Intensity-modulated radiotherapy prolongs the survival of patients with nasopharyngeal carcinoma compared with conventional two-dimensional radiotherapy: A 10-year experience with a large cohort and long follow-up

Development and validation of Prediction models for radiation-induced hypoglossal neuropathy in patients with nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

To establish predictive models for radiation-induced hypoglossal neuropathy (RIHN) in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Data from 423 NPC patients receiving IMRT-based treatment were retrospectively reviewed. They were randomly (3:2) divided into a training set (n = 256) and a testing set (n = 167). Dosimetric variables were selected by penalized regression and machine learning, with area under the receiver operating curve (AUC) calculated. Clinical variables were selected by the competitive risk analysis. A competitive risk model including clinical and dosimetric variables was performed, and a nomogram was generated as a visualization of the model to predict the incidence of RIHN.

RESULTS

During a median follow-up of 102 months (IQR: 89.5 to 112.9 months), the cumulative incidence of RIHN at 3, 5, and 8 years were 2.1 %, 5.4 %, and 10.5 %, respectively. D1cc and aV75 were the most predictive dosimetric variables. The dose-effect curve plotted with D1cc indicated the tolerance dose for a 5 % probability of developing RIHN in 8 years (TD5/8) was 77.3 Gy (EQD2). The restricted cubic spline between aV75 and RIHN indicated a volume threshold of 0.81 cm3. A competitive risk model including hypoglossal canal involvement, concurrent chemotherapy, D1cc, and aV75 was established, with the C-index of the training set and testing set being 0.726 and 0.691, respectively. The nomogram-defined high-risk group had the higher RIHN incidences in the training and testing sets.

CONCLUSIONS

This study identified the most critical dosimetric predictors, which is expected to become a feasible dose constraint for hypoglossal nerves in radiation plan. Combining dosimetric and clinical predictors, we further proposed and validated the first nomogram model to quantify the risk of RIHN, contributing to identifying high-risk patients and early intervention. Further multicenter studies are needed to validate or complement our findings.

Deep learning MRI-based radiomic models for predicting recurrence in locally advanced nasopharyngeal carcinoma after neoadjuvant chemoradiotherapy: a multi-center study

Local recurrence and distant metastasis were a common manifestation of locoregionally advanced nasopharyngeal carcinoma (LA-NPC) after neoadjuvant chemoradiotherapy (NACT). To validate the clinical value of MRI radiomic models based on deep learning for predicting the recurrence of LA-NPC patients. A total of 328 NPC patients from four hospitals were retrospectively included and divided into the training(n = 229) and validation (n = 99) cohorts randomly. Extracting 975 traditional radiomic features and 1000 deep radiomic features from contrast enhanced T1-weighted (T1WI + C) and T2-weighted (T2WI) sequences, respectively. Least absolute shrinkage and selection operator (LASSO) was applied for feature selection. Five machine learning classifiers were conducted to develop three models for LA-NPC prediction in training cohort, namely Model I: traditional radiomic features, Model II: combined the deep radiomic features with Model I, and Model III: combined Model II with clinical features. The predictive performance of these models were evaluated by receive operating characteristic (ROC) curve analysis, area under the curve (AUC), accuracy, sensitivity and specificity in both cohorts. The clinical characteristics in two cohorts showed no significant differences. Choosing 15 radiomic features and 6 deep radiomic features from T1WI + C. Choosing 9 radiomic features and 6 deep radiomic features from T2WI. In T2WI, the Model II based on Random forest (RF) (AUC = 0.87) performed best compared with other models in validation cohort. Traditional radiomic model combined with deep radiomic features shows excellent predictive performance. It could be used assist clinical doctors to predict curative effect for LA-NPC patients after NACT.

Classifications of Postradiation Nasopharyngeal Necrosis for Guiding Transnasal Endoscopic Nasopharyngeal Skull Base Surgery

OBJECTIVE

Postradiation nasopharyngeal necrosis (PRNN) is a severe postradiation complication of nasopharyngeal carcinoma. PRNN not only severely impacts the quality of life but also endangers the lives of patients. Definite grades of PRNN and their corresponding standard surgical procedures are lacking. we aimed to establish the classifications of PRNN for transnasal endoscopic skull base surgery (TESS).

METHODS

We enrolled 82 postirradiation NPC patients with PRNN, 75 of whom received TESS. PRNN was categorized into four grades: I, necrosis of the nasopharyngeal mucosa and submucosal muscularis; II, necrosis extending to the pharyngobasilar fascia; III, necrotic area breaking through the pharyngobasilar fascia and involving the internal carotid artery (ICA); IV, necrosis encompassing the ICA or invading the posterior cranial nerves. Overall survival (OS) analysis based on the PRNN grades was assessed. Headache was assessed using a numeric rating scale.

RESULTS

The classifications of PRNN were as follows: Grade I, 18.3% (n = 15); Grade II, 30.5% (n = 25); Grade III, 24.4% (n = 20); Grade IV, 26.8% (n = 22). After surgery, headache was alleviated in most PRNN patients to varying degrees. By the last follow-up visit, 24 patients had died, including 6 of 7 in the unoperated group and 18 out of 75 in the operated group.

CONCLUSION

The classifications of PRNN grade provide an effective guideline for the TESS treatment of PRNN.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:1581-1589, 2025.

Establishment of a deep-learning-assisted recurrent nasopharyngeal carcinoma detecting simultaneous tactic (DARNDEST) with high cost-effectiveness based on magnetic resonance images: a multicenter study in an endemic area

BACKGROUND

To investigate the feasibility of detecting local recurrent nasopharyngeal carcinoma (rNPC) using unenhanced magnetic resonance images (MRI) and optimize a layered management strategy for follow-up with a deep learning model.

METHODS

Deep learning models based on 3D DenseNet or ResNet frames using unique sequence (T1WI, T2WI, or T1WIC) or a combination of T1WI and T2WI sequences (T1_T2) were developed to detect local rNPC. A deep-learning-assisted recurrent NPC detecting simultaneous tactic (DARNDEST) utilized DenseNet was optimized by superimposing the T1WIC model over the T1_T2 model in a specific population. Diagnostic efficacy (accuracy, sensitivity, specificity) and examination cost of a single MR scan were compared among the conventional method, T1_T2 model, and DARNDEST using McNemar's Z test.

RESULTS

No significant differences in overall accuracy, sensitivity, and specificity were found between the T1WIC model and T1WI, T2WI, or T1_T2 models in both test sets (all P > 0.0167). The DARNDEST had higher accuracy and sensitivity but lower specificity than the T1_T2 model in both the internal (accuracy, 85.91% vs. 84.99%; sensitivity, 90.36% vs. 84.26%; specificity, 82.20% vs. 85.59%) and external (accuracy, 86.14% vs. 84.16%; sensitivity, 90.32% vs. 84.95%; specificity, 82.57% vs. 83.49%) test sets. The cost of a single MR examination using DARNDEST was $330,724 (internal) and $328,971 (external) with a hypothetical cohort of 1,000 patients, relative to $313,250 of the T1_T2 model and $340,865 of the conventional method.

CONCLUSIONS

Detecting local rNPC using unenhanced MRI with deep learning is feasible and DARNDEST-driven follow-up management is efficient and economic.

Nasopharyngeal Endoscopic Submucosal Dissection (NESD) for Stage I Nasopharyngeal Carcinoma

This study introduces nasopharyngeal endoscopic submucosal dissection (NESD), a new, standardized surgical technique for treating early-stage nasopharyngeal carcinoma by removing the entire nasopharyngeal mucosa and preserving key anatomical structures. NESD was successfully performed in the stage I nasopharyngeal carcinoma patient with minimal blood loss and no complications, showing promising results for safety and efficacy over a 2-year follow-up.

The impact of different cervical planning target volume designs on efficacy and toxicity in nasopharyngeal carcinoma: a single-center retrospective study

BACKGROUND

In nasopharyngeal carcinoma (NPC) patients, two radiation target delineation patterns are used for the cervical lymph node area.

PURPOSE

This study compares the efficacy and toxicity of two radiation target volume delineation patterns for planning target volumes (PTVs) in NPC patients.

METHODS

This retrospective analysis included 387 non-metastatic NPC patients treated with concurrent chemoradiotherapy from January 2017 to December 2020. Patients were divided into two groups: the 2-PTV group with two dose gradients (50-54 Gy and 66-70 Gy) and the 3-PTV group with an additional 60-63 Gy dose.

RESULTS

After a median follow-up of 51.2 months, the 3-year regional relapse-free survival (RRFS) showed no significant differences between the 3-PTV and 2-PTV groups (96.6% [95% confidence interval (CI): 96.5%-96.8%] and 96.3% [95% CI: 96.2%-96.3%]). In the N3 subgroup, the 3-year RRFS was also comparable between the 3-PTV and 2-PTV groups (96.2% [95% CI: 76%-99%] vs. 95% [95% CI: 69%-99%], p = 0.727). Importantly, the 2-PTV group demonstrated significantly lower rates of grade 3/4 dermatitis (5.1% vs. 16.5%; HR 0.88, 95% CI: 0.82-0.94, p = 0.002) and xerostomia (49.6% vs. 67%; HR 0.78, 95% CI: 0.72-0.84, p = 0.002).

CONCLUSIONS

The 2-PTV regimen achieved equivalent survival outcomes while significantly reducing treatment-related toxicities compared to the 3-PTV approach. These results suggest that the 2-PTV strategy may offer a more favorable therapeutic profile for NPC patients, particularly in minimizing severe dermatitis and xerostomia.

Long-term results of locoregionally advanced nasopharyngeal carcinoma treated with cisplatin and 5-fluorouracil induction chemotherapy with or without docetaxel in young and middle aged adults

PURPOSE

This study aims to evaluate the efficacy and toxicity of the two induction chemotherapy (IC) regimens (TPF: docetaxel, cisplatin and 5-fluorouracil, and PF: cisplatin and 5-fluorouracil) combined with radiotherapy in young and middle aged patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

A retrospective analysis was conducted on 329 cases with stage III-IVA nasopharyngeal carcinoma from September 2005 to February 2017. Of the 329 cases, 253 cases underwent TPF (docetaxel: 60 mg/m2 on day 1, cisplatin: 25 mg/m2 on days 1-3, 5-fluorouracil: 500 mg/m2 on days 1-5, intravenous 120-h infusion), while 76 cases received the PF regimen (cisplatin: 25 mg/m2 on days 1-3, 5-fluorouracil: 500 mg/m2 on days 1-5, intravenous 120-h infusion) every 3 weeks. Radiotherapy was administered after IC with or without concurrent chemotherapy. The survival rates were assessed by Kaplan-Meier analysis, and the survival curves were compared using a log‑rank test.

