Intensity-modulated radiation therapy with or without chemotherapy for nasopharyngeal carcinoma: radiation therapy oncology group phase II trial 0225

Long non-coding RNA LINC01133 mediates nasopharyngeal carcinoma tumorigenesis by binding to YBX1

Recently, long non-coding RNAs (lncRNAs) have been reported as the vital regulators of various cancers including nasopharyngeal carcinoma (NPC). An increasing number of studies have suggested that lncRNA LINC01133 is dysregulated and involved in human carcinogenesis. However, the roles of LINC01133 in NPC remain largely unknown. In this work, we demonstrated that LINC01133 was significantly downregulated in NPC tissues and cell lines. Loss and gain of function experiments provided evidence that LINC01133 inhibited NPC cell proliferation, invasion and migration both in vitro and in vivo. Besides, Fluorescence in situ hybridization (FISH) assay was performed to determine the localization of LINC01133 and LINC01133 was observed mainly distributed in the nucleus. Importantly, RNA pull-down and RIP assays showed that LINC01133 directly combined with YBX1, and YBX1 can partly reverse the repression of NPC cell proliferation, migration, and invasion caused by LINC01133. Collectively, our exploration indicate that LINC01133 inhibits the malignant-biological behavior of NPC cells by binding to YBX1, thereby suggesting a novel biomarker for the NPC prognosis and treatment.

MicroRNA-183 and microRNA-141 are potential risk factors for poor prognosis in patients with nasopharyngeal carcinoma

This study investigated whether microRNA-183 and microRNA-141 in nasopharyngeal carcinoma (NPC) lesions are potential risk factors for poor prognosis. A total of 317 NPC patients admitted to Zhengzhou Central Hospital Affiliated to Zhengzhou University from January 2010 to March 2015 were included. Reverse transcription-quantitative PCR (RT-qPCR) was used to detect the expression of microRNA-183 and microRNA-141 in lesions and adjacent tissues, and the relationship between the microRNA-183 and microRNA-141 expression levels and prognosis was analyzed. The expression levels of microRNA-183 and microRNA-141 in lesions were significantly higher than those in adjacent tissues (p<0.05). Patients with distant metastasis had significantly higher expression levels of microRNA-183 and microRNA-141 than patients without distant metastasis (p<0.01). Patients with disease-free survival (DFS) <3 years showed significantly higher expression levels of microRNA-183 and microRNA-141 than those with DFS ≥3 years (p<0.01). NPC patients with high expression levels of microRNA-183 and microRNA-141 showed poor prognosis. MicroRNA-183 and microRNA-141 may play an important role in the distant metastasis of NPC, and have a great impact on prognosis.

Predictive value of pretreatment MRI texture analysis in patients with primary nasopharyngeal carcinoma

Objectives

To determine the predictive value of pretreatment MRI texture analysis for progression-free survival (PFS) in patients with primary nasopharyngeal carcinoma (NPC).

Methods

Ethical approval by the institutional review board was obtained for this retrospective analysis. In 79 patients with primary NPC, texture analysis of the primary tumour was performed on pretreatment T2 and contrast-enhanced T1-weighted images (T2WIs and CE-T1WIs). The Cox proportional hazards model was used to determine the association of texture features, tumour volume and the tumour-node-metastasis (TNM) stage with PFS. Survival curves were plotted using the Kaplan-Meier method. The prognostic performance was evaluated with the receiver operating characteristic (ROC) analyses and C-index.

Results

Tumour volume (hazard ratio, 1.054; 95% confidence interval [CI], 1.016–1.093) and CE-T1WI-based uniformity (hazard ratio, 0; 95% CI, 0–0.001) were identified as independent predictors for PFS (p < 0.05). Kaplan-Meier analysis showed that smaller tumour volume (less than the cut-off value, 11.699 cm³) and higher CE-T1WI-based uniformity (greater than the cut-off value, 0.856) were associated with improved PFS (p < 0.05). The combination of CE-T1WI-based uniformity with tumour volume and the overall stage predicted PFS better (area under the curve [AUC], 0.825; Cindex, 0.794) than the tumour volume (AUC, 0.659; C-index, 0.616) or the overall stage (AUC, 0.636; C-index, 0.627) did (p < 0.05).

Conclusions

A texture parameter of pretreatment CE-T1WI-based uniformity improves the prediction of PFS in NPC patients.

Key Points

• Higher CE-T1WI-based uniformity and smaller tumour volume are predictive of improved PFS in NPC patients.

• The combination of CE-T1WI-based uniformity with tumour volume and the overall stage has a better predictive ability for PFS than the tumour volume or the overall stage alone.

• Pretreatment MRI texture analysis has a prognostic value for NPC patients.

Electronic supplementary material

The online version of this article (10.1007/s00330-018-5961-6) contains supplementary material, which is available to authorized users.

Concurrent chemoradiotherapy by simultaneously integrated boost volumetric-modulated arc therapy for nasopharyngeal carcinoma-toxicity/quality of life and survival

BACKGROUND

To investigate the toxicity, changes of quality of life (QOL), and survival for patients with nasopharyngeal cancer (NPC) treated by concurrent chemoradiotherapy (CCRT) with simultaneously integrated boost volumetric-modulated arc therapy (SIB-VMAT).

METHODS

A total of 68 NPC patients treated by CCRT with SIB-VMAT technique were collected. QOL was longitudinally assessed by the EORTC QLQ-C30 and HN35 questionnaires at the 4 time points: baseline, 42.4 Gy (20 fractions), and 3, 12 months after CCRT.

RESULTS

The 4-year locoregional relapse free, distant metastasis free, failure free, and overall survival rates were 97.0%, 86.4%, 82.0%, and 88.1%, respectively. The 4-year cumulative incidence rate of late toxicities with grade 3 or more was 3.0%. One year after CCRT, most QOL scales, except some oral related symptoms, recovered to baseline level.

CONCLUSION

CCRT with SIB-VMAT produces excellent locoregional control, few severe late toxicity, and good general health status for NPC patients.

High-Dose Static and Dynamic Intensity-Modulated Radiotherapy Combined with Chemotherapy for Patients with Locally Advanced Nasopharyngeal Carcinoma Improves Survival and Reduces Brainstem Toxicity

BACKGROUND Intensity-modulated radiotherapy (IMRT) is the standard treatment for patients with nasopharyngeal cancer (NPC). However, the dose-volume criteria for adjacent anatomically normal organs at risk (OARs) remain controversial. The aim of this study was to evaluate the effects of higher than conventional doses of static and dynamic IMRT on the locoregional control of NPC, patient survival, and brainstem radiation toxicity. MATERIAL AND METHODS Patients (n=186) with stage III and stage IVa NPC underwent high-dose static and dynamic IMRT treatment (68-76.96 Gy) with or without chemotherapy for 34-57 days. Overall survival (OS), the presence of distant metastases, and brainstem toxicity were assessed. One-year, three-year, and five-year follow-up was performed. RESULTS High-dose IMRT alone or in combination with chemotherapy resulted in a 100% objective response rate and significantly improved OS rates, with one-year, three-year, and five-year OS rates of 94.1%, 89.8%, and 88.2%, respectively. The local recurrence rate (17.6%), and distant metastasis to the lung, liver, and bone (17.2%), and mortality (n=22) were reduced. Chemotherapy was the only factor that was significantly correlated with patient survival. Brainstem toxicity was reduced in patients treated with static IMRT (0.07%) and dynamic IMRT (0.08%). There were 26 additional factors that were not found to significantly affect brainstem toxicity. CONCLUSIONS High-dose static or dynamic IMRT combined with chemotherapy improved survival and reduces distal metastasis with a very low occurrence of brainstem toxicity in patients with locally advanced NPC. These findings might provide therapeutic guidance for clinicians when planning optimal dose-volume IMRT parameters.

Clinical and prognostic analyses of 110 patients with N3 nasopharyngeal carcinoma

OBJECTIVE

To analyze the clinical outcome and prognostic factors of N3 nasopharyngeal carcinomas (NPCs), provide a basis for rational treatment and improve the cure rate.

METHODS

A total of 110 patients with a pathologically confirmed diagnosis of N3 (NPC 2008 stage in China) NPC from our hospital were retrospectively included in the study conducted from April 2007 to July 2011. All patients received intensity-modulated radiation therapy. Some of these patients received various chemotherapies. The doses of the planning gross primary tumor and retropharyngeal lymph node volume, high-risk planning tumor volume, low-risk planning tumor volume, and gross tumor volume of neck lymph nodes were 6000 to 7600, 5400 to 6600, 5000 to 6000, and 6000 to 6996 cGy, respectively. The Kaplan-Meier analysis and logrank test were carried out to calculate and compare the survival rates of the patients, and the Statistical Package for the Social Sciences software version 17.0 was used for all analyses. Meanwhile, the Cox model was used to analyze the prognostic factors.

RESULTS

In this study, the 1-, 3-, and 5-year overall survival rates of the patients were 92.63%, 83.16%, and 70.53%, respectively. Based on the univariate analysis, T stage (P = .043) and chemotherapy (P = .003) were significant factors for survival. In the multivariate analysis, only chemotherapy influenced survival (). Recent toxicity included radioactive oral mucosa inflammation and skin injury, and difficulty opening the mouth and hearing loss were considered late adverse reactions. None of the patients died during treatment.(Table is included in full-text article.) CONCLUSIONS:: Patients with N3 NPC are at high risk of distant metastasis, and their 5-year survival rate is poor. The more important prognostic factors were T stage and chemotherapy. Patients with N3 NPC should be treated with combined chemotherapy and radiotherapy.

