Anaplastic Lymphoma Kinase Inhibition in Non–Small-Cell Lung Cancer

Next-Generation Sequencing Identified a Novel Crizotinib-Sensitive PLB1-ALK Rearrangement in Lung Large-Cell Neuroendocrine Carcinoma

Background. Inflammatory myofibroblastic tumor (IMFT) is a rare mesenchymal neoplasm, mainly driven by anaplastic lymphoma kinase (ALK) rearrangement, which is present in 50% of cases and target for ALK inhibition. For the current project we used tumor material from IMFT patients treated with the ALK/ROS1/MET inhibitor crizotinib in the frame of EORTC 90101, where IMFT patients were attributed to ALK+/- sub-cohorts based on the presence (>15% of cells) or absence (<15%) of ALK rearrangement by fluorescence in situ hybridization (FISH) and/or immunohistochemistry (IHC) [Schöffski at al. Lancet Respir Med. 2018]. The aim of the project was to evaluate the frequency of ALK rearrangement, compare different methods of ALK detection, perform a detailed characterization of ALK rearrangement partners, and to identify other potential molecular drivers with potential pharmacodynamic relevance. Material and Methods. Archival material from 24 IMFT cases, both primary or metastatic samples, was analyzed by IHC using ALK antibodies: ALK1 (DAKO) and ALK-D5F3 (Cell Signalling), and pan-NTRK (Ventana, clone EPR17341). ALK and ROS1 rearrangement were studied by FISH and fusion genes were detected using the Archer CTL Fusion Panel. Results. ALK immunopositivity by ALK1 and ALK-D5F3 was observed in 14 out of 24 cases and 11/21, respectively. ALK rearrangement by FISH was found in 13/23 samples. With Archer, fusion transcripts were identified in 13/20 specimens, all but one involving ALK with 11 different fusion partners. In one case we detected an ETV6-NTRK3 fusion; NTRK positivity was confirmed by IHC. Interestingly, the NTRK fusion case responded to crizotinib, which shows cone anti-NTRK activity [Okamura et al. JCO Precis Oncol 2019]. We did not detect ROS1 rearrangement by FISH in any sample. Two samples with ALK rearrangement by Archer were negative by FISH, with 11% and 0% of cells with ALK split signal, but both showed protein expression with both antibodies used. They responded to crizotinib with either a RECIST 1.1 complete response or stable disease, for 43 and 9 months, respectively. All but one case with ALK rearrangement by Archer were positive by ALK IHC with ALK1 antibody. The only immunonegative sample had an EML4-ALK1 fusion. Two cases were positive with ALK-D5F3 antibody but no ALK positivity was detected using ALK1, and no ALK rearrangement was detected by FISH or Archer panel, suggesting false positive results. Conclusions. ALK rearrangement is the most common driver in IMFT and the fusion can involve multiple partners. ALK1 but not the ALK-D5F3 antibody shows high ALK specificity in IMFT. The Archer CTL Fusion panel is a reliable and sensitive method for detecting fusion transcripts in IMFT, also allowing to detect alternative fusion genes, which may be responsible for the sensitivity to kinase inhibitors. Citation Format: Agnieszka Wozniak, Che-Jui Lee, Tom van Wezel, Jozef Sufliarsky, Hans Gelderblom, Jean-Yves Blay, Maria Debiec-Rychter, Raf Sciot, Judith V.M.G. Bovee, Patrick Schöffski. Detection of molecular drivers in inflammatory myofibroblastic tumor: study on archival tissue from EORTC 90101 “CREATE” phase II clinical trial [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3191.

