Outcomes With Local Therapy and Tyrosine Kinase Inhibition in Patients With ALK/ROS1/RET-Rearranged Lung Cancers

Local Therapy for Isolated Central Nervous System Progression Among Patients Receiving Antibody-Drug Conjugate Therapy

Purpose

Antibody drug conjugates (ADCs) are an increasingly important class of therapeutics among patients with breast, lung, urothelial, and other malignancies. Guidelines recommend local therapy and continuation of current systemic therapy among patients with isolated brain relapse. We describe the clinical outcomes of this approach among patients receiving ADCs.

Methods and Materials

We queried our institutional database for patients receiving radiation therapy (RT) in the setting of isolated brain progression on ADCs with a plan to continue same-line therapy after radiation. Patients with ≤3 brain metastases at the time of recurrence were categorized as oligoprogressive. Study endpoints included overall survival, progression-free survival (PFS), and the cumulative incidence of next therapy from the start of local therapy.

Results

We identified 17 patients receiving ADC therapy with isolated brain progression treated with radiation (stereotactic radiosurgery [SRS]: n = 13, whole brain radiation: n = 4). All patients received concurrent ADC and RT. The median follow-up from local therapy was 29.5 months (95% CI, 21.4-not reached). The median overall survival was 19 months (95% CI, 16-not reached), and the median PFS was 8.1 months (range, 6.7-19 months). One lesion treated with SRS had local failure 21 months after treatment, and the 24-month cumulative incidence of local failure across the entire cohort was 1.6% (95% CI, 0.13%-7.7%). The 6-month cumulative incidence of radiation necrosis was 12% (95% CI, 1.8%-32%). The cumulative incidence of next therapy at 6 and 12 months was 47% (95% CI, 22%-69%) and 71% (95% CI, 41%-87%), respectively, and was significantly lower among patients with oligoprogressive brain recurrence. After SRS, 2 patients were without evidence of disease, discontinued systemic therapy, and were stable on observation at last follow-up.

Conclusions

To the best of our knowledge, this is the first clinical report of outcomes using the guideline-recommended approach of local therapy for isolated brain relapse among patients receiving ADCs. Local therapy may delay the need for next line systemic therapy, particularly among patients with oligoprogressive brain relapse.

Anti-ALK autoantibodies in patients with ALK-positive Non-Small Cell Lung Cancer (NSCLC): A monocentric experience

Importance

Deregulation of anaplastic lymphoma kinase (ALK) occurs in 3-7% of advanced NSCLC mainly because of chromosomic rearrangements at the ALK locus. Next to its oncogenic function, ALK chimeric oncoprotein is a possible antigen for human immune system. The prognostic value of natural anti-ALK immunogenicity remains poorly explored in ALK ​+ ​NSCLC. We hereby report preliminary results of a plasmatic anti-ALK a-abs titration assessment in a cohort of ALK ​+ ​NSCLC pts.

Objective

To evaluate the prevalence of pre-existing circulating anti-ALK a-abs in ALK ​+ ​NSCLC pts. Key secondary objectives are the assessment of anti-ALK a-abs prognostic value and association with brain metastases (BM).

Design

This monocentric case series included 60 ALK ​+ ​NSCLC pts progressing on any anti-ALK TKIs between October 2015 and February 2021 ​at Gustave Roussy Cancer Campus. Fifty-six plasma samples were analyzed through a semiquantitative immunocytochemical technique. Plasma samples were obtained from two prospective studies approved by our Institutional Review Board: the MATCH-R trial (NCT02517892) and the MSN trial (RECF1256).

Participants

We included pts diagnosed with unresectable stage III or IV NSCLC, either by contemporaneous or historical biopsy. ALK-rearrangement was identified by FISH, IHC or NGS. Pts were aged more than 18-year-old and had previously signed informed consent for one of the studies. Pts had received at least one anti-ALK-TKI during the disease history. Pts were not eligible if they had been diagnosed with a second cancer.

Main outcomes and measures

The prevalence of plasmatic anti-ALK a-abs titer was reported as percentage. Progression-free survival, overall survival, and time to BM were analyzed using Kaplan-Meier methods.

Results

We found an anti-ALK a-abs titer in 5 (9 ​%) pts. anti-ALK a-abs did not contribute to prolongation of survival. Although not significant, there was a trend towards protection against BM in the presence of anti-ALK a-abs.

Conclusions and relevance

Because ALK fusion proteins are exclusively produced intracellularly, not all ALK autoantibodies may have direct anti-tumor impact with favorable prognostic value. This is the first investigation to explore the impact of circulating anti-ALK a-abs on BM. Prospective studies with longer follow-up are warranted to further explore the impact of anti-ALK a-abs on BM.

