Complex Mutations & Subpopulations of Deletions at
Exon 19 of EGFR in NSCLC Revealed by Next Generation
Sequencing: Potential Clinical Implications
Antonio Marchetti1*., Maela Del Grammastro1., Giampaolo Filice1., Lara Felicioni1, Giulio Rossi2,
Paolo Graziano3, Giuliana Sartori2, Alvaro Leone3, Sara Malatesta1, Michele Iacono4, Luigi Guetti5,
Patrizia Viola1, Felice Mucilli5, Franco Cuccurullo1, Fiamma Buttitta1,6*
1Center of Predictive Molecular Medicine, Center of Excellence on Aging, University-Foundation, Chieti, Italy, 2Anatomic Pathology Unit, Azienda Ospedaliero-
Universitaria Policlinico of Modena, Modena, Italy, 3Anatomic Pathology Unit, San Camillo-Forlanini Hospital, Rome, Italy, 4Applied Science - Roche Diagnostics, Monza,
Italy, 5Department of Surgery, University of Chieti, Chieti, Italy, 6Oncological and Cardiovascular Molecular Medicine Unit, University-Foundation, Chieti, Italy
Microdeletions at exon 19 are the most frequent genetic alterations affecting the Epidermal Growth Factor Receptor (EGFR)
gene in non-small cell lung cancer (NSCLC) and they are strongly associated with response to treatment with tyrosine kinase
inhibitors. A series of 116 NSCLC DNA samples investigated by Sanger Sequencing (SS), including 106 samples carrying exon
19 EGFR deletions and 10 without deletions (control samples), were subjected to deep next generation sequencing (NGS).
All samples with deletions at SS showed deletions with NGS. No deletions were seen in control cases. In 93 (88%) cases,
deletions detected by NGS were exactly corresponding to those identified by SS. In 13 cases (12%) NGS resolved deletions
not accurately characterized by SS. In 21 (20%) cases the NGS showed presence of complex (double/multiple) frameshift
deletions producing a net in-frame change. In 5 of these cases the SS could not define the exact sequence of mutant alleles,
in the other 16 cases the results obtained by SS were conventionally considered as deletions plus insertions. Different
interpretative hypotheses for complex mutations are discussed. In 46 (43%) tumors deep NGS showed, for the first time to
our knowledge, subpopulations of DNA molecules carrying EGFR deletions different from the main one. Each of these
subpopulations accounted for 0.1% to 17% of the genomic DNA in the different tumors investigated. Our findings suggest
that a region in exon 19 is highly unstable in a large proportion of patients carrying EGFR deletions. As a corollary to this
study, NGS data were compared with those obtained by immunohistochemistry using the 6B6 anti-mutant EGFR antibody.
The immunoreaction was E746-A750del specific. In conclusion, NGS analysis of EGFR exon 19 in NSCLCs allowed us to
formulate a new interpretative hypothesis for complex mutations and revealed the presence of subpopulations of deletions
with potential pathogenetic and clinical impact.
Citation: Marchetti A, Del Grammastro M, Filice G, Felicioni L, Rossi G, et al. (2012) Complex Mutations & Subpopulations of Deletions at Exon 19 of EGFR in
NSCLC Revealed by Next Generation Sequencing: Potential Clinical Implications. PLoS ONE 7(7): e42164. doi:10.1371/journal.pone.0042164
Editor: Pan-Chyr Yang, National Taiwan University Hospital, Taiwan
Received April 27, 2012; Accepted July 2, 2012; Published July 27, 2012
Copyright: ? 2012 Marchetti et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported in part by the Italian Ministry of University and Research (MIUR) and Ministry of Health. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript. No additional external funding was received for this study.
Competing Interests: Dr. M. Iacono is a full-time employee of Applied Science - Roche Diagnostics, Monza, Italy. This does not alter the authors’ adherence to
all the PLoS ONE policies on sharing data and materials. The authors declare that no other competing interests exist.
* E-mail: firstname.lastname@example.org (AM); email@example.com (FB)
. These authors contributed equally to this work.
Lung cancer is the leading cause of cancer-related deaths in
western countries and standard therapeutic strategies including
surgery, chemotherapy, and radiotherapy have almost reached a
plateau . In recent years, the pharmacological treatment of
non-small cell lung cancer (NSCLC) has undergone a major
contribution by the introduction of new molecular targeted drugs
whose effectiveness is closely dependent on the presence of specific
genetic mutations in the tumor context [2–6]. Somatic mutations
in the tyrosine kinase domain of the Epidermal Growth Factor
Receptor (EGFR) gene emerged as one of the most relevant targets
for lung cancer treatment [7–12]. Most of EGFR mutations are in-
frame microdeletions at exon 19 affecting the conserved amino
acids ELREA. These mutations represent 44% to 80% of EGFR
mutations in different studies  and they are strongly associated
with sensitivity to tyrosine kinase inhibitors [14–16]. Exon 19
deletions usually affect one allele, with the other one being wild
type. The technique most widely used to detect and characterize
EGFR deletions is Sanger sequencing (SS) of an exon 19 PCR
product [17,18]. The presence of wild type DNA amplified from
the normal exon 19 allele may hamper an accurate detection of
the microdeletion in the mutant allele even if the best sequence
alignment algorithms are used. DNA-cloning in plasmids followed
by sequencing of multiple clones can allow a more accurate
analysis of deletions, especially in case of complex mutations. Since
DNA-cloning and sequencing is time consuming this approach has
been rarely used [19,20].
