Ensartinib in advanced ALK-positive non-small cell lung cancer: a multicenter, open-label, two-staged, phase 1 trial

Mechanisms of Resistance to ALK Inhibitors and Corresponding Treatment Strategies in Lung Cancer

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.

Ensartinib as a neoadjuvant therapy for stage IIIA non-small cell lung cancer patients with EML4-ALK fusion: a case report and literature review

Anaplastic lymphoma kinase (ALK) inhibitors have shown efficacy in treating ALK-positive advanced non-small cell lung cancer (NSCLC) patients. However, the effectiveness of ensartinib neoadjuvant therapy remains ambiguous. Herein, we reported that preoperative systemic treatment with the ALK inhibitor ensartinib can be beneficial for treating initially inoperable tumors. In this study, we present a case of a 60-year-old female patient who was diagnosed with stage IIIA (cT2aN2aM0, ninth TNM stage) lower left lung adenocarcinoma harboring an EML4-ALK fusion. After three months of therapy, the neoadjuvant treatment with ensartinib provided a partial response, with significant tumor and lymph node shrinkage. Preoperative ensartinib neoadjuvant therapy for NSCLC is safe and effective. Nevertheless, clinical trials can be conducted in the future to validate our results. Moreover, we performed multiple immunofluorescence staining analyses on samples before and after neoadjuvant therapy, observed and compared the changes in the expression of relevant immune cells (CD8+ T cells, macrophages, PD-1, and PD-L1), and performed a simple analysis.

Ensartinib for EML4-ALK-positive lung adenocarcinoma with comorbid mutations in TP53, EGFR, and ERBB2: a case report

Background

In non-small cell lung cancer (NSCLC), anaplastic lymphoma kinase (ALK) gene rearrangements are commonly detected in lung adenocarcinoma. ALK-positive (ALK+) patients may occasionally exhibit concurrent genetic alterations that potentially impact prognosis. New therapeutic strategies are needed for ALK+ NSCLC patients with multiple simultaneous gene mutations.

Case presentation

A 58-year-old man was diagnosed with lung adenocarcinoma (stage IVB, T4N3M1c) with an echinoderm microtubule-associated protein-like 4-ALK+ (EML4-ALK+) rearrangement, harboring tumor protein 53 (TP53), epidermal growth factor receptor (EGFR), and receptor tyrosine-protein kinase erbB-2 (ERBB2) mutations. After three cycles of chemotherapy, the patient developed intolerance. Subsequently, ensartinib (225 mg daily) was administered orally on April 14, 2021. After 3 months of ensartinib treatment, the patient achieved a partial response and reached stable disease at six months, which sustained for 30 months till April 8, 2024, with grade 1 rash and no brain metastases. Currently, the patient remains on ensartinib treatment, without disease progression.

Conclusion

This case demonstrates the potential for ensartinib in the treatment of EML4-ALK+ lung adenocarcinoma with multiple gene mutations. Further investigation through clinical trials is needed to evaluate the safety and efficacy of this targeted therapy.

Repotrectinib: a promising new therapy for advanced nonsmall cell lung cancer

Nonsmall cell lung cancer (NSCLC) is the major cause of cancer-related mortality worldwide, accounting for 84% of lung cancer cases. The newly FDA-approved kinase inhibitor, repotrectinib (AUGTYRO), offers a promising option for treating advanced or metastatic NTRK/ROS1-positive Nonsmall cell lung cancer. Repotrectinib has demonstrated significant efficacy in clinical trials. Notably, the phase 1/2 TRIDENT-1 study showed impressive progression-free survival and intracranial activity in both TKI-naïve and pretreated patients. With its high response rates and manageable side effects, repotrectinib is set to play a significant role in treating ROS1+ and NTRK+advanced solid tumors, highlighting the ongoing need for research and clinical application.

The Use of Anaplastic Lymphoma Kinase Inhibitors in Non-Small-Cell Lung Cancer Treatment-Literature Review

Lung cancer is the leading cause of cancer-related morbidity and mortality. The median survival time for patients with advanced non-small-cell lung cancer before the era of molecular-based personalized treatment was 7.9 months. The discovery of predictive factors and the introduction of molecular diagnostics into daily practice made a breakthrough, enabling several years of survival in patients with advanced disease. The discovery of rearrangements in the ALK gene and ALK tyrosine kinase inhibitors has resulted in a dramatic improvement in the prognosis of patients with this subtype of cancer. Currently, three generations of ALK inhibitors differing in activity, toxicity and degree of penetration into the central nervous system are available in clinical practice. The current state of knowledge on ALK inhibitors used in clinical practice is summarised in this research paper. Methods of diagnosis of abnormalities in ALK have been shown, and the review of research that contributed to the development of the next generation of ALK inhibitors has been presented.

Expert Consensus on the Management of Adverse Events of Lorlatinib in the Treatment of ALK+ Advanced Non-small Cell Lung Cancer

The use of anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs), such as lorlatinib, for the treatment of patients with ALK gene rearrangement (or ALK-positive) non-small cell lung cancer (NSCLC) has been shown to improve the overall survival and quality of life of these patients. However, lorlatinib is not exempt from potential adverse events. Adequate monitoring and management of these adverse events are critical for increasing patient adherence to lorlatinib, thereby maximizing the benefits of treatment and minimizing the risks associated with treatment discontinuation. Considering that the adverse events of lorlatinib can affect different organs and systems, the participation of a multidisciplinary team, including cardiologists, neurologists, internal medicine specialists, and oncology pharmacists, is needed. This article presents specific and pragmatic strategies for identifying and treating the most relevant adverse events associated with lorlatinib in patients with advanced ALK-positive NSCLC based on the clinical experience of a multidisciplinary panel of experts.

