In this phase Ib study, the activity of T-DM1 plus N was assessed in patients (pt) previously treated with trastuzumab, pertuzumab, and a taxane (H+P+T). Several mechanisms of resistance have been hypothesized in pts progressing following H+P+T, including acquired alterations in the ERBB (HER) family proteins, reactivation of bypass or parallel pathways, or selective elimination of HER2-overexpressing clones. Loss of HER2 amp has been shown to occur in 25-35% of pts with residual tumor after neoadjuvant therapy or in metastatic disease after initial therapy with chemotherapy and HER2-targeted agents. Data on concordance of HER2 status between tissue and blood is limited. In 7 pts with cfDNA HER2 amp, concomitant tissue was concordant in all 7 pairs and response to anti-HER2 therapy occurred in 6. In our study we have retrospectively analyzed cfDNA in blood samples obtained at study entry.


Eligible pts had prior H+P+T as neoadjuvant therapy, or 1st-line metastatic disease, measurable disease, ECOG PS ≤2, and adequate hematologic, renal, and liver function. Pts with stable brain metastases were eligible. Treatment consisted of T-DM1 3.6 mg/kg iv q3wk and N 120, 160, 200, or 240 mg/d using a 3+3 dose-escalation design. HER2+ was determined at initial diagnosis; tissue confirmation at study entry (after H+P+T progression) was not required. Blood was collected in for pharmacokinetic analyses of N peak and trough, and for cfDNA using the Guardant360 assay, which is a 73-gene next-generation cfDNA-sequencing panel that detects SNVs, indels, CNAs, and fusions, utilizing Digital Sequencing and custom bioinformatics methods for error correction. The cut-off for HER2 amp was a copy number of ≥2.0 established by Guardant based on training-set data.


There were 27 H+P+T-resistant pts enrolled and all pts had a blood sample analyzed for HER2 amp. Eighteen pts were evaluable for efficacy at 6 wks and 11 pts at 12 wks. Dose-limiting toxicity occurred in 6 pts during cycle 1, 1 pt was withdrawn for non-compliance, and 2 pts were withdrawn for disease complications. The recommended phase II dose of N was determined to be 160 mg/d. Responses were seen at all dose-levels of N. Pharmacokinetic analyses did not show a clear relationship with either peak or trough and dose-level. Ten pts showed HER2 amp in blood and 17 were non-amp. Of 18 pts evaluable after 2 cycles (6 wks), 12 pts had an objective response (7 amp; 5 non-amp) and 5 had progressive disease (1 amp; 4 non-amp). At 12 wks, there were 3 CRs and 8 PRs (7 amp; 4 non-amp). All CRs were in amp pts and lasted 364, 510, and 859+ days.


HER2 amp as determined by cfDNA was found in 10 of 27 pts. The deeper and more prolonged (>12 wk) responses occurred in 7 of 10 amp HER2 pts v 4 of 17 non-amp HER2 pts (p=0.04). In our ongoing phase II study of this regimen concomitant tissue and blood will be analyzed to better understand potential benefit or lack of benefit, with continued use of anti-HER2 therapy after progression on anti-HER2 therapies.

Support: Puma Biotechnology, Inc.

Citation Format: Abraham J, Puhalla SL, Sikov WM, Montero AJ, Salkeni MA, Razaq WA, Beumer JH, Kiesel BF, Buyse ME, Adamson LM, Srinivasan A, Pogue-Geile KL, Allegra CJ, Nagy RJ, Jacobs SA. Analysis of ERBB2 (HER2) amplification by ctDNA in a phase Ib dose-escalation trial evaluating trastuzumab emtansine (T-DM1) with neratinib in women with metastatic disease with initially diagnosed HER2+ breast cancer: NSABP FB-10 [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD3-04.