Establishment and Validation of Prognostic Nomograms for Endemic Nasopharyngeal Carcinoma

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

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

The prognostic value of pretreatment 18F-FDG PET-CT parameters with peripheral blood markers in patients with de novo metastatic nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

To develop and validate a prognostic nomogram based on pretreatment 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET-CT)radiomics parameters and peripheral blood markers for risk stratification in patients with de novo metastatic nasopharyngeal carcinoma (dmNPC).

MATERIALS AND METHODS

A total of 558 patients with dmNPC were retrospectively enrolled between 2011 and 2019. Eligible patients were randomly divided into training and validation cohorts (7:3 ratio). A Cox regression model was used to identify prognostic factors for overall survival (OS). The predictive accuracy and discriminative ability of the prognostic nomogram were determined using the concordance index (C-index) and calibration curve.

RESULTS

Independent factors derived from multivariable analysis of the training cohort to predict death were lactate dehydrogenase levels, pretreatment Epstein-Barr virus DNA, total lesion glycolysis of locoregional lesions, number of metastatic lesions, and age, all of which were assembled into a nomogram with (nomogram B) or without PET-CT parameters (nomogram A). The C-index of nomogram B for predicting death was 0.70, which was significantly higher than the C-index values for nomogram A. Patients were then stratified into low- and high-risk groups based on the scores calculated using nomogram B for OS. The median OS was significantly higher in the low-risk group than in the high-risk group (69.60 months [95 % CI: 58.50-108.66] vs. 21.40 months [95 % CI: 19.20-23.90]; p＜0.01). All the results were confirmed in the validation cohort.

CONCLUSION

The proposed nomogram including PET-CT parameters yielded accurate prognostic predictions for patients with dmNPC, enabling effective risk stratification for these patients.

Clinical significance of serum lactate dehydrogenase combined with a multivariate model for predicting the near-term outcome of primary nasopharyngeal carcinoma

BACKGROUND AND OBJECTIVES

This investigation explores the clinical significance of integrating serum lactate dehydrogenase (LDH) with a multivariate model for assessing the short-term prognosis of primary nasopharyngeal carcinoma (NPC). Epstein-Barr virus (EBV) quantification is a crucial prognostic indicator in NPC cases, but not all patients with NPC test positive for EBV. Furthermore, widespread adoption of EBV-DNA quantification remains challenging due to its high cost. Consequently, it is imperative to incorporate additional convenient and cost-effective prognostic markers to comprehensively evaluate patient outcomes.

METHODS

This retrospective analysis included 203 newly diagnosed NPC cases treated at the Affiliated Qingyuan Hospital of Guangzhou Medical University between January 2018 and March 2022. The dataset included personal information and clinical data, and the treatment protocols followed the CSCO guidelines. Efficacy assessments were based on the RECIST 1.1 criteria and were conducted after induction chemotherapy and one week and three months after radiotherapy.

RESULTS

A noteworthy correlation emerged between baseline serum LDH levels and treatment efficacy at one week after radiotherapy (P = 0.03) and at three months after radiotherapy (P < 0.01). Additionally, a prognostic model that incorporates age (P = 0.010), LDH (P < 0.001), C-reactive protein (P = 0.010), and alkaline phosphatase (P = 0.005) demonstrated robust predictive accuracy and clinical applicability.

CONCLUSION

This investigation substantiates the significant correlation between baseline serum LDH levels and NPC outcomes. Furthermore, we introduce a refined prognostic model that holds promise for informing personalized treatment strategies, thereby contributing to the advancement of the diagnosis of NPC.

A novel fully automatic segmentation and counting system for metastatic lymph nodes on multimodal magnetic resonance imaging: Evaluation and prognostic implications in nasopharyngeal carcinoma

BACKGROUND

The number of metastatic lymph nodes (MLNs) is crucial for the survival of nasopharyngeal carcinoma (NPC), but manual counting is laborious. This study aims to explore the feasibility and prognostic value of automatic MLNs segmentation and counting.

METHODS

We retrospectively enrolled 980 newly diagnosed patients in the primary cohort and 224 patients from two external cohorts. We utilized the nnUnet model for automatic MLNs segmentation on multimodal magnetic resonance imaging. MLNs counting methods, including manual delineation-assisted counting (MDAC) and fully automatic lymph node counting system (AMLNC), were compared with manual evaluation (Gold standard).

RESULTS

In the internal validation group, the MLNs segmentation results showed acceptable agreement with manual delineation, with a mean Dice coefficient of 0.771. The consistency among three counting methods was as follows 0.778 (Gold vs. AMLNC), 0.638 (Gold vs. MDAC), and 0.739 (AMLNC vs. MDAC). MLNs numbers were categorized into three-category variable (1-4, 5-9, > 9) and two-category variable (<4, ≥ 4) based on the gold standard and AMLNC. These categorical variables demonstrated acceptable discriminating abilities for 5-year overall survival (OS), progression-free, and distant metastasis-free survival. Compared with base prediction model, the model incorporating two-category AMLNC-counting numbers showed improved C-indexes for 5-year OS prediction (0.658 vs. 0.675, P = 0.045). All results have been successfully validated in the external cohort.

CONCLUSIONS

The AMLNC system offers a time- and labor-saving approach for fully automatic MLNs segmentation and counting in NPC. MLNs counting using AMLNC demonstrated non-inferior performance in survival discrimination compared to manual detection.

The interplay between microRNAs and Nrf2 signaling in human cancers

MicroRNAs (miRNAs), as a class of nonprotein-coding RNAs, post-transcriptionally regulate the expression of target genes by base pairing to 3'-untranslated regions (3'-UTRs). Nuclear factor E2-related factor 2 (Nrf2) has been identified as a critical component of the antioxidant defense mechanism. Dysregulation is associated with chemoresistance and radioresistance in cancerous cells. MiRNA-mediated regulation of the Nrf2 signaling pathway has been shown to have important implications for the development of various cancers. In this article, we review the roles of miRNAs as regulators of the Nrf2 pathway in different human cancers. Ras-associated binding (Rab) proteins have an essential role regulation of vesicle transport, as well as oncogenic functions in preventing chemotherapy efficacy and cancer development. More importantly, increased evidence indicated that the interaction between miRNAs and Rabs has been determined to play critical roles in cancer therapy. However, the significant limitations in using miRNAs for therapeutic applications include cross-targeting and instability of miRNAs. The detailed aspect of the interaction of miRNAs and Rabs is not clearly understood. In the current review, we highlighted the involvement of these molecules as regulators of the Nrf2 pathway in cancer pathogenesis. Potential methods and several obstacles in developing miRNAs as an anticancer therapy are also mentioned.

The relationship between LDH and GLIM criteria for cancer cachexia: Systematic review and meta-analysis

INTRODUCTION

Cancer cachexia is a clinical condition characterized by recognizable "sickness behaviors" accompanied by loss of lean body tissue. The Global Leadership on Malnutrition (GLIM) has proposed phenotypic (unintentional weight loss, low body mass index and low muscle mass) and aetiologic (reduced food intake and inflammation or disease burden) diagnostic criteria. Recent work has suggested serum lactate dehydrogenase (LDH) might represent a 3rd aetiologic criteria. Little is known of its relationship with GLIM. A systematic review and meta-analysis of their comparative prognostic value and association was performed.

METHODS

A search of electronic databases (PubMed, Medline, Ovid, Cochrane) up to February 2023 was used to identify studies that compared the prognostic value of LDH and components of the GLIM criteria in cancer. An analysis of the relationship between LDH and the components of GLIM was undertaken where this data was available. RevMan 5.4.1 was used to perform a meta-analysis for each diagnostic criteria that had 3 or more studies which reported hazard ratios with a 95 per cent confidence interval for overall survival (OS).

RESULTS

A total of 119 studies were reviewed. Advanced lung cancer was the most studied population. Included in the meta-analysis were 6 studies (n=2165) on LDH and weight loss, 17 studies (n=7540) on LDH and low BMI, 5 studies (n=758) on LDH and low muscle mass, 0 studies on LDH and food intake and 93 studies (n=32,190) on LDH and inflammation. There was a significant association between elevated serum LDH and each of low BMI (OR 1.39, 1.09 - 1.77; p=0.008), elevated NLR (OR 2.04, 1.57 - 2.65; p<0.00001) and elevated CRP (OR 2.58, 1.81 - 3.67; p<0.00001). There was no association between elevated serum LDH and low muscle mass. Only one study presented data on the association between LDH and unintentional weight loss. Elevated LDH showed a comparative OS (HR 1.86, 1.57 - 2.07; p<0.00001) to unintentional weight loss (HR 1.57, 1.23 - 1.99; p=0.0002) and had a similar OS (HR 2.00, 1.70 - 2.34; p<0.00001) to low BMI (HR 1.57, 1.29-2.90; p<0.0001). LDH also showed an OS (HR 2.25, 1.76 - 2.87; p<0.00001) congruous with low muscle mass (HR 1.93, 1.14 - 3.27; p=0.01) and again, LDH conferred as poor an OS (HR 1.77, 1.64-1.90; p<0.00001) as elevated NLR (HR 1.61, 1.48 - 1.77; p<0.00001) or CRP (HR 1.55, 1.43 - 1.69; p<0.00001).

