Clinical and Translational Oncology

https://doi.org/10.1007/s12094-019-02075-1

REVIEW ARTICLE

Strategies to overcome acquired resistance to EGFR TKI

in the treatment of non‑small cell lung cancer
J. Gao1 · H.‑R. Li1   · C. Jin1,2 · J.‑H. Jiang1 · J.‑Y. Ding1

Received: 9 December 2018 / Accepted: 26 February 2019

© Federación de Sociedades Españolas de Oncología (FESEO) 2019

Abstract
Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) represents a paradigm shift in the treatment of
non-small cell lung cancer (NSCLC) patients and has been the first-line therapy in clinical practice. While erlotinib, gefi-
tinib and afatinib have achieved superior efficacy in terms of progression-free survival and overall survival compared with
conventional chemotherapy in NSCLC patients, most people inevitably develop acquired resistance to them, which presents
another challenge in the treatment of NSCLC. The mechanisms of acquired resistance can be classified as three types: target
gene mutation, bypass signaling pathway activation and histological transformation. And the most common mechanism is
T790M which accounts for approximately 50% of all subtypes. Many strategies have been explored to overcome the acquired
resistance to EGFR TKI. Continuation of EGFR TKI beyond progressive disease is confined to patients in asymptomatic stage
when the EGFR addiction is still preserved in some subclones. While the combination of EGFR TKI and chemotherapy or
other targeted agents has improved the survival benefit in EGFR TKI resistant patients, there are controversies within them.
The next-generation EGFR TKI and immunotherapy represent two novel directions for overcoming acquired resistance and
have achieved promising efficacy. Liquid biopsy provides surveillance of the EGFR mutation by disclosing the entire genetic
landscape but tissue biopsy is still indispensable because of the considerable rate of false-negative plasma.

Keywords  Non-small cell lung cancer (NSCLC) · Epidermal growth factor receptor tyrosine kinase inhibitor (EGFR TKI) ·
Acquired resistance · Mechanism · Strategy

Abbreviations AE Adverse event

EGFR TKI Epidermal growth factor receptor tyrosine WT Wild type
kinase inhibitor ILD Interstitial lung disease
NSCLC Non-small cell lung cancer PD-1 Programmed death 1
PFS Progression-free survival PD-L1 Programmed death ligand 1
OS Overall survival
PD Progressive disease
RR Response rate Introduction
ATP Adenosine triphosphate
ORR Objective response rate Lung cancer is the leading cause of cancer-related death
CNS Central nervous system worldwide with the 5-year overall survival (OS) of all
patients diagnosed with lung cancer about only 17%, since
most patients are in stage IIIB even IV when diagnosed due
J. Gao and H.-R. Li contributed equally to this work. to the asymptom in early stage [1–3]. Non-small cell lung
cancer (NSCLC) accounts for approximately 80–85% of all
* J.‑Y. Ding
dingjianyongmd@163.com histo-subtypes of lung cancer [4]. The conventional treat-
ment with platinum-based chemotherapy for NSCLC pre-
1
Department of Thoracic Surgery, Zhongshan Hospital, sented no superiority in any regimen and the efficacy has
Fudan University, 180 Fenglin Road, Xuhui District, reached a plateau with one-year survival of only 33% [5].
Shanghai 200032, People’s Republic of China
While the maintenance treatment with pemetrexed improved
2
Department of Thoracic Surgery, Xuhui District Center the survival benefit of NSCLC patients with non-squamous
Hospital of Shanghai, Shanghai 200031, China

13
Vol.:(0123456789)

histology compared with the placebo group in terms of
median OS (JMEN trial: 15.5 vs 10.3  months; PARA-
MOUNT trial: 13.9 vs 11.0 months), no significant differ-
ence was observed in squamous histology [6, 7]. Another
randomized study—ECOG 4599—also revealed the supe-
rior efficacy in the regimen of bevacizumab (PD-L1 inhibi-
tor) and chemotherapy vs chemotherapy alone with median
OS of 12.3 vs 10.3 months in patients with non-squamous
NSCLC [8]. Epidermal growth factor receptor (EGFR) is
a member of the HER/ErbB family which mediates the
proliferation, migration and survival of cell, and would be
involved in the development of NSCLC when it was mutated
[9]. EGFR mutation exists in approximately 50% of Asian
patients and 16% of Caucasian patients. The most common
activated mutations are 19-del and L858R which accounts
for 46.4% and 43.8% in Asian patients, 62.2% and 37.8% in
Caucasian patients, respectively [10, 11]. Thus, epidermal
growth factor receptor tyrosine kinase inhibitors (EGFR
TKIs) provide a potent strategy in the treatment of NSCLC
and represent a paradigm shift in clinical practice. Although
considerable improvement has been reached by targeted
therapy with response rate (RR) of 73% and progression-free
survival (PFS) of 10.8 months, most patients will invariably
develop acquired resistance to EGFR TKI within 12 months
[12]. The definition of acquired resistance to EGFR TKI
proposed by Jackman et al. is that achieved significant or
durable clinical benefit more than 6 months after initiation
of gefitinib or erlotinib and subsequently developed systemic
progression of disease while continued on the treatment of
EGFR TKIs [13]. To date, various mechanisms of acquired
resistance to EGFR TKI have been validated. And the most
common mechanism is EGFR T790M mutation which
accounts for approximately 50% of all EGFR TKI resist-
ance in NSCLC patients [14].
We try to summarize the current mechanisms of acquired
resistance to EGFR TKI and explore the promising strategies
aim at providing a vital reference for treatment of NSCLC
patients for clinicians.
Current state of EGFR TKI in the treatment
of NSCLC
First‑ and second generation of EGFR TKI
in the treatment of NSCLC
Both gefitinib and erlotinib are first generation of EGFR
TKIs which compete with adenosine triphosphate (ATP)
reversibly to bind to the intracellular tyrosine kinase
domain of EGFR, and subsequently inhibit autophospho-
rylation and the activation of downstream signaling [15].
Two open label, randomized, phase 3 trials: OPTIMAL,
CTONG-0802 and WJTOG3405 compared the efficacy
13
Clinical and Translational Oncology
of erlotinib or gefitinib with chemotherapy in the treat-
ment of EGFR-mutant NSCLC patients, respectively,
and revealed the significant superiority of EGFR TKIs in
terms of median PFS with 13.1 months vs 4.6 months and
9.2 months vs 6.3 months, respectively [16, 17]. In addi-
tion, another phase 3 trial—EURTAC—also observed the
promising benefit of erlotinib in EGFR-mutant NSCLC
Caucasians with median PFS of 9.7  months (95% CI
8.4–12.3) vs 5.2 months (95% CI 4.5–5.8) in chemother-
apy group [18]. A meta-analysis of 13 randomized tri-
als revealed that the objective response rate of erlotinib
and gefitinib was more than twofold when compared
with chemotherapy (67.6% vs 32.8%) but there was no
improvement in OS, probably due to the crossover from
chemotherapy to EGFR TKI after progression [19]. One
mechanism of acquired resistance to gefitinib or erlotinib
which accounts for around 50% of resistant cases is a sec-
ondary mutation in exon 20 of the EGFR kinase domain
with the threonine substituted by methionine at position
790 (T790M), and subsequently activation of autophos-
phorylation at Y992 and Y1068 [20, 21].
The second generation of EGFR TKIs afatinib
(BIBW2992) and dacomitinib (PF00299804) are two oral,
ErbB family blockers which inhibit the EGFR signaling
pathway by irreversibly binding to the ATP domain of
ErbB family kinase domains [22, 23]. In a phase 3 trial—
ARCHER 1050—which investigated the benefit of dacomi-
tinib vs gefitinib, dacomitinib obtained superior efficacy in
the first-line treatment of EGFR-mutant NSCLC patients
with median PFS of 14.7 vs 9.2 months in gefitinib group
[24]. Two randomized, phase 3 trials of afatinib vs chemo-
therapy for the treatment of EGFR-mutant NSCLC patients
revealed the superior efficacy of afatinib over chemotherapy
in terms of median PFS (LUX-Lung 3: 11.1 vs 6.9 months;
LUX-Lung 6: 11.0 vs 5.6 months). Additionally, while the
median PFS of del19 and exon 20 substitution subgroup
was comparable to the whole population in LUX-Lung 6,
patients with these common EGFR mutations presented
larger PFS benefit in LUX-Lung3 (median PFS:13.6 vs
6.9  months) [25, 26]. Nonetheless, the phase IIb LUX-
Lung 7 trial reported no significant improvement in OS of
afatinib vs gefitinib(27.9 vs 24.5 months, HR 0.86; 95% CI
0.66–1.12, p  =  0.2580); however, the imbalance of patients
in both groups and the limited sample size may affect the OS
[27]. While a clinical trial by Megan Campo et al. found that
T790M was the main mechanism of acquired resistance to
afatinib, more clinical trials are needed to unveil comprehen-
sive profile of the resistant mechanisms owing to the small
samples [28]. Another preclinical trial in in vitro and in vivo
NSCLC cells revealed that deregulation of the Keap1-Nrf2
pathway conferred the cross-resistance to afatinib and the
enhancement of invasiveness and proliferation of NSCLC
[29].
Clinical and Translational Oncology
Clinical characteristics of acquired resistance
to EGFR TKI in NSCLC
While NSCLC patients with EGFR mutation are initially
sensitive to EGFR TKI, the development of acquired resist-
ance is inevitable [30]. EGFR-mutant NSCLC patients are
prone to present the characteristics of female, never-smok-
ers, adenocarcinoma and stage IV. The most common symp-
toms of disease progression are cough and dyspnea with the
median time to progression (TTP) of 10.2 months (95% CI
9.5–10.9) and median post-progression survival (PPS) of
8.9 months (95% CI 7.4–10.4). The most common site of
disease progression is the lung followed by central nervous
system, pleura and bone [31].
Given the heterogeneity in disease progression might
impact on the efficacy of treatment modalities, Gandara
et al. divided the progressive disease (PD) after EGFR TKI
utility into three subtypes, including: (1) central nervous
system (CNS) sanctuary PD (isolated CNS failure, primary
brain parenchyma metastasis, lack of systemic progression
and excluding leptomeningeal carcinomatosis), (2) oligo-PD
(new lesions or relapse in a limited number of areas, maxi-
mum of three lesions), (3) systemic PD (multiple progres-
sion including new metastatic lesions and relapse in previous
lesions) [32]. When CNS sanctuary PD or oligo-PD arises,
Fig. 1  Mechanisms of acquired resistance to EGFR TKI. The mecha-
nisms of acquired resistance to EGFR TKI: a point mutation of target
gene-T790M where the threonine at position 790 in exon 20 is sub-
stituted by methionine and subsequently hinder the binding of EGFR
TKI and the ATP binding domain. b The activation of bypass sign-
local–regional approach with surgery or radiotherapy and
continuation of EGFR TKI can prolong the median PFS in
EGFR TKI-resistant NSCLC patients [33, 34].
Mechanisms of acquired resistance to EGFR
TKI
The mechanisms of acquired resistance to EGFR TKI can be
classified as three types including point mutation of target
gene, activation of bypass signaling pathway and phenotypic
or histological transformation (Fig. 1).
Point mutation of target gene and activation
of bypass signaling pathway
T790M
T790M is a point mutation at position 790 in exon 20 of
EGFR kinase domain where the threonine is substituted
by methionine and subsequently activates the downstream
signaling pathway [20, 21]. The residues at 790 which
control the entrance of EGFR TKIs to the ATP-binding
pocket will increase the affinity to ATP and elicit the
acquired resistance to targeted agents when it is shut down.
aling pathways like MET, HER2, AXL, BRAF, etc. and the down-
stream pathways PI3K/AKT/mTOR or NF-κB and RAS/RAF/MEK/
ERK or MAPK, which are also shared by EGF. c The phenotypic or
histological transformation with epithelial cells to mesenchymal cells
and NSCLC to SCLC
13

