Skip to main content

Second- and third-generation ALK inhibitors for non-small cell lung cancer


Crizotinib as the first-generation ALK inhibitor has shown significant activity in ALK-mutated non-small cell lung cancer (NSCLC). Second- and third-generation ALK inhibitors are entering clinical applications for ALK+ NSCLC. In addition, a third-generation ALK inhibitor, lorlatinib (PF-06463922), was reported to resensitize NSCLC to crizotinib. This review provided a summary of clinical development of alectinib, ceritinib, brigatinib (AP26113), and lorlatinib.


Small molecule inhibitors of EGFR (epidermal growth factor receptor) have been widely used for lung cancer therapy [19]. A small subset (3–13 %) of non-small cell lung cancer (NSCLC) has been shown to have rearrangements in the ALK (anaplastic lymphoma kinase) gene [10, 11]. Over the last few years, ALK inhibitors have shown significant benefits in the management of ALK-positive NSCLC compared to conventional chemotherapy [1215]. A big caveat however is the emergence of resistance to ALK inhibitors [16]. This article provided a summary of clinical development of alectinib, ceritinib, brigatinib (AP26113), and lorlatinib for NSCLC.

ALK gene and the roles in oncogenesis

The ALK gene encodes for ALK receptor tyrosine kinase enzyme. The gene is located on the short arm of chromosome 2 (2p23) and belongs to the insulin receptor superfamily. Like other receptor tyrosine kinases, it has an extracellular domain, a transmembrane segment, and a cytoplasmic receptor kinase segment [17]. Physiologically, ALK is involved in the development of brain and neurons [18]. It is highly expressed during embryogenesis and thereafter becomes dormant. ALK mutation can lead to tumorigenesis [19]. Most mutations of the ALK gene are in the form of a translocation with another partner gene leading to a fusion oncogene which becomes overtly expressed in cancers [20] (Fig. 1). The first ALK mutation was reported in 1994 when NPM-ALK was described in a subset of anaplastic large cell lymphomas [21]. This mutation involves fusion of the nucleophosmin (NPM) gene and ALK as a result of t(2; 5) (p23; q35) [21, 22]. Additional gene partners have been discovered in fusion oncogenes with ALK gene. A few examples are TPM3-t(1;2)(q25;p23), TFG-t(2;3)(p23;q21), CLTCL1-t(2;17)(p23;q23), and ATIC-inv(p23;q35) [22]. More mutations of ALK gene have been reported in several cancers, including NSCLC, inflammatory myofibroblastic tumors, diffuse large B cell lymphoma, colon cancer, renal cell carcinoma, breast carcinoma, esophageal cancer, and neuroblastoma [23].

Fig. 1
figure 1

ALK mutations in non-small cell lung cancer. Most mutations of the ALK gene are in the form of a translocation with another partner gene leading to a fusion oncogene. Most common fusion oncogenes in non-small cell lung cancer are presented in this diagram

ALK mutations were first described in NSCLC in 2007 when a subset (7 %) of Japanese patients were found to have echinoderm microtubule associated protein like-4 (EML4) rearrangement with ALK leading to a fusion oncogene EML4-ALK [24, 25]. This was due to an inversion rearrangement from inv(2) (p21;p23). As a result, EML4 replaces the extracellular and intramembranous parts of ALK and fuses with the juxta membranous part. The EML4-ALK gene induced tumor formation in nude mice [23, 24]. Due to different breakpoint on EML4, several variants of EML4-ALK mutation have been described [10, 26, 27]. EML4-ALK variants with differing frequencies are V1 (54.5 %), V2 (10 %), V3a/V3b (34 %), and V5a (1.5 %) [26, 27]. Rearrangements of the ALK gene with partner genes other than EML4 have been described, namely, KIF5B, KLC1, TFG, TPR, HIP1, STRN, DCTN1, SQSTM1, and BIRC6 [28] (Fig. 1).

ALK translocations result in increased tyrosine kinase activity leading to increased cell proliferation and survival and ultimately tumorigenesis. The ALK signaling pathways involve phospholipase Cγ (PLCγ), Janus kinase (JAK)–signal transducer and activator of transcription (STAT), PI3K–AKT, mTOR, sonic hedgehog (SHH), JUN-B, CRKL–C3G (also known as RAPGEF1), RAP1 GTPase, and MAPK signaling cascades [23].

ALK + NSCLC characteristics

ALK-positive NSCLCs are generally seen in non-smokers, occur at a younger age, and are mostly adenocarcinoma in histology [15]. They also seem to have a female gender predisposition [1113, 27]. Pathological features include solid morphology and presence of signet ring cells [29, 30].

Crizotinib (PF-02341066, xalkori)

Crizotinib (PF-02341066, xalkori) is the first-generation ALK inhibitor approved for ALK-positive NSCLC [12]. It has a IC50 against EML4-ALK of 250–300 nm [31]. In addition to having activity against ALK, it also has activity against c-MET and ROS1 tyrosine kinases [3134]. It was approved for ALK positive, locally advanced, and metastatic NSCLC [35].

The PROFILE 1007 study involving 347 patients with ALK-positive NSCLC compared crizotinib with chemotherapy in patients who failed at least one prior platinum-containing regimen [13]. These patients were randomly assigned to receive either 250 mg twice daily of oral crizotinib vs intravenous pemetrexed or docetaxel. The median PFS was 7.7 months (95 % CI 6.0–8.8) in crizotinib group compared with 3.0 (95 % CI 2.6–4.3) months in the chemotherapy group. The ORR was 65 % (95 % CI 58–72) in crizotinib compared to 20 % (95 % CI 14–26) in the chemotherapy group (P < 0.001) [13]. The adverse events reported were mostly grades 1 or 2. Grade 3 or 4 events were elevated aminotransferase levels and neutropenia which occurred in 16 and 13 % of patients, respectively [13, 15].