Intensity-modulated radiotherapy combined with sequential cisplatin and fluorouracil chemotherapy for locoregionally advanced nasopharyngeal carcinoma

To investigate the efficacy and toxicity of intensity-modulated radiotherapy (IMRT) combined with induction-adjuvant cisplatin and fluorouracil (PF) in locoregionally advanced nasopharyngeal carcinoma (NPC).A total of 91 biopsy-proven NPC patients treated with IMRT were retrospectively analyzed. All patients received induction chemotherapy (IC) consisting of cisplatin 25 mg/m2 on day 1 to 3, and 5-Fu 2500 mg/m as an intravenous infusion over 120 hours every 3 weeks for 2 cycles. Adjuvant chemotherapy of the same regime was given 28 days after the end of IMRT.A total of 87 patients completed 2 cycles of IC. During adjuvant chemotherapy phase, 74.7% patients received at least 1 cycle. With a median follow-up time of 45 months (10-123 months), the 5-year local control, regional control, distant metastasis-free (DMF) and overall survival (OS) rates were 84.1%, 86.9%, 81.3%, and 74.4%, respectively. The 5-year local control rates for patients with Stage T1-2 and T3-4 was 94.6% and 76.5%, respectively (P = .045). The 5-year DMF rates for patients with N0-1 and N2-3 diseases were 90.6% and 73.3%, respectively (P = .072). During radiotherapy (RT), 24.2% patients suffered severe acute mucositis (grade 3-4). Severe late toxicities included cranial nerve palsy in 1 patient and grade 3 hearing impairment in 1 patient.IMRT combined with induction-adjuvant chemotherapy consisting of PF regimen is well tolerated and provides satisfactory local-regional control for locoregionally advanced NPC. Further treatment strategies to control distant metastasis are needed in the future.

A comparison of neoadjuvant chemotherapy with gemcitabine versus docetaxel plus cisplatin in locoregionally advanced nasopharyngeal carcinoma: a propensity score matching analysis

Purpose

To compare the efficacy and safety of neoadjuvant chemotherapy (NACT) with gemcitabine (GEM) vs docetaxel plus cisplatin (CDDP) in locoregionally advanced nasopharyngeal carcinoma (NPC).

Methods

A total of 222 patients with locoregionally advanced NPC between February 2012 and May 2014 in our hospital who received NACT with GEM or docetaxel plus CDDP combined with concurrent chemoradiotherapy (CCRT) were retrospectively analyzed. Fifty-two patients treated with GEM plus CDDP (GP) combined with CCRT were matched with 52 patients who received docetaxel plus CDDP (TP) combined with CCRT.

Results

With a median follow-up time of 60 months (range, 14–72 months), the 5-year overall survival, progression-free survival (PFS), local relapse-free survival and distant metastasis-free survival (DMFS) rates were 78.8%, 66.0%, 81.0% and 75.9%, respectively, in the GP group and 79.4%, 60.5%, 79.6% and 73.6%, respectively, in the TP group. No statistically significant survival differences were found between the two groups. In multivariate analysis, T3–4 and N2–3 were prognostic factors for poor 5-year PFS and DMFS (all P-values <0.05). Patients in the TP group experienced less grade 3–4 thrombocytopenia but more grade 3–4 leucopenia and neutropenia than those in the GP group (all P-values <0.05). There were no significant differences between the two groups in other toxicities (all P-values >0.05).

Conclusion

NACT with GP or TP regimen achieved comparable clinical outcome with acceptable toxicities. Both regimens might be a treatment option for patients with locoregionally advanced NPC.

Famitinib in combination with concurrent chemoradiotherapy in patients with locoregionally advanced nasopharyngeal carcinoma: a phase 1, open-label, dose-escalation Study

BACKGROUND

Famitinib is a tyrosine kinase inhibitor against multiple targets, including vascular endothelial growth factor receptor 2/3, platelet-derived growth factor receptor, and stem cell factor receptor (c-kit). Previous studies have demonstrated anti-tumour activities of famitinib against a wide variety of advanced-stage solid cancers. We aimed to determine the safety and efficacy of famitinib with concurrent chemoradiotherapy (CCRT) in patients with locoregionally advanced nasopharyngeal carcinoma (NPC). We also evaluated the feasibility of contrast-enhanced ultrasound (D-CEUS) as a predictor of early tumour response to famitinib and to correlate functional parameters with clinical efficacy.

METHODS

The trial was conducted in subjects with stage III or IVa-b NPC using a 3 + 3 design of escalating famitinib doses. Briefly, subjects received 2 weeks of famitinib monotherapy followed by 7 weeks of famitinib plus CCRT. D-CEUS of the neck lymph nodes was performed at day 0, 8 and 15 after famitinib was administered before starting concurrent chemoradiotherapy. End points included safety, tolerability and anti-tumour activity.

RESULTS

Twenty patients were enrolled (six each for 12.5, 16.5 and 20 mg and two for 25 mg). Two patients in the 25 mg cohort developed dose-limiting toxicities, including grade 4 thrombocytopenia and grade 3 hypertension. The most common grade 3/4 adverse events were leukopenia, neutropenia and radiation mucositis. D-CEUS tests showed that more than 60% of patients achieved a perfusion parameter response after 2 weeks taking famitinib alone, and the parameter response was associated with disease improvement. In the famitinib monotherapy stage, three patients (15%) showed partial responses. The complete response rate was 65% at the completion of treatment and 95% 3 months after the treatment ended. After a median follow-up of 44 months, the 3-year progression-free survival (PFS) and distant metastasis-free survival were 70% and 75%, respectively. Subjects with a decrease of perfusion parameter response, such as peak intensity decreased at least 30% after 1 week of famitinib treatment, had higher 3-year PFS (90.9% vs. 44.4%, 95% CI 73.7%-100% vs. 11.9%-76.9%, P < 0.001) than those with an increase or a reduction of less than 30%.

CONCLUSIONS

The recommended famitinib dose for phase II trial is 20 mg with CCRT for patients with local advanced NPC. D-CEUS is a reliable and early measure of efficacy for famitinib therapies. Further investigation is required to confirm the effects of famitinib plus chemoradiotherapy.

Prognostic value of gross tumor regression and plasma Epstein Barr Virus DNA levels at the end of intensity-modulated radiation therapy in patients with nasopharyngeal carcinoma

PURPOSE

To assess gross tumor regression and plasma Epstein-Barr virus (EBV)-DNA levels at the end of intensity-modulated radiation therapy (IMRT) and its prognostic impact on patients with nasopharyngeal carcinoma (NPC).

PARTICIPANTS AND METHODS

In total, 397 patients with non-metastatic, histologically confirmed NPC were retrospectively examined. All patients underwent magnetic resonance imaging of the nasopharynx and neck, and plasma EBV DNA assays before treatment and at the end of IMRT.

RESULTS

The estimated 5-year loco-regional, local and regional relapse-free survival rates for patients with complete response (CR) and non-CR of the total tumor, primary tumor and metastatic lymph nodes at the end of IMRT were 94.9% vs. 85.8%, 96.6% vs. 87.3%, and 98.7% vs. 89.8%, respectively (P < 0.05). The estimated 5-year loco-regional relapse-free survival (LRRFS) rates for patients with persistent tumor with and without boost irradiation were 95.3% vs. 83%, respectively (P = 0.034). The estimated 5-year overall survival (OS), failure-free survival (FFS) and distant metastasis-free survival (DMFS) rates for patients with negative and positive plasma EBV DNA at the end of IMRT were 83.1% vs. 50.3%, 81.5% vs. 49.3%, and 87.6% vs. 61.5%, respectively (P < 0.001). Multivariate analyses indicated that regression of the total tumor and boost irradiation was an independent predictor of LRRFS, and plasma EBV DNA levels were independent predictors of OS, FFS and DMFS.

CONCLUSIONS

Gross tumor regression and plasma EBV DNA levels at the end of IMRT served as predictors of poor prognosis for patients with NPC. The patients with persistent tumor and/or positive plasma EBV DNA might require timely strengthening treatment.

Individualization of Clinical Target Volume Delineation Based on Stepwise Spread of Nasopharyngeal Carcinoma: Outcome of More Than a Decade of Clinical Experience

PURPOSE

Radiation-related toxicity in nasopharyngeal carcinoma (NPC) is common. There are no well-established guidelines for clinical target volume (CTV) delineation with long-term follow-up. Current consensus continues to rely heavily on bony landmarks and fixed margins around the gross tumor volume (GTV), an approach used to define fields in the conventional 2- and 3-dimensional radiation therapy era.

METHODS AND MATERIALS

We retrospectively evaluated patients with newly diagnosed nonmetastatic NPC treated with definitive radiation therapy using a technique of CTV delineation based on individual tumor extent and the orderly stepwise pattern of tumor spread. Dosimetric comparisons were made between national protocol HN001 and our contouring strategies on a representative early- and advanced-stage NPC. The primary endpoints were patterns of failure and local control; secondary endpoints included regional control and survival, estimated using the Kaplan-Meier method.

RESULTS

Between 1999 and 2013, 73 patients (88% with stage 3-4 disease) were treated with median follow-up of 90 months for surviving patients. Median dose to GTV was 70 Gy. Four patients developed local recurrence and 1 patient developed regional recurrence. All locoregional recurrences occurred within the high-dose GTV. The 5-year local control, regional control, and overall survival was 94% (95% confidence interval [CI], 85%-98%), 99% (95% CI, 90%-100%), and 84% (95% CI, 73%-91%), respectively. Compared with HN001, our contouring strategy resulted in 62% and 36% reduction in CTV for T1 and T4 disease, respectively. In the T1 tumor, the reduction of doses to the contralateral parotid, optic nerve, and cochlea were 54%, 50%, 34% respectively. In the T4 case, there was a decrease of optic chiasm dose of 46% and contralateral optic nerve of 37%. There were 10 grade 3 toxicities. There was no grade 2 or higher xerostomia and no grade 4/5 toxicity.

CONCLUSIONS

Our long-term experience with individualized CTV delineation based on stepwise patterns of spread results in excellent local control, with no recurrence outside the GTV.

