Pretreatment prognostic factors of survival and late toxicities for patients with nasopharyngeal carcinoma treated by simultaneous integrated boost intensity-modulated radiotherapy

Optimizing Cervical Target Volume in Patients with Nasopharyngeal Cancer Based On Nodal Drainage Distance

PURPOSE

To determine the potential nodal drainage distances of nasopharyngeal carcinoma (NPC) by investigating spatial distribution of metastatic lymph nodes (LN).

EXPERIMENTAL DESIGN

Patients with NPC harboring at least two ipsilateral metastatic LNs were enrolled. LN spreading distances were analyzed in nonrestricted direction, cranial-to-caudal direction, and between the two most caudal LNs. Euclidean distance (ED) and vertical distance (VD) between any two LNs were computed. The nearest-neighbor ED and VD covering 95% of LNs or patients (p95-ED and p95-VD) were considered drainage distances, and were further validated by independent internal and external cohorts with recurrent LNs.

RESULTS

In all, 5,836 metastatic LNs in 948 patients were contoured. Corresponding to the three scenarios, per-LN level, the p95-EDs were 2.83, 3.28, and 3.55 cm, and p95-VDs were 2.17, 2.32, and 2.63 cm, respectively. Per-patient level, the p95-EDs were 3.25, 3.95, and 3.81 cm, and p95-VDs were 2.67, 2.81, and 2.73 cm, respectively. In internal validation, over 95% of recurred LNs occurred within ED of 2.91 cm and VD of 0.82 cm to the neighbor LN, and the corresponding distances in external validation were 2.77 and 0.67 cm, respectively.

CONCLUSIONS

In NPC, the maximum LN drainage distance was 3.95 cm without considering the direction. Specifically, in cranial-to-caudal direction, the sufficient vertical drainage distance was 2.81 cm, indicating that a 3-cm extension from the most inferior node may be rational as caudal border of the prophylactic clinical target volume (CTV). These findings promote in-depth understanding of nodal spreading patterns, uncovering paramount evidence for individualized CTV.

Correlation of serum IL-2 and IFN-γ levels with clinical prognosis of nasopharyngeal carcinoma patients and analysis of risk factors

Background

This study aims to investigate the correlation between serum levels of interleukin-2 (IL-2) and interferong (IFN-g) and the clinical prognosis of patients with nasopharyngeal carcinoma (NPC). Additionally, the study aims to analyse the risk factors associated with this correlation.

Methods

The clinical data of 195 NPC patients admitted to our hospital from October 2020 to October 2022 were selected for a retrospective study. Based on the Glasgow score, patients were divided into two groups: the good prognosis group (group g), consisting of patients who scored 0 points, and the poor prognosis group (group p), consisting of patients who scored 1-2 points. The levels of serum IL-2 and IFN-g were compared between the two groups, and the clinical values of serum IL-2 and IFN-g in the prognosis of patients were analysed. The clinical parameters of the patients were collected, and the risk factors affecting the prognosis of NPC were analysed by univariate and multivariate logistic regression.

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.

Involved site radiation therapy in stage I-III nasopharyngeal carcinoma with limited lymph node burden (ISRT-NPC) or elective region irradiation: a study protocol for a multicenter non-inferiority randomized controlled phase III clinical trial

BACKGROUND

Current radiotherapy guidelines and consensus statements uniformly recommend elective region irradiation (ERI) as the standard strategy for nasopharyngeal carcinoma (NPC). However, given the scarcity of skip-metastasis, the improved assessment accuracy of nodal involvement, and the striking advancements in chemotherapy for NPC, a one-fits-all delineation scheme for clinical target volumes of the nodal region (CTVn) may not be appropriate anymore, and modifications of the CTVn delineation strategy may be warranted. Involved site irradiation (ISI) covering merely the initially involved nodal site and potential extranodal extension has been confirmed to be as effective as ERI with decreased radiation-related toxicities in some malignancies, but has not yet been investigated in NPC. This study aims to compare the regional control, survival outcomes, radiation-related toxicities, and quality of life (QoL) of ISI with conventional ERI in NPC patients with a limited nodal burden.

