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Poei D, Ali S, Ye S, Hsu R. ALK inhibitors in cancer: mechanisms of resistance and therapeutic management strategies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2024; 7:20. [PMID: 38835344 PMCID: PMC11149099 DOI: 10.20517/cdr.2024.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 06/06/2024]
Abstract
Anaplastic lymphoma kinase (ALK) gene rearrangements have been identified as potent oncogenic drivers in several malignancies, including non-small cell lung cancer (NSCLC). The discovery of ALK inhibition using a tyrosine kinase inhibitor (TKI) has dramatically improved the outcomes of patients with ALK-mutated NSCLC. However, the emergence of intrinsic and acquired resistance inevitably occurs with ALK TKI use. This review describes the molecular mechanisms of ALK TKI resistance and discusses management strategies to overcome therapeutic resistance.
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Affiliation(s)
- Darin Poei
- Department of Internal Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Sana Ali
- Division of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
| | - Shirley Ye
- Department of Internal Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Robert Hsu
- Division of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
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Zhao J, Li X, Fan R, Qin Y, Wang Z, Wang B, Li S, Fan J, Wu X, Liu H, Guan Y, Liang Y, Zhang X, Guo Y. Primary resistance to first- and second-generation ALK inhibitors in a non-small cell lung cancer patient with coexisting ALK rearrangement and an ALK F1174L-cis-S1189C de novo mutation: A case report. Front Pharmacol 2022; 13:1060460. [PMID: 36506539 PMCID: PMC9727108 DOI: 10.3389/fphar.2022.1060460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022] Open
Abstract
The effectiveness of the tyrosine kinase inhibitor ALK (TKI) for non-small cell lung cancer has been confirmed. However, resistance to ALK-TKIs seems inevitable. Mutations in the ALK kinase domain have been reported as an important mechanism of acquired resistance to ALK therapy. However, patients with de novo ALK kinase domain mutations and ALK rearrangements who were not treated with ALK inhibitors have rarely been reported. Here, we report a case of primary drug resistance to first- and second-generation ALK inhibitors in a NSCLC patient with ALK-rearrangement. The next-generation sequencing test of the pathological biopsy showed that the de novo ALK kinase domain mutation F1174L-cis-S1189C may be the cause of primary drug resistance.
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Affiliation(s)
- Jiuzhou Zhao
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China
| | - Xiang Li
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Ruizhe Fan
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yaping Qin
- School of Basic Medical Sciences, Academy of Medical Sciences, Henan Institute of Medical and Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan, China
| | - Zhizhong Wang
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China
| | - Bo Wang
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China
| | - Shaomei Li
- Department of Medical Oncology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Jianfeng Fan
- Department of Medical Imaging, Zhenping People’s Hospital, Nanyang, China
| | - Xinxin Wu
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China
| | - Hongxia Liu
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China
| | - Yuping Guan
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yinfeng Liang
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Xiao Zhang
- Department of Medical Oncology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yongjun Guo
- Department of Molecular Pathology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China,Henan Key Laboratory of Molecular Pathology, Zhengzhou, China,*Correspondence: Yongjun Guo,
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The Landscape of ALK-Rearranged Non-Small Cell Lung Cancer: A Comprehensive Review of Clinicopathologic, Genomic Characteristics, and Therapeutic Perspectives. Cancers (Basel) 2022; 14:cancers14194765. [PMID: 36230686 PMCID: PMC9563286 DOI: 10.3390/cancers14194765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary In recent years, prognosis of non-small cell lung cancer (NSCLC) patients significantly improved thanks to the introduction of tyrosine kinase inhibitors (TKIs) in clinical practice. ALK-rearranged NSCLC patients benefit from treatment with ALK inhibitors (ALK-i), which have shown a greater efficacy and a better intracranial activity than chemotherapy. Comparative studies between next-generation ALK-i are still lacking and clinicians are looking for reliable tools to determine which drug suits best for each patient. The aim of this review is to deepen the role of clinical and pathological characteristics influencing patients’ prognosis during treatment with ALK-i and to provide an overview of molecular mechanisms of ALK-i resistance. In this setting, liquid biopsy may play an important role in predicting tumor response and monitoring resistance mutations. We will summarize ongoing trials developing new ALK-i or combinations between ALK-i and other agents, which may represent future scenarios in the field of NSCLC research. Abstract During the last decade, the identification of oncogenic driver mutations and the introduction of tyrosine kinase inhibitors (TKIs) in daily clinical practice have substantially revamped the therapeutic approach of oncogene-addicted, non-small cell lung cancer (NSCLC). Rearrangements in the anaplastic lymphoma kinase (ALK) gene are detected in around 3–5% of all NSCLC patients. Following the promising results of Crizotinib, a first-generation ALK inhibitor (ALK-i), other second-generation and more recently third-generation TKIs have been developed and are currently a landmark in NSCLC treatment, leading to a significant improvement in patients prognosis. As clinical trials have already demonstrated high efficacy of each ALK-i, both in terms of systemic and intracranial disease control, comparative studies between second and third generation ALK-i are still lacking, and primary or secondary ALK-i resistance inevitably limit their efficacy. Resistance to ALK-i can be due to ALK-dependent or ALK-independent mechanisms, including the activation of bypass signaling pathways and histological transformation: these findings may play an important role in the future to select patients’ subsequent therapy. This review aims to provide an overview of underlying molecular alterations of ALK-i resistance and point out promising role of liquid biopsy in predicting tumor response and monitoring resistance mutations. The purpose of this review is also to summarize current approval for ALK-rearranged NSCLC patients, to help clinicians in making decisions on therapeutic sequence, and to deepen the role of clinicopathological and genomic characteristics influencing patients’ prognosis during treatment with ALK-i.
