Unexpected response with palliative conventional therapy in head and neck squamous cell carcinoma after anti-programmed death-1 progression

Major and durable responses to photon and electron-beam palliative radiotherapies after immune-checkpoint inhibitors in head and neck cancer

BACKGROUND

The immuno-modulatory effects of ionizing radiation are well-known and preclinical studies suggest a synergistic effect of combining radiotherapy (RT) and IO. However, data regarding the clinical activity and safety of this approach are limited.

METHODS

We present the cases of two patients with SCCHN primary progressing to PDL1-based IO within a clinical trial (NCT03383094), that received subsequent but not concurrent palliative RT using two different modalities (electron beam and photon beam therapies).

RESULTS

Both patients achieved major and durable responses at 4 irradiated sites, with excellent tolerance and no grade ≥ 3 toxicities. Complete response occurred in 3 of the disease areas (all locoregional) and partial response in 1 metastatic lesion.

CONCLUSION

Palliative radiotherapy after progression to IO was safe and demonstrated profound and durable responses in the cases presented.

Taxanes in the Treatment of Head and Neck Squamous Cell Carcinoma

Taxanes, particularly docetaxel (DTX), has been widely used for combination therapy of head and neck squamous cell carcinoma (HNSCC). For locally advanced unresectable HNSCC, DTX combined with cisplatin and 5-fluorouracil as a revolutionary treatment revealed an advantage in the improvement of patient outcome. In addition, DTX plus immune check inhibitors (ICIs) showed low toxicity and an increased response of patients with recurrent or metastatic HNSCC (R/M HNSCC). Accumulated data indicate that taxanes not only function as antimitotics but also impair diverse oncogenic signalings, including angiogenesis, inflammatory response, ROS production, and apoptosis induction. However, despite an initial response, the development of resistance remains a major obstacle to treatment response. Taxane resistance could result from intrinsic mechanisms, such as enhanced DNA/RNA damage repair, increased drug efflux, and apoptosis inhibition, and extrinsic effects, such as angiogenesis and interactions between tumor cells and immune cells. This review provides an overview of taxanes therapy applied in different stages of HNSCC and describe the mechanisms of taxane resistance in HNSCC. Through a detailed understanding, the mechanisms of resistance may help in developing the potential therapeutic methods and the effective combination strategies to overcome drug resistance.

Durable complete remission with local therapies after neoadjuvant and adjuvant nivolumab in recurrent/metastatic head and neck cancer

Up to 10-15% of patients with first-line recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC) present with platinum-refractory disease. The anti-PD1 nivolumab is the first therapeutic option in this setting achieving a 19.2% objective response rate and a 7.7-month median overall survival (OS). Given the poor prognosis of platinum-refractory patients, those showing slow progressive disease with no functional status deterioration should maintain nivolumab beyond progression in the absence of severe or unmanageable toxicities. Another strategy is to use local therapies such as radiotherapy and surgical tumor resection in cases of oligometastatic or oligoprogressive disease. Both strategies may significantly improve disease control and OS in these populations. We present the case of a patient with platinum-refractory disease treated with first-line nivolumab beyond progression who achieved a durable complete response after palliative radiation and surgical resection of five tumor lesions. To our knowledge, this is the first reported case of an R/M HNSCC treated with such a strategy outside a clinical trial and contributes to the evidence for combining anti-PD1 agents and local therapies in selected patients with R/M HNSCC.

Unexpected response to fourth-line paclitaxel in a patient with metastatic oropharyngeal squamous cell carcinoma, immunotherapy-refractory: a case report

In recent years, immune checkpoint inhibitors (ICIs), including nivolumab and pembrolizumab have revolutionized the treatment landscape in recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HNSCC). However, many patients do not respond to ICIs for reasons that remain largely unknown. For patients who progress on ICIs, chemotherapy and/or biologic therapies are the most widely used treatments based on the clinician's choice, with no defined sequence strategy. We report the experience of a patient with metastatic oropharyngeal squamous cell cancer p16 and human papillomavirus-DNA positive who received chemotherapy with weekly paclitaxel after progressing on nivolumab. Our patient presented a partial response to fourth line paclitaxel, which lasted more than 2 years, with an improvement of his quality of life too. These results support the hypothesis of synergism between immunotherapy and conventional chemotherapies. Even in the setting of immune-refractory disease, immunotherapy may affect tumor immune microenvironment thus leading to a synergistic effect with conventional chemotherapy and achieving unexpected results.

