1
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Ingles Garces AH, Porta N, Graham TA, Banerji U. Clinical trial designs for evaluating and exploiting cancer evolution. Cancer Treat Rev 2023; 118:102583. [PMID: 37331179 DOI: 10.1016/j.ctrv.2023.102583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 06/20/2023]
Abstract
The evolution of drug-resistant cell subpopulations causes cancer treatment failure. Current preclinical evidence shows that it is possible to model herding of clonal evolution and collateral sensitivity where an initial treatment could favourably influence the response to a subsequent one. Novel therapy strategies exploiting this understanding are being considered, and clinical trial designs for steering cancer evolution are needed. Furthermore, preclinical evidence suggests that different subsets of drug-sensitive and resistant clones could compete between themselves for nutrients/blood supply, and clones that populate a tumour do so at the expense of other clones. Treatment paradigms based on this clinical application of exploiting cell-cell competition include intermittent dosing regimens or cycling different treatments before progression. This will require clinical trial designs different from the conventional practice of evaluating responses to individual therapy regimens. Next-generation sequencing to assess clonal dynamics longitudinally will improve current radiological assessment of clinical response/resistance and be incorporated into trials exploiting evolution. Furthermore, if understood, clonal evolution can be used to therapeutic advantage, improving patient outcomes based on a new generation of clinical trials.
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Affiliation(s)
- Alvaro H Ingles Garces
- Drug Development Unit, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, UK
| | - Nuria Porta
- Clinical Trials and Statistical Unit, The Institute of Cancer Research, UK
| | - Trevor A Graham
- Centre for Evolution and Cancer, The Institute of Cancer Research, UK
| | - Udai Banerji
- Drug Development Unit, The Institute of Cancer Research and The Royal Marsden NHS Foundation Trust, UK.
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2
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Zhong J, Bai H, Wang Z, Duan J, Zhuang W, Wang D, Wan R, Xu J, Fei K, Ma Z, Zhang X, Wang J. Treatment of advanced non-small cell lung cancer with driver mutations: current applications and future directions. Front Med 2023; 17:18-42. [PMID: 36848029 DOI: 10.1007/s11684-022-0976-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/05/2022] [Indexed: 03/01/2023]
Abstract
With the improved understanding of driver mutations in non-small cell lung cancer (NSCLC), expanding the targeted therapeutic options improved the survival and safety. However, responses to these agents are commonly temporary and incomplete. Moreover, even patients with the same oncogenic driver gene can respond diversely to the same agent. Furthermore, the therapeutic role of immune-checkpoint inhibitors (ICIs) in oncogene-driven NSCLC remains unclear. Therefore, this review aimed to classify the management of NSCLC with driver mutations based on the gene subtype, concomitant mutation, and dynamic alternation. Then, we provide an overview of the resistant mechanism of target therapy occurring in targeted alternations ("target-dependent resistance") and in the parallel and downstream pathways ("target-independent resistance"). Thirdly, we discuss the effectiveness of ICIs for NSCLC with driver mutations and the combined therapeutic approaches that might reverse the immunosuppressive tumor immune microenvironment. Finally, we listed the emerging treatment strategies for the new oncogenic alternations, and proposed the perspective of NSCLC with driver mutations. This review will guide clinicians to design tailored treatments for NSCLC with driver mutations.
