Poziotinib

Poziotinib for EGFR and HER2 exon 20 insertion mutation in advanced NSCLC: Results from the expanded access program

Arsela Prelaj a,b,*, Achille Bottiglieri a, Claudia Proto a,
Giuseppe Lo Russo a, Diego Signorelli a, Roberto Ferrara a, Giulia Galli a, Alessandro De Toma a, Giuseppe Viscardi a, Marta Brambilla a,
Riccardo Lobefaro a, Federico Nichetti a, Sara Manglaviti a, Mario Occhipinti a, Alice Labianca a, Monica Ganzinelli a,
Rosaria Gallucci a, Nicoletta Zilembo a, Gabriella Francesca Greco c, Valter Torri d, Filippo de Braud a, Marina C. Garassino a

aDepartment of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Via Giacomo Venezian 1, 20133, Milan, Italy
bDepartment of Electronics, Information, and Bioengineering, Polytechnic University of Milan, Piazza L. da Vinci 32, Milano, 20133, Italy
cDepartment of Radiology, Fondazione IRCCS Istituto Nazionale Dei Tumori di Milano, Via Giacomo Venezian 1, 20133, Milan, Italy
dDepartment of Oncology, IRCCS “Mario Negri” Institute, Milano, Via La Masa 19, 20156, Milano, Italy

Received 17 November 2020; received in revised form 16 January 2021; accepted 24 February 2021 Available online 2 April 2021

KEYWORDS Poziotinib; NSCLC; EGFR; HER2;
Exon 20 insertion mutation
Abstract Background: The treatment of metastatic nonesmall-cell lung cancer (mNSCLC) patients with EGFR/HER2 exon 20 insertion mutation (i-mut) remains an unmet clinical need. Poziotinib, a new generation tyrosine kinase inhibitor, is currently under investigation as a potential targeted therapy. This compassionate study of its use aims to describe the activ- ity/toxicity of poziotinib in mNSCLC with EGFR/HER2-exon-20-i-mut.
Patients and methods: NSCLC patients who were treated either with EGFR or HER2 exon 20- i-mut within an expanded access program were included in this study. Poziotinib (16 mg or less) was administrated orally quaque die (QD). The primary end-point was the overall response rate (ORR) assessed by central review using RECIST v1.1, and secondary end-points

* Corresponding author: Medical Oncology Department, Fondazione IRCCS Istituto Nazionale Tumori, Via Giacomo Venezian, 1, 20133, Milan, Italy.
E-mail address: [email protected] (A. Prelaj). https://doi.org/10.1016/j.ejca.2021.02.038
0959-8049/ª 2021 Elsevier Ltd. All rights reserved.

were median progression free survival (PFS), disease control rate (DCR), median overall sur- vival (OS) and toxicity.
Results: The median age of all the 30 patients was 58 years (25e80 years), most of them were females (73%); ECOG 0e1 (83%), EGFR i-mut (73%) and pre-treated (83%). 73% started with poziotinib at a dose of 16 mg. At data cut-off, 22 of 33 patients (73%) experienced a progress in the disease and 12 of 30 (40%) died. Median PFS was 5.6 months (95% CI: 3.6e6.7 months) and the mOS 9.5 months (95% CI: 5.3 e not-reached months). The ORR was 30% (EGFR/
HER2: 23/50%) and DCR 80%. G3 AEs were reported in 66% of the patients and were found with skin rash (50%), diarrhoea (17.6%), mucositis (7%) and paronychia (3%). G5, possibly associated with pneumonitis might also have occurred.
Conclusions: Poziotinib exhibited effects in mNSCLC patients with EGFR/HER2-exon 20-i- mut. The toxicity rate was high leading to frequent dose interruption and reduction, thereby reducing mPFS in patients with good ORR/DCR. ZENITH20 trial is now being used to eval- uate the low dose and new scheduled dose (e.g. bis in die (BID)).
ª 2021 Elsevier Ltd. All rights reserved.

1.Introduction

Over the years, the treatment panorama of advanced nonesmall-cell lung cancer (NSCLC) has radically changeddinitially with the advent of targeted therapies and, more recently, with the advent of immunotherapy, including immune checkpoint inhibitors.
Mutations in EGFR gene have been observed in about 10% of NSCLC cases in Caucasian patients, and up to 50% of Asian patients. Usually, EGFR sensitive mutations (exon 19 deletions and L858R exon 21 mu- tations) occur mostly in women, non-smokers, younger patients and in adenocarcinoma histology [1]. The exon 20 T790M mutation is quite uncommon in treatment- naive patients, whereas it could be detected up to about 60% in patients during- and post-treatment with target therapy, assuming the meaning of acquired resistance mutation [2].
Other EGFR mutations are less common, and among them, the most frequent ones include insertions and duplications in exon 20, representing about 4e10% of EGFR driver alterations in NSCLC. They are generally resistant to the first- and second-generation EGFR in- hibitors including tyrosine kinase inhibitors (TKIs); therefore, conventional chemotherapy including platinum-based therapy is still the standard of care [3].
HER2 exon 20 insertions mutation (i-mut) have been identified in about 4% of NSCLC patients. They are mutually exclusive with other driver gene alterations and are usually correlated with non-smoker status, female gender and adenocarcinoma histology. When consid- ering invasive adenocarcinomas, HER2 mutations represent an independent factor for a poor outcome [4], and similar to EGFR exon 20 i-mut, are intrinsically resistant to current therapies, and the standard of care (SOC) remains as chemotherapy ti immunotherapy [5].
To meet this crucial unmet need, several trials are presently underway investigating the potential next- generation TKIs, targeting the exon 20 insertions
(including EGFR and HER2), for example: poziotinib [6], TAK-788 (mobocertinib) [7] and JNJ-372 (ami- vantamab) [8].
The small size of poziotinib makes it a powerful in- hibitor of the most common HER2 and EGFR exon 20-i- mut. Both in vitro and in vivo analyses confirmed it as a strong and clinically promising molecule. However, a high rate of G3 toxicity was reported at a dose of 16 mg [5,6].
This study aims to evaluate the clinical efficacy of poziotinib in NSCLC patients harbouring exon 20 EGFR or HER2 i-mut in a real-world population, under an expanded access program (EAP) for compas- sionate usage.

