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Rao A, Reddy A, Dinunno C, Elali I. Life-threatening hypertriglyceridemia-induced pancreatitis related to alectinib successfully treated by plasmapheresis: A review of the literature on metabolic toxicities associated with anaplastic lymphoma kinase inhibitors. J Oncol Pharm Pract 2020; 26:1533-1537. [DOI: 10.1177/1078155220904141] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Introduction Actionable mutations are tested as standard of care for all new metastatic non-small cell lung cancers. Tumors harboring an anaplastic lymphoma kinase mutation respond to tyrosine kinase inhibitors targeting anaplastic lymphoma kinase pathway. Patients are monitored for common adverse effects, although we occasionally encounter unexpected side effects. Case report A 52-year-old male presented with a right hilar lung mass, and workup revealed a stage IIIA adenocarcinoma. He underwent treatment with concurrent chemoradiation; however, disease recurred one year later with a right hilar mass and contralateral mediastinal lymphadenopathy, biopsy of which resulted positive for adenocarcinoma. Molecular analysis showed anaplastic lymphoma kinase rearrangement and alectinib was started. Six months into therapy, he presented with hematochezia, nausea, and epigastric pain and was diagnosed with acute pancreatitis. Triglyceride level resulted above the measurable level at >5680mg/dL, thought to be the inciting event of pancreatitis. Management and outcome: Despite treatment with intravenous hydration, insulin infusion, and antibiotics, he decompensated with development of respiratory failure, shock requiring intensive care. Therapeutic plasmapheresis was initiated due to persistently elevated triglyceride. Following the third plasmapheresis, triglyceride level decreased to 359 mg/dL. With aggressive multidisciplinary management, he made a complete recovery. Follow-up imaging studies at three and six months show a stable mass-like abnormality in the right hilum without evidence of disease progression. Discussion Prior to starting alectinib, our patient’s triglyceride level was 420 mg/dL. While he consumed alcohol, he had no other traditional risk factor. To our knowledge, this is the first reported case of hypertriglyceridemia-induced acute pancreatitis related to treatment with an anaplastic lymphoma kinase inhibitor.
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Affiliation(s)
- Arundati Rao
- Department of Medicine, University of Connecticut Health, Farmington, CT, USA
| | - Aswanth Reddy
- Department of Medicine, University of Connecticut Health, Farmington, CT, USA
| | - Corey Dinunno
- Department of Medicine, University of Connecticut Health, Farmington, CT, USA
| | - Ibrahim Elali
- Department of Medicine, University of Connecticut Health, Farmington, CT, USA
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2
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Tiotiu A, Billon Y, Vaillant P, Menard O, Hofman P, Mascaux C. [Therapeutic strategies in advanced ALK positive non-small cell lung cancer]. Rev Mal Respir 2019; 36:1107-1116. [PMID: 31727555 DOI: 10.1016/j.rmr.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/19/2019] [Indexed: 11/30/2022]
Abstract
Anaplastic lymphoma kinase (ALK) rearrangement is a therapeutically targetable oncogenic driver found in 5% of patients with non-small-cell lung cancer (NSCLC). The objective of this paper is to synthesise current knowledge on ALK rearrangement and its impact on the management of advanced NSCLC. Several inhibitors of the tyrosine kinase of ALK (crizotinib, ceritinib, alectinib) have been approved as first line therapies in patients with advanced ALK positive NSCLC, which are associated with a better median progression-free survival than conventional chemotherapy. Unfortunately, the emergence of drug resistance leads to tumor progression. In patients with oligoprogressive disease if local ablative therapy can be effected, continuing with the same ALK tyrosine kinase inhibitor is one option. In patients with progression, clinicians may consider switching to another therapy. Rebiopsy of the tumor or liquid biopsy could be attempted to identify the mechanisms of resistance and to customize ALK-target therapy. The emergence of crizotinib drug resistance has prompted the development of next generation drugs including ceritinb, alectinib, brigatinib and lorlatinib. The ability to quickly develop targeted therapies against specific oncogenic drivers will require close co-operation between pathologists, pulmonologists and oncologists in the future to keep pace with drug discoveries and to define optimal therapeutic strategies.
