A prognostic scoring system for locoregional control in nasopharyngeal carcinoma following conformal radiotherapy

Rare early presentation of bilateral compressive optic neuropathy with complete vision loss from nasopharyngeal carcinoma

Nasopharyngeal carcinoma is very rarely associated with bilateral vision loss, and only in advanced disease. We report a case of bilateral severe compressive optic neuropathy as a first presentation from massive nasopharyngeal carcinoma with poor visual outcome despite corticosteroid, chemotherapy and radiotherapy. Red flag symptoms and signs of mass lesions in the posterior nasal space should be investigated and treated promptly to prevent devastating visual and prognostic consequences.

Serum lactate dehydrogenase is a predictive biomarker in patients with oropharyngeal cancer undergoing radiotherapy: Retrospective study on predictive factors

BACKGROUND

The present study aimed to evaluate the prognostic factors in human papillomavirus (HPV)-positive and HPV-negative oropharyngeal cancer (OPC) treated with definitive radiotherapy.

METHODS

We retrospectively evaluated 101 patients with OPC who underwent definitive radiotherapy between 2008 and 2018.

RESULTS

The median follow-up period of the surviving patients was 68 months (range, 8-164 months). The 5-year overall survival rate was 69.8%. Univariate analyses revealed that poor survival was associated with male sex, smoking ≥30 pack-years, Eastern Cooperative Oncology Group performance status ≥1, tumor-node-metastasis (TNM) stage III-IV (8th edition), HPV-negativity, serum lactate dehydrogenase (LDH) ≥202, C-reactive protein/albumin ratio ≥0.15, and lymphocyte-to-monocyte ratio <2.90. In multivariate analyses, poor survival was independently correlated with smoking ≥30 pack-years (p < 0.01) and LDH ≥202 (p = 0.02).

CONCLUSIONS

The present study suggested that high LDH levels predicted poor survival after definitive radiotherapy for patients with both HPV-positive and HPV-negative OPC.

Detailed analysis of recovery process of cranial nerve palsy after IMRT-based comprehensive treatment in nasopharyngeal carcinoma

Background

Cranial nerve (CN) palsy due to cancer involvement has been considered as an unfavorable prognostic factor for patients with nasopharyngeal carcinoma (NPC). We assessed the role of IMRT based treatment on the recovery of CN palsy and investigated the prognostic value of complete recovery of CN palsy.

Methods

A total of 115 NPC patients with cancer-related CN palsy were included in the study. We referred CTCAE version 5.0 to evaluate the grade of CN palsy.

Results

All patients with grade 1 CN palsy recovered completely during the 2 years of follow-up after definite treatment. Most grade 2 palsy could change gradually to grade 1 palsy or complete recovery during 2 years of follow-up. Patients with more than 2 symptoms of CN palsy had poor 3-year disease-free survival (DFS) than these with 1 or 2 symptoms (60.3% vs. 84.9%, HR 0.25, 95% CI 0.07–0.89, P = 0.001). There were no significant differences for PFS, OS, DMFS and LRFS between patients with complete recovery and non-complete recovery from CN palsy after receiving IMRT based comprehensive treatment.

Conclusions

IMRT based comprehensive treatment could effectively promote the recovery of tumor-related CN palsy for NPC patient. More than 2 symptoms of CN palsy was a poor prognostic factor for DFS of NPC patients. The prognostic role of complete recovery of CN palsy was not identified in our study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01846-x.

Pretreatment MRI radiomics analysis allows for reliable prediction of local recurrence in non-metastatic T4 nasopharyngeal carcinoma

BACKGROUND

To identify a radiomics signature to predict local recurrence in patients with non-metastatic T4 nasopharyngeal carcinoma (NPC).

METHODS

A total of 737 patients from Sun Yat-sen University Cancer Center (training cohort: n = 360; internal validation cohort: n = 120) and Wuzhou Red Cross Hospital (external validation cohort: n = 257) underwent feature extraction from the largest axial area of the tumor on pretreatment magnetic resonance imaging scans. Feature selection was based on the prognostic performance and feature stability in the training cohort. Radscores were generated using the Cox proportional hazards regression model with the selected features in the training cohort and then validated in the internal and external validation cohorts. We also constructed a nomogram for predicting local recurrence-free survival (LRFS).

FINDINGS

Eleven features were selected to construct the Radscore, which was significantly associated with LRFS. For the training, internal validation, and external validation cohorts, the Radscore (C-index: 0.741 vs. 0.753 vs. 0.730) outperformed clinical prognostic variables (C-index for primary gross tumor volume: 0.665 vs. 0.672 vs. 0.577; C-index for age: 0.571 vs. 0.629 vs. 0.605) in predicting LRFS. The generated radiomics nomogram, which integrated the Radscore and clinical variables, exhibited a satisfactory prediction performance (C-index: 0.810 vs. 0.807 vs. 0.753). The nomogram-defined high-risk group had a shorter LRFS than did the low-risk group (5-year LRFS: 73.6% vs. 95.3%, P < .001; 79.6% vs 95.8%, P = .006; 85.7% vs 96.7%, P = .005).

INTERPRETATION

The Radscore can reliably predict LRFS in patients with non-metastatic T4 NPC, which might guide individual treatment decisions. FUND: This study was funded by the Health & Medical Collaborative Innovation Project of Guangzhou City, China.

A Predictive Scoring Model for Short-Term Local Recurrent Nasopharyngeal Carcinoma Based on Magnetic Resonance Imaging

OBJECTIVE

To predict the early identification of recurrence based on magnetic resonance imaging (MRI) in nasopharyngeal cancer (NPC) patients.

METHODS

The clinical and MRI data of 215 patients with local recurrent NPC were retrospectively reviewed. Logistic regression analysis was performed to distinguish the independent risk factors for the short-term (less than 24 months) local recurrence of NPC. The predictive score model was based on the regression coefficients of significant independent variables.