PROFILE 1014 study compared crizotinib vs chemotherapy in 343 patients who had no previous treatment for advanced NSCLC. They were randomized to either receive crizotinib vs pemetrexed plus platinum (cisplatin or carboplatin). Progression-free survival for crizotinib group (n = 172) was 10.9 months and for chemotherapy group (n = 171) was 7.0 months. The ORR was 74 % (95 % CI 67–81) for crizotinib group vs 45 % (95 % CI 37–53) for chemotherapy (P < 0.001). Median OS was not reached in either group at the time of report (hazard ratio for death with crizotinib, 0.82; 95 % CI, 0.54 to 1.26; P = 0.36); the 1-year estimated survival was 84 % with crizotinib vs 79 % with chemotherapy. Crizotinib-associated AEs were vision disorders, diarrhea, nausea, and edema. It was concluded from PROFILE 1014 study that crizotinib was superior to standard first-line pemetrexed-plus-platinum chemotherapy in patients with previously untreated advanced ALK-positive NSCLC. Hence, crizotinib is currently approved for first line in ALK+ NSCLC [14, 36].

Crizotinib has also been shown to be highly efficacious in ROS1-positive NSCLC which comprises 1 % of all NSCLC. In a phase 1 study of 50 patients, the ORR was 72 % (95 % CI 58–84) (33 PR and 3 CR). The median PFS was 19.2 months [31]. Among 30 tumors that were tested, 7 ROS1 fusion partners were identified, 2 of these partner genes were novel. However, there was no correlation between the type of ROS1 rearrangement and the clinical response to crizotinib. ROS1 rearrangement molecularly marks a small subgroup of NSCLC for which crizotinib can play an active role in clinical therapy.

Limitations of crizotinib

Resistance to crizotinib

Majority of patients develop resistance to crizotinib within 1 to 2 years from the initiation of therapy [37]. The resistance to ALK inhibitors can be classified into primary and secondary resistance [38].

Primary resistance is seen when the tumor is deemed refractory to the agent at the beginning of the therapy itself as reported in chronic myeloid leukemia [39]. In the case of ALK+ NSCLC, the primary resistance can be attributed to the different fusion variants of EML4 with ALK or other partner genes [38]. Different sensitivities to crizotinib have been shown to be dependent upon the ALK variant or fusion gene partner [40, 41]. Currently, FISH has been the gold standard for detecting ALK mutations in NSCLC.

Secondary resistances are acquired mechanisms after the tumor has been exposed to an ALK inhibitor and can be further classified into two categories: ALK dominant and ALK non-dominant. In the ALK dominant type, there is mutation in the target ALK gene resulting in inability to inhibit the encoded tyrosine kinase. These are termed as ALK dominant as they depend upon ALK tyrosine kinase activity [42]. Most of the mutations are in the form of point mutations and the first ones to be described are C1156Y and L1196M [43]. There have been several other secondary point mutations that have been identified and are the following: G1269A, F1174L, 1151Tins, L1152R, S1206Y, I1171T, G1202, D1203N, and V1180L [4144].

The ALK non-dominant resistance involves emergence of bypass tracks such as EGFR mutation, KRAS mutation, amplification of KIT, phosphorylated amplification of ErbB, MET, and activation of IGF-1R in the downstream signaling. It has been shown that in the same ALK resistant tumor, multiple mechanisms of resistances may occur [42, 45].

Secondary mutations of the ALK gene result in 29 % of resistant cases, and gene amplification is implicated in 9 % of these cases. The remaining of the cases can be attributed to bypass pathways and other mechanisms that have yet to be defined [46].

CNS metastasis

Crizotinib has poor activity against CNS metastasis in NSCLC as evidenced by low concentrations detected in CNS samples during the course of systemic chemotherapy. The ratio of CNS to serum concentration of crizotinib has been in the range of 0.0006–0.001 as established by individual case reports [4749]. In a retrospective analysis of trials involving crizotinib, 20 % of patients who did not have CNS disease at the beginning had CNS metastasis while on therapy [50]. PF-06463922 (lorlatinib) is a newly developed ALK inhibitor that has been designed for better CNS penetration and is currently in phase I/II trials (NCT01970865) (see below) [15].

In another analysis of 90 patients with brain metastases from ALK-mutated NSCLC, 84 of 90 patients received radiotherapy to the brain, and 86 of 90 received TKI therapy [51]. Significant improvement in this population of poor-prognostic patients was reported. The median OS after development of brain metastases was 49.5 months (95 % CI, 29.0 months to not reached), and median intracranial PFS was 11.9 months (95 % CI, 10.1 to 18.2 months). Four groups of patients were classified in this analysis with distinct outcomes: absence of extracranial metastases, high Karnofsky performance score ≥90, and no prior therapy with TKIs before development of brain metastases had longer survival (P = .003, <.001, and <.001, respectively), whereas isolated brain metastasis or initial treatment with radiation were not (P = .633 and .666, respectively). It was concluded that brain radiotherapy and TKIs to control intracranial disease in ALK+ NSCLC can lead to prolonged survival. Newer TKIs are playing an important role in this population of patients.

Crizotinib toxicity

There have been case reports of significant adverse effects that were not reported in the initial trials. These included erythema multiforme [52], acute interstitial lung disease [53, 54], renal polycytosis [5557], contact esophagitis [58, 59], decrease in GFR, and hypersensitivity reactions [14].

Second-generation ALK inhibitors


Within the first year or two after crizotinib treatment is initiated, resistance typically arises. As mentioned above, mechanisms commonly include secondary mutations within the ALK tyrosine kinase domain and activation of alternative signaling pathways. More potent and structurally different inhibitors are therefore developed.

