Small-molecule Inhibitors Of Anaplastic Lymphoma Kinase Research Articles

Liver Toxicity Observed With Lorlatinib When Combined With Strong CYP3A Inducers: Evaluation of Cynomolgus Monkey as a Nonclinical Model for Assessing the Mechanism of Combinational Toxicity.

Lorlatinib is a potent small-molecule anaplastic lymphoma kinase inhibitor approved for the treatment of patients with nonsmall cell lung cancer. In a drug-drug interaction study in healthy human participants, liver enzyme elevations were observed when a single 100 mg dose of lorlatinib was administered after multiple doses of rifampin, a strong cytochrome P450 (CYP) 3A inducer and a pregnane X receptor (PXR) agonist. A series of in vitro and in vivo studies were conducted to evaluate potential mechanisms for the observed clinical toxicity. To investigate the involvement of CYP3A and/or PXR in the observed liver toxicity, studies were conducted in cynomolgus monkeys administered lorlatinib alone or with coadministration of multiple doses of known CYP3A inducers that are predominantly PXR agonists (rifampin, St. John's wort) or predominantly constitutive androstane receptor agonists (carbamazepine, phenytoin) and a net CYP3A inhibitory PXR agonist (ritonavir). Results from the investigative studies identified cynomolgus monkeys as a pharmacologically relevant nonclinical model, which recapitulated the elevated liver function test results observed in humans. Furthermore, liver toxicity was only observed in this model when lorlatinib was coadministered with strong CYP3A inducers, and the effects were not restricted to, or exclusively dependent upon, a PXR activation mechanism. These results generated mechanistic insights on the liver enzyme elevations observed in the clinical drug-drug interaction study and provided guidance on appropriate product safety label for lorlatinib.

48-Year-Old Woman With Dyspnea and Chest Pain

48-Year-Old Woman With Dyspnea and Chest Pain

Elimination of dormant, autophagic ovarian cancer cells and xenografts through enhanced sensitivity to anaplastic lymphoma kinase inhibition.

Poor outcomes for patients with ovarian cancer relate to dormant, drug-resistant cancer cells that survive after primary surgery and chemotherapy. Ovarian cancer (OvCa) cells persist in poorly vascularized scars on the peritoneal surface and depend on autophagy to survive nutrient deprivation. The authors have sought drugs that target autophagic cancer cells selectively to eliminate residual disease. By using unbiased small-interfering RNA (siRNA) screens, the authors observed that knockdown of anaplastic lymphoma kinase (ALK) reduced the survival of autophagic OvCa cells. Small-molecule ALK inhibitors were evaluated for their selective toxicity against autophagic OvCa cell lines and xenografts. Autophagy was induced by reexpression of GTP-binding protein Di-Ras3 (DIRAS3) or serum starvation and was evaluated with Western blot analysis, fluorescence imaging, and transmission electron microscopy. Signaling pathways required for crizotinib-induced apoptosis of autophagic cells were explored with flow cytometric analysis, Western blot analysis, short-hairpin RNA knockdown of autophagic proteins, and small-molecule inhibitors of STAT3 and BCL-2. Induction of autophagy by reexpression of DIRAS3 or serum starvation in multiple OvCa cell lines significantly reduced the 50% inhibitory concentration of crizotinib and other ALK inhibitors. In 2 human OvCa xenograft models, the DIRAS3-expressing tumors treated with crizotinib had significantly decreased tumor burden and long-term survival in 67% to 79% of mice. Crizotinib treatment of autophagic cancer cells further enhanced autophagy and induced autophagy-mediated apoptosis by decreasing phosphorylated STAT3 and BCL-2 signaling. Crizotinib may eliminate dormant, autophagic, drug-resistant OvCa cells that remain after conventional cytoreductive surgery and combination chemotherapy. A clinical trial of ALK inhibitors as maintenance therapy after second-look operations should be seriously considered.

505P - PD-L1 expression in ALK rearranged NSCLC: All questions answered?

