Nasopharyngeal carcinoma and therapeutic management: the place of chemotherapy

A two-stage genome-wide association study identifies novel germline genetic variations in CACNA2D3 associated with radiotherapy response in nasopharyngeal carcinoma

BACKGROUND

Radiotherapy (RT) is the standard treatment for nasopharyngeal carcinoma (NPC). However, due to individual differences in radiosensitivity, biomarkers are needed to tailored radiotherapy to cancer patients. However, comprehensive genome-wide radiogenomic studies on them are still lacking. The aim of this study was to identify genetic variants associated with radiotherapy response in patients with NPC.

METHODS

This was a large‑scale genome-wide association analysis (GWAS) including a total of 981 patients. 319 individuals in the discovery stage were genotyped for 688,783 SNPs using whole genome-wide screening microarray. Significant loci were further genotyped using MassARRAY system and TaqMan SNP assays in the validation stages of 847 patients. This study used logistic regression analysis and multiple bioinformatics tools such as PLINK, LocusZoom, LDBlockShow, GTEx, Pancan-meQTL and FUMA to examine genetic variants associated with radiotherapy efficacy in NPC.

RESULTS

After genome-wide level analysis, 19 SNPs entered the validation stage (P < 1 × 10^- 6), and rs11130424 ultimately showed statistical significance among these SNPs. The efficacy was better in minor allele carriers of rs11130424 than in major allele carriers. Further stratified analysis showed that the association existed in patients in the EBV-positive, smoking, and late-stage (III and IV) subgroups and in patients who underwent both concurrent chemoradiotherapy and induction/adjuvant chemotherapy.

CONCLUSION

Our study showed that rs11130424 in the CACNA2D3 gene was associated with sensitivity to radiotherapy in NPC patients.

TRIAL REGISTRATION NUMBER

Effect of genetic polymorphism on nasopharyngeal carcinoma chemoradiotherapy reaction, ChiCTR-OPC-14005257, Registered 18 September 2014, http://www.chictr.org.cn/showproj.aspx?proj=9546 .

Lymphepithelial carcinoma - a rare tumor of the larynx. Case Report

Lymphoepithelioma was described in 1921 separately by Regaud and Schmincke as nests of non-keratinizing squamous cells embedded in a lymphoid stroma (Regaud) and isolated transitional cells scattered in lymphoid tissue resembling sarcoma (Schmincke). Lymphoepithelial tumors are the most common lesions of the nasopharynx, although they have also been reported in other localizations, such as the nasal cavity, maxillary sinus, the base of the tongue, parapharyngeal area, tonsils and thymus. Lymphoepithelioma of the larynx is extremely rare. We present a case of a 55-year-old patient treated due to this type of lesion to share our experience in the management of this type of malignancy and contribute to the field of rare laryngeal tumors diagnosis and treatment.

A Case of Neurotrophic Keratopathy Associated with Nasopharyngeal Carcinoma

Purpose

To report a case of neurotrophic keratopathy associated with nasopharyngeal carcinoma.

Case Report

A 59-year-old man who had been diagnosed with a nasopharyngeal carcinoma was referred to the authors because of visual disturbance and pain in his right eye. Slit-lamp examination revealed a corneal epithelial defect and corneal stromal edema surrounding the epithelial defect area in his right eye. Magnetic resonance imaging showed a mass in his cavernous sinus, which was identified as nasopharyngeal carcinoma (NPC). We diagnosed neurotrophic keratopathy associated with NPC and initiated treatment with preservative-free artificial tears, antibiotic eye drops, fibronectin, a therapeutic contact lens, and amniotic membrane transplantation. However, the persistent corneal epithelial defect was unresponsive to these treatments.

Conclusion

Neurotrophic keratopathy secondary to NPC is thought to be rare. We presented a case of neurotrophic keratopathy associated with cavernous sinus metastasis of an NPC. The development of new and more effective treatments for this refractory disease is anticipated.