2.Materials and methods

2.1.Study population

From May 2019 to June 2020, we enrolled in the EAP at Fondazione IRCCS Istituto Nazionale dei Tumori of Milan, Italy, 30 NSCLC patients with adenocarcinoma, harbouring EGFR/HER2 exon 20 i-mut. The patient eligibility for the presence of an exon 20 mutation was determined by the use of next generation sequencing (NGS) diagnostic test. All patients received a single- agent poziotinib and complete data necessary were collected. This study was conducted in accordance with the Declaration of Helsinki, Good Clinical Practice, and local ethical guidelines, and was approved by the local ethical committee. As the study was approved in the name of each patient with a specific EAP program protocol, there is no other specific ID.
All the patients being treated have signed an informed consent before enrolment into the study.

2.2.Treatment, response and safety evaluation

Poziotinib was administered orally quaque die (QD). Twenty-two patients were started on at a dose of 16 mg;

six patients at a dose of 14 mg, one patient at a dose of 12 mg and another at a dose of 10 mg. Dose reduction for toxicity was allowed up to 8 mg. Response Evalua- tion Criteria in Solid Tumours (RECIST) v.1.1 was used to assess tumour response [9]; defined as complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Overall response rate (ORR) was defined as the sum of CR and PR, and disease control rate (DCR) as the sum of CR, PR and SD. Therapy was continued until PD, intolerable toxicity, withdrawal or death. Treatment beyond PD was allowed if there was a clinical benefit according to the clinician’s decision. Baseline radiological evaluations included a baseline total body computed tomography scan and brain magnetic resonance imaging (MRI) for known brain metastases; subsequently, radiological im- aging was performed every 9e12 weeks, or whenever PD was clinically suspected. The RECIST criteria were also evaluated by an independent radiologist to minimise the inter-variability between the values given by different radiologists. Adverse events were assessed by CTCAE v. 5.0.

2.3.Molecular analysis

Most patients came from different local/general hospi- tals and were referred to our centre, which is a reference centre for lung cancer; thus, different methods were used for the molecular analysis. The methods used for 23 of 30 patients with known exact mutations were as follows: next-generation sequencing (e.g.: Ion Torrent,

discontinuation due to toxicity, PD, death or last follow-up visit for patients alive without discontinuation (censored). All the above time-to-event analyses were performed with the KaplaneMeier method for median and 95% confidence interval (CI), and a comparison test was performed by the log-rank test at a 5% level of significance [10]. Median follow-up was calculated with the reverse KaplaneMeier based method.

3.Results

3.1.Patients’ characteristics

In total, 30 mNSCLC patients with EGFR or HER2 exon 20 i-mut treated with poziotinib in first- or subsequent-line were included in the analyses (Table 1).
Most patients were females (73%) and non-smokers (77%), with a median age of 58 years (range 25e80 years) and 63% of patients younger than 65 years. Eastern Cooperative Oncology Group (ECOG) PS was 0e1 in 83.4% and 2 in 16.6% of the patients. Two pa- tients (16.6%) received poziotinib in first-line and the rest of them received it as a second- (36.6%) or subse- quent- (46.6%) line of treatment with a median of 1 prior

Table 1
Patients’ characteristics at baseline poziotinib.
Baseline characteristics (30 patients) N % Sex
F 22 73.3
M 8 26.7