RESULTS

The 5-year and 8-year overall survival (OS) rates of the PF group and TPF group were 80.1% and 72.1%, 87.3% and 78.4% respectively (p = 0.405). There were no statistical differences in regional recurrence-free survival (RRFS) and distant metastasis-free survival (DMFS) rates between PF and TPF groups(p = 0.585 and 0.500, respectively).The 5-year and 8-year estimated local recurrence free survival (LRFS) rates for patients in PF and TPF group were 91.1% and 78.0%, 96.2% and 93.7%, respectively (p = 0.026). Moreover, The OS, LRFS, RRFS and DMFS rates were comparable between the non CCRT or CCRT subgroup (p = 0.542, 0.319, 0.070, 0.986, respectively). Compared with PF group, the TPF group significantly increased the occurrence of grade 3 or 4 neutropenia and leukopenia (p < 0.001).

CONCLUSION

PF and TPF followed by radiotherapy with or without concurrent chemotherapy performed encouraging anti-tumor effects in LA-NPC, there was no statistical significance in 5-year and 8-year OS, RRFS, and DMFS rates between two chemotherapy regimens. Compared with PF, TPF induction chemotherapy achieved more satisfactory LRFS rate in LA-NPC with acceptable toxicity.

A Serial MRI-based Deep Learning Model to Predict Survival in Patients with Locoregionally Advanced Nasopharyngeal Carcinoma

Purpose To develop and evaluate a deep learning-based prognostic model for predicting survival in locoregionally advanced nasopharyngeal carcinoma (LA-NPC) using serial MRI before and after induction chemotherapy (IC). Materials and Methods This multicenter retrospective study included 1039 patients with LA-NPC (779 male and 260 female patients; mean age, 44 years ± 11 [SD]) diagnosed between December 2011 and January 2016. A radiomics-clinical prognostic model (model RC) was developed using pre- and post-IC MRI acquisitions and other clinical factors using graph convolutional neural networks. The concordance index (C-index) was used to evaluate model performance in predicting disease-free survival (DFS). The survival benefits of concurrent chemoradiation therapy (CCRT) were analyzed in model-defined risk groups. Results The C-indexes of model RC for predicting DFS were significantly higher than those of TNM staging in the internal (0.79 vs 0.53) and external (0.79 vs 0.62, both P < .001) testing cohorts. The 5-year DFS for the model RC-defined low-risk group was significantly better than that of the high-risk group (90.6% vs 58.9%, P < .001). In high-risk patients, those who underwent CCRT had a higher 5-year DFS rate than those who did not (58.7% vs 28.6%, P = .03). There was no evidence of a difference in 5-year DFS rate in low-risk patients who did or did not undergo CCRT (91.9% vs 81.3%, P = .19). Conclusion Serial MRI before and after IC can effectively help predict survival in LA-NPC. The radiomics-clinical prognostic model developed using a graph convolutional network-based deep learning method showed good risk discrimination capabilities and may facilitate risk-adapted therapy. Keywords: Nasopharyngeal Carcinoma, Deep Learning, Induction Chemotherapy, Serial MRI, MR Imaging, Radiomics, Prognosis, Radiation Therapy/Oncology, Head/Neck Supplemental material is available for this article. © RSNA, 2025.

A prognostic and predictive model based on deep learning to identify optimal candidates for intensity-modulated radiotherapy alone in patients with stage II nasopharyngeal carcinoma: A retrospective multicenter study

PURPOSE

To develop and validate a prognostic and predictive model integrating deep learning MRI features and clinical information in patients with stage II nasopharyngeal carcinoma (NPC) to identify patients with a low risk of progression for whom intensity-modulated radiotherapy (IMRT) alone is sufficient.

METHODS

This multicenter, retrospective study enrolled 999 patients with stage II NPC from two centers. 3DResNet was used to extract deep learning MRI features and eXtreme Gradient Boosting model was employed to integrate the pre-trained features and clinical information to obtain an overall score for each patient. Based on the optimal cutoff value of the overall score, patients were stratified into high- and low- risk groups. Model performance was evaluated using concordance indexes (C-indexes), the area under the curve (AUC) values and calibration tests. Survival curves were used to analyze the clinical benefits of additional chemotherapy in each risk group.

RESULTS

The combined model achieved a concordance index of 0.789 (95 % confidence interval [CI] 0.787-0.791), 0.768 (95 % CI 0.764-0.771), and 0.804 (95 % CI 0.801-0.807) for the training, internal validation, and external test cohorts, respectively, demonstrating a statistically significant improvement compared to the MRI model, T Stage, and N Stage. An overall score of < 0.405 in patients was significantly associated with a low risk of progression. In the low-risk group, patients treated with IMRT alone had comparable or even superior progression-free survival (PFS) compared to those who received additional chemotherapy.

CONCLUSION

The model demonstrated a satisfactory prognostic and predictive performance for PFS. Patients with stage II NPC were stratified into different risk groups to help identify optimal candidates who could benefit from IMRT alone.

Antiangiogenic therapy with recombinant human endostatin may improve blood perfusion of cervical node with necrosis in nasopharyngeal carcinoma patients: a preliminary study by using contrast-enhanced ultrasound

Background

The cervical node with necrosis (CNN) is an important poor prognostic factor for nasopharyngeal carcinoma (NPC) patients. The tumor microenvironment of the CNN has severely insufficient blood perfusion, thus leading to hypoxia and reducing the effect of radiotherapy (RT) and chemotherapy. By using contrast-enhanced ultrasound (CEUS) as a monitoring method, we conducted this study to assess whether antiangiogenic therapy (AT) with recombinant human endostatin (RHES) may improve blood perfusion of the CNN.

Materials and methods

Fifteen NPC patients with CNN were enrolled and underwent CEUS the day before and day 5 after AT with RHES initiation, respectively. By analyzing the variations of CEUS parameters of CNN, such as peak intensity (PI), time to peak (TTP), and mean transit time (MTT) at different time points, we evaluate the impact of AT with RHES on blood perfusion of CNN.

Results

The PI of day 5 after AT was significantly enhanced compared to the PI of the day before AT [-44.94 ± 4.72 (dB) vs. -50.33 ± 6.85 (dB), p < 0.001]. The TTP of day 5 after AT became dramatically shorter than the TTP of the day before AT [19.48 ± 3.63 (s) vs. 24.19 ± 6.93 (s), p = 0.031]. The MTT of day 5 after AT became obviously shorter than the MTT of the day before AT [28.08 ± 3.03 (s) vs. 33.76 ± 6.20 (s), p = 0.001].

Conclusion

These results revealed that the blood volume and the blood flow velocity in the microvessels of the CNN increased after AT, indicating that AT with RHES may improve blood perfusion in the CNN of NPC, thus providing valuable insights for the clinical application of AT combined with RT and/or chemotherapy in NPC patients with CNN. Moreover, CEUS as a noninvasive and real-time monitoring method may be suitable for clinically evaluating tumor blood perfusion changes.

Delineation of reduced CTV2 on the basis of the characteristics and distribution of cervical lymph node metastasis in nasopharyngeal carcinoma

INTRODUCTION

The core objective of this study was to precisely locate metastatic lymph nodes, identify potential areas in nasopharyngeal carcinoma patients that may not require radiotherapy, and propose a hypothesis for reduced target volume radiotherapy on the basis of these findings. Ultimately, we reassessed the differences in dosimetry of organs at risk (OARs) between reduced target volume (reduced CTV2) radiotherapy and standard radiotherapy.

METHODS AND MATERIALS

A total of 209 patients participated in the study. We used image registration techniques to map patients' neck metastatic lymph nodes onto a template CT of healthy individuals. Using MIM software, we integrated all patients' lymph node images onto the template CT images and conducted an in-depth analysis of their distribution characteristics and metastatic patterns. Subsequently, we randomly selected the localization images of 30 patients and used paired t test methods to compare the differences in the dosimetry of target volumes and OARs between reduced target volume radiotherapy and standard radiotherapy.

RESULTS

A total of 2314 metastatic lymph nodes were identified and mapped. There were no metastatic lymph nodes observed at level VIIb or within the lateral border of the common carotid artery. The percentages of metastatic lymph nodes at levels Ia, Ib, IIa, IIb, III, IVa, IVb, Va, Vb, Vc, VIa, VIb, VIIa, VIIb and VIII accounted for 0%, 1.5%, 22.8%, 41.1%, 15.9%, 3.0%, 0%, 4.4%, 1.0%, 0.3%, 0%, 0%, 9.7%, 0% and 0.3%, respectively, of the 2314 metastatic lymph nodes. Further analysis of the dosimetric outcomes revealed a significantly lower mean dose to the oral cavity, laryngeal cavity, esophagus, trachea, pharyngeal constrictor muscles, parotid gland, submandibular gland and thyroid gland with the implementation of reduced-target radiotherapy than with standard radiotherapy.

CONCLUSION

IMRT sparing level I, IVb, VI, and VIIb lymph nodes and the area within the lateral border of the common carotid artery for stage II-IVa NPC patients is feasible. This method can significantly reduce the dose to peripheral organs at risk.

Evaluating the Efficacy of Different Treatment Intensities in Nasopharyngeal Carcinoma Patients: A Nationwide Cancer Registry-Based Study

OBJECTIVE

The aim of this study was to evaluate the efficacy of different treatment intensities (TIs) in patients with nasopharyngeal carcinoma (NPC).

METHODS

The study assessed newly diagnosed, non-metastatic NPC patients from the Taiwan Cancer Registry between 2010 and 2017. TIs were divided into four groups: TI1 [radiotherapy (RT) alone or induction chemotherapy (IC) followed by RT); TI2 (concurrent chemoradiotherapy (CRT) alone); TI3 (IC followed by CRT or CRT followed by adjuvant chemotherapy (AC)]; and TI4 (IC followed by CRT followed by AC). The primary outcome was cancer-specific survival (CSS).

