Surgical treatment of nasopharyngeal cancer - a consensus recommendation from two Chinese associations

BACKGROUND

Surgical treatment is playing an increasingly important role in the management of nasopharyngeal carcinoma (NPC). This consensus focuses on the indications for optimal surgery, and surgical methods in the whole process of treatment for NPC to provide a useful reference to assist these difficult clinical decisions.

METHODOLOGY

A thorough review of available literature on NPC and surgery was conducted by the Association for the prevention and treatment of nasopharyngeal carcinoma in China, international exchange and promotion Association for medicine and healthcare, and the Committee on nasopharyngeal cancer of Guangdong provincial anticancer association. A set of questions and a preliminary draft guideline was circulated to a panel of 1096 experienced specialists on this disease for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the experts in two authoritative medical science and technology academic groups in the prevention and treatment of NPC in China for review and reconsideration.

RESULTS

The initial round of questions showed variations in clinical practice even among similar specialists, reflecting the lack of high-quality supporting data and resulting difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of surgery, including indications and surgical approaches.

CONCLUSION

By standardizing the surgical indications and practice, we hope not only to improve the surgical outcomes, but also to highlight the key directions of future clinical research in the surgical management of NPC.

Occult Lymph Node Metastasis in cN0 Tongue Squamous Cell Carcinoma: A Prospective Observational Study

PURPOSE/OBJECTIVE(S)

Tongue squamous cell carcinoma (TSCC) is prone to occult lymph node metastasis, and preoperative evaluation of cervical nodes is critical for determining treatment strategies. There is scarce report of detecting occult lymph node metastasis in TSCC by using multi-parameter magnetic resonance imaging (mpMRI), spectral computed tomography (spectral CT) or other diagnostic functional imaging. In this study, we aimed to analyze the incidence and risk factors of occult lymph node metastasis in cN0 TSCC by comparing preoperative imaging with postoperative pathology results.

MATERIALS/METHODS

This study prospectively enrolled newly-diagnosed cN0 TSCC patients admitted to the Hunan Cancer Hospital between May, 2022 and December, 2022. All patients underwent primary resection and selective dissection of cervical lymph nodes. MpMRI and spectral CT scan of oral cavity and neck were performed prior to surgery. Preoperative evaluation of lymph node metastasis was conducted by two senior radiologists independently. The location of cervical lymph nodes was assigned based on the 2013 consensus guidelines.

RESULTS

A total of 26 cN0 TSCC patients (6 cT1 stage, 13 cT2 stage, and 7 cT3 stage) were enrolled. The median age was 53 (range, 36-64), and there were 25 males. Among all patients, 13 patients underwent unilateral cervical lymph node dissection, while 13 patients underwent bilateral cervical lymph node dissection. A total of 208 lymphatic drainage areas were resected, and 1003 lymph nodes were removed. There were 7 of pT1, 12 of pT2, 7 of pT3 based on postoperative pathological stages. Besides, there are 21 cases staged pN0, 2 cases staged pN1, 2 cases staged pN2, and 1 case staged pN3. Among the 26 patients, 5 (19.23%) cases had occult lymph node metastasis. A total of 8 metastatic lymph nodes (4 in ipsilateral Ib level, 1 in contralateral Ib level, 3 in IIa level ipsilateral side) were detected in the whole group. No lymph node metastasis was detected in level IIb, III and IV. The median maximum diameter of metastatic lymph nodes was 12 mm (range 5 to 15 mm), and 1 extra-nodal extension was observed. Moreover, all occult lymph node metastases occurred in patients with a primary invasion depth of ≥ 5 mm (29.41%, 5/17).

CONCLUSION

The incidence of occult lymph node metastasis in cN0 TSCC remains high under functional imaging diagnostic technology. Preventive neck dissection is necessary for patients with cN0 disease, especially those with primary tumor invasion depth exceeding 5 mm.