How Chemotherapy Affects the Tumor Immune Microenvironment: A Narrative Review

Chemotherapy is much more effective in immunocompetent mice than in immunodeficient ones, and it is now acknowledged that an efficient immune system is necessary to optimize chemotherapy activity and efficacy. Furthermore, chemotherapy itself may reinvigorate immune response in different ways: by targeting cancer cells through the induction of cell stress, the release of damage signals and the induction of immunogenic cell death, by targeting immune cells, inhibiting immune suppressive cells and/or activating immune effector cells; and by targeting the host physiology through changes in the balance of gut microbiome. All these effects acting on immune and non-immune components interfere with the tumor microenvironment, leading to the different activity and efficacy of treatments. This article describes the correlation between chemotherapy and the immune changes induced in the tumor microenvironment. Our ultimate aim is to pave the way for the identification of the best drugs or combinations, the doses, the schedules and the right sequences to use when chemotherapy is combined with immunotherapy.

Impact of previous nivolumab treatment on the response to taxanes in patients with recurrent/metastatic head and neck squamous cell carcinoma

BACKGROUND

Immune checkpoint inhibitors are widely used in recurrent and/or metastatic head and neck squamous cell carcinoma (R/M HNSCC). We aimed to describe response rates to taxanes after progression on nivolumab in R/M HNSCC patients.

METHODS

In this multicentric retrospective comparative study, we included patients treated with taxane monotherapy from 2014 to 2020. Patients were divided into two groups depending on whether they received nivolumab before taxanes (post-nivolumab group) or not (control group). The primary end-point was objective response rate (ORR) comparison between the two groups. The secondary end-points included disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and PFS ratio (PFSr=PFS associated with taxanes divided by PFS associated with the previous line of treatment), a survival marker used for comparison of different treatment lines.

RESULTS

Between July 2014 and August 2020, 185 patients were included (114 in the control group and 71 in the post-nivolumab group). ORR was significantly higher in the post-nivolumab group (39.4% versus 26.3%, p = 0.03) as was DCR (69% versus 50%, P = 0.06). The median OS (7.5 months) and PFS (3.5 months) were not significantly different in the two groups, whereas PFSr was significantly improved in the post-nivolumab group (1.63 versus 1.11, P = 0.004).

CONCLUSION

Response and DCRs with taxanes are improved after prior exposure to nivolumab. Thus, taxane monotherapy could be a good choice as third-line therapy after nivolumab following a platinum-based first line. These results currently apply to patients without access to or potential benefit from first-line pembrolizumab.

Re-irradiation for oligoprogression under Nivolumab in recurrent head and neck squamous cell carcinoma: A case report

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Immunotherapy is a new option for head and neck squamous cell carcinoma.

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Very limited data are available for concurrent radio-immunotherapy in recurrent disease.

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Our case report adds to this very limited series, focusing on oligopression under immunotherapy.

Immune checkpoint inhibitors (ICIs) represent a recently introduced class of agents active in head and neck squamous cell carcinoma (HNSCC). For a subgroup of patients with recurrent or metastatic disease, long-term benefit can be achieved: maintaining a sustained response to immunotherapy is therefore a critical factor for its efficacy at an individual level. In analogy to targeted agents, a limited pattern of progression, or “oligoprogression”, can occur. For locally recurrent HNSCC, the potential biologic interplay between the efficacy of ICIs and the design of radiation fields chosen for primary treatment is currently unknown. Here, we report on a patient who presented two subsequent oligoprogressions successfully treated with re-irradiation without interrupting Nivolumab. Both oligoprogressive lesions developed in previously unirradiated areas. We hypothesize the existence of a synergistic effect with optimal spatial cooperation between ICIs and re-irradiation for oligoprogressive disease under immunotherapy.

Knowing the tumour microenvironment to optimise immunotherapy

Effective immunotherapy requires thorough knowledge of the tumour microenvironment. Indeed, the interplay among the immune system, the tumour and treatment is conditioned by the composition of the tumour microenvironment. In addition, it must be taken into account that homeostasis of the tumour microenvironment is highly dynamic and changes rapidly in function of many factors, such as inflammation, hypoxia, tumour volume, all of which change over time, and the effect of treatments. All these elements interact with each other and with conditions related to the tumour (i.e. mutational load, rate of clonal and subclonal mutations) and to host (life style, diet, obesity, age). All these factors as well as their interplay, affect the response to immunotherapy. The target of this short review is to summarise some of the major aspects that impact the homeostasis of the tumour microenvironment and how its structure can drive treatment choice.