Assessment of Nasopharyngeal Cancer in Young Patients Aged ≤ 30 Years

Clinical significance of serum lactate dehydrogenase combined with a multivariate model for predicting the near-term outcome of primary nasopharyngeal carcinoma

BACKGROUND AND OBJECTIVES

This investigation explores the clinical significance of integrating serum lactate dehydrogenase (LDH) with a multivariate model for assessing the short-term prognosis of primary nasopharyngeal carcinoma (NPC). Epstein-Barr virus (EBV) quantification is a crucial prognostic indicator in NPC cases, but not all patients with NPC test positive for EBV. Furthermore, widespread adoption of EBV-DNA quantification remains challenging due to its high cost. Consequently, it is imperative to incorporate additional convenient and cost-effective prognostic markers to comprehensively evaluate patient outcomes.

METHODS

This retrospective analysis included 203 newly diagnosed NPC cases treated at the Affiliated Qingyuan Hospital of Guangzhou Medical University between January 2018 and March 2022. The dataset included personal information and clinical data, and the treatment protocols followed the CSCO guidelines. Efficacy assessments were based on the RECIST 1.1 criteria and were conducted after induction chemotherapy and one week and three months after radiotherapy.

RESULTS

A noteworthy correlation emerged between baseline serum LDH levels and treatment efficacy at one week after radiotherapy (P = 0.03) and at three months after radiotherapy (P < 0.01). Additionally, a prognostic model that incorporates age (P = 0.010), LDH (P < 0.001), C-reactive protein (P = 0.010), and alkaline phosphatase (P = 0.005) demonstrated robust predictive accuracy and clinical applicability.

CONCLUSION

This investigation substantiates the significant correlation between baseline serum LDH levels and NPC outcomes. Furthermore, we introduce a refined prognostic model that holds promise for informing personalized treatment strategies, thereby contributing to the advancement of the diagnosis of NPC.

Multiple myeloma in a young female presenting as an aggressive skull-base tumour

Plasma cell neoplasia has a wide presentation of disease (localised or systemic) according to the International Myeloma Working Group. Radiological imaging identifies plasmacytomas as solitary lesions or part of multiple myeloma. We present a rare case of a 21-year-old female who presented with a skull-base tumour.

Contribution

A head and neck plasmacytoma with further lytic bone lesions was confirmed on imaging. This article presents and discusses the clinical, CT, MRI, positron emission tomography (PET)-CT, histology and laboratory findings.

Short-term OS as a surrogate endpoint for 5-year OS in nasopharyngeal carcinoma in non-endemic area

PURPOSE

To address this evidence gap and validate short-term OS at less than 5 years as a reliable surrogate endpoint for 5-year OS.

METHODS

We analyzed data from the Surveillance, Epidemiology, and End Results (SEER) database, focusing on non-metastatic NPC patients diagnosed between 2010 and 2015. Patients were categorized into radiotherapy and chemoradiotherapy groups.

RESULTS

This retrospective study examined 2,047 non-metastatic NPC patients. Among them, 217 received radiotherapy, and 1,830 received chemoradiotherapy. Our analysis results indicated that the 4-year OS may serve as a reliable surrogate endpoint for patients with AJCC clinical stage I (80 vs. 78%, P = 0.250), regardless of the treatment received. Specifically, in the radiotherapy group, patients with stage I, T0-T1, and N0 NPC showed similar OS rates at 4 and 5 years (83 vs. 82%, P = 1.000; 78 vs. 76%, P = 0.250; 78 vs. 77%, P = 0.500, respectively). Similarly, patients with stage II-IV, T2-T4, and N1-3 NPC showed no significant difference in OS rates between 3 and 5 years (57 vs. 51%, P = 0.063; 52 vs. 46%, P = 0.250; 54 vs. 46%, P = 0.125, respectively) in the radiotherapy group. In the chemoradiotherapy group, only the 3-year OS rate did not significantly differ from that at 5 years in stage I patients (79vs. 72%, P = 0.063).

