Gene Mutations in Lung Adenocarcinomas 17 years ago 25 chromosomal translocation in most anaplastic largecell nonHodgkins lymphomas which fused the NPM gene on chromosome 5q35 to ALK on chromosome 2p23 ID: 1014725
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1. ALK in lung cancer: Past, present, and future
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3. Gene Mutations in Lung Adenocarcinomas
4. 17 years ago……2;5 chromosomal translocation in most anaplastic large-cell non-Hodgkin's lymphomas , which fused the NPM gene on chromosome 5q35 to ALK, on chromosome 2p23. Expressed in the small intestine, testis, and brain but not in normal lymphoid cells, ALK shows greatest sequence similarity to the insulin receptor subfamily of kinases. Unscheduled expression of the truncated ALK may contribute to malignant transformation in these lymphomas.
5. The Mechanism of Carcinogenesis
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7. Discovery of the EML4-ALK fusion in NSCLCInitially reported in 2007 as a result of an inversion in chromosome 2p, which results in the fusion of the N-terminal portion of the echinoderm microtubule-associated protein-like 4 (EML4) with the kinase domain of ALK.Soda et al., Nature 2007; 448:561-567
8. 1Soda M, et al. Nature. 2007;448:561–67.EML4–ALK Is an Oncogenic Driver3T3Nudemicetumour/ injection 0/8 0/8 0/8 8/8 0/8 8/8 2/2Vector EML4 ALK EML4–ALK K589M NPM–ALK v-RasExpression plasmids for WT, EML4, ALK, EML4-ALK, EML4-ALK K589M, and NPM-ALK were introduced into 3T3 fibroblasts.Subcutaneous injection of the transfected 3T3 cells into nude mice revealed those that formed tumors
9. Evidence for EML4-ALK as a Lung Cancer Oncogene Insertion of EML4-ALK into NIH 3T3 fibroblasts was tumorigenic when implanted subcutaneously into nude mice Engineered the specific expression of EML4-ALK fusion gene in lung progenitor cells using a surfactant protein C gene promoter 100% of EML4-ALK transgenic mice developed lung adenocarcinoma that were + for ALK by IHC. No other primary cancers were observed. Following IV injection of EML4-ALK/3T3 cells into nude mice, all developed lung cancer. Ten animals were treated with an ALK-specific TKI and 10 were observed:PNAS December 16, 2008 vol. 105 no. 50 19893–19897
10. Frequency of ALK RearrangementsAuthorTotal NumberPos%NotesShaw ASCO 20091411913%More likely in adenocarcinoma, light or never smokers, didn’t overlap with EGFR or KRAS, younger patientsInamura, JTO 200814953%No overlap with EGFR or KRASTakeuchi, CCR 2008253114%Koivuner, CCR 200830583%More common in never or light smokersWong, Cancer 2009266135%Mostly adenocarcinoma, never smokers, youngerRodig, CCR 2009358206%More common in younger, never smokers, adenocarcinoma with signet ring features, no overlap with EGFR mutationsKris, ASCO 2011598437%Rare overlap with EGFR, BRAF, KRAS
11. ALK fusions occur in numerous tumors ALK fusionIncidenceALCLNPM-ALK60-80%TPM3-ALK12-18%TGF-ALKrareCLTC1-ALKrareATIC-ALKrareTPM4-ALKrareMSN-ALKrareALO17-ALKrareMYH9-ALKrareIMTTPM3-ALK50-60%TPM4-ALK50-60%CARS-ALKrareRANBP2-ALKrareCTLC1-ALKrareSEC 31L1-ALKrareALK fusion IncidenceLungEML4-ALK3-5%KIF5B-ALKrareTGF-ALKrareBreastEML4-ALK0-2.4%ColorectalEML4-ALK0-2.4%DLBCLCTLC1-ALKrareNPM-ALKrareEsophagealTPM4-ALK-RenalVCL-ALK-NPCTBD14/51 (27.5%)Atypical myeloproliferative leukemiaRANBP2-ALK-Grande et al., Mol Cancer Ther 2011; 10:569-579Barreca et al., J Molec Endocrinol 2011; 47:R11-R23 Garber, J Natl Cancer Inst 2010; 102:672-675Röttgers et al., Leukemia 2010; 24:1197-1200
12. Other ALK alterations (mutations, gene amplification)ALK alteration IncidenceThyroidMutations(L1198F, G1201E)11%NeuroblastomaMutations(F1174L, R1275Q) 6-8%Amplification 4%GlioblastomaALK protein expressionGrowth factor PTN protein, mRNA expression-Murugan et al., Cancer Res 2011; 71:4403–4411Grande et al., Mol Cancer Ther 2011; 10:569-579Powers et al., J Biol Chem 2002; 277:14153-14158 Lu et al., J Biol Chem 2005; 280:26953-26964