RESULTS

Residual disease in the nasopharyngeal cavity (NC), masticator space invasion (MSI), skull base bone erosion (SBBE), and MRI-detected cranial nerve invasion (MDCNI) were all significant independent risk factors for the short-term recurrence of NPC (p < 0.05). The receiver operating characteristic curve showed that the total score had a maximal AUC (area under the curve) value of 0.897, with a cutoff point of 10.50. The sensitivity and specificity were 79.4% and 80.5%, respectively.

CONCLUSION

Residual lesions in NC, MSI, SBBE, and MDCNI are independent risk factors in predicting the short-term recurrence of NPC. The authors' findings suggest that patients with a score of more than 10.50 points should be hypervigilant regarding the possibility of short-term recurrence.

Proposal of a Pretreatment Nomogram for Predicting Local Recurrence after Intensity-Modulated Radiation Therapy in T4 Nasopharyngeal Carcinoma: A Retrospective Review of 415 Chinese Patients

PURPOSE

Local relapse-free survival (LRFS) differs widely among patients with T4 category nasopharyngeal carcinoma (NPC). We aimed to build a nomogram incorporating clinicopathological information to predict LRFS in T4 NPC after definitive intensity-modulated radiation therapy (IMRT).

MATERIALS AND METHODS

Retrospective study of 415 Chinese patients with non-metastatic T4 NPC treated with definitive IMRT with or without chemotherapy at our cancer center between October 2009 and September 2013. The nomogram for LRFS at 3 and 5 years was generated based on multivariate Cox proportional hazards regression, and validated using bootstrap resampling, assessing discriminative performance using the concordance index (C-index) and determining calibration ability via calibration curves.

RESULTS

Five-year LRFS was 88.8%. We identified and incorporated four independent prognostic factors for LRFS: ethmoid sinus invasion, primary gross tumor volume, age, and pretreatment body mass index. The C-index of the nomogram for local recurrence was 0.732 (95% confidence interval, 0.726 to 0.738), indicating excellent predictive accuracy. The calibration curve revealed excellent agreement between nomogram-predicted and observed LRFS probabilities. Risk subgroups based on total point score cutoff values enabled effective discrimination of LRFS.

CONCLUSION

This pretreatment nomogram enables clinicians to accurately predict LRFS in T4 NPC after definitive IMRT, and could help to facilitate personalized patient counselling and treatment strategies.

Post-treatment serum lactic dehydrogenase as a predictive indicator for distant metastasis and survival of patients with nasopharyngeal carcinoma

Purpose

To examine the function of serum lactic dehydrogenase (SLDH) level after intensity-modulated radiotherapy (IMRT) as a predictive factor for and loco-regional relapse free survival (LRFS), distant metastasis-free survival (DMFS), disease free survival (DFS), and overall survival(OS) among patients with in-situ nasopharyngeal carcinoma (NPC).

Results

Compared with the normal pt-SLDH group, elevated pt-SLDH demonstrated significant lower DMFS (46 versus 66 months, hazard ratio (HR) 4.07, 95% CI 2.43–6.80, p < 0.001), DFS (46 versus 63 months, HR 2.78, 95% CI 1.70–4.53, p < 0.001), and OS (54 versus 66 months, HR 2.93, 95% CI 1.65–5.23, p < 0.001). Distant metastasis were observed in 32.8% (20/61) patients with elevated pt-SLDH, and 8% (54/678) in normal SLDH (odds ratio (OR) 6.13, 95% CI 3.35–11.18, p < 0.001). COX regression showed that pt-SLDH was an independent prognostic factors for OS (HR 2.91, 95% CI 1.57–5.41, p < 0.001), DMFS (HR 4.21, 95% CI 2.51–7.07, p < 0.001), LRFS (HR 2.53, 95% CI 1.22–5.24, p < 0.001), and DFS (HR 2.81, 95% CI 1.72–4.59, p < 0.001).

Materials and Methods

The records of 739 in-situ NPC patients admitted to Zhejiang Cancer Hospital between January 2007 and May 2012 were retrospectively reviewed. The relationships between post-treatment SLDH (pt-SLDH) and LRFS, DMFS, DFS, and OS were analyzed.

Conclusions

Our finding indicated that elevated pt-SLDH could be a simple available prognostic indicator for distant metastasis and survival for in-situ NPC patients.

Accuracy of a Staging System for Prognosis of 5-Year Survival of Patients With Nasopharyngeal Carcinoma Who Underwent Chemoradiotherapy

Importance

Concurrent chemoradiotherapy delivers a high level of tumor control and survival benefits for patients with nasopharyngeal carcinoma (NPC). However, many uncertainties still exist regarding the outcomes of chemoradiotherapy, making a more precise survival prognostic system necessary.

Objective

To introduce a new staging system that combines tumor and clinical characteristics to improve the accuracy of prognosis for patients with NPC.

Design, Setting, and Participants

This cohort study enrolled 207 patients with newly diagnosed NPC who underwent concurrent chemoradiotherapy between January 1, 2007, and December 31, 2014, at Chi-Mei Medical Center in Tainan, Taiwan. Data on these patients were collected from the cancer registry database of the Chi-Mei Medical Center. Patients who had a history of cancer or were unable to complete a full course of radiotherapy were excluded. Follow-up was completed on September 30, 2016, and the data analysis was performed from January 1, 2017, to February 28, 2017.

Main Outcomes and Measures

The risk factors associated with 5-year disease-specific survival were incorporated into the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer TNM staging system to construct a new prognostic staging system. The χ2 test for linear trend, the Akaike information criterion, and the C statistic were used to evaluate the monotonicity and discriminatory ability of the new prognostic staging system and the AJCC TNM staging system.

