Abstract
Gene fusions that contain the kinase domain of the three neurotrophic tyrosine kinase receptor (NTRK) genes are frequently observed in infantile high and low-grade gliomas. While these tumors initially respond to treatment with NTRK tyrosine kinase inhibitors (TKIs), treatment resistance and recurrence eventually occur. Treatment-resistant tumors frequently harbor either on-target (in the fusion's kinase domain) or off-target mutations (in downstream effectors of mitogen-activated signaling pathways). Therefore, overcoming this resistance requires a three-pronged strategy: 1) identifying new kinase inhibitors capable of targeting NTRK fusions with on-target kinase domain mutations, 2) identifying druggable targets in the downstream pathways activated by these fusions, and 3) targeting persister cells that contribute to disease recurrence. We utilized the RCAS/tv-a system to establish several mouse models of NTRK1/2/3 fusion-driven gliomas. We found that all analyzed fusions were strong oncogenic drivers on their own, while the loss of additional tumor suppressors (Cdkn2a or Pten) further increased the aggressiveness of these tumors. These mouse models exhibit similar treatment responses as human tumors, initially responding to various TKIs but eventually recurring due to the presence of treatment-resistant persister cells. To mimic the emergence of resistance-associated mutations, we directly introduced different kinase domain mutations into the NTRK fusion sequence or co-expressed secondary mutations (BRAF-V600E or KRAS-G12D). These modifications altered the response to TKI treatment both in vitro and in vivo. Overall, these models serve as valuable tools for studying the biology of NTRK fusion tumors, their treatment response in a treatment-naïve or -experienced state, and the mechanisms underlying treatment resistance.