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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 89-92

Molecular tumor board: Case 2 – Evolution of resistance in anaplastic lymphoma kinase driven non-small-cell lung carcinoma

1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Department of Molecular Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
3 Pathology, Tata Memorial Hospital, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India

Date of Submission15-Jan-2020
Date of Decision30-Jan-2020
Date of Acceptance03-Feb-2020
Date of Web Publication24-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/CRST.CRST_26_20

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How to cite this article:
Kapoor A, Noronha V, Shetty O, Chougule A, Chandrani P, Patil VM, Menon N, Joshi A, Kumar R, Gurav M, Kumar A, Prabhash K. Molecular tumor board: Case 2 – Evolution of resistance in anaplastic lymphoma kinase driven non-small-cell lung carcinoma. Cancer Res Stat Treat 2020;3:89-92

How to cite this URL:
Kapoor A, Noronha V, Shetty O, Chougule A, Chandrani P, Patil VM, Menon N, Joshi A, Kumar R, Gurav M, Kumar A, Prabhash K. Molecular tumor board: Case 2 – Evolution of resistance in anaplastic lymphoma kinase driven non-small-cell lung carcinoma. Cancer Res Stat Treat [serial online] 2020 [cited 2022 May 22];3:89-92. Available from: https://www.crstonline.com/text.asp?2020/3/1/89/279104

  History Top

A 52-year-old gentleman with no comorbidities or addictions presented in June 2017 with a 2-month history of progressive cough and dyspnea.

  Diagnosis Top

Contrast-enhanced computed tomography scan showed a 4.5 cm × 3.2 cm right upper lobe mass with mediastinal lymphadenopathy, enlarged left supraclavicular node, and bilobar hepatic and multiple skeletal lesions. There were linear filling defects along the left lower lobe segmental and subsegmental branches of the descending pulmonary artery, suggestive of thrombosis. Biopsy from the liver lesion revealed poorly differentiated adenocarcinoma with signet ring cells, which was positive for CK7 and Napsin A and weakly positive for thyroid transcription factor (TTF)-1 while being negative for CK20 and CDX-2 [Figure 1]. The patient was immediately started on injection enoxaparin.
Figure 1: Histological examination showed a signet ring adenocarcinoma of primary pulmonary origin. The tumor was positive for CK7 and thyroid transcription factor-1, while negative for CK20. Immunohistochemistry for anaplastic lymphoma kinase 1 showed granular cytoplasmic positivity

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  Molecular Testing and Treatment Top

Real-time polymerase chain reaction was negative for epidermal growth factor receptor (EGFR) mutation; programmed death-ligand 1 by immunohistochemistry (IHC) using SP263 clone was negative while it showed strong granular staining for anaplastic lymphoma kinase (ALK) IHC by D5F3 Ventana antibody clone [Figure 1]. Since crizotinib was easily available and data supporting first-line use of next-generation ALK inhibitors were not mature; the patient was started on crizotinib 250 mg orally twice a day along with injection zoledronate monthly. He tolerated the therapy well and attained a partial response at 3 months which was sustained for 13 months. In July 2018, the patient had progression in the liver. The patient was advised a repeat liver biopsy; however, he was not willing to undergo a rebiopsy. He was started on alectinib 600 mg orally twice a day. Tolerance was good with no toxicities and the best response was stable disease (maximum reduction in target lesions of 10%). After about 9 months of second-line alectinib, he developed the progressive disease in liver, nodes, and a new-onset abdominal wall nodule. Since the abdominal wall nodule was small, repeat biopsy was obtained from the liver and the patient was started on lorlatinib 100 mg orally daily in April 2019. The patient developed hyperlipidemia, anorexia, and Grade 2 diarrhea after 2 months of lorlatinib use, which were managed conservatively.

Next-generation sequencing (NGS) testing was done on the liver biopsy using solid-tumor gene panel (AmpliSeq for Illumina Focus Panel) which detects single-nucleotide variants, indels from 269 amplicons on 41 genes and fusions from 284 amplicons on 24 genes. The NGS data for DNA panel were with a mean coverage of ×4000, Q30 value of 95%, and data analysis was performed using integrative genomics viewer, Base space, and Local Run Manager, Illumina. The alterations obtained were classified as per the recommendations of the Association for Molecular Pathology guidelines into tier I (pathogenic) missense alteration in exon 23 of the ALK gene (L1196M, c. 3586C >A, NM_004304.5) with allele variant frequency of 15.2%. There were tier IV (benign alterations) in JAK1, FGFR3, FGFR4, PDGFRA, RET, and EGFR. The patient's reports were discussed in the molecular tumor board and he was continued on lorlatinib.

