Prognostic stratification of patients with metastatic nasopharyngeal carcinoma using a clinical and biochemical scoring system

Risk stratification of LA-NPC during chemoradiotherapy based on clinical classification and TVRR

PURPOSE

To investigate the correlation between tumor volume reduction rate (TVRR) and prognosis in patients with diverse clinical types of nasopharyngeal carcinoma (NPC) undergoing chemoradiotherapy, thereby aptly categorizing risks and directing the personalized treatment of NPC.

MATERIALS AND METHODS

A total of 605 NPC patients with varying clinical types were enrolled in this study and subsequently segregated into six subgroups based on their clinical types and TVRR. To accentuate the efficacy of grouping, Groups 1-6 underwent clustered analysis of hazard atio (HR) values pertaining to progression-free survival (PFS), forming three risk clusters denoted as low, intermediate, and high. The log-rank test was employed to discern differences, and R 4.1.1 was utilized for cluster analysis.

RESULTS

According to survival rates, we classified the first (G2 and G4), second (G1 and G6), and third (G3 and G5) risk clusters as low-, intermediate-, and high-risk, respectively. When comparing risk stratification with the 8th edition of the TNM staging system, our classification exhibited superior predictive prognostic performance. Subgroup analysis of treatments for each risk cluster revealed that the PFS in the neoadjuvant chemotherapy (NACT) + concurrent chemoradiotherapy (CCRT) group surpassed that of the CCRT group significantly (p < 0.05).

CONCLUSION

The reliance on clinical types and TVRR facilitates risk stratification of NPC during chemoradiotherapy, providing a foundation for physicians to tailor therapeutic strategies. Moreover, the risk cluster delineated for NPC patients during the mid-term of chemoradiotherapy stands as an independent prognostic factor for progression-free survival (PFS), overall survival (OS), distantmetastasis-free survival (DMFS), and local recurrence-free (LRRFS) posttreatment. Additionally, individuals in the high-risk cluster are recommended to undergo adjuvant chemotherapy after CCRT.

Prognostic value of pre-treatment FDG PET/CT SUVmax for metastatic lesions in de novo metastatic nasopharyngeal carcinoma following chemotherapy and locoregional radiotherapy

BACKGROUND

To explore the prognostic role of FDG PET/CT maximal standard uptake values of metastatic lesions (SUVmax-M) in patients with de novo metastatic nasopharyngeal carcinoma (mNPC) following palliative chemotherapy and locoregional radiotherapy (LRRT).

METHODS

We retrospectively collected the information of 86 eligible patients between Jan 2012 and Oct 2020. All the parameters involving SUVmax and serum lactate dehydrogenase (LDH) at diagnosis were evaluated and cutoff values were determined by the maximum log-rank statistic method. The multivariate analysis was performed using Cox proportional hazards regression to identify the independent prognostic factors associated with overall survival (OS). All estimated survival rates were conducted with Kaplan-Meier method.

RESULTS

Median survival and progression time in the cohort were 38.2 and 13.9 months, respectively. The univariable analysis showed that male, number of metastatic sites ≥ 4, presence of liver, serum LDH ≥ 229, SUVmax-M ≥ 10, SUVmax-M-sum ≥ 10, and SUVmax-M-mean ≥ 8.8 were significant prognostic factors. Five variables were identified after LASSO regression and entered into the multivariate analysis. Furthermore, liver involvement (P = 0.039), elevated LDH (≥ 229) (P = 0.05) and higher SUVmax-M (≥ 10) (P = 0.004) were significantly associated with worse OS.

CONCLUSION

The high SUVmax of metastatic lesions (≥ 10), liver involvement, and elevated serum LDH (≥ 229) at diagnosis could independently predict poor survival for de novo mNPC patients treated with palliative chemotherapy following LRRT.

Management of first-line palliative chemotherapy for post-treatment metastasis after gemcitabine plus cisplatin induction chemotherapy: Gemcitabine plus cisplatin and non-gemcitabine plus cisplatin chemotherapy

BACKGROUND

To evaluate whether patients with post-treatment metastasis are suitable for GP first-line palliative chemotherapy (PCT) after undergoing GP IC.

METHODS

Seven hundred and forty-six patients with post-treatment metastasis after undergoing GP IC were eligible. Survival outcomes were compared.

