Comparison between atlas and convolutional neural network based automatic segmentation of multiple organs at risk in non-small cell lung cancer

Delineation of organs at risk (OARs) is important but time consuming for radiotherapy planning. Automatic segmentation of OARs based on convolutional neural network (CNN) has been established for lung cancer patients at our institution. The aim of this study is to compare automatic segmentation based on CNN (AS-CNN) with automatic segmentation based on atlas (AS-Atlas) in terms of the efficiency and accuracy of OARs contouring.The OARs, including the lungs, esophagus, heart, liver, and spinal cord, of 19 non-small cell lung cancer patients were delineated using three methods: AS-CNN, AS-Atlas in the Pinnacle-software, and manual delineation (MD) by a senior radiation oncologist. MD was used as the ground-truth reference, and the segmentation efficiency was evaluated by the time spent per patient. The accuracy was evaluated using the Mean surface distance (MSD) and Dice similarity coefficient (DSC). The paired t-test or Wilcoxon signed-rank test was used to compare these indexes between the 2 automatic segmentation models.In the 19 testing cases, both AS-CNN and AS-Atlas saved substantial time compared with MD. AS-CNN was more efficient than AS-Atlas (1.6 min vs 2.4 min, P < .001). In terms of the accuracy, AS-CNN performed well in the esophagus, with a DSC of 73.2%. AS-CNN was better than AS-Atlas in segmenting the left lung (DSC: 94.8% vs 93.2%, P = .01; MSD: 1.10 cm vs 1.73 cm, P < .001) and heart (DSC: 89.3% vs 85.8%, P = .05; MSD: 1.65 cm vs 3.66 cm, P < .001). Furthermore, AS-CNN exhibited superior performance in segmenting the liver (DSC: 93.7% vs 93.6%, P = .81; MSD: 2.03 cm VS 2.11 cm, P = .66). The results obtained from AS-CNN and AS-Atlas were similar in segmenting the right lung. However, the performance of AS-CNN in the spinal cord was inferior to that of AS-Atlas (DSC: 82.1% vs 86.8%, P = .01; MSD: 0.87 cm vs 0.66 cm, P = .01).Our study demonstrated that AS-CNN significantly reduced the contouring time and outperformed AS-Atlas in most cases. AS-CNN can potentially be used for OARs segmentation in patients with pathological N2 (pN2) non-small cell lung cancer.

Cerebral functional abnormalities in patients with nasopharyngeal carcinoma after radiotherapy: an observational magnetic resonance resting-state study

BACKGROUND

Nasopharyngeal carcinoma (NPC) is sensitive to radiotherapy (RT). However, neurocognitive complications such as memory loss and learning and attention deficits emerge in the survivors of NPC who received RT. It remains unclear how radiation affects patient brain function. This pilot study aimed at finding cerebral functional alterations in NPC patients who have received RT.

METHODS

From September 2014 to December 2016, 42 individuals, including 22 NPC patients and 20 normal volunteer controls in National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, were recruited in this study. All patients received resting-state functional magnetic resonance imaging scans and neurocognitive tests 1 day before the initiation of RT (baseline) and 1 day after the completion of RT; the 20 normal controls were also subjected to the same scans and tests. The amplitude of the low-frequency fluctuations (ALFF) in blood oxygen level-dependent signals and functional connectivity (FC) were used to characterize cerebral functional changes. Independent t test, paired t test, and analysis of variances were used to obtain statistical significance across groups.

RESULTS

After RT, NPC patients showed significantly decreased ALFF values in the calcarine sulcus, lingual gyrus, cuneus, and superior occipital gyrus and showed significantly reduced FC mainly in the default mode network (P < 0.05, corrected by AlphaSim). Relative to the controls, ALFF was decreased in the lingual gyrus, calcarine sulcus, cingulate cortex, medial prefrontal gyrus (P < 0.05, corrected by AlphaSim), and FC reduction was found in multiple cerebellar-cerebral regions, including the cerebellum, parahippocampus, hippocampus, fusiform gyrus, inferior frontal gyrus, inferior occipital gyrus, precuneus, and cingulate cortex (P < 0.001, corrected by AlphaSim).

CONCLUSIONS

Cerebral functional alterations occur immediately after RT. This study may provide an explanation for the cognitive deficits in the morphologically normal-appearing brains of NPC patients after RT and may contribute to the understanding of the complex mechanism of RT.

Chidamide and Radiotherapy Synergistically Induce Cell Apoptosis and Suppress Tumor Growth and Cancer Stemness by Regulating the MiR-375-EIF4G3 Axis in Lung Squamous Cell Carcinomas