Distribution Pattern of Metastatic Lymph Nodes in 870 Cases of Nasopharyngeal Carcinoma: A Clue for Individualized Elective Prophylactic Neck Irradiation

PURPOSE/OBJECTIVE(S)

We aimed to explore a potential individualized elective prophylactic neck irradiation (iEPNI) to optimize the current strategy by investigating the distribution of metastatic lymph nodes (LNs) in nasopharyngeal carcinoma (NPC).

MATERIALS/METHODS

Magnetic resonance imaging (MRI) and clinical data of 870 non-distant metastatic NPC patients admitted to the Hunan Cancer Hospital between January 2019 and December 2019 were reviewed. All patients were staged using the 8th TNM staging system, and the LNs location was assigned based on the 2013 guidelines. According to the distribution patterns of the LNs in NPC, the intra-regional lymphatic drainage levels were categorized into the following three stations: Station 1st of level VIIa and II; Station 2nd of level III and Va; and Station 3rd of level IV, Vb, and Vc. Other levels were defined as extra-regional areas.

RESULTS

The incidence of LNs metastasis was 822/870 (94.5%), including 198 cases of unilateral metastasis and 624 cases of bilateral metastasis. Among the 870 patients, the most frequently involved intra-regional lymphatic drainage was level IIb (87.1%), followed by level VIIa (80.0%), IIa (61.8%), Va (30.6%), IV (21.4%), Vb (8.9%), and Vc (1.1%). In the extra-regional areas, the detailed LNs distribution was: level Ia (0.2%), level Ib (7.7%), level VI (0.1%), level VIIb (5.6%), level VIII (5.5%), level IX (0.3%), and level X (0.2%). The rates of LNs metastasis in Station 1st, Station 2nd, and Station 3rd were 820/870 (94.3%), 532/870 (61.1%), and 199/870 (22.9%), respectively. Only 4 patients were considered to be skipping metastasis among the three stations (4/870, 0.5%). Additionally, in 203 patients with unilateral Station 1st LNs metastasis, there were 86 (42.4%) and 37 (18.2%) patients with ipsilateral Station 2nd and Station 3rd metastasis, respectively, and 3 (1.5%) and 1 (0.5%) patients with contralateral Station 2nd and Station 3rd LNs metastasis, respectively.

CONCLUSION

LNs spread from Station 1st to Station 3rd successively with rare skipping metastasis. A potential iEPNI strategy of prophylactical neck irradiation to the ipsilateral latter node-negative station might be feasible, which is detailed as follows: irradiation to Station 1st in patients with no LNs metastasis, irradiation to Station 2nd in patients with only Station 1st metastasis, and irradiation to Station 3rd in patients with Station 2nd metastasis but without Station 3rd metastasis. Further prospective investigations are expected to validate the strategy.

[To compare the efficacy and incidence of severe hematological adverse events of flumatinib and imatinib in patients newly diagnosed with chronic phase chronic myeloid leukemia]

Objective: To analyze and compare therapy responses, outcomes, and incidence of severe hematologic adverse events of flumatinib and imatinib in patients newly diagnosed with chronic phase chronic myeloid leukemia (CML) . Methods: Data of patients with chronic phase CML diagnosed between January 2006 and November 2022 from 76 centers, aged ≥18 years, and received initial flumatinib or imatinib therapy within 6 months after diagnosis in China were retrospectively interrogated. Propensity score matching (PSM) analysis was performed to reduce the bias of the initial TKI selection, and the therapy responses and outcomes of patients receiving initial flumatinib or imatinib therapy were compared. Results: A total of 4 833 adult patients with CML receiving initial imatinib (n=4 380) or flumatinib (n=453) therapy were included in the study. In the imatinib cohort, the median follow-up time was 54 [interquartile range (IQR), 31-85] months, and the 7-year cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) were 95.2%, 88.4%, 78.3%, and 63.0%, respectively. The 7-year FFS, PFS, and OS rates were 71.8%, 93.0%, and 96.9%, respectively. With the median follow-up of 18 (IQR, 13-25) months in the flumatinib cohort, the 2-year cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) were 95.4%, 86.5%, 58.4%, and 46.6%, respectively. The 2-year FFS, PFS, and OS rates were 80.1%, 95.0%, and 99.5%, respectively. The PSM analysis indicated that patients receiving initial flumatinib therapy had significantly higher cumulative incidences of CCyR, MMR, MR(4), and MR(4.5) and higher probabilities of FFS than those receiving the initial imatinib therapy (all P<0.001), whereas the PFS (P=0.230) and OS (P=0.268) were comparable between the two cohorts. The incidence of severe hematologic adverse events (grade≥Ⅲ) was comparable in the two cohorts. Conclusion: Patients receiving initial flumatinib therapy had higher cumulative incidences of therapy responses and higher probability of FFS than those receiving initial imatinib therapy, whereas the incidence of severe hematologic adverse events was comparable between the two cohorts.