CONCLUSION

Current literature suggests elevated serum LDH is associated with inflammation in cancer (an aetiologic GLIM criterion), however more work is required to establish the relationship between LDH and the phenotypic components of GLIM. Additionally, elevated serum LDH appears to be a comparative prognosticator of overall survival in cancer when compared to the GLIM criteria.

Matted Lymph Nodes on MRI in Nasopharyngeal Carcinoma: Prognostic Factor and Potential Indication for Induction Chemotherapy Benefits

BACKGROUND

Lymph node characteristics markedly affect nasopharyngeal carcinoma (NPC) prognosis. Matted node (MN), an important characteristic for lymph node, lacks explored MRI-based prognostic implications.

PURPOSE

Investigate MRI-determined MNs' prognostic value in NPC, including 5-year overall survival (OS), distant metastasis-free survival (DMFS), local recurrence-free survival (LRFS), progression-free survival (PFS), and its role in induction chemotherapy (IC).

STUDY TYPE

Retrospective cohort survival study.

POPULATION

Seven hundred ninety-two patients with non-metastatic NPC (female: 27.3%, >45-year old: 50.1%) confirmed by biopsy.

FIELD STRENGTH/SEQUENCE

5-T/3.0-T, T1-, T2- and post-contrast T1-weighted fast spin echo sequences acquired.

ASSESSMENT

MNs were defined as ≥3 nodes abutting with intervening fat plane replaced by extracapsular nodal spread (ENS). Patients were observed every 3 months for 2 years and every 6 months for 5 years using MRI. Follow-up extended from treatment initiation to death or final follow-up. MNs were evaluated by three radiologists with inter-reader reliability calculated. A 1:1 matched-pair method compared survival differences between MN-positive patients with or without IC. Primary endpoints (OS, DMFS, LRFS, PFS) were calculated from therapy initiation to respective event.

STATISTICAL TESTS

Kappa values assessed inter-reader reliability. Correlation between MN, ENS, and LNN was studied through Spearman's correlation coefficient. Clinical characteristics were calculated via Fisher's exact, Chi-squared, and Student's t-test. Kaplan-Meier curves and log-rank tests analyzed all time-to-event data. Confounding factors were included in Multivariable Cox proportional hazard models to identify independent prognostic factors. P-values <0.05 were considered statistically significant.

RESULTS

MNs incidence was 24.6%. MNs independently associated with decreased 5-year OS, DMFS, and PFS; not LRFS (P = 0.252). MN-positive patients gained significant survival benefit from IC in 5-year OS (88.4% vs. 66.0%) and PFS (76.4% vs. 53.5%), but not DMFS (83.1% vs. 69.9%, P = 0.145) or LRFS (89.9% vs. 77.8%, P = 0.140).

DATA CONCLUSION

MNs may independently stratify NPC risk and offer survival benefit from IC.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Cross-site prognosis prediction for nasopharyngeal carcinoma from incomplete multi-modal data

Accurate prognosis prediction for nasopharyngeal carcinoma based on magnetic resonance (MR) images assists in the guidance of treatment intensity, thus reducing the risk of recurrence and death. To reduce repeated labor and sufficiently explore domain knowledge, aggregating labeled/annotated data from external sites enables us to train an intelligent model for a clinical site with unlabeled data. However, this task suffers from the challenges of incomplete multi-modal examination data fusion and image data heterogeneity among sites. This paper proposes a cross-site survival analysis method for prognosis prediction of nasopharyngeal carcinoma from domain adaptation viewpoint. Utilizing a Cox model as the basic framework, our method equips it with a cross-attention based multi-modal fusion regularization. This regularization model effectively fuses the multi-modal information from multi-parametric MR images and clinical features onto a domain-adaptive space, despite the absence of some modalities. To enhance the feature discrimination, we also extend the contrastive learning technique to censored data cases. Compared with the conventional approaches which directly deploy a trained survival model in a new site, our method achieves superior prognosis prediction performance in cross-site validation experiments. These results highlight the key role of cross-site adaptability of our method and support its value in clinical practice.

Development and Internal Validation of a Prediction Model for Nasopharyngeal Carcinoma: Using BMI and Inflammatory Response for Deciding Sequence of Chemotherapy

PURPOSE

Concurrent chemoradiotherapy followed by adjuvant chemotherapy (CRT-AC) and induction chemotherapy followed by concurrent chemoradiotherapy (IC-CRT) are among the best treatments in nasopharyngeal carcinoma (NPC). This study aimed to develop a model for deciding the sequence of chemotherapy in NPC.

METHODS

Data were separated into two cohorts. The CRT-AC cohort had 295 patients, while the IC-CRT cohort had 112. The predictors were standard factors with BMI and neutrophil-lymphocyte ratio (NLR) to predict overall survival (OS). A flexible parametric survival model was used.

RESULTS

A total of 132 (44.7%) and 72 patients (64.3%) died in the CRT-AC and IC-CRT cohorts, respectively. The predictors in the final models were age, sex, T, N, NLR, and BMI. The models of OS for CRT-AC and IC-CRT had concordance indices of 0.689 and 0.712, respectively, with good calibration curves. When changing the burden of disease along with NLR and BMI, we found that CRT-AC was not significantly different OS from IC-CRT when low NLR (<3) and high burden of disease (T3N3). By contrast, CRT-AC was remarkably more effective when there were high levels of NLR (≥3) and BMI (≥25) with any burden of disease (anyT anyN).

CONCLUSION

With additional BMI and NLR in model, it could be easier to decide between CRT-AC and IC-CRT in countries with limited health care resources.

Combined pre-treatment and middle-treatment Epstein-Barr virus DNA load contributes to prognostication and treatment modification in nasopharyngeal carcinoma patients

Objective

To investigate whether pre-treatment and middle-treatment plasma Epstein-Barr virus (EBV) DNA loads are useful predictors of prognosis and indicators of therapy modification in nasopharyngeal carcinoma (NPC) patients undergoing radical concurrent chemoradiotherapy (CCRT).

Methods

Plasma EBV DNA load was measured by quantitative polymerase chain reaction before treatment (pre-DNA) and during the second cycle of DDP (mid-DNA). The primary endpoint was 5-year progression-free survival (PFS).

Results

A total of 775 NPC patients treated with CCRT were included. In total, 553 patients with pre-DNA <4000 copies/mL and 222 with ⩾4000 copies/mL. A total of 559 patients had mid-DNA undetectable and 216 had detectable. Multivariate analysis showed that pre- and mid-DNA were independent prognostic predictors of PFS [hazard ratio (HR), 2.035; 95% confidence interval (CI), 1.406-2.944; p < 0.001; HR, 1.597; 95% CI, 1.101-2.316; p = 0.014]. The area under the curve of the combination of pre-DNA and mid-DNA for 5-year PFS was higher than that of pre-DNA, mid-DNA, and tumor node metastasis (TNM) stage (0.679 versus 0.622, 0.608, 0.601). In the low-risk group (pre-DNA <4000 copies/mL and undetectable mid-DNA), patients receiving ⩽200 mg/m2 showed similar efficacy as those receiving >200 mg/m2 cumulative cisplatin dose (CCD) but were associated with fewer all-grade late toxicities. However, in the high-risk group (pre-DNA ⩾4000 copies/mL or detectable mid-DNA), patients receiving >200 mg/m2 CCD showed a higher 5-year PFS (73.1% versus 58.6%, p = 0.027) and locoregional relapse-free survival (88.5% versus 76.1%, p = 0.028) than those receiving ⩽200 mg/m2 CCD.

Conclusion

The combination of pre-DNA and mid-DNA could be particularly useful for guiding risk stratification and early treatment modification for NPC treated with CCRT. A total of 200 mg/m2 cisplatin seemed to be the optimal dose for the low-risk patients, while >200 mg/m2 cisplatin may be adequate to achieve satisfactory survival outcomes in the high-risk group.

Clinical characteristics and prognosis analysis of postoperative patients with stage I-III colon cancer based on SEER database

PURPOSE

To identify the relevant factors affecting the prognosis and survival time of colon cancer and construct a survival prediction model.

METHODS

Data on postoperative stage I-III colon cancer patients were obtained from the Surveillance, Epidemiology, and End Results database. We used R project to analyze the data. Univariate and multivariate Cox regression analyses were performed for independent factors correlated with overall survival from colon cancer. The C-index was used to screen the factors that had the greatest influence in overall survival after surgery in colon cancer patients. Receiver operating characteristic (ROC) curve was made according to the Risk score and calculated to validate the predictive accuracy of the model. In addition, we used decision curve analysis (DCA) to evaluate the clinical benefits and utility of the nomogram. We created a model survival curve to determine the difference in prognosis between patients in the low-risk group and those in the high-risk group.

RESULTS

Univariate and multifactor COX analyses showed that the race, Grade, tumor size, N-stage and T-stage were independent risk factors affecting survival time of patients. The analysis of ROC and DCA showed the nomogram prediction model constructed based on the above indicators has good predictive effects.

CONCLUSION

Overall, the nomogram constructed in this study has good predictive effects. It can provide a reference for future clinicians to evaluate the prognosis of colon cancer patients.

Nomograms containing body dose parameters for predicting survival in patients with nasopharyngeal carcinoma

PURPOSE

To assess the impact of body dose on survival outcomes in nasopharyngeal carcinoma (NPC) patients and to create novel nomograms incorporating body dose parameters for predicting survival.

