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Single ALK 7% Complex ALK 4% ALK + others 11% Others 30% None 48% None Other mutations Complex ALK Single ALK Efficacy of TKIs based on the ALK resistance mutations on amplicon-based liquid biopsy in ALK positive Non-Small Cell Lung Cancer (NSCLC) patients L Mezquita 1* , A Swalduz 2* , C Jovelet 1 , S Ortiz-Cuaran 2 , D Planchard 1 , G Recondo 3 , JC Benitez 1 , K Howarth 4 , F de Kievit 4 , C Morris 4 , E Green 4 , L Lacroix 5 , L Odier 6 , E Rouleau 5 , P Fournel 7 , C Caramella 8 , C Tissot 9 , C Nicotra 10 , M Pérol 2 , C Massard 10 , L Friboulet 3 , B Besse 1+ , P Saintigny 2+ * L.M. and A.S. and + P.S. and B.B. contributed equally to this work. 1 Medical Oncology Department, Gustave Roussy, Villejuif, France; 2 Medical Oncology Department, Centre Léon Bérard Lyon,France ; 3 INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France; 4 Inivata, Cambridge UK, Cambridge/United Kingdom; 5 Biopathology Department, Gustave Roussy, Villejuif, France ; 6 Department of Pneumology, Hôpital Nord-Ouest Villefranche, Villefranche Sur Saône/France; 7 Department of Medical Oncology, Institut de Cancérologie de la Loire, St. Priest En Jarez/France ; 8 Radiology Department, Gustave Roussy, Villejuif, France; 9 Department of Pneumonology and Thoracic Oncology, CHU Nord Saint-Etienne, Saint-Priest-en-Jarez/France; 10 Early Drug Development Department, Gustave Roussy, Villejuif, France. Acquired ALK resistance mutations (mut.) are the main mechanism of tyrosine kinase inhibitor (TKI) resistance (30-50%) While next-generation TKIs are more active on mut. than earlier TKIs, compound ALK resistance are associated with failure to next- generation TKIs Advanced ALK NSCLC patients were prospectively enrolled from October 2015 to April 2018 across 9 French institutions All patients were ALK positive by an approved molecular diagnostic test: immunochemistry (IHC) or Fluorescent In Situ Hybridization (FISH) using dual-color break-apart rearrangement probes and/or other validated test ctDNA molecular analysis was performed using amplicon-based NGS (InVision® liquid biopsy platform, InVisionFirst®-Lung) for ALK (EML4 variants v1, v2, v3), ROS1 (CD74, SLC34A2, SDC4 and EZR) fusions, and other somatic mutations A total of 20 to 30 ml of blood were collected in Streck BCT or EDTA tubes and processed for DNA extraction Correlation with clinical outcomes: overall survival (OS) and progression-free survival (PFS) to the current and subsequent TKIs ctDNA genomic alterations were stratified as: - Negative ctDNA, if no mutation detected - ALK mut. group: Single ALK mut., if one ctDNA ALK mut. Complex ALK mut., if 2 ctDNA ALK mut. - Other mut.: if ctDNA non-ALK mut. INTRODUCTION REFERENCES 1. 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 Jul 18; 2. Yoda S, Lin JJ, Lawrence MS, Burke BJ, Friboulet L, Langenbucher A, et al. Sequential ALK Inhibitors Can Select for Lorlatinib-Resistant Compound ALK Mutations in ALK-Positive Lung Cancer. Cancer Discov. 2018 Jun;8(6):714–29. 