Applying Genomics to Cancer 21 st September The Frequency of EGFR mutations in Lung Adenocarcinoma: The Cardiff Experience

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1 Applying Genomics to Cancer 21 st September 2015 The Frequency of EGFR mutations in Lung Adenocarcinoma: The Cardiff Experience Aled Daniels R Butler, R Attanoos, H Davies University Hospital of Wales Cardiff

2 UK Statistics Lung cancer 2 nd most common cancer with 13% of all new cases (2012) 1 (44,488 cases) Incidence decreasing in males ; increasing in females Lung cancer is the most common cause of cancer death accounting for 22% of all deaths from cancer in Histology Adenocarcinoma >40% Squamous cell carcinoma 20% Small cell 13% Large cell carcinoma 2% Small cell NOS 18% 1. Cancer Research UK, Accessed Sept [2015] 2.

3 Epidemiology Lung Cancer (C34): 2012 Proportion of Cancers Diagnosed at Each Stage, All Ages, England Source: cruk.org/cancerstats 70% of lung ca are unresectable 3 Importance of cytology and biopsies 3. Travis,W et al Arch Pathol Lab Med Vol 137, May 2013

4 EGFR mutation EGFR positive rate 4 China 50% 4 Spanish 16.6% 5 USA 15% German 8.5% 5 Switzerland 8.1% 5 Genetic alteration 90% del ex 19 mutation exon 21 6 Prognosis EGFR TKI treatment is associated with 57% and 66% reduction in risk of disease progression in EGFR mutation +ve patients (1 st and 2 nd line) 7 4. Journal of the National Cancer Institute, Vol. 97, No. 5, March 2, Boch C et al. BMJ Open 2013;3:e Lindeman et al. Journal of Thoracic Oncology. Volume 8 number 7 july Chee Khoon Lee et alj Natl Cancer Inst;2013;105:595 60

5 Aims 1. Investigate EGFR positive rates at Cardiff compared with published literature Subgroup analysis Histological diagnosis Tissue type 2. Identify areas for improvement in our current practice

6 Methodology EGFR requests from Cardiff and Vale NHS trust between 1/1/2010 and 31/10/14 Demographics Specimen type Histopathology diagnostic details Smoking status Stage EGFR mutation Exclusion criteria Cases with no histopathological data available Analysis Microsoft Excel Telepath

7 Genetic testing Pyrosequencing Fragment length analysis Exon 19 deletions Criterion for testing samples Desired neoplastic cell content >20% Statement included in report indicating can not exclude a false negative result in cases with <20% content.

8 percentage (%) Results - Demographics 350 specimens 337 patients Mean age 69 years, standard deviation 9.84 Range years 25 Age range of patients age

9 Genetics result all specimens (11.17% positive 39 specimens) % 45.00% 5.16 N/N Exon 19 Exon % 35.00% 30.00% 25.00% Exon % Exon20 V765v failed 15.00% 10.00% 5.00% 0.00% Exon 19 del G719a L858R L861Q S7681 T790M V765V

10 Gender GRAPH SHOWING GENDER DISTRIBUTION OF PATIENTS 16.00% EGFR positivity rate for males and females 13.78% 14.00% Male, 44.00% 12.00% 10.00% 8.00% 6.00% 7.14% Female, 56.00% 4.00% 2.00% 0.00% Male Female

11 Smoking Status EGFR status smoker/ ex smoker 9.19% 1.06% EGR frequency non smokers 3.57% 21.43% 75.00% 89.75% no yes failed no yes failed

12 Histopathological diagnosis all samples Histopathological diagnosis 1.2% 2.0% 0.3% 4.6% 6.7% 13.3% 71.9% lung primary adeno unclear site squamous neuroendocrine NSCC non lung other