Massive parallel sequencing, also known as next generation
sequencing (NGS), could be particularly suited for the detection of
PLoS ONE | www.plosone.org1 July 2012 | Volume 7 | Issue 7 | e42164
microdeletions. This new technology, based on PCR from single
molecules before sequencing, realizes a sort of chemical cloning.
Therefore, wild type and mutant alleles are analyzed separately,
resorting in an accurate characterization of mutations. The high
accuracy of NGS technologies is also achieved by multiple read
coverage of a variant base in an individual sample [21–24].
These particular features make the NGS one of the most
sensitive technology currently available for mutation scanning,
allowing to detect somatic mutations in subpopulations of DNA
molecules, as shown in dilution experiments [25,26].
We decide to investigate a large number of somatic microdele-
tions of the EGFR gene by deep sequencing. Results were
compared with those obtained by SS and potential biological
and clinical implications are highlighted.
A series of 116 NSCLC DNA samples investigated by SS,
including 106 samples carrying exon 19 EGFR deletions and 10
samples without deletions (control samples), were subjected to
deep NGS. About 440.000 sequences, with a mean of 3497+/
2158 sequences per samples, for a total of about 72.000.000 bp,
All the samples with deletions at SS were found to be positive
for exon 19 deletions with NGS. No deletions were observed in
control cases. Deletions detected by SS were exactly confirmed in
93 (88%) cases and the frequency of concordant data was not
statistically different in the three centers. In 13 cases (12%) the
deletion was not correspondent to that observed by SS where, in 6
cases the starting-ending point was not correctly detected and the
deletion was misinterpreted (i.e. c2235–2249del instead of c2236–
2250del and viceversa or 2237_2251del instead of 2236_2250del,
as reported in Figure 1), in 7 cases the starting-ending point of the
deletions were clear, but the exact sequence of the deleted bases
could not be accurately defined (Table 1).
In 21 cases (20%) the AVA software of the 454 Junior
instrument showed the presence of double or multiple frameshift
deletions that produced a net in-frame change. Most of these
complex mutations (16 cases) were the sum of a long and short
non-in frame deletion (17 bp_del+1 bp_del). A double deletion of
18 bp (10 bp_del+8 bp_del), two double deletions of 15 bp
(12 bp_del+3 bp_del and 8 bp_del+7 bp_del), and a triple dele-
tion of 12 bp (2 bp_del+8 bp_del+2b p_del) were also observed
(Figure 2). In addition to these multiple deletions, a case showing a
novel, particularly complex mutation, composed of a 24 bp_del
followed by a duplication-insertion of 12 bp was also seen. In 5
(24%) of these cases carrying complex mutations the SS did not
allow to define the exact sequence of the mutant alleles (Table 1),
in the other 16 (14%) cases the alterations obtained by SS were
interpreted by the operators as complex deletions (deletions+inser-
tions), according to previously reported data [19,27,28]. A
comparison between SS and NGS data is reported in Table 2.
Figure 3 shows selected cases exemplifying the new interpretation
of data by the 454 Life Sciences software compared with
Seventeen (81%) of 21 double/multiple deletions resort in a loss
of 18 bp. Among the 28 deletions of 18 bp in this series, 17 (61%)
were double deletions, whereas only 2 (3%) of 74 deletions of
15 bp were double/multiple (P,0,000001).
Five of the complex mutations observed in the present study
were considered novel mutations, as they were never reported
before (cases indicated by an asterisk* in Table 1 and 2). In 3
(60%) of these cases the SS was unable to accurately detect the
Selected cases with different simple and complex deletions were
investigated by immunohistochemistry with monoclonal antibody
6B6 anti-mutant EGFR [EGF Receptor (E746-A750del Specific)
(6B6) XPH Rabbit mAb #2085 (Cell Signaling)] that recognize
EGFR proteins with exon 19 deletions. A strong immunohisto-
chemical staining (2+/3+) was seen in tumors carrying the 2235–
2249del and 2236–2250del (E746-A750del). No immunohisto-
chemical signal was present in tumors with other simple or
complex deletions (Table 3).
