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Emergence of KRAS mutations and acquired resistance to anti-EGFR therapy in colorectal cancer

Abstract

A main limitation of therapies that selectively target kinase signalling pathways is the emergence of secondary drug resistance. Cetuximab, a monoclonal antibody that binds the extracellular domain of epidermal growth factor receptor (EGFR), is effective in a subset of KRAS wild-type metastatic colorectal cancers1. After an initial response, secondary resistance invariably ensues, thereby limiting the clinical benefit of this drug2. The molecular bases of secondary resistance to cetuximab in colorectal cancer are poorly understood3,4,5,6,7,8. Here we show that molecular alterations (in most instances point mutations) of KRAS are causally associated with the onset of acquired resistance to anti-EGFR treatment in colorectal cancers. Expression of mutant KRAS under the control of its endogenous gene promoter was sufficient to confer cetuximab resistance, but resistant cells remained sensitive to combinatorial inhibition of EGFR and mitogen-activated protein-kinase kinase (MEK). Analysis of metastases from patients who developed resistance to cetuximab or panitumumab showed the emergence of KRAS amplification in one sample and acquisition of secondary KRAS mutations in 60% (6 out of 10) of the cases. KRAS mutant alleles were detectable in the blood of cetuximab-treated patients as early as 10 months before radiographic documentation of disease progression. In summary, the results identify KRAS mutations as frequent drivers of acquired resistance to cetuximab in colorectal cancers, indicate that the emergence of KRAS mutant clones can be detected non-invasively months before radiographic progression and suggest early initiation of a MEK inhibitor as a rational strategy for delaying or reversing drug resistance.

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Figure 1: KRAS amplification mediates acquired resistance to cetuximab in DiFi cells.
Figure 2: KRAS mutations mediate acquired resistance to cetuximab in Lim1215 cells.
Figure 3: Mutational analysis of the KRAS gene in patients.
Figure 4: Detection of circulating KRAS mutant DNA in a patient with acquired resistance to cetuximab therapy.

References

  1. Ciardiello, F. & Tortora, G. EGFR antagonists in cancer treatment. N. Engl. J. Med. 358, 1160–1174 (2008)

    CAS  Article  PubMed  Google Scholar 

  2. Karapetis, C. S. et al. K-ras mutations and benefit from cetuximab in advanced colorectal cancer. N. Engl. J. Med. 359, 1757–1765 (2008)

    CAS  Article  PubMed  Google Scholar 

  3. Wheeler, D. L. et al. Mechanisms of acquired resistance to cetuximab: role of HER (ErbB) family members. Oncogene 27, 3944–3956 (2008)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. Benavente, S. et al. Establishment and characterization of a model of acquired resistance to epidermal growth factor receptor targeting agents in human cancer cells. Clin. Cancer Res. 15, 1585–1592 (2009)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. Li, C., Iida, M., Dunn, E. F., Ghia, A. J. & Wheeler, D. L. Nuclear EGFR contributes to acquired resistance to cetuximab. Oncogene 28, 3801–3813 (2009)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  6. Hatakeyama, H. et al. Regulation of heparin-binding EGF-like growth factor by miR-212 and acquired cetuximab-resistance in head and neck squamous cell carcinoma. PLoS ONE 5, e12702 (2010)

    Article  ADS  PubMed  PubMed Central  Google Scholar 

  7. Yonesaka, K. et al. Activation of ERBB2 signaling causes resistance to the EGFR-directed therapeutic antibody cetuximab. Sci. Transl. Med. 3, 99ra86 (2011)

    Article  PubMed  PubMed Central  Google Scholar 

  8. Montagut, C. et al. Identification of a mutation in the extracellular domain of the Epidermal Growth Factor Receptor conferring cetuximab resistance in colorectal cancer. Nature Med. 18, 221–223 (2012)

    CAS  Article  PubMed  Google Scholar 

  9. Moroni, M. et al. Gene copy number for epidermal growth factor receptor (EGFR) and clinical response to antiEGFR treatment in colorectal cancer: a cohort study. Lancet Oncol. 6, 279–286 (2005)

    CAS  Article  PubMed  Google Scholar 

  10. De Roock, W. et al. Effects of KRAS, BRAF, NRAS, and PIK3CA mutations on the efficacy of cetuximab plus chemotherapy in chemotherapy-refractory metastatic colorectal cancer: a retrospective consortium analysis. Lancet Oncol. 11, 753–762 (2010)

    CAS  Article  PubMed  Google Scholar 

  11. Diehl, F. et al. Circulating mutant DNA to assess tumor dynamics. Nature Med. 14, 985–990 (2008)

    CAS  Article  ADS  PubMed  Google Scholar 

  12. Di Nicolantonio, F. et al. Replacement of normal with mutant alleles in the genome of normal human cells unveils mutation-specific drug responses. Proc. Natl Acad. Sci. USA 105, 20864–20869 (2008)

