Nasopharyngeal cancer: the impact of guidelines and teaching on radiation target volume delineation

Target volume delineation in the radiation treatment of nasopharyngeal cancer is challenging due to several reasons such as the complex anatomy of the site, the need for the elective coverage of definite anatomical regions, the curative intent of treatment and the rarity of the disease, especially in non-endemic areas. We aimed to analyze the impact of educational interactive teaching courses on target volume delineation accuracy between Italian radiation oncology centers. Only one contour dataset per center was admitted. The educational course consisted in three parts: (1) The completely anonymized image dataset of a T4N1 nasopharyngeal cancer patient was shared between centers before the course with the request of target volume and organs at risk delineation; (2) the course was held online with dedicated multidisciplinary sessions on nasopharyngeal anatomy, nasopharyngeal cancer pattern of diffusion and on the description and explanation of international contouring guidelines. At the end of the course, the participating centers were asked to resubmit the contours with appropriate corrections; (3) the pre- and post-course contours were analyzed and quantitatively and qualitatively compared with the benchmark contours delineated by the panel of experts. The analysis of the 19 pre- and post-contours submitted by the participating centers revealed a significant improvement in the Dice similarity index in all the clinical target volumes (CTV1, CTV2 and CTV3) passing from 0.67, 0.51 and 0.48 to 0.69, 0.65 and 0.52, respectively. The organs at risk delineation was also improved. The qualitative analysis consisted in the evaluation of the inclusion of the proper anatomical regions in the target volumes; it was conducted following internationally validated guidelines of contouring for nasopharyngeal radiation treatment. All the sites were properly included in target volume delineation by  >50% of the centers after correction. A significant improvement was registered for the skull base, the sphenoid sinus and the nodal levels. These results demonstrated the important role that educational courses with interactive sessions could have in such a challenging task as target volume delineation in modern radiation oncology.

Durable response of tislelizumab plus cisplatin, nab-paclitaxel followed by concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma: A case report

RATIONALE

Limited patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) have achieved complete response (CR) from induction chemotherapy (IC). Neoadjuvant immunotherapy combined with chemotherapy has marked therapeutic effects in some locoregionally advanced solid tumors. However, its efficacy and safety of NPC have not been reported so far. The rapid response of neoadjuvant tislelizumab combined with chemotherapy on LA-NPC may be associated with long-term survival benefit.

PATIENT CONCERNS

A 57-year-old male patient presented with a 2-month history of bloody nasal discharge and right neck mass for 2 weeks.

DIAGNOSIS

The patient was eventually diagnosed with nasopharyngeal nonkeratinizing undifferentiated cell carcinoma (stage IVA).

INTERVENTIONS

The patient received tislelizumab combined with nanoparticle albumin-bound paclitaxel (nab-paclitaxel) nab-paclitaxel plus cisplatin for 4 cycles, followed by cisplatin-based concurrent chemoradiotherapy (CCRT).

OUTCOMES

A partial response (PR) was achieved after 2 cycles of tislelizumab and nab-paclitaxel plus cisplatin, and CR was achieved after 4 cycles of neoadjuvant treatment. The duration of response lasted 24 months, and the patient was still in CR as of November 2022. The patient had no serious adverse event (AEs) during the treatment.

LESSONS

This case report showed that tislelizumab combined with cisplatin plus nab-paclitaxel followed CCRT for treatment of patients with LA-NPC may receive a fast and durable response with a manageable safety profile and long-term survival.

Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy in patients with nasopharyngeal carcinoma: open label, non-inferiority, multicentre, randomised, phase 3 trial

OBJECTIVES

To address whether sparing the medial retropharyngeal lymph node (MRLN) region from elective irradiation volume provides non-inferior local relapse-free survival versus standard radiotherapy in patients with nasopharyngeal carcinoma.

DESIGN

Open-label, non-inferiority, multicentre, randomised, phase 3 trial.

SETTING

Three Chinese hospitals between 20 November 2017 and 3 December 2018.

PARTICIPANTS

Adults (18-65 years) with newly diagnosed, non-keratinising, non-distant metastatic nasopharyngeal carcinoma without MRLN involvement.

INTERVENTIONS

Randomisation was done centrally by the Clinical Trials Centre at Sun Yat-sen University Cancer Center. Eligible patients were randomly assigned (1:1; block size of four) to receive MRLN sparing radiotherapy or standard radiotherapy (both medial and lateral retropharyngeal lymph node groups), and stratified by institution and treatment modality as follows: radiotherapy alone; concurrent chemoradiotherapy; induction chemotherapy plus radiotherapy or concurrent chemoradiotherapy.

MAIN OUTCOME MEASURES

Non-inferiority was met if the lower limit of the one sided 97.5% confidence interval of the absolute difference in three year local relapse-free survival (MRLN sparing radiotherapy minus standard radiotherapy) was greater than -8%.

RESULTS

568 patients were recruited: 285 in the MRLN sparing radiotherapy group; 283 in the standard radiotherapy group. Median follow-up was 42 months (interquartile range 39-45), intention-to-treat analysis showed that the three year local relapse-free survival of the MRLN sparing radiotherapy group was non-inferior to that of the standard radiotherapy group (95.3% v 95.5%, stratified hazard ratio 1.04 (95% confidence interval 0.51 to 2.12), P=0.95) with a difference of -0.2% ((one sided 97.5% confidence interval -3.6 to ∞), P_{non-inferiority}<0.001). In the safety set (n=564), the sparing group had a lower incidence of grade ≥1 acute dysphagia (25.5% v 35.1%, P=0.01) and late dysphagia (24.0% v 34.3%, P=0.008). Patient reported outcomes at three years after MRLN sparing radiotherapy were better in multiple domains after adjusting for the baseline values: global health status (mean difference -5.6 (95% confidence interval -9.1 to -2.0), P=0.002), role functioning (-5.5 (-7.4 to -3.6), P<0.001), social functioning (-6.2 (-8.9 to -3.6), P<0.001), fatigue (7.9 (4.0 to 11.8), P<0.001), and swallowing (11.0 (8.4 to 13.6), P<0.001). The difference in swallowing scores reached clinical significance (>10 points difference).

CONCLUSION

Compared with standard radiotherapy, MRLN sparing radiotherapy showed non-inferiority in terms of risk of local relapse with fewer radiation related toxicity and improved patient reported outcomes in patients with non-metastatic nasopharyngeal carcinoma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03346109.

LncRNA CASC19 Enhances the Radioresistance of Nasopharyngeal Carcinoma by Regulating the miR-340-3p/FKBP5 Axis

Radioresistance remains a serious obstacle encountered in the radiotherapy of nasopharyngeal carcinoma (NPC). Both mRNAs and non-coding RNAs (ncRNAs), including long ncRNA (lncRNA) and microRNA (miRNA), play essential roles in radiosensitivity. However, the comprehensive expression profiles and competing endogenous RNA (ceRNA) regulatory networks among lncRNAs, miRNAs, and mRNAs in NPC radioresistance are still bewildering. In this study, we performed an RNA-sequencing (RNA-seq) assay in the radioresistant NPC cells CNE2R and its parental cells CNE2 to identify the differentially expressed lncRNAs, miRNAs, and mRNAs. The ceRNA networks containing lncRNAs, miRNAs, and mRNAs were predicted on the basis of the Pearson correlation coefficients and authoritative miRanda databases. In accordance with bioinformatic analysis of the data of the tandem mass tag (TMT) assay of CNE2R and CNE2 cells and the gene chip assay of radioresistant NPC samples in pre- and post-radiotherapy, the radioresistance-related signaling network of lncRNA CASC19, miR-340-3p, and FKBP5 was screened and further verified using an RT-qPCR assay. CASC19 was positively associated with FKBP5 expression while negatively correlated with miR-340-3p, and the target binding sites of CASC19/miR-340-3p and miR-340-3p/FKBP5 were confirmed using a dual-luciferase reporter assay. Moreover, using an mRFP-GFP-LC3 maker, it was found that autophagy contributed to the radioresistance of NPC. MiR-340-3p inhibition or FKBP5 overexpression could rescue the suppression of autophagy and radioresistance induced by CASC19 knockdown in CNE2R cells. In conclusion, the CASC19/miR-340-3p/FKBP5 network may be instrumental in regulating NPC radioresistance by enhancing autophagy, which provides potential new therapeutic targets for NPC.

Post-irradiation sarcoma after definitive radiation therapy for nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

Postirradiation sarcoma (PIS) is a rare radiation-induced malignancy after nasopharyngeal carcinoma (NPC) treatment.

MATERIALS AND METHODS

We retrospectively screened 9,185 NPC patients between 2000 and 2020 and identified 41 patients with PIS according to the modified Cahan's criteria: (1) the PIS must have arisen within a previous radiation field; (2) a latent period must have existed; (3) histologically proved sarcoma; (4) the tissue in which the PIS arose must have been healthy prior to the radiation. The initial radiation therapy techniques used were 2D (25; 61.0%), 3D (7; 17.1%), and IMRT (9; 22%).

RESULTS

The time (year) from radiotherapy (RT) to PIS was longer when using 2D or 3D irradiation techniques (median, 14.2; range, 3.4-28.1; Q1-Q3, 8.6-19.7) than when using IMRT (median, 6.6; range, 3.8-15.7; Q1-Q3, 4.5-11.7; P =.026). The time (year) from RT to PIS diagnosis was significantly longer when using lower radiation energy from cobalt-60 (median, 15.8; range, 10.4-28.4; Q1-Q3, 12.5-23.8) than when using a higher radiation energy of 6 or 10 MV (median, 10.2; range, 3.4-23.3; Q1-Q3, 6.5-16.1; P =.006). The 2-year overall survival rates for patients who underwent surgery, radical radiotherapy, systemic therapy alone and no treatment were 60.7 %, 42.9 %, 0 % and 0 %, respectively (P =.000). Of the 3 retrievable initial RT dosimetry plans for NPC, the D95 values (dose that covers 95 % of the PIS volume) for PIS were 6267, 6344 and 5820 cGy, respectively.

CONCLUSION

High radiation energy and modern techniques may shorten NPC PIS latency. Surgery may be associated with improved survival if feasible.

Set-up errors of the neck are underestimated using the overall registration frame of head and neck in IMRT for NPC

BACKGROUND

There is no standardized registration frame of cone beam CT (CBCT) in intensity modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC). The overall registration frame that covers the whole head and neck is the most commonly used CBCT registration frame for NPC patients in IMRT.

OBJECTIVE

To compare the set-up errors using different registration frames of CBCT for NPC to assess the set-up errors for different region of the commonly used clinical overall registration frame.