CONCLUSIONS

Our study suggests that short-term surrogate endpoints may be valuable for evaluating 5-year OS outcomes in NPC patients in non-endemic areas.

Optimized Nomogram for Nasopharyngeal Carcinoma Prognosis Prediction in Younger Patients (Aged 18-59): Development and Validation

PURPOSE

To develop a nomogram model for the predicted overall survival (OS) in patients aged 18 to 59 years with nasopharyngeal carcinoma (NPC) and assess the value of the clinical application.

METHODS

In total, 1334 registers of NPC patients from 2010 to 2015 were retrieved from the Surveillance, Epidemiology, and End Results database. Univariate and multivariate Cox analysis were used to screen out independent risk factors affecting patients. Cox analysis predicted OS for patients with NPC at 3, 5, and 8 years. Nomogram performance was validated using the concordance index (C-index), receiver operating characteristic, calibration curve, and decision curve analysis (DCA).

RESULTS

Age, sex, race, marital, histological type, tumor size, AJCC stage, and radiotherapy were independent risk factors. The C-index of the nomogram was 0.69 [95% confidence interval (CI): 0.68-0.71] for the training set, and the C-index of the AJCC stage was 0.63 (95% CI: 0.62-0.65), both statistically significant (P < .01). The area under the curve for the nomogram at these intervals (0.755, 0.729, and 0.729, respectively) was higher than that of the AJCC stage (0.667, 0.646, and 0.646, respectively), indicating better predictive accuracy. The calibration curves revealed a high degree of agreement between the observation and the prediction. Compared to the American Joint Committee on Cancer (AJCC) stage, DCA showed better clinical utility.

CONCLUSION

The nomogram as novel predictor for nasopharyngeal carcinoma patients' survival.

Machine learning explainability in nasopharyngeal cancer survival using LIME and SHAP

Nasopharyngeal cancer (NPC) has a unique histopathology compared with other head and neck cancers. Individual NPC patients may attain different outcomes. This study aims to build a prognostic system by combining a highly accurate machine learning model (ML) model with explainable artificial intelligence to stratify NPC patients into low and high chance of survival groups. Explainability is provided using Local Interpretable Model Agnostic Explanations (LIME) and SHapley Additive exPlanations (SHAP) techniques. A total of 1094 NPC patients were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database for model training and internal validation. We combined five different ML algorithms to form a uniquely stacked algorithm. The predictive performance of the stacked algorithm was compared with a state-of-the-art algorithm-extreme gradient boosting (XGBoost) to stratify the NPC patients into chance of survival groups. We validated our model with temporal validation (n = 547) and geographic external validation (Helsinki University Hospital NPC cohort, n = 60). The developed stacked predictive ML model showed an accuracy of 85.9% while the XGBoost had 84.5% after the training and testing phases. This demonstrated that both XGBoost and the stacked model showed comparable performance. External geographic validation of XGBoost model showed a c-index of 0.74, accuracy of 76.7%, and area under curve of 0.76. The SHAP technique revealed that age of the patient at diagnosis, T-stage, ethnicity, M-stage, marital status, and grade were among the prominent input variables in decreasing order of significance for the overall survival of NPC patients. LIME showed the degree of reliability of the prediction made by the model. In addition, both techniques showed how each feature contributed to the prediction made by the model. LIME and SHAP techniques provided personalized protective and risk factors for each NPC patient and unraveled some novel non-linear relationships between input features and survival chance. The examined ML approach showed the ability to predict the chance of overall survival of NPC patients. This is important for effective treatment planning care and informed clinical decisions. To enhance outcome results, including survival in NPC, ML may aid in planning individualized therapy for this patient population.

Development and validation of an MRI-based radiomic model for predicting overall survival in nasopharyngeal carcinoma patients with local residual tumors after intensity-modulated radiotherapy

BACKGROUND

To investigate the potential value of the pretreatment MRI-based radiomic model in predicting the overall survival (OS) of nasopharyngeal carcinoma (NPC) patients with local residual tumors after intensity-modulated radiotherapy (IMRT).

