1
|
Regua AT, Najjar M, Lo HW. RET signaling pathway and RET inhibitors in human cancer. Front Oncol 2022; 12:932353. [PMID: 35957881 PMCID: PMC9359433 DOI: 10.3389/fonc.2022.932353] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Rearranged during transfection (RET) receptor tyrosine kinase was first identified over thirty years ago as a novel transforming gene. Since its discovery and subsequent pathway characterization, RET alterations have been identified in numerous cancer types and are most prevalent in thyroid carcinomas and non-small cell lung cancer (NSCLC). In other tumor types such as breast cancer and salivary gland carcinomas, RET alterations can be found at lower frequencies. Aberrant RET activity is associated with poor prognosis of thyroid and lung carcinoma patients, and is strongly correlated with increased risk of distant metastases. RET aberrations encompass a variety of genomic or proteomic alterations, most of which confer constitutive activation of RET. Activating RET alterations, such as point mutations or gene fusions, enhance activity of signaling pathways downstream of RET, namely PI3K/AKT, RAS/RAF, MAPK, and PLCγ pathways, to promote cell proliferation, growth, and survival. Given the important role that mutant RET plays in metastatic cancers, significant efforts have been made in developing inhibitors against RET kinase activity. These efforts have led to FDA approval of Selpercatinib and Pralsetinib for NSCLC, as well as, additional selective RET inhibitors in preclinical and clinical testing. This review covers the current biological understanding of RET signaling, the impact of RET hyperactivity on tumor progression in multiple tumor types, and RET inhibitors with promising preclinical and clinical efficacy.
Collapse
Affiliation(s)
- Angelina T. Regua
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Mariana Najjar
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Hui-Wen Lo
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| |
Collapse
|
2
|
Fancelli S, Caliman E, Mazzoni F, Brugia M, Castiglione F, Voltolini L, Pillozzi S, Antonuzzo L. Chasing the Target: New Phenomena of Resistance to Novel Selective RET Inhibitors in Lung Cancer. Updated Evidence and Future Perspectives. Cancers (Basel) 2021; 13:cancers13051091. [PMID: 33806299 PMCID: PMC7961559 DOI: 10.3390/cancers13051091] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/13/2021] [Accepted: 02/26/2021] [Indexed: 12/11/2022] Open
Abstract
Simple Summary REarranged during Transfection (RET) is an emerging target for several types of cancer, including non-small cell lung cancer (NSCLC). The recent U.S. FDA approval of pralsetinib and selpercatinib raises issues regarding the emergence of secondary mutations and amplifications involved in parallel signaling pathways and receptors, liable for resistance mechanisms. The aim of this review is to explore recent knowledge on RET resistance in NSCLC in pre-clinic and in clinical settings and accordingly, the state-of-the-art in new drugs or combination of drugs development. Abstract The potent, RET-selective tyrosine kinase inhibitors (TKIs) pralsetinib and selpercatinib, are effective against the RET V804L/M gatekeeper mutants, however, adaptive mutations that cause resistance at the solvent front RET G810 residue have been found, pointing to the need for the development of the next-generation of RET-specific TKIs. Also, as seen in EGFR- and ALK-driven NSCLC, the rising of the co-occurring amplifications of KRAS and MET could represent other escaping mechanisms from direct inhibition. In this review, we summarize actual knowledge on RET fusions, focusing on those involved in NSCLC, the results of main clinical trials of approved RET-inhibition drugs, with particular attention on recent published results of selective TKIs, and finally, pre-clinical evidence regarding resistance mechanisms and suggestion on hypothetical and feasible drugs combinations and strategies viable in the near future.
Collapse
Affiliation(s)
- Sara Fancelli
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
| | - Enrico Caliman
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Francesca Mazzoni
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
| | - Marco Brugia
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
| | - Francesca Castiglione
- Pathological Histology and Molecular Diagnostics Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Luca Voltolini
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Thoraco-Pulmonary Surgery Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Serena Pillozzi
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
| | - Lorenzo Antonuzzo
- Medical Oncology Unit, Careggi University Hospital, 50134 Florence, Italy; (S.F.); (E.C.); (F.M.); (M.B.); (S.P.)
