alk in lung cancer: past, present, and future
DESCRIPTION
ALK in lung cancer: Past, present, and future. Gene Mutations in Lung Adenocarcinomas. 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. - PowerPoint PPT PresentationTRANSCRIPT
ALK IN LUNG CANCER: PAST, PRESENT, AND FUTURE
Gene Mutations in Lung Adenocarcinomas
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.
The Mechanism of Carcinogenesis
Discovery of the EML4-ALK fusion in NSCLC
Initially 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
1Soda M, et al. Nature. 2007;448:561–67.
EML4–ALK Is an Oncogenic Driver
3T3
Nudemice
tumour/ injection 0/8 0/8 0/8 8/8 0/8 8/8 2/2
Vector EML4 ALK EML4–ALK K589M NPM–ALK v-Ras
•Expression 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
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
Frequency of ALK Rearrangements
Author Total Number
Pos % Notes
Shaw ASCO 2009
141 19 13% More likely in adenocarcinoma, light or never smokers, didn’t overlap with EGFR or KRAS, younger patients
Inamura, JTO 2008
149 5 3% No overlap with EGFR or KRAS
Takeuchi, CCR 2008
253 11 4%
Koivuner, CCR 2008
305 8 3% More common in never or light smokers
Wong, Cancer 2009
266 13 5% Mostly adenocarcinoma, never smokers, younger
Rodig, CCR 2009
358 20 6% More common in younger, never smokers, adenocarcinoma with signet ring features, no overlap with EGFR mutations
Kris, ASCO 2011
598 43 7% Rare overlap with EGFR, BRAF, KRAS
ALK fusions occur in numerous tumors
ALK fusion Incidence
ALCL
NPM-ALK 60-80%TPM3-ALK 12-18%TGF-ALK rare
CLTC1-ALK rareATIC-ALK rareTPM4-ALK rareMSN-ALK rare
ALO17-ALK rareMYH9-ALK rare
IMT
TPM3-ALK 50-60%TPM4-ALK 50-60%CARS-ALK rare
RANBP2-ALK rareCTLC1-ALK rare
SEC 31L1-ALK rare
ALK fusion Incidence
Lung
EML4-ALK 3-5%
KIF5B-ALK rare
TGF-ALK rareBreast EML4-ALK 0-2.4%
Colorectal EML4-ALK 0-2.4%
DLBCLCTLC1-ALK rare
NPM-ALK rare
Esophageal TPM4-ALK -
Renal VCL-ALK -
NPC TBD 14/51 (27.5%)
Atypical myeloproliferative
leukemia
RANBP2-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
Other ALK alterations (mutations, gene amplification)
ALK alteration Incidence
ThyroidMutations
(L1198F, G1201E)11%
NeuroblastomaMutations
(F1174L, R1275Q) 6-8%
Amplification 4%
Glioblastoma
ALK protein expression
Growth factor PTN protein, mRNA
expression
-
Murugan et al., Cancer Res 2011; 71:4403–4411Grande et al., Mol Cancer Ther 2011; 10:569-579
Powers et al., J Biol Chem 2002; 277:14153-14158 Lu et al., J Biol Chem 2005; 280:26953-26964
How do we test for ALK rearrangments?
Histology/IHC FISH/Cytogenetics PCR Sequencing
What can we do in ALK+ NSCLC patient?
Crizotinib: A Dual MET/ALK Tyrosine Kinase Inhibitor
KinaseIC50 (nM)mean*
Selectivity ratio
c-MET 8 –
ALK 40-60 5-8X
ROS 60 7X
RON 80 10X
Axl294 34X
322 37X
Tie-2 448 52X
Trk A 580 67X
Trk B 399 46X
Abl 1,159 166X
IRK 2,887 334X
Lck 2,741 283X
Sky >10,000 >1,000X
VEGFR2 >10,000 >1,000X
PDGFR >10,000 >1,000X
Co-crystal structure of crizotinib (PF-02341066) bound to c-MET
Cui et al. J. Med. Chem. 2011;54:6342-63 and Pfizer data on file
Early-phase clinical trial of crizotinib (PF-02341066)
N Engl J Med 2010;363:1693-703.
