Prognostic Value of Cervical Nodal Necrosis in Nasopharyngeal Carcinoma: Analysis of 1800 Patients with Positive Cervical Nodal Metastasis at MR Imaging

Anatomical and dosimetric variations during volumetric modulated arc therapy in patients with locally advanced nasopharyngeal carcinoma after induction therapy: Implications for adaptive radiation therapy

Purpose

To investigate anatomical and dosimetric changes during volumetric modulated arc therapy (VMAT) in patients with locally advanced nasopharyngeal carcinoma (LA-NPC) after induction therapy (IT) and explore characteristics of patients with notable variations.

Materials and methods

From July 2021 to June 2023, 60 LA-NPC patients undergoing VMAT after IT were retrospectively recruited. Adaptive computed tomography (aCT), reconstructed from weekly cone-beam computed tomography(CBCT), facilitates recontouring and planning transplantation. Volume, dice similarity coefficients, and dose to target volumes and organs at risk(OARs) on planning CT(pCT) and aCT were compared to identify changing patterns. Multivariate logistic regression was used to investigate risk factors.

Results

The volumes of PGTVnasopharynx (PGTVp), PGTVnode (PGTVn), ipsilateral and contralateral parotid glands decreased during VMAT, with reductions of 2.25 %, 6.98 %, 20.09 % and 18.00 %, respectively, at 30 fractions from baseline (P < 0.001). After 25 fractions, D99 and D95 of PGTVn decreased by 7.94 % and 4.18 % from baseline, respectively, while the Dmean of ipsilateral and contralateral parotid glands increased by 7.80 % and 6.50 %, marking the peak rates of dosimetric variations (P < 0.001). The dosimetric fluctuations in PGTVp, the brainstem, and the spinal cord remained within acceptable limits. Furthermore, an initial BMI ≥ 23.5 kg/m2 and not-achieving objective response (OR) after IT were regarded as risk factors for a remarkable PGTVn dose reduction in the later stages of VMAT.

Conclusions

Replanning for post-IT LA-NPC patients appears reasonable at 25F during VMAT. Patients with an initial BMI ≥ 23.5 kg/m2 and not-achieving OR after IT should be considered for adaptive radiation therapy to stabilize the delivered dose.

Radiomics-based lymph nodes prognostic models from three MRI regions in nasopharyngeal carcinoma

Accurate prediction of the prognosis of nasopharyngeal carcinoma (NPC) is important for treatment. Lymph nodes metastasis is an important predictor for distant failure and regional recurrence in patients with NPC. Traditionally, subjective radiological evaluation increases concerns regarding the accuracy and consistency of predictions. Radiomics is an objective and quantitative evaluation algorithm for medical images. This retrospective analysis was conducted based on the data of 729 patients newly diagnosed with NPC without distant metastases to evaluate the performance of radiomics pretreatment using magnetic resonance imaging (MRI)-determined metastatic lymph nodes models to predict NPC prognosis with three delineation methods. Radiomics features were extracted from all lymph nodes (ALN), largest lymph node (LLN), and largest slice of the largest lymph node (LSLN) to generate three radiomics signatures. The radiomics signatures, clinical model, and radiomics-clinic merged models were developed in training cohort for predicting overall survival (OS). The results showed that LSLN signature with clinical factors predicted OS with high accuracy and robustness using pretreatment MR-determined metastatic lymph nodes (C-index [95 % confidence interval]: 0.762[0.760-0.763]), providing a new tool for treatment planning in NPC.

Incidental findings of cervical magnetic resonance imaging: A retrospective reinterpretation of a large adult population

Background

Magnetic resonance imaging (MRI) of the cervical spine is one of the routine MRI scans of the cervical region in investigating spinal disc pathologies, spinal stenosis, and the detection of spinal lesions, which are the major parameters to be evaluated in this examination.

Purpose

The authors of this study are focused on a different aspect of cervical MRI, revealing the incidences and reporting rates of extraspinal incidental findings.

Methods

A total of 1000 patients (324 males, 676 females, mean age 47 ± 14) who had undergone an MRI of the cervical spine were enrolled in this study. The magnetic resonance (MR) images of these patients were re-interpreted with respect to the incidental extraspinal imaging findings. The incidence and reporting rate of each incidental finding encountered during the evaluation were presented in percentages.

Results

726 patients in this study had at least one incidental lesion. The results of this study revealed that the most common incidental lesions encountered during the reinterpretation of cervical MRI were nasopharyngeal mucosal thickening (n = 442) and thyroid hypertrophy (n = 231). The total reporting rate of incidental findings was 5.29%.

Conclusion

There are many data to be reported and evaluated by MR imaging of the cervical spine, not only the main parameters of MRI scanning in the routine daily practice of radiologists. All our colleagues should be aware and careful of these incidental findings, which may be the initial medical data of the patients' diagnoses, or to avoid undesirable medicolegal problems.

Radiologic extranodal extension for nodal staging in nasopharyngeal carcinoma

PURPOSE

Extranodal extension (ENE) has the potential to add value to the current nodal staging system (N8th) for predicting outcome in nasopharyngeal carcinoma (NPC). This study aimed to incorporate ENE, as well as cervical nodal necrosis (CNN) to the current stage N3 and evaluated their impact on outcome prediction. The findings were validated on an external cohort.

METHODS & MATERIALS

Pre-treatment MRI of 750 patients from the internal cohort were retrospectively reviewed. Predictive values of six modified nodal staging systems that incorporated four patterns of ENE and two patterns of CNN to the current stage N3 for disease-free survival (DFS) were compared with that of N8th using multivariate cox-regression and concordance statistics in the internal cohort. Performance of stage N3 for predicting disease recurrence was calculated. An external cohort of 179 patients was used to validate the findings.

RESULTS

Incorporation of advanced ENE, which infiltrates into adjacent muscle/skin/salivary glands outperformed the other five modifications for predicting outcomes (p < 0.01) and achieved a significantly higher c-index for 5-year DFS (0.69 vs 0.72) (p < 0.01) when compared with that of N8th staging system. By adding advanced ENE to the current N3 increased the sensitivity for predicting disease recurrence from 22.4 % to 47.1 %. The finding was validated in the external cohort (5-year DFS 0.65 vs. 0.72, p < 0.01; sensitivity of stage N3 increased from 14.0 % to 41.9 % for disease recurrence).

CONCLUSION

Results from two centre cohorts confirmed that the radiological advanced ENE should be considered as a criterion for stage N3 disease in NPC.

Prognostic value of metastatic cervical lymph node stiffness in nasopharyngeal carcinoma: A prospective cohort study

OBJECTIVES

Extracellular matrix stiffness plays an important role in tumorigenesis. In this study, we assessed the prognostic value of metastatic cervical lymph node (CLN) stiffness measured using ultrasound shear wave elastography (SWE) in patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 325 consecutive patients with NPC and CLN metastases were prospectively enrolled in this study. The association between the CLN stiffness and patient characteristics was also evaluated. Survival analysis was performed for 307 patients with stage M0 disease. Distant metastasis-free survival (DMFS) was the primary endpoint. Log-rank test and multivariate analysis were used to explore the prognostic value of CLN stiffness.

RESULTS

Eighteen patients developed distant metastases before treatment (stage M1) and had significantly higher CLN stiffness (Pt-test < 0.001) than the other patients (stage M0). For stage M0 patients, those in the high-stiffness group had lower 3-year DMFS (83.3% vs. 91.7%, P = 0.013) and 3-year progression-free survival (PFS) (78.2% vs. 87.9%, P = 0.015) than those in the low-stiffness group. Multivariate analysis identified CLN stiffness and pretreatment Epstein-Barr virus (EBV) DNA as independent prognostic factors for DMFS and PFS. We further established stiffness-EBV risk stratification based on these two factors. The concordance index, receiver operating characteristic curve, and decision curve analyses showed that our risk stratification outperformed the TNM classification for predicting metastasis.

CONCLUSION

The stiffness of metastatic CLN is closely associated with the prognosis of patients with NPC. SWE can be used as a pretreatment examination for CLN-positive patients. A multicenter study is required to verify our results.

Efficacy of induction chemotherapy in lymph node-positive stage III nasopharyngeal carcinoma and identification of beneficiaries based on clinical features: A propensity score matching analysis

PURPOSE

To investigate the role of induction chemotherapy (IC) in lymph node-positive (LN-positive) stage III nasopharyngeal carcinoma (NPC) receiving concurrent chemoradiotherapy (CCRT).

METHODS

In total, 627 patients with newly diagnosed LN-positive stage III NPC receiving CCRT or IC plus CCRT were included. The primary endpoint was progression-free survival (PFS). Propensity-score matching (PSM) was conducted to balance the intergroup covariates. Kaplan-Meier method with log-rank test was employed to compare survival curves. Subgroup analyses were conducted based on baseline characteristics.

RESULTS

After 1:1 PSM, 414 patients were identified (207 patients per group). Compared with CCRT, IC plus CCRT provided better survival (5-year PFS 88.4% vs. 78.6%, P = 0.01; overall survival [OS] 94.8% vs. 85.3%, P = 0.003; and distant metastasis-free survival [DMFS] 93.1% vs. 85.6%, P = 0.03). The IC beneficial effects on PFS were mainly present in patients with grade 2-3 ENE, elevated serum lactate dehydrogenase (LDH > 170U/L), and N2 disease. Patients with grade 2 CNN had comparable PFS benefits to those with grade 0-1 CNN. For patients with grade 0-1 ENE combined with LDH ≤ 170U/L, survival between the two groups was similar with 5-year PFS 93.6% vs. 90.4% (P = 0.50), OS 94.2% vs. 93.0% (P = 0.72), and DMFS 98.6% vs. 97.7% (P = 0.98).

