Prognostic factors and failure patterns in non-metastatic nasopharyngeal carcinoma after intensity-modulated radiotherapy

Toripalimab plus chemotherapy in American patients with recurrent or metastatic nasopharyngeal carcinoma: A cost-effectiveness analysis

BACKGROUND

Toripalimab, combined with gemcitabine and cisplatin, has been approved as the first-line treatment for recurrent or metastatic nasopharyngeal carcinoma (RM-NPC), representing a significant milestone as the first FDA-approved innovative therapy for this condition. Despite this achievement, there's a lack of data on the cost-effectiveness of toripalimab for RM-NPC patients in the American context.

METHODS

To assess the cost-effectiveness of toripalimab plus chemotherapy versus chemotherapy alone, a 3-state partitioned survival model was constructed. The study involved participants with characteristics matching those in the JUPITER-02 trial. Cost and utility inputs were collected from literature. Main outcomes measured were quality-adjusted life year (QALY), and incremental cost-effectiveness ratio (ICER). Univariate and probabilistic sensitivity analyses, subgroup analyses, and scenario analyses were conducted to verify the robustness of results.

RESULTS

The study found that the toripalimab regimen resulted in 4.390 QALYs at a cost of $361,813, while the chemotherapy-only regimen yielded 1.685 QALYs at a cost of $161,632. This translates to an ICER of $74,004/QALY, below the willingness-to-pay threshold of $150,000/QALY. Sensitivity analyses indicated that utility values, discount rate, and the price of toripalimab significantly impact INMB. With an 87.10% probability of being cost-effective at a $150,000/QALY threshold, the probabilistic sensitivity analysis supports toripalimab plus chemotherapy as a viable option. Scenario analysis showed that toripalimab remains cost-effective unless its price increases by 125%. Additionally, a simulated 15-year study period increases the ICER to $88,026/QALY. Subgroup analysis revealed ICERs of $76,538/QALY for PD-L1 positive and $70,158/QALY for PD-L1 negative groups.

CONCLUSIONS

Toripalimab in combination with chemotherapy is likely to be a cost-effective alternative to standard chemotherapy for American patients with RM-NPC. This evidence can guide clinical and reimbursement decision-making in treating RM-NPC patients.

Cisplatin-docetaxel induction chemotherapy for patients with nasopharyngeal carcinoma in a non-endemic cohort

This is the report on our clinic's 15 years of experience (2004-2018) on nasopharyngeal carcinoma (NPC), treated with induction chemotherapy (IC) and subsequent concomitant chemoradiotherapy (CCRT), comprising population characteristics and treatment outcomes of 203 patients with non-metastatic NPC. IC comprised docetaxel (75 mg/m2) and cisplatin (75 mg/m2) combination (TP). Concurrent cisplatin (P) was applied either weekly (40 mg/m2, 32 cases) or every-3-week (100 mg/m2, 171 cases). The median follow-up duration was 85 months (range, 5-204 months). Overall and distant failure rates were observed in 27.1% (n = 55) and 13.8% (n = 28) patients, respectively. The 5-year locoregional recurrence-free survival (LRRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) rates were 84.1%, 86.4%, 75%, and 78.7% respectively. The overall stage was an independent prognostic factor for the LRRFS, DMFS, DFS, and OS. The WHO histological type was a prognostic factor for the LRRFS, DFS, and OS. Age was a prognostic factor for the DMFS, DFS, and OS. Concurrent P schedule was independent prognostic only the LRRFS.

Addition of nimotuzumab to concurrent chemoradiotherapy after induction chemotherapy improves outcomes of patients with locally advanced nasopharyngeal carcinoma

Purpose

To investigate the survival outcomes and toxicities associated with the addition of nimotuzumab to concurrent chemoradiotherapy (CCRT) in locally advanced nasopharyngeal carcinoma (LANPC) patients who received induction chemotherapy (IC).

Methods

Patients with stage III-IVA nasopharyngeal carcinoma who received IC and CCRT between January 2017 and October 2021 were retrospectively included. We aimed to compare the locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival (OS) between patients treated with CCRT+nimotuzumab and CCRT alone.

Results

We included 411 patients in the analysis. Of these patients, 267 (65.0%) and 144 (35.0%) had CCRT+nimotuzumab and CCRT alone, respectively. Similar LRFS was found between those with and without nimotuzumab (92.9% vs. 92.6%, p = 0.855). The 3-year DMFS was 88.2% and 76.2% in those with and without nimotuzumab (p = 0.002). The 3-year DFS was 83.4% and 70.6% in those with and without nimotuzumab treatment (p = 0.003). The 3-year OS was 92.1% and 81.1% in those with and without nimotuzumab (p = 0.003). The multivariate Cox regression analysis indicated that the addition of nimotuzumab was independently associated with better DMFS (hazard ratio [HR] 0.606, p = 0.049), DFS (HR 0.613, p = 0.028), and OS (HR 0.497, p = 0.019). No significant differences in major toxicities were found between the two treatment arms, including hematologic toxicities, hepatoxicity, nephrotoxicity, gastrointestinal reactions, and mucositis (all p > 0.05).

Conclusion

The addition of nimotuzumab to CCRT after IC in LANPC has shown promising results in improving treatment outcomes and acceptable toxicities.

Using machine learning algorithms to predict the prognosis of advanced nasopharyngeal carcinoma after intensity-modulated radiotherapy

BACKGROUND

The prognosis of advanced nasopharyngeal carcinoma (NPC) patients after intensity-modulated radiotherapy (IMRT) has not been well studied. We aimed to construct prognostic models for advanced NPC patients with stage III-IV after their first treatment with IMRT by using machine learning algorithms and to identify the most important predictors.

METHODS

A total of 427 patients treated in Meizhou People's Hospital in Guangdong province, China from January 1, 2013 to December 12, 2018 were enrolled in this study, with an average follow-up period of 7.16 years from July 2020 to March 2021. Candidate predictors were selected from demographics, clinical features, medical examinations and test results. Three machine learning algorithms were applied to construct advanced NPC prognostic models: logistic regression (LR), decision tree (DT), and random forest (RF). Area under the receiver operating characteristic curve (AUC) was used to evaluate the model performance. The important predictors of the optimal model for unfavourable prognosis were identified and ranked.

RESULTS

There were 50 (11.7%) NPC-related deaths observed in this study. The mean age of all participants was 49.39±11.29 years, of whom 299 (70.0%) were males. In general, RF showed the best predictive performance with the highest AUC (0.753, 95% CI: 0.609, 0.896), compared to LR (0.736, 95% confidence interval (CI): 0.590, 0.881), and DT (0.720, 95% CI: 0.520, 0.921). The six most important predictors identified by RF were Epstein-Barr virus deoxyribonucleic acid, aspartate aminotransferase, body mass index, age, blood glucose level, and alanine aminotransferase.

CONCLUSIONS

We proposed RF as a simple and accurate tool for the evaluation of the prognosis of advanced NPC patients after the treatment with IMRT in clinical settings.

In situ vaccination caused by diverse irradiation-driven cell death programs

Interest surrounding the effect of irradiation on immune activation has exponentially grown within the last decade. This includes work regarding mechanisms of the abscopal effect and the success achieved by combination of radiotherapy and immunotherapy. It is hypothesized that irradiation triggers the immune system to eliminate tumors by inducing tumor cells immunogenic cell death (ICD) in tumor cells. Activation of the ICD pathways can be exploited as an in situ vaccine. In this review, we provide fundamental knowledge of various forms of ICD caused by irradiation, describe the relationship between various cell death pathways and the immune activation effect driven by irradiation, and focus on the therapeutic value of exploiting these cell death programs in the context of irradiation. Furthermore, we summarize the immunomodulatory effect of different cell death programs on combinative radiotherapy and immunotherapy. In brief, differences in cell death programs significantly impact the irradiation-induced immune activation effect. Evaluating the transition between them will provide clues to develop new strategies for radiotherapy and its combination with immunotherapy.

Oral chemotherapy versus observation alone in nasopharyngeal carcinoma patients with persistently detected circulating cell-free Epstein-Barr virus DNA during follow-up

AIM

Despite the high risk of tumor recurrence, patients with nasopharyngeal carcinoma (NPC) with persistently (at least twice) detected circulating cell-free Epstein-Barr virus (EBV) DNA levels during follow-up are routinely recommended to keep observation. For these patients, whether administering more aggressive treatment could improve survival outcomes remains unknown.

MATERIALS AND METHODS

We retrospectively included 431 patients with nonmetastatic NPC with persistently detected EBV DNA during follow-up, who do not have clinical or imaging evidence of recurrence. Among these patients, 79 were administered oral chemotherapy, and the remaining 352 underwent observation alone. Baseline characteristics were balanced with propensity score matching (PSM) analysis. The primary endpoint was modified disease-free survival (mDFS), defined as time from detectable EBV DNA result to tumor recurrence or death. The secondary endpoints were disease-free survival (DFS) and overall survival (OS).

RESULTS

One-to-three PSM resulted in 251 eligible patients (oral chemotherapy group, 73; observation group, 178). In the matched cohort, the oral chemotherapy group had higher median mDFS (12.9 months [95 % confidence interval [CI] 9.6-16.3] vs. 6.8 months [95 % CI 5.8-7.8], p = 0.009) and DFS (24.1 months [95 % CI 18.5-29.7] vs. 16.7 months [95 % CI 14.4-19.1], p = 0.035) than the observation group. The median OS was numerically higher in the oral chemotherapy group than in the observation group (57.9 months [95 % CI 42.5-73.3] vs. 50.8 months [95 % CI 39.7-61.9], p = 0.71). A consistent benefit favoring oral chemotherapy was observed for mDFS in all subgroups analyses for male, <45 years, stage III-IVa disease, pretreatment EBV DNA load ≥ 4,000 copies/mL, no induction chemotherapy, or a detectable EBV DNA load ≥ 1,200 copies/mL. After adjusting for other confounders in the multivariate analysis, oral chemotherapy remained a significantly favorable factor for both mDFS (hazard ratio [HR] 0.67, 95 % CI 0.50-0.89; p = 0.006) and DFS (HR 0.68, 95 % CI 0.51-0.91; p = 0.01), but not a significant factor for OS (HR 0.89, 95 % CI 0.62-1.27; p = 0.52).

