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

Volumetric measurement to evaluate treatment response to induction chemotherapy on MRI outperformed RECIST guideline in outcome prediction in advanced nasopharyngeal carcinoma

BACKGROUND

Treatment response evaluated by tumour size change is an important indicator for outcome prediction. Advanced nasopharyngeal carcinoma (adNPC) grows irregularly, and so the unidimensional measurement may not be accurately applied to adNPC for outcome prediction. This study aimed to evaluate values of unidimensional and volumetric measurements for treatment response to induction chemotherapy (IC) for outcome prediction in adNPC and compared the values with that of RECIST 1.1 guideline.

MATERIALS AND METHODS

Pre-treatment and post-IC magnetic resonance images (MRIs) from 124 patients with stage III-IVA NPC were retrospectively reviewed. Sums of the maximum unidimensional diameters (D) and volumes of the targeted tumours (primary tumour and two largest metastatic lymph nodes) on the pre- (Dpre and Vpre) and post-IC MRIs (Dpost-IC and Vpost-IC) and percentage changes in D (Δ D%) and V (ΔV%) between two scans were calculated and correlated with disease-free survival (DFS), locoregional recurrence-free survival (LRRFS), and distant metastases-free survival (DMFS) using Cox regression analysis. Area under the curves (AUCs) of independent measurements and RECIST groups (RECIST response and non-response groups) for predicting disease recurrence, locoregional recurrence, and distant metastases, respectively, were calculated and compared using the DeLong test.

RESULTS

Univariable analysis showed correlations between high Dpost-IC with poor DFS and DMFS (P < 0.05), but not with LRRFS (P = 0.07); high Vpost-IC and low ΔV% (less decrease in volume on post-IC) with poor DFS, LRRFS, and DMFS (P < 0.05); and no correlations between Dpre, ΔD%, and Vpre and the outcomes (P > 0.05). Multivariable analysis showed that ΔV% was the only independent measurement for outcomes (P < 0.05). Compared with RECIST groups, ΔV% of 47.9% (median value) showed a higher AUC for disease recurrence (0.682 versus 0.526, P < 0.01) and for locoregional recurrence (0.782 versus 0.585, P < 0.01), but not for distant metastases (0.593 versus 0.518, P = 0.26).

CONCLUSIONS

Volumetric measurement to evaluate treatment response to IC outperformed unidimensional measurement and RECIST guideline in outcome prediction in adNPC.

Interconnected influences of tumour and host microbiota on treatment response and side effects in nasopharyngeal cancer

This study elucidates the intricate relationship between nasopharyngeal carcinoma (NPC), a significant malignancy predominant in Asia with notable global incidence and mortality rates, and the host microbiota, including those of tumour, nasal, nasopharyngeal, oral, oropharyngeal, and gut communities. It underscores how the composition and diversity of microbiota are altered in NPC, delving into their implications for disease pathogenesis, treatment response, and the side effects of therapies. A consistent reduction in alpha diversity across oral, nasal, and gut microbiomes in NPC patients compared to healthy individuals signals a distinct microbial signature indicative of the diseased state. The study also shows unique microbial changes tied to different NPC stages, indicating a dynamic interplay between disease progression and microbiota composition. Patients with specific microbial profiles exhibit varied responses to chemotherapy and immunotherapy, underscoring the potential for treatment personalisation based on microbiota analysis. Furthermore, the side effects of NPC treatments, such as oral mucositis, are intensified by shifts in microbial communities, suggesting a direct link between microbiota composition and treatment tolerance. This nexus offers opportunities for interventions aimed at modulating the microbiota to alleviate side effects, improve quality of life, and potentially enhance treatment efficacy. Highlighting the dual potential of microbiota as both a therapeutic target and a biomarker for NPC, this review emphasises its significance in influencing treatment outcomes and side effects, heralding a new era in NPC management through personalised treatment strategies and innovative approaches.

