Treatment options for EGFR mutant NSCLC with CNS involvement—Can patients BLOOM with the use of next generation EGFR TKIs?

Treatment Advances in Lung Cancer with Leptomeningeal Metastasis

Leptomeningeal metastasis (LM) is a serious and often fatal complication in patients with advanced lung cancer, resulting in significant neurological deficits, decreased quality of life, and a poor prognosis. This article summarizes current research advances in treating lung cancer with meningeal metastases, discusses clinical challenges, and explores treatment strategies. Through an extensive review of relevant clinical trial reports and screening of recent conference abstracts, we collected clinical data on treating patients with lung cancer with meningeal metastases to provide an overview of the current research progress. Exciting progress has been made by focusing on specific mutations within lung cancer, including the use of EGFR tyrosine kinase inhibitors or inhibitors for anaplastic lymphoma kinase gene rearrangement, such as osimertinib, alectinib, and lorlatinib. These targeted therapies have shown impressive results in penetrating the central nervous system (CNS). Regarding whole-brain radiotherapy, there is currently some controversy among investigators regarding its effect on survival. Additionally, immune checkpoint inhibitors (ICIs) have demonstrated reliable clinical benefits due to their ability to retain anticancer activity in CNS metastases. Moreover, combination therapy shows promise in providing further treatment possibilities. Considerable progress has been made in the clinical research of lung cancer with LM. However, the sample size of prospective clinical trials investigating LM for lung cancer is still limited, with most reports being retrospective. Developing more effective management protocols for metastatic LM in lung cancer remains an ongoing challenge for the future.

Mechanism exploration and prognosis study of Astragali Radix-Spreading hedyotis herb for the treatment of lung adenocarcinoma based on bioinformatics approaches and molecular dynamics simulation

Background: Herb pair of Astragali Radix (AR) and Spreading Hedyotis Herb (SH) has been frequently prescribed in clinical for the treatment of lung cancer owing to its favorable efficacy. Yet, the mechanism under the therapeutic effects remained unveiled, which has limited its clinical applications, and new drug development for lung cancer.

Methods: The bioactive ingredients of AR and SH were retrieved from the Traditional Chinese Medicine System Pharmacology Database, with the targets of obtained components predicted by Swiss Target Prediction. Genes related to lung adenocarcinoma (LUAD) were acquired from GeneCards, OMIM and CTD databases, with the hub genes of LUAD screened by CTD database. The intersected targets of LUAD and AR-SH were obtained by Venn, with David Database employed to perform Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses. Survival analysis of the hub genes of LUAD was carried out using TCGA-LUAD dataset. Molecular docking of core proteins and active ingredients was performed by Auto-Dock Vina software, followed by molecular dynamics simulations of protein-ligand complexes with well-docked conformations.

Results: 29 active ingredients were screened out with 422 corresponding targets predicted. It is revealed that AR-SH can act on various targets such as EGFR, MAPK1, and KARS by ursolic acid (UA), Astragaloside IV(ASIV), and Isomucronulatol 7,2′-di-O-glucoside (IDOG) to alleviate the symptoms of LUAD. Biological processes involved are protein phosphorylation, negative regulation of apoptotic process, and pathways involved are endocrine resistance, EGFR tyrosine kinase inhibitor resistance, PI3K-Akt, and HIF-1 pathway. Molecular docking analysis indicated that the binding energy of most of the screened active ingredients to proteins encoded by core genes was less than −5.6 kcal/mol, with some active ingredients showing even lower binding energy to EGFR than Gefitinib. Three ligand-receptor complexes including EGFR-UA, MAPK1-ASIV, and KRAS-IDOG were found to bind relatively stable by molecular dynamics simulation, which was consistent with the results of molecule docking.

Conclusion: We suggested that the herb pair of AR-SH can act on targets like EGFR, MAPK1 and KRAS by UA, ASIV and IDOG, to play a vital role in the treatment and the enhancement of prognosis of LUAD.

Two non-small cell lung cancer (NSCLC) patients with brain metastasis harboring epidermal growth factor receptor (EGFR) G719X and L861Q mutations benefited from aumolertinib: two cases report and review of the literature

