Pyrimethamine as an Inhibitor of NRF2 in HPV-negative Locally Advanced Head and Neck Squamous Cell Carcinoma

Inclusion Criteria: Histologically or cytologically confirmed HPV-negative, locally advanced (Stage III-IV) head and neck squamous cell carcinoma (HNSCC) undergoing surgical-based treatment with curative intent. At least 18 years of age. ECOG performance status ≤ 1 Normal bone marrow and organ function as defined below: Leukocytes ≥ 3.0 K/cumm Absolute neutrophil count ≥ 1.5 K/cumm Platelets ≥ 100 K/cumm Total bilirubin ≤ 1.5 x IULN AST(SGOT)/ALT(SGPT) ≤ 3.0 x IULN Creatinine clearance > 50 mL/min by Cockcroft-Gault Able to swallow study drug The effects of pyrimethamine on the developing human fetus are unknown. For this reason and because it is in Pregnancy Category C, women of childbearing potential and men must agree to use adequate contraception (hormonal or barrier method of birth control, abstinence) prior to study entry and for the duration of study participation. Should a woman become pregnant or suspect she is pregnant while participating in this study, she must inform her treating physician immediately. Ability to understand and willingness to sign an IRB approved written informed consent document. Patient must be able to undergo a research biopsy prior to starting treatment, or have previously banked baseline tumor biopsy of at least 20 mg of frozen tissue collected under Tissue Acquisition Protocol (IRB 201102323). Exclusion Criteria: Prior therapy for this cancer. A history of other malignancy with the exception of malignancies for which all treatment was completed at least 2 years before registration and the patient has no evidence of disease. Prior treatment with pyrimethamine in the year prior to HNSCC diagnosis. Currently receiving any other investigational agents. A history of allergic reactions attributed to compounds of similar chemical or biologic composition to pyrimethamine or other agents used in the study. Uncontrolled intercurrent illness including, but not limited to, ongoing or active infection, current use of systemic immunosuppressive medications, symptomatic congestive heart failure, unstable angina pectoris, or cardiac arrhythmia. Documented megaloblastic anemia due to folate deficiency. Treatment with anticoagulant or antiplatelet therapy in the year prior to HNSCC diagnosis. Pregnant and/or breastfeeding. Women of childbearing potential must have a negative pregnancy test within 7 days of Day 1. Patients with HIV are eligible unless their CD4+ T-cell counts are < 350 cells/mcL or they have a history of AIDS-defining opportunistic infection within the 12 months prior to registration. Concurrent treatment with effective ART according to DHHS treatment guidelines is recommended. Active alcohol abuse in the opinion of the treating physician. Currently taking phenytoin