PRT543, a protein arginine methyltransferase 5 inhibitor, in patients with advanced adenoid cystic carcinoma: An open-label, phase I dose-expansion study

OBJECTIVES

Currently, no systemic treatments are approved for patients with recurrent and/or metastatic (R/M) adenoid cystic carcinoma (ACC). PRT543, a protein arginine methyltransferase 5 inhibitor that downregulates NOTCH1 and MYB signalling in tumours, is a potential candidate for R/M ACC treatment. We report the safety, tolerability and preliminary efficacy of PRT543 in a dose-expansion cohort of patients with R/M ACC.

MATERIALS AND METHODS

This phase I multicentre, open-label, sequential-cohort, dose-escalation and dose-expansion study (NCT03886831) enrolled patients with advanced solid tumours and select haematologic malignancies. Dose-escalation study design and results were reported previously. In the dose expansion, patients with R/M ACC received recommended phase II doses of 35 or 45 mg PRT543 orally on days 1-5 of each week. Primary objectives were to establish the safety and tolerability of PRT543. Secondary objectives included efficacy.

RESULTS

Between February 2019 and May 2022, 56 patients with ACC were enrolled across 23 US sites and received either 35 mg (n = 28) or 45 mg (n = 28) of PRT543. Overall, 23% of patients experienced a grade 3 treatment-related adverse event, most commonly anaemia (16%) and thrombocytopaenia (9%). No grade 4/5 treatment-emergent adverse events were reported. Median progression-free survival was 5.9 months (95% CI: 3.8-8.3). The clinical benefit rate was 57% (95% CI: 43-70). Overall response rate (per Response Evaluation Criteria in Solid Tumours v1.1) was 2%, with 70% of patients having stable disease.

CONCLUSION

In this analysis, PRT543 was tolerable, and the observed efficacy was limited in patients with R/M ACC.

Intensity-Modulated Neutron Therapy (IMNT) for Head and Neck Cancer: Early Toxicity Outcomes

PURPOSE/OBJECTIVE(S)

Locally advanced head & neck cancers (HNC) are challenging to treat due to abutment of critical, dose-limiting structures. Fast neutron radiotherapy (NT) is a high linear energy transfer (LET) modality that provides better local control than photons for radioresistant cancers such as salivary gland tumors, but there have been concerns of toxicity with 3D conformal neutron therapy in the past. Recent technological advances have enabled the planning and delivery of IMNT, which improves target conformality and may reduce toxicity compared to 3D conformal NT. We report the first clinical evaluation of early toxicity outcomes of IMNT for HNC.

MATERIALS/METHODS

Study is a single-institution retrospective review of all HNC patients treated with curative-intent IMNT from 10/2022 to 2/2023, using a hospital-based cyclotron (50.5 MeV 1H+ beam incident on a Be target) equipped with an isocentric gantry and multileaf collimator (MLC). A commercial treatment planning system with custom neutron-specific scattering kernels was used for IMNT planning using 4-6 fields. Patient-specific quality assurance included ionization chamber measurements and a novel 12C(n,2n)11C positron emission portal imaging system. kV portal imaging was used to confirm patient setup prior to each treatment session. All patients were prescribed 18.4 Gy at 1.15 Gy/fraction, delivered 4 days/week, which is equivalent to an x-ray EQD2 of approximately 70 Gy (RBE ∼ 3.8). Clinical observations suggest the RBE for radioresistant HNC may be as large as 8. Patients underwent weekly toxicity assessment, and acute toxicities were graded (G) by CTCAE v5.0.

RESULTS

Ten patients received IMNT, median age 61 (range 34-78). Primary tumor sites were base of tongue (n = 3), sinonasal (n = 3), parotid (n = 2), submandibular (n = 1), larynx (n = 1). Tumor histologies included adenoid cystic carcinoma (n = 7), other salivary gland carcinomas (n = 2) and mucosal melanoma (n = 1). Most had T4 disease (n = 8) and one had N3b disease. Six had surgical resection with high-risk features, and 6 had gross measurable disease prior to IMNT. None had concurrent systemic therapy. Uninvolved salivary glands were spared in most patients. All patients completed treatment. Median follow up was 22 days (0-48). Acute toxicities (n, G 1, 2, 3) included skin (8, 3, 0), dysgeusia (1, 6, 0), xerostomia (3, 5, 0), mucositis (2, 0, 5), nausea (3, 0, 1). One patient had >10% weight loss and brief admission for supportive care and PEG placement; one patient had prophylactic PEG; both regained oral independence during follow-up. There was no Grade 4+ toxicity.

CONCLUSION

IMNT improves the therapeutic ratio compared to 3D conformal NT and expands indications for NT in patients with radiorefractory tumors. Acute toxicity compares favorably with photons. Longer clinical and toxicity follow-up is anticipated. A prospective trial is planned to evaluate quality of life measures.

Radiation therapy for low- and high-risk perineural invasion in head and neck cutaneous squamous cell carcinoma: Clinical outcomes and patterns of failure

BACKGROUND

Perineural invasion (PNI) in head and neck squamous cell carcinoma (HNSCC) portends poor prognosis. Extent of treatment of nerve pathways with varying degrees of PNI and patterns of failure following elective neural radiotherapy (RT) remain unclear.

METHODS

Retrospective review of HNSCC patients with high-risk (clinical/gross, large-nerve, extensive) or low-risk (microscopic/focal) PNI who underwent curative-intent treatment from 2010 to 2021.

RESULTS

Forty-four patients (mean follow-up 22 months; 59% high-risk, 41% low-risk PNI) were included. Recurrence following definitive treatment occurred in 31% high-risk and 17% low-risk PNI patients. Among high-risk patients, 69% underwent surgery with post-operative RT and 46% underwent elective neural RT. Local control (83% low-risk vs. 75% high-risk), disease-free, and overall survival did not differ between groups.

CONCLUSIONS

High local control rates were achieved in high-risk PNI patients treated with adjuvant or primary RT, including treatment of both involved and uninvolved, communicating cranial nerves, with few failures in electively treated regions.

Peripheral lymphocytes and lactate dehydrogenase correlate with response and survival in head and neck cancers treated with immune checkpoint inhibitors

BACKGROUND

Little is known regarding associations between peripheral blood biomarkers (PBBMs) and survival, response, and toxicity in recurrent/metastatic head and neck squamous cell carcinomas (R/M HNSCC) treated with immune checkpoint inhibitors (ICIs).

METHODS

In this single-institution retrospective cohort study, a dataset of patients with R/M HNSCC treated with ICIs between 08/2012-03/2021 was established, including demographic and clinicopathologic characteristics. Pretreatment PBBMs were collected and evaluated for associations with grade ≥3 adverse events (G ≥ 3AE) by CTCAEv5, objective response (ORR) by RECIST 1.1, overall survival (OS), and progression-free survival (PFS). Multivariable models for each outcome were created using elastic net variable selection.

RESULTS

Our study included 186 patients, with 51 (27%) demonstrating complete or partial response to immunotherapy. Multivariable models adjusted for ECOG performance status (PS), p16, and smoking demonstrated that pretreatment higher LDH and absolute neutrophils, as well as lower percent lymphocytes correlated with worse OS and PFS. Higher LDH and lower % lymphocytes also correlated with worse ORR.

CONCLUSIONS

In the largest study to date examining PBBMs in ICI-treated R/M HNSCCs, our variable selection method revealed PBBMs prognostic for survival and response to immunotherapy. These biomarkers warrant further investigation in a prospective study along with validation with CPS biomarker.

Neutrophil to lymphocyte ratio and peripheral blood biomarkers correlate with survival outcomes but not response among head and neck and salivary cancer treated with pembrolizumab and vorinostat

BACKGROUND

Associations between peripheral blood biomarkers and oncologic outcomes were explored in recurrent/metastatic (R/M) head and neck squamous cell carcinoma (HN) and salivary gland cancer (SGC) treated with pembrolizumab and vorinostat on a phase II trial (NCT02538510).

EXPERIMENTAL DESIGN

Twenty-five HN and 25 SGCs were treated with pembrolizumab and vorinostat. Baseline peripheral blood was available in 21 HN and 20 SGCs and evaluated for associations with grade ≥3 adverse events (G ≥ 3AE) by CTCAEv4, objective response rate (ORR), overall survival (OS), and progression-free survival (PFS).