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Affiliation(s)
- Jia Zhong
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hua Bai
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zhijie Wang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jianchun Duan
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Wei Zhuang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Di Wang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Rui Wan
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jiachen Xu
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Kailun Fei
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Zixiao Ma
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Xue Zhang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jie Wang
- State Key Laboratory of Molecular Oncology, Department of Medical Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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3
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The prospect of combination therapies with the third-generation EGFR-TKIs to overcome the resistance in NSCLC. Biomed Pharmacother 2022; 156:113959. [DOI: 10.1016/j.biopha.2022.113959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
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4
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Giustini NP, Patel SP, Myall NJ, Fernando do Prado Moura J, Kulkarni A, Chao RC, Wakelee H, Bazhenova L. Resistance to EGFR Tyrosine Kinase Inhibitor Therapy in Non-Small-Cell Lung Cancer via Newly Acquired Targetable Oncogenic Driver Alterations With an Emphasis on BRAF: Case Series and Literature Review of Treatment. JCO Precis Oncol 2022; 6:e2100551. [PMID: 35952324 DOI: 10.1200/po.21.00551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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5
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Shi K, Wang G, Pei J, Zhang J, Wang J, Ouyang L, Wang Y, Li W. Emerging strategies to overcome resistance to third-generation EGFR inhibitors. J Hematol Oncol 2022; 15:94. [PMID: 35840984 PMCID: PMC9287895 DOI: 10.1186/s13045-022-01311-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/28/2022] [Indexed: 02/08/2023] Open
Abstract
Epidermal growth factor receptor (EGFR), the receptor for members of the epidermal growth factor family, regulates cell proliferation and signal transduction; moreover, EGFR is related to the inhibition of tumor cell proliferation, angiogenesis, invasion, metastasis, and apoptosis. Therefore, EGFR has become an important target for the treatment of cancer, including non-small cell lung cancer, head and neck cancer, breast cancer, glioma, cervical cancer, and bladder cancer. First- to third-generation EGFR inhibitors have shown considerable efficacy and have significantly improved disease prognosis. However, most patients develop drug resistance after treatment. The challenge of overcoming intrinsic and acquired resistance in primary and recurrent cancer mediated by EGFR mutations is thus driving the search for alternative strategies in the design of new therapeutic agents. In view of resistance to third-generation inhibitors, understanding the intricate mechanisms of resistance will offer insight for the development of more advanced targeted therapies. In this review, we discuss the molecular mechanisms of resistance to third-generation EGFR inhibitors and review recent strategies for overcoming resistance, new challenges, and future development directions.
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Affiliation(s)
- Kunyu Shi
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China.,Tianfu Jincheng Laboratory, Chengdu, 610041, China
| | - Guan Wang
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Junping Pei
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jifa Zhang
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China.,Tianfu Jincheng Laboratory, Chengdu, 610041, China
| | - Jiaxing Wang
- Department of Pharmaceutical Sciences, College of Pharmacy, University of Tennessee Health Science Center, Memphis, TN, 38163, USA
| | - Liang Ouyang
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China. .,State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, and Collaborative Innovation Center of Biotherapy, Sichuan University, Chengdu, 610041, China. .,Tianfu Jincheng Laboratory, Chengdu, 610041, China.
| | - Yuxi Wang
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China. .,Precision Medicine Key Laboratory of Sichuan Province and Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, 610041, China. .,Tianfu Jincheng Laboratory, Chengdu, 610041, China.
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, Targeted Tracer Research and Development Laboratory, Institute of Respiratory Health, Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Sichuan University, Chengdu, 610041, China. .,Precision Medicine Key Laboratory of Sichuan Province and Precision Medicine Research Center, West China Hospital, Sichuan University, Chengdu, 610041, China. .,Tianfu Jincheng Laboratory, Chengdu, 610041, China.
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6
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Acquired Resistance to Osimertinib in EGFR-Mutated Non-Small Cell Lung Cancer: How Do We Overcome It? Int J Mol Sci 2022; 23:ijms23136936. [PMID: 35805940 PMCID: PMC9266773 DOI: 10.3390/ijms23136936] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 06/20/2022] [Accepted: 06/21/2022] [Indexed: 02/04/2023] Open
Abstract
Osimertinib is currently the preferred first-line therapy in patients with non-small cell lung cancer (NSCLC) with common epidermal growth factor receptor (EGFR) mutation and the standard second-line therapy in T790M-positive patients in progression to previous EGFR tyrosine kinase inhibitor. Osimertinib is a highly effective treatment that shows a high response rate and long-lasting disease control. However, a resistance to the treatment inevitably develops among patients. Understanding the secondary mechanisms of resistance and the possible therapeutic options available is crucial to define the best management of patients in progression to osimertinib. We provide a comprehensive review of the emerging molecular resistance mechanism in EGFR-mutated NSCLC pre-treated with osimertinib and its future treatment applications.
