Synthetic educational example. Do not self-treat: a qualified treating physician must verify the sources, patient data, contraindications, and final plan.
Patient
VERIFIED-HNSCC-L2-HNSCC_RM_2L_NIVOLUMAB · Algorithm: ALGO-HNSCC-RM-2L
Etiological driver
Etiological driver · etiologically_driven archetype
Head and neck squamous cell carcinoma
- Tobacco (smoked + smokeless) — dominant in HPV-negative disease
- Alcohol (synergistic with tobacco)
- HPV (high-risk, mostly type 16) — defines HPV+ oropharyngeal SCC, distinct biology and better prognosis
- EBV — defines nasopharyngeal carcinoma (separate entity in many guidelines but tracked under HNSCC umbrella)
- Betel nut chewing (South / Southeast Asia)
- Fanconi anemia, dyskeratosis congenita (germline susceptibility)
Clinical significance of mutations (ESCAT)
Tumor-board context — the engine does not use these tiers to rank tracks
| Biomarker | Variant | ESCAT | Evidence | Clinical significance | Drugs | Sources |
|---|
| No clinically actionable variants matched in this profile. |
Primary current-line option
- Indication
- IND-HNSCC-RM-2L-NIVOLUMAB
- Regimen
- Nivolumab monotherapy
- Drugs + NSZU
- Nivolumab (DRUG-NIVOLUMAB) 240 mg IV over 30 min (flat dose q2w) OR 480 mg IV over 60 min q4w (flat dose) · q2w (240 mg) or q4w (480 mg flat dose — FDA-approved equivalent) · IV ⚠ NSZU — not for this indication
- Reason
- Provisional current-line default from ALGO-HNSCC-RM-2L: step 1 did not select a treatment branch. ECOG ≥3: best supportive care; palliative RT for symptomatic sites.
Other current-line alternatives (1 tracks)
Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.
- Indication
- IND-HNSCC-RM-2L-PEMBROLIZUMAB
- Regimen
- Pembrolizumab monotherapy
- Drugs + NSZU
- Pembrolizumab (DRUG-PEMBROLIZUMAB) 200 mg IV over 30 min (flat dose) · Day 1 q21d (q3w); or 400 mg q6w (alternative flat dose — equivalent exposure) · IV ⚠ NSZU — not for this indication
- Reason
- Current-line alternative presented for HCP consideration
Pre-treatment investigations
Investigations before treatment start · critical / standard / desired · merged across tracks
| ID | Name | Priority | Category | Where to order | Needed for |
|---|
| TEST-CBC | Complete Blood Count with Differential | Critical | lab | — | all tracks |
| TEST-CMP | Comprehensive Metabolic Panel | Critical | lab | — | all tracks |
| TEST-LFT | Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin) | Critical | lab | — | all tracks |
| TEST-CT-CAP | CT chest/abdomen/pelvis | Standard | imaging | — | all tracks |
Red flags — PRO / CONTRA aggressive
PRO-AGGRESSIVE
Triggers that push toward the aggressive track
- Active or latent infection requiring resolution / prophylaxis before initiating cisplatin-based chemoradiation, cetuximab + RT, or pembrolizumab in HNSCC: HBsAg-positive (HBV reactivation on cytotoxic chemotherapy + checkpoint inhibitors), anti-HBc-positive (occult HBV on cetuximab — anti-EGFR class), HIV-positive (ART coordination, often comorbid in HPV-related HNSCC), or active TB.
Cetuximab — anti-EGFR mAb — has documented HBV reactivation reports (less than rituximab but non-zero); FDA label notes warning. Standard HBsAg + anti-HBc + anti-HBs serology pre-treatment; entecavir / tenofovir for HBsAg+. HIV-related…
RF-HNSCC-INFECTION-SCREENINGSRC-NCCN-HNSCC-2025SRC-ESMO-HNSCC-2020 - Baseline organ dysfunction precluding standard cisplatin-based chemoradiation or pembrolizumab + 5-FU + cisplatin / cetuximab in head and neck squamous cell carcinoma: CrCl <60 mL/min (cisplatin contraindicated at full dose, switch to carboplatin or cetuximab), hearing loss / ototoxicity baseline (cisplatin contraindicated), LVEF <50% (5-FU cardiac risk), bilirubin >3× ULN (taxane / 5-FU metabolism), or severe peripheral neuropathy (cisplatin + taxane contraindicated).
