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De Carlo E, Bertoli E, Schiappacassi M, Stanzione B, Del Conte A, Doliana R, Spina M, Bearz A. Case report: First evidence of impressive efficacy of modulated dose selpercatinib in a young Caucasian with ANK3-RET fusion-positive NSCLC. Front Oncol 2024; 14:1307458. [PMID: 38420011 PMCID: PMC10900756 DOI: 10.3389/fonc.2024.1307458] [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: 10/04/2023] [Accepted: 01/18/2024] [Indexed: 03/02/2024] Open
Abstract
Over the past decade, molecular characterization has led to change the management of advanced non-small cell lung cancer (NSCLC) harboring driver mutations. Rearranged during transfection (RET) gene fusions, occurring in 1% to 2% of NSCLC, have emerged as an oncogenic druggable target. Systemic targeted therapies with highly selective RET inhibitors (RETi), selpercatinib and pralsetinib, represent a recent clinical breakthrough. While the development of RETi has improved survival, with their increasing use, it is crucial to be aware of the risks of rare but serious adverse events (AEs). A particular challenge for clinicians in applying targeted therapies is not only diagnosing but also interpreting rare mutations. Herein, we report a case of a 43-year-old Caucasian advanced NSCLC patient diagnosed with a rare RET gene fusion, ANK3::RET, identified with Next Generation Sequencing (NGS). Selpercatinib has been initiated at the recommended initial dose after one incomplete chemotherapy cycle due to a severe infusion reaction, but it subsequently required a dose adjustment following grade 3 (G3) AEs. During treatment, we used a particular selpercatinib dosage (160 mg in the morning and 80 mg in the evening) with good tolerance and without compromising effectiveness. Our finding broadens the range of RET fusion types in not-Asian NSCLC. To the best of our knowledge, our case demonstrates, for the first time, a clinical and radiological response to frontline highly selective RETi selpercatinib, expanding the spectrum of potential oncogenic RET fusion partners in newly diagnosed NSCLC patients. Furthermore, to our knowledge, this is the first case describing a RET fusion-positive (RET+) NSCLC patient treated with a modified selpercatinib dosage outside the drug data sheet and demonstrating a safe and effective use.
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Affiliation(s)
- Elisa De Carlo
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Elisa Bertoli
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
- Department of Medicine (DAME), University of Udine, Udine, Italy
| | - Monica Schiappacassi
- Molecular Oncology Unit, Oncologia Molecolare e dei Modelli Preclinici di Progressione Tumorale (OMMPPT) Department of Translational Research, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Brigida Stanzione
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Alessandro Del Conte
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Roberto Doliana
- Molecular Oncology Unit, Oncologia Molecolare e dei Modelli Preclinici di Progressione Tumorale (OMMPPT) Department of Translational Research, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Michele Spina
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
| | - Alessandra Bearz
- Department of Medical Oncology, Centro di Riferimento Oncologico di Aviano (CRO), Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Aviano, Italy
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Bertaglia V, Morelli AM, Solinas C, Aiello MM, Manunta S, Denaro N, Tampellini M, Scartozzi M, Novello S. Infections in lung cancer patients undergoing immunotherapy and targeted therapy: An overview on the current scenario. Crit Rev Oncol Hematol 2023; 184:103954. [PMID: 36878396 DOI: 10.1016/j.critrevonc.2023.103954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Patients with a diagnosis of lung cancer are often vulnerable to infection, and the risk is increased by tumor-associated immunosuppression and the effects of the treatments. Historically, links between the risk of infection and cytotoxic chemotherapy due to neutropenia and respiratory syndromes are well established. The advent of tyrosine kinase inhibitors (TKIs) and immune-checkpoint inhibitors (ICIs) targeting the programmed cell death-1 (PD-1)/programmed cell death- ligand 1 (PD-L1) axis and cytotoxic T-lymphocyte antigen-4 (CTLA-4) have changed the treatment paradigm for lung cancer patients. Our understanding of the risk of infections while administrating these drugs is evolving, as are the biological mechanisms that are responsible. In this overview, we focus on the risk of infection with the use of targeted therapies and ICIs, summarizing current evidence from preclinical and clinical studies and discussing their clinical implications.
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Affiliation(s)
- Valentina Bertaglia
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Orbassano, Torino, Italy
| | - Anna Maria Morelli
- Medical Oncology, ASL TO3 Ospedale degli Infermi, 10098 Rivoli, Torino, Italy
| | - Cinzia Solinas
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, 09042 Monserrato, Cagliari, Italy.
| | - Marco Maria Aiello
- Medical Oncology, AOU Policlinico Vittorio Emanuele di Catania, 95100 Catania, Italy
| | - Silvia Manunta
- Medical Oncology, Ospedale Civile di Alghero, 07041 Alghero, Italy
| | - Nerina Denaro
- Oncology Department, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Marco Tampellini
- Medical Oncology, ASL TO3 Ospedale degli Infermi, 10098 Rivoli, Torino, Italy
| | - Mario Scartozzi
- Medical Oncology, AOU Cagliari, Policlinico di Monserrato, 09042 Monserrato, Cagliari, Italy
| | - Silvia Novello
- Department of Oncology, University of Turin, San Luigi Gonzaga Hospital, 10043 Orbassano, Torino, Italy
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Wu G, Guo L, Gu Y, Huang T, Liu M, Zou X, Yang B, Huang P, Wen C, Yi L, Liao W, Zhao D, Zhu J, Zhang X, Liu Y, Yin Y, Chen S. The genomic characteristics of RET fusion positive tumors in Chinese non-small cell lung cancer (NSCLC) patients. J Cancer Res Clin Oncol 2023; 149:1019-1028. [PMID: 35220468 PMCID: PMC9984339 DOI: 10.1007/s00432-022-03959-6] [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: 08/30/2021] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Approximately 1-2% of non-small cell lung cancer (NSCLC) patients harbor RET (rearranged during transfection) fusions. The oncogenic RET fusions could lead to constitutive kinase activation and oncogenesis. METHODS 1746 Chinese NSCLC patients were analyzed in this study. Tumor tissues were collected, and were formalin fixed, paraffin-embedded (FFPE) and archived. Peripheral blood (PB) samples were also collected from each patient as control. In addition, we selected 17 of them for cfDNA NGS testing and 14 tumor samples for immunohistochemistry testing using PD-L1 rabbit monoclonal antibody, clones 28-8 (Abcam, Cambridge, UK). RESULTS Of the 1746 NSCLC cases, RET rearrangements were identified in 25 cases (1.43%) with locally advanced or metastatic NSCLC, of which 20 (80%) were female. We found that 14 out of 25 patients had an KIF5B-RET fusion, with KIF5B exon15-RET exon12, KIF5B exon23-RET exon12, and KIF5B exon24-RET exon11 detected in 14, 3, and 1 patients, respectively. We also identified one novel RET fusion partner PLCE1 and 4 intergenic-breakpoint fusions. CONCLUSION In this study, using the hybrid capture based next generation sequencing (NGS) techniques, we revealed the genomic profiling for the patients with RET fusion-positive NSCLC. To the best of our knowledge, this is the first study that exhibited the detailed breakpoints of Chinese NSCLC patients with RET rearrangement, and we found a novel new partner PLCE1. The results provided genomic information for patients with RET fusion which is significant for personalized clinical management in the era of precision medicine.