RESULTS

The study included 9863 patients. For stage I-II NPC patients, there was no significant difference in CSS among the different TI groups. For stage III patients, those receiving TI3 had better CSS (hazard ratio [HR] 0.69) compared with those receiving TI1. No significant differences in CSS were noted among those receiving TI2, TI3, and TI4. For stage IVA-B patients, those receiving TI2 (HR 0.70), TI3 (HR 0.49), and TI4 (HR 0.43) had better CSS compared with those receiving TI1. Compared with stage IVA-B patients receiving TI2, those receiving TI3 (HR 0.70) and TI4 (HR 0.61) had significantly better CSS. No differences in CSS were noted between those receiving TI3 and TI4.

CONCLUSIONS

For stage I-II NPC patients, RT alone is appropriate. For stage III and IVA-B patients, IC + CRT or CRT + AC may be needed to achieve optimal outcomes. No advantage of IC + CRT + AC over IC + CRT or CRT + AC was observed.

Intratumoral habitat radiomics based on magnetic resonance imaging for preoperative prediction treatment response to neoadjuvant chemotherapy in nasopharyngeal carcinoma

PURPOSE

The aim of this study is to determine intratumoral habitat regions from multi-sequences magnetic resonance imaging (MRI) and to assess the value of those regions for prediction of patient response to neoadjuvant chemotherapy (NAC) in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Two hundred and ninety seven patients with NPC were enrolled. Multi-sequences MRI data were used to outline three-dimensional volumes of interest (VOI) of the whole tumor. The original imaging data were divided into two groups, which were resampled to an isotropic resolution of 1 × 1 × 1 mm3 (group_1mm) and 3 × 3 × 3 mm3 (group_3mm). Nineteen radiomics features were computed for each voxel of three sequences in group_3mm, within the tumor region to extract local information. Then, k-means clustering was implemented to segment the whole tumor regions in two groups. After radiomics features were extracted and dimension reduction, habitat models were built using Multi-Layer Perceptron (MLP) algorithm.

RESULTS

Only T stage was included as the clinical model. The habitat3mm model, which included 10 radiomics features, achieved AUCs of 0.752 and 0.724 in the training and validation cohorts, respectively. Given the slightly better outcome of habitat3mm model, nomogram was developed in combination with habitat3mm model and T stage with the AUC of 0.749 and 0.738 in the training and validation cohorts. The decision curve analysis provides further evidence of the nomogram's clinical practicality.

CONCLUSIONS

A nomogram based on intratumoral habitat predicts the efficacy of NAC in NPC patients, offering the potential to improve both the treatment plan and patient outcomes.

Novel prediction model combining PET/CT metabolic parameters, inflammation markers, and TNM stage: prospects for personalizing prognosis in nasopharyngeal carcinoma

PURPOSE

This study aims to develop a novel prediction model and risk stratification system that could accurately predict progression-free survival (PFS) in patients with nasopharyngeal carcinoma (NPC).

METHODS

Herein, we included 106 individuals diagnosed with NPC, who underwent 18F-FDG PET/CT scanning before treatment. They were divided into training (n = 76) and validation (n = 30) sets. The prediction model was constructed based on multivariate Cox regression analysis results and its predictive performance was evaluated. Risk factor stratification was performed based on the nomogram scores of each case, and Kaplan-Meier curves were used to evaluate the model's discriminative ability for high- and low-risk groups.

RESULTS

Multivariate Cox regression analysis showed that N stage, M stage, SUVmax, MTV, HI, and SIRI were independent factors affecting the prognosis of patients with NPC. In the training set, the model considerably outperformed the TNM stage in predicting PFS (AUCs of 0.931 vs. 0.841, 0.892 vs. 0.785, and 0.892 vs. 0.804 at 1-3 years, respectively). The calibration plots showed good agreement between actual observations and model predictions. The DCA curves further justified the effectiveness of the model in clinical practice. Between high- and low-risk group, 3-year PFS rates were significantly different (high- vs. low-risk group: 62.8% vs. 9.8%, p < 0.001). Adjuvant chemotherapy was also effective for prolonging survival in high-risk patients (p = 0.009).

CONCLUSION

Herein, a novel prediction model was successfully developed and validated to improve the accuracy of prognostic prediction for patients with NPC, with the aim of facilitating personalized treatment.

Radiotherapy-Related Quality of Life in Nasopharyngeal Carcinoma Patients: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review and meta-analysis evaluated the quality of life (QoL) for nasopharyngeal carcinoma (NPC) patients with radiotherapy.

METHODS

A systematic literature search was performed to identify relevant studies published until March 2022. Quality evaluation and data extraction were performed for the included studies, and meta-analysis was performed using Stata.

RESULTS

Nine studies, including 1,659 patients, were eligible. Most QoL scales developed at the end of the treatment course and then followed by a gradual recovery to 1 year and more than 1 year after treatment. However, some items have not changed significantly and have a deteriorating trend. Items of cognitive functioning and constipation in EORTC QLQ-C30, and sexuality, felt ill, and weight gain in EORTC QLQ-H&N35 showed that scales with follow-up of more than 1 year were worse than those within 1 year but still better than those after treatment. In the intensity-modulated radiotherapy (IMRT) subgroup in EORTC QLQ-C30, cognitive functioning was similar to those before, and there was no significant change in insomnia. There was no significant change in the teeth item in EORTC QLQ-H&N35. In the IMRT subgroup, scales of swallowing, felt ill, and weight gain with follow-up of more than 1 year were worse than those within 1 year.

CONCLUSION

The QoL of patients with NPC is significantly impaired after radiotherapy-treated compared to baseline, and most of these items will gradually improve.

Neoadjuvant chemotherapy plus concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in elderly patients with stage III-IVa nasopharyngeal carcinoma: A real-world study based on medical comorbidities

PURPOSE

To evaluate the outcomes and toxicities of adding neoadjuvant chemotherapy (NAC) to concurrent chemoradiotherapy (CCRT) in elderly (≥65 years) patients with locoregionally advanced nasopharyngeal carcinoma (LANPC, stage III-IVa).

METHODS AND MATERIALS

Using an NPC-specific database, 245 elderly patients with stage III-IVa NPC, receiving CCRT +/- NAC, and an Adult Co-morbidity Evaluation 27 (ACE-27) score <2 were included. Recursive partitioning analysis (RPA) based on TNM stage and Epstein-Barr virus (EBV) DNA were applied for risk stratification. The primary end point was disease-free survival (DFS).

RESULTS

Two risk groups were generated by the RPA model. In the high-risk group (EBV DNA < 4000 copy/ml with stage IVa & EBV DNA ≥4000 copy/ml with stage III-IVa), patients treated with NAC plus CCRT achieved improved 5-year DFS rates compared to those who received CCRT alone (56.9% vs. 29.4%; p = 0.003). But we failed to observe the survival benefit of additional NAC in the low-risk group (EBV DNA <4000 copy/ml with stage III). The most common severe acute toxic effects were leucopenia (46.8% vs. 24.4%) and neutropenia (43.7% vs. 20.2%) in the NAC plus CCRT group versus CCRT group with statistically significant differences.

CONCLUSIONS

The addition of NAC to CCRT was associated with better DFS for the high-risk group of elderly LANPC patients with ACE-27 score <2. However, the survival benefit of additional NAC was not observed in low-risk patients.

New T staging recommendations for recurrent nasopharyngeal carcinoma

OBJECTIVE

The International Union for Cancer Control/American Joint Committee on Cancer (UICC/AJCC) rT staging is not clinically practical for recurrent nasopharyngeal carcinoma (rNPC). The aim of this study was to establish a new rT staging to guide the treatment of rNPC.

METHODS

We conducted a retrospective analysis of 175 patients diagnosed with rNPC between January 2012 and December 2020, using ROC curve analysis to evaluate its effectiveness.

RESULTS

We analyzed the overall survival (OS) and progression-free survival(PFS) of patients diagnosed with rNPC according to the 8th (UICC/AJCC) rT staging, and found that the overall survival of rT1 and rT2 patients (OS; 29.98% vs. 27.09%, p = 0.8059) and progression-free survival (PFS; 28.48% vs. 26.12%, p = 0.4045) had no significant difference. In rT1 and rT2 patients of this study, overall survival(OS; 30.44% vs. 24.91%, p = 0.0229) and progression-free survival(PFS 29.12% vs. 24.03%, p = 0.0459) had a significant difference. Smoking, family history, and time interval of initial recurrence were independent prognostic factors for OS and PFS.

CONCLUSION

The new rT staging of this study has a better predictive value for survival of rNPC patients than the 8th (UICC/AJCC) rT staging.

Angiogenesis in nasopharyngeal carcinoma: insights, imaging, and therapeutic strategies

Nasopharyngeal carcinoma (NPC) is a highly prevalent head and neck malignancy in southern China frequently diagnosed at advanced stages owing to subtle early symptoms and associated metastasis. Angiogenesis emerges as a pivotal factor in NPC progression, with numerous angiogenesis-related factors showing aberrant expression and contributing to increased neovascularization within NPC tumors. These abnormal vessels not only nourish tumor growth but also facilitate metastasis, culminating in unfavorable patient outcomes. Multiple studies have demonstrated the applicability of various imaging techniques for assessing angiogenesis in NPC tumors, thus serving as a foundation for personalized treatment strategies and prognostic assessments. Anti-angiogenic therapies have exhibited significant potential for inhibiting NPC angiogenesis and exerting anti-tumor effects. To enhance efficacy, anti-angiogenic drugs are frequently combined with other treatment modalities to synergistically enhance anti-tumor effects while mitigating the side effects associated with single-agent therapies, consequently improving patient prognosis. Identifying the potential mechanisms and key targets underlying NPC angiogenesis and exploring more effective detection and treatment approaches holds promise for shaping the future of NPC diagnosis, treatment, and prognosis, thereby offering new avenues and perspectives for research and clinical practice.

