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Venur VA, Cohen JV, Brastianos PK. Targeting Molecular Pathways in Intracranial Metastatic Disease. Front Oncol 2019; 9:99. [PMID: 30886831 PMCID: PMC6409309 DOI: 10.3389/fonc.2019.00099] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/04/2019] [Indexed: 12/15/2022] Open
Abstract
The discovery and clinical application of agents targeting pivotal molecular pathways in malignancies such as lung, breast, renal cell carcinoma, and melanoma have led to impressive improvements in clinical outcomes. Mutations in epidermal growth factor receptor (EGFR), and rearrangements of anaplastic lymphoma kinase (ALK) are targetable in lung cancer, while BRAF mutations have been successfully targeted in metastatic melanoma. Targeting estrogen receptors, cyclin dependent kinases, and HER2 (Human Epidermal Receptor) have resulted in improvement in survival in breast cancer. Major strides have been made in the management of metastatic renal cell carcinoma by targeting the vascular endothelial growth factor (VEGF) pathway. However, intracranial metastases remain a major hurdle in the setting of targeted therapies. Traditional treatment options for brain metastases include surgery, whole brain radiation therapy (WBRT), and stereotactic radiosurgery (SRS). Surgery is effective in symptomatic patients with dominant lesions or solitary intracranial metastases, however, recovery time can be prolonged, often requiring an interruption in systemic treatment. WBRT and SRS provide symptomatic relief and local control but data on improving overall survival is limited. Most targeted therapies which provide extracranial control have limited penetration through the blood brain barrier. Given the limited therapeutic options and increasing prevalence of brain metastases, finding new strategies for the management of intracranial metastatic disease is critical. Genomic analysis of brain metastases has led to a better understanding of variations in the driver mutations compared to the primary malignancy. Furthermore, newer generations of targeted agents have shown promising intracranial activity. In this review, we will discuss the major molecular alterations in brain metastases from melanoma, lung, breast, and renal cell carcinoma. We will provide an in-depth review of the completed and ongoing clinical trials of drugs targeting the molecular pathways enriched in brain metastases.
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Affiliation(s)
| | | | - Priscilla K. Brastianos
- Divisions of Neuro-Oncology and Hematology/Oncology, Departments of Neurology and Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Abstract
Central nervous system metastases cause grave morbidity in patients with advanced malignancies. Lung cancer, breast cancer, and melanoma are the three most common causes of brain metastases. Although the exact incidence of brain metastases is unclear, there appears to be an increasing incidence which has been attributed to longer survival, better control of systemic disease, and better imaging modalities. Until recently surgical resection of solitary or symptomatic brain metastases, and radiation therapy (either whole-brain radiation therapy or stereotactic radiation) were the mainstay of treatment for patients with brain metastases. The majority of traditional chemotherapies have shown limited activity in the central nervous system, which has been attributed to the blood-brain barrier and the molecular structure of the used agents. The discovery of driver mutations and drugs targeting these mutations has changed the treatment landscape. Several of these targeted small-molecule tyrosine kinase inhibitors do cross the blood-brain barrier and/or have shown activity in the central nervous system. Another major advance in the care of brain metastases has been the advent of new immunotherapeutic agents, for which initial studies have shown intracranial activity. In this chapter, we will review the unique challenges in the treatment of brain metastases. The pertinent clinical studies of chemotherapy in brain metastases will be discussed. The currently reported clinical trials and evidence for use of targeted therapies and immunotherapeutic agents will be emphasized.