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Affiliation(s)
- Guowu Wu
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China.
| | - Longhua Guo
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China.
| | - Yinfang Gu
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | | | - Ming Liu
- HaploX Biotechnology Co., Ltd., Shenzhen, China
| | - Xiaofang Zou
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | - Bo Yang
- HaploX Biotechnology Co., Ltd., Shenzhen, China
| | - Ping Huang
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | - Chunling Wen
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | - Lilan Yi
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | | | - Dongdong Zhao
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | - Junlin Zhu
- Department of Medical Oncology, Cancer Center, Meizhou People's Hospital (Huangtang Hospital), 63 Huangtang Road, Meizhou, China
| | | | | | - Yan Yin
- HaploX Biotechnology Co., Ltd., Shenzhen, China
| | - Shifu Chen
- HaploX Biotechnology Co., Ltd., Shenzhen, China.
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Kucharczyk T, Krawczyk P, Kowalski DM, Płużański A, Kubiatowski T, Kalinka E. RET Proto-Oncogene-Not Such an Obvious Starting Point in Cancer Therapy. Cancers (Basel) 2022; 14:5298. [PMID: 36358717 PMCID: PMC9657474 DOI: 10.3390/cancers14215298] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/26/2023] Open
Abstract
Mutations and fusions of RET (rearranged during transfection) gene are detected in a few common types of tumors including thyroid or non-small cells lung cancers. Multiple kinase inhibitors (MKIs) do not show spectacular effectiveness in patients with RET-altered tumors. Hence, recently, two novel RET-specific inhibitors were registered in the US and in Europe. Selpercatinib and pralsetinib showed high efficacy in clinical trials, with fewer adverse effects, in comparison to previously used MKIs. However, the effectiveness of these new drugs may be reduced by the emergence of resistance mutations in RET gene and activation of different activating signaling pathways. This review presents the function of the normal RET receptor, types of molecular disturbances of the RET gene in patients with various cancers, methods of detecting these abnormalities, and the effectiveness of modern anticancer therapies (ranging from immunotherapies, through MKIs, to RET-specific inhibitors).
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Affiliation(s)
- Tomasz Kucharczyk
- Chair and Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Paweł Krawczyk
- Chair and Department of Pneumonology, Oncology and Allergology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Dariusz M. Kowalski
- Department of Lung and Thoracic Tumours, Maria Skłodowskiej-Curie National Research Institute, 02-718 Warsaw, Poland
| | - Adam Płużański
- Department of Lung and Thoracic Tumours, Maria Skłodowskiej-Curie National Research Institute, 02-718 Warsaw, Poland
| | - Tomasz Kubiatowski
- Oncology and Immunology Clinic, Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration’s Hospital, 10-228 Olsztyn, Poland
| | - Ewa Kalinka
- Department of Oncology, Polish Mother’s Memorial Hospital-Research Institute, 90-302 Lodz, Poland
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Zito Marino F, Alì G, Facchinetti F, Righi L, Fontanini G, Rossi G, Franco R. Fusion proteins in lung cancer: addressing diagnostic problems for deciding therapy. Expert Rev Anticancer Ther 2021; 21:887-900. [PMID: 33715580 DOI: 10.1080/14737140.2021.1903875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Introduction: Gene fusions are frequent chromosomal aberrations in solid tumors. In Lung cancer (LC) several druggable-fusions involving tyrosine kinase receptor genes have been described, including ALK, ROS1, RET and NTRK. In non-small cell lung cancer, testing for targetable fusions has become a part of routine clinical practice, greatly impacting therapeutic choice for patients with these aberrations. Although substantial technologies for gene fusion detection have been implemented over time including; cytogenetic, Fluorescence in situ hybridization (FISH), Immunohistochemistry (IHC), Retro-transcription Real-Time PCR (RT-qPCR), to Next Generation Sequencing (NGS), nCounter system (Nanostring technology), several critical issues remain. To date, only the companion diagnostic tests FISH and IHC for ALK-rearrangements and NGS for ROS1-rearrangments were approved. Other fusion approved tests are currently unavailable.Areas covered: In this review, we explore current diagnostic problems of gene fusion detection relative to the technologies available, in order to clarify future standardization of analyses which determine therapeutic choices.Expert opinion: The establishment of a gold standard, an effective diagnostic algorithm, and a standardized interpretation for the analysis of each druggable-fusions in lung cancer is essential for adequate therapeutic management.
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Affiliation(s)
- Federica Zito Marino
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Greta Alì
- Department of Surgical Pathology, Medical, Molecular, and Critical Area, University of Pisa, Pisa, Italy
| | - Francesco Facchinetti
- Université Paris-Saclay, Institut Gustave Roussy, INSERM, Biomarqueurs prédictifs et nouvelles stratégies thérapeutiques en oncologie, Villejuif, France.,Medical Oncology Unit, University Hospital of Parma, Italy
| | - Luisella Righi
- Department of Oncology, University of Turin, Pathology Division, San Luigi Hospital, University of Turin, Turin, Italy
| | - Gabriella Fontanini
- Department of Surgical Pathology, Medical, Molecular, and Critical Area, University of Pisa, Pisa, Italy
| | - Giulio Rossi
- Operative Unit of Pathologic Anatomy, Azienda Della Romagna, Teaching Hospital S. Maria Delle Croci, Ravenna, Italy
| | - Renato Franco
- Pathology Unit, Department of Mental and Physical Health and Preventive Medicine, University of Campania 'Luigi Vanvitelli', Naples, Italy
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6
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Belli C, Penault-Llorca F, Ladanyi M, Normanno N, Scoazec JY, Lacroix L, Reis-Filho JS, Subbiah V, Gainor JF, Endris V, Repetto M, Drilon A, Scarpa A, André F, Douillard JY, Curigliano G. ESMO recommendations on the standard methods to detect RET fusions and mutations in daily practice and clinical research. Ann Oncol 2021; 32:337-350. [PMID: 33455880 DOI: 10.1016/j.annonc.2020.11.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/26/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022] Open
Abstract
Aberrant activation of RET is a critical driver of growth and proliferation in diverse solid tumours. Multikinase inhibitors (MKIs) showing anti-RET activities have been tested in RET-altered tumours with variable results. The low target specificity with consequent increase in side-effects and off-target toxicities resulting in dose reduction and drug discontinuation are some of the major issues with MKIs. To overcome these issues, new selective RET inhibitors such as pralsetinib (BLU-667) and selpercatinib (LOXO-292) have been developed in clinical trials, with selpercatinib recently approved by the Food and Drug Administration (FDA). The results of these trials showed marked and durable antitumour activity and manageable toxicity profiles in patients with RET-altered tumours. The European Society for Medical Oncology (ESMO) Translational Research and Precision Medicine Working Group (TR and PM WG) launched a collaborative project to review the available methods for the detection of RET gene alterations, their potential applications and strategies for the implementation of a rational approach for the detection of RET fusion genes and mutations in human malignancies. We present here recommendations for the routine clinical detection of targetable RET rearrangements and mutations.