In 70 (66%) tumors the NGS analysis revealed, in addition to
the main deletion, the presence of subpopulations of DNA
molecules carrying different deletions which, in most cases, were
structurally related to the main one. Each of these deletions
accounted for 0.03% to 17% of the genomic DNA in the different
tumors investigated. Most (69%) of the deletions observed in
subpopulations of DNA molecules were in frame, in 31% of cases
minimally expanded non-in frame deletions were seen. In the cases
with subpopulations of deletions, PCR amplification and NGS
analysis were repeated using the same experimental conditions.
Figure 1. Sanger sequencing (SS) analysis of two mutated cases
(#70 and #31) compared with a wild type reference DNA. Wild
type and deleted alleles are superimposed in SS electropherograms. In
case #70, carrying a 2236–2250del, the peaks are perfectly aligned and
the starting point of the deletion at base 2236 is easily detectable. Next
generation sequencing (NGS) confirmed this type of deletion. In case
#31, carrying the same mutation, as detected by NGS, peaks in the SS
electropherogram are not well aligned and the starting point of the
deletion was incorrectly positioned by the operator at base 2237.
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org2 July 2012 | Volume 7 | Issue 7 | e42164
We confirmed all the subpopulations present in at least the 0.1%
of the DNA molecules. Instead, we were able to confirm the data
in only a portion (about 40%) of cases carrying subpopulations in
less than 0.1% of the DNA molecules (data not shown). Aware of
the fact that it is theoretically very difficult to confirm, in
independent PCRs, the presence of subpopulations of deletions if
they are present in few readouts, we decided to consider these data
as low confidence events. Therefore, we divided the subpopula-
tions in high confidence events, when they were present in at least
the 0.1% and low confidence events when they occurred in less
than 0.1% of the DNA. Forthy-six tumors (43%) showed high
confidence subpopulations of deletions. Four tumors (4%) showed
substantial subpopulations of deletions with at least one of them
representing more than 2% of genomic DNA. These substantial
subpopulations were present in 4 (19%) of 21 cases in which the
main mutation was a double/multiple deletion and in none of the
85 cases carrying simple deletions as main mutations (P,0.001). A
selection of cases carrying subpopulations of deletions is shown in
Figure 4. Table S2 reports all the EGFR mutations observed by
NGS in the whole series of tumors investigated.
Table 1. Cases in which the accurate sequence of deleted bases was incorrectly determined or not assessable by Sanger
sequencing compared with data obtained by Next generation sequencing.
Sanger Sequencing Next Generation Sequencing
# 1 NA c.2240_2254del p.L747_T751del
# 10NA c.2238_2249del c.2252_2253CA.ATp.L746_A750del; T751N
# 31 c.2237_2251del c.2236_2250delp.E746_A750del
# 35c.2235_2249del c.2236_2250delp.E746_A750del
# 45c.2236_2250del c.2235_2249delp.E746_A750del
# 47 NAc.2237_2253del c.2255del p.E746_S752.V
# 49 c.2235_2249delc.2236_2250delp.E746_A750del
# 51NA c.2237_2253del c.2255delp.E746_S752.V
# 53NAc.2239_2248del c.2253_2260delp.L747_K754.QQa
# 54c.2235_2249del c.2236_2250del p.E746_A750del
# 59 NA c.2230_2237del c.2245_2251delp.I744_A750.IKa
# 60 c.2235_2249delc.2236_2250del p.E746_A750del
# 61 NA c.2239_2262del
Abbreviations: NA, the exact sequence of deleted bases could not be accurately defined (not assessable).
Figure 2. Double/multiple deletions in exon 19 of EGFR revealed by the 454 GS Junior system. Complex mutations are grouped
according to the length of the deletion. Deleted bases are indicated by dashes highlighted in grey. Correspondence with numbers of tumor samples:
A (#22); B (#14, #67); C (#25); D (#12, #16, #24, #38, #39, #44, #47, #51, #73, #74, #81, #89); E (#53); F (#59); G (#64); H (#38); I (#95).
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org3 July 2012 | Volume 7 | Issue 7 | e42164
The present study was devised to evaluate a large series of
microdeletions at exon 19 of the EGFR gene by the 454 GS Junior
system. This new technical approach is based on the amplification
of single DNA molecules by emulsion PCR giving rise to a sort of
chemical cloning before pyrosequence analysis. Since expanded
wild type and mutant alleles are examined separately, the method
can allow an accurate evaluation of mutations without the
interference of wild type alleles as it occurs when conventional
sequencing methods are used. The results of NGS were compared
with those obtained by conventional SS. In about 12% of the
samples analyzed, SS failed in finding the accurate sequence of
deleted bases, either using a dedicated software or manually. In
particular, in 6 cases, the starting-ending point of the deletion
point was not correctly detected. This can be ascribed to the fact
that, by using Sanger sequencing, the wild type and mutated
alleles are superimposed on the same electropherogram. In some
samples, it can happen that the alignment of the two alleles is not
perfect, as shown in Figure 1, so that the operator can misinterpret
the starting-ending point of the deletion. In other 7 cases, the
starting-ending point of the deletions were clear but the exact
sequence of the mutant alleles was partially obscured (not
An accurate detection of EGFR microdeletions is highly
recommendable, in that different deletions could have different
effect on tumor development and progression or patient outcome
after treatment with EGFR TKIs. Moreover, different deletion
may have specific effects on the antigenicity of proteins carrying
deletion. In our study, we have tested this hypothesis by evaluating
the possibility to detect EGFR deletions with specific monoclonal
antibodies in tumors with different deletions accurately charac-
terized by NGS. We have shown that the 6B6 anti-mutant EGFR
E746_A750del, whereas the immunoreaction was absent in
tumors affected by other types of deletions. Our data are in
agreement with previously published data obtained with this
antibody in larger series of NSCLCs [29,30]. However, due to the
limited number of cases examined in these reports, additional
studies will be required to definitely clarify this point. Our results
suggest that the development of new monoclonal antibodies or
cocktails of antibodies would require the exact knowledge of the
deletions and that NGS could be a very accurate and reliable
technique to address this point.