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Affiliation(s)
- A Tiotiu
- Département de pneumologie, CHRU Nancy site Brabois, bâtiment de spécialités médicales, 9, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France.
| | - Y Billon
- Département de pneumologie, CHRU Nancy site Brabois, bâtiment de spécialités médicales, 9, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - P Vaillant
- Département de pneumologie, CHRU Nancy site Brabois, bâtiment de spécialités médicales, 9, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - O Menard
- Département de pneumologie, CHRU Nancy site Brabois, bâtiment de spécialités médicales, 9, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - P Hofman
- Laboratoire de pathologie clinique et expérimentale, CHU de Nice, 06000 Nice, France; Centre IRCAN, Inserm U1081 et CNRS/UMR 7284, Centre de lutte contre le cancer Antoine-Lacassagne, 06000 Nice, France; Université Côte d'Azur, 06000 Nice, France
| | - C Mascaux
- Département d'oncologie multidisciplinaire et Innovations thérapeutiques, Assistance Publique-Hôpitaux de Marseille, 13354 Marseille, France; Aix Marseille université, CNRS, Inserm, CRCM, 13354 Marseille, France
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3
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Kong X, Pan P, Sun H, Xia H, Wang X, Li Y, Hou T. Drug Discovery Targeting Anaplastic Lymphoma Kinase (ALK). J Med Chem 2019; 62:10927-10954. [PMID: 31419130 DOI: 10.1021/acs.jmedchem.9b00446] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
As a receptor tyrosine kinase of insulin receptor (IR) subfamily, anaplastic lymphoma kinase (ALK) has been validated to play important roles in various cancers, especially anaplastic large cell lymphoma (ALCL), nonsmall cell lung cancer (NSCLC), and neuroblastomas. Currently, five small-molecule inhibitors of ALK, including Crizotinib, Ceritinib, Alectinib, Brigatinib, and Lorlatinib, have been approved by the U.S. Food and Drug Administration (FDA) against ALK-positive NSCLCs. Novel type-I1/2 and type-II ALK inhibitors with improved kinase selectivity and enhanced capability to combat drug resistance have also been reported. Moreover, the "proteolysis targeting chimera" (PROTAC) technique has been successfully applied in developing ALK degraders, which opened a new avenue for targeted ALK therapies. This review provides an overview of the physiological and biological functions of ALK, the discovery and development of drugs targeting ALK by focusing on their chemotypes, activity, selectivity, and resistance as well as potential therapeutic strategies to overcome drug resistance.
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Affiliation(s)
- Xiaotian Kong
- Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , Zhejiang 310058 , China.,Institute of Functional Nano and Soft Materials (FUNSOM) , Soochow University , Suzhou , Jiangsu 215123 , China
| | - Peichen Pan
- Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , Zhejiang 310058 , China
| | - Huiyong Sun
- Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , Zhejiang 310058 , China
| | - Hongguang Xia
- Department of Biochemistry & Research Center of Clinical Pharmacy of the First Affiliated Hospital , Zhejiang University , Hangzhou 310058 , China
| | - Xuwen Wang
- Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , Zhejiang 310058 , China
| | - Youyong Li
- Institute of Functional Nano and Soft Materials (FUNSOM) , Soochow University , Suzhou , Jiangsu 215123 , China
| | - Tingjun Hou
- Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences , Zhejiang University , Hangzhou , Zhejiang 310058 , China
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4
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Thai AA, Solomon BJ. Alectinib as first-line therapy for ALK-rearranged NSCLC: a no-brainer? Ann Oncol 2019; 29:2160-2162. [PMID: 30239586 DOI: 10.1093/annonc/mdy415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- A A Thai
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne
| | - B J Solomon
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia.
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Abstract
PURPOSE OF REVIEW The review will highlight recent advances in development of ALK-TKIs and management of patients with ALK-positive nonsmall cell lung cancer. RECENT FINDINGS There has been rapid progress in the use of targeted therapies for ALK-positive NSCLC. Since the discovery, development and approval of crizotinib in 2011, three second-generation ALK-TKIs, ceritinib, alectinib and brigatinib have been approved by the FDA. A range of newer generation ALK inhibitors with improved potency against ALK and against mutations that confer resistance to crizotinib are in clinical development. SUMMARY Our review will discuss the recent phase III data with ceritinib and alectinib as well as clinical trials with other ALK inhibitors. We will also address two important issues in the management of ALK-positive NSCLC, prevention and treatment of brain metastases and management of emergent ALK-TKI resistance mechanisms.