RESULTS

Higher pretreatment neutrophil-to-lymphocyte ratio (NLR) and neutrophils, as well as lower pretreatment lymphocytes and T helper cells correlated with worse OS and PFS. Higher NLR further predicted increased rates of G ≥ 3AEs. No correlations with ORR were observed.

CONCLUSIONS

In a prospectively evaluated cohort of HN and SGCs treated with pembrolizumab and vorinostat, we observed novel associations between peripheral blood biomarkers and oncologic outcomes and toxicities.

Clinical Trial Development in TP53-Mutated Locally Advanced and Recurrent and/or Metastatic Head and Neck Squamous Cell Carcinoma

TP53 mutation is the most frequent genetic event in head and neck squamous cell carcinoma (HNSCC), found in more than 80% of patients with human papillomavirus-negative disease. As mutations in the TP53 gene are associated with worse outcomes in HNSCC, novel therapeutic approaches are needed for patients with TP53-mutated tumors. The National Cancer Institute sponsored a Clinical Trials Planning Meeting to address the issues of identifying and developing clinical trials for patients with TP53 mutations. Subcommittees, or breakout groups, were tasked with developing clinical studies in both the locally advanced and recurrent and/or metastatic (R/M) disease settings as well as considering signal-seeking trial designs. A fourth breakout group was focused on identifying and standardizing biomarker integration into trial design; this information was provided to the other breakout groups prior to the meeting to aid in study development. A total of 4 concepts were prioritized to move forward for further development and implementation. This article summarizes the proceedings of the Clinical Trials Planning Meeting with the goal of developing clinical trials for patients with TP53-mutant HNSCC that can be conducted within the National Clinical Trials Network.

Socioeconomic factors and outcomes among patients with recurrent/metastatic head and neck cancer receiving immunotherapy

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Background: Immune checkpoint inhibitors (ICI) are now a therapeutic standard for recurrent/metastatic head and neck squamous cell cancer (R/M HNSCC). There is limited data on the impact of demographics and socioeconomic (SES) factors on outcomes in this population, and we sought to evaluate these in our single institution cohort. Methods: R/M HNSCC patients (pts) receiving ICI were retrospectively reviewed from an institutional database. SES factors included income, distance to center (dist), marital status, race, and insurance. Median household income by residence zip code was obtained from the US Census Bureau. Time to ICI initiation (TTI) was time from initial visit recommending ICI and first ICI dose. Opiate use was calculated using morphine equivalents prior to ICI initiation and either at best response or end of ICI if no response. Associations between SES factors with overall survival (OS) and TTI were assessed using Cox proportional hazards regression. Binary outcomes were assessed using logistic regression and included ER visits/unplanned hospitalizations (UH) and increase in opioid use. Analyses were adjusted for disease characteristics, smoking status, ECOG, and demographics. Results: Between 1/2012-12/2019, 152 pts received ICI; 124 (82%) were male, with median age of 64 years (range 23-90), and 103 (68%) were partnered/married. The most common races were 114 white (75%), 14 Asian (9%) and 6 Hispanic, any race (4%). Out of 149 (98%) insured pts, 27 (18%) were Medicaid and 69 (46%) Medicare. Median dist was 39 miles (Q1 21, Q3 100), and median income was $80,586 (Q1 $61,202, Q3 $103,059). The most common primary sites were oropharynx (36%), oral cavity (22%), and nasopharynx (7%); 29 (19%) had an ECOG ≥2. While on or within 100 days of ICI, 69 (45%) had ER visits, and 57 (38%) had UH. Increased dist was associated with improved OS (4th vs 1st quartile, p = 0.0002; HR 0.33; 95% CI [0.18,0.59]); we observed no other SES association with OS. Increased opioid use was associated with Medicaid/no insurance (p = 0.05; OR 2.89; 95% CI [1.02,8.77]). No SES association with TTI was found, although there was a nonsignificant trend of higher TTI with increasing dist. We saw no correlation with ER/UH and any SES variables. Conclusions: Among R/M HNSCC pts receiving ICI, insurance had an impact on opiate usage, suggesting more advance disease/higher burden of symptoms and indicating need for augmentation of supportive care in this group. Higher dist was associated with improved OS, even accounting for performance status, which may reflect increased resources in this group. Further studies should examine pt factors that may contribute to disparities in the setting of novel therapies for R/M HNSCC pts.

Gastrostomy, tracheostomy, opioid, and health care utilization among patients with recurrent/metastatic head and neck cancer receiving immunotherapy

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Background: Immune checkpoint inhibitors (ICI) are approved for recurrent and/or metastatic squamous head and neck cancers (R/M HNSCC). Landmark trials have shown stable or improved patient (pt) reported quality of life outcomes. It is unclear how these translate into gastrostomy (G) and tracheostomy (T) dependence, opioid use, or ER/unplanned hospitalizations (UH) in an unselected population. We sought to explore these in our large single institution cohort. Methods: We reviewed R/M HNSCC pts receiving ICI at a tertiary referral NCI designated cancer center. Outcomes were assessed between the first dose of ICI and 100 days after the last dose of ICI. Overall survival (OS) was estimated via Kaplan-Meier estimation. Differences between groups were assessed via log-rank testing procedure and adjusted for age, tumor characteristics, and smoking status. Results: Between 1/2012 and 12/2019, we treated 152 pts with ICI, mostly male (n = 142, 82%), partnered/married (n = 103, 68%), with median age 64 years (range 23 – 90). The most common primary sites were oropharynx (n = 55, 36%) and oral cavity (n = 33, 22%). 50 (35%) had ≥2 lines of prior systemic therapy and 29 (19%) had an ECOG ≥2. The most common pt races were white (n = 114, 75%), Asian (n = 14, 9%), and Hispanic, any race (n = 6, 4%). 83 (55%) and 23 (15%) had history of smoking and heavy alcohol use respectively. Median duration of ICI therapy was 95 days (range 1-1720). Prior to ICI, 49 (32%) had G, 17 (11%) had T, and 15 (10%) had both. While on ICI, 6 (4%) had G placed, and 1 (1%) had a G removed; 1 (1%) had T placed, and 2 (1%) had T removed. 69 (45%) had ER visits and 57 (38%) had UH; 11 (7%) were directly related to ICI adverse effects. Prior to ICI, 104 (68%) were on opiates; requirements increased in 58 (41%) pts and decreased in 17 (12%) pts. Pre-existing G prior to ICI had worse OS on log-rank testing, but significance was lost when adjusted for variables. Pre-existing T prior to ICI (p = 0.001, HR 3.08, 95% Cl [1.56,6.08]), and pts with increasing opiate requirements on ICI (p value = 0.0007, HR 2.13, 95% Cl [1.38,3.28]) had worse OS. Conclusions: In our cohort, ICI did not change G or T usage. Pre-existing T and increasing opiate use were also associated with worse survival. Our data supports augmentation of palliative care and advanced care planning in the R/M HNSCC population.

Oncologic outcomes of salvage surgery and immune checkpoint inhibitor therapy in recurrent head and neck squamous cell carcinoma: A single-institution retrospective study

BACKGROUND

Survival outcomes in recurrent head and neck squamous cell carcinoma (HNSCC) are poor. This study aimed to compare survival outcomes between salvage surgery and immunotherapy in patients with recurrent advanced HNSCC.

METHODS

Patients with advanced stage (stage III or IV) recurrent HNSCC following treatment with platinum-based chemotherapy were included. Survival was estimated using the Kaplan-Meier method, and Cox regression was used for multivariate logistic regression.

RESULTS

Two-year overall survival after salvage surgery was 68.6% and after immunotherapy patients was 24.6%. Multivariate logistic regression showed that salvage surgery was associated with improved survival without statistical significance (hazard ratio [HR] 0.12, p = 0.25). Subgroup analysis of patients with oral cavity/oropharyngeal cancer noted improved survival with salvage surgery over immunotherapy (HR 0.006, p = 0.01) and decreased survival with neutrophil-to-lymphocyte ratio (NLR) > 5 (HR 6.4, p = 0.02).

CONCLUSION

Our retrospective single-institutional data suggest that resectable advanced stage recurrent HNSCC may have improved survival with salvage surgery in appropriately selected patients, but larger prospective studies are required.

