Immune Checkpoint Inhibitors in Advanced Cutaneous Squamous Cell Carcinoma: Real-World Experience from a Canadian Comprehensive Cancer Centre

Immune biomarkers and predictive signatures in gastric cancer: Optimizing immunotherapy responses

Gastric cancer is a malignant disease with a poor prognosis and few therapeutic options once it has advanced. Immunotherapy using ICIs has emerged as a viable therapeutic method; nevertheless, reliable immunological biomarkers are required to identify who may benefit from these therapies. It focuses on key immune biomarkers and predictive signatures in gastric cancer, such as PD-L1 expression, microsatellite instability (MSI), tumor mutational burden (TMB), and Epstein-Barr virus (EBV) status, to optimize gastric cancer patients' immunotherapy responses. PD-L1 expression is a popular biomarker for ICI effectiveness. Tumors with high MSI-H and TMB are the most susceptible to ICIs because they are highly immunogenic. EBV-positive stomach tumors are highly immunogenic, and immunotherapy has a high response rate. Combining composite biomarker panels with multi-omics-based techniques improved patient selection accuracy. In recent years, machine learning models have been integrated into next-generation sequencing. Dynamic, real-time-monitorable biomarkers for real-time immune response monitoring are also being considered. Thus, enhancing biomarker-driven immunotherapy is critical for improving clinical outcomes with gastric cancer. There is still more work to be done in this field, and verifying developing biomarkers will be an important component in the future of customized cancer therapy.

Visor flap: A solution for the reconstruction of large skin defects on the frontal and parietal parts of the skull

BACKGROUND

Reconstruction of skin defects after oncological surgery for a cutaneous squamous cell carcinoma is often mandatory to facilitate adjuvant treatment and/or to prevent chronic wound problems. Some of the most challenging regions to reconstruct after resection of a skin tumor are the frontal and parietal parts of the skull.

METHODS

This article describes three patients with large skin defects after oncological surgery that were reconstructed with the use of a (hemi) visor flap.

RESULTS

The (hemi) visor flap is easy to harvest, resulting in a concise procedure and short hospitalization with maximum wound control.

CONCLUSION

The (hemi) visor flap is a safe and reliable option for the closure of large skin defects on the skull. Especially in the older and frail patient group.

Tumour budding as a risk factor for lymph node metastases in cutaneous squamous cell carcinoma: a systematic review and meta-analysis

BACKGROUND

Current staging systems have limitations in stratifying high-risk cutaneous squamous cell carcinoma (cSCC). Tumour budding (TB) has emerged as a potential prognostic factor in various cancers.

OBJECTIVES

To evaluate the prognostic significance of TB in predicting lymph node metastases (NM) in cSCC.

METHODS

A comprehensive search of the PubMed, Web of Science, Embase and Cochrane databases was conducted. Studies investigating the association of TB using a 5-bud cutoff and NM in cSCC were included. A meta-analysis was performed using odds ratios (OR) to evaluate the association between TB and NM.

RESULTS

Six retrospective studies comprising 793 patients with cSCC were included. The random-effects analysis showed a significant association between high TB (≥ 5 buds) and NM (OR = 13.29, 95% confidence interval 5.55-31.86).

DISCUSSION

TB is a promising histopathological feature for predicting NM in cSCC. The results show a strong association between high TB and NM, supporting its utility as a risk factor for NM in cSCC. Its inclusion in clinical practice and cSCC staging might be helpful in the stratification of patients with high-risk cases and to guide optimal management strategies for each patient. However, further investigation is needed to determine standardized reporting guidelines for TB in cSCC.

Successful Use of Cemiplimab in a Very Elderly Patient With Cutaneous Squamous Cell Carcinoma

Background/Aim

Cutaneous squamous cell carcinoma (SCC) is a common skin cancer with significant morbidity and mortality, particularly in advanced stages. Treatment options for metastatic cutaneous SCC in very elderly patients are limited due to concerns about treatment tolerability and potential adverse effects.

Case Report

We report the case of a 90-year-old female patient with metastatic cutaneous SCC who was treated with cemiplimab, a monoclonal antibody (m-Ab) against programmed cell death protein 1 (PD-1), in combination with radiotherapy. The patient received cemiplimab for a limited period, during which time she demonstrated significant clinical improvement without severe adverse events. Radiotherapy was performed as a locoregional treatment with the aim to enhance immunotherapy efficacy.

Discussion

This case highlights the feasibility and effectiveness of cemiplimab in very elderly patients with metastatic cutaneous SCC. Despite the common apprehensions regarding the use of immunotherapy in this age group, our patient tolerated cemiplimab well, and the combination with radiotherapy proved beneficial. This suggests that even in very elderly patients, short-term use of cemiplimab, in conjunction with locoregional treatments such as radiotherapy, can be a viable and successful therapeutic approach.