13. How do we test for ALK rearrangments?Histology/IHC FISH/Cytogenetics PCR Sequencing
14. What can we do in ALK+ NSCLC patient?
15. Crizotinib: A Dual MET/ALK Tyrosine Kinase InhibitorKinaseIC50 (nM)mean* Selectivity ratioc-MET8–ALK40-605-8XROS607XRON8010XAxl29434X32237XTie-244852XTrk A58067XTrk B39946XAbl1,159166XIRK2,887334XLck2,741283XSky>10,000>1,000XVEGFR2>10,000>1,000XPDGFR>10,000>1,000XCo-crystal structure of crizotinib (PF-02341066) bound to c-METCui et al. J. Med. Chem. 2011;54:6342-63 and Pfizer data on file
16. Early-phase clinical trial of crizotinib (PF-02341066)N Engl J Med 2010;363:1693-703.Key entry criteriaPositive for ALK by central laboratoryExpanded from phase I dose escalation trialMost were previously treatedN=82Crizotinib 250mg bid for 28-day cycle 6-month PFS among crizotinib users was estimated at 72% (95% CI, 61–83%)
17. Lancet Oncol 2012; 13: 1011–19Updated of the phase I studyCommon treatment-related grade 1/2 AE
18. Overview of ongoing trialsALK inhibition, NSCLCPROFILE 1007 – Ph III 2nd line (NCT00932893)PROFILE 1014 – Ph III frontline (NCT01154140)PROFILE 1005 – Ph II pretreated (NCT00932451)PROFILE 1001 – Ph II expansion cohort (NCT00585195)ALK inhibition, other tumor typesPROFILE 1013 – Ph I in non-NSCLC (NCT01121588)Met inhibitionStudy 1002 – Ph I/II with erlotinib (NCT00965731)Study 1006 – Ph I with PF-0299804 (dacomitinib), NSCLC (NCT01121575)
19. Key entry criteriaPositive for ALK by central laboratory1 prior chemotherapy (platinum-based)PROFILE 1007 – phase IIIKey entry criteriaPositive for ALK by central laboratoryProgressive disease in Arm B of study A8081007>1 prior chemotherapyPROFILE 1005 – phase IICrizotinib 250 mg BID (n=159)administered on a continuous dosing schedulePemetrexed 500 mg/m2 ordocetaxel 75 mg/m2 (n=159)infused on day 1 of a 21-day cyclePrimary endpoint = PFS metCrizotinib 250 mg BID (N=250)administered on a continuous dosing schedulePrimary endpoint = ORRPROFILE 1007: NCT00932893; PROFILE 1005: NCT00932451
20. 100806040200–20–40–60–80–100–120Decrease or increase from baseline (%)*n=240 response-evaluable patients from the mature population, and excludes patients with early death, indeterminate response and non-measurable disease+Per RECIST 1.1, percent change from baseline for subjects with best overall response of CR can be less than 100% when lymph nodes are included as target lesions PD++ ++Marked Activity of Crizotinib in ALK+ NSCLCUpdate of the Phase 2 Study SD PR CRKim et al., ASCO 2012
21. Median PFS 8.1 months (95% CI: 6.8–9.7)28% patients in follow-up for progression1.00.80.60.40.20Probability of survival without progression0 5 10 15 20Time (months)+ Censored 95% Hall-Wellner Band n at risk 261 175 95 26 2 Marked Activity of Crizotinib in ALK+ NSCLCUpdate of the Phase 2 StudyKim et al., ASCO 2012
22. PROFILE 1005: Any-Grade Treatment-Related AEs in ≥10% of PatientsAEMature population, n=261n (%)Overall population, n=901n (%)Any AE 245 (93.9)827 (91.8)Vision disorder*154 (59)468 (51.9)Nausea 148 (56.7)423 (46.9)Vomiting 116 (44.4)352 (39.1)Diarrhea 106 (40.6)369 (41.0)Constipation 86 (33.0)249 (27.6)Peripheral edema 72 (27.6)211 (23.4)Fatigue 64 (24.5)163 (18.1)Decreased appetite 59 (22.6)167 (18.5)Increased alanine aminotransferase 45 (17.2)146 (16.2)Dysguesia 43 (16.5)149 (16.5)Dizziness 40 (15.3) 95 (10.5)Neutropenia 36 (13.8)84 (9.3)Increased aspartate aminotransferase 33 (12.6)106 (11.8)*Includes visual impairment, photopsia, vision blurred, vitreous floaters, photophobia and diplopiaRare instances of fatal pneumonitis and fatal hepatotoxicity were reported in crizotinib clinical trial program
23. N Engl J Med 2013. DOI: 10.1056/NEJMoa1214886Result of PROFILE 1007
