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High P, Guernsey C, Subramanian S, Jacob J, Carmon KS. The Evolving Paradigm of Antibody-Drug Conjugates Targeting the ErbB/HER Family of Receptor Tyrosine Kinases. Pharmaceutics 2024; 16:890. [PMID: 39065587 PMCID: PMC11279420 DOI: 10.3390/pharmaceutics16070890] [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: 06/14/2024] [Revised: 06/28/2024] [Accepted: 06/30/2024] [Indexed: 07/28/2024] Open
Abstract
Current therapies targeting the human epidermal growth factor receptor (HER) family, including monoclonal antibodies (mAbs) and tyrosine kinase inhibitors (TKIs), are limited by drug resistance and systemic toxicities. Antibody-drug conjugates (ADCs) are one of the most rapidly expanding classes of anti-cancer therapeutics with 13 presently approved by the FDA. Importantly, ADCs represent a promising therapeutic option with the potential to overcome traditional HER-targeted therapy resistance by delivering highly potent cytotoxins specifically to HER-overexpressing cancer cells and exerting both mAb- and payload-mediated antitumor efficacy. The clinical utility of HER-targeted ADCs is exemplified by the immense success of HER2-targeted ADCs including trastuzumab emtansine and trastuzumab deruxtecan. Still, strategies to improve upon existing HER2-targeted ADCs as well as the development of ADCs against other HER family members, particularly EGFR and HER3, are of great interest. To date, no HER4-targeting ADCs have been reported. In this review, we extensively detail clinical-stage EGFR-, HER2-, and HER3-targeting monospecific ADCs as well as novel clinical and pre-clinical bispecific ADCs (bsADCs) directed against this receptor family. We close by discussing nascent trends in the development of HER-targeting ADCs, including novel ADC payloads and HER ligand-targeted ADCs.
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Affiliation(s)
- Peyton High
- Center for Translational Cancer Research, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (P.H.); (C.G.); (S.S.); (J.J.)
- Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center and UTHealth Houston, Houston, TX 77030, USA
| | - Cara Guernsey
- Center for Translational Cancer Research, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (P.H.); (C.G.); (S.S.); (J.J.)
- Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center and UTHealth Houston, Houston, TX 77030, USA
| | - Shraddha Subramanian
- Center for Translational Cancer Research, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (P.H.); (C.G.); (S.S.); (J.J.)
- Graduate School of Biomedical Sciences, The University of Texas MD Anderson Cancer Center and UTHealth Houston, Houston, TX 77030, USA
| | - Joan Jacob
- Center for Translational Cancer Research, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (P.H.); (C.G.); (S.S.); (J.J.)
| | - Kendra S. Carmon
- Center for Translational Cancer Research, The Brown Foundation Institute of Molecular Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (P.H.); (C.G.); (S.S.); (J.J.)
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Högnäsbacka AA, Poot AJ, Kooijman E, Schuit RC, Schreurs M, Verlaan M, Beaino W, van Dongen GAMS, Vugts DJ, Windhorst AD. Synthesis and Preclinical Evaluation of [ Methylpiperazine- 11C]brigatinib as a PET Tracer Targeting Both Mutated Epidermal Growth Factor Receptor and Anaplastic Lymphoma Kinase. J Med Chem 2023; 66:12130-12140. [PMID: 37647220 PMCID: PMC10510377 DOI: 10.1021/acs.jmedchem.3c00722] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Indexed: 09/01/2023]
Abstract
Brigatinib, a tyrosine kinase inhibitor (TKI) with specificity for gene rearranged anaplastic lymphoma kinase (ALK), such as the EML4-ALK, has shown a potential to inhibit mutated epidermal growth factor receptor (EGFR). In this study, N-desmethyl brigatinib was successfully synthesized as a precursor in five steps. Radiolabeling with [11C]methyl iodide produced [methylpiperazine-11C]brigatinib in a 10 ± 2% radiochemical yield, 91 ± 17 GBq/μmol molar activity, and ≥95% radiochemical purity in 49 ± 4 min. [Methylpiperazine-11C]brigatinib was evaluated in non-small cell lung cancer xenografted female nu/nu mice. An hour post-injection (p.i.), 87% of the total radioactivity in plasma originated from intact [methylpiperazine-11C]brigatinib. Significant differences in tumor uptake were observed between the endogenously EML4-ALK mutated H2228 and the control xenograft A549. The tumor-to-blood ratio in H2228 xenografts could be reduced by pretreatment with ALK inhibitor crizotinib. Tracer uptake in EGFR Del19 mutated HCC827 and EML4-ALK fusion A549 was not significantly different from uptake in A549 xenografts.
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Affiliation(s)
- Antonia A. Högnäsbacka
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Alex J. Poot
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Esther Kooijman
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Robert C. Schuit
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Maxime Schreurs
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mariska Verlaan
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Wissam Beaino
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Guus A. M. S. van Dongen
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Danielle J. Vugts
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Albert D. Windhorst
- Department
of Radiology & Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081HV Amsterdam, The Netherlands
- Biomarkers
& Imaging, Cancer Center Amsterdam, Amsterdam, The Netherlands
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3
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Högnäsbacka A, Poot AJ, Kooijman E, Schuit RC, Schreurs M, Verlaan M, van den Hoek J, Heideman DAM, Beaino W, van Dongen GAMS, Vugts DJ, Windhorst AD. Synthesis and preclinical evaluation of two osimertinib isotopologues labeled with carbon-11 as PET tracers targeting the tyrosine kinase domain of the epidermal growth factor receptor. Nucl Med Biol 2023; 120-121:108349. [PMID: 37209556 DOI: 10.1016/j.nucmedbio.2023.108349] [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: 02/22/2023] [Revised: 04/05/2023] [Accepted: 04/18/2023] [Indexed: 05/22/2023]
Abstract
INTRODUCTION Osimertinib is a third-generation tyrosine kinase inhibitor (TKI) that is able to inhibit the EGFR treatment resistance mutation T790M and primary EGFR mutations Del19 and L858R. The aim of the study was to evaluate the potential of carbon-11 labeled osimertinib to be used as a tracer for the PET imaging of tumors bearing the T790M mutation. METHODS Osimertinib was labeled with carbon-11 at two positions, and the effect of the labeling position on the metabolism and biodistribution was studied in female nu/nu mice. The mutation status specificity of osimertinib was confirmed in vitro in a cell growth inhibition experiment, and the tumor-targeting potential of the carbon-11 isotopologues was evaluated using female nu/nu mice xenografted with NSCLC cell lines; the wild-type EGFR expressing A549, the primary Del19 EGFR mutated HCC827 and the resistance T790M/L858R mutated H1975. One of the osimertinib tracers was selected based on the results acquired and evaluated for tracer specificity and selectivity by assessment of tumor uptake in a PET study where HCC827 tumor-bearing mice were pretreated with osimertinib or afatinib. RESULTS [Methylindole-11C]- and [dimethylamine-11C]osimertinib were synthesized by 11C-methylation of precursors AZ5104 and AZ7550, respectively. Rapid metabolism of both analogs of [11C]osimertinib was observed. Although the tumor uptake and retention of [methylindole-11C]- and [dimethylamine-11C]osimertinib in tumors were similar, the tumor-to-muscle ratios appeared to be higher for [methylindole-11C]osimertinib. The highest uptake, tumor-to-blood, and tumor-to-muscle ratio were observed in the Del19 EGFR mutated HCC827 tumors. However, the specificity and selectivity of [methylindole-11C]osimertinib PET could not be demonstrated in HCC827 tumors. The uptake of [methylindole-11C]osimertinib was not significantly higher in T790M resistance mutated H1975 xenografts compared to the negative control cell line A549. CONCLUSIONS Osimertinib was successfully labeled at two positions with carbon-11, yielding two EGFR PET tracers, [methylindole-11C]osimertinib and [dimethylamine-11C]osimertinib. The preclinical evaluation demonstrated uptake and retention in three NSCLC xenografts; A549, HCC827, and H1975. The highest uptake was observed in the primary Del19 EGFR mutated HCC827. The ability of [methylindole-11C]osimertinib to distinguish between the T790M resistance mutated H1975 xenografts and the wild-type EGFR expressing A549 could not be confirmed in the ex vivo study.