BackgroundTreatment of non-small cell lung cancer (NSCLC) has undergone a paradigm shift in the last decade with the advent of targeted therapy and immunotherapy. Anaplastic Lymphoma Kinase (ALK) rearrangement and Programmed Death-Ligand 1 (PD-L1) expression are important predictive biomarkers for response to targeted therapy and immunotherapy respectively. How these two biomarkers interplay with each other is yet to be determined. Various studies have tried to establish a relationship between PD-L1 expression in tumors and treatment outcomes in ALK rearranged NSCLC, with conflicting results. There is a paucity of data regarding this relationship from the Indian subcontinent. MethodsPD-L1 expression was assessed in tissue samples of 58 patients with advanced ALK rearranged NSCLC treated between 2015 and 2018. PD-L1 expression was measured by immunohistochemistry using VENTANA PD-L1 (SP263) antibody on formalin-fixed paraffin-embedded specimens. The epidemiological profile of patients and the relationship between progression free survival (PFS) on small molecule ALK inhibitor and PD-L1 expression were noted. ResultsThe median age was 47 years (range 25-72 years) and there were 25 males (50%). Most of the patients were never smokers (88%). Thirty-seven (63.7%) of tumors expressed PD-L1 (≥1%) and 13 (22.4%) tumors had a PD-L1 expression of ≥ 50%. All of the patients received crizotinib as first line ALK inhibitor. Of the 44 patients evaluable for treatment response there was no significant difference in PFS between PDL1 negative cohort (median PFS - 13.8 months, CI 6.2-21.3 months) and PDL1 positive cohort (median PFS 10.9 months, CI 6.5-15.2 months, P-0.81). No association was seen between PD-L1 expression and PFS when PD-L1 expression levels were stratified by median or quartiles. In the subgroup analysis, PFS was not significantly different between different patterns of PDL1 expression or intensity of staining. ConclusionsIn contrast to previous studies, we found a higher incidence of PD-L1 expression in patients with ALK rearranged advanced NSCLC. PFS on ALK inhibitors did not differ based on PD-L1 expression. However, this was a retrospective study in a limited number of patients. More prospective studies are needed to confirm our findings. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Drug Discovery Targeting Anaplastic Lymphoma Kinase (ALK).

As a receptor tyrosine kinase of insulin receptor (IR) subfamily, anaplastic lymphoma kinase (ALK) has been validated to play important roles in various cancers, especially anaplastic large cell lymphoma (ALCL), nonsmall cell lung cancer (NSCLC), and neuroblastomas. Currently, five small-molecule inhibitors of ALK, including Crizotinib, Ceritinib, Alectinib, Brigatinib, and Lorlatinib, have been approved by the U.S. Food and Drug Administration (FDA) against ALK-positive NSCLCs. Novel type-I1/2 and type-II ALK inhibitors with improved kinase selectivity and enhanced capability to combat drug resistance have also been reported. Moreover, the "proteolysis targeting chimera" (PROTAC) technique has been successfully applied in developing ALK degraders, which opened a new avenue for targeted ALK therapies. This review provides an overview of the physiological and biological functions of ALK, the discovery and development of drugs targeting ALK by focusing on their chemotypes, activity, selectivity, and resistance as well as potential therapeutic strategies to overcome drug resistance.

Lorlatinib for the treatment of anaplastic lymphoma kinase-positive non-small cell lung cancer

ABSTRACT Introduction Approximately 3–5% of patients with non-small cell lung cancer （NSCLC）belonged to anaplastic lymphoma kinase (ALK)-positive NSCLC. The treatment drugs of ALK-positive NSCLC mainly included crizotinib, ceritinib, alectinib, and brigatinib. Although these drugs had some effects, most of them were usually easy to develop drug resistance. Lorlatinib is a new inhibitor of ALK for treating ALK-positive NSCLC,the effect is obvious, and not easy to develop resistance. Areas covered The main mechanism of action, pharmacokinetics, clinical efficacy and safety of lorlatinib were introduced in this paper. Expert commentary Lorlatinib is a new, reversible, ATP-competitive small molecule inhibitor of ALK and c-ros oncogene 1 (ROS1). It can inhibit tumor cell growth in ALK- and ROS1-overexpressing tumor cells. Clinical trial indicated that lorlatinib had obvious therapeutic effect for patients with ALK-positive NSCLC. Lorlatinib could also pass through the blood-brain barrier, which had a good effect on patients with brain metastasis. Adverse events of lorlatinib were mostly mild and moderate in severity, and patients were easily tolerated. Most common adverse events were edema, peripheral neuropathy, cognitive effects, dyspnea, fatigue, weight gain, arthralgia, mood effects, and diarrhea.

SHP2 inhibition restores sensitivity in ALK-rearranged non-small-cell lung cancer resistant to ALK inhibitors.

