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Slijepcevic AA, Roh J, Pipkorn P, Lipsey K, Bradley JP. Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS. Laryngoscope 2023; 133:576-587. [PMID: 35575599 DOI: 10.1002/lary.30157] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS. METHODS A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected. RESULTS A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality. CONCLUSIONS Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low. LEVEL OF EVIDENCE N/A Laryngoscope, 133:576-587, 2023.
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Affiliation(s)
- Allison A Slijepcevic
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joseph Roh
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Patrik Pipkorn
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Kim Lipsey
- Bernard Becker Medical Library, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Joseph P Bradley
- Department of Otolaryngology-Head & Neck Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Li C, Lu J, Luo Y, Feng D. Case report: Endovascular intervention of internal carotid artery pseudoaneurysm secondary to nasopharyngeal carcinoma radiotherapy. Front Surg 2023; 9:1099416. [PMID: 36713655 PMCID: PMC9879062 DOI: 10.3389/fsurg.2022.1099416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/05/2022] [Indexed: 01/09/2023] Open
Abstract
Background Internal carotid artery pseudoaneurysm (PSA) is a serious complication after radiotherapy for nasopharyngeal carcinoma, and once it ruptures and bleeds, it will seriously affect the patient's survival and prognosis. However, because of its relatively low incidence, many medical institutions lack experience in managing this type of emergency. Case information In this case report, we described two cases suffered ruptured internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, including their history, diagnosis, and treatment. Both cases underwent emergency endovascular interventions, one of which with long-term healing after embolization of the PSA, and the other one with re-bleeding after embolization and was eventually stopped by embolization of the parent artery. Ultimately, both cases received timely and effective treatment. Conclusion This case report detailed the diagnosis and treatment course of internal carotid artery PSA after radiotherapy for nasopharyngeal carcinoma, which enhanced the understanding of this emergency, and provided valuable information and experience for the treatment strategy of similar PSA on the internal carotid artery.
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Affiliation(s)
| | | | - Yu Luo
- Correspondence: Daqin Feng ; Yu Luo
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Endovascular embolisation of external carotid artery system haemorrhage in radiated nasopharyngeal carcinoma. Eur Arch Otorhinolaryngol 2022; 279:5851-5858. [PMID: 35792916 DOI: 10.1007/s00405-022-07491-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/06/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE To review the effectiveness and safety of embolisation in managing haemorrhage from the external carotid artery (ECA) system in radiated nasopharyngeal carcinoma (NPC) patients. METHODS Radiated NPC patients who presented with severe oronasal bleeding and underwent digital subtraction angiography that excluded blowouts from the internal carotid artery from 2011 to 2021 were reviewed. Those who subsequently underwent embolisation of the ECA system were analysed for technical success rate, post-embolisation re-bleeding rate and complications. RESULTS Seventeen embolisations were performed in fifteen patients during the 10-year period. The technical success rate was 100%, however the early haemostatic rate (no re-bleed within 7 days of embolisation) was 70.6% (12/17) and the overall long-term haemostatic rate was 58.8% (10/17). The re-bleed rates of targeted and empiric embolisations were 33.3% (3/9) and 50.0% (4/8), respectively. The re-bleed rates with liquid agents, coils and particles were 0% (0/7), 33.3% (1/3) and 85.7% (6/7), respectively. Amongst the embolisations utilising liquid agents, 71.4% (5/7) were targeted, distal embolisations. All re-bleeds underwent surgical ligation or repeat embolisation; half of them further experienced recurrent bleeding. There were no significant complications with embolisation. CONCLUSION Although embolisation of the ECA system in NPC has a high technical success rate and is safe, re-bleeding appears to be common. Targeted, distal embolisation with liquid embolics appear to have good haemostatic effect. Clinicians should be aware that patients may need repeated procedures to secure haemostasis.
