RM-HNSCC
Recurrent/Metastatic HNSCC
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)
- Current FDA label pdf link (Drugs@FDA)
- Current FDA label web link (DailyMed)
- FDA approval announcement links:
KEYNOTE-012
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)
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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