Disclosures: Alice T Shaw, MD, PhD Consultant/Advisory Boards: Pfizer [ALK inhibitor (Crizotinib)]; Novartis [ALK inhibitor (Ceritinib)]; Ariad [ALK inhibitor (AP26113)]; Genentech [ALK inhibitor (Alectinib)]; Ignyta [ALK inhibitor (Entrectinib)]; Roche [ALK inhibitor (Alectinib)]; Chugai [ALK inhibitor (Alectinib)]; Daiichi-sankyo [ALK inhibitor (Brigatinib)]. Benjamin Solomon, MBBS, PhD Constultant/Adivsory Boards: Pfizer [cancer-NSCLS (Crizotinib, PF06463922)]; Novartis [cancer-NSCLC (ceretinib)]; Roche-Genentech [cancer-NSCLC (alectinib)]. James R Jett, MD Grant/Research/Clinical Trial Support: Oncimmune Inc [Biomarkers of cancer (Early CDT lung)]. Consultant/Advisory Boards: Eli Lilly Inc [Treatment of Lung Cancer (Educational Program on Squamous Cell Lung Cancer)]. Rogerio C Lilenbaum, MD, FACP Consultant/Advisory Boards: Genentech [Lung cancer (Bevacizumab)]; Celgene [Lung cancer (Paclitaxel)]; Boehringer-Ingelheim [Lung cancer (Afatinib)]. Sadhna R Vora, MD Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
INTRODUCTION — A group of patients with non-small cell lung cancer (NSCLC) have tumors that contain an inversion in chromosome 2 that juxtaposes the 5' end of the echinoderm microtubule-associated protein-like 4 (EML4) gene with the 3' end of the anaplastic lymphoma kinase (ALK) gene, resulting in the novel fusion oncogene EML4-ALK . This fusion oncogene rearrangement is transforming both in vitro and in vivo and defines a distinct clinicopathologic subset of NSCLC.
Tumors that contain the EML4-ALK fusion oncogene or its variants are associated with specific clinical features, including never or light smoking history, younger age, and adenocarcinoma with signet ring or acinar histology. ALK gene arrangements are largely mutually exclusive with epidermal growth factor receptor (EGFR) or KRAS mutations . Screening for this fusion gene in NSCLC is important, as "ALK-positive" tumors (tumors harboring a rearranged ALK gene/fusion protein) are highly sensitive to therapy with ALK-targeted inhibitors.
The molecular pathogenesis, clinical features, and treatment of NSCLC associated with the ALK fusion oncogene are discussed here.
An overview of the treatment of metastatic NSCLC is presented separately, as are the indications for molecular testing. (See "Overview of the treatment of advanced non-small cell lung cancer" and "Personalized, genotype-directed therapy for advanced non-small cell lung cancer", section on 'Molecular testing'.)
MOLECULAR PATHOGENESIS — The echinoderm microtubule-associated protein-like 4-anaplastic lymphoma kinase (EML4-ALK) fusion oncogene arises from an inversion on the short arm of chromosome 2 (Inv(2)(p21p23)) that joins exons 1-13 of EML4 to exons 20-29 of ALK . The resulting chimeric protein, EML4-ALK, contains an N-terminus derived from EML4 and a C-terminus containing the entire intracellular tyrosine kinase domain of ALK.
Since the discovery of this fusion oncogene in 2007, multiple variants of EML4-ALK have been reported, all of which encode the same cytoplasmic portion of ALK but contain different truncations of EML4 (figure 1) [3-5]. In addition, fusions of ALK with other partners including TRK-fused gene TFG and KIF5B have also been described in lung cancer patients, but appear to be much less common than EML4-ALK [5,6].
For EML4-ALK, the EML4 fusion partner mediates ligand-independent dimerization and/or oligomerization of ALK, resulting in constitutive kinase activity. In cell culture systems, EML4-ALK possesses potent oncogenic activity . In transgenic mouse models, lung-specific expression of EML4-ALK leads to the development of numerous lung adenocarcinomas .
The oncogenic role of the ALK fusion oncogene provides a potential avenue for therapeutic intervention. Cancer cell lines harboring the EML4-ALK translocation are effectively inhibited by small molecule inhibitors that target the ALK tyrosine kinase (TK) . In vivo, treatment of EML4-ALK transgenic mice with ALK inhibitors results in tumor regression , supporting the notion that ALK-driven lung cancers are "addicted" to the fusion oncogene.
DIAGNOSIS — Anaplastic lymphoma kinase (ALK) gene rearrangements or the resulting fusion proteins may be detected in tumor specimens using fluorescence in situ hybridization (FISH), immunohistochemistry (IHC), and reverse transcription polymerase chain reaction of cDNA (RT-PCR) .