CONCLUSIONS

In patients with NPC having persistently detected EBV DNA levels but without clinical or imaging evidence of recurrence during follow-up, oral chemotherapy significantly prolongs mDFS and DFS. Employing oral chemotherapy as a more aggressive treatment option, as opposed to mere observation, could potentially benefit these patients, although further prospective validation is necessitated.

A Case of Photoimmunotherapy for Nasopharyngeal Carcinoma Requiring Emergency Tracheostomy

Introduction

Photoimmunotherapy (PIT) is a treatment wherein intravenous cetuximab sarotalocan sodium is administered followed by laser light irradiation. This treatment exhibits a specific antitumor effect if in tumors expressing the epidermal growth factor receptor, regardless of the carcinoma [Mitsunaga et al.: Nat Med. 2011;17(12):1685-91, Sato et al.: ACS Cent Sci. 2018;4(11):1559-69, Nakajima et al.: Cancer Sci. 2018;109(9):2889-96]. The current indications are unresectable, locally advanced, or locally recurrent head and neck cancer. If standard treatments, such as radiotherapy and chemotherapy, are available, they are given priority. However, a significant concern in PIT is the occurrence of airway emergencies related to pharyngeal edema. Prophylactic tracheostomy is often performed in cases of PIT involving the root of the tongue, hypopharynx, or larynx.

Case Presentation

In this study, we administered transoral PIT to a patient diagnosed with radiation-induced nasopharyngeal carcinoma (squamous cell carcinoma (SCC) cT1N0M0 stage I). Although previous case reports and our own experiences did not report airway emergencies following PIT for nasopharyngeal carcinoma, a unique case occurred in our study [Omura et al.: Auris Nasus Larynx. 2023;50(4):641-5, Kushihashi et al.: Int J Otolaryngol Head Neck Surg. 2022;11(5, Sep):258-65]. The patient experienced poor oxygenation and a decreased level of consciousness early in the morning following the laser irradiation. Nasal endoscopy revealed airway narrowing due to upper airway edema, and intubation was challenging. Consequently, we performed emergency bedside tracheostomy and the patient's condition improved.

Conclusion

Therefore, it is crucial to note that airway emergencies can be life-threatening and should be diligently monitored as a potential complication of PIT.

A deep learning-based semiautomated workflow for triaging follow-up MR scans in treated nasopharyngeal carcinoma

It is imperative to optimally utilize virtues and obviate defects of fully automated analysis and expert knowledge in new paradigms of healthcare. We present a deep learning-based semiautomated workflow (RAINMAN) with 12,809 follow-up scans among 2,172 patients with treated nasopharyngeal carcinoma from three centers (ChiCTR.org.cn, Chi-CTR2200056595). A boost of diagnostic performance and reduced workload was observed in RAINMAN compared with the original manual interpretations (internal vs. external: sensitivity, 2.5% [p = 0.500] vs. 3.2% [p = 0.031]; specificity, 2.9% [p < 0.001] vs. 0.3% [p = 0.302]; workload reduction, 79.3% vs. 76.2%). The workflow also yielded a triaging performance of 83.6%, with increases of 1.5% in sensitivity (p = 1.000) and 0.6%-1.3% (all p < 0.05) in specificity compared to three radiologists in the reader study. The semiautomated workflow shows its unique superiority in reducing radiologist's workload by eliminating negative scans while retaining the diagnostic performance of radiologists.

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.

Emerging roles of circular RNAs in the invasion and metastasis of head and neck cancer: Possible functions and mechanisms

Head and neck cancer (HNC) is the seventh most prevalent malignancy worldwide in 2020. Cancer metastasis is the main cause of poor prognosis in HNC patients. Recently, circular RNAs (circRNAs), initially thought to have no biological function, are attracting increasing attention, and their crucial roles in mediating HNC metastasis are being extensively investigated. Existing studies have shown that circRNAs primarily function through miRNA sponges, transcriptional regulation, interacting with RNA-binding proteins (RBPs) and as translation templates. Among these functions, the function of miRNA sponge is the most prominent. In this review, we summarized the reported circRNAs involved in HNC metastasis, aiming to elucidate the regulatory relationship between circRNAs and HNC metastasis. Furthermore, we summarized the latest advances in the epidemiological information of HNC metastasis and the tumor metastasis theories, the biogenesis, characterization and functional mechanisms of circRNAs, and their potential clinical applications. Although the research on circRNAs is still in its infancy, circRNAs are expected to serve as prognostic markers and effective therapeutic targets to inhibit HNC metastasis and significantly improve the prognosis of HNC patients.

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.

Two web-based dynamically interactive nomograms and risk stratification systems for predicting survival outcomes and guiding treatment in non-metastatic nasopharyngeal carcinoma

BACKGROUND

A nomogram is a valuable and easily accessible tool for individualizing cancer prognosis. This study aims to establish and validate two prognostic nomograms for long-term overall survival (OS) and cancer-specific survival (CSS) in non-metastatic nasopharyngeal carcinoma (NPC) patients and to investigate the treatment options for the nomogram-based risk stratification subgroups.

METHODS

A total of 3959 patients with non-metastatic NPC between 2004 and 2015 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. The patients were randomly allocated to the training and validation cohorts in a 7:3 ratio. Prognostic nomograms were constructed to estimate OS and CSS by integrating significant variables from multivariate Cox regression employing a backward stepwise method. We examined the correlation indices (C-index) and areas under the curves (AUC) of time-dependent receiver operating characteristic curves to assess the discriminative ability of our survival models. The comprehensive enhancements of predictive performance were evaluated with net reclassification operating improvement (NRI) and integrated discrimination improvement (IDI). Reliability was validated using calibration plots. Decision curve analysis (DCA) was used to estimate clinical efficacy and capability. Finally, the nomogram-based risk stratification system used Kaplan-Meier survival analysis and log-rank tests to examine differences between subgroups.

RESULTS

The following independent parameters were significant predictors for OS: sex, age, race, marital status, histological type, median household income, AJCC stage tumor size, and lymph node size. Except for the race variables mentioned above, the rest were independent prognostic factors for CSS. The C-index, AUC, NRI, and IDI indicated satisfactory discriminating properties. The calibration curves exhibited high concordance with the exact outcomes. Moreover, the DCA demonstrated performed well for net benefits. The prognosis significantly differed between low- and high-risk patients (p < 0.001). In a treatment-based stratified survival analysis in risk-stratified subgroups, chemotherapy benefited patients in the high-risk group compared to radiotherapy alone. Radiotherapy only was recommended in the low-risk group.

CONCLUSIONS

Our nomograms have satisfactory performance and have been validated. It can assist clinicians in prognosis assessment and individualized treatment of non-metastatic NPC patients.

Deep learning-based recurrence detector on magnetic resonance scans in nasopharyngeal carcinoma: A multicenter study

OBJECTIVES

Accuracy in the detection of recurrent nasopharyngeal carcinoma (NPC) on follow-up magnetic resonance (MR) scans needs to be improved.

MATERIAL AND METHODS

A total of 5 035 follow-up MR scans from 5 035 survivors with treated NPC between April 2007 and July 2020 were retrospectively collected from three cancer centers for developing and evaluating the deep learning (DL) model MODERN (MR-based Deep learning model for dEtecting Recurrent Nasopharyngeal carcinoma). In a reader study with 220 scans, the accuracy of two radiologists in detecting recurrence on scans with vs without MODERN was evaluated. The performance was measured using the area under the receiver operating characteristic curve (ROC-AUC) and accuracy with a 95% confidence interval (CI).

RESULTS

MODERN exhibited sound performance in the validation cohort (internal: ROC-AUC, 0.88, 95% CI, 0.86-0.90; external 1: ROC-AUC, 0.88, 95% CI, 0.86-0.90; external 2: ROC-AUC, 0.85, 95% CI, 0.82-0.88). In a reader study, MODERN alone achieved reliable accuracy compared to that of radiologists (MODERN: 84.1%, 95% CI, 79.3%-88.9%; competent: 80.9%, 95% CI, 75.7%-86.1%, P < 0.001; expert: 85.9%, 95% CI, 81.3%-90.5%, P < 0.001). The accuracy of radiologists was boosted by the MODERN score (competent with MODERN score: 84.6%, 95% CI, 79.8%-89.3%, P < 0.001; expert with MODERN score: 87.7%, 95% CI, 83.4%-92.1%, P < 0.001).

CONCLUSION

We developed a DL model for recurrence detection with reliable performance. Computer-human collaboration has the potential to refine the workflow in interpreting surveillant MR scans among patients with treated NPC.

Multimodality radiomics analysis based on [18F]FDG PET/CT imaging and multisequence MRI: application to nasopharyngeal carcinoma prognosis

OBJECTIVES

To determine whether radiomics models developed from 2-deoxy-2-[18F]fluoro-D-glucose ([18F]FDG) PET/CT combined with multisequence MRI could contribute to predicting the progression-free survival (PFS) of nasopharyngeal carcinoma (NPC) patients.

METHODS

One hundred thirty-two NPC patients who underwent both PET/CT and MRI scanning were retrospectively enrolled (88 vs. 44 for training vs. testing). For each modality/sequence (i.e., PET, CT, T1, T1C, and T2), 1906 radiomics features were extracted from the primary tumor volume. Univariate Cox model and correlation analysis were used for feature selection. A multivariate Cox model was used to establish radiomics signature. Prognostic performances of 5 individual modality models and 12 multimodality models (3 integrations × 4 fusion strategies) were assessed by the concordance index (C-index) and log-rank test. A clinical-radiomics nomogram was built to explore the clinical utilities of radiomics signature, which was evaluated by discrimination, calibration curve, and decision curve analysis (DCA).

