Chemotherapy in Combination With Radiotherapy for Definitive-Intent Treatment of Stage II-IVA Nasopharyngeal Carcinoma: CSCO and ASCO Guideline

Chemoimmunotherapy as induction treatment in concurrent chemoradiotherapy for patients with nasopharyngeal carcinoma stage IVa

BACKGROUND

Chemoimmunotherapy is the first-line therapy for patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) and is currently the main induction treatment option for patients with locoregionally advanced NPC. However, it remains unclear whether combining immunotherapy with standard induction chemotherapy enhances its efficacy. This study aimed to evaluate the efficacy, toxicity, and survival outcomes of induction chemoimmunotherapy in patients with locoregionally advanced NPC.

METHODS

This study analyzed 50 patients with stage IVa NPC between January 2020 and December 2023 in our hospital. Among them, 23 received induction chemoimmunotherapy, and 27 received induction chemotherapy. All patients underwent standard platinum-based concurrent intensity-modulated radiation therapy. We compared tumor response and toxicity during induction treatment and concurrent chemoradiotherapy (CCRT) between the two groups.

RESULTS

The objective and complete response rates were significantly higher in the induction chemoimmunotherapy group compared to the induction chemotherapy group (95.7% vs 77.8%, and 39.1% vs 22.2%, respectively). All patients completed radical CCRT. Median follow-up was 24 months. Patients who received induction chemoimmunotherapy had longer event-free survival (EFS) compared to those who received induction chemotherapy (p = 0.029, Hazard Ratio and 95%confidence interval [CI]: 0.24 [0.07-0.85]). The 24-month EFS was higher in the induction chemoimmunotherapy group compared with the chemotherapy group (24-month EFS rates and 95%CI: 88.9% [95%CI: 68.3%-100%] vs 62.6% [95%CI: 43.1%-82.1%]). No significant differences in adverse events were observed between the two groups during induction treatment and CCRT.

CONCLUSIONS

Adding immunotherapy to induction chemotherapy may be an effective and safe choice for treating patients with stage IVa NPC.

Updates on Treatments and Management of Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma (NPC) is a unique head and neck cancer, where the endemic subtype is strongly associated with Epstein-Barr virus (EBV) infection, whereas emerging data suggest that a subset of nonendemic NPC may be associated with human papillomavirus (HPV) infection. Nonetheless, treatment advances have been driven by clinical trials conducted in endemic NPC, investigating optimal sequencing of chemotherapy and immune checkpoint inhibitors with radiotherapy for locoregionally advanced disease. The preference for induction chemotherapy (IC) in these patients has also led to evolution in the concept of radiotherapy target delineation. Because of its association with EBV, plasma EBV DNA is an archetypal biomarker for endemic NPC, and it is being explored for precise stratification and treatment individualization in several ongoing trials. In the space of recurrent or metastatic-NPC, with the advent of platinum-doublet chemotherapy and anti-PD-1 antibody as the new standard of care, several trials are investigating new immunotherapeutic combinations, bispecific antibodies, and antibody-drug conjugates that have demonstrated promise in early phase trials. An important advance for NPC in 2025 is the update of the 9th version of the TNM staging system, which has introduced several key changes, including downgrading of the TNM stage groupings for localized disease, and splitting of metastatic NPC into IVA and IVB based on the number of metastatic lesions. These revisions would have implications for the treatment and design of future trials. These advances are also relevant to nonendemic NPC, where evidence is inconclusive whether this disease responds differently to current treatments compared with endemic NPC.

Determining the optimal duration of oral adjuvant chemotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

Concurrent chemoradiotherapy (CCRT) followed by adjuvant chemotherapy (AC) is the standard treatment for locoregionally advanced nasopharyngeal carcinoma (LA-NPC). However, the optimal duration of oral AC remains poorly defined.

METHODS

This study examined newly diagnosed patients between April 2017 and December 2020. The primary endpoint was overall survival (OS). Restricted cubic splines (RCS) and Kaplan-Meier method were used to evaluate the relationship between AC maintenance and survival. Inverse probability of treatment weighting (IPTW) was used to control for confounding factors.

RESULTS

The RCS demonstrated an L-shaped association between oral AC maintenance and OS. The risk of mortality was relatively flat after 12 months. Patients with oral AC duration >186 days (defined by RCS) had a significantly better OS (HR 0.23 [95% CI 0.10-0.55], log-rank p < 0.001), with a higher 3-year OS rate (98.7% [95% CI 96.8-100.0] vs 88.3% [95% CI 82.5-94.5]). For patients with pretreatment Epstein-Barr virus (EBV) DNA level >4000 copies/mL, mortality risk decreased to 1 at 194 days of AC duration.

CONCLUSIONS

The optimal duration of oral AC after CCRT was >186 days (6 months) for LA-NPC. And the maintenance beyond 12 months may not bring additional benefits.

Induction versus Concurrent Chemotherapy for Advanced Nasopharyngeal Carcinoma

BACKGROUND

Cisplatin-based concurrent chemoradiotherapy (CCRT) is the mainstay treatment for locoregionally advanced nasopharyngeal carcinoma (LA-NPC), which usually leads to intolerable toxicities. We investigated whether or not induction chemotherapy (IC) plus intensity-modulated radiation therapy (IMRT) could replace CCRT.

METHODS

This is an open-label, phase 3, noninferiority trial. Patients with stage T1-4N2-3 or T3-4N0-1 LA-NPC were randomly assigned (1:1) to receive gemcitabine (1000 mg/m2) and cisplatin (80 mg/m2) for two cycles followed by IMRT, or IMRT plus concomitant weekly cisplatin (40 mg/m2) for up to seven cycles. Two-year failure-free survival (FFS) was the primary end point, and noninferiority was confirmed by an upper limit of the 95% confidence interval (CI) for a hazard ratio of less than 2.12 (absolute margin of -10 percentage points). Secondary end points include overall survival, locoregional recurrence-free survival, distant metastasis-free survival, toxicity profile, and quality of life (QoL).

RESULTS

We enrolled 124 patients in the IC group and 125 patients in the CCRT group. The median follow-up was 60 months. Two-year FFS was 90.2% for IC versus 86.3% for CCRT, with a hazard ratio of 0.636 (95% CI, 0.267 to 1.514) and an absolute difference of 3.9 percentage points (95% CI, -5.2 to 13.0). Compared with the CCRT group, fewer grade ≥3 adverse events occurred in the IC group (47.5% vs. 61.5%; P=0.029), including leukopenia, anemia, mucositis, nausea, and dysphagia. IC was associated with better QoL, including global health status, social and cognitive functioning, fatigue, nausea and vomiting, pain, appetite loss, and constipation.

CONCLUSIONS

For 2-year FFS for LA-NPC, gemcitabine and cisplatin IC plus IMRT alone was noninferior to CCRT. (Funded by Key-Area Research and Development of Guangdong Province and others.).

Mutant p53 confers chemoresistance by activating KMT5B-mediated DNA repair pathway in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC), a malignancy arising from the nasopharyngeal epithelium, is common in the east and southeast area of Asia. Treatments for locally advanced and recurrent NPC include chemotherapy (usually combined with 5-Fluorouracil, 5-FU) and radiotherapy, but response is limited due to chemo-resistance. p53 mutation is a critical factor for 5-FU resistance in some cancers, but its role in NPC chemo-resistance remains unclear. Here, we demonstrate that p53(R280T), a common p53 somatic mutation found in multiple NPC tumor samples, induces gain-of-function upregulation of DNA repair genes which leads to 5-FU resistance in NPC. p53(R280T) specifically upregulates the expression of DNA repair-associated gene KMT5B by binding to its promoter, which leads to 5-FU resistance. Depletion of KMT5B in NPCs restores 5-FU induced DNA damages and improve the efficacy of 5-FU. By screening compounds affecting KMT5B expression, we identify curcumin as an effective down-regulator of KMT5B in NPC cells. We therefore evaluate the therapeutic potential of a 5-FU/curcumin combination to treat NPC and discover that curcumin enhances the efficacy of 5-FU to suppress NPC tumor growth. In summary, our findings indicate that mutant p53 and its regulated DNA repair genes serve as potential therapeutic targets to reverse 5-FU resistance for NPC patients.

Nasopharyngeal necrosis following intensity-modulated radiation therapy of primary nasopharyngeal carcinoma-incidence rate and predictors of risk

OBJECTIVES

This study aimed to investigate the incidence of post radiation nasopharyngeal necrosis (PRNN) in primary NPC after intensity modulated radiation therapy (IMRT) and identify the predictors of risk.

METHODS

Data of 5798 NPC patients who received IMRT-based treatment between April 2009 and December 2015 were retrospectively reviewed. PRNN was diagnosed by MRI or nasopharyngoscopy. Dosimetric factors were selected by the least absolute shrinkage and selection operator logistic regression and applied to Cox proportional hazards modeling with clinical predictors.

RESULTS

Among the 5798 patients, 53 developed PRNN-an incidence rate of 0.89%. Age > 55 years, diabetes, LDH > 170 U/L, and tumor volume of nasopharynx > 60.5 cm3,were independently associated with risk of PRNN(all p < 0.05. Dosimetric analysis showed that D0.5ccEQD2 of 80.20 Gy might be the dose constraint for nasopharynx (sensitivity = 62.3%, 33 out of 53; specificity = 84.2%, 4897 out of 5925). Besides, the RTOG dose constraints of V110% (V77.0) should be less than 0.2% in case of increasing risk of PRNN(HR = 2.28, 95% CI: 1.26-4.41, p = 0. 01).

CONCLUSION

Nasopharyngeal necrosis is rare after primary IMRT. The independent risk factors for this rare complication include age > 55 years, diabetes mellitus, LDH > 170 U/L, tumor volume of nasopharynx > 60.5 cm3, D0.5ccEQD2 > 80.20 Gy, and V77.0 < 0.2% to the planning treatment volume of nasopharynx.

KEYPOINTS

High radiation dose may lead to devastating nasopharyngeal necrosis after primary IMRT. Real world analysis will provide valuable information for prevention.

FINDINGS

The aged, diabetes mellitus, large tumor volume, D0.5ccEQD2 > 80.20 Gy and V77.0 < 0.2% to planning treatment volume increased the risk of nasopharyngeal necrosis.

CLINICAL RELEVANCE

This real-world study provided valuable information for prevention of PRNN. Compared with RTOG protocol, D0.5ccEQD2 > 80.20 Gy is a reliable evidence-based new complement to dose constraint, especially for T3-4 disease, who received high prescribe dose in China.