Oncomine and Foundation One), Matrix-assisted laser desorption ionization mass spectrometry (MALDI- TOF; Sequenom) and Sanger sequencing. For seven of 30 patients who performed the analysis with real-time polymerase chain reaction (rtPCR), the exact position of i-mut was missed. In ten of 30 patients who used Sequenom method, A763_Y764insFQEA was not detected.
Age (years)
<70 ti70 Smoking status Former Never ECOG 0 1 2 22 8 7 23 9 16 5 73.3 26.7 23 77 30.0 53.3 16.7 Type of mutation 2.4. Statistical analysis EGFR 22 73.3 Primary end-points were progression-free survival (PFS) and ORR. Secondary end-points were DCR, overall survival (OS), intracranial PFS (ic-PFS), time-to- treatment discontinuation (TTD), Duration of response (DoR), and toxicity. PFS was calculated as the number of days from the poziotinib start date to PD, death due to any cause (events), or last follow-up visit for patients alive without PD (censored). OS was calculated as the number of days from the poziotinib start date to death or last follow-up. ic-PFS was calcu- lated as the number of days from the poziotinib start date to intracranial PD, death due to any cause (events), or last follow-up visit for patients alive without intra- HER2 Baseline mets No Yes Liver mets No Yes Bone mets No Yes Pleural/pericardial mets No Yes CNS mets No Yes Total 8 2 28 18 12 6 24 11 19 15 15 30 26.7 6.7 93.3 60.0 40.0 20.0 80.0 36.7 63.3 50.0 50.0 100.0 cranial PD (censored). TTD was calculated as the number of days from the poziotinib start date to its ECOG, Eastern Cooperative Oncology Group; CNS, central nervous system; mets, metastases. therapy (range 0e6). At the baseline, pleural/pericardial effusion and metastases in the central nervous system (CNS), liver and bone were present in 19 (63%), 16 (53.3%) [12], 40% and 24 (80%) patients, respectively. 3.2.Treatment response Radiologic evaluation was performed with a central review. Twenty-eight of 30 patients were evaluated for the response. Two patients (6.7%) died before their first radiologic evaluation because of disease progression and were considered as not evaluable. Four of 30 patients (13.3%) experienced PD, 15 of 30 (50%) SD, and nine of 30 (30%) PR with an ORR of 30% (EGFR/HER2: 22.7%/50%) and a DCR of 80% (EGFR/HER2: 77%/ 75%). Fig. 1 reported the tumour burden change as best response (BR) to poziotinib. Table 2 reported the rela- tion between BR and mutation type for each patient. Two patients, who continued with poziotinib beyond PD, obtained SD as BR. Among the 15 patients (50%) with baseline brain metastases, Twelve of 15 were previously treated with local radiotherapy (RT), and three of 15 were RT-naive. Including all patients with baseline brain metastases, the intracranial ORR and intracranial DCR were 46.6% and 80%, respectively. Among patients with RT-naive (n Z 3), two PR and one SD were reported. Finally, cancer cells with insertions at residue 773 were more resistant to EGFR TKIs. Between EGFR and HER2, 16 of 30 and seven of eight patients, respectively, had a known exact i-mut. In EGFR, among 16 patients, four were located in the ‘far loop’ ins20 (insertion at residues 773,774 or 775), 10 in the ‘near loop’ ins20 (insertion at residues 767e772) and two in the c-helix (insertion at residues 771e776) (Fig. 2). Differences were not observed between patients with near and far loop in ORR (20% vs 25%, p Z 0.836) and DCR (80% vs 75%, p Z 0.834). 3.3.Survival analyses All patients included in the study were assessed for time- to-event analyses. Median follow-up was 9.5 months (95% CI 4.7e14.3 months). At data cut-off (15th May 2020), 22 of 33 patients (73%) experienced a progressive disease (PD) and 12 of 30 patients (40%) died. Median PFS was 5.6 months (95% CI 3.6e6.7 months) (Fig. 3A), and median overall survival (mOS) was 9.5 months (95% CI 5.3enot-reached months) (Fig. 3B). Nineteen of 30 patients (63.3%) experienced an ic- progression or died. Median ic-PFS was 5.6 months (95% CI 3.6e8.6 months) (Fig. 3C). No statistical dif- ference was observed in ic-PFS between patients with or without baseline brain metastases (hazard ratio [HR] 2.2, 95% CI 0.86e5.68, p Z 0.184). At the time of data cut-off, 18 of 30 patients (60%) had discontinued poziotinib. Median TTD was 6.2 months (95% CI 3.4e8.7 months) (Fig. 3D). 