RESULTS

The radiomics signatures of individual modalities showed limited prognostic efficacy with a C-index of 0.539-0.664 in the testing cohort. Different fusion strategies exhibited a slight difference in predictive performance. The PET/CT and MRI integrated model achieved the best performance with a C-index of 0.745 (95% CI, 0.619-0.865) in the testing cohort (log-rank test, p < 0.05). Clinical-radiomics nomogram further improved the prognosis, which also showed satisfactory discrimination, calibration, and net benefit.

CONCLUSIONS

Multimodality radiomics analysis by combining PET/CT with multisequence MRI could potentially improve the efficacy of PFS prediction for NPC patients.

KEY POINTS

• Individual modality radiomics models showed limited performance in prognosis evaluation for NPC patients. • Combined PET, CT and multisequence MRI radiomics signature could improve the prognostic efficacy. • Multilevel fusion strategies exhibit comparable performance but feature-level fusion deserves more attention.

Clinical evaluation of radiation-induced sinusitis by MRI-based scoring system in nasopharyngeal carcinoma patients

OBJECTIVE

To explore the application of magnetic resonance imaging (MRI) in the evaluation of radiation-induced sinusitis (RIS), MRI-based scoring system was used to evaluate the development regularity, characteristics and influencing factors of RIS in nasopharyngeal carcinoma (NPC) patients.

PATIENTS AND METHODS

A retrospective analysis was performed by collecting the clinical and MRI data of 346 NPC patients to analyze the characteristics and prognosis of RIS. The predictive model was constructed according to the influencing factors of RIS.

RESULTS

(1) In the 2-year follow-up after radiotherapy (RT), there was significant change in L-M score in both groups of NPC patients (sinusitis before RT group: p = 0.000 vs. non-sinusitis before RT group: p = 0.000). After 6 months of RT, the L-M scores of the two groups tended to plateau (sinusitis before RT group: p = 0.311 vs. non-sinusitis before RT group: p = 0.469). (2) The prevalence of sinusitis in two groups of NPC patients (without or with sinusitis before RT) was 83% vs. 93%, 91% vs. 99%, 94% vs. 98% at 1, 6 and 24 months after RT, respectively. (3) In the patients without sinusitis before RT, the incidence of sinusitis in maxillary and anterior/posterior ethmoid, sphenoid and frontal sinuses was 87.1%, 90.0%/87.1%, 49.5%, 11.8% respectively, 1 month after RT. (4) A regression model was established according to the univariate and multivariate analysis of the factors related to RIS (smoking history: p = 0.000, time after RT: p = 0.008 and TNM staging: p = 0.040).

CONCLUSION

(1) RIS is a common complication in NPC patients after RT. This disorder progressed within 6 months after RT, stabilized and persisted within 6 months to 2 years. There is a high incidence of maxillary sinus and ethmoid sinus inflammation in NPC patients after RT. (2) Smoking history, time after RT and TNM staging were significant independent risk factors for RIS. (3) The intervention of the risk factors in the model may prevent or reduce the occurrence of RIS in NPC patients.

HILPDA-mediated lipidomic remodelling promotes radiotherapy resistance in nasopharyngeal carcinoma by accelerating mitophagy

Radiotherapy resistance is a major obstacle to nasopharyngeal carcinoma (NPC) therapy and contributes to tumour recurrence and metastasis. Lipid metabolism is a key regulatory mechanism in cancer biology; however, its role in NPC radiotherapy resistance remains unclear. In this study, we identified hypoxia-inducible lipid droplet-associated protein (HILPDA) as a newly discovered regulator of radioresistance that induces not only lipid droplet (LD) formation but also intracellular lipid remodelling, notably changing mitochondrial cardiolipin (CL) levels. Additionally, we found that the upregulation of CL promotes mitophagy in response to irradiation exposure. Mechanistically, HILPDA inhibits PINK1-mediated CLS1 ubiquitination and degradation. The combination of a mitophagy inhibitor and irradiation significantly increases the radiosensitivity of NPC cells. Human cancer-derived data confirmed that the HILPDA-CLS1 pathway promotes NPC radioresistance. Collectively, these findings suggest that HILPDA plays a critical role in promoting NPC radioresistance and might be targeted to overcome radiotherapeutic resistance in NPC patients in the clinic.

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.

Explainable machine learning via intra-tumoral radiomics feature mapping for patient stratification in adjuvant chemotherapy for locoregionally advanced nasopharyngeal carcinoma

PURPOSE

This study aimed to discover intra-tumor heterogeneity signature and validate its predictive value for adjuvant chemotherapy (ACT) following concurrent chemoradiotherapy (CCRT) in locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

MATERIALS AND METHODS

397 LA-NPC patients were retrospectively enrolled. Pre-treatment contrast-enhanced T1-weighted (CET1-w) MR images, clinical variables, and follow-up were retrospectively collected. We identified single predictive radiomic feature from primary gross tumor volume (GTVnp) and defined predicted subvolume by calculating voxel-wised feature mapping and within GTVnp. We independently validate predictive value of identified feature and associated predicted subvolume.

RESULTS

Only one radiomic feature, gldm_DependenceVariance in 3 mm-sigma LoG-filtered image, was discovered as a signature. In the high-risk group determined by the signature, patients received CCRT + ACT achieved 3-year disease free survival (DFS) rate of 90% versus 57% (HR, 0.20; 95%CI, 0.05-0.94; P = 0.007) for CCRT alone. The multivariate analysis showed patients receiving CCRT + ACT had a HR of 0.21 (95%CI: 0.06-0.68, P = 0.009) for DFS compared to those receiving CCRT alone. The predictive value can also be generalized to the subvolume with multivariate HR of 0.27 (P = 0.017) for DFS.

CONCLUSION

The signature with its heterogeneity mapping could be a reliable and explainable ACT decision-making tool in clinical practice.

Can the apparent transverse relaxation rate (R2*) evaluate the efficacy of concurrent chemoradiotherapy in locally advanced nasopharyngeal carcinoma? a preliminary experience

BACKGROUND

The use of the apparent transverse relaxation rate (R2^*) in nasopharyngeal carcinoma (NPC) has not been previously reported in the literature. The aim of this study was to investigate the role of the R2^* value in evaluating response to concurrent chemoradiotherapy (CCRT) in patients with NPC.

METHODS

Forty-one patients with locoregionally advanced NPC confirmed by pathology were examined by blood oxygenation level-dependent (BOLD) magnetic resonance imaging (MRI) before and after CCRT, and conventional MRI was performed 3 months after the completion of CCRT. All patients were divided into a responding group (RG) and a nonresponding group (NRG), according to MRI findings 3 months after the end of treatment. The R2^* values before (R2*_preT) and after (R2^*_postT) CCRT and the ΔR2^* (ΔR2^*=R2^*_postT - R2^*_preT) were calculated in the tumor.

RESULTS

Among the 41 patients, 26 were in the RG and 15 were in the NRG. There was no statistical difference in the R2^*_preT between RG and NRG (P = 0.307); however, there were significant differences in R2^*_postT and ΔR2^* (P < 0.001). The area under the curve of R2^*_postT and ΔR2^* for predicting the therapeutic response of NPC was 0.897 and 0.954, respectively, with cutoff values of 40.95 and 5.50 Hz, respectively.

CONCLUSION

The R2^* value can be used as a potential imaging indicator to evaluate the therapeutic response of locoregionally advanced NPC.

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.

m6A-enriched lncRNA LINC00839 promotes tumor progression by enhancing TAF15-mediated transcription of amine oxidase AOC1 in nasopharyngeal carcinoma

Dysregulation of long non-coding RNAs (lncRNAs) contributes to tumorigenesis by modulating specific cancer-related pathways, but the roles of m6A-enriched lncRNAs and underlying mechanisms remain elusive in nasopharyngeal carcinoma (NPC). Here, we reanalyzed the previous genome-wide analysis of lncRNA profiles in 18 pairs of NPC and normal tissues, as well as in 10 paired samples from NPC with or without posttreatment metastases. We discerned that an oncogenic m6A-enriched lncRNA, LINC00839, which was substantially upregulated in NPC and correlated with poor clinical prognosis, promoted NPC growth and metastasis both in vitro and in vivo. Mechanistically, by using RNA pulldown assay combined with mass spectrometry, we found that LINC00839 interacted directly with the transcription factor, TATA-box binding protein associated factor (TAF15). Besides, ChIP and dual-luciferase report assays demonstrated that LINC00839 coordinated the recruitment of TAF15 to the promoter region of amine oxidase copper-containing 1 (AOC1), which encodes a secreted glycoprotein playing vital roles in various cancers, thereby activating AOC1 transcription in trans. In this study, potential effects of AOC1 in NPC progression were first proposed. Moreover, ectopic expression of AOC1 partially rescued the inhibitory effect of downregulation of LINC00839 in NPC. Furthermore, we showed that silencing vir-like m6A methyltransferase-associated (VIRMA) and insulin-like growth factor 2 mRNA-binding proteins 1 (IGF2BP1) attenuated the expression level and RNA stability of LINC00839 in an m6A-dependent manner. Taken together, our study unveils a novel oncogenic VIRMA/IGF2BP1-LINC00839-TAF15-AOC1 axis, and highlights the significance and prognostic value of LINC00839 expression in NPC carcinogenesis.

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.