Regulation mechanism of chemokine CXCL3 in nasopharyngeal carcinoma

Nasopharyngeal carcinoma (NPC), a malignancy arising from the nasopharyngeal mucosal epithelium, remains poorly understood at molecular level. This study identifies CXCL3, a chemokine, as a critical oncogenic driver in NPC through multi-dataset transcriptomic analysis (GSE12452, GSE53819 and GSE61218). CXCL3 was identified to be upregulated in NPC tissues and correlated with tumor progression (P = 0.022) and poor prognosis. Immune infiltration analysis revealed its association with mast cell accumulation and immunosuppressive checkpoints (CD200, CD44 and CD70). Gene Set Enrichment Analysis (GSEA) linked CXCL3 to ECM-receptor-interaction, JAK-STAT and MAPK pathways. Functional assays demonstrated that CXCL3 silencing suppressed the SUNE-1 cells proliferation (P < 0.01), migration, and invasion abilities (P < 0.05), induced G2/M-phase arrest and reduced S-phase populations via MAPK/ERK pathway inhibition (p-ERK1/2, p-P38 and p-STAT3 down-regulated). Immunohistochemistry confirmed elevated CXCL3 expression in NPC tissues (approximately 80 % positivity) versus normal controls (100 % negative). Notably, CXCL3 knockdown impaired tubule formation in vitro, implicating its role in vascular remodeling. These findings establish CXCL3 as a multifaceted regulator of NPC progression through immune microenvironment modulation, MAPK/ERK signaling, and angiogenesis, nominating it as a potential therapeutic target in NPC.

Transoral Robotic Surgery in the Multidisciplinary Care of Patients With Oropharyngeal Squamous Cell Carcinoma: ASCO Guideline

PURPOSE

To provide evidence-based recommendations for the use of transoral robotic surgery (TORS) in the multidisciplinary management of oropharyngeal squamous cell cancer (OPC).

METHODS

ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. The literature search included studies published between January 1, 2002, and August 31, 2024, and comprised systematic reviews, meta-analyses, randomized controlled trials, and observational studies. Outcomes of interest include overall and disease-free survival, functional outcomes, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations.

RESULTS

A total of 58 publications were identified to inform the evidence base for this guideline.

RECOMMENDATIONS

Evidence-based recommendations address the evaluation and workup of patients with human papillomavirus (HPV)-positive OPC, the role of TORS, patient selection, adjuvant therapy, HPV-negative OPC, and use of TORS in salvage or recurrent setting.Additional information is available at www.asco.org/head-neck-cancer-guidelines.

Plasma Epstein-Barr Virus DNA Temporal Clearance Pattern During Induction-Concurrent (Chemo)Radiation Therapy for Risk Stratification in Nasopharyngeal Carcinoma

PURPOSE

Plasma Epstein-Barr virus (EBV) DNA is a widely used biomarker for nasopharyngeal carcinoma (NPC). Prior investigations predominantly assessed EBV DNA at a single time point, thus neglecting the differential prognostic implications of the temporal clearance pattern of EBV DNA during induction-concurrent (chemo)radiation therapy (RT).

METHODS AND MATERIALS

We retrospectively reviewed EBV DNA clearance patterns during induction-concurrent chemoRT in newly diagnosed patients with nonmetastatic NPC. EBV DNA was tested at 3 time points (baseline [T0], end of induction chemotherapy [T1], and end of RT [T2]) and recorded as detectable (D) and undetectable (U). The association between EBV DNA pattern and progression-free survival was analyzed.

RESULTS

A total of 2203 NPCs were included. Five distinct EBV DNA trajectory patterns were identified: type Ⅰ (negative-stable, U-U-U, 7.3%), type Ⅱ (induction chemotherapy-elimination, D-U-U, 42.8%), type Ⅲ (RT-elimination, D-D-U, 35.0%), type Ⅳ (persistent-positive, D-D-D, 11.7%), and type Ⅴ (resurgence, D-U-D [1.5%], U-D-U [1.2%], U-D-D [0.4%], or U-U-D [0.2%]). The median follow-up was 53.5 months (IQR, 43.1-66.9). Type Ⅱ patients displayed superior 5-year progression-free survival (82.9% [95% CI, 80.4%-85.5%]) versus type Ⅲ (75.9% [72.8%-79.1%], P < .001), type Ⅳ (52.5% [46.4%-59.5%], P < .001), and type Ⅴ (72.5% [62.2%-84.6%], P = .028). The 5-year progression-free survival for type V patients with "D-U-D," "U-D-U," "U-D-D," and "U-U-D" patterns was 62.4% (46.2%-84.3%), 78.6% (63.1%-97.8%), 85.7% (63.3%-100.0%), and 75.0% (42.6%-100.0%), respectively. All 33 patients with the "D-U-D" pattern had stage Ⅲ-Ⅳ disease at diagnosis.

CONCLUSIONS

Temporal EBV DNA clearance patterns during induction-concurrent chemoRT provide valuable prognostic insights, enabling the identification of patients with high-risk NPC and informing personalized treatment strategies. Resurgence of EBV DNA may occur occasionally (3.3%). Caution is required when considering reduced-intensity therapy in patients with locoeregionally advanced disease when EBV DNA becomes U after induction chemotherapy.

Personalising Nasopharyngeal Cancer: Systemic Therapy and Radiotherapy Treatment Volumes

Nasopharyngeal carcinoma (NPC) is sensitive to chemotherapy and radiotherapy, with current treatment recommendations largely based on TNM-stage. Radiotherapy remains the backbone of treatment for NPC. Over the past decades, the addition of concurrent chemotherapy to radiotherapy for early-stage disease, and the combination of induction chemotherapy (IC) or adjuvant chemotherapy (AC) with chemoradiotherapy vs chemoradiotherapy alone for advanced disease have led to substantial improvements in survival of patients with NPC. Nonetheless, in the era of precision oncology, there is growing recognition that patients with NPC are clinically heterogeneous even within the same stage-group, and future advances must focus on individualisation of systemic therapy and radiotherapy. In this review, we summarised the published evidence on EBV DNA as a biomarker for clinical stratification and treatment response in NPC, and discussed some of the ongoing clinical trials of EBV DNA-directed personalisation of systemic therapy in locoregionally-advanced disease. Next, we assessed the evidence concerning individualised radiotherapy strategies for target volume delineation of the primary tumour and cervical nodes that ought to be based on individual tumour extent and IC response (for locoregionally-advanced NPC) as opposed to the historical one-size fits all approach. In the same vein, radiotherapy dose de-escalation may be considered in good responders to IC, whereas for the poor responders, altered fractionation or dose escalation may be required to target resistant disease. These concepts are particularly relevant in the era of combinatorial immune checkpoint blockade therapy with radiotherapy, where preservation of circulating immune cells is crucial to evoke immune-mediated antitumour cytotoxicity.

A rare KLHDC4 variant Glu510Lys is associated with genetic susceptibility and promotes tumor metastasis in nasopharyngeal carcinoma

Various genetic association studies have identified numerous single nucleotide polymorphisms (SNPs) associated with nasopharyngeal carcinoma (NPC) risk. However, these studies have predominantly focused on common variants, leaving the contribution of rare variants to the "missing heritability" largely unexplored. Here, we integrate genotyping data from 3925 NPC cases and 15,048 healthy controls to identify a rare SNP, rs141121474, resulting in a Glu510Lys mutation in KLHDC4 gene linked to increased NPC risk. Subsequent analyses reveal that KLHDC4 is highly expressed in NPC and correlates with poorer prognosis. Functional characterizations demonstrate that KLHDC4 acts as an oncogene in NPC cells, enhancing their migratory and metastatic capabilities, with these effects being further augmented by the Glu510Lys mutation. Mechanistically, the Glu510Lys mutant exhibits increased interaction with Vimentin compared to the wild-type KLHDC4 (KLHDC4-WT), leading to elevated Vimentin protein stability and modulation of the epithelial-mesenchymal transition process, thereby promoting tumor metastasis. Moreover, Vimentin knockdown significantly mitigates the oncogenic effects induced by overexpression of both KLHDC4-WT and the Glu510Lys variant. Collectively, our findings highlight the critical role of the rare KLHDC4 variant rs141121474 in NPC progression and propose its potential as a diagnostic and therapeutic target for NPC patients.

Adaptive radiotherapy triggering for nasopharyngeal cancer based on bayesian decision model

Objective.To develop a Bayesian decision model for adaptive radiotherapy (ART) in nasopharyngeal cancer (NPC) that balances clinical capacity of ART and inter-fraction dosimetric changes.Approach.A retrospective analysis was conducted on 84 fractions from 17 NPC patients treated with intensity-modulated radiotherapy using a CT-Linac. Fourteen patients were included for the model construction, and three for validation. Daily diagnostic-level CT images were rigidly registered to the planning CT for regions of interest and treatment plan propagation. The propagated contours were reviewed and refined by radiation oncologists. For each daily CT, percentage differences in 27 dose metrics were compared to the original plan. Composite scores of dose differences were developed using factor analysis on planning target volume (PTV) and organ at risk (OAR) dose metrics. These scores were integrated into a Bayesian decision model, which incorporated a subjective trigger rate to determine the initiation of ART.Main results.The model generated individualized re-plan strategies based on composite scores for PTV or OAR, with trigger rates ranging from 10% to 60%. In the validation with 14 fractions, significant anatomical and dosimetric variations were identified. At a 30% trigger rate, only one fraction was misclassified.Significance.It is feasible to employ a Bayesian decision model for ART, merging subjective clinical insights with objective dosimetric data to refine re-planning decisions.

International Consensus Guidelines on the Delineation of Radiation Therapy Target Volumes for Nasopharyngeal Carcinoma After Induction Chemotherapy Using a 2-Round Modified Delphi Survey

PURPOSE

Induction chemotherapy (ICT), a new standard in the management of locally advanced nasopharyngeal carcinoma (NPC), is increasingly used in endemic regions. Radiation therapy (RT) target volume delineation protocols and dose level prescriptions vary significantly in the literature. High-level evidence to support a particular approach is currently lacking. We developed an international consensus guideline toward harmonizing practices based on a literature review and expert opinion.

METHODS AND MATERIALS

The study entailed the following: consensus scope definition by focus group discussion (FGD); evidence gap identification by a scoping review of guidelines and literature reviews; evidence review and synthesis by a systematic review of experimental and observational studies and drafting of consensus statements by FGD; and consensus voting by modified Delphi process and FGD. The task force consisted of radiation oncologists from intermediate- and high-endemicity regions with expertise in treating NPC, evidence review, and consensus guideline development. The consensus panel consisted of relevant specialists from intermediate- and high-endemicity regions or with expertise in treating NPC. A modified e-Delphi method was used.

RESULTS

Four clinical situations after ICT for patients with NPC were selected for the consensus questions: optimal timing of chemoradiation; optimal imaging modalities for simulation and target volume delineation; optimal dose and fractionation; and RT target volume delineation. The consensus panel consisted of radiation oncologists (12), clinical oncologists (4), radiologists (3), a nuclear medicine specialist, medical physicists (2), and dosimetrists (2). The consensus guidelines were formulated after 2 rounds of Delphi voting and FGD; iterative revisions were made based on 2 rounds of internal review. The guidelines were subjected to external review and open commentary; further revisions were made if the consensus vote was not invalidated.

CONCLUSIONS

An international consensus guideline on delineating RT target volumes and corresponding dose levels in post-ICT NPC, as well as timing and modalities for imaging, was developed to help harmonize practices and enhance the comparability of interpretations of reported outcomes.

