[Metastatic nasopharyngeal carcinoma: clinical study and therapeutic results of 95 cases]

An Exploratory Study of Refining TNM-8 M1 Categories and Prognostic Subgroups Using Plasma EBV DNA for Previously Untreated De Novo Metastatic Nasopharyngeal Carcinoma

(1) Background: NPC patients with de novo distant metastasis appears to be a heterogeneous group who demonstrate a wide range of survival, as suggested by growing evidence. Nevertheless, the current 8th edition of TNM staging (TNM-8) grouping all these patients into the M1 category is not able to identify their survival differences. We sought to identify any anatomic and non-anatomic subgroups in this study. (2) Methods: Sixty-nine patients with treatment-naive de novo M1 NPC (training cohort) were prospectively recruited from 2007 to 2018. We performed univariable and multivariable analyses (UVA and MVA) to explore anatomic distant metastasis factors, which were significantly prognostic of overall survival (OS). Recursive partitioning analysis (RPA) with the incorporation of significant factors from MVA was then performed to derive a new set of RPA stage groups with OS segregation (Set 1 Anatomic-RPA stage groups); another run of MVA was performed with the addition of pre-treatment plasma EBV DNA. A second-round RPA with significant prognostic factors of OS identified in this round of MVA was performed again to derive another set of stage groups (Set 2 Prognostic-RPA stage groups). Both sets were then validated externally with an independent validation cohort of 67 patients with distant relapses of their initially non-metastatic NPC (rM1) after radical treatment. The performance of models in survival segregation was evaluated by the Akaike information criterion (AIC) and concordance index (C-index) under 1000 bootstrapping samples for the validation cohort; (3) Results: The 3-year OS and median follow-up in the training cohort were 36.0% and 17.8 months, respectively. Co-existence of liver-bone metastases was the only significant prognostic factor of OS in the first round UVA and MVA. Set 1 RPA based on anatomic factors that subdivide the M1 category into two groups: M1a (absence of co-existing liver-bone metastases; median OS 28.1 months) and M1b (co-existing liver-bone metastases; median OS 19.2 months, p = 0.023). When pre-treatment plasma EBV DNA was also added, it became the only significant prognostic factor in UVA (p = 0.001) and MVA (p = 0.015), while co-existing liver-bone metastases was only significant in UVA. Set 2 RPA with the incorporation of pre-treatment plasma EBV DNA yielded good segregation (M1a: EBV DNA ≤ 2500 copies/mL and M1b: EBV DNA > 2500 copies/mL; median OS 44.2 and 19.7 months, respectively, p < 0.001). Set 2 Prognostic-RPA groups (AIC: 228.1 [95% CI: 194.8−251.8] is superior to Set 1 Anatomic-RPA groups (AIC: 278.5 [254.6−301.2]) in the OS prediction (p < 0.001). Set 2 RPA groups (C-index 0.59 [95% CI: 0.54−0.67]) also performed better prediction agreement in the validation cohort (vs. Set 1: C-index 0.47 [95% CI: 0.41−0.53]) (p < 0.001); (4) Conclusions: Our Anatomic-RPA stage groups yielded good segregation for de novo M1 NPC, and prognostication was further improved by incorporating plasma EBV DNA. These new RPA stage groups for M1 NPC can be applied to countries/regions regardless of whether reliable and sensitive plasma EBV DNA assays are available or not.

Refining TNM-8 M1 categories with anatomic subgroups for previously untreated de novo metastatic nasopharyngeal carcinoma

PURPOSE

To propose a refined M1 classification in de novo metastatic nasopharyngeal carcinoma (NPC) based on pooled data from two academic institutions.

METHODS

Previously untreated de novo M1 NPC patients prospectively treated at The University of Hong Kong (N = 69) and Fujian Cancer Hospital (N = 114) between 2007 and 2016 were recruited and randomized in a 2:1 ratio to generate training (N = 120) and validation (N = 63) cohorts, respectively. Multivariable analysis (MVA) was performed for the training and validation cohorts to identify anatomic prognostic factors for overall survival (OS). Recursive partitioning analysis (RPA) was performed which incorporated the anatomic prognostic factors identified in the MVA to derive Anatomic-RPA groups which stratified OS in the training cohort, and were then validated in the validation cohort.