METHODS

A total of 218 consecutive nonmetastatic NPC patients with local residual tumors after IMRT [training cohort (n = 173) and validation cohort (n = 45)] were retrospectively included in this study. Clinical and MRI data were obtained. Univariate Cox regression and the least absolute shrinkage and selection operator (LASSO) were used to select the radiomic features from pretreatment MRI. The clinical, radiomic, and combined models for predicting OS were constructed. The models' performances were evaluated using Harrell's concordance index (C-index), calibration curve, and decision curve analysis.

RESULTS

The C-index of the radiomic model was higher than that of the clinical model, with the C-index of 0.788 (95% CI 0.724-0.852) versus 0.672 (95% CI 0.599-0.745) in the training cohort and 0.753 (95% CI 0.604-0.902) versus 0.634 (95% CI 0.593-0.675) in the validation cohort. Calibration curves showed good agreement between the radiomic model-predicted probability of 2- and 3-year OS and the actual observed probability in the training and validation groups. Decision curve analysis showed that the radiomic model had higher clinical usefulness than the clinical model. The discrimination of the combined model improved significantly in the training cohort (P < 0.01) but not in the validation cohort, with the C-index of 0.834 and 0.734, respectively. The radiomic model divided patients into high- and low-risk groups with a significant difference in OS in both the training and validation cohorts.

CONCLUSIONS

Pretreatment MRI-based radiomic model may improve OS prediction in NPC patients with local residual tumors after IMRT and may assist in clinical decision-making.

Cancer of the nasopharynx in Aotearoa New Zealand from 1994 to 2018: Incidence and survival in a population-based, national registry cohort study

BACKGROUND

Cancer of the nasopharynx has remarkable geographic and ethnic variation in incidence and outcomes globally. Recent advances in diagnostic and therapeutic technologies provide new opportunities for early detection and improved outcomes. This study aimed to determine the incidence, demographics, outcomes and time trends of cancer of the nasopharynx in Aotearoa New Zealand over the last 25 years.

METHODS

In a population-based, national registry cohort study of notifications of malignant neoplasms of the nasopharynx made to the New Zealand Cancer Registry between 1994 and 2018, age-specific and age-standardised incidence rates and survival outcomes were evaluated.

FINDINGS

577 registrations of nasopharyngeal cancer from between 1994 and 2018 were analysed; median age at diagnosis 54 years; 72.4% male; 37.4% Asian, 24.3% New Zealand European, 25.3% Pacific peoples, 13.0% Māori. Age-standardised annual incidence remained low (<1/100,000 person-years) and stable from 1994 to 2018. Age-standardised incidence rates in Pacific peoples, Asian and Māori were 21 (95% CI 12.07-35.21)-, 17 (10.95-25.33)- and 4 (2.79-7.07)-fold higher, respectively, than New Zealand Europeans. Epstein-Barr virus-related morphologies predominated keratinising squamous cell carcinoma and not-otherwise-specified morphological subtypes. Ten-year overall survival rate for the cohort was 49.2% (95% CI 44.7-53.5). Older age at diagnosis (65-94 years), Māori or Pacific ethnicity, keratinising squamous cell carcinoma and distant disease were associated with shorter overall survival, whereas younger age at diagnosis (10-29 years), and Asian ethnicity were associated with longer survival.

INTERPRETATION

Aotearoa New Zealand has a distinct profile of nasopharyngeal cancer, with age, ethnicity and morphology among the main determinants of incidence and survival.

FUNDING

None.

Trends in the Incidence of Nasopharyngeal Cancer in Saudi Arabia Across One Decade (2007 to 2016)

Background

Cancer is an ongoing global health concern; it is the greatest cause of mortality in the industrialized world and the second-highest cause of death in the developing world. This study aims to assess the incidence and geographic distribution of nasopharyngeal cancer between 2007 and 2016 in Saudi Arabia.