Early prediction of progression-free survival of patients with locally advanced nasopharyngeal carcinoma using multi-parametric MRI radiomics

PURPOSE

Prognostic prediction plays a pivotal role in guiding personalized treatment for patients with locoregionally advanced nasopharyngeal carcinoma (LANPC). However, few studies have investigated the incremental value of functional MRI to the conventional MRI-based radiomic models. Here, we aimed to develop a radiomic model including functional MRI to predict the prognosis of LANPC patients.

METHODS

One hundred and twenty-six patients (training dataset, n = 88; validation dataset, n = 38) with LANPC were retrospectively included. Radiomic features were extracted from T1-weighted imaging (T1WI), T2-weighted imaging (T2WI), contrast-enhanced T1WI (cT1WI), and diffusion-weighted imaging (DWI). Pearson correlation analysis and recursive feature elimination or Relief were used for identifying features associated with progression-free survival (PFS). Five machine learning algorithms with cross-validation were compared to develop the optimal single-layer and fusion radiomic models. Clinical and combined models were developed via multivariate Cox regression model.

RESULTS

The clinical model based on TNM stage achieved a C-index of 0.544 in the validation dataset. The fusion radiomic model, incorporating DWI-, T1WI-, and cT1WI-derived imaging features, yielded the highest C-index of 0.788, outperforming DWI-based (C-index = 0.739), T1WI-based (C-index = 0.734), cT1WI-based (C-index = 0.722), and T1WI plus cT1WI-based models (C-index = 0.747) in predicting PFS. The fusion radiomic model yielded the C-index of 0.786 and 0.690 in predicting distant metastasis-free survival and overall survival, respectively. However, the addition of TNM stage to the fusion radiomic model could not improve the predictive power.

CONCLUSION

The fusion radiomic model demonstrates favorable performance in predicting survival outcomes in LANPC patients, surpassing TNM staging alone. Integration of DWI-derived features into conventional MRI radiomic models could enhance predictive accuracy.

A Randomized, Multicenter, Phase 2 Trial of Camrelizumab With or Without Metastasis-directed Stereotactic Body Radiation Therapy in Recurrent or Metastatic Nasopharyngeal Carcinoma

PURPOSE

To investigate the efficacy of metastasis-directed therapy (MDT) when added to camrelizumab (Cam) in patients with recurrent or metastatic nasopharyngeal carcinoma (R/M-NPC).

METHODS AND MATERIALS

We conducted a randomized, controlled, multicenter, phase 2 trial in 3 centers from China (NCT04830267). Patients with R/M-NPC, without prior exposure to immunotherapy, who presented with ≥2 lesions, and at least 1 measurable lesion were randomized 1:1 to either Cam alone or Cam plus MDT (Cam+MDT). Patients randomized to the MDT group must have 1 lesion that is amendable to stereotactic body radiation therapy (SBRT) prescribed to 27 Gy in 3 fractions every other day. The primary endpoint was objective response rate (ORR) of unirradiated lesions using Response Evaluation Criteria in Solid Tumors v1.1.

RESULTS

Between April 2021 and August 2023, 39 patients were randomly assigned to receive either Cam (n = 20) or Cam+MDT (n = 19). In total, 17 out of 39 (43.6%) patients had oligometastatic disease (≤3 lesions), 18 out of 39 (46.2%) had liver involvement, and 3 out of 39 (7.7%) had locoregional recurrent disease. ORR of unirradiated lesions did not differ between the treatment groups (26.3% [Cam+MDT] vs 30.0% [Cam], P = 1.0). The disease control rate of unirradiated lesions was 73.7% in the Cam+MDT group compared with 60.0% in the Cam group (P = .571). After a median follow-up of 25.8 months, median progression-free survival was 9.3 (95% CI, 6.2-not reached [NR]) months in the Cam+MDT group and 8.8 (95% CI, 3.3-NR) months in the Cam group (P = .750). Exploratory analyses suggested a longer overall survival (OS) with Cam+MDT for patients with >3 lesions (HR, 0.23; 95% CI, 0.07-0.77; P = .009). G3 and above adverse events were comparable between the treatment groups (15.8% [Cam+MDT] vs 20.0% [Cam]). The overall rate of capillary proliferation was 17.9% (7/39) for the trial.

CONCLUSIONS

Our study did not meet its primary endpoint of superior ORR of unirradiated lesions with the addition of MDT to Cam in patients with R/M-NPC.

Adjuvant PD-1 Blockade With Camrelizumab for Nasopharyngeal Carcinoma: The DIPPER Randomized Clinical Trial

Importance

Approximately 20% to 30% of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) experience disease relapse despite definitive chemoradiotherapy. The programmed cell death 1 (PD-1) blockade camrelizumab has demonstrated considerable value in recurrent or metastatic NPC, while its role in locoregionally advanced NPC is unclear.

Objective

To evaluate the efficacy and safety of adjuvant camrelizumab for patients with locoregionally advanced NPC.

Design, Setting, and Participants

Randomized, open-label, multicenter, phase 3 clinical trial conducted from August 2018 to November 2021 at 11 centers in China and enrolling 450 patients with T4N1M0 or T1-4N2-3M0 NPC who had completed induction-concurrent chemoradiotherapy. The final date of follow-up was March 20, 2024.

Interventions

Patients were randomized (1:1) to receive adjuvant camrelizumab (200 mg intravenously once every 3 weeks for 12 cycles; n = 226) or observation (standard therapy group; n = 224).

Main Outcomes and Measures

The primary end point was event-free survival (freedom from distant metastasis, locoregional relapse, or death due to any cause). Secondary end points included distant metastasis-free survival, locoregional relapse-free survival, overall survival, safety, and health-related quality of life.

Results

Among the 450 participants (mean age, 45 [SD, 10] years; 24% women), after a median follow-up of 39 (IQR, 33-50) months, the camrelizumab group had a 3-year event-free survival rate of 86.9%, whereas the standard therapy group had a rate of 77.3% (stratified hazard ratio, 0.56; 95% CI, 0.36-0.89; P = .01). Grade 3 or 4 adverse events were reported in 23 patients (11.2%) in the camrelizumab and 7 (3.2%) in the standard therapy group. Reactive capillary endothelial proliferation was the most common adverse event related to camrelizumab, occurring in 85.8% of patients at grade 1 or 2, while 2% of patients had grade 3 or 4 events. There was no significant deterioration in quality of life associated with camrelizumab treatment.

Conclusions and Relevance

Adjuvant PD-1 blockade with camrelizumab significantly improved event-free survival with manageable toxicities, highlighting its potential role in the management of locoregionally advanced NPC.

Trial Registration

ClinicalTrials.gov Identifier: NCT03427827.

The correlation between epithelial-mesenchymal transition classification and MMP2 expression of circulating tumor cells and prognosis of advanced or metastatic nasopharyngeal carcinoma

Background

Epithelial-mesenchymal transition (EMT) and circulating tumor cells (CTCs) are key prognostic factors in nasopharyngeal carcinoma (NPC). However, the role of EMT status in CTCs for predicting outcomes in advanced NPC treated with radiotherapy after induction chemotherapy remains unclear.

Methods

A total of 143 CTC tests from 95 advanced/metastatic NPC patients were analyzed before, during, and after radiotherapy, with a 60-month follow-up. CTC count, matrix metalloproteinase 2 (MMP2)) protein expression, and EMT subtypes were examined.

Results

During radiotherapy, CTC counts increase but decrease afterward. Patients with higher pre-radiotherapy tumor-node-metastasis (TNM) stages have lower total and M-subtype CTC counts. Higher T and TNM stages during radiotherapy correlate with increased EMT-state CTCs, especially hybrid CTCs. EA/IgG-positive patients have a higher number of hybrid CTCs and E-type (epithelial + hybrid) CTCs, while EBV-EA-negative patients have more mesenchymal CTCs. A higher post-radiotherapy CTC count predicts relapse, and the positive rate of MMP2 expression on hybrid and epithelial CTCs is higher than that on mesenchymal CTCs.

Conclusion

EMT status, particularly in hybrid CTCs, is a potential prognostic marker for relapse in advanced NPC after radiotherapy.

Induction chemotherapy plus camrelizumab combined with concurrent chemoradiotherapy in locoregionally advanced nasopharyngeal carcinoma in non-endemic areas: a phase 2 clinical trial in North China

BACKGROUND

Immunotherapy has been confirmed efficient in recurrent or metastatic nasopharyngeal carcinoma (NPC), but its role in the locoregionally advanced setting is undetermined. Previous evidence in non-endemic areas of NPC is also lacking. This study evaluated the efficacy and safety of induction chemotherapy plus camrelizumab followed by concurrent chemoradiotherapy (CCRT) for patients with locoregionally advanced NPC in non-endemic areas.

METHODS

In this phase 2 trial, patients born and living in North China with untreated stage III to IVa NPC were enrolled. All patients received two 21-day cycles of camrelizumab (200 mg) plus docetaxel (75 mg/m2) and cisplatin (75 mg/m2), followed by intensity modulated radiotherapy and concurrent cisplatin (80 mg/m2 for two 21-day cycles). After CCRT, patients received camrelizumab maintenance for 12 cycles. The primary endpoint was 3-year disease-free survival (DFS) rate.

RESULTS

From February 2021 to September 2023, a total of 57 patients were included for analysis. The objective response rate was 92.8% after induction therapy and 100% after CCRT. With a median follow-up time of 21 months, the 3-year DFS rate was 84%. The 3-year locoregional recurrence-free survival, distant metastasis-free survival, and overall survival rates were 95.8%, 90.9%, and 89.5%, respectively. The most common grade 3 or 4 treatment-related adverse events were leukopenia and neutropenia during induction therapy, and weight loss and lymphopenia during CCRT.

CONCLUSIONS

Induction immunochemotherapy combined with CCRT shows promising antitumor activity with a manageable safety profile in patients with locoregionally advanced NPC from non-endemic areas, which deserves further validation.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04782765.

Efficacy and Safety of Combined PD-1 Inhibitor With Induction Chemotherapy Followed by IMRT Plus Nimotuzumab in Locally Advanced Nasopharyngeal Carcinoma: A Retrospective Analysis

Background

Induction chemotherapy (IC) is the standard treatment protocol for locally advanced nasopharyngeal carcinoma (LANPC), though concerns persist regarding high rates of recurrence and metastasis. This retrospective study aims to evaluate the efficacy, potential benefits, and safety of combining PD-1 inhibitors with IC, followed by nimotuzumab and intensity-modulated radiation therapy (IMRT).

Methodology

We analyzed data from 103 patients diagnosed with non-keratinizing LANPC (according to WHO criteria) at clinical stages III-IVA. These patients, treated from May 2020 to November 2023, received four cycles of IC combined with PD-1 inhibitors, followed by nimotuzumab and IMRT. Efficacy assessments were conducted according to RECIST v1.1 guidelines, with the primary endpoint being a clinical complete response (CCR), defined as the absence of detectable tumors or mucosal bulges upon nasoendoscopy.

