EGFR Mutations in US Hispanic Versus Non-Hispanic White Patients With Lung Adenocarcinoma.
Approximately 90% of the TKI-responsive EGFR mutations in lung adenocarcinomas are deletions in exon 19 and a point mutation that substitutes an arginine for a leucine at codon 858 (L858R) in exon 21. Point mutations or insertions in exons 18 and 20 are other genetic alterations commonly included. (14,15)
Per the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology guidelines, (13) clinical criteria such as racial/ethnic group, sex, or smoking status are not recommended as a basis for selecting patients for EGFR TKI therapy. That is, these criteria exclude too many patients who might benefit from targeted therapy. However, the frequency of actionable EGFR mutations in racial/ethnic groups is important to assess because of its possible clinical impact on specific communities. The frequency of EGFR mutations is approximately 30% in Asian populations, 15% in whites, and 19% in African Americans. (16,17) However, data on the frequency of EGFR mutations in lung adenocarcinoma among Hispanics in the United States is not currently available, to our knowledge. Of note, the frequency of EGFR mutations in non-small cell carcinoma of the lung has been reported to be 33.2% in Latin American countries overall, which is similar to the Asian population. (18,19) The objective of this study was to determine the prevalence and type of EGFR mutations that occur in adenocarcinomas among the US Hispanic population.
MATERIALS AND METHODS
With approval by the institutional review board (IRB HSC20110421H), lung adenocarcinoma tumor tissue samples from 83 patients (40 patients who self-identified as Hispanic and 43 non-Hispanic white patients) were retrieved from the surgical pathology archives at The University of Texas Health Sciences Center at San Antonio and the Audie L. Murphy Memorial Veterans Affairs Medical Center in San Antonio. Demographic information was collected by medical record review and included sex, age and tumor stage at diagnosis, and smoking status. In 2 cases, a second sample was obtained from the adenocarcinoma, providing a total of 85 samples.
Formalin-fixed, paraffin-embedded tumor tissue was cut in 10im sections onto uncharged glass slides. One slide from each case was reviewed by a board-certified pathologist (JJ) and marked for macrodissection to enrich the sample for tumor cells compared with benign cells. A minimum of 50% tumor cells in the sample was sought. The number of sections used for genomic DNA extraction ranged from 5 to 10 depending on tumor volume. Tissue was deparaffinized using CitriSolv (Thermo Fisher Scientific Inc, Waltham, Massachusetts), followed by treatment in 100% ethanol. Puregene Cell Lysis Buffer (Qiagen, Germantown, Maryland) was applied, and tumor tissue was scraped from the slides and digested with proteinase K. DNA was purified using an EZ1 tissue kit (Qiagen) on an automated workstation according to the manufacturer's instructions. The quantity and quality of genomic DNA were assessed using a spectrophotometer (NanoDrop, Thermo Fisher Scientific Inc, Waltham, Massachusetts), and genomic DNA was stored at -20[degrees]C.
A custom assay to test for the EGFR mutations was designed using the MassARRAY Assay Design 3.0 software (Sequenom, San Diego, California). Molecular testing was performed at The Methodist Hospital, Houston, Texas, using a MassARRAY instrument (Sequenom). Locus-specific polymerase chain reaction and detection primers were selected, and lung tumor DNA was amplified in a multiplex polymerase chain reaction, followed by a single-base extension reaction. The resulting nucleotides were desalted and transferred to a 384-element SpectroCHIP array (Sequenom), and alleles were discriminated by mass spectrometry.
[chi square] Contingency table analysis was used to identify significant associations between mutation status and sex, age at diagnosis, race/ethnicity, smoking status, and tumor stage at diagnosis. Significance was set at P <.05 by Fisher exact test.
