Treatment outcomes and late complications of 849 patients with nasopharyngeal carcinoma treated with radiotherapy alone

A nomogram based on circulating CD8+ T cell and platelet-to-lymphocyte ratio to predict overall survival of patients with locally advanced nasopharyngeal carcinoma

PURPOSE

To explore the influence of circulating lymphocyte subsets, serum markers, clinical factors, and their impact on overall survival (OS) in locally advanced nasopharyngeal carcinoma (LA-NPC). Additionally, to construct a nomogram predicting OS for LA-NPC patients using independent prognostic factors.

METHODS

A total of 530 patients with LA-NPC were included in this study. In the training cohort, Cox regression analysis was utilized to identify independent prognostic factors, which were then integrated into the nomogram. The concordance index (C-index) was calculated for both training and validation cohorts. Schoenfeld residual analysis, calibration curves, and decision curve analysis (DCA) were employed to evaluate the nomogram. Kaplan-Meier methods was performed based on risk stratification using the nomogram.

RESULTS

A total of 530 LA-NPC patients were included. Multivariate Cox regression analysis revealed that the circulating CD8+T cell, platelet-to-lymphocyte ratio (PLR), lactate dehydrogenase (LDH), albumin (ALB), gender, and clinical stage were independent prognostic factors for LA-NPC (p < 0.05). Schoenfeld residual analysis indicated overall satisfaction of the proportional hazards assumption for the Cox regression model. The C-index of the nomogram was 0.724 (95% CI: 0.669-0.779) for the training cohort and 0.718 (95% CI: 0.636-0.800) for the validation cohort. Calibration curves demonstrated good correlation between the model and actual survival outcomes. DCA confirmed the clinical utility enhancement of the nomogram over the TNM staging system. Significant differences were observed in OS among different risk stratifications.

CONCLUSION

Circulating CD8+ T cell, PLR, LDH, ALB, gender and clinical stage are independent prognostic factors for LA-NPC. The nomogram and risk stratification constructed in this study effectively predict OS in LA-NPC.

Interconnected influences of tumour and host microbiota on treatment response and side effects in nasopharyngeal cancer

This study elucidates the intricate relationship between nasopharyngeal carcinoma (NPC), a significant malignancy predominant in Asia with notable global incidence and mortality rates, and the host microbiota, including those of tumour, nasal, nasopharyngeal, oral, oropharyngeal, and gut communities. It underscores how the composition and diversity of microbiota are altered in NPC, delving into their implications for disease pathogenesis, treatment response, and the side effects of therapies. A consistent reduction in alpha diversity across oral, nasal, and gut microbiomes in NPC patients compared to healthy individuals signals a distinct microbial signature indicative of the diseased state. The study also shows unique microbial changes tied to different NPC stages, indicating a dynamic interplay between disease progression and microbiota composition. Patients with specific microbial profiles exhibit varied responses to chemotherapy and immunotherapy, underscoring the potential for treatment personalisation based on microbiota analysis. Furthermore, the side effects of NPC treatments, such as oral mucositis, are intensified by shifts in microbial communities, suggesting a direct link between microbiota composition and treatment tolerance. This nexus offers opportunities for interventions aimed at modulating the microbiota to alleviate side effects, improve quality of life, and potentially enhance treatment efficacy. Highlighting the dual potential of microbiota as both a therapeutic target and a biomarker for NPC, this review emphasises its significance in influencing treatment outcomes and side effects, heralding a new era in NPC management through personalised treatment strategies and innovative approaches.

Post-radiation middle ear effusion in NPC patients: Analysis of patient, tumour, and radiation factors

OBJECTIVE

The purpose of this study was to investigate whether patient, tumour and radiation therapy factors are associated with development of middle ear effusion (MEE) in nasopharyngeal carcinoma (NPC) patients.

DEIGN, SETTINGS, AND PARTICIPANTS

A retrospective review of NPC patients treated between January 2000 and June 2018 at Rabin Medical Center. Patient factors, tumour factors, radiation doses, and radiation fields were collected and outlined if needed (middle ear, eustachian tube [ET], tensor veli palatini [TVP], and levator palatini [LVP] muscles), then analysed and compared between patients with MEE and those without and between sides in patients with unilateral MEE.

MAIN OUTCOME MEASURES AND RESULTS

Seventy-three patients were enrolled. Most were males (71.2%) with advanced-stage diseases (78%). At the time of diagnosis 14 patients (19.2%) presented with MEE. Following radiation, 18 patients, with no evidence of MEE at presentation, developed MEE. Tumour stage, histology, and laterality were not associated with development of MEE. Comparison of mean radiation field dosages including-gross target volume, clinical target volume, and patient target volume showed no association with post-radiation MEE. In addition, no difference was found in the radiation doses to the middle ear, ET or the LVP nor the TVP between ears with and without MEE.

CONCLUSIONS

Post-irradiation MEE remains a common adverse effect in NPC patients. Surprisingly, tumour stage, tumour laterality, and histology were not associated with MEE. Similar findings were observed for total radiation doses and specific doses to the middle ear, ET, and ET muscles.

Rehabilitation strategies for trismus post oral cancer treatment: Progress in the study of mouth opening exercises

Oral cancer is a significant public health issue worldwide. Although its treatment methods effectively control tumor growth, they can lead to complications, including Trismus, severely affecting patients' quality of life. The practice standards for mouth opening exercises, a rehabilitative method to prevent and treat Trismus, are not yet clear. Therefore, this article aims to review the research progress of mouth opening exercises in the rehabilitation of Trismus post oral cancer treatment, providing a scientific and effective rehabilitation plan for oral cancer patients to improve their quality of life.

Improvement in Swallowing Function in Patients with Previous Irradiation for Nasopharyngeal Carcinoma by Expiratory Muscle Strength Training

Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8 weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy

Background

Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy.

Methods

Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire.

Results

Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group.

Conclusion

Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations.

Level of evidence

1B.

High-Density Surface Electromyography for Swallowing Evaluation in Post-Radiation Dysphagia

OBJECTIVES

Our study aimed to investigate the feasibility of using high-density surface electromyography (HD-sEMG) for swallowing assessment by comparing the quantitative parameters and topographic patterns of HD-sEMG between post-irradiated patients and healthy individuals.

METHODS

Ten healthy volunteers and ten post-irradiated nasopharyngeal carcinoma patients were recruited. 96-channel HD-sEMG was recorded although each participant consumed different consistencies of food (thin and thick liquid, puree, congee, and soft rice). Dynamic topography was generated from the root mean square (RMS) of the HD-sEMG signals to illustrate the anterior neck muscle function in the swallowing process. The averaged power of muscles and the symmetry of swallowing patterns were assessed by objective parameters including average RMS, Left/Right Energy Ratio, and Left/Right Energy Difference.

RESULTS

The study showed different swallowing patterns between patients with dysphagia and healthy individuals. The mean RMS values were higher in the patient group compared to the healthy group, but the difference was not statistically significant. Asymmetrical patterns were shown in patients with dysphagia.

CONCLUSION

HD-sEMG is a promising technique that could be used to quantitatively evaluate the average power of neck muscles and the symmetry of swallowing activities in patients with swallowing difficulties.

LEVEL OF EVIDENCE

Level 3 Laryngoscope, 133:2920-2928, 2023.

Nutritional status and its correlation to prognosis of nasopharyngeal carcinoma patients in different ages in China: a multicenter cohort study

Nasopharyngeal carcinoma (NPC) patients usually presented malnutrition under chemoradiotherapy (CRT)/radiotherapy (RT). Few studies stratified by age to investigate the association of nutritional status with overall survival (OS) in NPC patients. This study aimed to explore the nutritional parameters related prognosis of NPC patients in different age. The total 1365 NPC patients were classified into young (18~45), middle-aged (46~60), and old groups (> 60). PG-SGA scores, NRS-2002 scores, Karnofsky performance status scores, anthropometric, and blood indicators (albumin, prealbumin, transferrin, C-reactive protein, hemoglobin, and total lymphocyte) were assessed. Cox regression analysis was performed to evaluate the association between risk factors of nutritional status and the overall survival in different age group of NPC patients. Kaplan-Meier (KM) survival analysis was used to estimate the effect of nutritional indexes on prognosis. The abnormal rate of albumin, prealbumin, hemoglobin, hand grip strength, and calf circumference increased with age. The malnutrition occurred in all age group and low calf circumference (HR, 4.427, 1.167-16.791) was an independent death risk in young adults. Distant metastasis (HR, 4.754, 2.737-8.260), low albumin (HR, 3.530, 1.708-7.296), hand grip strength (HR, 1.901, 1.160-3.115), and the nutritional intervention requirement (NRS-2002 ≥ 3) (HR, 2.802, 1.211-6.483) was significantly correlated with poor OS in NPC patients with middled age adults. Distant metastasis (HR, 2.546, 1.497-4.330), low albumin (HR, 1.824, 0.949-3.507), low hemoglobin (HR, 1.757, 1.015-3.044), low hand grip strength (HR, 1.771, 1.112-2.818), and low calf circumference (HR, 1.951, 1.074-3.545) were associated with increased risk of death in the elderly. KM analysis indicated that over 60 years, distant metastasis, low albumin, low hand grip strength, low calf circumference, and malnutritional risk (NRS-2002 ≥ 3) were correlated to prognosis of NPC patients. Low calf circumference could be a prognosis not only in elderly but also in young adults of NPC patients, whereas low albumin and distant metastasis were the prognostic factors in middle-aged and elderly patients. Patients aged over 60 years exhibited poorer OS compared with young and middle-aged adults.

