Different prognostic values of plasma Epstein-Barr virus DNA and maximal standardized uptake value of 18F-FDG PET/CT for nasopharyngeal carcinoma patients with recurrence

Prognostic value of primary tumor and lymph node volumetric metabolic parameters at pre-treatment F-18 FDG PET/CT in nasopharyngeal carcinoma

BACKGROUND

The aim of this study was to evaluate the prognostic significance of volumetric metabolic parameters of pre-treatment PET/CT along with clinical characteristics in patients with non-metastatic nasopharyngeal carcinoma.

MATERIAL AND METHODS

Seventy-nine patients with nasopharyngeal carcinoma underwent F18- FDG PET/CT for pretreatment evaluation and included in this study. The patient features (patient age, tumor histopathology, T and N stage, size of primary tumor and the largest cervical lymph node) and PET parameters were analyzed: maximum, mean and peak standardized uptake values (SUVmax, SUVmean, SUVpeak), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) for primary tumor and largest cervical lymph node. After treatment, patients were evaluated for disease progression and mortality. Survival analysis for progression-free survival (PFS) and over-all survival (OS) was performed with Kaplan-Meier method using PET findings and clinical characteristics.

RESULTS

The median follow-up duration was 29.7 months (range 3-125 months). Among clinical characteristics, no parameters had significance association for PFS. Primary tumor-MTV and cervical lymph node-MTV were independent prognostic factors for PFS (p = 0.025 and p = 0.004, respectively).Patients with primary tumor-MTV >19.4 and patients with lymph node-MTV>3.4 had shorter PFS. For OS, age and the size of the lymph node were independent prognostic factor (p = 0.031 and p = 0.029).Patients with age over 54 years and patients with lymph node size >1 cm were associated with decreased OS.

CONCLUSION

Primary tumor-MTV and lymph node-MTV on pre-treatment PET/CT are significant prognostic factors for long-term PFS in non-metastatic nasopharyngeal carcinoma. We consider that measuring MTV as volume-based metabolic parameter on pretreatment PET/CT may contribute decision of treatment intensity and individualized risk stratification and may improve long-term PFS. Additionally, age and the size of lymph node are independent prognostic factors for mortality.

Radiomics-clinical nomogram based on pretreatment 18F-FDG PET-CT radiomics features for individualized prediction of local failure in nasopharyngeal carcinoma

To explore the prognostic significance of PET/CT-based radiomics signatures and clinical features for local recurrence-free survival (LRFS) in nasopharyngeal carcinoma (NPC). We retrospectively reviewed 726 patients who underwent pretreatment PET/CT at our center. Least absolute shrinkage and selection operator (LASSO) regression and the Cox proportional hazards model were applied to construct Rad-score, which represented the radiomics features of PET-CT images. Univariate and multivariate analyses were used to establish a nomogram model. The concordance index (C-index) and calibration curve were used to evaluate the predictive accuracy and discriminative ability. Receiver operating characteristic analysis was performed to stratify the local recurrence risk of patients. The nomogram was validated by evaluating its discrimination ability and calibration in the validation cohort. A total of eight features were selected to construct Rad-score. A radiomics-clinical nomogram was built after the selection of univariate and multivariable Cox regression analyses, including the Rad-score and maximum standardized uptake value (SUVmax). The C-index was 0.71 (0.67-0.74) in the training cohort and 0.70 (0.64-0.76) in the validation cohort. The nomogram also performed far better than the 8th T-staging system with an area under the receiver operating characteristic curve (AUC) of 0.75 vs. 0.60 for 2 years and 0.71 vs. 0.60 for 3 years. The calibration curves show that the nomogram indicated accurate predictions. Decision curve analysis (DCA) revealed significantly better net benefits with this nomogram model. The log-rank test results revealed a distinct difference in prognosis between the two risk groups. The PET/CT-based radiomics nomogram showed good performance in predicting LRFS and showed potential to identify patients at high-risk of developing NPC.

The value of intravoxel incoherent motion model-based diffusion-weighted imaging for predicting long-term outcomes in nasopharyngeal carcinoma

Objective

The aim of this study was to evaluate the prognostic value for survival of parameters derived from intravoxel incoherent motion diffusion-weighted imaging (IVIM-DWI) in patients with nasopharyngeal carcinoma (NPC).

Materials

Baseline IVIM-DWI was performed on 97 newly diagnosed NPC patients in this prospective study. The relationships between the pretreatment IVIM-DWI parametric values (apparent diffusion coefficient (ADC), D, D*, and f) of the primary tumors and the patients’ 3-year survival were analyzed in 97 NPC patients who received chemoradiotherapy. The cutoff values of IVIM parameters for local relapse-free survival (LRFS) were identified by a non-parametric log-rank test. The local-regional relapse-free survival (LRRFS), LRFS, regional relapse-free survival (RRFS), distant metastasis-free survival (DMFS), progression-free survival (PFS), and overall survival (OS) rates were calculated by using the Kaplan–Meier method. A Cox proportional hazards model was used to explore the independent predictors for prognosis.

