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Liu QG, Wu J, Wang ZY, Chen BB, Du YF, Niu JB, Song J, Zhang SY. ALK-based dual inhibitors: Focus on recent development for non-small cell lung cancer therapy. Eur J Med Chem 2025; 291:117646. [PMID: 40262298 DOI: 10.1016/j.ejmech.2025.117646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 04/11/2025] [Accepted: 04/15/2025] [Indexed: 04/24/2025]
Abstract
As a prevalent oncogenic driver gene in non-small cell lung cancer (NSCLC), ALK represents a crucial and efficacious therapeutic target. To date, seven ALK inhibitors have been approved for ALK fusion-positive NSCLC, with several others undergoing clinical trials. These therapies demonstrate significant efficacy in ALK fusion-positive NSCLC patients. However, acquired resistance mechanisms, including ALK kinase domain mutations, ALK gene amplification, and bypass pathway activation, significantly compromise the efficacy of targeted therapy in ALK fusion-positive NSCLC. Therefore, the discovery of novel ALK inhibitors and the development of related treatment strategies remain critical. Compared to the combination therapy strategy based on ALK inhibitors, dual-target inhibitors (targeting two distinct pathways within a single molecule) may reduce systemic toxicity and mitigate resistance mechanisms in cancer treatment. Notably, recent years have witnessed remarkable progress in dual-target ALK inhibitor development for NSCLC. Consequently, this review aims to summarize the advancements achieved through dual ALK-based inhibitors in NSCLC therapy, analyze their rational design and structure-activity relationships, and provide perspectives for overcoming resistance through next-generation inhibitors and innovative therapeutic approaches.
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Affiliation(s)
- Qiu-Ge Liu
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Ji Wu
- School of Pharmaceutical Sciences, Institute of Drug Discovery & Development, Key Laboratory of Advanced Drug Preparation Technologies (Ministry of Education), Zhengzhou University, Zhengzhou, 450001, China
| | - Zi-Yue Wang
- School of Pharmaceutical Sciences, Institute of Drug Discovery & Development, Key Laboratory of Advanced Drug Preparation Technologies (Ministry of Education), Zhengzhou University, Zhengzhou, 450001, China
| | - Bing-Bing Chen
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Yi-Fei Du
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China
| | - Jin-Bo Niu
- The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jian Song
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China.
| | - Sai-Yang Zhang
- School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, 450001, China.
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2
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Chen JF, Guo SJ, He B, Zheng W, Jiang WJ, Yuan Z, Xiang Y, Peng C, Xiong W, Shi JY. Advances of dual inhibitors based on ALK for the treatment of cancer. Bioorg Chem 2025; 159:108417. [PMID: 40168884 DOI: 10.1016/j.bioorg.2025.108417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2025] [Revised: 03/17/2025] [Accepted: 03/25/2025] [Indexed: 04/03/2025]
Abstract
Anaplastic lymphoma kinase (ALK), which encodes a highly conserved receptor tyrosine kinase (RTK), is important for the development and progression of many tumors, especially non-small cell lung cancer (NSCLC). Currently, third-generation ALK inhibitors are used to treat ALK-mutant NSCLC, but the rapid emergence of resistance during treatment greatly limits their efficacy in clinic. In comparison to single-target inhibitors, ALK dual inhibitors offer the benefits of reducing the emergence of drug resistance, improving treatment efficacy, and optimizing pharmacokinetic features due to the synergistic function of ALK and other associated targets involved in tumor progression. Therefore, we outline the development of ALK dual inhibitors, highlight their design approaches and structure-activity relationship (SAR), and offer insights into new challenges and potential future directions in this area.
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Affiliation(s)
- Jin-Feng Chen
- Sichuan Provincial Key Laboratory for Human Disease Gene Study, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu 611731. China; Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Shu-Jin Guo
- Department of Health Management Center, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Bin He
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Wei Zheng
- Department of Integrative Medicine, Xinqiao Hospital, Army Medical University, Chongqing 400037, China
| | - Wen-Jie Jiang
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Zhuo Yuan
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China
| | - Yu Xiang
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Cheng Peng
- School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, China; State Key Laboratory of Southwestern Chinese Medicine Resources, School of Medical Technology, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Wei Xiong
- Department of urology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, Chengdu 610072, China.
| | - Jian-You Shi
- Department of Pharmacy, Personalized Drug Therapy Key Laboratory of Sichuan Province, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, China.
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3
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Voena C, Ambrogio C, Iannelli F, Chiarle R. ALK in cancer: from function to therapeutic targeting. Nat Rev Cancer 2025; 25:359-378. [PMID: 40055571 DOI: 10.1038/s41568-025-00797-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2025] [Indexed: 05/01/2025]
Abstract
Anaplastic lymphoma kinase (ALK) is a receptor tyrosine kinase (RTK) that acts as an oncogenic driver in solid and haematological malignancies in both children and adults. Although ALK-expressing (ALK+) tumours show strong initial responses to the series of ALK inhibitors currently available, many patients will develop resistance. In this Review, we discuss recent advances in ALK oncogenic signalling, together with existing and promising new modalities to treat ALK-driven tumours, including currently approved ALK-directed therapies, namely tyrosine kinase inhibitors, and novel approaches such as ALK-specific immune therapies. Although ALK inhibitors have changed the management and clinical history of ALK+ tumours, they are still insufficient to cure most of the patients. Therefore, more effort is needed to further improve outcomes and prevent the tumour resistance, recurrence and metastatic spread that many patients with ALK+ tumours experience. Here, we outline how a multipronged approach directed against ALK and other essential pathways that sustain the persistence of ALK+ tumours, together with potent or specific immunotherapies, could achieve this goal. We envision that the lessons learned from treating ALK+ tumours in the clinic could ultimately accelerate the implementation of innovative combination therapies to treat tumours driven by other tyrosine kinases or oncogenes with similar properties.
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Affiliation(s)
- Claudia Voena
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy.
| | - Chiara Ambrogio
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy
| | - Fabio Iannelli
- Division of Hematopathology, IEO European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Chiarle
- Department of Molecular Biotechnology and Health Sciences, Molecular Biotechnology Center, University of Torino, Torino, Italy.
- Division of Hematopathology, IEO European Institute of Oncology IRCCS, Milan, Italy.
- Department of Pathology, Children's Hospital and Harvard Medical School, Boston, MA, USA.
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4
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Xie J, Gao Y, Xu W, Zhu J. Mechanisms of Resistance to ALK Inhibitors and Corresponding Treatment Strategies in Lung Cancer. Int J Gen Med 2025; 18:2151-2171. [PMID: 40259931 PMCID: PMC12010037 DOI: 10.2147/ijgm.s512395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Accepted: 04/02/2025] [Indexed: 04/23/2025] Open
Abstract
Lung cancer continues to be a leading cause of cancer-related mortality and morbidity worldwide. The echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion gene accounts for approximately 3%-5% of gene mutation types. Targeted therapies for ALK mutations have made significant advancements in recent decades, enabling a considerable number of patients to achieve the goal of five-year survival benefits. However, overcoming the drug resistance that arises with current ALK tyrosine kinase inhibitors (TKIs) remain a major challenge in ALK-targeted therapies. In this review, we briefly discuss the primary and secondary mechanisms of resistance to ALK-TKIs, and explore treatment strategies based on progressive resistance models. Meanwhile, novel drugs and combination therapies are being actively researched and developed to address these challenges. The aim is to offer new insights into the mechanisms of resistance and the corresponding treatment strategies to ALK inhibitors.
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Affiliation(s)
- Jiajun Xie
- Department of Respiratory and Critical Care Medicine, Mian yang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, People’s Republic of China
| | - Yinghao Gao
- Department of pulmonology, Mianyang hospital of T.C.M, Mianyang, People’s Republic of China
| | - Weiguo Xu
- Department of Respiratory and Critical Care Medicine, Mian yang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, People’s Republic of China
| | - Jing Zhu
- Department of Respiratory and Critical Care Medicine, Mian yang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang, People’s Republic of China
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5
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Su PL, Furuya N, Asrar A, Rolfo C, Li Z, Carbone DP, He K. Recent advances in therapeutic strategies for non-small cell lung cancer. J Hematol Oncol 2025; 18:35. [PMID: 40140911 PMCID: PMC11948873 DOI: 10.1186/s13045-025-01679-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 02/17/2025] [Indexed: 03/28/2025] Open
Abstract
The development of targeted therapy with small-molecule tyrosine kinase inhibitors and immunotherapy with immune checkpoints inhibitors has ushered in the era of precision medicine in treating lung cancer, which remains the leading cause of cancer-related deaths worldwide. Both targeted therapy and immunotherapy have significantly improved the survival of patients with metastatic non-small-cell lung cancer (NSCLC). Additionally, recent groundbreaking studies have demonstrated their efficacy in both the perioperative setting and following concurrent chemoradiotherapy in early-stage NSCLC. Despite significant advancements in first-line treatment options, disease progression remains inevitable for most patients with advanced NSCLC, necessitating the exploration and optimization of subsequent therapeutic strategies. Emerging novel agents are expanding treatment options in the first-line setting and beyond. Recently, emerging bispecific antibodies have shown enhanced efficacy. For instance, amivantamab has been approved as a treatment for epidermal growth factor receptor (EGFR)-mutant NSCLC, including those with EGFR exon 20 insertion mutations. Additionally, antibody-drug conjugates (ADCs), including HER2-targeting trastuzumab deruxtecan, TROP2-targeting ADCs, HER3-targeting patritumab deruxtecan, and MET-targeting telisotuzumab vedotin, have demonstrated promising outcomes in several clinical trials. This review summarizes the recent advancements and challenges associated with the evolving NSCLC therapeutic landscape.
