexed 140 4.4 (4.2-5.6)
Hazard ratio for disease progression
or death, 0.30 (95% CI, 0.2 3-0.41)
P<0.001
No. at Risk
Osimertinib 279 240 162 88 50 13 0
Platinum- 140 93 44 17 7 1 0
pemetrexed
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Beneficio di osimertinib osservato in pazienti con e senza metastasi cerebrali al
basale
Attività di osimertinib nelle metastasi cerebrali
Dati clinici dallo studio AURA 31
1. Mok T.S. et al, NEJM 2016
Pazienti con metastasi cerebrali
Median
No. of Progression-free
Patients Survival
mo (95% CI)
Osimertinib 93 8.5 (6.8-12.3)
Platinum-pemetrexed 51 4.2 (4.1-5.4)
Hazard ratio for disease progression
or death, 0.32 (95% CI, 0.2 1-0.49)
No. at Risk
Osimertinib 93 80 46 27 14 4 0
Platinum- 51 32 9 4 2 0 0
pemetrexed
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Acquired resistance to 3rd-generation inhibitors
EGFR dependent -C797S (in trans: could be sensitive to combined therapy with first and third
generation TKI, cis:resistant), C797G, L798I, E790K, L692V, L781Q
-T790M reduction, disappearance or loss
-EGFR amplification
EGFR independent -HER2 amplification, MET amplification, PIK3CA mutations, PTEN loss, RAS-
MAPK pathway activation (KRAS mut, BRAF mut, MAPK1/AKT3), FGF2-
FGFR1 autocrine loop, EMT, NRAS mut/CNG, IGF1R activation, SCLC)
Thress KS et al. Nat Med 2015; 21(6): 560–2; Piotrowska Z et al. Cancer Discov 2015; 5(7): 713–22
T790-WT SCLC
T790-WT NSCLC
T790-positive NSCLC (EGFR-
amplified) (3
T790-positive NSCLC
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Approaches for managing patients with resistant tumors
Osimertinib in combination with…
Ramucirumab (NCT02789345), bevacizumab
(NCT02803203)
Necitumumab (NCT02496663, NCT02789345)
Savolitinib (NCT02143466)
Durvalumab (NCT02454933, NCT027119671,
NCT02143466, NCT02664935)
INCB039110 (JAK inhibitor) (NCT02917993)
Selumetinib (NCT02143466, NCT02664935)
INK128 (TORC1 / 2) (NCT02503722)
Navitoclax (Bcl2) (NCT02520778)
AZD6094 (MET) (NCT02143466)
EGF816 + INC280 (MET), EGF816 + nivolumab
Agents targeting C797S
Targeting T790M-negative…
MET inhibition
MEK inhibitor combinations
EMT:AXL inhibition
SMO gene amplification (Hh receptor)
with MET activation
FGFR 1, 2, 3 activation
ErBB2 activation mutations
IGF1R activation
BRAF (Val600Glu, Gly469Ala) mutation
PIK3CA mutation
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CASO CLINICO anamnesi
Giunge alla nostra osservazione nel novembre 2015:
• Antonio 15/01/1949, maschio, PS 0
• Non fumatore
• Pensionato, ex impiegato
• Nessuna comorbilità di rilievo
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CASO CLINICO iter diagnostico-terapeutico
Storia clinica • Nel Dicembre 2013 diagnosi di adenocarcinoma polmonare IV stadio,
per lesioni epatiche, delezione dell’esone 19 del gene EGFR
• Intraprese subito trattamento con Gefitinib 250 mg/die
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CASO CLINICO REFERTO CITOLOGICO
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CASO CLINICO ANALISI MOLECOLARE BASALE
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CASO CLINICO PD durante Gefitinib
• Per PD toracica ed epatica nell’ agosto 2015 intraprende 4 cicli di
CBDCA-PACLITAXEL, per ulteriore PD giunge alla nostra UOC nel
novembre dello stesso anno
•Si richiede BL per determinazione T790M
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CASO CLINICO BL T790M+
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CASO CLINICO trattamento dopo risultato BL
•Alla luce del dato molecolare il paziente viene inserito nello studio
ASTRIS ed inizia OSIMERTINIB 80 mg/die
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CASO CLINICO SD DURANTE OSIMERTINIB REFERTO
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CASO CLINICO SD DURANTE OSIMERTINIB IMMAGINE
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CASO CLINICO PD DURANTE OSIMERTINIB REFERTO
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CASO CLINICO PD DURANTE OSIMERTINIB IMMAGINE
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CASO CLINICO BL IN PD DURANTE OSIMERTINIB
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Open questions
Is there a difference in efficacy among TKIs?