13 EGFR results per histopathological diagnosis (i) Non lung adenocarcinoma 0/4 EGFR positivity Lung non adenocarcinomas (7 Squamous +1 neuroendocrine) 0/8 EGFR positivity Adenocarcinoma unknown primary 0/20 positive 1 failed

14 EGFR results per histopathological diagnosis (ii) EGFR STATUS NSCC DIAGNOSIS positive, 10.91% EGFR STATUS LUNG ADENOCARCINOMA positive, negative, 89.09% negative, n=47 n=249

15 Specimen type (%) extra pleural / lymph nodes pleural fluid / cytology EBUS lung biopsy bronchial biopsy lung wedge resection lobectomy/pneumonectomy pleural tissue 15.4

16 EGFR status - Tissue type analysis (i) n=69 EGFR STATUS SURGICAL RESECTIONS positive, 18.31% negative, 81.69%

17 EGFR status - Tissue type analysis (ii) n=50 n=40 EGFR status lung biopsy EGFR status bronchial biopsies 12% 7.50% 92.50% 88% negative positive negative positive

18 EGFR status - tissue type analysis (iii) n=59 n=53 positive, 13.56% EGFR STATUS EBUS positive, 13.21% EGFR STATUS CYTOLOGY failed, 1.89% negative, 86.44% negative, 84.91%

19 Tumour content % of each sample type Specimen type Average tumour % resection 53.4 Bronchial biopsy 40.5 EBUS 28.3 Lung biopsy 43.1 Cytology EGFR mutation rate by tumour %

20 Discussion Possible reasons behind differences Surgical resection specimens Best morphological area chosen based on microscopy Necrotic areas avoided in large specimens Biopsies Biopsies sample periphery of lesion. Rely on macroscopic examination of tissue EBUS High proportion of non tumour cells lymphoid cells Cytology Therapeutic procedures possible to obtain large amount of material, Possibly to verify adequacy quickly. Mansuet-Lupo et al. Journal of Translational Medicine 2014, 12:131 J.C.-H. Yang et al. / Lung Cancer 83 (2014)

21 Conclusion Overall positivity (11.17%) within expected range for European population Gender difference and smoking status is consistent with literature Immunohistochemistry improves EGFR mutation detection rate Possible difference between histopathological specimen type is present small biopsies are valuable but communication is vital to ensure testing is performed on most appropriate specimen. Further work is being undertaken at another two sites across Wales

22 Questions?

23 References Cancer Research UK, Sept [2015] William D. Travis et al (eds): WHO Classification of Tumous of Lung, Pleura, Thymus and Heart (4 th Edition) IARC: Lyon Travis,W et al. Lung Adenocarcinoma Diagnosis in Resections. Arch Pathol Lab Med Vol 137, May 2013 Shigematsu,H et al. Clinical and Biological Features Associated With Epidermal Growth Factor Receptor Gene Mutations in Lung Cancers. Journal of the National Cancer Institute, Vol. 97, No. 5, March 2, 2005 Boch C, Kollmeier J, Roth A, et al. The frequency of EGFR and KRAS mutations in non-small cell lung cancer (NSCLC): routine screening data for central Europe from a cohort study. BMJ Open 2013;3:e doi: /bmjopen Lindeman et al. Molecular Testing Guideline for Selection of Lung Cancer Patients for EGFR and ALK Tyrosine Kinase Inhibitors. Journal of Thoracic Oncology. Volume 8 number 7 july 2013 Lee CK, et al.impact of epidermal growth factor receptor inhibitor in non small cell lung cancer on progression-free and overall survival: a meta-analysis. J Natl Cancer Inst Mansuet-Lupo et al. Intratumoral distribution of EGFR mutations and copy number in metastatic lung cancer, what impact on the initial molecular diagnosis? Journal of Translational Medicine :131. Yang et al. Epidermal growth factor receptor mutation analysis in previously unanalysed histology samples and cytology samples from the phase III Iressa Pan-Asia Study (IPASS)/ Lung Cancer 83 (2014)