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1
Bhujbal, Swapnil P., Seketoulie Keretsu, and Seung Joo Cho. "Molecular Modelling Studies on Pyrazole Derivatives for the Design of Potent Rearranged during Transfection Kinase Inhibitors." Molecules 26, no. 3 (January 28, 2021): 691. http://dx.doi.org/10.3390/molecules26030691.
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RET (rearranged during transfection) kinase, one of the receptor tyrosine kinases, plays a crucial role in the development of the human nervous system. It is also involved in various cell signaling networks responsible for the normal cell division, growth, migration, and survival. Previously reported clinical studies revealed that deregulation or aberrant activation of RET signaling can cause several types of human cancer. For example, medullary thyroid carcinoma (MTC) and multiple endocrine neoplasia (MEN2A, MEN2B) occur due to sporadic mutation or germline RET mutation. A number of RET kinase inhibitors have been approved by the FDA for the treatment of cancer, such as cabozantinib, vandetanib, lenvatinib, and sorafenib. However, each of these drugs is a multikinase inhibitor. Hence, RET is an important therapeutic target for cancer drug design. In this work, we have performed various molecular modelling studies, such as molecular docking and dynamics simulation for the most active compound of the pyrazole series as RET kinase inhibitors. Furthermore, molecular mechanics Poisson–Boltzmann surface area (MM/PBSA) free energy calculation and 3-dimensional quantitative structure–activity relationship (3D-QSAR) were performed using g_mmpbsa and SYBYL-X 2.1 package. The results of this study revealed the crucial binding site residues at the active site of RET kinase and contour map analysis showed important structural characteristics for the design of new highly active inhibitors. Therefore, we have designed ten RET kinase inhibitors, which showed higher inhibitory activity than the most active compound of the series. The results of our study provide insights to design more potent and selective RET kinase inhibitors.
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Kim, Dong Wook, Young Suk Jo, Hye Sook Jung, Hyo Kyun Chung, Jung Hun Song, Ki Cheol Park, Su Hyeon Park, et al. "An Orally Administered Multitarget Tyrosine Kinase Inhibitor, SU11248, Is a Novel Potent Inhibitor of Thyroid Oncogenic RET/Papillary Thyroid Cancer Kinases." Journal of Clinical Endocrinology & Metabolism 91, no. 10 (October 1, 2006): 4070–76. http://dx.doi.org/10.1210/jc.2005-2845.
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Abstract Context: The oncogenic RET/PTC tyrosine kinase causes papillary thyroid cancer (PTC). The use of inhibitors specific for RET/PTC may be useful for targeted therapy of PTC. Objective: The objective of the study was to evaluate the efficacies of the recently developed kinase inhibitors SU11248, SU5416, and SU6668 in inhibition of RET/PTC. Design: SU11248, SU5416, and SU6668 were synthesized, and their inhibitory potencies were evaluated using an in vitro RET/PTC kinase assay. The inhibitory effects of the compounds on RET/PTC were evaluated by quantifying the autophosphorylation of RET/PTC, signal transducer and activator of transcription (STAT)-3 activation, and the morphological reversal of RET/PTC-transformed cells. Results: An in vitro kinase assay revealed that SU5416, SU6668, and SU11248 inhibited phosphorylation of the synthetic tyrosine kinase substrate peptide E4Y by RET/PTC3 in a dose-dependent manner with IC50 of approximately 944 nm for SU5416, 562 nm for SU6668, and 224 nm for SU11248. Thus, SU11248 effectively inhibits the kinase activity of RET/PTC3. RET/PTC-mediated Y705 phosphorylation of STAT3 was inhibited by addition of SU11248, and the inhibitory effects of SU11248 on the tyrosine phosphorylation and transcriptional activation of STAT3 were very closely correlated with decreased autophosphorylation of RET/PTC. SU11248 caused a complete morphological reversion of transformed NIH-RET/PTC3 cells and inhibited the growth of TPC-1 cells that have an endogenous RET/PTC1. Conclusion: SU11248 is a highly effective tyrosine kinase inhibitor of the RET/PTC oncogenic kinase.
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Subbiah, Vivek, Dong Yang, Vamsidhar Velcheti, Alexander Drilon, and Funda Meric-Bernstam. "State-of-the-Art Strategies for Targeting RET-Dependent Cancers." Journal of Clinical Oncology 38, no. 11 (April 10, 2020): 1209–21. http://dx.doi.org/10.1200/jco.19.02551.
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Activating receptor tyrosine kinase RET (rarranged during transfection) gene alterations have been identified as oncogenic in multiple malignancies. RET gene rearrangements retaining the kinase domain are oncogenic drivers in papillary thyroid cancer, non–small-cell lung cancer, and multiple other cancers. Activating RET mutations are associated with different phenotypes of multiple endocrine neoplasia type 2 as well as sporadic medullary thyroid cancer. RET is thus an attractive therapeutic target in patients with oncogenic RET alterations. Multikinase inhibitors with RET inhibitor activity, such as cabozantinib and vandetanib, have been explored in the clinic for tumors with activating RET gene alterations with modest clinical efficacy. As a result of the nonselective nature of these multikinase inhibitors, patients had off-target adverse effects, such as hypertension, rash, and diarrhea. This resulted in a narrow therapeutic index of these drugs, limiting ability to dose for clinically effective RET inhibition. In contrast, the recent discovery and clinical validation of highly potent selective RET inhibitors (pralsetinib, selpercatinib) demonstrating improved efficacy and a more favorable toxicity profile are poised to alter the landscape of RET-dependent cancers. These drugs appear to have broad activity across tumors with activating RET alterations. The mechanisms of resistance to these next-generation highly selective RET inhibitors is an area of active research. This review summarizes the current understanding of RET alterations and the state-of-the-art treatment strategies in RET-dependent cancers.
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Ramesh, Priyanka, and Shanthi Veerappapillai. "Designing Novel Compounds for the Treatment and Management of RET-Positive Non-Small Cell Lung Cancer—Fragment Based Drug Design Strategy." Molecules 27, no. 5 (February 28, 2022): 1590. http://dx.doi.org/10.3390/molecules27051590.
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Rearranged during transfection (RET) is an oncogenic driver receptor that is overexpressed in several cancer types, including non-small cell lung cancer. To date, only multiple kinase inhibitors are widely used to treat RET-positive cancer patients. These inhibitors exhibit high toxicity, less efficacy, and specificity against RET. The development of drug-resistant mutations in RET protein further deteriorates this situation. Hence, in the present study, we aimed to design novel drug-like compounds using a fragment-based drug designing strategy to overcome these issues. About 18 known inhibitors from diverse chemical classes were fragmented and bred to form novel compounds against RET proteins. The inhibitory activity of the resultant 115 hybrid molecules was evaluated using molecular docking and RF-Score analysis. The binding free energy and chemical reactivity of the compounds were computed using MM-GBSA and density functional theory analysis, respectively. The results from our study revealed that the developed hybrid molecules except for LF21 and LF27 showed higher reactivity and stability than Pralsetinib. Ultimately, the process resulted in three hybrid molecules namely LF1, LF2, and LF88 having potent inhibitory activity against RET proteins. The scrutinized molecules were then subjected to molecular dynamics simulation for 200 ns and MM-PBSA analysis to eliminate a false positive design. The results from our analysis hypothesized that the designed compounds exhibited significant inhibitory activity against multiple RET variants. Thus, these could be considered as potential leads for further experimental studies.
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Marcello, Krista, Marcia S. Brose, Taofeek K. Owonikoko, Karen L. Reckamp, Laura J. Tafe, Rachael Andrie, and Kevin Obholz. "Clinical application of precision medicine among oncologists: A case study in RET-targeted therapy." Journal of Clinical Oncology 40, no. 16_suppl (June 1, 2022): e18705-e18705. http://dx.doi.org/10.1200/jco.2022.40.16_suppl.e18705.
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e18705 Background: Precision medicine has revolutionized cancer care across multiple tumor types and new actionable biomarkers and targeted therapies are emerging at an unprecedented pace, creating myriad opportunities to optimize care and mitigate the often-dire sequelae of traditional cancer therapy. Many oncology healthcare professionals (HCPs) in practice are not employing optimal testing methodologies to detect biomarkers in patients who could benefit from novel targeted therapies. In this study, we analyze HCP awareness and application of RET alteration testing and integration of recently approved, new-generation selective RET inhibitors into practice for appropriate patients with NSCLC and thyroid cancer. Methods: In August 2020 HCPs were surveyed on RET alteration testing and use of RET-targeted therapeutics in their current practice. Study eligibility criteria included active HCPs in an oncology, pulmonology, or pathology practice. A curriculum of live and online educational activities was then developed for any interested oncologists and pathologists on RET alteration testing and/or targeted therapy for RET-altered lung and thyroid cancers. These activities included case studies, polling, and evaluations that provided additional insight on self-identified practice trends. In June 2021, at the completion of the educational program, eligible HCPs were surveyed again on RET alteration testing and selection of RET inhibitor therapy for appropriate patients. Results: In August 2020, 123 practicing HCPs completed the initial survey and 33% were testing patients for RET gene alterations and 18% were aware of the most sensitive testing assay for detection of RET fusions. 25% and 7%, respectively, were aware of the current indications for RET inhibitors in RET fusion–positive NSCLC and RET-altered thyroid cancer. Self-identified practice trends identified among the unselected cohort of 12,537 individual HPCs participating in the educational activities also demonstrated similar lack of appropriate testing for RET alterations and use of RET inhibitors. In June 2021, 60 practicing HCPs completed the follow-up survey and 40% were testing patients for RET gene alterations and 25% were aware of the most sensitive testing assay for detection of RET fusions. 52% and 22%, respectively, were aware of the current indications for RET inhibitors in RET fusion–positive NSCLC and RET-altered thyroid cancer. Conclusions: The rate of broad testing for RET alterations across patients with NSCLC and thyroid cancer remains low and many HCPs lack understanding of when to consider treating with a RET inhibitor. These results underscore the lag in adoption of optimal precision medicine approaches in oncology and the need for expert guidance and educational activities to optimize individualized, biomarker-driven treatment approaches for patients with cancer.
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Marcello, Krista, Marcia S. Brose, Taofeek K. Owonikoko, Karen L. Reckamp, Laura J. Tafe, Rachael Andrie, and Kevin Obholz. "Clinical application of precision medicine among oncologists: A case study in RET-targeted therapy." Journal of Clinical Oncology 40, no. 16_suppl (June 1, 2022): e18705-e18705. http://dx.doi.org/10.1200/jco.2022.40.16_suppl.e18705.
