Failure patterns and survival in patients with nasopharyngeal carcinoma treated with intensity modulated radiation in Northwest China: a pilot study

Patterns of treatment failure in patients with nasopharyngeal carcinoma and salvage treatment outcome: A retrospective analysis study

INTRODUCTION

In Saudi Arabia, head and neck cancers represent 6 % of all malignancies. 33 % of these are nasopharyngeal. Thus, we aimed to distinguish patterns of treatment failure and salvage treatment outcomes among patients with nasopharyngeal carcinoma (NPC).

METHODS

A retrospective review of patients treated for NPC in a tertiary care hospital. From May 2012 to January 2020, we retrospectively reviewed 175 patients that fit our inclusion criteria. Those who did not complete their treatment, started treatment in another institution, or did not complete a 3-year follow-up were excluded. In addition, the primary treatment outcome and the salvage treatment for those who failed initial treatment were collected and analyzed.

RESULTS

Patients were predominantly stage 4 disease. 67 % of the patients were alive without evidence of disease during their last follow-up. However, 75 % of failure occurs in the first 20 months of completing the treatment regimen. Neoadjuvant therapy and delays in referral play a significant role in treatment failure. For failed cases, concurrent salvage chemoradiotherapy showed the best survival.

CONCLUSION

Advanced stage 4A and T4 nasopharyngeal carcinoma should receive the maximum treatment, with a close follow-up, particularly during the first 2 years after treatment. Furthermore, the excellent outcome from salvage chemoradiotherapy and radiotherapy alone would make physicians aware of the importance of aggressive primary treatment.

Why subclinical involvement is prescribed the same high dose as gross tumor volume: A study on high-dose clinical target volume in intensity-modulated radiotherapy plan of nasopharyngeal carcinoma

BACKGROUND

Most nasopharyngeal carcinoma (NPC) protocols define primary gross tumor volume (GTVnx) plus a range from 2 to 5 mm as the high-dose clinical target volume (hd-CTV). However, in China, hd-CTV is defined as GTVnx plus 0 mm.

METHODS

A total of 40 patients with newly diagnosed nonmetastatic NPC (T1-T4 ten cases each) treated with IMRT were consecutively enrolled. Real and virtual treatment plans were designed according to the definitions of hd-CTV recommended by China and Radiation Therapy Oncology Group (RTOG), respectively.

RESULTS

The hd-CTV in China was significantly smaller than that of RTOG. Exposure doses to 5 mm subclinical involvement and OARs as well as NTCP in the China treatment plan were significantly lower than those of RTOG.

CONCLUSION

It could be recommended to divide the hd-CTV into GTV and subclinical target volume and to prescribe different doses for the GTV and subclinical involvement in the IMRT plan of NPC.

C2orf40 inhibits metastasis and regulates chemo-resistance and radio-resistance of nasopharyngeal carcinoma cells by influencing cell cycle and activating the PI3K/AKT/mTOR signaling pathway

Background

Nasopharyngeal carcinoma (NPC) is a malignant tumor of epithelial origin in head and neck with high incidence rate in Southern China. C2orf40 has been identified as a tumor suppressor gene in many cancers. However, the roles of C2orf40 in nasopharyngeal carcinoma has not been studied.

Methods

In this study, a bioinformatics analysis was performed to identify the differentially expressed genes in NPC. The quantitative methylation levels was detected using pyrosequencing. qRT-PCR, western blotting, immunohistochemistry and immunofluorescence were used to detect the expression level of related RNA and proteins. Cell proliferation was detected using CCK-8 assay, and colony formation capability was detected using colony formation assays. Cell migration and invasion were analyzed using wound-healing and Transwell assays, respectively. The apoptosis level of cells was assessed using TUNEL staining. Endogenous DNA damage and repair were assessed by the comet assay. Cell cycle analyses carried out by flow cytometry. Finally, We used a xenograft nude mouse to verify the roles of C2orf40 in chemoresistance and radioresistance in vivo.

Results

We found that the C2orf40 expression was significantly downregulated in NPC tissues and inversely associated with a poor prognosis. In vivo and in vitro functional experiments confirmed that overexpression of C2orf40 significantly inhibited the migration and invasion of NPC cells, and promoted their sensitivity to radiotherapy and chemotherapy of NPC cells. Mechanically, the expression level of C2orf40 was negatively correlated with the expression levels of CCNE1 and CDK1. Overexpression of C2orf40 induced cell cycle arrest of NPC cells at G/M phase. In addition, C2orf40 can down-regulated the expression levels of homologous recombination-related proteins (BRCA1, BRCA2, RAD51, and CDC25A) and inhibited the activity of the PI3K/AKT/mTOR signaling pathway.

Conclusion

The results clarified the biological functions and mechanisms of C2orf40, as a tumor suppressor gene, in NPC, and provided a potential molecular target for improving the sensitivity of NPC to radiotherapy and chemotherapy.

Kiss1 Inhibits the Proliferation of Nasopharyngeal Carcinoma Cells Via Activation of the LKB1/AMPK Pathway

Nasopharyngeal carcinoma (NPC) is a cancer that occurs in the nasopharynx. Infinite proliferation and distant metastasis are the main characteristics of NPC cells, and the main reason for the current failure of malignant tumor treatment. In this study, by integrating the immunohistochemical, cell transfection, western blot and real-time reverse transcriptase polymerase chain reaction (RT-PCR) analysis, we observed that the expression of KISS1 and its receptor gene (KISS1R) negatively related with the proliferation of NPC cells. Overexpression of the KISS1 genes in cells reduced cell proliferation, slow down the cell cycle, and increased apoptosis. Additionally, overexpression of these genes significantly increased Liver Kinase B1 (LKB1), phosphorylation of LKB1 and AMPK, indicated by Western blotting. Together, all of these results suggested for the first time that KISS1 and KISS1R suppress the proliferation of NPC cells by activating the LKB1/AMPK pathway, thus revealing a viable indicator for diagnosis of NPC in clinical practice.

Computed tomography-based deep-learning prediction of induction chemotherapy treatment response in locally advanced nasopharyngeal carcinoma

BACKGROUND

Deep learning methods have great potential to predict treatment response. The objective of this study was to evaluate and validate the predictive performance of the computed tomography (CT)-based model using deep learning features for identification of responders and nonresponders to induction chemotherapy (IC) in nasopharyngeal carcinoma (NPC).

MATERIALS AND METHODS

All eligible patients were included retrospectively between January 2012 and December 2018, and assigned to the training (n = 208) or the testing cohort (n = 89). We extracted deep learning features of six pretrained convolutional neural networks (CNNs) via transfer learning method, and handcrafted radiomics features manually. Support vector machine (SVM) was adopted as the classifier. All predictive models were evaluated using the area under the receiver operating characteristics curve (AUC), by which an optimal model was selected. We also built clinical and clinical-radiological models for comparison.

RESULTS

The model with features extracted from ResNet50 (RN-SVM) had optimal performance among all models with features extracted from pretrained CNNs with an AUC of 0.811, accuracy of 68.54%, sensitivity of 61.54%, specificity of 87.50%, positive predictive value (PPV) of 93.02%, and negative predictive value (NPV) of 45.65% in the testing cohort. The handcrafted radiomics model was slightly inferior to the RN-SVM model with an AUC of 0.663 and accuracy of 60.67% in the testing cohort. All the imaging-derived models had better predictive performance than the clinical model.

CONCLUSION

The noninvasive deep learning method could provide efficient prediction of treatment response to IC in locally advanced NPC and might be a practicable approach in therapeutic strategy decision-making.

Residual Volume of Lymph Nodes During Chemoradiotherapy Based Nomogram to Predict Survival of Nasopharyngeal Carcinoma Patient Receiving Induction Chemotherapy

Purpose

To accurately stratify nasopharyngeal carcinoma (NPC) patients who were benefit from induction chemotherapy (IC) followed by chemoradiotherapy (CCRT), we established residual volume of lymph nodes during chemoradiotherapy based nomogram to predict survival for NPC patients.

Methods

Cox regression analysis were used to evaluate predictive effects of tumor volume parameters. Multivariate Cox regression analysis was used to identify the prognostic factors, and nomogram models were developed to predict survival of NPC patients receiving IC followed by CCRT.

Results

Compared with other tumor volumetric parameters, midRT GTVnd was the best predictive factor for OS (HR: 1.043, 95%CI: 1.031-1.055), PFS (HR: 1.040, 95%CI: 1.030- 1.051), and DMFS (HR: 1.046, 95%CI: 1.034 – 1.059) according to the HR of Cox regression analysis. Based on multivariate analysis, three nomograms included midRT GTVnd were constructed to predict 4-year survival. The C-index of nomograms for each survival endpoints were as follow (training cohort vs. validation cohort): 0.746 vs. 0.731 for OS; 0.747 vs. 0.735 for PFS; 0.768 vs. 0.729 for DMFS, respectively. AUC showed a good discriminative ability. Calibration curves demonstrated a consistence between actual results and predictions. Decision curve analysis (DCA) showed that the nomograms had better clinical predictive effects than current TNM staging system.

