MEETING SUMMARY

Consensus for EGFR Mutation Testing in Non-small Cell

Lung Cancer
Results from a European Workshop
Robert Pirker, MD,* Felix J. F. Herth, MD, PhD, FCCP,† Keith M. Kerr, MD, FRCPath,‡
Martin Filipits, PhD,* Miquel Taron, PhD,§储 David Gandara, MD,¶ Fred R. Hirsch, MD,#
Dominique Grunenwald, MD,** Helmut Popper, MD,†† Egbert Smit, MD, PhD,‡‡
Manfred Dietel, MD,§§ Antonio Marchetti, MD, PhD,储储 Christian Manegold, MD,¶¶
Peter Schirmacher, MD,## Michael Thomas, MD, PhD,† Rafael Rosell, MD, PhD,§储
Federico Cappuzzo, MD,*** and Rolf Stahel, MD†††; on Behalf of the European EGFR Workshop Group

cell lung cancer (NSCLC). Patients harboring these mutations in

Introduction: Activating somatic mutations of the tyrosine kinase
domain of epidermal growth factor receptor (EGFR) have recently
been characterized in a subset of patients with advanced non-small
*Medical University of Vienna, Vienna, Austria; †Thoraxklinik University of
Heidelberg, Heidelberg, Germany; ‡Aberdeen Royal Infirmary, Aberdeen,
United Kingdom; §Catalan Institute of Oncology, Badalona, Spain; 储Pan-
gaea Biotech, USP Institut Universitari Dexeus, Barcelona, Spain; ¶Univer-
sity of California Davis Cancer Center, Sacramento, California; #University
of Colorado Health Sciences Center, Aurora, Colorado; **Hopital Tenon,
University of Paris VI, Paris, France; ††Medical University of Graz, Graz,
Austria; ‡‡Vrije Universiteit Medical Centre, Amsterdam, The Netherlands;
§§Institute of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Ger-
many; 储储Clinical Research Center, Center of Excellence on Aging, Univer-
sity-Foundation, Chiety, Italy; ¶¶Medical Center Mannheim, Heidelberg
University, Mannheim, Germany; ##Institute of Pathology, University Hos-
pital Heidelberg, Heidelberg, Germany; ***Livorno Hospital, Livorno, Italy;
and †††University Hospital Zurich, Zurich, Switzerland.
Disclosure: Robert Pirker, MD, has received speaker’s fees and honorari for
consulting from AstraZeneca, Boehringer Ingelheim, Merck Serono, and
Roche. Keith M. Kerr, MD, FRCPath, has received consulting fees and
honoraria from AstraZeneca and Roche. Martin Filipitis, PhD, has received
speaker’s feed and honoraria for advisory boards from AstraZeneca. Miquel
Taron, PhD, has received honoraria for advisory boards and speaker’s fees
from AstraZeneca. David Gandara, MD, has received consulting fees from
Amgen, AstraZeneca, Biodesix, Boehringer Ingelheim, BMS/Imclone,
GlaxoSmithKline, Genentech, Merck, Novartis, and Sanofi-Aventis, as well
as research grants from Abbott, BMS/Imclone, Genentech, Eli Lilly, Merck,
Novartis, and Pfizer. Fred R. Hirsch, MD, has received honoraria for
advisory boards from AstraZeneca, OSI, Roche, Genentech, and Boehringer
Ingelheim; research grants from AstraZeneca, OSI, and Genentehc; and is an
inventor of a University of Colorado-owned patent (EGFR FISH predictive
marker for EGFR inhibitors). Helmut Popper, MD, has received honoraria
for advisory boards from AstraZeneca and Roche. Manfred Dietel, MD, has
received honoraria for scientific advisory boards from AstraZeneca. Peter
Schirmacher, MD, had received honoraria fror advisory boards from Astra-
Zeneca and Roche, as well as research grants from AstraZeneca. Rolf Stahel,
MD, has received honoraria for scientific advisory boards from AstraZeneca
and merck Serono. The other authors declare no conflicts of interest.