Results

There were 97 participants (mean age, 48.4 ± 10.5 years; 65 men) analyzed. Non-parametric log-rank test results showed that the optimal cutoff values of ADC, D, D*, and f were 0.897 × 10−3 mm2/s, 0.699 × 10−3 mm2/s, 8.71 × 10−3 mm2/s, and 0.198%, respectively. According to the univariable analysis, the higher ADC group demonstrated significantly higher OS rates than the low ADC group (p = 0.036), the higher D group showed significantly higher LRFS and OS rates than the low D group (p = 0.028 and p = 0.017, respectively), and the higher D* group exhibited significantly higher LRFS and OS rates than the lower D* group (p = 0.001 and p = 0.002, respectively). Multivariable analyses indicated that ADC and D were the independent prognostic factors for LRFS (p = 0.041 and p = 0.037, respectively), D was an independent prognostic factor for LRRFS (p = 0.045), D* and f were the independent prognostic factors for OS (p = 0.019 and 0.029, respectively), and f acted was an independent prognostic factor for DMFS (p = 0.020).

Conclusions

Baseline IVIM-DWI perfusion parameters ADC and D, together with diffusion parameter D*, could act as useful factors for predicting long-term outcomes and selecting high-risk patients with NPC.

Maintenance therapy improves the survival outcomes of patients with metastatic nasopharyngeal carcinoma responding to first-line chemotherapy: a multicentre, randomized controlled clinical study

PURPOSE

To explore the safety and role of tegafur/gimeracil/oteracil (S1) maintenance therapy (MT) in metastatic nasopharyngeal carcinoma (NPC) patients after response to first-line chemotherapy and to assess outcome-associated biomarkers.

METHODS

This was a multicentre, open-label, randomized controlled study involving metastatic NPC patients recruited (from May 2015 to May 2019) at five hospitals in China. The participants were randomized to S1-MT (receiving S1 MT until disease progression or intolerance) or non-MT (followed up until disease progression) groups. The primary endpoint was the progression-free survival (PFS). The secondary endpoints were the overall survival (OS), the correlation between EBV-DNA, serum amyloid A (SAA) status, and outcomes after the first-line chemotherapy, and safety.

RESULTS

The median follow-up was 24.3 months; 88 and 95 participants were evaluable in the S1-MT and non-MT groups, respectively. Compared with non-MT, S1-MT prolonged PFS (16.9 vs. 9.3 months, P < 0.001) and OS (33.6 vs. 20.6 months, P < 0.001). Regardless of their EBV-DNA status after first-line chemotherapy, participants were able to benefit from S1 MT, but EBV-DNA-positive participants benefited more significantly (PFS: HR = 0.600, 95% CI = 0.373-0.965, P = 0.035; OS: HR = 0.393, 95% CI = 0.227-0.681, P = 0.001). MT only improved PFS and OS in patients with an SAA decline after first-line chemotherapy (PFS: HR = 0.570, 95% CI = 0.350-0.919, P = 0.021; OS: HR = 0.404, 95% CI = 0.230-0.709, P = 0.002). The median S1 treatment was 23 cycles. Grade 1-2 skin pigmentation, oral mucositis, and hand and foot syndrome were the main adverse reactions.

CONCLUSION

For metastatic NPC patients with first-line chemotherapy response, S1 MT can improve PFS and OS, with good tolerability. EBV-DNA and SAA can better help us identify patients who can benefit from MT after standard treatment.

TRIAL REGISTRATION

The study protocol was registered at the Chinese Clinical Trial Registry (ChiCTR-IOR-16007939).

Association of Epstein-Barr virus DNA and SAA with S1 maintenance therapy outcomes in patients with metastatic nasopharyngeal carcinoma

Objectives: The relevant biomarkers in predicting maintenance therapy (MT) outcomes in metastatic nasopharyngeal carcinoma (NPC) are yet unclear. Patients & methods: Metastatic NPC patients were randomly divided into MT (S1-MT) and non-MT groups. The association of Epstein-Barr virus DNA (EBV-DNA) and SAA with survival was assessed. Results: A total of 183 patients were included. S1-MT significantly increased the progression-free survival (PFS) and overall survival (OS) of the metastatic NPC patients (both p < 0.001). For patients who were EBV-DNA positive or had decreased SAA, the PFS and OS increased significantly after S1-MT (both p < 0.001), while patients with stable SAA did not benefit from S1-MT. Conclusion: S1-MT improved the PFS and OS of metastatic NPC patients. EBV-DNA and SAA status were closely associated with the outcomes of S1-MT. Clinical trial registration number: ChiCTR-IOR-16007939.

