Salvage surgery for nasopharyngeal cancer

Natural compounds targeting YAP/TAZ axis in cancer: Current state of art and challenges

Cancer has become a burgeoning global healthcare concern marked by its exponential growth and significant economic ramifications. Though advancements in the treatment modalities have increased the overall survival and quality of life, there are no definite treatments for the advanced stages of this malady. Hence, understanding the diseases etiologies and the underlying molecular complexities, will usher in the development of innovative therapeutics. Recently, YAP/TAZ transcriptional regulation has been of immense interest due to their role in development, tissue homeostasis and oncogenic transformations. YAP/TAZ axis functions as coactivators within the Hippo signaling cascade, exerting pivotal influence on processes such as proliferation, regeneration, development, and tissue renewal. In cancer, YAP is overexpressed in multiple tumor types and is associated with cancer stem cell attributes, chemoresistance, and metastasis. Activation of YAP/TAZ mirrors the cellular "social" behavior, encompassing factors such as cell adhesion and the mechanical signals transmitted to the cell from tissue structure and the surrounding extracellular matrix. Therefore, it presents a significant vulnerability in the clogs of tumors that could provide a wide window of therapeutic effectiveness. Natural compounds have been utilized extensively as successful interventions in the management of diverse chronic illnesses, including cancer. Owing to their capacity to influence multiple genes and pathways, natural compounds exhibit significant potential either as adjuvant therapy or in combination with conventional treatment options. In this review, we delineate the signaling nexus of YAP/TAZ axis, and present natural compounds as an alternate strategy to target cancer.

A Case of Photoimmunotherapy for Nasopharyngeal Carcinoma Requiring Emergency Tracheostomy

Introduction

Photoimmunotherapy (PIT) is a treatment wherein intravenous cetuximab sarotalocan sodium is administered followed by laser light irradiation. This treatment exhibits a specific antitumor effect if in tumors expressing the epidermal growth factor receptor, regardless of the carcinoma [Mitsunaga et al.: Nat Med. 2011;17(12):1685-91, Sato et al.: ACS Cent Sci. 2018;4(11):1559-69, Nakajima et al.: Cancer Sci. 2018;109(9):2889-96]. The current indications are unresectable, locally advanced, or locally recurrent head and neck cancer. If standard treatments, such as radiotherapy and chemotherapy, are available, they are given priority. However, a significant concern in PIT is the occurrence of airway emergencies related to pharyngeal edema. Prophylactic tracheostomy is often performed in cases of PIT involving the root of the tongue, hypopharynx, or larynx.

Case Presentation

In this study, we administered transoral PIT to a patient diagnosed with radiation-induced nasopharyngeal carcinoma (squamous cell carcinoma (SCC) cT1N0M0 stage I). Although previous case reports and our own experiences did not report airway emergencies following PIT for nasopharyngeal carcinoma, a unique case occurred in our study [Omura et al.: Auris Nasus Larynx. 2023;50(4):641-5, Kushihashi et al.: Int J Otolaryngol Head Neck Surg. 2022;11(5, Sep):258-65]. The patient experienced poor oxygenation and a decreased level of consciousness early in the morning following the laser irradiation. Nasal endoscopy revealed airway narrowing due to upper airway edema, and intubation was challenging. Consequently, we performed emergency bedside tracheostomy and the patient's condition improved.

Conclusion

Therefore, it is crucial to note that airway emergencies can be life-threatening and should be diligently monitored as a potential complication of PIT.

Nasopharyngectomy Without Maxillary Swing via a Combined Open Lateral and Endoscopic Approach

Nasopharyngeal tumors in the proximity of the internal carotid artery are often difficult to dissect. Here, we describe a combined transcervical and endoscopic endonasal approach that provides improved internal carotid artery protection and confident tumor resection. Laryngoscope, 133:105-108, 2023.

Reconstruction of nasopharyngeal defect with submental flap during surgery for nasopharyngeal malignant tumors

Objective

To investigate the feasibility and effect of a pedicled submental flap in postoperative defect repair of nasopharyngeal malignant tumors.

