Role of chemotherapy in patients with nasopharynx carcinoma treated with radiotherapy (MAC-NPC): an updated individual patient data network meta-analysis

Sintilimab‑induced acute erosive hemorrhagic gastritis as an adverse reaction of third‑line therapy in a nasopharyngeal carcinoma patient: A case report

Immune checkpoint inhibitors (ICIs) have become an important treatment option for patients with nasopharyngeal carcinoma. With the increasing use of such agents, immune-related adverse events (irAEs) have become a concern. Identifying and managing the toxicity and side effects of ICIs is crucial, since it not only has implications for their safety but also the intensity and efficacy of subsequent use by patients. The present case report documents a 40-year-old male patient with acute erosive hemorrhagic gastritis associated with sintilimab treatment. In particular, the clinical manifestations, treatment, side effects and prognosis of this case was focused upon. The patient was diagnosed with locally advanced nasopharyngeal carcinoma (cT4N3M0 stage IVa) and developed bone metastases after 1 year of standard radiotherapy and adjuvant chemotherapy. After the first- and second-line treatments, pulmonary metastases occurred and sintilimab monotherapy was used as the third-line therapy. During the course of treatment, the optimal outcome for this patient was partial response according to the Response Evaluation Criteria in Solid Tumors (version 1.1). However, after 14 cycles of sintilimab the patient developed melena and epigastric pain and was diagnosed with acute erosive hemorrhagic gastritis, which was treated with methylprednisolone therapy. Progression-free survival with the third-line treatment was 542 days. Sintilimab-associated hemorrhagic gastritis is not fully recognized as an irAE. Therefore, early identification, diagnosis and management of irAEs are critical for subsequent therapy and progression-free survival of patients.

Induction vs Adjuvant Chemoradiotherapy in Patients With High-Risk N2 to N3 Nasopharyngeal Carcinoma: A Phase 3 Randomized Clinical Trial

Importance

It remains uncertain which chemotherapy sequence is more effective for locoregionally advanced nasopharyngeal carcinoma.

Objective

To compare the efficacy and safety of induction-concurrent with concurrent-adjuvant chemotherapy in high-risk N2 to N3 nasopharyngeal carcinoma.

Design, Setting, and Participants

In this open-label, randomized, phase 3 clinical trial conducted at Sun Yat-sen University Cancer Center (China) from November 20, 2017, to March 19, 2021, patients aged 18 to 65 years with stage T1-4N2-3M0 and a pretreatment Epstein-Barr virus DNA level of 1500 or more copies/mL were enrolled. The data were analyzed from December 2024 to March 2025.

Intervention

The patients were randomly assigned to receive 3 cycles of paclitaxel-cisplatin-fluorouracil induction chemotherapy followed by concurrent chemoradiotherapy or concurrent chemoradiotherapy followed by 3 cycles of cisplatin-fluorouracil adjuvant chemotherapy.

Main Outcome and Measure

The primary end point was 3-year progression-free survival, assessed locally by the investigator and defined as the time from random assignment to documented local or regional relapse, distant metastasis, or death of any cause, whichever occurred first.

Results

A total of 162 patients (median [IQR] age, 44 [34-53] years; 40 female individuals [24.7%]) were assigned to the induction-concurrent group and 162 (median [IQR] age, 45 [37-52] years; 36 female individuals [22.2%]) to the concurrent-adjuvant group. Regarding the data cutoff (October 8, 2024), the median (IQR) follow-up period was 60.4 (58.2-62.6) months. The 3-year progression-free survival rates were 73.5% (95% CI, 65.9%-79.6%) in the induction-concurrent group and 70.4% (95% CI, 62.7%-76.8%) in the concurrent-adjuvant group (stratified hazard ratio, 0.86; 95% CI, 0.58-1.27; P = .45). The most common short-term grade 3 or worse adverse events were leukopenia (53 of 160 [33.1%] in the induction-concurrent group vs 47 of 142 [33.1%] in the concurrent-adjuvant group), neutropenia (52 [32.5%] vs 32 [22.5%], respectively), and mucositis (47 [29.4%] vs 42 [29.6%], respectively). The most common grade 3 or worse late adverse event was auditory or hearing loss (10 [6.3%] vs 12 [8.5%], respectively). Two patients in the induction-concurrent group died of treatment-related toxic effects. No treatment-related death occurred in the concurrent-adjuvant group.

Conclusions and Relevance

This randomized clinical trial found that induction-concurrent chemotherapy did not significantly improve progression-free survival compared with concurrent-adjuvant chemotherapy in high-risk N2 to N3 nasopharyngeal carcinoma. Both treatment strategies were effective, and clinicians should discuss with the patients about the potential risks and benefits of the induction chemotherapy or adjuvant chemotherapy to provide the most appropriate treatment for patients with high-risk features.

Trial Registration

ClinicalTrials.gov Identifier: NCT03306121.

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.

Concurrent chemotherapy for older patients with locoregionally advanced nasopharyngeal carcinoma: A randomized clinical trial

INTRODUCTION

We aimed to evaluate the efficacy of two different radiotherapy strategies in elderly patients with locally advanced nasopharyngeal carcinoma (NPC) using geriatric assessment.

MATERIALS AND METHODS

We conducted a randomized phase 2 trial for older patients (≥ 65 years) with stage III-IVA NPC. Patients were randomized into either intensity-modulated radiotherapy (IMRT) alone (RT Arm) or concurrent chemoradiotherapy (CCRT Arm). The primary endpoint was therapeutic success. The secondary endpoints were survival, safety and geriatric assessment.