Results

Of the 207 patients enrolled in the study, 157 (75.8%) were men, and the mean (SD) age was 48 (11) years. Multivariate analysis identified advanced clinical T stage (adjusted hazard ratio [aHR], 3.20; 95% CI, 1.58-6.48), poor performance status (aHR, 2.62; 95% CI, 1.30-5.28), and cumulative cisplatin dose lower than 100 mg/m2 (aHR, 2.28; 95% CI, 1.10-4.74) as independent prognostic factors. The β coefficients from the Cox proportional hazards regression model were used to develop an integer-based, weighted point system; advanced clinical T stage, poor performance, and cumulative cisplatin dose lower than 100 mg/m2 were each assigned a score of 1. The sum of these risk scores was stratified into new stage I (score of 0), new stage II (score of 1), new stage III (score of 2), and new stage IV (score of 3). Compared with the AJCC TNM staging system, the new prognostic staging category had better monotonicity with a higher χ2 value (17.8 vs 25.6) for linear trend, better discriminatory ability with a smaller Akaike information criterion (367 vs 360), and a greater C statistic (0.702 vs 0.740) for 5-year disease-specific survival.

Conclusions and Relevance

The new prognostic staging system has a better accuracy of prognosis of survival than the routinely used AJCC TNM staging system and thus is more useful in identifying high-risk patients for more intense treatment and care.

Pretreatment Nomograms for Local and Regional Recurrence after Radical Radiation Therapy for Primary Nasopharyngeal Carcinoma

Background: The aim of this study was to build nomograms to predict local recurrence (LR) and regional recurrence (RR) in patients with nasopharyngeal carcinoma (NPC) underwent intensity-modulated radiation therapy (IMRT).

Patients and Methods: A total of 1811 patients with non-metastatic NPC treated with IMRT (with or without chemotherapy) between October 2009 and February 2012 at our center were involved for building the nomograms. Nomograms for LR-free rate and RR-free rate at 3- and 5- year were generated as visualizations of Cox proportional hazards regression models, and validated using bootstrap resampling, estimating discrimination and calibration.

Results: With a median follow up of 49.50 months, the 3- and 5- year LR-free rate were 95.43% and 94.30% respectively; the 3- and 5- year RR-free rate were 95.94% and 95.41% respectively. The final predictive model for LR included age, the neutrophil/leukocyte ratio (NWR), pathological type, primary gross tumor volume, maxillary sinus invasion, ethmoidal sinus invasion and lacerated foramen invasion; the model for RR involved NWR, plasma Epstein-Barr virus (EBV) DNA copy number, cervical lymph node volume and N category. The models showed fairly good discriminatory ability with concordance indices (c-indices) of 0.76 and 0.74 for predicting LR and RR, respectively, as well as good calibration. The proposed stratification of risk groups based on the nomograms allowed significant distinction between Kaplan-Meier curves for LR and RR.

Conclusions: The proposed nomograms resulted in more-accurate prognostic prediction for LR and RR with a high concordance, hence to inform patients with high risk of recurrence on more aggressive therapy. The prognostic nomograms could better stratify patients into different risk groups.

The Ratio of C-Reactive Protein/Albumin is a Novel Inflammatory Predictor of Overall Survival in Cisplatin-Based Treated Patients with Metastatic Nasopharyngeal Carcinoma

The C-reactive protein/albumin (CRP/Alb) ratio has been recently identified as a prognostic factor in various cancers, whereas its role remains unclear in metastatic nasopharyngeal carcinoma (NPC). The current study retrospectively analyzed 148 patients with metastatic NPC who underwent cisplatin-based chemotherapy and further evaluated the prognostic value of the CRP/Alb ratio and its association with clinical characteristics in these patients. The optimal cut-off value was 0.189 for the CRP/Alb ratio. The high CRP/Alb ratio was significantly associated with elevated NLR, platelet-to-lymphocyte ratio (PLR), and EBV-DNA levels and decreased haemoglobin level (all p < 0.05). The results of multivariate analysis showed that the CRP/Alb ratio was an independent prognostic factor of overall survival. Patients with a high CRP/Alb ratio (≥0.189) had a 1.867 times (p = 0.024, 95% CI = 1.085–3.210) greater risk of mortality compared with those with a low CRP/Alb ratio (<0.189). In addition, combining the CRP/Alb ratio with GPS could accurately discriminate the prognosis of our patients. Our results suggested that the CRP/Alb ratio is a feasible and inexpensive tool for predicting survival outcomes and is a valuable coadjutant for the GPS to further identify differences in survivals of patients with metastatic NPC.

Proteomic Characterization Reveals a Molecular Portrait of Nasopharyngeal Carcinoma Differentiation

Nasopharyngeal carcinoma (NPC) is categorized into three different differentiated subtypes by World Health Organization (WHO). Based on an earlier comparative proteomic database of the three histological subtypes, the study was to deepen our understanding of molecular mechanisms associated with NPC differentiation through bio-information mining. Among the three subtypes were 194 differentially expressed proteins (DEPs) of 725 identified proteins. Two DEPs, heat shock protein family B (small) member 1 (HSPB1) and keratin 5 (KRT5), were validated in a series of NPC tissue samples by using immunohistochemistry. Quantified protein families including keratins, S100 proteins (S100s) and heat shock proteins exhibited characteristic expression alterations. Comparisons of predicted bio-function activation states among different subtypes, including formation of cellular protrusion, metastasis, cell death, and viral infections, were conducted. Canonical pathway analysis inferred that Rho GTPases related signaling pathways regulated the motility and invasion of dedifferentiated NPC. In conclusion, the study explored the proteomic characteristics of NPC differentiation, which could deepen our knowledge of NPC tumorigenesis and allow the development of novel targets of therapeutic and prognostic value in NPC.