Thus, it is deemed as a “gatekeeper” of EGFR [35]. Since
T790M positive can switch to T790M negative after over
1-year withdrawal of TKI because of the spatiotemporal
heterogeneity of T790M, re-challenging EGFR TKI after
the disappearance of T790M positive received significant
outcome with 80% of response rate, 100% disease control
rate and 6.0 months of median PFS [36]. And the progno-
sis of T790M-positive patients seems better than T790M-
negative patients due to the indolent nature of T790M
mutation [37].
HER2 amplification
HER2 is a kind of receptor tyrosine kinase which cooperates
with other family members of ErbB/HER to elicit down-
stream signaling pathway owing to forming heterodimers
[38]. While HER2 amplification had been founded in only
1–3% of lung adenocarcinomas, it ranked the second fre-
quent mechanism of acquired resistance to EGFR TKI with
the incidence of 12% [38–40]. Furthermore, it was thought
to be mutual exclusively with T790M in EGFR TKI-resist-
ant NSCLC patients [40]. In a preclinical trial, osimertinib
was demonstrated to have superior efficacy against HER2
amplification through the inhibition of downstream signaling
pathway targets in genetically modified mice models [38].
MET amplification
MET amplification has been found in around 5% of EGFR-
mutated NSCLC patients with acquired resistance to EGFR
TKI [41]. MET gene encodes c-met which is the receptor
for hepatocyte growth factor (HGF) and binding of the two
substances activates the phosphorylation of HER3 (a mem-
ber of the EGFR family) and subsequent phosphorylation
of PI3 K-AKT signaling pathway [42, 43]. Thus, its ampli-
fication causes the acquired resistance to EGFR TKI and
facilitates the progression of NSCLC. MET amplification
had been found to co-exist with T790M mutation in approxi-
mately one-third of NSCLC patients with acquired resist-
ance to reversible EGFR TKI in contrast to HER2 amplifica-
tion [44, 45]. And in genetically engineered mice models,
the combination therapies targeting both T790M mutation
and MET amplification simultaneously have presented supe-
rior efficacy compared with monotherapy targeting T790M
mutation or MET amplification alone [45]. In a phase II
trial, the combination of onartuzumab (humanized mono-
clonal antibody targeting MET) and erlotinib significantly
improved FPS (2.9 vs 1.5 months, HR 0.53) and OS (12.6
vs 3.8 months, HR 0.37) compared with erlotinib alone in
MET-positive NSCLC patients with acquired resistance to
EGFR TKI [46].
13
Clinical and Translational Oncology
BRAF mutation
BRAF mutation which accounts for 50–70% of melano-
mas cases also exists in 3% of lung adenocarcinomas and
is classified as V600E, G469A and D594G mutations [47].
In xenograft mice models, V600E mutation has been found
to constitutively activate ERK and subsequent downstream
signaling pathway, resulting in the tumor proliferation [48].
Another clinical trial by Ho et al. found the V600E mutation
in cells from malignant pleural effusion of lung adenocarci-
noma patients with acquired resistance to osimertinib. And a
potential mechanism is attributed to the inhibition of T790M
by osimertinib through BRAF pathway [49].
PIK3CA mutation
Phosphoinositide-3-kinase catalytic alpha (PIK3CA) muta-
tion is a reliable predictor of resistance to EGFR TKI in
NSCLC [50]. The incidence of such mutation in squamous
cell lung carcinoma and lung adenocarcinoma is 3.9% and
2.7%, respectively, and it is not mutually exclusive with
EGFR [51]. Inhibition of one signaling pathway may acti-
vate the bypass signaling pathway resulting in the acquired
resistance to EGFR TKI because of the mutual substitution
between signal transduction pathways. And in xenograft
mice models of EGFR TKI-resistant NSCLC, the combi-
nation of trametinib and taselisib targeting both MEK and
PI3K pathways induced tumor regression [52].
AXL upregulation
The upregulation of receptor tyrosine kinase AXL and its
ligand GAS6 has been found in patients with acquired resist-
ance to EGFR TKI [53]. Both EGFR and AXL can activate
PI3 K/AKT and MAPK/ERK signaling pathways and the
upregulation of AXL confers acquired resistance to EGFR
TKI [54]. It is an independent biomarker of poor prognosis
in NSCLC patients with brain metastasis [55]. Since AXL
inhibitor reversed resistance to gefitinib and presented potent
inhibition of mesenchymal cells, it had been a promising
target in overcoming acquired resistance to EGFR TKI and
inhibiting transition from epithelial to mesenchymal (EMT)
[56]. Currently, the AXL inhibitors BGB324 (ClinicalTri-
als.gov: NCT02424617); TP-0903 (ClinicalTrials.gov:
NCT02729298) and multiple AXL inhibitors cabozantinib
(ClinicalTrials.gov: NCT00596648); MGCD516 (Clini-
calTrials.gov: NCT02219711) are still under evaluation in
clinical trials.
IGF1R
Because of the activation of downstream MAPK and AKT
signaling mediated by EGFR and insulin-like growth factor
Clinical and Translational Oncology
1 receptor (IGF1R), there is a crosstalk between EGFR and
IGF1R. And inhibition of EGFR subsequently activates
IGF1R bypass signaling pathway, which is the mechanism
of acquired resistance to afatinib [57, 58]. Thus, the IGF1R
inhibitor can restore the sensitivity to afatinib [59]. Another
mechanism of acquired resistance to erlotinib is the cross-
talk between IGF1R and EMT mediated by transforming
growth factor beta 1 (TGFβ1), suggesting that dual IGF1R/
EMT inhibitors may be a promising strategy to circumvent
acquired resistance to erlotinib [60]. Other strategies tar-
geting IGF1R/MEK and PI3 K/AKT may also re-sensitize
EGFR TKI [61, 62].
Histological or phenotypic transformation
EMT
Epithelial mesenchymal transition (EMT) is implicated in
the development of invasion and metastasis of NSCLC with
low E-cadherin (cell adhesion protein) but high vimentin/
fibronectin expression resulting in the acquired resistance to
EGFR TKI [63, 64]. The activation of AXL, TGF-β, IL-6,
Notch-1, PDGFR, MED12 and ZEB1 is associated with the
EMT in EGFR TKI-resistant NSCLC [65]. And the silenc-
ing of microRNA (miR) family members like miR-200c,
-483-3p through the promoter methylation also plays a piv-
otal role in the conformation of EMT [65, 66].
SCLC transformation
Approximately 3% of EGFR TKI-resistant NSCLC patients
experienced the histological transformation from EGFR-
mutant adenocarcinoma to SCLC which was first reported
in 2006 [41, 67]. The inactivation of TP53, RB1 and MYC
amplification has been discovered to be implicated in the
process of SCLC transformation [68, 69]. And previously
activating EGFR mutations were still presented in SCLC
[70]. In some cases, SCLC co-existed with lung adenocarci-
noma, suggesting that SCLC may be overlooked in the origi-
nal tumor. Thus, repeated biopsy is warranted [71]. Neuron-
specific enolase (NSE) level in serum may be a potential
biomarker for SCLC transformation and more trials are
necessary to validate the association of NSE and SCLC [72].
Strategies to overcome acquired resistance
to EGFR TKI
Continuation of EGFR TKI beyond disease
progression
Some oncologists insist on the continuation of EGFR TKI
beyond disease progression (defined by RECIST) when
patients are in asymptomatic stage because of the remaining
sensitivity to EGFR TKI [73]. A retrospective study reported
more durable disease control beyond focal progression by
continuation of EGFR TKI with median PFS of 10.9 months
and 12 months PFS rate of 33% [74]. In contrast, the con-
tinuation of erlotinib along with chemotherapy in EGFR
TKI-resistant patients received no survival benefit but more
toxicity compared with chemotherapy alone in a phase II
trial [75]. While another retrospective study also reported
no statistical differences between TKI continuation subgroup
and TKI discontinuation subgroup in EGFR TKI resistant
NSCLC patients in terms of OS, the less symptomatic pro-
gression and lower risk of death in TKI continuation sub-
group may recommend EGFR TKI continuation as the first
option in particular circumstances [76].
Disease flare is a common phenomenon in EGFR TKI-
resistant NSCLC patients after discontinuation of TKI. The
underlining mechanism is attributed to the heterogeneity of
tumor, in which cells preserving sensitivity to EGFR TKI
may accelerate proliferation, progression and metastasis
after the withdrawal of EGFR TKI [77]. Thus, EGFR TKI
continuation is a relatively rational option beyond progres-
sion of disease (PD). In addition, NCCN guideline suggested
the continuation of gefitinib, erlotinib or afatinib beyond PD
[78].
Combination therapy
Combination of EGFR TKI and chemotherapy
For further improvement of survival benefit in EGFR TKI-
resistant NSCLC patients, many clinical trials have explored
the combination of EGFR TKI and chemotherapy. Given
the aforementioned heterogeneity in EGFR TKI-resistant
NSCLC, the remaining EGFR addiction warranted sensi-
tivity to EGFR TKI. And the combination of EGFR TKI and
chemotherapy targeted EGFR TKI-sensitive and -resistant
subgroups, respectively (Fig. 2).
An in vitro EGFR TKI-resistant NSCLC cells model
revealed superior efficacy of the combination of EGFR
TKI and chemotherapy. In addition, the sequential regi-
men of chemotherapy and subsequent EGFR TKI achieved
more powerful potency compared with the opposite order
[79]. Nonetheless, there existed controversy in the efficacy
of EGFR TKI plus chemotherapy in EGFR TKI-resistant
NSCLC patients in clinical trials. A retrospective study com-
pared erlotinib plus chemotherapy with chemotherapy alone
in erlotinib-resistant NSCLC patients, the ORR in erlotinib
group was more than twofold of chemotherapy group (41%
vs 18%) but the median PFS was comparable between two
groups (4.4 vs 4.2 months, HR 0.79; 95% CI 0.48–1.29;
p  =  0.34) [80]. Another phase III trial of gefitinib plus
chemotherapy vs chemotherapy alone in gefitinib-resistant
13