RESULTS

Median follow-up for the training and validation cohorts was 27.2 and 30.2 months with 3-year OS of 51.6% and 51.1%, respectively. MVA revealed that co-existing liver-bone metastases was the only factor prognostic for OS in both the training and validation cohorts. Anatomic-RPA separated M1 disease into M1a (no co-existing liver-bone metastases) and M1b (co-existing liver-bone metastases) with median OS 39.5 and 23.7 months, respectively (p = 0.004) in the training cohort. RPA for the validation cohort also confirmed good segregation with co-existing liver-bone metastases with median OS 47.7 and 16.0 months, respectively (p = 0.008).

CONCLUSION

Our proposal to subdivide de novo M1 NPC into M1a (no co-existing liver-bone metastases) vs. M1b (co-existing liver-bone metastases) provides better OS segregation.

[Metastatic nasopharynx cancer at diagnosis: clinical and prognostic (study of 51 cases)]

L’objectif de cette étude rétrospective était de détailler les différents aspects épidémiologiques, cliniques, thérapeutiques et pronostiques du cancer du cavum d'emblée métastatique dans le centre Tunisien. Il s’agit d’une étude portant sur 51 patients atteints d’un cancer du nasopharynx (CNP) histologiquement prouvé et métastatique d’emblée, soit au moment du diagnostic , colligés dans les services ORL du CHU Farhat Hached de Sousse et les services de radiothérapie du centre tunisien, à savoir du CHU Farhat Hached de Sousse, et du centre médical Ibn Khaldoun de Hammam Sousse, entre Janvier 1995 et Décembre 2010. Cinquante et un patients atteints de cancer du nasopharnx, d’emblée métastatiques ont été recensés. L’âge moyen était de 49 ans. Le Sex-Ratio était de 6,2. Les métastases osseuses étaient les plus fréquentes (94,1%), suivies par les métastases hépatiques (34,6%). Sur le plan thérapeutique, la majorité de nos patients a reçu une chimiothérapie (41 patients), dont 31 en association avec une radiothérapie. Le protocole adriamycine et cisplatine a été le plus fréquemment utilisé (92,6%). Vingt patients ont eu une radiothérapie cervicofaciale à intention curative (doses ≤ 70 Gy), quatorze autres patients ont reçu au niveau du cavum une radiothérapie à visée symptomatique ( doses de 30Gy en 10 séances) associée à une irradiation des sites métastatiques dans 9 cas. Les survies globales à 2 ans et à 5 ans étaient respectivement de 29% et de 10%. Au stade de métastases inaugurales, le cancer du cavum est une maladie grave, rapidement mortelle malgré les avancées thérapeutiques. Au vue des données de notre étude et de celles de la littérature, la chimiothérapie à base de cisplatine et la radiothérapie cervico-faciale à doses curatives et celle des métastases a permis d’obtenir de longues survies et même des réponses complètes. Les futurs essais pourraient tester de nouvelles molécules en vue d'une intensification thérapeutique.

Establishment and validation of M1 stage subdivisions for de novo metastatic nasopharyngeal carcinoma to better predict prognosis and guide treatment

BACKGROUND

To better manage patients with de novo metastatic NPC (mNPC) including easily identifying individuals' survival outcomes and accurately choosing the most suitable treatment.

MATERIALS AND METHODS

Three independent cohorts of mNPC patients (a training set of n = 462, an internal prospective validation set of n = 272 and an external prospective validation set of n = 243) were studied. The radiological characteristics of distant metastases, including number of metastatic locations, number of metastatic lesions and size of metastatic lesions, were carefully defined based on imaging data. These three factors and other potential prognostic factors were comprehensively analysed and were further integrated into new subdivisions of stage M1 using a Cox proportional hazards model.

RESULTS

We successfully subdivided the M1 stage into three categories: M1a, oligo metastasis without liver involvement; M1b, multiple metastases without liver involvement; and M1c, liver involvement irrespective of metastatic lesions. The 3-year overall survival ranged from 54.5% to 72.8%, from 34.3% to 41.6% and from 22.6.0%-23.6% for M1a, M1b and M1c, respectively (P < 0.001). Systemic chemotherapy combined with radical loco-regional radiotherapy may benefit patients in M1a and M1b, not in M1c. Further aggressive treatment of metastatic lesions based on systemic chemotherapy and definitive loco-regional radiotherapy showed no survival benefit, even for patients in M1a (P > 0.05).