Address correspondence to: Robert Pirker, Medical University of Vienna,
Waehringer Guertel 18 –20, 1090 Vienna, Austria. E-mail: robert.
pirker@meduniwien.ac.at
Copyright © 2010 by the International Association for the Study of Lung
Cancer
ISSN: 1556-0864/10/0510-1706
their tumors show excellent response to EGFR tyrosine kinase
inhibitors (EGFR-TKIs). The EGFR-TKI gefitinib has been ap-
proved in Europe for the treatment of adult patients with locally
advanced or metastatic NSCLC with activating mutations of the
EGFR TK. Because EGFR mutation testing is not yet well estab-
lished across Europe, biomarker-directed therapy only slowly
emerges for the subset of NSCLC patients most likely to benefit:
those with EGFR mutations.
Methods: The “EGFR testing in NSCLC: from biology to clinical
practice” International Association for the Study of Lung Cancer-
European Thoracic Oncology Platform multidisciplinary workshop
aimed at facilitating the implementation of EGFR mutation testing.
Recommendations for high-quality EGFR mutation testing were
formulated based on the opinion of the workshop expert group.
Results: Co-operation and communication flow between the various
disciplines was considered to be of most importance. Participants
agreed that the decision to request EGFR mutation testing should be
made by the treating physician, and results should be available
within 7 working days. There was agreement on the importance of
appropriate sampling techniques and the necessity for the standard-
ization of tumor specimen handling including fixation. Although
there was no consensus on which laboratory test should be preferred
for clinical decision making, all stressed the importance of standard-
ization and validation of these tests.
Conclusion: The recommendations of the workshop will help im-
plement EGFR mutation testing in Europe and, thereby, optimize the
use of EGFR-TKIs in clinical practice.
Key Words: Epidermal growth factor receptor, EGFR mutation,
EGFR testing recommendations, Gefitinib, Erlotinib, Non-small cell
lung cancer, Tyrosine kinase inhibitors.
(J Thorac Oncol. 2010;5: 1706–1713)
E pidermal growth factor receptor-tyrosine kinase inhibitors
(EGFR-TKIs) such as gefitinib and erlotinib have demon-
strated efficacy in the treatment of advanced non-small cell

1706 Journal of Thoracic Oncology • Volume 5, Number 10, October 2010

Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
FIGURE 1. EGFR mutations in NSCLC. (Reproduced from reference 10 with permission from the publisher.)
lung cancer (NSCLC), particularly in females, never-smok-
ers, and those with adenocarcinoma histology.1–3 In 2004,
specific mutations in the EGFR TK domain were identified,
which confer sensitivity to EGFR TKIs.4 – 6 These activating
somatic mutations of the EGFR gene were more prevalent in
patients who derived greater clinical benefit from EGFR-
TKIs.4 –9 The most common EGFR sensitizing mutations are
exon 19 microdeletions, which remove a leucine-arginine-
glutamic acid-alanine motif, and the exon 21 L858R point
mutation, which produces a leucine-to-arginine substitution
(Figure 1). Together, these two types of mutations comprise
up to approximately 85 to 90% of known EGFR activating
mutations in NSCLC.8 –11 Some mutations, particularly in
exon 20, are associated with resistance to EGFR TKIs.10,12
The Phase III IRESSA Pan-ASia Study compared ge-
fitinib with carboplatin/paclitaxel in previously untreated,
never-smokers/light ex-smokers with advanced pulmonary
adenocarcinoma in East Asia and confirmed the predictive
value of EGFR mutations. Patients with EGFR mutation-
positive tumors (n ⫽ 261) had significantly longer progres-
sion-free survival (PFS) with gefitinib (hazard ratio [HR,
gefitinib:carboplatin/paclitaxel] 0.48; 95% confidence inter-
val [CI] 0.36 – 0.64; p ⬍ 0.001), whereas those in the muta-
tion-negative subgroup (n ⫽ 176) had significantly shorter
PFS with gefitinib (HR 2.85; 95% CI 2.05–3.98; p ⬍
0.001).13 Patients with EGFR mutation-positive tumors also
had higher objective response rates with gefitinib versus
carboplatin/paclitaxel (71.2% versus 47.3%; p ⬍ 0.001),
whereas those with EGFR mutation-negative tumors had
Copyright © 2010 by the International Association for the Study of Lung Cancer
Consensus for EGFR Mutation Testing in NSCLC
lower objective response rates with gefitinib compared with
carboplatin/paclitaxel (1.1% versus 23.5%; p ⫽ 0.001).