As a selective histone deacetylase (HDAC) inhibitor developed in China, chidamide has been applied for the treatment of refractory peripheral T-cell lymphoma (PTCL) and multiple solid tumors, including lung cancer. However, the underlying mechanisms are not well elucidated. In our present study, we found that chidamide and radiation acted synergistically to suppress cell and xenograft growth of lung squamous cell carcinoma cells by inducing cell apoptosis. Moreover, chidamide alone or a combination of chidamide and radiation treatment inhibited cancer cell stemness. miRNA microarray analysis demonstrated that miR-375 was the highest upregulated microRNA (miRNA) in NCI-2170 and NCI-H226 cells treated with chidamide alone or treated with chidamide plus radiation, compared with normal control. Inhibition of miR-375 attenuated the promoting effect of chidamide alone and chidamide plus radiation-induced NCI-2170 and NCI-H226 cell apoptosis and reverted the suppression of cancer stemness caused by chidamide alone or chidamide plus radiation treatment. Moreover, EIF4G3, a scaffold protein in the translation initiation complex, was found to be a direct target of miR-375 based on the luciferase reporter assay and western blot analysis. Interestingly, both chidamide alone and chidamide plus radiation treatments suppressed the mRNA and protein expression of EIF4G3. Silence of EIF4G3 also induced cell apoptosis and suppressed tumor growth in NCI-2170 and NCI-H226 cells. These data suggest that chidamide shows a synergistic effect with radiation therapy on lung squamous cell carcinomas by modulating the miR-375-EIF4G3 axis, which may afford an effective strategy to overcome the drug resistance of chidamide in clinical cancer therapy.

Response-Adapted Treatment Following Radiotherapy in Patients With Resectable Locally Advanced Hypopharyngeal Carcinoma

IMPORTANCE

Laryngeal preservation strategies for resectable locally advanced hypopharyngeal carcinoma (LAHPC) have been explored. However, the optimal strategy remains unclear.

OBJECTIVE

To evaluate a response-adapted strategy based on an early response to radiotherapy (RT) in patients with resectable LAHPC.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted from May 2009 to October 2019 with a median (IQR) follow-up period of 66.5 (44.7-97.0) months. The study was conducted at a tertiary academic medical center and included 423 patients pathologically confirmed stage III and IVB LAHPC. A total of 250 patients with previous cancer history, synchronous primary cancer, stage I or II, or with unresectable hypopharyngeal carcinoma were excluded.

EXPOSURES

Patients who reached 80% or greater tumor regression when evaluated endoscopically and by imaging methods at 50 Gy received definitive RT or concurrent chemoradiotherapy, and those with less than 80% regression underwent surgery 4 to 6 weeks after RT.

MAIN OUTCOMES AND MEASURES

Five-year overall survival and survival with a functional larynx.

RESULTS

Overall, 423 patients were included in the study (median [IQR] age, 55 [50-63] years; 408 [96.5%] men and 15 [3.5%] women). The response-adapted and primary surgery groups had significantly better survival than the primary RT group (52.7% and 54.4% vs 27.7%, respectively; P < .001). The response-adapted and primary surgery groups had similar 5-year overall survival of 52.7% vs 54.4%, respectively (hazard ratio [HR], 1.02; 95% CI, 0.75 to 1.39; P = .89). The response-adapted group had better 5-year survival with functional larynx than the primary surgery group (40.6% vs 33.9%; HR, 0.64; 95% CI, 0.49 to 0.84, P = .001). Surgery complications did not significantly differ between the 2 groups. Among patients in the response-adapted group who required total laryngectomy (n = 186) as indicated by pretreatment evaluation, the 5-year cumulative Kaplan-Meier survival with functional larynx was 39.8%.

CONCLUSIONS AND RELEVANCE

In this cohort study, the response-adapted strategy based on an early RT response facilitated better treatment tailoring, maximum tumor control, and higher laryngeal preservation compared with primary surgery and primary RT strategies. This approach could provide a feasible laryngeal preservation strategy in patients with LAHPC.

Impact of Magnetic Field on Dose Distribution in MR-Guided Radiotherapy of Head and Neck Cancer

Purpose

This study investigates the impact of the magnetic field on plan quality and dose at the tissue-air interface in MR-guided radiotherapy of head and neck cancer.

Materials and Methods

The charts of 10 patients with hypopharyngeal carcinoma who were treated with conventional fractionated radiotherapy were collected and reviewed. The skin and tissues containing air cavities were contoured. Three plans using 9 fields of intensity-modulated radiation therapy were generated for each patient in the Monaco treatment planning system of an Elekta Unity MR-linac. The first plan was optimized without the magnetic field (plan0T). The second plan was recalculated in the presence of a 1.5-T magnetic field (plan1.5T_reCal) using the same segment shape and monitor units as the first plan. The third plan was reoptimized in the presence of a 1.5-T magnetic field (plan1.5T_reOpt) using the same cost function as the first plan. The dose to the skin and tissues containing air cavities were compared across the three types of plans. A plan-quality metric method was used to evaluate the plan quality according to the clinical requirements.

Results

The skin dose was increased in the presence of the 1.5-T magnetic field, and the amplitude increase of plan1.5T_reOpt (ΔDmean 1.30 ± 0.42 Gy, ΔDmax 1.68 ± 1.36 Gy) was smaller than that of plan1.5T_reCal (ΔDmean 1.81 ± 0.79 Gy, ΔDmax 5.43 ± 2.26 Gy). There were no significant differences in terms of the metrics of interfaces of tissues containing air cavities except for an increased maximum dose to the larynx and trachea. The plan quality of plan1.5T_reCal (68.0 ± 9.2) was significantly worse than that of plan0T (82.2 ± 7.0), and the plan quality of plan1.5T_reOpt (80.0 ± 7.0) was similar to that of plan0T.