●FISH – The gold standard assay for diagnosing ALK-positive NSCLC is FISH [10-13]. The commercial break-apart probes include two differently colored (red and green) probes that flank the highly conserved translocation breakpoint within ALK. In non-rearranged cells, the overlying red and green probes result in a yellow (fused) signal; in the setting of an ALK rearrangement, these probes are separated, and splitting of the red and green signals is observed (picture 1A-B). Atypical patterns of rearrangement have also been identified, and these are also responsive to ALK inhibition. ALK gene amplification alone is not predictive of responsiveness to these agents and does not carry the same significance as rearrangement.
●IHC – Multiple monoclonal antibodies have been developed to use for the IHC detection of the ALK fusion oncogene, and IHC using these antibodies is highly sensitive and specific . Thus, IHC can potentially be used to screen for and identify the presence of ALK positivity. In the United States, FISH is the only approved test to diagnose ALK-positive NSCLC, and thus FISH should be used to confirm the IHC results. In Europe, immunohistochemistry is widely used to detect ALK rearrangement.
●RT-PCR – RT-PCR of cDNA has been a commonly used screening strategy for detecting ALK gene rearrangements in NSCLC, but is no longer recommended . A number of multiplex assays were developed to simultaneously capture all possible in-frame fusions between EML4 and ALK in which the kinase domain of ALK would be preserved [3,8,16]. While different breakpoints in EML4 or ALK may be detected, novel ALK fusion partners will not. Furthermore, this method is frequently limited by the quality of the RNA that can be isolated from archival tissue.
CLINICOPATHOLOGIC FEATURES — With increasing identification of this molecular abnormality, the key epidemiologic, demographic, and pathologic features associated with anaplastic lymphoma kinase (ALK) fusion oncogenes have been identified.
Epidemiology — In unselected NSCLC populations, the ALK rearrangement is a relatively rare event. In the initial report, 5 of 75 lung tumors (7 percent) demonstrated expression of the fusion transcript. The overall incidence of ALK gene rearrangements in subsequent series has been about 4 percent [3,8,11-13,16-18]. Except in rare cases, the presence of ALK gene rearrangements in NSCLC tumors tends to occur independent of epidermal growth factor receptor (EGFR) or KRAS mutations. Similar frequencies of ALK gene rearrangements have been reported in Asian and Western populations .
While the overall frequency of ALK fusion oncogene in the general NSCLC population is low, knowledge of the clinicopathologic features enables enrichment for this genetically defined subset. In one study in which patients were selected for genetic screening based on clinical features commonly associated with EGFR mutation, including never/light smoking status and adenocarcinoma histology, 13 percent harbored the ALK fusion oncogene. Within the group of never or light smokers in this study, the frequency of ALK positivity was 22 percent, and among never or light smokers who did not have an EGFR mutation, the frequency was 33 percent . These findings suggest that in NSCLC patients with clinical characteristics associated with EGFR mutation but with negative EGFR testing, as many as one in three may harbor the ALK fusion oncogene. (See "Systemic therapy for advanced non-small cell lung cancer with an activating mutation in the epidermal growth factor receptor", section on 'Rationale'.)
Age of onset — Patients with ALK fusion oncogene-positive lung cancer are relatively younger at onset than those without this abnormality [12,20]. The two studies that were used to support the approval of crizotinib included 255 patients whose tumors contained an ALK fusion oncogene; in this database, the median age was 52 years (range 21 to 82 years) . The estimated median age for unselected patients with lung cancer is approximately 70 years .
Interestingly, other cancers known to harbor ALK rearrangements such as NPM-ALK positive anaplastic large cell lymphoma are also associated with younger age and are, in fact, most common in children and young adults.
Smoking history — The ALK fusion oncogene in patients with NSCLC is strongly associated with a history of never or light smoking (<10 packet years) [1,12,20]. In the crizotinib study database of 255 patients, never smokers and former smokers comprised 70 and 28 percent of cases, respectively [1,12,20].
Histology — The vast majority of lung tumors that harbor the ALK fusion oncogene are adenocarcinomas. In the 255 patients with the ALK fusion oncogene included in the crizotinib database, 97 percent were adenocarcinoma . ALK rearrangement has been reported in squamous cell carcinoma, but this is rare [11,18].
Adenocarcinomas in ALK fusion oncogene positive cases from Caucasian patients are significantly more likely to have abundant signet ring cells than those with an EGFR mutation or wild type tumors . Signet ring cells are frequently found in gastric cancers and rarely in cancers of other organs such as the lung. Several small case series suggest that signet ring cells may be associated with an aggressive clinical course and a poor prognosis. Whether the presence of signet ring cells in ALK fusion oncogene lung cancer has biological or clinical significance remains to be determined.
Other studies of ALK in NSCLC have not reported an association with signet ring cells, but have noted a possible association with the acinar subtype of adenocarcinoma, at least in Asian patients. This discrepancy may reflect differences in pathologic interpretation rather than ethnic differences in patients with ALK fusion oncogene-positive lung cancer.