METHODS

294 CBCT images of 59 NPC patients were collected. Four registration frames were used for matching. The set-up errors were obtained using an automatic matching algorithm and then compared. The expansion margin from the clinical target volume (CTV) to the planned target volume (PTV) in the four groups was also calculated.

RESULTS

The average range of the isocenter translation and rotation errors of four registration frames are 0.89∼2.41 mm and 0.49∼1.53°, respectively, which results in a significant difference in the set-up errors (p < 0.05). The set-up errors obtained from the overall frame are smaller than those obtained from the head, upper neck, and lower neck frames. The margin ranges of the overall, head, upper neck, and lower neck frames in three translation directions are 1.49∼2.39 mm, 1.92∼2.45 mm, 1.86∼3.54 mm and 3.02∼4.78 mm, respectively. The expansion margins calculated from the overall frame are not enough, especially for the lower neck.

CONCLUSION

Set-up errors of the neck are underestimated by the overall registration frame. Thus, it is important to improve the position immobilization of the neck, especially the lower neck. The margin of the target volume of the head and neck region should be expanded separately if circumstances permit.

Optimal plan target in cases with locally advanced nasopharyngeal cancer: Comparison of VMAT, IMRT, hybrid, and tomotherapy results

PURPOSE

In locally advanced nasopharyngeal cancer (NC), the spread of the disease, proximity to critical structures, and high dose requirement for tumor control may complicate the treatment plan. In this study, VMAT/IMRT/hybrid/tomotherapy plans were made to reach the safest and most effective dose distribution for each of the patients and the results were compared.

METHODS

Double volumetric-modulated arc therapy (VMAT) and 7- and 9-field intensity-modulated radiation therapy (IMRT) plans were made to 21 locally advanced NCs with Varian Trilogy System. It was observed that appropriate dose distributions could not be achieved with IMRT or VMAT, and hybrid IMRT-VMAT plans were made. All cases were also planned with Tomotherapy Precision System, and the data of four different techniques were compared retrospectively.

RESULTS

For normal tissue tolerances in 73 structures could not be obtained with VMAT and 38 structures with IMRT whereas the desired tolerance was provided with the hybrid plan. Hybrid plans were made with an average of 14 VMATs and 20 IMRTs. The maximum brainstem and spinal cord doses were found significantly lower in hybrid and tomotherapy techniques. Homogeneity index (HI) and conformity index (CI) values were the best in hybrid plans. No statistically significant difference between the hybrid plan and tomotherapy in terms of normal tissue tolerance doses and HI whereas a significant difference was found in the hybrid plan for CI.

CONCLUSION

It was observed that the most ideal plans for the locally advanced NC could be obtained with tomotherapy and hybrid plan techniques that the better protection in critical structures and desired dose distribution at target volumes.

Predicting Nomogram for Severe Oral Mucositis in Patients with Nasopharyngeal Carcinoma during Intensity-Modulated Radiation Therapy: A Retrospective Cohort Study

BACKGROUND

Oral mucositis is an acute adverse reaction with high incidence during radiotherapy. Severe oral mucositis can seriously affect patients' quality of life and compliance with radiotherapy. The aim of this study was to identify the risk factors for severe oral mucositis and to develop a nomogram for predicting severe oral mucositis in patients with nasopharyngeal carcinoma.

METHODS

One hundred and ninety patients with nasopharyngeal carcinoma were retrospectively screened in this study. Least absolute shrinkage and selection operator regression and multivariate logistic regression analyses were performed to identify the best predictors of severe oral mucositis. A nomogram was constructed based on the factors. Finally, the discriminative ability of the nomogram was evaluated.

RESULTS

Four independent factors predicting severe oral mucositis were identified: age, N stage, the cycle of induction chemotherapy, and dose-volumetric parameter V40 (%) of oral cavity. The area under the receiver of operating characteristic curve of the nomogram was 0.759 (95% confidence interval: 0.691-0.827).

CONCLUSIONS

A predictive nomogram for severe oral mucositis was established and validated in this study. The nomogram provides a reliable and practical model for clinically predicting the probability of severe oral mucositis in patients with nasopharyngeal carcinoma before intensity-modulated radiation therapy.

[circ-WHSC1 affects the growth, metastasis and radiotherapy sensitivity of nasopharyngeal carcinoma cells by targeting miR-338-3p/ELAVL1 axis]

Objective: To study the effect of circ-WHSC1 on the growth, metastasis and radiosensitivity of nasopharyngeal carcinoma cells and its molecular mechanism. Methods: Cancerous tissues and adjacent tissues were collected from 23 patients with nasopharyngeal carcinoma, and real-time fluorescent quantitative PCR (RT-qPCR) was used to detect the expression levels of circ-WHSC1, miR-338-3p, and ELAVL1 mRNA. Western blot was used to detect the expression of ELAVL1 protein. Nasopharyngeal carcinoma cells 5-8F and SUNE1 were divided into si-NC group, si-circ-WHSC1 group, pCD5-ciR group, circ-WHSC1 group, anti-miR-NC group, anti-miR-338-3p group, miR-NC group, miR-338-3p group, si-circ-WHSC1+ anti-miR-NC group, si-circ-WHSC1+ anti-miR-338-3p group, miR-338-3p+ pcDNA group, miR-338-3p+ ELAVL1 group. Tetramethylazolium salt colorimetric method (MTT) was used to detect cell viability. Clone formation test was used to detect cell clone formation and cell radiosensitivity. Flow cytometry was used to detect cell apoptosis. Transwell was used to detect cell migration and invasion. Dual luciferase assay was used to detect the targeting relationship between circ-WHSC1 and miR-338-3p, miR-338-3p and ELAVL1. The SUNE1 cells stably transfected with sh-circ-WHSC1 were injected into nude mice and irradiated with radiation, and then the tumor volume and weight of mice were detected. Results: The expressions of circ-WHSC1 (1.57±0.94 vs 3.78±1.18, 1.00±0.10 vs 1.64±0.14/2.00±0.21/2.81±0.26/3.36±0.34) and ELAVL1 (1.28±0.74 vs 3.36±0.77, 1.00±0.08 vs 2.51±0.19/3.27±0.27) in nasopharyngeal carcinoma tissues and cells were increased, and the expression of miR-338-3p (3.13±0.96 vs 1.37±0.98, 1.00±0.08 vs 0.48±0.08/0.38±0.07) was decreased (P<0.05). After knockdown of circ-WHSC1, the activity of nasopharyngeal carcinoma cells was decreased [(100.00±8.00)% vs (51.33±8.62)%, (100.00±10.10)% vs (41.02±7.31)%], the number of clone-forming cells was decreased (101.00±8.54 vs 50.33±8.02, 114.00±14.10 vs 42.33±10.01), the rate of apoptosis was increased [(5.37±1.20)% vs (18.3±1.01)%, (6.5±1.18)% vs (22.43±1.40)%], and the numbers of migration (136.00±13.00 vs 72.33±9.50, 154.00±14.10 vs 62.67±11.50) and invasion (113.67±11.59 vs 60.67±9.07, 124.33±15.57 vs 50.33±9.01) were decreased; after different doses of radiation, the cell survival score was decreased (0.23±0.04 vs 0.06±0.01, 0.32±0.07 vs 0.05±0.02) (P<0.05). Circ-WHSC1 targeted and negatively regulated miR-338-3p. Inhibition of miR-338-3p affected the effect of knockdown of circ-WHSC1 on the proliferation, apoptosis, migration, invasion and radiosensitivity of nasopharyngeal carcinoma cells. MiR-338-3p targeted and negatively regulated ELAVL1; ELAVL1 overexpression affected the effects of miR-338-3p on the proliferation, apoptosis, migration, invasion and radiosensitivity of nasopharyngeal carcinoma cells. After the cells stably transfected with sh-circ-WHSC1 were injected into nude mice, the tumor volume [(884.67±95.63)mm(3) vs (487.33±76.51)mm(3)] and weight [(899.01±88.54)mg vs (558.67±75.04) mg] of the nude mice were reduced; after further irradiation, the tumor volume [(395.00±73.50)mm(3) vs 243.13±42.51)mm(3)] and weight[ (452.33±67.30)mg vs (211.09±57.51)mg] of the nude mice were reduced (P<0.05). Circ-WHSC1 regulated the expression of ELAVL1 by targeting miR-382. Conclusion: Knockdown of circ-WHSC1 can inhibit the growth and metastasis of nasopharyngeal carcinoma cells by targeting miR-338-3p/ELAVL1 axis, and enhances the radiosensitivity of nasopharyngeal carcinoma cells.

Effect of Radiotherapy Alone vs Radiotherapy With Concurrent Chemoradiotherapy on Survival Without Disease Relapse in Patients With Low-risk Nasopharyngeal Carcinoma: A Randomized Clinical Trial

IMPORTANCE

Concurrent chemoradiotherapy has been the standard treatment for stage II nasopharyngeal carcinoma (NPC) based on data using 2-dimensional conventional radiotherapy. There is limited evidence for the role of chemotherapy with use of intensity-modulated radiation therapy (IMRT).

OBJECTIVE

To assess whether concurrent chemotherapy can be safely omitted for patients with low-risk stage II/T3N0 NPC treated with IMRT.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, open-label, randomized, phase 3, noninferiority clinical trial was conducted at 5 Chinese hospitals, including 341 adult patients with low-risk NPC, defined as stage II/T3N0M0 without adverse features (all nodes <3 cm, no level IV/Vb nodes; no extranodal extension; Epstein-Barr virus DNA <4000 copies/mL), with enrollment between November 2015 and August 2020. The final date of follow-up was March 15, 2022.

INTERVENTIONS

Patients were randomly assigned to receive IMRT alone (n = 172) or concurrent chemoradiotherapy (IMRT with cisplatin, 100 mg/m2 every 3 weeks for 3 cycles [n = 169]).

MAIN OUTCOMES AND MEASURES

The primary end point was 3-year failure-free survival (time from randomization to any disease relapse or death), with a noninferiority margin of 10%. Secondary end points comprised overall survival, locoregional relapse-free survival, distant metastasis-free survival, adverse events, and health-related quality of life (QOL) measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (QLQ-C30; range, 0-100 points; minimum clinically important difference ≥10 for physical function, symptom control, or health-related QOL; higher score indicates better functioning and global health status or worse symptoms).

RESULTS

Among 341 randomized patients (mean [SD] age, 48 [10] years; 30% women), 334 (98.0%) completed the trial. Median follow-up was 46 months (IQR, 34-58). Three-year failure-free survival was 90.5% for the IMRT-alone group vs 91.9% for the concurrent chemoradiotherapy group (difference, -1.4%; 1-sided 95% CI, -7.4% to ∞; P value for noninferiority, <.001). No significant differences were observed between groups in overall survival, locoregional relapse, or distant metastasis. The IMRT-alone group experienced a significantly lower incidence of grade 3 to 4 adverse events (17% vs 46%; difference, -29% [95% CI, -39% to -20%]), including hematologic toxicities (leukopenia, neutropenia) and nonhematologic toxicities (nausea, vomiting, anorexia, weight loss, mucositis). The IMRT-alone group had significantly better QOL scores during radiotherapy including the domains of global health status, social functioning, fatigue, nausea and vomiting, pain, insomnia, appetite loss, and constipation.

