Rare ROS1-CENPW gene in pancreatic acinar cell carcinoma and the effect of crizotinib plus AG chemotherapy:A case report

BACKGROUND This is the first report of an ROS1-CENPW fusion gene in pancreatic malignancies.CASE SUMMARY A 77-year-old woman with a pancreatic tumor and multiple liver metastases was admitted to our hospital.Genetic testing revealed the presence of the ROS1-CENPW fusion gene,a rare fusion gene that has not been previously reported in the field of pancreatic cancer.The patient received crizotinib plus AG(albumin paclitaxel plus gemcitabine)chemotherapy.After treatment,the patient’s condition stabilized,and her prognosis was good.CONCLUSION The ROS1-CENPW gene treatment regimen used in this case is an excellent treatment option that provides new hope for patients with advanced pancreatic cancer and similar genetic mutations.To date,owing to the rarity of the ROS1-CENPW fusion gene,our team has encountered only a single case.Therefore,the efficacy of crizotinib plus AG chemotherapy in patients with pancreatic acinar cell carcinoma harboring the ROS1-CENPW fusion gene requires further validation.

体外诱导建立NCI-H2228/Crizotinib耐药细胞株的方法学探讨及鉴定分析

背景与目的小分子靶向药物发生耐药的机制及寻找克服耐药的手段是目前提高临床疗效需要迫切解决的问题。本研究探讨采用不同方法建立对Crizotinib耐药的非小细胞肺癌NCI-H2228/Crizotinib细胞株的可行性及鉴定分析,为深入研究Crizotinib耐药发生的机制并寻找克服耐药的手段提供实验基础和理论依据。方法采用逐步增加药物浓度和化学诱变剂处理NCI-H2228细胞,诱导细胞对Crizotinib耐药。MTT法检测亲本细胞和耐药细胞的50%抑制浓度(50%inhibitory concentration,IC50)和群体倍增时间。RT-PCR和Western blot实验检测棘皮动物微管相关蛋白样4-间变性淋巴瘤激酶(echinoderm microtubule-associated protein like 4-anaplastic lymphoma kinase,EML4-ALK)基因表达。对耐药细胞和亲本细胞的EML4-ALK基因全长测序并对比分析发生耐药的机制。结果逐步增加药物浓度的方法耗时过长,细胞恢复生长缓慢,不能有效诱导NCI-H2228细胞对Crizotinib耐药;化学诱变剂ENU可以在短时间内诱导NCI-H2228细胞对Crizotinib耐药[IC50=(3.810±1.100)μmol/L,P=0.002,9,vs亲本细胞]。耐药细胞EML4-ALK基因发生点突变的频率高于亲本细胞。结论化学诱变剂诱导细胞耐药操作简便,可有效缩短实验流程,为深入研究耐药发生机制,寻找克服靶向药物耐药的手段提供了前期技术方法和实验依据。

间变性淋巴瘤激酶靶向治疗非小细胞肺癌新药Crizotinib

2003年在美国表皮生长因子受体（EGFR）酪氨酸激酶抑制药首先获准用于治疗非小细胞肺癌（NSCLC）,激活EG-FR突变接着在2004年被发现,标志着进入分子靶向治疗NSCLC的时代。

