STRN-ALK rearranged malignant peritoneal mesothelioma—Presenting with bilateral extensive pelvic masses in a young woman: Mimicking low-grade serous ovarian carcinoma

Malignant peritoneal mesothelioma (MPM) is an exceptionally rare tumor type. Although some somatic/germline genetic alterations including BAP1 loss have been identified in some cases, the molecular properties of MPMs are remained poorly understood. In recent years, anaplastic lymphoma kinase (ALK) gene rearrangement was revealed in a subset of (3.4%) MPMs. Low-grade serous carcinomas (LGSCs) are a rare subtype of ovarian carcinoma and have some morphologic and immunophenotypic overlapping features with MPMs and this may cause misdiagnosis in daily practice. Here, we report a case of 18-year-old women with STRN-ALK-rearranged MPM and no previous exposure to asbestos. This case was presented with bilateral pelvic masses and histologically was displaying pure papillary morphology with mild-to-moderate nuclear atypia, psammoma bodies, and diffuse PAX8 expression as LGSCs. With the detection of ALK alteration in some of the MPMs, a targeted treatment option has emerged for these unusual tumor types.

Potential unreliability of ALK variant allele frequency in the efficacy prediction of targeted therapy in NSCLC / 医学前沿

Anaplastic lymphoma kinase (ALK) is the most common fusion gene involved in non-small cell lung cancer (NSCLC), and remarkable response has been achieved with the use of ALK tyrosine kinase inhibitors (ALK-TKIs). However, the clinical efficacy is highly variable. Pre-existing intratumoral heterogeneity (ITH) has been proven to contribute to the poor treatment response and the resistance to targeted therapies. In this work, we investigated whether the variant allele frequencies (VAFs) of ALK fusions can help assess ITH and predict targeted therapy efficacy. Through the application of next-generation sequencing (NGS), 7.2% (326/4548) of patients were detected to be ALK positive. On the basis of the adjusted VAF (adjVAF, VAF normalization for tumor purity) of four different threshold values (adjVAF < 50%, 40%, 30%, or 20%), the association of ALK subclonality with crizotinib efficacy was assessed. Nonetheless, no statistical association was observed between median progression-free survival (PFS) and ALK subclonality assessed by adjVAF, and a poor correlation of adjVAF with PFS was found among the 85 patients who received first-line crizotinib. Results suggest that the ALK VAF determined by hybrid capture-based NGS is probably unreliable for ITH assessment and targeted therapy efficacy prediction in NSCLC.

Ceritinib as First-line Treatment for Advanced Lung Adenocarcinoma with COX7A2L-ALK Fusion: A Case Report and Literature Review / 中国肺癌杂志

Lung cancer is the most common in incidence and mortality worldwide. With the development of next generation sequencing (NGS) detection technology, more and more patients with rare anaplastic lymphoma kinase (ALK) fusion mutations were detected. A case of advanced lung adenocarcinoma with rare COX7A2L-ALK (C2:A20) fusion detected by NGS was reported in Peking Union Medical College Hospital, and all cases with rare ALK fusion mutations were searched from medical datebase from January 1, 2014 to March 31, 2021, to investigate the treatment of rare ALK fusion mutations with ALK inhibitors. The best response of the patient was assessed as partial response (PR) with Ceritinib treatment. By literature review, 22 cases of rare ALK fusion were reported in 19 articles. Combined with this case, 23 cases were analyzed. The objective response rate (ORR) was 82.6% (19/23) and disease control rate (DCR) was 95.7% (22/23) for rare ALK fusions patients treated with ALK inhibitors. Lung adenocarcinoma patients with rare ALK fusion could benefit from ALK inhibitors.
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Lung Squamous Cell Carcinoma with EML4-ALK Fusion and TP53 Co-mutation Treated with Ensartinib: A Case Report and Literature Review / 中国肺癌杂志

