ROS1 comprises a small molecular subset of NSCLC, and several fusion partners have been discovered. Concomitant mutations of EGFR and ROS1 in NSCLC have been occasionally reported, while no clear standard of treatment has been revealed. Here we report a case with metastatic lung adenocarcinoma detected to have EGFR 21 exon L858R mutation at diagnosis, who responded to first-line gefitinib and second-line osimertinib treatment. Next-generation sequencing during the treatment course revealed multiple alterations, including an OPRM1-ROS1 Ointergenic: R36 fusion. We reviewed the related literatures but found no report of this fusion type previously. The application of ctDNA detection results in the finding of new alterations, which need further confirmation.

Great progress has been achieved in molecular targeted therapy for lung adenocarcinoma. The targetable driver genes include mutant EGFR, BRAF, HER2, and MET, rearrangements in ALK, ROS1, RET, and so on [1]. Molecular genotyping has been routinely conducted in clinic to determine the therapeutic regimen with the development of sequencing technology, and novel mutations are being identified which may lead to more treatment opportunities.

EGFR mutation and ROS1 rearrangement occur in about 50% and 2–3% of Asian patients with advanced lung adenocarcinoma, respectively [2, 3]. There were 2.8% of patients harboring EGFR mutations who carry additional alterations, among which KRAS mutations (31.7%) and ALK rearrangement (17.5%) were relatively common, while EGFR/ROS1/KRAS was rare (0.13%) [4]. In patients with ROS1 rearrangement, the incidence of concomitant mutations involving EGFR were detected as 0–24% [5-7]. With the popularization of next-generation sequencing (NGS), more and more fusion gene partners of ROS1 have been reported, including CD74, EZR, SLC34A2, TPM3, SDC4, LRIG3, FIG(GOPC)1, CCDC6, CLTC, KDELR2, LRIG3, TPD52L1, CEP72, TMEM106B, ZCCHC8, and WNK1 [3, 8-13]. We report a novel OPRM1-ROS1 Ointergenic: R36 fusion concomitant with EGFR mutations in a patient with stage IV lung adenocarcinoma.

A 66-year-old male never-smoker was diagnosed as stage IV lung adenocarcinoma of the left lower lobe with extensive metastases (multiple ribs and vertebras, pelvis) in May 2016 (Fig. 1a). The biopsy specimen obtained by fiber bronchoscope was tested for EGFR and ALK using ARMS-PCR and FISH, respectively, and the tumor was found to be positive for EGFR 21 exon L858R mutation and negative for ALK rearrangement.

Fig. 1.

Lung computed tomography scans during the treatment course. a PET/CT scan before treatment (May 2016). b A computed tomography scan after treatment with gefitinib for 1.5 months (June 2016). c A computed tomography scan after treatment with gefitinib for 11 months (March 2017). d A computed tomography scan after treatment with osimertinib for 2 months (May 2017). e A computed tomography scan after treatment with 2 cycles of pemetrexed and cisplatin (Dec 2017). f A magnetic resonance scan after treatment with 2 cycles of pemetrexed and cisplatin (Dec 2017).

Fig. 1.

Lung computed tomography scans during the treatment course. a PET/CT scan before treatment (May 2016). b A computed tomography scan after treatment with gefitinib for 1.5 months (June 2016). c A computed tomography scan after treatment with gefitinib for 11 months (March 2017). d A computed tomography scan after treatment with osimertinib for 2 months (May 2017). e A computed tomography scan after treatment with 2 cycles of pemetrexed and cisplatin (Dec 2017). f A magnetic resonance scan after treatment with 2 cycles of pemetrexed and cisplatin (Dec 2017).