RESULTS

Between June 1, 2017 and June 11, 2019, 22 patients were allocated to the RT arm and 19 to the CCRT arm. There was therapeutic success in 11 patients (57.9 %) in the CCRT arm and 18 patients (81.8 %) in the RT arm. The median follow-up time was 60.4 months (interquartile range [IQR], 49.8-67.8) months. The five-year locoregional relapse-free survival, cancer-specific survival, and overall survival rates for patients in the CCRT and RT arms were 93.8 % and 85.7 % (p = 0.77), 93.8 % and 80.7 % (p = 0.12), 78.9 % and 56.8 % (p = 0.09), respectively. The five-year distant metastasis-free survival rates for patients in the CCRT and RT arms were 100.0 % and 76.6 % (p = 0.002), respectively. Compared with the CCRT arm, lower incidence of acute toxicities was observed in the RT arm, including grade 1 or higher vomiting, nausea, anemia, and leukopenia (p < 0.05).

DISCUSSION

CCRT was not more efficacious than IMRT alone but was more likely to cause acute toxicities in older patients with locally advanced NPC. CCRT should only be used in selected older patients with locally advanced NPC.

SYT7 accelerates nasopharyngeal carcinoma progression via ALDH1A3-mediated STAT3 signaling activation

Nasopharyngeal carcinoma (NPC) is a special histological and ethical type of head and neck cancer with unsatisfactory clinical outcome. Thus, exploring effective molecular targets is critical for NPC treatment. We observed increased expression levels of synaptotagmin-7 (SYT7) in NPC tissues, which correlated with unfavorable prognoses. Furthermore, knockdown of SYT7 in NPC cells suppressed proliferation and migration rates, and enhanced apoptosis. In contrast, overexpression of SYT7 accelerated NPC tumor growth. Using whole-genome gene arrays and immunoprecipitation-mass spectrometry assays, aldehyde dehydrogenase 1 family member A3 (ALDH1A3), a regulator of glycolytic metabolism, was identified as a critical downstream target of SYT7. Mechanistically, SYT7 binds and promotes ALDH1A3 deubiquitination, resulting in decreased ALDH1A3 degradation. Notably, we also observed an increased expression of ALDH1A3 in NPC. More importantly, the knockdown of ALDH1A3 resulted in suppressed proliferation, migration, glycolysis, and promoted apoptosis, all of which could be restored by the overexpression of SYT7 in NPC cells. Taken together, we found that SYT7 increases ALDH1A3-mediated STAT3 activation and glycolysis, contributing to NPC progression, which provides a possible molecular mechanism for the development of targeted therapeutics interventions.

Determining the optimal duration of oral adjuvant chemotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Concurrent chemoradiotherapy (CCRT) followed by adjuvant chemotherapy (AC) is the standard treatment for locoregionally advanced nasopharyngeal carcinoma (LA-NPC). However, the optimal duration of oral AC remains poorly defined.

METHODS

This study examined newly diagnosed patients between April 2017 and December 2020. The primary endpoint was overall survival (OS). Restricted cubic splines (RCS) and Kaplan-Meier method were used to evaluate the relationship between AC maintenance and survival. Inverse probability of treatment weighting (IPTW) was used to control for confounding factors.

RESULTS

The RCS demonstrated an L-shaped association between oral AC maintenance and OS. The risk of mortality was relatively flat after 12 months. Patients with oral AC duration >186 days (defined by RCS) had a significantly better OS (HR 0.23 [95% CI 0.10-0.55], log-rank p < 0.001), with a higher 3-year OS rate (98.7% [95% CI 96.8-100.0] vs 88.3% [95% CI 82.5-94.5]). For patients with pretreatment Epstein-Barr virus (EBV) DNA level >4000 copies/mL, mortality risk decreased to 1 at 194 days of AC duration.

CONCLUSIONS

The optimal duration of oral AC after CCRT was >186 days (6 months) for LA-NPC. And the maintenance beyond 12 months may not bring additional benefits.

Induction versus Concurrent Chemotherapy for Advanced Nasopharyngeal Carcinoma

BACKGROUND

Cisplatin-based concurrent chemoradiotherapy (CCRT) is the mainstay treatment for locoregionally advanced nasopharyngeal carcinoma (LA-NPC), which usually leads to intolerable toxicities. We investigated whether or not induction chemotherapy (IC) plus intensity-modulated radiation therapy (IMRT) could replace CCRT.

METHODS

This is an open-label, phase 3, noninferiority trial. Patients with stage T1-4N2-3 or T3-4N0-1 LA-NPC were randomly assigned (1:1) to receive gemcitabine (1000 mg/m2) and cisplatin (80 mg/m2) for two cycles followed by IMRT, or IMRT plus concomitant weekly cisplatin (40 mg/m2) for up to seven cycles. Two-year failure-free survival (FFS) was the primary end point, and noninferiority was confirmed by an upper limit of the 95% confidence interval (CI) for a hazard ratio of less than 2.12 (absolute margin of -10 percentage points). Secondary end points include overall survival, locoregional recurrence-free survival, distant metastasis-free survival, toxicity profile, and quality of life (QoL).

