Circulating EBV DNA, Globulin and Nodal Size Predict Distant Metastasis after Intensity-Modulated Radiotherapy in Stage II Nasopharyngeal Carcinoma

A prognostic and predictive model based on deep learning to identify optimal candidates for intensity-modulated radiotherapy alone in patients with stage II nasopharyngeal carcinoma: A retrospective multicenter study

PURPOSE

To develop and validate a prognostic and predictive model integrating deep learning MRI features and clinical information in patients with stage II nasopharyngeal carcinoma (NPC) to identify patients with a low risk of progression for whom intensity-modulated radiotherapy (IMRT) alone is sufficient.

METHODS

This multicenter, retrospective study enrolled 999 patients with stage II NPC from two centers. 3DResNet was used to extract deep learning MRI features and eXtreme Gradient Boosting model was employed to integrate the pre-trained features and clinical information to obtain an overall score for each patient. Based on the optimal cutoff value of the overall score, patients were stratified into high- and low- risk groups. Model performance was evaluated using concordance indexes (C-indexes), the area under the curve (AUC) values and calibration tests. Survival curves were used to analyze the clinical benefits of additional chemotherapy in each risk group.

RESULTS

The combined model achieved a concordance index of 0.789 (95 % confidence interval [CI] 0.787-0.791), 0.768 (95 % CI 0.764-0.771), and 0.804 (95 % CI 0.801-0.807) for the training, internal validation, and external test cohorts, respectively, demonstrating a statistically significant improvement compared to the MRI model, T Stage, and N Stage. An overall score of < 0.405 in patients was significantly associated with a low risk of progression. In the low-risk group, patients treated with IMRT alone had comparable or even superior progression-free survival (PFS) compared to those who received additional chemotherapy.

CONCLUSION

The model demonstrated a satisfactory prognostic and predictive performance for PFS. Patients with stage II NPC were stratified into different risk groups to help identify optimal candidates who could benefit from IMRT alone.

Selection of induction chemotherapy cycles for stage N3 nasopharyngeal carcinoma based on pre-treatment plasma EBV DNA

This study aimed to explore the selection of induction chemotherapy (IC) cycles for stage N3 nasopharyngeal carcinoma (NPC). We employed propensity score matching (PSM) to categorize patients into 3-cycle and 4-cycle IC groups (IC = 3 and IC = 4). The log-rank and chi-squared tests were used respectively to evaluate the differences in survival and acute toxicities. Survival outcomes including overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRRFS) were evaluated among the two groups. After PSM, each group comprised 99 patients. The IC = 4 group exhibited markedly improved survival outcomes compared with the IC = 3 group. Multivariate analysis revealed that pre-EBV DNA was an independent risk factor affecting PFS and DMFS. For high-risk patients with pre-EBV DNA ≥ 7800 copies/ml, the IC = 4 group demonstrated greater survival compared to the IC = 3 group. Among low-risk patients with pre-EBV DNA < 7800 copies/ml, both groups showed comparable survival outcomes. In terms of acute adverse reactions, the IC = 4 group experienced higher incidences, particularly with grade 2-4 alanine transaminase elevation and thrombocytopenia. For stage N3 NPC, pre-EBV DNA could be a powerful predictor for guiding the selection of IC cycles. The IC = 4 regimen is probably more beneficial to high-risk patients due to superior survival, while for low-risk patients, the IC = 3 regimen may be sufficient.

Association between serum globulins and diabetes mellitus in American latent tuberculosis infection patients: A cross-sectional study

Diabetes mellitus (DM) is predisposing to the development of latent tuberculosis infection (LTBI). An understanding of the underlying factors of LTBI-DM is important for tuberculosis prevention and control. This study aims to evaluate the association between LTBI and DM among the noninstitutionalized civilian population in the United States, focusing on the impact of serum globulins. We performed a cross-sectional study design using public data from 2011 to 2012 National Health and Nutrition Examination Survey, focusing on participants diagnosed with LTBI who were aged 20 and above. Weighted Wilcoxon rank-sum and weighted chi-square tests were used to compare group differences. A multivariable logistic regression model was constructed to assess the association between serum globulin and DM, with subgroup analyses and evaluations of nonlinear relationships. Receiver operating characteristic curves were used to assess the predictive power of the models. A total of 694 participants (512 DM and 182 nonDM) were included in our study and the incidence of DM was 22%. Higher serum globulin levels were significantly associated with an increased risk of DM, with a 21% increase in risk for each unit increase in serum globulin (odds ratio = 1.21, 95% confidence interval [1.03, 1.43], P < .001). The relationship between serum globulin and DM was linear, and higher serum globulin levels were associated with a higher risk of DM, particularly in males (P = .043) and obese individuals (P = .019). The area under the curve for serum globulin predicting DM was 0.795, with an optimal cutoff value of 2.9. Elevated serum globulin levels are significantly associated with an increased risk of DM among individuals with LTBI, highlighting the potential role of serum globulin as a predictive biomarker for DM in this population. However, the specific mechanism between globulin and LTBI-DM needs to be further investigated.