Crizotinib治疗ALK阳性伴骨髓转移的肺腺癌1例及文献复习

背景与目的肺癌患者常伴远处转移,其中伴骨髓转移患者治疗手段有限,预后差。Crizotinib已被证实可用于治疗间变淋巴瘤激酶(anaplastic lymphoma kinase,ALK)阳性的肺腺癌,但对于骨髓转移癌的疗效如何罕见报道。本文总结1例crizotinib治疗ALK阳性肺腺癌伴骨髓转移患者,并对其有效性及安全性进行讨论和分析。方法采用原位免疫荧光杂交法(fluorescence in situ hybridization,FISH)检测ALK融合基因阳性,一线化疗失败后给予crizotinib治疗,250 mg,2次/d。按照实体瘤疗效评价标准1.1版(Response Evaluation Criteriation in Solid Tumours,RECIST v1.1)评价客观疗效,采用骨髓活检评价骨髓转移瘤疗效。按照不良反应通用术语标准4.0版(Common Terminology Criteria for Adverse Events v4.0,CTC AE v4.0)评估用药期间发生的不良事件。结果该患者服用crizotinib 6周后,总体疗效评价为部分缓解(partial response,PR),骨髓疗效为完全缓解(complete response,CR)。因出现肺炎停药,无进展生存期(progression-free survival,PFS)20周,总生存期(overall survival,OS)22周。结论 Crizotinib治疗ALK阳性的肺癌伴骨髓转移患者可达骨髓完全缓解,耐受性好。

Crizotinib治疗EML4-ALK阳性晚期非小细胞肺癌的临床转化研究

棘皮动物微管相关蛋白样4(echinoderm microtubule associated protein like 4,EML4)间变性淋巴瘤激酶(anaplasticlymphoma kinase,ALK)融合基因(EML4-ALK)是近年来新发现的癌变驱动基因,该融合基因阳性的非小细胞肺癌(non-smallcell lung cancer,NSCLC)患者有其独特的临床特征,可能与表皮生长因子受体(epidermal growth factor receptor,EGFR)酪氨酸激酶抑制剂(tyrosine kinase inhibitor,TKI)耐药相关。针对EML4-ALK基因突变的新靶向药物———ALK抑制剂crizotinib,现已经进入Ⅲ期临床试验。Ⅰ期及Ⅱ期临床试验均证实,crizotinib治疗EML4-ALK阳性晚期NSCLC患者有效,能够改善肿瘤患者症状,患者的无进展生存期(progression free survival,PFS)延长,总体有效率(overall response rate,ORR)提高。且crizotinib的毒性作用较小,与传统化疗相比,患者耐受性较好。与其他TKI一样,crizotinib也存在获得性耐药现象,其耐药机制有待进一步研究。本文就crizotinib从基础研究向治疗EML4-ALK阳性晚期NSCLC患者临床应用的转化过程作一回顾。

Sequential therapy according to distinct disease progression patterns in advanced ALK-positive non-small-cell lung cancer after crizotinib treatment

Objective: Crizotinib is recommended as the first-line therapy for advanced anaplastic lymphoma kinase(ALK)-positive non-small-cell lung cancer(NSCLC). Despite its initial efficacy, patients ultimately acquire resistance to crizotinib within 1 year. In such patients, the optimal sequential therapy after crizotinib treatment remains unknown. This study explored which sequential therapy option confers the greatest benefit.Methods: A total of 138 patients with advanced ALK-positive NSCLC resistant to crizotinib were studied. Based on patterns of disease progression of metastases, patients were divided into 3 groups: brain progression, non-liver progression, and liver progression. Sequential therapies included crizotinib continuation plus local therapy, nextgeneration ALK inhibitors(ALKi's), and chemotherapy. The primary endpoint was overall survival(OS) from the time of crizotinib resistance to death or last follow-up.Results: The 138 patients included 64 cases with progression in brain, 57 cases in non-liver sites and 17 cases in liver. A significant difference in OS was observed among the distinct progression pattern(median OS, 25.4 months in brain, 15.8 months in non-liver, and 10.8 months in liver, respectively, P=0.020). The difference in OS among sequential therapies was statistically significant in the non-liver progression group(median OS, 27.6 months with next-generation ALKi's, 13.3 months with crizotinib continuation, and 10.8 months with chemotherapy,respectively, P=0.019). However, crizotinib continuation plus local therapy seems to provide non-inferior median OS compared with next-generation ALKi's for patients with brain progression(median OS, 28.9 months vs.32.8 months, P=0.204). And no significant differences in OS were found in patients with progression in liver(P=0.061).Conclusions: Crizotinib continuation together with local therapy might be a feasible strategy for patients with progression in brain beyond crizotinib resistance, as well as next-generation ALKi's. Next-generation ALKi's tended to provide a survival benefit in patients with non-liver progression.