Most anaplastic lymphoma kinase (ALK)-rearranged non-small-cell lung tumors initially respond to small-molecule ALK inhibitors, but drug resistance often develops. Of tumors that develop resistance to highly potent second-generation ALK inhibitors, approximately half harbor resistance mutations in ALK, while the other half have other mechanisms underlying resistance. Members of the latter group often have activation of at least one of several different tyrosine kinases driving resistance. Such tumors are not expected to respond to lorlatinib-a third-generation inhibitor targeting ALK that is able to overcome all clinically identified resistant mutations in ALK-and further therapeutic options are limited. Herein, we deployed a shRNA screen of 1,000 genes in multiple ALK-inhibitor-resistant patient-derived cells (PDCs) to discover those that confer sensitivity to ALK inhibition. This approach identified SHP2, a nonreceptor protein tyrosine phosphatase, as a common targetable resistance node in multiple PDCs. SHP2 provides a parallel survival input downstream of multiple tyrosine kinases that promote resistance to ALK inhibitors. Treatment with SHP099, the recently discovered small-molecule inhibitor of SHP2, in combination with the ALK tyrosine kinase inhibitor (TKI) ceritinib halted the growth of resistant PDCs through preventing compensatory RAS and ERK1 and ERK2 (ERK1/2) reactivation. These findings suggest that combined ALK and SHP2 inhibition may be a promising therapeutic strategy for resistant cancers driven by several different ALK-independent mechanisms underlying resistance.

Metabolites of alectinib in human: their identification and pharmacological activity.

Two metabolites (M4 and M1b) in plasma and four metabolites (M4, M6, M1a and M1b) in faeces were detected through the human ADME study following a single oral administration of [14C]alectinib, a small-molecule anaplastic lymphoma kinase inhibitor, to healthy subjects. In the present study, M1a and M1b, which chemical structures had not been identified prior to the human ADME study, were identified as isomers of a carboxylate metabolite oxidatively cleaved at the morpholine ring. In faeces, M4 and M1b were the main metabolites, which shows that the biotransformation to M4 and M1b represents two main metabolic pathways for alectinib. In plasma, M4 was a major metabolite and M1b was a minor metabolite. The contribution to in vivo pharmacological activity of these circulating metabolites was assessed from their in vitro pharmacological activity and plasma protein binding. M4 had a similar cancer cell growth inhibitory activity and plasma protein binding to that of alectinib, suggesting its contribution to the antitumor activity of alectinib, whereas the pharmacological activity of M1b was insignificant.

ALK inhibitors in non-small cell lung cancer: the latest evidence and developments.

The treatment of patients with advanced non-small cell lung cancer (NSCLC) harbouring chromosomal rearrangements of ALK (anaplastic lymphoma kinase) was revolutionized by crizotinib, a small molecule inhibitor of ALK, ROS1 and MET. Unfortunately, the disease progressed within the first 12 months in most of the patients because of the development of crizotinib resistance in the majority of patients and the emergence of acquired resistance mutations in most of them. Many of them had been reported even before its approval leading to the rapid development of second-generation ALK inhibitors for crizotinib-resistant NSCLC. In the last few years, novel potent ALK inhibitors with promising results and a good toxicity profile have become available: ceritinib (LDK378), alectinib (RG7853/AF-802/RO5424802/CH5424802), brigatinib (AP26113), entrectinib (RXDX-101, NMS-E628), PF-06463922, ASP3026, TSR-011, X-376/X-396 and CEP-28122/CEP-37440. Moreover, HSP90 (90 kDa heat shock protein) inhibitors have demonstrated clinical activity in patients with ALK+ NSCLC. This review focuses on the molecular and clinical properties of this new generation of ALK inhibitors under development in the clinic.

Discovery of Inhibitors That Overcome the G1202R Anaplastic Lymphoma Kinase Resistance Mutation.

The treatment of patients with advanced non-small-cell lung cancer harboring chromosomal rearrangements of anaplastic lymphoma kinase (ALK) has been revolutionized by the development of crizotinib, a small-molecule inhibitor of ALK, ROS1, and MET. However, resistance to crizotinib inevitably develops through a variety of mechanisms, leading to relapse both systemically and in the central nervous system (CNS). This has motivated the development of "second-generation" ALK inhibitors, including alectinib and ceritinib, that overcome some of the mutations leading to resistance. However, most of the reported ALK inhibitors do not show inhibition of the G1202R mutant, which is one of the most common mutations. Herein, we report the development of a structural analogue of alectinib (JH-VIII-157-02) that is potent against the G1202R mutant as well as a variety of other frequently observed mutants. In addition, JH-VIII-157-02 is capable of penetrating the CNS of mice following oral dosing.