CONCLUSION

The subdividing of M1 provided promising prognostic value and could aid clinicians in choosing the most suitable treatment for de novo mNPC patients.

Development of a ten-signature classifier using a support vector machine integrated approach to subdivide the M1 stage into M1a and M1b stages of nasopharyngeal carcinoma with synchronous metastases to better predict patients' survival

The aim of this study was to develop a prognostic classifier and subdivided the M1 stage for nasopharyngeal carcinoma patients with synchronous metastases (mNPC). A retrospective cohort of 347 mNPC patients was recruited between January 2000 and December 2010. Thirty hematological markers and 11 clinical characteristics were collected, and the association of these factors with overall survival (OS) was evaluated. Advanced machine learning schemes of a support vector machine (SVM) were used to select a subset of highly informative factors and to construct a prognostic model (mNPC-SVM). The mNPC-SVM classifier identified ten informative variables, including three clinical indexes and seven hematological markers. The median survival time for low-risk patients (M1a) as identified by the mNPC-SVM classifier was 38.0 months, and survival time was dramatically reduced to 13.8 months for high-risk patients (M1b) (P < 0.001). Multivariate adjustment using prognostic factors revealed that the mNPC-SVM classifier remained a powerful predictor of OS (M1a vs. M1b, hazard ratio, 3.45; 95% CI, 2.59 to 4.60, P < 0.001). Moreover, combination treatment of systemic chemotherapy and loco-regional radiotherapy was associated with significantly better survival outcomes than chemotherapy alone (the 5-year OS, 47.0% vs. 10.0%, P < 0.001) in the M1a subgroup but not in the M1b subgroup (12.0% vs. 3.0%, P = 0.101). These findings were validated by a separate cohort. In conclusion, the newly developed mNPC-SVM classifier led to more precise risk definitions that offer a promising subdivision of the M1 stage and individualized selection for future therapeutic regimens in mNPC patients.

Combined CT-guided radiofrequency ablation with systemic chemotherapy improves the survival for nasopharyngeal carcinoma with oligometastasis in liver: Propensity score matching analysis

The aim of this study was to retrospectively compare the treatment efficacy of systemic chemotherapy combined with sequential CT-guided radiofrequency ablation (Chemo-RFA) to chemotherapy alone (Chemo-only) in the management of nasopharyngeal carcinoma (NPC) with liver metastasis. Between 2003 and 2011, 328 NPC patients diagnosed with liver metastasis at Sun Yat-sen University Cancer Center were enrolled. One-to-one matched pairs between Chemo-RFA group with the Chemo-only group were generated using propensity score matching. The associations of treatment modality with overall survival (OS) and progression-free survival (PFS) were determined by Cox regression. Of the patients enrolled, 37 patients (11.8 %) received combined treatment, 291 (82.2) received chemotherapy alone. The patients in Chemo-RFA group were more frequently classified as lower number (≤3) of liver metastatic lesions (P<0.001), had lower rates of bi-lobar liver metastasis (P<0.001) and extra-hepatic metastasis (P<0.001) than patients in Chemo-only group. After propensity score matching, 37 pairs of well-matched liver metastatic NPC patients were selected from different treatment groups. The adjusted hazard ratio in OS and PFS of the choice for Chemo-RFA approach to Chemo-only was 0.53 (95%CI, 0.30-0.93) and 0.60 (95%CI, 0.36-0.97), respectively. In conclusion, combined CT-guided RFA and chemotherapy approach offer the chance of improved survival for NPC patients with oligometastasis in liver, and should be considered if the ablation is technically feasible.

Overexpression of the PSAT1 Gene in Nasopharyngeal Carcinoma Is an Indicator of Poor Prognosis

Purpose: Nasopharyngeal carcinoma (NPC) is a common cancer in southern China and Southeast Asia, but risk stratification and treatment outcome in NPC patients remain suboptimal. Our study identified and validated metabolic drivers that are relevant to the pathogenesis of NPC using a published transcriptome. Phosphoserine aminotransferase 1 (PSAT1) is an enzyme that is involved in serine biosynthesis, and its overexpression is associated with colon cancer, non-small cell lung cancer and breast cancer. However, its expression has not been systemically evaluated in patients with NPC.

