Defining the Role of Immunotherapy in the Curative Treatment of Locoregionally Advanced Head and Neck Cancer: Promises, Challenges, and Opportunities

Immunotherapy for Head and Neck Squamous Cell Carcinoma: Present and Future Approaches and Challenges

Despite significant progress and improving outcomes in the management of head and neck squamous cell carcinoma (HNSCC), there are few effective treatment options for patients with recurrent or metastatic head and neck squamous cell carcinoma. The advent of immune checkpoint inhibitors has changed the treatment algorithm of head and neck squamous cell carcinoma and are approved in the frontline setting for recurrent and metastatic (R/M) head and neck squamous cell carcinomas. Although promising for some patients, most patients with R/M HNSCC do not derive clinical benefit from currently approved checkpoint inhibitors. Many studies are underway to identify the patient population that would benefit the most from immunotherapy as well as postimmunotherapy treatment failures, including novel combinations of immunomodulatory therapies. In this review, we summarize the clinical development of all major clinical trials of immunotherapy in HNSCC.

Durvalumab in combination with chemoradiotherapy in patients with head and neck squamous cell carcinoma: Results from the Phase 1 CLOVER study

BACKGROUND

The Phase 1 CLOVER study (NCT03509012) assessed durvalumab in combination with concurrent chemoradiotherapy (cCRT) in patients with advanced solid tumors; we report results from the head and neck squamous cell carcinoma (HNSCC) cohort.

METHODS

Patients with histologically/cytologically confirmed locally advanced HNSCC, eligible for definitive cCRT and not considered for primary surgery, received durvalumab plus cisplatin and concurrent external beam radiation. Objectives were to assess safety/tolerability and preliminary efficacy.

RESULTS

Eight patients were enrolled. The most frequent any-cause adverse events (AEs) were nausea and radiation skin injury (each n = 5); most frequent grade 3/4 AEs were lymphopenia and stomatitis (each n = 3). No patients had dose-limiting toxicities. Objective response rate was 71.4% (5/7 patients; four complete responses, one partial response); disease control rate was 85.7% at 18 weeks and 83.3% at 48 weeks.

CONCLUSIONS

Durvalumab plus cCRT was tolerable and active in patients with unresected, locally advanced HNSCC.

Remodeling the tumor microenvironment to overcome treatment resistance in HPV-negative head and neck cancer

Despite intensive efforts and refined techniques, overall survival in HPV-negative head and neck cancer remains poor. Robust immune priming is required to elicit a strong and durable antitumor immune response in immunologically cold and excluded tumors like HPV-negative head and neck cancer. This review highlights how the tumor microenvironment could be affected by different immune and stromal cell types, weighs the need to integrate metabolic regulation of the tumor microenvironment into cancer treatment strategies and summarizes the emerging clinical applicability of personalized immunotherapeutic strategies in HPV-negative head and neck cancer.

Improved antitumor immunity of chemotherapy in OSCC treatment by Gasdermin-E mediated pyroptosis

Oral squamous cell carcinoma (OSCC) is a malignant tumor with high mortality and poor prognosis. Many OSCC patients have low response rate to current treatments including immunotherapies largely due to the immune-suppressive tumor microenvironment (TME). Chemotherapy could induce immunogenic cell death (ICD), a type of cell death such as pyroptosis and necroptosis, which has proved to be capable to alter the immune-suppressive TME and beneficial for better anti-tumor effect. GSDME, a key protein of pyroptosis, is however often silenced in tumors due to abnormal methylation. To overcome these limitations, we utilizied methyltransferase inhibitor (decitabine, DAC) to trigger pyroptosis of tumor cells, combined with chemodrug cisplatin (DDP) and immune checkpoints inhibitors to amplify the immunotherapies outcomes. To the best of our knowledge, this is the first study of tumor suppressive effect of GSDME in OSCC. Our investigation demonstrated that stimulation of GSDME expression could improve the sensitivity of chemotherapeutics, activate inflammatory tumor cell pyroptosis and alter the tumor immune-suppressive microenvironment, providing an important perspective for clinical OSCC treatment.

Liquid Biopsy-Guided Interventional Oncology: A Proof of Concept with a Special Focus on Radiotherapy and Radiology

Simple Summary

Over the last decade radiology interventions for tumor ablation have steadily increased and new procedures of interventional Oncology (IO) have been developed. Minimal residual disease (MRD) management and its quantification has a critical role to assess the efficacy or failure of the treatment adopted.The assessment of the MRD depends by multiple and repetitive measurements performed through a no invasive procedure like as Liquid biopsy (LB). LB is a rapidly evolving technology with potentially relevant consequences in the management of patients with cancer. Despite its high potential, the LB approach cannot give spatial information and still lacks of standardization and required specificity and sensitivity to be extensively implemented in the routine clinical practice. The review is aimed at investigating how LB can monitor the effects of locoregional treatment highliting the potential synergies between interventional techniques and LB to improve cancer patient’ management. The review suggests combining Interventional techniques and LB technology could improve LB overcoming its sensitivity limitations. Furthermore, LB techniques may enhance the outcomes of minimally invasive loco-regional treatments not only via ongoing periodic MRD monitoring of a patient during and subsequent to IO procedures.