A retrospective dosimetry study of intensity-modulated radiotherapy for nasopharyngeal carcinoma: radiation-induced brainstem injury and dose-volume analysis

Background

Radiation therapy is the standard radical treatment for nasopharyngeal carcinoma (NPC) but also causes transient as well as long-term complications. Patients who develop severe radiation-induced brainstem injuries have a poor prognosis due to the lack of effective medical therapies. However, the relationship between brainstem injury and radiation volume dose is unknown. In this study, we found that radiation-induced brainstem injury was significantly associated with brainstem dose per unit volume.

Methods

A retrospective analysis was performed on a consecutive cohort of 327 patients with NPC receiving IMRT from May 2005 to December 2014. Dose-volume data and long-term outcome were analyzed.

Results

The median follow-up duration was 56 months (range, 3–141 months), and six with T₄ and two with T₃ patients had radiation-induced brainstem injuries. The 3-year and 5-year incidences were 2.2% and 2.8%, respectively. The latency period of brainstem injury ranged from 9 to 58 months, with a median period of 21 months. The Cox regression analysis showed that brainstem radiation toxicity was associated with the T₄ stage, D_2% of gross tumor volume of nasopharyngeal primary lesions and their direct extensions (GTVnx), D_max (the maximum point dose), D_1%, D_0.1cc (the top dose delivered to a 0.1-ml volume), and D_1cc (the top dose delivered to a 1-ml volume) of the brainstem (p < 0.05). Receiver operating characteristic (ROC) curves showed that GTVnx D_2% and the D_max, D_1%, D_0.1cc, and D_1cc of the brainstem were significant predictors of brainstem injury. The area under the ROC curve for these five parameters was 0.724, 0.813, 0.818, 0.818, and 0.798, respectively (p < 0.001), and the cutoff points 77.26 Gy, 67.85 Gy, 60.13 Gy, 60.75 Gy, and 54.58 Gy, respectively, were deemed as the radiation dose limit.

Conclusions

Radiotherapy-induced brainstem injury was uncommon in patients with NPC who received definitive IMRT. Multiple dose-volume data may be the dose tolerance of radiation-induced brainstem injury.

Current Role of Chemotherapy in Nonmetastatic Nasopharyngeal Cancer

Nasopharyngeal carcinoma is highly radio- and chemosensitive tumor with its unique clinical and biological behavior. Treatment of stage I disease is radical radiotherapy alone. For stage II disease treatment is radiotherapy with or without chemotherapy. The standard of care for locally advanced nasopharyngeal cancer (stages III-IVB) is concurrent chemoradiation. Optimum timing and sequence of chemotherapy are not yet well-defined. The role of adjuvant and induction chemotherapy is debatable. Here we are going to highlight the role of chemotherapy in nasopharyngeal carcinoma, its benefit, and controversies regarding timing and sequences.

Development and validation of an endoscopic images-based deep learning model for detection with nasopharyngeal malignancies

Background

Due to the occult anatomic location of the nasopharynx and frequent presence of adenoid hyperplasia, the positive rate for malignancy identification during biopsy is low, thus leading to delayed or missed diagnosis for nasopharyngeal malignancies upon initial attempt. Here, we aimed to develop an artificial intelligence tool to detect nasopharyngeal malignancies under endoscopic examination based on deep learning.

Methods

An endoscopic images-based nasopharyngeal malignancy detection model (eNPM-DM) consisting of a fully convolutional network based on the inception architecture was developed and fine-tuned using separate training and validation sets for both classification and segmentation. Briefly, a total of 28,966 qualified images were collected. Among these images, 27,536 biopsy-proven images from 7951 individuals obtained from January 1st, 2008, to December 31st, 2016, were split into the training, validation and test sets at a ratio of 7:1:2 using simple randomization. Additionally, 1430 images obtained from January 1st, 2017, to March 31st, 2017, were used as a prospective test set to compare the performance of the established model against oncologist evaluation. The dice similarity coefficient (DSC) was used to evaluate the efficiency of eNPM-DM in automatic segmentation of malignant area from the background of nasopharyngeal endoscopic images, by comparing automatic segmentation with manual segmentation performed by the experts.

Results

All images were histopathologically confirmed, and included 5713 (19.7%) normal control, 19,107 (66.0%) nasopharyngeal carcinoma (NPC), 335 (1.2%) NPC and 3811 (13.2%) benign diseases. The eNPM-DM attained an overall accuracy of 88.7% (95% confidence interval (CI) 87.8%–89.5%) in detecting malignancies in the test set. In the prospective comparison phase, eNPM-DM outperformed the experts: the overall accuracy was 88.0% (95% CI 86.1%–89.6%) vs. 80.5% (95% CI 77.0%–84.0%). The eNPM-DM required less time (40 s vs. 110.0 ± 5.8 min) and exhibited encouraging performance in automatic segmentation of nasopharyngeal malignant area from the background, with an average DSC of 0.78 ± 0.24 and 0.75 ± 0.26 in the test and prospective test sets, respectively.

Conclusions

The eNPM-DM outperformed oncologist evaluation in diagnostic classification of nasopharyngeal mass into benign versus malignant, and realized automatic segmentation of malignant area from the background of nasopharyngeal endoscopic images.

Weekly versus triweekly cisplatin plus intensity-modulated radiotherapy in locally advanced nasopharyngeal carcinoma: A propensity score analysis with a large cohort

Purpose: To directly compare the efficacy and acute toxicities of intensity-modulated radiotherapy (IMRT) concurrent with weekly cisplatin (40 mg/m²) to high-dose concurrent cisplatin (100 mg/m²) at three-week intervals.

Materials and Methods: A total of 3,799 patients diagnosed with locally advanced nasopharyngeal carcinoma (NPC) at Sun Yat-Sen University Cancer Center between January 2010 and December 2013 were retrospectively reviewed. Propensity score analysis was conducted to balance the baseline characteristics between the groups, which allowed us to draw reliable conclusions. The efficacy and safety profiles were then assessed in the well-balanced large cohort.

Results: The risk of distant metastasis was lower among the patients treated with weekly concurrent cisplatin than among those treated with the triweekly regimen (hazard ratio [HR], 0.45; P = .028). However, the disease-free survival, loco-regional relapse-free survival and overall survival rates were similar. The weekly group showed significantly higher rates of grade 3-4 thrombocytopenia, but lower rates of grade 3-4 mucositis, nausea and vomiting than the triweekly group.

Conclusion: IMRT concurrent with a weekly cisplatin regimen was associated with significantly improved distant metastasis-free survival in locally advanced NPC. Differences in the selected acute toxicities between the weekly and triweekly concurrent cisplatin regimens were noted.

Neoadjuvant Chemotherapy with Fluorouracil plus Nedaplatin or Cisplatin for Locally Advanced Nasopharyngeal Carcinoma: a Retrospective Study

The present study aimed to evaluate the efficacy, toxicity and long-term outcome of nedaplatin or cisplatin combined with 5-fluorouracil neoadjuvant chemotherapy (NF or PF regimen) followed by concurrent chemoradiotherapy (CCRT) for treatment of locally advanced nasopharyngeal carcinoma (NPC). In this study, a total of 186 patients with locally advanced NPC between January 2009 and November 2011 in our center were retrospectively analyzed. 103 cases were received NF neoadjuvant chemotherapy followed by nedaplatin concurrent intensity-modulated radiotherapy (IMRT), and 83 cases were received PF neoadjuvant chemotherapy followed by cisplatin concurrent IMRT. Overall survival (OS), progression-free survival (PFS), local relapse-free survival (LRFS), regional relapse-free survival (RRFS) and distant metastasis-free survival (DMFS), as well as acute toxicities were monitored. Results showed that there were no significant differences in 5-year OS, PFS, LRFS, RRFS and DMFS between NF and PF groups. NF group had a higher incidence of grade 3-4 neutropenia (46.6% vs. 31.3%, P=0.035) and thrombocytopenia (17.5% vs. 7.3%, P=0.042) compared with PF group. However, NF group was less common to suffer from grade 3-4 nausea (1.9% vs. 24.1%, P<0.001), vomiting (0% vs. 13.3%, P<0.001) and weight loss (0% vs. 4.8%, P=0.025). In multivariate analysis, N stage was an independent factor for OS, PFS, RRFS and DMFS. In conclusion, neoadjuvant chemotherapy with fluorouracil plus nedaplatin followed by nedaplatin concurrent with IMRT exhibited similar efficacy but more tolerable toxicity than cisplatin setting, which might be an effective and safe choice for treatment of locally advanced NPC.

Induction chemotherapy followed by concurrent chemoradiotherapy is benefit for advanced stage nasopharyngeal carcinoma with different nonkeratinizing carcinoma subtypes

Given the potentially distinctive histological variations in northwest of China, the aim of current study was to compare the efficacy of induction chemotherapy plus concurrent chemoradiotherapy (IC + CCRT) with concurrent chemoradiotherapy (CCRT) in nasopharyngeal carcinoma (NPC) patients with different histological types. A total of 301 patients were included in this study. Patients were classified in two cohorts according to the 2005 WHO World Health Organization histological classification: WHO type IIa group and WHO type IIb group. The Kaplan-Meier method was used to detect the efficacy between IC + CCRT and CCRT in two WHO types cohorts. Propensity score matching method was adopted to balance the baseline covariate and eliminate potential selection bias. On propensity matched analyses, IC + CCRT was found to produce better 3-year DMFS and OS than CCRT in WHO type IIa cohort (DMFS, 76.2% vs. 42.2%, p = 0.029; OS, 78.3% vs. 65.5%, p = 0.027). For WHO type IIb cohort, IC + CCRT was associated with a better 3-year OS (87.4% vs. 77.9%, p = 0.029) and a trend of better 3-year DMFS (85.9% vs. 76%, p = 0.162) compared with CCRT. IC + CCRT was benefit for advanced stage nasopharyngeal carcinoma with different nonkeratinizing carcinoma subtypes.