The third-generation epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) established a new standard for EGFR mutation positive non-small cell lung cancer (NSCLC) treatment. Brain metastases (BMS) are common in NSCLCs with poor prognosis, and patients with BMS who carry uncommon mutations is lack of treatment options. Aumolertinib is the first third-generation EGFR TKI in China and the second in the global context. There are few reports of the efficacy of aumolertinib in treating NSCLC patients with BMS who harboring uncommon EGFR mutations, which is needs to be investigated. Here we reported two cases of aumolertinib in treating NSCLC patients with BMS harboring EGFR G719X/L861Q mutations. The first one was diagnosed with poorly differentiated stage IVB adenocarcinoma with brain metastases. Genetic tests showed mutations in exons of EGFR 18 (G719D) and 21 (L861Q) initially. The patient was administered with pemetrexed 0.8 g and lobaplatin 30 mg, and aumolertinib (110 mg QD) combined with one-month of WBRT(Whole Brain Radiation Therapy) (42 Gy in 7 fractions). In order to avoid the side effects of radiotherapy on brain, radiotherapy was discontinued on February 5, 2020. The regime was continued with pemetrexed 0.75 g, lobaplatin 30 mg, bevacizumab 400 mg, and aumolertinib 110 mg QD. The four-drug combination regimen lasted for 6 months until serum tumor markers were elevated slightly. Then lobaplatin was replaced with nedaplatin, and the new four-drug combination regimen (pemetrexed 0.75 g, nedaplatin 90mg, bevacizumab 400 mg, and aumolertinib 110mg QD) was used with a one-month cycle for 3 cycles. Aumolertinib was administered daily throughout the four-drug combination, with the rest administered on day 1 of this treatment cycle. Chest CT scan were performed each month, which showed no progressed of lung disease. The patient had a progression-free survival of 13 months and is still being treated with aumolertinib. The second patient was diagnosed as right lung adenocarcinoma (T3N2M1) IVB secondary bone and brain malignancy carrying EGFR 18 (G719A) and 21 (L861Q) exon mutation. Aumolertinib combined with local radiotherapy was used after failure of afatinib combined with radiotherapy. Follow-up chest CT and brain MRI revealed that the lung lesions were partially relieved. Furthermore, the multiple nodules in the brain were relieved and cerebral edema was reduced. The aumolertinib monotherapy was continued, and follow-up imaging showed no disease progression. PFS was 13 months during the treatment with aumolertinib. The two cases showed good efficacy of aumolertinib in treating patients with brain metastases (BMS) that harbored EGFR 18 (G719X) and 21 (L861Q) mutations.

[Advances in Diagnosis and Treatment of Leptomeningeal Metastasis of Lung Cancer]

Leptomeningeal metastases (LM), a special type of metastasis in advanced lung cancer, is known for its severe clinical symptoms, rapid progression and poor prognosis. LM used to be featured with low clinical diagnosis rate, limited treatment options, poor treatment efficacy, and very short survival if treatment not given. Though cerebrospinal fluid (CSF) cytology remains to be the gold standard for the diagnosis of LM, the positive rate of the first CSF cytology even in patients with suggestive clinical symptoms and positive imaging generally does not exceed 50%, leading to a delay in the diagnosis and treatment of patients with LM. With the progress of targeted therapy for driver gene-positive lung cancer and immunotherapy for driver gene-negative lung cancer, the overall survival of patients with lung cancer has been prolonged, meanwhile incidence of LM has been increasing year by year. Current clinical research in this field center around how to improve diagnosis rate and to find effective treatment approaches. This paper reviews advances in diagnosis and treatment of LM of lung cancer..
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Survival Outcomes of Patients With Epidermal Growth Factor Receptor Mutations in Non-Small Cell Lung Cancer With Leptomeningeal Metastasis

Background

Leptomeningeal metastasis (LM) is a commonly observed complication in patients with epidermal growth factor receptor (EGFR)-mutated non-small cell lung cancer (NSCLC). This study aimed to investigate the gene mutations, treatment strategies, and clinical outcomes in patients with LM.

Methods

We retrospectively analyzed the clinical and survival outcomes of 53 patients with EGFR-mutated NSCLC with LM.

Results

The median overall survival after LM diagnosis was 13.0 months, ranging from 0.5 to 42.0 months (95% CI = 9.067–16.933), with 64.2% maturity. Patients who received osimertinib after developing LM (n = 35) had a significantly higher rate of LM disease control (p = 0.008) and significantly longer overall survival (15.0 versus 6.0 months; hazard ratio (HR), 2.4292; 95% CI, 1.234–4.779; p = 0.045) than those who received previous generations of EGFR tyrosine kinase inhibitors (TKIs) or other localized therapies (n = 6). Logistic regression analysis showed that LM disease control status was a positive predictive factor for overall survival after developing LM (p < 0.001, odds ratio = 10.797, 95% CI = 4.102–28.419).

Conclusions

Our study provides real-world clinical evidence that patients with EGFR-mutated NSCLC diagnosed with LM who developed LM had better clinical outcomes with osimertinib therapy. Our findings also suggest that LM disease control is the most effective strategy to prolong the overall survival outcomes of these patients.

Osimertinib in advanced EGFR-mutant lung adenocarcinoma with asymptomatic brain metastases: an open-label, 3-arm, phase II pilot study

BACKGROUND

Osimertinib is selective for both epidermal growth factor receptor (EGFR)-tyrosine-kinase inhibitor (TKI) sensitizing and Thr790Met mutations. While intracranial activity of osimertinib is documented in larger trials, a prospective study focusing exclusively on patients with asymptomatic brain metastases has not been reported.