Results similar to the Phase III IRESSA Pan-ASia
Study have also been seen in several other studies including
other prospective studies of first-line gefitinib,14 –21 and three
further randomized phase III studies that compared first-line
gefitinib with doublet chemotherapy.22–24 In one of these
phase III studies (NEJ002; n ⫽ 198), gefitinib compared with
carboplatin/paclitaxel resulted in a higher response rate
(74.5% versus 29.0%) and longer PFS (HR 0.357; 95% CI
0.252– 0.507; p ⬍ 0.001) in patients with EGFR mutation-
positive tumors.24
Activating EGFR mutations also seem to be associated
with response to erlotinib. A large-scale screening study
identified EGFR mutations in patients with NSCLC, who
were then considered for first- or second-line therapy with
erlotinib.25 From 2105 screened patients, EGFR mutations
were detected in 350 patients, and of these, 217 patients
received erlotinib. In those patients with EGFR mutation-
positive tumors, erlotinib resulted in an objective response
rate of 70.6%. The exon 19 deletion mutation was associated
with a higher probability of response (odds ratio 3.08; 95%
CI 1.63–5.81; p ⫽ 0.001). This study also demonstrated that
large-scale screening of patients for EGFR mutations is
feasible and results in improved clinical outcome.
Gefitinib has received European approval for the treat-
ment of adult patients with locally advanced or metastatic
NSCLC with activating mutations of the EGFR-TK. Al-
though American Society of Clinical Oncology guidelines
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Pirker et al. Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
FIGURE 2. Sample preparation, pathology, and
EGFR mutation analysis.
recommend EGFR mutation testing in patients with
NSCLC,26 this procedure has yet to be broadly established in
Europe as it has been for KRAS mutation testing in colorectal
cancer.27–29
The “EGFR testing in NSCLC: from biology to clinical
practice” workshop was held on 27–28 November 2009,
Vienna, Austria, under the auspices of the International As-
sociation for the Study of Lung Cancer and the European
Thoracic Oncology Platform. This European multidisci-
plinary workshop, which was attended by clinical and scien-
tific experts involved in the management of advanced
NSCLC, aimed to develop recommendations to facilitate the
implementation of EGFR mutation testing in clinical practice.
The 122 participants included molecular biologists, patholo-
gists, surgeons, chest physicians, and medical oncologists.
Breakout groups addressed the identification and preparation
of suitable biopsy/sample material and optimal methods for
high-quality EGFR mutation testing. The key conclusions of
the breakouts were reviewed and discussed in plenary ses-
sions among the entire workshop group. Here, we summarize
consensus recommendations for biopsy methods and EGFR
mutation testing and provide a flowchart of the overall pro-
cess (Figure 2).
GENERAL CONSIDERATIONS FOR EGFR
MUTATION TESTING
A key conclusion was that close collaboration, commu-
nication flow, and coordination between the departments
involved in the management of lung cancer is essential to
implement EGFR mutation testing in routine practice. This
process involves clinicians, pathologists, molecular biolo-
gists, and radiologists. Awareness of the need for tumor
material for routine EGFR mutation testing has to be
raised. This is a key step in allowing all patients with
EGFR sensitizing mutations to benefit from treatment with
an EGFR TKI.
1708 Copyright © 2010 by the International Association for the Study of Lung Cancer
Which Patients Should Be Tested?
The decision to test for EGFR mutations should be
made by the treating physician at the time of diagnosis. This
decision may depend on the availability of sufficient tissue;
therefore, it is vital that biopsy methods are optimized, and
that tissue is conserved at initial diagnosis and whenever
possible thereafter. Although all patients with NSCLC may
eventually be tested, the primary focus could be on patients
with adenocarcinoma and/or patients with a negative smoking
history because the frequencies of mutations are particularly
high in these patients.
