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Leidner R, Crittenden M, Young K, Xiao H, Wu Y, Couey MA, Patel AA, Cheng AC, Watters AL, Bifulco C, Morris G, Rushforth L, Nemeth S, Urba WJ, Gough M, Bell RB. Neoadjuvant immunoradiotherapy results in high rate of complete pathological response and clinical to pathological downstaging in locally advanced head and neck squamous cell carcinoma. J Immunother Cancer 2021; 9:jitc-2021-002485. [PMID: 33963014 PMCID: PMC8108690 DOI: 10.1136/jitc-2021-002485] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Checkpoint inhibitors targeting programmed death receptor-1 (PD-1) have been tested in the neoadjuvant setting for the treatment of locoregionally advanced head and neck squamous cell carcinoma (HNSCC); however, response rates are modest. We hypothesized that adding stereotactic body radiation therapy (SBRT) to anti-PD-1 would be safe prior to definitive surgical resection and would enhance pathological response compared with historical cohorts of patients with locoregionally advanced HNSCC treated with checkpoint inhibitor alone. METHODS The Neoadjuvant Immuno-Radiotherapy Trial was an investigator-initiated single institution phase Ib clinical trial that enrolled patients with previously untreated locally advanced HPV-positive and HPV-negative HNSCC between 2018 and 2019. Eligible patients were treated with neoadjuvant SBRT at a total dose of either 40 Gy in 5 fractions or 24 Gy in 3 fractions, delivered in a 1-week timespan, with or without nivolumab, prior to definitive surgical resection. Patients were then planned for treatment with adjuvant nivolumab for 3 months. The primary safety endpoint was unplanned delay in surgery considered to be at least possibly related to neoadjuvant treatment. The primary efficacy endpoints included pathological complete response (pCR), major pathological response (mPR), and the rate of clinical to pathological downstaging after neoadjuvant treatment. RESULTS Twenty-one patients underwent neoadjuvant treatment, which was well tolerated and did not delay surgery, thus meeting the primary endpoint. Tissue responses were characterized by robust inflammatory infiltrates in the regression bed, plasma cells and cholesterol clefts. Among the entire study group, the mPR and pCR rate was 86% and 67%, respectively. Clinical to pathological downstaging occurred in 90% of the patients treated. CONCLUSION These data demonstrate that radiation delivered only to the gross tumor volume combined with immunotherapy was safe, resulted in a high rate of mPR and should be further evaluated as a locally focused neoadjuvant therapy for patients with head and neck cancer. TRIAL REGISTRATION NUMBER This study is registered with clinicaltrials.gov (NCT03247712) and is active, but closed to patient accrual.
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Affiliation(s)
- Rom Leidner
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Marka Crittenden
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Division of Radiation Oncology, The Oregon Clinic, Portland, Oregon, USA
| | - Kristina Young
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Division of Radiation Oncology, The Oregon Clinic, Portland, Oregon, USA
| | - Hong Xiao
- Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | - Yaping Wu
- Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | | | - Ashish A Patel
- Providence Cancer Institute, Portland, Oregon, USA.,Head and Neck Institute, Portland, Oregon, USA
| | | | | | - Carlo Bifulco
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA.,Department of Pathology, Providence Health and Services- Oregon, Portland, Oregon, USA
| | - George Morris
- Earle A Chiles Research Institute, Portland, Oregon, USA
| | | | | | - Walter J Urba
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - Michael Gough
- Providence Cancer Institute, Portland, Oregon, USA.,Earle A Chiles Research Institute, Portland, Oregon, USA
| | - R Bryan Bell
- Providence Cancer Institute, Portland, Oregon, USA .,Earle A Chiles Research Institute, Portland, Oregon, USA
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202
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Abstract
Tumor metastasis is a singularly important determinant of survival in most cancers. Historically, radiation therapy (RT) directed at a primary tumor mass was associated infrequently with remission of metastasis outside the field of irradiation. This away-from-target or "abscopal effect" received fringe attention because of its rarity. With the advent of immunotherapy, there are now increasing reports of abscopal effects upon RT in combination with immune checkpoint inhibition. This sparked investigation into underlying mechanisms and clinical trials aimed at enhancement of this effect. While these studies clearly attribute the abscopal effect to an antitumor immune response, the initial molecular triggers for its onset and specificity remain enigmatic. Here, we propose that DNA damage-induced inflammation coupled with neoantigen generation is essential during this intriguing phenomenon of systemic tumor regression and discuss the implications of this model for treatment aimed at triggering the abscopal effect in metastatic cancer.
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203
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Khalifa J, Mazieres J, Gomez-Roca C, Ayyoub M, Moyal ECJ. Radiotherapy in the Era of Immunotherapy With a Focus on Non-Small-Cell Lung Cancer: Time to Revisit Ancient Dogmas? Front Oncol 2021; 11:662236. [PMID: 33968769 PMCID: PMC8097090 DOI: 10.3389/fonc.2021.662236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/23/2021] [Indexed: 12/15/2022] Open
Abstract
Radiation-induced immune effects have been extensively deciphered over the last few years, leading to the concept of the dual immune effect of radiotherapy with both immunostimulatory and immunosuppressive effects. This explains why radiotherapy alone is not able to drive a strong anti-tumor immune response in most cases, hence underlining the rationale for combining both radiotherapy and immunotherapy. This association has generated considerable interest and hundreds of trials are currently ongoing to assess such an association in oncology. However, while some trials have provided unprecedented results or shown much promise, many hopes have been dashed. Questions remain, therefore, as to how to optimize the combination of these treatment modalities. This narrative review aims at revisiting the old, well-established concepts of radiotherapy relating to dose, fractionation, target volumes and organs at risk in the era of immunotherapy. We then propose potential innovative approaches to be further assessed when considering a radio-immunotherapy association, especially in the field of non-small-cell lung cancer (NSCLC). We finally propose a framework to optimize the association, with pragmatic approaches depending on the stage of the disease.