P3.02a-002 Pulmonary Sarcomatoid Carcinoma with ALK Rearrangement: Frequency, Clinical-Pathologic Characteristics, and Response to ALK Inhibitor: Topic: ALK

BackgroundPulmonary carcinoids (PC), including typical (TC) and atypical carcinoids (AC), are low-grade neuroendocrine tumors (NETs) which account for 1–5% of all lung tumors. Due to the low prevalence of PC and extreme rarity of anaplastic lymphoma kinase (ALK) rearrangements in patients with PC, the advances in targeted therapy development in PC are still limited and there is no standard treatment. Even though in patients with PC harboring ALK rearrangements there is a room for a success in targeted therapy. To our knowledge, case 1 was the first report to detect ALK gene p.I1171N mutation after taking alectinib and sensitive to ceritinib in patients with atypical carcinoid.Case DescriptionHerein, we report the cases of 2 non-smoking patients, 51 year-old female with tumor in left lower lobe and 49 year-old female with tumor in right upper lobe, both with metastatic PC who harbored EML4-ALK fusion and were sensitive to small-molecule ALK inhibitors. The first patient initially received alectinib, then therapy was switched to ceritinib after developing drug resistance due to the missense mutation of ALK gene p.I1171N mutation in exon 22 detected by next-generation sequencing (NGS), and finally died of intracranial disease progression. The second patient also received alectinib, and her treatment is currently ongoing with good effect and tolerance. After conducting comprehensive review of literature, we found that 14 lung NETs with ALK rearrangements have been reported to date. The clinical outcome was partial response for 6 NETs patients and 5 patients exhibited stable disease after treatment with ALK inhibitors.ConclusionsAccording to the effectiveness of ALK inhibitors in our cases and previous articles, we recommend alectinib for the first-line treatment of metastatic PC with EML4-ALK fusion and highlight the need for molecular profiling of metastatic lung NETs patients and that ALK inhibitors are feasible in the treatment for metastatic lung NETs patients with ALK rearrangements. Finally, further studies to assess the real prevalence of ALK gene fusions and their spectrum of sensitivity to different ALK inhibitors are needed in larger cohorts.

ALK Inhibitors: What Is the Best Way to Treat Patients With ALK+ Non–Small-Cell Lung Cancer?

A novel HIP1-ALK fusion variant in lung adenocarcinoma showing resistance to Crizotinib

PURPOSEIn GI cancers, anaplastic lymphoma kinase (ALK) rearrangements are extremely less frequent than in non–small-cell lung cancer but may be important to offer personalized strategies of treatment in selected patients. Data about the activity and efficacy of ALK inhibitors (ALKi) in GI cancers are scarce.MATERIALS AND METHODSWe assembled a clinical and molecular international data set of pretreated patients with metastatic or nonresectable cancers of GI primary tumor origin with documented ALK rearrangement treated with at least one line of ALKi. Measurable disease as per RECIST 1.1 was required for response analysis.RESULTSPrimary tumor sites were distributed as follows: 5 (38%) pancreas, 3 (23%) right colon, and 1 (8%) for each one of gastric, duodenal, rectal, left colon, and biliary tract sites. Seven patients (54%) were treated with alectinib, 5 (38%) with crizotinib, and 1 (8%) with entrectinib. After disease progression, five patients (38%) received a subsequent ALKi treatment line, and at the time of data cutoff date, treatment was still ongoing in two patients. Five of 12 evaluable patients (41%) achieved a partial response to first-line ALKi, five patients (41%) had stable disease, and 2 (17%) had progressive disease. No complete responses were registered. At a median follow-up of 39.6 months (interquartile range: 19.8-59.5), the median progression-free survival was 5.0 months (95% CI, 3.68 to no response) and the median overall survival was 9.3 months (95% CI, 5.46 to no response).CONCLUSIONTreatment with ALKi provides remarkable responses and clinical benefit in pretreated patients with ALK fusion–positive GI malignancies. Despite the rarity, ALK rearrangements represent an important therapeutic target in individual pretreated patients with GI solid tumors. Further work providing prospective clinical validation of this target is needed.