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Current Knowledge about Mechanisms of Drug Resistance against ALK Inhibitors in Non-Small Cell Lung Cancer. Cancers (Basel) 2021; 13:cancers13040699. [PMID: 33572278 PMCID: PMC7915291 DOI: 10.3390/cancers13040699] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 02/03/2021] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Simple Summary Lung cancer is a devastating disease, with non-small cell lung cancer (NSCLC) being the most common subtype. With the development of novel targeted therapeutics, survival times have continuously improved over the past two decades. In a subset of NSCLC, gene rearrangements of the anaplastic lymphoma kinase (ALK), or gene fusions involving ALK, can be determined. ALK-inhibitors are increasingly used as a standard of care in patients with ALK gene abnormalities, and can also be administered as first-line treatment in advanced-stage NSCLC. However, over the disease course, cancers tend to develop resistance mechanisms, warranting the switch from first- to second- or third-generation ALK inhibitors. With this literature review, we aim to give a concise overview about these resistance mechanisms, and what kind of sequential treatment may be feasible if therapy failure upon an ALK inhibitor occurs. Abstract Non-small cell lung cancer (NSCLC) accounts for the majority of lung cancer subtypes. Two to seven percent of NSCLC patients harbor gene rearrangements of the anaplastic lymphoma kinase (ALK) gene or, alternatively, harbor chromosomal fusions of ALK with echinoderm microtubule-associated protein-like 4 (EML4). The availability of tyrosine kinase inhibitors targeting ALK (ALK-TKIs) has significantly improved the progression-free and overall survival of NSCLC patients carrying the respective genetic aberrations. Yet, increasing evidence shows that primary or secondary resistance to ALK-inhibitors during the course of treatment represents a relevant clinical problem. This necessitates a switch to second- or third-generation ALK-TKIs and a close observation of NSCLC patients on ALK-TKIs during the course of treatment by repetitive molecular testing. With this review of the literature, we aim at providing an overview of current knowledge about resistance mechanisms to ALK-TKIs in NSCLC.
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Hofman P. Detecting Resistance to Therapeutic ALK Inhibitors in Tumor Tissue and Liquid Biopsy Markers: An Update to a Clinical Routine Practice. Cells 2021; 10:168. [PMID: 33467720 PMCID: PMC7830674 DOI: 10.3390/cells10010168] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/12/2021] [Accepted: 01/14/2021] [Indexed: 12/16/2022] Open
Abstract
The survival of most patients with advanced stage non-small cell lung cancer is prolonged by several months when they are treated with first- and next-generation inhibitors targeting ALK rearrangements, but resistance inevitably emerges. Some of the mechanisms of resistance are sensitive to novel ALK inhibitors but after an initial tumor response, more or less long-term resistance sets in. Therefore, to adapt treatment it is necessary to repeat biological sampling over time to look for different mechanisms of resistance. To this aim it is essential to obtain liquid and/or tissue biopsies to detect therapeutic targets, in particular for the analysis of different genomic alterations. This review discusses the mechanisms of resistance to therapeutics targeting genomic alterations in ALK as well as the advantages and the limitations of liquid biopsies for their identification.
