EGFR expression is associated with relapse in a melanoma cohort receiving adjuvant PD-1-based immunotherapy
2023-07-22

Adjuvant therapy with immune checkpoint inhibitors (ICIs) became standard for resected stage III/IV melanoma after the results from the CheckMate-238 and KEYNOTE-054 studies. However, 30% to 40% of patients relapse despite adjuvant therapy.1Weber J. Mandala M. Del Vecchio M. et al.Adjuvant nivolumab versus ipilimumab in resected stage III or IV melanoma.N Engl J Med. 2017; 377: 1824-1835https://doi.org/10.1056/NEJMoa1709030Crossref PubMed Scopus (1555) Google Scholar,2Eggermont A.M.M. Blank C.U. Mandala M. et al.Adjuvant pembrolizumab versus placebo in resected stage III melanoma.N Engl J Med. 2018; 378: 1789-1801https://doi.org/10.1056/NEJMoa1802357Crossref PubMed Scopus (1225) Google Scholar Epidermal growth factor receptor (EGFR) expression is linked to melanoma dedifferentiation, acquired resistance to MEK inhibitors,3Sun C. Wang L. Huang S. et al.Reversible and adaptive resistance to BRAF(V600E) inhibition in melanoma.Nature. 2014; 508: 118-122https://doi.org/10.1038/nature13121Crossref PubMed Scopus (614) Google Scholar and is targeted in various tumor entities. We reported that there is an enrichment of EGFR amplifications in patients progressing under ICI.4Hilke F.J. Sinnberg T. Gschwind A. et al.Distinct mutation patterns reveal melanoma subtypes and influence immunotherapy response in advanced melanoma patients.Cancers. 2020; 12: 2359https://doi.org/10.3390/cancers12092359Crossref PubMed Scopus (25) Google Scholar Therefore, we investigated if EGFR expression could predict relapse to adjuvant ICI in melanoma patients. Two cohorts were included: a discovery cohort from University Hospital Zürich and a confirmation cohort from University Hospital Tübingen. We analyzed all available samples used for diagnosis (Supplementary Fig 1, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). Immunohistochemistry for EGFR was performed on formalin-fixed paraffin-embedded tissues. Quantitative digital morphometry was performed using the QuPath v0.2.3 software for image analysis5Bankhead P. Loughrey M.B. Fernández J.A. et al.QuPath: open source software for digital pathology image analysis.Sci Rep. 2017; 716878https://doi.org/10.1038/s41598-017-17204-5Crossref PubMed Scopus (2739) Google Scholar (Supplementary Fig 2, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). A cut-off for EGFR expression that would best identify 2 groups of patients with higher relapse-free survival (RFS) difference was calculated using receiver operating characteristic curve analysis and Youden’s index for EGFR positivity values. RFS and follow-up time were calculated considering the date of ICI therapy start and relapse date or date of the last contact, respectively. Results are reported as 2-sided P values with 95% confidence intervals (95% CI). Statistical significance was set at P < .05. We included 137 therapy-naïve patients receiving adjuvant ICI (pembrolizumab or nivolumab). The median follow-up time was 45 and 39 months in the discovery and confirmation cohorts, respectively (95% CI 41.8-48.2 and 36.8-41.2, respectively) (Supplementary Table 1, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). A total of 71 (52%) therapy-naïve lymph nodes, in-transit or cutaneous metastases, and 23 (17%) primary tumors were available for evaluation of EGFR expression (Supplementary Figs 1, 3, and 4, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). In both cohorts, patients with high EGFR expression in therapy-naïve metastatic tissue had a significantly higher relapse rate than patients with low EGFR expression (P = .0004 and P = .0168 for the discovery and confirmation cohorts, respectively) (Supplementary Fig 5, A, B, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). The optimal cut-offs for EGFR expression in therapy-naïve metastatic tissue were 18.37% and 0.048% for discovery and confirmation cohorts, respectively (Fig 1, A, B). In both cohorts, patients with high EGFR expression had significantly worse outcomes. In the discovery cohort, the median RFS for these patients was 3 months; in patients with low EGFR expression, the median RFS was not reached (95% CI: 0.00-11.6 and not reached; P = .0004). Similar results were seen in the confirmation cohort; the median RFS was 8 months in the subgroup with high EGFR expression and not reached in the subgroup with low EGFR expression (95% CI: 5.3-10.6 and not reached; P = .0225). EGFR expression in primary tumors did not correlate with survival (Supplementary Fig 6, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). Next-generation