RESULTS

We enrolled 124 patients in the IC group and 125 patients in the CCRT group. The median follow-up was 60 months. Two-year FFS was 90.2% for IC versus 86.3% for CCRT, with a hazard ratio of 0.636 (95% CI, 0.267 to 1.514) and an absolute difference of 3.9 percentage points (95% CI, -5.2 to 13.0). Compared with the CCRT group, fewer grade ≥3 adverse events occurred in the IC group (47.5% vs. 61.5%; P=0.029), including leukopenia, anemia, mucositis, nausea, and dysphagia. IC was associated with better QoL, including global health status, social and cognitive functioning, fatigue, nausea and vomiting, pain, appetite loss, and constipation.

CONCLUSIONS

For 2-year FFS for LA-NPC, gemcitabine and cisplatin IC plus IMRT alone was noninferior to CCRT. (Funded by Key-Area Research and Development of Guangdong Province and others.).

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.

Advances in individualization of systemic treatment for locoregionally advanced nasopharyngeal carcinoma: a systematic review

BACKGROUND

The optimal treatment strategy (radiotherapy with induction, concurrent or adjuvant chemotherapy) for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) remains to be addressed. Identifying biomarkers related to precise prognostic risk stratification and treatment benefits gained have been explored in recent years.

METHODS

We carried out a systematic review of the published literature covering these topics. Of 3732 references screened, 26 articles were found eligible for inclusion.

RESULTS

Regarding the issue of treatment pathway in LA-NPC, induction chemotherapy is usually preferred over adjuvant chemotherapy. It is paramount to stress patient selection to identify those cases at high risk of relapse requiring systemic intensification. Concerning a role for Epstein-Barr virus (EBV) DNA-based personalized therapy, EBV DNA and its kinetics in plasma potentially represents a robust prognostic marker after (chemo)radiotherapy, but it is necessary to standardize test and cut-off levels.

CONCLUSIONS

This systematic review provides an overview of biomarker-guided systemic treatment designed to improve prognosis, including key aspects of current guidelines, biomolecular signature aspects and potential limitations between applicability to cancer treatment in endemic regions versus non-endemic regions.

Analysis of factors related to radiation-induced oral mucositis in patients with head and neck tumors undergoing radiotherapy

OBJECTIVE

To explore the risk factors of radiation-induced oral mucositis (RIOM) in patients with head and neck tumors undergoing radiotherapy.

METHODS

A retrospective collection was conducted on patients with head and neck tumors who underwent radiotherapy and chemotherapy in our hospital from April 1, 2015 to April 1, 2019. They were divided into an incidence group (n = 48) and a non-incidence group (n = 76) based on whether RIOM occurred, and relevant data was collected for comparison.

RESULTS

There were statistically significant differences between the two groups of patients in terms of tumor type, smoking percentage, education level percentage, tumor stage, oral mucosal inflammation stage, radiotherapy dose, mucosal protectants, and oral hygiene condition(P < 0.05); The regression analysis results showed that smoking (OR=1.274, 95 % CI: 1.095-2.007), high-dose radiotherapy (OR=1.223, 95 % CI: 1.098-2.077), and poor oral hygiene (OR=1.367, 95 % CI: 1.024-2.890) were risk factors for RIOM.

CONCLUSION

Smoking, high-dose radiotherapy, and poor oral hygiene were risk factors for RIOM in head and neck patients after radiotherapy and chemotherapy.

Multi-Omics Characterization of Genome-Wide Abnormal DNA Methylation Reveals FGF5 as a Diagnosis of Nasopharyngeal Carcinoma Recurrence After Radiotherapy

BACKGROUND

Aberrant expression and mutations in the fibroblast growth factor (FGF) family play crucial roles in cell differentiation, growth, and migration, contributing to tumor progression across various cancers. Nasopharyngeal carcinoma (NPC), a malignancy prevalent in East Asia, is primarily treated with radiotherapy; however, radioresistance remains a major challenge, leading to recurrence and poor outcomes. While FGFs are known to activate signaling pathways such as MAPK, PI3K/AKT, and JAK/STAT to promote cancer progression, the specific role of individual FGFs in NPC radioresistance remains unclear. Emerging evidence highlights FGF5 as a key player in NPC progression, metastasis, and radioresistance, underscoring its potential as a therapeutic target to overcome treatment resistance and improve clinical outcomes.

METHODS

We analyzed single nucleotide variation (SNV) data, gene expression, and DNA methylation patterns using cancer datasets, including TCGA and GTEx, to investigate FGF5 expression. Differentially expressed genes (DEGs) were identified and interpreted using functional enrichment analysis, while survival analysis and gene set enrichment analysis (GSEA) were conducted to identify clinical correlations. DNA methylation patterns were specifically assessed using the HumanMethylation850 BeadChips on tissue samples from nine recurrent and nine non-recurrent NPC patients. Functional assays, including cell viability, migration, invasion, and clonogenic survival assays, were performed to evaluate the effects of FGF5 on NPC cell behavior in vitro and in vivo.

RESULTS

FGF5 showed elevated SNV frequencies across multiple cancers, particularly in HNSC and NPC. DNA methylation analysis revealed an inverse relationship between FGF5 expression and methylation levels in recurrent NPC tumors. Functional assays demonstrated that FGF5 enhances migration, invasion, and radioresistance in NPC cells. High FGF5 expression was associated with reduced distant metastasis-free survival (DMFS) and increased radioresistance, highlighting its role in metastatic progression and recurrence.

CONCLUSIONS

FGF5 plays a significant role in the progression and recurrence of nasopharyngeal carcinoma. Its elevated expression correlates with increased migration, invasion, and radioresistance as well as reduced distant metastasis-free survival. These findings suggest that FGF5 contributes to the metastatic and recurrence potential of NPC, making it a potential target for therapeutic intervention in treating these cancers.