The application of 3-dimensional magnetic resonance imaging in nasopharyngeal carcinoma with pterygopalatine fossa invasion

OBJECT

The pterygopalatine fossa (PPF) is a covert neurovascular pathway in the skull base and connects with numerous intracranial and extracranial spaces. The aim of this study was to explore the magnetic resonance imaging (MRI) features of PPF invasion in patients with nasopharyngeal carcinoma (NPC).

MATERIAL AND METHODS

The medical records of 88 patients with stage T3 or T4 NPC were retrospectively analyzed. The 3-Dimensional (3D) volumetric images of MRI were reconstructed for the tiny connecting conduits of the invaded PPFs in the NPC patients. The infiltration incidence of conduits and connected further structures were calculated.

RESULTS

Forty-six PPFs from 37 patients were invaded by NPC. The proportions of stage T4 NPC and intracranial extension were higher in patients with PPF invasion than that without PPF invasion (P < 0.05). Each connecting conduit of the PPF had corresponding optimal reconstructed orientation based on 3D volumetric MRI images. The first three most common infiltrated conduits were palatovaginal canal, vidian canal and sphenopalatine foramen, which were adjacent to the nasopharynx. Among the conduits connecting with further structures, the most common infiltrated conduit was pterygomaxillary fissure, followed by foramen rotundum and inferior orbital fissure. Furthermore, The NPC lesions involved stage T4 structures via the conduits from 19.6% of the invaded PPFs.

CONCLUSIONS

The application of high-quality reconstruction images based on 3D sequence of MRI in NPC patients proved to be feasible and beneficial for the manifestation of the invaded PPFs and connecting conduits.

Comprehensive and clinically accurate head and neck cancer organs-at-risk delineation on a multi-institutional study

Accurate organ-at-risk (OAR) segmentation is critical to reduce radiotherapy complications. Consensus guidelines recommend delineating over 40 OARs in the head-and-neck (H&N). However, prohibitive labor costs cause most institutions to delineate a substantially smaller subset of OARs, neglecting the dose distributions of other OARs. Here, we present an automated and highly effective stratified OAR segmentation (SOARS) system using deep learning that precisely delineates a comprehensive set of 42 H&N OARs. We train SOARS using 176 patients from an internal institution and independently evaluate it on 1327 external patients across six different institutions. It consistently outperforms other state-of-the-art methods by at least 3-5% in Dice score for each institutional evaluation (up to 36% relative distance error reduction). Crucially, multi-user studies demonstrate that 98% of SOARS predictions need only minor or no revisions to achieve clinical acceptance (reducing workloads by 90%). Moreover, segmentation and dosimetric accuracy are within or smaller than the inter-user variation.

Acute radiation dermatitis among patients with nasopharyngeal carcinoma treated with proton beam therapy: Prognostic factors and treatment outcomes

A high incidence of severe acute radiation dermatitis (ARD) has been reported for cancer patients treated by proton beam therapy (PBT). This observational study investigated the prognostic factors and treatment outcomes of ARD among patients with nasopharyngeal carcinoma (NPC) treated with PBT. Fifty-seven patients with newly diagnosed NPC and treated with PBT were enrolled. ARD was recorded weekly based on the criteria of Common Terminology Criteria for Adverse Events version 4.0 at treatment visits (1st to 7th weeks) and 1 week (8th week) and 1 month (11th week) after the completion of PBT. The maximum ARD grade was 1, 2, and 3 in 26 (45.6%), 24 (42.1%), and 7 (12.3%) of the patients, respectively. The peak incidence of grade 2 and 3 ARD was observed during the period of the 6th to 8th weeks. Treatment of ARD included topical corticosteroid alone in 24 (42.1%) patients, topical corticosteroid plus silver sulfadiazine in 33 (57.9%) patients, and non-adhering silicone dressing to cover severe skin wound area in 25 (43.8%) patients. In the 11th week, most grade 2 and 3 ARD had disappeared and 93.0% of the patients had ARD of grade 1 or lower. In the binary logistic regression model, we identified habitual smoking (odds ratio [OR]: 5.2, 95% confidence interval [CI]: 1.3-18.8, P = .012) and N2 to N3 nodal status (OR: 4.9, 95% CI: 1.6-15.4, P = .006) as independent predictors of grade 2 and 3 ARD. The results show ARD is a major concern for patients with NPC treated with PBT, especially those with habitual smoking or advanced nodal status. Topical corticosteroid, silver sulfadiazine, and non-adhering silicone dressing are effective for treating ARD induced by PBT.

Prognostic value of cervical nodal necrosis on staging imaging of nasopharyngeal carcinoma in era of intensity-modulated radiotherapy: a systematic review and meta-analysis

Purposes

To systematically review and perform meta-analysis to evaluate the prognostic value of cervical nodal necrosis (CNN) on the staging computed tomography/magnetic resonance imaging (MRI) of nasopharyngeal carcinoma (NPC) in era of intensity-modulated radiotherapy.

Methods

Literature search through PubMed, EMBASE, and Cochrane Library was conducted. The hazard ratios (HRs) with 95% confidence intervals (CIs) of CNN for distant metastasis-free survival (DMFS), disease free survival (DFS) and overall survival (OS) were extracted from the eligible studies and meta-analysis was performed to evaluate the pooled HRs with 95%CI.

Results

Nine studies, which investigated the prognostic values of 6 CNN patterns on MRI were included. Six/9 studies were eligible for meta-analysis, which investigated the CNN presence/absence in any nodal group among 4359 patients. The pooled unadjusted HRs showed that the CNN presence predicted poor DMFS (HR =1.89, 95%CI =1.72-2.08), DFS (HR =1.57, 95%CI =1.08-2.26), and OS (HR =1.87, 95%CI =1.69-2.06). The pooled adjusted HRs also showed the consistent results for DMFS (HR =1.34, 95%CI =1.17-1.54), DFS (HR =1.30, 95%CI =1.08-1.56), and OS (HR =1.61, 95%CI =1.27-2.04). Results shown in the other studies analysing different CNN patterns indicated the high grade of CNN predicted poor outcome, but meta-analysis was unable to perform because of the heterogeneity of the analysed CNN patterns.

Conclusion

The CNN observed on the staging MRI is a negative factor for NPC outcome, suggesting that the inclusion of CNN is important in the future survival analysis. However, whether and how should CNN be included in the staging system warrant further evaluation.

Effects of 3-Methyladenine on Microglia Autophagy and Neuronal Apoptosis After Radiation-Induced Brain Injury

Objective

To determine the effect of the autophagy inhibitor, 3-methyladenine (3-MA), on cognitive function changes, microglia activity, neuronal apoptosis, and inflammation in rats following radiation-induced brain injury.

Methods

The following groups were established: control, model, and 3-MA. A rat model of radiation-induced brain injury was generated with a medium dose of X-rays. A Morris water maze was used to observe the cognitive function of the rats. H&E staining was used to observe the pathological changes in the hippocampus. The morphological and quantitative changes of neuronal nuclear (NeuN)-positive neurons and Iba-1-positive microglia in the ipsilateral hippocampus were analyzed by immunohistochemistry. Western blot analysis was done to measure the changes of NeuN ionized calcium binding adapter molecule 1(Iba-1) and apoptosis-related proteins. Immunofluorescence staining of Iba-1 and Microtuble-associated protein light chain 3 (LC3) was done to evaluate the changes in microglia autophagy. TUNEL staining was used to detect apoptosis in the hippocampus. Enzyme-Linked Immunosorbent Assay was used to detect the levels of TNF-α and IL-6 as a measure of the inflammatory response in the hippocampus.

