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Jorge SE, Lucena-Araujo AR, Yasuda H, Piotrowska Z, Oxnard GR, Rangachari D, Huberman MS, Sequist LV, Kobayashi SS, Costa DB. EGFR Exon 20 Insertion Mutations Display Sensitivity to Hsp90 Inhibition in Preclinical Models and Lung Adenocarcinomas. Clin Cancer Res 2018; 24:6548-6555. [PMID: 30154228 DOI: 10.1158/1078-0432.ccr-18-1541] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 08/21/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE EGFR exon 20 insertions account for up to 10% of all EGFR mutations in lung adenocarcinomas, representing the third most common cluster of mutations. The management of advanced cancers with these mutations remains elusive, without an approved inhibitor. EXPERIMENTAL DESIGN Preclinical models of a representative set of EGFR exon 20 insertion mutations to evaluate the efficacy of different inhibitors and description of the clinical outcome of an advanced lung cancer. RESULTS We show that select first-, second-, and third-generation EGFR inhibitors are unable to deter common EGFR exon 20 insertion mutants in concentrations that spare the wild-type kinase. Nonetheless, EGFR exon 20 insertion mutants associate with the Hsp90 chaperone system. We exploit this vulnerability to show that the nongeldanamycin Hsp90 inhibitor luminespib (formerly AUY922) degrades EGFR exon 20 mutations, downstream targets, and induces apoptosis. In addition, a patient whose EGFR inhibitor-insensitive lung adenocarcinoma harbored an EGFR exon 20 insertion mutation had a confirmed radiographic response to luminespib. CONCLUSIONS The report confirms that EGFR exon 20 mutations are dependent on Hsp90 and are readily inhibited by the Hsp90 inhibitor luminespib; a treatment strategy that has been pursued in a confirmatory clinical trial (NCT01854034) for this group of lung adenocarcinomas that currently represent an unmet clinical need in precision oncology.
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Sehgal K, Patell R, Rangachari D, Costa DB. Targeting ROS1 rearrangements in non-small cell lung cancer with crizotinib and other kinase inhibitors. Transl Cancer Res 2018; 7:S779-S786. [PMID: 30327756 DOI: 10.21037/tcr.2018.08.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sehgal K, Peters MLB, VanderLaan PA, Rangachari D, Kobayashi SS, Costa DB. Activity of Brigatinib in the Setting of Alectinib Resistance Mediated by ALK I1171S in ALK-Rearranged Lung Cancer. J Thorac Oncol 2018; 14:e1-e3. [PMID: 29981924 DOI: 10.1016/j.jtho.2018.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/20/2018] [Accepted: 06/27/2018] [Indexed: 11/17/2022]
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Rangachari D, VanderLaan PA, Costa DB. Updated Correlation of 22C3-PD-L1 ≥50% Expression with Driver Oncogene Mutations and Response to Pembrolizumab in the Kinase Inhibitor-Resistant Setting. J Thorac Oncol 2018; 13:e81-e83. [PMID: 29703544 DOI: 10.1016/j.jtho.2018.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/26/2018] [Indexed: 10/17/2022]
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Nemeth Z, Csizmadia E, Vikstrom L, Li M, Bisht K, Feizi A, Otterbein S, Zuckerbraun B, Costa DB, Pandolfi PP, Fillinger J, Döme B, Otterbein LE, Wegiel B. Alterations of tumor microenvironment by carbon monoxide impedes lung cancer growth. Oncotarget 2018; 7:23919-32. [PMID: 26993595 PMCID: PMC5029674 DOI: 10.18632/oncotarget.8081] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/29/2016] [Indexed: 12/26/2022] Open
Abstract
We hypothesized that tumor-associated macrophages (TAMs) are controlled by the diffusible gas carbon monoxide (CO). We demonstrate that induction of apoptosis in lung tumors treated with low doses of CO is associated with increased CD86 expression and activation of mitogen-activated protein kinase (MAPK)/extracellular signal-regulated kinases (Erk) 1/2 pathway in tumor microenvironment. Presence of CD86-positive cells was required for the anti-tumoral effects of CO in established A549 xenografts. We show that the effects of CO on tumor stroma and reprogramming of macrophages towards the anti-tumoral phenotype is mediated by reactive oxygen species (ROS)-dependent activation of MAPK/Erk1/2-c-myc pathway as well as Notch 1-dependent negative feedback on the metabolic enzyme heme oxygenase-1 (HO-1). We find a similar negative correlation between HO-1 and active MAPK-Erk1/2 levels in human lung cancer specimens. In summary, we describe novel non-cell autonomous mechanisms by which the diffusible gas CO dictates changes in the tumor microenvironment through the modulation of macrophages.
