ROS1 Tyrosine Kinase Inhibitors Research Articles

Repotrectinib: Redefining the therapeutic landscape for patients with ROS1 fusion-driven non-small cell lung cancer.

The ROS1 proto-oncogene encodes a receptor tyrosine kinase with structural homology to other oncogenic drivers, including ALK and TRKA-B-C. The FDA-approved tyrosine kinase inhibitors (TKIs) crizotinib and entrectinib have demonstrated efficacy in treating ROS1 fusion-positive NSCLC. However, limitations such as poor blood-brain barrier penetration and acquired resistance, particularly the ROS1 G2032R solvent-front mutation, hinder treatment durability. Repotrectinib, a next-generation macrocyclic TKI, was rationally designed to overcome on-target resistance mutations and improve brain distribution through its low molecular weight. In the TRIDENT-1 clinical trial, repotrectinib demonstrated significant efficacy in both TKI-naïve and TKI-pretreated patients with ROS1-rearranged NSCLC, including those with CNS metastases and G2032R resistance mutations. In the TKI-naïve cohort (n = 71), 79% of patients achieved an objective response, with a median progression-free survival (PFS) of 35.7 months, surpassing all previously approved ROS1 TKIs. In patients who had received one prior ROS1 TKI but were chemotherapy-naïve (n = 56), objective responses were observed in 38%, and median PFS was 9.0 months. The safety profile of repotrectinib was consistent with earlier-generation ROS1 TKIs and common adverse events included anemia, neurotoxicity, increased creatine kinase levels, and weight gain. These findings underscore the potential of repotrectinib to address unmet needs in ROS1-rearranged NSCLC, offering durable responses and improved intracranial activity. Future research should prioritize developing next-generation, selective ROS1 inhibitors to reduce Trk-mediated toxicities and improve treatment tolerance.

Advances and future directions in ROS1 fusion-positive lung cancer.

ROS1 gene fusions are an established oncogenic driver comprising 1%-2% of non-small cell lung cancer (NSCLC). Successful targeting of ROS1 fusion oncoprotein with oral small-molecule tyrosine kinase inhibitors (TKIs) has revolutionized the treatment landscape of metastatic ROS1 fusion-positive (ROS1+) NSCLC and transformed outcomes for patients. The preferred Food and Drug Administration-approved first-line therapies include crizotinib, entrectinib, and repotrectinib, and currently, selection amongst these options requires consideration of the systemic and CNS efficacy, tolerability, and access to therapy. Of note, resistance to ROS1 TKIs invariably develops, limiting the clinical benefit of these agents and leading to disease relapse. Progress in understanding the molecular mechanisms of resistance has enabled the development of numerous next-generation ROS1 TKIs, which achieve broader coverage of ROS1 resistance mutations and superior CNS penetration than first-generation TKIs, as well as other therapeutic strategies to address TKI resistance. The approach to subsequent therapy depends on the pace and pattern of progressive disease on the initial ROS1 TKI and, if known, the mechanisms of TKI resistance. Herein, we describe a practical approach for the selection of initial and subsequent therapies for metastatic ROS1+ NSCLC based on these clinical considerations. Additionally, we explore the evolving evidence for the optimal treatment of earlier-stage, non-metastatic ROS1+ NSCLC, while, in parallel, highlighting future research directions with the goal of continuing to build on the tremendous progress in the management of ROS1+ NSCLC and ultimately improving the longevity and well-being of people living with this disease.

FDA Approval Summary: Repotrectinib for Locally Advanced or Metastatic ROS1-Positive Non-Small Cell Lung Cancer.

On November 15, 2023, the U.S. Food and Drug Administration (FDA) granted traditional approval to repotrectinib (Augtyro, Bristol Myers Squibb Corporation) for the treatment of adult patients with locally advanced or metastatic receptor tyrosine kinase encoded by the ROS1 gene (ROS1)-positive non-small cell lung cancer (NSCLC). The approval was based on TRIDENT-1, a single-arm trial with multiple cohorts of patients with ROS1 fusion-positive (hereafter "ROS1-positive") NSCLC (NCT03093116), who were either treatment naïve or had received prior ROS1 tyrosine kinase inhibitor (TKI) and/or platinum-based chemotherapy. The primary efficacy outcome measure is objective response rate (ORR) assessed by blinded independent central review (BICR) using response evaluation criteria in solid tumors version 1.1. ORR was assessed in 71 patients who were ROS1 TKI naïve and 56 patients who had received a prior ROS1 TKI. Among the 71 patients who were ROS1 TKI naïve, the ORR was 79% (95% CI, 68-88), median duration of response was 34.1 months (95% CI, 26-NE). In patients who had received a prior ROS1 TKI and no prior chemotherapy, the ORR was 38% (95% CI, 25-52). The median duration of response was 14.8 months (95% CI, 7.6-NE); BICR-assessed responses were observed in CNS metastases in patients in both cohorts and in patients who developed resistance mutations following prior TKI therapy. The most common (>20%) adverse reactions were dizziness, dysgeusia, peripheral neuropathy, constipation, dyspnea, ataxia, fatigue, cognitive disorders, and muscular weakness. A unique feature of this ROS1 TKI approval is the inclusion of robust evidence of efficacy in patients with ROS1-positive NSCLC who had progressed on prior ROS1 TKIs.