Results

After irradiation, the nucleus of the neurons in the hippocampus was constricted, the pyramidal tract structure was disordered, neuronal apoptosis was increased (P < .001), the expression of microglia increased (P < .01), autophagy was increased (P < .05), and conversion of microglia to the M2 type increased (P < .05). After 3-MA administration, the level of autophagy decreased (P < .05), the damage to the hippocampal region was reduced, neuronal apoptosis decreased (P < .01), and the activity of the microglia decreased (P < .01).

Conclusion

Radiation can active the Microglia. 3-MA inhibits autophagy and excessive activity in microglia, and promotes the conversion of microglia from the M1 to the M2 type, thereby promoting the recovery of brain tissue following radiation exposure.

Reflecting on the utility of standardized uptake values on 18F-FDG PET in nasopharyngeal carcinoma

Background

To rethink the clinical significance of standardized uptake values (SUVs) of nasopharyngeal carcinoma (NPC) on ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron-emission tomography (PET).

Methods

We retrospectively reviewed 369 NPC patients who underwent pretreatment ¹⁸F-FDG PET. The predictive value of the SUVmax of the primary tumor (SUVmax-t) and regional lymph nodes (SUVmax-n) was evaluated using probability density functions. Receiver operating characteristic curves were used to determine optimal cutoffs for the SUVmax-n/SUVmax-t ratio (NTR). Kaplan–Meier and Cox regression analyses were used to assess survival.

Results

The optimal SUVmax-t and SUVmax-n cutoffs were 7.5 and 6.9, respectively. High SUVmax-t and SUVmax-n were related to local and regional recurrence, respectively. Patients with low SUVmax had better 3-year overall survival (OS). To avoid cross-sensitization of cutoff points, we stratified patients with high SUVmax into the low and high NTR groups. The 3-year distant metastasis-free survival (DMFS; 92.3 vs. 80.6%, P = 0.009), progression-free survival (PFS; 84.0 vs. 67.7%, P = 0.011), and OS (95.9 vs. 89.2%, P = 0.002) significantly differed between the high vs. low NTR groups for patients with high SUVmax. Multivariable analysis showed that NTR was an independent prognostic factor for DMFS (hazard ratio [HR]: 2.037, 95% CI: 1.039–3.992, P = 0.038), PFS (HR: 1.636, 95% CI: 1.021–2.621, P = 0.041), and OS (HR: 2.543, 95% CI: 1.214–5.325, P = 0.013).

Conclusion

High SUVmax was associated with NPC recurrence. NTR is a potential prognosticator for DMFS, suggesting that heterogeneity in the pretreatment ¹⁸F-FDG uptake between the primary tumor and lymph nodes is associated with high invasion and metastatic potential.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09626-w.

A model of radiation-induced temporomandibular joint damage in mice

PURPOSE

A small animal radiation research platform (SARRP) equipped with a miniature beam system, an image-guided positioning system, and a dose planning system was used to develop and evaluate a mouse model of radiation-induced temporomandibular damage.

METHODS

Left jaw disks of adult male C57BL/6 mice and C3H mice were targeted using the SARRP for image-guided irradiation. The total radiation dose was 75 Gy. Experiment 1 (Scoping study): Mice in the C57BL/6 mouse test and control groups were sacrificed at 1, 3, 6, 9, 12, 15, and 18 weeks after irradiation, whereas mice in the C3H test and control groups were sacrificed at 1, 3, 6, 9, and 12 weeks after irradiation. Experiment 2 (Full -scale validation study): Mice in the C57BL/6 mouse test and control groups were sacrificed at 1, 3 and 6 weeks after irradiation. Histopathological analysis of the temporomandibular skeletal muscle in each group was performed using hematoxylin and eosin (H&E) and Masson staining; the temporal mandibular bone was examined through H&E staining.

RESULTS

SARRP delivered the rated dose to the temporomandibular joints of C57BL/6 and C3H mice. C3H and C57BL/6 mice in the test group showed different degrees of osteocytic necrosis and osteoporosis at different time points. H&E staining of skeletal muscle tissue showed slight fibrosis in the C57BL/6 test at 3 and 6 weeks time point.

CONCLUSION

We established a model of radiation-induced damage in the temporomandibular joint of C57BL/6 mice and demonstrated that the observed physiological and histological changes correspond to radiation damage observed in humans. Furthermore, the SARRP can deliver precise radiation doses.

Failure Patterns of Recurrence and Metastasis After Intensity-Modulated Radiotherapy in Patients With Nasopharyngeal Carcinoma: Results of a Multicentric Clinical Study

Purpose

This study aimed to explore factors associated with recurrence and metastasis after intensity-modulated radiotherapy (IMRT) in patients with nasopharyngeal carcinoma (NPC) and provide evidence for NPC treatment.

Methods

We retrospectively analysed the treatment dose and survival outcomes of 645 patients with nasopharyngeal carcinoma without distant metastases treated with IMRT for the first time at three treatment centres in the Guangxi Zhuang Autonomous Region, China, between January 2009 and December 2012.

Results

There were 9.3% of patients (60/645) had recurrence and 17.5% (113/645) had distant metastasis 5 years after treatment. The 1-year, 3-year and 5-year local recurrence rates were 0.9%, 6.5% and 9.0% respectively. And the 1-year, 3-year and 5-year distant metastasis rates were 3.4%, 10% and 17.2%, respectively. In the 60 patients with recurrence, the in-field, marginal-field, and out-field recurrence rates were 93.3% (56/60), 5.0% (3/60) and 1.7% (1/60), respectively. Recurrence failures occurring within the first three years after treatment accounted for 81.7% (49/60). In the 113 patients with metastasis, the size of the cervical lymph node, the presence of lower cervical lymph node metastasis, the residual cervical lymph node size and the time of residual cervical lymph node complete response (CR) were independent prognostic factors for DMFS (P <0.05).

Conclusion

Most recurrences occured in the first three years after IMRT. In-field recurrence was the most common pattern for loco-regional failure of NPC treatment. The risk of distant metastasis was positively correlated with higher N stage, lower neck nodal metastasis, larger size of cervical lymph nodes, and longer time to response for residual NPC in cervical adenopathy.

Tumor Prognostic Prediction of Nasopharyngeal Carcinoma Using CT-Based Radiomics in Non-Chinese Patients

Purpose

We aimed to construct predictive models for the overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) for nasopharyngeal carcinoma (NPC) patients by using CT-based radiomics.

Materials and Methods

We collected data from 197 NPC patients. For each patient, radiomic features were extracted from the CT image acquired at pretreatment via PyRadiomics. Feature selection was performed in two steps. First, features with high inter-observer variability based on multiple tumor delineations were excluded. Then, stratified bootstrappings were performed to identify feature combinations that most frequently achieved the highest (i) area under the receiver operating characteristic curve (AUC) for predicting 3-year OS, PFS, and DMFS or (ii) Harrell’s C-index for predicting time to event. Finally, regularized logistic regression and Cox proportional hazard models with the most frequently selected feature combinations as input were tuned using cross-validation. Additionally, we examined the robustness of the constructed model to variation in tumor delineation by simulating 100 realizations of radiomic feature values to mimic features extracted from different tumor boundaries.

Results

The combined model that used both radiomics and clinical features yielded significantly higher AUC and Harrell’s C-index than models using either feature set alone for all outcomes (p &lt; 0.05). The AUCs and Harrell’s C-indices of the clinical-only and radiomics-only models ranged from 0.758 ± 0.091 to 0.789 ± 0.082 and from 0.747 ± 0.062 to 0.767 ± 0.074, respectively. In comparison, the combined models achieved AUC of 0.801 ± 0.075 to 0.813 ± 0.078 and Harrell’s C-indices of 0.779 ± 0.066 to 0.796 ± 0.069. The results showed that our models were robust to variation in tumor delineation with the coefficient of variation ranging from 4.8% to 6.4% and from 6.7% to 9.3% for AUC and Harrell’s C-index, respectively.

Conclusion

Our results demonstrated that using CT-based radiomic features together with clinical features provided superior NPC prognostic prediction than using either clinical or radiomic features alone.