The significance of diffusion tensor magnetic resonance imaging for patients with nasopharyngeal carcinoma and trigeminal nerve invasion

To investigate the significance of diffusion tensor imaging (DTI) for patients with nasopharyngeal carcinoma (NPC) and trigeminal nerve invasion.Fifty-two patients with NPC and unilateral infringement and 30 healthy controls were recruited for our study. Routine magnetic resonance imaging (MRI) and DTI were performed for all participants. Within-group and between-group comparisons of DTI metrics, including fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) of the third (V3) branch of the bilateral trigeminal nerves of all participants, were carried out.The FA and ADC values on the affected sides of patients revealed a significant decrease and increase, respectively, when compared with those on the unaffected sides of patients and the healthy controls (P = 0.000 for all), whereas there were no significant differences in DTI metrics between both sides of healthy controls or between the unaffected sides of patients and the healthy controls (P = 0.930, 0.580, 0.095, and 0.360, respectively). The decreasing FA rate on the affected sides of patients correlated negatively with the increasing ADC rate (r = -0.675, P = 0.000).DTI can quantitatively evaluate microstructural abnormalities of the V3 branch of the trigeminal nerve in patients with NPC, which is important for the early detection of trigeminal nerve invasion to achieve a precise T classification, assess prognosis, and guide treatment.

Diffusion-Weighted Imaging of Nasopharyngeal Carcinoma: Can Pretreatment DWI Predict Local Failure Based on Long-Term Outcome?

BACKGROUND AND PURPOSE

Pretreatment prediction of patients with nasopharyngeal carcinoma who will fail conventional treatment would potentially allow these patients to undergo more intensive treatment or closer posttreatment monitoring. The aim of the study was to determine the ability of pretreatment DWI to predict local failure in patients with nasopharyngeal carcinoma based on long-term clinical outcome.

MATERIALS AND METHODS

One hundred fifty-eight patients with pretreatment DWI underwent analysis of the primary tumor to obtain the ADC mean, ADC skewness, ADC kurtosis, volume, and T-stage. Univariate and multivariate analyses using logistic regression were performed to compare the ADC parameters, volume, T-stage, and patient age in primary tumors with local failure and those with local control, by using a minimum of 5-year follow-up to confirm local control.

RESULTS

Local control was achieved in 131/158 (83%) patients (range, 60.3-117.7 months) and local failure occurred in 27/158 (17%) patients (range, 5.2-79.8 months). Compared with tumors with local control, those with local failure showed a significantly lower ADC skewness (ADC values with the greatest frequencies were shifted away from the lower ADC range) (P = .006) and lower ADC kurtosis (curve peak broader) (P = .024). The ADC skewness remained significant on multivariate analysis (P = .044). There was a trend toward higher tumor volumes in local failure, but the volume, together with T-stage and ADC mean, were not significantly different between the 2 groups.

CONCLUSIONS

Pretreatment DWI of primary tumors found that the skewness of the ADC distribution curve was a predictor of local failure in patients with nasopharyngeal carcinoma, based on long-term clinical outcome.

Prognostic implications of dynamic serum lactate dehydrogenase assessments in nasopharyngeal carcinoma patients treated with intensity-modulated radiotherapy

The prognostic value of dynamic serum lactate dehydrogenase (LDH) levels in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT) hasn’t been explored. We retrospectively analyzed 1,428 cases of NPC treated with IMRT with or without chemotherapy. Elevated pre- and/or post-treatment LDH levels were found to be associated with unfavorable overall survival (OS), disease-free survival (DFS) and distant metastasis-free survival (DMFS), but not with local relapse-free survival (LRFS). The dynamic variations in LDH levels were prognostic factors for OS, DFS and DMFS, but not for LRFS. Multivariate analysis revealed that the N category, T category, post-treatment serum LDH level and age were independent prognostic factors for OS. Our results demonstrated that dynamic variations in LDH levels were associated with risk of distant failure and death, which may shed light on the dynamics of the disease and the response to therapy. We consider that LDH measurements will be of great clinical importance in the management of NPC, especially, when considering “decision points” in treatment algorithms. Therefore, we strongly recommend that LDH levels should be determined before and after treatment in NPC patients and the results integrated into decisions regarding treatment strategies.

Risk factors and prediction-score model for distant metastasis in nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

The objective of this study is to identify the risk factors and construct a prediction-score model for distant metastasis (DM) in nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiotherapy (IMRT). A total of 520 nonmetastatic NPC patients were analysed retrospectively. The independent risk factors for DM were tested by multivariate Cox regression analysis. The prediction-score model was established according to the regression coefficient. The median follow-up was 88.4 months. The 5-year DM rate was 15.1%. N2-3, primary tumour volume of nasopharynx (GTVnx) >24.56 cm(3), haemoglobin change after treatment (ΔHGB) >25.8 g/L, albumin-globulin ratio (AGR) ≤1.34, pretreatment neutrophil-lymphocyte ratio (NLR) >2.81 and pretreatment serum lactate dehydrogenase (LDH) >245 U/L were significantly adverse independent predictive factors for DM. Three subgroups were defined based on the prediction-score model: low risk (0-2), intermediate risk (3-4) and high risk (5-8). The 5-year DM rates were 4.6, 21.8 and 50.8%, respectively (P < 0.001). The areas under the curve for DM in the prediction-score model and the UICC/AJCC staging system seventh edition were 0.748 and 0.627, respectively (P < 0.001). The scoring model is useful in evaluating the risk of DM in IMRT-treated NPC patients and guiding future therapeutic trials. Further prospective study is needed.

Prognostic model for distant metastasis in locally advanced nasopharyngeal carcinoma after concurrent chemoradiotherapy

BACKGROUND

A prognostic model should be established for distant metastasis in locally advanced nasopharyngeal carcinoma (NPC) after concurrent chemoradiotherapy (CCRT).

METHODS

Patients with locally advanced NPC who received CCRT were divided into a construction set (230 patients) and a validating set (115 patients). The constructed index was derived on the former and then tested on the latter.

RESULTS

The prognostic score was defined as the number of adverse prognostic factors: age >45, N3 category, hemoglobin <11.0 g/dL and lactate dehydrogenase ≥240 U/L. The score predicted the 5-year distant metastasis-free survival as follows: 0, 91%; 1, 74%; 2, 51%; and ≥3, 12%. In the validating set, the observed 5-year distant metastasis-free survival of these 4 groups with scores of 0, 1, 2, 3, or higher were 81%, 68%, 47%, and 15%, respectively.

