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Poei D, Ali S, Ye S, Hsu R. ALK inhibitors in cancer: mechanisms of resistance and therapeutic management strategies. CANCER DRUG RESISTANCE (ALHAMBRA, CALIF.) 2024; 7:20. [PMID: 38835344 PMCID: PMC11149099 DOI: 10.20517/cdr.2024.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/18/2024] [Accepted: 05/08/2024] [Indexed: 06/06/2024]
Abstract
Anaplastic lymphoma kinase (ALK) gene rearrangements have been identified as potent oncogenic drivers in several malignancies, including non-small cell lung cancer (NSCLC). The discovery of ALK inhibition using a tyrosine kinase inhibitor (TKI) has dramatically improved the outcomes of patients with ALK-mutated NSCLC. However, the emergence of intrinsic and acquired resistance inevitably occurs with ALK TKI use. This review describes the molecular mechanisms of ALK TKI resistance and discusses management strategies to overcome therapeutic resistance.
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Affiliation(s)
- Darin Poei
- Department of Internal Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Sana Ali
- Division of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
| | - Shirley Ye
- Department of Internal Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Robert Hsu
- Division of Medical Oncology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
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Bailey H, Lee A, Eccles L, Yuan Y, Burlison H, Forshaw C, Varol N. Treatment patterns and outcomes of patients with metastatic non-small cell lung cancer in five European countries: a real-world evidence survey. BMC Cancer 2023; 23:603. [PMID: 37386452 DOI: 10.1186/s12885-023-11074-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/15/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND The landscape of non-small cell lung cancer (NSCLC) therapy is rapidly changing. This analysis aimed to understand patient characteristics, diagnosis and treatment patterns in patients with metastatic NSCLC (mNSCLC) without EGFR and ALK mutations across five European countries. METHODS Data were drawn from the Adelphi NSCLC Disease Specific Programme™, a point-in-time survey of oncologists/pulmonologists and their consulting patients in France, Germany, Italy, Spain and UK. Physicians completed record forms (RFs) for the next six consecutive consulting patients with advanced NSCLC, who then voluntarily completed questionnaires. As an oversample, physicians provided a further ten RFs specifically for patients with EGFR-wild-type mNSCLC: five patients diagnosed before March 2020 (pre-SARS-CoV-2 [COVID-19]) and five patients diagnosed from March 2020 (during COVID-19). Only EGFR-wild-type/ALK-wild-type patients were included for analysis. RESULTS Mean (standard deviation [SD]) age for 1073 patients with EGFR-wild-type/ALK-wild-type mNSCLC was 66.2 (8.9) years, 65.2% were male and 63.7% had adenocarcinoma. Level of PD-L1 expression at advanced diagnosis was < 1% for 23.1% of patients, 1-49% for 40.9% and ≥ 50% for 36.0%. Most common first-line (1L) advanced treatment was chemotherapy only (36.9%), immunotherapy monotherapy (30.5%) or immunotherapy + chemotherapy (27.6%). Of 158 patients who had progressed beyond 1L therapy, the mean (SD) time-to-treatment discontinuation was 5.1 (4.3) months; 75.9% of whom completed their 1L treatment as intended. A complete response was achieved by 6.7% and a partial response by 69.2% of patients. Of 38 patients who discontinued 1L treatment early, disease progression was reported for 73.7%. Quality of life (QoL) reported by patients was generally lower than normative reference values. Of 2373 oversample patients, physicians reported management changes for 34.7% due to COVID-19, ranging from 19.6% in Germany to 79.7% in the UK. Immunotherapy was prescribed as 1L NSCLC treatment during COVID-19 for 64.2% (n = 786) of patients and pre-COVID-19, for 47.8% (n = 549). CONCLUSIONS Real-world treatment patterns suggest that chemotherapy use remains high despite guidelines recommending immunotherapy-based 1L treatment for mNSCLC. QoL reported by patients was generally lower than population reference values. Not implying causality, 1L immunotherapy use was higher during COVID-19 than pre-COVID-19, and the UK saw the biggest impact to patient management due to COVID-19.