Therapeutic Evaluation of Induction Chemotherapy for Locoregionally Advanced Nasopharyngeal Carcinoma With Low-risk N Stage : A Multicenter Retrospective Study From Nonendemic Region of China

OBJECTIVES

The role of induction chemotherapy (IC) remains ambiguous in a patient with T3-4N0-1 nasopharyngeal carcinoma (NPC) according to data from the endemic area of China. Here, we conducted a multicenter retrospective study to investigate the value of adding IC to concurrent chemoradiotherapy (CCRT) for T3-4N0-1 NPC from Northwest China.

METHODS

Data were extracted in 3 hospitals from Northwest China between May 1, 2010 and August 30, 2018. The Kaplan-Meier method was used to estimate the endpoints. Survival curves were compared using the log-rank test. Initial propensity matching was conducted with a 1:1 match of IC + CCRT to CCRT. The primary endpoint of this study was overall survival (OS).

RESULTS

A total of 108 patients with staging T3-4N0-1 were included in this study. The median follow-up time was 50 months (range: 6 to 118 months). IC followed by CCRT did not significantly improve OS compared with CCRT in the whole cohort (89.5% vs 77.6%, hazard ratio: 0.41, 95% CI: 0.16-1.04, P = 0.100). But significantly better OS was found when a well-balanced propensity score-matched cohort was analyzed. Adjusted 4-year OS was 89.5% for IC followed by CCRT versus 71.1% for CCRT (hazard ratio: 0.30, 95% CI: 0.11-0.80, P = 0.027). No significant differences were detected in side effects between the two groups.

CONCLUSION

This study suggested IC followed by CCRT had the potential to further improve OS in patients with T3-4N0-1M0 NPC from Northwest China compared with CCRT. However, prospective studies with a large sample are warranted to confirm the results.

VIRMA Promotes Nasopharyngeal Carcinoma Tumorigenesis and Metastasis by Upregulation of E2F7 in an m6A-Dependent Manner

The N6-methyladenosine (m6A) modification possesses new and essential roles in tumor initiation and progression by regulating mRNA biology. However, the role of aberrant m6A regulation in nasopharyngeal carcinoma (NPC) remains unclear. Here, through comprehensive analyses of NPC cohorts from the GEO database and our internal cohort, we identified that VIRMA, an m6A writer, is significantly upregulated in NPC and plays an essential role in tumorigenesis and metastasis of NPC, both in vitro and in vivo. High VIRMA expression served as a prognostic biomarker and was associated with poor outcomes in patients with NPC. Mechanistically, VIRMA mediated the m6A methylation of E2F7 3'-UTR, then IGF2BP2 bound and maintained the stability of E2F7 mRNA. An integrative high-throughput sequencing approach revealed that E2F7 drives a unique transcriptome distinct from the classical E2F family in NPC, which functioned as an oncogenic transcriptional activator. E2F7 cooperated with CBFB-recruited RUNX1 in a non-canonical manner to transactivate ITGA2, ITGA5, and NTRK1, strengthening Akt signaling-induced tumor-promoting effect.

Identifying the prognostic value of MRI-based tumor response and predicting the risk of radio-resistance in re-radiotherapy for locally recurrent nasopharyngeal carcinoma

OBJECTIVE

To investigate the prognostic value of tumor response (TR) for locoregionally recurrent nasopharyngeal carcinoma (lrNPC) patients at the end of re-radiotherapy (re-RT) and develop a risk score model to predict patient's radiosensitivity to re-RT.

MATERIALS AND METHODS

A total of 594 patients with lrNPC from 2010 to 2020 were retrospectively reviewed as the total cohort. Among these, 310 patients with complete first-line treatment data were reviewed as a secondary cohort. Overall survival (OS) was the primary endpoint. Locoregional control (LRC) was the secondary endpoint. Multivariate Cox analysis was performed to investigate the prognostic value of TR at the end of re-RT (rTR). A risk score model for predicting rTR was obtained by logistic regression analysis, and its effectiveness was compared using receiver operating characteristic (ROC) analysis.

RESULTS

Patients with complete response (CR) to rTR had higher 5-year OS and LRC rate than non-CR patients in both the total and secondary cohort. rTR was an independent prognostic factor for OS (P=0.002) and LRC (P=0.008). We developed a risk score model including four significant risk factors (relapse T stage, relapse gross tumor volume, time to recurrence, and initial TR). The area under the curve of the risk score model was 0.73 (95% CI: 0.678 to 0.780), which was significantly higher than that of each variable alone. Patients with the highest risk scores may be insensitive to re-RT and had a residual tumor risk of 89.9% after rRT.

CONCLUSION

rTR was an independent prognostic factor for OS and LRC in lrNPC patients. We developed a risk score model for predicting patients' sensitivity to re-RT to screen for radiosensitive patients. This can serve as a treatment decision-making tool for clinicians.

Age is a significant biomarker for the selection of neoadjuvant chemotherapy plus radiotherapy versus concurrent chemoradiotherapy in patients with advanced nasopharyngeal carcinoma

BACKGROUND

The optimal timing of combined chemotherapy with radiotherapy for locally advanced nasopharyngeal carcinoma (LA-NPC) is undetermined.

OBJECTIVE

This study aimed to compare the therapeutic efficacy of neoadjuvant chemotherapy (NACT) followed by radiotherapy (RT) and concurrent chemoradiotherapy (CCRT).

METHODS

Five hundred and thirty-eight patients diagnosed with LA-NPC and treated with NACT + RT or CCRT alone were enrolled in the study. Restricted cubic spline regression (RCS) was used to determine the relationship between age and the hazard Ratio of death. A Kaplan-Meier analysis was performed to evaluate overall survival (OS) related to NACT + RT or CCRT alone. Cox proportional hazards models were used to adjust for potential confounding factors.

RESULTS

Compared with the CCRT alone regimen, the NACT + RT regimen showed a significantly better OS rate with a 62% decreased risk of death in a subgroup of patients aged ⩾ 45 years (hazard ratio, HR: 0.38; 95% confidence interval, CI: 0.24-0.61). In patients aged < 45 years, the risk of death was significantly increased when NACT + RT was chosen compared with CCRT (HR: 4.10; 95% CI: 2.09-8.07).

CONCLUSIONS

Age is a significant biomarker when selecting NACT + RT or CCRT alone in patients with advanced NPC.

A prognostic nomogram incorporating tumor size and lymph node size for patients with nasopharyngeal carcinoma

PURPOSE

The goal of this study was to establish a nomogram that included pre-treatment tumor size and lymph node (LN) size to assess personalized overall survival (OS) of patients with nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

The Surveillance, Epidemiology, and End Results dataset was used to extract statistics for 1083 individuals with NPC (training cohort). In the validation cohort, 266 patients were included from the Affiliated Cancer Hospital & Institute of Guangzhou Medical University. Age, tumor-node-metastasis (TNM) stage, pre-treatment tumor size, and LN size were chosen in both the training and validation sets to build a nomogram to forecast the 3-year and 5-year OS probability using the multivariate Cox regression model. Using the C-index, calibration plot, and receiver operating characteristic (ROC) curve, the predictive model's predictive value and discriminative capacity were determined.

RESULTS

Pre-treatment tumor size, LN size, age, and TNM stage were all independent prognostic factors in the multivariate analysis. After combining these characteristics, a nomogram with a C-index of 0.7367 in the training cohort and 0.795 in the validation cohort was created, suggesting strong predictive capacity. Analysis of the ROC curve revealed that the constructed nomogram was clinically applicable.

CONCLUSIONS

In patients with NPC, the developed nomogram, which includes pre-treatment tumor size, LN size, age, and TNM stage, is a reliable predictive predictor of OS.

A dynamic nomogram combining tumor stage and magnetic resonance imaging features to predict the response to induction chemotherapy in locally advanced nasopharyngeal carcinoma

OBJECTIVES

To establish an effective dynamic nomogram combining magnetic resonance imaging (MRI) findings of primary tumor and regional lymph nodes with tumor stage for the pretreatment prediction of induction chemotherapy (IC) response in locoregionally advanced nasopharyngeal carcinoma (LANPC).

METHODS

A total of 498 LANPC patients (372 in the training and 126 in the validation cohort) with MRI information were enrolled. All patients were classified as "favorable responders" and "unfavorable responders" according to tumor response to IC. A nomogram for IC response was built based on the results of the logistic regression model. Also, the Cox regression analysis was used to identify the independent prognostic factors of disease-free survival (DFS).

RESULTS

After two cycles of IC, 340 patients were classified as "favorable responders" and 158 patients as "unfavorable responders." Calibration curves revealed satisfactory agreement between the predicted and the observed probabilities. The nomogram achieved an AUC of 0.855 (95% CI, 0.781-0.930) for predicting IC response, which outperformed TNM staging (AUC, 0.661; 95% CI 0.565-0.758) and the MRI feature-based model alone (AUC, 0.744; 95% CI 0.650-0.839) in the validation cohort. The nomogram was used to categorize patients into high- and low-response groups. An online dynamic model was built ( https://nomogram-for-icresponse-prediction.shinyapps.io/DynNomapp/ ) to facilitate the application of the nomogram. In the Cox multivariate analysis, clinical stage, tumor necrosis, EBV DNA levels, and cervical lymph node numbers were independently associated with DFS.

CONCLUSIONS

The comprehensive nomogram incorporating MRI features and tumor stage could assist physicians in predicting IC response and formulating personalized treatment strategies for LANPC patients.

KEY POINTS

• The nomogram can predict IC response in endemic LANPC. • The nomogram combining tumor stage with MRI-based tumor features showed very good predictive performance. • The nomogram was transformed into a web-based dynamic model to optimize clinical application.

