Neoadjuvant Immunotherapy of Oral Squamous Cell Carcinoma: Case Report and Assessment of Histological Response

Multiplex immunofluorescence assessment of macrophages and IL-23R in inflammatory and malignant diseases of the oral mucosa: a pilot study

Background

Immune cells play a major role in the development and progression of inflammatory and malignant diseases of the oral mucosa. There is growing evidence that immune cells contribute to oral cancer progression and metastases. Inflammatory carcinogenesis is believed to be relevant for oral Lichen Planus as well as for oral Leukoplakia. In addition, there is growing evidence that periodontitis might also be linked to oral cancer development. Yet there is no analysis available comparing the immune cell composition in these different inflammatory and malignant neoplastic diseases. A better understanding of similarities and differences of the diseases could eventually also pave the way for the use of immunotherapy in non-malignant diseases.

Methods

In the current pilot study, a tissue microarray (TMA) was created of a total of 29 patients with periodontitis (PD, n=4), oral Leukoplakia (OL, n=4), oral Lichen Planus (OLP, n=4), oral squamous cell cancer without lymphatic metastases (OSCC N0, n=5), or with lymphatic metastases (OSCC N+, n=4), OSCC biopsies prior to and resection specimens after anti-PD1 immunotherapy (IT) (each n=3) as well as healthy control gingiva (n=5). In each patient two tissue samples were analyzed. The TMA was stained with a 4X multiplex immunofluorescent staining for IL-23R, CD68, CD11c, and CD163. Samples were digitalized and an AI-based cell counting was performed. Statistical analysis was performed using the Mann-Whitney U test.

Results

IL-23R expression, macrophage infiltration as well as M2 polarization in OL and OLP were significantly higher compared to controls. OLP showed a significantly higher M2 infiltration and polarization than OL. PD showed a trend for increased macrophage infiltration compared to controls without significance. N+ OSCC showed a significantly increased macrophage infiltration compared to N0 cases. In response to anti-PD1 IT, CD11c and CD163 infiltration was significantly increased. Most IL-23R positive cells co-expressed macrophage markers.

Conclusion

A TMA in combination with 4-plex immunofluorescence is suitable for immune cell characterization in different oral diseases. Macrophage infiltration and polarization in precursor lesions seems to be associated with OSCC development as well as metastatic spread. IL-23 pathway inhibition might be a potential target for oral Lichen and Leukoplakia.

Microenvironment-based immunotherapy in oral cancer: a comprehensive review

Oral cancer, a prevalent form of head and neck malignancy, accounts for 4% of global cancer cases. The most common type, oral squamous cell carcinoma (OSCC), has a survival rate of about 50%. Even though emerging molecular therapies show promise for managing oral cancer, current treatments like surgery, radiotherapy, and chemotherapy have significant side effects. In addition, the complex tumor microenvironment (TME), involving the extracellular matrix (ECM) and cells like fibroblasts and stromal cells like immune cells, promotes tumor growth and inhibits immune responses, complicating treatment. Nonetheless, immunotherapy is crucial in cancer treatment, especially in oral cancers. Indeed, its effectiveness lies in targeting immune checkpoints such as PD-1 and CTLA-4 inhibitors, as well as monoclonal antibodies like pembrolizumab and cetuximab, adoptive cell transfer methods (including CAR-T cell therapy), cytokine therapy such as IL-2, and tumor vaccines. Thus, these interventions collectively regulate tumor proliferation and metastasis by targeting the TME through autocrine-paracrine signaling pathways. Immunotherapy indeed aims to stimulate the immune system, leveraging both innate and adaptive immunity to counteract cancer cell signals and promote tumor destruction. This review will explore how the TME controls tumor proliferation and metastasis via autocrine-paracrine signaling pathways. It will then detail the effectiveness of immunotherapy in oral cancers, focusing on immune checkpoints, targeted monoclonal antibodies, adoptive cell transfer, cytokine therapy, and tumor vaccines.

