Outcomes of patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

A machine learning approach for predicting radiation-induced hypothyroidism in patients with nasopharyngeal carcinoma undergoing tomotherapy

The purpose of this study was to establish an integrated predictive model that combines clinical features, DVH, radiomics, and dosiomics features to predict RIHT in patients receiving tomotherapy for nasopharyngeal carcinoma. Data from 219 patients with nasopharyngeal carcinoma were randomly divided into a training cohort (n = 175) and a test cohort (n = 44) in an 8:2 ratio. RIHT is defined as serum thyroid-stimulating hormone (TSH) greater than 5.6 μU/mL, with or without a decrease in free thyroxine (FT4). Clinical features, 27 DVH features, 107 radiomics features and 107 dosiomics features were extracted for each case and included in the model construction. The least absolute shrinkage and selection operator (LASSO) regression method was used to select the most relevant features. The eXtreme Gradient Boosting (XGBoost) was then employed to train separate models using the selected features from clinical, DVH, radiomics and dosiomics data. Finally, a combined model incorporating all features was developed. The models were evaluated using receiver operating characteristic (ROC) curves and decision curve analysis. In the test cohort, the area under the receiver operating characteristic curve (AUC) for the clinical, DVH, radiomics, dosiomics and combined models were 0.798 (95% confidence interval [CI], 0.656-0.941), 0.673 (0.512-0.834), 0.714 (0.555-0.873), 0.698 (0.530-0.848) and 0.842 (0.724-0.960), respectively. The combined model exhibited higher AUC values compared to other models. The decision curve analysis demonstrated that the combined model had superior clinical utility within the threshold probability range of 1% to 79% when compared to the other models. This study has successfully developed a predictive model that combines multiple features. The performance of the combined model is superior to that of single-feature models, allowing for early prediction of RIHT in patients with nasopharyngeal carcinoma after tomotherapy.

Prognostic modeling for nasopharyngeal carcinoma (NC) undergoing concurrent chemoradiotherapy using clinical and enhanced MRI-Delta radiomics data: A preliminary study

BACKGROUND

Nasopharyngeal carcinoma (NC) is one of the prevalent malignancies of the head and neck region with poor prognosis.

OBJECTIVE

The aim of this study is to establish a predictive model for assessing NC prognosis based on clinical and MR radiomics data, subsequently to develop a nomogram for practical application.

METHODS

Retrospective analysis was conducted on clinical and imaging data collected between May 2010 and August 2018, involving 211 patients diagnosed with histologically confirmed NC who received concurrent chemoradiotherapy or radical surgery in Xiangyang No. 1 People's Hospital. According to 5-10 years of follow-up results, the patients were divided into two groups: the study group (n= 76), which experienced recurrence, metastasis, or death, and the control group (n= 135), characterized by normal survival. Training and testing subsets were established at a 7:3 ratio, with a predefined time cutoff. In the training set, three prediction models were established: a clinical data model, an imaging model, and a combined model using the integrated variation in clinical characteristics along with MR radiomics parameters (Delta-Radscore) observed before and after concurrent chemoradiotherapy. Model performance was compared using Delong's test, and net clinical benefit was assessed via decision curve analysis (DCA). Then, external validation was conducted on the test set, and finally a nomogram predicting NC prognosis was created.

RESULTS

Univariate analysis identified that the risk factors impacting the prognosis of NC included gender, pathological type, neutrophil to lymphocyte ratio (NLR), degree of tumor differentiation, MR enhancement pattern, and Delta-Radscore (P< 0.05). The combined model established based on the abovementioned factors exhibited significantly higher predictive performance [AUC: 0.874, 95% CI (0.810-0.923)] than that of the clinical data model [AUC: 0.650, 95% CI (0.568-0.727)] and imaging model [AUC: 0.824, 95% CI (0.753-0.882)]. DCA also demonstrated superior clinical net benefit in the combined model, a finding further verified by results from the test set. The developed nomogram, based on the combined model, exhibited promising performance in clinical applications.

CONCLUSION

The Delta-Radscore derived from MR radiomics data before and after concurrent chemoradiotherapy helps enhance the performance of the NC prognostic model. The combined model and resultant nomogram provide valuable support for clinical decision-making in NC treatment, ultimately contributing to an improved survival rate.