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Affiliation(s)
- Hollie Bailey
- Adelphi Real World, Adelphi Mill, Grimshaw Lane, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
| | - Adam Lee
- Bristol Myers Squibb, Uxbridge, UK
| | | | - Yong Yuan
- Bristol Myers Squibb, Princeton, NJ, USA
| | - Helen Burlison
- Adelphi Real World, Adelphi Mill, Grimshaw Lane, Bollington, Macclesfield, Cheshire, SK10 5JB, UK
| | - Cameron Forshaw
- Adelphi Real World, Adelphi Mill, Grimshaw Lane, Bollington, Macclesfield, Cheshire, SK10 5JB, UK.
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Zhang M, Chen R, Zheng S, Wang Z. Acquired crizotinib-resistant pulmonary adenocarcinoma and subsequent primary gallbladder cancer: A case report. Medicine (Baltimore) 2023; 102:e33162. [PMID: 36930086 PMCID: PMC10019204 DOI: 10.1097/md.0000000000033162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/13/2023] [Indexed: 03/18/2023] Open
Abstract
RATIONALE Proto-oncogene-oriented targeted therapy has limited benefits in elderly patients with multiple primary tumors. PATIENT CONCERNS A woman with anaplastic lymphoma kinase-positive lung adenocarcinoma developed acquired resistance after 3 years of targeted therapy with crizotinib. DIAGNOSES Diagnosis of unexpected subsequent primary gallbladder tumor. INTERVENTIONS Lenvatinib was administered therapeutically. Meanwhile, next-generation sequencing results before and after crizotinib treatment were analyzed by comparing the tumor-driving mutation genes with bioinformatics methods. OUTCOMES The patient died of ascites and liver failure. Furthermore, bypass activation was found to be the main reason for acquired drug resistance for this patient, and the abnormal expression of tumor suppressor genes and senescence-related genes was the likely cause of the second primary tumor. LESSONS A bioinformatic comparison of pre- and post-treatment sequencing in elderly oncology patients is of interest. CONCLUSIONS For diagnosing, precision bioinformatics analysis and repeat biopsy are equally valuable. For therapy, potential therapy such as p53 gene replacement therapy and CAR-T therapy need to be practiced for senescence-related conditions.
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Affiliation(s)
- Min Zhang
- The First Clinical Medical College, Zhejiang Chinese Medicine University, HangZhou, China
| | - Ruilin Chen
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Suqun Zheng
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou, China
| | - Zhen Wang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Zhejiang Chinese Medicine University, Hangzhou, China
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Qiu YF, Song LH, Jiang GL, Zhang Z, Liu XY, Wang G. Hallmarks of Anaplastic Lymphoma Kinase Inhibitors with Its Quick Emergence of Drug Resistance. PHARMACEUTICAL FRONTS 2022. [DOI: 10.1055/s-0042-1758542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Anaplastic lymphoma kinase (ALK) is one of the most popular targets for anticancer therapies. In the past decade, the use of anaplastic lymphoma tyrosine kinase inhibitors (ALK-TKIs), including crizotinib and ceritinib, has been a reliable and standard options for patients with lung cancer, particularly for patients with nonsmall cell lung carcinoma. ALK-targeted therapies initially benefit the patients, yet, resistance eventually occurs. Therefore, resistance mechanisms of ALK-TKIs and the solutions have become a formidable challenge in the development of ALK inhibitors. In this review, based on the knowledge of reported ALK inhibitors, we illustrated the crystal structures of ALK, summarized the resistance mechanisms of ALK-targeted drugs, and proposed potential therapeutic strategies to prevent or overcome the resistance.