3. J Remon, L Lacroix, C Jovelet, C Caramella, et al. Real-World Utility of an Amplicon-Based Next-Generation Sequencing Liquid Biopsy for Broad Molecular Profiling in Patients With Advanced Non–Small-Cell Lung Cancer. JCO Precision Oncology 2019 :3, 1-14 Figure 1. The InVisionFirst™-Lung assay identifies SNVs, indels, CNVs and gene fusions with whole gene and gene hotspots, using an amplicon-based technology to selectively amplify genomic breakpoints. The sequence of the junctions are then identified using NGS, allowing the genomic breakpoint in ctDNA to be mapped 4 Poster Board Number: P.47 (Abstract 3055) We evaluated the clinical utility of detecting ALK resistance mut. in blood (ctDNA) to predict TKI efficacy METHODS RESULTS CONCLUSIONS 101 ALK positive patients were enrolled in the study, with 328 blood samples collected. Of these, 74 samples were at progression (PD) to TKIs, from 55 patients) Routine liquid biopsies can assess the heterogeneity of the TKI resistance, detecting ALK resistance and other acquired mutations in pretreated advanced ALK positive NSCLC patients The absence of ctDNA mutations at TKI failure was associated with prolonged OS, whereas complex ALK mutations at TKI failure may predict resistance to subsequent therapy These results will be validated in a larger cohort in the future Table 1. Baseline characteristics of patients at PD to TKI therapy Median follow-up (FU) from 1 st liquid biopsy was 9.9 mo. [95%CI, 1.0-30.1]. The median PFS to the therapy to which the patients progressed (“current” therapy) was 9.6 mo [95%CI, 7.9-11.8] No differences were observed in PFS to current therapy by ctDNA mutations detected (P=0.31) Figure 2. Distribution of ctDNA mutations at PD The median PFS to the subsequent therapy was 7.3 mo. [95%CI, 4.6-20.7] The ALK complex mut. group had median PFS of 1.7 mo . [95% CI, 0.9-NR] vs. 6.3 mo. [95% CI, 1.8-NR] in the ALK single mut. group (P=0.003) In the 4 cases with emergence of ALKG1202R PFS to the sequential therapy was 3.7 mo. [95% CI, 1.2-NR] OBJECTIVE PFS, CURRENT therapy based on ctDNA ALK mut. Figure 5. OS according the presence of ctDNA ALK resistance mut. N=8 N=1 N=1 N=1 OVERALL SURVIVAL (OS) by ctDNA resistance mutations PFS, SUBSEQUENT therapy based on ctDNA ALK mut. 0 10 20 30 40 50 60 70 80 90 100 Crizotinib 2nd gen TKI None Others ALK + others Complex ALK Single ALK Figure 3. Distribution of ctDNA mutations at PD according to the previous TKI Higher incidence of ALK mut. after 3 rd -gen TKI (43%) vs. 2 nd -gen (29%) vs. crizotinib (11%) None ALK mutation Other mutations Single ALK 7% Complex ALK 4% NFE2L2 + NFE2L2 + NFE2L2 + NFE2L2 + Complex ALK 1% TP53+ TP53 + TP53 + Complex ALK 1% TP53 + Complex ALK 1% TP53 + MYC + Complex ALK 1% TP53 + Complex ALK 1% TP53 + Single ALK 3% TP53+KRAS+PI3KCA 1% TP53+PTEN+PI3KCA 3% TP53 + MYC 1% TP53+STK11 1% TP53 19% GNAS 1% CKN2A 1% MET 1% None 49% Table 4. Clinical efficacy of TKIs according to the ALK resistance mutations in blood. Green: mPFS to subsequent therapy 6 mo.; orange: mPFS between 3-6 mo.; red: mPFS < 3 mo.; : patient has previously received this TKI; ** : de novo mutations (in blood); - fusion not detected/not tested. ALK & non- ALK mutations The median OS from 1 st line beginning was 100.4 months (mo.) [95% CI 51.3-not reached-NR-] The median OS was 105 mo. [95%CI 105.7- NR] if negative ctDNA vs. 58.5 mo . [95%CI 26.9- NR] if 1 ALK mut.