Prevalence and natural history of ALK positive non-small-cell lung cancer and the clinical impact of targeted therapy with ALK inhibitors.

Improved understanding of molecular drivers of carcinogenesis has led to significant progress in the management of lung cancer. Patients with non-small-cell lung cancer (NSCLC) with anaplastic lymphoma kinase (ALK) gene rearrangements constitute about 4%–5% of all NSCLC patients. ALK+ NSCLC cells respond well to small molecule ALK inhibitors such as crizotinib; however, resistance invariably develops after several months of treatment. There are now several newer ALK inhibitors, with the next generation of agents targeting resistance mutations. In this review, we will discuss the prevalence and clinical characteristics of ALK+ lung cancer, current treatment options, and future directions in the management of this subset of NSCLC patients.

Development of anaplastic lymphoma kinase (ALK) inhibitors and molecular diagnosis in ALK rearrangement-positive lung cancer

The fusion of echinoderm microtubule-associated protein-like 4 with anaplastic lymphoma kinase (ALK) was identified as a transforming gene for lung cancer in 2007. This genetic rearrangement accounts for 2%–5% of non-small-cell lung cancer (NSCLC) cases, occurring predominantly in younger individuals with adenocarcinoma who are never- or light smokers. A small-molecule tyrosine-kinase inhibitor of ALK, crizotinib, was rapidly approved by the US Food and Drug Administration on the basis of its pronounced clinical activity in patients with ALK rearrangement-positive NSCLC. Next-generation ALK inhibitors, such as alectinib, LDK378, and AP26113, are also being developed in ongoing clinical trials. In addition, the improvement and validation of methods for the detection of ALK rearrangement in NSCLC patients will be key to the optimal clinical use of ALK inhibitors. We here summarize recent progress in the development of new ALK inhibitors and in the molecular diagnosis of ALK rearrangement-positive NSCLC.

IS7-14 - Results of a GlobaL Phase II Study with Crizotinib in Advanced ALK-Positive Non-Small-Cell Lung Cancer (NSCLC)

ABSTRACT Background Anaplastic lymphoma kinase (ALK) is a known oncogenic driver in NSCLC, and approximately 5% of patients harbor ALK gene rearrangements. Crizotinib is a first-in-class, selective small-molecule ALK inhibitor with demonstrated clinical activity in ALK-positive NSCLC. PROFILE 1005 is a global, multicenter, open-label, single-arm phase II study evaluating the safety and efficacy of crizotinib in previously treated patients with ALK-positive advanced NSCLC. Methods Crizotinib 250 mg was administered BID to patients with ALK-positive advanced NSCLC who had received ≥1 chemotherapy for locally advanced/metastatic disease, including those with treated brain metastases. Most patients had centrally confirmed ALK-positivity by break-apart fluorescence in-situ hybridization, defined as ≥15% of tumor cells with split signals. Disease response was evaluated by RECIST 1.1 every 6 weeks. Results As of January 2012, 901 patients had been dosed. The first 261 patients who had enrolled and started crizotinib by February 2011, with a median duration of treatment of 48 weeks, were considered to be the mature population. Demographic, exposure, and efficacy results in both the overall and mature populations are provided in the table. Among all 901 patients, 15% discontinued treatment due to adverse events (AEs) and 10% had a dose reduction due to an AE. The most frequent AEs of any cause were vision disorder (54%), nausea (51%), diarrhea (44%), vomiting (44%), and constipation (37%), which were mostly grade 1/2. Conclusions Crizotinib demonstrated a high response rate that was durable, with a median progression-free survival of 8.1 months. Crizotinib has a favorable tolerability profile. These findings continue to provide strong evidence for crizotinib as a standard of care for advanced ALK-positive NSCLC. Overall population Mature population Total no. of patients, n 901 261 Response-evaluable patients, n 803 259 Demographics: Median age, years Male/female, % ECOG PS 0/1, % Adenocarcinoma, % 53 43/57 82 92 52 46/54 83 94 Duration of treatment (weeks), median (range) 20 ( 48 (1 - 94) ORR, % (95% exact CI) 46 (42–50) 60 (54–66) Duration of response (weeks), median a (95% CI) 47 (36–54) 46 (35–54) Disease control rate, % (95% exact CI): At 6 weeks At 12 weeks 80 (77–83) 61 (58–64) 86 (82–90) 75 (70–80) PFS (months), median a (95% CI) 8.1 (6.9–9.5) 8.1 (6.8–9.7) ECOG PS, Eastern Cooperative Oncology Group performance status; ORR, objective response rate; PFS, progression-free survival. a Kaplan–Meier estimate Disclosure D. Kim: Compensated advisory relationship: Pfizer. Honoraria: Pfizer. S. Lanzalone: Employment: Pfizer. Stock ownership: Pfizer. A. Polli: Employment: Pfizer. Stock ownership: Pfizer. A. Shaw: Compensated advisory relationship: Pfizer, Ariad, Chugai, Novartis, Daiichi-Sankyo. Research funding: AstraZeneca, Novartis. All other authors have declared no conflicts of interest.