Toripalimab plus chemotherapy in American patients with recurrent or metastatic nasopharyngeal carcinoma: A cost-effectiveness analysis

BACKGROUND

Toripalimab, combined with gemcitabine and cisplatin, has been approved as the first-line treatment for recurrent or metastatic nasopharyngeal carcinoma (RM-NPC), representing a significant milestone as the first FDA-approved innovative therapy for this condition. Despite this achievement, there's a lack of data on the cost-effectiveness of toripalimab for RM-NPC patients in the American context.

METHODS

To assess the cost-effectiveness of toripalimab plus chemotherapy versus chemotherapy alone, a 3-state partitioned survival model was constructed. The study involved participants with characteristics matching those in the JUPITER-02 trial. Cost and utility inputs were collected from literature. Main outcomes measured were quality-adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER). Univariate and probabilistic sensitivity analyses, subgroup analyses, and scenario analyses were conducted to verify the robustness of results.

RESULTS

The study found that the toripalimab regimen resulted in 4.390 QALYs at a cost of $361,813, while the chemotherapy-only regimen yielded 1.685 QALYs at a cost of $161,632. This translates to an ICER of $74,004/QALY, below the willingness-to-pay threshold of $150,000/QALY. Sensitivity analyses indicated that utility values, discount rate, and the price of toripalimab significantly impact INMB. With an 87.10% probability of being cost-effective at a $150,000/QALY threshold, the probabilistic sensitivity analysis supports toripalimab plus chemotherapy as a viable option. Scenario analysis showed that toripalimab remains cost-effective unless its price increases by 125%. Additionally, a simulated 15-year study period increases the ICER to $88,026/QALY. Subgroup analysis revealed ICERs of $76,538/QALY for PD-L1 positive and $70,158/QALY for PD-L1 negative groups.

CONCLUSIONS

Toripalimab in combination with chemotherapy is likely to be a cost-effective alternative to standard chemotherapy for American patients with RM-NPC. This evidence can guide clinical and reimbursement decision-making in treating RM-NPC patients.

Prognostic value of pre-treatment [18F] FDG PET/CT in recurrent nasopharyngeal carcinoma without distant metastasis

BACKGROUND

[18 F]-Fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) has the ability to detect local and/or regional recurrence as well as distant metastasis. We aimed to evaluate the prognosis value of PET/CT in locoregional recurrent nasopharyngeal (lrNPC).

METHODS

A total of 451 eligible patients diagnosed with recurrent I-IVA (rI-IVA) NPC between April 2009 and December 2015 were retrospectively included in this study. The differences in overall survival (OS) of lrNPC patients with and without PET/CT were compared in the I-II, III-IVA, r0-II, and rIII-IVA cohorts, which were grouped by initial staging and recurrent staging (according to MRI).

RESULTS

In the III-IVA and rIII-IVA NPC patients, with PET/CT exhibited significantly higher OS rates in the univariate analysis (P = 0.045; P = 0.009; respectively). Multivariate analysis revealed that with PET/CT was an independent predictor of OS in the rIII-IVA cohort (hazard ratio [HR] = 0.476; 95% confidence interval [CI]: 0.267 to 0.847; P = 0.012). In the rIII-IVA NPC, patients receiving PET/CT sacns before salvage surgery had a better prognosis compared with MRI alone (P = 0.036). The recurrent stage (based on PET/CT) was an independent predictor of OS. (r0-II versus [vs]. rIII-IVA; HR = 0.376; 95% CI: 0.150 to 0.938; P = 0.036).

CONCLUSION

The present study showed that with PET/CT could improve overall survival for rIII-IVA NPC patients. PET/CT appears to be an effective method for assessing rTNM staging.

Induction Chemotherapy Followed by Radiotherapy vs Chemoradiotherapy in Nasopharyngeal Carcinoma: A Randomized Clinical Trial

Importance

Induction chemotherapy plus concurrent chemoradiotherapy is recommended for locoregionally advanced nasopharyngeal carcinoma but is associated with higher rates of acute toxic effects and low compliance. Evidence on de-escalating treatment intensity after induction chemotherapy is limited.

Objective

To assess if radiotherapy was noninferior to chemoradiotherapy after induction chemotherapy for locoregionally advanced nasopharyngeal carcinoma.

Design, Setting, and Participants

From April 2015 to March 2018, a multicenter, open-label, randomized, noninferiority, phase 3 trial was conducted at 5 Chinese hospitals. A total of 383 patients aged 18 to 70 years with an untreated histologically confirmed nonkeratinizing tumor, Karnofsky performance status score not worse than 70, proper organ function, and stage III to IVB nasopharyngeal cancer were enrolled. Data were analyzed from April 2023 to June 2023.

Interventions

Patients were assigned randomly. Both groups received 3 cycles of induction chemotherapy consisting of intravenous administration (on day 1) of cisplatin at 60 mg/m2 and docetaxel at 60 mg/m2 and continuous intravenous infusion (from day 1 to day 5) of daily fluorouracil (600 mg/m2), repeated every 21 days. Subsequently, the patients received radiotherapy alone (induction chemotherapy in combination with radiotherapy [IC-RT] group) or concomitant cisplatin (30 mg/m2/week) with radiotherapy for 6 to 7 weeks (induction chemotherapy combined with chemoradiotherapy [IC-CCRT] group).

Main Outcomes and Measures

The primary end point was 3-year progression-free survival (time from the initiation of therapy until the first indication of disease progression or death), with a noninferiority margin of 10%. The secondary end points included overall survival, locoregional failure-free survival, distant metastasis-free survival, response rate, and toxic effects.

Results

A total of 383 patients (median [range] age, 48 [19-70] years; 100 women [26%]). Median follow-up time was 76 months (IQR, 70-89 months). The 3-year progression-free survival was 76.2% and 76.8% in the IC-RT (n = 193) and IC-CCRT groups (n = 190), respectively, in the intention-to-treat population, showing a difference of 0.6% (95% CI, -7.9% to 9.1%; P = .01 for noninferiority). Identical outcomes were reported in the per-protocol population. The incidence of grade 3 to 4 short-term toxic effects in the IC-RT group was less than the IC-CCRT group. No differences were observed in late toxic effects.

Conclusions and Relevance

The results of this randomized clinical trial suggest that after induction chemotherapy for locoregionally advanced nasopharyngeal carcinoma, radiotherapy alone was noninferior to chemoradiotherapy in terms of 3-year progression-free survival.

Trial Registration

ClinicalTrials.gov Identifier: NCT02434614.

Clinical characteristics and prognostic factors in nasopharyngeal carcinoma with brain metastasis: A retrospective, single-center study

BACKGROUND

Brain metastasis is rare in nasopharyngeal carcinoma (NPC), with only anecdotal cases reported. Conducting a systematic study is crucial for improving the management of these patients.

MATERIALS AND METHODS

Forty-one patients with brain metastasis were retrospectively included between February 2000 and February 2023. The clinical characteristics and treatment information of patients were analyzed. Overall survival (OS) was estimated by Kaplan-Meier survival analysis, and Cox proportional hazard regression analysis was performed to explore prognostic factors.

RESULTS

The median OS for patients was 11.2 months, with a 3-year OS rate of 16.3%. The number of extracranial metastatic organs (HR = 5.533, P = 0.041) and the response of extracranial tumors to treatment (HR = 0.079, P = 0.003) were independent prognostic factors in the cohort.

CONCLUSIONS

Brain metastasis in NPC is a devastating condition that commonly occurs through hematogenous dissemination. Systemic therapy remains fundamental treatment, while local therapy for brain metastases may further improve survival in selected patients.

Long-term survival, toxicities, and the role of chrono-chemotherapy with different infusion rates in locally advanced nasopharyngeal carcinoma patients treated with intensity-modulated radiation therapy: a retrospective study with a 5-year follow-up

Purpose

This study aimed to evaluate 5-year outcomes and the late toxicity profile of chrono-chemotherapy with different infusion rates in patients with locally advanced nasopharyngeal carcinoma (NPC).

Methods and materials

Our retrospective analysis included 70 patients with locally advanced NPC stages III and IVB (according to the 2010 American Joint Committee on Cancer staging system). Patients were treated with two cycles of induction chemotherapy (IC) before concurrent chemoradiotherapy (CCRT) at Guizhou Cancer Hospital. The IC with docetaxel, cisplatin (DDP) and fluorouracil regimen. Patients were divided into two groups during CCRT. Using a "MELODIE" multi-channel programmed pump, DDP (100 mg/m2) was administered for 12 hours from 10:00 am to 10:00 pm and repeated every 3 weeks for 2-3 cycles. DDP was administered at the peak period of 4:00 pm in the sinusoidal chrono-modulated infusion group (Arm A, n=35). The patients in Arm B received a constant rate of infusion. Both arms received radiotherapy through the same technique and dose fraction. The long-term survival and disease progression were observed.

Results

After a median follow-up of 82.8 months, the 5-year progression-free survival rate was 81.3% in Arm A and 79.6% in Arm B (P = 0.85). The 5-year overall survival rate was not significantly different between Arm A and Arm B (79.6% vs 85.3%, P = 0.79). The 5-year distant metastasis-free survival rate was 83.6% in Arm A and 84.6% in Arm B (P = 0.75). The 5-year local recurrence-free survival rate was 88.2% in Arm A and 85.3% in Arm B (P = 0.16). There were no late toxicities of grade 3-4 in either group. Both groups had grade 1-2 late toxicities. Dry mouth was the most common late toxic side effect, followed by hearing loss and difficulty in swallowing. There was no statistically significant difference between Arm A and Arm B in terms of side effects.

Conclusion

Long-term analysis confirmed that in CCRT, cisplatin administration with sinusoidal chrono-modulated infusion was not superior to the constant infusion rate in terms of long-term toxicity and prognosis.