CHEMOTHERAPY VERSUS TARGETED THERAPY — Advanced non-small cell lung cancer (NSCLC) associated with the anaplastic lymphoma kinase (ALK) fusion oncogene is highly sensitive to ALK tyrosine kinase (TK) inhibitors. Treatment with ALK TK inhibitors should be limited to patients whose tumors contain this abnormality as demonstrated by fluorescence in situ hybridization (FISH). (See 'Diagnosis' above and "Overview of the treatment of advanced non-small cell lung cancer", section on 'Initial systemic therapy'.)
An ALK inhibitor is preferred as the initial therapy for patients whose tumor contains this genetic abnormality in countries where it is approved for this indication. Results of a phase III trial comparing ALK inhibition using crizotinib with chemotherapy in treatment-naïve patients have demonstrated a prolongation in progression-free survival, improved response rate and quality of life . No significant differences in overall survival were seen, potentially due to the confounding effects of crossover. (See 'Crizotinib' below.)
In other countries, its use may be restricted to those who have progressed following chemotherapy. Thus patients should have tumor tissue assessed for the presence of ALK rearrangement, as well as for other driver mutations (especially in the epidermal growth factor receptor [EGFR]). (See "Personalized, genotype-directed therapy for advanced non-small cell lung cancer", section on 'Molecular testing'.)
If systemic treatment is required before the results of genotype testing are available, systemic chemotherapy rather than targeted therapy is indicated . When the results of genotype testing become available, the treatment plan should be reassessed. There are no clinical trials that directly address the optimal timing of ALK inhibitors in patients who have already started on chemotherapy (algorithm 1).
If an ALK fusion oncogene is identified after the initiation of treatment, we suggest continuing chemotherapy for four cycles if therapy is tolerated and there is no evidence of disease progression. There are no data directly comparing continuation using maintenance chemotherapy versus a switch to crizotinib after completion of this initial chemotherapy. The authors’ preference is to switch to crizotinib, rather than to use maintenance chemotherapy, because there are some patients who will deteriorate due to disease progression and thus miss the opportunity to be treated with an ALK inhibitor.
For patients who continue treatment with chemotherapy, crizotinib is indicated when there is evidence of disease progression. Factors that should be discussed with the patient in defining a treatment plan include the quality of the initial response to chemotherapy and the potential side effects of maintenance therapy.
ALK INHIBITORS: EFFICACY — Two tyrosine kinase (TK) inhibitors, crizotinib and ceritinib, have established roles in the treatment of anaplastic lymphoma kinase (ALK) fusion oncogene positive NSCLC, and additional agents are under development.
Crizotinib — Crizotinib is a multitargeted small molecule tyrosine kinase inhibitor, which was originally developed as an inhibitor of mesenchymal epithelial transition growth factor (c-MET); it is also a potent inhibitor of ALK phosphorylation and signal transduction . This inhibition is associated with G1-S phase cell cycle arrest and induction of apoptosis in ALK-positive cells in vitro and in vivo . Crizotinib also inhibits the related ROS1 receptor tyrosine kinase.
Randomized trials — The efficacy of crizotinib has been demonstrated in two randomized trials limited to patients whose tumors had the ALK rearrangement:
●Previously treated patients − A phase III trial randomly assigned 347 patients who had previously been treated with one prior platinum-based chemotherapy regimen to either crizotinib or single agent pemetrexed or docetaxel . Patients who were assigned to chemotherapy were allowed to be treated with crizotinib when they developed progressive disease.
•At a median follow-up of 12 months, progression-free survival, the primary endpoint of the trial was significantly increased with crizotinib compared with chemotherapy (median 7.7 versus 3 months, hazard ratio [HR] for progression 0.49, 95% CI 0.37-0.64).
•The objective response rate based upon independent radiologic review was also significantly increased (65 versus 20 percent). Responses were achieved more rapidly than with chemotherapy (median time to response 6.3 versus 12.6 weeks) and were of longer duration (32 versus 24 weeks).
•There was no significant difference in overall survival (median 20.3 versus 22.8 months, HR for death 1.02). The absence of an overall survival benefit presumably reflects subsequent treatment since 64 percent of chemotherapy-treated patients had crossed over to crizotinib after progressing on chemotherapy.
●Chemotherapy naïve patients − In a second trial, 343 chemotherapy naïve patients were randomly assigned to crizotinib or chemotherapy with pemetrexed plus either cisplatin or carboplatin . Crossover to crizotinib was permitted for those treated with chemotherapy. Progression-free survival, the primary endpoint of the trial, was significantly prolonged with crizotinib compared with chemotherapy (median 10.9 versus 7 months, HR 0.45, 95% CI 0.35-0.60). The objective response rate was also significantly increased (74 versus 45 percent). The difference in overall survival was not significantly different (HR 0.82, 95% CI 0.54-1.26). However, the majority of patients assigned to initial chemotherapy subsequently were treated with crizotinib.
Brain metastases — Crizotinib appears to have modest activity against brain metastases. A retrospective analysis of patients from two randomized trials identified 275 patients with asymptomatic brain metastases who were treated with crizotinib; 166 had received prior RT while 109 were treatment naïve . (See 'Brain metastases' below.)