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6
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Camidge DR, Lee EQ, Lin NU, Margolin K, Ahluwalia MS, Bendszus M, Chang SM, Dancey J, de Vries EGE, Harris GJ, Hodi FS, Lassman AB, Macdonald DR, Peereboom DM, Schiff D, Soffietti R, van den Bent MJ, Wefel JS, Wen PY. Clinical trial design for systemic agents in patients with brain metastases from solid tumours: a guideline by the Response Assessment in Neuro-Oncology Brain Metastases working group. Lancet Oncol 2018; 19:e20-e32. [PMID: 29304358 DOI: 10.1016/s1470-2045(17)30693-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 07/24/2017] [Accepted: 08/22/2017] [Indexed: 12/30/2022]
Abstract
Patients with active CNS disease are often excluded from clinical trials, and data regarding the CNS efficacy of systemic agents are usually obtained late in the drug development process or not at all. In this guideline from the Response Assessment in Neuro-Oncology Brain Metastases (RANO-BM) working group, we provide detailed recommendations on when patients with brain metastases from solid tumours should be included or excluded in clinical trials of systemic agents. We also discuss the limitations of retrospective studies in determining the CNS efficacy of systemic drugs. Inclusion of patients with brain metastases early on in the clinical development of a drug or a regimen is needed to generate appropriate CNS efficacy or non-efficacy signals. We consider how to optimally incorporate or exclude such patients in systemic therapy trials depending on the likelihood of CNS activity of the agent by considering three scenarios: drugs that are considered very unlikely to have CNS antitumour activity or efficacy; drugs that are considered very likely to have CNS activity or efficacy; and drugs with minimal baseline information on CNS activity or efficacy. We also address trial design issues unique to patients with brain metastases, including the selection of appropriate CNS endpoints in systemic therapy trials.
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Affiliation(s)
- D Ross Camidge
- Anschutz Medical Campus, University of Colorado, Aurora, CO, USA.
| | - Eudocia Q Lee
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Nancy U Lin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Kim Margolin
- Department of Medical Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Manmeet S Ahluwalia
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Susan M Chang
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Janet Dancey
- Department of Oncology, Queen's University, Kingston, ON, Canada
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Netherlands
| | - Gordon J Harris
- Department of Radiology, 3D Imaging Lab, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - F Stephen Hodi
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA; Department of Medicine, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Andrew B Lassman
- Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, Columbia University, NY, USA
| | - David R Macdonald
- Department of Oncology and Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - David M Peereboom
- Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Solid Tumor Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia, Charlottesville, VA, USA
| | - Ricardo Soffietti
- Department of Neurology/Neuro-Oncology, University of Turin, Turin, Italy
| | | | - Jeffrey S Wefel
- Department of Neuro-Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Patrick Y Wen
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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Vecchiarelli S, Bennati C. Oncogene addicted non-small-cell lung cancer: current standard and hot topics. Future Oncol 2018; 14:3-17. [PMID: 29989448 DOI: 10.2217/fon-2018-0095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Lung cancer is the leading cause of cancer mortality worldwide. Activating mutations in the EGFR and rearrangements in the anaplastic lymphoma kinase (ALK) or ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) genes have been identified as oncogenic drivers in non-small-cell lung cancer. Development of specific small-molecule tyrosine kinase inhibitors, able to interfere with tumor growth and metastatic spread, dramatically changed the natural history of oncogene-addicted non-small-cell lung cancer. However, despite advances in targeted therapies, all patients inevitably develop acquired resistance to tyrosine kinase inhibitors. Novel promising and effective treatments are under investigations.
