 Solution

Two distinct possibilities are a second mutation affecting drug sensitivity of the targeted receptor tyrosine kinase, so that it remains active at the achieved inhibitor concentration, and activation of a bypass signaling route, such as another receptor tyrosine kinase or a downstream Ras or protein kinase component, restoring proliferation despite inhibition of the original target. The resistant population may arise by selection of rare pre-existing biological cells or by later acquisition of a change; recurrence alone cannot distinguish those histories. Compare target engagement, target phosphorylation and downstream signaling in the original and recurrent samples, with DNA sequencing and functional rescue or perturbation of the candidate resistance mechanism.