A multivariable normal tissue complication probability model for predicting radiation-induced hypothyroidism in nasopharyngeal carcinoma patients in the modern radiotherapy era

Radiation-induced hypothyroidism (RHT) is a common long-term complication for nasopharyngeal carcinoma (NPC) survivors. A model using clinical and dosimetric factors for predicting risk of RHT could suggest a proper dose-volume parameters for the treatment planning in an individual level. We aim to develop a multivariable normal tissue complication probability (NTCP) model for RHT in NPC patients after intensity-modulated radiotherapy or volumetric modulated arc therapy. The model was developed using retrospective clinical data and dose-volume data of the thyroid and pituitary gland based on a standard backward stepwise multivariable logistic regression analysis and was then internally validated using 10-fold cross-validation. The final NTCP model consisted of age, pretreatment thyroid-stimulating hormone and mean thyroid dose. The model performance was good with an area under the receiver operating characteristic curve of 0.749 on an internal (200 patients) and 0.812 on an external (25 patients) validation. The mean thyroid dose at ≤45 Gy was suggested for treatment plan, owing to an RHT incidence of 2% versus 61% in the >45 Gy group.

Clinical and dosimetric predictors of radiation-induced rhinosinusitis following VMAT for nasopharyngeal carcinoma: A retrospective study

Background

We aimed to investigate the clinical and dosimetric factors associated with radiation-induced rhinosinusitis, and further elucidate the optimal dose-volume constraints for nasopharyngeal cancer patients who underwent volumetric-modulated arc therapy (VMAT).

Methods

A retrospective review of 196 nasopharyngeal carcinoma (NPC) patients who underwent definitive VMAT between August 2018 and May 2021 was conducted. Both clinical and dose-volume histogram (DVH) data of NPC patients without rhinosinusitis at baseline were selected for analysis.

Results

The cumulative incidence of post-RT rhinosinusitis at the 3-, 6-, 9-, and 12-months, and >1 year were 29.6 %, 41.3 %, 42.9 %, and 45.4 %, and 47.4 %, respectively. Nasal irrigation was negatively associated with post-RT rhinosinusitis (p < 0.001). Higher cumulative incidences of maxillary and ethmoid sinusitis were associated with V70 > 1.16 % and >1.00 %, respectively (p = 0.027 and p = 0.002). Sphenoid sinusitis was more frequent when Dmax(maxillary sinus) exceeded 69.2Gy (p = 0.005).

Conclusions

Regular nasal irrigation may reduce the development of rhinosinusitis. Dose-volume constraints of V70 and Dmax to the maxillary sinus are suggested for VMAT planning. Patients exceeding these thresholds should be closely monitored and potentially offered preventative interventions within 3-6 months post-RT.

A deep learning-based semiautomated workflow for triaging follow-up MR scans in treated nasopharyngeal carcinoma

It is imperative to optimally utilize virtues and obviate defects of fully automated analysis and expert knowledge in new paradigms of healthcare. We present a deep learning-based semiautomated workflow (RAINMAN) with 12,809 follow-up scans among 2,172 patients with treated nasopharyngeal carcinoma from three centers (ChiCTR.org.cn, Chi-CTR2200056595). A boost of diagnostic performance and reduced workload was observed in RAINMAN compared with the original manual interpretations (internal vs. external: sensitivity, 2.5% [p = 0.500] vs. 3.2% [p = 0.031]; specificity, 2.9% [p < 0.001] vs. 0.3% [p = 0.302]; workload reduction, 79.3% vs. 76.2%). The workflow also yielded a triaging performance of 83.6%, with increases of 1.5% in sensitivity (p = 1.000) and 0.6%-1.3% (all p < 0.05) in specificity compared to three radiologists in the reader study. The semiautomated workflow shows its unique superiority in reducing radiologist's workload by eliminating negative scans while retaining the diagnostic performance of radiologists.

Clinical course of longer than five years after definitive radiotherapy for nasopharyngeal carcinoma

BACKGROUND

This study aimed to reveal the long-term outcomes and late toxicities (> 5 years) after definitive intensity-modulated radiation therapy (IMRT) in patients with nasopharyngeal carcinoma (NPC).

METHODS

Data from 43 patients (median age, 55 years; range, 17-72 years) with NPC who underwent definitive IMRT between 2001 and 2018 were analyzed. All patients were alive and disease-free 5 years after IMRT. A total dose of 70 (range, 66-70) Gy was delivered in 35 (33-35) fractions with concurrent cisplatin chemotherapy.

RESULTS

The median follow-up duration was 119 (range, 61.5-242.1) months. Three patients developed locoregional failure at 79, 92, and 149 months after IMRT, respectively. Of these, 2 patients died of disease progression at 136 and 153 months after IMRT. One patient died of aspiration pneumonia 141 months after IMRT, despite salvage of the recurrent tumor by re-irradiation. In addition, one patient died of aspiration pneumonia 62 months after the IMRT. Thus, the 10-year overall survival, progression-free survival, and locoregional control rates were 98%, 92%, and 94%, respectively. Grade ≥ 2 and ≥ 3 late toxicities were observed in 28 (65%) and 9 (21%) patients, respectively. Nine second primary cancers, including five tongue cancers and two external auditory canal carcinomas, were observed in seven (16%) patients.

CONCLUSION

Late recurrences, severe late toxicities, and second primary cancers were observed > 5 years after IMRT. A long-term follow-up of > 5 years is needed in patients with NPC.

Prognostic nutritional index and serum lactate dehydrogenase predict the prognosis of nasopharyngeal carcinoma patients who received intensity-modulated radiation therapy

PURPOSE

This research aimed to evaluate the prognostic significance of baseline prognostic nutritional index (PNI) and lactate dehydrogenase (LDH) for the outcome of individuals diagnosed with non-metastatic nasopharyngeal carcinoma (NPC).

METHODS

A retrospective analysis was conducted on data from 810 patients with non-metastatic NPC who underwent intensity-modulated radiation therapy (IMRT) with or without chemotherapy. The best cut-offs for PNI and LDH were identified by X-tile software to be 48.5 and 150, respectively. To find the independent prognostic factors for survival outcomes, univariate and multivariate regression analyses were conducted, and AUCs were used to compare their prognostic values.

RESULTS

Multivariate analysis revealed that patients with PNI > 48.5 had better overall survival (OS) (HR: 0.502, P < 0.001), progression-free survival (PFS) (HR: 0.618, P < 0.001), and distant metastasis-free survival (DMFS) (HR: 0.637, P = 0.005). Higher LDH was associated with poorer OS (HR: 1.798, P < 0.001), PFS (HR: 1.671, P < 0.001), and DMFS (HR: 1.756, P < 0.001). The combination of low PNI and high LDH in non-metastatic NPC patients was correlated with poor OS (P < 0.001), PFS (P < 0.001), and DMFS (P < 0.001). The combination of PNI and LDH had the highest AUCs for predicting OS, PFS, and DMFS.

CONCLUSIONS

PNI and LDH might become valuable predictors of the prognosis of non-metastatic NPC patients undergoing IMRT with or without chemotherapy. Prognostic accuracy can be enhanced by combining PNI and LDH.

A Novel Prognostic Model Predicts Outcomes in Non-Metastatic Nasopharyngeal Carcinoma Based on Inflammation, Nutrition, and Coagulation Signature

Purpose

This study aimed to assess the prognostic and predictive value of a circulating hematological signature (CHS) and to develop a CHS-based nomogram for predicting prognosis and guiding individualized chemotherapy in non-metastatic nasopharyngeal carcinoma (NPC) patients.

Patients and Methods

NPC patients were recruited between January 2014 and December 2017 at the Jiangxi Cancer Hospital. The CHS was constructed based on a series of hematological indicators. The nomogram was developed by CHS and clinical factors.

Results

A total of 779 patients were included. Three biomarkers were selected by least absolute shrinkage and selection operator regression, including prognostic nutritional index, albumin-to-fibrinogen ratio, and prealbumin-to-fibrinogen ratio, were used to construct the CHS. The patients in the low-CHS group had better 5-year DMFS and OS than those in the high-CHS group in the training (DMFS: 85.0% vs 56.6%, p<0.001; OS: 90.3% vs 65.4%, p<0.001) and validation cohorts (DMFS: 92.3% vs 43.6%, p<0.001; OS: 92.1% vs 65.5%, p<0.001). The nomogram_CHS showed better performance than clinical stage in predicting distant metastasis (concordance index: 0.728 vs 0.646). In the low-TRS (total risk scores) group, the patients received RT alone, CCRT and IC plus CCRT had similar 5-year DMFS and OS (p>0.05). In the middle-TRS group, the patients received RT alone had worse 5-year DMFS (58.7% vs 80.8% vs 90.8%, p=0.002) and OS (75.0% vs 94.1% vs 95.0%, p=0.001) than those received CCRT or IC plus CCRT. In the high-TRS group, the patients received RT alone and CCRT had worse 5-year DMFS (18.6% vs 31.3% vs 81.5%, p<0.001) and OS (26.9% vs 53.2% vs 88.8%, p<0.001) than those received IC plus CCRT.

Conclusion

The developed nomogram_CHS had satisfactory prognostic accuracy in NPC patients and may individualize risk estimation to facilitate the identification of suitable IC candidates.

The m6A reader IGF2BP3 preserves NOTCH3 mRNA stability to sustain Notch3 signaling and promote tumor metastasis in nasopharyngeal carcinoma

Metastasis remains the major cause of treatment failure in patients with nasopharyngeal carcinoma (NPC), in which sustained activation of the Notch signaling plays a critical role. N6-Methyladenosine (m6A)-mediated post-transcriptional regulation is involved in fine-tuning the Notch signaling output; however, the post-transcriptional mechanisms underlying NPC metastasis remain poorly understood. In the present study, we report that insulin-like growth factor 2 mRNA-binding proteins 3 (IGF2BP3) serves as a key m6A reader in NPC. IGF2BP3 expression was significantly upregulated in metastatic NPC and correlated with poor prognosis in patients with NPC. IGF2BP3 overexpression promoted, while IGF2BP3 downregulation inhibited tumor metastasis and the stemness phenotype of NPC cells in vitro and in vivo. Mechanistically, IGF2BP3 maintains NOTCH3 mRNA stability via suppression of CCR4-NOT complex-mediated deadenylation in an m6A-dependent manner, which sustains Notch3 signaling activation and increases the transcription of stemness-associated downstream genes, eventually promoting tumor metastasis. Our findings highlight the pro-metastatic function of the IGF2BP3/Notch3 axis and revealed the precise role of IGF2BP3 in post-transcriptional regulation of NOTCH3, suggesting IGF2BP3 as a novel prognostic biomarker and potential therapeutic target in NPC metastasis.

