Managing Resistance to EFGR- and ALK-Targeted Therapies

2017 ◽  
pp. 607-618
Author(s):  
Christine M. Lovly ◽  
Puneeth Iyengar ◽  
Justin F. Gainor
Keyword(s):  
Targeted Therapies ◽  
Molecular Mechanisms ◽  
Acquired Resistance ◽  
Growth Factor Receptor ◽  
Genetic Alterations ◽  
Mechanisms Of Resistance ◽  
Lung Cancers ◽  
Anaplastic Lymphoma ◽  
Ablative Therapies ◽  
Egfr Mutant

Targeted therapies have transformed the management of non–small cell lung cancer (NSCLC) and placed an increased emphasis on stratifying patients on the basis of genetic alterations in oncogenic drivers. To date, the best characterized molecular targets in NSCLC are the epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK). Despite steady advances in targeted therapies within these molecular subsets, however, acquired resistance to therapy is near universal. Recent preclinical models and translational efforts have provided critical insights into the molecular mechanisms of resistance to EGFR and ALK inhibitors. In this review, we present a framework for understanding resistance to targeted therapies. We also provide overviews of the molecular mechanisms of resistance and strategies to overcome resistance among EGFR-mutant and ALK-rearranged lung cancers. To date, these strategies have centered on the development of novel next-generation inhibitors, rationale combinations, and use of local ablative therapies, such as radiotherapy.

scholarly journals Brain Metastases in Lung Cancers with Emerging Targetable Fusion Drivers

2020 ◽  
Vol 21 (4) ◽  
pp. 1416 ◽  
Author(s):  
Aaron C. Tan ◽  
Malinda Itchins ◽  
Mustafa Khasraw
Keyword(s):  
Brain Metastases ◽  
Molecular Mechanisms ◽  
Treatment Options ◽  
Growth Factor Receptor ◽  
Standard Of Care ◽  
Driver Mutations ◽  
Lung Cancers ◽  
Anaplastic Lymphoma ◽  
Egfr Mutant ◽  
Line Setting

The management of non-small cell lung cancer (NSCLC) has transformed with the discovery of therapeutically tractable oncogenic drivers. In addition to activating driver mutations, gene fusions or rearrangements form a unique sub-class, with anaplastic lymphoma kinase (ALK) and c-ros oncogene 1 (ROS1) targeted agents approved as the standard of care in the first-line setting for advanced disease. There are a number of emerging fusion drivers, however, including neurotrophin kinase (NTRK), rearrangement during transfection (RET), and neuregulin 1 (NRG1) for which there are evolving high-impact systemic treatment options. Brain metastases are highly prevalent in NSCLC patients, with molecularly selected populations such as epidermal growth factor receptor (EGFR) mutant and ALK-rearranged tumors particularly brain tropic. Accordingly, there exists a substantial body of research pertaining to the understanding of brain metastases in such populations. Little is known, however, on the molecular mechanisms of brain metastases in those with other targetable fusion drivers in NSCLC. This review encompasses key areas including the biological underpinnings of brain metastases in fusion-driven lung cancers, the intracranial efficacy of novel systemic therapies, and future directions required to optimize the control and prevention of brain metastases.

Monitoring of plasma pro-GRP level during EGFR-TKI treatment.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. 10604-10604
Author(s):  
Yuko Kawano ◽  
Atsushi Horiike ◽  
Azusa Tanimoto ◽  
Toshio Sakatani ◽  
Ryota Saito ◽  
...  
Keyword(s):  
Kinase Inhibitors ◽  
Receptor Gene ◽  
Acquired Resistance ◽  
Growth Factor Receptor ◽  
Patient Characteristics ◽  
T790m Mutation ◽  
Lung Cancers ◽  
Tki Treatment ◽  
Egfr Mutant ◽  
Egfr Tki

