title: Triplet therapy with afatinib, cetuximab, and bevacizumab induces deep remission in lung cancer cells harboring EGFR T790M in vivo.
abstract: Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have changed the treatment strategy for EGFR-mutant lung cancers; however, resistance usually occurs due to a secondary mutation, T790M, in EGFR. Combination therapy using afatinib and cetuximab has had good results in lung tumors harboring EGFRT790Mmutations in clinical trials. The effect of bevacizumab, an antivascular endothelial growth factor (VEGF) antibody, combined with EGFR-TKIs has also been investigated. We hypothesized that the dose of afatinib and cetuximab could be reduced by combination with bevacizumab and that the triplet therapy may result in better tumor inhibition with tolerable toxicity. Using a xenograft mouse model with H1975-harboring EGFRL858R+T790Mand RPC-9-harboring EGFR19DEL+T790M, we tested the efficacy of the triplet therapy with a modified dose of afatinib, cetuximab, and bevacizumab, and compared this therapy to single and double therapies. Triplet therapy with afatinib, cetuximab, and bevacizumab induced pathological complete remission in xenograft tumors with H1975 and RPC-9 cells versus tumors treated with single or double therapies. We saw no body weight loss in the mice. The triple therapy induced a significant reduction in CD31-positive vascular endothelial cells and increased cleaved caspase-3-positive cells in the tumors. This suggests that one mechanism underlying the deep remission could be suppression of neovascularization and induction of apoptosis by intensive inhibition of driver oncoproteins and VEGF. These results highlight the potential of afatinib, cetuximab, and bevacizumab to induce deep remission in tumors harboring EGFRT790Mmutations. Therefore, clinical trials of this combination therapy are warranted.
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Kenichiro
authors.initials: K
authors.lastname: Kudo
authors.affiliation: Department of Respiratory Medicine, Okayama University Hospital, Japan.
authors.forename: Kadoaki
authors.initials: K
authors.lastname: Ohashi
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Go
authors.initials: G
authors.lastname: Makimoto
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Hisao
authors.initials: H
authors.lastname: Higo
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Yuka
authors.initials: Y
authors.lastname: Kato
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Hiroe
authors.initials: H
authors.lastname: Kayatani
authors.affiliation: Department of Pharmacy, Okayama University Hospital, Japan.
authors.forename: Yasuko
authors.initials: Y
authors.lastname: Kurata
authors.affiliation: Pharmaceutical Care and Health Sciences, School of Pharmacy, Shujitsu University, Okayama, Japan.
authors.forename: Yoichiro
authors.initials: Y
authors.lastname: Takami
authors.affiliation: Department of Respiratory Medicine, Okayama University Hospital, Japan.
authors.forename: Daisuke
authors.initials: D
authors.lastname: Minami
authors.affiliation: Department of Respiratory Medicine, Okayama University Hospital, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Ninomiya
authors.affiliation: Center for Clinical Oncology, Okayama University Hospital, Japan.
authors.forename: Toshio
authors.initials: T
authors.lastname: Kubo
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Eiki
authors.initials: E
authors.lastname: Ichihara
authors.affiliation: Department of Respiratory Medicine, Okayama University Hospital, Japan.
authors.forename: Akiko
authors.initials: A
authors.lastname: Sato
authors.affiliation: Center for Innovative Clinical Medicine, Okayama University Hospital, Japan.
authors.forename: Katsuyuki
authors.initials: K
authors.lastname: Hotta
authors.affiliation: Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Tadashi
authors.initials: T
authors.lastname: Yoshino
authors.affiliation: Department of Hematology, Oncology and Respiratory Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Japan.
authors.forename: Mitsune
authors.initials: M
authors.lastname: Tanimoto
authors.affiliation: Department of Respiratory Medicine, Okayama University Hospital, Japan.
authors.forename: Katsuyuki
authors.initials: K
authors.lastname: Kiura
mesh_terms: D000230:Adenocarcinoma / Q000188:drug therapy* / Q000235:genetics*; D000077716:Afatinib; D020533:Angiogenesis Inhibitors / Q000627:therapeutic use; D000818:Animals; D000074322:Antineoplastic Agents, Immunological / Q000627:therapeutic use; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017209:Apoptosis; D000068258:Bevacizumab / Q000627:therapeutic use*; D045744:Cell Line, Tumor; D000068818:Cetuximab / Q000627:therapeutic use*; D019008:Drug Resistance, Neoplasm; D066246:ErbB Receptors / Q000037:antagonists & inhibitors / Q000235:genetics*; D005260:Female; D006801:Humans; D008175:Lung Neoplasms / Q000188:drug therapy* / Q000235:genetics*; D051379:Mice; D008819:Mice, Nude; D009154:Mutation; D019408:Platelet Endothelial Cell Adhesion Molecule-1 / Q000032:analysis; D011799:Quinazolines / Q000627:therapeutic use*; D012074:Remission Induction; D023041:Xenograft Model Antitumor Assays
chemical_list: D020533:Angiogenesis Inhibitors; D000074322:Antineoplastic Agents, Immunological; D019408:Platelet Endothelial Cell Adhesion Molecule-1; D011799:Quinazolines; D000068258:Bevacizumab; D000077716:Afatinib; D066246:ErbB Receptors; D000068818:Cetuximab
keywords: EGFR T790M; afatinib; bevacizumab; cetuximab; deep remission