ROS1 Mutations Research Articles

1057P ROS1 mutation can serve- as a potential efficacious predictor of immunotherapy in melanoma patients

Melanoma is a serious skin cancer. Immune checkpoint inhibitors (ICIs) including atezolizumab, pembrolizumab, nivolumab, ipilimumab have shown durable responses and have been approved by FDA. However, ICIs demonstrate antitumor effects only in a fraction of patients, and research exploring the association between gene mutation and clinical benefit is limited. ROS1 mutation rate is high in melanoma. Studies have shown that ROS1 substitutions/indels correlated with higher TMB (Tumor Mutation Burden) and PD-L1+/TMB-H proportions than wild-type genotypes in NSCLC, which means that the mutation of ROS1 gene may be related to the efficacy of immunotherapy in patients with NSCLC, but the association between ROS1 mutation and TMB or survival in melanoma is unknown.

OTHR-05. Diagnosis and Treatment of Solitary Pituitary Metastatic Cancer: A Case Series

ObjectiveMetastatic pituitary carcinoma accounted for only 1% of pituitary lesions.MethodsPatients with isolated pituitary metastatic carcinoma admitted to our hospital from 2014 to 2018 were retrospectively collected, clinical features and prognosis were analyzed.ResultsA total of 5 patients (4 males and 1 female) with a median age of 48 years (21 to 66 years) were included, all with single intracranial pituitary nodules as the initial clinical presentation. The related symptoms were visual impairment (5/5 cases), hypopituitarism (5/5 cases), visual field defect (5/5 cases), headache (4/5 cases), hypothyroidism (4/5 cases), diabetes insipidus (2/5 cases). All the 5 patients received surgical resection (total or partial resection) of tumors in the sellar region via nasal sphenoidal approach. Postoperative pathology confirmed that 4 cases were metastatic adenocarcinoma and 1 case was metastatic squamous carcinoma. Further imaging examinations, such as CT or whole-body PET/CT, confirmed that the primary lesions of all the 5 patients were from the lung. Gene testing indicated that 3 of the 4 adenocarcinoma patients were EGFR mutation positive and 1 of the 4 adenocarcinoma patients was ROS1 mutation positive. Patients received radiotherapy (5/5 cases), targeted therapy (4/5 cases), or chemotherapy (1/5 cases) after surgery. Survival follow-up to May 2019 showed that 4 patients had died, with a survival of 2, August, 28, and 30 months, respectively, and 1 patient was still alive with a survival of 4 months.ConclusionThe first clinical manifestation of isolated pituitary metastatic carcinoma is nervous system related symptoms, which is easily misdiagnosed. The most of the primary lesions are from lung, especially lung adenocarcinoma with positive driver gene. Surgery, radiotherapy combined with targeted therapy or chemotherapy can provide survival benefits for patients with pituitary metastatic carcinoma.

Non-smoking woman with adenocarcinoma of the lung, IV stage with ROS1 mutation and acquired thrombophilia

Despite the fact, that lung cancer is more common among older smoking men, however it may also develop among young women without a smoking anamnesis. We report here a history of a non-smoking woman, 40 years old, with a diagnosis of lung adenocarcinoma at IV stage. Despite the fact, the woman received three lines of palliative chemotherapy, the disease progressed. After the sample of the tumor was tested by genetic approach, ROS1 mutation was detected, and the patient was treated with a ROS1 inhibitor, Crizotinib. Sharp improvement was observed already after the first week of treatment. After one-month adenocarcinoma shrink, and specific supraclavicular lymph nodes disappeared. Unfortunately, due to problems with financing the treatment was stopped, after what the disease began to progress rapidly, and the patient died after a month due to brain metastasis. This case is noteworthy also because the patient was first diagnosed a thrombophilia with thrombi present in deep calf veins, left heart ventricle and lungs Adenocarcinoma was discovered occasionally when during video-assisted thoracoscopic surgery biopsy specimen was taken from suspicious mass in the lower lobe of the right lung. This story reminds us that lung carcinoma may start with a paraneoplastic syndrome, like thrombophilia as in this case and finding of adenocarcinoma of the lung in young, non-smoking persons is indicative for possible ROS1 gene mutation. In such cases early treatment with ROS1 protein-tyrosine kinase inhibitors should be started as soon as possible.