METHODS

In this nonrandomized, phase II, open-label, 3-arm prospective proof-of-concept pilot study, 48 patients with metastatic EGFR-mutant lung adenocarcinoma (LUAD) received osimertinib 80 mg daily. Patients were either treatment naive (arm A = 20) or previously treated with an EGFR-TKI and Thr790Met positive (arm B = 18) or negative (arm C = 10). In cases of isolated intracranial progression, osimertinib dose was escalated (160 mg). The primary endpoints were intracranial objective response rate (iORR) and intracranial disease control rate (iDCR). The secondary endpoint was intracranial progression-free survival (iPFS). This study is registered at Clinicaltrials.gov, NCT02736513.

RESULTS

The iORRs were 84.2%, 66.7%, and 50% and the iDCRs were 94.7%, 94.4%, and 80% in arms A, B, and C, respectively. The median iPFS was 11.8 months (95% CI 7.7 to NA), 7.6 months (95% CI 5.3 to NA), and 6.3 months (95% CI 3.9 to NA) in arms A, B, and C, respectively. Following dose escalation, pooled iORR was 54% (arm A = 5, arm B = 4, arm C = 2). Adverse events were similar to those in previously published literature.

CONCLUSION

Osimertinib demonstrated high efficacy on brain metastases. All trial arms displayed a significant decrease in the number and diameter of target lesions. These findings indicate that osimertinib is effective for Thr790Met-positive and -negative LUAD patients with asymptomatic brain metastases. Therefore, osimertinib should be considered a viable option for EGFR-mutant patients with brain involvement regardless of their Thr790Met mutation status.

Efficacy of osimertinib for preventing leptomeningeal metastasis derived from advanced EGFR-mutated non-small cell lung cancer: a propensity-matched retrospective study

Background

Leptomeningeal metastasis (LM) is a severe complication of advanced non-small cell lung cancer (NSCLC). This retrospective study aimed to investigate the potential use of osimertinib for preventing LM in patients with advanced epidermal growth factor receptor (EGFR)-mutated NSCLC.

Methods

Patients with advanced NSCLC harboring EGFR mutations who underwent tyrosine kinase inhibitors (TKIs) therapy for at least 8 weeks between September 2016 and September 2019 were eligible for this study. All included patients were divided into two groups based on whether they received osimertinib, the osimertinib group (patients treated with osimertinib) and the control group (patients not treated with osimertinib). Propensity score matching (PSM, ratio of 1:1) was used to account for differences in baseline characteristics. The cumulative incidence of LM and the overall survival (OS) were evaluated.

Results

A total of 304 patients were included in the study population. Among them, 116 patients received osimertinib, and 188 did not. A total of 112 patients remained in each group after PSM, and the baseline characteristics were not significantly different between the two cohorts. LM developed in 11 patients (9.82%) in the osimertinib group and 24 patients (21.42%) in the control group (hazard ratio [HR] 0.38, 95% confidence interval [CI] 0.19–0.79, p = 0.009). Multivariate analysis indicated that osimertinib was an independent, statistically significant predictor for determining the risk for LM, with an HR of 0.33 (p = 0.042). At present, the OS rate data are too immature for statistical analysis.

Conclusion

Real-world data demonstrate that osimertinib can significantly reduce the incidence of LM in patients with advanced NSCLC harboring common EGFR mutations. Given this result, osimertinib should be encouraged in clinical practice for specific patient populations.

Efficacy and safety of treatment modalities across EGFR selected/unselected populations with non-small cell lung cancer and brain metastases: A systematic review and Bayesian network meta-analysis

OBJECTIVE

To compare the efficacy and safety of treatment modalities across different populations with non-small cell lung cancer and brain metastases.

METHODS

A comprehensive search for randomized controlled trials was conducted in databases including PubMed, Embase, the Cochrane library, the ClinicalTrials.gov, and major international conferences. The main outcomes of interest were progression-free survival, overall survival, and severe adverse events. Bayesian network meta-analytical techniques were implemented, to compare treatment modalities based on efficacy and safety profiles. The protocol for this study has been registered in the Prospective Register of Systematic Reviews (PROSPERO, CRD42020155330).

RESULTS

15 randomized controlled trials with a total of 1216 patients were analyzed. Network meta-analysis generated six comparisons both in EGFR positive and EGFR unselected populations. For patients harboring EGFR positive mutations, osimertinib appears to significantly increase progression-free survival, compared to 1st generation EGFR-TKI (HR 0.46, 95 %CI 0.38-0.55), 2nd generation EGFR-TKI (HR: 0.59, 95 %CI 0.34-0.99), conventional chemotherapy (HR 0.30, 95 %CI 0.14-0.66), radiotherapy (HR 0.20, 95 %CI 0.14-0.29), and radiotherapy plus 1st generation TKI (HR 0.21, 95 %CI 0.14-0.32). Osimertinib also appears to increase the likelihood of survival and prolong overall survival. For EGFR unselected patients, combined anti-PD1 monoclonal antibody with conventional chemotherapy appears superior to radiotherapy (HR: 0.20, 95 % CI 0.14-0.29), conventional chemotherapy (HR: 0.42, 95 %CI 0.28-0.68), radiotherapy plus conventional chemotherapy (HR: 0.59, 95 %CI 0.32-0.98), radiotherapy plus 1st generation TKI (HR:0.49, 95 %CI 0.25-0.96), and immune checkpoint inhibitors monotherapy (HR:0.44, 95 %CI 0.28-0.69). However, combination therapies are generally more toxic causing an increased number of severe adverse events, particularly when anti-PD1 monoclonal antibody is combined with conventional chemotherapy.