Results

Among the evaluable patients, the CCR rate reached 66% (95% CI, 56-75%), while the objective response rate (ORR) was 97% (95% CI, 92-99%) and the disease control rate (DCR) reached 99% (95% CI, 95-100%). During the median follow-up of 16.1 months, neither the median progression-free survival (PFS) nor median overall survival (OS) was reached. Notably, patients with T4-stage disease exhibited lower CCR rates, highlighting stage-specific variations in treatment responses. The treatment regimen was well-tolerated, with no significant adverse safety events reported.

Conclusion

The combination of PD-1 inhibitors with IC, followed by nimotuzumab and IMRT, shows promising efficacy and safety in the treatment of LANPC.

Financial toxicity-related factors in patients with nasopharyngeal carfcinoma: a cross-sectional study

PURPOSE

This cross-sectional study aimed to investigate the incidence and related factors of financial toxicity among nasopharyngeal carcinoma (NPC) patients and propose strategies for improvement.

METHODS

Patients with nasopharyngeal carcinoma were recruited from December 2022 to June 2023 in Changsha, Hunan Province, China, using convenience sampling. A questionnaire survey focusing on financial toxicity among patients with nasopharyngeal carcinoma was conducted. The assessment tools used in this study include Comprehensive Scores for Financial Toxicity Based on the Patient-Reported Outcome Measures (COST-PROM), Medical Coping Modes Questionnaire (MCMQ), and Perceived Social Support Scale (PSSS).

RESULTS

A total of 155 patients with nasopharyngeal carcinoma were included in the study. The incidence of financial toxicity among participants was found to be 65.8%, with an average COST score of 22.45 ± 7.91. A significant negative correlation was shown between MCMQ scores and financial toxicity in patients (r = -0.235, p = 0.003), while a significant positive correlation was demonstrated between the PSSS scores and financial toxicity (r = 0274, p = 0.001). The multiple linear regression analysis showed that personal monthly income, MCMQ scores, and PSSS scores were related to financial toxicity in patients with nasopharyngeal carcinoma.

CONCLUSION

This study revealed a high prevalence of financial toxicity in patients with nasopharyngeal carcinoma. The medical staff needs to identify the financial toxicity early and adopt appropriate strategies to help patients with nasopharyngeal carcinoma return to work, guide them to choose positive medical coping modes, and access more excellent social support.

Nivolumab combined with induction chemotherapy and radiotherapy in nasopharyngeal carcinoma: A multicenter phase 2 PLATINUM trial

Severe toxicities caused by concurrent cisplatin are a critical problem in nasopharyngeal carcinoma (NPC) treatment. In this phase 2 multicenter PLATINUM trial (NCT03984357), we recruited 152 NPC patients who received 12-cycle nivolumab plus induction chemotherapy and radiotherapy without concurrent cisplatin. After a median follow-up of 43 months, the 3-year failure-free survival (FFS) was 88.5% (95% confidence interval [CI], 83.4%-93.8%) and the 3-year overall survival was 97.9%. An early clearance of Epstein-Barr virus (EBV) DNA after induction-phase treatment was associated with FFS benefit. Sixty (40.2%) and eight (5.2%) patients had acute and late grade 3-4 adverse events (AEs), respectively. Most patients had good tolerance to AE-associated frequency (68.0%-96.7%), severity (56.0%-98.6%), and interference (58.0%-98.0%); 86.7%-100.0% of quality-of-life domains showed either no clinically meaningful deterioration or a rapid recovery. Nivolumab plus induction chemotherapy and radiotherapy demonstrated efficacious anti-tumor activity, low toxicity, and favorable tolerability and quality-of-life for NPC patients.

Identification and validation of a prognostic risk model based on radiosensitivity-related genes in nasopharyngeal carcinoma

BACKGROUND

Despite advancements with intensity-modulated radiation therapy (IMRT), about 10 % of nasopharyngeal carcinoma (NPC) patients remain resistant to radiotherapy, leading to recurrence and poor prognosis. This study aims to identify radiosensitivity-related genes in NPC and develop a prognostic model to predict patient outcomes.

METHODS

We analyzed 179 NPC samples from Fujian Cancer Hospital using RNA sequencing. Differentially expressed genes (DEGs) were identified between radiotherapy-sensitive and resistant samples. Machine learning algorithms and Cox regression were used to construct a prognostic risk model, validated in the GSE102349 dataset. Additional analyses included functional pathway, immune infiltration, and drug sensitivity.

RESULTS

A risk model based on six genes (LCN8, IGSF1, RIMS2, RBP4, TBX10, ETV4) was developed. Kaplan-Meier analysis showed significantly shorter progression-free survival (PFS) in the high-risk group. The model's AUC values were 0.872, 0.807, and 0.802 for 1-year, 3-year, and 5-year predictions. A nomogram including clinical factors was created, and enrichment analysis linked the high-risk group to radiotherapy resistance mechanisms.

CONCLUSIONS

This study established a novel radiosensitivity-related prognostic model, offering insights into NPC prognosis and radiotherapy resistance mechanisms.

A multi-center, multi-organ, multi-omic prediction model for treatment-induced severe oral mucositis in nasopharyngeal carcinoma

PURPOSE

Oral mucositis (OM) is one of the most prevalent and crippling treatment-related toxicities experienced by nasopharyngeal carcinoma (NPC) patients receiving radiotherapy (RT), posing a tremendous adverse impact on quality of life. This multi-center study aimed to develop and externally validate a multi-omic prediction model for severe OM.

METHODS

Four hundred and sixty-four histologically confirmed NPC patients were retrospectively recruited from two public hospitals in Hong Kong. Model development was conducted on one institution (n = 363), and the other was reserved for external validation (n = 101). Severe OM was defined as the occurrence of CTCAE grade 3 or higher OM during RT. Two predictive models were constructed: 1) conventional clinical and DVH features and 2) a multi-omic approach including clinical, radiomic and dosiomic features.

RESULTS

The multi-omic model, consisting of chemotherapy status and radiomic and dosiomic features, outperformed the conventional model in internal and external validation, achieving AUC scores of 0.67 [95% CI: (0.61, 0.73)] and 0.65 [95% CI: (0.53, 0.77)], respectively, compared to the conventional model with 0.63 [95% CI: (0.56, 0.69)] and 0.56 [95% CI: (0.44, 0.67)], respectively. In multivariate analysis, only the multi-omic model signature was significantly correlated with severe OM in external validation (p = 0.017), demonstrating the independent predictive value of the multi-omic approach.

CONCLUSION

A multi-omic model with combined clinical, radiomic and dosiomic features achieved superior pre-treatment prediction of severe OM. Further exploration is warranted to facilitate improved clinical decision-making and enable more effective and personalized care for the prevention and management of OM in NPC patients.

Anti-programmed death-1 inhibitors and nimotuzumab in combination with induction chemotherapy for locoregionally advanced nasopharyngeal carcinoma: a propensity score-matched analysis

Background

The poor prognosis of locoregionally advanced nasopharyngeal carcinoma (LANPC) due to the high incidence of metastasis necessitates effective treatment strategies. Synergistic effects have been observed when anti-programmed death-1 (PD-1) inhibitors are combined with chemotherapy or targeted therapy.

Objectives

To compare the efficacy and safety of induction chemotherapy in combination with nimotuzumab with or without anti-PD-1 inhibitors for LANPC.

Design

Retrospective study.

Methods

In total, 319 patients with LANPC were retrospectively enrolled between December 2017 and November 2022. The primary endpoint was progression-free survival (PFS). Propensity score matching was performed to adjust for potential confounders.

Results

Overall, 150 patients were included after propensity score matching. The immunotherapy + nimotuzumab + chemotherapy (INC) group (n = 50) had a higher 3-year PFS rate (96.6% (95% confidence interval (CI): 93.2-100.0)) than the nimotuzumab + chemotherapy (NC) group (n = 100) (79.8% (95% CI: 75.6-84.0)). The INC group had a hazard ratio of 0.16 (95% CI: 0.02-1.22; p = 0.04). The objective response rates were 100% and 99% for the INC and NC groups, respectively. Grade ⩾3 treatment-related adverse events were reported in eight (5.3%) patients, and hyponatremia (2.0%) was the most common. Grade ⩾3 immune-related adverse events (rash and reactive capillary proliferation) were reported in two (4.0%) patients.

Conclusion

INC demonstrated remarkable anti-tumor activity with acceptable safety for LANPC.

Comparison of TPF and PF induction chemotherapy combined with cisplatin concurrent chemoradiotherapy for locoregionally advanced nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

The standard of care for locoregionally advanced nasopharyngeal carcinoma (LA-NPC) is induction chemotherapy (ICT) followed by concurrent chemoradiation (CCRT). However, the ideal ICT regimen for LA-NPC remains unclear. We conducted a meta-analysis to evaluate the survival outcomes, responses, and incidences of toxicities between taxane, cisplatin and fluorouracil (TPF) and cisplatin and fluorouracil (PF) ICT regimens plus CCRT in LA-NPC.

METHODS

A systematic review and meta-analysis of the literature was conducted to compare the efficacy and safety of TPF versus PF followed by CCRT with cisplatin every 3 weeks or weekly cisplatin and intensity-modulated radiotherapy in LA-NPC.

RESULTS

Three studies with 2482 patients met the inclusion criteria. ICT with the TPF regimen plus CCRT resulted in a significantly improved progression-free survival (hazard ratios [HR] 0.84 [95% CI 0.73-0.96], P = .01), overall survival (HR 0.83 [95% CI 0.71-0.97], P = .02), and 3-year locoregional recurrence-free survival (risk ratios [RR] 1.03 [95% CI 1.01-1.06], P = .009) compared with the PF regimen plus CCRT in LA-NPC. However, distant metastasis-free survival was not statistically significant (P = .07). The incidence of grade 3 or 4 neutropenia (RR 2.08 [95% CI 1.84-2.36]) and diarrhea (RR 1.94 [95% CI 1.07-3.52]) during ICT was higher in the TPF group than in the PF group.

CONCLUSIONS

In terms of progression-free survival, overall survival, locoregional recurrence-free survival, in the era of intensity-modulated radiotherapy, the TPF plus CCRT with cisplatin is superior to PF plus CCRT with cisplatin in LA-NPC. Thus, the TPF plus CCRT regimen appears to be a reasonable treatment option, and further confirmation by prospective studies is needed.

Retrospective analysis of 1539 nasopharyngeal carcinoma cases: chemotherapy should not be excluded for non-Asian patients with T1-2N1M0 stage

Background

Many results suggested that chemotherapy cannot provide survival benefit for stage II nasopharyngeal carcinoma. It remained unclear whether the efficacy of chemotherapy differed in non-Asian populations.

Objective

It was designed to analyze the effect of chemotherapy for Asian and non-Asian patients with stage II nasopharyngeal carcinoma.

Method

Patients were collected using the SEER program. The variables included age, sex, race, marital status, survival time, survival status, TNM stage, radiation and chemotherapy. Utilizing the Rstudio (version: 2024.4.1.748) and R (version: 4.4.1), backward elimination method was employed to screen the variables and multivariate Cox regression analyses was conducted on the screened variables. Kaplan-Meier method was utilized to analyze the survival of sub-stages and different races with T1-2N1M0 stage. The log-rank test was used for statistical analysis.

