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

Brown B, Chan TA, Chand D, Constanzo J, Demaria S, I. Gabrilovich D, Golden E, Godkin A, Guha C, P. Gupta G, Hasan A, G. Herrera F, Kaufman H, Li D, A. Melcher A, McDonald S, Merghoub T, Monjazeb AM, Paris S, Pitroda S, Sadanandam A, Schaue D, Santambrogio L, Szapary P, Sage J, W. Welsh J, Wilkins A, H. Young K, Wennerberg E, Zitvogel L, Galluzzi L, Deutsch E, C. Formenti S. Updates on radiotherapy-immunotherapy combinations: Proceedings of 8th Annual ImmunoRad Conference

The annual ImmunoRad Conference has established itself as a recurrent occasion to explore the possibility of combining radiation therapy (RT) and immunotherapy (IT) for clinical cancer management. Bringing together a number of preclinical and clinical leaders in the fields of radiation oncology, immuno-oncology and IT, this annual event fosters indeed essential conversations and fruitful exchanges on how to address existing challenges to expand the therapeutic value of RT-IT combinations. The 8th edition of the ImmunoRad Conference, which has been held in October 2024 at the Weill Cornell Medical College of New York City, highlighted exciting preclinical and clinical advances at the interface between RT and IT, setting the stage for extra progress toward extended benefits for patients with an increasing variety of tumor types. Here, we critically summarize the lines of investigation that have been discussed at the occasion of the 8th Annual ImmunoRad Conference.

Chemoimmunotherapy as induction treatment in concurrent chemoradiotherapy for patients with nasopharyngeal carcinoma stage IVa

BACKGROUND

Chemoimmunotherapy is the first-line therapy for patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) and is currently the main induction treatment option for patients with locoregionally advanced NPC. However, it remains unclear whether combining immunotherapy with standard induction chemotherapy enhances its efficacy. This study aimed to evaluate the efficacy, toxicity, and survival outcomes of induction chemoimmunotherapy in patients with locoregionally advanced NPC.

METHODS

This study analyzed 50 patients with stage IVa NPC between January 2020 and December 2023 in our hospital. Among them, 23 received induction chemoimmunotherapy, and 27 received induction chemotherapy. All patients underwent standard platinum-based concurrent intensity-modulated radiation therapy. We compared tumor response and toxicity during induction treatment and concurrent chemoradiotherapy (CCRT) between the two groups.

RESULTS

The objective and complete response rates were significantly higher in the induction chemoimmunotherapy group compared to the induction chemotherapy group (95.7% vs 77.8%, and 39.1% vs 22.2%, respectively). All patients completed radical CCRT. Median follow-up was 24 months. Patients who received induction chemoimmunotherapy had longer event-free survival (EFS) compared to those who received induction chemotherapy (p = 0.029, Hazard Ratio and 95%confidence interval [CI]: 0.24 [0.07-0.85]). The 24-month EFS was higher in the induction chemoimmunotherapy group compared with the chemotherapy group (24-month EFS rates and 95%CI: 88.9% [95%CI: 68.3%-100%] vs 62.6% [95%CI: 43.1%-82.1%]). No significant differences in adverse events were observed between the two groups during induction treatment and CCRT.

CONCLUSIONS

Adding immunotherapy to induction chemotherapy may be an effective and safe choice for treating patients with stage IVa NPC.

MK2 promotes p16 negative head and neck cancer migration, invasion, and metastasis

For patients with locally advanced, p16-negative head and neck squamous cell carcinoma (HNSCC), overall survival remains poor due to primary locoregional failure and distant metastasis following curative therapy. We aimed to understand how MAPKAPK2 (MK2) regulates HNSCC tumor cell migration and invasion, important first steps in cancer metastases. The TCGA database and HNSCC tissue microarrays were used to show that MK2 expression was associated with more advanced cancers and faster cancer recurrence rates. We observed that silencing of tumor MK2 in human cell lines (shRNA) caused a significant reduction in tumor cell migration-invasion in a complex HNSCC microphysiologic system used to recapitulate the tumor microenvironment. Murine cells (Ly2) with MK2 silenced (CRISPR-Cas9) also demonstrated reduced migration and invasion using 2D and 3D monoculture cell migration-invasions assays. Ly2 cells are orthotopic p16-negative murine metastatic cells that spontaneously metastasize, and we observed that MK2 inhibition via genetic (Cas9/CRISPR) or pharmacologic (PF-3644022) methods led to a significant reduction in the number of circulating tumor cells, fewer lymph node and lung metastases, and MK2 inhibited mice showed improved overall survival. Our findings suggest that HNSCC MK2 regulates tumor cell migration-invasion and may be a promising therapeutic target to reduce metastases.

Extracellular vesicles as the common denominator among the 7 Rs of radiobiology: From the cellular level to clinical practice

Extracellular vesicles (EVs) are lipid-bound particles released by tumor cells and widely explored in cancer development, progression, and treatment response, being considered as valuable components to be explored as biomarkers or cellular targets to modulate the effect of therapies. The mechanisms underlying the production and profile of EVs during radiotherapy (RT) require addressing radiobiological aspects to determine cellular responses to specific radiation doses and fractionation. In this review, we explore the role of EVs in the 7 Rs of radiobiology, known as the molecular basis of a biological tissue response to radiation, supporting EVs as a shared player in all the seven processes. We also highlight the relevance of EVs in the context of liquid biopsy and resistance to immunotherapy, aiming to establish the connection and utility of EVs as tools in contemporary and precision radiotherapy.

Partial versus whole tumor-volume irradiation in combination with immunotherapy: Comparable outcomes in immunosuppressed mouse models of oral squamous cell carcinoma

Radiotherapy is a standard therapy for oral squamous cell carcinoma (OSCC) with immunomodulatory potential. Due to high lymphocyte radiosensitivity, partial tumor-volume irradiation (pIR), targeting only part of the tumor, is being explored for immunomodulation. This study compared the effects of whole tumor-volume irradiation (IR) and pIR, targeting approximately 50 % of the tumor volume, in combination with anti-PD-1 immune checkpoint inhibitors (ICI). The therapeutic efficacy of a single 15 Gy IR or pIR dose combined with anti-PD-1 ICI was evaluated in two immune cold murine OSCC models: human papillomavirus (HPV)-negative MOC1 and HPV-positive MOC1-HPV K1 stably expressing HPV-16 oncogenes E6/E7. Additionally, immune cell populations in the tumor microenvironment (TME) were analyzed using flow cytometry. Both IR and pIR induced transient immune cell infiltration in the TME. However, pIR led to significantly lower tumor growth inhibition than IR. While IR + ICI failed to improve survival compared to IR alone, pIR + ICI significantly prolonged survival compared to pIR alone in the MOC1 model, along with increase in cytotoxic T cell infiltration. In the MOC1-HPV K1 model, responses varied. Responding tumors were enriched with effector memory T cells, whereas non-responders exhibited increased neutrophil (MDSCs) and monocyte-derived dendritic cells infiltration. The study indicates that while pIR has immunomodulatory potential, its effects are comparable to IR in the tested settings. Further research is needed to optimize dosing and scheduling for pIR and anti-PD-1 ICI. Additionally, combination with other immunotherapies could be explored in further studies to enhance treatment efficacy in immune cold OSCC models.

Randomized Phase II Study of Concurrent Versus Sequential Pembrolizumab in Combination With Chemoradiation in Locally Advanced Head and Neck Cancer

PURPOSE

The optimal timing of pembrolizumab with chemoradiation (CRT) in locally advanced (LA) head and neck squamous cell carcinoma (HNSCC) is unknown.

PATIENTS AND METHODS

Our phase II trial randomly assigned patients 1:1 to concurrent pembrolizumab (200 mg once every 3 weeks × 8) starting 1 week before CRT (cisplatin 40 mg/m2 once weekly + radiation 70 Gy) versus sequential pembrolizumab starting 2 weeks after CRT. Human papillomavirus (HPV)+ (>10 pack-years or T4 or N3) and HPV(-) LA HNSCC were included, stratified by HPV and N stage. In our pick-the-winner design, if both arms met the trivariate primary end point (1-year locoregional failure <60%, progression-free survival [PFS] ≥60%, and dose limiting toxicity rate ≤20%), the arm with numerically superior 1-year PFS would be selected. Survival end points were compared by a univariate Cox model. Pretreatment and on-treatment tumor biopsies (week 2 of CRT) were evaluated by multispectral imaging and compared using two-sided paired t-tests.

RESULTS

Treated patients (41 concurrent and 39 sequential) were 71% oropharynx (53% HPV+), 92.5% stage IV (46% T4, 76% N2), similar by arm. Both arms met the trivariate primary end point, with superior 1-year PFS in the sequential arm (84% v 71%) and favorable 4-year outcomes: locoregional control (96% v 64%; hazard ratio [HR], 0.11 [95% CI, 0.01 to 0.89]; P = .012), PFS (69% v 49%; HR, 0.55 [95% CI, 0.25 to 1.22]; P = .132), and overall survival (83% v 71%; HR, 0.51 [95% CI, 0.19 to 1.37]; P = .17). There was a significant increase in macrophages, PD-L1+ macrophages, and PD-L1+ tumor cells with treatment in the concurrent but not the sequential arm.

CONCLUSION

CRT with sequential pembrolizumab met criteria for further study. Immunosuppressive changes in the TME differed between arms, reflecting the impact of one dose of pembrolizumab in the concurrent arm.

Combining Radiotherapy with Immune Checkpoint Inhibitors for the Management of Muscle-Invasive Bladder Cancer: A Comprehensive Systematic Review from the Y-ECI ROSC EORTC group

OBJECTIVE

This review aims to evaluate the efficacy and safety of combining immune checkpoint inhibitors (ICI) with RT in the treatment of non-metastatic MIBC, focusing on neoadjuvant and bladder preservation strategies.

EVIDENCE ACQUISITION

A systematic literature review was conducted from January 2000 to December 2023 using PubMed and Clinicaltrials.gov databases. Studies investigating outcomes after combining immunotherapy with RT for non-metastatic MIBC were selected. Data extraction included study identifiers, patient characteristics, intervention and control arm details, and primary outcomes.