Use of medical aid in dying by individuals with cancer at a comprehensive cancer center

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Background: Understanding the experience of individuals with cancer (pts) who utilize Medical Aid in Dying (MAID) is important given growing access and limited research in the U.S. Methods: Chart review from January 1, 2014-October 1, 2020, of all pts who inquired (but did not initiate completion of all legal requirements), initiated (but did not complete all legal requirements to obtain access to the medications), or completed all legal requirements and could have had access to medications (whether or not they were obtained or used) at Seattle Cancer Care Alliance/University of Washington. Chi-square tests were used to compare differences in pt characteristics between the inquired/initiated versus completed group. Results: Of 498 total pts, 116 (23.3%) inquired, 127 (25.5%) initiated, and 255 (51.2%) completed the MAID process, of which, 45.9% (117/255) were known to have used the medications. At time of first inquiry (FI), mean age was 66 years (standard deviation [SD] = 11.9)/median 67.3/range 22-94; 206 (41.4%) were female; and 40 (8.0%) were non-white, while 11 (2.2%) were Hispanic/Latino and 14 (2.8%) were non-English speaking. At FI, 292 (58.6%) pts were married or had a significant other; 152 (30.5%) had a religious affiliation; 23 (4.6%) were uninsured; and 282 (56.6%) had Medicare. Mean months from the original cancer diagnosis and FI was 36.5 (SD = 50.3, range 0.1-366.1). 461 (92.6%) pts had solid/central nervous system (CNS) tumors, of which 231 (46.4%) had presented with metastatic disease. At FI, 84 (16.9%) were currently hospitalized; in total, 236 (47.4%) pts had been hospitalized within the 3 months prior to FI. A total of 71.9% (358/498) had not yet initiated hospice at FI; 51.8% (258/498) had evidence of advance care planning (ACP), including 41.5% (107/258) with a Physician Order for Life Sustaining Treatment on file. Overall, 152 (30.5%) and 166 (33.3%) of pts had seen social work or palliative care in the 30 days prior to FI, while 62 (12.4%) had met with a spiritual health clinician. Statistically significant differences were found between those who inquired/initiated versus completed with the following pt characteristics: non-white (ꭓ2= 6.596, p = .010); Medicaid versus all other insured (ꭓ2= 9.489, p = .002); those hospitalized at FI (ꭓ2= 6.101, p = .014); and those without evidence of ACP (ꭓ2= 17.090, p < .001). Pts with a hematologic malignancy (HM, n = 37/498, 7.4%) were less likely to complete the MAID process compared to pts with solid/CNS tumors (ꭓ2= 7.378, p = .007); 43.2% (16/37) of HM pts did not complete due to rapid decline. Conclusions: Less than half of pts who initially inquired about MAID completed the process. Recent hospitalizations and evidence of ACP were relatively common compared to current utilization of hospice or prior use of supportive care services. Future research should investigate why non-white pts, those with Medicaid and those with HM may be less likely to complete the MAID process.

Death with dignity utilization among patients with thoracic, head, and neck cancer

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Background: Death with Dignity (DWD) legislation, which took effect in 2009 in Washington state, allows terminally ill patients (pts) to self-administer physician-prescribed, life-ending medication. Thoracic, head and neck cancer (THN) pts are among the top cancer types requesting DWD; however, data describing this group are limited. Methods: This retrospective chart review, conducted at Seattle Cancer Care Alliance/University of Washington and Fred Hutch, collected demographics, disease, treatment, support services and steps of the DWD process. We tested the association between disease characteristics of interest and DWD completion using Fisher’s Exact test. Results: Between Jan 2014 and October 2020, 498 pts inquired about DWD, and 108 (22%) were THN pts. Among THN pts, 51 (47%) only initiated the DWD request process, 35 (33%) only completed the DWD request process, and 22 (20%) completed the DWD request and self-administered the medication. Pts were white (n=90, 83%), male (n=64, 59%), primarily English speaking (n=103, 95%), nonreligious (n=69, 64%), single/divorced/non-partnered (n=55, 51%), and insured (n=103, 95%). Median age at request was 68 years (range 35-88). The table details THN DWD utilization. At time of DWD request, the median time from diagnosis was 14 months (range=0.2-242.7), and 62 (57%) had received ≥2 lines of therapy. Among 78 (72%) pts who received systemic therapy, 51 (65%) were ≥30 days from last therapy to time of death. Within 30 days prior to DWD request, 30 (28%), 25 (23%), and 7 (7%) pts saw social work, palliative care, and spiritual health respectively, and 35 (32%) were hospice-enrolled. Stage IV at diagnosis had higher rates of DWD medication use (p=0.05). There was no significant correlation between DWD medication use and primary site, ECOG score at request, insurance type, mental health diagnosis, use of depression/anxiety or pain medications, or hospice enrollment during DWD process. Conclusions: THN pts requesting DWD were predominantly white, nonreligious, insured males. Pts with advanced stage at diagnosis were more likely to use DWD medication. There was a higher proportion of DWD medication use with poorer performance status, and no association between use of depression/anxiety, pain medications, or utilization of supportive care services and DWD medication usage. Future research should investigate DWD utilization among THN pts in multiple centers and states to evaluate these patterns. [Table: see text]

A phase I/II trial of concurrent immunotherapy with chemoradiation in locally advanced larynx cancer

Objectives

Cisplatin-based chemoradiation is an established organ-preserving strategy for locally advanced laryngeal cancer, but long-term survival remains suboptimal. Immunotherapy has been studied in the metastatic and unresectable recurrent settings. However, additional data are needed to assess its role in organ preservation for locally advanced laryngeal cancer.

Methods

This trial was an open-label, single-arm, multi-institutional study with a Phase I run-in portion followed by a planned Phase II component, which closed early due to low accrual. Study patients had Stage III or IV (T2-3; N0-3; M0) laryngeal squamous cell carcinoma and were candidates for larynx preservation. Pembrolizumab was given 2-3 weeks prior to chemoradiation and then, q21 days concurrently with high-dose cisplatin and radiation prescribed to a total dose of 70 Gy. The primary endpoint of the trial was organ-preservation rate (OPR) at 18 months.

Results

A total of nine patients were enrolled with a median follow-up of 30.1 months. No patient required laryngectomy, resulting in 100% OPR at 18 months. The 12-month overall survival (OS) rate was 77.8% and the median duration of OS was not reached. All acute Grade 4 (n = 3) toxicities occurred in a single patient with poorly controlled diabetes at baseline. One patient had late Grade 4 laryngeal edema requiring tracheostomy 8 months after chemoradiation, which self-resolved.

Conclusion

UCCI-HN-15-02 demonstrated the safety of the addition of immunotherapy to definitive chemoradiation and the patient outcomes suggest the potential for improving long-term survival while minimizing negative impact from treatment. While results from this trial were promising, a randomized study with a larger number of patients and longer follow-up is warranted to verify this treatment approach prior to wider adoption. NCT #: NCT02759575.Level of evidence: 2b.

Performance status (PS) as a predictor of poor response to immune checkpoint inhibitors (ICI) in recurrent/metastatic head and neck cancer (RMHNSCC) patients

BACKGROUND

Anti-PD1 checkpoint inhibitors (ICI) represent an established standard-of-care for patients with recurrent/metastatic head and neck squamous cell carcinoma (RMHNSCC). Landmark studies excluded patients with ECOG performance status (PS) ≥2; the benefit of ICI in this population is therefore unknown.

METHODS

We retrospectively reviewed RMHNSCC patients who received 1+ dose of ICI at our institution between 2013 and 2019. Demographic and clinical data were obtained; the latter included objective response (ORR), toxicity, and any unplanned hospitalization (UH). Associations were explored using uni- and multivariate analysis. Overall survival (OS) was estimated using a Cox proportional hazards model; ORR, toxicity, and UH were evaluated with logistic regression.

RESULTS

Of the 152 patients, 29 (19%) had an ECOG PS ≥2. Sixty-six (44%) experienced toxicity; 54 (36%) had a UH. A multivariate model for OS containing PS, smoking status, and HPV status demonstrated a strong association between ECOG ≥2 and shorter OS (p < 0.001; HR = 3.30, CI = 2.01-5.41). An association between OS and former (vs. never) smoking was also seen (p < 0.001; HR = 2.17, CI = 1.41-3.35); current smoking did not reach statistical significance. On univariate analysis, poor PS was associated with inferior ORR (p = 0.03; OR = 0.25, CI = 0.06-0.77) and increased UH (p = 0.04; OR = 2.43, CI = 1.05-5.71). There was no significant association between toxicity and any patient characteristic.