Radiotherapy Combined with PD-1 Inhibition Increases NK Cell Cytotoxicity towards Nasopharyngeal Carcinoma Cells

BACKGROUND

Nasopharyngeal carcinoma (NPC) in endemic regions and younger patients is characterized by a prominent lymphomononuclear infiltration. Radiation is the principal therapeutic modality for patients with NPC. Recent data suggest that the efficacy of radiotherapy in various cancers can be augmented when combined with immune checkpoint blockade. Here, we investigate the effect of radiotherapy on the killing of NPC cells by Natural Killer (NK) cells.

METHODS

NPC cell lines and a patient-derived xenograft were exposed to NK cells in the context of radiotherapy. Cytotoxicity was measured using the calcein-release assay. The contribution of the PD-L1/PD-1 checkpoint and signaling pathways to killing were analyzed using specific inhibitors.

RESULTS

Radiotherapy sensitized NPC cells to NK cell killing and upregulated expression of PD-1 ligand (PD-L1) in NPC cells and PD-1 receptor (PD-1) in NK cells. Blocking of the PD-L1/PD-1 checkpoint further increased the killing of NPC cells by NK cells in the context of radiotherapy.

CONCLUSION

Radiation boosts the killing of NPC cells by NK cells. Killing can be further augmented by blockade of the PD-L1/PD-1 checkpoint. The combination of radiotherapy with PD-L1/PD-1 checkpoint blockade could therefore increase the efficacy of radiotherapy in NPC tumors.

Antitumor and Radiosensitization Effects of a CXCR2 Inhibitor in Nasopharyngeal Carcinoma

CXCR2, a member of the G-protein-coupled cell surface chemokine receptor family, is commonly found on leukocytes, endothelial cells and tumor cells including nasopharyngeal carcinoma cells. However, how the activity of CXCR2 and its ligand CXCL8 affects the development of nasopharyngeal carcinoma (NPC) remains unknown. Here, we found that CXCR2 and CXCL8 were both predicted poor prognosis in NPC patients. Furthermore, we identified that treatment with CXCR2 antagonist SB225002 of nasopharyngeal carcinoma cell lines resulted tumorigenesis inhibition in vitro and in vivo. In addition, we found that SB225002 could enhance NPC cells radiosensitivity through regulating cell circle distribution and interfering with cellular DNA damage repair. SB225002 also exhibited an efficient radiosensitization effect in C666-1 and HONE-1 bearing mice. Functionally, we showed that SB225002 reduced microvessel density and proliferation and induced tumor apoptosis. Furthermore, changes in the tumor microenvironment were also observed in this study. We observed that SB225002 reduced tumor-associated neutrophils (TANs) in the tumors tissue which were recruited especially after irradiation. Taken together, our results suggested that targeting the CXCL8-CXCR2 pathway is a promising therapeutic strategy for comprehensive NPC treatment.

Outcomes of patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

Nasopharyngeal cancer shows a good response to intensity-modulated radiotherapy. However, there is no clear evidence for the benefits of routine use of image-guided radiotherapy. The purpose of this study was to perform a retrospective investigation of the treatment outcomes, treatment-related complications and prognostic factors for nasopharyngeal cancer treated with intensity-modulated radiotherapy and image-guided radiotherapy techniques. Retrospective analysis was performed on 326 consecutive nasopharyngeal cancer patients treated between 2004 and 2015. Potentially significant patient-related and treatment-related variables were analyzed. Radiation-related complications were recorded. The 5-year overall survival and disease-free survival rates of these patients were 77.9% and 70.5%, respectively. Age, AJCC (American Joint Committee on Cancer) stage, retropharyngeal lymphadenopathy, treatment interruption and body mass index were independent prognostic factors for overall survival. Age, AJCC stage, retropharyngeal lymphadenopathy, image-guided radiotherapy and body mass index were independent prognostic factors for disease-free survival. In conclusion, intensity-modulated radiotherapy significantly improves the treatment outcomes of nasopharyngeal cancer. With the aid of image-guided radiotherapy, the advantage of intensity-modulated radiotherapy might be further amplified.

Effect of X-rays on transcript expression of rat brain microvascular endothelial cells: role of calcium signaling in X-ray-induced endothelium damage

Radiation-induced brain edema is a serious adverse effect of radiotherapy. Although there are many causes of radiation-induced brain edema, the pathogenesis is not clear and clinical treatment is not ideal. Therefore, knowing the differential expression of the brain microvascular endothelial cell (BMEC) transcriptome after brain radiotherapy may shed light on the pathogenesis of radiation-induced brain edema. The present study used RNA-Seq technique to identify 383 BMEC transcripts differentially expressed (many 2-fold or higher; P < 0.05) between control and X-ray–treated primary cultured rat BMECs. Compared with controls, X-ray–treated BMECs had 183 significantly up-regulated transcripts and 200 significantly down-regulated transcripts. The differentially expressed genes were associated with the biological processes of the cell cycle, apoptosis, vascular permeability, and extracellular junctions. The functional changes identified in the X-ray–treated BMECs included Ca²⁺ signaling, phosphoinositide 3-kinase–Akt signaling, and methionine degradation. These results indicated that transcript expression was substantially affected by radiation exposure and the proteins encoded by these differentially expressed genes may play a significant role in radiotherapy-induced brain edema. Our findings provide additional insight into the molecular mechanisms of radiation-induced brain edema and may be helpful in the development of clinical treatment of this adverse reaction to radiotherapy.

Cancer-associated fibroblasts promote the survival of irradiated nasopharyngeal carcinoma cells via the NF-κB pathway

Background

Irradiation has emerged as a valid tool for nasopharyngeal carcinoma (NPC) in situ treatment; however, NPC derived from tissues treated with irradiation is a main cause cancer-related death. The purpose of this study is to uncover the underlying mechanism regarding tumor growth after irradiation and provided potential therapeutic strategy.

Methods

Fibroblasts were extracted from fresh NPC tissue and normal nasopharyngeal mucosa. Immunohistochemistry was conducted to measure the expression of α-SMA and FAP. Cytokines were detected by protein array chip and identified by real-time PCR. CCK-8 assay was used to detect cell proliferation. Radiation-resistant (IRR) 5-8F cell line was established and colony assay was performed to evaluate tumor cell growth after irradiation. Signaling pathways were acquired via gene set enrichment analysis (GSEA). Comet assay and γ-H2AX foci assay were used to measure DNA damage level. Protein expression was detected by western blot assay. In vivo experiment was performed subcutaneously.

Results

We found that radiation-resistant NPC tissues were constantly infiltrated with a greater number of cancer-associated fibroblasts (CAFs) compared to radiosensitive NPC tissues. Further research revealed that CAFs induced the formation of radioresistance and promoted NPC cell survival following irradiation via the IL-8/NF-κB pathway to reduce irradiation-induced DNA damage. Treatment with Tranilast, a CAF inhibitor, restricted the survival of CAF-induced NPC cells and attenuated the of radioresistance properties.

Conclusions

Together, these data demonstrate that CAFs can promote the survival of irradiated NPC cells via the NF-κB pathway and induce radioresistance that can be interrupted by Tranilast, suggesting the potential value of Tranilast in sensitizing NPC cells to irradiation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13046-021-01878-x.

[Therapeutic outcomes of nasopharyngeal carcinomas: a single-center study conducted at the Fattouma Bourguiba University Hospital in Monastir, Tunisia]

INTRODUCTION

nasopharyngeal carcinomas (NPCs) are relatively common in the Mediterranean basin. Survival has been greatly improved by new radiation techniques and new molecular-targeted chemotherapy. The purpose of our study was to analyze the therapeutic outcomes and to describe the prognostic factors of NPCs.

METHODS

we conducted a retrospective study of patients with nasopharyngeal carcinoma on treatment and follow-up in our department between January 1995 and December 2014. Data were collected using a standardized sheet. Statistical analysis was performed using SPSS software. Kaplan-Meier method was used to determine patient´s overall survival.

RESULTS

seventy-three cases of NPC were reported. The average age of patients was 48 years. A male predominance was noted. The majority of cancers (56%) were locally advanced tumors (T3-T4). After an average follow-up of 45.5 months, the rate of locoregional recurrences was 19.4%. Three patients (4%) had bone metastases. Five-year overall survival was 65%. Factors positively influencing overall survival were early-stage tumor (TNM classification) and 1.8 Gy single fraction radiotherapy. Local and lymph node recurrence rates were 13.8% and 5.5% respectively, mainly for T4 N2 tumors. Therapeutic sequelae were dominated by seromucous otitis (42.7%), trismus (38.7%), and xerostomia (32%).