TKI type switching overcomes ROS1 L2086F in ROS1 fusion-positive cancers

ROS1 tyrosine kinase inhibitors (TKIs) are highly effective in ROS1-positive non-small cell lung cancer, but resistance remains a challenge. We investigated the activity of various TKIs against wildtype and mutant ROS1, focusing on the emerging L2086F resistance mutation. Using Ba/F3 and NIH3T3 cell models, CRISPR/Cas9-edited isogenic wildtype and mutant patient-derived cell lines, and in vivo tumor growth studies, we compared type I TKIs (crizotinib, entrectinib, taletrectinib, lorlatinib, and repotrectinib) to type II TKIs (cabozantinib and merestinib) and the type I FLT3 inhibitor gilteritinib. The ROS1 L2086F mutant kinase showed resistance to type I TKIs, while type II TKIs retained activity. Gilteritinib inhibited both wildtype and L2086F mutant ROS1 but was ineffective against the G2032R mutation. Structural analyses revealed distinct binding poses for cabozantinib and gilteritinib, explaining their efficacy against L2086F. Clinical cases demonstrated cabozantinib’s effectiveness in patients with TKI-resistant, ROS1 L2086F mutant NSCLCs. This study provides the first comprehensive report of ROS1 L2086F in the context of later-generation TKIs, including macrocyclic inhibitors. While cabozantinib effectively inhibits ROS1 L2086F, its multi-kinase inhibitor nature highlights the need for more selective and better-tolerated TKIs to overcome kinase-intrinsic resistance. Gilteritinib may offer an alternative for targeting ROS1 L2086F with distinct off-target toxicities, but further studies are required to fully evaluate its potential in this setting.

Efficacy and Safety of Taletrectinib in Chinese Patients With ROS1+ Non-Small Cell Lung Cancer: The Phase II TRUST-I Study.

Taletrectinib, a highly potent, CNS-active, ROS1 tyrosine kinase inhibitor (TKI), has demonstrated high and durable response rates, high intracranial objective response rate (ORR), prolonged progression-free survival (PFS), and activity against G2032R with a favorable safety profile. We report outcomes from the pivotal TRUST-I study (ClinicalTrials.gov identifier: NCT04395677) of taletrectinib for ROS1+ non-small cell lung cancer in China. TRUST-I evaluated TKI-naїve and crizotinib-pretreated patients. The primary end point was confirmed ORR (cORR) by independent review committee; key secondary end points included duration of response (DOR), PFS, and safety. As of November 2023, 173 patients were enrolled (median age, 55 years; 58% female; 73% never smoked; TKI naїve: n = 106; crizotinib pretreated: n = 67). In TKI-naїve patients, cORR and intracranial cORR were 91% and 88%, respectively, and 52% and 73% in crizotinib-pretreated patients. In TKI-naїve patients, median DOR and median PFS were not reached (NR) with 22.1-month and 23.5-month follow-up, respectively. In crizotinib-pretreated patients, the median DOR was 10.6 months (95% CI, 6.3 months to NR; 8.4-month follow-up), and the median PFS was 7.6 months (95% CI, 5.5 to 12.0 months; 9.7-month follow-up). Eight of 12 patients (67%) with G2032R mutations responded. The most frequent treatment-emergent adverse events (TEAEs) were increased AST (76%), diarrhea (70%), and increased ALT (68%), most of which were grade 1-2. Incidences of neurologic TEAEs were low (dizziness: 23%; dysgeusia: 10%) and mostly grade 1. Discontinuations (5%) and dose reductions (19%) due to TEAEs were low. Taletrectinib continues to show high and durable overall responses, prolonged PFS, robust activity against intracranial lesions and acquired resistance mutations including G2032R, and a favorable safety profile with a low incidence of neurologic TEAEs.

Updated study results of novel FAK/ALK/ROS1 inhibitor APG-2449 in patients (pts) with non-small-cell lung cancer (NSCLC) resistant to second-generation ALK inhibitors.

3124 Background: ALK inhibitors increase FAK pathway gene expression in ALK+ NSCLC cell lines, with the highest induced expression in drug-tolerant persister cells. This suggests that FAK pathway activation is involved in ALK inhibitor-induced early adaptive tolerance in ALK+ NSCLC. Investigational APG-2449 is a novel, orally active FAK inhibitor and a third-generation (3G) ALK/ROS1 tyrosine kinase inhibitor (TKI) with potent activity in preclinical models. APG-2449 is well tolerated at the recommended phase 2 dose (RP2D) and showed preliminary efficacy in pts resistant to 2G ALK TKIs. Here, we provide further safety and efficacy results and demonstrate associations between this therapy and FAK signaling pathways. Methods: After the RP2D was determined as 1,200 mg daily (QD), pts with NSCLC were enrolled into 2 dose expansion cohorts. Cohort 1 included pts who were resistant to 2G ALK TKIs. Cohort 2 included those who were ALK or ROS1 TKI naïve. Results: As of December 9, 2023, 144 pts (median [range] age, 53 [21-78] years; 53.5% female) with NSCLC, mesothelioma, or ovarian cancer were treated with APG-2449 at doses of 150 to 1,500 mg. A total of 129 (89.6%) pts had treatment-related adverse events (TRAEs), the most frequent of which were elevated serum creatinine (49.3%), ALT (42.4%), and AST (36.1%); nausea (28.5%); vomiting (23.6%); diarrhea (22.9%); and decreased leukocyte count (22.2%). In all, 20 (13.9%) TRAEs were grade ≥ 3. Of pts with TKI-naïve NSCLC (n = 36) treated at the RP2D, the overall response (ORR) and disease control rates (DCR = CR + PR + SD) were 68.2% (15/22) and 90.1% (20/22) in ROS1 TKI-naïve pts; and 78.6% (11/14) and 100% (14/14) in ALK TKI-naïve pts. Median progression-free survival (mPFS) in ALK TKI-naïve pts was not reached. Of 22 pts with NSCLC resistant to 2G ALK inhibitors and without targetable bypass gene mutations (e.g., KRAS G12C, BRAF V600E), 9 had PRs (9/22; 40.9%) and the mPFS during APG-2449 treatment at RP2D was 11.86 months. Nine of 12 pts in the RP2D group achieved intracranial PR, resulting in an intracranial ORR of 75.0%. Before APG-2449 administration, 17 tumor tissue samples were collected from pts with NSCLC resistant to 2G ALK inhibitors (in the RP2D group), and IHC was used to assess protein levels of phosphorylated FAK (pFAK). The PFS of pts treated with APG-2449 correlated with pFAK levels in baseline tumor tissue, and pts with higher pFAK levels were more likely to benefit from APG-2449 treatment. Conclusions: APG-2449 demonstrated preliminary efficacy in pts with NSCLC whose disease was TKI naïve and resistant to 2G ALK inhibitors, especially in brain metastases. High pFAK expression levels in baseline tumor tissue correlated with improved APG-2449 treatment responses in pts with NSCLC resistant to 2G ALK inhibitors. Internal study identifier: APG2449XC101. Clinical trial information: NCT03917043 .