RESULTS

Significant differences in survival rates were observed between patients treated with GP and non-GP chemotherapy (2-year progression-free survival [PFS]: 0.7% vs. 9.7%). We investigated survival outcomes of patients treated with GP PCT within 2 years after undergoing GP IC, treated with GP PCT 2 years after undergoing GP IC, and those of non-GP PCT patients (2-year PFS: 0.0%, 2.3%, 9.7%). However, there was no difference in the 2-year PFS between the patients that received GP PCT 2 years after undergoing GP IC and the non-GP PCT treated patients.

CONCLUSIONS

GP is not recommended for patients that have received GP IC within 2 years. Two years after undergoing GP IC, GP can be considered.

Metastatic Patterns and Prognosis of de novo Metastatic Nasopharyngeal Carcinoma in the United States

OBJECTIVE

To evaluate the distant metastatic patterns and prognostic factors for overall survival (OS) and cancer-specific survival (CSS) in de novo metastatic nasopharyngeal carcinoma (mNPC) using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patients with de novo mNPC who had been diagnosed between 2004 and 2016 were identified from the SEER database. Kaplan-Meier analysis was used to calculate OS and CSS. Log-rank tests were employed to measure survival variation among subgroups. Individual predictors of CSS and OS were examined using Cox proportional-hazards regression models in patients with de novo mNPC.

RESULTS

We evaluated 224 patients with de novo mNPC who matched our inclusion criteria. Three-year CSS and OS for the whole cohort was 29.8% and 27.9%, respectively. Univariate analysis indicated that CSS and OS were influenced by age, histology, radiotherapy, chemotherapy, and liver metastasis. Neither the number of metastatic sites nor their specific location in bone, lungs, distant lymph nodes or brain significantly affected CSS or OS. The aforementioned independent prognosticators continued to significantly influence survival following multivariate analysis. Taking distant metastasis without liver involvement as a reference, liver metastasis was associated significantly with shorter OS at a hazard ratio (HR) of 1.581 (P = .021) and CSS at a HR of 1.643 (P = .016). Older age, keratinizing squamous cell carcinoma, no chemotherapy, and no radiotherapy were also prognosticators for poor OS (P < .05). Similar results were documented for CSS (P < .05).

CONCLUSION

For patients with de novo mNPC, liver metastasis is an independent prognosticator for inferior CSS and OS.

LEVEL OF EVIDENCE

3a Laryngoscope, 131:E1130-E1138, 2021.

Identification of Potential Therapeutic Gene Markers in Nasopharyngeal Carcinoma Based on Bioinformatics Analysis

Nasopharyngeal carcinoma (NPC) is a common cancer found in the nasopharynx with high metastatic and invasive nature. Increasing evidences have identified the critical role of gene therapy in NPC treatment. Hence, this study was designed to identify specific gene markers that affected NPC progression through gene expression profile analysis. NPC‐related gene expression data set gene set enrichment (GSE)53819 were retrieved and analyzed to screen out differentially expressed genes (DEGs), followed by determination of their expression in noncancerous tissues and NPC specimens. Next, weighted gene co‐expression network analysis (WGCNA) was conducted on DEGs to obtain tumor‐associated gene modules. Genes in those modules were intersected with DEGs for gene ontology and Kyoto Encyclopedia of Genes and Genomes functional enrichment analysis. Then protein‐protein interaction network of tumor‐associated genes was constructed to select genes most closely linked to NPC. Afterward, expression of chromosome 9 open reading frame 24 (c9orf24), primary ciliary dyskinesia protein 1 (PCDP1), and leucine‐rich repeat‐containing protein 46 (LRRC46) was detected in GSE53819 and further verified in GSE12452 and GSE64634. Differential analysis on GSE53819 found that 2,173 genes were aberrantly expressed in NPC, among which 917 genes are upregulated and 1,256 genes are downregulated. WGCNA showed that genes were enriched in 17 modules and 727 genes exhibited ectopic expression in NPC and enriched in cytokine‐cytokine receptor interaction, cytochrome P450, and chemical carcinogenesis signaling pathways, among which c9orf24, PCDP1, and LRRC46 were poorly expressed in NPC. Therefore, c9orf24, PCDP1, and LRRC46 might serve as prominent diagnostic markers for NPC, which presents new insights for NPC therapy.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma is characterised by distinct geographical distribution and is particularly prevalent in east and southeast Asia. Epidemiological trends in the past decade have shown that its incidence has declined gradually but progressively, and mortality has been reduced substantially. These findings probably reflect lifestyle and environmental changes, enhanced understanding of the pathogenesis and risk factors, population screening, advancements in imaging techniques, and individualised comprehensive chemoradiotherapy strategies. In particular, plasma Epstein-Barr virus (EBV) DNA has been used for population screening, prognostication, predicting treatment response for therapeutic adaptation, and disease surveillance. Moreover, the widespread application of intensity-modulated radiotherapy and optimisation of chemotherapy strategies (induction, concurrent, adjuvant) have contributed to improved survival with reduced toxicities. Among the existing developments in novel therapeutics, immune checkpoint therapies have achieved breakthroughs for treating recurrent or metastatic disease and represent a promising future direction in nasopharyngeal carcinoma.

