Auswahl der wissenschaftlichen Literatur zum Thema „MAPK-targeted therapies“

About eight percent of all human tumors (including 50% of melanomas) carry gain-of-function mutations in the BRAF oncogene. Mutated BRAF and subsequent hyperactivation of the MAPK signaling pathway has motivated the use of MAPK-targeted therapies for these tumors. Despite great promise, however, MAPK-targeted therapies in BRAF-mutant tumors are limited by the emergence of drug resistance. Mechanisms of resistance include genetic, non-genetic and epigenetic alterations. Epigenetic plasticity, often modulated by histone-modifying enzymes and gene regulation, can influence a tumor cell’s BRAF dependency and therefore, response to therapy. In this review, focusing primarily on class 1 BRAF-mutant cells, we will highlight recent work on the contribution of epigenetic mechanisms to inter- and intratumor cell heterogeneity in MAPK-targeted therapy response.

Extracellular signal-regulated kinase (ERK) is a part of the mitogen-activated protein kinase (MAPK) signaling pathway which allows the transduction of various cellular signals to final effectors and regulation of elementary cellular processes. Deregulation of the MAPK signaling occurs under many pathological conditions including neurodegenerative disorders, metabolic syndromes and cancers. Targeted inhibition of individual kinases of the MAPK signaling pathway using synthetic compounds represents a promising way to effective anti-cancer therapy. Cross-talk of the MAPK signaling pathway with other proteins and signaling pathways have a crucial impact on clinical outcomes of targeted therapies and plays important role during development of drug resistance in cancers. We discuss cross-talk of the MAPK/ERK signaling pathway with other signaling pathways, in particular interplay with the Hippo/MST pathway. We demonstrate the mechanism of cell death induction shared between MAPK/ERK and Hippo/MST signaling pathways and discuss the potential of combination targeting of these pathways in the development of more effective anti-cancer therapies.

The recent development of high-throughput genomics has revolutionized personalized medicine by identifying key pathways and molecular targets controlling tumor progression and survival. Mitogen-activated protein kinase (MAPK) pathways are examples of such targets, and inhibitors against these pathways have shown promising clinical responses in patients with melanoma, non-small-cell lung cancer, colorectal cancer, pancreatic cancer, and thyroid cancer. Although MAPK pathway-targeted therapies have resulted in significant clinical responses in a large proportion of cancer patients, the rate of tumor recurrence is high due to the development of resistance. Conversely, immunotherapies have shown limited clinical responses, but have led to durable tumor regression in patients, and complete responses. Recent evidence indicates that MAPK-targeted therapies may synergize with immune cells, thus providing rationale for the development of combination therapies. Here, we review the current status of ongoing clinical trials investigating MAPK pathway inhibitors, such as BRAF and MAPK/ERK kinase (MEK) inhibitors, in combination with checkpoint inhibitors targeting programmed death protein 1 (PD-1), programmed death-ligand 1 (PD-L1), and cytotoxic T cell associated antigen-4 (CTLA-4). A better understanding of an individual drug’s mechanism of action, patterns of acquired resistance, and the influence on immune cells will be critical for the development of novel combination therapies.

Multiple myeloma (MM) is a hematological malignancy that remains incurable because most patients will eventually relapse or become refractory to the treatments. Although the treatments have improved, the major problem in MM is the resistance to therapy. Novel agents are currently in development for the treatment of relapsed/refractory MM, including immunomodulatory drugs, proteasome inhibitors, monoclonal antibodies, cell signaling targeted therapies, and strategies targeting the tumor microenvironment. We have previously reviewed in detail the contemporary immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies therapies for MM. Therefore, in this review, we focused on the role of molecular targeted therapies in the treatment of relapsed/refractory multiple myeloma, including cell signaling targeted therapies (HDAC, PI3K/AKT/mTOR, p38 MAPK, Hsp90, Wnt, Notch, Hedgehog, and cell cycle) and strategies targeting the tumor microenvironment (hypoxia, angiogenesis, integrins, CD44, CXCR4, and selectins). Although these novel agents have improved the therapeutic outcomes for MM patients, further development of new therapeutic agents is warranted.