CONCLUSIONS

Osimertinib appears to be the most effective and safest treatment in NSCLC patients with brain metastases, harboring EGFR positive mutations. The anti-PD1 monoclonal antibody and conventional chemotherapy combination increases survival for NSCLC patients with brain metastases who were not selected according to EGFR mutation, although this increased benefit positively correlates with an increased number of severe adverse events.

Proteomic Reveals Reasons for Acquired Drug Resistance in Lung Cancer Derived Brain Metastasis Based on a Newly Established Multi-Organ Microfluidic Chip Model

Anti-tumor drugs can effectively shrink the lesions of primary lung cancer; however, it has limited therapeutic effect on patients with brain metastasis (BM). A BM preclinical model based on a multi-organ microfluidic chip has been established proficiently in our previous work. In this study, the BM subpopulation (PC9-Br) derived from the parental PC9 cell line was isolated from the chip model and found to develop obvious resistance to antineoplastic drugs including chemotherapeutic agents (cisplatin, carboplatin, pemetrexed) and tyrosine kinase inhibitors (TKIs) which target epidermal growth factor receptor (EGFR); this suggested that the acquisition of drug-resistance by brain metastatic cells was attributable to the intrinsic changes in PC9-Br. Hence, we performed proteomic and revealed a greatly altered spectrum of BM protein expression compared with primary lung cancer cells. We identified the hyperactive glutathione (GSH) metabolism pathway with the overexpression of various GSH metabolism-related enzymes (GPX4, RRM2, GCLC, GPX1, GSTM4, GSTM1). Aldehyde dehydrogenases (ALDH1A1, ALDH3A1) were also found to be upregulated in BM. What's more, loss of EGFR and phosphorylated EGFR in PC9-Br gave reasons for the TKIs resistance. Collectively, our findings indicated potential mechanisms for the acquirement of drug resistance occurred in BM, providing new strategies to overcome therapeutic resistance in lung cancer BM.

[Acquired Drug Resistance Mechanism of Osimertinib in the Targeted Therapy of Non-small Cell Lung Cancer]

While treating cancer, epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) still faces inevitable drug resistance. Investigations into the mechanisms which foster resistance to EGFR-TKI has led to the discovery of novel biomarkers and drug targets, and in turn has enabled the development of third-generation TKIs and proposals for rational therapeutic combinations. The threonine-to-methionine substitution mutation at position 790 (T790M) is clinically validated to engender refractoriness to first- and second-generation TKI, and is a standard-of-care predictive biomarker used in therapeutic stratification. For patients who are T790M-negative, cytotoxic chemotherapy or protracted EGFR-TKI treatment are acceptable treatment standards after disease progression, although combinations of targeted therapies and checkpoint blockade immunotherapy may offer promising alternatives in the future. Among T790M-positive patients, the third-generation EGFR-TKI, osimertinib, has shown superiority over both platinum-doublet chemotherapy and first-generation EGFR-TKI in randomized clinical trials. This article appraises the key literature on the contemporary management of non-small cell lung cancer patients with acquired resistance to EGFR-TKIs, and envisions future directions in translational and clinical research.

Determining the appropriate treatment for different EGFR mutations in non-small cell lung cancer patients

Introduction: Epidermal growth factor receptor (EGFR) mutations occur in a significant fraction of non-small cell lung cancer (NSCLC) patients. Most common activating mutations are in-frame deletion in exon 19 and point mutation in exon 21. EGFR tyrosine kinase inhibitors (TKIs) represent standard of care of EGFR mutated patients bearing common mutations. Therapy for individuals carrying uncommon mutations, such as G719X, L861Q, S768I, is less defined and few options exist for individuals harboring EGFR exon 20 mutations. In all mutated patients, drug resistance remains the most critical clinical problem and new agents and strategies are under investigation.Areas covered: We have reviewed the current status of NSCLC EGFR mutated treatment by analyzing data from preclinical studies, clinical prospective and retrospective trials in order to analyze current and future options for patients harboring different EGFR mutations.Expert opinion: At the present time, available data demonstrated that osimertinib is the best EGFR-TKI for front-line therapy. Other agents, such as dacomitinib, and new drug combinations, such as regimens including anti-angiogenic agents or chemotherapy, demonstrated to significantly prolong progression-free survival or overall survival, representing potential alternative to osimertinib. Many questions remain opened, including best drug sequencing and needing of new therapeutic approaches extending patient survival and cure rate.