Baseline hemoglobin <11.0 g/dL has stronger prognostic value than anemia status in nasopharynx cancers treated with chemoradiotherapy

BACKGROUND

To retrospectively investigate the influence of pretreatment anemia and hemoglobin levels on the survival of nasopharyngeal carcinoma patients treated with concurrent chemoradiotherapy (C-CRT).

METHODS

A total of 149 nasopharyngeal carcinoma patients who received C-CRT were included. All patients had received 70 Gy to the primary tumor plus the involved lymph nodes, and 59.4 Gy and 54 Gy to the intermediate- and low-risk neck regions concurrent with 1-3 cycles of cisplatin. Patients were dichotomized into non-anemic and anemic (hemoglobin <12 g/dL (women) or <13 g/dL (men)) groups according to their pre-treatment hemoglobin measures. Receiver operating characteristic (ROC) curve analysis was utilized for accessibility of a pre-treatment hemoglobin cut-off that impacts outcomes. Potential interactions between baseline anemia status and hemoglobin measures and overall survival, locoregional progression-free survival (LRPFS), and progression-free survival were assessed.

RESULTS

Anemia was evident in 36 patients (24.1%), which was related to significantly shorter overall survival (P=0.007), LRPFS (P<0.021), and progression-free survival (P=0.003) times; all three endpoints retained significance in multivariate analyses (P<0.05, for each). A baseline hemoglobin value of 11.0 g/dL exhibited significant association with outcomes in ROC curve analysis: hemoglobin <11.0 g/dL (N=26) was linked with shorter median overall survival (P<0.001), LRPFS (P=0.004), and progression-free survival (P<0.001) times, which also retained significance for all three endpoints in multivariate analyses and suggested a stronger prognostic worth for the hemoglobin <11.0 g/dL cut-off value than the anemia status.

CONCLUSION

Pre-C-CRT hemoglobin <11.0 g/dL has a stronger prognostic worth than the anemia status with regard to LRPFS, progression-free survival, and overall survival for nasopharyngeal carcinoma patients.

Long non-coding RNA DANCR stabilizes HIF-1α and promotes metastasis by interacting with NF90/NF45 complex in nasopharyngeal carcinoma

Long noncoding RNAs (lncRNAs) play an important role in the development and progression of cancers. However, the clinical significances of lncRNAs and their functions and mechanisms in nasopharyngeal carcinoma (NPC) remain largely unclear. Methods: Quantitative RT-PCR was used to determine DANCR expression and Kaplan-Meier curves were used to evaluate its prognostic value. RNA sequencing followed by bioinformatic analysis was performed to determine the potential function of DANCR. In vitro and in vivo experiments were conducted to investigate its biological effects. DANCR-interacting proteins were identified by RNA pull-down assay followed by mass spectrometry and western blotting, and then confirmed by RNA immunoprecipitation (RIP) assays. Results: Our previous microarray analysis identified a metastasis-associated lncRNA DANCR. Here, we found that DANCR was upregulated in NPC, especially in those with lymph lode metastasis, and its upregulation could predict poor survival. We then constructed a prognostic predictive model. RNA sequencing followed by bioinformatic analysis revealed that DANCR was responsible for NPC metastasis and hypoxia phenotype. Functional studies showed that DANCR promoted NPC cell invasion and metastasis in vitro and in vivo. Further investigation suggested that DANCR could increase HIF-1α mRNA stability through interacting with the NF90/NF45 complex. Additionally, overexpression of HIF-1α in DANCR knockdown cells restored its suppressive effects on NPC cell migration and invasion. Conclusions: Taken together, our results suggest that DANCR acts as a prognostic biomarker and increases HIF-1α mRNA stability by interacting with NF90/NF45, leading to metastasis and disease progression of NPC.

Downregulation of ribophorin II suppresses tumor growth, migration, and invasion of nasopharyngeal carcinoma

Background

It has been reported that ribophorin II (RPN2) expression is increased in many cancers, but the role of RPN2 in nasopharyngeal carcinoma (NPC) remains unclear.