Methods

Eight cases (six women, two men; age, 29–63 years) of postoperative defects after resection of malignant nasopharyngeal tumors with a lesion stage of (r) T_1–3N_0–2M₀ were retrospectively analyzed. Preoperative enhanced thin-slice computed tomography of the neck was performed to predict the submental flap reflux vein. The submental flap was prefabricated during the operation, and the nasopharyngeal mass was removed through the parapharyngeal space approach combined with nasal endoscopy/mandibular external rotation/maxillary overturning. The submental flap was elevated to the nasopharyngeal defect area through the parapharyngeal space for repair.

Results

Intraoperative examination confirmed that among the eight submental flaps, three had venous drainage into the internal jugular vein and five had venous drainage into the external jugular vein; these findings were consistent with the preoperative computed tomography findings. The size of the submental flap was 8–10 cm × 5–6 cm. The repair range reached the eustachian orifice on the healthy side and extended to the posterior wall of the maxillary sinus on the affected side. The flap extended to the posterior upper part of the nasal septum at the top, to the oropharynx at the bottom, and to the bony surface of the skull base at the deep side. Primary healing after surgery was achieved, and no flap necrosis occurred. After 3–77 months of follow-up, one patient with recurrent nasopharyngeal carcinoma after radiotherapy developed cervical lymph node recurrence again, one patient with adenoid cystic carcinoma had lung metastasis, and the remaining six patients had no recurrence.

Conclusions

The pedicled submental flap is used to repair postoperative defects in the nasopharyngeal region through the cervical parapharyngeal space. It is a simple and fast procedure with adequate tissue volumes. The flap can effectively protect important structures such as the internal carotid artery and reduce the risk of infection and bleeding from postoperative wound exposure.

Treatment of Recurrent Nasopharyngeal Carcinoma: A Sequential Challenge

Simple Summary

Recurrent nasopharyngeal carcinoma is one of the major causes of death among NPC patients. However, there are no international guidelines for the treatment of patients with recurrent NPC now. In this article, we summarize past publications on clinical research and mechanistic studies related to recurrent NPC, combined with the experience and lessons learned by our institutional multidisciplinary team in the treatment of recurrent NPC. We propose an objective protocol for the treatment of recurrent NPC.

Abstract

Recurrent nasopharyngeal carcinoma (NPC), which occurs in 10–20% of patients with primary NPC after the initial treatment modality of intensity-modulated radiation therapy (IMRT), is one of the major causes of death among NPC patients. Patients with recurrent disease without distant metastases still have a chance to be saved, but re-treatment often carries more serious toxicities or higher risks. For this group of patients, both otolaryngologists and oncologists are committed to developing more appropriate treatment regimens that can prolong patient survival and improve survival therapy. Currently, there are no international guidelines for the treatment of patients with recurrent NPC. In this article, we summarize past publications on clinical research and mechanistic studies related to recurrent NPC, combined with the experience and lessons learned by our institutional multidisciplinary team in the treatment of recurrent NPC. We propose an objective protocol for the treatment of recurrent NPC.

Health Insurance Coverage and Survival Outcomes among Nasopharyngeal Carcinoma Patients: A SEER Retrospective Analysis

Objectives Insurance coverage plays a critical role in head and neck cancer care. This retrospective study examines how insurance coverage affects nasopharyngeal carcinoma (NPC) survival in the United States using the Surveillance, Epidemiology, and End Results (SEER) program database.

Design, Setting, and Participants A total of 2,278 patients aged 20 to 64 years according to the International Classification of Diseases for Oncology (ICD-O) codes C11.0–C11.9 and ICD-O histology codes 8070–8078 and 8080–8083 between 2007 and 2016 were included and grouped into privately insured, Medicaid, and uninsured groups. Log-rank test and multivariable Cox's proportional hazard model were performed.

Main Outcome Measures Tumor stage, age, sex, race, marital status, disease stage, year of diagnosis, median household county income, and disease-specific survival outcomes including cause of death were analyzed.