Implementation of temporal lobe contouring protocol in head and neck cancer radiotherapy planning: A quality improvement project

Temporal lobe necrosis as result of radiation for nasopharyngeal cancer (NPC) occurs up to 28% of NPC patients. The only effective mitigation is by strict adherence to temporal lobe dose tolerances during radiotherapy planning, which in turn hinges on accurate temporal lobe delineation. We aim to improve the accuracy and to standardize temporal lobe contouring for patients receiving head and neck radiotherapy for NPC in a tertiary teaching hospital in Singapore.The baseline data were obtained from 10 patients in the diagnostic phase and the effect of interventions were measured in 37 patients who underwent head and neck radiotherapy over a 6-month period.We conducted the project based on the Clinical Practice Improvement Program methodology. The baseline pooled mean percentage variation in temporal lobe contouring was 39.9% (0.8%-60.2%). There was a low level of temporal lobe contouring concordance and this provided the impetus for implementation of strategies to improve the accuracy and reproducibility of temporal lobe contouring. The interventions included supervision and training of radiation therapists and residents in temporal lobe contouring, and standardization of temporal lobe contouring with a protocol and contouring atlas.Thirty-seven patients were treated during the study period from June to November 2014. Following implementation of the first set of interventions, the pooled mean percentage variation in temporal lobe contouring decreased but was not sustained. The implementation of the second set of interventions resulted in a decrease from 39.9% (January to September 2014) to 17.3% (October to November 2014) where P = .004 using t test. Weekly variation was seen throughout the study period but the decrease was sustained after standardizing and providing a contouring atlas for temporal lobe contouring.Temporal lobe contouring can be standardized through effective implementation of a temporal lobe contouring protocol and atlas.

Enhancing the immune stimulatory effects of cetuximab therapy through TLR3 signalling in Epstein-Barr virus (EBV) positive nasopharyngeal carcinoma

Cetuximab immunotherapy targeting the epidermal growth factor receptor (EGFR) has been used to treat nasopharyngeal cancer (NPC) with some success. Therefore, combining an immune adjuvant to boost the immune microenvironment may improve its clinical efficacy. Herein, we investigate the immune-stimulatory effects of Poly-ICLC (a TLR3 agonist) in enhancing cetuximab-based immunotherapy and correlate these responses with FcɣRIIIa (V158F) or TLR3 single nucleotide polymorphisms (SNPs- L412F and C829T) expressed on immune effector cells. We observed high levels of TLR3 mRNA in NPC cells; and both TLR3 and EGFR expression were unaffected by Poly-ICLC treatment. Cetuximab plus Poly-ICLC significantly enhanced NK-mediated ADCC through up-regulation of CD107a and Granzyme B expression. This effect was independent of FcɣRIIIa-V158F and TLR3-L412F or TLR3-C829T polymorphisms expressed on NK cells. Additionally, IFN-ɣ expression and secretion were doubled following cetuximab plus poly-ICLC treatment; compared to either treatment alone. This effect was independent of TLR3 polymorphisms. Consequentially, adaptive immune responses were also seen with increased DC maturation (CD83), co-stimulatory molecules expression (CD80 and CD86) and increased frequency of EGFR-specific CD8 + T cells following Poly-ICLC treatment. The percentage of CD80+ CD83+ and CD83+ CD86+ DC was highest in the Poly-ICLC plus cetuximab group, compared to either treatment alone. These results demonstrate the effectiveness of Poly-ICLC in enhancing both cetuximab-mediated innate and adaptive anti-tumor immunity against NPC, which is independent of FcɣRIIIa-158, TLR3-L412F or TLR3-C829T polymorphisms. Additionally, Poly-ICLC does not downregulate EGFR expression on NPC cells and hence, will not dampen cetuximab anti-tumor activity.

Second cancer risk after radiation therapy of ependymoma using the flattening filter free irradiation mode of a linear accelerator

Pediatric patients suffering from ependymoma are usually treated with cranial or craniospinal three‐dimensional (3D) conformal radiotherapy (3DCRT). Intensity‐modulated techniques spare dose to the surrounding tissue, but the risk for second malignancies may be increased due to the increase in low‐dose volume. The aim of this study is to investigate if the flattening filter free (FFF) mode allows reducing the risk for second malignancies compared to the mode with flattening filter (FF) for intensity‐modulated techniques and to 3DCRT. A reduction of the risk would be advantageous for treating pediatric ependymoma. 3DCRT was compared to intensity‐modulated radiation therapy (IMRT) and volumetric‐modulated arc therapy (VMAT) with and without flattening filter. Dose–volume histograms (DVHs) were compared to evaluate the plan quality and used to calculate the excess absolute risk (EAR) to develop second cancer in the brain. Dose verification was performed with a two‐dimensional (2D) ionization chamber array and the out‐of‐field dose was measured with an ionization chamber to determine the EAR in peripheral organs. Delivery times were measured. Both VMAT and IMRT achieved similar plan quality in terms of dose sparing in the OAR and higher PTV coverage as compared to 3DCRT. Peripheral dose in low‐dose region, which is proportional to the EAR in organs located in this region, for example, gonads, bladder, or bowel, could be significantly reduced using FFF. The lowest peripheral EAR and lowest delivery times were hereby achieved with VMAT_FFF. The EAR calculated based on DVH in the brain could not be reduced using FFF mode. VMAT_FFF improved the target coverage and homogeneity and kept the dose in the OAR similar compared to 3DCRT. In addition, delivery times were significantly reduced using VMAT_FFF. Therefore, for radiotherapy of ependymoma patients, VMAT_FFF may be considered advantageous for the combination of Elekta Synergy linac and Oncentra External Beam planning system used in this study.

Induction chemotherapy plus concurrent chemoradiotherapy versus induction chemotherapy plus volumetric modulated arc therapy alone in the treatment of stage II-IVB nasopharyngeal carcinoma patients: a retrospective controlled study

BACKGROUND

In the era of intensity-modulated radiotherapy (IMRT), the role of additional concurrent chemotherapy (CC) to radiotherapy (RT) after induction chemotherapy (IC) compared to IC followed by RT alone remains unclear for stage II-IVB nasopharyngeal carcinoma (NPC) patients. The aim of this study was to evaluate the efficacy and toxicities of IC/RT and IC/CCRT in the treatment of NPC with volumetric modulated arc therapy (VMAT).

METHODS

From January 2012 to March 2016, a total of 217 NPC patients were retrospectively assessed. Of the 217 patients, 139 patients received IC followed by VMAT alone and 78 patients received IC plus CCRT. Overall survival (OS), progression-free survival (PFS) and toxicities were assessed.

RESULTS

The 5-year OS, PFS rates were 57.5%, 41.8% and 47.8%, 38.4% for the IC/RT and IC/CCRT arms, respectively, without significant difference in survival between the two groups (both p > 0.05). Multivariate analysis indicated that treatment modality (IC/RT vs. IC/CCRT) was not an independent prognostic factor for OS or PFS. Grade 3-4 leukopenia/neutropenia (3.60% vs. 20.51%, p < 0.001), gastrointestinal disorder (nausea/vomiting/diarrhea, 2.16% vs. 41.03%, p < 0.001), mucositis (29.50% vs. 47.44%, p = 0.01) and xerostomia (34.53% vs. 48.72%, p = 0.04) were more frequent in the IC/ CCRT arm than in the IC/RT arm during VMAT.

CONCLUSIONS

No significant difference in OS and PFS was observed between IC plus VMAT alone and IC/CCRT in the treatment of stage II-IVB NPC patients, however, more side effects were observed in the IC/CCRT arm.

Predicting the dose absorbed by organs at risk during intensity modulated radiation therapy for nasopharyngeal carcinoma

OBJECTIVE:

To develop a model for predicting the dose absorbed by organ at risk (OAR) during intensity modulated radiation therapy for nasopharyngeal carcinoma (NPC).

METHODS:

55 patients underwent intensity modulated radiation therapy for NPC. The OARs were divided into several suborgans, and SPSS software was used to evaluate multiple linear method for fitting the normalized volume for each suborgan, normalized mean dose (D_mean) D_nm (D_nm = D_mean/D_prescription), and normalized D_10%-D_100% values D_n10%-n100%(D_n10%-_n100% = D_10%-D_100%/D_prescription) for each OAR. Based on the Matlab software, the predicted D_n10%-n100% value was fitted to obtain the predicted DVH curve.

RESULTS:

The multiple linear fitting formulas revealed significant results for the oral cavity D_n100% (p = 0.017), the parotid gland D_n100% (p = 0.001), and the remaining OAR (all p < 0.0001). The correlation coefficients and p values indicated that the fitting formula was a good fit. The p values for the White test show that the prediction model is robust. This method was successfully used for verification cases.

CONCLUSION:

The present study provided a simple and effective model for predicting the dose absorbed by OAR for NPC.

ADVANCES IN KNOWLEDGE:

This method is a relatively simple mathematical model, just use prescription dose and V₀-V_n to predict the D_mean and D_10%-100%, which predict does not require buying new modules of treatment planning software or extracting the distance of each sampling point of the OAR with the dose information.

