ERA’S JOURNAL OF MEDICAL RESEARCHVOL.3 NO.2
ANAPLASTIC LYMPHOMA KINASE (ALK) GENE REARRANGEMENT
DETECTION USING FLUORESCENE IN–SITU HYBRIDIZATION (FISH) IN
LUNG CANCER PROGNOSTICATION
Alok Singh, A.N. Srivastava, Pooja Singh.
Department of Pathology
Era's Lucknow Medical College and Hospital, Lucknow, U.P., India.
Received : August 2016
Accepted : October 2016
Lung cancer is a leading cause of cancer related death worldwide. It is
increasing at a very fast rate in both men and women. Some significant
Address for correspondence
mutations occurring at molecular level in lung adenocarcinoma, like ALK,
Dr. Anand Narain Srivastava
EGFR, KRAS, MET, and, ALK (anaplastic lymphoma kinase) gene
Director Research & Consulting
mutations for an ALK encoded transmembrane receptor tyrosine kinase
Faculty, Department of Pathology,
domain and subsequently participating in the progression of Non–Small Cell
Era's Lucknow Medical College and
Lung Adenocarcinoma (NSCLC). Some fusion partner genes involved in this
Hospital, Lucknow, U.P., India.
process are EML–4, KLC1, KIF5B and TFG. The ALK–EML–4
rearrangement is the second most common oncogenic mutation in the non–
small cell lung adenocarcinoma. There is 3–7% ALK mutation occurring in
early or never–smokers in accompanying NSCLC. The NSCLC with ALK
gene mutation generally do not have EGFR or KRAS gene mutation which
are also molecular markers, which get mutated in cancer. For the detection of
ALK mutation in NSCLC, different types of techniques like Fluorescence in
situ Hybridization (FISH), Immunohistochemistry (IHC) and Reverse Transcriptase–Polymerase Chain Reaction
(RT–PCR) are being used. On the basis of sensitivity and specificity, FISH is gold standard in detecting the mutation
when compared with other methodologies like IHC and RT– PCR. However in the Indian setting, FISH is more
expensive and hence not available everywhere. In this review the efficacy of these different techniques in detecting
ALK mutation and the detailed interpretation of results obtained with FISH has been discussed. For the treatment of
ALK/MET mutated NSCLC patients an orally administered drug, crizotinib drug (tyrosine kinase inhibitor) has been
approved by Food and Drug Administration (FDA) of United States. Highly sensitive and specific techniques are used
for the detection of ALK gene mutation in NSCLC patients which have to be given for crizotinib treatment.
Keyword: Anaplastic Lymphoma Kinase; Non–Small Cell Lung Carcinoma; Polysomy.
development lung cancer.5,6 Some vegetables and
fruits help in the protection from lung cancer risk,
according to Sankaranarayanan et al.(1994) the green
vegetable and banana reduces the risk of lung cancer.
Nowadays lung cancer is one of the most common
Onion and Pumpkin also reduce the risk of lung cancer.
causes of cancer related deaths worldwide in both men
On the contrary, the animal fat and dietary cholesterol
and women, nearly more than one million deaths occur
increase the lung cancer risk.7
per year due to this dreaded disease.1 According to
America cancer society (2016), death rate due to lung
cancer is more than breast cancer, prostate cancer and
Small Cell Lung Carcinoma (SCLC)
colorectal cancer in the world.2 The 5 years survival in
The metastasis rate is very high with this cancer and it
cases of lung cancer is only 15%. Hence necessity for
contributes to about 15% of all types of lung cancer.2
searching more targeted and effective therapeutic drug
According to Sorensen M. (2010) tobacco smoking is
for its treatment is the need of the hour.3 On the basis of
the main cause of SCLC.8 In SCLC, gene mutation has
cell shape and size the lung cancer is divided in two
been found to occur in C–myc, L–myc, N–myc, C–raf
types, Small cell carcinoma (SCLC) and Non–small
(oncogene) Rb and p53 (tumour suppressor gene).