Clinical Outcomes for Nasopharyngeal Cancer in Non-Asian Patients: A Single-Center Experience

Background/Objectives: According to Globocan, Romania has the highest incidence of nasopharyngeal cancer (NPC) in Europe. Our objective was to evaluate the survival data for a cohort of non-Asian patient population treated with curative intent at a tertiary cancer center in Romania. Methods: We retrospectively analyzed 161 patients with histologically proven, non-metastatic NPC treated at our institution between October 2014 and December 2021 with intensity modulated arc radiotherapy (IMRT) with or without neoadjuvant or concomitant chemotherapy according to the stage of the disease. Kaplan-Meier estimates of overall, disease-free, locoregional relapse free and distant metastasis free survival were calculated. The log-rank test was used to determine significant prognostic determinants of overall and disease-free survival. Results: The median age was 50 years (range 19-80), 88% had nonkeratinizing undifferentiated carcinoma. Epstein Barr virus status was not evaluated routinely. 42.2% of patients were stage III and 46% stage IVA disease. Induction chemotherapy was prescribed for 72.7% of patients and 89.4% received concurrent chemotherapy. After a median follow up of 44 months (range: 3.6, 104.7 months), the estimated 3 years overall, disease free, locoregional relapse free and distant metastasis free survival of the entire cohort were 82.6%, 73.3%, 83.2% and 86.3% respectively. On testing interactions, concomitant chemotherapy offered significant survival benefit (HR-0.287; 95% CI 0.137-0.603; p = 0.001) and cumulative Cisplatin dose of more than 100 mg/mp was statistically significant for survival (HR-0.350;95% CI 0.157-0.779; p = 0.01) Conclusions: This is the largest retrospective series of nasopharyngeal cancer from Romania reporting survival data. Despite the high percentage of advanced stage disease our data shows very good disease control. Compliance to optimal concomitant chemotherapy should represent a priority in clinical practice in a non-Asian patient population.

Specific Immune Responses and Oncolytic Effects Induced by EBV LMP2A-Armed Modified Ankara-Vaccinia Virus Vectored Vaccines in Nasopharyngeal Cancer

BACKGROUND

The Epstein-Barr virus (EBV) is intricately linked to a range of human malignancies, with EBV latent membrane protein 2A (LMP2A) emerging as a potential target antigen for immunotherapeutic strategies in the treatment of nasopharyngeal carcinoma (NPC).

METHODS

The modified vaccinia virus Ankara (MVA) is universally used in vector vaccine research because of its excellent safety profile and highly efficient recombinant gene expression. Here, we constructed a novel MVA-LMP2A recombinant virus and investigated its specific immune response induction and oncolytic effect.

RESULTS

An immunization dose of 2 × 107 PFU induced the highest specific immune response, which was no longer increased by boost injections after four doses. Three weeks post-final immunization, the specific immune response reached its peak. The MVA-LMP2A vaccine-induced LMP2A-specific cytotoxic T lymphocytes (CTLs), which exhibited substantial efficacy against target cells and effectively inhibited tumor growth.

CONCLUSIONS

Thus, the MVA-LMP2A recombinant virus effectively induces strong LMP2A-specific cellular and humoral immune responses and anti-tumor activity. This work provides a promising therapeutic strategy for developing NPC candidate vaccines, as well as a reference for the treatment of EBV LMP2-associated malignancies.

Neoadjuvant and adjuvant toripalimab for locoregionally advanced nasopharyngeal carcinoma: a randomised, single-centre, double-blind, placebo-controlled, phase 2 trial

BACKGROUND

Patients with locoregionally advanced nasopharyngeal carcinoma with a high pretreatment plasma concentration of Epstein-Barr virus (EBV) DNA remain at high risk for recurrence after concurrent chemoradiotherapy. This study aimed to compare the efficacy and safety of neoadjuvant-adjuvant treatment with the PD-1 inhibitor toripalimab and concurrent chemoradiotherapy versus placebo and concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma.

METHODS

This randomised, single-centre, double-blind, placebo-controlled, phase 2 trial was conducted at Sun Yat-sen University Cancer Centre in Guangzhou, China. Adult patients (aged 18-65 years) with newly diagnosed high-risk stage III-IVa locoregionally advanced nasopharyngeal carcinoma, with a pretreatment plasma EBV DNA concentration of at least 1500 copies per mL and an Eastern Cooperative Oncology Group performance score of 0-1, were eligible. Patients were randomly assigned (2:1) using an interactive web response system (block size of six), stratified by TNM stage (III vs IVa), to neoadjuvant toripalimab (240 mg intravenously) or placebo once every 2 weeks for two cycles, followed by concurrent cisplatin (100 mg/m2 intravenously) on days 1, 22, and 43 during intensity-modulated radiotherapy and adjuvant toripalimab (240 mg intravenously) or placebo once every 3 weeks for up to eight cycles. The primary endpoint was 2-year progression-free survival in the intention-to-treat population. This study was registered with ClinicalTrials.gov, NCT03925090, and is closed to enrolment; follow-up is ongoing.