Design of InnoPrimers-Duplex Real-Time PCR for Detection and Treatment Response Prediction of EBV-Associated Nasopharyngeal Carcinoma Circulating Genetic Biomarker

Nasopharyngeal carcinoma (NPC) is an epithelial tumor with high prevalence in southern China and Southeast Asia. NPC is well associated with the Epstein-Barr virus (EBV) latent membrane protein 1 (LMP1) 30 bp deletion by having its vital role in increased tumorigenicity and decreased immune recognition of EBV-related tumors. This study developed an InnoPrimers-duplex qPCR for detection of NPC blood circulating LMP1 30 bp deletion genetic biomarker for early diagnosis and treatment response prediction of NPC patients. The analytical and diagnostic evaluation and treatment response prediction were conducted using NPC patients’ whole blood (WB) and tissue samples and non-NPC cancer patients and healthy individuals’ WB samples. The assay was able to detect as low as 20 ag DNA per reaction (equivalent to 173 copies) with high specificity against broad reference microorganisms and archive NPC biopsy tissue and FNA samples. The diagnostic sensitivity and specificity were 83.3% and 100%, respectively. The 30 bp deletion genetic biomarker was found to be a good prognostic biomarker associated with overall clinical outcome of NPC WHO type III patients. This sensitive and specific assay can help clinicians in early diagnosis and treatment response prediction of NPC patients, which will enhance treatment outcome and lead to better life-saving.

Prognostic Factors for Overall Survival in Nasopharyngeal Cancer and Implication for TNM Staging by UICC: A Systematic Review of the Literature

This study aims to identify prognostic factors in nasopharyngeal carcinoma (NPC) to improve the current 8th edition TNM classification. A systematic review of the literature reported between 2013 and 2019 in PubMed, Embase, and Scopus was conducted. Studies were included if (1) original clinical studies, (2) ≥50 NPC patients, and (3) analyses on the association between prognostic factors and overall survival. The data elements of eligible studies were abstracted and analyzed. A level of evidence was synthesized for each suggested change to the TNM staging and prognostic factors. Of 5,595 studies screened, 108 studies (44 studies on anatomical criteria and 64 on non-anatomical factors) were selected. Proposed changes/factors with strong evidence included the upstaging paranasal sinus to T4, defining parotid lymph node as N3, upstaging N-category based on presence of lymph node necrosis, as well as the incorporation of non-TNM factors including EBV-DNA level, primary gross tumor volume (GTV), nodal GTV, neutrophil-lymphocyte ratio, lactate dehydrogenase, C-reactive protein/albumin ratio, platelet count, SUVmax of the primary tumor, and total lesion glycolysis. This systematic review provides a useful summary of suggestions and prognostic factors that potentially improve the current staging system. Further validation studies are warranted to confirm their significance.

Epstein–Barr Virus (EBV) Viral Load in Tumor Cells Did Not Predict Tumor Extensiveness in Nasopharyngeal Cancer

Background: Nasopharyngeal cancer is commonly associated with Epstein–Barr virus (EBV) infection, especially undifferentiated non-keratinized histology. EBV DNA quantification through nasopharyngeal brushing was previously reported to be not related to disease stage. This study aimed to reinvestigate the relationship of EBV viral load in tumor tissue with tumor extensiveness by more accurate EBV DNA quantification through microscopically confirmed tumor cells from nasopharyngeal biopsy. Method: The specimens for EBV DNA quantification were derived from histopathology slides which were pre-treated following the QIAsymphony® SP protocol for tissue DNA extraction. Then, the extracted DNA underwent real-time polymerase chain reaction (RT-PCR) using the artus® EBV RG PCR Kit for EBV DNA quantification. The tumor volume was determined by delineating the gross tumor based on 3D imaging of the patient’s nasopharynx. Result: Twenty-four subjects were included in this study. All subjects were stage III and above, with more males (75%) than females. EBV viral load in tumor cells was found to have no correlation to tumor volume both in local and nodal regions. The median local tumor volume was 81.3 cm3 ± 80 cm3. The median EBV viral load in tumor cells was 95,644.8 ± 224,758.4 copies/100 ng of DNA. The median nodal or regional tumor volume was 35.7 ± 73.63 cm3. Conclusion: EBV viral load from tumor cells from nasopharyngeal biopsy has no relationship with tumor extensiveness in nasopharyngeal cancer. The presence and amount of EBV in tumor cells did not translate into larger or smaller tumors. The EBV viral proteins and RNAs were perhaps more likely to confer some prognostic information due to the fact that those molecules were related to carcinogenesis.