Efficacy and safety of taletrectinib in patients with advanced or metastatic ROS1+ non–small cell lung cancer: The phase 2 TRUST-I study.

8520 Background: Taletrectinib, a highly potent, next-generation, central nervous system–active, selective ROS1 tyrosine kinase inhibitor (TKI), was previously reported to provide high overall and intracranial (IC) response rates, prolonged progression-free survival (PFS), and activity against G2032R with favorable tolerability. We report updated data from the TRUST-I study (NCT04395677), the largest clinical trial to date conducted in patients living with ROS1+ NSCLC. Methods: TRUST-I, a multicenter, single-arm, open-label, pivotal phase 2 study of taletrectinib conducted in China, had 2 cohorts: TKI-naïve and TKI-pretreated. The primary endpoint was objective response rate (ORR) by Independent Review Committee (IRC) per RECIST 1.1. Secondary endpoints included duration of response (DoR), PFS, overall survival (OS), and safety. Results: As of November 2023, 173 patients were enrolled (median age: 55 y; 58% female; 73% never smoked; TKI-naïve: n = 106; TKI-pretreated: n = 67). In TKI-naïve patients, 21% had prior chemotherapy, and 17% had brain metastases; in TKI-pretreated patients, 34% had prior chemotherapy, and 42% had brain metastases. In TKI-naïve patients, the ORR was 91% (95% CI: 83, 95) and IC-ORR was 88% (7/8; 95% CI: 47, 100). In TKI-pretreated patients, the ORR was 52% (95% CI: 40, 65) and IC-ORR was 75% (12/16; 95% CI: 48, 93). In patients with G2032R mutation, 8 of 12 patients (67% [95% CI: 35, 90]) responded. DoR and PFS remain durable, with median follow-up of 23.5 months in TKI-naïve patients and 9.7 months in TKI-pretreated patients (Table). Among all patients (n = 173), the most frequent treatment-emergent adverse events (TEAEs) were AST increase (76%), diarrhea (70%), and ALT increase (68%). Rates of neurologic TEAEs were low (dizziness: 23%; dysgeusia: 10%) and mostly grade 1. Discontinuation (5%) and dose reductions (19%) due to TEAEs were low. Conclusions: With longer follow-up, taletrectinib continues to show high and durable overall responses, robust intracranial and G2032R activity, and a favorable safety profile with a low incidence of neurologic AEs. An additional ongoing pivotal phase 2 study, TRUST-II (NCT04919811), is further evaluating the efficacy and safety of taletrectinib in patients in the US, Europe, and Asia. Clinical trial information: NCT04395677 . [Table: see text]

Repotrectinib in tyrosine kinase inhibitor (TKI)-naïve patients (pts) with advanced ROS1 fusion-positive (ROS1+) NSCLC in the phase 1/2 TRIDENT-1 trial: Clinical update, treatment beyond progression and subsequent therapies.

8522 Background: Repotrectinib, a next-generation ROS1 TKI, has demonstrated durable clinical activity in the pivotal phase 1/2 TRIDENT-1 trial (NCT03093116). We report updated efficacy with a median follow-up of 33.9 months (mo) [~10 mo of additional follow-up], the first analyses of progression patterns, treatment beyond progression, and an update on subsequent anticancer therapies. Methods: Recommended phase 2 dose was 160 mg QD for 14 days, then 160 mg BID. Phase 2 primary endpoint was confirmed objective response rate (cORR) by blinded independent central review (BICR) per RECIST v1.1. Secondary endpoints included duration of response (DOR), progression-free survival (PFS), intracranial ORR (icORR), and safety. Treatment beyond BICR-assessed progression and sites of progression (per investigator) were also assessed. Safety assessments included all treated pts. Results: As of 15 Oct 2023, median follow-up in the TKI-naïve cohort (n = 71) was 33.9 (range, 24.0–76.5) months (mo). cORR was 79% (95% CI, 68–88); median DOR was 34.1 (95% CI, 27.4–not estimable [NE]) mo and 70% (95% CI, 57–83) of responders maintained a response of ≥ 24 mo. Median PFS was 35.7 (95% CI, 24.6–NE) mo and 63% (95% CI, 51–75) of pts were progression-free at 24 mo. Of 9 pts with measurable baseline brain metastases, icORR was 89% (95% CI, 52–100). Results for pts who received repotrectinib beyond progression are shown in the table. Of pts with disease progression per investigator (n = 37), the most common sites were lung (49%) and lymph nodes (35%). Of 42 (59%) pts who discontinued repotrectinib for any reason, 11 (26%) received single-agent TKI as the first subsequent anticancer therapy, 10 (24%) received chemo with/without immunotherapy (IO), and 2 (5%) received IO alone. Among all pts who received ≥ 1 dose of repotrectinib (n = 565), grade ≥ 3 treatment-emergent adverse events occurred in 323 (57%) pts and treatment-related adverse events in 162 (29%) pts. Treatment-emergent dizziness occurred in 63% of pts and was mostly grade 1-2. Conclusions: With a median follow-up of ~3 years in TRIDENT-1, repotrectinib continued to demonstrate durable clinical activity in ROS1 TKI-naïve pts. Progression patterns and treatment beyond progression were described for the first time. Clinical trial information: NCT03093116 . [Table: see text]

Nonsmall-cell lung cancer treatment: current status of drug repurposing and nanoparticle-based drug delivery systems.