Lack of association between XRCC1 SNPs and acute radiation‑induced injury or prognosis in patients with nasopharyngeal carcinoma

The response to radiation therapy (RT) is closely associated with DNA damage repair. X-ray repair cross-complementing group-1 (XRCC1) is a key gene in the DNA damage repair pathway, and SNPs in this gene alter the expression and activity of its effector protein, which may in turn affect sensitivity to RT. Therefore, the course of tumor treatment and local control rate can be influenced. In the present study, a group of 158 patients with nasopharyngeal carcinoma (NPC) who received intensity-modulated RT at Fujian Cancer Hospital (Fuzhou, China) between July 2012 and October 2013 were included in retrospective chart review and followed up. Plasma was collected before treatment for genotype analysis of the three SNPs of XRCC1, namely Arg194Trp, Arg280His and Arg399Gln. Acute radiation-induced injuries sustained during treatment was graded according to the Radiation Therapy Oncology Group scoring criteria. Post-treatment follow-up was performed until August 2020. In the 158 cases of NPC, no statistically significant association was observed between the three SNPs of the XRCC1 gene and the severity of acute radiation-induced injury or prognosis. However, the AA genotype of XRCC1-Arg399Gln tended to be associated with worse progression-free survival (PFS) compared with the GA + GG genotype, although this was not significant (P=0.069). In addition, multivariate logistic analysis showed that nodal stage was significantly associated with the occurrence of acute severe radiation-induced oral mucositis (P=0.018), and there was also a trend towards an association between nodal stage and the incidence of acute severe radiation-induced pharyngitis; however, this was not statistically significant (P=0.061). Furthermore, multivariate Cox regression analysis showed that older age, distant metastasis and higher clinical stage were independent risk factors for PFS in patients with NPC. In conclusion, relying solely on the aforementioned SNPs of the XRCC1 gene may not provide a robust enough basis to predict the response to RT or prognosis in patients with NPC.

[Clinical study of endoscopic surgery for recurrent nasopharyngeal carcinoma]

Objective:To compare the clinical effects and complications of surgery + chemotherapy and radiotherapy + chemotherapy in patients with nasopharyngeal carcinoma recurrence, so as to compare the safety and efficacy of two different therapeutic methods. Methods:A retrospective analysis was performed on 40 patients with recurrent nasopharyngeal carcinoma after radiotherapy and chemotherapy admitted to our hospital from January 2016 to June 2020. Among them, 26 patients were treated with surgery. The recurrent tumor was removed under nasal endoscope, and the frozen resection margin was negative during the operation. Chemotherapy was continued for stage Ⅲ and Ⅳ patients from 3 to 5 weeks after surgery. Fourteen patients received secondary radiotherapy and chemotherapy. Postoperative complications and survival rate were observed. Results:There were 14 patients in the secondary chemoradiotherapy group（control group） and 26 patients in the nasal endoscopic surgery group（observation group）. Among the 26 patients, 19 patients underwent nasal septal mucosal repair, 5 patients underwent temporal muscle flap repair, 2 patients underwent submental flap repair, 2 patients had nasal septal mucosal flap necrosis and cerebrospinal fluid leakage, and the temporal muscle flap was used for secondary repair in the second stage operation, and 8 patients needed cervical lymph node dissection. The patients recovered well after surgery, and the patients in stage Ⅲ and Ⅳ were treated with chemotherapy after 3 weeks to 5 weeks according to the patient's wound condition. There were significant differences in the incidence of complications and 1-, 2-, and 3-year survival rates between the two groups（P<0.05）. Conclusion:Patients with recurrent nasopharyngeal carcinoma can be treated by nasal endoscopic surgery to remove the tumor, and the use of pedicled nasal septal mucosal flap or temporal muscle flap for skull base reconstruction, The operation can effectively prevent major complications such as internal carotid artery rupture and hemorrhage, and improve the survival rate and quality of life of patients. It provides a safe and effective treatment for patients with recurrent nasopharyngeal carcinoma.