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Affiliation(s)
- Silvia Vecchiarelli
- Onco-Hematology Department, S Maria delle Croci Hospital, viale Randi 5, 48121, Ravenna, Italy
| | - Chiara Bennati
- Onco-Hematology Department, S Maria delle Croci Hospital, viale Randi 5, 48121, Ravenna, Italy
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Spagnuolo A, Maione P, Gridelli C. Evolution in the treatment landscape of non-small cell lung cancer with ALK gene alterations: from the first- to third-generation of ALK inhibitors. Expert Opin Emerg Drugs 2018; 23:231-241. [DOI: 10.1080/14728214.2018.1527902] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alessia Spagnuolo
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | - Paolo Maione
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
| | - Cesare Gridelli
- Division of Medical Oncology, ‘S. G. Moscati’ Hospital, Avellino, Italy
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9
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Brastianos PK, Ippen FM, Hafeez U, Gan HK. Emerging Gene Fusion Drivers in Primary and Metastatic Central Nervous System Malignancies: A Review of Available Evidence for Systemic Targeted Therapies. Oncologist 2018; 23:1063-1075. [PMID: 29703764 PMCID: PMC6192601 DOI: 10.1634/theoncologist.2017-0614] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/07/2018] [Indexed: 12/11/2022] Open
Abstract
Primary and metastatic tumors of the central nervous system present a difficult clinical challenge, and they are a common cause of disease progression and death. For most patients, treatment consists primarily of surgery and/or radiotherapy. In recent years, systemic therapies have become available or are under investigation for patients whose tumors are driven by specific genetic alterations, and some of these targeted treatments have been associated with dramatic improvements in extracranial and intracranial disease control and survival. However, the success of other systemic therapies has been hindered by inadequate penetration of the drug into the brain parenchyma. Advances in molecular characterization of oncogenic drivers have led to the identification of new gene fusions driving oncogenesis in some of the most common sources of intracranial tumors. Systemic therapies targeting many of these alterations have been approved recently or are in clinical development, and the ability to penetrate the blood-brain barrier is now widely recognized as an important property of such drugs. We review this rapidly advancing field with a focus on recently uncovered gene fusions and brain-penetrant systemic therapies targeting them. IMPLICATIONS FOR PRACTICE Driver gene fusions involving receptor tyrosine kinases have been identified across a wide range of tumor types, including primary central nervous system (CNS) tumors and extracranial solid tumors that are associated with high rates of metastasis to the CNS (e.g., lung, breast, melanoma). This review discusses the systemic therapies that target emerging gene fusions, with a focus on brain-penetrant agents that will target the intracranial disease and, where present, also extracranial disease.
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Affiliation(s)
- Priscilla K Brastianos
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Franziska Maria Ippen
- Department of Hematology and Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Umbreen Hafeez
- Medical Oncology, Austin Hospital, Heidelberg, Melbourne, Australia
| | - Hui K Gan
- Medical Oncology, Austin Hospital, Heidelberg, Melbourne, Australia
- La Trobe University School of Cancer Medicine, Heidelberg, Victoria, Australia
- Department of Medicine, University of Melbourne, Heidelberg, Victoria, Australia
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10
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Lin JJ, Zhu VW, Schoenfeld AJ, Yeap BY, Saxena A, Ferris LA, Dagogo-Jack I, Farago AF, Taber A, Traynor A, Menon S, Gainor JF, Lennerz JK, Plodkowski AJ, Digumarthy SR, Ou SHI, Shaw AT, Riely GJ. Brigatinib in Patients With Alectinib-Refractory ALK-Positive NSCLC. J Thorac Oncol 2018; 13:1530-1538. [PMID: 29935304 DOI: 10.1016/j.jtho.2018.06.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/06/2018] [Accepted: 06/11/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The second-generation anaplastic lymphoma kinase (ALK) inhibitor alectinib recently showed superior efficacy compared to the first-generation ALK inhibitor crizotinib in advanced ALK-rearranged NSCLC, establishing alectinib as the new standard first-line therapy. Brigatinib, another second-generation ALK inhibitor, has shown substantial activity in patients with crizotinib-refractory ALK-positive NSCLC; however, its activity in the alectinib-refractory setting is unknown. METHODS A multicenter, retrospective study was performed at three institutions. Patients were eligible if they had advanced, alectinib-refractory ALK-positive NSCLC and were treated with brigatinib. Medical records were reviewed to determine clinical outcomes. RESULTS Twenty-two patients were eligible for this study. Confirmed objective responses to brigatinib were observed in 3 of 18 patients (17%) with measurable disease. Nine patients (50%) had stable disease on brigatinib. The median progression-free survival was 4.4 months (95% confidence interval [CI]: 1.8-5.6 months) with a median duration of treatment of 5.7 months (95% CI: 1.8-6.2 months). Among 9 patients in this study who underwent post-alectinib/pre-brigatinib biopsies, 5 had an ALK I1171X or V1180L resistance mutation; of these, 1 had a confirmed partial response and 3 had stable disease on brigatinib. One patient had an ALK G1202R mutation in a post-alectinib/pre-brigatinib biopsy, and had progressive disease as the best overall response to brigatinib. CONCLUSIONS Brigatinib has limited clinical activity in alectinib-refractory ALK-positive NSCLC. Additional studies are needed to establish biomarkers of response to brigatinib and to identify effective therapeutic options for alectinib-resistant ALK-positive NSCLC patients.