Deep learning-based recurrence detector on magnetic resonance scans in nasopharyngeal carcinoma: A multicenter study

OBJECTIVES

Accuracy in the detection of recurrent nasopharyngeal carcinoma (NPC) on follow-up magnetic resonance (MR) scans needs to be improved.

MATERIAL AND METHODS

A total of 5 035 follow-up MR scans from 5 035 survivors with treated NPC between April 2007 and July 2020 were retrospectively collected from three cancer centers for developing and evaluating the deep learning (DL) model MODERN (MR-based Deep learning model for dEtecting Recurrent Nasopharyngeal carcinoma). In a reader study with 220 scans, the accuracy of two radiologists in detecting recurrence on scans with vs without MODERN was evaluated. The performance was measured using the area under the receiver operating characteristic curve (ROC-AUC) and accuracy with a 95% confidence interval (CI).

RESULTS

MODERN exhibited sound performance in the validation cohort (internal: ROC-AUC, 0.88, 95% CI, 0.86-0.90; external 1: ROC-AUC, 0.88, 95% CI, 0.86-0.90; external 2: ROC-AUC, 0.85, 95% CI, 0.82-0.88). In a reader study, MODERN alone achieved reliable accuracy compared to that of radiologists (MODERN: 84.1%, 95% CI, 79.3%-88.9%; competent: 80.9%, 95% CI, 75.7%-86.1%, P < 0.001; expert: 85.9%, 95% CI, 81.3%-90.5%, P < 0.001). The accuracy of radiologists was boosted by the MODERN score (competent with MODERN score: 84.6%, 95% CI, 79.8%-89.3%, P < 0.001; expert with MODERN score: 87.7%, 95% CI, 83.4%-92.1%, P < 0.001).

CONCLUSION

We developed a DL model for recurrence detection with reliable performance. Computer-human collaboration has the potential to refine the workflow in interpreting surveillant MR scans among patients with treated NPC.

Distribution of regional lymph lode metastasis in unilateral nasopharyngeal carcinoma and the suggestions for selective prophylactic irradiation with intensity-modulated radiotherapy

PURPOSE

To address the regional lymph node (RLN) distribution and the long-term efficacy in unilateral nasopharyngeal carcinoma (NPC), providing elective irradiation for RLN with intensity-modulated radiotherapy (IMRT).

METHODS

The involvement of clinical data of 136 patients with unilateral NPC, who underwent IMRT from November 2003 to December 2020 were analyzed retrospectively. The therapeutic effect and failure pattern of RLN metastasis were evaluated.

RESULTS

Of 57.1% patients have bilateral RLN metastasis. The rate of contralateral RLNs metastasis is lower than that of ipsilateral RLNs. Contralateral RLN metastasis mainly occurs in level VIIa (39.0%) and II (38.2%). While level IVa is only 0.7%, and none of RLN metastasis was found in level IVb and Va. The median follow-up was 70 months, and the 3-, 5-and 10-year regional recurrence-free survival (RRFS) were 94.1%, 93.1%, and 93.1%, respectively.

CONCLUSION

Routine prophylactic irradiation may not include contralateral lower neck LN and level Va for N0-1 unilateral NPC.

Induction chemotherapy plus re-irradiation versus re-irradiation alone in locally recurrent nasopharyngeal carcinoma: A model-based analysis

OBJECTIVE

To investigate the role of additional induction chemotherapy (IC) prior to re-irradiation in locally recurrent nasopharyngeal carcinoma (lrNPC).

METHODS

A total of 480 patients from three cancer treatment centers who received re-irradiation between 2012 and 2020 were retrospectively analyzed. Overall survival (OS) was determined using the Kaplan-Meier method and compared with log-rank method. Inverse probability of treatment weighting (IPTW) was performed to match the patients in pairwise treatment groups. Multivariate analysis using the Cox proportional hazards regression method identified predictors of OS. The risk stratification model was defined by the risk score calculated with the sum of coefficients.

RESULTS

In the entire cohort, the addition of IC was associated with similar OS compared with radiotherapy alone (P = 0.58) or with concomitant chemoradiation (P = 0.76). A risk stratification model was constructed and validated based on significant prognostic factors (coefficient) including male (0.6), age ≥ 60 years (0.9), volume of recurrence gross tumor volume ≥ 16 cc (0.7), and lactate dehydrogenase (LDH)-ratio ≥ 0.5 (0.4). In the intermediate-risk group (sum of coefficient: 0.9---1.6), patients with IC plus re-irradiation had a significantly better OS than those who received re-irradiation (P = 0.03). After adjustments for several potentially confounding variables with IPTW, survival benefit of IC was also observed (P = 0.031). However, no significant difference in OS for the additional IC prior to re-irradiation was demonstrated in the low- (sum of coefficient: <0.9) and high-risk group (sum of coefficient: > 1.6).

CONCLUSION

Additional IC prior to re-irradiation was associated with improved OS in the intermediate-risk group of lrNPC, whereas there was no difference for the low-risk and high-risk group. Prospective validation is required to validate these findings.

Weekly versus triweekly cisplatin treatment in patients with locally advanced nasopharyngeal cancer during concurrent chemoradiotherapy

BACKGROUND

For patients with locally advanced nasopharyngeal cancer (LA-NPC), concurrent chemoradiotherapy (CCRT) is the standardized treatment. However, whether a weekly or triweekly cisplatin regimen should be used during CCRT is controversial. Therefore, we conducted this meta-analysis to explore differences in the effects and toxicities of the two regimens.

METHODS

We searched PubMed, Embase, and the Cochrane Library (until June 10, 2022). We evaluated overall survival (OS), distant metastasis-free survival (DMFS), locoregional recurrence-free survival (LRFS), disease-free survival (DFS) and grade ≥ 3 adverse events. The effect indices were hazard ratios (HRs) and odds ratios (ORs), and Review Manager software 5.4 (RevMan 5.4) was used for computations.

RESULTS

We identified 7 studies in our analysis. There was no significant difference in OS (HR = 1.00, 95% CI 0.73-1.38, P = 0.99), DMFS (HR = 0.84, 95% CI 0.58-1.22, P = 0.36), LRFS (HR = 0.91, 95% CI 0.63-1.32, P = 0.62) or DFS (HR = 0.93, 95% CI 0.56-1.56; P = 0.78) between the weekly and triweekly cisplatin regimens. We found that the weekly cisplatin regimen was more likely to cause grade ≥ 3 hematological toxicity events than the triweekly cisplatin regimen. In addition, subgroup analyses revealed that patients undergoing CCRT and CCRT plus adjuvant chemotherapy (AC) had similar OS or DFS.

CONCLUSION

Weekly and triweekly cisplatin regimens had similar efficacy for LA-NPC. The triweekly regimen may replace the weekly regimen for LA-NPC because of lower toxicity. Larger data accumulation and more multicenter clinical trials may be needed to verify these results.

Concurrent chemoradiotherapy with or without neoadjuvant chemotherapy in pediatric patients with stage III-IVa nasopharyngeal carcinoma: a real-world propensity score-matched cohort study

OBJECTIVES

To compare neoadjuvant chemotherapy (NAC) plus concurrent chemoradiotherapy (CCRT) to CCRT alone in children and adolescents (age ≤ 18 years) with locoregionally advanced nasopharyngeal carcinoma (CA-LANPC, stage III-IVA).

MATERIALS AND METHODS

195 CA-LANPC patients who were treated through CCRT with or without NAC between 2008 and 2018 were enrolled in this study. A matched cohort composed of CCRT patients and NAC-CCRT patients was generated by propensity score matching (PSM) at a 1:2 ratio. Survival outcomes and toxicities were compared between the CCRT group and NAC-CCRT group.

RESULTS

Of the 195 patients, 158 (81%) received NAC plus CCRT, and 37 (19%) received CCRT alone. The NAC-CCRT group had higher EBV DNA levels (≥ 4000 copy/mL), more advanced TNM stage (stage IV disease), and lower incidence of a high radiation dose (> 6600 cGy) than the CCRT group. To avoid bias in treatment selection within retrospectively analysis, 34 patients from the CCRT group were matched with 68 patients from the NAC-CCRT group. In the matched cohort, the 5-year DMFS rate was 94.0% in the NAC-CCRT group versus 82.4% in the CCRT group, with marginal statistical significance (HR = 0.31; 95%CI 0.09-1.10; P = 0.055). During treatment, the accumulate incidence of severe acute toxicities (65.8% vs 45.9%; P = 0.037) in the NAC-CCRT group was higher than the CCRT group. However, the CCRT group had significantly higher accumulate incidence of severe late toxicities (30.3% vs 16.8%; P = 0.041) than the NAC-CCRT group.

CONCLUSIONS

Addition of NAC to CCRT tended to improve long-term DMFS in CA-LANPC patients with acceptable toxicity. However, relative randomized clinical trial is still needed in the future.

LINC01376 promotes nasopharyngeal carcinoma tumorigenesis by competitively binding to the SP1/miR-4757/IGF1 axis

The long non-coding RNA (lncRNA)-microRNA (miRNA) interaction network plays a crucial part in the pathogenesis of nasopharyngeal carcinoma (NPC). Here, we discovered a relationship between LINC01376 and miR-4757 in NPC tumor development. First, LINC01376 was abnormally overexpressed in NPC tissues and cells, and its elevated expression was associated with advanced clinical stage and shorter distant metastasis-free survival time. Moreover, biological experiments showed that LINC01376 facilitated the proliferative, invasive, and migratory abilities of NPC cells in vitro and in vivo. Mechanistically, bioinformatics and RT-qPCR assays revealed that LINC01376 knockdown upregulated the expression level of downstream miR-4757, including miR-4757 primary transcript (pri-miR-4757) and mature miR-4757. Furthermore, LINC01376 competitively sponged the transcription factor SP1 and reduced its enrichment in the upstream promoter region of miR-4757 to repress miR-4757 expression. Finally, insulin-like growth factor 1(IGF1) was identified as the target of miR-4757. Rescue experiments indicated that LINC01376 accelerated NPC cell proliferation, migration, and invasion through the miR-4757-5p/IGF1 axis. In conclusion, the SP1/miR-4757/IGF1 axis, which is regulated by LINC01376 in NPC deterioration and metastasis, is expected to provide new insights into the molecular mechanism of NPC carcinogenesis.

