Validation of published nomograms and accordingly individualized induction chemotherapy in nasopharyngeal carcinoma

Does three cycles of neoadjuvant chemotherapy prior to concurrent chemoradiotherapy provide benefits for all childhood patients with locoregionally advanced nasopharyngeal carcinoma?

BACKGROUND

Adding neoadjuvant chemotherapy (NAC) to concurrent chemoradiotherapy (CCRT) is the main strategy in treatment of children and adolescents with locoregionally advanced nasopharyngeal carcinoma (CA-LANPC). Yet, an optimal number of NAC cycles remains unknown. We aimed to optimize the NAC cycle and potentially contribute to clinical decision making for the individual treatment of CA-LANPC.

PATIENTS AND METHODS

Utilizing an NPC-specific database through an acknowledged big-data information system at our center, we identified 143 CA-LANPC treated with NAC followed by CCRT between September 2007 through April 2018. Recursive partitioning analysis (RPA) was performed to categorize the patients and predict disease-free survival (DFS). The clinical benefits of NAC cycles (two cycles vs three cycles) were assessed in each risk group.

RESULTS

Independent factors derived from multivariable analysis to predict DFS were T stage (T1-3 vs T4) and plasma Epstein-Barr virus (EBV) DNA (< 4000 vs ≥ 4000 copies/mL) for risk stratification. Consequently, 87 (61%) participants were classified as low-risk group (T1-3 with low or high EBV DNA, and T4 with low EBV DNA) and the other 56 patients (39%) were classified as a high-risk group (T4 with high EBV DNA) through RPA, and corresponding 5-year DFS rates of 91.9% and 71.2%, respectively (p = 0.001). Among the high-risk group, patients receiving three cycles of NAC had statistically significant improvement in 5-year DFS over those who received two cycles of NAC (86.7% vs 59.1%; p = 0.020), while the survival benefit of three cycles NAC for low-risk groups were not observed (94.7% vs 89.7%; p = 0.652).

CONCLUSIONS

We found three cycles of NAC with CCRT was a positive prognostic indicator for improved DFS for the high-risk group among CA-LANPC. However, whether low-risk patients could benefit from three cycles NAC needs further study.

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

BACKGROUND

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

PURPOSE

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

STUDY TYPE

Retrospective study.

POPULATION

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

FIELD STRENGTH/SEQUENCE

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

ASSESSMENT

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

STATISTICAL TESTS

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

RESULTS

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

DATA CONCLUSION

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

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY: Stage 2.

Development of a Nomogram Model for Treatment of Nonmetastatic Nasopharyngeal Carcinoma

IMPORTANCE

Because of tumor heterogeneity, overall survival (OS) differs significantly among individuals with nasopharyngeal carcinoma (NPC), even among those with the same clinical stage. Relying solely on TNM staging to guide treatment remains imperfect.

OBJECTIVES

To establish a comprehensive nomogram to estimate individualized OS and to explore stratified treatment regimens for risk subgroups in nonmetastatic NPC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 8093 patients diagnosed with NPC at a single center in China from April 2009 to December 2015. The sample was split into a training cohort (5398 participants [66.7%]) and validation cohort (2695 [33.3%]). Data were analyzed in May 2020.

EXPOSURES

Age, T stage, N stage, Epstein-Barr virus (EBV) DNA level, serum lactate dehydrogenase (LDH) levels, and albumin (ALB) levels.

MAIN OUTCOMES AND MEASURES

The primary end point was OS. The nomogram for estimating OS was generated based on multivariate Cox proportional hazards regression. The performance of the nomogram was quantified using Harrell concordance index (C index), the area under the curve (AUC) of the receiver operating characteristic curve, and a calibration curve. OS rates were established using the Kaplan-Meier method, and intersubgroup differences were examined by the log-rank test.