METHODS

ISRT-NPC is a prospective, multicenter, open-label, noninferiority, phase III randomized controlled trial. A total of 414 patients will be randomly assigned in a 1:1 ratio to receive ISI or ERI. Randomization will be stratified by institution scale and N stage. Generally, in the ISI group, the high-risk CTV1 (dose: 60 Gy) includes a 1-cm expansion of the positive LN as well as the VIIa and the retrostyloid space above the bilateral transverse process of the atlantoaxial spine (C1), regardless of N status. The low-risk CTV2 (dose: 50 Gy) covers the cervical nodal region with a 3-cm caudal expansion below the transverse process of C1 for N0 disease and a 3-cm expansion below the positive LN for positive LNs.

DISCUSSION

The results of this trial are expected to confirm that ISI is a non-inferior strategy to ERI in stage I-III patients with low LN burden, enabling the minimization of treatment-related toxicity and improvement of long-term QoL without compromising regional control.

TRIAL REGISTRATION

ClinicalTrails.gov, NCT05145660. Registered December 6, 2021.

Construction of Prognostic Nomogram in Patients with N3-Stage Nasopharyngeal Carcinoma

INTRODUCTION

The aim of the study was to retrospectively identify the metastatic influence factors and predict the prognosis and develop an individualized prognostic prediction model for patients with N3-stage nasopharyngeal carcinoma (NPC).

METHODS

The study collected 446 NPC patients with N3 stage from the Surveillance, Epidemiology, and End Results database between 2010 and 2015. The patients were classified into subgroups based on the histological types and metastatic status. Multivariable logistic, Cox regression, and Kaplan-Meier method with the log-rank test were performed. The nomogram model was created using the prognostic factors identified from Cox regression analysis. The predictive accuracy was determined based on the concordance index (c-index) and calibration curves.

RESULTS

The 5-year overall survival (OS) of the NPC patients with N3 stage was 43.9%, and the prognosis of patients without any distant metastases was largely longer than that with metastases. No difference was observed between different pathological types in the entire cohort. However, patients with non-keratinized squamous cell carcinoma had a better OS than that of the patients with keratinized squamous cell carcinoma in a nonmetastatic subgroup. Using the Cox regression analysis results, the nomogram successfully classified these patients into low- and high-risk subgroups and presented the survival difference. The c-index of the nomogram for predicting the prognosis was satisfactory.

CONCLUSION

This study identified metastatic risk factors and developed a convenient clinical tool for the prognosis of NPC patients. This tool can be used for individualized risk classification and decision-making regarding treatment of NPC patients with N3 stage.

Long-term outcomes of chemoradiotherapy versus radiotherapy alone in patients with intermediate-risk nasopharyngeal carcinoma: a population-based analysis

PURPOSE

To investigate the efficacy of chemotherapy among intermediate-risk (stage II/T3N0) nasopharyngeal carcinoma (NPC) patients receiving radiotherapy (RT).

METHODS

We identified stage II/T3N0 NPC patients who received radiotherapy with or without chemotherapy from the Surveillance, Epidemiology and End Results database (2004-2019). Overall survival (OS) and cancer-specific survival (CSS) were assessed using the Kaplan-Meier method with log-rank test and Cox proportional hazards models to evaluate the efficacy of chemotherapy. Subgroup analysis was also conducted based on the baseline characteristics. Propensity score matching (PSM) was performed to balance the intergroup covariates.

RESULTS

A total of 1623 patients were enrolled in the study, 1444 received chemoradiotherapy (CRT) and 179 received RT alone. CRT, compared to RT alone, was independently associated with a better OS (HR 0.57, 95% CI 0.45-0.71) and CSS (HR 0.55, 95% CI 0.39-0.79). After PSM, similar results were obtained, and CRT was superior to RT alone in terms of OS (HR 0.60, 95% CI 0.39-0.92) and CSS (HR 0.60, 95% CI 0.40-0.91). Subgroup analysis revealed that OS benefits from CRT were mainly observed in T0-2N1(HR 0.51, 95% CI 0.38-0.70) and T3N0 (HR 0.64, 95% CI 0.42-0.98) rather than T2N0 (HR 1.00, 95% CI 0.51-1.94). Interestingly, after PSM, OS benefits were still seen in T0-2N1 (HR 0.44, 95% CI 0.24-0.82), while not seen in T2N0 (HR 1.83, 95% CI 0.56-5.97) and T3N0 (HR 0.56, 95% CI 0.28-1.12).

