6546 Background: Anti-PD-1 mAbs have changed the landscape of R/M HNSCC treatment, but physical, immunologic, and metabolic barriers present in the tumor microenvironment are likely drivers of low response rates. Hypoxia is a well-established feature of the tumor microenvironment and may act as a barrier to T cell infiltration and function. We evaluated the effect of hypoxia on the efficacy of anti-PD-1 mAb treatment in R/M HNSCC patients. Methods: We conducted a retrospective analysis of R/M patients treated with anti-PD-1 mAb that had consented to the UPMC Hillman tissue banking protocol (HCC 99-069). Pre-treatment archival FFPE samples were analyzed via immunofluorescent imaging for number of CD8+ T cells (CD8), Tregs, and the percent area (% CAIX) and mean intensity (Int) of carbonic anhydrase IX, a well-described marker of hypoxia. Tissue sections stained with PanCK, CAIX, CD8, Foxp3, and DAPI were imaged with an Olympus IX 83 microscope. ImageJ software and custom software plugins were used to determine %CAIX, Int, CD8, and Treg. PD-L1 by IHC was reported as a combined positive score (CPS) defining positive as CPS > 1. We compared non-responders (NR) i.e. PD to responders (R) i.e. PR or SD, and analyzed OS, PFS. All data were analyzed using GraphPad Prism software. Two-tailed unpaired t test was used when comparing 2 groups, 1-way ANOVA was used for multiple comparisons, and log-rank test was used for survival analysis. Results: The 36 patients included were 69% male, median age 59, 58% smokers. 61% were platinum failure. Primary site included 39% OC, 22% OPC (38% HPV positive), 17% Larynx, 17% other, 5% hypopharynx. Low %CAIX/Int, high CD8, and high CD8/Treg were all significantly associated with R. Patients with low %CAIX/Int (12 month OS Low: 75% vs. Mid: 17% vs. High:8%, p = 0.02) and high CD8/Treg had a significant increase in OS. Only high CD8 was associated with significantly higher PFS. Low %CAIX alone showed a non-significant trend towards increased R and no difference in PFS/OS. There was no difference in CD8, CD8/Treg, PD-L1 and Treg between %CAIX/Int groups. Conclusions: To our knowledge this is the first evaluation of tumor hypoxia as a predictive biomarker in anti-PD-1 mAb treated R/M HNSCC patients. Lower hypoxia by %CAIX/Int was associated with significantly increased response and OS. While further analysis in a larger dataset is needed to confirm, the lack of significant difference in CD8, Treg, PD-L1, and CD8/Treg between %CAIX/Int groups (Low, Mid, High) suggests that hypoxia may be an independent predictive marker.
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