Ingrid Breuskin

High-Throughput Genomics and Clinical Outcome in Hard-to-Treat Advanced Cancers: Results of the MOSCATO 01 Trial

High-throughput genomic analyses may improve outcomes in patients with advanced cancers. MOSCATO 01 is a prospective clinical trial evaluating the clinical benefit of this approach. Nucleic acids were extracted from fresh-frozen tumor biopsies and analyzed by array comparative genomic hybridization, next-generation sequencing, and RNA sequencing. The primary objective was to evaluate clinical benefit as measured by the percentage of patients presenting progression-free survival (PFS) on matched therapy (PFS2) 1.3-fold longer than the PFS on prior therapy (PFS1). A total of 1,035 adult patients were included, and a biopsy was performed in 948. An actionable molecular alteration was identified in 411 of 843 patients with a molecular portrait. A total of 199 patients were treated with a targeted therapy matched to a genomic alteration. The PFS2/PFS1 ratio was >1.3 in 33% of the patients (63/193). Objective responses were observed in 22 of 194 patients (11%; 95% CI, 7%-17%), and median overall survival was 11.9 months (95% CI, 9.5-14.3 months).Significance: This study suggests that high-throughput genomics could improve outcomes in a subset of patients with hard-to-treat cancers. Although these results are encouraging, only 7% of the successfully screened patients benefited from this approach. Randomized trials are needed to validate this hypothesis and to quantify the magnitude of benefit. Expanding drug access could increase the percentage of patients who benefit. Cancer Discov; 7(6); 586-95. ©2017 AACR.See related commentary by Schram and Hyman, p. 552This article is highlighted in the In This Issue feature, p. 539.

Confocal laser endomicroscopy for non-invasive head and neck cancer imaging: A comprehensive review

Histological assessment is an essential tool in the diagnosis and guidance of the treatment of various diseases, in particular cancer, of the head and neck. Recent major advances in optical imaging techniques have made it possible to acquire high-resolution in vivo images at the cellular scale. Confocal endomicroscopy is a non-invasive technique, which can be highly useful whenever meaningful in situ histological information is required. The technical aspects of confocal endomicroscopy are introduced, followed by an overview of major clinical studies in the field of head and neck cancer. Ongoing technical developments, contributing to improvements in imaging of the upper aero-digestive tract, are also discussed. Finally, the potential complementarities of functional and molecular imaging, as compared to morphological endomicroscopy, are highlighted.

Evidence-based management of the thyroid gland during a total laryngectomy

To propose an original experience‐based reference framework for the management of the thyroid gland during a total laryngectomy in our institution. The steps were based on 1) the incidence and patterns of thyroid gland invasion (TGI), 2) preoperative and pathologic factors associated with TGI, and 3) the relationship between TGI and oncologic efficacy endpoints after treatment.

Clinical relevance of tumor infiltrating lymphocytes, PD-L1 expression and correlation with HPV/p16 in head and neck cancer treated with bio- or chemo-radiotherapy

ABSTRACT To investigate the prognostic value of tumor infiltrating lymphocytes (TILs: CD8+ and FoxP3+), and PD-L1 expression in patients with head and neck squamous cell carcinoma (HNSCC) treated with radiotherapy combined with cisplatin (CRT) or cetuximab (BRT). Immunohistochemistry for CD8, FoxP3 was performed on pretreatment tissue samples of 77 HNSCC patients. PD-L1 results were evaluable in 38 patients. Cox regression analysis was used to analyze the correlations of these biomarkers expression with clinicopathological characteristics and treatment outcomes. High CD8+ TILs level was identified in multivariate analysis (MVA) as an independent prognostic factor for improved progression-free survival with a non-significant trend for better overall survival (OS). High FoxP3+ TILs and PD-L1+ correlated with a favorable OS in the uni-variate analysis, respectively, but not in the MVA. In subgroup analysis, CD8+TILs appear to play a pivotal role, p16+/high CD8+TILs patients had superior 5-year OS compared with p16+/low CD8+TILs, p16-/ high CD8+TILs, and p16-/ low CD8+TILs patients. p16+/PD-L1+ patients had improved 3-year OS compared with p16+/PD-L1-, p16-/ PD-L1+, and p16-/ PD-L1- patients. In low CD8+ TILs tumors, 5-year loco-regional control of patients treated with CRT was improved vs. those with BRT (p = 0.01) while no significant difference in high CD8+ TILs was observed. CD8+ TILs correlated with an improved clinical outcome in HNSCC patients independent of Human papillomavirus status. The immunobiomarkers may provide information for selecting suitable patients for cisplatin or cetuximab treatment. Additionally, the impact of TILs and PD-L1 of deciphering among the p16+ population a very favorable outcome population could be of interest for patients tailored approaches.