In total, 85 lung adenocarcinoma tissue samples collected from 83 patients (40 Hispanic and 43 non-Hispanic white) were available for testing. Of the 40 Hispanic patients, 5 were nonsmokers, 13 were smokers, and 22 had unknown smoking status. Of the 43 non-Hispanic white patients, 8 were nonsmokers, 21 were smokers, and 14 had unknown smoking status. The 14 Hispanic female patients were nonsmokers or had an unknown smoking status. Among 12 non-Hispanic white female patients, 2 were smokers, and 10 were nonsmokers or had unknown smoking history. The median ages at diagnosis were 63 years among Hispanics and 62 years among non-Hispanic whites. The average ages at diagnosis were 65 years for white men and 58 years for white women. The average ages at diagnosis were 68 years for Hispanic men and 59 years for Hispanic women. Women were younger than men at diagnosis of lung adenocarcinoma for both populations.
Fourteen of 83 patients (16.9%) had EGFR mutations in their tumor DNA. Six were Hispanic (15.0%), and 8 were non-Hispanic white (18.6%) (Table). No statistically significant difference in EGFR mutation rates was observed between Hispanic and non-Hispanic white patients in our series (P =.66). Similarly, no significant association between EGFR mutations and sex was identified (P =.70). Smoking history could not be obtained for most of the 83 patients, although 8 of the 11 patients with EGFR mutations for whom smoking history was obtained were nonsmokers. Most of the tumors with EGFR mutations (12 of 14; 85.7%) were acinar with lepidic or papillary subtypes in both populations. EGFR mutations occurred in exon 19 (42.8%), exon 18 (28.6%), exon 20 (28.6%), and exon 21 (14.3%). Two cases had 2 mutations in different exons. In the 2 cases in which 2 samples were obtained, both samples showed identical results.
The frequency of the EGFR mutations in different populations is well documented. (16-19) For example, the mutation rate is higher in Asians and female nonsmokers. (20) However, the EGFR mutation rate in lung adenocarcinomas among the US Hispanic population has not been previously investigated to our knowledge. In this limited study, we demonstrate that the EGFR mutation rate in US Hispanics is not significantly different from that in non-Hispanic whites. Unexpectedly, we discovered that US Hispanics seem to have a lower frequency of actionable EGFR mutations in their lung cancers than those reported in Latin America. Arrieta et al, (18) in a study of 1150 patients in Latin America, found that the frequency of EGFR mutations in non-small cell carcinoma of the lung was 33.2% overall, including 19.3% in Argentina, 24.8% in Colombia, 31.2% in Mexico, and 67.0% in Peru. Of note, these authors' findings may be skewed because of the disproportionate inclusion of nonsmokers and women. The number of Hispanic women was approximately the same as the number of non-Hispanic white women in our study. Smoking history could not be obtained for most of the 83 patients herein, although 8 of the 11 patients with EGFR mutations for whom smoking history was obtained were nonsmokers. Also, we observed EGFR mutations mostly in lepidic, papillary, or acinar subtypes of adenocarcinoma, similar to previous findings. (21)
Most of the genetic alterations identified in our study were deletions in exon 19. Exon 21 mutations occurred in only 14.3% of mutation-positive tumors, with proportionately more mutations in exons 18 and 20. None had the exon 20 T790M mutation associated with acquired resistance to EGFR TKI treatment. (13,22,23) Arrieta et al, (18) in their Latin American patients, showed that 48.4% of mutation-positive patients had exon 19 deletions, and 49.0% had the L858R mutation (exon 21). These findings are consistent with data collected from Asian (60% exon 19 and 40% exon 21) and European (62% exon 19 and 38% exon 21) populations. (24)
In summary, our limited study found that the frequency of EGFR mutations in lung adenocarcinomas among US Hispanics is similar to the frequency among non-Hispanic whites. Hispanics in the United States with lung adenocarcinoma can be expected to benefit clinically from EGFR mutation testing.
We thank Leif Peterson, PhD, for assistance with the statistical analysis.
(1.) World Health Organization. Cancer fact sheet No. 297. Reviewed January 2013. http://www.who.int/mediacentre/factsheets/fs297/en/. Accessed October 26, 2012.