CONCLUSION

overall survival in patients with NPC has improved, in particular with the advent of concomitant radiotherapy and chemotherapy; however, disabling late toxicity is significant. Good prognostic factors reported in this study include early tumor stage as well as radiotherapy fractionation.

A retrospective study on the predictive factors in chronic trismus

Trismus is one of the most debilitating and treatment-resistant complications resulting from head and neck oncological treatments. The objective of this study was to assess how primary tumour variables could assist in predicting chronic trismus. From a (retrospective) oncological database (Department of Oral and Maxillofacial Surgery, University Hospitals Leuven), tumour-related, surgical, and oral functional variables were reviewed. Contributing factors for chronic trismus, defined as a mouth opening of less than 35 mm, at least one year after treatment for oral squamous cell cancer, were assessed via logistic regression. A mediational analysis was conducted on the significant predictive variables. Thirteen out of 52 patients were observed to have chronic trismus. A significantly higher prevalence of trismus was found for increasing clinical T classification (p < 0.01), tumours based in the maxilla or the retromolar trigone (p = 0.04), after adjuvant radiotherapy (p = 0.04), and/or with masticatory muscle tumour invasion (p ≤ 0.02). Furthermore, radiotherapy significantly impacted T classification in chronic trismus, while T classification was significantly related to masticatory muscle invasion. Although radiotherapy and clinical T classification are well-established risk factors for postoperative trismus, masticatory muscle invasion should be considered as one of the main predictive factors.

Development and Validation of a Nomogram for Predicting Radiation-Induced Temporal Lobe Injury in Nasopharyngeal Carcinoma

Background

The purpose was to develop and validate a nomogram for prediction on radiation-induced temporal lobe injury (TLI) in patients with nasopharyngeal carcinoma (NPC).

Methods

The prediction model was developed based on a primary cohort that consisted of 194 patients. The data was gathered from January 2008 to December 2010. Clinical factors associated with TLI and dose–volume histograms for 388 evaluable temporal lobes were analyzed. Multivariable logistic regression analysis was used to develop the predicting model, which was conducted by R software. The performance of the nomogram was assessed with calibration and discrimination. An external validation cohort contained 197 patients from January 2011 to December 2013.

Results

Among the 391 patients, 77 patients had TLI. Prognostic factors contained in the nomogram were Dmax (the maximum point dose) of temporal lobe, D1cc (the maximum dose delivered to a volume of 1 ml), T stage, and neutrophil-to-lymphocyte ratios (NLRs). The Internal validation showed good discrimination, with a C-index of 0.847 [95%CI 0.800 to 0.893], and good calibration. Application of the nomogram in the external validation cohort still obtained good discrimination (C-index, 0.811 [95% CI, 0.751 to 0.870]) and acceptable calibration.

Conclusions

This study developed and validated a nomogram, which may be conveniently applied for the individualized prediction of TLI.

Dysphagia after chemo-radiation for nasopharyngeal cancer: A scoping review

Objective

Nasopharyngeal cancer (NPC) has distinct characteristics regarding its global prevalence, initial presentation, management and patient outcomes compared to other subtypes of head and neck cancer (HNC). The mainstay of NPC treatment is chemo-radiation (C/RT) and while dysphagia is a known early and late toxicity of C/RT treatment, the nature of dysphagia post NPC treatment has had limited investigation. The objective of this review is to summarise the existing evidence regarding dysphagia following NPC to inform the future research agenda for this population. Dysphagia incidence, characteristic deficits observed across the phases of swallowing, efficacy of current dysphagia interventions, and effect on quality of life will be explored.

Data sources

Databases including MEDLINE, CINAHL, Embase, Scopus and Web of Science were included.

Methods

A scoping review was conducted according to PRISMA-ScR guidelines. Two independent reviewers screened selected full text articles.

Results

Of the initial 2495 articles found, 28 articles were included. Reports of penetration and aspiration varied widely (0%–91.6%), with high rates of silent aspiration identified in 2 studies (42%, 66%). Oral, pharyngeal and upper esophageal phase impairments were reported. Of these, upper esophageal stasis and multiple pharyngeal stage deficits were most prevalent. The pharyngeal constrictors were found to have a significant dose–effect relationship and shielding to the anterior neck field was effective to preserve swallowing function. Six treatment studies were identified with limited evidence supporting the use of neuromuscular electrical stimulation, dilatation and swallowing exercises. Quality of life was adversely affected.

Conclusions

Dysphagia is a prevalent early and late problem post NPC treatment, with impairments across all phases of the swallow. Studies on preventing dysphagia and treatment efficacy remain limited. More systematic study of the nature of dysphagia and the efficacy of treatment in this population is warranted.

Safety and Feasibility of Low-Dose Apatinib Combined with S-1 as the Second-Line Therapy or Beyond in Chinese Patients with Pulmonary and Hepatic Metastasis of Nasopharyngeal Carcinoma

Introduction

The purpose of this study was to analyze the safety and feasibility of low-dose apatinib combined with S-1 as a second-line therapy or beyond in Chinese patients with pulmonary and/or hepatic metastases of nasopharyngeal carcinoma (NPC).

Methods

Forty-one Chinese NPC patients with pulmonary and hepatic metastases were treated with low-dose apatinib plus S-1. The S-1 dose was determined according to each patient’s body surface area (BSA): 40 mg twice a day for BSA <1.25 m²; 50 mg twice a day for 1.25 m²≤BSA <1.5 m²; and 60 mg twice a day for BSA ≥1.5 m². S-1 was received for 14 days, after stopping for 7 days, given 3 weeks apart. Apatinib, 125 mg was orally administered daily on days 1 through 28 of each 4-week cycle. If the toxicity was not tolerable, the dose of apatinib was reduced to 125 mg every other day.

Results

Treatment efficacy was evaluated in all 41 patients after four courses of chemotherapy. The objective response rate was 34.1%, and the disease control rate was 80.4%. The median progression-free survival was 9.7 months (95% confidence interval, 6.2–13.8 months), and the median overall survival was 22.1 months (95% confidence interval, 15.1–28.9 months). The 2-year survival rate was 41.5%. The most common toxicities included loss of appetite in 39.0% of patients, dyslipidemia in 34.1%, hypertension in 31.7%, myelosuppression in 24.4%, fatigue in 21.9%, and hand-foot syndrome in 17.1%. Seven patients received dose adjustment of apatinib due to side effects.

Conclusion

In patients with pulmonary and/or hepatic metastases of NPC, low-dose apatinib plus S-1 yielded an excellent survival benefit, and the toxicities were mild and tolerable.

Over-expression of cyclo-oxygenase-2 predicts poor survival of patients with nasopharyngeal carcinoma: a meta-analysis

OBJECTIVES

The conclusive prognostic significance of cyclo-oxygenase-2 has been determined in various cancers but not in nasopharyngeal carcinoma. Therefore, this study aimed to evaluate the relationship of cyclo-oxygenase-2 expression with the survival outcome and treatment response of nasopharyngeal carcinoma patients via a systematic meta-analysis approach.

METHODS

A meta-analysis was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ('PRISMA') checklist. The primary clinical characteristics of patients, and hazard ratios with 95 per cent confidence intervals of overall survival data, were tabulated from eligible studies. The relationship of cyclo-oxygenase-2 expression with survival outcome (expressed as hazard ratio) and treatment response (expressed as odds ratio) in nasopharyngeal carcinoma patients was analysed, and explained with the aid of forest plot charts.

RESULTS AND CONCLUSION

The pooled hazard ratio for overall survival was 2.02 (95 per cent confidence interval = 1.65-2.47). This indicates that the over-expression of cyclo-oxygenase-2 is significantly associated with the poor survival of nasopharyngeal carcinoma patients. The pooled odds ratio of 0.98 (95 per cent confidence interval = 0.27-3.49) reveals that over-expression of cyclo-oxygenase-2 was not significantly related to the treatment outcome.

Masses of the Paranasal Sinuses After Treatment of Nasopharyngeal Carcinoma: A Case Report

The development of a new mass in the field of irradiation of a previously treated Nasopharyngeal carcinoma is generally considered a sign of recurrence. We report a case of a 46-year-old male, with a past history of undifferentiated NPC, with an expansive lesion discovered during radiological follow-up that occupied nasal cavity and paranasal sinuses. The endoscopic sinuses surgery was necessary in order to analyze and remove the mass with intraoperative frozen sections to highlight mucosa free from disease. The presence of non-malignant masses in the paranasal sinuses are rare complications after radiotherapy at the skull base, but represent an eventuality that must be considered in the differential diagnosis of a suspected recurrence or with a secondary malignancies after radiation therapy. It is therefore required a final diagnosis based on biopsy, follow-up and an eventual endoscopic surgical treatment.