CONCLUSION

The established model might be useful for predicting the risk of distant metastasis in patients with locally advanced NPC who underwent CCRT and may identify the patients' need for intensified adjuvant chemotherapy.

Prognostic value of pretreatment serum alkaline phosphatase in nasopharyngeal carcinoma

BACKGROUND

The prognostic value of serum alkaline phosphatase (S-ALP) has not been fully validated for nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

S-ALP levels were measured in 601 patients newly diagnosed with NPC before radical treatment, and possible associations of these levels with 5-year overall survival (OS) and tumor-free survival (TFS) were explored using univariate and multivariate analyses.

RESULTS

Elevated pretreatment S-ALP (>85 U/L) was significantly less frequent among patients classified as T1+2 or stage I+II than among those classified as T3+4 or stage III+IV. Multivariate analysis showed that elevated pretreatment S-ALP (>85 U/L), age, T classification and N stage were independent predictors of poor OS and TFS.

CONCLUSIONS

Pretreatment S-ALP may be a reliable biomarker to evaluate the long-term prognosis of patients with NPC.

Nasopharyngeal carcinoma presenting with rapidly progressive severe visual disturbance: a case report

INTRODUCTION

Nasopharyngeal carcinoma is one of the most difficult tumors to diagnose correctly at the initial phase because of the occasional lack of nasal symptoms. The perineural spread of the trigeminal nerve is one of the most common and important routes in the intracranial paracavernous extension of nasopharyngeal carcinoma, but visual loss is very rare.

CASE PRESENTATION

We report the case of a 54-year-old Japanese man with nasopharyngeal carcinoma, who presented with rapid and severe disturbance of left monocular visual acuity and eye movement with a 10-month history of ipsilateral otitis media and facial pain. Magnetic resonance imaging revealed a lesion in the left fossa of Rosenmüller, pterygopalatine fossa, sphenoid and ethmoid sinus, and the left cavernous sinus extending to the orbital apex through the superior orbital fissure. The histopathological diagnosis was nonkeratinizing undifferentiated nasopharyngeal carcinoma. Epstein-Barr virus was detected by in situ hybridization. Although focal radiotherapy induced remarkable tumor shrinkage and relieved ocular motor disturbance and facial pain, his visual acuity did not improve.

CONCLUSION

The awareness of cranial nerves in addition to intracranial and orbital apex involvement, as in this case, is important for appropriate diagnosis and treatment planning of nasopharyngeal carcinoma.

Prognostic value of pretreatment serum levels of lactate dehydrogenase in nonmetastatic nasopharyngeal carcinoma: single-site analysis of 601 patients in a highly endemic area

Background

Numerous studies have generated promising but incomplete evidence for the prognostic value of pretreatment serum levels of lactate dehydrogenase (S-LDH) in nasopharyngeal carcinoma (NPC).

Methods

Pretreatment serum levels of S-LDH in 601 patients with NPC were measured before treatment, and their associations with overall survival and tumor-free survival were studied. Univariate and multivariate analysis of subgroups was used to evaluate the prognostic value of S-LDH in early-stage and late-stage NPC separately.

Results

Pretreatment S-LDH levels were significantly lower in T1+2 patients than in T3+4 patients, lower in N0+1 patients than in N2+3 ones, and lower in stage I + II patients than in III + IV ones. Multivariate analysis showed that among patients with late-stage NPC, high pretreatment S-LDH levels >225 U/L were an independent predictor of poor overall survival and tumor-free survival. Among patients with early-stage NPC, pretreatment S-LDH levels >171 U/L, which overlap with the normal range, were an independent predictor of shorter overall survival and tumor-free survival.

Conclusion

Pretreatment S-LDH levels may be a reliable biomarker for predicting the long-term prognosis of patients with early-stage or late-stage NPC.

MR imaging prediction of local control of nasopharyngeal carcinoma treated with radiation therapy and chemotherapy

OBJECTIVE

To retrospectively evaluate the association of MRI findings with local control of nasopharyngeal carcinoma (NPC) treated with radiation therapy and chemotherapy (chemoradiotherapy).

METHODS

Pre-treatment MRIs of 101 patients (78 males and 23 females, 23-79 years of age) who had NPC treated with chemoradiotherapy were retrospectively reviewed to evaluate tumour involvement of nasopharyngeal anatomic subsites, tumour volume and MRI appearance. Local control rates were evaluated with respect to these MRI findings.

RESULTS

Univariate analysis (using the Kaplan-Meier method) showed that invasion of the skull base as determined by MRI was a significant predictor of local control. In terms of clinical characteristics, T stage and pathological subtype were significant predictors of local control. Multivariate analysis (Cox regression model) of the radiologic findings and clinical characteristics revealed that invasion of the skull base (p = 0.003) and pathological subtype (p < 0.001) were independent prognostic factors for local control.

CONCLUSION

Invasion of the skull base as determined by MRI predicts the likelihood of local failure and may be helpful in identifying a subset of patients with tumours at risk of local recurrence within 3 years after primary chemoradiotherapy.

ADVANCES IN KNOWLEDGE

It has now become common practice to use MRI for pre-treatment evaluation of patients with NPC. The potential role for MRI findings in predicting local control and prognosis in patients with NPC has implications for treatment planning.