[Clinical and genetic characteristics of young patients with myeloproliferative neoplasms]

Objectives: To investigate the clinical and genetic features of young Chinese patients with myeloproliferative neoplasms (MPN). Methods: In this cross-sectional study, anonymous questionnaires were distributed to patients with MPN patients nationwide. The respondents were divided into 3 groups based on their age at diagnosis: young (≤40 years) , middle-aged (41-60 years) , and elderly (>60 years) . We compared the clinical and genetic characteristics of three groups of MPN patients. Results: 1727 assessable questionnaires were collected. There were 453 (26.2%) young respondents with MPNs, including 274 with essential thrombocythemia (ET) , 80 with polycythemia vera (PV) , and 99 with myelofibrosis. Among the young group, 178 (39.3%) were male, and the median age was 31 (18-40) years. In comparison to middle-aged and elderly respondents, young respondents with MPN were more likely to present with a higher proportion of unmarried status (all P<0.001) , a higher education level (all P<0.001) , less comorbidity (ies) , fewer medications (all P<0.001) , and low-risk stratification (all P<0.001) . Younger respondents experienced headache (ET, P<0.001; PV, P=0.007; MF, P=0.001) at diagnosis, had splenomegaly at diagnosis (PV, P<0.001) , and survey (ET, P=0.052; PV, P=0.063) . Younger respondents had fewer thrombotic events at diagnosis (ET, P<0.001; PV, P=0.011) and during the survey (ET, P<0.001; PV, P=0.003) . JAK2 mutations were found in fewer young people (ET, P<0.001; PV, P<0.001; MF, P=0.013) ; however, CALR mutations were found in more young people (ET, P<0.001; MF, P=0.015) . Furthermore, mutations in non-driver genes (ET, P=0.042; PV, P=0.043; MF, P=0.004) and high-molecular risk mutations (ET, P=0.024; PV, P=0.023; MF, P=0.001) were found in fewer young respondents. Conclusion: Compared with middle-aged and elderly patients, young patients with MPN had unique clinical and genetic characteristics.

Impact of intracytoplasmic sperm injection in women with non-male factor infertility: A systematic review and meta-analysis

OBJECTIVE

The purpose of this study is to determine whether intracytoplasmic sperm injection (ICSI) is beneficial in patients with non-male factor infertility.

METHODS

This systematic review and meta-analysis included articles from inception to May 2022. Published studies of non-male factor infertile women undergoing ICSI or in vitro fertilization (IVF) included in PubMed, Embase, web of science, Wanfang Database, and CNKI were searched by computer, without language restrictions. A random-effect model was applied to calculate the risk ratios (RRs) and their 95% confidence intervals (CIs). Letters, case reports, and review articles including meta-analyses and expert opinions were excluded. The primary endpoints were laboratory outcomes and pregnancy outcomes. The Secondary endpoints were neonatal outcomes.

