The relationship between nasopharyngeal carcinoma tumor volume and TNM T-classification: a quantitative analysis

Patterns of failure in patients with nasopharyngeal cancer of Northeastern region of India: a retrospective observational study

PURPOSE

We aimed to analyze patterns of failure and disease volume-treatment outcomes in patients with Nasopharyngeal carcinoma (NPC) treated with definitive radiation with or without concurrent chemotherapy at a tertiary cancer centre in northeast India.

METHODS

From February 2018 to February 2022, 99 histopathologically proved non-metastatic NPC patients treated with curative-intent RT with or without chemotherapy were retrospectively analyzed. Locally advanced patients received neoadjuvant or adjuvant chemotherapy. The Cox proportional hazards model was used to investigate the impact of various prognostic factors on locoregional free survival (LRFS), distant metastasis free survival (DMFS), progression free survival (PFS) and overall survival (OS). The log-rank test and Kaplan-Meir curves compared outcome variables based on ROC analysis-classified tumor volume.

RESULTS

During a median follow up of 25.4 months (17.3-39.2), 35(35.4%) patients developed recurrence. Twenty-three patients developed locoregional failures, of which 11 were in-field; 12 patient showed an out-field failure. The 3-year LRFS, DMFS, PFS and OS was 71.10%, 70.90%, 64.10% and 74.10% respectively. There was statistically significant difference in LRFS according to T staging (p < 0.0001). Gross tumor volume (GTVp) and gross nodal volume (GTVn) were an independent prognostic factor for OS, PFS, LRFS and DMFS. The cut-off volumes for GTVp and GTVn for distant metastases and locoregional failure, respectively, were found to be 13 and 22.7 mL and 3.7 and 39.2 mL, respectively, by ROC curve analysis. Based on this, 99 patients were divided into three subgroups. OS demonstrated significant differences among patients in different volume subgroups for GTVp (p = 0.03) and GTVn (p = 0.00024).

CONCLUSIONS

For NPC patients who undergo curative IMRT, primary tumour and nodal volumes are independent prognostic indicators. GTVp and GTVn are highly predictive of local control, distant metastases, disease-free survival, and overall survival. This justifies their use as quantitative prognostic indicator for NPC.

Optimized Nomogram for Nasopharyngeal Carcinoma Prognosis Prediction in Younger Patients (Aged 18-59): Development and Validation

PURPOSE

To develop a nomogram model for the predicted overall survival (OS) in patients aged 18 to 59 years with nasopharyngeal carcinoma (NPC) and assess the value of the clinical application.

METHODS

In total, 1334 registers of NPC patients from 2010 to 2015 were retrieved from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox analysis were used to screen out independent risk factors affecting patients. Cox analysis predicted OS for patients with NPC at 3, 5, and 8 years. Nomogram performance was validated using the concordance index (C-index), receiver operating characteristic, calibration curve, and decision curve analysis (DCA).

RESULTS

Age, sex, race, marital, histological type, tumor size, AJCC stage, and radiotherapy were independent risk factors. The C-index of the nomogram was 0.69 [95% confidence interval (CI): 0.68-0.71] for the training set, and the C-index of the AJCC stage was 0.63 (95% CI: 0.62-0.65), both statistically significant (P < .01). The area under the curve for the nomogram at these intervals (0.755, 0.729, and 0.729, respectively) was higher than that of the AJCC stage (0.667, 0.646, and 0.646, respectively), indicating better predictive accuracy. The calibration curves revealed a high degree of agreement between the observation and the prediction. Compared to the American Joint Committee on Cancer (AJCC) stage, DCA showed better clinical utility.

CONCLUSION

The nomogram as novel predictor for nasopharyngeal carcinoma patients' survival.

The influence of tumor volume on the risk of distant metastases in head and neck squamous cell carcinomas

BACKGROUND AND PURPOSE

Distant metastases (DM) in head and neck squamous cell carcinomas (HNSCC) are in most circumstances non-curable. The TNM staging system is insufficient to predict the risk of DM. This study investigates if the DM risk can be predicted using a multivariate model including pre-treatment total tumor volume for both p16-positive oropharyngeal squamous cell carcinoma (OPSCC) and all other sites (other HNSCC).

MATERIALS AND METHODS

The study includes patients with localized pharyngeal and laryngeal squamous cell carcinomas treated with primary radiotherapy from 2008-2017 from three head and neck cancer centers. Patients were identified in the Danish Head and Neck Cancer (DAHANCA) database. Total (nodal and primary) tumor volume (Gross Tumor Volume, GTV) was extracted from local treatment planning systems. The GTV was grouped by volume (cm3) in four intervals and included in a multivariate Cox proportional hazard regression controlled for pre-selected clinical values incl. stage.