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Affiliation(s)
- Po-Lan Su
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Rd., North District, Tainan, 704, Taiwan
| | - Naoki Furuya
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Division of Respiratory Medicine, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Alahmadi Asrar
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Christian Rolfo
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Zihai Li
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - David P Carbone
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA
| | - Kai He
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, College of Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Pelotonia Institute for Immuno-Oncology, The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute, The Ohio State University, Columbus, OH, USA.
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6
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Jimenez Munarriz BE, Khan S, Li Y, Ghazali N, Liu G. Update advances in anaplastic lymphoma kinase-positive non-small cell lung cancer treatment. Cancer 2025; 131 Suppl 1:e35786. [PMID: 40172161 DOI: 10.1002/cncr.35786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Revised: 09/24/2024] [Accepted: 10/09/2024] [Indexed: 04/04/2025]
Abstract
Lung cancer is the leading cause of cancer death worldwide. However, since the discovery and development of targeted therapies and immune checkpoint inhibitors, it has been a dramatically improved in survival outcomes and quality of life. Anaplastic lymphoma kinase (ALK) rearrangements occur in approximately 5% of patients with advanced non-small cell lung cancer (NSCLC), and the introduction of ALK tyrosine kinase inhibitors (TKIs) has changed the treatment paradigm. Although head-to-head randomized controlled trials for late generation inhibitors are lacking, the authors will review the current available options, treatments efficacy, safety profiles, ALK mechanisms of resistance, as well as new promising treatments in this field.
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Affiliation(s)
- Beatriz E Jimenez Munarriz
- Medical Oncology Department, University Health Network-Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Sam Khan
- Medical Oncology Department, University Health Network-Princess Margaret Cancer Center, Toronto, Ontario, Canada
- Division of Medical oncology, Leicester Cancer Research, University of Leicester, Leicester, UK
| | - Yuchen Li
- Medical Oncology Department, University Health Network-Princess Margaret Cancer Center, Toronto, Ontario, Canada
- Department of Oncology, Queen's School of Medicine, Kingston, Ontario, Canada
- Cancer Centre of Southeastern Ontario, Kingston, Ontario, Canada
| | - Nadia Ghazali
- Medical Oncology Department, University Health Network-Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - Geoffrey Liu
- Medical Oncology Department, University Health Network-Princess Margaret Cancer Center, Toronto, Ontario, Canada
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7
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Schneider JL, Kurmi K, Dai Y, Dhiman I, Joshi S, Gassaway BM, Johnson CW, Jones N, Li Z, Joschko CP, Fujino T, Paulo JA, Yoda S, Baquer G, Ruiz D, Stopka SA, Kelley L, Do A, Mino-Kenudson M, Sequist LV, Lin JJ, Agar NYR, Gygi SP, Haigis KM, Hata AN, Haigis MC. GUK1 activation is a metabolic liability in lung cancer. Cell 2025; 188:1248-1264.e23. [PMID: 39919745 PMCID: PMC12148050 DOI: 10.1016/j.cell.2025.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/14/2024] [Accepted: 01/15/2025] [Indexed: 02/09/2025]
Abstract
Little is known about metabolic vulnerabilities in oncogene-driven lung cancer. Here, we perform a phosphoproteomic screen in anaplastic lymphoma kinase (ALK)-rearranged ("ALK+") patient-derived cell lines and identify guanylate kinase 1 (GUK1), a guanosine diphosphate (GDP)-synthesizing enzyme, as a target of ALK signaling in lung cancer. We demonstrate that ALK binds to and phosphorylates GUK1 at tyrosine 74 (Y74), resulting in increased GDP biosynthesis. Spatial imaging of ALK+ patient tumor specimens shows enhanced phosphorylation of GUK1 that significantly correlates with guanine nucleotides in situ. Abrogation of GUK1 phosphorylation reduces intracellular GDP and guanosine triphosphate (GTP) pools and decreases mitogen-activated protein kinase (MAPK) signaling and Ras-GTP loading. A GUK1 variant that cannot be phosphorylated (Y74F) decreases tumor proliferation in vitro and in vivo. Beyond ALK, other oncogenic fusion proteins in lung cancer also regulate GUK1 phosphorylation. These studies may pave the way for the development of new therapeutic approaches by exploiting metabolic dependencies in oncogene-driven lung cancers.
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Affiliation(s)
- Jaime L Schneider
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA; Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA.
| | - Kiran Kurmi
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Yutong Dai
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA; Department of Chemistry and Chemical Biology, Harvard University, Boston, MA, USA
| | - Ishita Dhiman
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Shakchhi Joshi
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Brandon M Gassaway
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | | | - Nicole Jones
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Zongyu Li
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Christian P Joschko
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Toshio Fujino
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Joao A Paulo
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Satoshi Yoda
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Gerard Baquer
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniela Ruiz
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sylwia A Stopka
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Liam Kelley
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Andrew Do
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lecia V Sequist
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Jessica J Lin
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Nathalie Y R Agar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven P Gygi
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA
| | - Kevin M Haigis
- Department of Cancer Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Aaron N Hata
- Massachusetts General Hospital Cancer Center and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcia C Haigis
- Department of Cell Biology, Blavatnik Institute, Harvard Medical School, Boston, MA, USA.
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8
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Lin CW, Huang KY, Lin CH, Hou MH, Lin SH. Diverse clinical outcomes for the EGFR‑mutated and ALK‑rearranged advanced non‑squamous non‑small cell lung cancer. Oncol Lett 2025; 29:125. [PMID: 39807107 PMCID: PMC11726284 DOI: 10.3892/ol.2025.14872] [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: 05/27/2024] [Accepted: 10/11/2024] [Indexed: 01/16/2025] Open
Abstract
EGFR and ALK are key driver mutations in non-small cell lung cancer (NSCLC). Tyrosine kinase inhibitors are recommended as the first-line treatment for advanced NSCLC with driving oncogenes because they have fewer side effects and provide better disease control than chemotherapy. The present retrospective analysis aimed to investigate how altered driver genes impact cancer outcomes and clinical presentation. A total of 628 patients with advanced-stage NSCLC and documented EGFR and ALK mutations were enrolled at Changhua Christian Hospital in Taiwan between August 2011 and January 2021. EGFR mutations were identified by PCR. ALK rearrangements were identified by immunostaining. Patients without EGFR or ALK mutations were labeled as wild-type (WT). EGFR mutation was detected in 446 (71.02%) patients, ALK rearrangement in 36 (5.73%) patients and WT in 146 (23.25%) patients. EGFR mutations resulted in higher frequency of lung, brain and multiple extrapulmonary metastases than ALK rearrangement. The ALK group exhibited the longest median overall survival (OS), followed by EGFR and WT groups (ALK: 51.60±13.32, EGFR: 24.03±1.22 and WT: 19.63±2.43 months, respectively; P=0.011). In patients with brain metastases, ALK group had a longer median OS than the EGFR group. Because there were few recruited patients with ALK rearrangement, the results were not significant. According to the results of Cox regression model analysis, driver mutations with EGFR and ALK, lower smoking pack-years, younger age, better performance status, no pleural metastasis and fewer extrapulmonary metastases were key prognostic factors. In conclusion, diverse clinical outcomes are driven by different driver mutations. EGFR mutation leads to more extrapulmonary metastases. Median OS was superior in ALK-rearranged NSCLC than EGFR-mutated NSCLC regardless of brain metastases.