Multigene Combined Detection by RT-qPCR Using Cytological Specimens

Objective: The aim of the study was to investigate the mutation status of multiple driver genes by RT-qPCR and their significance in advanced lung adenocarcinoma using cytological specimens. Materials and Methods: 155 cytological specimens that had been diagnosed with lung adenocarcinoma in the Fourth Hospital of Hebei Medical University were selected from April to November 2019. The cytological specimens included serous cavity effusion and fine-needle aspiration biopsies. Among cytological specimens, 108 cases were processed by using the cell block method (CBM), and 47 cases were processed by the disposable membrane cell collector method (MCM) before DNA/RNA extraction. Ten drive genes of EGFR, ALK, ROS1, BRAF, KRAS, NRAS, HER2, RET, PIK3CA, and MET were combined detected at one step by the amplification refractory mutation system and ABI 7500 RT-qPCR. Results: The purity of RNA (p = 0.005) and DNA (p = 0.001) extracted by using the MCM was both significantly higher than that extracted by using the CBM. Forty-seven cases of fresh cell specimens processed by the MCM all succeeded in multigene detections, while of 108 specimens processed by the CBM, 6 cases failed in multigene detections. Among 149 specimens, single-gene mutation rates of EGFR, ALK, ROS1, RET, HER2, MET, KRAS, NRAS, BRAF, and PIK3CA mutations were 57.71%, 6.04%, 3.36%, 2.68%, 2.01%, 2.01%, 1.34%, 0.67%, 0% and 0% respectively, and 6 cases including 2 coexistence mutations. We found that mutation status was correlated with gender (p = 0.047), but not correlated with age (p = 0.141) and smoking status (p = 0.083). We found that the EGFR mutation status was correlated with gender (p = 0.003), age (p = 0.015) and smoking habits (p = 0.007), and ALK mutation status was correlated with age (p = 0.002). Conclusion: Compared with the CBM, the MCM can improve the efficiency of DNA/RNA extraction and PCR amplification by removing impurities and enriching tumor cells. And we speculate that the successful detection rate of fresh cytological specimens was higher than that of paraffin-embedded specimens. EGFR, ALK, and ROS1 mutations were the main driver mutations in patients with advanced lung adenocarcinoma. We speculate that EGFR and ALK are more prone to concomitant mutations, respectively. Targeted therapies for patients with coexisting mutations need further study.

The Emerging Importance of Tumor Genomics in Operable Non-Small Cell Lung Cancer.

Simple SummaryNext-generation sequencing (NGS) has revolutionized care for patients with advanced and metastatic non-small cell lung cancer through the identification of specific oncogenic driver mutations and pairing with matched targeted therapies. The application of NGS technologies also has the potential to improve outcomes in patients with earlier-stage disease who undergo surgery as their first line of treatment. We review clinically relevant topics in this patient cohort, for whom NGS technologies have spearheaded our understanding of tumor heterogeneity, the underlying genomic features associated with lung adenocarcinoma histologic subtypes, the prediction of recurrence after surgery, the identification of minimal residual disease by circulating tumor DNA, the discernment of intrapulmonary metastases versus synchronous or metachronous disease, and the identification of patients with early-stage non-small cell lung cancer who are likely to benefit from induction or adjuvant therapies.During the last two decades, next-generation sequencing (NGS) has played a key role in enhancing non-small cell lung cancer treatment paradigms through the application of “targeted therapy” in advanced and metastatic disease. The use of specific tyrosine kinase inhibitors in patients with oncogenic driver alterations, such as EGFR, ALK, ROS1, BRAF V600E, MET, and NTRK mutations, among others, has changed treatment approaches and improved outcomes in patients with late-stage disease. Although NGS technology has mostly been used in the setting of systemic therapy to identify targets, response to therapy, and mechanisms of resistance, it has multiple potential applications for patients with earlier-stage disease, as well. In this review, we discuss the emerging role of NGS technologies to better understand tumor biology in patients with non-small cell lung cancer who are undergoing surgery with curative intent. In this patient cohort, we examine tumor heterogeneity, the underlying tumor genomics associated with lung adenocarcinoma subtypes, the prediction of recurrence after complete surgical resection, the use of plasma circulating tumor DNA for detection of early cancers and monitoring for minimal residual disease, the differentiation of separate primaries from intrapulmonary metastases, and the use of NGS to guide induction and adjuvant therapies.

Abstract 470: Evaluation of two receptor tyrosine kinase (ROS1) clones by immunohistochemistry