Result

1539 patients were collected. Chemotherapy was statistically significant, with a hazard ratio (HR) of 0.64, P=0.003 in stage II patients. The HR for radiation was 0.33, P<0.001. Chemotherapy didn't improve cancer-specific survival for patients with T2N0M0 stage. Asian and non-Asian races showed no difference in cancer-specific survival in T2N0M0 stage with HR of 1.85, P=0.13. For patients with T1-2N1M0 stage, chemotherapy improved cancer-specific survival with a HR of 0.53, P<0.001. No significant difference was in the Kaplan-Meier analysis between the two sub-stages (P=0.065). In T1-2N1M0 stage, multivariate Cox regression analysis for Asian race indicated that chemotherapy didn't improve cancer-specific survival with a HR of 0.64, P=0.190. For non-Asian race, chemotherapy was found to improve cancer-specific survival, with a HR of 0.51, P<0.001. The Kaplan-Meier analysis of Asian and non-Asian patients with T1-2N1M0 stage exhibited significant differences (P<0.0001).

Conclusion

Chemotherapy is correlated with the cancer-specific survival in non-Asian patients with T1-2N1M0-stage nasopharyngeal carcinoma, but not in Asian patients at the same stage. For patients with the T2N0M0 stage, chemotherapy is not correlated with the cancer-specific survival rate, regardless of ethnicity.

Study of PEG-rhG-CSF for the prevention of neutropenia in concurrent chemoradiotherapy for nasopharyngeal carcinoma

BACKGROUND

To study the efficacy and safety of Polyethylene glycolated recombinant human granulocyte colony-stimulating factor (PEG-rhG-CSF) in the prevention of neutropenia during concurrent chemoradiotherapy for nasopharyngeal carcinoma (NPC).

METHODS

This is a single-center, prospective, randomized controlled study conducted from June 1, 2021, to October 31, 2022 on patients diagnosed with locally advanced NPC. Participants were divided into an experimental group and a control group. The experimental group received PEG-rhG-CSF injections post-chemotherapy cycles, whereas the control group received standard care without additional intervention. Outcomes assessed included grade 3/4 neutropenia incidence, blood cell count changes, febrile neutropenia rates, delays or interruptions in chemotherapy/radiotherapy due to hematological toxicity, oral mucositis incidents, and bone pain occurrences, comparing these between both groups.

RESULTS

1. 88 patients with locally advanced NPC were included, the incidence of grade 3 neutropenia in the experimental group was lower than that in the control group (P = 0.026); 2. The white blood cell count and neutrophil count in D7, D10, D14, and D21 in the experimental group were higher than those in the control group (P<0.01); 3. The rate of delayed chemotherapy in the experimental group was lower than that in the control group (2.3% vs. 29.5%), P = 0.001; the rate of interruption of radiotherapy in the experimental group was lower than that in the control group (2.3% vs.27.3%), P = 0.003; 4. The incidence of bone pain in the experimental group was 34.1%, of which most were mild bone pain, and no severe bone pain occurred. The leukocyte and neutrophil counts of the patients in the bone pain group were significantly higher than those of the patients in the no bone pain group, P(WBC) = 0.001, P(ANC) = 0.002.

CONCLUSIONS

The preventive use of PEG-rhG-CSF decreases the incidence of neutropenia in patients undergoing concurrent chemoradiotherapy for NPC, thereby reducing rates of chemotherapy delays and radiotherapy interruptions, with mild adverse reactions that are tolerable by patients.

Combination therapy of low-dose radiotherapy and immunotherapy in advanced metastatic nasopharyngeal carcinoma: a case report and literature review

BACKGROUND

Nasopharyngeal cancer (NPC) is a common head and neck malignant tumor, which is difficult to treat at the advanced NPC due to its occult and high metastatic potential to the cervical lymph nodes and distant organs. Low-dose radiotherapy (LDRT) is increasingly being investigated for potential cancer treatment. When combined with immune checkpoint inhibitors, LDRT has been shown to significantly improve the immune microenvironment of tumors, thereby promote the immune attack on tumor cells. However, the therapeutic effect of LDRT combined with immunotherapy in advanced NPC is not well understood. We report a case of a 31-year-old man was diagnosed with advanced metastatic nasopharnygeal non-keratinizing carcinoma (T4N3M1 stage IVb AJCC8th). The patient was treated with a high-dose of radiation therapy combined with LDRT and immunotherapy to inhibit tumor cell proliferation and activate the body's immune system. The initial treatment procedure was as follows: chemotherapy regimen (nedaplatin + docetaxel + fluorouracil) induction, followed by radical radiotherapy for the primary lesion, LDRT for the L5 vertebral body metastasis, and concurrent use of low-dose capecitabine beat chemotherapy and toripalimab immunotherapy. The patient was also administered with human granulocyte-macrophage colony-stimulating factor and aspirin to enhance the immune function. This combination therapy approach alleviated patient symptoms, improved bone changes in the L5 vertebral body and resolved the tumor without any adverse effects signals. The progression-free survival (PFS) has reached 27 months and he is currently stable without tumor recurrence.

CONCLUSION

The combination of chemotherapy and LDRT with aspirin and human granulocyte macrophage colony-stimulating factor improved the disease state of advanced NPC cancer, effectively reducing the level of tumor markers, enhanced the immune function without significant adverse reactions.

Unveiling immune resistance mechanisms in nasopharyngeal carcinoma and emerging targets for antitumor immune response: tertiary lymphoid structures

Nasopharyngeal carcinoma (NPC) is a prevalent malignancy in China, commonly associated with undifferentiated cell types and Epstein-Barr virus (EBV) infection. The presence of intense lymphocytic infiltration and elevated expression of programmed cell death ligand 1(PD-L1) in NPC highlights its potential for immunotherapy, yet current treatment outcomes remain suboptimal. In this review, we explore the tumor microenvironment of NPC to better understand the mechanisms of resistance to immunotherapy, evaluate current therapeutic strategies, and pinpoint emerging targets, such as tertiary lymphoid structures (TLSs), that could enhance treatment outcomes and prognostic accuracy. TLSs have demonstrated positive prognostic value in NPC, making them a promising target for future therapies. This review summarizes the key characteristics of TLSs and latest research in the context of NPC. We are optimistic that targeting TLSs could improve immunotherapy outcomes for NPC patients, ultimately leading to more effective treatment strategies and better patient survival.

Thyroid Dysfunction After Intensity-Modulated Radiotherapy and PD⁃1 Inhibitor Treatment for Locally Advanced Nasopharyngeal Carcinoma

Purpose

Analyze the incidence and risk factors of thyroid dysfunction in patients with advanced nasopharyngeal carcinoma (LA-NPC) after intensity-modulated radiotherapy (IMRT) and PD⁃1 inhibitor treatment and their relationship with treatment efficacy and prognosis.

Methods

Eighty-five LA-NPC patients treated with IMRT and PD-1 inhibitors were retrospectively collected from March 1, 2019, to May 30, 2022. The incidence of thyroid dysfunction after combination therapy was analyzed. The Kaplan-Meier method was used to analyze the relationship between thyroid dysfunction and patient prognosis. Logistic regression analysis was used to screen independent risk factors for thyroid dysfunction.

Results

As of data cutoff (May 31, 2024), the median follow-up time was 27.8 months (range: 25.6 to 32.0 months). The median time of onset of thyroid dysfunction was 8.26 months. The incidence of thyroid dysfunction is 47.06% (40/85), with clinical hypothyroidism being the main cause at an incidence rate of 28.24% (24/85) and clinical hyperthyroidism at an incidence rate of 3.53% (3/85). The incidence of grade 1 thyroid immune-related adverse events (irAEs) was 29.41% (25/85), and the incidence of grade 2 thyroid irAEs was 17.65% (15/85). Patients with thyroid dysfunction had longer overall survival, progression-free survival, and distant metastasis-free survival at both one and two years compared to patients with normal thyroid function, but the difference was not statistically significant (p > 0.05). Multivariate logistic regression analysis showed that pretreatment lactate dehydrogenase (LDH) (p = 0.079) is an independent predictor of thyroid dysfunction after radiotherapy in combination with immunotherapy for LA-NPC.

Conclusion

The study found that the addition of immunotherapy increases the risk and shortens the onset time of thyroid dysfunction in LA-NPC patients treated with chemoradiotherapy. Pretreatment LDH may serve as an independent risk factor for thyroid dysfunction for LA-NPC patients.

Machine learning-derived prognostic signature for progression-free survival in non-metastatic nasopharyngeal carcinoma

BACKGROUND

Early detection of high-risk nasopharyngeal carcinoma (NPC) recurrence is essential. We created a machine learning-derived prognostic signature (MLDPS) by combining three machine learning (ML) models to predict progression-free survival (PFS) in patients with non-metastatic NPC.

METHODS

A cohort of 653 patients with non-metastatic NPC was divided into a training (n = 457) and validation (n = 196) dataset (7:3 ratio). The study included clinicopathological characteristics, hematologic markers, and MRI findings in three machine learning models-random forest (RF), extreme gradient boosting (XGBoost), and least absolute shrinkage and selection operator (LASSO)-to predict progression-free survival (PFS). A Venn diagram identified the overlapping signatures from the three ML algorithms. Cox proportional hazard analysis determined the MLDPS for PFS.

RESULTS

The RF, XGBoost, and LASSO algorithms identified six consensus factors from the 33 signatures. Cox proportional hazards analysis showed that the MLDPS includes age, lymphocyte count, number of positive lymph nodes, and regional lymph node density. Additionally, MLDPS effectively stratified prognosis, with low-risk individuals showing better PFS than high-risk individuals (p < 0.001).

CONCLUSION

MLDPS, based on clinicopathological characteristics, hematologic markers, and MRI findings, is crucial for guiding clinical management and personalizing treatments for patients with non-metastatic NPC.

Optimizing Radiotherapy Timing for Nasopharyngeal Carcinoma: The Impact of Radiation Scheduling on Survival

PURPOSE

Chronoradiobiology has emerged as a potential field of study with therapeutic implications for cancer treatment. We aimed to investigate the association between radiation chronotherapy and the efficacy and toxicity of patients with nasopharyngeal carcinoma (NPC).

PATIENTS AND METHODS

Patients with nonmetastatic NPC treated with intensity-modulated radiotherapy in Fujian Cancer Hospital between January 2017 and December 2019 were included. Propensity score matching (PSM) with 1:1:1 was used to account for selection bias. Cox regression analysis was performed to explore the impact of radiotherapy timing on patient survival. Sensitivity analysis was implemented to determine the size and directional stability.

RESULTS

One thousand forty patients met study inclusion criteria and 332 patients were included in a PSM cohort. In the unmatched cohort analysis, morning radiotherapy exhibited a significantly superior overall survival (OS) outcome (hazard ratio [HR], 0.60 [95% CI, 0.40 to 0.91], adjusted log-rank P = .028) than the afternoon one. After PSM analysis, it was observed that individuals undergoing radiotherapy in the afternoon group (HR, 5.88 [95% CI, 2.55 to 13.58], adjusted log-rank P = .004) and the night group (HR, 4.81 [95% CI, 1.91 to 12.11], adjusted log-rank P = .018) displayed a tendency toward shorter OS compared with the morning group. No significant differences in acute treatment-related adverse effects were observed among the three groups. Morning radiotherapy demonstrated consistent robustness in the multivariable analysis, thereby establishing an association with higher OS. The directionality of the effect size was consistent across sensitivity analysis.