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Affiliation(s)
- C Belli
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - F Penault-Llorca
- University Clermont Auvergne, INSERM U1240, Centre Jean Perrin, Department of BioPathology, Clermont-Ferrand, France
| | - M Ladanyi
- Department of Pathology and Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, USA
| | - N Normanno
- Cell Biology and Biotherapy Unit, Istituto Nazionale Tumori "Fondazione G. Pascale"-IRCCS, Naples, Italy
| | - J-Y Scoazec
- AMMICa, CNRS-UMS 3655 and INSERM-US23, Gustave Roussy, Villejuif, France; Department of Pathology and Translational Research, Gustave Roussy Cancer Centre, Villejuif, France
| | - L Lacroix
- Translational Research Laboratory and Biobank, Gustave Roussy, Villejuif, France; Inserm U981, Gustave Roussy, Villejuif, France; Department of Medical Biology and Pathology, Gustave Roussy, Villejuif, France
| | - J S Reis-Filho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, USA
| | - V Subbiah
- The University of Texas MD Anderson Cancer Center, Houston, USA
| | - J F Gainor
- Massachusetts General Hospital, Boston, USA
| | - V Endris
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - M Repetto
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - A Drilon
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, USA
| | - A Scarpa
- ARC-Net Research Centre and Department of Diagnostics and Public Health - Section of Pathology, University of Verona, Verona, Italy
| | - F André
- Gustave Roussy Cancer Center, Villejuif, France
| | - J-Y Douillard
- Scientific and Medical Division, European Society for Medical Oncology, Lugano, Switzerland
| | - G Curigliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy.
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7
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Batra U, Nathany S, Diwan H. RET in non-small cell lung carcinoma: A narrative review. CANCER RESEARCH, STATISTICS, AND TREATMENT 2021. [DOI: 10.4103/crst.crst_254_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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A fusion of CD63-BCAR4 identified in lung adenocarcinoma promotes tumorigenicity and metastasis. Br J Cancer 2020; 124:290-298. [PMID: 33204025 PMCID: PMC7782829 DOI: 10.1038/s41416-020-01146-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 09/29/2020] [Accepted: 10/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background Recently, fusion variants of the breast cancer anti-oestrogen-resistance 4 (BCAR4) gene were recurrently discovered in lung adenocarcinoma from the genome-wide studies. However, the functional characterisation of BCAR4 fusion has not been investigated. Methods Based on the analysis of RNA-sequencing data, we identified a fusion transcript of CD63–BCAR4 in a Korean patient with lung adenocarcinoma who did not harbour any known activating mutations in EGFR and KRAS genes. To investigate the oncogenic effect of CD63–BCAR4, in vitro and in vivo animal experiments were performed. Results In vitro experiments showed strongly enhanced cell migration and proliferation by the exogenous expression of CD63–BCAR4 protein in bronchial epithelial cells. Cell migration was notably reduced after knockdown of BCAR4 fusion by small-interfering RNA. The tumorigenic and metastatic capability of the CD63–BCAR4 fusion was confirmed by using the mouse xenograft model. Fusion-overexpressed cells result in metastasis to the liver and lung as well as the primary tumours after subcutaneous injection into mice. Cyclin D1, MMP1, Slug and mesenchymal markers were significantly increased after CD63–BCAR4 overexpression in the in vitro and in vivo experiments. Conclusions Taken together, our results suggest a newly identified fusion gene, CD63–BCAR4 as a potential novel oncogene in lung adenocarcinoma.
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9
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Zhao Z, Fu T, Gao J, Xu Y, Wu X, Chen W, Li X, Yu R, Shao YW, Li M, Yao Y. Identifying novel oncogenic RET mutations and characterising their sensitivity to RET-specific inhibitors. J Med Genet 2020; 58:jmedgenet-2019-106546. [PMID: 32284345 DOI: 10.1136/jmedgenet-2019-106546] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/06/2020] [Accepted: 03/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Rearranged during transfection (RET) is a well-known proto-oncogene. Multiple RET oncogenic alterations have been identified, including fusions and mutations. Although RET fusions have been reported in multiple cancers, RET mutations were mainly found in multiple endocrine neoplasia type 2 and medullary thyroid carcinoma. RET mutations in other cancers were underinvestigated and their functional annotation was less well studied. METHODS We retrospectively reviewed next-generation sequencing data from 37 056 patients with cancer to search for RET mutations. We excluded patients with other co-occurring known driver mutations to enrich potential activating RET mutations for further analysis. Moreover, we performed in vitro functional validation of the oncogenic property of several high frequent and novel RET mutants and their sensitivity to RET-specific inhibitors LOXO-292 and BLU-667. RESULTS Within 560 (1.5%) patients with cancer who harbour RET mutations, we identified 380 distinct RET mutation sites, including 252 sites without co-occurring driver mutations. RET mutations were more frequently found in thyroid cancer, mediastinal tumour and several other cancers. The mutation sites spread out through the whole protein with a few hotspots within the kinase domain. In addition, we functionally validated that 898-901del, T930P and T930K were novel RET-activating mutations and they were all sensitive to RET inhibitors. CONCLUSION Our results demonstrated the frequency of RET mutations across different cancers. We reported and/or validated several previously uncharacterised RET oncogenic mutations and demonstrated their sensitivity to RET-specific inhibitors. Our results help to stratify patients with cancer based on their RET mutation status and potentially provide more targeted treatment options.
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Affiliation(s)
- Zheng Zhao
- Third Department of Medical Oncology, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, China
| | - Tao Fu
- Gastrointestinal Surgery Department, Beijing Cancer Hospital, Beijing, China
| | - Jiyue Gao
- Department of Breast Surgery, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yang Xu
- Translational Medicine Research Institute, Geneseeq Technology Inc, Toronto, Ontario, Canada
| | - Xue Wu
- Translational Medicine Research Institute, Geneseeq Technology Inc, Toronto, Ontario, Canada
| | - Wenjuan Chen
- Third Department of Medical Oncology, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, China
| | - Xuesong Li
- Translational Medicine Research Institute, Geneseeq Technology Inc, Toronto, Ontario, Canada
| | - Ruoying Yu
- Translational Medicine Research Institute, Geneseeq Technology Inc, Toronto, Ontario, Canada
| | - Yang Washington Shao
- Nanjing Geneseeq Technology Inc, Nanjing, Jiangsu, China
- School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Man Li
- Department of Oncology, The Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yu Yao
- Internal Medicine-Oncology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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Ackermann CJ, Stock G, Tay R, Dawod M, Gomes F, Califano R. Targeted Therapy For RET-Rearranged Non-Small Cell Lung Cancer: Clinical Development And Future Directions. Onco Targets Ther 2019; 12:7857-7864. [PMID: 31576143 PMCID: PMC6767757 DOI: 10.2147/ott.s171665] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Approximately 1-2% of unselected patients with Non-small Cell Lung Cancer (NSCLC) harbor RET rearrangements resulting in enhanced cell survival and proliferation. The initial treatment strategy for RET rearranged NSCLC has been multi-target tyrosine kinase inhibition. With overall response rates (ORR) of 16-53% and a median progression-free survival (PFS) of 4.5-7.3 months these outcomes are clearly inferior to the efficacy outcomes of selective tyrosine kinase inhibitors (TKI) in other oncogene-addicted NSCLC. Additionally, multi-kinase inhibition in RET-driven NSCLC patients showed concerning rates of high-grade toxicity, mainly induced by anti-VEGFR-kinase activity. Novel selective RET inhibitors like BLU-667, LOXO-292 and RXDX-105 have been recently investigated in early phase clinical trials showing promising efficacy with a manageable toxicity profile.