Maackiain inhibits proliferation and promotes apoptosis of nasopharyngeal carcinoma cells by inhibiting the MAPK/Ras signaling pathway

Nasopharyngeal carcinoma (NPC) is the third most common malignancy with a high recurrence and metastasis rate in South China. Natural compounds extracted from traditional Chinese herbal medicines have been developed and utilized for the treatment of a variety of cancers with modest properties and slight side effects. Maackiain (MA) is a type of flavonoid that was first isolated from leguminous plants, and it has been reported to relieve various nervous system disorders and exert anti-allergic as well as anti-inflammatory effects. In this study, we demonstrated that MA inhibited proliferation, arrested cell cycle and induced apoptosis in nasopharyngeal carcinoma CNE1 and CNE2 cells in vitro and in vivo. The expression of the related proteins associated with these processes were consistent with the above effects. Moreover, transcriptome sequencing and subsequent Western blot experiments revealed that inhibition of the MAPK/Ras pathway may be responsible to the anti-tumor effect of MA on NPC cells. Therefore, the effects of MA and an activator of this pathway, tertiary butylhydroquinone (TBHQ), alone or combination, were investigated. The results showed TBHQ neutralized the inhibitory effects of MA. These data suggest that MA exerts its anti-tumor effect by inhibiting the MAPK/Ras signaling pathway and it has the potential to become a treatment for patients with NPC.

Analysis of risk characteristics for metachronous metastasis in different period of nasopharyngeal carcinoma

OBJECTIVE

To identify the main risk factors for metachronous metastatic nasopharyngeal carcinoma (NPC) in different periods after radiotherapy and estimate the weight of various factors in the early or late metachronous metastasis (EMM/LMM) groups.

METHODS

This retrospective registry consists of 4434 patients with newly diagnosed NPC. Cox regression analysis was used to assess the independent significance of various risk factors. The Interactive Risk Attributable Program (IRAP) was used to calculate the attributable risks (ARs) for metastatic patients during different periods.

RESULTS

Among 514 metastatic patients, 346 (67.32%) patients diagnosed with metastasis within 2 years after treatment were classified into the EMM group, while other 168 patients were classified into the LMM group. The ARs of T-stage, N-stage, pre-Epstein-Barr virus (EBV) DNA, post-EBV DNA, age, sex, pre-neutrophil-to-lymphocyte ratio, pre-platelet-to-lymphocyte ratio, pre-hemoglobin (HB), and post-HB were 20.19, 67.25, 2.81, 14.28, 18.50, - 11.17%, 14.54, 9.60, 3.74% and - 9.79%, respectively, in the EMM group. In the LMM group, the corresponding ARs were 3.68, 49.11, - 18.04%, 2.19, 6.11, 0.36, 4.62, 19.77, 9.57 and 7.76%, respectively. After multivariable adjustment, the total AR for tumor-related factors was 78.19%, and that for patient-related factors was 26.07% in the EMM group. In the LMM group, the total AR of tumor-related factors was 43.85%, while the weights of patient-related factors was 39.97%. In addition, except for these identified tumor- and patient-related factors, other unevaluated factors played a more important role in patients with late metastasis, with the weight increasing by 15.77%, from 17.76% in the EMM group to 33.53% in the LMM group.

CONCLUSION

Most metachronous metastatic NPC cases occurred in the first 2 years after treatment. Early metastasis was mainly affected by tumor-related factors, which accounted for a declining percentage in the LMM group.

Medial retropharyngeal nodal region sparing radiotherapy versus standard radiotherapy in patients with nasopharyngeal carcinoma: open label, non-inferiority, multicentre, randomised, phase 3 trial

OBJECTIVES

To address whether sparing the medial retropharyngeal lymph node (MRLN) region from elective irradiation volume provides non-inferior local relapse-free survival versus standard radiotherapy in patients with nasopharyngeal carcinoma.

DESIGN

Open-label, non-inferiority, multicentre, randomised, phase 3 trial.

SETTING

Three Chinese hospitals between 20 November 2017 and 3 December 2018.

PARTICIPANTS

Adults (18-65 years) with newly diagnosed, non-keratinising, non-distant metastatic nasopharyngeal carcinoma without MRLN involvement.

INTERVENTIONS

Randomisation was done centrally by the Clinical Trials Centre at Sun Yat-sen University Cancer Center. Eligible patients were randomly assigned (1:1; block size of four) to receive MRLN sparing radiotherapy or standard radiotherapy (both medial and lateral retropharyngeal lymph node groups), and stratified by institution and treatment modality as follows: radiotherapy alone; concurrent chemoradiotherapy; induction chemotherapy plus radiotherapy or concurrent chemoradiotherapy.

MAIN OUTCOME MEASURES

Non-inferiority was met if the lower limit of the one sided 97.5% confidence interval of the absolute difference in three year local relapse-free survival (MRLN sparing radiotherapy minus standard radiotherapy) was greater than -8%.

RESULTS

568 patients were recruited: 285 in the MRLN sparing radiotherapy group; 283 in the standard radiotherapy group. Median follow-up was 42 months (interquartile range 39-45), intention-to-treat analysis showed that the three year local relapse-free survival of the MRLN sparing radiotherapy group was non-inferior to that of the standard radiotherapy group (95.3% v 95.5%, stratified hazard ratio 1.04 (95% confidence interval 0.51 to 2.12), P=0.95) with a difference of -0.2% ((one sided 97.5% confidence interval -3.6 to ∞), P_{non-inferiority}<0.001). In the safety set (n=564), the sparing group had a lower incidence of grade ≥1 acute dysphagia (25.5% v 35.1%, P=0.01) and late dysphagia (24.0% v 34.3%, P=0.008). Patient reported outcomes at three years after MRLN sparing radiotherapy were better in multiple domains after adjusting for the baseline values: global health status (mean difference -5.6 (95% confidence interval -9.1 to -2.0), P=0.002), role functioning (-5.5 (-7.4 to -3.6), P<0.001), social functioning (-6.2 (-8.9 to -3.6), P<0.001), fatigue (7.9 (4.0 to 11.8), P<0.001), and swallowing (11.0 (8.4 to 13.6), P<0.001). The difference in swallowing scores reached clinical significance (>10 points difference).

CONCLUSION

Compared with standard radiotherapy, MRLN sparing radiotherapy showed non-inferiority in terms of risk of local relapse with fewer radiation related toxicity and improved patient reported outcomes in patients with non-metastatic nasopharyngeal carcinoma.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03346109.

The valuable role of dynamic (18)F FDG PET/CT-derived kinetic parameter K(i) in patients with nasopharyngeal carcinoma prior to radiotherapy: A prospective study

BACKGROUND AND PURPOSE

Dynamic positron emission tomography/computed tomography (PET/CT) served the potential role of characterizing malignant foci. The main objective of this prospective study was to explore the advantage of dynamic PET/CT imaging in characterizing nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Patients with probable head and neck disease underwent a local dynamic PET/CT scan followed by a whole-body static scan. Patlak analysis was used to generate parametric influx rate constant (K_i) images from 48 frames obtained from a dynamic PET/CT scan. By delineating the volumes-of-interest (VOIs) of: primary tumor (PT), lymph node (LN), and normal nasopharyngeal tissues (N), we acquired the corresponding K_i mean and SUVmean of each site respectively to perform the quantitative statistical analysis.

RESULTS

Qualified images of 71 patients with newly diagnosed NPC and 8 without nasopharyngeal malignant lesions were finally included. We found the correlations between K_i mean-PT and critical clinical features, including clinical stage (r = 0.368), T category (r = 0.643) and EBV-DNA copy status (r = 0.351), and K_i mean-PT differed within the group. SUVmean-PT showed correlations with clinical stage (r = 0.280) and T category (r = 0.472), but could hardly differ systematically within group of clinical features except T category. K_i mean-LN offered the positive correlations with N category (r = 0.294), M category (r = 0.238) and EBV-DNA copy status (r = 0.446), and differed within the group. In addition, K_i mean represented a sensitivity of 94.4 % and a specificity of 100 %, in distinguishing NPC from the non-NPC, when the cut-off was defined as 0.0106. When the cut-off of SUV being defined as 2.03, the sensitivity and specificity were both 100 %.

CONCLUSION

Our research confirmed K_i compared favorably to SUV in characterizing NPC and found that K_i can serve as an effective imaging marker of NPC.

Induction chemotherapy with sequential nimotuzumab plus concurrent chemoradiotherapy in advanced nasopharyngeal carcinoma: A retrospective real-world study

Many locally advanced nasopharyngeal carcinoma patients develop local recurrence or distant metastasis. Our retrospective real-world study aims to evaluate the efficacy and safety of curative sequential approach with induction chemotherapy followed by concurrent chemoradiation + nimotuzumab as first-line therapy in advanced nasopharyngeal carcinoma. From 2015 to 2021, the clinic data of 117 patients with advanced nasopharyngeal carcinoma (stage III-IV a) who were treated in the Affiliated Hospital of Guangdong Medical University were retrospectively reviewed. Fifty-four patients in observation group received taxanes, cisplatin, and 5-fluorouracil/taxanes and cisplatin induction chemotherapy and nimotuzumab (200 mg, weekly) combined with concurrent chemo-radiotherapy (cisplatin: 40 mg/m2 weekly; intensity-modulated radiation therapy); 63 patients in control group received same therapy without nimotuzumab. There was no significant difference in patients' characteristic baseline between 2 groups (P > .05). The complete response rate and objective response rate of the observational group was significantly higher than control group (46.30% vs 17.64%, P = .01; 96.30% vs 82.54%, P = .02). The median follow-up time was 24.77 (3.53-65.97) months. Both of the median progress free survival time and overall survival time were not reached. The 5-year progression-free survival rate of observation group was greater than control group (84.40% vs 63.70%, hazard ratios 0.365, 95% confidence intervals 0.147-0.909, P = .03). The 5-year overall survival rate of observation group and control group were 91.70% and 84.60%, respectively (P = .20). None of the patients withdrew from the study due to adverse events. Nimotuzumab combined with concurrent chemoradiotherapy as first-line therapy in advanced nasopharyngeal carcinoma can improve objective response rate and 5-year progress free survival rate with good safety profile.