10604 Background: Lung cancers harboring mutations in the epidermal growth factor receptor gene (EGFR) respond to EGFR tyrosine kinase inhibitors (EGFR-TKI), but drug resistance invariably emerges. The major acquired mechanisms of resistance are the EGFR T790M mutation or MET gene amplification. Transformation from NSCLC into small-cell lung cancer (SCLC) has been recently identified in acquired resistance to EGFR-TKI. However, it is difficult to predict the transformation during EGFR-TKI treatment because obtaining serial and sufficient specimens for biopsy is difficult. Pro-gastrin-releasing peptide (Pro-GRP) is a specific and sensitive tumor marker for SCLC. We evaluated the plasma Pro-GRP levels in EGFR-mutant NSCLCs and determined whether plasma Pro-GRP levels could predict SCLC transformation in resistance to EGFR-TKI. Methods: From July 2008 to December 2011, 49 patients with EGFR-mutant NSCLC who received EGFR-TKI treatment were enrolled. Plasma was obtained from these patients before EGFR-TKI treatment and when EGFR-TKI treatment failed. Pro-GRP and CEA levels were measured and compared before and after treatment. Results: Patient characteristics for 49 patients (15 men, 34 women) were as follows: median age, 62 years (41–81 years); histology, 46 adenocarcinomas (AD) and 3 non-AD tumors; and EGFR mutation type, 25 exon 19 deletions and 24 exon 21 L858R. All 49 patients had received EGFR-TKI treatment (45 with gefitinib and 4 with erlotinib); the response to EGFR-TKI treatment was PR in 39 patients, SD in 7, PD in 2, and NE in 1. Positive rate of ProGRP and CEA at pre-EGFR-TKI treatment was 2.0% and 57.2% and that at post-EGFR-TKI treatment was 6.1% and 69.4%, respectively. In 3 of 49 patients, the Pro-GRP levels had increased after treatment, but the CEA level did not increase. Objective responses to cytotoxic chemotherapy were noted in all 3 patients after EGFR-TKI treatment. Conclusions: Monitoring of plasma Pro-GRP during EGFR-TKI treatment may be useful for early detection of SCLC transformation in resistance to EGFR-TKI.

Tissue-based molecular and histological landscape of acquired resistance to osimertinib given initially or at relapse in patients with EGFR-mutant lung cancers.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 9028-9028 ◽  
Author(s):  
Adam Jacob Schoenfeld ◽  
Joseph Minhow Chan ◽  
Hira Rizvi ◽  
Natasha Rekhtman ◽  
Yahya Daneshbod ◽  
...  
Keyword(s):  
Initial Treatment ◽  
Tumor Tissue ◽  
Cell Transformation ◽  
Chromosomal Rearrangements ◽  
Acquired Resistance ◽  
Resistance Mechanisms ◽  
Resistance Mutations ◽  
Mechanisms Of Resistance ◽  
Lung Cancers ◽  
Egfr Mutant

9028 Background: Even though osimertinib (osi) is now the initial treatment for patients with EGFR-mutant lung cancers, our knowledge about mechanisms of resistance (MOR) is largely derived from patients who received osi after developing acquired resistance to initial EGFR inhibitor. Further, studies of osi resistance to date have mainly reported genotyping of plasma which suboptimally detects lineage plasticity, copy number changes, and chromosomal rearrangements. Methods: To identify MOR to osi and characterize clinical, molecular and histologic factors associated with duration of response, we identified patients with EGFR-mutant lung cancers who had next-generation sequencing performed on tumor tissue after developing acquired resistance to osi. Results: From January 2016 to December 2018, post-osi tumor tissue was collected from 71 patients (42 with paired pre-treatment specimens). See mechanisms of resistance below. Histologic transformation was identified in 19% of initial cases and 14% of all cases. When osi is given as initial treatment, with median follow up of 17 months, early emerging MOR rarely included on-target resistance mechanisms (1/16 cases of acquired EGFR G724S). Acquired alterations representing potential resistance mechanisms included CCNE1 and MYC amplifications, and mutations in MTOR and MET H1094Y. We confirmed in preclinical studies that an amino acid substitution at MET H1094 can reduce sensitivity to osi. Conclusions: In this analysis of MOR identified on NGS from tumor tissue, we found a different spectrum of resistance mechanisms to initial and later-line osi, with histologic transformation (including squamous cell transformation) a dominant MOR, particularly in the first-line setting, that cannot be identified on plasma testing. Subsequent studies are needed to assess patients with a longer time on initial osi as there may be a temporal bias to MOR, with off-target MOR emerging earlier and on-target resistance mutations later. [Table: see text]

Strategies for Overcoming Acquired Resistance to Epidermal Growth Factor Receptor–Targeted Therapies in Lung Cancer

