BackgroundLung adenocarcinomas from patients who respond to the tyrosine kinase inhibitors gefitinib (Iressa) or erlotinib (Tarceva) usually harbor somatic gain-of-function mutations in exons encoding the kinase domain of the epidermal growth factor receptor (EGFR). Despite initial responses, patients eventually progress by unknown mechanisms of “acquired” resistance.Methods and FindingsWe show that in two of five patients with acquired resistance to gefitinib or erlotinib, progressing tumors contain, in addition to a primary drug-sensitive mutation in EGFR, a secondary mutation in exon 20, which leads to substitution of methionine for threonine at position 790 (T790M) in the kinase domain. Tumor cells from a sixth patient with a drug-sensitive EGFR mutation whose tumor progressed on adjuvant gefitinib after complete resection also contained the T790M mutation. This mutation was not detected in untreated tumor samples. Moreover, no tumors with acquired resistance had KRAS mutations, which have been associated with primary resistance to these drugs. Biochemical analyses of transfected cells and growth inhibition studies with lung cancer cell lines demonstrate that the T790M mutation confers resistance to EGFR mutants usually sensitive to either gefitinib or erlotinib. Interestingly, a mutation analogous to T790M has been observed in other kinases with acquired resistance to another kinase inhibitor, imatinib (Gleevec).ConclusionIn patients with tumors bearing gefitinib- or erlotinib-sensitive EGFR mutations, resistant subclones containing an additional EGFR mutation emerge in the presence of drug. This observation should help guide the search for more effective therapy against a specific subset of lung cancers.

Purpose: In patients whose lung adenocarcinomas harbor epidermal growth factor receptor (EGFR) tyrosine kinase domain mutations, acquired resistance to the tyrosine kinase inhibitors (TKI) gefitinib (Iressa) and erlotinib (Tarceva) has been associated with a second-site EGFR mutation, which leads to substitution of methionine for threonine at position 790 (T790M). We aimed to elucidate the frequency and nature of secondary EGFR mutations in patients with acquired resistance toTKI monotherapy. Experimental Design: Tumor cells from patients with acquired resistance were examined for secondary EGFR kinase domain mutations by molecular analyses. Results: Eight of 16 patients (50% observed rate; 95% confidence interval, 25-75%) had tumor cells with second-site EGFR mutations. Seven mutations were T790M and one was a novel D761Y mutation found in a brain metastasis. When combined with a drug-sensitive L858R mutation, the D761Y mutation modestly reduced the sensitivity of mutant EGFR to TKIs in both surrogate kinase and cell viability assays. In an autopsy case, theT790M mutation was found in multiple visceral metastases but not in a brain lesion. Conclusions: TheT790M mutation is common in patients with acquired resistance. The limited spectrum of TKI-resistant mutations in EGFR, which binds to erlotinib in the active conformation, contrasts with a wider range of second-site mutations seen with acquired resistance to imatinib, which binds to ABL and KIT, respectively, in closed conformations. Collectively, our data suggest that the type and nature of kinase inhibitor resistance mutations may be influenced by both anatomic site and mode of binding to the kinase target.

Non–small cell lung cancers (NSCLCs) that harbor mutations within the epidermal growth factor receptor (EGFR) gene are sensitive to the tyrosine kinase inhibitors (TKIs) gefitinib and erlotinib. Unfortunately, all patients treated with these drugs will acquire resistance, most commonly as a result of a secondary mutation within EGFR (T790M). Because both drugs were developed to target wild-type EGFR, we hypothesized that current dosing schedules were not optimized for mutant EGFR or to prevent resistance. To investigate this further, we developed isogenic TKI-sensitive and TKI-resistant pairs of cell lines that mimic the behavior of human tumors. We determined that the drug-sensitive and drug-resistant EGFR-mutant cells exhibited differential growth kinetics, with the drug-resistant cells showing slower growth. We incorporated these data into evolutionary mathematical cancer models with constraints derived from clinical data sets. This modeling predicted alternative therapeutic strategies that could prolong the clinical benefit of TKIs against EGFR-mutant NSCLCs by delaying the development of resistance.

AAA-PKB did not prevent actin bundling (membrane ruffling), though this response was PI 3-kinase dependent. Therefore, it is unlikely that AAA-PKB acted by inhibiting PI 3-kinase signaling. These results outline an important role for PKB␣/Akt1 in the stimulation of glucose transport by insulin in muscle cells in culture.Translocation of GLUT4 from an intracellular compartment to the plasma membrane largely accounts for the stimulation of glucose transport by insulin in skeletal muscle (16,31,38), cardiac muscle (48), and adipose cells (23,24). Two insulinresponsive cell lines also express this transporter: L6 rat skeletal myotubes (34, 40) and 3T3-L1 mouse adipocytes (24). Transfection of a molecularly engineered form of this transporter containing an exofacial epitope tag between the first and second transmembrane domains allows for the detection of surface transporters in intact cells. GLUT4 molecules with an exofacial epitope tag have been heterologously expressed in rat adipose cells (44, 51), 3T3-L1 adipocytes (26), CHO cells (12, 26), H9c2 cardiomyocytes (55), and rat 3Y1 cells (22). We have recently shown that stable expression of GLUT4myc in L6 myoblasts (L6-GLUT4myc myoblasts) mimics the response to insulin seen with endogenous GLUT4 in differentiated myotubes (29, 60).Insulin-induced translocation of GLUT4 to the plasma membrane requires the activity of phosphatidylinositol (PI) 3-kinase (47) in rat adipocytes (43, 45), 3T3-L1 adipocytes (8,9,21,27,39,51), L6 muscle cells (53), and rat skeletal muscle (62). Moreover, treatment of intact 3T3-L1 adipocytes with a cell-permeant PI 3,4,5-triphosphate [PI (3,4,5)-P 3 ] compound, which is converted into a product of PI 3-kinase once inside the cell, partly rescued the inhibition of insulin-stimulated glucose transport by wortmannin (25). It is unclear how the lipid products of PI 3-kinase relay the insulin signal to the glucose transporters, but the serine/threonine kinase protein kinase B (PKB)/Akt interacts with the lipid products of PI 3-kinase (19), and activation of PKB/Akt by insulin is prevented by inhibitors of PI 3-kinase (1). To date, three isoforms of PKB/Akt have been identified: PKB␣, -␤, and -␥ (Akt1, -2, and -3) (17). In skeletal muscle and L6 muscle cells, PKB␣ and PKB␥, but not PKB␤, are stimulated by insulin (59). Full activation of PKB/ Akt by insulin requires hierarchical phosphorylation on two residues, Thr308 (Thr309 and Thr305 in the case of PKB␤ and -␥, respectively) and Ser473 (Ser474 in the case of PKB␤; PKB␥ lacks an equivalent site) by 3-phosphoinositide-dependent protein kinase 1 (PDK-1) and PDK-2, respectively (1-3, 14, 50).Recent reports have suggested that activation of PKB/Akt may mediate the stimulation of glucose transport by insulin, since stable overexpression of wild-type PKB␣/Akt1 or constitutively active mutants of PKB␣/Akt1 increased glucose transport and translocation of GLUT4 to levels similar to or greater than those achieved with insulin in rat adipocytes (52), 3T3-L1 adipocytes (33,56), and L6 muscle cells (20,56...