cell lung carcinoma (NSCLC).There are various
Molecular studies have shown that the lung cancer is
causes of lung cancer viz tobacco smoking, (cigarette
caused by genetic abnormalities due to deletion or
followed by exposure to asbestos, arsenic,
translocation of the DNA sequences, which play the
chloromethyle, and radiation. These exposures cause
main role in cancer development. The genes where
genetic mutation in the patients leading to the
29ANAPLASTIC LYMPHOMA KINASE (ALK) GENE REARRANGEMENT DETECTION USING FLUORESCENE IN–SITU HYBRIDIZATION (FISH) IN LUNG CANCER PROGNOSTICATION
inversion between ALK and EML–4 gene.17 There are
mutation causes lung cancer may be proto–oncogene
several types of genes involved in the fusion with ALK
or tumour suppressor gene. After mutation, the proto–
gene which participates in the NSCLC development
oncogene is converted into oncogene which causes
such as KLC1, KIF5B and TFG gene 20 but EML–4 is
carcinogenesis. The tumour suppressor gene
predominant fusion partner. The fusion of ALK and
suppresses the formation of tumour but after mutation
EML–4 on chromosome '2p' has also been observed in
it is converted into tumour promoting gene that may
non–smokers, light smoker and young age patients.22
help in develop of the cancer.9,10
EML4–ALK fusion is found with wild type EGFR and
Non–Small Cell Lung Carcinoma (NSCLC)
NSCLC is a well–known type of lung cancer and
constitute nearly 85% in all type of lung carcinoma.
United States, FDA approved ALK/MET and ROS1
NSCLC metastasizes slower than small cell lung
tyrosine kinase inhibitor Crizotinib in August 2011, as
carcinoma and its diagnosis is very difficult in
a therapeutic drug for NSCLC.24 This drug is taken up
comparison to SCLC in early stage. Approximately
orally and it interferes with the constitutive
70% of cases of NSCLC are diagnosed at advanced
phosphorylating activity of the tyrosine kinase domain
stage.2 The gene which are associated with NSCLC
of ALK receptor.25 EGFR tyrosine kinase inhibitor
are EGFR, ALK, KRAS, HER2, PI3KCA, MAP2K1,
does not have affinity to inhibit the ALK mutated
BRAF, MET3 N–ras, H–ras, C–raf, p16, Rb.9,10
tyrosine kinase activity of the receptor.26 The copy
number of ALK gene with its fusion partner increases
Lung Cancer in Indian Scenario
in cases of crizotinib resistance. ALK gene fusion copy
Ito. Y et al. (2007), reported that the 5 year survival of
number is detected in each cell before and after
NSCLC in India was 12–14% and in case of SCLC was
crizotinib treatment using fluorescence in situ
only 2–3%.11 Ferguson MK. et al. (2000) have found
hybridization method. The copy number increases
better survival with squamous cell carcinoma in
nearly more than 2 time of ALK gene rearrangement in
comparison to other types of lung carcinoma.12
every cell after the treatment than before treatment
Radzikowska E. et al. in 2003 reported that women
with crizotinib in the samples and sometimes it may be
have better survival rate in comparison to men.
