Introduction: The randomized phase II OPUS study demonstrated that the addition of cetuximab to FOLFOX4 significantly improved response and progression-free survival in the first-line treatment of patients with KRAS codon 12/13 (hereinafter, exon 2) wild-type metastatic colorectal cancer (mCRC). Patients with KRAS exon 2 tumor mutations showed no such cetuximab benefit, with worse outcome in patients in the FOLFOX4 plus cetuximab arm compared with FOLFOX4 alone arm.Methods: Available KRAS exon 2 wild-type tumors from OPUS study patients were screened for 26 mutations (new RAS) in 4 additional KRAS codons (exons 3 and 4) and 6 NRAS codons (exons 2, 3 and 4) using BEAMing technology, an approach based on polymerase chain reaction (PCR) amplification of single target DNA molecules on individual magnetic beads within an emulsion. Bead-associated PCR products from tumor DNA samples were subsequently typed for the presence of mutant or wild-type sequences using specific fluorescent probes and flow cytometry. Where mutations were detected, this approach allowed for the determination of the ratio of mutant to wild-type RAS DNA molecules in the original tumor DNA sample. As the predictive value of low prevalence RAS mutations in tumors in which the overwhelming majority of cells were wild-type was not clear, and in line with current clinical practice in relation to KRAS exon 2 screening, a 5% diagnostic cutoff was selected for analysis. Treatment outcome was subsequently assessed according to RAS mutation status (RAS wild-type, new RAS mutant and RAS mutant [KRAS exon 2 or new RAS]).Results: Mutation status was evaluable in 118/179 (66%) patients with KRAS exon 2 wild-type tumors. New RAS mutations were detected in 31/118 (26%) patients. In those with RAS wild-type tumors, response was significantly improved by the addition of cetuximab to FOLFOX4 (Table). The treatment effect for those with new RAS tumor mutations could not be definitively assessed due to low patient numbers. In patients with any tumor RAS mutation (KRAS exon 2 or new RAS), no benefit from the addition of cetuximab to FOLFOX4 was seen, with a clear trend for worse outcome.Conclusion: In the first-line setting, patients with mCRC harboring any activating RAS mutation are unlikely to benefit from the addition of cetuximab to FOLFOX4. Restricting the administration of FOLFOX4 plus cetuximab to patients with tumors wild-type at all such loci might help further tailoring of therapy to maximize patient benefit. Introduction: The randomized phase II OPUS study demonstrated that the addition of cetuximab to FOLFOX4 significantly improved response and progression-free survival in the first-line treatment of patients with KRAS codon 12/13 (hereinafter, exon 2) wild-type metastatic colorectal cancer (mCRC). Patients with KRAS exon 2 tumor mutations showed no such cetuximab benefit, with worse outcome in patients in the FOLFOX4 plus cetuximab arm compared with FOLFOX4 alone arm. Methods: Available KRAS exon 2 wild-type tumors from OPUS study patients were screened for 26 mutations (new RAS) in 4 additional KRAS codons (exons 3 and 4) and 6 NRAS codons (exons 2, 3 and 4) using BEAMing technology, an approach based on polymerase chain reaction (PCR) amplification of single target DNA molecules on individual magnetic beads within an emulsion. Bead-associated PCR products from tumor DNA samples were subsequently typed for the presence of mutant or wild-type sequences using specific fluorescent probes and flow cytometry. Where mutations were detected, this approach allowed for the determination of the ratio of mutant to wild-type RAS DNA molecules in the original tumor DNA sample. As the predictive value of low prevalence RAS mutations in tumors in which the overwhelming majority of cells were wild-type was not clear, and in line with current clinical practice in relation to KRAS exon 2 screening, a 5% diagnostic cutoff was selected for analysis. Treatment outcome was subsequently assessed according to RAS mutation status (RAS wild-type, new RAS mutant and RAS mutant [KRAS exon 2 or new RAS]). Results: Mutation status was evaluable in 118/179 (66%) patients with KRAS exon 2 wild-type tumors. New RAS mutations were detected in 31/118 (26%) patients. In those with RAS wild-type tumors, response was significantly improved by the addition of cetuximab to FOLFOX4 (Table). The treatment effect for those with new RAS tumor mutations could not be definitively assessed due to low patient numbers. In patients with any tumor RAS mutation (KRAS exon 2 or new RAS), no benefit from the addition of cetuximab to FOLFOX4 was seen, with a clear trend for worse outcome. Conclusion: In the first-line setting, patients with mCRC harboring any activating RAS mutation are unlikely to benefit from the addition of cetuximab to FOLFOX4. Restricting the administration of FOLFOX4 plus cetuximab to patients with tumors wild-type at all such loci might help further tailoring of therapy to maximize patient benefit.
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