CONCLUSIONS AND RELEVANCE

Among patients with low-risk NPC, treatment with IMRT alone resulted in 3-year failure-free survival that was not inferior to concurrent chemoradiotherapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02633202.

Final Overall Survival Analysis of Gemcitabine and Cisplatin Induction Chemotherapy in Nasopharyngeal Carcinoma: A Multicenter, Randomized Phase III Trial

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically on the based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.We previously reported significantly improved failure-free survival using gemcitabine plus cisplatin induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma. Here, we present the final overall survival (OS) analysis. In this multicenter, randomized trial, patients were assigned to be treated with concurrent chemoradiotherapy alone (standard therapy, n = 238) or gemcitabine and cisplatin induction chemotherapy before concurrent chemoradiotherapy (n = 242). With a median follow-up of 69.8 months, the induction chemotherapy group had a significantly higher 5-year OS (87.9% v 78.8%, hazard ratio, 0.51 [95% CI 0.34 to 0.78]; P = .001) and a comparable risk of late toxicities (≥ grade 3, 11.3% v 11.4%). Notably, the depth of the tumor response to induction chemotherapy correlated significantly and positively with survival (complete response v partial response v stable/progressive disease, 5-year OS, 100% v 88.4% v 61.5%, P = .005). Besides, patients with a low pretreatment cell-free Epstein-Barr virus DNA load (< 4,000 copies/mL) might not benefit from induction chemotherapy (5-year OS, 90.6% v 91.4%, P = .77). In conclusion, induction chemotherapy before concurrent chemoradiotherapy improved OS significantly in patients with locally advanced nasopharyngeal carcinoma, without increasing the risk of late toxicities. Tumor response to induction chemotherapy and pretreatment cell-free Epstein-Barr virus DNA might be useful to guide individualized treatment.

Propolis mouthwash for preventing radiotherapy-induced mucositis in patients with nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is the most common head and neck cancer in Malaysia. The gold standard treatment of NPC is radiotherapy (RT), as NPC is a radiosensitive tumour. Although RT is successful in treating NPC, patients cannot avoid the resulting RT complications. Oral mucositis is the most frequently encountered debilitating complication of RT and has no specific preventive treatment. The aim of this study was to evaluate the efficacy and safety of a 2.5% propolis mouthwash for preventing RT-induced mucositis in patients with NPC.

MATERIALS AND METHODS

The study was a prospective, double-arm, randomised control trial with intervention. The patients were randomly divided into an experimental group receiving propolis mouthwash and a placebo group receiving normal saline mouthwash. All patients were instructed to rinse their mouths with 7mL mouthwash three times daily for six weeks. The severity of oral mucositis was then evaluated by the World Health Organization Oral Toxicity Scale at the second, fourth, and sixth weeks of the study.

RESULTS

In total, 17 patients completed the study: 10 patients used the propolis mouthwash and seven used the placebo mouthwash. The mean mucositis scores for the propolis mouthwash compared to the placebo at the second, fourth, and sixth weeks were 0.10 vs. 1.14, 0.50 vs. 2.00, and 1.20 vs. 2.86, respectively, and the differences between the two groups were statistically significant (p<0.001).

CONCLUSION

A 2.5% propolis mouthwash was both safe and effective for reducing the severity of oral mucositis following RT for NPC.

A prospective study on defining the indications of prophylactic level IB radiotherapy in nasopharyngeal carcinoma based on a risk score model

OBJECTIVE

To investigate clinical evidence for defining the indications of prophylactic level IB radiotherapy in nasopharyngeal carcinoma (NPC).

METHODS

We conducted a phase 2 prospective study in 116 newly diagnosed patients with NPC treated by intensity-modulated radiotherapy (IMRT). Whether level IB was irradiated based on the risk score model (RSM). Two groups based on RSM were obtained: low risk and high risk. Omission of level IB irradiation was conducted in low risk group, otherwise level IB was contoured as part of the treatment target. Grade 2 or worse xerostomia at 12 months was assessed by the European Organization for Research and Treatment of Cancer (EORTC) QLQ-H&N35 questionnaire.

RESULTS

At a median follow-up of 16months (range, 1-26 months). None patients developed failures at level IB. The 1-year overall survival (OS), locoregional recurrence-free survival (LRRFS) and distant metastasis-free survival (DMFS) rates were 98.3%, 97.2% and 95.8%, respectively. At 12 months xerostomia side-effects were reported 90 of 126 alive patients, grade 2 or worse xerostomia at 12 months was significantly lower in the low risk group than in the high risk group.

CONCLUSION

Omission of level IB irradiation was feasible for patients with low-risk IB lymph nodes metastasis.

[Expression of pepsin in nasopharyngeal carcinoma and its correlation with quality of life after radiotherapy]

Objective: By analyzing the expression of pepsin in nasopharyngeal carcinoma (NPC) tissues, to investigate the correlation between laryngeal reflux (LPR) and NPC, as well as the effect of LPR on the quality of life of patients with NPC after radiotherapy. Methods: A total of 133 patients with NPC who underwent radiotherapy at the Department of Otorhinolaryngology of the Affiliated Hospital of Guizhou Medical University and the Affiliated Cancer Hospital of Guizhou Medical University from 2005 to 2019 were enrolled consecutively, including 90 males and 43 females, aged (44.32±7.47) years old. At the same period, 58 patients with chronic nasopharyngitis who underwent nasopharyngeal biopsy were selected as the control group. Immunohistochemical method was used to detect the expression of pepsin in nasopharyngeal specimens of the two groups. In addition, 188 normal individuals were selected as the normal group in the same period. NPC patients before and within 6 months after radiotherapy were inverstigated by the General Information Questionnaire and the Quality of Life Scale, and the pepsin levels in saliva of NPC patients before and after radiotherapy and the individuals in normal group were measured. SPSS 21.0 software was used for statistical analysis. Results: Pepsin expression in 133 specimens of NPC patients was strongly positive in 24 cases (18.05%), positive in 21 cases (15.79%), weakly positive in 69 cases (51.88%), and negative in 19 cases (14.29%). The specimens of control group had 10 cases of weakly positive (17.24%), 48 cases of negative (82.76%), but no strong positive or positive pepsin expression. The rate of positive pepsin expression in the NPC group was higher than that in the control group, with a statistically significant (χ²=83.15, P<0.001). The pepsin content in the saliva of NPC patients after radiotherapy ((30.31±7.82) ng/ml) was higher than that before radiotherapy ((20.47±8.21) ng/ml) and the normal group (5.11±2.13) ng/ml), and the pepsin content in saliva before radiotherapy was higher than that in the normal group, and all differences were statistically significant (all P<0.05). After radiotherapy, the five functional domains of quality of life and overall quality of life of NPC patients decreased, while the related symptom scores increased (all P<0.05). Multiple linear regression analysis showed that pepsin content in saliva was the influential factor of five functional domains of quality of life, related symptoms and overall quality of life in NPC patients after radiotherapy (all P<0.05). Conclusion: The positive rate of pepsin expression in NPC tissues is high, and the pepsin in saliva before and after radiotherapy of NPC patients is significantly higher than that in normal, suggesting that LPR may be involved in the process of NPC and affect the quality of life after radiotherapy in NPC patients.

Cytokeratin 13 promotes radiotherapy sensitivity of nasopharyngeal carcinoma by downregulating the MEK/ERK pathway

BACKGROUND

Radiation therapy is the first treatment choice for nasopharyngeal carcinoma (NPC), while radiation resistance and recurrence have become the primary factors and are associated with poor prognosis in the clinical treatment of NPC patients. The purpose of the present study was to explore the sensitivity and molecular basis of cytokeratin 13 (CK13) that regulates NPC radiotherapy.

METHODS

HNE-3 or C666-1 cell line was used for overexpression and knockdown tests. Under radiotherapy conditions, CCK-8 assay, clone formation assay, and flow cytometry analyzed the effects of CK13 overexpression on cell proliferation, apoptosis, and cell cycle, respectively. In addition, Western blotting detected CK13-mediated downregulation of cell cycle-related genes. The mouse subcutaneous tumor-bearing experiment identified the effects of CK13 overexpression on the treatment of NPC in vivo. Further, Western blotting, CCK-8 assay, and flow cytometry investigated whether the CK13-mediated cell apoptosis involves the MEK/ERK signaling pathway.

RESULTS

Overexpression of CK13 significantly inhibited the survival of HNE-3 cells under radiotherapy in vitro and in vivo, and there was a substantial decrease in cyclin-dependent kinase 4 and 6 (CDK4/6) levels promoting the cell percentage number in the G2/M phase and, subsequently, the ratio of the apoptotic cells. In contrast, the knockdown of CK13 showed the opposite partial regulatory effect. Interestingly, CK13 overexpression also showed a reduction in the survival of C666-1 cells and an increased ratio of the apoptotic cells under radiotherapy treatment. Furthermore, higher levels of CK13 downregulated the MEK/ERK signaling pathway, resulting in decreased HNE-3 cell proliferation and increased apoptosis. However, ERK activators were able to rescue the process partially.

CONCLUSIONS

Together, these results showed that CK13 promoted the radiosensitivity of NPC cells by downregulating the MEK/ERK signaling pathway. Thus, targeting CK13 provided insights into the treatment of NPC radiotherapy.

Quantifying the dosimetric effects of neck contour changes and setup errors on the spinal cord in patients with nasopharyngeal carcinoma: establishing a rapid estimation method

The purpose of this study was to quantify the effect of neck contour changes and setup errors on spinal cord (SC) doses during the treatment of nasopharyngeal carcinoma (NPC) and to establish a rapid dose estimation method. The setup errors and contour changes in 60 cone-beam computed tomography (CBCT) images of 10 NPC patients were analysed in different regions of the neck (C1-C3, C4-C5 and C6-C7). The actual delivered dose to the SC was calculated using the CBCT images, and univariate simulations were performed using the planning CT to evaluate the dose effects of each factor, and an index ${\mathrm{Dmax}}_{\mathrm{displaced}}$ was introduced to estimate the SC dose. Compared with the planned dose, the mean (maximum) Dmax increases in the C1-C3, C4-C5 and C6-C7 regions of the SC were 2.1% (12.3%), 1.8% (8.2%) and 2.5% (9.2%), respectively. The simulation results showed that the effects of setup error in the C1-C3, C4-C5 and C6-C7 regions were 1.5% (9.7%), 0.9% (8.2%) and 1.3% (6.3%), respectively, and the effects of contour change were 0.4% (1.7%), 0.7% (2.5%) and 1.5% (4.9%), respectively. The linear regression model can be used to estimate the dose effect of contour changes (R2 > 0.975) and setup errors (R2 = 0.989). Setup errors may lead to a significant increase in the SC dose in some patients. This study established a rapid dose estimation method, which is of great significance for the daily dose evaluation and the adaptive re-planning trigger of the SC.