RESULTS

Among the 8093 participants, 5688 (70.3%) were men, and the median age at diagnosis was 45 years (range, 7-85 years). Six variables (age, T stage, N stage, EBV DNA levels, LDH levels, and ALB levels) were identified through multivariate Cox regression and incorporated into a nomogram to estimate OS. The resulting nomogram showed excellent discriminative ability and significantly outperformed the eighth edition of the American Joint Committee on Cancer/Union for International Cancer Control TNM staging system for estimating OS (C index, 0.716 [95% CI, 0.698-0.734] vs 0.643 [95% CI, 0.624-0.661]; P < .001; AUC, 0.717 [95% CI, 0.698-0.737] vs 0.643 [95% CI, 0.623-0.662]; P < .001), and the calibration curves showed satisfactory agreement between the actual and nomogram-estimated OS rates. The validation cohort confirmed the results. Patients were stratified into 4 risk groups based on the 25th, 50th, and 75th percentile score values estimated from the nomogram. The 4 nomogram-defined risk groups demonstrated significantly different intergroup OS (3-year OS rates: risk group 1, 1328 of 1345 [98.7%]; risk group 2, 1289 of 1341 [96.1%]; risk group 3, 1222 of 1321 [92.5%]; risk group 4, 1173 of 1391 [84.3%]; P < .001). These risk groups were associated with the efficacy of different treatment regimens. For example, for risk group 4, induction chemotherapy with concurrent chemoradiotherapy was associated with a significantly better OS than concurrent chemoradiotherapy (log-rank P = .008) and intensity-modulated radiotherapy alone (log-rank P < .001).

CONCLUSIONS AND RELEVANCE

In this study, the proposed nomogram model enabled individualized prognostication of OS and could help to guide risk-adapted treatment for patients with nonmetastatic NPC.

The emerging data on choice of optimal therapy for locally advanced nasopharyngeal carcinoma

PURPOSE OF REVIEW

We focus on the emerging data from randomized clinical trials for optimal integration of induction, concurrent, and/or adjuvant chemotherapy with intensity-modulated radiotherapy in locally advanced nasopharyngeal carcinoma (NPC), and the use of plasma Epstein-Barr virus (EBV) DNA for risk stratification.

RECENT FINDINGS

Several phase 3 trials have shown that induction chemotherapy followed by concurrent chemoradiation (CRT) improved overall survival or disease-free survival when compared to CRT alone in stage III/IV NPC who is at high risk of distant metastases. The benefit of adjuvant chemotherapy following CRT when compared to CRT alone is uncertain. There are increasing clinical data supporting the use of plasma EBV DNA for risk stratification. There are growing clinical data supporting the integration of immune checkpoint inhibitors into the induction, concurrent, and/or adjuvant/maintenance phase of treatment in locally advanced NPC.

SUMMARY

Concurrent chemoradiation remains the standard treatment backbone in locally advanced NPC. There is level 1 evidence for induction chemotherapy followed by CRT in stage III/IV NPC. There is increasing evidence against the indiscriminate use of adjuvant chemotherapy following CRT. With the increasing treatment intensification, future treatment algorithm in NPC should incorporate plasma EBV DNA and other biomarkers for risk stratification and treatment selection.

Risk stratification for nasopharyngeal carcinoma: a real-world study based on locoregional extension patterns and Epstein-Barr virus DNA load

Aim:

The present study aimed to evaluate the combined value of locoregional extension patterns (LEPs) and circulating cell-free Epstein–Barr virus (cf EBV) DNA for risk stratification of locoregionally advanced nasopharyngeal carcinoma (LA-NPC) to better guide therapeutic strategies.

Methods:

A total of 7227 cases of LA-NPC were reviewed retrospectively and classified into six groups according to their LEP (ascending, descending, or mixed type) and pre-treatment cf EBV-DNA load (⩾ versus <4000 copy/ml). Using a supervised statistical clustering approach, patients in the six groups were clustered into low, intermediate, and high-risk clusters. Progression-free survival (PFS), overall survival (OS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRRFS) were calculated using the Kaplan–Meier method and differences were compared using the log-rank test.