Concurrent chemoradiotherapy versus radiotherapy alone in older patients with stage II nasopharyngeal carcinoma after intensity-modulated radiotherapy: A propensity score-matched cohort study

BACKGROUND AND PURPOSE

Whether concurrent chemoradiotherapy (CCRT) benefits the older (age ≥ 60 years) patients with stage II nasopharyngeal carcinoma (NPC) has not been determined. This study aimed to compare the outcomes and toxicities of CCRT with Intensity-Modulated Radiotherapy (IMRT) alone in older patients with stage II NPC.

MATERIALS AND METHODS

Between January 2010 and December 2017, 220 older (age ≥ 60 years) patients with stage II NPC were analyzed. A pair of 53 patients were matched between the CCRT group and RT group by using propensity score matching (PSM) in terms of age, sex, pathological type, T and N stage, ACE-27 scores, CRP, LDH and Hb. Cancer-specific survival (CSS), progression-free survival (PFS), locoregional relapse-free survival (LRRFS) and distant metastasis-free survival (DMFS) were analysed by the Kaplan-Meier method and log-rank test. Multivariate analysis was performed to assess the prognostic risk factors by using a Cox's proportional hazards regression model. Treatment toxicities were clarified and compared between the two groups by using the χ2 test.

RESULTS

The median follow-up time of the whole cohort was 82.0 months (range, 11-151 months). PSM analysis indicated that compared with the RT group, significantly higher 5-year CSS (98.1 % vs. 83.0 %, P = 0.02), PFS (98.1 % vs. 79.2 %, P = 0.01) and DMFS (100.0 % vs. 92.4 %, P = 0.04) were observed in the CCRT group. Multivariate analysis showed that CCRT was an independent prognostic factor predicting CSS (HR, 0.34; 95 % CI, 0.15-0.79; P = 0.01), PFS (HR, 0.48; 95 % CI, 0.25-0.93; P = 0.03), and LRRFS (HR, 0.36; 95 % CI, 0.14-0.90; P = 0.03), and a higher ACE-27 score predicted a worse CSS. Patients in the CCRT group experienced higher frequencies of the acute toxicities than patients in the RT group. Late complications were comparable between the two groups.

CONCLUSION

CCRT significantly improved the survival benefits for the older patients with stage II NPC compared with IMRT alone without adding late complications, whereas increased some of the treatment-associated acute toxicities.

Albumin-to-globulin ratio predicts clinical outcomes of heart failure with preserved ejection fraction in women

Despite advances in medicine, heart failure with preserved ejection fraction (HFpEF) remains an increasing health concern associated with a high mortality rate. Research has shown sex-based differences in the clinical characteristics of patients with HF; however, definitive biomarkers for poor clinical outcomes of HFpEF in women are unavailable. We focused on the albumin-to-globulin ratio (AGR), a biomarker for malnutrition and inflammation and investigated its usefulness as a predictor of clinical outcomes of HFpEF in women. We measured the AGR in consecutive 224 women with HFpEF and 249 men with HFpEF. There were 69 cardiac events in women with HFpEF and 69 cardiac events in men with HFpEF during the follow-up period. The AGR decreased with advancing New York Heart Association functional class in women with HFpEF. Patients were categorized into three groups based on AGR tertiles. Kaplan-Meier analysis showed that among the three groups, the risk for cardiac events and HF-associated rehospitalizations was the highest in the lowest tertile in women with HFpEF. Univariate and multivariate Cox proportional hazard regression analyses showed that after adjustment for confounding risk factors, the AGR was an independent predictor of cardiac events and HF-associated rehospitalizations in women with HFpEF, but not in men with HFpEF. The addition of AGR to the risk factors significantly improved the net reclassification and integrated discrimination indices in women with HFpEF. This is the first study that highlights the significant association between the AGR and the severity and clinical outcomes of HFpEF in women. Addition of AGR to the risk factors improved its prognostic value for clinical outcomes, which indicates that this variable may serve as a useful clinical biomarker for HFpEF in women.

