Effects of locoregional radiotherapy in de novo metastatic nasopharyngeal carcinoma: A real-world study

Treatment of primary tumor in metastatic head and neck Carcinoma: A systematic review and Meta-Analysis

INTRODUCTION

The treatment of primary tumors in metastatic squamous cell carcinoma of the head and neck (HNSCC) is a complex and debated issue. This study evaluates the impact of treating primary tumors on overall survival (OS) and progression-free survival (PFS) in metastatic HNSCC through a systematic review and meta-analysis, with a focus on identifying potential biases and limitations in the available evidence.

MATERIALS AND METHODS

A comprehensive literature search was conducted in PubMed, EMBASE, and The Cochrane Library for studies published up to January 2024. Studies comparing systemic therapy alone to systemic therapy combined with locoregional therapy targeting the primary tumor, with or without neck nodes, were included. Eligible studies reported OS or PFS outcomes in stage IV HNSCC or nasopharyngeal cancers. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using random-effects models to account for study heterogeneity.

RESULTS

The meta-analysis included 48 studies comprising 33,637 patients. Treating the primary tumor significantly improved OS (HR = 0.55; 95 % CI, 0.49-0.61; P < 0.01) and PFS (HR = 0.57; 95 % CI, 0.35-0.95; P = 0.03). However, significant heterogeneity was observed (I2 = 86 %), reflecting variability in patient populations, treatment protocols, and study designs.

CONCLUSIONS

This meta-analysis suggests that treating the primary tumor in metastatic HNSCC may be associated with improved survival outcomes. However, these findings must be interpreted with caution due to significant limitations, including high heterogeneity, potential biases, and the predominance of retrospective studies.

Efficacy of local-regional radiotherapy in de novo metastatic nasopharyngeal carcinoma patients receiving chemo-immunotherapy: A multicenter, propensity score matching study

BACKGROUND

To evaluate the efficacy of local-regional radiotherapy (LRRT) in de novo metastatic nasopharyngeal carcinoma (dm NPC) patients receiving chemo-immunotherapy as first-line treatment and select the beneficiaries from LRRT.

METHODS AND MATERIALS

M1-NPC patients receiving platinum-based chemo-immunotherapy with or without LRRT from four centers were included in this study. The propensity score matching (PSM) analysis was employed to balance the baseline characteristics between the LRRT and non-LRRT groups.

RESULTS

546 dm NPC patients (140 patients in the non-LRRT group and 406 patients in the LRRT group) were incorporated. Patients receiving LRRT demonstrated significantly improved progression-free survival (3-year PFS rate, 53.2 % vs 31.2 %, p < 0.001). After PSM analysis, there were 244 patients in the LRRT group and 122 patients in the non-LRRT group. Multivariable analysis indicated that LRRT was not an independent prognostic factor in the matched cohort (HR, 1.25, 95 % CI, 0.92-1.69, p = 0.156). Subgroup analysis among the matched cohort showed a significant increase in PFS for patients with oligo metastatic disease (OMD) who received LRRT (3-year PFS rate, 70.6 % vs 49.3 %, p = 0.043). In contrast, no such benefit was observed in patients with poly metastatic disease (PMD, 3-year PFS rate, 35.8 % vs 27.8 %, p = 0.17). Furthermore, LRRT significantly enhanced survival in patients with undetectable EBV DNA2-6 cycles (3-year PFS rate, 57.9 % vs. 43.4 %, p = 0.043), whereas no survival improvement was noted in patients with detectable EBV DNA2-6 cycles (16.2 % vs. 20.3 %, p = 0.21).

CONCLUSION

LRRT could prolong PFS in M1-NPC patients. OMD and undetectable EBV DNA2-6 cycles are potential indicators for selecting beneficiaries from LRRT.

Immunotherapy combined with chemotherapy without locoregional radiotherapy in de novo metastatic nasopharyngeal carcinoma: two case reports and a literature review

Background

There is no consensus regarding the optimal regimen for de novo metastatic nasopharyngeal carcinoma (dmNPC). Locoregional intensity modulated radiotherapy (LRRT) following palliative chemotherapy (PCT) has been shown to prolong the overall survival (OS) and improve the progression-free survival (PFS) of patients with dmNPC, compared with PCT alone. However, patients with a high tumor burden do not benefit from additional LRRT, which inevitably results in toxicity. Recently, immunotherapy has made great progress in the treatment of recurrent or metastatic NPC (RM-NPC). Compared with PCT alone, programmed death-1(PD-1) inhibitors combined with PCT have shown a promising survival outcome and an acceptable safety profile. Therefore, this treatment strategy is recommended as a first-line therapy for RM-NPC. However, whether dmNPC can be treated with immunochemotherapy alone (without LRRT) remains controversial.