Abivertinib in patients with T790M-positive advanced NSCLC and its subsequent treatment with osimertinib

BACKGROUND

Abivertinib is a novel oral, third generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) that overcomes T790M-induced resistance in non-small cell lung cancer (NSCLC) patients. Here, we report the results of a complete and detailed clinical data of patients treated with abivertinib at our hospital in a phase I dose escalation/expansion study of abivertinib.

METHODS

NSCLC patients with the EGFR T790M mutation were orally administered abivertinib (150-300 mg) twice daily for cycles of 28 continuous days and tumor response was assessed. Further data regarding subsequent treatment protocols and survival were collected.

RESULTS

A total of 28 NSCLC patients were included. Of the 24 assessable patients, 12 (50%) achieved a partial response (PR), and six (25%) achieved stable disease (SD). Median progression-free survival (PFS) was 5.9 months (95% confidence interval (CI): 3.259-8.541) and median overall survival (OS) was 17.9 months (95% CI: 11.36-24.5). For salvage therapy in 15 (53.6%) patients after abivertinib, the median PFS following osimertinib treatment was 12 months. The median total treatment duration for the two third-generation EGFR TKIs was 15.9 months (95% CI: 12.5-19.3). The most frequent abivertinib-associated adverse effects were elevated hepatic transaminases (10/28, 35.7%) and diarrhea (10/28, 35.7%).

CONCLUSIONS

Abivertinib is a unique novel third-generation EGFR TKI with good tolerance and efficacy in EGFR T790M(+) NSCLC patients. For patients with progressive disease after treatment with abivertinib, osimertinib could be an option for subsequent therapy but further studies are required.

KEY POINTS

Abivertinib is a novel third-generation EGFR TKI targeting the EGFR T790M mutation Abivertinib is well tolerated and efficacious in T790M-positive patients Abivertinib has a unique structure, efficacy, and resistance mechanism compared with osimertinib Osimertinib treatment after AC0010 showed a good response.

Intraoperative squash cytology provides a qualitative intraoperative diagnosis for cases in which frozen section yields a diagnosis of equivocal brain tumour

OBJECTIVE

We assessed whether intraoperative squash cytology could provide surgeons with a qualitative diagnosis of brain lesions when frozen section diagnosis is equivocal.

METHODS

The study included 51 lesions that were diagnosed intraoperatively as equivocal brain tumour on the basis of frozen section. We retrospectively classified the lesions into five groups according to the final histopathological diagnoses (I: malignant lymphomas; II: diffuse astrocytic and oligodendroglia tumours; III: pituitary adenomas, IV: metastatic carcinomas; V: others). We assessed the squash cytology features of Groups I-IV and of the specific lesion types, and compared features among the groups.

RESULTS

The four groups differed in a range of salient cytomorphological features: lymphoglandular bodies in Group I (eight of nine cases), cytoplasmic fibrillary processes in Group II (six of eight cases), low-grade nuclear atypia in Group III (seven of seven cases), and large nuclei (approximately 80 μm² ) and nuclear crush artefacts in Group IV (seven of nine cases).

CONCLUSION

Findings of lymphoglandular bodies on intraoperative squash cytology can be considered characteristic of malignant lymphomas, while cytoplasmic fibrillary processes indicate diffuse astrocytic and oligodendroglial tumours. We conclude that squash cytology could yield a qualitative intraoperative diagnosis in over 25% of cases for which frozen section yields a diagnosis of equivocal brain tumour.

Osimertinib in Patients With Epidermal Growth Factor Receptor Mutation-Positive Non-Small-Cell Lung Cancer and Leptomeningeal Metastases: The BLOOM Study

PURPOSE

In this phase I study (BLOOM), osimertinib, a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), was evaluated in patients with leptomeningeal metastases (LMs) from EGFR-mutated (EGFRm) advanced non-small-cell lung cancer (NSCLC) whose disease had progressed on previous EGFR-TKI therapy.

PATIENTS AND METHODS

Patients with cytologically confirmed LM received osimertinib 160 mg once daily. Objectives were to assess confirmed objective response rate (ORR), duration of response (DoR), progression-free survival (PFS), overall survival (OS), pharmacokinetics (PK), and safety. Additional efficacy evaluations included changes from baseline in CSF cytology and neurologic examination. Measurable lesions were assessed by investigator according to RECIST version 1.1. LMs were assessed by neuroradiologic blinded central independent review (BICR) according to Response Assessment in Neuro-Oncology LM radiologic criteria and by investigator.