    CAS  Article  ADS  PubMed  PubMed Central  Google Scholar 

  13. Bardelli, A. & Siena, S. Molecular mechanisms of resistance to cetuximab and panitumumab in colorectal cancer. J. Clin. Oncol. 28, 1254–1261 (2010)

    CAS  Article  PubMed  Google Scholar 

  14. Van Cutsem, E. et al. Cetuximab and chemotherapy as initial treatment for metastatic colorectal cancer. N. Engl. J. Med. 360, 1408–1417 (2009)

    CAS  Article  PubMed  Google Scholar 

  15. Amado, R. G. et al. Wild-type KRAS is required for panitumumab efficacy in patients with metastatic colorectal cancer. J. Clin. Oncol. 26, 1626–1634 (2008)

    CAS  Article  PubMed  Google Scholar 

  16. Janne, P. A. Challenges of detecting EGFR T790M in gefitinib/erlotinib-resistant tumours. Lung Cancer 60, (suppl. 2)S3–S9 (2008)

    Article  PubMed  Google Scholar 

  17. Engelman, J. A. et al. Allelic dilution obscures detection of a biologically significant resistance mutation in EGFR-amplified lung cancer. J. Clin. Invest. 116, 2695–2706 (2006)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  18. Arcila, M. E. et al. Rebiopsy of lung cancer patients with acquired resistance to EGFR inhibitors and enhanced detection of the T790M mutation using a locked nucleic acid-based assay. Clin. Cancer Res. 17, 1169–1180 (2011)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. Molinari, F. et al. Increased detection sensitivity for KRAS mutations enhances the prediction of anti-EGFR monoclonal antibody resistance in metastatic colorectal cancer. Clin. Cancer Res. 17, 4901–4914 (2011)

    CAS  Article  PubMed  Google Scholar 

  20. Whitehead, R. H., Macrae, F. A., St John, D. J. & Ma, J. A colon cancer cell line (LIM1215) derived from a patient with inherited nonpolyposis colorectal cancer. J. Natl. Cancer Inst. 74, 759–765 (1985)

    CAS  PubMed  Google Scholar 

  21. Smith, G. et al. Activating K-Ras mutations outwith ‘hotspot’ codons in sporadic colorectal tumours - implications for personalised cancer medicine. Br. J. Cancer 102, 693–703 (2010)

    CAS  Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We are particularly indebted to S. Lamba for generating the KRAS(G12R) knock-in in Lim1215 cells. We thank C. Cancelliere and S. Destefanis for technical assistance. We thank S. Arena, M. Russo and D. Zecchin for critically reading the manuscript. We also thank A. Heguy, A. Viale, N. Socci and M. Pirun for assistance with analysis of next generation sequencing data. This work was supported by European Union Seventh Framework Programme, grant 259015 COLTHERES (A.B. and S.S.); Associazione Italiana per la Ricerca sul Cancro (AIRC) 2010 Special Program Molecular Clinical Oncology 5 × 1000, project 9970 (A.B. and S.S.); Regione Piemonte (A.B. and F.D.N.); Fondazione Piemontese per la Ricerca sul Cancro (FPRC) Intramural Grant, 5xmille 2008, ONLUS (A.B. and F.D.N.); AIRC MFAG 11349 (F.D.N.); Oncologia Ca’ Granda ONLUS (OCGO) (S.S.); Mr William H. Goodwin and Mrs Alice Goodwin and the Commonwealth Foundation for Cancer Research; the Experimental Therapeutics Center of Memorial Sloan-Kettering Cancer Center (D.S.); the Society of MSKCC (M.W.); the National Institutes of Health (D.S.); the Beene Foundation (D.S.) and Regione Lombardia and Ministerio Salute grant ‘Gene Mutation Monitoring in mCRC’ (S.S.).

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A.B., D.S., S.S. and F.D.N. planned the project and supervised all research. A.B., D.S. and F.D.N. wrote the manuscript. S.M., R.Y., S.H., E.S., M.W. and F.D.N. designed the experiments. A.B. conceived the molecular analysis of plasma samples. S.M., R.Y., S.H., E.S., M.J., D.L., E.V., R.S., M.B., G.S., C.-T.C., S.V., M.G. and V.B. performed the experiments. C.Z., A.S.-B., M.G. and E.M. analysed data. K.B., A.C. and E.V. provided samples for analysis. S.S., D.S. and A.B. devised dual biopsy clinical protocols for EGFR mAb resistant mCRC.

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Correspondence to David Solit or Alberto Bardelli.

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The authors declare no competing financial interests.

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Misale, S., Yaeger, R., Hobor, S. et al. Emergence of KRAS mutations and acquired resistance to anti-EGFR therapy in colorectal cancer. Nature 486, 532–536 (2012). https://doi.org/10.1038/nature11156

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