A Polytherapy Strategy Using Vincristine and ALK Inhibitors to Sensitise EML4-ALK-Positive NSCLC

Simple Summary Lung cancer is the third most common cancer worldwide with poor survival after initial diagnosis. A large proportion, approximately 85%, of patients with lung cancer are classified as non-small cell lung cancer (NSCLC). The most common genetic alterations in NSCLCs are KRAS, EGFR and ALK mutations. Patients carrying the EML4-ALK mutation are treated with potent ALK drugs. Up to date, there are 15 different EML4-ALK mutations found in NSCLC patients. Of note, patients carrying the EML4-ALK V3 mutation respond poorly to ALK chemotherapeutic regime and acquire resistance. The aim of the present study was to assess the potential of a combination chemotherapy using vincristine, a traditional chemotherapeutic drug, and potent ALK drugs. We demonstrated that vincristine sensitises cells carrying EML4-ALK V1 mutation but not V3. Cells carrying the EML4-ALK V3 mutation confer low response to drug combination due to high levels of tubulin acetylation and active proliferation pathways compared to V1 cells. The oncogenic fusion of EML4-ALK is present in about 4-6% of non-small cell lung cancer (NSCLC). A targeted approach with ALK tyrosine kinase inhibitors (TKIs) has been proven highly effective in ALK-positive NSCLC patients. However, despite the initial responses, the outcome of the treatment is variable. Previous studies have shown that the differential response depends in part on the type of EML4-ALK variant. Here, we examined the combination of ALK inhibitors and microtubule poison, vincristine, in cells expressing EML4-ALK V1 and V3, the two most common variants in NSCLC. We showed that combination therapy of ALK-TKIs with vincristine had anti-proliferative effects and blocked RAS/MAPK, PI3K/AKT and JAK/STAT3 signalling pathways in EML4-ALK V1 but not V3 cells. Our results demonstrate that high levels of tubulin acetylation are associated with poor response to vincristine in EML4-ALK V3 cells. Additionally, we demonstrated differences in microtubule stability between the two EML4-ALK fusions. EML4-ALK V3 cells exhibited dynamic microtubules that confer poor response to vincristine compared to V1 cells. Hence, we suggested that the portion of EML4 in the fusion has an important role for the outcome of the combination treatment.

Automated summary

The study evaluated the potential of combination chemotherapy using vincristine and potent ALK drugs. It was found that cells carrying the EML4-ALK V3 mutation exhibited low response to the drug combination due to high levels of tubulin acetylation and active proliferation pathways.