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Affiliation(s)
- Chun-Wei Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan, ROC
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan, ROC
- Department of Doctoral Program in Medical Biotechnology, National Chung Hsing University, Taichung 40227, Taiwan, ROC
| | - Kuo-Yang Huang
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan, ROC
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan, ROC
| | - Ching-Hsiung Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan, ROC
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan, ROC
| | - Ming-Hon Hou
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan, ROC
- Department of Doctoral Program in Medical Biotechnology, National Chung Hsing University, Taichung 40227, Taiwan, ROC
- Department of Life Sciences, National Chung Hsing University, Taichung 40227, Taiwan, ROC
| | - Sheng-Hao Lin
- Division of Chest Medicine, Department of Internal Medicine, Changhua Christian Hospital, Changhua 50006, Taiwan, ROC
- Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung 40227, Taiwan, ROC
- Department of Doctoral Program in Medical Biotechnology, National Chung Hsing University, Taichung 40227, Taiwan, ROC
- Department of Post-baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 40227, Taiwan, ROC
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Zhang X, Tong J, Wang T, Wang Z, Gu S, Xu L, Hou T, Pan P. In-depth theoretical modeling to explore the mechanism of TPX-0131 overcoming lorlatinib resistance to ALK L1196M/G1202R mutation. Comput Biol Med 2024; 183:109265. [PMID: 39405725 DOI: 10.1016/j.compbiomed.2024.109265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2024] [Revised: 09/19/2024] [Accepted: 10/07/2024] [Indexed: 11/20/2024]
Abstract
A number of anaplastic lymphoma kinase (ALK) inhibitors have been clinically approved, with lorlatinib, particularly as a third-generation drug, demonstrating efficacy against various drug-resistant ALK single mutations. However, continued clinical use of lorlatinib has led to the emergence of ALK double mutations conferring resistance to lorlatinib, notably ALKL1196M/G1202R. TPX-0131 is a potential fourth-generation ALK inhibitor currently under development. TPX-0131 demonstrates a broader spectrum of activity against ALK-resistant mutations, efficiently inhibiting 26 single-point mutations and various double/triple mutations, including solvent front mutations and gatekeeper mutations. In this study, for the first time, a comprehensive elucidation of the molecular mechanisms by which TPX-0131 overcomes lorlatinib resistance to ALKL1196M/G1202R through modeling, MD simulations, free energy calculations, and US simulations. The results indicate that the interactions between lorlatinib and key residues at the hinge region are disturbed by L1196M/G1202R double mutation, leading to the disruption of important hydrogen bonding between Glu1197 and lorlatinib. For TPX-0131, the L1196M/G1202R mutation enhances electrostatic and van der Waals interactions, causing significant conformational changes primarily in the hinge region, G-loop, and β-strands. The tight binding of TPX-0131 to residues Arg1202, Met1199 and Arg1120 contribute significantly to overcoming lorlatinib resistance in ALKL1196M/G1202R mutant. These research results are expected to offer insights into the mechanism of TPX-0131 in treating ALKG1202R/L1196M-induced NSCLC resistance and optimizing of ALK inhibitors.
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Affiliation(s)
- Xing Zhang
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, Zhejiang, PR China; College of Chemistry and Chemical Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China
| | - Jianbo Tong
- College of Chemistry and Chemical Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China.
| | - Tianhao Wang
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, Zhejiang, PR China; College of Chemistry and Chemical Engineering, Shaanxi University of Science and Technology, Xi'an, 710021, PR China
| | - Zhe Wang
- School of Pharmacy, Hangzhou Normal University, Hangzhou, 310058, Zhejiang, PR China
| | - Shukai Gu
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, Zhejiang, PR China
| | - Lei Xu
- Institute of Bioinformatics and Medical Engineering, School of Electrical and Information Engineering, Jiangsu University of Technology, Changzhou, 213001, PR China
| | - Tingjun Hou
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, Zhejiang, PR China.
| | - Peichen Pan
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, 310058, Zhejiang, PR China.
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10
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Attwa MW, Abdelhameed AS, Kadi AA. An ultra-fast green ultra-high-performance liquid chromatography-tandem mass spectrometry method for estimating the in vitro metabolic stability of zotizalkib in human liver microsomes. J Sep Sci 2024; 47:e2400393. [PMID: 39087620 DOI: 10.1002/jssc.202400393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Revised: 07/10/2024] [Accepted: 07/18/2024] [Indexed: 08/02/2024]
Abstract
Zotizalkib (ZTK, TPX-0131) is a fourth-generation highly effective inhibitor of wild-type anaplastic lymphoma kinase (ALK) and ALK-resistant mutations that can penetrate the central nervous system. It exhibited greater potency compared to all five officially approved ALK inhibitors. The aim of this study was to develop a rapid, accurate, eco-friendly, and highly sensitive ultra-high-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) method for measuring the concentration of ZTK in human liver microsomes (HLMs). The validation aspects of the current UHPLC-MS/MS methodology in the HLMs were conducted in accordance with the bioanalytical method validation standards specified by the US Food and Drug Administration. ZTK and encorafenib were separated using an Agilent C8 column (Eclipse Plus) and an isocratic mobile phase. The calibration curve for the developed ZTK exhibited a linear relationship within the concentration range of 1-3000 ng/mL. The results from the Analytical Green-ness Metric Approach program (0.76) suggested that the created method demonstrated a significant degree of environmental sustainability. The in vitro half-life (t1/2) and intrinsic clearance (Clint) of ZTK were determined to be 15.79 min and 51.35 mL/min/kg, respectively that suggests the ZTK exhibits characteristics similar to those of a medication with a high extraction ratio. These approaches are crucial for the progress of novel pharmaceutical development, especially in improving metabolic stability.
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Affiliation(s)
- Mohamed W Attwa
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Ali S Abdelhameed
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Adnan A Kadi
- Department of Pharmaceutical Chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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11
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de Jager VD, Timens W, Bayle A, Botling J, Brcic L, Büttner R, Fernandes MGO, Havel L, Hochmair MJ, Hofman P, Janssens A, Johansson M, van Kempen L, Kern I, Lopez-Rios F, Lüchtenborg M, Machado JC, Mohorcic K, Paz-Ares L, Popat S, Ryška A, Taniere P, Wolf J, Schuuring E, van der Wekken AJ. Developments in predictive biomarker testing and targeted therapy in advanced stage non-small cell lung cancer and their application across European countries. THE LANCET REGIONAL HEALTH. EUROPE 2024; 38:100838. [PMID: 38476742 PMCID: PMC10928289 DOI: 10.1016/j.lanepe.2024.100838] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/16/2023] [Accepted: 01/08/2024] [Indexed: 03/14/2024]
Abstract
In the past two decades, the treatment of metastatic non-small cell lung cancer (NSCLC), has undergone significant changes due to the introduction of targeted therapies and immunotherapy. These advancements have led to the need for predictive molecular tests to identify patients eligible for targeted therapy. This review provides an overview of the development and current application of targeted therapies and predictive biomarker testing in European patients with advanced stage NSCLC. Using data from eleven European countries, we conclude that recommendations for predictive testing are incorporated in national guidelines across Europe, although there are differences in their comprehensiveness. Moreover, the availability of recently EMA-approved targeted therapies varies between European countries. Unfortunately, routine assessment of national/regional molecular testing rates is limited. As a result, it remains uncertain which proportion of patients with metastatic NSCLC in Europe receive adequate predictive biomarker testing. Lastly, Molecular Tumor Boards (MTBs) for discussion of molecular test results are widely implemented, but national guidelines for their composition and functioning are lacking. The establishment of MTB guidelines can provide a framework for interpreting rare or complex mutations, facilitating appropriate treatment decision-making, and ensuring quality control.
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Affiliation(s)
- Vincent D. de Jager
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Wim Timens
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arnaud Bayle
- Oncostat U1018, Inserm, Paris-Saclay University, Gustave Roussy, Villejuif, France
| | - Johan Botling
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy of University of Gothenburg, Gothenburg, Sweden
| | - Luka Brcic
- Diagnostic and Research Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Reinhard Büttner
- Institute of Medical Genetics and Applied Genomics, University of Tuebingen, Tuebingen, Germany
| | | | - Libor Havel
- Charles University and Thomayer Hospital, Prague, Czech Republic
| | - Maximilian J. Hochmair
- Karl Landsteiner Institute of Lung Research and Pulmonary Oncology, Klinik Floridsdorf, Vienna, Austria
- Department of Respiratory and Critical Care Medicine, Klinik Floridsdorf, Vienna Healthcare Group, Vienna, Austria
| | - Paul Hofman
- IHU RespirERA, FHU OncoAge, Nice University Hospital, Côte d’Azur University, Nice, France
| | - Annelies Janssens
- Department of Oncology, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - Mikael Johansson
- Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
| | - Léon van Kempen
- Department of Pathology, University Hospital Antwerp, University of Antwerp, Edegem, Belgium
| | - Izidor Kern
- Laboratory for Cytology and Pathology, University Clinic Golnik, Golnik, Slovenia
| | - Fernando Lopez-Rios
- Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Research Institute Hospital 12 de Octubre (i+12), Ciberonc, Madrid, Spain
| | - Margreet Lüchtenborg
- National Disease Registration Service, NHS England, London, United Kingdom
- Centre for Cancer, Society & Public Health, King’s College London, London, United Kingdom
| | - José Carlos Machado
- Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Faculty of Medicine of the University of Porto, Institute for Research and Innovation in Health (i3S), Porto, Portugal
| | - Katja Mohorcic
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Luis Paz-Ares
- Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, H12O-CNIO Lung Cancer Clinical Research Unit, Research Institute Hospital 12 de Octubre (i+12)/Spanish National Cancer Research Center (CNIO), Ciberonc, Madrid, Spain
| | - Sanjay Popat
- Lung Unit, Royal Marsden NHS Trust, London, United Kingdom
| | - Aleš Ryška
- The Fingerland Department of Pathology, Charles University Medical Faculty and University Hospital, Czech Republic
| | - Phillipe Taniere
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Jürgen Wolf
- Lung Cancer Group Cologne, Department I for Internal Medicine and Center for Integrated Oncology Cologne/Bonn, University Hospital Cologne, Cologne, Germany
| | - Ed Schuuring
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Anthonie J. van der Wekken
- Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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12
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Lee ATM, Ou SHI. Overcoming Central β-Sheet #6 (Cβ6) ALK Mutation (L1256F), TP53 Mutations and Short Forms of EML4-ALK v3/b and v5a/b Splice Variants are the Unmet Need That a Re-Imagined 5th-Generation (5G) ALK TKI Must Deliver. LUNG CANCER (AUCKLAND, N.Z.) 2024; 15:19-27. [PMID: 38433979 PMCID: PMC10908247 DOI: 10.2147/lctt.s446878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 02/01/2024] [Indexed: 03/05/2024]
Abstract
Despite the development and approval of seven anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) spanning over three "generations" since the discovery of ALK fusion positive (ALK+) non-small cell lung cancer (NSCLC), there remains intrinsic and acquired resistances to these approved TKIs. Currently, a fourth-generation (4G) ALK TKI, NVL-655, is being developed to attack some of the unmet needs such as compound resistance mutations in cis. However, EML4-ALK variant 3 and TP53 mutations are intrinsic genomic alterations that negatively modulate efficacy of ALK TKIs. Potentially, in the shifting landscape where lorlatinib should be the first-line ALK TKI of choice based on the CROWN trial, the central β-sheet #6 (Cβ6) mutation ALK L1256F will be the potential acquired resistance mutation to lorlatinib which may be resistant to current ALK TKIs. Here we opine on what additional capacities a putative fifth-generation (5G) ALK TKI will need to possess if it can be achieved in one single molecule. We propose randomized trial schemas targeting some of the intrinsic resistance mechanisms that will lead to approval of a prototypic fifth-generation (5G) ALK TKI and actually be beneficial to ALK+ NSCLC patients rather than just design a positive pivotal superiority trial for the sole purpose of drug approval.