Materials and Methods: We evaluated two public transcriptomes of NPC tissues and benign nasopharyngeal mucosal epithelial tissues that deposited in the NIH Gene Expression Omnibus database under accession number GSE34574 and GSE12452. We also performed immunohistochemical staining and assessment of PSAT1 in a total of 124 NPC patients received radiotherapy and were regularly followed-up until death or loss. The endpoints analyzed were local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease-specific survival (DSS), and overall survival (OS).

Results: We retrospectively evaluated 124 patients with NPC and found that high PSAT1 expression was associated with poor prognosis of NPC and indicator of advanced tumor stage. High PSAT1 expression also correlated with an aggressive clinical course, with significantly shorter DSS (HR= 2.856, 95% CI 1.599 to 5.101), DMFS (HR= 3.305, 95% CI 1.720 to 6.347), LRFS (HR= 2.834, 95% CI 1.376 to 5.835), and OS HR= 2.935, 95% CI 1.646-5.234) in multivariate analyses.

Conclusions: Our study showed that PSAT1 is a potential prognostic biomarker and higher expression of PSAT1 is associated with a poor prognosis in NPC.

Prognostic factors on overall survival of newly diagnosed metastatic nasopharyngeal carcinoma

BACKGROUND

To investigate factors associated with overall survival in patients with newly diagnosed metastatic nasopharyngeal carcinoma.

MATERIALS AND METHODS

Two hundred and two consecutive patients with pathologically confirmed nasopharyngeal carcinoma with distant metastasis at diagnosis seen between December 2007 and May 2011 were reviewed. Patient, tumor and treatment factors were analyzed for their significance regarding overall survival.

RESULTS

The median follow-up time was 22 months. At the time of this report, 116 patients had died. For 112 patients, cause of death was nasopharyngeal carcinoma. The 1, 2, 3, and 4-year overall survival rates were 75.6%, 50.2%, 39.2%, and 28.2%, respectively. Cox regression multivariate analysis showed that T-stage (p=0.045), N-stage (p=0.014), metastasis number (p<0.001) and radiotherapy for nasopharynx and neck (p<0.001) were significant factors for overall survival.

CONCLUSIONS

Early T-stage and N-stage, solitary metastasis in a single organ were good prognostic factors for patients with newly diagnosed metastatic nasopharyngeal carcinoma. Radiotherapy should be strongly recommended in systemic treatment.

Partial hepatectomy for liver metastases from nasopharyngeal carcinoma: a comparative study and review of the literature

BACKGROUND

The management of liver metastases from nasopharyngeal carcinoma (NPC) has not been extensively investigated. This study aimed to compare the long-term outcome of patients with liver metastases from NPC who were treated by a partial hepatectomy or transcatheter hepatic artery chemoembolization (TACE).

METHODS

Between January 1993 and December 2010, 830 patients were diagnosed with liver metastases from NPC and exhibited a complete response to the primary cancer of the nasopharynx and regional lymph nodes. Fifteen patients with intrahepatic metastasis underwent R0 partial hepatectomy. As a parallel control group, another 15 patients with a resectable liver metastasis who underwent TACE were selected. Prior to the resection and TACE that were performed on patients in these two groups, radical radiotherapy with or without adjuvant chemotherapy was administered. Clinicopathological data and treatment outcomes were compared retrospectively.

RESULTS

No significant differences were observed between the two groups in terms of the clinicopathological features, which include gender ratio, liver function, accompanying cirrhosis, rate of infection with the hepatitis B virus, tumor size, tumor number, pathological type and preoperative comorbidities. The 1-, 3- and 5-year overall survival rates from the time of hepatectomy were 85.7%, 64.2% and 40.2%, respectively, with a median survival of 45.2 months, whereas the 1-, 3- and 5-year overall survival rates were 53.3%, 26.6% and 20.0% for patients in the control group (P = 0.039), respectively, with a median survival of 14.1 months. The actuarial median progression-free survival (PFS) of the patients in the resection group was 21.2 months, and the 1-, 3- and 5-year PFS rates were 70%, 53% and 18%, respectively. In the control group, the 1-, 3- and 5-year PFS rates were 27%, 7% and 0.0% (P = 0.007), respectively, with a median survival of 4.2 months. Thus far, 5 patients have survived for more than 5 years, and the longest survival time is 168.1 months.