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Affiliation(s)
- Antonia Högnäsbacka
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands.
| | - Alex J Poot
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Esther Kooijman
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Robert C Schuit
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Maxime Schreurs
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Mariska Verlaan
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Johan van den Hoek
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Daniëlle A M Heideman
- Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands; Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Pathology, De Boelelaan 1117, Amsterdam, the Netherlands
| | - Wissam Beaino
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Guus A M S van Dongen
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Danielle J Vugts
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
| | - Albert D Windhorst
- Amsterdam UMC location Vrije Universiteit Amsterdam, Dept. Radiology & Nuclear Medicine, De Boelelaan 1117, Amsterdam, the Netherlands; Cancer Center Amsterdam, Imaging and Biomarkers, Amsterdam, the Netherlands
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Kulkarni MB, Ayachit NH, Aminabhavi TM. A Short Review on Miniaturized Biosensors for the Detection of Nucleic Acid Biomarkers. BIOSENSORS 2023; 13:412. [PMID: 36979624 PMCID: PMC10046286 DOI: 10.3390/bios13030412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 06/18/2023]
Abstract
Even today, most biomarker testing is executed in centralized, dedicated laboratories using bulky instruments, automated analyzers, and increased analysis time and expenses. The development of miniaturized, faster, low-cost microdevices is immensely anticipated for substituting for these conventional laboratory-oriented assays and transferring diagnostic results directly onto the patient's smartphone using a cloud server. Pioneering biosensor-based approaches might make it possible to test biomarkers with reliability in a decentralized setting, but there are still a number of issues and restrictions that must be resolved before the development and use of several biosensors for the proper understanding of the measured biomarkers of numerous bioanalytes such as DNA, RNA, urine, and blood. One of the most promising processes to address some of the issues relating to the growing demand for susceptible, quick, and affordable analysis techniques in medical diagnostics is the creation of biosensors. This article critically discusses a short review of biosensors used for detecting nucleic acid biomarkers, and their use in biomedical prognostics will be addressed while considering several essential characteristics.
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Affiliation(s)
- Madhusudan B. Kulkarni
- School of Electronics and Communication Engineering, KLE Technological University, Vidyanagar, Hubballi 580023, Karnataka, India
- Medical Physics Department, Wisconsin Institutes for Medical Research, University of Wisconsin, Madison, WI 53705, USA
| | - Narasimha H. Ayachit
- School of Advanced Sciences, KLE Technological University, Hubballi 580031, Karnataka, India
| | - Tejraj M. Aminabhavi
- School of Advanced Sciences, KLE Technological University, Hubballi 580031, Karnataka, India
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Nakamura T, Sato A, Nakashima C, Abe T, Iwanaga K, Umeguchi H, Kawaguchi A, Sueoka-Aragane N. Absence of copy number gain of EGFR: A possible predictive marker of long-term response to afatinib. Cancer Sci 2023; 114:1045-1055. [PMID: 36382532 PMCID: PMC9986088 DOI: 10.1111/cas.15655] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/27/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022] Open
Abstract
Treatment efficacy of epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) is diverse even in non-small cell lung cancer (NSCLC) patients with EGFR activating mutations. Extraordinary long-term responses sustained over 3 years among NSCLC patients treated with afatinib, an EGFR-TKI, have been reported, but how to predict such long survivors has not been clarified. A multi-institutional prospective observational study, based on comprehensive genomic examination performed with next-generation sequencing of circulating tumor DNA (ctDNA), was conducted to identify potential predictive markers of long-term response to afatinib. Twenty-nine patients with advanced stage NSCLC and EGFR driver mutations detected by standard techniques were enrolled in the study. ctDNA from plasma collected before afatinib treatment was analyzed by Guardant360. ctDNA was detected in 25 of the 29 samples. Median progression-free survival was shorter in patients whose tumors had EGFR copy number gain (7.0 vs 23.0 months, p = 0.022). The impact of EGFR copy number on cell proliferation and the antitumor effect of afatinib were evaluated using genome-editing lung cancer cell lines. HCC827 with EGFR amplification was relatively resistant to afatinib at concentrations below 0.5 nM, but genome-edited derivatives of HCC827 with decreased EGFR copy number demonstrated growth inhibition with 0.1 nM afatinib. The absence of EGFR copy number gain detected in ctDNA may be a predictive marker of long-term response to afatinib. Comprehensive genomic analysis could lead to a more accurate prediction of EGFR-TKI efficacy.
