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Li Z, Dang X, Huang D, Jin S, Li W, Shi J, Wang X, Zhang Y, Song Z, Zhang J, Zhuang W, Liu X, Jiang L, Meng X, Zhao M, Zhou J, Zhang L, Wang P, Luo H, Yang J, Cang S, Wang X, Zhang L, Lu S. Garsorasib in patients with KRAS G12C-mutated non-small-cell lung cancer in China: an open-label, multicentre, single-arm, phase 2 trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:589-598. [PMID: 38870979 DOI: 10.1016/s2213-2600(24)00110-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/11/2024] [Accepted: 03/20/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Garsorasib (D-1553; InventisBio, Shangai, China), a potent KRASG12C inhibitor, has shown promising antitumour activity in patients with KRASG12C-mutated (ie, Gly12Cys) non-small-cell lung cancer (NSCLC) in a phase 1 study. We report results from a phase 2 study conducted to evaluate the efficacy and safety of garsorasib in patients with locally advanced or metastatic KRASG12C-mutated NSCLC. METHODS This open-label, multicentre, single-arm, phase 2 trial enrolled adult patients with KRASG12C-mutated NSCLC who had previously been treated with platinum-based chemotherapy and immune checkpoint inhibitors from 43 hospitals in China. Participants received 600 mg garsorasib orally twice per day. Tumour assessments were performed at baseline, at the end of every two cycles (of 21 days) for the first eight cycles, and at the end of every three cycles thereafter. The primary endpoint was objective response rate (ORR) as assessed by an independent review committee (IRC) following the guidelines in Response Evaluation Criteria in Solid Tumours, version 1.1. Efficacy and safety were assessed in all patients who received at least one dose of garsorasib. This trial is registered at ClinicalTrials.gov, NCT05383898, and is active but no longer recruiting. FINDINGS From June 17, 2022, to May 17, 2023, of 225 patients screened for eligibility, 123 patients were enrolled and treated with garsorasib. Of these 123 participants, the median age was 64 years (IQR 59-68), 108 (88%) were male and 15 (12%) were female. At data cutoff (Nov 17, 2023), the median follow-up duration was 7·9 months (IQR 6·3-10·4), and 82 (67%) of 123 patients had discontinued treatment. The IRC-confirmed ORR was 50% (61 of 123 patients; 95% CI 41-59). 117 (95%) of 123 patients reported treatment-related adverse events, with 61 (50%) experiencing grade 3 or higher events. The most common types of adverse events of grade 3 or higher associated with garsorasib were hepatic and gastrointestinal events, including increased liver enzymes, such as aspartate aminotransferase (21 [17%] of 123 participants), alanine aminotransferase (19 [15%] of 123 participants), and gamma-glutamyltransferase (28 [23%] of 123 participants); nausea (2 [2%] of 123 participants); and vomiting (2 [2%] of 123 participants). No new safety signals were identified, and most of the adverse events were well managed. INTERPRETATION The results show that garsorasib has a high response rate, long duration of response, and an acceptable and manageable safety profile in patients with previously treated KRASG12C-mutated NSCLC. Garsorasib potentially provides a promising treatment option for this patient population. FUNDING InventisBio.
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Affiliation(s)
- Ziming Li
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaomin Dang
- Department of Respiratory Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Dingzhi Huang
- Pulmonary Oncology Department, Tianjin Medical University Cancer Institute & Hospital, Tianjin, China
| | - Shi Jin
- Department of Oncology, Cancer Hospital and Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shenzhen, China
| | - Weiwei Li
- The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
| | - Jianhua Shi
- Department of Medical Oncology II, Linyi Cancer Hospital, Linyi, China
| | - Xicheng Wang
- Department of Oncology, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Yiping Zhang
- Department of Thoracic Medical Oncology, Zhejiang Cancer Hospital, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
| | - Zhengbo Song
- Department of Clinical Trial, Zhejiang Cancer Hospital, Cancer Hospital of the University of Chinese Academy of Sciences, Hangzhou, China
| | - Junping Zhang
- Shanxi Bethune Hospital, The Affiliated Bethune Hospital of Shanxi Medical University, Taiyuan, China
| | - Wu Zhuang
- Department of Thoracic Oncology, Fujian Provincial Cancer Hospital, Fuzhou, China
| | - Xuewen Liu
- Department of Oncology, The Third Xiangya Hospital of Central South University, Changsha, China
| | - Liyan Jiang
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiangjiao Meng
- The Four Wards of Thoracic Radiotherapy, Shandong Cancer Hospital, Jinan, China
| | - Mingfang Zhao
- Oncology, Medical Ward 2, The First Hospital of China Medical University, Shenyang, China
| | - Jianying Zhou
- Department of Respiratory Medicine, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Liangming Zhang
- Department of Medical Oncology I, Yantai Yuhuangding Hospital, Yantai, China
| | - Pingli Wang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Luo
- Department of Thoracic Cancer Radiotherapy, Jiangxi Cancer Hospital, Nanchang, China
| | - Junquan Yang
- Department 1 of Chemoradiotherapy, Tangshan Cancer Hospital, Tangshan, China
| | - Shundong Cang
