Despite aggressive treatment modalities including surgery and chemoradiation therapy, ∼30% of patients with squamous cell carcinoma of the head and neck (HNSCC) will present with recurrent disease for which the median survival is less than one year. Recently, stereotactic body radiation therapy (SBRT) in combination with anti PD-1 based immune-oncology (IO) has emerged as an effective salvage therapy in the recurrent setting. In a recent randomized, placebo controlled, Phase II clinical trial for patients undergoing chemoradiation therapy for treatment of HNSCC, the penta-aza macrocyclic compound GC4419 (St. Louis, MO) demonstrated a statistically significant reduction in the duration, incidence, and severity of patients who developed severe oral mucositis (SOM), proving its clinical utility as a radioprotector. Recent work in our laboratory using pre-clinical animal models for non-small cell lung cancer (NSCLC) demonstrated that GC4419 does not protect NSCLC tumors from radiation, but enhances the radiation response when utilized specifically with high dose per fraction exposures alone or combined immune therapy. These two pieces of evidence led us to hypothesize that GC4419 would be effective in enhancing SBRT combined with anti-PD-1 therapy in the setting of recurrent HNSCC, reducing the rate of normal tissue complications (SOM) while also improving survival. The AT-84 HNSCC tumor cell line, syngenic to the C3H mouse strain, was selected for these studies. Subcutaneous AT-84 tumors were treated with differing biologically equivalent radiation fractionation schedules of 17 Gy x 1 fx, 10.24 Gy x 2 fxn, 5 Gy x 5 fxn, and 2 Gy x 14 fxn in combination with an α-PD-1 antibody (BioXcell) and GC4419. Tumor growth delay (TGD) was measured. A TCD50 experiment is underway. To assess normal tissue protection, the epithelial layer thickness on the tongues of adult female C3H mice was measured 12 days post a single dose of 12 or 17 Gy. GC4419 significantly enhanced radiation induced TGD as a single agent regardless of the fractionation schedule, the exception being the 2 Gy x 14 fxn group which grew too quickly to administer the full course of radiation. α-PD-1 therapy did not enhance the efficacy of radiation in any dose per fraction schedule, however the triple combination of radiation, GC4419, and α-PD-1 therapy demonstrated an increased efficacy over radiation and GC4419 alone. This triple combination effect was more effective at higher doses per fraction. Experiments for normal tissue damage are ongoing and will be reported. The ability of GC4419 to enhance the radioresponse of syngenic AT-84 tumors to radiation alone, and a further enhancement of that response when combined with α-PD-1 therapy suggests that GC4419 will be effective at improving outcomes in those patients being treated for recurrent disease using immune-SBRT.
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