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Affiliation(s)
- Jessica J Lin
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Viola W Zhu
- Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California
| | - Adam J Schoenfeld
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beow Y Yeap
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ashish Saxena
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lorin A Ferris
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Ibiayi Dagogo-Jack
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Anna F Farago
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Angela Taber
- Lifespan Cancer Institute, Providence, Rhode Island
| | - Anne Traynor
- Department of Medicine, University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
| | - Smitha Menon
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Justin F Gainor
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Jochen K Lennerz
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts
| | - Andrew J Plodkowski
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Subba R Digumarthy
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Sai-Hong Ignatius Ou
- Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California
| | - Alice T Shaw
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.
| | - Gregory J Riely
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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Abstract
Brain metastases from solid tumors are associated with increased morbidity and mortality. Standard treatment is local therapy with surgery and/or radiation therapy although there is increasing interest in systemic therapies that can control both intracranial and extracranial disease. We review the most recent data for local therapy and systemic therapy options. Active areas of research within radiation oncology include hippocampal sparing whole brain radiation therapy and stereotactic approaches for patients with more than 4 brain metastases. Newer targeted therapies with better central nervous system penetration and immunotherapies have demonstrated promising results in clinical trials of patients with brain metastases.
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Affiliation(s)
- Ayal A Aizer
- Department of Radiation Oncology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Eudocia Q Lee
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA; Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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12
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Sharma GG, Mota I, Mologni L, Patrucco E, Gambacorti-Passerini C, Chiarle R. Tumor Resistance against ALK Targeted Therapy-Where It Comes From and Where It Goes. Cancers (Basel) 2018; 10:E62. [PMID: 29495603 PMCID: PMC5876637 DOI: 10.3390/cancers10030062] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/25/2018] [Accepted: 02/26/2018] [Indexed: 12/12/2022] Open
Abstract
Anaplastic lymphoma kinase (ALK) is a validated molecular target in several ALK-rearranged malignancies, particularly in non-small-cell lung cancer (NSCLC), which has generated considerable interest and effort in developing ALK tyrosine kinase inhibitors (TKI). Crizotinib was the first ALK inhibitor to receive FDA approval for ALK-positive NSCLC patients treatment. However, the clinical benefit observed in targeting ALK in NSCLC is almost universally limited by the emergence of drug resistance with a median of occurrence of approximately 10 months after the initiation of therapy. Thus, to overcome crizotinib resistance, second/third-generation ALK inhibitors have been developed and received, or are close to receiving, FDA approval. However, even when treated with these new inhibitors tumors became resistant, both in vitro and in clinical settings. The elucidation of the diverse mechanisms through which resistance to ALK TKI emerges, has informed the design of novel therapeutic strategies to improve patients disease outcome. This review summarizes the currently available knowledge regarding ALK physiologic function/structure and neoplastic transforming role, as well as an update on ALK inhibitors and resistance mechanisms along with possible therapeutic strategies that may overcome the development of resistance.
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Affiliation(s)
- Geeta Geeta Sharma
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy.
| | - Ines Mota
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10124, Italy.
| | - Luca Mologni
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy.
- Galkem Srl, Monza 20900, Italy.
| | - Enrico Patrucco
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10124, Italy.
| | - Carlo Gambacorti-Passerini
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy.
- Galkem Srl, Monza 20900, Italy.
- Hematology and Clinical Research Unit, San Gerardo Hospital, Monza 20900, Italy.
| | - Roberto Chiarle
- Department of Molecular Biotechnology and Health Sciences, University of Turin, Turin 10124, Italy.