RESULTS

The study includes 2,865 patients, of which 321 (11 %) had DM post-treatment. The risk of DM was assessed in a multivariate model based on 2,751 patients (p16-positive OPSCC: 1,032; and other HNSCC: 1,719). There was a significant association between GTV and the risk of DM, and in tumor volumes ≥ 50 cm3 hazard ratios of 7.6 (2.5-23.4) for p16-positive OPSCC and 4.1 (2.3-7.2) in other HNSCC were observed.

CONCLUSION

Tumor volume is an independent risk factor for DM. The addition of total tumor volume to a predictive model is important to identify subgroups of HNSCC patients at high risk of DM.

Identification of key pathways and genes in nasopharyngeal carcinoma based on WGCNA

OBJECTIVE

We aim to identify the potential genes and signaling pathways associated with the nasopharyngeal carcinoma (NPC) prognosis using Weighted Gene Co-Expression Network Analysis (WGCNA).

METHODS

Gene Expression Omnibus (GEO) query was utilized to download two NPC mRNA microarray data. WGCNA was conducted on differentially expressed genes (DEGs) to obtain tumor-associated gene modules. Genes in core modules were intersected with DEGs for gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) functional enrichment analysis. GSE102349 dataset was devoted to identifying prognostic hub genes by survival analysis and the results were confirmed by quantitative polymerase chain reaction (qPCR).

RESULTS

Co-expression networks were built, and we detected 12 gene modules. The Brown module and Magenta module were extremely associated with NPC samples. GO functional analysis and KEGG pathway analysis was carried out to the genes in the Brown and Magenta modules. Our data indicated that DEGs in Brown module and Magenta module were correlated with the biological regulation, metabolic process, reproduction, and cellular proliferation. Twenty-six hub genes were obtained and were considered to be closely related to NPC. GSE102349 dataset was devoted to identifying prognostic hub genes by survival analysis. The expression of IL33, MPP3 and SLC16A7 in GSE102349 dataset was significantly correlated with the progression-free survival (PFS). The results of qPCR indicated a strong correlation between SLC16A7 expression and the overall survival (OS).

CONCLUSIONS

WGCNA contributed to the detection of gene modules and identification of hub genes and crucial genes. These crucial genes might be potential targets for pharmaceutic therapies with potential clinical significance.

The evolution of nasopharyngeal carcinoma staging

The prevalence of nasopharyngeal carcinoma is characterized by an unbalanced distribution: the disease is particularly prevalent in East and Southeast Asia. In this article, we review the evolution of the International Union Against Cancer/American Joint Committee on Cancer staging system for nasopharyngeal carcinoma. With the increasing using of newer imaging methods, more advanced radiotherapy techniques and systemic chemotherapy, we also discuss newer clinical features that might affect staging. Finally, we propose the future direction of staging and potential prognostic factors that have a major influence on the treatment outcomes of this disease.

Progression of understanding for the role of Epstein-Barr virus and management of nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) is very common in southern China and Southeast Asia. In regions where NPC is endemic, undifferentiated subtypes constitute most cases and are invariably associated with Epstein-Barr virus (EBV) infection, whereas the differentiated subtype is more common in other parts of the world. Undifferentiated NPC is a unique malignancy with regard to its epidemiology, etiology, and clinical presentation. Clinically, NPC is highly invasive and metastatic, but sensitive to both chemotherapy and radiotherapy (RT). Overall prognosis has dramatically improved over the past three decades because of advances in management, including the improvement of RT technology, the broader application of chemotherapy, and more accurate disease staging. Despite the excellent local control with modern RT, distant failure remains a challenging problem. Advances in molecular technology have helped to elucidate the molecular pathogenesis of NPC. This article reviews the contribution of EBV gene products to NPC pathogenesis and the current management of NPC.