Overactivation of the mitogen-activated protein kinase (MAPK) pathway is an important driver of many human cancers. First line, FDA-approved therapies targeting MAPK signalling, which include BRAF and MEK inhibitors, have variable success across cancers, and a significant number of patients quickly develop resistance. In recent years, a number of preclinical studies have reported alternative methods of overcoming resistance, which include promoting apoptosis, modulating autophagy, and targeting mitochondrial metabolism. This review summarizes mechanisms of resistance to approved MAPK-targeted therapies in BRAF-mutated cancers and discusses novel preclinical approaches to overcoming resistance.

Melanoma is one of the most aggressive forms of skin cancer and is therapeutically challenging, considering its high mutation rate. Following the development of therapies to target BRAF, the most frequently found mutation in melanoma, promising therapeutic responses were observed. While mono- and combination therapies to target the MAPK cascade did induce a therapeutic response in BRAF-mutated melanomas, the development of resistance to MAPK-targeted therapies remains a challenge for a high proportion of patients. Resistance mechanisms are varied and can be categorised as intrinsic, acquired, and adaptive. RASSF1A is a tumour suppressor that plays an integral role in the maintenance of cellular homeostasis as a central signalling hub. RASSF1A tumour suppressor activity is commonly lost in melanoma, mainly by aberrant promoter hypermethylation. RASSF1A loss could be associated with several mechanisms of resistance to MAPK inhibition considering that most of the signalling pathways that RASSF1A controls are found to be altered targeted therapy resistant melanomas. Herein, we discuss resistance mechanisms in detail and the potential role for RASSF1A reactivation to re-sensitise BRAF mutant melanomas to therapy.

Mitogen-activated protein kinase (MAPK) pathways represent ubiquitous signal transduction pathways that regulate all aspects of life and are frequently altered in disease. Here, we focus on the role of MAPK pathways in modulating drug sensitivity and resistance in cancer. We briefly discuss new findings in the extracellular signaling-regulated kinase (ERK) pathway, but mainly focus on the mechanisms how stress activated MAPK pathways, such as p38 MAPK and the Jun N-terminal kinases (JNK), impact the response of cancer cells to chemotherapies and targeted therapies. In this context, we also discuss the role of metabolic and epigenetic aberrations and new therapeutic opportunities arising from these changes.