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Affiliation(s)
- Tomomi Nakamura
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Akemi Sato
- Department of Clinical Laboratory Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Chiho Nakashima
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomonori Abe
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Kentaro Iwanaga
- Division of Respiratory Medicine, Saga-Ken Medical Centre Koseikan, Saga, Japan
| | - Hitomi Umeguchi
- Department of Respiratory Medicine, Karatsu Red Cross Hospital, Saga, Japan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Naoko Sueoka-Aragane
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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6
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Hong KS, Cho J, Jang JG, Jang MH, Ahn JH. Endobronchial ultrasound-guided re-biopsy of non-small cell lung cancer with acquired resistance after EGFR tyrosine kinase inhibitor treatment. Thorac Cancer 2022; 14:363-370. [PMID: 36525475 PMCID: PMC9891861 DOI: 10.1111/1759-7714.14719] [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: 09/30/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Few studies assessed the use of endobronchial ultrasound (EBUS)-guided re-biopsy for detecting the T790M mutation after epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) failure. METHODS A total of 2996 EBUS procedures were performed during the study period (January 2019-June 2022). In total, 44 consecutive patients who underwent EBUS-guided re-biopsy (56 procedures) for detecting the T790M mutation were analyzed. The success rates and T790M mutation frequencies were analyzed according to the re-biopsy site and EBUS method. Multivariate logistic regression analyses were used to identify factors affecting the likelihood of the T790M mutation. RESULTS The success rates for the mutation analyses using EBUS with a guide-sheath (EBUS-GS), EBUS guided transbronchial needle aspiration (EBUS-TBNA), and EBUS-GS with EBUS-TBNA for re-biopsy were 80.6% (29/36), 93.3% (14/15), and 100% (5/5), respectively. Patients who underwent lymph node biopsy using EBUS-TBNA had an increased rates of the T790M mutation compared with those undergoing lung biopsy using EBUS-GS (EBUS-TBNA, 60.0%; EBUS-GS with EBUS-TBNA, 40.0%; EBUS-GS, 11.1%; p < 0.001). In multivariate analysis, the use of a first-generation EGFR-TKI (odds ratio [OR], 4.29; 95% confidence interval [CI], 1.05-17.58; p = 0.043) was associated with occurrence of the T790M mutation. Re-biopsy of the metastatic site tended to be associated with a higher T790M mutation rate. Mild hemoptysis occurred in 3.6% (2/56) of the patients. CONCLUSIONS EBUS-guided re-biopsy can be used for detecting the T790M mutation in patients who failed EGFR-TKI therapy. The T790M mutation frequency differed according to the re-biopsy site. The use of a first-generation EGFR-TKI was an independent predictor of the T790M mutation.
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Affiliation(s)
- Kyung Soo Hong
- Division of Pulmonology and Allergy, Department of Internal Medicine, College of MedicineYeungnam University, Yeungnam University Medical CenterDaeguRepublic of Korea
| | - Jinmo Cho
- Division of Pulmonology and Allergy, Department of Internal Medicine, College of MedicineYeungnam University, Yeungnam University Medical CenterDaeguRepublic of Korea
| | - Jong Geol Jang
- Division of Pulmonology and Allergy, Department of Internal Medicine, College of MedicineYeungnam University, Yeungnam University Medical CenterDaeguRepublic of Korea
| | - Min Hye Jang
- Department of Pathology, College of MedicineYeungnam UniversityDaeguRepublic of Korea
| | - June Hong Ahn
- Division of Pulmonology and Allergy, Department of Internal Medicine, College of MedicineYeungnam University, Yeungnam University Medical CenterDaeguRepublic of Korea
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Vaquero J, Pavy A, Gonzalez-Sanchez E, Meredith M, Arbelaiz A, Fouassier L. Genetic alterations shaping tumor response to anti-EGFR therapies. Drug Resist Updat 2022; 64:100863. [DOI: 10.1016/j.drup.2022.100863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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8
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Högnäsbacka A, Poot AJ, Vugts DJ, van Dongen GAMS, Windhorst AD. The Development of Positron Emission Tomography Tracers for In Vivo Targeting the Kinase Domain of the Epidermal Growth Factor Receptor. Pharmaceuticals (Basel) 2022; 15:ph15040450. [PMID: 35455447 PMCID: PMC9033078 DOI: 10.3390/ph15040450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/24/2022] [Accepted: 03/25/2022] [Indexed: 11/16/2022] Open
Abstract
Multiple small molecule PET tracers have been developed for the imaging of the epidermal growth factor receptor (EGFR). These tracers target the tyrosine kinase (TK) domain of the receptor and have been used for both quantifying EGFR expression and to differentiate between EGFR mutational statuses. However, the approaches for in vivo evaluation of these tracers are diverse and have resulted in data that are hard to compare. In this review, we analyze the historical development of the in vivo evaluation approaches, starting from the first EGFR TK PET tracer [11C]PD153035 to tracers developed based on TK inhibitors used for the clinical treatment of mutated EGFR expressing non-small cell lung cancer like [11C]erlotinib and [18F]afatinib. The evaluation of each tracer has been compiled to allow for a comparison between studies and ultimately between tracers. The main challenges for each group of tracers are thereafter discussed. Finally, this review addresses the challenges that need to be overcome to be able to efficiently drive EGFR PET imaging forward.
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Affiliation(s)
- Antonia Högnäsbacka
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.J.P.); (D.J.V.); (G.A.M.S.v.D.)
- Cancer Center Amsterdam, Imaging and Biomarkers, 1081 HV Amsterdam, The Netherlands
- Correspondence: (A.H.); (A.D.W.)
| | - Alex J. Poot
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.J.P.); (D.J.V.); (G.A.M.S.v.D.)
- Cancer Center Amsterdam, Imaging and Biomarkers, 1081 HV Amsterdam, The Netherlands
| | - Danielle J. Vugts
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.J.P.); (D.J.V.); (G.A.M.S.v.D.)
- Cancer Center Amsterdam, Imaging and Biomarkers, 1081 HV Amsterdam, The Netherlands
| | - Guus A. M. S. van Dongen
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.J.P.); (D.J.V.); (G.A.M.S.v.D.)
- Cancer Center Amsterdam, Imaging and Biomarkers, 1081 HV Amsterdam, The Netherlands
| | - Albert D. Windhorst
- Department of Radiology & Nuclear Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; (A.J.P.); (D.J.V.); (G.A.M.S.v.D.)
- Cancer Center Amsterdam, Imaging and Biomarkers, 1081 HV Amsterdam, The Netherlands
- Correspondence: (A.H.); (A.D.W.)