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Correspondence: ; Tel.: +39-055-7948406
| |
Collapse
|
3
|
Ding S, Wang R, Peng S, Luo X, Zhong L, Yang H, Ma Y, Chen S, Wang W. Targeted therapies for RET-fusion cancer: Dilemmas and breakthrough. Biomed Pharmacother 2020; 132:110901. [PMID: 33125973 DOI: 10.1016/j.biopha.2020.110901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/04/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022] Open
Abstract
Genomic profiling has revolutionized treatment options for patients with oncogene-driven cancers, such as epidermal growth factor receptor (EGFR) mutant carcinoma. Rearranged during transfection (RET) rearrangement, as one of the main activated oncogenes, has been well studied and found to be involved in the malignant behavior of carcinogenesis, resulting in acquired resistance to EGFR tyrosine kinase inhibitors and inducing an intrinsic resistance to immunotherapy. Thus, targeted therapies have been investigated against RET arrangement cancers, including several multi-kinase inhibitors and selective RET inhibitors. However, modest efficacy, a relatively high rate of toxicity, and poor effectiveness against brain metastasis are common limitations of multi-targeted novel molecular inhibitors. A promising prospect was shown recently in selective RET inhibitors in several ongoing clinical trials. In this review, we reviewed the concurrent dilemmas of targeted therapies against RET arrangement cancer from preclinical and clinical studies and proposed several clinical considerations for clinical practice prospectively.
Collapse
Affiliation(s)
- SiJie Ding
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Rong Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - ShunLi Peng
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Xiaoqing Luo
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - LongHui Zhong
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Hong Yang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China; Department of Oncology, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, PR China
| | - YueYun Ma
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - ShiYu Chen
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China
| | - Wei Wang
- Department of Radiation Oncology, Nanfang Hospital, Southern Medical University, Guangzhou, PR China.
| |
Collapse
|
4
|
Madison R, Schrock AB, Castellanos E, Gregg JP, Snider J, Ali SM, Miller VA, Singal G, Alexander BM, Venstrom JM, Chung JH. Retrospective analysis of real-world data to determine clinical outcomes of patients with advanced non-small cell lung cancer following cell-free circulating tumor DNA genomic profiling. Lung Cancer 2020; 148:69-78. [PMID: 32823229 DOI: 10.1016/j.lungcan.2020.07.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 07/12/2020] [Accepted: 07/27/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Liquid biopsy and comprehensive genomic profiling (CGP) of circulating tumor DNA (ctDNA) are increasingly used for detection of targetable genomic alterations (GA) in non-small cell lung cancer (NSCLC). To examine the clinical outcomes for patients following CGP using liquid biopsy versus tissue biopsy, receipt of matched targeted therapy post-CGP and associated outcomes were evaluated in the real-world setting. METHODS 6491 patients with NSCLC and liquid biopsy (N = 937 tests) and/or tissue (N = 5582 tests) CGP were included in a de-identified commercial clinico-genomic database. Targetable GAs included National Comprehensive Cancer Network NSCLC guideline biomarkers. Clinical characteristics, real-world progression, and real-world response (rwR) were obtained via technology-enabled abstraction of clinician notes and radiology/pathology reports. RESULTS At the time of liquid biopsy CGP, 53% (496/937) of patients were documented to have received ≥1 line of prior therapy (tissue CGP: 13%, 735/5582). 90% (832/928) of liquid biopsy cases had evidence of ctDNA. A targetable GA was detected in 20% (188/937) of liquid biopsy and 22% (1215/5582) of tissue CGP cases. Use of matched targeted therapy overall was similar post-liquid biopsy or post-tissue CGP but varied considerably across emerging (25%, 79/317) versus standard of care (SOC) (74%, 475/640) GA. Real-world-progression free survival for patients receiving SOC first line matched targeted therapy administered following liquid biopsy (n = 33) and tissue (n = 229) CGP were similar (13.8 vs 10.6 months; aHR = 0.68 [0.36-1.26]). Among patients evaluated for rwR, overall response rate (partial/complete response) to matched targeted therapy post-liquid biopsy CGP was 75% (39/52) versus 66% post-tissue CGP (254/385, P = 0.51). CONCLUSION Retrospective analysis of real-world clinico-genomic data demonstrated that clinical outcomes on matched targeted therapy were similar following liquid biopsy and tissue CGP in NSCLC, which suggests routine clinical use of liquid biopsy CGP can reliably guide therapy selection.