Results:

Survival curves for the low, intermediate, and high-risk clusters were significantly different for all endpoints. The 5-year survival rate for the low, intermediate, and high-risk clusters, respectively, were: PFS (83.5%, 73.2%, 62.6%, p < 0.001), OS (91.0%, 82.7%, 73.2%, p < 0.001), DMFS (92.3%, 83.0%, 73.4%, p < 0.001), and LRRFS (91.0%, 88.0%, 83.3%, p < 0.001). The risk clusters acted as independent prognostic factors for all endpoints. Among the patients in the high-risk cluster, neoadjuvant chemotherapy combined with concurrent chemoradiotherapy (CCRT) significantly improved the patients 5-year PFS (66.4% versus 57.9%, p = 0.014), OS (77.6% versus 68.6%; p < 0.002), and DMFS (76.6% versus 70.6%; p = 0.028) compared with those treated with CCRT.

Conclusion:

Our results could facilitate the development of risk-stratification and risk-adapted therapeutic strategies for patients with LA-NPC.

Stratification of Candidates for Induction Chemotherapy in Stage III-IV Nasopharyngeal Carcinoma: A Large Cohort Study Based on a Comprehensive Prognostic Model

Objective: To establish a prognostic index (PI) for patients with stage III-IV nasopharyngeal carcinoma (NPC) patients to personalize recommendations for induction chemotherapy (IC) before intensity-modulated radiotherapy (IMRT).

Patients and Methods: Patients received concurrent chemoradiotherapy (CCRT) with or without IC. Factors used to construct the PI were selected by a multivariate analysis of progression-free survival (PFS), which was the primary endpoint (P < 0.05). Five variables were selected based on a backward procedure in a Cox proportional hazards model: gender, T stage, N stage, lactate dehydrogenase (LDH), and Epstein–Barr virus (EBV) DNA. The cutoff value for the PI was determined by the receiver operating characteristic curve analysis.

Results: The present study involved 3,586 patients diagnosed with stage III-IV NPC. The cutoff value for PI was 0.8. The high-risk subgroup showed worse outcomes than did the low-risk subgroup on all endpoints: PFS, overall survival (OS), locoregional relapse-free survival (LRFS), and distant metastasis-free survival (DMFS). In the low-risk subgroup (PI <0.8), patients showed comparable survival outcomes on all clinical endpoints regardless of IC application, whereas in the high-risk subgroup (PI > 0.8), the addition of IC significantly improved PFS, OS, and DMFS, but not LRFS. In multivariate analyses, IC was a protective factor for PFS, OS, and DMFS in the high-risk subgroup, while it had no significant benefit in the low-risk subgroup.

Conclusion: The proposed prognostic model effectively stratifies patients with stage III-IV NPC. High-risk patients are candidates for IC before CCRT, while low-risk patients are unlikely to benefit from it.

Long-Term Survival After Nasopharyngeal Carcinoma Treatment in a Local Prefecture-Level Hospital in Southern China

Purpose

NPC is a malignant and invasive tumor with the incidence rate of 19/100,000 per year in Zhongshan City, a prefecture city in southern China. Long-term survival analysis on intensity-modulated radiotherapy (IMRT)-based treatment in local prefecture-level hospitals have not been investigated. We aimed to evaluate the 5-year clinical outcomes and prognostic factors of NPC treated with IMRT in Zhongshan City People's Hospital (ZSPH), a prefecture-level hospital in South China.

Patients and Methods

The number of 149 newly diagnosed non-metastatic NPC cases treated with IMRT were included from Zhongshan City People's Hospital between January 2010 and December 2011. The survival outcomes, treatment toxicities and prognostic factors were analyzed by Kaplan-Meier method and Cox proportional hazards model.