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Affiliation(s)
- Jonathan Khalifa
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
| | - Julien Mazieres
- Department of Pulmonology, Centre Hospitalo-Universitaire Larrey, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Carlos Gomez-Roca
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Department of Medical Oncology, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
| | - Maha Ayyoub
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
| | - Elizabeth Cohen-Jonathan Moyal
- Department of Radiotherapy, Institut Claudius Regaud/Institut Universitaire du Cancer de Toulouse – Oncopole, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale U1037, Centre de Recherche contre le Cancer de Toulouse, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
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204
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Lim AM, Cavanagh K, Hicks RJ, McLean L, Goh MS, Webb A, Rischin D. Delayed Response After Confirmed Progression (DR) and Other Unique Immunotherapy-Related Treatment Concepts in Cutaneous Squamous Cell Carcinoma. Front Oncol 2021; 11:656611. [PMID: 33937066 PMCID: PMC8081898 DOI: 10.3389/fonc.2021.656611] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
Non-melanoma skin cancers are one of the most common cancers diagnosed worldwide, with the highest incidence in Australia and New Zealand. Systemic treatment of locally advanced and metastatic cutaneous squamous cell carcinomas has been revolutionized by immune checkpoint inhibition with PD-1 blockade. We highlight treatment issues distinct to the management of the disease including expansion of the traditional concept of pseudoprogression and describe delayed responses after immune-specific response criteria confirmed progressive disease with and without clinical deterioration. We term this phenomenon “delayed response after confirmed progression (DR)”. We also discuss the common development of second primary tumors, heterogeneous disease responses, and expanding clinical boundaries for immunotherapy use.
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Affiliation(s)
- Annette M Lim
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, VIC, Australia
| | - Karda Cavanagh
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Rodney J Hicks
- Department of Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Luke McLean
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michelle S Goh
- Department of Dermatology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Angela Webb
- Department of Plastic Surgery, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Danny Rischin
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, VIC, Australia
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205
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Xu Y, Zhu G, Maroun CA, Wu IXY, Huang D, Seiwert TY, Liu Y, Mandal R, Zhang X. Programmed Death-1/Programmed Death-Ligand 1-Axis Blockade in Recurrent or Metastatic Head and Neck Squamous Cell Carcinoma Stratified by Human Papillomavirus Status: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:645170. [PMID: 33897693 PMCID: PMC8058384 DOI: 10.3389/fimmu.2021.645170] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background Programmed death-1/programmed death-ligand 1 (PD-1/PD-L1) inhibitors have provided clinical benefit to head and neck squamous cell carcinoma (HNSCC) patients in recent clinical trials. However, it remains unclear as to whether human papillomavirus (HPV) status is associated with improved clinical outcome of anti-PD-1 or anti-PD-L1 immunotherapy in HNSCC. Methods PubMed, EMBASE, Cochrane Library, and Web of Science were systematically searched up to February 28, 2021. Published clinical trials of HNSCC patients treated with only PD-1 or PD-L1 inhibitors were selected. The primary or secondary outcome of these studies included objective response rate (ORR) stratified by HPV status. The pooled odds ratio (OR) and hazard ratio (HR) were estimated using a fixed-effect model. Results A total of seven eligible studies comprising 814 patients were included. The ORR of HPV positive HNSCC patients was significantly higher than that of HPV negative HNSCC patients (OR = 1.77; 95%CI = 1.14-2.74; P = 0.01), and this favorable effect occurred in pooled anti-PD-L1 trials (OR = 2.66; 95%CI = 1.16-6.11; P = 0.02). In comparison, the pooled OR was 1.51 in anti-PD-1 trials (95%CI = 0.90-2.54; P = 0.12). Survival analysis indicated that HPV positive HNSCC patients had a lower risk of overall death as compared to HPV negative HNSCC patients (HR = 0.77; 95%CI = 0.60–0.99; P = 0.04). Conclusions HPV positive HNSCC patients display improved outcomes with PD-1/PD-L1 axis blockade as compared to HPV negative HNSCC patients. These improved outcomes are likely driven to a greater extent by anti-PD-L1 inhibitors. However, randomized controlled trials with greater numbers of patients are needed for validation of these early findings.
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Affiliation(s)
- Yimin Xu
- Department of Otolaryngology-Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China.,Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China
| | - Gangcai Zhu
- Department of Otolaryngology-Head and Neck Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.,Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States.,Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins Medicine, Baltimore, MD, United States
| | - Christopher A Maroun
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States.,Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins Medicine, Baltimore, MD, United States
| | - Irene X Y Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Donghai Huang
- Department of Otolaryngology-Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China.,Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China.,National Clinical Research Center for Geriatric Disorders, XiangYa Hospital, Changsha, China
| | - Tanguy Y Seiwert
- Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins Medicine, Baltimore, MD, United States.,Department of Oncology, Johns Hopkins University, Baltimore, MD, United States
| | - Yong Liu
- Department of Otolaryngology-Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China.,Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China.,National Clinical Research Center for Geriatric Disorders, XiangYa Hospital, Changsha, China.,Otolaryngology Major Disease Research Key Laboratory of Hunan Province, Changsha, China
| | - Rajarsi Mandal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States.,Bloomberg-Kimmel Institute for Cancer Immunotherapy at Johns Hopkins Medicine, Baltimore, MD, United States
| | - Xin Zhang
- Department of Otolaryngology-Head and Neck Surgery, Xiangya Hospital, Central South University, Changsha, China.,Clinical Research Center for Pharyngolaryngeal Diseases and Voice Disorders in Hunan Province, Changsha, China.,National Clinical Research Center for Geriatric Disorders, XiangYa Hospital, Changsha, China.,Otolaryngology Major Disease Research Key Laboratory of Hunan Province, Changsha, China
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206
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Demaria S, Guha C, Schoenfeld J, Morris Z, Monjazeb A, Sikora A, Crittenden M, Shiao S, Khleif S, Gupta S, Formenti SC, Vikram B, Coleman CN, Ahmed MM. Radiation dose and fraction in immunotherapy: one-size regimen does not fit all settings, so how does one choose? J Immunother Cancer 2021; 9:jitc-2020-002038. [PMID: 33827904 PMCID: PMC8031689 DOI: 10.1136/jitc-2020-002038] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2021] [Indexed: 12/12/2022] Open
Abstract
Recent evidence indicates that ionizing radiation can enhance immune responses to tumors. Advances in radiation delivery techniques allow hypofractionated delivery of conformal radiotherapy. Hypofractionation or other modifications of standard fractionation may improve radiation’s ability to promote immune responses to tumors. Other novel delivery options may also affect immune responses, including T-cell activation and tumor-antigen presentation changes. However, there is limited understanding of the immunological impact of hypofractionated and unique multifractionated radiotherapy regimens, as these observations are relatively recent. Hence, these differences in radiotherapy fractionation result in distinct immune-modulatory effects. Radiation oncologists and immunologists convened a virtual consensus discussion to identify current deficiencies, challenges, pitfalls and critical gaps when combining radiotherapy with immunotherapy and making recommendations to the field and advise National Cancer Institute on new directions and initiatives that will help further development of these two fields. This commentary aims to raise the awareness of this complexity so that the need to study radiation dose, fractionation, type and volume is understood and valued by the immuno-oncology research community. Divergence of approaches and findings between preclinical studies and clinical trials highlights the need for evaluating the design of future clinical studies with particular emphasis on radiation dose and fractionation, immune biomarkers and selecting appropriate end points for combination radiation/immune modulator trials, recognizing that direct effect on the tumor and potential abscopal effect may well be different. Similarly, preclinical studies should be designed as much as possible to model the intended clinical setting. This article describes a conceptual framework for testing different radiation therapy regimens as separate models of how radiation itself functions as an immunomodulatory ‘drug’ to provide alternatives to the widely adopted ‘one-size-fits-all’ strategy of frequently used 8 Gy×3 regimens immunomodulation.