FINDINGS

Between Dec 6, 2019, and Dec 9, 2021, 150 patients were enrolled and randomly assigned to the toripalimab group (n=100) or placebo group (n=50). 115 (77%) patients were male and 35 (23%) were female. As of data cutoff (May 31, 2024), median follow-up for progression-free survival was 37·8 months (IQR 34·2-46·5) for the intention-to-treat population analyses. 2-year progression-free survival was higher in the toripalimab group (92·0% [95% CI 86·7-97·3]) than in the placebo group (74·0% [61·8-86·2]; stratified hazard ratio 0·40 [95% CI 0·18-0·89]; log-rank p=0·019). The most common grade 3 or worse acute adverse events (occurring within 1 year of randomisation) were leukopenia (40 [40%] of 99 patients in the toripalimab group vs 22 [44%] of 50 patients in the placebo group), mucositis (28 [28%] vs ten [20%]), neutropenia (17 [17%] vs nine [18%]), anaemia (16 [16%] vs five [10%]), and weight loss (12 [12%] vs six [12%]). The most common grade 3 or worse late adverse events (occurring >1 year after randomisation) was auditory or hearing loss (eight [8%] vs four [8%]). Immune-mediated adverse events of grade 3 or worse occurred in ten (10%) patients only in the toripalimab group. One (2%) of 50 patients in the placebo group died due to septic shock caused by bacteraemia considered not treatment related. There were no treatment-related deaths in the toripalimab group.

INTERPRETATION

Our findings suggested that a so-called sandwich approach involving toripalimab (in the neoadjuvant and adjuvant phases) combined with concurrent chemoradiotherapy could be a highly promising therapy for the treatment of locoregionally advanced nasopharyngeal carcinoma. Phase 3 non-inferiority trials are warranted comparing neoadjuvant and adjuvant toripalimab versus cisplatin plus gemcitabine neoadjuvant chemotherapy combined with concurrent chemoradiotherapy.

FUNDING

National Key Research and Development Program of China, National Natural Science Foundation of China, Guangdong Basic and Applied Basic Research Foundation, Science and Technology Program of Guangzhou, Sun Yat-sen University Clinical Research 5010 Program, Innovative Research Team of High-level Local Universities in Shanghai, Postdoctoral Innovative Talent Support Program, Planned Science and Technology Project of Guangdong Province, Key Youth Teacher Cultivating Program of Sun Yat-sen University, and Fundamental Research Funds for the Central Universities.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

[Special entities of the head and neck region: cancers of the nasopharynx, (para)nasal cavities, salivary glands, and the thyroid gland : Post ASCO 2024]

BACKGROUND

Malignancies of the nasopharynx (NPC), the (para)nasal cavities, the salivary glands, and the thyroid gland are distinct to head and neck squamous cell carcinomas (HNSCC) in the oro-/hypopharynx and larynx in terms of etiology, tumor biology, and the therapeutic concept.

OBJECTIVE

The contributions to the 2024 American Society of Oncology (ASCO) Annual Meeting provide insight into the latest developments in these "special entities of the head and neck region."

METHODS

Abstracts were examined for their clinical relevance and placed into context with current therapeutic concepts.

RESULTS AND CONCLUSION

In the treatment of locally advanced NPC, a randomized phase III study showed equivalence of induction (ICT) and adjuvant therapy (AT; NCT03306121). PD-1 inhibitors have become established in the palliative therapy of NPC in recent years and could now also play an increasing role in curation: the phase III study "Dipper" showed a significantly better 3‑year event-free survival in patients adjuvantly treated with camrelizumab versus placebo after IT and definitive platinum-containing chemoradiotherapy (dRCT; 89% vs. 80%; NCT03427827). The phase III study "Beacon" showed complete remission in 30.5% of patients after IT with gemcitabine/cisplatin and the PD‑1 inhibitor tislelizumab (three cycles), a rate almost twice as high as with gemcitabine/cisplatin alone (NCT05211232). Intensification of dRCT in NPC using EGFR and VEGF inhibitors appears promising (NCT04447326). Abstracts on salivary gland and nasal and sinus cancers emphasize the importance of targeted therapies. In anaplastic thyroid carcinoma, the combination of a PD‑1 inhibitor and a CTLA4 inhibitor showed a 50% response.

Risk Factors for Unplanned Emergency Department Visits in Patients with Nasopharyngeal Carcinoma During Radiotherapy

Background/Objectives: Nasopharyngeal carcinoma (NPC) is commonly treated with radiotherapy (RT) or concurrent chemoradiotherapy (CCRT). However, unplanned emergency department (ED) visits during treatment can disrupt therapy and impact patient outcomes. This study aims to identify the risk factors associated with unplanned ED visits in patients with NPC receiving RT or CCRT. Methods: We retrospectively analyzed 2111 patients with NPC treated between 2001 and 2019 at Chang Gung Memorial Hospital. Patients were categorized based on whether they experienced an unplanned ED visit during or up to three months post-treatment. Demographic and clinical variables were compared using the Chi-squared test, and survival outcomes were assessed using Kaplan-Meier analysis. Results: Among the cohort, 573 patients (27.2%) experienced at least 1 unplanned ED visit. Risk factors for unplanned ED visits included older age (p < 0.001), hypertension (p < 0.001), higher Charlson Comorbidity Index (p = 0.001), and advanced clinical stage (T stage, p = 0.0046; N stage, p = 0.0034; M stage, p = 0.0008). No significant difference in ED visit rates was observed between RT alone and CCRT groups. Conclusions: Unplanned ED visits were common during NPC treatment, with risk factors primarily related to patient age, comorbidities, and disease stage. Identifying high-risk patients may enable interventions to reduce ED visits, improve survival outcomes, and alleviate healthcare costs.