Le mélanome est le cancer de la peau le plus agressif de par sa grande plasticité phénotypique, son potentiel métastatique et sa résistance aux traitements. Malgré la percée des thérapies ciblant la voie oncogénique MAP kinase, la résistance du mélanome a ces traitements demeure un obstacle majeur qui limite le bénéfice pour les patients porteurs de la mutation BRAFV600E. Les cellules de mélanome peuvent transiter vers un état de type mésenchymateux dédifférencie en fonction des pressions du microenvironnement et des traitements. Cette plasticité cellulaire phénotypique adaptative a été décrite comme un facteur essentiel de résistance aux thérapies ciblées. Mon équipe de recherche travaille sur ce type de résistance non-génétique définie comme ≪ mésenchymateuse ≫, dans lequel les cellules tumorales présentent un comportement invasif et acquièrent des caractéristiques observées typiquement dans les fibroses telles que la capacité à accumuler et à remodeler la matrice extracellulaire et activer les voies de mécanotransduction. Dans ce contexte, mon projet a consiste à caractériser un cluster compose de deux ≪ FibromiRs ≫, microARN impliques dans les mécanismes de fibrogènes et qui sont fortement exprimes dans les mélanomes résistants. Mes résultats obtenus à l’aide d’approches in vitro et in vivo démontrent le rôle du locus miR-143/-145 dans la régulation de la résistance non-génétique en raison de sa capacite à remodeler la matrice et façonner une niche de protection et de tolérance pour la tumeur face aux inhibiteurs de la voie MAP kinase. MiR-143 et miR-145 contribuent également au passage d’un phénotype cellulaire différentié prolifératif a un phénotype mésenchymal plus invasif et résistant. Au niveau moléculaire, j’ai identifié parmi les nombreuses cibles potentielles du cluster, la FSCN1 comme un gène clé cible de miR-143 et -145. Ces travaux ont permis de dévoiler le rôle du cluster miR143/-145 dans le comportement agressif des cellules de mélanome dédifférenciées résistantes et de proposer miR-143 et miR-145 comme nouvelles cibles thérapeutiques pour vaincre la résistance mésenchymateuse et mieux combattre la maladie métastatique réfractaire
Because of its intrinsic plasticity and resistance to treatment, melanoma is one of the most aggressive cancers. Due to the MAPK pathway hyperactivation, targeted therapies counteracting this signaling cascade are efficient in most patients harboring BRAFV600E metastatic melanoma. However, innate and acquired resistances constitute major therapeutic challenges. Acquired resistance to MAPK-targeted therapies arises from de novo genetic lesions and non-genetic events such as transcriptional reprogramming and epigenetic changes. Upon MAPK inhibitors exposure, melanoma cells assume functionally different phenotypic states defined by master transcription factors differential activity and fixed by epigenetic events. Among them, the emergence of a poorly differentiated cell state is strongly associated with resistance acquisition and tumor recurrence. Our team has previously shown that melanoma cells switching to a dedifferentiated phenotype in response to MAPK-targeted therapies display features of cancer-associated fibroblasts (CAFs) like extracellular matrix (ECM) remodeling and markers observed in fibrotic diseases, allowing them to generate a drug tolerant microenvironment.This fibrotic state is characterized in vitro and in vivo by increased deposition and altered ECM organization associated with a mechanophenotype regulated by the mechanotransducers YAP and MRTFA. However, post-transcriptional signaling networks that underpin this mesenchymal-like phenotype are still unknown and effective therapeutic treatments to overcome MAPK-targeted therapy resistance are missing. Given the tumorigenic role of ECM in cancer progression and resistance, therapies aimed at “normalizing” the tumorigenic ECM represent promising strategies to overcome non-genetic resistance to MAPK inhibitors. Based on the role of miRNAs in post-transcriptional regulation, I focused on the characterization of a pool of miRNAs, defined as “FibromiRs,” which have been shown to participate in the onset and progression of fibrotic diseases. Their crucial role in the fibrogenic process and the possibility to therapeutically manipulate them make them promising druggable targets to prevent the onset of resistance to MAPK-targeted therapies in melanoma. Starting from a screening designed to compare the expression of “FibromiRs” in MAPK inhibitors resistant mesenchymal melanoma cells compared to therapy-naive parental cells, we have identified the profibrotic miR-143/145 cluster as overexpressed in mesenchymal resistant cells. We then explored the profibrotic function of miR-143/145 cluster in the mesenchymal-like resistant cell state and melanoma phenotypic plasticity. First, we analysed the regulation of miR-143 and miR-145 in melanoma, identifying a negative regulation of the MAPK pathway on its expression and the involvement of signaling pathways typical of the mesenchymal resistant state, such as TGFβ and PDGF signaling, in the activation of their expression. Next, we investigated the function of the cluster in the context of adaptive and acquired resistance, showing its contribution in ECM reprogramming, activation of mechanotransduction pathways, and in driving the switch from a differentiated proliferative phenotype to a dedifferentiated invasive one with decreased sensitivity to MAPK inhibition. We characterized its mechanism of action, identifying FSCN1 as a key target gene of both mature miR-143 and miR-145 in the acquisition of the mesenchymal invasive phenotype. Finally, we tested the cluster as a potential therapeutic target in vitro and in vivo through antisense oligonucleotide-mediated inhibition of its expression or pharmacological modulation combined with MAPK inhibitors administration. Overall, this work highlights the importance of a FibromiR cluster in the acquisition of a dedifferentiated phenotype resistant to MAPK-targeted therapies and proposes new therapeutic strategies based on the inhibition of FibromiRs to overcome such resistance mechanism