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Rolfo C, Arias D, Gandia JF, Manca P, Santos E, Raez LE. Ceritinib: an orphan drug for ALK positive non-small cell lung cancer with robust clinical evidence. Expert Opin Orphan Drugs 2017. [DOI: 10.1080/21678707.2017.1406347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Christian Rolfo
- Phase I - Early Clinical Trials Unit, Antwerp University Hospital & Center for Oncological Research (CORE), Edegem, Belgium
| | - David Arias
- Phase I - Early Clinical Trials Unit, Antwerp University Hospital & Center for Oncological Research (CORE), Edegem, Belgium
- Ourense University Hospital Complex, Ourense, Spain
| | - Jose Ferri Gandia
- Phase I - Early Clinical Trials Unit, Antwerp University Hospital & Center for Oncological Research (CORE), Edegem, Belgium
| | - Paolo Manca
- Phase I - Early Clinical Trials Unit, Antwerp University Hospital & Center for Oncological Research (CORE), Edegem, Belgium
- Medical Oncology Department, Campus Bio-Medico University, Rome, Italy
| | - Edgardo Santos
- Oncology Department, Lynn Cancer Institute, Boca Raton, FL, USA
| | - Luis E. Raez
- Thoracic Oncology Program, Memorial Cancer Institute, Memorial Health Care System, Pembroke Pines, FL, USA
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Melosky B. Current Treatment Algorithms for Patients with Metastatic Non-Small Cell, Non-Squamous Lung Cancer. Front Oncol 2017; 7:38. [PMID: 28373963 PMCID: PMC5357779 DOI: 10.3389/fonc.2017.00038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Accepted: 02/28/2017] [Indexed: 12/26/2022] Open
Abstract
The treatment paradigm for metastatic non-small cell, non-squamous lung cancer is continuously evolving due to new treatment options and our increasing knowledge of molecular signal pathways. As a result of treatments becoming more efficacious and more personalized, survival for selected groups of non-small cell lung cancer (NSCLC) patients is increasing. In this paper, three algorithms will be presented for treating patients with metastatic non-squamous, NSCLC. These include treatment algorithms for NSCLC patients whose tumors have EGFR mutations, ALK rearrangements, or wild-type/wild-type tumors. As the world of immunotherapy continues to evolve quickly, a future algorithm will also be presented.
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Affiliation(s)
- Barbara Melosky
- Medical Oncology, British Columbia Cancer Agency, Vancouver Centre , Vancouver, BC , Canada
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Kwok WC, Tam TCC, Lui MMS, Lam DCL, Ho JCM. Control of brain metastases with alectinib in anaplastic lymphoma kinase-rearranged lung cancer. Respirol Case Rep 2017; 5:e00224. [PMID: 28275428 PMCID: PMC5338141 DOI: 10.1002/rcr2.224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 01/26/2017] [Accepted: 02/07/2017] [Indexed: 11/28/2022] Open
Abstract
Brain metastasis from non‐small cell lung cancer remains a challenge to physicians. It occurs in 30% of patients with advanced stage adenocarcinoma of lung and is often regarded as the ominous sign of disease progression and death. Alectinib is likely to be a promising agent, even after the failure of crizotinib and ceritinib, for patients with anaplastic lymphoma kinase (ALK) ‐driven non‐small cell lung cancer with brain metastasis, resulting in a durable response for both intracranial and extra‐cranial diseases.
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Affiliation(s)
- Wang Chun Kwok
- Department of Medicine Queen Mary Hospital Hong Kong China
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Venur VA, Ahluwalia MS. Targeted Therapy in Brain Metastases: Ready for Primetime? Am Soc Clin Oncol Educ Book 2016; 35:e123-e130. [PMID: 27249714 DOI: 10.1200/edbk_100006] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Brain metastasis is a serious complication of cancer that causes significant morbidity for patients. Over the last decade, numerous new driver somatic mutations have been recognized and targeted therapies are changing the landscape of treatment in lung cancer, breast cancer, and melanoma, which are also the three most common cancers that result in brain metastases. The common actionable mutations include the EGFR mutation and anaplastic lymphoma kinase (ALK) translocations in non-small cell lung cancer, the HER2 mutation in breast cancer, and the BRAF mutation in melanoma. However, most of the early trials with targeted agents excluded patients with brain metastases. With a better understanding of the biology, several recent trials of targeted therapy that focus on brain metastases have been reported and others are ongoing. Novel agents with better penetration across the blood-brain barrier are currently being investigated for patients with brain metastases. In this review, we discuss the current state of use and future directions of targeted therapies in brain metastases.