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Affiliation(s)
- Sandra Demaria
- Department of Radiation Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Chandan Guha
- Radiation Oncology, Pathology and Urology, and Institute of Onco-Physics, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Jonathan Schoenfeld
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Zachary Morris
- Human Oncology, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Arta Monjazeb
- Radiation Oncology, UC Davis, Davis, California, USA
| | - Andrew Sikora
- Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marka Crittenden
- Department of Radiation Oncology, Providence Portland Medical Center, Portland, Oregon, USA
| | - Stephen Shiao
- Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Samir Khleif
- The Loop Immuno-Oncology Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Seema Gupta
- The Loop Immuno-Oncology Laboratory, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Silvia Chiara Formenti
- Department of Radiation Oncology, Weill Cornell Medical College, New York, New York, USA
| | - Bhadrasain Vikram
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
| | - C Norman Coleman
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
| | - Mansoor M Ahmed
- Radiation Research Program, National Cancer Institute Division of Cancer Treatment and Diagnosis, Bethesda, Maryland, USA
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207
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Lee NY, Ferris RL, Psyrri A, Haddad RI, Tahara M, Bourhis J, Harrington K, Chang PMH, Lin JC, Razaq MA, Teixeira MM, Lövey J, Chamois J, Rueda A, Hu C, Dunn LA, Dvorkin MV, De Beukelaer S, Pavlov D, Thurm H, Cohen E. Avelumab plus standard-of-care chemoradiotherapy versus chemoradiotherapy alone in patients with locally advanced squamous cell carcinoma of the head and neck: a randomised, double-blind, placebo-controlled, multicentre, phase 3 trial. Lancet Oncol 2021; 22:450-462. [PMID: 33794205 DOI: 10.1016/s1470-2045(20)30737-3] [Citation(s) in RCA: 278] [Impact Index Per Article: 92.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/02/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chemoradiotherapy is the standard of care for unresected locally advanced squamous cell carcinoma of the head and neck. We aimed to assess if addition of avelumab (anti-PD-L1) to chemoradiotherapy could improve treatment outcomes for this patient population. METHODS In this randomised, double-blind, placebo-controlled, phase 3 study, patients were recruited from 196 hospitals and cancer treatment centres in 22 countries. Patients aged 18 years or older, with histologically confirmed, previously untreated, locally advanced squamous cell carcinoma of the oropharynx, hypopharynx, larynx, or oral cavity (unselected for PD-L1 status), an Eastern Cooperative Oncology Group performance status score of 0 or 1, and who could receive chemoradiotherapy were eligible. Patients were randomly assigned (1:1) centrally by means of stratified block randomisation with block size four (stratified by human papillomavirus status, tumour stage, and nodal stage, and done by an interactive response technology system) to receive 10 mg/kg avelumab intravenously every 2 weeks plus chemoradiotherapy (100 mg/m2 cisplatin every 3 weeks plus intensity-modulated radiotherapy with standard fractionation of 70 Gy [35 fractions during 7 weeks]; avelumab group) or placebo plus chemoradiotherapy (placebo group). This was preceded by a single 10 mg/kg avelumab or placebo lead-in dose given 7 days previously and followed by 10 mg/kg avelumab or placebo every 2 weeks maintenance therapy for up to 12 months. The primary endpoint was progression-free survival by investigator assessment per modified Response Evaluation Criteria in Solid Tumors, version 1.1, in all randomly assigned patients. Adverse events were assessed in patients who received at least one dose of avelumab or placebo. This trial is registered with ClinicalTrials.gov, NCT02952586. Enrolment is no longer ongoing, and the trial has been discontinued. FINDINGS Between Dec 12, 2016, and Jan 29, 2019, from 907 patients screened, 697 patients were randomly assigned to the avelumab group (n=350) or the placebo group (n=347). Median follow-up for progression-free survival was 14·6 months (IQR 8·5-19·6) in the avelumab group and 14·8 months (11·6-18·8) in the placebo group. Median progression-free survival was not reached (95% CI 16·9 months-not estimable) in the avelumab group and not reached (23·0 months-not estimable) in the placebo group (stratified hazard ratio 1·21 [95% CI 0·93-1·57] favouring the placebo group; one-sided p=0·92). The most common grade 3 or worse treatment-related adverse events were neutropenia (57 [16%] of 348 patients in the avelumab group vs 52 [15%] of 344 patients in the placebo group), mucosal inflammation (50 [14%] vs 45 [13%]), dysphagia (49 [14%] vs 47 [14%]), and anaemia (41 [12%] vs 44 [13%]). Serious treatment-related adverse events occurred in 124 (36%) patients in the avelumab group and in 109 (32%) patients in the placebo group. Treatment-related deaths occurred in two (1%) patients in the avelumab group (due to general disorders and site conditions, and vascular rupture) and one (<1%) in the placebo group (due to acute respiratory failure). INTERPRETATION The primary objective of prolonging progression-free survival with avelumab plus chemoradiotherapy followed by avelumab maintenance in patients with locally advanced squamous cell carcinoma of the head and neck was not met. These findings may help inform the design of future trials investigating the combination of immune checkpoint inhibitors plus CRT. FUNDING Pfizer and Merck KGaA, Darmstadt, Germany.