METHODS

594 of non-metastasis NPC patients (training group, 396; validation group, 198) received intensity-modulated radiation therapy at our institution from January 2012 to December 2016. Patient characteristics, body dose parameters in dose-volume histogram (DVH) and hematology profiles were collected for predicting overall survival (OS) and progression-free survival (PFS). Nomograms for OS and PFS were developed using the selected predictors. Each nomogram was evaluated based on its C-index and calibration curve.

RESULTS

Body dose-based risk score for OS (RSOS), N stage, age, and induction chemotherapy were independent predictors for OS, with a C-index of 0.784 (95% CI 0.749-0.819) in the training group and 0.763 (95% CI 0.715-0.810) in the validation group for the nomogram. As for PFS, the most important predictors were the body dose-based risk score for PFS (RSPFS), N stage, and induction chemotherapy. C-index of PFS nomogram was 0.706 (95% CI 0.681-0.720) in the training group and 0.691 (95% CI 0.662-0.711) in the validation group. The two models outperformed the TNM staging system in predicting outcomes.

CONCLUSIONS

Body dose coverage is a useful predictor of prognosis in clinical routine patients. The novel nomograms integrating body dose parameters can precisely predict OS and PFS in NPC patients.

Optimal Size Threshold for MRI-Detected Retropharyngeal Lymph Nodes to Predict Outcomes in Nasopharyngeal Carcinoma: A Two-Center Study

BACKGROUND. Retropharyngeal lymph node (RLN) metastases have profound prognostic implications in patients with nasopharyngeal carcinoma (NPC). However, the AJCC staging system does not specify a size threshold for determining RLN involvement, resulting in inconsistent thresholds in practice. OBJECTIVE. The purpose of this article was to determine the optimal size threshold for determining the presence of metastatic RLNs on MRI in patients with NPC, in terms of outcome predictions. METHODS. This retrospective study included 1752 patients (median age, 46 years; 1297 men, 455 women) with NPC treated by intensity-modulated radiotherapy (RT) from January 2010 to March 2014 from two hospitals; 438 patients underwent MRI 3-4 months after treatment. Two radiologists measured the minimal axial diameter (MAD) of the largest RLN for each patient using a consensus process. A third radiologist measured MAD in 260 randomly selected patients to assess interobserver agreement. Initial ROC and restricted cubic spline (RCS) analyses were used to derive an optimal MAD threshold for predicting progression-free survival (PFS). The threshold's predictive utility was assessed in multivariable Cox regression analyses, controlling for standard clinical predictors. The threshold's utility for predicting PFS and overall survival (OS) was compared with a 5-mm threshold using Kaplan-Meier curves and log-rank tests. RESULTS. The intraclass correlation coefficient for MAD was 0.943. ROC and RCS analyses yielded an optimal threshold of 6 mm. In multivariable analyses, MAD of 6 mm and greater independently predicted PFS in all patients (HR = 1.35, p = .02), patients with N0 or N1 disease (HR = 1.80, p = .008), and patients who underwent posttreatment MRI (HR = 1.68, p = .04). In patients with N1 disease without cervical lymph node involvement, 5-year PFS was worse for MAD greater than or equal to 6 mm than for MAD that was greater than or equal to 5 mm but less than 6 mm (77.2% vs 89.7%, p = .03). OS was significantly different in patients with stage I and stage II disease defined using a 6-mm threshold (p = .04), but not using a 5-mm threshold (p = .09). The 5-year PFS rate was associated with a post-RT MAD of 6 mm and greater (HR = 1.68, p = .04) but not a post-RT MAD greater than or equal to 5 mm (HR = 1.09, p = .71). CONCLUSION. The findings support a threshold MAD of 6 mm for determining RLN involvement in patients with NPC. CLINICAL IMPACT. Future AJCC staging updates should consider incorporation of the 6-mm threshold for N-category and tumor-stage determinations.

Recent Advances in Assessing the Clinical Implications of Epstein-Barr Virus Infection and Their Application to the Diagnosis and Treatment of Nasopharyngeal Carcinoma

Reports about the oncogenic mechanisms underlying nasopharyngeal carcinoma (NPC) have been accumulating since the discovery of Epstein-Barr virus (EBV) in NPC cells. EBV is the primary causative agent of NPC. EBV-host and tumor-immune system interactions underlie the unique representative pathology of NPC, which is an undifferentiated cancer cell with extensive lymphocyte infiltration. Recent advances in the understanding of immune evasion and checkpoints have changed the treatment of NPC in clinical settings. The main EBV genes involved in NPC are LMP1, which is the primary EBV oncogene, and BZLF1, which induces the lytic phase of EBV. These two multifunctional genes affect host cell behavior, including the tumor-immune microenvironment and EBV behavior. Latent infections, elevated concentrations of the anti-EBV antibody and plasma EBV DNA have been used as biomarkers of EBV-associated NPC. The massive infiltration of lymphocytes in the stroma suggests the immunogenic characteristics of NPC as a virus-infected tumor and, at the same time, also indicates the presence of a sophisticated immunosuppressive system within NPC tumors. In fact, immune checkpoint inhibitors have shown promise in improving the prognosis of NPC patients with recurrent and metastatic disease. However, patients with advanced NPC still require invasive treatments. Therefore, there is a pressing need to develop an effective screening system for early-stage detection of NPC in patients. Various modalities, such as nasopharyngeal cytology, cell-free DNA methylation, and deep learning-assisted nasopharyngeal endoscopy for screening and diagnosis, have been introduced. Each modality has its advantages and disadvantages. A reciprocal combination of these modalities will improve screening and early diagnosis of NPC.

Nomogram incorporating Epstein-Barr virus DNA and a novel immune-nutritional marker for survival prediction in nasopharyngeal carcinoma

BACKGROUND

Since Immune response, nutritional status and Epstein-Barr Virus (EBV) DNA status have been confirmed to be relevant to the prognosis of patients with nasopharyngeal carcinoma (NPC), we believe that the combination of these factors is of great value for improving the predictive ability. LA (lymphocytes × albumin), a novel indicator, had not been studied yet in NPC. We combined it with EBV DNA and used nomograms to increase the accuracy of prognosis.

METHODS

A total of 688 NPC patients were retrospectively reviewed and further divided into training and validation cohort randomly. Kaplan-Meier analyses were used to to distinguish the different survival outcomes. Multivariate Cox analyses were used to identify the independent prognostic factors for progression-free survival (PFS) and overall survival (OS). Calibration curves, concordance indexes (C-indexes) and decision curve analyses (DCA) were used to evaluate the nomograms' predictive value.

RESULTS

Patients with low LA and positive EBV DNA correlated with poorer 5-year PFS and OS (all P < 0.005). In multivariate Cox analyses, LA and EBV DNA were both confirmed to be independent prognostic factors for PFS and OS (all P < 0.05). Prognostic nomograms incorporating LA and EBV DNA achieved ideal C-indexes of 0.69 (95% CI: 0.65-0.73) and 0.77 (95% CI: 0.71-0.82) in the prediction of PFS and OS. Otherwise, the calibration curves and DCA curves also revealed that our nomograms had pleasant predictive power.

CONCLUSIONS

LA is a novel and powerful biomarker for predicting clinical outcomes in NPC. Our nomograms based on LA and EBV DNA can predict individual prognosis more accurately and effectively.

Prognostic value of metastatic cervical lymph node stiffness in nasopharyngeal carcinoma: A prospective cohort study

OBJECTIVES

Extracellular matrix stiffness plays an important role in tumorigenesis. In this study, we assessed the prognostic value of metastatic cervical lymph node (CLN) stiffness measured using ultrasound shear wave elastography (SWE) in patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 325 consecutive patients with NPC and CLN metastases were prospectively enrolled in this study. The association between the CLN stiffness and patient characteristics was also evaluated. Survival analysis was performed for 307 patients with stage M0 disease. Distant metastasis-free survival (DMFS) was the primary endpoint. Log-rank test and multivariate analysis were used to explore the prognostic value of CLN stiffness.

RESULTS

Eighteen patients developed distant metastases before treatment (stage M1) and had significantly higher CLN stiffness (Pt-test < 0.001) than the other patients (stage M0). For stage M0 patients, those in the high-stiffness group had lower 3-year DMFS (83.3% vs. 91.7%, P = 0.013) and 3-year progression-free survival (PFS) (78.2% vs. 87.9%, P = 0.015) than those in the low-stiffness group. Multivariate analysis identified CLN stiffness and pretreatment Epstein-Barr virus (EBV) DNA as independent prognostic factors for DMFS and PFS. We further established stiffness-EBV risk stratification based on these two factors. The concordance index, receiver operating characteristic curve, and decision curve analyses showed that our risk stratification outperformed the TNM classification for predicting metastasis.

CONCLUSION

The stiffness of metastatic CLN is closely associated with the prognosis of patients with NPC. SWE can be used as a pretreatment examination for CLN-positive patients. A multicenter study is required to verify our results.