Case presentation

We report two cases of dmNPC, both in middle-aged men who mainly presented with epistaxis and systemic pain. Radiological examination with positron emission tomography-computed tomography (PET-CT) and contrast-enhanced magnetic resonance imaging (MRI) showed NPC with multiple systemic lymph node metastases, multiple bone metastases, and liver metastases. Both patients were diagnosed with dmNPC and received pabolizumab in combination with six courses of platinum-based chemotherapy treatment. After complete remission (CR) was achieved, the patients were maintained on pabolizumab alone. No LRRT was used throughout the course of the disease. Pre- and post-treatment levels of plasma Epstein-Barr virus (EBV) DNA were measured, and radiological imaging was performed before and after treatment.

Results

We achieved good efficacy in these two cases of dmNPC. Both patients exhibited survival benefits (PFS has reached 31 months since diagnosis), and no serious chemotherapy- or immune-related adverse reactions occurred. Treatment-related toxicity from radiotherapy was avoided. Levels of plasma EBV DNA decreased and remained below the minimum detection level consistently after four or five cycles of treatment, with no obvious symptoms of neck muscle fibrosis, throat mucosa dryness, ear congestion, or nasal congestion.

Conclusion

Our findings suggested that chemotherapy combined with a PD-1 inhibitor without LRRT, followed by sequential immunotherapy as maintenance, can achieve good results in some dmNPC patients. Further validation of our results may be required in large, high-quality prospective clinical studies.

Establishing M1 subdivision for de novo nasopharyngeal carcinoma patients receiving immuno-chemotherapy: A multicenter, retrospective cohort study

OBJECTIVES

This study aims to better manage de novo metastatic nasopharyngeal carcinoma (NPC) patients receiving palliative immuno-chemotherapy (PICT), thereby easily determining individual survival outcomes.

MATERIALS AND METHODS

Patients with de novo metastatic NPC from four centers who received first-line PICT were included. We developed a nomogram for the pretherapy overall survival (OS) prediction using a logistic regression model in the training cohort (n = 296). We assessed the performance of this nomogram in a validation cohort.

RESULTS

A total of 592 patients were included. The median follow-up time was 29.83 months. Bone metastasis (HR, 2.46; 95 % CI, 1.01-6.21; p = 0.049) and the number of metastatic lesions > 3 (HR, 2.78; 95 % CI, 1.24-6.24; p = 0.013) were independent prognostic indicators. A new two-category M1 subdivision was generated: M1a, defined by the absence of co-existing bone metastasis and the presence of more than three metastatic lesions; and M1b, characterized by the presence of co-existing bone metastasis and the presence of more than three metastatic lesions. The 3-year OS rates of patients with M1a vs. M1b were 87.1 % vs. 60.3 % (p < 0.001). The C-indexes were 0.652 and 0.581 in the training and validation cohorts. The 1-, 2-, and 3-year areas under the curve (AUC) were 0.69, 0.68, 0.68 in the training cohort and 0.64, 0.6, 0.6 in the validation cohort. DCA curves also indicated that the nomogram has good clinical utility.

CONCLUSION

The proposed M1 subdivision provides good OS segregation for patients receiving PICT.

Long-term efficacy analysis of radiotherapy and local management of metastases in patients with newly diagnosed oligometastatic nasopharyngeal carcinoma: A prospective, single-arm, single-center clinical study

PURPOSE

We conducted a single-center, single-arm study (NCT03129412) to prospectively analyze the long-term outcomes of newly diagnosed patients with oligometastatic nasopharyngeal carcinoma (NPC) who received radical radiotherapy and local treatment of metastases.

PATIENTS AND METHODS

Patients who reached disease controll after platinum-based palliative chemotherapy continued to receive radical radiotherapy for the nasopharyngeal region and neck. Appropriate local treatments were selected to treat the metastatic lesions. The primary endpoint of this study was overall survival (OS) and the secondary endpoint was progression-free survival (PFS).