Protective role of antithrombin III in suppressing acute responses in a rat model of renal ischemia-reperfusion injury

Renal ischemia-reperfusion (IR) produces-induced injury and is characterized by restriction of blood supply to the kidney followed by restoration and re-oxygenation of the tissue. IR injury in the kidney contributes to pathological processes known as acute renal injury (ARI). Ischemia-perfusion injury (IRI) of the left renal artery has been demonstrated in Wistar rats. A total of 32 animals were divided into four groups: control group (SHAM), IR animals with induced ischemia-reperfusion, AT-IR animals treated by antithrombin III (AT) before IR, and AT-IR-AT animals with AT administered before and after IR. IR-induced hyperproteinemia, hyperalbuminemia, hyperglobulinemia, and a significantly low A/G ratio. Exogenous administration of AT prior to IR development effectively regulates protein fraction levels by establishing normoproteinemia. The preventive effect of AT regulates serum protein levels and reduces acute inflammation by reducing globulin and establishing physiological levels of A/G ratios. The therapeutic effect of AT given after IR is not effective compared to AT administered before IR. Protein fractions can serve as an important predictive marker for the prognosis and duration of acute inflammation. Serum globulin levels and the A/G ratio may serve as effective prognostic markers in acute inflammation caused by ischemia-reperfusion injury of the kidney. A strong correlation between globulin and the A/G ratio suggests novel markers associated with acute inflammation that can lead to chronic kidney disease.

Prognostic Factors for Overall Survival in Nasopharyngeal Cancer and Implication for TNM Staging by UICC: A Systematic Review of the Literature

This study aims to identify prognostic factors in nasopharyngeal carcinoma (NPC) to improve the current 8th edition TNM classification. A systematic review of the literature reported between 2013 and 2019 in PubMed, Embase, and Scopus was conducted. Studies were included if (1) original clinical studies, (2) ≥50 NPC patients, and (3) analyses on the association between prognostic factors and overall survival. The data elements of eligible studies were abstracted and analyzed. A level of evidence was synthesized for each suggested change to the TNM staging and prognostic factors. Of 5,595 studies screened, 108 studies (44 studies on anatomical criteria and 64 on non-anatomical factors) were selected. Proposed changes/factors with strong evidence included the upstaging paranasal sinus to T4, defining parotid lymph node as N3, upstaging N-category based on presence of lymph node necrosis, as well as the incorporation of non-TNM factors including EBV-DNA level, primary gross tumor volume (GTV), nodal GTV, neutrophil-lymphocyte ratio, lactate dehydrogenase, C-reactive protein/albumin ratio, platelet count, SUVmax of the primary tumor, and total lesion glycolysis. This systematic review provides a useful summary of suggestions and prognostic factors that potentially improve the current staging system. Further validation studies are warranted to confirm their significance.

A systematic review and recommendations on the use of plasma EBV DNA for nasopharyngeal carcinoma

INTRODUCTION

Nasopharyngeal carcinoma (NPC) is an endemic malignancy in Southeast Asia, particularly Southern China. The classical non-keratinising cell type is almost unanimously associated with latent Epstein-Barr virus (EBV) infection. Circulating plasma EBV DNA can be a useful biomarker in various clinical aspects, but comprehensive recommendations and international guidelines are still lacking. We conducted a systematic review of all original articles on the clinical application of plasma EBV DNA for NPC; we further evaluated its strengths and limitations for consideration as standard recommendations.

METHODS

The search terms 'nasopharyngeal OR nasopharynx', and 'plasma EBV DNA OR cell-free EBV OR cfEBV' were used to identify full-length articles published up to December 2020 in the English literature. Three authors independently reviewed the article titles, removed duplicates and reviewed the remaining articles for eligibility.

RESULTS

A total of 81 articles met the eligibility criteria. Based on the levels of evidence and grades of recommendation assessed, it is worth considering the inclusion of plasma EBV DNA in screening, pre-treatment work-up for enhancing prognostication and tailoring of treatment strategy, monitoring during radical treatment, post-treatment surveillance for early detection of relapse, and monitoring during salvage treatment for recurrent or metastatic NPC. One major limitation is the methodology of measurement requiring harmonisation for consistent comparability.

CONCLUSIONS

The current comprehensive review supports the inclusion of plasma EBV DNA in international guidelines in the clinical aspects listed, but methodological issues must be resolved before global application.

Significance of albumin to globulin ratio as a predictor of febrile urinary tract infection after ureteroscopic lithotripsy

Background

We aimed to analyze the effectiveness of albumin to globulin ratio (AGR) in predicting postoperative febrile urinary tract infection (fUTI) after ureteroscopic lithotripsy (URS) and retrograde intrarenal surgery (RIRS).

Methods

From January 2013 to May 2018, 332 patients underwent URS and RIRS. The rate of postoperative fUTI and risk factors for postoperative fUTI were analyzed using logistic regression. Patients were divided into postoperative fUTI and non-postoperative fUTI (non-fUTI) groups. AGR with other demographic and perioperative data were compared between the two groups to predict the development of fUTI after URS.