A Rulefit-based prognostic analysis using structured MRI report to select potential beneficiaries from induction chemotherapy in advanced nasopharyngeal carcinoma: A dual-centre study

BACKGROUND AND PURPOSE

Structured MRI report facilitate prognostic prediction for nasopharyngeal carcinoma (NPC). However, the intrinsic association among structured variables is not fully utilised. This study aimed to investigate the performance of a Rulefit-based model in feature integration behind structured MRI report and prognostic prediction in advanced NPC.

MATERIALS AND METHODS

We retrospectively enrolled 1207 patients diagnosed with non-metastatic advanced NPC from two centres, and divided into training (N = 544), internal testing (N = 367), and external testing (N = 296) cohorts. Machine learning algorithms including multivariate analysis, deep learning, Lasso, and Rulefit were used to establish corresponding prognostic models. The concordance indices (C- indices) of three clinical and six combined models with different algorithms for overall survival (OS) prediction were compared. Survival benefits of induction chemotherapy (IC) were calculated among risk groups stratified by different models. A website was established for individualised survival visualisation.

RESULTS

Incorporating structured variables into Stage model significantly improved the prognostic prediction performance. Six prognostic rules with structured variables were identified by Rulefit. OS prediction of Rules model was comparable to Lasso model in internal testing cohort (C-index: 0.720 vs. 0.713, P = 0.100) and achieved the highest C-index of 0.711 in external testing cohort, indicating better generalisability. The Rules model stratified patients into risk groups with significant 5-year OS differences in each cohort, and revealed significant survival benefits from additional IC in high-risk group.

CONCLUSION

The Rulefit-based Rules model, with the revelation of intrinsic associations behind structured variables, is promising in risk stratification and guiding individualised IC treatment for advanced NPC.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Super-enhancer driven SOX2 promotes tumor formation by chromatin re-organization in nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a malignant head and neck cancer with a high incidence in Southern China and Southeast Asia. Patients with remote metastasis and recurrent NPC have poor prognosis. Thus, a better understanding of NPC pathogenesis may identify novel therapies to address the unmet clinical needs.

METHODS

H3K27ac ChIP-seq and HiChIP was applied to understand the enhancer landscapes and the chromosome interactions. Whole genome sequencing was conducted to analyze the relationship between genomic variations and epigenetic dysregulation. CRISPRi and JQ1 treatment were used to evaluate the transcriptional regulation of SOX2 SEs. Colony formation assay, survival analysis and in vivo subcutaneous patient-derived xenograft assays were applied to explore the function and clinical relevance of SOX2 in NPC.

FINDINGS

We globally mapped the enhancer landscapes and generated NPC enhancer connectomes, linking NPC specific enhancers and SEs. We found five overlapped genes, including SOX2, among super-enhancer regulated genes, survival related genes and NPC essential genes. The mRNA expression of SOX2 was repressed when applying CRISPRi targeting different SOX2 SEs or JQ1 treatment. Next, we identified a genetic variation (Chr3:181422197, G > A) in SOX2 SE which is correlated with higher expression of SOX2 and poor survival. In addition, SOX2 was highly expressed in NPC and is correlated with short survival in patients with NPC. Knock-down of SOX2 suppressed tumor growth in vitro and in vivo.

INTERPRETATION

Our study demonstrated the super-enhancer landscape with chromosome interactions and identified super-enhancer driven SOX2 promotes tumorigenesis, suggesting that SOX2 is a potential therapeutic target for patients with NPC.

FUNDING

A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Precision medicine in nasopharyngeal carcinoma: comprehensive review of past, present, and future prospect

Nasopharyngeal carcinoma (NPC) is an aggressive malignancy with high propensity for lymphatic spread and distant metastasis. It is prominent as an endemic malignancy in Southern China and Southeast Asia regions. Studies on NPC pathogenesis mechanism in the past decades such as through Epstein Barr Virus (EBV) infection and oncogenic molecular aberrations have explored several potential targets for therapy and diagnosis. The EBV infection introduces oncoviral proteins that consequently hyperactivate many promitotic pathways and block cell-death inducers. EBV infection is so prevalent in NPC patients such that EBV serological tests were used to diagnose and screen NPC patients. On the other hand, as the downstream effectors of oncogenic mechanisms, the promitotic pathways can potentially be exploited therapeutically. With the apparent heterogeneity and distinct molecular aberrations of NPC tumor, the focus has turned into a more personalized treatment in NPC. Herein in this comprehensive review, we depict the current status of screening, diagnosis, treatment, and prevention in NPC. Subsequently, based on the limitations on those aspects, we look at their potential improvements in moving towards the path of precision medicine. The importance of recent advances on the key molecular aberration involved in pathogenesis of NPC for precision medicine progression has also been reported in the present review. Besides, the challenge and future outlook of NPC management will also be highlighted.

Multi-task deep learning-based radiomic nomogram for prognostic prediction in locoregionally advanced nasopharyngeal carcinoma

PURPOSE

Prognostic prediction is crucial to guide individual treatment for locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients. Recently, multi-task deep learning was explored for joint prognostic prediction and tumor segmentation in various cancers, resulting in promising performance. This study aims to evaluate the clinical value of multi-task deep learning for prognostic prediction in LA-NPC patients.

METHODS

A total of 886 LA-NPC patients acquired from two medical centers were enrolled including clinical data, [18F]FDG PET/CT images, and follow-up of progression-free survival (PFS). We adopted a deep multi-task survival model (DeepMTS) to jointly perform prognostic prediction (DeepMTS-Score) and tumor segmentation from FDG-PET/CT images. The DeepMTS-derived segmentation masks were leveraged to extract handcrafted radiomics features, which were also used for prognostic prediction (AutoRadio-Score). Finally, we developed a multi-task deep learning-based radiomic (MTDLR) nomogram by integrating DeepMTS-Score, AutoRadio-Score, and clinical data. Harrell's concordance indices (C-index) and time-independent receiver operating characteristic (ROC) analysis were used to evaluate the discriminative ability of the proposed MTDLR nomogram. For patient stratification, the PFS rates of high- and low-risk patients were calculated using Kaplan-Meier method and compared with the observed PFS probability.

RESULTS

Our MTDLR nomogram achieved C-index of 0.818 (95% confidence interval (CI): 0.785-0.851), 0.752 (95% CI: 0.638-0.865), and 0.717 (95% CI: 0.641-0.793) and area under curve (AUC) of 0.859 (95% CI: 0.822-0.895), 0.769 (95% CI: 0.642-0.896), and 0.730 (95% CI: 0.634-0.826) in the training, internal validation, and external validation cohorts, which showed a statistically significant improvement over conventional radiomic nomograms. Our nomogram also divided patients into significantly different high- and low-risk groups.

CONCLUSION

Our study demonstrated that MTDLR nomogram can perform reliable and accurate prognostic prediction in LA-NPC patients, and also enabled better patient stratification, which could facilitate personalized treatment planning.

Prognostic significance of MRI-defined sarcopenia in patients with nasopharyngeal carcinoma: A propensity score matched analysis of real-world data

BACKGROUND AND PURPOSE

Image-defined sarcopenia is linked to increased mortality among patients with cancer. Nevertheless, its effect on patients with nasopharyngeal carcinoma (NPC) is incompletely established. This study's aim was to investigate the prognostic significance of MRI-defined sarcopenia on the survival of patients undergoing concurrent chemoradiotherapy (CCRT) ± inducing chemotherapy (IC) for NPC treatment.

METHODS

1,307 patients with stage II-IVa NPC were included in this retrospective study. Sarcopenia was defined using skeletal muscle index (SMI) determined through baseline MRI at the C3 level. The association of sarcopenia with overall survival (OS) and progression-free survival (PFS) was assessed by Cox regression models using 1:1 propensity score matching (PSM) analysis. We also conducted a stratification analysis using BMI and treatment strategies.

RESULTS

Sarcopenia was an independent risk factor for both OS and PFS (all P < 0.05). However, BMI was not substantially linked to OS and PFS (all P > 0.05). Sarcopenic patients showed lower rates of OS (HR = 2.00, 95% CI: 1.54-2.60, P < 0.001) and PFS (HR = 1.67, 95% CI: 1.35-2.07, P < 0.001) in contrast with nonsarcopenic patients. According to stratification analysis, being overweight was linked to a protective effect in nonsarcopenic patients only. Sarcopenic patients showed similar OS and PFS regardless of the treatment modality.

CONCLUSIONS

Sarcopenia is underrecognized in NPC patients. Measurement of sarcopenia using routine MRI scans in NPC patients provided significant prognostic information, outperforming BMI. Patients with sarcopenia failed to benefit from an additional IC regimen.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Integrating Baseline Nutritional and Inflammatory Parameters with Post-Treatment EBV DNA Level to Predict Outcomes of Patients with De Novo Metastatic Nasopharyngeal Carcinoma Receiving Chemotherapy Combination PD-1 Inhibitor

OBJECTIVES

To develop and validate a prognostic nomogram based on baseline nutritional and inflammatory parameters for risk stratification in patients with de novo metastatic nasopharyngeal carcinoma (dmNPC) receiving chemotherapy combination programmed death-1 (PD-1) inhibitor.

METHODS

This retrospective study analyzed 131 patients with dmNPC (88 and 43 in the training and validation cohorts, respectively) between March 2017 and November 2020. All these patients received chemotherapy combined with PD-1 inhibitor treatment. We identified independent risk factors using univariate and multivariate Cox regression analyses and established a nomogram to predict the progression-free survival (PFS). The predictive accuracy of the nomogram was evaluated and independently validated.