Crizotinib在ALK基因阳性非小细胞肺癌中的临床研究进展

Crizotinib是小分子ATP竞争性抑制剂,对间变性淋巴瘤激酶(ALK)和肝细胞生长因子受体(c-Met/HGFR)以及它们的致癌变异体有选择性抑制作用。在临床研究PROFILE 1001和PROFILE 1005中,ALK重排阳性NSCLC患者对crizotinib有效率达50%～60%,大多数不良反应为1～2度。Vysis ALK breakapart FISH probe kit为检测ALK重排的标准方法。ALK重排更易出现在不吸烟或少吸烟的肺腺癌患者中。crizotinib的耐药机制比较复杂。

Impact of crizotinib on long-term survival of ALK-positive advanced non-small-cell lung cancer: A Chinese multicenter cohort study

Objective: Crizotinib has demonstrated promising efficacy in patients with anaplastic lymphoma kinase(ALK)-positive non-small-cell lung cancer(NSCLC) in clinical trials. We conducted this retrospective multicenter study to assess the outcomes of crizotinib therapy in, to our knowledge, a large sample cohort of patients with ALKpositive advanced NSCLC.Methods: We reviewed the medical records of 484 unselected ALK-positive NSCLC patients treated with crizotinib at 5 cancer centers in China from January 2013 to November 2017. Clinical data were collected from the initiation of crizotinib therapy to Response Evaluation Criteria in Solid Tumors(RECIST)-defined progressive disease(PD).Results: A total of 428 eligible ALK-positive NSCLC patients were enrolled, 273(63.8%) of whom received crizotinib as first-line treatment. The median progression-free survival(PFS) and overall survival(OS) from the initiation of crizotinib treatment were 14.4 [95% confidence interval(95% CI), 12.4-16.4] months and 53.4(95%CI, 33.7-73.1) months, respectively. In subgroup analyses, patients who received crizotinib as first-line treatment showed a higher disease control rate(DCR) and a longer median OS compared with second-/later-line crizotinib treatment(94.8% and OS not reached vs. 89.0% and 40.5 months, respectively). For 261 patients with RECISTdefined PD, multivariate Cox analysis revealed that in patients who received first-line crizotinib therapy, continued crizotinib beyond progressive disease(CBPD) and next-generation ALK inhibitors after crizotinib failure were associated with improved survival.Conclusions: This study has demonstrated the clinically meaningful benefit of crizotinib treatment in a large cohort of Chinese ALK-positive NSCLC patients. CBPD and next-generation ALK inhibitor treatment may provide improved survival after RECIST-defined progression on crizotinib.

Primary resistance to crizotinib treatment in a non-small cell lung cancer patient with an EML4-ALK rearrangement:a case report

Crizotinib,a small molecular tyrosine kinase inhibitor,manifests dramatic responses in patients with non-small cell lung cancer with echinoderm microtubule associated protein like 4-anaplastic lymphoma kinase(EML4-ALK)rearrangements.ALK gene point mutation is the primary mechanism of acquired crizotinib resistance;however,the intrinsic mechanism is not fully understood.Here,we report a patient with a low mutant allele fraction(MAF)of EML4-ALK rearrangement,who experienced primary resistance to crizotinib treatment.The patient was a 66-year-old Chinese man,who had a history of metastatic lung cancer and was treated with first-and third-generation epidermal growth factor receptor tyrosine kinase inhibitors(EGFR TKIs).After 14 months of osimertinib treatment,his disease progressed,and next-generation sequencing was performed from a liquid biopsy of the patient’s blood.An EML4-ALK rearrangement was found and crizotinib was administered.The patient’s lung lesions continued to progress after one month of crizotinib treatment,and pemetrexed-bevacizumab was initiated.After two cycles of chemotherapy,the metastatic cancers shrunk,and the patient maintained stable disease at his last follow-up.EML4-ALK rearrangements can happen in patients with EGFR-positive NSCLC,after acquired resistance to EGFR TKI treatment.The EGFR T790M and C797G mutations occur in cis is a critical mechanism of resistance to osimertinib therapy.The MAF of EML4-ALK rearrangements in cancer cells might be a predictive factor for crizotinib treatment.