Results

Of the 332 patients, postoperative fUTI occurred in 41 (12.3%). Preoperative pyuria, microscopic hematuria, diabetes mellitus, hypoalbuminemia, and hyperglobulinemia were more prevalent in the fUTI group. Patients in the fUTI group had larger stone size, lower preoperative AGR, longer operation time, and longer preoperative antibiotic coverage period. In a multivariable logistic analysis, preoperative pyuria, AGR, and stone size were independently correlated with postoperative fUTI (p<0.001, p=0.008, and p=0.041, respectively). Receiver operating curve analysis showed that the cutoff value of AGR that could predict a high risk of fUTI after URS was 1.437 (sensitivity, 77.3%; specificity, 76.9%), while the cutoff value of stone size was 8.5 mm (sensitivity, 55.3%; specificity, 44.7%).

Conclusion

This study demonstrated that preoperative pyuria, AGR, and stone size can serve as prognostic factors for predicting fUTI after URS.

Prediction of local recurrence and distant metastasis using radiomics analysis of pretreatment nasopharyngeal [18F]FDG PET/CT images

OBJECTIVES

To develop a radiomics signature to predict locoregional recurrence (LR) and distant metastasis (DM), as extracted from pretreatment 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([18F]FDG) positron emission tomography/X-ray computed tomography (PET/CT) images in locally advanced nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

Eighty-five patients with Stage III-IVB NPC underwent pretreatment [¹⁸F]FDG PET/CT scans and received radiotherapy or chemoradiotherapy. 53 of them achieved disease control, and 32 of them failed after treatment (15: LR, 17: DM). A total of 114 radiomic features were extracted from PET/CT images. For univariate analysis, Wilcoxon test and Chi-square test were used to compare median values of features between different treatment outcomes and predict the risk of treatment failure, respectively. For multivariate analysis, all features were grouped into clusters based on Pearson correlation using hierarchical clustering, and the representative feature of each cluster was chosen by the Relief algorithm. Then sequential floating forward selection (SFFS) coupled with a support vector machine (SVM) classifier were used to derive the optimized feature set in terms of the area under receiver operating characteristic (ROC) curve (AUC). The performance of the model was evaluated by leave-one-out-cross-validation, fivefold cross-validation, tenfold cross-validation.

RESULTS

Twenty features had significant differences between disease control and treatment failure. NPC patients with values of Compactness1, Compactness2, Coarseness_NGTDM or SGE_GLGLM above the median as well as patients with values of Irregularity, RLN_GLRLM or GLV_GLSZM below the median, showed a significant (p < 0.05) higher risk of treatment failure (about 50% vs. 25%). The derived radiomics signature consisted of 5 features with the highest AUC value of 0.8290 (sensitivity: 0.8438, specificity: 0.7736) using leave-one-out-cross-validation.

CONCLUSION

Locoregional recurrence (LR) and DM of locally advanced NPC can be predicted using radiomics analysis of pretreatment [¹⁸F]FDG PET/CT. The SFFS feature selection coupled with SVM classifier can derive the optimized feature set with correspondingly highest AUC value for pretreatment prediction of LR and/or DM of NPC.

Low value of whole-body dual-modality [18f]fluorodeoxyglucose positron emission tomography/computed tomography in primary staging of stage I-II nasopharyngeal carcinoma: a nest case-control study

Objectives

The value of using PET/CT for staging of stage I–II NPC remains unclear. Hence, we aimed to investigate the survival benefit of PET/CT for staging of early-stage NPC before radical therapy.

Methods

A total of 1003 patients with pathologically confirmed NPC of stages I–II were consecutively enrolled. Among them, 218 patients underwent both PET/CT and conventional workup ([CWU], head-and-neck MRI, chest radiograph, liver ultrasound, bone scintigraphy) before treatment. The remaining 785 patients only underwent CWU. The standard of truth (SOT) for lymph node metastasis was defined by the change of size according to follow-up MRI. The diagnostic efficacies were compared in 218 patients who underwent both PET/CT and CWU. After covariate adjustment using propensity scoring, a cohort of 872 patients (218 with and 654 without pre-treatment PET/CT) was included. The primary outcome was overall survival based on intention to treat.

Results

Retropharyngeal lymph nodes were metastatic based on follow-up MRI in 79 cases. PET/CT was significantly less sensitive than MRI in detecting retropharyngeal lymph node lesions (72.2% [62.3–82.1] vs. 91.1% [84.8–97.4], p = 0.004). Neck lymph nodes were metastatic in 89 cases and PET/CT was more sensitive than MRI (96.6% [92.8–100.0] vs. 76.4% [67.6–85.2], p < 0.001). In the survival analyses, there was no association between pre-treatment PET/CT use and improved overall survival, progression-free survival, local relapse-free survival, regional relapse-free survival, and distant metastasis-free survival.