Results Across all tumor stages, privately insured patients had a 59.0% lower mortality risk than uninsured patients (hazard ratio [HR]: 0.410, 95% confidence interval [CI]: [0.320, 0.526], p < 0.01). Medicaid patients were also estimated to have 19.0% lower mortality than uninsured patients (HR: 0.810, 95% CI: [0.626, 1.048], p = 0.108). Privately insured patients with regional and distant NPC had significantly better survival outcomes compared with uninsured individuals. Localized tumors did not show any association between survival and type of insurance coverage.

Conclusion Privately insured individuals had significantly better survival outcomes than uninsured or Medicaid patients, a trend that was preserved after accounting for tumor grade, demographic and clinicopathologic factors. These results underscore the difference in survival outcomes when comparing privately insured to Medicaid/uninsured populations and warrant further investigation in efforts for health care reform.

Open and endoscopic surgery improve survival for squamous and nonsquamous cell nasopharyngeal carcinomas: An NCDB cohort study

BACKGROUND

Nasopharyngeal tumors (NPTs) are primarily treated with nonsurgical therapy. Recent studies have demonstrated endoscopic salvage surgery for NPT recurrences may improve survival relative to reirradiation. However, there are very limited data on open compared with endoscopic approaches for NPTs. We investigated whether endoscopic and open surgical approaches to the nasopharynx improve overall survival for all histologic subtypes of NPTs.

METHODS

We performed a retrospective cohort study using the National Cancer Database (NCDB). All adult patients with NPTs from 2004 to 2016 without distant metastasis who underwent treatment with curative intent were included. We extracted clinical and treatment variables to assess our primary outcome of overall survival.

RESULTS

On univariate analysis, patients undergoing endoscopic surgery, but not open surgery, had significantly improved overall survival relative to those undergoing nonsurgical treatment. Post hoc analysis demonstrated significantly improved overall survival for surgery in patients with minor salivary gland histology, but not squamous cell carcinoma (SCC) histology or by T or N classification. A Cox proportional hazards model was used for multivariate regression. After adjusting for covariates, both endoscopic and open approaches were associated with improved overall survival relative to nonsurgical treatment for all tumor types. A multivariate regression of SCC found that open surgery, but not endoscopic surgery, was significantly associated with improved overall survival.

CONCLUSION

Both endoscopic and open surgical approaches are associated with improved overall survival of patients with NPT. These findings highlight important oncologic validity as endoscopic and robotic platforms to the nasopharynx become more widely adopted.

Nasopharyngeal carcinoma: A new synthesis of literature data (Review)

Nasopharyngeal carcinoma (NPC) is an epithelial tumor, which develops most frequently from the lateral pharyngeal recess and holds some complex epidemiological characteristics. Its unusual race and geographic distribution suggests that not only the environmental factors are a contributing factor to the development of this rare cancer type, but also the genetic traits play an important role, along with nitrosamine-containing food consumption and Epstein-Barr virus infection. The signs and symptoms which a patient can present and suffer from are various and include nasal, otic, neurological as well as general ones; the way this tumor manifests being dependent on the stage of the tumor. The therapeutic management applicable in NPC needs to be established according to the case of the patient and include radiotherapy, chemotherapy, surgery, immune therapy, targeted therapy or combined treatment. The main objective of the treatment is local and regional tumor control; relapse is an important factor for future development of distant metastases. New therapeutic concepts are always sought of, current research focusing on precision medicine, meaning systemic treatment with a personalized radiotherapy approach according to the characteristics of the tumor.

Preliminary Efficacy Report and Prognosis Analysis of Endoscopic Endonasal Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma

Background: Compared with radiotherapy, endoscopic endonasal nasopharyngectomy (EEN) is increasingly used to treat recurrent nasopharyngeal carcinoma (NPC) because of its good prognosis and mild complications. This study aims to investigate the efficacy of EEN in the treatment of recurrent NPC and factors affecting prognosis.

Methods: This study included all patients who received EEN for recurrent nasopharyngeal carcinoma from April 2016 to April 2020. All operations were performed in Xiangya Hospital Central South University. The patient's 2-year overall survival (OS) rate, disease-free survival (DFS) rate and significant prognostic factors are reported.

