Activating mutations of the epidermal growth factor receptor (EGFR) gene in non-small cell lung cancer predicts a significantly higher clinical response rate to tyrosine kinase inhibitors targeting EGFR, and it is currently recommended that patients under consideration for EGFR TKI as first-line therapy be tested for such mutations to determine the appropriateness of treatment. For lung cancer patients who present with advanced stage disease where surgical treatment is not indicated, cytology specimens obtained through bronchoscopy, drainage of body fluid, or fine-needle aspiration are the only means to obtain tumor cells for tissue diagnosis and EGFR gene mutation testing. We reviewed the experience of 1,410 consecutive EGFR mutation testing requests at a single institution in Hong Kong that comprised 269 cytology specimens and 1,141 surgical specimens. The material inadequacy issue in cytology specimens may be overcome by tumor cell enrichment strategies and employment of mutation detection techniques with increased analytical sensitivity. The use of cytology specimens to test for predictive molecular cancer biomarkers is without a doubt expected to increase, and cytopathologists should be closely engaged with the clinicians in the therapeutic process and become acquainted with new technology in order to directly participate in personalized oncology care.

Keywords:
Epidermal growth factor, Mutation, Non-small cell lung cancer
1.
Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, Brannigan BW, Harris PL, Haserlat SM, Supko JG, Haluska FG, Louis DN, Christiani DC, Settleman J, Haber DA: Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med 2004;350:2129–2139.
2.
Paez JG, Janne PA, Lee JC, Tracy S, Greulich H, Gabriel S, Herman P, Kaye FJ, Lindeman N, Boggon TJ, Naoki K, Sasaki H, Fujii Y, Eck MJ, Sellers WR, Johnson BE, Meyerson M: EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science 2004;304:1497–1500.
3.
Pao W, Miller V, Zakowski M, Doherty J, Politi K, Sarkaria I, Singh B, Heelan R, Rusch V, Fulton L, Mardis E, Kupfer D, Wilson R, Kris M, Varmus H: EGF receptor gene mutations are common in lung cancers from ‘never smokers’ and are associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci USA 2004;101:13306–13311.
4.
Mitsudomi T, Kosaka T, Yatabe Y: Biological and clinical implications of EGFR mutations in lung cancer. Int J Clin Oncol 2006;11:190–198.
5.
Politi K, Zakowski MF, Fan PD, Schonfeld EA, Pao W, Varmus HE: Lung adenocarcinomas induced in mice by mutant EGF receptors found in human lung cancers respond to a tyrosine kinase inhibitor or to down-regulation of the receptors. Genes Dev 2006;20:1496–1510.
6.
Weinstein IB, Joe AK: Mechanisms of disease: oncogene addiction – a rationale for molecular targeting in cancer therapy. Nat Clin Pract Oncol 2006;3:448–457.
7.
Riely GJ, Pao W, Pham D, Li AR, Rizvi N, Venkatraman ES, Zakowski MF, Kris MG, Ladanyi M, Miller VA: Clinical course of patients with non-small cell lung cancer and epidermal growth factor receptor exon 19 and exon 21 mutations treated with gefitinib or erlotinib. Clin Cancer Res 2006;12:839–844.
8.
Keedy VL, Temin S, Somerfield MR, Beasley MB, Johnson DH, McShane LM, Milton DT, Strawn JR, Wakelee HA, Giaccone G: American Society of Clinical Oncology provisional clinical opinion: epidermal growth factor receptor (EGFR) mutation testing for patients with advanced non-small-cell lung cancer considering first-line EGFR tyrosine kinase inhibitor therapy. J Clin Oncol 2011;29:2121–2127.
9.
Pirker R, Herth FJ, Kerr KM, Filipits M, Taron M, Gandara D, Hirsch FR, Grunenwald D, Popper H, Smit E, Dietel M, Marchetti A, Manegold C, Schirmacher P, Thomas M, Rosell R, Cappuzzo F, Stahel R: Consensus for EGFR mutation testing in non-small cell lung cancer: results from a European workshop. J Thorac Oncol 2010;5:1706–1713.
10.
da Cunha SG, Saieg MA, Geddie W, Leighl N: EGFR gene status in cytological samples of nonsmall cell lung carcinoma: controversies and opportunities. Cancer Cytopathol 2011;119:80–91.
11.
Garcia-Olive I, Monso E, Andreo F, Sanz-Santos J, Taron M, Molina-Vila MA, Llatjos M, Castella E, Moran T, Bertran-Alamillo J, Mayo-de-Las-Casas C, Queralt C, Rosell R: Endobronchial ultrasound-guided transbronchial needle aspiration for identifying EGFR mutations. Eur Respir J 2010;35:391–395.
12.
Molina-Vila MA, Bertran-Alamillo J, Reguart N, Taron M, Castella E, Llatjos M, Costa C, Mayo C, Pradas A, Queralt C, Botia M, Perez-Cano M, Carrasco E, Tomas M, Mate JL, Moran T, Rosell R: A sensitive method for detecting EGFR mutations in non-small cell lung cancer samples with few tumor cells. J Thorac Oncol 2008;3:1224–1235.