Abstract Introduction: ROS1 is a receptor tyrosine kinase which regulates growth and cell division. ROS1 chromosomal rearrangements have been identified in a variety of human malignancies including non-small-cell lung carcinoma (NSCLC). However, patients diagnosed specifically with ROS1+ lung adenocarcinoma accounts for 1-2 percent of all NSCLC cases. Increased expression of ROS1 may suggest a ROS1 gene rearrangement. This is similar to ALK+ NSCLC tumors. Some ALK inhibitors can also be effective in tumors having the ROS1 mutation. Therefore, the development of targeted therapies has enhanced the importance of an accurate classification of the cancer subtypes. Materials and Methods: Immunohistochemistry: Both, the Biocare ROS1 rabbit monoclonal antibody (clone EPMGHR2) and the Roche VENTANA ROS1 (SP384) rabbit antibody were used in a ready-to-use format. ROS1 antibodies were run on the intelliPATH FLX, VALENT and the Ventana BenchMark Ultra platforms with in-house control and commercially available tissues from US Biolabs. Detection strategies utilized an HRP 2-step polymerized approach on the Biocare instruments, whereas the Optiview DAB IHC Detection kit was used on the Ventana platform. Fluorescence in Situ Hybridization (FISH): FISH was performed on a fully automated ONCORE Pro autostainer using the ROS1 (6q22) Break Apart (BA) (Orange/Green) FISH probe diluted in Biocare zipFISH hybridization buffer. Results: Initially, the NSCLC tissues were screened with a ROS1 BA FISH probe to identify the ROS1 mutation. Results indicated that the mutation was present on tumor cells throughout the tissue. When compared to FISH results on adjacent sections, a direct correlation between the ROS1 antibody staining and FISH results showed a good staining overlap. IHC staining on the intelliPATH FLX exhibited better signal-to-noise ratio for the Biocare ROS1 antibody compared to the Ventana antibody. A more concentrated Biocare antibody was required to obtain equivalent or better staining on the intelliPATH FLX than the Ventana ROS1 on the VENTANA ULTRA platform. However, the Biocare ROS1 in certain regions showed better staining than the Ventana ROS1. Biocare ROS1 at the same concentration produced a comparable staining on both the IntelliPATH FLX and the VALENT platforms. Conclusions: The availability of high quality ROS1 antibodies from alternative sources can be beneficial for labs performing lung cancer screening. Our rabbit monoclonal ROS1 antibody has been shown to produce strong and consistent signals with exceptional signal-to-noise. These results have been verified by using highly sensitive FISH probes in combination with a well-characterized commercially available ROS1 antibody. Citation Format: Julio S. Masabanda, Tatiana Scoggin, Joseph Vargas, Jason Ramos. Evaluation of two receptor tyrosine kinase (ROS1) clones by immunohistochemistry [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 470.

Abstract 2187: Circulating tumor DNA (ctDNA) gene sequencing results from prospective screening of patients with newly diagnosed metastatic gastric and gastroesophageal adenocarcinoma (GEA) for the bemarituzumab FIGHT randomized trial using a plasma NGS assay

Abstract Background: Metastatic GEA is a molecularly heterogeneous disease with limited therapeutic options. It is the third most common cause of cancer death globally. Targeted therapies against HER2 positive and microsatellite instability-high (MSI-H) GEA have improved overall survival. There has not been a prospective evaluation of the prevalence of potentially actionable molecular targets in a global population with newly diagnosed advanced-stage GEA. Methods: As part of the global FIGHT study of bemarituzumab (NCT03694522), patients with newly diagnosed advanced stage GEA that was not known to be HER2 positive were screened using the PGDx elioTM Plasma Resolve Investigation Use Only assay. This next generation sequencing (NGS) hybrid-capture assay was developed to include coding and select noncoding regions of 33 cancer-related genes. Circulating cell free DNA (cfDNA) extracted from plasma samples was used as input. FGFR2-amplification positive clinical samples were identified in a primary report for enrollment in the trial. Variant calls for translocations, amplifications and SNVs/indels were reported for informational use only. Results: Of the 721 samples submitted for analyses, 661 had sufficient cfDNA to proceed with the assay, 51 samples failed to generate sufficient sequencing data to be interpreted based upon quality cutoffs. Of the 610 remaining samples 5% were amplified for FGFR2. Of these 610 samples, 496 (82%) individual patient samples were tested for additional molecular changes with 29 failing to generate sufficient sequencing data; leaving 467 patient samples with evaluable data. 81% of patients had at least one gene aberration. Of the 8 genes evaluated for amplification, the most common to least commonly amplified were MYC (10%), EGFR (7%), ERBB2 (7%), MET (7%), FGFR2 (5%), CCND1 (4%), and CD274 (1%). No KIT amplification was reported. The most frequently mutated genes among the 33 examined were p53, ARID1A, PIK3CA, BRCA2, KRAS, CDH1, APC, ATM, BRCA1 and FGFR2. Other identified mutations in genes of interest for which targeted therapies exist include mutations in NTRK1 (n=8) and ROS1 (n=15). Screening for 5 gene fusions identified fusions in 15 patients with 12 involving FGFR2. Conclusions: This is the largest prospective global survey of genetic abnormalities using targeted ctDNA testing in newly-diagnosed advanced-stage GEA in patients whose tumors were not known to be HER2 positive. Using a multi-gene panel NGS approach to identify patients with FGFR2 amplification by ctDNA, other potentially clinically actionable genetic abnormalities were identified. Citation Format: Daniel Catenacci, Yoon-Koo Kang, Peter Enzinger, Giovanni G. Cardellino, Raquel Guardeno Sanchez, Aaron Q. Xu, Allie Tappe, Michelle Y. Sun, Siddhartha Mitra, Derek Murphy, Ian Misner, Steven Smith, Zev Wainberg. Circulating tumor DNA (ctDNA) gene sequencing results from prospective screening of patients with newly diagnosed metastatic gastric and gastroesophageal adenocarcinoma (GEA) for the bemarituzumab FIGHT randomized trial using a plasma NGS assay [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2187.