CONCLUSIONS

We observed inferior OS, ORR, and rates of UH among ICI-treated RMHNSCC patients with ECOG 2/3. Our findings help frame discussion of therapeutic options in this poor-risk population.

NCCN Guidelines® Insights: Head and Neck Cancers, Version 1.2022

The NCCN Guidelines for Head and Neck Cancers address tumors arising in the oral cavity (including mucosal lip), pharynx, larynx, and paranasal sinuses. Occult primary cancer, salivary gland cancer, and mucosal melanoma (MM) are also addressed. The specific site of disease, stage, and pathologic findings guide treatment (eg, the appropriate surgical procedure, radiation targets, dose and fractionation of radiation, indications for systemic therapy). The NCCN Head and Neck Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's most recent recommendations regarding management of HPV-positive oropharynx cancer and ongoing research in this area.

High End-of-Life Health Care Utilization in a Contemporary Cohort of Head and Neck Cancer Patients Treated with Immune Checkpoint Inhibitors

Background/Objective: End-of-life health care utilization (EOLHCU) is largely uncharacterized among patients with recurrent/metastatic head and neck squamous cell carcinomas (RMHNSCC), particularly now that immune checkpoint inhibitors (ICI) have been introduced to the treatment landscape. We examined this in a single-institution, retrospective study. Design/Settings: We utilized a database of deceased, ICI-treated RMHNSCC patients to obtain demographic and EOLHCU data, the latter of which included advanced care plan documentation (ACPD) and systemic therapy or emergency room (ER)/hospital/intensive care unit (ICU) admission within 30 days of death (DOD). This was compared with a cohort of deceased thoracic malignancy (TM) patients in an exploratory analysis. Multivariate analysis was performed to examine for association between patient factors (such as age, Eastern Cooperative Oncology Group (ECOG) performance status, or smoking status) and overall survival (OS); associations between the said patient factors and EOLHCU were also evaluated. This study was conducted at an academic, tertiary center in the United States. Results: The RMHNSCC patients (n = 74) were more likely to have ACPD (p < 0.01), an emergency department visit (p < 0.01), and/or hospital admission (p < 0.01) within 30 DOD relative to the TM group. There was no difference in ICU admissions, ICU deaths, or systemic therapy at end of life (EOL). The OS declined in association with ECOG performance status (PS) and smoking. No association was observed between patient factors and any EOLHCU metric. Conclusions: At our center, patients with ICI-treated RMHNSCC have higher rates of both ACPD and EOLHCU, suggesting high symptom burden and representing opportunities for further study into supportive care augmentation.

Timing of postoperative radiation therapy and survival in resected salivary gland cancers: Long-term results from a single institution

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Background: Timely administration of postoperative radiation therapy (PORT) impacts oncologic outcomes in resected squamous cell carcinomas of the head and neck. Salivary gland cancers (SGCs) are uncommon, and timing of PORT has not been extensively explored. We aimed to determine if the interval between surgery and PORT impacts outcomes in SGCs. Methods: We retrospectively identified patients with SGCs who underwent curative intent surgical resection followed by adjuvant PORT at our tertiary referral center. Demographic, tumor, and treatment data were collected. Patients with non-oncologic resections and/or delay of > 6 months to radiation start were excluded. Locoregional control (LRC), relapse free survival (RFS), and overall survival (OS) were estimated using the Kaplan Meier method. A multivariate analysis explored the association between demographics, tumor characteristics, and PORT timing with oncologic outcomes using a stepwise Cox proportional hazards model. Results: Between 1/1/1997 and 12/31/2017 180 eligible patients were identified. Patient characteristics are described in Table. The median time to PORT start was 61 (range 8-121) days, 169 (93.9%) of patients received neutron beam PORT. With a median follow up of 8.2 years in surviving patients, the 5-year OS and LRC estimates were 73% and 67%, respectively. In a multivariate analysis, only nodal involvement, histologic grade, and age at diagnosis were associated with OS, while nodal involvement, tumor size, and age at time of diagnosis were associated with LCR and RFS. Time to PORT start or completion was not statistically associated with survival outcomes on multivariate analysis. Conclusions: SGC patients who underwent surgery in our tertiary institution received PORT within a median of 61 days after surgery. With long term follow up, PORT timing in this retrospective series was not associated with worse oncologic outcomes, and support timely administration of PORT with 3 months of surgical resection. Further work is necessary to assess generalizability of these results.[Table: see text]

Impact of ECOG performance status on recurrent/metastatic head and neck squamous cell carcinomas treated with anti-PD1 inhibitors

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Background: Anti-PD1 checkpoint inhibitors (ICI) represent an established standard of care for patients with recurrent/metastatic head & neck squamous cell carcinoma (RMHNSCC). Landmark studies excluded patients with ECOG performance status (PS) ≥ 2; the benefit of ICI in this population is therefore unknown. Methods: We retrospectively reviewed RMHNSCC patients who received at least 1 dose of ICI at our institution. Demographic data and clinical outcomes were obtained; the latter included objective response to ICI (ORR), physician-documented CTCAE grade 2+ toxicity (irAE), and any unplanned hospitalization within 100-days of last ICI dose (UH). Associations between demographic data and clinical outcomes were explored using both uni- and multivariate analysis. Overall survival (OS) was estimated using a Cox proportional hazards model; ORR, irAE, and UH were evaluated with logistic regression. This project was approved by our institutional IRB. Results: We identified 152 RMHNSCC patients who were treated with ICI between 1/2013 and 1/2019. ECOG PS was 0 in 42 (27%), 1 in 75 (50%), 2 in 27 (18%), 3 in 2 (1%), and unknown in 6 (4%) patients. The median age was 61 (range: 25 - 90). 124 (82%) were male, 124 (82%) were white, and 69 (45%) were never-smokers. The most common primary sites were the oropharynx (n = 59, 40%), oral cavity (n = 39, 26%), nasopharynx (n = 11, 7%), and larynx (n = 10, 6%). 54 (36%) were p16+ oropharynx cancers. CPS score was available in 10 (6.6%). Single agent ICI was received by 118 (77%) patients. 66 (44%) had a documented irAE and 54 (36%) had an UH. A multivariate model for OS containing PS, smoking status and HPV status showed a strong association between inferior OS and ECOG 2/3 compared to 0/1 (p < 0.001; HR = 3.30, CI = 2.01-5.41), as well as former (vs. never) smoking status (p < 0.001; HR = 2.17, CI = 1.41-3.35). Current smoking (p = 0.25) did not reach statistical significance. On univariate analysis, poor PS was associated with inferior ORR (p = 0.03; OR = 0.25, CI = 0.06-0.77) and increased UH (p = 0.04; OR = 2.43, CI = 1.05—5.71). There was no significant association between irAE and any patient characteristic. Conclusions: We observed inferior overall survival among ICI-treated RMHNSCC patients with ECOG 2/3 in our single-institution, retrospective series. Our findings help frame discussion of therapeutic options in this poor-risk population. Further study must be done to determine which interventions are of greatest benefit for RMHNSCC patients with declining performance status.

Head and Neck Cancers, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology

Treatment is complex for patients with head and neck (H&N) cancers with specific site of disease, stage, and pathologic findings guiding treatment decision-making. Treatment planning for H&N cancers involves a multidisciplinary team of experts. This article describes supportive care recommendations in the NCCN Guidelines for Head and Neck Cancers, as well as the rationale supporting a new section on imaging recommendations for patients with H&N cancers. This article also describes updates to treatment recommendations for patients with very advanced H&N cancers and salivary gland tumors, specifically systemic therapy recommendations.