CONCLUSION

Adding IC before CCRT improved survival in LN-positive stage III NPC patients. Additional IC did not provide better survival for patients with grade 0-1 ENE combined with LDH ≤ 170U/L and could be avoided in this population. CNN may not be a good risk factor for tailoring a personalized treatment plan.

Prognostic significance of MRI-defined sarcopenia in patients with nasopharyngeal carcinoma: A propensity score matched analysis of real-world data

BACKGROUND AND PURPOSE

Image-defined sarcopenia is linked to increased mortality among patients with cancer. Nevertheless, its effect on patients with nasopharyngeal carcinoma (NPC) is incompletely established. This study's aim was to investigate the prognostic significance of MRI-defined sarcopenia on the survival of patients undergoing concurrent chemoradiotherapy (CCRT) ± inducing chemotherapy (IC) for NPC treatment.

METHODS

1,307 patients with stage II-IVa NPC were included in this retrospective study. Sarcopenia was defined using skeletal muscle index (SMI) determined through baseline MRI at the C3 level. The association of sarcopenia with overall survival (OS) and progression-free survival (PFS) was assessed by Cox regression models using 1:1 propensity score matching (PSM) analysis. We also conducted a stratification analysis using BMI and treatment strategies.

RESULTS

Sarcopenia was an independent risk factor for both OS and PFS (all P < 0.05). However, BMI was not substantially linked to OS and PFS (all P > 0.05). Sarcopenic patients showed lower rates of OS (HR = 2.00, 95% CI: 1.54-2.60, P < 0.001) and PFS (HR = 1.67, 95% CI: 1.35-2.07, P < 0.001) in contrast with nonsarcopenic patients. According to stratification analysis, being overweight was linked to a protective effect in nonsarcopenic patients only. Sarcopenic patients showed similar OS and PFS regardless of the treatment modality.

CONCLUSIONS

Sarcopenia is underrecognized in NPC patients. Measurement of sarcopenia using routine MRI scans in NPC patients provided significant prognostic information, outperforming BMI. Patients with sarcopenia failed to benefit from an additional IC regimen.

Integrating pretreatment MRI-detected nodal features and Epstein-Barr virus DNA to identify optimal candidates for intensity-modulated radiotherapy alone in patients with stage II nasopharyngeal carcinoma

OBJECTIVES

To develop and validate a prognostic nomogram based on MRI-detected features of retropharyngeal and cervical lymph nodes and Epstein-Barr virus (EBV) DNA in patients with stage II nasopharyngeal carcinoma (NPC) to distinguish low-risk patients for whom intensity-modulated radiotherapy (IMRT) alone is sufficient.

METHODS

This retrospective study enrolled 894 patients with stage II NPC (596 and 298 in the training and validation cohorts, respectively) with pretreatment MRI between August 2010 and May 2019. All patients received IMRT with or without additional chemotherapy. We identified independent risk factors using univariate and multivariate Cox regression analyses. Survival was compared using Kaplan-Meier curves with the log-rank test.

RESULTS

Independent factors derived from the multivariate analysis include cervical nodal necrosis (CNN), the extracapsular spread (ECS) of cervical and retropharyngeal lymph nodes, and gamma-glutamyl transferase (γ-GGT). Nomograms A, B, and C were established based on the clinical [tumor-node-metastasis (TNM) stage + Epstein-Barr virus (EBV) DNA], the clinical-radiological [all independent predictors] and the combined models [the clinical-radiological model + EBV DNA], respectively. Nomogram C (C-index 0.769 [0.718-0.820]) demonstrated better risk discrimination than nomogram B (0.762 [0.715-0.809]), nomogram A (0.619 [0.564-0.674]), and the TNM stage (0.560 [0.509-0.611]). In the low-risk group divided by nomogram C, no significant survival differences were observed between patients treated with radiotherapy (RT) alone and other regimens including additional chemotherapy.

CONCLUSIONS

The nomogram combining MRI-detected retropharyngeal and cervical lymph node features with pretreatment EBV-DNA improved the prognostic risk stratification for stage II NPC.

Automated localization and segmentation of cervical lymph nodes on contrast-enhanced CT using a 3D foveal fully convolutional neural network

BACKGROUND

In the management of cancer patients, determination of TNM status is essential for treatment decision-making and therefore closely linked to clinical outcome and survival. Here, we developed a tool for automatic three-dimensional (3D) localization and segmentation of cervical lymph nodes (LNs) on contrast-enhanced computed tomography (CECT) examinations.

METHODS

In this IRB-approved retrospective single-center study, 187 CECT examinations of the head and neck region from patients with various primary diseases were collected from our local database, and 3656 LNs (19.5 ± 14.9 LNs/CECT, mean ± standard deviation) with a short-axis diameter (SAD) ≥ 5 mm were segmented manually by expert physicians. With these data, we trained an independent fully convolutional neural network based on 3D foveal patches. Testing was performed on 30 independent CECTs with 925 segmented LNs with an SAD ≥ 5 mm.

RESULTS

In total, 4,581 LNs were segmented in 217 CECTs. The model achieved an average localization rate (LR), i.e., percentage of localized LNs/CECT, of 78.0% in the validation dataset. In the test dataset, average LR was 81.1% with a mean Dice coefficient of 0.71. For enlarged LNs with a SAD ≥ 10 mm, LR was 96.2%. In the test dataset, the false-positive rate was 2.4 LNs/CECT.

CONCLUSIONS

Our trained AI model demonstrated a good overall performance in the consistent automatic localization and 3D segmentation of physiological and metastatic cervical LNs with a SAD ≥ 5 mm on CECTs. This could aid clinical localization and automatic 3D segmentation, which can benefit clinical care and radiomics research.

RELEVANCE STATEMENT

Our AI model is a time-saving tool for 3D segmentation of cervical lymph nodes on contrast-enhanced CT scans and serves as a solid base for N staging in clinical practice and further radiomics research.

KEY POINTS

• Determination of N status in TNM staging is essential for therapy planning in oncology. • Segmenting cervical lymph nodes manually is highly time-consuming in clinical practice. • Our model provides a robust, automated 3D segmentation of cervical lymph nodes. • It achieves a high accuracy for localization especially of enlarged lymph nodes. • These segmentations should assist clinical care and radiomics research.

MRI-Based Metastatic Nodal Number and Associated Nomogram Improve Stratification of Nasopharyngeal Carcinoma Patients: Potential Indications for Individual Induction Chemotherapy

BACKGROUND

Metastatic lymph nodal number (LNN) is associated with the survival of nasopharyngeal carcinoma (NPC); however, counting multiple nodes is cumbersome.

PURPOSE

To explore LNN threshold and evaluate its use in risk stratification and induction chemotherapy (IC) indication.

STUDY TYPE

Retrospective.

POPULATION

A total of 792 radiotherapy-treated NPC patients (N classification: N0 182, N1 438, N2 113, N3 59; training group: 396, validation group: 396; receiving IC: 390).

FIELD STRENGTH/SEQUENCE

T1-, T2- and postcontrast T1-weighted fast spin echo MRI at 1.5 or 3.0 T.

ASSESSMENT

Nomogram with (model B) or without (model A) LNN was constructed to evaluate the 5-year overall (OS), distant metastasis-free (DMFS), and progression-free survival (PFS) for the group as a whole and N1 stage subgroup. High- and low-risk groups were divided (above vs below LNN- or model B-threshold); their response to IC was evaluated among advanced patients in stage III/IV.

STATISTICAL TESTS

Maximally selected rank, univariate and multivariable Cox analysis identified the optimal LNN threshold and other variables. Harrell's concordance index (C-index) and 2-fold cross-validation evaluated discriminative ability of models. Matched-pair analysis compared survival outcomes of adding IC or not. A P value < 0.05 was considered statistically significant.

RESULTS

Median follow-up duration was 62.1 months. LNN ≥ 4 was independently associated with decreased 5-year DMFS, OS, and PFS in entire patients or N1 subgroup. Compared to model A, model B (adding LNN, LNN ≥ 4 vs <4) presented superior C-indexes in the training (0.755 vs 0.727) and validation groups (0.676 vs 0.642) for discriminating DMFS. High-risk patients benefited from IC with improved post-IC response and OS, but low-risk patients did not (P = 0.785 and 0.690, respectively).

CONCLUSIONS

LNN ≥ 4 is an independent risk stratification factor of worse survival in entire or N1 staging NPC patients. LNN ≥ 4 or the associated nomogram has potential to identify high-risk patients requiring IC.

EVIDENCE LEVEL

4 TECHNICAL EFFICACY: 4.

Intra- and peritumoral MRI radiomics assisted in predicting radiochemotherapy response in metastatic cervical lymph nodes of nasopharyngeal cancer

BACKGROUND

To establish and validate radiomic models combining intratumoral (Intra) and peritumoral (Peri) features obtained from pretreatment MRI for the prediction of treatment response of lymph node metastasis from nasopharyngeal cancer (NPC).