Drug repurposing is the strategy of drug utilization for a treatment option other than the intended indications. This strategy has witnessed increased adoption over the past decades, especially within cancer nanomedicine. Cancer nanomedicine has been facilitated through nanoparticle-based (NP-based) delivery systems which can combat nonsmall-cell lung cancer (NSCLC) via recent advances in nanotechnology and apply its benefits to existing drugs. The repurposing of drugs, coupled with NP-based drug delivery systems, presents a promising avenue for achieving effective therapeutic solutions with accelerated outcomes. This review aims to present an overview of NSCLC treatments, with a specific focus on drug repurposing. It seeks to elucidate the latest advances in clinical studies and the utilization of NP-based drug delivery systems tailored for NSCLC treatment. First, the molecular mechanisms of Food and Drug Administration (FDA)-approved drugs for NSCLC, including ROS1 tyrosine kinase inhibitors (TKI) like repotrectinib, approved in November 2023, are detailed. Further, in vitro studies employing a combination strategy of drug repurposing and NP-based drug delivery systems as a treatment approach against NSCLC are listed. It includes the latest study on nanoparticle-based drug delivery systems loaded with repurposed drugs.

Abstract LB182: Mutagenesis screens support potential best-in-class profile for selective, brain-penetrant, and TRK-sparing ROS1 inhibitor NVL-520

Abstract Introduction. ROS1 fusions are recurrent oncogenic drivers in non-small cell lung cancer (NSCLC). Tyrosine kinase inhibitors (TKIs) crizotinib, entrectinib, and repotrectinib have been approved for the treatment of ROS1-positive NSCLC. Response to these TKIs can be limited by emergence of drug resistance, with ~40% of patients acquiring on-target ROS1 mutations at progression on crizotinib. NVL-520 is an investigational, brain-penetrant, and TRK-sparing ROS1 TKI designed to maintain activity for ROS1 mutations that confer resistance to approved therapies. To investigate suppression of resistance by NVL-520, we performed two N-ethyl-N-nitrosourea (ENU) mutagenesis screens and determined the frequency and identity of resistance mutations following treatment with NVL-520 versus earlier-generation ROS1 TKIs. Methods. Cells were treated with ENU for 1 day followed by crizotinib, entrectinib, repotrectinib, or NVL-520 for 28 days. Frequency of resistance indicates the fraction of wells that proliferated on day 28 despite continuous TKI treatment. Resistance mutations in the ROS1 kinase domain were identified by Sanger sequencing. Resistant clones harboring ROS1 kinase-domain mutations were expanded and used to profile the inhibitory activity of ROS1 TKIs. Results. The first ENU screen was performed on Ba/F3 CD74-ROS1, simulating a first-line treatment setting. NVL-520 at an unbound drug concentration (Cunbound) of 8.2 nM yielded 1 resistant clone among 480 replicate wells (frequency of resistance = 0.2%). The second screen was performed on Ba/F3 CD74-ROS1 G2032R, which is the most common point mutation after progression on previous-generation therapies, simulating a later-line treatment setting. NVL-520 at Cunbound of 41 nM yielded 6 resistant clones among 480 replicate wells (frequency of resistance = 1.3%). These NVL-520 concentrations (8.2 - 41 nM) were well within its average Cunbound of 166 nM at the recommended phase 2 dose (RP2D) of 100 mg once daily. None of the 7 resistant clones harbored ROS1 kinase-domain mutations, suggesting an off-target resistance mechanism. Crizotinib, entrectinib, and repotrectinib at their respective average human Cunbound yielded frequencies of resistance ranging from >33% to 100% in at least one of the screens, indicating that they were less effective than NVL-520 at suppressing resistance in these screens. Conclusion. NVL-520 was highly effective at suppressing resistance in ENU mutagenesis screens simulating first-line (CD74-ROS1) and later-line (CD74-ROS1 G2032R) treatment. The screens did not reveal any novel ROS1 mutations that could confer resistance to NVL-520 at the RP2D. The broad preclinical activity against ROS1 and diverse ROS1 mutations, together with its brain penetrance and TRK-sparing design, suggests NVL-520 as a potential best-in-class ROS1 therapy. Citation Format: Anupong Tangpeerachaikul, Franklin Gu, Henry E. Pelish. Mutagenesis screens support potential best-in-class profile for selective, brain-penetrant, and TRK-sparing ROS1 inhibitor NVL-520 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB182.

ROS1 Positive Non-Small Cell Lung Cancer Patient with Brain Metastases Who Overcame Crizotinib Resistance with Lorlatinib: Case Report

Background: ROS1-positive patients account for 1-2% of non small cell lung cancer (NSCLC) cases. Crizotinib is the first tyrosine kinase inhibitor (TKI) indicated in first line treatment of ROS1-rearranged NSCLC. However, crizotinib resistance is frequent within the first 12 months of treatment. Lorlatinib is a novel tyrosine kinase inhibitor of ROS-1 recently indicated for metastatic or locally advanced crizotinib-resistant NSCLC. Case report: We report a case of a 43-year-old female patient with no medical history, diagnosted with stage IVB NSCLC including asymptomatic brain metastasis, and harboring ROS1 rearrangement. Within the first three months of starting crizotinib, the patient showed on CT scan evaluation new bone and brain metastases. Lorlatinib in the second line revealed a noteworthy improvement in metastasis and primary lesion. Conclusion: Brain metastases frequently occur in ROS1-rearranged NSCLC at the time of diagnosis and treatment course. However the efficacy of crizotinib might not translate to intracranial control of the disease, one of the cause of resistance to this drug.