Comparing treatment outcomes of concurrent chemoradiotherapy with or without nimotuzumab in patients with locoregionally advanced nasopharyngeal carcinoma

Purpose: The benefits of additional use of nimotuzumab (NTZ) in the treatment of locoregionally advanced nasopharyngeal carcinoma (LA-NPC) is largely unclear. We aim to compare LA-NPC treatment outcomes in patients that received CCRT with nimotuzumab (NTZ) to patients that received CCRT only. Materials and Methods: Between October 2009 and January 2012, 31 previously untreated and newly diagnosed LA-NPC patients were administered CCRT (3 cycles of 100 mg/m2 cisplatin every third week with intensity-modulated radiotherapy) plus NTZ according to an IRB-approved institutional research protocol. A well-balanced cohort of 62 patients who received CCRT alone was created by matching each patient who received CCRT plus NTZ via propensity-matched analysis in a 2:1 ratio. Results: Compared with CCRT only, CCRT plus NTZ was significantly associated with superior overall survival (5-year OS; 96.8% vs. 82.3%; P = 0.001), superior distant metastasis-free survival (5-year DMFS; 90.3% vs. 80.6%, P = 0.012) and superior progression-free survival (5-year PFS; 83.9% vs. 71.0%, P = 0.006). In multivariate analysis, the inclusion of NTZ to CCRT was confirmed to be a favorable factor for OS (HR, 0.31; 95% CI, 0.02-0.71; P = 0.027), DMFS (HR, 0.45; 95% CI, 0.13-0.77; P = 0.034), and PFS (HR, 0.38; 95% CI, 0.11-0.89; P = 0.041). In addition, no significant differences in hematology parameters, dermatitis, nausea, vomiting, xerostomia, nephrotoxicity or neurotoxicity were found between the two arms (all P > 0.05). Conclusion: The inclusion of NTZ to CCRT is more effective for long-term survival among LA-NPC patients than CCRT only.

Feasibility of ipsilateral lower neck sparing irradiation for unilateral or bilateral neck node-negative nasopharyngeal carcinoma: systemic review and meta-analysis of 2, 521 patients

Background

To compare the efficacy of ipsilateral lower neck sparing irradiation (ILNSI) versus ipsilateral lower neck prophylactic irradiation (ILNPI) for unilateral or bilateral neck node-negative nasopharyngeal cancer (NPC).

Methods

A comprehensive literature search of PubMed, EMBASE, the Cochrane Library and other public databases was conducted in October, 2017. The outcomes were 3-year overall/regional recurrence-free/disease-free/distant metastasis-free survival (OS/RRFS/DFS/DMFS) and ipsilateral lower neck (ILN) recurrence. We performed subgroup analysis of ILNSI versus ILNPI for different radiotherapy techniques. Sensitivity analysis was performed to examine the stability of the results.

Results

Nine head-to-head comparative studies (2, 521 patients) were included in the meta-analysis. For the comparison of ILNSI versus ILNPI, there was no significant difference in 3-year OS (HR = 1.16, 95% confidence interval [CI] = 0.85–1.58, P = 0.36), RRFS (HR = 1.37, 95% CI = 0.76–2.47, P = 0.30), DFS (HR = 1.08, 95% CI = 0.80–1.44, P = 0.62) and DMFS (HR = 1.00, 95% CI = 0.69–1.44, P = 0.99). ILNSI and ILNPI also led to equivalent ILN recurrence rates (OR = 0.98, 95% CI = 0.47–2.03, P = 0.96). No significant heterogeneity was observed for any outcome. Subgroup analysis confirmed no significant differences between ILNSI and ILNPI for any outcome, regardless of radiotherapy technique. Sensitivity analysis indicated all outcomes were highly stable in favor of the original conclusions.

Conclusions

ILNSI provided equivalent survival outcomes and regional control compared to ILNPI; ILNSI represents an appropriate alternative strategy for patients with unilateral or bilateral neck node-negative NPC.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1087-x) contains supplementary material, which is available to authorized users.

Concurrent Chemoradiotherapy versus Intensity-modulated Radiotherapy Alone for Elderly Nasopharyngeal Carcinoma Patients with Pre-treatment Epstein-Barr Virus DNA: A Cohort Study in an Endemic Area with Long-term Follow-up

Purpose: To date, no guidelines exist for elderly nasopharyngeal carcinoma (NPC) patients (60 years of age or older) due to a lack of prospective clinical trials. This study evaluated the efficacy of concurrent chemotherapy (CCRT) for NPC in elderly patients treated with intensity-modulated radiotherapy (IMRT). Methods: Patients were identified from a prospectively maintained database. A total of 198 consecutive cases of elderly patients with NPC receiving IMRT, including 103 patients treated with IMRT plus CCRT and 95 patients treated with IMRT alone, were analysed from January 2002 to December 2013. Multivariate analysis (MVA) using the Cox proportional hazards model and propensity score analysis (PSA) were performed for overall survival (OS) and disease-free survival (DFS). Finally, sensitivity analysis was performed. Results: The median follow-up time was 55.3 months (range, 3-135.6 months). In the entire cohort, both MVA and PSA models showed that compared with IMRT alone, IMRT plus CCRT significantly improved survival (hazard ratio [HR] 2.143, 95% confidence interval [95% CI] 1.180-3.890; HR 1.961, 95% CI, 1.117-3.443, for OS and DFS, respectively). Similar results were found in the subgroups with high levels of Epstein-Barr virus (EBV) DNA, except in the low-EBV-DNA cohort. The total rates of severe acute toxicity, including leukopenia, neutropenia, stomatitis, and emesis, were significantly higher in the IMRT+CCRT group than in the IMRT-alone group (P < 0.001) but were similar to the rates of severe late toxicity (P = 0.818). Sensitivity analysis confirmed the robustness of our analysis. Conclusions: In the era of IMRT, CCRT retained survival benefits at high EBV DNA levels but not at low EBV DNA levels for elderly NPC patients. Randomized clinical trials are needed to confirm our findings.

The detrimental effects of radiotherapy interruption on local control after concurrent chemoradiotherapy for advanced T-stage nasopharyngeal carcinoma: an observational, prospective analysis

Background

Previous studies have reported radiotherapy interruption (RTI) is associated with poor local control in two-dimensional radiotherapy (2DRT) era. However, it remains unclear whether RTI still affects local control for advanced T stage (T3–4) in the intensity-modulated radiation therapy (IMRT) era. We aim to evaluate whether RTI affects local control for T3–4 NPC treated with definitive IMRT.

Methods

In this observational prospective study, 447 T3–4 NPC patients treated with IMRT plus concurrent chemotherapy were included. All patients completed the planned radiotherapy course, and RTI was defined as the actual time taken to finish the prescribed course of radiotherapy minus the planned radiotherapy time. Receiver operating characteristic (ROC) curve was used for determined the cutoff point of RTI. The effects of RTI on local control were analyzed in multivariate analysis.

Results

At 5 years, the local relapse-free survival (LRFS) and overall survival (OS) rates were 93.7 and 85.7%, respectively. The cutoff RTI for LRFS was 5.5 days by ROC curve. Compared to patients with RTI >  5 days, patients with RTI ≤ 5 days had a significantly lower rate of LRFS (97% vs. 83%; P < 0.001). In multivariate analysis, RTI was a risk factor independently associated with LRFS (HR = 9.64, 95% CI, 4.10–22.65), but not for OS (HR = 1.09, 95% CI, 0.84–1.64).

Conclusions

The current analysis demonstrates a significant correlation between prolonged RTI and local control in NPC, even when concurrent chemotherapy is used. We consider that attention to RTI seems to be warranted for patients with advanced T-stage NPC in the era of IMRT.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4495-2) contains supplementary material, which is available to authorized users.

Induction chemotherapy in the treatment of nasopharyngeal carcinoma: Clinical outcomes and patterns of care

The role of induction chemotherapy in nasopharyngeal carcinoma (NPC) remains controversial. The primary aim of this study was to use the National Cancer Database to evaluate the patterns of care of induction chemotherapy in NPC and its impact on overall survival (OS). Patients with NPC from 2004 to 2014 were obtained from the NCDB. Patients were considered to have received induction chemotherapy if it was started ≥43 days before the start of RT and concurrent CRT if chemotherapy started within 21 days after the start of RT. Propensity score matching was used to control for selection bias. Cox proportional hazards model was used to determine significant predictors of OS. Logistic regression model was used to determine predictors of the use of induction chemotherapy. Significance was defined as a P value <.05. A total of 4857 patients were identified: 4041 patients (87.2%) received concurrent CRT and 816 patients (16.8%) received induction chemotherapy. The use of induction therapy remained stable between 2004 and 2014. Younger patients and those with higher T- and N-stage had a higher likelihood of being treated with induction chemotherapy. The 5-year OS in patients treated with induction chemotherapy and CRT was 66.3% vs 69.1%, respectively (P = .25). There was no difference in OS when these two groups were analyzed after propensity score matching. No differences in OS existed between these treatment groups in patients with T3-T4N1 or TanyN2-3 disease (P = .76). Propensity score matching also did not reveal any difference in OS in patients with T3-T4N1 or TanyN2-3 disease. The use of induction chemotherapy has remained stable in the last decade. In this study of patients with NPC, induction chemotherapy was not associated with improved OS compared to CRT alone.

Systematic review and meta-analyses of intensity-modulated radiation therapy versus conventional two-dimensional and/or or three-dimensional radiotherapy in curative-intent management of head and neck squamous cell carcinoma

Introduction

Technological advancements in treatment planning and delivery have propelled the use of intensity-modulated radiation therapy (IMRT) in head and neck squamous cell carcinoma (HNSCC). This review compares IMRT with conventional two-dimensional (2D) and/or three-dimensional (3D) radiotherapy (RT) in curative-intent management of HNSCC.

Methods

Only randomized controlled trials (RCTs) offering curative-intent RT in patients with non-metastatic HNSCC were included. Outcome data was extracted independently by two reviewers, pooled using the Cochrane methodology, and expressed as risk ratio (RR) or hazard ratio (HR) as appropriate with 95% confidence intervals (CIs). Xerostomia was the primary outcome of interest whereas loco-regional control, overall survival and quality-of-life (QOL) were secondary endpoints.

