Search

Objectives The purposes of this study are to clarify the details of the ALK tyrosine kinase inhibitor (TKI) resistance mechanism in rebiopsy cases and to predict novel resistance gene alterations using molecular dynamics simulation. Methods A total of 21 patients with ALK-positive NSCLC who underwent a rebiopsy after ALK TKI failure were included in this analysis. ALK fluorescence in situ hybridization and reverse transcription polymerase chain reaction were performed with paired initial and rebiopsy tumor specimens. Results Nine patients had no known ALK resistance mechanisms. Four had ALK amplification. L1196M, I1171N, and G1269A, mutations that are known to indicate resistance to ALK TKIs, were detected in one patient each. Small cell carcinoma and sarcomatoid transition were found in one case each. L1196Q, P1094H, and exon 24 76-base pair insertion were detected after the second-generation ALK TKIs. Conclusions The combination of a genetic analysis and a computational simulation model may make a prediction of resistance mechanisms for overcoming ALK TKI resistance, and the construction of a genomic and simulation fused database is important for the development of personalized medicine in this field.

Dual blockade of the EGFR and VEGF pathways in EGFR-mutated metastatic non-small-cell lung cancer (NSCLC) is supported by preclinical and clinical data, yet the approach is not widely implemented. RELAY assessed erlotinib, an EGFR tyrosine kinase inhibitor (TKI) standard of care, plus ramucirumab, a human IgG1 VEGFR2 antagonist, or placebo in patients with untreated EGFR-mutated metastatic NSCLC.This is a worldwide, double-blind, phase 3 trial done in 100 hospitals, clinics, and medical centres in 13 countries. Eligible patients were aged 18 years or older (20 years or older in Japan and Taiwan) at the time of study entry, had stage IV NSCLC, with an EGFR exon 19 deletion (ex19del) or exon 21 substitution (Leu858Arg) mutation, an Eastern Cooperative Oncology Group performance status of 0 or 1, and no CNS metastases. We randomly assigned eligible patients in a 1:1 ratio to receive oral erlotinib (150 mg/day) plus either intravenous ramucirumab (10 mg/kg) or matching placebo once every 2 weeks. Randomisation was done by an interactive web response system with a computer-generated sequence and stratified by sex, geographical region, EGFR mutation type, and EGFR testing method. The primary endpoint was investigator-assessed progression-free survival in the intention-to-treat population. Safety was assessed in all patients who received at least one dose of study treatment. This trial is registered at ClinicalTrials.gov, NCT02411448, and is ongoing for long-term survival follow-up.Between Jan 28, 2016, and Feb 1, 2018, 449 eligible patients were enrolled and randomly assigned to treatment with ramucirumab plus erlotinib (n=224) or placebo plus erlotinib (n=225). Median duration of follow-up was 20·7 months (IQR 15·8-27·2). At the time of primary analysis, progression-free survival was significantly longer in the ramucirumab plus erlotinib group (19·4 months [95% CI 15·4-21·6]) than in the placebo plus erlotinib group (12·4 months [11·0-13·5]), with a stratified hazard ratio of 0·59 (95% CI 0·46-0·76; p0·0001). Grade 3-4 treatment-emergent adverse events were reported in 159 (72%) of 221 patients in the ramucirumab plus erlotinib group versus 121 (54%) of 225 in the placebo plus erlotinib group. The most common grade 3-4 treatment-emergent adverse events in the ramucirumab plus erlotinib group were hypertension (52 [24%]; grade 3 only) and dermatitis acneiform (33 [15%]), and in the placebo plus erlotinib group were dermatitis acneiform (20 [9%]) and increased alanine aminotransferase (17 [8%]). Treatment-emergent serious adverse events were reported in 65 (29%) of 221 patients in the ramucirumab plus erlotinib group and 47 (21%) of 225 in the placebo plus erlotinib group. The most common serious adverse events of any grade in the ramucirumab plus erlotinib group were pneumonia (seven [3%]) and cellulitis and pneumothorax (four [2%], each); the most common in the placebo plus erlotinib group were pyrexia (four [2%]) and pneumothorax (three [1%]). One on-study treatment-related death due to an adverse event occurred (haemothorax after a thoracic drainage procedure for a pleural empyema) in the ramucirumab plus erlotinib group.Ramucirumab plus erlotinib demonstrated superior progression-free survival compared with placebo plus erlotinib in patients with untreated EGFR-mutated metastatic NSCLC. Safety was consistent with the safety profiles of the individual compounds in advanced lung cancer. The RELAY regimen is a viable new treatment option for the initial treatment of EGFR-mutated metastatic NSCLC.Eli Lilly.

