Impact of EML4-ALK Variant on Resistance Mechanisms and Clinical Outcomes in ALK-Positive Lung Cancer

Abstract

Purpose Advanced anaplastic lymphoma kinase ( ALK) fusion-positive non-small-cell lung cancers (NSCLCs) are effectively treated with ALK tyrosine kinase inhibitors (TKIs). However, clinical outcomes in these patients vary, and the benefit of TKIs is limited as a result of acquired resistance. Emerging data suggest that the ALK fusion variant may affect clinical outcome, but the molecular basis for this association is unknown. Patients and Methods We identified 129 patients with ALK-positive NSCLC with known ALK variants. ALK resistance mutations and clinical outcomes on ALK TKIs were retrospectively evaluated according to ALK variant. A Foundation Medicine data set of 577 patients with ALK-positive NSCLC was also examined. Results The most frequent ALK variants were EML4-ALK variant 1 in 55 patients (43%) and variant 3 in 51 patients (40%). We analyzed 77 tumor biopsy specimens from patients with variants 1 and 3 who had progressed on an ALK TKI. ALK resistance mutations were significantly more common in variant 3 than in variant 1 (57% v 30%; P = .023). In particular, ALK G1202R was more common in variant 3 than in variant 1 (32% v 0%; P < .001). Analysis of the Foundation Medicine database revealed similar associations of variant 3 with ALK resistance mutation and with G1202R ( P = .010 and .015, respectively). Among patients treated with the third-generation ALK TKI lorlatinib, variant 3 was associated with a significantly longer progression-free survival than variant 1 (hazard ratio, 0.31; 95% CI, 0.12 to 0.79; P = .011). Conclusion Specific ALK variants may be associated with the development of ALK resistance mutations, particularly G1202R, and provide a molecular link between variant and clinical outcome. ALK variant thus represents a potentially important factor in the selection of next-generation ALK inhibitors.

Fig 1.

Frequency of ALK variants in the study cohort (N = 129). Schematic key: blue, coiled-coil region of EML4; gold, tandem atypical propeller EML domain of EML4; gray, tyrosine kinase domain of ALK. Note that v3 and v5 exist as isoforms (v3a and v3b and v5a and v5b, respectively) generated by alternative splicing. A, ALK exon; E, EML4 exon; v, variant.

Fig 2.

ALK resistance mutations in tumor biopsy specimens obtained after progression on an ALK inhibitor according to EML4-ALK variant.

Fig 3.

Distribution of ALK resistance mutations in tumor biopsy specimens obtained after disease progression on a second-generation ALK inhibitor by EML4-ALK variant. WT, wild-type (nonmutated) ALK.

Fig 4.

Distribution of ALK resistance mutations in tumor biopsy specimens obtained after disease progression on crizotinib by EML4-ALK variant. WT, wild-type ALK.

Fig 5.

Kaplan-Meier curves for progression-free survival (PFS) for (A) crizotinib as first ALK tyrosine kinase inhibitor (TKI) in patients with EML4-ALK variant 1 (v1; n = 51) versus v3 (n = 48), (B) crizotinib as first-line therapy in v1 (n = 27) versus v3 (n = 28), (C) second-generation ALK TKI administered as the second ALK inhibitor after crizotinib in v1 (n = 37) versus v3 (n = 40), and (D) lorlatinib administered after crizotinib and at least one second-generation ALK TKI in v1 (n = 12) and v3 (n = 17).