CONCLUSION

For T0-2N1 NPC patients, CRT was superior to RT alone with better survival, whereas, for T2-3N0 patients, CRT was comparable to RT alone. Prospective large studies should be encouraged to verify the results.

Nomogram to Predict Long-Term Overall Survival and Cancer-Specific Survival of Radiotherapy Patients with Nasopharyngeal Carcinoma

Objective

To establish and validate a nomogram to predict the overall survival (OS) and cancer-specific survival (CSS) in patients with nasopharyngeal carcinoma (NPC) receiving radiotherapy by integrating multiple independent prognostic factors.

Materials and Methods

Data from 5663 patients with NPC who received definite radiotherapy between 2004 and 2018 were included and divided into training and validation cohorts. Univariate and multivariate Cox regression analyses were performed to determine the independent prognostic factors of patients with NPC after radiotherapy. Thereafter, the predictive accuracy of the nomogram model was evaluated.

Results

Age, race, marital status, pathological type, tumor size, T stage, N stage, M stage, American Joint Committee on Cancer stage, and chemotherapy were independent factors affecting the prognosis of patients with NPC receiving radiotherapy. Nomograms with a concordance index of 0.726 (95% confidence interval (CI): 0.675-0.777) and 0.732 (95% CI: 0.680-0.785) were able to predict OS and CSS, respectively. The area under the curve showed excellent predictive performance. Additionally, the calibration curve indicated that the predicted survival rate was consistent with the actual survival rate, and the decision curve indicated its clinical value. The established risk stratification system was able to accurately stratify patients receiving radiotherapy for NPC into three risk subgroups with significant differences in prognosis (P < 0.05).

Conclusions

The constructed nomogram had good prognostic performance and could be used as an effective tool to evaluate the prognosis of patients with NPC after radiotherapy. This nomogram could be further used to guide clinical decisions and personalized treatment plans.

Efficacy and safety of weekly versus triweekly cisplatin concurrent with radiotherapy in nasopharyngeal carcinoma: A meta-analysis

BACKGROUND

Cisplatin-based concurrent chemoradiotherapy is a standard of care for locally advanced nasopharyngeal carcinoma (NPC), and weekly and triweekly cisplatin are both alternative regimens based on the results of squamous cell carcinoma of the head and neck. However, there is a lack of direct evidence on the efficacy and safety of weekly versus triweekly cisplatin concurrent with radiotherapy in NPC alone. This meta-analysis aimed to identify which regimen is more superior between weekly and triweekly cisplatin in patients with NPC treated with concurrent chemoradiotherapy.

METHODS

The PubMed, Embase, and Cochrane Library were searched for eligible literatures. Clinical outcome measures including 1-year overall survival (OS), 3-year OS, 5-year OS, 5-year loco-regional failure-free survival, 5-year distant metastasis-free survial and the most common 3 grade or higher acute toxicities (hematological toxicity, mucositis and nausea and vomiting) were analyzed by RevMan 5.4 software; significance level was 0.05.

RESULTS

Seven clinical controlled studies with 1795 patients were included in the meta-analysis. There were no significant differences between weekly and triweekly cisplatin in 1-year OS, 3-year OS, 5-year OS, 5-year loco-regional failure-free survival, and 5-year distant metastasis-free survial) (all P > .05). Grade 3 or higher mucositis and nausea and vomiting showed similar between the 2 arms. However, grade 3 or higher hematological toxicity of weekly cisplatin was significantly higher than that of triweekly cisplatin (1.55; 95% CI, 1.22-1.98, P = .0004).

CONCLUSIONS

Weekly cisplatin resulted in similar survival benifit as triweekly cisplatin, but with higher hematological toxicity.

A Systematic Review and Meta-Analysis of Studies Comparing Concurrent Chemoradiotherapy With Radiotherapy Alone in the Treatment of Stage II Nasopharyngeal Carcinoma

Purpose

The role of concurrent chemoradiotherapy (CCRT) in stage II nasopharyngeal carcinoma (NPC) is still controversial. Our objective is to evaluate the value of concurrent chemotherapy in stage II NPC receiving radiotherapy (RT).

Methods

We searched the PubMed, Embase, and Scopus databases for studies comparing CCRT versus RT alone in stage II NPC with survival outcomes and toxicities, including locoregional recurrence-free survival (LRFS), metastasis-free survival (DMFS), progression-free survival (PFS), overall survival (OS), and grade 3–4 acute toxicities. The hazard ratios (HRs) of survival outcomes and risk ratios (RRs) of toxicities were extracted for meta-analysis. Subgroup analysis for stage N1 patients was performed to further explore whether these populations can earn benefits from concurrent chemotherapy.