2012 ◽  
Vol 136 (10) ◽  
pp. 1205-1209 ◽  
Author(s):  
Geoffrey R. Oxnard
Keyword(s):  
Lung Cancer ◽  
Epidermal Growth Factor Receptor ◽  
Growth Factor ◽  
Epidermal Growth Factor ◽  
Targeted Therapies ◽  
Acquired Resistance ◽  
Growth Factor Receptor ◽  
Egfr Inhibition ◽  
Epidermal Growth ◽  
Egfr Mutant

Acquired resistance to targeted therapy in epidermal growth factor receptor (EGFR)–mutant lung cancer represents a valuable model for considering strategies of overcoming different types of cellular resistance mechanisms. Using existing data on resistance in EGFR-mutant lung cancer, this review will discuss 3 basic approaches for overcoming resistance to EGFR-targeted therapies: intensification of EGFR inhibition, combination of EGFR inhibitors with other targeted therapies, and changing to anticancer therapies acting via alternate pathways.

scholarly journals Emerging Molecular Dependencies of Mutant EGFR-Driven Non-Small Cell Lung Cancer

Cells ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 3553
Author(s):  
Dylan A. Farnsworth ◽  
Yankuan T. Chen ◽  
Georgia de Rappard Yuswack ◽  
William W. Lockwood
Keyword(s):  
Molecular Mechanisms ◽  
Kinase Inhibitors ◽  
Growth Factor Receptor ◽  
Small Cell ◽  
Egfr Mutations ◽  
Small Cell Lung ◽  
Lung Cancers ◽  
Egfr Mutant ◽  
Successive Generations ◽  
Mutant Egfr

Epidermal growth factor receptor (EGFR) mutations are the molecular driver of a subset of non-small cell lung cancers (NSCLC); tumors that harbor these mutations are often dependent on sustained oncogene signaling for survival, a concept known as “oncogene addiction”. Inhibiting EGFR with tyrosine kinase inhibitors has improved clinical outcomes for patients; however, successive generations of inhibitors have failed to prevent the eventual emergence of resistance to targeted agents. Although these tumors have a well-established dependency on EGFR signaling, there remain questions about the underlying genetic mechanisms necessary for EGFR-driven oncogenesis and the factors that allow tumor cells to escape EGFR dependence. In this review, we highlight the latest findings on mutant EGFR dependencies, co-operative drivers, and molecular mechanisms that underlie sensitivity to EGFR inhibitors. Additionally, we offer perspective on how these discoveries may inform novel combination therapies tailored to EGFR mutant NSCLC.

scholarly journals Noninvasive Detection of Polyclonal Acquired Resistance to FGFR Inhibition in Patients With Cholangiocarcinoma Harboring FGFR2 Alterations

2021 ◽  
pp. 44-50
Author(s):  
Anna M. Varghese ◽  
Juber Patel ◽  
Yelena Y. Janjigian ◽  
Fanli Meng ◽  
S. Duygu Selcuklu ◽  
...  
Keyword(s):  
Effective Means ◽  
Acquired Resistance ◽  
Growth Factor Receptor ◽  
High Sensitivity ◽  
Circulating Tumor Dna ◽  
Kinase Domain ◽  
Genetic Alterations ◽  
Noninvasive Detection ◽  
Mechanisms Of Resistance ◽  
Next Generation Sequencing Ngs

PURPOSE Fibroblast growth factor receptor (FGFR) 2 alterations, present in 5%-15% of intrahepatic cholangiocarcinomas (IHC), are targets of FGFR-directed therapies. Acquired resistance is common among patients who respond. Biopsies at the time of acquired resistance to targeted agents may not always be feasible and may not capture the genetic heterogeneity that could exist within a patient. We studied circulating tumor DNA (ctDNA) as a less invasive means of potentially identifying genomic mechanisms of resistance to FGFR-targeted therapies. MATERIALS AND METHODS Serial blood samples were collected from eight patients with FGFR-altered cholangiocarcinoma for ctDNA isolation and next-generation sequencing (NGS) throughout treatment and at resistance to anti-FGFR–targeted therapy. ctDNA was sequenced using a custom ultra-deep coverage NGS panel, incorporating dual index primers and unique molecular barcodes to enable high-sensitivity mutation detection. RESULTS Thirty-one acquired mutations in FGFR2, 30/31 located in the kinase domain, were identified at resistance in six of eight patients with detectable ctDNA. Up to 13 independent FGFR2 mutations were detected per patient, indicative of striking genomic concordance among resistant subclones. CONCLUSION ctDNA could be an effective means to longitudinally monitor for acquired resistance in FGFR2-altered IHC. The numerous acquired genetic alterations in FGFR2 suggest frequent polyclonal mechanisms of resistance that cannot be detected from single-site tissue biopsies.