ACSL4 promotes ferroptosis and M1 macrophage polarization to regulate the tumorigenesis of nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a head and neck malignant tumor with a high incidence and recurrence rate. The crosstalk between ferroptosis and tumor-associated macrophages (TAMs) is thought to have major implications in interfering with cancers. We intended to explore the effect of acyl-CoA synthetase long-chain family member 4 (ACSL4) on the pathogenesis of NPC via ferroptosis and TAMs.

METHODS

Differential genes in NPC patients were analyzed using publicly available databases, and the ferroptosis-related gene ACSL4 was identified. Expression of ACSL4 in NPC cell lines and xenografted mice was examined. Colony formation, cell proliferation, migration, and invasion were assessed. The abundance of epithelial-mesenchymal transition (EMT) markers (E-cadherin, N-cadherin, and Vimentin) was confirmed. Lipid peroxidation levels and related markers were measured. Clophosome was administered to determine the role of TAMs in NPC mice.

RESULTS

Low levels of ACSL4 were observed in NPC patients and CNE-2 and 5-8F cells. Erastin (a ferroptosis inducer) and ACSL4 increased lipid peroxidation, decreased cell viability, colony formation, cell proliferation, migration and invasion, and inhibited EMT. Moreover, Erastin and ACSL4 promoted M2 to M1 macrophage polarization. The effects of erastin and ACSL4 were additive. Ferrostatin-1, an inhibitor of ferroptosis, exerted the opposite effect and reversed the beneficial effects of ACSL4 overexpression. In xenograft mice, ACSL4 and clophosome hindered the growth of NPC, and extra clophosome slightly enhanced the antitumor effect of ACSL4.

CONCLUSION

Our findings indicated that ACSL4 inhibited the pathogenesis of NPC, at least through crosstalk between ferroptosis and macrophages, providing potential direction for NPC therapy.

The therapeutic utility of combining dynamic contrast-enhanced magnetic resonance imaging with arterial spin labeling in the staging of nasopharyngeal carcinoma

BACKGROUND

To research the pathological and clinical staging uses of arterial spin labeling (ASL) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

MATERIALS AND METHODS

64 newly diagnosed nasopharyngeal carcinoma (NPC) patients were enrolled from December 2020 to January 2022, and 3.0 T MRI (Discovery 750W, GE Healthcare, USA) were used for ASL and DCE-MRI scans. The DCE-MRI and ASL raw data were processed post-acquisition on the GE image processing workstation (GE Healthcare, ADW 4.7, USA). The volume transfer constant (Ktrans), blood flow (BF), and accompanying pseudo-color images were generated automatically. Draw the region of interest (ROIs), and the Ktrans and BF values for each ROI were recorded separately. Based on pathological information and the most recent AJCC staging criteria, patients were divided into low T stage groups = T_1-2 and high T stage groups = T_3-4, low N stage groups = N_0-1 and high N stage groups = N_2-3, and low AJCC stage group = stage I-II and high AJCC stage group = stage III-IV. The association between the Ktrans_t and BF parameters and the T, N, and AJCC stages was compared using an independent sample t-test. Using a receiver operating characteristic (ROC) curve, the sensitivity, specificity, and AUC of Ktrans_t, BF_t, and their combined use in T and AJCC staging of NPC were investigated and assessed.

RESULT

The tumor-BF (BF_t) (t = - 4.905, P < 0.001) and tumor-Ktrans (Ktrans_t) (t = - 3.113, P = 0.003) in the high T stage group were significantly higher than those in the low T stage group. The Ktrans_t in the high N stage group was significantly higher than that in the low N stage group (t = - 2.071, P = 0.042). The BF_t (t = - 3.949, P < 0.001) and Ktrans_t (t = - 4.467, P < 0.001) in the high AJCC stage group were significantly higher than those in the low AJCC stage group. BF_t was moderately positively correlated with the T stage (r = 0.529, P < 0.001) and AJCC stage (r = 0.445, P < 0.001). Ktrans_t was moderately positively correlated with T staging (r = 0.368), N staging (r = 0.254), and AJCC staging (r = 0.411). There was also a positive correlation between BF and Ktrans in gross tumor volume (GTV) (r = 0.540, P < 0.001), parotid (r = 0.323, P < 0.009) and lateral pterygoid muscle (r = 0.445, P < 0.001). The sensitivity of the combined application of Ktrans_t and BF_t for AJCC staging increased from 76.5 and 78.4 to 86.3%, and the AUC value increased from 0.795 and 0.819 to 0.843, respectively.

