Relationship between pretreatment concentration of plasma Epstein-Barr virus DNA and tumor burden in nasopharyngeal carcinoma: An updated interpretation

Nomogram incorporating Epstein-Barr virus DNA and a novel immune-nutritional marker for survival prediction in nasopharyngeal carcinoma

BACKGROUND

Since Immune response, nutritional status and Epstein-Barr Virus (EBV) DNA status have been confirmed to be relevant to the prognosis of patients with nasopharyngeal carcinoma (NPC), we believe that the combination of these factors is of great value for improving the predictive ability. LA (lymphocytes × albumin), a novel indicator, had not been studied yet in NPC. We combined it with EBV DNA and used nomograms to increase the accuracy of prognosis.

METHODS

A total of 688 NPC patients were retrospectively reviewed and further divided into training and validation cohort randomly. Kaplan-Meier analyses were used to to distinguish the different survival outcomes. Multivariate Cox analyses were used to identify the independent prognostic factors for progression-free survival (PFS) and overall survival (OS). Calibration curves, concordance indexes (C-indexes) and decision curve analyses (DCA) were used to evaluate the nomograms' predictive value.

RESULTS

Patients with low LA and positive EBV DNA correlated with poorer 5-year PFS and OS (all P < 0.005). In multivariate Cox analyses, LA and EBV DNA were both confirmed to be independent prognostic factors for PFS and OS (all P < 0.05). Prognostic nomograms incorporating LA and EBV DNA achieved ideal C-indexes of 0.69 (95% CI: 0.65-0.73) and 0.77 (95% CI: 0.71-0.82) in the prediction of PFS and OS. Otherwise, the calibration curves and DCA curves also revealed that our nomograms had pleasant predictive power.

CONCLUSIONS

LA is a novel and powerful biomarker for predicting clinical outcomes in NPC. Our nomograms based on LA and EBV DNA can predict individual prognosis more accurately and effectively.

A promising predictive biomarker combined EBV NDA with PNI for nasopharyngeal carcinoma in nonendemic area of China

In endemic areas, EBV DNA is used to guide diagnosis, detect recurrence and distant metastasis of NPC. Until now, the importance of EBV DNA in the prediction of NPC has received little attention in non-endemic regions. To explore the prognostic value of EBV DNA alone or in combination with PNI in NPC patients from a non-endemic area of China. In this retrospective study, 493 NPC patients were enrolled. Clinical pathologic data, pre-treatment plasma EBV DNA, and laboratory tests were all performed. A standard anticancer treatment was prescribed, and follow up data were collected. EBV DNA was found to be positively related to clinical stage (r = 0.357, P < 0.001), T stage (r = 0.193, P < 0.001), N stage (r = 0.281, P < 0.001), and M stage (r = 0.215, P < 0.001). The difference in EBV DNA loads between clinical stage, T, N and M stage was statistically significant (P < 0.001). In this study, the best cutoff value for EBV-DNA to distinguish the prognosis of NPC was 262.7 copies/ml. The 5-year OS of patients in the EBV-DNA ≤ 262.7 copies/ml group and EBV-DNA > 262.7 copies/ml group was 88% and 65.3%, respectively (P < 0.001). EBV-DNA and PNI were found to be independent prognostic factors for OS in multivariate analysis (P < 0.05). EBV-DNA was independent prognostic factors for PFS. In predicting NPC patients OS, the novel combination marker of EBV DNA and PNI outperformed TNM staging (AUC: 0.709 vs. 0.675). In addition, the difference between EBV + PNI and EBV + TNM was not statistically significant for OS or PFS (P > 0.05). This novel combination biomarker was a promising biomarker for predicting NPC survival and may one day guide treatment option.

Chemotherapy for locoregionally advanced nasopharyngeal carcinoma: Who really needs it

OBJECTIVES

The CSCO and ASCO guidelines in 2021 recommend chemotherapy for stage III-IVA (8th edition of AJCC staging) nasopharyngeal carcinoma (NPC). Actually, patients with stage T3-4N0M0 are often excluded from various clinical trials of the locoregionally advanced NPC, and the survival benefit of chemotherapy in such patients has always been controversial. This study aims to explore the benefit of chemotherapy in patients with locoregionally advanced NPC, especially those with negative lymph nodes.

METHODS

A total of 2741 patients were extracted from the SEER database. After a 1:1 PSM analysis, 272 patients were obtained to further explore whether the addition of chemotherapy would achieve survival benefits.