Neoadjuvant and Adjuvant Immunotherapy in the Treatment of Oral Squamous Cell Carcinoma

Oral squamous cell carcinoma (OSCC) is experiencing a progressive increase in global incidence. Regrettably, this entity is typically discovered at an advanced stage in the majority of patients, which indicates increased therapeutic challenges and a poorer prognosis. Programmed cell death protein 1 (PD-1) appears to have a significant role in immunotherapy and monoclonal antibodies targeting this molecule have been utilized as a therapeutic intervention. A decade of research indicates that neoadjuvant immunotherapy has garnered greater interest than adjuvant immunotherapy in OSCC. This may be due to neoadjuvant immunotherapy serving as a preventive and adjunctive treatment. Enhanced outcomes may be achieved by optimizing the cancer microenvironment before surgery. Of note, neoadjuvant immunotherapy has been introduced preoperatively for untreated OSCC.

Synergistic anti-cancer effects of metformin and cisplatin on YD-9 oral squamous carcinoma cells via AMPK pathway

OBJECTIVE

This study evaluated whether hypoglycemic drug metformin enhances the anti-cancer effects of cisplatin in YD-9 cells.

METHODOLOGY

YD-9 cells, derived from oral mucosal squamous cell carcinoma of oral mucosa, were used to assess the combined effects of metformin and cisplatin by means of MTT assay, live and dead cell staining, and colony formation assays to evaluate cell viability and proliferation. Reactive oxygen species level was measured using a Muse cell analyzer. Apoptosis, epithelial-mesenchymal transition, and related molecular pathways were analyzed by western blot. Wound healing assays and Transwell migration assays examined cell migration, whereas monophosphate-activated protein kinase inhibitor Compound C, was utilized to investigate the AMPK pathway.

RESULTS

Sequential treatment of YD-9 cells with metformin and cisplatin resulted in decreased cell viability and proliferation, increased ROS levels, and elevated apoptosis compared with the individual drugs. Moreover, the treatment inhibited EMT, wound healing, and cell migration. These results correlated with increased AMPK phosphorylation, a key regulator of cellular energy homeostasis. Introduction of Compound C pre-treatment upregulated N-cadherin and α-smooth muscle actin along with enhanced cell migration.

CONCLUSION

This study found synergism in anti-cancer effects between metformin and cisplatin. Additionally, introduction of Compound C confirmed that EMT inhibition is AMPK dependent. These findings indicate the potential use of metformin as an adjunct drug in anti-cancer treatments, warranting further investigation.

Less is more: Exploring neoadjuvant immunotherapy as a de-escalation strategy in head and neck squamous cell carcinoma treatment

Head and neck squamous cell carcinoma (HNSCC) constitutes a significant global cancer burden, given its high prevalence and associated mortality. Despite substantial progress in survival rates due to the enhanced multidisciplinary approach to treatment, these methods often lead to severe tissue damage, compromised function, and potential toxicity. Thus, there is an imperative need for novel, effective, and minimally damaging treatment modalities. Neoadjuvant treatment, an emerging therapeutic strategy, is designed to reduce tumor size and curtail distant metastasis prior to definitive intervention. Currently, neoadjuvant chemotherapy (NACT) has optimized the treatment approach for a subset of HNSCC patients, yet it has not produced a noticeable enhancement in overall survival (OS). In the contemporary cancer therapeutics landscape, immunotherapy is gaining traction at an accelerated pace. Notably, neoadjuvant immunotherapy (NAIT) has shown promising radiological and pathological responses, coupled with encouraging efficacy in several clinical trials. This potentially paves the way for a myriad of possibilities in treatment de-escalation of HNSCC, which warrants further exploration. This paper reviews the existing strategies and efficacies of neoadjuvant immune checkpoint inhibitors (ICIs), along with potential de-escalation strategies. Furthermore, the challenges encountered in the context of the de-escalation strategies of NAIT are explored. The aim is to inform future research directions that strive to improve the quality of life (QoL) for patients battling HNSCC.

Surgical margins in head and neck squamous cell carcinoma: A narrative review

Head and neck squamous cell carcinoma (HNSCC), a prevalent and frequently recurring malignancy, often necessitates surgical intervention. The surgical margin (SM) plays a pivotal role in determining the postoperative treatment strategy and prognostic evaluation of HNSCC. Nonetheless, the process of clinical appraisal and assessment of the SMs remains a complex and indeterminate endeavor, thereby leading to potential difficulties for surgeons in defining the extent of resection. In this regard, we undertake a comprehensive review of the suggested surgical distance in varying circumstances, diverse methods of margin evaluation, and the delicate balance that must be maintained between tissue resection and preservation in head and neck surgical procedures. This review is intended to provide surgeons with pragmatic guidance in selecting the most suitable resection techniques, and in improving patients' quality of life by achieving optimal functional and aesthetic restoration.