What is the appropriate skin cleaning method for nasopharyngeal cancer radiotherapy patients? A randomized controlled trial

PURPOSE

To determine the effect of various cleaning methods for skin with acute radiation dermatitis (RD) in patients treated for nasopharyngeal carcinoma (NPC).

METHODS

A total of 168 NPC inpatients were randomized, while 152 patients completed the whole trial and the data were analyzed. Patients were randomly divided into the non-washing group (Group 1), washing with water alone group (Group 2), and washing with water and soap group (Group 3). All three groups received intensity-modulated radiation therapy (IMRT) with other treatments. Follow-up from recruitment or the initial radiotherapy dose to 1 month after the final radiotherapy dose. CONSORT checklist was applied as the reporting guidelines for this study. The study evaluated a range of endpoints, including incidence, timing, severity of acute RD, and quality of life (QOL).

RESULTS

There were no allergic reactions or aggravating in both washing groups during the whole treatment. The incidence of acute RD was 100% in all three groups, while the incidence of severe RD (grades 2-3) differed among groups (Group 1 vs. Group 2 vs. Group 3: 51% vs. 23.5% vs. 18%; P = 0.001), washing moderately reduced severity compared with patients without washing. Washing also delayed the onset time of acute RD; the incidence of acute RD was significantly lower than non-washing during the first 20 fractions (P < 0.001). What is more, washing reduced the incidence of moist desquamation (25.5% vs. 5.9% vs. 6%; P = 0.003) and helped relieve itching (6.49 ± 2.09 vs. 4.90 ± 1.90 vs. 4.00 ± 1.58; P < 0.001). There were no significant differences among groups with respect to pain or burning sensation. Washing improved QOL on physical (64.37 ± 4.08 vs. 67.41 ± 4.05 vs. 71.30 ± 4.87; P < 0.001), emotional (61.47 ± 4.75 vs. 65.75 ± 3.46 vs. 70.80 ± 3.27; P < 0.001), and social functional dimensions (62.64 ± 3.57 vs. 64.87 ± 3.88 vs. 68.04 ± 4.89; P < 0.001) at the end of radiotherapy, and the outcome was similar at 1 month after radiotherapy (P < 0.05). Washing with water and soap was the most effective way to reduce itching and improving QOL among the three groups (P < 0.05).

CONCLUSION

Washing irradiated skin reduces the occurrence and severity of acute radiation dermatitis.

CLINICAL TRIAL INFORMATION

ChiCTR2000038231, date of registration 09.18.2020.

Individualized Whole Course Nutrition Management for Nasopharyngeal Carcinoma Patients Undergoing Radiotherapy

BACKGROUND

Radiotherapy-induced oral mucositis (RIOM) is the most common toxicity associated with radiotherapy for nasopharyngeal carcinoma (NPC). Patients with RIOM become malnourished, which can affect the delivery and dose of radiotherapy. The value of personalizing nutrition recommendations for cancer prevention and management is increasingly recognized. To investigate the effect of individualized whole course nutrition management on nutritional status and the incidence and severity of RIOM in NPCs.

METHODS

This retrospective study included 77 patients who were provided individualized whole course nutrition management during radiotherapy (RT) and a 1-month follow-up. Seventy-one patients were included in the control group.

RESULTS

During radiotherapy, severity of RIOM was significantly lower in the intervention group. There were statistically significant differences in oral mucosa recovery time and nutritional status between the two groups (p < 0.05).

CONCLUSIONS

Individualized whole course nutrition management had the potential to maintain nutritional status and decrease the adverse effects of radiotherapy in NPCs.

miRNA profiling of human nasopharyngeal carcinoma cell lines HONE1 and CNE2 after X-ray therapy

BACKGROUND

Radiotherapy is the main treatment for nasopharyngeal carcinoma. The radioresistance mechanism of cells is related to miRNAs.

OBJECTIVES

To investigate the miRNA profiling of HONE1 and CNE2 after X-ray therapy.

MATERIAL AND METHODS

The HONE1 and CNE2 cells were treated with X-ray at 4 Gy, 8 Gy, 16 Gy, and 20 Gy doses. The cell lines CNE2 with the best therapy effects and HONE1 with the worst therapy effects were screened out. Apoptosis and cell viability were detected with flow cytometry and Cell Counting Kit-8 (CCK-8). High-throughput sequencing was performed. A miRNA library was constructed. The miRNA annotation expression distribution, family prediction and target gene interaction, Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis were conducted.

RESULTS

The 24-hour 20 Gy dose X-rays were selected as the optimal therapy conditions. The CNE2_C, CNE2_M, HONE1_C and HONE1_M miRNAs accounted for 26.5%, 31.7%, 21.3%, and 22.9% of the Cleandata reads count, respectively, and the contents of rRNAs accounted for 24.9%, 14.7%, 25.1%, and 25.1% of the Cleandata reads count, respectively. The miRNAs with differential expression between the HONE1 and CNE2 cell lines including hsa-miR-21-5p, hsa-let-7a-5p, hsa-miR-125a-5p, hsa-miR-26a-5p, hsa-let-7f-5p, hsa-miR-20a-5p, and hsa-miR-24a-3p. There were also differentially expressed miRNAs in HONE1_C vs. HONE1_M, such as hsa-miR-21-5p and hsa-let-7i-5p. The differentially expressed miRNA in CNE2_C vs. CNE2_M was hsa-miR-148b-3p. The Gene Ontology analysis showed that the differentially expressed miRNA interacting genes in HONE1_M vs. CNE2_M were mainly enriched in biological process such as negative and positive regulation of transcription from RNA polymerase II promoter, cellular component such as cytosol and molecular function such as protein binding factor. The KEGG pathway analysis revealed that the differentially expressed miRNA interacting genes in HONE1_M vs. CNE2_M were enriched in the cancer-related pathways, such as pathways in cancer, MAPK signaling pathway and Wnt signaling pathway.

CONCLUSIONS

Twelve miRNAs and 9 genes which contribute to X-ray radiation resistance were identified. Among those with differential expression between the HONE1 and CNE2 cell lines, which played a regulatory role in multiple pathways, were hsa-miR-20a-5p, hsa-let-7a-5p, hsa-let-7f5p, hsa-let-7i-5p, hsa-miR-30e-5p, hsa-miR-148b-3p, and hsa-miR-200c-3p. The corresponding genes were MAPK1, SOS1, TGFBR1, TGFBR2, TP53, CASP3, CCNE2, PTEN, and CDK2.

Application of Artificial Intelligence in Radiotherapy of Nasopharyngeal Carcinoma with Magnetic Resonance Imaging

The value of automatic organ-at-risk outlining software for radiotherapy is based on artificial intelligence technology in clinical applications. The accuracy of automatic segmentation of organs at risk (OARs) in radiotherapy for nasopharyngeal carcinoma was investigated. In the automatic segmentation model which is proposed in this paper, after CT scans and manual segmentation by physicians, CT images of 147 nasopharyngeal cancer patients and their corresponding outlined OARs structures were selected and grouped into a training set (115 cases), a validation set (12 cases), and a test set (20 cases) by complete randomization. Adaptive histogram equalization is used to preprocess the CT images. End-to-end training is utilized to improve modeling efficiency and an improved network based on 3D Unet (AUnet) is implemented to introduce organ size as prior knowledge into the convolutional kernel size design to enable the network to adaptively extract features from organs of different sizes, thus improving the performance of the model. The DSC (Dice Similarity Coefficient) coefficients and Hausdorff (HD) distances of automatic and manual segmentation are compared to verify the effectiveness of the AUnet network. The mean DSC and HD of the test set were 0.86 ± 0.02 and 4.0 ± 2.0 mm, respectively. Except for optic nerve and optic cross, there was no statistical difference between AUnet and manual segmentation results (P > 0.05). With the introduction of the adaptive mechanism, AUnet can achieve automatic segmentation of the endangered organs of nasopharyngeal carcinoma based on CT images more accurately, which can substantially improve the efficiency and consistency of segmentation of doctors in clinical applications.

Regenerating gene IA predicts radiosensitivity and survival in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is a common malignancy in Southern China and Southeast Asia. Radiotherapy is the main treatment option. However, radiotherapy does not benefit all patients because there is no known precise biomarker that can be used for screening radioresistant patients. Genetic predisposition is closely related to tumor development, therapeutic response, and prognosis. The relationship between regenerating gene IA (REGIA) and NPC is unclear. This study aimed to retrospectively analyze the association between REGIA expression and metastasis, radiosensitivity, and survival in patients with NPC as well as assess the effect of radiation on REGIA expression in vitro. Immunohistochemical staining was used to detect REGIA. The relationship between REGIA expression in radioresistant NPC and the prognosis of CNE1 NPC cells were analyzed using quantitative real-time polymerase chain reaction and Western blotting. We found that increased doses of radiation in CNE1 cells significantly decreased REGIA expression (P<0.05). The overall rate of REGIA-positive expression was 47.15% in NPC tissues and 45.00% and 61.02% in radiosensitive and radioresistant cases, respectively, showing significant differences (P<0.05). A REGIA-positive protein expression rate had a negative correlation with radiosensitivity in NPC (r= -0.109, P=0.047). Both REGIA-positive and REGIA-negative expression strongly predicted the overall survival rate and progression-free survival of NPC patients (P<0.01). A multivariate analysis indicated that REGIA was an inverse prognostic factor in NPC patients (REGIA-positive expression: hazard ratio (HR)=2.139, 95% confidence interval (CI)=1.56-2.94, P<0.001 and REGIA-negative expression: HR=1.958, 95% CI=1.42-2.69, P<0.001). In conclusion: Radiation can affect REGIA expression. The REGIA expression level correlated with radioresistance and a poor prognosis. In addition, REGIA expression might act as a potential therapeutic target and prognostic predictor in NPC patients.

Dynamic Change of Amide Proton Transfer Imaging in Irradiated Nasopharyngeal Carcinoma and Related Histopathological Mechanism

OBJECTIVE

To investigate the dynamic change of amide proton transfer (APT) imaging before and after irradiation in nasopharyngeal carcinoma (NPC) and the underlying histopathological mechanism.