Potential prescreening strategies were discussed. These
included the issue of whether focus should be on specific
patient populations such as never-smokers and/or patients
with adenocarcinoma. Molecular prescreening techniques
such as high-resolution melting analysis were of some inter-
est for prescreening.30 –32 Immunohistochemistry could be a
useful prescreening test because it detects the most common
and relevant mutations at the protein level (e.g., exon 19
deletions), but does not detect all mutations.33,34 Circulating
tumor cell DNA testing could also provide an initial screen.
However, circulating tumor cells are limited by numbers and
difficult to extract. Some participants suggested KRAS muta-
tion testing as a prescreen method but currently, its use is not
standard for excluding EGFR mutations in clinical practice.
Although some of these assays may prove useful as pre-
screening methods in the future, there was no consensus
agreement on current prescreening algorithms.
Are There Minimum Requirements for a
Laboratory to Undertake EGFR Mutation
Testing?
EGFR mutation testing should only be done in a qual-
ity-assured setting. There should be accreditation for EGFR
mutation testing in Europe, at a national or even European
level. The establishment of reference laboratories in Europe
Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
may also be helpful: such laboratories exist for KRAS muta-
tion testing in colorectal cancer.27–29
What Are Acceptable Timelines for the
Different Stages in the Process?
Timelines are a key consideration in the management of
patients with advanced NSCLC. Results from mutation test-
ing should become available to the treating physician as soon
as possible. After tumor biopsy and its transport to the
pathologist within 24 hours, the pathology report (except
immunohistochemistry) should be completed within 1 to 2
working days. The EGFR mutation testing should then be
completed within another 5 to 7 working days. The overall
process from sampling (or ordering of the test) to availability
of the mutation results should not take more than 10 working
days (Figure 2).
BIOPSY AND TISSUE SAMPLING METHODS
When Should Tissue Collection Occur?
Tissue collection specifically for EGFR mutation test-
ing is unlikely to occur. Therefore, samples used for tumor
diagnosis will also be used for mutation analysis. Rebiopsy,
specifically for EGFR mutation testing could be considered at
the time of recurrence or disease progression, or even during
initial patient work-up, if diagnostic samples are inadequate
for mutation analysis. The benefits of obtaining as much
tumor tissue as possible during any biopsy procedure and
storage of this tissue after initial pathologic diagnosis were
emphasized.
It might be good to also obtain a plasma or blood
sample that can be tested if the tumor analysis fails, but this
approach is currently considered experimental.
From Which Tumor Site Should the Biopsy Be
Taken?
The biopsy site should be selected by the clinician who
will perform the biopsy. In general, the biopsy should be
taken from the most easily accessible tumor. Although pa-
thologists had no preference with regard to the disease site,
e.g., primary tumor, lymph node, or distant metastases, all
participants agreed that further research into the potential
mutation discordance between the primary and different met-
astatic sites is clearly indicated.35
Which Biopsy Techniques Should Be Used to
Ensure High-Quality Tissue Samples and What
Volume of Sample Is Needed?
Several well-established biopsy techniques can be used
to obtain high-quality tissue samples: needle core biopsy,
transbronchial biopsy, endobronchial biopsy, computed to-
mography-guided needle biopsy, mediastinoscopy, video-as-
sisted thoracic surgery, and thoracotomy. Number of biopsies
and cells obtained by the various techniques are summarized
in Table 1.
Copyright © 2010 by the International Association for the Study of Lung Cancer
Consensus for EGFR Mutation Testing in NSCLC
TABLE 1. Biopsy Techniques
21-g 19-g CT-Guided
Needle Needle Transbronchial Needle
Aspiration Aspiration Biopsy Biopsy
Total no. of cells ⱖ100 ⱖ150 ⱖ300 ⱖ500
per biopsy/
aspiration
No. of biopsies 4 4 4–5 2–3
How Can Complications Be Prevented and
Minimized?