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9
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Kolesar J, Peh S, Thomas L, Baburaj G, Mukherjee N, Kantamneni R, Lewis S, Pai A, Udupa KS, Kumar An N, Rangnekar VM, Rao M. Integration of liquid biopsy and pharmacogenomics for precision therapy of EGFR mutant and resistant lung cancers. Mol Cancer 2022; 21:61. [PMID: 35209919 PMCID: PMC8867675 DOI: 10.1186/s12943-022-01534-8] [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: 11/30/2021] [Accepted: 02/07/2022] [Indexed: 11/22/2022] Open
Abstract
The advent of molecular profiling has revolutionized the treatment of lung cancer by comprehensively delineating the genomic landscape of the epidermal growth factor receptor (EGFR) gene. Drug resistance caused by EGFR mutations and genetic polymorphisms of drug metabolizing enzymes and transporters impedes effective treatment of EGFR mutant and resistant lung cancer. This review appraises current literature, opportunities, and challenges associated with liquid biopsy and pharmacogenomic (PGx) testing as precision therapy tools in the management of EGFR mutant and resistant lung cancers. Liquid biopsy could play a potential role in selection of precise tyrosine kinase inhibitor (TKI) therapies during different phases of lung cancer treatment. This selection will be based on the driver EGFR mutational status, as well as monitoring the development of potential EGFR mutations arising during or after TKIs treatment, since some of these new mutations may be druggable targets for alternative TKIs. Several studies have identified the utility of liquid biopsy in the identification of EGFR driver and acquired resistance with good sensitivities for various blood-based biomarkers. With a plethora of sequencing technologies and platforms available currently, further evaluations using randomized controlled trials (RCTs) in multicentric, multiethnic and larger patient cohorts could enable optimization of liquid-based assays for the detection of EGFR mutations, and support testing of CYP450 enzymes and drug transporter polymorphisms to guide precise dosing of EGFR TKIs.
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Affiliation(s)
- Jill Kolesar
- Department of Pharmacy Practice & Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Spencer Peh
- Department of Pharmacy Practice & Science, University of Kentucky, Lexington, KY, 40536, USA
| | - Levin Thomas
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Gayathri Baburaj
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Nayonika Mukherjee
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Raveena Kantamneni
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shirley Lewis
- Department of Radiotherapy and Oncology, Kasturba Medical College, Manipal Comprehensive Cancer Care Centre, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Ananth Pai
- Department of Medical Oncology, Kasturba Medical College, Manipal Comprehensive Cancer Care Centre, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Karthik S Udupa
- Department of Medical Oncology, Kasturba Medical College, Manipal Comprehensive Cancer Care Centre, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Naveena Kumar An
- Department of Surgical Oncology, Kasturba Medical College, Manipal Comprehensive Cancer Care Centre, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Vivek M Rangnekar
- Markey Cancer Centre and Department of Radiation Medicine, University of Kentucky, Lexington, KY, 40536, USA
| | - Mahadev Rao
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
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10
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Zhao J, Bai H, Wang X, Wang Y, Duan J, Chen H, Xue Z, Tian Y, Cseh A, Huang DCL, Wu YL, Wang J. Biomarker subset analysis of a phase IIIb, open-label study of afatinib in EGFR tyrosine kinase inhibitor-naive patients with EGFRm+ non-small-cell lung cancer. Future Oncol 2022; 18:1485-1497. [PMID: 35114807 DOI: 10.2217/fon-2021-0394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Aim: To explore the relationship between mutations in cfDNA and response to afatinib. Patients & methods: In total, 64 patients from one Chinese site with locally advanced/metastatic EGFRm+ non-small-cell lung cancer, who received afatinib 40 mg once daily, were included. Results: Overall, 33 (82.5%) patients became EGFRm- by visit 3; median progression-free survival was longer in these patients vs those who did not (11.0 vs 5.5 months). Progression-free survival was shorter in 42 (45.2%) patients with non-EGFR co-mutations at baseline vs those without (8.1 vs 12.5 months). Neither difference was significant. Conclusion: Afatinib provided clinical benefit for patients with EGFRm+ non-small-cell lung cancer across all subgroups. EGFRm status assessment in plasma cfDNA is a useful method of monitoring treatment.
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Affiliation(s)
- Jun Zhao
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Thoracic Medical Oncology-I, Peking University Cancer Hospital & Institute, 52 Fucheng Rd., Haidian District, Beijing, 100142, China
| | - Hua Bai
- Molecular Oncology, Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Panjiayuannanli Number 17, Chaoyang District, Beijing, 100121, China
| | - Xin Wang
- Molecular Oncology, Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Panjiayuannanli Number 17, Chaoyang District, Beijing, 100121, China
| | - Yuyan Wang
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Thoracic Medical Oncology-I, Peking University Cancer Hospital & Institute, 52 Fucheng Rd., Haidian District, Beijing, 100142, China
| | - Jianchun Duan
- Molecular Oncology, Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Panjiayuannanli Number 17, Chaoyang District, Beijing, 100121, China
| | - Hanxiao Chen
- Key Laboratory of Carcinogenesis & Translational Research (Ministry of Education), Department of Thoracic Medical Oncology-I, Peking University Cancer Hospital & Institute, 52 Fucheng Rd., Haidian District, Beijing, 100142, China
| | - Zhiyi Xue
- Boehringer Ingelheim (China) Investment Co., Ltd, 29/F Park Place, 1601 Nanjing Road (West), Jingan District, Shanghai, 200040, China
| | - Yahui Tian
- Boehringer Ingelheim (China) Investment Co., Ltd, 29/F Park Place, 1601 Nanjing Road (West), Jingan District, Shanghai, 200040, China
| | - Agnieszka Cseh
- Boehringer Ingelheim International GmbH, Binger Strasse 173, Ingelheim, 55216, Germany
| | - Dennis Chin-Lun Huang
- Boehringer Ingelheim Taiwan Limited, 12F, No. 2, Sec 3, Minsheng E Road, Taipei, 104, Taiwan
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, 106 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Jie Wang
- Department of Medical Oncology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Panjiayuannanli Number 17, Chaoyang District, Beijing, 10021, China
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11
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Hayashi H, Nadal E, Gray JE, Ardizzoni A, Caria N, Puri T, Grohe C. Overall Treatment Strategy for Patients With Metastatic NSCLC With Activating EGFR Mutations. Clin Lung Cancer 2021; 23:e69-e82. [PMID: 34865963 DOI: 10.1016/j.cllc.2021.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/18/2021] [Accepted: 10/13/2021] [Indexed: 02/07/2023]
Abstract
Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (EGFR-TKIs) are standard of care in the first-line (1L) setting for patients with metastatic non-small cell lung cancer (mNSCLC) with activating EGFR mutations. EGFR-activating mutations are a predictive factor for response to EGFR-TKIs. Meta-analyses have shown that patients with exon 21_L858R mutations exhibit reduced sensitivity to EGFR-TKIs, resulting in inferior patient outcomes compared to those with exon 19 deletion mutations, with worse overall survival, progression-free survival, objective response, and disease control rates. Clinical activity observed with 1L therapy with first-generation (1G), second-generation (2G), and third-generation (3G) EGFR-TKIs is not permanent, and resistance inevitably develops in all cases, supporting the importance of overall treatment planning. The introduction of the 3G EGFR-TKI, osimertinib, provides an opportunity to overcome T790M-mediated resistance to 1G, and 2G EGFR-TKIs. Additionally, with the use of osimertinib, fewer T790M mutations are being detected as T790M is not a reported resistance mechanism to 3G EGFR-TKIs. However, there are currently no approved targeted therapies after 3G EGFR-TKIs. In order to further improve patient outcomes, there is a need to explore additional options for the overall treatment strategy for patients, including 1L and beyond. Combination of vascular endothelial growth factor (VEGF) inhibitors and EGFR-TKIs or chemotherapy and EGFR-TKIs may be a potential therapeutic approach in the 1L setting. This review discusses current treatment options for mNSCLC with activating EGFR mutations based on tumor, patient, and treatment characteristics and how an overall treatment plan may be developed.