Conclusions

This study showed PET/CT is of little value for staging of stage I–II NPC patients at initial imaging.

Key Points

• PET/CT was more sensitive than MRI in detecting neck lymph node lesions whereas it was significantly less sensitive than MRI in detecting retropharyngeal lymph node lesions.

• No association existed between pre-treatment PET/CT use and improved survival in stage I–II NPC patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-020-07478-1.

Adding Concurrent Chemotherapy to Intensity-Modulated Radiotherapy Does Not Improve Treatment Outcomes for Stage II Nasopharyngeal Carcinoma: A Phase 2 Multicenter Clinical Trial

Purpose: To explore the efficacy of concomitant chemotherapy in intensity-modulated radiotherapy (IMRT) to treat stage II nasopharyngeal carcinoma (NPC). Methods and Materials: In this randomized phase 2 study [registered with ClinicalTrials.gov (NCT01187238)], eligible patients with stage II (2010 UICC/AJCC) NPC were randomly assigned to either IMRT alone (RT group) or IMRT combined with concurrent cisplatin (40 mg/m², weekly) (CCRT group). The primary endpoint was overall survival (OS). The second endpoints included local failure-free survival (LFFS), regional failure-free survival (RFFS), disease-free survival (DFS), distant metastasis-free survival (DMFS), and acute toxicities. Results: Between May 2010 to July 2012, 84 patients who met the criteria were randomized to the RT group (n = 43) or the CCRT group (n = 41). The median follow-up time was 75 months. The OS, LFFS, RFFS, DFS, and DMFS for the RT group and CCRT group were 100% vs. 94.0% (p = 0.25), 93.0% vs. 89.3% (p = 0.79), 97.7% vs. 95.1% (p = 0.54), 90.4% vs. 86.6% (p = 0.72), and 95.2% vs. 94.5% (p = 0.77), respectively. A total of 14 patients experienced disease failure, 7 patients in each group. The incidence of grade 2 to 4 leukopenia was higher in the CCRT group (p = 0.022). No significant differences in liver, renal, skin, or mucosal toxicity was observed between the two groups. Conclusion: For patients with stage II NPC, concomitant chemotherapy with IMRT did not improve survival or disease control but had a detrimental effect on bone marrow function.

[Viral co-infection with head and neck tumors]

The review is devoted to assessing the prevalence of human papillomavirus (HPV) in combination with other viral agents for head and neck tumors (HNT). HPV is recognized as an etiological factor in the development of cervical cancer, but there is evidence that it may be involved in carcinogenesis in other locations, in particular the upper respiratory tract. However, HPV is not the most important factor in tumor growth and progression. Recently, many researchers have reported the presence of concomitant co-infection, affecting tumor progression. Of all the studies analyzed, only 3 studies showed the absence or low rates of co-infection in HNT: from the Czech Republic (0%), China (0.6%) and Japan (3%). Most often, HPV infection was detected together with the Epstein-Barr virus (EBV) - from 12.5 to 34.1% of cases. In Russia, the prevailing combination of viral co-infection was a combination of EBV and cytomegalovirus (9.5%) and a combination of EBV and herpes simplex virus (6.7%). Thus, the degree of incidence of HPV in HNT varies greatly, and the mechanisms of coinfection are poorly understood, which raises the question of whether HPV and concomitant infection can be involved in tumor progression. This makes further research in this direction relevant and promising.

The efficacy of chemotherapy in survival of stage II nasopharyngeal carcinoma

PURPOSE

Chemotherapy use remains controversial for stage II nasopharyngeal carcinoma (NPC). This retrospective study was conducted to identify whether chemoradiotherapy was associated with better survival compared to radiotherapy.

MATERIALS AND METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was queried for stage II NPC patients between 2004 and 2015. Patients were divided into radiotherapy and chemoradiotherapy groups. Overall survival (OS) and cancer-specific survival (CSS) were examined using the Kaplan-Meier method, Cox proportional hazards models, and propensity score matching analyses.

RESULTS

This study examined 908 patients, including 102 receiving radiotherapy and 806 receiving chemoradiotherapy. Chemoradiotherapy was associated with 5-year OS (78.01% vs. 75.12%; p = 0.22) and CSS (78.92% vs. 78.26%; p = 0.40) rates comparable to those of radiotherapy. Propensity score matching analyses demonstrated similar OS (HR: 0.63, 95% CI: 0.36--1.10; p = 0.10) and CSS (HR: 0.77, 95% CI: 0.41-1.48; p = 0.44) rates with radiotherapy. Age >60 years and non-Asian patients were associated with worse survival.

CONCLUSION

This study revealed that chemoradiotherapy showed similar survivals to stage II NPC patients compared with radiotherapy. Due to the limitations of SEER database, further studies should be performed to verify the results.