>4 times.27 An increased copy number of non–
However, some workers have found an opposite
rearranged ALK gene signals correspond to polysomy
(≥ 4 ALK copies in ≥ 10% cell nuclei in figure 1) or
ALK amplification (≥10 ALK copies in ≥10% cell
nuclei). The ALK gene copy number observed in 10%
Anaplastic Lymphoma Kinase Gene (ALK)
to 39% of nuclei is considered as low grade polysomy,
The ALK gene occurs on short arm (p) of chromosome
whereas >40% of nuclei is taken as high grade
number two (2p23),14 which codes a transmembrane
polysomy (Cappuzzo et al. 2005).28
receptor protein (receptor tyrosine kinase), a
member of the insulin like tyrosine receptor kinase
superfamily.15 Generally the expression of receptor
tyrosine kinase is not noticed in lung cancer.16 In
IHC, FISH, and RT–PCR are in use for the detection of
2007, Soda et al. revealed a mutation causing the
ALK–EML4 fusion in NSCLC on formalin fixed
fusion between two different genes– ALK and EML–4
paraffin embedded tissue (FFPE) sample but some
(Echinoderm microtubule protein like four). EML–4 is
problems occur during these experiments. For IHC
another mutated gene, also present on short arm (p) of
and FISH the cancer tissue should be enough because
chromosome number two (2p21), present upstream of
it is not always possible to obtain large tissue from the
ALK gene and its mutation culminates into different
NSCLC patients. The tissue size is a major issue with
types of Non–Small Cell Lung Carcinoma.17 EML–4
the IHC and FISH. FISH is a more expensive test and
encoded protein may aid in assembly of
may not be suitable for mass screening.29 RT–PCR for
microtubules.19 Fusion between ALK and EML–4
detecting ALK–EML–4 mutation is not easy like FISH
results in the constitutive kinase activity of ALK
and IHC because it requires sufficient quantity of RNA
receptor tyrosine kinase that induces the abnormal
for the experiment and the RNA extraction should be
proliferation of cells which cause cancer like lung
done instantly after the sample collection from the
carcinoma.18 According to Soda et al. (2007)
NSCLC patients for the feasibility of the result. More
signaling part of ALK receptor tyrosine kinase is fused
researchers have studied ALK mutation in NSCLC, by
with the N– terminal end of EML–4 protein due to
Reverse Transcriptase Polymerase Chain Reaction
30 – Dec 2016ERA’S JOURNAL OF MEDICAL RESEARCHVOL.3 NO.2Jul
Fig.1: It is showing polysomy of ALK gene
clones (ALK1, 5A4 and D5F3) showing variation in
sensitivity and specificity (Table–2), are available in
Fluorescence In–Situ Hybridization (FISH). To
the market for the analysis of ALK gene mutation
determine the ALK mutation in NSCLC patients,IHC
detection in NSCLC cases using
is cheap as compared to other techniques but it does
immunohistochemical techniques.31 Thunnissen
not give confirmatory results. FISH and RT–PCR
et,al. (2012) described the recent challenges in the
provide confirmatory results. On the basis of
standardization of IHC for ALK mutation detection in
sensitivity and specificity, the FISH is a gold standard
NSCLC patients like tissue preparation, antibody
method for the analysis of the ALK gene
alternatives, signal intensity improvement and exact
rearrangement in NSCLC patients (Table 1).30
scoring. The benefits of IHC are that it is less
expensive technique, easy to interpret the result by
general pathologists, less time taking technique.
There are different types of monoclonal antibody
TECHNIQUES ADVANTAGES DRAWBACKS
1. On FFPE tissue
2. It can distinguish any
Negative case Positive Case
1. It is cheap in comparison
1. Unique antibodies are
not present in the market
1. It cannot identify
1. Require a smaller
2. Chances of RNA
Negative (Non ALK Gene Positive (ALK gene
Table 1. Advantages and disadvantages of different
types of techniques for the detection of ALK–EML–4
Figure 2. Difference between Immunohistochemistry
rearrangement in Lung Adenocarcinoma.36
and FISH Interpretation of ALK Mutation in NSCLC.32
Fluorescence in– situ Hybridization for ALK
However, it has been recently seen that ALK mutation
by IHC in NSCLC require further scrutiny and
validation using FISH because sometimes IHC
For the interpretation of ALK mutation of 2p23 locus
positive cases become negative after the FISH
in NSCLC patients a FDA approved diagnostic probe
kit is available in the market known as Vysis LSI ALK
dual colour Break Apart Rearrangement Probe (United
31ANAPLASTIC LYMPHOMA KINASE (ALK) GENE REARRANGEMENT DETECTION USING FLUORESCENE IN–SITU HYBRIDIZATION (FISH) IN LUNG CANCER PROGNOSTICATION
diameter (Positive) (d) One fused and one separate
State). The probes are of two types for the same gene
red signal which is presenting green signal deletion
which are labeled with two different colour green and
but it will be considered as positive.
orange (Red) fluorochromes which bind at a specific
DNA target sequence (fig.–3).33 In non ALK mutated
cells the green and orange signals are fused or less than
two diameters distance. In case of gene rearrangement
of ALK gene with EML–4 gene, the orange and green
signals appears separately (>2 diameter) and one fused
signals, sometimes due to deletion, only one orange
and one fused signal appear (fig.–4).
