European Review for Medical and Pharmacological Sciences 2017; 21: 3496-3503 Effect of ALK-inhibitors in the treatment of non-small cell lung cancer: a systematic review and meta-analysis

G. LI1, W.-R. DAI2, F.-C. SHAO3

1Department of Surgical Oncology, Hangzhou Tumor Hospital, Hangzhou, Zhejiang Province, China 2Department of Pharmacy, The First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang Province, China 3Department of Respiratory Medicine, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang Province, China Gang Li and Wanrong Dai are co-first authors

Abstract. – OBJECTIVE: Key Words: Lung cancer is the NSCLC, Anaplastic lymphoma kinase, Echinoderm leading cause of cancer-related mortality. Over microtubule-associated protein-like 4, Meta-analysis. 80% of all lung cancer cases are non-small-cell lung cancer (NSCLC) and approximately 5% of NSCLC patients are positive for anaplastic lym- phoma kinase (ALK) gene rearrangement or fu- Introduction sion with echinoderm microtubule-associated protein-like 4 (EML4). NSCLC patients with pos- itive ALK-EML4 gene fusion are highly sensi- Lung cancer remains the leading cause of can- tive to ALK-inhibitors. While the efficacy of the cer-associated mortality, with non-small-cell lung ALK-inhibitors in the treatment of NSCLC has cancer (NSCLC) accounting for 85-90% of the been consistently reported, a limited number of cases1. Genetic alterations of the anaplastic lym- randomized, large-scale clinical trials have been phoma kinase (ALK) gene have been reported in reported. The current study was, therefore, de- 2-7% of the patients with NSCLC2,3, and the most signed to systematically review and appraise common alteration of ALK is the fusion of the current knowledge and conduct a meta-analy- sis on phase I, II, and III clinical trials in which ALK gene with the Echinoderm microtubule-as- 4,5 ALK-inhibitors were used to treat NSCLC. sociated protein-like 4 (EML4) gene . NSCLC MATERIALS AND METHODS: The PubMed with positive ALK-EML4 gene fusion is highly online database was thoroughly searched. A to- sensitive to ALK inhibition by molecules desi- tal of 26 articles were included in a qualitative gned to target tyrosine kinases. systematic review, and four of them were used to The ALK gene rearrangements or fusion of conduct the quantitative meta-analysis. RESULTS: We found that ALK inhibitors sig- ALK-EML4 genes in NSCLC can be detected in nificantly improved the overall survival (OS) and clinical samples using several techniques, pri- progress free survival (PFS) of NSCLC patients, marily fluorescence in situ hybridization (FISH), especially of ALK or ROS1 gene fusion-posi- reverse transcriptase polymerase chase reaction tive cases. ALK inhibitors contributed to better (RT-PCR), and immunohistochemistry (IHC). therapeutic outcomes regarding increased one- The methods for detection of ALK gene fusion or year and two-year OS, PFS, and ORR (Odds ra- rearrangement have been rapidly developed, and tio: 4.393, 95% CI: 3.302-5.845, p < 0.001). Visu- al disturbance was the most common side effect ALK-inhibitors have been recently approved to observed in the patients treated with , use in clinic and are increasingly applied for the whereas mild gastrointestinal reactions, such as treatment of ALK-positive NSCLC patients. diarrhea and nausea, were most frequent in the Crizotinib, the first generation of ALK-targe- patients treated with the 2nd generation of ALK ted molecule, is an oral tyrosine kinase inhibitor inhibitors. (TKI) that has been shown to improve overall CONCLUSIONS: ALK inhibitors are safe and effective in the treatment of NSCLC patients, es- survival (OS), progression-free survival (PFS), pecially those with positive ALK-EML4 gene fu- and objective response rate (ORR) in NSCLC sion or rearrangement. patients compared with standard second-line