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Affiliation(s)
| | - Gustavo Stock
- Department of Medical Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil
| | - Rebecca Tay
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Mohammed Dawod
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Fabio Gomes
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Raffaele Califano
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
- Department of Medical Oncology, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cancer Sciences, University of Manchester, Manchester, UK
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11
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Bronte G, Ulivi P, Verlicchi A, Cravero P, Delmonte A, Crinò L. Targeting RET-rearranged non-small-cell lung cancer: future prospects. LUNG CANCER-TARGETS AND THERAPY 2019; 10:27-36. [PMID: 30962732 PMCID: PMC6433115 DOI: 10.2147/lctt.s192830] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Non-small-cell lung cancer (NSCLC) patients with mutated or rearranged oncogene drivers can be treated with upfront selective inhibitors achieving higher response rates and longer survival than chemotherapy. The RET gene can undergo chromosomal rearrangements in 1%–2% of all NSCLC patients, involving various upstream fusion partners such as KIF5B, CCDC6, NCOA4, and TRIM33. Many multikinase inhibitors are active against rearranged RET. Cabozantinib, vandetanib, sunitinib, lenvatinib, and nintedanib achieved tumor responses in about 30% of these patients in retrospective studies. Prospective phase II trials investigated the activity and toxicity of cabozantinib, vandetanib, sorafenib, and lenvatinib, and did not reach significantly higher response rates. VEGFR and EGFR inhibition represented the main ways of developing off-target toxicity. An intrinsic resistance emerged according to the type of RET fusion partners, as KIF5B-RET fusion is the most resistant. Also acquired mutations in rearranged RET oncogene developed as resistance to these multikinase inhibitors. Interestingly, RET fusions have been found as a resistance mechanism to EGFR-TKIs in EGFR-mutant NSCLC patients. The combination of EGFR and RET inhibition can overcome this resistance. The limitations in terms of activity and tolerability of the various multikinase inhibitors prompted the investigation of new highly selective RET inhibitors, such as RXDX-105, BLU-667, and LOXO-292. Some data emerged about intracranial antitumor activity of BLU-667 and LOXO-292. If these novel drugs will achieve high activity in RET rearranged NSCLC, also these oncogene-addicted tumors can undergo a significant survival improvement.
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Affiliation(s)
- Giuseppe Bronte
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
| | - Paola Ulivi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
| | - Alberto Verlicchi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
| | - Paola Cravero
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
| | - Angelo Delmonte
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
| | - Lucio Crinò
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, FC, Italy,
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12
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Tuna M, Amos CI, Mills GB. Molecular mechanisms and pathobiology of oncogenic fusion transcripts in epithelial tumors. Oncotarget 2019; 10:2095-2111. [PMID: 31007851 PMCID: PMC6459343 DOI: 10.18632/oncotarget.26777] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/22/2019] [Indexed: 02/07/2023] Open
Abstract
Recurrent fusion transcripts, which are one of the characteristic hallmarks of cancer, arise either from chromosomal rearrangements or from transcriptional errors in splicing. DNA rearrangements include intrachromosomal or interchromosomal translocation, tandem duplication, deletion, inversion, or result from chromothripsis, which causes complex rearrangements. In addition, fusion proteins can be created through transcriptional read-through. Fusion genes can be transcribed to fusion transcripts and translated to chimeric proteins, with many having demonstrated transforming activities through multiple mechanisms in cells. Fusion proteins represent novel therapeutic targets and diagnostic biomarkers of diagnosis, disease status, or progression. This review focuses on the mechanisms underlying the formation of oncogenic fusion genes and transcripts and their impact on the pathobiology of epithelial tumors.
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Affiliation(s)
- Musaffe Tuna
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Christopher I Amos
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA.,Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Gordon B Mills
- Department of Systems Biology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Cell, Developmental and Cancer Biology, School of Medicine, Oregon Health Science University, Portland, OR, USA.,Precision Oncology, Knight Cancer Institute, Portland, OR, USA
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13
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Peyvandipour A, Saberian N, Shafi A, Donato M, Draghici S. A novel computational approach for drug repurposing using systems biology. Bioinformatics 2018; 34:2817-2825. [PMID: 29534151 PMCID: PMC6084573 DOI: 10.1093/bioinformatics/bty133] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2017] [Revised: 02/07/2018] [Accepted: 03/08/2018] [Indexed: 12/21/2022] Open
Abstract
Motivation Identification of novel therapeutic effects for existing US Food and Drug Administration (FDA)-approved drugs, drug repurposing, is an approach aimed to dramatically shorten the drug discovery process, which is costly, slow and risky. Several computational approaches use transcriptional data to find potential repurposing candidates. The main hypothesis of such approaches is that if gene expression signature of a particular drug is opposite to the gene expression signature of a disease, that drug may have a potential therapeutic effect on the disease. However, this may not be optimal since it fails to consider the different roles of genes and their dependencies at the system level. Results We propose a systems biology approach to discover novel therapeutic roles for established drugs that addresses some of the issues in the current approaches. To do so, we use publicly available drug and disease data to build a drug-disease network by considering all interactions between drug targets and disease-related genes in the context of all known signaling pathways. This network is integrated with gene-expression measurements to identify drugs with new desired therapeutic effects based on a system-level analysis method. We compare the proposed approach with the drug repurposing approach proposed by Sirota et al. on four human diseases: idiopathic pulmonary fibrosis, non-small cell lung cancer, prostate cancer and breast cancer. We evaluate the proposed approach based on its ability to re-discover drugs that are already FDA-approved for a given disease. Availability and implementation The R package DrugDiseaseNet is under review for publication in Bioconductor and is available at https://github.com/azampvd/DrugDiseaseNet. Supplementary information Supplementary data are available at Bioinformatics online.