Lung squamous cell carcinoma (LSCC) accounts for approximately 30% of non-small cell lung cancer (NSCLC) cases and is the second most common histological type of lung cancer. Anaplastic lymphoma kinase (ALK)-positive NSCLC accounts for only 2%-5% of all NSCLC cases, and is almost exclusively detected in patients with lung adenocarcinoma. Thus, ALK testing is not routinely performed in the LSCC population, and the efficacy of such treatment for ALK-rearranged LSCC remains unknown. Echinoderm microtubule associated protein like 4 (EML4)-ALK (V1) and TP53 co-mutations were identified by next generation sequencing (NGS) in this patient with advanced LSCC. On December 3, 2020, Ensatinib was taken orally and the efficacy was evaluated as partial response (PR). The progression-free survival (PFS) was 19 months. When the disease progressed, the medication was changed to Loratinib. To our knowledge, Enshatinib created the longest PFS of ALK-mutant LSCC patients treated with targeted therapy since literature review. Herein, we described one case treated by Enshatinib involving a patient with both EML4-ALK and TP53 positive LSCC, and the relevant literatures were reviewed for discussing the treatment of this rare disease.
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Identification of Drug-resistance Core Genes and Drug Targets in Lung Adenocarcinoma Patients Harboring ALK Fusion Gene / 肿瘤防治研究

Objective To compare DEGs between primary and metastatic lesions in lung adenocarcinoma patients with positive ALK fusion gene, and to explore the mechanism of drug-resistance and the potential drug targets in metastatic lesions of lung adenocarcinoma patients. Methods GSE125864 was obtained from GEO database. According to the different sampling sites of tumor tissue, two groups were divided: primary tumor lesions group and metastatic tumor lesions group. The DEGs between the two groups were compared, and the differences in biological functions and enrichment signaling pathways of these DEGs were analyzed. The protein-protein interaction network was constructed and applied to screen hub genes. Based on TCGA and cancer treatment response portal database, the prognosis and drug target prediction of the 10 key cores were analyzed. Results In total, 227 DEGs were identified, with 134 upregulated DEGs and 93 downregulated DEGs in the metastatic tumor lesions group, compared with primary tumor lesions group. GO and KEGG enrichment analyses showed that the functions of these DEGs were mainly involved in complement and coagulation cascade, chemical carcinogenesis and retinol metabolism pathways. The top 10 hub genes with the highest degree were analyzed in the protein-protein interaction network. The expression of HRG and AHSG genes were associated with poor prognosis of lung adenocarcinoma patients, and SERPINC1, HRG, ApoA1, FGA and FGG genes were correlated with a variety of potential small molecule drugs. Conclusion The molecular functions and signaling pathways involved in DEGs may induce drug-resistance in metastatic ALK-positive lung adenocarcinoma patients.

A Case of Non-small Cell Lung Cancer Treated with Three ALK Inhibitors and Chemotherapy / 中国肺癌杂志

The echinoderm microtubule associated protein-like 4 (EML4) and anaplastic lymphoma kinase (ALK) were fractured and fused to become EML4-ALK. Most of these EML4-ALK-positive non-small cell lung cancer patients respond well to the ALK inhibitor. Many patients can benefit from drug target therapy for a long time, and some patients can achieve long-term survival of more than 7 years under the optimized treatment mode. This patient has lung adenocarcinoma positive for EML4-ALK fusion gene, but the treatment outcome is obviously different from that of other patients with lung cancer positive for EML4-ALK fusion gene. After the first to third generations of ALK inhibitor targeted therapy and chemotherapy, the disease progresses rapidly, the drug resistance time is short, the survival time is short, and the benefit is limited. The patient received targeted therapy of Crizotinib, Ceritinib and Lorlatinib successively from July 15, 2019, followed by two chemotherapy courses of Bevacizumab combined with Pemetrexed and Carboplatin. The patient died on September 10, 2020, with a survival of 15 months. At the same time, the treatment showed common adverse reactions of ALK inhibitors. This paper analyzed the therapeutic effect and treatment dilemma of this patient, and provided an exploration direction for the treatment of patients with EML4-ALK fusion gene positive lung cancer.
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Postoperative clinicopathological features of the patients with micropapillary lung adenocarcinoma / 医学研究生学报