Results

Nine eligible studies with a total of 4,092 patients were included. CCRT was associated with a better OS (HR = 0.61, 95% CI 0.44–0.82), LRFS (HR = 0.62, 95% CI 0.50–0.78), and PFS (HR = 0.65, 95% CI 0.54–0.79), but with similar DMFS (HR = 0.81, 95% CI = 0.46–1.45) compared with two-dimensional RT (2DRT) alone. However, CCRT showed no survival benefit in terms of OS (HR = 0.84, 95% CI 0.62–1.15), LRFS (HR = 0.85, 95% CI 0.54–1.34), DMFS (HR = 0.96, 95% CI 0.60–1.54), and PFS (HR = 0.96, 95% CI 0.66–1.37) compared with intensity-modulated RT (IMRT) alone. Subgroup analyses indicated that CCRT had similar OS (HR = 1.04, 95% CI 0.37–2.96), LRFS (HR = 0.70, 95% CI 0.34–1.45), DMFS (HR = 1.03, 95% CI 0.53–2.00), and PFS (HR = 1.04, 95% CI 0.58–1.88) in the stage N1 populations. Meanwhile, compared to RT alone, CCRT significantly increased the incidence of grade 3–4 leukopenia (RR = 4.00, 95% CI 2.29–6.97), mucositis (RR = 1.43, 95% CI 1.16–1.77), and gastrointestinal reactions (RR = 8.76, 95% CI 2.63–29.12). No significant differences of grade 3–4 toxicity in thrombocytopenia (RR = 3.45, 95% CI 0.85–13.94) was found between the two groups.

Conclusion

For unselected patients with stage II NPC, CCRT was superior to 2DRT alone with better LRFS, PFS, and OS, while adding concurrent chemotherapy to IMRT did not significantly improve survival but exacerbated acute toxicities.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022318253.

Prognostic and clinicopathological significance of lymphocyte-to-monocyte ratio in patients with nasopharyngeal carcinoma: A meta-analysis

BACKGROUND

This study aimed to evaluate the prognostic effect of LMR in NPC through meta-analysis.

METHODS

The prognostic value of LMR for overall survival (OS) and disease-free survival (DFS)/progression-free survival (PFS) was evaluated by pooling hazard ratios (HRs) and 95% confidence intervals (CIs). The association between LMR and clinicopathological characteristics was estimated by using odds ratios (ORs) and 95% CIs.

RESULTS

A total of 7 studies with 3773 patients were included in this meta-analysis. The results showed that a low LMR was associated with poor OS (HR = 1.94, 95%CI = 1.71-2.20, p < 0.001) and reduced DFS/PFS (HR = 1.51, 95%CI = 1.23-1.85, p < 0.001) in NPC. Furthermore, a low LMR was significantly associated with male sex (OR = 1.34, 95%CI = 1.12-1.59, p = 0.001), T3-T4 stage (OR = 1.58, 95%CI = 1.02-2.45, p = 0.040), and tumor stage III-IV (OR = 1.54, 95%CI = 1.22-1.95, p < 0.001).

CONCLUSIONS

Our study indicated that a low LMR was correlated with poor survival and advanced tumor stage in patients with NPC.

Long-term outcomes of nasopharyngeal carcinoma patients with T1-2 stage in intensity-modulated radiotherapy era