Quantitative parameter analysis of pretreatment dual-energy computed tomography in nasopharyngeal carcinoma cervical lymph node characteristics and prediction of radiotherapy sensitivity

BACKGROUND

Treatment efficacy may differ among patients with nasopharyngeal carcinoma (NPC) at similar tumor-node-metastasis stages. Moreover, end-of-treatment tumor regression is a reliable indicator of treatment sensitivity. This study aimed to investigate whether quantitative dual-energy computed tomography (DECT) parameters could predict sensitivity to neck-lymph node radiotherapy in patients with NPC.

METHODS

Overall, 388 lymph nodes were collected from 98 patients with NPC who underwent pretreatment DECT. The patients were divided into complete response (CR) and partial response (PR) groups. Clinical characteristics and quantitative DECT parameters were compared between the groups, and the optimal predictive ability of each parameter was determined using receiver operating characteristic (ROC) analysis. A nomogram prediction model was constructed and validated using univariate and binary logistic regression.

RESULTS

DECT parameters were higher in the CR group than in the PR group. The iodine concentration (IC), normalized IC, Mix-0.6, spectral Hounsfield unit curve slope, effective atomic number, and virtual monoenergetic images were significantly different between the groups. The area under the ROC curve of the DECT parameters was 0.73-0.77. Based on the binary logistic regression, a column chart was constructed using 10 predictive factors, including age, sex, N stage, maximum lymph node diameter, arterial phase NIC, venous phase NIC, λHU and spectral Hounsfield units at 70 keV. The area under the ROC curve value of the constructed model was 0.813, with a sensitivity and specificity of 85.6% and 81.3%, respectively.

CONCLUSION

Quantitative DECT parameters could effectively predict the sensitivity of NPC to radiotherapy. Therefore, DECT parameters and NPC clinical features can be combined to construct a nomogram with high predictive power and used as a clinical analytical tool.

Early Stage and Locally Advanced Nasopharyngeal Carcinoma Treatment from Present to Future: Where Are We and Where Are We Going?

OPINION STATEMENT

Nasopharyngeal carcinoma (NPC) is a rare malignancy, endemic in China, that is commonly diagnosed in locally advanced scenarios. Its pathogenesis is strongly associated with Epstein-Barr virus (EBV), an infection for which measuring EBV plasma DNA levels has helped as a prognostic factor guiding treatment options, including a stronger treatment in those with high titers. Additionally, tobacco and alcohol are often implicated in EBV-negative patients. The local disease is treated with radiotherapy alone, preferentially intensity modulated radiotherapy. For locally advanced disease, the backbone treatment is concurrent chemoradiotherapy with the ongoing research dilemma being adding adjuvant chemotherapy or induction chemotherapy. The ongoing research is focused not only on identifying patients that will benefit from adjuvant or induction chemotherapy, but also on identifying the best chemotherapeutic regimen, regimen alternatives to diminish toxicity, the role that immune checkpoint inhibitors play, and the use of molecularly guided treatment targeting patients with NPC whether driven by EBV or tobacco and alcohol. Knowing the precise oncogenesis of NPC not only offers a better understanding of the role that EBV plays in this tumor but also helps create targeted therapies that could potentially block important pathways such as the NF-κB pathway. Much is yet to be done, but the prognosis and management of NPC patients have changed drastically, offering precise treatment methods and excellent control of the disease, even in locally advanced scenarios.

Hairy gene homolog increases nasopharyngeal carcinoma cell stemness by upregulating Bmi-1