Results

With a median follow-up period of 65 months for the cohort, the 5-year local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS) and distant metastasis-free survival (DMFS) and overall survival (OS) were 86.80%, 94.80%, 86.10% and 80.50%, respectively. The 5-year OS rates were 100%, 95.2%, 87% and 67.2% for stage I, II, II and IVa-b, respectively (P=0.004). The 5-year LRFS rates were 97.2%, 96.0%, 90.4% and 72.0% for T1, T2, T3 and T4, respectively (P=0.001); the 5-year DMFS rates were 100% for T1, 96.8% for T2, 81.9% for T3 and 74.6% for T4 (P=0.022). A multivariate analysis revealed tumor stage as an independent prognostic factor for LRFS, DMFS and OS. No patients died from acute toxicities. Late toxicities were observed for 130 (87.2%) patients, and most late toxicities were graded I/II.

Conclusion

NPC treatment effect in a prefecture-level hospital in South China was comparable to international results and toxicities were tolerable. Tumour stage was an independent prognostic factor for survival outcome. More NPC survival data from local and remote places are needed.

Examining Bias and Reporting in Oral Health Prediction Modeling Studies

Recent efforts to improve the reliability and efficiency of scientific research have caught the attention of researchers conducting prediction modeling studies (PMSs). Use of prediction models in oral health has become more common over the past decades for predicting the risk of diseases and treatment outcomes. Risk of bias and insufficient reporting present challenges to the reproducibility and implementation of these models. A recent tool for bias assessment and a reporting guideline—PROBAST (Prediction Model Risk of Bias Assessment Tool) and TRIPOD (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis)—have been proposed to guide researchers in the development and reporting of PMSs, but their application has been limited. Following the standards proposed in these tools and a systematic review approach, a literature search was carried out in PubMed to identify oral health PMSs published in dental, epidemiologic, and biostatistical journals. Risk of bias and transparency of reporting were assessed with PROBAST and TRIPOD. Among 2,881 papers identified, 34 studies containing 58 models were included. The most investigated outcomes were periodontal diseases (42%) and oral cancers (30%). Seventy-five percent of the studies were susceptible to at least 4 of 20 sources of bias, including measurement error in predictors ( n = 12) and/or outcome ( n = 7), omitting samples with missing data ( n = 10), selecting variables based on univariate analyses ( n = 9), overfitting ( n = 13), and lack of model performance assessment ( n = 24). Based on TRIPOD, at least 5 of 31 items were inadequately reported in 95% of the studies. These items included sampling approaches ( n = 15), participant eligibility criteria ( n = 6), and model-building procedures ( n = 16). There was a general lack of transparent reporting and identification of bias across the studies. Application of the recommendations proposed in PROBAST and TRIPOD can benefit future research and improve the reproducibility and applicability of prediction models in oral health.

Development and validation of a prognostic nomogram for the pre-treatment prediction of early metachronous metastasis in endemic nasopharyngeal carcinoma: a big-data intelligence platform-based analysis

BACKGROUND

Early failure of cancer treatment generally indicates a poor prognosis. Here, we aim to develop and validate a pre-treatment nomogram to predict early metachronous metastasis (EMM) in nasopharyngeal carcinoma (NPC).

METHODS

From 2009 to 2015, a total of 9461 patients with NPC (training cohort: n = 7096; validation cohort: n = 2365) were identified from an institutional big-data research platform. EMM was defined as time to metastasis within 2 years after treatment. Early metachronous distant metastasis-free survival (EM-DMFS) was the primary endpoint. A nomogram was established with the significant prognostic factors for EM-DMFS determined by multivariate Cox regression analyses in the training cohort. The Harrell Concordance Index (C-index), area under the receiver operator characteristic curve (AUC), and calibration curves were applied to evaluate this model.

