Establishment of a Prognostic Nomogram for Patients With Locoregionally Advanced Nasopharyngeal Carcinoma Incorporating TNM Stage, Post-Induction Chemotherapy Tumor Volume and Epstein-Barr Virus DNA Load

Embracing Personalized Strategies in Radiotherapy for Nasopharyngeal Carcinoma: Beyond the Conventional Bounds of Fields and Borders

Radiotherapy is the primary treatment modality for non-metastatic nasopharyngeal carcinoma (NPC) across all TN-stages. Locoregional control rates have been impressive even from the 2D radiotherapy (RT) era, except when the ability to deliver optimal dose coverage to the tumor is compromised. However, short- and long-term complications following head and neck RT are potentially debilitating, and thus, there has been much research investigating technological advances in RT delivery over the past decades, with the primary goal of limiting normal tissue damage. On this note, with a plateau in gains of therapeutic ratio by modern RT techniques, future advances have to be focused on individualization of RT, both in terms of dose prescription and the delineation of target volumes. In this review, we analyzed the guidelines and evidence related to contouring methods, and dose prescription for early and locoregionally advanced (LA-) NPC. Next, with the preference for induction chemotherapy (IC) in patients with LA-NPC, we assessed the evidence concerning radiotherapy adaptations guided by IC response, as well as functional imaging and contour changes during treatment. Finally, we discussed on RT individualization that is guided by EBV DNA assessment, and its importance in the era of combinatorial immune checkpoint blockade therapy with RT.

A single center retrospective study assessing the prognostic significance of pre-treatment neutrophil/lymphocyte ratio in locally advanced nasopharyngeal carcinoma

Background

In light of the growing evidence suggesting the impact of inflammatory parameters on the survival of individuals with cancer, this research assessed the prognostic significance of the neutrophil-to-lymphocyte ratio (NLR) in individuals diagnosed with locally advanced nasopharyngeal carcinoma (NPC) prior to undergoing intensity-modulated radiation therapy (IMRT).

Methods

A total of 163 individuals diagnosed with locally advanced NPC treated with IMRT at our hospital between January 2012 and December 2017 were included in this research. For each patient, the absolute counts of neutrophils and lymphocytes were recorded, and the NLR was calculated at the first diagnosis. To determine the optimal cut-off values for NLR, receiver operating characteristic (ROC) curve analysis was conducted. The effects of the determined cut-off value on local failure-free survival (LFFS), overall survival (OS), progression-free survival (PFS), and distant failure-free survival (DFFS) were evaluated employing the Cox regression model.

Results

The median follow-up duration for the individuals in this study was 15 months (ranging from 6 to 79 months). According to the determined NLR cut-off value of 3.27, individuals were classified into two groups (high NLR and low NLR). Individuals in the high-NLR group had remarkably poorer 3-year OS (62.8% vs. 91.7%), PFS (51.4% vs. 82.4%), and DFFS (70.7% vs. 89.6%) compared to the low-NLR group. Furthermore, the outcomes of univariate and multivariate survival analyses revealed that NLR served as an independent predictor of DFFS (HR: 2.81, 95% CI: 1.195-6.608, P=0.018), OS (HR: 3.1, 95% CI: 1.211-7.935, P=0.018), and PFS (HR: 2.21, 95% CI: 1.133-4.292, P=0.02).

Conclusions

Elevated NLR exhibited a significant correlation with reduced OS, DFFS, and PFS. These findings suggest that NLR holds promise as a cost-effective and reliable marker for the prediction of clinical outcomes among patients with locoregionally advanced nasopharyngeal carcinoma (LANPC). Furthermore, incorporating NLR into clinical decision-making regarding LANPC treatment strategies may contribute to a more targeted approach aimed at reducing the risk of distant failure.

Prognostic effect of residual plasma Epstein-Barr viral DNA after induction chemotherapy for locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

To assess the prognostic effect of plasma Epstein-Barr virus (EBV) DNA load after induction chemotherapy (postIC -EBV DNA) on survival outcomes in locoregionally advanced nasopharyngeal carcinoma (LA-NPC).

METHODS

Patients who were diagnosed with LA-NPC between August 2017 and October 2021 were included. The chi-squared test, receiver operating characteristic, Kaplan-Meier survival analysis, and Cox proportional hazard model were used for statistical analysis.

RESULTS

We included 172 patients with EBV DNA-positive LA-NPC in this study. There were 35.5% (n = 61) of patients had plasma residual EBV DNA after induction chemotherapy (IC). Patients with higher EBV DNA before IC (p < 0.001) and advanced nodal stage (p = 0.031) were significantly related to a higher rate of residual postIC -EBV DNA. Patients with detectable postIC -EBV DNA had inferior 3-year locoregional relapse-free survival (LRFS) (86.7% vs. 96.9%, p = 0.020), distant metastasis-free survival (DMFS) (76.8% vs. 94.2%, p < 0.001), disease-free survival (DFS) (68.2% vs. 91.1%, p < 0.001), and overall survival (OS) (87.8% vs. 97.9%, p = 0.044) compared to those with undetectable postIC -EBV DNA. The multivariate prognostic analyses showed that detectable postIC -EBV DNA was the independent prognostic factor related to LRFS (p = 0.032), DMFS (p = 0.010), and DFS (p = 0.004) than those with undetectable postIC -EBV DNA. Pretreatment EBV DNA load had no prognostic effect in the multivariate analyses.