MATERIALS AND METHODS

Tumor-bearing BALB/C nude mouse models were established and randomly divided into three groups: high-dose group (20 Gy/2 fractions), low-dose group (10 Gy/2 fractions), and control group (0 Gy). MRI scanning was performed before irradiation and 3rd, 6th, and 9th day post-irradiation. Scanning sequence included T1 weighted, T2 weighted, and APT. HE staining and TUNEL immunofluorescence detection were performed to detect necrosis and apoptosis.

RESULTS

After high-dose irradiation, the mean tumor APT values decreased significantly on the 3rd day and 6th day (from 3.83 before radiotherapy to 2.41%, P < 0.001, 3rd day; from 2.41 to 1.80%, P = 0.001, 6th day). For low-dose irradiation, the mean tumor APT values decreased slightly on the 3rd day and 6th day (from 3.52 to 3.13%, P = 0.109, 3rd day; from 3.13 to 3.05%, P = 0.64, 6th day). The mean APT values of nonirradiated tumor changed slightly. In contrast, the average volume of high-dose irradiated tumors did not decrease obviously until the 9th day post-irradiation (from 290 before radiotherapy to 208 mm3 on the 9th day). The low-dose irradiated tumors showed slow growth, and the nonirradiated tumors showed rapid growth. Subsequent HE staining and TUNEL staining showed obvious necrosis characteristics and higher proportion of positive apoptotic cell nucleus in high-dose irradiated tumors, but not nonirradiated tumors.

CONCLUSION

The APT signal intensity decreased after irradiation, which is earlier than the change of tumor volume. What is more, the decrease of APT signal intensity is more significant in high-dose group. Histological analysis showed obvious apoptosis and necrosis histological characteristic in irradiated tumor, which may explain the decrease of APT signal intensity. These results indicate that APT imaging has the potential to serve as a reliable biomarker for response assessment in NPC.

Effect of Concurrent Chemoradiotherapy With Nedaplatin vs Cisplatin on the Long-term Outcomes of Survival and Toxic Effects Among Patients With Stage II to IVB Nasopharyngeal Carcinoma: A 5-Year Follow-up Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

Nedaplatin-based concurrent chemoradiotherapy (CCRT) regimen at 2 years was noninferior to cisplatin-based regimen in patients with locoregional, stage II to IVB nasopharyngeal carcinoma (NPC) and was associated with fewer late adverse events, but longer-term outcomes and toxicity are unclear.

OBJECTIVE

To evaluate the 5-year outcomes and late toxicity profile of nedaplatin-based CCRT in patients with locoregional, stage II to IVB NPC.

DESIGN, SETTINGS, AND PARTICIPANTS

This 5-year follow-up secondary analysis of an open-label, noninferiority, multicenter randomized clinical trial enrolled patients with nonkeratinizing stage II to IVB NPC between January 16, 2012, and July 16, 2014, with a median follow-up duration of 78 months (IQR, 3-99 months). Data analysis was conducted from November 10, 2020, to July 8, 2021.

INTERVENTIONS

Patients were randomly assigned (1:1) to receive nedaplatin (100 mg/m2)- or cisplatin (100 mg/m2)-based chemotherapy every 3 weeks for 3 cycles concurrently with intensity-modulated radiotherapy.

MAIN OUTCOMES AND MEASURES

The primary end point was progression-free survival (PFS). Secondary end points were overall survival, distant metastasis-free survival, and locoregional relapse-free survival.

RESULTS

A total of 402 eligible participants were enrolled (median [IQR] age, 45 [18-65] years; 302 [75.1%] male). Patients were randomly assigned to receive nedaplatin- or cisplatin-based CCRT (n = 201 for each): 196 patients (97.5%) started nedaplatin-based CCRT and 197 patients (98.0%) started cisplatin-based CCRT. Intention-to-treat analysis demonstrated a 5-year progression-free survival rate of 81.4% (95% CI, 75.9%-86.9%) for the cisplatin group and 79.8% (95% CI, 74.1%-85.5%) for nedaplatin group, with a difference of 1.6% (95% CI, -6.3% to 9.5%; P = .002 for noninferiority). No significant survival differences were observed between the cisplatin and nedaplatin groups for 5-year overall survival (89.4% vs 88.8%, P = .63), distant metastasis-free survival (85.9% vs 90.4%, P = .17), and locoregional relapse-free survival (92.6% vs 89.6%, P = .17) rates. The cisplatin group had a higher incidence of grade 3 and 4 auditory toxic effects than the nedaplatin group (35 [17.7%] vs 21 [10.5%], P = .04).

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, long-term analysis confirmed that nedaplatin-based CCRT could be regarded as an alternative doublet treatment strategy to cisplatin-based CCRT in stage II to IVB NPC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01540136.

Development of a web-based prognostic model to quantify the survival benefit of cumulative cisplatin dose during concurrent chemoradiotherapy in childhood nasopharyngeal carcinoma

PURPOSE

To quantify and predict the survival benefits of cumulative cisplatin dose during concurrent chemoradiotherapy (CC-CCD) in children and adolescents with locoregionally advanced nasopharyngeal carcinoma (CA-LANPC).

MATERIALS AND METHODS

Patients with CA-LANPC who received first-line neoadjuvant chemotherapy (NAC) followed by concurrent chemoradiotherapy (CCRT) between September 2007 and April 2018 were evaluated. Recursive partitioning analyses (RPAs) helped identify the ideal thresholds of CC-CCD on disease-free survival (DFS). We then developed a web-based predictive model to quantify the survival benefit of CC-CCD for CA-LANPC.

RESULTS

In total, 139 patients were eligible for the analysis. The median CC-CCD was 162 mg/m² (IQR, 138-192 mg/m²). The optimum cut-off point of CC-CCD was 160 mg/m² for DFS. Hence, we selected 160 mg/m² as the cut-off to classify CA-LANPC into either high or low CC-CCD groups for survival analysis. The 5-year DFS rates were 91.6% in the high (≥160 mg/m²) CC-CCD group and 77.8% in the low (<160 mg/m²) CC-CCD group (P = 0.011). Multivariate analysis indicated CC-CCD (HR, 0.34; 95%CI, 0.13-0.87; P = 0.024), T stage (HR, 3.72; 95%CI, 1.35-10.22; P = 0.011), and EBV DNA (HR, 3.00; 95%CI, 1.00-8.97; P = 0.049) were independent prognostic factors and were incorporated into the prognostic model. N stage was also included due to its clinical importance. The predictive model was demonstrably accurate (C-index, 0.741) when predicting 5-year DFS rates.

CONCLUSIONS

We built a predictive model to quantify the survival benefit of CC-CCD for CA-LANPC treated with NAC plus CCRT. This tool may improve individual treatment consultations and facilitate evidence-based decision-making.

Prognostic nomogram to predict the distant metastasis after intensity-modulated radiation therapy for patients with nasopharyngeal carcinoma

Distant metastasis-free survival (DMFS) significantly differs among individuals with nasopharyngeal carcinoma (NPC). This analysis was carried out to find prognostic risk factors of DMFS and create a nomogram to predict DMFS for NPC patients who received Intensity-Modulated Radiation Therapy (IMRT).During March 2008 to January 2010, 437 patients with confirmed NPC from First Affiliated Hospital of Guangxi Medical University were recruited into this study. We developed a nomogram for predicting DMFS according to Cox regression analysis. Nomogram performance was assessed by concordance index (C-index), bootstrap validation method, and operating characteristics curves (ROC), respectively.Four independent prognostic factors for distant metastasis were identified, including age, chemotherapy, N-stage and residual tumor. C-index of the nomogram for prediction of DMFS was 0.807 (95% confidence interval, 0.726 to 0.738), which was confirmed using bootstrap validation, indicating satisfactory predictive accuracy. The calibration curves also showed adequate agreement in predicting the 3 and 5-year DMFS. The 3 and 5-year area under the curve (AUC) of ROC for nomogram and TMN stage were 0.828 and 0.612, 0.809, and 0.571, respectively. Classifying risk subgroups based on optimal cut-off value contributes to the effective discrimination of distant metastasis.The nomogram developed for this study is useful for oncologists to accurately predict DMFS and facilitates individualized treatment for patients with NPC.

PAD4 inhibitor promotes DNA damage and radiosensitivity of nasopharyngeal carcinoma cells

Peptidylarginine deiminases 4 (PAD4), a kind of enzyme capable of converting protein arginine or mono-methylarginine into citrulline, has been identified to display a key role in diverse diseases. Radiotherapy is frequently used in nasopharyngeal carcinoma (NPC) treatment and induces DNA double strand breaks. In this study, whether PAD4 inhibitor YW3-56 affects the radiosensitivity of NPC cells was explored. RT-qPCR, immunofluorescence, western blot, clonogenic survival, and flow cytometry assays were used to assess the function of PAD4 and YW3-56 in NPC. We found the upregulation of PAD4 expression in NPC cells. PAD4 overexpression suppressed NPC cell apoptosis and promoted cell cycle, while PAD4 depletion had an opposite result. Moreover, the survival of NPC cells after irradiation was increased by overexpression of PAD4. PAD4 overexpression inhibited DNA damage and sensitivity of NPC cells to irradiation. Functional assays showed that YW3-56 treatment promoted DNA damage, apoptosis, and radiosensitivity of NPC cells. Importantly, YW3-56 treatment inhibited tumor growth in vivo. Overall, this study revealed the efficacy of PAD4 inhibitor YW3-56 in promoting sensitivity of NPC cells to irradiation.

Retrospective analysis of massive epistaxis and pseudoaneurysms in nasopharyngeal carcinoma after radiotherapy

OBJECTIVE

Epistaxis after radiotherapy for nasopharyngeal carcinoma (NPC) is a common clinical critical illness, which often leads to death of patients. This article focuses on the relationship between massive epistaxis and pseudoaneurysm after radiotherapy in patients with NPC and discusses clinically relevant treatment strategies.

METHODS

A review was performed in 21 patients with massive epistaxis after radiotherapy for NPC from January 2011 to December 2019, and all of the patients were examined by computed tomography angiography (CTA). We also reviewed the English literature over the past 10 years to analyze the characteristics and related causes of pseudoaneurysms in terms of the clinical stage of NPC, course of radiotherapy, and affected artery. An analysis was performed on the methods of endovascular interventional treatment of such pseudoaneurysms.

RESULTS

Among the 21 patients, 19 cases had bone destruction of the skull base; 13 cases were also found to have tumor recurrence; 15 cases were in stage III or IV of NPC; pseudoaneurysms were observed in 14 cases, of which nine cases had pseudoaneurysms in the internal carotid artery (ICA), and the rest had pseudoaneurysms in the external carotid artery (ECA). These data were consistent with the results of the literature review. Analysis with imaging revealed that the petrous ICA was the common predilection site. There were 11 out of 14 cases of pseudoaneurysms with sentinel hemorrhage in the initial phase. All 14 pseudoaneurysm patients underwent endovascular interventional therapy, but one died from hemorrhagic shock during the procedure. No rebleeding was observed among the other patients during 72 h after intravascular treatment. Nevertheless, regrettably two patients died on the 10th and 17th days after intervention.

