Cited by 164Protein Kinase Regulation and GTPase SignalingMelanoma and MAPK PathwaysProtein Tyrosine Phosphatases

The DOI matches its Crossref record; 184 of the 185 references it cites were found in a registry or an index; 11 of the 93 sources its claims cite were checked for support.

Drugging KRAS: current perspectives and state-of-art review

Open access

Abstract

After decades of efforts, we have recently made progress into targeting KRAS mutations in several malignancies. Known as the ‘holy grail’ of targeted cancer therapies, KRAS is the most frequently mutated oncogene in human malignancies. Under normal conditions, KRAS shuttles between the GDP-bound ‘off’ state and the GTP-bound ‘on’ state. Mutant KRAS is constitutively activated and leads to persistent downstream signaling and oncogenesis. In 2013, improved understanding of KRAS biology and newer drug designing technologies led to the crucial discovery of a cysteine drug-binding pocket in GDP-bound mutant KRAS G12C protein. Covalent inhibitors that block mutant KRAS G12C were successfully developed and sotorasib was the first KRAS G12C inhibitor to be approved, with several more in the pipeline. Simultaneously, effects of KRAS mutations on tumour microenvironment were also discovered, partly owing to the universal use of immune checkpoint inhibitors. In this review, we discuss the discovery, biology, and function of KRAS in human malignancies. We also discuss the relationship between KRAS mutations and the tumour microenvironment, and therapeutic strategies to target KRAS. Finally, we review the current clinical evidence and ongoing clinical trials of novel agents targeting KRAS and shine light on resistance pathways known so far.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review summarizes KRAS biology, oncogenic mutations, tumor microenvironment effects, and therapeutic strategies, focusing on the clinical development of KRAS G12C inhibitors sotorasib and adagrasib. It highlights modest single-agent efficacy in NSCLC, tissue-specific differences, emerging resistance mechanisms, and investigational agents for non-G12C KRAS mutations.

Key findings

  • KRAS is the most frequently mutated oncogene in human malignancies, seen in 1 in 7 cancers; incidence is highest in pancreatic cancer (>85%), followed by colorectal cancer (~40%), NSCLC (~30%), and cholangiocarcinoma (~20%). G12C is the commonest KRAS mutation in NSCLC (~14% of lung adenocarcinomas), while G12D and G12V predominate in pancreatic and colorectal cancers.
  • In phase II CodeBreaK100, sotorasib 960 mg daily in KRAS G12C NSCLC (n=126) produced an ORR of 37.1%, median PFS of 6.8 months, and median OS of 12.5 months. Phase III CodeBreaK200 showed PFS of 5.6 vs 4.5 months with docetaxel (HR 0.66, 95% CI 0.51–0.86; p=0.002) but no OS benefit (10.6 vs 11.3 months; HR 1.01, 95% CI 0.77–1.33; p=0.53).
  • In phase II KRYSTAL-1, adagrasib 600 mg twice daily in KRAS G12C NSCLC (n=116) produced an ORR of 42.9%, median PFS of 6.5 months, and median OS of 12.6 months; intracranial confirmed ORR was 33.3% (95% CI 18.0–51.8) among 33 patients with previously treated, stable CNS metastases.
  • Acquired resistance to adagrasib monotherapy was identified in 45% of 38 patients; 88% of resistance mechanisms involved RAS-MAPK reactivation, including KRAS switch-II pocket mutations and alternate KRAS activating mutations. Co-mutations in STK11/KEAP1 reduced ORR to sotorasib and adagrasib (e.g., KEAP1-mut/STK11-wt ORR 14% and 14.3%, respectively).

Methods

  • Design: narrative review covering KRAS discovery, biology, signaling pathways, tumor microenvironment, and therapeutic targeting.
  • Data/sample: published literature, preclinical studies, and clinical trial data; includes a table of KRAS mutation incidence across aerodigestive malignancies extracted using cBioPortal.
  • Analysis: narrative synthesis of clinical evidence and ongoing trials; no systematic search strategy or meta-analytic methods are described.