CONCLUSIONS

The monitoring of plasma postIC -EBV DNA has improved prognostication in LA-NPC. Our findings suggest that postIC -EBV DNA may be a robust indicator to identify the optimal candidate for intensive treatment.

A dynamic nomogram combining tumor stage and magnetic resonance imaging features to predict the response to induction chemotherapy in locally advanced nasopharyngeal carcinoma

OBJECTIVES

To establish an effective dynamic nomogram combining magnetic resonance imaging (MRI) findings of primary tumor and regional lymph nodes with tumor stage for the pretreatment prediction of induction chemotherapy (IC) response in locoregionally advanced nasopharyngeal carcinoma (LANPC).

METHODS

A total of 498 LANPC patients (372 in the training and 126 in the validation cohort) with MRI information were enrolled. All patients were classified as "favorable responders" and "unfavorable responders" according to tumor response to IC. A nomogram for IC response was built based on the results of the logistic regression model. Also, the Cox regression analysis was used to identify the independent prognostic factors of disease-free survival (DFS).

RESULTS

After two cycles of IC, 340 patients were classified as "favorable responders" and 158 patients as "unfavorable responders." Calibration curves revealed satisfactory agreement between the predicted and the observed probabilities. The nomogram achieved an AUC of 0.855 (95% CI, 0.781-0.930) for predicting IC response, which outperformed TNM staging (AUC, 0.661; 95% CI 0.565-0.758) and the MRI feature-based model alone (AUC, 0.744; 95% CI 0.650-0.839) in the validation cohort. The nomogram was used to categorize patients into high- and low-response groups. An online dynamic model was built ( https://nomogram-for-icresponse-prediction.shinyapps.io/DynNomapp/ ) to facilitate the application of the nomogram. In the Cox multivariate analysis, clinical stage, tumor necrosis, EBV DNA levels, and cervical lymph node numbers were independently associated with DFS.

CONCLUSIONS

The comprehensive nomogram incorporating MRI features and tumor stage could assist physicians in predicting IC response and formulating personalized treatment strategies for LANPC patients.

KEY POINTS

• The nomogram can predict IC response in endemic LANPC. • The nomogram combining tumor stage with MRI-based tumor features showed very good predictive performance. • The nomogram was transformed into a web-based dynamic model to optimize clinical application.

Individualized number of induction chemotherapy cycles for locoregionally advanced nasopharyngeal carcinoma patients based on early tumor response

BACKGROUND

The optimal number of cycles of induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (LANPC) is unclear. We aimed to combine the tumor response during IC and tumor stage to individualize the number of IC cycles.

METHODS

Totally, 498 LANPC patients who received IC plus CCRT between 2014 and 2018 were reviewed. Tumor response during IC was used to stratify patients with different risks. All patients were classified into those who received two cycles of IC and those who were treated with three cycles. Propensity score matching methods were performed to compare the treatment efficiency.

RESULTS

After two cycles of IC, 340/498 (68.3%) cases showed complete tumor response (CR)/partial response (PR) and 158 (31.7%) achieved stable disease (SD)/disease progression (PD). Unfavorable responders (SD/PD) exhibited poor survival outcomes. The three-cycle IC regimen was correlated with better OS and PFS than the two-cycle regimen for N2-3 patients in the CR/PR group. However, the use of different IC cycle strategies achieved similar survival outcomes for SD/PD or N0-1 patients. The incidences of acute toxicities were higher in the IC = 3 group.

CONCLUSIONS

Tumor response during IC could be a powerful predictor of LANPC and could be used to guide the individualized number of IC cycles. A three-cycle IC regimen seemed to be preferable for N2-3 patients who received CR/PR during IC. However, an additional cycle of IC could not benefit N0-1 or SD/PD patients, and the optimal treatment strategies for these patients require further consideration.

Establishment of a prognostic nomogram for patients with locoregionally advanced nasopharyngeal carcinoma incorporating clinical characteristics and dynamic changes in hematological and inflammatory markers

Background

This study aims to investigate the prognostic value of changes in hematological and inflammatory markers during induction chemotherapy (IC) and concurrent chemo-radiation (CCRT), thus construct nomograms to predict progression free survival (PFS) of patients with locally advanced nasopharyngeal carcinoma (LANPC).

Methods

130 patients were included in this prospective analysis. Univariate and multivariate cox regression analyses were conducted to identify prognostic factors. Three multivariate analyses integrating different groups of variables were conducted independently. Concordance indexes (c-index), calibration plots and Kaplan-Meier curves were used to evaluate the nomograms. Bootstrap validation was performed to determine the accuracy of the nomogram using 1000 resamples. The performances of proposed nomograms and TNM staging system were compared to validate the prognostic value of hematological and inflammatory markers.