EVIDENCE SYNTHESIS

Among 28 selected studies, diverse approaches were observed, including neoadjuvant and bladder preservation strategies. Neoadjuvant trials, such as RACE IT, explored the feasibility of combining ICI with RT before radical cystectomy, showing promising efficacy and safety outcomes. In bladder preservation strategies, completed as well as ongoing trials demonstrated acceptable toxicity profiles and promising early efficacy data for combining ICI with chemoradiotherapy or RT alone.

CONCLUSION

Combining ICI with RT holds significant promise as a treatment strategy for non-metastatic MIBC. Preliminary evidence suggests favorable efficacy and safety profiles, supporting further exploration and potential integration into standard care. Ongoing phase III trials will provide crucial insights into the comparative effectiveness of adding ICI to conventional definitive treatments. In the evolving landscape of MIBC management, the combination of ICI and RT has the potential to reshape therapeutic paradigms and improve outcomes for patients.

Carbon ion irradiation mobilizes antitumor immunity: from concept to the clinic

Carbon ion radiotherapy (CIRT), a type of particle therapy, is at the forefront of clinical oncology treatments due to its superior physical properties and biological performance. Although CIRT has demonstrated outstanding therapeutic outcomes in clinical settings, the biological mechanisms underpinning its effects, particularly its immunogenic potential and the superiority of its induced antitumor immune response compared to photon radiotherapy, remain areas of active investigation. This review summarizes the latest research progress on the mechanisms of antitumor immune responses triggered by CIRT and discusses preclinical and clinical studies related to combined CIRT and immunotherapy (CCIT). Against the backdrop of extensive research and significant clinical efficacy achieved by combining radiotherapy with immunotherapy, this review provides a theoretical foundation for a better understanding of the superior tumor cell-killing effects of CIRT and the underlying immunological mechanisms. Further insights into the factors affecting the efficacy, toxic effects, and developmental limitations of this combination therapy mode will be instrumental in guiding the conduction of CCIT studies.

High-Sensitivity PD-L1 Staining Using Clone 73-10 Antibody and Spatial Transcriptomics for Precise Expression Analysis in Non-Tumorous, Intraepithelial Neoplasia, and Squamous Cell Carcinoma of Head and Neck

PURPOSE

While immune checkpoint inhibitors (ICIs) targeting the PD-1/PD-L1 axis have improved outcomes in head and neck squamous cell carcinoma (HNSCC), eligibility criteria based on immunohistochemistry (IHC) target PD-1 solely. We aimed to evaluate the PD-L1 (CD274) expression using highly sensitive clone 73 - 10 and spatial transcriptomics (ST) analysis to elucidate the role of PD-L1 in HNSCC and thus potentially expand the pool of eligible patients.

METHODS

Immunohistochemical staining of 73 - 10, CD3, CD4, and CD8 were performed in 94 HNSCC clinical samples along with paired adjacent squamous intraepithelial neoplasm (SIN) and normal oral mucosa (NOM) samples. The 73 - 10 positivity was evaluated using a tumor cell score ≥ 1%, and the results were analyzed against clinicopathological features including CD4+ and CD8+ tumor-infiltrating lymphocytes (TILs), and clinical outcomes. Furthermore, ST and PD-L1 related pathway analysis was performed in 6 paired HNSCC, SIN and NOM samples.

RESULTS

The 73 - 10 detected-PD-L1 positivity was high in HNSCC (79%) compared to SIN (10%) and NOM (3%). 73 - 10+ correlated with high CD4+ TILs, as well as the independent prognostic factor of OS, DSS, and PFS of HNSCC (all p < 0.05). ST analysis revealed that the upregulated distribution of CD274 correlated with 73 - 10 positivity. Pathway analysis revealed a significant upregulation of CD274 and CD4 in HNSCC compared to SIN and NOM, and HIF-1α and IFN-γ as key regulators of PD-L1 expression in HNSCC.

CONCLUSION

Clone 73 - 10 is a relatively suitable candidate for identifying patients with PD-L1 expression eligible for ICI therapy. It demonstrates high sensitivity in detecting PD-L1 (CD274) in HNSCC, offering immunological and prognostic insights.

CD8+ T cells in patients with hypopharyngeal squamous cell carcinoma are susceptible to radiation-induced damage

Radiotherapy (RT) is a commonly used clinical management for hypopharyngeal squamous cell carcinoma (HPSCC), which represents the most unfavorable prognosis among all subtypes of head and neck squamous cell carcinoma. However, radiation may cause lymphopenia, a significantly adverse event with detrimental prognostic implications for patients. While CD8+ T cells are vital in tumor immunity, the specific effects of RT on CD8+ T cells as well as the underlying mechanisms have not been clearly elucidated. Here we found that subpopulations of peripheral T lymphocytes exhibited differential profiles in patients with HPSCC compared to healthy individuals both pre- and post-irradiation. Importantly, CD8+ T cells from HPSCC patients showed greater reduction of cytokine production, more severe proliferation defect, and increased apoptosis compared to those from healthy individuals after in vitro irradiation. Mechanistically, the ATM-Chk2 pathway mediated the enhanced apoptosis of CD8+ T lymphocytes from HPSCC patients upon irradiation. Therefore, our study demonstrated that CD8+ T cells in patients with HPSCC exhibit a higher susceptibility to radiation-induced damage compared to those in healthy individuals. The ATM-Chk2 pathway represents a potential immunotherapeutic target for safeguarding CD8+ T cells in HPSCC patients against radiation-induced apoptosis.

Radiation Dose-Volume Effects on Negative Tumor-Draining Lymph Nodes Affected T-cell Activation and Prognosis in Esophageal Cancer with Chemoradiotherapy

PURPOSE

A preclinical model found that elective nodal irradiation attenuated the efficacy of radiotherapy (RT) and radio-immunotherapy. However, limited clinical studies have explored the correlation between radiation dose-volume parameters of negative tumor-draining lymph nodes (TDLN) and T-cell activation/prognosis for patients with cancer treated with definitive radiochemotherapy.

EXPERIMENTAL DESIGN

Patients with locally advanced esophageal cancer undergoing definitive chemoradiotherapy (CRT) were selected from two prospective trials. Dose-volume parameters of TDLN as well as other lymphocyte-related organs at risk and lymphocyte subsets such as CD3-CD19+ B cells, CD8+CD28+ T cells, and activated T cells (CD3+CD8+HLA-DR+) before and at the end of RT were collected. Logistic analysis was utilized to correlate dose-volume parameters with reductions in lymphocyte subsets. Prognosis of TDLN irradiation was investigated through Kaplan-Meier analysis and Cox hazards models.

RESULTS

Among 512 patients, the median mean dose of TDLN and negative non-TDLN was 25.6 and 15.1 Gy, respectively. Multivariable analyses indicated that TDLN V15 >50% was an independent predictor of poorer local recurrence-free survival (HR, 1.31; P = 0.029) and distant metastasis-free survival (HR, 1.39; P < 0.001), as well as greater reductions in CD3-CD19+ B cells (OR, 1.98; P = 0.002), CD8+CD28+ T cells (OR, 3.42; P < 0.001), and CD3+CD8+HLA-DR+ T cells (OR, 4.67; P = 0.002) after RT.

CONCLUSIONS

A higher radiation dose-volume parameter of TDLNs in patients with esophageal cancer undergoing CRT was significantly associated with suppression of T-cell activation and a worse prognosis. Limiting the percentage of TDLN V15 may be beneficial for improving the prognosis of CRT with or without PD-1 inhibitors.

Adjuvant PD-1 Blockade With Camrelizumab for Nasopharyngeal Carcinoma: The DIPPER Randomized Clinical Trial

Importance

Approximately 20% to 30% of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) experience disease relapse despite definitive chemoradiotherapy. The programmed cell death 1 (PD-1) blockade camrelizumab has demonstrated considerable value in recurrent or metastatic NPC, while its role in locoregionally advanced NPC is unclear.

Objective

To evaluate the efficacy and safety of adjuvant camrelizumab for patients with locoregionally advanced NPC.

Design, Setting, and Participants

Randomized, open-label, multicenter, phase 3 clinical trial conducted from August 2018 to November 2021 at 11 centers in China and enrolling 450 patients with T4N1M0 or T1-4N2-3M0 NPC who had completed induction-concurrent chemoradiotherapy. The final date of follow-up was March 20, 2024.

Interventions

Patients were randomized (1:1) to receive adjuvant camrelizumab (200 mg intravenously once every 3 weeks for 12 cycles; n = 226) or observation (standard therapy group; n = 224).

Main Outcomes and Measures

The primary end point was event-free survival (freedom from distant metastasis, locoregional relapse, or death due to any cause). Secondary end points included distant metastasis-free survival, locoregional relapse-free survival, overall survival, safety, and health-related quality of life.

Results

Among the 450 participants (mean age, 45 [SD, 10] years; 24% women), after a median follow-up of 39 (IQR, 33-50) months, the camrelizumab group had a 3-year event-free survival rate of 86.9%, whereas the standard therapy group had a rate of 77.3% (stratified hazard ratio, 0.56; 95% CI, 0.36-0.89; P = .01). Grade 3 or 4 adverse events were reported in 23 patients (11.2%) in the camrelizumab and 7 (3.2%) in the standard therapy group. Reactive capillary endothelial proliferation was the most common adverse event related to camrelizumab, occurring in 85.8% of patients at grade 1 or 2, while 2% of patients had grade 3 or 4 events. There was no significant deterioration in quality of life associated with camrelizumab treatment.

Conclusions and Relevance

Adjuvant PD-1 blockade with camrelizumab significantly improved event-free survival with manageable toxicities, highlighting its potential role in the management of locoregionally advanced NPC.

Trial Registration

ClinicalTrials.gov Identifier: NCT03427827.