Clinical outcomes of ROS1-positive non-small cell lung cancer with limited access to ROS1-tyrosine kinase inhibitors (TKIs): experience from an Indian tertiary referral centre.

ROS1 as a driver mutation is observed in approximately 1%-2% of all non-small cell lung cancer (NSCLC). Given its rarity, we share our experience regarding ROS1-positive NSCLC including the access to ROS1 tyrosine kinase inhibitors (TKIs) in a low-middle income country like India. It is a retrospective analysis of ROS1-positive NSCLC patients registered between January 2015 to December 2021 for demographics, treatment patterns and outcomes i.e., overall survival (OS) and progression free survival (PFS). Baseline characteristics were available for 70 patients of 78 patients positive for ROS1 by fluorescent in situ hybridisation. Median age at presentation was 52 years, 39 (55.7%) were males, most (51, 72.86%) were non-smokers and ten patients (14.3%) had poor Eastern Cooperative Oncology Group (ECOG) performance status (PS) i.e., PS >2 at presentation. A total of 67 patients receiving cancer directed therapy were analysed for survival. The first line (1L) therapies included - ROS1 TKIs in 38, chemotherapy in 20, epidermal growth factor receptor TKI in eight and chemotherapy-bevacizumab in one only. ROS1 TKI was provided to 20 patients as part of an assistance programme. The median OS for patients who received ROS1 TKI was not attained (95% CI 37.85-NA), while it was 8.11 (95% CI 6.31-NA) months for those who did not (HR-0.1673). The median PFS for the 1L ROS1 TKI compared to the no-TKI group was 27.07 (95% CI 24.28-NA) months versus 5.78 (95% CI 3.42-12) months (HR: 0.2047). Poor ECOG PS at presentation was the only independent prognosticator for survival. Using ROS1 TKI improves clinical outcomes in all-comers though statistically not significant. To further improve outcomes, future trials should pay special attention to patients with poor PS and find a way to increase the current limited access to TKI.

Repotrectinib in ROS1 Fusion–Positive Non–Small-Cell Lung Cancer

BackgroundThe early-generation ROS1 tyrosine kinase inhibitors (TKIs) that are approved for the treatment of ROS1 fusion–positive non–small-cell lung cancer (NSCLC) have antitumor activity, but resistance develops in tumors, and intracranial activity is suboptimal. Repotrectinib is a next-generation ROS1 TKI with preclinical activity against ROS1 fusion–positive cancers, including those with resistance mutations such as ROS1 G2032R.MethodsIn this registrational phase 1–2 trial, we assessed the efficacy and safety of repotrectinib in patients with advanced solid tumors, including ROS1 fusion–positive NSCLC. The primary efficacy end point in the phase 2 trial was confirmed objective response; efficacy analyses included patients from phase 1 and phase 2. Duration of response, progression-free survival, and safety were secondary end points in phase 2.ResultsOn the basis of results from the phase 1 trial, the recommended phase 2 dose of repotrectinib was 160 mg daily for 14 days, followed by 160 mg twice daily. Response occurred in 56 of the 71 patients (79%; 95% confidence interval [CI], 68 to 88) with ROS1 fusion–positive NSCLC who had not previously received a ROS1 TKI; the median duration of response was 34.1 months (95% CI, 25.6 to could not be estimated), and median progression-free survival was 35.7 months (95% CI, 27.4 to could not be estimated). Response occurred in 21 of the 56 patients (38%; 95% CI, 25 to 52) with ROS1 fusion–positive NSCLC who had previously received one ROS1 TKI and had never received chemotherapy; the median duration of response was 14.8 months (95% CI, 7.6 to could not be estimated), and median progression-free survival was 9.0 months (95% CI, 6.8 to 19.6). Ten of the 17 patients (59%; 95% CI, 33 to 82) with the ROS1 G2032R mutation had a response. A total of 426 patients received the phase 2 dose; the most common treatment-related adverse events were dizziness (in 58% of the patients), dysgeusia (in 50%), and paresthesia (in 30%), and 3% discontinued repotrectinib owing to treatment-related adverse events.ConclusionsRepotrectinib had durable clinical activity in patients with ROS1 fusion–positive NSCLC, regardless of whether they had previously received a ROS1 TKI. Adverse events were mainly of low grade and compatible with long-term administration. (Funded by Turning Point Therapeutics, a wholly owned subsidiary of Bristol Myers Squibb; TRIDENT-1 ClinicalTrials.gov number, NCT03093116.)