Conclusion

We identified the best volumetric indicator associated with prognosis was the residual volume of lymph nodes at the fourth week of chemoradiotherapy for patients receiving IC followed by CCRT. We developed and validated three nomograms to predict specific probability of 4-year OS, PFS and DMFS for NPC patient receiving IC followed by CCRT.

Are People With Blood Group O More Susceptible to Nasopharyngeal Carcinoma and Have Worse Survival Rates? A Systematic Review and Meta-Analysis

Objective

Nasopharyngeal carcinoma (NPC) is a common malignant tumour in Southeast Asia, especially in southern China. ABO blood groups have been proven to play an important role in many cancers. However, it is still controversial whether the ABO blood group has a definite relationship to susceptibility to NPC and the prognosis of NPC patients. This meta-analysis was performed to elucidate the correlation between ABO blood group and NPC to provide more data for clinical practice.

Methods

A systematic search was performed of the Chinese National Knowledge Infrastructure (CNKI), Wanfang, Web of Science, EMBASE, and PubMed databases up to December 31, 2020. Stata 11.0 statistical software was used for this meta-analysis.

Results

According to the inclusion and exclusion criteria, a total of 6 studies including 6938 patients with NPC were selected. Blood group O was relevant to Chinese NPC patients, and patients with blood group O had a significantly lower incidence of NPC, while blood group A had no correlation with susceptibility to NPC. There was no difference in the 3-year overall survival (OS), locoregional relapse-free survival (LRRFS) or distant metastasis-free survival (DMFS) rates between patients with blood group O and those with non-O blood groups; worse 5-year OS, LRRFS and DMFS rates were found in patients with blood group O, whereas blood group A was not related to prognosis.

Conclusion

Blood group O in Chinese patients with NPC seems to be a protective factor for morbidity. However, once patients with blood group O are diagnosed with NPC, this blood group often indicates unfavourable OS, LRRFS and DMFS rates. It is recommended that more attention should be paid to the influence of blood group factor on patients in the treatment of NPC.

Long-term survival outcomes and adverse effects of nasopharyngeal carcinoma patients treated with IMRT in a non-endemic region: a population-based retrospective study

OBJECTIVES

To evaluate the long-term survival outcomes and adverse effects of intensity-modulated radiotherapy (IMRT) for nasopharyngeal carcinoma (NPC) and to summarise the experiences of IMRT in NPC in the past few decades in non-endemic northwest China.

DESIGN

A population-based retrospective study.

SETTING

An experience of using IMRT in non-endemic region of China.

PARTICIPANTS

The study included 792 newly diagnosed and non-metastatic NPC patients who received IMRT from January 2006 to September 2018 in Xijing Hospital.

OUTCOME MEASURES

The survival outcomes, adverse effects and failure patterns were evaluated by univariate, multivariate and subgroup analyses.

RESULTS

With a median follow-up time of 46.2 months, the 5-year local recurrence-free survival, regional recurrence-free survival, distant metastasis-free survival, disease-free survival (DFS) and overall survival (OS) rates were 90.8%, 97.0%, 82.8%, 69.6% and 78.0%, respectively. Multivariate analysis showed that age, N stage, clinical stage, pathological type and primary tumour volume of more than 23 cm³ were the independent prognosis factors for DFS (all p<0.05); age, N stage, pathological type, cervical lymph node necrosis, and anaemia were significantly associated with OS (all p<0.05). The most common acute toxicities of IMRT were dermatitis, mucositis and dysphagia. Xerostomia and hearing impairment were the top two late toxicities. The main failure patterns were distant metastasis and local and/or regional relapses.

CONCLUSIONS

Similar survival, toxicities and failure patterns have been observed in patients treated with IMRT in a non-endemic area of China when compared with that in endemic areas. Induction chemotherapy combined with concurrent chemoradiotherapy may benefit locally advanced NPC in non-endemic areas of China.

Gemcitabine and cisplatin versus docetaxel and cisplatin as induction chemotherapy followed by concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma from non-endemic area of China

PURPOSE

Although several trials have confirmed the treatment efficacy of induction chemotherapy followed by concurrent chemoradiotherapy (CCRT) in locoregionally advanced nasopharyngeal carcinoma (NPC) from endemic area of China, little is known about the best regime for induction chemotherapy in non-endemic region. This study compared the treatment effect of Gemcitabine and cisplatin (GP) versus docetaxel and cisplatin (TP) followed by concurrent chemoradiotherapy in locoregionally advanced NPC from non-endemic area of China.

MATERIALS AND METHODS

A total of 196 locoregionally advanced NPC patients were enrolled in this study, with 142 and 54 patients in TP and GP followed by concurrent chemoradiotherapy groups. The primary endpoint was treatment response of induction chemotherapy. The secondary endpoints included disease-free survival. The Kaplan-Meier method was used to evaluate the efficacy between treatment groups.

RESULTS

The median follow-up time was 45.5 months (range: 6-60.5 months). During induction chemotherapy course, GP contributed higher treatment response rate than TP (68.1% vs. 47.1%, p = 0.007). Patients in GP group had better DFS and LRFS than those in TP group (3-year and 5-year DFS, 86.8% and 82.5% vs. 71.7% and 68%, p = 0.036; 3-year and 5-year LRFS, 96.2% and 96.2% vs. 90.5% and 82.8%, p = 0.03). No significant difference of adverse events was observed between two treatment groups in the whole course.

CONCLUSION

This study suggested that GP followed by CCRT was better than TP followed by CCRT in improving survival outcomes of locoregionally advanced NPC patients from non-endemic area of China.

Inhibition of HMGB1 Overcomes Resistance to Radiation and Chemotherapy in Nasopharyngeal Carcinoma

Objective

This study aimed to investigate the effect of high mobility group protein B1 (HMGB1) on chemoresistance and radioresistance in nasopharyngeal carcinoma (NPC).

Materials and Methods

HMGB1-knockout HK1 cell lines were generated using clustered regularly interspaced short palindromic repeats/CRISPR-associated protein 9 (CRISPR/Cas9) system. Western blotting was used to evaluate the protein expression level of HMGB1. DNA repair efficiency of non-homologous end joining (NHEJ) and homologous recombination (HR) was monitored through NHEJ and HR reporter assay. Cellular protein–protein interaction between HMGB1 and NHEJ apparatus was determined by immunoprecipitation. Direct protein–protein interaction was examined by affinity capture assay with purified protein. Protein-DNA binding was evaluated by chromatin fractionation assay. Cell viability assay was employed to measure cell sensitivity to ionizing radiation (IR) or cisplatin.

Results

HMGB1-knockout NPC cells showed significant decrease in NHEJ efficiency. HMGB1 immunoprecipitated NHEJ key factors in NPC cells and promoted DNA-binding activity of Ku70. Mutational analysis revealed that serine 155 of Ku70 was required for its direct interaction with HMGB1. HMGB1 was highly expressed in radio- and chemoresistant NPC cells. Deficiency of HMGB1 sensitized wild-type (WT) and resistant NPC cells to IR and cisplatin. Glycyrrhizin, which is HMGB1 inhibitor, impaired DNA binding of HMGB1 and exhibited excellent synergy with IR and cisplatin.

Conclusion

HMGB1 promotes NHEJ via interaction with Ku70 resulting in resistance to IR and cisplatin. Inhibition of HMGB1 by glycyrrhizin is a potential therapeutic regimen to treat cisplatin and IR resistant NPC patients.

Analysis of Clinical Target Volume Delineation in Local-regional Failure of Nasopharyngeal Carcinoma after Intensity-modulated Radiotherapy

OBJECTIVE: To analyze the pattern of local failure in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT) and find a more reasonable delineation of the clinical target volume (CTV).

METHODS AND MATERIALS: A total of 212 patients with non-metastatic NPC who underwent IMRT were analyzed. Radiation therapy was run at a total dose of 66-74 Gy (2.0-2.2 Gy fractions). The follow-up of local recurrence and the recurrence-related features were analyzed for the original treatment situation. The failures were delimited as “in-field failure” if V_recur within the 95% isodose curve (V95%) was ≥95%; “marginal failure” if V95% was less than 95% and not less than 20%; or “out-field failure” if V95% was< 20%. Kaplan-Meier method was used to calculate the survival rates.

RESULTS: The median follow-up was 43.4 months. The 5-year local relapse-free survival and overall survival rates were 85.6 and 77.8%, respectively. A total of 18 patients have relapsed. The in-field failure, marginal failure, and out-field failure accounted for 83.3%, 11.1%, and 5.6%, respectively. The site of recurrence was basically in the high dose area.

CONCLUSION: These findings suggested that IMRT provide a good local control for patients with NPC, and the in-field failure is the main mode. A wide range of CTV cannot prevent the local recurrence, narrowing the CTV to protect the adjacent organs should be taken into consideration.