Cisplatin-based CRT is the curative-intent standard (Intergroup 0099, TAX 324, EORTC 24891) but ~30% of HNSCC patients are cisplatin- ineligible at presentation due to age + organ dysfunction. CrCl <60: switch to carboplatin (RTOG 81-17…
RF-HNSCC-ORGAN-DYSFUNCTIONSRC-NCCN-HNSCC-2025SRC-ESMO-HNSCC-2020
CONTRA-AGGRESSIVE
Hard contraindications to escalation
What NOT to do
Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity
Standard plan (IND-HNSCC-RM-2L-NIVOLUMAB)
- Не призначати при попередnoй ICI-терапії (пembro, атезолізумаб) — повторний ICI не підтверджений
- Не відміняти noвалумаб при ендокринних іrAE — гормональна замісна терапія без відміни
- Не призначати при активному аутоімунному захворюванno під системними ГКС
Standard plan (IND-HNSCC-RM-2L-PEMBROLIZUMAB)
- Не призначати при попередньому ICI — повторний anti-PD-1 не підтверджений
- Не відміняти при ендокринних іrAE — тільки гормональна замісна терапія
- Не додавати пembro до хіміотерапії в цьому сетингу — тільки монотерапія
MDT brief
Data quality
Usable with caveats. No critical default-track gap was found, but the MDT should review the listed caveats before final sign-off.
- Biomarker coverage: 0/0 known (100%), 0 missing, 0 default-track gaps
- Unevaluated RedFlags: RF-ACTIVE-AUTOIMMUNE-DISEASE-ICI-RISK, RF-HNSCC-FRAILTY-AGE, RF-HNSCC-HIGH-RISK-BIOLOGY, RF-HNSCC-INFECTION-SCREENING, RF-HNSCC-ORGAN-DYSFUNCTION, RF-HNSCC-TRANSFORMATION-PROGRESSION, RF-LIFESTYLE-SMOKELESS-TOBACCO-PREVENTION, RF-OCC-FORMALDEHYDE-PREVENTION, RF-OCC-WOOD-LEATHER-DUST-PREVENTION
Technical MDT skill metadata (0/16 activated in this plan)
All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).
| Specialist | skill_id | Version | Last reviewed | Sign-offs | Domain |
|---|
| Cellular therapy specialist (CAR-T) | cellular_therapy_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
| Clinical pharmacist | clinical_pharmacist | v0.1.0 | 2026-04-25 | 0 | clinical_pharmacy |
| Hematologist / oncohematologist | hematologist | v0.1.0 | 2026-04-25 | 0 | hematology_oncology |
| Hematopathologist (lymphoma / leukemia / myeloma) | hematopathologist | v0.1.0 | 2026-04-25 | 0 | hematopathology |
| Infectious disease / hepatology | infectious_disease_hepatology | v0.1.0 | 2026-04-25 | 0 | infectious_diseases |
| Medical oncologist (solid-tumor chemotherapist) | medical_oncologist | v0.1.0 | 2026-04-25 | 0 | solid_oncology |
| Molecular geneticist / molecular oncologist | molecular_geneticist | v0.1.0 | 2026-04-25 | 0 | molecular_oncology |
| Palliative care | palliative_care | v0.1.0 | 2026-04-25 | 0 | palliative_care |
| Pathologist (general) | pathologist | v0.1.0 | 2026-04-25 | 0 | pathology |
| Primary care / family physician | primary_care | v0.1.0 | 2026-04-25 | 0 | primary_care |
| Psycho-oncologist | psychologist | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Radiation oncologist | radiation_oncologist | v0.1.0 | 2026-04-25 | 0 | radiation_oncology |
| Radiologist | radiologist | v0.1.0 | 2026-04-25 | 0 | diagnostic_imaging |
| Social worker / case manager | social_worker_case_manager | v0.1.0 | 2026-04-25 | 0 | psychosocial |
| Surgical oncologist | surgical_oncologist | v0.1.0 | 2026-04-25 | 0 | surgical_oncology |
| Transplant specialist (BMT) | transplant_specialist | v0.1.0 | 2026-04-25 | 0 | cellular_therapy |
Sources cited
- SRC-CHECKMATE-141-FERRIS-2016: Nivolumab for Recurrent Squamous-Cell Carcinoma of the Head and Neck
()
- SRC-KEYNOTE-040-COHEN-2019: Pembrolizumab versus methotrexate, docetaxel, or cetuximab for recurrent or metastatic head-and-neck squamous cell carcinoma (KEYNOTE-040): a randomised, open-label, phase 3 study
()
Experimental options (clinical trials)
Last synced: 2026-09-09 · ctgov.
No active trials matched this scenario in ctgov.
Option availability in Ukraine
Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).
| Option | UA registration | NSZU | Cost orientation | Access pathway |
|---|
| Standard plan Nivolumab monotherapy (REG-NIVOLUMAB-MONO) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
| Standard plan Pembrolizumab monotherapy (REG-PEMBROLIZUMAB-MONO) | ✓ registered | ✓ covered | ₴-? — verify pathway | NSZU formulary |
Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-09-09.