Identifying pretreatment baseline factors predictive of distant metastasis in patients with nasopharyngeal carcinoma after radiotherapy

This retrospective study was performed to identify pretreatment baseline factors that could predict the development of distant metastasis (DM) in patients with nasopharyngeal carcinoma (NPC).A cohort of 119 NPC patients undergoing radiotherapy (RT) or chemoradiotherapy (CRT) were recruited into the study. Among them, 51 developed DM (DM group) within 3 years after treatment and 68 did not (DM-free group). Various clinicopathological factors were measured before the treatment and analyzed by univariate as well as multivariate analyses for the potential correlation with DM development.Univariate analysis revealed that increased peripheral lactate dehydrogenase (LDH) level, lower lymphocyte-monocyte ratio (LMR), higher neutrophil-lymphocyte ratio (NLR), advanced American Joint Committee on Cancer (AJCC) stage, advanced T stage, and advanced N stage were significantly correlated with the presence of DM. Multivariate analysis identified advanced AJCC stage and high LDH level were independent predictive factors for DM.Routinely measured pretreatment clinical factors, including AJCC state and serum LDH level, could independently predict DM. These factors will benefit the selection of appropriate treatment options and improve the overall survival of NPC patients.

BEX3 contributes to cisplatin chemoresistance in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC) can develop cisplatin‐resistant phenotype. Research has revealed that enriched in cancer stem cell population is involved in developing cisplatin‐resistant phenotype. CD271 is a candidate stem cell maker in head and neck cancers. The CD receptor does not possess any enzymatic property. Signal transduction function of CD271 is mediated by the cellular receptor‐associated protein. Our data showed that Brain‐expressed X‐linked 3 (BEX3), a CD271 receptor‐associated protein, was overexpressed in NPC. BEX3 overexpression was a unique event in cancer developed in the head and neck regions, especially NPC. BEX3 expression was inducible by cisplatin in NPC. In cisplatin‐resistant NPC xenograft, treatment with nontoxic level of cisplatin led to a remarkable increase in BEX3 level. High BEX3 expression was accompanied with high octamer‐binding transcription factor 4 (OCT4) expression in cisplatin‐resistant NPC. To confirm the inducing role of BEX3 on OCT4 expression, we knockdown BEX3 using siRNA and compared the expression of OCT4 with mock transfectants. Suppressing BEX3 transcripts led to a significant reduction in OCT4. In addition, targeting BEX3 using shRNA could increase the sensitivity of NPC cells to cisplatin. In summary, our results indicated a unique functional role of BEX3 in mediating the sensitivity of NPC cells to cisplatin. Targeting or blocking BEX3 activity might be useful in reversing the cisplatin‐resistant phenotype in NPC.

Solitary splenic metastasis from nasopharyngeal carcinoma: a case report and systematic review of the literature

Background

Solitary splenic metastases are a rare occurrence, and the nasopharyngeal carcinoma represents one of the most uncommon primary sources. The present study aimed to describe a rare case of a solitary single splenic metastasis from nasopharyngeal carcinoma and to assess the number of cases of isolated nasopharyngeal carcinoma metastases to the spleen reported in the literature.

Main body

We describe the case of a 56-year-old man with a history of nasopharyngeal carcinoma and complete remission after chemo-radiotherapy. Three months after complete remission, positron emission tomography/computed tomography scan revealed a hypermetabolic splenic lesion without increased metabolic activity in other areas. After laparoscopic splenectomy, the pathology report confirmed a single splenic metastasis from undifferentiated carcinoma of the nasopharyngeal type. The postoperative period was uneventful. We also performed a systematic review of the literature using MEDLINE and Google Scholar databases. All articles reporting cases of splenic metastases from nasopharyngeal carcinoma, with or without histologic confirmation, were evaluated. The literature search yielded 15 relevant articles, which were very heterogeneous in their aims and methods and described only 25 cases of splenic metastases from nasopharyngeal carcinoma.

Conclusion

The present review shows that solitary splenic metastases from nasopharyngeal carcinoma are a rare event, but it should be considered in patients presenting with splenic lesions at imaging and a history of primary or recurrent nasopharyngeal carcinoma. No evidence supports a negative impact of splenectomy in patients with solitary splenic metastasis from nasopharyngeal carcinoma.

Low Prognostic Nutritional Index (PNI) Predicts Unfavorable Distant Metastasis-Free Survival in Nasopharyngeal Carcinoma: A Propensity Score-Matched Analysis

Background

Poor nutritional status is associated with progression and advanced disease in patients with cancer. The prognostic nutritional index (PNI) may represent a simple method of assessing host immunonutritional status. This study was designed to investigate the prognostic value of the PNI for distant metastasis-free survival (DMFS) in patients with nasopharyngeal carcinoma (NPC).

Methods

A training cohort of 1,168 patients with non-metastatic NPC from two institutions was retrospectively analyzed. The optimal PNI cutoff value for DMFS was identified using the online tool “Cutoff Finder”. DMFS was analyzed using stratified and adjusted analysis. Propensity score-matched analysis was performed to balance baseline characteristics between the high and low PNI groups. Subsequently, the prognostic value of the PNI for DMFS was validated in an external validation cohort of 756 patients with NPC. The area under the receiver operating characteristics curve (AUC) was calculated to compare the discriminatory ability of different prognostic scores.