Atezolizumab in High-Risk Locally Advanced Squamous Cell Carcinoma of the Head and Neck: A Randomized Clinical Trial

Importance

Treating locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) involves any combination of surgery, radiation, and chemotherapy, followed by routine monitoring for local recurrence or distant metastases. Given the poor patient outcomes, a significant unmet clinical need for improved treatment options remains.

Objective

To evaluate efficacy and safety of maintenance atezolizumab in patients with LA SCCHN at high risk of disease progression after multimodal definitive treatment.

Design, Setting, and Participants

IMvoke010 was a phase 3, global, double-blind, randomized clinical trial. Patients were recruited at 128 sites in 23 countries between April 3, 2018, and February 14, 2020 (clinical cutoff date: September 27, 2023). Eligible patients had LA SCCHN (stage IVa/IVb involving the oral cavity, larynx, hypopharynx, or human papillomavirus-negative oropharynx, or stage III human papillomavirus-positive oropharynx [AJCC Cancer Staging Manual, eighth edition]) without disease progression after multimodal definitive treatment.

Intervention

Patients were randomized (1:1) to receive atezolizumab 1200 mg or placebo every 3 weeks for 1 year or until disease recurrence, disease progression, unacceptable toxicity, or consent withdrawal.

Main Outcomes and Measures

The primary end point was investigator-assessed event-free survival. Other end points included overall survival and safety.

Results

Overall, 406 patients were randomized to receive atezolizumab (n = 203) or placebo (n = 203); baseline demographics were balanced between both treatment groups (<65 years, 142 [70.0%] vs 155 [76.4%]; male, 168 [82.8%] vs 174 [85.7%]; Asian, 68 [35.6%] vs 61 [31.0%]; Black, 1 [0.5%] vs 1 [0.5%]; and White, 121 [63.4%] vs 135 [68.5%], respectively). At clinical cutoff (median follow-up, 46.5 months), median investigator-assessed event-free survival was 59.5 months (95% CI, 46.8 to not estimable) with atezolizumab vs 52.7 months (95% CI, 41.4 to not estimable) with placebo (hazard ratio, 0.94; 95% CI, 0.70-1.26; P = .68). There was no difference in overall survival between atezolizumab and placebo (24-month overall survival, 82.0% vs 79.2%, respectively). No new or unexpected safety signals were identified.

Conclusions and Relevance

In this study, atezolizumab did not improve clinical outcomes in patients with LA SCCHN at high risk of disease progression after multimodal definitive treatment. These data contribute to evidence on the limited activity of checkpoint inhibitors in the global population of this disease setting. Overall, the role of immunotherapy for patients with LA SCCHN remains to be determined.

Trial Registration

ClinicalTrials.gov Identifier: NCT03452137.

Nivolumab combined with induction chemotherapy and radiotherapy in nasopharyngeal carcinoma: A multicenter phase 2 PLATINUM trial

Severe toxicities caused by concurrent cisplatin are a critical problem in nasopharyngeal carcinoma (NPC) treatment. In this phase 2 multicenter PLATINUM trial (NCT03984357), we recruited 152 NPC patients who received 12-cycle nivolumab plus induction chemotherapy and radiotherapy without concurrent cisplatin. After a median follow-up of 43 months, the 3-year failure-free survival (FFS) was 88.5% (95% confidence interval [CI], 83.4%-93.8%) and the 3-year overall survival was 97.9%. An early clearance of Epstein-Barr virus (EBV) DNA after induction-phase treatment was associated with FFS benefit. Sixty (40.2%) and eight (5.2%) patients had acute and late grade 3-4 adverse events (AEs), respectively. Most patients had good tolerance to AE-associated frequency (68.0%-96.7%), severity (56.0%-98.6%), and interference (58.0%-98.0%); 86.7%-100.0% of quality-of-life domains showed either no clinically meaningful deterioration or a rapid recovery. Nivolumab plus induction chemotherapy and radiotherapy demonstrated efficacious anti-tumor activity, low toxicity, and favorable tolerability and quality-of-life for NPC patients.

Laryngeal Cancer in the Modern Era: Evolving Trends in Diagnosis, Treatment, and Survival Outcomes

Background/Objectives: Laryngeal cancer (LC), predominantly squamous cell carcinoma (SCC), represents a considerable health burden worldwide. Tumour subsite heterogeneity (supraglottic, glottic, subglottic) influences clinical behavior and outcomes. This review synthesizes current knowledge on epidemiology, risk factors, diagnostics, histological variants, biomarkers, treatment modalities, and survival. Results: This narrative review synthesizes current literature on the epidemiology, risk factors, diagnosis, histological variants, biomarkers, and prognosis of LC. The review highlights the critical influence of tumour sites (supraglottic, glottic, subglottic) on metastatic patterns and survival. Key risk factors of LC include tobacco and alcohol use, human papillomavirus (HPV) infection, and occupational exposures. The diagnostic process encompasses clinical examination, endoscopy, biopsy, and imaging. Several biomarkers that aid in diagnosis, treatment plan determination, and prognosis prediction have been established. These biomarkers include long noncoding RNAs, cell cycle regulators, apoptosis regulators, oncogenes, tumour suppressor genes, growth factor pathway components, angiogenic factors, structural proteins, sex hormone receptors, and immunological markers. Current treatment modalities range from organ-preserving surgery and radiotherapy to combined chemoradiotherapy and total laryngectomy. Finally, survival data are presented and stratified by stage and subsite. Conclusions: The review underscores the need for a multidisciplinary approach to LC management, integrating clinical, pathological, and molecular information to optimize patient outcomes.

Xevinapant plus avelumab in advanced solid tumours, with a dose expansion in advanced non-small-cell lung cancer: exploratory biomarker, safety and efficacy analyses from an open-label, nonrandomised phase Ib study

Background

Xevinapant, an inhibitor of apoptosis protein (IAP) inhibitor, has shown promising activity in combination with anticancer agents, including radiotherapy, and, in preclinical studies, anti-PD-(L)1 antibodies. This, in part, is due to its ability to restore apoptosis and increase antitumour immunity.

Objectives

We report efficacy, safety and exploratory biomarker analyses of xevinapant plus avelumab (anti-PD-L1) in a two-part, open-label, nonrandomised, phase Ib study.

Design

Part A assessed patients with advanced solid tumours who received xevinapant (100, 150, 200 or 250 mg/day, with no random allocation, on Days 1-10 and 15-24) in combination with avelumab (10 mg/kg) on Days 1 and 15 in 28-day cycle. Part B assessed patients with advanced non-small-cell lung cancer (NSCLC) who received xevinapant at the recommended phase II dose (RP2D) plus avelumab (maximum 26 cycles).

Methods

Part A assessed the safety and tolerability of the combination and established the maximum tolerated dose (MTD) and RP2D of xevinapant. Part B assessed the antitumour activity of xevinapant at the RP2D combined with avelumab compared with a historical control (avelumab alone). Exploratory biomarker analyses were also conducted.

Results

In part A (n = 16), xevinapant 200 mg/day was established as the RP2D with avelumab and the MTD was not reached. The most common treatment-emergent adverse events (TEAEs) irrespective of xevinapant dose were nausea and fatigue (n = 11 (68.8%) each). In part B (n = 38; four patients received prior anti-PD-(L)1 antibody), the objective response rate (ORR) was 10.5% (95% confidence interval (CI), 2.9-24.8; partial response, n = 4) and the most common TEAE was decreased appetite (n = 13 (34.2%)). Levels of plasma IL-10, IL-1β, IL-13 and CD8+ T cells increased during the study, and circulating levels of CD4+ T cells and Tregs increased during cycle 1. Macrophage-related gene expression signatures increased in patients with a partial response or stable disease. Low baseline Ki-67 expression in tumour samples correlated with a partial response.

Conclusion

The RP2D of xevinapant with avelumab was established; however, the ORR was not superior to the historical control (avelumab alone). The combination had a manageable safety profile in both study parts. Biomarker analyses provide insights into drivers associated with efficacy in patients with NSCLC receiving xevinapant plus avelumab.

Trial registration

NCT03270176 (https://clinicaltrials.gov/study/NCT03270176). Registered on ClinicalTrials.gov on 29 August 2017.

Effects of Cisplatin on the Radiation Response and DNA Damage Markers in Peripheral Blood Lymphocytes Ex Vivo

Platinum-based radiochemotherapy is associated with hematologic side effects, impacting patient outcomes. However, the clinical mechanisms of cisplatin and its interaction with ionizing radiation (IR), including in biodosimetry for radiotherapy, have not yet been fully clarified. For this purpose, healthy donors' peripheral blood lymphocytes (PBLs) were pretreated with cisplatin in a pulse (1-4 h) or continuous (24 h) regimen followed by X-rays. DNA damage was assessed as DNA double-strand breaks using repair foci of γH2AX and 53BP1 after 0.5 h and 24 h in G1 PBLs and a proliferation-based cytokinesis-block micronucleus assay. Additionally, cell death and proliferation activity were measured. Unlike a 1 h pulse, a 24 h cisplatin pretreatment caused a concentration-dependent increase in cisplatin-induced foci while decreasing IR-induced foci, especially 24 h after irradiation. This was accompanied by increased apoptosis, with cisplatin and IR having additive effects. Both genotoxins alone caused a dose-dependent increase in micronuclei, while cisplatin significantly reduced binuclear cells, especially after the 24 h treatment, leading to lower micronuclei frequencies post-irradiation. Our results show that prolonged cisplatin exposure, even at low concentrations, impacts the vitality and division activity of PBLs, with significantly stronger effects post-irradiation. This has major implications and must be considered for the detection of DNA damage-associated biomarkers in PBLs used in clinical prediction or biodosimetry during radiotherapy.

Neoadjuvant Nivolumab Plus Chemotherapy Followed by Response-Stratified Chemoradiation Therapy in HPV-Negative Head and Neck Cancer: The DEPEND Phase 2 Nonrandomized Clinical Trial

Importance

Neoadjuvant immunotherapy in human papillomavirus (HPV)-negative locoregionally advanced (LA) head and neck squamous cell carcinoma (HNSCC) appears promising, yet its role in nonsurgical treatment for head and neck cancer remains undefined. Neoadjuvant nivolumab plus chemotherapy followed by response-stratified de-escalated chemoradiation therapy (CRT) in HPV-negative LA stage IVa/b HNSCC may improve treatment efficacy while reducing treatment-related toxic effects.

