Squamous Cell Carcinoma of the Head and Neck
Conditions
Keywords
Carcinoma, Head and Neck, Cetuximab, Locally Advanced Head and Neck Squamous Cell Carcinoma
Brief summary
There are currently no useful tests to identify patients who will respond to cetuximab therapy, notably because EGFR levels do not correlate with the clinical responses observed. Thus, the investigators are investigating the role of cellular immunity and immune escape mechanisms to explain the differential clinical response to cetuximab.
Detailed description
This prospective phase II clinical trial of preoperative, single-agent cetuximab treated patients is being conducted in order to obtain specimens before and after 4 weeks of cetuximab for immune biomarker studies. Stage III/IV HNC patients will be treated with definitive surgical resection and observed for disease recurrence. Cetuximab will be administered for a 3-4 week preoperative period to study biomarker modulation in correlation clinical response by CT scan and tumor apoptosis/proliferation after tumor excision, immediately after neoadjuvant cetuximab but before surgery. We will biopsy the skin/acneiform rash in all patients to correlate rash with biomarker modulation and clinical response. Cetuximab may also be given in the adjuvant setting. A primary scientific hypothesis will be tested: does short term pre-operative exposure to cetuximab modulate blood immune biomarkers and is immune modulation associated with anti-tumor effect? Forty (n=40) patients with complete specimens (tumor, peripheral blood mononuclear cells (PBMC) and serum) are necessary to enable adequate statistical power to be reached using paired specimens. A secondary set of hypotheses will evaluate the association between pre-operative biomarker levels and modulation with disease recurrence. The proposed trial will accrue stage II, III or IV surgical candidates without distant metastasis.
Interventions
DRUGCetuximab
Pre-Surgery: IV, 400 mg/m2 day 1 then 250 mg/m2 alone days 8 and 15; Post-surgery: IV, 250 mg/m2 weekly concurrent with RT
PROCEDURESurgery
Surgery for tumor
RADIATIONPost-surgical radiation
Radiation (2 Gy/d) to min of 60 Gy + max of 66 Gy post-surgery
Cisplatin 30 mg/m2 or carboplatin AUC 1.5-2/week weekly, Concurrent with radiotherapy
Sponsors
Bristol-Myers Squibb
Robert Ferris
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Histologically or cytologically confirmed, previously untreated HNC. Clinical stage III or IVA disease without distant metastases as determined by CT, and as defined by the American Joint Committee on Cancer Staging System, Sixth edition (See Appendix I). * Primary tumors of the oral cavity, oropharynx, hypopharynx, or larynx will be included. Primary tumors of the sinuses, paranasal sinuses, or nasopharynx, or unknown primary tumors are NOT allowed. * Macroscopic complete resection of the primary tumor must be planned. * Age greater than or equal to 18 years. * ECOG performance status 0-1. * Adequate hematologic, renal and hepatic function, as defined by: * Absolute neutrophil count (ANC) greater than or equal to 1,500/ul, platelets greater than or equal to 100,000/ul. * Creatinine clearance \> 40 * Bilirubin less than or equal to 1.5 x ULN, AST or ALT less than or equal to 2.5 x ULN. * Have signed written informed consent.
Exclusion criteria
* Subjects who fail to meet the above criteria. * Prior severe infusion reaction to a monoclonal antibody. * Pregnancy or breastfeeding. Women of childbearing potential (WOCBP) must practice acceptable methods of birth control to prevent pregnancy. Prior to study enrollment, WOCBP must be advised of the importance of avoiding pregnancy during trial participation and the potential risk factors for an unintentional pregnancy. In addition, men enrolled on this study should understand the risks to any sexual partner of childbearing potential and should practice an effective method of birth control. * All WOCBP MUST have a negative pregnancy test within 7 days prior to first receiving investigational product. If the pregnancy test is positive, the patient must not receive investigational product and must not be enrolled in the study. In addition, all WOCBP should be instructed to contact the Investigator immediately if they suspect they might be pregnant (e.g., missed or late menstrual period) at any time during study participation. The Investigator must immediately notify BMS in the event of a confirmed pregnancy in a patient participating in the study. * Subjects with an ECOG performance status of 2 or worse. * Evidence of distant metastasis. * Any other malignancy active within 5 years except for non-melanoma