PurposeWith the continuous development and progress of next-generation gene sequencing technology, many types of anaplastic lymphoma kinase (ALK) rearrangement have been discovered. However, in small cell lung cancer (SCLC), ALK rearrangement is extremely rare and there is no standard treatment protocol. By reviewing the literature, we summarized the previously reported cases of ALK-positive SCLC, and discussed the significance of molecular detection.MethodWe report a rare patient with EML4-ALK fusion gene SCLC, a 41-year-old woman with no history of smoking or drinking, who was admitted to the hospital with chest tightness, dyspnea, and cough and sputum. Extensive SCLC (cT4N0M1) was diagnosed after relevant examination and pathological examination. The patient relapsed again six months after receiving first-line chemoradiotherapy. And the patient still developed disease progression (PD) after continued multi-line treatment including chemotherapy, immunotherapy, and anti-vascular therapy. ALK inhibitor is currently being taken orally, and significant clinical response has been achieved. Progression-free survival (PFS) was more than 8 months.ResultALK rearrangement of SCLC is rare. The stage IV patient with ALK rearrangement benefit from ALK inhibitors after multiline therapy.ConclusionFor patients with ALK-positive SCLC, ALK inhibitors may be a reliable treatment option.

We investigated the incidence of concomitant epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) rearrangements in Chinese patients with non-small cell lung cancer (NSCLC), and assessed responses to EGFR tyrosine kinase inhibitors (EGFR-TKIs) and crizotinib in such tumors. We screened 977 consecutive patients with NSCLC for the presence of concomitant EGFR mutations and ALK rearrangements by rapid amplification of cDNA ends-coupled PCR sequencing and FISH. Immunohistochemistry (IHC) and Western blotting were used to correlate the activation of EGFR, ALK, and downstream proteins with responses to EGFR-TKIs and crizotinib. The overall frequency of concomitant EGFR mutations and ALK rearrangements was 1.3% (13/977). EGFR/ALK co-alterations were found in 3.9% (13/336) EGFR-mutant and 18.6% (13/70) ALK-rearranged patients. Ten tumors were treated with first-line EGFR-TKIs, with a response rate of 80% (8/10). Two tumors with high phospho-ALK levels and low phospho-EGFR levels achieved stable and progressive disease, respectively. Median progression-free survival was 11.2 months. Coexpression of mutant EGFR and ALK fusion proteins in the same tumor cell populations was detected by IHC. Two cases with high phospho-ALK levels treated with crizotinib achieved partial responses; two cases with low phospho-ALK levels had progressive or stable disease. ALK rearrangements and EGFR mutations could coexist in a small subgroup of NSCLC. Advanced pulmonary adenocarcinomas with such co-alterations could have diverse responses to EGFR-TKIs and crizotinib. Relative phospho-ALK and phospho-EGFR levels could predict the efficacy of EGFR-TKI and crizotinib.