1268P - Visual Disturbances in Patients (PTS) with Anaplastic Lymphoma Kinase (ALK)-Positive Advanced Non-Small Cell Lung Cancer (NSCLC) Treated with Crizotinib

ABSTRACT Background Crizotinib is a potent, small-molecule ALK inhibitor with a high response rate in advanced ALK-positive NSCLC. In early phase studies, patients (pts) commonly reported mild visual disturbances. Here we characterize such visual effects with objective and subjective measures in an ongoing phase II study (PROFILE 1005). Methods Previously treated pts with advanced ALK-positive NSCLC received crizotinib 250 mg BID. Ophthalmological examinations, comprising best corrected visual acuity (BCVA), biomicroscopy, and fundoscopy, were performed at screening and after a visual effect event was reported, except for a subset of pts in France, where examinations were done every 4 cycles. In addition, on day 1 of each cycle, pts completed the Visual Symptom Assessment Questionnaire (VSAQ) that assessed the presence, frequency, timing, duration, and severity of visual effects and their impact on activities of daily living (ADL). Results As of Jan 2012, 901 pts had enrolled in PROFILE 1005; 21 - 27% were evaluable for ophthalmological examinations (visual acuity: 193/901; biomicroscopy: 239/901; fundoscopy: 239/901). There were no changes in BCVA, conjunctiva, cornea, anterior chamber, iris, lens, or fundus attributable to crizotinib. The most frequently reported ophthalmological finding was worsening of cataracts (right eye: 9%; left eye: 10%), which was not attributed to crizotinib. Visual effects as identified by the VSAQ were reported by 65% of pts (405/622) at cycle 2 (C2), 58% at C3 (323/558), 55% at C4 (287/519), and 50% at C5 (247/495). The most common were appearance of flashing lights, streamers/strings/floaters, and overlapping shadows. Most pts reported each event as lasting ≤1 min (C2: 63%; C3: 68%; C4: 72%; C5: 75%), occurring mostly in the morning (46–59%) and/or evening (70–74%). The majority of pts reported that visual effects were not at all or a little bothersome, with no or minimal impact on ADL. Similar results were observed in the French pt subset. Conclusions There were no objective ophthalmological changes associated with the visual effects on crizotinib. Pt-reported visual effects were frequent, but transient, with no or minimal impact on ADL. Disclosure B. Besse: Research funding: Pfizer. B. Solomon: Compensated advisory relationship: Pfizer. Research funding: Pfizer. A. Shaw: Compensated advisory relationship: Pfizer, Ariad, Chugai, Novartis, and Daiichi-Sankyo. Research funding: AstraZeneca and Novartis. D. Kim: Compensated advisory relationship: Pfizer. Honoraria: Pfizer. R. Schachar: Compensated employment: Pfizer. Stock ownership: Pfizer. K. Wilner: Compensated employment: Pfizer. Stock ownership: Pfizer. A. Reisman: Compensated employment: Pfizer. Stock ownership: Pfizer. C.H. Bartlett: Compensated employment: Pfizer. Stock ownership: Pfizer. S. Iyer: Compensated employment: Pfizer. All other authors have declared no conflicts of interest.