Results: There were 38 (67.9%) males and 28 (32.1%) females, with a median age of 43 (range, 24–69 years).43 (76.8%) of the patients in our study were in advanced rT3-rT4 stage and 32 (74.4%) of the patients in the advanced stage had tumor growth closely related to the internal carotid artery (ICA). During a mean follow up period of 44 month (range 1–65 months) post-surgery. The 2-year OS rate was 48.6%, 2-year DFS rate was 42.6%. The 2-year OS rates of rT1-2 and rT3-4 recurrent NPC were 83.9 and 35.6%, respectively. The 2-year DFS rates of rT1-2 and rT3-4 recurrent NPC 76.2 and 56.3%. The advanced T stage were associated with a poor prognosis in terms of OS and DFS.

Conclusions: Data indicate that T staging may be an independent prognostic factor for OS and DFS. Through proper preoperative evaluation, EEN is an alternative treatment option for advanced recurrent NPC that ensures a certain level of efficacy and is relatively safe with few complications. However, additional studies with long-term follow-up and a larger sample size are required.

International Recommendations on Reirradiation by Intensity Modulated Radiation Therapy for Locally Recurrent Nasopharyngeal Carcinoma

PURPOSE

Reirradiation for locally recurrent nasopharyngeal carcinoma (NPC) is challenging because prior radiation dose delivered in the first course is often close to the tolerance limit of surrounding normal structures. A delicate balance between achieving local salvage and minimizing treatment toxicities is needed. However, high-level evidence is lacking because available reports are mostly retrospective studies on small series of patients. Pragmatic consensus guidelines, based on an extensive literature search and the pooling of opinions by leading specialists, will provide a useful reference to assist decision-making for these difficult decisions.

METHODS AND MATERIALS

A thorough review of available literature on recurrent NPC was conducted. A set of questions and preliminary draft guideline was circulated to a panel of international specialists with extensive experience in this field for voting on controversial areas and comments. A refined second proposal, based on a summary of the initial voting and different opinions expressed, was recirculated to the whole panel for review and reconsideration. The current guideline was based on majority voting after repeated iteration for final agreement.

RESULTS

The initial round of questions showed variations in clinical practice even among the specialists, reflecting the lack of high-quality supporting data and the difficulties in formulating clinical decisions. Through exchange of comments and iterative revisions, recommendations with high-to-moderate agreement were formulated on general treatment strategies and details of reirradiation (including patient selection, targets contouring, dose prescription, and constraints).

CONCLUSION

This paper provides useful reference on radical salvage treatment strategies for recurrent NPC and optimization of reirradiation through review of published evidence and consensus building. However, the final decision by the attending clinician must include full consideration of an individual patient's condition, understanding of the delicate balance between risk and benefits, and acceptance of risk of complications.

Transinfratemporal Fossa Transposition of the Temporalis Muscle Flap for Skull Base Reconstruction after Endoscopic Expanded Nasopharyngectomy: Anatomical Study and Clinical Application

Objective Temporalis muscle flap (TMF) is widely used in traditional skull base surgery, but its application in endoscopic skull base surgery remains rarely reported. We aimed to investigate the surgical anatomy and clinical application of TMF for reconstruction of skull base defects after expanded endoscopic nasopharyngectomy.

Methods Nine fresh cadaver heads (18 sides) were used for endoscopic dissection at the University of Pittsburgh School of Medicine in the United States. TMF was harvested using a traditional open approach and then transposed into the maxillary sinus and nasal cavity through the infratemporal fossa using an endoscopic transnasal transmaxillary approach. TMF length was then measured. Moreover, TMF was used for the reconstruction of skull base defects of six patients with recurrent nasopharyngeal carcinoma after expanded endoscopic nasopharyngectomy.