Collapse
|
5
|
Drilon A, Lin JJ, Filleron T, Ni A, Milia J, Bergagnini I, Hatzoglou V, Velcheti V, Offin M, Li B, Carbone DP, Besse B, Mok T, Awad MM, Wolf J, Owen D, Camidge DR, Riely GJ, Peled N, Kris MG, Mazieres J, Gainor JF, Gautschi O. Frequency of Brain Metastases and Multikinase Inhibitor Outcomes in Patients With RET-Rearranged Lung Cancers. J Thorac Oncol 2018; 13:1595-1601. [PMID: 30017832 PMCID: PMC6434708 DOI: 10.1016/j.jtho.2018.07.004] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/18/2018] [Accepted: 07/03/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION In ret proto-oncogene (RET)-rearranged lung cancers, data on the frequency of brain metastases and, in particular, the outcomes of multikinase inhibitor therapy in patients with intracranial disease are not well characterized. METHODS A global, multi-institutional registry (cohort A, n = 114) and a bi-institutional data set (cohort B, n = 71) of RET-rearranged lung cancer patients were analyzed. Patients were eligible if they had stage IV lung cancers harboring a RET rearrangement by local testing. The incidence of brain metastases and outcomes with multikinase inhibitor therapy were determined. RESULTS The frequency of brain metastases at the time of diagnosis of stage IV disease was 25% (95% confidence interval [CI]: 18%-32%) in all patients from both cohorts. The lifetime prevalence of brain metastasis in stage IV disease was 46% (95% CI: 34%-58%) in patients for whom longitudinal data was available. The cumulative incidence of brain metastases was significantly different (p = 0.0039) between RET-, ROS1-, and ALK receptor tyrosine kinase (ALK)-rearranged lung cancers, with RET intermediate between the other two groups. Although intracranial response data was not available in cohort A, the median progression-free survival of multikinase inhibitor therapy (cabozantinib, vandetanib, or sunitinib) in patients with brain metastases was 2.1 months (95% CI: 1.3-2.9 months, n = 10). In cohort B, an intracranial response was observed in 2 of 11 patients (18%) treated with cabozantinib, vandetanib (± everolimus), ponatinib, or alectinib; the median overall progression-free survival (intracranial and extracranial) was 3.9 months (95% CI: 2.0-4.9 months). CONCLUSIONS Brain metastases occur frequently in RET-rearranged lung cancers, and outcomes with multikinase inhibitor therapy in general are suboptimal. Novel RET-directed targeted therapy strategies are needed.
Collapse
Affiliation(s)
- Alexander Drilon
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY.