Prognostic scoring system for locoregional control among the patients with nasopharyngeal carcinoma treated by intensity-modulated radiotherapy

The prognostic value of T category for locoregional control in patients with nasopharyngeal carcinoma (NPC) has decreased with the extensive use of intensity-modulated radiotherapy (IMRT). We aimed to develop a prognostic scoring system (PSS) that incorporated tumor extension and clinical characteristics for locoregional control in NPC patients treated with IMRT. The magnetic resonance imaging scans and medical records of 717 patients with nonmetastatic NPC treated with IMRT at Sun Yat-sen University Cancer Center between January 2003 and January 2008 were reviewed. Age, pathologic classification, primary tumor extension, primary gross tumor volume (GTV-p), T and N categories, and baseline lactate dehydrogenase (LDH) level were analyzed. Hierarchical cluster analysis as well as univariate and multivariate analyses were used to develop the PSS. Independent prognostic factors for locoregional relapse included N2–3 stage, GTV-p ≥26.8 mL, and involvement of one or more structures within cluster 3. We calculated a risk score derived from the regression coefficient of each factor and classified patients into four groups: low risk (score 0), intermediate risk (score >0 and ≤1), high risk (score >1 and ≤2), and extremely high risk (score >2). The 5-year locoregional control rates for these groups were 97.4%, 93.6%, 85.2%, and 78.6%, respectively (P < 0.001). We have developed a PSS that can help identify NPC patients who are at high risk for locoregional relapse and can guide individualized treatments for NPC patients.

High pretreatment serum lactate dehydrogenase level correlates with disease relapse and predicts an inferior outcome in locally advanced nasopharyngeal carcinoma

PURPOSE

Here, we evaluate the prognostic effect of pretreatment serum lactate dehydrogenase (LDH) in locally advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

Pretreatment serum samples from a randomized controlled trial, which contained 199 neoadjuvant chemoradiotherapy patients and 201 neoadjuvant-concurrent chemoradiotherapy cases with locally advanced NPC, were collected and examined for LDH. With 5-year follow-up, the prognostic effect of pretreatment serum LDH was analysed by Kaplan-Meier analysis and multivariate Cox regression model.

RESULTS

Three hundred and sixty-seven patients (91.75%) had a normal (109.0-245.0 U/L) pretreatment LDH level, compared to 33 cases (8.25%) that had a higher (≥245.0 U/L) LDH level. The mean and median pretreatment LDH levels of these 400 patients were 186.6 and 174.0 U/L (range, 83.0-751.0 U/L), respectively. Compared with the normal subset, elevated LDH level predicted an inferior 5-year overall survival (56.9% versus 76.8%, P=0.004), disease-free survival (DFS, 45.4% versus 64.7%, P=0.001), local relapse-free survival (76.1% versus 89.6%, P=0.019) and distant metastasis-free survival (DMFS, 54.3% versus 72.2%, P=0.001). Multivariate analysis confirmed that the LDH level was an independent prognostic factor to predict death, disease progression, local relapse and distant metastasis. For the subgroup with normal LDH (median point of 177.0 U/L), we detected an evident 5-year DFS (68.8% versus 59.5%, P=0.047) and DMFS advantage (77.3% versus 65.3%, P=0.016) in 109.0-177.0 U/L subset than that of 178.0-245.0 U/L subgroup.

CONCLUSIONS

Serological LDH level was an independent prognostic factor for locally advanced NPC. Combining pretreatment LDH with TNM staging might lead to more accurate risk definition.

A novel statistical prognostic score model that includes serum CXCL5 levels and clinical classification predicts risk of disease progression and survival of nasopharyngeal carcinoma patients

BACKGROUND

Aberrant expression of C-X-C motif chemokine 5 (CXCL5) contributes to the progression of various cancers. This study analyzed the clinical significance of serum CXCL5 (sCXCL5) levels of nasopharyngeal carcinoma (NPC) patients, with the goal of building a novel prognostic score model.

EXPERIMENTAL DESIGN

Serum samples were collected prior to treatment from 290 NPC patients for the detection of sCXCL5 with ELISA. Half of the patients (n = 145) were randomly assigned to the training set to generate the sCXCL5 cutoff point using receiver operator characteristic (ROC) analysis, while the other half (n = 145) were assigned to the testing set for validation. Associations between sCXCL5 levels and clinical characteristics were analyzed. A prognostic score model was built using independent predictors derived from multivariate analysis. A concordance index (C-Index) was used to evaluate prognostic ability.

RESULTS

The sCXCL5 cutoff point was 0.805 ng/ml. Sex, age, histology, T classification, clinical classification and local recurrence were not associated with sCXCL5 levels. However, sCXCL5 levels were positively associated with N classification, distant metastasis and disease progression (P<0.05). A high sCXCL5 level predicted poor 6-year overall survival (OS), poor 6-year distant metastasis-free survival (DMFS), and poor 6-year progression-free survival (PFS). A prognostic score model was subsequently constructed based on sCXCL5 levels and clinical classification (C-C model), which are independent predictors of OS, DMFS, and PFS, as confirmed by the multivariate analysis. Furthermore, this novel model successfully divided the patients into four risk subgroups in the training set, the testing set and the entire set of patients. The C-Indices were 0.751 and 0.762 for the training set and the testing set, respectively.

CONCLUSIONS

sCXCL5 level was determined to be an independent prognostic factor for NPC patients. The novel statistical C-C model, which includes sCXCL5 levels and clinical classification, could be helpful in predicting the prognosis of NPC patients.

Prognostic value of pretreatment and recovery duration of cranial nerve palsy in nasopharyngeal carcinoma

Background

The purpose of this study was to evaluate the prognostic value of cranial nerve (CN) palsy in nasopharyngeal carcinoma (NPC) patients.

Methods

A retrospective analysis was performed on CN involvement using medical records of 178 consecutive patients with histologically diagnosed, non-disseminated NPC.

Results

In 178 NPC patients with CN palsy, the 5-year survival rates were as follows: overall survival (OS), 61.0%; disease-specific survival (DSS), 69.6%; local relapse-free survival (LRFS), 75.2%; distant metastasis-free survival (DMFS), 73.4%; and disease-free survival (DFS), 55.3%. Significant differences were observed in the 5-year OS rates between patients with single and multiple CN palsy (69.8% vs. 54.3%; P = 0.033) and the OS rates between patients with different pretreatment durations (68.7% vs. 43.3%, P = 0.007). However, no significant differences were observed in OS, DSS, LRFS and DFS rates between patients with upper and lower CN palsy (P = 0.581, P = 0.792, P = 0.729 and P = 0.212, respectively). The results showed that recovery duration was an independent prognostic factor for OS (HR = 2.485; P < 0.001), DSS (HR = 2.065; P = 0.016), LRFS (HR = 3.051; P = 0.001) and DFS (HR = 2.440; P < 0.001).