De Novo Mutation in Non-Tyrosine Kinase Domain of ROS1 as a Potential Predictor of Immune Checkpoint Inhibitors in Melanoma.

PurposeDespite the success of targeted therapy in c-ros oncogene 1 (ROS1)-rearranged cancers, especially non-small cell lung cancer (NSCLC), the clinical significance of ROS1 de novo mutation has not yet been understood. We sought to elucidate the predictive effect of ROS1 mutation for immune checkpoint inhibitor (ICI) therapy in melanoma.MethodsThe Cancer Genome Atlas [TCGA (n = 10967)] and Memorial Sloan Kettering Cancer Center [MSK (n = 10,945)] datasets, as well as two clinical cohorts of melanoma received ICI [CA209-038 (n = 73) and MEL-IPI (n = 110)], were included to explore the prevalence, prognostic effect, and immunotherapeutic predictive effect of ROS1 mutation in melanoma. Overall survival (OS) was defined as the primary outcome.ResultsOverall, melanoma accounted for the highest proportion of ROS1 mutation (~20%) which made up the majority (~95%) of the ROS1-alterated cases. Remarkably, ROS1 mutation yielded longer OS from ICI than the wild-type counterpart in the MSK melanoma population [hazard ratio (HR) 0.47, 95% confidence interval (CI) 0.30–0.74], and two external melanoma cohorts (CA209-038: HR 0.42, 95% CI 0.20–0.89; MEL-IPI: HR 0.55, 95% CI 0.34–0.91), without affecting the prognosis of patients. Elevated tumor mutational burden and enrichment of DNA damage repair was observed in ROS1 mutated patients, providing an explanation for the favorable responses to ICI therapy. Precisely, ROS1 mutation in non-protein tyrosine kinase (PTK) domain but not PTK mutation was responsible for the immunotherapy-specific responses of the ROS1 mutated patients in melanoma.ConclusionsCollectively, ROS1 mutation, specifically the non-PTK mutation, is a potential predictor of ICI therapy in melanoma, which is distinct from the well-established role of ROS1 rearrangement for targeted therapy in NSCLC.

Clinical and genetic characteristics of EGFR-mutant lung adenocarcinoma transformed SCLC.

e20588 Background: Transformation from non-small cell lung cancer (NSCLC) to small cell lung cancer (SCLC) is one of the resistance mechanism of EGFR tyrosine kinase inhibitors. However, the clinical course of transformed SCLC and the difference of genomic profiling between de novo SCLC patients and transformed SCLC patients are still poorly characterized. Methods: Patients from our hospital diagnosed with SCLC were enrolled retrospectively in this study, including de novo SCLC patients and SCLC patients transformed from EGFR-mutant lung adenocarcinomas. Genomic profiling was performed on formalin-fixed paraffin-embedded tumor samples by next generation sequencing (NGS). In statistical analysis, fisher ‘exact test was used. All tests were bilateral, with P<0.05 indicating significant statistical difference. Results: In total, 16 patients with SCLC transformed from EGFR-mutant lung adenocarcinomas and 230 de novo SCLC patients were included in our study. Transformed SCLC patients were more in younger (p=0.007), female (p<0.001) and non-smokers (p<0.001) than de novo SCLC patients. In transformed SCLC patients, 12 patients (75%) occurred SCLC transformation within 2 years after the lung adenocarcinomas diagnosis. Median transformation time was 20 months. During the treatment of adenocarcinomas, the overall response rate (ORR) was 75% and the median progression-free survival was 12 months. After the initiation of SCLC therapy, the ORR of 1st line chemotherapy was 40%. For the genomic profiling, EGFR mutations, including exon 19 deletion (56%), L858R (38%), and others (6%), were detected. 11 patients with acquired resistance were received EGFR T790M test, 82% of patients had acquired EGFR T790M mutation. 11 patients after transformation to SCLC had NGS test, 100% maintained their founder EGFR mutation, and other recurrent mutations included TP53, RB1 and EGFR amplification. Compared with the genetic alterations in de novo SCLC patients, TP53 mutations were significantly decreased (p=0.006) while EGFR mutations were significantly elevated (p<0.001) in transformed SCLC patients. However, no significant difference on RB1, ALK and ROS1 mutations were observed. Interestingly, a 60-year-old woman in our transformed SCLC cohort harbored EGFR 19 del mutant at allele frequency of 50.39%，she received osimertinib plus epirubicin/cyclophosphamide as 1st line treatment and reached partial response, with survival of 4 years to date. Conclusions: We demonstrated the clinical and genetic characteristics of EGFR-mutant lung adenocarcinoma transformed SCLC and found one patient still benefited from EGFR-TKI. Our study suggested that SCLC patients with EGFR mutation who transformed from lung adenocarcinoma may be potential benefit population using EGFR inhibitors.