End-of-life health care utilization (EOLHCU) in patients with recurrent, metastatic head and neck squamous cell carcinoma (RMHNSCC) treated with immune checkpoint inhibitors (IO)

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Background: Demographic and EOLHCU trends are undefined in the growing population of IO-treated RMHNSCC; we sought to study these in a single institution retrospective study. Methods: We identified 228 RMHNSCC pts who received ≥1 IO dose between 01/2013 and 12/2018; of these, 74 were deceased with accessible EOLHCU data such as advanced care plan documentation (ACPD) or evidence of systemic therapy or ER/hospital/ICU admission within 30 days of death (DOD). Demographic, tumor and treatment data were obtained. Overall survival (OS) was estimated using the Kaplan Meier method; multivariable analysis was performed using a Cox proportional hazards model. In an exploratory analysis, EOLHCU was compared to a cohort of 379 deceased thoracic malignancy (TM) pts using a chi-square test. This project was approved by our institutional IRB. Results: Median pt age was 62 (25 – 90). Most were male (56, 75%), white (60, 81%), current/former smokers (46, 62%); 34 (46%) smoked ≥10 pack years. Common primary sites included the oral cavity (28, 37.8%) and oropharynx (24, 32.4%). ECOG PS at IO initiation was 0 in 15 pts (20%,) 1 in 37 (50%), 2 in 20 (27%), 3 in 1 (1%), and unknown in 1 (1%). Of the 42 (57%) treated off-trial, 18 (42%) had an ECOG ≥ 2. 71 (95%) had prior curative intent therapy. 42 (57%) had distant metastases. Compared to TM, IO-treated RMHNSCC pts were more likely to have ACPD (66% vs. 45% p < 0.01), an ED visit (42.3% vs 19.5%, p < 0.01) and/or a hospital admission (42.3% vs 17%, p < 0.01) within 30 DOD. There was no difference in ICU admissions within 30 DOD (9.9% vs. 8.2%, p = 0.81), ICU deaths (7% vs. 4%, p = 0.4), or systemic therapy within 7 (4.2% vs. 2.4%, p = 0.63), 14 (8.5% vs. 6.6%, p = 0.76) or 30 (25% vs 19%, p = 0.31) DOD. Among IO-treated RMHNSCC pts, multivariable analysis revealed inferior OS with worse PS (ECOG 2-3 vs. 0: HR = 7.76, p = 0.00002, 95% CI = 3.07 - 19.64; ECOG 1 vs. 0: HR = 2.97, p = 0.008, CI = 1.33 - 6.62). OS also decreased with smoking status (current/former vs. never: HR 2.18, p = 0.007, CI = 1.24-3.84). No association was observed between ECOG PS, age or smoking status at IO initiation and any EOLHCU metric. Conclusions: At our center, a significant proportion of deceased, IO-treated RMHNSCC pts had an ECOG PS ≥ 2 and an inferior OS compared to ECOG 0/1. Exploratory comparison with a non-RMHNSCC TM cohort suggests high rates of EOLHCU within 30 DOD despite ACPD, representing an opportunity for supportive care augmentation. Whether EOLHCU differs among IO vs non-IO treated RMHNSCC is unknown and merits further study.

End-of-life health care utilization (EOLHCU) in patients with thoracic, head and neck cancers with or without phase I study participation at a single institution

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Background: Several retrospective studies suggest patients enrolled in clinical trials have more end-of-life health care utilization (EOLHCU). This is particularly concerning for phase I clinical trial participants who are known to have therapeutic misconceptions about the purpose and benefits of phase I clinical trial participation. Methods: We identified all phase I participants at the Seattle Cancer Care Alliance (SCCA) with thoracic, head and neck cancers (THNC) who died between July 1, 2014 and June 30, 2018(P1C). We compared them to 139 randomly selected THNC patients who died within the same time period without phase I study participation (NP1C). Patient records were abstracted from the electronic health record (and Epic Care Everywhere if patients received EOL care outside of SCCA). A chi-square test was used to compare categorial variables and t-tests were used for numerical variables. Results: 67 P1C patients were identified; 3 patients had no outside records at the end of life and were removed from the database. No statistically significant differences in gender, ethnicity, marital status, or form of insurance were found between the two groups. P1C patients were younger (median age of 62 (interquartile range (IQR) 55-69) vs. 66 (IQR 59-72), p=0.008) and had more lines of therapy from diagnosis until death (median 4 (IQR 1-3) vs. 2 (IQR 1-3), p=<0.0001). No difference in end-of-life care or quality of death metrics were found between the two groups, however a trend toward more referrals to palliative care were noted in phase I participants. (Table). Conclusions: At our center no differences in EOLHCU or quality of death parameters were seen in THNC patients who did or did not participate in phase I studies. [Table: see text]

NCCN Guidelines Insights: Head and Neck Cancers, Version 1.2018

The NCCN Guidelines for Head and Neck (H&N) Cancers provide treatment recommendations for cancers of the lip, oral cavity, pharynx, larynx, ethmoid and maxillary sinuses, and salivary glands. Recommendations are also provided for occult primary of the H&N, and separate algorithms have been developed by the panel for very advanced H&N cancers. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding evaluation and treatment of nasopharyngeal carcinoma.

The role of elective neck dissection in high-grade parotid malignancy: A hospital-based cohort study

OBJECTIVES/HYPOTHESIS

The role of elective neck dissection (END) in patients with clinically N0 (cN0), high-grade parotid carcinoma is unclear. The objective of this study was to assess the association between END and survival in patients with cN0, high-grade parotid carcinoma.

STUDY DESIGN

Retrospective, multicenter cohort study.

METHODS

A review of hospital-based cases from the National Cancer Data Base was performed. Participants included patients diagnosed with cN0, high-grade parotid cancer between January 1, 2004 and December 31, 2013. The primary exposure was receipt of neck dissection. Secondary exposures included receipt of adjuvant radiation and/or chemotherapy. Univariate and multivariate survival analyses were performed. Unadjusted and adjusted survival estimates were determined.

RESULTS

Overall, 1,547 patients were included, with a median follow-up time of 48 months. END did not have a statistically significant effect on 3-year survival (3-year: 69.9%, 95% confidence interval [CI]: 67.2 to 72.6). Survival at 3-years among those not receiving END was 66.1% (95% CI: 62.7 to 69.5). Parotidectomy and adjuvant radiotherapy had the strongest effect on mortality. There was no difference in 3-year survival among patients who underwent parotidectomy and adjuvant radiation stratified by receipt of END nor did END have a statistically significant effect on survival in mucoepidermoid carcinoma, adenocarcinoma, high-risk histology, high T stage, or academic center treatment subgroups.

CONCLUSIONS

END did not have a statistically significant effect on survival among cN0 patients with high-grade parotid cancer when taking into account receipt of adjuvant therapy and confounding. The role of END on survival and locoregional control remains to be further elucidated in prospective studies.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1487-1495, 2020.

A Phase I/Ib Trial of the VEGFR-Sparing Multikinase RET Inhibitor RXDX-105

RET fusions are oncogenic drivers of various tumors, including non-small cell lung cancers (NSCLC). The safety and antitumor activity of the multikinase RET inhibitor RXDX-105 were explored in a phase I/Ib trial. A recommended phase II dose of 275 mg fed daily was identified. The most common treatment-related adverse events were fatigue (25%), diarrhea (24%), hypophosphatemia (18%), maculopapular rash (18%), and nonmaculopapular rash (17%). In the phase Ib cohort of RET inhibitor-naïve patients with RET fusion-positive NSCLCs, the objective response rate (ORR) was 19% (95% CI, 8%-38%, n = 6/31). Interestingly, the ORR varied significantly by the gene fusion partner (P < 0.001, Fisher exact test): 0% (95% CI, 0%-17%, n = 0/20) with KIF5B (the most common upstream partner for RET fusion-positive NSCLC), and 67% (95% CI, 30%-93%, n = 6/9) with non-KIF5B partners. The median duration of response in all RET fusion-positive NSCLCs was not reached (range, 5 to 18+ months). SIGNIFICANCE: Although KIF5B-RET is the most common RET fusion in NSCLCs, RET inhibition with RXDX-105 resulted in responses only in non-KIF5B-RET-containing cancers. Novel approaches to targeting KIF5B-RET-containing tumors are needed, along with a deeper understanding of the biology that underlies the differential responses observed.This article is highlighted in the In This Issue feature, p. 305.

Management of the Neck in Squamous Cell Carcinoma of the Oral Cavity and Oropharynx: ASCO Clinical Practice Guideline

PURPOSE

The aim of the current work is to provide evidence-based recommendations to practicing physicians and others on the management of the neck in patients with squamous cell carcinoma of the oral cavity and oropharynx.

METHODS

ASCO convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and prospective and retrospective comparative observational studies published from 1990 through 2018. Outcomes of interest included survival, regional disease control, neck recurrence, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

The literature search identified 124 relevant studies to inform the evidence base for this guideline. Six clinical scenarios were devised; three for oral cavity cancer and three for oropharynx cancer, and recommendations were generated for each one.