The Prognostic Ability of Log Odds of Positive Lymph Nodes in Oral Cavity Squamous Cell Carcinoma

Recently, log odds of positive lymph nodes (LODDS) was proven a better prediction of outcomes than other methods in gastric cancer, pancreatic cancer, and colon cancer. However, the validity is not yet tested in oral cavity squamous cell carcinoma (OSCC). We conducted a retrospective study to compare the predictive ability of LODDS, traditional pN classification and lymph node ratio (rN) in OSCC patients.In total, 347 OSCC patients receiving surgery with or without adjuvant therapy at the time of diagnosis between 2004 and 2013 were identified from the cancer registry database of the Dalin Tzu Chi Hospital. Cox proportional hazards models were used to compare the disease-specific survival (DSS) rates for pN, rN, and LODDS after adjusting for possible confounding risk factors. The discriminatory ability of different classification systems was evaluated using the adjusted hazard ratio and Akaike information criterion (AIC) by multivariate regression model. The prediction accuracy of the model was assessed by Harrell's c-statistic.The 347 OSCC patients had a mean age of 57 years old. Among them, 322 patients (92.8%) were male and 189 patients (54.5%) were in stages III to IV. LODDS showed better discriminatory ability for patients with <5 pathological cervical metastatic nodes and those with rN < 0.2. The hypothetical T-LODDS-M staging system had higher linear trend Chi-square, lower AIC, and higher prediction accuracy compared with the American Joint Committee on Cancer (AJCC) TNM, or hypothetical T-rN-M system. After adjusting for other factors, the LODDS unfavorable group had the highest adjusted hazard ratio (HR, 5.42; 95% confidence interval [CI], 3.19-9.12) and LODDS-based model lowest AIC of 704, comparing with pN and rN-based model. The LODDS-based system had the highest prediction accuracy for 3-year DSS (Harrell's c-statistic, 0.803).In our series, LODDS shows great promise as a prognostic tool for OSCC. Compared with the AJCC pN classification and the rN classification, LODDS can stratify OSCC patients and help to identify high-risk patients missed by the other systems.

Overexpression of Wild-Type p53-Induced Phosphatase 1 Confers Poor Prognosis of Patients with Nasopharyngeal Carcinoma

This study aimed to analyze the expression, clinical significance of proto-oncogene in nasopharyngeal carcinoma and the biological effect in its cell line by siRNA targeting wild-type p53-induced phosphatase 1 (Wip1). Immunohistochemistry and western blot were respectively used to analyze Wip1 protein expression in 85 cases of nasopharyngeal cancer and normal tissues to study the relationship between Wip1 expression and clinical factors. Wip1 siRNA was transiently transfected into papillary nasopharyngeal carcinoma cell by liposome-mediated method and was detected by Quantitative real-time RT-PCR (qRT-PCR) and western blot. MTT assay, cell apoptosis, migration and invasion were also conducted as to the influence of the down-regulated expression of Wip1 that might be found on CNE2 cells biological effect. The level of Wip1 protein expression was found to be significantly higher in nasopharyngeal cancer tissue than normal tissues (P <0.05). There were significant differences between Wip1 expression and T stages, lymph node metastasis, clinical stages, tumor differentiation and radiotherapy response (P < 0.05), regardless of age, gender (P > 0.05). Meanwhile, Increased expression of Wip1 was significantly with poor overall survival time by Kaplan-Meier analysis (P < 0.05). Wip1 expression deletion determines independent risk factors for prognosis of patients with nasopharyngeal carcinoma in addition to tumor T stage, clinical stage, histological grade and lymph node metastasis outside by Cox-2 in the regression analysis (P < 0.05). qRT-PCR and Western blot showed that CNE2 cell transfected Wip1 siRNA had a lower relative expressive content than normal cell (P < 0.05). MTT assay, cell apoptosis, cell cycles demonstrated that CNE2 cell transfected Wip1 siRNA had a lower survival fraction, higher cell apoptosis, more percentage of the G0/G1 phases, significant decrease in migration and invasion, and higher P53 and P16 protein expression compared with CNE2 cell untransfected Wip1 siRNA (P < 0.05). Wip1 protein was increased in nasopharyngeal carcinoma, specifically in T stages, lymph node metastasis, clinical stages and tumor differentiation. Wip1 may involved in the biological processes of nasopharyngeal cancer cell proliferation, apoptosis, and migration and invasion by regulation P53 and P16 protein expression.

Diagnostic accuracy of sonography versus magnetic resonance imaging for primary nasopharyngeal carcinoma

OBJECTIVES

The purpose of this study was to prospectively assess the accuracy of sonography versus magnetic resonance imaging (MRI) for a diagnosis of primary nasopharyngeal carcinoma.

METHODS

A total of 150 patients suspected of having nasopharyngeal carcinoma underwent sonography and MRI. A diagnosis was obtained from an endoscopic biopsy that was collected from the suspected tumor or a normal nasopharynx. The diagnostic performance of sonography and MRI for nasopharyngeal carcinoma was evaluated by receiver operating characteristic curve analysis. The sensitivity and specificity of the two imaging methods were compared by the McNemar test.