CONCLUSION

These results underscore the potential benefits of scheduling radiotherapy in the morning for NPC management, although prospective studies are needed to confirm these findings.

Dosimetric comparison and evaluation of different convergence modes in nasopharyngeal carcinoma using VMAT treatment deliveries

Background

This study investigates the impact of convergence mode (CM) in Eclipse (Varian Medical Systems) on the quality and complexity of volumetric modulated arc therapy (VMAT) plans for nasopharyngeal carcinoma (NPC) patients.

Methods

We retrospectively analyzed data from 21 NPC patients. For each patient, three VMAT plans with different CM settings (Off, On, and Extended) were created using identical optimization objectives. Plan quality was assessed using indices such as the conformity index (CI) and homogeneity index (HI), as well as evaluating target coverage and sparing of organs at risk (OARs). Complexity was measured by metrics including average leaf pair opening (ALPO), modulation complexity scores for VMAT (MCSv), monitor units (MUs), and optimization time. Dosimetric verification was performed based on the gamma pass rate.

Results

Different CM settings can generate treatment plans that meet clinical dose objectives for planning target volumes (PTVs) and OARs. The 'On' or 'Extended' CM settings improved CI and HI for the NPC target volume and reduced OAR doses, especially the mean dose, without compromising target coverage. The 'Extended' CM setting produced the most favorable outcomes. ALPO values for CM settings 'Off', 'On', and 'Extended' were 29.1 ± 4.3 mm, 28.6 ± 4.2 mm, and 28.4 ± 4. 2 mm, respectively. MCSv values for these settings were 0.1730 ± 0.0215, 0.1691 ± 0.0204, and 0.1693 ± 0.0208, respectively. MUs were 796.2 ± 110.8 for CM 'Off', 798.6 ± 106.1 for CM 'On', and 799.7 ± 103.6 for CM 'Extended', with no significant differences (p > 0.05). Gamma pass rates for all plans were above 99% (3%/3 and 2%/2 mm), with no significant differences among groups (p > 0.05). The average optimization times for CM settings 'Off', 'On', and 'Extended' were 14.4 ± 3.2, 35.9 ± 8.9, and 145.6 ± 50.3 min, respectively (p < 0.001).

Conclusion

CM usage can improve the CI and HI of the target volume and decrease the dose to OARs in VMAT plans for NPC patients. This study suggests that CM can be a valuable tool in VMAT planning for nasopharyngeal carcinoma, given adequate planning time.

Evaluating the Efficacy of Different Treatment Intensities in Nasopharyngeal Carcinoma Patients: A Nationwide Cancer Registry-Based Study

OBJECTIVE

The aim of this study was to evaluate the efficacy of different treatment intensities (TIs) in patients with nasopharyngeal carcinoma (NPC).

METHODS

The study assessed newly diagnosed, non-metastatic NPC patients from the Taiwan Cancer Registry between 2010 and 2017. TIs were divided into four groups: TI1 [radiotherapy (RT) alone or induction chemotherapy (IC) followed by RT); TI2 (concurrent chemoradiotherapy (CRT) alone); TI3 (IC followed by CRT or CRT followed by adjuvant chemotherapy (AC)]; and TI4 (IC followed by CRT followed by AC). The primary outcome was cancer-specific survival (CSS).

RESULTS

The study included 9863 patients. For stage I-II NPC patients, there was no significant difference in CSS among the different TI groups. For stage III patients, those receiving TI3 had better CSS (hazard ratio [HR] 0.69) compared with those receiving TI1. No significant differences in CSS were noted among those receiving TI2, TI3, and TI4. For stage IVA-B patients, those receiving TI2 (HR 0.70), TI3 (HR 0.49), and TI4 (HR 0.43) had better CSS compared with those receiving TI1. Compared with stage IVA-B patients receiving TI2, those receiving TI3 (HR 0.70) and TI4 (HR 0.61) had significantly better CSS. No differences in CSS were noted between those receiving TI3 and TI4.

CONCLUSIONS

For stage I-II NPC patients, RT alone is appropriate. For stage III and IVA-B patients, IC + CRT or CRT + AC may be needed to achieve optimal outcomes. No advantage of IC + CRT + AC over IC + CRT or CRT + AC was observed.

Relationship between changes in nutritional status during treatment and overall survival of newly diagnosed nasopharyngeal carcinoma patients

PURPOSE

This study investigates the relationship between changes in nutritional status during treatment and overall survival in NPC patients.

METHOD

Using a prospective cohort design, the electronic health records of newly diagnosed NPC patients from a medical center in Taiwan (from January 1, 2018, to March 31, 2024) were analyzed. A total of 73 newly diagnosed NPC patients were tracked; nutritional indicators such as body mass index (BMI), prealbumin levels, and Patient-Generated Subjective Global Assessment (PG-SGA) scores were recorded at four time points: one week before treatment, the first week of treatment, and four and eight weeks after treatment began.

RESULTS

The study found that most patients experienced a decrease in BMI (B = -0.62, p < .001) and prealbumin levels (B = -0.79, p = .015) during treatment, although BMI remained in the overweight range and prealbumin stayed within normal levels. PG-SGA scores increased (B = 1.01, p < .001), indicating a shift from low to moderate nutritional risk. Univariate Cox regression analysis showed that the Charlson Comorbidity Index (HR = 1.86, 95% CI: 1.38-2.51), NPC stage (HR = 15.67, 95% CI: 2.07-118.61), treatment method (HR = 2.96, 95% CI: 1.45-6.04), prealbumin (HR = 2.95, 95% CI: 1.46-5.99), and PG-SGA score trajectories (HR = 2.85, 95% CI: 1.27-6.40) were associated with overall survival. However, multivariate analysis revealed that the survival of NPC patients was only associated with CCI and NPC stage.

CONCLUSIONS

The study underscores the importance of monitoring nutritional status changes during treatment, particularly prealbumin and PG-SGA trajectories.

Analysis of patients with parotid recurrence after parotid-sparing IMRT for nasopharyngeal carcinoma: case series and review of the literature

PURPOSE

Intensity-modulated radiotherapy (IMRT) is the standard treatment approach for nasopharyngeal cancer (NPC). IMRT enables effective sparing of the parotid glands and reduces the risk of xerostomia, a common complication of head and neck irradiation. Nevertheless, it is essential to determine whether the parotid-sparing IMRT (ps-IMRT) technique yields increased intra-/periparotid recurrence rates, which constitutes the main purpose of this study.

METHODS

Patients with a diagnosis of NPC that received definitive chemoradiotherapy/radiotherapy (CRT/RT) between 1991 and 2021 were evaluated retrospectively. Patients with intra-/periparotid recurrence were detected and prognostic factors for recurrence were sought.

RESULTS

A total of 746 patients were evaluated. Two-dimensional (2D)-RT was applied to 541, 3D conformal RT (3D-CRT) to 10, and ps-IMRT to 195 patients. After a median 85-month follow-up, one (0.18%) patient who received 2D-RT and four (2%) patients who received ps-IMRT experienced an intra-/periparotid recurrence. The median time to intra-/periparotid recurrence was 11.9 months. All patients had been diagnosed with a metastatic lymph node > 2 cm at level II of the ipsilateral neck. In addition, all recurrences occurred on the same side as the positive neck at the time of diagnosis. The 3‑year overall survival, locoregional recurrence-free survival, and distant metastasis-free survival rates were 80%, 40%, and 60%, respectively.

CONCLUSION

Intra-/periparotid recurrence is extremely rare in NPC. However, it is still possible to identify and characterize particular risk factors, which include a metastatic lymph node at level II, particularly > 2 cm, and multinodal disease at the time of diagnosis.

Guiding induction chemotherapy of locoregionally advanced nasopharyngeal carcinoma with ternary classification of predicted individual treatment effect

BACKGROUND AND PURPOSE

Induction chemotherapy (IC) before concurrent chemoradiotherapy does not universally improve long-term overall survival (OS) in locoregionally advanced nasopharyngeal carcinoma (LANPC). Conventional risk stratification often yields suboptimal IC decisions. Our study introduces a ternary classification of predicted individual treatment effect (PITE) to guide personalized IC decisions.

MATERIALS AND METHODS

A two-center retrospective analysis of 1,213 patients with LANPC was conducted to develop and validate prognostic models integrating magnetic resonance imaging and clinical data to estimate individual 5-year OS probabilities for IC and non-IC treatments. Differences in these probabilities defined PITE, facilitating patient stratification into three IC recommendation categories. Model effectiveness was validated using Kaplan-Meier estimators, decision curve-like analysis, and evaluations of variable importance and distribution.

RESULTS

The models exhibited strong predictive performance in both treatments across training and cross-validation sets, enabling accurate PITE calculations and patient classification. Compared with non-IC treatment, IC markedly improved OS in the IC-preferred group (HR = 0.62, p = 0.02), had no effect in the IC-neutral group (HR = 1.00, p = 0.70), and worsened OS in the IC-opposed group (HR = 2.00, p = 0.03). The ternary PITE classification effectively identified 41.7 % of high-risk patients not benefiting from IC, and yielded a 2.68 % higher mean 5-year OS probability over risk-based decisions. Significantly increasing distributions of key prognostic indicators, such as metastatic lymph node number and plasma Epstein-Barr virus DNA level from IC-opposed to IC-preferred groups, further validated the clinical relevance of PITE classification.

CONCLUSION

The ternary PITE classification offers an accurate and clinically advantageous approach to guide personalized IC decision-making in patients with LANPC.

CircKRT75 augments the cisplatin chemoresistance of nasopharyngeal carcinoma via targeting miR-659/CCAR2 axis

Cisplatin resistance is a clinical challenge limiting the treatment of nasopharyngeal carcinoma (NPC). CircRNAs have been evidenced as key molecules involved in tumor advancement and drug resistance. The present study aimed to elucidate the potential biological value of circKRT75 in NPC cisplatin resistance. CircKRT75 levels in NPC clinical samples and parental/resistant cell lines were analyzed based on qRT-PCR. CCK-8 and flow cytometry were adopted to assess the impacts of circKRT75 on the growth viability and apoptotic ability of NPC resistant cells. Meanwhile, western blot was performed to detect changes in the expression of apoptosis-related proteins. Bioinformatics analysis predicted miRNAs and mRNAs downstream of circKRT75, and the interaction between circKRT75 and downstream targets was validated by RNA pull-down, dual-luciferase reporter and rescue experiments. CircKRT75 was notably enhanced in NPC tissues and NPC cisplatin-resistant cells. Functional experiments disclosed that circKRT75 silencing repressed NPC-resistant cell growth and promoted apoptosis. Bioinformatics screening identified that circKRT75 performed as a molecular sponge for miR-659, and CCAR2 was a direct target of miR-659. Further rescue assays confirmed that miR-659 inhibitor restored the inhibitory effect of circKRT75 knockdown on the growth of drug-resistant cells, while CCAR2 silencing could reverse the promotion of NPC cisplatin resistance by circKRT75 upregulation. Additionally, animal experiments revealed that circKRT75 knockdown restrained NPC cisplatin resistance in vivo. CircKRT75 contributed to cisplatin resistance in NPC through miR-659/CCAR2 signaling, which provided a novel perspective and direction to solve the problem of chemoresistance in NPC.