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Affiliation(s)
| | | | - Adib Shafi
- Computer Science, Wayne State University, Detroit, MI, USA
| | - Michele Donato
- Computer Science, Wayne State University, Detroit, MI, USA
| | - Sorin Draghici
- Computer Science, Wayne State University, Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University, Detroit, MI, USA
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14
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Zarredar H, Ansarin K, Baradaran B, Ahdi Khosroshahi S, Farajnia S. Potential Molecular Targets in the Treatment of Lung Cancer Using siRNA Technology. Cancer Invest 2018; 36:37-58. [DOI: 10.1080/07357907.2017.1416393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Habib Zarredar
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Science, Tabriz, Iran
- Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Science, Tabriz, Iran
| | - Behzad Baradaran
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Safar Farajnia
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Science, Tabriz, Iran
- Biotechnology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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15
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Identification of a novel partner gene, KIAA1217, fused to RET: Functional characterization and inhibitor sensitivity of two isoforms in lung adenocarcinoma. Oncotarget 2017; 7:36101-36114. [PMID: 27150058 PMCID: PMC5094986 DOI: 10.18632/oncotarget.9137] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 04/16/2016] [Indexed: 12/27/2022] Open
Abstract
REarranged during Transfection (RET) fusion genes are detected in approximately 1% of lung adenocarcinomas and known primarily as oncogenic driver factors. Here, we found a novel RET fusion gene, KIAA1217-RET, and examined the functional differences of RET51 and RET9 protein, fused with KIAA1217 in cancer progression and drug response. KIAA1217-RET, resulting from the rearrangement of chromosome 10, was generated by the fusion of KIAA1217 exon 11 and RET exon 11 from a non-small cell lung cancer patient. Expression of this gene led to increased cell growth and invasive properties through activations of the PI3K/AKT and ERK signaling pathways and subsequently enabled oncogenic transformation of lung cells. We observed that cells expressing KIAA1217-RET9 fusion protein were more sensitive to vandetanib than those expressing KIAA1217-RET51 and both isoforms attenuated cellular growth via cell cycle arrest. These results demonstrated that KIAA1217-RET fusion represents a novel oncogenic driver gene, the products of which are sensitive to vandetanib treatment, and suggested that the KIAA1217-RET-fusion gene is a promising target for lung cancer treatment.
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16
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Lee SH, Lee JK, Ahn MJ, Kim DW, Sun JM, Keam B, Kim TM, Heo DS, Ahn JS, Choi YL, Min HS, Jeon YK, Park K. Vandetanib in pretreated patients with advanced non-small cell lung cancer-harboring RET rearrangement: a phase II clinical trial. Ann Oncol 2017; 28:292-297. [PMID: 27803005 DOI: 10.1093/annonc/mdw559] [Citation(s) in RCA: 159] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Chromosomal rearrangements involving RET, which are found in about 1% of non-small cell lung cancer (NSCLC), define a unique molecular subset. We performed this study to examine the efficacy and safety of vandetanib 300 mg daily in this patient population. Patients and methods This study was a multi-center, open-label, phase II clinical trial. Patients were enrolled if they had metastatic or recurrent NSCLC with a RET rearrangement, which was confirmed by fluorescence in situ hybridization, had progressive disease against platinum-based doublet chemotherapy, and had a performance status of 0-2. The primary endpoint was the objective response rate. Results A total of 18 patients were enrolled in this study between July 2013 and October 2015. Patients were aged 35-71 years; three had a performance status of 2, and the majority were a heavily pretreated population (≥ two different previous chemotherapy regimens in 72% of the patients). Among the 17 evaluable patients, three had a partial response (objective response rate = 18%) and eight had a stable disease (disease control rate = 65%). Among these patients, the partial response or disease stabilization was durable for more than 6 months in eight patients. Vandetanib also showed a progression-free survival of 4.5 months, and an overall survival of 11.6 months during a median follow-up duration of 14 months. The safety profile was comparable with previous studies of vandetanib. Most vandetanib-related adverse events were mild with prevalent hypertension and rash (in >70% of patients). Grade 3 toxicity included hypertension (n = 3), QT prolongation (2), and elevation of aminotransferases (1), and as a consequence the dose was reduced in four patients. There were no adverse events associated with grade 4 or 5 toxicity. Conclusion Vandetanib is moderately active in pretreated patients with advanced NSCLC-harboring RET rearrangements.
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Affiliation(s)
- S-H Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - J-K Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul
| | - M-J Ahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - D-W Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul
| | - J-M Sun
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - B Keam
- Department of Internal Medicine, Seoul National University Hospital, Seoul
| | - T M Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul
| | - D S Heo
- Department of Internal Medicine, Seoul National University Hospital, Seoul
| | - J S Ahn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Y-L Choi
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - H-S Min
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Y K Jeon
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - K Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
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Lau KW, Seng C, Lim TKH, Tan DSW. Expanded molecular interrogation for potential actionable targets in non-squamous non-small cell lung cancer. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:372. [PMID: 29057232 PMCID: PMC5635263 DOI: 10.21037/atm.2017.08.42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 08/03/2017] [Indexed: 12/15/2022]
Abstract
The advent of targeted therapies has established new standards of care for defined molecular subsets of non-small cell lung cancer (NSCLC). Not only has this led to significant changes in the routine clinical management of lung cancer e.g., multiplexed genomic testing, but it has provided important principles and benchmarks for determining "actionability". At present, the clinical paradigms are most evolved for EGFR mutations and ALK rearrangements, where multiple randomized phase III trials have determined optimal treatment strategies in both treatment naïve and resistant settings. However, this may not always be feasible with low prevalence alterations e.g., ROS1 and BRAF mutations. Another emerging observation is that not all targets are equally "actionable", necessitating a rigorous preclinical, clinical and translational framework to prosecute new targets and drug candidates. In this review, we will cover the role of targeted therapies for NSCLC harbouring BRAF, MET, HER2 and RET alterations, all of which have shown promise in non-squamous non-small cell lung cancer (ns-NSCLC). We further review some early epigenetic targets in NSCLC, an area of emerging interest. With increased molecular segmentation of lung cancer, we discuss the upcoming challenges in drug development and implementation of precision oncology approaches, especially in light of the complex and rapidly evolving therapeutic landscape.
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Affiliation(s)
- Kah Weng Lau
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
- Institute of Molecular and Cell Biology, ASTAR, Singapore
| | - Claudia Seng
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
| | - Tony K H Lim
- Department of Anatomical Pathology, Singapore General Hospital, Singapore
| | - Daniel S W Tan
- Division of Medical Oncology, National Cancer Centre Singapore, Singapore
- Cancer Therapeutics Research Laboratory, Singapore
- Genome Institute of Singapore, ASTAR, Singapore
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18
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Kanwal M, Ding XJ, Cao Y. Familial risk for lung cancer. Oncol Lett 2017; 13:535-542. [PMID: 28356926 PMCID: PMC5351216 DOI: 10.3892/ol.2016.5518] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/26/2016] [Indexed: 01/07/2023] Open
Abstract
Lung cancer, which has a low survival rate, is a leading cause of cancer-associated mortality worldwide. Smoking and air pollution are the major causes of lung cancer; however, numerous studies have demonstrated that genetic factors also contribute to the development of lung cancer. A family history of lung cancer increases the risk for the disease in both smokers and never-smokers. This review focuses on familial lung cancer, in particular on the familial aggregation of lung cancer. The development of familial lung cancer involves shared environmental and genetic factors among family members. Familial lung cancer represents a good model for investigating the association between environmental and genetic factors, as well as for identifying susceptibility genes for lung cancer. In addition, studies on familial lung cancer may help to elucidate the etiology and mechanism of lung cancer, and may identify novel biomarkers for early detection and diagnosis, targeted therapy and improved prevention strategies. This review presents the aetiology and molecular biology of lung cancer and then systematically introduces and discusses several aspects of familial lung cancer, including the characteristics of familial lung cancer, population-based studies on familial lung cancer and the genetics of familial lung cancer.