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7
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Acquired Mechanisms of Resistance to Osimertinib-The Next Challenge. Cancers (Basel) 2022; 14:cancers14081931. [PMID: 35454838 PMCID: PMC9027936 DOI: 10.3390/cancers14081931] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 12/03/2022] Open
Abstract
Simple Summary Osimertinib has revolutionized the treatment of EGFR-mutated tumors. Its current applications include the first-line setting, second-line setting, as well as the adjuvant setting. Although it represents a milestone in the context of targeted therapy, inevitably all tumors develop an acquired resistance, some mechanisms involve EGFR, others do so through alternative pathways leading to a bypass in osimertinib inhibition. It is key to understand these acquired mechanisms of resistance, both in the clinical setting, as well as in preclinical models, in order to develop and contribute to the identification of possible therapeutic strategies to overcome this acquired resistance. Abstract EGFR-mutated tumors represent a significant percentage of non-small cell lung cancer. Despite the increasing use of osimertinib, a treatment that has demonstrated an outstanding clinical benefit with a tolerable toxicity profile, EGFR tumors eventually acquire mechanisms of resistance. In the last years, multiple mechanisms of resistance have been identified; however, after progressing on osimertinib, treatment options remain bleak. In this review, we cover the most frequent alterations and potential therapeutic strategies to overcome them.
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8
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Di Noia V, D'Aveni A, D'Argento E, Rossi S, Ghirardelli P, Bortolotti L, Vavassori V, Bria E, Ceresoli GL. Treating disease progression with osimertinib in EGFR-mutated non-small-cell lung cancer: novel targeted agents and combination strategies. ESMO Open 2021; 6:100280. [PMID: 34634633 PMCID: PMC8506968 DOI: 10.1016/j.esmoop.2021.100280] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 01/10/2023] Open
Abstract
A precision medicine approach has been successfully applied in medical oncology for the treatment of non-small-cell lung cancer (NSCLC) through the identification of targetable driver molecular aberrations; activating mutations of epidermal growth factor receptor (EGFR) are the most common. Osimertinib, a third-generation, wild-type sparing, irreversible EGFR tyrosine kinase inhibitor (TKI), originally showed a striking activity after progression to first- and second-generation EGFR-TKIs when T790M resistance mutation was identified. Thereafter, upfront use of osimertinib became the standard of care based on overall survival benefit over first-generation TKIs erlotinib and gefitinib as reported in the FLAURA trial. For patients progressing on osimertinib, identification of resistance mechanisms is crucial to develop novel targeted therapeutic approaches. Moreover, innovative drugs or combination therapies are being developed for cases in which a specific resistance mechanism is not identifiable. In this review, the post-osimertinib treatment options for EGFR-mutated NSCLC are analyzed, with an outlook to ongoing clinical trials. An algorithm to guide clinicians in managing progression on osimertinib is proposed.
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Affiliation(s)
- V Di Noia
- Medical Oncology 1 Unit, IRCCS Regina Elena National Cancer Institute, Rome, Italy.
| | - A D'Aveni
- Department of Medical Oncology 1, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - E D'Argento
- Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - S Rossi
- Department of Oncology and Hematology, Humanitas Clinical and Research Center, Rozzano, Italy
| | - P Ghirardelli
- Department of Medical Oncology 1, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - L Bortolotti
- Department of Medical Oncology 1, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - V Vavassori
- Department of Medical Oncology 1, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - E Bria
- Comprehensive Cancer Center, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Istituto di Medicina Interna e Geriatria, Università; Cattolica del Sacro Cuore, Rome, Italy
| | - G L Ceresoli
- Department of Medical Oncology 1, Cliniche Humanitas Gavazzeni, Bergamo, Italy
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9
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He J, Huang Z, Han L, Gong Y, Xie C. Mechanisms and management of 3rd‑generation EGFR‑TKI resistance in advanced non‑small cell lung cancer (Review). Int J Oncol 2021; 59:90. [PMID: 34558640 PMCID: PMC8562388 DOI: 10.3892/ijo.2021.5270] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/09/2021] [Indexed: 12/17/2022] Open
Abstract