Results The length of TMF harvested from the temporal line to the tip of the coronoid process of the mandible was 11.8 ± 0.9 cm. The widest part of the flap was 9.0 ± 0.4 cm. When TMF was dislocated from the coronoid process of the mandible, approximately another 2 cm of reach could be obtained. When the superficial layer of the temporalis muscle was split from the deep layer, the pedicle length could be extended 1.9 ± 0.2 cm. TMF could cover skull base defects in the anterior skull base, sellar, and clivus regions.

Conclusion TMF can be used to reconstruct skull base defects after endoscopic expanded nasopharyngectomy and can effectively prevent the occurrence of serious complications in patients with recurrent nasopharyngeal carcinoma.

Manuscript title: the maxillary swing approach - the first Scandinavian experience

BACKGROUND

The maxillary swing approach was introduced three decades ago in the head and neck field providing optimal surgical exposure for tumors in the nasopharyngeal and/or the retromaxillary space.

OBJECTIVES

To report the clinical experience, patient surgical morbidity and survival outcomes following the introduction of the maxillary swing approach in Denmark.

MATERIAL AND METHODS

A retrospective study including patients who underwent the maxillary swing approach from January 2012 - January 2020. Baseline and perioperative data, pathology, postoperative morbidity and survival outcomes were registered.

RESULTS

Sixteen patients were included of which 15 had a malignant tumor with different histology, while one patient had a benign tumor. Most commonly reported short-term morbidity were trismus, cheek hypoesthesia, nasopalatal fistula, lacrimation and nasal stenosis (<3 months postoperatively) improving markedly at 12 months follow-up. For patients with malignant tumors, the 5-year overall survival and recurrence-free survival rates were 60% and 66.7%, respectively.

CONCLUSIONS AND SIGNIFICANCE

The maxillary swing approach was safely implemented by a multidisciplinary team at a high-volume centralized head and neck cancer center in Denmark. The procedure may be considered for salvage surgery of recurrent nasopharyngeal carcinomas and selected malignant and benign tumors located in the nasopharynx and/or retromaxillary space inaccessible by other surgical modalities.

Contemporary management of the neck in nasopharyngeal carcinoma

Up to 85% of the patients with nasopharyngeal carcinoma present with regional nodal metastasis. Although excellent nodal control is achieved with radiotherapy, a thorough understanding of the current TNM staging criteria and pattern of nodal spread is essential to optimize target delineation and minimize unnecessary irradiation to adjacent normal tissue. Selective nodal irradiation with sparing of the lower neck and submandibular region according to individual nodal risk is now emerging as the preferred treatment option. There has also been continual refinement in staging classification by incorporating relevant adverse nodal features. As for the uncommon occurrence of recurrent nodal metastasis after radiotherapy, surgery remains the standard of care.

Treatment and outcomes of nasopharyngeal carcinoma in a unique non-endemic population

OBJECTIVE

Nasopharyngeal carcinoma (NPC) is common in Southeast Asia. Due to the influx of immigrants from this region, the incidence in British Columbia is increasing. Current literature from non-endemic populations encompasses heterogeneous cohorts. This study examines NPC in a North American population, with a high incidence, to understand the population's characteristics, treatment outcomes and recurrence patterns.

METHODS AND MATERIALS

A retrospective analysis of patients treated for primary and recurrent NPC over 15-years. Regression analyses were used to identify predictors of disease recurrence and death. A subgroup analysis of the locoregional recurrence cohort was conducted. Five-year survival outcomes were determined.

RESULTS

601 patients were included. Asian ethnicity comprised 77% and the majority had non-keratinizing carcinoma (81%). In total, 19.3% of patients experienced recurrence: 58% local, 22% regional and 20% distant. Five-year overall survival was 70%. Smoking, advancing T-stage, poorer performance status and advanced overall stage were all associated with worse overall survival (p < 0.05). Asian ethnicity improved overall survival but not recurrence free survival. Similar features in addition to non-keratinizing histology were associated with increased locoregional recurrence (p < 0.05). Competing risk analysis indicated radiotherapy alone had a higher recurrence relative to chemoradiotherapy (HR 1.91, CI 1.17-3.09, p = 0.01).