Objective

To determine the deep response rate and tolerability of neoadjuvant nivolumab plus chemotherapy followed by response-stratified CRT in nonvirally mediated stage IVa/b HNSCC.

Design, Setting, and Participants

In this investigator-initiated phase 2 nonrandomized clinical trial conducted at a single academic center, patients with stage IVa/b (American Joint Committee on Cancer Tumor Classification, 8th edition) HPV-negative LA HNSCC were enrolled between 2019 and 2022. Data were analyzed from February 2023 to January 2024.

Interventions

The DEPEND trial evaluated neoadjuvant nivolumab plus carboplatin and paclitaxel, followed by response-stratified CRT. Patients with 50% or greater reduction per Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 received de-escalated CRT to 66 Gy with elimination of elective nodal volumes; patients with less than 50% reduction received standard CRT to 70 to 75 Gy. Adjuvant nivolumab was administered for 9 cycles.

Main Outcomes and Measures

The primary end point was deep response rate (DRR; 50% or greater shrinkage per RECIST version 1.1) following neoadjuvant nivolumab plus chemotherapy. Secondary end points included progression-free survival (PFS), overall survival (OS), locoregional control, and distant control. Exploratory end points included acute toxic effects in patients who received response-adapted de-escalated CRT.

Results

Of 36 included patients, 28 (78%) were male, and the median (range) age was 58.9 (27-77) years. All patients started treatment and were available for analysis. The median (range) follow-up was 20 (13-40) months. The primary end point was met, with a DRR following neoadjuvant nivolumab/chemotherapy of 53% (95% CI, 35-70). The objective response rate was 86% (95% CI, 71-95). A total of 19 received de-escalated CRT and 16 received standard CRT. PFS and OS at 2 years were 66% (95% CI, 34-76) and 73% (95% CI, 52-86), respectively. The most common treatment-emergent adverse events for de-escalated and standard CRT were mucositis (14 of 19 [74%] and 15 of 16 [94%], respectively), radiation dermatitis (13 of 19 [68%] and 14 of 16 [88%], respectively), and dry mouth (7 of 19 [37%] and 10 of 16 [63%], respectively).

Conclusions and Relevance

In this phase 2 nonrandomized clinical trial, neoadjuvant nivolumab/chemotherapy led to deep responses in 53% of patients with HPV-negative LA stage IVa/b HNSCC, and response-adapted de-escalated CRT led to favorable survival with lower acute toxic effects among deep responders.

Trial Registration

ClinicalTrials.gov Identifier: NCT03944915.

Neoadjuvant chemoradiotherapy plus sequential tislelizumab followed by surgery for esophageal carcinoma (CRISEC study): A single-arm, bicentric, phase 2 trial

BACKGROUND AND PURPOSE

To explore the efficacy and safety of neoadjuvant chemoradiotherapy (NCRT) plus sequential tislelizumab followed by surgery for esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

This single-arm, bicentric, phase 2 trial enrolled patients with resectable or potentially resectable thoracic ESCC to receive neoadjuvant radiotherapy (41.4 Gy in 23 fractions) with concurrent chemotherapy (albumin-bound paclitaxel, 50-100 mg/m2, and carboplatin, area under the curve of 2 mg/ml/min, once weekly, five times) plus sequential tislelizumab (200 mg Q3W, three cycles) followed by surgery. The primary endpoint was pathologic complete response (pCR) rate. The secondary endpoints included safety, R0 resection rate, major pathologic response (MPR) rate, disease-free survival (DFS), and overall survival (OS).

RESULTS

Of the 30 patients enrolled from January 2021 to October 2022, 24 (80.0 %) completed planned surgery and gained R0 resection (100 %). Among the 24 patients, nine (37.5 %) achieved pCR and 21 (87.5 %) achieved MPR. Ten patients (35.7 %) developed grade 3-4 toxicities during tislelizumab therapy, including lymphopenia (32.1 %), neutropenia (3.6 %), and thrombocytopenia (3.6 %). Grade 5 hematemesis occurred in two patients and both were attributed to aortic invasion. Three patients (12.5 %) developed grade 3 postoperative complications, including pulmonary infection (8.3 %) and hoarseness (4.2 %). After a median follow-up of 35.4 months, the 2-year OS and DFS rates were 83.3 % and 79.2 %, respectively.

CONCLUSION

Sequential tislelizumab after NCRT in ESCC is safe and feasible. Further study is warranted to validate the efficacy of this combination mode.

Current Progress and Future Directions of Immunotherapy in Head and Neck Squamous Cell Carcinoma: A Narrative Review

Importance

For decades, the 3 therapeutic pillars for head and neck squamous cell carcinoma (HNSCC) have been radiation therapy, chemotherapy, and surgery. In recent years, a fourth pillar, immunotherapy, has shifted the existing paradigm of oncologic care by improving survival outcomes. This narrative review highlights key completed and ongoing clinical trials that have led to new therapeutic approaches and are aiming to further alter the current standard of care.

Observations

Immunotherapy in HNSCC first saw success in phase 3 clinical trials with immune checkpoint inhibitors (ICIs) for programmed cell death 1 protein in patients with recurrent or metastatic (R/M) disease. However, only approximately 15% to 20% of patients with R/M HNSCC achieve durable responses. Subsequent trials aimed to broaden ICIs to the definitive or curative setting, in combination with established chemoradiation modalities. These studies have yielded disappointing results, raising concerns that concurrent administration of ICI with chemoradiation- or radiation-induced attenuation of immune responses may contribute to lack of efficacy. Therefore, recent studies have attempted to introduce ICI sequentially, either prior to standard of care surgery in the neoadjuvant setting or following definitive treatment in the adjuvant or maintenance setting. These trials have demonstrated mixed results but with promising initial results from early phase neoadjuvant trials demonstrating early signals of response. Further trials are currently underway with various combinatorial approaches in the neoadjuvant and adjuvant settings to assess response rates and survival.

Conclusions and Relevance

The introduction of ICIs has brought a dramatic shift in the treatment landscape of HNSCC. Completed trials have provided new hope for patients, but failures in several settings suggest that further studies based on a biologic understanding of immune responses are required to expand immunotherapeutic approaches.

Tumor Asphericity in FDG PET Is an Independent Prognostic Parameter Improving Risk Stratification in Patients with Head and Neck Squamous Cell Carcinoma

Tumor asphericity in 18F-FDG PET is a prognostic marker that has been investigated in small pilot studies of patients with head and neck squamous cell carcinoma (HNSCC). Here, we investigated the prognostic role of asphericity in a large multicenter database of patients with HNSCC treated with primary radiotherapy or chemoradiation and assessed its independent prognostic value. Methods: In total, 1,104 patients were included in this analysis. All received pretreatment 18F-FDG PET scans. Clinical risk factors were evaluated, and quantitative PET parameters SUVmax, metabolic tumor volume (MTV), total lesion glycolysis, and asphericity were calculated. Primary study endpoints were overall survival (OS) and locoregional control (LRC). Uni- and multivariate Cox regression analyses were performed. Additionally, asphericity was combined with the best-established quantitative PET parameter of MTV, and the combinatory approach of using asphericity and MTV was compared with the use of only asphericity or MTV by bootstrap analyses. Results: Asphericity showed only a modest correlation with the established PET parameters of MTV, SUVmax, and total lesion glycolysis. On univariate testing asphericity was strongly associated with the outcome of patients (LRC and OS with P < 0.001). In multivariate testing of all imaging parameters that were not highly correlated, both MTV and asphericity showed a significant association with LRC (P < 0.001 for MTV and P = 0.021 for asphericity) and OS (P < 0.001 for MTV and asphericity). Asphericity and MTV were binarized and combined for risk stratification, and the prognostic value of the combination was compared with the prognostic value of individual parameters. Bootstrapping revealed significantly better performance by the combinatory approach when compared with MTV (P = 0.012 for LRC and P < 0.001 for OS) and asphericity with regard to OS (P < 0.001) but not for LRC (P = 0.53). Conclusion: We were able to show that asphericity bears independent prognostic value and significantly improves risk stratification when combined with MTV in a comprehensive retrospective cohort of HNSCC patients.

Efficacy and safety of PD-1/PD-L1 inhibitors combined with standard of care for locally advanced head and neck squamous cell carcinoma: A meta-analysis of randomized controlled trials

OBJECTIVES

Chemoradiotherapy (CRT) or radiotherapy (RT) combined with cetuximab (for cisplatin-ineligible patients) is the standard of care (SoC) for locally advanced head and neck squamous cell carcinoma (LA-HNSCC). This study investigates whether adding programmed cell death-1/programmed cell death-ligand 1 (PD-1/PD-L1) immune checkpoint inhibitors (ICIs) to standard therapy improves survival in patients with LA-HNSCC.

METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library identified randomized controlled trials (RCTs) evaluating PD-1/PD-L1 inhibitors plus SoC compared with SoC alone for LA-HNSCC. The primary endpoints were progression-free survival (PFS), overall survival (OS), locoregional event-free survival (LEFS), and distant metastasis-free survival (DMFS) at the 1-year and 2-year time points, as well as the incidence of grade 3 or higher adverse events (AEs).

RESULTS

Four RCTs encompassing 1818 patients met the inclusion criteria. Compared with SoC alone, PD-1/PD-L1 inhibitors combined with SoC did not significantly improve 1-year or 2-year PFS, OS, LEFS, or DMFS (all p > 0.05). Subgroup analyses further showed no survival benefit at 2 years in the ICI + CRT, ICI + RT-cetuximab, anti-PD-1, or anti-PD-L1 subgroups. Additionally, there was no statistically significant difference in the incidence of grade 3 or higher AEs between the combined and SoC-only groups (p = 0.69).