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e18705 Background: Precision medicine has revolutionized cancer care across multiple tumor types and new actionable biomarkers and targeted therapies are emerging at an unprecedented pace, creating myriad opportunities to optimize care and mitigate the often-dire sequelae of traditional cancer therapy. Many oncology healthcare professionals (HCPs) in practice are not employing optimal testing methodologies to detect biomarkers in patients who could benefit from novel targeted therapies. In this study, we analyze HCP awareness and application of RET alteration testing and integration of recently approved, new-generation selective RET inhibitors into practice for appropriate patients with NSCLC and thyroid cancer. Methods: In August 2020 HCPs were surveyed on RET alteration testing and use of RET-targeted therapeutics in their current practice. Study eligibility criteria included active HCPs in an oncology, pulmonology, or pathology practice. A curriculum of live and online educational activities was then developed for any interested oncologists and pathologists on RET alteration testing and/or targeted therapy for RET-altered lung and thyroid cancers. These activities included case studies, polling, and evaluations that provided additional insight on self-identified practice trends. In June 2021, at the completion of the educational program, eligible HCPs were surveyed again on RET alteration testing and selection of RET inhibitor therapy for appropriate patients. Results: In August 2020, 123 practicing HCPs completed the initial survey and 33% were testing patients for RET gene alterations and 18% were aware of the most sensitive testing assay for detection of RET fusions. 25% and 7%, respectively, were aware of the current indications for RET inhibitors in RET fusion–positive NSCLC and RET-altered thyroid cancer. Self-identified practice trends identified among the unselected cohort of 12,537 individual HPCs participating in the educational activities also demonstrated similar lack of appropriate testing for RET alterations and use of RET inhibitors. In June 2021, 60 practicing HCPs completed the follow-up survey and 40% were testing patients for RET gene alterations and 25% were aware of the most sensitive testing assay for detection of RET fusions. 52% and 22%, respectively, were aware of the current indications for RET inhibitors in RET fusion–positive NSCLC and RET-altered thyroid cancer. Conclusions: The rate of broad testing for RET alterations across patients with NSCLC and thyroid cancer remains low and many HCPs lack understanding of when to consider treating with a RET inhibitor. These results underscore the lag in adoption of optimal precision medicine approaches in oncology and the need for expert guidance and educational activities to optimize individualized, biomarker-driven treatment approaches for patients with cancer.
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Gild, Matti L., Iñigo Landa, Mabel Ryder, Ronald A. Ghossein, Jeffrey A. Knauf, and James A. Fagin. "Targeting mTOR in RET mutant medullary and differentiated thyroid cancer cells." Endocrine-Related Cancer 20, no. 5 (July 4, 2013): 659–67. http://dx.doi.org/10.1530/erc-13-0085.
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Inhibitors of RET, a tyrosine kinase receptor encoded by a gene that is frequently mutated in medullary thyroid cancer, have emerged as promising novel therapies for the disease. Rapalogs and other mammalian target of rapamycin (mTOR) inhibitors are effective agents in patients with gastroenteropancreatic neuroendocrine tumors, which share lineage properties with medullary thyroid carcinomas. The objective of this study was to investigate the contribution of mTOR activity to RET-induced signaling and cell growth and to establish whether growth suppression is enhanced by co-targeting RET and mTOR kinase activities. Treatment of the RET mutant cell lines TT, TPC-1, and MZ-CRC-1 with AST487, a RET kinase inhibitor, suppressed growth and showed profound and sustained inhibition of mTOR signaling, which was recapitulated by siRNA-mediated RET knockdown. Inhibition of mTOR with INK128, a dual mTORC1 and mTORC2 kinase inhibitor, also resulted in marked growth suppression to levels similar to those seen with RET blockade. Moreover, combined treatment with AST487 and INK128 at low concentrations suppressed growth and induced apoptosis. These data establish mTOR as a key mediator of RET-mediated cell growth in thyroid cancer cells and provide a rationale for combinatorial treatments in thyroid cancers with oncogenic RET mutations.
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Drilon, Alexander, Jun Zhong, Ying Lu, Yongbo Liu, Hao Wang, Minchun Chen, Xiaohu Chen, John Zhu, Shun Lu, and Vivek Subbiah. "Abstract 5363: The preclinical selectivity and activity of APS03118, a highly selective and potent next-generation RET inhibitor." Cancer Research 82, no. 12_Supplement (June 15, 2022): 5363. http://dx.doi.org/10.1158/1538-7445.am2022-5363.
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Abstract Backgroud: Oncogenic RET is an actionable target across a variety of cancers. Selective RET inhibitors selpercatinib and pralsetinib were recently approved by the FDA and EMA for patients with RET-dependent NSCLC and thyroid cancers. The solvent front mutations (SFMs) RET G810C/S/R have been identified as mechanisms of acquired resistance to both drugs. The gatekeeper RET V804 mutation cannot be inhibited by selected next-generation RET inhibitors in development. APS03118 is a novel next-generation RET inhibitor which is potent against a range of RET fusions and mutations including both SFMs and gatekeeper mutations. Methods: The selectivity, anti-RET activity, and intracranial efficacy of APS03118 were confirmed in vitro and in vivo in a variety of RET-dependent tumor models. Results: APS03118 was highly selective against a panel of 468 kinases and demonstrated 130-fold selectivity over VEGFR-2. In enzymatic assays, APS03118 showed low nanomolar potency against wild type RET and 25 RET mutations/fusions, including the inhibition of RET G810R/C/S (IC50 0.04-5 nM) and RET V804M/L/E (IC50 0.04-1 nM). APS03118 inhibited RET phosphorylation (IC50 <15 nM) in Ba/F3 engineered RET cells (WT, G810R, V804M, M918T). In cell proliferation assays, APS03118 potently inhibited KIF5B-RET Ba/F3 (WT, V804M, V804L, M918T), CCDC6-RET Ba/F3 (WT, V804M, S904F), LC2/ad (CCDC6-RET), TT (RET C634W) (IC50 < 10nM); Ba/F3 RET G810R and G810S IC50 (8-65 nM). APS03118 demonstrated marked anti-tumor efficacy in vivo in RET-driven cell-derived (Ba/F3 KIF5B-RET, V804M, TT (C634W)) and patient-derived (KIF5B-RET, CCDC6-RET, CCDC6-RET V804M) xenograft tumor models. At 10 mg/kg BID, tumor regression was observed in these xenograft models (TGI 87-108%). Tumors completely subsided in CCDC6-RET orthotopic brain model with a 100% survival rate. In the Ba/F3 KIF5B-RET G810R xenograft model, APS03118 30 mg/kg BID showed 90% TGI and was well tolerated, and RET G810 mutations often drive clinical progression on current RET inhibitors. Conclusions: APS03118 is a novel highly selective next-generation RET inhibitor that possesses potent in vitro and in vivo activity against a diverse range of RET alterations, including SFMs-mediated resistance. A first-in-human phase 1 trial for patients with RET-driven solid tumors with activating RET alterations is planned for 2022. Citation Format: Alexander Drilon, Jun Zhong, Ying Lu, Yongbo Liu, Hao Wang, Minchun Chen, Xiaohu Chen, John Zhu, Shun Lu, Vivek Subbiah. The preclinical selectivity and activity of APS03118, a highly selective and potent next-generation RET inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5363.
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Nosaki, Kaname, Shingo Matsumoto, Kiyotaka Yoh, Takaya Ikeda, Yuichiro Ohe, Masahiro Kodani, Noriko Yanagitani, et al. "Genetic profiling and the response to RET inhibitors in RET fusion positive non-small cell lung cancer (NSCLC) identified by international genomic screening project (LC-SCRUM-Asia)." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 9557. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.9557.
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9557 Background: RET fusions are targetable oncogenic drivers in 1 – 2 % of NSCLC, yet no RET inhibitors are approved. Selective RET inhibitors, such as LOXO-292 and BLU-667, are currently in development. The impact of co-occurring mutation on outcome in RET-TKI therapy remains largely unknown. Methods: In an international genome screening project in Asia (LC-SCRUM-Asia), 161 cancer-related genes have been analyzed by a next-generation sequencing (NGS) system, Oncomine™ Comprehensive Assay. The therapeutic efficacy and survival of RET fusion+ NSCLC were evaluated using a large-scale clinicogenomic database in the LC-SCRUM-Japan. Results: From Feb 2013 to Dec 2019, a total of 7177 patients with non-squamous NSCLC were enrolled. RET fusion were detected in 167 patients (2.3 %). Median age was 61 years (range: 29 - 85), 60 % were female, 61 % were never-smokers, 99 % had adenocarcinoma, and 78 % had stage IIIB/IV disease. Based on our database, the median overall survival was 37 months. 62 patients received RET inhibitor therapy. RET fusions was identified by NGS assay (KIF5B-RET: 75, CCDC6-RET: 30, Others: 2) in 107 patients. Co-occurring genomic alterations were detected in 62 (58 %) patients, the median number of co-mutations was 1 (range 0 - 4). The most common co-occurring mutations in tumor involved TP53 (31; 29 %), STK11 (6; 6 %), CDKN2A (5; 5 %) and TSC2 (5; 5 %). In 23 patients treated with RET inhibitor (unapproved drugs), there was a strong association between co-occurring mutation and time to treatment discontinuation (TTD) in RET inhibitor therapy; HR 2.75 (95%CI 1.71 - 15.6, P = 0.0096). Conclusions: RET rearrangements continue to represent a rare but high unmet need disease. Co-occurring mutation was significantly associated with shorter TTD. Our data is the largest cohort of advanced-stage RET fusion+ NSCLC profiled by NGS to date. Co-occurring mutation should be evaluated in the development of novel targeted therapies for RET fusion+ NSCLC.
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Cascetta, Priscilla, Vincenzo Sforza, Anna Manzo, Guido Carillio, Giuliano Palumbo, Giovanna Esposito, Agnese Montanino, et al. "RET Inhibitors in Non-Small-Cell Lung Cancer." Cancers 13, no. 17 (September 1, 2021): 4415. http://dx.doi.org/10.3390/cancers13174415.
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RET rearrangements are observed in 1–2% of non-small-cell lung cancer (NSCLC) patients and result in the constitutive activation of downstream pathways normally implied in cell proliferation, growth, differentiation and survival. In NSCLC patients, RET rearrangements have been associated with a history of non-smoking, a higher rate of brain metastasis at initial diagnosis and a low immune infiltrate. Traditionally, RET fusions are considered mutually exclusive with other oncogenic drivers, even though a co-occurrence with EGFR mutations and MET amplifications has been observed. Cabozantinib, vandetanib and lenvatinib are the first multi-kinase inhibitors tested in RET-rearranged NSCLC patients with contrasting results. More recently, two selective RET inhibitors, selpercatinib and pralsetinib, demonstrated higher efficacy rates and good tolerability and they were approved for the treatment of patients with metastatic RET fusion-positive NSCLC on the bases of the results of phase II studies. Two ongoing phase III clinical trials are currently comparing selpercatinib or pralsetinib to standard first line treatments and will definitively establish their efficacy in RET-positive NSCLC patients.
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Watson, Amanda J., Gemma V. Hopkins, Samantha Hitchin, Habiba Begum, Stuart Jones, Allan Jordan, Sarah Holt, et al. "Identification of selective inhibitors of RET and comparison with current clinical candidates through development and validation of a robust screening cascade." F1000Research 5 (May 26, 2016): 1005. http://dx.doi.org/10.12688/f1000research.8724.1.
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RET (REarranged during Transfection) is a receptor tyrosine kinase, which plays pivotal roles in regulating cell survival, differentiation, proliferation, migration and chemotaxis. Activation of RET is a mechanism of oncogenesis in medullary thyroid carcinomas where both germline and sporadic activating somatic mutations are prevalent. At present, there are no known specific RET inhibitors in clinical development, although many potent inhibitors of RET have been opportunistically identified through selectivity profiling of compounds initially designed to target other tyrosine kinases. Vandetanib and cabozantinib, both multi-kinase inhibitors with RET activity, are approved for use in medullary thyroid carcinoma, but additional pharmacological activities, most notably inhibition of vascular endothelial growth factor - VEGFR2 (KDR), lead to dose-limiting toxicity. The recent identification of RET fusions present in ~1% of lung adenocarcinoma patients has renewed interest in the identification and development of more selective RET inhibitors lacking the toxicities associated with the current treatments. In an earlier publication [Newton et al, 2016; 1] we reported the discovery of a series of 2-substituted phenol quinazolines as potent and selective RET kinase inhibitors. Here we describe the development of the robust screening cascade which allowed the identification and advancement of this chemical series. Furthermore we have profiled a panel of RET-active clinical compounds both to validate the cascade and to confirm that none display a RET-selective target profile.