(s) vs. 44.1 mo. [95%CI 21.7- NR] if non-ALK mut. This effect was observed regardless of the number of lines of TKI received (P=0.01) The presence of complex ALK mut. was associated with poor OS [median 26.9 mo. ; (95% CI13.9- NR)] compared to single ALK mut. [median NR ; (95% CI 57.0-NR)] (P=0.003) 74 samples were collected at PD to TKIs ALK mut. in 22% (16/74) 9, ALK single mut. - 5 ALK mut. only - 4 ALK mut. + others 7, ALK complex mut. - 3 complex ALK only - 4 complex ALK + others N=16 N=31 N=7 Figure 4: Distribution of ctDNA non- ALK mutations and at PD to TKIs. N=55 patients (74 samples) P=0.009 P=0.003 OS OS Median PFS to current therapy All population 9.6 mo. [95%CI 7.9-11.8] Negative ctDNA 14.8 mo. [95% CI, 8.1-23.1] 1 ALK mut. 9.6 mo. [95% CI, 6.6-19.9] Non-ALK mut. (other) 7.8 mo. [95% CI, 4.5-11.7] Table 3: Progression-free survival to current TKI therapy (n=74 samples) We explored it specifically in the subgroup with ctDNA ALK mut. (n=16 samples) [email protected] ctDNA mutations Time point ctDNA mutations ctDNA mutations De novo ALK mutations* N#1 CTC925 Post CRIZOTINIB Single ALK* ALKL1196M TP53 ALKL1196M N#2 G-A-01-034 Post ALECTINIB Single ALK* ALKC1156Y ALKC1156Y N#3 CTC534 Post CERITINIB Single ALK ALKT1151R TP53 NA N#4 R-C-01-020 Single ALK ALKF1174L NA N#5 CTC435 Single ALK ALKG1202R NA N#6 L-Y-01-045 Post BRIGATINIB Single ALK ALKF1174V NA N#7 B-B-01-127 Single ALK* ALKR1192P TP53 ALKR1192P N#8 CTC861 Single ALK ALKG1202R - N#9 CTC1342 Single ALK* ALKG1202R TP53 ALKG1202R N#10 CTC861 Post CRIZOTINIB Complex ALK* ALKG1202R ALKI1268V ALKG1202R ALKI1268V N#11 B-B-01-127 Complex ALK* ALKL1196M ALKC1156Y TP53 ALKL1196M ALKC1156Y N#12 CTC1105 Complex ALK* ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K NFE2L2(x4) ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K N#13 R-C-01-020 Post BRIGATINIB Complex ALK* ALKG1202R ALKF1174L TP53 ALKG1202R N#14 R-C-01-020 Post LORLATINIB Complex ALK ALKG1202R ALKF1174L - N#15 CTC861 Complex ALK* ALKG1202R ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M N#16 L-Y-01-045 Complex ALK* ALKF1174V ALKL1198F TP53 MYC ALKL1198F Table 2: Distribution of ctDNA ALK mut. at PD to TKIs (n=16) Characteristics Patients included, N=55 (%) Age, Median (year-old), range 56 (20-82) Sex Female 29 (53%) Smoking status Never Smoker 30 (55%) 23 (42%) Histology Adenocarcinoma 54 (98%) Stage at diagnosis I-IIIA IIIB-IV 2 (4%) 53 (96%) Brain metastasis at baseline 19 (36%) Molecular diagnosis FISH (+) IHC (+) Other (+) 34 (49%) 34 (49%) 1 N# prior systemic lines at inclusion Median, range 3 (1-8) Patients PD Sites Variant Time point ALK resistance mutations ALK G1202R Crizotinib Alectinib Ceritinib Brigatinib Lorlatinib Chemo CTC861 Liver V3 Post CRIZOTINIB Complex ALK** G1202R - - - - CTC 1105 Bone V3 Complex ALK** - - - - BB 01-127 Adrenal Brain, Liver V2 Complex ALK** - - - - RC01-020 Brain Bone - Post BRIGATINIB Complex ALK** G1202R - - LY 01-045 Brain, Lung, Nodal, Pleural - Post LORLATINIB Complex ALK** - RC01-020 Brain - Complex ALK G1202R - CTC861 Liver V3 Complex ALK G1202R - CTC 925 Nodal - Post CRIZOTINIB Single ALK** - - - - CTC 435 Pleural V3 Post CERITINIB Single ALK G1202R - - - CTC 534 Liver - Single ALK - - - RC01-020 Brain - Single ALK - - - GA 01-034 Brain - Post ALECTINIB Single ALK ** - - - LY 01-045 Brain, Lung, Nodal - Post BRIGATINIB Single ALK - - CTC861 Liver V3 Single ALK ** G1202R - - CTC 1342 Bone V3 Single ALK ** G1202R - - BB 01-127 Brain Liver V2 Single ALK ** - - 3 rd -gen TKI N=56 samples

