Therapeutic targeting of ERBB2 in breast cancer: understanding resistance in the laboratory and combating it in the clinic.

ERBB2 gene amplification occurs in about one quarter of breast carcinomas (BCs) and identifies a distinct clinical subset of BC. The introduction in the clinic of Trastuzumab, a humanized monoclonal antibody (mAb) directed to the ERBB2 extracellular domain, has had a great impact on the therapeutic management of ERBB2+ BC. Yet, not all patients respond to Trastuzumab and resistance develops also among patients that initially benefit from Trastuzumab-based regimens. Pre-clinical studies have discovered several mechanisms through which tumor cells may escape from Trastuzumab-mediated ERBB2 inhibition. These include rewiring of the ErbB signaling network, loss of ERBB2 expression, expression of ERBB2 isoforms refractory to Trastuzumab inhibition, vicarious signaling by non-ErbB tyrosine kinases and constitutive activation of downstream signaling routes, such as the PI3K pathway. While the relative contribution of each of these mechanisms to establishing Trastuzumab resistance in the clinical setting is not fully understood, much attention has been focused on abating resistance by achieving complete blockade of ERBB2-containing dimers. This approach, propelled by the development of novel anti-ERBB2 therapeutics, has led to the recent approval of Lapatinib, Pertuzumab and T-DM1 as additional anti-ERBB2 therapeutics in BC. However, full success is far from being achieved and resistance to ERBB2 targeting remains a relevant problem in the clinical management of BC. Herein, we provide an overview of biological and molecular bases underpinning resistance to ERBB2 therapeutics in BC, discuss outstanding issues in the field of ERBB2 therapeutic targeting and elaborate on future directions of translational research on ERBB2+ breast cancer.