Establishment and validation of a nomogram for predicting the benefit of concurrent chemotherapy in stage II nasopharyngeal carcinoma: A study based on a phase III randomized clinical trial with 10-year follow-up

BACKGROUND AND PURPOSE

Our previous phase III randomized trial demonstrated that the addition of concurrent chemotherapy to radiotherapy (RT) could improve survival in stage II nasopharyngeal carcinoma (NPC). Based on the study, we sought to develop a nomogram for predicting the 5-year and 10-year survival of patients with stage II NPC and estimating the benefit of concurrent chemoradiotherapy (CCRT) for individual patients.

MATERIALS AND METHODS

Data of 199 enrolled patients from the original trial was analyzed to build a nomogram. Overall survival (OS) was the primary endpoint. The discrimination and calibration capacities were evaluated using Harrell Concordance Index (C-index) and calibration curves, respectively. Internal validation of the nomogram was performed by a separate cohort of 306 patients from the same cancer center.

RESULT

In training cohort, patients in CCRT group achieved higher 5-year and 10-year OS compared with patients in RT group. Three independent prognostic factors, which were age, N stage and treatment method from multivariable analysis were extracted to enter the nomogram. T stage was also included due to its importance in clinical decisions. The Harrell C-index of the nomogram in training and validation cohort was 0.748 and 0.653 respectively. The calibration curves showed an acceptable agreement between prediction and observed probability.

CONCLUSION

We developed and validated a nomogram to predict the 5-year and 10-year OS in stage II NPC patients. The nomogram could serve as a pragmatic tool in clinical decisions to estimate the individual risk of stage II patients and identify those who could benefit from chemotherapy.

Association between Albumin-Globulin Ratio and Mortality in Patients with Chronic Kidney Disease

Background: Malnutrition and inflammation are highly prevalent and tightly regulated with each other in chronic kidney disease (CKD) patients. Inflammation can lead to malnutrition in patients with sufficient nourishment, while malnutrition may also induce an inflammatory response. This study investigated whether the albumin-globulin ratio (AGR) can predict the mortality risk in CKD patients. Methods: We enrolled 956 stage 3–5 CKD patients retrospectively at a medical center. Patients’ baseline characteristics including demographics, laboratory data, pharmacotherapy, and comorbidities were collected for statistical adjustments. The study patients were stratified into three AGR groups according to similar magnitudes of hazards for mortality as follows: low AGR group, AGR ≤ 1.0; moderate AGR group, 1.1 ≤ AGR < 1.3; high AGR group, AGR ≥1.3. Multivariate Cox proportional hazard analysis was performed to evaluate the association of the AGR with the study outcomes, including overall and cardiovascular disease (CVD) mortality. Results: During a median follow-up duration of 2.44 years, 108 (11.3%) deaths were recorded and 50 patients died from CVD. In adjusted model 1, the moderate AGR group was associated with hazard ratios (HR) of 0.57 (95% CI = 0.36–0.90, p = 0.016) and 0.52 (95% CI = 0.28–0.98, p = 0.043) for all-cause and CVD mortality compared with the low AGR group, respectively. The high AGR group was associated with HRs of 0.49 (95% CI = 0.27–0.90, p = 0.021) and 0.27 (95% CI = 0.1–0.74, p = 0.01) for all-cause and CVD mortality compared with the low AGR group, respectively. Similar results were obtained in the adjusted model 2 (inverse probability of the group weighted Cox model). In addition, the association between the AGR and mortality risk remained significant when the AGR was treated as a continuous variable. Conclusion: AGR is a significant biomarker predicting overall and cardiovascular mortality risk independent of various important factors amongst stage 3–5 CKD patients. We suggest that the AGR may be a simple and inexpensive measurement for detecting CKD patients at risk of mortality.

Neutrophil-to-lymphocyte ratio predicts the prognosis of stage II nasopharyngeal carcinoma

Purpose

To assess the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in stage II nasopharyngeal carcinoma (NPC).

Methods

Stage II (2010 UICC/AJCC staging system) NPC patients treated between January 2007 and December 2014 were retrospectively analyzed. The NLR was calculated from peripheral blood cell counts before treatment. The optimal cut-off value of NLR was determined by receiver operating characteristic curve analysis. Survival rates were compared according to the NLR value. Multivariable Cox regression analyses were performed to assess the association between the NLR and overall survival (OS), locoregional-free survival (LRFS), and distant metastasis-free survival (DMFS).

Results

Two hundred and fifty-one stage II NPC patients were included in this study. The NLR was correlated with T stage (r=0.158, p=0.012). An NLR ≥2.92 was associated with poor 5-year OS (84.3% vs 97.4%, p=0.001) and LRFS (91.4% vs 98.4%, p=0.003). An NLR ≥2.82 was associated with poor 5-year DMFS (92.6% vs 98.2%, p=0.033). The multivariate Cox regression analysis showed that an NLR ≥2.92 was an independent prognostic biomarker in stage II NPC.