Objectives: To evaluate long-term outcomes and late toxicities of nasopharyngeal carcinoma (NPC) patients with T1-2N0-3M0 stage in intensity-modulated radiotherapy (IMRT) era. Materials and Methods: From June 2005 to October 2013, 276 patients confirmed T1-2N0-3M0 NPC treated with IMRT were reviewed, with 143 (51.8%) N0-1 disease and 133 (48.2%) N2-3 disease. Among them, 76.4% received chemotherapy. The prescribed doses given to the primary tumor and lymph nodes were 66Gy in 30 fractions. Results: After a median follow-up of 103 months, the 5-year and 10-year overall survival (OS) were 90.6% and 79.2%. The 5-year and 10-year local control (LC) rate, regional control (RC) rate and distant metastasis free survival (DMFS) were 97.0% and 91.9%, 94.1% and 92.2%, 89.4% and 87.0%, respectively. The 5-year and 10-year OS, RC rate and DMFS of N0-1 compared with those of N2-3 were 98.6% vs. 82.0% and 86.8% vs. 70.9% (P=0.000), 99.3% vs. 88.3% and 99.3% vs. 84.1% (P=0.000), 97.9% vs. 80.1% and 95.7% vs. 77.5% (P=0.000). The incidence of 3-4 late toxicities were low and mainly xerostomia and hearing deficit. The rates of radiation-induced cranial nerve palsy and temporal necrosis were 2.5% and 2.5%, respectively. Eighteen patients had the second primary tumor, of whom eight were lung cancer, six were head and neck cancer, four were others. Conclusions: Satisfactory locoregional control was achieved in T1-2N0-3M0 NPC treated with IMRT. Distant metastasis was the main failure cause and N2-3 was the main adverse prognostic factor. Second primary tumor occurred 6.5% and negatively impacted OS in NPC.

Toripalimab plus intensity-modulated radiotherapy for recurrent nasopharyngeal carcinoma: an open-label single-arm, phase II trial

Background

Toripalimab is a humanized immunoglobulin G₄ monoclonal antibody against programmed death 1. We aimed to investigate the efficacy and safety of toripalimab in combination with intensity-modulated radiotherapy (IMRT) for recurrent nasopharyngeal carcinoma (rNPC).

Methods

We conducted a single-arm, phase II trial with patients with rNPC who had biopsy-proven disease and were unsuitable for local surgery. Eligible patients received IMRT in combination with toripalimab administered via intravenous infusion of 240 mg once every 3 weeks for a maximum of seven cycles. The primary endpoint was the objective response rate at 3 months post radiotherapy. The secondary endpoints included safety profiles, progression-free survival (PFS).

Results

Between May 2019 and January 2020, a total of 25 patients with rNPC were enrolled (18 men (72.0%) and 7 women (28.0%); median (IQR) age, 49.0 (43.5–52.5) years). With a median (IQR) follow-up duration of 14.6 months (13.1–16.2) months, 19 patients (79.2%) achieved an overall response, and disease control was achieved in 23 (95.8%) patients at 3 months post radiotherapy. The 12-month PFS was 91.8% (95% CI 91.7% to 91.9%). The incidences of acute (grade ≥3) blood triglyceride elevation, creatine kinase elevation, skin reaction, and mucositis were 1 (4.0%), 1 (4.0%), 2 (8.0%), and 1 (4.0%), respectively. The incidences of late severe (grade ≥3) nasopharyngeal wall necrosis, nasal bleeding, and trismus were 28.0%, 12.0%, and 4.0%, respectively.

Conclusions

Toripalimab combined with IMRT was tolerable and showed promising antitumor activity in patients with rNPC.

Trial registration number

NCT03854838.

Significant Reduction in Vertebral Artery Dose by Intensity Modulated Proton Therapy: A Pilot Study for Nasopharyngeal Carcinoma

Intensity modulated proton therapy (IMPT) with the vertebral artery (VA)-sparing technique has been initially proposed in our institution. This pilot study was conducted to compare the dose to VAs between IMPT and volumetric-modulated arc therapy (VMAT) for patients with nasopharyngeal carcinoma (NPC). A total of six patients with NPC treated by IMPT were enrolled in the study. Target volumes and organs at risk (OARs) were delineated, including 12 samples of right and left VAs, respectively, for each patient. Treatment planning by IMPT and dual-arc VMAT was carried out for comparison. The IMPT plan significantly reduced VA mean dose, V10, V20, V30, V40, and V50, compared to the VMAT plan in all 12 samples (p < 0.001). The average mean dose to VAs for IMPT was 35.2% (23.4–46.9%), which was less compared to VMAT (p < 0.001). Adequate dose coverage was achieved with both IMPT and VMAT plans for three different dose levels of target volumes for all patients. IMPT significantly reduces VA dose while maintaining adequate dose coverage of all target volumes. For patients with head and neck cancer who seek to preserve their blood flow to the brain in order to decrease late vascular and neurologic sequelae, IMPT should be considered. A prospective study with longer follow-up is ongoing to confirm our preliminary results.