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Affiliation(s)
- Paul Hofman
- Laboratory of Clinical and Experimental Pathology, Université Côte d’Azur, CHU Nice, FHU OncoAge, Pasteur Hospital, 30 Avenue de la Voie Romaine, BP69, CEDEX 01, 06001 Nice, France; ; Tel.: +33-4-92-03-88-55; Fax: +33-4-92-88-50
- Hospital-Integrated Biobank BB-0033-00025, Université Côte d’Azur, CHU Nice, FHU OncoAge, 06001 Nice, France
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Russo A, Cardona AF, Caglevic C, Manca P, Ruiz-Patiño A, Arrieta O, Rolfo C. Overcoming TKI resistance in fusion-driven NSCLC: new generation inhibitors and rationale for combination strategies. Transl Lung Cancer Res 2020; 9:2581-2598. [PMID: 33489820 PMCID: PMC7815353 DOI: 10.21037/tlcr-2019-cnsclc-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/18/2020] [Indexed: 12/27/2022]
Abstract
During the last several years, multiple gene rearrangements with oncogenic potential have been described in NSCLC, identifying specific clinic-pathological subgroups of patients that benefit from a targeted therapeutic approach, including anaplastic lymphoma kinase (ALK), c-ros protooncogene 1 (ROS1) and, more recently, REarranged during Transfection (RET) and neurotrophic tyrosine receptor kinases (NTRK) genes. Despite initial impressive antitumor activity, the use of targeted therapies in oncogene-addicted NSCLC subgroups is invariably associated with the development of acquired resistance through multiple mechanisms that can include both on-target and off-target mechanisms. However, the process of acquired resistance is a rapidly evolving clinical scenario that constantly evolves under the selective pressure of tyrosine kinase inhibitors. The development of increasingly higher selective and potent inhibitors, traditionally used to overcome resistance to first generation inhibitors, is associated with the development of novel mechanisms of resistance that encompass complex resistance mutations, highly recalcitrant to available TKIs, and bypass track mechanisms. Herein, we provide a comprehensive overview on the therapeutic strategies for overcoming acquired resistance to tyrosine kinase inhibitors (TKIs) targeting the most well-established oncogenic gene fusions in advanced NSCLC, including ALK, ROS1, RET, and NTRK rearrangements.
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Affiliation(s)
| | - Andrés F. Cardona
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
- Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia
- Clinical and Translational Oncology Group, Institute of Oncology, Clínica del Country, Bogotá, Colombia
| | - Christian Caglevic
- Head of Cancer Research Department, Instituto Oncologico Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Paolo Manca
- Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Alejandro Ruiz-Patiño
- Foundation for Clinical and Applied Cancer Research (FICMAC), Bogotá, Colombia
- Molecular Oncology and Biology Systems Research Group (FOX-G), Universidad el Bosque, Bogotá, Colombia
| | - Oscar Arrieta
- Thoracic Oncology Unit, Instituto Nacional de Cancerología (INCan), México City, México
| | - Christian Rolfo
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Itchins M, Lau B, Hudson AL, Westman H, Xia CY, Hayes SA, Howell VM, Rodriguez M, Cooper WA, Wei H, Buckland M, Li BT, Li M, Rathi V, Fox SB, Gill AJ, Clarke SJ, Boyer MJ, Pavlakis N. ALK-Rearranged Non-Small Cell Lung Cancer in 2020: Real-World Triumphs in an Era of Multigeneration ALK-Inhibitor Sequencing Informed by Drug Resistance Profiling. Oncologist 2020; 25:641-649. [PMID: 32558067 PMCID: PMC7418351 DOI: 10.1634/theoncologist.2020-0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022] Open
Abstract
Since its discovery in 2007, we have seen the lives of patients diagnosed with advanced anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancers (NSCLC) transform with the advent of molecular therapies with first-, second-, and third-generation ALK inhibitors now available in the clinic. Despite great gains in patient survival now measured in years and preserved quality of life with targeted therapies, drug resistance is unfortunately inevitably encountered in this rare and unique molecular subset of lung cancer, and patients will eventually succumb to the disease. As these patients are often young, fit, and never smokers, the clinical and scientific communities have aligned to expedite drug development and access. Drug resistance profiling and further strategies are being explored through clinical trials, including the evaluation of specific drug sequencing and combinations to overcome such resistance and promote patient longevity. The cases of this report focus on precision medicine and aim to portray the pertinent aspects to consider when treating ALK-rearranged NSCLC in 2020, an ever-shifting space. By way of case examples, this report offers valuable information to the treating clinician, including the evolution of systemic treatments and the management of oligo-progression and multisite drug resistance. With the maturation of real-world data, we are fortunate to be experiencing quality and length of life for patients with this disease surpassing prior expectations in advanced lung cancer. KEY POINTS: This report focuses on the importance of genetic analysis of serial biopsies to capture the dynamic therapeutic vulnerabilities of a patient's tumor, providing a perspective on the complexity of ALK tyrosine kinase inhibitor (ALKi) treatment sequencing. These case examples contribute to the literature on ALK-rearranged and oncogene addicted non-small cell lung cancer (NSCLC), providing a framework for care in the clinic. In oligo-progressive disease, local ablative therapy and continuation of ALKi postprogression should be considered with potential for sustained disease control. ALK G1202R kinase domain mutations (KDM), highly prevalent at resistance to second-generation ALKi resistances, may emerge in non-EML4-ALK variant 3 cases and is sensitive to third-generation lorlatinib. When in compound with one or more ALK KDMs, resistance to lorlatinib is expected. In the case of rampantly progressive disease, rebiopsy and redefining biology in a timely manner may be informative.