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Shea M, Rangachari D, Hallowell RW, Hollie NI, Costa DB, VanderLaan PA. Radiologic and autopsy findings in a case of fatal immune checkpoint inhibitor-associated pneumonitis. Cancer Treat Res Commun 2018; 15:17-20. [PMID: 30207283 DOI: 10.1016/j.ctarc.2018.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 01/24/2018] [Accepted: 02/19/2018] [Indexed: 01/21/2023]
Abstract
Oncologists are increasingly managing drug-induced pneumonitis in lung cancer patients treated with PD-1/PD-L1 immune checkpoint inhibitors. To date only few studies on the topic have described both radiologic and pathologic findings in these patients. Here, we report a fatal case of immune checkpoint inhibitor-associated pneumonitis initially presenting with an organizing pneumonia, but who rapidly developed acute respiratory distress syndrome (confirmed histologically at the time of autopsy). As such, this case illustrates the need for clinicians to maintain a high index of suspicion for immune checkpoint inhibitor associated pneumonitis and have a low threshold to perform CT imaging in any symptomatic patient receiving checkpoint inhibition therapy. CLINICAL PRACTICE POINTS.
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VanderLaan PA, Rangachari D, Majid A, Parikh MS, Gangadharan SP, Kent MS, McDonald DC, Huberman MS, Kobayashi SS, Costa DB. Tumor biomarker testing in non-small-cell lung cancer: A decade of change. Lung Cancer 2018; 116:90-95. [PMID: 29413057 DOI: 10.1016/j.lungcan.2018.01.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 12/06/2017] [Accepted: 01/04/2018] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Although a growing list of essential genomic/immune-based biomarkers are linked to approved non-small-cell lung cancer (NSCLC) therapies worldwide, few reports have detailed the evolution of NSCLC predictive biomarker assessment in routine clinical practice. METHODS We retrospectively reviewed the first one thousand plus NSCLC patient specimens from our institution analyzed for predictive biomarkers from 2004 to 2017 and evaluated patterns of testing as well as correlation with clinical-pathologic characteristics. RESULTS The majority of 1009 NSCLC patients had advanced stages of adenocarcinoma with most tissues obtained from the lung, mediastinal/hilar nodes, or pleura. The majority of testing was performed on cytology or small biopsy specimens. All were tested for EGFR mutations, 895 for ALK rearrangement, 841 for KRAS mutation, 537 for ROS1 rearrangement, and 179 using comprehensive genomic profiling. Implementation of near-universal genomic biomarker testing at our institution for EGFR, ALK, ROS1 and PD-L1 all occurred within the first year following evidence of clinical activity or regulatory body approval of an associated inhibitor. The overall testing failure rate after use of the best specimen for the most common tests was ≤5.5%. A quarter of tumors had a driver oncogene identified (EGFR/ALK/ROS1/BRAF V600E) with an approved oral targeted therapy, with the highest prevalence in those patients with no or light (≤15 pack-years) history of tobacco use. CONCLUSIONS Tumor biomarker testing using clinical NSCLC specimens in routine oncologic care evolves rapidly following approval of targeted therapies linked to diagnostic assays. Our practice's decade plus experience highlights the rapid evolution of biomarker testing and confirms the therapeutic relevance of such testing in all patients-particularly those patients with light/no history of tobacco use.