CONCLUSION

Pseudoaneurysm, which was a serious complication after radiotherapy in patients with NPC, could cause massive epistaxis with high mortality. The formation of a pseudoaneurysm was closely associated with a high carcinoma stage, re-radiotherapy, and local bone destruction and infection. Most cases had sentinel epistaxis, which was considered the bleeding characteristic. The imaging material prompted that pseudoaneurysm had a predisposition to the petrous part of the ICA, while the preferred therapy was endovascular embolization treatment.

Prognostic role of the prognostic nutritional index (PNI) in patients with head and neck neoplasms undergoing radiotherapy: A meta-analysis

BACKGROUND

This novel meta-analysis was conducted to systematically and comprehensively evaluate the prognostic role of the pretreatment PNI in patients with head and neck neoplasms (HNNs) undergoing radiotherapy.

METHODS

Three databases, PubMed, Embase, and Web of Science, were used to retrieve desired literature. Hazard ratios (HRs) with 95% confidence intervals (CIs) were extracted and pooled by fixed-effects or random-effects models to analyze the relationship between the PNI and survival outcomes: overall survival (OS), distant metastasis-free survival (DMFS), and progression-free survival (PFS).

RESULTS

Ten eligible studies involving 3,458 HNN patients were included in our analysis. The robustness of the pooled results was ensured by heterogeneity tests (I2 = 22.6%, 0.0%, and 0.0% for OS, DMFS, and PFS, respectively). The fixed-effects model revealed a lower pretreatment PNI was significantly related to a worse OS (HR = 1.974; 95% CI: 1.642-2.373; P<0.001), DMFS (HR = 1.959; 95% CI: 1.599-2.401; P<0.001), and PFS (HR = 1.498; 95% CI: 1.219-1.842; P<0.001). The trim-and-fill method (HR = 1.877; 95% CI: 1.361-2.589) was also used to prove that the existing publication bias did not deteriorate the reliability of the relationship.

CONCLUSION

The pretreatment PNI is a promising indicator to evaluate and predict the long-term prognostic survival outcomes in HNN patients undergoing radiotherapy.

Cutoff point of neutrophil-to-lymphocyte ratio for predicting survival in nasopharyngeal carcinoma

Neutrophil-to-lymphocyte ratio (NLR) was reported as an independent prognostic factor in many studies, but its cutoff point was not yet concluded. We set forth to prove and validate cutoff point of NLR as a poor prognostic factor for overall survival (OS) in nonmetastatic nasopharyngeal carcinoma (NPC) patients.Retrospective cohort of nonmetastatic NPC adult patients treated with intensity-modulated radiotherapy with curative aim at Siriraj hospital during 2007 to 2014 was enrolled. NLR was defined as absolute neutrophil count divided by absolute lymphocyte count. OS was the primary outcome. We explored our cutoff value by maximum concordance index (C-index) method, and we validated our cutoff and previously reported cutoff values by categorizing patients as NLR ≤ 3 or >3. Internal validation was done by bootstrapping method.Four hundred sixty-three patients were included. The median follow-up time was 70.8 months. By the end of June 2019, 211 patients had died. In univariable analysis of OS by Cox model, an NLR value of 3 showed the highest C-index (0.548) with an HR of 1.43 (95% CI: 1.08-1.89). After adjustment for body mass index, overall staging, age, gender, and histology in multivariable analysis, an NLR >3 was still an independent prognostic factor of poor OS (HR = 1.34, 95% CI = 1.01-1.79). After internal validation, the resampling method shows no overfitting condition and corrected C-index was 0.547 for univariable analysis.A cutoff point of NLR of 3 from routine blood test was found to be an independent poor prognostic factor among patients with nonmetastatic NPC. This prognostic factor could be included in clinical prediction model of NPC and this further prediction model would select high risk patients for intensive treatment.

Dosiomics-based prediction of radiation-induced hypothyroidism in nasopharyngeal carcinoma patients

PURPOSE

To predict the incidence of radiation-induced hypothyroidism (RHT) in nasopharyngeal carcinoma (NPC) patients, dosiomics features based prediction models were established.

MATERIALS AND METHODS

A total of 145 NPC patients treated with radiotherapy from January 2012 to January 2015 were included. Dosiomics features of the dose distribution within thyroid gland were extracted. The minimal-redundancy-maximal-relevance (mRMR) criterion was used to rank the extracted features and selected the most relevant features. Machine learning (ML) algorithms including logistic regression (LR), support vector machine (SVM), random forest (RF), and k-nearest neighbor (KNN) were utilized to establish prediction models, respectively. Nested sampling and hyper-tuning methods were adopted to train and validate the prediction models. The dosiomics-based (DO) prediction models were evaluated through comparing with the dose-volume factor-based (DV) models in terms of the area under the receiver operating characteristic (ROC) curve (AUC). The demographics factors (age and gender) were included in both DO model and DV model.

RESULTS

Age, V45 and 37 dosiomics features exhibited significant correlations with RHT in univariate analysis. For prediction performance, DO prediction models exhibited better results with the best AUC value 0.7 while DV prediction models 0.61. In DO prediction models, the AUC values displayed a trend from ascending to descending with the increasing of selected features. The highest AUC value was achieved when the number of selected features was 3. In DV prediction model, similar trend was not observed.

CONCLUSION

This study established a prediction model based on the dosiomics features with better performance than conventional dose-volume factors, leading to early predict the possible RHT among NPC patients who had received radiotherapy and take precaution measures for NPC patients.

Central nervous system metastases: a rare presentation of nasopharyngeal carcinoma

We report a case of a male patient. He presented with nasal obstruction and epistaxis. The MRI of the brain showed a mass in the nasopharynx and enlarged cervical lymph nodes. Besides this, there was an extra-axial, dural-based lesion in brain and subcentimetre nodules in both lungs. He received induction chemotherapy followed by chemoradiation therapy to the primary site and dural-based metastatic deposit. He re-presented with bilateral lower limb weakness. The MRI of the spine showed metastatic deposits within the thoracic cord parenchyma and meningeal deposits at the lumbar region. Palliative radiation was used to treat spinal cord and meningeal metastases. He died a few months later because of systemic disease progression. Considering the rarity of this presentation in nasopharyngeal carcinoma and lack of clear guidelines for standard treatment, we report this case to share our experience of management.

Long-term survival outcomes and adverse effects of nasopharyngeal carcinoma patients treated with IMRT in a non-endemic region: a population-based retrospective study

OBJECTIVES

To evaluate the long-term survival outcomes and adverse effects of intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC) and to summarise the experiences of IMRT in NPC in the past few decades in non-endemic northwest China.

DESIGN

A population-based retrospective study.

SETTING

An experience of using IMRT in non-endemic region of China.

PARTICIPANTS

The study included 792 newly diagnosed and non-metastatic NPC patients who received IMRT from January 2006 to September 2018 in Xijing Hospital.

OUTCOME MEASURES

The survival outcomes, adverse effects and failure patterns were evaluated by univariate, multivariate and subgroup analyses.

RESULTS

With a median follow-up time of 46.2 months, the 5-year local recurrence-free survival, regional recurrence-free survival, distant metastasis-free survival, disease-free survival (DFS) and overall survival (OS) rates were 90.8%, 97.0%, 82.8%, 69.6% and 78.0%, respectively. Multivariate analysis showed that age, N stage, clinical stage, pathological type and primary tumour volume of more than 23 cm³ were the independent prognosis factors for DFS (all p<0.05); age, N stage, pathological type, cervical lymph node necrosis, and anaemia were significantly associated with OS (all p<0.05). The most common acute toxicities of IMRT were dermatitis, mucositis and dysphagia. Xerostomia and hearing impairment were the top two late toxicities. The main failure patterns were distant metastasis and local and/or regional relapses.

CONCLUSIONS

Similar survival, toxicities and failure patterns have been observed in patients treated with IMRT in a non-endemic area of China when compared with that in endemic areas. Induction chemotherapy combined with concurrent chemoradiotherapy may benefit locally advanced NPC in non-endemic areas of China.

Brain-Specific Relative Biological Effectiveness of Protons Based on Long-term Outcome of Patients With Nasopharyngeal Carcinoma

PURPOSE

Uncertainties in relative biological effectiveness (RBE) constitute a major pitfall of the use of protons in clinics. An RBE value of 1.1, which is based on cell culture and animal models, is currently used in clinical proton planning. The purpose of this study was to determine RBE for temporal lobe radiographic changes using long-term follow-up data from patients with nasopharyngeal carcinoma.

METHODS AND MATERIALS

Five hundred sixty-six patients with newly diagnosed nasopharyngeal carcinoma received double-scattering proton therapy or intensity modulated radiation therapy at our institutions. The 2 treatment cohorts were well matched. Proton dose distributions were simulated using Monte Carlo and compared with those obtained from the proton clinical treatment planning system. Late treatment effect was defined as development of enhancement of temporal lobe on T1-weighted magnetic resonance imaging, with or without accompanying clinical symptoms. The tolerance dose was calculated with receiving operator characteristic analysis and the Youden index. Tolerance curves, expressed as a cumulative dose-volume histogram, were generated using the cutoff points.

RESULTS

With a median follow-up period >5 years for both cohorts, 10% of proton patients and 4% of patients undergoing intensity modulated radiation therapy developed temporal lobe enhancement in unilateral temporal lobe. There was no significant difference in dose distributions between the Monte Carlo method and treatment planning system. The tolerance dose-volume levels were V10 (26.1%), V20 (21.9%), V30 (14.0%), V40 (7.7%), V50 (4.8%), and V60 (3.3%) for proton therapy (P < .03). Comparison of the two tolerance curves revealed that tolerance doses of proton treatments were lower than that of photon treatments at all dose levels. The dose tolerance at D1% was 58.56 Gy for protons and 69.07 Gy for photons. The RBE for temporal lobe enhancement from proton treatments were calculated to be 1.18.

CONCLUSIONS

Using long-term clinical outcome of patients with nasopharyngeal carcinoma, our data suggest that the RBE for temporal lobe enhancement is 1.18 at D1%. A prospective study in a large cohort would be necessary to confirm these findings.