Objectives Pneumonitis related to the use of anti-programmed death 1 (PD-1) antibodies is a common immune-related adverse event that can be life-threatening. However, the relationship between pulmonary fibrosis/emphysema and the incidence of anti-PD-1-related pneumonitis is unclear. Materials and methods We retrospectively reviewed data from 123 patients who were diagnosed with non-small-cell lung cancer and treated with anti-PD-1 antibodies (nivolumab or pembrolizumab) at the Aichi Cancer Center Hospital, Japan, between December 17, 2015, and November 30, 2017. Patients who previously received thoracic radiotherapy to the primary lesion, mediastinum, spinal, or rib metastases were excluded from the analysis. Fibrosis score (0–5) and emphysema score (0–4) on baseline chest computed tomography (CT) were determined by two diagnostic radiologists. Results Eighteen patients (14.6%) experienced anti-PD-1-related pneumonitis, of which four (3.3%) were grade ≥3. The median onset time of pneumonitis after starting anti-PD-1 therapy was 60 days (range, 6–634 days). According to the analysis of fibrosis score, pneumonitis occurred in 13 (35.1%) of the 37 patients with a fibrosis score ≥1 and in 5 (5.8%) of 86 patients with a fibrosis score of 0. Univariate and multivariate logistic regression analysis revealed that fibrosis score ≥1 was the only risk factor for anti-PD-1-related pneumonitis (p = 0.0008). Conclusion Our results indicate that pre-existing pulmonary fibrosis significantly increases the risk of anti-PD-1-related pneumonitis. Further studies are needed to identify predictive factors of anti-PD-1-related pneumonitis in patients with fibrotic changes on CT findings.

Malignant mesothelioma (MM) frequently exhibits Hippo signaling pathway inactivation (HPI) mainly due to NF2 and/or LATS2 mutations, which leads to the activation of YAP transcriptional co-activator. Here, we show antitumor effects of statin on MM cells with HPI, through the interplay of the mevalonate and Hippo signaling pathways. Statin attenuated proliferation and migration of MM cells harboring NF2 mutation by accelerating YAP phosphorylation/inactivation. CD44 expression was decreased by statin, in parallel with YAP phosphorylation/inactivation. Importantly, we discovered that YAP/TEAD activated CD44 transcription by binding to the CD44 promoter at TEAD-binding sites. On the other hand, CD44 regulated Merlin phosphorylation according to cell density and sequentially promoted YAP transcriptional co-activator, suggesting that CD44 plays two pivotal functional roles as an upstream suppressor of the Hippo pathway and one of downstream targets regulated by YAP/TEAD. Moreover, the YAP/CD44 axis conferred cancer stem cell (CSC)-like properties in MM cells leading to chemoresistance, which was blocked by statin. Together, our findings suggest that YAP mediates CD44 up-regulation at the transcriptional level, conferring CSC-like properties in MM cells, and statin represents a potential therapeutic option against MM by inactivating YAP.

Background Concurrent chemoradiation therapy (CRT) is the current standard of care for patients with locally advanced lung adenocarcinoma; however, little has been reported about the impact of epidermal growth factor receptor ( EGFR ) mutation on CRT efficacy. Methods From 2006 to 2013, we retrospectively screened 104 unresectable stage III adenocarcinoma patients who were examined for EGFR mutation status and received definitive concurrent CRT consisting of platinum doublet chemotherapy in first-line setting and compared the clinical outcomes and recurrence patterns according to mutation status. Results Among 104 patients, EGFR mutation was detected in 29 (28%). The overall response rate did not differ between EGFR -mutant and wild-type patients (72.4% versus 72.0%, p = 0.607). The median progression-free survival in concurrent CRT was significantly shorter in EGFR-mutant patients than in wild-type patients (9.8 [95% confidence interval, CI: 7.6–19.0] versus 16.5 [95% CI: 11.8–19.9] months, p = 0.041). The 2-year recurrence-free survival rate was 7.7% and 28.1% in EGFR -mutant and wild-type patients, respectively ( p = 0.028). Distant metastases were more frequently identified as the first recurrence site in EGFR-mutant patients than in wild-type patients (76% versus 40%, p = 0.001). The brain was the most often affected site in EGFR -mutant patients (35%). However, locoregional recurrence was less common in EGFR -mutant patients than in the wild-type population (14% versus 35%, p = 0.027). Overall survival was similar between EGFR -mutant and wild-type patients (51.1 [95% CI: 28.2–70.2] versus 42.9 [95% CI: 35.3 to not available] months, p = 0.637). Among the EGFR wild-type population who were examined for Kras mutation, Kras -mutant patients had significantly worse overall survival than Kras wild-type patients (21.6 versus 49.8 months, p = 0.024). Conclusion Concurrent CRT resulted in shorter progression-free survival in EGFR -mutant stage III adenocarcinoma patients than in wild-type patients, mainly because of distant metastasis relapse, regardless of better local control. Because of these distinct biological features, a different strategy, including EGFR-tyrosine kinase inhibitors for EGFR -mutant locally advanced adenocarcinoma patients receiving definitive CRT may be needed.

