Background HER2 amplification is detected in 3% of patients with colorectal cancer (CRC), making tumors in the metastatic setting vulnerable to double pharmacological HER2 blockade. Preclinical findings show that it also might impair response to anti‐epidermal growth factor receptor (EGFR) treatment. Subjects and Methods Patients with KRAS exon 2 wild‐type metastatic CRC underwent molecular screening of HER2 positivity by HERACLES criteria (immunohistochemistry 3+ or 2+ in ≥50% of cells, confirmed by fluorescence in situ hybridization). A sample of consecutive HER2‐negative patients was selected as control. A regression modeling strategy was applied to identify predictors explaining the bulk of HER2 positivity and the association with response to previous anti‐EGFR treatment. Results From August 2012 to April 2018, a total of 100 HER2‐positive metastatic CRC tumors were detected out of 1,485 KRAS exon 2 wild‐type screened patients (6.7%). HER2‐positive patients show more frequently lung metastases (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.15–3.61; p = .014) and higher tumor burden (OR, 1.48; 95% CI, 1.10–2.01; p = .011), and tumors were more likely to be left sided (OR, 0.50; 95% CI, 0.22–1.11; p = .088). HER2‐positive patients who received treatment with anti‐EGFR agents (n = 79) showed poorer outcome (objective response rate, 31.2% vs. 46.9%, p = .031; progression‐free survival, 5.7 months vs. 7 months, p = .087). Conclusion Testing for HER2 should be offered to all patients with metastatic CRC because the occurrence of this biomarker is unlikely to be predicted based on main clinicopathological features. Patients with HER2‐amplified metastatic CRC are less likely to respond to anti‐EGFR therapy. Implications for Practice Patients with HER2‐amplified/overexpressed metastatic colorectal cancer (mCRC) harbor a driver actionable molecular alteration that has been shown in preclinical models to hamper efficacy of the anti‐epidermal growth factor receptor (EGFR) targeted therapies. The present study confirmed that this molecular feature was associated with worse objective tumor response and shorter progression‐free survival in response to previous anti‐EGFR therapies. Moreover, it was found that the occurrence of this biomarker is unlikely to be predicted based on main clinicopathological features. Therefore, HER2 status assessment should be included in the molecular diagnostic workup of all mCRC for speedy referral to clinical trials encompassing HER2‐targeted double blockade independently of previous anti‐EGFR treatment.

Liquid biopsy recently gained widespread attention as a noninvasive alternative/complementary technique to tissue biopsy in patients with cancer. As technological advances have improved both feasibility and turnaround time, liquid biopsy has expanded tumor molecular analysis with acknowledgement of both spatial and temporal heterogeneity, overcoming many limitations of traditional tissue biopsy. Because of its diagnostic, prognostic, and predictive value, liquid biopsy has been extensively studied also in metastatic colorectal cancer. Indeed, as personalized medicine establishes its role in cancer treatment, genetic biomarkers unveiling the emergence of early resistance are needed. Among the wide variety of tumor analytes amenable to collection, circulating DNA and circulating tumor cells are the most adopted approaches, and both carry clinical relevance in colorectal cancer. However, few studies focused on comparing feasibility between these two approaches. In this review, we discuss the potential implications of liquid biopsy in metastatic colorectal cancer, assessing the advantages and drawbacks of circulating DNA and circulating tumor cells, and highlighting the most relevant trials for clinical practice.

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Background: HER2 positivity is found in 3-5% of mCRC. The phase II HERACLES-A trial showed that dual anti-HER2 therapy with T + L has 30% response rate (RR) in HER2+ RAS wt mCRC after failure of standard care (Sartore-Bianchi 2016). These data led to inclusion of T+ L among recommended treatments by NCCN and other guidelines, but still lack confirmation by large trials comparing treatments. The latter, especially for this uncommon subset of mCRC, would require efforts unbearable in the setting of independent clinical research. We designed this study to confirm HERACLES-A data of efficacy through a Bayesian approach allowing to monitor longitudinally efficacy of T + L in the practice setting.Methods: We adopted a Bayesian design for an observational cohort study in order to report the RR of T + L in HER2+ mCRC by updating the prior probability of response observed in the HERACLES-A trial with the likelihood of the RR in all consecutive patients with the same characteristics treated at Niguarda Cancer Center after the HERACLES-A closure. We simultaneously monitored efficacy and toxicity using the Bayesian optimal phase II (BOP2) design (Zhou, Lee, e Yuan 2017), with futility boundaries for efficacy and safety and a total sample size of 40 patients. We planned 3 interim analyses at 10, 20 and 30 patients evaluable for RR. Type I ¼ II error was w10%, calculated after 10000 simulations under H 0 and H 1 scenario.Results: From May 2019 to Jan 2021, we collected data of HER2+ mCRC patients treated with T + L according to HERACLES-A inclusion criteria (Sartore-Bianchi et al. 2016). Patients were followed for RR and adverse events (AE). On May 1 st 2021, at the first interim analysis, 2/10 evaluable patients had PR according to RECIST criteria, with an updated likelihood of response of 26.2% and a 95% credible interval of 13.7-39.2%. No AE G3 drug-related were reported.Conclusions: At the first planned interim analysis, treatment with T + L for HER2+ mCRC patients was confirmed to be safe and effective. A Bayesian approach, allowing to monitor results accounting for previously available data, can support the process of approval by regulatory authorities for treatments targeted to uncommon subsets such as HER2+ mCRC.Legal entity responsible for the study: The authors.

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