CONCLUSIONS

These findings suggest that adding PD-1/PD-L1 inhibitors to standard therapy does not enhance 1-year or 2-year survival for patients with LA-HNSCC, and confers a similar severe safety profile.

Palbociclib, a Selective CDK4/6 Inhibitor, Administered Before and After Chemoradiotherapy for Human Papillomavirus-Negative, Locally Advanced Head and Neck Squamous Cell Carcinoma: A Single-Arm, Phase II Trial

PURPOSE

The primary aim of this single-arm, phase II trial was to determine the objective response rate (ORR) with palbociclib, a selective CDK4/6 inhibitor, administered before chemoradiotherapy (CRT) in patients with human papillomavirus (HPV)-negative head and neck squamous cell carcinoma (HNSCC).

PATIENTS AND METHODS

Eligibility required untreated stage III-IVB HPV-negative HNSCC. Palbociclib 125 mg once daily was administered on days 1-21 of each 28-day cycle for two cycles before and six cycles after CRT. Pretreatment tumor samples underwent genome sequencing. The primary end point was tumor response to palbociclib given before CRT, assessed by RECIST1.1. A sample of 24 evaluable patients (those with response assessment) yielded an 80% power at a one-sided significance level of 0.05 if the ORR was ≥38% (null ORR 17%). A key secondary end point was relapse.

RESULTS

We enrolled 26 patients with HPV-negative, locally advanced HNSCC. Alterations in CDKN2A were identified in 15 patients (58%), and alterations in CCND1 were identified in eight (31%). Twenty-four patients were evaluable for the primary end point, and 25 were evaluable for relapse. The ORR with palbociclib given before CRT was 41.7% (95% CI, 22.1 to 63.4). Response to palbociclib occurred in 10 of 15 patients (66.7%) with versus 0 of 9 (0%) without tumor CDKN2A alterations (P = .002) and in one of six patients (16.7%) with versus nine of 18 (50%) without CCND1 alterations (P = .34). The median follow-up was 33.9 months (IQR, 31.3-49.2). Relapse occurred in two of 15 patients (13.3%) with versus seven of 10 (70%) without tumor CDKN2A alterations (P = .009) and in one of seven patients (14.3%) with versus 8 of 18 (44.4%) without CCND1 alterations (P = .36).

CONCLUSION

Palbociclib is an active drug in previously untreated HPV-negative, locally advanced HNSCC. Alterations in CDKN2A were associated with a higher ORR with palbociclib and a lower relapse risk after CRT.

[Medical tumor therapy for head and neck cancer: between standardization and personalization]

In the field of systemic cancer therapy for head and neck neoplasms, new approvals have led to several changes in treatment standards, primarily in the palliative situation. At the same time, molecular biomarkers have been established that can contribute to therapeutic decision-making in addition to clinical factors. These developments are summarized, and potential strategies to resolve the tension between standardization and personalization are described. Results from randomized phase III studies with therapeutic antibodies targeting the PD1/PD-L1 axis in combination with definitive chemoradiation are described and discussed. Finally, inspired by the press release about the positive results of the neoadjuvant KEYNOTE-689 trial in locoregionally advanced resectable disease, potential measures and suggestions for integrating neoadjuvant immunotherapy into clinical routine are discussed.

Chemotherapy-free innovations in locally advanced head and neck cancer: a comprehensive review

The treatment of locally advanced head and neck squamous cell carcinoma (LA-HNSCC) has traditionally relied on a multimodal approach, combining surgery, radiation therapy (RT), and chemotherapy. While chemotherapy plays a critical role in improving cure rates and functional outcomes, its substantial toxicity remains a major concern, particularly in older patients. These challenges are especially relevant for those who are unfit for chemotherapy or decline conventional concurrent chemoradiotherapy (CCRT), highlighting the need for alternative therapeutic options. Many patients are at high risk for severe side effects, often preventing them from completing the full chemotherapy regimen. This review explores alternative strategies to definitive CCRT of carcinomas of the larynx, hypopharynx and oropharynx, aiming to optimize treatment outcomes while minimizing toxicity. We discuss altered fractionation strategies as a promising alternative to conventional RT, offering a balance between treatment efficacy and quality of life. Additionally, we examine emerging approaches, including the combining of targeted therapies, immunotherapy, hyperthermia, photodynamic therapy and nanoparticle-based treatments with RT, which provide alternative or complementary options to traditional therapies in the management of LA-HNSCC.

Prognostic gene expression signatures for HPV-negative head and neck squamous cell carcinoma

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is a leading cause of cancer-related deaths worldwide, with HPV-negative cases being particularly aggressive. These cases often show poor prognosis and low responsiveness to radiotherapy. Improved prognostic tools and treatment strategies are needed to enhance outcomes.

AIM

To evaluate the prognostic value of various gene expression signatures in predicting survival outcomes in HPV-negative HNSCC patients receiving radiotherapy and to compare their accuracy against the current TNM staging system.

METHODS

This observational cohort study used data from the European BD2Decide project, systematically analyzing gene expression in loco-regionally advanced, non-metastatic HPV-negative HNSCC patients (stage III-IVa/b) treated with curative radiotherapy (post-operative or definitive) between 2008 and 2017. The primary outcome was overall survival (OS), with secondary outcomes including disease-free survival (DFS), distant metastasis-free survival (DMFS), and loco-regional recurrence-free survival (LRRFS). The prognostic performance of selected gene expression signatures was evaluated using receiver operating characteristic (ROC) curves and hazard ratios (HR) from Cox models.

RESULTS

The study included 783 patients, with a median age of 63 years, mostly male (68 %), with significant tobacco (84 %) and alcohol (69 %) exposure. The 172-gene signature (172GS) showed the highest prognostic accuracy, outperforming the TNM system in predicting OS, DFS, DMFS, and LRRFS. Multivariable analysis confirmed its independent prognostic value.

CONCLUSIONS

The 172GS gene signature offers superior prognostic information compared to TNM staging, supporting its potential use for better risk stratification and personalized treatment planning in HPV-negative HNSCC. Future trials should consider tumor biology and gene signatures for better patient selection.

TRIAL REGISTRATION

NCT02832102.

Experimental Investigation of Hematological Toxicity After Radiation Therapy Combined With Immune Checkpoint Inhibitors

PURPOSE

Combining immune checkpoint inhibitors (ICIs) with radiation therapy (RT) has led to significant advancements in cancer treatment. However, evidence from clinical and experimental studies suggests that this combination may increase hematopoietic and lymphatic toxicity. This study aims to investigate the effects of the concurrent application of ICIs (anti-PD-1 and anti-CTLA-4) on radiation-induced hematopoietic and lymphatic injuries under standardized and controlled experimental conditions.

METHODS AND MATERIALS

We used various experimental models in C57BL/6 and BALB/c mice to evaluate the impact of ICIs combined with RT on the hematopoietic system. These models involved different RT doses, regimens, and target sites in both healthy and tumor-bearing mice.

RESULTS

Our findings showed that the concurrent use of ICIs did not meaningfully affect post-RT pancytopenia kinetics or the regeneration of specific blood cell lineages over time. Consistently, combining RT with ICIs did not significantly enhance DNA damage in immune cells within the bloodstream. This outcome was comparable across different RT doses, regimens, and target sites and was reproducible in both tumor-bearing and nontumor-bearing mice. Additionally, there were no significant increases in late side effects, including reductions in bone marrow cell counts or megakaryocyte numbers, after combined radioimmunotherapy.

CONCLUSIONS

These findings suggest that combining ICIs with RT does not exacerbate hematological toxicity. This information is valuable for interpreting adverse events in clinical trials involving radioimmunotherapy and for predicting potential hematological side effects in cancer patients receiving these treatments.

Immunotherapeutic strategies in head and neck cancer: challenges and opportunities

HNSCC remains a substantial health issue, with treatment options including surgery, radiation, and platinum-based chemotherapy. Unfortunately, despite progress in research, only modest gains have been made in disease control, with existing treatments resulting in significant functional and quality-of-life issues. The introduction of immunotherapy in the treatment of HNSCC has resulted in some improvements in outlook for patients and is now standard of care for populations with both recurrent and metastatic disease. However, despite the early successes, responses to immune checkpoint inhibition (ICI) remain modest to low, approaching 14%-22% objective response rates. Challenges to the effectiveness of ICI and other immunotherapies are complex, including the diverse and dynamic molecular plasticity and heterogeneity of HNSCCs; lack of immunogenic antigens; accumulated suppressive immune populations such as myeloid cells and dysfunctional T cells; nutrient depletion; and metabolic dysregulation in the HNSCC tumor microenvironment. In this Review, we explore the mechanisms responsible for immunotherapy resistance, dissect these challenges, and discuss potential opportunities for overcoming hurdles to the development of successful immunotherapy for HNSCC.

Combination radiation and αPD-L1 enhance tumor control by stimulating CD8+ PD-1+ TCF-1+ T cells in the tumor-draining lymph node

Combination radiotherapy (RT) and αPD-L1 therapy has potential to enhance local and distant (abscopal) tumor control, however, clinical results in humans have been variable. Using murine melanoma models, we found RT + αPD-L1 increases intra-tumor progenitor CD8+ PD-1+ TCF-1+ T cells. This increase depends on trafficking of the PD-1+ TCF-1+ cells from the tumor-draining lymph node (TdLN) to the tumor. RT alone promotes the expansion and differentiation of the TdLN derived PD-1+ TCF-1+ cells into TIM-3+ GZMB+ TCF-1- effector-like cells in the tumor with further enhancement after the addition of αPD-L1. In the TdLN, combination therapy enriches for a novel PD-1+ TCF-1+ TOX- LY6A+ subset with expression of a type I interferon and migratory signature. This subset is able to traffic to the tumor and differentiate into TIM-3+ TCF-1- cells. Finally, we found that ablation of the PD-1+ TCF-1+ T cell population attenuates the enhanced tumor control observed with combination RT + αPD-L1. These results suggest that abscopal response failures may be secondary to impaired stimulation of TdLN CD8+ PD-1 + TCF-1+ T cells or an inability of PD-1+ TCF-1+ cells in the TdLN to traffic to the tumor.