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Affiliation(s)
- Yong-Fu Qiu
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry, Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, People's Republic of China
| | - Lian-Hua Song
- Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, People's Republic of China
| | - Gang-Long Jiang
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry, Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, People's Republic of China
| | - Zhen Zhang
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry, Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, People's Republic of China
- School of Chemistry and Chemical Engineering, Shanghai University of Engineering Science, Shanghai, People's Republic of China
| | - Xu-Yan Liu
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry, Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, People's Republic of China
| | - Guan Wang
- Novel Technology Center of Pharmaceutical Chemistry, Shanghai Institute of Pharmaceutical Industry, Co., Ltd., China State Institute of Pharmaceutical Industry, Shanghai, People's Republic of China
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Pasau T, Wauters E, Wauters I, Duplaquet F, Pirard L, Pop-Stanciu C, D’Haene N, Dupont M, Vander Borght T, Rondelet B, Ocak S. Case report: BRAF A598-T599insV mutation as a potential resistance mechanism to alectinib in ALK-rearranged lung adenocarcinoma. Front Oncol 2022; 12:985446. [DOI: 10.3389/fonc.2022.985446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 10/10/2022] [Indexed: 11/09/2022] Open
Abstract
Anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) have improved the prognosis of advanced-stage non-small cell lung cancer (NSCLC) with ALK rearrangement, but resistance mechanisms limit their efficacy. We describe the case of a 63-year-old man with a stage cIVA ALK-rearranged lung adenocarcinoma who developed a BRAF A598-T599insV mutation as a potential resistance mechanism to alectinib, a second-generation ALK TKI. He was treated with an association of BRAF and MEK inhibitors but death occurred two months after treatment initiation in a context of tumor progression and toxicity. Based on this first report of BRAF A598-T599insV mutation occurring in lung cancer, we discuss resistance mechanisms to ALK TKIs, implications of BRAF mutation in NSCLC, and BRAF A598-T599insV mutation in other cancers.
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Repetto M, Crimini E, Ascione L, Boscolo Bielo L, Belli C, Curigliano G. The return of RET GateKeeper mutations? an in-silico exploratory analysis of potential resistance mechanisms to novel RET macrocyclic inhibitor TPX-0046. Invest New Drugs 2022; 40:1133-1136. [PMID: 35612671 DOI: 10.1007/s10637-022-01259-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/16/2022] [Indexed: 12/15/2022]
Abstract
TPX-0046 is designed to overcome resistance to FDA approved RET inhibitors Selpercatinib and Pralsetinib. Early prediction of resistance mechanisms to investigational drugs may facilitate subsequent drug and trial designs. This study aims to predict potential mutations inducing resistance to TPX-0046. We conducted an in-silico analysis of TPX-0046 macrocyclic structure and predicted the binding mode on RET. We used as reference literary examples of resistance mechanisms to other macrocyclic inhibitors (Lorlatinib on ALK/ROS1) to construct RET secondary resistance mutations. We conducted docking simulations to evaluate impact of mutations on TPX-0046 binding. TPX-0046 binding mode on RET appears to not be influenced by Solventfront G810X mutation presence. Bulky Gatekeeper V804X mutations affect predicted TPX-0046 binding mode. Mutations in Beta 7 strand region L881F and xDFG S891L impair TPX-0046 docking. Our findings suggest that development of second generation RET inhibitors focused mainly on Solventfront G810X mutations granting resistance to selective RET inhibitors Selpercatinib and Pralsetinib. If these findings are confirmed by identification of Gatekeeper V804X mutations in patients progressing to TPX-0046, explanation of acquired resistance and loss of benefit will be easier These findings might accelerate development of third generation RET inhibitors, as well as clinical trial design in precision oncology settings.