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Affiliation(s)
- Madiha Kanwal
- Laboratory of Molecular and Experimental Pathology, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, P.R. China
- Kunming College of Life Sciences, University of Chinese Academy of Sciences, Beijing 100049, P.R. China
| | - Xiao-Ji Ding
- Laboratory of Molecular and Experimental Pathology, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, P.R. China
| | - Yi Cao
- Laboratory of Molecular and Experimental Pathology, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, P.R. China
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19
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Lung Cancer Genomics in the Era of Accelerated Targeted Drug Development. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 890:1-23. [PMID: 26703796 DOI: 10.1007/978-3-319-24932-2_1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Lung cancer is the leading cause of cancer-related deaths in the United States and the 5-year overall survival outlook for a patient has not improved in several decades. Recently, however, molecular and genomic profiling of the lung tumors has revealed recurring somatic mutations. As a result the therapeutic landscape of lung cancer is undergoing a paradigm shift from a purely histology-based understanding of the disease to subtype distinctions based on tumor genetics, which has launched cancer-specific, mechanism-based targeted therapies with clear benefit to patients. While targeted therapy advancements are being made at an ever increasing rate, a new challenge in the form of drug resistance has also emerged. This review summarizes the current literature for these issues.
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20
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Emerging Biomarkers in Personalized Therapy of Lung Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 890:25-36. [DOI: 10.1007/978-3-319-24932-2_2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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21
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Clinical and prognostic implications of RET rearrangements in metastatic lung adenocarcinoma patients with malignant pleural effusion. Lung Cancer 2015; 88:208-14. [DOI: 10.1016/j.lungcan.2015.02.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 12/26/2022]
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22
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Lee SE, Lee B, Hong M, Song JY, Jung K, Lira ME, Mao M, Han J, Kim J, Choi YL. Comprehensive analysis of RET and ROS1 rearrangement in lung adenocarcinoma. Mod Pathol 2015; 28:468-79. [PMID: 25234288 DOI: 10.1038/modpathol.2014.107] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 06/22/2014] [Accepted: 06/23/2014] [Indexed: 11/09/2022]
Abstract
The success of crizotinib in ALK-positive patients has elicited efforts to find new oncogenic fusions in lung cancer. These efforts have led to the discovery of novel oncogenic fusion genes such as ROS1 and RET. However, the molecular and clinicopathologic characteristics associated with RET or ROS1 fusion, compared with ALK fusion-positive lung cancer, remain unclear. We accordingly analyzed the clinicopathologic characteristics of RET- and ROS1-fusion-positive lung adenocarcinomas. We further performed immunohistochemistry and fluorescence in situ hybridization analysis (FISH) in 15 cases of RET and 9 cases of ROS1 fusion tumors by identified NanoString's nCounter screening. RET fusion-positive patients were younger in age, never-smokers, and in early T stage; ROS1 fusion-positive patients had a higher number of never-smokers compared with patients with quintuple-negative (EGFR-/KRAS-/ALK-/ROS1-/RET-) lung adenocarcinoma. Histologically, RET and ROS1 fusion tumors share the solid signet-ring cell and mucinous cribriform pattern, as previously mentioned in the histology of ALK fusion tumors. Therefore, it can be presumed that fusion gene-associated lung adenocarcinomas share similar histologic features. In immunohistochemistry, the majority of 15 RET and 9 ROS1 fusion-positive cases showed positivity of more than moderate intensity and cytoplasmic staining for RET and ROS1 proteins, respectively. In FISH, the majority of RET and ROS1 rearrangement showed two signal patterns such as one fusion signal and two separated green and orange signals (1F1G1O) and an isolated 3' green signal pattern (1F1G). Our study has provided not only characteristics of fusion gene-associated histologic features but also a proposal for a future screening strategy that will enable clinicians to select cases needed to be checked for ROS1 and RET rearrangements based on clinicohistologic features.
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Affiliation(s)
- Seung Eun Lee
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Boram Lee
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mineui Hong
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji-Young Song
- 1] Laboratory of Cancer Genomics and Molecular Pathology, Samsung Medical Center, Samsung Biomedical Research Institute, Seoul, Korea [2] Institute for Refractory Cancer Research, Samsung Medical Center, Seoul, Korea
| | - Kyungsoo Jung
- 1] Laboratory of Cancer Genomics and Molecular Pathology, Samsung Medical Center, Samsung Biomedical Research Institute, Seoul, Korea [2] Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Maruja E Lira
- Oncology Research Unit, Pfizer Worldwide Research and Development, San Diego, CA, USA
| | - Mao Mao
- Oncology Research Unit, Pfizer Worldwide Research and Development, San Diego, CA, USA
| | - Joungho Han
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jhingook Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-La Choi
- 1] Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea [2] Laboratory of Cancer Genomics and Molecular Pathology, Samsung Medical Center, Samsung Biomedical Research Institute, Seoul, Korea [3] Institute for Refractory Cancer Research, Samsung Medical Center, Seoul, Korea [4] Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University School of Medicine, Seoul, Korea
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Khoo C, Rogers TM, Fellowes A, Bell A, Fox S. Molecular methods for somatic mutation testing in lung adenocarcinoma: EGFR and beyond. Transl Lung Cancer Res 2015; 4:126-41. [PMID: 25870795 PMCID: PMC4384221 DOI: 10.3978/j.issn.2218-6751.2015.01.10] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 01/21/2015] [Indexed: 12/27/2022]
Abstract
Somatic mutational profiling in cancer has revolutionized the practice of clinical oncology. The discovery of driver mutations in non-small cell lung cancer (NSCLC) is an example of this. Molecular testing of lung adenocarcinoma is now considered standard of care and part of the diagnostic algorithm. This article provides an overview of the workflow of molecular testing in a clinical diagnostic laboratory discussing in particular novel assays that are currently in use for somatic mutation detection in NSCLC focussing on epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK), ROS1 and RET rearrangements.