3496 Corresponding Author: Fangchun Shao, MD; e-mail: [email protected] Effect of ALK-inhibitors in the treatment of non-small cell lung cancer chemotherapy6. Crizotinib was approved for dless of whether it was first- or second-generation use in clinic for the treatment of ALK-positive ALK inhibitor; (2) The study was a full-text article. NSCLC patients in the U.S. within four years of its discovery. It has subsequently been appro- Data Extraction ved in many European countries, and effective Information was carefully extracted from all outcomes from phase I and II clinical trials are included literature sources. The following data consistently reported4,7-9. However, acquired was collected: study title, name of the first author, resistance to crizotinib could be developed wi- year of publication, study design, total number thin one year of application of this molecule in of cases treated with ALK inhibitors (crizotinib most NSCLC patients. To overcome the acqui- or ), median survival months, one-year red resistance to crizotinib, a second generation survival rate, 2-year survival rate, and adverse ef- of ALK inhibitors, such as ceritinib and alecti- fects of ALK inhibitors. nib, have recently been developed and approved for use in clinical settings. These second ge- Statistical Analysis neration of ALK inhibitors are not only highly For the data entry, event number treated with selective, but also more potent than crizotinib an ALK inhibitor, total number of the cases trea- in their activity against ALK 10. ted with an ALK inhibitor, event number treated While consistent efficacy findings from pha- without ALK inhibitor, and the total number of se I and II studies have been reported, a limited the cases treated without an ALK inhibitor was number of randomized clinical trials on the use of used. The effect of the treatment with an ALK ALK-inhibitors to treat NSCLC have been repor- inhibitor on NSCLC outcome was determined ted. The current review is, therefore, designed to by the odds ratio and 95% confidence interval systematically review the scientific literature and (95% CI). A fixed-effects model was adopted for summarize the outcomes of phase I and II clinical statistical analysis when no heterogeneity was studies as well as to conduct a meta-analysis on observed among the studies; otherwise, a ran- limited reports of phase III clinical studies. dom-effect model was applied. The heterogeneity between studies was assessed by the Q-test and I2 statistic, and values of p < 0.10 and I2 > 50% were Materials and Methods considered to indicate heterogeneity between the studies11. The meta-analysis was performed using Data Sources the Comprehensive Meta-analysis software (Ver- We searched the relevant literature published sion 3, NJ, USA). up to July 2016 on PubMed site of using the fol- lowing phrases: “anaplastic lymphoma kinase”, OR “ALK inhibitor”, AND “lung cancer”, AND Results “clinical trial” OR “clinical study”. The search was limited to English-language publications. Features of the Clinical Studies The processes of literature screening and final Inclusion Criteria selection of the articles are outlined in Figure 1. To be included in the current systematic review, After careful reading of the Abstract sections of each study had to meet the following criteria: (1) It the initially selected publications, a total of 60 was a phase I, II, or III clinical study on the treat- full-text articles were retrieved. The retrieved ment of lung cancer with an ALK inhibitor regar- full-text articles were then independently asses-

Table I. Studies on the methods of ALK detection.

Authors Year Country Detection methods No. of samples References

Cutz, JC 2014 Canada FISH and IHC comparison 28 30 Fu, S 2015 China FISH, qRT-PCR, sequencing 173 26 Zwaenepoel, K 2015 Italy Automation of FISH assay 40 28 Ma, D 2016 China FISH and IHC comparison 6 27

FISH: Fluorescence in-situ hybridization; qRT-PCR: quantitative reverse transcriptase polymerase chain reaction; IHC: immunohistochemistry.

3497 G. Li, W.-R. Dai, F.-C. Shao

Table II. Study designs included in qualitative synthesis.

Authors Year Country Study design ALK-inhibitor No. of patients References

Kwak, EL 2010 USA Phase I crizotinib 82 4 Mosse, YP 2013 USA Phase I crizotinib 79 7 Seto, T 2013 Japan Phase I and II CH5424802 70 23 Sargis, RM 2015 USA ? crizotinib 7 15 Shaw, AT 2014 USA Phase I crizotinib 50 14 Costa, DB 2015 USA Retrospective crizotinib 888 9 Mazieres, J 2015 France Retrospective crizotinib 31 31 Gadgeel, SM 2014 USA Phase I and II 47 16 Nishio, M 2015 Japan Phase I ceritinib 20 24 Kim, DW 2016 USA Phase I ceritinib 255 17 Li, T 2016 USA Phase I ASP3026 33 18 Shaw, AT 2016 USA Phase I alectinib 87 25

Table III. Studies on resistance of ALK-inhibitors. Authors Year Country Mechanism of resistance Overcome resistance References