RESULTS

After PSM, Kaplan-Meier curves showed that the overall survival (OS) of patients receiving chemoradiotherapy (p = 0.031) was higher than those receiving radiotherapy alone. Similar results were observed for cancer-specific survival (CSS). We further stratified the patients according to lymph node status and found that the addition of chemotherapy in patients with positive lymph nodes could significantly improve 5-year OS rates (58.08% vs. 43.95%; p = 0.025) and 5-year CSS rates (67.42% vs. 51.95%; p = 0.015) compared with radiotherapy alone, but there was no additional benefit of chemotherapy in patients with negative lymph nodes. For all 449 cases of T3-4N0M0 NPC, radiotherapy improved the OS rates (HR 0.293, 95% CI 0.203-0.424) and the CSS rates (HR 0.252, 95% CI 0.171-0.371) compared with no radiotherapy, while chemotherapy did not show significant survival benefit compared with no chemotherapy.

CONCLUSION

Our results reveal that stage T3-4N0M0 NPC may be exempted from chemotherapy, and use radiotherapy alone to reduce toxic and side effects. These results still need to be verified by future prospective trials.

Prognostic value of systemic inflammation response index in nasopharyngeal carcinoma with negative Epstein-Barr virus DNA

Background

Inflammatory parameters and Epstein–Barr virus (EBV) DNA status have been confirmed to be associated with prognosis in nasopharyngeal carcinoma (NPC) patients. However, there are few in-depth studies on the prognosis of NPC patients with negative EBV DNA. Our study aimed to look for inflammatory biomarkers that can identify disease progression in NPC patients with negative EBV DNA.

Methods

A total of 795 NPC patients were recruited, and ultimately 325 NPC patients with negative EBV DNA were included in this study (170 in training cohort and 155 in validation cohort). Kaplan–Meier method and log-rank test were used to analyze progression-free survival (PFS) and overall survival (OS). The multivariate analysis of Cox proportional hazards regression model was used to determine the independent prognostic factors. Receiver operating characteristic (ROC) curves were used to assess prognostic value. The logistic regression was used to evaluate the relationship between EBV DNA status and inflammatory parameters. The correlation between clinical characteristics was analyzed by the chi-squared test or the Fisher’s exact test.

Results

The optimal cutoff point for the SIRI was 1.12. The EBV DNA-negative NPC patients with high SIRI level had worse PFS and OS (all p < 0.001). In multivariate Cox proportional hazard models analysis, SIRI was an independent prognostic factor for PFS and OS (all p < 0.05), and had higher prognostic value than other indicators. Above results were found in the training cohort and confirmed in the validation cohort. In addition, EBV DNA status was not associated with any inflammatory parameters.

Conclusions

The SIRI can provide more accurate risk stratification and better prognostic prediction for NPC patients with negative EBV DNA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09942-1.

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

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

Nasopharyngeal carcinoma in children and adolescents: The EXPeRT/PARTNER diagnostic and therapeutic recommendations

Nasopharyngeal carcinoma (NPC) is a rare pediatric tumor. Collaborative studies performed over the last decades showed improved results compared to historical data, but standardized guidelines for diagnosis and management of pediatric NPC are still unavailable. This study presents a European consensus guideline for the diagnosis and treatment of pediatric NPC developed by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT). Main recommendations include induction chemotherapy with cisplatin and 5-flurouracil, concomitant chemoradiotherapy in advanced disease, and to consider maintenance treatment with interferon beta (IFN-β) for selected high-risk patients. Dose adjustments of radiotherapy based on response to induction chemotherapy may decrease the rates of long-term treatment-related complications that affect most of the survivors.

Epstein-Barr virus DNA loads in the peripheral blood cells predict the survival of locoregionally-advanced nasopharyngeal carcinoma patients

OBJECTIVE

Circulating cell-free Epstein-Barr virus (EBV) DNA has been shown to be a valuable biomarker for population screening and prognostic surveillance for nasopharyngeal carcinoma (NPC). Despite important insights into the biology of persistence, few studies have addressed the clinical significance of cell-based EBV-DNA loads in peripheral blood cells (PBCs).

METHODS

A prospective observational cohort study was conducted involving 1,063 newly diagnosed, locoregionally-advanced NPC patients at Sun Yat-sen University Cancer Center from 2005 to 2007. Cox regression analysis was conducted to identify the association of PBC EBV DNA loads to overall survival (OS) and other prognostic outcomes. Prognostic nomograms were developed based on PBC EBV DNA loads to predict survival outcomes for NPC patients.