RESULTS

Fifty-one patients were included in the final analysis. During a median follow-up of 60 months, the median OS and PFS were 53.87 and 24.23 months, respectively. The 1-year, 3-year, and 5-year PFS and OS rates were 76.5 %, 38.1 %, and 31.8 % and 98 %, 75.4 %, 45.6 %, respectively. Both single and multivariate analysis indicated that maintenance therapy after radiotherapy could significantly increase PFS (36.43 vs. 16.1 months, P = 0.005). The OS of patients with single organ metastasis was significantly better than that of patients with double organ metastasis (P = 0.001). In addition, the number of metastatic organs also significantly affected PFS in the multifactor analysis.

CONCLUSION

Patients with newly diagnosed oligometastatic NPC can achieve long-term survival after receiving radical radiotherapy to the primary site and local treatment for metastases.

De novo metastatic head and neck squamous cell carcinoma: Why does locoregional control "always" matter?

De novo metastatic Head and Neck Squamous Cell Carcinoma (HNSCC) constitutes 10% of recurrent/metastatic (RM) cases. Radiotherapy (RT) has a crucial role in the treatment of locally advanced HNSCC, however its application on RM diseases is still limited. The advent of immune checkpoint inhibitors (ICIs) improves the survival of RM HNSCC, however median overall survival is still limited. Integration of locoregional RT with ICIs in de novo metastatic HNSCC represents a promising treatment option. This perspective aims to explore the role of the combination of locoregional and systemic treatment in improving outcomes for synchronous de novo metastatic HNSCC patients and highlights the principal crucial point in decision making.

Anatomic prognostic factors and their potential roles in refining M1 classification for de novo metastatic nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

To identify anatomic prognostic factors and their potential roles in refining M1 classification for de novo metastatic nasopharyngeal carcinoma (M1-NPC).

MATERIALS AND METHODS

All M1-NPC treated with chemotherapy and/or radiotherapy between 2010 and 2019 from two centers (training and validation cohort) were included. The prognostic value of metastatic disease extent and involved organs for overall survival (OS) were assessed by several multivariable analyses (MVA) models. A new M1 classification was proposed and validated in a separate cohort who received immuno-chemotherapy.

RESULTS

A total of 197 M1-NPC in the training and 307 in the validation cohorts were included for M1 subdivision study with median follow-up of 46 and 57 months. MVA model with "≤2 organs/≤5 lesions" as the definition of oligometastasis had the highest C-index (0.623) versus others (0.606-0.621). Patients with oligometastasis had better OS versus polymetastasis (hazard ratio [HR] 0.47/0.63) while liver metastases carried worse OS (HR 1.57/1.45) in MVA in the training/validation cohorts, respectively. We proposed to divide M1-NPC into M1a (oligometastasis without liver metastases) and M1b (liver metastases or polymetastasis) with 3-year OS of 66.5%/31.7% and 64.9%/35.0% in the training/validation cohorts, respectively. M1a subset had a better median progress-free survival (not reach vs. 17 months, p < 0.001) in the immuno-chemotherapy cohort (n = 163).

CONCLUSION

Oligometastasis (≤2 organs/≤5 lesions) and liver metastasis are prognostic for M1-NPC. Subdivision of M1-NPC into M1a (oligometastasis without liver metastasis) and M1b (liver metastasis or polymetastasis) depicts the prognosis well in M1-NPC patients who received immuno-chemotherapy.

Clinical observational study on the efficacy of induction chemotherapy sequential concurrent radiotherapy combined with targeted therapy in patients with locally advanced EGFR-positive nasopharyngeal carcinoma: prediction model construction and efficacy testing

OBJECTIVE

To establish a nomogram for prediction of prognosis in EGFR-positive advanced nasopharyngeal carcinoma (NPC) patients who were treated with induction chemotherapy (IC) and concurrent chemoradiotherapy (CCRT). The clinical data of 124 NPC patients who received IC sequential CCRT combined with targeted therapy at the Department of Oncology of the Affiliated Hospital of North Sichuan Medical College between June 2017 and September 2022 were retrospectively reviewed. Logistic regression analysis was used to identify the prognostic factors for building the nomogram.

RESULTS

Multifactorial regression analysis showed that the use of targeted drugs and T stage were independent factors of prognosis (p < 0.05) and the equation Y = 0.476 + 2.733X1 + - 0.758 × 2 (Y = efficacy, X1 = targeted drug therapy, X2 = T stage) was obtained. Then, a prognostic nomogram prediction model was constructed. The prediction model was validated internally for 1000 times using the Bootstrap resampling method with an accuracy of 79.29%. The calibration curve suggests that the predicted values fit well with the true values. The clinical decision curve (DCA) shows that the model has good clinical predictive value.