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Watson, Amanda J., Gemma V. Hopkins, Samantha Hitchin, Habiba Begum, Stuart Jones, Allan Jordan, Sarah Holt, et al. "Identification of selective inhibitors of RET and comparison with current clinical candidates through development and validation of a robust screening cascade." F1000Research 5 (August 23, 2016): 1005. http://dx.doi.org/10.12688/f1000research.8724.2.
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RET (REarranged during Transfection) is a receptor tyrosine kinase, which plays pivotal roles in regulating cell survival, differentiation, proliferation, migration and chemotaxis. Activation of RET is a mechanism of oncogenesis in medullary thyroid carcinomas where both germline and sporadic activating somatic mutations are prevalent. At present, there are no known specific RET inhibitors in clinical development, although many potent inhibitors of RET have been opportunistically identified through selectivity profiling of compounds initially designed to target other tyrosine kinases. Vandetanib and cabozantinib, both multi-kinase inhibitors with RET activity, are approved for use in medullary thyroid carcinoma, but additional pharmacological activities, most notably inhibition of vascular endothelial growth factor - VEGFR2 (KDR), lead to dose-limiting toxicity. The recent identification of RET fusions present in ~1% of lung adenocarcinoma patients has renewed interest in the identification and development of more selective RET inhibitors lacking the toxicities associated with the current treatments. In an earlier publication [Newton et al, 2016; 1] we reported the discovery of a series of 2-substituted phenol quinazolines as potent and selective RET kinase inhibitors. Here we describe the development of the robust screening cascade which allowed the identification and advancement of this chemical series. Furthermore we have profiled a panel of RET-active clinical compounds both to validate the cascade and to confirm that none display a RET-selective target profile.
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Gou, Qitao, Xiaochuan Gan, Longhao Li, Qiheng Gou, and Tao Zhang. "Precious Gene: The Application of RET-Altered Inhibitors." Molecules 27, no. 24 (December 13, 2022): 8839. http://dx.doi.org/10.3390/molecules27248839.
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The well-known proto-oncogene rearrangement during transfection (RET), also known as ret proto-oncogene Homo sapiens (human), is a rare gene that is involved in the physiological development of some organ systems and can activate various cancers, such as non-small cell lung cancer, thyroid cancer, and papillary thyroid cancer. In the past few years, cancers with RET alterations have been treated with multikinase inhibitors (MKIs). However, because of off-target effects, these MKIs have developed drug resistance and some unacceptable adverse effects. Therefore, these MKIs are limited in their clinical application. Thus, the novel highly potent and RET-specific inhibitors selpercatinib and pralsetinib have been accelerated for approval by the Food and Drug Administration (FDA), and clinical trials of TPX-0046 and zetletinib are underway. It is well tolerated and a potential therapeutic for RET-altered cancers. Thus, we will focus on current state-of-the-art therapeutics with these novel RET inhibitors and show their efficacy and safety in therapy.
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Vodopivec, Danica M., and Mimi I. Hu. "RET kinase inhibitors for RET-altered thyroid cancers." Therapeutic Advances in Medical Oncology 14 (January 2022): 175883592211016. http://dx.doi.org/10.1177/17588359221101691.
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Precision oncology has opened a new era in cancer treatment focused on targeting specific cellular pathways directly involved in tumorigenesis. The REarrangement during Transfection ( RET) proto-oncogene is involved in the pathogenesis of various thyroid cancer subtypes. Mutations in RET give rise to both hereditary and sporadic medullary thyroid cancer (MTC). RET fusions are found in follicular cell-derived thyroid cancers (papillary, poorly differentiated, and anaplastic). Hence, drugs that block the RET tyrosine kinase receptor have been explored in the management of locally advanced or metastatic thyroid cancer. The multikinase inhibitors (MKIs) with nonselective RET inhibition are sorafenib, lenvatinib, vandetanib, cabozantinib, and sunitinib. Although the efficacy of these drugs varies, a major issue is the lack of specificity resulting in a higher rate of drug-related toxicities, leading to dose reduction, interruption, or discontinuation. Moreover, MKIs are subject to drug resistance by RET Val804 residue gatekeeper mutations. In phase I/II clinical studies, the highly selective first-generation RET inhibitors, selpercatinib and pralsetinib, demonstrate high efficacy in controlling disease even in the presence of gatekeeper mutations combined with greater tolerability. However, resistance mechanisms such as RET solvent front mutations (SFMs) have evolved in some patients, giving the need to develop the selective second-generation RET inhibitors. Although the approval of selpercatinib and pralsetinib in 2020 has profoundly benefited patients with RET-altered thyroid cancer, further research into optimal treatment strategies, mechanisms of drug resistance, long-term consequences of potent RET-inhibition, and development of more effective agents against emergent mutations are much needed.
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Jia, Cong-Cong, Wang Chen, Zi-Li Feng, and Zhao-Peng Liu. "Recent developments of RET protein kinase inhibitors with diverse scaffolds as hinge binders." Future Medicinal Chemistry 13, no. 1 (January 2021): 45–62. http://dx.doi.org/10.4155/fmc-2020-0170.
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RET is a proto-oncogene encoding a receptor tyrosine kinase. RET regulates key aspects of cellular proliferation, differentiation and survival. The activation of RET via gene fusions or point mutations is closely related to lung, thyroid and other cancers. This review summarizes the developments of a diversity of small molecule RET protein kinase inhibitors in the past 10 years. These RET inhibitors are classified according to their hinge binder chemotypes as: pyrimidines, including the pyrazolopyrimidines, pyrimidine oxazines, quinazolines, 4-aminopyrimidines and 4-aminopyridines; indolinones; 5-aminopyrazole-4-carboxamides; 3-trifluoromethylanilines; imidazopyridines, imidazopyridazines and pyrazopyridines; nicotinonitriles; pyridones and 1,2,4-triazoles. In each section, the biological activities of the inhibitors, their structure–activity relationships and possible binding modes with the RET kinase are introduced.
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Drilon, Alexander E., Dayong Zhai, Evan Rogers, Wei Deng, Xin Zhang, Jane Ung, Dong Lee, et al. "The next-generation RET inhibitor TPX-0046 is active in drug-resistant and naïve RET-driven cancer models." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): 3616. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.3616.
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3616 Background: RET fusions/mutations drive oncogenesis in lung and thyroid cancers, and several other malignancies. Selective RET inhibitors (selpercatinib/pralsetinib) are active in patients with these cancers; unfortunately, resistance often occurs. On-target resistance includes the acquisition of solvent front mutations (SFMs i.e. RET G810 substitutions). TPX-0046 is a structurally differentiated RET inhibitor that is potent against a range of RET fusions and mutations including SFMs. Methods: The rationally-designed, compact, macrocyclic RET/SRC inhibitor TPX-0046 was characterized in RET-driven in vitro and in vivo tumor models. Results: In enzymatic assays, TPX-0046 showed low nanomolar potency against wild-type RET and 18 RET mutations/fusions. It was potent against SRC and spared VEGFR2/KDR. TPX-0046 inhibited RET phosphorylation (IC50 < 10 nM) in tumor cell lines (LC2/ad, CCDC6-RET; TT, RET C634W) and Ba/F3 engineered RET models (WT, G810R). In cell proliferation assays, TPX-0046 inhibited KIF5B-RET Ba/F3, LC2/ad, and TT cells with IC50 values ~1 nM. Ba/F3 RET engineered cells with SFMs (e.g. G810C/R/S) were potently inhibited by TPX-0046 (mean proliferation IC50 1–17 nM). TPX-0046 demonstrated marked in vivo anti-tumor efficacy in RET-driven cell-derived and patient-derived xenograft tumor models. In a Ba/F3 KIF5B-RET xenograft model, a single dose of 5 mg/kg TPX-0046 inhibited > 80% of RET phosphorylation (corresponding mean free plasma concentration: 51 nM). At 5 mg/kg BID, tumor regression was observed in RET-dependent xenograft models, including those that harbor RET SFMs: TT, CTG-0838 PDX (NSCLC, KIF5B-RET), CR1520 PDX (CRC, NCOA4-RET), Ba/F3 KIF5B-RET, and Ba/F3 KIF5B-RET G810R. Conclusions: TPX-0046 is a unique next-generation RET inhibitor that possesses potent in vitro and in vivo activity against a diverse range of RET alterations, including SFM-mediated resistance. A phase 1/2 trial for RET inhibitor-resistant and naïve RET-driven cancers is on-going (NCT04161391).
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Schoffski, Patrick, Philippe Georges Aftimos, Christophe Massard, Antoine Italiano, Christiane Jungels, Karen Andreas, Mitchell Keegan, and Peter T. C. Ho. "A phase I study of BOS172738 in patients with advanced solid tumors with RET gene alterations including non-small cell lung cancer and medullary thyroid cancer." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): TPS3162. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.tps3162.
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TPS3162 Background: RET gene alterations (mutations and fusions) leading to constitutive kinase activity have been identified in various tumor types including non-small cell lung cancer (NSCLC), medullary thyroid (MTC), colon, breast and ovarian cancer. The current generation of multi-kinase inhibitors approved for treatment of such tumors, do not selectively target RET and exhibit significant off-target activity especially against vascular endothelial growth factor receptor 2 (VEGFR2), resulting in dose-limiting toxicities that prevent the full inhibition of RET in those tumors. Recently, early clinical data from a class of more selective RET inhibitors have shown promising results with a more favorable safety profile in patients with RET alterations. BOS172738 is a novel RET inhibitor with nanomolar potency against RET and approximately 300-fold selectivity against VEGFR2. This phase 1 study is assessing the safety and tolerability of BOS172738 in patients with advanced solid tumors with RET alterations. Methods: NCT03780517 is a phase 1, open label, multicenter, dose escalation trial to evaluate the safety, efficacy, pharmacokinetics, and pharmacodynamics of BOS172738, an orally dosed RET kinase inhibitor, in patients with advanced solid tumors with RET gene alterations. RET gene alteration status will be assessed locally but confirmed centrally. The study is comprised of 2 parts: in Part A (dose escalation), patients with advanced solid tumors with RET gene alterations will receive BOS172738 orally once daily in each 28-day cycle. Select patients in Part A are eligible for intrapatient dose escalation. On establishing the recommended phase 2 dose (RP2D), Part B (expansion) will enroll up to an additional 60 patients to 1 of 3 tumor type-specific cohorts. The 3 expansion cohorts will each consist of up to 20 advanced cancer patients with: 1) RET gene-fusion NSCLC; 2) RET gene-mutant MTC; and 3) other RET gene-altered advanced tumors or NSCLC/MTC with prior specific RET gene-targeted therapy. Patients in expansion cohorts will receive BOS172738 daily at the RP2D until disease progression or other discontinuation criteria have been met. The study is currently open to enrollment globally with the first patient entered in 01/2019. Clinical trial information: NCT03780517.