Close modal

He received gefitinib as first-line therapy and had a stable disease (Fig. 1b) until progression occurred after 11 months, presenting with aggravating pain in the waist and left iliac region (Fig. 1c). CT scan showed enlargement of primary lesion and new lesions of bone metastasis. We did ctDNA multiplex genotyping analysis using NGS with peripheral blood (Burnig Rock, Guangzhou, China), and the results showed EGFR 21 exon L858R (abundance 36.62%), EGFR 20 exon T790M (7.95%) and OPRM1-ROS1 Ointergenic: R36 fusion (15.81%), EGFR, HER2, and BRAF amplification (copy number [CN] 2.69, 3.07, and 2.63, respectively). He received osimertinib as second-line therapy with palliative radiotherapy for vertebral lesions (30 Gy/10 fx) and had a stable disease (Fig. 1d). Progression was confirmed with CT scan after 7 months. Using NGS, we detected EGFR exon 18 L718Q (abundance 0.79%), 20 exon T790M (5.04%), C797S (0.11%), 21 exon L858R (24.58%), and OPRM1-ROS1 Ointergenic: R36 fusion (6.11%), HER2 amplification (CN 2.66). He received pemetrexed and carboplatin as third-line therapy for 2 cycles, with multiple bilateral pulmonary nodules on CT scan and multiple new intracranial lesions on MR (Fig. 1e, f). Repeated NGS showed EGFR exon 18 L718Q (abundance 1.09%), 20 exon T790M (2.43%), 21 exon L858R (13.80%), OPRM1-ROS1 Ointergenic: R36 fusion (3.97%), and EGFR amplification (CN 2.25), HER2 amplification (CN 2.26) (the genetic alterations detected by NGS are listed in supplementary table 1; see www.karger.com/doi/10.1159/000507980). He refused further treatment and died 3 months later without re-evaluation.

This is the first report of co-existing OPRM1-ROS1 fusion and EGFR mutation in NSCLC. OPRM1 (opioid receptor mu 1) gene occupies a 200-kb region on the 6q25.2 (genecard.org) and encodes mu-opioid receptor, which is a transmembrane receptor regulating the analgesic response to pain [14]. ROS1 gene is located on the 6q22 [15]. OPRM1 is located near EZR (6q25.3), and the fusion may be generated from intra-chromosomal inversion similar to EZR-ROS1. ROS1 receptor has no known ligand, and the downstream oncogenic pathway differs with different fusion partners. The most reported breakpoints are exon 32, 34, and 35 [16]. The breakpoint of ROS1 in this case was exon 36, which encodes the transmembrane domain of ROS1 together with exon 35, and the reserved ROS1 kinase domain is sufficient to drive carcinogenesis independent of partners [17]. There were several limitations with this case. ROS1 detection was not performed at baseline. The patient did not receive crizotinib and the function of the fusion could not be proven. The detection of EGFR T790M after treatment with gefitinib, C797S, and L718Q after osimertinib were in accordance with the course of EGFR TKI treatment [18, 19], confirming that EGFR mutation was a definite driver. Generally, pemetrexed-based chemotherapy is favorable in patients with ROS1 arrangements [20], while in this case there was no response to pemetrexed. Many other alterations were also present in this case, for the use of NGS may result in a higher ratio of concomitant mutations. The dynamic monitoring of mutation was carried out with blood, while repeated biopsy for FISH was lacked because of the unwillingness of the patient. The function of this fusion needs further illustration.

In conclusion, a new ROS1 rearrangement was found, which was concomitant with EGFR mutation and should be further examined for the oncogenicity. NGS is a feasible method to detect novel types of gene arrangement and concomitant mutations, while the treatment standard needs further studies.

We thank the patient and his families for the agreement of the publication of the report.

The patient provided written informed consent to publish his case including the NGS results and images.

All the authors declare that there is no conflict of interests.

There was no funder involved.

Sicai Zhang drafted the manuscript, Zhiyong Xu reported the case, and Weimin Zhang revised manuscript. All the authors reviewed and approved the submitted article.