Maximal lymph nodal diameter on N stage of nasopharyngeal carcinoma

To assess the maximal lymph nodal diameter on the 8th edition American Joint Committee on Cancer staging system of nasopharyngeal carcinoma (NPC).This study extracted NPC patients between 2004 and 2016 in the Surveillance, Epidemiology, and End Results database. Included patients were divided into 3 groups: ≤3 cm, >3-6 cm, and >6 cm based on the maximal lymph nodal diameter. Cumulative survival curves of 5-year overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method between the 3 groups.The 5-year OS (64.0% vs 59.3%, P = .240) and CSS (71.8% vs 67.0%, P = .242) of ≤3 cm and >3-6 cm groups were not different. In contrast, the 5-year OS and CSS were different between >6 cm and ≤3 cm groups, and between >6 cm and >3-6 cm groups. The stratified hazard ratio of OS and CSS was 1.75 (95% confidence interval: 1.25-2.45; P = .001) and 1.77 (95% confidence interval: 1.20-2.60; P = .004) for the >6 cm group in the multivariate regression analysis.It is reasonable that the maximal lymph nodal diameter with >6 cm is classified as stage N3 of the 8th edition American Joint Committee on Cancer staging system for NPC.

Comparing the 7th and 8th editions of UICC/AJCC staging system for nasopharyngeal carcinoma in the IMRT era

Background

To compare the prognostic value of 7th and 8th editions of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system for patients with nonmetastatic nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy and simultaneous integrated boost– intensity-modulated radiation therapy (SIB-IMRT).

Methods

Patients with NPC (n = 300) who received SIB-IMRT were included. Survival by T-classification, N-classification, and stage group of each staging system was assessed.

Results

For T-classification, nonsignificant difference was observed between T1 and T3 and between T2 and T3 disease (P = 0.066 and 0.106, respectively) for overall survival (OS) in the 7th staging system, whereas all these differences were significant in the 8th staging system (all P < 0.05). The survival curves for disease-free survival (DFS) and locoregional recurrence-free survival (LRRFS) in both staging systems were similar, except for the comparison of T2 and T4 disease for LRRFS (P = 0.070 for 7th edition; P = 0.011 for 8th edition). For N-classification, significant differences were observed between N2 and N3 diseases after revision (P = 0.046 and P = 0.043 for OS and DFS, respectively). For staging system, no significant difference was observed between IVA and IVB of 7th edition.

Conclusion

The 8th AJCC staging system appeared to have superior prognosis value in the SIB-IMRT era compared with the 7th edition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08036-8.

Survival outcome and prognostic factors of patients with nasopharyngeal cancer in Yogyakarta, Indonesia: A hospital-based retrospective study

Purpose

This study aimed to determine the survival outcome and prognostic factors of patients with nasopharyngeal cancer accessing treatment in Yogyakarta, Indonesia.

Methods

Data on 759 patients with NPC diagnosed from 2007 to 2016 at Dr Sardjito General Hospital were included. Potential prognostic variables included sociodemographic, clinicopathology and treatment parameters. Multivariable analyses were implemented using semi-parametric Cox proportional hazards modelling and fully parametric survival analysis.

Results

The median time of observation was 14.39 months. In the whole cohort the median observed survival was 31.08 months. In the univariable analysis, age, education status, insurance type, BMI, ECOG index, stage and treatment strategy had an impact on overall survival (OS) (p values <0.01). Semi-parametric multivariable analyses with stage stratification showed that education status, ECOG index, and treatment modality were independent prognostic factors for OS (p values <0.05). In the fully parametric models age, education status, ECOG index, stage, and treatment modality were independent prognostic factors for OS (p values <0.05). For both multivariable analyses, all treatment strategies were associated with a reduced hazard (semi-parametric models, p values <0.05) and a better OS (parametric models, p values <0.05) compared with no treatment. Furthermore, compared with radiation alone or chemotherapy alone, a combination of chemotherapy and radiation either in a form of concurrent chemoradiotherapy (CCRT), sequential chemotherapy and radiation, or induction chemotherapy followed by CCRT demonstrated a reduced hazard (hazard ratio/HR 0.226, 95% confidence interval/CI 0.089–0.363, and HR 0.390, 95%CI 0.260–0.519) and a better OS (time ratio/TR 3.108, 95%CI 1.274–4.942 and TR 2.531, 95%CI 1.829–3.233) (p values < 0.01).