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Kucharczyk, Tomasz, Paweł Krawczyk, Dariusz M. Kowalski, Adam Płużański, Tomasz Kubiatowski, and Ewa Kalinka. "RET Proto-Oncogene—Not Such an Obvious Starting Point in Cancer Therapy." Cancers 14, no. 21 (October 27, 2022): 5298. http://dx.doi.org/10.3390/cancers14215298.
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Mutations and fusions of RET (rearranged during transfection) gene are detected in a few common types of tumors including thyroid or non-small cells lung cancers. Multiple kinase inhibitors (MKIs) do not show spectacular effectiveness in patients with RET-altered tumors. Hence, recently, two novel RET-specific inhibitors were registered in the US and in Europe. Selpercatinib and pralsetinib showed high efficacy in clinical trials, with fewer adverse effects, in comparison to previously used MKIs. However, the effectiveness of these new drugs may be reduced by the emergence of resistance mutations in RET gene and activation of different activating signaling pathways. This review presents the function of the normal RET receptor, types of molecular disturbances of the RET gene in patients with various cancers, methods of detecting these abnormalities, and the effectiveness of modern anticancer therapies (ranging from immunotherapies, through MKIs, to RET-specific inhibitors).
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Besse, Benjamin, Enriqueta Felip, Corinne Clifford, Melinda Louie-Gao, Jennifer Green, Christopher D. Turner, and Sanjay Popat. "AcceleRET Lung: A phase III study of first-line pralsetinib in patients (pts) with RET-fusion+ advanced/metastatic non-small cell lung cancer (NSCLC)." Journal of Clinical Oncology 38, no. 15_suppl (May 20, 2020): TPS9633. http://dx.doi.org/10.1200/jco.2020.38.15_suppl.tps9633.
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TPS9633 Background: RET gene fusions have been identified as oncogenic drivers in multiple tumor types, including 1-2% of NSCLC, but no selective RET inhibitors are approved for use. The investigational RET inhibitor, pralsetinib, potently and selectively targets oncogenic RET alterations, including those that confer resistance to multikinase inhibitors. In the registration-enabling phase 1/2 study (ARROW; NCT03037385), pts with RET-fusion+ NSCLC treated with 400 mg once daily (QD) of pralsetinib (N = 80) after platinum-based chemotherapy achieved an overall response rate (ORR) of 61% (95% CI 50, 72; 2 responses pending confirmation) per independent central review. In addition, a promising ORR of 73% (all centrally confirmed responses) was attained in the treatment naïve cohort (N = 26). Most treatment-related adverse events were grade 1-2 across the entire safety population treated at 400 mg QD (N = 354). AcceleRET Lung, an international, open-label, randomized, phase 3 study, will evaluate the efficacy and safety of pralsetinib versus standard of care (SOC) for first-line treatment of advanced/metastatic RET fusion+ NSCLC (NCT04222972). Methods: Approximately 250 pts with metastatic RET-fusion+ NSCLC will be randomized 1:1 to oral pralsetinib (400 mg QD) or SOC (non-squamous histology: platinum/pemetrexed ± pembrolizumab followed by maintenance pemetrexed ± pembrolizumab; squamous histology: platinum/gemcitabine). Stratification factors include intended use of pembrolizumab, history of brain metastases, and ECOG PS. Key eligibility criteria include no prior systemic treatment for metastatic disease; RET-fusion+ tumor by local or central assessment; no additional actionable oncogenic drivers; no prior selective RET inhibitor; measurable disease per RECIST v1.1. Pts randomized to SOC will be permitted to cross-over to receive pralsetinib upon disease progression. The primary endpoint is progression-free survival (blinded independent central review; RECIST v1.1). Secondary endpoints include ORR, overall survival, duration of response, disease control rate, clinical benefit rate, time to intracranial progression, intracranial ORR, safety/tolerability and quality of life evaluations. Recruitment has begun with sites (active or planned) in North America, Europe and Asia. Clinical trial information: NCT04222972 .
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Drilon, Alexander E., Thomas Filleron, Isabella Bergagnini, Julie Milia, Vaios Hatzoglou, Vamsidhar Velcheti, Benjamin Besse, et al. "Baseline frequency of brain metastases and outcomes with multikinase inhibitor therapy in patients with RET-rearranged lung cancers." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): 9069. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.9069.
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9069 Background: In phase 2 trials, multikinase inhibitors with activity against RET are active in a subset of patients (pts) with RET-rearranged lung cancers (response rate of 28%, phase 2 study of cabozantinib; Drilon et al Lancet Oncol 2016). Data on the incidence of brain metastases and outcomes with multikinase inhibitor therapy in pts with intracranial disease have not previously been reported. Methods: The frequency of brain metastases at diagnosis of metastatic disease was evaluated in pts accrued to a global registry of RET-rearranged lung cancer pts identified by a multicenter network of thoracic oncologists (Gautschi et al JCO 2017). A proportion of pts were treated with 9 multikinase inhibitors including cabozantinib, vandetanib, lenvatinib, alectinib, and ponatinib. On a prospective phase 2 trial (NCT01639508), patients with asymptomatic brain metastases were eligible. Intracranial response to cabozantinib (RECIST v1.1) was evaluated in an exploratory fashion. Results: 114 registry pts with RET-rearranged lung cancers had metastatic disease at diagnosis. Baseline brain metastases were identified in 27% (95%CI 18-34%, n = 20/75) of pts with available information. No differences (p > 0.05) in age, smoking history, or upstream fusion partner ( KIF5B100% vs 84%, with and without brain metastases, p = 0.53) were noted. In 37 pts treated with multikinase inhibitors with activity against RET, there were no significant differences in median PFS (2.1 vs 2.1 months, p = 0.41) or median OS (3.9 vs 7.0 months, p = 0.10) in pts with (n = 10) and without (n = 27) brain metastases. On a phase 2 trial of cabozantinib, baseline untreated brain metastases were present in 5 pts. Intracranial disease control (stable disease; -34% and -1% in 2 pts with measurable disease) was achieved in 4 of 4 pts with measurable or evaluable intracranial disease with time to treatment discontinuation ranging from 2.4 months to 2.9 years. Conclusions: Brain metastases are present in a substantial proportion of RET-rearranged lung cancer pts. Intracranial disease control can be achieved in select pts by a multikinase inhibitor. Novel RET-directed targeted therapy strategies should address intracranial disease. Clinical trial information: NCT01639508.
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Frasca, Francesco, Veronica Vella, Maria Luisa Nicolosi, Rosa Linda Messina, Fiorenza Gianì, Sonia Lotta, Paolo Vigneri, Concetto Regalbuto, and Riccardo Vigneri. "Thyroid Cancer Cell Resistance to gefitinib Depends on the Constitutive Oncogenic Activation of the ERK Pathway." Journal of Clinical Endocrinology & Metabolism 98, no. 6 (June 1, 2013): 2502–12. http://dx.doi.org/10.1210/jc.2012-3623.
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Context: Poorly differentiated thyroid carcinomas are refractory to common anticancer therapies, and novel inhibitors are being tested in these deadly malignancies. The epidermal growth factor receptor (EGFR) tyrosine kinase represents an attractive target for treatment because it is up-regulated in thyroid cancer and plays a role in cancer progression. However, EGFR inhibitors have provided poor results in thyroid carcinomas. Objective: We evaluated the possible mechanism underlying the resistance of thyroid cancer cells to EGFR inhibitors. Design: We tested the effect of the EGFR tyrosine kinase inhibitor gefitinib in a panel of thyroid cancer cell lines. Results: We found that in most of the cell lines, although gefitinib inhibited EGFR phosphorylation, it was poorly effective in reducing cell viability. gefitinib, however, was able to inhibit epidermal growth factor-induced cell migration and matrix invasion. In most thyroid cancer cell lines, gefitinib significantly inhibited Akt phosphorylation by inhibiting EGFR activation, but it had limited or no effect on ERK phosphorylation. The poor cell response to gefitinib was associated with genetic alterations, leading to constitutive activation of the ERK pathway, including BRAF(V600E) and HRASG12A/Q61R mutations and RET/PTC1 rearrangement. When BRAF(V600E)-positive thyroid cancer cells were incubated with the specific BRAF inhibitor PLX4032, sensitivity to gefitinib was restored. Similar results were obtained with rat sarcoma and RET/papillary thyroid cancer inhibitors. Conclusions: These results indicate that thyroid cancer resistance to gefitinib is due to the constitutive activation of the mitogenic pathway by either signals downstream of EGFR or other tyrosine kinase receptors. This resistance can be overcome by the combined use of selective inhibitors.
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Hegde, Aparna, Alexander Y. Andreev-Drakhlin, Jason Roszik, Le Huang, Shuang Liu, Kenneth Hess, Maria Cabanillas, et al. "Responsiveness to immune checkpoint inhibitors versus other systemic therapies in RET-aberrant malignancies." ESMO Open 5, no. 5 (October 2020): e000799. http://dx.doi.org/10.1136/esmoopen-2020-000799.
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PurposeThe receptor tyrosine kinase rearranged during transfection (RET) can be oncogenically activated by gene fusions or point mutations. Multikinase inhibitors such as cabozantinib, lenvatinib and vandetanib have demonstrated activity in RET-dependent malignancies, and selective RET inhibitors (Selpercatinib and Pralsetinib) are in clinical trials. However, the responsiveness of RET-dependent malignancies to immune checkpoint inhibitors (ICIs) is unknown. We compared the time to treatment discontinuation (TTD) for ICI versus non-ICI therapy in patients with malignancies harbouring activating RET mutations or fusions (RET+).MethodsA retrospective review of all RET+ patients who were referred to the phase I clinical trials programme at the University of Texas MD Anderson Cancer Center was conducted. TTD was estimated using Kaplan-Meier analysis. Multivariate analysis using the Cox proportional hazard model was performed to identify independent risk factors of treatment discontinuation.ResultsOf 70 patients who received systemic therapy for RET+ malignancies, 20 (28.6%) received ICI and 50 (71.4%) received non-ICI therapy. Non-ICI therapy was associated with decreased risk for treatment discontinuation compared with ICI in the overall population (HR=0.31; 95% CI 0.16–0.62; p=0.000834) and in patients with RET point mutations (HR=0.13; 95% CI 0.04–0.45; p=0.00134). In patients with RET fusions, non-ICI therapy was associated with a non-statistically significant decreased risk of treatment discontinuation (HR=0.59; 95% CI 0.25–1.4; p=0.24). ICI therapy and a diagnosis other than medullary thyroid cancer (MTC) were independent risk factors for treatment discontinuation.ConclusionOur study supports the prioritisation of non-ICI over ICI therapy in patients with RET+ tumours.
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Kohno, Takashi, Junya Tabata, and Takashi Nakaoku. "REToma: a cancer subtype with a shared driver oncogene." Carcinogenesis 41, no. 2 (November 11, 2019): 123–29. http://dx.doi.org/10.1093/carcin/bgz184.