CONCLUSIONS

We report the largest study evaluating treatment and outcomes of NPC in a non-endemic population. This unique population falls between described endemic and non-endemic populations. Non-keratinizing pathology and primary radiotherapy did not affect survival; however, both had a propensity for recurrence. Finally, patients experienced more locoregional and less distant recurrence, supporting that this cohort may be amenable to curative salvage therapy.

Anticancer effects of brusatol in nasopharyngeal carcinoma through suppression of the Akt/mTOR signaling pathway

PURPOSE

Brusatol, a natural quassinoid that is isolated from a traditional Chinese herbal medicine known as Bruceae Fructus, possesses biological activity in various types of human cancers, but its effects in nasopharyngeal carcinoma (NPC) have not been reported. This study aimed to explore the effect and molecular mechanism of brusatol in NPC in vivo and in vitro.

METHODS

The antiproliferative effect of brusatol was assessed by MTT and colony formation assays. Apoptosis was determined by flow cytometry. The expression of mitochondrial apoptosis, cell cycle arrest, and Akt/mTOR pathway proteins were determined by western blot analysis. Further in vivo confirmation was performed in a nude mouse model.

RESULTS

Brusatol showed antiproliferative activity against four human NPC cell lines (CNE-1, CNE-2, 5-8F, and 6-10B) in a dose-dependent manner. This antiproliferative effect was accompanied by mitochondrial apoptosis and cell cycle arrest through the modulation of several key molecular targets, such as Bcl-xl, Bcl-2, Bad, Bax, PARP, Caspase-9, Caspase-7, Caspase-3, Cdc25c, Cyclin B1, Cdc2 p34, and Cyclin D1. In addition, we found that brusatol inhibited the activation of Akt, mTOR, 4EBP1, and S6K, suggesting that the Akt/mTOR pathway is a key underlying mechanism by which brusatol inhibits growth and promotes apoptosis. Further in vivo nude mouse models proved that brusatol significantly inhibited the growth of CNE-1 xenografts with no significant toxicity.

CONCLUSIONS

These observations indicate that brusatol is a promising antitumor drug candidate or a supplement to current chemotherapeutic therapies to treat NPC.

Local and Lymph Node Relapse of Nasopharyngeal Carcinoma: A Single-Center Experience

OBJECTIVES

The study aimed to investigate the epidemiological and clinical characteristics as well as the therapeutic results in patients with locoregional (LR) relapse after treatment of nasopharyngeal carcinoma (NPC).

METHODS

We retrospectively reviewed the medical records of patients with local and/or regional recurrent NPC over 13 years (2003-2015).

RESULTS

Twenty-five patients were treated for local or/and local-regional recurrence of NPC. The rate of LR relapse was 7.2%. The mean age of the patients was 46 ± 13.9 years. The median time to relapse was 25 months. The recurrence was nasopharyngeal in 17 patients, nasopharyngeal and neck lymph nodes in 7 patients, and neck lymph nodes in 1 patient. Fifteen relapsed patients had a locally advanced disease (rT3-rT4). Patients who had initially T1 or T2 tumor had a locally advanced relapsed disease (rT3rT4) in 27.3% and patients whose disease was initially classified as T3 or T4 had a locally advanced relapsed disease (rT3T4) in 85.7% (P = .005, Fisher test). Twelve patients had chemotherapy after relapse. Chemotherapy was followed by concurrent chemoradiotherapy in 3 patients and by radiotherapy (RT) in 4 patients. Nine patients had concurrent chemoradiotherapy and 1 patient had exclusive RT. The overall survival (OS) at 1 year, 3 years, and 5 years was, respectively, 58%, 18%, and 10%. The OS was significantly higher in patients with good performance status at the time of relapse (World Health Organization = 1; P = .01) and in patients with late relapse (after 2 years; P = .03).

CONCLUSIONS

Locoregional relapse rate in our study was 7.2%. Locoregional reirradiation was the mainstay treatment modality in relapsed NPC. Relapsed NPC had a poor prognosis with a 5-year survival rate of 18%. The OS was significantly higher in patients with good performance status and in patients with late relapse (after 2 years).