METHODS

One hundred forty-five NPC patients (102 in the training and 43 in the validation set) were retrospectively enrolled. Radiomic features were extracted from Intra and Peri regions on the metastatic cervical lymph node, and selected with the least absolute shrinkage and selection operator (LASSO). Multivariate logistic regression analysis was applied to build radiomic models. Sensitivity, specificity, accuracy, and the area under the curve (AUC) of receiver operating characteristics were employed to evaluate the predictive power of each model.

RESULTS

The AUCs of the radiomic model of Intra, Peri, Intra + Peri, and Clinical-radiomic were 0.910, 0.887, 0.934, and 0.941, respectively, in the training set and 0.737, 0.794, 0.774, and 0.783, respectively, in the validation set. There were no significant differences in prediction performance among the radiomic models in the training and validation sets (all P > 0.05). The calibration curve of the radiomic model of Peri demonstrated good agreement between prediction and observation in the training and validation sets.

CONCLUSIONS

The pretreatment MRI-based radiomics model may be useful in predicting the treatment response of metastatic lymph nodes of NPC. Besides, the generalization ability of the radiomic model of Peri was better than that of Intra and Intra + Peri.

Prognostic significance of cervical radiologic carotid artery invasion by lymph node on magnetic resonance imaging in nasopharyngeal carcinoma

PURPOSE

Carotid artery invasion (CAI) has been demonstrated to be an important prognosticator in some head and neck cancers. This study aimed to examine the prognostic value of radiologic CAI (rCAI) by cervical lymphadenopathy in nasopharyngeal carcinoma (NPC).

METHODS

NPC patients treated between January 2013 and December 2016 were included. Pre-treatment MRIs were reviewed for cervical rCAI according to the radiologic criteria. Univariate and multivariate models were constructed to assess the association between cervical rCAI and clinical outcomes. A new N classification system was proposed and compared to the 8th AJCC system.

RESULTS

The percentage of patients with MRI-positive lymph nodes was 84.7% (494/583), of whom cervical rCAI cases accounted for 42.3% (209/494). Cervical rCAI was associated with significantly poorer OS, DFS, DFFS and RFFS compared to non-rCAI (P < 0.05). Multivariate analyses confirmed that cervical rCAI was an independent prognosticator for DFS and DFFS, surpassing other nodal features, such as laterality, size, cervical node necrosis (CNN) and radiologic extranodal extension (rENE), while location of positive LNs remained independently associated with OS, DFS and DFFS. We propose a refined N classification: New_N1: upper neck LNs only without cervical rCAI; New_N2: upper neck LNs only with cervical rCAI; New_N3: upper and lower LNs. The proposed classification broadened the differences in OS, DFS and DFFS between N1 and N2 disease, and achieved a higher c-index for DFS and DFFS.

CONCLUSIONS

Cervical rCAI was an independent unfavorable indicator of NPC. Compared to the AJCC system, the proposed N category showed satisfactory stratification between N1 and N2 disease, and better prediction of distant metastasis and disease failure.

Diagnostic Efficacy of Ultrasonography, Doppler Ultrasonography and Elastography in the Evaluation of Suspected Malignant Lymph Nodes

Aim

In this prospective study, the efficiency of imaging findings was investigated by comparing the histopathological results of lymph nodes with Doppler and ultrasound features and elasticity scores.

Material and method

A total of 100 cervical or axillary lymph nodes with a suspected malignancy or whose size did not decrease after treatment were examined. In addition to the demographic data of the patients, B-mode ultrasound, Doppler ultrasound, and elastography features of the lymph nodes were evaluated prospectively. The irregular shape, increased size, pronounced hypoechogenicity, presence of micro/macro calcification, short axis/long axis ratio >2, increased size of the short axis, increased cortex thickness, obliterated hilus or increased cortex thickness >3.5 mm were evaluated on ultrasound. Resistivity index, pulsatility index, acceleration rate and time were evaluated for intranodal arterial structures on color. Doppler ultrasound, strain ratio value and elasticity score were recorded on ultrasound elastography. After sonographic examination, patients underwent ultrasound-guided fine needle aspiration cytology or tru-cutting needle biopsy. Histopathological examination results of the patients were compared with the B-mode ultrasound, Doppler ultrasound, and ultrasound elastography.

Results

When the individual and combined effects of the ultrasound, Doppler ultrasound, and ultrasound elastography were evaluated, the combination of all three imaging methods was found to have the highest sensitivity and the highest overall accuracy (90.4% and 73.9%). As an individual method Doppler ultrasound had the highest specificity (77.8%). B-mode ultrasound was found to have the lowest accuracy (56.7%) both in individual and combined evaluations.

Conclusion

Addition of ultrasound elastography to the combination of B-mode and Doppler ultrasound findings increases diagnostic sensitivity and accuracy in the differentiation of benign and malignant lymph nodes.

Prognostic value of the cervical lymph node necrosis ratio in nasopharyngeal carcinoma

PURPOSE

Whether cervical lymph node necrosis (CNN) is an independent adverse prognostic factor in nasopharyngeal carcinoma (NPC) has not been determined. In this study, the CNN ratio was graded quantitatively to explore the prognostic value in NPC.

PARTICIPANTS AND METHODS

We retrospectively reviewed a total of 648 pathologically confirmed as NPC. We outlined metastatic lymph nodes and necrotic area of lymph nodes slice by slice on the magneticresonanceimages (MRI) cross section, and calculated the corresponding CNN ratio.

RESULTS

The median CNN ratio (17.37 %) was taken as the cut-off point, 256 (39.51 %) patients were divided into CNN1 group (<17.37 %, n = 128) and CNN2 group (≥17.37 %, n = 128), 392 (60.49 %) patients without lymph nodes necrosis were CNN0. Among the CNN0, CNN1 and CNN2 groups, five-year overall survival (OS) was 82.4 %, 76.6 % and 71.1 %, locoregional recurrence-free survival (LRRFS) was 91.3 %, 91.1 % and 90.5 %, distant metastasis-free survival (DMFS) was 83.7 %, 78.5 % and 68.7 %, progression-free survival (PFS) was 78.3 %, 71.7 % and 61.6 % respectively. By multivariate analysis, CNN was an independent prognostic factor for OS (P = 0.003), DMFS (P = 0.019) and PFS (P = 0.007). More than 3 cycles of chemotherapy significantly increased OS (P = 0.024) and DMFS (P = 0.015) in the CNN1 group.

CONCLUSIONS

This study indicated that CNN is one of the factors with the negative prognosis of NPC. The CNN ratio might be used as one of the reference factors in the formulation of individualized treatment plan.

Prognostic value of quantitative cervical nodal necrosis burden on MRI in nasopharyngeal carcinoma and its role as a stratification marker for induction chemotherapy

OBJECTIVES

This study aimed to assess the prognostic value of quantitative cervical nodal necrosis (CNN) burden in N staging risk stratification in patients with nasopharyngeal carcinoma.

METHODS

Univariate and multivariate Cox regression models evaluated the association between lymph node variables based on MRI images and survival. Revisions for the N classification system were proposed and compared to the 8th edition AJCC staging system using Harrell's concordance index (C-index). The survival outcomes of induction chemotherapy plus concurrent chemoradiotherapy (CCRT) and CCRT alone in patients with multiple CNNs were compared.

RESULTS

In 1319 patients enrolled, CNN was not an independent prognostic factor for the main survival outcomes, but multiple CNNs (three or more necrotic nodes) were independent prognostic factors for distant metastasis-free survival (DMFS) (adjusted hazard ratio [HR], 2.05; p = 0.020) and progression-free survival (PFS) (HR, 1.78; p = 0.004), surpassing other nodal variables. On upgrading patients with multiple CNNs to revised N3 disease, the proposed N staging widened the differences in DMFS and PFS between N2 and N3 disease. The overall survival of patients with multiple CNNs who received CCRT plus induction chemotherapy was improved compared to that of those who received CCRT alone (76.1% vs. 55.7%; adjusted p = 0.030).

CONCLUSIONS

Upgrading patients with multiple CNNs to stage N3 may improve prognostication of the current AJCC staging system. Multiple CNNs might be a potential marker for stratifying patients who would benefit from induction chemotherapy.

KEY POINTS

• Quantitatively assessed the prognostic value of CNN burden in patients with NPC. • Upgrading patients with multiple CNNs to stage N3 may improve prognostication. • Multiple CNNs may be used as a stratification marker for induction chemotherapy.

The Failure Patterns of Nasopharygeal Carcinoma After Intensity-Modulated Radiotherapy and Implications for Surveillance

Objective

To investigate the treatment outcomes, failure patterns and surveillance strategy in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

Methods

A cohort of patients with NPC who had received the full course of IMRT between 2008 and 2012 were retrospectively analyzed. The failure patterns, time to recurrence, and detection methods were recorded. The survival was calculated using the Kaplan–Meier method. Multivariate proportional hazard regression models were used to test the prognostic factors.

Results

In total, 2607 patients with NPC treated with IMRT were recruited. After the median follow-up of 112 months, 402 (15.4%) patients experienced distant metastasis, 225 (8.6%) patients had local recurrence, and 77 (3.0%) patients had regional recurrences. The 10-year overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 74.5%, 90.1%, and 79.3%, respectively. The factors of male sex, age >50 years, lactate dehydrogenase >245 IU/L, advanced T classification, and advanced N classification were associated with poor OS. The N disease classification was the most important factor in predicting distant metastasis, and advanced T disease classification for high risk of local recurrence. For patients with T1 disease, the incidence of local recurrence was less than 2%, and the incidence of distant metastasis was less than 5% for patients with N0 disease. About 83% of the recurrence occurred in the first 5 years, and 20% of the recurrences showed no symptoms.