Epstein-Barr virus microRNA miR-BART2-5p accelerates nasopharyngeal carcinoma metastasis by suppressing RNase Ⅲ endonuclease DICER1

The development and progression of nasopharyngeal carcinoma (NPC) is closely associated with Epstein-Barr virus (EBV) infection. NPC is usually asymptomatic until it spreads to other sites, and more than 70% of cases are classified as locally advanced disease at diagnosis. EBV-positive nasopharyngeal cancer tissues express only limited viral latent proteins, but express high levels of the EBV-encoded BamHI-A rightward transcript (BART) miRNA molecules. Here, we report that EBV-miRNA-BART2-5p (BART2-5p) promotes NPC cell invasion and metastasis in vivo and in vitro but has no effect on NPC cell proliferation and apoptosis. In addition, BART2-5p altered the mRNA and miRNA expression profiles of NPC cells. The development of human tumors has been reported to be associated with altered miRNAs expression, and overall miRNAs expression is reduced in many types of tumors. We found that BART2-5p downregulated the expression of several miRNAs that could exert oncogenic functions. Mechanistically, BART2-5p directly targets the RNase III endonuclease DICER1, inhibiting its function of cleaving double-stranded stem-loop RNA into short double-stranded RNA, which in turn causes altered expression of a series of key epithelial-mesenchymal transition molecules, and reverting DICER1 expression can rescue this phenotype. Furthermore, analysis from clinical samples showed a negative correlation between BART2-5p and DICER1 expression. According to our study, high expression of BART2-5p in tissues and plasma of patients with NPC is associated with poor prognosis. Our results suggest that, BART2-5p can accelerate NPC metastasis through modulating miRNA profiles which are mediated by DICER1, implying a novel role of EBV miRNAs in the pathogenesis of NPC.

Thyroid V40 is a good predictor for subclinical hypothyroidism in patients with nasopharyngeal carcinoma after intensity modulated radiation therapy: a randomized clinical trial

BACKGROUND

Hypothyroidism (HT) and subclinical HT after radiotherapy is frequent in nasopharyngeal carcinoma (NPC) patients, results in negative impact on patients' quality of life. The percentage of thyroid volume receiving more than 40 Gy (V40) ≤ 85% was reported to be a useful dose constraint to adopt during intensity-modulated radiation therapy (IMRT) planning. This study aims to verify whether V40 ≤ 85% can be used as an effective dose constraint in IMRT planning in a randomized clinical trial.

METHODS

This single-center 1:1 randomized clinical trial was conducted in Fujian province hospital between March 2018 and September 2022. All patients were treated with IMRT and randomized to induction chemo followed by concurrent chemo-IMRT or concurrent chemo-IMRT alone. Ninety-two clinically NPC patients were included in this study. The thyroid function tests were performed for all patients before and after radiation at regular intervals. Thyroid dose-constraint was defined as V40 ≤ 85%. The primary outcome in this study was subclinical HT.

RESULTS

Median follow up was 34 months. Significant difference in the incidence of subclinical HT between the thyroid dose-constraint group and unrestricted group was observed (P = 0.023). The risk of subclinical HT in the thyroid dose-constraint group was lower than that in the unrestricted group (P = 0.022). Univariate and multivariate cox regression analysis indicated that thyroid dose-constraint was a protective effect of subclinical HT (HR = 0.408, 95% CI 0.184-0.904; HRadjusted = 0.361, 95% CI 0.155-0.841).

CONCLUSION

V40 ≤ 85% can be used as an effective dose constraint in IMRT planning to prevent radiation-induced subclinical HT.

Development of Prognostic Nomogram Based on Lipid Metabolic Markers and Lactate Dehydrogenase in Non-Metastatic Nasopharyngeal Carcinoma

Purpose

To establish and verify a comprehensive prognostic nomogram for predicting survival outcomes and improving the prognosis for non-metastatic nasopharyngeal carcinoma (NPC).

Patients and Methods

Our retrospective study screened 613 cases of non-metastatic NPC who received radiotherapy from July 2012 to December 2016. A reliable nomogram was formulated for predicting overall survival (OS) and progression-free survival (PFS) using all independent predictors selected by Cox regression analysis. A comparison is conducted between the current staging and the predictive performance of the nomogram. Internal validation was performed in a single center using the validation cohort to assess predictive accuracy and discrimination.

Results

High-density lipoprotein cholesterol, Epstein-Barr virus DNA and lactate dehydrogenase were determined to be valuable predictive indicators for predicting OS and PFS. Triglycerides were a valuable predictive indicator for predicting OS. Calibration curves demonstrated that the nomogram had remarkable correspondence between the prediction outcomes and the actual observations. Receiver operating characteristic curves showed that the nomogram had greater area under the curve and more satisfactory discrimination capability than the current TNM staging. Decision curve analysis revealed that the nomogram had high net clinical benefits. Significant differences were observed when low- and high-risk groups were stratified via Kaplan-Meier curves.

Conclusion

Our proposed nomogram combining lipid metabolic markers and lactate dehydrogenase could assist clinicians in the accurate prognostic prediction of non-metastatic NPC patients and provide personalized treatment recommendations.

Robotic stereotactic body radiotherapy for recurrent nasopharyngeal carcinoma

Background

We aimed to evaluate the outcomes of patients reirradiated with stereotactic body radiotherapy for recurrent nasopharyngeal carcinoma (r-NPC) in our hospital.

Methods

We retrospectively analyzed 10 patients with r-NPC previously irradiated with definitive radiotherapy. Local recurrences were irradiated with a dose of 25 to 50 Gy (median: 26.25 Gy) in 3 to 5 fractions (fr) (median: 5 fr). The survival outcomes calculated from the time of recurrence diagnosis were obtained using Kaplan-Meier analysis and compared with the log-rank test. Toxicities were assessed by using Common Terminology Criteria for Adverse Events Version 5.0.

Results

The median age was 55 years (37-79 years), and nine patients were men. The median follow-up was 26 months (3-65 months) after reirradiation. The median overall survival (OS) was 40 months, OS in 1 and 3 years were 80% and 57%, respectively. OS rate of rT4 (n = 5, 50%) was worse compared with rT1, rT2, and rT3 (P = 0.040). In addition, those with less than 24 months of interval between first treatment and recurrence had worse OS (P = 0.017). One patient exhibited Grade 3 toxicity. There is no other Grade ≥3 acute or late toxicities.

Conclusion

In r-NPC, reirradiation is inevitable for patients who are not suitable for radical surgical resection. However, serious complications and side effects prevent dose escalation due to the critical structures previously irradiated. Prospective studies with a large number of patients are required to find the optimal acceptable dose.

Treating radiation‑related nasopharyngeal necrosis with endostar in patient with nasopharyngeal carcinoma: A report of two cases and a literature review

Radiation-related nasopharyngeal necrosis (RRNN) is a rare and often fatal complication in patients with nasopharyngeal carcinoma (NPC). Currently, no standard treatments are recommended for RRNN. The effects of traditional conservative treatments are suboptimal, and surgery for RRNN cannot be performed by inexperienced doctors. In the present study, the use of Endostar in two patients with RRNN was evaluated. Two patients with RRNN were treated at the Department of Oncology, Panyu Central Hospital (Guangzhou, China). Endostar was administrated (15 mg/day from day 1 to day 7, every three weeks) intravenously for four and seven cycles in a male and a female patient, respectively. The effects of Endostar were assessed using magnetic resonance imaging (MRI) and a nasopharyngoscope. The symptoms of RRNN in both patients were relieved after treatment with Endostar. MRI and nasopharyngoscope analysis revealed that necrosis of the nasopharynx was substantially decreased and nasopharyngeal ulcers were healed. Endostar has the potential to be a novel, effective therapy for the treatment of patients with RRNN. However, clinical trials are required to confirm the results of the present study.

Tumor residue in patients with stage II-IVA nasopharyngeal carcinoma who received intensity-modulated radiation therapy: development and validation of a prediction nomogram integrating postradiotherapy plasma Epstein-Barr virus deoxyribonucleic acid, clinical stage, and radiotherapy dose

BACKGROUND

To develop and validate a predictive nomogram for tumor residue 3-6 months after treatment based on postradiotherapy plasma Epstein-Barr virus (EBV) deoxyribonucleic acid (DNA), clinical stage, and radiotherapy (RT) dose in patients with stage II-IVA nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT).

METHODS

In this retrospective study, 1050 eligible patients with stage II-IVA NPC, who completed curative IMRT and underwent pretreatment and postradiotherapy (-7 to +28 days after IMRT) EBV DNA testing, were enrolled from 2012 to 2017. The prognostic value of the residue was explored using Cox regression analysis in patients (n=1050). A nomogram for predicting tumor residues after 3-6 months was developed using logistic regression analyses in the development cohort (n=736) and validated in an internal cohort (n=314).

RESULTS

Tumor residue was an independent inferior prognostic factor for 5-year overall survival, progression-free survival, locoregional recurrence-free survival and distant metastasis-free survival (all P<0.001). A prediction nomogram based on postradiotherapy plasma EBV DNA level (0 vs. 1-499 vs. ≥500 copies/ml), clinical stage (II vs. III vs. IVA), and RT dose (68.00-69.96 vs. 70.00-74.00 Gy) estimated the probability of residue development. The nomogram showed better discrimination (area under the curve (AUC): 0.752) than either the clinical stage (0.659) or postradiotherapy EBV DNA level (0.627) alone in the development and validation cohorts (AUC: 0.728).

CONCLUSIONS

We developed and validated a nomogram model integrating clinical characteristics at the end of IMRT for predicting whether tumor will residue or not after 3-6 months. Thus, high-risk NPC patients who might benefit from immediate additional intervention could be identified by the model, and the probability of residue can be reduced in the future.