It has been demonstrated that lung cancers, specifically a subset of pulmonary adenocarcinomas, with epidermal growth factor receptor (EGFR) mutation are highly sensitive to EGFR-targeted drugs. Therefore, a rapid, sensitive assay for mutation detection using routine pathological specimens is demanded in clinical practice to predict the response. We therefore developed a new assay for detecting EGFR mutation using only a paraffin section of a small biopsy specimen. The method was very sensitive, detecting as few as 5% cancer cells in a background of normal cells, the results usually being obtained within 4 hours. Furthermore, it was accurate, as shown by the high concordance with reverse transcriptase-polymerase chain reaction-coupled direct sequencing (186 of 195, 95%). The practical application of this assay to 29 cases treated with gefitinib resulted in a high prediction rate: 10 of the 11 responders were shown to be positive for the mutation, and all patients with progressive disease were negative. In addition, a mutation at codon 790, conferring gefitinib resistance, was successfully analyzed in a similar manner. In conclusion, the assay is a rapid, sensitive method using paraffin sections of biopsy specimens without a tumor cell-enrichment procedure and is quite useful to select a treatment of choice in clinical practice.

To explore the potential of an adenoviral antisense RNA transcript for gene therapy of cervical cancer, we introduced the antisense RNA transcript of E6 and E7 genes of human papillomavirus (HPV) 16 into cervical cancer cells harboring HPV 16 via a recombinant adenoviral vector, Ad5CMV-HPV 16 AS and analyzed the effects of expression of these genes on cell growth and tumor growth. Ad5CMV-HPV 16 AS contains the cytomegalovirus-promoter, E6 and E7 genes of HPV 16 in antisense orientation, and the SV40 polyadenylation signal in a mini-gene cassette, which is inserted into the E1-deleted region of modified adenovirus 5. The entire E6/E7 region of HPV 16 was amplified by polymerase chain reaction (PCR) before cloning into the mini-gene cassette. By reverse transcriptase-PCR, HPV 16 E6/E7 antisense RNA was detected in SiHa cells infected with Ad5CMV-HPV 16 AS. The growth of the Ad5CMV-HPV 16 AS-infected cells was greatly suppressed, as evidenced by a decrease in cell count. The growth inhibitory effect of Ad5CMV-HPV 16 AS was significantly enhanced by an adenoviral p53 construct, Ad5CMV-p53. In an ex vivo study in nude mice, tumorigenicity was completely inhibited in mice injected with Ad5CMV-HPV 16 AS-infected SiHa cells. These data suggest that transfection of cervical cancer cells with HPV 16 E6/E7 antisense RNA in a form such as Ad5CMV-HPV 16 AS is a potential novel approach to the therapy of HPV 16-positive cervical cancer.

Background: Mutations in the exon 14 of the MET gene affecting RNA splice acceptor and donor sites, which lead to exon skipping, have been recently associated to responsiveness to crizotinib. Up to date, patient selection for Met inhibitors has been made according to MET amplification/high polysomy and/or protein overexpression. We have investigated the prevalence of MET exon 14 mutations and their correlation with gene copy number alterations (CNAs) in NSCLC patients. Methods: We tested 132 lung adenocarcinomas and adenosquamous carcinoma samples for mutations in MET exon 14 by Sanger sequencing and for MET gene CNAs by FISH (Abbott Molecular). We collected clinical data together with EGFR and KRASmutational status and ALK, ROS1 and RET rearrangements. Results: MET alterations were found in 23 patients (17.5%): 3 exon 14 skipping mutations (2.3%), 8 gene amplifications (6.1%), and 12 high polysomy cases (9.1%). Among the 11 MET altered cases (3 mutated and 8 amplified): 8 patients were male, with a median age of 64.5 years (range: 46–91), current or former smokers (50 pack/years, range: 30–80), and all were diagnosed in an advanced stage disease (III and IV). None of the 3 mutated cases had concurrent MET CNAs. One MET mutated case presented also a KRAS p.G12C substitution while the other two were wild type for EGFR (exons 18 to 21) and KRAS (exon 2). Interestingly, patients with MET alterations have a shorter overall survival (p < 0.001). Conclusions: We have identified alterations of the MET gene (mutations in exon 14 and CNAs) in 8.4% of NSCLC patients. Our data support the usefulness of prospective screening of MET exon 14 mutations and gene amplifications due to their prognostic and predictive role. These mutations define a new subset of NSCLC patients that should be analyzed independently of the MET gene copy number status. Legal entity responsible for the study: Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain Funding: Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain Disclosure: All authors have declared no conflicts of interest.