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Affiliation(s)
- Alexandria T M Lee
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA
| | - Sai-Hong Ignatius Ou
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA
- Chao Family Comprehensive Cancer Center, Orange, CA, USA
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13
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Lee ATM, Ou SI. ALESIA 5-Year Update: Alectinib at 600 mg Twice Daily Gives Lorlatinib a Run for Its Money in Asia. LUNG CANCER (AUCKLAND, N.Z.) 2023; 14:71-78. [PMID: 37440867 PMCID: PMC10335304 DOI: 10.2147/lctt.s419395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
Alectinib, a next-generation anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitor (TKI), has demonstrated superior progression-free survival over crizotinib with both 300 mg twice daily (J-ALEX) or 600 mg twice daily (ALEX, ALESIA) dosing in three pivotal clinical trials. Given the similar median PFS achieved in the J-ALEX trial and the Asian subgroup of the ALEX trial, there remains debate about the optimal alectinib dose for Asians. The third pivotal alectinib trial, ALESIA, which was conducted exclusively in Asia to support the registration of alectinib in China, utilized 600 mg alectinib twice daily. The mature PFS was not reached at the initial publication of ALESIA. At ESMO Asia 2022, the 5-year update of ALESIA was presented with an impressive mature investigator-assessed PFS of 41.6 months (95% CI 33.1-58.9), which is numerically longer than the mature PFS of 34.1 months achieved by alectinib at 300 mg twice daily in the J-ALEX trial. Based on these results, as well as retrospective pharmacokinetic and responses and PFS data, Alectinib at 600 mg twice daily is the optimal dose for Asians. This has been based on the ALESIA trial and on the retrospective pharmacokinetic and responses and PFS data and has set the benchmark for ALK TKI as the first-line treatment for advanced ALK+ NSCLC in Asia. Importantly, lorlatinib, another next generation ALK TKI, also achieved an impressive hazard ratio with a still immature PFS in all patients, including Asian patients, in a recent subgroup analysis after a median follow-up time of 36.7 months. We await the final mature PFS of lorlatinib overall and for Asian patients in the CROWN trial to see if lorlatinib will set a new standard.
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Affiliation(s)
- Alexandria T M Lee
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA
| | - Saihong Ignatius Ou
- Department of Medicine, University of California Irvine School of Medicine, Orange, CA, USA
- Chao Family Comprehensive Cancer Center, Orange, CA, USA
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14
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Fukuda A, Yoshida T. Treatment of advanced ALK-rearranged NSCLC following second-generation ALK-TKI failure. Expert Rev Anticancer Ther 2023; 23:1157-1167. [PMID: 37772744 DOI: 10.1080/14737140.2023.2265566] [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: 05/12/2023] [Accepted: 09/27/2023] [Indexed: 09/30/2023]
Abstract
INTRODUCTION Anaplastic lymphoma kinase (ALK) gene rearrangement is detected in approximately 3-5% of non-small cell lung cancer (NSCLC) cases. Tyrosine kinase inhibitors (TKIs) targeting ALK rearrangement (ALK-TKIs) have shown significant efficacy and improved the survival of patients with NSCLC exhibiting ALK rearrangement. However, almost all patients exhibit disease progression during TKI therapy owing to resistance acquired through various molecular mechanisms, including both ALK-dependent and ALK-independent. AREAS COVERED Here, we review the mechanisms underlying resistance to second-generation ALK-TKIs, and the clinical management strategies following resistance in patients with ALK rearrangement-positive NSCLC. EXPERT OPINION Treatment strategies following the failure of second-generation ALK-TKIs failure should be based on resistant mechanisms. For patients with ALK mutations who exhibit resistance to second-generation ALK-TKIs, lorlatinib is the primary treatment option. However, the identification of resistance profiles of second-generation ALK-TKIs can aid in the selection of an appropriate treatment strategy. In cases of ALK-dependent resistance mutations, lorlatinib could be the first choice as it exhibits the broadest coverage of mutations that lead to resistance against second-generation ALK-TKIs, such as G1202R, and L1196M. In cases of no resistance mutations, atezolizumab, bevacizumab, and platinum-based chemotherapy could be the alternative treatment options.
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Affiliation(s)
- Akito Fukuda
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Tatsuya Yoshida
- Department of Thoracic Oncology, National Cancer Center Hospital, Tokyo, Japan
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15
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Lee ATM, Ou SI. From ASCEND-5 to ALUR to ALTA-3, an Anti-Climactic End to the Era of Randomized Phase 3 Trials of Next-Generation ALK TKIs in the Crizotinib-Refractory Setting. LUNG CANCER (AUCKLAND, N.Z.) 2023; 14:57-62. [PMID: 37377783 PMCID: PMC10292622 DOI: 10.2147/lctt.s413091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023]
Abstract
The competing roles of various next-generation ALK TKIs in the first and second line treatment setting of advanced ALK+ NSCLC were based on many phase 3 clinical trials in both the first-line and crizotinib-refractory settings. The approval of all next-generation ALK TKIs was first in the crizotinib-refractory setting, based on a large-scale Phase 2 trial, and was then followed by at least one global randomized phase 3 trial comparing to platinum-based chemotherapy (ASCEND-4) or to crizotinib (ALEX, ALTA-1L, eXalt3, CROWN). In addition, three randomized phase 3 trials in the crizotinib-refractory setting were also conducted by next-generation ALK TKIs that were developed earlier before the superiority of next-generation ALK TKIs was demonstrated in order to secure the approval of these ALK TKIs in the crizotinib-refractory setting. These three crizotinib-refractory randomized trials were: ASCEND-5 (ceritinib), ALUR (alectinib), and ALTA-3 (brigatinib). The outcome of the ATLA-3 trial was recently presented closing out the chapter where next-generation ALK TKIs were investigated in the crizotinib-refractory setting as they have replaced crizotinib as the standard of care first-line treatment of advanced ALK+ NSCLC. This editorial summarizes the results of next-generation ALK TKIs in randomized crizotinib-refractory trials and provides a perspective on how natural history of ALK+ NSCLC may potentially be altered with sequential treatment. ALTA-3 compared brigatinib to alectinib, showing that both achieved near identical blinded independent review committee (BIRC)-assessed progression-free survival (PFS) (19.2-19.3 months). Importantly, 4.8% of brigatinib-treated patients developed interstitial lung disease (ILD) while no alectinib-treated patients developed ILD. Dose reduction and discontinuation due to treatment-related adverse events were 21% and 5%, respectively, for brigatinib-treated patients compared to 11% and 2%, respectively, for alectinib-treated patients. Upon analysis of these findings, we speculate that brigatinib may have a diminishing role in the treatment of advanced ALK+ NSCLC.