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Affiliation(s)
- Malinda Itchins
- Department of Medical Oncology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Brandon Lau
- Chris O'Brien LifehouseCamperdownNew South WalesAustralia
| | - Amanda L. Hudson
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Helen Westman
- Department of Medical Oncology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
| | - Cathy Yi Xia
- Department of Medical Oncology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
| | - Sarah A. Hayes
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Viive M. Howell
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Michael Rodriguez
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
- Department of Anatomical Pathology, Douglas Hanly MoirMacquarie ParkNew South WalesAustralia
| | - Wendy A. Cooper
- Central Clinical School, School of Medicine, University of SydneySt LeonardsNew South WalesAustralia
- Department of Tissue Pathology and Diagnostic Oncology, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
- School of Medicine, Western Sydney UniversitySydneyNew South WalesAustralia
| | - Heng Wei
- Brain and Mind Centre, University of SydneySt LeonardsNew South WalesAustralia
| | - Michael Buckland
- Brain and Mind Centre, University of SydneySt LeonardsNew South WalesAustralia
- Department of Neuropathology, Royal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Bob T. Li
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
- Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Mark Li
- Resolution BioscienceRedmondWashingtonUSA
| | - Vivek Rathi
- Department of Anatomical Pathology, St Vincent's, Victoria ParadeFitzroyVictoriaAustralia
| | - Stephen B. Fox
- Department of Pathology, Peter MacCallum Cancer Centre, and University of MelbourneVictoriaAustralia
| | - Anthony J. Gill
- Department of Anatomical Pathology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Stephen J. Clarke
- Department of Medical Oncology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
| | - Michael J. Boyer
- Chris O'Brien LifehouseCamperdownNew South WalesAustralia
- Department of Pathology, Peter MacCallum Cancer Centre, and University of MelbourneVictoriaAustralia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore HospitalSt LeonardsNew South WalesAustralia
- Bill Walsh Translational Research Laboratory, Kolling InstituteSt LeonardsNew South WalesAustralia
- Northern Clinical School, Faculty of Medicine and Health, University of SydneySt LeonardsNew South WalesAustralia
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Mezquita L, Swalduz A, Jovelet C, Ortiz-Cuaran S, Howarth K, Planchard D, Avrillon V, Recondo G, Marteau S, Benitez JC, De Kievit F, Plagnol V, Lacroix L, Odier L, Rouleau E, Fournel P, Caramella C, Tissot C, Adam J, Woodhouse S, Nicotra C, Auclin E, Remon J, Morris C, Green E, Massard C, Pérol M, Friboulet L, Besse B, Saintigny P. Clinical Relevance of an Amplicon-Based Liquid Biopsy for Detecting ALK and ROS1 Fusion and Resistance Mutations in Patients With Non-Small-Cell Lung Cancer. JCO Precis Oncol 2020; 4:PO.19.00281. [PMID: 32923908 PMCID: PMC7448797 DOI: 10.1200/po.19.00281] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Liquid biopsy specimen genomic profiling is integrated in non-small-cell lung cancer (NSCLC) guidelines; however, data on the clinical relevance for ALK /ROS1 alterations are scarce. We evaluated the clinical utility of a targeted amplicon-based assay in a large prospective cohort of patients with ALK/ROS1-positive NSCLC and its impact on outcomes. PATIENTS AND METHODS Patients with advanced ALK/ROS1-positive NSCLC were prospectively enrolled in the study by researchers at eight French institutions. Plasma samples were analyzed using InVisionFirst-Lung and correlated with clinical outcomes. RESULTS Of the 128 patients included in the study, 101 were positive for ALK and 27 for ROS1 alterations. Blood samples (N = 405) were collected from 29 patients naïve for treatment with tyrosine kinase inhibitors (TKI) or from 375 patients under treatment, including 105 samples collected at disease progression (PD). Sensitivity was 67% (n = 18 of 27) for ALK/ROS1 fusion detection. Higher detection was observed for ALK fusions at TKI failure (n = 33 of 74; 46%) versus in patients with therapeutic response (n = 12 of 109; 11%). ALK-resistance mutations were detected in 22% patients (n = 16 of 74) overall; 43% of the total ALK-resistance mutations identified occurred after next-generation TKI therapy. ALK G1202R was the most common mutation detected (n = 7 of 16). Heterogeneity of resistance was observed. ROS1 G2032R resistance was detected in 30% (n = 3 of 10). The absence of circulating tumor DNA mutations at TKI failure was associated with prolonged median overall survival (105.7 months). Complex ALK-resistance mutations correlated with poor overall survival (median, 26.9 months v NR for single mutation; P = .003) and progression-free survival to subsequent therapy (median 1.7 v 6.3 months; P = .003). CONCLUSION Next-generation, targeted, amplicon-based sequencing for liquid biopsy specimen profiling provides clinically relevant detection of ALK/ROS1 fusions in TKI-naïve patients and allows for the identification of resistance mutations in patients treated with TKIs. Liquid biopsy specimens from patients treated with TKIs may affect clinical outcomes and capture heterogeneity of TKI resistance, supporting their role in selecting sequential therapy.