Results

Seven RCTs involving 1155 patients directly comparing IMRT with 2D/3D-RT in HNSCC were included. The primary objective in five of seven index RCTs was reduction in xerostomia, with only one trial each using loco-regional control and overall survival as primary endpoints for sample size calculation. The use of IMRT was associated with a 36% relative risk reduction in ≥grade 2 acute xerostomia (RR = 0.64, 95%CI = 0.49–0.84; p = 0.001) compared to 2D/3D-RT. More importantly, IMRT significantly reduced the risk of ≥grade 2 late xerostomia (RR = 0.44, 95%CI = 0.34–0.57; p = 0.00001) compared to non-IMRT techniques at all time-points. Within the limitations of inadequate sample size and low statistical power, IMRT also resulted in 24% relative reduction in the risk of loco-regional relapse (HR = 0.76, 0.57–1.01; p = 0.06) and 30% relative reduction in risk of death (HR = 0.70, 95%CI = 0.57–0.88; p = 0.002) compared to 2D/3D-RT. However, this benefit of IMRT for loco-regional control and overall survival was limited to nasopharyngeal cancer patients alone, with no significant difference in efficacy between the two techniques in patients with cancers of the laryngo-pharynx in this analysis, highlighting the inconsistency in results of subgroup analyses stratified by primary site. Inadequate reporting of data precluded statistically pooling of results for QOL outcomes.

Conclusions

There is consistent moderate-quality evidence that IMRT significantly reduces the risk of moderate to severe acute and late xerostomia compared to 2D/3D-RT in curative-intent radiotherapeutic management of HNSCC. However, the quality of evidence regarding the superiority of IMRT over conventional techniques for disease-related endpoints is rather low due to relative lack of power and inconsistency of results precluding robust conclusions.

A novel N staging system for NPC based on IMRT and RTOG guidelines for lymph node levels: Results of a prospective multicentric clinical study

The present study aimed to investigate the cervical lymph node metastasis of nasopharyngeal carcinoma (NPC) and to establish a novel N staging standard for NPC, based on intensity modulated radiation therapy (IMRT) via a prospective multicenter clinical trial. Between January 2006 and December 2009, a total of 492 patients with NPC without distant metastasis were included in the present study. All patients were treated with IMRT. According to Radiation Therapy Oncology Group division standards, the present study proposed a novel N staging system following the review of magnetic resonance images in comparison with the 7th edition of Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system. Retropharyngeal lymph nodes, cervical lymph node level and cervical lymph node laterality were independent prognostic factors used in multivariate analyses. According to the results of the risk variety, the present study suggested that the novel N staging system included: N0 (no lymph node metastasis), N1 [retropharyngeal or/and unilateral upper cervical (I, II, III, Va, VIIb, VIII, IX and X regions) lymph node metastasis], N2 [bilateral upper cervical (I, II, III, Va, VIIb, VIII, IX and X regions) lymph node metastasis] and N3 (lymph node metastasis in IVa and Vb regions and their lower regions). The novel N staging system proposed in the present study performs better in risk difference and distribution balance. Furthermore, the differences of 5-year curves of distant metastasis-free survival and overall survival had greater statistically significant differences compared with the 7th edition of the UICC/AJCC staging system. The present study suggested a novel N staging system for cervical lymph node metastasis of NPC, which may predict the prognosis of patients with NPC in a more objective and accurate way.

Optimization of cervical lymph node clinical target volume delineation in nasopharyngeal carcinoma: a single center experience and recommendation

Nasopharyngeal carcinoma (NPC) are characterized by distinct lymph node metastasis patterns. In order to minimize cervical lymph node irradiation volume, 379 NPC patients with metastatic cervical lymph nodes were eligible for geographic mapping. All lymph nodes were mapped into simulation computed tomography images of a template lymph node negative patient. The proportions of retropharyngeal lymph nodes (RLNs), Level Ib, II, III, IV, Va, Vb and supraclavicular (SCV) lymph nodes were 6.9%, 0.5%, 55.25%, 20.4%, 8.2%, 4.9%, 3.1% and 0.75%, respectively. Based on their distribution profile, we proposed the following modifications: 1. the lateral border of RLNs clinical target volume (CTV) be the medial edge of the internal carotid artery above the level of mastoid process, the medial border be adjacent to the cervical vessels below the free edge of the soft palate; 2. the submandibular gland should not be included in Level Ib; 3. Level II should include the posterior belly of digastric muscle, and the space between the posterior edge of submandibular gland and the anterior edge of sternocleidomastoid muscle; 4. the anterior border of Level III and IV should gradually shift backwards and the CTV only include part of the cervical vessels below the level where the thyroid gland appears; 5. the space of the posterior edge of trapezius muscle also should be included if there are metastatic lymph nodes in the transverse cervical vessle plexus. Our recommendations might adequately encompass metastatic lymph nodes while sparing the organs at risk and reducing adverse events.

Study of dosimetric indices and dose constraints to critical organs for head and neck tumours treated with inverse planned simultaneous integrated boost intensity-modulated radiotherapy

Aim

This study aimed to investigate tolerance dose to organs at risk (OARs) as well as degree of conformity and homogeneity for head and neck cancer patients by using simultaneous integrated boost intensity-modulated radiotherapy technique (SIB IMRT).

Materials and methods

This study analysed 15 head and neck cancer patients receiving treatment using inverse planned SIB IMRT technique. Using a beam energy of 6 MV, two dose levels of 70 and 55·4 Gy were used to treat the tumour. Doses of 2 Gy in 35 fractions and 1·68 Gy in 33 fractions were simultaneously delivered for effective planning target volume (PTV1) and boost planning target volume (PTV2), respectively.

Results

Dose distribution in PTV and critical organs lies within tolerance dose guidelines protecting spinal cord, brain stem, optic chiasm, optic nerve, thus reducing the risk of damage to normal tissues. Minor deviation from tolerance limit was observed for parotid glands. This technique provided highly conformal and homogenous dose distribution as well as better sparing of OARs, hence verifying quality assurance results to be satisfactory.

Findings

SIB IMRT technique offers best solution for preserving organ function by keeping dose below tolerance level. Treatment of head and neck carcinoma using SIB IMRT is feasible, more efficient, and dose escalation is achieved in a single plan.

Pathologic study of tumour extension for clinically localized unilateral nasopharyngeal carcinoma: Should the contralateral side be included in the clinical target volume?

INTRODUCTION

The clinical target volume (CTV) delineation is crucial for tumour control and normal tissue protection. This study investigated the contralateral extension of nasopharyngeal carcinoma (NPC) in patients with a clinically diagnosed unilateral tumour to pursue the possibility of CTV reduction.

METHODS

Twenty NPC patients with localized tumours confined to only one side of the nasopharynx as shown by magnetic resonance imaging and fibreoptic endoscopy were selected for biopsy. The tissues of the contralateral pharyngeal recess (CPR) and the contralateral posterosuperior wall (CPSW) of the nasopharynx were obtained in each case and prepared for pathological examination. The factors associated with contralateral tumour infiltration were analysed.

RESULTS

Five of 20 (25.0%) patients were pathologically confirmed to have carcinoma cell infiltration in the CPSW, including 2 (10.0%) that had carcinoma cell infiltration in the CPR. The T classification (P = 0.014) and primary tumour volume (P = 0.033) were positively associated with the infiltration of the CPSW, but none of the primary tumour factors affected the involvement of the CPR. The contralateral retropharyngeal lymph node (LN) metastasis (P = 0.016), but not the contralateral cervical LN, was significantly associated with the infiltration of the CPR. Positive Epstein-Barr virus DNA (EBV-DNA) was another factor that increased the probability of CPR invasion (P = 0.044).

CONCLUSIONS

Contralateral pharyngeal recess infiltration is rare in patients with clinically diagnosed unilateral primary NPC. Reduced CTV coverage, including the CPSW but not CRP, is feasible for patients with unilateral cancer of the nasopharynx without contralateral LN metastasis or positive EBV-DNA. Further large-sample studies are needed.

Development of a normal tissue complication probability (NTCP) model for radiation-induced hypothyroidism in nasopharyngeal carcinoma patients

BACKGROUND

The objectives of this study were to build a normal tissue complication probability (NTCP) model of radiation-induced hypothyroidism (RHT) for nasopharyngeal carcinoma (NPC) patients and to compare it with other four published NTCP models to evaluate its efficacy.

METHODS

Medical notes of 174 NPC patients after radiotherapy were reviewed. Biochemical hypothyroidism was defined as an elevated level of serum thyroid-stimulating hormone (TSH) value with a normal or decreased level of serum free thyroxine (fT4) after radiotherapy. Logistic regression with leave-one-out cross-validation was performed to establish the NTCP model. Model performance was evaluated and compared by the area under the receiver operating characteristic curve (AUC) in our NPC cohort.

RESULTS

With a median follow-up of 24 months, 39 (22.4%) patients developed biochemical hypothyroidism. Gender, chemotherapy, the percentage thyroid volume receiving more than 50 Gy (V50), and the maximum dose of the pituitary (Pmax) were identified as the most predictive factors for RHT. A NTCP model based on these four parameters were developed. The model comparison was made in our NPC cohort and our NTCP model performed better in RHT prediction than the other four models.

CONCLUSIONS

This study developed a four-variable NTCP model for biochemical hypothyroidism in NPC patients post-radiotherapy. Our NTCP model for RHT presents a high prediction capability.

TRIAL REGISTRATION

This is a retrospective study without registration.

