Rapid, complete and sustained tumour response to the TRK inhibitor larotrectinib in an infant with recurrent, chemotherapy-refractory infantile fibrosarcoma carrying the characteristic ETV6-NTRK3 gene fusion

S S Bielack, M C Cox, M Nathrath, K Apel, C Blattmann, T Holl, R Jenewein, U Klenk, P Klothaki, P Müller-Abt, S Ortega-Lawerenz, M Reynolds, M Scheer, K Simon-Klingenstein, S Stegmaier, R Tupper, C Vokuhl, T von Kalle, S S Bielack, M C Cox, M Nathrath, K Apel, C Blattmann, T Holl, R Jenewein, U Klenk, P Klothaki, P Müller-Abt, S Ortega-Lawerenz, M Reynolds, M Scheer, K Simon-Klingenstein, S Stegmaier, R Tupper, C Vokuhl, T von Kalle

Abstract

Background: The ETV6-NTRK3 gene fusion is present in the majority of cases of infantile fibrosarcoma (IFS) and acts as a potent oncogenic driver. We report the very rapid, complete, and sustained response of an advanced, chemotherapy-refractory, recurrent IFS to targeted treatment with the oral tropomyosin receptor kinase (TRK) inhibitor larotrectinib.

Patient and methods: A male infant born with a large congenital IFS of the tongue had the tumour surgically resected at age 4 days. Within 2 months, he developed extensive lymph node recurrence that progressed during two cycles of vincristine-doxorubicin-cyclophosphamide chemotherapy. At screening, a large right cervical mass was clinically visible. Magnetic resonance imaging (MRI) revealed bilateral cervical and axillary lymph node involvement as well as infiltration of the floor of the mouth. The largest lesion measured 5.5×4.5×4.4 cm (ca. 55 cm3). The patient started outpatient oral larotrectinib at 20 mg/kg twice daily at age 3.5 months.

Results: After 4 days on treatment, the parents noted that the index tumour was visibly smaller and softer. The rapid tumour regression continued over the following weeks. On day 56 of treatment, the first scheduled control MRI showed the target lesion had shrunk to 1.2×1.2×0.8 cm (ca. 0.6 cm3), corresponding to a complete response according to the Response Evaluation Criteria In Solid Tumors version 1.1. This response was maintained over subsequent follow-up visits, and on day 112 at the second control MRI the target lymph node was completely normal. At last follow-up, the disease remained in complete remission after 16 months on larotrectinib, with negligible toxicity and no safety concerns.

Conclusion(s): Selective TRK inhibition by larotrectinib offers a novel, highly specific and highly effective therapeutic option for IFS carrying the characteristic ETV6-NTRK3 gene fusion. Its use should be considered when surgery is not feasible. (NCT02637687).

Keywords: infantile fibrosarcoma; larotrectinib; tropomyosin receptor kinase inhibition.

© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society for Medical Oncology.

Figures

Figure 1.
Figure 1.
Clinical impression of the right-sided cervical mass (A) before initiation of larotrectinib, (B) at week 3 of treatment, (C) at week 9 of treatment and (D) at week 25 of treatment.
Figure 2.
Figure 2.
Visualisation of the largest diameters of the right cervical lesion upon coronal and planar magnetic resonance imaging (A) at screening, (B) on day 56 of treatment and (C) on day 112 of treatment.

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