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Page 1: Efficacy of TKIs based on the ALK resistance mutations on ......Single ALK 7% Complex ALK 4% ALK + others 11% Others 30% None 48% None Other mutations Complex ALK Single ALK Efficacy

Single ALK 7%

Complex ALK 4%

ALK + others 11%

Others 30%

None 48%

None

Other mutations

Complex ALK

Single ALK

Efficacy of TKIs based on the ALK resistance mutations on amplicon-based liquid biopsy in ALK positive Non-Small Cell Lung Cancer (NSCLC) patients

L Mezquita1*, A Swalduz2*, C Jovelet1, S Ortiz-Cuaran2, D Planchard1, G Recondo3, JC Benitez1, K Howarth4, F de Kievit4, C Morris4, E Green4, L Lacroix5, L Odier6, E Rouleau5, P Fournel7,

C Caramella8, C Tissot9, C Nicotra10, M Pérol2, C Massard10, L Friboulet3, B Besse1+, P Saintigny2+

* L.M. and A.S. and + P.S. and B.B. contributed equally to this work. 1 Medical Oncology Department, Gustave Roussy, Villejuif, France; 2 Medical Oncology Department, Centre Léon Bérard Lyon,France ; 3 INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France; 4 Inivata, Cambridge UK, Cambridge/United Kingdom; 5 Biopathology Department, Gustave Roussy, Villejuif, France ; 6 Department of Pneumology, Hôpital Nord-Ouest Villefranche, Villefranche Sur Saône/France; 7 Department of Medical Oncology, Institut de Cancérologie de la Loire, St. Priest En Jarez/France ; 8 Radiology Department, Gustave Roussy, Villejuif, France; 9 Department of Pneumonology and Thoracic Oncology,

CHU Nord Saint-Etienne, Saint-Priest-en-Jarez/France; 10 Early Drug Development Department, Gustave Roussy, Villejuif, France.

§  Acquired ALK resistance mutations (mut.) are the main mechanism of tyrosine kinase inhibitor (TKI) resistance (30-50%)

§  While next-generation TKIs are more active on mut. than earlier TKIs, compound ALK resistance are associated with failure to next-generation TKIs

§  Advanced ALK NSCLC patients were prospectively enrolled from October 2015 to April 2018 across 9 French institutions

§  All patients were ALK positive by an approved molecular diagnostic test: immunochemistry (IHC) or Fluorescent In Situ Hybridization (FISH) using dual-color break-apart rearrangement probes and/or other validated test

§  ctDNA molecular analysis was performed using amplicon-based NGS (InVision® liquid biopsy platform, InVisionFirst®-Lung) for ALK (EML4 variants v1, v2, v3), ROS1 (CD74, SLC34A2, SDC4 and EZR) fusions, and other somatic mutations

§  A total of 20 to 30 ml of blood were collected in Streck BCT or EDTA tubes and processed for DNA extraction

§  Correlation with clinical outcomes: overall survival (OS) and progression-free survival (PFS) to the current and subsequent TKIs

§  ctDNA genomic alterations were stratified as: -  Negative ctDNA, if no mutation detected -  ALK mut. group:

ü  Single ALK mut., if one ctDNA ALK mut. ü  Complex ALK mut., if ≥ 2 ctDNA ALK mut.

-  Other mut.: if ctDNA non-ALK mut.

INTRODUCTION

©2018 Inivata Ltd. ©2018 Inivata Ltd.

REFERENCES 1. 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 Jul 18;

2. Yoda S, Lin JJ, Lawrence MS, Burke BJ, Friboulet L, Langenbucher A, et al. Sequential ALK Inhibitors Can Select for Lorlatinib-Resistant Compound ALK Mutations in ALK-Positive Lung Cancer. Cancer Discov. 2018 Jun;8(6):714–29. 3. J Remon, L Lacroix, C Jovelet, C Caramella, et al. Real-World Utility of an Amplicon-Based Next-Generation Sequencing Liquid Biopsy for Broad Molecular Profiling in Patients With Advanced Non–Small-Cell Lung Cancer. JCO Precision Oncology 2019 :3, 1-14

Figure 1. The InVisionFirst™-Lung assay identifies SNVs, indels, CNVs and gene fusions with whole gene and gene hotspots, using an amplicon-based technology to selectively amplify genomic breakpoints. The sequence of the junctions are then identified using NGS, allowing the genomic breakpoint in ctDNA to be mapped4

Poster Board Number: P.47 (Abstract 3055)

§  We evaluated the clinical utility of detecting ALK resistance mut. in blood (ctDNA) to predict TKI efficacy

METHODS

RESULTS

CONCLUSIONS

§  101 ALK positive patients were enrolled in the study, with 328 blood samples collected. Of these, 74 samples were at progression (PD) to TKIs, from 55 patients)

§  Routine liquid biopsies can assess the heterogeneity of the TKI resistance, detecting ALK resistance and other acquired mutations in pretreated advanced ALK positive NSCLC patients