Conclusion

The NLR is an independent prognostic factor in stage II NPC.

The next decade of clinical trials in locoregionally advanced nasopharyngeal carcinoma

Clinical trials are powerful weapons in the battle against nasopharyngeal carcinoma (NPC). Based on clinical trials conducted in the past two decades, concurrent chemoradiotherapy combined with adjuvant chemotherapy or induction chemotherapy has been recommended as the standard treatment for locoregionally advanced NPC in various guidelines. However, there remain shortcomings concerning current treatment modalities that should be refined in future research. In this article, we review the achievements of published clinical trials for locoregionally advanced NPC and propose future directions for subsequent clinical trials. We believe that refinement of current regimens of chemotherapy, de-intensification of treatment for specific groups of patients, developing personalized treatment based on predictors ( e.g. applying plasma Epstein-Barr virus DNA) and investigating novel therapies, such as targeted therapy and immunotherapy, should be applied with the highest priority when designing clinical trials for locoregionally advanced NPC in the next decade.

Comparison between the seventh and eighth edition of the AJCC/UICC staging system for nasopharyngeal cancer integrated with pretreatment plasma Epstein–Barr virus DNA level in a non-Chinese population: secondary analysis from a prospective randomized trial

The eighth AJCC/UICC staging for nasopharyngeal cancer had higher prognostic values than the previous edition. Pretreatment plasma EBV DNA integrated into the next edition could further improve the outcome prediction.

Ten-year outcomes of survival and toxicity for a phase III randomised trial of concurrent chemoradiotherapy versus radiotherapy alone in stage II nasopharyngeal carcinoma

PURPOSE

Our previous results showed survival benefits of concurrent chemoradiotherapy (CCRT) in treating stage II nasopharyngeal carcinoma (NPC) compared with radiotherapy (RT) alone. Here, we present the updated 10-year survival results and late toxicity profile to assess the ultimate effectiveness of concurrent chemotherapy.

METHODS

Patients with stage II NPC were randomly assigned to RT arm (n = 114) or to CCRT arm (n = 116) with a concurrent weekly cisplatin regimen. The primary end-point was overall survival (OS).

RESULTS

With a median follow-up of 125 months, significant improvements in OS (83.6% vs 65.8%, P = 0.001), progression-free survival (76.7% vs 64.0%, P = 0.014), cancer-specific survival (86.2% vs 71.9%, P = 0.002), distant-metastasis free survival (94.0% vs 83.3%, P = 0.007) were observed in CCRT arm. In point of locoregional-relapse free survival, the impact of CCRT was not remarkable. The findings were in accordance with our previous report. The survival benefits earned by CCRT mainly reflected in T2N1 population. Although CCRT brought more acute toxic effects (P = 0.001), as presented in previous report, the late toxicities and treatment-associated deaths events were comparable between two arms.

CONCLUSIONS

Ten-year outcomes confirmed that CCRT could improve the OS of stage II patients without adding late toxicities compared with conventional RT.

Individualized induction chemotherapy by pre-treatment plasma Epstein-Barr viral DNA in advanced nasopharyngeal carcinoma

Background

The role of pretreatment Epstein-Barr virus DNA (pre-DNA) for individualized induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (LA-NPC) still remains unknown. We aimed to address this clinical issue.

Methods

In total, data on 6218 patient with newly diagnosed LA-NPC receiving concurrent chemoradiotherapy (CCRT) with or without IC were retrospectively reviewed. Receiver operating characteristics (ROC) curve was adopted to calculate the cut-off value of pre-DNA based on disease-free survival (DFS). Propensity score matching (PSM) method was adopted to balance prognostic factors and match patients. Survival outcomes between IC + CCRT and CCRT groups were compared.

Results

Among the original cohort, no survival difference between IC + CCRT and CCRT groups was found. The cut-off value of pre-DNA was 4650 copies/ml (area under curve [AUC], 0.620; sensitivity, 0.6224; specificity, 0.5673). For patients with Pre-DNA ≤ 4650 copies/ml, the IC + CCRT and CCRT groups also achieved comparable survival outcomes (P > 0.05 for all rates). However, IC + CCRT was associated with significantly improved 3-year DFS (78.6% vs. 74.8%, P = 0.03), overall survival (OS; 91.4% vs. 87.5%, P = 0.002) and distant metastasis-free survival (DMFS; 86.0% vs. 82.2%, P = 0.036) for patient with pre-DNA > 4650 copies/ml. Multivariate analysis also confirm that IC + CCRT was an independent prognostic factor for DFS (HR, 0.817; 95% CI, 0.683–0.977; P = 0.027), OS (HR, 0.675; 95% CI, 0.537–0.848; P = 0.001) and DMFS (HR, 0.782; 95% CI, 0.626–0.976; P = 0.03).