Results

The optimal PNI cutoff value was determined to be 51. Low PNI was significantly associated with poorer DMFS than high PNI in univariate analysis (P<0.001) as well as multivariate analysis (P<0.001) before propensity score matching. In subgroup analyses, PNI could also stratify different risks of distant metastases. Propensity score-matched analyses confirmed the prognostic value of PNI, excluding other interpretations and selection bias. In the external validation cohort, patients with high PNI also had significantly lower risk of distant metastases than those with low PNI (Hazards Ratios, 0.487; P<0.001). The PNI consistently showed a higher AUC value at 1-year (0.780), 3-year (0.793) and 5-year (0.812) in comparison with other prognostic scores.

Conclusion

PNI, an inexpensive and easily assessable inflammatory index, could aid clinicians in developing individualized treatment and follow-up strategies for patients with non-metastatic NPC.

Screening for nasopharyngeal cancer

BACKGROUND

Nasopharyngeal cancer is endemic in a few well-defined populations. The prognosis for advanced nasopharyngeal cancer is poor, but early-stage disease is curable and a high survival rate can be achieved. Screening for early-stage disease could lead to improved outcomes. Epstein-Barr virus (EBV) serology and nasopharyngoscopy are most commonly used for screening. The efficacy and true benefit of screening remain uncertain due to potential selection, lead-time and length-time biases.

OBJECTIVES

To determine the effectiveness of screening of asymptomatic individuals by EBV serology and/or nasopharyngoscopy in reducing the mortality of nasopharyngeal cancer compared to no screening. To assess the impact of screening for nasopharyngeal cancer on incidence, survival, adverse effects, cost-effectiveness and quality of life.

SEARCH METHODS

The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 6); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 6 July 2015.

SELECTION CRITERIA

Randomised controlled trials (RCT) and controlled clinical trials (CCT) evaluating screening for nasopharyngeal cancer versus no screening. Randomisation either by clusters or individuals was acceptable.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. Our primary outcome measure was nasopharyngeal cancer-specific mortality. Secondary outcomes were incidence of nasopharyngeal cancer by stage and histopathological classification at diagnosis, survival (two-year, three-year, five-year and 10-year), harms of screening (physical and psychosocial), quality of life (via validated tools such as the SF-36 and patient satisfaction), cost-effectiveness and all-cause mortality.

MAIN RESULTS

We identified no trials that met the review inclusion criteria. We retrieved 31 full-text studies for further investigation following the search. However, none met the eligibility criteria for a RCT or CCT investigation on the efficacy of screening for nasopharyngeal cancer.

AUTHORS' CONCLUSIONS

No data from RCTs or CCTs are available to allow us to determine the efficacy of screening for nasopharyngeal cancer, or the cost-effectiveness and cost-benefit of a screening strategy. High-quality studies with long-term follow-up of mortality and cost-effectiveness are needed.

Ribonucleotide reductase M2 subunit expression and prognostic value in nasopharyngeal carcinoma

The ribonucleotide reductase M2 subunit (RRM2) modulates the enzymatic activity of ribonucleotide reductase, and is involved in tumor progression. Recently, high levels of RRM2 expression were reported to correlate with poor survival outcomes in patients with colorectal and bladder cancer. However, changes in RRM2 expression in nasopharyngeal carcinoma (NPC), and its effect on the prognosis of this disease remain unknown. The aim of the present study was to analyze the expression of RRM2 in NPC cell lines, and to identify whether RRM2 may serve as a biomarker with which to assess the prognosis of NPC. The present study found that RRM2 expression was higher in NPC cell lines and tissue samples than in noncancerous nasopharyngeal epithelial cell lines and noncancerous tissues, as shown by reverse transcription-quantitative polymerase chain reaction analysis, western blotting and immunohistochemistry staining. Kaplan-Meier survival analysis demonstrated that patients with higher RRM2 expression levels had poorer disease-free survival outcomes than those with lower expression levels of RRM2. Univariate analysis showed that a lower survival rate was significantly associated with high RRM2 expression levels [hazard ratio (HR), 6.424; 95% confidence interval (CI), 2.381-17.333; P<0.001]. Multivariate analysis indicated that RRM2 expression is an independent prognostic factor for patients with NPC (HR, 3.461; 95 % CI, 1.204-9.949; P=0.021). Overexpression of RRM2 led to increased cell proliferation, colony formation, migration and invasion in vivo. These results suggest that high levels of RRM2 expression may be a useful predictor for survival in patients with NPC and may serve as a novel prognostic indicator for these individuals.