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Affiliation(s)
- Hidetoshi Hayashi
- Department of Medical Oncology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan.
| | - Ernest Nadal
- Catalan Institute of Oncology, IDIBELL, L'Hospitalet, Barcelona, Spain
| | - Jhanelle E Gray
- Department of Thoracic Oncology, Moffitt Cancer Center, Tampa, FL, USA
| | - Andrea Ardizzoni
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Nicola Caria
- Eli Lilly and Company, Indianapolis, Indiana, United States
| | - Tarun Puri
- Eli Lilly and Company, Indianapolis, Indiana, United States
| | - Christian Grohe
- Klinik fur Pneumologie, Evangelische Lungenlinik, Berlin, Germany
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12
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Repetto M, Crimini E, Giugliano F, Morganti S, Belli C, Curigliano G. Selective FGFR/FGF pathway inhibitors: inhibition strategies, clinical activities, resistance mutations, and future directions. Expert Rev Clin Pharmacol 2021; 14:1233-1252. [PMID: 34591728 DOI: 10.1080/17512433.2021.1947246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Fibroblast growth factor receptor (FGFR)/fibroblast growth factor (FGF) is a pathway characterized by recurring alterations in cancer. Its dysregulations enhance cancer cell proliferation, survival, migration and invasion, as well as angiogenesis and immune evasion.Areas covered: FGFR/FGF selective inhibitors belong to a broad class of drugs with some being approved for specific indications and others under investigation in ongoing phase I and II clinical trials. In this review, all available clinical data from trials on selective FGFR/FGF inhibitors as well as described resistance mutations and mechanisms are presented. FGFR/FGF pathway inhibitors are classified according to the mechanism they employ to dampen/suppress signaling and to the preferred FGFR binding mode when X-ray crystal structure is available.Expert opinion: Data presented suggests the general actionability of FGFR1,2,3 mutations and fusions across histologies, whereas FGFR1,2,3 amplifications alone are poor predictors of response to tyrosine kinase inhibitors. Overexpression on immunohistochemistry (IHC) of FGF19, the stimulatory ligand of FGFR4, can predict response to FGFR selective inhibitors in hepatocellular carcinoma. Whereas IHC overexpression of FGFR1,2,3 is not sufficient to predict benefit from FGFR inhibitors across solid tumors. FGFR1,2,3 mRNA overexpression can predict response even in absence of structural alteration. Data on resistance mutations suggests the need for new inhibitors to overcome gatekeeper mutations.
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Affiliation(s)
- Matteo Repetto
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Edoardo Crimini
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Federica Giugliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Stefania Morganti
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
| | - Carmen Belli
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy
| | - Giuseppe Curigliano
- Division of Early Drug Development for Innovative Therapies, European Institute of Oncology IRCCS, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
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13
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Di Capua D, Bracken-Clarke D, Ronan K, Baird AM, Finn S. The Liquid Biopsy for Lung Cancer: State of the Art, Limitations and Future Developments. Cancers (Basel) 2021; 13:cancers13163923. [PMID: 34439082 PMCID: PMC8391249 DOI: 10.3390/cancers13163923] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary During the development and progression of lung tumors, processes such as necrosis and vascular invasion shed tumor cells or cellular components into various fluid compartments. Liquid biopsies consist of obtaining a bodily fluid, typically peripheral blood, in order to isolate and investigate these shed tumor constituents. Circulating tumor cells (CTCs) are one such constituent, which can be isolated from blood and can act as a diagnostic aid and provide valuable prognostic information. Liquid-based biopsies may also have a potential future role in lung cancer screening. Circulating tumor DNA (ctDNA) is found in small quantities in blood and, with the recent development of sensitive molecular and sequencing technologies, can be used to directly detect actionable genetic alterations or monitor for resistance mutations and guide clinical management. While potential benefits of liquid biopsies are promising, they are not without limitations. In this review, we summarize the current state and limitations of CTCs and ctDNA and possible future directions. Abstract Lung cancer is a leading cause of cancer-related deaths, contributing to 18.4% of cancer deaths globally. Treatment of non-small cell lung carcinoma has seen rapid progression with targeted therapies tailored to specific genetic drivers. However, identifying genetic alterations can be difficult due to lack of tissue, inaccessible tumors and the risk of complications for the patient with serial tissue sampling. The liquid biopsy provides a minimally invasive method which can obtain circulating biomarkers shed from the tumor and could be a safer alternative to tissue biopsy. While tissue biopsy remains the gold standard, liquid biopsies could be very beneficial where serial sampling is required, such as monitoring disease progression or development of resistance mutations to current targeted therapies. Liquid biopsies also have a potential role in identifying patients at risk of relapse post treatment and as a component of future lung cancer screening protocols. Rapid developments have led to multiple platforms for isolating circulating tumor cells (CTCs) and detecting circulating tumor DNA (ctDNA); however, standardization is lacking, especially in lung carcinoma. Additionally, clonal hematopoiesis of uncertain clinical significance must be taken into consideration in genetic sequencing, as it introduces the potential for false positives. Various biomarkers have been investigated in liquid biopsies; however, in this review, we will concentrate on the current use of ctDNA and CTCs, focusing on the clinical relevance, current and possible future applications and limitations of each.