RECOMMENDATIONS

For oral cavity cancers, clinical scenarios focused on the indications for and the hallmarks of a high-quality neck dissection, indications for postoperative radiotherapy or chemoradiotherapy, and whether radiotherapy alone is sufficient elective treatment of an undissected neck compared with high-quality neck dissection. For oropharynx cancers, clinical scenarios focused on hallmarks of a high-quality neck dissection, factors that would favor operative versus nonoperative primary management, and clarifying criteria for an incomplete response to definitive chemoradiation for which salvage neck dissection would be recommended. Consensus was reached and recommendations were made for all six clinical scenarios. Additional information is available at www.asco.org/head-neck-cancer-guidelines .

Postoperative Combined Modality Treatment in High Risk Resected Locally Advanced Squamous Cell Carcinomas of the Head and Neck (HNSCC)

Patients who undergo upfront curative intent resection for locally advanced squamous cell carcinomas and who have adverse pathologic features benefit from adjuvant therapy. Concurrent cisplatin based chemoradiation is an established standard of care endorsed by national guidelines. Controversy now exists on the applicability of this strategy to the good risk human papilloma virus (HPV) related oropharynx cancer (OPC) patient. Ongoing clinical studies are exploring therapeutic de-escalation in the postoperative setting for this distinct patient population. The introduction of immune checkpoint inhibitors to the therapeutic armamentarium for recurrent/metastatic head and neck cancer patients has led to clinical investigation of incorporation of PD-1 inhibition in the postoperative setting.

The mutational landscape of recurrent versus nonrecurrent human papillomavirus-related oropharyngeal cancer

BACKGROUND

Human papillomavirus-related (HPV-related) oropharyngeal squamous cell carcinomas (OPSCCs) have an excellent response rate to platinum-based chemoradiotherapy. Genomic differences between primary HPV-related OPSCCs that do or do not recur are unknown. Furthermore, it is unclear if HPV-related OPSCCs that recur share a genomic landscape with HPV-negative head and neck cancers (HNCs).

METHODS

We utilized whole exome sequencing to analyze somatic nucleotide (SNVs) and copy number variants (CNVs) among a unique set of 51 primary HPV-related OPSCCs, including 35 that did not recur and 16 that recurred. We evaluated 12 metachronous recurrent OPSCCs (7 with paired primary OPSCCs) and 33 primary HPV-unrelated oral cavity and OPSCCs.

RESULTS

KMT2D was the most frequently mutated gene among primary HPV-related OPSCCs (n = 51; 14%) and among metachronous recurrent OPSCCs (n = 12; 42%). Primary HPV-related OPSCCs that recurred shared a genomic landscape with primary HPV-related OPSCCs that did not recur. However, TSC2, BRIP1, NBN, and NFE2L2 mutations occurred in primary OPSCCs that recurred but not in those that did not recur. Moreover, primary HPV-related OPSCCs that recur harbor features of HPV-unrelated HNCs, notably including MAPK, JAK/STAT, and differentiation signaling pathway aberrations. Metachronous recurrent OPSCCs shared a genomic landscape with HPV-unrelated HNCs, including a high frequency of TP53, CASP8, FAT1, HLA-A, AJUBA, and NSD1 genomic alterations.

CONCLUSION

Overall, primary HPV-related OPSCCs that recur share a genomic landscape with nonrecurrent OPSCCs. Metachronous recurrent OPSCCs share genomic features with HPV-negative HNCs. These data aim to guide future deescalation endeavors and functional experiments.

FUNDING

This study is supported by the American Cancer Society (RSG TBG-123653), funding support for RAH (T32DC00018, Research Training in Otolaryngology, University of Washington), funds to EM from Seattle Translational Tumor Research (Fred Hutchinson Cancer Research Center), and center funds from the Fred Hutchinson Cancer Research Center to EM. UD is supported by the Department of Veterans Affairs, Biomedical Laboratory Research and Development (BLR&D), grant IO1-oo23456, and funds from the Pittsburgh Foundation and PNC Foundation.

A Phase I Clinical Trial of AZD1775 in Combination with Neoadjuvant Weekly Docetaxel and Cisplatin before Definitive Therapy in Head and Neck Squamous Cell Carcinoma

Purpose: The WEE1 tyrosine kinase regulates G₂-M transition and maintains genomic stability, particularly in p53-deficient tumors which require DNA repair after genotoxic therapy. Thus, a need arises to exploit the role of WEE1 inhibition in head and neck squamous cell carcinoma (HNSCC) mostly driven by tumor-suppressor loss. This completed phase I clinical trial represents the first published clinical experience using the WEE1 inhibitor, AZD1775, with cisplatin and docetaxel.Patients and Methods: We implemented an open-label phase I clinical trial using a 3+3 dose-escalation design for patients with stage III/IVB HNSCC with borderline-resectable or -unresectable disease, but who were candidates for definitive chemoradiation. Escalating AZD1775 was administered orally twice a day over 2.5 days on the first week, then in combination with fixed cisplatin (25 mg/m²) and docetaxel (35 mg/m²) for 3 additional weeks. The primary outcome measure was adverse events to establish MTD. Secondary measures included response rates, pharmacokinetics (PK), pharmacodynamics, and genomic data.Results: The MTD for AZD1775 was established at 150 mg orally twice per day for 2.5 days. RECISTv1.1 responses were seen in 5 of 10 patients; histologic adjustment revealed three additional responders. The only drug-limiting toxicity was grade 3 diarrhea. The PK C8hr target of 240 nmol/L was achieved on day 4 at all three doses tested. Pharmacodynamic analysis revealed a reduction in pY15-Cdk, and increases in γH2AX, CC3, and RPA32/RPA2 were noted in responders versus nonresponders.Conclusions: The triplet combination of AZD1775, cisplatin, and docetaxel is safe and tolerable. Preliminary results show promising antitumor efficacy in advanced HNSCC, meriting further investigation at the recommended phase II dose. Clin Cancer Res; 24(12); 2740-8. ©2018 AACR.

Immunotherapy for Head and Neck Cancer in the Era of Exponentially Increasing Health Care Expenditure

The FDA‐approved immune checkpoint inhibitors, nivolumab and pembrolizumab, are the most recent biological therapies in the therapeutic armamentarium for recurrent metastatic head and neck squamous cell carcinomas. This article highlights the tools for analyzing the costeffectiveness of such therapies.

Abstract 2713: The mutational landscape of recurrent and nonrecurrent human papillomavirus-associated head and neck squamous cell carcinoma

Background: Despite the better prognosis for human papillomavirus (HPV)-associated head and neck squamous cell carcinoma (HNSCC) compared to HPV-negative HNSCC, 10% to 25% of HPV-associated cases recur within 3 years of completing therapy. We sought to compare the mutational profiles of primary tumors among recurrent and non-recurrent HPV-associated HNSCC. We hypothesized that the mutational profile of primary tumors from recurrent cases resembles that of HPV-negative HNSCC.

Methods: Sequencing was performed on DNA extracted from the primary tumors of p16-positive recurrent and non-recurrent HNSCC cases utilizing a high-coverage (&gt;500X), CLIA-certified, 262 multiplexed gene sequencing panel (i.e., UW OncoPlex). Primary tumors from 11 recurrent and 13 non-recurrent cases were included in our sample. Mutational differences between the primary tumors of recurrent and non-recurrent tumors were evaluated.

Results: 88% of patients were male with a mean (standard deviation; SD) age of 60.3 (11) years. Among the recurrent cases, 100% arose from the oropharynx. Among the non-recurrent cases, 77% arose from the oropharynx with the remainder originating from the oral cavity, nasal cavity, and larynx. 83% of patients presented with stage III or higher disease, and the median survival time was 21 months and 19 months among the recurrent and non-recurrent cases, respectively. The mean (SD) number of somatic nucleotide variants per tumor among the recurrent cases was 16.4 (12.2) compared to 4.3 (1.5) among non-recurrent cases (p &lt; 0.05). The ratio of nonsynonymous to synonymous variants among primary tumors of recurrent cases was 2 vs 5 among the non-recurrent cases (p = 0.224). Among primary tumors of recurrent cases, 17% of variants included indels, splice site, and nonsense mutations vs 14% of variants among the non-recurrent cases. The mean (SD) number of tumor suppressor mutations per tumor was 1.2 (1.3) among recurrent cases vs 1.0 (1.0) among non-recurrent cases (p = 0.81). Interestingly, the mean (SD) number of mutations in DNA damage response (DDR) genes among the primary tumors of recurrent cases was 2.7 (2.4) compared to 0.7 (1.2) mutations per tumor among non-recurrent cases (p = 0.07).