Le cancer du sein triple négatif (CSTN) représente 10-15% des cancers du sein. Son pronostic est sombre en particulier face à la rareté des thérapies ciblées adaptées à ce sous type. Sa complexité de prise en charge est directement liée à sa grande hétérogénéité tant au niveau moléculaire que morphologique.Dans ce contexte, nous avons développés des modèles de Patient Derived Xenograft (PDX) issus de CSTN. Ce modèle, robuste, a la particularité de retenir les caractéristiques (histologiques, génotypiques mais aussi phénotypiques) des tumeurs observées chez les patients.Dans notre cohorte de 61 PDX de CSTN, nous avons confirmé l’hétérogénéité anatomopathologique et génomique de ce sous type. Les différentes anomalies moléculaires mises en évidence sont de faible fréquence (<10%) mais 88% de nos modèles ont une altération potentiellement ciblables et plus de la moitié ont au moins 2 altérations ciblables. Nous nous sommes particulièrement intéressés à 2 sous types de CSTN : (i) le sous -type LAR (Luminal Androgen Receptor) dont nous avons décrit les premiers modèles de PDX : ces modèles présentent des altérations fréquentes de la voie PI3K ainsi que des réponses majeures aux inhibiteurs de cette voie ; (ii) le sous type métaplasique, dont 4 de nos 9 modèles présentent une double altération genomique dans les voies PI3K et RTK-MAPK ainsi que des réponses complètes et durables à la combinaison d’inhibiteurs de PI3K et de MAPK.Dans les autres sous-types de CSTN, nous avons également mis en évidence des taux de réponse importants aux inhibiteurs de la voie PI3K et MAPK. Les biomarqueurs de réponse à ces différentes thérapies ciblées testées sont en cours d’étude en particulier par intégration des données génomique et protéique de nos modèles
Triple negative breast cancer (TNBC) accounts for 10-15% of breast cancers. Its prognosis is worse, particularly due to the rarity of targeted therapies adapted to this subtype. Its complexity of management is directly related to its high heterogeneity, both at the morphological and genomical levels.In this context, we developed Patient Derived Xenograft (PDX) models from TNBC. This robust model has the specificity of retaining the characteristics (histological, genotypic but also phenotypic) of the tumors observed in patients.In our cohort of 61 PDXs of TNBC, we confirmed the anatomopathological and genomical heterogeneity of this subtype. Majority of targeted alterations are of low frequency (<10%) but 88% of our models harbour a potential targetable alteration and more than half have at least 2 targetable alterations. We were particularly interested in 2 subtypes of TNBC: (i) the LAR subtype for which we have described the first PDX models: these models present frequent alterations of the PI3K pathway as well as major responses to PI3K inhibitors; (ii) the metaplastic subtype, of which 4 of our 9 models show double alterations in the PI3K and RTK-MAPK pathways and complete and durable responses to the combination of PI3K-MAPK inhibitors.In the other CSTN subtypes, we have also demonstrated significant response rates to PI3K and MAPK inhibitors. Biomarkers of response to these various targeted therapies tested are being studied, in particular by integrating the genomic and protein data from a higher number of PDX models

Il est clairement admis que la voie des MAPK est essentielle à la mélanomagenèse. Le développement de nouveaux médicaments ciblant cette voie, tels que les inhibiteurs de BRAF et/ou de MEK, a constitué une avancée majeure dans la prise en charge thérapeutique du mélanome. Cependant, les patients rechutent systématiquement sous traitement, ce qui suggère l'émergence de mécanismes de résistances. De nombreuses études montrent que l'expression et l'activation du facteur de transcription c-Jun sont induites après traitement de cellules de mélanome BRAF-mutées par des inhibiteurs de la voie des MAPK (MAPKi). De plus, la déplétion de c-Jun sensibilise ces cellules à ces inhibiteurs en induisant l'apoptose. Nous avons transfecté des lignées cellulaires de mélanome BRAF-mutées par des siARN dirigés contre c-Jun et traité ces cellules avec un inhibiteur de BRAF (PLX4032). Nous avons ensuite analysé l'expression du génome par une étude de transcriptomique afin de déterminer les gènes cibles de c-Jun qui pourraient être impliqués dans la réponse pharmacologique aux MAPKi. Cette étude a révélé que SLIT And NTRK Like Family Member 6 (SLITRK6) est un gène cible de c-Jun qui pourrait être associé à une réponse pharmacologique antitumorale aux MAPKi. En effet, l'ARNm et la protéine SLITRK6 sont induits dans les lignées cellulaires de mélanome BRAF-mutées après traitement par inhibiteur de BRAF seul ou en association avec un inhibiteur de MEK (AZD6244). Nous avons également montré que la combinaison des inhibiteurs de la voie des MAPK avec un anticorps conjugué à un cytotoxique ciblant SLITRK6 augmente la mort des cellules de mélanome BRAF-mutées en induisant de l'apoptose in vitro. Finalement, nos travaux montrent que SLITRK6 pourrait être une nouvelle cible pharmacologique pour le traitement du mélanome métastatique BRAF-muté et/ou être un biomarqueur potentiel de cellules résistantes aux MAPKi
It is clearly recognized that the MAPK pathway is essential for melanomagenesis. The development of new drugs targeting this pathway such as BRAF inhibitors and/or MEK inhibitors has been a major advance in the therapeutic management of melanoma. However, patients still relapse suggesting the emergence of mechanisms of resistance. Many data show that both the expression and activation of the transcription factor c-Jun are induced after treatment of BRAF-mutant cells with MAPK pathway inhibitors (MAPKi). Furthermore, depletion of c-Jun sensitizes cells to these inhibitors triggering apoptosis. We depleted BRAF-mutant melanoma cell lines for c-Jun by siRNA and treated cells with a BRAF inhibitor (PLX4032). Whole genome expression was then analysed by transcriptomic study to determine target genes of c-Jun that could be associated with pharmacological response to MAPKi. This study revealed that SLIT And NTRK Like Family Member 6 (SLITRK6) is a target gene of c-Jun that could be associated with antitumor pharmacological response to MAPKi. Indeed, SLITRK6 mRNA and protein are induced in BRAF-mutant melanoma cell lines after BRAF inhibitor treatment alone or in combination with MEK inhibitor (AZD6244). We also show that the combination of MAPKi with an antibody conjugated with a cytotoxic drug targeting SLITRK6 increases BRAF-mutant melanoma cell death triggering apoptosis in vitro. Finally, our data show that SLITRK6 could be a new pharmacological target for the treatment of BRAF-mutant metastatic melanoma and/or a potential biomarker of resistant cells to MAPKi