MRI-based radiomics nomogram may predict the response to induction chemotherapy and survival in locally advanced nasopharyngeal carcinoma

OBJECTIVES

To establish and validate a radiomics nomogram for prediction of induction chemotherapy (IC) response and survival in nasopharyngeal carcinoma (NPC) patients.

METHODS

One hundred twenty-three NPC patients (100 in training and 23 in validation cohort) with multi-MR images were enrolled. A radiomics nomogram was established by integrating the clinical data and radiomics signature generated by support vector machine.

RESULTS

The radiomics signature consisting of 19 selected features from the joint T1-weighted (T1-WI), T2-weighted (T2-WI), and contrast-enhanced T1-weighted MRI images (T1-C) showed good prognostic performance in terms of evaluating IC response in two cohorts. The radiomics nomogram established by integrating the radiomics signature with clinical data outperformed clinical nomogram alone (C-index in validation cohort, 0.863 vs 0.549; p < 0.01). Decision curve analysis demonstrated the clinical utility of the radiomics nomogram. Survival analysis showed that IC responders had significant better PFS (progression-free survival) than non-responders (3-year PFS 84.81% vs 39.75%, p < 0.001). Low-risk groups defined by radiomics signature had significant better PFS than high-risk groups (3-year PFS 76.24% vs 48.04%, p < 0.05).

CONCLUSIONS

Multiparametric MRI-based radiomics could be helpful for personalized risk stratification and treatment in NPC patients receiving IC.

KEY POINTS

• MRI Radiomics can predict IC response and survival in non-endemic NPC. • Radiomics signature in combination with clinical data showed excellent predictive performance. • Radiomics signature could separate patients into two groups with different prognosis.

Silencing UBE4B induces nasopharyngeal carcinoma apoptosis through the activation of caspase3 and p53

Aim

The human ubiquitination factor E4B (UBE4B) gene is frequently amplified in some solid cancers. However, the role of UBE4B in nasopharyngeal carcinoma (NPC) has not yet been investigated.

Methods

Firstly, we analyzed the expression of UBE4B in NPC samples using real-time quantitative PCR and Western blot analysis. After knocking down UBE4B using small interfering RNA technology, the functions of UBE4B on cell proliferation, apoptosis, and cell cycle, as well as underlying mechanism, were investigated.

Results

Compared with matched adjacent non-tumor tissues, both protein and mRNA levels of UBE4B were much higher in most NPC cancerous specimens. Deficiency of UBE4B could significantly inhibit tumor cell growth and induce cell apoptosis. Knocking down UBE4B could promote the expression of cleaved caspase3 and p53, and inhibition of caspase3 could prevent cell apoptosis induced by the deficiency of UBE4B.

Conclusion

These results indicate that expression of UBE4B was higher in most NPC tissues compared to adjacent non-tumoral tissues, and that knockdown of UBE4B inhibited the cell growth and induced apoptosis in NPC cells. This process was regulated by the activation of caspase3 and p53. Thus, UBE4B gene might act as a potential molecular target to develop novel strategy for NPC patients.

Induction chemotherapy followed by concurrent chemoradiotherapy is benefit for advanced stage nasopharyngeal carcinoma with different nonkeratinizing carcinoma subtypes

Given the potentially distinctive histological variations in northwest of China, the aim of current study was to compare the efficacy of induction chemotherapy plus concurrent chemoradiotherapy (IC + CCRT) with concurrent chemoradiotherapy (CCRT) in nasopharyngeal carcinoma (NPC) patients with different histological types. A total of 301 patients were included in this study. Patients were classified in two cohorts according to the 2005 WHO World Health Organization histological classification: WHO type IIa group and WHO type IIb group. The Kaplan-Meier method was used to detect the efficacy between IC + CCRT and CCRT in two WHO types cohorts. Propensity score matching method was adopted to balance the baseline covariate and eliminate potential selection bias. On propensity matched analyses, IC + CCRT was found to produce better 3-year DMFS and OS than CCRT in WHO type IIa cohort (DMFS, 76.2% vs. 42.2%, p = 0.029; OS, 78.3% vs. 65.5%, p = 0.027). For WHO type IIb cohort, IC + CCRT was associated with a better 3-year OS (87.4% vs. 77.9%, p = 0.029) and a trend of better 3-year DMFS (85.9% vs. 76%, p = 0.162) compared with CCRT. IC + CCRT was benefit for advanced stage nasopharyngeal carcinoma with different nonkeratinizing carcinoma subtypes.

Efficacy of concurrent chemoradiotherapy combined with nimotuzumab for low-risk T4 stage nasopharyngeal carcinoma: A pilot study

BACKGROUND

The purpose of this study was to analyze the efficacy and safety of concurrent chemoradiotherapy combined with Nimotuzumab for low-risk T4 stage nasopharyngeal carcinoma (NPC).

METHODS

This study included 49 low-risk T4 stage NPC patients treated with concurrent chemoradiotherapy plus Nimotuzumab. The IMRT doses were planning target volume (PTV) 70-72 Gy for gross disease in the nasopharynx, and 66-70 Gy for positive lymph nodes. The doses for high risk and low risk region PTV were 60-62 Gy and 54-56 Gy in 31-33 fractions. All patients received a chemotherapy program consisting of Cisplatin 100mg/m2, day 1, Q3w and were treated by Nimotuzumab (Nimotuzumab 200mg, iv, Qw).

RESULTS

All 49 patients completed at least two cycles of chemotherapy and seven weeks of Nimotuzumab. The total efficiency of therapy was 100.0%. The 3-year overall survival (OS), distant metastasis-free survival (DMFS), local-regional control (LRC) and progression-free survival (PFS) rates were 89.7%, 87.8%, 97.9% and 85.7%, respectively. No regional lymph node recurrence was detected. The most serious acute toxicity was mucositis, with prevalence of Grades 0 to IV being 0.0%, 57.1%, 34.7%, 8.2%, and 0.0%, respectively. Late toxicity manifested as Grades I and II xerostomia in 32 and 10 patients.

CONCLUSION

In patients with low-risk T4 stage NPC, concurrent chemoradiotherapy combined with Nimotuzumab yielded an excellent local control rate, and the toxicities were mild and tolerable. Distant metastasis was the main cause of treatment failure.

Association of E-cadherin methylation with risk of nasopharyngeal cancer: A meta-analysis

BACKGROUND

Various studies have assessed the association between E-cadherin methylation and risk of nasopharyngeal cancer (NPC) but the conclusion remains unclear. This meta-analysis was conducted to evaluate the effects of E-cadherin methylation on the incidence and clinicopathological characteristics of NPC.

METHODS

Ten studies published up to June 30, 2016, were collected. Odds ratios (ORs) with corresponding confidence intervals (CIs) were calculated and summarized, respectively.

RESULTS

The E-cadherin methylation in NPC was significantly higher than those in normal groups (OR 16.23; 95% CI 8.34-31.60; P < .001). Ethnicity-stratified analysis indicated that E-cadherin methylation was strongly correlated with NPC among both Asians (OR 16.98; 95% CI 8.45-34.14; P < .001) and North Africans (OR 10.67; 95% CI 1.21-93.72; P = .033). However, further analysis showed that E-cadherin methylation was not strongly associated with clinicopathological feathers in patients with NPC.

CONCLUSION

The E-cadherin methylation is strongly associated with the incidence of NPC, which can serve as an effective biomarker for early detection of NPC.

A retrospective study of concurrent chemoradiotherapy plus S-1 adjuvant chemotherapy on curative effect for treatment of patients with N3 stage nasopharyngeal carcinoma

Introduction

The purpose of this study was to analyze the efficacy and safety of concurrent chemoradiotherapy plus S-1 adjuvant chemotherapy for N3 stage nasopharyngeal carcinoma (NPC).

Methods

This study included 44 N3 stage NPC patients treated with concurrent chemoradiotherapy plus S-1 adjuvant chemotherapy. The intensity-modulated radiation therapy doses were planning target volume (PTV) 70–72 Gy for gross disease in the nasopharynx and 66–70 Gy for positive lymph nodes. The doses for high-risk- and low-risk region PTV were 60–62 and 54–56 Gy in 31–33 fractions. All patients received a concurrent chemotherapy program consisting of cisplatin 100 mg/m², day 1, and the cycle repetition was every 21 days. The adjuvant chemotherapy program consisted of 4 cycles of S-1. The dose of S-1 was determined according to the body surface area (BSA): 40 mg twice a day for BSA <1.25 m²; 50 mg twice a day for 1.25 m²≤BSA<1.5 m²; and 60 mg twice a day for BSA ≥1.5 m². S-1 was given on days 1–28, given 6 weeks apart.

Results

All 44 patients completed at least 2 cycles of concurrent chemotherapy and 4 cycles of adjuvant chemotherapy. The total efficiency of therapy was 100.0%. The 3-year overall survival (OS), distant metastasis-free survival (DMFS), local-regional control, and progression-free survival rates were 86.4%, 84.1%, 97.7%, and 81.8%, respectively. There were no differences in the OS, DMFS, and efficiency between fast-fading group (reaching partial response before the second cycle of concurrent chemotherapy) and general-fading group (the rest of the group). The incidence of rash in the entire group was low, and there was also no association with prognosis.