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Affiliation(s)
- Nancy Y Lee
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | | | - Amanda Psyrri
- Attikon University Hospital, National Kapodistrian University of Athens, Athens, Greece
| | | | - Makoto Tahara
- National Cancer Center Hospital East, Kashiwa, Japan
| | - Jean Bourhis
- Centre Hospitalier Universitaire Vaudois, Lausanne, Vaud, Switzerland
| | - Kevin Harrington
- The Royal Marsden Hospital-The Institute of Cancer Research National Institute for Health Research Biomedical Research Centre, London, UK
| | - Peter Mu-Hsin Chang
- Taipei Veterans General Hospital, National Yang Ming University, Taipei, Taiwan
| | - Jin-Ching Lin
- Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan
| | | | | | - József Lövey
- Országos Onkológiai Intézet, Sugárterápiás Osztály Semmelweis Egyetem, Onkológiai Tanszék, Budapest, Hungary
| | - Jerome Chamois
- Centre Hospitalier Prive Saint Gregoire, Saint Gregoire, France
| | - Antonio Rueda
- Medical Oncology, Costa del Sol Sanitary Agency and Regional University Hospital, IBIMA, Málaga, Spain
| | - Chaosu Hu
- Fudan University Cancer Hospital, Xuhui, Shanghai, China
| | - Lara A Dunn
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | | | | | - Ezra Cohen
- Moores Cancer Center, UC San Diego Health, La Jolla, CA, USA
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208
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Altay-Langguth A, Balermpas P, Brandts C, Balster S, Ghanaati S, Winkelmann R, Burck I, Rödel F, Martin D, Rödel C, von der Grün J. Re-irradiation with concurrent and maintenance nivolumab in locally recurrent and inoperable squamous cell carcinoma of the head and neck: A single-center cohort study. Clin Transl Radiat Oncol 2021; 28:71-78. [PMID: 33889760 PMCID: PMC8050105 DOI: 10.1016/j.ctro.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/15/2021] [Accepted: 03/20/2021] [Indexed: 12/21/2022] Open
Abstract
Combination of in-field ReRT and nivolumab for locally recurrent HNSCC is feasible. No unexpected radiation-related toxicity occurred. CRP-, hemoglobin-levels, and neutrophil/lymphocyte ratio were associated with LPFS.
Background The rate of loco-regional recurrences for locally advanced head and neck squamous cell carcinoma (HNSCC) following standard treatment reaches up to 50%, accompanied by a probability of 20% to develop a second primary tumor in the head and neck region. Methods Ten patients with inoperable, in-field recurrence of HNSCC following previous primary or adjuvant radiotherapy (RT) in combination with concurrent platinum-based chemotherapy were re-irradiated with 60 Gray in 30 fractions between December 2017 and January 2020 with concurrent and maintenance nivolumab administration. Data were retrospectively collected and compared with patients who underwent re-irradiation (ReRT) with concurrent cisplatin following propensity score matching (PSM). Local progression-free survival (LPFS) and overall survival (OS) were visualized using Kaplan-Meier method (log-rank test). Results All patients completed ReRT. Median number of applied courses of nivolumab was 12 (range, 3–38). OS rate was 50% at 12 months and the median OS was 11 (range, 2–23) months. Six and 12 month LPFS rates were 60% and 30%, respectively. Median LPFS was 8 (range, 2–19) months. OS and LPFS rates were not inferior to those of patients treated with concurrent cisplatin. No unexpected radiation-related toxicity occurred. A total of four patients developed any-grade immune-related adverse events of which two presented with grade 3 toxicities. One patient died within 3 weeks after ReRT. Higher blood levels of CRP (p = 0.004), lower levels of hemoglobin (p = 0.029) and higher neutrophil/lymphocyte ratio (p = 0.004) were associated with impaired LPFS. Higher recursive portioning analysis (RPA) class was associated with impaired LPFS (p = 0.022) and OS (p = 0.024). Conclusion The combination of ReRT and nivolumab for locally recurrent HNSCC was feasible without occurrence of unexpected toxicities. Combined radioimmunotherapy might offer an effective treatment option for carefully selected pre-irradiated patients ineligible for salvage surgery.
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Affiliation(s)
- Alev Altay-Langguth
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Panagiotis Balermpas
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Department of Radiation Oncology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland
| | - Christian Brandts
- Department of Medicine, Hematology and Oncology, University Hospital, Goethe University, 60590 Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg and German Cancer Consortium (DKTK), Partner Site Frankfurt am Main/Mainz, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Sven Balster
- Department of Otorhinolaryngology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Shahram Ghanaati
- Department of Oral, Maxillofacial and Facial Plastic Surgery, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Ria Winkelmann
- Senckenberg Institute of Pathology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Iris Burck
- Department of Diagnostic and Interventional Radiology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Franz Rödel
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg and German Cancer Consortium (DKTK), Partner Site Frankfurt am Main/Mainz, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Daniel Martin
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg and German Cancer Consortium (DKTK), Partner Site Frankfurt am Main/Mainz, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Claus Rödel
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg and German Cancer Consortium (DKTK), Partner Site Frankfurt am Main/Mainz, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Frankfurt Cancer Institute (FCI), University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
| | - Jens von der Grün
- Department of Radiotherapy and Oncology, University Hospital, Goethe University, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg and German Cancer Consortium (DKTK), Partner Site Frankfurt am Main/Mainz, Theodor-Stern-Kai 7, 60590 Frankfurt am Main, Germany
- Corresponding author at: Department of Radiotherapy and Oncology, University Hospital, Goethe University, 60590 Frankfurt am Main, Germany.