In October 2019, restaging scan showed an increase in the size of the liver lesion by 22% [Figure 2]; however, the increase was primarily in the necrotic component only with no increase in symptoms and liver functions were normal. Therefore, lorlatinib was continued and the disease has now been under control for approximately 9 months. The patient has been tolerating lorlatinib well, and medical management for dyslipidemia and thrombosis has been continued. Enoxaparin injection has been continued at once a day dose [Table 1].
Figure 2: Computed tomography scan images of the patient showing increase in primarily necrotic component of liver lesion (from 7.7 cm to 9.4 cm) on lorlatinib

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Table 1: Timeline of the events, tests, and treatment of the patient

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  Excerpts from the Discussion in Molecular Tumor Board Top

In this patient with non-small-cell lung carcinoma (NSCLC) with ALK mutation, NGS revealed c.3586C >A mutation with transcript ID NM_004304.4 which encodes for L1196M. This alteration is a gatekeeper mutation affecting the bottom of the ATP-binding pocket of the protein conferring resistance to the tyrosine kinase inhibitor (TKI) crizotinib but has been reported to be sensitive to the second-generation TKIs such as ceritinib. This mutation in ALK is considered analogous to EGFR T790M. However, the story of ALK resistance mutation differs from EGFR-mutant NSCLC, in which T790M is usually the dominant resistant mutation to first- and second-generation EGFR inhibitors, whereas multiple ALK resistance mutations have been described in response to earlier generation ALK inhibitors. Furthermore, acquired secondary mutations in the ALK tyrosine kinase domain are seen only in one-third of the patients who develop resistance to crizotinib.[1] Besides, the ALK resistance mutations are distributed throughout the kinase domain as against the ATP-binding pocket in case of EGFR resistance mutations.[2] L1196M constitutes the most common resistance mechanism to crizotinib, with G1269A, C1156Y, and I1171T/N/S being the other important secondary resistance mutations. The mutations seen after ceritinib use include C1156Y, G1202R, and F1174L/C/V and deletion of G1202, while after alectinib, V1180L and I1171T/N/S may be expected. In the majority of the patients progressing on ALK inhibitors, the resistance mutation is not identified; thus, it is not considered essential to do a repeat biopsy at progression as against the progression of EGFR targeted agents where rebiopsy and testing for resistance mutations is the standard-of-care approach.[2],[3] The absence of identification of ALK resistance mutations can be explained by alternative bypass signaling pathways. These include HER2/3 and protein kinase C activation by purinergic receptors as the driving signals for crizotinib resistance.[4] Other implicated pathways include amplification of KIT proto-oncogene, activation of insulin-like growth factor 1 receptor, and nonreceptor tyrosine kinase (SRC) signaling.[5],[6] Amplification of the ALK fusion gene can occur alone or in combination with a resistance mutation. Liquid biopsy has become standard for the detection of resistance mechanisms due to the high specificity of plasma cell-free DNA.[7] However, it might not be always possible due to limited availability of Guardant 360. In our patient, liquid biopsy was not performed as the test was not available.

In our patient, L1196M mutation explained resistance to crizotinib but not to alectinib; thus, activation of a bypass signaling pathway was considered a possibility and it was planned to continue lorlatinib, as this has the strongest data in the third-line setting and there was an absence of resistance mutation demonstrable. It could be presumed that L1196M mutation had appeared post-crizotinib itself as the patient was not tested for it, post-progression on crizotinib. The patient has been on ALK-directed therapy for 31 months and still continues to respond which shows the progress that has been made in the field.