●Among patients who had received prior RT, the 12-week disease control rate was 65 percent for systemic disease and 62 percent for brain metastases. For patients with previously treated brain metastases, the median time to intracranial progression was 13 months.
●In asymptomatic patients who had not received prior RT, the 12-week disease control rates for systemic and intracranial disease were 63 and 56 percent, respectively. The median time to intracranial progression was seven months.
However, such responses are not durable, and central nervous system relapses can result in rapid neurologic deterioration and death. For patients with very small (<5 mm) brain metastases that are asymptomatic, crizotinib can be used initially and RT deferred. However, these patients should be monitored closed with magnetic resonance imaging (MRI) every two months.
Isolated brain metastases (a central nervous system [CNS] relapse without evidence of extracranial progression) may be a particular problem for patients treated with crizotinib. In this setting, continuation of treatment with crizotinib after treatment of the CNS relapse with surgery and/or RT may be associated with a significant period of control of extracranial disease .
Duration of treatment — Treatment with crizotinib is generally continued until there is evidence of disease progression. The standard approach for patients with progressive disease is the use of the second generation ALK inhibitor ceritinib. In carefully selected patients (eg, an isolated site of recurrence that can be treated with local therapy, those with extremely mild and asymptomatic progression), crizotinib may be continued after initial evidence of progressive disease . (See 'Ceritinib' below.)
Resistance to crizotinib — While crizotinib is highly active in patients with ALK-positive NSCLC, almost all patients develop resistance to the drug, typically within the first few years of treatment. Several distinct mechanisms of resistance have been reported in the literature.
●In approximately one-third of resistant cases, tumors have acquired a secondary mutation within the ALK tyrosine kinase domain. The most common resistance mutation is the gatekeeper L1196M mutation, followed closely by the G1269A mutation. Other mutations occur at residues 1151, 1152, 1156, 1174, 1202, 1203, and 1206. The G1202R mutation is notable, as it confers high level resistance to crizotinib as well as to next generation ALK inhibitors (see below).
●A second mechanism of crizotinib resistance is amplification of the ALK fusion gene. This can occur alone or in combination with a secondary resistance mutation.
●Finally, a number of alternative or bypass signaling pathways have been shown to mediate crizotinib resistance. These include abnormalities in the epidermal growth factor receptor (EGFR), KIT, and insulin-like growth factor-1 receptor (IGF1R) pathways, and suggest the potential need for combination therapies to overcome resistance.
Ceritinib — Ceritinib is a second generation TK inhibitor of ALK that is approximately 20 times more potent than crizotinib. Ceritinib is indicated for patients who are resistant to or unable to tolerate crizotinib. Preclinical studies suggested that ceritinib had significant activity against cells that were either sensitive or resistant to crizotinib, including resistant tumors with the most common L1196M and G1269A resistance mutations.
After the maximum tolerated dose was established in the phase I study , ceritinib was studied in a dose expansion cohort of NSCLC patients with the ALK rearrangement [30,31]. Results from that expansion cohort were updated at the 2014 ASCO meeting :
●A total of 246 patients with ALK positive NSCLC were treated with ceritinib. Of these patients, 163 had previously been treated with an ALK inhibitor and 83 were ALK inhibitor naïve.
●The objective response rate was 58 percent overall, 55 percent in those with prior crizotinib treatment, and 66 percent in ALK inhibitor naïve patients. The median duration of response was 10 months in the entire cohort, and 7.4 months in those with prior crizotinib treatment. The median progression-free survival for the entire cohort was 8.2 months, including 6.9 months for those previously treated with an ALK inhibitor and not estimable (lower bound of 95% CI 8.3 months) for those who had not previously received an ALK inhibitor.
Two phase III trials are currently recruiting patients with ALK-positive NSCLC, one in which ceritinib is being compared with single-agent chemotherapy after progression on a platinum-based doublet and on crizotinib (NCT01828112), and the other as first line treatment compared with a platinum-based doublet (NCT01828099).
The most extensive data come from a phase II study in which 138 patients were treated with alectinib (600 mg po bid); 122 of the patients were evaluable for efficacy based upon RECIST criteria . All patients had crizotinib resistant disease, 80 percent had progressed after prior platinum-based chemotherapy, and 61 percent had brain metastases.
●With a median follow-up of 47 weeks, the overall objective response rate was 50 percent, and the disease control rate (objective response plus stable disease) was 79 percent. Responses were durable, and the median duration of response was 11 months. The median progression-free survival for the entire cohort was 8.9 months.
●In the 84 patients (61 percent) with brain metastases, the disease control rate was 83 percent. The objective response rate among the 35 patients with measurable brain lesions was 57 percent; the median duration of central nervous system response was 10 months. The activity of alectinib against brain metastases was similar in those who had received prior radiation therapy (RT) and those who had not received RT.
Alectinib is investigational and is not commercially available.
Brain metastases — Surgery and/or radiation therapy are the primary treatment modalities for most patients with brain metastases from NSCLC, including those with the EML4-ALK fusion oncogene [38,39]. However, advances in targeted therapy may eventually provide an important alternative. (See "Overview of the clinical manifestations, diagnosis, and management of patients with brain metastases", section on 'Overview of management' and "Systemic therapy for brain metastases", section on 'Targeted agents'.)