Every precaution should be taken to prevent and min-
imize complications. Additional biopsies have little adverse
effect on the complication rate.
What Tumor Content Should the Biopsy
Material Have for Successful EGFR Mutation
Analysis?
Before molecular analysis, the tumor cell content of the
tissue sample should be determined to assess the reliability of
subsequent test results. There was agreement that the ratio of
malignant to normal cells within the sample is crucial for the
detection of tumor-specific mutations. In this regard, deter-
mination of the relative proportion of tumor (cellularity) in
the sample being tested, as a percentage of all cells, is
recommended. Tumor cell enrichment by manual dissection
may be required to improve accuracy of the test results in
case of sequencing. Laser capture microdissection can also be
used but is not required.
The minimum number of tumor cells required for
adequate mutation testing is ill-defined, although the clear
consensus was that as much material as possible should be
obtained. Ideally, a sample should contain at least 200 to 400
tumor cells, but this is rarely achieved in routine. For DNA
sequencing, the percentage of tumor cells should ideally be at
least 50% although with good technical procedures reliable
results can be obtained with tumor percentage as low as 10 to
20%. Several methods with higher detection sensitivity can
detect mutations present at very low levels (1–5% of EGFR
gene copies mutated), allowing the possibility of mutation
detection when tumor cell proportion is less than 10% of the
test sample.
How Should the Biopsy Material Be Prepared
for Subsequent Pathology and EGFR Mutation
Testing?
Handling of tumor specimens has yet to be standard-
ized. There was agreement that 10% neutral-buffered forma-
lin is the optimum fixative, whereas Bouin’s fluid should not
be used and other fixatives have yet to be validated against
formalin. The fixation time should be as short as possible, yet
sufficient to permit diagnosis. For example, it has been shown
that fixation times of 6 to 12 hours for small biopsy samples
and 8 to 18 hours for larger surgical specimens generally give
best results. For other techniques, such as DNA extraction
and polymerase chain reaction (PCR), the optimal fixation
times have yet to be established. Because tissue samples are
1709
Pirker et al.
only fixed once, immediately after the biopsy procedure,
variations in fixation time according to analytical technique
are not practical, and techniques are best adapted to these
standard fixation times. Sections cut from the formalin-fixed
paraffin-embedded tissue block are the standard resource
used for DNA extraction. Between 1 and 6 sections of 5- to
10-␮m thickness should be used. Laboratories that use laser
capture microdissection will require thinner sections. Tissue
fixation and processing have the potential to denature DNA,
especially when using automated processes.
Can Cytology Samples Be Used?
Cytology samples may be suitable for analysis but
further research is needed to fully understand the clinical
reliability of mutational data obtained from these samples.
Until then, clinicians should be encouraged to provide tissue
biopsy samples whenever possible.
STANDARD METHODS FOR EGFR MUTATION
TESTING
What Are the Best DNA Extraction Methods?
A range of extraction methods may be used. There was
no consensus on which was the best method. Simple column-
free methods, e.g., Gentra Puregene Blood kit (QIAGEN
GmbH, Germany), were recommended in cases in which
sample material is limited, whereas other methods, e.g.,
QIAGEN FFPET kit (Formalin-Fixed Paraffin-Embedded
Tissue kit; QIAGEN GmbH, Germany) can be used when
material is more abundant. Alternative, simple purification
steps may be appropriate for all samples. Further research to
define the optimal DNA extraction method is needed.
There was general agreement that the quality of ampli-
fiable DNA is more important than its quantity. Mutation
testing should only proceed when the PCR-amplified DNA
has been judged to be sufficient. To improve results, quality
assurance (QA) procedures have been recommended, based
on defined criteria for the quality of the sample. The QA
results should also be reported to the clinician. If a sample
that does not meet these QA criteria is EGFR mutation
positive, and a standard EGFR mutation test has been carried
out, the result can be reported as it is rare to have false
positives. However, if a sample that does not meet these QA
criteria is EGFR mutation negative, it should be reported that
a mutation was not found but that the presence of a mutation
cannot be excluded due to the poor quality of the sample.