RESULTS

Forty-one patients were enrolled. LM ORR and DoR by neuroradiologic BICR were 62% (95% CI, 45% to 78%) and 15.2 months (95% CI, 7.5 to 17.5 months), respectively. Overall, ORR by investigator was 41% (95% CI, 26% to 58%), and median DoR was 8.3 months (95% CI, 5.6 to 16.5 months). Median investigator-assessed PFS was 8.6 months (95% CI, 5.4 to 13.7 months) with 78% maturity; median OS was 11.0 months (95% CI, 8.0 to 18.0 months) with 68% maturity. CSF tumor cell clearance was confirmed in 11 (28%; 95% CI, 15% to 44%) of 40 patients. Neurologic function was improved in 12 (57%) of 21 patients with an abnormal assessment at baseline. The adverse event and PK profiles were consistent with previous reports for osimertinib.

CONCLUSION

Osimertinib showed meaningful therapeutic efficacy in the CNS and a manageable safety profile at 160 mg once daily in patients with EGFRm NSCLC and LM.

Treatment of EGFR T790M-Positive Non-Small Cell Lung Cancer

The treatment of lung cancer has changed dramatically with the development of tyrosine kinase inhibitors (TKIs) that target sensitizing somatic mutations of the epidermal growth factor receptor (EGFR). Despite remarkable initial responses, patients eventually develop progressive disease, with the most common cause of resistance to first-line EGFR TKIs being the acquired T790M mutation. Various third-generation EGFR TKIs have been developed to specifically target this acquired mutation, of which osimertinib is currently the only approved agent. In addition, the eagerly anticipated data from the FLAURA study recently found improved efficacy with increased progression-free survival (PFS) with osimertinib compared to standard of care first-generation EGFR TKIs in the first-line setting. Of note, osimertinib has also demonstrated promising efficacy in patients with known brain metastases. However, as patients invariably develop resistance during treatment with osimertinib, most commonly with the development of triple mutated EGFR (sensitizing mutations/T790M/C797S), which is resistant to all existing EGFR TKIs, efforts are currently ongoing to develop new strategies or novel compounds to specifically target this resistance mechanism.

Efficacy of Osimertinib in EGFR-Mutated Non-Small Cell Lung Cancer with Leptomeningeal Metastases Pretreated with EGFR-Tyrosine Kinase Inhibitors

BACKGROUND

The prognosis of patients with non-small cell lung cancer (NSCLC) who develop leptomeningeal metastasis (LM) is poor.

OBJECTIVE

To assess the clinical efficacy of osimertinib, a third-generation tyrosine-kinase inhibitor (TKI), in patients with epidermal growth-factor receptor (EGFR)-mutated NSCLCs and LM.

PATIENTS AND METHODS

Retrospective study of NSCLC patients with osimertinib-treated EGFR-mutated NSCLC and LM.

RESULTS

Twenty patients (mean age, 61.2 years; 70% women) with adenocarcinoma NSCLC were included in the study. EGFR mutations were reported in exons 18 (n = 2), 19 (n = 7), and 21 (n = 11). Before starting osimertinib, patients had received a mean of 2.3 treatment lines. When LM was diagnosed, all patients had clinical symptoms. Sixteen (80%) patients had a performance status ≥2. At osimertinib initiation, 13 (65%) patients harbored the EGFR-T790M-resistance mutation. Osimertinib was started at 80 (n = 17), 160 (n = 2), or 40 mg/day (n = 1). All 13 (100%) patients with the T790M mutation and 4 (57%) of those without it obtained clinical responses. Among the 11 radiologically assessable patients, 9 (82%) responded, with 5 responses reported within 15 days after treatment initiation. Median overall survival and progression-free survival were 18.0 and 17.2 months, respectively, from the start of osimertinib.

CONCLUSIONS

In this non-selected population, osimertinib had remarkable efficacy in NSCLC patients with LM irrespective of the presence of the EGFR-T790M-resistance mutation. Osimertinib efficacy was rapid in several patients, even some with poor performance status.

The clinical responses of TNIP2-ALK fusion variants to crizotinib in ALK-rearranged lung adenocarcinoma

OBJECTIVES

Anaplastic lymphoma kinase (ALK) has been proven to be another driver oncogene that accounts for 3%-7% of non-small-cell lung cancer, and it is more common in young patients and nonsmokers. ALK rearrangements have been previously identified in about 5.1% of lung adenocarcinoma, including EML4-ALK fusion variants, KIF5B-ALK and TFG-ALK. However, a TNIP2-ALK fusion has not been reported in lung adenocarcinoma. Herein, we described a rare case of ALK-rearranged lung adenocarcinoma responding to crizotinib.

MATERIALS AND METHODS

Immunohistochemistry (IHC) assay and comprehensive next-generation sequencing (NGS) were performed on the aspirated biopsied tumor tissue.

RESULTS

The IHC analysis revealed an ALK-positive tumor, while NGS detected a TNIP2-ALK fusion. The patient achieved continuous remission after treatment with crizotinib (250 mg, twice a day).

CONCLUSION

This case provides valuable information on the response to crizotinib of patients with TNIP2-ALK fusion and better understanding of ALK-TKI applications in the future. NGS is a new method that can offer effective detection of gene fusion and gene mutations.