Better to be alone than in bad company:The antagonistic effect of cisplatin and crizotinib combination therapy in non-small cell lung cancer

AIM To investigate the potential benefit of combining the cMET inhibitor crizotinib and cisplatin we performed in vitro combination studies.METHODS We tested three different treatment schemes in four non-small cell lung cancer(NSCLC) cell lines with a different cMET/epidermal growth factor receptor genetic background by means of the sulforhodamine B assay and performed analysis with Calcusyn.RESULTS All treatment schemes showed an antagonistic effect in all cell lines,independent of the cMET status.Despite their different genetic backgrounds,all cell lines(EBC-1,HCC827,H1975 and LUDLU-1) showed antagonistic combination indexes ranging from 1.3-2.7.These results were independent of the treatment schedule.CONCLUSION These results discourage further efforts to combine cMET inhibition with cisplatin chemotherapy in NSCLC.

ALK gene expression status in pleural effusion predicts tumor responsiveness to crizotinib in Chinese patients with lung adenocarcinoma

Objective： The relationship between anaplastic lymphoma kinase（ALK） expression in malignant pleural effusion（MPE） samples detected only by Ventana immunohistochemistry（IHC） ALK（D5F3） and the efficacy of ALKtyrosine kinase inhibitor therapy is uncertain.Methods： Ventana anti-ALK（D5F3） rabbit monoclonal primary antibody testing was performed on 313 cell blocks of MPE samples from Chinese patients with advanced lung adenocarcinoma, and fluorescence in situ hybridization（FISH） was used to verify the ALK gene status in Ventana IHC ALK（D5F3）-positive samples. The follow-up clinical data on patients who received crizotinib treatment were recorded.Results： Of the 313 MPE samples, 27（8.6%） were confirmed as ALK expression-positive, and the Ventana IHC ALK（D5F3）-positive rate was 17.3%（27/156） in wild-type epidermal growth factor receptor（EGFR） MPE samples. Twenty-three of the 27 IHC ALK（D5F3）-positive samples were positive by FISH. Of the 11 Ventana IHC ALK（D5F3）-positive patients who received crizotinib therapy, 2 patients had complete response（CR）, 5 had partial response（PR） and 3 had stable disease（SD）.Conclusions： The ALK gene expression status detected by the Ventana IHC ALK（D5F3） platform in MPE samples may predict tumor responsiveness to crizotinib in Chinese patients with advanced lung adenocarcinoma.

Crizotinib-induced acute fatal liver failure in an Asian ALK-positive lung adenocarcinoma patient with liver metastasis: A case report

BACKGROUND Crizotinib-induce hepatotoxicity is rare and non-specific, and severe hepatotoxicity can develop into fatal liver failure. Herein, we report a case of fatal crizotinib-induced liver failure in a 37-year-old Asian patient.CASE SUMMARY The patient complained of dyspnea and upper abdominal pain for a week in August 2017. He was diagnosed with anaplastic lymphoma kinase-rearranged lung adenocarcinoma combined with multiple distant metastases. Crizotinib was initiated as a first-line treatment at a dosage of 250 mg twice daily. No adverse effects were seen until day 46. On day 55, he was admitted to the hospital with elevated liver enzymes aspartate aminotransferase(AST)(402 IU/L), alanine aminotransferase(ALT)(215 IU/L) and total bilirubin(145 μmol/L) and was diagnosed with crizotinib-induced fulminant liver failure. Despite crizotinib discontinuation and intensive supportive therapy, the level of AST(1075 IU/L),ALT(240 IU/L) and total bilirubin(233 μmol/L) continued to rapidly increase,and he died on day 60.CONCLUSION Physicians should be aware of the potential fatal adverse effects of crizotinib.