TABLE 2. Advantages and Disadvantages of Sequencing and ARMS
DNA Sequencing
Advantages Commonly used and widely available
Can detect all mutations, including novel variants
No need for batching of samples
Identifies the exact mutation
Disadvantages More time consuming
Lower sensitivity than targeted methods
Requires experienced operators
ARMS, Amplification Refractory Mutation System.
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Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
What Are the Best EGFR Mutation Testing
Techniques?
A variety of methods are used to detect EGFR muta-
tions. These methods include direct sequencing, the Ampli-
fication Refractory Mutation System (ARMS), length analy-
sis, and denaturing high-performance liquid chromatography.
These methods have different advantages and disadvantages
(Table 2), and there was no consensus agreement on which
was the best method. Some tests only detect the most com-
mon activating mutations, whereas other tests can detect all
mutations. DNA sequencing is widely used. It can detect all
mutations, but is usually more time-consuming. However,
with sequencing there is no need for batching of samples and
it provides better contamination control as the exact, specific
mutation in the sample can be determined. ARMS is more
sensitive than sequencing, but detects fewer mutations. In
cases in which available DNA template is limited, the most
common sensitizing mutations found within exons 19 and 21
should be assessed as a priority.
Under What Circumstances Should the EGFR
Mutation Test Be Repeated?
Several criteria for the test to be repeated have been
recommended. The test should be repeated if a new (unre-
ported) mutation is found because of the possibility of a false
positive result.36 The test should also be repeated in case of
poor sequence data (with primary PCR and sequencing), if
the cycle threshold is close to the defined cut-off limit (with
the ARMS-based kits) or if other quality assessment criteria
are not met.
In case of failed tests, the following options exist:
repeat PCR; fragment analysis for exon 19, which is very
sensitive; TaqMan for exon 20 and 21; DNA extraction from
new tissue sections; repeating the test using different sam-
ples, if available; and discussing other options with the
pathology team. Networking for second opinions with differ-
ent methodologies might also be useful. In all cases, it is best
to start again from tissue if available and to discuss difficult
samples with the individual clinician or team managing the
patient.
How Should the Results Be Reported?
The report on the mutation status should be submitted
by the pathologist or the molecular biologist in close collab-
oration with the pathologist. The report should contain the
ARMS
Increased sensitivity compared with sequencing technologies
Less time consuming than sequencing
Requires fewer tumor cells
Mutations not assayed for are missed
Requirement for batching of samples
Possibly more expensive
Copyright © 2010 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
following information: details of the tissue block tested,
sample source, biopsy method used, sample size and quality,
tumor content of the sample extracted for DNA, methodology
used, exons tested, and mutation present/absent. Details of
the specific mutation found and their relevance with regard to
response to EGFR-directed TKIs should be documented, e.g.,
whether they are sensitizing mutations to TKIs, TKI-resistant
mutations (T790M) or mutations with unknown relevance
with regard to response to EGFR-directed TKIs. New muta-
tions should be checked against the Greek mutations data-
base37 regarding their clinical implication and a recommen-
dation should be made accordingly, noting that it is a new or
minority mutation. Other relevant comments should be re-
corded to assist interpretation of the test, such as the analyt-
ical sensitivity of the test (in the context of the percentage of
tumor cells in the extracted sample). Quantitative data on
mutations may also be valuable.
PERSPECTIVES
Further evaluation of the significance of some EGFR
mutations is needed, including assessment of the func-
tional importance (clinical and/or predictive significance)
of the less-common activating mutations. The results of the
Greek mutations database have been published.37 A con-
tinuously up-dated international database of mutation vari-
ants and patients’ response to treatment is required. In
some patients, the T790M mutation in exon 20 has been
associated with acquired resistance to gefitinib.10,38 How-
ever, the clinical implications of the T790M mutation also
needs further investigation; this mutation has also been
found additionally in patients who have an activating
EGFR mutation.17 Other areas requiring further investiga-
tion include the reasons for nonresponse to TKIs in some
patients with EGFR activating mutations, the heterogene-
ity in mutation expression within the primary tumor and
mutation discordance between the primary tumor and metas-
tases, and the significant association that has been observed
between tumor histologic phenotype and EGFR mutations.39
The relationship between new imaging technologies and
EGFR mutation testing should also be investigated, as imag-
ing may provide a way of assessing changes in tissue during
treatment.40
Additional mutation testing techniques are being devel-
oped, such as the peptide nucleic acid-locked nucleic acid
PCR clamp assay,11,41– 43 and may be useful in the future.