Methods

Data between 2007 and 2016 from Saudi Cancer Registry reports were collected in this study. These reports provide information on all cancer cases, including the age, sex, geographic location, and year of diagnosis for each patient.

Result

Between 2007 and 2016, the Saudi Cancer Registry identified 110,075 cancer cases in total. The mean age-standardized rate of all cancer types for women was 51.7 compared with 48.2 for men. The percentage of cases of nasopharyngeal cancers was 1.2% for women and 2.2% for men in 2007. This percentage decreased to 0.8% for women and increased to 2.7% for men in 2016 in comparison to all cancer cases. The curve for nasopharyngeal cancer of all cancer types for men and women correlated with rises and drops in men over the study period, and a minor decrease in women over time, until another rise in 2016. A positive correlation was observed between nasopharyngeal cancer incidence and age. The age-standardized rate data for nasopharyngeal cancer cases demonstrated a wide variation across Saudi regions. The age-standardized rate per 100,000 people from 2007 to 2016 ranged from 0.39 in Jazan to 1.92 in Qassim, with a national average of 1.06.

Conclusion

From 2007 to 2016, the overall trend of the age-standardized rate for men fluctuated while the female rate slightly dropped before rising again. On the contrary, the incidence of nasopharyngeal cancer varies by region in Saudi Arabia. Further study of this variation would help focus awareness campaigns on the most susceptible regions.

The Role of Genetic Pathways in the Development of Chemoradiation Resistance in Nasopharyngeal Carcinoma (NPC) Patients

Management of nasopharyngeal carcinoma (NPC) remains elusive despite new developments and advancement that has been made in the current management approaches. A patient’s survival and prognosis remain dismal especially for a late-stage disease. This is highly attribute to the chemoradiation resistance. Arrays of genes and molecular mechanisms underlie the development of chemoradiation resistance in NPC. Imperatively, unravelling the true pathogenesis of chemoradiation resistance is crucial as these significant proteins and genes can be modulated to produce an effective therapeutic target. It is pivotal to identify the chemoradiation resistance at the very beginning in order to combat the chemoradiation resistance efficiently. Intense research in the genetic ecosphere is critical, as the discovery and development of novel therapeutic targets can be used for screening, diagnosis, and treating the chemoradiation resistance aggressively. This will escalate the management trajectory of NPC patients. This article highlights the significance of genetic and molecular factors that play critical roles in the chemoradiation resistance and how these factors may be modified for next-generation targeted therapy products.

Combination of Epithelial Growth Factor Receptor Blockers and CDK4/6 Inhibitor for Nasopharyngeal Carcinoma Treatment

Simple Summary

Our findings indicated that the EGF-EGFR pathway was highly activated in very young patients with recurrent or metastatic NPC. High EGFR expression in patients with metastatic NPC resulted in poor clinical outcomes. To examine whether the EGFR pathway serves as a therapeutic target for NPC, NPC patient-derived xenograft (PDX) and NPC cell lines were treated with EGFR inhibitors (EGFRi) and a cell cycle blocker. Either EGFRi or cell cycle blocker treatment alone could reduce NPC cell growth and PDX tumor growth. Furthermore, combination treatment exerted an additive suppression effect on PDX tumor growth. This study provides promising evidence that EGFRi used in combination with a cell cycle blocker may be used to treat patients with NPC.

Abstract

Background: Nasopharyngeal carcinoma (NPC) involves host genetics, environmental and viral factors. In clinical observations, patients of young and old ages were found to have higher recurrence and metastatic rates. Methods: Cytokine array was employed to screen druggable target(s). The candidate target(s) were confirmed through patient-derived xenografts (PDXs) and a new EBV-positive cell line, NPC-B13. Results: Overexpression of epithelial growth factor (EGF) and EGF receptor (EGFR) was detected in young patients than in older patients. The growth of NPC PDX tumors and cell lines was inhibited by EGFR inhibitors (EGFRi) cetuximab and afatinib when used separately or in combination with the cell cycle blocker palbociclib. Western blot analysis of these drug-treated PDXs demonstrated that the blockade of the EGF signaling pathway was associated with a decrease in the p-EGFR level and reduction in PDX tumor size. RNA sequencing results of PDX tumors elucidated that cell cycle-related pathways were suppressed in response to drug treatments. High EGFR expression (IHC score ≥ grade 3) was correlated with poor survival in metastatic patients (p = 0.008). Conclusions: Our results provide encouraging preliminary data related to the combination treatment of EGFRi and palbociclib in patients with NPC.