- Department of Oncology, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xiang Wang
- Department of Oncology, Xuzhou Central Hospital, Xuzhou, China
| | | | - Shun Lu
- Shanghai Lung Cancer Center, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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2
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Yousef M, Hurd MW, Yousef A, Ludmir EB, Pillai AB, Peterson J, Koay EJ, Albarouki S, Tzeng CW, Snyder R, Katz MHG, Wang H, Overman MJ, Maitra A, Pant S, Smaglo BG, Wolff RA, Yao J, Shen JP, Zhao D. Clinical and molecular characteristics of patients with brain metastasis secondary to pancreatic ductal adenocarcinoma. Oncologist 2024:oyae182. [PMID: 39014543 DOI: 10.1093/oncolo/oyae182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/21/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND The prognosis for patients with pancreatic ductal adenocarcinoma (PDAC) is poor. Secondary brain metastasis (Br-M) occurs in less than 1% of patients. Clinical characteristics and molecular alterations have not been characterized in this rare patients' subset. MATERIALS AND METHODS The Foundry software platform was used to retrospectively query electronic health records for patients with Br-M secondary to PDAC from 2005 to 2023; clinical, molecular, and overall survival (OS) data were analyzed. RESULTS Br-M was diagnosed in 44 patients with PDAC. Median follow-up was 78 months; median OS from initial PDAC diagnosis was 47 months. Median duration from PDAC diagnosis to Br-M detection was 24 months; median OS from Br-M diagnosis was 3 months. At Br-M diagnosis, 82% (n = 36) of patients had elevated CA19-9. Lung was the most common preexisting metastatic location (71%) with Br-M, followed by liver (66%). Br-M were most frequently observed in the frontal lobe (34%, n = 15), cerebellar region (23%, n = 10), and leptomeninges (18%, n = 8). KRAS mutations were detected in 94.1% (n = 16) of patients who had molecular data available (n = 17) with KRASG12V being the most frequent subtype 47% (n = 8); KRASG12D in 29% (n = 5); KRASG12R in 18% (n = 3). Patients who underwent Br-M surgical resection (n = 5) had median OS of 8.6 months, while median OS following stereotactic radiosurgery only (n = 11) or whole-brain radiation only (n = 20) was 3.3 and 2.8 months, respectively. CONCLUSION Br-M is a late PDAC complication, resulting in an extremely poor prognosis especially in leptomeningeal disease. KRAS was mutated in 94.1% of the patients and the KRASG12V subtype was prevalent.
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Affiliation(s)
- Mahmoud Yousef
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mark W Hurd
- Sheikh Ahmed Center for Pancreatic Cancer Research, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Abdelrahman Yousef
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ethan B Ludmir
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ashwathy B Pillai
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jennifer Peterson
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Eugene J Koay
- Department of Gastrointestinal Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sali Albarouki
- Department of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, United States
| | - Ching-Wei Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rebecca Snyder
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Matthew H G Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Huamin Wang
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Michael J Overman
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anirban Maitra
- Department of Anatomical Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Shubham Pant
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Brandon G Smaglo
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Robert A Wolff
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - James Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - John P Shen
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dan Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Boldig C, Boldig K, Mokhtari S, Etame AB. A Review of the Molecular Determinants of Therapeutic Response in Non-Small Cell Lung Cancer Brain Metastases. Int J Mol Sci 2024; 25:6961. [PMID: 39000069 PMCID: PMC11241836 DOI: 10.3390/ijms25136961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/16/2024] Open
Abstract
Lung cancer is a leading cause of cancer-related morbidity and mortality worldwide. Metastases in the brain are a common hallmark of advanced stages of the disease, contributing to a dismal prognosis. Lung cancer can be broadly classified as either small cell lung cancer (SCLC) or non-small cell lung cancer (NSCLC). NSCLC represents the most predominant histology subtype of lung cancer, accounting for the majority of lung cancer cases. Recent advances in molecular genetics, coupled with innovations in small molecule drug discovery strategies, have facilitated both the molecular classification and precision targeting of NSCLC based on oncogenic driver mutations. Furthermore, these precision-based strategies have demonstrable efficacy across the blood-brain barrier, leading to positive outcomes in patients with brain metastases. This review provides an overview of the clinical features of lung cancer brain metastases, as well as the molecular mechanisms that drive NSCLC oncogenesis. We also explore how precision medicine-based strategies can be leveraged to improve NSCLC brain metastases.
