Recurrent/Metastatic HNSCC

beau hilton, 2024-02-02

Recurrent/Metastatic HNSCC

beau hilton, 2024-02-02

Case presentation

60M, prev heavy tob use (dip x40y, quit 1y prior to dx), prev heavy EtOH use (6x/d, quit at time of dx), presented for routine dental care.

Dentist noted gingival lesion, iso 1-2y of gum recession, bleeding, loose teeth.

Bx: mod diff SCC
Staging -ve for distant disease.
Resected a couple of months later
- L floor of mouth, buccal mucosa, mandible w glossectomy, L neck dissection
- R0

The Oral Cavity?

The Oral Cavity?

localization can be tough
thank goodness for surgeons and pathologists
imaging alone may underdiagnose/be misleading
direct exam
resection
path matters (e.g. vermilion border SCC may be cSCC, not tx like OCC)

Oral Cavity - TN(M) Staging

T	N
T1 - <=2cm, DOI <=5mm	N1 - single ipsilateral, <=3cm, ENE-
T2 - <=2cm, DOI >5mm; >2cm <=4cm, DOI <=10mm	N2a - single ipsilateral and [<=3cm, ENE+] or [>3cm <6cm, ENE-]
T3 - >2cm <=4cm, DOI >10mm; >4cm, DOI <=10mm	N2b - multiple ipsilateral, <=6cm, ENE-
T4a - >4cm, DOI >10mm; invades adjacent structures only	N2c - bilateral/contralateral, <=6cm, ENE-
T4b - invades masticator space, pterygoid plates, skull base, encases internal carotid	N3a - >6cm, ENE-
	N3b - single ipsilateral >3cm, ENE+; multiple ipsi/contra/bilateral any ENE+; or single contralateral ENE+

First resection results

pT4a pN1 (stage IVA)
offered but declined adjuvant CRT

First recurrence

About 6mo later, local recurrence.

Re-resected, R0, rpT3 -> CRT (carbo -> cisplatin q7d)

Second recurrence

Just <6mo later, another local recurrence.

Re-resected, R0, 2/5LN+ (1.7cm), +PNI
Pembro monotherapy recommended
Insurance said no
(TMB 9.5, MSS, CPS 5)

Pembrolizumab approvals

2014-09-04: initial approval (for melanoma progressed on ipi or BRAF TKI - KEYNOTE-002)
2016-08-05: HNSCC: monotherapy for platinum-refractory RM-HNSCC (KEYNOTE-012)
2017-05-23: all MSI-H/dMMR with POD and no other great tx
2019-06-10: HNSCC: +platinum + FU for all; monotherapy for CPS >=1 (KEYNOTE-048)
2020-06-16: all TMB >=10 with POD and no other great tx
2024-01-12: newest indication (pembro + CRT for stage III-IVA cervical cancer)

KEYNOTE-012

Lancet Oncology 2016

British Journal of Cancer 2018

Progression

Seeking insurance approval delayed start of therapy x1mo.
Developed dermal mets, overall rapidly progressive disease.
–> KEYNOTE-B10 + Quad-Shot RT

KEYNOTE-B10 (1L R/M, carbo+taxol+pembro)

Annals of Oncology 2022

ESMO 2022

Current

dermal mets no longer apparent
primary appears to be shrinking (clinically and by PET)
delayed C6 d/t mucositis -> AKI ~10d after quad-shot
planning pembro maintenance and close observation

Bibliography

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