RESULTS

EMM account for 73.5% of the total metachronous metastasis rate and is associated with poor long-term survival in NPC. The final nomogram, which included six clinical variables, achieved satisfactory discriminative performance and significantly outperformed the traditional tumor-node-metastasis (TNM) classification for predicting EM-DMFS: C-index: 0.721 versus 0.638, p < 0.001; AUC: 0.730 versus 0.644, p < 0.001. The calibration curves showed excellent agreement between the predicted and actual EM-DMFS. The nomogram can stratify patients into three risk groups with distinct EM-DMFS (2-year DMFS: 96.8% versus 90.1% versus 80.3%, p < 0.001). A validation cohort supported the results. The three identified risk groups are correlated with the efficacy of different treatment regimens.

CONCLUSION

Our established nomogram can reliably predict EMM in patients with NPC and might aid in formulating risk-adapted treatment decisions and personalized patient follow-up strategies.

Combination treatment with cetuximab in advanced nasopharyngeal carcinoma patients: a meta-analysis

Purpose

Cetuximab, an anti-epidermal growth factor receptor monoclonal antibody, carries the potential for combination treatment against nasopharyngeal carcinoma (NPC). We conducted a meta-analysis to assess the possible benefits and safety between the combination treatment with cetuximab and conventional treatment in NPC patients. Skin toxicity (ST) associated with additional cetuximab was evaluated as well.

Methods

We performed a systematic search (PubMed, Embase, Cochrane library, China National Knowledge Infrastructure, and WanFang Data) for studies comparing combination treatment with cetuximab versus conventional treatment in NPC patients. The selected studies included completely or partly reported clinical outcomes including survivals, complete and partial responses, and adverse reactions (ST). The pooled HR, relative risk (RR), and respective 95% CI were estimated by using fixed effects model or random effects model.

Results

A total of 23 relevant studies with available data were included in the final analysis. According to the pooled data, combination treatment with cetuximab showed improved efficacy on increased objective response rate (studies with cetuximab treatment: RR: 1.39, 95% CI: 1.29–1.50; concurrent chemoradiotherapy with or without cetuximab: RR: 1.39, 95% CI: 1.25–1.54) and prolonged survival (studies with cetuximab treatment: the pooled HR for OS was 0.70, 95% CI: 0.55–0.89; concurrent chemoradiotherapy with or without cetuximab: the pooled HR for OS was 0.64, 95% CI: 0.49–0.84) compared with conventional treatment. Moreover, the improved efficacy was invariably accompanied by an increased occurrence of ST (studies with cetuximab treatment: RR: 2.46, 95% CI: 1.81–3.34; concurrent chemoradiotherapy with or without cetuximab: RR: 1.84, 95% CI: 1.02–3.31). However, the majority of adverse reactions exhibited similar occurrence rates between the different treatments.

Conclusion

Patients with NPC receiving additional cetuximab treatment can benefit more from this systemic comprehensive therapy, while the efficiency of conventional treatment for NPC is limited. ST associated with cetuximab may be used as a potential on-treatment marker to guide treatment with cetuximab against NPC.

A Pairwise Meta-Analysis of Induction Chemotherapy in Nasopharyngeal Carcinoma

BACKGROUND

Locoregionally advanced nasopharyngeal carcinoma has high risk of distant metastasis and mortality. Induction chemotherapy is commonly administrated in clinical practice, but the efficacy was quite controversial in and out of randomized controlled trials. We thus conducted this pairwise meta-analysis.

MATERIALS AND METHODS

Trials that randomized patients to receive radiotherapy or concurrent chemoradiotherapy with or without induction chemotherapy were identified via searches of PubMed, MEDLINE, and ClinicalTrials.gov.