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Affiliation(s)
- Daniel Di Capua
- Department of Histopathology, St. James’s Hospital, D08NHY1 Dublin, Ireland;
| | - Dara Bracken-Clarke
- Department of Medical Oncology, St. James’ Hospital, D08NHY1 Dublin, Ireland;
| | - Karine Ronan
- Faculty of Medicine, University College Dublin, D04V1W8 Dublin, Ireland;
| | - Anne-Marie Baird
- School of Medicine, Trinity Translational Medicine Institute, Trinity College, D02PN40 Dublin, Ireland;
| | - Stephen Finn
- Department of Histopathology, St. James’s Hospital, D08NHY1 Dublin, Ireland;
- Correspondence:
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14
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Wang J, Song Y, Zhang N, Li N, Liu C, Wang B. Using Liposomes to Alleviate the Toxicity of Chelerythrine, a Natural PKC Inhibitor, in Treating Non-Small Cell Lung Cancer. Front Oncol 2021; 11:658543. [PMID: 34123813 PMCID: PMC8190388 DOI: 10.3389/fonc.2021.658543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Aim of the Study CHE can inhibit the proliferation of lung cancer cells and induce apoptosis. However, despite having in vivo toxicity, CHE has not been thoroughly investigated in term of its in vivo antitumor effect. The present study evaluated the antitumor effect of CHE on non-small cell lung cancer cell line HCC827. Methods The antitumor effect of CHE on HCC827 was evaluated, and its potential work mechanism was investigated. CHE long circulation liposomes (CHELPs) modified with polyethylene glycol have been optimized and characterized by in vivo pharmacokinetic studies. A HCC827 xenograft model was developed on BALB/c nude mice for the assessment of the effects of CHE and CHELP. Results CHE might inhibit HCC827 growth through the ROS/PKC-ϵ/caspase 3 pathway and glycolysis. The optimized CHELP remained stable after storage for 10 days at 4°C and exhibited sustained drug release, showing approximately one-fifteenth of the in vivo clearance rate and 86 times the absorption concentration of free drug. While increasing the bioavailability of CHE, CHELP showed a good therapeutic effect on HCC827 tumor-bearing nude mice and reduced the toxicity of the free drug, improving the safety of CHE. Conclusions CHE is a candidate drug for NSCLC, and liposomes are effective in alleviating the toxicity of CHE.
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Affiliation(s)
- Jiahui Wang
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Yijie Song
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ning Zhang
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Ning Li
- Shenzhen Research Institute, The Hong Kong University of Science and Technology, Shenzhen, China
| | - Congying Liu
- Experiment Center for Science and Technology, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Bing Wang
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Center for Pharmaceutics Research, Shanghai Institute of Materia Medica Chinese Academy of Sciences, Shanghai, China
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15
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Tu HY, Wu YL. Afatinib for the first-line treatment of EGFR mutation-positive NSCLC in China: a review of clinical data. Future Oncol 2020; 16:2569-2586. [PMID: 32927981 DOI: 10.2217/fon-2020-0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Mutations in the EGFR gene are particularly prevalent among Chinese patients with non-small-cell lung carcinoma. Six EGFR tyrosine kinase inhibitors are approved for the first-line treatment of EGFR mutation-positive non-small-cell lung carcinoma in China, which poses questions about which agent is most suitable for a particular patient. In this article, we review available clinical trial and real-world data with afatinib in Chinese patients. We assess its efficacy and safety in key patient subgroups such as those with uncommon mutations or brain metastases. We also consider possible subsequent therapies following afatinib. Encouragingly, available data suggest that sequential afatinib and osimertinib confer prolonged overall time to failure of almost 4 years in Asian patients, and represents a viable option in this setting.
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Affiliation(s)
- Hai-Yan Tu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, 510080, PR China
| | - Yi-Long Wu
- Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangdong Provincial People's Hospital & Guangdong Academy of Medical Sciences, Guangzhou, 510080, PR China
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16
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Sun ZG, Zhao LH, Li ZN, Zhu HL. Development and Challenges of the Discovery of HER2 Inhibitors. Mini Rev Med Chem 2020; 20:2123-2134. [PMID: 32727326 DOI: 10.2174/1389557520666200729162118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/01/2020] [Accepted: 06/23/2020] [Indexed: 11/22/2022]
Abstract
The treatment of cancer has always been a major problem in the world. Some cancers cannot be treated with surgery, but only with cancer drugs. Among many cancer drugs, small molecule inhibitors play an irreplaceable role. HER2 is one of the HER families, and the development of HER2 inhibitors has made a huge contribution to the treatment of cancer. Some HER2 inhibitors are already on the market, and some HER2 inhibitors are undergoing clinical research. The design, synthesis and development of new HER2 inhibitors targeting different targets are also ongoing, and some are even under clinical research. The HER2 inhibitors that are on the market have developed resistance, which brings great challenges to the HER2 inhibitor development in the future. This article reviews the development and challenges of the discovery of HER2 inhibitors.
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Affiliation(s)
- Zhi-Gang Sun
- Central Laboratory, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China
| | - Liang-Hui Zhao
- Weifang Medical University, No. 7166 Baotong West Street, Weifang 261000, China
| | - Zhi-Na Li
- Central Laboratory, Linyi Central Hospital, No.17 Jiankang Road, Linyi 276400, China
| | - Hai-Liang Zhu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, No.163 Xianlin Road, Nanjing 210023, China
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17
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Lu X, Smaill JB, Ding K. Medicinal Chemistry Strategies for the Development of Kinase Inhibitors Targeting Point Mutations. J Med Chem 2020; 63:10726-10741. [PMID: 32432477 DOI: 10.1021/acs.jmedchem.0c00507] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinically acquired resistance to small molecule kinase inhibitors (SMKIs) has become a major "unmet clinical need" in cancer therapy. To date, there are six SMKIs to be approved for the treatment of cancer patients through targeting of clinically acquired resistance caused by on-target mutations. These are mainly focused on the mutant kinases Bcr-Abl T315I, EGFR T790M, and ALK L1196M. Herein, we summarize the major medicinal chemistry strategies employed in the discovery of these representative SMKIs, such as avoiding steric hindrance, making additional interactions with mutated residues, and forming a covalent bond with an active site cysteine to override resistance observed for reversible inhibitors. Additionally, we also briefly describe allosteric kinase inhibitors and proteolysis targeting chimera (PROTAC) as two other potential strategies while addressing future opportunities in this area.
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Affiliation(s)
- Xiaoyun Lu
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Discovery of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Jeff B Smaill
- Auckland Cancer Society Research Centre, School of Medical Sciences, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
| | - Ke Ding
- International Cooperative Laboratory of Traditional Chinese Medicine Modernization and Innovative Drug Discovery of Chinese Ministry of Education (MOE), Guangzhou City Key Laboratory of Precision Chemical Drug Development, School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
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18
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Chen JA, Riess JW. Advances in targeting acquired resistance mechanisms to epidermal growth factor receptor tyrosine kinase inhibitors. J Thorac Dis 2020; 12:2859-2876. [PMID: 32642199 PMCID: PMC7330402 DOI: 10.21037/jtd.2019.08.32] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Next-generation sequencing (NGS) of tumor samples and circulating tumor DNA has revolutionized diagnostic and therapeutic strategies in lung cancer. The identification of the epidermal growth factor receptor (EGFR) oncogenic driver has translated into successful therapy of advanced lung cancer using EGFR tyrosine kinase inhibitors (TKI). Unfortunately, responses are limited by acquired mechanisms of resistance. We review herein the current landscape of acquired resistance mechanisms to EGFR-TKI therapy and recent advances in therapeutic strategies to overcome acquired resistance.