FLASH radiotherapy spares lymphocytes in tumor-draining lymph nodes and increases infiltration of immune cells in tumors

Radiotherapy (RT) delivered at conventional dose rates (CONV) can both stimulate antitumor immune responses and inhibit these immune responses by depleting circulating lymphocytes. Given the observed normal tissue sparing associated with ultra-high dose rate (FLASH) RT, we hypothesized that FLASH RT may protect lymphocytes while increasing the immunogenicity of cancer cells. We irradiated cancer cell lines in vitro with FLASH RT or CONV RT and assessed immunogenic mRNA and protein expression. Both HPV-positive cell lines MEER and TC-1 showed upregulation of Calr, Hmgb1 , and cGAS-STING family members after FLASH RT but not after CONV RT in vitro . To assess changes in lymphocyte populations, we irradiated murine mEER tumors in syngeneic C57BL/6 mice with 27 Gy in 3 fractions of FLASH RT or CONV RT. In mice bearing FLASH irradiated tumors, tumor-draining lymph nodes contained greater numbers of CD8 + T cells (FLASH 1.7×10 4 vs 0.8×10 4 CONV; P <0.001) and CD4 + T cells (FLASH 2.3×10 4 vs CONV 1.2×10 4 ; P <0.001) after irradiation. FLASH RT was associated with increased numbers of activated CD44 + CD62L lo CD8 + and CD4 + lymphocytes. In irradiated tumors, FLASH RT was associated with increased CD8 + tumor-infiltrating lymphocytes, increased PD1 expression on these lymphocytes and increased PDL1 expression on macrophages. Compared with CONV RT, FLASH RT spared activated T cells in tumor-draining lymph nodes and in tumors but increased checkpoint inhibitor expression in tumors. These results suggest that FLASH RT may enhance antitumor immune responses by maintaining the immunogenic effects of RT while preserving lymphocyte numbers, which may be augmented with immune checkpoint blockade.

Significance

Radiation-induced lymphopenia is associated with poorer survival outcomes. New treatment approaches, like FLASH radiation therapy (FLASH RT), which reduce lymphopenia and enhance the antitumor response, could potentially lead to better outcomes for cancer patients.

Tobacco smoke exposure is a driver of altered oxidative stress response and immunity in head and neck cancer

BACKGROUND

Exposomes are critical drivers of carcinogenesis. However, how they modulate tumor behavior remains unclear. Extensive clinical data show cigarette smoke to be a key exposome that promotes aggressive tumors, higher rates of metastasis, reduced response to chemoradiotherapy, and suppressed anti-tumor immunity. We sought to determine whether smoke itself can modulate aggressive tumor behavior in head and neck squamous cell carcinoma (HNSCC) through reprogramming of the cellular reductive state.

METHODS

Using established human and murine HNSCC cell lines and syngeneic mouse models, we utilized conventional western blotting, steady state and flux metabolomics, RNA sequencing, quantitative proteomics and flow cytometry to analyze the impact of smoke exposure on HNSCC tumor biology and anti-tumor immunity.

RESULTS

Cigarette smoke persistently activated Nrf2 target genes essential for maintenance of the cellular reductive state and survival under conditions of increased oxidative stress in HNSCC regardless of human papillomavirus (HPV) association. In contrast to e-cigarette vapor, conventional cigarette smoke mobilizes cellular metabolism toward oxidative stress adaptation, resulting in development of cross-resistance to cisplatin. In parallel, smoke exposure modulates expression of PDL1 and the secretory phenotype of HNSCC cells resulting in an altered tumor immune microenvironment (TIME) in syngeneic mouse models and downregulated expression of antigen presentation and costimulatory genes in myeloid cells.

CONCLUSION

The cigarette smoke exposome is a potent activator of the Nrf2 pathway and appears to be the primary trigger for a tripartite phenotype of aggressive HNSCC consisting of: (1) reduced chemotherapy sensitivity, (2) enhanced metastatic potential and (3) suppressed anti-tumor immunity.

Managing Patients with Head and Neck Cancer and Advanced Age or Comorbidities

The dominant treatment paradigm for locoregionally advanced head and neck squamous cell carcinoma (HNSCC) involves postoperative or definitive radiotherapy with concurrent cisplatin chemotherapy. Despite years of research investigating de-intensified treatment, cisplatin-based chemoradiotherapy remains the standard, yet it is associated with significant acute and chronic toxicity. However, due to shared risk factors, such as advanced age, and tobacco and alcohol use, patients with HNSCC frequently have comorbid illnesses that impact treatment tolerability, adding complexity to treatment-related decision-making. In addition, many patients have medical contraindications to cisplatin, requiring alternative treatment strategies. It is thus important to consider how well patients are likely to tolerate treatment, and how to adapt treatment in response to a patient's condition, when weighing treatment options. In this review, we aim to offer readers guidance in managing the elderly or comorbid patient with HNSCC, with particular attention to (i) approaching comorbidity and fragility assessment to make determinations on intensity of treatment, (ii) considering primary treatment modality (eg, surgery vs radiotherapy, chemo-radiotherapy vs radiotherapy alone) and (iii) choice of concurrent systemic therapy agent.

Mid-treatment changes in intra-tumoural metabolic heterogeneity correlate to outcomes in oropharyngeal squamous cell carcinoma patients

BACKGROUND

This study evaluated mid-treatment changes in intra-tumoural metabolic heterogeneity and quantitative FDG-PET/CT imaging parameters and correlated the changes with treatment outcomes in oropharyngeal squamous cell cancer (OPSCC) patients. 114 patients from two independent cohorts underwent baseline and mid-treatment (week 3) FDG-PET. Standardized uptake value maximum (SUVmax), standardized uptake value mean (SUVmean), metabolic tumour volume (MTV), and total lesional glycolysis (TLG) were measured. Intra-tumoural metabolic heterogeneity was quantified as the area under a cumulative SUV-volume histogram curve (AUC-CSH). Baseline and relative change (%∆) in imaging features were correlated to locoregional recurrence free survival (LRRFS) using multivariate Cox regression analysis. Patients were stratified into three risk groups utilising ∆AUC-CSH and known prognostic features, then compared using Kaplan-Meier analysis.

RESULTS

Median follow up was 39 months. 18% of patients developed locoregional recurrence at 2 years. A decrease in heterogeneity (∆AUC-CSH: 24%) was observed mid-treatment. There was no statistically significant difference in tumour heterogeneity (AUC-CSH) at baseline (p = 0.134) and change at week 3 (p = 0.306) between p16 positive and p16 negative patients. Baseline imaging features did not correlate to LRRFS. However, ∆MTV (aHR 1.04; 95% CI 1.03-1.06; p < 0.001) and ∆AUC-CSH (aHR 0.96; 95% CI 0.94-0.98; p = 0.004) were correlated to LRRFS. Stratification using ∆AUC-CSH and p16 status into three groups showed significant differences in LRR (2 year LRRFS 94%, 79%, 17%; log rank p < 0.001). Stratification using ∆AUC-CSH and ∆MTV into three groups showed significant differences in LRR (2 year LRRFS 93%, 70%, 17%; log rank p < 0.001).

CONCLUSION

Mid-treatment changes in intra-tumoural FDG-PET/CT heterogeneity correlated with treatment outcomes in OPSCC and may help with response prediction. These findings suggest potential utility in designing future risk adaptive clinical trials.

Principles and Paradigms of De-Escalated Elective Nodal Irradiation: Boldly Going Towards an Inflection Point in Head and Neck Radiotherapy

Fundamental axioms of elective nodal irradiation (ENI) for head and neck cancers merit re-examination in contemporary practice. Standard ENI doses to volumes bordering critical organs-at-risk increased during the transition from two-dimensional radiation planning to intensity-modulated radiotherapy, despite improvements in detection of occult nodal metastases with modern imaging, use of concurrent chemotherapy, and identification of human papillomavirus (HPV)-related radiosensitivity. Historical large ENI volumes covering low-risk nodal regions continue to be commonly used even as awareness grows regarding the predominant pattern-of-failure within existing gross disease. In this review, we outline principles for de-escalating head and neck ENI dose and volume and highlight the emerging paradigm of ENI omission. We also propose a three-part approach to ENI de-escalation, the rationale for early adoption of de-escalated ENI in the absence of level-one evidence, and strategies to promote early adoption in light of modest equipoise and an inflection point towards changing the status quo.

Neoadjuvant Immunotherapy in Resectable HNSCC: An Updated Systematic Review and Meta-analysis

BACKGROUND

Immunotherapy is a recently recognised FDA-approved treatment for R/M HNSCC. Our goal is to explore the safety profile and the efficacy of immunotherapy in the neoadjuvant setting before surgery in mucosal head and neck cancer.

METHODS

Three electronic databases had been systematically searched through March 2024. Demographic and tumour characteristics were extracted. Primary outcomes obtained were disease-free survival (DFS), progression-free survival (PFS), overall survival (OS), complete pathological response (cPR), which was defined as no residual tumour, and major pathological response (MPR), which as defined as <10% residual viable tumour. Safety outcomes examined were grade 3 and above adverse event, median time to surgery, delays to surgery, and death related to neoadjuvant treatment.

RESULTS

A total of 459 patients from 15 studies were included in the analysis. The pooled estimate of cPR for all the studies was 14.9% (95% confidence interval [CI] 8.0-26.2). Subgroup analysis showed chemoimmunotherapy had a higher cPR 30.1% (95% CI 22.8-38.62) compared with immunotherapy alone 1.4% (95% CI 0.3-5.2). There was no treatment-related death. Chemoimmunotherapy had a higher pooled estimate of adverse events 22.9% (95% CI 11.0-41.5) compared with immunotherapy alone 8.5% (95% CI 2.6-24.3). Subgroup analysis demonstrated that chemoimmunotherapy had a higher DFS compared with immunotherapy alone: 89.8% (95% CI 81.4-94.7) versus 80.44% (95% CI 73.9-85.7), respectively. Neoadjuvant immunoradiotherapy had conflicting results.