B-cell-specific Moloney murine leukemia virus integration site 1 (Bmi-1) is overexpressed in various cancer types. We found that Bmi-1 mRNA levels were elevated in nasopharyngeal carcinoma (NPC) cell lines. In immunohistochemical analyses, high Bmi-1 levels were observed in not only 5 of 38 non-cancerous nasopharyngeal squamous epithelial biopsies, but also in 66 of 98 NPC specimens (67.3%). High Bmi-1 levels were detected more frequently in T3-T4, N2-N3 and stage III-IV NPC biopsies than in T1-T2, N0-N1 and stage I-II NPC samples, indicating that Bmi-1 is upregulated in advanced NPC. In 5-8F and SUNE1 NPC cells, stable depletion of Bmi-1 using lentiviral RNA interference greatly suppressed cell proliferation, induced G1-phase cell cycle arrest, reduced cell stemness and suppressed cell migration and invasion. Likewise, knocking down Bmi-1 inhibited NPC cell growth in nude mice. Both chromatin immunoprecipitation and Western blotting assays demonstrated that Hairy gene homolog (HRY) upregulated Bmi-1 by binding to its promoter, thereby increasing the stemness of NPC cells. Immunohistochemistry and quantitative real-time PCR analyses revealed that HRY expression correlated positively with Bmi-1 expression in a cohort of NPC biopsies. These findings suggested that HRY promotes NPC cell stemness by upregulating Bmi-1, and that silencing Bmi-1 can suppress NPC progression.

Gamma Knife Radiosurgery as a Salvage Treatment for Nasopharyngeal Carcinoma with Skull Base and Intracranial Invasion (T4b)

It is usually difficult to achieve good outcomes with salvage treatment for recurrent nasopharyngeal carcinoma (NPC) because of its deep-seated location, surrounding critical structures, and patient history of high-dose irradiation. Gamma Knife radiosurgery (GKS) is a treatment option for malignancies with skull base and intracranial invasion. We conducted a retrospective, observational, single-center study including 15 patients with recurrent NPC (stage T4b) involving the skull base and intracranial invasion, who underwent GKS as a salvage treatment. Patients were enrolled over 12 years. Per a previous study, the TNM classification T4b was subclassified into T4b1 and T4b2, defined as the involvement of the skull base or cavernous sinus with an intracranial extension of <5 mm and >5 mm, respectively. The effect of prognostic factors, including age, sex, survival period, magnetic resonance imaging (MRI) presentation, presence of other distant metastases, tumor volume, marginal dose, maximal dose, and Karnofsky Performance Status (KPS), on outcomes was analyzed. The patients with T4b1 NPC (p = 0.041), small tumor volume (p = 0.012), higher KPS (p < 0.001), and no other metastasis (p = 0.007) had better outcomes after GKS treatment, suggesting that it is a viable treatment modality for NPC. We also suggest that detailed brain imaging studies may enable the early detection of intracranial invasion.

Assessment of self-reported financial toxicity among patients with nasopharyngeal carcinoma undergoing radiotherapy: A cross-sectional study in western China

OBJECTIVE 

Using the Comprehensive Score for Financial Toxicity (COST) tool to measure financial toxicity (FT) among nasopharyngeal cancer (NPC) patients in western China and investigate the association between FT and psychological distress.

METHODS

We conducted a cross-sectional study of survivors with NPC in a tertiary oncology hospital in China. FT was assessed using the COST (Chinese version), a validated instrument widely used both at home and abroad. The NCCN Distress Thermometer (DT) was used to measure psychological distress. A multivariate logistic regression model was built to determine factors associated with FT, and the Pearson correlation was used to assess the correlation between COST and DT scores.

RESULTS

Of 210 patients included in this study, the mean FT score was 16.3 (median: 22.5, SD: 9.7), and the prevalence of FT was 66.2% (mild FT: 37.1%, moderate FT: 50.5%, severe FT: 2.4%). Suggested by the logistic regression model, 5 variables were associated with increased FT: unemployed, no commercial insurance, receiving lower annual income, advanced cancer, and receiving targeted therapy. The Pearson correlation showed a significantly moderate correlation between financial toxicity and psychological distress (r= -0.587, P < 0.001).

CONCLUSION

Patients with nasopharyngeal carcinoma (NPC) in western China demonstrated higher self-reported financial toxicity (FT) associated with factors including unemployed, no commercial insurance, receiving lower annual income, advanced cancer, and receiving targeted therapy. These predictors will help clinicians identify potential patients with FT in advance and conduct effective psychological interventions.