Crizotinib in non-small cell lung cancer

Chemotherapy and targeted therapy remain the cornerstone of treatment of locally advanced and metastatic non-small cells lung cancer (NSCLC). Given the intrinsic chemoresistance of tumor cells, new treatment options have been developped. The knowledge of the molecular mechanisms of tumor biology, and signal transduction pathways activating cancer cells led to the identification of a new targeted therapy such as Crizotinib. The small molecule Crizotinib is a selective inhibitor of the receptor tyrosine kinase ALK (anaplastic lymphoma kinase) and its oncogenic variants (ALK fusion gene and some mutations of ALK). Phases I and II trials showed the efficacy of Crizotinib in the treatment of locally advanced and metastatic NSCLC expressing ALK. Thereafter, randomized Phase III trial confirmed the significant superiority of Crizotinib versus standard chemotherapy in terms of progression free survival and objective response with good tolerance;therefore, it has been approved by the Food and Drug Administration (FDA) as the standard treatment for locally advanced and metastatic ALK-positive NSCLC.

Effective response to crizotinib of concurrent KIF5B-MET and MET-CDR2-rearranged non-small cell lung cancer:A case report

BACKGROUND Due to the rarity of mesenchymal-epithelial transition factor(MET)fusions,the clinical efficacy of crizotinib has only been described in a few patients with MET fusions involving various fusion partners.Herein,we report the clinical response to crizotinib of a patient with advanced poorly differentiated non-small cell carcinoma(NSCLC)having concurrent MET fusions.CASE SUMMARY A 46-year-old woman was diagnosed with poorly differentiated NSCLC(T4 N3 M1).With no classic driver mutations,she was treated with two cycles of gemcitabine and cisplatin without clinical benefit.Targeted sequencing revealed the detection of two concurrent MET fusions,KIF5 B-MET and novel MET-CDR2.Crizotinib was initiated at a dose of 250 mg twice daily.Within 4 wk of crizotinib therapy,repeat computed chromatography revealed a dramatic reduction in primary and metastatic lesions,assessed as partial response.She continued to benefit from crizotinib for 3 mo until disease progression and died within 1 mo despite receiving nivolumab therapy.CONCLUSION Crizotinib sensitivity was observed in an advanced poorly differentiated NSCLC patient with concurrent MET fusions KIF5 B-MET and MET-CDR2.Crizotinib can serve as a therapeutic option for patients with MET fusions.In addition,our case also highlights the importance of comprehensive genomic profiling particularly in patients with no classic driver mutation for guiding alternative therapeutic decisions.

Development of Aseptic Renal Abscess in a Patient with Non-Small-Cell Lung Cancer with ALK Translocation during Crizotinib Treatment

Background: Crizotinib is a tyrosine kinase inhibitor of ALK, MET and ROS1. In a safety database trial, it was suggested an association of Crizotinib with the development of renal cyst in patients with non-small-cell lung cancer (NSCLC). Aim: To report an uncommon side effect of Crizotinib in a patient with NSLC. Case Presentation: We report the case of a 68-year-old woman with NSCLC who developed bilateral progressive aseptic renal abscesses during Crizotinib treatment. Conclusion: Further studies may be necessary to determinate the risk of renal cyst development and the management of these complications.