Conclusion

High rate of local-regional control can be achieved for patients with NPC after IMRT, while distant metastasis remains as the major cause of failures. Patients with advanced N classification has high risk to develop distant metastasis, and most occurred within 5 years. Developing rational and individualized surveillance strategies based on the high risk factors of recurrence is helpful to balance the survival benefit and medical cost.

FMISO-Based Adaptive Radiotherapy in Head and Neck Cancer

Concurrent chemoradiotherapy represents one of the most used strategies in the curative treatment of patients with head and neck (HNC) cancer. Locoregional failure is the predominant recurrence pattern. Tumor hypoxia belongs to the main cause of treatment failure. Positron emission tomography (PET) using hypoxia radiotracers has been studied extensively and has proven its feasibility and reproducibility to detect tumor hypoxia. A number of studies confirmed that the uptake of FMISO in the recurrent region is significantly higher than that in the non-recurrent region. The escalation of dose to hypoxic tumors may improve outcomes. The technical feasibility of optimizing radiotherapeutic plans has been well documented. To define the hypoxic tumour volume, there are two main approaches: dose painting by contour (DPBC) or by number (DPBN) based on PET images. Despite amazing technological advances, precision in target coverage, and surrounding tissue sparring, radiation oncology is still not considered a targeted treatment if the “one dose fits all” approach is used. Using FMISO and other hypoxia tracers may be an important step for individualizing radiation treatment and together with future radiomic principles and a possible genome-based adjusting dose, will move radiation oncology into the precise and personalized era.

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

Purposes

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

Methods

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

Results

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

Conclusion

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

Development and validation of radiologic scores for guiding individualized induction chemotherapy in T3N1M0 nasopharyngeal carcinoma

OBJECTIVES

We aimed to develop and validate radiologic scores from [¹⁸F]FDG PET/CT and MRI to guide individualized induction chemotherapy (IC) for patients with T3N1M0 nasopharyngeal carcinoma (NPC).

METHODS

A total of 542 T3N1M0 patients who underwent pretreatment [¹⁸F]FDG PET/CT and MRI were enrolled in the training cohort. A total of 174 patients underwent biopsy of one or more cervical lymph nodes. Failure-free survival (FFS) was the primary endpoint. The radiologic score, which was calculated according to the number of risk factors from the multivariate model, was used for risk stratification. The survival difference of patients undergoing concurrent chemoradiotherapy (CCRT) with or without IC was then compared in risk-stratified subgroups. Another cohort from our prospective clinical trial (N = 353, NCT03003182) was applied for validation.

RESULTS

The sensitivity of [¹⁸F]FDG PET/CT was better than that of MRI (97.7% vs. 87.1%, p < 0.001) for diagnosing histologically proven metastatic cervical lymph nodes. Radiologic lymph node characteristics were independent risk factors for FFS (all p < 0.05). High-risk patients (n = 329) stratified by radiologic score benefited from IC (5-year FFS: IC + CCRT 83.5% vs. CCRT 70.5%; p = 0.0044), while low-risk patients (n = 213) did not. These results were verified again in the validation cohort.

CONCLUSIONS

T3N1M0 patients were accurately staged by both [¹⁸F]FDG PET/CT and MRI. The radiologic score can correctly identify high-risk patients who can gain additional survival benefit from IC and it can be used to guide individualized treatment of T3N1M0 NPC.

KEY POINTS

• [¹⁸F]FDG PET/CT was more accurate than MRI in diagnosing histologically proven cervical lymph nodes. • Radiologic lymph node characteristics were reliable independent risk factors for FFS in T3N1M0 nasopharyngeal carcinoma patients. • High-risk patients identified by the radiologic score based on [¹⁸F]FDG PET/CT and MRI could benefit from the addition of induction chemotherapy.

Long-term outcomes of induction chemotherapy followed by intensity-modulated radiotherapy and adjuvant chemotherapy in nasopharyngeal carcinoma patients with N3 disease

OBJECTIVES

To evaluate long-term outcomes of induction chemotherapy (IC) followed by intensity-modulated radiotherapy (IMRT) and adjuvant chemotherapy (AC) in nasopharyngeal carcinoma (NPC) patients with N3 disease.

MATERIALS AND METHODS

From September 2005 to August 2016, 143 patients confirmed NPC with the 8th AJCC/UICC staging criteria N3 were reviewed. All patients received IC followed by IMRT and AC.

RESULTS

After a median follow-up of 67 months, the 5-year and 10-year overall survival (OS), progression-free survival (PFS), distant metastasis free survival (DMFS), local progression-free survival (LPFS) and regional progression-free survival (RPFS) were 75.7% and 61.6%, 61.2% and 53.4%, 73.1% and 72.1%, 92.4% and 87%, 88.9% and 81.8%, respectively. Multivariate analyses indicated that T stage (P = 0.001) appeared to be prognostic factors for OS. T stage (P = 0.001 and P = 0.002) and neck lymph node necrosis (P = 0.015 and P = 0.045) were independent predictors of PFS and DMFS. The acute toxicities were mainly grade 1/2 hematologic toxicities in patients treated with IC+IMRT+AC, and severe toxicities were uncommon.

CONCLUSIONS

IC followed by IMRT and AC achieved satisfactory long-term survival outcomes in NPC patients with N3 disease. Neck lymph node necrosis and late T stage served as predictors of poor prognosis for patients.

The prognostic value of radiologic extranodal extension in nasopharyngeal carcinoma: Systematic review and meta-analysis

OBJECTIVES

The prognostic value of radiologic extranodal extension (rENE) in nasopharyngeal carcinoma remains controversial. In this study, a meta-analysis was performed to assess the prognostic value of ungraded rENE and unambiguous advanced rENE.

METHODS

A literature search through PubMed, Cochrane Library, EMBASE and manual searches was conducted until May 2021. The adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) of overall survival and distant metastasis-free survival were extracted and pooled.

RESULTS

Nine eligible studies were published between 2012 and 2021. The pooled patient number was 7532 (range 61-1887). Seven studies were eligible for the analysis of ungraded rENE, while 3 studies were eligible for unambiguous advanced rENE. The results showed that ungraded rENE was associated with worse overall survival (HR 1.85, 95% CI 1.04-3.27) and significantly associated with worse distant metastasis-free survival (HR 2.07, 95% CI 1.36-3.13). On the other hand, unambiguous advanced rENE was significantly associated with worse overall survival (HR 2.62, 95% CI 2.12-3.25) and worse distant metastasis-free survival (HR 3.14, 95% CI 1.85-5.33).

CONCLUSIONS

In nasopharyngeal carcinoma, both ungraded and unambiguous advanced rENE are significant prognosticators of overall survival and distant metastasis-free survival. More prospective studies are required to determine its role in risk stratification or clinical staging.

Extranodal Extension in Bilateral Cervical Metastases: A predictor of Undesirable Survival Outcomes despite Aggressive Salvage Treatment in Oral Cancer Patients

Objectives: Despite the inclusion of extranodal extension (ENE) in the recent staging system, the presence of ENE alone is not sufficient to depict all clinical situations, as ENE is frequently found in multiple nodes. Thus, the purpose of this study was to evaluate the surgery-based treatment outcomes and clinicopathological features of oral cavity squamous cell carcinoma (OCSCC) patients with ENE found in bilateral multiple cervical metastases.

Materials and methods: A retrospective single-institutional study of OCSCC patients with bilateral ENE nodes was performed from January 2011 to December 2018. OCSCC patients of different admission statuses (with primary lesions (PL), recurrent lesions (RL) and isolated neck metastases (INM)) were included for subgroup comparisons. All patients received surgical treatment with/without adjuvant therapies and had complete follow-up data. Disease-free survival (DFS) was regarded as the main outcome. Time-to-relapse data were also collected for comparison.

Results: A total of 128 patients were included, of whom 97 (75.8%) were male. The mean follow-up period reached 15 months. Among the patients, 85 (66.4%) were treated for PLs, followed by 26 (20.3%) treated for RLs after failed prior therapy and 17 (13.3%) treated for INMs (concurrent or sequential). The DFS rate was merely 35.2%. Treatment-related factors such as surgical margin (p=0.003), postoperative adjuvant therapy (p=0.014) and perioperative complications (p=0.036) were significantly associated with patient outcomes. In addition, oral lesion-related variables such as oral subsites (p=0.037), T classification (p=0.026) and skull base involvement (p=0.040) were indicators of a worse prognosis. For bilateral ENE features, ENE subclassification (p=0.036), maximum size of ENE nodes (p=0.039) and arterial nodal encasement (p=0.025) tended to predict the surgery-based treatment outcomes of these patients.

Conclusions: Bilateral cervical metastases with ENE features, though uncommon, are a serious regional burden, and these patients have lower-than-expected treatment outcomes, especially those with RLs or INMs. A fairly large number of OCSCC patients with advanced oral lesions gain little benefit from intensified salvage surgical treatment. Such treatment should instead be offered to select patients with smaller bilateral ENE nodes (<3 cm) and those with lower ENE subclassifications and no arterial nodal encasement.