Commentary: Another win for immunotherapy

In March 2014 a 51-year-old male nonsmoker received the diagnosis of locally advanced squamous cell carcinoma (SCC) of the left lung, grade 2, cT2cN2cM0, stage IIIA. The patient underwent three cycles of neoadjuvant chemotherapy (cisplatin, 75 mg/m2/d on day 1 of a 21-day cycle, and gemcitabine, 1000 mg/m2/d on days 1 and 8 of a 21-day cycle) with a partial response; as a result, he underwent radical surgery (pneumonectomy and lymphadenectomy) in June 2014. The histologic type was confirmed as SCC, grade 3. The final stage after surgery was defined as ypT1ypN1. In November 2015 the patient relapsed (in the contralateral lung and mediastinal lymph node). Two other cycles of chemotherapy (cisplatin, 75 mg/m2/d on day 1 of a 21-day cycle, and gemcitabine, 1000 mg/m2/d on days 1 and 8 of a 21-day cycle) were administered but the patient progressed. In consideration of the fact that the patient had no history of smoking, testing for EGFR and anaplastic lymphoma kinase gene (ALK) was performed. The tumor was determined to be EGFR wild type, but it included the fusion gene echinoderm microtubule associated protein like 4 gene (EML4)–ALK rearrangement. In consideration of the molecular results, a second-line therapy with first-generation ALK inhibitor (crizotinib, 250 mg twice a day) was administered. The patient achieved a partial response after four cycles of crizotinib (February–June 2015 [Fig. 1]), but then he progressed (in bone and brain) after eight cycles in October 2015. He received stereotactic brain radiotherapy and bisphosphonates. In consideration of the oligoprogression of the disease, crizotinib was continued. In December 2015 the patient progressed in the contralateral lung and bones; brain metastasis were stable after radiotherapy. So a third-line therapy with a second-generation ALK inhibitor (ceritinib, 750 mg daily) was administered beginning in February 2016. In March 2016 a computed tomography scan (performed after 2 months of therapy) showed good partial response of the target thoracic lesions (see Figs. 2 and 3), progression disease of the bone metastasis, and stable brain disease. In consideration of the mixed response, ceritinib was continued. The patient died of sepsis in June 2016.Figure 3Another target lesion of the right lung before (A) and after (B) two cycles of ceritinib.View Large Image Figure ViewerDownload Hi-res image Download (PPT) ALK rearrangement is identified in approximately 5% of patients affected by lung adenocarcinoma and allows treating patients with anti-ALK targeted therapy. ALK rearrangement has been associated with several clinicopathological characteristics: never-smoker or light smoker, younger age at diagnosis, adenocarcinoma histologic type, signet ring cells, and mutual exclusivity from other major driver genes.1Shaw A.T. Yeap B.Y. Mino-Knudson M. Digumarthy S.R. et al.Clinical features and outcome of patients with non-small-cell lung cancer who harbor EML4-ALK.J Clin Oncol. 2009; 27: 4247-4253Crossref PubMed Scopus (1641) Google Scholar ALK-rearranged SCCs are extremely rare tumors; very few cases of ALK-rearranged SCC tumors that responded to crizotinib in first- or second-line therapy are described in the literature.2Yamamoto Y. Kodama K. Maniwa T. Takeda M. Kishima H. Anaplastic lymphoma kinase-positive squamous cell carcinoma of the lung: a case report.Mol Clin Oncol. 2016; 5: 61-63PubMed Google Scholar, 3Mikes R.E. Jordan F. Hutarew G. Studnicka M. First line crizotinib in anaplastic lymphoma kinase (ALK) rearranged squamous cell lung cancer.Lung Cancer. 2015; 90: 614-616Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 4Wang Q. He Y. Yang X. Wang Y. Xiao H. Extraordinary response to crizotinib in a woman with squamous cell lung cancer after two courses of failed chemotherapy.BMC Pulm Med. 2014; 14: 83Crossref PubMed Scopus (16) Google Scholar, 5Wang W. Song Z. Zhang Y. Response to crizotinib in a squamous cell lung carcinoma patient harbouring echinoderm microtubule-associated protein-like 4-anaplastic lymphoma translocation: a case report.Thorac Cancer. 2016; 7: 355-357Crossref PubMed Scopus (14) Google Scholar So far, the present case is the first report of a patient with SCC harboring EML4-ALK rearrangement who received two lines of therapy with ALK inhibitors with partial response. Because of the lack of data available in the literature and the rarity of this condition, nowadays the molecular analysis of ALK status in SCC is not routinely recommended. Further studies are required.