Conclusion

Cemiplimab, even in combination with radiotherapy, can be effectively and safely administered to very elderly patients with metastatic cutaneous SCC. This case supports the consideration of immunotherapy, even for a limited duration, as a practical option in the management of advanced cutaneous SCC in elderly patients, expanding the potential treatment strategies for this population.

Real-world evidence study on the early use of cemiplimab in the UK: REACT-CEMI (Real World evidence of advanced CSCC treatment with cemiplimab)

Background

Cemiplimab was licensed in the United Kingdom (UK) in 2019 for the treatment of patients with locally advanced and metastatic CSCC not suitable for curative surgery or radiotherapy (advanced CSCC [aCSCC]). No UK multi-center studies have investigated the real-world experience of cemiplimab post marketing authorization in aCSCC.

Methods

This non-interventional retrospective study (10 UK centers) involved data collection from medical records of patients with aCSCC who initiated cemiplimab treatment between 2 July 2019 and 30 November 2020. The study period was a minimum of 12 and a maximum of 36 months post cemiplimab initiation. The primary objective was to describe the real-world clinical effectiveness of cemiplimab (primary outcome: overall response rate [ORR]).

Results

Of 105 patients, 70% (n=73/105) were male (median [range] age at index of 78.5 [55.4-93.2] years); most patients (63% [n=50/80]) had an Eastern Cooperative Oncology Group (ECOG) score of 1 and 62% (n=63/102) had metastatic disease. The ORR within 12 months was 42% (95% confidence interval [CI] 32%-51%) and the disease control rate was 62% (n=65/105). The median (95% CI) real-world progression-free survival and overall survival from index was 8.6 (6.0-18.7) and 21.0 (14.7-25.2) months, respectively. The median (range) number of cemiplimab infusions was 11.0 (1.0-44.0). Eighty-seven percent experienced no cemiplimab treatment interruptions; 13% (n=14/105) interrupted treatment due to immune-related adverse reactions (irARs) (47% [n=9/19] of treatment interruption events). Eighty-five percent (n=89/105) of patients had discontinued cemiplimab treatment by the end of the study; where reasons for discontinuation were recorded, 20% (n=17/87) discontinued due to the completion of their 2-year treatment course. Nineteen percent (n=20/105) of patients experienced irARs.

Conclusion

Effectiveness and safety data in this study are broadly similar to previous real-world studies of cemiplimab and the EMPOWER-CSCC1 clinical trial; with our cohort representing a broader population (included immunocompromised and transplant patients). Results support the use of cemiplimab for the treatment of aCSCC in a real-world setting.

Real-World Experience of Immune-Checkpoint Inhibitors in Older Patients with Advanced Cutaneous Squamous Cell Carcinoma

BACKGROUND

Older patients are often underrepresented in clinical trials owing to exclusionary comorbidities, which are more common with age. Chemotherapy is poorly tolerated in older comorbid advanced cutaneous squamous cell carcinoma (CSCC) patients; however, little is known on the efficacy and tolerability of immune-checkpoint inhibitors (ICIs) in this population. To our knowledge, this is the largest dedicated report on a cohort of older patients with advanced CSCC treated with immunotherapy to date.

OBJECTIVE

The aim was to report outcomes of ICI use in a real-world older cohort with advanced CSCC.

PATIENTS AND METHODS

A single-centre retrospective audit of all patients treated via an access scheme providing ICIs to patients with advanced CSCC was conducted. Participants were ≥ 70 years of age and had advanced CSCC not amenable to curative surgery or radiotherapy. Best overall response rate (ORR), 12-month overall survival (OS) and progression-free survival (PFS), and toxicity rates were assessed.

RESULTS

A total of 53 patients were analysed. The median age was 81.8 years (range 70.1-96.8); 81% were male; 34% were immunocompromised; and 34% had an Eastern Cooperative Oncology Group (ECOG) performance status score of ≥ 2. The ORR was 57%, and 12-month OS and PFS were 63% (95% confidence interval [CI] 44-78) and 41% (95% CI 25-57), respectively. Thirty-two per cent developed an immune-related adverse event (irAE), but only two patients experienced a grade 3 irAE, with no treatment-related deaths. Higher ECOG score was associated with worse OS and PFS. No significant association was identified for increasing age, sex, Charlson Comorbidity Index score, or immunocompromised status.

CONCLUSIONS

ICIs have demonstrated efficacy and have an acceptable safety profile among older patients with advanced CSCC, with comparable efficacy to what has been demonstrated in current clinical trials.