Blood Cadmium Level Is Associated with Short Progression-Free Survival in Nasopharyngeal Carcinoma

The prognosis of nasopharyngeal carcinoma (NPC) is poor with disease progression. Cadmium exposure is a risk factor for NPC. We aimed to investigate the effect of cadmium exposure, by measuring cadmium level, and clinicopathologic factors on NPC disease progression and prognosis. A total of 134 NPC cases were analyzed and venous blood samples were collected. Blood cadmium level was analyzed by graphite furnace atomic absorption spectrophotometry. Clinical data were collected at baseline for patients and tumor characteristics from medical records. Progression-free survival (PFS) was analyzed during follow-up. The effect of cadmium exposure and clinical factors on PFS was analyzed by the Kaplan-Meier method and Cox regression models. Blood cadmium level was associated with history of disease and smoking history and pack-years. On Kaplan-Meier analysis, a high blood cadmium level, male sex, smoking history and increasing pack-years, as well as advanced clinical stage were all associated with short PFS. On multivariate analysis, blood cadmium level was an independent risk factor and predictor of NPC prognosis and disease progression. Cadmium exposure and related clinical factors can affect the prognosis of NPC, which merits further study to clarify.

Very late xerostomia, dysphagia, and neck fibrosis after head and neck radiotherapy

BACKGROUND

Acute and late toxicity after intensity-modulated radiotherapy (IMRT) for head and neck cancer (HNC) impacts on patient quality of life; yet, very late toxicity data remain scarce. This study assessed dysphagia, xerostomia, and neck fibrosis 3-8 years after IMRT.

METHODS

A retrospective analysis using generalized estimated equations was performed on 60 patients with HNC treated with fractionated IMRT between 2000 and 2015 who had a follow-up ≥8 years. Toxicity was scored using LENT-SOMA scales.

RESULTS

A trend towards a nonlinear global time effect (P = .05) was noted for dysphagia with a decrease during the 5 years post-treatment and an increase thereafter. A significant decrease in xerostomia (P = .001) and an increase in neck fibrosis (P = .04) was observed until 8 years.

CONCLUSIONS

Dysphagia, xerostomia, and neck fibrosis do not appear stable over time and remain highly prevalent in the very late follow-up. Our findings support the need for prospective trials investigating very late toxicity in patients with HNC.

Evaluation of the Effect of Various Radiotherapy Modalities on Swallowing Function in Patients With Nasopharyngeal Cancer

The objective of this study was to compare the effect of curative 3-dimensional (3D) conformal radio-chemotherapy and intensity-modulated radiotherapy (IMRT) modalities on swallowing function in patients with nasopharyngeal cancer. Ten patients receiving 3D conformal radiotherapy and 10 patients receiving curative radiotherapy with IMRT, who were admitted for malignancy control for nasopharyngeal cancer, were included in the study. Swallowing functions were determined by flexible fiberoptic endoscopic evaluation. Premature spillage, retention pooling, penetration, aspiration, and reflex cough were evaluated. No statistically significant difference was found between patients receiving 3D conformal radiotherapy and IMRT regarding the scores of premature spillage, retention pooling, penetration, and aspiration with 3, 5, and 10 mL water and 5 mL yoghurt and fish crackers (P > .05). Velopharyngeal insufficiency or delayed onset of swallowing reflex was not found in any of the patients (P > .05). No significant difference was found between the groups in terms of the symptoms regarding subjective evaluation of swallowing (P > .05). Swallowing function did not differ among patients receiving IMRT and 3D conformal radiotherapy. Further studies with a larger sample size are warranted in order to verify the results.

Bimodal Radiotherapy with Active Raster-Scanning Carbon Ion Radiotherapy and Intensity-Modulated Radiotherapy in High-Risk Nasopharyngeal Carcinoma Results in Excellent Local Control

Background: In this analysis, we aimed to present the first results of carbon ion radiotherapy (CIRT), which is known for its conformal dose distribution and increased biological effectiveness in the treatment of high-risk nasopharyngeal carcinoma (NPC). Methods: We retrospectively analyzed twenty-six consecutive patients who had been treated at our center with CIRT for high-risk NPC between 2009 and 2018. Carbon ion (C12) boost was applied in a bimodal setting combined with intensity-modulated radiotherapy (IMRT) base plan. The median cumulative total dose was 74 Gy (RBE), and patients with inoperable (n = 17, 65%) or incompletely resected (n = 7, 27%) tumors were included in the analysis. Overall, 81% received concomitant chemotherapy (n = 21). Results: The median follow-up time was 40 months (range 10–97 months) for all patients. At the last follow-up, 92% of the patients were still alive. We could identify excellent tumor response with complete tumor remission (CR) in 60% (n = 15/25), partial tumor remission (PR) in 20% (n = 5/25), and stable disease (SD) in 12% (n = 3/25) of the patients according to the RECIST (Response Evaluation Criteria in Solid Tumors) criteria. Despite unfavorable tumor characteristics, only one patient showed a locally in-field recurrence after 56 months (4%) and another patient a locoregional recurrence in the unilateral cervical lymph nodes after 21 months (4%). The 2-year local control (LC), distant progression-free survival (DPFS), and overall survival (OS) were 95%, 93%, and 100% and the estimated 5-year LC, DPFS, and OS were 90%, 86%, and 86%, respectively. Overall, treatment was tolerated well with 20% acute and 16% chronic grade 3 side effects. No toxicity greater than grade 3 occurred. Conclusion: Bimodal radiotherapy including IMRT and active raster-scanning CIRT for high-risk nasopharyngeal cancer is a safe treatment method resulting in moderate toxicity and excellent local control. A larger patient number and longer follow-up time would be necessary to strengthen the current findings.

Dosimetric parameters associated with conductive or sensorineural hearing loss 5 years after intensity-modulated radiation therapy in nasopharyngeal carcinoma

BACKGROUND

Most previous studies are separate dosimetric analyses of conductive or sensorineural hearing loss, and they are not conducive to a comprehensive assessment of auditory radiation damage.

AIMS/OBJECTIVES

Our study aimed to evaluate the long-term incidence of sensorineural hearing loss (SNHL) or conductive hearing loss (CHL) in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiation therapy (IMRT), and to investigate the relationship between SNHL or CHL and patient factors, treatment-related factors, and radiation dose parameters.

MATERIAL AND METHODS

Seventy patients (117 ears) with NPC, who were also treated with IMRT in our hospital from 2006 to 2014, were retrospectively analyzed. Radiation doses to the Eustachian tube (ET), middle ear (ME), cochlear (Co), and internal auditory canal (IAC) were assessed. Pure tone audiometry and impedance audiometry were performed before and during the follow-up period. The relationships between low-frequencies (0.5-2 kHz) or high-frequency (4 kHz) SNHL/CHL and radiotherapy dose parameters were analyzed.

RESULTS

Of the 117 ears studied, 7.69% had low-frequency SNHL, 35.9% had high-frequency SNHL, 23.93% had low-frequency CHL, and 18.80% had high-frequency CHL. The incidence of high-frequency CHL was higher in the T4 group than in the T (1-3) group (p < .05). When IAC D_max > 42.13 Gy or IAC D_mean > 32.71 Gy, the risk of high-frequency SNHL increased in NPC patients. When ME D_max > 44.27 Gy, ME D_mean > 29.28 Gy, or ET D_max > 57.23 Gy, the risk of high-frequency CHL in NPC patients increased.

CONCLUSIONS AND SIGNIFICANCE

SNHL and CHL remain common ear complications after IMRT for NPC. IAC D_max, IAC D_mean, ME D_max, ME D_mean, and ET D_max all need to be carefully considered during the IMRT treatment protocol.