The alignment of the numerous sequences obtained by NGS by
dedicated softwares, allowed to formulate a new interpretative
hypothesis on the nature of particular EGFR deletions. A series of
frequent (20% of cases) complex deletions, most of which reported
as deletions associated to insertions in previous reports [19,27,28],
may also be ascribed to the presence of non-in frame double or
multiple deletions producing a net in-frame loss of genetic
material. This interpretation is in keeping with the hypothesis
that a short region within exon 19 is particularly fragile and
preferentially subjected to microdeletions. The frequency of these
complex mutations was statistically higher in cases with longer
(18 bp) losses: about 80% of double/multiple deletions resulted in
Figure 3. Different interpretation of sequence data in case of complex mutations. A complex in frame deletion of 15 bp (A) can be
considered as composed of two non-in frame deletions of 8 bp and 7 bp separated by a consensus sequence of 7 bp, in other words a double
deletion. Conventionally, this mutation could have been interpreted as the sum of a non-in frame deletion of 19 bp and non-in frame insertion of
4 bp. Accordingly, in B and C are reported different interpretations for mutations giving rise to complex in frame deletions of 18 bps. Deleted bases
are indicated by dashes. Inserted bases are reported a in a frame under the sequence. Correspondence with numbers of tumor samples: A (#59); B
(#22); C (#53).
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org4 July 2012 | Volume 7 | Issue 7 | e42164
a loss of 18 bps. Five novel mutations were observed by NGS in
this study and all of them were complex, double/multiple
mutations, that in 3 (60%) cases were not resolved by Sanger
Sequencing. This clearly confirms the superiority of NGS in the
characterization of EGFR microdeletions at exon 19. Rare cases of
double/multiple deletions have been reported in previous studies,
especially when conventional sequencing was conducted on
multiple samples after cloning of genomic DNA into plasmids
[19,20,31]. Cloning was essential to better characterize multiple
deletions and rule out the possibility that they were present on
different alleles. However, biological cloning and sequencing of
multiple samples is time consuming and not suitable for routine
clinical diagnostic purposes. The GS Junior Technology, based on
PCR cloning before pyrosequencing of multiple samples, is in our
opinion an ideal approach for a fine characterization of complex
deletions in exon 19 of the EGFR gene.
The NGS assay is one of the most sensitive methods available
for the detection of somatic mutations when used in deep
sequencing, and the sensitivity of NGS is dependent on the
number of sequences obtained per sample [25,26]. In this study we
decided to perform a deep NGS analysis taking a median of more
than 3.000 sequences per sample. The high sensitivity of this NGS
assay allowed us to detect in about 70% of cases, subpopulations of
DNA molecules carrying exon 19 deletions different from the
main mutation, but in most cases structurally related to it
(Figure 4). In the majority of cases these subpopulations carried
in frame simple or double deletions. In about one third of cases,
less expanded non-in frame deletions were observed. These
subpopulations were confirmed in independent PCR-NGS assays
in 43% of the tumors investigated. However, only 4 tumors (4%)
showed substantial subpopulations of deletions with at least one of
them representing more than 2% of genomic DNA.