  Tackling Acquired Secondary Resistance to Crizotinib Top

Two second-generation ALK inhibitors, ceritinib and alectinib, are available for patients with ALK mutation requiring second-line therapy. [Figure 3] summarizes the integration of NGS in the management of ALK-mutated NSCLC. It should be noted that although ceritinib and alectinib will cover most of the secondary acquired resistance mutations to crizotinib, G1202R mutation (present in approximately 2% of patients) will require the use of lorlatinib immediately rather than keeping it in reserve for use in the third line. Furthermore, the identification of I1171T/N/S and V1180L mutation should lead to the preferential use of ceritinib over alectinib, as these mutations are found to be resistant to alectinib but respond to ceritinib.[8]
Figure 3: Algorithm for the integration of next-generation sequencing in the management of anaplastic lymphoma kinase-mutated non-small-cell lung cancer (V1180L is resistant to alectinib and G1202R is considered sensitive only to lorlatinib)

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Ceritinib is an example of an antineoplastic agent that got approval on the basis of a Phase I study. ASCEND-1 was a single-arm Phase I study of 163 patients who had received prior crizotinib; ceritinib led to objective response rate (ORR) of 56% and a median progression-free survival (PFS) of 6.9 months.[9] In the similar setting, alectinib led to ORR of 48% and median PFS of 8.1 months.[10] Brigatinib, another second-generation ALK inhibitor, has received breakthrough designation on the basis of a randomized Phase II trial (ALTA), in which ORR was 54% and the median PFS was 12.9 months, with 180 mg dose of brigatinib used in patients post-crizotinib.[11]

  Tackling Acquired Secondary Resistance to Second-Generation Anaplastic Lymphoma Kinase Inhibitors Top

When the second-generation ALK inhibitors are used upfront, the profile of acquired resistance is completely different from that of crizotinib upfront. This is also dependent on ALK fusion variant 1 versus 3. ALK resistance mutations were nearly double in variant 3 as compared to variant 1 (57% vs. 30%; P = 0.023).[12] The incidence of G1202R mutation jumps from 2% post-crizotinib to 43% post-second generation ALK inhibitors.[13] In the study by Lin et al., ALK G1202R was found only in variant 3 (32% vs. 0%; P < 0.001).[12] Another important difference which can be clinically important is the absence of MET amplification as a resistance mechanism post-crizotinib, as crizotinib also inhibits MET, while the second-generation ALK inhibitors, especially alectinib have poor anti-MET activity. There have been case reports of small-cell transformation in ALK-mutated NSCLC on both crizotinib and alectinib.[14] However, no case of lineage transformation was identified in a series of 103 repeat biopsies in ALK-mutated NSCLC patients who progressed on the first- or second-generation ALK inhibitors, establishing the rarity of this event.[1] If lorlatinib is used in the second line, a very important co-mutation should be kept in mind, C1156Y + L1198F, whereby L1198F paradoxically improves binding to crizotinib, the effect of C1156Y is negated and the tumor is sensitized to crizotinib again.[15]

In the era of second-generation TKIs being used in the upfront settings, studies to determine the optimal therapy progression on these have become clinically important. In a small Phase II study, ASCEND-9, ceritinib 750 mg led to a modest PFS of 3.7 months and ORR of 25% in Japanese patients who had progressed on alectinib 300 mg twice a day.[16] In the lorlatinib Phase II study, out of 28 patients who previously received a second-generation ALK inhibitor, 9 (32%) had a response with a median PFS of 5.5 months.[17] Although lorlatinib has the widest spectrum of activity against various secondary mutations, it is unlikely that it will be able to replace alectinib in the first-line setting due to significantly increased neurological adverse effects and it is likely to be used in the second-line post-disease progression on alectinib.[18]

  Conclusions Top

Acquired secondary mutations to the first- and second-generation ALK inhibitors differ significantly, and the use of NGS to tailor the selection of second-line ALK inhibitor should be considered.