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Affiliation(s)
- Catherine Boldig
- Department of Neurology, University of South Florida, 2 Tampa General Circle, Tampa, FL 33606, USA
| | - Kimberly Boldig
- Department of Internal Medicine, University of Florida Jacksonville, 655 W. 8th St., Jacksonville, FL 32209, USA
| | - Sepideh Mokhtari
- Moffitt Cancer Center, Department of Neuro-Oncology, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
| | - Arnold B Etame
- Moffitt Cancer Center, Department of Neuro-Oncology, 12902 USF Magnolia Drive, Tampa, FL 33612, USA
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4
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Amouzegar A, Haig S, Kahn AM, Tawbi HA, Jones JA, Goldberg SB. Navigating the Complexities of Brain Metastases Management. Am Soc Clin Oncol Educ Book 2024; 44:e433694. [PMID: 38781565 DOI: 10.1200/edbk_433694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
The management of brain metastases, a potentially devastating complication of advanced cancers, has become increasingly complex with advancements in local and systemic therapies. Improved outcomes and extended survival for patients with metastatic solid tumors have led to a surge in the prevalence and possibly incidence of brain metastases, affecting up to 40% of individuals with solid tumors. Enhanced imaging technologies contribute to more accurate and early detection, shaping the understanding of the intricate landscape of this condition. Traditionally, surgery and radiation stood as the mainstays of treatment because of the limited efficacy of systemic therapies within the brain. However, emerging clinical data, particularly in melanoma, lung, and breast cancers, reveal promising results with novel systemic treatments such as immunotherapy and targeted therapies. Despite the historical exclusion of patients with active brain metastases from clinical trials, a shift is occurring toward a more inclusive approach. This chapter delves into the multifaceted challenges associated with managing brain metastases, with a focus on the evolving landscape of systemic approaches as well as the intricacies of shared decision making, providing a comprehensive overview of the current state and future directions in navigating the complexities of brain metastases management.
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Affiliation(s)
- Afsaneh Amouzegar
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shannon Haig
- Lake Erie College of Osteopathic Medicine, Greensburg, PA
| | - Adriana M Kahn
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
| | - Hussein A Tawbi
- Department of Melanoma Medical Oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joshua A Jones
- Department of Oncology, Division of Radiation Oncology and Division of Palliative Medicine, Rochester Regional Health System, Rochester, NY
| | - Sarah B Goldberg
- Section of Medical Oncology, Department of Medicine, Yale School of Medicine, New Haven, CT
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5
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Sreter KB, Catarata MJ, von Laffert M, Frille A. Resistance to KRAS inhibition in advanced non-small cell lung cancer. Front Oncol 2024; 14:1357898. [PMID: 38846975 PMCID: PMC11153770 DOI: 10.3389/fonc.2024.1357898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/06/2024] [Indexed: 06/09/2024] Open
Abstract
Lung cancer remains the leading cause of cancer death globally. More than 50% of new cases are diagnosed in an advanced or metastatic stage, thus contributing to the poor survival of such patients. Mutations in the KRAS (Kirsten rat sarcoma virus) gene occur in nearly a third of lung adenocarcinoma and have for decades been deemed an 'undruggable' target. Yet, in recent years, a growing number of small molecules, such as the GTPase inhibitors, has been investigated in clinical trials of lung cancer patients harboring KRAS mutations, yielding promising results with improved outcomes. Currently, there are only two approved targeted therapies (adagrasib and sotorasib) for advanced or metastatic KRAS-mutated NSCLC from the second-line setting onwards. In this narrative review, we will focus on KRAS, its molecular basis, the role of its co-mutations, clinical evidence for its inhibition, putative mutation to resistance, and future strategies to overcome resistance to KRAS inhibition.