Red and far-red fluorescent dyes for the characterization of head and neck cancer at the cellular level.

BACKGROUND Primary upper aerodigestive tract malignancy remains a cancer having a poor prognosis, despite current progress in treatment, due to a generally late diagnosis. OBJECTIVES We conducted a preliminary assessment of five dyes approved for human use for the imaging of head and neck tissues at the cellular level, which could be considered for clinical examination. METHODS We investigated fluorescence endomicroscopic images on fresh samples obtained from head and neck surgeries after staining with hypericin, methylene blue, toluidine blue, patent blue or indocyanine green to provide a preliminary consideration as to whether these images contain enough information for identification of non-pathologic and pathologic tissues. The distribution pattern of dye has been examined using probe-based confocal laser endomicroscopy (pCLE) in ex vivo specimens and compared with corresponding histology. RESULTS In most samples, the image quality provided by pCLE with both dyes allowed pathologists to recognize histological characteristics to identify the tissues. CONCLUSION The combination of pCLE imaging with these dyes provides interpretable images close to conventional histology; a promising clinical tool to assist physicians in examination of upper aerodigestive tract, as long as depth imaging issues can be overcome.

Oropharyngeal cancers: Significance of HPV16 detection in neck lymph nodes

BACKGROUND An increasing proportion of oropharyngeal squamous cell carcinomas (OPSCCs) is associated with human papillomavirus (HPV) type 16 infection. Several authors have suggested that HR-HPV DNA could be used as a marker of metastases in cervical cancers. Although HPV16 DNA has been detected in neck lymph node (LN) metastases of HPV16-positive OPSCC, its significance remains controversial. Does this presence correlate to metastatic involvement or is it just the consequence of LN filter function? OBJECTIVES This study aims to analyse the relationship between HPV16 detection in neck LNs of HPV16-positive OPSCC and their pathological status. STUDY DESIGN HP16-viral load (VL) was quantified by real-time-polymerase-chain reaction in primary tumours and neck LNs, in 11 patients with HPV16-positive OPSCC and in three patients with HPV16-negative OPSCC. HPV16 in situ hybridisation and p16 immunohistochemistry were performed in all LNs. RESULTS A total of 45 LN levels were assessed. HPV16 DNA was not identified in HPV16-negative OPSCC LNs. All metastatic LNs from HPV16-positive OPSCC had a high VL and the viral DNA was located within tumoural cells. Among 27 pathologically tumour-free LN (PTFLN) levels 16/27 had no detectable VL, whereas the VL was low or medium (<10(5)copies/million cells) in 8/27 and high (>10(5)copies/million cells) in 3/27 PTFLN. In the latter group, no metastatic cell was identified and the viral DNA was located in immune cells. CONCLUSION HPV16 detection in LN is explained by its presence within either metastatic cells or immune cells. HPV16 detection in PTFLN is not necessarily correlated to occult LN metastases.

OC-014: Molecular screening for cancer treatment optimization in head and neck cancer (MOSCATO 01)