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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
| | - Liliana Ascione
- 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
| | - Luca Boscolo Bielo
- 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
- Department of Oncology and Hemato-Oncology, University of Milan, 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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Detection of ALK fusion variants by RNA-based NGS and clinical outcome correlation in NSCLC patients treated with ALK-TKI sequences. Eur J Cancer 2022; 174:200-211. [PMID: 36044814 DOI: 10.1016/j.ejca.2022.07.026] [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: 03/28/2022] [Revised: 07/03/2022] [Accepted: 07/24/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Anaplastic lymphoma kinase (ALK) fusions identify a limited subset of non-small cell lung cancer (NSCLC) patients, whose therapeutic approach have been radically changed in recent years. However, diagnostic procedures and clinical-radiological responses to specific targeted therapies remain heterogeneous and intrinsically resistant or poor responder patients exist. METHODS A total of 290 patients with advanced NSCLC defined as ALK+ by immunohistochemistry (IHC) and/or fluorescent in situ hybridisation (FISH) test and treated with single or sequential multiple ALK inhibitors (ALKi) from 2011 to 2017 have been retrospectively retrieved from a multicentre Italian cancer network database. In 55 patients with enough leftover tumour tissue, specimens were analysed with both targeted and customised next generation sequencing panels. Identified fusion variants have been correlated with clinical outcomes. RESULTS Of the 55 patients, 24 received crizotinib as first-line therapy, 1 received ceritinib, while 30 received chemotherapy. Most of the patients (64%) received ALKi in sequence. An ALK fusion variant was identified in 73% of the cases, being V3 variant (E6A20) the most frequent, followed by V1 (E13A20) and more rare ones (e.g. E6A19). In three specimens, four new EML4-ALK fusion breakpoints have been reported. Neither fusion variants nor brain metastases were significantly associated with overall survival (OS), while it was predictably longer in patients receiving a sequence of ALKi. The presence of V1 variant was associated with progression-free survival (PFS) improvement when crizotinib was used (p = 0.0073), while it did not affect cumulative PFS to multiple ALKi. CONCLUSION Outcomes to sequential ALKi administration were not influenced by fusion variants. Nevertheless, in V1+ patients a prolonged clinical benefit was observed. Fusion variant identification by NGS technology may add relevant information about rare chromosomal events that could be potentially correlated to worse outcomes.
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Icard P, Simula L, Fournel L, Leroy K, Lupo A, Damotte D, Charpentier MC, Durdux C, Loi M, Schussler O, Chassagnon G, Coquerel A, Lincet H, De Pauw V, Alifano M. The strategic roles of four enzymes in the interconnection between metabolism and oncogene activation in non-small cell lung cancer: Therapeutic implications. Drug Resist Updat 2022; 63:100852. [PMID: 35849943 DOI: 10.1016/j.drup.2022.100852] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
NSCLC is the leading cause of cancer mortality and represents a major challenge in cancer therapy. Intrinsic and acquired anticancer drug resistance are promoted by hypoxia and HIF-1α. Moreover, chemoresistance is sustained by the activation of key signaling pathways (such as RAS and its well-known downstream targets PI3K/AKT and MAPK) and several mutated oncogenes (including KRAS and EGFR among others). In this review, we highlight how these oncogenic factors are interconnected with cell metabolism (aerobic glycolysis, glutaminolysis and lipid synthesis). Also, we stress the key role of four metabolic enzymes (PFK1, dimeric-PKM2, GLS1 and ACLY), which promote the activation of these oncogenic pathways in a positive feedback loop. These four tenors orchestrating the coordination of metabolism and oncogenic pathways could be key druggable targets for specific inhibition. Since PFK1 appears as the first tenor of this orchestra, its inhibition (and/or that of its main activator PFK2/PFKFB3) could be an efficacious strategy against NSCLC. Citrate is a potent physiologic inhibitor of both PFK1 and PFKFB3, and NSCLC cells seem to maintain a low citrate level to sustain aerobic glycolysis and the PFK1/PI3K/EGFR axis. Awaiting the development of specific non-toxic inhibitors of PFK1 and PFK2/PFKFB3, we propose to test strategies increasing citrate levels in NSCLC tumors to disrupt this interconnection. This could be attempted by evaluating inhibitors of the citrate-consuming enzyme ACLY and/or by direct administration of citrate at high doses. In preclinical models, this "citrate strategy" efficiently inhibits PFK1/PFK2, HIF-1α, and IGFR/PI3K/AKT axes. It also blocks tumor growth in RAS-driven lung cancer models, reversing dedifferentiation, promoting T lymphocytes tumor infiltration, and increasing sensitivity to cytotoxic drugs.