Objective　Studies are rarely reported on the factors influencing prognosis of surgically resected lung adenocarcinoma with a micropapillary pattern (LAC-MPP). This study aimed to explore the clinicopathological characteristics and risk factors of surgically resected LAC-MPP. Methods　We retrospectively analyzed 384 cases of LAC treated in Henan Cancer Hospital between June 2015 and December 2017, which were classified into an MPP group (n = 82) and a non-MPP control group (n = 302) according to the results of postoperative pathology. We determined the expression of the fusion protein anaplastic lymphoma kinase (ALK), analyzed its association with the clinicopathological features of LAC-MPP, and explored the risk factors of postoperative MPP. Results　Compared with the non-MPP group, the LAC-MPP patients showed a significantly higher expression of ALK (0.03% vs 12.20%, P < 0.05), rate of bronchial invasion (30.80% vs 48.78%, P < 0.05) and vascular tumor thrombus (0.99% vs 25.61%, P < 0.05), but a lower mutation rate of the epidermal growth factor receptor (EGFR) (64.24% vs 51.22%, P < 0.05). Multivariate logistic regression analysis revealed that the expression of ALK, vascular tumor thrombus, and age were significantly associated with the risk of postoperative MPP. Conclusion　There is a high incidence rate of ALK expression in LAC-MPP patients after operation, which may provide some new ideas for the clinical treatment of the disease. Special attention should be paid to the expression of the ALK fusion protein and vascular tumor thrombus, and age in patients with LAC-MPP after operation.

Statistical analysis of EGFR mutation and EML4-ALK gene fusion in non-small cell lung cancer patients of Zhongshan City / 国际检验医学杂志

Objective To detect the mutation of epidermal growth factor receptor(EGFR) gene,fusion of echinoderms microtubule associated protein sample-4 and gradual change of lymphoma kinase(EML4-ALK) gene,as well as describe their relationship with the clinicopathological features in patients with non-small cell lung cancer(NSCLC) from Zhongshan city of Guangdong province.Methods Mutations of EGFR gene and EML4-ALK fusion gene in 753 NSCLC patients from Zhongshan People's hospital were detected by ARMS real-time PCR.To study the relationship between the mutation and clinical features and explore the significance of EGFR gene mutation and EML4-ALK fusion in NSCLC.Results The EGFR mutation rate of 753 NSCLC patients is 43.16％(325/753),with highest mutation rate in 19 and 21 exons,43.08％(140/325) and 47.38％ (154/325) respectively,and the main mutation in 21 exon is L858R mutation.EGFR mutation is more common in female/non-smoking patients,or patients with adenocarcinoma/adenosquqmous carcinoma/adenocarcinoma metastasis(P＜0.05),but not relates with the age of patients(P＞0.05).The EML4-ALK fusion gene of 110 patients whose EGFR mutation were checked were simultaneously detected,showing a 9.09 ％ (10/110) mutation rate,and the mutation rate in type 1(80％) is significantly higher than type 2(10％) and 3(10％).Patients with EML4-ALK gene mutation tend to be younger(P＜0.05),but the EML4-ALK gene mutation rates show no significant differences in groups classified by gender,smoking history or pathological classification(P＞0.05).EGFR gene mutation and EML4-ALK fusion were detected in one patient simultaneously.Conclusion The EGFR mutation rate of patients with NSCLC in Zhongshan city is consistent with results reported in domestic and foreign literatures.Detections of EGFR gene mutation and EML4-ALK fusion are necessary test items,providing important evidence in molecular targeting therapy in NSCLS.

Distribution and clinical significance of EML4-ALK fusion gene in phase Ⅰ lung cancer / 中华胸心血管外科杂志