Grisel's Syndrome in an Adult After Endoscopic Nasopharyngectomy

Background

Grisel's syndrome is rare in adults, and is characterized by nontraumatic atlanto‐axial subluxation secondary to infection. Here, we report a case of Grisel's syndrome occurring after endoscopic nasopharyngectomy.

Methods

A 67‐year‐old man complained of fever and neck pain with reduced lateral rotation after an endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma. Flexion and extension X‐rays of the cervical spine demonstrated atlanto‐axial subluxation, and magnetic resonance imaging showed infective changes with cervical osteomyelitis. A diagnosis of Grisel's syndrome with cervical spine osteomyelitis was made. A later computed tomography (CT) scan demonstrated subluxation of C1 on C2, as well as the occipital‐C1 joint.

Results

The patient was treated with intravenous antibiotics and offered surgery for spinal stabilization, but declined. He remained well 15 months post‐op on a cervical collar with minimal pain and no neurologic deficits.

Conclusion

A high index of suspicion for Grisel's syndrome is suggested in patients who have neck pain with reduced range of motion postnasopharyngectomy, and imaging is useful in clinching the diagnosis.

Level of Evidence

4

Nasopharyngeal carcinoma

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

Does East meet West? Towards a unified vision of the management of Nasopharyngeal carcinoma

Nasopharyngeal cancer (NPC) is notable for its wide geographic variation, with incidences as high as 30 in 100,000 in endemic regions but < 1 in 100,000 worldwide. This review aims to identify areas where there could be differences in prognosis, management or outcomes among countries with high or low incidence of NPC. The incidence has generally declined both in endemic and non-endemic regions throughout the years, which may be attributed to the decrease in exposure to risk factors such as early exposure to salted fish and smoking. Ethnicity has an impact both on incidence and prognosis, with Southeast Asians having the highest incidence but also better survival. Concurrent chemoradiotherapy, with or without adjuvant and/or induction chemotherapy, is the standard of care for locoregionally advanced disease, as reflected in clinical practice guidelines. Despite improvements in management, a proportion of patients relapse. Salvage treatment is associated with significant morbidity due to the critical location of the nasopharynx and the toxicities of initial therapy. Clinical expertise is paramount, but is easier to attain in endemic regions and high volume centers where enrollment of patients in clinical trials is more feasible. Collaboration between low and high incidence countries and between low and high volume facilities is key to improving NPC prognosis worldwide.

Establishment of prognostic factors in recurrent nasopharyngeal carcinoma patients who received salvage intensity-modulated radiotherapy: A meta-analysis

Local recurrence remains a major cause of therapeutic failure in patients with nasopharyngeal carcinoma (NPC) and the effective treatment of recurrent NPC (r-NPC) is still a challenge. Intensity-modulated radiotherapy (IMRT) is considered as a favorable technique in the management of r-NPC, especially for extensive lesions. However, local r-NPC is a highly heterogeneous disease and the survival outcome following salvage IMRT varies. Furthermore, due to varied samples and therapeutic protocols, no consensus has been reached in the establishment of prognostic values. Hence, we used Medline and Embase electronic databases to conducted a meta-analysis to generate the best estimation of the prognostic factors in local r-NPC following salvage IMRT. Finally, a total of 783 patients in seven studies were enrolled. Overall, the pooled HR for OS of recurrent T stage and recurrent tumor volume was 1.77 (95% CI = 1.15-2.39) and 2.12 (95% CI = 1.42-2.82), without any heterogeneity. In addition, despite a significant association was observed in the pooled HR of significant compliance for OS, however, significant heterogeneity was also observed (I² = 76.6%, p = 0.039). Furthermore, no significant association was observed among the pooled HRs for OS in terms of age, gender, recurrent time interval, synchronous nodal recurrence, chemotherapy and total re-irradiation dose. Therefore, the present meta-analysis demonstrated that recurrent T stage and tumor volume may serve as the prognostic factors for OS in patients with r-NPC who received salvage IMRT. The other factors such as age, gender, and optimal re-irradiation dose warranted further investigation.