§  The absence of ctDNA mutations at TKI failure was associated with prolonged OS, whereas complex ALK mutations at TKI failure may predict resistance to subsequent therapy

§  These results will be validated in a larger cohort in the future

Table 1. Baseline characteristics of patients at PD to TKI therapy

§  Median follow-up (FU) from 1st liquid biopsy was 9.9 mo. [95%CI, 1.0-30.1]. The median PFS to the therapy to which the patients progressed (“current” therapy) was 9.6 mo [95%CI, 7.9-11.8]

§  No differences were observed in PFS to current therapy by ctDNA mutations detected (P=0.31)

Figure 2. Distribution of ctDNA mutations at PD

§  The median PFS to the subsequent therapy was 7.3 mo. [95%CI, 4.6-20.7]

§  The ALK complex mut. group had median PFS of 1.7 mo. [95% CI, 0.9-NR] vs. 6.3 mo. [95% CI, 1.8-NR] in the ALK single mut. group (P=0.003)

§  In the 4 cases with emergence of ALKG1202R PFS to the sequential therapy was 3.7 mo. [95% CI, 1.2-NR]

OBJECTIVE

PFS, CURRENT therapy based on ctDNA ALK mut.

Figure 5. OS according the presence of ctDNA ALK resistance mut.

N=8 N=1

N=1

N=1

OVERALL SURVIVAL (OS) by ctDNA resistance mutations PFS, SUBSEQUENT therapy based on ctDNA ALK mut.

0

10

20

30

40

50

60

70

80

90

100

Crizotinib 2nd gen TKI Next-gen TKI

None Others ALK + others Complex ALK Single ALK

Figure 3. Distribution of ctDNA mutations at PD according to the previous TKI

§  Higher incidence of ALK mut. after 3rd -gen TKI (43%) vs. 2nd-gen (29%) vs. crizotinib (11%)

None

ALK mutation

Other mutations

Single ALK 7%

Complex ALK 4%

NFE2L2 + NFE2L2 + NFE2L2 + NFE2L2 +

Complex ALK 1%

TP53+ TP53 + TP53 + Complex ALK

1%

TP53 + Complex ALK 1%

TP53 + MYC + Complex ALK 1%

TP53 + Complex ALK 1%

TP53 + Single ALK 3%

TP53+KRAS+PI3KCA 1%

TP53+PTEN+PI3KCA 3%

TP53 + MYC 1%

TP53+STK11 1%

TP53 19%

GNAS 1%

CKN2A 1%

MET 1%

None 49%

Table 4. Clinical efficacy of TKIs according to the ALK resistance mutations in blood. Green: mPFS to subsequent therapy ≥ 6 mo.; orange: mPFS between 3-6 mo.; red: mPFS < 3 mo.;

✓ : patient has previously received this TKI; ** : de novo mutations (in blood); - fusion not detected/not tested.

ALK & non- ALK mutations

§  The median OS from 1st line beginning was 100.4 months (mo.) [95% CI 51.3-not reached-NR-]

§  The median OS was 105 mo. [95%CI 105.7-NR] if negative ctDNA vs. 58.5 mo. [95%CI 26.9-NR] if ≥1 ALK mut.(s) vs. 44.1 mo. [95%CI 21.7-NR] if non-ALK mut.

§  This effect was observed regardless of the number of lines of TKI received (P=0.01)

§  The presence of complex ALK mut. was associated with poor OS [median 26.9 mo.; (95% CI13.9-NR)] compared to single ALK mut. [median NR; (95% CI 57.0-NR)] (P=0.003)

§  74 samples were collected at PD to TKIs

§  ALK mut. in 22% (16/74)

ü  9, ALK single mut. -  5 ALK mut. only -  4 ALK mut. + others

ü  7, ALK complex mut. -  3 complex ALK only -  4 complex ALK + others

N=16 N=31 N=7

Figure 4: Distribution of ctDNA non- ALK mutations and at PD to TKIs.