Fig. 2  Rationale for continua-
tion of EGFR TKI and combi-
nation with other agents. After
the initiation of EGFR TKI,
most NSCLC cells eventually
develop resistance to EGFR
TKI, while the EGFR TKI
addiction still exists. Thus, the
continuation of EGFR TKI and
the combination with other
agents target the EGFR TKI-
sensitive and -resistant NSCLC,
respectively
NSCLC patients also reported no prolonged survival benefit
in gefitinib group with median PFS of 5.4 months in both
groups [81]. And in the IMPRESS clinical trial, median OS
was even significantly shorter in gefitinib plus cisplatin/pem-
etrexed compared with control group (13.4 vs 19.5 months,
HR 1.44) in gefitinib-resistant NSCLC patients, particularly
in T790M-positive subgroup [82]. In contrast, another phase
III clinical trial revealed that median PPFS (Post RECIST
PD (response evaluation criteria in solid tumor progressive
disease) progression-free survival) of gefitinib plus pem-
etrexed-based chemotherapy was significantly longer than
chemotherapy alone (6.6 vs 3.5 months, HR 0.50; 95% CI
0.29–0.88) in T790M-negative gefitinib-resistant NSCLC
patients [83]. And the interferential factors like sample size,
patient’s selection bias, EGFR mutation and so on may con-
tribute to such discrepancy. Thus, more clinical trials are
warranted to validate the efficacy of combination of EFGR
TKI and chemotherapy.
Combination of EGFR TKI and other targeted agents
Dual EGFR blockade
Cetuximab is a humanized monoclonal antibody targeting
EGFR. In a preclinical trial, the combination of erlotinib and
cetuximab induced tumor regression by reducing the phos-
phorylation of EGFR and subsequent silence of downstream
signaling pathway in xenograft EGFR TKI-resistant NSCLC
mice models [84]. In contrast, the combination of erlotinib
and cetuximab conferred no prolonged survival benefit but
higher rate of AE to erlotinib-resistant NSCLC patients in
a phase I/II clinical trial. But small sample may challenge
the reliability of this trial [85]. In another phase Ib clinical
study, the combination of afatinib and cetuximab showed
no statistical difference between T790M positive and nega-
tive EGFR TKI-resistant NSCLC patients in terms of PFS
(4.8 vs 4.6 months; p = 0.643) and objective response rate
(ORR) (35% vs 25%; p = 0.341). Given the high rate of AEs
13
Clinical and Translational Oncology
including 90% of rash and 71% of diarrhea, the combina-
tion strategy of cetuximab and other EGFR TKI may not be
a rational option for EGFR TKI-resistant NSCLC patients
[86].
Bypass signaling pathway blockade
The activation of bypass signaling pathway warranted pro-
liferation, progression and metastasis to NSCLC prior to
EGFR TKI because of the crosstalk and mutual substitution
between variable signaling pathways. Thus, dual signaling
pathways blockade may provide another novel strategy to
overcome the acquired resistance to EGFR TKI.
The activation of MET/PI3K/AKT pathway is one of the
mechanisms of acquired resistance to EGFR TKI [42, 43].
In a phase II clinical trial of combining tivantinib (target-
ing c-Met) with erlotinib in EGFR TKI resistant NSCLC
patients, the c-Met high subgroup achieved more survival
benefit compared with c-Met low subgroup in terms of
median PFS (4.1 vs 1.4 months) and median OS (20.7 vs
13.9 months). The toxicity profile in both subgroups was
manageable with dermatitis acneiform of the most com-
mon AE followed by decreased appetite and stomatitis
compared with tivantinib or erlotinib alone [87]. In a phase
Ib/II clinical trial of capmatinib (targeting MET) plus gefi-
tinib in EGFR TKI-resistant NSCLC patients, the ORR was
27% and increased activity was correspond to higher MET
amplification [88]. Another clinical trial of onartuzumab
plus erlotinib in EGFR TKI-resistant NSCLC patients has
mentioned above [46]. Clinical trials of combination therapy
are summarized in Table 1. Other bypass signaling pathway
blockades including AXL inhibitor, BGB324 (Clinical-
Trials.gov: NCT02424617); heat shock protein 90 inhibi-
tor, AUY992 (ClinicalTrials.gov: NCT01259089); MEK
inhibitor, trametinib (ClinicalTrials.gov: NCT03516214,
NCT02580708); PI3 K inhibitor, BKM120 (ClinicalTri-
als.gov: NCT01487265, NCT01570296); mTOR inhibi-
tor, CC-223 (ClinicalTrials.gov: NCT01545947) and AKT
Clinical and Translational Oncology

Table 1  Clinical trials of combination therapy in EGFR TKI-resistant NSCLC patients

Study Phase Regimen Patient Median PFS (months) Median OS (months)
Female Male

Goldberg et al. [80] II CT + E vs CT 28 vs 30 6 vs 4 4.4 vs 4.2 14.2 vs 15.0

Soria et al. [81] III G + CT vs CT 87 vs 84 46 vs 48 5.4 vs 5.4 IM
Mok et al. [82] III G + CT vs CT 83 vs 79 50 vs 53 4.6 vs .3 13.4 vs 19.5
Ding et al. [83] III G + CT vs CT 46 vs 53 45 vs 26 PPFS 5.0 vs 4.0 IM
Janjigian et al. [85] I/II CE + E 12 7 3 NR
Janjigian et al. [86] Ib A + CE 93 33 4.7 NA
Azuma et al. [87] II E + TI 28 17 2.7 18
Spigel et al. [46] II ON + E vs E 17 vs 11 18 vs 20 2.9 vs 1.5 12.6 vs 3.8

CE cetuximab, ON onartuzumab, E erlotinib, G gefitinib, CT chemotherapy, A afatinib, TI tivantinib, NR not reached, NA not available IM,
immature, PFS progression-free survival, OS overall survival, PPFS post RECIST PD (response evaluation criteria in solid tumor progressive
disease) progression-free survival

inhibitor, MK-2206 (ClinicalTrials.gov: NCT01294306,
NCT01248247) are still under evaluation in clinical trials.
Third‑ and fourth generation EGFR TKIs
The third-generation EGFR TKIs are developed to target
activating EGFR- and T790M-resistant mutations but spar-
ing inhibition on wild type (WT) EGFR [89]. Several agents
are under evaluation in clinical trials.
Osimertinib is an oral third-generation EGFR TKI irre-
versibly covalent binding with EGFR TKI-sensitive and
T790M-resistant mutations and it is recommended for
T790M-positive advanced NSCLC patients prior to EGFR
TKI [90, 91]. In a phase 3 trial FLAURA of osimertinib in
untreated EGFR-mutant NSCLC patients, the median PFS of
osimertinib was almost twofold of gefitinib or erlotinib (18.9
vs 10.2 months) with similar ORR (80% vs 76%) [92]. In a
series of AURA clinical trials, osimertinib has significantly
improved the survival benefits in T790M-positive NSCLC
patients with acquired resistance to EGFR TKI. The objec-
tive response rate (ORR) was 61, 70, 62 and 71% in AURA
I, II, II extension and III clinical trial and the median PFS
was 9.6 months (95% CI, 8.3 to not reached), 9.9 months
(95% CI 8.5–12.3), 12.3 months (95% CI 9.5–13.8) and
10.1 months (95% CI 8.3–12.3), respectively. In addition,
these four clinical trials also presented a manageable toxic-
ity profile of osimertinib with diarrhea, rash of the most
common AEs and 2–4% of interstitial lung disease (ILD)
[93–96]. Rociletinib is another third-generation EGFR
TKI—an irreversibly covalent inhibitor of T790M. In a
preclinical trial, no manifestation on the inhibition of WT
EGFR had been observed in xenograft T790M positive
NSCLC mice model in addition to the tumor regression
induced by rociletinib [97]. The ORR and median PFS of
rociletinib was 59% and 13.1 months with manageable and
tolerable toxicity profile in T790M-positive NSCLC patients
with acquired resistance to EGFR TKI in a I/II clinical trial
[98]. Other agents including HM61716 [99], ASP8273
[100], EGF816 [101], PF06747775 [102], WZ4002 [103]
and AC0010 [104] have also achieved encouraging efficacy
in T790M-positive EGFR TKI-resistant NSCLC in pre-
clinical and clinical trials. Clinical trials of third-generation
EGFR TKI are summarized in Table 2.
While the osimertinib had been approved by FDA in
2015, the acquired resistance also presented another chal-
lenge in clinical practice and various mechanisms of resist-
ance have been elucidated. Preclinical trials have revealed
that the activation of bypass signaling pathways—MET,
BRAF, PIK3CA and AXL, and the EMT induction contrib-
uted to the acquired resistance to osimertinib [49, 105–107].
The liquid biopsy of osimertinib-resistant EGFR-mutant
NSCLC patients has further disclosed the loss of T790M
(50%) of the most common resistance mechanism followed
by the EGFR C797 and L792 mutations (26%) and MET
(14%) [107]. Within those of T790M lost, diverse novel
resistance mechanisms were detected including KRAS muta-
tion and RET fusion [108].
The fourth-generation EGFR TKI EAI045 is an allosteric
inhibitor designed to target T790M and C797S mutation
which confers the acquired resistance to the third-generation
EGFR TKIs and has induced the tumor regression in preclin-
ical trial [109, 110]. In addition, combination of EAI045 and
cetuximab significantly enhanced the efficacy of inhibition
of C797S mutation [109]. More clinical trials are needed to
evaluate the efficacy and safety profile of EAI045.
Immunotherapy
Immunotherapy provides another novel direction for the
treatment of EGFR TKI-resistant NSCLC patients because
of the close association between EGFR mutation and the
activation of immune check point (programmed death 1)

13
 Clinical and Translational Oncology

Table 2  Third generation EGFR Study Phase Agent T790M + patients ORR (%) Median PFS (mo)
TKIs in T790M-positive EGFR
TKI-mutant NSCLC patients AURA [93] I Osimertinib 127 61 9.6
AURA 2 [94] II Osimertinib 199 70 9.9
AURA 2 extension [95] II Osimertinib 201 62 12.3
AURA 3 [96] III Osimertinib vs Pl–PE 279 vs 140 71 vs 31 10.1 vs 4.4
Sequist et al. [98] I/II Rociletinib 46 59 13.1
Park et al. [99] II HM61713 76 62 NA
Yu et al. [100] I ASP8273 88 31 6.8
Ma et al. [104] I AC0010 45 NA NA
Hhsain et al. [102] I PF-06747775 14 NA NA

PI–PE platinum-pemetrexed, NA not available, mo month, ORR objective response rate, PFS progression-
free survival

PD-1/(programmed death ligand 1) PD-L1 [111, 112]. In Surveillance of the mutation

a preclinical trial, PD-L1 was overexpressed in EGFR-
driven NSCLC cells and the inhibition of PD-1 conversely
induced tumor regression in EGFR-mutant mice model
[111]. Nonetheless, a meta-analysis of PD-1 inhibitors in
EGFR-driven NSCLC patients with acquired resistance
to EGFR TKI found no improvement in OS compared
with docetaxel [113]. In contrast, combination of erlo-
tinib and nivolumab (humanized monoclonal antibody
targeting PD-1) in EGFR TKI-resistant patients achieved
durable response with median PFS of 5.1 months and OS
of 18.7 months in a phase I clinical trial. The toxicity
profile is tolerable, since most AES were at grades 1–2
[114]. In addition, a retrospective study reported that
nivolumab conferred more survival benefit to T790M-
negative patients compared with T790M-positive patients
in EGFR-mutant NSCLC patients with acquired resistance
to EGFR TKI, possibly owing to the higher PD-L1 expres-
sion in T790M-negative patients [115]. In a phase 2 trial—
ATLANTIC— NSCLC-advanced patients who had experi-
enced at least two regimens (chemotherapy or EGFR TKI)
were classified as three cohorts according to the EGFR/
ALK status of NSCLC and tumor expression of PD-L1,
patients with EGFR−/ALK− and higher expression of
PD-L1 obtained more benefit from durvalumab (PD-L1
inhibitor) with the ORR of 12.2% in cohort 1 (EGFR +/
ALK + ,  ≥  25% tumor cells expression of PD-L1), 16.4%
in cohort 2 (EGFR−/ALK−,  ≥  25% tumor cells expres-
sion of PD-L1) and 30.9% in cohort 3 (EGFR−/ALK−,  therascreen EGFR amplification refractory mutation system
≥  90% tumor cells expression of PD-L1) [116]. In another
phase 3 trial—IMpower 150—the combination of atezoli-
zumab (PD-L1 inhibitor) and bevacizumab (VEGF inhibi-
tor) conferred synergistic efficacy to patients with meta-
static non-squamous NSCLC in terms of PFS (8.3 months
in atezolizumab plus bevacizumab plus carboplatin plus
paclitaxel (ABCP) group vs 6.8 months in BCP group) and
median OS (19.2 vs 14.7 months) regardless of EGFR or
ALK aberration or the expression of PD-L1 [117].
Given the heterogeneity in the mechanisms of acquired
resistance to EGFR TKI, it is critical to identify the exact
mechanism of acquired resistance to direct more individual-
ized therapy [41].
Re-biopsy of tumors provide surveillance of the muta-
tion with superior feasibility. Ninety-four out of 105 patients
successfully underwent re-biopsy in a retrospective trial of
230 EGFR TKI-resistant NSCLC patients [118]. Because
of the comparable mutation rate between the primary lesion
and metastases detected by re-biopsy, the principle for site
choice falls on the most accessible lesion [119]. The detec-
tion of EGFR mutation between various lesions was coher-
ent in another retrospective study with 88 tumor specimens
extracted synchronously or metachronously from same or
different lesions [120].
Owing to the existence of intratumor heterogeneity, varia-
ble subclones with various driver mutations impact diversely
on the proliferation, progression and metastasis of NSCLC.
The genetic landscape of biopsy samples is potentially
biased and misleading, while the liquid biopsy could dis-
close the comprehensive genetic landscape of tumor [121].
In addition, the cell-free tumoral DNA (ctDNA), cell-free
DNA (cfDNA) and circulating tumor cell (CTC) in periph-
eral blood are tumor-derived resources for liquid biopsy,
which can be detected by various methods including next-
generation sequencing (NGS), cobas EGFR mutation test,
(ARMS), droplet digital polymerase chain reaction (ddPCR)
and bead, emulsion, amplification and magnetics (BEAM-
ing) [122–125]. The sensitivity for detection of T790M in
plasma was 70% and the T790M positive in plasma was
consistent with tissue biopsy in a retrospective study which
analyzed the genotyping of cfDNA in osimertinib-resistant
NSCLC patients by BEAMing [126]. The overall detection
rate among four different techniques for fifteen EGFR muta-
tions was 46.7, 73.3, 66.7 and 80% respectively; however,