Significance of cervical node necrosis in preoperative MRI as a prognostic indicator: retrospective study of patients with SCC of tongue

Aim: To ascertain the prognostic value of cervical nodal necrosis (CNN) observed in patients of tongue squamous cell carcinoma with magnetic resonance imaging. Materials and methods: In this retrospective observational study, records of 144 patients diagnosed with newly diagnosed SCC of tongue were considered. Preoperative MRI study, demographic and clinical data were reviewed. Based on MRI reports, patients were categorised into: with or without the presence of cervical node necrosis (CNN or non CNN). Subsequent treatments, histopathological reports and follow up data were studied to determine key prognostic elements, overall survival and disease free survival by statistical analysis. Results: The incidence of CNN was 55.55% in the study sample. CNN category, depth of invasion, N stage and extra nodal extension were significant negative prognostic factors for overall and disease free survival. Conclusion: Based on our results, pre operative MRI based presence of cervical node necrosis in tongue squamous cell carcinoma is an independent prognostic indicator for poor overall and disease free survival. Long term prospective studies with larger cohorts could be undertaken to establish its role as an important biomarker for precision treatments.

Benefit of [18F]-FDG PET/CT for treatment-naïve nasopharyngeal carcinoma

Background

To test the advantages of positron emission tomography and computed tomography (PET/CT) for diagnosing lymph nodes and staging nasopharyngeal carcinoma and to investigate its benefits for survival and treatment decisions.

Methods

The performance of PET/CT and magnetic resonance imaging (MRI) in diagnosis was compared based on 460 biopsied lymph nodes. Using the propensity matching method, survival differences of T3N1M0 patients with (n = 1093) and without (n = 1377) PET/CT were compared in diverse manners. A radiologic score model was developed and tested in a subset of T3N1M0 patients.

Results

PET/CT performed better than MRI with higher sensitivity, accuracy, and area under the receiver operating characteristic curve (96.7% vs. 88.5%, p < 0.001; 88.0% vs. 81.1%, p < 0.001; 0.863 vs. 0.796, p < 0.05) in diagnosing lymph nodes. Accordingly, MRI-staged T3N0-3M0 patients showed nondifferent survival rates, as they were the same T3N1M0 if staged by PET/CT. In addition, patients staged by PET/CT and MRI showed higher survival rates than those staged by MRI alone (p < 0.05), regardless of the Epstein-Barr virus DNA load. Interestingly, SUVmax-N, nodal necrosis, and extranodal extension were highly predictive of survival. The radiologic score model based on these factors performed well in risk stratification with a C-index of 0.72. Finally, induction chemotherapy showed an added benefit (p = 0.006) for the high-risk patients selected by the model but not for those without risk stratification (p = 0.78).

Conclusion

PET/CT showed advantages in staging nasopharyngeal carcinoma due to a more accurate diagnosis of lymph nodes and this contributed to a survival benefit. PET/CT combined with MRI provided prognostic factors that could identify high-risk patients and guide individualized treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05540-8.

18F-FMISO-PET Hypoxia Monitoring for Head-and-Neck Cancer Patients: Radiomics Analyses Predict the Outcome of Chemo-Radiotherapy

Tumor hypoxia is associated with radiation resistance and can be longitudinally monitored by 18F-fluoromisonidazole (18F-FMISO)-PET/CT. Our study aimed at evaluating radiomics dynamics of 18F-FMISO-hypoxia imaging during chemo-radiotherapy (CRT) as predictors for treatment outcome in head-and-neck squamous cell carcinoma (HNSCC) patients. We prospectively recruited 35 HNSCC patients undergoing definitive CRT and longitudinal 18F-FMISO-PET/CT scans at weeks 0, 2 and 5 (W0/W2/W5). Patients were classified based on peritherapeutic variations of the hypoxic sub-volume (HSV) size (increasing/stable/decreasing) and location (geographically-static/geographically-dynamic) by a new objective classification parameter (CP) accounting for spatial overlap. Additionally, 130 radiomic features (RF) were extracted from HSV at W0, and their variations during CRT were quantified by relative deviations (∆RF). Prediction of treatment outcome was considered statistically relevant after being corrected for multiple testing and confirmed for the two 18F-FMISO-PET/CT time-points and for a validation cohort. HSV decreased in 64% of patients at W2 and in 80% at W5. CP distinguished earlier disease progression (geographically-dynamic) from later disease progression (geographically-static) in both time-points and cohorts. The texture feature low grey-level zone emphasis predicted local recurrence with AUCW2 = 0.82 and AUCW5 = 0.81 in initial cohort (N = 25) and AUCW2 = 0.79 and AUCW5 = 0.80 in validation cohort. Radiomics analysis of 18F-FMISO-derived hypoxia dynamics was able to predict outcome of HNSCC patients after CRT.

The Value of Cervical Node Features in Predicting Long-Term Survival of Nasopharyngeal Carcinoma in the Intensity-Modulated Radiotherapy Era

Objective

To investigate the prognostic value of cervical node features in patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT) and build a prognostic nomogram to predict the long-term survival.

Methods

In this study, 1752 patients after IMRT from 2008 to 2011 were recruited. The clinical and laboratory characteristics and the nodal features including the nodal number, maximum dimension diameter, extranodal extension (ENE), and cervical node necrosis (CNN) were retrospective analyzed. Univariate Cox and multivariate proportional hazard regression models were used to test the prognostic value of nodal features. Prognostic nomograms were established to predict survival.

Results

The 10-year distant metastases-free survival (DMFS) and disease-specific survival (DSS) rates were 86.5% and 80.8%, respectively. Multivariate analysis showed that age, sex, lactate dehydrogenase (LDH), CNN, ENE, T stage, and N stage were independent factors for DSS. Two nomograms-nomogram A (without nodal features) and nomogram B (with nodal features)-were built. The calibration curve for the probability of DSS showed good agreement between prediction by nomogram and the actual observation. The C-index of nomogram B was higher than that for nomogram A in predicting DSS (0.708 vs 0.676, P<0.01).

Conclusion

The nodal features including ENE and CNN were negative prognostic factors for NPC, and the prognostic nomogram incorporating the nodal features was more accurate in predicting survival than the nomogram without nodal features.

The evolution of the nasopharyngeal carcinoma staging system over a 10-year period: implications for future revisions

BACKGROUND

The classification criteria and staging groups for nasopharyngeal carcinoma described in the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system have been revised over time. This study assessed the proportion of patients whose staging and treatment strategy have changed due to revisions of the UICC/AJCC staging system over the past 10 years (ie, from the sixth edition to the eighth edition), to provide information for further refinement.

METHODS

We retrospectively reviewed 1901 patients with non-metastatic nasopharyngeal carcinoma treated in our cancer center between November 2009 and June 2012. The Akaike information criterion and Harrell concordance index were applied to evaluate the performance of the staging system.

RESULTS

In total, 25 (1.3%) of the 1901 patients who were staged as T2a according to the sixth edition system were downgraded to T1 in the eighth edition; 430 (22.6%) staged as N0 in the sixth edition were upgraded to N1 in the eighth edition; 106 (5.6%) staged as N1/2 in the sixth edition were upgraded to N3 in the eighth edition. In addition, 51 (2.7%) and 25 (1.3%) of the study population were upstaged from stage I to stage II and stage II to stage IVa, respectively; 10 (0.5%) was downgraded from stage II to stage I. The survival curves of adjacent N categories and staging groups defined by eighth classification system were well-separated. However, there was no significant difference in the locoregional failure-free survival (P = 0.730) and disease-free survival (P = 0.690) rates between the T2 and T3 categories in the eighth edition classification system.

CONCLUSIONS

Modifications to the tumor-node-metastasis staging system over the past 10 years have resulted in N classification changes in numerous cases. Although the eighth edition tumor-node-metastasis staging system better predicts survival outcomes, the T classification could be simplified in future revisions.

MRI-based radiomics as response predictor to radiochemotherapy for metastatic cervical lymph node in nasopharyngeal carcinoma

OBJECTIVE

To establish and substantiate MRI-based radiomic models to predict the treatment response of metastatic cervical lymph node to radiochemotherapy in patients with nasopharyngeal carcinoma (NPC).

METHODS

A total of 145 consecutive patients with NPC were enrolled including 102 in primary cohort and 43 in validation cohort. Metastatic lymph nodes were diagnosed according to radiologic criteria and treatment response was evaluated according to the Response Evaluation Criteria in Solid Tumors. A total of 2704 radiomic features were extracted from contrast-enhanced T₁ weighted imaging (CE- T₁WI) and T₂ weighted imaging (T₂WI) for each patient, and were selected to construct radiomic signatures for CE-T₁WI, T₂WI, and combined CE-T₁WI and T₂WI, respectively. The area under curve (AUC) of receiver operating characteristic, sensitivity, specificity, and accuracy were used to estimate the performance of these radiomic models in predicting treatment response of metastatic lymph node.

RESULTS

No significant difference of AUC was found among radiomic signatures of CE-T₁WI, T₂WI, and combined CE-T₁WI and T₂WI in the primary and validation cohorts (all p > 0.05). For combined CE-T₁WI and T₂WI data set, 12 features were selected to develop the radiomic signature. The AUC, sensitivity, specificity, and accuracy were 0.927 (0.878-0.975), 0.911 (0.804-0.970), 0.826 (0.686-0.922), and 0.872 (0.792-0.930) in primary cohort, and were 0.772 (0.624-0.920), 0.792 (0.578-0.929), 0.790 (0.544-0.939), and 0.791 (0.640-0.900) in validation cohort.