RESULTS

After a median follow-up of 108 months, patients with higher PBC EBV-DNA loads had significantly worse OS [hazard ratio (HR) of medium, medium-high, and high vs. low were 1.50, 1.52, and 1.85 respectively; Ptrend < 0.001]. Similar results were found for progression-free survival and distant metastasis-free survival. The concordance index of the prognostic nomogram for predicting OS in the training set and validation set were 0.70 and 0.66, respectively. Our data showed that the PBC EBV DNA load was an independent and robust survival biomarker, which remained significant even after adjusting for plasma EBV DNA loads in a subset of 205 patients of the cohort (HR: 1.88; P = 0.025). Importantly, a combination of PBC EBV DNA load and plasma EBV DNA load improved the predicted OS.

CONCLUSIONS

The EBV-DNA load in PBCs may be an independent prognosis marker for NPC patients.

Whole-Tumor Histogram and Texture Imaging Features on Magnetic Resonance Imaging Combined With Epstein-Barr Virus Status to Predict Disease Progression in Patients With Nasopharyngeal Carcinoma

Purpose: We aimed to investigate whether Epstein–Barr virus (EBV) could produce differences on MRI by examining the histogram and texture imaging features. We also sought to determine the predictive value of pretreatment MRI texture analyses incorporating with EBV status for disease progression (PD) in patients with primary nasopharyngeal carcinoma (NPC).

Materials and Methods: Eighty-one patients with primary T2-T4 NPC and known EBV status who underwent contrast-enhanced MRI were included in this retrospective study. Whole-tumor-based histogram and texture features were extracted from pretreatment T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), and contrast-enhanced (CE)-T1WI images. Mann–Whitney U-tests were performed to identify the differences in histogram and texture parameters between EBV DNA-positive and EBV DNA-negative NPC images. The effects of clinical variables as well as histogram and texture features were estimated by using univariate and multivariate logistic regression analyses. Receiver operating characteristic (ROC) curve analysis was used to predict the EBV status and PD. Finally, an integrated model with the best performance was built.

Results: Of the 81 patients included, 54 had EBV DNA-positive NPC, and 27 had EBV DNA-negative NPC. Patients who were tested EBV DNA-positive had higher overall stage (P = 0.016), more lymphatic metastases (p < 0.0001), and easier distant metastases (P = 0.026) than the patients who were tested EBV DNA-negative. Tumor volume, T1WI_Skewness and T2WI_Kurtosis showed significant differences between the two groups. The combination of the three features achieved an AUC of 0.783 [95% confidence interval (CI) 0.678–0.888] with a sensitivity and specificity of 70.4 and 74.1%, respectively, in differentiating EBV DNA-positive tumors from EBV DNA-negative tumors. The combination of overall stage and tumor volume of T2WI_Kurtosis and EBV status was the most effective model for predicting PD in patients with primary NPC. The overall accuracy was 84.6%, with a sensitivity and specificity of 93.8 and 66.2%, respectively (AUC, 0.800; 95% CI 0.700–0.900).

Conclusion: This study demonstrates that MRI-based radiological features and EBV status can be used as an aid tool for the evaluation of PD, in order to develop tailored treatment targeting specific characteristics of individual patients.

Long-term monitoring of dynamic changes in plasma EBV DNA for improved prognosis prediction of nasopharyngeal carcinoma

Background

This study was performed to investigate whether long‐term monitoring of dynamic changes in plasma Epstein‐Barr virus (EBV) DNA could improve prognosis prediction of nasopharyngeal carcinoma (NPC).

Materials and methods

About 1077 nonmetastatic NPC patients were recruited to retrospectively analyze the prognostic value of plasma EBV DNA load pretreatment and 3, 12, 24, and 36 months posttreatment. We also examined the prognostic value of dynamic changes in plasma EBV DNA at various time points.

Results

Patients with plasma EBV DNA load above optimal pre‐ and posttreatment cut‐offs had significantly worse five‐year progression‐free survival, distant metastasis‐free survival, locoregional relapse‐free survival, and overall survival (OS) at all‐time points, excluding only OS at 36 months posttreatment due to limited mortalities. Patients with persistently undetectable plasma EBV DNA at the first four time points had the best prognosis, followed by those with positive detection pretreatment and consistently negative detection posttreatment, those with negative detection pretreatment and positive detection at one time point posttreatment, and those with positive detection pretreatment and at one time point posttreatment, whereas patients with positive detection at ≥2 time points posttreatment had the worst prognosis. Cox proportional hazard models identified the dynamic change pattern as an independent prognostic factor, and receiver operating characteristic curve analysis demonstrated that the dynamic change at four time point was more valuable than any single time point for predicting disease progression, distant metastasis, locoregional relapse, and mortality.