scholarly journals Patient-derived models of acquired resistance can identify effective drug combinations for cancer

Science ◽  
2014 ◽  
Vol 346 (6216) ◽  
pp. 1480-1486 ◽  
Author(s):  
Adam S. Crystal ◽  
Alice T. Shaw ◽  
Lecia V. Sequist ◽  
Luc Friboulet ◽  
Matthew J. Niederst ◽  
...  
Keyword(s):  
Growth Factor ◽  
Kinase Inhibitors ◽  
Acquired Resistance ◽  
Growth Factor Receptor ◽  
Drug Combinations ◽  
Effective Drug ◽  
Cancer Therapies ◽  
Lung Cancer Patients ◽  
Anaplastic Lymphoma ◽  
Culture Models

Targeted cancer therapies have produced substantial clinical responses, but most tumors develop resistance to these drugs. Here, we describe a pharmacogenomic platform that facilitates rapid discovery of drug combinations that can overcome resistance. We established cell culture models derived from biopsy samples of lung cancer patients whose disease had progressed while on treatment with epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors and then subjected these cells to genetic analyses and a pharmacological screen. Multiple effective drug combinations were identified. For example, the combination of ALK and MAPK kinase (MEK) inhibitors was active in an ALK-positive resistant tumor that had developed a MAP2K1 activating mutation, and the combination of EGFR and fibroblast growth factor receptor (FGFR) inhibitors was active in an EGFR mutant resistant cancer with a mutation in FGFR3. Combined ALK and SRC (pp60c-src) inhibition was effective in several ALK-driven patient-derived models, a result not predicted by genetic analysis alone. With further refinements, this strategy could help direct therapeutic choices for individual patients.

scholarly journals Emerging Paradigms in the Development of Resistance to Tyrosine Kinase Inhibitors in Lung Cancer

2013 ◽  
Vol 31 (31) ◽  
pp. 3987-3996 ◽  
Author(s):  
Justin F. Gainor ◽  
Alice T. Shaw
Keyword(s):  
Lung Cancer ◽  
Tyrosine Kinase ◽  
Tyrosine Kinase Inhibitors ◽  
Kinase Inhibitors ◽  
Genetic Alterations ◽  
Anaplastic Lymphoma ◽  
Development Of Resistance ◽  
Tki Resistance ◽  
Alk Positive ◽  
Egfr Mutant

The success of tyrosine kinase inhibitors (TKIs) in select patients with non–small-cell lung cancer (NSCLC) has transformed management of the disease, placing new emphasis on understanding the molecular characteristics of tumor specimens. It is now recognized that genetic alterations in the epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) define two unique subtypes of NSCLC that are highly responsive to genotype-directed TKIs. Despite this initial sensitivity, however, the long-term effectiveness of such therapies is universally limited by the development of resistance. Identifying the mechanisms underlying this resistance is an area of intense, ongoing investigation. In this review, we provide an overview of recent experience in the field, focusing on results from preclinical resistance models and studies of patient-derived, TKI-resistant tumor specimens. Although diverse TKI resistance mechanisms have been identified within EGFR-mutant and ALK-positive patients, we highlight common principles of resistance shared between these groups. These include the development of secondary mutations in the kinase target, gene amplification of the primary oncogene, and upregulation of bypass signaling tracts. In EGFR-mutant and ALK-positive patients alike, acquired resistance may also be a dynamic and multifactorial process that may necessitate the use of treatment combinations. We believe that insights into the mechanisms of TKI resistance in patients with EGFR mutations or ALK rearrangements may inform the development of novel treatment strategies in NSCLC, which may also be generalizable to other kinase-driven malignancies.

