Tumor hypoxia is associated with resistance to PD-1 blockade in squamous cell carcinoma of the head and neck
Dan P Zandberg, Ashley V Menk, Maria Velez, Daniel Normolle, Kristin DePeaux, Angen Liu, Robert L Ferris, Greg M Delgoffe, Dan P Zandberg, Ashley V Menk, Maria Velez, Daniel Normolle, Kristin DePeaux, Angen Liu, Robert L Ferris, Greg M Delgoffe
Abstract
The majority of patients with recurrent/metastatic squamous cell carcinoma of the head and neck (HNSCC) (R/M) do not benefit from anti-PD-1 therapy. Hypoxia induced immunosuppression may be a barrier to immunotherapy. Therefore, we examined the metabolic effect of anti-PD-1 therapy in a murine MEER HNSCC model as well as intratumoral hypoxia in R/M patients. In order to characterize the tumor microenvironment in PD-1 resistance, a MEER cell line was created from the parental line that are completely resistant to anti-PD-1. These cell lines were then metabolically profiled using seahorse technology and injected into C57/BL6 mice. After tumor growth, mice were pulsed with pimonidazole and immunofluorescent imaging was performed to analyze hypoxia and T cell infiltration. To validate the preclinical results, we analyzed tissues from R/M patients (n=36) treated with anti-PD-1 mAb, via immunofluorescent imaging for number of CD8+ T cells (CD8), Tregs and the percent area (CAIX) and mean intensity (I) of carbonic anhydrase IX in tumor. We analyzed disease control rate (DCR), progression free survival (PFS), and overall survival (OS) using proportional odds and proportional hazards (Cox) regression. We found that anti-PD-1 resistant MEER has significantly higher oxidative metabolism, while there was no difference in glycolytic metabolism. Intratumoral hypoxia was significantly increased and CD8+ T cells decreased in anti-PD-1 resistant tumors compared with parental tumors in the same mouse. In R/M patients, lower tumor hypoxia by CAIX/I was significantly associated with DCR (p=0.007), PFS, and OS, and independently associated with response (p=0.028) and PFS (p=0.04) in a multivariate model including other significant immune factors. During PD-1 resistance, tumor cells developed increased oxidative metabolism leading to increased intratumoral hypoxia and a decrease in CD8+ T cells. Lower tumor hypoxia was independently associated with increased efficacy of anti-PD-1 therapy in patients with R/M HNSCC. To our knowledge this is the first analysis of the effect of hypoxia in this patient population and highlights its importance not only as a predictive biomarker but also as a potential target for therapeutic intervention.
Trial registration: ClinicalTrials.gov NCT04114136.
Keywords: head and neck neoplasms; immunotherapy; lymphocytes; metabolic networks and pathways; tumor microenvironment; tumor-infiltrating.
Conflict of interest statement
Competing interests: DPZ has research support (institutional) for his role a PI for studies with Merck, BMS, GSK, AstraZeneca, Aduro, Lilly, Astellas, Macrogenics, Varastem, advisory board for Blueprint Medicines. GMD declares competing financial interests and has submitted patents covering the use of PGC1α in cell therapies that are licensed or pending and is entitled to a share in net income generated from licensing of these patent rights for commercial development. GMD consults for and/or is on the scientific advisory board of BlueSphere Bio, Century Therapeutics, Novasenta, Pieris Pharmaceuticals, and Western Oncolytics/Kalivir; has grants from bluebird bio, Novasenta, Pfizer, Pieris Pharmaceuticals, TCR2, and Western Oncolytics/Kalivir; GMD owns stock in Novasenta. RLF serves on advisory boards for BMS, EMD Serono, Macrogenics, Merck, Numab Therapeutics, Pfizer. RLF receives research funding from Astra-Zeneca/MedImmune, BMS, Novasenta, Tesaro. RLF consults for Aduro and Novasenta, RLF owns stock in Novasenta.
© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8126285/bin/jitc-2020-002088f01.jpg)
Figure 2
Hypoxia is associated with poor…
Figure 2
Hypoxia is associated with poor clinical efficacy with Programmed cell death protein 1…
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- Burtness B, Harrington KJ, Greil R, et al. . Pembrolizumab alone or with chemotherapy versus cetuximab with chemotherapy for recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-048): a randomised, open-label, phase 3 study. Lancet 2019;394:1915–28. 10.1016/S0140-6736(19)32591-7 - DOI - PubMed
- Research Support, N.I.H., Extramural
- Adult
- Aged
- Aged, 80 and over
- Animals
- Antineoplastic Agents, Immunological / adverse effects
- Antineoplastic Agents, Immunological / therapeutic use*
- Cell Line, Tumor
- Drug Resistance, Neoplasm*
- Energy Metabolism / drug effects
- Female
- Head and Neck Neoplasms / drug therapy*
- Head and Neck Neoplasms / immunology
- Head and Neck Neoplasms / metabolism
- Head and Neck Neoplasms / pathology
- Humans
- Immune Checkpoint Inhibitors / adverse effects
- Immune Checkpoint Inhibitors / therapeutic use*
- Lymphocytes, Tumor-Infiltrating / drug effects
- Lymphocytes, Tumor-Infiltrating / immunology
- Lymphocytes, Tumor-Infiltrating / metabolism
- Male
- Mice, Inbred C57BL
- Middle Aged
- Oxidation-Reduction
- Programmed Cell Death 1 Receptor / antagonists & inhibitors*
- Programmed Cell Death 1 Receptor / metabolism
- Progression-Free Survival
- Retrospective Studies
- Signal Transduction
- Squamous Cell Carcinoma of Head and Neck / drug therapy*
- Squamous Cell Carcinoma of Head and Neck / immunology
- Squamous Cell Carcinoma of Head and Neck / metabolism
- Squamous Cell Carcinoma of Head and Neck / pathology
- T-Lymphocytes / drug effects
- T-Lymphocytes / immunology
- T-Lymphocytes / metabolism
- Tumor Burden / drug effects
- Tumor Hypoxia*
- Tumor Microenvironment
- Xenograft Model Antitumor Assays
- Antineoplastic Agents, Immunological
- Immune Checkpoint Inhibitors
- PDCD1 protein, human
- Pdcd1 protein, mouse
- Programmed Cell Death 1 Receptor
- ClinicalTrials.gov/NCT04114136
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- Medical
- Research Materials
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/8126285/bin/jitc-2020-002088f02.jpg)
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Source: PubMed