Initial evaluation of (4S)-4-(3-[18F]fluoropropyl)-L-glutamate (FSPG) PET/CT imaging in patients with head and neck cancer, colorectal cancer, or non-Hodgkin lymphoma

Purpose

(4S)-4-(3-[¹⁸F]Fluoropropyl)-l-glutamic acid ([¹⁸F]FSPG) measures system x_C⁻ transporter activity and shows promise for oncologic imaging. We present data on tumor uptake of this radiopharmaceutical in human subjects with head and neck cancer (HNC), colorectal cancer (CRC), and non-Hodgkin lymphoma (NHL).

Methods

A total of 15 subjects with HNC (n = 5), CRC (n = 5), or NHL (n = 5) were recruited (mean age 66.2 years, range 44–87 years). 301.4 ± 28.1 MBq (8.1 ± 0.8 mCi) of [¹⁸F]FSPG was given intravenously to each subject, and 3 PET/CT scans were obtained 0–2 h post-injection. All subjects also had a positive [¹⁸F]FDG PET/CT scan within 1 month prior to the [¹⁸F]FSPG PET scan. Semi-quantitative and visual comparisons of the [¹⁸F]FSPG and [¹⁸F]FDG scans were performed.

Results

[¹⁸F]FSPG showed strong uptake in all but one HNC subject. The lack of surrounding brain uptake facilitated tumor delineation in the HNC patients. [¹⁸F]FSPG also showed tumor uptake in all CRC subjects, but variable uptake in the NHL subjects. While the absolute [¹⁸F]FDG SUV values were comparable or higher than [¹⁸F]FSPG, the tumor-to-background SUV ratios were greater with [¹⁸F]FSPG than [¹⁸F]FDG.

Conclusions

[¹⁸F]FSPG PET/CT showed promising results across 15 subjects with 3 different cancer types. Concordant visualization was mostly observed between [¹⁸F]FSPG and [¹⁸F]FDG PET/CT images, with some inter- and intra-individual uptake variability potentially reflecting differences in tumor biology. The tumor-to-background ratios were greater with [¹⁸F]FSPG than [¹⁸F]FDG in the cancer types evaluated. Future studies based on larger numbers of subjects and those with a wider array of primary and recurrent or metastatic tumors are planned to further evaluate the utility of this novel tracer.

Effects of oral maintenance chemotherapy and predictive value of circulating EBV DNA in metastatic nasopharyngeal carcinoma

Background/Objectives

Oral maintenance chemotherapy can effectively prolong overall survival (OS) in many types of metastatic cancer, but its role in metastatic nasopharyngeal carcinoma (mNPC) is unclear. In this study, the efficacy of oral maintenance chemotherapy in mNPC and the effectiveness of circulating tumor EBV‐DNA for screening patients were evaluated.

Methods

Between June 2016 and December 2017, 141 patients with mNPC who received platinum‐based systemic chemotherapy were included (median follow‐up time, 21 months). Patients were classified into two groups according to the administration of oral maintenance chemotherapy. Plasma samples were collected before, during, and after treatment for the measurement of circulating EBV DNA.

Results

The 2‐year OS was higher for patients who received maintenance chemotherapy than for patients without maintenance chemotherapy (78.9% vs 62.7%, P = .016). Patients with undetectable posttreatment EBV‐DNA after 4‐6 cycles of systemic chemotherapy (n = 73) had a higher 2‐year OS than that of patients with detectable EBV‐DNA (n = 68) (82.16% vs 51.45%, P = .001). For patients with undetectable posttreatment EBV‐DNA, OS was better for those with maintenance chemotherapy than for those without (86.7% vs 73%, P = .027). For patients with detectable posttreatment EBV‐DNA, maintenance chemotherapy did not improve outcomes (49.5% vs 55.4%, P = .824). The most common acute events were hematological toxicity, and all were tolerable and curable.

Conclusions

Oral maintenance chemotherapy with S1 or capecitabine can improve OS in mNPC. Posttreatment EBV‐DNA was not only an independent prognosis factor for mNPC but also can screen out beneficiaries of maintenance chemotherapy.

