Age-based efficacy and safety of nivolumab for recurrent or metastatic head and neck squamous cell carcinoma: A multicenter retrospective study

AIM

This study retrospectively investigated the efficacy and safety of nivolumab for patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) classified using age <65 years as the cutoff.

METHODS

Overall, 88 patients with R/M HNSCC treated with nivolumab were classified into the young group (<65 years; n = 39) and elderly group (≥65 years; n = 49). Efficacy was evaluated using overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and disease control rate (DCR). Safety was evaluated considering immune-related adverse events (irAEs).

RESULTS

The median OS was 9.7 and 8.6 months in the young and elderly groups, respectively. The 1-year OS rate was 42.0% and 29.4% in the young and elderly groups, respectively. The median PFS was 3.0 and 4.2 months in the young and elderly groups, respectively. The 1-year PFS rate was 30.0% and 27.9% in the young and elderly groups, respectively. In the young group, the ORR was 10.3% and DCR was 33.3%. In the elderly group, the ORR was 18.4% and DCR was 53.1%. There were no significant differences in OS, PFS, ORR, and DCR (P = 0.36, 0.53, 0.29 and 0.06, respectively). Interstitial lung disease (ILD) as an irAE occurred in the young group at a significantly higher rate (20.5% vs 4.1%; P = 0.02).

CONCLUSIONS

There were no significant differences in OS, PFS, ORR, and DCR between the young and elderly groups. DCR tended to be better in the elderly group (P = 0.06). ILD occurred at a significantly higher rate in the young group.

DUPLICATE: Overall survival and PD-L1 expression in patients with recurrent or metastatic head and neck cancer treated with nivolumab

The Publisher regrets that this article is an accidental duplication of an article that has already been published, https://doi.org/10.1016/j.anl.2020.02.018. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

Hematological predictive markers for recurrent or metastatic squamous cell carcinomas of the head and neck treated with nivolumab: A multicenter study of 88 patients

Background

There is increasing evidence that immunotherapy with nivolumab, an anti‐programmed death 1 monoclonal antibody, is effective in the treatment of recurrent or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN). However, the predictive role of hematological inflammatory markers such as neutrophil‐to‐lymphocyte ratio (NLR) and the modified Glasgow prognostic score (mGPS) in patients with R/M SCCHN treated with nivolumab remains unclear.

Methods

We conducted a multi‐institutional cohort study to evaluate the impact of pretreatment NLR and mGPS on overall survival (OS) and progression‐free survival (PFS) in patients with R/M SCCHN treated with nivolumab in Japan. From 2012 to 2013, 102 patients were eligible, of whom 88 were finally included in the analysis. mGPS was calculated as follows: mGPS of 0, C‐reactive protein (CRP) ≤1.0 mg/dL; 1, CRP > 1.0 mg/dL; and 2, CRP > 1.0 mg/dL and albumin < 3.5 mg/dL. Optimal cutoff point of dichotomized NLR was calculated using the area under the receiver operating characteristic curve (AUROC). Hazard ratios (HRs) and 95% confidence intervals (95% CIs) were estimated by Cox proportional hazard models adjusted by potential confounders.

Results

Higher NLR was significantly associated with worse survival (1‐year OS: 45.3% vs 16.3%, log‐rank P‐value < .001, adjusted HR: 4.40 (95% CIs: 1.78‐10.88); one‐year PFS: 39.1% vs 9.0%, P‐value = .001, adjusted HR: 3.37 (95% CI: 1.64‐6.92)). In addition, high mGPS (=2) was significantly associated with worse survival compared to low mGPS (=0) (1‐year OS: 37.4% vs 26.1%, P‐value = .004, adjusted HR: 4.20 (95% CI:1.54‐11.49); 1‐year PFS: 41.5% vs 24.8%, P‐value = .007, adjusted HR: 2.01 (95% CI: 0.87‐4.68)). These associations were consistent with subgroup analyses stratified by potential confounders.

Conclusions

Pretreatment NLR and mGPS might be predictive markers of survival in patients with R/M SCCHN treated with nivolumab.

Overall survival and PD-L1 expression in patients with recurrent or metastatic head and neck cancer treated with nivolumab

OBJECTIVE

Our facility measures programmed cell death ligand 1 (PD-L1) expression in all patients before administering nivolumab. The aim of the present study is to clarify the association between overall survival (OS) and PD-L1 expression.