CONCLUSIONS

For patients with limited liver metastases from NPC, hepatectomy provides a survival advantage over TACE. Due to the limited treatment options for patients with liver metastasis from NPC, hepatectomy should be recommended as an optimal treatment. Moreover, perioperative chemotherapy may be associated with an improved prognosis.

Prognosticators and risk grouping in patients with lung metastasis from nasopharyngeal carcinoma: a more accurate and appropriate assessment of prognosis

Background

Lung metastases arising from nasopharyngeal carcinomas (NPC) have a relatively favourable prognosis. The purpose of this study was to identify the prognostic factors and to establish a risk grouping in patients with lung metastases from NPC.

Methods

A total of 198 patients who developed lung metastases from NPC after primary therapy were retrospectively recruited from January 1982 to December 2000. Univariate and multivariate analyses of clinical variables were performed using Cox proportional hazards regression models. Actuarial survival rates were plotted against time using the Kaplan-Meier method, and log-rank testing was used to compare the differences between the curves.

Results

The median overall survival (OS) period and the lung metastasis survival (LMS) period were 51.5 and 20.9 months, respectively. After univariate and multivariate analyses of the clinical variables, age, T classification, N classification, site of metastases, secondary metastases and disease-free interval (DFI) correlated with OS, whereas age, VCA-IgA titre, number of metastases and secondary metastases were related to LMS. The prognoses of the low- (score 0-1), intermediate- (score 2-3) and high-risk (score 4-8) subsets based on these factors were significantly different. The 3-, 5- and 10-year survival rates of the low-, intermediate- and high-risk subsets, respectively (P < 0.001) were as follows: 77.3%, 60% and 59%; 52.3%, 30% and 27.8%; and 20.5%, 7% and 0%.

Conclusions

In this study, clinical variables provided prognostic indicators of survival in NPC patients with lung metastases. Risk subsets would help in a more accurate assessment of a patient's prognosis in the clinical setting and could facilitate the establishment of patient-tailored medical strategies and supports.

Factors determining the survival of nasopharyngeal carcinoma with lung metastasis alone: does combined modality treatment benefit?

Background

Nasopharyngeal carcinoma (NPC) with lung metastasis alone has been reported as a relatively favorable prognostic group, and combined modality treatment might be indicated for selected cases. However, the prognostic factors determining survival of this group and the indication of combined therapy have not been thoroughly studied.

Methods

We retrospectively reviewed 246 patients of NPC with lung metastasis(es) alone presented at diagnosis or as the first failure after primary treatment from 1993 to 2008 in an academic tertiary hospital. Univariate and multivariate survival analyses of post-metastasis survival (PMS) and overall survival (OS) were carried out to determine the prognostic factors.

Results

The 3-year, 5-year, and 10-year of PMS and OS for the whole cohort were 34.3%, 17.0%, 8.6% and 67.8%, 45.4%, 18.5%, respectively. The median PMS (45.6 months vs. 23.7 months) and OS (73.7 months vs. 46.2 months) of patients treated with combined therapy was significantly longer than that of those treated with chemotherapy alone (P < 0.001). Age, disease-free interval (DFI) and treatment modality were evaluated as independent prognostic factors of OS, while only age and treatment modality retain their independent significance in PMS analysis. In stratified survival analysis, compared to chemotherapy alone, combined therapy could benefit the patients with DFI > 1 year, but not those with DFI ≤ 1 year.

Conclusions

Age ≤ 45 years, DFI > 1 year, and the combined therapy were good prognostic factors for NPC patients with lung metastasis(es) alone. The combination of local therapy and the basic chemotherapy should be considered for these patients with DFI > 1 year.

Expression de c-kit dans les carcinomes nasopharyngés nord africains, corrélations avec l'âge et LMP1

PURPOSE

To determine the level and prognostic significance of c-kit expression in the two age groups of North African nasopharyngeal carcinomas.