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209
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Wilkins A, Ost P, Sundahl N. Is There a Benefit of Combining Immunotherapy and Radiotherapy in Bladder Cancer? Clin Oncol (R Coll Radiol) 2021; 33:407-414. [PMID: 33726945 DOI: 10.1016/j.clon.2021.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/10/2021] [Accepted: 02/25/2021] [Indexed: 01/13/2023]
Abstract
Immune checkpoint inhibitors have transformed the management of patients with metastatic urothelial cancer, by leading to long-term response and prolongation of survival in a subset of patients. Unfortunately, only one in five patients with metastatic urothelial cancer responds to anti-programmed death ligand-1 ([AQ1]anti-PD-1) monotherapy. Preclinical and early clinical evidence indicates that radiotherapy not only acts locally, but also exerts systemic anti-tumour effects by modulating the immune system. It is hypothesised that combining checkpoint inhibitors with radiotherapy might enhance an anti-tumour immune response and increase response rates. So far, a handful of early phase clinical trials have been performed seeking to answer this question in urothelial cancer patients. The current review summarises the available preclinical and clinical evidence on radiotherapy/immunotherapy combinations in locally advanced and metastatic bladder cancer and suggests future avenues worthy of exploration.
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Affiliation(s)
- A Wilkins
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK
| | - P Ost
- Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium
| | - N Sundahl
- Division of Radiotherapy and Imaging, Institute of Cancer Research, London, UK; Department of Radiation Oncology and Experimental Cancer Research, Ghent University Hospital, Ghent, Belgium.
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210
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Kazandjian D, Dew A, Hill E, Ramirez EG, Morrison C, Mena E, Lindenberg L, Yuan C, Maric I, Wang HW, Calvo K, Dulau-Florea A, Roswarski J, Emanuel M, Braylan R, Turkbey B, Choyke P, Camphausen K, Stetler-Stevenson M, Steinberg SM, Figg WD, C Jones J. Avelumab, a PD-L1 Inhibitor, in Combination with Hypofractionated Radiotherapy and the Abscopal Effect in Relapsed Refractory Multiple Myeloma. Oncologist 2021; 26:288-e541. [PMID: 33554406 PMCID: PMC8018315 DOI: 10.1002/onco.13712] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/01/2021] [Indexed: 12/23/2022] Open
Abstract
Lessons Learned Despite the initial optimism for using immune checkpoint inhibition in the treatment of multiple myeloma, subsequent clinical studies have been disappointing. Preclinical studies have suggested that priming the immune system with various modalities in addition to checkpoint inhibition may overcome the relative T‐cell exhaustion or senescence; however, in this small data set, radiotherapy with checkpoint inhibition did not appear to activate the antitumor immune response.
Background Extramedullary disease (EMD) is recognized as an aggressive subentity of multiple myeloma (MM) with a need for novel therapeutic approaches. We therefore designed a proof‐of‐principle pilot study to evaluate the synergy between the combination of the anti–PD‐L1, avelumab, and concomitant hypofractionated radiotherapy. Methods This was a single‐arm phase II Simon two‐stage single center study that was prematurely terminated because of the COVID‐19 pandemic after enrolling four patients. Key eligibility included patients with relapsed/refractory multiple myeloma (RRMM) who had exhausted or were not candidates for standard therapy and had at least one lesion amenable to radiotherapy. Patients received avelumab until progression or intolerable toxicity and hypofractionated radiotherapy to a focal lesion in cycle 2. Radiotherapy was delayed until cycle 2 to allow the avelumab to reach a study state, given the important observation from previous studies that concomitant therapy is needed for the abscopal effect. Results At a median potential follow‐up of 10.5 months, there were no objective responses, one minimal response, and two stable disease as best response. The median progression‐free survival (PFS) was 5.3 months (95% confidence interval [CI]: 2.5–7.1 months), and no deaths occurred. There were no grade ≥3 and five grade 1–2 treatment‐related adverse events. Conclusion Avelumab in combination with radiotherapy for patients with RRMM and EMD was associated with very modest systemic clinical benefit; however, patients did benefit as usual from local radiotherapy. Furthermore, the combination was very well tolerated compared with historical RRMM treatment regimens.
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Affiliation(s)
- Dickran Kazandjian
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.,Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida, USA
| | - Alexander Dew
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.,Hematology-Oncology Department, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Elizabeth Hill
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Gil Ramirez
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Candis Morrison
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Esther Mena
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Liza Lindenberg
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Constance Yuan
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Irina Maric
- Hematology Service, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Hao-Wei Wang
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Katherine Calvo
- Hematology Service, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Alina Dulau-Florea
- Hematology Service, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph Roswarski
- Multiple Myeloma Program, Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.,Hematology-Oncology Department, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Michael Emanuel
- Office Research Nursing, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Raul Braylan
- Hematology Service, Department of Laboratory Medicine, National Institutes of Health, Bethesda, Maryland, USA
| | - Baris Turkbey
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter Choyke
- Molecular Imaging Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kevin Camphausen
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Maryalice Stetler-Stevenson
- Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Seth M Steinberg
- Biostatistics & Data Management Section, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - William D Figg
- Molecular Pharmacology Section, Genitourinary Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer C Jones
- Radiation Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA.,Laboratory of Pathology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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211
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[Systemic effects of local radiotherapy: first clinical evidence]. Strahlenther Onkol 2021; 197:458-460. [PMID: 33665706 DOI: 10.1007/s00066-021-01752-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
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212
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dos Santos LV, Abrahão CM, William WN. Overcoming Resistance to Immune Checkpoint Inhibitors in Head and Neck Squamous Cell Carcinomas. Front Oncol 2021; 11:596290. [PMID: 33747915 PMCID: PMC7973277 DOI: 10.3389/fonc.2021.596290] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 01/08/2021] [Indexed: 12/11/2022] Open
Abstract
Preclinical data suggest that head and neck squamous cell carcinomas (HNSCC) may evade immune surveillance and induce immunosuppression. One mechanism of immune evasion involves the expression of programmed death ligand-1 (PD-L1) in tumor and immune cells, which is, to date, the only biomarker routinely used in clinical practice to select patients with advanced HNSCCs more likely to benefit from anti-PD-1 therapy. Nonetheless, PD-L1 expression alone incompletely captures the degree of sensitivity of HNSCCs to PD-1 inhibitors. Most patients exposed to anti-PD-1 antibodies do not respond to therapy, suggesting the existence of mechanisms of de novo resistance to immunotherapy. Furthermore, patients that initially respond to PD-1 inhibitors will eventually develop acquired resistance to immunotherapy through mechanisms that have not yet been completely elucidated. In this article, we will provide an overview of the immune landscape of HNSCCs. We will briefly describe the clinical activity of inhibitors of the PD-1/PD-L1 axis in this disease, as well as biomarkers of benefit from these agents that have been identified so far. We will review pre-clinical and clinical work in cancers in general, and in HNSCCs specifically, that have characterized the mechanisms of de novo and acquired resistance to immunotherapy. Lastly, we will provide insights into novel strategies under investigation to overcome resistance to immune checkpoint inhibitors.