Conclusion: We observed a greater mutational burden among the primary tumors of recurrent HPV-associated HNSCC compared to non-recurrent HNSCC. Moreover, among the primary tumors of recurrent cases, there were more mutations in DNA damage response genes coupled and relatively fewer deleterious mutations compared to non-recurrent cases. Dysregulation of DDR genes may select for advantageous mutations via genomic instability. Alternatively, gain of function of DDR genes may promote treatment resistance. Future work aims to further characterize mutational differences between the primary tumors of HPV-associated recurrent and non-recurrent HNSCC and evaluate mechanisms promoting treatment resistance.

Citation Format: Richard A. Harbison, Mark Kubik, Eric Q. Konnick, Seok-Geun Lee, Michael Kao, Michael Mason, Thomas Yu, Chang Xu, Daniel Faden, Colin C. Pritchard, Cristina P. Rodriguez, Chu Chen, Justin Guinney, Umamaheswar Duvvuri, Eduardo Mendez. The mutational landscape of recurrent and nonrecurrent human papillomavirus-associated head and neck squamous cell carcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 2713. doi:10.1158/1538-7445.AM2017-2713

Clonal repopulation dynamics in recurrent human papillomavirus-associated head and neck cancer

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Background: Despite the better prognosis for human papillomavirus (HPV)-associated head and neck cancer (HNC) relative to HPV-negative HNC, 10 to 25% of HPV-associated cases recur within 3 years of completing therapy. We sought to investigate clonal repopulation dynamics in recurrent HPV-related oropharyngeal squamous cell carcinoma (OPSCC). Methods: Deep sequencing ( > 500X) using a CLIA-certified, targeted 262-gene multiplexed assay was performed on DNA extracted from 11 pairs of matched FFPE-preserved primary and subsequent recurrent p16-positive OPSCC samples including two pairs from the University of Washington and nine from the University of Pittsburgh. Results: 82% of patients were male with a median (IQR) age of 62 (15) years. Nine of eleven patients presented with advanced stage disease. Five were initially treated with surgery and concurrent chemoradiation, two with surgery, and four with concurrent chemoradiation. Median (IQR) time to recurrence was 10 (10.5) months. Four patients reported a history of tobacco use. The mean (SD) number of somatic nucleotide variants (SNVs) per tumor was 16.4 (12.2). 42% of SNVs occurred in the primary alone while 28% were unique to recurrences. 28% of SNVs were shared between primary-recurrent pairs. Three patients with distant or regional recurrences had different mutational profiles between the primary and recurrence suggesting repopulation by an early-appearing clone vs sampling error. One patient developed two local recurrences with conserved mutations in addition to de novo mutations in each subsequent recurrence suggesting repopulation by early and late evolving clones. Genes with a substantial functional impact that were frequently mutated in primary tumors include IDH2 and FBXW7. Recurrently mutated genes found in recurrent tumors include TET3, PIK3CA, STK11, and HDAC4. Conclusions: In thistargeted exome sequencing study of matched primary-recurrent OPSCC tumor pairs, we observed clonal repopulation with both transmitted and de novo mutations. Intriguingly, we noted a predilection for mutations involving genes regulating metabolism including IDH2 among primary tumors which has potential implications for precision medicine approaches.

Patterns of recurrence in patients with sinonasal undifferentiated carcinoma (SNUC) treated with multimodality therapy at a single center

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Background: SNUCs are rare and without established therapeutic standards. This is a retrospective review of therapeutic outcomes in pts with SNUCs treated at our center. Methods: Data was collected retrospectively on pts with a confirmed diagnosis of SNUC treated at the University of Washington Medical Center. Demographic data, tumor/treatment characteristics,and dates of recurrence/progression and death were recorded. The Kaplan Meier method was used to estimate survival outcomes; the log-rank and Wilcoxon tests were used to explore associations of clinical characteristics with outcome. Results: Between 5/1992 and 11/2016, 32 pts were treated, 1 was excluded due to incomplete data. The median age was 52 (range 22-82) years, 14(45%) were female, 26(83%) were white, 17(54%) reported current or former tobacco use. One presented with distant metastases, 1 had T2N0 disease, and all other pts had locally advanced disease. Six pts had nodal involvement on initial staging, and 25 patients had T4 disease. Eleven(35%) pts had no skull base/CNS invasion, 7(22%) had skull base extension up to the cribriform plate, 13(42%) had extension beyond the cribriform plate and into the CNS. Twenty-one(67%) pts underwent surgical resection, 29(93%) underwent radiation(XRT) with a median dose of 70 (range 54-72) Gy, and 28(90%) received cisplatin based chemotherapy, with 24 of these given concurrent with XRT, 19(60%) were treated with surgery followed by chemoradiation. With a median 61 months of follow up, 15 pts have recurred, 10 of these recurrences occurred in local sites, with 6 having intracranial progression, 2 of which were leptomeningeal. The median time to progression was 15 months and median overall survival was 58 months . Any vs no tobacco use (58 vs 35 mo p = 0.8), was not predictive of overall survival. The presence of nodal disease (87 vs 7 mo p = 0.005), and CNS invasion beyond the cribriform plate (NR vs 14 mo p = 0.04) was associated with inferior median overall survival. Conclusions: Local/CNS recurrence was the predominant failure pattern in our pts. CNS invasion beyond the cribriform plate and nodal disease were associated with significantly worse survival.

Prognostic significance of performance status in patients with head and neck squamous cell carcinomas (HNSCC) receiving immune checkpoint monoclonal antibodies (ICmAB) in a single institution

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Background: The anti-PD1/-PDL1 ICmABs can result in objective responses in some (13-20%) patients (pts) with HNSCC. We evaluated clinical factors that may predict oncologic outcomes. Methods: We identified pts who received an ICmAB at our institution and retrospectively collected demographic, tumor, treatment, progression, and survival data. The Kaplan Meier method was used to estimate survival. Log-rank and Wilcoxon tests were used to explore associations between clinical features and outcomes. Results: 55 pts received ICmAB in a clinical trial at our center from 8/2012 to 12/2016. The median age was 64 years, 13 (24%) were female, and 45 (82%) were white. ECOG Performance Status (PS) was 0 and 1 in 23 (42%) and 32 (58%) pts, respectively. 29 (53%) were current/former smokers who smoked a median of 20 (range 0-70) pack years. Primary sites included: oropharynx (OP) 31 (56%), oral cavity 9 (16%), nasopharynx 6 (11%), nasal cavity 3 (5%), hypopharynx (HP) 2 (4%), unknown (UK) 2 (4%), and skin 2 (4%). 28 (51%) were p16+, with the following primary sites: OP in 26, UK in 1, and HP in 1. 53 (96%) received prior curative intent therapy. A median of 2 (range 0-5) lines of systemic therapy (including curative intent) were given prior to ICmAB initiation, and 31 received an ICmAB as a single agent. There were 19 (35%) objective responses with 1 complete response, and 14 (25%) had stable disease. With a median follow-up of 12 months (m), the median overall survival (OS) was 15m (95% CI 11,47), and median time to progression was 4m (95% CI 2.2, 6.8). An ECOG PS of 0 vs 1 was associated with superior OS (36m vs 11m p = 0.001). Tobacco use, p16+ disease, single agent ICmAB vs. combination, number of lines of prior systemic therapy, or radiation therapy within 3m prior to ICmAB initiation did not appear to have a relationship with survival. Conclusions: A PS of 0 predicted for more favorable OS among HNSCC pts receiving ICmAB in this single center retrospective cohort. In contrast to data with chemotherapy, established prognostic markers (including p16+ and limited/no tobacco use) did not appear to impact survival.