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Le X, Rangachari D, Costa DB. Moving more potent and less toxic options to the frontline in the management of advanced lung cancer. J Thorac Dis 2017; 9:2812-2818. [PMID: 29221246 DOI: 10.21037/jtd.2017.08.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Heidinger BH, Anderson KR, Nemec U, Costa DB, Gangadharan SP, VanderLaan PA, Bankier AA. Morphologic characteristics of pulmonary adenocarcinomas manifesting as pure ground-glass nodules on CT. J Thorac Dis 2017; 9:E1148-E1150. [PMID: 29313855 DOI: 10.21037/jtd.2017.11.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Heidinger BH, Nemec U, Anderson KR, Costa DB, Gangadharan SP, VanderLaan PA, Bankier AA. "Rounding" the Size of Pulmonary Nodules: Impact of Rounding Methods on Nodule Management, as Defined by the 2017 Fleischner Society Guidelines. Acad Radiol 2017; 24:1422-1427. [PMID: 28666724 DOI: 10.1016/j.acra.2017.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 05/18/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVES The objective of this study was to quantify the impact of different rounding methods on size measurements of pulmonary nodules and to determine the number of nodules that change management categories as a result of rounding. MATERIALS AND METHODS For this retrospective institutional review board-approved study, we included 503 incidental pulmonary nodules (308 solid and 195 subsolid) from a data repository. Long and short axes were measured. Average diameters were calculated using four different rounding methods (method 1: no rounding; method 2: rounding only the average diameter to the closest millimeter; method 3: rounding only short and long axes; and method 4: rounding short and long axes and the average diameter to the closest millimeter). Nodules were classified for each rounding method according to the 2017 Fleischner Society guideline management categories. Measurements were compared among the four rounding methods using analysis of variance. RESULTS Without rounding, the average nodule diameter was 15.67 ± 5.97 mm. This increased between 0.03 and 0.29 mm using rounding methods 2-4 (range: P < 0.001-0.017). The nodule size was more frequently rounded up (range: 52.1%-77.5%) than rounded down (range: 17.7%-42.5%) using rounding methods 2-4, as compared to no rounding. In the 308 solid nodules, up to 2.9% of the nodules changed management category, whereas none of the 195 subsolid nodules changed category. CONCLUSIONS Rounding methods have a small absolute but statically significant effect on nodule size, impacting management category in less than 3% of the nodules. This suggests that, in clinical practice, any rounding method can be used for determining nodule size without substantially biasing individual nodules toward given management categories.
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DiStasio M, Chen Y, Rangachari D, Costa DB, Heher YK, VanderLaan PA. Molecular Testing Turnaround Time for Non–Small Cell Lung Cancer in Routine Clinical Practice Confirms Feasibility of CAP/IASLC/AMP Guideline Recommendations: A Single-center Analysis. Clin Lung Cancer 2017; 18:e349-e356. [DOI: 10.1016/j.cllc.2017.03.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/21/2017] [Accepted: 03/06/2017] [Indexed: 11/29/2022]
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Heidinger BH, Anderson KR, Nemec U, Costa DB, Gangadharan SP, VanderLaan PA, Bankier AA. Lung Adenocarcinoma Manifesting as Pure Ground-Glass Nodules: Correlating CT Size, Volume, Density, and Roundness with Histopathologic Invasion and Size. J Thorac Oncol 2017; 12:1288-1298. [DOI: 10.1016/j.jtho.2017.05.017] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 05/14/2017] [Accepted: 05/15/2017] [Indexed: 12/15/2022]
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Soo RA, Stone ECA, Cummings KM, Jett JR, Field JK, Groen HJM, Mulshine JL, Yatabe Y, Bubendorf L, Dacic S, Rami-Porta R, Detterbeck FC, Lim E, Asamura H, Donington J, Wakelee HA, Wu YL, Higgins K, Senan S, Solomon B, Kim DW, Johnson M, Yang JCH, Sequist LV, Shaw AT, Ahn MJ, Costa DB, Patel JD, Horn L, Gettinger S, Peters S, Wynes MW, Faivre-Finn C, Rudin CM, Tsao A, Baas P, Kelly RJ, Leighl NB, Scagliotti GV, Gandara DR, Hirsch FR, Spigel DR. Scientific Advances in Thoracic Oncology 2016. J Thorac Oncol 2017; 12:1183-1209. [PMID: 28579481 DOI: 10.1016/j.jtho.2017.05.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 05/15/2017] [Accepted: 05/23/2017] [Indexed: 12/21/2022]
Abstract
Lung cancer care is rapidly changing with advances in genomic testing, the development of next-generation targeted kinase inhibitors, and the continued broad study of immunotherapy in new settings and potential combinations. The International Association for the Study of Lung Cancer and the Journal of Thoracic Oncology publish this annual update to help readers keep pace with these important developments. Experts in thoracic cancer and care provide focused updates across multiple areas, including prevention and early detection, molecular diagnostics, pathology and staging, surgery, adjuvant therapy, radiotherapy, molecular targeted therapy, and immunotherapy for NSCLC, SCLC, and mesothelioma. Quality and value of care and perspectives on the future of lung cancer research and treatment have also been included in this concise review.