CONCLUSIONS

Neoadjuvant immunotherapy was well tolerated. Neoadjuvant chemoimmunotherapy may be more effective in treating LAHNSCC over immunotherapy alone; however, TRAEs were higher.

De-escalation of Adjuvant Therapy in Operatively Managed HPV Associated Oropharyngeal Carcinoma: Current Status and Future Directions

Human papillomavirus (HPV) associated oropharyngeal carcinoma is currently the most frequently diagnosed head and neck cancer in the United States. Due to the generally high cure rates with standard therapies, de-intensification strategies are being explored to reduce acute and long-term side effects. For patients treated with definitive chemoradiation, unselected de-escalation has shown worse progression-free survival compared to standard therapy. Concurrently, surgical management is becoming more prevalent, and adjuvant de-escalation appears promising. Further research is required to identify optimal candidacy for adjuvant de-escalation and to understand the relationship between dose and volume de-escalation. Biomarkers such as ctDNA may assist in candidate selection, but validation and alignment with pathological criteria are necessary.

Radiotherapy is enhanced by CPH:SA IL-1α microparticles in a murine HNSCC tumor model

BACKGROUND

Radiotherapy (RT) can trigger immunogenic cell death which may be exploited to improve the effectiveness of immunotherapy. However, recent results from clinical trials testing RT/immunotherapy combinations in head and neck squamous cell carcinoma patients (HNSCC) have been disappointing. Interleukin-1 alpha (IL-1α) is a cytokine that can activate various aspects of anti-tumor immunity including dendritic cell (DC) activation which is critical for the recruitment of tumor infiltrating lymphocytes. Here we test the cytokine IL-1α encapsulated in 20:80 1,6-bis-(p-carboxyphenoxy)-hexane:sebacic acid (CPH:SA) copolymer-based microparticles (IL-1αMPs) as an adjuvant to RT in a murine syngeneic HNSCC mouse model. Thus the main research objective of this current study was to evaluate if IL-1αMPs can enhance the antitumor immune response of radiotherapy.

METHODS

Activation of immune cells in response to RT ± human recombinant IL-1α was evaluated in human peripheral blood mononuclear cell (PBMC):cancer cell co-cultures. A bilateral HNSCC tumor syngeneic mouse model was used to monitor mEERL tumor growth and immune cell recruitment in response to RT (8 Gy to irradiated tumor only) with and without intraperitoneal delivery of IL-1αMPs.  RESULTS: Results showed that IL-1α induced the activation of monocytes, NK cells, T cells, and DCs in PBMC:Cal-27 cell co-cultures but there was no enhanced immune cell activation (with the exception of NK cells) in vitro when combined with RT. RT and RT + IL-1αMPs significantly suppressed growth in irradiated mEERL tumors compared to control. However, only the combination therapy was able to slowdown growth of the non-irradiated tumors compared to the other treatment groups. Immune cell profiling revealed that RT caused acute lymphodepletion on treatment day 3 which was reversed by treatment day 11 in RT-exposed mice. The anti-tumor effect of RT + IL-1α was accompanied by significantly increased infiltration of DCs in the irradiated tumor and increased CD8 + and antigen (E7)-specific CD8 + T cell infiltration in both irradiated and non-irradiated tumors. The anti-tumor response of the combination therapy was completely abrogated by CD8 + T cell depletion.

CONCLUSIONS

This data suggests that the addition of CPH:SA IL-1αMPs to RT may boost anti-tumor immune response and target both local and systemic disease. This combination is worthy of further investigation as an immunotherapeutic strategy and could represent a promising approach to improve survival outcomes in HNSCC patients.

Neoadjuvant Chemoimmunotherapy for Resectable Head and Neck Squamous Cell Carcinoma: Systematic Review and Meta-analysis

BACKGROUND

Neoadjuvant chemoimmunotherapy provides a good pathological response in patients with resectable head and neck squamous cell carcinoma (HNSCC). Currently, there is no comprehensive systematic review that rigorously evaluates and summarizes the existing studies. In this study, we aimed to synthesize the results on the efficacy of neoadjuvant chemoimmunotherapy in resectable HNSCC to obtain higher-level evidence.

METHODS

The PubMed, Web of Science, Scopus, and Academic Search Complete (EBSCO) databases, along with ClinicalTrials.gov, Google Scholar, and conference abstracts, were comprehensively searched. The publication dates of the literature were limited to January 2015-July 2024. Meta-analysis was performed using a random-effects model. The percentage of major pathological response (MPR), pathological complete response (pCR), and overall disease-free survival (DFS) were synthesized. The odds ratios of a combined positive score (CPS) ≥ 20 for MPR and the diagnostic performance of using radiological objective response to determine MPR were further explored.

RESULTS

A total of 13 studies with 458 patients who received neoadjuvant chemoimmunotherapy and 443 patients who underwent curative surgery were included. The pooled MPR, pCR, and overall DFS rates were 61%, 37%, and 91%, respectively. The odds ratios of a CPS ≥ 20 for achieving MPR was 2.09 compared with those with a CPS < 20. The sensitivity of using radiological objective response to determine MPR was 0.91 and the specificity was 0.46, with an area under the curve of 0.76.

CONCLUSION

Neoadjuvant chemoimmunotherapy showed promising results for resectable HNSCC. A CPS ≥ 20 can be used to screen for treatment-sensitive patients, and radiological examinations can be used to detect pathological response. Definitive conclusions require data from longer follow-up periods and controlled studies.

Mathematical Modeling Predicts Optimal Immune Checkpoint Inhibitor and Radiotherapy Combinations and Timing of Administration

Radiotherapy (RT) combined with immune checkpoint inhibitor (ICI) therapy has attracted substantial attention due to its potential to improve outcomes for patients with several types of cancer. However, the optimal administration timepoints and drug combinations remain unclear because the mechanisms underlying RT-induced changes in immune checkpoint molecule expression and interaction with their ligand(s) remain unclear. In this study, we demonstrated the dynamics of lymphocyte-mediated molecular interactions in tissue samples from patients with esophageal cancer throughout RT schedules. Single-cell RNA sequencing and spatial transcriptomic analyses were performed to investigate the dynamics of these interactions. The biological signal in lymphocytes transitioned from innate to adaptive immune reaction, with increases in ligand-receptor interactions, such as PD-1-PD-L1, CTLA4-CD80/86, and TIGIT-PVR interactions. A mathematical model was constructed to predict the efficacy of five types of ICIs when administered at four different timepoints. The model suggested that concurrent anti-PD-1/PD-L1 therapy or concurrent/adjuvant anti-CTLA4/TIGIT therapy would exert a maximal effect with RT. This study provides rationale for clinical trials of RT combined with defined ICI therapy, and these findings will support future studies to search for more effective targets and timing of therapy administration.

Systemic therapy for laryngeal carcinoma

Laryngeal squamous cell carcinoma (LSCC) accounts for 100,000 deaths worldwide each year. Despite multimodal treatment, outcomes for both high-risk locally advanced and recurrent/metastatic laryngeal carcinoma remain poor. Treatment intensification through induction chemotherapy has not improved overall survival, although it may contribute to larynx preservation. Consequently, multiple recent efforts have been made to integrate novel immunotherapies into the current treatment algorithm for LSCC. In particular, perioperative immunotherapy regimens appear to be the most promising approach for preserving laryngeal function and optimizing event-free and overall survival rates in the locally advanced setting. In the recurrent/metastatic setting, the 5-year overall survival rate is approximately 20% with pembrolizumab-based regimens. Primary and secondary resistance to immunotherapy is frequently observed in the majority of patients. Along with trials of checkpoint inhibitor monotherapy, combinatorial approaches with novel immunotherapies, bispecific antibodies, targeted therapies, and antibody-drug conjugates are being explored for the treatment of recurrent/metastatic laryngeal carcinoma. This article aims to discuss recent efforts to improve outcomes and quality of life for patients with locally advanced and recurrent/metastatic LSCC.

Cost-Effectiveness of Pembrolizumab With Chemoradiotherapy for Locally Advanced Cervical Cancer

Importance

The KEYNOTE-A18 trial demonstrated that adding concurrent and adjuvant pembrolizumab to chemoradiotherapy and brachytherapy significantly improved survival in patients with newly diagnosed, locally advanced cervical cancer. However, considering the annual global incidence of 660 000 cases of cervical cancer, including 13 820 in the US in 2024, incorporating this regimen into the standard of care could have substantial health care economic implications for both patients and the health care system.

Objective

To determine the cost-effectiveness of adding pembrolizumab to the first-line treatment of newly diagnosed, locally advanced cervical cancer.

Design, Setting, and Participants

This economic evaluation created a Markov model simulating 50-year outcomes to evaluate cost-effectiveness from the payer perspective for patients receiving either pembrolizumab or placebo in addition to chemoradiotherapy plus brachytherapy. Probabilities, including disease progression, survival, and treatment-related toxic effects, were derived from KEYNOTE-A18 clinical trial data in patients with newly diagnosed, locally advanced cervical cancer. Costs and health utilities were obtained from published literature; 1-way, 3-way, and probabilistic sensitivity analyses were used to assess model uncertainty. Data analyses were conducted from April to November 2024.

Exposure

Pembrolizumab.

Main Outcomes and Measures

Costs, measured in 2024 US dollars, and effectiveness, measured in quality-adjusted life-years (QALYs) were used to calculate an incremental cost-effectiveness ratio (ICER). A willingness-to-pay threshold of $100 000 per QALY was chosen, below which pembrolizumab would be considered cost-effective.

Results

KEYNOTE-A18 enrolled 1060 patients (529 in pembrolizumab group, 531 in placebo group). The median age was 50 years. Pembrolizumab increased costs by $257 000 and effectiveness by 1.40 QALYs, yielding an incremental cost-effectiveness ratio of $183 400 per QALY. The addition of pembrolizumab became cost-effective if its monthly cost was decreased from $16 990 to $9190 (a 45.6% reduction) or its maximum duration of 24 months was decreased to 10 months. The model was insensitive to assumptions about treatment-related toxic effects, progression-free survival, and overall survival. Probabilistic sensitivity analysis indicated that at a willingness-to-pay threshold of $100 000 per QALY, the addition of pembrolizumab was cost-effective 37.3% of the time.