Conclusions

Pre-DNA may be a feasible and powerful consideration for individualized IC apart from other baseline clinical characteristics in LA-NPC.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-5177-9) contains supplementary material, which is available to authorized users.

Human cytomegalovirus and Epstein-Barr virus infections increase the risk of death in patients with head and neck cancers receiving radiotherapy or radiochemotherapy

Viral infections, including cytomegalovirus (CMV) and Epstein-Barr virus (EBV), play an important role in carcinogenesis and can influence patients' prognosis and condition during cancer treatment.The goal of this study was to investigate CMV and EBV infections in patients receiving radiotherapy or radiochemotherapy due to head and neck cancers to determine the influence of these infections on the risk of death. The observation period was 2 years.Of 41 patients enrolled, 11 received radiotherapy (simultaneous-integrated boost intensity-modulated radiation therapy [SIB-IMRT], 2.25 Gy/fraction, 30 fractions, [n = 7] or IMRT, 2 Gy per fraction, 35 fractions, [n = 4]) and 30 received radiochemotherapy (cisplatin 100 mg/m and SIB-IMRT [n = 13] or IMRT [n = 17]). Plasma CMV and EBV DNA levels were assessed using real-time PCR before or during treatment or 4 weeks posttreatment.The risk of death in the group positive for plasma CMV or EBV deoxyribonucleic acid (DNA) was significantly higher compared to the group without detectable plasma CMV (odd ratio [OR]: 7.5, 95% confidence interval [CI]: 1.11-50.67) or EBV DNA (OR: 10.91, 95% CI: 1.135-104.8). Results were confirmed using the Bayesian method. Plasma positivity for CMV or EBV DNA was associated with a higher risk of death (both P = .04).Viral infections negatively affect the survival of patients with head and neck cancers. Diagnosing and treating these viral infections in patients with positive results should be considered.

Differential prevalence and correlates of whole blood Epstein-Barr virus DNA between HIV-positive and HIV-negative men who have sex with men in Shanghai, China

This cross-sectional study aimed to examine and compare prevalence and correlates of whole blood Epstein-Barr virus (EBV) DNA between HIV-positive and HIV-negative men who have sex with men (MSM). Five hundred and four HIV-positive MSM and 504 age-matched HIV-negative MSM were recruited from an HIV counseling and testing clinic in Shanghai, China from November 2014 to November 2015 and were administered with a face-to-face questionnaire interview. Whole blood EBV DNA was tested by nested polymerase chain reaction assays on EBNA-1, EBNA-2, and LMP-1 genes. The prevalence of whole blood EBV DNA was 56·0% (95% CI 51·7-60·3%) among HIV-positive MSM and 26·0% (95% CI 22·4-30·0%) among HIV-negative MSM. Whole blood EBV DNA positivity was significantly associated with HIV infection (adjusted odds ratio (aOR) 3·43, 95% CI 2·58-4·57) and frequent intake of pickled, smoked, or salty food (aOR 1·71, 95% CI 1·02-2·86) in the whole sample, and with <200 cells/μl CD4 cell counts (aOR 1·79, 95% CI 1·05-3·05) and pickled, smoked, or salty food intake (aOR 3·14, 95% CI 1·39-7·08) in HIV-positive group. HIV-infected MSM are at higher risk of active EBV replication than HIV-uninfected MSM, underscoring needs of surveillance and research on EBV-related carcinogenesis in this population.

Identifying pretreatment baseline factors predictive of distant metastasis in patients with nasopharyngeal carcinoma after radiotherapy

This retrospective study was performed to identify pretreatment baseline factors that could predict the development of distant metastasis (DM) in patients with nasopharyngeal carcinoma (NPC).A cohort of 119 NPC patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT) were recruited into the study. Among them, 51 developed DM (DM group) within 3 years after treatment and 68 did not (DM-free group). Various clinicopathological factors were measured before the treatment and analyzed by univariate as well as multivariate analyses for the potential correlation with DM development.Univariate analysis revealed that increased peripheral lactate dehydrogenase (LDH) level, lower lymphocyte-monocyte ratio (LMR), higher neutrophil-lymphocyte ratio (NLR), advanced American Joint Committee on Cancer (AJCC) stage, advanced T stage, and advanced N stage were significantly correlated with the presence of DM. Multivariate analysis identified advanced AJCC stage and high LDH level were independent predictive factors for DM.Routinely measured pretreatment clinical factors, including AJCC state and serum LDH level, could independently predict DM. These factors will benefit the selection of appropriate treatment options and improve the overall survival of NPC patients.