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Affiliation(s)
| | | | - William N. William
- Centro de Oncologia, Hospital BP, A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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213
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Immunotherapy in Head and Neck Cancer-Ready for Prime Time or More Research Needed? Int J Radiat Oncol Biol Phys 2021; 109:647-650. [PMID: 33516431 DOI: 10.1016/j.ijrobp.2020.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022]
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214
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Qian JM, Schoenfeld JD. Radiotherapy and Immunotherapy for Head and Neck Cancer: Current Evidence and Challenges. Front Oncol 2021; 10:608772. [PMID: 33614492 PMCID: PMC7886974 DOI: 10.3389/fonc.2020.608772] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/16/2020] [Indexed: 12/25/2022] Open
Abstract
Immune checkpoint inhibitors (ICI) have revolutionized cancer treatment over the past decade. However, although the immune landscape suggests a strong rationale for the use of these agents in patients with head and neck squamous cell carcinoma, the available clinical evidence indicates that most patients currently do not respond to ICI monotherapy. Radiotherapy is a primary treatment modality for many patients with locally advanced head and neck cancer. While ionizing radiation traditionally has been thought to act in a purely cytotoxic fashion, a growing body of preclinical studies have demonstrated additional profound immunomodulatory effects. Consequently, there has been a surge of interest in the potential synergy between radiotherapy and immunotherapy, both the potential for radiotherapy to augment the systemic anti-tumor immune response and the potential for immunotherapy to improve in-field tumor response to radiation. In this review, we summarize the current preclinical and clinical evidence for radioimmunotherapy, with a particular focus on studies directly relevant to head and neck squamous cell carcinoma, as well as existing challenges and future directions for this emerging field.
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Affiliation(s)
- Jack M. Qian
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, MA, United States
- Harvard Radiation Oncology Program, Massachusetts General Hospital/Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA, United States
| | - Jonathan D. Schoenfeld
- Department of Radiation Oncology, Dana-Farber/Brigham and Women’s Cancer Center, Harvard Medical School, Boston, MA, United States
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215
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Donlon NE, Power R, Hayes C, Davern M, Reynolds JV, Lysaght J. Radiation and Immunotherapy in Upper Gastrointestinal Cancers: The Current State of Play. Int J Mol Sci 2021; 22:ijms22031071. [PMID: 33499003 PMCID: PMC7865314 DOI: 10.3390/ijms22031071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 02/06/2023] Open
Abstract
Radiotherapy remains one of the contemporary cornerstones of cancer treatment in the neoadjuvant, curative, adjuvant and palliative settings, either in isolation or as a multimodal approach. Moreover, recent advances in targeted immune checkpoint therapy have firmly established immunotherapy as the fourth pillar in cancer therapy alongside surgery, chemotherapy and notably radiotherapy. There is emerging evidence to suggest both radioresistance and reduced efficacy of immune checkpoint blockade (ICB) are potentiated by the tumour microenvironment (TME) and in fact modulating aspects of this immunosuppressive milieu is instrumental to unlocking anti-tumour immunity. The response rates of Upper Gastrointestinal (UGI) malignancies to ICB remains modest at 10–15%, compared to melanoma at 20–40%. Harnessing the effects of radiotherapy through remodelling of the TME using ICB as a radiosensitisor is an avenue showing promise. Here we explore the rationale behind combining radiotherapy with ICB, as a symbiotic relationship in shifting the balance in favour of anti-tumour immunity. We discuss the effects of radiotherapy on immunogenic cell death, the concept of the abscopal effect, the importance of the cGAS STING pathway, and their relevance in the context of the tumour microenvironment. Furthermore, dosing and timing of radiotherapy and ICB is now being evaluated for its synergistic effects on host tumour immunity, and we review the ongoing efforts and current available literature for single agent and dual agent ICB in combination multimodal therapy for both locally advanced operable and metastatic disease of the upper gastrointestinal tract.
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Affiliation(s)
- Noel E. Donlon
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Robert Power
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Conall Hayes
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Maria Davern
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - John V. Reynolds
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
| | - Joanne Lysaght
- Department of Surgery, School of Medicine, Trinity College Dublin, Dublin 8, Ireland; (N.E.D.); (R.P.); (C.H.); (M.D.); (J.V.R.)