Prognostic models for 1-year survival of NPC after radiotherapy in different ages

PURPOSE

Previous studies have shown that approximately 10% of nasopharyngeal cancer (NPC) patients die within a year of disease onset, and that age is an independent predictor. However, no predictive model has been developed. We aimed to establish novel prognostic models to predict the 1-year cancer-specific survival (CSS) of young, middle-aged, and older patients with NPC after radiotherapy.

METHODS

The data of 2822 NPC patients who underwent radiotherapy between 2004 and 2015 were reviewed from the surveillance, epidemiology, and end results database. We divided them into young, middle-aged, and older people groups according to age (< 44 years, 45-59 years, and ≥ 60 years, respectively). Multivariate analyses were performed, and prognostic models were constructed.

RESULTS

Multivariate analyses indicated that age, ethnicity, histological subtype, T, and M stage were independent predictors of 1-year CSS in the older people group. In contrast, ethnicity and age were not found to have predictive value in the young and middle-aged groups, respectively. Accordingly, three prognostic models with excellent predictive values were established for the three groups (C-indices: 0.791 [95% CI 0.722-0.859], 0.763 [95% CI 0.721-0.806] and 0.723 [95% CI 0.683-0.763], respectively). These predictive values are higher than those of the eighth edition American joint committee cancer tumor-node-metastasis (TNM) classification system.

CONCLUSION

Three prognostic models for predicting the 1-year CSS of young, middle-aged, and older NPC patients after radiotherapy showed better predictive power than the TNM classification system. These models may guide treatment strategies and clinical decision-making in different cohorts.

Effect of Chinese Herbal Medicine Therapy on Overall and Cancer Related Mortality in Patients With Advanced Nasopharyngeal Carcinoma in Taiwan

Nasopharyngeal carcinoma (NPC) is a head and neck cancer involving epithelial squamous-cell carcinoma of the nasopharynx that mainly occurs in individuals from East and Southeast Asia. We investigated whether Chinese herbal medicine (CHM) as a complementary therapy offers benefits to these patients. We retrospectively evaluated the Taiwan Cancer Registry (Long Form) database for patients with advanced NPC, using or not using CHM, between 2007–2013. Cox proportional-hazard model and Kaplan‒Meier survival analyses were applied for patient survival. CHM-users showed a lower overall and cancer-related mortality risk than non-users. For advanced NPC patients, the overall mortality risk was 0.799-fold for CHM-users, after controlling for age, gender, and Charlson comorbidity index (CCI) score (Cancer stages 3 + 4: adjusted hazard ratio [aHR]: 0.799, 95% confidence interval [CI]: 0.676–0.943, p = 0.008). CHM-users also showed a lower cancer-related mortality risk than non-users (aHR: 0.71, 95% CI: 0.53–0.96, p = 0.0273). Association rule analysis showed that CHM pairs were Ban-Zhi-Lian (BZL; Scutellaria barbata D.Don) and For single herbs, Bai-Hua-She-She-Cao (Herba Hedyotis Diffusae; Scleromitrion diffusum (Willd.) R.J.Wang (syn. Hedyotis diffusa Willd.) and Mai-Men-Dong (MMD; Ophiopogon japonicus (Thunb.) Ker Gawl.), and Gan-Lu-Yin (GLY) and BHSSC. Network analysis revealed that BHSSC was the core CHM, and BZL, GLY, and Xin-Yi-Qing-Fei-Tang (XYQFT) were important CHMs in cluster 1. In cluster 2, ShengDH, MMD, Xuan-Shen (XS; Scrophularia ningpoensis Hensl.), and Gua-Lou-Gen (GLG; Trichosanthes kirilowii Maxim.) were important CHMs. Thus, as a complementary therapy, CHM, and particularly the 8 CHMs identified, are important for the treatment of advanced NPC patients.