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Affiliation(s)
- Philippe Icard
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, Unité de recherche BioTICLA INSERM U1086, 14000 Caen, France.
| | - Luca Simula
- Department of Infection, Immunity and Inflammation, Cochin Institute, INSERM U1016, CNRS UMR8104, Paris University, Paris 75014, France
| | - Ludovic Fournel
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM UMR-S 1124, Cellular Homeostasis and Cancer, University of Paris, Paris, France
| | - Karen Leroy
- Department of Genomic Medicine and Cancers, Georges Pompidou European Hospital, APHP, Paris, France
| | - Audrey Lupo
- Pathology Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
| | - Diane Damotte
- Pathology Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
| | | | - Catherine Durdux
- Radiation Oncology Department, Georges Pompidou European Hospital, APHP, Paris, France
| | - Mauro Loi
- Radiotherapy Department, University of Florence, Florence, Italy
| | - Olivier Schussler
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France
| | | | - Antoine Coquerel
- INSERM U1075, COMETE " Mobilités: Attention, Orientation, Chronobiologie", Université Caen, France
| | - Hubert Lincet
- ISPB, Faculté de Pharmacie, Lyon, France, Université Lyon 1, Lyon, France; INSERM U1052, CNRS UMR5286, Cancer Research Center of Lyon (CRCL), France
| | - Vincent De Pauw
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France
| | - Marco Alifano
- Thoracic Surgery Department, Paris Center University Hospitals, AP-HP, Paris, France; INSERM U1138, Integrative Cancer Immunology, University of Paris, 75006 Paris, France
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Huang J, Zhang SL, Zhou C, Huang W, Luo P, Chen HJ, Yang JJ. Genomic and transcriptomic analysis of neuroendocrine transformation in ALK-rearranged lung adenocarcinoma after treatments with sequential ALK inhibitors: a brief report. JTO Clin Res Rep 2022; 3:100338. [PMID: 35677682 PMCID: PMC9168149 DOI: 10.1016/j.jtocrr.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Neuroendocrine (NE) transformation has been reported in patients with ALK-rearranged NSCLC after ALK inhibition, but unlike EGFR-mutant NSCLC, the exact mechanism of NE transformation in ALK-rearranged NSCLC is poorly studied. Methods We collected the matched pre- and post-transformation samples from a patient with ALK-rearranged lung adenocarcinoma (LUAD) and performed targeted panel sequencing, whole exome sequencing, and bulk RNA sequencing. Results Multiple mutations were shared between the pretransformation and post-transformation samples. Neither RB1 nor TP53 mutation was detected, but CDKN2A deletion and CDK4 amplification were found instead. Mismatch repair-associated mutational signature was significantly enriched after transformation. Genes associated with Notch signaling and PI3K/AKT pathway were significantly up-regulated, whereas genes related to lymphocyte activation and NF-kB signaling were down-regulated. Signatures relating to homologous recombination, mismatch repair, and Notch signaling pathways were enriched, which were further validated in The Cancer Genome Atlas cohorts. Macrophages M2 were found to have prominently higher abundance in the tumor immune microenvironment after NE transformation. Conclusions The mechanism of NE transformation in ALK-rearranged LUAD may be different from that in EGFR-mutant LUAD.
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Affiliation(s)
- Jie Huang
- Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Shi-Ling Zhang
- Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People’s Republic of China
| | - Chaozheng Zhou
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
- The First Clinical Medical School, Southern Medical University, Guangzhou, People’s Republic of China
| | - Weiye Huang
- Department of pathology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Peng Luo
- Department of Oncology, Zhujiang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Hua-Jun Chen
- Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Jin-Ji Yang
- Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
- Corresponding author. Address for correspondence: Jin-Ji Yang, MD, Guangdong Lung Cancer Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan 2nd Road, Guangzhou 510080, People’s Republic of China.