The Effect of Magnetic Resonance Imaging Based Radiomics Models in Discriminating stage I-II and III-IVa Nasopharyngeal Carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is a common tumor in China. Accurate stages of NPC are crucial for treatment. We therefore aim to develop radiomics models for discriminating early-stage (I-II) and advanced-stage (III-IVa) NPC based on MR images.

METHODS

329 NPC patients were enrolled and randomly divided into a training cohort (n = 229) and a validation cohort (n = 100). Features were extracted based on axial contrast-enhanced T1-weighted images (CE-T1WI), T1WI, and T2-weighted images (T2WI). Least absolute shrinkage and selection operator (LASSO) was used to build radiomics signatures. Seven radiomics models were constructed with logistic regression. The AUC value was used to assess classification performance. The DeLong test was used to compare the AUCs of different radiomics models and visual assessment.

RESULTS

Models A, B, C, D, E, F, and G were constructed with 13, 9, 7, 9, 10, 7, and 6 features, respectively. All radiomics models showed better classification performance than that of visual assessment. Model A (CE-T1WI + T1WI + T2WI) showed the best classification performance (AUC: 0.847) in the training cohort. CE-T1WI showed the greatest significance for staging NPC.

CONCLUSION

Radiomics models can effectively distinguish early-stage from advanced-stage NPC patients, and Model A (CE-T1WI + T1WI + T2WI) showed the best classification performance.

Systemic immune-inflammation index during treatment predicts prognosis and guides clinical treatment in patients with nasopharyngeal carcinoma

PURPOSE

Systemic immune-inflammation index (SII) has been demonstrated to be closely associated with the poor prognosis of nasopharyngeal carcinoma (NPC). However, the role of SII during treatment of NPC has not been reported. This study aimed to determine the prognostic value of SII during treatment for NPC patients.

METHODS

A total of 759 patients diagnosed with NPC were included in this retrospective study (393 in training cohort and 366 in validation cohort). The correlation between variables was analyzed by the chi-squared test, the Fisher's exact test or the likelihood test. Kaplan-Meier method and log-rank test were used to analyze progression-free survival (PFS) and overall survival (OS). The independent prognostic factors were determined by multivariate analysis of Cox proportional hazards regression model. The uncontrolled risk was analyzed by Logistic regression. Receiver operating characteristic (ROC) curves were used to assess prognostic value.

RESULTS

The optimal cut-off point for the SII during treatment was 937.32. High SII during treatment group had higher uncontrolled risk than low SII during treatment group (p = 0.008). In multivariate Cox proportional hazard models analysis, SII during treatment was an independent prognostic factor for 5-year PFS (p < 0.001) and 5-year OS (p < 0.001). All results were found in the training cohort and confirmed in the validation cohort.

CONCLUSIONS

The SII during treatment is a promising indicator of predicting the survival in NPC patients, especially the risk of uncontrolled occurrence. By monitoring the SII during treatment, it is possible to better evaluate the treatment effect and formulate personalized treatment.

Upper-Neck Versus Whole-Neck Irradiation at the Contralateral Uninvolved Neck in Patients With Unilateral N3 Nasopharyngeal Carcinoma

PURPOSE

Upper-neck irradiation (UNI) at the uninvolved neck has shown similar regional relapse-free survival as standard whole-neck irradiation (WNI) in patients with N0-1 nasopharyngeal carcinoma. However, whether UNI at the contralateral uninvolved neck is feasible in unilateral N3 disease, defined as >6 cm and/or below the caudal border of the cricoid cartilage, remains unclear.

METHODS AND MATERIALS

Data for 291 patients with nasopharyngeal carcinoma with unilateral N3 disease who were treated with intensity modulated radiation therapy from 2009 to 2015 were retrospectively analyzed. Among them, 190 received bilateral WNI (WNI group); the remaining 101 received WNI at the involved neck and UNI at the contralateral uninvolved neck (UNI group). Survival rates were estimated using the Kaplan-Meier method, and differences between groups were compared using the log rank tests.

RESULTS

The median follow-up was 79.4 months (interquartile range, 56.0-89.3). Twenty-five patients had regional lymph node relapses (UNI: 10.9%, 11/101 vs WNI: 7.4%, 14/190; P = .31). Of these, 23 patients relapsed within the previously involved neck regions, while only 2 patients had relapses in the contralateral uninvolved neck (1 each in the UNI and WNI groups). Five-year regional relapse-free survival rates were similar between groups (89.7% vs 92.7%, P = .29). Similar between-group findings were also observed for 5-year overall survival (76.1% vs 80.4%, P = .40), distant metastasis-free survival (74.9% vs 79.2%, P = .44), and local relapse-free survival (95.6% vs 94.7%, P = .64). Furthermore, oncologic outcomes in subgroup and multivariable analyses were similar between groups.

CONCLUSIONS

Regional control and survival outcomes were comparable in UNI at the contralateral uninvolved neck and standard WNI in patients with nasopharyngeal carcinoma with unilateral N3 disease. Our findings provide evidence for future radiation therapy guidelines of nasopharyngeal carcinoma.

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.

Prognostic value of the cervical lymph node necrosis ratio in nasopharyngeal carcinoma

PURPOSE

Whether cervical lymph node necrosis (CNN) is an independent adverse prognostic factor in nasopharyngeal carcinoma (NPC) has not been determined. In this study, the CNN ratio was graded quantitatively to explore the prognostic value in NPC.

PARTICIPANTS AND METHODS

We retrospectively reviewed a total of 648 pathologically confirmed as NPC. We outlined metastatic lymph nodes and necrotic area of lymph nodes slice by slice on the magneticresonanceimages (MRI) cross section, and calculated the corresponding CNN ratio.

RESULTS

The median CNN ratio (17.37 %) was taken as the cut-off point, 256 (39.51 %) patients were divided into CNN1 group (<17.37 %, n = 128) and CNN2 group (≥17.37 %, n = 128), 392 (60.49 %) patients without lymph nodes necrosis were CNN0. Among the CNN0, CNN1 and CNN2 groups, five-year overall survival (OS) was 82.4 %, 76.6 % and 71.1 %, locoregional recurrence-free survival (LRRFS) was 91.3 %, 91.1 % and 90.5 %, distant metastasis-free survival (DMFS) was 83.7 %, 78.5 % and 68.7 %, progression-free survival (PFS) was 78.3 %, 71.7 % and 61.6 % respectively. By multivariate analysis, CNN was an independent prognostic factor for OS (P = 0.003), DMFS (P = 0.019) and PFS (P = 0.007). More than 3 cycles of chemotherapy significantly increased OS (P = 0.024) and DMFS (P = 0.015) in the CNN1 group.

CONCLUSIONS

This study indicated that CNN is one of the factors with the negative prognosis of NPC. The CNN ratio might be used as one of the reference factors in the formulation of individualized treatment plan.

Clinical Outcomes and Prognostic Factors of Locally Advanced Nasopharyngeal Cancer Treated with Intensity Modulated Radiotherapy: First Experience Report from Northeast India

The aim is to retrospectively evaluate the clinical outcomes and prognostic factors in patients of locally advanced nasopharyngeal cancer (NPC) treated with intensity-modulated radiotherapy (IMRT). The northeastern states report relatively more NPC cases in comparison to other states of India. This study is an attempt to assess the treatment outcomes and prognostic factors of locally advanced NPC who had been treated with definitive radiotherapy with or without chemotherapy in our institute from 2012 to 2016 using IMRT. This is a single institutional retrospective study. Thirty-one consecutive patients of locally advanced NPC treated with definitive chemoradiation using the IMRT technique between 2012 to 2016 were evaluated. The survival was analyzed using Kaplan-Meir method and their relations with various clinicopathologic parameters were compared. After a median follow-up time of 36 months, the 5-year overall survival (OS) and disease-free survival (DFS) was 47.3% and 26.1% respectively. The younger patients of < 50 years had improved OS (p = 0.05). Patients of stage IVA had inferior 5-year OS (p = 0.1) and 5-years DFS (0.02) than those of stage III. The patients who received neoadjuvant chemotherapy showed improved DFS at 5 years (p = 0.09). The treatment-related toxicities were within acceptable limit. This retrospective analysis has reported outcomes of locally advanced NPC patients treated with IMRT with concurrent chemotherapy when IMRT was first introduced in our institute. This is the first of its kind from the Northeastern region of India.

Sanguinarine suppresses cell proliferation, migration and invasion in nasopharyngeal carcinoma inhibiting mTOR signaling

OBJECTIVE

To confirm the anti-NPC effect of sanguinarine (SA) through a series of wet experiments.

METHODS

NPC cell viability was determined by proliferation experiment. Cell clone formation experiment, cell scratch test, transwell migration and invasion experiment and flow cytometry-based cell apoptosis assay were further performed. In addition, Western blotting was performed to investigate the cell signaling pathway. All the relevant experimental data were statistically processed using SPSS 16.0 software.

RESULTS

The results showed that sanguinarine represented a time and dose dependent inhibition effects on NPC cell proliferation including the low differentiated CNE2 cells and high metastatic 5-8F cells, along with the cell cloning ability reduction. In addition, sanguinarine has a certain inhibitory effect on the invasion and migration of NPC cells. Mechanistically, sanguinarine displayed the anti-NPC effects mainly involved into the suppression of mTOR signaling and cell apoptosis, which is closely associated with the tumor growth and metastatic malignancy.

CONCLUSIONS

Collectively, we discover that sanguinarine is a new high-efficiency anti-NPC monomer of Chinese medicine, with a value for the follow-up pre-clinical research.