RESULTS

Baseline nutritional risk index (NRI), prognostic nutritional index (PNI), systemic immune-inflammation index (SII), uric acid (UA), and post-treatment Epstein-Barr virus (EBV) DNA were used to develop a nomogram that could divide patients into favorable- and unfavorable-prognosis groups. The median PFS (mPFS) was significantly longer in the favorable-prognosis group compared to the unfavorable-prognosis group (35.10 months [95% CI: 27.36-42.84] vs. 7.23 months [95% CI: 6.50-7.97]; p = 0.001). All results were confirmed in the validation cohort.

CONCLUSIONS

The proposed model improved the prognostic risk stratification for patients with dmNPC undergoing chemotherapy combined with PD-1 inhibitor treatment.

Development and validation of a nomogram for predicting intraoperative hypotension in cardiac valve replacement

Background: Cardiac valve replacement risks include intraoperative hypotension, endangering organ perfusion. Our nomogram predicted hypotension risk in valve surgery, guiding early intervention. Methods: Analyzing 561 patients from July to November 2022, we developed a nomogram to predict hypotension in valve replacement patients, validated using data from December 2022 to January 2023 on 241 patients, with robust statistical confirmation. Results: Our study identified age, hypertension, left ventricular ejection fraction and serum creatinine as hypotension predictors. The resulting nomogram, validated with high concordance index and area under the curve scores, provided a clinically useful tool for managing intraoperative risk. Conclusion: For valve replacement patients, factors like age, hypertension, low left ventricular ejection fraction and high serum creatinine predicted hypotension risk. Our nomogram enabled clinicians to quantify this risk and proactively manage it.

Contribution of age at diagnosis to cancer-specific survival of nasopharyngeal carcinoma patients receiving radiotherapy

To assess age as a continuous variable for the prognosis of patients with nasopharyngeal carcinoma (NPC) receiving radiotherapy. Patients diagnosed with NPC between 2004 and 2016 were extracted from the Surveillance, Epidemiology, and End Results database. The X-tile was used to calculate the optimal cutoff values for age at diagnosis. Age at diagnosis was divided into subgroups based on the cutoff values. Cancer-specific survival (CSS) between age subgroups was assessed using the Kaplan-Meier method. The age cutoff values for CSS were 42 and 70 years. The 5-year CSS was 85.8%, 73.8%, and 67.1% for the ≤42, 43 to 70, and >70 subgroups. Multivariate regression analysis revealed that race, pathology, T stage, N stage, and age were independent prognostic factors. A nomogram based on the prognostic factors showed that the area under the receiver operating characteristic curve was 0.723 (95% confidence interval, 0.697-0.749). The calibration plots showed good agreement for the 5-year CSS between the predicted and actual observations. All patients were divided into 3 groups according to risk score stratification. Kaplan-Meier survival analyses showed that patients in the low-risk cohort had a greater 5-year CSS than those in the medium- and high-risk cohorts (P < .05). Age subgroups of ≤42, 43 to 70, and >70 years may be useful for determining the prognosis of patients with NPC.

Nomogram Based on Liver Function Test Indicators for Survival Prediction in Nasopharyngeal Carcinoma Patients Receiving PD-1 Inhibitor Therapy

PURPOSE

The aim of this study was to investigate the prognostic significance of PD-1 inhibitor therapy in nasopharyngeal carcinoma (NPC) and to develop a nomogram to estimate individual risks.

METHODS

We retrospectively analyzed 162 NPC patients who were administered the PD-1 inhibitor combined with radiotherapy and chemotherapy at the Sun Yat-Sen University Cancer Center. In total, 108 NPC patients were included in the training cohort and 54 NPC patients were included in the validation cohort. Univariate and multivariate Cox survival analyses were performed to determine the prognostic factors for 1-year and 2-year progression-free survival (PFS). In addition, a nomogram model was constructed to predict the survival probability of PFS. A consistency index (C-index), a decision curve, a clinical impact curve, and a standard curve were used to measure predictive accuracy, the clinical net benefit, and the consistency of prognostic factors.

RESULTS

Univariate and multivariate analyses indicated that the metastasis stage, the levels of ALT, the AST/ALT ratio, and the LDH were independent risk factors associated with the prognosis of PD-1 inhibitor therapy. A nomogram based on these four indicators was constructed and the Kaplan-Meier survival analysis showed that patients with a higher total score have a shorter PFS. The C-index of this model was 0.732 in the training cohort and 0.847 in the validation cohort, which are higher than those for the TNM stages (training cohort: 0.617; validation cohort: 0.727; p <0.05). Decision Curve Analysis (DCA), Net Reclassification Improvement (NRI), and Integrated Discrimination Improvement (IDI) showed that our model has better prediction accuracy than TNM staging.

CONCLUSIONS

Predicting PFS in NPC patients based on liver function-related indicators before PD-1 treatment may help clinicians predict the efficacy of PD-1 treatment in these patients.

Nomogram incorporating potent inflammatory indicators for overall survival estimation of patients with primary oral squamous cell carcinoma

Background

Inflammation has been recognized to be a factor that substantially influences tumorigenesis and tumor prognosis. Hence, this study was aimed to investigate an inflammatory marker with the most potent prognostic ability and to evaluate the survival estimation capability of dynamic change in this marker for patients suffered from oral squamous cell carcinoma (OSCC).

Methods

469 patients' inflammatory indicators including lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and systemic inflammatory response index (SIRI), were calculated. Their predictive abilities for overall survival (OS) were evaluated by Kaplan-Meier curves to screen for the one with the most potent prognostic value. The predictive ability of dynamic changes in this marker was verified and a predictive nomogram incorporating inflammatory indicators was developed.

Results

A high LMR was identified to be an indicator of a satisfactory survival rate. Compared with that of other inflammatory markers, area under the receiver operating characteristics (ROC) curve (AUC) of LMR for 1-year and 3-year OS was significantly larger (P<0.001). Dynamic LMR change remained an significant parameter for predicting OS (OR: 2.492, 95% CI: 1.246-4.981, p = 0.010). The nomogram incorporating LMR exhibited a superior prognostic significance than the TNM system, as suggested by the C-index (0.776 vs 0.651 in primary cohort; 0.800 vs 0.707 in validation cohort, P<0.001) and AUC.

Conclusions

LMR was demonstrated to possess a more potent survival estimation capability than the other three inflammatory parameters. Dynamic changes in LMR serves as a significant parameter for overall survival estimation of primary OSCC patients. The established nomogram incorporating inflammatory markers showed more accuracy and sensitivity for survival estimation of primary OSCC patients.

Emerging roles of circ_NRIP1 in tumor development and cancer therapy (Review)

Circular RNA (circRNA) is a class of endogenous non-coding RNA, a type of single-stranded covalently closed RNA molecule formed by alternative splicing of exons or introns. Previous studies have demonstrated that circRNA participates in modulating biological processes such as cell proliferation, differentiation and apoptosis, and plays key roles in tumor occurrence and development. CircRNA nuclear receptor interacting protein 1 (circ_NRIP1), a form of circRNA, is abnormally expressed in certain human tumor types. It is present at a higher abundance compared with cognate linear transcripts and can regulate malignant biological behaviors such as tumor proliferation, invasion and migration, revealing a currently unexplored frontier in cancer progression. The present review presents a pattern of circ_NRIP1 expression in various malignant tumor types and highlights its significance in cancer development, in addition to its potential as a disease indicator or future therapeutic agent.

A New Online Dynamic Nomogram: Construction and Validation of a Predictive Model for Distant Metastasis Risk and Prognosis in Patients with Gastrointestinal Stromal Tumors

BACKGROUND

Gastrointestinal stromal tumor (GIST) is the most common sarcoma of the digestive tract, among which patients with distant metastases tend to have a poor prognosis. This study aimed to develop a model for predicting distant metastasis in GIST patients and to develop two models for monitoring overall survival (OS) and cancer-specific survival (CSS) in GIST patients with metastasis. This would allow us to develop an optimal, individualized treatment strategy.

METHODS

We reviewed demographic and clinicopathological characteristics data from 2010 to 2017 of patients diagnosed with GIST in the Surveillance, Epidemiology, and End Results (SEER) database. The data of the external validation group was reviewed from the Forth Hospital of Hebei Medical University. Univariate and multivariate logistic regression analyses were used to confirm the independent risk factors for distant metastasis in the GIST patients, and univariate and multivariate Cox regression analyses were performed to identify the independent prognostic factors for OS and CSS in the GIST patients with distant metastasis. Subsequently, three web-based novel nomograms were developed, which were evaluated by the receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

RESULTS

Of the 3639 patients who met the inclusion criteria, 418 (11.4%) had distant metastases. The risk factors for distant metastasis in GIST patients included sex, primary site, grade, N stage, tumor size, and mitotic count. For OS, the independent prognosis factors for GIST patients with metastasis included age, race, marital, primary site, chemotherapy, mitotic count, and metastasis at the lung, and for CSS, age, race, marital, primary site, and metastasis at the lung were the independent prognosis factors. Three web-based nomograms were constructed based on these independent factors, respectively. The ROC curves, calibration curves, and DCA were performed in the training, testing, and validation sets which confirmed the high accuracy and strong clinical practice power for the nomograms.