The experimental ALK inhibitor alectinib appears to have important clinical utility in patients with brain metastases, and this may provide an option for patients with brain metastases. (See 'Alectinib' above.)
ALK INHIBITORS: TOXICITY — Treatment with the anaplastic lymphoma kinase (ALK) inhibitors crizotinib and ceritinib is generally well tolerated. However, there are a number of significant toxicities that may require dose modification or treatment discontinuation.
Gastrointestinal side effects — Nausea, vomiting, and diarrhea are common with both crizotinib and ceritinib, but are more severe with ceritinib. With crizotinib, less than 1 percent of these side effects were severe. However, more than one-half of patients treated with ceritinib required dose modification, and 9 percent required treatment discontinuation. (See "Enterotoxicity of chemotherapeutic agents", section on 'ALK inhibitors'.)
Hepatotoxicity — Liver function test abnormalities are occasionally seen with crizotinib and are commonly seen with ceritinib. Hepatoxicity can progress and may require dose modification or discontinuation. (See "Chemotherapy hepatotoxicity and dose modification in patients with liver disease", section on 'Crizotinib and ceritinib'.)
Pneumonitis — Severe, life-threatening, or fatal treatment-related pneumonitis has been reported in 1 to 4 percent of patients treated with either crizotinib or ceritinib. The development of pneumonitis should result in discontinuation of treatment with these agents. (See "Pulmonary toxicity associated with antineoplastic therapy: Molecularly targeted agents", section on 'Crizotinib and ceritinib'.)
Other toxicities that have been observed with crizotinib include the following:
●Sinus bradycardia is relatively frequent in patients treated with crizotinib and may be severe in some cases [43,44]. However, patients with sinus bradycardia were asymptomatic, and the bradycardia was not explained by other comorbidity or medications. Caution should be used in the concomitant administration of beta blockers in patients treated with crizotinib. (See "Cardiotoxicity of nonanthracycline cancer chemotherapy agents".)
●QTc interval prolongation has been observed with crizotinib, and crizotinib should be avoided in patients with congenital long QT syndrome. Treatment should be temporarily discontinued if severe QTc prolongation develops and permanently discontinued if it recurs or is accompanied by an arrhythmia, heart failure, hypotension, shock, syncope, or torsade de pointes.
Our approach is to perform an EKG at baseline in all patients treated with either crizotinib or ceritinib. Subsequently, we check an EKG if the patient develops bradycardia (whether symptomatic or not) or if the patient is started on a drug that is known to cause QTc prolongation. (See "Cardiotoxicity of nonanthracycline cancer chemotherapy agents".)
Cytochrome p450 interactions — Both crizotinib and ceritinib are metabolized by cytochrome P450 CYP3A4. Thus, caution should be used when it is given concomitantly with CYP3A4 inhibitors, and care is required when these agents are coadministered with other agents that are predominantly metabolized by this system (table 1).
Visual disturbances — Visual disturbances were seen in 60 to 65 percent of patients treated with crizotinib in the phase II studies . These were primarily associated with the transition from dark to light. Uncommon visual manifestations included photophobia, decreased visual acuity, and blurred vision. Similar symptoms have been reported with ceritinib, but their overall incidence is less that 10 percent.
Detailed ophthalmological assessment in over 200 patients from phase II experience with crizotinib did not demonstrate any objective abnormalities associated with visual symptoms . However, optic neuropathy and blindness has been reported in one case, although that may have been related to prior whole brain radiation therapy .
●With crizotinib, rapid depression of serum testosterone levels has been observed [47,48]. In a series of 32 patients treated with crizotinib, the mean serum testosterone level was below the lower limit of normal in 27 of 32 men (84 percent) compared with 6 of 19 (32 percent) among those not receiving crizotinib . Levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH) were also low, suggesting a centrally mediated mechanism. A large component of the lowered total testosterone may be due to significant depression of sex hormone binding globulin. Male patients who report symptoms of hypogonadism can be referred to endocrinology to discuss potential testosterone replacement. These findings require validation in larger cohorts. (See "Clinical features and diagnosis of male hypogonadism".)
Renal cysts — Renal cysts have been reported in 4 percent of patients treated with crizotinib . The cysts may be positive on positron emission tomography (PET) and can create confusion with renal metastases . These cysts may be complex. Although the natural history of crizotinib-associated renal cysts is not fully known, one report found that complex renal cysts regress when treatment with crizotinib is discontinued . (See "Simple and complex renal cysts in adults".)
Hypersensitivity reactions — Hypersensitivity reactions have been described in two patients treated with crizotinib, manifested by a generalized rash developing hours after the administration of oral dosing . Desensitization was carried out using escalating doses of crizotinib administered every 15 minutes over a three hour period, preceded by one hour with single doses of loratadine (10 mg), cetirizine (10 mg), and fexofenadine (180 mg). Following desensitization there were no further symptom symptoms suggesting a hypersensitivity reaction.