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Hsu SC, Hung TH, Wang CW, Ng KF, Chen TC. Anaplastic lymphoma kinase translocation is correlated with anaplastic lymphoma kinase expression and mutually exclusive with epidermal growth factor receptor mutation in Taiwanese non-small cell lung cancer. Pathol Int 2015; 65:231-9. [PMID: 25708242 DOI: 10.1111/pin.12268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 01/14/2015] [Indexed: 01/27/2023]
Abstract
The echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion gene is an important biomarker for target therapy. The aim of this study is to better understand the clinical and molecular features of the EML4-ALK fusion gene in lung cancer patients in Taiwan and therefore to generate an efficient algorithm for the detection of ALK translocation. In the first cohort, ALK translocation was identified in 1 adenocarcinoma from 100 lung cancer patients by using break apart fluorescent in situ hybridization (FISH). Next, we detected 6 ALK translocations in another 40 EGFR wild type adenocarcinomas but not in 40 cases with EGFR mutation. Histological analysis revealed that solid growth with signet-ring cells or cribriform glands with extracellular mucin were noted in all the 7 ALK translocated cases. One ALK positive cancer with mucinous cribriform pattern had no ALK expression. ALK expression was correlated with ALK translocation (p < 0.001), but not with ALK gene copy number gain (CNG) (P = 0.838). ALK translocation was also mutually exclusive with EGFR mutation in Taiwanese non-small cell lung cancer (P = 0.033). These results indicate that screening tests for EGFR mutation status and/or ALK expression could help efficiently select ALK translocated patients for target therapy.
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Affiliation(s)
- Sheng-Chi Hsu
- Cancer Diagnostic Laboratory, Chang Gung Memorial Hospital, Tao-Yuan, Taiwan
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25
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Saber A, van der Wekken A, Hiltermann TJ, Kok K, van den Berg A, Groen HJ. Genomic aberrations guiding treatment of non-small cell lung cancer patients. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ctrc.2015.03.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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26
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Kohno T, Tsuchihara K, Ogiwara H, Ichikawa H. RET and other genes: therapeutic targets in lung adenocarcinoma. Lung Cancer Manag 2014. [DOI: 10.2217/lmt.13.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY: The RET fusion gene was recently identified as a new druggable driver gene present in 1–2% of lung adenocarcinomas (LADCs). Vandetanib (ZD6474) and cabozantininb (XL184), two RET tyrosine kinase inhibitors approved by US FDA for the therapy of medullary thyroid cancer, have demonstrated therapeutic effectiveness in a few RET fusion-positive LADC patients. Several clinical trials are under way to address the therapeutic effects of RET tyrosine kinase inhibitors, including these two drugs. Multiplex diagnosis of aberrations in druggable driver oncogenes, such as EGFR, ALK, RET, ROS1, HER2/ERBB2, BRAF and others, in clinical samples will facilitate the design of personalized therapies for LADC based on protein kinase inhibitors. The development of therapeutic methods targeting aberrations of other genes, such as chromatin remodeling genes, is necessary to further improve the treatment of LADC.
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Affiliation(s)
- Takashi Kohno
- Division of Genome Biology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
- Division of Translational Research, Exploratory Oncology Research & Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045 & 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
| | - Katsuya Tsuchihara
- Division of Translational Research, Exploratory Oncology Research & Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045 & 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
| | - Hideaki Ogiwara
- Division of Genome Biology, National Cancer Center Research Institute, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Hitoshi Ichikawa
- Division of Translational Research, Exploratory Oncology Research & Clinical Trial Center (EPOC), National Cancer Center, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045 & 6-5-1 Kashiwanoha, Kashiwa, Chiba 277-8577, Japan
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Fernandez-Cuesta L, Plenker D, Osada H, Sun R, Menon R, Leenders F, Ortiz-Cuaran S, Peifer M, Bos M, Daßler J, Malchers F, Schöttle J, Vogel W, Dahmen I, Koker M, Ullrich RT, Wright GM, Russell PA, Wainer Z, Solomon B, Brambilla E, Nagy-Mignotte H, Moro-Sibilot D, Brambilla CG, Lantuejoul S, Altmüller J, Becker C, Nürnberg P, Heuckmann JM, Stoelben E, Petersen I, Clement JH, Sänger J, Muscarella LA, la Torre A, Fazio VM, Lahortiga I, Perera T, Ogata S, Parade M, Brehmer D, Vingron M, Heukamp LC, Buettner R, Zander T, Wolf J, Perner S, Ansén S, Haas SA, Yatabe Y, Thomas RK. CD74-NRG1 fusions in lung adenocarcinoma. Cancer Discov 2014; 4:415-22. [PMID: 24469108 DOI: 10.1158/2159-8290.cd-13-0633] [Citation(s) in RCA: 196] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
UNLABELLED We discovered a novel somatic gene fusion, CD74-NRG1, by transcriptome sequencing of 25 lung adenocarcinomas of never smokers. By screening 102 lung adenocarcinomas negative for known oncogenic alterations, we found four additional fusion-positive tumors, all of which were of the invasive mucinous subtype. Mechanistically, CD74-NRG1 leads to extracellular expression of the EGF-like domain of NRG1 III-β3, thereby providing the ligand for ERBB2-ERBB3 receptor complexes. Accordingly, ERBB2 and ERBB3 expression was high in the index case, and expression of phospho-ERBB3 was specifically found in tumors bearing the fusion (P < 0.0001). Ectopic expression of CD74-NRG1 in lung cancer cell lines expressing ERBB2 and ERBB3 activated ERBB3 and the PI3K-AKT pathway, and led to increased colony formation in soft agar. Thus, CD74-NRG1 gene fusions are activating genomic alterations in invasive mucinous adenocarcinomas and may offer a therapeutic opportunity for a lung tumor subtype with, so far, no effective treatment. SIGNIFICANCE CD74–NRG1 fusions may represent a therapeutic opportunity for invasive mucinous lung adenocarcinomas, a tumor with no effective treatment that frequently presents with multifocal unresectable disease.
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Affiliation(s)
- Lynnette Fernandez-Cuesta
- 1Department of Translational Genomics; 2Department I of Internal Medicine; 3Laboratory of Translational Cancer Genomics; 4Network Genomic Medicine, University Hospital Cologne, Center of Integrated Oncology Cologne-Bonn; 5Center for Molecular Medicine Cologne (CMMC); 6Cologne Center for Genomics (CCG); 7Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD); 8Department of Pathology, University Hospital Medical Center, University of Cologne; 9Blackfield AG; 10Max Planck Institute for Neurological Research; 11Thoracic Surgery, Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH; 12Institute of Human Genetics, Cologne; 13Computational Molecular Biology Department, Max Planck Institute for Molecular Genetics, Berlin; 14Department of Prostate Cancer Research, Institute of Pathology; 15Institute for Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, Bonn; 16Institute of Pathology; 17Department of Internal Medicine II, Jena University Hospital, Friedrich-Schiller-University, Jena; 18Institute for Pathology Bad Berka, Bad Berka, Germany;19Division of Molecular Oncology, Aichi Cancer Center Research Institute; 20Department of Pathology and Molecular Diagnostics, Aichi Cancer Center, Nagoya, Japan; Departments of 21Surgery and22Pathology, St. Vincent's Hospital; 23Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia;24Department of Pathology, 25CHU Grenoble Institut National de la Santé et de la Recherche Medicale (INSERM) U823, Institute Albert Bonniot, Grenoble-Alpes University, Grenoble, France; 26Laboratory of Oncology IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo; 27Laboratory for Molecular Medicine and Biotechnology, University Campus Bio-Medico, Rome, Italy; 28Center for the Biology of Disease, VIB, Leuven; and 29Oncology Discovery, Janssen Research and Development, A Division of Janssen Pharmaceutica NV, Beerse, Belgium
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Gautschi O, Zander T, Keller FA, Strobel K, Hirschmann A, Aebi S, Diebold J. A patient with lung adenocarcinoma and RET fusion treated with vandetanib. J Thorac Oncol 2013; 8:e43-4. [PMID: 23584301 DOI: 10.1097/jto.0b013e31828a4d07] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Oliver Gautschi
- Department of Medical Oncology, Cantonal Hospital, Luzern, Switzerland.
