Journal of Thoracic Oncology:
Lung Adenocarcinoma with Concurrent Exon 19 EGFR Mutation and ALK Rearrangement Responding to Erlotinib
Popat, Sanjay MRCP, PhD*†; Vieira de Araújo, Alexandra MD‡; Min, Toon PhD*; Swansbury, John FRCPath*; Dainton, Melissa BSc*; Wotherspoon, Andrew FRCPath*; Lim, Eric MD, FRCS§; Nicholson, Andrew G. FRCPath†§; O'Brien, Mary E. R. MD, FRCP*
*Royal Marsden Hospital, London and Surrey, United Kingdom; †National Heart and Lung Institute, Imperial College London, London, United Kingdom; ‡Portuguese Institute of Oncology, Oporto, Portugal; and §Royal Brompton Hospital, London, United Kingdom.
Disclosure: Sanjay Popat, MRCP, PhD, and Mary E.R. O'Brien, MD, FRCP, have received research funds and honoraria from Roche.
Address for correspondence: Sanjay Popat, Royal Marsden Hospital, London, SW3 6JJ, UK. E-mail: firstname.lastname@example.org
Sanjay Popat is a recipient of a Clinical Senior Lecturer Award from the Higher Education Funding Council for England.
A 65-year-old Caucasian female never-smoker (<100 lifetime cigarettes) was found to have elevated carcinoembryonic antigen (CEA) after protracted gastrointestinal symptoms and underwent right lower lobectomy with systematic nodal dissection and pleural lavage for an asymptomatic 58-mm moderately differentiated TTF1-positive lung adenocarcinoma with acinar pattern and nodal metastasis (pT2N2M0, stage IIIA). CEA normalized after surgery and she completed four cycles of adjuvant carboplatin and vinorelbine without major toxicities. Nine months after surgery, she developed a new 1.3-cm right upper lobe nodule and right hilar nodes with elevated CEA. Genotyping identified KRAS wild-type and EGFR exon 19 deletion in the primary tumor. She commenced systemic treatment with erlotinib at 150 mg daily and continued on this for 25 months with normalized CEA levels and a complete metabolic response on positron emission tomography-computed tomography (Figure 1). ALK rearrangement tested by fluorescence in situ hybridization (FISH) using the commercially available break-apart probe set (Abbott Molecular, Des Plaines, IL) demonstrated loss of the ALK 5′ (centromeric) probe (Figure 2A). ALK immunohistochemistry (clone ALK1, Dako UK Ltd, DM828) was negative (Figure 2B).
Four previous cases have been described of lung adenocarcinomas with concurrent EGFR mutation and ALK translocation. Two are described in series for prevalence analysis with scarce clinical information.1,2 The remaining two are case reports detailing a 72-year-old East Asian woman (with adenocarcinoma treated with first-line gefitinib for 232 days with an initial excellent response, before progression),3 and a 48-year-old Caucasian man (mixed adenosquamous carcinoma treated with second-line erlotinib for 2 months, before dying from disease progression).4 All had classical ALK translocations with probe break-apart. In all cases, the EGFR mutation was an exon 19 deletion.
ALK rearrangement is considered a potential resistance mechanism to EGFR-tyrosine kinase inhibitors (TKIs)1 and is thought to occur mutually exclusively to other somatic mutations. Of the three patients (including our own) harboring simultaneous EGFR and ALK molecular aberration in which outcome data are reported, one was refractory to EGFR-TKI treatment but had mixed squamous/adenocarcinoma histology,4 while the other two (both older and female) demonstrated very good responses. To our knowledge, our patient presents the most durable response to an EGFR-TKI in this setting and is the first such case with an ALK rearrangement characterized by an isolated 3′ FISH signal. In addition, this case demonstrates no ALK expression by immunohistochemistry. Whether this is due to aberrant expression due to ALK 5′ loss or another mechanism such as variability in expression detection due to differences in antibody clone used5 remains unclear.
Concurrent EGFR mutation and ALK rearrangement remain rare. However, future larger planned collaborative group studies will inform better on clinical and molecular demographics of ALK rearrangement. Our case suggests that EGFR mutation when concordant with ALK rearrangement retains TKI sensitivity and that a common molecular event may underpin both exon 19 EGFR deletion and ALK rearrangement.
Sanjay Popat, MRCP, PhD, Toon Min, PhD, John Swansbury, FRCPath, Melissa Dainton, BSc, and Andrew Wotherspoon, FRCPath, acknowledge NHS funding to the Royal Marsden Hospital/Institute of Cancer Research NIHR Biomedical Research Centre.
1. 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
2. Zhang X, Zhang S, Yang X, et al. Fusion of EML4 and ALK is associated with development of lung adenocarcinomas lacking EGFR and KRAS mutations and is correlated with ALK expression. Mol Cancer
3. Kuo YW, Wu SG, Ho CC, et al. Good response to gefitinib in lung adenocarcinoma harboring coexisting EML4-ALK fusion gene and EGFR mutation. J Thorac Oncol
4. Tiseo M, Gelsomino F, Boggiani D, et al. EGFR and EML4-ALK gene mutations in NSCLC: a case report of erlotinib-resistant patient with both concomitant mutations. Lung Cancer
5. Camidge DR, Hirsch FR, Varella-Garcia M, et al. Finding ALK-positive lung cancer: what are we really looking for? J Thorac Oncol
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