Single ALK 7%

Complex ALK 4%

ALK + others 11%

Others 30%

None 48%

None

Other mutations

Complex ALK

Single ALK

Efficacy of TKIs based on the ALK resistance mutations on amplicon-based liquid biopsy in ALK positive Non-Small Cell Lung Cancer (NSCLC) patients

L Mezquita1*, A Swalduz2*, C Jovelet1, S Ortiz-Cuaran2, D Planchard1, G Recondo3, JC Benitez1, K Howarth4, F de Kievit4, C Morris4, E Green4, L Lacroix5, L Odier6, E Rouleau5, P Fournel7,

C Caramella8, C Tissot9, C Nicotra10, M Pérol2, C Massard10, L Friboulet3, B Besse1+, P Saintigny2+

* L.M. and A.S. and + P.S. and B.B. contributed equally to this work. 1 Medical Oncology Department, Gustave Roussy, Villejuif, France; 2 Medical Oncology Department, Centre Léon Bérard Lyon,France ; 3 INSERM U981, Gustave Roussy, Université Paris Saclay, Villejuif, France; 4 Inivata, Cambridge UK, Cambridge/United Kingdom; 5 Biopathology Department, Gustave Roussy, Villejuif, France ; 6 Department of Pneumology, Hôpital Nord-Ouest Villefranche, Villefranche Sur Saône/France; 7 Department of Medical Oncology, Institut de Cancérologie de la Loire, St. Priest En Jarez/France ; 8 Radiology Department, Gustave Roussy, Villejuif, France; 9 Department of Pneumonology and Thoracic Oncology,

CHU Nord Saint-Etienne, Saint-Priest-en-Jarez/France; 10 Early Drug Development Department, Gustave Roussy, Villejuif, France.

§  Acquired ALK resistance mutations (mut.) are the main mechanism of tyrosine kinase inhibitor (TKI) resistance (30-50%)

§  While next-generation TKIs are more active on mut. than earlier TKIs, compound ALK resistance are associated with failure to next-generation TKIs

§  Advanced ALK NSCLC patients were prospectively enrolled from October 2015 to April 2018 across 9 French institutions

§  All patients were ALK positive by an approved molecular diagnostic test: immunochemistry (IHC) or Fluorescent In Situ Hybridization (FISH) using dual-color break-apart rearrangement probes and/or other validated test

§  ctDNA molecular analysis was performed using amplicon-based NGS (InVision® liquid biopsy platform, InVisionFirst®-Lung) for ALK (EML4 variants v1, v2, v3), ROS1 (CD74, SLC34A2, SDC4 and EZR) fusions, and other somatic mutations

§  A total of 20 to 30 ml of blood were collected in Streck BCT or EDTA tubes and processed for DNA extraction

§  Correlation with clinical outcomes: overall survival (OS) and progression-free survival (PFS) to the current and subsequent TKIs

§  ctDNA genomic alterations were stratified as: -  Negative ctDNA, if no mutation detected -  ALK mut. group:

ü  Single ALK mut., if one ctDNA ALK mut. ü  Complex ALK mut., if ≥ 2 ctDNA ALK mut.

-  Other mut.: if ctDNA non-ALK mut.

INTRODUCTION

©2018 Inivata Ltd. ©2018 Inivata Ltd.

REFERENCES 1. Gainor JF, Dardaei L, Yoda S, Friboulet L, Leshchiner I, Katayama R, et al. Molecular Mechanisms of Resistance to First- and Second-Generation ALK Inhibitors in ALK-Rearranged Lung Cancer. Cancer Discov. 2016 Jul 18;

2. Yoda S, Lin JJ, Lawrence MS, Burke BJ, Friboulet L, Langenbucher A, et al. Sequential ALK Inhibitors Can Select for Lorlatinib-Resistant Compound ALK Mutations in ALK-Positive Lung Cancer. Cancer Discov. 2018 Jun;8(6):714–29. 3. J Remon, L Lacroix, C Jovelet, C Caramella, et al. Real-World Utility of an Amplicon-Based Next-Generation Sequencing Liquid Biopsy for Broad Molecular Profiling in Patients With Advanced Non–Small-Cell Lung Cancer. JCO Precision Oncology 2019 :3, 1-14

Figure 1. The InVisionFirst™-Lung assay identifies SNVs, indels, CNVs and gene fusions with whole gene and gene hotspots, using an amplicon-based technology to selectively amplify genomic breakpoints. The sequence of the junctions are then identified using NGS, allowing the genomic breakpoint in ctDNA to be mapped4

Poster Board Number: P.47 (Abstract 3055)

§  We evaluated the clinical utility of detecting ALK resistance mut. in blood (ctDNA) to predict TKI efficacy