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Abstract RET (REarranged during Transfection), which encodes a receptor tyrosine kinase for members of the glial cell line-derived neurotrophic factor, plays a role as driver oncogene in a variety of human cancers. Fusion of RET with several partner genes has been detected in papillary thyroid, lung, colorectal, pancreatic and breast cancers, and tyrosine kinase inhibitors (TKIs) for RET (particularly RET-specific inhibitors) show promising therapeutic effects against such cancers. Oncogenic mutations within the extracellular cysteine-rich and intracellular kinase domains of RET drive medullary thyroid carcinogenesis; the same mutations are also observed in a small subset of diverse cancers such as lung, colorectal and breast cancers. Considering the oncogenic nature of RET mutants, lung, colorectal and breast cancers are predicted to respond to RET TKIs in a manner similar to medullary thyroid cancer. In summary, cancers carrying oncogenic RET alterations as a driver mutation could be collectively termed ‘REToma’ and treated with RET TKIs in a tissue-agnostic manner.
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Redaelli, Sara, Ivan Plaza-Menacho, and Luca Mologni. "Novel targeted therapeutics for MEN2." Endocrine-Related Cancer 25, no. 2 (February 2018): T53—T68. http://dx.doi.org/10.1530/erc-17-0297.
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The rearranged during transfection (RET) proto-oncogene was recognized as the multiple endocrine neoplasia type 2 (MEN2) causing gene in 1993. Since then, much effort has been put into a clear understanding of its oncogenic signaling, its biochemical function and ways to block its aberrant activation in MEN2 and related cancers. Several small molecules have been designed, developed or redirected as RET inhibitors for the treatment of MEN2 and sporadic MTC. However, current drugs are mostly active against several other kinases, as they were not originally developed for RET. This limits efficacy and poses safety issues. Therefore, there is still much to do to improve targeted MEN2 treatments. New, more potent and selective molecules, or combinatorial strategies may lead to more effective therapies in the near future. Here, we review the rationale for RET targeting in MEN2, the use of currently available drugs and novel preclinical and clinical RET inhibitor candidates.
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Ramesh, Priyanka, Woong-Hee Shin, and Shanthi Veerappapillai. "Discovery of a Potent Candidate for RET-Specific Non-Small-Cell Lung Cancer—A Combined In Silico and In Vitro Strategy." Pharmaceutics 13, no. 11 (October 24, 2021): 1775. http://dx.doi.org/10.3390/pharmaceutics13111775.
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Rearranged during transfection (RET) is a tyrosine kinase oncogenic receptor, activated in several cancers including non-small-cell lung cancer (NSCLC). Multiple kinase inhibitors vandetanib and cabozantinib are commonly used in the treatment of RET-positive NSCLC. However, specificity, toxicity, and reduced efficacy limit the usage of multiple kinase inhibitors in targeting RET protein. Thus, in the present investigation, we aimed to figure out novel and potent candidates for the inhibition of RET protein using combined in silico and in vitro strategies. In the present study, screening of 11,808 compounds from the DrugBank repository was accomplished by different hypotheses such as pharmacophore, e-pharmacophore, and receptor cavity-based models in the initial stage. The results from the different hypotheses were then integrated to eliminate the false positive prediction. The inhibitory activities of the screened compounds were tested by the glide docking algorithm. Moreover, RF score, Tanimoto coefficient, prime-MM/GBSA, and density functional theory calculations were utilized to re-score the binding free energy of the docked complexes with high precision. This procedure resulted in three lead molecules, namely DB07194, DB03496, and DB11982, against the RET protein. The screened lead molecules together with reference compounds were then subjected to a long molecular dynamics simulation with a 200 ns time duration to validate the inhibitory activity. Further analysis of compounds using MM-PBSA and mutation studies resulted in the identification of potent compound DB07194. In essence, a cell viability assay with RET-specific lung cancer cell line LC-2/ad was also carried out to confirm the in vitro biological activity of the resultant compound, DB07194. Indeed, the results from our study conclude that DB07194 can be effectively translated for this new therapeutic purpose, in contrast to the properties for which it was originally designed and synthesized.
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Mulligan, Lois M. "65 YEARS OF THE DOUBLE HELIX: Exploiting insights on the RET receptor for personalized cancer medicine." Endocrine-Related Cancer 25, no. 8 (August 2018): T189—T200. http://dx.doi.org/10.1530/erc-18-0141.
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The focus of precision cancer medicine is the use of patient genetic signatures to predict disease occurrence and course and tailor approaches to individualized treatment to improve patient outcomes. The rearranged during transfection (RET) receptor tyrosine kinase represents a paradigm for the power of personalized cancer management to change cancer impact and improve quality of life. Oncogenic activation of RET occurs through several mechanisms including activating mutations and increased or aberrant expression. Activating RET mutations found in the inherited cancer syndrome multiple endocrine neoplasia 2 permit early diagnosis, predict disease course and guide disease management to optimize patient survival. Rearrangements of RET found in thyroid and lung tumors provide insights on potential disease aggressiveness and offer opportunities for RET-targeted therapy. Aberrant RET expression in a subset of cases is associated with tumor dissemination, resistance to therapies and/or poorer prognosis in multiple cancers. The potential of RET targeting through repurposing of small-molecule multikinase inhibitors, selective RET inhibitors or other novel approaches provides exciting opportunities to individualize therapies across multiple pathologies where RET oncogenicity contributes to cancer outcomes.
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Kim, Leeseul, Young Kwang Chae, Chan Mi Jung, Alice Daeun Lee, and Emma Yu. "Addition of selpercatinib to overcome osimertinib resistance in non-small cell lung cancer (NSCLC) with acquired RET fusion detected in ctDNA at very low allele frequency." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): 3046. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.3046.
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3046 Background: Osimertinib, a highly selective third generation EGFR tyrosine kinase inhibitor (TKI) became the standard front-line therapy for EGFR-mutant NSCLC. However, therapeutic options are limited for TKI resistance which commonly occurs. Therefore, overcoming acquired resistance to osimertinib remains an important high unmet need in the field of precision oncology. Herein, we present the first case of advanced adenocarcinoma of the lung that showed notable response with the addition of selpercatinib after acquired resistance to osimertinib monotherapy. Methods: Case presentation. Results: A 37-year-old woman with stage IVB adenocarcinoma of lung with osseous, hepatic and brain metastases initially received one cycle of carboplatin, pemetrexed and pembrolizumab. Based on the EGFR exon19 deletion detected from ctDNA NGS assay (Guardant 360) [variant allele frequency (VAF) 62.7%], the treatment regimen was changed to osimertinib monotherapy (80mg PO daily). Bevacizumab was empirically added given CNS involvement. She maintained overall stable disease for 10 months before subsequent CT showed disease progression. The treatment regimen was switched to atezolizumab, bevacizumab, paclitaxel and carboplatin combination therapy. She tolerated 6 cycles of the regimen in 4 month before a subsequent brain MRI revealed progression of the metastatic brain disease with new leptomeningeal disease. Whole brain radiotherapy was performed and decision was made to start combination TKI treatment of selpercatinib (120mg BID) added to the osimertinib (80mg daily) monotherapy based on her repeat ctDNA NGS assay result showing concurrent acquired CCDC6RET fusion (VAF 0.05%) and EGFR exon 19 deletion (VAF 10.0%). The 6 week follow-up CT demonstrated significant decrease in the largest lung mass (33.95*24.22mm->32.50*16.07mm). Repeat ctDNA NGS assay at one week after selpercatinib use showed disappearance of RET fusion and significant decrease in EGFR clone (VAF 10.0% to 0.05%). Conclusions: It has been reported that co-occurring RET fusions in NSCLC patients with EGFR mutations may contribute to acquired resistance to EGFR inhibitors. Several successful cases of cabozantinib, a non-selective RET inhibitor, or pralsetinib, a selective RET inhibitor combined with EGFR inhibitor, have been reported to aid in overcoming the acquired resistance to EGFR inhibitors. To date, there has been no report of clinical benefit in adding a RET inhibitor based on ctDNA detection of RET fusion with minute variant allele frequency. We for the first time report the case of overcoming acquired resistance to osimertinib by adding selpercatinib, a selective RET inhibitor in NSCLC patients with acquired RET fusion detected in ctDNA at VAF of 0.05%.
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Nguyen, Ly, and Shanada Monestime. "Pralsetinib: Treatment of metastatic RET fusion–positive non–small cell lung cancer." American Journal of Health-System Pharmacy 79, no. 7 (December 5, 2021): 527–33. http://dx.doi.org/10.1093/ajhp/zxab462.
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Abstract Purpose To review the pharmacology, efficacy, safety, dosing and administration, and place in therapy of pralsetinib, a tyrosine kinase inhibitor, for the treatment of metastatic RET fusion–positive non–small-cell lung cancer (NSCLC). Summary RET fusion–positive NSCLC is a rare cancer caused by chromosomal rearrangements that lead to fusions of the RET gene with other genes, such as KIF5B and CCDC6. Until recently, patients were treated with platinum-based chemotherapy or multitargeted tyrosine kinase inhibitors. However, because of their nonspecific mechanism of action, these drugs did not have high response rates. In September 2020, the Food and Drug Administration approved pralsetinib, the first once-daily oral tyrosine kinase inhibitor, for patients with metastatic RET fusion–positive NSCLC. Pralsetinib has been demonstrated to have response rates of 57% and 70% in patients who were previously treated with platinum chemotherapy and patients who were treatment naive, respectively. Clinicians using pralsetinib should monitor for fatigue, hepatotoxicity, hemorrhagic events, hypertension, myelosuppression, pyrexia, and respiratory infections, as these may require treatment interruption, dose reduction, or treatment discontinuation. Conclusion Pralsetinib is a unique targeted tyrosine kinase inhibitor approved for the treatment of patients with RET fusion–positive metastatic NSCLC who may desire a once-daily regimen.
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Giunti, Serena, Alessandro Antonelli, Andrea Amorosi, and Libero Santarpia. "Cellular Signaling Pathway Alterations and Potential Targeted Therapies for Medullary Thyroid Carcinoma." International Journal of Endocrinology 2013 (2013): 1–16. http://dx.doi.org/10.1155/2013/803171.
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Parafollicular C-cell-derived medullary thyroid cancer (MTC) comprises 3% to 4% of all thyroid cancers. While cytotoxic treatments have been shown to have limited efficacy, targeted molecular therapies that inhibit rearranged during transfection (RET) and other tyrosine kinase receptors that are mainly involved in angiogenesis have shown great promise in the treatment of metastatic or locally advanced MTC. Multi-tyrosine kinase inhibitors such as vandetanib, which is already approved for the treatment of progressive MTC, and cabozantinib have shown distinct advantages with regard to rates of disease response and control. However, these types of tyrosine kinase inhibitor compounds are able to concurrently block several types of targets, which limits the understanding of RET as a specific target. Moreover, important resistances to tyrosine kinase inhibitors can occur, which limit the long-term efficacy of these treatments. Deregulated cellular signaling pathways and genetic alterations in MTC, particularly the activation of the RAS/mammalian target of rapamycin (mTOR) cascades and RET crosstalk signaling, are now emerging as novel and potentially promising therapeutic treatments for aggressive MTC.
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Mologni, Luca, Martina Dalla Via, Adriana Chilin, Manlio Palumbo, and Giovanni Marzaro. "Discovery of wt RET and V804M RET Inhibitors: From Hit to Lead." ChemMedChem 12, no. 16 (July 25, 2017): 1390–98. http://dx.doi.org/10.1002/cmdc.201700243.
