Spectrum of Mechanisms of Resistance to Crizotinib and Lorlatinib in ROS1 Fusion–Positive Lung Cancer
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Abstract
Purpose: Current standard initial therapy for advanced, ROS proto-oncogene 1, receptor tyrosine kinase fusion (ROS1)-positive (ROS1+) non–small cell lung cancer (NSCLC) is crizotinib or entrectinib. Lorlatinib, a next-generation anaplastic lymphoma kinase/ROS1 inhibitor, recently demonstrated efficacy in ROS1+ NSCLC, including in crizotinib-pretreated patients. However, mechanisms of lorlatinib resistance in ROS1+ disease remain poorly understood. Here, we assessed mechanisms of resistance to crizotinib and lorlatinib. Experimental Design: Biopsies from patients with ROS1+ NSCLC progressing on crizotinib or lorlatinib were profiled by genetic sequencing. Results: From 55 patients, 47 post-crizotinib and 32 post-lorlatinib biopsies were assessed. Among 42 post-crizotinib and 28 post-lorlatinib biopsies analyzed at distinct timepoints, ROS1 mutations were identified in 38% and 46%, respectively. ROS1 G2032R was the most commonly occurring mutation in approximately one third of cases. Additional ROS1 mutations included D2033N (2.4%) and S1986F (2.4%) post-crizotinib and L2086F (3.6%), G2032R/L2086F (3.6%), G2032R/S1986F/L2086F (3.6%), and S1986F/L2000V (3.6%) post-lorlatinib. Structural modeling predicted ROS1L2086F causes steric interference to lorlatinib, crizotinib, and entrectinib, while it may accommodate cabozantinib. In Ba/F3 models, ROS1L2086F, ROS1G2032R/L2086F, and ROS1S1986F/G2032R/L2086F were refractory to lorlatinib but sensitive to cabozantinib. A patient with disease progression on crizotinib and lorlatinib and ROS1 L2086F received cabozantinib for nearly 11 months with disease control. Among lorlatinib-resistant biopsies, we also identified MET amplification (4%), KRAS G12C (4%), KRAS amplification (4%), NRAS mutation (4%), and MAP2K1 mutation (4%). Conclusions: ROS1 mutations mediate resistance to crizotinib and lorlatinib in more than one third of cases, underscoring the importance of developing next-generation ROS1 inhibitors with potency against these mutations, including G2032R and L2086F. Continued efforts are needed to elucidate ROS1-independent resistance mechanisms.
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Entrectinib was designed to cross the blood-brain barrier, but overall responses were marginal in patients with previous CNS progression (IC-ORR: 11%) and against G2032R.
“Entrectinib was designed to cross the blood-brain barrier, but overall responses were marginal in patients with previous CNS progression (intracranial [IC]-ORR: 11%) and against the most common acquired resistance mutation after crizotinib treatment, G2032R, which occurs in 30% to 40% of patients.8,14,15”
From Taletrectinib in <i>ROS1</i> + Non–Small Cell Lung Cancer: TRUST (2025) · cites this paper as [14]
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Self-citation
- Authors
- Lin, J. J., Choudhury, N. J., Yoda, S., Zhu, V. W., Johnson, T. W., Sakhtemani, R., Dagogo-Jack, I., Digumarthy, S. R., Lee, C., Do, A., Peterson, J., Prutisto-Chang, K., Malik, W., Hubbeling, H. G., Langenbucher, A., Schoenfeld, A. J., Falcon, C. J., Temel, J. S., Sequist, L. V., Yeap, B. Y., Lennerz, J. K., Shaw, A. T., Lawrence, M. S., Ou, S.-H. I., Hata, A. N., Drilon, A., & Gainor, J. F.
- Affiliations
- Harvard University (US)
- Memorial Sloan Kettering Cancer Center (US)
- University of California, Irvine (US)
- Pfizer (United States) (US)
- 1Department of Medicine, Massachusetts General Hospital Cancer Center, Boston, Massachusetts.
- Massachusetts General Hospital (US)
- Corresponding author
- Gainor, Justin F.
- ORCID
- Lin, Jessica J.
- Choudhury, Noura J.
- Yoda, Satoshi
- Zhu, Viola W.
- Johnson, Ted W.
- Sakhtemani, Ramin
- Digumarthy, Subba R.
- Lee, Charlotte
- Do, Andrew
- Prutisto-Chang, Kylie
- Malik, Wafa
- Hubbeling, Harper G.
- Langenbucher, Adam
- Schoenfeld, Adam J.
- Falcon, Christina J.
- Temel, Jennifer S.
- Sequist, Lecia V.
- Yeap, Beow Y.
- Lennerz, Jochen K.
- Shaw, Alice T.
- Lawrence, Michael S.
- Ou, Sai-Hong Ignatius
- Hata, Aaron N.
- Drilon, Alexander
- Gainor, Justin F.
- Venue
- Clinical Cancer Research
- Published
- 2021-03-08
- Volume
- 27
- Issue
- 10
- Pages
- 2899-2909
- ISSN
- 1078-0432 (ISSN-L)
- 1557-3265
- PMC
- PMC8127383
- OpenAlex
- W3134566625
- Cited by
- 145
- References
- 46
- Citations by year
- 2026: 18 · 2025: 34 · 2024: 34 · 2023: 25 · 2022: 30 · 2021: 4
- FWCI
- 15.08
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Clinical Cancer Research (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Lung Cancer Research Foundation (R01-CA164273)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Lung Cancer Treatments and Mutations
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Cancer Research › Cancer Genomics and Diagnostics
- Health Sciences › Medicine › Oncology › Lung Cancer Research Studies
- Keywords
- crizotinib resistance, lorlatinib resistance, ROS1 mutation, cabozantinib, ALK inhibitors, drug resistance mechanisms
- MeSH terms
- Crizotinib, Adult, Aged, Aged, 80 and over, Alleles, Aminopyridines, Antigens, Differentiation, B-Lymphocyte, Histocompatibility Antigens Class II, Biopsy, Female, Humans, Lactams, Lung Neoplasms, Male, Middle Aged, Models, Molecular, Mutation, Protein-Tyrosine Kinases, Proto-Oncogene Proteins, Pyrazoles, Structure-Activity Relationship, Oncogene Proteins, Fusion, Drug Resistance, Neoplasm, Amino Acid Substitution, Cell Line, Tumor, Protein Kinase Inhibitors, Young Adult
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