MicroRNA‑122 acts as tumor suppressor by targeting TRIM29 and blocking the activity of PI3K/AKT signaling in nasopharyngeal carcinoma in vitro

Nasopharyngeal carcinoma (NPC) is endemic in the southern provinces of China and Southeast Asia. It has been reported that microRNA-122 (miR-122) and tripartite motif-containing protein 29 (TRIM29) serve important roles in many types of tumor. The present study aimed to evaluate the expression of miR-122 and TRIM29, and their clinical significance in NPC, and to examine the associated molecular mechanisms. It was observed that low expression of miR-122 and high expression of TRIM29 led to a low overall survival rate in patients with NPC, which was associated with tumor-node-metastasis (TNM) stage and distant metastasis of NPC. Low expression of miR-122 was correlated reciprocally with high expression of TRIM29 in NPC tissues, and the two were aggravated by radiation treatment in NPC cell lines. Through Cell Counting kit-8 and Transwell assays, miR-122 was demonstrated to be able to inhibit the proliferation, migration and invasion of NPC cells. Through reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and western blot analyses, the expression of metastasis-associated genes, including E-cadherin, metastatic tumor antigen 1, matrix metalloproteinase-2 and metalloproteinase inhibitor 2 were demonstrated to be regulated by miR-122 in NPC cells. Additionally, through a luciferase assay, RT-qPCR and western blot analysis, it was demonstrated that TRIM29 may be a direct target of miR-122. In addition, it was noted that miR-122 decreased the expression of phosphorylated (p) phosphatidylinositol 3-kinase (PI3K) and p-RAC-α serine/threonine-protein kinase (AKT). Collectively, the results of the present study demonstrated that miR-122 may exert its tumor suppressive role by targeting TRIM29 and inhibiting the activity of PI3K/AKT signaling. It was indicated that miR-122 and TRIM29 may be developed as biomarkers of NPC, and possible molecular targets for the prevention of metastasis in patients with NPC.

Treatment for retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site: results of a prospective study with irradiation to nasopharyngeal mucosa plus bilateral neck

Background and Objective

To evaluate treatment outcomes for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma (SCC) from an unknown primary site.

Methods

From January 2005 to January 2015, patients who presented with enlarged retropharyngeal nodes underwent transoral sonography-guided fine-needle aspiration to confirm histology. Those with metastatic undifferentiated SCC with unknown primary tumors were treated with radical radiotherapy to nasopharyngeal mucosa plus bilateral neck. Chemotherapy was administered for patients staged N2-3. Endpoints included metastatic nodes control, the appearance of primary tumor, overall survival and treatment-related toxicities.

Results

A total of 49 patients were recruited into this study. Retropharyngeal and cervical nodal disease was controlled in 96% of all patients. The incidence of occult primary cancer appearance was 8%. No primary cancer other than of the nasopharynx was detected during the course of follow-up. Ten patients developed distant metastases. The 5-year overall survival, progression-free survival, regional relapse free survival, distant metastasis free survival were 79.6%, 61.1%, 83.4%, 73.8%, respectively. Common late adverse effects included xerostomia (57%) and hearing impairment (35%).

Conclusion

Radical radiotherapy to both the nasopharynx and bilateral neck can achieve excellent outcome with mild toxicities for patients with retropharyngeal metastatic undifferentiated squamous cell carcinoma from an unknown primary site.

MiR-152 functioning as a tumor suppressor that interacts with DNMT1 in nasopharyngeal carcinoma

Background

In recent years, miR-152 has been dysregulated in a variety of tumors and used as a tumor suppressor. Nevertheless, its role in nasopharyngeal carcinoma (NPC) remains unidentified.

Materials and methods

Real-time quantitative PCR (polymerase chain reaction) was performed to analyze the expression of miR-152 in NPC cell lines. MiR-152 expression profiles in NPC tissues were obtained from Gene Expression Omnibus (GEO GSE36682). The effect of miR-152 on the invasion and proliferation of NPC cells was determined through cell invasion, wound healing, and cell viability assays. Apoptosis was examined by flow cytometry, and Western blot was performed to measure expression of the target gene. Pyrosequencing was used to detect the methylation level of NPC cells.

Results

In this study, miR-152 was downregulated in the NPC tissues and cell lines. When miR-152 was enhanced, the invasion and migration of NPC cells were inhibited. However, miR-152 had no effect on the proliferation of NPC cells. Luciferase reporter gene analysis was performed, and the results showed that DNMT1 (DNA (cytosine-5)-methyltransferase 1) is a direct target of miR-152 in NPC cells. DNMT1 downregulation and miR-152 overexpression both reversed the effects of miR-152 inhibition on the NPC cells. In addition, miR-152 expression increased as a result of the inhibition of the methylation level of miR-152 when DNMT1 expression was downregulated.

Conclusion

The overexpression of miR-152 inhibited the migration and invasion of NPC cells by targeting DNMT1. Furthermore, DNMT1 regulated miR-152 expression through DNA methylation. Overall, the novel miR-152-DNMT1 regulatory circuit may provide better understanding of the pathogenesis of NPC and new epigenetic therapeutic target in NPC.

Long-term outcomes in patients with nasopharyngeal carcinoma treated with reduced-volume conformal radiotherapy: A retrospective cohort study

INTRODUCTION

While the optimal target volumes for primary nasopharyngeal tumour are still subject to debate, we evaluated primary tumour volumes in nasopharyngeal carcinoma (NPC) patients treated according to an institutional protocol with a reduced volume approach and compared them to those determined by Radiation Therapy Oncology Group (RTOG)-0615 guidelines.

METHODS

This single-centre retrospective analysis included 36 NPC patients treated between 2/2007 and 3/2014. Planning target volume (PTV)-P 50 (50 Gy isodose to the primary tumour) included the gross tumour and the entire nasopharyngeal mucosa (clinical target volume [CTV]-P 50) with 5 mm margins. The PTV-P 50 volumes, as determined by our protocol, were compared to those obtained with RTOG-0615 PTV-P 59.4 (59.4 Gy to the primary tumour). Clinical outcomes were also analysed.

RESULTS

Median (range) follow-up: 48 (21-108) months; 88.9% were males; median age was 53 (27-86) years; 14%, 53%, and 33% had stage II, III, and IV disease at diagnosis, respectively. Median volume of PTV-P 50: 209.0 (92.6-568.0) cc. Median volume of RTOG-0615 PTV-P 59.4-P: 292.0 (123.6-425.1) cc. The PTV-P volume was significantly smaller than that delineated according to the RTOG-0615 protocol (p < 0.001). Isolated local relapse as first site of recurrence occurred in five patients: two with stage III, two with IVA and one with IVB disease; all had advanced local disease at diagnosis. All local recurrences occurred in the PTV-P 69-70 region.

CONCLUSION

A reduced volume approach for radiotherapy in primary NPC provided acceptable long-term local control.

The role of concurrent chemotherapy for stage II nasopharyngeal carcinoma in the intensity-modulated radiotherapy era: A systematic review and meta-analysis

Objectives

To compare clinical outcomes of concurrent chemoradiotherapy (CCRT) with those of radiotherapy alone for stage II nasopharyngeal carcinoma in the intensity-modulated radiotherapy (IMRT) era.

Materials and methods

We comprehensively searched PubMed, Embase, and the Cochrane Library to identify eligible studies. Overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), locoregional recurrence-free survival (LRRFS) with hazard ratios (HRs), and toxicities with odd ratios (ORs) were analyzed.

Results

A total of seven studies met the criteria, with 1302 patients who were treated with IMRT alone or IMRT plus concurrent chemotherapy. No significant survival benefit was shown by CCRT regardless of OS (HR = 1.17, 95% CI 0.73–1.89, P = 0.508), PFS (HR = 0.76, 95% CI 0.38–1.50, P = 0.430), DMFS (HR = 0.89, 95% CI 0.33–2.41, P = 0.816), or LRRFS (HR = 1.03, 95% CI 0.95–1.12, P = 0.498). Additionally, CCRT notably increased the risk of acute grade 3–4 leukopenia (OR = 4.432, 95% CI 2.195–8.952, P < 0.001), compared to IMRT alone.

Conclusion

Adding concurrent chemotherapy to IMRT led to no survival benefit and increased acute toxicity reactions for stage II nasopharyngeal carcinoma.

Pretreatment prognostic factors of survival and late toxicities for patients with nasopharyngeal carcinoma treated by simultaneous integrated boost intensity-modulated radiotherapy

Background

To scrutinize the pretreatment prognosticators on survival and late toxicities in a homogenous cohort of nasopharyngeal carcinoma (NPC) patients treated by simultaneous integrated boost intensity-modulated radiation therapy (SIB-IMRT).

Methods

A total of 219 non-distant metastatic NPC patients consecutively treated by SIB-IMRT at a single institute were collected. The pretreatment factors including the socio-demographic variables, TNM stages, gross tumor volume (GTV), Epstein-Barr virus (EBV)-DNA, and hematologic inflammatory markers were analyzed. Cox model was used to screen the prognostic factors of late toxicities and four survival outcomes including locoregional relapse-free survival (LRRFS), distant metastasis-free survival (DMFS), failure-free survival (FFS), and overall survival (OS).

Results

Statistically significant inter-correlations were observed between the values of EBV-DNA, some hematologic inflammatory markers, GTV, and N classification. The 5-year LRRFS, DMFS, FFS, and OS rates were 87.9%, 89.4%, 79.4%, and 81.3%, respectively. Multivariate analysis revealed that advanced N classification (N2–3 vs. N0–1) remained the only significant negative prognosticator for all the four survival outcomes. An increased monocyte percentage and a decreased lymphocyte-to-monocyte ratio were significantly associated with poorer FFS and OS, respectively. Larger GTV was observed to be predictive of poorer LRRFS. Patients with T3–4 (HR: 3.5, 95% CI: 1.0–12.1, p = 0.048) or higher GTV (HR: 1.006, 95% CI: 1.001–1.011, p = 0.027) were associated with higher incidence of radiation neuropathy.

Conclusion

N classification remains the most significant survival predictor for NPC patients treated by SIB-IMRT after adjusting these biomarkers. GTV impacts not only on locoregional control but also radiation neuropathy.