  References Top

Rolfo C, Passiglia F, Castiglia M, Raez LE, Germonpre P, Gil-Bazo I, et al. ALK and crizotinib: After the honeymoon… what else? Resistance mechanisms and new therapies to overcome it. Transl Lung Cancer Res 2014;3:250-61.  Back to cited text no. 1
Le T, Gerber DE. ALK alterations and inhibition in lung cancer. Semin Cancer Biol 2017;42:81-8.  Back to cited text no. 2
Rajendra A, Noronha V, Joshi A, Patil VM, Menon N, Prabhash K. Epidermal growth factor receptor-mutated non-small-cell lung cancer: A primer on contemporary management. Cancer Res Stat Treat 2019;2:36-53.  Back to cited text no. 3
  [Full text]  
Wilson FH, Johannessen CM, Piccioni F, Tamayo P, Kim JW, Van Allen EM, et al. A functional landscape of resistance to ALK inhibition in lung cancer. Cancer Cell 2015;27:397-408.  Back to cited text no. 4
Lovly CM, McDonald NT, Chen H, Ortiz-Cuaran S, Heukamp LC, Yan Y, et al. Rationale for co-targeting IGF-1R and ALK in ALK fusion-positive lung cancer. Nat Med 2014;20:1027-34.  Back to cited text no. 5
Crystal AS, Shaw AT, Sequist LV, Friboulet L, Niederst MJ, Lockerman EL, et al. Patient-derived models of acquired resistance can identify effective drug combinations for cancer. Science 2014;346:1480-6.  Back to cited text no. 6
McCusker MG, Russo A, Scilla KA, Mehra R, Rolfo C. How I treat ALK-positive non-small cell lung cancer. ESMO Open 2019;4:e000524.  Back to cited text no. 7
Gainor JF, Dardaei L, Yoda S, Friboulet L, Leshchiner I, Katayama R, et al. Molecular mechanisms of resistance to first- and second-generation ALK inhibitors in ALK-rearranged lung cancer. Cancer Discov 2016;6:1118-33.  Back to cited text no. 8
Kim DW, Mehra R, Tan DSW, Felip E, Chow LQM, Camidge DR, et al. Activity and safety of ceritinib in patients with ALK-rearranged non-small-cell lung cancer (ASCEND-1): Updated results from the multicentre, open-label, phase 1 trial. Lancet Oncol 2016;17:452-63.  Back to cited text no. 9
Shaw AT, Gandhi L, Gadgeel S, Riely GJ, Cetnar J, West H, et al. Alectinib in ALK-positive, crizotinib-resistant, non-small-cell lung cancer: A single-group, multicentre, phase 2 trial. Lancet Oncol 2016;17:234-42.  Back to cited text no. 10
Kim DW, Tiseo M, Ahn MJ, Reckamp KL, Hansen KH, Kim SW, et al. Brigatinib in patients with crizotinib-refractory anaplastic lymphoma kinase-positive non-small-cell lung cancer: A randomized, multicenter Phase II trial. J Clin Oncol 2017;35:2490-8.  Back to cited text no. 11
Lin JJ, Zhu VW, Yoda S, Yeap BY, Schrock AB, Dagogo-Jack I, et al. Impact of EML4-ALK variant on resistance mechanisms and clinical outcomes in ALK-positive lung cancer. J Clin Oncol 2018;36:1199-206.  Back to cited text no. 12
Choi YL, Soda M, Yamashita Y, Ueno T, Takashima J, Nakajima T, et al. EML4-ALK mutations in lung cancer that confer resistance to ALK inhibitors. N Engl J Med 2010;363:1734-9.  Back to cited text no. 13
Miyamoto S, Ikushima S, Ono R, Awano N, Kondo K, Furuhata Y, et al. Transformation to small-cell lung cancer as a mechanism of acquired resistance to crizotinib and alectinib. Jpn J Clin Oncol 2016;46:170-3.  Back to cited text no. 14
Shaw AT, Friboulet L, Leshchiner I, Gainor JF, Bergqvist S, Brooun A, et al. Resensitization to Crizotinib by the Lorlatinib ALK Resistance Mutation L1198F. N Engl J Med 2016;374:54-61.  Back to cited text no. 15
Hida T, Seto T, Horinouchi H, Maemondo M, Takeda M, Hotta K, et al. Phase II study of ceritinib in alectinib-pretreated patients with anaplastic lymphoma kinase-rearranged metastatic non-small-cell lung cancer in Japan: ASCEND-9. Cancer Sci 2018;109:2863-72.  Back to cited text no. 16
Solomon BJ, Besse B, Bauer TM, Felip E, Soo RA, Camidge DR, et al. Lorlatinib in patients with ALK-positive non-small-cell lung cancer: Results from a global phase 2 study. Lancet Oncol 2018;19:1654-67.  Back to cited text no. 17
Recondo G, Facchinetti F, Olaussen KA, Besse B, Friboulet L. Making the first move in EGFR-driven or ALK-driven NSCLC:First-generation or next-generation TKI? Nat Rev Clin Oncol 2018;15:694-708.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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