PATIENTS AND METHODS

Subjects in this study were 52 patients with R/M-HNC cancer (45 men, 7 women) administered nivolumab in our facility between June 1, 2017 and January 31, 2019. Mean age was 62.2 years (median, 65 years; range, 28-81 years). Histopathological type was squamous cell carcinoma (SCC) in 48 cases, and non-SCC in 4 cases. We set OS as the primary endpoint and progression-free survival (PFS), overall response rate (ORR), association of OS and PD-L1 expression and association of PFS and PD-L1 expression as secondary endpoints. The cut-off for PD-L1 expression was set using the receiver operating characteristic (ROC) curve. We compared OS, PES and ORR using this PD-L1 cut-off for all patients and for the SCC group. OS and PFS were calculated using Kaplan-Meier methods. The log-rank test was used for statistical analysis, with values of p < 0.05 taken as significant. For PD-L1 immunohistochemistry assays, Dako 28-8 antibody was used.

RESULTS

In the all-patients group, median OS was 9.6 months and 1-year OS rate was 40.4%. Median PFS was 4.0 months and 1-year PFS rate was 37.8%. The cut-off value of PD-L1 expression for OS was 40% for all patients and the SCC group. When PD-L1 expression was ≥40%, OS was significantly better in both all patients and the SCC group (p = 0.004, 0.007). The cut-off value of PD-L1 expression for PFS was also 40%. When PD-L1 expression was ≥40%, PFS was better in all patients and the SCC group (P = 0.003, 0.009). In the all-patients group, ORR was 19.2% and disease control rate (DCR) was 44.2%. When PD-L1 expression was ≥40%, ORR was 44.4% and DCR 83.3%.

CONCLUSION

In the present study, when PD-L1 expression was high (≥40%), OS was significantly better (p = 0.004). This finding has not been reported in other research on R/M-HNC. PFS and ORR were also better with high PD-L1 expression. Regarding patterns of progression with a PD-L1 expression cut-off of 40%, hyperprogression was significantly more frequent for PD-L1 expression <40% (p = 0.039). Therefore, high PD-L1 expression could offer a predictor of prognosis and efficacy for nivolumab. The present findings may prove useful in considering treatment strategies.

Neck dissection prolongs survival in patient with stage IVC hypopharyngeal carcinoma with mixed responses to nivolumab

Surgical intervention aids in maintaining quality of life in patients with recurrent metastatic head and neck carcinoma with mixed responses to nivolumab treatment. However, the mechanisms involved in these mixed responses remain unclear. Systemic chemotherapy using the EXTREME regimen was administered to the patient with hypopharyngeal carcinoma and liver metastases as well as cervical lymph node metastases. The patient was subsequently treated with nivolumab after developing signs of progressive disease. Although the hypopharyngeal tumors and liver metastases were well-controlled, cervical lymph node dissection was performed because of the enlargement of some of the lymph node metastases. Postoperative nivolumab administration was resumed, and this patient is presently alive and disease-free. Immediately after neck dissection, the LNs that responded and those that did not respond to nivolumab were separated and evaluated. The LNs that responded well to nivolumab presented with prominent interstitial fibrosis. Conversely, in LNs that enlarged after nivolumab, significant proliferation of the viable tumor cells and almost no degeneration or necrosis was observed. Additionally, we performed immunohistological assessments on pathologic samples of multiple lesions with differing responses to treatment. Targeted surgical intervention appears to be a valuable adjunct to treatment with nivolumab.

Post-operative complications due to salvage total laryngectomy for recurrent laryngeal cancer after radiotherapy - a multicentre retrospective study

Background: Few studies have demonstrated the utility of pharyngeal interposition graft (PIG) applying pectoralis major myocutaneous flap (PMMCF) by comparing pharyngocutaneous fistula (PCF) rates.Objective: The objective of this retrospective study was to clarify the utility of PIG applying PMMCF in reducing post-operative complications due to salvage total laryngectomy (STL).Material and methods: STL was performed in 59 patients with recurrent laryngeal cancer after radiotherapy, comprising 37 non-PMMCF patients and 22 PMMCF patients. The primary endpoint was PCF rate. Comparisons were made between two groups: a group with simple closure not using PMMCF (non-PMMCF group), and the other with PMMCF used in a PIG (PMMCF group).Results: PCF occurred in 15 of the 59 subjects (25.4%), including 13 of the 37 patients in the non-PMMCF group (35.1%) and 2 of the 22 patients in the PMMCF group (9.1%). PCF rate was significantly lower in the PMMCF group than in the non-PMMCF group (p = .033).Conclusions and significance: We demonstrated that PIG applying PMMCF significantly reduced the PCF rate due to STL. In the future, surgeons need to conduct research focused on additional innovations to reduce post-operative complications as much as possible.