CONCLUSION

Combining Ktrans and BF measures may make it possible to identify the clinical stages in NPC patients.

Effect of radiotherapy interruption on nasopharyngeal cancer

Nasopharyngeal carcinoma (NPC) is a malignant tumor originating from the epithelial cells of the nasopharynx with a unique geographic distribution, and is particularly prevalent in East and Southeast Asia. Due to its anatomical location, the surgery is difficult to access and the high sensitivity of nasopharyngeal cancer to radiotherapy (RT) makes it the main treatment modality. Radical radiotherapy is the first-line treatment for early-stage nasopharyngeal carcinoma and the cornerstone of multidisciplinary treatment for patients with locally advanced nasopharyngeal carcinoma. Nevertheless, radiotherapy interruption is inevitable as a consequence of unavoidable factors such as public holidays, machine malfunction, patient compliance, and adverse response to treatment, which in turn leads to a reduction in bioactivity and causes sublethal loss of tumor cells to repair. Unirradiated tumor cells are more likely to repopulate at or near their original fastest growth rate during this interval. If no measures are taken after the radiotherapy interruption, such as increasing the dose of radiotherapy and systemic therapy, the tumor is most likely to go uncontrolled and then progress. This review describes the effects of radiotherapy interruption on nasopharyngeal carcinoma, the mechanism of the effect, and explores the measures that can be taken in response to such interruption.

Recurrence risk stratification based on Epstein–Barr virus DNA to identify enlarged retropharyngeal lymph nodes of nasopharyngeal carcinoma: A model-histopathologic correlation study

Background

Accurate assessment of the nature of enlarged retropharyngeal lymph nodes (RLN) of nasopharyngeal carcinoma (NPC) patients after radiotherapy is related to selecting appropriate treatments and avoiding unnecessary therapy. This study aimed to develop a non-invasive and effective model for predicting the recurrence of RLN (RRLN) in NPC.

Materials and methods

The data of post-radiotherapy NPC patients (N = 76) with abnormal enlargement of RLN who underwent endonasopharyngeal ultrasound-guided fine-needle aspirations (EPUS-FNA) were examined. They were randomly divided into a discovery (n = 53) and validation (n = 23) cohort. Univariate logistic regression was used to assess the association between variables (magnetic resonance imaging characteristics, EBV DNA) and RRLN. Multiple logistic regression was used to construct a prediction model. The accuracy of the model was assessed by discrimination and calibration, and decision curves were used to assess the clinical reliability of the model for the identification of high risk RLNs for possible recurrence.

Results

Abnormal enhancement, minimum axis diameter (MAD) and EBV-DNA were identified as independent risk factors for RRLN and could stratify NPC patients into three risk groups. The probability of RRLN in the low-, medium-, and high-risk groups were 37.5, 82.4, and 100%, respectively. The AUC of the final predictive model was 0.882 (95% CI: 0.782–0.982) in the discovery cohort and 0.926 (95% CI, 0.827–1.000) in the validation cohort, demonstrating good clinical accuracy for predicting the RRLN of NPC patients. The favorable performance of the model was confirmed by the calibration plot and decision curve analysis.

Conclusion

The nomogram model constructed in the study could be reliable in predicting the risk of RRLN after radiotherapy for NPC patients.