Ceritinib (LDK378, zykadia) is a potent ALK inhibitor compared to crizotinib [6062]. A phase I study with 130 patients with ALK-positive advanced tumors included 122 NSCLC [63]. The doses were 50 to 750 mg in the dose escalation phase which enrolled 59 patients. The MTD of ceritinib was shown to be 750 mg daily. The dose-limiting toxicities (DLT) were diarrhea, vomiting, dehydration, elevated aminotransferase levels, and hypophosphatemia. Seventy-one patients received ceritinib in the dose expansion phase. One hundred fourteen patients received ceritinib dose of at least 400 mg daily. The ORR was 58 % (95 % CI 48–67). Among the 80 patients who failed crizotinib, the response rate was 56 % (95 % CI, 45 to 67). Among patients with NSCLC who received ceritinib with doses 400 mg or higher, the median PFS was 7.0 months (95 % CI, 5.6 to 9.5).

Thus, this study proved that ceritinib induced high responses in patients who failed crizotinib. Ceritinib was approved for treatment of relapsed or refractory NSCLC after crizotinib [64] (Table 1).

Table 1 FDA approved ALK inhibitors for non-small cell lung cancer


Alectinib (CH5424802, alecensa) is a potent and highly selective inhibitor of ALK tyrosine kinase with IC50 of 1.9 nM [65, 66]. More importantly, it has activity against L1196M which is one of the commonly seen secondary mutations in ALK gene leading to resistance to crizotinib.

In a multicenter, single-arm, open-label phase 1–2 study conducted in Japan (AF-001JP), ALK inhibitor naïve patients who had ALK-positive NSCLC were treated with alectinib [67]. In the dose escalation phase which included 24 such patients, increasing doses in the 20–300 mg range were used. No dose-limiting toxicities (DLT) were noted. Hence, 300 mg twice daily was established as the recommended dose for phase II. The phase II portion enrolled 46 patients. Forty-one of these patients had PR and 2 had CR. Hence, ORR was around 94 % (95 % CI: 82-98). Grade 3 adverse events were reported in 26 % (n = 12) and included elevated creatinine phosphokinase and neutropenia [67].

In another phase 1–2 single-arm open-label study, 47 patients with ALK-positive NSCLC who had resistance to crizotinib or were intolerant were treated with alectinib [68]. In the dose escalation phase, doses were escalated from 300 to 900 mg in seven different cohorts of patients. DLTs were seen in the 900-mg cohort: grade 3 headache in one patient and grade 3 neutropenia in another one. Three patients dropped out of the study due to adverse events: grade 3 dyspnea, grade 4 CNS metastasis, and grade 3 abdominal pain. Out of the 47 patients, 44 were assessed for response and the ORR was found to be 55 % (24 PR, one CR). ORR for the 21 patients who had baseline CNS metastasis was 52 % (5 CR and another 6 having partial CNS response). Therefore, this study showed that alectinib not only was effective in patients pretreated with first-generation ALK inhibitor but also was active for CNS metastasis [68]. Alectinib is now FDA-approved for the treatment of metastatic ALK+ NSCLC in patients who have progressed on or are intolerant to crizotinib.

Brigatinib (AP26113)

Brigatinib is another second-generation ALK inhibitor. It is a potent dual inhibitor of ALK and EGFR, including ALK L1196M and EGFR T790M mutants, shown in preclinical and first-in-human studies [6971]. In the initial dose-finding study, there were 18 evaluable ALK+ pts. Among these patients, 10 responded. Fifteen ALK+ pts had 0 (n = 3) or 1 (n = 12) prior ALK TKI (crizotinib); of these, 8/12 pts (67 %) responded, including two complete responses. Radiographic improvement was seen in 4 of 5 ALK+ pts with untreated or progressing CNS lesions. There were 16 pts enrolled with EGFRm history (15 NSCLC, 1 SCLC); 14 pts had ≥1 prior EGFR TKI. Of 12 EGFRm pts with a follow-up scan, 1 pt (prior erlotinib) responded at 120 mg, 6 pts had stable disease.

In the last update of the phase I/II single-arm, open-label, multicenter study in patient pts with advanced malignancies (NCT01449461), patients received brigatinib as the following: phase I: 30–300 mg/day total daily dose; phase II: 90 mg/day, 180 mg/day, or 90 mg/day for 7 days followed by 180 mg/day. Safety was reported in all 137 treated pts; efficacy was evaluated in all 79 ALK+ NSCLC pts [72] (Table 2). Most common treatment-emergent adverse events (TEAE) included nausea, diarrhea, fatigue, cough, and headache. Early-onset pulmonary events were observed less frequently with the 90-mg starting dose compared with higher doses. Median progression-free survival (PFS) is 56 weeks, 47 weeks with prior crizotinib. In pts with baseline CNS metastases, half of 12 pts had a brain response and 8/26 pts with only non-measurable lesions had disappearance of all lesions. Median intracranial PFS for these pts is 97 weeks. Therefore, brigatinib was active in crizotinib-resistant NSCLC and showed activity in CNS lesions. A randomized phase 2 trial of brigatinib in crizotinib-resistant ALK+ NSCLC (ALTA) is underway.

Table 2 Brigatinib and lorlatinib in clinical development for non-small cell lung cancer

Third-generation ALK inhibitor

Lorlatinib (PF-06463922) is a novel, reversible, potent ATP-competitive small molecule inhibitor of ALK and ROS1. This third-generation inhibitor is effective against all known resistant mutants [7375]. In preclinical studies, lorlatinib was proven to be active in crizotinib-resistant cancers both in vitro and in xenograft models [7375]. To overcome ALK mutations and ALK inhibitor resistance, lorlatinib was combined with PI3K pathway inhibitors, such as PF-05212384 (PI3K/mTOR), GDC0941 (pan-PI3K), or GDC0032 (beta-sparing). Such rational combination was reported to lead to more robust activity in vitro and greater duration of efficacy in vivo in the ALK inhibitor resistant models [76].