Metabolic tumor volume predicts overall survival in patients with primary pulmonary lymphoepithelioma-like carcinoma

Pretreatment tumor metabolic burden, measured using fluorine-18 fluorodeoxyglucose positron emission tomography/computerized tomography (¹⁸F-FDG PET/CT), has been demonstrated to predict outcomes in various types of malignancies. Additionally, Epstein-Barr virus (EBV) serum titer is associated with stages of pulmonary lymphoepithelioma-like carcinoma (LELC). The present study aimed to investigate the prognostic value of the functional parameters of ¹⁸F-FDG PET/CT in pulmonary LELC and their association with serum EBV DNA. The present retrospective study analyzed data from 71 patients with pulmonary LELC; among these, 32 patients with pulmonary LELC underwent pretreatment ¹⁸F-FDG PET/CT staging between January 2008 and December 2016. EBV viral load and functional parameters of ¹⁸F-FDG PET/CT were used for survival analysis. Multivariate analysis identified tumor stage IV as a significant predictor of poor progression-free survival [hazard ratio (HR), 4.85; P=0.049], whereas elevated total metabolic tumor volume (MTV ≥72.6 ml) independently predicted worse overall survival (OS; HR, 12.59; P=0.024). Pretreatment serum EBV DNA titer was significantly positively associated with total MTV (P=0.0337) and total lesion glycolysis (TLG; P=0.0093), but could not predict outcomes. Total MTV was an independent predictor of OS, and may guide clinical management for pulmonary LELC.

Clinical value of a plasma Epstein-Barr virus DNA assay in the diagnosis of recurrent or metastatic nasopharyngeal carcinoma: a meta-analysis

BACKGROUND

To evaluate the diagnostic value of Epstein-Barr virus (EBV) DNA in nasopharyngeal carcinoma (NPC) patients with locoregional or distant recurrence.

METHODS

Articles related to the diagnosis of recurrent or metastatic NPC by the detection of EBV DNA in plasma or serum were retrieved from different databases. Sensitivity, specificity, summary receiver operating characteristic (SROC) curves, and likelihood ratios were pooled to assess the diagnostic value of individual diagnostic tests.

RESULTS

This meta-analysis pooled 25 eligible studies including 2496 patients with NPC. The sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR) of EBV DNA in the diagnosis of NPC were 0.858 (95% confidence interval (CI): 0.801-0.901), 0.890 (95% CI: 0.866-0.909), 7.782 (95% CI: 6.423-9.429) and 0.159 (95% CI: 0.112-0.226), respectively. The diagnostic odds ratio (DOR) was 48.865 (95% CI: 31.903-74.845). The SROC for EBV DNA detection was 0.93 (95% CI: 0.90-0.95).

CONCLUSION

The detection of EBV DNA for the diagnosis of recurrent or metastatic NPC has good sensitivity and specificity and might be helpful in monitoring recurrent or metastatic NPC.

Primary pulmonary lymphoepithelioma-like carcinoma in non-endemic region: A case report and literature review

RATIONALE

Pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare type of lung squamous cell carcinoma. In situ hybridization test for Epstein-Bar virus-encoded RNA (EBER) is generally used for distinguishing it from other lung cancers. Although plasma EBV DNA quantification has been widely used as a tumor biomarker in nasopharyngeal carcinoma (NPC), only a limiting number of studies have suggested that plasma EBV DNA quantification may be used as a tumor marker in pulmonary LELC patients.

PATIENT CONCERNS

We report two female patients diagnosed as poorly differentiated squamous cell carcinoma, subsequently, their further histological examinations showed that tumor cells were EBER positive and plasma EBV DNA was detectable.

DIAGNOSES

Two patients was diagnosed with advanced pulmonary LELC.

INTERVENTIONS

The patients were treated with chemotherapy and chemoradiotherapy respectively.

OUTCOMES

Both patients responded well to our treatment, in accordance with their decreased EBV DNA level.

LESSONS

Pulmonary LELC is a rare type of lung cancer which is sensitive to chemoradiotherapy, especially in late staged patients.

Significant value of 18F-FDG-PET/CT in diagnosing small cervical lymph node metastases in patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy

BACKGROUND

Little is known about the nature of metastasis to small cervical lymph nodes (SCLNs) in the patients with nasopharyngeal carcinoma (NPC) examined by using 18-fluoro-2-deoxy-glucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT). The present study aimed to evaluate the diagnostic values of PET/CT in identifying metastasis in SCLNs in NPC patients.

METHODS

Magnetic resonance images (MRI) and PET/CT scans for 470 patients with newly diagnosed, non-distant metastatic NPC were analyzed. Metastatic rates of SCLNs were defined by the positive number of SCLNs on PET/CT scans and total number of SCLNs on MRI scans. Receiver operating characteristic curve was applied to compare PET/CT-determined stage with MRI-determined stage.

