Neuroblastoma (NB) remains a leading cause of childhood cancer deaths. Children who do survive are left with long-term side effects, many of which can be life threatening. In this era of more rational therapies, substantial efforts are bein made to identify optimal targets. We discovered that activating mutations of the ALK oncogene are the major cause of hereditary NB, and that somatically acquired mutations and amplification events often drive the malignant process in a subset of sporadic tumors. This was the motivation for the first phase of this project, where we then demonstrated that the common ALK mutations result in differential kinase activation and differential sensitivity to ATP-competitive inhibitors. This work established ALK as a tractable molecular target in NB and led to a now completed pediatric phase 1 trial and ongoing phase 2 trial of crizotinib, the only FDA approved ALK inhibitor. The results from the first 4 years of our R01 show the complexity of ALK activation in NB, and demonstrate that inhibition of a mutant kinase domain is much more challenging than fusion proteins present in lymphomas and lung cancer. This provides the impetus for the long-term goal of this research proposal to develop novel therapeutic strategies aimed at effectively inhibiting ALK-mediated signaling. The primary objective is to develop a responder hypothesis for therapeutic stratification of newly diagnosed patients with ALK-mutant NB, to elucidate mechanisms of resistance to crizotinib, and to define circumvention strategies in the clinic. The central hypothesis to be explored here is that rational and effective ALK-inhibition strategies can only be successfully developed after elucidation of the clinical implications of ALK alterations identified in patients and the mechanisms driving intrinsic resistance. The motivation is the urgent need to improve high-risk NB survival rates and decrease treatment-related morbidities. We will test our central hypothesis in three specific aims: 1) Define the functional consequences of patient-derived ALK alterations;2) Identify mechanisms of sensitivity and resistance to ALK inhibition;and 3) Develop rational therapeutic combinations targeting ALK signaling pathways to overcome resistance.
The first Aim, based on recent unpublished data showing a variety of alternative genetic mechanisms for ALK activation, will be a discovery effort in the relapsed NB genome, correlating sequence variations with oncogenic potential and prioritizing next-generation ALK inhibitors for preclinical and clinical testing.
Aim 2 is devoted to elucidate mechanisms of intrinsic resistance to crizotinib that will allow for rational prediction of combinatorial therapies for further evaluation.
The final Aim will garner the preclinical justification required to move combination therapies to the clinic, building on our extensive preliminary data of synergistic drug interactions in crizotinib-resistant models. We consider this project significant because it will result in identification of key oncogenic vulnerabilities in NB cells, biomarkers of response and resistance which will be integrated into phase 1 trials, and the proof-of- concept required to justify alternative ALK inhibition strategies for early phase clinical trial development.

Public Health Relevance

This research project is relevant to public health because the development of rational and effective ALK- inhibition strategies will impact patients with neuroblastoma as well as histologically diverse tumors where ALK is a critical mediator oncogenesis. Defining oncogenic vulnerabilities in tumor cells with ALK alterations will lead to more precise clinical biomarkers and therapies. The proposed research is highly relevant to the NIH mission and the urgent unmet need of developing rational evidence-based strategies to reduce the burden of cancer in general, and neuroblastoma in particular.

National Institute of Health (NIH)
National Cancer Institute (NCI)
Research Project (R01)
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Basic Mechanisms of Cancer Therapeutics Study Section (BMCT)
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Forry, Suzanne L
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Children's Hospital of Philadelphia
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Wood, Andrew C; Krytska, Kateryna; Ryles, Hannah T et al. (2017) Dual ALK and CDK4/6 Inhibition Demonstrates Synergy against Neuroblastoma. Clin Cancer Res 23:2856-2868
Infarinato, Nicole R; Park, Jin H; Krytska, Kateryna et al. (2016) The ALK/ROS1 Inhibitor PF-06463922 Overcomes Primary Resistance to Crizotinib in ALK-Driven Neuroblastoma. Cancer Discov 6:96-107
Krytska, Kateryna; Ryles, Hannah T; Sano, Renata et al. (2016) Crizotinib Synergizes with Chemotherapy in Preclinical Models of Neuroblastoma. Clin Cancer Res 22:948-60
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Mossé, Yael P; Lim, Megan S; Voss, Stephan D et al. (2013) Safety and activity of crizotinib for paediatric patients with refractory solid tumours or anaplastic large-cell lymphoma: a Children's Oncology Group phase 1 consortium study. Lancet Oncol 14:472-80
Carpenter, Erica L; Mossé, Yael P (2012) Targeting ALK in neuroblastoma--preclinical and clinical advancements. Nat Rev Clin Oncol 9:391-9
Carpenter, E L; Haglund, E A; Mace, E M et al. (2012) Antibody targeting of anaplastic lymphoma kinase induces cytotoxicity of human neuroblastoma. Oncogene 31:4859-67
Light, Jennifer E; Koyama, Hiroshi; Minturn, Jane E et al. (2012) Clinical significance of NTRK family gene expression in neuroblastomas. Pediatr Blood Cancer 59:226-32
Bresler, Scott C; Wood, Andrew C; Haglund, Elizabeth A et al. (2011) Differential inhibitor sensitivity of anaplastic lymphoma kinase variants found in neuroblastoma. Sci Transl Med 3:108ra114

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