3.4.Univariate and multivariate subgroup analyses according to PFS and OS Subgroup analyses were performed by stratifying pa- tients according to ECOG PS 0e1 versus 2. Median progression free survival (mPFS) for patients with 20%20% 0%0% -20%-20% -40%-40% -60%-60% Percent change in tumor burden RECIST Disease progression Partial response Stable disease 11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121 2222 2323 2424 2525 2626 2727 2828 PatientPatient NumberNumber Fig. 1. Tumour burden changes as best response to poziotinib. Table 2 Relation between best response and type of mutation. Nr Gene Gender Type of mutation Best response 1 EGFR Male pH773_V774insH exon 20 SD 2 EGFR Male d770n771inssvd exon 20 SD 3 EGFR Female H773_V774insAH exon 20 PR 4 HER2 Male A775_G776insYVMA exon 20 PR 5 EGFR Male ins 9bp exon 20 NE 6 EGFR Male V769_D770insASV exon 20 SD 7 EGFR Female A767_V769DUP - inframe insertion exon 20 SD 8 EGFR Female ins 9bp p.Met766_Ala767insAlaSerVal exon 20 SD 9 EGFR Male ins exon 20 PD 10 HER2 Female pGlu770_Alains ALATyrValMet (p.E770_A771insAYVM) c.2324_2325ins exon 20 SD 11 HER2 Female pE770_A771insAYM (c.2310_2311ins12)þamp di 6.1 copie seq.LRG_724 PR 12 EGFR Female ins 9b S768_D770 exon 20 PD 13 EGFR Female G2311_2312insGCGTGGAC (p770_N771ins SVD) exon 20 SD 14 HER2 Female p.GLU770_Ala771insAlaTyrValMet exon20 PD 15 EGFR Female p772_H773 insHV exon 20 SD 16 HER2 Female pGlu770_Ala771insAlaTyrValMet (p.E770_A771insAYVM) exon 20 SD 17 EGFR Female D770_771insSVD exon 20 PR 18 EGFR Male p.Met766_Ala767 ins alaSerVal exon 20 PD 19 HER2 Female ins exon 20 PR 20 EGFR Female ins exon 20 PR 21 EGFR Female p.D770_N771insG exon 20 SD 22 EGFR Female delezione exon 19 SD 23 EGFR Female ins exon 20 SD 24 EGFR Female p.Ala767-Val769dupl exon 20 PD 25 EGFR Female c2300_2308dup, p.A767_V69dup exon 20 PR 26 EGFR Female c2300_2308dup, p.A767_V69dup exon 20 SD 27 HER2 Female A775_G776insYVMA exon 20 SD 28 EGFR Female H773_V774insAH exon 20 NE 29 EGFR Female p.D770_N771insSVD_exon20 PR 30 HER2 Male p.Ala775_Gly776ins exon 20 PR SD, stable disease; PR, partial response; PD, progressive disease; NE not evaluable, these patients died due to clinical progression before the first radiologic evaluation. ECOG PS 0e1 was 5.9 months (95% CI 3.6e7.1 months) compared with 2.2 months (95% CI 0.46e5.6 months) in those with ECOG PS 2 (HR 4.6, 95% CI 1.5e13.6, p Z 0.005) (Fig. 4A). Median OS for patients with ECOG PS 0e1 was not reached (NR) (95% CI 7.4eNR) compared with 2.3 months (95% CI 0.59e5.6 months) in those with ECOG PS 2 (Fig. 4B). A multivariate analysis confirmed ECOG PS 2 as a nega- tive prognostic factor for PFS (HR 5.1, 95% CI 1.5e16.8, p Z 0.007) and OS (HR 6.3, 95% CI 1.5e13.6, p Z 0.005), respectively. In the univariate analysis for sex according to OS, the mOS for female was NR (95% CI NReNR) compared with male for whom mOS was 5.3 months (95% CI 0.59e7.4 months), p Z 0.0036 (Supplementary Fig. 1). In the multivariate analysis according to OS, male sex was confirmed as a negative prognostic factor (HR 3.2, 95% CI 0.96e10.8, p Z 0.05). No survival differences were observed between patients with EGFR or HER2 exon 20 i-mut (HR 0.99, 95% CI 0.26e3.70, p Z 0.61) and be- tween those with or without brain metastases (HR 1.28, 95% CI 0.40e4.05, p Z 0.87). Also, no differences were found in patients who received poziotinib in the first-line compared with those who received it in the second or further line (HR 0.73, 95% CI 0.43e1.26, p Z 0.95). Finally, univariate analyses were performed to compare patients with ‘near’ and ‘far loop’ for EGFR i- mut. No differences were seen in terms of mPFS 7.3 versus 3.7 months (HR 0.99, 95% CI 0.26e3.70, p Z 0.6) and mOS 7.6 versus NR months (HR 1.46, 95% CI 0.16e13.10, p Z 0.734) for ‘near’ and ‘far loop’, respectively. 3.5.Toxicity All the patientsexperienced any of the grade adverse events (AEs): 89% a dose interruption and 76% a dose reduction. G3e4 AEs were reported in 66% of the patients (Table 3). The most frequent G3e4 AEs were: skin rash (50%) (Supplementary Fig. 2), gastrointestinal toxicity (31%d mostly diarrhoea with 17%), mucositis (7%) and paro- nychia (3%). Other rare toxicities were also reported such as alopecia G2 in 6.6% of the patients. In one patient, G5 alveolar pneumonitis, possibly drug-related occurred. Finally, a G4 skin toxicity (like a burn injury) (Supplementary Fig. 2E) occurred in a female leading to a Fig. 2. Schematic representation of the amino acids that span the kinase domain of EGFR and HER2 mut within the site of exon 20 insertion mutations, which illustrate the different insertions that are included in Table 2. leg infection and consequently, to a systemic infection with severe pneumonitis, acute respiratory distress syndrome and death. Supplementary Table 1 reported the AEs frequency at any grade. Toxicities occur more frequently with higher doses compared with those of lower doses. Fig. 5 provides the days on treatment and the days off treatment for all the patients with different doses. 