13
Clinical and Translational Oncology
the coincidence rate between plasma and tissue was only
45–65%, possibly due to the temporal tumor heterogeneity
or the dynamic change of EGFR mutation in EGFR TKI-
treated patients [127]. Another study which analyzed the
ctDNA for T790M detection in NSCLC patients by cobas
and NGS also found approximately 40% of discordance rate
between plasma and tissue [128]. Given the existence of
false-negative plasma cases, it is essential for patients to
apply tissue biopsy with negative plasma results derived
from liquid biopsy.
Conclusion
EGFR TKI has been the first-line therapy for the treatment
of EGFR-mutant NSCLC patients. As the mechanisms of
acquired resistance to EGFR TKI are gradually recognized
with clinical studies, new treatment strategies have been
explored in recent years. When patients are still in asymp-
tomatic progression, continuation of EGFR TKI is a rational
option, since disease flare may arise after the discontinuation
of EGFR TKI. Given the intratumor heterogeneity in EGFR
TKI-resistant patient, some subclones are still sensitive to
EGFR TKI and the combination of EGFR TKI and chemo-
therapy targets both sensitive and resistance subclones. But
the efficacy is still controversial among different clinical tri-
als. Since the most common mechanism of acquired resist-
ance to EGFR TKI is T790M, the third-generation EGFR
TKI is mainly designed to overcome the T790M-resistant
mutation and has achieved superior efficacy in clinical
trials. Another common mechanism is the activation of
bypass signaling pathway, and the combination of EGFR
TKI and other targeted agents for dual pathways blockade
is still under evaluation in clinical trials. Immunotherapy
represented a novel direction in the treatment of EGFR TKI-
resistant NSCLC patients and increased attention of clinician
on this field in recent years because of the close association
between the activation of immune check point and EGFR
mutation. Tissue and liquid biopsy both possess advantages
and defects in the surveillance of EGFR mutation. While
liquid biopsy provides more comprehensive EGFR mutation
profile by analysis of cfDNA, ctDNA and CTC of NSCLC
compared with tissue biopsy, higher detection rate of tis-
sue biopsy warrants its utility in exclusion of false-negative
plasma result derived from liquid biopsy.
Acknowledgements  This study was funded by Talent Funding Program
of Zhongshan Hospital of Fudan University.
Compliances with ethical standards  2009;361(10):958–67.
Conflict of interest  The authors declare no conflict of interest.
Ethical statements  This article does not contain any studies with
human participations or animals performed by any of the authors.
References
1. Ofuji K, Tada Y, Yoshikawa T, Shimomura M, Yoshimura M,
Saito K, Nakamoto Y, Nakatsura T. A peptide antigen derived
from EGFR T790M is immunogenic in non-small cell lung can-
cer. Int J Oncol. 2015;46(2):497–504.
2. Duggan MA, Anderson WF, Altekruse S, Penberthy L, Sherman
ME. The Surveillance, epidemiology, and end results (SEER)
program and pathology. Am J Surg Pathol. 2016;40(12):e94–102.
3. Ettinger DS, Bepler G, Bueno R, Chang A, Chang JY, Chirieac
LR, D’Amico TA, Demmy TL, Feigenberg SJ, Grannis FJ, Jahan
T, Jahanzeb M, Kessinger A, Komaki R, Kris MG, Langer CJ,
Le QT, Martins R, Otterson GA, Robert F, Sugarbaker DJ, Wood
DE. Non-small cell lung cancer clinical practice guidelines in
oncology. J Natl Compr Canc Netw. 2006;4(6):548–82.
4. Wu M, Yuan Y, Pan YY, Zhang Y. Antitumor activity of combi-
nation treatment with gefitinib and docetaxel in EGFR-TKI-sen-
sitive, primary resistant and acquired resistant human non-small
cell lung cancer cells. Mol Med Rep. 2014;9(6):2417–22.
5. Schiller JH, Harrington D, Belani CP, Langer C, Sandler A,
Krook J, Zhu J, Johnson DH. Comparison of four chemotherapy
regimens for advanced non-small-cell lung cancer. N Engl J Med.
2002;346(2):92–8.
6. Paz-Ares LG, de Marinis F, Dediu M, Thomas M, Pujol JL,
Bidoli P, Molinier O, Sahoo TP, Laack E, Reck M, Corral J,
Melemed S, John W, Chouaki N, Zimmermann AH, Visseren-
Grul C, Gridelli C. PARAMOUNT: final overall survival results
of the phase III study of maintenance pemetrexed versus placebo
immediately after induction treatment with pemetrexed plus cis-
platin for advanced nonsquamous non-small-cell lung cancer. J
Clin Oncol. 2013;31(23):2895–902.
7. Ciuleanu T, Brodowicz T, Zielinski C, Kim JH, Krzakowski M,
Laack E, Wu YL, Bover I, Begbie S, Tzekova V, Cucevic B,
Pereira JR, Yang SH, Madhavan J, Sugarman KP, Peterson P,
John WJ, Krejcy K, Belani CP. Maintenance pemetrexed plus
best supportive care versus placebo plus best supportive care for
non-small-cell lung cancer: a randomised, double-blind, phase
3 study. Lancet. 2009;374(9699):1432–40.
8. Sandler A, Gray R, Perry MC, Brahmer J, Schiller JH, Dowlati
A, Lilenbaum R, Johnson DH. Paclitaxel-carboplatin alone or
with bevacizumab for non-small-cell lung cancer. N Engl J Med.
2006;355(24):2542–50.
9. Bazley LA, Gullick WJ. The epidermal growth factor receptor
family. Endocr Relat Cancer. 2005;12(Suppl 1):S17–27.
10. Shi Y, Au JS, Thongprasert S, Srinivasan S, Tsai CM, Khoa MT,
Heeroma K, Itoh Y, Cornelio G, Yang PC. A prospective, molec-
ular epidemiology study of EGFR mutations in Asian patients
with advanced non-small-cell lung cancer of adenocarcinoma
histology (PIONEER). J Thorac Oncol. 2014;9(2):154–62.
11. Rosell R, Moran T, Queralt C, Porta R, Cardenal F, Camps
C, Majem M, Lopez-Vivanco G, Isla D, Provencio M, Insa A,
Massuti B, Gonzalez-Larriba JL, Paz-Ares L, Bover I, Garcia-
Campelo R, Moreno MA, Catot S, Rolfo C, Reguart N, Palm-
ero R, Sanchez JM, Bastus R, Mayo C, Bertran-Alamillo J,
Molina MA, Sanchez JJ, Taron M. Screening for epidermal
growth factor receptor mutations in lung cancer. N Engl J Med.
12. Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi
S, Isobe H, Gemma A, Harada M, Yoshizawa H, Kinoshita
I, Fujita Y, Okinaga S, Hirano H, Yoshimori K, Harada T,
13