Targeted therapy with epidermal growth factor receptor (EGFR)‑tyrosine kinase inhibitors (TKIs) is a standard modality of the 1st‑line treatments for patients with advanced EGFR‑mutated non‑small cell lung cancer (NSCLC), and substantially improves their prognosis. However, EGFR T790M mutation is the primary mechanism of 1st‑ and 2nd‑generation EGFR‑TKI resistance. Osimertinib is a representative of the 3rd‑generation EGFR‑TKIs that target T790M mutation, and has satisfactory efficacy in the treatment of T790M‑positive NSCLC with disease progression following use of 1st‑ or 2nd‑generation EGFR‑TKIs. Other 3rd‑generation EGFR‑TKIs, such as abivertinib, rociletinib, nazartinib, olmutinib and alflutinib, are also at various stages of development. However, the occurrence of acquired resistance is inevitable, and the mechanisms of 3rd‑generation EGFR‑TKI resistance are complex and incompletely understood. Genomic studies in tissue and liquid biopsies of resistant patients reveal multiple candidate pathways. The present review summarizes the recent findings in mechanisms of resistance to 3rd‑generation EGFR‑TKIs in advanced NSCLC, and provides possible strategies to overcome this resistance. The mechanisms of acquired resistance mainly include an altered EGFR signaling pathway (EGFR tertiary mutations and amplification), activation of aberrant bypassing pathways (hepatocyte growth factor receptor amplification, human epidermal growth factor receptor 2 amplification and aberrant insulin‑like growth factor 1 receptor activation), downstream pathway activation (RAS/RAF/MEK/ERK and PI3K/AKT/mTOR) and histological/phenotypic transformations (SCLC transformation and epithelial‑mesenchymal transition). The combination of targeted therapies is a promising strategy to treat osimertinib‑resistant patients, and multiple clinical studies on novel combined therapies are ongoing.
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Affiliation(s)
- Jingyi He
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Zhengrong Huang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Linzhi Han
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Yan Gong
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, Wuhan, Hubei 430071, P.R. China
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10
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Shaikh M, Shinde Y, Pawara R, Noolvi M, Surana S, Ahmad I, Patel H. Emerging Approaches to Overcome Acquired Drug Resistance Obstacles to Osimertinib in Non-Small-Cell Lung Cancer. J Med Chem 2021; 65:1008-1046. [PMID: 34323489 DOI: 10.1021/acs.jmedchem.1c00876] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The pyrimidine core-containing compound Osimertinib is the only epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) from the third generation that has been approved by the U.S. Food and Drug Administration to target threonine 790 methionine (T790M) resistance while sparing the wild-type epidermal growth factor receptor (WT EGFR). It is nearly 200-fold more selective toward the mutant EGFR as compared to the WT EGFR. A tertiary cystein 797 to serine 797 (C797S) mutation in the EGFR kinase domain has hampered Osimertinib treatment in patients with advanced EGFR-mutated non-small-cell lung cancer (NSCLC). This C797S mutation is presumed to induce a tertiary-acquired resistance to all current reversible and irreversible EGFR TKIs. This review summarizes the molecular mechanisms of resistance to Osimertinib as well as different strategies for overcoming the EGFR-dependent and EGFR-independent mechanisms of resistance, new challenges, and a future direction.
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Affiliation(s)
- Matin Shaikh
- H. R. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
| | - Yashodeep Shinde
- R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
| | - Rahul Pawara
- R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
| | - Malleshappa Noolvi
- Shree Dhanvantari College of Pharmacy, Kim, Surat, Gujarat, India 394111
| | - Sanjay Surana
- R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
| | - Iqrar Ahmad
- R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
| | - Harun Patel
- R. C. Patel Institute of Pharmaceutical Education and Research, Shirpur, Maharashtra, India 425405
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11
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Chen MT, Fu XH, Huang H, Wang Z, Fang XJ, Yao YY, Ren QG, Chen ZG, Lin TY. Combination of crizotinib and chemotherapy in patients with relapsed or refractory anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL). Leuk Lymphoma 2020; 62:571-580. [PMID: 33155495 DOI: 10.1080/10428194.2020.1839658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our aim was to explore the role of crizotinib, targeted anaplastic lymphoma kinase (ALK), on r/r systemic anaplastic large cell lymphoma (sALCL). The treated group prospectively screened 20 patients. After taking crizotinib in the first week, 16 patients who were tolerant and sensitive received the combination of crizotinib with chemotherapy. The control group included 27 patients receiving chemotherapy in the same hospital during the same period. The objective remission rates of the treated and control group were 81.3% and 74.1% (p = .869), respectively. The progression-free survival rates at two years in treated and control group were 68.7% and 45.0% (HR = 0.42, 95% CI 0.17-0.99, p < .05), respectively. The overall survival rates at two years in the treated and control group were 86.1% and 78.9% (p = .385, HR = 0.51, 95% CI 0.11-2.30), respectively. The main adverse events included elevated transaminase, diarrhea, and vision abnormalities. Thus, the combination of crizotinib with chemotherapy might be effective in ALK-positive and crizotinib sensitive r/r sALCL patients.