Effect of radiotherapy interruption on nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a malignant tumor originating from the epithelial cells of the nasopharynx with a unique geographic distribution, and is particularly prevalent in East and Southeast Asia. Due to its anatomical location, the surgery is difficult to access and the high sensitivity of nasopharyngeal cancer to radiotherapy (RT) makes it the main treatment modality. Radical radiotherapy is the first-line treatment for early-stage nasopharyngeal carcinoma and the cornerstone of multidisciplinary treatment for patients with locally advanced nasopharyngeal carcinoma. Nevertheless, radiotherapy interruption is inevitable as a consequence of unavoidable factors such as public holidays, machine malfunction, patient compliance, and adverse response to treatment, which in turn leads to a reduction in bioactivity and causes sublethal loss of tumor cells to repair. Unirradiated tumor cells are more likely to repopulate at or near their original fastest growth rate during this interval. If no measures are taken after the radiotherapy interruption, such as increasing the dose of radiotherapy and systemic therapy, the tumor is most likely to go uncontrolled and then progress. This review describes the effects of radiotherapy interruption on nasopharyngeal carcinoma, the mechanism of the effect, and explores the measures that can be taken in response to such interruption.

Identifying the prognostic value of MRI-based tumor response and predicting the risk of radio-resistance in re-radiotherapy for locally recurrent nasopharyngeal carcinoma

OBJECTIVE

To investigate the prognostic value of tumor response (TR) for locoregionally recurrent nasopharyngeal carcinoma (lrNPC) patients at the end of re-radiotherapy (re-RT) and develop a risk score model to predict patient's radiosensitivity to re-RT.

MATERIALS AND METHODS

A total of 594 patients with lrNPC from 2010 to 2020 were retrospectively reviewed as the total cohort. Among these, 310 patients with complete first-line treatment data were reviewed as a secondary cohort. Overall survival (OS) was the primary endpoint. Locoregional control (LRC) was the secondary endpoint. Multivariate Cox analysis was performed to investigate the prognostic value of TR at the end of re-RT (rTR). A risk score model for predicting rTR was obtained by logistic regression analysis, and its effectiveness was compared using receiver operating characteristic (ROC) analysis.

RESULTS

Patients with complete response (CR) to rTR had higher 5-year OS and LRC rate than non-CR patients in both the total and secondary cohort. rTR was an independent prognostic factor for OS (P=0.002) and LRC (P=0.008). We developed a risk score model including four significant risk factors (relapse T stage, relapse gross tumor volume, time to recurrence, and initial TR). The area under the curve of the risk score model was 0.73 (95% CI: 0.678 to 0.780), which was significantly higher than that of each variable alone. Patients with the highest risk scores may be insensitive to re-RT and had a residual tumor risk of 89.9% after rRT.

CONCLUSION

rTR was an independent prognostic factor for OS and LRC in lrNPC patients. We developed a risk score model for predicting patients' sensitivity to re-RT to screen for radiosensitive patients. This can serve as a treatment decision-making tool for clinicians.

Nasopharyngeal necrosis contributes to overall survival in nasopharyngeal carcinoma without distant metastasis: a comprehensive nomogram model

OBJECTIVES

This study focused on developing and validating a nomogram to predict the overall survival (OS) of patients with nasopharyngeal carcinoma (NPC) without distant metastasis based on their clinical characteristics, serum biomarkers, and presence of nasopharyngeal (NP) necrosis.

METHODS

This study included 9298 patients with NPC. Patients from January 2009 to December 2014 were randomly categorized into the training cohort and validation cohort A. Validation cohort B, whose data were collected from January 2015 to December 2017, was also included. OS was the primary endpoint of this study. Cox regression analysis was used to detect independent risk variables. Decision curve analysis, calibration curve, time-dependent receiver operating characteristic (ROC) curve, and concordance index (C-index) were used to evaluate the performance of the nomogram model.

RESULTS

A total of 267 patients developed NP necrosis after the first routine radiotherapy. After radiotherapy, patients with NP necrosis had significantly lower OS than other patients in all three cohorts (p < 0.001). Eleven factors, including NP necrosis, were involved in the nomogram, which had favorable discrimination and calibration with a C-index of 0.768 in the training cohort, 0.749 in validation cohort A, and 0.739 in validation cohort B. The nomogram exhibited a significantly larger area under the ROC curve for predicting OS than the TNM stage and Epstein-Barr virus (EBV) DNA (p < 0.001).

CONCLUSION

Compared with the TNM system and EBV DNA, we established a nomogram model with an accurate prognostic prediction for patients with NPC, which might help with patient management in NPC.

KEY POINTS

• This study included 9298 patients with NPC, and 11 factors were involved in the final model. • The nomogram had a significantly higher C-index and area under the ROC curve than the TNM stage and EBV DNA. • We established the first nomogram model for NPC involving the occurrence of NP necrosis, which was valuable for providing individual counseling and clinical assessments.

Can the prognosis of individual patients with nasopharyngeal carcinoma be predicted using a routine blood test at admission?

BACKGROUND AND PURPOSE

We sought to determine the prognostic value of a pre-treatment peripheral blood signature and the peripheral blood signature-based nomogram for patients with non-metastatic nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

We retrospectively collected 21 peripheral blood indicators from patients with NPC between 2004 and 2015. Data were randomly divided into a training and a validation set (ratio: 6:4). The peripheral blood signature was constructed based on candidate biomarkers using the least absolute shrinkage and selection operator Cox regression model. Multivariable logistic regression was applied to identify the independent risk factors of overall survival to build the nomogram. The predictive value of the peripheral blood nomogram was evaluated using time-dependent area under the curve, decision curve analysis, and calibration curve.

RESULTS

In total, 6668 patients were enrolled with 4000 and 2668 in the training and validation cohorts, respectively. Four peripheral blood indicators, (white blood cell count, lymphocyte percentage, haemoglobin, and mean platelet volume), were included to construct the peripheral blood signature. Patients were divided into low- and high-risk groups using an optimal cut-off value of - 1.71142. Patients in the high-risk group had significantly lower overall, distant metastasis-free, and progression-free survival than patients in the low-risk group in both cohorts (P < 0.05). We constructed and validated a peripheral blood signature-based nomogram in combination with five vital clinical characteristics, (age, sex, tumour stage, nodal stage, and pre-treatment Epstein-Barr virus DNA), which showed favourable performance.

CONCLUSION

Patients with NPC with different outcomes could be distinguished based on their peripheral blood signature score; the proposed peripheral blood signature-based nomogram offers individualised risk estimation.

Real-world evidence of cisplatin versus carboplatin in patients with locally advanced nasopharyngeal carcinoma receiving concurrent chemoradiotherapy: A multicenter analysis

BACKGROUND

Though concurrent chemoradiotherapy (CCRT) with cisplatin remains a standard of care for patients with locally advanced nasopharyngeal carcinoma (LA-NPC), carboplatin has alternatively been used without sufficient supportive evidences. Thus, we evaluated an efficacy and tolerability of carboplatin CCRT compared with cisplatin in LA-NPC patients.

METHODS

Patients with LA-NPC treated with CCRT were identified through the Thai multicenter head and neck cancer database. Patient tolerability and survival were analyzed and compared between regimens. Survivals were calculated by using the Kaplan-Meier method, and compared by the log-rank test. A p-value of <0.05 was considered statistically significant.

RESULTS

A total of 135 of 980 patients (13.8%) were treated with carboplatin. Patients treated with carboplatin were significantly associated with older age (p < 0.001), smoking (p = 0.003), more comorbidity (p = 0.014), kidney disease (p = 0.016), and lower baseline creatinine clearance (p < 0.001). Intensity-modulated radiation therapy was used significantly more in the cisplatin group than carboplatin group (p < 0.001). Patients who received carboplatin were associated with delay (p = 0.049) and hospitalization (p = 0.006), whereas cisplatin CCRT had more dose reduction (p = 0.001). Patients treated with cisplatin had CCRT interruption from grade 3-4 mucositis (p = 0.019) more than carboplatin, whereas carboplatin had more grade 3-4 thrombocytopenia (p < 0.001). The 5-year overall survival (OS) of patients treated with cisplatin and carboplatin was 59% and 49%, respectively (p = 0.128). Cisplatin or carboplatin CCRT was not a significant predictor for OS and locoregional recurrence-free survival in multivariate analysis.

CONCLUSIONS

Carboplatin CCRT provided acceptable efficacy and tolerability profiles in real-world practice. Carboplatin should be considered as an alternative regimen, particularly in cisplatin-ineligible patients with LA-NPC treated with CCRT.

Innovative Fudan rT staging in endoscopic surgery for recurrent nasopharyngeal carcinoma

BACKGROUND

American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) rT staging have great clinical impracticality. The aim of the present study was to establish a new rT staging to guide endoscopic surgery for the treatment of recurrent nasopharyngeal carcinoma (rNPC).

METHODS

This surgical rT staging (named Fudan rT staging) was constructed using two significant risk factors: the distance from the tumor margin to the internal carotid artery, and dural invasion. Log-rank and receiver operating characteristic (ROC) curve analyses were used to evaluate its effectiveness.

RESULTS

Fudan rT staging can effectively separate the overall survival (OS) and progression-free survival (PFS) of patients with rNPC according to the different rT stages (p < 0.05). In addition, ROC analysis showed that the Fudan rT staging exhibited enhanced prognostic value for OS and PFS compared with the AJCC/UICC rT staging.

CONCLUSIONS

The innovative Fudan rT staging has a better predictive value for the survival of patients with rNPC than AJCC/UICC rT staging.

Transoral robotic resection of advanced recurrent nasopharyngeal carcinoma involving the internal carotid artery

BACKGROUND

Transoral robotic surgery (TORS) is a reliable, minimally invasive approach for treating recurrent nasopharyngeal carcinoma (rNPC). However, tumours involving the internal carotid artery (ICA) are considered to be unsuitable for TORS. This paper presents the first case of transoral robotic resection of advanced rNPC involving the ICA.

MATERIALS AND METHODS

This case is a 55 year-old male patient who received radiotherapy 27 years ago. This patient underwent a standard TORS resection 2 weeks after ipsilateral ICA embolization.

RESULTS

Postoperative Magnetic resonance imaging and biopsy results indicated total resection. During the 2 month follow-up, no severe complications were found, and the primary site was tumour-free.

CONCLUSION

This study preliminarily presents the feasibility and efficiency of advanced rNPC resection with TORS. TORS can potentially provide better quality of life for patients as a less invasive approach than current endoscopic surgery. Even so, the surgical approach should be selected strictly according to the tumour's location.