However, it should be noted that any methodology that has
not been used in the main clinical trials require validation and
accreditation to ensure that they provide comparable results.
With this in mind, simple standardized techniques as vali-
dated in trials may be optimal. Advanced techniques with
increased sensitivity are being developed, but with these,
comes the increased risk of false-positive results. These must
be avoided, so that patients do not receive treatment from
which they are unlikely to benefit.
SUMMARY
Clinical characteristics and histology have previously
been documented as predictive factors for response to EGFR-
Copyright © 2010 by the International Association for the Study of Lung Cancer
Consensus for EGFR Mutation Testing in NSCLC
TABLE 3. Recommendations for EGFR Mutation Testing
in NSCLC
Which patient? NSCLC patientsa
Time point At diagnosis
When possible at disease progression
Sample source Most easily accessible
Biopsy preferred over cytology
Fixation 10% neutral-buffered formalin
Bouin’s fluid should not be used
Tumor cell content ⱖ50% Tumor cells for DNA
sequencing
Lower % acceptable with higher
sensitivity techniques
EGFR mutation analysis method No gold standard yet
Report to include Detail of biopsy sample and tissue
extracted
Type of mutation analysis
Mutation present/absent
Interpretation
a
Local policy may determine which patients are tested. In European studies, the
prevalence of EGFR mutation in definitively diagnosed squamous cell carcinoma,
neuroendocrine carcinomas, and mucinous bronchioloalveolar-pattern adenocarcinomas
is effectively zero.45 A pragmatic approach could be to exclude from testing those
patients with a confident diagnosis of the above tumor types, but to test all those with
other NSCLC subtypes, and all “never smokers,” regardless of tumor type. In cases in
which subtype is unclear, testing is indicated.
NSCLC, non-small cell lung cancer.
TKIs in NSCLC, e.g., female gender, never-smokers, and
adenocarcinoma histology. However, recent findings suggest
that tumor molecular profiling may soon supersede these
selection factors in individualizing NSCLC treatment.44 The
most striking biomarker results have been the identification of
activating EGFR mutations within NSCLC tumors, which
have conferred superior patient outcomes with gefitinib com-
pared with chemotherapy.13 In this dawning era of personal-
ized care in advanced NSCLC, EGFR mutations have
emerged as a key predictive biomarker for EGFR-TKI treat-
ment and should be the primary standard for selection of
patients for first-line treatment with an EGFR-TKI. These
recommendations from a multidisciplinary International As-
sociation for the Study of Lung Cancer-European Thoracic
Oncology Platform workshop will help to optimize routine
EGFR mutation testing in NSCLC for the use of EGFR-TKIs
in Europe (Table 3). These early recommendations will help
to facilitate the implementation of EGFR mutation testing,
but further research to identify the best techniques is required,
both within clinical studies and as the guidelines are validated
in clinical practice.
ACKNOWLEDGMENTS
The “EGFR Testing in NSCLC: from biology to clinical
practice” workshop that was held on November 27–28, 2009
in Vienna, Austria, was made possible by unrestricted edu-
cational grants from AstraZeneca (principal sponsor) and
Merck Serono (secondary sponsor).
The authors thank all the participants. A list of
participants is included in the Appendix.
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Pirker et al. Journal of Thoracic Oncology • Volume 5, Number 10, October 2010
APPENDIX: PARTICIPANTS OF THE “EGFR
TESTING IN NSCLC” WORKSHOP
Steering Committee
Robert Pirker, Martin Filipits, Helmut Popper (Aus-
tria); Dominique Grunenwald (France); Felix Herth (Ger-
many); Federico Cappuzzo (Italy); Egbert Smit (The Nether-
lands); Rafael Rosell (Spain); Rolf Stahel (Switzerland);
Keith Kerr (UK).