Lorlatinib is being studied in a phase I clinical trial in patients who were refractory to crizotinib and ceritinib (NCT01970865) [77]. One patient enrolled to this trial responded to lorlatinib for 8 months. Interestingly, the patient was resensitized to crizotinib after the patient failed the lorlatinib treatment, indicating that retreatment under molecular guidance can be a clinically meaningful approach.


Second- and third-generation ALK inhibitors are entering clinical applications for ALK+ NSCLC. Among these, dual inhibitors targeting ALK as well as EGFRm and ROS1 may provide additional benefits for crizotinib-refractory patients. Resensitization to and retreatment with crizotinib can be considered under molecular guidance. More and more biomarker-targeted agents are entering clinical applications [7881]. Immune therapies are showing remarkable benefits [8291]. It is foreseeable that combination of these novel agents and small molecular inhibitors may expand the potential for treatment of refractory lung cancer patients.


  1. 1.

    Lee CK, Wu Y-L, Ding PN, Lord SJ, Inoue A, Zhou C, et al. Impact of specific epidermal growth factor receptor (EGFR) mutations and clinical characteristics on outcomes after treatment with EGFR tyrosine kinase inhibitors versus chemotherapy in EGFR-mutant lung cancer: a meta-analysis. J Clin Oncol. 2015;33(17):1958–65.

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Cataldo VD, Gibbons DL, Perez-Soler R, Quintas-Cardama A. Treatment of non-small-cell lung cancer with erlotinib or gefitinib. N Engl J Med. 2011;364(10):947–55.

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Maheswaran S, Sequist L, Nagrath S, Ulkus L, Brannigan B, Collura C. Detection of mutations in EGFR in circulating lung-cancer cells. N Engl J Med. 2008;359(4):366–77.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Murtaza M, Dawson S, Tsui D, Gale D, Forshew T, Piskorz A. Non-invasive analysis of acquired resistance to cancer therapy by sequencing of plasma DNA. Nature. 2013;497(7447):108–12.

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Sun W, Yuan X, Tian Y, Wu H, Xu H, Hu G, et al. Non-invasive approaches to monitor EGFR-TKI treatment in non-small-cell lung cancer. J Hematol Oncol. 2015;8(1):95.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Wang S, Su X, Bai H, Zhao J, Duan J, An T, et al. Identification of plasma microRNA profiles for primary resistance to EGFR-TKIs in advanced non-small cell lung cancer (NSCLC) patients with EGFR activating mutation. J Hematol Oncol. 2015;8(1):127.

    Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Zhong W, Yang X, Yan H, Zhang X, Su J, Chen Z, et al. Phase II study of biomarker-guided neoadjuvant treatment strategy for IIIA-N2 non-small cell lung cancer based on epidermal growth factor receptor mutation status. J Hematol Oncol. 2015;8(1):54.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Niu F, Wu Y. Novel agents and strategies for overcoming EGFR TKIs resistance. Exp Hematol Oncol. 2014;3(1):2.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Tsao M, Sakurada A, Cutz J, Zhu C, Kamel-Reid S, Squire J. Erlotinib in lung cancer—molecular and clinical predictors of outcome. New Engl J Med. 2005;353(2):133–44.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Horn L, Pao W. EML4-ALK: honing in on a new target in non-small-cell lung cancer. J Clin Oncol. 2009;27(26):4232–5.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Shaw AT, Yeap BY, Mino-Kenudson M, Digumarthy SR, Costa DB, Heist RS, et al. Clinical features and outcome of patients with non-small-cell lung cancer who harbor EML4-ALK. J Clin Oncol. 2009;27(26):4247–53.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Kwak EL, Bang YJ, Camidge DR, Shaw AT, Solomon B, Maki RG, et al. Anaplastic lymphoma kinase inhibition in non-small-cell lung cancer. N Engl J Med. 2010;363(18):1693–703.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Shaw AT, Kim DW, Nakagawa K, Seto T, Crino L, Ahn MJ, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med. 2013;368(25):2385–94.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Solomon B. Refining the toxicity profile of crizotinib. J Thorac Oncol. 2014;9(11):1596–7.

    Article  PubMed  Google Scholar 

  15. 15.

    Iragavarapu C, Mustafa M, Akinleye A, Furqan M, Mittal V, Cang S, et al. Novel ALK inhibitors in clinical use and development. J Hematol Oncol. 2015;8(1):17.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Isozaki H, Takigawa N, Kiura K. Mechanisms of acquired resistance to ALK inhibitors and the rationale for treating ALK-positive lung cancer. Cancers (Basel). 2015;7(2):763–83.

    Article  Google Scholar 

  17. 17.

    Duyster J, Bai RY, Morris SW. Translocations involving anaplastic lymphoma kinase (ALK). Oncogene. 2001;20(40):5623–37.

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Webb TR, Slavish J, George RE, Look AT, Xue L, Jiang Q, et al. Anaplastic lymphoma kinase: role in cancer pathogenesis and small-molecule inhibitor development for therapy. Expert Rev Anticancer Ther. 2009;9(3):331–56.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Iwahara T, Fujimoto J, Wen D, Cupples R, Bucay N, Arakawa T, et al. Molecular characterization of ALK, a receptor tyrosine kinase expressed specifically in the nervous system. Oncogene. 1997;14(4):439–49.