4.Discussion Until now, patients diagnosed with exon 20 i-mut, involving both EGFR and HER2 genes, lack targeted therapy and represent a crucial unmet clinical need. Their poor prognosis emphasizes the general interest in developing a specific treatment. In mNSCLC, point mutations in exons 18 and 21 (L858R), and exon 19 deletions represent up to 90% aberrations and result in being sensitive to the treatment with EGFR TKIs. Conversely, EGFR exon 20 alter- ations amount to a small number of EGFR mutations, most commonly reported in adenocarcinomas. Unlike EGFR exon 20 T790M mutation, which is considered as a mechanism of acquired resistance and now treatable with osimertinib, other EGFR exon 20 mutations are associated with primary resistance to targeted therapy and poor prognosis. The resistance maybe because of the structural changes that reduce ATP-binding pocket’s size, as in HER2 exon 20 insertions. As a consequence, larger drugs such as osimertinib would struggle to effectively bind to these targets. Poziotinib, is an irreversible pan-HER TKI, initially being investigated in the Asian population. Two phase I studies enrolled 75 patients with solid tumours (NSCLC, breast, stomach cancers) to determine the maximum tolerated dose (MTD) for two different schedules of dosages (one-third of patients included had NSCLC diagnosis). Of the 51 patients evaluated for response, ORR and DCR were 16% and 63%, respectively. Among 27 NSCLC patients, three (11%) and 11 (41%) patients achieved PR and SD, respectively. The median PFS was 11.4 weeks (range 5.6e17.4 weeks). ZENITH20 trial is a multicohort, multicentre (including United States of America and Europe enroller) phase II study, for testing efficacy and safety of poziotinib in NSCLC patients, with EGFR and HER2 exon 20 i-mut. Results from cohort-1 (EGFR/pre- treated) reported in the last ASCO meeting did not meet the primary end-point with an ORR of 14.8%, although the responses were durable (median duration of response (mDoR) Z 7.2 months) and the median PFS was 4.2 months. The starting dose was 16 mg, but 65% of the patients needed a dose reduction. The following were the most common treatment-related serious (grade ti III) AEs: rash (28%), diarrhoea (26%), sto- matitis (9%) and paronychia (6%) [6]. Our study in a similar patient population has shown a slightly better ORR/DCR and PFS in EGFR exon 20 i- mut. Despite the long reported PFS compared with ZENITH20-1 trial (5.6 vs 4.2 months), and also mPFS in our study, it remains low because we expect more from a target-therapy. Still, this seems to be a better result compared with other historical PFS within a range of 2.5e3 months [11e13]. Moreover, the 16 mg of dose exhibits high toxicity and a high rate of dose A B Product-Limit Survival Estimate With Number of Subjects at Risk Product-Limit Survival Estimate With Number of Subjects at Risk 1.0 Censored 1.0 Censored 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0.0 0.0 0 1 2 3 4 At Risk 30 28 26 21 17 5 6 7 8 9 10 PFS time mos 149 5 3 3 2 11 12 13 2 2 1 14 15 1 0 0 1 2 3 4 At Risk 30 28 27 22 20 5 6 7 8 9 10 11 12 13 14 15 16 17 OS time mos 19 14 10 7 6 2 2 2 1 1 1 1 0 C D Product-Limit Survival Estimate With Number of Subjects at Risk Product-Limit Survival Estimate With Number of Subjects at Risk 1.0 Censored 1.0 Censored 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0.0 0.0 0 1 2 3 4 At Risk 30 28 26 22 19 5 6 7 8 9 10 11 12 13 14 15 16 17 IC PFS time mos 17 11 6 4 2 2 2 2 1 1 1 1 0 0 1 2 3 4 At Risk 30 28 26 20 16 5 6 7 8 9 10 11 12 13 14 15 16 17 TTD time mos 1512 7 5 4 3 3 3 2 2 1 1 0 Fig. 3. KaplaneMeier curves according to PFS (A), OS (B), ic-PFS (C) and TTD (D) for all the enrolled patients. PFS, progression-free survival; OS, overall survival; ic-PFS, intracranial PFS; TTD, time-to-treatment discontinuation. interruption (Fig. 5). This is probably because of MTD derived from the Asian population, which is well-known to have a different metabolism compared with those of the Caucasian population. The ongoing ZENITH20 trial opened a new cohort test with less dose (cohort 5: 16 mg vs 12 mg vs 10 mg) and new schedules (replacing 16 mg QD to 8 mg bis in die (BID)). Lower doses and new schedules of poziotinib could not only reduce toxicity, but also putatively increase the response rate and improve PFS. In this study, a significant difference in OS between male and female was also observed, confirming male sex as a negative prognostic factor in multivariate analysis. The biological mechanism to explain this difference is unknown. However, more number of females repre- sented our population, as small samples can be biased. Other trials investigating similar TKIs are either ongoing or have already reported the preliminary results. In 2019, the first results of the NCT02716116 trial, a phase I/II open-label, multicentre study, were published. In total, 101 NSCLC patients with EGFR exon 20 i-mut were treated with TAK-788 (mobocertinib), an