Reduced-dose radiotherapy for Epstein-Barr virus DNA selected staged III nasopharyngeal carcinoma: A single-arm, phase 2 trial

Updates on Treatments and Management of Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is a unique head and neck cancer, where the endemic subtype is strongly associated with Epstein-Barr virus (EBV) infection, whereas emerging data suggest that a subset of nonendemic NPC may be associated with human papillomavirus (HPV) infection. Nonetheless, treatment advances have been driven by clinical trials conducted in endemic NPC, investigating optimal sequencing of chemotherapy and immune checkpoint inhibitors with radiotherapy for locoregionally advanced disease. The preference for induction chemotherapy (IC) in these patients has also led to evolution in the concept of radiotherapy target delineation. Because of its association with EBV, plasma EBV DNA is an archetypal biomarker for endemic NPC, and it is being explored for precise stratification and treatment individualization in several ongoing trials. In the space of recurrent or metastatic-NPC, with the advent of platinum-doublet chemotherapy and anti-PD-1 antibody as the new standard of care, several trials are investigating new immunotherapeutic combinations, bispecific antibodies, and antibody-drug conjugates that have demonstrated promise in early phase trials. An important advance for NPC in 2025 is the update of the 9th version of the TNM staging system, which has introduced several key changes, including downgrading of the TNM stage groupings for localized disease, and splitting of metastatic NPC into IVA and IVB based on the number of metastatic lesions. These revisions would have implications for the treatment and design of future trials. These advances are also relevant to nonendemic NPC, where evidence is inconclusive whether this disease responds differently to current treatments compared with endemic NPC.

Treatment outcomes in nasopharyngeal carcinoma patients with parotid lymph node metastasis: An 11-year experience at a tertiary cancer center

Parotid lymph node (PLN) metastasis in nasopharyngeal carcinoma (NPC) is rare, with limited data guiding its management and prognosis. We retrospectively analyzed 6924 non-metastatic NPC patients at our tertiary cancer center, identifying 126 patients with PLN metastasis confirmed by fine-needle aspiration cytology (FNAC) and magnetic resonance imaging (MRI). Survival outcomes and prognostic factors were assessed using Kaplan-Meier estimates, log-rank tests, propensity score matching (PSM), and Cox regression. Compared to patients with N3 disease, those with PLN metastasis had worse regional relapse-free survival, distant metastasis-free survival, and progression-free survival. However, overall survival was not significantly affected. When PLN received radical-intensity radiation doses, outcomes were comparable to patients without PLN metastasis. Treatment failures with PLN involvement frequently co-occurred with regional relapse and distant metastasis. Among patients who were treated with PLN-sparing intensity-modulated radiotherapy (IMRT), compared to non-parotid relapse patients, parotid relapse patients were older, had more advanced N classification, lower baseline Epstein-barr virus DNA (EBV-DNA) level, and received fewer cycles of chemotherapy. Additionally, these recurrent PLNs were characterized by smaller size, being typically unilateral and isolated, exhibiting poor sensitivity to chemotherapy, and receiving lower doses of radiotherapy. In our study, PLN metastasis does not upstage the patient's N classification if comprehensive radiotherapy is administered at radical doses. We advise prudence when implementing parotid-sparing IMRT and strongly recommend FNAC for clinically suspicious lesions.

Plasma Epstein-Barr Virus DNA Temporal Clearance Pattern During Induction-Concurrent (Chemo)Radiation Therapy for Risk Stratification in Nasopharyngeal Carcinoma

PURPOSE

Plasma Epstein-Barr virus (EBV) DNA is a widely used biomarker for nasopharyngeal carcinoma (NPC). Prior investigations predominantly assessed EBV DNA at a single time point, thus neglecting the differential prognostic implications of the temporal clearance pattern of EBV DNA during induction-concurrent (chemo)radiation therapy (RT).