Table 2. Comparison of data obtained by Sanger Sequencing and Next Generation Sequencing analysis on cases carrying complex
Sanger SequencingNext Generation Sequencing
Mutation Rearrangement Mutation Rearrangement
# 22c.2236_2257delinsATCT22 bp_del/4 bp_ins c.2236_2252del c.2258del17 bp_del/1 bp_delp.E746_P753.ISa
# 14 c.2237_2257delinsTCT21 bp_del/3 bp_ins c.2237_2253del c.2258del 17 bp_del/1 bp_delp.E746_P753.VS
# 67c.2237_2257delinsTCT21 bp_del/3 bp_ins c.2237_2253del c.2258del17 bp_del/1 bp_del p.E746_P753.VS
# 25c.2237_2256delinsTC20 bp_del/2 bp_ins c.2237_2253del c.2256del 17 bp_del/1 bp_delp.E746_S752.V
# 12c.2237_2255delinsT19 bp_del/1 bp_ins c.2237_2253del c.2255del17 bp_del/1 bp_delp.E746_S752.V
# 16c.2237_2255delinsT 19 bp_del/1 bp_insc.2237_2253del c.2255del17 bp_del/1 bp_del p.E746_S752.V
# 24 c.2237_2255delinsT 19 bp_del/1 bp_insc.2237_2253del c.2255del17 bp_del/1 bp_delp.E746_S752.V
# 38 c.2237_2255delinsT19 bp_del/1 bp_insc.2237_2253del c.2255del 17 bp_del/1 bp_del p.E746_S752.V
# 39 c.2237_2255delinsT 19 bp_del/1 bp_insc.2237_2253del c.2255del 17 bp_del/1 bp_delp.E746_S752.V
# 44c.2237_2255delinsT19 bp_del/1 bp_ins c.2237_2253del c.2255del17 bp_del/1 bp_del p.E746_S752.V
# 73 c.2237_2255delinsT 19 bp_del/1 bp_ins c.2237_2253del c.2255del 17 bp_del/1 bp_delp.E746_S752.V
# 74 c.2237_2255delinsT19 bp_del/1 bp_insc.2237_2253del c.2255del 17 bp_del/1 bp_del p.E746_S752.V
# 81c.2237_2255delinsT 19 bp_del/1 bp_ins c.2237_2253del c.2255del 17 bp_del/1 bp_delp.E746_S752.V
# 89c.2237_2255delinsT19 bp_del/1 bp_ins c.2237_2253del c.2255del17 bp_del/1 bp_delp.E746_S752.V
# 64c.2235_2252delinsATT18 bp_del/3 bp_ins c.2234_2236del c.2241_2252del3 bp_del/12 bp_del p.K746_T751.La
# 95 c.2235_2251delinsAATTC17 bp_del/5 bp_ins c.2235_2236del
2 bp_del/8 bp_del/2 bp_del p.E746_T751.IP
Table 3. Immunohistochemical staining with deletion
specific 6B6 monoclonal antibody in Non-Small Cell Lung
Cancers carrying different deletions at exon 19 of the EGFR
gene detected by Next Generation Sequencing.
#11 c.2235_2249del15 p.E746_A750del
#17 c.2235_2249del15 p.E746_A750del
#19 c.2235_2249del15 p.E746_A750del
#2 c.2236_2250del15 p.E746_A750del
#18 c.2239_2248del10 insCp.L747_A750del.P0
aThe score system is described in detail in Materials and Methods.
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org5 July 2012 | Volume 7 | Issue 7 | e42164
The presence of these subpopulations in a large proportion of
cases examined is at moment unclear. It is extremely unlikely that
they are due to cross-contaminations, since they were highly
heterogeneous, usually related to the main deletion, and they
were not seen in control samples. In addition, particular strategies
were adopted to minimize cross-contaminations in our study (see
Materials and Methods). These subpopulations could represent
modifications of the main deletion or ex novo deletions acquired
in cell clones during tumor progression. In both cases, this finding
would support the hypothesis that this region within exon 19 of
EGFR is highly instable in most patients affected by NSCLC
carrying EGFR deletions. This genetic fragility may enable the
development of both complex deletions and multiple subpopu-
lations. To the best of our knowledge, this is the first
demonstration of subpopulations of EGFR deletions in NSCLC.
Our findings could have important clinical implications. Recent
evidence indicate that tumor genotype may evolve dynamically
under the selective pressure of targeted therapies . We are
tempted to hypothesize that the genetic fragility of exon 19 in
particular patients could take a role in the dynamic evolution of
lung tumors subjected to different therapeutic strategies. It would
be interesting to monitor by NGS on repeated biopsies the main
EGFR deletion as well as the deletions in minor clones during
In conclusion, our results indicate that NGS is particularly
suitable for the study of EGFR deletions. This technique can
accurately characterize EGFR deletions, even in cases in which
conventional methods fail. Data obtained by NGS analysis allowed
us to formulate a new interpretative hypothesis for complex
deletions which represent about 20% of EGFR mutations in exon
19 as well as to identify 5 novel deletions. In addition, we report,
for the first time to our knowledge, the presence of subpopulations
of different deletions in most of the tumors investigated with
pothential pathogenetic and clinical impact.