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Yuan B, Xin HN, Yuan K, Zhang JL, Duan F, Wang MQ. Heparin-bonded stent graft placement for treatment of massive epistaxis from ruptured radiation-induced internal carotid artery pseudoaneurysm: A case report. Radiol Case Rep 2022; 17:2129-2132. [PMID: 35464788 PMCID: PMC9024372 DOI: 10.1016/j.radcr.2022.03.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 11/28/2022] Open
Abstract
Rupture of an internal carotid artery (ICA) pseudoaneurysm is a rare but life-threatening complication of irradiation therapy for a nasopharyngeal carcinoma (NPC). A 36-year-old man had a history of NPC treated with radiotherapy 8 years previously. He was admitted to the hospital because of severe repetitive epistaxis with hemodynamically instablility. An emergent angiography showed the left ICA pseudoaneurysm at the petrous portion (C2 segment). The patient was successfully treated by a new-generation heparin-bonded stent graft without any complication. Emergent stent graft placement is effective in stopping hemorrhage and is therefore a life-saving intervention. Long-term follow-up is necessary to look out for delayed post-treatment complications.
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Affiliation(s)
- Bing Yuan
- Departments of Interventional Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R. China
| | - Hai-nan Xin
- Departments of Interventional Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R. China
| | - Kai Yuan
- Departments of Interventional Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R. China
| | - Jin-long Zhang
- Department of Radiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, P.R. China
| | - Feng Duan
- Departments of Interventional Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R. China
- Corresponding authors.
| | - Mao-Qiang Wang
- Departments of Interventional Radiology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, P.R. China
- Corresponding authors.
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Zeng L, Wan W, Luo Q, Jiang H, Ye J. Retrospective analysis of massive epistaxis and pseudoaneurysms in nasopharyngeal carcinoma after radiotherapy. Eur Arch Otorhinolaryngol 2021; 279:2973-2980. [PMID: 34623497 DOI: 10.1007/s00405-021-07111-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Liang Zeng
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Wei Wan
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Qing Luo
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Hongqun Jiang
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China
| | - Jing Ye
- Department of Otorhinolaryngology, Head and Neck Surgery, The First Affiliated Hospital of Nanchang University, No.17 Yongwaizheng Street, Nanchang, 330006, Jiangxi, China.
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Wang Y, Dong X, Zhou C, Shi Q, Liu J, Xiong B. Endovascular Management of Intractable Nasopharyngeal Hemorrhage in Patients Irradiated for Nasopharyngeal Carcinoma: A Twelve-Year Experience. Cancer Manag Res 2020; 12:11945-11952. [PMID: 33262648 PMCID: PMC7689356 DOI: 10.2147/cmar.s283968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose To evaluate the efficacy of endovascular treatment of intractable nasopharyngeal hemorrhage after radiotherapy for nasopharyngeal carcinoma (NPC) and report the relevant endovascular therapeutic experience. Patients and Methods Records of patients who underwent endovascular treatment for intractable nasopharyngeal hemorrhage after irradiation for NPC from January 2007 to December 2019 were reviewed. The demographics, endovascular therapeutic details, and clinical outcomes were analyzed. Results Twenty-four consecutive patients were included in this study. Nineteen patients underwent embolization of the bilateral internal maxillary arteries; one patient underwent embolization of the right internal maxillary artery and the left external carotid artery; one patient underwent embolization of the left internal maxillary artery and the right internal carotid artery, and the other three patients underwent embolization of the unilateral internal carotid artery. During a mean follow-up of 600.9 days (range, 2–1658 days), twenty patients showed no recurrence of bleeding; one patient died of hemorrhagic shock; one patient had recurrent bleeding, and angiography revealed a pseudoaneurysm in the right internal carotid artery, which was then embolized with spring coil after a 30-min occlusion test. Two patients had recurrent bleeding on 2.5 months and 29.9 months respectively after the endovascular treatment, and angiography showed hypervascularity supplied by the bilateral internal maxillary arteries and then was embolized with polyvinyl alcohol particles. The three patients who received re-interventions showed no re-bleeding until the last follow-up. Conclusion Pseudoaneurysm and hypervascularity are the main angiographic characteristics of patients with intractable nasopharyngeal hemorrhage after radiotherapy for NPC, and endovascular treatment provides a safe and effective management approach.