skin cancer or carcinoma in situ of the cervix, DCIS or LCIS of the breast. * Prior history of HNC. * Prior therapy targeting the EGFR pathway. * Any unresolved chronic toxicity greater than or equal to grade 2 from previous anticancer therapy (except alopecia), according to Common Terminology Criteria for Adverse Events v4.0 (CTCAE). * Acute hepatitis, known HIV, or active uncontrolled infection. * History of uncontrolled cardiac disease; i.e., uncontrolled hypertension, unstable angina, myocardial infarction within prior 6 months, untreated known coronary artery disease, uncontrolled congestive heart failure, and cardiomyopathy with decreased ejection fraction. * Uncontrolled peptic or gastric ulcer disease, or gastrointestinal bleeding within prior 6 months. * Active alcohol abuse or other illness that carries a likelihood of inability to comply with study treatment and follow-up. * Treatment with a non-approved or investigational drug within 30 days prior to Day 1 of study treatment.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| NK Cell Activation | Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments) | Cetuximab-mediated NK cell activation (percentage of activity) measures at pre-/post-cetuximab exposure for patients in peripheral blood lymphocytes (PBL) and tumor infiltrating lymphocytes (TIL) and in those patients that did and did not respond to treatment. |
| Serum Cytokines Levels | Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments) | Serum cytokines levels measured at pre-/post-cetuximab, exposure measured in picogram per milliliter of plasma (pg/ml) |
| T Cell Activation | Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments) | T cell activation measured at pre-/post-cetuximab exposure |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Objective Response (Rate) | Up to 2 years | The percentage of participants that experienced a response to study treatment, per RECIST 1.0: Number of participant with (Complete Response (CR) + number of participants with Partial Response (PR) / Total number of participants evaluable for response. |
| Frequency of EGFR-specific T Cells (EGFR853-861 Peptide-specific Tetramer+ CD8+T Cells) | Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments) | Difference in frequency of circulating EGFR-specific T cells between cetuximab-treated and cetuximab-naive patients |
| Change in Tumor Size | Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments) | Largest percent change (decrease) in tumor size before and after neoadjuvant cetuximab. |
| 3-year Progression-free Survival (PFS) | 3 years | Percentage of participants alive at 3 years that did not experience disease progression per RECIST 1.0. Progression per RECIST 1.0 is defined as a 20% increase the in longest dimension (LD) lesion from Nadir. |
| Progression-free Survival (PFS) | Up to 54 months | The length of time during and after study treatment that participants lived with disease that did not progress per RECIST 1.0. Progression per RECIST 1.0 is defined as a 20% increase the in longest dimension (LD) lesion from Nadir. |
| Overall Survival (OS) | Up to 2 years | Number of patients remaining alive. |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Neo-Adjuvant Cetuximab Patients with Head and Neck Squamous Cell Cancer (HNSCC) treated with Neo-Adjuvant Cetuximab + Surgery + Post-Surgical Radiation + Cisplatin (or Carboplatin)
NOTE: Based the results of surgery if the treating physician feels patient is not a candidate for chemotherapy, radiation can be given alone or with cetuximab.
Cetuximab: Pre-Surgery: IV, 400 mg/m\^2 day 1 then 250 mg/m\^2 alone days 8 and 15; Post-surgery: IV, 250 mg/m2 weekly concurrent with RT
Post-surgical radiation: Radiation (2 Gy/d) to min of 60 Gy + max of 66 Gy post-surgery
Cisplatin or carboplatin: Cisplatin 30 mg/m2 or carboplatin AUC 1.5-2/week weekly, Concurrent with radiotherapy | 40 |
| Total | 40 |
Baseline characteristics
| Characteristic | Neo-Adjuvant Cetuximab |
|---|---|
| Age, Continuous | 58.6 years |
| Sex: Female, Male Female | 10 Participants |
| Sex: Female, Male Male | 30 Participants |
Adverse events
| Event type | EG000 affected / at risk |
|---|---|
| deaths Total, all-cause mortality | 32 / 40 |
| other Total, other adverse events | 32 / 40 |
| serious Total, serious adverse events | 8 / 40 |
Outcome results
Primary
NK Cell Activation
Cetuximab-mediated NK cell activation (percentage of activity) measures at pre-/post-cetuximab exposure for patients in peripheral blood lymphocytes (PBL) and tumor infiltrating lymphocytes (TIL) and in those patients that did and did not respond to treatment.