(2.) Azzoli CG, Baker S Jr, Temin S, et al; American Society of Clinical Oncology. American Society of Clinical Oncology Clinical Practice Guideline update on chemotherapy for stage IV non-small-cell lung cancer. J Clin Oncol. 2009; 27(36):6251-6266.
(3.) Saintigny P, Burger JA. Recent advances in non-small cell lung cancer biology and clinical management. Discov Med. 2012; 13(71):287-297.
(4.) Bonomi M, Pilotto S, Milella M, et al. Adjuvant chemotherapy for resected non-small-cell lung cancer: future perspectives for clinical research. J Exp Clin Cancer Res. 2011; 30:115-123.
(5.) Heon S, Johnson BE. Adjuvant chemotherapy for surgically resected non-small cell lung cancer. J Thorac Cardiovasc Surg. 2012; 144(3):S39-S42.
(6.) Tsuruo T. Molecular cancer therapeutics: recent progress and targets in drug resistance. Intern Med. 2003; 42(3):237-243.
(7.) Yoshida T, Zhang G, Haur EB. Targeting epidermal growth factor receptor: central signaling kinase in lung cancer. Biochem Pharmacol. 2010; 80(5):613-623.
(8.) Mok TS, Wu YL, Thongprasert S, et al. Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med. 2009; 361(10):947-957.
(9.) Pao W, Chmielecki J. Rational, biologically based treatment of EGFR-mutant non-small-cell lung cancer. Nat Rev Cancer. 2010; 10(11):760-774.
(10.) Stinchcombe TE, Socinski MA. Gefitinib in advanced non-small cell lung cancer: does it deserve a second chance? Oncologist. 2008; 13(9):933-944.
(11.) Thatcher N, Chang A, Parikh P, et al. Gefitinib plus best supportive care in previously treated patients with refractory advanced non-small-cell lung cancer: results from a randomised, placebo-controlled, multicentre study (Iressa Survival Evaluation in Lung Cancer). Lancet. 2005; 366(9496):1527-1537.
(12.) Cagle PT, Allen TC. Lung cancer genotype-based therapy and predictive biomarkers: present and future. Arch Pathol Lab Med. 2012; 136(12):1482-1491.
(13.) Lindeman NI, Cagle PT, Beasley MB, et al. Molecular Testing Guideline for Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology [published online ahead of print April 4, 2013]. I Mol Diagn. doi:10.1016/j.jmoldx.2013.03. 001.
(14.) He M, Capelletti M, Nafa K, et al. EGFR exon 19 insertions: a new family of sensitizing EGFR mutations in lung adenocarcinoma. Clin Cancer Res. 2012; 18(6):1790-1797.
(15.) Yasuda H, Kobayashi S, Costa DB. EGFR exon 20 insertion mutations in non-small-cell lung cancer: preclinical data and clinical implications [published correction appears in Lancet Oncol. 2011; 12(13):1182]. Lancet Oncol. 2012; 13(1):e23-e31. http://www.sciencedirect.com/science/article/pii/ S1470204511701292. Accessed June 14, 2013.
(16.) Ma BB, Hui EP, Mok TS. Population-based differences in treatment outcome following anticancer drug therapies. Lancet Oncol. 2010; 11(1):75-84.
(17.) Cote ML, Haddad R, Edwards DJ, et al. Frequency and type of epidermal growth factor receptor mutations in African Americans with non-small cell lung cancer. J Thorac Oncol. 2011; 6(3):627-630.
(18.) Arrieta O, Cardona AF, Federico Bramuglia G, et al; CLICaP. Genotyping non-small cell lung cancer (NSCLC) in Latin America. J Thorac Oncol. 2011; 6(11):1955-1959.
(19.) Bacchi CE, Ciol H, Queiroga EM, Benine LC, Silva LH, Ojopi EB. Epidermal growth factor receptor and KRAS mutations in Brazilian lung cancer patients. Clinics (Sao Paulo). 2012; 67(5):419-424.