PATIENTS AND METHODS

A retrospective study of 99 NPC specimens from Tunisian patients was investigated by immunohistochemistry. Immunohistochemical data were correlated with Epstein-Barr virus LMP1 expression and pathological, clinical and survival parameters.

RESULTS

c-kit was detected in 79% of the cases for patients under 30 years of age (juvenile form) but in only 56% of specimens in patients over 30 years (P=0.039) and was significantly over-expressed for patients with lymph node involvement (P=0.015). LMP1 score was 5.78 (+/-1.84) for c-kit negative tumors compared to 8,23 (+/-2.39) for c-kit positive tumors (P=0.002). Multivariate analysis including age, lymph nodes involvement and LMP1 expression as co-variables, showed that only age (P=0.027) and LMP1 expression (P=0.005) were significantly correlated to the c-kit expression.

CONCLUSION

c-kit is highly expressed in the juvenile form of North African nasopharyngeal carcinomas. There is a significant association between LMP1 and c-kit expression. The contrasted levels of C-kit expression in the two age groups strengthen the hypothesis that these clinical forms result from distinct oncogenic mechanisms.

Prognostic factors in metastatic nasopharyngeal carcinoma

BACKGROUND

The current retrospective study aimed to identify some determinants of survival in metastatic NPC.

METHODS

The study concerned 95 patients with metastatic nasopharyngeal carcinoma treated between 1993 and 2001. Statistical comparison between patients subgroups survival was carried out employing the log-Rank test (statistical significance was defined as p<or=0.05). Multivariable analysis was performed using the Cox model (p<or=0.05 was used as the cut-off value of statistical significance). Factors that were considered included: age group(<or=45 years or>45 years and<or=25 years or>25 years), gender, performance status at diagnosis of metastatic disease (PS 0-1 or 2-3), time of metastasis diagnosis(at presentation or later), number of metastatic sites (single or multiple), specific metastatic sites(bone, liver, lung, distant nodes), number of bone metastasis (single or multiple), disease free survival (DFI) (<or= or >6 months), prior chemotherapy, radiotherapy of metastatic sites.

RESULTS

Negative prognostic factors in univariate analysis were: poor PS (>or=1), multiple metastatic sites, multiple bone metastasis, previous chemotherapy, visceral or node metastasis and non irradiated metastasis. Poor PS, multiple metastatic sites, and prior chemotherapy were independently significant negative prognostic factors in multivariable analysis.

CONCLUSIONS

In this study we identified new prognostic factors in univariate and multivariate analysis. A regular and careful follow-up of patients treated for NPC is then recommended in order to detect early metastatic dissemination (with minimal localizations) while patients have still a good PS.

Brachytherapy for primary and recurrent nasopharyngeal carcinoma: treatment techniques and results

PURPOSE

Nasopharyngeal cancer is the commonest head and neck cancer in Tunisia treated with radiotherapy. A dose effect relationship is established in this tumor. The aim of this study is to describe our Low-dose-rate endocavitary brachytherapy using a personalized mold called Tunis applicator.

PATIENTS AND METHODS

Seven patients (4 males and 3 females) with histologically confirmed undifferentiated nasopharyngeal carcinoma (UCNT) were treated between 2002 and 2005. Five patients with primary cancer and 2 with recurrent disease received external beam radiation followed by endocavitary brachytherapy. The mean applied dose of endocavitary brachytherapy was 5.5 Gy for primary site after external beam radiation (70-74 Gy) and 30 Gy for recurrent disease after external beam radiation (38 Gy). We have developed a personalized applicator with a balloon to optimize the placement of sources and a better conformity using the computer tomography scanning. Critical normal structures were identified on orthogonal radiographs and the dose was optimized to avoid excessive doses to these structures.

RESULTS

With a follow up of 18 months (8-41), only one local failure was observed, 3 years after external beam radiation therapy for a recurrent disease. Moderate grade mucositis was seen in most patients. One patient was diagnosed with bulb necrosis.

CONCLUSION

Endobrachytherapy can provide effective treatment for nasopharyngeal carcinoma with an easy application of the brachytherapy procedure.