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Affiliation(s)
- Laura Mezquita
- Cancer Medicine Department, Gustave Roussy, Villejuif, France
| | - Aurélie Swalduz
- Department of Medical Oncology, Centre Léon Bérard Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, INSERM U1052, CNRS UMR5286, Centre Léon Bérard, Cancer Research Center of Lyon, 69008 Lyon, France
| | - Cécile Jovelet
- Plateforme de Génomique, Module de Biopathologie Moléculaire et Centre de Ressources Biologiques, AMMICa, INSERM US23/CNRS UMS3655, Gustave Roussy, Villejuif, France
| | - Sandra Ortiz-Cuaran
- Université de Lyon, Université Claude Bernard Lyon 1, INSERM U1052, CNRS UMR5286, Centre Léon Bérard, Cancer Research Center of Lyon, 69008 Lyon, France
| | | | - David Planchard
- Cancer Medicine Department, Gustave Roussy, Villejuif, France
| | | | - Gonzalo Recondo
- INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Solène Marteau
- Department of Medical Oncology, Centre Léon Bérard Lyon, France
| | | | | | | | - Ludovic Lacroix
- Plateforme de Génomique, Module de Biopathologie Moléculaire et Centre de Ressources Biologiques, AMMICa, INSERM US23/CNRS UMS3655, Gustave Roussy, Villejuif, France
| | - Luc Odier
- Department of Pneumology, Hôpital Nord-Ouest Villefranche, Villefranche Sur Saône, France
| | - Etienne Rouleau
- Plateforme de Génomique, Module de Biopathologie Moléculaire et Centre de Ressources Biologiques, AMMICa, INSERM US23/CNRS UMS3655, Gustave Roussy, Villejuif, France
| | - Pierre Fournel
- Department of Medical Oncology, Institut de Cancérologie de la Loire, Saint-Priest-en-Jarez, France
| | | | - Claire Tissot
- Department of Pneumology, CHU Nord Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Julien Adam
- Pathology Department, Gustave Roussy, Villejuif, France
| | | | - Claudio Nicotra
- Early Drug Development Department, Gustave Roussy, Villejuif, France
| | - Edouard Auclin
- Medical Oncology Department, George Pompidou Hospital, Paris, France
| | | | | | | | - Christophe Massard
- INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France
- Early Drug Development Department, Gustave Roussy, Villejuif, France
| | - Maurice Pérol
- Department of Medical Oncology, Centre Léon Bérard Lyon, France
| | - Luc Friboulet
- INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Benjamin Besse
- Cancer Medicine Department, Gustave Roussy, Villejuif, France
- INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France
- Paris-Sud University, Orsay, France
| | - Pierre Saintigny
- Department of Medical Oncology, Centre Léon Bérard Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, INSERM U1052, CNRS UMR5286, Centre Léon Bérard, Cancer Research Center of Lyon, 69008 Lyon, France
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Kassem L, Shohdy KS, Lasheen S, Abdel-Rahman O, Ali A, Abdel-Malek RR. Safety issues with the ALK inhibitors in the treatment of NSCLC: A systematic review. Crit Rev Oncol Hematol 2018; 134:56-64. [PMID: 30771874 DOI: 10.1016/j.critrevonc.2018.11.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 02/04/2018] [Accepted: 11/20/2018] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Oral tyrosine kinase inhibitors targeting the chromosomal rearrangements of the anaplastic lymphoma kinase gene (ALK) in non-small cell lung cancer (NSCLC) were associated with superior clinical outcome. Tyrosine Kinase inhibitors (TKIs) are known to have peculiar toxicity profile, hence, increasing awareness to the safety profile of ALK inhibitors is essential. METHODS A comprehensive systematic review of literature has been conducted to include prospective trials that used the ALK inhibitors Crizotinib, Ceritinib, Alectinib, Brigatinib and Lorlatinib in patients with advanced NSCLC and have available efficacy and toxicity results. RESULTS A total of 14 studies including 2793 patients were considered eligible for our review and included two phase IB, seven phase II and five phase III studies. The most common adverse events (AEs) observed with ALK inhibitors were gastrointestinal (GI) toxicities as nausea (up to 83%), vomiting (up to 67%) and diarrhea (up to 86%), elevation of liver enzymes occurred in up to 60% and fatigue (up to 43%). There were differences in the toxicity patterns between the different ALK inhibitors with more GI and hepatic toxicities with Ceritinib, more visual disorders with Crizotinib, more dysgeusia with crizotinib and Alectinib and possibly more respiratory complications with Brigatinib. Most of the AEs were low grade and treatment-related deaths were associated with ALK inhibitors in 0-1% of patients. CONCLUSION Most of adverse effects of ALKi can be managed efficiently via dose modifications or interruptions. Timely identification of each ALKi pattern of toxicity can prevent treatment-related morbidity and mortality in this palliative setting.