RESULTS

Six randomized controlled studies and 20 retrospective cohort studies met the inclusion criteria. In meta-analytic forest plots, compared with IVF, those who received ICSI treatment were not different in fertilization rate (RR = 0.99, 95% CI [0.90-1.09], P = 0.88), total fertilization failure rate (RR = 1.30, 95% CI [1.17-1.45], P < 0.00001), and good quality embryo rate (RR = 0.94, 95% CI [ 0.86-1.02], P = 0.15), clinical pregnancy rate (RR = 0.84, 95% CI [0.70-1.01], P = 0.06), live birth rate (RR = 0.89, 95% CI [0.77-1.03], P = 0.13), miscarriage rate (RR = 1.06, 95% CI [0.78-1.43], P = 0.71), preterm neonatal delivery rate (RR = 0.92, 95% CI [0.67-1.26], P = 0.61), and low neonatal weight rate (RR = 1.13, 95% CI [0.80-1.61], P = 0.48). However, the implantation rate of IVF was better than ICSI (RR = 0.77, 95% CI [0.64-0.93], P = 0.005). In the subgroup analysis of the live birth rate of fresh embryo transfer, IVF performed in those ≥35 years had a higher live birth rate (RR = 0.82, 95% CI [0.78-0.83], P < 0.001).

CONCLUSION

The findings of this study indicate that ICSI is not superior to IVF in the treatment of infertility related to non-male factors. In order to confirm this result, more high-quality clinical studies are needed.

[A real world study on the relationship between drug resistance of targeted therapy and prognosis of HER-2-positive advanced breast cancer]

Objective: To explore the effect of primary and acquired resistance to anti-human epidermal growth factor receptor 2 (HER-2) on the overall survival of patients with HER-2 positive advanced breast cancer. Methods: The clinical characteristics of HER-2 positive patients with advanced breast cancer admitted to Cancer Hospital of Chinese Academy of Medical Sciences from January 1998 to December 2018 were collected, and their neoadjuvant/adjuvant and advanced three-line chemotherapy were summarized. Among them, targeted drugs for HER-2 included trastuzumab, pertuzumab, T-DM1, RC48-ADC, lapatinib, pyrotinib, allitinib, sipatinib, seratinib. Based on the duration of benefit from anti HER-2 treatment, the patients were divided into two groups: primary anti HER-2 resistance group and acquired anti HER-2 resistance group. In this study, the overall survival (OS) was used as the main end point. Kaplan-Meier analysis and Cox proportional risk regression model were used to analyze the effects of different drug resistance mechanisms on the overall survival. Results: The whole group of 284 patients were included. The median age of recurrence and metastasis was 48 years old, 155 (54.6%) were hormone receptor (HR) positive and 129 (45.4%) were HR negative, 128 cases (45.1%) were premenopausal and 156 cases (54.9%) were postmenopausal, 277 cases (97.5%) had a score of 0-1 in ECoG PS and 7 cases (2.5%) had a score of more than 2 in the first diagnosis of relapse and metastasis. There were 103 cases (36.3%) in the primary drug resistance group and 181 cases (63.7%) in the secondary drug resistance group. The median overall survival time of the two groups was 24.9 months and 40.4 months, respectively, with statistical significance (P<0.001). Conclusion: Primary resistance to HER-2 is one of the factors of poor prognosis in HER-2 positive breast cancer, and its mechanism needs to be further explored.

[Effect of integrated schistosomiasis control measures in Hunan Province from 2004 to 2019]

OBJECTIVE

To examine the effect of the integrated schistosomiasis control measures in Hunan Province from 2004 to 2019, so as to provide insights into the development of the schistosomiasis elimination strategy.

METHODS

The integrated schistosomiasis control measures implemented by the health, agriculture, water resources, forestry, land and resources sectors were retrospectively collected in Hunan Province from 2004 to 2019, and the completion of each measure, cost of control measures, Schistosoma japonicum infections in humans and bovines, and snail status were analyzed each year. An index system for assessing the integrated schistosomiasis control effect was constructed using the Delphi method to calculate the integrated schistosomiasis control effect index. In addition, a cost-effect analysis was performed in terms of the decline in the prevalence of S. japonicum infections in humans and bovines, areas with snails in inner embankments, and areas with infected snails.