Chemotherapy — Cytotoxic chemotherapy appears to have a similar level of activity in anaplastic lymphoma kinase (ALK)-positive patients with NSCLC compared with those with ALK-negative disease. The choice of a specific chemotherapy agent or regimen is based upon the same criteria applied in other cases of advanced NSCLC. When patients with ALK-positive advanced NSCLC require chemotherapy, pemetrexed or a pemetrexed-based regimen is generally preferred, since almost all of these patients have adenocarcinoma histology. (See "Advanced non-small cell lung cancer: Subsequent therapies for previously treated patients", section on 'Single agent chemotherapy' and "Systemic therapy for the initial management of advanced non-small cell lung cancer without a driver mutation", section on 'Effect of histology'.)
EGFR tyrosine kinase inhibitors — Patients with the ALK fusion oncogene do not appear to respond to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). In a retrospective cohort of 19 patients with the ALK fusion oncogene, there were no clinical responses to EGFR TKIs, and the median time to progression was only five months .
SUMMARY AND RECOMMENDATIONS
●The presence of an anaplastic lymphoma kinase (ALK) fusion oncogene defines a molecular subset of non-small cell lung cancer (NSCLC) with distinct clinical and pathologic features. The patients most likely to harbor ALK rearrangement are relatively young, never or light smokers with adenocarcinoma. (See 'Molecular pathogenesis' above and 'Clinicopathologic features' above.)
●Whenever possible, therapy of patients with advanced NSCLC should be individualized based upon the molecular and histologic features of the tumor. If feasible prior to treatment, patients should have tumor tissue assessed for the presence of the ALK fusion oncogene, which is associated with sensitivity to ALK tyrosine kinase inhibitors, as well as other driver mutations such as those seen in the epidermal growth factor receptor (EGFR). (See "Personalized, genotype-directed therapy for advanced non-small cell lung cancer" and 'Chemotherapy versus targeted therapy' above.)
●For patients with advanced or metastatic NSCLC whose tumors contain a characteristic ALK fusion oncogene, we recommend initial treatment with the ALK inhibitor crizotinib rather than chemotherapy (Grade 1B). There currently are insufficient data supporting the use of ceritinib as the initial ALK inhibitor. (See 'Crizotinib' above.)
•Therapy with crizotinib should be continued until there is evidence of progressive disease. In carefully selected patients with an isolated site of recurrence that can be treated with local therapy or those with extremely mild and asymptomatic progression, crizotinib may be continued after initial evidence of progressive disease. (See 'Crizotinib' above.)
•Crizotinib should not be used in patients without ALK rearrangement. In the United States, ALK-positivity must be demonstrated by fluorescence in situ hybridization (FISH) using the US Food and Drug Administration (FDA)-approved test (Vysis Probes) in accordance with the FDA label. In Europe, immunohistochemistry is widely used to detect ALK rearrangement. (See 'Crizotinib' above.)
•Crizotinib is indicated as second-line therapy when progressive disease occurs for patients whose tumor contains the ALK fusion oncogene and initially were treated with chemotherapy. (See 'Crizotinib' above.)
●For ALK-positive patients who develop resistance to crizotinib or who are unable to tolerate crizotinib, we recommend treatment with the second generation ALK inhibitor ceritinib (Grade 1B). (See 'Ceritinib' above.)
●Chemotherapy is an appropriate option for patients who no longer respond to ALK inhibition. (See "Systemic therapy for the initial management of advanced non-small cell lung cancer without a driver mutation" and "Advanced non-small cell lung cancer: Subsequent therapies for previously treated patients".)
●In some cases, chemotherapy is required before the results of molecular testing are available. If the tumor is found to contain the ALK fusion oncogene and patients have an ongoing objective response or stable disease after completing their initial doublet chemotherapy, the authors prefer to switch to crizotinib, although both crizotinib and single-agent maintenance chemotherapy are options. Factors that should be discussed with the patient in defining a treatment plan include the quality of the initial response to chemotherapy and the potential side effects of maintenance therapy. (See "Systemic therapy for the initial management of advanced non-small cell lung cancer without a driver mutation", section on 'Molecular characterization of tumor'.)
- Shaw AT, Solomon B. Targeting anaplastic lymphoma kinase in lung cancer. Clin Cancer Res 2011; 17:2081.
- Takahashi T, Sonobe M, Kobayashi M, et al. Clinicopathologic features of non-small-cell lung cancer with EML4-ALK fusion gene. Ann Surg Oncol 2010; 17:889.
- Soda M, Choi YL, Enomoto M, et al. Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer. Nature 2007; 448:561.
- Choi YL, Takeuchi K, Soda M, et al. Identification of novel isoforms of the EML4-ALK transforming gene in non-small cell lung cancer. Cancer Res 2008; 68:4971.