Breakout Session Chairs and Cochairs
Biopsy and sampling session: Felix Herth (Germany); Do-
minique Grunenwald (France); Robert Pirker (Austria).
Pathology session: Keith Kerr (UK); Egbert Smit (The Neth-
erlands); Peter Schirrmacher (Germany).
EGFR mutation testing session: Martin Filipits (Austria);
Miquel Taron (Spain); Antonio Marchetti (Italy).
Other methodologies session: Fred Hirsch (USA); Christian
Manegold (Germany).
Full List of Workshop Participants
Austria: Madeleine Arns-Dietl, Walter Berger, Martin Filip-
its, Michaela Hack, Balàzs Hegedús, Wolfgang Hilbe,
Maximilian Hochmair, Mir Alireza Hoda, Florian Huemer,
Wolfgang Hulla, Klaus Kirchbacher, Hubert Koller, Sören
Kreuzer, Elham Pedram, Robert Pirker, Helmut Popper,
Petra Prüfert-Holzinger, Michael Reiter, Richard Wasicky,
Christoph Zielinski, Sabine Zöchbauer-Müller.
Belgium: Nadia Badri, Brigitte Gutendorf, Christian Hansen,
Chrisitof Koelsch, Christof Kölsch, Adrien Lebrun, Mar-
leen Praet, Ilian Tchakov, Erik Teugels, Els Van De Walle,
Peter Vandenberghe.
Czech Republic: Jan Ledecky, Lubos Petruzelka, Ales Ryska,
Petr Zatloukal.
Denmark: Karin de Stricker, Morten Grauslund, Birgit Gul-
dhammer-Skov, Henrik Hager.
France: Marie Melanie Dauplat, Dominique Grunenwald.
Finland: Jenni Järvi, Aija Knuttila, Kaisa Salmenkivi.
Germany: Yuan Chen, Tiantian Cui, Barbara De Bals, Man-
fred Dietel, Wilfried Eberhardt, Isabella Eder, Beatrix
Hein, Felix Herth, Liu Hongyu, Rudolf M. Huber, Katrin
Kruetzfeldt, Christian Manegold, Roland Penzel, Peter
Schirmacher, Michael Thomas, Linlin Yang.
Ireland: Kathy Gately.
Greece: Ioannis Boukovinas, Alexandros Moulis, Samuel
Murray, Angelica Saetta, Antonios Vassias.
Italy: Letizia Bazzola, Fiamma Buttitta, Maria Dono, Mar-
cello Gambacorta, Antonio Marchetti, Ettore Mari, Nicola
Normanno, Antonio Rossi, Giancarlo Troncone, Silvio
Veronese, Simonetta Zupo.
Portugal: Margarida Almeida, Teresina Amara, Lina Car-
valho, Ana Rita Lima.
Spain: Susanna Benlloch, Jesus Garica Foncillas, Carmen
Gonzalez Arenas, Mangeles Lopez Garcia, Fernando
Lopez-Rios, Julian Sanz, Miquel Taron, Sandra Zazo
Hernandez.
1712 Copyright © 2010 by the International Association for the Study of Lung Cancer
Sweden: Johan Botling, Daniel Brattström, Simon Ekman,
Göran Elmberger, Leif Johansson, Hirsch Koyi, Jeanette
Spinnars, Karin Sundqvist.
Switzerland: Mico Frattini, Sonja Jehle, Rolf Stahel.
The Netherlands: Anne-Marie Dingemans, Manfred Marang,
Petra Nederlof, Egbert Smit, Erik Thunnissen.
Turkey: Havva Didem Akpir Soydan, Adnan Aydiner, E
Dilek Yilmazbayhen.
United Kingdom: Rachel Butler, Caroline Clark, Ian Cook,
Ian Cree, David Gonzalez De Castro, Alison Horsfield,
Keith Kerr, Gael McWalter, Philippe Taniere, Jane
Theaker, Graham Walker.
USA: David Gandara, Fred Hirsch.
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