Figure 3. Rearrangement pattern of ALK gene with
EML–4 gene by the help of dual colour ALK break
Figure 5. Signal patterning of ALK FISH result analysis
The interpretation criteria are 50% cells should be
positive out of 50 cells.34 Signal patterning for
positive and negative nucle i is given bellow (fig.–5).
Thunnissen E et al. (2012) reviewed that if the tissue
sample has less than five nuclei (10%) are positive,
(a) (b) (c) (d)
then the sample will be considered as FISH negative or
if the number of positive nuclei are 10–50 % in this
case, a second expert should evaluate the result after
Figure 4. Showing FISH result interpretation in
various type (a) Showing two fused (red and green)
that if average of two evaluator is at least 15% then the
signals (Negative) (b) Show one fused and one break
sample will be considered as FISH positive otherwise
apart signal but less than two diameter (Negative) (c)
One fused and one break apart signal of more than two
100 100 100
Table 2. Showing comparison of different
Figure 6. This diagram is showing interpretation
types of antibodies (Selinger et al. (2013).31
32 – Dec 2016ERA’S JOURNAL OF MEDICAL RESEARCHVOL.3 NO.2Jul
Table 3. ALK deregulated protein in different types of cancer (Taken from the review of Shackelford et al.2014)
ALK AberrationALK Mutation Percentage
Fusion between EML–4 and ALK
Non–Small cell lung
3–7% of NSCLC are ALK positive 37
on 2p arm of the chromosome
ALCL are 60–85% +ve, rare fusion with
ATIC, MYH9, ALO17, TPM3, TPM4, TFG,
MSN and ALTC 38
250 fold increased phosphor–ALK
Over Expression of ALK
Basal cell cancer
expression in near about 100% of BCCs 39
ALK is over expressed , lowering ALK expression,
Over Expression of ALK
decreases glioblastoma tumor growth 40
2.4% positive rearrangement 80%
inammatory breast carcinoma show
increased ALK protein expression 41
ALK shows over expression in over 50%
of cancer. Nearly 12.4% of cancer carry
Over expression of ALK
ALK point mutation which are common
in familial neuroblastoma42
ALK over expressed in 2–4% of ovarian
cancers, one stromal carried a FNI–ALK
Over expression of ALK
6.9% of acral melanomas were ALK positive,
ALK breakpoints suggest that translocations
Over expression of ALK
Anaplastic thyroid L1198F and G1201E amino acid changes
ALK activating point mutation
result in constitutive ALK kinase activation45
2.4% fusion positive by exon array proling46
1 case in 46 extramedullary plasmacytomas
was ALK posive by immunohistochemistry
and FISH analysis47
TPM4–ALK fusion oncoprotein type 2 found in
squamous cell carcinoma
~20% of cases48
ALK translocaons with EML4, TPM3, and
VCL fusion partners, the translocaons appear
to occur at a low frequency49
33ANAPLASTIC LYMPHOMA KINASE (ALK) GENE REARRANGEMENT DETECTION USING FLUORESCENE IN–SITU HYBRIDIZATION (FISH) IN LUNG CANCER PROGNOSTICATION
Table 4. Mechanism of crizotinib resistance (Taken from the review of Shackelford et al.2014)
Crizotinib resistance mechanismExplanation
Two cases; one with and one without an ALK mutation,
ALK Copy Number Gain
4–5–fold increased expression 50
5 fold –KIT amplication 51
Alters ALK crizotinib binding cavity, reducing crizotinib–protein
A mutation–specic strong H–bond pulls crizotinib out of the
position found in the non–crizotinib resistant EML–ALK fusion gene53
Mutation resistant to crizotinib and the structurally unrelated
compound TAE684 54
Lowers crizotinib–protein afnity by eliminating two H–bonds
between crizotinib and the ALK binding site53
Thr insertion is predicted to alter ATP binding to ALK51
Gly→Ala reduces crizotinib binding ATP–binding pocket
by steric hindrance50
L585R mutation in one case, other cases often show
in EGFR and EGFR amplication50
G12C and G12V activating KRAS mutations 50
Gatekeeper residue mutation blocks binding 51
used as a second confirmatory tool whenever FISH is
Immunohistochemistry seems to be the most reliable
screening technique for large–scale clinical practice,
when performed with different types of sensitive
antibody clones. For initial routine workup molecular
lAmerican Cancer Society. Cancer Facts and
technique in NSCLC should be IHC followed by ALK
Figures 2007. Atlanta, Ga: American Cancer
FISH as a confirmatory test of IHC positive cases.