Advances and future directions in ROS1 fusion-positive lung cancer

ROS1 gene fusions are an established oncogenic driver comprising 1%-2% of non-small cell lung cancer (NSCLC). Successful targeting of ROS1 fusion oncoprotein with oral small-molecule tyrosine kinase inhibitors (TKIs) has revolutionized the treatment landscape of metastatic ROS1 fusion-positive (ROS1+) NSCLC and transformed outcomes for patients. The preferred Food and Drug Administration-approved first-line therapies include crizotinib, entrectinib, and repotrectinib, and currently, selection amongst these options requires consideration of the systemic and CNS efficacy, tolerability, and access to therapy. Of note, resistance to ROS1 TKIs invariably develops, limiting the clinical benefit of these agents and leading to disease relapse. Progress in understanding the molecular mechanisms of resistance has enabled the development of numerous next-generation ROS1 TKIs, which achieve broader coverage of ROS1 resistance mutations and superior CNS penetration than first-generation TKIs, as well as other therapeutic strategies to address TKI resistance. The approach to subsequent therapy depends on the pace and pattern of progressive disease on the initial ROS1 TKI and, if known, the mechanisms of TKI resistance. Herein, we describe a practical approach for the selection of initial and subsequent therapies for metastatic ROS1+ NSCLC based on these clinical considerations. Additionally, we explore the evolving evidence for the optimal treatment of earlier-stage, non-metastatic ROS1+ NSCLC, while, in parallel, highlighting future research directions with the goal of continuing to build on the tremendous progress in the management of ROS1+ NSCLC and ultimately improving the longevity and well-being of people living with this disease.

Bombarding Oligoprogression: Oncologic Outcomes After Radiation to Patients With Oligoprogressive Non-Small Cell Lung Cancer on Maintenance Systemic Therapy

OBJECTIVES

This study aims to evaluate the efficacy and toxicity of radiotherapy (RT) to oligoprogressive metastatic non-small cell lung cancer (NSCLC).

METHODS

This is a retrospective analysis of 23 patients with metastatic NSCLC on maintenance systemic therapy, developed oligoprogression (1 to 5 sites), and all oligoprogressive sites amenable to and treated with RT. The primary endpoints included progression-free survival (PFS) and median time to start next-line therapy (MTT). Kaplan-Meier survival analysis and log-rank testing were performed using R-Studio software.

RESULTS

Twenty-three patients met the inclusion criteria. The median overall survival for the entire cohort was 31.3 months (interquartile range [IQR]: 17.86 to 45.4). The median event-free survival for the entire cohort was 8.3 months (IQR: 2.7 to 12). Patients with no prior radiation had longer median event-free survival of 11.9 months (IQR: 8.4 to 18.2) compared with patients with a history of prior radiation at 4.1 months (IQR: 2.7 to 12; P = 0.041). The local control rate for the treated lesions was 97.5%. At 12 months follow-up, 6 (43%) of 14 living patients maintained systemic therapy without initiating next-line therapy. The median PFS for the entire cohort was 8.4 months (IQR: 4.1 to 17.5). Patients who did not receive prior radiation had longer median PFS of 11.9 months (IQR: 8.4 to 18.2) compared with patients who received prior radiation 6.2 months (IQR: 2.7 to 8.5; P = 0.018). Two patients (9%) had grade 3 chronic toxicity related to RT and were medically managed.

CONCLUSION

We identified that in patients with oligoprogressive metastatic NSCLC, targeted RT to all progressive sites yielded high LC and favorable rates of PFS and MTT.

Local control strategies for management of NSCLC with oligoprogressive disease

Progresses of systemic treatments in advanced non-small cell lung cancer (NSCLC), such as immune checkpoint blockers (ICB) and targeted therapies, led to the increased incidence of oligoprogressive disease (OPD). The OPD is a subtype of oligometastatic disease (OMD) defined as a progression of a limited number of lesions during systemic treatment exposure. The hypothesis was formulated that local radical treatments (LRT) could eradicate progressive lesions resulting from resistant clones, ultimately leading to systemic treatment sensitivity restoration. Recently published international consensuses and guidelines aim to obtain a uniform definition of OMD NSCLC, to standardize the inclusion of these patients in future clinical trials, as well as their management in daily practice. Although there is no specific definition of OPD, LRT strategies in OPD are supported after reporting promising results. Both retrospective and preliminary prospective randomized data of LRT for patients with OPD NSCLC are encouraging. More clinical and translational data are needed for selecting best scenarios where LRT should be delivered. In this review, we analyze the current available literature on LRT for patients with OPD in advanced NSCLC and discuss about future trial design and challenges.