Immunotherapy for the treatment of perineural spread in cutaneous head and neck squamous cell carcinoma: Time to rethink treatment paradigms.

BACKGROUND: Immune checkpoint inhibitors have shown promising antitumour activity. Application in head and neck cutaneous squamous cell carcinoma (cSCC) large nerve perineural spread (PNS) is limited. METHODS: Retrospective review of 13 patients with PNS receiving anti-PD-1 therapy from September 2017 to May 2021 is presented. Primary endpoints were objective response (complete or partial response) and median time to progression, determined by Head and Neck Multi-Disciplinary Team (MDT) and independent radiology review of magnetic resonance imaging (MRI) and/or computed tomography/positron emission tomography (CT/PET). RESULTS: Objective response was observed in 9/13 patients (69%), with complete response in 6 (46%) and partial response in 3 patients (23%). Median time to response was 2.1 months (IQR 1.8-2.7 months). There were 3 (23%) patients with progressive disease, with median time to progression of 3.5 months. There were no grade 3-4 treatment related adverse events. CONCLUSIONS: This case series supports developing evidence for anti-PD-1 checkpoint inhibitor therapy for perineural spread, supporting future prospective clinical trials in this patient population.

Trans-oral robotic surgery: a safe and effective tool in head and neck surgery in an Australian rural setting.

BACKGROUND: Trans-oral robotic surgery (TORS) facilitates surgical resection of tumours as an alternative to open surgery and has demonstrated favourable oncological results. Given the novelty of TORS and the paucity of evidence on TORS-specific complications in a rural setting, we report our experience with TORS at an Australian rural head and neck centre. METHODS: A retrospective review of all robotic cases performed at a regional head and neck centre in Queensland was undertaken from 2014 to 2019. Patient demographics, pre-operative surgical risk, complications and outcomes such as margins and cancer recurrence were recorded. Complications were graded based on the Clavien-Dindo grading system. Descriptive statistics were used to present patient characteristics and statistical analyses were performed using Stata. RESULTS: Forty-two TORS surgeries were performed. Twenty-one had histology confirming malignancy. There were no adverse intraoperative effects. Overall, seven patients (16.7%) had at least one complication. Four were recorded as a Clavien-Dindo 3b (post-operative bleed, wound infection and drain dislodgment). Of two cases with residual positive margins, one declined further surgery, and another received chemoradiotherapy. One patient recurred with distant metastatic disease, and another had locoregional nodal recurrence. The distribution of complications was significant across the pre-operative risk categories for both American Society of Anaesthesiologists and surgical risk score (P = 0.02). CONCLUSION: TORS in a rural head and neck centre is a safe and viable treatment option for patients so long as this is undertaken with appropriate training, mentorship and teamwork.

Adenoid cystic carcinoma: a review of clinical features, treatment targets and advances in improving the immune response to monoclonal antibody therapy.

The natural history of adenoid cystic carcinoma (ACC) is relentless, defined by treatment failure heralded by locoregional recurrence and distant metastatic disease. In this review, we present an update of clinical features, molecular classification, current targeted therapies, immune landscapes and novel treatment targets with their respective clinical trials. The presented results are defined by a lack of overall response rate and limited progression free survival, with restriction to stable disease. In addition, ACC is resistant to immune checkpoint inhibition due to low tumour immunogenicity and lack of PD-L1 expression. Here we present a new prospective research paradigm for ACC, including the potential to target prostate specific membrane antigen (PSMA) and the potential for manipulation of target receptors in the clinic. The presentation of this review aims to promote future research to improve response rates and outcomes for therapeutics undergoing clinical trial in ACC.

Outpatient surgical management of non-melanoma skin cancers of the head and neck in a regional centre: an analysis of costs and outcomes.

BACKGROUND: Non-melanoma skin cancer is the most commonly diagnosed malignancy in Australia. Lesions of the head and neck are often outside the scope of primary care providers. The challenges of cancer care in regional Australia necessitate careful resource planning. This study presents an outpatient model that minimizes health service cost with local general practitioner follow-up. METHODS: A retrospective review of 105 patients with 122 skin lesions in a dedicated Facial Lesion Assessment Management and Excision clinic was performed from July 2018 to 2019. Clinical outcomes, patient travel and cost analysis/comparison were recorded. RESULTS: There were 85 malignant cases with 59 basal cell carcinomas and 25 squamous cell carcinomas. For basal cell carcinoma, clear margins (≥3 mm), close margins (<3 mm) and positive margins were achieved in 24 (48%), 23 (46%) and three (6%) cases, respectively. For squamous cell carcinoma, clear margins (≥5 mm), close margins (<5 mm) and positive margins were achieved in seven (38.8%), 11 (61.1%) and none (0%) of the cases, respectively. Complications included one haematoma and two wound infections. For 37% of patients living >100 km from the department, 72.3% had local general practitioner follow-up. Inpatient cost was $2870, $5697 and $9300 for primary closure, local flap and full-thickness skin graft, respectively, and outpatient cost was $746 for a single facial lesion. CONCLUSION: This study presents a cost-effective model for the management of non-melanoma skin cancers with improved departmental efficiency and streamlined patient care in an outpatient skin cancer management model in a regional centre.