Conclusion

The presence of a 1.5-T magnetic field had an apparent impact on the dose distribution, in particular, a significant increase in the skin dose. The plan quality of plan1.5T_reOpt was similar to that of the original plan0T when the same cost function was used.

Lymph node ratio-dependent prognosis stratification and postoperative radiotherapy utilization in T1-2N1 oral cavity carcinoma

OBJECTIVE

Pathological T1-2N1 oral cavity squamous cell carcinoma (pT1-2N1 OCSCC) is a setting with intermediate prognosis whilst without consensus regarding the utilization of postoperative radiotherapy (PORT). This study aimed to investigate the prognostic value of lymph node ratio (LNR) and to further examine its clinical validity for guiding PORT in pT1-2N1 OCSCC.

METHODS

OCSCC patients who received surgery between 2010 and 2015 with at least 6 lymph nodes dissection were extracted from the Surveillance, Epidemiology and End Results (SEER) database. Time-dependent receiver operating characteristic (ROC) analysis was used to identify the optimal cutoff of LNR. Multivariable Cox regression analysis was employed to assess the prognostic value of LNR. Impact of PORT was evaluated in respective subgroups stratified by LNR.

RESULTS

A total of 870 OCSCC patients with pT1-2N1 diseases were eligible for analysis. The 5-year overall survival (OS) and disease-specific survival (DSS) was 57.2% and 67.9% respectively. Time-dependent ROC analyses for OS and DSS concordantly revealed 5.5% as the optimal cutoff of LNR. Significantly higher risks of death (HR = 1.610, 95% CI: 1.139-2.276) and disease-specific death (HR = 1.731, 95% CI: 1.101-2.723) were unveiled in patients with LNR > 5.5%. PORT related improvement on OS (5-year rate: 57.6% vs. 47.3%, p = 0.095) and DSS (5-year rate: 71.0% vs. 53.8%, p = 0.030) was only found in LNR > 5.5% subgroup.

CONCLUSIONS

LNR > 5.5% is indicative of inferior outcome in pT1-2N1 OCSCC, warranting the utilization of PORT in this sub-setting.

Radical thoracic radiotherapy may provide favorable outcomes for stage IV non-small cell lung cancer

BACKGROUND

This study investigates the outcome of synchronous stage IV non-small cell lung cancer (NSCLC) patients who received radical thoracic radiotherapy (TRT).

METHODS

We retrospectively reviewed the charts of stage IV NSCLC patients treated with TRT between January 2007 and December 2011. Radiotherapy was considered radical if it was the primary therapy with non-symptom driven intent, or consolidation therapy after initial chemotherapy and the biologically equivalent dose ≥53 Gy halted disease progression. The patients' demographics, disease characteristics, and treatment parameters were uniformly collected.

RESULTS

Eighty-one patients were irradiated with radical intent, including 52% with more than five metastatic lesions. The minimum follow-up was 31.5 months for survivors. The median overall survival (OS) was 20.8 months, with three and four-year OS rates of 23% and 18%, respectively. The median progression-free survival (PFS) was 8.2 months, with one and two-year PFS rates of 23% and 9%, respectively. Partial response (PR) after TRT and administration of targeted therapy were predictive of longer OS. The factors associated with favorable PFS included earlier local tunor node stage, absence of concurrent chemotherapy, and post-TRT PR. No correlation was found between the number of metastatic lesions and survival outcome. Incidences of grade ≥2 toxicities in the lung and esophagus were 9% and 26%, respectively.

CONCLUSIONS

Radical TRT may result in advantageous outcomes for selected stage IV NSCLC patients, regardless of the number of metastatic foci. Patients who achieved post-TRT PR attained the best outcomes.

Availability of a simplified lung ventilation imaging algorithm based on four-dimensional computed tomography

PURPOSE

It is still not conclusive which four-dimensional computed tomography (4DCT)-based ventilation imaging algorithm is most accurate and efficient. In this study, we proposed a simplified algorithm (VIAAVG) which only requires the average computed tomography (AVG CT) as input, and quantitatively compared its accuracy and efficiency with three other popular algorithms.

MATERIAL AND METHODS

Fifty patients with lung or esophageal cancer who underwent radiotherapy were enrolled. Single photon emission computed tomography (SPECT) ventilation images (VI-SPECT) and 4DCT were acquired 1-3 days before the first treatment session. The end of exhalation and the end of inhalation CT were registered to derive deformable vector field (DVF) using MIMvista. 4DCT-based ventilation images (CTVI) were first calculated respectively by means of four algorithms (VIAJAC, VIAHU, VIAPRO and VIAAVG). The computation times were compared using paired t-test. The corresponding CTVIs (CTVIJAC, CTVIHU, CTVIPRO and CTVIAVG) and VI-SPECT were segmented into three equal sub-volumes (high, medium and low function lung, respectively) after smoothing and normalization. The Dice Similarity Coefficients (DSCs) were calculated for each sub-volume between each CTVI and VI-SPECT. The average DSCs for high, medium and low function lung in different CTVIs for each patient were compared using paired t-test.

RESULTS

The mean DSCs for CTVIJAC, CTVIHU, CTVIPRO and CTVIAVG were 0.3255, 0.4465, 0.5865 and 0.5958, respectively. The average computation times for CTVIJAC, CTVIHU, CTVIPRO and CTVIAVG were 18.3 s, 24.2 s, 144.8 s and 15.0 s.