Objective To detect the mutation frequency of EML4-ALK fusion gene in lung cancer patients, and to inves-tigate the distribution of mutation character for EML4-ALK fusion gene in Ⅰ stage lung cancer patients and clinical features as well as provide a reference for the individual treatment of lung cancer .Methods 256 fresh tumor tissue specimens of lung cancer patients were screened from the specimen bank of our hospital and all the patients had accepted the surgical treatment from February 2013 to December 2014.Total RNA was extracted and then be transcribed into cDNA, the amplification-refrac-tory mutation system(ARMS) was used to detect mutation of EML4-ALK fusion gene.The results according to the positive con-trol, negative control and RNA quality control for EML4-ALK fusion type were analyzed.Results During the 256 patients ofⅠ stage lung cancer, there were 17 patients(6.64%) had mutations in EML4-ALK fusion gene.In lung adenocarcinoma mu-tation rate(16/207, 7.73%) was higher than that of lung squamous cell mutation rate(1/39, 2.56%), lung adeno-squamous mutation rate(0/4, 0) and large cell carcinoma(0/5, 0) of the mutation rate;young lung cancer patients( <63 years) of the mutation rate(14/139, 10.07%) was significantly higher than the high age of lung cancer patients(≥63 years old) mutation rate(3/117, 2.56%), P =0.009.EML4-ALK fusion with tumor invasion and visceral pleura group incidence (9/80, 11. 25%) was significantly higher than that of non-invasive and visceral pleura group incidence rate(8/176, 4.55%), P =0.045.Conclusion The occurence of EML4-ALK fusion correlates with patients’ age as well as whether visceral pleura is in-vaded, type 1 EML4-ALK fusion was detected more in phase I lung cancer patients.

Bypass signaling pathway activation mediates resistance of EML4-ALK fusion gene positive lung cancer cell line H3122 to alectinib / 中国病理生理杂志

AIM:To detect the changes of active status of bypass signaling pathways in EML4-ALK positive lung cancer cell line H3122 treated with alectinib, hepatocyte growth factor (HGF), epidermal growth factor (EGF) and transforming growth factor-α (TGF-α), and to explore the potential mechanisms.METHODS:EML4-ALK positive cell line H3122 was treated with increasing concentrations of alectinib or/and induced by HGF, EGF and TGF-α.The cell viability was measured by CCK-8 assay.The cell apoptosis was analyzed by flow cytometry.The protein levels and phosphorylation status of ALK, c-Met and EGFR, and the downstream molecules AKT, ERK, p-AKT and p-ERK were examined by Western blot.RESULTS:The viability of the H3122 cells was inhibited by alectinib in a dose-dependent manner after administrated for 72 h, and the IC50 value was 0.042 μmol/L.The concentration-growth curves of the H3122 cells shifted to the right after induced by HGF, EGF and TGF-α.After treatment with alectinib at 0.05 μmol/L for 48 h, the apoptotic rate of H3122 cells was (20.12±1.36)%, while the apoptotic rates of the cells in the groups of alectinib combined with HGF, EGF or TGF-α were (7.85±1.03)%, (5.60±0.79)% and (4.58±1.00)%, respectively.Those values were remarkably lower than those in alectinib single treatment group (P<0.05).Alectinib inhibited the protein levels of p-ALK and its downstream signaling pathway molecules, while HGF significantly up-regulated the protein levels of p-Met and its downstream p-AKT and p-ERK.Besides, EGF and TGF-α remarkablely up-regulated the protein levels of p-EGFR and its downstream p-AKT and p-ERK.Combined treatment with crizotinib and 17-DMAG successfully inhibited the viability of the H3122 cells even in the presence of the HGF and EGFR ligands, respectively.CONCLUSION:Bypass signaling pathways are activated by HGF, EGF and TGF-α in EML4-ALK positive lung cancer cell line H3122, which may be linked to alectinib resistance.

Statistical analysis of EGFR mutation and EML4-ALK gene fusion in non-small cell lung cancer patients of Zhongshan City / 国际检验医学杂志