La neurofibromine, produit du gène NF1, agit comme un inhibiteur de la voie RAS-MAPK (Mitogen-activated protein kinases), voie majeure de la cancérogenèse. Le gène NF1 est donc un gène suppresseur de tumeurs. Des mutations constitutionnelles hétérozygotes perte-de-fonction de NF1 causent la neurofibromatose de type 1 (NF1 ; MIM#162200). Cette maladie rare prédispose notamment au développement de tumeurs des gaines nerveuses. Des mutations somatiques de NF1 ont par ailleurs été décrites dans des cancers sporadiques, hors contexte de neurofibromatose. Des données récentes de la littérature confirment que NF1 est un gène suppresseur de tumeurs crucial en oncologie. L'implication de la voie RAS-MAPK dans les cancers bronchiques non à petites cellules (CBNPC) est bien caractérisée avec la mise en évidence de mutations somatiques activatrices spécifiques de la voie, notamment des oncogènes EGFR, KRAS et BRAF dans les adénocarcinomes pulmonaires. Cependant, l'implication du gène NF1 a été peu étudiée dans les CBNPC. Nous avons confirmé l'implication de NF1 dans le développement des adénocarcinomes bronchiques par une approche ciblée de NGS (Next Generation Sequencing) sur une cohorte de 138 échantillons tumoraux : 36 altérations somatiques (26%) de NF1 ont été retrouvées dont 25 mutations ponctuelles (parmi lesquelles 4 homozygotes) et 11 délétions. Ces altérations étaient majoritairement exclusives de mutations affectant d'autres effecteurs de la voie RAS-MAPK. Il était retrouvé un nombre plus important d'altérations de NF1 dans les échantillons de patients ayant reçu une chimiothérapie. Une corrélation génotype-phénotype a pu être établie : il s'agissait en majorité d'hommes (72%), fumeurs (75%) avec une survie sans progression et une survie globale significativement meilleures que les patients KRAS mutés. Afin de déterminer les conséquences fonctionnelles des altérations de NF1, nous avons établi des modèles cellulaires mutés dans NF1 grâce au système d'édition du génome CRISPR/Cas9. Trois lignées de carcinomes bronchiques non à petites cellules ont été modifiées génétiquement. Nous avons notamment évalué les conséquences de l'inactivation bi- ou mono-allélique de NF1 réalisée respectivement par CRISPR/Cas9 et Nickase. Les western blot ont confirmé la perte d'expression partielle ou complète de la neurofibromine en cas de mutations mono- ou bi-alléliques du gène NF1 ainsi qu'une activation de la voie RAS-MAPK avec un ratio pERK/ERK augmenté en cas de mutations. Nous avons observé que les clones NF1-/- présentaient un phénotype plus agressif en termes de migration, invasion et prolifération que les clones NF1+/- ou sauvages. L'analyse différentielle des transcriptomes a montré des profils transcriptomiques distincts en cas d'altérations homozygotes ou hétérozygotes de NF1 ainsi que dans les cellules sauvages ; les profils transcriptomiques des clones sauvages étaient plus proches des clones avec mutations hétérozygotes de NF1. Des approches pharmacologiques in vitro sur nos modèles cellulaires transgéniques pour tester la sensibilité aux inhibiteurs de MEK seuls ou en association avec des inhibiteurs de PIK3CA, ainsi que la validation in vivo sur des modèles de xénogreffes murines sont en cours. Notre étude montre que les CBNPC présentant des altérations somatiques de NF1 constituent une entité clinique et pronostique distincte. L'étude de nos modèles cellulaires permettra (1) d'évaluer l'influence du caractère mono- ou bi-allélique des altérations de NF1 sur les conséquences fonctionnelles et (2) de tester de nouvelles perspectives thérapeutiques qu'il conviendra de confirmer in vivo sur des modèles pré-cliniques