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Sun S, Pithavala YK, Martini J, Chen J. Evaluation of Lorlatinib Cerebrospinal Fluid Concentrations in Relation to Target Concentrations for ALK Inhibition. J Clin Pharmacol 2022; 62:1170-1176. [PMID: 35373356 PMCID: PMC9542378 DOI: 10.1002/jcph.2056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/30/2022] [Indexed: 12/02/2022]
Abstract
Lorlatinib is a third‐generation, brain‐penetrant anaplastic lymphoma kinase (ALK) and c‐ros oncogene 1 (ROS1) tyrosine kinase inhibitor (TKI) with robust intracranial activity in patients with ALK‐ or ROS1‐positive non‐small cell lung cancer (NSCLC). Data from the ongoing open‐label, single‐arm, multicenter, phase‐1/2 study of lorlatinib in patients with metastatic ALK‐ or ROS1‐positive NSCLC were used to further investigate the potential brain penetration of lorlatinib. Patients received escalating lorlatinib doses (10–200 mg once daily or 35–100 mg twice daily) or the approved dosing (100 mg daily). Plasma was collected from all patients, and cerebrospinal fluid (CSF) was collected at baseline and during the study from 5 patients with suspected or confirmed leptomeningeal carcinomatosis or carcinomatous meningitis. For those 5 patients, lorlatinib concentrations ranged from 2.64 to 125 ng/mL in the CSF and from 12.7 to 457 ng/mL in the plasma; free plasma concentrations ranged from 4.318 to 155.385 ng/mL. The CSF/free plasma ratio was 0.77 (R2 = 0.96 and P < .001). Using a post‐hoc population pharmacokinetic model, the average steady‐state unbound plasma concentration of lorlatinib was derived and the CSF concentration was estimated for all patients. Known minimum efficacy concentrations (Ceff) for wild‐type and mutated (L1196M and G1202R) ALK were used to derive central nervous system (CNS) Ceff. Estimated CNS concentrations exceeded the derived CNS Ceff values in all patients for wild‐type ALK and the ALK L1196M mutation, and in 35.8% of patients for the ALK G1202R mutation. Projected lorlatinib CNS concentrations were consistent with the high intracranial response rates reported in clinical trials and provide further evidence of the potent CNS penetration of lorlatinib.
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Affiliation(s)
- Steven Sun
- Skaggs School of Pharmacy and Pharmaceutical Sciences (SSPPS) University of California, San Diego (UCSD) La Jolla CA USA
- Clinical Pharmacology, Oncology Business Unit Pfizer Inc. La Jolla CA USA
| | - Yazdi K. Pithavala
- Clinical Pharmacology, Oncology Business Unit Pfizer Inc. La Jolla CA USA
| | | | - Joseph Chen
- Clinical Pharmacology, Oncology Business Unit Pfizer Inc. La Jolla CA USA
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Hua G, Zhang X, Zhang M, Wang Q, Chen X, Yu R, Bao H, Liu J, Wu X, Shao Y, Liang B, Lu K. Real-world circulating tumor DNA analysis depicts resistance mechanism and clonal evolution in ALK inhibitor-treated lung adenocarcinoma patients. ESMO Open 2022; 7:100337. [PMID: 35123209 PMCID: PMC8818928 DOI: 10.1016/j.esmoop.2021.100337] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/01/2021] [Accepted: 11/15/2021] [Indexed: 12/11/2022] Open
Abstract
Background Sequential treatment with different generations of anaplastic lymphoma kinase (ALK) inhibitors have been widely applied to ALK-positive lung cancer; however, resistance mutations inevitably developed. Further characterization of ALK resistance mutations may provide key guidance to subsequent therapies. Here we explored the emergence of secondary ALK mutations during sequential ALK tyrosine kinase inhibitor (TKI) treatment in a real-world study of Chinese lung adenocarcinoma (ADC) patients. Methods A clinical-genomic database was queried for lung ADC patients with at least one ALK inhibitor treatment and at least one plasma sample collected following ALK inhibitor treatment. Targeted genome profiling was performed with a 139-gene panel in baseline tumor tissue and serial plasma samples of patients. Results A total of 116 patients met inclusion criteria. ALK G1202R was more common in patients with echinoderm microtubule-associated protein-like 4 (EML4)-ALK v3 fusion, whereas ALK L1196M was more common in v1. TP53 mutant patients were significantly associated with harboring multiple ALK resistance mutations (P = 0.03) and v3+/TP53 mutant patients had the highest rate of multiple ALK resistance mutations. The sequential use of ALK TKI led to an increased incidence of concurrent ALK mutations along the lines of therapies. Alectinib had a lower rate (9%) harboring ALK resistance mutation as