Conclusion

In patients with N3 stage NPC, concurrent chemoradiotherapy plus S-1 adjuvant chemotherapy yielded an excellent survival benefit, and the toxicities were mild and tolerable. Distant metastasis was the main cause of treatment failure.

Patterns of local failures and suggestions for reduction of clinical target volume for nasopharyngeal carcinoma patients without cervical lymph node metastasis

BACKGROUND

To demonstrate the robustness of clinical target volume delineation for nasopharyngeal carcinoma (NPC) patients, this study makes a detailed analysis of the initial irradiated dose of the recurrent site and local failure patterns after intensity-modulated radiation therapy (IMRT). Based on this analysis, further improvement of delineation recommendations may be made in order to improve the quality-of-life in NPC, without decreasing the local control and survival rate.

METHODS

In total, 382 newly diagnosed non-metastatic NPC patients were retrospectively enrolled, receiving elective neck irradiation to levels II, III, and VA. For patients with local failure, the location and extent of local failures were transferred to the pretreatment planning computed tomography (CT) for dosimetric analysis. The dose of radiation received by GTVr (gross tumor volume of recurrence) was calculated and analyzed with dose-volume histogram (DVH). Failures were classified as: "in field" if 95% of GTVr was within the 95% isodose, "marginal" if 20%-95% of GTVr was within the 95% isodose, or "outside" if less than 20% of GTVr was inside the 95% isodose.

RESULTS

With a median follow-up time of 61.3 months, 12 patients developed local recurrence (10 cases available). The 5-year overall survival, local relapse-free survival, regional relapse-free survival, distant metastasis failure-free survival, and disease-free survival were 87.8%, 95.2%, 99.1%, 93.3%, and 82.5%, respectively. Dose conformity with IMRT was excellent, and the recurrence was mainly within 3 years after the first treatment. The dosimetric analysis showed that seven failures were classified as "in-field", two failures as "marginal", and only one failure as "out-field". Most local relapse sites located just the same site of primary tumor and most anatomic sites were at low risk of concurrent bilateral tumor invasion.

CONCLUSIONS

IMRT with elective neck irradiation provides excellent local control for NPC patients without cervical lymph node metastasis. In-field failures are the main patterns for local recurrence, and the radioresistant subvolumes within the gross tumor volume are needed to be identified. This study proposed suggestions for reduction of target volume during IMRT treatment for NPC patients.

Twist1 promotes radioresistance in nasopharyngeal carcinoma

With the development of advanced imaging and radiation technologies, radiotherapy has been employed as the principal treatment approach for nasopharyngeal carcinoma (NPC). So far, a number of patients still suffer from the failure of this treatment due to the acquired radioresistance, but the underlying mechanisms are still poorly defined. In this study, we found that Twist1, participating in a variety of cell biological process, was associated with the malignancy of NPC and could induce NPC radioresistance in vitro and in vivo. Mechanically, Twist1 could promote the accumulation of DNA damage repair and inhibit the apoptosis of NPC cells. Therefore, our study not only elucidates the significant role of Twist1 in radioresistance of NPC, but also highlights Twist1 as a potential therapeutic target for NPC.

Induction chemotherapy for the treatment of non-endemic locally advanced nasopharyngeal carcinoma

Background

The role of induction chemotherapy is less clear in non-endemic locally advanced nanopharyngeal carcinomas (NPC).

Results

With a total of 233 eligible patients and a median follow-up of 36 months, 3-year overall survival (OS), local recurrence-free survival (LRFS), distant metastasis-free survival (DMFS), disease free survival (DFS) were 84.5%, 94.9%, 78.6% and 69.2%, respectively. The overall failure rate was 21.0% and distant metastasis occurred in 17.2% patients. Multivariate analyses showed that retropharyngeal and bilateral neck lymph node metastasis were significant prognostic factors for DFS and OS. Moreover, patients receiving both GP (gemcitabine+cisplatin) and TP (docetaxel+cisplatin) regimes had significantly higher DFS and OS compared with PF (cisplatin+5-FU) regime. GP regimes lead to significantly improved OS than TP/PF in some subgroup of patients. No severe toxicities were observed.

Materials and Methods

We retrospectively analyzed stage III-IVb NPC patients treated between Jan 2006 and Dec 2014, with induction chemotherapy followed by concurrent chemoradiation (IC-CCRT). Statistical analyses were performed on survival and failure patterns.

Conclusions

These results suggested IC-CCRT was safe and effective for NPCs from non-endemic region. The choice of induction regimen appeared to affect patient outcomes.

An open-label, single-arm phase II clinical study of docetaxel plus lobaplatin for Chinese patients with pulmonary and hepatic metastasis of nasopharyngeal carcinoma

To evaluate the efficacy and safety of the chemotherapy program of docetaxel combined with lobaplatin for Chinese patients with pulmonary and hepatic metastasis of nasopharyngeal carcinoma (NPC). This study included 37 NPC patients with pulmonary and hepatic metastasis. The chemotherapy program included docetaxel (75 mg/m, day 1) plus lobaplatin (30 mg/m, day 1). Cycle repetition was every 21 days. Patients were monitored for 7-41 months, with a median follow-up duration of 18 months. The total efficiency of this group was 67.6% and the disease control rate was 81.1%. The median progression-free survival was 9.4 months (95% confidence interval, 6.8-14.3 months), the median overall survival was 18.3 months (95% confidence interval, 13.7-22.8 months), and the 2-year survival rate was 37.8%. The main hematological toxicities were leukopenia (91.9%), anemia (81.1%), and thrombocytopenia (70.3%); other adverse reactions were mild. Changes in Epstein-Barr-DNA levels can basically reflect the dynamic changes in the efficacy of chemotherapy. Docetaxel combined with lobaplatin has a favorable outcome for the treatment of pulmonary and hepatic metastatic NPC. It has been a convenient regimen with tolerable toxicity.

Higher N stage and serum ferritin, but lower serum albumin levels are associated with distant metastasis and poor survival in patients with nasopharyngeal carcinoma following intensity-modulated radiotherapy

Purpose

To evaluate the potential risk factors for distant metastasis of nasopharyngeal carcinoma in Chinese patients following standard intensity-modulated radiotherapy and chemotherapy.

Methods

The potential risk factors for distant metastasis in 622 patients with newly-diagnosed primary nasopharyngeal carcinoma following standard radiotherapy and chemotherapy were evaluated retrospectively by stratification, univariate and multivariate analyses. The 5-year overall survival, distant metastasis-free survival, local recurrence-free survival and progression-free survival rates were determined.

Results

Univariate and multivariate analyses indicated that N2-3 stage, serum ferritin > 300 μg/L and serum albumin < 42 g/L were independent risk factors for distant metastasis of nasopharyngeal carcinoma (P < 0.001, P = 0.013, P = 0.002, respectively). A risk prediction model was developed as follows: 1) low-risk group: 0-1 risk factor; and 2) high-risk group: 2-3 risk factors. Compared with low-risk group, the high-risk group had significantly lower 5-year distant metastasis-free survival (76.4% vs. 89.6%, P < 0.001), overall survival (76% vs. 85.9%,P < 0.001), local recurrence-free survival (88% vs. 92.4%, P = 0.029) and progression-free survival rates (68.2% vs. 83.7%, P < 0.001). In the high-risk group, patients with three risk factors had the lowest distant metastasis-free survival rate (P = 0.036).

Conclusions

Combination of higher N stage, serum ferritin and lower serum albumin levels may be valuable for predicting distant metastasis of nasopharyngeal carcinoma patients following standard intensity-modulated radiotherapy and chemotherapy.

Downregulated ECRG4 is correlated with lymph node metastasis and predicts poor outcome for nasopharyngeal carcinoma patients

OBJECTIVE

Esophageal cancer-related gene 4 (ECRG4) is a new candidate tumor suppressor gene. In this retrospective study, we evaluated ECRG4 protein expression in patients with nasopharyngeal carcinoma (NPC) under curative treatment and examined its association with pathological features and clinical outcomes as a possible biomarker for diagnosis and prognosis of NPC.

METHODS

We enrolled 122 patients with a first diagnosis between January 2001 and December 2003. Tumor tissue and control tissue from biopsies underwent immunohistochemical staining for ECRG4. ECRG4 expression was analyzed by clinicopathological variables. After Kaplan-Meier survival analysis, we used Cox proportional hazards regression to estimate the predictive effect of ECRG4 expression on overall survival.

RESULTS

ECRG4 protein level was lower in NPC than control tissue (P < 0.01). It was inversely related to node status (P < 0.001) and clinical stage (P = 0.027). ECRG4 expression was associated with overall survival, and downregulated ECRG4 expression was an independent prognostic factor of poor survival (hazard ratio = 0.677, 95 % confidence interval 0.463-0.989, P = 0.044).