440O - Results of a First-In-Human Phase I Study of the Alk Inhibitor LDK378 in Advanced Solid Tumors

ABSTRACT Background Translocations of the anaplastic lymphoma kinase (ALK) gene occur in 3–8% of NSCLC. LDK378 is a novel, potent small molecule ALK inhibitor that produces tumor regressions in ALK-driven (ALK+) NSCLC xenografts. A Phase 1 study is being conducted with the primary objective of determining the MTD and safety profile in patients (pts) with ALK+ cancers. Other objectives are to assess safety, PK, and antitumor activity in pts with ALK+ NSCLC, either previously untreated with ALK inhibitors, or relapsed following ALK inhibitor treatment, and other ALK+ cancers. Methods LDK378 was administered orally once-daily on a continuous 21-day schedule, in adult pts with advanced malignancies harboring a genetic alteration in ALK who progressed on standard therapy or for whom there was no effective therapy. Dose escalation was guided by a Bayesian logistic regression model to determine the MTD, and started at 50 mg/day. Results As of 25 April2012, 56 pts (primary site: lung 50 pts [37 with prior crizotinib]; breast 4 pts; other 2 pts; median age 53 (22–76) years; 88% ECOG PS 0/1) had received LDK378 at doses of 50–750 mg/day. Of 47 pts evaluable for response (per investigator), there were 24 (51%) responses. All responses were in ALK+ NSCLC (FISH positive in ≥15% of tumor cells). In 26 pts with NSCLC who had progressed following crizotinib and were treated at ≥400 mg/day there were 21 (81%) responses. Dose limiting toxicities (DLTs) have occurred in 2/14 pts at 400 mg/day, 2/9 pts at 600 mg/day, and 1/9 pts at 750 mg/day. DLTs included diarrhea, vomiting, nausea, dehydration, and ALT elevation. The MTD was 750 mg/day. At the cutoff date, 36 (64%) pts remain on treatment. Discontinuations were due to adverse events (AEs) in 1 (2%), and disease progression in 19 (34%) pts. The most frequent AEs (all grades) were nausea 33 (59%), vomiting 30 (54%), and diarrhea 27 (48%) pts. The most frequent Grade 3/4 AE was diarrhea (5 [9%] pts). Oral absorption of LDK378 was rapid with a Tmax of 5–6 hours, and half-life was about 36 hours. Conclusions Daily oral LDK378 is well tolerated and the MTD was 750 mg/day. Striking activity was seen in ALK+ NSCLC pts treated at doses ≥400mg, who had previously progressed following crizotinib. Disclosure A.T. Shaw: I have a consultant/advisory role for Pfizer, Novartis, Chugar, Ariad, and Daiichi. D.R. Camidge: I have a compensated consultant/advisory role with Novartis Pharmacuticals Inc. S. Sharma: I have a compensated consultant/advisory role for Novartis (LEAD Summit). I have received honoraria for Novartis LEAD Summit. I have received research funding from Novartis (Phase Ib clinical trial). D.S.W. Tan: I have received research funding from Novartis. M. Goldwasser: Employment or leadership position to disclose: Associate Director Biostatistics: Novartis Pharmaceuticals. D. Dai: Employment or leadership position to disclose. Clinical Pharmacology Expert: Novartis Pharmaceuticals; Stock ownership: Myself; Novartis Pharmaceuticals. A.L. Boral: I am an employee of Novartis Institutes for Biomedical Sciences (Executive Director). I have stock ownership (Novartis). All other authors have declared no conflicts of interest.

1230PD - Updated Results of a Global Phase II Study with Crizotinib in Advanced Alk-Positive Non-Small Cell Lung Cancer (NSCLC)