Cisplatin and Fluorouracil Induction Chemotherapy With or Without Docetaxel in Locoregionally Advanced Nasopharyngeal Carcinoma

In this study, we aim to compare the progression-free survival (PFS) rates and side effects of induction chemotherapy based on docetaxel, cisplatin and fluorouracil (TPF) versus cisplatin and fluorouracil (PF) in patients with locoregionally-advanced nasopharyngeal carcinoma who received subsequent chemoradiotherapy. We randomly assigned 278 patients with stage III or IV NPC (without distant metastases) to receive either TPF or PF induction chemotherapy, followed by cisplatin-based chemoradiotherapy every 3 weeks and intensity-modulated radiation therapy for 5 days per week. After a minimum of 2 years follow-up, a PFS benefit was observed for TPF compared to PF, though this difference was not statistically significant (84.5% vs. 77.9%, P = .380). Due to increased frequencies of grade 3 or 4 neutropenia and diarrhea, significantly more patients in the TPF group required treatment delays and dose modifications. Our findings suggest that PF induction chemotherapy has substantially better tolerance and compliance rates than TPF induction chemotherapy. However, the treatment efficacy of PF is not superior to TPF induction chemotherapy in patients with locoregionally-advanced NPC (ClinicalTrials.gov number, NCT01536223).

Prospective cross-sectional study assessing prevalence and factors affecting trismus after multimodal treatment for oral cancers

BACKGROUND

Trismus is a common complication following treatment for oral cancers. However, its incidence in site-specific cancers is not adequately studied. The purpose of this study was to assess the prevalence and risk factors associated with trismus in treated patients with oral cancer.

METHODS

The maximal mouth opening in treated oral cancers was measured. Logistic regression analysis was performed to find risk factors for developing trismus in the entire cohort and in a subgroup of patients with gingivobuccal complex cancers.

RESULTS

A total of 401 patients were enrolled. The prevalence of trismus was 72.8%. On multivariate analysis, adjuvant therapy and submucous fibrosis were independent predictors. Reconstruction and method of reconstruction did not affect trismus. Bialveolar resections had significantly higher incidence of trismus.

DISCUSSION

High prevalence of trismus was seen in patients following multimodal therapy for oral cancers. Adequate reconstruction alone may not prevent trismus and aggressive rehabilitation is key to its prevention.

Long-term survival and late complications of intensity-modulated radiotherapy for recurrent nasopharyngeal carcinoma

BACKGROUND

To evaluate the effectiveness and toxicities of intensity-modulated radiotherapy (IMRT) for locally recurrent nasopharyngeal carcinoma (NPC).

METHODS

One hundred and eighty-four previously irradiated NPC patients with recurrent disease and re-irradiated by IMRT between February 2005 to May 2013 had been reviewed. The disease was re-staged I in 33, II in 27, III in 70 and IV in 54 patients. Seventy-five percent of the patients received cisplatin-based chemotherapy.

RESULTS

The median survival time was 33 months. The 3-year actuarial rates of local recurrence-free survival (LRFS), distant metastases-free survival (DMFS), and overall survival (OS) rates were 85.1, 91.1, and 46.0%, respectively. About 53% of the patients experienced Grade 3-4 late toxicities. Forty-four patients died of massive hemorrhage of the nasopharynx caused by radiation induced mucosal necrosis. Multivariate analysis indicated that chemotherapy and time interval between initial radiotherapy and re-irradiation were independent predictors for DMFS.

CONCLUSION

IMRT is an effective method for patients with locally recurrent NPC. Massive hemorrhage of the nasopharynx is the major sever late complication and also the leading cause of death. Early recurrence is negative factor for DMFS. Combination of chemotherapy can improve DMFS, but not for OS. Optimal salvage treatment strategies focusing on improvement of survival and minimization of late toxicities are warranted.

The efficacy of induction chemotherapy in the treatment of stage II nasopharyngeal carcinoma in intensity modulated radiotherapy era

PURPOSE

To evaluate the efficacy of induction chemotherapy in the treatment of stage II nasopharyngeal carcinoma (NPC) in era of intensity modulated radiotherapy (IMRT).

METHODS AND MATERIALS

A total of 173 patients with American Joint Committee on Cancer (AJCC) 7th stage II NPC from two institutions were included. All patients were divided into two groups: induction chemotherapy + concurrent chemoradiotherapy group (ICRT) group and concurrent chemoradiotherapy group (CCRT). Induction chemotherapy was consisted of one to three cycles of cisplatin plus fluorouracil (PF) or paclitaxel plus cisplatin (TP). Concurrent chemotherapy included one to three cycles of cisplatin. We retrospectively assessed overall survival (OS), progression-free survival (PFS), locoregional failure free survival (LRFFS) and distant metastasis free survival (DMFS) in patients of both groups. T-test, Chi-square test, Kaplan-Meier methodology and Cox proportional hazards model were used to analyze.

RESULTS

With a median follow up of 64.7 months, no significant difference was found in grade 3-4 hematologic toxicity, liver dysfunction and renal impairment between ICRT and CCRT group. Univariable analyses shown adding induction chemotherapy to CCRT significantly decreased 5-year OS (87.9% vs 95.5%, P = 0.033), 5-year PFS (74.0% vs 86.1%, P = 0.035), 5-year LRFFS (80.0% vs 91.2%, P = 0.016), but there was no statistically significant difference in 5-year DMFS (87.1% vs 94.7%, P = 0.095). In multivariable analyses, we found the consistent results that induction chemotherapy was a negative factor associated with OS (HR of death = 3.768, 95% CI = 1.117-12.709; P = 0.032), PFS (HR of progression = 2.156, 95% CI = 1.060-4.386; P = 0.034), LRFFS (HR of locoregional relapse = 2.435, 95% CI = 1.009-5.874; P = 0.048) and also DMFS (HR of metastasis = 2.873, 95% CI = 1.005-8.211; P = 0.049), in stage II NPC patients.

CONCLUSION

In present study, we found that induction chemotherapy caused deleterious effect on stage II NPC patients. However, this is a retrospective study and the adverse effects of induction chemotherapy has not been previously reported. It warrants further investigation.

Use of a Smartphone Medical App Improves Complications and Quality of Life in Patients with Nasopharyngeal Carcinoma Who Underwent Radiotherapy and Chemotherapy

Background

We explored the intervention effect of a smartphone medical app on complications and quality of life of patients with nasopharyngeal carcinoma who underwent radiotherapy and chemotherapy.

Material/Methods

We divided 132 patients with nasopharyngeal carcinoma who received radiotherapy and chemotherapy for the first time, in accordance with the random number table method, into a control group (67 patients) and an intervention group (65 patients). Patients in control group were discharged with standard care and patients in the intervention group used a smartphone medical app after discharge. Data on adverse effects of radiotherapy and chemotherapy, complications, and quality of life were collected and analyzed.

Results

There was no difference between the complications of radiotherapy and chemotherapy and quality of life between the 2 groups at discharge (P>0.05). The incidence of oral mucositis, xerostomia, mouth-opening difficulties, and nasal congestion in the intervention group was significantly lower than in the control group at 6 months after discharge and quality of life was significantly higher than in the control group (P<0.05).

Conclusions

Reasonable use of this smartphone app can improve the exercise compliance of discharged patients with nasopharyngeal carcinoma who underwent radiotherapy and chemotherapy, reduce the adverse reactions and complications of radiotherapy and chemotherapy, and improve quality of life and satisfaction of patients after discharge.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

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

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

Influence of POLG on Radiosensitivity of Nasopharyngeal Carcinoma Cells

BACKGROUND AND OBJECTIVE

There is a high incidence of nasopharyngeal carcinoma (NPC), malignant head and neck tumors, in southern China. Radioresistance is the main cause affecting the efficacy of NPC treatments. The POLG gene particularly plays an important role in radiation-induced damage repair. In this study, the authors established RNAi CNE-1 and CNE-2 knockdown in two NPC cell lines to observe whether this gene affects the radiosensitivity of NPC cells.

MATERIALS AND METHODS

Four short hairpin RNA (shRNA) expression plasmids targeting POLG gene were constructed and transfected into the NPC cell lines CNE-1 and CNE-2. Screening was performed to evaluate the stable expression of cloned cells, which were named CNE-1/POLG-shRNA1, CNE-1/POLG-shRNA2, CNE-2/POLG-shRNA1, and CNE-2/POLG-shRNA2. The negative controls CNE-1/Neg-shRNA and CNE-2/Neg-shRNA were additionally used. The MTT method, flow cytometry, clone formation analysis, cell migration, and other experimental methods were employed to verify changes in the radiosensitivity of the NPC cells.

RESULTS

Fluorescent quantitative PCR and Western blot confirmed the downregulation of the PLOG gene through diminished PLOG messenger RNA and protein levels. Consequently, the authors report the stable knockdown of the POLG gene in an NPC model. Dose-dependent radiation exposure of POLG inhibited NPC cell growth and increased apoptosis compared with control cells (p < 0.01), as demonstrated through colony formation assay and flow cytometry. Functional assays indicated that knockdown of the POLG in CNE-1 and CNE-2 cells remarkably reduced cell viability and proliferation. Specifically, POLG knockdown led to G1 phase arrest and apoptosis.