The emergence of tumor-infiltrating lymphocytes in nasopharyngeal carcinoma: Predictive value and immunotherapy implications

The clinical study of nasopharyngeal carcinoma (NPC) often reveals a large number of lymphocytes infiltrating the primary tumor site. As an important part of the tumor microenvironment, tumor-infiltrating lymphocytes (TILs) do not exist alone but as a complex multicellular population with high heterogeneity. TILs play an extremely significant role in the occurrence, development, invasion and metastasis of NPC. The latest research shows that they participate in tumorigenesis and treatment, and the composition, quantity, functional status and distribution of TILs subsets have good predictive value for the prognosis of NPC patients. TILs are an independent prognostic factor for TNM stage and significantly correlated with better prognosis. Additionally, adoptive immunotherapy using anti-tumor TILs has achieved good results in a variety of solid tumors including NPC. This review evaluates recent clinical and preclinical studies of NPC, summarizes the role of TILs in promoting and inhibiting tumor growth, evaluates the predictive value of TILs, and explores the potential benefits of TILs-based immunotherapy in the treatment of NPC.

DPCPX induces Bim-dependent apoptosis in nasopharyngeal carcinoma cells

ADORA1 promotes tumor growth and development in multiple cancers. DPCPX (a selective adenosine A1 receptor antagonist), a specific ADORA1 antagonist, has shown antitumor effects in many cancer types. Nevertheless, the function of DPCPX in nasopharyngeal carcinoma (NPC) still remains to be unraveled. In this study, we investigated the functional role of DPCPX on NPC cells. We found that DPCPX promotes NPC cells growth inhibition. DPCPX induced Bim-dependent apoptosis in NPC cells irrespective of p53 status via the FoxO3a pathway following PI3K/AKT inhibition. Furthermore, DPCPX enhanced the antitumor effect of cisplatin, 5-FU and Paclitaxel in NPC. Xenograft experiment revealed that deficiency of Bim in vivo stalls apoptosis and antitumor activity of DPCPX. In conclusion, the PI3K/AKT/FoxO3a/Bim axis plays a critical role in the anticancer effects of DPCPX in NPC.

Can 3D pseudo-continuous arterial spin labeling perfusion imaging be applied to predict early response to chemoradiotherapy in patients with advanced nasopharyngeal carcinoma?

BACKGROUND AND PURPOSE

Chemoradiotherapy (CRT) has been widely applied in patients with advanced nasopharyngeal carcinoma (ANPC). However, limited imaging modality exists on the evaluation of early response to CRT. The purpose of this study was therefore to investigate whether 3D pseudo-continuous arterial spin labeling (3D pCASL) perfusion imaging could predict early response to CRT in ANPC patients.

MATERIALS AND METHODS

Seventy ANPC patients who received CRT underwent pre-treatment MRI including 3D pCASL perfusion measurements, and were categorized into response group (RG) and no-response group (NRG) according to RECIST 1.1. Pre-treatment 3D pCASL derived cerebral blood flow (CBF) values in tumors were compared between RG and NRG patients. Receiver-operating characteristic (ROC) analysis was performed to determine the optimal diagnostic cutoff value for CBF in predicting tumor response to CRT. Clinicopathological variables were also analyzed by using univariate and binary logistic regression. The corresponding obtained variables with statistical significance were further applied to create a nomogram in which the bootstrap resampling method was used for calibration.

RESULTS

Forty-eight patients in RG had significantly higher pre-treatment CBF values in tumors compared with 22 patients in NRG (P < 0.001). CBF showed the high area under the ROC curve (AUC = 0.843) in distinguishing RG from NRG patients. The corresponding cutoff value for CBF was 103.68 ml/100 g/min, with respective accuracy, sensitivity and specificity of 82.86%, 87.50% and 72.73%. The nomogram was generated by binary logistic regression results, incorporating three variables: CBF value, clinical stage and pathological type. The AUC, accuracy, sensitivity and specificity of the nomogram was respectively 0.893, 84.28%, 81.25% and 90.91% in predicting tumor response to CRT. Moreover, as shown in the calibration curve, a strong agreement was observed between nomogram prediction probability and actual clinical findings (P = 0.309).