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Yoo SS, Jin G, Jung HJ, Hong MJ, Choi JE, Jeon HS, Lee SY, Lim JO, Park JY. RET fusion genes in Korean non-small cell lung cancer. J Korean Med Sci 2013; 28:1555-8. [PMID: 24133367 PMCID: PMC3795183 DOI: 10.3346/jkms.2013.28.10.1555] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/29/2013] [Indexed: 12/03/2022] Open
Abstract
Recently, rearranged during transfection (RET) fusions have been identified in approximately 1% of non-small cell lung cancer (NSCLC). To know the prevalence of RET fusion genes in Korean NSCLCs, we examined the RET fusion genes in 156 surgically resected NSCLCs using a reverse transcriptase polymerase chain reaction. Two KIF5B-RET fusions and one CCDC6-RET fusion were identified. All three patients were females and never smokers with adenocarcinomas. RET fusion genes were mutually exclusive from EGFR, KRAS mutations and EML4-ALK fusion. RET fusion genes occur 1.9% (3 of 156) of surgically treated NSCLC patients in Koreans.
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Affiliation(s)
- Seung Soo Yoo
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Guang Jin
- Cancer Research Center, Yanbian University School of Basic Medicine, Yanji, China
| | - Hye Jin Jung
- Departments of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Mi Jeong Hong
- Departments of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jin Eun Choi
- Departments of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Hyo-Sung Jeon
- Departments of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Shin Yup Lee
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jeong Ok Lim
- Bio-Medical Research Institute, Kyungpook National University School of Medicine, Daegu, Korea
| | - Jae Yong Park
- Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea
- Departments of Biochemistry and Cell Biology, Kyungpook National University School of Medicine, Daegu, Korea
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Genetic alterations defining NSCLC subtypes and their therapeutic implications. Lung Cancer 2013; 82:179-89. [PMID: 24011633 DOI: 10.1016/j.lungcan.2013.07.025] [Citation(s) in RCA: 233] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Revised: 07/20/2013] [Accepted: 07/29/2013] [Indexed: 01/03/2023]
Abstract
Lung cancer is the leading cause of cancer death worldwide, accounting for more deaths than breast, prostate and colon cancer combined. While treatment decisions are determined primarily by stage, therapeutically non small cell lung cancer (NSCLC) has traditionally been treated as a single disease. However, recent findings have led to the recognition of histology and molecular subtypes as important determinants in treatment selection. Identifying the genetic differences that define these molecular and histological subtypes has the potential to impact treatment and as such is currently the focus of much research. Microarray and genomic sequencing efforts have provided unparalleled insight into the genomes of lung cancer subtypes, specifically adenocarcinoma (AC) and squamous cell carcinoma (SqCC), revealing subtype specific genomic alterations and molecular subtypes as well as differences in cell signaling pathways. In this review, we discuss the recurrent genomic alterations characteristic of AC and SqCC (including molecular subtypes), their therapeutic implications and emerging clinical practices aimed at tailoring treatments based on a tumor's molecular alterations with the hope of improving patient response and survival.
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Abstract
The discovery of chromosomal rearrangements involving the anaplastic lymphoma kinase (ALK) gene in non-small cell lung cancer (NSCLC) has stimulated renewed interest in oncogenic fusions as potential therapeutic targets. Recently, genetic alterations in ROS1 and RET were identified in patients with NSCLC. Like ALK, genetic alterations in ROS1 and RET involve chromosomal rearrangements that result in the formation of chimeric fusion kinases capable of oncogenic transformation. Notably, ROS1 and RET rearrangements are rarely found with other genetic alterations, such as EGFR, KRAS, or ALK. This finding suggests that both ROS1 and RET are independent oncogenic drivers that may be viable therapeutic targets. In initial screening studies, ROS1 and RET rearrangements were identified at similar frequencies (approximately 1%-2%), using a variety of genotyping techniques. Importantly, patients with either ROS1 or RET rearrangements appear to have unique clinical and pathologic features that may facilitate identification and enrichment strategies. These features may in turn expedite enrollment in clinical trials evaluating genotype-directed therapies in these rare patient populations. In this review, we summarize the molecular biology, clinical features, detection, and targeting of ROS1 and RET rearrangements in NSCLC.
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Affiliation(s)
- Justin F Gainor
- Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts 02114, USA.
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Alamgeer M, Ganju V, Watkins DN. Novel therapeutic targets in non-small cell lung cancer. Curr Opin Pharmacol 2013; 13:394-401. [DOI: 10.1016/j.coph.2013.03.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/13/2013] [Accepted: 03/25/2013] [Indexed: 11/16/2022]
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[Four new drugs on the market: abiraterone, belatacept, vandetanib and fidaxomycine]. ANNALES PHARMACEUTIQUES FRANÇAISES 2013; 71:95-103. [PMID: 23537410 DOI: 10.1016/j.pharma.2013.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 01/14/2013] [Accepted: 01/22/2013] [Indexed: 11/24/2022]
Abstract
Among the 35 new molecular entities approved by the FDA in 2011, 17 were particularly notable for their significant contributions to the health of patients, including abiraterone acetate, vandetanib, belatacept and fidaxomicin. Thus, abiraterone acetate, namely Zytiga®, was included as the first in a new class of drugs to treat late-stage prostate cancer. The ability of Zytiga® to prolong survival in these patients was considered as significant because they have few other treatments options and the benefits of Zytiga® outweighed the risks of reported side-effects. Vandetanib, namely Caprelsa®, was also considered as a relevant drug since it represents the first drug approved to treat particularly aggressive medullary thyroid cancer, an orphan disease. Despite huge progress in transplantation, renal transplantation remains a serious problem since patients treated with the calcineurin inhibitors cyclosporine and tacrolimus are at high risk of developing renal injury. With longer follow-up, the novel immunosuppressant belatacept continued to show better renal function compared with a cyclosporine-based regimen, as well as a consistent safety profile and comparable efficacy. It was approved by the Food and Drug Administration in June 2011 for the prophylaxis of organ rejection in adult recipients of a kidney transplant acting by a selective T-cell costimulation blocker given as an infusion. Clostridium difficile is currently the most important cause of infectious diarrhea in the United States. Fidaxomicin, a macrolide antibiotic, was recently approved for treatment of these infections (CDIs). It could be an alternative treatment for infection with C. difficile, with similar efficacy and safety to vancomycin. Fidaxomicin has minimal activity against Bacteroides species, which may be advantageous in maintaining colonization resistance and protecting the gastrointestinal tract from colonization by C. difficile.
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