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Affiliation(s)
| | - Maria Joana Catarata
- Pulmonology Department, Hospital de Braga, Braga, Portugal
- Tumour & Microenvironment Interactions Group, I3S-Institute for Health Research & Innovation, University of Porto, Porto, Portugal
| | | | - Armin Frille
- Department of Respiratory Medicine, Leipzig University, Leipzig, Germany
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6
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Zhou KI, Lin C, Tseng CL, Ramnath N, Dowell JE, Kelley MJ. Brief Report: Real-World Efficacy and Safety of Sotorasib in U.S. Veterans with KRAS G12C-Mutated NSCLC. JTO Clin Res Rep 2024; 5:100670. [PMID: 38746048 PMCID: PMC11090863 DOI: 10.1016/j.jtocrr.2024.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/13/2024] [Accepted: 03/23/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction The KRAS G12C inhibitor sotorasib was approved for treating advanced NSCLC in the second line or later on the basis of the CodeBreaK100 trial. Nevertheless, data on the real-world efficacy and safety of sotorasib, and to its optimal dose, remain limited. Methods Patients treated with sotorasib for NSCLC through the Veterans Health Administration were retrospectively identified from the Corporate Data Warehouse. Survival, response, and toxicity data were obtained from chart review. Results Among the 128 patients treated with sotorasib through the Veterans Health Administration, objective response rate was 34%, progression-free survival (PFS) six months, and overall survival 12 months. Similar PFS was observed among the 16 patients who received frontline sotorasib without any prior systemic therapy for NSCLC. Toxicity leading to sotorasib interruption or dose reduction occurred in 37% of patients, whereas sotorasib discontinuation for toxicity occurred in 25%. Notably, sotorasib dose reduction was associated with substantially improved PFS and OS. Conclusions In this real-world study, the observed efficacy of sotorasib was similar to the results of CodeBreaK100. Patients who received frontline sotorasib had similar PFS to our overall cohort, suggesting that first-line sotorasib monotherapy may benefit patients who are not eligible for chemotherapy. Toxicities leading to sotorasib interruption, dose reduction, or discontinuation were common. Sotorasib dose reduction was associated with improved survival, suggesting that sotorasib dose reduction may not compromise efficacy.
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Affiliation(s)
- Katherine I. Zhou
- Division of Hematology–Oncology, Durham VA Medical Center, Durham, North Carolina
- Division of Medical Oncology, Duke University, Durham, North Carolina
| | - Chenyu Lin
- Division of Hematology–Oncology, Durham VA Medical Center, Durham, North Carolina
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Chin-Lin Tseng
- National Oncology Program, U.S. Department of Veterans Affairs, Durham, North Carolina
| | - Nithya Ramnath
- Section of Hematology–Oncology, Ann Arbor VA Medical Center, Ann Arbor, Michigan
- Division of Hematology and Oncology, University of Michigan, Ann Arbor, Michigan
| | - Jonathan E. Dowell
- Section of Hematology–Oncology, Veterans Affairs North Texas Healthcare System, Dallas, Texas
- Division of Hematology/Oncology, UT Southwestern Medical Center, Dallas, Texas
| | - Michael J. Kelley
- Division of Hematology–Oncology, Durham VA Medical Center, Durham, North Carolina
- Division of Medical Oncology, Duke University, Durham, North Carolina
- National Oncology Program, U.S. Department of Veterans Affairs, Durham, North Carolina
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7
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Torres-Jiménez J, Espinar JB, de Cabo HB, Berjaga MZ, Esteban-Villarrubia J, Fraile JZ, Paz-Ares L. Targeting KRAS G12C in Non-Small-Cell Lung Cancer: Current Standards and Developments. Drugs 2024; 84:527-548. [PMID: 38625662 DOI: 10.1007/s40265-024-02030-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 04/17/2024]
Abstract
Among the most common molecular alterations detected in non-small-cell lung cancer (NSCLC) are mutations in Kristen Rat Sarcoma viral oncogene homolog (KRAS). KRAS mutant NSCLC is a heterogenous group of diseases, different from other oncogene-driven tumors in terms of biology and response to therapies. Despite efforts to develop drugs aimed at inhibiting KRAS or its signaling pathways, KRAS had remained undruggable for decades. The discovery of a small pocket in the binding switch II region of KRASG12C has revolutionized the treatment of KRASG12C-mutated NSCLC patients. Sotorasib and adagrasib, direct KRASG12C inhibitors, have been approved by the US Food and Drug Administration (FDA) and other regulatory agencies for patients with previously treated KRASG12C-mutated NSCLC, and these advances have become practice changing. However, first-line treatment in KRASG12C-mutated NSCLC does not differ from NSCLC without actionable driver genomic alterations. Treatment with KRASG12C inhibitors is not curative and patients develop progressive disease, so understanding associated mechanisms of drug resistance is key. New KRASG12C inhibitors and several combination therapy strategies, including with immune checkpoint inhibitors, are being studied in clinical trials. The aim of this review is to explore the clinical impact of KRAS, and outline different treatment approaches, focusing on the novel treatment of KRASG12C-mutated NSCLC.
