title: Clonal Evolutionary Analysis during HER2 Blockade in HER2-Positive Inflammatory Breast Cancer: A Phase II Open-Label Clinical Trial of Afatinib +/- Vinorelbine.
abstract: BACKGROUND
  Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer associated with HER2 amplification, with high risk of metastasis and an estimated median survival of 2.9 y. We performed an open-label, single-arm phase II clinical trial (ClinicalTrials.gov NCT01325428) to investigate the efficacy and safety of afatinib, an irreversible ErbB family inhibitor, alone and in combination with vinorelbine in patients with HER2-positive IBC. This trial included prospectively planned exome analysis before and after afatinib monotherapy.
  
  
  RESULTS
  HER2-positive IBC patients received afatinib 40 mg daily until progression, and thereafter afatinib 40 mg daily and intravenous vinorelbine 25 mg/m2 weekly. The primary endpoint was clinical benefit; secondary endpoints were objective response (OR), duration of OR, and progression-free survival (PFS). Of 26 patients treated with afatinib monotherapy, clinical benefit was achieved in 9 patients (35%), 0 of 7 trastuzumab-treated patients and 9 of 19 trastuzumab-naïve patients. Following disease progression, 10 patients received afatinib plus vinorelbine, and clinical benefit was achieved in 2 of 4 trastuzumab-treated and 0 of 6 trastuzumab-naïve patients. All patients had treatment-related adverse events (AEs). Whole-exome sequencing of tumour biopsies taken before treatment and following disease progression on afatinib monotherapy was performed to assess the mutational landscape of IBC and evolutionary trajectories during therapy. Compared to a cohort of The Cancer Genome Atlas (TCGA) patients with HER2-positive non-IBC, HER2-positive IBC patients had significantly higher mutational and neoantigenic burden, more frequent gain-of-function TP53 mutations and a recurrent 11q13.5 amplification overlapping PAK1. Planned exploratory analysis revealed that trastuzumab-naïve patients with tumours harbouring somatic activation of PI3K/Akt signalling had significantly shorter PFS compared to those without (p = 0.03). High genomic concordance between biopsies taken before and following afatinib resistance was observed with stable clonal structures in non-responding tumours, and evidence of branched evolution in 8 of 9 tumours analysed. Recruitment to the trial was terminated early following the LUX-Breast 1 trial, which showed that afatinib combined with vinorelbine had similar PFS and OR rates to trastuzumab plus vinorelbine but shorter overall survival (OS), and was less tolerable. The main limitations of this study are that the results should be interpreted with caution given the relatively small patient cohort and the potential for tumour sampling bias between pre- and post-treatment tumour biopsies.
  
  
  CONCLUSIONS
  Afatinib, with or without vinorelbine, showed activity in trastuzumab-naïve HER2-positive IBC patients in a planned subgroup analysis. HER2-positive IBC is characterized by frequent TP53 gain-of-function mutations and a high mutational burden. The high mutational load associated with HER2-positive IBC suggests a potential role for checkpoint inhibitor therapy in this disease.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01325428.
authors.affiliation: Translational Cancer Therapeutics Laboratory, UCL Cancer Institute, London, United Kingdom.|Bill Lyons Informatics Centre, UCL Cancer Institute, London, United Kingdom.
authors.forename: Gerald
authors.identifier: http://orcid.org/0000-0002-3832-6466
authors.initials: G
authors.lastname: Goh
authors.affiliation: Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany.
authors.forename: Ramona
authors.initials: R
authors.lastname: Schmid
authors.affiliation: Boehringer Ingelheim Ltd, Bracknell, United Kingdom.
authors.forename: Kelly
authors.identifier: http://orcid.org/0000-0001-9523-7868
authors.initials: K
authors.lastname: Guiver
authors.affiliation: National Cancer Institute, Bangkok, Thailand.
authors.forename: Wichit
authors.initials: W
authors.lastname: Arpornwirat
authors.affiliation: Maharaj Nakhon Chiang Mai Hospital, Chiang Mai, Thailand.
authors.forename: Imjai
authors.initials: I
authors.lastname: Chitapanarux
authors.affiliation: Monash Medical Centre, Melbourne, Australia.
authors.forename: Vinod
authors.initials: V
authors.lastname: Ganju
authors.affiliation: Seoul National University Hospital, Seoul, South Korea.
authors.forename: Seock-Ah
authors.initials: SA
authors.lastname: Im
authors.affiliation: Asan Medical Center, University of Ulsan College of Medicine, Ulsan, South Korea.
authors.forename: Sung-Bae
authors.initials: SB
authors.lastname: Kim
authors.affiliation: Prince of Songkla University, Songkhla, Thailand.
authors.forename: Arunee
authors.initials: A
authors.lastname: Dechaphunkul
authors.affiliation: Rajavithi Hospital, Bangkok, Thailand.
authors.forename: Jedzada
authors.initials: J
authors.lastname: Maneechavakajorn
authors.affiliation: Duke University Medical Center, Durham, North Carolina, United States of America.
authors.forename: Neil
authors.initials: N
authors.lastname: Spector
authors.affiliation: Queen Mary Hospital, Hong Kong.
authors.forename: Thomas
authors.initials: T
authors.lastname: Yau
authors.affiliation: Abderrahman Mami Hospital, Ariana, Tunisia.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Afrit
authors.affiliation: Fahat Hached Hospital, Sousse, Tunisia.
authors.forename: Slim Ben
authors.initials: SB
authors.lastname: Ahmed
authors.affiliation: Royal Marsden Hospital Breast Unit, London, United Kingdom.
authors.forename: Stephen R
authors.initials: SR
authors.lastname: Johnston
authors.affiliation: Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany.
authors.forename: Neil
authors.initials: N
authors.lastname: Gibson
authors.affiliation: Boehringer Ingelheim Pharma GmbH & Co.KG, Biberach, Germany.
authors.forename: Martina
authors.identifier: http://orcid.org/0000-0001-5588-8332
authors.initials: M
authors.lastname: Uttenreuther-Fischer
authors.affiliation: Bill Lyons Informatics Centre, UCL Cancer Institute, London, United Kingdom.
authors.forename: Javier
authors.initials: J
authors.lastname: Herrero
authors.affiliation: Translational Cancer Therapeutics Laboratory, UCL Cancer Institute, London, United Kingdom.|The Francis Crick Institute, London, United Kingdom.
authors.forename: Charles
authors.initials: C
authors.lastname: Swanton
mesh_terms: D000293:Adolescent; D000328:Adult; D000077716:Afatinib; D000368:Aged; D000970:Antineoplastic Agents / Q000009:adverse effects / Q000627:therapeutic use*; D000972:Antineoplastic Agents, Phytogenic / Q000009:adverse effects / Q000627:therapeutic use; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects / Q000627:therapeutic use*; D015331:Cohort Studies; D005260:Female; D006801:Humans; D058922:Inflammatory Breast Neoplasms; D008875:Middle Aged; D011799:Quinazolines / Q000009:adverse effects / Q000627:therapeutic use*; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000037:antagonists & inhibitors*; D014747:Vinblastine / Q000009:adverse effects / Q000031:analogs & derivatives* / Q000627:therapeutic use; D000077235:Vinorelbine; D055815:Young Adult
chemical_list: D000077716:Afatinib; D000970:Antineoplastic Agents; D000972:Antineoplastic Agents, Phytogenic; D011799:Quinazolines; D018719:Erb-b2 Receptor Tyrosine Kinases; D014747:Vinblastine; D000077235:Vinorelbine; C508053:ERBB2 protein, human