N=55 patients (74 samples)

P=0.009  

P=0.003  

OS

OS

Median PFS to current therapy

All population 9.6 mo. [95%CI 7.9-11.8]

Negative ctDNA 14.8 mo. [95% CI, 8.1-23.1]

≥1 ALK mut. 9.6 mo. [95% CI, 6.6-19.9]

Non-ALK mut. (other) 7.8 mo. [95% CI, 4.5-11.7] Table 3:

Progression-free survival to current TKI therapy (n=74 samples)

§  We explored it specifically in the subgroup with ctDNA ALK mut. (n=16 samples)

 

[email protected]

ctDNA mutations

Time point ctDNA mutations

ctDNA mutations

De novo ALK mutations*

N#1 CTC925

Post CRIZOTINIB

Single ALK* ALKL1196M TP53

ALKL1196M

N#2 G-A-01-034

Post ALECTINIB

Single ALK* ALKC1156Y ALKC1156Y

N#3 CTC534

Post CERITINIB

Single ALK ALKT1151R TP53

NA

N#4 R-C-01-020

Single ALK ALKF1174L NA

N#5 CTC435

Single ALK ALKG1202R NA

N#6 L-Y-01-045

Post BRIGATINIB

Single ALK ALKF1174V NA

N#7 B-B-01-127

Single ALK* ALKR1192P TP53

ALKR1192P

N#8 CTC861

Single ALK ALKG1202R

-

N#9 CTC1342

Single ALK* ALKG1202R TP53

ALKG1202R

N#10 CTC861

Post CRIZOTINIB

Complex ALK* ALKG1202R ALKI1268V

ALKG1202R ALKI1268V

N#11 B-B-01-127

Complex ALK* ALKL1196M ALKC1156Y

TP53

ALKL1196M ALKC1156Y

N#12

CTC1105

Complex ALK*

ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K NFE2L2(x4)

ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K

N#13

R-C-01-020 Post

BRIGATINIB

Complex ALK*

ALKG1202R ALKF1174L

TP53

ALKG1202R

N#14 R-C-01-020

Post LORLATINIB

Complex ALK ALKG1202R ALKF1174L

-

N#15 CTC861

Complex ALK*

ALKG1202R ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M

ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M

N#16 L-Y-01-045

Complex ALK*

ALKF1174V ALKL1198F

TP53 MYC

ALKL1198F

!

Table 2: Distribution of ctDNA ALK mut. at PD to TKIs (n=16)

Characteristics Patients included, N=55 (%)

Age, Median (year-old), range 56 (20-82) Sex Female

29 (53%) Smoking status Never Smoker

30 (55%) 23 (42%)

Histology Adenocarcinoma

54 (98%) Stage at diagnosis I-IIIA IIIB-IV

2 (4%) 53 (96%)

Brain metastasis at baseline 19 (36%) Molecular diagnosis FISH (+) IHC (+) Other (+)

34 (49%) 34 (49%)

1 N# prior systemic lines at inclusion Median, range

3 (1-8)

Patients

PD Sites

Variant

Time point

ALK resistance

mutations

ALK

G1202R

Crizotinib

Alectinib

Ceritinib

Brigatinib

Lorlatinib

Chemo

CTC861 Liver

V3

Post CRIZOTINIB

Complex ALK**

G1202R ✓

- - -

-

CTC 1105 Bone

V3

Complex ALK**

✓ - - -

-

BB 01-127 Adrenal Brain, Liver

V2

Complex ALK**

✓ - - -

-

RC01-020 Brain Bone

- Post BRIGATINIB

Complex ALK**

G1202R ✓ - ✓ ✓

-

LY 01-045 Brain, Lung, Nodal, Pleural

-

Post LORLATINIB

Complex ALK**

✓ - ✓ ✓ ✓

RC01-020 Brain - Complex ALK

G1202R ✓ - ✓ ✓ ✓

CTC861 Liver V3

Complex ALK

G1202R ✓ - ✓ ✓ ✓

CTC 925 Nodal

-

Post CRIZOTINIB

Single ALK**

✓ - - - -

CTC 435 Pleural

V3

Post CERITINIB

Single ALK

G1202R ✓

- ✓ - -

CTC 534 Liver - Single ALK ✓ - ✓

-

-

RC01-020 Brain - Single ALK ✓ - ✓

-

-

GA 01-034 Brain - Post ALECTINIB

Single ALK ** ✓ ✓ - - -

LY 01-045 Brain, Lung, Nodal

-

Post BRIGATINIB

Single ALK

✓ - ✓ ✓

-

CTC861 Liver

V3

Single ALK **

G1202R ✓ - ✓ ✓ -

CTC 1342 Bone

V3

Single ALK **

G1202R ✓

- ✓ ✓

-

BB 01-127 Brain Liver

V2

Single ALK **

✓ - ✓ ✓

-

!

3rd-gen TKI

N=56 samples