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Affiliation(s)
- Javier Torres-Jiménez
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain.
| | - Javier Baena Espinar
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Helena Bote de Cabo
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - María Zurera Berjaga
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Jorge Esteban-Villarrubia
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
| | - Jon Zugazagoitia Fraile
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
- Lung Cancer Group, Clinical Research Program, CNIO (Centro Nacional de Investigaciones Oncológicas) and Instituto de Investigación i+12, Madrid, Spain
| | - Luis Paz-Ares
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Avda de Córdoba s/n, 28041, Madrid, Spain
- Lung Cancer Group, Clinical Research Program, CNIO (Centro Nacional de Investigaciones Oncológicas) and Instituto de Investigación i+12, Madrid, Spain
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8
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Singhal A, Li BT, O'Reilly EM. Targeting KRAS in cancer. Nat Med 2024; 30:969-983. [PMID: 38637634 DOI: 10.1038/s41591-024-02903-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Abstract
RAS family variants-most of which involve KRAS-are the most commonly occurring hotspot mutations in human cancers and are associated with a poor prognosis. For almost four decades, KRAS has been considered undruggable, in part due to its structure, which lacks small-molecule binding sites. But recent developments in bioengineering, organic chemistry and related fields have provided the infrastructure to make direct KRAS targeting possible. The first successes occurred with allele-specific targeting of KRAS p.Gly12Cys (G12C) in non-small cell lung cancer, resulting in regulatory approval of two agents-sotorasib and adagrasib. Inhibitors targeting other variants beyond G12C have shown preliminary antitumor activity in highly refractory malignancies such as pancreatic cancer. Herein, we outline RAS pathobiology with a focus on KRAS, illustrate therapeutic approaches across a variety of malignancies, including emphasis on the 'on' and 'off' switch allele-specific and 'pan' RAS inhibitors, and review immunotherapeutic and other key combination RAS targeting strategies. We summarize mechanistic understanding of de novo and acquired resistance, review combination approaches, emerging technologies and drug development paradigms and outline a blueprint for the future of KRAS therapeutics with anticipated profound clinical impact.
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Affiliation(s)
- Anupriya Singhal
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bob T Li
- Thoracic Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Early Drug Development Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Eileen M O'Reilly
- Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- David M. Rubenstein Center for Pancreatic Cancer, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medicine, New York, NY, USA.
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9
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Bernstein E, Luo J, Wang K, Negrao MV, Jänne PA, Sabari JK. Safety and Intracranial Activity of Adagrasib in Patients With KRASG12C-Mutated Non-Small-Cell Lung Cancer and Untreated CNS Metastases in the KRYSTAL-1 Trial: A Case Series. JCO Precis Oncol 2024; 8:e2300447. [PMID: 38330263 PMCID: PMC10860949 DOI: 10.1200/po.23.00447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/10/2023] [Accepted: 11/28/2023] [Indexed: 02/10/2024] Open
Affiliation(s)
- Ezra Bernstein
- Langone Department of Internal Medicine, New York University, New York, NY
| | - Jia Luo
- Lowe Center for Thoracic Oncology, Dana-Faber Cancer Institute, Boston, MA
| | - Kaiwen Wang
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcelo V. Negrao
- Department of Thoracic and Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pasi A. Jänne
- Lowe Center for Thoracic Oncology, Dana-Faber Cancer Institute, Boston, MA
| | - Joshua K. Sabari
- Perlmutter Cancer Center, New York University Langone Health, New York, NY
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10
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Dipasquale A, Barigazzi C, Losurdo A, Persico P, Di Muzio A, Navarria P, Pessina F, van den Bent M, Santoro A, Simonelli M. Brain metastases and next-generation anticancer therapies: a survival guide for clinicians. Crit Rev Oncol Hematol 2024; 194:104239. [PMID: 38128629 DOI: 10.1016/j.critrevonc.2023.104239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/23/2023] Open
Abstract
Historically, patients with brain metastases (BMs) have been characterized by few systemic treatment options and poor prognosis. The recent introduction of next-generation anticancer therapies such as molecular targeted agents and immunotherapy have revolutionized the clinical decision-making process of this sub-population, posing new challenges to physicians. In this review, current evidence for the use of checkpoint inhibitors and targeted therapies in patients with BMs are discussed, with a focus on lung cancer, breast cancer, melanoma and renal cell carcinoma, providing suggestions and potential workflows for daily clinical practice. Several other on-going and future challenges, such as clinical trials design, ways to improve CNS penetration of novel drugs and unique molecular characteristics of BMs, are also discussed. The aim is producing an updated and easy-to-read guide for physicians, to improve decision-making in clinical practice.