This report describes esophageal ulcer as a novel adverse event associated with crizotinib therapy. Although crizotinib is generally well tolerated, physicians should be aware of the possibility of this adverse event.

Background The purpose of this study is to investigate the clinical characteristics and the efficacy of the cytotoxic chemotherapy in the first and second line setting in EML4-ALK positive NSCLC with advanced stage. Methods EML4-ALK fusion was screened with RT-PCR and immunohistochemistry. When positive results were obtained with either method, gene rearrangement of ALK was confirmed with fluorescent in-situ hybridization. Clinical features and the efficacy of chemotherapy were evaluated retrospectively. Results We evaluated 20 EML4-ALK positive patients with advanced stage. Seventeen (85%) of 20 had stage IV disease. Nine cases were male, and 11 were female. The mean ages were 46.3 years (range26-79). Most of their CT findings demonstrated mass or nodule in primary sites, while 2 cases showed air-space consolidation. In patients with stage IV the most common sites of metastasis at the first onset were bone (47.0%), followed by pleura (35.2%), liver (29.4%), and lung (23.5%). In 13 cases of which were evaluable in the first line setting, 7 (53.8%) had a partial response (PR), 4 (30.8%) had stable disease (SD), and 2 (15.4%) had progressive disease (PD). Among 10 evaluable cases in the second line setting, 2 (20%) had a PR, 5 (50%) had SD, and 3 had PD (30%). Two patients who had a PR were both treated by oral ALK inhibitor (crizotinib). One case had no response to crizotinib. Within the 7 patients who were treated by cytotoxic agents, none had marked clinical response. Five patients (71.4%) had SD, 2 patients had PD (28.6%) on single cytotoxic drug. Conclusions Our study suggests that the EML4-ALK positive patients may show relatively favorable response to cytotoxic drug in the first line setting, but low response in the second line setting. These data could be helpful for further clinical trials including EML4-ALK patients. Disclosure T. Mitsudomi: Dr. Mitsudomi has received lecture fees from AstraZeneca and Chugai, and he is a member of advisory boards of Pfizer and Boehringer-Ingelheim. All other authors have declared no conflicts of interest.

Aim: The purpose of this study is to better identify imaging characteristics on computed tomography (CT) in patients with non-small-cell lung carcinoma (NSCLC) with known epidermal growth factor receptor (EGFR) mutations, KRAS mutations, and anaplastic lymphoma kinase (ALK) gene rearrangements. Methods: Two hundred fifty-seven patients with a diagnosis of NSCLC and EGFR mutations, KRAS mutations or ALK gene rearrangements were assessed. We retrospectively analyzed the CT characteristics of each cohort. Results: We evaluated 257 patients with NSCLC. One hundred fifty-three patients (59.5%) had EGFR mutations, 54 patients (21.0%) had KRAS mutations, and 50 (19.5%) had ALK gene rearrangements. All mutations were mutually exclusive. Most patients had stage III or IV disease. One hundred twenty-one cases were male, and 136 were female. The mean age was 62.1 years (range29-89). Patients with EGFR mutations tend to have ground grass opacity (GGO), air bronchograms, and lung metastases (p Conclusions: These findings may help to make a proper diagnosis in the current era of molecular targeted therapies. Disclosure: All authors have declared no conflicts of interest.

Background ALK-fluorescence in situ hybridization (FISH) testing in all EGFR/KRAS-negative adenocarcinomas remains time- and cost-consuming and not suitable for a large-scale screening, in contrast to immunohistochemistry (IHC) for ALK protein expression. However, there appeared some IHC positive but FISH negative cases for ALK in lung cancer. Methods and case report A 69-year-old man who had received a right lower lobectomy for lung adenocarcinoma (pT1N0M0), recurred with brain metastasis 3 years later and treated with gamma-knife therapy, was referred to our hospital. CT showed a right hilar mass and enlarged mediastinal lymph nodes. An endoscopically visible tumor protruding into the lumen of the right upper lobe was biopsied. Histopathology revealed CD56+ and synaptophysin-positive neuroendocrine carcinoma. ALK protein expression was positive by IHC but ALK rearrangement was negative by FISH using a dual-color break-apart probe. Interestingly, positive immunostainigs of ALK, CD56 and synaptophysin were observed in primary lung adenocarcinoma but no ALK rearrangement was shown by FISH. The patient received chemotherapy with carboplatin and pemetrexed. After local progeression, he was treated with carboplatin and etoposide. Conclusions A case of lung adenocarcinoma with neuroendocrine differentiation exhibiting discordance between IHC and FISH for ALK was presented. Although FISH is a gold-standard reference, sensitivity and specificity of IHC for ALK protein or the relationship between IHC and FISH for ALK should be further investigated in a large number of patients.