Sachiko Arai1, Shinji Takeuchi2, Koji Fukuda2, Hirokazu Taniguchi3, Akihiro Nishiyama4, Azusa Tanimoto1, Miyako Satouchi5, Kaname Yamashita1, Koshiro Ohtsubo1, Shigeki Nanjo6, Toru Kumagai7, Ryohei Katayama8, Makoto Nishio9, Mei-Mei Zheng10, Yi-Long Wu11, Hiroshi Nishihara12, Takushi Yamamoto13, Mitsutoshi Nakada14, Seiji Yano15. 1. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan. 2. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan; Nano Life Science Institute, Kanazawa University, Kanazawa University, Kanazawa, Japan. 3. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan; Department of Respiratory Medicine, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan. 4. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan; Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan. 5. Department of Thoracic Oncology, Hyogo Cancer Center, Akashi, Japan. 6. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan; Department of Medicine, Division of Hematology-Oncology, University of California San Francisco, San Francisco, California; Department of Medical Oncology, Kobe City Medical Center General Hospital, Kobe, Japan. 7. Department of Thoracic Oncology, Osaka International Cancer Institute, Osaka, Japan. 8. Division of Experimental Chemotherapy, Cancer Chemotherapy Center, Japanese Foundation for Cancer Research, Tokyo, Japan. 9. Department of Thoracic Medical Oncology, The Cancer Institute Hospital, Japanese Foundation For Cancer Research, Tokyo, Japan. 10. Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangzhou, People's Republic of China; Guangdong Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China. 11. Guangdong Lung Cancer Institute, Guangdong Provincial Key Laboratory of Translational Medicine in Lung Cancer, Guangzhou, People's Republic of China; Guangdong Hospital and Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China; Guangdong Hospital, School of Medicine, South China University of Technology, Guangzhou, People's Republic of China. 12. Keio Cancer Center, Keio University School of Medicine, Tokyo, Japan. 13. Analytical and Measuring Instruments Division, Global Application Development Center, Shimadzu Corporation, Kyoto, Japan. 14. Department of Neurosurgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. 15. Division of Medical Oncology, Kanazawa University Cancer Research Institute, Kanazawa, Japan; Nano Life Science Institute, Kanazawa University, Kanazawa University, Kanazawa, Japan. Electronic address: syano@staff.kanazawa-u.ac.jp.
Abstract
INTRODUCTION: Leptomeningeal carcinomatosis (LMC) occurs frequently in anaplastic lymphoma kinase (ALK)-rearranged NSCLC and develops acquired resistance to ALK tyrosine kinase inhibitors (ALK TKIs). This study aimed to clarify the resistance mechanism to alectinib, a second-generation ALK TKI, in LMC and test a novel therapeutic strategy. METHODS: We induced alectinib resistance in an LMC mouse model with ALK-rearranged NSCLC cell line, A925LPE3, by continuous oral alectinib treatment, established A925L/AR cells. Resistance mechanisms were analyzed using several assays, including Western blot and receptor tyrosine kinase array. We also measured amphiregulin (AREG) concentrations in cerebrospinal fluid from patients with ALK-rearranged NSCLC with alectinib-refractory LMC by enzyme-linked immunosorbent assay. RESULTS: A925L/AR cells were moderately resistant to various ALK TKIs, such as alectinib, crizotinib, ceritinib, and lorlatinib, compared with parental cells in vitro. A925L/AR cells acquired the resistance by EGFR activation resulting from AREG overexpression caused by decreased expression of microRNA-449a. EGFR TKIs and anti-EGFR antibody resensitized A925L/AR cells to alectinib in vitro. In the LMC model with A925L/AR cells, combined treatment with alectinib and EGFR TKIs, such as erlotinib and osimertinib, successfully controlled progression of LMC. Mass spectrometry imaging showed accumulation of the EGFR TKIs in the tumor lesions. Moreover, notably higher AREG levels were detected in cerebrospinal fluid of patients with alectinib-resistant ALK-rearranged NSCLC with LMC (n = 4), compared with patients with EGFR-mutated NSCLC with EGFR TKI-resistant LMC (n = 30), or patients without LMC (n = 24). CONCLUSIONS: These findings indicate the potential of novel therapies targeting both ALK and EGFR for the treatment of ALK TKI-resistant LMC in ALK-rearranged NSCLC.
INTRODUCTION: Leptomeningeal carcinomatosis (LMC) occurs frequently in anaplastic lymphoma kinase (ALK)-rearranged NSCLC and develops acquired resistance to ALK tyrosine kinase inhibitors (ALK TKIs). This study aimed to clarify the resistance mechanism to alectinib, a second-generation ALK TKI, in LMC and test a novel therapeutic strategy. METHODS: We induced alectinib resistance in an LMC mouse model with ALK-rearranged NSCLC cell line, A925LPE3, by continuous oral alectinib treatment, established A925L/AR cells. Resistance mechanisms were analyzed using several assays, including Western blot and receptor tyrosine kinase array. We also measured amphiregulin (AREG) concentrations in cerebrospinal fluid from patients with ALK-rearranged NSCLC with alectinib-refractory LMC by enzyme-linked immunosorbent assay. RESULTS: A925L/AR cells were moderately resistant to various ALK TKIs, such as alectinib, crizotinib, ceritinib, and lorlatinib, compared with parental cells in vitro. A925L/AR cells acquired the resistance by EGFR activation resulting from AREG overexpression caused by decreased expression of microRNA-449a. EGFR TKIs and anti-EGFR antibody resensitized A925L/AR cells to alectinib in vitro. In the LMC model with A925L/AR cells, combined treatment with alectinib and EGFR TKIs, such as erlotinib and osimertinib, successfully controlled progression of LMC. Mass spectrometry imaging showed accumulation of the EGFR TKIs in the tumor lesions. Moreover, notably higher AREG levels were detected in cerebrospinal fluid of patients with alectinib-resistant ALK-rearranged NSCLC with LMC (n = 4), compared with patients with EGFR-mutated NSCLC with EGFR TKI-resistant LMC (n = 30), or patients without LMC (n = 24). CONCLUSIONS: These findings indicate the potential of novel therapies targeting both ALK and EGFR for the treatment of ALK TKI-resistant LMC in ALK-rearranged NSCLC.