A prognostic model based on CGGA and TCGA databases for predicting outcome of glioma patients.

e14017 Background: Glioma is the most frequent primary malignance of the central nervous system (CNS) and causes the top-ten deaths of cancers. Isocitrate dehydrogenase ( IDH) mutations and chromosome 1p and 19q codeletion are the known prognostic factors of glioma. However, it is still not enough to predict the outcomes. Herein, we conduct a prognostic model of patients with gliomas. Methods: The Chinese Glioma Genome Atlas (CGGA) contained 286 patients with whole-exome sequencing (WES) was used to established the model. Kaplan-Meier analysis based on log-rank test was used to confirm the single mutation overall survival (OS) factors (allele frequency≥ 5) in CGGA. The model was established based on the Cox regression of above significant factors. The data of 1122 patients with glioma in TCGA (The Cancer Genome Atlas) was used to validate the model. Results: According to the CGGA database, the OS factors of glioma patients were 1p/19q, CIC, EGFR ( p< 0.001), IDH1, IRS2, NF1, NOTCH1, PDGFRA, PTEN, ROS1, SMARCA4 and TP53. The Cox regression revealed 1p/19q codeletion (HR = 2.008, 95%CI 1.397-2.885, p< 0.001), EGFR (HR = 0.420, 95%CI 0.217-0.811, p= 0.010), PDGFRA (HR = 0.271, 95%CI 0.139-0.528, p< 0.001), and ROS1 (HR = 0.197, 95%CI 0.071-0.549, p= 0.002). Based on the β value of the regression equation, we divided the glioma patients into 3 groups (G1: harboring EGFR, PDGFR and/or ROS1 mutations; G2: wide type; G3: harboring 1p/19q without mutations in three genes). In TCGA, the OS of glioma patients was also showed G1 < G2 < G3 significantly. Conclusions: The prognostic model was divided glioma patients into three groups reasonably and could provide new reference for the glioma management. It needed to be further verified in more cohorts.

Camrelizumab monotherapy or in combination with apatinib for PD-L1-positive advanced pulmonary sarcomatoid carcinoma: A multicenter, open-label, single-arm, phase II study.

TPS9130 Background: Pulmonary sarcomatoid carcinoma (PSC) is a rare subtype of non-small cell lung cancer (NSCLC) with a fairly poor prognosis. As a highly aggressive malignancy, PSC is insensitive to conventional chemotherapy or radiotherapy and no optimal treatment for PSC has been established yet. Immune checkpoint inhibitors (ICIs) were documented to possess encouraging therapeutic efficacy in PSC patients, which is demonstrated to be associated with high expression of programmed death-ligand 1 (PD-L1) in PSC. However, because of the rarity of PSC, most of the existed data were derived from case repots which could not reflect the true clinical efficacy of ICIs for PSC treatment. This clinical trial was designed to investigate the clinical outcomes of camrelizumab in treating PD-1-positive PSC. Apatinib may be used simultaneously based on the expression level of PD-L1 in PSC as the combination of camrelizumab and apatinib exhibited treatment potential in NSCLC in previous researches. Methods: In this multicenter, open-label, single-arm, phase II study conducted in 44 sites in China, 30 patients with an age of 18-80 years old, an Eastern Cooperative Oncology Group (ECOG) performance score of 0–2, positive PD-L1 expression, no EGFR, ALK, ROS1, and MET gene mutations, and histologically or cytologically confirmed stage IIIB-IV PSC regardless of prior lines of standard therapy will be enrolled. Patients with PD-L1 expression 1-49% will receive Camre (200 mg, IV, Q3W) and Apa (250mg, QD). Patients with PD-L1 expression≥50% receive Camre (200 mg IV Q3W) alone. The treatment will continue until a maximum treatment duration of 36 months, disease progression, intolerable toxicity, death or consent withdrawal. The primary endpoint is objective response rate (ORR). The secondary endpoints are progression-free survival (PFS), overall survival (OS), disease control rate (DCR), time to objective response (TTR), duration of response (DOR) and safety. This study is ongoing. Clinical trial information: ChiCTR2000032649, China.