    CAS  Article  PubMed  Google Scholar 

  20. 20.

    Kelleher FC, McDermott R. The emerging pathogenic and therapeutic importance of the anaplastic lymphoma kinase gene. Eur J Cancer. 2010;46(13):2357–68.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Morris SW, Kirstein MN, Valentine MB, Dittmer KG, Shapiro DN, Saltman DL, et al. Fusion of a kinase gene, ALK, to a nucleolar protein gene, NPM, in non-Hodgkin’s lymphoma. Science. 1994;263(5151):1281–4.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Boi M, Zucca E, Inghirami G, Bertoni F. Advances in understanding the pathogenesis of systemic anaplastic large cell lymphomas. Br J Haematol. 2015;168(6):771–83.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Hallberg B, Palmer RH. Mechanistic insight into ALK receptor tyrosine kinase in human cancer biology. Nat Rev Cancer. 2013;13(10):685–700.

    CAS  Article  PubMed  Google Scholar 

  24. 24.

    Soda M, Choi YL, Enomoto M, Takada S, Yamashita Y, Ishikawa S, et al. Identification of the transforming EML4-ALK fusion gene in non-small-cell lung cancer. Nature. 2007;448(7153):561–6.

    CAS  Article  PubMed  Google Scholar 

  25. 25.

    Takeuchi K, Choi YL, Soda M, Inamura K, Togashi Y, Hatano S, et al. Multiplex reverse transcription-PCR screening for EML4-ALK fusion transcripts. Clin Cancer Res. 2008;14(20):6618–24.

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Choi YL, Takeuchi K, Soda M, Inamura K, Togashi Y, Hatano S, et al. Identification of novel isoforms of the EML4-ALK transforming gene in non-small cell lung cancer. Cancer Res. 2008;68(13):4971–6.

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Li T, Maus MK, Desai SJ, Beckett LA, Stephens C, Huang E, et al. Large-scale screening and molecular characterization of EML4-ALK fusion variants in archival non-small-cell lung cancer tumor specimens using quantitative reverse transcription polymerase chain reaction assays. J Thorac Oncol. 2014;9(1):18–25.

    CAS  Article  PubMed  Google Scholar 

  28. 28.

    Iyevleva AG, Raskin GA, Tiurin VI, Sokolenko AP, Mitiushkina NV, Aleksakhina SN, et al. Novel ALK fusion partners in lung cancer. Cancer Lett. 2015;362(1):116–21.

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    Nishino M, Klepeis VE, Yeap BY, Bergethon K, Morales-Oyarvide V, Dias-Santagata D, et al. Histologic and cytomorphologic features of ALK-rearranged lung adenocarcinomas. Mod Pathol. 2012;25(11):1462–72.

    CAS  Article  PubMed  Google Scholar 

  30. 30.

    Yoshida A, Tsuta K, Nakamura H, Kohno T, Takahashi F, Asamura H, et al. Comprehensive histologic analysis of ALK-rearranged lung carcinomas. Am J Surg Pathol. 2011;35(8):1226–34.

    Article  PubMed  Google Scholar 

  31. 31.

    Shaw AT, Ou SH, Bang YJ, Camidge DR, Solomon BJ, Salgia R, et al. Crizotinib in ROS1-rearranged non-small-cell lung cancer. N Engl J Med. 2014;371(21):1963–71.

    Article  PubMed  PubMed Central  Google Scholar 

  32. 32.

    Cui JJ, Tran-Dube M, Shen H, Nambu M, Kung PP, Pairish M, et al. Structure based drug design of crizotinib (PF-02341066), a potent and selective dual inhibitor of mesenchymal-epithelial transition factor (c-MET) kinase and anaplastic lymphoma kinase (ALK). J Med Chem. 2011;54(18):6342–63.

    CAS  Article  PubMed  Google Scholar 

  33. 33.

    Yasuda H, de Figueiredo-Pontes LL, Kobayashi S, Costa DB. Preclinical rationale for use of the clinically available multitargeted tyrosine kinase inhibitor crizotinib in ROS1-translocated lung cancer. J Thorac Oncol. 2012;7(7):1086–90.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  34. 34.

    Zou HY, Li Q, Lee JH, Arango ME, McDonnell SR, Yamazaki S, et al. An orally available small-molecule inhibitor of c-Met, PF-2341066, exhibits cytoreductive antitumor efficacy through antiproliferative and antiangiogenic mechanisms. Cancer Res. 2007;67(9):4408–17.

    CAS  Article  PubMed  Google Scholar 

  35. 35.

    Camidge DR, Bang YJ, Kwak EL, Iafrate AJ, Varella-Garcia M, Fox SB, et al. Activity and safety of crizotinib in patients with ALK-positive non-small-cell lung cancer: updated results from a phase 1 study. Lancet Oncol. 2012;13(10):1011–9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  36. 36.

    Solomon BJ, Mok T, Kim D-W, Wu Y-L, Nakagawa K, Mekhail T, et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer. N Engl J Med. 2014;371(23):2167–77.

    Article  PubMed  Google Scholar 

  37. 37.

    Shaw AT, Engelman JA. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med. 2014;370(26):2537–9.

    Article  PubMed  Google Scholar 

  38. 38.

    Duchemann B, Friboulet L, Besse B. Therapeutic management of ALK+ nonsmall cell lung cancer patients. Eur Respir J. 2015;46(1):230–42.

    CAS  Article  PubMed  Google Scholar 

  39. 39.

    Quintas-Cardama A, Kantarjian HM, Cortes JE. Mechanisms of primary and secondary resistance to imatinib in chronic myeloid leukemia. Cancer Control. 2009;16(2):122–31.

    PubMed  Google Scholar 

  40. 40.