Key entry criteria• Positive for ALK by central
laboratory• Expanded from phase I dose
escalation trial• Most were previously treated• N=82
Crizotinib 250mg bid for 28-day cycle
6-month PFS among crizotinib users was estimated at 72% (95% CI, 61–83%)
Lancet Oncol 2012; 13: 1011–19
Updated of the phase I study Common treatment-related grade 1/2 AE
Overview of ongoing trials● ALK inhibition, NSCLC
– PROFILE 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 types– PROFILE 1013 – Ph I in non-NSCLC (NCT01121588)
● Met inhibition– Study 1002 – Ph I/II with erlotinib (NCT00965731)– Study 1006 – Ph I with PF-0299804 (dacomitinib),
NSCLC (NCT01121575)
Key entry criteria• Positive for ALK by central
laboratory• 1 prior chemotherapy
(platinum-based)
PROFILE 1007 – phase III
Key entry criteria• Positive for ALK by central
laboratory• Progressive disease in Arm B of
study A8081007• >1 prior chemotherapy
PROFILE 1005 – phase II
Crizotinib 250 mg BID (n=159)administered on a continuous dosing schedule
Pemetrexed 500 mg/m2 ordocetaxel 75 mg/m2 (n=159)infused on day 1 of a 21-day cycle
Primary endpoint = PFS met
Crizotinib 250 mg BID (N=250)administered on a continuous dosing schedule
Primary endpoint = ORR
PROFILE 1007: NCT00932893; PROFILE 1005: NCT00932451
100806040200
–20–40–60–80
–100–120
Dec
reas
e or
incr
ease
from
bas
elin
e (%
)
*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 CR
Kim et al., ASCO 2012
Median PFS 8.1 months (95% CI: 6.8–9.7)28% patients in follow-up for progression
1.0
0.8
0.6
0.4
0.2
0
Prob
abili
ty o
f sur
viva
l with
out p
rogr
essi
on
0 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 Study
Kim et al., ASCO 2012
PROFILE 1005: Any-Grade Treatment-Related AEs in ≥10% of Patients
AEMature population, n=261
n (%)Overall population, n=901
n (%)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
N Engl J Med 2013. DOI: 10.1056/NEJMoa1214886
Result of PROFILE 1007
1st line setting (PROFILE 1014):
Key entry criteria• Positive for ALK by central
laboratory• No prior systemic therapy
RANDOMIZE
Crizotinib 250 mg BIDadministered on a continuous dosing schedule
Pemetrexed 500 mg/m2 + Cisplatin 75mg/m2 OR Pemetrexed 500mg/m2 + Carboplatin AUC 5 or 6infused on day 1 of a 21-day cycle
Primary endpoint = PFS
Study Start Date: January 2011Estimated Study Completion Date: December 2013
The Future: Overcoming Crizotinib Resistance
Resistance develops on average within the first year or two of TKI therapy…
Acquired Crizotinib Resistance The 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 3 Current Opinion in Pharmacology 2013
Acquired Crizotinib ResistanceMutation
Up to 1/3 of relapsing patients, crizotinib resistance is mediated by secondary resistance mutations located in the ALK TK domain.Mutation Mechanism
L1196M gatekeeper mutation, hinder TKI binding through steric hindrance
Most common
G1269A lies directly in the ATP-binding Pocket
G1202R and S1206Y Locate in solvent-exposed region of the kinase domain, decrease binding affinity of Crizotinib
Acquired Crizotinib ResistanceAmplification
Amplification of the ALK fusion gene has also been reported in a small number of crizotinib-resistant tumors
Acquired Crizotinib ResistanceAlternative Pathway
In crizotinib-resistant tumors, several distinct bypass tracks mediating resistance have been reported. EGFR
½ cases with crizotinib resistance showed increased EGFR activity
c-KIT Confirmed by IHC, FISH, and c-Kit
ligand Stem cell factor (SCF) Can be overcome by Imatinib
combine with crizotinib There may be more than 1 bypass
pathway in 1 individual
Sci Transl Med 2012Cancer 2011
Sci Transl Med 2012
Mechanisms of resistance to crizotinib in ALK-positive NSCLC
Camidge, D. R. Nat Rev Clin Oncol. 2012 Apr 3
What Can We Do?
Summary of Crizotinib Resistance
Novel Agents to Overcome Crizotinib-resistance ALK+ NSCLC
LDK378 (Novartis, Basel, Switzerland)
AP26113(ARIAD Pharmaceuticals, Cambridge, MA),
AF802(Chugai Pharmaceutical, Tokyo, Japan)
ASP3026 (Astellas Pharma, Tokyo, Japan)
STA-9090(Ganetespib)
AUY922 IPI-504 AT 13387 DS-2248
2nd generation ALK inhibitors HSP90 inhibitors
The Possible Difficulties There 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 indicated
There may be other unknown bypass pathway
Frontline 2nd ALK inhibitor, sequential use, or combine with other agent/CT (cocktail use)
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 Timeline
2007 2009
EML4-ALK chromosomal rearrangements reported in NSCLC[1]
2011
EML4-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]
2008 2010Crizotinib 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
Take Home Message EML4-ALK defines a new molecular subset of
NSCLC Patients are more likely to be young,
never/light smokers with adenocarcinoma Crizotinib results in a 6-month PFS of 72%
and overall response rate of 57% at 6.4 months
2nd generation ALK TKIs and HSP90 inhibitors offer promise in patients with crizotinib resistance
Thanks for Your Attention!!