Prognostic significance of molecular characteristics of cerebrospinal fluid for non-small cell lung cancer patients with leptomeningeal metastasis

BACKGROUND

Studies in EGFR+ non-small cell lung cancer (NSCLC) patients with leptomeningeal metastasis (LM) comparing survival rates and gene mutation detection with matched cerebrospinal fluid (CSF) and plasma are relatively scarce. We evaluated gene mutations, treatment strategies, and clinical outcomes in EGFR+ NSCLC patients with LM.

METHODS

We retrospectively reviewed gene mutation status in the CSF and plasma of 32 EGFR+ NSCLC patients with LM for prognostic significance.

RESULTS

The rate of LM disease control was significantly higher in patients that switched EGFR-tyrosine kinase inhibitor (TKI) treatments, initiated EGFR-TKIs, or received high-dose EGFR-TKI treatment than those who continued their current EGFR-TKI treatment, received chemotherapy, or were not administered antitumor treatment (24/24, 100.0% vs. 1/8, 12.5%; P = 0.000). Overall survival was 27.0 months (95% confidence interval [CI] 19.0-37.5), median survival after LM was 7.0 months (95% CI 5.0-11.0), and median survival before LM was 17.0 months (95% CI 12-25.5). Median survival after LM was significantly shorter in patients with "worse" status (n = 7) than in those with "improved/stable" status (n = 25; 4.2 [95% CI 2.2-6.1] vs. 33.7 [95% CI 25.5-41.8] months, HR 10.114, 95% CI 0.29-1.37; P = 0.008).

CONCLUSIONS

EGFR-TKIs should be the priority course of treatment in EGFR+ NSCLC patients after a diagnosis of LM. Liquid biopsy in both plasma and CSF, as well as dynamic detection, play important roles in the direction of treatment for such patients.

Determination of osimertinib in human plasma, urine and cerebrospinal fluid

Aim: Osimertinib (Tagrisso, AZD9291) has been approved for the treatment of patients with metastatic EGFRm T790M non-small-cell lung cancer. Results: Rapid and sensitive LC–MC/MS methods were developed for osimertinib and its metabolites, AZ13597550 and AZ13575104, in human plasma (low- and high-range), urine and cerebrospinal fluid. We discuss the challenges of these multi-analyte and multiple matrix assays. The methods have been successfully validated and used for the analysis of over 20,000 clinical samples, with successful incurred sample reproducibility. Conclusion: The assays have been shown to be selective, accurate and robust, providing high-throughput analysis during the clinical development of osimertinib.

Role of cytokines in combinatorial immunotherapeutics of non-small cell lung cancer through systems perspective

Lung cancer is the leading cause of deaths related to cancer and accounts for more than a million deaths per year. Various new strategies have been developed and adapted for treatment; still the survival for 5 years is just 16% in patients with non‐small cell lung cancer (NSCLC). Most of these strategies to combat NSCLC whether it is a drug molecule or immunotherapy/vaccine candidate require a big cost and time. Integration of computational modeling with systems biology has opened new avenues for understanding complex cancer biology. Resolving the complex interactions of various pathways and their crosstalk leading to oncogenic changes could identify new therapeutic targets with lesser cost and time. Herein, this review provides an overview of various aspects of NSCLC along with available strategies for its cure concluding with our insight into how systems approach could serve as a therapeutic intervention dissecting the immunologic parameters and cross talk between various pathways involved.

Mechanisms and Therapy for Cancer Metastasis to the Brain

Advances in chemotherapy and targeted therapies have improved survival in cancer patients with an increase of the incidence of newly diagnosed brain metastases (BMs). Intracranial metastases are symptomatic in 60–70% of patients. Magnetic resonance imaging (MRI) with gadolinium is more sensitive than computed tomography and advanced neuroimaging techniques have been increasingly used in the detection, treatment planning, and follow-up of BM. Apart from the morphological analysis, the most effective tool for characterizing BM is immunohistochemistry. Molecular alterations not always reflect those of the primary tumor. More sophisticated methods of tumor analysis detecting circulating biomarkers in fluids (liquid biopsy), including circulating DNA, circulating tumor cells, and extracellular vesicles, containing tumor DNA and macromolecules (microRNA), have shown promise regarding tumor treatment response and progression. The choice of therapeutic approaches is guided by prognostic scores (Recursive Partitioning Analysis and diagnostic-specific Graded Prognostic Assessment-DS-GPA). The survival benefit of surgical resection seems limited to the subgroup of patients with controlled systemic disease and good performance status. Leptomeningeal disease (LMD) can be a complication, especially in posterior fossa metastases undergoing a “piecemeal” resection. Radiosurgery of the resection cavity may offer comparable survival and local control as postoperative whole-brain radiotherapy (WBRT). WBRT alone is now the treatment of choice only for patients with single or multiple BMs not amenable to surgery or radiosurgery, or with poor prognostic factors. To reduce the neurocognitive sequelae of WBRT intensity modulated radiotherapy with hippocampal sparing, and pharmacological approaches (memantine and donepezil) have been investigated. In the last decade, a multitude of molecular abnormalities have been discovered. Approximately 33% of patients with non-small cell lung cancer (NSCLC) tumors and epidermal growth factor receptor mutations develop BMs, which are targetable with different generations of tyrosine kinase inhibitors (TKIs: gefitinib, erlotinib, afatinib, icotinib, and osimertinib). Other “druggable” alterations seen in up to 5% of NSCLC patients are the rearrangements of the “anaplastic lymphoma kinase” gene TKI (crizotinib, ceritinib, alectinib, brigatinib, and lorlatinib). In human epidermal growth factor receptor 2-positive, breast cancer targeted therapies have been widely used (trastuzumab, trastuzumab-emtansine, lapatinib-capecitabine, and neratinib). Novel targeted and immunotherapeutic agents have also revolutionized the systemic management of melanoma (ipilimumab, nivolumab, pembrolizumab, and BRAF inhibitors dabrafenib and vemurafenib).