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Affiliation(s)
- Mei-Ting Chen
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiao-Hong Fu
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China.,Department of Medical Oncology, Shenzhen Nanshan People's Hospital, Shenzhen, China.,Department of Medical Oncology, Affiliated Shenzhen Sixth Hospital of Guangdong Medical University, Shenzhen, China
| | - He Huang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Zhao Wang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Xiao-Jie Fang
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Yu-Yi Yao
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Quan-Guang Ren
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Ze-Geng Chen
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
| | - Tong-Yu Lin
- Department of Medical Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
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12
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Yang SR, Schultheis AM, Yu H, Mandelker D, Ladanyi M, Büttner R. Precision medicine in non-small cell lung cancer: Current applications and future directions. Semin Cancer Biol 2020; 84:184-198. [PMID: 32730814 DOI: 10.1016/j.semcancer.2020.07.009] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/24/2020] [Accepted: 07/13/2020] [Indexed: 12/24/2022]
Abstract
Advances in biomarkers, targeted therapies, and immuno-oncology have transformed the clinical management of patients with advanced NSCLC. For oncogene-driven tumors, there are highly effective targeted therapies against EGFR, ALK, ROS1, BRAF, TRK, RET, and MET. In addition, investigational therapies for KRAS, NRG1, and HER2 have shown promising results and may become standard-of-care in the near future. In parallel, immune-checkpoint therapy has emerged as an indispensable treatment modality, especially for patients lacking actionable oncogenic drivers. While PD-L1 expression has shown modest predictive utility, biomarkers for immune-checkpoint inhibition in NSCLC have remained elusive and represent an area of active investigation. Given the growing importance of biomarkers, optimal utilization of small tissue biopsies and alternative genotyping methods using circulating cell-free DNA have become increasingly integrated into clinical practice. In this review, we will summarize the current landscape and emerging trends in precision medicine for patients with advanced NSCLC with a special focus on predictive biomarker testing.
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Affiliation(s)
- Soo-Ryum Yang
- Memorial Sloan Kettering Cancer Center, Department of Pathology, United States
| | | | - Helena Yu
- Memorial Sloan Kettering Cancer Center, Department of Medicine, United States
| | - Diana Mandelker
- Memorial Sloan Kettering Cancer Center, Department of Pathology, United States
| | - Marc Ladanyi
- Memorial Sloan Kettering Cancer Center, Department of Pathology, United States
| | - Reinhard Büttner
- University Hospital of Cologne, Department of Pathology, Germany.
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13
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Piper-Vallillo AJ, Sequist LV, Piotrowska Z. Emerging Treatment Paradigms for EGFR-Mutant Lung Cancers Progressing on Osimertinib: A Review. J Clin Oncol 2020; 38:JCO1903123. [PMID: 32552277 DOI: 10.1200/jco.19.03123] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2020] [Indexed: 02/28/2024] Open
Abstract
Since its approval in April 2018, osimertinib has been widely adopted as first-line therapy for patients with advanced EGFR-mutant non -small cell lung cancer (NSCLC). Understanding osimertinib resistance mechanisms and currently available treatment options are essential to selecting optimal second line therapy for patients whose disease progresses during front-line osimertinib. Using data compiled from 6 osimertinib-resistance series, we describe here the heterogeneous profile of EGFR-dependent and independent mechanisms of osimertinib treatment failure. We identified MET alterations (7%-24%), EGFR C797X (0%-29%), SCLC transformation (2%-15%), and oncogene fusions (1%-10%) as the most common mechanisms of resistance. This review provides an evidence-based, algorithmic approach to the evaluation and management of post-osimertinib progression as well as a compendium of active, enrolling clinical trials for this population.