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Affiliation(s)
- Loay Kassem
- Clinical Oncology Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
| | - Kyrillus S Shohdy
- Clinical Oncology Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
| | - Shaimaa Lasheen
- Clinical Oncology Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt.
| | - Omar Abdel-Rahman
- Clinical Oncology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Ahmad Ali
- Clinical Oncology Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
| | - Raafat R Abdel-Malek
- Clinical Oncology Department, Kasr Alainy School of Medicine, Cairo University, Cairo, Egypt
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10
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Sini C, Tuzi A, Rossi G, Russo A, Pezzuto A. Acquired resistance in oncogene-addicted non-small-cell lung cancer. Future Oncol 2018; 14:29-40. [PMID: 29989451 DOI: 10.2217/fon-2018-0097] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The advance of tyrosine kinase inhibitors has profoundly changed the therapeutic algorithm of non-small-cell lung cancer in molecularly selected patients. However, benefit from these agents is often transient and usually most patients progress within 12 months from treatment. Novel and more potent and selective tyrosine kinase inhibitors have been developed to overcome acquired resistance; however, these agents are once again associated with only temporary benefit and patients frequently develop secondary resistance, a heterogeneous phenomenon that involves different molecular mechanisms simultaneously. The aim of our paper is to provide a comprehensive overview of the mechanisms of acquired resistance in oncogene-addicted non-small-cell lung cancer, focusing on the two most studied target, EGFR mutations and ALK translocation, and reviewing the main challenges in clinical practice.
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Affiliation(s)
- Claudio Sini
- Medical Oncology, Ospedale Giovanni Paolo II, Olbia, Italy
| | | | - Giovanni Rossi
- Lung Unit, Ospedale Policlinico San Martino, Genova, Italy
| | - Alessandro Russo
- Medical Oncology Unit, AO Papardo & Department of Human Pathology, University of Messina, Messina, Italy.,Borsa Dottorati FSE XXXII Ciclo Unime, University of Messina, Messina, Italy
| | - Aldo Pezzuto
- Cardiovascular & Thoracic Department, AOU Sant'Andrea, Sapienza - Università di Roma, Roma, Italy
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11
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Wu H, Zeng C, Ye Y, Liu J, Mu Z, Xie Y, Chen B, Nong Q, Wu D. Exosomes from Irradiated Nonsmall Cell Lung Cancer Cells Reduced Sensitivity of Recipient Cells to Anaplastic Lymphoma Kinase Inhibitors. Mol Pharm 2018; 15:1892-1900. [PMID: 29595984 DOI: 10.1021/acs.molpharmaceut.8b00059] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Exosomes, released from various cell types, serve as vehicles of intercellular communication. Rearranged anaplastic lymphoma kinase (ALK) has been detected in exosomes released from cancer cells in ALK-positive nonsmall cell lung cancer (NSCLC), however, the functional consequence of ALK in exosomes has not been studied. This study aims to address whether exosomal ALK release is affected by stress, and whether exosomal ALK can modulate survival of recipient cells in vitro and in vivo. Exosomes, isolated from ALK-containing H3122 cells with (Exo-Apo) or without (Exo-Ctrl) irradiation treatment, were transferred to recipient H3122 cells in vitro or mouse xenograft in vivo. Western blot, flow cytometry, MTT, and xenograft were employed to respectively assess activation of the ALK pathway, apoptosis, cell viability, and tumor growth. Exo-Apo contained much higher levels of phosphorylated ALK (p-ALK) than that of Exo-Ctrl, and it activated AKT, STAT3, and the ERK pathway in recipient H3122 cells. ALK-specific inhibitors, including Crizotinib, Ceritinib, and TAE684, exhibited less effects on H3122 cells preincubated with Exo-Apo than on those treated with Exo-Ctrl in either inhibition of cell viability or promotion of apoptosis. Moreover, in an H3122 xenograft model, the Exo-Apo treatment resulted in a greater tumor growth and less sensitivity to Ceritinib than the Exo-Ctrl treatment. The ALK protein cargo in exosomes could be a key element to drive tumor growth and compromise therapeutic efficacy of ALK inhibitors for ALK-positive NSCLC.