Clinical Perspectives on the Evolution of Non-small Cell Lung Cancer Treatment With Immuno-oncology and ROS1 Tyrosine Kinase Inhibitors

The non-small cell lung cancer (NSCLC) treatment landscape has rapidly evolved over the last two decades. The addition of immuno-oncology (I-O) and targeted agents has improved treatment options for patients with non-metastatic and metastatic NSCLC; however, there remains significant unmet need. In this symposium, Jürgen Wolf, University Hospital Cologne, Germany; Tina Cascone, MD Anderson Cancer Center, Houston, Texas, USA; and Jose Luis Campo-Cañaveral de la Cruz, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain, discussed the increasingly complex NSCLC treatment landscape, and how the latest data may impact treatment selection. This symposium focused on I-O monotherapy and I-O combinations in treatment-naïve metastatic NSCLC, as well as the application of I-O in non-metastatic or resectable NSCLC in the neoadjuvant, peri-operative, and adjuvant settings. In addition, the latest data regarding treatment options for patients with targetable alterations, such as ROS1, were discussed, with a focus on next generation tyrosine kinase inhibitors (TKI), and how these may impact treatment selection in the future. The role of the surgeon as part of the multidisciplinary team was also discussed, with particular attention to assessment and definition of surgical complexity, as well as the importance of close collaboration and communication between the multidisciplinary team (MDT) and the patient, to ensure they are receiving the optimal treatment at the right time to improve outcomes.

Abstract C148: Type II ROS1 inhibitors and their liability on ROS1 rearranged non-small cell lung cancer with L2086F mutation

Abstract Introduction: Fusion oncoproteins involving the ROS1 receptor tyrosine kinase have been established as validated therapeutic targets in non-small cell lung cancer. FDA-approved ROS1 tyrosine kinase inhibitors (TKIs) such as crizotinib and entrectinib have shown substantial response rates in these patients, leading to improved outcomes. Historically, the solvent-front ROS1 kinase mutation, G2032R, was a recurrent resistance liability to first generation ROS1 TKI. Next-generation TKIs, including NVL-520, repotrectinib, and taletrectinib are active against the ROS1 G2032R and shown activity in both treatment-naïve and ROS1 G2032R acquired resistance setting. We and others showed that ROS1 L2086F a mutation in catalytic-spine 6 within the kinase domain confers resistance to all first and next-generation type I binding mode TKIs. Cabozantinib, a type II ROS1 inhibitor, is the only FDA-approved TKI that has showed clinical activity against ROS1 L2086F. Recent reports indicated that gilteritinib, an FLT3 TKI, exhibits activity against ALK L1256 (homologous to ROS1 L2086F). In this study, we investigated the efficacy of gilteritinib compared to cabozantinib in ROS1 L2086F resistance model systems. Methods: We tested the effectiveness of ROS1 TKI compared to gilteritinib in Ba/F3 cell lines expressing CD74-ROS1 and EZR-ROS1 resistant mutations. Additionally, we quantified the efficacy of cabozantinib and gilteritinib in ROS1 L2086F using soft agar assays. We engineered CRISPR-Cas9 genome-edited CUTO-28 cells expressing endogenous L2086F mutation, and to validate the activity of gilteritinib and cabozantinib against ROS1 L2086F. Results: The ROS1 kinase mutations F2004C, G2032R and L2086F are resistant to entrectinib inhibition. Cabozantinib, consistent with our previous published data, retains inhibitory activity against ROS1 G2032R and ROS1 L2086F, however the ROS1 F2004C mutation imposes cabozantinib-resistance. Gilteritinib, intriguingly, is active with IC50 ≤ 25 nM against ROS1 F2004C and ROS1 L2086F but not ROS1 G2032R. Immunoblotting studies showed on-target inhibition of ROS1 auto-phosphorylation and effector ERK1/2 activation in the case of ROS1 L2086F mutant cells treated with cabozantinib and gilteritinib. Conclusion: Gilteritinib demonstrates inhibitory activity against ROS1 L2086F mutation. Currently, patients with ROS1 L2086F resistance can be treated with cabozantinib as a second-line treatment option. The preclinical data presented herein suggest that gilteritinib could be an additional, potentially viable alternative to target the highly resistant ROS1 L2086F mutation. Additional studies are needed to explore the use of gilteritinib for ROS1 rearranged NSCLC. Citation Format: Rajat Thawani, Clare Keddy, Matteo Repetto, Kristen Jones, Katelyn Nicholson, Zoe Beach, Alexander Drilon, Monika Davare. Type II ROS1 inhibitors and their liability on ROS1 rearranged non-small cell lung cancer with L2086F mutation [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C148.

Abstract PR003: Repotrectinib in patients with ROS1 fusion-positive (ROS1+) non-small cell lung cancer (NSCLC): Update from the pivotal phase 1/2 TRIDENT-1 trial