Figure 4. Examples of subpopulations of EGFR deletions at exon 19. The Figure reports 10 selected cases of tumors (#53, #59, #47, #38,
#84, #27, #89, #49, #17, #77) showing subpopulations of EGFR deletions at exon 19. In each case the first line corresponds to the wild type
sequence. The different bases are highlighted by different colours. Deleted bases are reported as dashes. The black bars under the sequences indicate
the consensus for the different bases involved in deletions. On the right of each case is reported the percentage with which the wild type and deleted
molecules were present in tumor DNA. The number (N) of sequences obtained in each case were as follow: #53 (N=6.484), #59 (N=5.835), #47
(N=5.629), #38 (N=4.776), #84 (N=2.641), #27 (N=4.389), #89 (N=3.855), #49 (N=2.172), #17 (N=2.856), #77 (N=3.526). Cases carrying
subpopulations in less than 0.1% of the DNA molecules are labeled with an asterisk.
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org6 July 2012 | Volume 7 | Issue 7 | e42164
Materials and Methods
Patients and DNA samples
A series of 106 tumor DNA samples carrying EGFR deletions at
exon 19, obtained from as many stage III–IV NSCLC patients,
was collected in 3 reference diagnostic centers (Chieti, Rome, and
Modena Centers). Genomic DNA was isolated from formaline-
fixed, paraffin-embedded samples by standard procedures. Diag-
nostic evaluation of EGFR mutations was performed by High
Resolution Melting Analysis (HRMA) followed by Sanger
sequencing (Chieti Center), Fragment Analysis followed by Sanger
sequencing (Rome Center) or direct Sanger Sequencing (Modena
Center). Additional 10 NSCLC samples, found to be negative for
deletions by Sanger Sequencing (control samples), were also
available. All the DNA samples were subjected to deep sequencing
by the 454 GS Junior System (454 Life Sciences, Branford, CT,
and Roche Applied Sciences, Indianapolis, IN) in the Center of
Predictive Molecular Medicine (University-Foundation, Chieti).
Written consent was received by all patients. Researchers obtained
permits from the diagnostic centers to use the tumor samples. All
the samples were collected and received anonymously.
DNA fusions primers containing genome-specific sequences,
along with one of 7 distinct 10-bp MIDs (multiplex identifier
sequences used to differentiate samples being run together on the
same plate) and sequencing adapters were used to amplify a
108 bp region in EGFR (NM_005228.3) exon 19 (Figure S1 and
Table S1). PCR primers, were designed using the OligoAnalyzer
3.1 software (http://eu.idtdna.com/analyzer/Applications/
OligoAnalyzer/) and synthesized at MWG-Biotech AG.
PCR reactions were run in 30 ml reaction volumes, containing
5.5 mmols dNTPs, 11 mmols of each primer, 2.75 ml PCR buffer,
1 ml DNA, and 1.3 units of FastStart HiFi Polymerase (Roche
A touch-down PCR cycling program was performed on the
Gene Amp PCR system 9700 thermocycler (Applied Biosystems)
with an initial step at 94uC for 2 min followed by 43 cycles at 94uC
for 30 sec, 64uC (decreasing the temperature by 1uC each cycle for
six cycles) for 30 sec, and 70uC for 30 sec, and a final step at 70uC
for 5 min. Different strategies were adopted to avoid cross-
contaminations: a) reactions were set up in positive-pressure hoods
with UV sterilization systems to decontaminate reagents and
equipment prior to carrying out PCRs; b) different hoods were
used for PCR amplification of samples subjected to different runs;
c) PCR reactions were conducted on 96-well plates, with a
maximum of 4 samples loaded per plate.
Next Generation Sequencing
PCR products were visualized on agarose gel, purified using
size-exclusion SPRI Ampure-XP DNA-binding paramagnetic
beads (Agencourt Bioscience Corp., Beckman Coulter S.p.A,
Milan, Italy), and quantified in 96-well format with the
QuantiFluorTM-ST Fluorometer (Promega, Madison, Wisconsin,
USA) using a PicoGreenH assay (Invitrogen, Carlsbad, CA).
Samples were then diluted to an approximate concentration of
16109molecules/mL and pooled at equimolar concentrations to
create a highly multiplexed amplicon library. After pooling, the
library was further diluted to 106molecules/ml and subjected to
emulsion PCR (emPCR) using the 454 GS Junior Titanium Series
Lib-A emPCR Kit (Roche Diagnostics), according to the
manufacturer’s protocols. Following emPCR, the captured beads
with bound DNA were enriched with a second DNA capture
mechanism to separate out beads with and without bound emPCR
products. By using a bead counter, the number of enriched beads
was estimated to be between 300,000 and 1 million. The enriched
pool of beads was then used for massively parallel pyrosequencing
in a Titanium PicoTiterPlateH (PTP) with Titanium reagents
(Roche Diagnostics), on the GS Junior instrument, according to
the 454 GS Junior Titanium Series Amplicon Library Preparation
Method Manual (available online: www.454.com).