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Affiliation(s)
- Hao Wu
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Chao Zeng
- Department of Respiration , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Yiwang Ye
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Jixian Liu
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Zhimin Mu
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Yuancai Xie
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Baokun Chen
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Qiaohong Nong
- Department of Oncology , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
| | - Da Wu
- Department of Thoracic Surgery , Peking University Shenzhen Hospital , Lianhua Road N0.1120 , Shenzhen , 518036 Guangdong Province , China
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12
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Christopoulos P, Endris V, Bozorgmehr F, Elsayed M, Kirchner M, Ristau J, Buchhalter I, Penzel R, Herth FJ, Heussel CP, Eichhorn M, Muley T, Meister M, Fischer JR, Rieken S, Warth A, Bischoff H, Schirmacher P, Stenzinger A, Thomas M. EML4-ALK fusion variant V3 is a high-risk feature conferring accelerated metastatic spread, early treatment failure and worse overall survival in ALK + non-small cell lung cancer. Int J Cancer 2018; 142:2589-2598. [PMID: 29363116 DOI: 10.1002/ijc.31275] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/17/2017] [Accepted: 01/10/2018] [Indexed: 02/04/2023]
Abstract
In order to identify anaplastic lymphoma kinase-driven non-small cell lung cancer (ALK+ NSCLC) patients with a worse outcome, who might require alternative therapeutic approaches, we retrospectively analyzed all stage IV cases treated at our institutions with one of the main echinoderm microtubule-associated protein-like 4 (EML4)-ALK fusion variants V1, V2 and V3 as detected by next-generation sequencing or reverse transcription-polymerase chain reaction (n = 67). Progression under tyrosine kinase inhibitor (TKI) treatment was evaluated both according to Response Evaluation Criteria in Solid Tumors (RECIST) and by the need to change systemic therapy. EML4-ALK fusion variants V1, V2 and V3 were found in 39%, 10% and 51% of cases, respectively. Patients with V3-driven tumors had more metastatic sites at diagnosis than cases with the V1 and V2 variants (mean 3.3 vs. 1.9 and 1.6, p = 0.005), which suggests increased disease aggressiveness. Furthermore, V3-positive status was associated with earlier failure after treatment with first and second-generation ALK TKI (median progression-free survival [PFS] by RECIST in the first line 7.3 vs. 39.3 months, p = 0.01), platinum-based combination chemotherapy (median PFS 5.4 vs. 15.2 months for the first line, p = 0.008) and cerebral radiotherapy (median brain PFS 6.1 months vs. not reached for cerebral radiotherapy during first-line treatment, p = 0.028), and with inferior overall survival (39.8 vs. 59.6 months in median, p = 0.017). Thus, EML4-ALK fusion variant V3 is a high-risk feature for ALK+ NSCLC. Determination of V3 status should be considered as part of the initial workup for this entity in order to select patients for more aggressive surveillance and treatment strategies.