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Affiliation(s)
- Vyshak A Venur
- From the Division of Hematology and Oncology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Medicine, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Manmeet S Ahluwalia
- From the Division of Hematology and Oncology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA; Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Medicine, Neurologic Institute, Cleveland Clinic, Cleveland, OH; Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Sullivan I, Planchard D. ALK inhibitors in non-small cell lung cancer: the latest evidence and developments. Ther Adv Med Oncol 2016; 8:32-47. [PMID: 26753004 PMCID: PMC4699265 DOI: 10.1177/1758834015617355] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
The treatment of patients with advanced non-small cell lung cancer (NSCLC) harbouring chromosomal rearrangements of ALK (anaplastic lymphoma kinase) was revolutionized by crizotinib, a small molecule inhibitor of ALK, ROS1 and MET. Unfortunately, the disease progressed within the first 12 months in most of the patients because of the development of crizotinib resistance in the majority of patients and the emergence of acquired resistance mutations in most of them. Many of them had been reported even before its approval leading to the rapid development of second-generation ALK inhibitors for crizotinib-resistant NSCLC. In the last few years, novel potent ALK inhibitors with promising results and a good toxicity profile have become available: ceritinib (LDK378), alectinib (RG7853/AF-802/RO5424802/CH5424802), brigatinib (AP26113), entrectinib (RXDX-101, NMS-E628), PF-06463922, ASP3026, TSR-011, X-376/X-396 and CEP-28122/CEP-37440. Moreover, HSP90 (90 kDa heat shock protein) inhibitors have demonstrated clinical activity in patients with ALK+ NSCLC. This review focuses on the molecular and clinical properties of this new generation of ALK inhibitors under development in the clinic.
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Affiliation(s)
| | - David Planchard
- Gustave Roussy – Medical Oncology, 114 rue Édouard Vaillant, Villejuif 94805, France
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Lawler M, Sullivan R. Personalised and Precision Medicine in Cancer Clinical Trials: Panacea for Progress or Pandora's Box? Public Health Genomics 2015; 18:329-37. [PMID: 26555236 DOI: 10.1159/000441555] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Cancer clinical trials have been one of the key foundations for significant advances in oncology. However, there is a clear recognition within the academic, care delivery and pharmaceutical/biotech communities that our current model of clinical trial discovery and development is no longer fit for purpose. Delivering transformative cancer care should increasingly be our mantra, rather than maintaining the status quo of, at best, the often miniscule incremental benefits that are observed with many current clinical trials. As we enter the era of precision medicine for personalised cancer care (precision and personalised medicine), it is important that we capture and utilise our greater understanding of the biology of disease to drive innovative approaches in clinical trial design and implementation that can lead to a step change in cancer care delivery. A number of advances have been practice changing (e.g. imatinib mesylate in chronic myeloid leukaemia, Herceptin in erb-B2-positive breast cancer), and increasingly we are seeing the promise of a number of newer approaches, particularly in diseases like lung cancer and melanoma. Targeting immune checkpoints has recently yielded some highly promising results. New algorithms that maximise the effectiveness of clinical trials, through for example a multi-stage, multi-arm type design are increasingly gaining traction. However, our enthusiasm for the undoubted advances that have been achieved are being tempered by a realisation that these new approaches may have significant cost implications. This article will address these competing issues, mainly from a European perspective, highlight the problems and challenges to healthcare systems and suggest potential solutions that will ensure that the cost/value rubicon is addressed in a way that allows stakeholders to work together to deliver optimal cost-effective cancer care, the benefits of which can be transferred directly to our patients.
