Pilot trial of combined BRAF and EGFR inhibition in BRAF-mutant metastatic colorectal cancer patients

Abstract

Purpose: BRAF-mutant metastatic colorectal cancer (mCRC) forms an aggressive subset of colorectal cancer with minimal response to selective RAF inhibitors. Preclinical data show that reactivation of EGFR signaling occurs in colorectal tumor cells treated with RAF inhibitors and that the addition of an EGFR inhibitor enhances antitumor activity. These data suggest that combined therapy with RAF and EGFR inhibitors could be an effective strategy for treating BRAF V600E mCRC.

Experimental design: We undertook a pilot trial to assess the response rate and safety of the BRAF inhibitor vemurafenib combined with anti-EGFR antibody panitumumab in patients with BRAF-mutant mCRC. Patients received standard approved doses of panitumumab and vemurafenib.

Results: Fifteen patients were treated. Performance status was Eastern Cooperative Oncology Group (ECOG) 0 in 4 patients (27%) and ECOG 1 in 11 patients (73%). All patients had progressed through at least one standard treatment regimen, and 8 (53%) had received previous fluoropyrimidine, oxaliplatin, and irinotecan chemotherapy. Treatment was well tolerated, with less cutaneous toxicity than would be expected with either agent, and no cases of keratoacanthomas/squamous cell carcinomas. Tumor regressions were seen in 10 of 12 evaluable patients with partial responses in 2 patients (100% and 64% regression lasting 40 and 24 weeks, respectively), and stable disease lasting over 6 months in 2 patients.

Conclusions: Combined RAF and EGFR inhibition is well tolerated, with less cutaneous toxicity than would be expected with either agent, and results in modest clinical activity in this highly aggressive and chemoresistant subset of CRC.

Figure 1

Representative photographs of dermatologic adverse events showing (A) acneiform rash, (B) dry skin, and (C) cymotrichous.

Figure 2

Representative sections from IHC analysis of (A) phosphorylated ERK and (B) cyclin D1 expression. Samples collected before vemurafenib treatment, after 1 week of panitumumab therapy, are on the top row, and samples collected after two weeks of combined panitumumab and vemurafenib treatment are on the bottom row.

Figure 3

(A) Waterfall plot showing best response radiographic response to treatment. One patient, indicated with asterix, withdrew from the study after 8 weeks of treatment to pursue hepatectomy, and one patient, indicated with double asterix, had to stop treatment after 8 weeks for grade 4 hepatotoxicity. (B) Plot showing duration of treatment.

Figure 4

Kaplan-Meier curves showing (A) progression-free survival and (B) overall survival with panitumumab and vemurafenib combination therapy.