CONCLUSION

VIAAVG is available for clinical use because of its high accuracy, improved efficiency and less input requirement compared to the other algorithms.

Induction TPF followed by concurrent chemoradiotherapy versus concurrent chemoradiotherapy alone in locally advanced hypopharyngeal cancer: a preliminary analysis of a randomized phase 2 trial

PURPOSE

Concurrent chemoradiotherapy (CCRT) is a standard treatment choice for locally advanced hypopharyngeal carcinoma. The aim of this study was to investigate whether induction chemotherapy (IC) followed by CCRT is superior to CCRT alone to treat locally advanced hypopharyngeal carcinoma.

METHODS AND MATERIALS

Patients (n = 142) were randomized to receive two cycles of paclitaxel/cisplatin/5-fluorouracil (TPF) IC followed by CCRT or CCRT alone. The primary end point was overall survival (OS). The secondary end points included the larynx-preservation rate, progression-free survival (PFS), distant metastasis-free survival (DMFS), and toxicities.

RESULTS

Ultimately, 113 of the 142 patients were analyzed. With a median follow-up of 45.6 months (interquartile range 26.8-57.8 months), the 3-year OS was 53.1% in the IC + CCRT group compared with 54.8% in the CCRT group (hazard ratio, 1.004; 95% confidence interval, 0.573-1.761; P = 0.988). There were no statistically significant differences in PFS, DMFS, and the larynx-preservation rate between the two groups. The incidence of grade 3-4 hematological toxicity was much higher in the IC+ CCRT group than in the CCRT group (54.7% vs. 10%, P < 0.001).

CONCLUSIONS

Adding induction TPF to CCRT did not improve survival and the larynx-preservation rate in locally advanced hypopharyngeal cancer, but caused a higher incidence of acute hematological toxicities.

TRIAL REGISTRATION

ClinicalTrials.gov , number NCT03558035. Date of first registration, 15/06/2018.

Antiemetic prophylaxis for chemoradiotherapy-induced nausea and vomiting in locally advanced head and heck squamous cell carcinoma: a prospective phase II trial

Background

There is sparse research reporting effective interventions for preventing nausea and emesis caused by concurrent chemoradiotherapy (CCRT) in locally advanced head and neck squamous cell carcinoma (LA-HNSCC).

Methods

Treatment-naïve LA-HNSCC patients received intensity-modulated radiotherapy with concomitant cisplatin 100 mg/m² (33 mg/m²/days [d]1–3) every 3 weeks for two cycles. All patients were given oral aprepitant 125 mg once on d1, then 80 mg once on d2–5; ondansetron 8 mg once on d1; and dexamethasone 12 mg once on d1, then 8 mg on d2–5. The primary endpoint was complete response (CR). Pursuant to δ = 0.2 and α = 0.05, the expected CR rate was 80%.

Results

A total of 43 patients with LA-HNSCC were enrolled. The median age was 53 years, and 86.0% were male. All patients received radiotherapy and 86.0% of patients completed both cycles as planned. The overall CR rate was 86.0% (95% confidence interval [CI]: 72.1–94.7). The CR rates for cycles 1 and 2 were 88.4% (95% CI: 74.9–96.1) and 89.2% (95% CI: 74.6–97.0). The complete protection rate in the overall phase was 72.1% (95% CI: 56.3–84.7). The emesis-free and nausea-free responses in the overall phase were 88.4% (95% CI: 74.9–96.1) and 60.5% (95% CI: 44.4–75.0), respectively. The adverse events related to antiemetics were constipation (65.1%) and hiccups (16.3%), but both were grade 1–2. There was no grade 4 or 5 treatment-related toxicity with antiemetic usage.

Conclusion

The addition of aprepitant into ondansetron and dexamethasone provided effective protection from nausea and emesis in patients with LA-HNSCC receiving radiotherapy and concomitant high-dose cisplatin chemotherapy.

Proposal of a TNM classification-based staging system for esthesioneuroblastoma: More precise prediction of prognosis

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare malignant neoplasm. Currently, no consistent and universal staging system for ENB exists. The aim of this study is to propose a TNM-based classification.

SUBJECTS AND METHODS

Hundred and forty-two patients from our institution, with ENB pathologically confirmed between July 1978 and December 2018, were reviewed. All patients were restaged according to the Kadish stage, Morita stage and American Joint Committee on Cancer (AJCC) T classification from clinical and radiological data. Multivariate Cox proportional hazard regression analyses were performed to determine the impact of various factors. The goodness-of-fit and predictive accuracy of the different staging systems were calculated using R software.

RESULTS

The median follow-up time was 57 months (range: 4-229 months). According to the Kadish system, the 5-year overall survival (OS) for patients with stage A, B and C was 100%, 83.6% and 64.2%, respectively (P = .055). With respect to the Morita classification, 5-year OS for stages A, B, C and D was 100%, 83.6%, 70.7% and 50.0%, respectively (P = .004). Analysis based on the proposed staging model demonstrated 5-year OS for stage I, II, III and IV disease was 100%, 88.9%, 75.9% and 49.0%, respectively (P < .001). In separate multivariate Cox regression models, only the novel staging system exhibited independent effects on OS (P = .004); the Akaike information criterion and Harrell's concordance index were also superior to those calculated for the Kadish or Morita systems.