Abstract Introduction: Repotrectinib, a next-generation ROS1 tyrosine kinase inhibitor (TKI), has demonstrated durable activity and manageable safety in patients (pts) with locally advanced/metastatic ROS1+ NSCLC in the pivotal phase 1/2 TRIDENT-1 trial (NCT03093116). We report efficacy with a minimum follow-up of 14 months (mo) from start of treatment in two ROS1+ NSCLC primary efficacy cohorts and safety in all pts treated at the recommended phase 2 dose (RP2D). Methods: Pts with ROS1+ NSCLC were assigned to 4 cohorts by treatment history: TKI-naïve, 1 TKI and no chemo, 1 TKI and 1 platinum-based chemo, and 2 TKIs and no chemo. Repotrectinib RP2D was 160 mg once daily for 14 days, then 160 mg twice daily. Phase 2 primary endpoint was confirmed objective response rate (cORR) by Blinded Independent Central Review per RECIST v1.1. Secondary endpoints included duration of response (DOR), progression-free survival (PFS), intracranial ORR, cORR in TKI-pretreated pts with ROS1 G2032R NSCLC, and safety. Efficacy analyses included pts with ≥14 mo follow-up. Safety assessments included pts treated at RP2D across all study cohorts. Results: At data cutoff (December 19, 2022), median (range) follow-up in the primary efficacy cohorts was 24.0 (14.2–66.6) mo in the TKI-naïve cohort (n=71) and 21.5 (14.2–58.6) mo in the 1 prior TKI and no chemo cohort (n=56). In the TKI-naïve cohort, cORR was 79% (95% CI, 68–88). Median (95% CI) DOR was 34.1 (25.6–not estimable [NE]) mo; estimated 12- and 18-mo DOR rates were 83% (73–93) and 79% (68–90), respectively. Median PFS (95% CI) was 35.7 (27.4–NE) mo; estimated 12- and 18-mo PFS rates were 77% (66–87) and 70% (59–81), respectively. In the 1 prior TKI and no chemo cohort, cORR was 38% (95% CI, 25–52). Median DOR (95% CI) was 14.8 (7.6–NE) mo; estimated 12-mo DOR rate was 56% (34–77). Median PFS (95% CI) was 9.0 (6.8–19.6) mo; estimated 12-mo PFS rate was 41% (27–56). The median (range) time to response was 1.8 (0.9–5.6) mo in the TKI-naïve cohort and 1.8 (1.6–3.6) mo in the 1 prior TKI and no chemo cohort. Among pts with measurable brain metastasis at baseline, intracranial ORR was 89% (95% CI, 52–100) in the TKI-naïve cohort (n=9), and 38% (95% CI, 14–68) in the 1 prior TKI and no chemo cohort (n=13). In pts with TKI-pretreated ROS1 G2032R NSCLC (n=17), cORR was 59% (33–82). Among pts receiving repotrectinib at RP2D (n=426), treatment-emergent adverse events (TEAEs) occurred in 422 (99%), most commonly dizziness (62%). Grade ≥3 TEAEs occurred in 216 (51%) and were considered treatment-related in 122 (29%). TEAEs led to dose reduction and treatment discontinuation in 38% and 7% of pts, respectively. Additional analysis in CNS efficacy and by subsequent therapies will be presented. Conclusion: With a minimum follow-up of 14 mo in TRIDENT-1, repotrectinib continued to demonstrate durable efficacy in pts with ROS1+ NSCLC, including intracranial activity, in both TKI-naïve and 1 prior TKI and no chemo cohorts. Safety in pts treated at RP2D was manageable, consistent with previous reports in all treated pts. Prior:WCLC(Sep 10). Citation Format: Jessica J Lin, Byoung Chul Cho, D. Ross Camidge, Sang-We Kim, Benjamin Solomon, Rafal Dziadziuszko, Benjamin Besse, Koichi Goto, Adrianus Johannes de Langen, Jürgen Wolf, Ki Hyeong Lee, Sanjay Popat, Christoph Springfeld, Misako Nagasaka, Enriqueta Felip, Nong Yang, Shun Lu, Steven Kao, Vamsidhar Velcheti, Parneet Cheema, Shanna Stopatschinskaja, Minal Mehta, Denise Trone, Felipe Ades, Christophe Y. Calvet, Alexander Drilon. Repotrectinib in patients with ROS1 fusion-positive (ROS1+) non-small cell lung cancer (NSCLC): Update from the pivotal phase 1/2 TRIDENT-1 trial [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr PR003.

Preliminary Results of Phase 2 Open Label Study of Lorlatinib Monotherapy in Relapsed/Refractory ALK + Lymphomas Previously Treated with Other Tyrosine Kinase Inhibitors

Introduction: Both aggressive T and B cell lymphoma may harbour Anaplastic Lymphoma Kinase (ALK) translocations: ALK+ Anaplastic Large Cell lymphoma (ALCL) offer a good outcome with first line therapy with 5-year survival of 79%, but relapses occur in half of the patients (pts) and salvage therapy still represents a challenge for clinicians; ALK+ large B cell lymphoma (LBCL) are very rare cases but with dismal prognosis. In addition other hematologic neoplasms can be caused by ALK fusions. Crizotinib, an ALK/MET tyrosine kinase inhibitor (TKI), provides long-term response in up to 70% relapsed/refractory (R/R) ALK+ ALCL and can obtain a similar but less durable response rates in ALK+ LBCL. In both cases the loss of response to crizotinib is frequently a fatal event. Lorlatinib, a selective ALK and ROS1 TKI, demonstrated preclinical inhibition of all reported ALK kinase domain mutations responsible for resistance to Crizotinib. Methods: From 2019 to 2022 six relapsed/refractory ALK + neoplasm pts previously treated with at least one ALK-inhibitor were enrolled in a phase 2 open label monocentric study with lorlatinib monotherapy (EudraCT2016-003970-41): Three patients had diagnosis of ALK+ LBCL (# 1, 2, 3) and 2 (#5 and #6) had ALK+ ALCL. One patient (#4) with an ALK+ histiocytosis was also included. Median age was 22 years (range 19-57), Ratio M/F was 1, all pts were in stage IV. Median prior therapy lines was 3 (range 2-5); all pts previously received Crizotinib, two pts received also Alectinib and 1 Ceritinib as TKI treatment. Lorlatinib was administered daily at dose of 100 mg. Clinical, laboratory, radiological and molecular data were collected at screening and during scheduled follow-up. Response was evaluated with 18F-FDG PET/CT (and with contrast enhanced (ce) CT scan) according Lugano Classification, and with ALK RT-PCR on peripheral blood and bone marrow. Side effects were classified according to CTCAEv4.03. PFS and OS were determined from Lorlatinib start to relapse and/or death. The primary endpoint was the evaluation of ORR considering 18F-FDG PET/CT scan and ALK- RT-PCR. Secondary endpoints were: PFS, OS, toxicity, QoL. Results: ALK rearrangement fusion pattern was detected in 6/6 pts: 3 pts with LBCL harboured Clathrin-ALK (CTCL::ALK) rearrangement and 2 ALCL pts the ATIC::ALK fusion; the ALK+ histiocytosis patient harbored an EML4::ALK rearrangement. Median follow-up was 13.7 months (IQR 22-55). At month +1 (M1) 3/6 patients had complete response (CR) defined as complete metabolic and complete radiologic response (CMR/CR) according to PET/CT scans and ALK RT-PCR negativity. The remaining 3 pts had a partial response (PR), for an Overall Response Rate (ORR) of 100% (95%CI: 0.6-1.0). One pt is still on treatment and in CR at 45 months, receiving Lorlatinib 100 mg daily with neither toxicities nor need for Allogenic Stem Cell Transplantation (ASCT); 2 CR pts underwent ASCT after 1 month, resumed lorlatinib after ASCT and are still in CR. 2 pts with PR relapsed within month +3: one pt received salvage therapy without benefit, the other one underwent ASCT but progressed 3 months later. Both pts had ALK+ BCL with CTCL-ALK rearrangement. 1 pts in PR AT M1 (ALK+ istiocytosis) obtain CR at M3 after surgical resection of a residual lung mass and is still receiving Lorlatinib at month 36. Median PFS and OS were not reached: PFS at 6 and 12 months is 83% and 62% respectively; OS at 6 and 12 months is 83% and 55%. Safety: 2/6 pts had thrombocytopenia grade 1, whereas 3/6 pts showed grade I-II hypertriglyceridemia/hypercholesterolemia and muscle cramps. Conclusions: Lorlatinib represents a safe and effective salvage therapy for ALK+ Lymphoma patients failing first line TKI treatment. The obtainment of CR at M1 seems to represent a pivotal prognostic factor. Lorlatinib also offers a promising bridging regimen to salvage ASCT especially for ALK+ BCL patients, with high response rates and no additional toxicities, .