- Takeuchi K, Choi YL, Togashi Y, et al. KIF5B-ALK, a novel fusion oncokinase identified by an immunohistochemistry-based diagnostic system for ALK-positive lung cancer. Clin Cancer Res 2009; 15:3143.
- Rikova K, Guo A, Zeng Q, et al. Global survey of phosphotyrosine signaling identifies oncogenic kinases in lung cancer. Cell 2007; 131:1190.
- Soda M, Takada S, Takeuchi K, et al. A mouse model for EML4-ALK-positive lung cancer. Proc Natl Acad Sci U S A 2008; 105:19893.
- Koivunen JP, Mermel C, Zejnullahu K, et al. EML4-ALK fusion gene and efficacy of an ALK kinase inhibitor in lung cancer. Clin Cancer Res 2008; 14:4275.
- Weickhardt AJ, Aisner DL, Franklin WA, et al. Diagnostic assays for identification of anaplastic lymphoma kinase-positive non-small cell lung cancer. Cancer 2013; 119:1467.
- Martelli MP, Sozzi G, Hernandez L, et al. EML4-ALK rearrangement in non-small cell lung cancer and non-tumor lung tissues. Am J Pathol 2009; 174:661.
- Boland JM, Erdogan S, Vasmatzis G, et al. Anaplastic lymphoma kinase immunoreactivity correlates with ALK gene rearrangement and transcriptional up-regulation in non-small cell lung carcinomas. Hum Pathol 2009; 40:1152.
- Shaw AT, Yeap BY, Mino-Kenudson M, et al. Clinical features and outcome of patients with non-small-cell lung cancer who harbor EML4-ALK. J Clin Oncol 2009; 27:4247.
- Perner S, Wagner PL, Demichelis F, et al. EML4-ALK fusion lung cancer: a rare acquired event. Neoplasia 2008; 10:298.
- Conklin CM, Craddock KJ, Have C, et al. Immunohistochemistry is a reliable screening tool for identification of ALK rearrangement in non-small-cell lung carcinoma and is antibody dependent. J Thorac Oncol 2013; 8:45.
- Lindeman NI, Cagle PT, Beasley MB, et al. Molecular testing guideline for selection of lung cancer patients for EGFR and ALK tyrosine kinase inhibitors: guideline from the College of American Pathologists, International Association for the Study of Lung Cancer, and Association for Molecular Pathology. Arch Pathol Lab Med 2013; 137:828.
- Takeuchi K, Choi YL, Soda M, et al. Multiplex reverse transcription-PCR screening for EML4-ALK fusion transcripts. Clin Cancer Res 2008; 14:6618.
- Wong DW, Leung EL, So KK, et al. The EML4-ALK fusion gene is involved in various histologic types of lung cancers from nonsmokers with wild-type EGFR and KRAS. Cancer 2009; 115:1723.
- Inamura K, Takeuchi K, Togashi Y, et al. EML4-ALK fusion is linked to histological characteristics in a subset of lung cancers. J Thorac Oncol 2008; 3:13.
- Solomon B, Varella-Garcia M, Camidge DR. ALK gene rearrangements: a new therapeutic target in a molecularly defined subset of non-small cell lung cancer. J Thorac Oncol 2009; 4:1450.
- Food and Drug Administration http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/202570s000lbl.pdf.
- http://seer.cancer.gov/statfacts/html/lungb.html (Accessed on September 03, 2014).
- Rodig SJ, Mino-Kenudson M, Dacic S, et al. Unique clinicopathologic features characterize ALK-rearranged lung adenocarcinoma in the western population. Clin Cancer Res 2009; 15:5216.
- Solomon BJ, Mok T, Kim DW, et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer. N Engl J Med 2014; 371:2167.
- Moran T, Sequist LV. Timing of epidermal growth factor receptor tyrosine kinase inhibitor therapy in patients with lung cancer with EGFR mutations. J Clin Oncol 2012; 30:3330.
- Christensen JG, Zou HY, Arango ME, et al. Cytoreductive antitumor activity of PF-2341066, a novel inhibitor of anaplastic lymphoma kinase and c-Met, in experimental models of anaplastic large-cell lymphoma. Mol Cancer Ther 2007; 6:3314.
- Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med 2013; 368:2385.
- Costa DB, Shaw AT, Ou SH, et al. Clinical Experience With Crizotinib in Patients With Advanced ALK-Rearranged Non–Small-Cell Lung Cancer and Brain metastases. J Clin Oncol 2015.
- Takeda M, Okamoto I, Nakagawa K. Clinical impact of continued crizotinib administration after isolated central nervous system progression in patients with lung cancer positive for ALK rearrangement. J Thorac Oncol 2013; 8:654.
- Ou SH, Jänne PA, Bartlett CH, et al. Clinical benefit of continuing ALK inhibition with crizotinib beyond initial disease progression in patients with advanced ALK-positive NSCLC. Ann Oncol 2014; 25:415.
- Shaw AT, Kim DW, Mehra R, et al. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med 2014; 370:1189.