1.
Cancer Genome Atlas Research Network
.
Comprehensive molecular profiling of lung adenocarcinoma
.
Nature
.
2014
;
511
(
7511
):
543
50
.
2.
Han
B
,
Tjulandin
S
,
Hagiwara
K
,
Normanno
N
,
Wulandari
L
,
Laktionov
K
,
EGFR mutation prevalence in Asia-Pacific and Russian patients with advanced NSCLC of adenocarcinoma and non-adenocarcinoma histology: The IGNITE study
.
Lung Cancer
.
2017
;
113
:
37
44
.
3.
Kohno
T
,
Nakaoku
T
,
Tsuta
K
,
Tsuchihara
K
,
Matsumoto
S
,
Yoh
K
,
Beyond ALK-RET, ROS1 and other oncogene fusions in lung cancer
.
Transl Lung Cancer Res
.
2015
;
4
(
2
):
156
64
.
4.
Zhuang
X
,
Zhao
C
,
Li
J
,
Su
C
,
Chen
X
,
Ren
S
,
Clinical features and therapeutic options in non-small cell lung cancer patients with concomitant mutations of EGFR, ALK, ROS1, KRAS or BRAF
.
Cancer Med
.
2019
;
8
(
6
):
2858
66
.
5.
Lin
JJ
,
Ritterhouse
LL
,
Ali
SM
,
Bailey
M
,
Schrock
AB
,
Gainor
JF
,
ROS1 Fusions Rarely Overlap with Other Oncogenic Drivers in Non-Small Cell Lung Cancer
.
J Thorac Oncol
.
2017
;
12
(
5
):
872
7
.
6.
Scheffler
M
,
Schultheis
A
,
Teixido
C
,
Michels
S
,
Morales-Espinosa
D
,
Viteri
S
,
ROS1 rearrangements in lung adenocarcinoma: prognostic impact, therapeutic options and genetic variability
.
Oncotarget
.
2015
;
6
(
12
):
10577
85
.
7.
Wiesweg
M
,
Eberhardt
WE
,
Reis
H
,
Ting
S
,
Savvidou
N
,
Skiba
C
,
High Prevalence of Concomitant Oncogene Mutations in Prospectively Identified Patients with ROS1-Positive Metastatic Lung Cancer
.
J Thorac Oncol
.
2017
;
12
(
1
):
54
64
.
8.
Davies
KD
,
Doebele
RC
.
Molecular pathways: ROS1 fusion proteins in cancer
.
Clin Cancer Res
.
2013
;
19
(
15
):
4040
5
.
9.
Zhu
VW
,
Upadhyay
D
,
Schrock
AB
,
Gowen
K
,
Ali
SM
,
Ou
SH
.
TPD52L1-ROS1, a new ROS1 fusion variant in lung adenosquamous cell carcinoma identified by comprehensive genomic profiling
.
Lung Cancer
.
2016
;
97
:
48
50
.
10.
Zhu
YC
,
Zhou
YF
,
Wang
WX
,
Xu
CW
,
Zhuang
W
,
Du
KQ
,
CEP72-ROS1: A novel ROS1 oncogenic fusion variant in lung adenocarcinoma identified by next-generation sequencing
.
Thorac Cancer
.
2018
;
9
(
5
):
652
5
.
11.
Ou
SH
,
Chalmers
ZR
,
Azada
MC
,
Ross
JS
,
Stephens
PJ
,
Ali
SM
,
Identification of a novel TMEM106B-ROS1 fusion variant in lung adenocarcinoma by comprehensive genomic profiling
.
Lung Cancer
.
2015
;
88
(
3
):
352
4
.
12.
Zhu
YC
,
Wang
WX
,
Xu
CW
,
Zhuang
W
,
Song
ZB
,
Du
KQ
,
A novel co-existing
.
Cancer Biol Ther
.
2018
;
19
:
1097
101
.
13.
Liu
Y
,
Liu
T
,
Li
N
,
Wang
T
,
Pu
Y
,
Lin
R
.
Identification of a novel WNK1-ROS1 fusion in a lung adenocarcinoma sensitive to crizotinib
.
Lung Cancer
.
2019
;
129
:
92
4
.
14.
Crist
RC
,
Berrettini
WH
.
Pharmacogenetics of OPRM1
.
Pharmacol Biochem Behav
.
2014
;
123
:
25
33
.
15.
Robinson
DR
,
Wu
YM
,
Lin
SF
.
The protein tyrosine kinase family of the human genome
.
Oncogene
.
2000
;
19
:
5548
57
.
16.
Takeuchi
K
,
Soda
M
,
Togashi
Y
,
RET, ROS1 and ALK fusions in lung cancer
.
Nat Med
.
2012
;
18
:
378
81
.
17.
Acquaviva
J
,
Wong
R
,
Charest
A
.
The multifaceted roles of the receptor tyrosine kinase ROS in development and cancer
.
Biochim Biophys Acta
.
2009
;
1795
:
37
52
.
18.
Thress
KS
,
Paweletz
CP
,
Felip
E
,
Cho
BC
,
Stetson
D
,
Dougherty
B
,
Acquired EGFR C797S mutation mediates resistance to AZD9291 in non-small cell lung cancer harboring EGFR T790M
.
Nat Med
.
2015
;
21
:
560
2
.
19.
Bersanelli
M
,
Minari
R
,
Bordi
P
,
Gnetti
L
,
Bozzetti
C
,
Squadrilli
A
,
L718Q Mutation as New Mechanism of Acquired Resistance to AZD9291 in EGFR-Mutated NSCLC
.
J Thorac Oncol
.
2016
;
11
:
e121
3
.
20.
Kim
HR
,
Lim
SM
,
Kim
HJ
.
The frequency and impact of ROS1 rearrangement on clinical outcomes in never smokers with lung adenocarcinoma
.
Ann Oncol
.
2013
;
24
:
2364
70
.
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