CONCLUSIONS

A significant NPC patients showed downregulated ECRG4 expression, which is correlated with lymph node metastasis. The marker could be an independent prognostic factor for NPC patients. The precise function of ECRG4 in the progression of NPC, especially for lymphatic metastasis, deserves further investigation, which would bring a new target for personalized therapy.

Incidence and Mortality of Nasopharynx Cancer and Its Relationship With Human Development Index in the World in 2012

BACKGROUND

One of the most common cancers in head and neck is nasopharynx. Knowledge about the incidence and mortality of this disease and its distribution in terms of geographical areas is necessary for further study, better planning and prevention. Therefore, this study aimed to determine the incidence and mortality of nasopharynx cancer and its relationship with human development index (HDI) in the world in 2012.

METHODS

This study was an ecological study conducted based on GLOBOCAN project of World Health Organization (WHO) for the countries in world. The correlation between standardized incidence rates (SIRs) and standardized mortality rates (SMRs) of nasopharynx cancer with HDI and its components was assessed with correlation coefficient by using SPSS 15.

RESULTS

In 2012, 86,691 nasopharynx cancer cases occurred in the world, so that 60,896 new cases were seen in men and 25,795 new cases in women (sex ratio = 2.36). SIR of the cancer was 1.2 per 100,000 (1.7 in men and 0.7 in women per 100,000) in the world. In 2012, 50,831 nasopharynx death cases occurred in the world, so that 35,756 death cases were seen in men and 15,075 death cases in women (sex ratio = 2.37). SIR of mortality from the cancer was 0.7 per 100,000 (0.7 in women and 1 in men per 100,000) in the world. The results of correlation analysis showed a negative correlation between the SIR and HDI (r = -0.037, P = 0.629), and also the results of correlation analysis showed a negative correlation between the SMR and HDI (r = -0.237, P = 0.002).

CONCLUSION

Nasopharyngeal cancer is native to Southeast Asia and the highest incidence and mortality were seen in countries with moderate and low HDI. It is suggested that studies are conducted on determining the causes of the cancer incidence and mortality in the world and the differences between various regions.

Prognostic Model of Death and Distant Metastasis for Nasopharyngeal Carcinoma Patients Receiving 3DCRT/IMRT in Nonendemic Area of China

Few studies were conducted to explore the prognostic factors for nonendemic nasopharyngeal carcinoma (NPC) in the era of 3-dimensional conformal radiation therapy (3DCRT)/intensity-modulated radiation therapy (IMRT). The aim of this study was to evaluate the potential prognostic factors for nonendemic NPC.Between January 2004 and December 2011, a total of 393 nonendemic NPC patients receiving 3DCRT/IMRT were reviewed according to the inclusion and exclusion criteria. The prognostic factors we analyzed included age, T stage, N stage, lymph node diameter, primary tumor volume, WHO histology types, and cranial nerve related symptoms. All patients were staged according to the 7th edition of the American Joint Committee on Cancer (AJCC) system. The factors found to be associated with the endpoints by univariate analyses were then entered into multivariate Cox proportional hazards regression analysis.The median follow-up time was 61.4 months (range: 4-130 months). The 5-year local recurrent-free survival (LRFS), nodal relapse-free survival (NRFS), distant metastasis free survival (DMFS), and disease-specific survival (DSS) for all patients were 89.3%, 96.4%, 73.5%, and 74.3%, respectively. Multivariate analysis indicated that N stage (N2-3), WHO pathologic type II, and primary tumor volume (>23 mL) were 3 independent prognostic factors for DSS and DMFS. According to the number of prognostic factors, patients were divided into 3 risk groups: low-risk group (patients without any risk factors); intermediate-risk group (patients with only 1 risk factor); and high-risk group (patients with more than 2 risk factors). The 5-year DSS for low, intermediate, and high-risk groups were 91.5%, 75.2%, and 49.3%, respectively (P < 0.001). The 5-year DMFS for low, intermediate, and high-risk groups were 89.4%, 77.9%, and 49.4%, respectively (P < 0.001).Advanced N stage (N2-3), larger tumor volume (>23 mL), and histological WHO type II are independently prognostic factors for nonendemic NPC patients in China.

The dosimetric comparison of the radiotherapeutic plans between composite and synchronous planning approaches in sequential IMRT for nasopharyngeal carcinoma

The aim of present study was to compare the dosimetric differences of the radiotherapeutic plans between synchronous and composite planning approaches in sequential intensity-modulated radiation therapy (IMRT) for nasopharyngeal carcinoma (NPC). Twelve patients with NPC treated by sequential IMRT were enrolled. Two planning approaches were used to design sequential IMRT plan. The first was composite planning approach, in which the initial and boost plans were designed and optimized independently. The second was synchronous planning approach, in which the boost IMRT plan was designed on foundation of the initial IMRT plan, and its optimization would be adjusted based on dose distributions of the initial IMRT plan. Dosimetric comparisons in IMRT plans between composite and synchronous planning approaches were analyzed to evaluate (1) dose coverage, conformity, and homogeneity of the planning target volume (PTV), (2) sparing of organs at risk (OARs), and (3) the number of segments and monitor units (MUs). The results showed that both of the summed plans for the entire treatment course were achieved according to the original planning goals, and the dose coverage, conformity and homogeneity for each PTV was similar. With regard to sparing brain stem, spinal cord and parotid glands, there was no significant difference in the summed plans between two planning approaches. However, the boost IMRT plan by composite planning approach tended to have a higher dose coverage (P = 0.000), conformity (P = 0.000), and homogeneity (P = 0.000) than that of the plan by synchronous planning approach. Moreover, the boost plan by composite planning approach reduced the MUs significantly (P = 0.000). The results indicated that the radiotherapeutic plan by composite planning approach provides better dose coverage, conformity and homogeneity for the PTV in the boost plan than that by synchronous planning approach, and reduced MUs in sequential intensity modulated radiotherapy.

Distant metastasis risk and patterns of nasopharyngeal carcinoma in the era of IMRT: long-term results and benefits of chemotherapy

PURPOSE

To report the distant metastasis (DM) risk and patterns for nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy (IMRT) and to analyze the benefits of chemotherapy based on DM risk.

MATERIALS AND METHODS

576 NPC patients were analyzed. The DM rates were calculated using the Kaplan-Meier method, and the log-rank test was used to compare differences. The patients were divided into different risk subclassifications according to DM hazard ratios.

RESULTS

91 patients developed DM after treatment, with bone as the most common metastatic sites. 82.4% of DMs occurred within 3 years of treatment. Patients were classified as low-risk, intermediate-risk and high-risk, and the corresponding 5-year DM rates were 5.1%, 13.1% and 32.4%, respectively (P < 0.001). Chemotherapy failed to decrease the DM rate in the low-risk subclassification, but decreased the DM risk in the intermediate-risk subclassification (P = 0.025). In the high-risk subclassification, the DM rate was 31.9% though chemotherapy was used, which was significantly higher than that of other two subclassifications.

CONCLUSIONS

DM is the dominant treatment failure in NPC treated by IMRT, with similar occurrence times and distributions to those that occurred in the era of conventional radiotherapy. Further studies on treatment optimization are needed in high-risk patients.

Aberrant expression of CDK5 infers poor outcomes for nasopharyngeal carcinoma patients

PURPOSE

Aberrant expression of CDK5 involved in epithelial-to-mesenchymal transition had been reported in various types of cancers, but its functions in nasopharyngeal carcinoma have not been fully clarified yet. The principal purpose of this research was to investigate the clinicopathological significance of CDK5 and its potential effect on NPC carcinogenesis.

METHODS

Pre-treated formalin-fixed paraffin-embedded biopsy samples of 393 patients between January 2011 and December 2013 were collected for tissue microarrays (TMAs). Immunohistochemistry was performed on sequential TMA sections stained with antibodies against CDK5, EGFR and P53.

RESULTS

The expression of CDK5 in NPC tissues was significantly higher than that in normal nasopharyngeal tissues. Among squamous carcinomas, the expression of CDK5 in undifferentiated tissues was noticeably increased compared with that in differentiated tissues. NPC patients in advanced T category showed a perceptibly higher level of CDK5 than those in early T category. The relative level of CDK5 in NPC sufferers with lymph node metastasis was obviously higher than that of patients without. Compared with patients in early TNM stages, the relative expression level of CDK5 of those in advanced TNM stages was notably up-regulated. Moreover, the CDK5 expression was positively correlated with EGFR and P53 expression. Nevertheless, no significant association was observed between CDK5 and gender, age or histological type.

CONCLUSION

Overexpression of CDK5 might be considered as a warning signal for NPC. Consequently, CDK5 could serve as a potential target for diagnosis and gene therapy for NPC patients.

Clinical Outcome among Nasopharyngeal Cancer Patients in a Multi-Ethnic Society in Singapore

Background

Nasopharyngeal cancer (NPC) is endemic among Chinese populations in Southeast Asia. However, the outcomes of non-Chinese NPC patients in Singapore are not well reported.

