Abstract PD6-03: High prevalence and clonal heterogeneity of ESR1 mutations (mt) in circulating tumor DNA (ctDNA) from patients (pts) enrolled in FERGI, a randomized phase II study testing pictilisib (GDC-0941) in combination with fulvestrant (F) in pts that failed a prior aromatase inhibitor (AI)
Authors: Spoerke J , Gendreau S , Johnston S , Schmid P , Krop I , Qui J , Derynck M , Chan I , Walter K , Amler L , Hampton G , Lackner M 
Published: May 2016

Abstract
Background: Mutations in the ligand binding domain of the estrogen receptor gene (ESR1) have been associated with resistance to AI therapy in pts with ER+ breast cancer. To assess if ESR1 status has prognostic or predictive significance in the post-AI metastatic setting ESR1 mutation status was analyzed in circulating tumor DNA (ctDNA) from 168 pts enrolled on the FERGI study (NCT01437566; Krop et al., SABCS 2014).
Methods: Baseline and longitudinal mutational analysis for hotspot mutations in ESR1 (E380Q, S463P, V534E, P535H, L536R/H/P, L536Q, Y537N/S/C, D538G) and PIK3CA (C420R, E542K, E545K/G, Q546K, M1043I, H1047Y/R/L) was performed using droplet digital PCR (ddPCR) on ctDNA derived from plasma. Archival tissue was analyzed via RT-PCR and ddPCR.
Results: Baseline ctDNA analysis demonstrated a total of 62/156 (40%) and 57/153 (37%) pts with PIK3CA and ESR1 mutations, respectively. The most common ESR1 mutations are D538G, Y537S, and E380Q, representing 54%, 33% and 26% of the pts with a detectable ESR1 mutation at baseline, respectively. There was a numeric increase of ESR1 mutations in patients with LumA (41/99, 41%) vs LumB disease (14/44, 31%). PIK3CA mutations in asynchronously collected archival tissue were 85% concordant with plasma ctDNA mutations (sensitivity 78%, specificity 91%). PIK3CA mutations in baseline ctDNA showed a higher median allele frequency (AF) than ESR1 mutations (3.6% vs 0.46%), consistent with PIK3CA being an early event and ESR1 mutations occurring later in pts with recurrent disease. Of the pts with a detectable ESR1 mutation at baseline (n=57), 23 (40%) pts had multiple ESR1 mutations and 10 (18%) had ≥3 ESR1 mutations. The PFS outcomes for patients with and without ESR1 mutations detected at baseline are summarized below, indicating no obvious prognostic or predictive effect for combination of F with pictilisib compared with F in these underpowered subsets.
ArmESR1 MT - mPFS (mo)ESR1 WT - mPFS (mo)HR (95% CI)F + placebo5.4 (30 pts, 24 events)3.7 (40 pts, 31 events)1.06 (0.62, 1.81)F+pictilisib5.8 (27 pts, 20 events)6.7 (56 pts, 34 events)1.36 (0.78, 2.38)
PIK3CA and ESR1 ctDNA analysis on serial plasma samples from 40 pts and the assessment of ESR1 mutation status in the patient's tumor sample by ddPCR is currently in progress and will be reported.
Conclusions: Mutations in ESR1 detected by ddPCR in patient plasma samples occur in nearly 40% of pts that failed a prior AI. The polyclonal nature of ESR1 mutations is consistent with the convergent evolution of multiple AI resistant subclones. While these conclusions should be interpreted with caution due to the relatively small sample size and post hoc nature of the analysis, this data does not support a prognostic or predictive PFS hypothesis for ESR1 mutations with F or in combination with pictilisib.
Citation Format: Spoerke J, Gendreau S, Johnston S, Schmid P, Krop I, Qui J, Derynck M, Chan I, Walter K, Amler L, Hampton G, Lackner M. High prevalence and clonal heterogeneity of ESR1 mutations (mt) in circulating tumor DNA (ctDNA) from patients (pts) enrolled in FERGI, a randomized phase II study testing pictilisib (GDC-0941) in combination with fulvestrant (F) in pts that failed a prior aromatase inhibitor (AI). [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD6-03.