sequencing analysis of 40 therapy-naïve metastases showed that EGFR amplification did not correlate with the corresponding levels of EGFR protein (Supplementary Table 2, available via Mendeley at https://data.mendeley.com/datasets/p687n8sw3t/1). Using 2 independent cohorts, we showed that EGFR expression is positively associated with relapse in patients with melanoma treated with adjuvant ICI. Here we identified EGFR expression in therapy-naïve metastatic tissue as a potential negative predictive factor for adjuvant ICI. Dr Amaral reports personal honoraria from BMS, CeCaVa, Novartis, and Pierre Fabre, institutional financial support from iFIT, NeraCare, Novartis, Sanofi, and SkylineDx, and institutional research grants from Novartis, outside the submitted work. Drs Sinnberg and Niessner report institutional funding from Novartis and Pierre Fabre outside the submitted work. Dr Ring listed as inventors of the patent entitled “Arenavirus particles to treat solid tumors” (patent number WO2018/185307 A1) describing the application of artLCMV vectors in the treatment of tumors, outside the submitted work. Dr Joerger reports advisory role (institutional): Novartis, AstraZeneca, Basilea Pharmaceutica, Bayer, BMS, Debiopharm, MSD, Roche, and Sanofi, research funding: Swiss Cancer Research, and travel grants: Roche, Sanofi, and Takeda. Dr Schroeder reports institutional grants from Illumina and research grants from BMS Stiftung Immunonkologie outside the submitted work. Dr Cozzio has served as adviser for and/or received speaking fees from AbbVie, Almirall, Amgen, BMS, Eli Lilly, Galderma, LEO Pharma, Janssen-Cilag, Novartis, Pfizer, Pierre Fabre Pharma, Sanofi, and UCB, outside the submitted work. Dr Leiter reports research support from MSD, consulting fees and honoraria from Sun Pharma, Sanofi (personal and institutional), MSD (personal and institutional), Novartis, Roche, and Almirall Hermal, support for attending meeting from Sun Pharma and participation on a Data Safety Monitoring Board or Advisory Board from Sun Pharma, Sanofi, MSD, Novartis, Roche, and Almirall Hermal, outside the submitted work. Dr Thomas reports honoraria for talks or advisory boards from BMS and Pierre Fabre and also reports research funding (institutional) from BMS, Pfizer, MSD, Amgen, argenx, LEO, Novartis, UCB, 4SC, AstraZeneca, BioNtech, Genentech, Roche, Biotech, CureVac, HUYA, Incyte, Idera, Iovance, InflaRx, CerpassRx, Kartos, Nektar, Philogen, Pierre Fabre, Regeneron, Replimune, and Sanofi. Dr Garbe reports personal fees from Amgen, MSD, and Philogen and grants and personal fees from Novartis, NeraCare, BMS, Roche, and Sanofi, outside the submitted work. Dr Forchhammer received personal fees from Recordati, Kyowa Kirin, and Takeda Pharmaceuticals (speakers’ honoraria) as well as institutional grants from NeraCare, SkylineDx, and BioNTech outside the submitted work. Dr Levesque has received project-specific research funding outside the scope of this work from Novartis, Roche, Molecular Partners, and Oncobit. Dr Mangana has intermittent projects focused consultancy or advisory relationships with Merck/Pfizer, MSD, Amgen, Novartis, Roche, BMS, and Pierre Fabre and has received travel support from Ultrasun, L’Oreal, MSD, BMS, and Pierre Fabre outside of the submitted work. Dr Dummer reports research funding to their institution for clinical studies from MSD and consulting or advisory roles with MSD, Novartis, Roche, BMS, Amgen, Takeda, Pierre Fabre, Sun Pharma, Sanofi, Catalym, Second Genome, Regeneron, Alligator, T3 Pharma, MaxiVAX, Pfizer, and touchIME outside the submitted work. Dr Schürch is on the Scientific Advisory Board of and has received research funding from Enable Medicine, Inc, both outside the current work. Dr Forschner served as consultant to Roche, Novartis, MSD, BMS, and Pierre Fabre, received travel support from Roche, Novartis, BMS, and Pierre Fabre, received speaker fees from Roche, Novartis, BMS, MSD, and CeGaT and also reports institutional research grants from BMS Stiftung Immunonkologie. Dr Flatz reports grants or contracts from Hookipa Pharma, SAKK/Immunophotonics, DFG grant (Deutsche Forschungsgemeinschaft), Philogen, and Mundipharma, consulting fees from Philogen, Sanofi, Novartis, and BMS, participation on Data Safety Board University of Basel, outside the submitted work. The other authors have no conflicts of interest to declare. We thank Simone Golling (Institute for Pathology, Kantonsspital St. Gallen, Switzerland), and Karen Greif (Institute of Pathology, University Hospital Tübingen, Germany) for their help in preparing the samples for EGFR immunohistochemistry evaluation.