not received Proffered papers: Highlights of proffered papers OC-014 Molecular screening for cancer treatment optimization in head and neck cancer (MOSCATO 01) C. Even, I. Breuskin, E. Ileana, C. Massard, L. Lacroix, N. Lezghed, J. Guigay, F. Janot, J.C. Soria, C. Ferte Institut Gustave Roussy, Head and Neck Department, Villejuif, France Institut Gustave Roussy, Drug Development Department, Villejuif, France Institut Gustave Roussy, Medical Biology and Pathology Department, Villejuif, France Purpose/Objective: Patients with recurrent or metastatic head and neck cancers (HNC) have a poor prognosis. After first line chemotherapy, therapeutics are limited. The widespread use of high-throughput molecular techniques has allowed the identification of recurrent and actionable molecular traits across various tumor types. Translating these approaches to bedside may guide the decision-making for cancer patient candidates to early clinical trials. Materials and Methods: Patients with advanced HNC, referred to our early drug development department, were enrolled in a prospective molecular screening program. Surgical or CT-Scan biopsies were performed in metastatic or primary tumor sites to carry out a comprehensive molecular characterization. DNA was extracted from fresh tumor samples and analyzed by comparative genomic hybridization (CGH) (≥ 30% tumor cells required), and by Next Generation Sequencing (NGS) for up to 74 target genes (≥ 10% tumor cells required). A weekly molecular tumor board reviewed all the profiles to identify actionable traits for which the most relevant targeted therapy may be available through early clinical trials or marketed drugs. Treatment efficacy was evaluated by RECIST 1.1 or PERCIST criteria. Results: From July 2011 to August 2014, 78 heavily pretreated patients were included in the MOSCATO 01 trial. CGH and NGS profiles were assessed in 64 (82%) and 68 (87%) of biopsied patients, respectively. The median time for delivering results was 20 days. Actionable molecular aberrations were found in 30 patients (38%). Among these patients, 10 patients (33%) were treated with a targeted therapy according to the molecular profile. The most frequent actionable molecular aberrations were observed in the following pathways: FGFs/FGFRs (35%), PI3K/AKT/mTOR (26%), MYC (24%), CDKs/Cyclins (13%), EGFR (9%), HER2 (7%), NOTCH (4%), KIT (2%). Out of the 10 patients treated according to the genomic profile, we observed at first tumor evaluation: 3 partial responses (PR), 3 stable disease (SD) and 1 clinical progressive disease (PD), while 2 patients were not evaluable. Out of the 20 patients not treated according to the molecular triage whereas actionable traits were detected, we observed: 7 patients with exclusion criteria for clinical trial, 6 patients being dead during the process, 4 patients with feeding tube impairing oral treatment intake, and 3 patients treated by other antineoplastic therapy. Conclusions: High throughput genomic analysis is feasible in daily practice and allows the biological-orientation of up to 38% of recurrent or metastatic HNC patients. OC-015 Therapeutic HPV vaccine increases sensitivity of poorly immunogenic tumor to anti-PD-1 monotherapy S. Pai, D. Smith, S. Peng, E. Ishida, B. Akpeng, C.F. Hung, T.C. Wu Massachusetts General Hospital Harvard Medical school, Otolaryngology, Boston, USA Johns Hopkins Hospital, Otolaryngology, Baltimore, USA Purpose/Objective: The safety and efficacy of blocking antibodies to Programmed cell death-1 (PD-1) and its ligand (PD-L1) are actively being evaluated in the clinical arena for various cancers, including head and neck cancers. Identifying predictive biomarkers of clinical response to these immunomodulatory therapies is of great interest in the field. Since these agents aim to restore T cell function within the tumor microenvironment, one possible explanation for failed responses to immune checkpoint blockade may be attributed to a paucity or lack of immune responses to the host tumor. We found that our HPV tumor model is poorly immunogenic and, consequently, resistant to anti-PD-1 monotherapy. Thus, we aimed to evaluate whether an HPV vaccine can improve response rates to anti-PD-1 therapy by eliciting CD8+ antitumor immune responses. Materials and Methods: C57BL/6 mice were subcutaneously inoculated in the right flank with 1x10 TC-1 tumor cells on Day 0. The mice were then treated with either anti-PD-1 blocking antibody, CRT/E7(detox) DNA vaccine, or a combination of anti-PD-1 and CRT/E7(detox) DNA vaccine. The mice were treated 3 days after tumor inoculation and received treatment every 4 days for a total of three treatments. Mice were monitored for survival and tumor growth by measuring tumor diameter with calipers twice a week. We also characterized the HPV-specific T cells in the various treatment groups. Therefore, one week after the last vaccination, TC-1 tumors were surgically excised and HPV16 E7-specific CD8 T cells stained for PD-1 expression. The cells were acquired with a LSRII flow cytometer and analyzed with FACSDiva software. Results: The administration of an HPV vaccine increased the frequency of vaccine-induced CD8+ T cells which express the PD-1 receptor. Interestingly, vaccination also upregulated PD-L1 expression within the tumors and rendered the tumor cells resistant to vaccine-induced cytotoxic T cell killing. With the combination of HPV vaccine and anti-PD-1, we observed a synergistic anti-tumor effect which resulted in improved overall survival. Functional studies demonstrated that vaccine-induced T cell killing could be restored with anti-PD-1 treatment. Conclusions: We provide a rationale for combining vaccines with anti-PD-1 therapy as a strategy to further enhance clinical responses and/or overcome resistance to immune checkpoint blockade, particularly in poorly immunogenic

Influence of tumor-associated macrophages and HLA class I expression according to HPV status in head and neck cancer patients receiving chemo/bioradiotherapy

