Abstract

One strategy for combating cancer-drug resistance is to deploy rational polytherapy up front that suppresses the survival and emergence of resistant tumor cells. Here we demonstrate in models of lung adenocarcinoma harboring the oncogenic fusion of ALK and EML4 that the GTPase RAS–mitogen-activated protein kinase (MAPK) pathway, but not other known ALK effectors, is required for tumor-cell survival. EML4-ALK activated RAS-MAPK signaling by engaging all three major RAS isoforms through the HELP domain of EML4. Reactivation of the MAPK pathway via either a gain in the number of copies of the gene encoding wild-type K-RAS (KRASWT) or decreased expression of the MAPK phosphatase DUSP6 promoted resistance to ALK inhibitors in vitro, and each was associated with resistance to ALK inhibitors in individuals with EML4-ALK–positive lung adenocarcinoma. Upfront inhibition of both ALK and the kinase MEK enhanced both the magnitude and duration of the initial response in preclinical models of EML4-ALK lung adenocarcinoma. Our findings identify RAS-MAPK dependence as a hallmark of EML4-ALK lung adenocarcinoma and provide a rationale for the upfront inhibition of both ALK and MEK to forestall resistance and improve patient outcomes.

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Acknowledgements

We thank M. McMahon, F. McCormick, K. Shannon and M. Von Zastrow (UCSF) for advice and discussions, and H. Mano (University of Tokyo) for EML4-ALK cDNA constructs and for advice. We acknowledge funding support from the following sources: a US National Institute of Health (NIH) Director's New Innovator Award, the Howard Hughes Medical Institute, the Doris Duke Charitable Foundation, the American Lung Association, the National Lung Cancer Partnership, the Sidney Kimmel Foundation for Cancer Research and the Searle Scholars Program (T.G.B.); the UCSF Clinical and Translational Science Institute (G.H.); the National Cancer Institute (NCI) of the NIH (R01CA121210 and P01CA129243), a Damon Runyon Clinical Investigator Award and a LUNGevity Career Development Award (C.M.L.); the NIH (NCI5K12CA086913) (R.C.D.); an NIH Paul Calabresi Cancer Development Award in Clinical Oncology (K12CA138464) (J.W.R.); the NIH (NCI-P30CA046934) and Lung Cancer SPORE (NCI-P50CA058187) (M.V.G.); and the La Caixa Foundation and Redes Temáticas de Investigación en Cáncer (RD12/0036/0072) (R.R.).

Author information

Affiliations

  1. Department of Medicine, University of California at San Francisco, San Francisco, California, USA.

    • Gorjan Hrustanovic
    • , Victor Olivas
    • , Evangelos Pazarentzos
    • , Asmin Tulpule
    • , Saurabh Asthana
    • , Collin M Blakely
    • , Ross A Okimoto
    • , Luping Lin
    • , Dana S Neel
    • , Amit Sabnis
    • , Jennifer Flanagan
    • , Elton Chan
    • , Eric A Collisson
    •  & Trever G Bivona
  2. Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, San Francisco, California, USA.

    • Gorjan Hrustanovic
    • , Victor Olivas
    • , Evangelos Pazarentzos
    • , Asmin Tulpule
    • , Saurabh Asthana
    • , Collin M Blakely
    • , Ross A Okimoto
    • , Luping Lin
    • , Dana S Neel
    • , Amit Sabnis
    • , Jennifer Flanagan
    • , Elton Chan
    • , Eric A Collisson
    •  & Trever G Bivona
  3. Department of Medicine, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA.

    • Marileila Varella-Garcia
    • , Aria Vaishnavi
    •  & Robert C Doebele
  4. Department of Pathology, University of Colorado Anschutz Medical Campus, Denver, Colorado, USA.

    • Marileila Varella-Garcia
    •  & Dara L Aisner
  5. Division of Hematology-Oncology, University of California Irvine School of Medicine, Orange, California, USA.

    • Sai-Hong I Ou
  6. Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, California, USA.

    • Sai-Hong I Ou
  7. Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.

    • Eiki Ichihara
    •  & Christine M Lovly
  8. University of California Davis School of Medicine.

    • Philip C Mack
    •  & Jonathan W Riess
  9. Comprehensive Cancer Center, Sacramento, California, USA.

    • Philip C Mack
    •  & Jonathan W Riess
  10. Cancer Biology and Precision Medicine Program Catalan Institute of Oncology Hospital Germans Trias i Pujol Badalona, Barcelona, Spain.

    • Niki Karachaliou
    •  & Rafael Rosell

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Contributions

G.H. contributed to the design, conduct and interpretation of all experiments; V.O. contributed in vivo experiments; E.P., A.T., C.M.B., R.A.O., D.S.N., E.C., A.S. and A.V. contributed cell line experiments and aided in experimental design; S.A. contributed deep-sequencing analysis; L.L. contributed sequencing library preparation; J.F., M.V.-G., D.L.A. and R.C.D. contributed analysis of patient tumor data; S.-H.I.O., P.C.M., N.K., R.R., J.W.R. and R.C.D. contributed patient tumor samples and clinical data; E.A.C. contributed to experimental design and interpretation; E.I. and C.M.L. contributed patient-derived cell lines and conducted experiments; T.G.B. supervised the project and contributed to the design and interpretation of all experiments; and G.H. and T.G.B. wrote the manuscript with input from all co-authors.

Competing interests

T.G.B. is a consultant to Driver Group, Novartis, Clovis Oncology, Natera and Genoptix and is the recipient of a research grant from Servier, all of which are each engaged in cancer diagnostics and/or treatment.

Corresponding author

Correspondence to Trever G Bivona.

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https://doi.org/10.1038/nm.3930

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