METHODS AND MATERIALS

We retrospectively reviewed EBV DNA clearance patterns during induction-concurrent chemoRT in newly diagnosed patients with nonmetastatic NPC. EBV DNA was tested at 3 time points (baseline [T0], end of induction chemotherapy [T1], and end of RT [T2]) and recorded as detectable (D) and undetectable (U). The association between EBV DNA pattern and progression-free survival was analyzed.

RESULTS

A total of 2203 NPCs were included. Five distinct EBV DNA trajectory patterns were identified: type Ⅰ (negative-stable, U-U-U, 7.3%), type Ⅱ (induction chemotherapy-elimination, D-U-U, 42.8%), type Ⅲ (RT-elimination, D-D-U, 35.0%), type Ⅳ (persistent-positive, D-D-D, 11.7%), and type Ⅴ (resurgence, D-U-D [1.5%], U-D-U [1.2%], U-D-D [0.4%], or U-U-D [0.2%]). The median follow-up was 53.5 months (IQR, 43.1-66.9). Type Ⅱ patients displayed superior 5-year progression-free survival (82.9% [95% CI, 80.4%-85.5%]) versus type Ⅲ (75.9% [72.8%-79.1%], P < .001), type Ⅳ (52.5% [46.4%-59.5%], P < .001), and type Ⅴ (72.5% [62.2%-84.6%], P = .028). The 5-year progression-free survival for type V patients with "D-U-D," "U-D-U," "U-D-D," and "U-U-D" patterns was 62.4% (46.2%-84.3%), 78.6% (63.1%-97.8%), 85.7% (63.3%-100.0%), and 75.0% (42.6%-100.0%), respectively. All 33 patients with the "D-U-D" pattern had stage Ⅲ-Ⅳ disease at diagnosis.

CONCLUSIONS

Temporal EBV DNA clearance patterns during induction-concurrent chemoRT provide valuable prognostic insights, enabling the identification of patients with high-risk NPC and informing personalized treatment strategies. Resurgence of EBV DNA may occur occasionally (3.3%). Caution is required when considering reduced-intensity therapy in patients with locoeregionally advanced disease when EBV DNA becomes U after induction chemotherapy.

Personalising Nasopharyngeal Cancer: Systemic Therapy and Radiotherapy Treatment Volumes

Nasopharyngeal carcinoma (NPC) is sensitive to chemotherapy and radiotherapy, with current treatment recommendations largely based on TNM-stage. Radiotherapy remains the backbone of treatment for NPC. Over the past decades, the addition of concurrent chemotherapy to radiotherapy for early-stage disease, and the combination of induction chemotherapy (IC) or adjuvant chemotherapy (AC) with chemoradiotherapy vs chemoradiotherapy alone for advanced disease have led to substantial improvements in survival of patients with NPC. Nonetheless, in the era of precision oncology, there is growing recognition that patients with NPC are clinically heterogeneous even within the same stage-group, and future advances must focus on individualisation of systemic therapy and radiotherapy. In this review, we summarised the published evidence on EBV DNA as a biomarker for clinical stratification and treatment response in NPC, and discussed some of the ongoing clinical trials of EBV DNA-directed personalisation of systemic therapy in locoregionally-advanced disease. Next, we assessed the evidence concerning individualised radiotherapy strategies for target volume delineation of the primary tumour and cervical nodes that ought to be based on individual tumour extent and IC response (for locoregionally-advanced NPC) as opposed to the historical one-size fits all approach. In the same vein, radiotherapy dose de-escalation may be considered in good responders to IC, whereas for the poor responders, altered fractionation or dose escalation may be required to target resistant disease. These concepts are particularly relevant in the era of combinatorial immune checkpoint blockade therapy with radiotherapy, where preservation of circulating immune cells is crucial to evoke immune-mediated antitumour cytotoxicity.

Patterns of failure and prognosis in nasopharyngeal carcinoma according to Epstein-Barr virus DNA status

PURPOSE

To investigate the patterns of failure and prognosis in recurrent or metastatic nasopharyngeal carcinoma (rmNPC) according to Epstein-Barr virus-DNA (EBV-DNA) status.

