Neoadjuvant pembrolizumab plus nimotuzumab as a bridge to surgery in a frail elderly patient with maxillary gingival and palatal squamous cell carcinoma: a case report

A 75-year-old woman with maxillary gingival and hard-palatal squamous cell carcinoma experienced improved oral intake, weight and performance status during two cycles of neoadjuvant pembrolizumab plus nimotuzumab with supportive care, enabling subsequent maxillectomy and left neck dissection. The case report describes a single-patient course and does not establish the efficacy, comparative safety or durability of the regimen.

At presentation, the patient had severe oral pain, dysphagia, ulceration and intermittent bleeding associated with a progressively enlarging left maxillary lesion. She had lost 5 kg over approximately two weeks, weighing 70 kg despite a body mass index of 26.7 kg/m², and had an Eastern Cooperative Oncology Group performance status of 3. The treating team clinically assessed frailty from her rapid weight loss, reduced intake, functional limitations and cardiovascular comorbidities; no validated frailty instrument or baseline frailty score was recorded, and the authors cautioned that improvement should not be equated with documented reversal of frailty.

Biopsy confirmed well-differentiated squamous cell carcinoma. Immunohistochemistry showed negative p16, positive epidermal growth factor receptor expression and a programmed death ligand 1 combined positive score of 70. Contrast-enhanced computed tomography showed an approximately 44 × 42 mm left maxillary lesion with adjacent facial soft-tissue extension and destruction of the anterior and inferior maxillary sinus walls. Multiple ipsilateral cervical nodes were enlarged and considered suspicious, and the pretreatment clinical stage was recorded as cT4aN1M0. The tumor was considered anatomically resectable, but immediate extensive surgery and flap reconstruction were deferred because of concerns about the patient’s limited physiological reserve.

Because cisplatin was considered unsuitable because of poor performance status, nutritional compromise, clinically assessed frailty and cardiovascular comorbidities, the multidisciplinary team selected a chemotherapy-free preoperative regimen. Treatment began on 16 October 2025 with pembrolizumab 200 mg every three weeks and nimotuzumab 200 mg weekly. The rationale included the tumor’s high PD-L1 combined positive score and EGFR positivity, although the report states that this biomarker combination does not establish a validated treatment-selection rule. Supportive care included nutritional support, analgesia, oral care, correction of fluid or electrolyte disturbances, cardiovascular optimization and functional prehabilitation as tolerated. No grade 2 or higher immune-related adverse events or infusion reactions were reported during the neoadjuvant period.

After two treatment cycles, oral pain had largely resolved and the patient could eat independently. Her weight increased from 70 to 75 kg, performance status improved from 3 to 1, albumin rose from 32 g/L to 38 g/L, prealbumin increased from 125 mg/L to 235 mg/L and C-reactive protein declined from 38 mg/L to 6 mg/L. These laboratory changes accompanied the clinical improvement, but the report notes that albumin and prealbumin are influenced by inflammation and are not stand-alone measures of nutritional status. The available measurements also do not demonstrate recovery of muscle mass.

Computed tomography restaging showed marked regression of the primary tumor and reduced cervical lymphadenopathy, reported as a partial response under RECIST 1.1. Following the improvement in nutritional and functional status, the patient underwent maxillectomy and left neck dissection of levels Ia–IV on 12 December 2025. Frozen-section margins were negative, and no flap reconstruction was performed. The stated considerations for omitting flap reconstruction included her advanced age and limited physiological reserve; the report does not provide detailed postoperative morbidity or objective functional outcomes.

Final postoperative pathology was reported as ypT0N0, with no metastatic carcinoma in any of the 32 dissected lymph nodes: 0/10 at levels Ia–Ib, 0/10 at level II, 0/4 at level III and 0/8 at level IV. One node showed necrosis and dystrophic calcification compatible with treatment effect. However, the pathological narrative also described scattered degenerative atypical epithelial clusters interpreted as regressed carcinoma, and the report states that the original slides and final pathology record require confirmation before the complete pathological response is regarded as unequivocally established. Pretreatment nodal involvement was suspected radiologically rather than confirmed by biopsy, so the 0/32 result does not by itself demonstrate clearance of histologically confirmed nodal metastases.

Based on the negative resection margins and absence of metastatic carcinoma in the dissected nodes, the multidisciplinary team did not recommend postoperative radiotherapy or cytotoxic chemotherapy. The patient received maintenance immunotherapy, which was ongoing at the last reported follow-up in September 2026, approximately nine months after surgery. Assessments were conducted at one, three and six months after surgery, and no recurrence was reported at the last follow-up. The short follow-up does not permit conclusions about survival benefit or durable disease control, and the single case cannot validate the omission of postoperative radiotherapy in other patients.

The report emphasizes that recovery of access to surgery was the principal educational value, rather than pathological response alone. Because tumor-directed treatment and supportive care were provided concurrently, their separate contributions to improved intake, weight and performance status cannot be determined. The case also does not show that the antibody combination was necessary for surgery to become feasible, establish the independent contribution of either drug, or support reducing surgical margins, omitting neck dissection or withholding indicated local treatment. The authors state that the bridge-to-surgery concept warrants prospective evaluation in carefully selected patients, with assessment of treatment completion, nutritional intake, physical function, time to surgery, operative morbidity, pathological response, postoperative treatment delivery and longer-term disease control.

Subject of Research: A case report of neoadjuvant pembrolizumab plus nimotuzumab as a bridge to surgery for oral squamous cell carcinoma in a frail 75-year-old patient.

Article Title: Neoadjuvant pembrolizumab plus nimotuzumab as a bridge to surgery in a frail elderly patient with maxillary gingival and palatal squamous cell carcinoma: a case report

Article References: Lin, Q., Shang, L., Guo, Z.-Z., Wang, F., Li, B., Cai, B., Feng, L., Zhang, H., Song, Z., Wu, Z., & Xi, Q. (2026). Neoadjuvant pembrolizumab plus nimotuzumab as a bridge to surgery in a frail elderly patient with maxillary gingival and palatal squamous cell carcinoma: a case report. Frontiers in Oncology, 16, Article 1993693. https://doi.org/10.3389/fonc.2026.1993693

Image Credits: AI Generated

DOI: 10.3389/fonc.2026.1993693

Keywords: case report, oral squamous cell carcinoma, neoadjuvant immunotherapy, pembrolizumab, nimotuzumab, frailty, maxillectomy, pathological response, Neoadjuvant, plus, bridge, surgery