scholarly journals Oxidative Stress-Related Mechanisms in Melanoma and in the Acquired Resistance to Targeted Therapies

Antioxidants ◽  
2021 ◽  
Vol 10 (12) ◽  
pp. 1942
Author(s):  
Stefania Pizzimenti ◽  
Simone Ribero ◽  
Marie Angele Cucci ◽  
Margherita Grattarola ◽  
Chiara Monge ◽  
...  
Keyword(s):  
Oxidative Stress ◽  
Targeted Therapies ◽  
Current Knowledge ◽  
Mapk Pathway ◽  
Acquired Resistance ◽  
Genetic Alterations ◽  
Advanced Melanoma ◽  
Braf Mutations ◽  
Downstream Signaling ◽  
Activating Mutations

Melanoma is a highly aggressive cancer with the poorest prognosis, representing the deadliest form of skin cancer. Activating mutations in BRAF are the most frequent genetic alterations, present in approximately 50% of all melanoma cases. The use of specific inhibitors towards mutant BRAF variants and MEK, a downstream signaling target of BRAF in the MAPK pathway, has significantly improved progression-free and overall survival in advanced melanoma patients carrying BRAF mutations. Nevertheless, despite these improvements, resistance still develops within the first year of therapy in around 50% of patients, which is a significant problem in managing BRAF-mutated advanced melanoma. Understanding these mechanisms is one of the mainstreams of the research on BRAFi/MEKi acquired resistance. Both genetic and epigenetic mechanisms have been described. Moreover, in recent years, oxidative stress has emerged as another major force involved in all the phases of melanoma development, from initiation to progression until the onsets of the metastatic phenotype and chemoresistance, and has thus become a target for therapy. In the present review, we discuss the current knowledge on oxidative stress and its signaling in melanoma, as well as the oxidative stress-related mechanisms in the acquired resistance to targeted therapies.

scholarly journals CT features and disease spread patterns in ROS1-rearranged lung adenocarcinomas: comparison with those of EGFR-mutant or ALK-rearranged lung adenocarcinomas

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Jung Han Woo ◽  
Tae Jung Kim ◽  
Tae Sung Kim ◽  
Joungho Han
Keyword(s):  
Multivariable Analysis ◽  
Growth Factor Receptor ◽  
Disease Spread ◽  
Nodal Metastases ◽  
Multivariable Logistic Regression Model ◽  
Anaplastic Lymphoma ◽  
Epidermal Growth ◽  
Egfr Mutant ◽  
Lung Adenocarcinomas ◽  
Ct Features

Abstract The purpose of this study was to investigate the differences in CT characteristics and disease spread patterns between ROS1-rearranged adenocarcinomas and epidermal growth factor receptor (EGFR)-mutant or anaplastic lymphoma kinase (ALK)-rearranged adenocarcinomas. Patients with stage IIIb/IV adenocarcinoma with ROS1 rearrangement, EGFR mutations, or ALK rearrangement were retrospectively identified. Two radiologists evaluated CT features and disease spread patterns. A multivariable logistic regression model was applied to determine the clinical and CT characteristics that can discriminate between ROS1-rearranged and EGFR-mutant or ALK-rearranged adenocarcinomas. A cohort of 169 patients was identified (ROS1 = 23, EGFR = 120, and ALK = 26). Compared to EGFR-mutant adenocarcinomas, ROS1-rearranged adenocarcinomas were less likely to have air-bronchogram (p = 0.011) and pleural retraction (p = 0.048) and more likely to have pleural effusion (p = 0.025), pericardial metastases (p < 0.001), intrathoracic and extrathoracic nodal metastases (p = 0.047 and 0.023, respectively), and brain metastases (p = 0.017). Following multivariable analysis, age (OR = 1.06; 95% CI: 1.01, 1.12; p = 0.024), pericardial metastases (OR = 10.50; 95% CI: 2.10, 52.60; p = 0.005), and nodal metastases (OR = 8.55; 95% CI: 1.14, 62.52; p = 0.037) were found to be more common in ROS1-rearranged tumors than in non-ROS1-rearranged tumors. ROS1-rearranged adenocarcinomas appeared as solid tumors and were associated with young age, pericardial metastases and advanced nodal metastases relative to tumors with EGFR mutations or ALK rearrangement.

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