Limitations

  • The paper does not explicitly state limitations of the review itself. It notes trial limitations: CodeBreaK200 was underpowered for OS and OS data were immature; some subgroup analyses had limited sample size (e.g., PD-L1 high n=9).
  • Evident from the text: this is a narrative review without a described systematic search strategy, inclusion criteria, or formal risk-of-bias assessment.
  • Evident from the text: conclusions rely heavily on single-arm phase I/II trials and preclinical data, with limited randomized phase III evidence at the time of writing.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s13045-022-01375-4

Cites

184 of 184 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Fig. 1 Timeline of KRAS discovery
Fig. 1 Timeline of KRAS discoveryCC BY · PubMed Central
Fig. 2 KRAS gene and mutational hotspots
Fig. 2 KRAS gene and mutational hotspotsCC BY · PubMed Central
Fig. 3 KRAS signaling pathways with targeting drugs
Fig. 3 KRAS signaling pathways with targeting drugsCC BY · PubMed Central
Fig. 4 KRAS incidence across aerodigestive malignancies
Fig. 4 KRAS incidence across aerodigestive malignanciesCC BY · PubMed Central
Fig. 5 KRAS G12C structure with S-IIP inhibitor in place
Fig. 5 KRAS G12C structure with S-IIP inhibitor in placeCC BY · PubMed Central
Fig. 6 Resistance mechanisms to sotorasib and adagrasib
Fig. 6 Resistance mechanisms to sotorasib and adagrasibCC BY · PubMed Central

Verification

Claims the paper makes

70 Not checked yet · 6 Partly supported · 5 Own interpretation · 2 Supported · 2 No basis given · 1 Mixed support · accuracy not yet measured

Verify all 82 references — free account

Show all 35 claims

  • It may state two separate claims as one. 45
  • Probably not a substantial claim. 7
51 of 51
  • The paper relies on this without support.

    KRAS requires localization to the cell membrane for its activity and downstream signaling.

    “KRAS monomers require localization to the cell membrane for their activity.”
    “Since membrane localization of KRAS is essential for its downstream signaling, blocking it appeared a sound rationale for inhibition of mutant KRAS.”
  • The paper relies on this without support.

    Cysteine is the most reactive amino acid.

    “Cysteine is the most reactive amino acid, and experiences with agents such as ibrutinib and dacomitinib have shown that active cysteine acts as a nucleophile to form covalent bonds with these agents [85, 86].”
  • The paper relies on this without support.

    Preclinical findings in mouse models and cell lines are predictive of clinical efficacy and resistance in patients.

    “These results mirror those seen in preclinical mouse models; adagrasib has also demonstrated efficacy in intracranial xenograft mouse models.”
  • The paper relies on this without support.

    Immunotherapy and combination chemotherapy and immunotherapy remain the standard of care for patients with metastatic KRAS-mutant NSCLC.

    “As we await results of studies using KRAS inhibitors in the first line of treatment, immunotherapy and combination of chemotherapy and immunotherapy remain the standard of care for patients with metastatic KRAS-mutant NSCLC.”
4 of 4

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Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

5 of 5

Citations

Cites

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Metadata

Authors
Parikh, K., Banna, G., Liu, S. V., Friedlaender, A., Desai, A., Subbiah, V., & Addeo, A.
Affiliations
  • Mayo Clinic (US)
  • Portsmouth Hospitals NHS Trust (GB)
  • Georgetown University (US)
  • Générale-Beaulieu Clinic (CH)
  • The University of Texas MD Anderson Cancer Center (US)
  • University Hospital of Geneva (CH)
Corresponding author
Addeo, Alfredo
Venue
Journal of Hematology & Oncology
Published
2022-10-25
Volume
15
Issue
1
Pages
152-152
ISSN
1756-8722 (ISSN-L)
OpenAlex
W4307201601
Cited by
164
References
185
Citations by year
2026: 38 · 2025: 55 · 2024: 43 · 2023: 27 · 2022: 1
FWCI
3.28
Type
journal article
Language
en
Open access
Locations
  • Journal of Hematology & Oncology (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Protein Kinase Regulation and GTPase Signaling
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Melanoma and MAPK Pathways
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Protein Tyrosine Phosphatases
Keywords
KRAS, KRAS G12C, KRAS inhibitors, sotorasib, covalent inhibitors, tumor microenvironment, immune checkpoint inhibitors, drug resistance, oncogenes, targeted cancer therapy, clinical trials
MeSH terms
Immune Checkpoint Inhibitors, Antineoplastic Agents, Cysteine, Guanosine Triphosphate, Humans, Mutation, Neoplasms, Proto-Oncogene Proteins p21(ras), Tumor Microenvironment

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