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Affiliation(s)
- Andrew J Piper-Vallillo
- Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Lecia V Sequist
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Zofia Piotrowska
- Harvard Medical School, Boston, MA
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
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14
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Leonetti A, Tiseo M, Rolfo C, Van Der Steen N, Peters GJ, Giovannetti E. Can We Optimize the Selection of Patients With Lung Cancer Suitable for EGFR+MET Double Inhibition? JCO Precis Oncol 2019:1-2. [DOI: 10.1200/po.19.00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2019] [Indexed: 09/11/2023] Open
Affiliation(s)
- Alessandro Leonetti
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
| | - Marcello Tiseo
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
| | - Christian Rolfo
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
| | - Nele Van Der Steen
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
| | - Godefridus J. Peters
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
| | - Elisa Giovannetti
- Alessandro Leonetti, MD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and University Hospital of Parma, Parma, Italy; Marcello Tiseo, MD, PhD, University Hospital of Parma and University of Parma, Parma, Italy; Christian Rolfo, MD, PhD, MBA, University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD; Nele Van Der Steen, PhD, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, the Netherlands, and Center
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15
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Girard N. Optimizing outcomes and treatment sequences in EGFR mutation-positive non-small-cell lung cancer: recent updates. Future Oncol 2019; 15:2983-2997. [PMID: 31452384 DOI: 10.2217/fon-2019-0400] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The availability of several EGFR tyrosine kinase inhibitors (TKIs) for the treatment of EGFR mutation-positive NSCLC poses important questions regarding the optimum sequence of therapy. A key consideration is how best to use the third-generation TKI, osimertinib. While osimertinib has demonstrated impressive efficacy and tolerability in a first-line setting, there are currently no standard targeted treatment options following progression. There is an argument, therefore, for reserving osimertinib for second-line use in patients who acquire the T790M resistance mutation after first- or second-generation TKIs. This article reviews recent clinical studies that have assessed the activity of sequential EGFR TKI regimens. These studies support the hypothesis that sequential use of EGFR TKIs represents a viable treatment option in 'real-world' clinical practice.
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Affiliation(s)
- Nicolas Girard
- Thoracic Surgery, Institut Curie, Institut du Thorax Curie-Montsouris, Paris, France
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16
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Del Re M, Crucitta S, Gianfilippo G, Passaro A, Petrini I, Restante G, Michelucci A, Fogli S, de Marinis F, Porta C, Chella A, Danesi R. Understanding the Mechanisms of Resistance in EGFR-Positive NSCLC: From Tissue to Liquid Biopsy to Guide Treatment Strategy. Int J Mol Sci 2019; 20:ijms20163951. [PMID: 31416192 PMCID: PMC6720634 DOI: 10.3390/ijms20163951] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Liquid biopsy has emerged as an alternative source of nucleic acids for the management of Epidermal Growth Factor Receptor (EGFR)-mutant non-Small Cell Lung Cancer (NSCLC). The use of circulating cell-free DNA (cfDNA) has been recently introduced in clinical practice, resulting in the improvement of the identification of druggable EGFR mutations for the diagnosis and monitoring of response to targeted therapy. EGFR-dependent (T790M and C797S mutations) and independent (Mesenchymal Epithelial Transition [MET] gene amplification, Kirsten Rat Sarcoma [KRAS], Phosphatidyl-Inositol 4,5-bisphosphate 3-Kinase Catalytic subunit Alpha isoform [PI3KCA], and RAF murine sarcoma viral oncogene homolog B1 [BRAF] gene mutations) mechanisms of resistance to EGFR tyrosine kinase inhibitors (TKIs) have been evaluated in plasma samples from NSCLC patients using highly sensitive methods (i.e., digital droplet PCR, Next Generation Sequencing), allowing for the switch to other therapies. Therefore, liquid biopsy is a non-invasive method able to detect the molecular dynamic changes that occur under the pressure of treatment, and to capture tumor heterogeneity more efficiently than is allowed by tissue biopsy. This review addresses how liquid biopsy may be used to guide the choice of treatment strategy in EGFR-mutant NSCLC.