| | - Jessica J Lin
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Thomas Filleron
- Department of Medicine, Oncopole University Cancer Institute, Toulouse, France
| | - Ai Ni
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Julie Milia
- Department of Medicine, France Larrey Center University Hospital Toulouse, Toulouse, France
| | - Isabella Bergagnini
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vaios Hatzoglou
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vamsidhar Velcheti
- Department of Medicine, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
| | - Michael Offin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Bob Li
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - David P Carbone
- Department of Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Benjamin Besse
- Department of Medicine, Gustave Roussy Cancer Campus, Villejuif, France
| | - Tony Mok
- Department of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Mark M Awad
- Department of Medicine, Dana Farber Cancer Institute, Cambridge, MA
| | - Jurgen Wolf
- Department of Medicine, Lung Cancer Group Cologne, Center for Integrated Oncology, University Hospital Cologne, Cologne, Germany
| | - Dwight Owen
- Department of Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - D Ross Camidge
- Department of Medicine, University of Colorado-Denver, Aurora, CO
| | - Gregory J Riely
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Nir Peled
- Department of Medicine, Davidoff Cancer Center, Petah Tikva, Israel
| | - Mark G Kris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Julien Mazieres
- Department of Medicine, Oncopole University Cancer Institute, Toulouse, France
| | - Justin F Gainor
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Oliver Gautschi
- Department of Medicine, Cantonal Hospital Lucerne, Luzern, Switzerland
| |
Collapse
|
6
|
Subbiah V, Velcheti V, Tuch BB, Ebata K, Busaidy NL, Cabanillas ME, Wirth LJ, Stock S, Smith S, Lauriault V, Corsi-Travali S, Henry D, Burkard M, Hamor R, Bouhana K, Winski S, Wallace RD, Hartley D, Rhodes S, Reddy M, Brandhuber BJ, Andrews S, Rothenberg SM, Drilon A. Selective RET kinase inhibition for patients with RET-altered cancers. Ann Oncol 2018; 29:1869-1876. [PMID: 29912274 PMCID: PMC6096733 DOI: 10.1093/annonc/mdy137] [Citation(s) in RCA: 295] [Impact Index Per Article: 49.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background Alterations involving the RET kinase are implicated in the pathogenesis of lung, thyroid and other cancers. However, the clinical activity of multikinase inhibitors (MKIs) with anti-RET activity in RET-altered patients appears limited, calling into question the therapeutic potential of targeting RET. LOXO-292 is a selective RET inhibitor designed to inhibit diverse RET fusions, activating mutations and acquired resistance mutations. Patients and methods Potent anti-RET activity, high selectivity, and central nervous system coverage were confirmed preclinically using a variety of in vitro and in vivo RET-dependent tumor models. Due to clinical urgency, two patients with RET-altered, MKI-resistant cancers were treated with LOXO-292, utilizing rapid dose-titration guided by real-time pharmacokinetic assessments to achieve meaningful clinical exposures safely and rapidly. Results LOXO-292 demonstrated potent and selective anti-RET activity preclinically against human cancer cell lines harboring endogenous RET gene alterations; cells engineered to express a KIF5B-RET fusion protein -/+ the RET V804M gatekeeper resistance mutation or the common RET activating mutation M918T; and RET-altered human cancer cell line and patient-derived xenografts, including a patient-derived RET fusion-positive xenograft injected orthotopically into the brain. A patient with RET M918T-mutant medullary thyroid cancer metastatic to the liver and an acquired RET V804M gatekeeper resistance mutation, previously treated with six MKI regimens, experienced rapid reductions in tumor calcitonin, CEA and cell-free DNA, resolution of painful hepatomegaly and tumor-related diarrhea and a confirmed tumor response. A second patient with KIF5B-RET fusion-positive lung cancer, acquired resistance to alectinib and symptomatic brain metastases experienced a dramatic response in the brain, and her symptoms resolved. Conclusions These results provide proof-of-concept of the clinical actionability of RET alterations, and identify selective RET inhibition by LOXO-292 as a promising treatment in heavily pretreated, multikinase inhibitor-experienced patients with diverse RET-altered tumors.
Collapse
Affiliation(s)
- V Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - V Velcheti
- The Cleveland Clinic Foundation, Cleveland, USA
| | - B B Tuch
- Loxo Oncology, Inc., Stamford, USA
| | - K Ebata
- Loxo Oncology, Inc., Stamford, USA
| | - N L Busaidy
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - M E Cabanillas
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - L J Wirth
- Massachusetts General Hospital Cancer Center, Boston, USA
| | - S Stock
- The Cleveland Clinic Foundation, Cleveland, USA
| | - S Smith
- Loxo Oncology, Inc., Stamford, USA
| | | | | | - D Henry
- Loxo Oncology, Inc., Stamford, USA
| | | | - R Hamor
- Array BioPharma, Inc., Boulder, USA
| | | | - S Winski
- Array BioPharma, Inc., Boulder, USA
| | | | | | - S Rhodes
- Array BioPharma, Inc., Boulder, USA
| | - M Reddy
- Array BioPharma, Inc., Boulder, USA
| | | | | | | | - A Drilon
- Memorial Sloan Kettering Cancer Center, New York, USA.
| |
Collapse
|