Pulmonary Sarcomatoid Carcinoma with ALK Rearrangement: Frequency, Clinical-Pathologic Characteristics, and Response to ALK Inhibitor

BACKGROUND: Lung cancer is the leading cause of cancer-related deaths in the United States. Several anaplastic lymphoma kinase (ALK) rearrangement inhibitors have been approved for the treatment of metastatic ALK-positive non-small cell lung cancer (NSCLC). Effective disease management requires an understanding of how these treatments are used in clinical practice, since low treatment adherence and/or early discontinuation have been associated with poor patient outcomes. Owing to the recency of approvals, real-world data on the use of ALK inhibitors in patients with ALKpositive NSCLC are currently limited; this represents a notable gap in our understanding of ALK treatment use. OBJECTIVE: To assess real-world adherence and persistence with ALK inhibitors in patients with ALK-positive NSCLC. METHODS: This retrospective observational study used US commercial claims for patients aged at least 18 years with lung cancer receiving ALK inhibitors (alectinib, brigatinib, ceritinib, crizotinib) between July 1, 2015, and December 31, 2018. Patients' first and any subsequent ALK inhibitor uses were categorized into ALK inhibitor-naive and ALK inhibitor-pretreated cohorts, respectively. Adherence was measured by medication possession ratio and persistence by time from treatment initiation to discontinuation (earliest of a treatment switch or greater than a 60-day gap). Descriptive statistics were used to summarize patient characteristics. Cohort comparisons were made using chi-square tests and t-tests. Persistence and time to next ALK inhibitor were analyzed using Kaplan-Meier methods and the log-rank test. Poisson and Cox regression models of adherence and persistence, respectively, were applied to compare ALK inhibitors. RESULTS: We identified 1,482 patients treated with alectinib (n = 445) or crizotinib (n = 1,037) in the ALK inhibitor-naive cohort; 604, 142, and 134 patients received alectinib, brigatinib, or ceritinib in the ALK inhibitor-pretreated cohort. Adherence during the treatment period (95%-97%) and the proportion of patients with a medication possession ratio of at least 0.8 (92%-95%) were similar for all ALK inhibitors. In the ALK inhibitor-naive cohort, median time to treatment discontinuation with alectinib and crizotinib was 27.1 and 8.8 months, respectively; patients receiving alectinib were 46% less likely to discontinue than patients receiving crizotinib (adjusted hazard ratio [aHR] [95% CI]: 0.54 [0.44-0.65]; P < 0.0001). In the ALK inhibitor-pretreated cohort, the discontinuation risk for alectinib was 64% lower than for ceritinib (aHR [95% CI]: 0.36 [0.27-0.49]; P < 0.0001) and 34% lower than for brigatinib (aHR [95% CI]: 0.66 [0.42-1.02]; P = 0.062). CONCLUSIONS: To our knowledge, this study is the first to address a current research gap by assessing real-world adherence and persistence with ALK inhibitors among patients with ALK-positive NSCLC in real-world clinical practice. Alectinib was associated with longer real-world persistence than other ALK inhibitors, despite similar adherence. Further research with more patients and longer follow-up is needed to link persistence to real-world clinical outcomes. DISCLOSURES: This study was funded by Genentech Inc. Ganti has received research support from Takeda and has provided consulting services to Genentech Inc., AstraZeneca, Flagship Biosciences, Cardinal Health, BioGene, Mirati Therapeutics, Blueprint Medicines, and G1 Therapeutics. Lin, Wong, and Ogale are employees of Genentech Inc. and may own stock in F. Hoffmann-La Roche. Yang was employed by Genentech Inc. at the time of this study. Part of the study findings were presented as a poster at the NCCN 2020 Virtual Annual Conference, April 9, 2020.