RESULTS

A total of 7 110 926 500 Yuan were invested into the integrated schistosomiasis control program of Hunan Province from 2004 to 2019. During the 16-year period, a total of 277 437.12 hm² snail habitats received molluscicidal treatments, 6 927 230 person-times given expanded chemotherapy, 2 116 247 bovine-times given expanded chemotherapy, 954 850 harmless toilets built, 290 359 bovines fenced, 136 666 bovines eliminated, 141 905 machines used to replace bovines, 39 048.63 hm² water lands improved as dry lands, 724.12 km irrigation regions improved, 3 994 300 populations covered with safe water, 191 102.89 hm² forests planted and 38 535.27 hm² lands leveled. The prevalence of S. japonicum infections was 4.29% in humans and 4.48% in bovines in Hunan Province in 2004, with 2 449.37 hm² snail habitats in inner embankments and 3 423.74 hm² infected snail areas. In 2019, the prevalence of S. japonicum infections reduced to 0 in both humans and bovines, and areas of snail habitats reduced to 540.92 hm² (77.92% reductions), while the areas with infected snails reduced to 0. The overall integrated schistosomiasis control effect index appeared a tendency towards a rise over years since 2004, and the integrated schistosomiasis control effect index was 97.35 in 2019; the annual mean costs for a 1% reduction in the prevalence of S. japonicum infections in 100 populations and 100 bovines were 70.11 Yuan and 4 204.78 Yuan, and the annual mean costs for a 1% reduction in the snail areas in inner embankments and infected snail areas were 2 010.20 Yuan and 1 298.09 Yuan, respectively.

CONCLUSIONS

The integrated control measures achieve remarkable effectiveness for schistosomiasis control in Hunan Province, with a remarkable decline in the prevalence of S. japonicum infections in humans and bovines and great shrinking of snail areas in inner embankments and infected snail areas. Adequate fund investment is required to improve the integrated schistosomiasis control measures and consolidate the control achievements.

Molecular cloning and tissue distribution profiles of the chicken R-spondin1 gene

Rspo1 belongs to the Rspo family, which is composed of 4 members (Rspo1-4) that share 40 to 60% sequence homology and similar domain organizations, and regulate the WNT signaling pathway via a common mechanism. Rspo1 plays a key role in vertebrate development and is an effective mitogenic factor of gastrointestinal epithelial cells. We report the cloning of chicken Rspo1 and its gene expression distribution among tissues. It contained an open reading frame of 783 bp encoding a protein of 260 amino acids, and its molecular weight was predicted to be 28.80 kDa. Reverse transcription-polymerase chain reaction-based gene expression analysis indicated that chicken Rspo1 was highly expressed in the stomach muscle tissue, but was expressed at low levels in the lung, brain, jejunum, cecum, ileum, spleen, pancreas, kidney, and glandular stomach. These results suggest that Rspo1 plays a major role in muscular immune protection.

SAHA attenuates sevoflurane-induced learning and memory impairments in fetal mice

Previous studies have found that children with multiple exposures to anesthesia at an early age are at increased risk of learning and memory impairment. Sevoflurane is the most commonly used inhalational anesthetic for general anesthesia in children. Multiple exposures to sevoflurane have been shown to induce neuroinflammation, inhibit neurogenesis, and cause subsequent learning and memory impairments in fetal mice. Histone-tail acetylation has been implicated in memory formation. In this study, we employed suberanilohydroxamic acid (SAHA), an inhibitor of histone deacetylases, to treat sevoflurane-induced learning and memory impairments. Six-day-old C57BL/6 mice were exposed to sevoflurane for 2 h daily for 3 days. Morris water maze test performed to evaluate learning and memory impairments and the expression of genes related in to synaptic remodeling/plasticity, or regulated by neuronal activity or the cell cycle were detected by real-time PCR. We found that SAHA attenuated sevoflurane-induced learning and memory impairments in fetal mice. Our findings suggest that SAHA may have potential as a therapeutic agent for preventing or treating the neurotoxicity associated with anesthesia.