CONCLUSIONS

The proposed TNM-based staging system offers an improved prognostic assessment for patients with ENB. Further verification and refinement from additional dataset application is required.

MicroRNA-related polymorphisms in apoptosis pathway genes are predictive of clinical outcome in patients with limited disease small cell lung cancer

We examined the impact of single nucleotide polymorphisms (SNPs) at miRNA binding sites in the 3'-UTRs of genes in the apoptosis pathway on the prognosis of patients with limited disease-small cell lung cancer (LD-SCLC). Twelve tagSNPs in seven genes were genotyped using blood samples from 146 LD-SCLC patients treated with chemoradiotherapy. Cox proportional hazard regression models and recursive partitioning analysis were performed to identify SNPs significantly associated with overall survival. Three SNPs, CASP8: rs1045494 (C > T), PIK3R1: rs3756668 (A > G) and CASP7: rs4353229 (T > C), were associated with longer overall survival in LD-SCLC patients after chemoradiotherapy. The adjusted hazard ratios (95% confidence intervals) were 0.480 (0.258-0.894), 0.405 (0.173-0.947) and 0.446 (0.247-0.802), respectively, and remained significant after multiple comparison correction. Moreover, subset analysis showed these SNPs were still predictive of overall survival in stage III patients. Recursive partitioning analysis enabled patients to be classified into three risk subgroups based on unfavorable genotype combinations of the rs1045494 and rs4353229 SNPs. These findings suggest miRNA-related polymorphisms in the apoptosis pathway may be useful biomarkers for selection of LD-SCLC patients likely to benefit from chemoradiotherapy.

Unrevealing the therapeutic benefits of radiotherapy and consolidation immunotherapy using ctDNA-defined tumor clonality in unresectable locally advanced non-small cell lung cancer

Progression occurs in approximately two-thirds of patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving chemoradiation and consolidation immunotherapy. Molecular indicators for outcome prediction are under development. A novel metric, the ratio of mean to max variant allele frequency (mmVAF), was derived from 431 pre-treatment tissue biopsies from The Cancer Genome Atlas and evaluated in serial circulating tumor DNA (ctDNA) from 70 LA-NSCLC patients receiving definitive radiotherapy/chemoradiotherapy (RT/CRT) with/without immunotherapy. High mmVAFs in pre-treatment tissue biopsies, indicating clonal predominant tumors (P < 0.01), were associated with inferior overall survival [OS, hazard ratio (HR): 1.48, 95 % confidence interval (CI): 1.11-1.98]. Similar associations of mmVAF with clonality (P < 0.01) and OS (HR: 2.24, 95 % CI: 0.71-7.08) were observed in pre-treatment ctDNA. At 1-month post-RT, ctDNA mmVAF-high patients receiving consolidation immunotherapy exhibited improved progression-free survival (PFS) compared to those who did not (HR: 0.14, 95 % CI: 0.03-0.67). From the baseline to week 4 of RT and/or 1-month post-RT, survival benefits from consolidation immunotherapy were exclusively observed in ctDNA mmVAF-increased patients (PFS, HR: 0.39, 95 % CI: 0.14-1.15), especially in terms of distant metastasis (HR: 0.11, 95 % CI: 0.01-0.95). In summary, our longitudinal data demonstrated the applicability of ctDNA-defined clonality for prognostic stratification and immunotherapy benefit prediction in LA-NSCLC.

Omitting elective neck irradiation in clinically N0 sinonasal adenoid cystic carcinoma: A propensity score-matched analysis

OBJECTIVE

To explore the effects of elective neck irradiation (ENI) in clinically node-negative (cN0) sinonasal adenoid cystic carcinoma (SNACC).

MATERIALS AND METHODS

Between January 2000 and December 2016, 60 patients with cN0 sinonasal adenoid cystic carcinoma receiving surgery combined with radiotherapy were analyzed retrospectively, there were 39 received ENI (ENI group) and 21 with no ENI (non-ENI group). Propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan-Meier method and Cox proportional hazard model were used to evaluate the impact of ENI on regional relapse risk and survival outcomes.

RESULTS

The median follow-up time for our cohort was 82.0 months (12.4-190.7 months). Four patients (6.7%) developed neck nodal relapses, with a median time to progression of 38.8 months. Among them, two patients in ENI group but failed out-field. After PSM, 21 patients were matched in each group. The 7-year regional relapse-free survival (RRFS), distant metastasis free survival (DMFS), progression-free survival (PFS), and overall survival (OS) between ENI group and non-ENI group were 85.4% vs 73.3% (p = 0.845), 65.2% vs 65.6% (p = 0.548), 68.3% vs 66.2% (p = 0.425), and 87.3% vs 84.0% (p = 0.953). Multivariate Cox analysis showed ENI was not an independent prognostic factor associated with RRFS, DMFS, PFS and OS.

CONCLUSION

Our findings firstly demonstrated the omission of elective neck irradiation in the management of cN0 sinonasal adenoid cystic carcinoma might be safe without compromising disease control and should be further investigated.