    Heuckmann JM, Balke-Want H, Malchers F, Peifer M, Sos ML, Koker M, et al. Differential protein stability and ALK inhibitor sensitivity of EML4-ALK fusion variants. Clin Cancer Res. 2012;18(17):4682–90.

    CAS  Article  PubMed  Google Scholar 

  41. 41.

    Heuckmann JM, Holzel M, Sos ML, Heynck S, Balke-Want H, Koker M, et al. ALK mutations conferring differential resistance to structurally diverse ALK inhibitors. Clin Cancer Res. 2011;17(23):7394–401.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  42. 42.

    Toyokawa G, Seto T. Updated evidence on the mechanisms of resistance to ALK inhibitors and strategies to overcome such resistance: clinical and preclinical data. Oncol Res Treat. 2015;38(6):291–8.

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Choi YL, Soda M, Yamashita Y, Ueno T, Takashima J, Nakajima T, et al. EML4-ALK mutations in lung cancer that confer resistance to ALK inhibitors. N Engl J Med. 2010;363(18):1734–9.

    CAS  Article  PubMed  Google Scholar 

  44. 44.

    Sasaki T, Okuda K, Zheng W, Butrynski J, Capelletti M, Wang L, et al. The neuroblastoma-associated F1174L ALK mutation causes resistance to an ALK kinase inhibitor in ALK-translocated cancers. Cancer Res. 2010;70(24):10038–43.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Katayama R, Shaw AT, Khan TM, Mino-Kenudson M, Solomon BJ, Halmos B, et al. Mechanisms of acquired crizotinib resistance in ALK-rearranged lung cancers. Sci Transl Med. 2012;4(120):120ra117.

    Article  Google Scholar 

  46. 46.

    Awad MM, Shaw AT. ALK inhibitors in non-small cell lung cancer: crizotinib and beyond. Clin Adv Hematol Oncol. 2014;12(7):429–39.

    PubMed  PubMed Central  Google Scholar 

  47. 47.

    Costa DB, Kobayashi S, Pandya SS, Yeo WL, Shen Z, Tan W, et al. CSF concentration of the anaplastic lymphoma kinase inhibitor crizotinib. J Clin Oncol. 2011;29(15):e443–5.

    Article  PubMed  Google Scholar 

  48. 48.

    Klempner SJ, Ou SH. Anaplastic lymphoma kinase inhibitors in brain metastases from ALK+ non-small cell lung cancer: hitting the target even in the CNS. Chin Clin Oncol. 2015;4(2):20.

    PubMed  Google Scholar 

  49. 49.

    Metro G, Lunardi G, Floridi P, Pascali JP, Marcomigni L, Chiari R, et al. CSF concentration of crizotinib in two ALK-positive non-small-cell lung cancer patients with CNS metastases deriving clinical benefit from treatment. J Thorac Oncol. 2015;10(5):e26–7.

    Article  PubMed  Google Scholar 

  50. 50.

    Costa DB, Shaw AT, Ou SH, Solomon BJ, Riely GJ, Ahn MJ, et al. Clinical experience with crizotinib in patients with advanced ALK-rearranged non-small-cell lung cancer and brain metastases. J Clin Oncol. 2015;33(17):1881–8.

    CAS  Article  PubMed  Google Scholar 

  51. 51.

    Johung KL, Yeh N, Desai NB, Williams TM, Lautenschlaeger T, Arvold ND, et al. Extended survival and prognostic factors for patients with ALK-rearranged non-small-cell lung cancer and brain metastasis. J Clin Oncol. 2016;34(2):123–9.

    Article  PubMed  Google Scholar 

  52. 52.

    Sawamura S, Kajihara I, Ichihara A, Fukushima S, Jinnin M, Yamaguchi E, et al. Crizotinib-associated erythema multiforme in a lung cancer patient. Drug Discov Ther. 2015;9(2):142–3.

    Article  PubMed  Google Scholar 

  53. 53.

    Deiana L, Grisanti S, Ferrari V, Tironi A, Brugnoli G, Ferrari L, et al. Aspergillosis superinfection as a cause of death of crizotinib-induced interstitial lung disease successfully treated with high-dose corticosteroid therapy. Case Rep Oncol. 2015;8(1):169–73.

    Article  PubMed  PubMed Central  Google Scholar 

  54. 54.

    Maka VV, Krishnaswamy UM, Anil Kumar N, Chitrapur R, Kilara N. Acute interstitial lung disease in a patient with anaplastic lymphoma kinase-positive non-small-cell lung cancer after crizotinib therapy. Oxf Med Case Reports. 2014;2014(1):11–2.

    Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    Di Girolamo M, Paris I, Carbonetti F, Onesti EC, Socciarelli F, Marchetti P. Widespread renal polycystosis induced by crizotinib. Tumori. 2015;101(4):e128–31.

    PubMed  Google Scholar 

  56. 56.

    Schnell P, Bartlett CH, Solomon BJ, Tassell V, Shaw AT, de Pas T, et al. Complex renal cysts associated with crizotinib treatment. Cancer Med. 2015;4(6):887–96.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Souteyrand P, Burtey S, Barlesi F. Multicystic kidney disease: a complication of crizotinib. Diagn Interv Imaging. 2015;96(4):393–5.

    CAS  Article  PubMed  Google Scholar 

  58. 58.

    Conduit C, Wilson M, Hunter K, Murdolo V, Nott L. Severe contact esophagitis in a patient taking crizotinib: a case report. Asia Pac J Clin Oncol. 2015;11(2):187–9.

    Article  PubMed  Google Scholar 

  59. 59.

    Yoneshima Y, Okamoto I, Takano T, Enokizu A, Iwama E, Harada T, et al. Successful treatment with alectinib after crizotinib-induced esophageal ulceration. Lung Cancer. 2015;88(3):349–51.