METHODS

We included NPC patients who were diagnosed with locoregional recurrence (LRR) and/(or) distant metastasis (DM) between January 2017 and June 2024. Receiver operating characteristic analysis, Chi-square test, Wilcoxon rank sum test, Kaplan-Meier method, and Multivariate Cox regression analyses were used for statistical analysis.

RESULTS

This study involved 108 patients, including 105 (97.2%) who had EBV-DNA detectable at the initial diagnosis of NPC. Regarding progression patterns, 34 patients (31.5%) experienced only LRR, while 60 patients (55.6%) had only DM. LRR followed by DM was observed in 5 (4.6%) patients, DM followed by LRR occurred in 2 (1.8%) patients, and both LRR and DM were presented simultaneously in 7 (6.5%) patients. EBV-DNA positivity rates significantly differed between LRR and DM patients, at 76.9% and 97.1% respectively (P = 0.003). A significant difference was also observed in EBV-DNA levels, with a median level of 413 copies/mL for LRR and 6,550 copies/mL for DM (P < 0.001). While the EBV-DNA positivity rate did not differ significantly between oligometastatic disease and polymetastatic disease (P = 0.493), the levels were significantly elevated in the polymetastatic disease group than the oligometastatic disease group (P < 0.001). Multivariate analysis showed that liver metastasis (P = 0.012) and EBV-DNA levels ≥ 3,525 copies/mL at progression (P = 0.009) independently correlated with poorer overall survival.

CONCLUSIONS

Our study provides substantial evidence linking higher EBV-DNA levels with disease failure patterns and identifies liver metastasis and EBV-DNA levels at disease progression as independent prognostic factors for poorer overall survival in rmNPC patients.

Delta magnetic resonance imaging radiomics features‑based nomogram predicts long‑term efficacy after induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma

PURPOSE

To establish and validate a delta-radiomics-based model for predicting progression-free survival (PFS) in patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) following induction chemotherapy (IC).

METHODS AND MATERIALS

A total of 250 LA-NPC patients (training cohort: n = 145; validation cohort: n = 105) were enrolled. Radiomic features were extracted from MRI scans taken before and after IC, and changes in these features were calculated. Following feature selection, a delta-radiomics signature was constructed using LASSO-Cox regression analysis. A prognostic nomogram incorporating independent clinical indicators and the delta-radiomics signature was developed and assessed for calibration and discrimination. Risk stratification by the nomogram was evaluated using Kaplan-Meier methods.

RESULTS

The delta-radiomics signature, consisting of 12 features, was independently associated with prognosis. The nomogram, integrating the delta-radiomics signature and clinical factors demonstrated excellent calibration and discrimination. The model achieved a Harrell's concordance index (C-index) of 0.848 in the training cohort and 0.820 in the validation cohort. Risk stratification identified two groups with significantly different PFS rates. The three-year PFS for high-risk patients who received concurrent chemoradiotherapy (CCRT) or radiotherapy plus adjuvant chemotherapy (RT+AC) after IC was significantly higher than for those who received RT alone, reaching statistical significance. In contrast, for low-risk patients, the three-year PFS after IC was slightly higher for those who received CCRT or RT+AC compared to those who received RT alone; however, this difference did not reach statistical significance.

CONCLUSIONS

Our delta MRI-based radiomics model could be useful for predicting PFS and may guide subsequent treatment decisions after IC in LA-NPC.