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Heidinger BH, Anderson KR, Moriarty EM, Costa DB, Gangadharan SP, VanderLaan PA, Bankier AA. Size Measurement and T-staging of Lung Adenocarcinomas Manifesting as Solid Nodules ≤30 mm on CT: Radiology-Pathology Correlation. Acad Radiol 2017; 24:851-859. [PMID: 28256438 DOI: 10.1016/j.acra.2017.01.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 12/20/2022]
Abstract
RATIONALE AND OBJECTIVES This study aimed to compare long-axis diameter to average computed tomography (CT) diameter measurements of lung adenocarcinomas manifesting as solid lung nodules ≤30 mm on CT, as referenced to pathologic measurements, and to determine the impact of the two CT measurement approaches on tumor (T)-staging of nodules. MATERIALS AND METHODS This institutional review board-approved study included all 274 radiologic solid adenocarcinomas resected at our institution over 10 years. Two observers measured long- and short-axis diameters on pre-resection chest CT in lung and mediastinal windows. T-stages were determined. CT measurements and T-stages were compared to pathology measurements and T-stages using Wilcoxon signed rank test and McNemar test. Inter- and intraobserver variability was determined with intraclass correlation coefficients (ICC) and Bland-Altman plots. RESULTS For lung and mediastinal windows, nodule size was significantly larger using long-axis diameter rather than average diameter (16.93 vs. 14.92 mm, P <.001; and 14.02 vs. 12.17 mm, P <.001, respectively). The correlation of CT with pathologic measurements was stronger with long-axis than with average diameter (ICC 0.808 vs. 0.730; and 0.731 vs. 0.621, respectively). Lung window measurements correlated stronger with pathology than mediastinal window measurements. CT T-stages differed from pathology T-stages in more than 20% of nodules (P <.001). Inter- and intraobserver variability was small with long-axis and average diameter (ICC range 0.96-0.991, and 0.970-0.993, respectively), but long-axis diameter showed wider scatter on Bland-Altman plots. CONCLUSIONS Long-axis CT diameter is preferable for T-staging because it better reflects the pathology T-stage. Average CT diameter might be used for longitudinal nodule follow-up because it shows less measurement variability and is more conservative in size assessment.
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Costa DB. Ascending role of next-generation ALK inhibitors. Lancet Oncol 2017; 18:837-839. [PMID: 28602777 DOI: 10.1016/s1470-2045(17)30338-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/07/2017] [Indexed: 12/19/2022]
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Peters MLB, Costa DB, Rangachari D. Compound Uncommon EGFR Mutations in a Patient with Advanced NSCLC and Durable Response to Sequential EGFR Targeted Therapies. J Thorac Oncol 2017; 12:e35-e36. [DOI: 10.1016/j.jtho.2016.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 11/15/2022]
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Rangachari D, Costa DB. Moving the mountain in advanced non-small-cell lung cancer: evolving immunotherapies for a dire disease. Transl Cancer Res 2017; 6:S151-S157. [PMID: 30613479 PMCID: PMC6319878 DOI: 10.21037/tcr.2017.02.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lucena-Araujo AR, Moran JP, VanderLaan PA, Dias-Santagata D, Folch E, Majid A, Kent MS, Gangadharan SP, Rangachari D, Huberman MS, Kobayashi SS, Costa DB. De novo ALK kinase domain mutations are uncommon in kinase inhibitor-naïve ALK rearranged lung cancers. Lung Cancer 2016; 99:17-22. [PMID: 27565908 PMCID: PMC5002311 DOI: 10.1016/j.lungcan.2016.