Katayama, R 2011 USA EML4-ALK gene mutation 2nd-generation ALK-TKIs 20 or Hsp90 inhibitors Ceccon, M 2014 Italy Point mutation 29 An, R 2016 USA CRKL silence or inhibition 21 Dong, XY* 2016 USA Overexpression of p-ALK Combination of ALK 22 p-EGFR, p-HER3, p-IGFR-1R inhibitor and Upregulation of NRG1 Katayama, R* 2016 Japan p-glycoprotein (P-gp/ABCB1) Combination of P-gp 25 overexpression and ALK inhibitor Lin, YT 2016 Taiwan L1196M and 2nd domain 32 mutation

*Resistance to 2nd-generation ALK inhibitors; CRKL: CRK-like protein, downstream of ALK signaling; HER3: human epider- mal growth factor receptor3; NRG1: neuregulin1, is a ligand for HER3 sed by two investigators (GL and WD). Of the 60 one article was from France31, and one article was full-text articles, 34 articles, consisting mostly of from Taiwan32. Of them, four articles reported on case reports and review articles, were excluded, ALK gene fusion detection methods (Table I), 12 while 26 articles were included for systematic re- articles were in phase I and/or II studies or re- view (qualitative synthesis), and four articles were trospective analyses (Table II), six articles con- included in the meta-analysis (quantitative syn- cerned studies on resistance to ALK inhibitors thesis)6,12-14. Among the 26 articles included for (Table III), and four articles reported in phase III systematic review and meta-analysis, 13 articles clinical studies (Table IV). were from the USA4,7,9,12,14-22, three of the articles reported on studies performed in multiple coun- Efficacy of ALK Inhibitors tries6,13,14, three articles were from Japan23-25, two Of the 26 articles selected for our systematic articles were from China26,27, two articles were review, four were phase III clinical trials or com- from Europe28,29, one article was from Canada30, pared the efficacy of treatment with an ALK inhi-

Table IV. Randomized clinical studies. First author Year Country No. of cases ALK inhibitor References

Shaw, AT 2011 USA 438 crizotinib 12 Shaw, AT 2013 USA 347 crizotinib 6 Solomon, BJ 2014 Multi-country 343 crizotinib 13 Shaw, AT 2014 USA 130 ceritinib 14

3498 Effect of ALK-inhibitors in the treatment of non-small cell lung cancer

Figure 1. Flow diagram of literature search and eligible publication selection.

bitor vs. systemic , 12 studies were was not conducted by this meta-analysis since it phase I and/or II clinical trials with one-arm, was “not reached” in the ALK-inhibitor-treated open-labeled for ALK-inhibitors without compa- groups in three out of the four studies. Neverthe- rison with a control or chemotherapy treatment. less, a meta-analysis was conducted to compare All results of the one-arm, open-labeled phase I the OS, PFS, or objective response rate (ORR) or II studies indicated that the first and second ge- between the two groups of patients treated with neration of ALK inhibitors (crizotinib, ceritinib, or without ALK inhibitors. It is noteworthy that and alectinib) significantly improved the overall ALK inhibitors were found to have exerted posi- survival (OS) and progress free survival (PFS), of tive effects on the improved therapeutic outcome patients with non-small cell lung cancer especial- regarding one-year OS, two-year OS, PFS, and ly in the patients with positive ALK or ROS1 gene ORR (Odds ratio: 4.393, 95% CI: 3.302-5.845, p fusion. However, the data of phase I or II studies < 0.001, Figure 2). were not included in the meta-analysis due to the absence of a proper control group. Side Effects of ALK-Inhibitors The results of the four phase III studies showed Of the 26 articles included in the current sy- that the average of the median survival length was stematic review and meta-analysis, seven studies significantly greater in the patients treated with reported adverse effects of crizotinib4,6-8,13,14,23, and ALK-inhibitors than in the patients without the- four studies reported adverse effects of 2nd-gene- rapy with ALK inhibitors6,12-14. However, quan- ration ALK inhibitors16,17,19,24. As shown in Table titative comparison of median survival length V, visual disturbance was the most common side