RESULTS

A total of ten trials (2,627 patients) were included. The pooled hazard ratios (HRs) based on fixed effect model were 0.68 (95% confidence interval [CI] 0.56-0.80, p < .001) for overall survival (OS) and 0.70 (95% CI 0.61-0.79, p < .001) for progression-free survival (PFS), which strongly favored the addition of induction chemotherapy. The absolute 5-year survival benefits were 8.47% in OS and 10.27% in PFS, respectively. In addition, based on the available data of eight trials, induction chemotherapy showed significant efficacy in reducing locoregional failure rate (risk ratio [RR] = 0.81, 95% CI 0.68-0.96, p = .017) and distant metastasis rate (RR = 0.69, 95% CI 0.58-0.82, p < .001).

CONCLUSION

This pairwise meta-analysis confirms the benefit in OS, PFS, and locoregional and distant controls associated with the addition of induction chemotherapy in nasopharyngeal carcinoma.

IMPLICATIONS FOR PRACTICE

According to the results of this meta-analysis of ten trials, induction chemotherapy can prolong overall survival and progression-free survival and improve locoregional and distant controls for nasopharyngeal carcinoma.

A novel scoring model to predict benefit of additional induction chemotherapy to concurrent chemoradiotherapy in stage II-IVa nasopharyngeal carcinoma

OBJECTIVES

Induction chemotherapy (IC) is gaining recognition for the treatment of nasopharyngeal carcinoma (NPC). We aimed to develop a model to predict benefit from additional IC to concurrent chemoradiotherapy (CCRT).

MATERIALS AND METHODS

From an NPC-specific database, 7413 patients with stage II-IVa disease who received CCRT with or without IC were included. Distant metastasis-free survival (DMFS) was the primary outcome and benefit from IC was evaluated by adjusted hazard ratio. Interaction terms between IC and other prognostic factors were identified in multivariate Cox model, and IC benefit score (ICBS) was calculated based on β coefficients from the Cox model.

RESULTS

Nodal category, overall stage, and pre-treatment plasma Epstein-Barr virus DNA (log transformed as continuous variable) interacted with IC and determined ICBS. ICBS could discriminate patients who benefited differently from IC in terms of DMFS well, especially for patients with high and low ICBS. As for patients with medium ICBS, predictive performance of ICBS seemed reduced.

CONCLUSIONS

Based on the ICBS model, we proposed a decision-making process to help in clinical practice. Multi-institutional and prospective studies are warranted to further validate our findings.

Validation and comparison of the 7th and 8th edition of AJCC staging systems for non-metastatic nasopharyngeal carcinoma, and proposed staging systems from Hong Kong, Guangzhou, and Guangxi

OBJECTIVES

We aimed to validate and compare the 7th and 8th edition of AJCC staging systems for non-metastatic nasopharyngeal carcinoma, and proposed staging systems from Hong Kong, Guangzhou, and Guangxi.

MATERIALS AND METHODS

We retrospectively included 899 patients treated between November 5, 2002 and May 27, 2010. Separation and discrimination of each staging system in overall survival were primarily compared.

RESULTS

Compared with the 7th AJCC, the 8th AJCC and all proposed staging systems well separated across T-classification. T-classification from Guangzhou seemed to perform best in discrimination (C-index 0.6454), followed by the 8th AJCC (0.6451), the 7th AJCC (0.6386), Hong Kong (0.6376) and Guangxi (0.5889). For N-classification, no staging systems improved the weakness of the 7th AJCC in separating N2 and N1, except that suggestion from Guangzhou showed higher potential (P=0.096). Besides, N-classification from Guangzhou had a C-index of 0.6444, larger than that of the 8th AJCC (0.6235), the 7th AJCC (0.6179), Hong Kong (0.6175) and Guangxi (0.6175). Accordingly, stage group of staging system from Guangzhou showed higher discrimination (C-index 0.6839), compared with the 8th AJCC (0.6791), the 7th AJCC (0.6766), Hong Kong (0.6765) and Guangxi (0.6688), despite that stage I and II remained inseparable (P=0.322).

CONCLUSIONS

The 8th AJCC staging system appeared to be better than the 7th AJCC. But the proposed staging system from Guangzhou was more likely to improve the separation and discrimination abilities.