Final overall survival results of WJTOG3405, a randomized phase III trial comparing gefitinib versus cisplatin with docetaxel as the first-line treatment for patients with stage IIIB/IV or postoperative recurrent EGFR mutation-positive non-small-cell lung cancer

BACKGROUND

Primary analysis of the phase III study WJTOG 3405 demonstrated superiority of progression-free survival (PFS) for gefitinib (G) in patients treated with the epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) gefitinib compared with cisplatin plus docetaxel (CD) as the first-line treatment of stage IIIB/IV or postoperative recurrent EGFR mutation-positive non-small-cell lung cancer. This report presents final overall survival (OS) data.

PATIENTS AND METHODS

Patients were randomized between G (250 mg/day orally) and cisplatin (80 mg/m2 intravenously) plus docetaxel (60 mg/m2 i.v.), administered every 21 days for three to six cycles. After the exclusion of 5 patients, 172 patients (86 in each group, modified intention-to-treat population) were included in the survival analysis. OS was re-evaluated using updated data (data cutoff, 30 September 2013; median follow-up time 59.1 months). The Kaplan-Meier method and the log-rank test were used for analysis, and hazard ratios (HRs) for death were calculated using the Cox proportional hazards model.

RESULTS

OS events in the G group and CD group were 68 (79.1%) out of 86 and 59 (68.6%) out of 86, respectively. Median survival time for G and CD were 34.9 and 37.3 months, respectively, with an HR of 1.252 [95% confidence interval (CI): 0.883-1.775, P = 0.2070]. Multivariate analysis identified postoperative recurrence and stage IIIB/IV disease as independent prognostic factors, with an HR of 0.459 (95% CI: 0.312-0.673, P < 0.001). Median survival time (postoperative recurrence versus stage IIIB/IV disease) were 44.5 and 27.5 months in the G group and 45.5 and 32.8 months in the CD group, respectively.

CONCLUSION

G did not show OS benefits over CD as the first-line treatment. OS of patients with postoperative recurrence was better than that of stage IIIB/IV disease, even though both groups had metastatic disease.This study was registered with UMIN (University Hospital Medical Information Network in Japan), number 000000539.

Efficacy and safety of nivolumab in 100 patients with recurrent or metastatic head and neck cancer - a retrospective multicentre study

Background: No large-scale retrospective studies have examined the efficacy and safety of nivolumab. Objective: This retrospective study aimed to investigate the efficacy and safety of nivolumab administered to patients in multiple facilities. Material and methods: The primary endpoint was overall response rate (ORR) and secondary endpoints were progression-free survival (PFS) and overall survival (OS). For safety, adverse event occurrence rates by grade, deaths and severe adverse events were investigated. OS and PFS were also examined according to whether immune-related adverse events (irAEs) appeared. Statistical analysis was conducted using log-rank testing, with values of p < .05 considered significant. Results: Nivolumab was administered to 100 patients with a history of receiving platinum-based drugs. ORR was 13.5% and disease control rate was 49.0%. Median PFS was 3.7 months. Median OS was 9.6 months. For all grades, irAEs occurred in 30 patients. The 1-year survival rate in the subgroup without irAEs was 34.0%, compared to 52.6% with irAEs (p = .041). Conclusions and significance: The 1-year survival rate was better in patients who developed irAEs. This is a new finding for head and neck cancer. Appearance of irAEs could also be used as an indicator of expected therapeutic effect in head and neck cancer.

Pituitary-adrenal dysfunction caused by nivolumab for head and neck cancer

Nivolumab exerts antitumor effects by inhibiting binding of PD-L1 to PD-1, and offers proven effectiveness in various disease areas, including cancers of the head and neck. The mechanisms of action lead nivolumab to induce immune-related adverse events (irAE). We report a case of pituitary-adrenal dysfunction to isolated adrenocorticotropic hormone (ACTH) deficiency as an irAE of nivolumab in a patient treated for head and neck cancer. This is the first report of an irAE of nivolumab in the field of head and neck squamous cell cancer. The patient was a man in his 50s with cancer of the tongue and hypopharynx that recurred after chemoradiotherapy, surgery and chemotherapy. After starting nivolumab, irAEs developed after 8 courses. The case was managed from the early stages in collaboration with the endocrinology department. Pituitary-adrenal hypofunction due to isolated ACTH deficiency was diagnosed on the basis of endocrine tests. The patient responded to hydrocortisone replacement therapy and has been able to continue treatment with nivolumab while continuing oral hydrocortisone. Although irAEs involving pituitary gland disorders are rare, these events can become life-threatening when severe. Early diagnosis and treatment are essential and require regular blood sampling and collaboration with specialists from an early stage.