The Prognostic Significance of CD47, CD68, and CD163 Expression Levels and Their Relationship with MLR and MAR in Locally Advanced and Oligometastatic Nasopharyngeal Carcinoma

BACKGROUND

This study aimed to assess the prognostic and predictive implications of CD47, CD68, and CD163, biomarkers of tumor-associated macrophages (TAMs), on the treatment efficacy and clinical outcomes of nasopharyngeal carcinoma (NPC). Additionally, the prognostic value of TAM-related indices, such as the monocyte-to-lymphocyte ratio (MLR) and monocyte-to-albumin ratio (MAR), was evaluated.

METHODS

A retrospective cohort of 54 patients with locally advanced or oligometastatic NPC treated with concurrent chemoradiotherapy (CCRT), with or without induction chemotherapy, was analyzed. Patients were categorized based on the cumulative expression scores for CD47, CD68, and CD163: negative/low (0-3 points) and high (4-6 points). MLR and MAR were also stratified as low MLR (<0.545) vs. high MLR (≥0.545) and low MAR (<16.145) vs. high MAR (≥16.145). The primary endpoint was overall survival (OS).

RESULTS

High CD47, CD68, and CD163 expression levels were correlated with advanced clinical stage, reduced CCRT response, and elevated MLR and MAR. These TAM biomarkers were linearly correlated with each other and with established risk factors such as advanced age and elevated EBV-DNA levels. Kaplan-Meier analysis revealed that patients with low TAM expression had significantly longer OS and progression-free survival (PFS) than those with high TAM expression. Multivariate analysis identified high CD163, MLR, and MAR levels as independent adverse prognostic factors for OS. Elevated MLR is an independent risk factor for both OS and PFS in patients with NPC.

CONCLUSIONS

CD47, CD68, and CD163 are significant prognostic markers in NPC, with higher levels being associated with poorer OS and PFS. Elevated MLR and MAR values also predict worse outcomes, underscoring their value as prognostic tools. CD163 and MLR are particularly strong predictors, highlighting the crucial role of TAMs in NPC management and suggesting that CD163 is a potential therapeutic target within the immune checkpoint pathway.

Efficacy and safety of immune checkpoint inhibitors in the treatment of recurrent or metastatic nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

The combination of immune checkpoint inhibitors and chemotherapy (ICI + Chemo) shows promise in recurrent or metastatic nasopharyngeal carcinoma (RM-NPC), but some patients experience limited benefit and survival predictors remain unclear. Furthermore, ICIs efficacy in subsequent treatments needs further evaluation.

METHODS

A systematic search of PubMed, Embase, the Cochrane Library, and major conference proceedings was conducted to identify studies for meta-analysis. The objective was to compare ICI + Chemo with chemotherapy in first-line treatment and identify efficacy predictors, and to evaluate ICIs alone in subsequent-line treatment for RM-NPC, with a focus on progression-free survival (PFS), objective response rate (ORR), and treatment-related adverse events (AEs).

RESULTS

Fifteen trials involving 1928 patients were included. Three trials compared ICI + Chemo with chemotherapy as a first-line treatment, while 12 trials evaluated ICIs alone in subsequent-line treatment of RM-NPC patients. First-line ICI + Chemo showed superior PFS (hazard ratio [HR] = 0.52, 95% confidence interval [CI], 0.43-0.63; P <0.001) and ORR (risk ratio [RR] = 1.14, 95% CI, 1.05-1.24; P <0.001) compared to chemotherapy, without increased AEs (RR = 1.01, 95% CI, 0.99-1.03; P  = 0.481). Neither programmed death-ligand 1 (PD-L1) nor other factors predicted the efficacy of ICI + Chemo vs . chemotherapy. Subsequent-line ICIs alone had a median PFS of 4.12 months (95% CI, 2.93-5.31 months), an ORR of 24% (95% CI, 20-28%), with grade 1-5/grade 3-5 AEs at 79%/14%. However, ICIs alone were associated with significantly shorter PFS (HR = 1.31, 95% CI, 1.01-1.68; P  = 0.040) than chemotherapy alone.

CONCLUSIONS

ICI + Chemo confers superior survival benefits compared to chemotherapy in first-line RM-NPC treatment, independent of PD-L1 expression or other factors. However, ICIs alone demonstrate a manageable safety profile but do not surpass chemotherapy in efficacy for subsequent-line treatment.

Induction plus concurrent chemoradiotherapy versus concurrent chemoradiotherapy in elderly patients with locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

The effectiveness and safety of induction chemotherapy (IC) followed by concurrent chemoradiotherapy (CCRT) in elderly patients with locoregionally advanced nasopharyngeal carcinomas (LANPCs) remain subjects of debate. This study evaluated the efficacy of IC+CCRT compared to CCRT alone in elderly LANPC patients.

MATERIALS AND METHODS

This retrospective, single-center study analyzed 335 elderly patients diagnosed with stage III or IVa NPC who received CCRT with or without IC between 2010 and 2016. Kaplan-Meier analysis and log-rank tests were used to estimate and compare survival rates. Multivariate analysis using Cox proportional hazards regression model was conducted to assess prognostic risk factors. Toxicities were compared using the χ2 test.

RESULTS

The median follow-up duration was 69.3 months (interquartile range: 42.7-72.6). Baseline clinical characteristics were well-balanced between groups. No significant differences were observed between IC+CCRT and CCRT for any survival-related endpoints, including overall survival (hazard ratio [HR] = 1.26, 95 % confidence interval [CI]: 0.89-1.77, p = 0.188), locoregional relapse-free survival (HR=1.03, 95 % CI: 0.56-1.91, p = 0.913), distant metastasis-free survival (HR=1.39, 95 % CI: 0.90-2.16, p = 0.139), and failure-free survival (HR = 1.25, 95 % CI: 0.85-1.83, p = 0.255). However, the incidence and severity of acute and late toxicities were significantly higher in the IC+CCRT group compared to the CCRT group.

CONCLUSION

In elderly LANPC patients, the addition of IC to CCRT did not improve survival outcomes, but was associated with significant toxicities.

Dosimetric Evaluation of Hippocampus Sparing Intensity Modulated Radiation Therapy in Patients With Stage T1-T2 and Stage T3-T4 Nasopharyngeal Carcinoma

Purpose

To compare the hippocampus (HPC) dose reduced by HPC-sparing intensity modulated radiation therapy (IMRT) plans between nasopharyngeal carcinoma (NPC) patients of stages T1-T2 and T3-T4, and to investigate the correlation between the dose of the HPC and the volume of PTVnx70 (the planning target volume of the primary tumor in the nasopharynx that received 70 Gy).

Methods and Materials

Fifty-eight NPC patients were retrospectively evaluated. HPC-nonsparing IMRT or sparing IMRT for each patient was designed according to the protocol for NPC. Dose-volume histogram was used to evaluate the IMRT plans for each patient. The difference in values of HPC parameters (eg, Dmin[NS] - Dmin[S]) between HPC-sparing and nonsparing plans in the stage T1-T2 group and stage T3-T4 group were compared. The correlations between the dose of the HPC and the volume of PTVnx70 were analyzed.

Results

There was no significance between HPC-sparing and nonsparing IMRT plans. Compared with the HPC-nonsparing plans, the HPC-sparing plans significantly decreased both dosimetric and volumetric parameters for the HPC (P < .05), except for Dmin, D98%, and V5. The medians of Dmedian[NS] - Dmedian[S], Dmean[NS] - Dmean[S], D40%[NS] - D40%[S], V30[NS] - V30[S], V40[NS] - V40[S] and V50[NS] - V50[S] in the T1-T2 group were significantly lower than in the T3-T4 group (P < .05), respectively. Both dosimetric and volumetric parameters for the HPC were positively correlated with the volume of PTVnx70 in HPC-sparing and HPC-nonsparing plans (P < .05). The volume of PTVnx70 was positively correlated with Dmedian[NS] - Dmedian[S], Dmean[NS] - Dmean[S], D40%[NS] - D40%[S], V40[NS] - V40[S] and V50[NS] - V50[S] (P < .05).

Conclusions

HPC-sparing IMRT plans may play a more significant role in decreasing Dmedian, Dmean, D40%, and V30-V50 of HPC in NPC patients with stages T3-T4 than those in stages T1-T2. PTVnx70 volume of NPC patients is positively correlated with all dosimetric and volumetric parameters of HPC and the reduction of specific dosage parameters by HPC-sparing IMRT plans.

A phase 2 trial of gemcitabine plus toripalimab for cisplatin-ineligible patients with recurrent or metastatic nasopharyngeal carcinoma

Cisplatin is a cornerstone chemotherapy for nasopharyngeal carcinoma (NPC); however, certain patients are ineligible for cisplatin-based regimens. This phase 2 trial (NCT04405622) evaluated the efficacy and safety of gemcitabine and toripalimab in previously untreated patients with recurrent or metastatic NPC who were either ineligible for cisplatin or had experienced severe adverse events from prior cisplatin-based treatments. Patients received gemcitabine (1,000 mg/m2) and toripalimab (240 mg) every three weeks for six cycles, followed by toripalimab monotherapy for up to two years. The primary endpoint was the incidence of grade ≥3 adverse events, while secondary endpoints included objective response rate (ORR) and overall survival (OS). Of 30 screened patients, 21 were enrolled. No treatment-related fatalities occurred, with the most frequent adverse events being headache and nausea. The ORR was 61.9%, coupled with a disease control rate of 100%. Overall, gemcitabine plus toripalimab demonstrated low toxicity and promising efficacy for this specific patient cohort.

Ninth Version of the AJCC and UICC Nasopharyngeal Cancer TNM Staging Classification

Importance

Accurate staging is a fundamental step in treating patients with nasopharyngeal carcinoma (NPC) worldwide; this is crucial not only for prognostication, but also for guiding treatment decisions. The American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) tumor-node-metastasis (TNM) system is the global language for clinicians, researchers, and cancer registries. Continual improvement that aligns with contemporary pattern of care is essential.

Objective

To improve the prognostic accuracy and clinical applicability of the eighth edition (TNM-8) for NPC.

Design, Setting, and Participants

This multicenter study analyzed patients with NPC with detailed tumor features during January 2014 and December 2015 and was reviewed by experienced radiologists. The data analysis was completed in December 2023. The findings were further confirmed with internal and external validation. Statistical analyses and clinical considerations were reviewed by the AJCC/UICC multidisciplinary head and neck panels and attained consensus. The recommendations were evaluated by the AJCC Evidence-Based Medicine Committee before final endorsement as the ninth version (TNM-9).