Conclusions

Median OS for the cohort was low compared to those reported in both endemic and non-endemic regions. By combining the findings of multivariable analyses, we showed that age, education status, ECOG index, stage and first treatment modality were independent predictors for the OS.

Metastatic Patterns and Prognosis of de novo Metastatic Nasopharyngeal Carcinoma in the United States

OBJECTIVE

To evaluate the distant metastatic patterns and prognostic factors for overall survival (OS) and cancer-specific survival (CSS) in de novo metastatic nasopharyngeal carcinoma (mNPC) using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

Patients with de novo mNPC who had been diagnosed between 2004 and 2016 were identified from the SEER database. Kaplan-Meier analysis was used to calculate OS and CSS. Log-rank tests were employed to measure survival variation among subgroups. Individual predictors of CSS and OS were examined using Cox proportional-hazards regression models in patients with de novo mNPC.

RESULTS

We evaluated 224 patients with de novo mNPC who matched our inclusion criteria. Three-year CSS and OS for the whole cohort was 29.8% and 27.9%, respectively. Univariate analysis indicated that CSS and OS were influenced by age, histology, radiotherapy, chemotherapy, and liver metastasis. Neither the number of metastatic sites nor their specific location in bone, lungs, distant lymph nodes or brain significantly affected CSS or OS. The aforementioned independent prognosticators continued to significantly influence survival following multivariate analysis. Taking distant metastasis without liver involvement as a reference, liver metastasis was associated significantly with shorter OS at a hazard ratio (HR) of 1.581 (P = .021) and CSS at a HR of 1.643 (P = .016). Older age, keratinizing squamous cell carcinoma, no chemotherapy, and no radiotherapy were also prognosticators for poor OS (P < .05). Similar results were documented for CSS (P < .05).

CONCLUSION

For patients with de novo mNPC, liver metastasis is an independent prognosticator for inferior CSS and OS.

LEVEL OF EVIDENCE

3a Laryngoscope, 131:E1130-E1138, 2021.

Validation of Stage N3 of the Eighth Edition AJCC Staging System for Nasopharyngeal Carcinoma

OBJECTIVES

To validate stage nodal (N)3 of the 8th edition American Joint Committee on Cancer (AJCC) staging system for nasopharyngeal carcinoma (NPC).

METHODS

This retrospective cohort study extracted NPC patients from the Surveillance, Epidemiology, and End Results database between 2004 and 2016. Pathologically confirmed patients with complete data of level IV, N3a, and N3b lymph node metastasis were investigated. The included patients were divided into level IV, N3a, and N3b groups. Five-year overall survival (OS) and cancer-specific survival (CSS) were compared among the three groups.

RESULTS

A total of 693 patients were included: 285 (41.13%) patients in the level IV group, 124 (17.89%) patients in the N3a group, and 284 (40.98%) patients in the N3b group. The 5-year OS (57.1%, 55.0%, and 55.2%) and CSS (64.4%, 63.5%, and 64.4%) were not different among the level IV, N3a, and N3b groups. Multivariate regression analysis revealed that N stage was not an independent prognostic factor for OS (hazard ratio [HR] = 1.03, 95% confidence interval [CI]: 0.91-1.17; P = .65) or CSS (HR = 1.03, 95% CI: 0.89-1.19; P = .70).

CONCLUSION

Stage N3 of the 8th edition AJCC staging system for NPC is reasonable.

LEVEL OF EVIDENCE

III Laryngoscope, 131:535-540, 2021.

Comparison of radiomics tools for image analyses and clinical prediction in nasopharyngeal carcinoma

Objective:

Radiomics pipelines have been developed to extract novel information from radiological images, which may help in phenotypic profiling of tumours that would correlate to prognosis. Here, we compared two publicly available pipelines for radiomics analyses on head and neck CT and MRI in nasopharynx cancer (NPC).

Methods and materials:

100 biopsy-proven NPC cases stratified by T- and N-categories were enrolled in this study. Two radiomics pipeline, Moddicom (v. 0.51) and Pyradiomics (v. 2.1.2) were used to extract radiomics features of CT and MRI. Segmentation of primary gross tumour volume was performed using Velocity v. 4.0 by consensus agreement between three radiation oncologists. Intraclass correlation between common features of the two pipelines was analysed by Spearman’s rank correlation. Unsupervised hierarchical clustering was used to determine association between radiomics features and clinical parameters.