STAT3 regulates SRGN and promotes metastasis of nasopharyngeal carcinoma through the FoxO1-miR-148a-5p-CREB1 axis

Nasopharyngeal carcinoma (NPC), which is marked by a distinct distribution, is a common subtype of epithelial carcinoma arising from the nasopharyngeal mucosal lining. SRGN acts as an important and poor prognostic factor of NPC through multiple different mechanisms. However, the biological role and mechanism of SRGN in NPC remain unknown. Expression levels of miR-148a-5p, CREB1, FoxO1, and SRGN in NPC tissues and cell lines were tested by qRT-PCR or/and Western blot. The impacts of miR-148a-5p, CREB1, FoxO1, and SRGN on NPC cell viability, proliferation, migration, and invasion were estimated in vitro by CCK-8, colony formation, wound healing and Transwell experiments, and in vivo by a xenograft tumor model. JASPAR analysis was used to predict the binding activity of Foxo1 (CREB1) with the miR-148a-5p (SRGN) promoter, and the interaction was validated by EMSA and ChIP assays. The miR-148a-5p-CREB1 interaction was validated by a dual-luciferase reporter and RIP assays. CREB1 and SRGN were increased while miR-148a-5p was decreased in NPC. Silencing of SRGN and CREB1, as well as miR-148a-5p overexpression, repressed NPC tumor progression in vitro and in vivo. CREB1 promoted SRGN expression in NPC by targeting the promoter area of SRGN. Silencing of FoxO1 facilitated NPC tumor progression, while silencing of STAT3 repressed NPC tumor progression. FoxO1 bound to and regulated miR-148a-5p in NPC, and miR-148a-5p targeted CREB1. Additionally, FoxO1 knockdown abolished the downregulation of CREB1 and SRGN induced by STAT3 silencing. Our results suggest that STAT3 regulates SRGN and promotes the growth and metastasis of NPC through the FoxO1-miR-148a-5p-CREB1 axis.

A Nomogram to Identify the Optimal Candidates for Induction Chemotherapy in Advanced N-Stage Nasopharyngeal Carcinoma

Purpose

We aimed to select optimal candidates benefiting from the addition of induction chemotherapy (IC) to concurrent chemoradiotherapy (CCRT) in advanced N-stage nasopharyngeal carcinoma (NPC).

Patients and Methods

A total of 624 NPC patients with N2-3 stage received CCRT with or without IC were retrospectively reviewed. We constructed a nomogram for predicting overall survival (OS) based on the result of the multivariate analysis in the training cohort (n = 468) and then tested it on the validation cohort (n = 156). Harrell’s concordance indices (C-index) and time-independent receiver operating characteristic (tdROC) analysis were applied to evaluate the discriminatory ability of the nomogram and compare it with TNM staging. IC plus CCRT was compared with CCRT in the whole cohort and two risk groups based on the nomogram with balanced baseline characteristics. In addition, acute toxicities were compared between different treatment groups.

Results

The nomogram showed good prognostic accuracy with a C-index of 0.716 (95% CI 0.669–0.763) in the validation cohort. The 5-year OS of low and high-risk groups stratified by the nomogram were significantly different. IC+CCRT was significantly associated with superior OS as compared with CCRT (75.4 vs 52.6%, p = 0.009) in the high-risk group. However, no significant difference between IC plus CCRT and CCRT was observed (p = 0.843) in the low-risk group. IC plus CCRT was associated with more grade 1–4 acute toxicities.

Conclusion

Our study can help clinicians select NPC patients with advanced N stage who benefit from IC.

MRI-based random survival Forest model improves prediction of progression-free survival to induction chemotherapy plus concurrent Chemoradiotherapy in Locoregionally Advanced nasopharyngeal carcinoma

Background

The present study aimed to explore the application value of random survival forest (RSF) model and Cox model in predicting the progression-free survival (PFS) among patients with locoregionally advanced nasopharyngeal carcinoma (LANPC) after induction chemotherapy plus concurrent chemoradiotherapy (IC + CCRT).

Methods

Eligible LANPC patients underwent magnetic resonance imaging (MRI) scan before treatment were subjected to radiomics feature extraction. Radiomics and clinical features of patients in the training cohort were subjected to RSF analysis to predict PFS and were tested in the testing cohort. The performance of an RSF model with clinical and radiologic predictors was assessed with the area under the receiver operating characteristic (ROC) curve (AUC) and Delong test and compared with Cox models based on clinical and radiologic parameters. Further, the Kaplan-Meier method was used for risk stratification of patients.

Results

A total of 294 LANPC patients (206 in the training cohort; 88 in the testing cohort) were enrolled and underwent magnetic resonance imaging (MRI) scans before treatment. The AUC value of the clinical Cox model, radiomics Cox model, clinical + radiomics Cox model, and clinical + radiomics RSF model in predicting 3- and 5-year PFS for LANPC patients was [0.545 vs 0.648 vs 0.648 vs 0.899 (training cohort), and 0.566 vs 0.736 vs 0.730 vs 0.861 (testing cohort); 0.556 vs 0.604 vs 0.611 vs 0.897 (training cohort), and 0.591 vs 0.661 vs 0.676 vs 0.847 (testing cohort), respectively]. Delong test showed that the RSF model and the other three Cox models were statistically significant, and the RSF model markedly improved prediction performance (P < 0.001). Additionally, the PFS of the high-risk group was lower than that of the low-risk group in the RSF model (P < 0.001), while comparable in the Cox model (P > 0.05).

Conclusion

The RSF model may be a potential tool for prognostic prediction and risk stratification of LANPC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09832-6.

Prognostic significance of MRI-based late-course tumor volume in locoregionally advanced nasopharyngeal carcinoma

Background

To validate tumor volume-based imaging markers for predicting local recurrence-free survival (LRFS) in locoregionally advanced nasopharyngeal carcinoma patients, who underwent induction chemotherapy followed by definitive intensity-modulated radiotherapy.

Methods

We enrolled 145 patients with stage III–IVA nasopharyngeal carcinoma in this retrospective study. Pre-treatment tumor volume (V_pre) and late-course volume (LCV) were measured based on the MRIs scanned before treatment and during the first 3 days in the sixth week of radiotherapy, respectively. The volume regression rate (VRR) was calculated according to V_pre and LCV. Receiver operating characteristic (ROC) curves were used to identify the cut-off best separating patient subgroups in assessing the prognostic value of V_pre, LCV and VRR. The Kaplan–Meier method was used for survival analysis. Prognostic analyses were performed using univariate and multivariate COX proportional hazard models.

Results

The LCV was 5.3 ± 0.5 (range 0–42.1) cm³; The VRR was 60.4 ± 2.2% (range 2.9–100.0). The median follow-up period was 36 months (range 6–98 months). The cut-off value of LCV determined by the ROC was 6.8 cm³ for LRFS prediction (sensitivity 68.8%; specificity 79.8%). The combination of LCV and VRR for LRFS prediction (AUC = 0.79, P < 0.001, 95% CI 0.67–0.90), LCV (AUC = 0.74, P = 0.002, 95% CI 0.60–0.88) and V_pre (AUC = 0.71, P = 0.007, 95% CI 0.56–0.85) are better than T category (AUC = 0.64, P = 0.062, 95% CI 0.50–0.79) alone. Patients with LCV ≤ 6.8 cm³ had significantly longer LRFS (P < 0.001), disease-free survival (DFS, P < 0.001) and overall survival (OS, P = 0.005) than those with LCV > 6.8 cm³. Multivariate Cox regression showed LCV was the only independent prognostic factor for local control (HR = 7.80, 95% CI 2.69–22.6, P < 0.001).

Conclusions

LCV is a promising prognostic factor for local control and chemoradiosensitivity in patients with locoregionally advanced NPC. The LCV, and the combination of LCV with VRR are more robust predictors for patient survival than T category.

A Nomogram to Predict Survival in Patients With Locoregional Recurrent Nasopharyngeal Carcinoma Receiving Comprehensive Treatment

Objective

This study aimed to establish a prognostic stratified model of chemotherapy-based comprehensive treatment for patients with locoregional recurrent nasopharyngeal carcinoma (lrNPC), to help individualized treatment decision-making.

Materials and Methods

This study retrospectively reviewed patients with lrNPC who received chemotherapy-based comprehensive treatment from January 1, 2010, to December 31, 2018. A total of 422 eligible patients were divided into test (n = 338) and validation (n = 84) cohorts. A LASSO cox regression model was used to identify significant prognostic factors for overall survival (OS) in the test cohort. A nomogram was then developed based on a combined consideration of clinically meaningful prognostic factors and statistically significant prognostic factors. The performance of the nomogram was assessed with Harrell’s concordance index (C-index) and calibration plots.

Results

Five significant factors were identified: age, albumin (ALB), T stage after recurrent (rT), neutrophil to lymphocyte ratio (NLR), and systematic immune-inflammation index (SII). The nomogram was established with these five factors. C-index was 0.636 in the test cohort and 0.610 in the validation cohort. The calibration curves for the OS rate at 3, and 5 years showed an excellent agreement in both cohorts. In addition, the corresponding risk classification system successfully classified patients into low- and high-risk groups and performed well in stratification (P &lt; 0.001).

Conclusions

The nomogram shows well prognostic performance for lrNPC patients receiving chemotherapy-based comprehensive treatment.

The prognostic value of weight loss during radiotherapy among patients with nasopharyngeal carcinoma: a large-scale cohort study

BACKGROUND

We aim to investigate the prognostic value of weight loss during radiotherapy (RT) among patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 1149 NPC patients who received radical RT were retrospectively analyzed. Patients' weight were measured at initiation of RT (W_Pre-RT) and every week during RT (W_{RT1,2,3,4,5,6,7}). Percentage of weight loss (PWL) at 1st, 2nd, 3rd, 4th, 5th, 6th, and 7th week of RT (RT-PWL_{1,2,3,4,5,6,7}) were calculated using the following equation: (W_Pre-RT -W_{RT1,2,3,4,5,6,7})/W_Pre-RT × 100%. The optimal threshold of RT-PWL₇ was determined by recursive partitioning analyses (RPAs). Our endpoints included disease-free survival (DFS), overall survival (OS), distant metastasis-free survival (DMFS), and locoregional relapse-free survival (LRRFS).