Head and Neck Squamous Cell Carcinoma: Insights from Dual-Energy Computed Tomography (DECT)

Head and neck cancer represents the seventh most common neoplasm worldwide, with squamous cell carcinoma being the most represented histologic variant. The rising incidence of the neoplastic pathology of this district, coupled with the drastic changes in its epidemiology over the past decades, have posed significant challenges to physicians worldwide in terms of diagnosis, prognosis, and treatment. In order to meet these challenges, a considerable amount of effort has been spent by the authors of the recent literature to explore new technologies and their possible employment for the better diagnostic and prognostic definition of head and neck squamous cell carcinoma (HNSCC). Among these technologies, a growing interest has been gathering around the possible applications of dual-energy computed tomography (DECT) in head and neck pathology. Dual-energy computed tomography (DECT) utilizes two distinct X-ray energy spectra to obtain two datasets in a single scan, allowing for material differentiation based on unique attenuation profiles. DECT offers key benefits such as enhanced contrast resolution, reduced beam-hardening artifacts, and precise iodine quantification through monochromatic reconstructions. It also creates material decomposition images, like iodine maps, aiding in tumor characterization and therapy assessment. This paper aims to summarize recent findings on the use of DECT in HNSCC, providing a comprehensive overview to aid further research and exploration in the field.

The prognostic implications of radiologic extranodal extension in the lymph nodes of patients with nasopharyngeal cancer

Objective: This study was developed to explore the prognostic relevance of radiologic extranodal extension (rENE) in lymph node-positive nasopharyngeal carcinoma (NPC) patients.Materials and methods: A retrospective review of data from 249 eligible patients with NPC was performed, with magnetic resonance imaging scans being used for rENE grading. The prognostic value of rENE was assessed through univariate and multivariate analyses.Results: Log-rank tests revealed significant differences between patients with and without rENE in terms of overall survival, progression-free survival (PFS) and distant metastasis-free survival (DMFS). G2 and G3 patients tended to exhibit worse PFS and DMFS relative to G0/G1 patients (p < 0.05). Long-term chemotherapy cycles were associated with significant improvements in the PFS and DMFS of G2 and G3 patients.Conclusion: These results suggest that higher rENE grades (G2/G3) are independently associated with worse survival outcomes among NPC patients, with more aggressive treatment strategies potentially affording greater prognostic benefits to these individuals.

Gemcitabine/Cisplatin versus docetaxel, cisplatin and 5-fluorouracil as induction chemotherapy in locally advanced nasopharyngeal carcinoma

Induction chemotherapy followed by concomitant chemoradiation is the standard therapy for patients with locoregionally advanced NPC. There is a limitation of clinical studies that compare different induction regimens. The purpose of this work is to analyze the efficacy of two distinct chemotherapy regimens, docetaxel, cisplatin, and 5-fluorouracil (TPF) and gemcitabine/cisplatin (GP), in treating patients with loco-regionally advanced nasopharyngeal carcinoma (NPC). We analyzed 81 patients initially presented with stage III-IVA NPC from January 2019 to June 2023. Participants were randomized in 1:1 ratio to obtain GP regimen or TPF regimen followed by concurrent CRT. The overall response rate was 97.5% after induction chemotherapy in both groups (In GP arm, 78% of patients achieved complete remission compared to 70% of patients treated with TPF regimen). The satisfactory tumor response to induction chemotherapy was linked with significant enhanced progression free survival [CI (3.37-13.92), HR=2.16, P=0.001] and overall survival [CI (3.717-9.443), HR=1.873, P=0.001]. The GP regimen was both efficacious and well-tolerated. Leucopenia and neutropenia (Grade 3-4) were significantly lower in GP group contrasted to in TPF group. There was no significant difference in the 3-year DFS and OS between GP and TPF protocols.

Comparing long-term efficacy and safety of GP versus TPF sequential chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: a propensity score-matched analysis

PURPOSE

To evaluate the long-term efficacy and safety of GP and TPF sequential chemotherapy regimens in patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

From 2005 to 2016, a total of 408 LA-NPC patients treated with GP or TPF sequential chemoradiotherapy were retrospectively included. Propensity Score Matching (PSM) was employed to balance the baseline variables. Survival outcomes and acute toxicities were compared between both groups.

RESULTS

A total of 230 patients were selected by 1:1 PSM. At a median follow-up of 91 months, no significant differences were observed between the matched GP and TPF groups regarding 5-year overall survival, progression-free survival, distant metastasis-free survival, and locoregionally relapse-free survival (83.4% vs. 83.4%, P = 0.796; 75.6% vs. 68.6%, P = 0.301; 86.7% vs. 81.1%, P = 0.096; and 87.4% vs. 87.2%, P = 0.721). Notable disparities in adverse effects were identified, with higher incidences of grade 3/4 thrombocytopenia in the GP group while grade 3/4 leukopenia and neutropenia in the TPF group. Though not recorded in our cohort, combined with the FAERS database, thrombotic adverse reactions are a concern for the GP regimen, while the TPF regimen requires vigilance for life-threatening adverse reactions such as septic shock, acute respiratory distress syndrome, and laryngeal edema.

CONCLUSION

No significant difference in long-term outcomes was observed between the GP and TPF sequential chemotherapy regimens for LA-NPC. Differences in adverse effects should be noted when choosing the regimen.

The efficacy of adjuvant chemotherapy in patients with different midpoint-radiotherapy Epstein-Barr virus DNA plasma loads

OBJECTIVES

This study aimed to evaluate the efficacy of adjuvant chemotherapy (AC) in patients with different midpoint-radiotherapy (mid-RT) Epstein-Barr virus (EBV) DNA plasma loads for locoregionally advanced nasopharyngeal carcinoma (NPC), and to provide decision-making regarding the use of AC.