- Department of Pathology, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Second-Line Treatment Options in Non-Small-Cell Lung Cancer: Report From an International Experts Panel Meeting of the Italian Association of Thoracic Oncology. Clin Lung Cancer 2017; 19:301-314. [PMID: 29396237 DOI: 10.1016/j.cllc.2017.12.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 12/05/2017] [Accepted: 12/17/2017] [Indexed: 11/24/2022]
Abstract
Non-small-cell lung cancer (NSCLC) patients inevitably progress to first-line therapy and further active treatments are warranted. In the past few years, new second-line therapies, beyond chemotherapy agents, have become available in clinical practice. To date, several options for the second-line treatment of non-oncogene-addicted NSCLC patients ranging from chemotherapy in combination with antivascular endothelial growth factor receptor to immunotherapeutics are available. In oncogene-driven tumors, the better knowledge of mechanisms of acquired resistance to earlier tyrosine kinase inhibitors is leading to novel active inhibitors now available/in development. The second-line algorithm treatment of NSCLC becomes very intricate and the selection of proper patients with one of the new available therapeutic options is of paramount importance to personalize and optimize the treatment. In this review we discuss the second-line treatment opportunities of addicted as well as not-addicted NSCLC.
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14
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Qin A, Gadgeel S. The Current Landscape of Anaplastic Lymphoma Kinase (ALK) in Non-Small Cell Lung Cancer: Emerging Treatment Paradigms and Future Directions. Target Oncol 2017; 12:709-718. [PMID: 28856564 PMCID: PMC6000827 DOI: 10.1007/s11523-017-0526-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Tumorigenic rearrangements in anaplastic lymphoma kinase (ALK) account for 3-7% of all non-small cell lung cancers (NSCLC). Treatment with targeted tyrosine kinase inhibitors (TKIs) has shown impressive clinical responses. Crizotinib was the first agent approved for front-line therapy of ALK-rearranged NSCLC after it demonstrated superiority to chemotherapy in response rate, duration of response, and progression-free survival. However, eventually all patients progress on crizotinib therapy, with the central nervous system (CNS) being the most common site, which served as the impetus for the development of more potent next-generation ALK inhibitors. Currently, ceritinib, alectinib, and brigatinib are all approved for second-line therapy after progression on or intolerance to crizotinib. Investigations into whether the initiation of a second-generation ALK inhibitor as first-line therapy is the superior treatment paradigm has resulted in the approval of ceritinib as initial therapy. Alectinib has also shown impressive results as front-line therapy, as recently reported in two large randomized studies that compared it to crizotinib. There is a significant need to better understand the drivers of and mechanisms underlying resistance to ALK inhibitors. While specific mutations have been identified, there is currently only limited evidence that the identification of specific mutations should impact selection of the next ALK inhibitor. The best treatment option for patients who become TKI refractory is also unclear, though there is some evidence to suggests that these patients are not responsive to checkpoint inhibitors and may respond better to chemotherapy. Combination therapy with other classes of agents may help to overcome resistance mechanisms and should be investigated further.
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Affiliation(s)
- Angel Qin
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Shirish Gadgeel
- Department of Internal Medicine, Division of Hematology and Oncology, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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Morgan RL, Camidge DR. Reviewing RECIST in the Era of Prolonged and Targeted Therapy. J Thorac Oncol 2017; 13:154-164. [PMID: 29113950 DOI: 10.1016/j.jtho.2017.10.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 10/22/2017] [Accepted: 10/24/2017] [Indexed: 01/10/2023]
Abstract
Accurate assessment of disease response is the foundation of therapeutic trails, which is why the Response Evaluation Criteria in Solid Tumors (RECIST) serve as an international standard that investigators can utilize when examining patient outcomes. Nine years after the initial RECIST criteria were released, an update, RECIST 1.1, was published to improve on the initial criteria and address technologic advancements in imaging. Since then, advancements in both standard clinical and trial practices, combined with improvements in our understanding of cancer biology, have resulted in the identification of a number of limitations of the current RECIST 1.1, either in lack of clear guidance with regard to its best application or in potential benefit of capturing imaging-related data beyond standard categorical response details. As several of these situations reflect the consequences of prolonged control of metastatic disease by using targeted therapies, thoracic oncology has generated many of the key scenarios requiring elucidation and/or improvements. This article specifically examines current controversies in the interpretation and/or optimal utilization of RECIST 1.1, focusing on examples from thoracic oncology, and makes proposals, where possible, on how best to address these issues. These situations include addressing central nervous system versus extra-central nervous system response and progression, depth of response, oligoprogression versus polyprogression, continuation of systemic therapy after use of a local ablative therapy, and the impact of fluctuations in measurements bridging partial response and stable disease categories during prolonged therapy.