RESULTS

The median RT-PWLs were 0, 0, 1.5, 2.9, 4.1, 5.5, 6.6% at 1st, 2nd, 3rd, 4th, 5th, 6th, and 7th week of RT, respectively. RT-PWL₇ optimal threshold with respect to DFS was 5.3% based on RPAs. Therefore, a consistent threshold of 5% (<5% vs > ≥5%) was selected to classify NPC patients into low RT-PWL₇ and high RT-PWL₇ groups for survival analysis. Compared to high RT-PWL₇ (≥5%), patients with low RT-PWL₇ (< 5%) had significantly better ten-year DFS (61.2% vs 78.8%; P < 0.001), OS (70.1% vs 86.6%; P < 0.001), and DMFS (80.2% vs 88.5%; P = 0.007). However, no difference was observed between LRRFS groups (91.7% vs 94.3%; P = 0.173). In multivariate analysis, high RT-PWL₇ was an independent risk factor for DFS (HR, 1.56; 95%CI, 1.19-2.03; P = 0.001), OS (HR, 1.54; 95%CI, 1.11-2.15; P = 0.011), and DMFS (HR, 1.47; 95%CI, 1.03-2.10; P = 0.033) in patients with NPC. In addition, treatment strategy, plasma Epstein-Barr virus DNA, and N stage were associated with weight loss.

CONCLUSIONS

High RT-PWL₇ was significantly associated with decreased DFS, OS, and DMFS for NPC patients. Clinicians should continuously inform patients on the health impact of minimizing RT-PWL₇ under 5% during radiotherapy.

Upregulation of PNCK Promotes Metastasis and Angiogenesis via Activating NF-κB/VEGF Pathway in Nasopharyngeal Carcinoma

Background

Distant metastasis is the major cause of treatment failure in patients with nasopharyngeal carcinoma (NPC). Thus, the identification of the molecular mechanisms and the development of novel therapeutic strategies are important. Previous studies suggest that PNCK promotes tumor growth by suppressing PI3K/AKT/mTOR signaling in NPC. However, the underlying regulatory mechanism of PNCK for NPC invasion and metastasis remains unclear.

Methods

The PNCK expression level was evaluated in nonmetastatic and metastatic NPC specimens by mRNA sequencing and immunohistochemistry. In vitro migration and invasion and in vivo nude mouse metastasis model and zebrafish model were used to evaluate the effects of PNCK ectopic expression on the metastatic ability of NPC cells. Gene set enrichment and western blot analyses were used to investigate the PNCK downstream signaling pathway.

Results

Human metastatic NPC samples showed elevated PNCK expression at both mRNA and protein levels. Upregulated PNCK promoted in vitro NPC cell migration, invasion, and the formation of lung metastases; the vascular-labeled fluorescence signal increased in the in vivo zebrafish model. Mechanistically, pathway analysis showed that the upregulation of PNCK may promote cell metastasis by activating the NF-κB/VEGF signaling pathway.

Conclusions

These findings revealed the specific critical role of PNCK in promoting NPC metastasis and angiogenesis, which suggested that PNCK may have implications as a potential therapeutic target for individualized NPC treatment.

MFSD4A inhibits the malignant progression of nasopharyngeal carcinoma by targeting EPHA2

DNA Methylation can lead to abnormal gene expression. In the present study, we investigated whether the expression of methylated MFSD4A (major facilitator superfamily domain containing 4 A) was downregulated in nasopharyngeal carcinoma (NPC) and whether it is associated with malignant progression and poor prognosis of NPC. Bioinformatic analysis, bisulfite pyrosequencing, quantitative real-time reverse transcription PCR, and western blotting assays were performed to explore the relationship between hypermethylation of MFSD4A and its expression in NPC. The role of MFSD4A in NPC was verified by Cell Cycle Kit 8, transwell assays and flow cytometry in vitro and by animal experiments in vivo. Mass spectrometry, co-immunoprecipitation, and immunofluorescence assays were applied to explore the mechanism by which MFSD4A inhibits NPC. The prognostic significance of MFSD4A or EPHA2 was investigated by immunohistochemical analysis of clinical specimens. Hypermethylation of the promoter region of MFSD4A led to decreased expression of MFSD4A. When MFSD4A expression was upregulated or downregulated, the proliferation, apoptosis, migration, and invasion abilities of NPC cells were altered accordingly. Mechanistically, MFSD4A could specifically bind to and degrade EPH receptor A2 (EPHA2) by recruiting ring finger protein 149 (RNF149), which led to alterations in the EPHA2-mediated PI3K-AKT-ERK1/2 pathway and epithelial-mesenchymal transition (EMT), thereby affecting NPC progression. Clinically, high MFSD4A expression or low-EPHA2 expression was associated with better prognosis for patients with NPC. In all, reduced MFSD4A expression in NPC is caused by promoter hypermethylation. MFSD4A or EPHA2 expression is associated with the malignant biological behavior and prognosis of NPC. MFSD4A is a promising potential therapeutic target for NPC.

Establishment and Validation of a Novel MRI Radiomics Feature-Based Prognostic Model to Predict Distant Metastasis in Endemic Nasopharyngeal Carcinoma

Purpose

We aimed to establish a prognostic model based on magnetic resonance imaging (MRI) radiomics features for individual distant metastasis risk prediction in patients with nasopharyngeal carcinoma (NPC).

Methods

Regression analysis was applied to select radiomics features from T1-weighted (T1-w), contrast-enhanced T1-weighted (T1C-w), and T2-weighted (T2-w) MRI scans. All prognostic models were established using a primary cohort of 518 patients with NPC. The prognostic ability of the radiomics, clinical (based on clinical factors), and merged prognostic models (integrating clinical factors with radiomics) were identified using a concordance index (C-index). Models were tested using a validation cohort of 260 NPC patients. Distant metastasis-free survival (DMFS) were calculated by using the Kaplan-Meier method and compared by using the log-rank test.

Results

In the primary cohort, seven radiomics prognostic models showed similar discrimination ability for DMFS to the clinical prognostic model (P=0.070-0.708), while seven merged prognostic models displayed better discrimination ability than the clinical prognostic model or corresponding radiomics prognostic models (all P&lt;0.001). In the validation cohort, the C-indices of seven radiomics prognostic models (0.645-0.722) for DMFS prediction were higher than in the clinical prognostic model (0.552) (P=0.016 or &lt;0.001) or in corresponding merged prognostic models (0.605-0.678) (P=0.297 to 0.857), with T1+T1C prognostic model (based on Radscore combinations of T1 and T1C Radiomics models) showing the highest C-index (0.722). In the decision curve analysis of the validation cohort for all prognostic models, the T1+T1C prognostic model displayed the best performance.

Conclusions

Radiomics models, especially the T1+T1C prognostic model, provided better prognostic ability for DMFS in patients with NPC.

Long-Term Evaluation and Normal Tissue Complication Probability (NTCP) Models for Predicting Radiation-Induced Optic Neuropathy after Intensity-Modulated Radiation Therapy (IMRT) for Nasopharyngeal Carcinoma: A Large Retrospective Study in China

Purpose

To quantify the long-term evaluation of optic chiasma (OC) and/or optic nerve(s) (ONs) and to develop predictive models for radiation-induced optic neuropathy (RION) in nasopharyngeal carcinoma after intensity-modulated radiotherapy (IMRT).

Methods and Materials

A total of 3,662 patients' OC/ONs with full visual acuity and dosimetry data between 2010 and 2015 were identified. Critical dosimetry predictors of RION were chosen by machine learning and penalized regression for survival. A nomogram containing dosimetry and clinical variables was generated for predicting RION-free survival.

Results

The median follow-up was 71.79 (2.63–120.9) months. Sixty-six eyes in 51 patients (1.39%) developed RION. Two patients were visual field deficient, and 49 patients had visual acuity of less than 0.1 (20/200). The median latency time was 36 (3–90) months. The 3-, 5-, and 8-year cumulative incidence of RION was 0.78%, 1.19%, and 1.97%, respectively. Dmax was the most critical dosimetry variable for RION (AUC: 0.9434, the optimal cutoff: 64.48 Gy). Patients with a Dmax ≥64.48 Gy had a significantly higher risk of RION (HR = 102.25; 95%CI, 24.86–420.59; P < 0.001). Age (>44 years) (HR = 2.234, 95% CI = 1.233–4.051, p = 0.008), advanced T stage (T3 vs. T1-2: HR = 7.516, 95% CI = 1.725–32.767, p=0.007; T4 vs. T1-2: HR = 37.189, 95% CI = 8.796–157.266, P < 0.001), and tumor infiltration/compression of the OC/ONs (HR = 4.572, 95% CI = 1.316–15.874, p=0.017) were significant clinical risk factors of RION. A nomogram comprising age, T stage, tumor infiltration/compression of the OC/ON, and Dmax significantly outperformed the model, with only Dmax predicting RION (C-index: 0.916 vs. 0.880, P < 0.001 in the training set; 0.899 vs. 0.874, P=0.038 in the test set). The nomogram-defined high-risk group had a worse 8-year RION-free survival.

Conclusions

In the IMRT era, Dmax <60 Gy is safe and represents an acceptable dose constraint for most NPC patients receiving IMRT. A reasonable trade-off for selected patients with unsatisfactory tumor coverage due to proximity to the optic apparatus would be Dmax <65 Gy. Caution should be exercised when treating elderly and advanced T-stage patients or those with tumor infiltration/compression of the OC/ON. Our nomogram shows strong efficacy in predicting RION.