Aim

To determine if non-Chinese NPC patients have a different prognosis and examine the clinical outcomes of NPC patients in a multi-ethnic society.

Methods

Retrospective chart review of 558 NPC patients treated at a single academic tertiary hospital from 2002 to 2012. Survival and recurrence rates were analysed and predictive factors identified using the Kaplan-Meier method and Cox regression model.

Results

Our cohort comprised 409 males (73.3%) and 149 females (26.7%) with a median age of 52 years. There were 476 Chinese (85.3%), 57 Malays (10.2%), and 25 of other ethnic groups (4.5%). Non-Chinese patients were more likely to be associated with advanced nodal disease at initial presentation (p = 0.049), compared with the Chinese. However, there were no statistical differences in their overall survival (OS) or disease specific survival (DSS) (p = 0.934 and p = 0.857 respectively). The 3-year and 5-year cohort OS and DSS rates were 79.3%, 70.7%, and 83.2%, 77.4% respectively. Advanced age (p<0.001), N2 disease (p = 0.036), N3 disease (p<0.001), and metastatic disease (p<0.001) at presentation were independently associated with poor overall survival. N2 disease (p = 0.032), N3 disease (p<0.001) and metastatic disease (p<0.001) were also independently associated with poor DSS. No predictive factors were associated with loco-regional recurrence after definitive treatment. Advanced age (p = 0.044), N2 disease (p = 0.033) and N3 disease (p<0.001) were independently associated with distant relapse.

Conclusion

In a multi-ethnic society in Singapore, non-Chinese are more likely to present with advanced nodal disease. This however did not translate into poorer survival outcomes. Older patients with N2 or N3 disease are associated with a higher risk of distant relapse and poor overall survival.

Traditional Herbal Medicine as Adjunctive Therapy for Nasopharyngeal Cancer

The effectiveness of traditional herbal medicine (THM) as treatment for nasopharyngeal cancer (NPC) has not been clearly demonstrated. The aim of this study is to assess the effectiveness of THM as adjunctive therapies for NPC using the results of randomized controlled trials (RCTs). Five electronic databases, including English and Chinese databases, were systematically searched up to February 2014. All RCTs involving traditional herbal medicine in combination with conventional cancer therapy for NPC were included. Twenty-two RCTs involving 2,298 NPC patients were systematically reviewed. Of these 22 studies, 15 on 1482 patients reported a significant increase in the number surviving patients with survivals of more than 1, 3, or 5 years. Seven studies on 595 patients reported a significant increase in immediate tumor response, and three studies on 505 patients reported a significant decrease in distant metastasis. This meta-analysis of 22 studies suggests that THM combined with conventional therapy can provide an effective adjunctive therapy for NPC. More research and well-designed, rigorous, large clinical trials are required to address these issues

Expression of MTA1 in nasopharyngeal carcinoma and its correlation with prognosis

Metastasis-associated protein 1 (MTA1) is related to tumour metastasis and poor prognosis in various human cancers. The aim of this study was to investigate the expression of MTA1 in nasopharyngeal carcinoma (NPC) and explore the prognostic value of MTA1 in NPC patients. The expression of MTA1 in 136 human NPC tissues and 20 normal nasopharyngeal tissues was detected using immunohistochemistry, quantified and classified into low or high expression using a 50% cut-off level. The relationships of MTA1 expression with the clinical characteristics and survival of patients were analysed. MTA1-positive staining was observed in the nuclei of NPC cells, and MTA1 expression was significantly correlated with T stage (P = 0.006), clinical stage (P = 0.001) and distant metastasis (P < 0.001). Patients with high MTA1 expression exhibited significantly worse distant metastasis-free survival (DMFS) than those with low MTA1 expression (90.75% vs. 70.81%, P = 0.017). Multivariate survival analysis revealed that MTA1 expression was an independent prognostic factor for DMFS (P = 0.038). In this study, high MTA1 expression was significantly associated with poor DMFS in NPC, indicating that MTA1 could serve as a novel biomarker for assessing the metastatic potential of NPC and could act as a possible therapeutic target for the treatment of metastatic nasopharyngeal carcinoma.

3D-image-guided HDR-brachytherapy versus 2D HDR - brachytherapy after external beam radiotherapy for early T-stage nasopharyngeal carcinoma

Background

Two-dimensional high-dose-rate brachytherapy (2D-HDR-BT) is an effective method of dose escalation for local tumor control in early T-stage nasopharyngeal carcinoma (NPC). Treatment outcomes for 3D-image-guided high-dose-rate brachytherapy (3D-image-guided-HDR-BT) after external beam radiotherapy (ERT) have not been examined in early T-stage NPC patients. The current study was designed to evaluate whether addition of 3D-HDR-BT to ERT showed further improvement in treatment outcomes in patients with early T-stage NPC when compared to 2D-HDR-BT after ERT.

Methods

The current study retrospectively analyzed and compared treatment outcomes for patients with nonmetastatic stage T1-2b NPC treated with 2D-HDR-BT (n =101) or 3D-HDR-BT (n =118) after ERT. Patients in both groups were treated with ERT at a mean dose of 60 Gy and a brachytherapy dose of 12Gy (8 ~ 20Gy), 2.5 ~ 5Gy per fraction under local anesthesia.

Results

Compared to patients treated with 2D-HDR-BT after ERT, patients treated with 3D-HDR-BT after ERT showed improvement in five-year actuarial local control survival rates (p = 0.024), local/regional relapse-free survival rates (p = 0.038), and disease-free survival rates (p = 0.021). Multivariate analysis showed that NPC patients treated with 3D-HDR-BT had improved local control survival (p = 0.042). The incidence rates of acute or chronic complications were similar between two groups.

Conclusions

The current study showed that 3D-image-guided HDR-BT after ERT was an effective treatment modality for patients with stage T1-2 NPC with acceptable complications. The improvement in local tumor control and disease free survival is likely due to improved conformal dose distributions.

Prognoses and long-term outcomes of nasopharyngeal carcinoma in Han and Uyghur patients treated with intensity-modulated radiotherapy in the Xinjiang Autonomous Region of China

Objectives

The objective of this study was to investigate the long-term outcomes and prognostic factors for nasopharyngeal carcinoma (NPC) in Han and Uyghur patients treated with intensity-modulated radiotherapy (IMRT) in the Xinjiang region of China.

Materials and Methods

One hundred twenty-one Han and 60 Uyghur patients with newly diagnosed NPC without distant metastasis received IMRT at the Affiliated Tumor Hospital of Xinjiang Medical University between 2005 and 2008. The Kaplan-Meier method was used to estimate survival rates, and the log-rank test was used to evaluate differences in survival.

Results

Comparing Han and Uyghur patients, the 5-year overall survival (OS), disease-free survival (DFS), local control (LC), regional control (RC), and distant metastasis-free survival (DMFS) rates were 81.9% vs 77.6% (P = 0.297), 72.1% vs 65.6% (P = 0.493), 88.3% vs 86.5% (P = 0.759), 95.0% vs 94.6% (P = 0.929), and 79.1% vs 75.2% (P = 0.613), respectively. Multivariate Cox proportional hazards regression identified the following independent prognostic factors in Han patients: N stage (P = 0.007) and age (P = 0.028) for OS, and age (P = 0.028) for DFS. OS differed significantly between Han and Uyghur patients >60 years old group (P = 0.036). Among Uyghur patients, the independent prognostic factors were age for OS (P = 0.033), as well as N stage (P = 0.037) and age (P = 0.021) for DFS. Additionally, Uyghur patients were less likely to experience mucositis and dermatitis than Han patients.

Conclusion

Han and Uyghur patients with NPC had statistically significant differences in age, smoking history, and N staging. There was no significant difference in overall treatment outcomes with IMRT between these 2 ethnic populations in Xinjiang, China.

Clinical study of nasopharyngeal carcinoma treated by helical tomotherapy in China: 5-year outcomes

Background. To evaluate the outcomes of nasopharyngeal carcinoma (NPC) patients treated with helical tomotherapy (HT). Methods. Between September 2007 and August 2012, 190 newly diagnosed NPC patients were treated with HT. Thirty-one patients were treated with radiation therapy as single modality, 129 with additional cisplatin-based chemotherapy with or without anti-EGFR monoclonal antibody therapy, and 30 with concurrent anti-EGFR monoclonal antibody therapy. Results. Acute radiation related side effects were mainly grade 1 or 2. Grade 3 and greater toxicities were rarely noted. The median followup was 32 (3–38) months. The local relapse-free survival (LRFS), nodal relapse-free survival (NRFS), distant metastasis-free survival (DMFS), and overall survival (OS) were 96.1%, 98.2%, 92.0%, and 86.3%, respectively, at 3 years. Cox multivariate regression analysis showed that age and T stage were independent predictors for 3-year OS. Conclusions. Helical tomotherapy for NPC patients achieved excellent 3-year locoregional control, distant metastasis-free survival, and overall survival, with relatively minor acute and late toxicities. Age and T stage were the main prognosis factors.

Concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma: treatment outcomes of a prospective, multicentric clinical study

BACKGROUND AND PURPOSE

To evaluate long-term outcome in locoregionally advanced nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy.

MATERIAL AND METHODS

Between January 2006 and August 2008, 249 patients with stage III-IVb NPC were treated by IMRT plus concurrent chemotherapy in this multicenter prospective study.

RESULTS

With a mean follow-up of 54.1 months, the 5-year actuarial rates of overall survival (OS), local recurrence-free survival (LRFS), regional recurrence-free survival (RRFS), and distant metastasis-free survival (DMFS) were 78.4%, 86.8%, 88.4%, 78.0%, respectively. There were 29 local recurrences, 25 regional recurrences and 52 distant metastases, respectively. Distant metastasis is the main cause of treatment failure. N-stage was an independent prognostic factor for LRFS, RRFS, DMFS and OS. Acute toxicity ⩾grade III mainly consisted of mucositis (34.9%), neutropenia (11.2%), xerostomia (5.6%), and dermatitis (5.2%). The main documented late toxicity was xerostomia, and the severity of xerostomia decreased over time. At 24 months after treatment, 13.2% of patients had grade 2 xerostomia, and none had grade 3 or 4 xerostomia.

CONCLUSIONS

IMRT with concurrent cisplatin chemotherapy resulted in encouraging rates of local and distant control and overall survival with acceptable rates of acute and limited rates of late toxicity in patients with locoregionally advanced NPC. Distant metastasis remained the main cause of failure. More effective systemic therapy should be explored for patients with advanced N-stage.

Treatment outcome for nasopharyngeal carcinoma in University Malaya Medical Centre from 2004-2008

BACKGROUND

Nasopharyngeal carcinoma (NPC) is the commonest radiocurable cancer in Malaysia. This study aimed to determine the treatment outcomes and late effects of radiotherapy for NPC patients treated in University Malaya Medical Centre (UMMC).

MATERIALS AND METHODS

All newly diagnosed patients with NPC referred for treatment to the Oncology unit at UMMC from 2004-2008 were retrospectively analyzed. Treatment outcomes were 5 years overall survival (OS), disease free survival (DFS), cause-specific survival (CSS), loco- regional control (LRC) and radiotherapy-related late effects. The Kaplan-Meier method was used for survival analysis and differences in survival according to AJCC stage was compared using the log-rank test.

RESULTS

A total of 176 patients with newly diagnosed NPC were treated in UMMC during this period. Late presentation was common, with 33.5% presenting with T3-4 disease, 84.7% with N1-3 disease and 75.6% with AJCC stage 3-4 disease. Radical RT was given to 162 patients with 22.7% having RT alone and 69.3% having CCRT. The stipulated OTT was 7 weeks and 72.2% managed to complete their RT within this time period. Neoadjuvant chemotherapy was given to 14.8% while adjuvant chemotherapy was administered to 16.5%. The 5 years OS was 51.6% with a median follow up of 58 months. The 5 years OS according to stage were 81.8% for stage I, 77.9% for stage II, 47.4% for stage III and 25.9% for stage IV. The 5 years overall CSS, DFS and LRC were 54.4%, 48.4% and 70.6%, respectively. RT related late effects were documented in 80.2%. The commonest was xerostomia (66.7%). Other documented late effects were hearing deficit (17.3%), visual deficit (3.1%), neck stiffness (3.1%) , dysphagia (3.4%), cranial nerve palsy (2.5%), pneumonitis (0.6%) and hypothyroidism (1.2%).

CONCLUSIONS

The 5 years OS and LRC in this study are low compared to the latest studies especially those utilizing IMRT. Implementation of IMRT for NPC treatment should be strongly encouraged.

Interleukin-6 promotes the migration and invasion of nasopharyngeal carcinoma cell lines and upregulates the expression of MMP-2 and MMP-9

Nasopharyngeal carcinoma (NPC) shows the highest invasive and metastatic features among head and neck cancers. Distant metastasis remains the predominant mode of treatment failure in NPC patients. The role of interleukin-6 (IL-6) in NPC progression is not fully understood. In this study, we explored whether IL-6 could promote the migration and invasion activity of NPC cell lines, as well as whether the effect of IL-6 on cell migration and invasion is mediated through regulating the expression of matrix metalloproteinase-2 (MMP-2) and MMP-9. Our results revealed that IL-6 and its receptors are broadly expressed in various NPC cell lines including HNE1, HONE1, CNE1, CNE1-LMP1 and 5-8F. Exogenous IL-6 enhanced cell proliferation slightly, but promoted cell migration and invasion significantly in both HNE1 and CNE1-LMP1 cell lines. In addition, an elevation in the expression of MMP-2 and MMP-9 could be induced by IL-6 stimulation. On the contrary, combining treatment with monoclonal anti-human IL-6R antibody (anti-IL-6R mAb) resulted in decreased proliferation, migration and invasion capabilities of NPC cells. Anti-IL-6R mAb also inhibited the expression of MMP-2 and MMP-9 in IL-6-stimulated HNE1 and CNE1-LMP1 cells. In summary, our data suggested that IL-6 mainly promotes the cell migration and invasion of NPC cells. The effect of IL-6 on cell migration and invasion may be mediated through regulation of the expression of MMP-2 and MMP-9. Thus, IL-6 or its related signaling pathways may be a promising target for preventing and inhibiting NPC metastasis.

Update report of nasopharyngeal carcinoma treated with reduced-volume intensity-modulated radiation therapy and hypothesis of the optimal margin

BACKGROUND AND PURPOSE

To establish the minimally required margins in different directions measured from GTV in the definitive treatment of nasopharyngeal carcinoma (NPC) using IMRT based on the 5-year results.

METHODS AND MATERIALS

Between November 2003 and May 2007, 414 patients with non-metastatic NPC were treated with IMRT according to our institutional protocol. Treatment outcomes at 5 years were analyzed. Distances from GTV-T to CTV2 (i.e., CTV 59.4 Gy) in 6 directions (anterior, posterior, superior, inferior, and bilateral) were measured and analyzed.

RESULTS

The 5-year estimated overall survival (OS), disease free survival (DFS), local control (LC) were 80%, 77% and 95%, respectively. For the margins measured from GTV-T to CTV2, margins used with T4 disease were significantly and uniformly smaller than the whole group in all the 6 directions (P=0.000, 0.000, 0.000, 0.000 and 0.046, respectively). However, no increase of local recurrence was associated to this limited margins used.

CONCLUSIONS

Our 5-years' experience showed a very high LC rate. The strategy we used for CTV delineation was safe and reliable. Determined CTV through GTV expansion to a minimally required margin, using GTV+margin (used in our T4 patients)+the whole nasopharyngeal mucosa, especially for the patients with early T disease, might be feasible.

Prognostic role of epidermal growth factor receptor in nasopharyngeal carcinoma: a meta-analysis

BACKGROUND

Various studies have assessed the prognostic value of epidermal growth factor receptor (EGFR) overexpression in nasopharyngeal carcinoma (NPC), but their results remain controversial.

METHODS

Studies published up to January 2013 were collected. A total of 16 studies involving 1179 patients were reviewed. A meta-analysis was performed to clarify the prognostic role of EGFR in patients with NPC. The combined hazard ratio (HR) and 95% confidence interval (CI) were estimated using fixed-effects or random-effects models.

RESULTS

EGFR overexpression had significantly poor effect on overall survival (OS; HR, 1.86; 95% CI, 1.25-2.77), disease-free survival (DFS; HR, 2.25; 95% CI, 1.66-3.04) and locoregional control (HR, 2.93; 95% CI, 1.71-5.02). However, the association between EGFR overexpression and distant metastasis-free survival was not statistically significant (HR, 1.39; 95% CI, 0.72-2.67).

CONCLUSION

EGFR overexpression can be a prognostic factor for patients with NPC.

Prognostic value of kisspeptin expression in nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

The KiSS-1 gene has been reported to serve as a metastasis suppressor gene in various human malignancies. However, no information is available regarding the role of the KiSS-1 gene or its gene product kisspeptin in nasopharyngeal carcinoma.

STUDY DESIGN

Retrospective study.

METHODS

Kisspeptin and its receptor AXOR12 expression were assessed using immunohistochemistry in paraffin-embedded tumor tissues from 140 patients diagnosed with nasopharyngeal carcinoma. Immunoreactivity was quantified, and its relationships with patients' clinical parameters and survival were analyzed.

RESULTS

Using a 50% cutoff level, the immunoreactivities of kisspeptin and AXOR12 were divided into low and high expression. The expression levels of kisspeptin and AXOR12 in nasopharyngeal carcinoma were well correlated with each other (rs = 19.31, P < 0.01). Low expression of kisspeptin in nasopharyngeal carcinoma was correlated with clinical stage (P = 0.01), N stage (P = 0.03), and metastasis (P = 0.02). Patients with low kisspeptin expression had poorer distant metastasis-free survival than those with high kisspeptin expression (75.32% vs. 83.79%, P = 0.02). Although neither kisspeptin nor AXOR12 were found to be prognostic factors for overall survival, kisspeptin was determined to be an independent prognostic factor for distant metastasis-free survival (P = 0.03) using multivariate analysis.