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Affiliation(s)
- Justin A Chen
- Department of Internal Medicine, Division of Hematology and Oncology, UC Davis School of Medicine and UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Jonathan W Riess
- Department of Internal Medicine, Division of Hematology and Oncology, UC Davis School of Medicine and UC Davis Comprehensive Cancer Center, Sacramento, CA, USA
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19
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Tokudome N, Koh Y, Akamatsu H, Fujimoto D, Okamoto I, Nakagawa K, Hida T, Imamura F, Morita S, Yamamoto N. Differential significance of molecular subtypes which were classified into EGFR exon 19 deletion on the first line afatinib monotherapy. BMC Cancer 2020; 20:103. [PMID: 32028909 PMCID: PMC7006223 DOI: 10.1186/s12885-020-6593-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/31/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Epidermal growth factor receptor (EGFR)-sensitizing mutation, exon 19 deletion consists of several molecular variants. Influences of these variants on clinical response to EGFR tyrosine kinase inhibitors remain elusive. METHODS West Japan Oncology Group 8114LTR is a prospective, multi-institutional biomarker study. Treatment naïve, advanced non-small-cell lung cancer patients with EGFR-sensitizing mutation received afatinib monotherapy. We conducted a preplanned subset analysis of patients harboring exon 19 deletion. Tumor tissue exon 19 deletion molecular variants were identified by blocking-oligo-dependent polymerase chain reaction (PCR) and by Luminex Technology. Plasma cfDNA was also obtained before and after the treatment and EGFR mutations were detected with multiplexed, pico-droplet digital PCR assay. RESULTS Among 57 registered patients, twenty-nine patients were exon 19 deletion. Tissue DNA and cfDNA were available in 26 patients. Among the detected seven molecular variants, the most frequent was p.E746_A750delELREA (65.4%). According to the various classifications of molecular variants, twenty one (80.8%) were classified into 15-nucleotide deletion, one (3.8%) into 18-nucleotide deletion, and four patients (15.4%) into other insertion/substitution variant subgroups. The patient subgroup with 15-nucleotide deletion showed significantly longer progression-free survival than patients in other mixed insertion/substitution variant subgroup (p = 0.0244). CONCLUSIONS The clinical significance of molecular variants of exon 19 deletion on the first line afatinib monotherapy is reported here for the first time. Further investigation is needed for development of better therapeutic strategies. TRIAL REGISTRATION This trial was registered at UMIN Clinical Trials Registry at 2014/12/4 (UMIN000015847).
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Affiliation(s)
- Nahomi Tokudome
- Internal Medicine III, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Yasuhiro Koh
- Internal Medicine III, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan.
| | - Hiroaki Akamatsu
- Internal Medicine III, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Daichi Fujimoto
- Department of Respiratory Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Isamu Okamoto
- Research Institute for Diseases of the Chest, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuhiko Nakagawa
- Department of Medical Oncology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Toyoaki Hida
- Department of Thoracic Oncology, Aichi Cancer Center, Nagoya, Japan
| | - Fumio Imamura
- Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Nobuyuki Yamamoto
- Internal Medicine III, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
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20
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Li XY, Lin JZ, Yu SH. Front-line Therapy in Advanced Non-Small Cell Lung Cancer With Sensitive Epidermal Growth Factor Receptor Mutations: A Network Meta-analysis. Clin Ther 2020; 42:338-350.e4. [PMID: 31937461 DOI: 10.1016/j.clinthera.2019.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/06/2019] [Accepted: 12/10/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE Several epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) were firmly established as front-line treatment for non-small cell lung cancer (NSCLC) that harbored an activating EGFR mutation. Gefitinib or erlotinib was considered the standard of care. TKI-based combination therapy has been investigated and has shown encouraging results. METHODS The PubMed and EMBASE databases, the Cochrane Central Register of Controlled Trials, and meeting abstracts were screened for relevant studies between January 2000 and February 2019. Prospective randomized controlled trials were included that investigated EGFR TKIs (alone or in combination) in untreated patients with NSCLC whose tumors had sensitive EGFR mutations. A frequentist random effects network meta-analysis model was conducted to assess objective response rate, progression-free survival, and overall survival. P-score was used to rank treatment effects. FINDINGS Seventeen trials involving 9 treatments and 4373 patients were included. Heterogeneity existed in the network analysis. For progression-free survival, the top 3 treatments were osimertinib, standard of care plus chemotherapy, and standard of care plus bevacizumab; corresponding p-scores were 0.88, 0.79, and 0.75, respectively. For overall survival, the top 3 treatments were standard of care plus chemotherapy, osimertinib, and dacomitinib; corresponding p-scores were 0.89, 0.85, and 0.64. TKI-based combination therapy caused more toxicity than a TKI alone. IMPLICATIONS Osimertinib seemed to be a better option as upfront therapy for EGFR-mutant NSCLC in terms of efficacy and tolerability.
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Affiliation(s)
- Xu-Yuan Li
- Department of Medical Oncology, Shantou Central Hospital, Shantou, China.
| | - Jia-Zhou Lin
- Department of Clinical Laboratory Medicine, Cancer Hospital of Shantou University Medical College, Shantou, China
| | - Shu-Han Yu
- Department of Medical Oncology, Shantou Central Hospital, Shantou, China
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21
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Yang JCH, Schuler M, Popat S, Miura S, Heeke S, Park K, Märten A, Kim ES. Afatinib for the Treatment of NSCLC Harboring Uncommon EGFR Mutations: A Database of 693 Cases. J Thorac Oncol 2020; 15:803-815. [PMID: 31931137 DOI: 10.1016/j.jtho.2019.12.126] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Limited clinical data are available regarding the efficacy of EGFR tyrosine kinase inhibitors (EGFR TKIs) in patients with NSCLC harboring uncommon EGFR mutations. This pooled analysis assessed the activity of afatinib in 693 patients with tumors harboring uncommon EGFR mutations treated in randomized clinical trials, compassionate-use and expanded-access programs, phase IIIb trials, noninterventional trials, and case series or studies. METHODS Patients had uncommon EGFR mutations, which were categorized as follows: (1) T790M; (2) exon 20 insertions; (3) "major" uncommon mutations (G719X, L861Q, and S768I, with or without any other mutation except T790M or an exon 20 insertion); (4) compound mutations; and (5) other uncommon mutations. Key end points were overall response rate (ORR), duration of response, and time to treatment failure (TTF). RESULTS In EGFR TKI-naive patients (n = 315), afatinib demonstrated activity against major uncommon mutations (median TTF = 10.8 mo; 95% confidence interval [CI]: 8.1-16.6; ORR = 60.0%), compound mutations (median TTF = 14.7 mo; 95% CI: 6.8-18.5; ORR = 77.1%), other uncommon mutations (median TTF = 4.5 mo; 95% CI: 2.9-9.7; ORR = 65.2%), and some exon 20 insertions (median TTF = 4.2 mo; 95% CI: 2.8-5.3; ORR = 24.3%). The median duration of response for major uncommon mutations, compound mutations, other uncommon mutations, and some exon 20 insertions was 17.1, 16.6, 9.0, and 11.9 months, respectively. Activity of afatinib was also observed in EGFR TKI-pretreated patients (n = 378). A searchable database of these outcomes by individual genotype was generated. CONCLUSIONS Afatinib has clinical activity in NSCLC against major uncommon and compound EGFR mutations. It also has broad activity against other uncommon EGFR mutations and some exon 20 insertions. The data support the use of afatinib in these settings.