[The role of surgical treatment for nasopharyngeal carcinoma]

AIM

Presentation of experiences and results of surgical treatment of nasopharyngeal carcinoma.

MATERIAL AND METHODS

4 patients with nasopharyngeal carcinoma operated in Department of Otolaryngology and Laryngological Oncology of Poznan University of Medical Sciences between 2006 and 2011. In one case operation was performed via transpalatal approach and in other three cases via transfacial approach (via lateral rhinotomy). In all cases operation was supported by endoscopy and in advanced tumors (T4) also by navigation.

RESULTS

We have not observed any important intraoperation and postoperation complications. Two patients with T2 tumor are disease free (observation time 5 years and 1 year). One patient with T4 tumor developed local recurrence and after few months died. Second patient with T4 tumor refused further control.

CONCLUSIONS

1. Instead of that nasopharyngeal carcinoma is typically treated by radiotherapy or in advanced stages by radio-chemotherapy, in some cases surgical treatment should be used. 2. The main indication to surgical treatment are residual and recurrent tumors after radiotherapy or radio-chemotherapy--both in nasopharynx and in cervical lymph nodes. It can be also used in primary, limited, radio-resistant tumors. 3. Appropriate surgical approach and using of endoscopy and navigations are important factors which influence the radical and safe excision of tumor. 4. The results of treatment of residual and recurrent tumors of nasopharynx depend on stage of disease and complexity of excision of the tumor and the worst prognostic factor is intracranial extension of tumor.

Anti-tumor effect of oncolytic herpes simplex virus G47delta on human nasopharyngeal carcinoma

Oncolytic herpes simplex virus (HSV) can replicate in and kill cancer cells without harming normal tissue. G47Δ is a third-generation HSV vector. In this study, the therapeutic effects of G47Δ on human nasopharyngeal carcinoma (NPC) were determined in vitro and in vivo. The human NPC cell lines CNE-2 and SUNE-1, primary normal nasopharyngeal epithelial cells (NPECs), and immortalized nasopharyngeal cells NP-69 and NPEC2/Bmi1 were infected with G47Δ at different multiplicities of infection (MOIs). The survival of infected cells was observed daily. Two subcutaneous models of NPC were established with CNE-2 and SUNE-1 in Balb/c nude mice. G47Δ or virus buffer as control was injected into the subcutaneous tumors. Tumor size was measured twice a week, and animals were euthanized when the diameter of their tumors exceeded 18 mm or when the animals appeared moribund. For the NPC cell lines CNE-2 and SUNE-1, more than 85% and 95% of cells were killed on day 5 after G47Δ infection at MOI = 0.01 and MOI = 0.1, respectively. Similar results were observed for an immortalized cell line NPEC2/Bmi-1. A moderate effect of G47Δ was also found on another immortalized cell line NP-69, of which only 27.7% and 75.9% of cells were killed at MOI = 0.01 and MOI = 0.1, respectively. On the contrary, there was almost no effect observed on NPECs. The in vivo experiments showed that tumors in mice in the G47Δ-treated group regressed completely, and the mice exhibited much longer survival time than those in the control groups. Our results suggest that the potential therapeutic effects of G47Δ would be applicable for treatment of NPC patients in the future.

A prospective study on therapeutic gain by concurrent chemoradiotherapy for stage II-IV a nasopharyngeal carcinoma

The benefit achieved by concurrent chemoradiotherapy (CCR) and sequential chemoradiotherapy (SCR) vs radiotherapy (RT) alone for patients with stage II-IVa nasopharyngeal carcinoma (NPC) was compared. A total of 113 patients with stage II-IV a NPC were allotted into CCR group (n=38), SCR group (n=36) and RT alone group (n=39). All patients were irradiated with the same RT technique to ≥66 Gy at 2 Gy per fraction, conventional 5 fractions/week in all groups. The CCR group received concurrent chemotherapy of weekly cisplatin for 7 weeks, and the SCR group received neoadjuvant and (or) adjuvant chemotherapy. The results showed that the 3- and 5-year overall survival rate was significantly higher in CCR group than in RT alone group (92.16% vs 61.54%, 81.58% vs 51.28%, P<0.005). The median survival time was significantly longer in CCR group than in RT alone group (67.8 months vs 52.7 months, P<0.005). It was concluded that CCR could significantly improve overall survival rate, progression-free survival rate, and median survival time when compared with RT alone.