MATERIALS AND METHODS

A total of 675 consecutive patients diagnosed with stage III-IVa NPC were enrolled in this study. All patients underwent concurrent chemoradiotherapy (CCRT), either with or without induction chemotherapy or AC, or a combination of both. The primary endpoint of this study was progression-free survival (PFS).

RESULTS

Among the 675 enrolled patients, 248 (36.7 %) received AC and 427 (63.3 %) were only observed after CCRT. In total, 149 (22.1 %) patients had detectable mid-RT EBV DNA levels, whereas 526 (77.9 %) had undetectable mid-RT EBV DNA levels. Patients with detectable mid-RT EBV DNA had worse 5-year PFS than those with undetectable mid-RT EBV DNA (74.8 % vs. 81.9 %, P = 0.045). AC group showed significantly better 5-year PFS than observation in patients with detectable mid-RT EBV DNA (82.8 % vs. 66.8 %; HR, 0.480; 95 % CI 0.250-0.919, P = 0.027). Multivariate analyses demonstrated that the treatment methods (AC vs. observation) were independent prognostic factors for PFS (HR, 0.37; 95 % CI 0.19-0.74, P = 0.005). However, in patients with undetectable mid-RT EBV DNA (5-year PFS: HR 0.873, 95 % CI 0.565-1.349, P = 0.52), AC group showed no survival benefit for observation.

CONCLUSION

AC could reduce the risk of disease progression compared to observation in patients with detectable mid-RT EBV DNA. Our findings suggest that AC is effective in patients at a high risk of treatment failure.

Determining the optimal timing of adjuvant chemotherapy initiation after concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Studies on several malignancies have suggested that the time to commencement of adjuvant chemotherapy (AC) is associated with survival outcomes. There have, however, been no relevant reports of nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

This clinical study examined newly diagnosed patients between April 2017 and December 2020. The primary endpoint was progression-free survival (PFS). Inverse probability of treatment weighting was used to control for confounding factors. Cox models with restricted cubic splines, Kaplan-Meier method and log-rank tests were used to evaluate the relationship between AC timing and survival.

RESULTS

A total of 551 patients were identified [median age, 45 years (interquartile range 36-52 years); 383 (69.5%) male]. Restricted cubic splines demonstrated that the timing of AC initiation had a U-shaped association with PFS. The risk of disease progression decreased within 37 days and subsequently increased. From 37 to 90 days, each additional 7-day delay conferred worse PFS of 1.32 months {hazard ratio (HR): 1.14 [95% confidence interval (CI) 1.01-1.28], P = 0.04}. The cut-off value of the receiver operating characteristic curve for initiation was 69.5 days. At a median follow-up of 48 months, the PFS was significantly better in patients initiated within 69.5 days [HR: 2.18 (95% CI 1.17-4.06), log-rank P = 0.009], with a higher 3-year rate [78.8% (95% CI 75.1% to 82.7%) versus 59.0% (95% CI 42.2% to 82.5%)] than beyond 69.5 days. Positive results were also observed in secondary endpoints. The initiation group was an independent prognostic factor [HR: 2.28 (95% CI 1.42-3.66), P < 0.001].

CONCLUSIONS

The optimal timing of AC initiation is ∼37 days after concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma. A delay beyond 69.5 days is associated with compromised survival. Efforts should be made to address the reasons for delays and ensure the timely initiation of AC.

Global trends in research of nasopharyngeal carcinoma: a bibliometric and visualization analysis

Objective

This study aims to assess the current research status, focus areas, and developmental trends in nasopharyngeal carcinoma (NPC) through a bibliometric analysis.

Methods

Articles focusing on NPC published from 2000 to 2023 were retrieved from the Web of Science database. VOSviewer and CiteSpace were used for bibliometric and visual analysis.

Results

A total of 14516 related publications were retrieved. There has been a steady increase in the number of NPC-related publications from 2000 to 2023. China was the dominant country in this field with 8948 papers (61.64%), followed by the USA (2234, 15.39%). Sun Yat-sen University was the most influential institution, while Ma J was the most prolific author. Furthermore, Head And Neck-journal For The Sciences And Specialties Of The Head And Neck was the most prolific journal. International Journal of Radiation Oncology Biology Physics had the highest total citation counts. "Introduction chemotherapy", "Concurrent chemotherapy", "Epithelial-mesenchymal transition", "Cancer stem cells", "MicroRNAs", "LncRNA", "Exosomes", and "Biomarker" were the most common keywords. The reference "Chen YP, 2019, Lancet" had the highest citations and strong outbreak value.

Conclusion

The past two decades have witnessed a significant increase in research on NPC. The optimization of treatment mode is the most widely studied aspect at present. The mechanism of occurrence and development and the most favorable diagnostic and therapeutic targets are the research hotspots in the future.

Clinicopathologic Features and Efficacy of Induction Chemotherapy in Nasopharyngeal Carcinoma: Real-World Experience

INTRODUCTION

Nasopharyngeal carcinoma (NPC) accounts for 0.01% of all carcinomas, and 70% of patients have locally advanced disease with a poor prognosis. The mainstay therapy is chemoradiotherapy (CRT), and concurrent administration of platinum-based agents and irradiation provides high local control rates. However, induction (neoadjuvant) chemotherapy (ICT) prior to CRT is recommended for large tumors with a high tumor burden at the category 1 level. For ICT, platinum-based doublet or triplet combination regimens are recommended. Selected patients with a high tumor burden at the time of diagnosis who did not receive ICT before CRT were given adjuvant (consolidation) therapy after CRT. This multicenter study aimed to share our experience in treatment of NPC and evaluate the factors associated with survival.