CONCLUSION

Population-based nomograms can help clinicians predict the occurrence and prognosis of distant metastases in patients with GIST, which may be helpful for clinicians to formulate clinical management and appropriate treatment strategies.

Widely targeted quantitative lipidomics and prognostic model reveal plasma lipid predictors for nasopharyngeal carcinoma

BACKGROUND

Dysregulation of lipid metabolism is closely associated with cancer progression. The study aimed to establish a prognostic model to predict distant metastasis-free survival (DMFS) in patients with nasopharyngeal carcinoma (NPC), based on lipidomics.

METHODS

The plasma lipid profiles of 179 patients with locoregionally advanced NPC (LANPC) were measured and quantified using widely targeted quantitative lipidomics. Then, patients were randomly split into the training (125 patients, 69.8%) and validation (54 patients, 30.2%) sets. To identify distant metastasis-associated lipids, univariate Cox regression was applied to the training set (P < 0.05). A deep survival method called DeepSurv was employed to develop a proposed model based on significant lipid species (P < 0.01) and clinical biomarkers to predict DMFS. Concordance index and receiver operating curve analyses were performed to assess model effectiveness. The study also explored the potential role of lipid alterations in the prognosis of NPC.

RESULTS

Forty lipids were recognized as distant metastasis-associated (P < 0.05) by univariate Cox regression. The concordance indices of the proposed model were 0.764 (95% confidence interval (CI), 0.682-0.846) and 0.760 (95% CI, 0.649-0.871) in the training and validation sets, respectively. High-risk patients had poorer 5-year DMFS compared with low-risk patients (Hazard ratio, 26.18; 95% CI, 3.52-194.80; P < 0.0001). Moreover, the six lipids were significantly correlated with immunity- and inflammation-associated biomarkers and were mainly enriched in metabolic pathways.

CONCLUSIONS

Widely targeted quantitative lipidomics reveals plasma lipid predictors for LANPC, the prognostic model based on that demonstrated superior performance in predicting metastasis in LANPC patients.

MRI-Based Metastatic Nodal Number and Associated Nomogram Improve Stratification of Nasopharyngeal Carcinoma Patients: Potential Indications for Individual Induction Chemotherapy

BACKGROUND

Metastatic lymph nodal number (LNN) is associated with the survival of nasopharyngeal carcinoma (NPC); however, counting multiple nodes is cumbersome.

PURPOSE

To explore LNN threshold and evaluate its use in risk stratification and induction chemotherapy (IC) indication.

STUDY TYPE

Retrospective.

POPULATION

A total of 792 radiotherapy-treated NPC patients (N classification: N0 182, N1 438, N2 113, N3 59; training group: 396, validation group: 396; receiving IC: 390).

FIELD STRENGTH/SEQUENCE

T1-, T2- and postcontrast T1-weighted fast spin echo MRI at 1.5 or 3.0 T.

ASSESSMENT

Nomogram with (model B) or without (model A) LNN was constructed to evaluate the 5-year overall (OS), distant metastasis-free (DMFS), and progression-free survival (PFS) for the group as a whole and N1 stage subgroup. High- and low-risk groups were divided (above vs below LNN- or model B-threshold); their response to IC was evaluated among advanced patients in stage III/IV.

STATISTICAL TESTS

Maximally selected rank, univariate and multivariable Cox analysis identified the optimal LNN threshold and other variables. Harrell's concordance index (C-index) and 2-fold cross-validation evaluated discriminative ability of models. Matched-pair analysis compared survival outcomes of adding IC or not. A P value < 0.05 was considered statistically significant.

RESULTS

Median follow-up duration was 62.1 months. LNN ≥ 4 was independently associated with decreased 5-year DMFS, OS, and PFS in entire patients or N1 subgroup. Compared to model A, model B (adding LNN, LNN ≥ 4 vs <4) presented superior C-indexes in the training (0.755 vs 0.727) and validation groups (0.676 vs 0.642) for discriminating DMFS. High-risk patients benefited from IC with improved post-IC response and OS, but low-risk patients did not (P = 0.785 and 0.690, respectively).

CONCLUSIONS

LNN ≥ 4 is an independent risk stratification factor of worse survival in entire or N1 staging NPC patients. LNN ≥ 4 or the associated nomogram has potential to identify high-risk patients requiring IC.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: 4.

An Individualized Prognostic Model in Patients with Locoregionally Advanced Nasopharyngeal Carcinoma Based on Serum Metabolomic Profiling

PURPOSE

This study aims to evaluate the value of a serum metabolomics-based metabolic signature for locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients, thereby assisting clinical decisions.

METHODS

In this retrospective study, a total of 320 LA-NPC patients were randomly divided into a training set (ca. 70%; n = 224) and a validation set (ca. 30%; n = 96). Serum samples were analyzed using widely targeted metabolomics. Univariate and multivariate Cox regression analyses were used to identify candidate metabolites related to progression-free survival (PFS). Patients were categorized into high-risk and low-risk groups based on the median metabolic risk score (Met score), and the PFS difference between the two groups was compared using Kaplan-Meier curves. The predictive performance of the metabolic signature was evaluated using the concordance index (C-index) and the time-dependent receiver operating characteristic (ROC), and a comprehensive nomogram was constructed using the Met score and other clinical factors.

RESULTS

Nine metabolites were screened to build the metabolic signature and generate the Met score, which effectively separated patients into low- and high-risk groups. The C-index in the training and validation sets was 0.71 and 0.73, respectively. The 5-year PFS was 53.7% (95% CI, 45.12-63.86) in the high-risk group and 83.0% (95%CI, 76.31-90.26) in the low-risk group. During the construction of the nomogram, Met score, clinical stage, pre-treatment EBV DNA level, and gender were identified as independent prognostic factors for PFS. The predictive performance of the comprehensive model was better than that of the traditional model.

CONCLUSION

The metabolic signature developed through serum metabolomics is a reliable prognostic indicator of PFS in LA-NPC patients and has important clinical significance.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

MicroRNA-372 acts as a double-edged sword in human cancers

MicroRNAs (miRNAs or miRs) are non-coding, single-stranded, endogenous RNAs that regulate various biological processes, most notably the pathophysiology of many human malignancies. It process is accomplished by binding to 3'-UTR mRNAs and controlling gene expression at the post-transcriptional level. As an oncogene, miRNAs can either accelerate cancer progression or slow it down as a tumor suppressor. MicroRNA-372 (miR-372) has been found to have an abnormal expression in numerous human malignancies, implying that the miRNA plays a role in carcinogenesis. It is both increased and downregulated in various cancers, and it serves as both a tumor suppressor and an oncogene. This study examines the functions of miR-372 as well as the LncRNA/CircRNA-miRNA-mRNA signaling pathways in various malignancies and analyses its potential prognostic, diagnostic, and therapeutic implications.

A novel nomogram integrated with PDL1 and CEA to predict the prognosis of patients with gastric cancer

INTRODUCTION

This study aimed to develop a prognostic nomogram for patients with gastric cancer (GC) based on the levels of programmed death 1 ligand 1 (PDL1) and carcinoembryonic antigen (CEA).

METHODS

The nomogram was developed using data from a primary cohort of 247 patients who had been clinicopathologically diagnosed with GC, as well as a validation cohort of 63 patients. Furthermore, the nomogram divided the patients into three different risk groups for overall survival (OS)-the low-risk, middle-risk, and high-risk groups. Univariate and multivariate Cox hazard analyses were used to determine all of the factors included in the model. Decision curve analysis and receiver operating characteristic (ROC) curves were used to assess the accuracy of the nomogram.

RESULTS

The Kaplan-Meier survival analysis revealed that metastasis stage, clinical stage, and CEA and PDL1 levels were predictors for progress-free survival (PFS) and OS of patients with GC. Metastasis stage, clinical stage, and CEA and PDL1 levels were found to be independent risk factors for the PFS and OS of patients with GC in a multivariate analysis, and the nomogram was based on these factors. The concordance index of the nomogram was 0.763 [95% confidence interval (CI) 0.740-0.787]. The area under the concentration-time curve of the nomogram model was 0.81 (95% CI 0.780-0.900). According to the decision curve analysis and ROC curves, the nomogram model had a higher overall net efficiency in forecasting OS than clinical stage, CEA and PDL1 levels.

CONCLUSION

In conclusion, we proposed a novel nomogram that integrated PDL1 and CEA, and the proposed nomogram provided more accurate and useful prognostic predictions for patients with GC.