CONCLUSION

The use of targeted therapy significantly improved the prognosis of patients with EGFR-positive advanced NPC. For advanced NPC patients with T1 and T2 stages, IC sequenced with CCRT is more effective, and the addition of targeted therapy can further improve patients' prognosis. For advanced NPC patients with T3 and T4 stages, IC sequenced with CCRT is ineffective, and the addition of targeted therapy can significantly improve patient prognosis.

Locoregional radiotherapy improves survival outcomes in de novo metastatic nasopharyngeal carcinoma treated with chemoimmunotherapy

BACKGROUND

We aimed to investigate the efficacy of locoregional radiotherapy (LRRT) in patients with de novo metastatic nasopharyngeal carcinoma (dmNPC) receiving chemotherapy combined with anti-programmed cell death receptor-1 monoclonal antibodies (anti-PD-1 mAbs) as first-line treatment and identify optimal candidates for LRRT.

MATERIALS AND METHODS

We enrolled patients with dmNPC receiving platinum-based palliative chemotherapy and anti-PD-1 mAbs followed or not followed by LRRT from four centers. The endpoints were progression-free survival (PFS), objective response rate (ORR), and overall survival (OS). We used the inverse probability of treatment weighting (IPTW) to balance the baseline characteristics of the LRRT and non-LRRT groups to minimize selection bias before comparative analyses. Multivariate analyses were carried out using the Cox proportional hazards model.

RESULTS

We included 163 patients with dmNPC (median follow-up: 22 months). The median PFS was 20 months, and the ORR was 92.0%; the median OS was not achieved. After IPTW adjustments, patients who received LRRT had a significant survival benefit over those not receiving LRRT (median PFS: 28 versus 15 months, P < 0.001). The Epstein-Barr virus DNA (EBV DNA) level after four to six cycles of anti-PD-1 mAbs [weighted hazard ratio (HR): 2.19, 95% confidence interval (CI) 1.22-3.92, P = 0.008] and LRRT (weighted HR: 0.58, 95% CI 0.34-0.99, P = 0.04) were independent prognostic factors. Patients with undetectable EBV DNA levels after four to six cycles of anti-PD-1 mAbs (early EBV DNA clearance) benefitted from LRRT (HR: 0.41, 95% CI 0.22-0.79, P = 0.008), whereas those with detectable levels did not (HR: 1.30, 95% CI 0.59-2.87, P = 0.51).

CONCLUSIONS

Palliative chemotherapy combined with anti-PD-1 mAbs followed by LRRT was associated with improved PFS in patients with dmNPC, especially for patients with early EBV DNA clearance.

Proposed prognostic subgroups and facilitated clinical decision-making for additional locoregional radiotherapy in de novo metastatic nasopharyngeal carcinoma: a retrospective study based on recursive partitioning analysis

BACKGROUND

The high heterogeneity of de novo metastatic nasopharyngeal carcinoma (dmNPC) makes its prognosis and treatment challenging. We aimed to accurately stage dmNPC and assess the patterns of treatment strategies for different risk groups.

METHODS

The study enrolled a total of 562 patients, 264 from 2007 to 2013 in the training cohort and 298 from 2014 to 2017 in the validation cohort. Univariate and multivariate Cox regression analyses were conducted to determine the independent variables for overall survival (OS). Recursive partitioning analysis (RPA) was applied to establish a novel risk-stratifying model based on these variables.

RESULTS

After pairwise comparisons of OS, three risk groups were generated: low-risk (involved lesions ≤ 4 without liver involvement), intermediate-risk (involved lesions ≤ 4 with liver involvement or involved lesions > 4 with Epstein-Barr virus (EBV)-DNA < 62,000 copies/ml), and high-risk (involved lesions > 4 with EBV-DNA > 62,000 copies/ml). The 3-year OS rate differed significantly between groups (80.4%, 42.0%, and 20.4%, respectively, all P < 0.05). Adding locoregional intensity-modulated radiotherapy (LRRT) followed by palliative chemotherapy (PCT) resulted in a significant OS benefit over PCT alone for the low- and intermediate-risk groups (P = 0.0032 and P = 0.0014, respectively). However, it provided no survival benefits for the high-risk group (P = 0.6). Patients did not benefit from concurrent chemotherapy during LRRT among the three subgroups (P = 0.12, P = 0.13, and P = 0.3, respectively). These results were confirmed with the validation cohort.

CONCLUSIONS

The novel RPA model revealed superior survival performance in subgroup stratification and could facilitate more effective treatment strategies for dmNPC.