Objective To detect the mutation of epidermal growth factor receptor(EGFR) gene,fusion of echinoderms microtubule associated protein sample-4 and gradual change of lymphoma kinase(EML4-ALK) gene,as well as describe their relationship with the clinicopathological features in patients with non-small cell lung cancer(NSCLC) from Zhongshan city of Guangdong province.Methods Mutations of EGFR gene and EML4-ALK fusion gene in 753 NSCLC patients from Zhongshan People's hospital were detected by ARMS real-time PCR.To study the relationship between the mutation and clinical features and explore the significance of EGFR gene mutation and EML4-ALK fusion in NSCLC.Results The EGFR mutation rate of 753 NSCLC patients is 43.16％(325/753),with highest mutation rate in 19 and 21 exons,43.08％(140/325) and 47.38％ (154/325) respectively,and the main mutation in 21 exon is L858R mutation.EGFR mutation is more common in female/non-smoking patients,or patients with adenocarcinoma/adenosquqmous carcinoma/adenocarcinoma metastasis(P＜0.05),but not relates with the age of patients(P＞0.05).The EML4-ALK fusion gene of 110 patients whose EGFR mutation were checked were simultaneously detected,showing a 9.09 ％ (10/110) mutation rate,and the mutation rate in type 1(80％) is significantly higher than type 2(10％) and 3(10％).Patients with EML4-ALK gene mutation tend to be younger(P＜0.05),but the EML4-ALK gene mutation rates show no significant differences in groups classified by gender,smoking history or pathological classification(P＞0.05).EGFR gene mutation and EML4-ALK fusion were detected in one patient simultaneously.Conclusion The EGFR mutation rate of patients with NSCLC in Zhongshan city is consistent with results reported in domestic and foreign literatures.Detections of EGFR gene mutation and EML4-ALK fusion are necessary test items,providing important evidence in molecular targeting therapy in NSCLS.

Successful Treatment of Crizotinib-Associated Severe Hepatotoxicity in Anaplastic Lymphoma Kinase-Positive Non-Small Cell Lung Cancer

Crizotinib-associated severe hepatotoxicity has been rarely reported and experts recommended stopping crizotinib treatment in patients with grade 3/4 transaminase elevation. We experienced a case of anaplastic lymphoma kinase-positive non-small cell lung cancer occurring as a result of severe hepatotoxicity due to crizotinib-associated hepatitis, accompanied by the reactivation of chronic hepatitis B, which was reversed with dose reduction and anti-viral therapy. Our case highlights the possibility that crizotinib might induce hepatitis and this might be associated with the underlying presence of chronic hepatitis B. In addition, crizotinib could be continued with reduced unless there are any other therapeutic options.

Role of mTOR signaling pathway in crizotinib-induced apoptosis of EML4-ALK fusion gene-positive lung adenocarcinoma cell line H2228 / 中国病理生理杂志

AIM:To investigate the mammalian target of rapamycin ( mTOR) signaling pathway as the center playing a role in the crizotinib-induced apoptosis of non-small cell lung cancer (NSCLC) cell line H2228, which represents positive echinoderm microtubule-associated protein-like 4 (EML4)-anaplastic lymphoma kinase (ALK) fusion gene. METHODS:H2228 cells were processed according to different purposes .Fluorescence quantitative PCR is used to ob-serve the gene states .MTT assay is used to detect the cell inhibition rates .The cell apoptosis and cell cycle were analyzed by flow cytometry .The expression and activation levels of the key proteins in the mTOR signaling pathway were determined by Western blotting .RESULTS:Crizotinib promoted the apoptosis of H 2228 cells in a time-and dose-dependent manner . Crizotinib blocked the H2228 cells staying at the G1 phase.In apoptotic H2228 cells processed with crizotinib, the activa-tion level of mTOR was decreased , and the activation levels of the key proteins in upstream and downstream of mTOR path -way were both declined .The expression level of the fusion protein EML 4-ALK variant 3 was not affected , but its active form of p-ALK was significantly suppressed .CONCLUSION:mTOR signaling pathway has a certain relationship with the crizotinib-induced apoptosis of lung cancer cell H 2228, which represents positive EML4-ALK fusion gene.

Progress of EML4-ALK fusion gene non-small cell lung cancer inhibitor / 国际肿瘤学杂志

EML4-ALK fusion gene is a new molecular type of non-small cell lung cancer,which is formed by inversion of two gene segments on chromosome 2.Up to now,9 subtypes have been found and all of them have deteriorated and carcinogenic abilities. The detection rate of this fusion gene is much higher in patients who have adenocarcinoma,never or seldom smoke and lack EGFR/KRAS mutation.This fusion gene codes ALK tyrosine kinase,that abnormally phosphorylates downstream products through signaling pathways,leading to canceration.Therefore,the specific inhibitors which target this fusion gene could inhibit its expression and have good treatment effect.At present,the relevent inhibitors which are undergoing clinical trials are PF02341066 and TAE684.