HER2 expression and tumor-infiltrating lymphocytes predict response to tucatinib plus trastuzumab in HER2 -positive metastatic colorectal cancer (MOUNTAINEER): Exploratory analysis of a multicenter, Phase II trial

Introduction: The HER2-targeted doublet, tucatinib and trastuzumab, recently received FDA approval for previously treated HER2-positive metastatic colorectal cancer (mCRC). While the intensity of HER2 IHC staining and ERBB2 amplification have been proposed as potential markers of response, our understanding of the role of the tumor microenvironment remains limited. Methods: The phase II MOUNTAINEER Trial (NCT03043313) enrolled patients for tucatinib plus trastuzumab based on HER2 positivity (IHC or NGS amplification). Patients from cohort A with available HER2 IHC and H&E slides were included in this analysis. Previously validated AI-based models (Lunit SCOPE uIHC and SCOPE IO) were used to quantify the percentage of HER2 3+ stained tumor cells (AI-H3+) and the densities of tumor infiltrating lymphocytes (TILs) in the cancer epithelium (iTIL) and stroma (sTIL). Results: The analyzed cohort (N=30) had an objective response rate (ORR) of 43.4% and median progression-free survival (PFS) of 8.0 months. AI-H3+ percentage showed a strong, dose-dependent association with an ORR of 57.1%, 66.6%, and 80.0% for tumors with AI-H3+ ≥10% (n=14), ≥25% (n=12), and ≥50% (n=10), respectively. This benefit extended to PFS, with the ≥50% cohort reporting a PFS HR of 0.17 (P=0.002) compared to tumors with AI-H3+ <50%. Tumors with below median iTIL or sTIL had significantly shorter PFS. Notably, tumors with sTIL density in the bottom quantile had an ORR of 0% and PFS HR of 4.40 (P=0.002) despite including cases with high AI-H3+. TIL densities and AI-H3+ percentage were not correlated. Conclusion: These findings confirm AI-quantified HER2 intensity as a marker of response and suggests the importance of TILs, which may have a role through immunogenic cell death. Stratification by HER2 and TIL may be an approach to consider as this regimen progresses into the first-line setting. Overall OverallHigh AI-H3+ percentage Low iTIL density Low sTIL density Cutoff n/a ≧ 10% ≧ 25% ≧ 50% < 2.6 cells/mm 2 (median) < 131.8 cells/mm 2 (median) < 52.1 cells/mm 2 (25% quantile) N 30 14 12 10 15 15 8 ORR 43.4% 57.1% 66.6% 80.0% 26.7% 26.7% 0.0% PFS n/a HR 0.44 [95% CI 0.18-1.10], P=0.071 HR 0.31 [95% CI 0.11-0.85], P=0.017 HR 0.17 [95% CI: 0.05-0.59], P=0.002 HR 3.14 [95% CI: 1.27-7.73], P=0.010 HR 3.57 [95% CI: 1.42-9.00], P=0.005 HR 4.40 [95% CI: 1.55-10.51], P=0.002