ABSTRACT Background Anaplastic lymphoma kinase (ALK) is a known oncogenic driver in NSCLC, and approximately 5% of patients harbor ALK gene rearrangements. Crizotinib is a first-in-class, selective small-molecule ALK inhibitor with demonstrated clinical activity in ALK-positive NSCLC. PROFILE 1005 is a global, multicenter, open-label, single-arm phase II study evaluating the safety and efficacy of crizotinib in previously treated patients with ALK-positive advanced NSCLC. Methods Crizotinib 250 mg was administered BID to patients with ALK-positive advanced NSCLC who had received ≥1 chemotherapy for locally advanced/metastatic disease, including those with treated brain metastases. Most patients had centrally confirmed ALK-positivity by break-apart fluorescence in-situ hybridization, defined as ≥15% of tumor cells with split signals. Disease response was evaluated by RECIST 1.1 every 6 weeks. Results As of January 2012, 901 patients had been dosed. The first 261 patients who had enrolled and started crizotinib by February 2011, with a median duration of treatment of 48 weeks, were considered to be the mature population. Demographic, exposure, and efficacy results in both the overall and mature populations are provided in the table. Among all 901 patients, 15% discontinued treatment due to adverse events (AEs) and 10% had a dose reduction due to an AE. The most frequent AEs of any cause were vision disorder (54%), nausea (51%), diarrhea (44%), vomiting (44%), and constipation (37%), which were mostly grade 1/2. Conclusions Crizotinib demonstrated a high response rate that was durable, with a median progression-free survival of 8.1 months. Crizotinib has a favorable tolerability profile. These findings continue to provide strong evidence for crizotinib as a standard of care for advanced ALK-positive NSCLC. Overall population Mature population Total no. of patients, n 901 261 Response-evaluable patients, n 803 259 Demographics: Median age, years Male/female, % ECOG PS 0/1, % Adenocarcinoma, % 53 43/57 82 92 52 46/54 83 94 Duration of treatment (weeks), median (range) 20 ( 48 (1 - 94) ORR, % (95% exact CI) 46 (42–50) 60 (54–66) Duration of response (weeks), median a (95% CI) 47 (36–54) 46 (35–54) Disease control rate, % (95% exact CI): At 6 weeks At 12 weeks 80 (77–83) 61 (58–64) 86 (82–90) 75 (70–80) PFS (months), median a (95% CI) 8.1 (6.9–9.5) 8.1 (6.8–9.7) ECOG PS, Eastern Cooperative Oncology Group performance status; ORR, objective response rate; PFS, progression-free survival. a Kaplan–Meier estimate Disclosure D. Kim: Compensated advisory relationship: Pfizer. Honoraria: Pfizer. S. Lanzalone: Employment: Pfizer. Stock ownership: Pfizer. A. Polli: Employment: Pfizer. Stock ownership: Pfizer. A. Shaw: Compensated advisory relationship: Pfizer, Ariad, Chugai, Novartis, Daiichi-Sankyo. Research funding: AstraZeneca, Novartis. All other authors have declared no conflicts of interest.

The R1275Q Neuroblastoma Mutant and Certain ATP-competitive Inhibitors Stabilize Alternative Activation Loop Conformations of Anaplastic Lymphoma Kinase

Anaplastic lymphoma kinase (ALK) is a receptor tyrosine kinase that, when genetically altered by mutation, amplification, chromosomal translocation or inversion, has been shown to play an oncogenic role in certain cancers. Small molecule inhibitors targeting the kinase activity of ALK have proven to be effective therapies in certain ALK-driven malignancies and one such inhibitor, crizotinib, is now approved for the treatment of EML4-ALK-driven, non-small cell lung cancer. In neuroblastoma, activating point mutations in the ALK kinase domain can drive disease progression, with the two most common mutations being F1174L and R1275Q. We report here crystal structures of the ALK kinase domain containing the F1174L and R1275Q mutations. Also included are crystal structures of ALK in complex with novel small molecule ALK inhibitors, including a classic type II inhibitor, that stabilize previously unobserved conformations of the ALK activation loop. Collectively, these structures illustrate a different series of activation loop conformations than has been observed in previous ALK crystal structures and provide insight into the activating nature of the R1275Q mutation. The novel active site topologies presented here may also aid the structure-based drug design of a new generation of ALK inhibitors.

Echinoderm microtubule‐associated protein‐like 4–anaplastic lymphoma kinase‐targeted therapy for advanced non‐small cell lung cancer: Molecular and clinical aspects

The identification of oncogenic genomic alterations is expected to facilitate the development of new molecularly targeted therapies for cancer. EML4 (echinoderm microtubule-associated protein-like 4)-ALK (anaplastic lymphoma kinase) was recently identified as a transforming fusion gene in non-small cell lung cancer (NSCLC). A small-molecule tyrosine kinase inhibitor of ALK, crizotinib, shows pronounced clinical activity in the treatment of patients with NSCLC positive for EML4-ALK, and it has rapidly entered into daily clinical practice. This review focuses on the biology and clinical features of, as well as diagnostic testing for, EML4-ALK-positive NSCLC. Current data on the efficacy and toxicity of crizotinib are also examined, and future directions for the treatment of NSCLC positive for ALK rearrangement are addressed.