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Affiliation(s)
- Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL)
| | - Volker Endris
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL)
| | - Mei Elsayed
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL)
| | - Martina Kirchner
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ivo Buchhalter
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Roland Penzel
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix J Herth
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Department of Pneumology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Claus P Heussel
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Department of diagnostic and interventional Radiology with Nuclear Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Eichhorn
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Department of Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Muley
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Translational Research Unit, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Meister
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Translational Research Unit, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Jürgen R Fischer
- Department of Thoracic Oncology, Lungenklinik Löwenstein, Löwenstein, Germany
| | - Stefan Rieken
- Department of Radiation Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Arne Warth
- Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL).,Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Helge Bischoff
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Schirmacher
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg (TLRC-H), Heidelberg, Germany, member of the German Center for Lung Research (DZL)
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13
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Lin JJ, Riely GJ, Shaw AT. Targeting ALK: Precision Medicine Takes on Drug Resistance. Cancer Discov 2017; 7:137-155. [PMID: 28122866 PMCID: PMC5296241 DOI: 10.1158/2159-8290.cd-16-1123] [Citation(s) in RCA: 358] [Impact Index Per Article: 51.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 12/14/2022]
Abstract
Anaplastic lymphoma kinase (ALK) is a validated molecular target in several ALK-rearranged malignancies, including non-small cell lung cancer. However, the clinical benefit of targeting ALK using tyrosine kinase inhibitors (TKI) is almost universally limited by the emergence of drug resistance. Diverse mechanisms of resistance to ALK TKIs have now been discovered, and these basic mechanisms are informing the development of novel therapeutic strategies to overcome resistance in the clinic. In this review, we summarize the current successes and challenges of targeting ALK. SIGNIFICANCE Effective long-term treatment of ALK-rearranged cancers requires a mechanistic understanding of resistance to ALK TKIs so that rational therapies can be selected to combat resistance. This review underscores the importance of serial biopsies in capturing the dynamic therapeutic vulnerabilities within a patient's tumor and offers a perspective into the complexity of on-target and off-target ALK TKI resistance mechanisms. Therapeutic strategies that can successfully overcome, and potentially prevent, these resistance mechanisms will have the greatest impact on patient outcome. Cancer Discov; 7(2); 137-55. ©2017 AACR.
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Affiliation(s)
- Jessica J Lin
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Gregory J Riely
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Alice T Shaw
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
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14
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Affiliation(s)
- Daniel B Costa
- a Department of Medicine , Division of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , MA , USA
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15
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Cuyàs E, Pérez-Sánchez A, Micol V, Menendez JA, Bosch-Barrera J. STAT3-targeted treatment with silibinin overcomes the acquired resistance to crizotinib in ALK-rearranged lung cancer. Cell Cycle 2016; 15:3413-3418. [PMID: 27753543 DOI: 10.1080/15384101.2016.1245249] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The signal transducer and activator of transcription 3 (STAT3) has been suggested to play a prominent role in mediating non-small-cell lung cancer (NSCLC) resistance to some tyrosine kinase inhibitor (TKI)-mediated therapies. Using a model of anaplastic lymphoma kinase gene (ALK)-translocated NSCLC with acquired resistance to the ALK TKI crizotinib, but lacking amplifications or mutations in the kinase domain of ALK, we herein present evidence that STAT3 activation is a novel mechanism of crizotinib resistance that involves the upregulation of immune escape and epithelial to mesenchymal transition (EMT) signaling pathways. Taking advantage of the flavonolignan silibinin as a naturally occurring STAT3-targeted pharmacological inhibitor, we confirmed that STAT3 activation protects ALK-translocated NSCLC from crizotinib. Accordingly, silibinin-induced inhibition of STAT3 worked synergistically with crizotinib to reverse acquired resistance and restore sensitivity in crizotinib-resistant cells. Moreover, silibinin treatment significantly inhibited the upregulation of the immune checkpoint regulator PD-L1 and also EMT regulators (e.g., SLUG, VIM, CD44) in crizotinib-refractory cells. These findings provide a valuable strategy to potentially improve the efficacy of ALK inhibition by cotreatment with silibinin-based therapeutics, which merit clinical investigation for ALK TKI-resistant NSCLC patients.
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Affiliation(s)
- Elisabet Cuyàs
- a Program Against Cancer Therapeutic Resistance (ProCURE), Metabolism and Cancer Group, Catalan Institute of Oncology , Girona , Catalonia , Spain.,b Molecular Oncology Group, Girona Biomedical Research Institute (IDIBGI) , Girona , Spain
| | | | - Vicente Micol
- c Molecular and Cell Biology Institute, Miguel Hernández University , Elche , Spain
| | - Javier A Menendez
- a Program Against Cancer Therapeutic Resistance (ProCURE), Metabolism and Cancer Group, Catalan Institute of Oncology , Girona , Catalonia , Spain.,b Molecular Oncology Group, Girona Biomedical Research Institute (IDIBGI) , Girona , Spain
| | - Joaquim Bosch-Barrera
- b Molecular Oncology Group, Girona Biomedical Research Institute (IDIBGI) , Girona , Spain.,d Deparment of Medical Oncology , Catalan Institute of Oncology , Girona , Catalonia , Spain.,e Department of Medical Sciences , Medical School, University of Girona , Girona , Spain
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