A phase II study of pembrolizumab for HPV-associated papilloma patients with laryngeal, tracheal, and/or pulmonary involvement.
Authors: Pai Sara I. , Muniappan Ashok , Park Jong Chul , Friedman Aaron D. , Campbell Nicholas Paul , Krantz Seth B. , Shin Kee-Young , Song Phillip , Nocon Cheryl C. , Carroll Thomas L. , Faquin William C , ONeill Anne , Franco Ramon 
Published: June 2022

2590 Background: Recurrent respiratory papillomatosis (RRP) is caused by human papillomavirus (HPV) types 6 & 11. RRP proliferates in the squamous epithelium lining the respiratory tract impacting breathing, swallowing, and voice and carries a 3-5% risk of malignant transformation. Given the multi-focality of the disease and tolerized host immune response against HPV, in part through upregulation of the PD1:PDL1 axis, the safety and efficacy of systemic pembrolizumab (pembro) as a novel treatment for this benign tumor patient (pt) population was evaluated in a phase II clinical trial. Methods: RRP pts > 12 years of age were treated with pembro 200mg every 3 weeks. Primary endpoints were best overall response (ORR) (measured by endoscopic lesional burden) and safety. Greater than 5 pts with disease response out of 21 (assuming > 1 of first n = 11 with disease in response) provided 86% power to distinguish between a 15% and a 38% ORR (one-sided 8% binomial test). HPV-specific CD8+ T cell frequency and functional states and biomarkers of response and immune resistance are being evaluated in serial tissue and liquid biopsies (up to 8 biopsies/patient over the 24 months of treatment). Results: The Simon two-stage, stage 1 criteria was met. A total of 21 patients were enrolled and all are now off treatment. Median age (range) was 45 (19-68), 57% (12/21) were male and 67% (14/21) were white. 48% (10/21) had Juvenile-onset (Jo)-RRP, 57% (12/21) had pulmonary RRP involvement, and 19% (4/21) had SCC derived from their RRP. 62% (13/21) completed 24 months of treatment. Reasons for discontinuation included disease progression (14%, 3/21), treatment related adverse event (TRAEs) (14%, 3/21), and study withdrawal (10%, 2/21). A partial response (≥25% reduction in endoscopic tumor burden score) was observed in 57% (12/21) (95% CI: 34%-78.2%) of pts (7 of 10 with Jo-RRP and 5 of 11 with Adult-onset (Ao)-RRP disease responded). Stable disease was observed in 33% (7/21). No complete responses were observed. Fatigue was the most frequent TRAEs; Grade 3 TRAEs included uveitis and hypophysitis, both of which were reversible upon pembro discontinuation and steroid use. At a median follow-up: 25.6 (6.2-38.1 months), the mean number of surgical interventions was reduced by 7 surgeries/year (p = 0.004) in pts treated on the trial for > 12 months, and, upon treatment completion, durable clinical benefit was observed with no additional treatment needed for the duration of the clinical trial follow-up for some pts. Conclusions: Pembro reduces the need for routine surgical interventions based on the durable response rates being achieved. Further study of pembro +/- other agents is warranted to achieve and sustain complete responses in this population. Clinical trial information: NCT02632344.