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: 

, and PD-L1. Liquid biopsy may also be considered in conjunction with tissue NGS testing. 

Testing for c-MET and HER2 overexpression via IHC in patients with advanced or metastatic NSCLC is also recommended along side broad panel NGS testing.

For patients with early-stage NSCLC, testing should assess PD-L1 status, 

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.

In combination with lazertinib for the first-line treatment of adult patients with locally advanced or metastatic non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) exon 19 deletions or exon 21 L858R substitution mutations, as detected by an FDA-approved test.

In combination with carboplatin and pemetrexed for the treatment of adult patients with locally advanced or metastatic NSCLC with EGFR exon 19 deletions or exon 21 L858R substitution mutations, whose disease has progressed on or after treatment with an EGFR tyrosine kinase inhibitor.

In combination with carboplatin and pemetrexed for the first-line treatment of adult patients with locally advanced or metastatic NSCLC with EGFR exon 20 insertion mutations, as detected by an FDA-approved test.

As a single agent for the treatment of adult patients with locally advanced or metastatic NSCLC with EGFR exon 20 insertion mutations, as detected by an FDA-approved test, whose disease has progressed on or after platinum-based chemotherapy.

Amivantamab-vmjw is a bispecific antibody that binds to the extracellular domains of EGFR and MET. 

In in vitro and in vivo studies amivantamab-vmjw was able to disrupt EGFR and MET signaling functions in mutation models of exon 19 deletions, exon 21 L858R substitutions, and exon 20 insertions through blocking ligand binding or degradation of EGFR and MET. 

The presence of EGFR and MET on the surface of tumor cells also allows for targeting of these cells for destruction by immune effector cells, such as natural killer cells and macrophages, through antibody-dependent cellular cytotoxicity (ADCC) and trogocytosis mechanisms, respectively. 

Treatment with amivantamab in combination with lazertinib increased in vivo anti-tumor activity compared to either agent alone in a mouse xenograft model of human NSCLC with an EGFR L858R mutation.

https://www.rybrevant.com/support-and-resources/tools-and-resources/

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.

The treatment of adult patients with metastatic non–small cell lung cancer (NSCLC) whose tumors have a mutation that leads to mesenchymal-epithelial transition (

) exon 14 skipping as detected by an FDA-approved test.

Capmatinib is a kinase inhibitor that targets MET, including the mutant variant produced by exon 14 skipping. 

 exon 14 skipping results in a protein with a missing regulatory domain that reduces its negative regulation leading to increased downstream MET signaling.

Capmatinib inhibited cancer cell growth driven by a mutant

 variant lacking exon 14 at clinically achievable concentrations and demonstrated anti-tumor activity in murine tumor xenograft models derived from human lung tumors with either a mutation leading to MET exon 14 skipping or 

Capmatinib inhibited the phosphorylation of MET triggered by binding of hepatocyte growth factor or by 

 amplification, as well as MET-mediated phosphorylation of downstream signaling proteins and proliferation and survival of MET-dependent cancer cells.

https://www.novartis.com/us-en/patients-and-caregivers/patient-assistance

The treatment of adult patients with metastatic non-small cell lung cancer (NSCLC) harboring mesenchymal-epithelial transition (MET) exon 14 skipping alterations.

Tepotinib is a kinase inhibitor that targets MET, including variants with exon 14 skipping alterations. 

Tepotinib inhibits hepatocyte growth factor (HGF)-dependent and -independent MET phosphorylation and MET-dependent downstream signaling pathways. 

In vitro, tepotinib inhibited tumor cell proliferation, anchorage-independent growth, and migration of MET-dependent tumor cells. 

In mice implanted with tumor cell lines with oncogenic activation of MET, 10 including METex14 skipping alterations, tepotinib inhibited tumor growth, led to sustained inhibition of MET phosphorylation, and, in one model, decreased the formation of metastases.

https://www.tepmetko.com/us-en/patients-and-caregivers/resources.html

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

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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. 

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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. 

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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. 

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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. 

The FDA has approved adagrasib, as a single agent, for the treatment of adult patients with 

G12C-mutated, locally advanced or metastatic non–small cell lung cancer (NSCLC), as determined by an FDA-approved test, who have received at least 1 prior systemic therapy. 

This indication has received accelerated approval based on objective response rate and duration of response. Continued approval for these indications may be contingent upon verification and description of a clinical benefit in confirmatory trial(s).

Adagrasib is an irreversible inhibitor of KRAS G12C that covalently binds to the mutant cysteine in KRAS G12C and locks the mutant KRAS protein in its inactive state that prevents downstream signaling without affecting wild-type KRAS protein. 

Adagrasib inhibited tumor cell growth and viability in cells harboring KRAS G12C mutations and resulted in tumor regression in KRAS G12C-mutated tumor xenograft models with minimal off-target activity. 

The FDA has approved sotorasib for the treatment of adult patients with 

 G12C-mutated, locally advanced or metastatic non–small cell lung cancer (NSCLC), as determined by an FDA-approved test, who have received at least 1 prior systemic therapy. This indication has received accelerated approval based on overall response rate and duration of response. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial(s).

Sotorasib is an inhibitor of KRAS G12C, a tumor-restricted, mutant-oncogenic form of the RAS GTPase, KRAS. 

Sotorasib forms an irreversible, covalent bond with the unique cysteine of KRAS G12C, locking the protein in an inactive state that prevents downstream signaling without affecting wild-type KRAS. Sotorasib blocked KRAS signaling, inhibited cell growth, and promoted apoptosis only in KRAS G12C tumor cell lines. 

Sotorasib inhibited KRAS G12C in vitro and in vivo with minimal detectable off-target activity. In mouse tumor xenograft models, sotorasib-treatment led to tumor regressions and prolonged survival, and was associated with anti-tumor immunity in KRAS G12C models.

https://www.lumakras.com/resources/downloadable-resources

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

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

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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. 

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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. 

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Expert Sound Bites

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

Beyond the Report