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Affiliation(s)
- Alexandria T M Lee
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA
| | - Saihong Ignatius Ou
- University of California Irvine School of Medicine, Department of Medicine, Orange, CA, USA
- Chao Family Comprehensive Cancer Center, Orange, CA, USA
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16
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Saw SPL, Lim DWT. Diverse Resistant Mechanisms Identified Using Serial Next-Generation Sequencing in a Patient With ALK-Rearranged Metastatic Lung Adenocarcinoma: A Case Report. JTO Clin Res Rep 2023; 4:100512. [PMID: 37304651 PMCID: PMC10250920 DOI: 10.1016/j.jtocrr.2023.100512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/23/2023] [Accepted: 03/26/2023] [Indexed: 06/13/2023] Open
Abstract
Both tissue and plasma-based next generation sequencing (NGS) facilitate the identification of actionable oncogene alterations at diagnosis and resistant mechanisms on progression. The value of longitudinal profiling is less established among patients with ALK-rearranged NSCLC, underpinned by concerns of limited treatment options post-progression and assay sensitivity. We report a case of a patient with ALK-rearranged NSCLC with serial tissue and plasma NGS performed post-progression, whose results helped to guide sequencing of treatment options leading to an overall survival exceeding 8 years from diagnosis of metastatic disease.
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17
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Spitaleri G, Trillo Aliaga P, Attili I, Del Signore E, Corvaja C, Corti C, Crimini E, Passaro A, de Marinis F. Sustained Improvement in the Management of Patients with Non-Small-Cell Lung Cancer (NSCLC) Harboring ALK Translocation: Where Are We Running? Curr Oncol 2023; 30:5072-5092. [PMID: 37232842 DOI: 10.3390/curroncol30050384] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/06/2023] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
ALK translocation amounts to around 3-7% of all NSCLCs. The clinical features of ALK+ NSCLC are an adenocarcinoma histology, younger age, limited smoking history, and brain metastases. The activity of chemotherapy and immunotherapy is modest in ALK+ disease. Several randomized trials have proven that ALK inhibitors (ALK-Is) have greater efficacy with respect to platinum-based chemotherapy and that second/third generation ALK-Is are better than crizotinib in terms of improvements in median progression-free survival and brain metastases management. Unfortunately, most patients develop acquired resistance to ALK-Is that is mediated by on- and off-target mechanisms. Translational and clinical research are continuing to develop new drugs and/or combinations in order to raise the bar and further improve the results attained up to now. This review summarizes first-line randomized clinical trials of several ALK-Is and the management of brain metastases with a focus on ALK-I resistance mechanisms. The last section addresses future developments and challenges.
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Affiliation(s)
- Gianluca Spitaleri
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Pamela Trillo Aliaga
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Ilaria Attili
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Ester Del Signore
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Carla Corvaja
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Chiara Corti
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141 Milan, Italy
- Department of Oncology and Haematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Edoardo Crimini
- Division of New Drugs and Early Drug Development for Innovative Therapies, European Institute of Oncology, IRCCS, Via Ripamonti 435, 20141 Milan, Italy
- Department of Oncology and Haematology (DIPO), University of Milan, 20122 Milan, Italy
| | - Antonio Passaro
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
| | - Filippo de Marinis
- Division of Thoracic Oncology, IEO, European Institute of Oncology IRCCS, Via Ripamonti 435, 20141 Milan, Italy
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18
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Ou SHI, Lee ATM, Nagasaka M. From preclinical efficacy to 2022 updated CROWN trial, lorlatinib is the preferred 1 st-line treatment of advanced ALK+ NSCLC. Crit Rev Oncol Hematol 2023; 187:104019. [PMID: 37187318 DOI: 10.1016/j.critrevonc.2023.104019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/17/2023] Open
Abstract
Six ALK TKIs (crizotinib, ceritinib, alectinib, brigatinib, lorlatinib, ensartinib) have received first-line treatment indication of advanced ALK+ NSCLC in various countries. In Ba/F3 cells, lorlatinib achieved lowest IC50 among these 6 ALK TKIs against EML4-ALK variant 1 or 3. In 2022, 7 abstracts reported updated efficacy and safety data from CROWN. With a median follow-up time of 36.7 months, the 3-year progression-free survival (PFS) rate was 63.5%. The median PFS of lorlatinib still has not been reached. Post-lorlatinib treatment median PFS2 was 74.0% at 3-years. Lorlatinib-treated Asian patients achieved similar 3-year PFS rate as overall lorlatinib-treated patients. Median PFS was 33.3 months among lorlatinib-treated EML4-ALK v3 patients. CNS AE occurred fewer than 1 per patient over the median follow-up time of 36.7 months and most resolved without intervention. Altogether these data affirm our belief that lorlatinib should be the treatment of choice of advanced ALK+ NSCLC.
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Affiliation(s)
- Sai-Hong Ignatius Ou
- University of California Irvine School of Medicine, Orange, CA92868, USA; Chao Family Comprehensive Cancer Center, Orange, CA92868, USA.
| | - Alexandria T M Lee
- University of California Irvine School of Medicine, Orange, CA92868, USA
| | - Misako Nagasaka
- University of California Irvine School of Medicine, Orange, CA92868, USA; Chao Family Comprehensive Cancer Center, Orange, CA92868, USA
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19
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Schneider JL, Lin JJ, Shaw AT. ALK-positive lung cancer: a moving target. NATURE CANCER 2023; 4:330-343. [PMID: 36797503 PMCID: PMC10754274 DOI: 10.1038/s43018-023-00515-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 01/10/2023] [Indexed: 02/18/2023]
Abstract
Anaplastic lymphoma kinase (ALK) is a potent oncogenic driver in lung cancer. ALK tyrosine kinase inhibitors yield significant benefit in patients with ALK fusion-positive (ALK+) lung cancers; yet the durability of response is limited by drug resistance. Elucidation of on-target resistance mechanisms has facilitated the development of next-generation ALK inhibitors, but overcoming ALK-independent resistance mechanisms remains a challenge. In this Review, we discuss the molecular underpinnings of acquired resistance to ALK-directed therapy and highlight new treatment approaches aimed at inducing long-term remission in ALK+ disease.
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Affiliation(s)
- Jaime L Schneider
- Massachusetts General Hospital Cancer Center and Department of Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jessica J Lin
- Massachusetts General Hospital Cancer Center and Department of Medicine, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alice T Shaw
- Massachusetts General Hospital Cancer Center and Department of Medicine, Boston, MA, USA.
- Novartis Institutes for Biomedical Research, Cambridge, MA, USA.
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20
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Ando K, Manabe R, Kishino Y, Kusumoto S, Yamaoka T, Tanaka A, Ohmori T, Sagara H. Comparative Efficacy of ALK Inhibitors for Treatment-Naïve ALK-Positive Advanced Non-Small Cell Lung Cancer with Central Nervous System Metastasis: A Network Meta-Analysis. Int J Mol Sci 2023; 24:2242. [PMID: 36768562 PMCID: PMC9917367 DOI: 10.3390/ijms24032242] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/18/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Central nervous system (CNS) metastases and acquired resistance complicate the treatment of anaplastic lymphoma kinase (ALK) rearrangement-positive (ALK-p) advanced non-small cell lung cancer (NSCLC). Thus, this review aimed to provide a comprehensive overview of brain metastasis, acquired resistance, and prospects for overcoming these challenges. A network meta-analysis of relevant phase III randomized controlled trials was performed to compare the efficacies of multiple ALK inhibitors by drug and generation in overall patients with ALK-p untreated advanced NSCLC and a subgroup of patients with CNS metastases. The primary endpoint was progression-free survival (PFS). Generation-specific comparison results showed that third-generation ALK inhibitors were significantly more effective than second-generation ALK inhibitors in prolonging the PFS of the subgroup of patients with CNS metastases. Drug-specific comparison results demonstrated that lorlatinib was the most effective in prolonging PFS, followed by brigatinib, alectinib, ensartinib, ceritinib, crizotinib, and chemotherapy. While lorlatinib was superior to brigatinib for PFS in the overall patient population, no significant difference between the two was found in the subgroup of patients with CNS metastases. These results can serve as a foundation for basic, clinical, and translational research and guide clinical oncologists in developing individualized treatment strategies for patients with ALK-p, ALK inhibitor-naive advanced NSCLC.