NTRK, ALK and RET rearrangements in salivary gland cancer.

e18023 Background: We investigated the prevalence of rare genes rearrangements in salivary gland adenocarcinomas and the impact of these fusions on overall survival (OS) and progression free survival (PFS). Methods: For 51/60 (85.0%) patients with different types salivary gland adenocarcinomas (stage I-IVA), sufficient tumor tissue was available for molecular characterization by polymerase chain reaction (PCR) and has been tested for NTRK, ALK, ROS1, RET and MET deletion. OS and PFS curves were estimated with the Kaplan-Meier method and compared using the log-rank test. Results: Two cases (3.92%) of NTRK translocation were found, both are a classic rearrangement of ETV6ex5; NTRK3ex15. Of the other alterations, 2 cases (3.92%) of unbalanced ALK expression. However, it was not possible to establish the option of rebuilding. In addition, were found 2 cases (3.92%) of highly balanced expression of NTRK2 and ALK, and one case (1.96%) of high expression of ROS1. RET mRNA expression was detected in 13 of 48 cases (27.08%). NTRK, RET, ALK and ROS1 fusions were equally common in both men and women (p = 0.89), not depending on age (0.76). All patients bearing ALK, RET and NTRK fusions had shorter overall survival - 13.2 months, 95% confidence interval [CI] 13.0 to 32.0 months in multivariable model 105.0 moth (95% CI 105.0-105.0) in patient's group without mutations (p = 0.1817); and shorter PFS: 5.0 month (95% CI 5.0-16.0) vs not reached PFC in group (mean of PFS 63.15±5.58; 95% CI 52.20-74.09) without mutations (p = 0.0467). ALK fusion is an independent poor prognosis factor affecting on OS: p = 0.0168, hazard ratio (HR) = 8.65 (95% CI 1.47-50.77); and poor prognosis factor affecting on PFS: p = 0.0170, HR = 7.13 (95% CI 1.42-35.80). Conclusions: ALK, NTRK, ROS1 and RET mutations define a new rare subtype of salivary gland adenocarcinomas with enormously poor prognosis. The presence ALK-mutation is an independent poor prognosis factorб negatively affecting both overall survival and progression-free survival. It’s advisable to consider the possibilities of using ALK, NTRK and RET inhibitors in this cohort of patients.

Prevalence of Targetable Mutations in Black Patients With Lung Cancer: A Systematic Review and Meta-Analysis.

Inferior outcomes of Black patients with lung cancer compared with other racial groups are often linked to socioeconomic factors. It is crucial to determine whether a varying prevalence of targetable mutations limits treatments and contributes to disparities. We conducted a meta-analysis on the prevalence of lung cancer EGFR, ALK, ROS-1, and BRAF mutations in Black patients compared with White, Hispanic, and Asian patients. We searched PubMed/MEDLINE, Cochrane Library, EMBASE, CENTRAL, Google Scholar, and clinicaltrials.gov databases. We selected studies reporting the prevalence of at least one mutation in the Black population. We calculated the pooled prevalence of mutations using fixed effects, exact binomial distributions, and Freeman-Turkey double arcsine transformation to stabilize the variances. Twenty studies with 11,867 patients were included. In Black patients, EGFR was the most prevalent mutation (6%; 95% CI, 5 to 7), followed by BRAF (1%; 95% CI, 0 to 2), ALK (1%; 95% CI, 0 to 2), and ROS-1 (0%; 95% CI, 0 to 1). Black patients had a lower prevalence of EGFR mutations than White, Hispanic, and Asian patients (P < .01). BRAF mutations were less prevalent in Black compared with White patients (P < .05), and ALK mutations were less prevalent when compared with Hispanic patients (P < .05). EGFR is the most frequent mutation found in Black patients, although its prevalence is lower than that in other races. Black patients have a low overall prevalence of ALK, ROS-1, and BRAF mutations. Given that disproportional eligibility for targeted therapies may be contributing to inferior outcomes, research focused on the Black population is needed to evaluate specific tumor characteristics and therapeutic strategies.

Real-world utility of next-generation sequencing for targeted gene analysis and its application to treatment in lung adenocarcinoma.

PurposeThis study investigated the clinical utility of next‐generation sequencing (NGS) for detection of genetic alterations and its implications on treatment of lung adenocarcinoma in real‐world practice.Patients and MethodsData were reviewed for 391 patients with lung adenocarcinoma who underwent NGS between March 2017 and October 2018. Formalin‐fixed, paraffin‐embedded archival samples were used for performing NGS targeting 382 genes, including all exons of 199 genes, 184 hotspots, and the partial introns of 8 genes often rearranged in cancer. Survival analysis was performed for stage IV disease.ResultsAmong the 391 patients, at least one actionable mutation was identified in 294 patients (75.2%). The most commonly mutated gene was EGFR (n = 130, 33.2%), involving EGFR exon 19 deletion (n = 48, 12.3%), L858R (n = 47, 12%), and others (n = 35, 9%), followed by KRAS (n = 48, 12.3%), ALK (n = 40, 10.2%), RET (6%), MET (3%), ROS‐1 (3%), and BRAF (2%) mutations. TP53 (46.9%) and CDKN2A (12.6%) mutations were common co‐mutations in patients with AMs. With a median follow‐up duration of 16.8 months, median overall survival was 36.8 months in patients with stage IV disease. Patients treated with the corresponding targeted therapy for AMs based on NGS reports lived significantly longer than those not treated with such therapy (p < 0.001). After multivariate analysis, targeted therapy for AM was a significantly favorable factor for survival (AM without targeted therapy vs. AM with targeted therapy, hazard ratio 2.58, 95% confidence interval 1.57–4.25; p < 0.001).ConclusionThis study revealed that AMs could be comparably detected using NGS. Based on these NGS results, a suitable targeted therapy can be selected, which may improve survival in patients with lung adenocarcinoma. This NGS‐based approach is useful in real‐world practice to provide guidance when selecting targeted therapy.