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Affiliation(s)
- Angelo Dipasquale
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Chiara Barigazzi
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Agnese Losurdo
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pasquale Persico
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Antonio Di Muzio
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Piera Navarria
- Department of Radiotherapy and Radiosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Federico Pessina
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Neurosurgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | - Armando Santoro
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matteo Simonelli
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
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11
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Alharbi M, Awidi M, Dy GK. CodeBreak 200: study limitations, and future directions. Transl Cancer Res 2024; 13:15-21. [PMID: 38410207 PMCID: PMC10894345 DOI: 10.21037/tcr-23-1477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/08/2023] [Indexed: 02/28/2024]
Affiliation(s)
- Malak Alharbi
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Muhammad Awidi
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Grace K Dy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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12
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Moldvay J, Tímár J. KRASG12C mutant lung adenocarcinoma: unique biology, novel therapies and new challenges. Pathol Oncol Res 2024; 29:1611580. [PMID: 38239281 PMCID: PMC10794394 DOI: 10.3389/pore.2023.1611580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
KRAS mutant lung cancer is the most prevalent molecular subclass of adenocarcinoma (LUAD), which is a heterogenous group depending on the mutation-type which affects not only the function of the oncogene but affects the biological behavior of the cancer as well. Furthermore, KRAS mutation affects radiation sensitivity but leads also to bevacizumab and bisphosphonate resistance as well. It was highly significant that allele specific irreversible inhibitors have been developed for the smoking associated G12C mutant KRAS (sotorasib and adagrasib). Based on trial data both sotorasib and adagrasib obtained conditional approval by FDA for the treatment of previously treated advanced LUAD. Similar to other target therapies, clinical administration of KRASG12C inhibitors (sotorasib and adagrasib) resulted in acquired resistance due to various genetic changes not only in KRAS but in other oncogenes as well. Recent clinical studies are aiming to increase the efficacy of G12C inhibitors by novel combination strategies.
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Affiliation(s)
- Judit Moldvay
- National Institute of Pulmonology, Budapest, Hungary
- Pulmonology Clinic, Szentgyörgyi A. University, Szeged, Hungary
| | - József Tímár
- Department of Pathology, Forensic and Insurance Medicine, Semmelweis University, Budapest, Hungary
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13
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Lebouille-Veldman AB, Taros TN, Nawabi NLA, Mekary RA, Peng L, Phillips J. Brief report on the efficacy of sotorasib in KRAS-Mutated NSCLC patients with brain metastases. Lung Cancer 2024; 187:107425. [PMID: 38061200 DOI: 10.1016/j.lungcan.2023.107425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 01/08/2024]
Abstract
INTRODUCTION Sotorasib has emerged as a treatment option for patients with KRAS-mutated non-small cell lung cancer (NSCLC); however, its effect in patients with brain metastases is not well described. We assessed the intracranial response of sotorasib in a retrospective case series of patients with brain metastases (BMs) at a single institution. METHODS Patients with KRAS-mutated NSCLC with BMs who received sotorasib at Mass General Brigham Hospitals were included. Patients were stratified into three groups: patients with active BM without local therapy within one month of sotorasib initiation (group 1), patients with active BM with local therapy (surgery or radiation) within one month of sotorasib initiation (group 2), and patients with stable BM (group 3). Intracranial progression-free survival (ICPFS) and overall survival (OS) were explored using Kaplan Meier curves that were compared through log-rank test. RESULTS Thirty patients were included (five in group 1; seven in group 2; 18 in group 3). Mean age at sotorasib initiation was 60 years. Most (67 %) patients had between one and four BMs at sotorasib initiation. Median ICPFS was three months (95 % CI: 0- 7.7) from start of sotorasib for group 1, two months (0-5.7) for group 2, and 15 months (6.0-24.0) for group 3 (p-value = 0.02). Median OS was four months (1.9-6.1) for group 1, six months (0-13.7) for group 2, and 12 months (3.5-20.5) for group 3 (p-value = 0.13). 57 % of patients experienced intracranial progression, including 44 % of patients who had stable BM at sotorasib initiation. CONCLUSION While sotorasib may have some intracranial activity, a multidisciplinary approach to BM therapy is still warranted, as are future studies with larger patient samples, controls, and extended follow-up.