Analysis of sequence data
Processed and quality-filtered reads were analysed with the GS
Amplicon Variant Analyzer (AVA) software version 2.5.3 (454 Life
Sciences). EGFR exon 19 reference sequence was extracted from
Hg19 Human Genome Version together with both neighbor
intronic regions. Such sequence was used as Reference Sequence
to align every reads. The final alignments were checked manually
and wrong alignments were edited by Jalview Multi-alignment
Tool (http://www.jalview.org/). In order to parse and manage all
data sequences and results (variations, frequency of mutations,
forward and reverse reads check) custom scripts were created using
The EGFR E746-A750 deletion specific (6B6) antibody (Cell
Signaling Technology, Inc.) was used for immunohistochemical
staining. Paraffin embedded sections were dewaxed, hydrated,
treated with proteinase K (DAKO, Glostrup Denmark) and
immunostained using a labelled polymer detection system (Bond
Polymer Define Detection, Vision Biosystem, Mount Waverley,
Australia) and automated stainer (BOND-maX, Vision BioSystem).
The primary polyclonal antibody was used at a dilution of 1:100.
Negative controls were obtained by replacement of primary
antiserum with buffer. IHC expression of mAbs against EGFR
was evaluated using the following scoring: 0=negative; 1=weak
staining in .10% of cancer cells; 2=moderate staining in .10% of
cancer cells; 3=strong staining in .10% of cancer cells. A score of
0 was considered negative, a score of 1 was considered weakly
positive, and a score of 2 or 3 was considered highly positive.
The variables measured in the study were investigated for
association by the Fisher’s exact test or x2test as appropriate. A
P,0.05 was considered as significant. Statistical analyses were
performed using SPSS version 15 (SPSS, Chicago, IL).
design. The squares represent the primer binding sequence,
the circles represent the multiplex identifier (MID) sequence, and
the thick lines represent the fusion primer sequence for 454
applications. The lenght of each primer is 61 and 57 nucleotides
for forward and reverse, respectively. The total amplicon lenght is
178 bp including 108 bp of the EGFR gene.
Polymerase chain reaction (PCR) primer
59-end of each primer, fusion primer sequence for forward and
reverse emulsion PCR and pyrosequencing is in standard font,
followed by multiplex identifier sequence in italics and primer
binding sequence in bold.
Primer sequence for EGFR ex 19. Starting at the
sequencing in the whole series of tumors investigated.
EGFR mutations observed by next generation
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org7 July 2012 | Volume 7 | Issue 7 | e42164
Author Contributions Download full-text
Conceived and designed the experiments: AM FB. Performed the
experiments: MDG GF LF GS AL SM PV. Analyzed the data: MDG
GF LF GS AL AM FB. Contributed reagents/materials/analysis tools: GR
PG MI LG FM FC. Wrote the paper: AM FB MDG GF.
1. Molina JR, YangP, Cassivi SD, Schild SE, Adjei AA (2008) Non-small cell lung
cancer: epidemiology, risk factors, treatment, and survivorship. Mayo Clinic
2. Lynch TJ, Bell DW, Sordella R, Gurubhagavatula S, Okimoto RA, et al. (2004)
Activating mutations in the epidermal growth factor receptor underlying
responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med
3. Sun S, Schiller JH, Spinola M, Minna JD (2007) New molecularly targeted
therapies for lung cancer. J Clin Invest 117:2740–2750.
4. Choi YL, Soda M, Yamashita Y, Ueno T, Takashima J, et al. (2010) EML4-
ALK mutations in lung cancer that confer resistance to ALK inhibitors.
N Engl J Med 363:1734–1739.
5. Marchetti A, Felicioni L, Malatesta S, Sciarrotta M, Guetti L, et al. (2011)
Clinical features and outcome of patients with non-small-cell lung cancer
harboring BRAF mutations. J Clin Oncol 29:3574–3579.
6. Pao W, Girard N (2011) New driver mutations in non-small-cell lung cancer.
Lancet Oncol 12:175–180.
7. Rosell R, Moran T, Queralt C, Porta R, Cardenal F, et al. (2007) Screening for
epidermal growth factor receptor mutations in lung cancer. N Engl J Med
8. Sharma SV, Bell DW, Settleman J, Haber DA (2007) Epidermal growth factor
receptor mutations in lung cancer. Nat Rev Cancer 7:169–181.
9. Mok TS, Wu YL, Thongprasert S, Yang CH, Chu DT, et al. (2009) Gefitinib or
carboplatin-paclitaxel in pulmonary adenocarcinoma. N Engl J Med 361:947–
10. Lee DH, Park K, Kim JH, Lee JS, Shin SW, et al. (2010) Randomized Phase III
trial of gefitinib versus docetaxel in non-small cell lung cancer patients who have
previously received platinum-based chemotherapy. Clin Cancer Res 16:1307–
11. Maemondo M, Inoue A, Kobayashi K, Sugawara S, Oizumi S, et al. (2010)
Gefitinib or chemotherapy for non-small-cell lung cancer with mutated EGFR.
N Engl J Med 362:2380–2388.