3499 G. Li, W.-R. Dai, F.-C. Shao

Figure 2. Forest plot for therapeutic effect of ALK-inhibitors. The following parameters were used to perform the meta-a- nalysis: one-year and two-year overall survival (OS) extracted from the study conducted by Shaw et al (2011) on crizotinib used as 2nd- or 3rd-line therapy vs. any 2nd-line chemotherapy treatment; objective response rate (ORR) obtained by Shaw et al (2013) in the study of oral crizotinib vs. pemetrexed or docetaxel; ORR obtained by Solomon et al (2014) in the study of oral crizotinib administration vs. chemotherapy; progress-free survival (PFS) at 10, 15, and 20 months established by Shaw et al (2014) in the study of ceritinib application in the non-prior crizotinib treatment vs. prior treatment of crizotinib. Overall odds ratio (OR) was 4.393 with 95% CI: 3.302-5.845, p < 0.001. A fixed model was used.

effect of crizotinib (55 ± 11%, reported in five of Discussion the seven studies), followed by diarrhea (44 ± 20%, reported in six of the seven studies), nausea (41 ± The fusion of ALK with EML4 is a common ge- 9%, reported in all of these seven studies), vomi- netic alteration in NSCLC. ALK-positive tumors ting (39 ± 7%, reported in six of the seven studies), are highly sensitive to ALK inhibition, and thus, peripheral edema (34 ± 7%, reported in four of the seven studies), and constipation (31 ± 5%, repor- Table V. Adverse events of crizotinib. ted in six of the seven studies). Other side effects of crizotinib included elevated levels of alanine Adverse Event % (Mean ± SEM) References aminotransferase (ALT), aspartate aminotransfe- Visual disturbance 55 ± 11 4,6,7,13,14 rase (AST), and creatinine, as well as presence Diarrhea 44 ± 20 4,6-8,14 of dysgeusia, , abdominal pain, decreased appeti- Nausea 41 ± 9 4,6,7,13,14,23 te, fatigue, dizziness, rash, neutropenia, dyspnea, Vomiting 39 ± 7 4,6-8,13,14 anemia, hypophosphatemia, and lymphopenia. As Peripheral edema 34 ± 7 4,6,8,13 can be seen in Table VI, the most common adver- Constipation 31 ± 5 4,6,7,13,14,23 nd ALT elevation 25 ± 10 4,7,8,14,23 se effect caused by 2 -generation ALK inhibitors Dysgeusia 25 ± 3 6,13,14,23 (alectinib and ceritinib) was diarrhea (61 ± 20%, AST elevation 24 ± 9 4,7,8,14,23 reported in three of the four studies), followed by Creatinine elevation 24 ± 2 7,23 nausea (54 ± 21%, reported in the four studies), de- Abdominal pain 23 ± 3 7,13 creased appetite (44 ± 6%, reported in two of the Decreased appetite 22 ± 9 4,13 Fatigue 21 ± 4 4,6,7,13,14 four studies), creatinine elevation (39 ± 22%, re- Dizziness 18 ± 2 4,6,8,14 ported in two of the four studies) and fatigue (37 Rash 18 ± 9 6,23 ± 3%, reported in the four studies). Other adverse Neutropenia 16 ± 5 4,7,8,13,23 effects include vomiting, constipation, ALT eleva- Dyspnea 16 ± 3 6,13 tion, cough, abdominal pain, myalgia, peripheral Anemia 15 ± 6 7,13 Hypophosphatemia 8 ± 7 4,14 edema, AST elevation, dyspnea, headache, dizzi- Lymphopenia 7 ± 5 4,7 ness, rash, and neutropenia.