Conclusions

Dynamic changes in plasma EBV DNA pre‐ and posttreatment could predict the long‐term survival outcome and provide accurate risk stratification in NPC.

Association of Epstein-Barr virus infection with peripheral immune parameters and clinical outcome in advanced nasopharyngeal carcinoma

The purpose of this study was to investigate the association of Epstein-Barr virus (EBV) with peripheral blood immune cell counts and clinical outcomes in advanced nasopharyngeal carcinoma (NPC) patients. In a retrospective design, 146 patients with NPC at stage IV were enrolled in this study. The association of EBV status with peripheral blood immune cell counts, distant metastases, and long-term survival in patients with advanced NPC were determined. Eighty-seven (59.6%) of all patients were positive for EBV. Compared with patients with normal NK cell count, patients with lower NK cell count showed a significantly lower EBV viral load (median: 614.0 vs. 2190.0 copies/mL, P = 0.024). EBV-positive patients showed a significantly higher incidence of liver metastasis than EBV-negative patients (32.6% vs. 23.7%, P = 0.021). Multi-variant regression analysis showed that EBV infection was independently associated with liver metastasis (OR: 2.33, P = 0.043). EBV positive patients showed a significantly worse PFS (P = 0.001) and OS (P = 0.001) than EBV negative patients. Multivariate Cox regression analysis revealed that EBV infection was independently associated with a worse PFS (HR: 1.94, P = 0.003), and OS (HR: 2.12, P = 0.014) in advanced NPC. In conclusion, EBV infection is associated with a high risk of liver metastasis and is also an independent negative predictor for PFS and OS in patients with advanced NPC. EBV infection is associated with lower CD8% and higher NK%, while lower NK cell count is associated with lower EBV viral load.

Prognostic Value of Nodal Matting on MRI in Nasopharyngeal Carcinoma Patients

BACKGROUND

Nodal (N) stage is one of the most important predictors for distant metastasis in nasopharyngeal carcinoma (NPC) patients. It may ignore potentially useful nodal features, such as nodal matting (three or more lymph nodes abutting together with the absence of intervening fat planes).

PURPOSE

To explore the prognostic value of nodal matting in NPC patients and construct a nomogram with nodal matting for predicting distant metastasis-free survival (DMFS).

STUDY TYPE

Retrospective.

POPULATION

In all, 792 NPC patients treated with intensity modulated radiation therapy from 2010 to 2013 were enrolled with 2:1 training (n = 527) and validation (n = 65) cohorts.

FIELD STRENGTH/SEQUENCE

T₁ - and T₂ -weighted imaging at 1.5 or 3.0T.

ASSESSMENT

Nodal matting and other nodal characteristics were assessed with MRI. MR images were evaluated separately by three radiologists. The association between nodal matting and DMFS was analyzed.

STATISTICAL TESTS

Univariate and multivariate analyses were performed using the Cox proportional hazards regression model. Nomograms were constructed from a multivariate logistic regression model with and without nodal matting. The predictive accuracy and discriminative ability of the nomograms were determined by concordance index (C-index) and calibration curves. The results were validated using bootstrap resampling and validation cohort.

RESULTS

The incidence of nodal matting was 24.6% (195/792) in all patients. In the training cohort, nodal matting was independently associated with DMFS (hazard ratio [HR] = 1.97 [1.05-3.69], P < 0.05). N1 patients with nodal matting had worse DMFS than N1 patients without (P < 0.05). However, no significant difference was observed when comparing N1 patients with nodal matting to N2 patients (P = 0.464). The C-index of the nomogram with nodal matting was higher than the nomogram without (0.717 vs. 0.699, P = 0.084).

DATA CONCLUSION

Nodal matting was an independent prognostic factor for DMFS in NPC patients. It may help to select patients at high risk of distant metastasis.

Predicting Progression-Free Survival Using MRI-Based Radiomics for Patients With Nonmetastatic Nasopharyngeal Carcinoma

Objectives: This study aimed to explore the predictive value of MRI-based radiomic model for progression-free survival (PFS) in nonmetastatic nasopharyngeal carcinoma (NPC).

