Crizotinib versus chemotherapy in advanced ALK-positive lung cancer

BACKGROUND: In single-group studies, chromosomal rearrangements of the anaplastic lymphoma kinase gene (ALK ) have been associated with marked clinical responses to crizotinib, an oral tyrosine kinase inhibitor targeting ALK. Whether crizotinib is superior to standard chemotherapy with respect to efficacy is unknown. METHODS: We conducted a phase 3, open-label trial comparing crizotinib with chemotherapy in 347 patients with locally advanced or metastatic ALK-positive lung cancer who had received one prior platinum-based regimen. Patients were randomly assigned to receive oral treatment with crizotinib (250 mg) twice daily or intravenous chemotherapy with either pemetrexed (500 mg per square meter of body-surface area) or docetaxel (75 mg per square meter) every 3 weeks. Patients in the chemotherapy group who had disease progression were permitted to cross over to crizotinib as part of a separate study. The primary end point was progression-free survival. RESULTS: The median progression-free survival was 7.7 months in the crizotinib group and 3.0 months in the chemotherapy group (hazard ratio for progression or death with crizotinib, 0.49; 95% confidence interval [CI], 0.37 to 0.64; P<0.001). The response rates were 65% (95% CI, 58 to 72) with crizotinib, as compared with 20% (95% CI, 14 to 26) with chemotherapy (P<0.001). An interim analysis of overall survival showed no significant improvement with crizotinib as compared with chemotherapy (hazard ratio for death in the crizotinib group, 1.02; 95% CI, 0.68 to 1.54; P=0.54). Common adverse events associated with crizotinib were visual disorder, gastrointestinal side effects, and elevated liver aminotransferase levels, whereas common adverse events with chemotherapy were fatigue, alopecia, and dyspnea. Patients reported greater reductions in symptoms of lung cancer and greater improvement in global quality of life with crizotinib than with chemotherapy. CONCLUSIONS: Crizotinib is superior to standard chemotherapy in patients with previously treated, advanced non-small-cell lung cancer with ALK rearrangement. (Funded by Pfizer; ClinicalTrials.gov number, NCT00932893.) Copyright © 2013 Massachusetts Medical Society.

National working group meeting on ALK diagnostics in lung cancer

The global landscape of molecular testing is rapidly changing, with the recent publication of the International Association for the Study of Lung Cancer (IASLC)/College of American Pathologists (CAP) guidelines and the ALK Atlas. The IASLC/CAP guidelines recommend that tumors from patients with non-small cell lung cancer (NSCLC) be tested for ALK rearrangements in addition to epidermal growth factor receptor (EGFR) mutations. The spur for this recommendation is the availability of novel therapies that target these rearrangements. This article is based on coverage of a Pfizer-sponsored National Working Group Meeting on ALK Diagnostics in Lung Cancer, held around the 15th World Lung Cancer Conference, in Sydney on October 31, 2013. It is based on the presentations given by the authors at the meeting and the discussion that ensued. The content for this article was discussed and agreed on by the authors.

Prevalence and clinical outcomes for patients with ALK-positive resected stage I to III adenocarcinoma : results from the European Thoracic Oncology Platform Lungscape Project