Cell-Free Circulating Tumor DNA Improves Standard Genotyping of Non-Small-Cell Lung Cancer and Increases Detection of Targetable Alterations in a Selected Hispanic Cohort

Background: Several studies have shown that the non-small-cell lung cancer (NSCLC) genomic background among Hispanics differs from other populations. The finding of low-frequency genomic alterations in cell-free DNA (cfDNA) can increase diagnostic accuracy and could improve treatment in NSCLC. Methods: Data from 54 Hispanic patients with advanced NSCLC with high clinical suspicion for ALK, EGFR, and ROS1 mutations were collected (including young age, female sex, and non-smokers). cfDNA was extracted from plasma and analyzed using a commercial next-generation sequencing test (Guardant360) which detects genomic alterations in 74 genes. Results: The median age was 56 years (range 31–83). Most patients were female (661.1%) and never smokers (72.3%). Among the patients included, 96% (52/54) had cfDNA detectable alterations with a mean number of 3.37 cfDNA alterations per test (range 1–10). cfDNA was able to detect some genomic alterations previously undetected by tissue biopsy. Among patients with insufficient or unavailable tissue to perform testing, mutations in EGFR and ALK which led to a change in therapy were determined using cfDNA in 28.8 and 3.8% of cases, respectively. Among patients with cfDNA alterations, 46.1% (n = 24) were switched to a targeted therapy with a median progression-free survival of 11.1 months (95% CI 7.6–14.6) and an overall survival of 40.3 months (95% CI 27.1–53.6). Concurrent genetic mutations with TP53 and KRAS negatively impacted the prognosis. Conclusions: In a selected population of NSCLC Hispanic patients, comprehensive cfDNA analysis allowed a treatment change in 46.1% of the cases. Guardant360 allows the identification of genomic alterations to improve treatment selection and increase prognosis.

The Role of Pharmacists in Optimizing Molecular Testing with Evolving Biomarkers and Treatment for Non-Small Cell Lung Cancer

Molecular testing and the development of targeted therapies have revolutionized the treatment of non-small cell lung cancer (NSCLC). Despite the advantages of molecular testing in patients with NSCLC and guideline recommendations, there is no specific standard testing method, resulting in variable testing practices based on institution protocol and access. Pharmacists can help to improve coordination of care around appropriate testing as results are important in determining the most appropriate targeted treatment course. The majority of patients with NSCLC are tested for PD-L1, EGFR, ALK, ROS1, and BRAF mutations. These biomarkers and their corresponding targeted therapies are more understood than the remaining biomarkers, such as KRAS, RET, MET exon 14 (METex14), and NTRK. Multiple new and emerging therapies target these latter biomarkers, and this article will focus on these lesser-known biomarkers. As the treatment of NSCLC becomes increasingly biomarker-driven and more therapies are added to the armamentarium for the management of NSCLC, pharmacists will be called upon to assist the oncology care team to optimize NSCLC treatment to improve patient outcomes.

The Landscape of the Advanced NSCLC Treatment Paradigm: Molecular Testing and Actionable Mutations.

At JADPRO Live Virtual 2020, Rasheda Persinger, AGNP-C, explained the current lung cancer treatment landscape, including targeted therapies for EGFR and ALK rearrangements, as well as for BRAF, ROS1, NTRK, RET, MET, and KRAS mutations, and described the different testing modalities for molecular markers.

Spectrum of Mechanisms of Resistance to Crizotinib and Lorlatinib in ROS1 Fusion-Positive Lung Cancer.