A phase I clinical trial of AZD1775 in combination with neoadjuvant weekly cisplatin and docetaxel in borderline resectable head and neck squamous cell carcinoma (HNSCC)

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Background: The WEE1 tyrosine kinase regulates G2/M transition and maintains genomic stability. In TP53-deficient tumors (via mutation or HPV inactivation), inhibiting WEE1 with AZD1775 can lead to unrestrained mitosis and cell death. We conducted a Phase I clinical trial of AZD1775 in combination with chemotherapy to define the toxicity profile, establish the maximal tolerated dose (MTD) and assess preliminary efficacy in borderline resectable HNSCC. Methods: Stage III/IVB HNSCC deemed borderline resectable by a multidisciplinary team were enrolled in a phase 1, 3 + 3 design to evaluate escalating doses of AZD1775 starting at 125 mg PO BID x 2.5 days alone as lead-in and in combination with cisplatin (25mg/m2) and docetaxel (35 mg/m2) for three additional weeks. Tumors were sequenced with UWOncoPlex (262 cancer genes); HPV status assessed via p16 IHC; toxicities graded with CTCAE v. 4.04; responses measured via RECIST 1.1 and through pathologic assessment when available. Trial is open but primary endpoints were met. Results: Eleven patients were screened; 10 enrolled and were evaluable for toxicities. The most common Grade ≥ 2 toxicities were diarrhea (4), fatigue (4), neutropenia (3) and nausea (3). The drug-limiting toxicity was Grade 3 diarrhea (2). The MTD was established at 150mg PO BID x 2.5 days, alone and in combination with neoadjuvant cisplatin and docetaxel. Two patients were HPV+/TP53wt, 1 was HPV+/ TP53 mut; 6 were TP53mut/HPV-; 1 was TP53 wt/HPV-. Seven out 10 patients had a response. Two patients dropped out after the first week with AZD1775, one due to an allergic reaction to docetaxel and another due to non-compliance. Eight completed neoadjuvant therapy and 7 of those converted to surgery: 2 had pathologic CRs (both HPV+/TP53wt); 4 had PR (all TP53 mutants); 1 (TP53wt/HPV-) had a PR by RECIST, but SD by pathology and 1 had PD. Conclusions: AZD1775 is safe and tolerable in combination with neoadjuvant cisplatin and docetaxel. Results show this combination to have promising anti-tumor efficacy in borderline resectable HNSCC with TP53 deficiency, and merits further investigation with the established MTD as the recommended Phase II dose. Clinical trial information: NCT02508246.

Outcomes of definitive radiotherapy (dRT) and chemo-radiotherapy (dCRT) for loco-regionally confined (LRC) adenocarcinoma (ACA) of the esophagus and gastro-esophageal junction (E/GEJ)

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Background: Surgery is the cornerstone of curative intent therapy for patients with ACA of the E/GEJ. Many patients (pts) with LRC disease are medically unsuitable for resection, and thus alternative treatment strategies are required. Definitive CRT is a standard of care for esophageal squamous cell carcinoma, but less is known regarding the outcomes for ACA of the E/GEJ. Methods: Through the Cleveland Clinic tumor registry, and under an IRB approved protocol, pts with LRC (clinical stage I-III, AJCC 7th) ACA of the E/GEJ treated with either dRT or dCRT between 7/04 and 12/14 were identified. Overall survival (OS) from the date of diagnosis was the primary endpoint. In univariate analysis, Cox proportional hazard analysis was used to identify risk factors for mortality. On multivariable analysis, stepwise Cox proportional hazard analysis with variable entry criterion p≤0.10 and variable retention criteria p≤0.05 was used to identify risk factors for mortality. Results: From 7/04 to 12/14, 155 pts received definitive non-operative treatment (103 dCRT, 52 dRT). Clinical stage I disease was present in 20 (13.2%); stage II in 40 (26.5%) and stage III in 91 (60.3%) of the pts. Pts who received dCRT were younger (67 v 74 years, p<0.001) and had more advanced clinical stage (p=0.026). Loco-regional recurrence / persistence was the predominant form of treatment failure occurring in 60% of pts (dCRT 54.3%, dRT 71.2%, p=0.044). With a median follow-up of 34.9 months (range 2.0-107.1), the median OS was 17.3 months (15.6m dCRT, 19.8m dRT, p=0.40) and the projected 5 year OS was 11.5% (16.1% dCRT, 4.0% dRT, p = 0.030). On univariable and multivariable analysis, a worse ECOG performance status, increasing clinical T descriptor, and increasing clinical N descriptor were prognostic for a worse OS. After adjusting for these variables, dRT was associated with a worse OS [dRT/dCRT HR 1.79 (1.20-2.68) p=0.005]. Conclusions: Definitive RT/CRT for LRC ACA of the E/GEJ is associated with poor OS. Long-term survival is nonetheless possible in a small number of pts and appears more likely after dCRT.

Head and Neck Cancers, Version 1.2015

These NCCN Guidelines Insights focus on recent updates to the 2015 NCCN Guidelines for Head and Neck (H&N) Cancers. These Insights describe the different types of particle therapy that may be used to treat H&N cancers, in contrast to traditional radiation therapy (RT) with photons (x-ray). Research is ongoing regarding the different types of particle therapy, including protons and carbon ions, with the goals of reducing the long-term side effects from RT and improving the therapeutic index. For the 2015 update, the NCCN H&N Cancers Panel agreed to delete recommendations for neutron therapy for salivary gland cancers, because of its limited availability, which has decreased over the past 2 decades; the small number of patients in the United States who currently receive this treatment; and concerns that the toxicity of neutron therapy may offset potential disease control advantages.

The relationship between pathologic nodal disease and residual tumor viability after induction chemotherapy in patients with locally advanced esophageal adenocarcinoma receiving a tri-modality regimen

BACKGROUND

A complete pathologic response to induction chemo-radiotherapy (CRT) has been identified as a favorable prognostic factor for patients with loco-regionally advanced (LRA) adenocarcinoma (ACA) of the esophagus and gastro-esophageal junction (E/GEJ). Nodal involvement at the time of surgery has been found to be prognostically unfavorable. Less is known, however, about the prognostic import of less than complete pathologic regression and its relationship to residual nodal disease after induction chemotherapy.

METHODS

Between February 2008 and January 2012, 60 evaluable patients with ACA of the E/GEJ enrolled in a phase II trial of induction chemotherapy, surgery, and post-operative CRT. Eligibility required a clinical stage of T3-T4 or N1 or M1a (AJCC 6(th)). Induction chemotherapy with epirubicin 50 mg/m(2) d1, oxaliplatin 130 mg/m(2) d1, and fluorouracil 200 mg/m(2)/day continuous infusion for 3 weeks, was given every 21 days for three courses and was followed by surgical resection. Adjuvant CRT consisted of 50-55 Gy at 1.8-2.0 Gy/d and two courses of cisplatin (20 mg/m(2)/d) and fluorouracil (1,000 mg/m(2)/d) over 4 days during weeks 1 and 4 of radiotherapy. Residual viability (RV) was defined as the amount of remaining tumor in relation to acellular mucin pools and scarring.

RESULTS

Of the 60 evaluable patients, 54 completed induction therapy and underwent curative intent surgery. The Kaplan-Meier projected 3-year overall survival (OS) for patients with pathologic N0 (n=20), N1 (n=12), N2 (n=13), and N3 (n=9) disease is 73%, 57%, 35%, and 0% respectively (P<0.001). The Kaplan-Meier projected 3-year OS of patients with low (0-25%, n=19), intermediate (26-75%, n=26), and high (>75%, n=9) residual tumor viability was 67%, 42%, and 17% respectively (P=0.004). On multivariable analysis (MVA), both the pN descriptor and RV were independently prognostic for OS. In patients with less nodal dissemination (N0/N1), RV was prognostic for OS [3-year OS 85% (0-25% viable) vs. 51% (>25% viable), P=0.028]. Outcomes were poor, however, for patients with advanced nodal disease (N2/N3) regardless of RV [3-year OS 20% (0-25% viable) vs. 21% (>25% viable), P=0.55].

CONCLUSIONS

RV and the pN descriptor after induction chemotherapy are independent pathologic prognostic factors for OS in patients with LRA ACA of the E/GEJ. Patients with extensive nodal disease, however, have poor outcomes irrespective of residual tumor viability.

Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology

This selection from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Head and Neck Cancers focuses on glottic laryngeal cancer, which is the most common type of laryngeal cancer and has an excellent cure rate. The lymphatic drainage of the glottis is sparse, and early stage primaries rarely spread to regional nodes. Because hoarseness is an early symptom, most glottic laryngeal cancer is early stage at diagnosis. Updates to these guidelines for 2014 include revisions to "Principles of Radiation Therapy" for each site and "Principles of Surgery," and the addition of a new section on "Principles of Dental Evaluation and Management."