Ogura T, Ando M, Miyazawa H, Tanaka T, Saijo Y, Hagiwara
K, Morita S, Nukiwa T. Gefitinib or chemotherapy for non-
small-cell lung cancer with mutated EGFR. N Engl J Med.
2010;362(25):2380–8.
13. Jackman D, Pao W, Riely GJ, Engelman JA, Kris MG, Jänne
PA, Lynch T, Johnson BE, Miller VA. Clinical definition of
acquired resistance to epidermal growth factor receptor tyrosine
kinase inhibitors in non-small-cell lung cancer. J Clin Oncol.
2010;28(2):357–60.
14. Matsuo N, Azuma K, Sakai K, Hattori S, Kawahara A, Ishii H,
Tokito T, Kinoshita T, Yamada K, Nishio K, Hoshino T. Associa-
tion of EGFR Exon 19 deletion and EGFR-TKI treatment dura-
tion with frequency of T790M mutation in EGFR-mutant lung
cancer patients. Sci Rep. 2016;6:36458.
15. Cataldo VD, Gibbons DL, Perez-Soler R, Quintas-Cardama A.
Treatment of non-small-cell lung cancer with erlotinib or gefi-
tinib. N Engl J Med. 2011;364(10):947–55.
16. Mitsudomi T, Morita S, Yatabe Y, Negoro S, Okamoto I, Tsu-
rutani J, Seto T, Satouchi M, Tada H, Hirashima T, Asami K,
Katakami N, Takada M, Yoshioka H, Shibata K, Kudoh S,
Shimizu E, Saito H, Toyooka S, Nakagawa K, Fukuoka M. Gefi-
tinib versus cisplatin plus docetaxel in patients with non-small-
cell lung cancer harbouring mutations of the epidermal growth
factor receptor (WJTOG3405): an open label, randomised phase
3 trial. Lancet Oncol. 2010;11(2):121–8.
17. Zhou C, Wu YL, Chen G, Feng J, Liu XQ, Wang C, Zhang S,
Wang J, Zhou S, Ren S, Lu S, Zhang L, Hu C, Hu C, Luo Y,
Chen L, Ye M, Huang J, Zhi X, Zhang Y, Xiu Q, Ma J, Zhang
L, You C. Erlotinib versus chemotherapy as first-line treat-
ment for patients with advanced EGFR mutation-positive non-
small-cell lung cancer (OPTIMAL, CTONG-0802): a multi-
centre, open-label, randomised, phase 3 study. Lancet Oncol.
2011;12(8):735–42.
18. Rosell R, Carcereny E, Gervais R, Vergnenegre A, Massuti B,
Felip E, Palmero R, Garcia-Gomez R, Pallares C, Sanchez JM,
Porta R, Cobo M, Garrido P, Longo F, Moran T, Insa A, De
Marinis F, Corre R, Bover I, Illiano A, Dansin E, de Castro J,
Milella M, Reguart N, Altavilla G, Jimenez U, Provencio M,
Moreno MA, Terrasa J, Munoz-Langa J, Valdivia J, Isla D,
Domine M, Molinier O, Mazieres J, Baize N, Garcia-Campelo
R, Robinet G, Rodriguez-Abreu D, Lopez-Vivanco G, Gebbia
V, Ferrera-Delgado L, Bombaron P, Bernabe R, Bearz A, Artal
A, Cortesi E, Rolfo C, Sanchez-Ronco M, Drozdowskyj A,
Queralt C, de Aguirre I, Ramirez JL, Sanchez JJ, Molina MA,
Taron M, Paz-Ares L. Erlotinib versus standard chemotherapy as
first-line treatment for European patients with advanced EGFR
mutation-positive non-small-cell lung cancer (EURTAC): a mul-
ticentre, open-label, randomised phase 3 trial. Lancet Oncol.
2012;13(3):239–46.
19. Petrelli F, Borgonovo K, Cabiddu M, Barni S. Efficacy of EGFR
tyrosine kinase inhibitors in patients with EGFR-mutated non-
small-cell lung cancer: a meta-analysis of 13 randomized trials.
Clin Lung Cancer. 2012;13(2):107–14.
20. Pao W, Miller VA, Politi KA, Riely GJ, Somwar R, Zakowski
MF, Kris MG, Varmus H. Acquired resistance of lung adeno-
carcinomas to gefitinib or erlotinib is associated with a second
mutation in the EGFR kinase domain. PLoS Med. 2005;2(3):e73.
21. Vikis H, Sato M, James M, Wang D, Wang Y, Wang M, Jia D,
Liu Y, Bailey-Wilson JE, Amos CI, Pinney SM, Petersen GM, de
Andrade M, Yang P, Wiest JS, Fain PR, Schwartz AG, Gazdar A,
Gaba C, Rothschild H, Mandal D, Kupert E, Seminara D, Viswa-
nathan A, Govindan R, Minna J, Anderson MW, You M. EGFR-
T790M is a rare lung cancer susceptibility allele with enhanced
kinase activity. Cancer Res. 2007;67(10):4665–70.
22. Li D, Ambrogio L, Shimamura T, Kubo S, Takahashi M, Chirieac
LR, Padera RF, Shapiro GI, Baum A, Himmelsbach F, Rettig WJ,
13
Clinical and Translational Oncology
Meyerson M, Solca F, Greulich H, Wong KK. BIBW2992, an
irreversible EGFR/HER2 inhibitor highly effective in preclinical
lung cancer models. Oncogene. 2008;27(34):4702–11.
23. Engelman JA, Zejnullahu K, Gale CM, Lifshits E, Gonzales AJ,
Shimamura T, Zhao F, Vincent PW, Naumov GN, Bradner JE,
Althaus IW, Gandhi L, Shapiro GI, Nelson JM, Heymach JV,
Meyerson M, Wong KK, Janne PA. PF00299804, an irrevers-
ible pan-ERBB inhibitor, is effective in lung cancer models with
EGFR and ERBB2 mutations that are resistant to gefitinib. Can-
cer Res. 2007;67(24):11924–32.
24. Wu Y, Cheng Y, Zhou X, Lee KH, Nakagawa K, Niho S, Tsuji F,
Linke R, Rosell R, Corral J, Migliorino MR, Pluzanski A, Sbar
EI, Wang T, White JL, Nadanaciva S, Sandin R, Mok TS. Dac-
omitinib versus gefitinib as first-line treatment for patients with
EGFR-mutation-positive non-small-cell lung cancer (ARCHER
1050): a randomised, open-label, phase 3 trial. Lancet Oncol.
2017;18(11):1454–66.
25. Yang JC, Wu YL, Schuler M, Sebastian M, Popat S, Yamamoto
N, Zhou C, Hu CP, O’Byrne K, Feng J, Lu S, Huang Y, Geater
SL, Lee KY, Tsai CM, Gorbunova V, Hirsh V, Bennouna J,
Orlov S, Mok T, Boyer M, Su WC, Lee KH, Kato T, Massey D,
Shahidi M, Zazulina V, Sequist LV. Afatinib versus cisplatin-
based chemotherapy for EGFR mutation-positive lung adeno-
carcinoma (LUX-Lung 3 and LUX-Lung 6): analysis of overall
survival data from two randomised, phase 3 trials. Lancet Oncol.
2015;16(2):141–51.
26. Sequist LV, Yang JC, Yamamoto N, O’Byrne K, Hirsh V, Mok
T, Geater SL, Orlov S, Tsai CM, Boyer M, Su WC, Bennouna
J, Kato T, Gorbunova V, Lee KH, Shah R, Massey D, Zazulina
V, Shahidi M, Schuler M. Phase III study of afatinib or cisplatin
plus pemetrexed in patients with metastatic lung adenocarcinoma
with EGFR mutations. J Clin Oncol. 2013;31(27):3327–34.
27. Paz-Ares L, Tan EH, Byrne KO, Zhang L, Hirsh V, Boyer M,
Yang JCH, Mok T, Lee KH, Lu S, Shi Y, Lee DH, Laskin J, Kim
DW, Laurie SA, Kölbeck K, Fan J, Dodd N, Märten A, Park K.
Afatinib versus gefitinib in patients with EGFR mutation-positive
advanced non-small-cell lung cancer: overall survival data from
the phase IIb LUX-Lung 7 trial. Ann Oncol. 2017;28(2):270–7.
28. Campo M, Gerber D, Gainor JF, Heist RS, Temel JS, Shaw AT,
Fidias P, Muzikansky A, Engelman JA, Sequist LV. Acquired
resistance to first-line afatinib and the challenges of prearranged
progression biopsies. J Thorac Oncol. 2016;11(11):2022–6.
29. Park SH, Kim JH, Ko E, Kim JY, Park MJ, Kim MJ, Seo H, Li S,
Lee JY. Resistance to gefitinib and cross-resistance to irreversible
EGFR-TKIs mediated by disruption of the Keap1-Nrf2 pathway
in human lung cancer cells. FASEB J. 2018;32:j201800011R.
30. Wu M, Yuan Y, Pan YY, Zhang Y. Combined gefitinib and pem-
etrexed overcome the acquired resistance to epidermal growth
factor receptor tyrosine kinase inhibitors in non-small cell lung
cancer. Mol Med Rep. 2014;10(2):931–8.
31. Kim H, Lee JC, Kim Y, Kim K, Oh I, Lee SY, Jang TW, Lee MK,
Shin K, Lee GH, Ryu J, Jang SH, Son JW, Lee JE, Kim SY, Kim
HJ, Lee KY. Clinical characteristics of non-small cell lung cancer
patients who experienced acquired resistance during gefitinib
treatment. Lung Cancer. 2014;83(2):252–8.
32. Gandara DR, Li T, Lara PN, Kelly K, Riess JW, Redman MW,
Mack PC. Acquired resistance to targeted therapies against onco-
gene-driven non-small-cell lung cancer: approach to subtyping
progressive disease and clinical implications. Clin Lung Cancer.
2014;15(1):1–6.
33. Shukuya T, Takahashi T, Naito T, Kaira R, Ono A, Nakamura
Y, Tsuya A, Kenmotsu H, Murakami H, Harada H, Mitsuya K,
Endo M, Nakasu Y, Takahashi K, Yamamoto N. Continuous
EGFR-TKI administration following radiotherapy for non-small
cell lung cancer patients with isolated CNS failure. Lung Cancer.
2011;74(3):457–61.
Clinical and Translational Oncology
34. Weickhardt AJ, Scheier B, Burke JM, Gan G, Lu X, Bunn PJ,
Aisner DL, Gaspar LE, Kavanagh BD, Doebele RC, Camidge
DR. Local ablative therapy of oligoprogressive disease pro-
longs disease control by tyrosine kinase inhibitors in onco-
gene-addicted non-small-cell lung cancer. J Thorac Oncol.
2012;7(12):1807–14.
35. Doss GP, Rajith B, Chakraborty C, NagaSundaram N, Ali SK,
Zhu H. Structural signature of the G719S-T790M double muta-
tion in the EGFR kinase domain and its response to inhibitors.
Sci Rep. 2014;4:5868.
36. Hata A, Katakami N, Yoshioka H, Kaji R, Masago K, Fujita S,
Imai Y, Nishiyama A, Ishida T, Nishimura Y, Yatabe Y. Spa-
tiotemporal T790M heterogeneity in individual patients with
EGFR-mutant non-small-cell lung cancer after acquired resist-
ance to EGFR-TKI. J Thorac Oncol. 2015;10(11):1553–9.
37. Oxnard GR, Arcila ME, Sima CS, Riely GJ, Chmielecki J, Kris
MG, Pao W, Ladanyi M, Miller VA. Acquired resistance to
EGFR tyrosine kinase inhibitors in EGFR-mutant lung cancer:
distinct natural history of patients with tumors harboring the
T790M mutation. Clin Cancer Res. 2011;17(6):1616–22.
38. Liu S, Li S, Hai J, Wang X, Chen T, Quinn MM, Gao P, Zhang
Y, Ji H, Cross D, Wong KK. Targeting HER2 aberrations in
non-small cell lung cancer with osimertinib. Clin Cancer Res.
2018;24(11):2594–604.
39. Li BT, Ross DS, Aisner DL, Chaft JE, Hsu M, Kako SL, Kris
MG, Varella-Garcia M, Arcila ME. HER2 amplification and
HER2 mutation are distinct molecular targets in lung cancers. J
Thorac Oncol. 2016;11(3):414–9.
40. Takezawa K, Pirazzoli V, Arcila ME, Nebhan CA, Song X, de
Stanchina E, Ohashi K, Janjigian YY, Spitzler PJ, Melnick MA,
Riely GJ, Kris MG, Miller VA, Ladanyi M, Politi K, Pao W.
HER2 amplification: a potential mechanism of acquired resist-
ance to EGFR inhibition in EGFR-mutant lung cancers that
lack the second-site EGFRT790M mutation. Cancer Discov.
2012;2(10):922–33.
41. Yu HA, Arcila ME, Rekhtman N, Sima CS, Zakowski MF, Pao
W, Kris MG, Miller VA, Ladanyi M, Riely GJ. Analysis of tumor
specimens at the time of acquired resistance to EGFR-TKI ther-
apy in 155 patients with EGFR-mutant lung cancers. Clin Cancer
Res. 2013;19(8):2240–7.
42. Engelman JA, Zejnullahu K, Mitsudomi T, Song Y, Hyland C,
Park JO, Lindeman N, Gale CM, Zhao X, Christensen J, Kosaka
T, Holmes AJ, Rogers AM, Cappuzzo F, Mok T, Lee C, Johnson
BE, Cantley LC, Janne PA. MET amplification leads to gefitinib
resistance in lung cancer by activating ERBB3 signaling. Sci-
ence. 2007;316(5827):1039–43.
43. Cappuzzo F, Janne PA, Skokan M, Finocchiaro G, Rossi E, Ligo-
rio C, Zucali PA, Terracciano L, Toschi L, Roncalli M, Destro
A, Incarbone M, Alloisio M, Santoro A, Varella-Garcia M. MET
increased gene copy number and primary resistance to gefitinib
therapy in non-small-cell lung cancer patients. Ann Oncol.
2008;20(2):298–304.
44. Rho JK, Choi YJ, Kim SY, Kim TW, Choi EK, Yoon SJ, Park
BM, Park E, Bae JH, Choi CM, Lee JC. MET and AXL inhibi-
tor NPS-1034 exerts efficacy against lung cancer cells resistant
to EGFR kinase inhibitors because of MET or AXL activation.
Cancer Res. 2014;74(1):253–62.
45. Xu L, Kikuchi E, Xu C, Ebi H, Ercan D, Cheng KA, Padera R,
Engelman JA, Janne PA, Shapiro GI, Shimamura T, Wong KK.
Combined EGFR/MET or EGFR/HSP90 inhibition is effective in
the treatment of lung cancers codriven by mutant EGFR contain-
ing T790M and MET. Cancer Res. 2012;72(13):3302–11.
46. Spigel DR, Ervin TJ, Ramlau RA, Daniel DB, Goldschmidt
JJ, Blumenschein GJ, Krzakowski MJ, Robinet G, Godbert
B, Barlesi F, Govindan R, Patel T, Orlov SV, Wertheim MS,
Yu W, Zha J, Yauch RL, Patel PH, Phan SC, Peterson AC.
Randomized phase II trial of onartuzumab in combination with
erlotinib in patients with advanced non-small-cell lung cancer.
J Clin Oncol. 2013;31(32):4105–14.
47. Paik PK, Arcila ME, Fara M, Sima CS, Miller VA, Kris MG,
Ladanyi M, Riely GJ. Clinical characteristics of patients with
lung adenocarcinomas harboring BRAF mutations. J Clin
Oncol. 2011;29(15):2046–51.
48. Ji H, Wang Z, Perera SA, Li D, Liang MC, Zaghlul S, McNa-
mara K, Chen L, Albert M, Sun Y, Al-Hashem R, Chirieac
LR, Padera R, Bronson RT, Thomas RK, Garraway LA, Janne
PA, Johnson BE, Chin L, Wong KK. Mutations in BRAF and
KRAS converge on activation of the mitogen-activated pro-
tein kinase pathway in lung cancer mouse models. Cancer Res.
2007;67(10):4933–9.
49. Ho CC, Liao WY, Lin CA, Shih JY, Yu CJ, Chih-Hsin YJ.
Acquired BRAF V600E mutation as resistant mechanism after
treatment with osimertinib. J Thorac Oncol. 2017;12(3):567–72.
50. Ludovini V, Bianconi F, Pistola L, Chiari R, Minotti V, Colella
R, Giuffrida D, Tofanetti FR, Siggillino A, Flacco A, Baldelli E,
Iacono D, Mameli MG, Cavaliere A, Crino L. Phosphoinositide-
3-kinase catalytic alpha and KRAS mutations are important pre-
dictors of resistance to therapy with epidermal growth factor
receptor tyrosine kinase inhibitors in patients with advanced
non-small cell lung cancer. J Thorac Oncol. 2011;6(4):707–15.
51. Wang L, Hu H, Pan Y, Wang R, Li Y, Shen L, Yu Y, Li H, Cai
D, Sun Y, Chen H. PIK3CA mutations frequently coexist with
EGFR/KRAS mutations in non-small cell lung cancer and sug-
gest poor prognosis in EGFR/KRAS wildtype subgroup. PLoS
One. 2014;9(2):e88291.
52. Sato H, Yamamoto H, Sakaguchi M, Shien K, Tomida S, Shien T,
Ikeda H, Hatono M, Torigoe H, Namba K, Yoshioka T, Kurihara
E, Ogoshi Y, Takahashi Y, Soh J, Toyooka S. Combined inhi-
bition of MEK and PI3K pathways overcomes acquired resist-
ance to EGFR-TKIs in non-small cell lung cancer. Cancer Sci.
2018;109(10):3183–96.
53. Zhang Z, Lee JC, Lin L, Olivas V, Au V, LaFramboise T, Abdel-
Rahman M, Wang X, Levine AD, Rho JK, Choi YJ, Choi CM,
Kim SW, Jang SJ, Park YS, Kim WS, Lee DH, Lee JS, Miller
VA, Arcila M, Ladanyi M, Moonsamy P, Sawyers C, Boggon
TJ, Ma PC, Costa C, Taron M, Rosell R, Halmos B, Bivona TG.
Activation of the AXL kinase causes resistance to EGFR-targeted
therapy in lung cancer. Nat Genet. 2012;44(8):852–60.
54. Tian Y, Zhang Z, Miao L, Yang Z, Yang J, Wang Y, Qian D, Cai
H, Wang Y. Anexelekto (AXL) increases resistance to EGFR-TKI
and activation of AKT and ERK1/2 in non-small cell lung cancer
cells. Oncol Res. 2016;24(5):295–303.
55. Wu X, Ma W, Zhou Q, Yan H, Lim ZF, Huang M, Deng C, Yu
X, Su H, Komo S, Yang H, Zhang X, Wen S, Zhang Z, Ma PC.
AXL-GAS6 expression can predict for adverse prognosis in non-
small cell lung cancer with brain metastases. J Cancer Res Clin
Oncol. 2017;143(10):1947–57.
56. Byers LA, Diao L, Wang J, Saintigny P, Girard L, Peyton M,
Shen L, Fan Y, Giri U, Tumula PK, Nilsson MB, Gudikote J,
Tran H, Cardnell RJ, Bearss DJ, Warner SL, Foulks JM, Kanner
SB, Gandhi V, Krett N, Rosen ST, Kim ES, Herbst RS, Blumen-
schein GR, Lee JJ, Lippman SM, Ang KK, Mills GB, Hong WK,
Weinstein JN, Wistuba II, Coombes KR, Minna JD, Heymach
JV. An epithelial-mesenchymal transition gene signature predicts
resistance to EGFR and PI3K inhibitors and identifies Axl as a
therapeutic target for overcoming EGFR inhibitor resistance. Clin
Cancer Res. 2013;19(1):279–90.
57. van der Veeken J, Oliveira S, Schiffelers RM, Storm G, van
Bergen EHP, Roovers RC. Crosstalk between epidermal growth
factor receptor- and insulin-like growth factor-1 receptor signal-
ing: implications for cancer therapy. Curr Cancer Drug Targets.
2009;9(6):748–60.
13

