Longitudinal analysis of head and neck cancer-specific immunity in patients treated with (salvage) surgery

Longitudinal analysis of head and neck cancer-specific immunity in patients
treated with (salvage) surgery.


A vast majority of head and neck squamous cell carcinoma (HNSCC) patients
presents with advanced disease treated by either extensive surgery and / or
cisplatin chemoradiation (CRT). Despite these intensive treatment regimens the
overall survival of these patients is limited to 40-50% at 5 years, without
reliable predictive or prognostic biomarker.

Especially in case of surgically treated patients with advanced HPV negative
disease of the oral cavity, overall survival is limited to 30%-40% at 5 years,
while in case of salvage surgery after (C)RT radical excision is one of the
main concerns and clinical outcome may be maximum 10-20%. Moreover, these
patients suffer significantly impaired quality of the rest of their life due to
fistulas and mutilation of the face and dysfunction of the upper aerodigestive
tract. This specific patient population did not experience any improvement in
survival rates for the past 30-40 years despite advances in reconstruction
surgery and the addition of cisplatin to RT in adjuvant setting.

Recently, immunotherapy has shown its effect in patients with a broad range of
tumor types, including advanced melanoma and non-small cell lung carcinoma.
Tumors with a high mutational load have shown increased immunogenicity and are
therefore more likely to benefit from immunotherapy. Especially tumors of
patients with HPV negative HNSCC (as tumors of oral cavity) are characterized
by a substantial mutational load. Furthermore, promising results concerning
immunotherapy for HNSCC patients were presented at ASCO 2015, as pembrolizumab
has indeed shown partial response in 25% of recurrent or metastasized patients
with either HPV positive or negative disease and independent of PD1 expression.
In this study, 132 HNSCC -originating from various anatomical sites- patients
were included with recurrent and metastatic disease in a palliative setting.

However, a longitudinal analysis of tumor-specific T cells in patients with
HNSCC eligible for (salvage) surgery in a curative setting has not been
performed. We wish to study tumor-specific T-cells in RT and chemotherapy naïve
patients with SCC of the oral cavity submitted to major surgery (+- (C)RT) with
curative intent OR patients eligible for curative salvage surgery (after
(C)RT). The results of our study will provide us with a rationale for further
study and for the potential usage of immunotherapies (neo)adjuvant to surgical
intervention in this specific patient subgroup with an urgent need for improved
clinical outcome.

Aim of study
To investigate whether patients with disease eligible for (salvage) surgery
would potentially benefit from immunotherapy, we want to study the anti-tumor
reactivity of T cells that have infiltrated the tumor. Infiltration of T cells
in the tumors will be analyzed by using immunohistochemistry. Furthermore,
immune infiltrates will be isolated from tumor biopsies taken of the tumor to
study the functionality and anti-tumor reactivity of the T cells in the tumor.
Transcriptional profiling will be done on T cells from the tumor in
collaboration with an international collaborator.

In addition, T cell populations in the peripheral blood will be analyzed for
the presence of tumor specific T cells as well to study the kinetics of a
possible tumor specific T cell population in blood over time. For this, blood
samples taken before and after treatment are required from patients
participating in this study. If necessary, T cells from peripheral blood will
be used for anti-tumor reactivity assays if the T cell infiltrate from the
tumor is not sufficient for performing these assays.

Thirdly, the mutational load in the tumor will be investigated in order to find
predictive or prognostic markers for the response to immunotherapy. DNA and RNA
from the tumor will be used for sequencing to determine somatic mutations in
the tumor.

Analyses of the tumor biopsies and blood samples will either be done in house
or in collaboration with third parties outside the NKI-AVL.

Patients will be enrolled in this study only after signing of the ICF.

First tumor tissue will be taken during curative surgery.

Blood will be taken:
1. within 2 weeks prior to surgery (during last routine appointment before
surgery)
2: within 1 week post surgery, and week 4-5 after surgery (during first routine
appointment after surgery or at start (C)RT)
3: every 3 months after surgery, either with or without adjuvant (C)RT, the
remaining 1st year of FU after treatment
4. every 4 months during the 2nd year of FU.
Together, this is 500 mL blood in 2 year time FU, in case of complete remission
of the tumor.

In case of disease progression within 2 year FU time, the above scheme will be
left alone, and blood samples will be taken every 3 months 50mL, for a maximum
of 9 months, therefore in total 3 times an extra blood sample per patient.

In case of disease progression after the 2 years FU, extra blood will be taken
every 3 months 50 mL, maximum 9 months, thus maximum 3 times per patient.

In case of disease progression within 2-3 years extra tumor tissue will be
taken during routine diagnostic work-up

No toxicity is expected from drawing blood samples. As tumor biopsies are taken
during curative surgical excision of the tumor, no extra burden will be implied
on the patients. Tumor biopsies will not interfere with a proper diagnostic
pathology report after surgery. In case of disease progression or relapse of
tumor within the follow-up of 2-3 years, tumor tissue samples will be obtained,
only when easily accessible and limited complication risks; for example easily
accessible lymph nodes, primary tumors, subcutaneous or other distant
metastases.