CONCLUSION

MRI-based radiomic models were developed to predict the treatment response of metastatic cervical lymph nodes to radiochemotherapy in patients with NPC, which might facilitate individualized therapy for metastatic lymph nodes before treatment.

ADVANCES IN KNOWLEDGE

Predicting the response in patients with NPC before treatment may allow more individualizing therapeutic strategy and avoid unnecessary side-effects and costs. Radiomic features extracted from metastatic cervical lymph nodes showed promising application for predicting the treatment response in NPC.

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.

[Cervical CUP syndrome]

The term CUP syndrome (cancer of unknown primary) refers to a multifaceted clinical picture in which the affected patients have lymph node and/or distant metastases without the location of the primary tumor being known. The criteria of CUP syndrome are fulfilled if a histologically or cytologically confirmed malignancy is present without a detectable primary tumor after completion of the primary diagnosis. Due to the usually poor prognosis and the manifold appearance, which often does not allow a standardized therapy, cervical CUP syndrome makes specific demands on clinical and imaging diagnostics. Using modern techniques such as positron emission tomography-computed tomography (PET-CT), imaging plays a key role in the detection of a possible occult primary tumor as well as in staging and prognosis assessment.

Influence of tumor necrosis on treatment sensitivity and long-term survival in nasopharyngeal carcinoma

PURPOSE

To assess the impact of tumor necrosis on treatment sensitivity and long-term survival in patients with nasopharyngeal carcinoma (NPC) treated using intensity-modulated radiation therapy (IMRT).

PARTICIPANTS AND METHODS

In total, 757 patients with non-metastatic, histologically confirmed NPC were retrospectively examined. All patients were treated using IMRT; 93.7% patients with stage T3-T4/N1-N3 disease also received cisplatin-based chemotherapy.

RESULTS

The incidence rates of tumor necrosis in primary tumor, retropharyngeal lymph nodes, neck lymph nodes, and total tumor were 2%, 17.7%, 21.5%, and 31.4%. Overall, 40.8% patients with necrosis of the total tumor achieved complete response (CR) and 54.7% patients without tumor necrosis achieved CR at the end of treatment (χ² = 12.728, P < 0.001). The estimated 7-year overall survival (OS), failure-free survival (FFS), distant metastasis-free survival (DMFS), and loco-regional relapse-free survival (LRRFS) for patients with tumor necrosis and without tumor necrosis of the total tumor were 68.5% vs. 88.4%, 70.5% vs. 88.1%, 77.6% vs. 90.6%, and 85.9% vs. 91.3%, respectively (all P < 0.001). Multivariate analyses indicated that necrosis of the total tumor was an independent predictor of OS, FFS, DMFS, and LRRFS. The impact of lymph node necrosis on long-term survival was similar to that of necrosis of the total tumor. ROC curves verified that inclusion of lymph node necrosis improved the predictive value of the current N classification criteria (P = 0.006).

CONCLUSIONS

Tumor necrosis served as a predictor of treatment sensitivity and poor prognosis for patients with NPC. Lymph node necrosis significantly improved the prognostic value of the current N classification criteria for NPC.

Pretreatment Photopenia on 18F-Fluorodeoxyglucose Positron Emission Tomography-Computed Tomography Scans Predicts Poor Prognosis in Nasopharyngeal Cancer Patients Undergoing Concurrent Chemoradiotherapy

OBJECTIVES

To investigate the influence of pretreatment primary tumor or nodal photopenia (PP) on 18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT), an indicator of tumor ischemia, on survival results of nasopharyngeal cancers (NPCs) treated with concurrent chemoradiotherapy (C-CRT).

METHODS

The pre-C-CRT FDG PET-CT scans of 104 patients with NPC (cT1-4 N0-3 M0) were retrospectively examined to determine the presence of PP (PP+). Our primary endpoint was the influence of PP+ on overall survival (OS), while the progression-free survival (PFS) and locoregional PFS (LRPFS) constituted the secondary endpoints.

RESULTS

The PP+ was detected in 29 (27.9%): nine (8.7%), seven (6.7%), and 13 (12.5%) in the primary tumor alone, primary tumor plus neck nodes, and neck nodes alone, respectively. Because the PP+ cases were small by count per location, all comparative analyses were performed according to overall PP+/ PP- status instead of per detected site. At a median follow-up of 67.8 months (range, 9 to 130 months), the median survival times were not reached (NR) for the entire population, while 5-year OS, LRPFS, and PFS rates were 73.3%, 68.2%, and 63.4%, respectively. Comparatively the PP+ patients exhibited significantly poorer median OS (49.8 months vs. NR, P<0.001), LRPFS (40.7 months vs. NR, P=0.001), and PFS (31.8 months vs. NR, P=0.002) durations than their PP- counterparts. Furthermore, the PP+ retained its independent prognostic significance in multivariate analysis (P<0.001).

CONCLUSION

Present results uncovered the pre-C-CRT PP as an independent predictor of poor prognosis for NPC patients, which underscore the requirement for the fortification of the local and systemic treatments in hypoxic NPCs.

Prognostic and Treatment Guiding Significance of MRI-Based Tumor Burden Features and Nodal Necrosis in Nasopharyngeal Carcinoma

We aimed to develop a nomogram integrating MRI-based tumor burden features (MTBF), nodal necrosis, and some clinical factors to forecast the distant metastasis-free survival (DMFS) of patients suffering from non-metastatic nasopharyngeal carcinoma (NPC). A total of 1640 patients treated at Sun Yat-sen University Cancer Center (Guangzhou, China) from 2011 to 2016 were enrolled, among which 1148 and 492 patients were randomized to a training cohort and an internal validation cohort, respectively. Additionally, 200 and 257 patients were enrolled in the Foshan and Dongguan validation cohorts, respectively, which served as independent external validation cohorts. The MTBF were developed from the stepwise regression of six multidimensional tumor burden variables, based on which we developed a nomogram also integrating nodal necrosis and clinical features. This model divided the patients into high- and low-risk groups by an optimal cutoff. Compared with those of patients in the low-risk group, the DMFS [hazard ratio (HR): 4.76, 95% confidence interval (CI): 3.39–6.69; p < 0.0001], and progression-free survival (PFS; HR: 4.11, 95% CI: 3.13–5.39; p < 0.0001) of patients in the high-risk group were relatively poor. Furthermore, in the training cohort, the 3-year DMFS of high-risk patients who received induction chemotherapy (ICT) combined with concurrent chemoradiotherapy (CCRT) was better than that of those who were treated with CCRT alone (p = 0.0340), whereas low-risk patients who received ICT + CCRT had a similar DMFS to those who only received CCRT. The outcomes we obtained were all verified in the three validation cohorts. The survival model can be used as a reliable prognostic tool for NPC patients and is helpful to determine patients who will benefit from ICT.

Prognostic Value of Nodal Matting on MRI in Nasopharyngeal Carcinoma Patients

BACKGROUND

Nodal (N) stage is one of the most important predictors for distant metastasis in nasopharyngeal carcinoma (NPC) patients. It may ignore potentially useful nodal features, such as nodal matting (three or more lymph nodes abutting together with the absence of intervening fat planes).

PURPOSE

To explore the prognostic value of nodal matting in NPC patients and construct a nomogram with nodal matting for predicting distant metastasis-free survival (DMFS).

STUDY TYPE

Retrospective.

POPULATION

In all, 792 NPC patients treated with intensity modulated radiation therapy from 2010 to 2013 were enrolled with 2:1 training (n = 527) and validation (n = 65) cohorts.

FIELD STRENGTH/SEQUENCE

T₁ - and T₂ -weighted imaging at 1.5 or 3.0T.

ASSESSMENT

Nodal matting and other nodal characteristics were assessed with MRI. MR images were evaluated separately by three radiologists. The association between nodal matting and DMFS was analyzed.

STATISTICAL TESTS

Univariate and multivariate analyses were performed using the Cox proportional hazards regression model. Nomograms were constructed from a multivariate logistic regression model with and without nodal matting. The predictive accuracy and discriminative ability of the nomograms were determined by concordance index (C-index) and calibration curves. The results were validated using bootstrap resampling and validation cohort.

RESULTS

The incidence of nodal matting was 24.6% (195/792) in all patients. In the training cohort, nodal matting was independently associated with DMFS (hazard ratio [HR] = 1.97 [1.05-3.69], P < 0.05). N1 patients with nodal matting had worse DMFS than N1 patients without (P < 0.05). However, no significant difference was observed when comparing N1 patients with nodal matting to N2 patients (P = 0.464). The C-index of the nomogram with nodal matting was higher than the nomogram without (0.717 vs. 0.699, P = 0.084).

DATA CONCLUSION

Nodal matting was an independent prognostic factor for DMFS in NPC patients. It may help to select patients at high risk of distant metastasis.

The comparison of prognostic value of tumour volumetric regression ratio and RECIST 1.1 criteria after induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma

PURPOSE

To compare the prognostic value of the sum volumetric regression ratio (SVRR) of the primary tumour and metastatic lymph nodes with treatment response based on RECIST 1.1 criteria after induction chemotherapy in locoregionally advanced nasopharyngeal carcinoma (NPC).