Evidence of being cured for nasopharyngeal carcinoma: results of a multicenter patient-based study in China

BACKGROUND

The survival rates of patients with nasopharyngeal carcinoma (NPC) have improved significantly, but there is no consensus on whether they can be considered cured. We aimed to determine whether a statistical cure could be achieved for patients with NPC in the contemporary therapeutic landscape.

METHODS

This retrospective multicenter study enrolled 6315 patients with nonmetastatic NPC from nonendemic and endemic regions of China from 2007 to 2020. We applied mixture and nonmixture cure models to estimate the cure probabilities and cure times by incorporating background mortality for the general population, matching by gender, age, and diagnosed year.

FINDINGS

With death as the uncured event, the probability of patients with NPC achieving a life expectancy at par with the general population was 78.1%. Considering progression as the uncured event, the likelihood of patients attaining a life expectancy without progression equivalent to that of the general population was 72.4%. For individuals, the probabilities of achieving cure were conditional and time-dependent, requiring approximately 7.1 and 4.7 years with 95% certainty, respectively. The corresponding cure times for uncured patients were 8.9 and 6.8 years, respectively. The cure probability was correlated with age, Eastern Cooperative Oncology Group score, TNM staging, Epstein-Barr virus DNA copies, and lactate dehydrogenase. The correlation was excellent between 5-year overall survival/progression-free survival and cure fractions.

INTERPRETATION

Statistical cure is potentially achievable among patients with NPC undergoing contemporary treatment modalities. The results hold significant potential implications for both clinical practice and patient perspectives.

FUNDING

National High Level Hospital Clinical Research Funding; Beijing Xisike Clinical Oncology Research Foundation; Beijing hope run fund.

Efficacy and safety of concurrent chemoradiotherapy in ECOG 2 patients with locally advanced non-small-cell lung cancer: a subgroup analysis of a randomized phase III trial

BACKGROUND

There is no consensus on the therapeutic approach to ECOG 2 patients with locally advanced non-small-cell lung cancer (LA-NSCLC), despite the sizable percentage of these patients in clinical practice. This study focused on the efficacy, toxicity and the optimal chemotherapy regimen of CCRT in ECOG 2 patients in a phase III trial.

METHODS

Patients capable of all self-care with bed rest for less than 50% of daytime were classified as ECOG 2 subgroup. A subgroup analysis was performed for ECOG 2 patients recruited in the phase III trial receiving concurrent EP (etoposide + cisplatin)/PC (paclitaxel + carboplatin) chemotherapy with intensity-modulated radiation therapy (IMRT) or three-dimensional conformal external beam radiation therapy (3D-CRT).

RESULTS

A total of 71 ECOG 2 patients were enrolled into the study. Forty-six (64.8%) patients were treated with IMRT technique. The median overall survival (OS) and progression free survival (PFS) for ECOG 2 patients were 16.4 months and 9 months, respectively. No difference was observed in treatment compliance and toxicities between ECOG 2 patients and ECOG 0-1 patients. Within the ECOG 2 group (31 in the EP arm and 40 in the PC arm), median OS and 3-year OS were 15.7 months and 37.5% for the EP arm, and 16.8 months and 7.5% for the PC arm, respectively (p = 0.243). The incidence of grade ≥ 3 radiation pneumonitis was higher in the PC arm (17.5% vs. 0.0%, p = 0.014) with 5 radiation pneumonitis related deaths, while the incidence of grade 3 esophagitis was numerically higher in the EP arm (25.8% vs. 10.0%, p = 0.078).

CONCLUSIONS

CCRT provided ECOG 2 patients promising outcome with acceptable toxicities. EP might be superior to PC in terms of safety profile in the setting of CCRT for ECOG 2 patients. Prospective randomized studies based on IMRT technique are warranted to validate our findings.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT01494558. (Registered 19 December 2011).

Stage-dependent conditional survival and failure hazard of non-metastatic nasopharyngeal carcinoma after intensity-modulated radiation therapy: Clinical implications for treatment strategies and surveillance

Purpose

Conditional survival (CS) and failure hazard estimations can provide important dynamic prognostic information for clinical decision‐making and surveillance counseling. The current study aimed to investigate the CS and dynamic failure hazard in non‐metastatic nasopharyngeal carcinoma (NPC) treated with intensity‐modulated radiotherapy (IMRT).

Methods

Conditional overall survival (COS) and progression‐free survival (CPFS) estimates adjusted for age and gender against each AJCC 8th stage were calculated. Multivariable Cox regression (MCR) models were fitted in the entire population at baseline and subsequently separate MCR models were fitted in patients who have maintained event‐free time of 1 to 10 years to generate respective hazard ratio (HR). Annual hazard rates of death and progression over 10 years for each stage were also estimated.

Results

A total of 1993 patients were eligible for analysis. The estimated 5‐year OS and PFS for entire cohort were 79.0% and 70.7% at initial diagnosis. After 5 years of event‐free follow‐up, additional 5‐year COS and CPFS increased to 85.9% and 85.5%, respectively. Stage I/II maintained dramatically favorable CS and low hazard (< 5%) of death and progression over time. Relative to stage I/II, stage III manifested non‐significantly higher failure hazard for the first 3 years of survivorship and approached to similar level of stage I/II afterwards. Stage IVA presented most impressive improvement in terms of both COS (∆=9.8%) and CPFS (∆ = 16.8%) whereas still drastically inferior to that of stage I‐III across all conditional time points. After 4 years of follow‐up, progression hazard of stage IVA became relatively steady of approximate 6%.