Using ALK FISH break–apart probe for ALK gene
rearrangement analysis in NSCLC is documented as
lAmerican cancer society. Cancer Facts and
gold standard diagnostic criteria for ALK tyrosine
Figures 2016. Atlanta, Ga: American Cancer
kinase inhibitor therapy, the screening algorithm for
detection of ALK–rearranged lung cancer is still under
lSchiller JH, Harrington D, Belani CP, et al.
development. Many studies are being conducted for
Comparison of four chemotherapy regimens
the standardization of IHC and FISH technique as well
for advanced non–small–cell lung cancer. N
as assessment of the sensitivity and specificity of IHC
Engl J Med. 2002; (346); 92–98.
as a screening method. After FISH, RT–PCR can be
35 – Dec 2016ERA’S JOURNAL OF MEDICAL RESEARCHVOL.3 NO.2Jul
in non–Hodgkin's lymphoma, encodes a novel
lBehera D, Balamugesh T. Lung Cancer in
neural receptor tyrosine kinase that is highly
India. Indian J Chest Dis Allied Sci.
related to leukocyte tyrosine kinase (LTK).
lGupta D, Boffetta P, Gaborieau V, Jindal SK.
lSoda M, Choi YL, Enomoto M, et al. Takada S,
Risk factors of lung cancer in Chandigarh,
Yamashita Y, Ishikawa S, Fujiwara S,
India. Indian J Med Res. 2001;(113);142–50.
Watanabe H, Kurashina K, Hatanaka H, Bando
lCoultas DB, Samet JM. Occupational lung
M, Ohno S, Ishikawa Y, Aburatani H, Niki T,
cancer. Clin Chest Med. 1992;(13);341–354.
Sohara Y, Sugiyama Y, Mano H. Identification
of the transforming EML4–ALK fusion gene in
lSankarnarayanan R, Varghese C, Dugffy SW,
non–small–cell lung cancer. Nature.
Psdmakumary G, Day NE, Nair MK. A case
control study of diet and lung cancer in Kerala,
South India. Int J Cancer 1994;(58);644–649.
lMa Z, Cools J, Marynen P, et al. Inv(2)
(p23q35) in anaplastic large–cell lymphoma
lSørensen M, Pijls–Johannesma M, Felip E.
induces constitutive anaplastic lymphoma
Small–cell lung cancer: ESMO Clinical
kinase (ALK) tyrosine kinase activation by
Practice Guidelines for diagnosis, treatment
fusion to ATIC, an enzyme involved in purine
and follow–up. Annals of Oncology. 2010;(21);
nucleotide biosynthesis. Blood.
lJockel KH, Ahrens W, Wichmann HE.
lPollmann M, Parwaresch R, Adam–Klages S,
Occupational and environmental hazards
et al. Human EML4, a novel member of the
associated with lung cancer. Int J Epidemiol.
EMAP family, is essential for microtubule
formation. Exp Cell Res.
lMinna JD. Genetic events in the pathogenesis
of lung cancer. Chest. 1989;(96);17S.
lTogashi Y, Soda M, Sakata S, Hatano S, et al.
lIto Y, Ohno Y, Rachet B, et al: Cancer survival
KLC1–ALK: a novel fusion in lung cancer
trends in Osaka, Japan: the influence of age and
identified using a formalinfixed paraffin–
stage at diagnosis. Jpn J Clin Oncol. 2007;
embedded tissue only. PLoS One.
lFerguson MK, Wang J, Hoffman PC, et al: Sex–
lWu Y–C, Chang I–C, Wang C–L, et al.
associated differences in survival of patients
Comparison of IHC, FISH and RT–PCR
undergoing resection for lung cancer. Ann
Methods for Detection of ALK
Thoracic Sur. 2000;69(1);245–9.