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Affiliation(s)
- Anna Baukje Lebouille-Veldman
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Trent N Taros
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, MA, USA; University of Massachusetts Chan Medical School Department of Surgery 55 N Lake Ave, Worcester MA 01655, USA
| | - Noah L A Nawabi
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, MA, USA; School of Pharmacy, MCPHS University, Boston MA, USA
| | - Luke Peng
- Department of Radiation Oncology, Brigham and Women's Dana-Farber Cancer Center, Boston, MA, USA
| | - John Phillips
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, MA, USA; Tennessee Oncology, Nashville, TN, USA
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14
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Alder L, Broadwater G, Green M, Van Swearingen AED, Lipp ES, Clarke JM, Anders CK, Sammons S. Unique genomic alterations in the circulating tumor DNA of patients with solid tumors brain metastases. Neurooncol Adv 2024; 6:vdae052. [PMID: 38680992 PMCID: PMC11046982 DOI: 10.1093/noajnl/vdae052] [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] [Indexed: 05/01/2024] Open
Abstract
Background Although serum circulating tumor DNA (ctDNA) is routine, data from patients with brain metastases (BrMs) is limited. We assessed genomic alterations in ctDNA from patients with solid tumor BrMs in 3 groups: Isolated BrMs with stable extracranial disease (iCNS), concurrent brain and extracranial progression (cCNS), and extracranial progression with no active BrMs (eCNS). We also compared ctDNA alterations between patients with and without BrMs. Methods Patients with a Guardant360 ctDNA profile with (n = 253) and without BrMs (n = 449) from the Duke Molecular Registry between January 2014 and December 2020 were identified. Actionable alterations were defined as FDA-recognized or standard-of-care biomarkers. Disease status was determined via investigator assessment within 30 days of ctDNA collection. Results Among the 253 patients with BrMs: 29 (12%) had iCNS, 160 (63%) cCNS, and 64 (25%) eCNS. Breast (BC; 12.0%) and non-small cell lung cancer (NSCLC; 76.4%) were the most common tumor types. ESR1 (60% vs 25%, P < .001) and BRCA2 (17% vs 5%, P = .022) were more frequent in BC BrMs. In NSCLC BrMs, EGFR alterations were most frequent in the iCNS group (iCNS: 67%, cCNS: 40%, eCNS:37%, P = .08) and in patients with BrMs (36% vs 17%, P < .001). Sequencing from both brain tissue and ctDNA were available for 8 patients; 7 (87.5%) had identical alterations. Conclusions This study illustrates the feasibility of detecting alterations from ctDNA among patients with BrMs. A higher frequency of actionable mutations was observed in ctDNA in patients with BrMs. Additional studies comparing ctDNA and alterations in BrMs tissue are needed to determine if ctDNA can be considered a surrogate to support treatment decisions.
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Affiliation(s)
- Laura Alder
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Gloria Broadwater
- Biostatistics Shared Resource, Duke Cancer Institute, Durham, North Carolina, USA
| | - Michelle Green
- Department of Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Amanda E D Van Swearingen
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric S Lipp
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey Melson Clarke
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
| | - Carey K Anders
- Division of Medical Oncology, Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina, USA
- Duke Center for Brain and Spine Metastasis, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah Sammons
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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Attili I, Corvaja C, Spitaleri G, Del Signore E, Trillo Aliaga P, Passaro A, de Marinis F. New Generations of Tyrosine Kinase Inhibitors in Treating NSCLC with Oncogene Addiction: Strengths and Limitations. Cancers (Basel) 2023; 15:5079. [PMID: 37894445 PMCID: PMC10605462 DOI: 10.3390/cancers15205079] [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: 09/29/2023] [Revised: 10/17/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Tyrosine kinase inhibitors (TKIs) revolutionized the treatment of patients with advanced or metastatic non-small cell lung cancer (NSCLC) harboring most driver gene alterations. Starting from the first generation, research rapidly moved to the development of newer, more selective generations of TKIs, obtaining improved results in terms of disease control and survival. However, the use of novel generations of TKIs is not without limitations. We reviewed the main results obtained, as well as the ongoing clinical trials with TKIs in oncogene-addicted NSCLC, together with the biology underlying their potential strengths and limitations. Across driver gene alterations, novel generations of TKIs allowed delayed resistance, prolonged survival, and improved brain penetration compared to previous generations, although with different toxicity profiles, that generally moved their use from further lines to the front-line treatment. However, the anticipated positioning of novel generation TKIs leads to abolishing the possibility of TKI treatment sequencing and any role of previous generations. In addition, under the selective pressure of such more potent drugs, resistant clones emerge harboring more complex and hard-to-target resistance mechanisms. Deeper knowledge of tumor biology and drug properties will help identify new strategies, including combinatorial treatments, to continue improving results in patients with oncogene-addicted NSCLC.