Clinical outcomes of platinum-based chemotherapy plus cetuximab for recurrent or metastatic squamous cell carcinoma of the head and neck: comparison between platinum-sensitive and platinum-resistant patients

BACKGROUND

Combination therapy consisting of a platinum agent, 5-fluorouracil and cetuximab (EXTREME regimen) is recommended for recurrent or metastatic squamous cell carcinoma of the head and neck (R/M-SCCHN). However, it is advisable to use platinum-free regimens as first-line therapy in patients resistant to platinum agents. There has been no report comparing EXTREME regimen outcomes between platinum-resistant and platinum-sensitive patients.

OBJECTIVES

We conducted this study to examine the outcomes of the EXTREME regimen as first-line therapy in patients with R/M-SCCHN and a history of platinum agent use and assess whether the EXTREME regimen outcomes differ between platinum-resistant and platinum-sensitive patients.

MATERIALS AND METHODS

The study included 32 patients with R/M-SCCHN who received the EXTREME regimen as first-line therapy. Patients with recurrence or metastasis within 6 months after cisplatin administration were considered platinum-resistant and those with no recurrence or metastasis within 6 months were considered platinum-sensitive.

RESULTS

17 patients were platinum-resistant and 15 patients were platinum-sensitive. The median survival durations were 10.6 and 19.9 months in the platinum-resistant and platinum-sensitive patients, respectively, and the prognosis was significantly better in the platinum-sensitive patients (p = .02).

CONCLUSIONS

Our findings suggest that the EXTREME regimen is useful as first-line therapy for R/M-SCCHN in platinum-sensitive patients.

Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps

BACKGROUND

Salvage surgery for laryngeal cancer recurring after radiotherapy is difficult and complications readily occur. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous (PMMC) flap, which has copious blood flow, for preventing post-irradiation pharyngocutaneous fistula.

AIMS/OBJECTIVES

The purpose of this study was to examine the incidence of post-operative complications of salvage total laryngectomy (STL) using the PMMC flap for post-radiotherapy recurrent laryngeal cancer at our institution.

MATERIAL AND METHODS

From among 162 patients with laryngeal cancer who had been treated at Tokyo Medical University Hospital between January 2014 and March 2018, we enrolled 11 patients who had undergone STL applying a PMMC flap. We examined patient backgrounds (age, gender, subtype, stage), initial therapy (radiotherapy/chemoradiotherapy), radiation dose, irradiation area, surgery type (with/without neck dissection) and postoperative complications.

RESULTS

No severe systemic complications were encountered. Pharyngocutaneous fistula occurred as a severe local complication in one patient (8.3%) and wound infection as a mild local complication in one patient (8.3%).

CONCLUSIONS

Rates of post-operative complications following STL tended to be lower at our institution than those reported for other institutions.

SIGNIFICANCE

PIG may be a useful surgical procedure in STL.

Prevention of anastomotic leak using an advanced pectoral flap in total pharyngolaryngectomy and free jejunal reconstruction for hypopharyngeal or laryngeal carcinoma

BACKGROUND

We devised an advanced pectoral flap (APF) to prevent anastomotic leak after total pharyngolaryngectomy (TPL) and free jejunal reconstruction (FJR) in patients with hypopharyngeal or laryngeal carcinoma. The APF alleviates tension on the skin in the neck, reduces the subcutaneous dead space, and promotes adhesion between the neck skin and the anastomosis.

OBJECTIVE

To investigate whether an APF is effective for prevention of anastomotic leak associated with TPL/FJR.

PATIENTS AND METHODS

Anastomotic leak was compared between APF (n = 65) and non-APF groups (n = 25). Patients who had received preoperative radiotherapy or undergone tracheostomy or skin infiltration requiring neck reconstruction using a pedicle flap were excluded.

RESULTS

There were significantly fewer cases of anastomotic leak in the APF group than in the non-APF group (1.5% [1/65] vs. 16.0% [4/25]; p = .02). An APF could be created bilaterally within approximately 15 minutes. Unlike a deltopectoral flap, an APF does not require a skin graft.

CONCLUSIONS

The postoperative anastomotic leak rate was 1.5% in patients who underwent TPL and FJR for hypopharyngeal or laryngeal carcinoma with an APF.

SIGNIFICANCE

An APF is easily created and can reduce the incidence of anastomotic leak after TPL and FJR.