CONCLUSIONS

3D pCASL derived CBF in tumor could act as a noninvasive effective biomarker to predict tumor response to CRT in ANPC patients before clinical treatment. Furthermore, the nomogram combining CBF and clinicopathological variables could serve as a novel clinical analysis tool for treatment response prediction.

Dynamic Changes of Post-Radiotherapy Plasma Epstein-Barr Virus DNA in a Randomized Trial of Adjuvant Chemotherapy Versus Observation in Nasopharyngeal Cancer

PURPOSE

To study the dynamic changes in plasma Epstein-Barr virus (pEBV) DNA after radiotherapy in nasopharyngeal cancer (NPC).

EXPERIMENTAL DESIGN

We conducted a randomized controlled trial of adjuvant chemotherapy versus observation in patients with NPC who had detectable pEBV DNA at 6 weeks post-radiotherapy. Randomized patients had a second pEBV DNA checked at 6 months post-randomization. The primary endpoint was progression-free survival (PFS).

RESULTS

We prospectively enrolled 789 patients. Baseline post-radiotherapy pEBV DNA was undetectable in 573 (72.6%) patients, and detectable in 216 (27.4%) patients, of whom 104 (13.2%) patients were eligible for randomization to adjuvant chemotherapy (n = 52) versus observation (n = 52). The first post-radiotherapy pEBV DNA had a sensitivity of 0.48, specificity of 0.81, area under receiver-operator characteristics curve (AUC) of 0.65, false positive (FP) rate of 13.8%, and false negative (FN) rate of 14.4% for disease progression. The second post-radiotherapy pEBV DNA had improved sensitivity of 0.81, specificity of 0.75, AUC of 0.78, FP rate of 14.3%, and FN rate of 8.1%. Patients with complete clearance of post-radiotherapy pEBV DNA (51%) had survival superior to that of patients without post-radiotherapy pEBV DNA clearance (5-year PFS, 85.5% vs. 23.3%; HR, 9.6; P < 0.0001), comparable with patients with initially undetectable post-radiotherapy pEBV DNA (5-year PFS, 77.1%), irrespective of adjuvant chemotherapy or observation.

CONCLUSIONS

Patients with NPC with detectable post-radiotherapy pEBV DNA who experienced subsequent pEBV DNA clearance had superior survival comparable with patients with initially undetectable post-radiotherapy pEBV DNA. Post-radiotherapy pEBV DNA clearance may serve as an early surrogate endpoint for long-term survival in NPC.

Concurrent chemoradiotherapy with additional chemotherapy for nasopharyngeal carcinoma: A pooled analysis of propensity score-matching studies

OBJECTIVE

To determine the benefits of adding induction chemotherapy (IC) and adjuvant chemotherapy (AC) to concurrent chemoradiotherapy (CCRT) for nasopharyngeal carcinoma (NPC) based on propensity score-matching (PSM) studies.

METHODS

Eligible PSM studies were searched in the PubMed, Web of Science, and Embase databases from inception to September 1, 2020. The primary endpoints included overall survival (OS), distant metastasis-free survival (DMFS), and locoregional recurrence-free survival (LRFS).

RESULTS

A total of 14 trials consisting of 4086 participants were included. Significant benefits were observed between IC + CCRT and CCRT for OS (hazard ratio [HR], 0.76; 95% confidence interval [CI]: 0.64-0.91) and DMFS (HR, 0.77; 95% CI: 0.64-0.94) with the exception of LRFS (HR, 1.14; 95% CI: 0.90-1.43). However, CCRT + AC did not achieve significant improvements.

CONCLUSIONS

IC with CCRT yields significant survival benefits in terms of OS and DMFS, whereas CCRT with AC fails to achieve any additional benefit in all endpoints.