Results:

We observed a high proportion of correlated features in the CT data set, but not for MRI; 76.1% (51 of 67 common between Moddicom and Pyradiomics) of CT features and 28.6% (20 of 70 common) of MRI features were significantly correlated. Of these, 100% were shape-related for both CT and MRI, 100 and 23.5% were first-order-related, 61.9 and 19.0% were texture-related, respectively. This interpipeline heterogeneity affected the downstream clustering with known prognostic clinical parameters of cTN-status and GTVp. Nonetheless, shape features were the most reproducible predictors of clinical parameters among the different radiomics modules.

Conclusion:

Here, we highlighted significant heterogeneity between two publicly available radiomics pipelines that could affect the downstream association with prognostic clinical factors in NPC

Advances in knowledge:

The present study emphasized the broader importance of selecting stable radiomics features for disease phenotyping, and it is necessary prior to any investigation of multicentre imaging datasets to validate the stability of CT-related radiomics features for clinical prognostication.

Merkel Cell Polyoma Viral Load and Intratumoral CD8+ Lymphocyte Infiltration Predict Overall Survival in Patients With Merkel Cell Carcinoma

Introduction: Merkel cell carcinoma (MCC) is linked to the presence of clonally integrated Merkel cell polyomavirus (MCPyV) in up to 80% of the cases. The aim of the study was to determine the prognostic value of baseline MCPyV viral load and lymphocytic infiltration.

Methods: MCPyV DNA prevalence, integration status and viral load were determined by specific quantitative real-time PCR in surgical specimens obtained from 49 patients with MCC treated with (n = 22, 45%) or without postoperative radiotherapy (RT). CD8+ tumor infiltrating lymphocytes (TILs) and programmed death ligand 1 (PD-L1) status were assessed using immunohistochemistry. MCPyV characteristics and immune marker expression were correlated with clinicopathological factors and overall survival (OS).

Results: Median age at diagnosis was 74 (range, 42–100); 51% of the patients were female. One-, three, and five-year OS rates were 83.8, 58.6, and 47.1%, respectively. A positive MCPyV status was associated with female gender (p = 0.042). Tumor localization (head/arms vs. trunk) positively correlated with PD-L1 status (p = 0.011) and combined CD8/PD-L1 expression (p = 0.038). Overall CD8+ infiltration was inversely associated with N-stage (p = 0.048). Stromal TILs correlated significantly with both PD-L1 expression (p = 0.010) and N-stage (p = 0.037). A high viral load (>median) was significantly associated with worse OS (p = 0.029) and high intratumoral CD8+ infiltration with improved OS for the entire cohort (p = 0.045).

Conclusion: These data provide important insight on the role of MCPy DNA viral load and TILs in the context of PD-L1 in patients with Merkel cell carcinoma. Future clinical studies should aim to explore the effect of PD-1/PD-L1 immune-checkpoint inhibitors in combination with existing radiotherapy approaches.

Osthole sensitizes with radiotherapy to suppress tumorigenesis of human nasopharyngeal carcinoma in vitro and in vivo

BACKGROUND

Radiotherapy is one of the most comment and useful treatment for nasopharyngeal carcinoma (NPC), but the radioresistance remains a major obstacle. Osthole, a natural coumarin derivative, has been shown to have anti-tumor and anti-inflammatory activity. However, the relationship between osthole and NPC treatment, especially for radiotherapy, is still elusive.

METHODS

Osthole with or without X ray radiotherapy treated with CNE2 cells, a human EC cell line. Cell viability, proliferation, migration and apoptosis were measured by MTT, colony formation, Annexin V/PI double staining, Transwell assay, respectively. NPC tumor models were established on BALB/c nude mice by subcutaneously injection of CNE2 cells and the effect of osthole and radiotherapy on tumor growth in vivo was studied.

RESULTS

We found that in a dose-dependent manner, osthole could individually, and synergistically with radiotherapy, reduce NPC cell (CNE2) viability, proliferation, migration, and invasion, and induce apoptosis, respectively. This effect of anti-tumor growth and induction of apoptosis was further confirmed in mice induced by subcutaneously injection with CNE2 cells and following treated with osthole or/and radiation.

CONCLUSION

Osthole increases the effect of radiotherapy on anti-human nasopharyngeal cancer.