Comparison of Prognosis Between Juvenile and Adult Nasopharyngeal Carcinoma: A Propensity Score-Matched Analysis

Purpose

To investigate whether juvenile patients with nasopharyngeal carcinoma (NPC) in China have better prognosis than their adult counterparts in the intensity-modulated radiation therapy (IMRT) era, after controlling for potential confounding variables.

Methods

Data pertaining to 1139 patients with newly diagnosed NPC without metastasis, who were treated with IMRT at our hospital, were retrospectively analyzed. Of these, 60 patients were juvenile (age ≤18 years) diagnosed between January 2003 and December 2018, while 1079 patients were adults (≤65 years) diagnosed between January 2013 and December 2014. To minimize the influence of selection and confounding bias, 1:2 propensity score matching (PSM) was used. Overall survival (OS), disease-free survival (DFS), locoregional relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) were estimated using the Kaplan–Meier method and between-group differences assessed using the Log rank test. The long-term toxicity of the juvenile patients was evaluated according to the criteria of the Radiation Therapy Oncology Group (RTOG) and the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0.

Results

Five-year OS of juvenile and adult patients were 88.07% and 85.08%, respectively. Before PSM, OS, PFS, DMFS, or LRFS were comparable in the two groups (all P > 0.05). After PSM, OS, DFS, and LRFS in the juvenile group were markedly longer than that in adults (P = 0.005, P = 0.027, and P = 0.024, respectively). With respect to long-term toxicity, the most common adverse effects in juvenile patients were cervix fibrosis, ototoxicity, and xerostomia. However, except for two patients who developed grade 3 ototoxicity, all adverse effects were within grade 2.

Conclusion

In the IMRT era, juvenile Chinese patients with NPC had better 5-year OS, DFS, and LRFS than their adult counterparts. The adverse events in the juvenile cohort were relatively mild; however, the risk of severe ototoxicity should not be neglected.

Is nasopharyngeal carcinoma in young patients a distinct clinical entity? A single-institution case matched analysis in the era of intensity-modulated radiotherapy

OBJECTIVES

To compare the treatment outcomes between young and adult patients with nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiation therapy (IMRT).

MATERIALS AND METHODS

We conducted a retrospective case-matched analysis of all patients with non-metastatic NPC ≤20 years treated in our institution between January 2010 and July 2016. Adult patients ≥35 years treated over the same time period were included and matched at a ratio of 1:1 according to N classification, T classification, treatment modality, year of diagnosis, and gender. Survival outcomes and late toxicities were compared between the two groups.

RESULTS

Overall 112 young patients with NPC were included, and 112 out of 3105 consecutive patients with NPC aged ≥35 years were matched. The 5-year overall survival (OS), progression-free survival, locoregional control and distant control of young and control cohorts were 89.1% vs. 79.3% (p = 0.03), 80.3% vs. 67.0% (p = 0.02), 96.4% vs. 84.3% (p < 0.01), and 82.9% vs. 82.8% (p = 0.94), respectively. Multi-variate analysis showed that age ≤20 years was the only significant factor predicting for better OS (HR = 0.5, CI 0.3-0.97, p = 0.04). A trend of higher rate of hypothyroidism (grade 1-2) was observed in the young cohort (67.9% vs. 46.2%, p = 0.08).

CONCLUSION

Young patients with NPC treated with modern multimodality therapy have better survival outcomes. Age was an independent favorable prognostic factor for NPC in the IMRT era. Further prospective studies are needed to establish optimal management for the young population to minimize and manage long-term side-effects without compromising survival.