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Affiliation(s)
- Koichi Ando
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
- Division of Internal Medicine, Showa University Dental Hospital Medical Clinic, Senzoku Campus, Showa University, 2-1-1 Kita-senzoku, Ohta-ku, Tokyo 145-8515, Japan
| | - Ryo Manabe
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Yasunari Kishino
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Sojiro Kusumoto
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Toshimitsu Yamaoka
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
- Advanced Cancer Translational Research Institute, Hatanodai Campus, Showa University, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Akihiko Tanaka
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
| | - Tohru Ohmori
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
- Department of Medicine, Division of Respiratory Medicine, Tokyo Metropolitan Health and Hospitals Corporation, Ebara Hospital, 4-5-10 Higashiyukigaya, Ohta-ku, Tokyo 145-0065, Japan
| | - Hironori Sagara
- Division of Respirology and Allergology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan
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21
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Xiao Y, Liu P, Wei J, Zhang X, Guo J, Lin Y. Recent progress in targeted therapy for non-small cell lung cancer. Front Pharmacol 2023; 14:1125547. [PMID: 36909198 PMCID: PMC9994183 DOI: 10.3389/fphar.2023.1125547] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/10/2023] [Indexed: 02/24/2023] Open
Abstract
The high morbidity and mortality of non-small cell lung cancer (NSCLC) have always been major threats to people's health. With the identification of carcinogenic drivers in non-small cell lung cancer and the clinical application of targeted drugs, the prognosis of non-small cell lung cancer patients has greatly improved. However, in a large number of non-small cell lung cancer cases, the carcinogenic driver is unknown. Identifying genetic alterations is critical for effective individualized therapy in NSCLC. Moreover, targeted drugs are difficult to apply in the clinic. Cancer drug resistance is an unavoidable obstacle limiting the efficacy and application of targeted drugs. This review describes the mechanisms of targeted-drug resistance and newly identified non-small cell lung cancer targets (e.g., KRAS G12C, NGRs, DDRs, CLIP1-LTK, PELP1, STK11/LKB1, NFE2L2/KEAP1, RICTOR, PTEN, RASGRF1, LINE-1, and SphK1). Research into these mechanisms and targets will drive individualized treatment of non-small cell lung cancer to generate better outcomes.
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Affiliation(s)
- Yanxia Xiao
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China
| | - Pu Liu
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China
| | - Jie Wei
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China
| | - Xin Zhang
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China
| | - Jun Guo
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China
| | - Yajun Lin
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology of National Health Commission, Beijing, China.,Peking University Fifth School of Clinical Medicine, Beijing, China
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22
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Brazel D, Kim J, Ou SHI. CodeBreaK 200: Sotorasib (AMG510) Has Broken the KRAS G12C+ NSCLC Enigma Code. LUNG CANCER (AUCKLAND, N.Z.) 2023; 14:31-39. [PMID: 37101896 PMCID: PMC10124743 DOI: 10.2147/lctt.s403614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/10/2023] [Indexed: 04/28/2023]
Abstract
Per the US FDA sotorasib approval summary, KRAS G12C mutation is found in approximately 14% of adenocarcinoma of the lung, primarily in patients with a history of smoking. Until recently, targeted therapies against KRAS G12C have been largely unsuccessful due to the small protein size of KRAS and thus lack of binding pockets in KRAS and rapid hydrolysis of GTP to GDP by KRAS enzymes from abundance of GTP in the cytoplasm. Sotorasib, a first-in-class covalent KRAS G12C inhibitor that binds to the switch pocket II in the KRAS G12C-GDP "off" state, received US FDA accelerated approval on May 21, 2021 in the US, based on a Phase II dose expansion cohort of CodeBreaK 100 trial. Sotorasib at 960 mg once daily achieved an ORR of 36% (95% CI: 28%, 45%), with a median response duration of 10 months (range 1.3+, 11.1) in 124 KRAS G12C+ NSCLC. At the European Society of Medical Oncology (ESMO) 2022 annual meeting, sotorasib achieved a statistically significant improved PFS over docetaxel (HR = 0.66; 95% CI: 0. 51-0.86; P = 0.002). The modest magnitude of PFS improvement of 1.1 months (from 4.5 months to 5.6 months) and the ORR of 28% led to a vigorous debate on whether sotorasib was indeed a true breakthrough. In this pros and cons debate, we argue thatsotorasib has achieved a true breakthrough.
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Affiliation(s)
- Danielle Brazel
- University of California Irvine School of Medicine, Department of Internal Medicine, Division of Hematology-Oncology, Orange, CA, USA
| | - Jennifer Kim
- University of California Irvine School of Medicine, Department of Internal Medicine, Division of Hematology-Oncology, Orange, CA, USA
| | - Sai-Hong Ignatius Ou
- University of California Irvine School of Medicine, Department of Internal Medicine, Division of Hematology-Oncology, Orange, CA, USA
- Chao Family Comprehensive Cancer Center, Orange, CA, USA
- Correspondence: Sai-Hong Ignatius Ou, Chao Family Comprehensive Cancer Center, Division of Hematology-Medical Oncology, Department of Medicine, University of California Irvine School of Medicine, 200 South Manchester Avenue, Suite 400, Orange, CA, 92868-3298, USA, Tel +1 714-456-5153, Fax +1 714-456-2242, Email
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23
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Ou SHI, Nishio M, Ahn MJ, Mok T, Barlesi F, Zhou C, Felip E, de Marinis F, Kim SW, Pérol M, Liu G, Migliorino MR, Kim DW, Novello S, Bearz A, Garrido P, Mazieres J, Morabito A, Lin HM, Yang H, Niu H, Zhang P, Kim ES. Efficacy of Brigatinib in Patients With Advanced ALK-Positive NSCLC Who Progressed on Alectinib or Ceritinib: ALK in Lung Cancer Trial of brigAtinib-2 (ALTA-2). J Thorac Oncol 2022; 17:1404-1414. [PMID: 36096442 DOI: 10.1016/j.jtho.2022.08.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/03/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Brigatinib is a potent next-generation ALK tyrosine kinase inhibitor approved for treatment-naive and crizotinib-refractory advanced ALK-positive (ALK+) NSCLC. We evaluated brigatinib after other next-generation ALK tyrosine kinase inhibitors. METHODS In this single-arm, phase 2, ALK in Lung Cancer Trial of brigAtinib-2 (NCT03535740), patients with advanced ALK+ NSCLC whose disease progressed on alectinib or ceritinib received brigatinib 180 mg once daily (after 7-d 90-mg lead-in). Primary end point was independent review committee (IRC)-assessed overall response rate (ORR). Circulating tumor DNA (ctDNA) was analyzed. RESULTS Among 103 patients (data cutoff: September 30, 2020; median follow-up [range]: 10.8 [0.5-17.7] mo), confirmed IRC-ORR was 26.2% (95% confidence interval [CI]: 18.0-35.8), median duration of response, 6.3 months (95% CI: 5.6-not reached), and median progression-free survival (mPFS), 3.8 months (95% CI: 3.5-5.8). mPFS was 1.9 months (95% CI: 1.8-3.7) in patients with ctDNA-detectable baseline ALK fusion (n = 64). Among 86 patients who progressed on alectinib, IRC-ORR was 29.1% (95% CI: 19.8-39.9); mPFS was 3.8 months (95% CI: 1.9-5.4). Resistance mutations were present in 33.3% (26 of 78) of baseline ctDNA; 54% (14 of 26) of mutations were G1202R; 52% (33 of 64) of patients with detectable ALK fusion had EML4-ALK variant 3. Most common all-grade treatment-related adverse events were increased creatine phosphokinase (32%) and diarrhea (27%). The mean dose intensity of brigatinib (180 mg once daily) was 85.9%. CONCLUSIONS In ALK in Lung Cancer Trial of brigAtinib-2, brigatinib was found to have a limited activity in patients with ALK+ NSCLC post-ceritinib or post-alectinib therapy. mPFS was longer with brigatinib in patients without baseline detectable plasma ALK fusion.
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Affiliation(s)
- Sai-Hong Ignatius Ou
- Department of Medicine, Division of Hematology-Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California.