Induction chemotherapy with carboplatin and taxol followed by radiotherapy and concurrent weekly carboplatin + taxol in locally advanced nasopharyngeal carcinoma

PURPOSE

Aim of this study was the clinical evaluation of carboplatin-taxol combination in a neoadjuvant and concomitant setting with conventional radiotherapy in loco-regionally advanced nasopharyngeal carcinoma (A-NPC).

METHODS

Thirty patients were treated with three cycles of carboplatin (AUC6) plus taxol (175 mg/m(2)) on day 1 every 3 weeks, followed by weekly carboplatin (AUC1) plus Taxol (60 mg/m2) and concomitant radiotherapy (70 Gy).

RESULTS

We observed the objective complete response rates of 33% (after chemotherapy) and 87% (after chemo-radiotherapy). Treatment tolerability and toxicity were controllable. Three- and five-year progression-free survival were 80 and 75%, respectively, and 3- and 5-year overall survival were 85 and 80% (follow-up 49.5 months). Five-year loco-regional control was 90.3%, and five-year distant metastases-free survival was 85%.

CONCLUSIONS

Neoadjuvant chemotherapy with such protocol represents a feasible, efficient treatment for patients with A-NPC, ensuring excellent loco-regional disease control and overall survival with low incidence of distant metastases.

Different subsets of tumor infiltrating lymphocytes correlate with NPC progression in different ways

Background

Increasing amounts of evidence indicate that tumor infiltrating lymphocytes (TIL) are correlated with the prognosis of cancer patients. This study focuses on the association between the densities of tumor infiltrating cytotoxic T lymphocytes (CTL), activated CTL, regulatory T lymphocytes (Treg) and Th17 lymphocytes, and the prognosis and clinicopathological features of nasopharyngeal carcinoma (NPC) patients.

Results

Double immunohistochemical staining was performed in 106 biopsy specimens from newly diagnosed NPC patients. Prognostic values of infiltrating lymphocyte densities were evaluated by Kaplan-Meier analysis and Cox regression. The density of CD8+ TIL was positively correlated with lymph node metastasis, while the density of Foxp3⁺ TIL was negatively associated with T stage (P < 0.05). For survival evaluation, the density of Foxp3⁺ TIL or Foxp3⁺ TIL combined with GrB⁺ TIL together was associated with better overall survival (OS) and progression-free survival (PFS) (P < 0.01) in all patients and in the patients with late-stage diseases (Stages III and IV, P < 0.01). Meanwhile a low density of CD8⁺TIL or high ratio of FOXP3⁺TIL to CD8⁺TIL was correlated with better PFS in early stage patients (Stages I and II, P < 0.05). No significant association was found between IL-17⁺ TIL and clinicopathological characteristic or survival of NPC patients.

Conclusions

Our study identifies for the first time the tumor infiltrating Foxp3⁺ TIL as an independent favorable factor in the prognosis of NPC patients, especially for the patients with late-stage diseases.

Advances in nasopharyngeal carcinoma

PURPOSE OF REVIEW

Nasopharyngeal carcinoma prognosis is related to its potential locoregional invasion and metastatic spread. Among prognostic factors, initial tumor-node-metastasis stage is the main one, besides other biological parameters. Worldwide development of positron emission tomography imaging is changing modalities of staging. Concomitant chemoradiotherapy represents one of the most recent advances in the treatment of nasopharyngeal carcinoma patients, besides intensity-modulated radiation therapy. This review updates these recent advances in diagnosis and treatment of nasopharyngeal carcinoma.

RECENT FINDINGS

Recent publications have shown the superiority of fused positron emission tomography/computed tomography over positron emission tomography alone and conventional imaging to do an accurate staging and to impact on patient management. Circulating Epstein-Barr virus DNA load may be a useful prognostic marker in endemic regions. Recent meta-analysis confirmed the superiority of concurrent chemoradiotherapy to radiotherapy alone. Previous publications have shown that induction chemotherapy with new agents might be promising. Data demonstrating targeted therapies efficacy in metastatic nasopharyngeal carcinoma are limited to date.

SUMMARY

Positron emission tomography-computed tomography is replacing conventional imaging in the initial M staging of nasopharyngeal carcinoma. Its usefulness in response evaluation after therapy and its place in the follow-up need to be prospectively evaluated. Cisplatin-based concomitant chemoradiotherapy is now the standard treatment for locally advanced patients. However, incidence of relapses remains high, and new multimodal therapy is needed.