The Evolving Landscape of Brain Metastasis

Metastasis, involving the spread of systemic cancer to the brain, results in neurologic disability and death. Current treatments are largely palliative in nature; improved therapeutic approaches represent an unmet clinical need. However, recent experimental and clinical advances challenge the bleak long-term outcome of this disease. Encompassing key recent findings in epidemiology, genetics, microenvironment, leptomeningeal disease, neurocognition, targeted therapy, immunotherapy, and prophylaxis, we review preclinical and clinical studies to provide a comprehensive picture of contemporary research and the management of secondary brain tumors.

Expression and copy number gains of the RET gene in 631 early and mid stage non-small cell lung cancer cases

Background

To identify whether RET is a potential target for NSCLC treatment, we examined the status of the RET gene in 631 early and mid stage NSCLC cases from south central China.

Methods

RET expression was identified by Western blot. RET‐positive expression samples were verified by immunohistochemistry. RET gene mutation, copy number variation, and rearrangement were analyzed by DNA Sanger sequencing, TaqMan copy number assays, and reverse transcription‐PCR. ALK and ROS1 expression levels were tested by Western blot and EGFR mutation using Sanger sequencing.

Results

The RET‐positive rate was 2.5% (16/631). RET‐positive expression was related to poorer tumor differentiation (P < 0.05). In the 16 RET‐positive samples, only two samples of moderately and poorly differentiated lung adenocarcinomas displayed RET rearrangement, both in RET‐KIF5B fusion partners. Neither ALK nor ROS1 translocation was found. The EGFR mutation rate in RET‐positive samples was significantly lower than in RET‐negative samples (P < 0.05).

Conclusion

RET‐positive expression in early and mid stage NSCLC cases from south central China is relatively low and is related to poorer tumor differentiation. RET gene alterations (copy number gain and rearrangement) exist in all RET‐positive samples. RET‐positive expression is a relatively independent factor in NSCLC patients, which indicates that the RET gene may be a novel target site for personalized treatment of NSCLC.

Combination Strategies Using EGFR-TKi in NSCLC Therapy: Learning from the Gap between Pre-Clinical Results and Clinical Outcomes

Although epidermal growth factor receptor (EGFR) inhibitors have been used to treat non-small cell lung cancer (NSCLC) for decades with great success in patients with EGFR mutations, acquired resistance inevitably occurs after long-term exposure. More recently, combination therapy has emerged as a promising strategy to overcome this issue. Several experiments have been carried out to evaluate the synergism of combination therapy both in vitro and in vivo. Additionally, many clinical studies have been carried out to investigate the feasibility of treatment with EGFR-tyrosine kinase inhibitors (TKi) combined with other NSCLC treatments, including radiotherapy, cytotoxic chemotherapies, targeted therapies, and emerging immunotherapies. However, a significant gap still exists when applying pre-clinical results to clinical scenarios, which hinders the development and use of these strategies. This article is a literature review analysing the rationalities and controversies in the transition from pre-clinical investigation to clinical practice associated with various combination strategies. It also highlights clues and challenges regarding future combination therapeutic options in NSCLC treatment.

Targeted therapy for leptomeningeal metastases in non-small cell lung cancer - Changing treatment paradigms

Leptomeningeal metastasis is an uncommon but serious complication in patients with advanced cancers. Leptomeningeal metastasis is diagnosed in approximately 5% of the patients, most commonly among patients with cancers of breast and lung, melanoma, and gastrointestinal malignancies. Treatment goal is to improve survival and quality of the patients. Use of targeted therapies and immunotherapy has led to improved survival of patients with non-small cell lung cancer (NSCLC). In this article, we review emerging data on use of mutation-specific agents and immunotherapy in the treatment of leptomeningeal metastasis among patients with NSCLC.