Main Outcomes and Measures

The primary end point was overall survival. Adjusted hazard ratios of different subgroups were then assessed for confirmation of optimal stage grouping.

Results

Of the 4914 patients analyzed, 1264 (25.7%) were female and 3650 (74.3%) were male; the median (SD) age was 48.1 (12.0) years. Advanced radiological extranodal extension (with involvement of adjacent muscles, skin, and/or neurovascular bundles) was identified as an independent adverse factor for all end points: this was added as a criterion for N3. Patients with nonmetastatic disease were regrouped into stages I to III instead of TNM-8 stages I to IVA. Significant hazard discrimination was achieved by grouping T1-2N0-1 as stage I, T3/N2 as stage II, and T4/N3 as stage III. Although the T1-2N0-1 subgroups had comparable 5-year overall survival, subdivisions into IA (T1-T2N0) and IB (T1-T2N1) were recommended due to the distinction in adjusted hazard ratios following adjustment for chemotherapy use. Metastatic disease was exclusively classified as stage IV, and prognostication was further refined by subdivision into IVA (M1a, ≤3 lesions) and IVB (M1b, >3 lesions). TNM-9 demonstrated superiority compared with TNM-8 in major statistical aspects.

Conclusion and Relevance

The results of this diagnostic study suggest that the ninth version of TNM staging for NPC, based on robust analyses and a comprehensive review by the AJCC/UICC staging committees, provides an improved staging system for global application and a framework for future incorporation of nonanatomical factors. This will be launched for global application in January 2025.

Individualised cumulative cisplatin dose for locoregionally advanced nasopharyngeal carcinoma patients based on induction chemotherapy response and tumour volume

Background and objectives

To evaluate the prognostic value of an integrated model consisting of tumour response to induction chemotherapy (IC) and gross tumour volume (GTV) after IC in nasopharyngeal carcinoma (NPC) and elucidate optimal cumulative cisplatin dose (CCD) in concurrent chemoradiotherapy (CCRT) for different subgroups.

Design and methods

This retrospective study enrolled 896 patients with NPC diagnosed from 2010 to 2017 receiving IC plus radiotherapy. The primary endpoint was disease-free survival (DFS). Cut-off points for GTV were combined with IC response to develop an integrated model. Propensity score matching (PSM) was used to adjust for potential confounders. Survival outcomes and acute toxicity were compared between the different CCD groups.

Results

Unsatisfactory IC response and large GTV after IC were correlated with poor survival outcomes; the AUC increased to 0.668 when these factors were incorporated. The integrated model classified patients into three groups. After PSM, radiotherapy alone and CCRT demonstrated similar efficacy in the low-risk group (complete response (CR)/partial response (PR) and GTV <68 cm3 after IC). In the intermediate-risk group (CR/PR but GTV ⩾68 cm3), CCD of >200 mg/m2 and 101-200 mg/m2 increased the 5-year DFS rates (83.7% vs 81.1% vs 65.3%, p = 0.042). In the high-risk group (stable disease/progressive disease and any GTV), the use of different CCDs did not result in significantly different survival outcomes (p = 0.793). Additionally, high CCD was significantly associated with increased incidence of grade 1-4 acute toxicity.

Conclusion

The integrated model incorporating IC response and GTV after IC demonstrates satisfactory value in risk stratification and the potential to guide individualised decision-making in CCD selection. Balancing toxicity and efficacy, RT alone seems to be the optimal treatment for patients in low-risk groups and 200 mg/m2 might be the optimal dose for intermediate-risk groups. Moreover, increasing CCD does not benefit patients in high-risk groups, and treatment options for these patients require further consideration.

Development and validation of a nomogram to predicting the efficacy of PD-1/PD-L1 inhibitors in patients with nasopharyngeal carcinoma

PURPOSE

With the treatment of nasopharyngeal carcinoma (NPC) by PD-1/PD-L1 inhibitors used widely in clinic, it becomes very necessary to anticipate whether patients would benefit from it. We aimed to develop a nomogram to evaluate the efficacy of anti-PD-1/PD-L1 in NPC patients.

METHODS

Totally 160 NPC patients were enrolled in the study. Patients were measured before the first PD-1/PD-L1 inhibitors treatment and after 8-12 weeks of immunotherapy by radiological examinations to estimate the effect. The least absolute shrinkage and selection operator (LASSO) logistic regression was used to screen hematological markers and establish a predictive model. The nomogram was internally validated by bootstrap resampling and externally validated. Performance of the model was evaluated using concordance index, calibration curve, decision curve analysis and receiver operation characteristic curve.

RESULTS

Patients involved were randomly split into training cohort ang validation cohort. Based on Lasso logistic regression, systemic immune-inflammation index (SII) and ALT to AST ratio (LSR) were selected to establish a predictive model. The C-index of training cohort and validating cohort was 0.745 and 0.760. The calibration curves and decision curves showed the precise predictive ability of this nomogram. The benefit of the model showed in decision curve was better than TNM stage. The area under the curve (AUC) value of training cohort and validation cohort was 0.745 and 0.878, respectively.

CONCLUSION

The predictive model helped evaluating efficacy with high accuracy in NPC patients treated with PD-1/PD-L1 inhibitors.

Optimal cut-off value for identifying objective response in patients with nasopharyngeal carcinoma after induction chemotherapy

BACKGROUND

We aimed to establish the most suitable threshold for objective response (OR) in the Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 in patients with nasopharyngeal carcinoma (NPC).

METHODS

According to RECIST 1.1, we retrospectively evaluated MR images of NPC lesions in patients before and after induction chemotherapy (IC). Restricted cubic spline and maximally selected rank statistics were used to determine the cut-off value. Survival rates and differences between groups were compared with Kaplan-Meier curves and log-rank tests.

RESULTS

Of 1126 patients, 365 cases who received IC treatment were suitable for RECIST 1.1 evaluation. The 20% cut-off value maximized between-group differences according to maximally selected rank statistics. No difference in distant metastasis-free survival between OR and non-response groups was shown using the primary threshold of OR (30%), while it differed when 20% was employed.

CONCLUSIONS

With an optimal cut-off value of 20%, RECIST may assist clinicians to accurately evaluate disease response in NPC patients.

Metronomic S-1 Adjuvant Chemotherapy Improves Survival in Patients with Locoregionally Advanced Nasopharyngeal Carcinoma

PURPOSE

This study aimed to investigate the efficacy and safety of using metronomic S-1 adjuvant chemotherapy in locoregionally advanced nasopharyngeal carcinoma (LANPC).

MATERIALS AND METHODS

We retrospectively collected data on patients diagnosed with LANPC between January 2016 and December 2021. All patients were treated with induction chemotherapy and concurrent chemoradiotherapy with or without metronomic chemotherapy (MC). Toxicities during MC were recorded. The chi-square test, Kaplan-Meier methods, propensity score matching (PSM), and Cox proportional hazards model were used for statistical analyses.

RESULTS

A total of 474 patients were identified, including 64 (13.5%) and 410 (83.5%) patients with or without receiving MC, respectively. Patients who received metronomic S-1 had significantly better 3-year locoregional recurrence-free survival (LRFS) (100% vs. 90.9%, p=0.038), distant metastasis-free survival (DMFS) (98.5% vs. 84.1%, p=0.002), disease-free survival (DFS) (98.4% vs. 77.5%, p < 0.001), and overall survival (OS) (98.0% vs. 87.7%, p=0.008) compared to those without metronomic S-1. The multivariate prognostic analysis revealed that metronomic S-1 was identified as an independent prognostic factor associated with better DMFS (hazard ratio [HR], 0.074; p=0.010), DFS (HR, 0.103; p=0.002) and OS (HR, 0.127; p=0.042), but not in LRFS (p=0.071). Similar results were found using PSM. Common adverse events observed in the metronomic S-1 group included leukopenia, neutropenia, increased total bilirubin, anorexia, rash/desquamation, and hyperpigmentation. All patients with adverse events were grade 1-2.

CONCLUSION

It is worth conducting a randomized controlled trial to assess the effect of metronomic S-1 on survival outcomes and toxicities of LANPC.

Optimizing Hearing Outcomes in Nasopharyngeal Cancer Survivors in the Era of Modern Radiotherapy and Systemic Therapy

Intensity-modulated radiation therapy (IMRT) improves disease control and reduces treatment-related toxicity in patients with localized nasopharyngeal carcinoma (NPC). However, due to the proximity of the auditory apparatus to the treatment volume and the frequent incorporation of cisplatin-based chemotherapy, treatment-related sensorineural hearing loss (SNHL) remains a common debilitating complication among NPC survivors. The reported crude incidence of SNHL following IMRT for NPC varies widely at 1-46% due to differences in auditory assessment methods and thresholds, follow-up durations, chemotherapy usage, and patient compositions. International guidelines and radiation dosimetric studies have recommended constraining the cochlear mean dose to less than 44-50 Gy, but the risk of SNHL remains high despite adherence to these constraints. Potential strategies to improve hearing outcomes in NPC survivors include cautious de-escalation of radiotherapy dose and volume, individualization of cochlear constraints, optimization of radiotherapy planning techniques, and the use of substitutes or alternative schedules for cisplatin-based chemotherapy. The addition of immune checkpoint inhibitors to chemoradiotherapy did not impact ototoxicity. Prospective studies that employ both objective and patient-reported auditory outcomes are warranted to test the long-term benefits of various approaches. This article aims to provide a comprehensive review of the incidence and radiation dose-toxicity relationship of SNHL in NPC survivors and to summarize potential strategies to optimize hearing outcomes in relation to nuances in radiotherapy planning and the selection of systemic therapy.

Gemcitabine/Cisplatin versus docetaxel, cisplatin and 5-fluorouracil as induction chemotherapy in locally advanced nasopharyngeal carcinoma

Induction chemotherapy followed by concomitant chemoradiation is the standard therapy for patients with locoregionally advanced NPC. There is a limitation of clinical studies that compare different induction regimens. The purpose of this work is to analyze the efficacy of two distinct chemotherapy regimens, docetaxel, cisplatin, and 5-fluorouracil (TPF) and gemcitabine/cisplatin (GP), in treating patients with loco-regionally advanced nasopharyngeal carcinoma (NPC). We analyzed 81 patients initially presented with stage III-IVA NPC from January 2019 to June 2023. Participants were randomized in 1:1 ratio to obtain GP regimen or TPF regimen followed by concurrent CRT. The overall response rate was 97.5% after induction chemotherapy in both groups (In GP arm, 78% of patients achieved complete remission compared to 70% of patients treated with TPF regimen). The satisfactory tumor response to induction chemotherapy was linked with significant enhanced progression free survival [CI (3.37-13.92), HR=2.16, P=0.001] and overall survival [CI (3.717-9.443), HR=1.873, P=0.001]. The GP regimen was both efficacious and well-tolerated. Leucopenia and neutropenia (Grade 3-4) were significantly lower in GP group contrasted to in TPF group. There was no significant difference in the 3-year DFS and OS between GP and TPF protocols.