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Bing, Zhongxing, Weiran Wang, Danhua Wang, and Tonghui Ma. "Identification of RET fusion as mechanisms of resistance to EGFR tyrosine-kinase inhibitors." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): e21074-e21074. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.e21074.
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e21074 Background: Responses to EGFR-targeted therapy are generally temporary, due to inevitable drug resistance. Although RET fusions have been identified in resistant EGFR-mutant non–small cell lung cancer (NSCLC), their characteristics acquired resistance to EGFR tyrosine-kinase inhibitors (TKIs) are rarely investigated. Methods: We retrospectively reviewed next-generation sequencing data of EGFR+ lung cancer patients, and 8 patients were identified coexisting of EGFR mutations and RET fusion. Their treatment history was collected. Results: The co-occurrence of RET fusion with EGFR oncogenic variations was observed in eight patients, and all of the 8 patients have received previous EGFR-TKI treatment. EGFR mutations were including 4 L858R mutations, 4 exon 19 deletions, and 6 T790M mutations. And the partner genes of RET identified by NGS were including TRIM33 (2/8), GPRC6A (1/8), TLN1 (1/8), KIAA1598 (1/8), SPECC1 (1/8), TRIM24 (1/8) and CCDC6 (1/8). The allelic fractions (AFs) of first-generation EGFR-TKI sensitizing mutations were higher than AFs of EGFR T790M mutations as well as AFs of RET fusion. These RET fusions are fused with rare partner genes, rather than the most common KIF5B in lung cancer. Conclusions: This study extended the knowledge of RET fusion as resistance mechanism to EGFR TKIs in lung cancer. The detection of RET fusions may uncover potential resistance mechanisms of EGFR TKIs, which might inform therapeutic strategies, such as combination-therapy approaches.[Table: see text]
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Burns, Emily, Kerry Goodman, Svend Kjaer, Fabienne Beuron, Andrew Purkiss, Agata Nawrotek, Phillip Knowles, et al. "Understanding RET receptor tyrosine kinase ligand recognition and chemical inhibition." Acta Crystallographica Section A Foundations and Advances 70, a1 (August 5, 2014): C440. http://dx.doi.org/10.1107/s205327331409559x.
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The RET receptor tyrosine kinase is crucial for embryonic and adult development, with mutations in both the extracellular and kinase domains leading to several types of cancer. In order to understand the mechanisms of RET activation in more detail, we have investigated how RET interacts with its bipartite ligand comprising of a glial cell line derived neurotrophic factor (GDNF) family ligand and a GDNF family receptor (GFRalpha). To visualise this interaction, we have reconstituted two vertebrate RET ternary complexes containing both ligand and co-receptor and have determined a pseudo-atomic model for a mammalian RET ternary complex using electron microscopy. Our structures reveal the basis for ligand recognition and will be presented. As RET is a validated anti-cancer target, we are actively investigating RET chemical inhibitors in collaboration with several chemistry laboratories. We have determined structures of a diverse set of chemical scaffolds bound to RET leading to an improved RET pharmacophore based on crystallographic, biochemical and cell-based data. As current FDA-approved drugs for RET-dependent metastatic thyroid cancer suffer from off-target dose-dependent toxicity and lack of specificity, we hope our data will usefully contribute to the design of second generation RET chemical inhibitors.
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Kim, Jeong-Oh, Jung-Young Shin, Min Young Kim, Kyoung Hwa Son, Chan-Kwon Jung, Tae-Jung Kim, Su Young Kim, et al. "Coexistence of rearranged during transfection (RET) variants and activating EGFR mutations with their molecular implications in lung adenocarcinomas." Journal of Clinical Oncology 35, no. 15_suppl (May 20, 2017): e20610-e20610. http://dx.doi.org/10.1200/jco.2017.35.15_suppl.e20610.
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e20610 Background: RET rearrangements have been identified in 1-2% of lung adenocarcinomas. The most common fusion is the KIF5B-RET, the function and roles of the RET fusion oncogene, and its downstream signaling molecules remain unclear. Methods: We constructed a tissue microarray (TMA) comprising 581 resected tumor tissues from lung adenocarcinoma patients and investigated them using FISH with RET break-apart and KIF5B-RET SY translocation probes. NanoString’s nCounter technology was used to assay RETtranscripts. We evaluated the protein expressions of RET and RET-related signaling molecules, including p-AKT and p-ERK, using TMA-based IHC staining. Results: Using FISH, we identified 51 cases (8.8%) of RET variants and 10 cases (1.7%) of KIF5B-RET fusion genes among the 581 cases. RET protein expression was lower in the group harboring KIF5B-RET fusion gene than that in the group harboring a wild type RET gene. We found the activating EGFR mutations in 11 (21.6%) cases of 51 RET variants. For the group with KIF5B-RET fusion gene, the expression of p-ERK was significantly lower in EGFR mutation subgroup with presence of RET protein compared to EGFR mutation subgroup with absence of RET protein. For the group with RET rearrangement, there were significant differences in the expression level of p-AKT (P = 0.028) and, p-ERK protein expression was remarkably increased, especially in cases with no RET protein expression. Conclusions: Taken together, the expression of p-ERK protein was meaningfully increased in the RET variants group regardless of RET protein expression. This result suggests that RET inhibitors combined with ERK inhibitors may be an effective treatment strategy for lung adenocarcinoma patients harboring the RET variants.
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Reale, Maria Lucia, Valentina Bertaglia, Angela Listì, Silvia Novello, and Francesco Passiglia. "Molecular Testing and Treatment Strategies in RET-Rearranged NSCLC Patients: Stay on Target to Look Forward." Journal of Molecular Pathology 3, no. 1 (January 18, 2022): 24–37. http://dx.doi.org/10.3390/jmp3010003.
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RET alterations are recognized as key oncogenic drivers in different cancer types, including non-small cell lung cancer (NSCLC). Multikinase inhibitors (MKIs) with anti-RET activities resulted in variable efficacy with significant toxicities because of low target specificity. Selective RET kinase inhibitors, such as pralsetinib and selepercatinib, demonstrated high efficacy and favorable tolerability in advanced RET-rearranged NSCLC patients, leading to their introduction in the clinical setting. Among the different approaches available for the identification of RET rearrangements, next-generation sequencing (NGS) assays present substantial advantages in terms of turnaround time and diagnostic accuracy, even if potentially limited by accessibility issues. The recent advent of novel effective targeted therapies raises several questions regarding the emergence of resistance mechanisms and the potential ways to prevent/overcome them. In this review, we discuss molecular testing and treatment strategies to manage RET fusion positive NSCLC patients with a focus on resistance mechanisms and future perspectives in this rapidly evolving scenario.
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Taylor, Matthew H., Rom S. Leidner, Richard Bryan Bell, Bernard Fox, Hong Xiao, Marcus Couey, Andrew Baker, George Morris, and Lessli Rushforth. "Encorafenib and binimetinib with or without nivolumab in treating patients with metastatic radioiodine refractory BRAF V600 mutant thyroid cancer." Journal of Clinical Oncology 39, no. 15_suppl (May 20, 2021): TPS6085. http://dx.doi.org/10.1200/jco.2021.39.15_suppl.tps6085.
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TPS6085 Background: Differentiated thyroid cancer is the most common endocrine malignancy and has a high frequency of actionable molecular aberrations including BRAF V600E mutations (45%), RET fusions (10%), and NTRK fusions ( < 2%). FDA approved systemic therapies for metastatic radioiodine refractory differentiated thyroid cancer (RR-DTC) include multikinase inhibitors (Lenvatinib and sorafenib), NTRK inhibitors (larotrectinib and entrectinib for NTRK fusion+ cancers), and RET inhibitors (selpercatinib and pralsetinib for RET fusion+ cancers). Previous phase II clinical trials showed clinical efficacy with first and second generation BRAF inhibitors in patients with BRAF mutant RR-DTC. BRAF inhibitors have not yet been FDA approved for treatment of BRAF mutant RR-DTC. Effective therapeutic options for patients with BRAF mutant RR-DTC remains an important unmet clinical need. BRAF mutant thyroid cancers often show elevated expression of PD-L1. Additionally, BRAF inhibition results in increased expression of PD-L1 in thyroid cancer. This clinical trial seeks to evaluate the safety and efficacy of encorafenib plus binimetinib with or without nivolumab in patients with BRAF mutant metastatic RR-DTC. Encorafenib and binimetinib are highly selective and potent oral inhibitors of BRAF and MEK, respectively. Nivolumab is a potent inhibitor of the immune co-inhibitory receptor programmed cell death protein 1 (PD-1). Methods: This is a phase II, single institution, open-label, randomized clinical trial evaluating the combinations of (Arm 1) encorafenib 450 mg/day + binimetinib 45 mg twice daily and (Arm 2) encorafenib 450 mg/day + binimetinib 45 mg twice daily + nivolumab 480 mg I.V. every 4 weeks in patients with metastatic BRAF mutant RR-DTC. The trial will enroll 20 patients in each arm and treatment will be given in 28 day cycles for up to 2 years. Eligible patients must have metastatic/unresectable BRAF mutant RR-DTC, an ECOG performance status of 0-1 and adequate bone marrow, liver and kidney function. Patients with CNS metastases are included if the metastases have been treated and remained stable or are asymptomatic and ≤10 mm in diameter. Patients may be systemic therapy naïve or have previously been treated with multikinase inhibitors. Prior therapy with BRAF, MEK or immune checkpoint inhibitors is exclusionary. The primary endpoint is confirmed objective response rate (ORR) determined by RECIST v1.1 with restaging imaging every 12 weeks. Secondary endpoints include progression free survival, overall survival, and safety/tolerability (CTCAE v5.0). Arms 1 and 2 will be evaluated independently and are not powered for direct comparison. The trial design includes continuous toxicity monitoring with a Pocock-type stopping boundary. This clinical trial is in progress and 3 patients have been enrolled. Clinical trial information: NCT04061980.
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Rotkopf, Shay, DIkla Haham, Natalie Fillipov-Levy, Lea Birnbaum, Elinor Dehan, Ilona Kifer, Zohar Barbash, and Gabi Tarcic. "Abstract 1162: A systematic analysis of RET mutations and their sensitivity to different RET inhibitors." Cancer Research 82, no. 12_Supplement (June 15, 2022): 1162. http://dx.doi.org/10.1158/1538-7445.am2022-1162.