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Affiliation(s)
- Rustain L Morgan
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado
| | - D Ross Camidge
- Division of Medical Oncology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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Lung Toxicity in Non-Small-Cell Lung Cancer Patients Exposed to ALK Inhibitors: Report of a Peculiar Case and Systematic Review of the Literature. Clin Lung Cancer 2017; 19:e151-e161. [PMID: 29174221 DOI: 10.1016/j.cllc.2017.10.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/10/2017] [Accepted: 10/19/2017] [Indexed: 01/17/2023]
Abstract
Lung toxicity is a potential fatal effect involving non-small-cell lung cancer (NSCLC) patients exposed to tyrosine kinase inhibitors (TKIs). Moving from our experience regarding a patient who developed lung toxicity while receiving 2 different anaplastic lymphoma kinase (ALK)-TKIs, we performed a systematic review to assess the epidemiologic magnitude and the clinical significance of such toxicity in NSCLC patients treated with ALK-TKIs. Studies were identified using MEDLINE and additional sources (European Society for Medical Oncology, American Society of Clinical Oncology, and World Conference on Lung Cancer abstracts) in agreement with Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines. Lung toxicity was reported in 105 of 4943 NSCLC patients (2.1%). Crizotinib was responsible for pulmonary adverse events (AEs) in 1.8% of exposed patients (49 of 2706). With the limit of a lower number of treated patients (n = 359), brigatinib resulted as the most frequently involved in lung toxicity (7%; n = 25). Pulmonary AEs during therapy with ceritinib, alectinib, and lorlatinib occurred in 1.1%, 2.6%, and 1.8% of the patients, respectively. Sixty-five percent of cases accounted for Grade 3 or 4 events, with a mortality rate of 9%. Radiological patterns of pneumonia were reported in 25 patients, whereas imaging evocative of interstitial lung disease in 37. Overall, 26 of 105 patients (25%) permanently discontinued treatment because of lung toxicity. Lung toxicity is a rare albeit potentially severe side effect in NSCLC patients receiving ALK-TKIs, apparently more frequent with brigatinib. Its early recognition and treatment are crucial for the best outcome of this subgroup of patients, whose overall prognosis is being improved by the availability of several targeted agents.
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Mayekar MK, Bivona TG. Current Landscape of Targeted Therapy in Lung Cancer. Clin Pharmacol Ther 2017; 102:757-764. [PMID: 28786099 DOI: 10.1002/cpt.810] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 12/14/2022]
Abstract
Lung cancer is the leading cause of cancer mortality worldwide. Comprehensive genomic profiling of lung cancers revealed their genetic heterogeneity and complexity and identified numerous targetable oncogenic driver alterations. These molecular profiling efforts have made it possible to exploit the potential of molecularly targeted therapies. Selection of patients for targeted therapies is becoming biomarker-driven, where the oncogenic drivers in patient tumors are first identified, and subsequently patients bearing drug-sensitizing genetic aberrations are matched to the appropriate targeted therapy. Success of this design of clinical trials and practice was first demonstrated in EGFR inhibitor trials in lung cancer and has since been incorporated into subsequent targeted therapy trials including ALK-, ROS1-, and BRAF V600E-targeted therapies. In this review we discuss the current landscape of clinically approved and other promising molecularly targeted approaches for the treatment of lung cancers, the challenges with these approaches, and the strategies that could be deployed to overcome these challenges.
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Affiliation(s)
- Manasi K Mayekar
- Department of Medicine, University of California, San Francisco, San Francisco, USA.,Department of Cellular and Molecular Pharmacology, University of California, San Francisco, San Francisco, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, USA
| | - Trever G Bivona
- Department of Medicine, University of California, San Francisco, San Francisco, USA.,Department of Cellular and Molecular Pharmacology, University of California, San Francisco, San Francisco, USA.,Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, USA
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