METHODS

RESULTS

CONCLUSIONS

§  101 ALK positive patients were enrolled in the study, with 328 blood samples collected. Of these, 74 samples were at progression (PD) to TKIs, from 55 patients)

§  Routine liquid biopsies can assess the heterogeneity of the TKI resistance, detecting ALK resistance and other acquired mutations in pretreated advanced ALK positive NSCLC patients

§  The absence of ctDNA mutations at TKI failure was associated with prolonged OS, whereas complex ALK mutations at TKI failure may predict resistance to subsequent therapy

§  These results will be validated in a larger cohort in the future

Table 1. Baseline characteristics of patients at PD to TKI therapy

§  Median follow-up (FU) from 1st liquid biopsy was 9.9 mo. [95%CI, 1.0-30.1]. The median PFS to the therapy to which the patients progressed (“current” therapy) was 9.6 mo [95%CI, 7.9-11.8]

§  No differences were observed in PFS to current therapy by ctDNA mutations detected (P=0.31)

Figure 2. Distribution of ctDNA mutations at PD

§  The median PFS to the subsequent therapy was 7.3 mo. [95%CI, 4.6-20.7]

§  The ALK complex mut. group had median PFS of 1.7 mo. [95% CI, 0.9-NR] vs. 6.3 mo. [95% CI, 1.8-NR] in the ALK single mut. group (P=0.003)

§  In the 4 cases with emergence of ALKG1202R PFS to the sequential therapy was 3.7 mo. [95% CI, 1.2-NR]

OBJECTIVE

PFS, CURRENT therapy based on ctDNA ALK mut.

Figure 5. OS according the presence of ctDNA ALK resistance mut.

N=8 N=1

N=1

N=1

OVERALL SURVIVAL (OS) by ctDNA resistance mutations PFS, SUBSEQUENT therapy based on ctDNA ALK mut.

0

10

20

30

40

50

60

70

80

90

100

Crizotinib 2nd gen TKI Next-gen TKI

None Others ALK + others Complex ALK Single ALK

Figure 3. Distribution of ctDNA mutations at PD according to the previous TKI

§  Higher incidence of ALK mut. after 3rd -gen TKI (43%) vs. 2nd-gen (29%) vs. crizotinib (11%)

None

ALK mutation

Other mutations

Single ALK 7%

Complex ALK 4%

NFE2L2 + NFE2L2 + NFE2L2 + NFE2L2 +

Complex ALK 1%

TP53+ TP53 + TP53 + Complex ALK

1%

TP53 + Complex ALK 1%

TP53 + MYC + Complex ALK 1%

TP53 + Complex ALK 1%

TP53 + Single ALK 3%

TP53+KRAS+PI3KCA 1%

TP53+PTEN+PI3KCA 3%

TP53 + MYC 1%

TP53+STK11 1%

TP53 19%

GNAS 1%

CKN2A 1%

MET 1%

None 49%

Table 4. Clinical efficacy of TKIs according to the ALK resistance mutations in blood. Green: mPFS to subsequent therapy ≥ 6 mo.; orange: mPFS between 3-6 mo.; red: mPFS < 3 mo.;

✓ : patient has previously received this TKI; ** : de novo mutations (in blood); - fusion not detected/not tested.

ALK & non- ALK mutations

§  The median OS from 1st line beginning was 100.4 months (mo.) [95% CI 51.3-not reached-NR-]

§  The median OS was 105 mo. [95%CI 105.7-NR] if negative ctDNA vs. 58.5 mo. [95%CI 26.9-NR] if ≥1 ALK mut.(s) vs. 44.1 mo. [95%CI 21.7-NR] if non-ALK mut.

§  This effect was observed regardless of the number of lines of TKI received (P=0.01)

§  The presence of complex ALK mut. was associated with poor OS [median 26.9 mo.; (95% CI13.9-NR)] compared to single ALK mut. [median NR; (95% CI 57.0-NR)] (P=0.003)

§  74 samples were collected at PD to TKIs

§  ALK mut. in 22% (16/74)

ü  9, ALK single mut. -  5 ALK mut. only -  4 ALK mut. + others

ü  7, ALK complex mut. -  3 complex ALK only -  4 complex ALK + others

N=16 N=31 N=7

Figure 4: Distribution of ctDNA non- ALK mutations and at PD to TKIs.