58. Lee Y, Wang Y, James M, Jeong JH, You M. Inhibition of
IGF1R signaling abrogates resistance to afatinib (BIBW2992)
in EGFR T790M mutant lung cancer cells. Mol Carcinog.
2016;55(5):991–1001.
59. Yamaoka T, Ohmori T, Ohba M, Arata S, Murata Y, Kusumoto
S, Ando K, Ishida H, Ohnishi T, Sasaki Y. Distinct afatinib resist-
ance mechanisms identified in lung adenocarcinoma harboring
an EGFR mutation. Mol Cancer Res. 2017;15(7):915–28.
60. Vazquez-Martin A, Cufi S, Oliveras-Ferraros C, Torres-Garcia
VZ, Corominas-Faja B, Cuyas E, Bonavia R, Visa J, Martin-Cas-
tillo B, Barrajon-Catalan E, Micol V, Bosch-Barrera J, Menendez
JA. IGF-1R/epithelial-to-mesenchymal transition (EMT) cross-
talk suppresses the erlotinib-sensitizing effect of EGFR exon 19
deletion mutations. Sci Rep. 2013;3:2560.
61. Cortot AB, Repellin CE, Shimamura T, Capelletti M, Zejnullahu
K, Ercan D, Christensen JG, Wong KK, Gray NS, Janne PA.
Resistance to irreversible EGF receptor tyrosine kinase inhibitors
through a multistep mechanism involving the IGF1R pathway.
Cancer Res. 2013;73(2):834–43.
62. Guix M, Faber AC, Wang SE, Olivares MG, Song Y, Qu S, Rine-
hart C, Seidel B, Yee D, Arteaga CL, Engelman JA. Acquired
resistance to EGFR tyrosine kinase inhibitors in cancer cells
is mediated by loss of IGF-binding proteins. J Clin Investig.
2008;118(7):2609–19.
63. Poh ME, Liam CK, Rajadurai P, Chai CS. Epithelial-to-mesen-
chymal transition (EMT) causing acquired resistance to afatinib
in a patient with epidermal growth factor receptor (EGFR)-
mutant lung adenocarcinoma. J Thorac Dis. 2018;10(7):E560–3.
64. Thomson S, Buck E, Petti F, Griffin G, Brown E, Ramnarine
N, Iwata KK, Gibson N, Haley JD. Epithelial to mesenchymal
transition is a determinant of sensitivity of non-small-cell lung
carcinoma cell lines and xenografts to epidermal growth factor
receptor inhibition. Cancer Res. 2005;65(20):9455–62.
65. Sato H, Shien K, Tomida S, Okayasu K, Suzawa K, Hashida S,
Torigoe H, Watanabe M, Yamamoto H, Soh J, Asano H, Tsukuda
K, Miyoshi S, Toyooka S. Targeting the miR-200c/LIN28B axis
in acquired EGFR-TKI resistance non-small cell lung cancer cells
harboring EMT features. Sci Rep. 2017;7:40847.
66. Yue J, Lv D, Wang C, Li L, Zhao Q, Chen H, Xu L. Epigenetic
silencing of miR-483-3p promotes acquired gefitinib resistance
and EMT in EGFR-mutant NSCLC by targeting integrin beta3.
Oncogene. 2018;37(31):4300–12.
67. Zakowski MF, Ladanyi M, Kris MG. EGFR mutations in small-
cell lung cancers in patients who have never smoked. N Engl J
Med. 2006;355(2):213–5.
68. Meuwissen R, Linn SC, Linnoila RI, Zevenhoven J, Mooi WJ,
Berns A. Induction of small cell lung cancer by somatic inac-
tivation of both Trp53 and Rb1 in a conditional mouse model.
Cancer Cell. 2003;4(3):181–9.
69. Peifer M, Fernandez-Cuesta L, Sos ML, George J, Seidel D,
Kasper LH, Plenker D, Leenders F, Sun R, Zander T, Menon
R, Koker M, Dahmen I, Muller C, Di Cerbo V, Schildhaus
HU, Altmuller J, Baessmann I, Becker C, de Wilde B, Vandes-
ompele J, Bohm D, Ansen S, Gabler F, Wilkening I, Heynck S,
Heuckmann JM, Lu X, Carter SL, Cibulskis K, Banerji S, Getz
G, Park KS, Rauh D, Grutter C, Fischer M, Pasqualucci L,
Wright G, Wainer Z, Russell P, Petersen I, Chen Y, Stoelben E,
Ludwig C, Schnabel P, Hoffmann H, Muley T, Brockmann M,
Engel-Riedel W, Muscarella LA, Fazio VM, Groen H, Timens
W, Sietsma H, Thunnissen E, Smit E, Heideman DA, Snijders
PJ, Cappuzzo F, Ligorio C, Damiani S, Field J, Solberg S,
Brustugun OT, Lund-Iversen M, Sanger J, Clement JH, Solter-
mann A, Moch H, Weder W, Solomon B, Soria JC, Validire P,
Besse B, Brambilla E, Brambilla C, Lantuejoul S, Lorimier P,
Schneider PM, Hallek M, Pao W, Meyerson M, Sage J, Shen-
dure J, Schneider R, Buttner R, Wolf J, Nurnberg P, Perner
13
Clinical and Translational Oncology
S, Heukamp LC, Brindle PK, Haas S, Thomas RK. Integra-
tive genome analyses identify key somatic driver mutations of
small-cell lung cancer. Nat Genet. 2012;44(10):1104–10.
70. Sequist LV, Waltman BA, Dias-Santagata D, Digumarthy
S, Turke AB, Fidias P, Bergethon K, Shaw AT, Gettinger S,
Cosper AK, Akhavanfard S, Heist RS, Temel J, Christensen
JG, Wain JC, Lynch TJ, Vernovsky K, Mark EJ, Lanuti M,
Iafrate AJ, Mino-Kenudson M, Engelman JA. Genotypic and
histological evolution of lung cancers acquiring resistance to
EGFR inhibitors. Sci Transl Med. 2011;3(75):26r–75r.
71. Wahab A, Kesari K, Chaudhary S, Khan M, Khan H, Smith S,
Boumber Y. Sequential occurrence of small cell and non-small
lung cancer in a male patient: Is it a transformation? Cancer
Biol Ther. 2017;18(12):940–3.
72. Zhang Y, Li XY, Tang Y, Xu Y, Guo WH, Li YC, Liu XK,
Huang CY, Wang YS, Wei YQ. Rapid increase of serum neu-
ron specific enolase level and tachyphylaxis of EGFR-tyrosine
kinase inhibitor indicate small cell lung cancer transforma-
tion from EGFR positive lung adenocarcinoma? Lung Cancer.
2013;81(2):302–5.
73. Riely GJ, Kris MG, Zhao B, Akhurst T, Milton DT, Moore E,
Tyson L, Pao W, Rizvi NA, Schwartz LH, Miller VA. Prospec-
tive assessment of discontinuation and reinitiation of erlotinib
or gefitinib in patients with acquired resistance to erlotinib or
gefitinib followed by the addition of everolimus. Clin Cancer
Res. 2007;13(17):5150–5.
74. Conforti F, Catania C, Toffalorio F, Duca M, Spitaleri G, Barb-
eris M, Noberasco C, Delmonte A, Santarpia M, Lazzari C, De
Pas TM. EGFR tyrosine kinase inhibitors beyond focal progres-
sion obtain a prolonged disease control in patients with advanced
adenocarcinoma of the lung. Lung Cancer. 2013;81(3):440–4.
75. Halmos B, Pennell NA, Fu P, Saad S, Gadgeel S, Otterson GA,
Mekhail T, Snell M, Kuebler JP, Sharma N, Dowlati A. Rand-
omized phase II trial of erlotinib beyond progression in advanced
erlotinib-responsive non-small cell lung cancer. Oncologist.
2015;20(11):1298–303.
76. Auliac JB, Fournier C, Audigier VC, Perol M, Bizieux A, Vinas
F, Decroisette PVHC, Bota OS, Corre R, Le Garff G, Fournel P,
Baize N, Lamy R, Vergnenegre A, Arpin D, Marin B, Chouaid
C, Gervais R. Impact of continuing first-line EGFR tyrosine
kinase inhibitor therapy beyond RECIST disease progression
in patients with advanced EGFR-mutated non-small-cell lung
cancer (NSCLC): retrospective GFPC 04-13 study. Target Oncol.
2016;11(2):167–74.
77. Chaft JE, Oxnard GR, Sima CS, Kris MG, Miller VA, Riely GJ.
Disease flare after tyrosine kinase inhibitor discontinuation in
patients with EGFR-mutant lung cancer and acquired resistance
to erlotinib or gefitinib: implications for clinical trial design. Clin
Cancer Res. 2011;17(19):6298–303.
78. Ettinger DS, Wood DE, Aisner DL, Akerley W, Bauman J, Chir-
ieac LR, D’Amico TA, DeCamp MM, Dilling TJ, Dobelbower
M, Doebele RC, Govindan R, Gubens MA, Hennon M, Horn L,
Komaki R, Lackner RP, Lanuti M, Leal TA, Leisch LJ, Lilen-
baum R, Lin J, Loo BJ, Martins R, Otterson GA, Reckamp K,
Riely GJ, Schild SE, Shapiro TA, Stevenson J, Swanson SJ, Tauer
K, Yang SC, Gregory K, Hughes M. Non-small cell lung cancer,
version 5. 2017, NCCN clinical practice guidelines in oncology.
J Natl Compr Canc Netw. 2017;15(4):504–35.
79. Laurila N, Koivunen JP. EGFR inhibitor and chemotherapy com-
binations for acquired TKI resistance in EGFR-mutant NSCLC
models. Med Oncol. 2015;32(7):205.
80. Goldberg SB, Oxnard GR, Digumarthy S, Muzikansky A, Jack-
man DM, Lennes IT, Sequist LV. Chemotherapy with Erlotinib or
chemotherapy alone in advanced non-small cell lung cancer with
acquired resistance to EGFR tyrosine kinase inhibitors. Oncolo-