Conclusions

Survival prospect of non‐metastatic NPC improves over years with distinct dynamic patterns across stages, providing important implications for personalized decision‐making in terms of both clinical management and surveillance counseling. Stage‐dependent and hazard‐adapted clinical management and surveillance are warranted.

Feasibility of ipsilateral elective neck irradiation of levels Ib and II without level III in patients with node-negative sinonasal squamous cell carcinoma

BACKGROUND

The necessity of level III irradiation in patients with node-negative advanced sinonasal squamous cell carcinoma (SNSCC) is unclear.

METHODS

Seventy-eight patients with advanced SNSCC were included. Survival rates were estimated and compared between treatment groups.

RESULTS

Twenty-five patients received ipsilateral levels Ib and II irradiation (group 1) and 53 patients received ipsilateral levels Ib and II plus level III irradiation (group 2). The median follow-up time was 75.56 months. Five-year survival rates (regional relapse-free survival, overall survival, local relapse-free survival, and distant metastasis-free survival) were similar between groups 1 and 2 (all p > 0.05). Irradiation doses to the thyroid and larynx were significantly lower in group 1 than in group 2.

CONCLUSIONS

Ipsilateral irradiation of levels Ib and II neck provides similar regional control and results as irradiation of these levels plus level III, with lower irradiation doses to normal neck tissue, in patients with node-negative advanced SNSCC.

Hypofractionated radiotherapy for medically inoperable stage I non-small cell lung cancer

BACKGROUND

To investigate the clinical outcomes and toxicity of hypofractionated radiotherapy for medically inoperable stage I non-small cell lung cancer (NSCLC).

METHODS

Patients treated with radiotherapy at a dose of 4-6 Gy per fraction using fixed-field intensity modulated radiotherapy (IMRT) or volumetric-modulated arc therapy (VMAT) at our hospital from June 2005 to December 2013 were analyzed. The total prescription doses ranged from 50-78 Gy with 4-6 Gy per fraction. The median follow-up period was 24 months.

RESULTS

A total of 65 patients with stage I NSCLC were analyzed, including 43 primary NSCLC patients and 22 patients with recurrent or second primary NSCLC. An objective response (complete or partial response) was achieved at six months in 84.6% of patients. The three-year local control rate was 90.8%. Kaplan-Meier estimates of local failure-free, progression-free, overall, and cancer-specific survival rates at three years were 90.3%, 64.3%, 68.9%, and 88.8%, respectively. The rate of symptomatic radiation pneumonitis was 16.9%, and no grade 4-5 toxicity was observed.

CONCLUSION

Favorable local control and outcome was achieved with hypofractionated radiotherapy in patients with inoperable stage I NSCLC with acceptable toxicity. The most common schedule of 6 Gy × 12 fractions may be a promising regimen, and a prospective study is in process.

Evaluation of the prevalence of metachronous second primary malignancies in hypopharyngeal carcinoma and their effect on outcomes

Background

To investigate the clinical characteristics of metachronous second primary malignancies (Met‐SPMs) and its impact on prognosis in hypopharyngeal carcinoma (HPC).

Methods

We reviewed 593 newly diagnosed HPC patients without invasive synchronous SPMs (Syn‐SPMs) who were treated in our cancer center between 2009 and 2019. According to the status during follow‐up, patients were classified into three groups: (a) without SPMs (No‐SPMs, n = 440), (b) with tumors in situ in the esophagus or stomach (Tis, n = 80), or (c) with Met‐SPMs (n = 73).

Results

The median follow‐up time for entire cohort (n = 593) was 66.7 months. Met‐SPMs were present in 12.3% of the cohort (73/593). The predominant site of SPMs was esophagus, followed by lung, oral cavity, thyroid, stomach, and oropharynx. In Met‐SPMs group, both index tumor and SPMs were the main causes of death. Tis group exhibited comparable 5‐year overall survival (OS) and disease‐specific survival (DSS) with that of No‐SPMs group. The Met‐SPMs group had similar 5‐year OS rate and better 5‐year DSS rate of 47.3% versus 43.6% (odds ratio [OR], 0.931; 95% confidence interval [CI], 0.681–1.274, p = 0.657) and 66.3% vs. 46.2% (OR, 0.600; 95% CI, 0.402–0.896, p = 0.012), respectively, compared with the No‐SPMs group.

Conclusion

The overall incidence of Met‐SPMs in HPC was 12.3%. The occurrence of Met‐SPMs does not jeopardize the survival outcome of HPC. Routine surveillance of Met‐SPMs was requisite for patients with HPC.

[Technical advancement improves survival in patients with locally advanced non-small cell lung cancer (LA-NSCLC) receiving definitive radiotherapy]

OBJECTIVE

This study aimed to evaluate the impact of technical advancement of radiation therapy in patients with LA-NSCLC receiving definitive radiotherapy (RT).