美国FDA批准Xalkori(crizotinib)治疗一种罕见肺癌

美国FDA于2016年3月11日批准辉瑞公司生产的Xalkori（crizotinib,克唑替尼）增加新的适用证,即用于治疗ROS-1基因突变型晚期（转移性）非小细胞肺癌,这是FDA批准的首个用于此适用证的药品,并同时获授予孤儿药地位。

Development of a new choroidal metastasis in resistance to crizotinib therapy in anaplastic lymphoma kinaserearranged non-small cell lung cancer

INTRODUCTION Non-small cell lung cancer（NSCLC）is a common malignant disease with an extremely poor prognosis.Lung cancer has been reported to metastasize to the eye in 0.2%to7%of patients based on clinical studies,and in 6%to 7%of patients based on postmortem histopathologic studies.

Role of the STAT3/survivin signaling pathway in the EML4-ALK-positive lung adenocarcinoma cell line H2228 before and after crizotinib-induced resistance

Objective This study investigated the role of the STAT3/survivin signaling pathway in the EML4-ALK- positive lung adenocarcinoma cell line H2228 before and after crizotinib-induced resistance. The mecha- nism of resistance was studied. Methods Cell viability was determined using the MTT assay. Crizotinib-induced apoptosis in H2228 and H2228 crizotinib-resistant cells treated with the indicated doses of crizotinib was measured at different times （24 h, 48 h, 72 h） using flow cytometry. The levels of p-ALK, ALK, p-STAT3, STAT3, and survivin after treatment of cells with 0, 0.3, and 1 pM crizotinib for 72 h were determined using Western blot analysis. DNA sequencing was used to identify mutations in H2228 crizotinib-resistant cells. Results The crizotinib IC50 values in H2228 and H2228 crizotinib-resistant cells at 72 h were 334.5 nM and 3418 nM, respectively. The resistance index of 1-12228 crizotinib-resistant cells was 10.20. Crizotinib induced apoptosis in H2228 cells and reduced the levels of p-ALK, p-STAT3, and survivin. In contrast, no changes in the levels of p-ALK, p-STAT3, and survivin were observed in H2228 crizotinib-resistant cells. The mutations 2067G--,A and 2182G--,C in EML4-ALK were present in the H2228 crizotinib-resistant cells. Conclusion Crizotinib decreased the viability of H2228 cells in a dose- and time-dependent manner. In the STAT3/survivin pathway, downregulation of p-ALK, p-STAT3, and survivin might contribute to crizo- tinib-induced apoptosis in H2228 ceils. However, the STAT3/survivin pathway in H2228 crizotinib-resistant cells was unaffected by crizotinib treatment. Acquired resistance in H2228 cells might be related to ALK mutations.

克唑替尼(crizotinib)获FDA突破性肺癌药物资格

据媒体报道,2015年4月,克唑替尼被FDA授予突破性药物资格,用于ROS1阳性非小细胞肺癌的潜在治疗。非小细胞肺癌是肺癌的一种,占所有肺癌病历的80%以上。而克唑替尼的适应证——ROS1阳性非小细胞肺癌约占所有非小细胞肺癌病例的1%左右,代表非小细胞肺癌中一个特定的分子亚型。

Crizotinib： From Chemical Entity to Anticancer Agent

Crizotinib is a mesenchymal-epithelial transition/anaplastic largecell kinase （MET/ALK） multi-targeted receptor tyrosine kinase inhibitor and has been rapidly and successfully developed as an inhibitor in ALK-rearranged NSCLC （non-small cell lung cancer）. Lung cancer is the major cause of cancer-related mortality, accounting for over one quarter of cancer deaths. Lung cancers are generally divided into two main categories： SCLC （small cell lung cancer） and NSCLC. NSCLC accounts for approximately 85% of all lung cancers. ALK gene rearrangements are identified and targeted resulting in promising response rates for NSCLC in early studies. Considering the significance of Crizotinib in the treatment of NSCLC, the synthesis, pharmacodynamics, pharmacokinetics, therapeutic trials and adverse events are briefly overviewed in order to make more scholars, medical workers and patients have a more clear and comprehensive recognition on Crizotinib.