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Affiliation(s)
- Marzia Del Re
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy.
| | - Stefania Crucitta
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giulia Gianfilippo
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, European Institute of Oncology, 20141 Milano, Italy
| | - Iacopo Petrini
- General Pathology, Department of Translational Research & New Technologies in Surgery and Medicine, University of Pisa, 56126 Pisa, Italy
| | - Giuliana Restante
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Angela Michelucci
- Unit of Molecular Genetics, Department of Laboratory Medicine, University Hospital, 56126 Pisa, Italy
| | - Stefano Fogli
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Filippo de Marinis
- Division of Thoracic Oncology, European Institute of Oncology, 20141 Milano, Italy
| | - Camillo Porta
- Department of Internal Medicine, University of Pavia, 27100 Pavia, Italy
- Division of Translational Oncology, I.R.C.C.S. Istituti Clinici Scientifici Maugeri, 27100 Pavia, Italy
| | - Antonio Chella
- Unit of Respiratory Medicine, Department of Critical Area and Surgical, Medical and Molecular Pathology, University Hospital, 56126 Pisa, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
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17
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Zhang YC, Zhou Q, Wu YL. Clinical management of third-generation EGFR inhibitor-resistant patients with advanced non-small cell lung cancer: Current status and future perspectives. Cancer Lett 2019; 459:240-247. [PMID: 31201840 DOI: 10.1016/j.canlet.2019.05.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 05/31/2019] [Accepted: 05/31/2019] [Indexed: 12/14/2022]
Abstract
Discovery of activating mutations in epidermal growth factor receptor (EGFR) as a predictive biomarker for first-generation EGFR tyrosine kinase inhibitors (TKIs) has initiated an era of precision oncology for the treatment of advanced EGFR-mutant non-small cell lung cancer (NSCLC). Despite the robust efficacy of first- and second-generation EGFR TKIs, disease relapse is inevitable. EGFR T790M mutation is the predominant cause of disease relapse and third-generation, irreversible EGFR inhibitors designed for targeting EGFR T790M and activating mutations have demonstrated promising clinical activity and tolerability. Unfortunately, disease progression inevitably occurs and heterogenous resistance mechanisms have been reported with limited subsequent treatment strategies available. Till now, treatment approaches for patients progressed from third-generation EGFR TKIs have not been clearly established. In this review, we summarize the recent findings in resistance mechanisms to third-generation EGFR TKIs and emerging treatment approaches for EGFR-mutant patients after resistance to third-generation EGFR TKIs. We further discuss clinical challenges and future perspectives for management of EGFR-mutant patients resistant to third-generation EGFR TKIs.
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Affiliation(s)
- Yi-Chen Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qing Zhou
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China.
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18
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Zhang YC, Chen ZH, Zhang XC, Xu CR, Yan HH, Xie Z, Chuai SK, Ye JY, Han-Zhang H, Zhang Z, Bai XY, Su J, Gan B, Yang JJ, Li WF, Tang W, Luo FR, Xu X, Wu YL, Zhou Q. Analysis of resistance mechanisms to abivertinib, a third-generation EGFR tyrosine kinase inhibitor, in patients with EGFR T790M-positive non-small cell lung cancer from a phase I trial. EBioMedicine 2019; 43:180-187. [PMID: 31027916 PMCID: PMC6558024 DOI: 10.1016/j.ebiom.2019.04.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/12/2019] [Accepted: 04/15/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Resistance to third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) presents a major clinical challenge in advanced non-small cell lung cancer (NSCLC). Here, we report resistance mechanisms to abivertinib, a novel third-generation EGFR TKI, from a phase I dose-escalation/expansion study (NCT02330367). METHODS Patients with EGFR T790M-positive advanced NSCLC and progression on prior EGFR TKIs received abivertinib in dose escalation (50-350 mg twice daily [BID]) or expansion (300 mg BID) cohorts. Patients enrolled at Guangdong Lung Cancer Institute who underwent next-generation sequencing (NGS)-based genomic profiling upon abivertinib progression (prior to October 30, 2018) were enrolled in this exploratory analysis. FINDINGS Thirty of 73 patients enrolled were eligible for resistance analysis. Upon abivertinib progression, 27 patients provided plasma samples (six patients also provided paired samples from the progression sites) and three patients only provided tissue samples from the progression sites for NGS. A heterogeneous landscape of resistance to abivertinib was observed: 15% (4/27) experienced EGFR T790M loss and 13% (4/30) developing EGFR tertiary mutations including C797S. EGFR amplification was observed in 11 patients (37%), and considered a putative resistance mechanism in seven (23%) patients. Other EGFR-independent resistance mechanisms involved CDKN2A, MET, PIK3CA, HER2, TP53, Rb1 and small-cell lung cancer transformation. INTERPRETATION Our findings reveal a heterogenous pattern of resistance mechanisms to abivertinib which is distinct from that previously reported with osimertinib. EGFR amplification was the most common resistance mechanism in this cohort. FUND: The National Key R&D Program of China (Grant No. 2016YFC1303800), Key Lab System Project of Guangdong Science and Technology Department - Guangdong Provincial Key Lab of Translational Medicine in Lung Cancer (Grant No. 2012A061400006/2017B030314120).