- Trinity St James’ Cancer Institute, St James’s Hospital Dublin, Dublin 8, Ireland
- Correspondence:
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216
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Szturz P, Nevens D, Vermorken JB. Oligometastatic Disease Management: Finding the Sweet Spot. Front Oncol 2020; 10:617793. [PMID: 33415080 PMCID: PMC7783387 DOI: 10.3389/fonc.2020.617793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/16/2020] [Indexed: 12/25/2022] Open
Abstract
Hematogenous dissemination represents a common manifestation of squamous cell carcinoma of the head and neck, and the recommended therapeutic options usually consist of systemically administered drugs with palliative intent. However, mounting evidence suggests that patients with few and slowly progressive distant lesions of small size may benefit from various local ablation techniques, which have already been established as standard-of-care modalities for example in colorectal and renal cell carcinomas and in sarcomas. In principle, serving as radical approaches to eradicate cancer, these interventions can be curative. Their impact on local control and overall survival has been shown in numerous retrospective and prospective studies. The term oligometastatic refers to the number of distant lesions which should generally not surpass five in total, ideally in one organ. Currently, surgical resection remains the method of choice supported by the majority of published data. More recently, stereotactic (ablative) body radiotherapy (SABR/SBRT) has emerged as a viable alternative. In cases technically amenable to such local interventions, several other clinical variables need to be taken into account also, including patient-related factors (general health status, patient preferences, socioeconomic background) and disease-related factors (primary tumor site, growth kinetics, synchronous or metachronous metastases). In head and neck cancer, patients presenting with late development of slowly progressive oligometastatic lesions in the lungs secondary to human papillomavirus (HPV)-positive oropharyngeal cancer are the ideal candidates for metastasectomy or other local therapies. However, literature data are still limited to say whether there are other subgroups benefiting from this approach. One of the plausible explanations is that radiological follow-up after primary curative therapy is usually not recommended because its impact on survival has not been unequivocal, which is also due to the rarity of oligometastatic manifestations in this disease. At the same time, aggressive treatment of synchronous metastases early in the disease course should be weighed against the risk of futile interventions in a disease with already multimetastatic microscopic dissemination. Therefore, attentive treatment sequencing, meticulous appraisal of cancer extension, refinement of post-treatment surveillance, and understanding of tumor biology and kinetics are crucial in the management of oligometastases.
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Affiliation(s)
- Petr Szturz
- Medical Oncology, Department of Oncology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Daan Nevens
- Department of Radiation Oncology, IridiumNetwork, Wilrijk (Antwerp), Belgium
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Jan B. Vermorken
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
- Department of Medical Oncology, Antwerp University Hospital, Edegem, Belgium
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217
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Metastasis-directed therapy for oligometastasis and beyond. Br J Cancer 2020; 124:136-141. [PMID: 33204024 PMCID: PMC7782796 DOI: 10.1038/s41416-020-01128-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/19/2020] [Accepted: 09/22/2020] [Indexed: 12/25/2022] Open
Abstract
Metastasis-directed therapy (MDT)-local therapy that is intended to eradicate specific metastatic lesions-has hitherto been used with varying degrees of clinical efficacy and acceptance as a meaningful therapy for metastatic disease. Over the past 25 years, however, the momentum for using MDT to manage patients with metastatic solid tumours has increased, driven by several factors. Among these factors is the recognition that patients with limited metastatic burden could potentially derive survival benefits from MDT. Furthermore, although current systemic therapies are increasingly effective, they are infrequently curative. In addition, technological advances have broadened the spectrum of metastatic lesions that can be treated with ablative intent. Here we aim to briefly review the status of evidence for the clinical benefit of MDT based on current data mainly from trials in patients with oligometastatic disease, discuss the myriad of clinical states that might fall under and beyond the definition of oligometastasis, review technological advances in MDT and their applications beyond oligometastasis, and discuss the need for the continued co-evolution of MDT and systemic therapy as we seek to understand which patients with metastatic cancer can achieve durable remission and how to optimally manage those who cannot.
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218
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Wijetunga NA, Yu Y, Morris LG, Lee N, Riaz N. The head and neck cancer genome in the era of immunotherapy. Oral Oncol 2020; 112:105040. [PMID: 33197752 DOI: 10.1016/j.oraloncology.2020.105040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 10/04/2020] [Accepted: 10/04/2020] [Indexed: 12/19/2022]
Abstract
The recent success of immunotherapy in head and neck squamous cell carcinoma (HNSCC) has necessitated a new perspective on the cancer genome. Here we review recent advances in the carcinogenesis and molecular genetics of HNSCC with an eye on their implications for cancer immunity. Newer sequencing technologies have recently facilitated dissection of the complex interaction between the HPV virus, tumor, host factors, and the tumor microenvironment (TME) that help shed light on how the immune system interacts with head and neck malignancies.
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Affiliation(s)
- N Ari Wijetunga
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yao Yu
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luc G Morris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nancy Lee
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Nadeem Riaz
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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219
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Plavc G, Jesenko T, Oražem M, Strojan P. Challenges in Combining Immunotherapy with Radiotherapy in Recurrent/Metastatic Head and Neck Cancer. Cancers (Basel) 2020; 12:E3197. [PMID: 33143094 PMCID: PMC7692120 DOI: 10.3390/cancers12113197] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/28/2020] [Indexed: 12/14/2022] Open
Abstract
Immunotherapy with immune checkpoint inhibitors (ICI) has recently become a standard part of the treatment of recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC), although the response rates are low. Numerous preclinical and clinical studies have now illuminated several mechanisms by which radiotherapy (RT) enhances the effect of ICI. From RT-induced immunogenic cancer cell death to its effect on the tumor microenvironment and vasculature, the involved mechanisms are diverse and intertwined. Moreover, the research of these interactions is challenging because of the thin line between immunostimulatory and the immunosuppressive effect of RT. In the era of active research of immunoradiotherapy combinations, the significance of treatment and host-related factors that were previously seen as being less important is being revealed. The impact of dose and fractionation of RT is now well established, whereas selection of the number and location of the lesions to be irradiated in a multi-metastatic setting is something that is only now beginning to be understood. In addition to spatial factors, the timing of irradiation is as equally important and is heavily dependent on the type of ICI used. Interestingly, using smaller-than-conventional RT fields or even partial tumor volume RT could be beneficial in this setting. Among host-related factors, the role of the microbiome on immunotherapy efficacy must not be overlooked nor can we neglect the role of gut irradiation in a combined RT and ICI setting. In this review we elaborate on synergistic mechanisms of immunoradiotherapy combinations, in addition to important factors to consider in future immunoradiotherapy trial designs in R/M HNSCC.