3500 Effect of ALK-inhibitors in the treatment of non-small cell lung cancer it is an important target for anticancer drug thera- ALK. For example, upregulation of EGFR signa- pies in NSCLC. The current study systematically ling has been observed in ALK-positive cell lines reviewed phase I, II, and III clinical studies and made resistant to crizotinib in vitro21,22,25. Due to found that ALK-inhibitors significantly improved the increasing number of cases of acquired resi- the overall survival (OS) and progress free survi- stance to crizotinib, 2nd-generation ALK-inhi- val (PFS) of non-small cell lung cancer patients bitors have been developed and are being exa- as evidenced by the results of the meta-analysis of mined in the most of the clinical trials16,17,19,24. the phase III studies. Treatment with ALK-inhi- In this regard, preclinical trial10 of ceritinib, a bitors was specifically favored in the patients that second-generation multi-targeted oral tyrosine were positive for fusion of ALK or ROS1 genes. kinase inhibitor, has been demonstrated to be ap- However, more than 50% of the patients treated proximately 20 times more potent against ALK with crizotinib had visual disturbance and over than crizotinib. Moreover, previous clinical trials 50% of the participants treated with 2nd-genera- on ceritinib have shown the antitumor activity in tion ALK inhibitors (ceritinib or alectinib) had both crizotinib-resistant and crizotinib-sensitive gastrointestinal adverse effects, such as diarrhea tumors5, and thus, in 2014, the FDA granted ac- and nausea. celerated approval of ceritinib for the treatment Previous researches2,3 reported that 3-7% of of ALK-positive metastatic NSCLC in patients NSCLC patients had ALK and/or MET fusion or who are intolerant to or have progressed despite mutation. With the discovery of the abnormal fu- therapy with crizotinib33. Based on the aforemen- sion of ALK-EML4 genes, crizotinib, an oral tyro- tioned mechanisms of acquired resistance deve- sine kinase inhibitor (TKI), has been developed lopment, targeting ALK signaling may also be an and approved for use in clinic. In this regard, in alternative strategy in addition to developing a a multicenter phase I study, Shaw et al8 reported new generation of ALK-inhibitors. In this context that crizotinib was associated with an objective Katayama et al25 reported that a P-glycoprotein response rate (ORR) of 72%, a median duration inhibitor with ceritinib could overcome the ceriti- of response of 17.6 months, and a median PFS of nib or crizotinib resistance mediated by P-glycan 19.2 months among 50 patients with advanced protein overexpression. Meanwhile, An et al21 ROS1 rearrangement NSCLC. Also, several pha- reported that the treatment with CRKL, a novel ses I and II clinical investigations4,7-9,15,23 have also downstream effector of ALK signaling, and the reported a reduction in key lung cancer-related combined inhibition of ALK and CRKL may be symptoms including cough, pain, and dyspnea. an effective strategy for treating ALK-rearranged Consistent with the outcomes of phase I and II cli- NSCLC patients. nical studies, a phase III trial (N = 347) conducted Detection of ALK gene fusion or rearrangemen- by Shaw et al6 demonstrated that median PFS ts in NSCLC is achieved by the following three after treatment with crizotinib was 7.7 months techniques: fluorescence in situ hybridization vs. 3.0 months of chemotherapy with pemetrexed (FISH), quantitative reverse transcriptase PCR or docetaxel (hazard ratio, 0.49; p < 0.0001); the (qRT-PCR), and immunohistochemistry (IHC), ORR with crizotinib was more than three times each of them having its advantages and limita- that observed with chemotherapy (65% vs. 20%, p tions. FISH is the gold standard because it has < 0.0001). These findings suggest that crizotinib been clinically validated in trials with crizotinib is an effective antitumor agent for NSCLC treat- and approved by the U.S. FDA for this indication. ment, especially in cases positive for ALK-EML4 The FISH assay, using ALK break-apart probes, gene fusion. involves labeling of the 5’ and 3’ ends of the ALK Although the initial response to crizotinib tre- gene with differently colored fluorescent probes atment is significant in most of phase I and II cli- (typically, red and green). In at least 15% of the nical studies, development of resistance has been cells counted, rearrangements result in a split observed in several studies20-22,25,29,32. The mecha- appearance of the signal (in approximately 70% nisms of the development of resistance to crizoti- of cases) or loss of the 5’ signal in approximately nib can be classified into two general categories. 30%)34. FISH can be performed on formalin-fixed The first category involves a genetic alteration paraffin-embedded tissue as well as on snap-fro- of the target, i.e., ALK or ELM4, by mutation or zen samples. Nevertheless, the FISH technique is gene amplification20,29,32. The secondary category expensive and technically challenging. Quantita- of resistance mechanisms involves the activation tive reverse transcriptase PCR (qRT-PCR) is hi- of alternative signaling pathways that can bypass ghly sensitive and detects mRNA for ALK with