RESULTS

In total, 2082 SCLNs were identified, with 808 (38.8%) ≥ 5 and < 6 mm in diameter (group A), 526 (25.3%) ≥ 6 and < 7 mm in diameter (group B), 374 (18.0%) ≥ 7 and < 8 mm in diameter (group C), 237 (11.4%) ≥ 8 and < 9 mm in diameter (group D), and 137 (6.5%) ≥ 9 and < 10 mm in diameter (group E). The overall metastatic rates examined by using PET/CT for groups A, B, C, D, and E were 3.5%, 8.0%, 31.3%, 60.0%, and 83.9%, respectively (P < 0.001). In level IV/Vb, the metastatic rate for nodes ≥ 8 mm was 84.6%. PET/CT examination resulted in modification of N category and overall stage for 135 (28.7%) and 46 (9.8%) patients, respectively. The areas under curve of MRI-determined and PET/CT-determined overall stage were 0.659 and 0.704 for predicting overall survival, 0.661 and 0.711 for predicting distant metastasis-free survival, and 0.636 and 0.663 for predicting disease-free survival.

CONCLUSIONS

PET/CT was more effective than MRI in identifying metastatic SCLNs, and the radiologic diagnostic criteria for metastatic lymph nodes in level IV/Vb should be re-defined.

Prognostic value of plasma Epstein-Barr virus DNA level during posttreatment follow-up in the patients with nasopharyngeal carcinoma having undergone intensity-modulated radiotherapy

Background

The value of Epstein–Barr virus (EBV) DNA assay during posttreatment follow-up of the patients with nasopharyngeal carcinoma (NPC) presenting with different pretreatment plasma EBV DNA levels remains unclear. In the present study, we aimed to evaluate the prognostic value of plasma EBV DNA assay during posttreatment follow-up in the patients with NPC who have undergone intensity-modulated radiotherapy.

Methods

The medical records of 385 NPC patients treated with intensity-modulated radiotherapy between November 2009 and February 2012 were reviewed. All patients underwent plasma EBV DNA assays before treatment, within 3 months after treatment, and then every 3–12 months during posttreatment follow-up period. The recurrence rates for patients with different pretreatment and posttreatment follow-up plasma EBV DNA levels were analyzed.

Results

Of the 385 patients, 267 (69.4%) had detectable pretreatment plasma EBV DNA (> 0 copy/mL) and 93 (24.2%) had detectable posttreatment EBV DNA during a median follow-up of 52.8 months (range 9.3–73.8 months). Detectable EBV DNA during posttreatment follow-up was found in 14.4% (17/118) and 28.5% (76/267) of patients with undetectable and detectable pretreatment EBV DNA, respectively, and was significantly associated with tumor recurrence in both patient groups. EBV DNA was detectable in 12.8% (40/313) of patients who remained disease-free, 56.4% (22/39) of patients with locoregional recurrence alone, and 93.9% (31/33) of patients with distant metastasis as the first recurrence event (P < 0.001); 6.5% (19/292) of patients with undetectable EBV DNA and 57.0% (53/93) of patient with detectable EBV DNA during posttreatment follow-up experienced tumor recurrence. Compared with other cut-off values, the cut-off value of 0 copy/mL for EBV DNA during posttreatment follow-up had the highest area under the ROC curve (AUC) value (0.804, 95% confidence interval 0.741–0.868) for predicting tumor recurrence (sensitivity, specificity, and accuracy: 73.6%, 87.2%, and 84.7%, respectively).

Conclusion

Plasma EBV DNA level during posttreatment follow-up is a good marker for predicting distant metastasis but not locoregional recurrence in the patients with NPC irrespective of the pretreatment EBV DNA levels.

Clinical outcomes of residual or recurrent nasopharyngeal carcinoma treated with endoscopic nasopharyngectomy plus chemoradiotherapy or with chemoradiotherapy alone: a retrospective study

BACKGROUND

Local residual and recurrent nasopharyngeal carcinoma (NPC) generally shows treatment failure after standard radiotherapy with or without concurrent chemotherapy. Whether endoscopic nasopharyngectomy might provide an additional therapeutic advantage remains controversial. Therefore, we retrospectively compared the clinical prognoses of patients with residual or recurrent NPC treated with endoscopic nasopharyngectomy combined with chemoradiotherapy (CRT) with those of patients treated with CRT alone.

METHODS AND MATERIALS

A total of sixty-two patients with local residual or recurrent NPC were studied retrospectively: 36 patients received endoscopic nasopharyngectomy combined with CRT, whereas 26 patients who refused the surgery or had surgical contraindications received CRT alone. Serum Epstein-Barr virus (EBV) DNA levels were measured pre- and post-treatment. The differences in prognosis between the two treatment regimens and the pre- and post-treatment changes in EBV-DNA levels were analyzed.

