Small cell transformation of ROS1 fusion-positive lung cancer resistant to ROS1 inhibition

Histologic transformation from non-small cell to small cell lung cancer has been reported as a resistance mechanism to targeted therapy inEGFR-mutant andALKfusion-positive lung cancers. Whether small cell transformation occurs in other oncogene-driven lung cancers remains unknown. Here we analyzed the genomic landscape of two pre-mortem and 11 post-mortem metastatic tumors collected from an advanced,ROS1fusion-positive lung cancer patient, who had received sequential ROS1 inhibitors. Evidence of small cell transformation was observed in all metastatic sites at autopsy, with inactivation ofRB1andTP53, and loss ofROS1fusion expression. Whole-exome sequencing revealed minimal mutational and copy number heterogeneity, suggestive of hard clonal sweep. Patient-derived models generated from autopsy retained features consistent with small cell lung cancer and demonstrated resistance to ROS1 inhibitors. This case supports small cell transformation as a recurring resistance mechanism, and underscores the importance of elucidating its biology to expand therapeutic opportunities.