Efficacy of crizotinib in children with relapsed/refractory ALK-driven tumors including anaplastic large cell lymphoma and neuroblastoma: A Children's Oncology Group phase I consortium study.

9500 Background: Genetic aberrations in the anaplastic lymphoma kinase (ALK) gene are found in anaplastic large cell lymphoma (ALCL), neuroblastoma (NB) and other tumors.Crizotinib,a small molecule inhibitor of ALK and c-Met, is active in non-small cell lung cancers (NSCLC) harboring an ALK translocation. We performed a phase 1 dose-escalation and pharmacokinetic (PK) trial of crizotinib in patients (pts) with refractory solid tumors and ALCL. Methods: Crizotinib was administered bid without interruption in 28 day cycles using the rolling-six design. Six dose levels (100, 130, 165, 215, 280, 365 mg/m2/dose) have been evaluated (A1). Pts with confirmed ALK fusion proteins, mutations or amplification (A2) could enroll at one dose level lower than part A1 and those with NB could enroll on a separate stratum (A3). PK studies were performed on day 1 and at steady state (SS). ALK genomic status in tumor tissue was evaluated and qPCR was used to measure NPM-ALK fusion transcript in bone marrow and blood samples of ALCL pts. Results: 70 pts were enrolled, 57 fully evaluable for toxicity, [median (range) age 9.9 yrs (1.1–21.3)]: 29 on A1, 18 on A2, and 10 on A3. In A1, 2/7 pts developed DLT (grade 3 dizziness, grade 5 intra-tumoral hemorrhage) at 215 mg/m2 and 1/6 pts developed DLT (grade 4 liver enzyme elevation) at 365 mg/m2. In A2, 1 grade 4 DLT (neutropenia) occurred at 165 mg/m2; in A3, no DLTs occurred. Mean (±SD) Cave (=AUC0-12h/12h) of crizotinib at SS was 466±114 ng/mL at 215 mg/m2/dose (n=5), 443±121 ng/mL at 280 mg/m2/dose (n=8), and 720±230 ng/mL at 365mg/m2/dose (n=4). Response data for pts with ALCL (six at 165 mg/m2, two at 280 mg/m2) approved for release by the Data Safety Monitoring Committee demonstrates 7/8 (88%) complete response (CR) rate to date. RT-PCR data for 6 of these pts at 57 time points was obtained and will be described. In addition, 2 pts with NB have had CRs, one with a documented ALK mutation. One patient with an inflammatory myofibroblastic tumor and one with NSCLC had PRs. Conclusions: Inhibition of ALK in pediatric pts with ALK-driven tumors occurs with minimal toxicity and is associated with objective anti-tumor activity.

Development of treatment strategies for advanced neuroblastoma

Neuroblastoma is the most common cancer in childhood. The majority of patients with neuroblastoma are assigned to the high-risk group based on age at diagnosis, stage, histology, MYCN status, and DNA ploidy. Their prognosis remains unsatisfactory; the 5-year event-free survival (EFS) rate is generally 40 %. During the past 20 years, much effort has been made to reinforce chemotherapy, including the introduction of high-dose chemotherapy with autologous stem cell rescue, resulting in a 5-year EFS rate of around 30 %. Subsequently, maintenance therapy aimed at eradicating residual tumors after induction and consolidation therapies was introduced, consisting of differentiation-inducing agents, retinoids, and immunotherapy using anti-GD2 antibodies combined with cytokines. However, such additional treatment provided benefit to only 10-20 % of patients, while the prognosis of about half the patients remains poor. Currently, novel targeted agents are under development. Among them, anaplastic lymphoma kinase (ALK) inhibitors and aurora kinase A inhibitors are promising. ALK somatic mutation or gene amplification predisposing neuroblastoma development occurs in up to 15 % of neuroblastomas. Crizotinib is a dual-specific inhibitor of ALK/Met and inhibits proliferation of neuroblastoma cells harboring R1275Q-mutated ALK or amplified wild-type ALK, but not cells harboring F1174L. Instead, cells with F1174L are sensitive to another small molecule ALK inhibitor, TAE684. Aurora kinase A plays a pivotal role in centrosome maturation and spindle formation during mitosis. MLN8237 (alisertib) is a small molecule inhibitor of aurora kinase A that is currently in early-phase clinical testing. Future treatment will be individually planned, adapting targeted agents based on personal biological tumor characteristics.