Rearrangements in 312 Non–Small Cell Lung
Cancer Patients in Taiwan. PLoS One.
lRadzikowska E, Gtaz P, Roszkowski K: Lung
cancer in women: age, smoking, histology,
performance status, stage, initial treatment and
lHorn L, Pao W. EML4–ALK: honing in on a
survival. Population–based study of 20 561
new target in non–small cell lung cancer. J Clin
cases. Ann Oncol. 2002;13(7);1087–93.
Oncol. 2009; (27); 4247–53.
lMorris SW, Kirstein MN, Valentine MB:
lShaw AT, Yeap BY, Mino–Kenudson M, et al.
Fusion of a kinase gene, ALK, to a nucleolar
clinical feature and outcome of patients with
protein gene, NPM, in non–Hodgkin's
non–small cell lung cancer harboring EML4–
ALK. J Clin Oncol. 2009;(27);4247–4253.
lStoica GE, Kuo A, Power C, et al. Bowden ET,
lOu SH, Kwak EL, Siwak–Tapp C, et al.
Sale EB, Riegel AT, Wellstein A Midkine binds
Activity of crizotinib (PF02341066), a dual
to anaplastic lymphoma kinase (ALK) and acts
mesenchymal–epithelial transition (MET) and
as a growth factor for different cell types.J
anaplastic lymphoma kinase (ALK) inhibitor,
in non small cell lung cancer patient with de
novo MET amplification, J Thorac Oncol.
lMorris SW, Naeve C, Mathew P, et al. ALK, the
chromosome 2 gene locus altered by the t(2;5)
36ANAPLASTIC LYMPHOMA KINASE (ALK) GENE REARRANGEMENT DETECTION USING FLUORESCENE IN–SITU HYBRIDIZATION (FISH) IN LUNG CANCER PROGNOSTICATION
lChristensen JG, Zou HY, Arango ME, et al.
ular.com/static/cms. Accessed August
Cytoreductive antitumor activity of PF–
2341066, A novel inhibitor of anaplastic
limphoma kinase and c–Met, in experimental
lWojas–Krawczyk K, Krawczyk PA,
models of anaplastic large–cell lymphoma,
RamlauRA et al. The analysis of ALK gene
Mol cancer Ther. 2007;6(12 ); 3314–3322.
rearrangement by fluorescence in situ
hybridization in non small cell lung cancer
lKwak EL, Bang YJ, Camidge DR, et al.
patients. ContempOncol (Pozn). 2013;17
Anaplastic lymphoma kinase inhibitor in non–
cell lung cancer. Nengl J Med. 2010;
lGandhi L, Janne PA. Crizotinib for ALK–
rearranged non–small cell lung cancer: anew
lDoebele RC, Pilling AB, Aisner DL, et
targeted therapy for a new target. Clin Cancer
al.Mechanism of resistance to crizotinib in
patients with ALK gene rearranged non–small
cell lung cancer. Clin Cancer Res. 2012;
lHallberg B,Palmer RH. Mechanistic insight
into ALK receptor tyrosin kinase in human
cancer biology. Nat Rev Cancer.
lCappuzzo F,Hirsch FR,RossiE, et al.
Epidermal growth factor receptor gene and
protein and gefitinib sensitivity in non–small
lPulford K, Lamant L, Espinos E, et al. The
cell lung cancer. J Natl Cancer Inst. 2005;
emerging normal and disease–related related
roles of anaplastic lymphoma kinase. Cell Mol
Life Sci. 2004;(61);2939–53.
lMitsudomi T, Yatabe Y, Akita H, et al.