Clinical therapeutic effects of acupuncture in treating patients with dysphagia after radiotherapy in nasopharyngeal carcinoma: A protocol for systematic review and meta-analysis

BACKGROUND

Dysphagia is a commonly occurring condition in nasopharyngeal carcinoma (NPC) patients after radiotherapy. There has been an increasing number of studies focused on assessing the use of acupuncture to manage dysphagia. Moreover, the quality of the research has gradually increased. The present research will be conducted to systematically evaluate the efficiency and safety of using acupuncture to treat cases of dysphagia after radiation therapy in NPC patients.

METHODS

Literature search will include all potential randomized controlled trials using MEDLINE, Cochrane Library, Web of Science, EMBASE, Chinese National Knowledge Infrastructure, Chinese BioMedical Literature, and WanFang database from their inception to May, 2021 without language or publication status restrictions, to evaluate the efficiency and safety of using acupuncture to treat dysphagia cases following radiation therapy in NPC patients. A couple of independent authors will select related literature, extract data from studies, and estimate this risk in the bias of the selected study articles. In the instance of contrasting opinions, the outcome is mediated through discussion with a different independent author. The data synthesis and statistical analysis will be completed with the RevMan software (version 5.3).

RESULTS

This study will evaluate the efficiency and safety of using acupuncture to treat dysphagia cases after radiation therapy in NPC patients.

CONCLUSION

This study will determine the suitability of acupuncture as an effective and safe intervention for dysphagia in NPC patients after radiotherapy.

ETHICS AND DISSEMINATION

The present study does not need ethical approval.

REGISTRATION NUMBER

May 19, 2021.osf.io/f2cvt. (https://osf.io/f2cvt/).

International Recommendations on Reirradiation by Intensity Modulated Radiation Therapy for Locally Recurrent Nasopharyngeal Carcinoma

PURPOSE

Reirradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging because prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking because available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions.

METHODS AND MATERIALS

A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the whole panel for review and reconsideration. The current guideline was based on majority voting after repeated iteration for final agreement.

RESULTS

The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of reirradiation (including patient selection, targets contouring, dose prescription, and constraints).

CONCLUSION

This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of reirradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's condition, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications.

Outcomes of patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Nasopharyngeal cancer shows a good response to intensity-modulated radiotherapy. However, there is no clear evidence for the benefits of routine use of image-guided radiotherapy. The purpose of this study was to perform a retrospective investigation of the treatment outcomes, treatment-related complications and prognostic factors for nasopharyngeal cancer treated with intensity-modulated radiotherapy and image-guided radiotherapy techniques. Retrospective analysis was performed on 326 consecutive nasopharyngeal cancer patients treated between 2004 and 2015. Potentially significant patient-related and treatment-related variables were analyzed. Radiation-related complications were recorded. The 5-year overall survival and disease-free survival rates of these patients were 77.9% and 70.5%, respectively. Age, AJCC (American Joint Committee on Cancer) stage, retropharyngeal lymphadenopathy, treatment interruption and body mass index were independent prognostic factors for overall survival. Age, AJCC stage, retropharyngeal lymphadenopathy, image-guided radiotherapy and body mass index were independent prognostic factors for disease-free survival. In conclusion, intensity-modulated radiotherapy significantly improves the treatment outcomes of nasopharyngeal cancer. With the aid of image-guided radiotherapy, the advantage of intensity-modulated radiotherapy might be further amplified.

Efficacy of induction chemotherapy combined with chrono-chemotherapy and intensity-modulated radiotherapy on locally advanced nasopharyngeal carcinoma

PURPOSE

The purpose of this study was to compare the efficacy and safety of induction chemotherapy combined with chrono-chemotherapy or conventional chemotherapy and intensity-modulated radiotherapy (IMRT) in locally advanced nasopharyngeal carcinoma.

METHODS

150 patients with locally advanced nasopharyngeal carcinoma were divided into two groups: chrono-chemotherapy group (n=75, receiving induction chemotherapy combined with chrono-chemotherapy and IMRT, and control group (n=75, receiving induction chemotherapy combined with conventional chemotherapy and IMRT. Besides, the levels of T lymphocyte subsets in peripheral blood before and after treatment were compared, and the long-term survival and disease progression were followed up and recorded.

RESULTS

After treatment, the short-term efficacy of patients was evaluated. The overall response rate was 94.7% (71/75) in chrono-chemotherapy group and 96.0% (72/75) in control group. Moreover, the levels of cluster of differentiation (CD)3+, CD4+, CD8+, CD4+/CD8+, CD16+CD56+ and CD19+ T cells in peripheral blood of patients at 6 months after treatment were significantly lower than those before treatment. The level of posttreatment CD16+CD56+ T cells in chrono-chemotherapy group was significantly higher than that in control group. Furthermore, the follow-up results showed that the 3-year overall survival (OS) was 73.3% and 69.3%, and the 3-year progression-free survival (PFS) was 60.0% and 62.7% in chrono-chemotherapy group and control group, respectively. Finally, Log-rank test showed no significant differences in OS and PFS between the two groups of patients.

CONCLUSIONS

As a new treatment mode, chrono-chemotherapy combined with induction chemotherapy and IMRT can reduce the incidence rate and severity of treatment-related adverse reactions and improve immunosuppression without reducing clinical efficacy, which is worthy of clinical promotion and application.

FOXD1, negatively regulated by miR-186, promotes the proliferation, metastasis and radioresistance of nasopharyngeal carcinoma cells

BACKGROUND

Foxhead box D1 (FOXD1) is validated to be over-expressed in a variety of human malignancies and promotes cancer progression. Nevertheless, the role of FOXD1 and the associated mechanism in nasopharyngeal carcinoma (NPC) remain largely unknown.

METHODS

A total of seventy-five cases of NPC tissue samples were collected. FOXD1 expression in NPC tissues and cells (SUNE1, CNE1, CNE2, and HONE1) was detected using immunohistochemistry and Western blot, respectively. The relationship between FOXD1 expression and clinicopathological parameters of NPC patients was analyzed. FOXD1 mRNA and miR-186 expression in NPC tissues and cells was detected using quantitative polymerase chain reaction (qPCR). The cell viability of NPC cells was detected using CCK-8 assay. Colony survival of NPC cells exposed to different doses of radiation was detected using colony formation assay. Transwell assay was used to evaluate the migration and invasion of NPC cells. The dual-luciferase reporter gene assay was employed to verify the targeting relationship between miR-186 and FOXD1.

RESULTS

FOXD1 was over-expressed in NPC tissues (average fold change on mRNA level = 4.72), and its high expression was correlated to NPC positive lymph node metastasis and tissue differentiation. The over-expression of FOXD1 promoted the proliferation, migration, invasion and radio-resistance of NPC cells. On the contrary, the knock-down of FOXD1 inhibited the malignant phenotypes of the above cells. It was verified that FOXD1 was one of the downstream targets of miR-186 and was negatively regulated by it.

CONCLUSION

FOXD1, which is negatively regulated by miR-186, acts as a novel oncogene in NPC and serves as potential biomarker and therapeutic target for NPC. The research will provide great theoretical basis for further clinical diagnosis and therapy.

Pre-symptomatic local brain activity and functional connectivity alterations in nasopharyngeal carcinoma patients who developed radiation encephalopathy following radiotherapy

Radiation encephalopathy (RE) is a common complication in patients with nasopharyngeal carcinoma (NPC) who have received radiotherapy (RT), and recent neuroimaging studies have shown brain alterations in Post-RT patients prior to RE. However, whether there are functional alterations between those Post-RT patients who are proved to have RE in follow-up and those who do not develop it remains largely unknown. Here, we used resting state functional MRI to explore regional homogeneity (ReHo) and functional connectivity (FC) alterations in Post-RT patients with (Post-RT _{RE proved}; n = 18) or without (Post-RT _non-RE; n = 22) RE at follow-up, also making comparisons with a Pre-RT group (n = 23). Compared with the Pre-RT group, patients in Post-RT _non-RE and Post-RT _{RE proved} groups showed concurrent increased and decreased ReHo values in different brain regions inside and/or outside the radiation field, with the alterations in ReHo tending to increase if RE occurred. Seed-based FC analysis showed that compared with the Post-RT _non-RE group, patients in the Post-RT _{RE proved} group had different changing patterns of FC between a region of interest (ROI) in the right temporal lobe and distant brain regions (mainly in the sensorimotor system and default mode network). Receiver operating characteristic (ROC) curve analysis showed that the altered ReHo value in the ROI had excellent diagnostic performance for differentiating NPC patients who developed RE in follow-up from those who did not, with an area under the curve (AUC) value of 0.94. These ReHo and FC findings may provide new insights into the early diagnosis of RE.

The efficacy and safety of gemcitabine-based induction chemotherapy for locally advanced nasopharyngeal carcinoma treated with concurrent chemoradiation: A meta-analysis

OBJECTIVES

To assess the efficacy and toxicity of gemcitabine-based induction chemotherapy followed by concurrent chemoradiotherapy (CCRT) in locally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

Both observational studies (OBS) and randomized controlled trials (RCT) were included in the meta-analysis. Systematic online searches were conducted in Web of Sciences, PubMed, Embase, meeting proceedings and ClinicalTrials.gov from the inception to May 25, 2020. The primary endpoint of interest was overall survival.

RESULTS

five OBSs and 2 RCTs including 1680 patients were incorporated in the analysis. The evidence from the RCTs showed that adding gemcitabine-based induction chemotherapy to CCRT significantly improved progression free survival (hazard ratio (HR): 0.60, 95% confidence interval (CI): 0.40-0.88; P = .010; chi square P = .25; I2 = 24%) and overall survival (HR: 0.47; 95% CI: 0.28-0.80; P = 0.005; chi square P = .49, I2 = 0%) and was related to a higher risk of hematological toxicities. Furthermore, based on the data of OBSs, overall survival (HR: 0.52; 95% CI: 0.31-0.88; P = .02; chi square P = .37, I2 = 6%) was significantly improved in patients treated with gemcitabine-based induction chemotherapy compared to those treated with taxane-based induction chemotherapy. However, the progression free survival (HR: 0.67; 95% CI: 0.45-1.01; P = .06; chi square P = .74; I2 = 0%) showed no significant difference.

CONCLUSIONS

For LA-NPC patients, adding gemcitabine-based induction chemotherapy to CCRT significantly improved overall survival and progression free survival with a higher risk of hematological toxicities when compared to CCRT alone. Also, gemcitabine-based regimen could be used as an alternative induction chemotherapy regimen to taxane-based regimen in the treatment of LA-NPC.

Beam complexity and monitor unit efficiency comparison in two different volumetric modulated arc therapy delivery systems using automated planning

BACKGROUND

To investigate the beam complexity and monitor unit (MU) efficiency issues for two different volumetric modulated arc therapy (VMAT) delivery technologies for patients with left-sided breast cancer (BC) and nasopharyngeal carcinoma (NPC).