Is there a role of TKI in uncommon EGFR mutations?
Is there a difference in safety among TKIs?
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Open questions
Is there a difference in efficacy among TKIs?
Is there a role of TKI in uncommon EGFR mutations?
Is there a difference in safety among TKIs?
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Is there a difference in efficacy among TKIs?
Direct comparisons….
STUDY Comparison
CTONG 0901 Erlotinib vs Gefitinib
LUX-LUNG 7 Afatinib vs Gefitinib
ARCHER 1050 Dacomitinib vs Gefitinib
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Erlotinib versus Gefitinib:
CTONG0901
Jin-Ji Yang, Denver 2015
Erlotinib was not superior to
Gefitinib in PFS and OS
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Afatinib vs Gefitinib:
Lux-Lung-7
Treatment beyond progression allowed if deemed beneficial by investigator
RECIST assessment performed at Weeks 4, 8 and every 8 weeks thereafter until Week 64, and every 12 weeks thereafter
Afatinib 40 mg once daily†
Gefitinib 250 mg once daily
Primary endpoints:
• PFS (independent) • TTF • OS Secondary endpoints:
• ORR • Time to response • Duration of response • Duration of disease control • Tumor shrinkage • HRQoL • Safety
1:1
• Stage IIIB/IV adenocarcinoma of the lung
• EGFR mutation (Del19 and/or L858R) in the tumor tissue*
• No prior treatment for advanced/ metastatic disease
• ECOG PS 0/1
Stratified by • Mutation type (Del19/L858R) • Brain metastases (present/absent)
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11 vs 10.9 mesi
27%
15%
18%
8%
Park K, Lancet Oncol 2016
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Lux-Lung-7:
TTF e OS
Park K, Lancet Oncol 2016; Paz-Ares L, Ann Oncol 2017
27.9 versus 24.5 months
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Yu YL, Clin Lung Cancer 2018
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Yu YL, Clin Lung Cancer 2018
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Yu YL, Clin Lung Cancer 2018
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Yu YL, Clin Lung Cancer 2018
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FLAURA
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ASCO 2018: EGFR+
Dacomitinib: ARCHER 1050
Erlotinib + Bevacizumab: JO25567
Erlotinib + Bevacizumab: NEJ026
Gefitinib + Chemioterapia: NEJ009
Afatinib in real world
EGFR
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Slide 4
Presented By Tony Mok at 2018 ASCO Annual Meeting
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Slide 6
Presented By Tony Mok at 2018 ASCO Annual Meeting
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Slide 8
Presented By Tony Mok at 2018 ASCO Annual Meeting
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Slide 5
Presented By Tony Mok at 2018 ASCO Annual Meeting
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Slide 9
Presented By Tony Mok at 2018 ASCO Annual Meeting
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Erlotinib + bevacizumab: JO25567
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Final Overall survival
Presented By Noboru Yamamoto at 2018 ASCO Annual Meeting
JO25567
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Phase III study comparing bevacizumab plus erlotinib <br />to erlotinib in patients with untreated NSCLC <br />harboring activating EGFR‐mutations:<br /> NEJ 026
Presented By Naoki Furuya at 2018 ASCO Annual Meeting
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Primary endpoint : PFS by independent review
Presented By Naoki Furuya at 2018 ASCO Annual Meeting
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Phase III Study Comparing Gefitinib Monotherapy to Combination Therapy with Gefitinib, Carboplatin, and Pemetrexed for Untreated Patients with Advanced Non-Small Cell Lung Cancer with EGFR Mutations
(NEJ009)
Presented By Atsushi Nakamura at 2018 ASCO Annual Meeting
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Study Design of NEJ009
Presented By Atsushi Nakamura at 2018 ASCO Annual Meeting
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Progression-Free Survival 1<br /><br /><br /><br />
Presented By Atsushi Nakamura at 2018 ASCO Annual Meeting
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Overall Survival
Presented By Atsushi Nakamura at 2018 ASCO Annual Meeting
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This non-interventional, observational, multi-country/site study used medical records
of TKI-naïve pts with EGFRm+ (Del19/L858R) NSCLC treated with first-line afatinib
Primary outcomes were % pts with adverse drug reactions (ADRs) by severity, time
on treatment, and time to progression
Halmos B, ASCO 2018
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228 pts from 13 countries were included (Europe, Asia, North America)
Dose modifications were more frequent in females, older pts, Eastern Asian pts, and
lower body weight pts
67% of ≥40 mg starters underwent dose reductions, with 86% of those occurring in
the first 6 mos
There were no new safety signals, and fewer ≥G3 ADRs and SAEs than in LL3 (25%
vs 49% and 5% vs 14%)
Median time on treatment and TTP was 18.7 mos and 20.8 mos respectively and was
not impacted by reduced starting dose or dose modification
Halmos B, ASCO 2018
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Post-ASCO18 Options for First-Line Treatment of EGFR mutation-positive NSCLC:
Presented By Lecia Sequist at 2018 ASCO Annual Meeting
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Osimertinib is best first line treatment
Presented By Helena Yu at 2018 ASCO Annual Meeting
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Gefitinib 10.8 mesi
Osimertinib 10.1 mesi
tot. 20.9
Erlotinib 11.0 mesi
Osimertinib 10.1 mesi
tot. 21.1
Conti dell’Oste
Afatinib 11.1 mesi
Osimertinib 10.1 mesi
tot. 21.2
Dacomitinib 14.7 mesi
Osimertinib 10.1 mesi
tot. 24.8
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Strategia terapeutica futura dei con
EGFRmut+
Farmaco ultima generazione?
