Targeted treatment of ALK-rearranged advanced NSCLC
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摘要: 肺癌是目前世界范围内最常见的恶性肿瘤之一,其中80%以上为非小细胞肺癌,由于起病隐匿且缺乏特异性症状,多数患者诊断时已是晚期,放化疗及分子靶向治疗成为其主要的治疗手段。EML4-ALK融合基因是非小细胞肺癌的治疗靶点之一,它是通过细胞外配体结合区与胞内的酪氨酸激酶区结合,导致酪氨酸激酶激活并表达,从而获得致癌作用。ALK融合基因阳性肺癌占非小细胞肺癌总体的3%~5%,对ALK酪氨酸激酶抑制剂治疗有效。克唑替尼作为第一个用于治疗晚期ALK重排肺癌的药物,耐受良好,与传统化疗相比受益更大,提高客观缓解率,且改善患者的生活质量。二三代药物包括赛瑞替尼、艾乐替尼、布格替尼和劳拉替尼也取得可观的临床获益,与一代药物相比更具优势。随之而来的问题是ALK酪氨酸激酶抑制剂的耐药,包括固有耐药和获得性耐药,目前最常见的耐药机制是ALK基因的二次突变,L1196M突变和G1202R突变分别是克唑替尼和二代ALK抑制剂最常见的耐药突变。目前针对耐药发生后,首选的治疗措施是下一代ALK抑制剂,其他还包括与热休克蛋白90抑制剂或培美曲塞的联合治疗。充分了解耐药机制将有助于耐药后的个体化治疗。本文叙述了ALK阳性晚期非小细胞肺癌靶向治疗的关键临床试验,以及有关耐药诊治的相关进展。Abstract: Lung cancer is one of the most common malignant tumors in the world, more than 80% of whom are non-small cell lung cancer. Due to the insidious onset and lack of specific symptoms, most patients are diagnosed at an advanced stage, thus chemotherapy and molecular targeted therapy have become main treatment. The EML4-ALK fusion gene is one of the therapeutic targets for non-small cell lung cancer. It binds the intracellular tyrosine kinase domain to the extracellular ligand binding domain, resulting in the activation and expression of tyrosine kinase, toobtain carcinogenic effects. ALK fusion gene-positive lung cancer accounts for 3%-5% of non-small cell lung cancer and generally be in response to ALK tyrosine kinase inhibitors(TKIs). Crizotinib, as the first ALK inhibitors used in treatment of patients with advanced ALK-rearranged lung cancer, is well tolerated, benefits more than traditional chemotherapy, and improves objective response rateand quality of life. Ceritinib, alectinib, brigatinib, and lorlatinib also achieved considerable clinical benefit and were superior to crizotinib in clinical trials. The resistance of ALK inhibitors develops subsequently, including intrinsic resistance and acquired resistance, of which the most common mechanism is ALK-secondary mutations. The L1196 M mutation and the G1202 R mutation are the most common resistance mutations for crizotinib and second-generation ALK inhibitors, respectively. Currently, the first choice for drug resistance is the next-generation ALK inhibitors, and other treatments include combination with HSP90 inhibitor or pemetrexed. Fully understanding of the different mechanisms of resistance will help us to exploit personalized approaches overcoming resistance. This review aims to describe the key clinical trials of targeted therapy for ALK-positive advanced non-small cell lung cancer, and introduce advances in the diagnosis and treatments of drug resistance.
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Key words:
- Lung cancer /
- Non-small-cell lung cancer /
- ALK gene /
- Targeted therapy /
- Resistance
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