CONCLUSION

In this study, we report for the first time that low kisspeptin expression in nasopharyngeal carcinoma is correlated with poor clinical outcome; kisspeptin could serve as an independent prognostic marker for metastasis in nasopharyngeal carcinoma.

Clinical outcomes for early-stage nasopharyngeal carcinoma with predominantly WHO II histology treated by intensity-modulated radiation therapy with or without chemotherapy in nonendemic region of China

BACKGROUND

The clinical outcomes for early-stage nasopharyngeal carcinoma (NPC) in northwest China were evaluated.

METHODS

A retrospective study was performed from 69 patients with NPC patients treated with intensity-modulated radiation therapy (IMRT) with or without chemotherapy.

RESULTS

Median follow-up was 34 months. World Health Organization (WHO) type II was the predominant histology (71%). All treatment failures occurred in T2N1 NPCs (14.5%), with metastasis the major reason. The 3-year overall survival (OS), local recurrence-free survival (LRFS), and distant metastasis-free survival (DMFS) were 93.3%, 94.1%, and 94.8% respectively. The 3-year survival rate for T2N1 and IMRT alone group were both significantly poorer than the T1N0, T2N0, and T1N1 groups and the chemoradiation group, respectively (p < .05). N1 classification, T2N1 classification, and addition of chemoradiation were significant independent predictors (p < .05). No grade IV toxicities were observed.

CONCLUSION

T2N1 classification is a unique subgroup with higher risk of distant metastasis. Improved outcomes of T2N1 NPC with predominantly WHO II histology after chemoradiation has not been reported.

A sequence polymorphism in miR-608 predicts recurrence after radiotherapy for nasopharyngeal carcinoma

Nasopharyngeal carcinoma is treated with radiotherapy and other modalities, but there is little information on individual genetic factors to help predict and improve patient outcomes. Single-nucleotide polymorphisms (SNP) in mature microRNA (miRNA) sequences have the potential to exert broad impact as miRNAs target many mRNAs. The aim of this study was to evaluate the effects of SNPs in mature miRNA sequences on clinical outcome in patients with nasopharyngeal carcinoma receiving radiotherapy. In particular, we analyzed associations between seven SNPs and nasopharyngeal carcinoma locoregional recurrence (LRR) in 837 patients from eastern China, validating the findings in an additional 828 patients from southern China. We found that miR-608 rs4919510C > G exhibited a consistent association with LRR in the discovery set [HR, 2.05; 95% confidence interval (CI), 1.35-3.21], the validation set (HR, 2.24; 95% CI, 1.45-3.38), and the combined dataset (HR, 2.08; 95% CI, 1.41-3.26). Biochemical investigations showed that rs4919510C > G affects expression of miR-608 target genes along with nasopharyngeal carcinoma cell growth after irradiation in vivo and in vitro. Notably, X-ray radiation induced more chromatid breaks in lymphocyte cells from rs4919510CC carriers than in those from subjects with other genotypes (P = 0.0024). Our findings reveal rs4919510C > G in miR-608 as a simple marker to predict LRR in patients with radiotherapy-treated nasopharyngeal carcinoma.

Protein tyrosine kinase 6 is associated with nasopharyngeal carcinoma poor prognosis and metastasis

Background

The aim of this study was to analyze the expression of protein tyrosine kinase 6 (PTK6) in nasopharyngeal carcinoma (NPC) samples, and to identify whether PTK6 can serve as a biomarker for the diagnosis and prognosis of NPC.

Methods

We used quantitative RT-PCR and Western blotting analysis to detect mRNA and protein expression of PTK6 in NPC cell lines and immortalized nasopharyngeal epithelial cell lines. 31 NPC and 16 non-tumorous nasopharyngeal mucosa biopsies were collected to detect the difference in the expression of mRNA level of PTK6 by quantitative RT-PCR. We also collected 178 NPC and 10 normal nasopharyngeal epithelial cases with clinical follow-up data to investigate the expression of PTK6 by immunohistochemistry staining (IHC). PTK6 overexpression on cell growth and colony formation ability were measured by the method of cell proliferation assay and colony formation assay.

Results

The expression of PTK6 was higher in most of NPC cell lines at both mRNA and protein levels than in immortalized nasopharyngeal epithelial cell lines (NPECs) induced by Bmi-1 (Bmi-1/NPEC1, and Bmi-1/NPEC2). The mRNA level of PTK6 was high in NPC biopsies compared to non-tumorous nasopharyngeal mucosa biopsies. IHC results showed the expression of PTK6 was significantly correlated to tumor size (P<0.001), clinical stage (P<0.001), and metastasis (P=0.016). The patients with high-expression of PTK6 had a significantly poor prognosis compared to those of low-expression (47.8% versus 80.0%, P<0.001), especially in the patients at the advanced stages (42.2% versus 79.1%, P<0.001). Multivariate analysis indicated that the level of PTK6 expression was an independent prognostic factor for the overall survival of patients with NPC (P <0.001). Overexpression of PTK6 in HNE1 cells enhanced the ability of cell proliferation and colony formation.

Conclusions

Our results suggest that high-expression of PTK6 is an independent factor for NPC patients and it might serve as a potential prognostic biomarker for patients with NPC.

Dose planning study of target volume coverage with intensity- modulated radiotherapy for nasopharyngeal carcinoma: Penang General Hospital experience

BACKGROUND

To compare the dosimetric coverage of target volumes and organs at risk in the radical treatment of nasopharyngeal carcinoma (NPC) between intensity-modulated radiotherapy (IMRT) and three- dimensional conformal radiotherapy (3DCRT).

MATERIALS AND METHODS

Data from 10 consecutive patients treated with IMRT from June-October 2011 in Penang General Hospital were collected retrospectively for analysis. For each patient, dose volume histograms were generated for both the IMRT and 3DCRT plans using a total dose of 70Gy. Comparison of the plans was accomplished by comparing the target volume coverage (5 measures) and sparing of organs at risk (17 organs) for each patient using both IMRT and 3DCRT. The means of each comparison target volume coverage measures and organs at risk measures were obtained and tested for statistical significance using the paired Student t-test.

RESULTS

All 5 measures for target volume coverage showed marked dosimetric superiority of IMRT over 3DCRT. V70 and V66.5 for PTV70 showed an absolute improvement of 39.3% and 24.1% respectively. V59.4 and V56.4 for PTV59.4 showed advantages of 18.4% and 16.4%. Moreover, the mean PTV70 dose revealed a 5.1 Gy higher dose with IMRT. Only 4 out of 17 organs at risk showed statistically significant difference in their means which were clinically meaningful between the IMRT and 3DCRT techniques. IMRT was superior in sparing the spinal cord (less 5.8Gy), V30 of right parotid (less 14.3%) and V30 of the left parotid (less 13.1%). The V55 of the left cochlea was lower with 3DCRT (less 44.3%).

CONCLUSIONS

IMRT is superior to 3DCRT due to its dosimetric advantage in target volume coverage while delivering acceptable doses to organs at risk. A total dose of 70Gy with IMRT should be considered as a standard of care for radical treatment of NPC.

Concurrent chemoradiotherapy versus radiotherapy alone for locoregionally advanced nasopharyngeal carcinoma

OBJECTIVE

To compare the clinical effects of concurrent radiochemotherapy with those of radiotherapy in treating locally advanced nasopharyngeal carcinoma (Stage III~IVa).

METHODS

A total of 95 patients suffering from nasopharyngeal carcinoma (Stage III~IVa) were divided into two groups: concurrent radiochemotherapy (Group CCRT, n=49) and radiotherapy (Group RT, n=46). The two groups were both delivered conventional fractionated radiotherapy, while Group CCRT also received three cycles of PF (DDP+5-Fu) or PLF (DDP+5- Fu+CF) chemotherapy.

RESULTS

The complete remission rate and total remission rate of Group CCRT were higher than those of Group RT (X2=4.72~7.19, P<0.05). The one-year overall survival (OS) rate calculated by the life table method, was also higher than that of Group RT (X2=4.24, P<0.05) as well as the 3-year OS rate, nasopharyngeal control rate and cervical lymph nodes' control rate (X2=4.28~4.40, P<0.05). In addition, the 5-year OS and metastasis-free rates of Group CCRT were higher than those of Group RT and the differences were of statistical importance (X2=3.96~8.26, P<0.05). However, acute toxicity was also obviously higher, the difference in gastrointestinal reactions being statistically significant (X2=11.70, P<0.05).

CONCLUSION

This study demonstrated that concurrent radiochemotherapy could improve the remission rate, overall survival rate and locally control rate. The toxicity of concurrent radiochemotherapy could be tolerated by the patients.