Abstract
Duligotuzumab, a novel dual-action humanized IgG1 antibody that blocks ligand binding to epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 3 (HER3), inhibits signaling from all ligand-dependent HER dimers, and can elicit antibody-dependent cell-mediated cytotoxicity. High tumor-expression of neuregulin 1 (NRG1), a ligand to HER3, may enhance sensitivity to duligotuzumab. This multicenter, open-label, randomized phase II study (MEHGAN) evaluated drug efficacy in patients with recurrent/metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN) progressive on/after chemotherapy and among patients with NRG1-high tumors. Patients received duligotuzumab (1100 mg IV, q2w) or cetuximab (400 mg/m2 load, 250 mg/m2 IV, q1w) until progression or intolerable toxicity. Tumor samples were assayed for biomarkers [NRG1, ERBB3, and human papillomavirus (HPV) status]. Patients (N = 121) were randomized (duligotuzumab:cetuximab; 59:62), median age 62 years; ECOG 0-2. Both arms (duligotuzumab vs. cetuximab, respectively) showed comparable progression-free survival [4.2 vs. 4.0 months; HR: 1.23 (90% confidence interval (CI): 0.89-1.70)], overall survival [7.2 vs. 8.7 months; HR 1.15 (90% CI: 0.81-1.63)], and objective response rate (12 vs. 14.5%), with no difference between patients with NRG1-high tumors or ERBB3-low tumors. Responses in both arms were confined to HPV-negative patients. Grade ≥3 adverse events (AEs) (duligotuzumab vs. cetuximab, respectively) included infections (22 vs. 11.5%) and GI disorders (17 vs. 7%), contributing to higher rates of serious AEs (41 vs. 29.5%). Metabolic disorders were less frequent with duligotuzumab (10 vs. 16%); any grade rash-related events were less with duligotuzumab (49 vs. 67%). While several lines of preclinical evidence had supported the premise that the blockade of HER3 in addition to that of EGFR may improve outcomes for patients with R/M SCCHN overall or specifically in those patients whose tumors express high levels of NRG1, this study provided definitive clinical evidence refuting this hypothesis. Duligotuzumab did not improve patient outcomes in comparison to cetuximab despite frequent expression of NRG1. These data indicate that inhibition of EGFR alone is sufficient to block EGFR-HER3 signaling, suggesting that HER2 plays a minimal role in this disease. Extensive biomarker analyses further show that HPV-negative SCCHN but not HPV-positive SCCHN are most likely to respond to EGFR blockage by cetuximab or duligotuzumab.
Highlights
Multiple members of the HER family receptor tyrosine kinases, including epidermal growth factor receptor (EGFR), HER1, and HER2, are established therapeutic targets in several epithelial malignancies [1]
Factors thought to contribute to cetuximab resistance in SCCHN patients include upregulation of ligands for EGFR and human epidermal growth factor receptor 3 (HER3) [7, 8], heterodimerization of EGFR and HER2 with HER3 [9], overexpression of HER2 and HER3 [10], and overexpression and aberrant nuclear localization of EGFR [11]
Key baseline characteristics included the stratification factors, ECOG, and time to progressive disease (PD), since most recent platinum treatment were well-balanced overall (Table 1) with the exception of fewer human papillomavirus (HPV)-positive patients and fewer patients with locoregional recurrence only who enrolled on the experimental duligotuzumab arm, as compared to the cetuximab arm
Summary
Multiple members of the HER family receptor tyrosine kinases, including epidermal growth factor receptor (EGFR), HER1, and HER2, are established therapeutic targets in several epithelial malignancies [1]. Many SCCHN patients do not respond to cetuximab therapy, and for those who do, they commonly manifest acquired resistance following prolonged exposure to the drug. A subset of SCCHN cell lines are resistant to anti-EGFR tyrosine kinase inhibitor (TKI) treatment and do not overexpress HER2 but are sensitive to combined anti-EGFR/anti-HER2 TKI inhibition [12]. Many of these cell lines were found to have high expression of heregulin (HRG), the ligand binding to HER3, and activation of HER3 signaling. High tumor-expression of neuregulin 1 (NRG1), a ligand to HER3, may enhance sensitivity to duligotuzumab
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