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Affiliation(s)
| | - Martin Schuler
- West German Cancer Center, University Duisburg-Essen and German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Sanjay Popat
- Lung Unit, Royal Marsden National Health Service Foundation Trust, London, United Kingdom; The Institute of Cancer Research, London, United Kingdom
| | - Satoru Miura
- Department of Internal Medicine, Niigata Cancer Center Hospital, Niigata, Japan
| | - Simon Heeke
- Laboratory of Clinical and Experimental Pathology, Centre Hospitalier Universitaire de Nice, University Hospital Federation OncoAge, Nice, France
| | - Keunchil Park
- Division of Hematology/Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Angela Märten
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Edward S Kim
- Department of Solid Tumor Oncology, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
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22
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Shah R, Lester JF. Tyrosine Kinase Inhibitors for the Treatment of EGFR Mutation-Positive Non-Small-Cell Lung Cancer: A Clash of the Generations. Clin Lung Cancer 2019; 21:e216-e228. [PMID: 32014348 DOI: 10.1016/j.cllc.2019.12.003] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 11/20/2019] [Accepted: 12/13/2019] [Indexed: 02/06/2023]
Abstract
The availability of 3 generations of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) with different pharmacologic characteristics and clinical profiles has provided oncologists with a potentially confusing choice for the treatment of EGFR mutation-positive non-small-cell lung cancer. Although recent head-to-head clinical trials have demonstrated improved efficacy with second-generation (ie, afatinib, dacomitinib) and third-generation (ie, osimertinib) TKIs compared with the first-generation TKIs (eg, erlotinib, gefitinib), acquired resistance has been inevitable, regardless of which agent has been chosen as first-line therapy. Thus, the potential availability of subsequent treatment options is an important consideration. Recent data have demonstrated that osimertinib confers an overall survival benefit compared with first-generation EGFR TKIs, and dacomitinib has shown an overall survival benefit compared with gefitinib in an exploratory analysis. However, the relative benefits of different sequential EGFR-TKI regimens, especially those involving second- and third-generation agents, have remained uncertain and require prospective evaluation. Few such data currently exist to inform treatment choices. In the present review, we examined the pharmacologic characteristics and current clinical data for EGFR TKIs, including emerging information on the molecular mechanisms of resistance across the different generations of TKIs. Given the uncertainties regarding the optimal treatment choice, we have focused on the factors that might help determine the treatment decisions, such as efficacy and safety in patient subgroups. We also discussed the emerging real-world data, which have provided some insights into the benefits of sequential regimens in everyday clinical practice.
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Affiliation(s)
- Riyaz Shah
- Kent Oncology Centre, Maidstone Hospital, Kent, UK.
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23
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Zhu VW, Klempner SJ, Ou SHI. Receptor Tyrosine Kinase Fusions as an Actionable Resistance Mechanism to EGFR TKIs in EGFR-Mutant Non-Small-Cell Lung Cancer. Trends Cancer 2019; 5:677-692. [DOI: 10.1016/j.trecan.2019.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 09/14/2019] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
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24
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Del Re M, Petrini I, Mazzoni F, Valleggi S, Gianfilippo G, Pozzessere D, Chella A, Crucitta S, Rofi E, Restante G, Miccoli M, Garassino MC, Danesi R. Incidence of T790M in Patients With NSCLC Progressed to Gefitinib, Erlotinib, and Afatinib: A Study on Circulating Cell-free DNA. Clin Lung Cancer 2019; 21:232-237. [PMID: 31735523 DOI: 10.1016/j.cllc.2019.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/02/2019] [Accepted: 10/02/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Insights into the mechanism of resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) could provide important information for further patient management, including the choice of second-line treatment. The EGFR T790M mutation is the most common mechanism of resistance to first- and second-generation EGFR TKIs. Owing to its biologic relevance in the response of non-small-cell lung cancer (NSCLC) to the selective pressure of treatment, the present study investigated whether the occurrence of T790M at progression differed among patients receiving gefitinib, erlotinib, or afatinib. PATIENTS AND METHODS The present retrospective study included patients with NSCLC with an EGFR activating mutation, who had received gefitinib, erlotinib, or afatinib as first-line treatment. Plasma samples for the analysis of cell-free DNA were taken at disease progression and analyzed using a digital droplet polymerase chain reaction EGFR mutation assay. RESULTS A total of 83 patients were enrolled; 42 had received gefitinib or erlotinib and 41afatinib. The patient characteristics were comparable across the 2 groups. The median time to progression (TTP) was 14.4 months for the gefitinib and erlotinib group and 10.2 months for the afatinib group (P = .09). Of the 83 patients, 47 (56.6%) were positive for the T790M in plasma. A greater incidence of T790M was observed in patients with progression during gefitinib or erlotinib therapy compared with patients treated with afatinib (33 [79%] vs. 14 [34%], respectively; odds ratio, 7.1; 95% confidence interval, 2.7-18.5; P = .0001). CONCLUSIONS Although gefitinib, erlotinib, and afatinib showed a comparable TTP in patients receiving first-line therapy, the incidence of T790M differed among them, as demonstrated by the present study, which could have implications for the choice of second-line treatment.
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Affiliation(s)
- Marzia Del Re
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Iacopo Petrini
- Unit of Pneumology, Azienda Ospedaliero-Universitaria Pisana and Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Francesca Mazzoni
- Unit of Medical Oncology, Department of Oncology, University Hospital of Firenze, Firenze, Italy
| | - Simona Valleggi
- Unit of Pneumology, Azienda Ospedaliero-Universitaria Pisana and Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Giulia Gianfilippo
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Daniele Pozzessere
- Unit of Medical Oncology, Department of Oncology, Hospital of Prato, Prato, Italy
| | - Antonio Chella
- Unit of Pneumology, Azienda Ospedaliero-Universitaria Pisana and Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Stefania Crucitta
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eleonora Rofi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuliana Restante
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Marina Chiara Garassino
- Thoraco-pulmonary Medical Oncology Unit, Medical Oncology and Hematology Department, National Tumor Institute, IRCCS, Milan, Italy
| | - Romano Danesi
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
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