Precision nanomedicine to treat non-small cell lung cancer

Lung cancer is a major cause of death worldwide, being often detected at a later stage due to the non-appearance of early symptoms. Therefore, specificity of the treatment is of utmost importance for its effective treatment. Precision medicine is a personalized therapy based on the genomics of the patient to design a suitable drug approach. Genetic mutations render the tumor resistant to specific mutations and the therapy is in vain even though correct medications are prescribed. Therefore, Precision medicine needs to be explored for the treatment of Non-small cell lung cancer (NSCLC). Nanoparticles are widely explored to give personalized interventions to treat lung cancer due to their various advantages like the ability to reach cancer cells, enhanced permeation through tissues, specificity, increased bioavailability, etc. Various nanoparticles (NPs) including gold nanoparticles, carbon nanotubes, aptamer-based NPs etc. were conjugated with biomarkers/diagnostic agents specific to cancer type and were delivered. Various biomarker genes have been identified through precision techniques for the diagnosis and treatment of NSCLC like EGFR, RET, KRAS, ALK, ROS-1, NTRK-1, etc. By incorporating of drug with the nanoparticle through bioconjugation, the specificity of the treatment can be enhanced with this revolutionary treatment. Additionally, integration of theranostic cargos in the nanoparticle would allow diagnosis as well as treatment by targeting the site of disease progression. Therefore, to target NSCLC effectively precision nanomedicine has been adopted in recent times. Here, we present different nanoparticles that are used as precision nanomedicine and their effectiveness against NSCLC disease.

Rutin attenuates ensartinib-induced hepatotoxicity by non-transcriptional regulation of TXNIP

Ensartinib, an approved ALK inhibitor, is used as a first-line therapy for advanced ALK-positive non-small cell lung cancer in China. However, the hepatotoxicity of ensartinib seriously limits its clinical application and the regulatory mechanism is still elusive. Here, through transcriptome analysis we found that transcriptional activation of TXNIP was the main cause of ensartinib-induced liver dysfunction. A high TXNIP level and abnormal TXNIP translocation severely impaired hepatic function via mitochondrial dysfunction and hepatocyte apoptosis, and TXNIP deficiency attenuated hepatocyte apoptosis under ensartinib treatment. The increase in TXNIP induced by ensartinib is related to AKT inhibition and is mediated by MondoA. Through screening potential TXNIP inhibitors, we found that the natural polyphenolic flavonoid rutin, unlike most reported TXNIP inhibitors can inhibit TXNIP by binding to TXNIP and partially promoting its proteasomal degradation. Further studies showed rutin can attenuate the hepatotoxicity of ensartinib without antagonizing its antitumor effects. Accordingly, we suggest that TXNIP is the key cause of ensartinib-induced hepatotoxicity and rutin is a potential clinically safe and feasible therapeutic strategy for TXNIP intervention.

A retrospective study of ensartinib-treated ALK-positive locally advanced or metastatic NSCLC patients in China

Aim

This retrospective study aimed to assess the efficacy and safety of ensartinib in Chinese patients with ALK-positive advanced NSCLC in real-world clinical practice.

Methods

Clinical data from ALK-positive NSCLC patients treated with ensartinib in China were collected and analyzed. Efficacy end points included objective response rate and progression-free survival. Safety profiles were also evaluated.

Results

A total of 682 patients were included in this study. The study demonstrated promising efficacy with an objective response rate of 54.0%, and the median progression-free survival was not estimable. Ensartinib exhibited a manageable safety profile with treatment-related adverse events (TRAEs) consistent with prior clinical trials. The most common TRAE was rash (21.1%) and no TRAE led to death.

Conclusion

Ensartinib is active and well tolerated for ALK-positive NSCLC patients in real-world clinical settings.

Prediction of Drug-Drug Interactions with Ensartinib as a Time-Dependent CYP3A Inhibitor Using Physiologically Based Pharmacokinetic Model

Ensartinib (X-396) is a second-generation anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitor (TKI) indicated for the treatment of ALK-positive patients with locally advanced or metastatic non-small cell lung cancer. Although in vitro experiments and molecular docking suggested its potential as a cytochrome P450 inhibitor, no further investigation or clinical trials have been conducted to assess its drug-drug interaction (DDI) risk. In this study, we conducted a series of in vitro experiments to elucidate the inhibition mechanism of ensartinib. Furthermore, a physiologically-based pharmacokinetic (PBPK) model was developed based on in vitro, in silico, and in vivo parameters, verified using clinical data, and applied to predict the clinical DDI mediated by ensartinib. The in vitro incubation experiments suggested that ensartinib exhibited strong time-dependent inhibition. Simulation results from the PBPK model indicated a significant increase in the exposure of CYP3A substrates in the presence of ensartinib, with the maximal plasma concentration and area under the plasma concentration-time curve increasing up to 12-fold and 29-fold for sensitive substrates. Based on these findings, it is evident that co-administration of ensartinib and CYP3A substrates requires careful regulatory consideration. SIGNIFICANCE STATEMENT: Ensartinib was found to be a strong time-dependent inhibitor of CYP3A for the first time based on in vitro experiments, but there was no research conducted to estimate the risk of drug-drug interaction (DDI) of ensartinib in clinic. Therefore, the first ensartinib physiologically based pharmacokinetic model was developed and applied to predict various untested scenarios. The simulation result indicated that the exposure of CYP3A substrate increased significantly and urged the further clinical DDI study.