    Article  PubMed  Google Scholar 

  60. 60.

    Friboulet L, Li N, Katayama R, Lee CC, Gainor JF, Crystal AS, et al. The ALK inhibitor ceritinib overcomes crizotinib resistance in non-small cell lung cancer. Cancer Discov. 2014;4(6):662–73.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  61. 61.

    Marsilje TH, Pei W, Chen B, Lu W, Uno T, Jin Y, et al. Synthesis, structure-activity relationships, and in vivo efficacy of the novel potent and selective anaplastic lymphoma kinase (ALK) inhibitor 5-chloro-N2-(2-isopropoxy-5-methyl-4-(piperidin-4-yl)phenyl)-N4-(2-(isopropylsulf onyl)phenyl)pyrimidine-2,4-diamine (LDK378) currently in phase 1 and phase 2 clinical trials. J Med Chem. 2013;56(14):5675–90.

    CAS  Article  PubMed  Google Scholar 

  62. 62.

    Rolfo C, Passiglia F, Russo A, Pauwels P. Looking for a new panacea in ALK-rearranged NSCLC: may be ceritinib? Expert Opin Ther Targets. 2014;18(9):983–5.

    CAS  Article  PubMed  Google Scholar 

  63. 63.

    Shaw AT, Kim D-W, Mehra R, Tan DSW, Felip E, Chow LQM, et al. Ceritinib in ALK-rearranged non-small-cell lung cancer. N Engl J Med. 2014;370(13):1189–97.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  64. 64.

    Chabner BA. Approval after phase I: ceritinib runs the three-minute mile. Oncologist. 2014;19(6):577–8.

    Article  PubMed  PubMed Central  Google Scholar 

  65. 65.

    Kinoshita K, Asoh K, Furuichi N, Ito T, Kawada H, Hara S, et al. Design and synthesis of a highly selective, orally active and potent anaplastic lymphoma kinase inhibitor (CH5424802). Bioorg Med Chem. 2012;20(3):1271–80.

    CAS  Article  PubMed  Google Scholar 

  66. 66.

    Sakamoto H, Tsukaguchi T, Hiroshima S, Kodama T, Kobayashi T, Fukami TA, et al. CH5424802, a selective ALK inhibitor capable of blocking the resistant gatekeeper mutant. Cancer Cell. 2011;19(5):679–90.

    CAS  Article  PubMed  Google Scholar 

  67. 67.

    Seto T, Kiura K, Nishio M, Nakagawa K, Maemondo M, Inoue A, et al. CH5424802 (RO5424802) for patients with ALK-rearranged advanced non-small-cell lung cancer (AF-001JP study): a single-arm, open-label, phase 1-2 study. Lancet Oncol. 2013;14(7):590–8.

    CAS  Article  PubMed  Google Scholar 

  68. 68.

    Gadgeel SM, Gandhi L, Riely GJ, Chiappori AA, West HL, Azada MC, et al. Safety and activity of alectinib against systemic disease and brain metastases in patients with crizotinib-resistant ALK-rearranged non-small-cell lung cancer (AF-002JG): results from the dose-finding portion of a phase 1/2 study. Lancet Oncol. 2014;15(10):1119–28.

    CAS  Article  PubMed  Google Scholar 

  69. 69.

    Camidge DR, Bazhenova L, Salgia R, Weiss GJ, Langer CJ, Shaw AT, et al. First-in-human dose-finding study of the ALK/EGFR inhibitor AP26113 in patients with advanced malignancies: updated results. ASCO Meeting Abstracts. 2013;31(15_suppl):8031.

    Google Scholar 

  70. 70.

    Huang W-S, Li F, Cai L, Xu Y, Zhang S, Wardwell SD, et al. Abstract 2827: discovery of AP26113, a potent, orally active inhibitor of anaplastic lymphoma kinase and clinically relevant mutants. Cancer Res. 2015;75(15 Supplement):2827.

    Article  Google Scholar 

  71. 71.

    Zhang S, Nadworny S, Wardwell SD, Eichinger L, Das B, Ye EY, et al. Abstract 781: the potent ALK inhibitor AP26113 can overcome mechanisms of resistance to first- and second-generation ALK TKIs in preclinical models. Cancer Res. 2015;75(15 Supplement):781.

    Article  Google Scholar 

  72. 72.

    Camidge DR, Bazhenova L, Salgia R, Langer CJ, Gold KA, Rosell R, et al. Safety and efficacy of brigatinib (AP26113) in advanced malignancies, including ALK+ non-small cell lung cancer (NSCLC). ASCO Meeting Abstracts. 2015;33(15_suppl):8062.

    Google Scholar 

  73. 73.

    Zou HY, Friboulet L, Kodack DP, Engstrom LD, Li Q, West M, et al. PF-06463922, an ALK/ROS1 inhibitor, overcomes resistance to first and second generation ALK inhibitors in preclinical models. Cancer Cell. 2015;28(1):70–81.

    CAS  Article  PubMed  Google Scholar 

  74. 74.

    Tucker ER, Danielson LS, Innocenti P, Chesler L. Tackling crizotinib resistance: the pathway from drug discovery to the pediatric clinic. Cancer Res. 2015;75(14):2770–4.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  75. 75.

    Infarinato NR, Park JH, Krytska K, Ryles HT, Sano R, Szigety KM, et al. The ALK/ROS1 inhibitor PF-06463922 overcomes primary resistance to crizotinib in ALK-driven neuroblastoma. Cancer Discovery. 2016;6(1):96–107.

    CAS  Article  PubMed  Google Scholar 

  76. 76.