Patients and methods

This study found that the expression of RPN2 is increased dramatically in NPC tissues of patients compared with that in the adjacent normal tissues. This study attempted at understanding the effect of siRNA-RPN2 treatment on the migration and invasion of NPC cell lines CNE2 and HNE1.

Results

RT-PCR and Western blotting showed that RPN2 was highly expressed in CNE2 and HNE1 cells. siRNA-RPN2 treatment significantly inhibited cell viability at 24 and 48 h compared with the control group. Results of the transwell assay showed that, compared to the control groups, migration and invasion of the cells treated with siRNA-RPN2 decreased markedly. In addition, compared to the control groups, caspase-3, caspase-9, and E-cadherin expression levels increased and MMP 2 expression decreased significantly in the siRNA-RPN2-treated group. Phosphorylation of AKT and PI3K was also inhibited after siRNA-RPN2 treatment.

Conclusion

siRNA-RPN2 can effectively inhibit the invasion and migration of human NPC cells via AKT/PI3K signaling. This can serve as a novel strategy for NPC treatment.

Curcumol attenuates epithelial-mesenchymal transition of nasopharyngeal carcinoma cells via TGF-β1

The current study aimed to identify the effect and primary mechanism of Curcumol on the migration of nasopharyngeal carcinoma (NPC) cells in vitro and in vivo. Curcumol was dissolved in absolute ethyl alcohol and the experiment was performed in NPC 5–8F cells in vitro and in vivo. The effect of different concentrations of Curcumol on cell migration was determined using wound healing and Transwell assays. A cell counting kit-8 (CCK-8) assay was also performed in order to determine cell viability. Flow cytometry was used to detect the effect of Curcumol on apoptosis. The expression of epithelial-mesenchymal transition (EMT)-associated proteins and genes was evaluated by western blotting, reverse transcription-quantitative polymerase chain reaction (RT-qPCR) and ELISA. In addition, the antitumor activity of Curcumol was investigated in female BALB/C nude mice with orthotopic tumor implants. The results indicated that cell apoptosis was increased and the viability of NPC 5–8F cells was decreased following treatment with Curcumol at doses of 0.1, 0.2 and 0.4 µM/ml. The results of in vivo experiments indicated that tumor growth and weight were decreased following Curcumol administration. Furthermore, the results of western blotting and RT-qPCR demonstrated that Curcumol altered the level of E-cadherin and N-cadherin in a dose-dependent manner in vivo. Curcumol also regulated the secretion of protein markers in the serum that were associated with EMT and TGF-β1 in the 5–8F xenograft mouse model. Thus, the results indicated that Curcumol induced TGF-β1-mediated EMT arrest by regulating E-cadherin and N-cadherin, which may prevent further development of NPC.

The combination of systemic therapy and locoregional radiotherapy prolongs survival in newly diagnosed metastatic nasopharyngeal carcinoma patients

Background

The purpose of this study is to assess the role of locoregional radiotherapy (RT) when used in combination with systemic chemotherapy, for patients with newly diagnosed metastatic nasopharyngeal carcinoma (NPC), in a non-endemic region of northern China.

Methods

In total, 611 patients with NPCs were newly diagnosed between June 2011 and June 2016 following visits to our hospital; of these, 32 patients presented with metastasis at initial diagnosis. Among these 32 patients, 29 had single-organ metastasis and 3 had multiple-organ metastasis. All patients were treated with RT for local and regional disease.

Results

The median follow-up for all patients was 20 months (range 9-59 months), and median survival was not achieved (some patients had succumbed) at the time of the last follow-up. The 2-year overall survival (OS) rate was 75.2%, and 3-year OS rate was 50.1%. There was a significant difference between patients with single- and multiple-organ metastasis: 2-year OS was 67.5% for single- vs 0% for multiple-organ metastasis (p=0.039). Patients treated with intensity-modulated RT had a better prognosis than patients treated by conventional RT: 2-year OS was 76.6% for single- vs 44.4% for multiple-organ metastasis (no significant difference was found between the 2 groups, p=0.297). For patients with progression (all were with distant disease progression), the median progression time was 8 months (6-22 months), and the median survival after disease progression was 6 months (2-14 months).

Conclusion

For patients with newly diagnosed metastatic NPCs, especially with single-organ metastasis, the addition of RT to systemic chemotherapy improved survival and disease control compared with historical cohort.