Role of Surgical Pathologist for Detection of Immunooncologic Predictive Factors in Head and Neck Cancer

Immunotherapy has shown promising results in the treatment of recurrent and metastatic head and neck cancers. Antiprogrammed cell death (PD)-1 therapies have been recently approved in this setting and they are currently tested also in the treatment of locally advanced diseases and in the neoadjuvant setting. However, the clinical benefits of these treatments have been quite variable, hence the need to select those patients who may obtain the maximal efficacy through the identification of predictive biomarkers. Currently, PD-L1 immunohistochemical expression by tumor and immune cells is the most widely used predictive biomarker for immunotherapy in head and neck squamous cell carcinoma. Nevertheless, patients with PD-L1 - tumors may still respond to treatments, thereby emphasizing the need for the identification of other predictive biomarkers. In this review, we summarize the current data on histologic and molecular parameters that can be used to select patients with head and neck cancers for immunotherapy, with a focus on squamous cell carcinoma and salivary gland carcinomas.

Circ_0004491 stimulates guanine nucleotide-binding protein alpha subunit to inhibit the malignant progression of oral squamous cell carcinoma by sponging miR-2278

Background/purpose

Circular RNA origin recognition complex subunit 4 (circORC4; ID: hsa_circ_0004491) have been confirmed to be a novel potential biomarker of oral squamous cell carcinoma (OSCC). This study aimed to explore the molecular mechanism of circ_0004491 in OSCC progression.

Materials and methods

Levels of circ_0004491, microRNA (miR)-2278, guanine nucleotide-binding protein alpha subunit (GNAS), Bax, Bcl-2, E-cadherin and ki-67 were detected by quantitative real-time PCR, western blotting and immunohistochemistry. The proliferation of OSCC cells was measured using colony formation assay and EdU staining. Cell apoptosis and motility were detected by flow cytometry and transwell assays respectively. Interaction between miR-2278 and circ_0004491 or GNAS was predicted by bioinformatics analysis and confirmed via luciferase reporter assay and RNA immunoprecipitation assay. Xenograft tumor model was used to analyze the role of circ_0004491 in tumor growth in vivo.

Results

Circ_0004491 was downregulated in OSCC tissues and cell lines. Circ_0004491 overexpression suppressed the proliferation, migration and invasion whereas facilitated the apoptosis of OSCC cells. Circ_0004491 acted as a molecular sponge for miR-2278, and circ_0004491 overexpression-mediated effect was partly reversed by miR-2278 mimic in OSCC cells. MiR-2278 interacted with the 3'UTR of GNAS. Circ_0004491 contributed to GNAS level by sponging miR-2278 in OSCC cells. GNAS knockdown restored miR-2278 inhibitor-mediated effect in OSCC cells. Circ_0004491 overexpression repressed xenograft tumor growth in vivo.

Conclusion

Circ_0004491 can repress OSCC progression by regulation of miR-2278/GNAS axis, providing a possible circRNA-targeted therapy for OSCC.

Case report: Patient specific combination of surgery and immunotherapy in advanced squamous cell carcinoma of the head and neck - a case series and review of literature

BACKGROUND

Prognosis of patients with recurrent or metastatic head and neck cancer is generally poor. Adjuvant immunotherapy (IT) featuring immune checkpoint inhibition (ICI) is standard of care in advanced stage head and neck squamous cell carcinoma (HNSCC) and cutaneous squamous cell carcinoma (CSCC). ICI response rates in CSCC are described as higher than in HNSCC. IT is constantly shifting into earlier disease stages which confronts the surgeon with immunotherapeutically pre-treated patients. It is therefore becoming increasingly difficult to assess which patients with symptomatic tumor disease and a lack of curative surgical option might benefit from salvage surgery.