METHODS AND MATERIALS

A total of 117 stage III-IVA NPC patients treated with induction chemotherapy followed by concurrent chemoradiotherapy (CCRT) were retrospectively reviewed. The SVRR and the treatment response based on RECIST 1.1 were measured using contrast-enhanced computed tomography (CT) localisations before and after induction chemotherapy. The receiver operating characteristic (ROC) curve analysis was used to identify the optimal cutoff point of the SVRR and compare the prognostic value of the SVRR and RECIST 1.1criteria.

RESULTS

The optimal cutoff points of SVRR for progression-free survival (PFS), locoregional failure-free survival (LRFFS) and distant metastasis-free survival (DMFS) were all 25.15%, while for overall survival (OS) it was 16.63%. The area under the ROC curve (AUC) of optimal cutoff points of SVRR was superior than that of RECIST 1.1 for PFS (AUC: 0.716 vs. 0.578; P = 0.0022), LRFFS (AUC: 0.700 vs. 0.574; P = 0.0080) and DMFS (AUC: 0.736 vs. 0.606; P = 0.0053), respectively. The 3-year PFS, DMFS and OS rates for SVRR less than vs. greater than or equal to the cutoff points were 55.8% vs. 92.2% (P < 0.001, hazard ratio (HR): 0.209, 95% confidence interval (CI): 0.091-0.480), 59.7% vs. 96.7% (P < 0.001, HR: 0.120, 95% CI: 0.043-0.336) and 66.7% vs. 98.1% (P < 0.001, HR: 0.069, 95% CI: 0.014-0.342), while the responses [stable disease (SD), partial response (PR)] based on RECIST 1.1 were not significantly associated with 3-year survival rates. Multivariate analysis indicated that SVRR was an independent prognostic factor for PFS, DMFS and OS (all P < 0.05).

CONCLUSIONS

The sum volumetric regression ratio and response based on RECIST 1.1 were related to the prognosis in locoregionally advanced NPC after induction chemotherapy. Sum volumetric regression ratio is an independent outcome predictor for survival in locoregionally advanced NPC, playing a better prognostic role than RECIST 1.1.

Prognostic value and the potential role of treatment options for cervical lymph node necrosis in nasopharyngeal carcinoma

OBJECTIVE

There were few studies focused on the cervical lymph necrosis (CNN) of nasopharyngeal carcinoma (NPC) patients to develop a nomogram and guide the treatment decision at the era of intensity modulated radiation therapy (IMRT).

MATERIAL AND METHODS

The prognostic accuracy of CNN in the training cohort (n = 1940) was validated in Guangzhou internal validation cohort (n = 832) and two external validation cohorts (Dongguan, n = 232; Foshan, n = 134).

RESULTS

The primary end point was progression-free survival (PFS), calculated using the Kaplan-Meier method. After a median 60.0 months' follow-up, patients with CNN in the training cohort had worse 5-year PFS (70.8% vs. 89.1%, P < 0.001) than patients without CNN, which was validated in the validation cohorts. The nomogram based on CNN predicted an individual PFS risk (training: C-index 0.733; Guangzhou validation: C-index 0.736; Foshan: C-index 0.722; Dongguan: C-index 0.756). Stage N2 patients in the CNN group and stage IV patients no matter the status of CNN, PFS was better with induction chemotherapy (ICT) and CCRT than CCRT (P < 0.05).

CONCLUSION

Taken together, CNN reliably predicts survival risk in NPC patients. N2 patients in the CNN group and stage IV patients may receive survival benefit from ICT.

Association of body composition with survival and inflammatory responses in patients with non-metastatic nasopharyngeal cancer

OBJECTIVES

It is unknown whether or not the body composition is correlated with the prognosis and inflammatory response in patients with nasopharyngeal cancer (NPC).

MATERIALS AND METHODS

This cohort included 1767 patients with NPC. Visceral, subcutaneous and intra muscular adipose tissues (VAT, SAT and IMAT), and skeletal muscle index were quantified with computed tomography. We used the optimal stratification to select cut points for VAT, SAT and IMAT. We defined sarcopenia according to a widely used cut-point. The primary endpoint was overall survival (OS). The association between body composition and inflammatory response was also examined.

RESULTS

Low VAT, SAT, IMAT and sarcopenia were observed in 260 (14.7%), 451 (25.5%), 773 (43.7%) and 683 (38.7%) patients, respectively. Low VAT (P < 0.001, hazard ratio [HR], 1.884; 95% confidence interval [CI], 1.436-2.473,) and SAT (P = 0.022, HR, 1.334, 95%CI, 1.043-1.706) were both associated worse survival. IMAT and sarcopenia were not with prognostic value. In multivariate analysis, we found the prognostic value of the VAT (HR: 1.544, 95% CI: 1.128-2.114; P = 0.007) was independent of T stage, N stage, disease stage, lactic dehydrogenase, neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), the systemic immune-inflammation index (SII), EBV-DNA and body mass index. We observed higher NLR (P = 0.028) and PLR (P < 0.001) in patients with low SAT. Both low VAT (P = 0.009) and SAT (P = 0.005) were associated with decreased stromal lymphocyte infiltrating intensity.

CONCLUSIONS

Among body composition parameters, VAT was an independent prognostic factor, especially in patients with locally advanced NPC.

A Nomogram for Predicting Distant Metastasis Using Nodal-Related Features Among Patients With Nasopharyngeal Carcinoma

Distant metastasis is among the main reasons for treatment failure in nasopharyngeal carcinoma (NPC) patients. To identify patients with a high risk of distant metastasis is important to guide posttreatment surveillance, appropriate time treatments, and prolonging their long-term survival. In this study, we systematically examined the associations between a series of nodal-related characteristics and distant metastasis-free survival (DMFS) by detailed MRI reading and established a nomogram for DMFS in NPC patients. T-stage, age group, Epstein-Barr virus (EBV) level, central nodal necrosis, and nodal number were identified as independent risk factors for distant metastasis and were included into the final nomogram. The calibration plot showed a high agreement between the prediction by the nomogram and actual observations. Our established nomogram achieved a high C-index in predicting distant metastasis in both of the training cohort (0.737) and the validation cohort (0.718). This nomogram incorporated several readily available nodal features from the MR images, and it might be useful for guiding clinical decision and NPC patients' posttreatment surveillance. It also provides cues for how to redefine N-stage. Additional research is needed to confirm our conclusions.

Normative measurements of parotid lymph nodes on CT imaging

PURPOSE

The goal of this study is to characterize the normal size of parotid lymph nodes among healthy adult patients on CT.

METHODS

This was a single-center retrospective observational study of 543 patients who underwent maxillofacial CT scans between January 2019 and July 2019. The long and short axis diameters of the largest lymph nodes in the bilateral superficial parotid glands were measured.

RESULTS

Among the 543 patients, 407 subjects with a mean age of 47.0 ± 18.4 years had a total of 719 detectable intraparotid lymph nodes. The mean patient age was 47.0 ± 18.4 years. Of all 719 measured intraparotid lymph nodes, the measured long and short axis diameter means were 4.4 ± 1.4 mm and 3.3 ± 1.1 mm, respectively. In our study, 96% (689/719) of all lymph nodes had a long axis diameter of 7 mm or less and 93% (671/719) of all lymph nodes had a short axis diameter of 5 mm or less. Younger patients had significantly larger lymph nodes than older patients in both long axis (4.5 vs 4.3 mm; P = 0.03) and short axis (3.4 vs 3.1 mm, P = 0.01) measurements.

CONCLUSION

Our findings suggest 5 mm as an upper limit of normal for the short axis diameter of superficial intraparotid lymph nodes.

Integrating Tumor and Nodal Imaging Characteristics at Baseline and Mid-Treatment Computed Tomography Scans to Predict Distant Metastasis in Oropharyngeal Cancer Treated With Concurrent Chemoradiotherapy

PURPOSE

Prognostic biomarkers of disease relapse are needed for risk-adaptive therapy of oropharyngeal cancer (OPC). This work aims to identify an imaging signature to predict distant metastasis in OPC.

METHODS AND MATERIALS

This single-institution retrospective study included 140 patients treated with definitive concurrent chemoradiotherapy, for whom both pre- and midtreatment contrast-enhanced computed tomography (CT) scans were available. Patients were divided into separate training and testing cohorts. Forty-five quantitative image features were extracted to characterize tumor and involved lymph nodes at both time points. By incorporating both imaging and clinicopathological features, a random survival forest (RSF) model was built to predict distant metastasis-free survival (DMFS). The model was optimized via repeated cross-validation in the training cohort and then independently validated in the testing cohort.

RESULTS

The most important features for predicting DMFS were the maximum distance among nodes, maximum distance between tumor and nodes at mid-treatment, and pretreatment tumor sphericity. In the testing cohort, the RSF model achieved good discriminability for DMFS (C-index = 0.73, P = .008), and further divided patients into 2 risk groups with different 2-year DMFS rates: 96.7% versus 67.6%. Similar trends were observed for patients with p16+ tumors and smoking ≤10 pack-years. The RSF model based on pretreatment CT features alone achieved lower performance (concordance index = 0.68, P = .03).

CONCLUSIONS

Integrating tumor and nodal imaging characteristics at baseline and mid-treatment CT allows prediction of distant metastasis in OPC. The proposed imaging signature requires prospective validation and, if successful, may help identify high-risk human papillomavirus-positive patients who should not be considered for deintensification therapy.