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Affiliation(s)
- Gaber Plavc
- Department of Radiation Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (P.S.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Tanja Jesenko
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
- Department of Experimental Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia
| | - Miha Oražem
- Department of Radiation Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (P.S.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Primož Strojan
- Department of Radiation Oncology, Institute of Oncology Ljubljana, 1000 Ljubljana, Slovenia; (M.O.); (P.S.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia;
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220
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Schubert P, Rutzner S, Eckstein M, Frey B, Schweizer C, Haderlein M, Lettmaier S, Semrau S, Gostian AO, Zhou JG, Gaipl US, Fietkau R, Hecht M. Prospective Evaluation of All-lesion Versus Single-lesion Radiotherapy in Combination With PD-1/PD-L1 Immune Checkpoint Inhibitors. Front Oncol 2020; 10:576643. [PMID: 33251140 PMCID: PMC7673414 DOI: 10.3389/fonc.2020.576643] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/08/2020] [Indexed: 12/25/2022] Open
Abstract
Background Local ablative treatments improve survival in patients with oligometastatic disease in addition to chemotherapy. The application of immune checkpoint inhibitors prolonged patients’ survival in different tumor entities. This raises the question if patients still benefit from intensified local treatments in combination with a more efficient systemic treatment with immune checkpoint inhibitors. Methods The prospective non-interventional ST-ICI trial investigates treatment with PD-1/PD-L1 (Programmed cell death protein 1/Programmed cell death 1 ligand 1) immune checkpoint inhibitors and radiotherapy in different tumor entities. Patients who started radiotherapy and immunotherapy concomitantly were included in this interim analysis. In this cohort patients with all-lesion radiotherapy (all tumor lesions irradiated, al-RT) were compared to patients with radiotherapy to only a single of their tumor lesions (single-lesion radiotherapy, sl-RT). Endpoints of the interim analysis were progression-free survival (PFS), overall survival (OS) and time to progression (TTP). Results A total of 104 patients were registered between April 2017 and August 2019. Fifty patients started immune checkpoint inhibitor treatment and radiotherapy concomitantly and were included. Most frequent tumor entities were non-small cell lung cancer (62%) followed by head and neck squamous cell cancer (26%). Most frequent location of radiotherapy was lung (34%) and central nervous system (20%). Median duration of follow-up was 8.6 months beginning with first administration of the immune-checkpoint-inhibitor. Median PFS was 9.2 months (95% CI, 5.8 – 12.6) in the al-RT group and 3.0 months (95% CI, 2.5 – 3.5) in the sl-RT group (p<0.001). Median OS was 11.6 months (95% CI, 8.1 - 15.1) in the al-RT group and 4.2 months (95% CI, 3.0 - 5.4) in the sl-RT group (p=0.007). Median TTP was not reached in the al-RT group compared to 4.6 months (95% CI, 1.1–8.0) in the sl-RT group (p=0.028). Univariate Cox regression analyses computed tumor entity, histology, central nervous system metastases, immunotherapy drug and al-RT as predictors of OS (with an effect p-value of ≤ 0.1). In the multivariable analysis only tumor entity and al-RT remained prognostic factors for OS. Conclusion Patients with PD-1/PD-L1 immune checkpoint inhibitor therapy benefit from local radiotherapy to all known lesions compared to single-lesion radiotherapy regarding PFS and OS.
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Affiliation(s)
- Philipp Schubert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sandra Rutzner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Markus Eckstein
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany.,Institute of Pathology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Claudia Schweizer
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Marlen Haderlein
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sebastian Lettmaier
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Sabine Semrau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Antoniu-Oreste Gostian
- Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany.,Department of Otolaryngology-Head & Neck Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jian-Guo Zhou
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany.,Department of Oncology, The Second Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
| | - Markus Hecht
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany.,Comprehensive Cancer Center Erlangen-EMN, Erlangen, Germany
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221
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Multivariable Analysis of 169 Cases of Advanced Cutaneous Melanoma to Evaluate Antibiotic Exposure as Predictor of Survival to Anti-PD-1 Based Immunotherapies. Antibiotics (Basel) 2020; 9:antibiotics9110740. [PMID: 33120998 PMCID: PMC7692514 DOI: 10.3390/antibiotics9110740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/16/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022] Open
Abstract
Recently antibiotic exposure has been associated with worse outcomes in patients undergoing treatment with antibodies directed against programmed cell death protein-1 (PD-1). We reviewed data of 1264 patients enrolled at Melanoma Skin and Ocular Tissue Repositories at University of Iowa Hospitals and Clinic. Reviewed data included patient demographics, prior medical history, baseline hematologic and disease parameters and outcomes including progression-free survival (PFS) and overall survival (OS). Cox regression models were used to determine predictive markers. Overall, 169 patients with advanced cutaneous melanoma received anti-PD-1 based therapies. Median follow up was 18.46 (range 0.89 to 62.52) months. On multivariable analysis brain metastasis, higher absolute neutrophil count (ANC) and lower absolute lymphocyte count were associated with poorer PFS while brain and liver metastasis and lower albumin were associated with poorer OS. Prior antibiotics, radiation as well as age, gender, basal metabolic index (BMI), smoking status, BRAF mutation, line of therapy (first or latter), prior treatments (ipilimumab or BRAF inhibitors), hemoglobin, neutrophil-to-lymphocyte ratio, white blood cell, platelet and eosinophil counts were not associated with PFS or OS in multivariable analysis. Contrary to some prior studies BMI, radiation, and antibiotics were not associated with PFS or OS.
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222
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Seiwert TY, Kiess AP. Time to Debunk an Urban Myth? The "Abscopal Effect" With Radiation and Anti-PD-1. J Clin Oncol 2020; 39:1-3. [PMID: 32986527 DOI: 10.1200/jco.20.02046] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Tanguy Y Seiwert
- Department of Medical Oncology, Johns Hopkins University, Baltimore, MD
| | - Ana P Kiess
- Department of Radiation Oncology, Johns Hopkins University, Baltimore, MD
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