CONCLUSIONS

Overall, the authors conclude that POLG downregulation alters the radiosensitivity of NPC cells, indicating that the gene is likely involved in conferring the radiation response of the cells. In addition, findings in this study suggest a novel role for POLG as a potential predictive marker for NPC radiotherapy efficiency. POLG gene can be used as a potential clinical target to effectively improve the radiosensitivity of NPC.

Antitumor and radiosensitizing effects of SKLB-163, a novel benzothiazole-2-thiol derivative, on nasopharyngeal carcinoma by affecting the RhoGDI/JNK-1 signaling pathway

BACKGROUND AND PURPOSE

SKLB-163 is a novel benzothiazole-2-thiol derivative with antitumor activities. This study investigated the effects of SKLB-163 on nasopharyngeal carcinoma (NPC) and its mechanisms.

MATERIALS AND METHODS

Rho GDP-dissociation inhibitor (RhoGDI) expression was examined in NPC cell lines by western blot. Effects of SKLB-163 on proliferation, migration and radiosensitivity were assessed by MTT, wound healing and colony formation assays in vitro. Anti-tumor and anti-metastatic effects, and radiosensitizing effects of SKLB-163 were evaluated in a NPC lung metastatic nude mouse model and a subcutaneous xenograft mouse model. Effects of SKLB-163 on proliferation and apoptosis were assessed by PCNA immunohistochemistry and TUNEL assay in vivo. Key molecules in RhoGDI/c-Jun N-terminal kinases-1 (JNK-1) pathway were examined by western blot.

RESULTS

RhoGDI was up-regulated in NPC cell lines. SKLB-163 inhibited proliferation and migration, and increased radiosensitivity of NPC cells. SKLB-163 inhibited tumor growth and metastases, and sensitized tumor to irradiation. The radiosensitizing effects were correlated with induction of apoptosis and suppression of proliferation. The molecular mechanism was the down-regulation of RhoGDI and activation of JNK-1 signaling, and the subsequent activation of caspase-3 and the decrease in phosphorylated AKT.

CONCLUSIONS

SKLB-163 shows strong anti-tumor activities against NPC and sensitizes NPC to irradiation by affecting the RhoGDI/JNK-1 pathway.

Prognostic analysis of patients with locally advanced nasopharyngeal carcinoma following intensity modulated radiation therapy

The present study retrospectively analyzed the prognostic factors of 135 patients with locally advanced nasopharyngeal carcinoma (NPC) who received intensity modulated radiation therapy between August 2008 and January 2012 at Xiangya Hospital of Central South University. Patients were staged from III-IVA according to the 7th American Joint Committee on Cancer staging system. Using Statistical Analysis System 9.3 software, the present study demonstrated that, among these 135 patients, the 5-year overall survival, the 5-year local relapse-free survival, and the 5-year disease metastasis-free survival were 84, 82, and 78%, respectively. Multivariate Cox regression analysis identified that targeted treatment [hazard ratio (95% confidence interval), 2.642 (1.001, 6.972); P=0.0497] served as an independent negative prognostic factor in locally advanced NPC. The results of immunostaining revealed that the staining intensity of the radiation-resistant group was increased compared with that of the radiation-sensitive group. These results demonstrate that a high expression of EGFR may be associated with radiation resistance, and targeted treatment may not be effective in patients with locally advanced nasopharyngeal carcinoma with low expression of EGFR.

Patient- and treatment-related risk factors associated with neck muscle spasm in nasopharyngeal carcinoma patients after intensity-modulated radiotherapy

BACKGROUND

To evaluate the incidence of neck muscle spasm in nasopharyngeal carcinoma (NPC) patients that received intensity-modulated radiotherapy (IMRT), and to analyse the patient- and treatment-related risk factors associated with neck muscle spasm.

METHODS

A sample of 152 IMRT-treated, biopsy-proven, nondisseminated NPC patients were retrospectively analysed. All had documented IMRT treatment plans and had returned for follow-up review at 4 years post-radiotherapy. Spasm of the sternocleidomastoid (SCM) muscle was graded from 0 to 3 (absent to severe) and this grade served as the clinical endpoint. Risk factors were identified using logistic regression analysis.

RESULTS

Within 4 years of radiotherapy, neck muscle spasm developed in 23.68% of the patients; Grades 0, 1, 2 and 3 were respectively assigned to 83.55, 7.57, 6.58 and 2.30% of assessed SCMs. Multivariate analysis indicated that gender, N stage, V60 (percentage of SCM volume that received >60 Gy) were independent prognostic variables, and that the optimal threshold for using V60 to predict neck muscle spasm was 61.92% (sensitivity = 0.900, specificity = 0.953).

CONCLUSIONS

Gender, N stage and V60 were independent predictive factors for post-radiotherapy neck muscle spasm, and a V60 of ≤61.92% in the SCM was relatively safe.

Clinical Variables for Prediction of the Therapeutic Effects of Bevacizumab Monotherapy in Nasopharyngeal Carcinoma Patients With Radiation-Induced Brain Necrosis

PURPOSE

To identify the predictive and prognostic factors for a decrease or recurrence of brain edema in patients who developed radiation-induced brain necrosis (RN) after radiation therapy for nasopharyngeal carcinoma (NPC) and who received bevacizumab monotherapy.

METHODS AND MATERIALS

This was a retrospective study. The charts of 50 patients who were diagnosed with RN after radiation therapy for NPC, treated with bevacizumab, and followed up for 6 months were reviewed. Clinical data of these patients were collected, and their brain edema volume before bevacizumab administration, after bevacizumab administration, at 3-month follow-up, and at 6-month follow-up was evaluated on the basis of brain magnetic resonance imaging findings. The baseline serum vascular endothelial growth factor levels of 15 patients were measured by enzyme-linked immunosorbent assay. A random forests model was developed for statistical analysis.

RESULTS

The median percentage of decrease in RN volume shown on T2-weighted fluid-attenuated inversion recovery images at the end of bevacizumab therapy was 72.6% (interquartile range, 34.5% to 89.5%; P < .001). Twelve of these 50 patients (24.0%) did not have an effective response, and 38 patients (76.0%) showed an effective response after bevacizumab administration. Fifteen of the 38 patients showed RN recurrence. According to the random forests model the maximum radiation dose of the temporal lobe (D_max of the temporal lobe) was a highly ranked predictor for the therapeutic effect of bevacizumab. The duration between radiation therapy and bevacizumab treatment and the duration between radiation therapy and RN diagnosis were highly ranked predictors for RN recurrence after bevacizumab treatment.

CONCLUSIONS

Prediction models for the therapeutic effect of bevacizumab in RN patients were developed, using the random forests model. Bevacizumab might be more effective in patients with a lower maximum radiation dose to the temporal lobe.

STAT3 mediates resistance to anoikis and promotes invasiveness of nasopharyngeal cancer cells

Nasopharyngeal carcinoma (NPC), a tumor arising from the epithelial cells of the nasopharynx, is endemic in Southeast Asia and Taiwan. The prognosis of NPC patients with local recurrence and metastasis is poor. Resistance to anoikis is a primary characteristic of tumor cells that metastasize. However, the mechanism through which NPC cells resist anoikis and are able to metastasize has not been fully elucidated. In the present study, the acquisition of anoikis resistance was analyzed in the TW01 and TW06 human NPC cell lines growing under anchorage-independent conditions. A considerable number of TW01 and TW06 cells was found to be resistant to anoikis and exhibited a higher capability of migration and invasion. These anoikis-resistant NPC cells exhibited significantly increased expression of signal transducer and activation of transcription 3 (Stat3) compared with adherent cells. Furthermore, blockade of STAT3 expression by STAT3 inhibitors or STAT3 silencing significant increased anoikis in anoikis-resistant NPC cells. Moreover, silencing STAT3 not only reduced the capacity of NPC cells to resist anoikis, but also reversed their invasive properties. The expression of epithelial‑to-mesenchymal transition‑related proteins and CD44 was also significantly decreased following STAT3 knockdown. The results of the present study established that STAT3 mediates anoikis resistance, with enhanced cell migration and invasion of NPC cells, and that activation of STAT3 may increase metastatic capacity, indicating the crucial role of STAT3 in conferring anoikis resistance and enhanced invasive properties to NPC cells.