Conclusions

Recovery duration is an independent prognostic factor for NPC patients with CN palsy and is related to recurrence, which leads to poor survival. Recovery duration requires close surveillance and different treatment regimens.

Outcomes following treatment for patients with cranial nerve involvement from nasopharyngeal cancer

INTRODUCTION

Patients with locally advanced nasopharyngeal carcinoma (NPC) commonly present with cranial nerve (CN) involvement, which can cause significant morbidity. We aimed to characterise the pattern of involvement and outcomes of these patients, as well as determine if these differed according to the mode of diagnosis.

METHODS

Patients were included if they had non-distant metastatic NPC, presented with CN involvement and completed radiotherapy treatment between 2002 and 2008. The clinical response was categorised as complete response, partial response, stable or progressive disease. The radiological response was assessed using the Response Evaluation Criteria in Solid Tumors criteria. The loco-regional control and disease-free survival rates were estimated with the Kaplan-Meier method.

RESULTS

Forty-seven patients fulfilled the inclusion criteria. CN lesions were diagnosed on clinical examination in 15% of patients, radiologically in 40% and both clinically and radiologically in 45% of patients. A complete or partial response of the CN lesions was seen clinically in 82% and radiologically in 95% of patients. The 3-year local relapse free survival was 64.3%, distant metastasis-free survival was 46.1% and overall survival was 82.8%. There were no differences in outcomes between patients with clinically versus radiologically detected CN lesions.

CONCLUSION

Most of these patients are likely to undergo clinical and/or radiological resolution of the nerve lesions following chemoradiotherapy, but the outcome was not determined by the mode of diagnosis (radiological or clinical).

Increased pretreatment levels of serum LDH and ALP as poor prognostic factors for nasopharyngeal carcinoma

Serum enzymes that play potential roles in tumor growth have recently been reported to have prognostic relevance in a diverse array of tumors. However, prognosis-related serum enzymes are rarely reported for nasopharyngeal carcinoma (NPC). To clarify whether the level of serum enzymes is linked to the prognosis of NPC, we reviewed the pretreatment data of lactate dehydrogenase (LDH), alkaline phosphatase (ALP), and glutamyl transferase (GGT) in 533 newly diagnosed NPC patients who underwent radical radiotherapy between May 2002 and October 2003 at Sun Yat-sen University Cancer Center. Patients were grouped according to the upper limit of normal values of LDH, ALP, and GGT. The Kaplan-Meier method and log-rank test were used for selecting prognostic factors from clinical characteristics and serum enzymes, and the Chi-square test was applied to analyze the relationships of clinical characteristics and serum enzymes. Finally, a Cox proportional hazards model was used to identify the independent prognostic factors. We found that increased levels of LDH had poor effects on both overall survival and distant metastasis-free survival (P = 0.009 and 0.035, respectively), and increased pretreatment level of serum ALP had poor effects on both overall survival and local recurrence-free survival (P = 0.037 and 0.039, respectively). In multivariate analysis, increased LDH level was identified as an independent prognostic factor for overall survival. Therefore, we conclude that increased pretreatment serum LDH and ALP levels are poor prognostic factors for NPC.

Baseline serum lactate dehydrogenase levels for patients treated with intensity-modulated radiotherapy for nasopharyngeal carcinoma: a predictor of poor prognosis and subsequent liver metastasis

PURPOSE

To evaluate the prognostic value of baseline serum lactate dehydrogenase (LDH) levels in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

Cases of NPC (n = 465) that involved treatment with IMRT with or without chemotherapy were retrospectively analyzed.

RESULTS

The mean (±SD) and median baseline serum LDH levels for this cohort were 172.77 ± 2.28 and 164.00 IU/L, respectively. Levels of LDH were significantly elevated in patients with locoregionally advanced disease (p = 0.016). Elevated LDH levels were identified as a prognostic factor for rates of overall survival (OS), disease-free survival (DFS), and distant metastasis-free survival (DMFS), with p values <0.001 in the univariate analysis and p < 0.001, p = 0.004, and p = 0.003, respectively, in the multivariate analysis. Correspondingly, the prognostic impact of patient LDH levels was found to be statistically significant for rates of OS, DFS, and DMFS (p = 0.028, 0.024, and 0.020, respectively). For patients who experienced subsequent liver failure after treatment, markedly higher pretreatment serum LDH levels were detected compared with patients experiencing distant metastasis events at other sites (p = 0.032).

CONCLUSIONS

Elevated baseline LDH levels are associated with clinically advanced disease and are a poor prognosticator for OS, DFS, and DMFS for NPC patients. These results suggest that elevated serum levels of LDH should be considered when evaluating treatment options.

Prognostic value of prevertebral space involvement in nasopharyngeal carcinoma based on intensity-modulated radiotherapy

PURPOSE

To investigate the prognostic significance of prevertebral space involvement (PSI) in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

A retrospective review of data from 506 biopsy-proven, nonmetastatic NPCs was performed. Patients underwent magnetic resonance imaging examinations and received IMRT as their primary treatment.

RESULTS

In this series, 161 NPC patients (31.8%) had PSI. Parapharyngeal space (p < 0.001), skull base (p < 0.001), and paranasal sinuses (p = 0.009) were associated with PSI after multivariate analysis. The 4-year overall survival (OS), local relapse-free survival (LRFS), distant metastasis-free survival (DMFS) for NPC patients with and without PSI was 69.1% and 89.2% (p < 0.0001), 83.9% and 96.4% (p < 0.0001), and 71.6% and 89.6% (p < 0.0001), respectively. Multivariate analysis identified PSI as an independent negative prognostic factor for both OS (HR = 1.478-4.380; p = 0.001) and DMFS (HR = 1.389-4.174; p = 0.002). Patients with PSI had similar survival rates in OS and DMFS (p = 0.241 and p = 0.493, respectively) to that of T4 disease, while the differences between PSI and T3 disease in both OS and DMFS were distinctly significant (p = 0.029 and p = 0.029, respectively).