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Affiliation(s)
- Ilaria Attili
- Division of Thoracic Oncology, European Institute of Oncology IRCCS, Via G. Ripamonti 435, 20141 Milan, Italy
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Pan K, Concannon K, Li J, Zhang J, Heymach JV, Le X. Emerging therapeutics and evolving assessment criteria for intracranial metastases in patients with oncogene-driven non-small-cell lung cancer. Nat Rev Clin Oncol 2023; 20:716-732. [PMID: 37592034 PMCID: PMC10851171 DOI: 10.1038/s41571-023-00808-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/19/2023]
Abstract
The improved survival outcomes of patients with non-small-cell lung cancer (NSCLC), largely owing to the improved control of systemic disease provided by immune-checkpoint inhibitors and novel targeted therapies, have highlighted the challenges posed by central nervous system (CNS) metastases as a devastating yet common complication, with up to 50% of patients developing such lesions during the course of the disease. Early-generation tyrosine-kinase inhibitors (TKIs) often provide robust systemic disease control in patients with oncogene-driven NSCLCs, although these agents are usually unable to accumulate to therapeutically relevant concentrations in the CNS owing to an inability to cross the blood-brain barrier. However, the past few years have seen a paradigm shift with the emergence of several novel or later-generation TKIs with improved CNS penetrance. Such agents have promising levels of activity against brain metastases, as demonstrated by data from preclinical and clinical studies. In this Review, we describe current preclinical and clinical evidence of the intracranial activity of TKIs targeting various oncogenic drivers in patients with NSCLC, with a focus on newer agents with enhanced CNS penetration, leptomeningeal disease and the need for intrathecal treatment options. We also discuss evolving assessment criteria and regulatory considerations for future clinical investigations.
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Affiliation(s)
- Kelsey Pan
- Department of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kyle Concannon
- Department of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Li
- Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianjun Zhang
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John V Heymach
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xiuning Le
- Department of Thoracic/Head and Neck Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Levis M, Gastino A, De Giorgi G, Mantovani C, Bironzo P, Mangherini L, Ricci AA, Ricardi U, Cassoni P, Bertero L. Modern Stereotactic Radiotherapy for Brain Metastases from Lung Cancer: Current Trends and Future Perspectives Based on Integrated Translational Approaches. Cancers (Basel) 2023; 15:4622. [PMID: 37760591 PMCID: PMC10526239 DOI: 10.3390/cancers15184622] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/01/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Brain metastases (BMs) represent the most frequent metastatic event in the course of lung cancer patients, occurring in approximately 50% of patients with non-small-cell lung cancer (NSCLC) and in up to 70% in patients with small-cell lung cancer (SCLC). Thus far, many advances have been made in the diagnostic and therapeutic procedures, allowing improvements in the prognosis of these patients. The modern approach relies on the integration of several factors, such as accurate histological and molecular profiling, comprehensive assessment of clinical parameters and precise definition of the extent of intracranial and extracranial disease involvement. The combination of these factors is pivotal to guide the multidisciplinary discussion and to offer the most appropriate treatment to these patients based on a personalized approach. Focal radiotherapy (RT), in all its modalities (radiosurgery (SRS), fractionated stereotactic radiotherapy (SRT), adjuvant stereotactic radiotherapy (aSRT)), is the cornerstone of BM management, either alone or in combination with surgery and systemic therapies. We review the modern therapeutic strategies available to treat lung cancer patients with brain involvement. This includes an accurate review of the different technical solutions which can be exploited to provide a "state-of-art" focal RT and also a detailed description of the systemic agents available as effective alternatives to SRS/SRT when a targetable molecular driver is present. In addition to the validated treatment options, we also discuss the future perspective for focal RT, based on emerging clinical reports (e.g., SRS for patients with many BMs from NSCLC or SRS for BMs from SCLC), together with a presentation of innovative and promising findings in translational research and the combination of novel targeted agents with SRS/SRT.
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Affiliation(s)
- Mario Levis
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Alessio Gastino
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Greta De Giorgi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Cristina Mantovani
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paolo Bironzo
- Oncology Unit, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, 10043 Orbassano, Italy;
| | - Luca Mangherini
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Alessia Andrea Ricci
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Umberto Ricardi
- Radiation Oncology Unit, Department of Oncology, University of Turin, 10126 Turin, Italy; (M.L.); (A.G.); (G.D.G.); (C.M.); (U.R.)
| | - Paola Cassoni
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
| | - Luca Bertero
- Pathology Unit, Department of Medical Sciences, University of Turin, 10126 Turin, Italy; (L.M.); (A.A.R.); (P.C.)
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