METHODS

The study included patients diagnosed with NPC who were followed and treated between 2008 and 2022. Hundred and forty-two patients from 6 centers were evaluated. The factors associated with disease-free survival (DFS) and overall survival (OS) were evaluated.

RESULTS

The median age of our patients was 51 years (IQR: 16-81 years), and the male:female ratio was 2.5:1. A majority of patients (71%) had stage 3-4 disease. They had locally advanced disease, and 48 patients (34%) received ICT. Twenty patients (14%) received adjuvant therapy. The median follow-up was 41 months (range, 2.7-175.1 months). The median DFS in NPC was 92.6 months (range, 71.9-113.3 months), with a 40th month DFS of 70.9%. The median OS was 113 months (range, 91-135 months), with a 40th month OS of 84.7%. Median DFS was 95.3 months (range, 64.2-126.4 months) in patients who received ICT before CRT, which was longer than in the CRT-only group (p = 0.6). DFS at the 40th month was 75.1% in patients treated with ICT compared to 65.1% in the CRT-only group. Median OS was 117 months (range, 92-142 months) in patients receiving ICT, which was longer than in the CRT-only group (p = 0.4). OS at the 40th month was 86.7% in patients receiving ICT but 83.6% in the CRT-only group.

CONCLUSIONS

Both the objective response rate and survival were longer in patients who radiologically responded to CRT following ICT. Nonresponse to ICT is a negative predictive indicator. The role of ICT in locally advanced NPC is increasing.

Phase I dose-escalation study of nab-paclitaxel combined with cisplatin and capecitabin as induction chemotherapy followed by concurrent chemoradiotherapy in patients with nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

Nab-paclitaxel is a promising albumin-bound paclitaxel with a therapeutic index superior to that of docetaxel, but the optimal dose of nab-paclitaxel combined with cisplatin and capecitabine as induction chemotherapy followed by concurrent chemoradiotherapy for patients with locally advanced nasopharyngeal carcinoma remains unknown.

MATERIALS AND METHODS

This was an open-label, single-arm study investigating the safety and efficacy of nab-paclitaxel + cisplatin + capecitabin as IC for three cycles, followed by cisplatin CCRT, conducted by using the standard "3 + 3" design in LA-NPC. If more than one-third of the patients in a cohort experienced dose-limiting toxicity (DLT), the dose used in the previous cohort was designated the maximum tolerated dose (MTD). The recommended phase 2 dose (RP2D) was defined as one level below the MTD.

RESULTS

From 29 May 2021 to 17 March 2022, 19 patients with LA-NPC were enrolled, one patient withdrew informed consent. Two DLTs occurred in cohort 4 (grade 4 febrile neutropenia and grade 3 peripheral neuropathy), and an MTD was established as 225 mg/m2. The most frequent grade 3 or 4 adverse events were neutropenia (16.7 %), hypertriglyceridemia (16.7 %), leukopenia (5.6 %) and peripheral neuropathy (5.6 %) during IC.

CONCLUSION

The RP2D is nab-paclitaxel 200 mg/m2 on day 1, combined with cisplatin 75 mg/mg2 on day 1 and capecitabin1000 mg/m2 on days 1-14, twice a day, every 3 weeks, for three cycles as an IC regimen prior to CCRT.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04850235.

Definitive radiotherapy for nasopharyngeal carcinoma in Japan: analysis of cases in the National Head and Neck Cancer Registry from 2011 to 2014

OBJECTIVE

This study aimed to analyze the nationwide prognosis of patients with nasopharyngeal carcinoma who underwent definitive radiotherapy in Japan, utilizing the National Head and Neck Cancer Registry data.

METHODS

A total of 741 patients diagnosed with primary nasopharyngeal carcinoma were screened from 2011 to 2014. The inclusion criteria were histologically proven nasopharyngeal squamous cell carcinoma, receiving definitive radiotherapy, and no distant metastases. Patients with unclear prognoses or unknown staging were excluded. The primary endpoint was 5-year overall survival, and secondary endpoints were 5-year progression-free survival and survival by stage.

RESULTS

A total of 457 patients met the inclusion criteria. The median age was 60 years, and 80% were male. The proportions of patients with performance status 0, 1, 2 and 3 were 69, 10, 1 and 1%, respectively. Chemoradiotherapy was administered to 84.7%. Radiotherapy modalities were recorded only for 29 patients (three received intensity-modulated radiotherapy and 26 received two/three-dimensional radiotherapy). Of those included, 7.4, 24.7, 35.7, 24.5 and 7.7% had Stage I, II, III, IVA and IVB disease, respectively. The 5-year overall survival was 72.5% for all patients: 82.6, 86.6, 76.0, 51.4 and 66.5% for Stage I, II, III, IVA and IVB disease, respectively. The 5-year progression-free survival was 58.6%: 75.6, 66.8, 61.5, 43.7 and 46.5% for Stage I, II, III, IVA and IVB disease, respectively.

CONCLUSIONS

This nationwide survey demonstrated favorable prognoses and provided valuable foundational data for similar future surveys to monitor the penetration of appropriate treatment and changes in clinical structures based on new evidence.