Prognostication of serial post-intensity-modulated radiation therapy undetectable plasma EBV DNA for nasopharyngeal carcinoma

Plasma Epstein-Barr virus (EBV) DNA titers have been used to monitor treatment response and provide prognostic information on survival for nasopharyngeal carcinoma (NPC). However, the long-term prognostic role of pretreatment and posttreatment titers after radical contemporaneous radiation therapy remains uncertain. We recruited 260 evaluable patients with non-metastatic NPC treated with radical intensity-modulated radiation therapy (IMRT) with or without adjunct chemotherapy. Plasma EBV DNA titers at baseline and then 8 weeks and 6 months after IMRT were measured. Cox regression models were employed to identify interaction between post-IMRT 8^th week and 6^th month undetectable titers and 3-year survival endpoints. Concordance indices (Ct) from time-dependent receiver-operating characteristics (TDROC) were compared between patients with post-IMRT undetectable and those with detectable titers. After a median follow-up duration of 3.4 years (range 1.4-4.6 years), patients with post-IMRT 8^th week and 6^th month undetectable plasma EBV DNA titers enjoyed longer 3-year survival endpoints than those who had detectable titers at the same time points. Post-IMRT 8^th week, and more significantly, post-IMRT 6^th month undetectable plasma EBV DNA were the only significant prognostic factors of 3-year survival endpoints. Ct values for all 3-year survival endpoints for both post-IMRT 8^th week and 6^th month undetectable plasma EBV DNA were significantly higher in those with stage IVA–IVB diseases compared to stage I-III counterparts. Early post-IMRT undetectable plasma EBV DNA titers were prognostic of 3-year survival endpoints in patients with non-metastatic NPC. Intensified treatment should be further explored for patients with persistently detectable titers after IMRT.

Early Changes in Apparent Diffusion Coefficient for Salivary Glands during Radiotherapy for Nasopharyngeal Carcinoma Associated with Xerostomia

Objective

To evaluate the early changes in the apparent diffusion coefficient (ADC) of the salivary glands during radiotherapy (RT) and their association with the degree of xerostomia at 6 months after RT in patients with nasopharyngeal carcinoma (NPC).

Materials and Methods

We enrolled 26 patients with NPC who underwent RT. Each patient underwent diffusion-weighted MRI of the salivary glands at rest and with gustatory stimulation within 1 week before RT and 2 weeks after the beginning of RT. The ADC at rest (ADC_R) and increase and increase rate with stimulation (ADC_I, ADC_IR) of the submandibular and parotid glands were calculated. The differences in the variables' values between 2 weeks after the beginning of RT and baseline (ΔADC_R, ΔADC_I, and ΔADC_IR) were compared to the degree of xerostomia at 6 months after RT.

Results

The ADC_R of the submandibular and parotid glands were both significantly higher at 2 weeks after the beginning of RT than found at baseline (both p < 0.01). The ADC_I and ADC_IR for the parotid glands were both significantly lower at 2 weeks after the beginning of RT than found at baseline (both p < 0.01). ΔADC_I and ΔADC_IR of the parotid glands were associated with the degree of xerostomia at 6 months after RT (r = −0.61 and −0.72, both p < 0.01).

Conclusion

The ADCs of the salivary glands change early during RT. The differences in the ADC increase and increase rate of the parotid glands between 2 weeks after the beginning of RT and baseline were associated with the degree of xerostomia at 6 months after RT.

Induction chemotherapy for the treatment of non-endemic locally advanced nasopharyngeal carcinoma

Background

The role of induction chemotherapy is less clear in non-endemic locally advanced nanopharyngeal carcinomas (NPC).

Results

With a total of 233 eligible patients and a median follow-up of 36 months, 3-year overall survival (OS), local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease free survival (DFS) were 84.5%, 94.9%, 78.6% and 69.2%, respectively. The overall failure rate was 21.0% and distant metastasis occurred in 17.2% patients. Multivariate analyses showed that retropharyngeal and bilateral neck lymph node metastasis were significant prognostic factors for DFS and OS. Moreover, patients receiving both GP (gemcitabine+cisplatin) and TP (docetaxel+cisplatin) regimes had significantly higher DFS and OS compared with PF (cisplatin+5-FU) regime. GP regimes lead to significantly improved OS than TP/PF in some subgroup of patients. No severe toxicities were observed.

Materials and Methods

We retrospectively analyzed stage III-IVb NPC patients treated between Jan 2006 and Dec 2014, with induction chemotherapy followed by concurrent chemoradiation (IC-CCRT). Statistical analyses were performed on survival and failure patterns.

Conclusions

These results suggested IC-CCRT was safe and effective for NPCs from non-endemic region. The choice of induction regimen appeared to affect patient outcomes.

RapidArc vs Conventional IMRT for Head and Neck Cancer Irradiation: Is Faster Necessary Better?

Purpose:

The aim of this study was to dosimetrically evaluate and compare double arc RapidArc (RA) with conventional IMRT (7 fields) plans for irradiation of locally advanced head and neck cancers (LAHNC), focusing on target coverage and doses received by organs at risk (OAR).

Methods:

Computed tomography scans of 20 patients with LAHNC were obtained. Contouring of the target volumes and OAR was done. Two plans were made for each patient, one using IMRT and the other double arc RA, and calculated doses to planning target volume (PTV) and OAR were compared. Monitor units for each technique were also calculated.

Results:

PTV coverage was similar with both techniques. The homogeneity index (HI) was higher for the IMRT plans with a value of 0.108 ± 0.021 compared to 0.0975 ± 0.017 for double arc RA plans (p-value of 0.540). The double arc RA plans achieved a better conformity with a CI95%= 1.01 ± 0.021 compared to 1.05 ± 0.057 achieved with the IMRT plans (p-value of 0.036). The average monitor units (MU) ±SD were 930.5 ± 142.42 for the IMRT plans as opposed to 484.25 ± 69.47 for the double arc RA plans (P-value of 0.002). Double arc plans provided better OAR sparing with a significant p-value of 0.002 and 0.004 for the right and left parotid glands, respectively.

Conclusions:

RA is a rapid and accurate technique that uses lower MUs than conventional IMRT. Double arc plans provide better dose conformity, OAR sparing and a more homogeneous target coverage compared to IMRT.

Long-term prognostic implications and therapeutic target role of hexokinase II in patients with nasopharyngeal carcinoma

Tumor cells preferentially use anaerobic glycolysis rather than oxidative phosphorylation to generate energy. Hexokinase II (HK-II) is necessary for anaerobic glycolysis and displays aberrant expression in malignant cells. The current study aimed to evaluate the role of HK-II in the survival and biological function of nasopharyngeal carcinoma (NPC). Our study demonstrated that high expression of HK-II was associated with poor survival outcomes in NPC patients. When using 3-BrOP (an HK-II inhibitor) to repress glycolysis, cell proliferation and invasion were attenuated, accompanied by the induction of apoptosis and cell cycle arrest at the G1 stage. Furthermore, 3-BrOP synergized with cisplatin (DDP) to induce NPC cell death. Collectively, we provided that the aberrant expression of HK-II was associated with the malignant phenotype of NPC. A combined treatment modality that targets glycolysis with DDP holds promise for the treatment of NPC patients.

The efficacy and toxicity of individualized intensity-modulated radiotherapy based on the tumor extension patterns of nasopharyngeal carcinoma

Background

To evaluate the efficacy and toxicity of intensity-modulated radiotherapy (IMRT) using individualized clinical target volumes (CTVs) based on the loco-regional extension patterns of nasopharyngeal carcinoma (NPC).

Methods

From December 2009 to February 2012, 220 patients with histologically-proven, non-disseminated NPC were prospectively treated with IMRT according to an individualized delineation protocol. CTV1 encompassed the gross tumor volume, entire nasopharyngeal mucosa and structures within the pharyngobasilar fascia with a margin. CTV2 encompassed bilateral high risk anatomic sites and downstream anatomic sites adjacent to primary tumor, bilateral retropharyngeal regions, levels II, III and Va, and prophylactic irradiation was gave to one or two levels beyond clinical lymph nodes involvement. Clinical outcomes and toxicities were evaluated.

Results

Median follow-up was 50.8 (range, 1.3–68.0) months, four-year local relapse-free, regional relapse-free, distant metastasis-free, disease-free and overall survival rates were 94.7%, 97.0%, 91.7%, 87.2% and 91.9%, respectively. Acute severe (≥ grade 3) mucositis, dermatitis and xerostomia were observed in 27.6%, 3.6% and zero patients, respectively. At 1 year, xerostomia was mild, with frequencies of Grade 0, 1, 2 and 3 xerostomia of 27.9%, 63.3%, 8.3% and 0.5%, respectively.

Conclusions

IMRT using individualized CTVs provided high rates of local and regional control and a favorable toxicity profile in NPC. Individualized CTV delineation strategy is a promising one that may effectively avoid unnecessary or missed irradiation, and deserve optimization to define more precise individualized CTVs.

The role of adjuvant chemotherapy in nasopharyngeal carcinoma with bulky neck lymph nodes in the era of IMRT

Nasopharyngeal carcinoma (NPC) patients with N2-3 diseases are prone to develop distant metastasis even treated with standard concurrent chemoradiotherapy (CCRT). Our study is aim to determine the optimal treatment strategy of these patients. Patients with histologically proven NPC were retrospectively analyzed according to the AJCC 2002 stage classification system. A total of 547 patients who had N2-3 diseases were enrolled. They were all treated with Intensity-modulated radiation therapy (IMRT) combined with systemic treatments, including radiotherapy alone (RT alone), neoadjuvant chemotherapy followed by radiotherapy (NACT+RT), CCRT, NACT+CCRT, NACT followed by radiotherapy and adjuvant chemotherapy (NACT+RT+AC), CCRT+AC and NACT+CCRT+AC. A subgroup analysis was also conducted. With a median follow-up time of 53.8 months, adjuvant chemotherapy significantly decreased the risk of distant metastasis (HR 0.413, 95% CI 0.194-0.881, p = 0.022) as well as significantly increased the OS (HR 0.398, 95% CI 0.187-0.848, p = 0.017) in patients with N3 disease. The addition of adjuvant chemotherapy seemed to provide benefits to patients with N3 stage NPC and the current study may indicate the need for further randomized investigation.