Prediction of Changes in Tumor Regression during Radiotherapy for Nasopharyngeal Carcinoma by Using the Computed Tomography-Based Radiomics

This work aimed to explore the application value of computed tomography (CT)-based radiomics in predicting changes in tumor regression during radiotherapy for nasopharyngeal carcinoma. In this work, 144 patients with nasopharyngeal carcinoma who underwent concurrent chemoradiotherapy (CCRT) in our hospital from January 2015 to December 2021 were selected. The patients were divided into a radiosensitive group (79 cases) and an insensitive group (65 cases) according to the tumor volume shrinkage during radiotherapy. The 3D Slicer 4.10.2 software was used to delineate the tumor region of interest (ROI), and a total of 1223 radiomics features were extracted using the radiomics module under the software. After between-group and within-group consistency tests, one-way ANOVA, and LASSO dimensionality reduction, three omics features were finally selected for the establishment of predictive models. At the same time, the age, gender, tumor T stage and N stage, hemoglobin, and albumin of the patients were collected to establish a clinical prediction model. The results showed that compared with logistic regression, decision tree, random forest, and AdaBoost models, the SVM model based on CT radiomics features had the best performance in predicting tumor regression changes during tumor radiotherapy (training group area under the receiver operating characteristic curve (AUC): 0.840 (95% confidence interval (CI): 0.764-0.916); validation group: AUC: 0.810 (95% CI: 0.676-0.944)). Compared with the supported vector machine (SVM) prediction model based on clinical features, the SVM model based on radiomics features had better performance in predicting the change of retraction during tumor radiotherapy (training group: omics feature SVM model AUC: 0.84, clinical feature SVM model: 0.78; validation group: omics feature SVM model AUC: 0.8, clinical feature SVM model: 0.58, P = 0.044). Based on the radiomics characteristics and clinical characteristics of patients, a nomo prediction map was established, and the calibration curve shows good consistency, which can be visualized to assist clinical judgment. In this work, the prediction model composed of CT-based radiomic features combined with clinical features can accurately predict withdrawal changes during tumor radiotherapy, ensuring the accuracy of treatment planning, and minimizing the number of CT scans during radiotherapy.

Mortality-to-Incidence Ratio for Nasopharyngeal Carcinoma Is Associated with Health Expenditure

Geographic and gender-specific disparity can be observed in nasopharyngeal carcinoma (NPC). While screening and more effective therapies, such as induction chemotherapy, could improve survival rates, they are costly. This study aims to explore the correlation between healthcare expenditure and the mortality-to-incidence ratio (MIR) in NPC. Data were obtained from the World Health Organization and the Global Cancer Observatory. The correlation was evaluated by Spearman’s rank correlation coefficient. Most new cases and deaths occur in Asia, and more males are affected than females. Our study shows that countries with higher MIRs have lower levels of health expenditure regardless of the NPC’s gender-specific incidence. Correspondingly, MIRs are all significantly negatively associated with current health expenditure (CHE) per capita and CHE as a percentage of gross domestic product (CHE/GDP) in both genders. CHE per capita and CHE/GDP have a significant impact on NPC outcomes. Moreover, economic status is a potential major factor in MIR differences between countries.

Clinical Characteristics and Predictive Outcomes of Recurrent Nasopharyngeal Carcinoma-A Lingering Pitfall of the Long Latency

Purpose: To investigate the clinical characteristics, risk factors, and clinical outcomes of long-latent recurrence (>five years) of nasopharyngeal carcinoma (NPC). Methods: This retrospective study enrolled newly diagnosed NPC patients from the Chang Gung Research Database between January 2007 and December 2019. We analyzed the patients’ characteristics and survival outcomes after recurrence. Results: A total of 2599 NPC patients were enrolled. The overall recurrence rate was 20.5%, while 8.1% of patients had long-latent recurrence (>five years). These patients had a higher percentage of initial AJCC (The American Joint Committee on Cancer) stage I/II (60.5%, p = 0.001) and local recurrence (46.5%, p < 0.001). Unresectable rT3 and rT4 were found in 60% of patients when recurrence and 30% of local recurrence occurred in the skull base, which could not be detected by the regular endoscopy. The five-year overall survival rate of long-latent recurrence was 19.7%. Alive patients tended to be asymptomatic but have regular follow-ups with the interval less than six months. Multivariate analysis showed age and initial advanced AJCC stages were independent risk factors of death after recurrence. In contrast, patients with recurrence between two and five years, salvage surgeries, and regional recurrence had favorable survival outcomes. Conclusion: Long-latent NPC recurrence is not rare, and the survival outcome is poor. Regular follow-up for early detection of NPC recurrence is necessary even after five years of disease-free period.