PURPOSE: The prevalence of anaplastic lymphoma kinase (ALK) gene fusion (ALK positivity) in early-stage non-small-cell lung cancer (NSCLC) varies by population examined and detection method used. The Lungscape ALK project was designed to address the prevalence and prognostic impact of ALK positivity in resected lung adenocarcinoma in a primarily European population. METHODS: Analysis of ALK status was performed by immunohistochemistry (IHC) and fluorescent in situ hybridization (FISH) in tissue sections of 1,281 patients with adenocarcinoma in the European Thoracic Oncology Platform Lungscape iBiobank. Positive patients were matched with negative patients in a 1:2 ratio, both for IHC and for FISH testing. Testing was performed in 16 participating centers, using the same protocol after passing external quality assessment. RESULTS: Positive ALK IHC staining was present in 80 patients (prevalence of 6.2%; 95% CI, 4.9% to 7.6%). Of these, 28 patients were ALK FISH positive, corresponding to a lower bound for the prevalence of FISH positivity of 2.2%. FISH specificity was 100%, and FISH sensitivity was 35.0% (95% CI, 24.7% to 46.5%), with a sensitivity value of 81.3% (95% CI, 63.6% to 92.8%) for IHC 2+/3+ patients. The hazard of death for FISH-positive patients was lower than for IHC-negative patients (P = .022). Multivariable models, adjusted for patient, tumor, and treatment characteristics, and matched cohort analysis confirmed that ALK FISH positivity is a predictor for better overall survival (OS). CONCLUSION: In this large cohort of surgically resected lung adenocarcinomas, the prevalence of ALK positivity was 6.2% using IHC and at least 2.2% using FISH. A screening strategy based on IHC or H-score could be envisaged. ALK positivity (by either IHC or FISH) was related to better OS.

Concentrations of constitutive alk(en)ylresorcinols in peel of commercial mango varieties and resistance to postharvest anthracnose

Mature green mango fruits of commercially important varieties were screened to investigate the levels of constitutive antifungal compounds in peel and to assess anthracnose disease after inoculation with Colletotrichum gloeosporioides. High pressure liquid chromatography was used to quantify the levels of 5-n-heptadecenylresorcinol and 5-n-pentadecylresorcinol in the peel extracts. The fruit peel of the varieties ‘Kensington Pride’ and ‘Keitt’ were observed to have the highest levels of both 5-n-heptadecenylresorcinol (107.3-123.7 and 49.9-61.4 μg/g FW, respectively) and 5-n-pentadecylresorcinol (6.32-7.99 and 3.30-6.05 μg/g FW, respectively), and the fruit of the two varieties were found to have some resistance to postharvest anthracnose. The varieties ‘Kent’, ‘R2E2’, ‘Nam Doc Mai’, ‘Calypso’, and ‘Honey Gold’ contained much lower concentrations of resorcinols in their peel and three of these varieties were found to be more susceptible to anthracnose. Concentrations of 5-nheptadecenylresorcinol were significantly lower at the ‘sprung’ and ‘eating ripe’ stages of ripening compared to levels at harvest. Concentrations of 5-n-pentadecylresorcinol did not differ significantly across the three stages of ripening. The levels of these two resorcinols were found to be strongly inter-correlated (P < 0.001, r2 = 0.71), with concentrations of 5-nheptadecenylresorcinol being an average 18 times higher than those of 5-npentadecylresorcinol. At the ‘eating ripe’ stage, significant relationships were observed between the concentrations of each type of alk(en)ylresorcinol and anthracnose lesion areas following postharvest inoculation, P<0.001, r2= 0.69 for 5-n pentadecylresorcinol, and P<0.001, r2= 0.44 for 5-n-heptadecenylresorcinol.

Sap properties and alk(en)ylresorcinol concentrations in Australian-grown mangoes.

Physical and chemical properties of sap and sap concentrations of constitutive alk(en)ylresorcinols were determined in several varieties of mango grown in different locations in Queensland, Australia, over two consecutive cropping seasons. Sap weight from individual fruit, sap pH, percentage of non-aqueous sap and concentrations of constitutive alk(en)ylresorcinols (5-n-heptadecenylresorcinol and 5-n-pentadecylresorcinol) in sap varied significantly among the varieties. 'Calypso', 'Keitt', 'Kensington Pride' and 'Celebration' had the greatest proportion of non-aqueous sap, whereas 'Nam Doc Mai' had the least. The highest concentrations of 5-n-heptadecenylresorcinol were found in the sap of 'Kensington Pride', and the lowest in 'Honey Gold' and 'Nam Doc Mai'. Highest concentrations of 5-n-pentadecylresorcinol were found in sap of 'Calypso' and 'Celebration', and the lowest levels were in 'Honey Gold' and 'Nam Doc Mai'. There was a direct relationship between the percentage of non-aqueous sap and the concentrations of alk(en)ylresorcinols (r(2) = 0.77 for 5-n-heptadecenylresorcinol, and r(2) = 0.87 for 5-n-pentadecylresorcinol). The alk(en)ylresorcinols were distributed mainly in the upper non-aqueous phase of 'Kensington Pride' sap. Growing location also had significant effects on the composition of mango sap but the effects appeared to be related to differences in maturity. Sap removal is necessary to prevent sapburn, but considerable quantities of alk(en)ylresorcinols that assist in protecting the harvested fruit from anthracnose disease are also removed.