Effects of troglitazone and voluntary running on insulin resistance induced high fat diet in the rat

It is well known that troglitazone and voluntary running have the capacity to improve insulin resistance. The purpose of this study was to evaluate the combination effect of troglitazone and voluntary running on insulin action. Female rats aged 7 weeks were divided into high-fat diet (HF), high-fat diet + troglitazone (0.3% in diet; Tg), high-fat diet + voluntary running (for 3 wks; Tr), high-fat diet + troglitazone + voluntary running (Tg-Tr), and control (C) groups. A sequential euglycemic clamp experiment with two different insulin infusion rates of 3.0 (L-clamp) and 30.0 mU/kg BW/min (H-clamp) was performed on these rats after an overnight fast. Blood glucose concentrations were kept at fasting levels by periodic adjustment of the intravenous glucose infusion rate during the clamp experiment. Glucose infusion rates (GIRs) calculated from 60 to 90, 150 to 180 min were regarded as an index of whole body insulin action. After the clamp experiment, we determined the amount of glycogen content in the gastrocnemius muscle. Fat feeding markedly reduced GIRs in both L- and H- clamp experiments compared with C. Troglitazone treatment did not improve high-fat induced insulin resistance. In both L- and H-clamp experiments, GIRs were increased by voluntary running compared with HF, and reached the same levels as in C. GIRs of Tg-Tr were not greater than those of Tr. Glycogen content in gastrocnemius muscle showed the same trend as the results for GIRs. Therefore, the combination effect of troglitazone and voluntary running on insulin action was not found, but the effect of voluntary running was shown in fat-induced insulin resistance.

Nitric oxide decreases insulin resistance induced by high-fructose feeding

The effect of nitric oxide (NO) on insulin resistance was studied in high-fructose-fed rats. A sequential hyperinsulinemic euglycemic clamp procedure was employed (insulin infusion rates: 3 and 30 mU/kg BW/min) in 12 high-fructose-fed rats and 12 chow-fed rats while awake. Half of the high-fructose-fed and the chow-fed rats, respectively, were continuously given sodium nitroprusside (SNP, 3 ng/kg BW/min) during the clamp study. Blood glucose was clamped at the fasting level in each rat. Plasma insulin levels during the 3 and 30 mU/kg BW/min insulin infusions were 30 and 400 microU/ml, respectively. Metabolic clearance rate of glucose (MCR) was regarded as an index of whole body insulin action. At both 3 and 30 mU/kg BW/min insulin infusions, high-fructose feeding showed a significant decrease in MCR compared with the chow-fed rats. However, decreased MCRs were stimulated by SNP administration and reached similar levels as the chow-fed rats. SNP infusion did not influence MCRs in the chow-fed rats. Therefore it could be concluded that NO can improve insulin resistance induced by high-fructose feeding.

[Effect of shengmai san on diaphragmatic function in rabbits]

After stimulation of the bilateral phrenic nerves of the rabbits, the effect of Shengmai San (SMS) on their normal function and the diaphragmatic fatigue was observed with the measuring of diaphragm evoked potential (DEP), and the analysis of the power spectrum of diaphragmatic electromyogram (EMGdi) at spontaneous breathing. The results were as follows: (1) After the administration of 2 ml/kg of SMS, amplitude of DEP, central frequency, and the high/low frequency ratio were markedly increased. (2) Injecting SMS in 2 ml/kg in 30 minutes before injury could protect significantly against diaphragmatic fatigue following electrical stimulation of the phrenic nerves. (3) Injecting SMS in 2 ml/kg after fatigue could enhance the recovery of the diaphragmatic fatigue.