3501 G. Li, W.-R. Dai, F.-C. Shao

both gene fusion and mutation. A disadvantage of 3) Soda M, Enomoto M. Identification of the transfor- qRT-PCR is the requirement for RNA extraction ming EML4-ALK fusion gene in non-small-cell from frozen or fresh tissues or cells. IHC is a lung cancer. Nature 2007; 448: 561-566. readily available, inexpensive, and rapid techni- 4) Kwak EL, Bang YJ, Camidge DR, Shaw AT, Solomon que, and thus, it may be suitable for ALK scree- B, Maki RG, Ou SH, Dezube BJ, Jane PA, Costa DB. ning30. However, the validation of this method in Anaplastic lymphoma kinase inhibition in non- small-cell lung cancer. N Engl J Med 2010; 363: larger-scale studies might be required for quality 1693-1703. 35 control before its routine use in clinic . 5) Marsile TH, Pei W, Chen B, Lu W, Uno T, Jin Y, Jiang We found that gastrointestinal adverse even- T, Kim S, Li N, Warmuth M. Synthesis, structu- ts, such as diarrhea, nausea, and vomiting, were re-activity relationships, and in vivo efficacy of the commonly experienced by the patients treated novel potent and selective anaplastic lymphoma with crizotinib, although these symptoms were kinase (ALK) inhibitor 5-chloro-N2-(2-isopro- mild to moderate. By systematic review, the cur- poxy-5-methyl-4-(piperidin-4-yl)phenyl)-N4-(2-(i- sopropylsulf onyl)phenyl)pyrimidine-2,4-diamine rent study found that visual disturbance was the (LDK378) currently in phase 1 and phase 2 clini- most common side effect for crizotinib, while ga- cal trials. J Med Chem 2013; 56: 5675-5690. strointestinal reactions, such as diarrhea and nau- 6) Shaw AT, Kim DW, Nakagawa K, Seto T, Crino L, sea, were the most common adverse effect in pa- Ahn MJ, De Pas T, Besse B, Solomon BJ, Blackhall tients treated with 2nd-generation ALK inhibitors. F. Crizotinib versus chemotherapy in advanced Furthermore, visual disturbance, lymphopenia, ALK-positive lung cancer. N Engl J Med 2013; hypophosphatemia, anemia, and dysgeusia were 368: 2385-2394. not reported in the patients treated with 2nd-gene- 7) Mosse YP, Lim MS, Voss SD, Wilner K, Ruffner K, Laliberte J, Rolland D, Balis FM, Maris JM, Weigel ration ALK inhibitors; conversely, other side ef- BJ. Safety and activity of crizotinib for paediatric fects, such as myalgia, cough, and headache, were patients with refractory solid tumours or anapla- reported. These findings indicated that first- and stic large-cell lymphoma: a Children’s Oncology second-generation ALK inhibitors have slightly Group phase 1 consortium study. Lancet Oncol different targets of tissue or organ. 2013; 14: 472-480. 8) Shaw AT, Ou SH, Bang YJ, Camidge DR, Solomon BJ, Salgia R, Riely GJ, Varella-Garcia M, Shapiro GI, Co- Conclusions sta DB. Crizotinib in ROS1-rearranged non-small- cell lung cancer. N Engl J Med 2014; 371:1963- 1971. This systematic review and meta-analysis 9) Costa DB, Shaw AT, Ou SH, Solomon BJ, Riely GJ, show that the first-generation ALK inhibitor cri- Ahn MJ, Zhou C, Shreeve SM, Selaru P, Polli A. Cli- zotinib is effective in the treatment of NSCLC, nical experience with crizotinib in patients with especially in cases positive for ALK-ELM4 gene advanced ALK-rearranged non-small-cell lung fusion. Side effects of ALK-inhibitors are mild cancer and brain metastases. J Clin Oncol 2015; or moderate. However, the development of ac- 33: 1881-1888. quired resistance to crizotinib is a problem fa- 10) Friboulet L, Li N, Katayama R, Lee CC, Gainor JF, Cry- stal AS, Michells YS, Awad MM, Yanagitan N, Kim cing the long-term clinical application of ALK S. The ALK inhibitor ceritinib overcomes crizotinib inhibitors. Therefore, combined strategies to resistance in non-small cell lung cancer. Cancer overcome the acquired resistance to ALK inhi- Discov 2014; 4: 662-673. bitors are urgently required. 11) Higgins J, Thompson S, Deeks J, Altman D. Statisti- cal heterogeneity in systematic reviews of clinical trials: a critical appraisal of guidelines and practi- Conflict of interest ce. J Health Serv Res Policy 2002; 7: 51-61. Shaw AT, Yeao BY, Solomon BJ, Riely GJ, Gainor The authors declare no conflicts of interest. 12) J, Engelman JA, Shapiro GI, Costa DB, Ou SH, Bu- tabey M. Effect of crizotinib on overall survival in patients with advanced non-small-cell lung References cancer harbouring ALK gene rearrangement: a retrospective analysis. Lancet Oncol 2002; 12: 1004-1012. Siegel R, Ma J, Zou Z, Jemal A 1) . Cancer statistics. CA 13) Solomon BJ, Mok T, Kim DW, Wu YL, Nakagawa Cancer J Clin 2014; 64: 9-29. K, Mekhail T, Felip E, Cappuzzo F, Paolini J, Usa- 2) Rikova K, Guo A, Zeng Q. Global survey of pho- ri T. First-line crizotinib versus chemotherapy in sphotyrosine signaling identifies oncogenic kina- ALK-positive lung cancer. N Engl J Med 2014; ses in lung cancer. Cell 2007; 131: 1190-1203. 371: 2167-2177.