gist. 2013;18(11):1214–20.
Clinical and Translational Oncology
81. Soria JC, Wu YL, Nakagawa K, Kim SW, Yang JJ, Ahn MJ,
Wang J, Yang JC, Lu Y, Atagi S, Ponce S, Lee DH, Liu Y, Yoh
K, Zhou JY, Shi X, Webster A, Jiang H, Mok TS. Gefitinib plus
chemotherapy versus placebo plus chemotherapy in EGFR-
mutation-positive non-small-cell lung cancer after progression
on first-line gefitinib (IMPRESS): a phase 3 randomised trial.
Lancet Oncol. 2015;16(8):990–8.
82. Mok T, Kim SW, Wu YL, Nakagawa K, Yang JJ, Ahn MJ,
Wang J, Yang JC, Lu Y, Atagi S, Ponce S, Shi X, Rukazenkov
Y, Haddad V, Thress KS, Soria JC. gefitinib plus chemother-
apy versus chemotherapy in epidermal growth factor receptor
mutation-positive non-small-cell lung cancer resistant to first-line
gefitinib (IMPRESS): overall survival and biomarker analyses. J
Clin Oncol. 2017;35(36):4027–34.
83. Ding T, Zhou F, Chen X, Zhang S, Liu Y, Sun H, Ren S, Li
X, Zhao C, Wang H, Zhou C. Continuation of gefitinib plus
chemotherapy prolongs progression-free survival in advanced
non-small cell lung cancer patients who get acquired resist-
ance to gefitinib without T790M mutations. J Thorac Dis.
2017;9(9):2923–34.
84. Wang M, Zhao J, Zhang LM, Li H, Yu JP, Ren XB, Wang CL.
Combined Erlotinib and Cetuximab overcome the acquired
resistance to epidermal growth factor receptors tyrosine kinase
inhibitor in non-small-cell lung cancer. J Cancer Res Clin Oncol.
2012;138(12):2069–77.
85. Janjigian YY, Azzoli CG, Krug LM, Pereira LK, Rizvi NA,
Pietanza MC, Kris MG, Ginsberg MS, Pao W, Miller VA, Riely
GJ. Phase I/II trial of cetuximab and erlotinib in patients with
lung adenocarcinoma and acquired resistance to erlotinib. Clin
Cancer Res. 2011;17(8):2521–7.
86. Janjigian YY, Smit EF, Groen HJ, Horn L, Gettinger S, Camidge
DR, Riely GJ, Wang B, Fu Y, Chand VK, Miller VA, Pao W.
Dual inhibition of EGFR with afatinib and cetuximab in kinase
inhibitor-resistant EGFR-mutant lung cancer with and without
T790M mutations. Cancer Discov. 2014;4(9):1036–45.
87. Azuma K, Hirashima T, Yamamoto N, Okamoto I, Takahashi T,
Nishio M, Hirata T, Kubota K, Kasahara K, Hida T, Yoshioka H,
Nakanishi K, Akinaga S, Nishio K, Mitsudomi T, Nakagawa K.
Phase II study of erlotinib plus tivantinib (ARQ 197) in patients
with locally advanced or metastatic EGFR mutation-positive
non-small-cell lung cancer just after progression on EGFR-TKI,
gefitinib or erlotinib. ESMO Open. 2016;1(4):e63.
88. Wu YL, Zhang L, Kim DW, Liu X, Lee DH, Yang JC, Ahn MJ,
Vansteenkiste JF, Su WC, Felip E, Chia V, Glaser S, Pultar P,
Zhao S, Peng B, Akimov M, Tan D. Phase Ib/II study of cap-
matinib (INC280) plus gefitinib after failure of epidermal growth
factor receptor (EGFR) inhibitor therapy in patients with EGFR-
mutated, MET factor-dysregulated non-small-cell lung cancer. J
Clin Oncol. 2018;31:3101–9 (O2018777326).
89. Dearden S, Brown H, Jenkins S, Thress KS, Cantarini M, Cole R,
Ranson M, Janne PA. EGFR T790M mutation testing within the
osimertinib AURA phase I study. Lung Cancer. 2017;109:9–13.
90. Cross DA, Ashton SE, Ghiorghiu S, Eberlein C, Nebhan CA,
Spitzler PJ, Orme JP, Finlay MR, Ward RA, Mellor MJ, Hughes
G, Rahi A, Jacobs VN, Red BM, Ichihara E, Sun J, Jin H, Bal-
lard P, Al-Kadhimi K, Rowlinson R, Klinowska T, Richmond
GH, Cantarini M, Kim DW, Ranson MR, Pao W. AZD9291,
an irreversible EGFR TKI, overcomes T790M-mediated
resistance to EGFR inhibitors in lung cancer. Cancer Discov.
2014;4(9):1046–61.
91. Ettinger DS, Wood DE, Akerley W, Bazhenova LA, Borghaei H,
Camidge DR, Cheney RT, Chirieac LR, D’Amico TA, Dilling
TJ, Dobelbower MC, Govindan R, Hennon M, Horn L, Jahan
TM, Komaki R, Lackner RP, Lanuti M, Lilenbaum R, Lin J, Loo
BJ, Martins R, Otterson GA, Patel JD, Pisters KM, Reckamp
K, Riely GJ, Schild SE, Shapiro TA, Sharma N, Stevenson J,
Swanson SJ, Tauer K, Yang SC, Gregory K, Hughes M. NCCN
guidelines insights: non-small cell lung cancer, version 4.2016.
J Natl Compr Canc Netw. 2016;14(3):255–64.
92. Soria JC, Ohe Y, Vansteenkiste J, Reungwetwattana T,
Chewaskulyong B, Lee KH, Dechaphunkul A, Imamura F,
Nogami N, Kurata T, Okamoto I, Zhou C, Cho BC, Cheng Y,
Cho EK, Voon PJ, Planchard D, Su WC, Gray JE, Lee SM,
Hodge R, Marotti M, Rukazenkov Y, Ramalingam SS. Osimer-
tinib in untreated EGFR-mutated advanced non-small-cell lung
cancer. N Engl J Med. 2018;378(2):113–25.
93. Janne PA, Yang JC, Kim DW, Planchard D, Ohe Y, Rama-
lingam SS, Ahn MJ, Kim SW, Su WC, Horn L, Haggstrom
D, Felip E, Kim JH, Frewer P, Cantarini M, Brown KH,
Dickinson PA, Ghiorghiu S, Ranson M. AZD9291 in EGFR
inhibitor-resistant non-small-cell lung cancer. N Engl J Med.
2015;372(18):1689–99.
94. Goss GDP, Tsai CP, Shepherd FAP, Bazhenova LP, Lee JSM,
Chang GM, Crino LM, Satouchi MM, Chu QM, Hida TM, Han
JP, Juan OM, Dunphy FP, Nishio MM, Kang JM, Majem MM,
Mann HM, Cantarini MM, Ghiorghiu SM, Mitsudomi TP. Osi-
mertinib for pretreated EGFR Thr790 met-positive advanced
non-small-cell lung cancer (AURA2): a multicentre, open-label,
single-arm, phase 2 study. Lancet Oncol. 2016;17(12):1643–52.
95. Yang JC, Ahn M, Kim D, Ramalingam SS, Sequist LV, Su W,
Kim S, Kim J, Planchard D, Felip E, Blackhall F, Haggstrom
D, Yoh K, Novello S, Gold K, Hirashima T, Lin C, Mann H,
Cantarini M, Ghiorghiu S, Jänne PA. Osimertinib in pre-
treated T790M-positive advanced non-small-cell lung cancer:
AURA study phase II extension component. J Clin Oncol.
2017;35(12):1288–96.
96. Mok TS, Wu Y, Ahn M, Garassino MC, Kim HR, Ramalingam
SS, Shepherd FA, He Y, Akamatsu H, Theelen WS, Lee CK,
Sebastian M, Templeton A, Mann H, Marotti M, Ghiorghiu
S, Papadimitrakopoulou VA. Osimertinib or platinum-peme-
trexed in EGFR T790M-positive lung cancer. N Engl J Med.
2017;376(7):629–40.
97. Walter AO, Sjin RTT, Haringsma HJ, Ohashi K, Sun J, Lee K,
Dubrovskiy A, Labenski M, Zhu Z, Wang Z, Sheets M, St Martin
T, Karp R, Van Kalken D, Chaturvedi P, Niu D, Nacht M, Petter
RC, Westlin W, Lin K, Jaw-Tsai S, Raponi M, Van Dyke T, Etter
J, Weaver Z, Pao W, Singh J, Simmons AD, Harding TC, Allen
A. Discovery of a mutant-selective covalent inhibitor of EGFR
that overcomes T790M-mediated resistance in NSCLC. Cancer
Discov. 2013;3(12):1404–15.
98. Sequist LV, Soria JC, Goldman JW, Wakelee HA, Gadgeel SM,
Varga A, Papadimitrakopoulou V, Solomon BJ, Oxnard GR,
Dziadziuszko R, Aisner DL, Doebele RC, Galasso C, Garon
EB, Heist RS, Logan J, Neal JW, Mendenhall MA, Nichols S,
Piotrowska Z, Wozniak AJ, Raponi M, Karlovich CA, Jaw-Tsai S,
Isaacson J, Despain D, Matheny SL, Rolfe L, Allen AR, Camidge
DR. Rociletinib in EGFR-mutated non-small-cell lung cancer. N
Engl J Med. 2015;372(18):1700–9.
99. Park K, Lee JS, Han JY, Lee KH, Kim JH, Cho EK, Cho JY, Min
YJ, Kim JS, Kim DW. 1300: efficacy and safety of BI 1482694
(HM61713), an EGFR mutant-specific inhibitor, in T790M-pos-
itive NSCLC at the recommended phase II dose. J Thorac Oncol.
2016;11(4 Supplement):S113.
100. Yu HA, Spira A, Horn L, Weiss J, West H, Giaccone G, Evans
T, Kelly RJ, Desai B, Krivoshik A, Moran D, Poondru S, Jie
F, Aoyama K, Keating A, Oxnard GR. A Phase I, dose escala-
tion study of oral ASP8273 in patients with non-small cell lung
cancers with epidermal growth factor receptor mutations. Clin
Cancer Res. 2017;23(24):7467–73.
101. Jia Y, Juarez J, Li J, Manuia M, Niederst MJ, Tompkins C, Tim-
ple N, Vaillancourt MT, Pferdekamper AC, Lockerman EL, Li C,
Anderson J, Costa C, Liao D, Murphy E, DiDonato M, Bursulaya
13