BACKGROUND AND PURPOSE To investigate the prognostic value of tumor-associated macrophages (TAM) and HLA class I expression according to HPV status in patients with head and neck squamous cell carcinoma treated with definitive radiotherapy combining cisplatin (CRT) or cetuximab (BRT). MATERIAL AND METHODS Ninety-five patients were enrolled. The density of CD68+ cells and CD68+ CD163+ cells (further referred as M2) in the intraepithelial and the stromal compartments, respectively, as well as HLA class I expression in tumor cells, were evaluated semi-quantitatively. Correlations between biomarker expression and treatment outcomes were analyzed. RESULTS Multivariate analysis showed that the intraepithelial macrophage density (IEMD) was prognostic for favorable progression-free survival (PFS) and there was a non-significant trend for improved overall survival (OS). HLA class I down-regulation was not an independent prognostic factor. Subgroup analysis showed that in p16+ population, patients with high IEMD had improved 5-year PFS vs. patients with low IEMD (81.2% vs. 25.0%, p < 0.001), while in p16- population, no difference was observed. Similarly, when stratified by primary tumor site, IEMD showed prognostic value in oropharyngeal cancer patients (OPC) but not non-OPC patients. Five-year PFS of patients with low stromal M2 macrophage density treated with CRT was significantly improved vs. those with BRT (54.5% vs. 36.1%, p = 0.03), while in tumors with high M2, there was no significant difference (50.3% vs. 42.9%, p = 0.67). CONCLUSIONS The prognostic role of TAM phenotype and distribution depends on HPV status and might predict treatment response. They prompt further validation in prospective studies.

Randomized trial comparing two methods of re-irradiation after salvage surgery in head and neck squamous cell carcinoma: Once daily split-course radiotherapy with concomitant chemotherapy or twice daily radiotherapy with cetuximab

BACKGROUND A previous randomized trial in recurrent Head and Neck squamous-cell carcinoma (HNSCC) has shown re-irradiation combined with chemotherapy after salvage surgery significantly improved disease-free survival (DFS). The objective of this randomized trial was to compare two methods of re-irradiation in terms of toxicity and survival. PATIENTS AND METHODS Patients with recurrence/second primary in previously irradiated area were randomly allocated to receive either 60 Gy over 11 weeks with concomitant 5FU - hydroxyurea (VP-arm), or 60 Gy (1.2 Gy twice daily) over 5 weeks with cetuximab (HFR-arm). Primary endpoint was treatment interruption >15 days (acute toxicity). RESULTS Twenty-six patients were included in VP-arm and 27 in HFR-arm. One patient in VP-arm experienced >15 days interruption due to toxicity, and none in HFR-arm. In both arms, all patients received at least 60 Gy. In VP-arm, 8/26 patients had chemotherapy delay and/or dose reduction. In HFR-arm, 4/27 patients had <6 cycles cetuximab. There was no significant difference in overall survival (Median OS: 37.4 months vs 21.9 months, p = 0.12). Toxicities and DFS were not different between 2 arms. CONCLUSIONS Twice daily schedule of re-irradiation of 60 Gy/5 weeks with cetuximab was tolerable and no significant difference in treatment delays occurred between two arms.

Smoking impact on HPV driven head and neck cancer’s oncological outcomes?

INTRODUCTION HPV-driven oropharyngeal cancer (OPC) patients have a better prognosis than their HPV-negative counterparts but several studies have suggested that among HPV-positive patients those with a smoking history had worse oncological outcomes. The aim of our study is to characterize the interplay between tobacco consumption, patient and disease characteristics, and disease control. MATERIALS AND METHODS All patients diagnosed with HPV-driven OPC and treated with curative intent between 2007 and 2009 and 2011-2016 at Gustave Roussy cancer center were included (n = 282). Demographic, clinical, morphological and tobacco consumption were correlated with oncologic outcomes. RESULTS 157 (56%) patients had a positive smoking history, including 23.8% who were smoking at the time of diagnosis and 37.6% who had a tobacco consumption exceeding 20 pack-years. In multivariate analysis, the strongest prognostic factor for survival was smoking status at cancer diagnosis, with a hazard ratio (HR) for non-smokers compared to smokers of 0.25 ([0.12, 0.50], p = 0.0001). Smoking history, either more than 20 pack-years or smoking at diagnosis, was associated with local relapse and distant relapse. There was no difference in terms of comorbidity (p = 0.32) and radiotherapy duration (p = 0.93) according to tobacco consumption. DISCUSSION Smoking is frequent among patients with HPV-driven OPC and increases the risk of death and oncologic failure.