- Kim DW, Mehra R, Tan DS, et al. Ceritinib in advanced anaplastic lymphoma kinase (ALK)-rearranged (ALK+) non-small cell lung cancer (NSCLC): Results of the ASCEND-1 trial (abstract 8003). 2014 American Society of Clinical Oncology (ASCO) meeting.
- http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/205755lbl.pdf?et_cid=33681002&et_rid=585254827&linkid=http%3a%2f%2fwww.accessdata.fda.gov%2fdrugsatfda_docs%2flabel%2f2014%2f205755lbl.pdf (Accessed on April 29, 2014).
- Seto T, Kiura K, Nishio M, et al. CH5424802 (RO5424802) for patients with ALK-rearranged advanced non-small-cell lung cancer (AF-001JP study): a single-arm, open-label, phase 1-2 study. Lancet Oncol 2013; 14:590.
- Gadgeel SM, Gandhi L, Riely GJ, et al. Safety and activity of alectinib against systemic disease and brain metastases in patients with crizotinib-resistant ALK-rearranged non-small-cell lung cancer (AF-002JG): results from the dose-finding portion of a phase 1/2 study. Lancet Oncol 2014.
- Gainor JF, Sherman CA, Willoughby K, et al. Alectinib salvages CNS relapses in ALK-positive lung cancer patients previously treated with crizotinib and ceritinib. J Thorac Oncol 2015; 10:232.
- Ajimizu H, Kim YH, Mishima M. Rapid response of brain metastases to alectinib in a patient with non-small-cell lung cancer resistant to crizotinib. Med Oncol 2015; 32:477.
- Ou S, Ahn JS, De Petris L, et al. Efficacy and safety of the ALK inhibitor alectinib in ALK+ non-small-cell lung cancer (NSCLC) patients who have failed prior crizotinib: an open-label, single-arm, global phase 2 study (NP28673). J Clin Oncol 33, 2015 (suppl; abstr 8008)
- Kaneda H, Okamoto I, Nakagawa K. Rapid response of brain metastasis to crizotinib in a patient with ALK rearrangement-positive non-small-cell lung cancer. J Thorac Oncol 2013; 8:e32.
- Maillet D, Martel-Lafay I, Arpin D, Pérol M. Ineffectiveness of crizotinib on brain metastases in two cases of lung adenocarcinoma with EML4-ALK rearrangement. J Thorac Oncol 2013; 8:e30.
- Li S, Qi X, Huang Y, et al. Ceritinib (LDK378): a potent alternative to crizotinib for ALK-rearranged non-small-cell lung cancer. Clin Lung Cancer 2015; 16:86.
- Camidge DR, Bazhenova L, Salgia R, et al. Safety and efficacy of brigatinib (AP26113) in advanced malignancies, including ALK+ non–small cell lung cancer (NSCLC). J Clin Oncol 33, 2015 (suppl; abstr 8062)
- Shaw AT, Bauer TM, Felip E, et al. Clinical activity and safety of PF-06463922 from a dose escalation study in patients with advanced ALK+ or ROS1+ NSCLC. J Clin Oncol 33, 2015 (suppl; abstr 8018)
- Ou SH, Azada M, Dy J, Stiber JA. Asymptomatic profound sinus bradycardia (heart rate ≤45) in non-small cell lung cancer patients treated with crizotinib. J Thorac Oncol 2011; 6:2135.
- Ou SH, Tong WP, Azada M, et al. Heart rate decrease during crizotinib treatment and potential correlation to clinical response. Cancer 2013; 119:1969.
- Besse B, Salgia R, Bolomon B, et al. VISUAL DISTURBANCES IN PATIENTS (PTS) WITH ANAPLASTIC LYMPHOMA KINASE (ALK)-POSITIVE ADVANCED NON-SMALL CELL LUNG CANCER (NSCLC) TREATED WITH CRIZOTINIB (abstract 1268P). European Society Medical Oncology 2012.
- Chun SG, Iyengar P, Gerber DE, et al. Optic Neuropathy and Blindness Associated With Crizotinib for Non–Small-Cell Lung Cancer With EML4-ALK Translocation. J Clin Oncol 2014.
- Ramalingam SS, Shaw AT. Hypogonadism related to crizotinib therapy: implications for patient care. Cancer 2012; 118:E1.
- Weickhardt AJ, Doebele RC, Purcell WT, et al. Symptomatic reduction in free testosterone levels secondary to crizotinib use in male cancer patients. Cancer 2013; 119:2383.
- Klempner SJ, Aubin G, Dash A, Ou SH. Spontaneous regression of crizotinib-associated complex renal cysts during continuous crizotinib treatment. Oncologist 2014; 19:1008.
- Lin YT, Wang YF, Yang JC, et al. Development of renal cysts after crizotinib treatment in advanced ALK-positive non-small-cell lung cancer. J Thorac Oncol 2014; 9:1720.
- Awad MM, Lax TP, Slawski BR, Shaw AT. Successful desensitization of two patients with ALK-positive lung cancer and hypersensitivity to crizotinib. J Thorac Oncol 2014; 9:1726.