3502 Effect of ALK-inhibitors in the treatment of non-small cell lung cancer

14) Shaw AT, Kim DW, Mehra R, Tan DS, Felip E, Chow 24) Nishio M, Murakami H, Horiike A, Takahashi T, Hirai LQ, Camidge DR, Vansteenkiste J, Sharma S, De Pas F, Suenaga N, Tajima T, Tokushige K, Ishii M, Boral T. Ceritinib in ALK-rearranged non-small-cell lung A. Phase I study of ceritinib (LDK378) in Japane- cancer. N Engl J Med 2014; 370: 1189-1197. se patients with advanced, anaplastic lymphoma 15) Sargis RM, Salgia R. Multiple endocrine disruption kinase-rearranged non-small-cell lung cancer or by the MET/ALK inhibitor crizotinib in patients with other tumors. J Thorac Oncol 2015; 10: 1058-1066. non-small cell lung cancer. Am J Clin Oncol 2015; 25) Shaw AT, Friboulet L, Leshchiner I, Gainor JF, Bergq- 38: 442-447. vist S, Brooun A, Burke BJ, Deng YL, Liu W, Darda- ei L 16) Gadgeel SM, Gandhi L, Riely GJ, Chiappori AA, West . Resensitization to crizotinib by the HL, Azada MC, Morocos PN, Lee RM, Garcia L, Yu ALK resistance mutation L1198F. N Engl J Med L. Safety and activity of alectinib against syste- 2016; 374: 54-61. mic disease and brain metastases in patients with 26). Fu S, Wang F, Shao Q, Zhang X, Duan LP, Zhang crizotinib-resistant ALK-rearranged non-small- X, Zhang L, Shao JY. Detection of EML4-ALK fu- cell lung cancer (AF-002JG): results from the sion gene in Chinese non-small cell lung cancer dose-finding portion of a phase 1/2 study. Lancet by using a sensitive quantitative real-time reverse Oncol 2014; 15: 1119-1128. transcriptase PCR technique. Appl Immunohisto- 17) Kim DW, Mehra R, Tan DS, Felip E, Chow LQ, Ca- chem Mol Morphol 2015; 23: 245-254. midge DR, Vansteenkiste J, SHharma S, De Pas T, Ri- 27) Ma D, Wang Z, Yang L, Mu XL, Wang Y, Zhao XM, ely GJ. Activity and safety of ceritinib in patients Li JL, Lin DM. Responses to crizotinib in patien- with ALK-rearranged non-small-cell lung cancer ts with ALK-positive lung adenocarcinoma who (ASCEND-1): updated results from the multicen- tested immunohistochemistry (IHC)-positive and tre, open-label, phase 1 trial. Lancet Oncol 2016; fluorescence in situ hybridization(FISH)-negative. 17: 452-463. Oncotarget 2016; 7: 64410-64420. 18) Li T, Lorousso P, Maitland ML, Ou SH, Bahceci E, Ball 28) Zwaenepoel K, Merkle D, Cabillic F, Berg E, Be- HA, Park JW, Yurn G, Tolcher A. First-in-human, laud-Rotureau MA, Grazioli V, Herelle O. Hummel open-label dose-escalation and dose-expansion M, Le Calve M, Lenze D. Automation of ALK gene study of the safety, pharmacokinetics, and anti- rearrangement testing with fluorescence in situ tumor effects of an oral ALK inhibitor ASP3026 in hybridization (FISH): a feasibility study. Exp Mol patients with advanced solid tumors. J Hematol Pathol 2015; 98: 113-118. Oncol 2016; 9: 23. 