Current standard initial therapy for advanced, ROS proto-oncogene 1, receptor tyrosine kinase fusion (ROS1)-positive (ROS1+) non-small cell lung cancer (NSCLC) is crizotinib or entrectinib. Lorlatinib, a next-generation anaplastic lymphoma kinase/ROS1 inhibitor, recently demonstrated efficacy in ROS1+ NSCLC, including in crizotinib-pretreated patients. However, mechanisms of lorlatinib resistance in ROS1+ disease remain poorly understood. Here, we assessed mechanisms of resistance to crizotinib and lorlatinib. Biopsies from patients with ROS1 + NSCLC progressing on crizotinib or lorlatinib were profiled by genetic sequencing. From 55 patients, 47 post-crizotinib and 32 post-lorlatinib biopsies were assessed. Among 42 post-crizotinib and 28 post-lorlatinib biopsies analyzed at distinct timepoints, ROS1 mutations were identified in 38% and 46%, respectively. ROS1 G2032R was the most commonly occurring mutation in approximately one third of cases. Additional ROS1 mutations included D2033N (2.4%) and S1986F (2.4%) post-crizotinib and L2086F (3.6%), G2032R/L2086F (3.6%), G2032R/S1986F/L2086F (3.6%), and S1986F/L2000V (3.6%) post-lorlatinib. Structural modeling predicted ROS1L2086F causes steric interference to lorlatinib, crizotinib, and entrectinib, while it may accommodate cabozantinib. In Ba/F3 models, ROS1L2086F, ROS1G2032R/L2086F, and ROS1S1986F/G2032R/L2086F were refractory to lorlatinib but sensitive to cabozantinib. A patient with disease progression on crizotinib and lorlatinib and ROS1 L2086F received cabozantinib for nearly 11 months with disease control. Among lorlatinib-resistant biopsies, we also identified MET amplification (4%), KRAS G12C (4%), KRAS amplification (4%), NRAS mutation (4%), and MAP2K1 mutation (4%). ROS1 mutations mediate resistance to crizotinib and lorlatinib in more than one third of cases, underscoring the importance of developing next-generation ROS1 inhibitors with potency against these mutations, including G2032R and L2086F. Continued efforts are needed to elucidate ROS1-independent resistance mechanisms.

Treatment patterns in non-small-cell lung cancer in China: Results from the CancerMPact survey 2020

PurposeTo report the treatment patterns of non-small-cell lung cancer (NSCLC) patients in China based on a survey of physicians (CancerMPact). Methods117 Chinese physicians from 27 cities in mainland China were recruited for an online survey in October 2020, reporting on how they treat their patients across all disease stages, including histology and relevant biomarkers in advanced or metastatic NSCLC. ResultsSurveyed physicians indicated that almost half of their stage I patients were treated with surgery only. For stage II patients, it is more common to treat with surgery in combination with radiation and/or systemic therapy (44.5%), whereas the use of surgery decreases for stage III patients and the overall use of systemic therapy increases (63.4%-68.8%). Physicians are more likely to use systemic therapy alone for stage IV patients (31.4%). Chosen treatment regimens for stage IV NSCLC varied by histology and biomarkers, and several observed treatment patterns differed from the USA. In China, platinum-based chemotherapy is standard of care for treating stage IV NSCLC patients, unlike the USA, where checkpoint inhibitors are the dominant choice in first-line. Further, Chinese physicians reported prescribing biomarker-targeted agents for one-third or less of their patients with EGFR, ALK, ROS-1, or BRAF driver mutations, compared to 60–95% in the USA. ConclusionAs treatment options expand in NSCLC in China, physicians face complex decisions for the treatment of their patients. Treatment patterns often vary, including by disease histology and clinically relevant biomarkers. The standard of care for NSCLC in China also differs from the USA.

FISH patterns of ROS1, MET, and ALK with a correlation of ALK immunohistochemistry in lung cancer: a case for introducing ALK immunohistochemistry 'Equivocal' interpretation category in the Ventana anti-ALK (D5F3) CDx assay - A tertiary cancer center experience.

Mutations in ROS1, ALK, and MET genes are targetable alterations in non-small cell lung cancer (NSCLC). They can be evaluated by different techniques, most commonly fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC). We explored the prevalence of ROS1, ALK, MET mutations, discuss clinicopathological associations and FISH signal patterns on 413 consecutive cases of EGFR negative lung carcinoma from March 2016 to April 2017 using FISH for ALK, ROS1, and MET along with ALK (D5F3) IHC. ROS1 gene rearrangement, ALK positivity (IHC and/or FISH), and MET amplification were seen in 18/358 (5%) cases, 76/392 cases (19.4%), and 10/370 (2.7%) cases, respectively. ALK FISH and ALK IHC were positive in 51/300 (17%) and 58/330 cases (17.57%), respectively, while 8/330 (2.4%) cases were ALK IHC "equivocal" of which 3/8 (37.5%) were ALK FISH positive. Of ALK FISH and IHC co-tested cases, 43/238 (18.07%) cases were positive by both techniques, while 15/43 (34.88%) of ALK positive cases showed discordant ALK FISH and IHC results. All ROS1 rearranged and MET amplified cases were adenocarcinoma. Signet ring cell histology was associated with 78.57% likelihood of being either ALK or ROS1 positive. Genomic heterogeneity was seen in 30% of MET amplified cases. ALK/ROS1/MET gene alterations were found in 25.18% of NSCLC cases. An ALK IHC "equivocal" interpretation category should be incorporated into practice. Atypical patterns of ROS1 and genomic heterogeneity need to be evaluated further for any clinical relevance.