Recent years have borne witness to the development of numerous anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors (TKIs) for patients with ALK-rearranged non–small-cell lung cancer (NSCLC). Crizotinib, amultitargeted ALK/ROS1/MET inhibitor, was the first ALK-targeted agent tested in the clinic. In randomized phase III trials, crizotinib showed superior efficacy compared with standard firstand second-line chemotherapy in advanced ALKpositive NSCLC, leading to the widespread adoption of crizotinib as the standard of care for this molecular subset of lung cancer. Since then, two second-generation ALK inhibitors, ceritinib and alectinib, have received accelerated approval by the US Food and Drug Administration for patients with crizotinib-refractory, ALKpositive NSCLC. Several other next-generation ALK TKIs are also under development. Although most patients with ALK-rearranged NSCLC respond to ALK TKIs, a wide range of responses has been observed. For example, although the average duration of crizotinib treatment is 8 to 11 months, some patients experience relapse within only a few months, and others have not yet experienced disease relapse after more than 5 years. The biologic mechanisms underlying this heterogeneity in TKI response are unknown. One of the earliest proposedmechanisms focused on the different variants of the most common ALK rearrangement, EML4-ALK. To date, more than 10 distinct EML4-ALK variants have been identified, each with a discrete breakpoint in EML4. Other fusion partner genes including KIF5B, TFG, and KLC1 have also been reported. In all cases, the fusion oncogene contains the 59 portion of the partner gene, including its promoter, and the entire ALK kinase domain (exons 20 to 29). The fusion partners generally contain oligomerization domains leading to constitutive, ligandindependent ALK activation. Early in vitro studies suggested differential sensitivity of four EML4-ALK variants (v1, v2, v3a, and v3b) to crizotinib and the tool compound TAE684. Interestingly, the differential sensitivity observed correlated with the protein stability of the EML4-ALK variants. This work suggested a potential molecular basis for the differential responses seen with crizotinib. In the article accompanying this editorial, Yoshida et al report the results of a single-institution retrospective analysis addressing the question of clinical impact of EML4-ALK fusion variants on crizotinib sensitivity in patients. The efficacy of crizotinib was examined in 35 patients with ALK-positive NSCLC, whose tumor specimens were assessed for the presence of ALKvariants by reverse transcription polymerase chain reaction with concurrent testing by either fluorescent in situ hybridization (n 5 25) or immunohistochemistry (n5 28). Nineteen patients (54%) had EML4-ALKv1, five (14%) had v2, four (12%) had v3a/3b, and seven (20%) had other variants. Non-EML4 partner proteins were not assessed. Notably, crizotinib was the first-line treatment of 10 patients (29%) and second-line or later treatment for the remaining 25 patients (71%). For the entire cohort, both the response rate (69%) and median progress-free survival (PFS) time (9.7 months) were consistent with published data from crizotinib trials. However, although the response rates were comparable in v1 and non-v1 groups (74% and 63%, respectively; P 5 .7160), there was a statistically significant difference in the disease control rate (95% v 63%, respectively; P5 .0318) and median PFS (11 v 4.2 months, respectively; P, .05). These observations support the notion that the type of ALK fusion could be a determinant of sensitivity to crizotinib in ALKrearranged lung cancers. However, there are several important limitations of this study. First, there is no biologic rationale for categorizing patients with ALK-rearranged lung cancer on the basis of the presence of EML4-ALK v1 versus non-v1. Indeed, the findings of this study are not consistent with prior in vitro studies that showed differences among the EML4-ALK variants v1, v2, v3a, and v3b. On the basis of the in vitro results, EML4-ALK v2 (not v1) was most sensitive to ALK inhibitors, v1 and v3b had intermediate sensitivity, and v3a was least sensitive. At present, there are limited data to suggest how biologically similar, or different, the non-v1 EML4-ALK variants may be compared with one another; therefore, grouping these variants together is somewhat artificial. Second, the study by Yoshida et al was limited by the small sample size, with only four to seven patients in each individual subgroup of non-v1 variants. Within the v1 and non-v1 groups, a remarkably wide range of PFS times was observed. For example, one patient with EML4-ALK v5b had PFS censored at greater than 36 months, which is significantly longer than the median PFS of the v1 group. Furthermore, for three of the 16 patients in the non-v1 group, the PFS was censored at a relatively short follow-up (, 6 months). It is worth noting that other studies examining the role of ALK variants have also been limited by small numbers and have not reported differences in response on the basis of specific variant. The original phase I study of crizotinib included analysis of EML4-ALK variants by reverse transcription polymerase chain

Ensartinib as Treatment for ALK-Rearranged NSCLC