EGFR/HER2 inhibitor, at 5e180 mg QD. Therapy was discontinued by 10.7% of patients because of AEs, such as diarrhoea (85%), rash (43%), nausea (41%), vomiting (30%), decreased appetite (28%) and stomatitis (22%). Data showed an ORR of 43% and a PFS of 7.3 months [7]. In the CHRYSALIS trial, a phase I multicentre study, testing JNJ-61186372 (amivantamab), a bispecific EGFR/ cMET inhibitor, in 116 NSCLC patients with EGFR exon 20 mutations, including cases relapsed to treatment with 3rd EGFR TKIs; the dose ranged from 140 to 1400 mg, and were administrated weekly for the first 28 days, and biweekly thereafter. Most common AEs included rash (59%), infusion-related reaction (58%), paronychia (28%), constipation (22%), stomatitis (17%), pruritus (15%), pe- ripheral oedema (11%) and diarrhoea (7%). The resulted ORR was 36% and the DFS 8.3 months [8]. A Product-Limit Survival Estimates With Number of Subjects at Risk 1.0 0.8 0.6 0.4 0.2 0.0 NO 25 25 23 19 16 13 YES 5 3 3 2 1 1 9 0 5 3 3 2 2 2 1 1 0 B Product-Limit Survival Estimates With Number of Subjects at Risk 1.0 0.8 0.6 0.4 0.2 0.0 NO 25 25 24 20 18 17 14 10 YES 5 3 3 2 2 2 0 7 6 2 2 2 1 1 1 1 0 Fig. 4. KaplaneMeier curves and subgroup analysis for ECOG PS 1 vs ECOG PS 2, according to PFS (A) and OS (B). ECOG, Eastern Cooperative Oncology Group. In 2020, a first sight of ECOG-ACRIN 5162 trial results was made public at the ASCO meeting. This phase II open-label, multicentric study tested osimerti- nib at a dose of 160 mg QD, in 21 NSCLC patients with EGFR exon 20 mutated. Anaemia (9.5%), fatigue (9.5%) and QT interval prolongation (9.5%) were the most commonly reported AEs. Data showed an ORR of 25% and an mPFS of 9.7 months [14] (Table 4). As re- ported by Elamin et al., T790M can be a potential mechanism of acquired resistance in patients treated Table 3 Grades 1e5 poziotinib-related toxicity rate were reported for all pa- tients at data cut-off. Pyrotinib is an oral, irreversible pan-HER TKI against HER1/2/4. In 2019, Gao et al. published the first results of an open-label, multicentric, single-arm phase II study. AE Grade 1n (%) Grade 2n (%) Grade 3n (%) Grade 4n (%) Grade 5n (%) Sixty pre-treated patients harboured with HER2 exon 20 i-mut advanced NSCLC were enrolled. Patients with Diarrhoea Skin rash Mucositis Paronychia Nausea 13 (43) 2 (7) 5 (17) 4 (13) 8 (27) 13 (43) 1 (3) 15 (50) 6 (20) 4 3 (10) 7 (23) 1 (3) 1 (3) active brain metastases or previously treated with anti- HER2 therapy were excluded. The ORR was 31.7% and the mPFS 6.8 months. The treatment was well-tolerated; diarrhoea was reported as the only G3 AE, occurring in Hypertrichosis 1 (3) Anorexia 3 (10) 3 (10) Hypomagnesaemia 4 (13) Hypertransaminasemia 1 (3) ti 2 patients [18] (Table 4). To date, the molecular relationship of HER2 muta- tion, HER2 gene amplification and HER2 protein over- Hypoalbuminemia Headache Hypokalaemia Epitaxis Rhinitis Conjunctivitis Folliculitis Xerosis 1(3) 2(7) 1(3) 2(7) 1 (3) 1 (3) 7 (23) 3 (10) 1 (3) 1 (3) 3(10) 1 (3) expression has not been definitively clarified. HER2 amplifications and HER2 mutations have been detected in 2%e5% and 2%e3% of lung adenocarcinomas [19e22], respectively. Furthermore, HER2 protein over- expression (defined as a high level (3þ) at immunohisto- chemical assessment) could be observed in 2%e4% of lung cancer patients. This confusion was forcefully Vomiting Alopecia Abdominal pain Haematochezia Muscle cramps 1(3) 2(7) 1 (3) 1 (3) 1(3) 2(7) 1 (3) revealed during the patient selection phase of those clin- ical trials, testing HER2-targeted therapies for NSCLC. In 2015, Li et al. studied about this by evaluating the presence of HER2 gene amplification and mutation, and Fatigue 1 (3) 3 (10) 4 (13) HER2 protein overexpression on tumour specimens Lower limbs oedema 2 (7) 1 (3) from 175 patients with stage IV or recurrent lung ade- Dizziness Pruritus Pneumonia 1 (3) 1 (3) 1 (3) nocarcinomas [22]ddemonstrating no overlaps between HER2 mutation and amplification in lung cancer [19,21] enhancing the conclusion that they represent two The empty spaces mean 0 toxicity events. with poziotinib, but no data are reported regarding the use of osimertinib after poziotinib, whereas patients exposed to both EGFR exon 20 and T790M mutations demonstrated to be resistant to poziotinib [15]. I-mut in exon 20 HER2 gene, account for a small number of cases of lung adenocarcinomas and correlate with a single clinical phenotype. Similar to EGFR mu- tations, they are commonly found in younger patients, non-smokers and in patients with a small tumour size. Unlike EGFR mutations, the prevalence of i-mut in HER2 gene appears to be comparable between the Caucasian and Asian population. Results from DESTINY-Lung01, a multicentre phase II ongoing trial, were