RESULTS

The median follow-up time was 31 months, with a 3-year overall survival (OS) of 51.40% and a 3-year disease-free survival (DFS) of 46.86%. The surgery + CRT group had a better OS than the CRT alone group did (χ² = 4.054, P = 0.044). The pretreatment EBV-DNA levels showed a positive correlation with the clinical staging of recurrent NPC (χ² = 11.674, P = 0.009). Patients with negative pretreatment serum EBV-DNA levels showed a superior OS to those of patients who tested positive for EBV-DNA (>0 copy/mL) (χ² = 9.833, P = 0.002). The post-treatment EBV-DNA levels, compared with the pretreatment levels, decreased significantly in the surgery + CRT group (Z =  - 3.484, P = 0.000). In contrast, the EBV-DNA levels after CRT alone did not decrease significantly (Z =  - 1.956, P = 0.051). Multivariate analysis indicated that local staging, pretreatment EBV-DNA load, and the treatment method were independent risk factors for OS. Subgroup analysis indicated that the patients who tested negative for EBV-DNA before the treatment and those who received surgery + CRT showed a better OS than those who received CRT alone.

CONCLUSIONS

The pretreatment serum EBV-DNA level was associated with disease prognosis. The combination therapy preceded by surgery can effectively decrease the copy number of EBV-DNA. Patients with local intermediate- and late-stage NPC, especially those negative for EBV-DNA, may consider opting for surgery followed by post-operative adjuvant radiotherapy or chemotherapy.

Prognostic value of maximum standard uptake value, metabolic tumor volume, and total lesion glycolysis of positron emission tomography/computed tomography in patients with nasopharyngeal carcinoma: A systematic review and meta-analysis

BACKGROUND

The maximal standard uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of positron emission tomography/computed tomography (PET/CT) in patients with nasopharyngeal carcinoma (NPC) perform as new prognostic factors, but the outcomes of the published articles were inconclusive. In this meta-analysis, we evaluated the prognostic value of SUVmax, MTV, and TLG of PET/CT in patients with NPC.

METHODS

Relevant English articles were searched in PubMed and EMBASE. The data of patients and the survival outcomes were extracted. Pooled hazard ratios (HRs) were accounted to assess the prognostic value of the SUVmax, MTV, and TLG.

RESULTS

This meta-analysis combined 10 primary studies including 941 patients with NPC. The combined HRs (95% confidence interval [CI] of higher SUVmax, higher MTV, and higher TLG for event-free survival were 2.33 (95% CI, 1.39-3.91, P = .001), 2.51 (95% CI, 1.61-3.91, P < .0001), and 2.74 (95% CI, 1.91-3.93, P < .00001), respectively. Regarding overall survival, the combined HRs were 2.50 (95%CI, 1.65-3.78, P < .0001) with higher SUVmax, 3.30 (95% CI, 1.92-5.69, P < .0001) with higher MTV and 3.18 (95% CI, 1.70-5.96, P = .0003) with higher TLG.

CONCLUSION

SUVmax, MTV, and TLG were significant prognostic predictors in patients with NPC. And the results suggested that higher SUVmax, MTV, and TLG were associated with worse prognosis.

Prognostic value of 18F-FDG-PET/CT in patients with nasopharyngeal carcinoma: a systematic review and meta-analysis

BACKGROUND

The prognostic role of 18F-fluorodeoxyglucose positron emission tomography CT (18F-FDG PET/CT) parameters is still controversial in nasopharyngeal carcinoma patients. We sought to perform a systematic review and meta-analysis to explore the prognostic value of maximal standardized uptake value (SUVmax), metabolic tumor volume (MTV) and total lesion glycolysis (TLG) on event-free survival (EFS) and overall survival (OS) in nasopharyngeal carcinoma patients.

RESULTS

Fifteen studies comprising 1,938 patients were included in this study. The combined hazard ratios (HRs) for EFS were 2.63 (95%CI 1.71-4.05) for SUVmax, 2.55 (95%CI 1.49-4.35) for MTV, and 3.32 (95%CI 1.23-8.95) for TLG. The pooled HRs for OS were 2.07 (95%CI 1.54-2.79) for SUVmax, 3.86 (95%CI 1.85-8.06) for MTV, and 2.60 (95%CI 1.55-4.34) for TLG. The prognostic role of SUVmax, MTV and TLG remained similar in the sub-group analyses.

METHODS

A systematic literature search was performed to identify studies which associated 18F-FDG PET/CT to clinical survival outcomes of nasopharyngeal carcinoma patients. The summarized HRs for EFS and OS were estimated by using fixed- or random-effect models according to heterogeneity between trials.