24. 1st line setting (PROFILE 1014):Key entry criteriaPositive for ALK by central laboratoryNo prior systemic therapyRANDOMIZECrizotinib 250 mg BIDadministered on a continuous dosing schedulePemetrexed 500 mg/m2 + Cisplatin 75mg/m2 OR Pemetrexed 500mg/m2 + Carboplatin AUC 5 or 6infused on day 1 of a 21-day cyclePrimary endpoint = PFSStudy Start Date: January 2011Estimated Study Completion Date: December 2013
25. The Future: Overcoming Crizotinib ResistanceResistance develops on average within the first year or two of TKI therapy…
26. Acquired Crizotinib ResistanceThe target gene can be altered by mutation or by amplification, limiting the ability of the drug to inhibit the kinase. (like T790M in EGFR and T315I in BCR-ABL)Alternative signaling pathways (bypass tracks) can be activated in resistant cells, bypassing the need for signaling from the target. Nat Rev Clin Oncol. 2012 Apr 3Current Opinion in Pharmacology 2013
27. Acquired Crizotinib ResistanceMutationUp to 1/3 of relapsing patients, crizotinib resistance is mediated by secondary resistance mutations located in the ALK TK domain.MutationMechanismL1196Mgatekeeper mutation, hinder TKI binding through steric hindrance Most commonG1269Alies directly in the ATP-binding PocketG1202R and S1206YLocate in solvent-exposed region of the kinase domain, decrease binding affinity of Crizotinib
28. Acquired Crizotinib ResistanceAmplificationAmplification of the ALK fusion gene has also been reported in a small number of crizotinib-resistant tumors
29. Acquired Crizotinib ResistanceAlternative Pathway In crizotinib-resistant tumors, several distinct bypass tracks mediating resistance have been reported. EGFR½ cases with crizotinib resistance showed increased EGFR activityc-KITConfirmed by IHC, FISH, and c-Kit ligand Stem cell factor (SCF)Can be overcome by Imatinib combine with crizotinibThere may be more than 1 bypass pathway in 1 individualSci Transl Med 2012Cancer 2011Sci Transl Med 2012
30. Mechanisms of resistance to crizotinib in ALK-positive NSCLCCamidge, D. R. Nat Rev Clin Oncol. 2012 Apr 3
31. What Can We Do?
32. Summary of Crizotinib Resistance
33. Novel Agents to Overcome Crizotinib-resistance ALK+ NSCLCLDK378 (Novartis, Basel, Switzerland)AP26113(ARIAD Pharmaceuticals, Cambridge, MA),AF802(Chugai Pharmaceutical, Tokyo, Japan)ASP3026 (Astellas Pharma, Tokyo, Japan)STA-9090(Ganetespib)AUY922IPI-504AT 13387DS-22482nd generation ALK inhibitorsHSP90 inhibitors
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37. The Possible DifficultiesThere may be more than 1 bypass mechanisms in one patient, therefore combination therapy may be needed.The mutation may be different in different tumor sites in the same patient. Biopsy in different site may be indicatedThere may be other unknown bypass pathwayFrontline 2nd ALK inhibitor, sequential use, or combine with other agent/CT (cocktail use)
38. 1. Soda M, et al. Nature 2007; 448: 561-566. 2. McDermott U, et al. Cancer Res 2008; 68: 3389-3395.3. Koivunen JP, et al. Clin Cancer Res 2008; 14: 4275-4283.4. Shaw AT, et al. JCO 2009; 27: 4247-4253.5. Kwak EL, et al. N Engl J Med. 2010; 363: 1693-1703. 6. US Food and Drug Administration.ALK-Positive Timeline20072009EML4-ALK chromosomal rearrangements reported in NSCLC[1]2011EML4-ALK defines a molecular subset of NSCLC with distinct clinical characteristics[4]Preclinical studies document antitumor activity of ALK inhibitors in lung cancer cell lines and xenografts[2,3]20082010Crizotinib produces a response in 47/82 ALK+ patients and a 6-month PFS of 72%[5]FDA approves crizotinib for treatment of ALK+ NSCLC[6]? 2012 ?2nd generation ALK inhibitor TKIs and hsp inhibitors
39. Take Home MessageEML4-ALK defines a new molecular subset of NSCLCPatients are more likely to be young, never/light smokers with adenocarcinomaCrizotinib results in a 6-month PFS of 72% and overall response rate of 57% at 6.4 months2nd generation ALK TKIs and HSP90 inhibitors offer promise in patients with crizotinib resistance
40. Thanks for Your Attention!!