Conclusions and Relevance

In this economic evaluation of adding concurrent and adjuvant pembrolizumab to first-line treatment of newly diagnosed, locally advanced cervical cancer, this regimen was not cost-effective at current prices despite data demonstrating improved survival with this regimen.

Proteogenomic characterisation of primary oral cancer unveils extracellular matrix remodelling and immunosuppressive microenvironment linked to lymph node metastasis

Oral squamous cell carcinoma (OSCC) is an increasingly prevalent malignancy worldwide. This study aims to understand molecular alterations associated with lymph node metastasis of OSCC in order to improve treatment strategies. We analysed a cohort of 46 patients with primary OSCC, including 10 with lymph node metastasis and 36 without. Using a comprehensive multi-omics approach - encompassing genomic, transcriptomic, proteomic, epigenetic, single-cell, and spatial analyses - we integrated data to delineate the molecular landscape of OSCC in the context of lymph node metastasis. Our genomic analysis identified significant mutations in key genes within the MAPK, TGF-β and WNT signalling pathways, which are essential for tumour development. The proteogenomic analysis highlighted pathways critical for lymph node dissemination and factors contributing to an immunosuppressive tumour microenvironment. Elevated levels of POSTN were found to reorganise the extracellular matrix (ECM), interact with TGF-β, disrupt cell cycle regulation and suppress the immune response by reducing VCAM1 activity. Integrated analyses of single-cell and spatial transcriptome data revealed that cancer-associated fibroblasts (CAFs) secrete TGF-β1/2, promoting cancer cell metastasis through epithelial-mesenchymal transition (EMT). Our integrated multi-omics analysis provides a detailed understanding of molecular mechanisms driving lymph node metastasis of OSCC. These insights could lead to more precise diagnostics and targeted treatments. This article is protected by copyright. All rights reserved.

Resistance to immunotherapy in non-small cell lung cancer: Unraveling causes, developing effective strategies, and exploring potential breakthroughs

Over the last two decades, advancements in deciphering the intricate interactions between oncology and immunity have fueled a meteoric rise in immunotherapy for non-small cell lung cancer, typified by an explosive growth of immune checkpoint inhibitors. However, resistance to immunotherapy remains inevitable. Herein we unravel the labyrinthine mechanisms of resistance to immunotherapy, characterized by their involvement of nearly all types of cells within the body, beyond the extrinsic cancer cells, and importantly, such cells are not only (inhibitory or excitatory, or both) signal recipients but also producers, acting in a context-dependent manner. At the molecular level, these mechanisms underlie genetic and epigenetic aberrations, which are regulated by or regulate various protein kinases, growth factors, and cytokines with inherently dynamic and spatially heterogeneous properties. Additionally, macroscopic factors such as nutrition, comorbidities, and the microbiome within and around organs or tumor cells are involved. Therefore, developing therapeutic strategies combined with distinct action informed by preclinical, clinical, and real-world evidence, such as radiotherapy, chemotherapy, targeted therapy, antibody-drug conjugates, oncolytic viruses, and cell-based therapies, may stand as a judicious reality, although the ideality is to overcome resistance point-by-point through a novel drug. Notably, we highlight a realignment of treatment aims, moving the primary focus from eliminating cancer cells -- such as through chemotherapy and radiotherapy -- to promoting immune modulation and underscore the value of regulating various components within the host macro- or micro-environment, as their effects, even if seemingly minimal, can cumulatively contribute to visible clinical benefit when applied in combination with ICIs. Lastly, this review also emphasizes the current hurdles scattered throughout preclinical and clinical studies, and explores evolving directions in the landscape of immunotherapy for NSCLC.

Total lesion glycolysis of primary tumor and lymphnodes is a strong predictor for development of distant metastases in oropharyngeal carcinoma patients with independent validation in automatically delineated lesions

BACKGROUND

Oropharyngeal carcinomas are characterized by an increasing incidence and a relatively good prognosis. Nonetheless, a considerable number of patients develops metachronous distant metastases; identification of these patients is an urgent medical need.

METHODS

This is a retrospective multicenter evaluation of 431 patients. All patients underwent [18F]-FDG positron emission tomography (PET). The cohort was split into an explorative group (n = 366) and a validation group (n = 65). Lesions were manually delineated in the explorative group and automatically delineated by a convolutional neuronal network (CNN) in the validation group. Quantitative PET parameters standardized uptake value (SUV), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated for primary tumors (prim) and tumor plus lymphnodes (all). Association of parameters with freedom from distant metastases (FFDM) and overall survival (OS) was tested by cox regression analyses.

RESULTS

In the explorative group, univariate analyses revealed an association of metric MTVprim (p = 0.022), MTVall (p < 0.001) and TLGall (p < 0.001) with FFDM, binarized parameters were also associated with FFDM (p < 0.001 and p = 0.002). Bootstrap analyses revealed a significantly better association of TLGall compared to TLGprim with FFDM (p = 0.02). MTVall and TLGall remained significantly associated with FFDM upon multivariate testing (p = 0.002, p = 0.031, respectively). In the validation group, the cutoff value for TLGall but not for TLGprim was significantly associated with FFDM (HR = 3.1, p = 0.045). Additional analyses with manually delineated contours of the validation cohort revealed a similar effect (HR = 3.47, p = 0.026). No considerable differences between HPV positive and negative disease were observed.

CONCLUSIONS

TLGall is a promising biomarker to select OPC patients with high risk for metachronous distant metastases.

Challenges and Opportunities for the Clinical Application of the Combination of Immune-Checkpoint Inhibitors and Radiation Therapy in the Treatment of Advanced Pancreatic Cancer

The treatment landscape of pancreatic ductal adenocarcinoma (PDAC) has seen slow progress, with immune-checkpoint inhibitors (ICIs) failing to replicate the success observed in other malignancies. The immune-suppressive tumor microenvironment (TME) in PDAC represents a significant barrier, limiting the activation of an effective antitumor immune response following ICI administration. Radiation therapy (RT), with its immunomodulatory effects, has emerged as a promising partner for ICIs. This review discusses the recent efforts evaluating the combination of ICIs and RT in advanced PDAC. While the combination therapy has demonstrated an acceptable safety profile, the reported clinical efficacy remains modest, particularly for patients with refractory metastatic PDAC. The ongoing phase III trial (JCOG1908E) will clarify whether the combination of ICI and RT improves overall survival in chemo-naïve patients with locally advanced PDAC.

Vaccine-Based Immunotherapy for Oropharyngeal and Nasopharyngeal Cancers

Viral infections such as human papillomavirus (HPV) and Epstein-Barr virus (EBV) play a critical role in the onset of oropharyngeal (OPC) and nasopharyngeal cancer (NPC), respectively. Despite advancements in targeted therapies and immunotherapies, in the recurrent/metastatic setting, these tumors remain incurable diseases with poor prognosis. The development of therapeutic tumor vaccines, utilizing either neoantigens or oncoviral antigens, represents a promising addition to the cancer immunotherapy arsenal. Research on vaccine-based immunotherapy for OPC and NPC focuses on targeting viral antigens, particularly HPV E6/E7 and EBV EBNA1/LMP2. The potential for vaccine platforms, including peptide-based, DNA, RNA, and viral vector-based vaccines, to induce durable immune responses against viral antigens is reported. The early-phase clinical trials evaluating vaccine-based therapies for HPV-related OPC and EBV-related NPC revealed safety and preliminary signs of efficacy; however, further clinical trials are crucial for validation. This review provides an overview of the current landscape of vaccine-based strategies for HPV-related OPC and EBV-related NPC, discussing their biological mechanisms and immune processes involved in anti-HPV and anti-EBV vaccine treatments, with a particular focus on the immune factors that influence these therapies.

Safety and efficacy of neoadjuvant therapy with tislelizumab plus chemotherapy for locally advanced head and neck squamous cell carcinoma: a single-arm, retrospective study

BACKGROUND

Head and neck squamous cell carcinoma (HNSCC) is a very common type of head and neck cancer, and the 5-year overall survival (OS) rate is only 50%. Inhibitors targeting the programmed death 1 (PD-1) pathway have gained widespread clinical adoption. However, the relationship between the infiltration characteristics of immune cells in the tumor immune microenvironment (TIME) and the effect of immunotherapy on HNSCC remains to be explored.

METHODS

Patients diagnosed with HNSCC who received Tislelizumab combined with chemotherapy were reviewed between February 2021 and March 30, 2024, in our single center. The laryngoscopy, magnetic resonance imaging (MRI), and pathologic response were evaluated to the efficacy of neoadjuvant therapy with Tislelizumab plus chemotherapy treatment. Treatment-related adverse events (TRAEs) were evaluated according to the Common Terminology Criteria for Adverse Events version 5.0.

RESULT

Our analysis involved 42 patients who received Tislelizumab combined with chemotherapy. A total of 18 patients underwent surgical treatment following the completion of immunotherapy combined with chemotherapy. Among them, 6 patients achieved pCR (33%). The 1-year OS rate of the 42 patients enrolled in the study was 95.05%, and the 1-year PFS rate was 89.86%. There was a significant positive correlation between the lymphocyte density in HNSCC prior to the administration of neoadjuvant PD-1 inhibitor therapy combined with chemotherapy and the immunotherapy efficacy. Compared with pretreatment, the neutrophil-to-lymphocyte ratio (NLR) was significantly decreased, and the lymphocyte density was significantly increased in HNSCC patients after immunotherapy.

CONCLUSIONS

The integration of neoadjuvant PD-1 inhibitor therapy with chemotherapy has been demonstrated to be a safe and effective strategy, can improve the tumor response rate and survival rate, and is a valuable treatment for patients with HNSCC. Furthermore, the study suggests that an elevated NLR within the HNSCC tumor microenvironment could potentially serve as a biomarker indicative of diminished immunotherapy efficacy.