| | - Makoto Nishio
- Department of Thoracic Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Myung-Ju Ahn
- Division of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tony Mok
- State Key Laboratory of Translational Oncology, The Chinese University of Hong Kong, Hong Kong, People's Republic of China
| | - Fabrice Barlesi
- Aix-Marseille University, CNRS, INSERM, CRCM, Marseille, France; Multidisciplinary Oncology & Therapeutic Innovations Department, Gustave Roussy Cancer Campus, Villejuif, France
| | - Caicun Zhou
- Shanghai Pulmonary Hospital, Shanghai, People's Republic of China
| | - Enriqueta Felip
- Department of Medical Oncology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Filippo de Marinis
- Division of Thoracic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Sang-We Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Maurice Pérol
- Department of Medical Oncology, Centre Leon Berard, Lyon, France
| | - Geoffrey Liu
- Department of Medical Oncology, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Maria Rita Migliorino
- Azienda Ospedaliera San Camillo-Forlanini Padiglione Flajani 1° piano DH-2° piano Reparto, Rome, Italy
| | - Dong-Wan Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, South Korea
| | - Silvia Novello
- Department of Oncology, University of Turin, AOU San Luigi, Orbassano, Italy
| | | | - Pilar Garrido
- Department of Medical Oncology, IRYCIS Ramón y Cajal University Hospital, Madrid, Spain
| | - Julien Mazieres
- Centre Hospitalier Universitaire, Université Toulouse III, Toulouse, France
| | | | - Huamao M Lin
- Global Evidence and Outcome, Takeda Development Center Americas, Lexington, Massachusetts
| | - Hui Yang
- Oncology Stats, Takeda Development Center Americas, Lexington, Massachusetts
| | - Huifeng Niu
- Oncology Translational Sciences, Takeda Development Center Americas, Lexington, Massachusetts
| | - Pingkuan Zhang
- Clinical Science, Takeda Development Center Americas, Lexington, Massachusetts
| | - Edward S Kim
- City of Hope National Medical Center, Duarte, California
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24
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Zhai X, Liu Y, Liang Z, Wang W, Qin T, Liu SV, Um SW, Luo F, Liu J. Classical ALK G1202R resistance mutation was identified in a lung adenocarcinoma patient with rare LOC388942-ALK fusion after sequential treatment with ALK-TKIs and anlotinib: a case report. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1180. [PMID: 36467355 PMCID: PMC9708479 DOI: 10.21037/atm-22-5194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/07/2022] [Indexed: 07/30/2023]
Abstract
BACKGROUND Anaplastic lymphoma kinase (ALK)-positive non-small cell lung cancer (NSCLC) is a heterogeneous disease. To date, more than ninety ALK fusions in lung cancer have been found. Here, we report for the first time a rare LOC388942-ALK fusion in NSCLC was sensitive to crizotinib but resistant to the sequential ceritinib and alectinib and acquired classical ALK G1202R resistance mutation after long-term treatment with anlotinib. This case highlights dynamic monitoring of gene alteration using next-generation sequencing (NGS) is necessary during the anti-tumor process. CASE DESCRIPTION A 55-year-old male, with no history of smoking history and no family history of cancer, was found malignant pleural effusion and multiple metastasis nodules in the left lung. He was histopathologically diagnosed with ALK-positive cT4N0M1a adenocarcinoma in June 2016. NGS of the tumor identified a rare LOC388942-ALK fusion (L intergenic: A 20, 1.41%). Then, the patient was treated with chemotherapy, crizotinib, ceritinib, alectinib, and anlotinib sequentially. The patient achieved partial response (PR) to chemotherapy and crizotinib. No evidence of a secondary resistant molecular event was found after resistance to crizotinib, ceritinib, or Alectinib. After 8 months of alectinib treatment, the tumor gradually enlarged again. Anlotinib was followed for 13 months. Thirteen months later, new lesions in the lower lobe of the right lung appeared and increased gradually, indicating definite progression of the tumor. Classical ALK G1202R resistance mutations was detected using cfDNA NGS. The patient refused to receive lorlatinib targeting G1202R resistance mutations and continued with anlotinib. He dead in August 2022, achieving 5-year overall survival (OS). CONCLUSIONS Distinct ALK fusions in NSCLC have different cancer biology, leading to different response to ALK tyrosine kinase inhibitors (ALK-TKIs), even developed different resistance mechanism. Reporting the clinical details of rare ALK fusions in NSCLC is necessary to guide the treatment for clinicians and researchers.
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Affiliation(s)
- Xiaoqian Zhai
- Lung Cancer Center & Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Yanyang Liu
- Lung Cancer Center & Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Zuoyu Liang
- Pathology Department, West China Hospital, Sichuan University, Chengdu, China
| | - Weiya Wang
- Pathology Department, West China Hospital, Sichuan University, Chengdu, China
| | - Tian Qin
- Burning Rock Biotech, Guangzhou, China
| | - Stephen V. Liu
- Department of Medicine, Georgetown University, Washington, DC, USA
| | - Sang-Won Um
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Feng Luo
- Lung Cancer Center & Institute, West China Hospital, Sichuan University, Chengdu, China
| | - Jiewei Liu
- Lung Cancer Center & Institute, West China Hospital, Sichuan University, Chengdu, China
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25
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Wiedemann C, Kazdal D, Cvetkovic J, Kunz J, Fisch D, Kirchner M, Kriegsmann M, Sültmann H, Heussel CP, Bischoff H, Thomas M, Stenzinger A, Christopoulos P. Lorlatinib and compound mutations in ALK+ large-cell neuroendocrine lung carcinoma: a case report. Cold Spring Harb Mol Case Stud 2022; 8:mcs.a006234. [PMID: 36207130 PMCID: PMC9632356 DOI: 10.1101/mcs.a006234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/05/2022] [Indexed: 01/31/2023] Open
Abstract
Large-cell neuroendocrine lung carcinoma (LCNEC) is a high-grade neoplasm with median survival of 1 year and limited therapeutic options. Here, we report the unusual case of a 47-yr-old female smoker with stage IV LCNEC featuring EML4-ALK variant 2 (E20:A20), wild-type TP53/RB1, and low tumor mutational burden of 3.91 mut/Mb. Despite early progression within 3 mo under crizotinib, a durable response was achieved with alectinib. Oligoprogression in the left breast 10 mo later was treated by surgery, followed by a switch to ceritinib upon multifocal progression and detection of ALK:p.V1180L in the mastectomy specimen, but without success. Another rebiopsy revealed ALK:p.L1196M, but the tumor did not respond to brigatinib or carboplatin/pemetrexed, before stabilization under lorlatinib. Diffuse progression 8 mo later with detection of ALK :p.L1196M/p.G1202R and p.L1196M/ p.D1203N evolving from the previous p.L1196M did not respond to chemoimmunotherapy, and the patient succumbed with an overall survival (OS) of 37 mo. This case illustrates the importance of molecular profiling for LCNEC regardless of smoking status, and the superiority of next-generation ALK inhibitors compared to crizotinib for ALK+ cases. Lorlatinib retained efficacy in the heavily pretreated setting, whereas its upfront use could possibly have prevented the stepwise emergence of compound ALK mutations. Furthermore, the disease course was more aggressive and OS shorter compared to the V2/TP53wt ALK+ lung adenocarcinoma, whereas crizotinib, ceritinib, and brigatinib did not confer the benefit expected according to next-generation sequencing results, which also underline the need for more potent drugs against ALK in the high-risk setting of neuroendocrine histology.
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Affiliation(s)
- Christiane Wiedemann
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany
| | - Daniel Kazdal
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, 69120 Germany;,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany
| | - Jelena Cvetkovic
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany
| | - Julia Kunz
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany
| | - David Fisch
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany
| | - Martina Kirchner
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, 69120 Germany
| | - Mark Kriegsmann
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, 69120 Germany;,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany
| | - Holger Sültmann
- Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany;,Division of Cancer Genome Research, German Cancer Research Center (DKFZ), Heidelberg, 69120 Germany
| | - Claus-Peter Heussel
- Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany;,Department of Radiology with Nuclear Medicine, Thoraxklinik at Heidelberg University Hospital, Heidelberg, 69126 Germany
| | - Helge Bischoff
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany;,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany
| | - Albrecht Stenzinger
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, 69120 Germany;,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany
| | - Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital and National Center for Tumor Diseases, Heidelberg, 69126 Germany;,Translational Lung Research Center Heidelberg (TLRC-H), member of the German Center for Lung Research (DZL), Heidelberg, 69120 Germany
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26
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Ashrafi A, Akter Z, Modareszadeh P, Modareszadeh P, Berisha E, Alemi PS, Chacon Castro MDC, Deese AR, Zhang L. Current Landscape of Therapeutic Resistance in Lung Cancer and Promising Strategies to Overcome Resistance. Cancers (Basel) 2022; 14:4562. [PMID: 36230484 PMCID: PMC9558974 DOI: 10.3390/cancers14194562] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/12/2022] [Accepted: 09/15/2022] [Indexed: 02/06/2023] Open
Abstract
Lung cancer is one of the leading causes of cancer-related deaths worldwide with a 5-year survival rate of less than 18%. Current treatment modalities include surgery, chemotherapy, radiation therapy, targeted therapy, and immunotherapy. Despite advances in therapeutic options, resistance to therapy remains a major obstacle to the effectiveness of long-term treatment, eventually leading to therapeutic insensitivity, poor progression-free survival, and disease relapse. Resistance mechanisms stem from genetic mutations and/or epigenetic changes, unregulated drug efflux, tumor hypoxia, alterations in the tumor microenvironment, and several other cellular and molecular alterations. A better understanding of these mechanisms is crucial for targeting factors involved in therapeutic resistance, establishing novel antitumor targets, and developing therapeutic strategies to resensitize cancer cells towards treatment. In this review, we summarize diverse mechanisms driving resistance to chemotherapy, radiotherapy, targeted therapy, and immunotherapy, and promising strategies to help overcome this therapeutic resistance.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Li Zhang
- Department of Biological Sciences, The University of Texas at Dallas, Richardson, TX 75080, USA
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27
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Itchins M, Pavlakis N. The quantum leap in therapeutics for advanced ALK+ non-small cell lung cancer and pursuit to cure with precision medicine. Front Oncol 2022; 12:959637. [PMID: 36003760 PMCID: PMC9393505 DOI: 10.3389/fonc.2022.959637] [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: 06/01/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Since the discovery 15 years ago, we have seen a quantum leap in the treatment and survival for individuals diagnosed with ALK+ lung cancers. Unfortunately however, for most, the diagnosis is made in an incurable circumstance given the late presentation of symptoms. Through a revolutionary wave of therapeutics, individuals may remarkably live over a decade, however many fall short of this milestone, as the molecular profile of this disease is very heterogeneous, reflected in variable survival outcomes. Despite a significant improval in survival and quality of life with ALK-inhibitor monotherapies, now available across multiple-generations, drug resistance and disease relapse remains inevitable, and treatment is offered in an empiric, stepwise, non personalised biomarker informed fashion. A proposed future focus to treating ALK to improve the chronicity of this disease and even promote cure, is to deliver a personalised dynamic approach to care, with rational combinations of drugs in conjunction with local ablative therapies to prevent and constantly proactively alter clonal selection. Such an approach would be informed by precision imaging with MRI-brain and FDG-PETs sequentially, and by regular plasma sampling including for circulating tumour DNA sequencing with personalised therapeutic switches occurring prior to the emergence of radiological and clinical relapse. Such an approach to care will require a complete paradigm shift in the way we approach the treatment of advanced cancer, however evidence to date in ALK+ lung cancers, support this new frontier of investigation.