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Abstract The RET oncogene is a receptor tyrosine kinase, mainly expressed in neural crest-derived tissues, that plays a role in cell growth and differentiation. Since the first identification of inherited mutations in RET as the cause of Multiple endocrine neoplasia type 2 (MEN2), somatic RET alterations have been identified as actionable drivers in subtypes of lung and thyroid, among other cancer types. This enabled the development of several RET targeted treatments, such as pralsetinib and selpercatinib, showing meaningful clinical benefit. To understand the full scope of RET alteration frequency and heterogeneity we used the AACR-GENIE database. We found that the frequency of RET alterations pan-cancer is 3%, of which two-thirds are missense mutations. The major cancer types with RET alterations are medullary thyroid, papillary thyroid and NSCLC, as expected, but also breast, colorectal and melanoma. An important distinction between NSCLC and thyroid cancer compared to colorectal, breast and melanoma is the fraction of missense vs. fusion events, with 30%-40% of samples in the former group containing RET fusions. This is in contrast with >80% of samples in the latter group containing RET missense mutations. Moreover, the heterogeneity of RET alterations is large, with over 1,000 unique types of missense mutations identified. The vast majority of mutations are classified as variants of uncertain significance (VUS). To better understand the potential activity of these mutations, we assayed over 200 different missense mutations and fusions using a high-throughput cell-based functional assay. Results were analyzed using a novel machine learning model consisting of a multi-scale deep convolutional neural net, followed by a tree-based regressor. Our results show that the assay correctly predicted the activity of both known activating alterations as well as of loss of function mutations. Interestingly, only ~3% of over 150 VUS tested were found to be activating. Furthermore, we show that the active alterations are sensitive to the FDA-approved targeted agents pralsetinib and selpercatinib, with varying IC50 values. Taken together, these results uncover the full extent of actionable RET alterations, differentiating between active and non-active variants, as well as the effectiveness of RET inhibitors. Citation Format: Shay Rotkopf, DIkla Haham, Natalie Fillipov-Levy, Lea Birnbaum, Elinor Dehan, Ilona Kifer, Zohar Barbash, Gabi Tarcic. A systematic analysis of RET mutations and their sensitivity to different RET inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1162.
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Rocco, Danilo, Luigi Sapio, Luigi Della Gravara, Silvio Naviglio, and Cesare Gridelli. "Treatment of Advanced Non-Small Cell Lung Cancer with RET Fusions: Reality and Hopes." International Journal of Molecular Sciences 24, no. 3 (January 26, 2023): 2433. http://dx.doi.org/10.3390/ijms24032433.
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RET-selective tyrosine kinase inhibitors (TKIs) selpercatinib and pralsetinib have revolutionized the landscape of RET-positive (RET+) advanced non-small cell lung cancer (NSCLC) treatment thanks to their efficacy and safety profiles. This class of medications currently represents the standard of care for both naïve and patients that have not received selective RET-TKIs in the first-line setting. However, we presently lack a satisfactory understanding of resistance mechanism developing after selective RET-TKIs usage, as well as a specific treatment for patients progressing on selpercatinib or pralsetinib. Chemotherapy ± immunotherapy is considered as a recommended subsequent second-line regimen in these patients. Therefore, it is of paramount importance to better define and understand the resistance mechanisms triggered by RET-TKIs. With this in mind, the present review article has been conceived to provide a comprehensive overview about RET+ advanced NSCLC, both from a therapeutic and molecular point of view. Besides comparing the clinical outcome achieved in RET+ advanced NSCLC patients after multikinase inhibitors (MKIs) and/or RET-selective TKIs’ administration, we focused on the molecular mechanisms accountable for their long-term resistance. Finally, a critical perspective on many of today’s most debated issues and concerns is provided, with the purpose of shaping the possible pharmacological approaches for tomorrow’s therapies.
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Rosell, Rafael, and Niki Karachaliou. "RET inhibitors for patients with RET fusion-positive and RET wild-type non-small-cell lung cancer." Lancet Oncology 17, no. 12 (December 2016): 1623–25. http://dx.doi.org/10.1016/s1470-2045(16)30557-5.
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Taylor, Matthew H., Justin F. Gainor, Mimi I.-Nan Hu, Viola Weijia Zhu, Gilberto Lopes, Sophie Leboulleux, Marcia S. Brose, et al. "Activity and tolerability of BLU-667, a highly potent and selective RET inhibitor, in patients with advanced RET-altered thyroid cancers." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): 6018. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.6018.
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6018 Background: RET alterations are targetable oncogenic drivers in ~90% of advanced medullary thyroid cancer (MTC) and 20% of papillary thyroid cancer (PTC), yet no selective RET inhibitors are approved. BLU-667 is an investigational highly potent and selective RET inhibitor targeting oncogenic RET alterations including those that confer resistance to multikinase inhibitors (MKIs). We provide an update on the expanded experience of BLU-667 in RET-altered thyroid cancer from the registration-enabling ARROW study (NCT03037385). Methods: ARROW is a global DE (30-600 mg daily [QD or BID]) and dose expansion (DX; 400 mg QD) study in pts with advanced solid tumors. Primary objectives are response rate (ORR; RECIST 1.1) and safety. Results: As of 19Dec2018, 60 pts with RET-mutated MTC (M918T [37], C634R/S/W [8], V804M [4], other/pending [11]) and 5 pts with RET-fusion+ PTC (NCOA4 [3], CCDC6 [2]) received BLU-667 (37 DE, 28 DX). 58% had prior MKI therapy. Among 49 response-evaluable MTC pts, ORR is 47% (95% CI: 33, 62; 2 complete and 21 partial responses (PR); 4 PR pending confirmation; 25 stable disease; 1 progressive disease). 96% (22/23) of responding pts continue treatment; 15 with response duration ≥ 6 months. 2/4 evaluable PTC pts had PR; all 5 enrolled PTC pts continue treatment at 8-11 months. Responses in MTC occur regardless of MKI resistance (prior cabozantinib/vandetanib: ORR 46% (12/26)) or RET genotype (PR in 2/3 evaluable pts with V804M). Disease control rate in MTC pts is 98%. Rapid plasma clearance of RET variants and marked reduction in CEA and calcitonin is observed. Treatment-related toxicity in MTC/PTC pts, generally low-grade and reversible (28% had grade 3 events, no grade 4/5 events, no events requiring discontinuation), includes decreased WBC (23%), increased AST (17%), increased ALT, blood creatinine, and phosphate, hypertension, and decreased neutrophils (all 15%). Conclusions: BLU-667 demonstrates potent, durable and broad antitumor activity and is well tolerated in MTC/PTC pts regardless of MKI resistance and may significantly improve outcomes for pts with RET-altered thyroid cancers. Enrollment of the expansion is ongoing with registrational intent. Clinical trial information: NCT03037385.
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Gramza, A. W., J. Patterson, J. Peters, M. Kaufman, S. Wise, and D. Flynn. "Activity of novel RET inhibitors against RET genotypes associated with medullary thyroid cancer." Journal of Clinical Oncology 28, no. 15_suppl (May 20, 2010): 5559. http://dx.doi.org/10.1200/jco.2010.28.15_suppl.5559.
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Fallatah, Arwa. "Abstract 1006: Understanding the resistance mechanisms of MTC to RTK inhibitors." Cancer Research 82, no. 12_Supplement (June 15, 2022): 1006. http://dx.doi.org/10.1158/1538-7445.am2022-1006.
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Abstract Medullary thyroid carcinoma (MTC) is a rare neuroendocrine tumor caused by activating mutations in the RET proto-oncogene. Vandetanib is an FDA approved systemic therapy targeting RET, EGFR, VEGFR, BRK, TIE2, members of EPH receptors kinase family, and members of Src family of tyrosine kinases. Treatment of MTC patients with metastatic disease leads to partial response accompanied by adverse side effects, poor tolerability, and the development of resistance. The mechanisms of MTC resistance to Vandetanib are not completely understood. Our overall goal is to understand the genetic and epigenetic mechanisms of resistance to Vandetanib, which would lead to novel combination therapies to prevent resistance or utilized to treat MTC patients. TT cell line, a MTC cell line with activating mutation C634W in RET, was used to generate resistant cell lines at 600 nM concentration compared to 270 nM IC50 in the parental cell line. To study the resistance in MTC, exome sequencing was done to identify genetic alterations such as novel mutations and copy number alterations. RNA-seq was performed to identify altered pathways, alternation in drug targets expression, and splicing events of some mRNAs. CRISPR KO screening was performed to validate our finding and identify genes that are synthetic lethal or conforming resistance to vandetanib. Also, we are analyzing the chromosomal changes by SKY analysis to validate copy number variations identified by exome sequencing and investigate tumor heterogeneity and epigenetic changes will be studied by DNA methylation. Preliminary results from exome sequencing confirmed that there is an enrichment in variant allele fraction in resistant cell line of C634W mutation from 0.72 to 0.99 in drug resistant cells. Also, RNA-seq data showed that there is an increased an expression in mutant RET transcript from log2(TPM) of 8.58 to 9.37 in resistance cell lines. Moreover, SKY analysis demonstrated four copies of chromosome 10 where RET gene is located indicating that there three mutant copies and one wild type copy. Western blot data confirmed the activation and an increased in RET expression in resistant cell line. CRISPR Knock-Out data showed that Cdk5, NF-ĸB, and IGF-1 were enriched in resistant cell line; whereas STAT, drug resistance, and mTOR pathway genes found to be depleted, suggest these genes may be synthetic lethal with vandetanib. Overall, our results suggest that the resistance is a result of an increase in mutated RET copies leading to increased RET transcripts. We will explore this hypothesis by performing CRISPR activation screening to identify genes confirms resistance upon activation. Also, we will perform SKY analysis in resistant cell line to determine the copy number of chromosome10. Additionally, simple western and phosphoproteomics will be conducted to identify other signaling alongside RET that may be altered as part of the resistance mechanism. Citation Format: Arwa Fallatah. Understanding the resistance mechanisms of MTC to RTK inhibitors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1006.
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Capelletti, Marzia, Doron Lipson, Geoff Otto, Roman Yelensky, Dalia Ercan, Jhingook Kim, Hidefumi Sasaki, et al. "Discovery of recurrent KIF5B-RET fusions and other targetable alterations from clinical NSCLC specimens." Journal of Clinical Oncology 30, no. 15_suppl (May 20, 2012): 7510. http://dx.doi.org/10.1200/jco.2012.30.15_suppl.7510.
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7510 Background: Many NSCLCs have driving oncogenic alterations including in EGFR, KRAS, ERBB2, BRAF, ALK and ROS1. Clinically effective drugs are approved for EGFR and ALK and clinical trials are underway for other genomic targets. Thus having a means of identifying genomic alterations in routine formalin fixed paraffin embedded (FFPE) clinical specimens is critical. Methods: We sequenced 24 FFPE NSCLC specimens with a next generation sequencing (NGS) assay that captures and sequences 2574 coding exons of 145 cancer relevant genes plus 37 introns from 14 genes often rearranged in cancer. Tumors from 643 additional patients were genotyped for KIF5B-RET. Results: We identified 50 alterations in 21 genes with at least one in 83% (20/24) of tumors (range 1-7). In 72% (36/50) of NSCLCs, at least one alteration was associated with a current clinical treatment or targeted therapy trial, including mutations in KRAS, BRAF, EGFR, MDM2, CDKN2A, CCNE1, CDK4, NF1 and PIK3CA. We also found an 11,294,741 bp pericentric inversion on chromosome 10 generating a novel gene fusion joining exons 1-15 of KIF5B to exons 12-20 of RET (K15:R12) in a Caucasian never smoker. This fusion gene contains the kinesin motor and coiled-coil domains of KIF5B and the entire RET tyrosine kinase domain. In 643 additional tumors we identified 11 fusion positive patients who were all wild type for known oncogenes (frequency of 6.3% (10/159)). Four unique KIF5B-RET variants were found: 8 K15:R12, 3 K16:R12, 1 K22:R12 and 1 K15:R11. We introduced K15:R12 into Ba/F3 cells and observed IL-3 independent growth consistent with oncogenic transformation. KIF5B-RET Ba/F3 cells were sensitive to sunitinib, sorafenib and vandetinib, multi-targeted kinase inhibitors that inhibit RET, but not gefitinib, an EGFR kinase inhibitor. Sunitinib, but not gefitinib, inhibited RET phosphorylation in these cells. Conclusions: We identified both known and novel genomic alterations from NSCLC FFPE specimens using a single test. Our findings suggest that RET inhibitors should be tested in prospective clinical trials in NSCLC patients bearing KIF5B-RET rearrangements and that NGS is a feasible approach to stratifying patients for treatment based on their genomic profiles.