CONCLUSIONS

For NPC patients treated with IMRT, PSI was found to be an independent prognostic factor for both OS and DMFS. It seems reasonable that PSI should be classified as a T4 disease on the basis of the current American Joint Committee on Cancer staging classification criteria.

Increased risk of ischemic stroke in young nasopharyngeal carcinoma patients

PURPOSE

Radiation/chemoradiotherapy-induced carotid stenosis and cerebrovascular events in patients with nasopharyngeal carcinoma (NPC) can cause severe disability and even death. This study aimed to estimate the risk of ischemic stroke in this patient population over more than 10 years of follow-up.

METHODS AND MATERIALS

The study cohorts consisted of all patients hospitalized with a principal diagnosis of NPC (n=1094), whereas patients hospitalized for an appendectomy during 1997 and 1998 (n=4376) acted as the control group and surrogate for the general population. Cox proportional hazard model was performed as a means of comparing the stroke-free survival rate between the two cohorts after adjusting for possible confounding and risk factors.

RESULTS

Of the 292 patients with ischemic strokes, 62 (5.7%) were from the NPC cohort and 230 (5.3%) were from the control group. NPC patients ages 35-54 had a 1.66 times (95% CI, 1.16-2.86; p=0.009) higher risk of ischemic stroke after adjusting for patient characteristics, comorbidities, geographic region, urbanization level of residence, and socioeconomic status. There was no statistical difference in ischemic stroke risk between the NPC patients and appendectomy patients ages 55-64 years (hazard ratio=0.87; 95% CI, 0.56-1.33; p=0.524) after adjusting for other factors.

CONCLUSIONS

Young NPC patients carry a higher risk for ischemic stroke than the general population. Besides regular examinations of carotid duplex, different irradiation strategies or using new technique of radiotherapy, such as intensity modulated radiation therapy or volumetric modulated arc therapy, should be considered in young NPC patients.

Validation of bidimensional measurement in nasopharyngeal carcinoma

BACKGROUND

Our previous study showed a close relationship between computed tomography (CT)-derived bidimensional measurement of primary tumor and retropharyngeal nodes (BDMprn) and gross tumor volume of primary tumor and retropharyngeal nodes (GTVprn) in nasopharyngeal carcinoma (NPC) and better prognosis for NPC patients with smaller BDMprn. In this study, we report the results on of a study to validate the use of BDM in a separate cohort of NPC patients.

METHODS

We retrospectively reviewed 103 newly diagnosed NPC cases who were treated with radiotherapy/concurrent chemoradiotherapy (CCRT) or CCRT with adjuvant chemotherapy from 2002 to 2009. We used magnetic resonance imaging (MRI) to measure BDMprn. We calculated overall survival, recurrence-free and distant metastasis-free survival curves and set a BDMprn cut off point to categorize patients into a high- or low-risk group. We then used Cox proportional hazard model to evaluate the prognostic influence of BDMprn after correcting age, gender and chemotherapy status.

RESULTS

After adjusting for age, gender, and chemotherapy status, BDMprn remained an independent prognostic factor for distant metastasis [Hazard ratio (HR) = 1.046; P = 0.042] and overall survival (HR = 1.012; P = 0.012). Patients with BDMprn < 15 cm2 had a greater 3-year overall survival rate than those with BDMprn > or = 15 cm2 (92.3% vs. 73.7%; P = 0.009). They also had a greater 3-year distant metastasis-free survival (94% vs.75%; P = 0.034).

CONCLUSION

The predictive ability of BDMprn was validated in a separate NPC cohort. A BDMprn of 15 cm2 can be used to separate NPC patients into high- and low-risk groups and predict survival rates and metastasis potential. It can, therefore, be used as a reference to design clinical trials, predict prognosis, and make treatment decisions.

Prognostic impact of magnetic resonance imaging-detected cranial nerve involvement in nasopharyngeal carcinoma

BACKGROUND

: The purpose of this study was to evaluate the prognostic value of magnetic resonance imaging (MRI)-detected cranial nerve (CN) involvement in nasopharyngeal carcinoma (NPC).

METHODS

: Retrospective analysis was made of the magnetic resonance images and medical records of 924 consecutive patients with newly diagnosed NPC.

RESULTS

: Of 924 patients, 82 (8.9%) initially presented with CN palsy. CN involvement was seen on MRI in 333 (36%) patients. In T3-4 disease, MRI-evidenced CN involvement was associated with poor 3-year overall survival (OS) (35.7% vs 89.2%, P = .001) and distant metastasis-free survival (DMFS) (77.1% vs 87.8%, P = .002) rates. The survival curves of OS and DMFS for T3 disease with MRI-detected CN involvement approximated those of T4 disease (P = .322 and P = .809, respectively). In patients with MRI-detected CN involvement, no significant differences were observed in 3-year OS (78.3% vs 72.9%, P = .120), local relapse-free survival (LRFS) (89.7% vs 84.1%, P = .154), or DMFS (79.6% vs 74.8%, P = .466) rates between those with and without intracranial or orbital CN involvement. Furthermore, in patients with clinical and/or MRI-detected CN involvement, there were no significant differences in the 3-year OS (74.2% vs 80.1%, P = .067), LRFS (86.7% vs 87.9%, P = .899), or DMFS (74.6% vs 84.6%, P = .094) rates between symptomatic and asymptomatic patients.

CONCLUSIONS

: The incidence of MRI-detected CN involvement was higher than CN palsy. MRI-detected CN involvement has a negative impact on the prognosis independent of lesion localization and symptoms. Cancer 2009. (c) 2009 American Cancer Society.