Terapia sequenziale farmaco A+B ?
Farmaco A Farmaco B
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Open questions
Is there a difference in efficacy among TKIs?
Is there a role of TKI in uncommon EGFR mutations?
Is there a difference in safety among TKIs?
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TKI in uncommon EGFR mutations
• Uncommon mutations:
Group 1: point mutations or duplications in exons 18–21
Group 2: de-novo Thr790Met mutations in exon 20 alone or in combination with other mutations
Group 3: exon 20 insertions
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Open questions
Is there a difference in efficacy among TKIs?
Is there a role of TKI in uncommon EGFR mutations?
Is there a difference in safety among TKIs?
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Costanzo R.. and Morabito A, Expert Rev Anticancer Ther 2013
Toxicity in randomized trials
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Yang, IASLC 2015
CTONG 0901: toxicity Table 2.Treatment-Emergent AEs≥10% of Patients in Either Treatment Arm
AE
Gefitinib (n = 128) No. (%)
Erlotinib (n = 128) No. (%)
All grades Grade≥3 All grades Grade≥3
Rash 80 (62.5) 0 (0.0) 89 (69.5) 3 (2.3)
Cough 38 (29.7) 0 (0.0) 30 (23.4) 0 (0.0)
Diarrhea 24 (18.8) 0 (0.0) 22 (17.2) 0 (0.0)
Hand and foot syndrome
16 (12.5) 0 (0.0) 8 (6.3) 0 (0.0)
Nail changes 16 (12.5) 0 (0.0) 24 (18.8) 0 (0.0)
Anorexia 15 (11.7) 0 (0.0) 7 (5.4) 0 (0.0)
ALT increase 13 (10.2) 0 (0.0) 6 (4.7) 0 (0.0)
Bilirubin increase 13 (10.2) 0 (0.0) 7 (5.4) 3 (2.3)
Dry skin 11 (8.6) 0 (0.0) 13 (10.2) 0 (0.0)
Abbreviation: AE, adverse event. ALT, alanine aminotransferase.
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LUX-LUNG-7: toxicity
†Plus 1 case of grade 4 diarrhea ; ‡Plus 1 case of grade 4 increased ALT ALT, alanine aminotransferase; AST, aspartate aminotransferase
AE category, %
Afatinib (n=160) Gefitinib (n=159)
All Grade 3 All Grade 3
Diarrhea 90.0 11.9† 61.0 1.3
Rash/acne* 88.8 9.4 81.1 3.1
Stomatitis* 64.4 4.4 23.9 -
Paronychia* 55.6 1.9 17.0 0.6
Dry skin 32.5 - 37.1 -
Pruritus 23.1 - 22.6 -
Fatigue* 20.6 5.6 14.5 -
Decreased appetite 16.3 0.6 11.9 -
Nausea 16.3 1.3 13.8 -
Alopecia 10.6 - 15.1 -
Vomiting 10.6 - 3.8 0.6
ALT increased 9.4 - 23.9 7.5‡
AST increased 6.3 - 20.8 2.5
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LUX-LUNG-7:
toxicity in elderly
Yu YL, Clin Lung Cancer 2018
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Grazie