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 05/31/2016] [Accepted: 06/11/2016] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Anaplastic lymphoma kinase (ALK) rearranged lung adenocarcinomas are responsive to the multitargeted ALK inhibitor crizotinib. One of the common mechanisms of resistance to crizotinib is the acquisition of ALK kinase domain mutations. However, the presence of ALK mutations in crizotinib-naïve tumors has not been widely reported and it is unclear if de novo ALK mutations affect the response to crizotinib. METHODS We analyzed preclinical models of ALK rearranged lung cancers that were sensitive/resistant to ALK inhibitors, probed our institutional and other lung cancer databases for tumors with ALK kinase domain mutations, and evaluated tumor response to crizotinib. RESULTS ALK rearranged cell lines with ALK kinase domain mutations were heterogeneously less inhibited by increasing concentrations of crizotinib than cells driven solely by EML4-ALK fusions. Previous ALK rearranged lung cancer cohorts did not report ALK kinase mutations in inhibitor-naïve tumors. We identified one TKI-naïve ALK rearranged tumor with an ALK kinase domain mutation: ALK-S1206F (mutations at ALK-S1206 shifted crizotinib inhibitory curves only minimally in preclinical models). The never smoker whose tumor harbored de novo EML4-ALK-E5;A20+ALK-S1206F only achieved a 4-month radiographic response to crizotinib 250mg twice daily. CONCLUSIONS Combining data from our and prior cohorts, ALK kinase domain mutations were uncommon events (<3% of cases) in ALK inhibitor-naïve ALK rearranged lung adenocarcinomas but their effect on intrinsic resistance to ALK inhibitors should be better evaluated.
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Redig AJ, Costa DB, Taibi M, Boucher D, Johnson BE, Jänne PA, Jackman DM. Prospective Study of Repeated Biopsy Feasibility and Acquired Resistance at Disease Progression in Patients With AdvancedEGFRMutant Lung Cancer Treated With Erlotinib in a Phase 2 Trial. JAMA Oncol 2016; 2:1240-2. [DOI: 10.1001/jamaoncol.2016.1304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Solomon BJ, Cappuzzo F, Felip E, Blackhall FH, Costa DB, Kim DW, Nakagawa K, Wu YL, Mekhail T, Paolini J, Tursi J, Usari T, Wilner KD, Selaru P, Mok TSK. Intracranial Efficacy of Crizotinib Versus Chemotherapy in Patients With Advanced ALK-Positive Non-Small-Cell Lung Cancer: Results From PROFILE 1014. J Clin Oncol 2016; 34:2858-65. [PMID: 27022118 DOI: 10.1200/jco.2015.63.5888] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Intracranial efficacy of first-line crizotinib versus chemotherapy was compared prospectively in the phase III PROFILE 1014 study in ALK-positive non-small-cell lung cancer. PATIENTS AND METHODS Patients were randomly assigned to receive crizotinib (250 mg twice daily; n = 172) or chemotherapy (pemetrexed 500 mg/m(2) plus cisplatin 75 mg/m(2) or carboplatin at area under the curve 5 to 6, every 3 weeks for ≤ six cycles; n = 171). Patients with stable treated brain metastases (tBM) were eligible. Intracranial efficacy was assessed at baseline and every 6 or 12 weeks in patients with or without known brain metastases (BM), respectively; intracranial time to tumor progression (IC-TTP; per protocol) and intracranial disease control rate (IC-DCR; post hoc) were measured. The intent-to-treat population was also assessed. RESULTS Of 343 patients in the intent-to-treat population, 23% had tBM at baseline. A nonsignificant IC-TTP improvement was observed with crizotinib in the intent-to-treat population (hazard ratio [HR], 0.60; P = .069), patients with tBM (HR, 0.45; P = .063), and patients without BM (HR, 0.69; P = .323). Among patients with tBM, IC-DCR was significantly higher with crizotinib versus chemotherapy at 12 weeks (85% v 45%, respectively; P < .001) and 24 weeks (56% v 25%, respectively; P = .006). Progression-free survival was significantly longer with crizotinib versus chemotherapy in both subgroups (tBM present: HR, 0.40; P < .001; median, 9.0 v 4.0 months, respectively; BM absent: HR, 0.51; P < .001; median, 11.1 v 7.2 months, respectively) and in the intent-to-treat population (HR, 0.45; P < .001; median, 10.9 v 7.0 months, respectively). CONCLUSION Compared with chemotherapy, crizotinib demonstrated a significantly higher IC-DCR in patients with tBM. Improvements in IC-TTP were not statistically significant in patients with or without tBM, although sensitivity to detect treatment differences in or between the two subgroups was low.