B, Lelais G, Barretina J, McNeill M, Epple R, Marsilje TH,
Pathan N, Engelman JA, Michellys PY, McNamara P, Harris J,
Bender S, Kasibhatla S. EGF816 exerts anticancer effects in non-
small cell lung cancer by irreversibly and selectively targeting
primary and acquired activating mutations in the EGF receptor.
Cancer Res. 2016;76(6):1591–602.
102. Husain H, Martins R, Goldberg S, Senico P, Ma W, Masters J,
Pathan N, Kim D, Socinski M, Goldberg Z, Cho BC. P3.02b–001
phase 1 dose escalation of PF-06747775 (EGFR-T790M inhibi-
tor) in patients with advanced EGFRm (Del 19 or L858R ±
T790M) NSCLC: topic: EGFR biomarkers. J Thorac Oncol.
2017;12(1, Supplement):S1185.
103. Sakuma Y, Yamazaki Y, Nakamura Y, Yoshihara M, Matsukuma
S, Nakayama H, Yokose T, Kameda Y, Koizume S, Miyagi Y.
WZ4002, a third-generation EGFR inhibitor, can overcome
anoikis resistance in EGFR-mutant lung adenocarcinomas more
efficiently than Src inhibitors. Lab Invest. 2012;92(3):371–83.
104. Ma Y, Zheng X, Zhao H, Fang W, Zhang Y, Ge J, Wang L,
Wang W, Jiang J, Chuai S, Zhang Z, Xu W, Xu X, Hu P, Zhang
L. First-in-human phase I study of AC0010, a mutant-selective
EGFR inhibitor in non-small cell lung cancer: safety, effi-
cacy, and potential mechanism of resistance. J Thorac Oncol.
2018;13(7):968–77.
105. Namba K, Shien K, Takahashi Y, Torigoe H, Sato H, Yosh-
ioka T, Takeda T, Kurihara E, Ogoshi Y, Yamamoto H, Soh
J, Tomida S, Toyooka S. Activation of AXL as a preclinical
acquired resistance mechanism against osimertinib treatment in
egfr-mutant non-small cell lung cancer cells. Mol Cancer Res.
2019;17(2):499–507.
106. Weng CH, Chen LY, Lin YC, Shih JY, Lin YC, Tseng RY, Chiu
AC, Yeh YH, Liu C, Lin YT, Fang JM, Chen CC. Epithelial-
mesenchymal transition (EMT) beyond EGFR mutations per se
is a common mechanism for acquired resistance to EGFR TKI.
Oncogene. 2019;38(4):455–68.
107. Le X, Puri S, Negrao MV, Nilsson MB, Robichaux J, Boyle T,
Hicks JK, Lovinger KL, Roarty E, Rinsurongkawong W, Tang
M, Sun H, Elamin Y, Lacerda LC, Lewis J, Roth JA, Swisher SG,
Lee JJ, William WJ, Glisson BS, Zhang J, Papadimitrakopoulou
VA, Gray JE, Heymach JV. Landscape of EGFR-dependent and
-independent Resistance mechanisms to osimertinib and continu-
ation therapy beyond progression in EGFR-mutant NSCLC. Clin
Cancer Res. 2018;24(24):6195–203.
108. Oxnard GR, Hu Y, Mileham KF, Husain H, Costa DB, Tracy P,
Feeney N, Sholl LM, Dahlberg SE, Redig AJ, Kwiatkowski DJ,
Rabin MS, Paweletz CP, Thress KS, Janne PA. Assessment of
resistance mechanisms and clinical implications in patients with
EGFR T790M-positive lung cancer and acquired resistance to
osimertinib. JAMA Oncol. 2018;4(11):1527–34.
109. Jia Y, Yun CH, Park E, Ercan D, Manuia M, Juarez J, Xu C,
Rhee K, Chen T, Zhang H, Palakurthi S, Jang J, Lelais G,
DiDonato M, Bursulaya B, Michellys PY, Epple R, Marsilje
TH, McNeill M, Lu W, Harris J, Bender S, Wong KK, Janne
PA, Eck MJ. Overcoming EGFR(T790M) and EGFR(C797S)
resistance with mutant-selective allosteric inhibitors. Nature.
2016;534(7605):129–32.
110. Niederst MJ, Hu H, Mulvey HE, Lockerman EL, Garcia AR,
Piotrowska Z, Sequist LV, Engelman JA. The Allelic Context of
the C797S mutation acquired upon treatment with third-genera-
tion EGFR inhibitors impacts sensitivity to subsequent treatment
strategies. Clin Cancer Res. 2015;21(17):3924–33.
111. Akbay EA, Koyama S, Carretero J, Altabef A, Tchaicha JH,
Christensen CL, Mikse OR, Cherniack AD, Beauchamp EM,
Pugh TJ, Wilkerson MD, Fecci PE, Butaney M, Reibel JB,
Soucheray M, Cohoon TJ, Janne PA, Meyerson M, Hayes DN,
Shapiro GI, Shimamura T, Sholl LM, Rodig SJ, Freeman GJ,
Hammerman PS, Dranoff G, Wong KK. Activation of the PD-1
13
Clinical and Translational Oncology
pathway contributes to immune escape in EGFR-driven lung
tumors. Cancer Discov. 2013;3(12):1355–63.
112. Azuma K, Ota K, Kawahara A, Hattori S, Iwama E, Harada T,
Matsumoto K, Takayama K, Takamori S, Kage M, Hoshino T,
Nakanishi Y, Okamoto I. Association of PD-L1 overexpression
with activating EGFR mutations in surgically resected nonsmall-
cell lung cancer. Ann Oncol. 2014;25(10):1935–40.
113. Lee CK, Man J, Lord S, Links M, Gebski V, Mok T, Yang JC.
Checkpoint inhibitors in metastatic EGFR-mutated non-small cell
lung cancer-a meta-analysis. J Thorac Oncol. 2017;12(2):403–7.
114. Gettinger S, Hellmann MD, Chow L, Borghaei H, Antonia S,
Brahmer JR, Goldman JW, Gerber DE, Juergens RA, Shepherd
FA, Laurie SA, Young TC, Li X, Geese WJ, Rizvi N. Nivolumab
plus erlotinib in patients with EGFR-mutant advanced NSCLC.
J Thorac Oncol. 2018;13(9):1363–72.
115. Haratani K, Hayashi H, Tanaka T, Kaneda H, Togashi Y, Sakai K,
Hayashi K, Tomida S, Chiba Y, Yonesaka K, Nonagase Y, Taka-
hama T, Tanizaki J, Tanaka K, Yoshida T, Tanimura K, Takeda
M, Yoshioka H, Ishida T, Mitsudomi T, Nishio K, Nakagawa
K. Tumor immune microenvironment and nivolumab efficacy
in EGFR mutation-positive non-small-cell lung cancer based on
T790M status after disease progression during EGFR-TKI treat-
ment. Ann Oncol. 2017;28(7):1532–9.
116. Garassino MC, Cho BC, Kim JH, Mazieres J, Vansteenkiste
J, Lena H, Corral JJ, Gray JE, Powderly J, Chouaid C, Bidoli
P, Wheatley-Price P, Park K, Soo RA, Huang Y, Wadsworth
C, Dennis PA, Rizvi NA. Durvalumab as third-line or later
treatment for advanced non-small-cell lung cancer (ATLAN-
TIC): an open-label, single-arm, phase 2 study. Lancet Oncol.
2018;19(4):521–36.
117. Socinski MA, Jotte RM, Cappuzzo F, Orlandi F, Stroyakovskiy
D, Nogami N, Rodriguez-Abreu D, Moro-Sibilot D, Thomas
CA, Barlesi F, Finley G, Kelsch C, Lee A, Coleman S, Deng
Y, Shen Y, Kowanetz M, Lopez-Chavez A, Sandler A, Reck M.
Atezolizumab for first-line treatment of metastatic nonsquamous
NSCLC. N Engl J Med. 2018;378(24):2288–301.
118. Kim TO, Oh IJ, Kho BG, Park HY, Chang JS, Park CK, Shin HJ,
Lim JH, Kwon YS, Kim YI, Lim SC, Kim YC, Choi YD. Feasi-
bility of re-biopsy and EGFR mutation analysis in patients with
non-small cell lung cancer. Thorac Cancer. 2018;9(7):856–64.
119. Kawamura T, Kenmotsu H, Taira T, Omori S, Nakashima
K, Wakuda K, Ono A, Naito T, Murakami H, Mori K, Naka-
jima T, Ohde Y, Endo M, Takahashi T. Rebiopsy for patients
with non-small-cell lung cancer after epidermal growth fac-
tor receptor-tyrosine kinase inhibitor failure. Cancer Sci.
2016;107(7):1001–5.
120. Quere G, Descourt R, Robinet G, Autret S, Raguenes O, Fercot
B, Alemany P, Uguen A, Ferec C, Quintin-Roue I, Le Gac G.
Mutational status of synchronous and metachronous tumor sam-
ples in patients with metastatic non-small-cell lung cancer. BMC
Cancer. 2016;16:210.
121. Mao X, Zhang Z, Zheng X, Xie F, Duan F, Jiang L, Chuai S,
Han-Zhang H, Han B, Sun J. Capture-based targeted ultradeep
sequencing in paired tissue and plasma samples demonstrates
differential subclonal ctDNA-releasing capability in advanced
lung cancer. J Thorac Oncol. 2017;12(4):663–72.
122. Jamal-Hanjani M, Wilson GA, Horswell S, Mitter R, Sakarya
O, Constantin T, Salari R, Kirkizlar E, Sigurjonsson S, Pelham
R, Kareht S, Zimmermann B, Swanton C. Detection of ubiq-
uitous and heterogeneous mutations in cell-free DNA from
patients with early-stage non-small-cell lung cancer. Ann Oncol.
2016;27(5):862–7.
123. Guo N, Lou F, Ma Y, Li J, Yang B, Chen W, Ye H, Zhang JB,
Zhao MY, Wu WJ, Shi R, Jones L, Chen KS, Huang XF, Chen
SY, Liu Y. Circulating tumor DNA detection in lung cancer
patients before and after surgery. Sci Rep. 2016;6:33519.
Clinical and Translational Oncology
124. Turetta M, Bulfoni M, Brisotto G, Fasola G, Zanello A, Biscon-
tin E, Mariuzzi L, Steffan A, Di Loreto C, Cesselli D, Del BF.
Assessment of the mutational status of NSCLC using hypermeta-
bolic circulating tumor cells. Cancers (Basel). 2018;10(8):270.
125. Thress KS, Brant R, Carr TH, Dearden S, Jenkins S, Brown H,
Hammett T, Cantarini M, Barrett JC. EGFR mutation detection
in ctDNA from NSCLC patient plasma: A cross-platform com-
parison of leading technologies to support the clinical develop-
ment of AZD9291. Lung Cancer. 2015;90(3):509–15.
126. Oxnard GR, Thress KS, Alden RS, Lawrance R, Paweletz
CP, Cantarini M, Yang JC, Barrett JC, Janne PA. Association
between plasma genotyping and outcomes of treatment with osi-
mertinib (AZD9291) in advanced non-small-cell lung cancer. J
Clin Oncol. 2016;34(28):3375–82.
127. Xu T, Kang X, You X, Dai L, Tian D, Yan W, Yang Y, Xiong
H, Liang Z, Zhao GQ, Lin S, Chen KN, Xu G. Cross-platform
comparison of four leading technologies for detecting EGFR
mutations in circulating tumor DNA from non-small cell lung
carcinoma patient plasma. Theranostics. 2017;7(6):1437–46.
128. Jenkins S, Yang JC, Ramalingam SS, Yu K, Patel S, Weston
S, Hodge R, Cantarini M, Janne PA, Mitsudomi T, Goss GD.
Plasma ctDNA analysis for detection of the EGFR T790M
mutation in patients with advanced non-small cell lung cancer. J
Thorac Oncol. 2017;12(7):1061–70.
Publisher’s Note Springer Nature remains neutral with regard to
jurisdictional claims in published maps and institutional affiliations.
13