Abstract

Although the role of liquid biopsy (LB) to measure minimal residual disease (MRD) in the treatment of epithelial cancer is well known, the biology of the change in the availability of circulating biomarkers arising throughout treatments such as radiotherapy and interventional radio-oncology is less explained. Deep knowledge of how therapeutic effects can influence the biology of the release mechanism at the base of the biomarkers available in the bloodstream is needed for selecting the appropriate treatment-induced tumor circulating biomarker. Combining existing progress in the LB and interventional oncology (IO) fields, a proof of concept is provided, discussing the advantages of the traditional risk assessment of relapsing lesions, limitations, and the timing of detection of the circulating biomarker. The current review aims to help both interventional radiologists and interventional radiation oncologists evaluate the possibility of drawing a tailor-made board of blood-based surveillance markers to reveal subclinical diseases and avoid overtreatment.

Immunotherapy in Head and Neck Cancer When, How, and Why?

Head and neck cancer (HNC) is one of the most common cancers worldwide. Alcohol and tobacco consumption, besides viral infections, are the main risk factors associated with this cancer. When diagnosed in advanced stages, HNC patients present a higher probability of recurrence or metastasising. The complexity of therapeutic options and post-treatment surveillance is associated with poor prognosis and reduced overall survival (OS). This review aims to explore immunotherapy (immune checkpoint inhibitors (ICI), therapeutic vaccines, and oncolytic viruses) in HNC patients’ treatment, and to explore when, how, and why patients can benefit from it. The monotherapy with ICI or in combination with chemotherapy (QT) shows the most promising results. Compared to standard therapy, ICI are able to increase OS and patients’ quality of life. QT in combination with ICI demonstrates significant response rates and considerable long-term clinical benefits. However, the toxicity associated with this approach is still a hurdle to overcome. In parallel, the therapeutic vaccines directed to the Human Papilloma Virus are also efficient in increasing the antitumour response, inducing cellular and humoral immunity. Although these results demonstrate clinical benefits compared to standard therapy, it is also important to unravel the resistance mechanisms in order to predict the clinical benefit of immunotherapy.

Lymphatic-preserving treatment sequencing with immune checkpoint inhibition unleashes cDC1-dependent antitumor immunity in HNSCC

Despite the promise of immune checkpoint inhibition (ICI), therapeutic responses remain limited. This raises the possibility that standard of care treatments delivered in concert may compromise the tumor response. To address this, we employ tobacco-signature head and neck squamous cell carcinoma murine models in which we map tumor-draining lymphatics and develop models for regional lymphablation with surgery or radiation. We find that lymphablation eliminates the tumor ICI response, worsening overall survival and repolarizing the tumor- and peripheral-immune compartments. Mechanistically, within tumor-draining lymphatics, we observe an upregulation of conventional type I dendritic cells and type I interferon signaling and show that both are necessary for the ICI response and lost with lymphablation. Ultimately, we provide a mechanistic understanding of how standard oncologic therapies targeting regional lymphatics impact the tumor response to immune-oncology therapy in order to define rational, lymphatic-preserving treatment sequences that mobilize systemic antitumor immunity, achieve optimal tumor responses, control regional metastatic disease, and confer durable antitumor immunity.

Optimizing the prescription doses and tolerability of systemic therapy in head and neck cancer patients

PURPOSE OF REVIEW

Squamous cell carcinoma of the head and neck accounts for 330 000 deaths and 650 000 cases worldwide annually. Systemic therapy is an essential pillar of multimodal therapy despite being accompanied with substantial toxicity. This article reviews the latest advances in systemic therapy for the treatment of locoregionally advanced and reccurent/metastatic head and neck cancer from a tolerability perspective.

RECENT FINDINGS

Multiple recent attempts have been made to optimize tolerability (and efficacy) of systemic therapy utilizing new regimens, modified prescription doses, drugs such as immunotherapies or genotyping to tailor the systemic therapy to the individual patient.

SUMMARY

Although treatment benefit has to be weighed against potential toxicity, it is reasonable to anticipate potential side effects of systemic therapies. In a vulnerable elderly or Asian patient population upfront dose modifications of cytotoxic chemotherapies might be reasonable. Special attention should be laid on the patient's nutritional status and early intervention recommended. Dihydropyrimidine dehydrogenase genotyping can predict 5-fluorouracil toxicity and identify patients for whom alternative regimens are more suitable. As for immune checkpoint inhibitor therapy, despite being well tolerated, the identification of biomarkers to predict reduced tolerability or severe toxicity would be highly desirable.