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Affiliation(s)
- Yingliang Wang
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Xiangjun Dong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Chen Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Qin Shi
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Jiacheng Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
| | - Bin Xiong
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China.,Hubei Key Laboratory of Molecular Imaging, Wuhan 430022, People's Republic of China
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Dong F, Li Q, Wu J, Zhang M, Zhang G, Li B, Jin K, Min J, Liang W, Chao M. Carotid blowout syndrome after nasopharyngeal carcinoma radiotherapy: successful treatment by internal carotid artery occlusion after stent implantation failure. SPRINGERPLUS 2016; 5:1553. [PMID: 27652126 PMCID: PMC5021652 DOI: 10.1186/s40064-016-3209-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 09/02/2016] [Indexed: 12/18/2022]
Abstract
Introduction Carotid blowout syndrome (CBS) secondary to radiation therapy is life-threatening and requires emergency treatment. More recently, endovascular treatment has provided an effective way to control CBS-related bleeding. Case description We present a case of CBS with a rupture of the internal carotid artery (ICA) pseudo-aneurysm after Gamma Knife radiation therapy for nasopharyngeal carcinoma (NPC). The patient was a 55-year-old man who was transferred to our hospital with severe repetitive epistaxis. He had a history of NPC and had been treated with Gamma Knife radiation therapy 7 months prior, with a central dose of 32 Gy and marginal dose of 16 Gy. As CBS was confirmed by angiography, and the affected part of the ICA lumen exhibited moderate stenosis, the patient was successfully treated by ICA occlusion after stent implantation failure. The patient died 40 months after this operation from tumor recurrence, but without epistaxis during follow up. Discussion and Evaluation Quick selection of an appropriate treatment method is very important for an acute CBS patient. Conclusion ICA occlusion can be directly considered for an acute CBS patient, if the affected ICA exhibits stenosis that is moderate or above.
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Affiliation(s)
- Fei Dong
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - Qian Li
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - JianJun Wu
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - MinMing Zhang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - GuangQiang Zhang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - Bin Li
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - Kai Jin
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - Jie Min
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - WeiRen Liang
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
| | - Ming Chao
- Department of Radiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310009 China
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Yu YH, Xia WX, Shi JL, Ma WJ, Li Y, Ye YF, Liang H, Ke LR, Lv X, Yang J, Xiang YQ, Guo X. A model to predict the risk of lethal nasopharyngeal necrosis after re-irradiation with intensity-modulated radiotherapy in nasopharyngeal carcinoma patients. CHINESE JOURNAL OF CANCER 2016; 35:59. [PMID: 27357728 PMCID: PMC4928250 DOI: 10.1186/s40880-016-0124-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 06/14/2016] [Indexed: 11/25/2022]
Abstract
Background For patients with nasopharyngeal carcinoma (NPC) who undergo re-irradiation with intensity-modulated radiotherapy (IMRT), lethal nasopharyngeal necrosis (LNN) is a severe late adverse event. The purpose of this study was to identify risk factors for LNN and develop a model to predict LNN after radical re-irradiation with IMRT in patients with recurrent NPC. Methods Patients who underwent radical re-irradiation with IMRT for locally recurrent NPC between March 2001 and December 2011 and who had no evidence of distant metastasis were included in this study. Clinical characteristics, including recurrent carcinoma conditions and dosimetric features, were evaluated as candidate risk factors for LNN. Logistic regression analysis was used to identify independent risk factors and construct the predictive scoring model. Results Among 228 patients enrolled in this study, 204 were at risk of developing LNN based on risk analysis. Of the 204 patients treated, 31 (15.2%) developed LNN. Logistic regression analysis showed that female sex (P = 0.008), necrosis before re-irradiation (P = 0.008), accumulated total prescription dose to the gross tumor volume (GTV) ≥145.5 Gy (P = 0.043), and recurrent tumor volume ≥25.38 cm3 (P = 0.009) were independent risk factors for LNN. A model to predict LNN was then constructed that included these four independent risk factors. Conclusions A model that includes sex, necrosis before re-irradiation, accumulated total prescription dose to GTV, and recurrent tumor volume can effectively predict the risk of developing LNN in NPC patients who undergo radical re-irradiation with IMRT.
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Affiliation(s)
- Ya-Hui Yu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Wei-Xiong Xia
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Jun-Li Shi
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Biodevices and Diagnostics, Institute of Bioengineering and Nanotechnology, Singapore, 138669, Singapore
| | - Wen-Juan Ma
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Radiation Therapy, 3rd Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, Guangdong, P. R. China
| | - Yong Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Yan-Fang Ye
- Department of Biostatistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, 510080, Guangdong, P. R. China
| | - Hu Liang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Liang-Ru Ke
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Xing Lv
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Jing Yang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China
| | - Yan-Qun Xiang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
| | - Xiang Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China. .,Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, Guangzhou, 510060, Guangdong, P. R. China.
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