Nomogram to predict the prognosis of patients with AFP-negative hepatocellular carcinoma undergoing chemotherapy: A SEER based study

This study aimed to formulate reliable nomograms for predicting the outcomes of α-fetoprotein (AFP)-negative hepatocellular carcinoma (HCC) patients after chemotherapy. HCC patients with normal AFP expression who received chemotherapy were screened and evaluated from the surveillance, epidemiology, and end results database. The prognostic factors for predicting outcomes of HCC patients undergoing chemotherapy were chosen by analyzing the results of Cox analyses. Then, a nomogram integrating the prognostic factors was established. The discrimination ability of the nomogram was evaluated with computation of area under the curve (AUC) and calibration curve. A total of 2424 patients with AFP-negative HCC undergoing chemotherapy were identified. The median overall survival (OS) for HCC patients undergoing chemotherapy was 33 months. Age, race, pathologic grade, N stage, M stage, surgery, and lung metastases were significantly linked to OS. These relevant factors were incorporated into the nomogram. AUC values of the prognostic nomogram for 3- and 5-year OS were 0.696 and 0.706 in the training groups, which were superior to those of the tumor node metastasis (TNM) stage (0.641 and 0.671) in training groups. The calibration curves indicated a high consistency between the predicted probability of nomograms and the actual observation. The validation groups produced AUC values of 0.674 and 0.736 for 3- and 5-year OS, which were superior to those of the TNM stage (0.601 and 0.637) in validation groups. The results revealed significantly unfavorable OS in the high-risk group (P < .001). Nomograms to accurately predict the OS for AFP-negative HCC patients after chemotherapy were established and exhibited a more accurate predication than the conventional TNM staging system.

An overall survival predictive nomogram to identify high-risk patients among locoregionally advanced nasopharyngeal carcinoma: Developed based on the SEER database and validated institutionally

Objective

Locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients, even at the same stage, have different prognoses. We aim to construct a prognostic nomogram for predicting the overall survival (OS) to identify the high-risk LA-NPC patients.

Materials and methods

Histologically diagnosed WHO type II and type III LA-NPC patients in the Surveillance, Epidemiology, and End Results (SEER) database were enrolled as the training cohort (n= 421), and LA-NPC patients from Shantou University Medical College Cancer Hospital (SUMCCH) served as the external validation cohort (n= 763). Variables were determined in the training cohort through Cox regression to form a prognostic OS nomogram, which was verified in the validation cohort, and compared with traditional clinical staging using the concordance index (C-index), Kaplan–Meier curves, calibration curves and decision curve analysis (DCA). Patients with scores higher than the specific cut-off value determined by the nomogram were defined as high-risk patients. Subgroup analyses and high-risk group determinants were explored.

Results

Our nomogram had a higher C-index than the traditional clinical staging method (0.67 vs. 0.60, p&lt;0.001). Good agreement between the nomogram-predicted and actual survival were shown in the calibration curves and DCA, indicating a clinical benefit of the nomogram. High-risk patients identified by our nomogram had worse prognosis than the other groups, with a 5-year overall survival (OS) of 60.4%. Elderly patients at advanced stage and without chemotherapy had a tendency for high risk than the other patients.

Conclusions

Our OS predictive nomogram for LA-NPC patients is reliable to identify high-risk patients.

Prognostic models for early and late tumor progression prediction in nasopharyngeal carcinoma: An analysis of 8292 endemic cases

OBJECTIVES

The time for posttreatment tumor progression differs between nasopharyngeal carcinoma (NPC) patients. Herein, we established effective nomograms for predicting early tumor progression (ETP) and late tumor progression (LTP) in NPC patients.

METHODS

We retrospectively enrolled 8292 NPC patients (training cohort: n = 6219; validation cohort: n = 2073). The ELP and LTP were defined as the time to tumor progression ≤24 and >24 months after treatment, respectively.

RESULTS

The ETP and LTP accounted for 52.6 and 47.4% of the total patient cohort, respectively. Patients who developed ETP had markedly worse overall survival (OS) versus patients who suffered from LTP (5-year OS: 26.2% vs. 59.7%, p < 0.001). Further, we identified 10/6 predictive factors significantly associated with ETP/LTP via logistic regression analyses. These indicators were used separately to construct two predictive nomograms for ETP and LTP. In the training group, the ETP nomogram [Harrell Concordance Index (C-index) value: 0.711 vs. 0.618; p < 0.001] and LTP nomogram (C-index value: 0.701 vs. 0.612; p < 0.001) were significantly superior for risk stratification than the TNM staging. These results were supported in the validation group with a C-index value of 0.753 and 0.738 for the ETP and LTP nomograms, respectively. High-risk patients defined by ETP/LTP nomograms had shorter progression-free survival than low-risk patients (all p < 0.001).

CONCLUSION

The established nomograms can help in ELP or LTP risk stratification for NPC patients. Our current results might also provide insights into individualized treatment decisions and designing surveillance strategies for NPC patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

KEY POINTS

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

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

BACKGROUND AND PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Synergistic Association of Hepatitis B Surface Antigen and Plasma Epstein-Barr Virus DNA Load on Distant Metastasis in Patients With Nasopharyngeal Carcinoma

IMPORTANCE

Hepatitis B surface antigen (HBsAg) reportedly increases the risk of distant metastasis among patients with nasopharyngeal carcinoma (NPC). However, the associated potential interaction and changes in hazard ratios (HRs) between HBsAg and different plasma Epstein-Barr (EBV) DNA levels are unknown. Moreover, the potential HBsAg-positive-associated NPC metastatic mechanism remains unclear.

OBJECTIVE

To investigate the prognostic value and biological associations of HBsAg and plasma EBV DNA levels on distant metastasis in patients with NPC.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study performed at Sun Yat-sen University Cancer Center between January 2010 and January 2013. A total of 792 patients with nonmetastatic NPC were enrolled. The median (range) follow-up time was 62.1 (1.4-83.4) months. Of these patients, 17.8% presented with HBsAg positivity. Cytological experiments were performed to evaluate the role of HBsAg in the invasion and migration of EBV-positive NPC cells. Data analysis was performed from July 2020 to April 2021.

MAIN OUTCOMES AND MEASURES

The primary end point was distant metastasis-free survival. Association rules were used to identify new rules related to distant metastasis. Interaction plots, univariate and multivariate Cox regression analyses, stratification analysis, and quantification using HRs were conducted. Additionally, cell migration and invasion assays, as well as Western blotting, were performed in the cytological validation.

RESULTS

Among the 792 patients, 576 (72.7%) were male, with a median (IQR) age of 45 (38-53) years. The HBsAg-positive group exhibited a significant interaction and increased risk of distant metastasis when plasma EBV DNA cutoff levels were 1.5 × 1000 copies/mL or greater. The HR was 9.16 (95% CI, 2.46-34.14) when the plasma EBV DNA load reached 6 × 1000 copies/mL, which was higher than that in patients with stage IV disease (HR, 2.01; 95% CI, 1.13-3.56; P = .02). In cytological experiments, HBsAg promoted epithelial-mesenchymal transition by upregulating vimentin and fibronectin in EBV-positive NPC cells in vitro, thereby promoting invasion and migration of EBV-positive NPC cells.

CONCLUSIONS AND RELEVANCE

In this cohort study, the observed synergistic association between HBsAg and plasma EBV DNA load represented a novel potential mechanism underlying the increased risk of distant metastasis in patients with NPC. Hence, attention should be paid to patients with NPC with HBsAg positivity, especially when the plasma EBV DNA level is 6 × 1000 copies/mL or greater. Consideration of this synergistic association will contribute to more accurate individualized management.

Treating Head and Neck Cancer in the Age of Immunotherapy: A 2023 Update

Most patients diagnosed with head and neck squamous cell carcinoma (HNSCC) will present with locally advanced disease, requiring multimodality therapy. While this approach has a curative intent, a significant subset of these patients will develop locoregional failure and/or distant metastases. The prognosis of these patients is poor, and therapeutic options other than palliative chemotherapy are urgently needed. Epidermal growth factor receptor (EGFR) overexpression is an important factor in the pathogenesis of HNSCC, and a decade ago, the EGFR targeting monoclonal antibody cetuximab was approved for the treatment of late-stage HNSCC in different settings. In 2016, the anti-programmed death-1 (PD-1) immune checkpoint inhibitors nivolumab and pembrolizumab were both approved for the treatment of patients with recurrent or metastatic HNSCC with disease progression on or after platinum-containing chemotherapy, and in 2019, pembrolizumab was approved for first-line treatment (either as monotherapy in PD-L1 expressing tumors, or in combination with chemotherapy). Currently, trials are ongoing to include immune checkpoint inhibition in the (neo)adjuvant treatment of HNSCC as well as in novel combinations with other drugs in the recurrent/metastatic setting to improve response rates and survival and help overcome resistance mechanisms to immune checkpoint blockade. This article provides a comprehensive review of the management of head and neck cancers in the current era of immunotherapy.

Pretreatment Serum Lactate Dehydrogenase and Metastases Numbers as Potential Determinants of Anti-PD-1 Therapy Outcome in Nasopharyngeal Carcinoma

BACKGROUND

We aimed to investigate the determinant factors of anti-PD-1 therapy outcome in nasopharyngeal carcinoma (NPC).

METHODS

In this retrospective study, we included 64 patients with recurrent/metastatic NPC. The association of patients' characteristics, C-reactive protein (CRP), neutrophil to lymphocyte ratio (NLR), and lactate dehydrogenase (LDH) with survival benefit of anti-PD-1 therapy were analyzed using Cox regression models and Kaplan-Meier analyses. Patients were divided based on the median value of CRP, NLR or LDH into different subgroups.