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Costa DB. Kinase inhibitor-responsive genotypes in EGFR mutated lung adenocarcinomas: moving past common point mutations or indels into uncommon kinase domain duplications and rearrangements. Transl Lung Cancer Res 2016; 5:331-7. [PMID: 27413714 DOI: 10.21037/tlcr.2016.06.04] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The most frequent epidermal growth factor receptor (EGFR) mutations found by traditional or comprehensive molecular profiling of lung adenocarcinomas include indels of exon 19 (the exon 19 deletion delE746_A750 being the most common) and the exon 21 L858R point mutation. The current approval labels for first line palliative gefitinib 250 mg/day, erlotinib 150 mg/day and afatinib 40 mg/day for advanced lung cancers require the presence of the aforementioned classical/sensitizing EGFR mutations. Other gefitinib, erlotinib and afatinib sensitizing mutations include exon 18 indels, G719X, exon 19 insertions, A763_Y764insFQEA, S768I and L861Q; for which off-label EGFR kinase inhibitor use is generally agreed upon by thoracic oncologists. The main biological mechanism of resistance to approved first line EGFR inhibitors is the selection/acquisition of EGFR-T790M that in itself can be inhibited by osimertinib 80 mg/day, a 3(rd) generation EGFR inhibitor that is bypassed by EGFR-C797X mutations. Another class of de novo inhibitor insensitive mutation includes EGFR exon 20 insertions. More recently, the dichotomy of only point mutations or indels explaining aberrant kinase activation of EGFR plus inhibitor response has been shattered by the discovery of uncommon (<0.5% of all EGFR mutations) genomic events involving exon 18-25 kinase domain duplications (KDD) and rearrangements (EGFR-RAD51 or EGFR-PURB). The latter lead to oncogene addiction, enhanced sensitivity to kinase inhibitors in vitro and clinical responses to approved EGFR inhibitors. The enhanced landscape of EGFR inhibitor-responsive genotypes highlights that comprehensive molecular profiling may be necessary to maximize the identification of all cases that can benefit from precision oncology.
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Yanagita M, Redig AJ, Paweletz CP, Dahlberg SE, O'Connell A, Feeney N, Taibi M, Boucher D, Oxnard GR, Johnson BE, Costa DB, Jackman DM, Jänne PA. A Prospective Evaluation of Circulating Tumor Cells and Cell-Free DNA in EGFR-Mutant Non-Small Cell Lung Cancer Patients Treated with Erlotinib on a Phase II Trial. Clin Cancer Res 2016; 22:6010-6020. [PMID: 27281561 DOI: 10.1158/1078-0432.ccr-16-0909] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/21/2016] [Accepted: 05/23/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE Genotype-directed therapy is the standard of care for advanced non-small cell lung cancer (NSCLC), but obtaining tumor tissue for genotyping remains a challenge. Circulating tumor cell (CTC) or cell-free DNA (cfDNA) analysis may allow for noninvasive evaluation. This prospective trial evaluated CTCs and cfDNA in EGFR-mutant NSCLC patients treated with erlotinib until progression. EXPERIMENTAL DESIGN EGFR-mutant NSCLC patients were enrolled in a phase II trial of erlotinib. Blood was collected at baseline, every 2 months on study, and at disease progression. Plasma genotyping was performed by droplet digital PCR for EGFR19del, L858R, and T790M. CTCs were isolated by CellSave, enumerated, and analyzed by immunofluorescence for CD45 and pan-cytokeratin and EGFR and MET FISH were also performed. Rebiopsy was performed at disease progression. RESULTS Sixty patients were enrolled; 44 patients discontinued therapy for disease progression. Rebiopsy occurred in 35 of 44 patients (80%), with paired CTC/cfDNA analysis in 41 of 44 samples at baseline and 36 of 44 samples at progression. T790M was identified in 23 of 35 (66%) tissue biopsies and 9 of 39 (23%) cfDNA samples. CTC analysis at progression identified MET amplification in 3 samples in which tissue analysis could not be performed. cfDNA analysis identified T790M in 2 samples in which rebiopsy was not possible. At diagnosis, high levels of cfDNA but not high levels of CTCs correlated with progression-free survival. CONCLUSIONS cfDNA and CTCs are complementary, noninvasive assays for evaluation of acquired resistance to first-line EGFR TKIs and may expand the number of patients in whom actionable genetic information can be obtained at acquired resistance. Serial cfDNA monitoring may offer greater clinical utility than serial monitoring of CTCs. Clin Cancer Res; 22(24); 6010-20. ©2016 AACR.