Alk (en) ylresorcinol concentrations in'Kensington Pride'mango peel and antifungal activity against Colletotrichum gloeosporioides

Two preformed alk(en)ylresorcinols, 5-n-heptadecenylresorcinol and 5-n-pentadecylresorcinol, were identified in ‘Kensington Pride’ mango fruit peel. The alk(en)ylresorcinols had antifungal activity against C. gloeosporioides, as determined from thin layer chromatography bioassays. Soil-applied activators of plant defence (Acibenzolar at 150 mg L-1, and soluble potassium silicate at 200 and 1000 mg L-1) did not influence concentrations of 5-n-heptadecenylresorcinol or 5-n-pentadecyl¬resorcinol in mango peel when applied 2 months after fruit set and one month later. Concentrations of both alk(en)ylresorcinols were high 2 months after fruit set but levels declined by 50% within 1 month (2 months before commercial harvest) and did not change significantly from commercial harvest until eating-ripe.

Neoadjuvant crizotinib in advanced inflammatory myofibroblastic tumour with ALK gene rearrangement

Background Inflammatory myofibroblastic tumours (IMTs) are rare sarcomas that were first described in the lung. They are composed of myofibroblastic mesenchymal spindle cells accompanied by an inflammatory infiltrate of plasma cells. Complete resection is the treatment of choice. There is currently no standard treatment for inoperable or recurrent disease. Expression of ALK protein triggered by ALK gene rearrangement at chromosome 2p23 has been found in 36%-60% of IMTs. Case report We report a rapid early response to crizotinib as neoadjuvant therapy, enabling surgical excision of a large ALK-translocated IMT, which resulted in complete disease clearance. To the best of our knowledge, this is the first case in the literature of a patient with IMT in whom crizotinib was used successfully in the neoadjuvant or curative setting.

Spiroannulation of a cyclopentane ring. Synthesis of spiro[4.n](n+5)alk-2-en-1-ones

A methodology based on Claisen rearrangement-Wacker oxidation and intramolecular aldol condensation strategy starting from cyclic ketones leading to spiro[4.n](n+5)alk-2-en-1-ones has been developed. Thus one-pot Claisen rearrangement of the alkyl alcohols 6a-c furnished the aldehydes 8a-c, which on regiospecific oxidation using Wacker conditions generated the keto-aldehydes 9a-c. Finally, intramolecular aldol condensation transformed the keto-aldehydes 9a-c into spiroannulated products 10a-c.

New alk genes detected in Antarctic marine sediments

Alkane monooxygenases (Alk) are the key enzymes for alkane degradation. In order to understand the dispersion and diversity of alk genes in Antarctic marine environments, this study analysed by clone libraries the presence and diversity of alk genes (alkB and alkM) in sediments from Admiralty Bay, King George Island, Peninsula Antarctica. The results show a differential distribution of alk genes between the sites, and the predominant presence of new alk genes, mainly in the pristine site. Sequences presented 53.10-69.60% nucleotide identity and 50.90-73.40% amino acid identity to alkB genes described in Silicibacter pomeroyi, Gordonia sp., Prauserella rugosa, Nocardioides sp., Rhodococcus sp., Nocardia farcinica, Pseudomonas putida, Acidisphaera sp., Alcanivorax borkumensis, and alkM described in Acinetobacter sp. This is the first time that the gene alkM was detected and described in Antarctic marine environments. The presence of a range of previously undescribed alk genes indicates the need for further studies in this environment.