CONCLUSIONS

The present meta-analysis confirms that high values of SUVmax, MTV and TLG predicted a higher risk of adverse events or death in patients with nasopharyngeal carcinoma, despite clinically heterogeneous nasopharyngeal carcinoma patients and the various methods adopted between these studies.

Designing an effective vaccine to prevent Epstein-Barr virus-associated diseases: challenges and opportunities

INTRODUCTION

Epstein-Barr virus (EBV) is a ubiquitous herpesvirus associated with a number of clinical manifestations. Primary EBV infection in young adolescents often manifests as acute infectious mononucleosis and latent infection is associated with multiple lymphoid and epithelial cancers and autoimmune disorders, particularly multiple sclerosis. Areas covered: Over the last decade, our understanding of pathogenesis and immune regulation of EBV-associated diseases has provided an important platform for the development of novel vaccine formulations. In this review, we discuss developmental strategies for prophylactic and therapeutic EBV vaccines which have been assessed in preclinical and clinical settings. Expert commentary: Major roadblocks in EBV vaccine development include no precise understanding of the clinical correlates of protection, uncertainty about adjuvant selection and the unavailability of appropriate animal models. Recent development of new EBV vaccine formulations provides exciting opportunities for the formal clinical assessment of novel formulations.

Value of intravoxel incoherent motion and dynamic contrast-enhanced MRI for predicting the early and short-term responses to chemoradiotherapy in nasopharyngeal carcinoma

The aim of the study was to investigate the value of intravoxel incoherent motion diffusion-weighted magnetic resonance imaging (IVIM-DWI) and dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) in predicting the early and short-term responses to chemoradiotherapy (CRT) in patients with nasopharyngeal carcinoma (NPC).Forty-three NPC patients underwent IVIM-DWI and DCE-MRI at baseline (pretreatment) and after the first cycle of induction chemotherapy (posttreatment). Based on whether locoregional lesions were identified, patients were divided into the residual and nonresidual groups at the end of CRT and into the good-responder and poor-responder groups 6 months after the end of CRT. The pretreatment and posttreatment IVIM-DWI parameters (ADC, D, D*, and f) and DCE-MRI parameters (K, Kep, and Ve) values and their percentage changes (Δ%) were compared between the residual and nonresidual groups and between the good-responder and poor-responder groups.None of perfusion-related parametric values derived from either DCE-MRI or IVIM-DWI showed significant differences either between the residual and nonresidual groups or between the good-responder and poor-responder groups. The nonresidual group exhibited lower pre-ADC, lower pre-D, and higher Δ%D values than did the residual group (all P <0.05). The good-responder group had lower pre-D and pre-ADC values than did the poor-responder group (both P <0.05). Based on receiver operating characteristic (ROC) curve analysis, pre-D had the highest area under the curve in predicting both the early and short-term responses to CRT for NPC patients (0.817 and 0.854, respectively).IVIM-DWI is more valuable than DCE-MRI in predicting the early and short-term response to CRT for NPC, and furthermore diffusion-related IVIM-DWI parameters (pre-ADC, pre-D, and Δ%D) are more powerful than perfusion-related parameters derived from both IVIM-DWI and DCE-MRI.

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

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

18F-FDG PET/CT for the Diagnosis of Residual or Recurrent Nasopharyngeal Carcinoma After Radiotherapy: A Metaanalysis

The aim of this work was to assess the overall value of (18)F-FDG PET/CT in the diagnosis of residual or recurrent nasopharyngeal carcinoma using a metaanalysis.

METHODS

The literature published between January 1990 and September 2014 was searched in the PubMed, EMBASE, Cochrane Library, EBSCO, VIP, CNKI, and Wanfang databases to identify eligible studies on PET/CT of residual or recurrent lesions. The methodologic quality of the included studies was evaluated using the "quality assessment for studies of diagnostic accuracy" tool. Summary sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and receiver-operating characteristic curve were obtained using Meta-DiSc freeware. Subgroups were also analyzed.

RESULTS

A total of 23 studies, involving 1,253 subjects, were included in the metaanalysis. Pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio, with 95% confidence intervals in parentheses, for (18)F-FDG PET or PET/CT were 0.93 (0.91-0.95), 0.87 (0.84-0.89), 5.52 (3.96-7.71), 0.12 (0.09-0.15), and 55.31 (34.94-87.57), respectively. The area under the receiver-operating characteristic curve and Q* index estimate of PET/CT were 0.9473 and 0.8869, respectively. There was no significant difference between the area under the curve of PET and PET/CT (P > 0.05).

CONCLUSION

Our study has confirmed that (18)F-FDG PET/CT has high sensitivity and specificity but significant heterogeneity in the diagnosis of residual or recurrent nasopharyngeal carcinoma.