Next-Generation Sequencing Identifies and Immunohistochemistry Confirms a Novel Crizotinib-Sensitive ALK Rearrangement in a Patient with Metastatic Non–Small-Cell.

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Next-Generation Sequencing Identifies and Immunohistochemistry Confirms a Novel Crizotinib-Sensitive ALK Rearrangement in a Patient with Metastatic Non–Small-Cell Lung Cancer Nir Peled, MD, PhD, Gary Palmer, MD, Fred R. Hirsch, MD, PhD, Murry W. Wynes, PhD, Maya Ilouze, PhD, Marileila Varella-Garcia, PhD, Lior Soussan-Gutman, PhD, Geoff A. Otto, PhD, Philip J. Stephens, PhD, Jeffrey S. Ross, MD, Maureen T. Cronin, PhD, Doron Lipson, PhD, Vincent A. Miller, MD Journal of Thoracic Oncology Volume 7, Issue 9, Pages e14-e16 (September 2012) DOI: 10.1097/JTO.0b013e3182614ab5 Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

Figure 1 Panel A, Using a manual fluorescent in situ hybridization technique, paraffin sections were hybridized with fluorescent ALK Break-Apart probe (Abbott Molecular, Des Plaines, IL). The specimen displayed an atypical pattern of double 3′ALK signals (red) fused with the 5′ALK signal (green), which was classified as negative for ALK gene rearrangement (< 15% of cells with split signals, 3′ ALK and 5′ ALK signals apart by >2 times signal size or single 3′ ALK signal, 50 cells scored). Panels B, C, and D, ALK immunohistochemistry was performed using a primary antibody (clone D5F3, Cell Signaling Technology, Inc, Danvers, MA). All paraffin tissue sections were stained with ALK and were reviewed by two pathologists. The tumor cells have predominantly strong staining (3+) in 50% of the tumor cells (lower right). The remaining tumor cells showed (2+) in 30% (lower left) and (1+) in 20% of the tumor cells, thus resulting in a histologic score of 230 on a 0–300 scale. The top right is 200× and bottom two panels are 400×. Journal of Thoracic Oncology 2012 7, e14-e16DOI: (10.1097/JTO.0b013e3182614ab5) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

Figure 2 A, Hypothetical structure of rearrangement in genomic DNA (top) complex rearrangement placing EML4 exons 1–13 upstream of ALK exons 20–29, separated by small genomic shards; RNA (bottom) transcription and splicing remove connective region and generate a canonical EML4-ALK fusion transcript; (B) Expression of ALK as measured by RNA-seq coverage, dashed line denotes boundary between exons 19 and 20. Journal of Thoracic Oncology 2012 7, e14-e16DOI: (10.1097/JTO.0b013e3182614ab5) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions

Figure 3 A, Chest and (B) pelvic positron emission tomographic computed tomographic scans before, after 4 weeks, and after 4 months of crizotinib. Journal of Thoracic Oncology 2012 7, e14-e16DOI: (10.1097/JTO.0b013e3182614ab5) Copyright © 2012 International Association for the Study of Lung Cancer Terms and Conditions