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Affiliation(s)
- Malinda Itchins
- Department of Medical Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
- Northern Clinical School, University of Sydney, Kolling Institute, St Leonards, NSW, Australia
- North Shore Health Hub, GenesisCare, St Leonards, NSW, Australia
- *Correspondence: Malinda Itchins,
| | - Nick Pavlakis
- Department of Medical Oncology, Northern Sydney Cancer Centre, Royal North Shore Hospital, St Leonards, NSW, Australia
- Northern Clinical School, University of Sydney, Kolling Institute, St Leonards, NSW, Australia
- North Shore Health Hub, GenesisCare, St Leonards, NSW, Australia
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Review of Therapeutic Strategies for Anaplastic Lymphoma Kinase-Rearranged Non-Small Cell Lung Cancer. Cancers (Basel) 2022; 14:cancers14051184. [PMID: 35267492 PMCID: PMC8909087 DOI: 10.3390/cancers14051184] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Anaplastic lymphoma kinase (ALK)-rearranged non-small cell lung cancer (NSCLC) was first reported in 2007. Following the development of crizotinib as a tyrosine kinase inhibitor (TKI) targeting ALK, the treatment of advanced NSCLC with ALK-rearrangements has made remarkable progress. Currently, there are five ALK-TKIs approved by the FDA, and the development of new agents, including fourth-generation TKI, is ongoing. Clinical trials with angiogenesis inhibitors and immune checkpoint inhibitors are also underway, and further progress in the treatment of ALK-rearranged advanced NSCLC is expected. The purpose of this manuscript is to provide information on the recent clinical trials of ALK-TKIs, angiogenesis inhibitors, immune checkpoint inhibitors, and chemotherapy, to describe tissue and liquid biopsy as a method to investigate the mechanisms of resistance against ALK-TKIs and suggest a proposed treatment algorithm. Abstract Non-small cell lung cancer (NSCLC) with anaplastic lymphoma kinase rearrangement (ALK) was first reported in 2007. ALK-rearranged NSCLC accounts for about 3–8% of NSCLC. The first-line therapy for ALK-rearranged advanced NSCLC is tyrosine kinase inhibitors (TKI) targeting ALK. Following the development of crizotinib, the first ALK-TKI, patient prognosis has been greatly improved. Currently, five TKIs are approved by the FDA. In addition, clinical trials of the novel TKI, ensartinib, and fourth-generation ALK-TKI for compound ALK mutation are ongoing. Treatment with angiogenesis inhibitors and immune checkpoint inhibitors is also being studied. However, as the disease progresses, cancers tend to develop resistance mechanisms. In addition to ALK mutations, other mechanisms, including the activation of bypass signaling pathways and histological transformation, cause resistance, and the identification of these mechanisms is important in selecting subsequent therapy. Studies on tissue and liquid biopsy have been reported and are expected to be useful tools for identifying resistance mechanisms. The purpose of this manuscript is to provide information on the recent clinical trials of ALK-TKIs, angiogenesis inhibitors, immune checkpoint inhibitors, and chemotherapy to describe tissue and liquid biopsy as a method to investigate the mechanisms of resistance against ALK-TKIs and suggest a proposed treatment algorithm.
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29
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Song Z, Lian S, Mak S, Chow MZY, Xu C, Wang W, Keung HY, Lu C, Kebede FT, Gao Y, Cheuk W, Cho WCS, Yang M, Zheng Z. Deep RNA Sequencing Revealed Fusion Junctional Heterogeneity May Predict Crizotinib Treatment Efficacy in ALK-Rearranged NSCLC. J Thorac Oncol 2022; 17:264-276. [PMID: 34626839 DOI: 10.1016/j.jtho.2021.09.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/13/2021] [Accepted: 09/18/2021] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Gene fusion variants in ALK-rearranged NSCLC may predict patient outcomes, but previous results have been inconclusive. Fusion isoforms coexisting in the same tumor may affect the efficacy of targeted therapy, but they have not been investigated. METHODS Patients with ALK-rearranged NSCLC who received crizotinib treatments were recruited. Precrizotinib tumor tissues were analyzed by the anchored multiplex polymerase chain reaction for targeted RNA sequencing. Kaplan-Meier and Cox regression were used to compare overall and progression-free survivals. RESULTS Of the 51 studied subjects, EML4-ALK variant types v1, v2, v3, and others were detected in 23 (45.1%), five (9.8%), 19 (37.3%), and four patients (7.8%), respectively. Multiple EML4-ALK RNA isoforms were detected in 24 tumors (47.1%), and single isoform in 27 (52.9%). Most of the v3 tumors (16 of 19) harbored both v3a and v3b RNA isoforms. Multiple isoforms were also detected in eight non-v3 tumors (33.3% of all 24 multiple isoforms; five v1, two v5', and one v2). Compared with patients with single isoform, those with multiple isoforms had worse progression-free (hazard ratio and 95% confidence interval: 2.45 [1.06-5.69]) and overall (hazard ratio [95% confidence interval]: 3.74 [1.26-11.13]) survivals after adjusting for potential confounders including variant type. Using the patient-derived H2228 cells known to express v3a and v3b, our single-cell polymerase chain reaction detected either v3a or v3b in most single cells. Treatment of H2228 cells by three ALK inhibitors revealed increased ratios of v3a-to-v3b expression over time. CONCLUSIONS Intratumoral EML4-ALK isoforms may predict the efficacy of targeted therapy in ALK-rearranged NSCLC. Temporal changes of intratumoral fusion isoforms may result from differential selection pressures that a drug might have on one isoform over another. Larger studies on fusion heterogeneity using RNA sequencing are warranted.
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Affiliation(s)
- Zhengbo Song
- Department of Clinical Trial, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, People's Republic of China; Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou, Zhejiang, People's Republic of China
| | - Shifeng Lian
- Unit of Integrative Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Silvia Mak
- Ming Wai Lau Centre for Reparative Medicine, Karolinska Institutet, Sha Tin, Hong Kong Special Administrative Region of the People's Republic of China
| | - Maggie Zi-Ying Chow
- Ming Wai Lau Centre for Reparative Medicine, Karolinska Institutet, Sha Tin, Hong Kong Special Administrative Region of the People's Republic of China
| | - Chunwei Xu
- Department of Respiratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Nanjing, People's Republic of China
| | - Wenxian Wang
- Department of Clinical Trial, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, Zhejiang, People's Republic of China; Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou, Zhejiang, People's Republic of China
| | - Hoi Yee Keung
- Institute of Basic Medicine and Cancer, Chinese Academy of Sciences, Hangzhou, Zhejiang, People's Republic of China
| | - Chenyu Lu
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China; Biotechnology and Health Centre, City University of Hong Kong Shenzhen Research Institute, Shenzhen, People's Republic of China
| | - Firaol Tamiru Kebede
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China
| | - Yanqiu Gao
- Helitec Limited, Shenzhen, People's Republic of China
| | - Wah Cheuk
- Department of Pathology, Queen Elizabeth Hospital, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China
| | - William Chi Shing Cho
- Department of Clinical Oncology, Queen Elizabeth Hospital, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China
| | - Mengsu Yang
- Department of Biomedical Sciences, City University of Hong Kong, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China; Biotechnology and Health Centre, City University of Hong Kong Shenzhen Research Institute, Shenzhen, People's Republic of China
| | - Zongli Zheng
- Ming Wai Lau Centre for Reparative Medicine, Karolinska Institutet, Sha Tin, Hong Kong Special Administrative Region of the People's Republic of China; Department of Biomedical Sciences, City University of Hong Kong, Kowloon, Hong Kong Special Administrative Region of the People's Republic of China; Biotechnology and Health Centre, City University of Hong Kong Shenzhen Research Institute, Shenzhen, People's Republic of China.
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Nagasaka M, Ou SHI. Targeting Alternative Splicing as Adjunctive Treatment in EML4-ALK v3a/b+ NSCLC: Knowing Our Socratic Paradox and Learning From Spinal Muscular Atrophy. J Thorac Oncol 2022; 17:182-185. [PMID: 35074224 DOI: 10.1016/j.jtho.2021.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 01/17/2023]
Affiliation(s)
- Misako Nagasaka
- University of California Irvine School of Medicine, Orange, California; Division of Neurology, Department of Internal Medicine, St. Marianna University, Kawasaki, Kanagawa, Japan
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