Optimizing Hearing Outcomes in Nasopharyngeal Cancer Survivors in the Era of Modern Radiotherapy and Systemic Therapy

Intensity-modulated radiation therapy (IMRT) improves disease control and reduces treatment-related toxicity in patients with localized nasopharyngeal carcinoma (NPC). However, due to the proximity of the auditory apparatus to the treatment volume and the frequent incorporation of cisplatin-based chemotherapy, treatment-related sensorineural hearing loss (SNHL) remains a common debilitating complication among NPC survivors. The reported crude incidence of SNHL following IMRT for NPC varies widely at 1-46% due to differences in auditory assessment methods and thresholds, follow-up durations, chemotherapy usage, and patient compositions. International guidelines and radiation dosimetric studies have recommended constraining the cochlear mean dose to less than 44-50 Gy, but the risk of SNHL remains high despite adherence to these constraints. Potential strategies to improve hearing outcomes in NPC survivors include cautious de-escalation of radiotherapy dose and volume, individualization of cochlear constraints, optimization of radiotherapy planning techniques, and the use of substitutes or alternative schedules for cisplatin-based chemotherapy. The addition of immune checkpoint inhibitors to chemoradiotherapy did not impact ototoxicity. Prospective studies that employ both objective and patient-reported auditory outcomes are warranted to test the long-term benefits of various approaches. This article aims to provide a comprehensive review of the incidence and radiation dose-toxicity relationship of SNHL in NPC survivors and to summarize potential strategies to optimize hearing outcomes in relation to nuances in radiotherapy planning and the selection of systemic therapy.

Potential predictive value of IVIM MR for xerostomia in nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

Xerostomia, caused by radiation-induced parotid damage, is the most commonly reported radiotherapy (RT) complication for nasopharyngeal carcinoma (NPC). The purpose of this study was to evaluate the value of intravoxel incoherent motion (IVIM) MR in monitoring radiation-induced parotid gland damage and predicting the risk of xerostomia.

METHODS

Fifty-four NPC patients were enrolled and underwent at least three IVIM MR scans: before (pre-RT), after 5 fractions of (5th-RT), halfway through (mid-RT), and after RT (post-RT). The degree of xerostomia patients was assessed before each MR examination. Furthermore, the time when patients first reported xerostomia symptoms was recorded. The changes in IVIM parameters throughout RT, as well as the relationships between IVIM parameters and xerostomia, were analysed.

RESULT

All IVIM parameters increased significantly from pre-RT to post-RT (p < 0.001). The rates of D, D* and f increase increased significantly from pre-RT to mid-RT (p < 0.001), indicating that cell necrosis mainly occurs in the first half of RT. In multivariate analysis, N3 (p = 0.014), pre-D (p = 0.007) and pre-D* (p = 0.003) were independent factors influencing xerostomia. D and f were significantly higher at 5th-RT than at pre-RT (both p < 0.05). IVIM detected parotid gland injury at 5th-RT at an average scanning time of 6.18 ± 1.07 days, earlier than the 11.94 ± 2.61 days when the patient first complained of xerostomia according to the RTOG scale (p < 0.001).

CONCLUSIONS

IVIM MR can dynamically monitor radiation-induced parotid gland damage and assess it earlier and more objectively than RTOG toxicity. Moreover, IVIM can screen people at risk of more severe xerostomia early.

Enhancing efficacy and reducing toxicity: Therapeutic optimization in locoregionally advanced nasopharyngeal carcinoma

When applied as the standard therapeutic modality, intensity-modulated radiotherapy (IMRT) improves local control and survival rates in patients with nasopharyngeal carcinoma (NPC). However, distant metastasis continues to be the leading cause of treatment failure. Here, we review the most recent optimization strategies for combining chemotherapy with IMRT in high-risk patients with locoregionally advanced NPC. We focus on major clinical trials on induction chemotherapy and metronomic adjuvant chemotherapy, emphasizing their efficacy in mitigating distant metastasis and prognosis. We also highlight innovations in reducing toxicity in low-risk patients, particularly through approaches of excluding chemotherapy, adopting equivalent low-toxicity drugs, or selectively exempting lymph nodes with low metastatic risk from irradiation. These approaches have provided positive treatment outcomes and significantly enhanced patients' quality of life. Finally, we provide an overview of the evolving immunotherapy landscape, with a focus on the ongoing trials and future potential of immune checkpoint inhibitors in advanced NPC treatment.