presented at the last ASCO meeting [16]. A total of 42 patients diagnosed with non- squamous mNSCLC HER2 unspecified mutations were treated with Fam-trastuzumab deruxtecan-nxki (T- DXd), a conjugate anti-HER2 antibody. The most commonly reported, serious (grade ti III) drug-related AEs included neutropenia (26.2%) and anaemia (16.7%). Grade II interstitial lung disease was reported in 11.9% of patients. The ORR and mPFS were 61.9% and 14.0 months, respectively [16]. These excellent re- sults can probably change the clinical practice of these patients (Table 4). Afatinib showed limited efficacy in HER2 mut NSCLC both in retrospective multicentre studies [17] and clinical trials (Table 4). different cancerogenic entities, with an incidence of approximately 3%, individually. This entails that the definition ‘HER2þ NSCLC’ is insufficient, as it does not recognize to the fullest the intricacy of these gene alterations. Not separating these alterations from the same cohort/analyses would probably have been the reason for the failure of many different precious studies [23,24]. A good example is the DESTINY-Lung01 trial, which maintained HER overexpression and HER2 mutated patients separately in respective cohorts 1 and 2. In Table 4, we have also reported almost all the trials that investigated different agents against EGFR/HER2 mutations/ alterations. 5.Conclusion Poziotinib demonstrated clinical activity in mNSCLC patients treated with EGFR and HER2 exon 20 i-mut in a real-world setting. The high toxicity rate reported led to frequent dose reduction and interruption, possibly explaining the relatively low mPFS even in patients with good ORR and DCR. Ongoing trials will demonstrate whether lower doses and new dose scheduled (e.g. 8 mg BID) may lead to better dose compliance/intensity with a consequential reduction of the toxicity and a potential improvement of the survival outcome. Although the results are preliminary, we can announce that finally, Fig. 5. Poziotinib administration, with days on and days off treatment at 16 mg (A), 14 mg (B), 12 mg (C) and 10 mg (D). Apparently, it can be observed that lower the dose, longer is the adherence to the trial with less days off treatment (in some patients we can notice no column, which means that there are no days off treatment) compared with the days on treatment. Table 4 Main clinical studies investigated the use of targeted therapies against EGFR and HER2 exon 20 insertion mutation. Drug Study Phase Population N N ORR (%) PFS (months) OS (months) Most common Grade ti 3 DR AE Reference Osimertinib 160 mg ECOG-ACRIN 5162 Phase II EGFR exon 20ins advanced NSCLC 21 25% 9.7 months (95% CI 4.07eNA) N/A Anaemia (9.5%), fatigue (9.5%), prolonged QT interval (9.5%) (Piotrowska et al., 2020) Mobocertinib (TAK-788) NCT02716116 Phase I Refractory advanced NSCLC with EGFR/HER2- activating mutations 57 (EGFR exon 20ins Z 39, HER2 exon mutations Z 13) EGFR exon 20ins cohort Z 7 (39%) N/A N/A Diarrhoea (6%), nausea (6%), vomiting (6%) (Neal et al., 2018) Mobocertinib (TAK-788) NCT02716116 Phase I/II (expansion cohort) Refractory EGFR mutant-advanced NSCLC 28 14(43%) 7.3 N/A Diarrhoea (26%), hypokalaemia (7%), nausea (7%), stomatitis (7%) (Riely et al., 2019; Janne et al., 2019) Amivantamab (JNJ-372) CHRYSALIS Phase II Third-generation- relapsed EGFR mutant or EGFR exon 20ins advanced NSCLC 20 6 (30%) 8.3 N/A Dyspnoea (6%), pneumonia (3%) (Haura et al., 2019) Afatinib Pooled analysis Phase III TKI-naı¨ve EGFR- 600 (EGFR exon EGFR exon EGFR exon EGFR exon N/A (Yang et al., (LUX-Lung 2LUX-Lung 3and LUX- Lung 6) mutant advanced NSCLC 20ins Z 23) 20ins Z 2 (8.7%) 20ins Z 2.7 (95% 20ins Z 9.2 CI 1.8e4.2) (95% CI 4.1e14.2) 2015) Afatinib NICHE Phase II Pre-treated HER2- mutant advanced NSCLC 13 7.7% 15.9 weeks 56 weeks Dyspnoea (15.3%), acute renal injury (7.6%), mucositis (7.6%) (Dziadziuszko R. et al., 2019) Poziotinib Phase II Pre-treated EGFR and HER2 exon 20ins advanced NSCLC EGFR exon 20ins cohort Z 50 HER2 exon 20ins cohort Z 12 EGFR exon 20ins cohort Z 24 (55%) EGFR exon 20ins cohort Z 5.5 (95% CI 5.2 e NR) N/A Both cohorts: skin rash (34.9%), diarrhoea (17.5%), paronychia (9.5%) (Heymach et al., 2018) Poziotinib ZENITH20-1 Phase II EGFR exon 20ins advanced NSCLC 115 19.3% 4.2 N/A Skin rash (28%), diarrhoea (26%),stomatitis (9%), paronychia (6%), pneumonia (4%) (Le et al., 2020) Trastuzumab Deruxtecan DESTINY- Lung01 Phase II HER2- overexpressing or -mutated advanced NSCLC 42 61.9% (95% CI 45.6%e76.4%) 14.0 (95% CI 6.4 e14.0) N/A Neutropenia (26.2%), anaemia (16.7%), interstitial lung disease (11.9%) Smit E.F. et al. (2020) Trastuzumab Emtansine NCT02675829 Phase II HER2-mutant advanced NSCLC 18 (HER2 exon 20ins Z 11) 8 (44%) (HER2 exon 5.0 (95% 20ins Z 6 (54.5%)) CI 