Repotrectinib's Clinical Benefit and Its Brain Penetration in a Patient with Meningeal Carcinomatosis from G2032R-Mutated ROS-1 Positive Non-Small Cell Lung Cancer.

In this work, we report on a clinically significant response of meningeal carcinomatosis to repotrectinib in a woman with a heavily pretreated ROS1-rearranged non-small cell lung cancer (NSCLC) that harbored the concomitant solvent front G2032R mutation. Meningeal carcinomatosis has a higher incidence in oncogene addicted NSCLC due to increased life expectancy, yet no report has ever documented the activity of repotrectinib in this context. In line with its activity, we documented the presence of the drug at potentially active concentrations in the cerebrospinal fluid. Nevertheless, the short-lived response reported by our patient highlights the importance for novel ROS1-tyrosine kinase inhibitors (TKIs) to be specifically developed to be able to penetrate the blood-brain barrier.

Pan-tumor survey of ROS1 fusions detected by next-generation RNA and whole transcriptome sequencing

BackgroundTwo ROS1 tyrosine kinase inhibitors have been approved for ROS1 fusion positive (ROS1+) non-small cell lung cancer (NSCLC) tumors. We performed a pan-tumor analysis of the incidence of ROS1 fusions to assess if more ROS1+ patients who could benefit from ROS1 TKIs could be identified.MethodsA retrospective analysis of ROS1 positive solid malignancies identified by targeted RNA sequencing and whole transcriptome sequencing of clinical tumor samples performed at Caris Life Science (Phoenix, AZ).ResultsA total of 259 ROS1+ solid malignancies were identified from approximately 175,350 tumors that underwent next-generation sequencing (12% from targeted RNA sequencing [Archer]; 88% from whole transcriptome sequencing). ROS1+ NSCLC constituted 78.8% of the ROS1+ solid malignancies, follow by glioblastoma (GBM) (6.9%), and breast cancer (2.7%). The frequency of ROS1 fusion was approximately 0.47% among NSCLC, 0.29% for GBM, 0.04% of breast cancer. The mean tumor mutation burden for all ROS1+ tumors was 4.8 mutations/megabase. The distribution of PD-L1 (22C3) expression among all ROS1+ malignancies were 0% (18.6%), 1%-49% (29.4%), and ≥ 50% (60.3%) [for NSCLC: 0% (17.8%); 1–49% (27.7%); ≥ 50% (53.9%).The most common genetic co-alterations of ROS1+ NSCLC were TP53 (29.1%), SETD2 (7.3%), ARIAD1A (6.3%), and U2AF1 (5.6%).ConclusionsROS1+ NSCLC tumors constituted the majority of ROS1+ solid malignancies with four major fusion partners. Given that > 20% of ROS1+ solid tumors may benefit from ROS1 TKIs treatment, comprehensive genomic profiling should be performed on all solid tumors.

Differential network analysis of ROS1 inhibitors reveals lorlatinib polypharmacology through co-targeting PYK2

Multiple tyrosine kinase inhibitors (TKIs) are often developed for the same indication. However, their relative overall efficacy is frequently incompletely understood and they may harbor unrecognized targets that cooperate with the intended target. We compared several ROS1 TKIs for inhibition of ROS1-fusion-positive lung cancer cell viability, ROS1 autophosphorylation and kinase activity, which indicated disproportionately higher cellular potency of one TKI, lorlatinib. Quantitative chemical and phosphoproteomics across four ROS1 TKIs and differential network analysis revealed that lorlatinib uniquely impacted focal adhesion signaling. Functional validation using pharmacological probes, RNA interference, and CRISPR-Cas9 knockout uncovered a polypharmacology mechanism of lorlatinib by dual targeting ROS1 and PYK2, which form a multiprotein complex with SRC. Rational multi-targeting of this complex by combining lorlatinib with SRC inhibitors exhibited pronounced synergy. Taken together, we show that systems pharmacology-based differential network analysis can dissect mixed canonical/non-canonical polypharmacology mechanisms across multiple TKIs enabling the design of rational drug combinations.