RESULTS

Nasopharyngeal carcinoma was present in 71 of 150 patients (47.3%) and absent in 79 (52.7%). The sensitivity, specificity, and accuracy of sonography versus MRI for these cases were 90.1%, 84.8%, and 87.3% for sonography and 97.2%, 89.9%, and 93.3% for MRI, respectively. Both sonography and MRI had good diagnostic performance for nasopharyngeal carcinoma, with area under the curve values of 0.958 and 0.987, respectively. There was no significant difference in the rate of tumor detectability between sonography and MRI (P = .12), and the specificities of sonography and MRI were similar (P = .22).

CONCLUSIONS

Both sonography and MRI are useful tools for clinical screening of nasopharyngeal carcinoma. However, sonography is less expensive and easier to perform. The results of this study also suggest that nasopharyngeal sonography could be used for the initial investigation of primary cancer in patients suspected of having nasopharyngeal carcinoma.

The diagnostic accuracy of ultrasonography versus endoscopy for primary nasopharyngeal carcinoma

Objective

To compare the accuracy of ultrasonography (US) with the current clinical standard of endoscopy for a diagnosis of nasopharyngeal carcinoma (NPC).

Methods

A total of 150 patients suspected of having NPC underwent US and endoscopy. A diagnosis was obtained from an endoscopic biopsy collected from each suspected tumor and was compared with a biopsy obtained from a normal nasopharynx. The diagnostic accuracy of US and endoscopy for NPC was evaluated using receiver operating curve (ROC) analysis performed by MedCalc Software.

Results

The sensitivity, specificity, and accuracy of US versus endoscopy for this cohort were 90.1%, 84.8%, and 87.3% for US, and 88.7%, 97.5%, and 93.3% for endoscopy, respectively. Both US and endoscopy exhibited good diagnostic accuracy for NPC with area under the curve (AUC) values of 0.929 and 0.938, respectively. However, this difference was not significant (Z = 0.36, P = 0.72).

Conclusion

US is a useful tool for the detection of tumors in endoscopically suspicious nasopharynx tissues, and also for the detection of subclinical tumors in endoscopically normal nasopharynx tissues.

EMP1 inhibits nasopharyngeal cancer cell growth and metastasis through induction apoptosis and angiogenesis

This study aimed to analyze the expression, clinical significance of epithelial membrane protein-1 (EMP1) in nasopharyngeal carcinoma, and the biological effect in its cell line by EMP1 overexpression. Immunohistochemistry and Western blot were used to analyze the EMP1 protein expression in 75 cases of nasopharyngeal cancer and 31 cases of normal tissues to study the relationship between EMP1 expression and clinical factors. Recombinant lentiviral vector was constructed to overexpress EMP1 and then infect nasopharyngeal cancer CNE2 cell line. Quantitative real-time RT-PCR and Western blot were used to detect the mRNA level and protein of EMP1. MTT assay, cell apoptosis, migration, and invasion assays were also conducted to determine the influence of the upregulated expression of EMP1 that might be found on CNE2 cells' biological effect. Immunohistochemistry and Western blot: The level of EMP1 protein expression was found to be significantly lower in nasopharyngeal cancer tissue than in the normal tissues (P < 0.05). Decreased expression of EMP1 was significantly correlated with T stages, lymph node metastasis, clinic stage, and histological grade of patients with nasopharyngeal cancer (P < 0.05). Meanwhile, the loss of EMP1 expression correlated significantly with poor overall survival time by Kaplan-Meier analysis (P < 0.05). The result of biological function has shown that CNE2 cell-transfected EMP1 had a lower survival fraction, higher cell apoptosis, significant decrease in migration and invasion, higher caspase-9, and lower vascular endothelial growth factor C protein expression compared with CNE2 cell-untransfected EMP1 (P < 0.05). EMP1 expression decreased in nasopharyngeal cancer and correlated significantly T stages, lymph node metastasis, clinic stage, histological grade, and poor overall survival, suggesting that EMP1 may play important roles as a negative regulator to nasopharyngeal cancer cell.

Staging of nasopharyngeal carcinoma--the past, the present and the future

This article reviews the evolution of the International Union Against Cancer/American Joint Committee on Cancer staging system for nasopharyngeal carcinoma. With the increasing availability of newer imaging methods, more sophisticated radiotherapy techniques and rapidly evolving molecular assays, we also examine newer clinical features that might have impact on staging. A new version of the staging system taking into account of some of these factors is also proposed.