Time frame: Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments)
Population: Participants that received preoperative treatment with single-agent cetuximab for a minimum of 3-4 weeks.Patients defined as responders, demonstrated upregulation of CD137 on tumor infiltrating NK cells following cetuximab therapy compared with non-responders.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Perforin+ cells (TIL): post-cetuximab | 10 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD107a+ cells (PBL): pre-cetuximab | 1 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent NK cells (PBL): pre-cetuximab | 19 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent NK cells (PBL): post-cetuximab | 20 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent NK cells (TIL): pre-cetuximab | 4 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent NK cells (TIL): post-cetuximab | 3 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD16+ NK cells(PBL): pre-cetuximab | 55 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD16+ NK cells (PBL): post-cetuximab | 49 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD16+ NK cells (TIL): pre-cetuximab | 10 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD16+ NK cells (TIL): post-cetuximab | 6 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Granzyme B+ cells (PBL): pre-cetuximab | 54 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Granzyme B+ cells(PBL): post-cetuximab | 64 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Granzyme B+ cells (TIL): pre-cetuximab | 17 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Granzyme B+ cells (TIL): post-cetuximab | 21 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Perforin+ cells (PBL): pre-cetuximab | 50 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Perforin+ cells (PBL): post-cetuximab | 60 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent Perforin+ cells (TIL): pre-cetuximab | 6 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD107a+ cells (PBL): post-cetuximab | 0 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD107a+ cells (TIL): pre-cetuximab | 36 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD107a+ cells (TIL): post-cetuximab | 60 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD137+ cells (PBL): pre-cetuximab | 2 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD137+ cells (PBL): post-cetuximab | 0 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD137+ cells (TIL): pre-cetuximab | 6 percentage of activity |
| Neo-Adjuvant Cetuximab | NK Cell Activation | Percent CD137+ cells (TIL): post-cetuximab | 10 percentage of activity |
Primary
Serum Cytokines Levels
Serum cytokines levels measured at pre-/post-cetuximab, exposure measured in picogram per milliliter of plasma (pg/ml)
Time frame: Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments)
Population: Participants that received preoperative treatment with single-agent cetuximab for a minimum of 3-4 weeks.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: pre-cetuximab GM-CSF | 2.5 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: pre-cetuximab GM-CSF | 18.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: post-cetuximab GM-CSF | 11.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: post-cetuximab GM-CSF | 5.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: pre-cetuximab CCL2 | 260 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: pre-cetuximab CCL2 | 500 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: post-cetuximab CCL2 | 250 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: post-cetuximab CCL2 | 200 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: pre-cetuximab MP-1 alpha | 6.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: pre-cetuximab MP-1 alpha | 10.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Responders: post-cetuximab MP-1 alpha | 7.0 pg/ml |
| Neo-Adjuvant Cetuximab | Serum Cytokines Levels | Non-responders: post-cetuximab MP-1 alpha | 3.0 pg/ml |
Primary
T Cell Activation
T cell activation measured at pre-/post-cetuximab exposure
Time frame: Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments)
Population: Participants that received preoperative treatment with single-agent cetuximab for a minimum of 3-4 weeks.
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Neo-Adjuvant Cetuximab | T Cell Activation | Pre-cetuximab | 0.25 percentage of T cell activation |
| Neo-Adjuvant Cetuximab | T Cell Activation | Post-cetuximab | 1.0 percentage of T cell activation |
Secondary
3-year Progression-free Survival (PFS)
Percentage of participants alive at 3 years that did not experience disease progression per RECIST 1.0. Progression per RECIST 1.0 is defined as a 20% increase the in longest dimension (LD) lesion from Nadir.
Time frame: 3 years
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Neo-Adjuvant Cetuximab | 3-year Progression-free Survival (PFS) | 84 percentage of participants |
Secondary
Change in Tumor Size
Largest percent change (decrease) in tumor size before and after neoadjuvant cetuximab.
Time frame: Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments)
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Neo-Adjuvant Cetuximab | Change in Tumor Size | 10 percent |
Secondary
Frequency of EGFR-specific T Cells (EGFR853-861 Peptide-specific Tetramer+ CD8+T Cells)
Difference in frequency of circulating EGFR-specific T cells between cetuximab-treated and cetuximab-naive patients
Time frame: Prior to each weekly cetuximab treatment (up to 4 weeks); at the time of surgery (at 3-4 weeks after first cetuximab treatments)
| Arm | Measure | Group | Value (MEAN) |
|---|---|---|---|
| Neo-Adjuvant Cetuximab | Frequency of EGFR-specific T Cells (EGFR853-861 Peptide-specific Tetramer+ CD8+T Cells) | cetuximab-treatment | 120 EGFR+ T cells/10^4 T cells |
| Neo-Adjuvant Cetuximab | Frequency of EGFR-specific T Cells (EGFR853-861 Peptide-specific Tetramer+ CD8+T Cells) | no cetuximab-treatment | 45 EGFR+ T cells/10^4 T cells |
Secondary
Objective Response (Rate)
The percentage of participants that experienced a response to study treatment, per RECIST 1.0: Number of participant with (Complete Response (CR) + number of participants with Partial Response (PR) / Total number of participants evaluable for response.
Time frame: Up to 2 years
Population: Participant that where evaluable for response to treatment with cetuximab (400 mg/m2 then 250mg/m2/week) for 3-4 weeks preoperatively, followed by adjuvant chemoradiation with or without cetuximab.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Neo-Adjuvant Cetuximab | Objective Response (Rate) | 33 percentage of participants |
Secondary
Overall Survival (OS)
Number of patients remaining alive.
Time frame: Up to 2 years
Population: All patients enrolled in the study.
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Neo-Adjuvant Cetuximab | Overall Survival (OS) | 40 participants |
Secondary
Progression-free Survival (PFS)
The length of time during and after study treatment that participants lived with disease that did not progress per RECIST 1.0. Progression per RECIST 1.0 is defined as a 20% increase the in longest dimension (LD) lesion from Nadir.
Time frame: Up to 54 months
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Neo-Adjuvant Cetuximab | Progression-free Survival (PFS) | 24 months |