METHODS

Patients treated with definitive RT (≥50 Gy) between 2000 and 2010 were retrospectively reviewed. Overall survival (OS), cancer specific survival (CSS), locoregional progression-free survival (LRPFS), distant metastasis-free survival (DMFS) and progression-free survival (PFS) were calculated and compared among patients irradiated with different techniques. Radiation-induced lung injury (RILI) and esophageal injury (RIEI) were assessed according to the National Cancer Institute Common Terminology Criteria for Adverse Events 3.0 (NCI-CTCAE 3.0).

RESULTS

A total of 946 patients were eligible for analysis, including 288 treated with two-dimensional radiotherapy (2D-RT), 209 with three-dimensional conformal radiation therapy (3D-CRT) and 449 with intensity-modulated radiation therapy (IMRT) respectively. The median follow-up time for the whole population was 84.1 months. The median OS of 2D-RT, 3D-CRT and IMRT groups were 15.8, 19.7 and 23.3 months, respectively, with the corresponding 5-year survival rate of 8.7%, 13.0% and 18.8%, respectively (P<0.001). The univariate analysis demonstrated significantly inferior OS, LRPFS, DMFS and PFS of 2D-RT than those provided by 3D-CRT or IMRT. The univariate analysis also revealed that the IMRT group had significantly loger LRPFS and a trend toward better OS and DMFS compared with 3D-CRT. Multivariate analysis showed that TNM stage, RT technique and KPS were independent factors correlated with all survival indexes. Compared with 2D-RT, the utilization of IMRT was associated with significantly improved OS, LRPFS, DMFS as well as PFS. Compared with 3D-CRT, IMRT provided superior DMFS (P=0.035), a trend approaching significance with regard to LRPFS (P=0.073) but no statistically significant improvement on OS, CSS and PFS in multivariate analysis. The incidence rates of RILI were significantly decreased in the IMRT group (29.3% vs. 26.6% vs.14.0%, P<0.001) whereas that of RIET rates were similar (34.7% vs. 29.7% vs. 35.3%, P=0.342) among the three groups.

CONCLUSIONS

Radiation therapy technique is a factor affecting prognosis of LA-NSCLC patients. Advanced radiation therapy technique is associated with improved tumor control and survival, and decreased radiation-induced lung toxicity.

Sinonasal mucosal melanoma: Is there a need for elective neck irradiation?

BACKGROUND AND PURPOSE

Sinonasal mucosal melanoma (SNMM) is a rare malignant neoplasm. The regional failure pattern and effectiveness of elective neck irradiation (ENI) were not well defined. Here, we would assess the value of ENI for clinical node negative (cN0) SNMM patients.

MATERIALS AND METHODS

A total of 107 SNMM patients treated at our institution over a period of 30 years was retrospectively analyzed.

RESULTS

Five patients had lymph node metastases at diagnosis. Among the 102 cN0 patients analyzed, 37 patients had received ENI, and 65 patients had not. ENI significantly reduced the regional recurrence rate from 23.1% (15/65) to 2.7% (1/37). Ipsilateral levels Ib and II were the most common locations of regional relapse. Multivariate analysis also showed that ENI was the only independent favorable predictor for the achievement of regional control (HR: 9.120; 95% CI: 1.204-69.109; P = 0.032).

CONCLUSION

This is the largest cohort of SNMM patients from a single institution analyzed for the assessment of the value of ENI on regional control and survival. ENI significantly reduced the regional relapse rate in our study. Ipsilateral levels Ib and II might be considerable when deliver elective neck irradiation, more evidence is needed in the future.

Pretreatment systemic immune-inflammation index predicts survival for non-metastatic nasopharyngeal carcinoma: two independent institutional studies

Objective

This study aimed to evaluate the prognostic value of the pretreatment systemic immune-inflammation index (SII) in non-metastatic nasopharyngeal carcinoma (NPC).

Methods

We retrospectively analyzed the data of 839 patients with non-metastatic NPC recruited from two independent institutions. The training-set cohort and the external validation-set cohort was comprised of 459 and 380 patients from each institution, respectively. The optimal cut-off value of SII was determined, and a prognostic risk stratification model was developed based on the training cohort and further assessed in the validation cohort. The propensity score matching (PSM) method was applied to minimize the confounding effects of unbalanced covariables.

Results

The optimal cut-off value of the SII in the training cohort was 686, which was confirmed using the validation cohort. Multivariate analysis showed that both before and after PSM, SII values > 686 were independently associated with worse progression-free survival (PFS) ratio in both cohorts (before PSM, P = 0.008 and P = 0.008; after PSM, P = 0.008 and P = 0.007, respectively). Based on the analysis of independent prognostic factors of SII and N stage, we developed a categorical risk stratification model, which achieved significant discrimination among risk indexes associated with PFS and distant metastasis-free survival (DMFS) in the training cohort. There was no significant difference in PFS between RT alone and combined therapies within the low- and intermediate-risk groups (5-year PFS, 77.5% vs. 75.3%, P = 0.275). Patients in the high-risk group who received concurrent chemoradiotherapy experienced superior PFS compared with those who received other therapies (5-year PFS, 64.9% vs. 40.3%, P = 0.003).

Conclusion

Pretreatment SII predicts PFS of patients with non-metastatic NPC. Prognostic risk stratification incorporating SII is instructive for selecting individualized treatment.