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Affiliation(s)
- Mark Lawler
- Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, UK
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Targeting brain metastases in ALK-rearranged non-small-cell lung cancer. Lancet Oncol 2015; 16:e510-21. [DOI: 10.1016/s1470-2045(15)00013-3] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 01/04/2023]
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Lukas RV, Mehta MP, Lesniak MS. Society for Neuro-Oncology 2014 annual meeting updates on central nervous system metastases. Neurooncol Pract 2015; 2:57-61. [PMID: 27621837 PMCID: PMC5013812 DOI: 10.1093/nop/npv009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The 19th Annual Meeting of the Society for Neuro-Oncology (SNO) took place in November of 2014. The focus of many abstracts, as well as the Education Day, was on recent advances in the study of central nervous system (CNS) metastases. TUMOR BIOLOGY Key studies evaluating the factors in tumors and their microenvironment associated with the development and growth of brain metastases are reviewed. PROGNOSTICATION Studies investigating the factors that independently influence survival in participants with brain metastases are presented. RESPONSE ASSESSMENT The Response Assessment for Neuro-Oncology criteria for brain metastases (RANO-BM) and the Neurological Assessment in Neuro-Oncology (NANO) criteria, which were both presented, are recapped. RADIOTHERAPY Studies are reviewed evaluating factors that influence survival outcomes in participants with brain metastases who were treated with radiotherapy. Studies investigating the potential risk of radiation necrosis with the combination of radiotherapy and immunotherapies are presented. SYSTEMIC THERAPIES Brain metastases-focused subset analyses from the ASCEND-1 trial for ALK-translocated non-small cell lung cancer are presented. Preclinical and clinical work on solid tumor leptomeningeal carcinomatosis is also covered. SEQUELAE OF CENTRAL NERVOUS SYSTEM METASTASES AND THEIR TREATMENTS An overview is provided of treatment- related toxicities as well as important concepts that may influence strategies to protect against these toxicities. CONCLUSIONS Key concepts regarding tumor biology, prognostication, response assessment, therapeutic management, and sequelae of treatment for CNS metastases are summarized. Advances in our understanding of the basic and clinical science of CNS metastases have the potential to improve outcomes for patients.
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Affiliation(s)
- Rimas V. Lukas
- Department of Neurology, University of Chicago, Chicago, Illinois (R.V.L.); Section of Neurosurgery, University of Chicago, Chicago, Illinois (M.S.L.); Department of Radiation Oncology, University of Maryland, Baltimore, Maryland (M.P.M.)
| | - Minesh P. Mehta
- Department of Neurology, University of Chicago, Chicago, Illinois (R.V.L.); Section of Neurosurgery, University of Chicago, Chicago, Illinois (M.S.L.); Department of Radiation Oncology, University of Maryland, Baltimore, Maryland (M.P.M.)
| | - Maciej S. Lesniak
- Department of Neurology, University of Chicago, Chicago, Illinois (R.V.L.); Section of Neurosurgery, University of Chicago, Chicago, Illinois (M.S.L.); Department of Radiation Oncology, University of Maryland, Baltimore, Maryland (M.P.M.)
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Mechanisms of Acquired Resistance to ALK Inhibitors and the Rationale for Treating ALK-positive Lung Cancer. Cancers (Basel) 2015; 7:763-83. [PMID: 25941796 PMCID: PMC4491683 DOI: 10.3390/cancers7020763] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 04/14/2015] [Accepted: 04/21/2015] [Indexed: 12/24/2022] Open
Abstract
The discovery of an echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) fusion gene led to improved clinical outcomes in patients with lung cancer after the development of the first ALK-targeting agent, crizotinib. Some second-generation ALK tyrosine kinase inhibitors (TKIs), which might be more potent than crizotinib or effective on crizotinib-resistant patients, have been developed. Although these ALK-TKIs show an excellent response initially, most patients eventually acquire resistance. Therefore, careful consideration of the resistance mechanisms might lead to superior therapeutic strategies. Here, we summarize the history of ALK-TKIs and their underlying resistance mechanisms in both the preclinical and clinical settings. In addition, we discuss potential future treatment strategies in ALK-TKI-naïve and -resistant patients with lung cancer harboring the EML4-ALK fusion gene.
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