    Wei P, Qiu M, Lee N, Cao J, Wang H, Tsaparikos K, et al. Abstract 764: rational combination of PF-06463922 (next-generation ALK inhibitor) with PI3K pathway inhibitors overcomes ALKi resistance in EML4-ALK+ NSCLC models. Cancer Res. 2015;75(15 Supplement):764.

    Article  Google Scholar 

  77. 77.

    Shaw AT, Friboulet L, Leshchiner I, Gainor JF, Bergqvist S, Brooun A, et al. Resensitization to crizotinib by the lorlatinib ALK resistance mutation L1198F. N Engl J Med. 2016;374(1):54–61.

    Article  PubMed  Google Scholar 

  78. 78.

    Gravina G, Senapedis W, McCauley D, Baloglu E, Shacham S, Festuccia C. Nucleo-cytoplasmic transport as a therapeutic target of cancer. J Hematol Oncol. 2014;7(1):85.

    Article  PubMed  PubMed Central  Google Scholar 

  79. 79.

    Smith A, Roda D, Yap T. Strategies for modern biomarker and drug development in oncology. J Hematol Oncol. 2014;7(1):70.

    Article  PubMed  PubMed Central  Google Scholar 

  80. 80.

    Yuan X, Wu H, Han N, Xu H, Chu Q, Yu S, et al. Notch signaling and EMT in non-small cell lung cancer: biological significance and therapeutic application. J Hematol Oncol. 2014;7(1):87.

    Article  PubMed  PubMed Central  Google Scholar 

  81. 81.

    Tibes R, Mesa R. Targeting hedgehog signaling in myelofibrosis and other hematologic malignancies. J Hematol Oncol. 2014;7(1):18.

    Article  PubMed  PubMed Central  Google Scholar 

  82. 82.

    Goel G, Sun W. Advances in the management of gastrointestinal cancers—an upcoming role of immune checkpoint blockade. J Hematol Oncol. 2015;8(1):86.

    Article  PubMed  PubMed Central  Google Scholar 

  83. 83.

    Goel G, Sun W. Novel approaches in the management of pancreatic ductal adenocarcinoma: potential promises for the future. J Hematol Oncol. 2015;8(1):44.

    Article  PubMed  PubMed Central  Google Scholar 

  84. 84.

    Lin A, Lin E. Programmed death 1 blockade, an Achilles heel for MMR-deficient tumors? J Hematol Oncol. 2015;8(1):124.

    Article  PubMed  PubMed Central  Google Scholar 

  85. 85.

    Tsai K, Daud A. Nivolumab plus ipilimumab in the treatment of advanced melanoma. J Hematol Oncol. 2015;8(1):123.

    Article  PubMed  PubMed Central  Google Scholar 

  86. 86.

    Fan G, Wang Z, Hao M, Li J. Bispecific antibodies and their applications. J Hematol Oncol. 2015;8(1):130.

    Article  PubMed  PubMed Central  Google Scholar 

  87. 87.

    Reusch U, Burkhardt C, Fucek I, Le Gall F, Le Gall M, Hoffmann K, et al. A novel tetravalent bispecific TandAb (CD30/CD16A) efficiently recruits NK cells for the lysis of CD30+ tumor cells. mAbs. 2014;6(3):728–39.

    Article  PubMed  Google Scholar 

  88. 88.

    Robert C, Long GV, Brady B, Dutriaux C, Maio M, Mortier L, et al. Nivolumab in previously untreated melanoma without BRAF mutation. N Engl J Med. 2015;372(4):320–30.

    CAS  Article  PubMed  Google Scholar 

  89. 89.

    Robert C, Schachter J, Long GV, Arance A, Grob JJ, Mortier L, et al. Pembrolizumab versus ipilimumab in advanced melanoma. N Engl J Med. 2015;372(26):2521–32.

    CAS  Article  PubMed  Google Scholar 

  90. 90.

    Topp MS, Gokbuget N, Stein AS, Zugmaier G, O’Brien S, Bargou RC, et al. Safety and activity of blinatumomab for adult patients with relapsed or refractory B-precursor acute lymphoblastic leukaemia: a multicentre, single-arm, phase 2 study. Lancet Oncol. 2015;16(1):57–66.

    CAS  Article  PubMed  Google Scholar 

  91. 91.

    Herbst RS, Baas P, Kim DW, Felip E, Perez-Gracia JL, Han JY, Molina J, Kim JH, Arvis CD, Ahn MJ, Majem M, Fidler MJ, de Castro G, Jr., Garrido M, Lubiniecki GM, Shentu Y, Im E, Dolled-Filhart M, Garon EB. Pembrolizumab versus docetaxel for previously treated, PD-L1-positive, advanced non-small-cell lung cancer (KEYNOTE-010): a randomised controlled trial. Lancet 2015, 286(10012):10.1016/S0140-6736(1015)01281-01287.

Download references


Jingjing Wu is a recipient of the Henan Provincial Grant for Overseas Research for Young Leaders of Medical Technology (No. 2014041). In addition, Jingjing Wu also received grant support from the Natural Science Foundation of China (NSFC No. 81201793). The grants supported her research training at the Division of Hematology and Oncology, New York Medical College, USA.

Author information



Corresponding author

Correspondence to Delong Liu.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

DL designed the study. JW, JS, and DL drafted the manuscript. DL and JW designed and finalized the figure preparation and tables. All authors read and approved final manuscript.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wu, J., Savooji, J. & Liu, D. Second- and third-generation ALK inhibitors for non-small cell lung cancer. J Hematol Oncol 9, 19 (2016).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • Brain Metastasis
  • Pemetrexed
  • Anaplastic Lymphoma Kinase
  • Anaplastic Large Cell Lymphoma
  • Crizotinib