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Affiliation(s)
- Yi-Chen Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi-Hong Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xu-Chao Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Chong-Rui Xu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hong-Hong Yan
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhi Xie
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | | | - Jun-Yi Ye
- Burning Rock Biotech, Guangzhou, China
| | | | | | - Xiao-Yan Bai
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Su
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Bin Gan
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin-Ji Yang
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wen-Feng Li
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei Tang
- ACEA Therapeutics Inc., San Diego, CA, USA
| | | | - Xiao Xu
- ACEA Therapeutics Inc., San Diego, CA, USA
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China.
| | - Qing Zhou
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China.
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19
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Singhi EK, Horn L, Sequist LV, Heymach J, Langer CJ. Advanced Non-Small Cell Lung Cancer: Sequencing Agents in the EGFR-Mutated/ALK-Rearranged Populations. Am Soc Clin Oncol Educ Book 2019; 39:e187-e197. [PMID: 31099642 DOI: 10.1200/edbk_237821] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Personalized therapy based on actionable molecular markers has completely transformed the therapeutic landscape in advanced non-small cell lung cancer (NSCLC). In less than 15 years, multiple molecular targets, led by EGFR and anaplastic lymphoma kinase (ALK), have been identified, and myriad oral tyrosine kinase inhibitors (TKIs) are now available to target these oncogenic drivers, with the expectation that the majority of patients will respond to treatment and that progression-free survival (PFS) will exceed 10 to 30 months, far better than we observed historically with chemotherapy alone. As a result, prognosis has improved dramatically in this subset of patients. Osimertinib has largely displaced first- and second-generation EGFR TKIs, including gefitinib, erlotinib, and afatinib, in the management of EGFR-mutated NSCLC. PFS now exceeds 18 months, and central nervous system penetrance is enhanced. Dacomitinib has the distinction of being the first EGFR TKI to demonstrate a survival advantage compared with older TKIs. Recent data suggest therapeutic additivity, if not synergy, for the concurrent use of chemotherapy, as well as monoclonal antibodies targeting angiogenesis, with EGFR TKIs. Alectinib and brigatinib, very specific ALK inhibitors, have proven superior to the erstwhile standard crizotinib in treatment-naive ALK+ NSCLC; PFS now routinely exceeds 2 to 3 years. In addition, these newer agents have far superior central nervous system penetration. As a result, many patients with ALK+ advanced NSCLC with brain metastases, even some who are symptomatic, can defer or indefinitely avoid brain irradiation. Mechanisms of resistance in ALK are complicated, with multiple new agents being developed in this arena. Although many patients with molecular targets can reasonably expect to live 5 years or more, the emergence of molecular resistance is virtually inevitable. In this regard, systemic platinum-based chemotherapy is the final common therapeutic pathway for virtually all patients with oncogenic drivers. Standard regimens include pemetrexed and carboplatin, as well as the E4599 regimen, combination solvent-based paclitaxel, carboplatin, and bevacizumab. Checkpoint inhibitors, as single agents, have not yielded much benefit, even in those with high levels of PD-L1 expression. However, in a subanalysis of patients with ALK and EGFR mutations enrolled in IMpower150, the addition of atezolizumab to the E4599 regimen led to a major overall survival benefit (hazard ratio < 0.40). In the absence of systemic chemotherapy, combining checkpoint inhibitors with TKIs in this setting remains investigational; several studies have demonstrated untoward pulmonary and hepatic toxicity.
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Affiliation(s)
- Eric K Singhi
- 1 Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | - Leora Horn
- 1 Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, TN
| | | | | | - Corey J Langer
- 4 Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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