Failure patterns and survival in patients with nasopharyngeal carcinoma treated with intensity modulated radiation in Northwest China: a pilot study

Purpose

To evaluate the clinical outcomes and patterns of failure in patients with nasopharyngeal carcinoma (NPC) treated with intensity modulated radiotherapy (IMRT) in Northwest China.

Methods and materials

From January 2006 to December 2009, 138 NPC patients were treated at Xijing Hospital. Of them, 25 cases with stage I-II received IMRT only, 113 cases with stage III-IVb received IMRT plus accomplished platinum-based chemotherapy. The IMRT prescribed dose was PTV 68-74 Gy to gross disease in nasopharynx and 66-72 Gy to positive lymph nodes in 30-33 fractions, and high risk and low risk region PTV was 60-63 Gy and 50.4~56 Gy in 30~33 and 28 fractions respectively. Plasma Epstein Barr virus (EBV) DNA load was measured before treatment. The clinical toxicities, outcomes and patterns of failure were observed.

Results

The median follow up time was 23 months (range 2 to 53 months). EBV infection positive was only 15.9%. Overall disease failure developed in 36 patients, 99% belonged to stage III/IV disease. Among these, there were 26 distant metastases, 6 local recurrence, and 4 regional recurrence. The 3-year local control rate(LCR), distant metastasis-free survival (MFS), disease-free survival (DFS) and the overall survival (OS) was 93.9%, 79.5%, 70% and 83.1% respectively. Multivariate analyses revealed that age and anemia pre-radiotherapy were independent predictors for OS.

Conclusion

IMRT with or without chemotherapy can improve the long term survival of NPC patients in Northwest China. Distant metastasis becomes the main cause of treatment failure. Age and anemia before radiotherapy were the main prognosis factors of NPC patients.

Significance of primary tumor volume and T-stage on prognosis in nasopharyngeal carcinoma treated with intensity-modulated radiation therapy

OBJECTIVE

The aim of this study was to evaluate the effect of the primary tumor volume on prognosis in nasopharyngeal carcinoma treated with intensity-modulated radiation therapy.

METHODS

Between August 2003 and April 2005, 112 patients with Stage I-IVB nasopharyngeal carcinoma treated by intensity-modulated radiation therapy were included. Measurement of the primary tumor volume was based on contrast-enhanced computed tomography scans before treatment. A receiver operating characteristics curve was used to determine the best cut-off point of the primary tumor volume.

RESULTS

The mean primary tumor volume for 112 patients with nasopharyngeal carcinoma was 33.9 ± 28.7 ml. Within the framework of UICC T-staging, all patients were divided into four groups according to the primary tumor volume. We call it the volume stage (V1 <15.65 ml, V2 = 15.65-24.25 ml, V3 = 24.25-50.55 ml and V4 >50.55 ml). The 5-year overall survival rates for V1, V2, V3 and V4 were 88.5, 83.3, 82.4 and 54.5% (P = 0.014), respectively. The cumulative survival curves for V1, V2 and V3 were very close, but clearly separated from V4. In addition, Cox proportional hazards regression model analysis showed that a primary tumor volume >50 ml was an independent risk factor for radiotherapy (risk ratio = 3.485, P = 0.025).

CONCLUSIONS

This study demonstrated that the primary tumor volume had significantly impacted on the prognosis of patients with nasopharyngeal carcinoma. We proposed that the primary tumor volume should be considered as an additional stage indicator in the new revision of the clinical stage of nasopharyngeal carcinoma.

Clinical application of tumor volume in advanced nasopharyngeal carcinoma to predict outcome

BACKGROUND

Current staging systems have limited ability to adjust optimal therapy in advanced nasopharyngeal carcinoma (NPC). This study aimed to delineate the correlation between tumor volume, treatment outcome and chemotherapy cycles in advanced NPC.

METHODS

A retrospective review of 110 patients with stage III-IV NPC was performed. All patients were treated first with neoadjuvant chemotherapy, then concurrent chemoradiation, and followed by adjuvant chemotherapy as being the definitive therapy. Gross tumor volume of primary tumor plus retropharyngeal nodes (GTVprn) was calculated to be an index of treatment outcome.

RESULTS

GTVprn had a close relationship with survival and recurrence in advanced NPC. Large GTVprn (> or =13 ml) was associated with a significantly poorer local control, lower distant metastasis-free rate, and poorer survival. In patients with GTVprn > or =13 ml, overall survival was better after > or =4 cycles of chemotherapy than after less than 4 cycles.

CONCLUSIONS

The incorporation of GTVprn can provide more information to adjust treatment strategy.