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Gao X, Le X, Costa DB. The safety and efficacy of osimertinib for the treatment of EGFR T790M mutation positive non-small-cell lung cancer. Expert Rev Anticancer Ther 2016; 16:383-90. [PMID: 26943236 DOI: 10.1586/14737140.2016.1162103] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
First- and second-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) are the evidence-based first-line treatment for metastatic non-small-cell lung cancers (NSCLCs) that harbor sensitizing EGFR mutations (i.e. exon 19 deletions or L858R). However, acquired resistance to EGFR TKI monotherapy occurs invariably within a median time frame of one year. The most common form of biological resistance is through the selection of tumor clones harboring the EGFR T790M mutation, present in >50% of repeat biopsies. The presence of the EGFR T790M mutation negates the inhibitory activity of gefitinib, erlotinib, and afatinib. A novel class of third-generation EGFR TKIs has been identified by probing a series of covalent pyrimidine EGFR inhibitors that bind to amino-acid residue C797 of EGFR and preferentially inhibit mutant forms of EGFR versus the wild-type receptor. We review the rapid clinical development and approval of the third-generation EGFR TKI osimertinib for treatment of NSCLCs with EGFR-T790M.
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Koyama S, Akbay EA, Li YY, Herter-Sprie GS, Buczkowski KA, Richards WG, Gandhi L, Redig AJ, Rodig SJ, Asahina H, Jones RE, Kulkarni MM, Kuraguchi M, Palakurthi S, Fecci PE, Johnson BE, Janne PA, Engelman JA, Gangadharan SP, Costa DB, Freeman GJ, Bueno R, Hodi FS, Dranoff G, Wong KK, Hammerman PS. Adaptive resistance to therapeutic PD-1 blockade is associated with upregulation of alternative immune checkpoints. Nat Commun 2016; 7:10501. [PMID: 26883990 PMCID: PMC4757784 DOI: 10.1038/ncomms10501] [Citation(s) in RCA: 1082] [Impact Index Per Article: 135.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Accepted: 12/21/2015] [Indexed: 12/11/2022] Open
Abstract
Despite compelling antitumour activity of antibodies targeting the programmed death 1 (PD-1): programmed death ligand 1 (PD-L1) immune checkpoint in lung cancer, resistance to these therapies has increasingly been observed. In this study, to elucidate mechanisms of adaptive resistance, we analyse the tumour immune microenvironment in the context of anti-PD-1 therapy in two fully immunocompetent mouse models of lung adenocarcinoma. In tumours progressing following response to anti-PD-1 therapy, we observe upregulation of alternative immune checkpoints, notably T-cell immunoglobulin mucin-3 (TIM-3), in PD-1 antibody bound T cells and demonstrate a survival advantage with addition of a TIM-3 blocking antibody following failure of PD-1 blockade. Two patients who developed adaptive resistance to anti-PD-1 treatment also show a similar TIM-3 upregulation in blocking antibody-bound T cells at treatment failure. These data suggest that upregulation of TIM-3 and other immune checkpoints may be targetable biomarkers associated with adaptive resistance to PD-1 blockade. Blocking immune checkpoints is a promising strategy to treat lung cancer, but patients often become resistant to the therapy. Here, the authors analyse resistance in mouse models of lung cancer and show in mice and two patients, an increase in the expression of TIM3, which is also involved in the immune response to cancer.
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