Methods: A total of 327 nonmetastatic NPC patients [training cohort (n = 230) and validation cohort (n = 97)] were enrolled. The clinical and MRI data were collected. The least absolute shrinkage selection operator (LASSO) and recursive feature elimination (RFE) were used to select radiomic features. Five models [Model 1: clinical data, Model 2: overall stage, Model 3: radiomics, Model 4: radiomics + overall stage, Model 5: radiomics + overall stage + Epstein–Barr virus (EBV) DNA] were constructed. The prognostic performances of these models were evaluated by Harrell's concordance index (C-index). The Kaplan–Meier method was applied for the survival analysis.

Results: Model 5 incorporating radiomics, overall stage, and EBV DNA yielded the highest C-indices for predicting PFS in comparison with Model 1, Model 2, Model 3, and Model 4 (training cohorts: 0.805 vs. 0.766 vs. 0.749 vs. 0.641 vs. 0.563, validation cohorts: 0.874 vs. 0.839 vs. 836 vs. 0.689 vs. 0.456). The survival curve showed that the high-risk group yielded a lower PFS than the low-risk group.

Conclusions: The model incorporating radiomics, overall stage, and EBV DNA showed better performance for predicting PFS in nonmetastatic NPC patients.

Usefulness of Hybrid PET/MRI in Clinical Evaluation of Head and Neck Cancer Patients

(1) Background: The novel hybrid of positron emission tomography/magnetic resonance (PET/MR) examination has been introduced to clinical practice. The aim of our study was to evaluate PET/MR usefulness in preoperative staging of head and neck cancer (HNC) patients (pts); (2) Methods: Thirty eight pts underwent both computed tomography (CT) and PET/MR examination, of whom 21 pts underwent surgical treatment as first-line therapy and were further included in the present study. Postsurgical tissue material was subjected to routine histopathological (HP) examination with additional evaluation of p16, human papillomavirus (HPV), Epstein-Barr virus (EBV) and Ki67 status. Agreement of clinical and pathological T staging, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of CT and PET/MR in metastatic lymph nodes detection were defined. The verification of dependences between standardized uptake value (SUV value), tumor geometrical parameters, number of metastatic lymph nodes in PET/MR and CT, biochemical parameters, Ki67 index, p16, HPV and EBV status was made with statistical analysis of obtained results; (3) Results: PET/MR is characterized by better agreement in T staging, higher specificity, sensitivity, PPV and NPV of lymph nodes evaluation than CT imaging. Significant correlations were observed between SUVmax and maximal tumor diameter from PET/MR, between SUVmean and CT tumor volume, PET/MR tumor volume, maximal tumor diameter assessed in PET/MR. Other correlations were weak and insignificant; (4) Conclusions: Hybrid PET/MR imaging is useful in preoperative staging of HNC. Further studies are needed.

The next decade of clinical trials in locoregionally advanced nasopharyngeal carcinoma

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

Relationship between pretreatment concentration of plasma Epstein-Barr virus DNA and tumor burden in nasopharyngeal carcinoma: An updated interpretation

Background

Pretreatment plasma Epstein‐Barr virus (EBV) DNA is an important tumor marker and prognostic factor in nasopharyngeal carcinoma (NPC). This study aimed to clarify the relationship between plasma EBV DNA level and tumor burden.

Materials and Methods

Pretreatment tumor burden was measured by radiologically delineated volumes, including nasopharynx tumor volume (GTVnx) and malignant nodes volume (GTVnd); pretreatment level of plasma EBV DNA was quantified by quantitative polymerase chain reaction. The relationship between natural logarithm of EBV DNA (ln‐DNA) and square root of tumor volume (sq‐GTV) was analyzed by Pearson correlation coefficient and partial correlation coefficient. Correlations in subgroups of tumor and nodal stages were also analyzed. A linear regression model was constructed to evaluate the contribution of tumor volumes to plasma EBV DNA. The prognostic effects of EBV DNA independent of tumor burden were evaluated.

Results

Two thousand two hundred and forty nine nonmetastatic NPC patients with detectable plasma EBV DNA were included in correlation analyses. Ln‐DNA showed significant correlation with sq‐GTVnx (r = 0.171) and sq‐GTVnd (r = 0.339) separately. Together, sq‐GTVnx and sq‐GTVnd could only explain 12.9% of the ln‐DNA. Tumor and nodal stages of disease could clearly influence the strength of relationship in subgroup analysis. After excluding confounding volume information, EBV DNA still can predict death and distant metastasis, but not locoregional relapse.

Conclusion

This study suggests that plasma EBV DNA is not only an index of tumor burden, but may also reflect other tumor features, such as accessibility to circulation, angiogenesis, tumor cell kinetics, metabolic activity, and metastatic potential, among others.