Crizotinib in ALK-rearranged inflammatory myofibroblastic tumor

Abstract

Inflammatory myofibroblastic tumor (IMT) is a distinctive mesenchymal neoplasm characterized by a spindle-cell proliferation with an inflammatory infiltrate. Approximately half of IMTs carry rearrangements of the anaplastic lymphoma kinase (ALK) locus on chromosome 2p23, causing aberrant ALK expression. We report a sustained partial response to the ALK inhibitor crizotinib (PF-02341066, Pfizer) in a patient with ALK-translocated IMT, as compared with no observed activity in another patient without the ALK translocation. These results support the dependence of ALK-rearranged tumors on ALK-mediated signaling and suggest a therapeutic strategy for genomically identified patients with the aggressive form of this soft-tissue tumor. (Funded by Pfizer and others; ClinicalTrials.gov number, NCT00585195.).

Figure 1. Histologic, Immunohistochemical, and Molecular Analyses of IMT Samples from Patient 1

A sample of the inflammatory myofibroblastic tumor (IMT) obtained on biopsy shows epithelioid cells containing vesicular nuclei, prominent nucleoli, and amphophilic cytoplasm embedded in a myxoid stroma containing prominent neutrophils (Panel A, hematoxylin and eosin). Immunohistochemical analysis for ALK shows positive staining in tumor cells, with a nuclear membrane pattern (Panel B). Dual-color fluorescence in situ hybridization (FISH) shows rearrangement of centromeric (green) and telomeric (orange) probes flanking the ALK locus at 2p23 (Panel C). Gel electrophoresis of polymerase-chain-reaction (PCR) products after reverse-transcriptase PCR (RT-PCR) is shown for primers directed at known ALK translocation partners in IMT, including CARS, CLTC, RANBP2, ATIC, SEC31L1 (which generates both long-form [L] and short-form [S] fusion transcripts), TPM3, and TPM4, (Panel D). Only RANBP2-ALK primers produce an amplification product in the presence of (but not in the absence of) reverse transcriptase. Sequencing of the PCR product confirmed that RANBP2 exon 18 is fused in frame with ALK exon 20 (Panel E). Sections from progressing tumor masses in the liver (Panel F) and perirectal region (Panel G), which were resected after approximately 8 months of crizotinib administration, show histologic heterogeneity, with cellular areas similar in appearance to the initial biopsy sample but also revealing extensive areas suggestive of a treatment effect, with foci of tumor-cell necrosis in the liver sample and marked stromal hyalinization in the perirectal sample (hematoxylin and eosin in Panels F and G). Methods for immunostaining, FISH, and RT-PCR are described in the Supplementary Appendix, available with the full text of this article at NEJM.org.

Figure 2. CT Scans Showing the Response to Crizotinib in Patient 1

The baseline abdominal CT scan shows a hepatic mass measuring 4.8 by 3.3 cm (top) and one of several mesenteric masses measuring 3.8 by 3.3 cm (bottom) (Panel A, arrows). After 13 weeks of treatment with crizotinib, the hepatic and mesenteric masses measured 2.3 by 0.8 cm and 1.3 by 1.2 cm, respectively (Panel B, arrows). In October 2008, these masses measured 3.6 by 2.2 cm and 0.5 by 0.5 cm, respectively (not shown), indicating that the hepatic mass had regrown, despite a continued response, according to the Response Evaluation Criteria in Solid Tumors.

Figure 3. Histologic and Immunohistochemical Analyses of IMT Samples from Patient 2

A sample of the inflammatory myofibroblastic tumor (IMT) obtained on biopsy shows ganglion-like, plump epithelioid cells with abundant eosinophilic cytoplasm and nuclei with open chromatic and prominent nucleoli; scattered small lymphocytes are in the background (Panel A, hematoxylin and eosin). A different area of the tumor shows a prominent inflammatory component that is composed primarily of plasma cells, dense fibrous stroma, and scattered plump spindle and ganglion-like cells (Panel B, arrows; hematoxylin and eosin). Results of immunostaining for ALK are negative (Panel C), and FISH analysis shows no ALK rearrangement (Panel D).