12. Mitsudomi T, Morita S, Yatabe Y, Negoro S, Okamoto I, et al. (2010) Gefitinib
versus cisplatin plus docetaxel in patients with non-small-cell lung cancer
harbouring mutations of the epidermal growth factor receptor (WJTOG3405):
an open label, randomised phase 3 trial. Lancet Oncol 11:121–128.
13. Yamamoto H, Toyooka S, Mitsudomi T (2009) Impact of EGFR mutation
analysis in non-small cell lung cancer. Lung Cancer 63:315–321.
14. Jackman DM, Yeap BY, Sequist LV, Lindeman N, Holmes AJ, et al. (2006)
Exon 19 deletion mutations of epidermal growth factor receptor are associated
with prolonged survival in non-small cell lung cancer patients treated with
gefitinib or erlotinib. Clin Cancer Res 12:3908–3914.
15. Sakurada A, Shepherd FA, Tsao MS (2006) Epidermal growth factor receptor
tyrosine kinase inhibitors in lung cancer: impact of primary or secondary
mutations. Clin Lung Cancer 7:S138–S144.
16. Riely GJ, Politi KA, Miller VA, Pao W (2006) Update on epidermal growth
factor receptor mutations in non-small cell lung cancer. Clin Cancer Res
17. Marchetti A, Martella C, Felicioni L, Barassi F, Salvatore S, et al. (2005) EGFR
mutations in non-small-cell lung cancer: analysis of a large series of cases and
development of a rapid and sensitive method for diagnostic screening with
potential implications on pharmacologic treatment. J Clin Oncol 23:857–865.
18. Marchetti A, Felicioni L, Buttitta F (2006) Assessing EGFR mutations.
N Engl J Med 354:526–8.
19. Tam IY, Chung LP, Suen WS, Wang E, Wong MC, et al. (2006) Distinct
epidermal growth factor receptor and KRAS mutation patterns in non-small cell
lung cancer patients with different tobacco exposure and clinicopathologic
features. Clin Cancer Res 12: 1647–1653.
20. Yokoyama T, Kondo M, Goto Y, Fukui T, Yoshioka H, et al. (2006) EGFR
point mutation in non-small cell lung cancer is occasionally accompanied by a
second mutation or amplification. Cancer Sci 97:753–759.
21. Mardis ER (2008) Next-generation DNA sequencing methods. Annu Rev
Genomics Hum Genet 9:387–402.
22. Schuster SC (2008) Next-generation sequencing transforms today’s biology. Nat
23. Durbin RM, Abecasis GR, Altshuler DL, Auton A, Brooks LD, et al. (2010) A
map of human genome variation from population-scale sequencing. Nature
24. Metzker ML (2010) Sequencing technologies-the next generation. Nat Rev
25. Campbell PJ, Pleasance ED, Stephens PJ, Dicks E, Rance R, et al. (2008)
Subclonal phylogenetic structures in cancer revealed by ultra-deep sequencing.
Proc Natl Acad Sci USA 105:13081–13086.
26. De Grassi A, Segala C, Iannelli F, Volorio S, Bertario L, et al. (2010) Ultradeep
sequencing of a human ultraconserved region reveals somatic and constitutional
genomic instability. PLoS Biol 8:e1000275.
27. Gu D, Scaringe WA, Li K, Saldivar JS, Hill KA, et al. (2007) Database of
somatic mutations in EGFR with analyses revealing indel hotspots but no
smoking-associated signature. Hum Mutat 28:760–770.
28. Penzel R, Sers C, Chen Y, Lehmann-Mu ¨hlenhoff U, Merkelbach-Bruse S, et al.
(2011) EGFR mutation detection in NSCLC-assessment of diagnostic applica-
tion and recommendations of the German Panel for Mutation Testing in
NSCLC. Virchows Arch 458:95–98.
29. Yu J, Kane S, Wu J, Benedettini E, Li D, et al. (2009) Mutation-specific
antibodies for the detection of EGFR mutations in non-small-cell lung cancer.
Clin Cancer Res 15:3023–3028.
30. Simonetti S, Molina MA, Queralt C, de Aguirre I, Mayo C, et al. (2010)
Detection of EGFR mutations with mutation-specific antibodies in stage IV non-
small-cell lung cancer. J Transl Med. 8:135.
31. Pao W, Miller V, Zakowski M, Doherty J, Politi K, et al. (2004) EGF receptor
gene mutations are common in lung cancers from ‘‘never smokers’’ and are
associated with sensitivity of tumors to gefitinib and erlotinib. Proc Natl Acad Sci
32. Sequist LV, Waltman BA, Dias-Santagata D, Digumarthy S, Turke AB, et al.
(2011) Genotypic and histological evolution of lung cancers acquiring resistance
to EGFR inhibitors. Sci Transl Med 3:75ra26.
EGFR Mutations by Next Generation Sequencing
PLoS ONE | www.plosone.org8 July 2012 | Volume 7 | Issue 7 | e42164