Driver molecular alterations are found in >40% of non-small cell lung cancers (NSCLCs). They specifically target the RAS-MAPK pathway, including the EGFR, KRAS, and BRAF oncogenes. NF1 is a tumor suppressor gene that encodes neurofibromin, an inhibitor of the RAS-MAPK pathway. NF1 mutation detection is challenging owing to the large size of the gene, the presence of numerous pseudogenes, and the absence of mutation hotspot. Recent studies showed that NF1 is a major tumor suppressor gene implicated in carcinogenesis. According to The Cancer Genome Atlas data (TCGA), NF1 somatic mutations are found in ~15% of lung cancer. However, NF1 mutations in NSCLCs are not extensively explored in NSCLCs to date. We hypothesized that NF1 alterations could define a specific NSCLC subtype with distinct clinical and molecular profiles. We performed NF1 analysis using next generation sequencing (NGS) in lung adenocarcinoma surgical specimens with known KRAS, EGFR, TP53, BRAF, HER2, and PIK3CA status. We evaluated the molecular and clinical specificities of NF1 mutated NSCLCs. Then, we established NF1-mutated cellular models from different NF1 wild-type (WT) cell lines, using the CRISPR-Cas9 system. Mono- and bi-allelic NF1 mutations were generated using CRISPR-Cas9 and nickase CRISPR-Cas9 technologies. In vitro functional tests and drug screening were performed using these isogenic cell models. In our series of 138 lung adenocarcinoma specimens, 25 tumours showed NF1 mutations (18%) and 11 showed NF1 deletions (8%). NF1 mutations were rarely associated with other mutations. Most of patients with NF1 alterations were males (72%) and smokers (75%). Overall survival and disease-free survival were statistically better in patients with NF1 alterations patients (N=35) than in KRAS mutated patients (N=30) in univariate analysis. There were more NF1 mutations in patients treated by neoadjuvant chemotherapy (p = 0.01). Then, we established cellular models of NF1-mutated NSCLCs, using nickase and CRISPR-Cas9 technology. Mono- and bi-allelic NF1 mutations were generated. Loss of NF1 expression was confirmed by western blot: partial and total loss-of-expression of neurofibromin was found in mono-allelic and bi-allelic NF1 mutated cell lines, respectively. Using western blot, we showed that pERK/ERK ratio was higher in NF1-mutated cell lines versus WT cell lines, confirming that NF1 loss-of-function triggered RAS-MAPK pathway activation. Homozygous NF1 mutated cells seemed to be more aggressive in vitro compared to heterozygous and WT mutated cells, using migration, invasion, and proliferation tests. Transcriptome analysis confirmed that WT, heterozygous, and homozygous NF1 mutations defined distinct clusters. WT and NF1 heterozygous clones showed closer transcriptional profiles. In vitro pharmacological screens in this isogenic NSCLC model are ongoing using MEK and PIK3CA inhibitors alone and in combination. In vivo pharmacological screen will also be performed on murine PDX models. Our results confirm that NF1 is frequently mutated and represents a distinct molecular and clinical subtype of NSCLCs. A better comprehension of functional consequences of NF1 mutations, including mono- and bi-allelic alterations, may open new avenues for NSCLCs therapy