Enhanced antitumorigenic effects in glioblastoma on double targeting of pleiotrophin and its receptor ALK

In adults, glioblastomas are the most lethal and most frequent malignant brain tumors, and the poor prognosis despite aggressive treatment indicates the need to establish novel targets for molecular intervention. The secreted growth factor pleiotrophin (PTN, HB-GAM, HBNF, OSF-1) shows mitogenic, chemotactic, and transforming activity. Whereas PTN expression is tightly regulated during embryogenesis and is very limited in normal adult tissues, a marked PTN up-regulation is seen in tumors including glioblastomas. Likewise, the PTN receptor anaplastic lymphoma kinase (ALK) has been shown previously to be upregulated and functionally relevant in glioblastoma. In this study, we explore the antitumorigenic effects of the simultaneous ribozyme-mediated knockdown of both receptor and ligand. Various glioblastoma cell lines are analyzed for PTN and ALK expression. Beyond the individual efficacies of several specific ribozymes against PTN or ALK, respectively, antiproliferative and proapoptotic effects of a single gene targeting approach are strongly enhanced on double knockdown of both genes in vitro. More importantly, this results in the abolishment of tumor growth in an in vivo subcutaneous tumor xenograft model. Finally, the analysis of various downstream signaling pathways by antibody arrays reveals a distinct pattern of changes in the activation of signal transduction molecules on PTN/ALK double knockdown. Beyond the already known ones, it identifies additional pathways relevant for PTN/ALK signaling. We conclude that double targeting of PTN and ALK leads to enhanced antitumorigenic effects over single knockdown approaches, which offers novel therapeutic options owing to increased efficacy also after prolonged knockdown.

Kitab alhidayaḧ ili faraʾiṫs alḳulub = Sefer Torat Ḥovot ha-levavot /

"Die dritte, vierte und fünfte Pforte des Naturbetrachtung, des Gottesdienstes und des Gottvertrauens".

Euripidou Alkēstis = Euripidis Alcestis /

Includes bibliographical references and index.

A comparison of immunohistochemical assays and FISH in detecting the ALK translocation in diagnostic histological and cytological lung tumor material.

Introduction: Detection of the ALK rearrangement in a solid tumor gives these patients the option of crizotinib as an oral form of anticancer treatment. The current test of choice is fluorescence in situ hybridization (FISH), but various cheaper and more convenient immunohistochemical (IHC) assays have been proposed as alternatives. 
Methods: Fifteen FISH-positive cases from patients, seven with data on crizotinib therapy and clinical response, were evaluated for the presence of ALK protein using three different commercially available antibodies: D5F3, using the proprietary automated system (Ventana), ALK1 (Dako), and 5A4 (Abcam). A further 14 FISH-negative and three uncertain (<15% rearrangement detected) cases were also retrieved. Of the total 32 specimens, 17 were excisions and 15 were computed tomography-guided biopsies or cytological specimens. All three antibodies were applied to all cases. Antibodies were semiquantitatively scored on intensity, and the proportion of malignant cells stained was documented. Cutoffs were set by receiver operating curve analysis for positivity to optimize correct classification. 
Results: All three IHC assays were 100% specific but sensitivity did vary: D5F3 86%, ALK 79%, 5A4 71%. Intensity was the most discriminating measure overall, with a combination of proportion and intensity not improving the test. No FISH-negative IHC-positive cases were seen. Two FISH-positive cases were negative with all three IHC assays. One of these had been treated with crizotinib and had failed to show clinical response. The other harbored a second driving mutation in the EGFR gene.
Conclusions: IHC with all three antibodies is especially highly specific (100%) although variably sensitive (71%-86%), specifically in cases with scanty material. D5F3 assay was most sensitive in these latter cases. Occasional cases are IHC-positive but FISH-negative, suggesting either inaccuracy of one assay or occasional tumors with ALK rearrangement that do not express high levels of ALK protein.