N=55 patients (74 samples)

P=0.009  

P=0.003  

OS

OS

Median PFS to current therapy

All population 9.6 mo. [95%CI 7.9-11.8]

Negative ctDNA 14.8 mo. [95% CI, 8.1-23.1]

≥1 ALK mut. 9.6 mo. [95% CI, 6.6-19.9]

Non-ALK mut. (other) 7.8 mo. [95% CI, 4.5-11.7] Table 3:

Progression-free survival to current TKI therapy (n=74 samples)

§  We explored it specifically in the subgroup with ctDNA ALK mut. (n=16 samples)

 

laura.mezquita@gustaveroussy.fr

ctDNA mutations

Time point ctDNA mutations

ctDNA mutations

De novo ALK mutations*

N#1 CTC925

Post CRIZOTINIB

Single ALK* ALKL1196M TP53

ALKL1196M

N#2 G-A-01-034

Post ALECTINIB

Single ALK* ALKC1156Y ALKC1156Y

N#3 CTC534

Post CERITINIB

Single ALK ALKT1151R TP53

NA

N#4 R-C-01-020

Single ALK ALKF1174L NA

N#5 CTC435

Single ALK ALKG1202R NA

N#6 L-Y-01-045

Post BRIGATINIB

Single ALK ALKF1174V NA

N#7 B-B-01-127

Single ALK* ALKR1192P TP53

ALKR1192P

N#8 CTC861

Single ALK ALKG1202R

-

N#9 CTC1342

Single ALK* ALKG1202R TP53

ALKG1202R

N#10 CTC861

Post CRIZOTINIB

Complex ALK* ALKG1202R ALKI1268V

ALKG1202R ALKI1268V

N#11 B-B-01-127

Complex ALK* ALKL1196M ALKC1156Y

TP53

ALKL1196M ALKC1156Y

N#12

CTC1105

Complex ALK*

ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K NFE2L2(x4)

ALKF1174L ALKF1174L ALKL1196Q ALKC1156Y ALKG1269A ALKR1264K

N#13

R-C-01-020 Post

BRIGATINIB

Complex ALK*

ALKG1202R ALKF1174L

TP53

ALKG1202R

N#14 R-C-01-020

Post LORLATINIB

Complex ALK ALKG1202R ALKF1174L

-

N#15 CTC861

Complex ALK*

ALKG1202R ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M

ALKF1174L ALKC1156Y ALKG1269A ALKS1206F ALKT1151M

N#16 L-Y-01-045

Complex ALK*

ALKF1174V ALKL1198F

TP53 MYC

ALKL1198F

!

Table 2: Distribution of ctDNA ALK mut. at PD to TKIs (n=16)

Characteristics Patients included, N=55 (%)

Age, Median (year-old), range 56 (20-82) Sex Female

29 (53%) Smoking status Never Smoker

30 (55%) 23 (42%)

Histology Adenocarcinoma

54 (98%) Stage at diagnosis I-IIIA IIIB-IV

2 (4%) 53 (96%)

Brain metastasis at baseline 19 (36%) Molecular diagnosis FISH (+) IHC (+) Other (+)

34 (49%) 34 (49%)

1 N# prior systemic lines at inclusion Median, range

3 (1-8)

Patients

PD Sites

Variant

Time point

ALK resistance

mutations

ALK

G1202R

Crizotinib

Alectinib

Ceritinib

Brigatinib

Lorlatinib

Chemo

CTC861 Liver

V3

Post CRIZOTINIB

Complex ALK**

G1202R ✓

- - -

-

CTC 1105 Bone

V3

Complex ALK**

✓ - - -

-

BB 01-127 Adrenal Brain, Liver

V2

Complex ALK**

✓ - - -

-

RC01-020 Brain Bone

- Post BRIGATINIB

Complex ALK**

G1202R ✓ - ✓ ✓

-

LY 01-045 Brain, Lung, Nodal, Pleural

-

Post LORLATINIB

Complex ALK**

✓ - ✓ ✓ ✓

RC01-020 Brain - Complex ALK

G1202R ✓ - ✓ ✓ ✓

CTC861 Liver V3

Complex ALK

G1202R ✓ - ✓ ✓ ✓

CTC 925 Nodal

-

Post CRIZOTINIB

Single ALK**

✓ - - - -

CTC 435 Pleural

V3

Post CERITINIB

Single ALK

G1202R ✓

- ✓ - -

CTC 534 Liver - Single ALK ✓ - ✓

-

-

RC01-020 Brain - Single ALK ✓ - ✓

-

-

GA 01-034 Brain - Post ALECTINIB

Single ALK ** ✓ ✓ - - -

LY 01-045 Brain, Lung, Nodal

-

Post BRIGATINIB

Single ALK

✓ - ✓ ✓

-

CTC861 Liver

V3

Single ALK **

G1202R ✓ - ✓ ✓ -

CTC 1342 Bone

V3

Single ALK **

G1202R ✓

- ✓ ✓

-

BB 01-127 Brain Liver

V2

Single ALK **

✓ - ✓ ✓

-

!

3rd-gen TKI

N=56 samples