Guidance for ALK gene testing in lung cancer
lNing H, Mitsui H, Wang CQ, et al.
patients, Biomarker Committee, the Lung
Identification of anaplastic lymphoma kinase
Cancer Society. 2011;(14);48–69.
as a potential therapeutic target in Basal Cell
Carcinoma. Oncotarget. 2013; 4(12);2237–48.
lZhang YG, Jin ML, Li L et al. Evaluation of
ALK rearrangement in Chinese non small cell
lBilsland JG. Wheeldon A, Mead A, et al.
lung cancer using FISH,
Behavioral and neurochemical alterations in
Immunohistochemistry, and real time
mice deficient in anaplastic lymphoma kinase
quantitative RT–PCT on paraffin–embedded
suggest therapeutic potential for psychiatric
tissue. PLoS One. 2013;31(8(5)); 64–82.
lSelinger CI, Rogers TM, Russel PA, et al.
Testing for ALK rearrangement in lung
lRobert FM, Ill PEF, Laere SJV, et al. Presence
adenocarcinoma: amulticenter comparision of
of anaplastic lymphoma kinase in
immunohistochemistry and fluorescent in situ
inflammatory breast cancer. SpringerPlus.
hybridization. Modern Pathology. 2013;
lWang M, Zhou C, Sun Q, et al. ALK
lThunnissen E, Bubendorf L, Dietel M. et al.
amplification and protein expression predict
EML4–ALK testing in non small cell
inferior prognosis in neuroblastomas. Exp Mol
carcinomas of the lung: a review with
recommendations. Virchows Arch.
lRen H, Tan ZP, Zhu X, et al. Identification of
anaplastic lymphoma kinase as a potential
lMarchetti A, Ardizzoni A, Papotti M et al.
therapeutic target in ovarian cancer. Cancer
Recommendation for the analysis of ALK gene
rearrangements in non –small cell lung cancer:
a consensus of Italian Association of Medical
lNiu HT, Zhou QM, Wang F, et al. Identification
Oncology and the Italian Society of Pathology
of anaplastic lymphoma kinase break points
and Cytopathology. J Thorac Oncol. 2013;
and oncogenic mutation profiles in acral
mucosal melanomas. Pigment Cell Melanoma
lVysis ALK Break Apart FISH Probe Kit
37 – Dec 2016ERA’S JOURNAL OF MEDICAL RESEARCHVOL.3 NO.2Jul
cell lung cancer. Clin Cancer Res.
lMurugan AK,Xing M. Anaplastic thyroid
cancer harbor novel oncogenic mutations of
the ALK gene. Cancer Res. 2011;71(13);4403–
lKatayama R, Shaw AT, Khan TM, et al.
Mechanisms of acquired crizotinib resistance
in ALK–rearranged lung Cancers. Sci Transl
lLin E, Li I, Guan Y et al. Exon array profiling
detects EML4–ALK fusion in breast,
colorectal, and non small cell lung cancers.
lChoi YL, Soda M, Yamashita Y, et al. EML4–
Mol Cancer Res. 2009;7(9);1466–7
ALK mutations in lung cancer that confer
resistance to ALK inhibitors. N Engl J Med.
lWang WY, Gu L, Liu WP, et al. ALK positive
extramedullary plasmacytoma with expression
of the CLTC_ALK fusion transcript. Pathol
lSun HY, Ji FQ. A molecular dynamics
Res Pract. 2011;(207);587–91.
investigation on the crizotinib resistance
mechanism of C1156Y mutation in ALK.
lDu XL, Hu H, Lin DC et al. Proteomic
Biochem Biophys Res Commun.
profiling of proteins dysregulated in Chinese
esophageal squamous cell carcinoma. J Mol
lSasaki T, Koivunen J, Ogino A, et al. A novel
ALK secondary mutation and EGFR signaling
lSugawara E, Togashi Y, Kuroda N, et al.
cause resistance to ALK kinase inhibitors.
Identification of anaplastic lymphoma kinase
Cancer Res. 2011;(71);6051–60.
fusion in renal cancer: large scale
immunohistochemical screening by the
lThunnissen E, Bubendorf L, Dietel M et al.
intercalated antibody– enhanced by polymer
EML4–ALK testing in non–small cell
method. Cancer. 2012;118(18);4427–36.
carcinomas of the lung: a review with
recommendations. Virchows Arch. 2012
lDoebele RC, Pilling AB, Aisner DL, et al.
Mechanism of resistance to crizotinib in
patients with ALK gene rearranged non–small
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