first-line ALK TKI compared with crizotinib (36%). ALK compound mutations identified included ALK D1203N/L1196M, ALK G1202R/L1196M, and ALK G1202R/F1174C, which may be lorlatinib resistant. Using paired pretreatment and post-treatment samples, we identified several ALK-independent resistance-related genetic alterations, including PTPRD and CNKN2A/B loss, MYC, MYCN and KRAS amplification, and EGFR19del. Conclusions Sequential postprogression plasma profiling revealed that increased lines of ALK inhibitors can accelerate the accumulation of ALK resistance mutations and may lead to treatment-refractory compound ALK mutations. The selection for optimal first-line TKI is very important to achieve a more efficacious long-term strategy and prevent the emergence of on-target resistance, which may provide guidance for clinical decision making. ALK resistance mutations were differentially enriched in the setting of EML4-ALK v1/v3 and TP53 status. Serial liquid biopsies NGS depicted accumulation of multiple ALK secondary mutations during sequential ALK treatments. Several lorlatinib-resistant ALK compound mutations and ALK-independent resistance genetic alterations were identified.
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Affiliation(s)
- G Hua
- Department of Cardiothoracic Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China; Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - X Zhang
- Respiratory and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - M Zhang
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Q Wang
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - X Chen
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China
| | - R Yu
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China
| | - H Bao
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China
| | - J Liu
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China
| | - X Wu
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China
| | - Y Shao
- Geneseeq Research Institute, Nanjing Geneseeq Technology Inc., Nanjing, China; School of Public Health, Nanjing Medical University, Nanjing, China
| | - B Liang
- Department of Respiratory Medicine, Foshan Hospital of Traditional Chinese Medicine Affiliated to Guangzhou University of Traditional Chinese Medicine, Foshan, China.
| | - K Lu
- Department of Oncology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
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Minari R, Valentini S, Madeddu D, Cavazzoni A, La Monica S, Lagrasta C, Bertorelli R, De Sanctis V, Fassan P, Azzoni C, Bottarelli L, Frati C, Gnetti L, Facchinetti F, Petronini P, Alfieri R, Romanel A, Tiseo M. YES1 and MYC amplifications as synergistic resistance mechanisms to different generation ALK-TKIs in advanced NSCLC: brief report of clinical and preclinical proofs. JTO Clin Res Rep 2022; 3:100278. [PMID: 35199053 PMCID: PMC8851257 DOI: 10.1016/j.jtocrr.2022.100278] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction ALK tyrosine kinase inhibitors (TKIs) are the standard treatment for advanced ALK-positive NSCLC. Nevertheless, drug resistance inevitably occurs. Here, we report a case of a patient with metastatic ALK-positive lung adenocarcinoma with an impressive resistance to sequential treatment with ALK TKIs mediated by YES1 and MYC amplification in a contest of epithelial-to-mesenchymal transition and high progressive chromosomal instability. Methods The patient received, after chemotherapy and 7 months of crizotinib, brigatinib and lorlatinib with no clinical benefit to both treatments. A study of resistance mechanisms was performed with whole exome sequencing on different biological samples; primary cell lines were established from pleural effusion after lorlatinib progression. Results At whole exome sequencing analysis, YES1 and MYC amplifications were observed both in the pericardial biopsy and the pleural effusion samples collected at brigatinib and lorlatinib progression, respectively. Increasing chromosomal instability from diagnostic biopsy to pleural effusion was also observed. The addition of dasatinib to brigatinib or lorlatinib restored the sensitivity in primary cell lines; data were confirmed also in H3122_ALK-positive model overexpressing both YES1 and MYC. Conclusions In conclusion, YES1 and MYC amplifications are candidates to justify a rapid acquired resistance to crizotinib entailing primary brigatinib and lorlatinib resistance. In this context, a combination strategy of ALK TKI with dasatinib could be effective to overcome a rapid resistance.
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