3.0e9.0) N/A Anaemia (6%) (Li et al., 2018) Trastuzumab Emtansine Phase II Pre-treated HER2- positive NSCLC 15(HER2 exon 20ins Z 7) 1 (6.7%) (HER2 exon 20 mutations Z 1 2.0 (95% CI 1.4 e4.0) 10.9 (4.4e12.0) Thrombocytopaenia (40%), hepatotoxicity (40%), acute renal failure (Hotta et al., 2018) (continued on next page) Table 4 (continued ) Drug Study Phase Population N N ORR (%) PFS (months) OS (months) Most common Grade ti 3 DR AE Reference (14.3%)) (7%) Trastuzumab Deruxtecan Phase I Advanced breast cancer, gastric cancer and other HER2- expressing/-mutated solid tumours, including NSCLC NSCLC cohort Z 18 (HER2 exon 20ins Z 8) 10 (58.8%) (HER2 exon 20 mutations Z 6 (75%)) 14.1 (95% CI 0.9 e14.1) N/A Neutropenia (11.1%), pneumonitis (5.6%), nausea (5.6%) (Tsurutani et al., 2018) Trastuzumab Deruxtecan DESTINY- Lung01 Phase II HER2- overexpressing or -mutated advanced NSCLC 42 61.9% (95% CI 45.6%e76.4%) 14.0 (95% CI 6.4 e14.0) N/A Neutropenia (26.2%), anaemia (16.7%), interstitial lung disease (11.9%) Smit E.F. et al. (2020) Neratinib þ temsirolimus Phase II expansion cohort HER2-mutant advanced NSCLC 62 (neratinib þ temsirolimus Z 43) 7(16.2%) 4.1 (95% CI 2.9 e5.6) 15.8 (95% CI 10.8e19.5) Diarrhoea (14%), stomatitis (7%) (Gandhi et al., 2017) Mobocertinib (TAK-788) Phase I Refractory advanced NSCLC with EGFR/ HER2-activating mutations 57 (EGFR exon 20ins Z 39, HER2 exon mutations Z 13) EGFR exon 20 insertions cohort Z 7 (39%) N/A N/A Diarrhoea (6%), nausea (6%), vomiting (6%) (Neal et al., 2018) Pyrotinib NCT02834936 Phase II Pre-treated HER2 exon 20-mutated advanced NSCLC 60 31.7% (95% CI 20.3 e45.0) 6.8 (95% CI 4.1 e8.3) N/A Diarrhoea (20%) (Gao et al., 2019) Pyrotinib Phase II Pre-treated HER2 exon 20-mutated advanced NSCLC 15 8(53.3%) 6.4 (95% CI 1.60e11.20) 12.9 (95% CI 2.05e23.75) None (Wang et al., 2019) Poziotinib Phase II Pre-treated EGFR and HER2 exon 20ins advanced NSCLC EGFR exon 20ins cohort Z 50 HER2 exon 20ins cohort Z 12 EGFR exon 20ins cohort Z 24 (55%) EGFR exon 20ins cohort Z 5.5 (95% CI 5.2 eNR) N/A Both cohorts: skin rash (34.9%), diarrhoea (17.5%), paronychia (9.5%) (Heymach et al., 2018) Poziotinib ZENITH20-1 Phase II EGFR exon 20ins advanced NSCLC 115 19.3% 4.2 N/A Skin rash (28%), diarrhoea (26%), stomatitis (9%), paronychia (6%), pneumonia (4%) (Le et al., 2020) CI, confidence interval; ECOG, Eastern Cooperative Oncology Group; NSCLC, nonesmall-cell lung cancer. A. Prelaj et al. / European Journal of Cancer 149 (2021) 235e248 247 progress is happening for patients with these negative prognostic driver alterations. Funding No funding was received. Conflict of interest statement M.C.G. declares personal financial interests with the following organizations: AstraZeneca, MSD Inter- national GmbH, BMS, Boehringer Ingelheim Italia S.p.A, Celgene, Eli Lilly, Ignyta, Incyte, Inivata, Med- Immune, Novartis, Pfizer, Roche, Takeda. F.dB. declares Consultant Advisory Board for Ignyta, BMS, Daiichi Sankyo, Pfizer, Octimet Oncology, Incyte, Teofarma, Pierre Fabre, Roche, EMD Serono, Sanofi, NMS Nerviano Medical Science, Pharm Research Associated (U.K) Ltd; as a Speaker BMS, Roche, MSD, Ignyta, Bayer, ACCMED, Dephaforum S.r.l., Nadirex, Merck, Biotechspert Ltd, PriME Oncology, Pfizer, Servier, Celgene, Tesaro, Loxo Oncology Inc., Sanofi, Healthcare Research & Pharmacoepidemiology, as P.I for Novartis, Roche, BMS, Celgene, Incyte, NMS, Merck KGAA, Kymab, Pfizer, Tesaro, MSD. A.P. de- clares personal fees from Roche, AstraZeneca and BMS outside the submitted work. C.P. declares personal fees from BMS and MSD, outside the submitted work. G.LR. declares personal fees from BMS, MSD and Astra Zeneca outside the submitted work. D.S. declares personal fees from AstraZeneca, Boehringer Ingelheim and BMS, outside the submitted work. The other au- thors report no conflict of interest. Acknowledgements We would like to acknowledge SPECTRUM for supplying the drug within the compassionate use pro- gram, as well as the pharmacy, Dr. Gabriella Saibene and her staff for supporting us in managing the drug. Finally, we also would like to acknowledge our nursesdGiuliano Molino and Anna Maria Leone for their contribution in assisting the patients. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.ejca.2021.02.038. References [1]Dearden S, Stevens J, Wu Y-L, Blowers D. Mutation incidence and coincidence in non small-cell lung cancer: meta-analyses by ethnicity and histology (mutMap). Ann Oncol Off J Eur Soc Med Oncol 2013;24(9):2371e6. [2]Jenkins S, Yang JC-H, Ramalingam SS, Yu K, Patel S, Weston S, et al. Plasma ctDNA analysis for detection of the EGFR T790M mutation in patients with advanced nonesmall cell lung cancer. J Thorac Oncol 2017;12(7):1061e70. 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