Prognostic value of retropharyngeal lymph node metastasis laterality in nasopharyngeal carcinoma and a proposed modification to the UICC/AJCC N staging system

BACKGROUND AND PURPOSE

Metastasis laterality is used for N classification of cervical lymph nodes, but not retropharyngeal lymph nodes (RLNs). This study explored the prognostic value of laterality of RLN metastasis to provide suggestions for a better N standard classification.

MATERIALS AND METHODS

This retrospective study evaluated 1225 patients with new biopsy-confirmed nasopharyngeal carcinoma (NPC). Univariable and multivariable Cox regression models were used to assess overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS). A new N classification system was developed and compared to the 8th AJCC system. Kaplan-Meier methods with log-rank tests were used to compare OS, PFS, and DMFS between our proposed N stage and the AJCC N stages.

RESULTS

The incidence of RLN metastasis was 38.7% (unilateral) and 27.5% (bilateral). In the N1 subgroup, metastasis laterality was associated with significant differences in the 5-year rates of OS (89.4% vs. 82.6%, p = 0.016), DMFS (91.5% vs. 82.9%, p = 0.004), and PFS (80.3% vs. 71.2%, p = 0.016). However, no significant differences in these outcomes were observed when we compared N2 disease to N1 bilateral RLN metastasis. Multivariate analysis confirmed that bilateral RLN metastasis independently predicted OS, DMFS, and PFS. The proposed classification broadened the differences in OS, DMFS, PFS between N1 and N2 disease.

CONCLUSION

Patients with NPC and unilateral RLN metastasis had better survival than did patients with bilateral RLN metastasis. Upgrading cases with bilateral RLN metastasis from N1 to N2 may help improve prognostication using the 8th AJCC system.

Additional Cervical Lymph Node Biopsy is Not a Significant Prognostic Factor for Nasopharyngeal Carcinoma in the Intensity-Modulated Radiation Therapy Era: A Propensity Score-matched Analysis from an Epidemic Area

Introduction: This study aimed to evaluate the prognostic value of cervical lymph node biopsy and whether different biopsy methods would lead different outcomes in NPC in the intensity-modulated radiotherapy (IMRT) era. Material and Methods: 1492 patients with biopsy-proven, non-metastatic NPC, and treated by IMRT with or without chemotherapy were retrospectively reviewed. Cervical lymph node biopsy was performed in 183 (12.3%) patients: 61(4.1%) by needle puncture and 118(7.9%) by excision biopsy. Propensity-score matching was used to match patients in both arms at an equal ratio. Overall survival (OS), distant metastasis-free survival (DMFS), locoregional relapse-free survival (LRFS), and nodal relapse-free survival (NRFS) were assessed using the Kaplan-Meier method and compared using the log-rank test. Independent prognostic factors were identified using the Cox proportional hazards model. Results: In the original cohort of 1492 patients, patients receiving cervical lymph node biopsy had comparable survival (OS: P = 0.736, DMFS: P = 0.749, LRFS: P = 0.538, NRFS: P = 0.093,) with patients receiving isolated napharynx biopsy. The results for the propensity-match cohort of 316 patients were similar. Interestingly, compared with the control group and needle puncture biopsy group, a slightly lower nodal recurrence rate was observed in the excision biopsy group (P = 0.082 and P = 0.072, respectively). Adjusting for the known prognostic factors in multivariate analysis, cervical biopsy did not cause a higher risk of death, distant metastasis, or nodal relapse. Conclusions: Pretreatment cervical lymph node biopsy is not associated with impaired survival in NPC, suggesting the resist of the biopsy and more aggressive treatment after the biopsy may be unnecessary.

Elevated plasma fibrinogen level shows superior prognostic value than Epstein-Barr virus DNA load for stage IVA/B nasopharyngeal carcinoma patients in the intensity-modulated radiotherapy era

Purpose

Effective prognostic factors for patients with stage IVA/B nasopharyngeal carcinoma (NPC) who are susceptible to distant metastases are limited. We aim to investigate the prognostic value of pretreatment plasma fibrinogen (FIB) level and Epstein–Barr virus DNA (EBV-DNA) load in these patients in the era of intensity-modulated radiotherapy (IMRT).

Results

The 5-year DSS, DFS and DMFS rates of the entire cohort were 72.7%, 66.8%, 80.0%, respectively. High FIB level was identified as a negative prognostic factor for survival: the 5-year DSS, DFS and DMFS rates for patients with high FIB (> 4.0 g/L) and normal FIB (≤ 4.0 g/L) were 60.3% vs. 76.0%, 56.0% vs. 69.9%, and 59.4% vs. 85.5%, respectively (all P < 0.001). Subgroup analysis demonstrated that DSS, DFS and DMFS decreased as FIB gradually increased, even within the normal range. The risk of distant metastasis in patients with high FIB was over 3-fold than patients with normal FIB. EBV-DNA was not an independent prognostic factor for any survival outcomes in multivariate analysis.

Conclusion

High pretreatment FIB level shows superior prognostic value than EBV-DNA load for stage IVA/B NPC patients in the era of IMRT.

Materials and Methods

A total of 755 patients with newly-diagnosed stage IVA/B NPC treated with definitive IMRT between January 2007 and December 2011 were enrolled. Plasma FIB and EBV-DNA were measured before treatment. Disease-specific survival (DSS), disease-free survival (DFS) and distant metastasis-free survival (DMFS) were calculated using the Kaplan-Meier method; differences were compared using the log-rank test.

Overexpression of Nogo receptor 3 (NgR3) correlates with poor prognosis and contributes to the migration of epithelial cells of nasopharyngeal carcinoma patients

Lymph node metastasis (N classification) is one of the most important prognostic factors of nasopharyngeal carcinoma (NPC), and nerve involvement is associated with the transition of the N category in NPC patients. Although the nervous system has been reported to participate in many types of cancer progression, its functions in NPC progression remains unknown. Through analysis of gene profiling data, we demonstrate an enrichment of genes associated with neuronal development and differentiation in NPC tissues and cell lines. Among these genes, Nogo receptor 3 (NgR3), which was originally identified in the nervous system and plays a role in nerve development and regeneration, was inappropriately overexpressed in NPC cells and tissues. Immunohistochemical analysis demonstrated that the overexpression of NgR3 was correlated with poor prognosis in NPC patients. Overexpression of NgR3 promoted, and knocking down NgR3 inhibited, NPC cell migration and invasion in vitro and metastasis in vivo. The ability of NgR3 to promote cell migration was triggered by the downregulation of E-cadherin and enhanced cytoskeletal rearrangement and cell polarity, which were correlated with the activation of focal adhesion kinase (FAK). Collectively, NgR3 is a novel indicator of poor outcomes in NPC patients and plays an important role in driving the progression of NPC. These results suggest a potential link between the nervous system and NPC progression.

KEY MESSAGES

Genes involved in the neuronal biological process are enriched in nasopharyngeal carcinoma. Overexpression of NgR3 correlates with poor prognosis of nasopharyngeal carcinoma. NgR3 promotes NPC cell migration by downregulating E-cadherin. NgR3 promotes NPC cell polarity and enhances the formation of NPC cell pseudopodia by activating FAK/Src pathway.

The Prognosis and Risk Stratification Based on Pelvic Lymph Node Characteristics in Patients With Locally Advanced Cervical Squamous Cell Carcinoma Treated With Concurrent Chemoradiotherapy

BACKGROUND

The purpose of this study is to determine the prognostic significance of pelvic lymph node (PLN) characteristics and perform risk stratification in patients undergoing concurrent chemoradiotherapy for locally advanced cervical squamous cell carcinoma.

METHODS

We retrospectively reviewed the records of 609 patients with Federation Internationale de Gynecologie et d'Obstetrique (FIGO) stage II to IVa who underwent concurrent chemoradiotherapy, compared overall survival (OS), distant metastasis-free survival (DMFS), and pelvic recurrence-free survival between patients with or without PLN involvement. We further analyzed prognostic factors for OS and DMFS including FIGO stage, tumor volume, and lymph node (LN) characteristics in 300 patients with PLN involvement.

RESULTS

The 3-year OS rate was 81.7% versus 92.8% (P = 0.002) and the 3-year DMFS rate was 79.3% versus 92.7% (P = 0.006) in patients with or without PLN involvement, respectively. With univariable analysis, FIGO stage, LN-volume, LN-number, LN-diameter, and matted/necrotic LN affected both OS and DMFS. Based on multivariable analysis, we created a risk stratification model. For OS, the independent risk factors were FIGO stage III or IVa, LN-volume of 3 cm or more, LN-diameter of 1.5 cm or more, and matted/necrotic LN. The low-risk group (no risk factors), mid-risk group (1 or 2 risk factors), and high-risk group (3 or 4 risk factors) had a 3-year OS of 96.6%, 84.9%, and 64.7%, respectively (P = 0.005). For DMFS, LN-diameter of 1.5 cm or more, LN-number of 3 or more, and matted/necrotic LN were the independent risk factors. The subgroups for DMFS were the low-risk group (no risk factors), the mid-risk group (1 risk factor), and the high-risk group (2 or 3 risk factors), and the 3-year DMFS was 92.4%, 76.2%, and 64.6%, respectively (P = 0.001).

CONCLUSIONS

The prognosis was significantly poorer for patients with high-risk lymph node characteristics. Using this risk stratification, we should select the most appropriate and individualized treatment modality to improve outcomes in those patients with a poorer prognosis.