RESULTS

At a median follow-up time of 11.4 months (range: 1-28 months), median progression-free survival (PFS) and overall survival (OS) were 1.9 months (95% CI, .18-3.6) and 15 months (95% CI, 10.9-19.1) months, respectively. Pretreatment metastases numbers was significant predictor of PFS (HR = 1.99; 95% CI 1.10-3.63; P = .024) and OS (HR = 2.77; 95% CI 1.36-5.61; P = .005). Baseline LDH level was independent predictor of OS (HR = 7.01; 95% CI 3.09-15.88; P < .001). Patients with LDH level >435 U/L at the baseline had significantly shorter PFS and OS compared to patients with LDH level ≤435 U/L (median PFS: 1.7 vs 3.5 months, P = .040; median OS: 3.7 vs 18.5 months, P < .001). Patients with non-durable clinical benefit (NDB) had significantly higher LDH level at the baseline compared to patients who achieved durable clinical benefit (DCB) (P = .025). Post-treatment levels of CRP, LDH, and NLR were decreased compared to baseline in patients with DCB (P = .030, P = .088, and P = .066, respectively), whereas, there was a significant increase in post-treatment level of LDH compared with baseline in patients with NDB (P = .024).

CONCLUSIONS

LDH level at the baseline was an independent predictor of OS and pretreatment metastases numbers was a significant predictor of PFS and OS.

The prognostic nutritional index represents a novel inflammation-nutrition-based prognostic factor for nasopharyngeal carcinoma

Purpose

This study explored the relationship between the prognostic nutritional index (PNI) and overall survival rate (OS) in patients with nasopharyngeal carcinoma (NPC), and established and validated an effective nomogram to predict clinical outcomes.

Methods

This study included 618 patients newly diagnosed with locoregionally advanced NPC. They were divided into training and validation cohorts at a ratio of 2:1 based on random numbers. The primary endpoint of this study was OS, progression-free survival (PFS) was the second endpoint. A nomogram was drawn from the results of multivariate analyses. Harrell's concordance index (C-index), area under the receiver operator characteristic curve (AUC), and decision curve analysis (DCA) were used to evaluate the clinical usefulness and predictive ability of the nomogram and were compared to the current 8th edition of the International Union Against Cancer/American Joint Committee (UICC/AJCC) staging system.

Results

The PNI cutoff value was 48.1. Univariate analysis revealed that age (p < 0.001), T stage (p < 0.001), N stage (p = 0.036), tumor stage (p < 0.001), PNI (p = 0.001), lymphocyte-neutrophil ratio (NLR, p = 0.002), and lactate dehydrogenase (LDH, p = 0.009) were significantly associated with OS, age (p = 0.001), T-stage (p < 0.001), tumor stage (p < 0.001), N-stage (p = 0.011), PNI (p = 0.003), NLR (p = 0.051), and LDH (p = 0.03) were significantly associated with PFS. Multivariate analysis showed that age (p < 0.001), T-stage (p < 0.001), N-stage(p = 0.02), LDH (p = 0.032), and PNI (p = 0.006) were significantly associated with OS, age (p = 0.004), T-stage (<0.001), N-stage (<0.001), PNI (p = 0.022) were significantly associated with PFS. The C-index of the nomogram was 0.702 (95% confidence interval [CI]: 0.653-0.751). The Akaike information criterion (AIC) value of the nomogram for OS was 1142.538. The C-index of the TNM staging system was 0.647 (95% CI, 0.594-0.70) and the AIC was 1163.698. The C-index, DCA, and AUC of the nomogram demonstrated its clinical value and higher overall net benefit compared to the 8th edition of the TNM staging system.

Conclusion

The PNI represents a new inflammation-nutrition-based prognostic factor for patients with NPC. In the proposed nomogram, PNI and LDH were present, which led to a more accurate prognostic prediction than the current staging system for patients with NPC.

Genetic characteristics and clinical-specific survival prediction in elderly patients with gallbladder cancer: a genetic and population-based study

Background

Biliary system cancers are most commonly gallbladder cancers (GBC). Elderly patients (≥ 65) were reported to suffer from an unfavorable prognosis. In this study, we analyzed the RNA-seq and clinical data of elderly GBC patients to derive the genetic characteristics and the survival-related nomograms.

Methods

RNA-seq data from 14 GBC cases were collected from the Gene Expression Omnibus (GEO) database, grouped by age, and subjected to gene differential and enrichment analysis. In addition, a Weighted Gene Co-expression Network Analysis (WGCNA) was performed to determine the gene sets associated with age grouping further to characterize the gene profile of elderly GBC patients. The database of Surveillance, Epidemiology, and End Results (SEER) was searched for clinicopathological information regarding elderly GBC patients. Nomograms were constructed to predict the overall survival (OS) and cancer-specific survival (CSS) of elderly GBC patients. The predictive accuracy and capability of nomograms were evaluated through the concordance index (C-index), calibration curves, time-dependent operating characteristic curves (ROC), as well as area under the curve (AUC). Decision curve analysis (DCA) was performed to check out the clinical application value of nomograms.

Results

Among the 14 patients with GBC, four were elderly, while the remaining ten were young. Analysis of gene differential and enrichment indicated that elderly GBC patients exhibited higher expression levels of cell cycle-related genes and lower expression levels of energy metabolism-related genes. Furthermore, the WGCNA analysis indicated that elderly GBC patients demonstrated a decrease in the expression of genes related to mitochondrial respiratory enzymes and an increase in the expression of cell cycle-related genes. 2131 elderly GBC patients were randomly allocated into the training cohort (70%) and validation cohort (30%). Our nomograms showed robust discriminative ability with a C-index of 0.717/0.747 for OS/CSS in the training cohort and 0.708/0.740 in the validation cohort. Additionally, calibration curves, AUCs, and DCA results suggested moderate predictive accuracy and superior clinical application value of our nomograms.

Conclusion

Discrepancies in cell cycle signaling and metabolic disorders, especially energy metabolism, were obviously observed between elderly and young GBC patients. In addition to being predictively accurate, the nomograms of elderly GBC patients also contributed to managing and strategizing clinical care.

Silencing PARP-1 binding protein Inhibits Cell Migration and Invasion via Suppressing UBE2C in Nasopharyngeal Cancer Cells

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a malignancy with a 2 per 100 000 incidence rate in the world. Overall survival (OS) of patients in stage I-II disease is around 80%, whereas OS of patients in stage III-IVB disease drops to 60%, implying the importance of diagnosis to reduce NPC mortality. However, more than 70% patients of NPC were diagnosed at advanced stages (stage III and IV) in clinics, and it definitely contributes to little substantial improvement in the 5-year survival rates although NPC is sensitive to radio-and chemotherapy. Hence, development of novel biomarkers and targetable genes in NPC is eagerly awaited.

METHODS

We had analyzed the dataset GSE12452 and found hundreds of genes trans-activated in NPC. Among them, this study focused on PARP-1 binding protein (PARPBP) whose overexpression was also validated in GSE13597 and GSE53819 datasets.

RESULTS

Knockdown of PARPBP significantly reduced cell viability in NPC and also identified hundreds of differentially expressed genes including 377 downregulated and 518 upregulated genes in HONE-1 cells with stably knockdown PARPBP. Furthermore, PARPBP might promote cell migration and invasion in NPC through positive regulation of ubiquitin-conjugating enzyme 2C (UBE2C).

CONCLUSION

The results demonstrate the aberrant expression of PARPBP in NPC, and imply its importance in nasopharyngeal carcinogenesis which further opens up the possibility of PARPBP as a novel diagnostic biomarker for NPC therapy.

Utilization of the lymph node-to-primary tumor ratio of PET standardized uptake value and circulating Epstein-Barr virus DNA to predict distant metastasis in nasopharyngeal carcinoma

BACKGROUND AND PURPOSE

To determine the clinical impact of integrating Epstein-Barr virus (EBV) DNA and lymph node-to-primary tumor ratio (NTR) of positron emission tomography (PET) standardized uptake value (SUV) in predicting distant metastasis, such as distant metastasis-free survival (DMFS), in patients with nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

We retrospectively reviewed patients diagnosed with non-disseminated NPC between 2010 and 2017. The optimal cut-off values of EBV DNA and SUV NTR were determined using receiver operating characteristic analysis. The prognostic values of SUV NTR and EBV DNA on DMFS and overall survival were evaluated using the Kaplan-Meier method. Univariate and multivariable analyses were performed using the Wald Chi-squared test and Cox proportional hazards regression, respectively.

RESULTS

A total of 488 patients were included in the analysis. The median follow-up period was 61.6 months. The optimal cut-off values of EBV DNA and SUV NTR were 3377.5 copies per mL and 0.64, respectively. The five-year DMFS for patients with high vs low EBV DNA and SUV NTR levels were 64.9% vs 86.6% (p < 0.001) and 78.7% vs 87.4% (p = 0.021), respectively. In subgroup analysis, the high-risk group with high levels of pretreatment EBV DNA and SUV NTR had worse DMFS in either American Joint Committee on Cancer (AJCC) stage I-III or IVA-B (p = 0.001 and <0.001, respectively). Univariate and multivariable analyses showed the statistical significance of EBV DNA, SUV NTR, and their composite in DMFS (p < 0.001 for EBV DNA; p = 0.022 for SUV NTR; p < 0.001 for their composite).

CONCLUSION

This study showed that EBV DNA and SUV NTR have independent and additive values as prognosticators for distant metastasis in patients with NPC, suggesting that these two individual factors, except the AJCC staging system, should be included in future studies.