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Varella-Garcia, Marileila, Liang Guo Xu, Sakshi Mahale, Eamon M. Berge, Chiara Bennati, Anh T. Le, Dara Aisner, et al. "RET rearrangements detected by FISH in “pan-negative” lung adenocarcinoma." Journal of Clinical Oncology 31, no. 15_suppl (May 20, 2013): 8024. http://dx.doi.org/10.1200/jco.2013.31.15_suppl.8024.
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8024 Background: RET rearrangements have recently been reported in NSCLC and there is pre-clinical evidence that RET tyrosine kinase inhibitors (TKIs) block activated RET kinase. Efficient and accurate detection of RET rearrangements are crucial for the success of RET TKIs in clinical trials. RET rearrangements have been detected by specialized sequencing techniques with limited applicability to clinical practice. Methods: A 3-target FISH probe set was developed to detect KIF5B-RET fusions and identify patterns suggestive of RET rearrangements with non-KIF5B partners. 51 lung adenocarcinomas negative for EGFR, KRAS, ALK and ROS1 (36 were also negative for 7 other molecular markers) were investigated. Clinical and demographic characteristics were collected. Results: Eight patients (15%) had rearrangements in the RET gene: 5 with KIF5B-RET fusions, 2 with patterns consistent with the CCDC6-RET fusion, and 1 with extra copies of single 3’RET (loss of 5’RET). Atypical FISH patterns were detected both in RET + and negative specimens suggesting high genomic instability in the KIF5B – RET region. RT-PCR assay determined the exon/fusion variant in 4 cases including 2 patients with K15:R12, 1 with K16:R12 and 1 with C1:R12. Median age at diagnosis was 58.5 in the mutation negative and 63 in the RET+ patients. Both cohorts were predominantly male (66% and 56%, respectively), with a majority of never smokers (59 and 89%, respectively), and stage IV disease at diagnosis (72 and 89%, respectively). Two heavily pretreated RET+ patients had stable disease at their initial restaging scans following treatment with the RET inhibitor vandetanib (radiographic assessment per RECIST 1.1); two others had early radiographic progression with sunitinib. Conclusions: The FISH probe proved efficient to detect RET rearrangements in lung adenocarcinomas, involving KIF5B and non-KIF5B partners. Frequency of RET rearrangements in this enriched lung adenocarcinoma cohort was considerably higher than reported in unselected cohorts. Further molecular analyses are being performed to increase understanding of the natural history of this new molecular subtype of NSCLC. Support: B J Addario Foundation, NCI P50CA058187, NCI CCSG P30CA046934.
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Hwang, Eun Suk, Dong Wook Kim, Jung Hwan Hwang, Hye Sook Jung, Jae Mi Suh, Young Joo Park, Hyo Kyun Chung, et al. "Regulation of Signal Transducer and Activator of Transcription 1 (STAT1) and STAT1-Dependent Genes by RET/PTC (Rearranged in Transformation/Papillary Thyroid Carcinoma) Oncogenic Tyrosine Kinases." Molecular Endocrinology 18, no. 11 (November 1, 2004): 2672–84. http://dx.doi.org/10.1210/me.2004-0168.
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Abstract Chimeric RET/PTC (rearranged in transformation/papillary thyroid carcinoma) oncoproteins are constitutively active tyrosine kinases found in thyroid papillary carcinoma and nonneoplastic Hashimoto’s thyroiditis. Although several proteins have been identified to be substrates of RET/PTC kinases, the pathogenic roles played by RET/PTC in malignant and benign thyroid diseases and the molecular mechanisms that are involved are not fully understood. We found that RET/PTC expression phosphorylates the Y701 residue of STAT1, a type II interferon (IFN)-responsive protein. RET/PTC-mediated signal transducer and activator of transcription 1 (STAT1) phosphorylation requires RET/PTC kinase activity to be intact but other tyrosine kinases, such as Janus kinases or c-Src, are not involved. RET/PTC-induced STAT1 transcriptional activation was not inhibited by suppressor of cytokine signaling-1 or -3, or protein inhibitors of activated STAT3 [(protein inhibitor of activated STAT (PIAS3)], but PIAS1 strongly repressed the RET/PTC-induced transcriptional activity of STAT1. RET/PTC-induced STAT1 activation caused IFN regulatory factor-1 expression. We found that STAT1 and IFN regulatory factor-1 cooperated to significantly increase transcription from type IV IFN-γresponsive promoters of class II transactivator genes. Significantly, cells stably expressing RET/PTC expressed class II transactivator and showed enhanced de novo membrane expression of major histocompatibility complex (MHC) class II proteins. Furthermore, RET/PTC1-bearing papillary thyroid carcinoma cells strongly expressed MHC class II (human leukocyte-associated antigen-DRα) genes, whereas the surrounding normal tissues did not. Thus, RET/PTC is able to phosphorylate and activate STAT1. This may lead to enhanced MHC class II expression, which may explain why the tissues surrounding RET/PTC-positive cancers are infiltrated with lymphocytes. Such immune response-promoting activity of RET/PTC may also relate to the development of Hashimoto’s thyroiditis.
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Zuercher, W. J., B. J. Turunen, and K. E. Rai Lackey. "Current Review of Small Molecule Ret Kinase Inhibitors." Mini-Reviews in Medicinal Chemistry 999, no. 999 (April 9, 2010): 1–9. http://dx.doi.org/10.2174/1389210201051315575.
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Sabari, Joshua K., Evan D. Siau, and Alexander Drilon. "Targeting RET-rearranged lung cancers with multikinase inhibitors." Oncoscience 4, no. 3-4 (April 14, 2017): 23–24. http://dx.doi.org/10.18632/oncoscience.345.
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Zuercher, W. J., B. J. Turunen, and K. E. Lackey. "Current Review of Small Molecule Ret Kinase Inhibitors." Mini-Reviews in Medicinal Chemistry 10, no. 2 (February 1, 2010): 138–46. http://dx.doi.org/10.2174/138955710791185154.
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Koehler, Viktoria Florentine, Pia Adam, Carmina Teresa Fuss, Linmiao Jiang, Elke Berg, Karin Frank-Raue, Friedhelm Raue, et al. "Treatment of RET-Positive Advanced Medullary Thyroid Cancer with Multi-Tyrosine Kinase Inhibitors—A Retrospective Multi-Center Registry Analysis." Cancers 14, no. 14 (July 13, 2022): 3405. http://dx.doi.org/10.3390/cancers14143405.
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Background: RET (rearranged during transfection) variants are the most prevalent oncogenic events in medullary thyroid cancer (MTC). In advanced disease, multi-tyrosine kinase inhibitors (MKIs) cabozantinib and vandetanib are the approved standard treatment irrespective of RET status. The actual outcome of patients with RET-positive MTC treated with MKIs is ill described. Methods: We here retrospectively determined the RET oncogene variant status with a targeted DNA Custom Panel in a prospectively collected cohort of 48 patients with advanced MTC treated with vandetanib and/or cabozantinib at four German referral centers. Progression-free survival (PFS) and overall survival (OS) probabilities were estimated using the Kaplan-Meier method. Results: In total, 44/48 (92%) patients had germline or somatic RET variants. The M918T variant was found in 29/44 (66%) cases. In total, 2/32 (6%) patients with a somatic RET variant had further somatic variants, while in 1/32 (3%) patient with a germline RET variant, additional variants were found. Only 1/48 (2%) patient had a pathogenic HRAS variant, and no variants were found in 3 cases. In first-line treatment, the median OS was 53 (95% CI (95% confidence interval), 32–NR (not reached); n = 36), and the median PFS was 21 months (12–39; n = 33) in RET-positive MTC patients. In second-line treatment, the median OS was 18 (13–79; n = 22), and the median PFS was 3.5 months (2–14; n = 22) in RET-positive cases. Conclusions: RET variants were highly prevalent in patients with advanced MTC. The treatment results in RET-positive cases were similar to those reported in unselected cohorts.
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Wan, R., J. Duan, Z. Wang, L. Lin, W. Li, and W. Jie. "47P Real-world outcomes of immune checkpoint inhibitors and selective RET inhibitors for RET fusion non-small cell lung cancer." Annals of Oncology 33 (April 2022): S54. http://dx.doi.org/10.1016/j.annonc.2022.02.056.
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Gainor, Justin F., Dae Ho Lee, Giuseppe Curigliano, Robert Charles Doebele, Dong-Wan Kim, Christina S. Baik, Daniel Shao-Weng Tan, et al. "Clinical activity and tolerability of BLU-667, a highly potent and selective RET inhibitor, in patients (pts) with advanced RET-fusion+ non-small cell lung cancer (NSCLC)." Journal of Clinical Oncology 37, no. 15_suppl (May 20, 2019): 9008. http://dx.doi.org/10.1200/jco.2019.37.15_suppl.9008.
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9008 Background: RET fusions are targetable oncogenic drivers in up to 2% of NSCLC, yet no selective RET inhibitors are approved. BLU-667 is an investigational highly potent and selective RET inhibitor targeting oncogenic RET alterations, including those that confer resistance to multikinase inhibitors (MKIs). We provide an update on the registration-enabling ARROW study (NCT03037385) of BLU-667 in pts with RET-fusion+ NSCLC. Methods: The global ARROW study includes DE (30-600 mg daily [QD or BID]) and dose expansion (DX) at the recommended phase 2 dose (RP2D; 400 mg QD) in pts with advanced solid tumors. Primary objectives are overall response rate (ORR; RECIST 1.1) and safety. Results: As of 19Dec2018, 79 pts (21 DE, 58 DX) with advanced RET fusion+ NSCLC (44 KIF5B, 16 CCDC6, 19 other/pending) received BLU-667. Median number of prior therapies was 2 (range 0-8) and includes chemotherapy (76%), immunotherapy (41%), and MKI (27%). 39% had baseline brain metastases. ORR among 57 response-evaluable pts with measurable disease and at least one follow-up disease assessment was 56% (95% CI: 42, 69; 32 partial responses (PR), 9 PR pending confirmation, 20 stable disease, 5 progressive disease). 91% (29/32) of responding pts remain on treatment; 6 have achieved response duration ≥ 6 months. Disease control rate (DCR) was 91% (52/57). Among 30 pts at the RP2D previously treated with platinum chemotherapy, ORR was 60% (18 PRs; 7 pending confirmation). Responses occur regardless of prior treatment or RET fusion genotypes. Intracranial activity has been observed with shrinkage of brain metastases. 80% of NSCLC pts treated at RP2D remain on treatment and only 3% discontinued due to related adverse event. In NSCLC patients, treatment-related toxicity (TRT), generally low-grade and reversible (28% had ≥ grade 3 events), included increased AST (22%), hypertension (18%), increased ALT (17%), constipation (17%), fatigue (15%) and decreased neutrophils (15%). Conclusions: BLU-667 demonstrated potent, durable and broad antitumor activity and was well tolerated in pts with advanced RET-fusion+ NSCLC. Enrollment of the expansion is ongoing with registrational intent. Clinical trial information: NCT03037385.