29) Ceccon M. Ceritinib as a promising therapy for 19) Shaw AT, Gandhi L, Gadgeel S, Riely GJ, Cetnar ALK related diseases. Transl Lung Cancer Res J, West H, Camidge DR, Socinski MA, Chiappori A, 2014; 3: 376-378. Mekhail T. Alectinib in ALK-positive, crizotinib-resi- 30). Cutz JC, Craddock KJ, Torlakovic E, Brandao G, Car- stant, non-small-cell lung cancer: a single-group, ter RF, Bigras G, Deschenes J, Izevbaye I, Xu Z, Greer multicentre, phase 2 trial. Lancet Oncol 2016; 17: W. Canadian anaplastic lymphoma kinase study: 234-242. a model for multicenter standardization and opti- 20) Katayama R, Khan TM, Benes C, Lifshits E, Eei H, Ri- mization of ALK testing in lung cancer. J Thorac vera VM, Shakespeare WC, Iafrate AJ, Engleman JA, Oncol 2014; 9: 1255-1263. Shaw AT. Therapeutic strategies to overcome cri- 31) Mazieres J, Zalcman G, Crino L, Biondani P, Barlesi F, Fil- zotinib resistance in non-small cell lung cancers leron T, Dingemans AM, Lena H, Monnet I, Rothschild harboring the fusion oncogene EML4-ALK. Proc SI. Crizotinib therapy for advanced lung adenocarci- Natl Acad Sci U S A 2011; 108: 7535-7540. noma and a ROS1 rearrangement: results from the 21) Ahr WY, Voeller D, Gower A, Kim IK, Zhang YW, EUROS1 cohort. J Clin Oncol 2015; 33: 992-999. Giaccone G . CRKL mediates EML4-ALK signaling 32) Lin YT, Yang JCH, Shih JY. Anaplastic lymphoma and is a potential therapeutic target for ALK-rear- kinase (ALK) kinase domain mutation following ranged lung adenocarcinoma. Oncotarget 2016; ALK inhibitor(s) failure in advanced ALK positive 7: 29199-29210. non-small cell lung cancer: analysis and literature 22) Dong X, Li E, Wang S. Elucidation of resistance review. Clin Lung Cancer 2016; 17: e77-e94. mechanisms to second-generation ALK inhibitors 33) FDA, U. (2014). In: (http://www.fda.gov/drugs/in- alectinib and ceritinib in non-small cell lung can- formationdrugs/approveddrugs/ucm395386.htm cer cells. Neoplasia 2016; 18: 162-171. 34) Shaw AT, Solomon B, Kenudson MM. Crizotinib and Seto T, Kiura K, Nishio M, Nakagawa K, Maemondo 23) testing for ALK. J Natl Compr Canc Netw 2011; 9: M, Inoue A, Hida T, Yamamot N, Yoshioka H, Hara- 1335-1341. da M. CH5424802 (RO5424802) for patients with Solomon B, Wilner KD, Shaw AT. ALK-rearranged advanced non-small-cell lung 35) Current status cancer (AF-001JP study): a single-arm, open-la- of for anaplastic lymphoma ki- bel, phase 1-2 study. Lancet Oncol 2013; 14: 590- nase-rearranged non-small cell lung cancer. Clin 598. Pharmacol Ther 2014; 95: 15-23.

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