(20.) Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med. 2004; 350(21):2129-2139.
(21.) Liu Y, Xu ML, Zhong HH, Heng WJ, Wu BQ. EGFR mutations are more frequent in well-differentiated than in poorly-differentiated lung adenocarcinomas. Pathol Oncol Res. 2008; 14(4):373-379.
(22.) Kobayashi S, Boggon TJ, Dayaram T, et al. EGFR mutation and resistance of non-small-cell lung cancer to gefitinib. N Engl J Med. 2005; 352(8):786-792.
(23.) Arcila ME, Nafa K, Chaft JE, et al. EGFR exon 20 insertion mutations in lung adenocarcinomas: prevalence, molecular heterogeneity, and clinicopathologic characteristics. Mol Cancer Ther. 2013; 12(2):220-229.
(24.) Rosell R, Moran T, Queralt C, et al. Screening for epidermal growth factor receptor mutations in lung cancer. New Engl J Med 2009; 361:958-967.
Wei Zhang, MD; Elizabeth B. McQuitty, MD; Randall Olsen, MD, PhD; Hongxin Fan, MD; Heather Hendrickson, MB(ASCP)CM, MBA; Fermin O. Tio, MD; Keith Newton, MB(ASCP)CM; Philip T. Cagle, MD; Jaishree Jagirdar, MD
Accepted for publication June 6, 2013.
Published as an Early Online Release August 12, 2013.
From the Department of Pathology (Dr Zhang), Molecular Diagnostics Laboratory (Dr Fan), and Department of Pathology (Dr Jagirdar), The University of Texas Health Science Center at San Antonio, and Laboratory Service, Audie L. Murphy Memorial Veterans Affairs Medical Center (Dr Tio), San Antonio; and Department of Pathology and Immunology, Baylor College of Medicine (Dr McQuitty), and Department of Pathology and Genomic Medicine, The Methodist Hospital (Drs Olsen and Cagle, Ms Hendrickson, and Mr Newton), Houston, Texas.
The authors have no relevant financial interest in the products or companies described in this article.
Reprints: Jaishree Jagirdar, MD, Department of Pathology, University of Texas Health Science Center, Mail Code 7750 7703, Floyd Curl Drive, San Antonio, TX 78229-3900 (e-mail: Jagirdar@ UTHSCSA.edu).
EGFR Mutations in US Hispanic Versus Non-Hispanic White Patients With Lung Adenocarcinoma Sex Age at Race/Ethnicity Smoking Diagnosis, y Status Female 43 Non-Hispanic white No Female 62 Non-Hispanic white No Female 46 Non-Hispanic white No Male 79 Non-Hispanic white No Male 88 Non-Hispanic white No Male 63 Non-Hispanic white Yes Male 58 Non-Hispanic white Yes Male 64 Non-Hispanic white Yes Female 63 Hispanic Unknown Female 61 Hispanic No Male 69 Hispanic No Male 83 Hispanic No Male 69 Hispanic Unknown Male 63 Hispanic Unknown Sex EGFR Mutation Female Exon 19 E746_A750del Female Exon 19 E746_A750del Female Exon 20 S768I Male Exon 20 H773 > NYP Male Exon 18 E709K, exon 20 S761I Male Exon 18 E709K, exon 21 L861Q Male Exon 21 L861Q Male Exon 18 E709K Female Exon 19 del NOS Female Exon 19 E746_A750del Male Exon 19 del NOS Male Exon 18 E709K Male Exon 20 H773 > NYP Male Exon 19 del NOS Sex Growth Pattern Female Acinar and papillary Female Acinar Female Lepidic and focal acinar and papillary Male Acinar, bronchioloalveolar carcinoma Male Acinar and papillary Male Acinar Male Acinar Male Acinar Female Acinar Female Acinar and solid Male Lepidic and acinar Male Acinar Male Solid with signet ring feature Male Solid Abbreviations: EGFR, epidermal growth factor receptor; NOS, not otherwise specified.