Targeting EGFR is a validated approach in the treatment of squamous-cell cancers (SCCs), although there are no established biomarkers for predicting response. We have identified a synonymous mutation in EGFR, c.2361G>A (encoding p.Gln787Gln), in two patients with head and neck SCC (HNSCC) who were exceptional responders to gefitinib, and we showed in patient-derived cultures that the A/A genotype was associated with greater sensitivity to tyrosine kinase inhibitors (TKIs) as compared to the G/A and G/G genotypes. Remarkably, single-copy G>A nucleotide editing in isogenic models conferred a 70-fold increase in sensitivity due to decreased stability of the EGFR-AS1 long noncoding RNA (lncRNA). In the appropriate context, sensitivity could be recapitulated through EGFR-AS1 knockdown in vitro and in vivo, whereas overexpression was sufficient to induce resistance to TKIs. Reduced EGFR-AS1 levels shifted splicing toward EGFR isoform D, leading to ligand-mediated pathway activation. In co-clinical trials involving patients and patient-derived xenograft (PDX) models, tumor shrinkage was most pronounced in the context of the A/A genotype for EGFR-Q787Q, low expression of EGFR-AS1 and high expression of EGFR isoform D. Our study reveals how a 'silent' mutation influences the levels of a lncRNA, resulting in noncanonical EGFR addiction, and delineates a new predictive biomarker suite for response to EGFR TKIs.
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We would like to extend our gratitude to all patients and families involved in this study. We would also like to thank C. Chuan Young Ng of the National Cancer Centre Singapore Genomics Service for technical support with the NanoString assays. D.S.W.T. and N.G.I. are both supported by National Medical Research Council (NMRC) (Singapore) clinician–scientist awards (D.S.W.T.: NMRC/CSA/007/2016; N.G.I.: NMRC/CSA/042/2012, NMRC/CSA-INV/011/2016). Further support for this project was obtained from NMRC (grant no. NMRC/1304/2011, NMRC/CIRG/1434/2015), National Cancer Centre Research Funds and a Singhealth Foundation Grant (SHF/FG496P/2012).
The authors declare no competing financial interests.
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Tan, D., Chong, F., Leong, H. et al. Long noncoding RNA EGFR-AS1 mediates epidermal growth factor receptor addiction and modulates treatment response in squamous cell carcinoma. Nat Med 23, 1167–1175 (2017). https://doi.org/10.1038/nm.4401
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