What hides behind the MASC: clinical response and acquired resistance to entrectinib after ETV6-NTRK3 identification in a mammary analogue secretory carcinoma (MASC)

A Drilon, G Li, S Dogan, M Gounder, R Shen, M Arcila, L Wang, D M Hyman, J Hechtman, G Wei, N R Cam, J Christiansen, D Luo, E C Maneval, T Bauer, M Patel, S V Liu, S H I Ou, A Farago, A Shaw, R F Shoemaker, J Lim, Z Hornby, P Multani, M Ladanyi, M Berger, N Katabi, R Ghossein, A L Ho, A Drilon, G Li, S Dogan, M Gounder, R Shen, M Arcila, L Wang, D M Hyman, J Hechtman, G Wei, N R Cam, J Christiansen, D Luo, E C Maneval, T Bauer, M Patel, S V Liu, S H I Ou, A Farago, A Shaw, R F Shoemaker, J Lim, Z Hornby, P Multani, M Ladanyi, M Berger, N Katabi, R Ghossein, A L Ho

Abstract

Background: Mammary analogue secretory carcinoma (MASC) is a recently described pathologic entity. We report the case of a patient with an initial diagnosis of salivary acinic cell carcinoma later reclassified as MASC after next-generation sequencing revealed an ETV6-NTRK3 fusion.

Patients and methods: This alteration was targeted with the pan-Trk inhibitor entrectinib (Ignyta), which possesses potent in vitro activity against cell lines containing various NTRK1/2/3 fusions.

Results: A dramatic and durable response was achieved with entrectinib in this patient, followed by acquired resistance that correlated with the appearance of a novel NTRK3 G623R mutation. Structural modeling predicts that this alteration sterically interferes with drug binding, correlating to decreased sensitivity to drug inhibition observed in cell-based assays.

Conclusions: This first report of clinical activity with TrkC inhibition and the development of acquired resistance in an NTRK3-rearranged cancer emphasize the utility of comprehensive molecular profiling and targeted therapy for rare malignancies (NCT02097810).

Keywords: ETV6-NTRK3; TrkC; entrectinib; mammary analogue secretory carcinoma.

© The Author 2016. Published by Oxford University Press on behalf of the European Society for Medical Oncology.

Figures

Figure 1.
Figure 1.
ETV6-NTRK3 identification results in tumor reclassification. In panel A, pathology from a superficial parotidectomy revealed an infiltrative carcinoma with predominantly tubular and microcystic/macrocystic growth patterns and intraluminal secretions. Tumor cells exhibited granular eosinophilic cytoplasm with occasional vacuolation and had relatively bland cytology with mild atypia. A diagnosis of acinic cell carcinoma (AciCC) was made. In panel B, the ETV6-NTRK3 fusion detected via broad, hybrid-capture-based next-generation sequencing is depicted. Reciprocal translocation between chromosome 12 and chromosome 15 resulted in fusion of ETV6 exons 1–5 to NTRK3 exons 15–20 containing the receptor tyrosine kinase (RTK) domain. On the lower left, a positive break-apart fluorescence in situ hybridization (FISH) NTRK3 assay is shown with split signals (arrows). On the lower right, immunohistochemistry for TrkC revealed strong staining signifying TrkC overexpression. The patient's diagnosis was reclassified as mammary analogue secretory carcinoma (MASC).
Figure 2.
Figure 2.
A durable partial response is achieved with entrectinib therapy in an ETV6-NTRK3-rearranged mammary analogue secretory carcinoma. Computed tomography (CT) imaging of the patient after progression on crizotinib and before entrectinib therapy is shown on the left. Repeat CT imaging at 9 weeks revealed a dramatic partial response to therapy (RECIST v1.1) with an interval decrease and resolution of pleural-based metastases in the right hemithorax (arrows). This response was confirmed at 13 weeks and further shrinkage was noted at 21 weeks. A best radiologic response of 89% reduction in tumor burden from baseline was achieved.
Figure 3.
Figure 3.
The development of clinical entrectinib resistance is mediated by the appearance of a novel NTRK3 G623R mutation. In panel A, areas of tumor acquisition via serial biopsies are depicted: before crizotinib (M1, paraesophageal right lower lobe mass), after progression on crizotinib and before entrectinib (M2a, pleural-based right lower lobe mass), and after progression on entrectinib (M2b, pleural-based right lower lobe mass immediately adjacent to M2a). In panel B, broad, hybrid-capture-based next-generation sequencing confirmed the appearance of an NTRK3 G623R mutation after progression on entrectinib (M2b) that was not present in pre-entrectinib tumor samples (M1 and M2a). Panel C depicts the antiproliferative activity of entrectinib in engineered Ba/F3 cells expressing a variety of Trk fusion proteins with IC50s ranging from 1.4 to 4.5 nM. Entrectinib was found to inhibit phospho-TrkC and phospho-PLCy1, with less inhibition of PI3K, MAPK, and Stat3 as depicted in panel D. In panel E, introduction of the NTRK3 G623R mutation into the ETV6-NTRK3 construct (Ba/F3-ETV6-NTRK3 G623R) conferred reduced sensitivity to entrectinib, increasing the IC50 value in the proliferation assays by more than 250-fold relative to the Ba/F3-ETV6-NTRK3 cells. Homology alignment in panel F suggests that the native glycine at position 623 of TrkC is highly conserved among TrkC paralogs. A comparison to glycine residues at position 1202 of ALK, position 2032 of ROS1, and position 595 of TrkA, in addition to other paralogs, is shown. Panel G depicts the binding of entrectinib to both wild-type TrkC and NTRK3 G623-mutant TrkC. Extensive hydrogen bonding and hydrophobic interactions between wild-type TrkC and entrectinib occur in the ATP binding pocket where the G623 residue is located (left). The substitution of arginine for glycine at position 623 results in steric hindrance that decreases the binding of entrectinib to mutant TrkC (right).

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