METHODS

Twelve left-sided BC and seven NPC cases were enrolled in this study. Each delivered treatment plan was optimized in the Pinnacle3 treatment planning system with the Auto-Planning module for the Trilogy and Synergy systems. Similar planning dose objectives and beam configurations were used for each site in the two different delivery systems to produce clinically acceptable plans. The beam complexity was evaluated in terms of the segment area (SA), segment width (SW), leaf sequence variability (LSV), aperture area variability (AAV), and modulation complexity score (MCS) based on the multileaf collimator sequence and MU. Plan delivery and a gamma evaluation were performed using a helical diode array.

RESULTS

With similar plan quality, the average SAs for the Trilogy plans were smaller than those for the Synergy plans: 55.5 ± 21.3 cm2 vs. 66.3 ± 17.9 cm2 (p < 0.05) for the NPC cases and 100.7 ± 49.2 cm2 vs. 108.5 ± 42.7 cm2 (p < 0.05) for the BC cases, respectively. The SW was statistically significant for the two delivery systems (NPC: 6.87 ± 1.95 cm vs. 6.72 ± 2.71 cm, p < 0.05; BC: 8.84 ± 2.56 cm vs. 8.09 ± 2.63 cm, p < 0.05). The LSV was significantly smaller for Trilogy (NPC: 0.84 ± 0.033 vs. 0.86 ± 0.033, p < 0.05; BC: 0.89 ± 0.026 vs. 0.90 ± 0.26, p < 0.05). The mean AAV was significantly larger for Trilogy than for Synergy (NPC: 0.18 ± 0.064 vs. 0.14 ± 0.037, p < 0.05; BC: 0.46 ± 0.15 vs. 0.33 ± 0.13, p < 0.05). The MCS values for Trilogy were higher than those for Synergy: 0.14 ± 0.016 vs. 0.12 ± 0.017 (p < 0.05) for the NPC cases and 0.42 ± 0.106 vs. 0.30 ± 0.087 (p < 0.05) for the BC cases. Compared with the Synergy plans, the average MUs for the Trilogy plans were larger: 828.6 ± 74.1 MU and 782.9 ± 85.2 MU (p > 0.05) for the NPC cases and 444.8 ± 61.3 MU and 393.8 ± 75.3 MU (p > 0.05) for the BC cases. The gamma index agreement scores were never below 91% using 3 mm/3% (global) distance to agreement and dose difference criteria and a 10% lower dose exclusion threshold.

CONCLUSIONS

The Pinnacle3 Auto-Planning system can optimize BC and NPC plans to achieve the same plan quality using both the Trilogy and Synergy systems. We found that these two systems resulted in different SAs, SWs, LSVs, AAVs and MCSs. As a result, we suggested that the beam complexity should be considered in the development of further methodologies while optimizing VMAT autoplanning.

Image-based diagnosis of residual or recurrent nasopharyngeal carcinoma may be a phantom tumor phenomenon

Some nasopharyngeal carcinoma (NPC) patients may present convincing radiological evidence mimicking residual or recurrent tumor after radiotherapy. However, by means of biopsies and long term follow-up, the radiologically diagnosed residuals/recurrences are not always what they appear to be. We report our experience on this "phantom tumor" phenomenon. This may help to avoid the unnecessary and devastating re-irradiation subsequent to the incorrect diagnosis.In this longitudinal cohort study, we collected 19 patients of image-based diagnosis of residual/recurrent NPC during the period from Feb, 2010 to Nov. 2016, and then observed them until June, 2019. They were subsequently confirmed to have no residual/recurrent lesions by histological or clinical measures. Image findings and pathological features were analyzed.Six patients showed residual tumors after completion of radiotherapy and 13 were radiologically diagnosed to have recurrences based on magnetic resonance imaging (MRI) criteria 6 to 206 months after radiotherapy. There were 3 types of image patterns: extensive recurrent skull base lesions (10/19); a persistent or residual primary lesion (3/19); lesions both in the nasopharynx and skull base (6/19). Fourteen patients had biopsy of the lesions. The histological diagnoses included necrosis/ inflammation in 10 (52.7%), granulation tissue with inflammation in 2, and reactive epithelial cell in 1. Five patients had no pathological proof and were judged to have no real recurrence/residual tumor based on the absence of detectable plasma EB virus DNA and subjective judgment. These 5 patients have remained well after an interval of 38-121 months without anti-cancer treatments.Image-based diagnosis of residual or recurrent nasopharyngeal carcinoma may be unreliable. False positivity, the "phantom tumor phenomenon", is not uncommon in post-radiotherapy MRI. This is particularly true if the images show extensive skull base involvement at 5 years or more after completion of radiotherapy. MRI findings compatible with NPC features must be treated as a real threat until proved otherwise. However, the balance between under- and over-diagnosis must be carefully sought. Without a pathological confirmation, the diagnosis of residual or recurrent NPC must be made taking into account physical examination results, endoscopic findings and Epstein-Barr virus viral load. A subjective medical judgment is needed based on clinical and laboratory data and the unique anatomic complexities of the nasopharynx.

Grading Soft Tissue Involvement in Nasopharyngeal Carcinoma Using Network and Survival Analyses: A Two-Center Retrospective Study

BACKGROUND

Soft tissue involvement (STI) indicates poor prognosis in nasopharyngeal carcinoma (NPC). However, only a few studies have systematically assessed this extension using network analysis.

PURPOSE

To investigate the prognostic value of STI and to propose an improved STI grading system for NPC therapy.

STUDY TYPE

Retrospective study.

POPULATION

A total of 1225 consecutive patients with pathologically confirmed NPC treated with intensive-modulated radiotherapy from January 2010 to March 2014 were enrolled from two centers.

FIELD STRENGTH/SEQUENCE

T1- and T2-weighted imaging and enhanced T1-weighted imaging with fast spin echo sequence at 1.5 or 3.0 T.

ASSESSMENT

The levator veli palatini and tensor veli palatini involvement were graded "mild," prevertebral muscle involvement, "moderate," medial pterygoid, lateral pterygoid, and the infratemporal fossa involvement, "severe" STI. The above STI sites were evaluated separately by three radiologists using MRI images and graded using network analysis. Overall survival (OS) and progression-free survival (PFS) were assessed.

STATISTICAL TESTS

Kaplan-Meier method, Cox's proportional hazards model, and concordance index (C-index) were used.

RESULTS

Five-year OS and PFS rates between mild and moderate groups (90.5% vs. 81.7%, P < 0.05 and 82.9% vs. 72.5%, P < 0.05, respectively) and between moderate and severe groups (81.7% vs. 70.4%, P < 0.05 and 72.5% vs. 61.2%, P < 0.05, respectively) revealed significant differences. The C-index of the nomogram with STI grading was higher compared with current T-classification (OS 0.641 vs. 0.604, P < 0.05 and PFS 0.605 vs. 0.581, P < 0.05, respectively). Significant OS differences were observed between patients with severe STI who underwent induction chemotherapy (IC) and those who did not (84.5% vs. 70.7%, P < 0.05).

DATA CONCLUSION

STI grading was an independent prognostic factor for OS and PFS in NPC patients and it may be help to improve the accuracy in predicting survival outcomes. Patients with severe STI might benefit from IC to improve OS.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

lncRNA CASC19 Contributes to Radioresistance of Nasopharyngeal Carcinoma by Promoting Autophagy via AMPK-mTOR Pathway

Nasopharyngeal carcinoma (NPC) is one of the most frequent head and neck malignant tumors and is majorly treated by radiotherapy. However, radiation resistance remains a serious obstacle to the successful treatment of NPC. The aim of this study was to discover the underlying mechanism of radioresistance and to elucidate novel genes that may play important roles in the regulation of NPC radiosensitivity. By using RNA-seq analysis of NPC cell line CNE2 and its radioresistant cell line CNE2R, lncRNA CASC19 was screened out as a candidate radioresistance marker. Both in vitro and in vivo data demonstrated that a high expression level of CASC19 was positively correlated with the radioresistance of NPC, and the radiosensitivity of NPC cells was considerably enhanced by knockdown of CASC19. The incidence of autophagy was enhanced in CNE2R in comparison with CNE2 and another NPC cell line HONE1, and silencing autophagy with LC3 siRNA (siLC3) sensitized NPC cells to irradiation. Furthermore, CASC19 siRNA (siCASC19) suppressed cellular autophagy by inhibiting the AMPK/mTOR pathway and promoted apoptosis through the PARP1 pathway. Our results revealed for the first time that lncRNA CASC19 contributed to the radioresistance of NPC by regulating autophagy. In significance, CASC19 might be a potential molecular biomarker and a new therapeutic target in NPC.

Effect of cetuximab combined with IMRT and concurrent chemotherapy in treating locally advanced nasopharyngeal carcinoma

PURPOSE

To explore the efficacy and safety of cetuximab combined with intensity-modulated radiotherapy (IMRT) and concurrent cisplatin-based chemotherapy in the treatment of patients with locally advanced nasopharyngeal carcinoma.

METHODS

The clinical information of 126 patients with locally advanced nasopharyngeal carcinoma, who were admitted to and treated in our department from September 2013 to May 2016, was collected, and they were randomly divided into two groups: cetuximab combined with IMRT and concurrent cisplatin-based chemotherapy group (Cetuximab group, n=63) and IMRT combined with concurrent cisplatin-based chemotherapy group (Control group, n=63). The clinical efficacy, changes in patients' quality of life and incidence of adverse reactions were observed and compared between the two groups, and the tumor progression and survival of the patients were followed up and recorded.

RESULTS

The patients in Cetuximab group exhibited substantially higher objective remission rate (ORR) and disease control rate (DCR) [90.5% (57/63) and 100%] than those in Control group [71.4% (46/63) and 88.9% (56/63)] (p=0.011 and 0.007). After treatment, the physiological status, social and familial status and emotional status based on the FACT-H&N scale were not statistically significantly different between the two groups of patients, but the patients in Cetuximab group had notably superior functional status, additional items for the head and neck and total scale score to those in Control group (p=0.011, 0.021 and 0.038). Additionally, the main adverse reactions of patient after treatment included myelosuppression, fever, gastrointestinal reactions, acne-like rash, radiodermatitis, oral mucositis, and liver and kidney function impairment, most of which were in grade I-II (p>0.05), and the differences between the two groups were not statistically significant (p>0.05). According to the log-rank test, the differences in the OS and PFS of patients between the two groups were not statistically significant (p=0.411 and 0.114).

CONCLUSIONS

Cetuximab combined with IMRT and concurrent cisplatin-based chemotherapy has better clinical short-term efficacy in treating locally advanced nasopharyngeal carcinoma, and the patients treated have improved quality of life and can tolerate adverse reactions.