|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 403-404
Anaplastic lymphoma kinase-positive metastatic non-small-cell lung cancer: Emerging resistance and treatment options
Amba Prasad Dubey1, Shivshankar Swamy2, Anvesh Rathore2, MR Kaushik2
1 Department of Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
2 Department of Medical Oncology, Army Hospital Research and Referral, New Delhi, India
|Date of Submission||08-Mar-2020|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||19-Jun-2020|
Amba Prasad Dubey
Department of Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dubey AP, Swamy S, Rathore A, Kaushik M R. Anaplastic lymphoma kinase-positive metastatic non-small-cell lung cancer: Emerging resistance and treatment options. Cancer Res Stat Treat 2020;3:403-4
|How to cite this URL:|
Dubey AP, Swamy S, Rathore A, Kaushik M R. Anaplastic lymphoma kinase-positive metastatic non-small-cell lung cancer: Emerging resistance and treatment options. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 5];3:403-4. Available from: http://www.crstonline.com/text.asp?2020/3/2/403/287263
I congratulate the authors for the interesting narration of the course of anaplastic lymphoma kinase (ALK)-positive non-small-cell lung cancer patients on ALK inhibitors. In the era of genomic sequencing, it is very common to stumble upon varied types of mutations. Molecular tumor boards will be of great help in choosing patients who may benefit from genomic sequencing, understanding the importance of these mutations and choosing appropriate therapy.
ALK-positive lung cancer patients in the Indian scenario constitute 4%–5% of adenocarcinoma lung cancer patients. Although alectinib has clearly demonstrated prolongation of the median progression-free survival to 34.1 months in these patients, its use in the first-line setting in resource-limited situations is not feasible. In these situations, sequencing of ALK inhibitors and understanding the mechanism of resistance are of paramount importance.
The site of progression in ALK-positive lung cancer patients on crizotinib is the first crucial information. Intracranial progression is the major reason for failure, accounting for approximately 30% of cases. The reason for these failures is the decreased central nervous system penetration of crizotinib. The role of genomic sequencing either with liquid biopsy or stereotactic brain biopsy is questionable.
However, in extracranial progression, like in this patient, the chances of acquired resistance to crizotinib are high. The mechanisms of resistance may be additional mutations in the ALK gene altering its drug-binding capacity or oncogenic bypass through activation of MET, ERBB2, or other pathways. In these subsets of patients, the case should be discussed in the molecular tumor boards and the utility of genomic sequencing should be discussed. Genomic sequencing will not only help in choosing further therapy but may also help in understanding the resistance pattern.
Second, I would like to emphasize the role of local therapy such as stereotactic body radiotherapy (SBRT) in oligoprogressive disease, like in this patient. SBRT to sites of oligoprogression may possibly eliminate the resistant clone and result in the opportunity to continue the same systemic therapy. Though in the era of availability of newer ALK inhibitors, the role of local therapy is not clearly known, it merits consideration.
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Conflicts of interest
There are no conflicts of interest.
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