CASE PRESENTATIONS

The following 6 cases describe therapeutic decision-making regarding ICI and (salvage) surgery in patients with advanced stage HNSCC or CSCC. Cases A and B focus on neoadjuvant ICI followed by salvage surgery. In Cases C and D salvage surgery was performed after short-term stabilization with partial response to ICI. The last two cases (Cases E and F) address the surgical approach after failure of ICI. All cases are discussed in the context of the current study landscape and with focus on individual decision-making. For better understanding, a timetable of the clinical course is given for each case.

CONCLUSIONS

ICI is rapidly expanding its frontiers into the neoadjuvant setting, frequently confronting the surgeon with heavily pretreated patients. Salvage surgery is a viable therapeutic concept despite the rise of systemic treatment options. Decision-making on surgical intervention in case of a salvage surgery remains an individual choice. For neoadjuvant ICI monitoring regarding pathological tumor response or tumor necrosis rate, we suggest correlation between the initial biopsy and the definite tumor resectate in order to increase its significance as a surrogate marker. Scheduling of neoadjuvant ICI should be further investigated, as recent studies indicate better outcomes with shorter time frames.

Molecular Research on Oral Diseases and Related Biomaterials: A Journey from Oral Cell Models to Advanced Regenerative Perspectives

Oral diseases such as gingivitis, periodontitis, and oral cancer affect millions of people worldwide. Much research has been conducted to understand the pathogenetic mechanisms of these diseases and translate this knowledge into therapeutics. This review aims to take the reader on a journey from the initial molecular discoveries to complex regenerative issues in oral medicine. For this, a semi-systematic literature search was carried out in Medline and Web of Science databases to retrieve the primary literature describing oral cell models and biomaterial applications in oral regenerative medicine. First, an in vitro cell model of gingival keratinocytes is discussed, which illustrates patho- and physiologic principles in the context of oral epithelial homeostasis and carcinogenesis and represents a cellular tool to understand biomaterial-based approaches for periodontal tissue regeneration. Consequently, a layered gradient nonwoven (LGN) is described, which demonstrates that the key features of biomaterials serve as candidates for oral tissue regeneration. LGN supports proper tissue formation and obeys the important principles for molecular mechanotransduction. Furthermore, current biomaterial-based tissue regeneration trends, including polymer modifications, cell-based treatments, antimicrobial peptides and optogenetics, are introduced to represent the full spectrum of current approaches to oral disease mitigation and prevention. Altogether, this review is a foray through established and new concepts in oral regenerative medicine and illustrates the process of knowledge translation from basic molecular and cell biological research to future clinical applications.

Clinical Response to Neoadjuvant Immunotherapy Combined with Targeted Therapy and Chemotherapy in Oral Squamous Cell Carcinoma: Experience in Three Patients

Immune checkpoint inhibitors (ICIs) pembrolizumab and nivolumab have been approved for the treatment of head and neck squamous cell carcinoma (HNSCC) and used in neoadjuvant immunotherapy in clinical trials. However, combination of ICIs with targeted therapy and chemotherapy was rarely used in pre-surgical HNSCC patients. Herein, we encountered three cases of patients with oral squamous cell carcinoma (OSCC) who all had good responses to neoadjuvant immunotherapy (anti-PD-1 inhibitors) combined with nimotuzumab (anti-EGFR monoclonal antibody) plus paclitaxel. Both Case 1 and Case 2 underwent the same neoadjuvant therapeutic combination (nivolumab, nimotuzumab and paclitaxel) and exhibited a marked tumor shrinkage even complete disappearance by radiological evaluation. Moreover, pathological response was observed in post-surgical tissues of Case 1. Additionally, Case 3 with tongue squamous cell carcinoma also had satisfactory tumor regression (complete healing of his tongue ulcer upon treatment) after receiving similar neoadjuvant therapy with sintilimab (another PD-1 inhibitor), nimotuzumab and paclitaxel. We characterized their potential causes behind favorable treatment outcomes. While there were differences in driver mutations and tumor mutation burden (TMB) identified in pre-treatment tumor tissues among the three patients, numerous CD68+ (macrophages) infiltrates were common for all the cases. Of note, the majority (>80%) of the total macrophages were molecularly defined as PD-L1-positive macrophages. Given the high expression of PD-L1 in macrophages is associated with better immunotherapy outcomes, we propose that the high proportion of CD68+PD-L1+ cells in total macrophages alone could serve as a promising biomarker for neoadjuvant immunotherapy in combination with other therapies in HNSCC.