13.
Savic S, Tapia C, Grilli B, Rufle A, Bihl MP, de Vito BA, Herzog M, Terracciano L, Baty F, Bubendorf L: Comprehensive epidermal growth factor receptor gene analysis from cytological specimens of non-small-cell lung cancers. Br J Cancer 2008;98:154–160.
14.
Smouse JH, Cibas ES, Janne PA, Joshi VA, Zou KH, Lindeman NI: EGFR mutations are detected comparably in cytologic and surgical pathology specimens of nonsmall cell lung cancer. Cancer 2009;117:67–72.
15.
Horiike A, Kimura H, Nishio K, Ohyanagi F, Satoh Y, Okumura S, Ishikawa Y, Nakagawa K, Horai T, Nishio M: Detection of epidermal growth factor receptor mutation in transbronchial needle aspirates of non-small cell lung cancer. Chest 2007;131:1628–1634.
16.
Travis WD, Rekhtman N, Riley GJ, Geisinger KR, Asamura H, Brambilla E, Garg K, Hirsch FR, Noguchi M, Powell CA, Rusch VW, Scagliotti G, Yatabe Y: Pathologic diagnosis of advanced lung cancer based on small biopsies and cytology: a paradigm shift. J Thorac Oncol 2010;5:411–414.
17.
Malapelle U, Bellevicine C, Zeppa P, Palombini L, Troncone G: Cytology-based gene mutation tests to predict response to anti-epidermal growth factor receptor therapy: a review. Diagn Cytopathol 2011;39:703–710.
18.
Ma ES, Wong CL, Law FB, Chan WK, Siu D: Detection of KRAS mutations in colorectal cancer by high-resolution melting analysis. J Clin Pathol 2009;62:886–891.
19.
Nomoto K, Tsuta K, Takano T, Fukui T, Fukui T, Yokozawa K, Sakamoto H, Yoshida T, Maeshima AM, Shibata T, Furuta K, Ohe Y, Matsuno Y: Detection of EGFR mutations in archived cytologic specimens of non-small cell lung cancer using high-resolution melting analysis. Am J Clin Pathol 2006;126:608–615.
20.
Smith GD, Chadwick BE, Willmore-Payne C, Bentz JS: Detection of epidermal growth factor receptor gene mutations in cytology specimens from patients with non-small cell lung cancer utilising high-resolution melting amplicon analysis. J Clin Pathol 2008;61:487–493.
21.
Ma ES, Wong CL, Siu D, Chan WK: Amplification, mutation and loss of heterozygosity of the EGFR gene in metastatic lung cancer. Int J Cancer 2007;120:1828–1831.
22.
Ma ES, Cheng PN, Wong CL, Yim AP: Synchronous primary lung cancer and epidermal growth factor receptor mutation. Ann Thorac Surg 2010;90:e38–e39.
23.
Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, Saijo N, Sunpaweravong P, Han B, Margono B, Ichinose Y, Nishiwaki Y, Ohe Y, Yang JJ, Chewaskulyong B, Jiang H, Duffield EL, Watkins CL, Armour AA, Fukuoka M: Gefitinib or carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 2009;361:947–957.
24.
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, 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;362:2380–2388.
25.
Mitsudomi T, Morita S, Yatabe Y, Negoro S, Okamoto I, Tsurutani 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: Gefitinib 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;11:121–128.
26.
Fassina A, Gazziero A, Zardo D, Corradin M, Aldighieri E, Rossi GP: Detection of EGFR and KRAS mutations on trans-thoracic needle aspiration of lung nodules by high resolution melting analysis. J Clin Pathol 2009;62:1096–1102.
27.
van Eijk R, Licht J, Schrumpf M, Talebian YM, Ruano D, Forte GI, Nederlof PM, Veselic M, Rabe KF, Annema JT, Smit V, Morreau H, van Wezel T: Rapid KRAS, EGFR, BRAF and PIK3CA mutation analysis of fine needle aspirates from non-small-cell lung cancer using allele-specific qPCR. PLoS One 2011;6:e17791.
28.
Sequist LV, Waltman BA, as-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;3:75ra26.
29.
Querings S, Altmuller J, Ansen S, Zander T, Seidel D, Gabler F, Peifer M, Markert E, Stemshorn K, Timmermann B, Saal B, Klose S, Ernestus K, Scheffler M, Engel-Riedel W, Stoelben E, Brambilla E, Wolf J, Nurnberg P, Thomas RK: Benchmarking of mutation diagnostics in clinical lung cancer specimens. PLoS One 2011;6:e19601.
30.
Clark DP: Seize the opportunity: underutilization of fine-needle aspiration biopsy to inform targeted cancer therapy decisions. Cancer 2009;117:289–297.
© 2012 S. Karger AG, Basel
2012
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.