Results

Pretreatment gross tumor volume of nodal disease (GTVn), Δe/bHGB (hemoglobin count at end of treatment/baseline hemoglobin count), and stage were selected as predictors for 3-year PFS in first multivariate analysis of clinical factors. The second multivariate analysis of clinical factors and all hematological variables demonstrated that ΔminLYM (minimum lymphocyte count during CCRT/lymphocyte count post-IC), pretreatment GTVn and stage were associated with 3-year PFS. Final multivariate analysis, incorporating all clinical factors, hematological variables and inflammatory markers, identified the following prognostic factors: pretreatment GTVn, stage, ΔmaxPLR (maximum platelet-to-lymphocyte ratio (PLR) during CCRT/PLR post-IC), and ΔminPLT (minimum platelet count during CCRT/platelet count post-IC). Calibration plots showed agreement between the PFS predicted by the nomograms and actual PFS. Kaplan–Meier curves demonstrated that patients in the high-risk group had shorter PFS than those in the low-risk group (P ≤ 0.001). The c-indexes of the three nomograms for PFS were 0.742 (95% CI, 0.639-0.846), 0.766 (95% CI, 0.661-0.871) and 0.815 (95% CI,0.737-0.893) respectively, while c-index of current TNM staging system was 0.633 (95% CI, 0.531-0.736).

Conclusion

We developed and validated a nomogram for predicting PFS in patients with LANPC who received induction chemotherapy and concurrent chemo-radiation. Our study confirmed the prognostic value of dynamic changes in hematological and inflammatory markers. The proposed nomogram outperformed the current TNM staging system in predicting PFS, facilitating risk stratification and guiding individualized treatment plans.

A Clinical-Radiomics Nomogram Based on Magnetic Resonance Imaging for Predicting Progression-Free Survival After Induction Chemotherapy in Nasopharyngeal Carcinoma

Purpose

This paper aimed to establish and verify a radiomics model based on magnetic resonance imaging (MRI) for predicting the progression-free survival of nasopharyngeal carcinoma (NPC) after induction chemotherapy (IC).

Materials and Methods

This cohort consists of 288 patients with clinical pathologically confirmed NPC, which was collected from January 2015 to December 2018. All NPC patients were randomly divided into two cohorts: training (n=202) and validation (n=86). Radiomics features from the MRI images of NPC patients were extracted and selected before IC. The patients were classified into high- and low-risk groups according to the median of Radscores. The significant imaging features and clinical variables in the univariate analysis were constructed for progression-free survival (PFS) using the multivariate Cox regression model. A survival analysis was performed using Kaplan–Meier with log-rank test and then each model’s stratification ability was evaluated.

Results

Epstein–Barr virus (EBV) DNA before treatment was an independent predictor for PFS (p &lt; 0.05). Based on the pyradiomic platform, we extracted 1,316 texture parameters in total. Finally, 16 texture features were used to build the model. The clinical radiomics-based model had good prediction capability for PFS, with a C-index of 0.827. The survival curve revealed that the PFS of the high-risk group was poorer than that of the low-risk group.

Conclusion

This research presents a nomogram that merges the radiomics signature and the clinical feature of the plasma EBV DNA load, which may improve the ability of preoperative prediction of progression-free survival and facilitate individualization of treatment in NPC patients before IC.

A nomogram based on tumor response to induction chemotherapy may predict survival in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

To evaluate the clinical significance of tumor response to induction chemotherapy (IC) in locoregionally advanced nasopharyngeal carcinoma (LANPC) patients and further to develop a nomogram for predicting survival prognosis.

METHODS

A total of 498 patients with stage III-IVA NPC applying IC and concurrent chemotherapy were reviewed (training cohort, n = 376; validation cohort, n = 122).

RESULTS

Tumor response was an independent predictor for clinical outcomes. The nomogram included age, N stage, pretreatment Epstein-Barr virus DNA, lymphocyte-to-monocyte ratio, and tumor response achieved an ideal C-index of 0.703 (95% CI 0.655-0.751) in the validation cohort for predicting overall survival (OS), which outperformed than that of the TNM system alone (C-index, 0.670, 95% CI: 0.622-0.718). In addition, the nomogram could successfully classified patients into different risk groups.

CONCLUSIONS

We established and validated a precise and convenient nomogram based on tumor response for predicting the OS of LANPC patients.

Prognostic significance of wait time for radical radiotherapy in locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

The prognostic significance of wait time between definite diagnosis and initial radical radiotherapy is not well established in patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC) receiving both induction chemotherapy (IC) and concurrent chemoradiotherapy (CCRT).

METHODS

From 2010 to 2018, 648 patients with LA-NPC treated with IC followed by CCRT were included.

RESULTS

A total of 172 pairs of patients with LA-NPC were selected by propensity score matching (PSM). Compared to patients with an acceptable wait time (≤75 days), patients with a prolonged wait time (>75 days) had a significant lower 5-year DMFS rate (86.6% vs. 74.1%, p = 0.006). Subgroup analyses indicated that the unfavorable effects of longer waiting times were mainly seen among stage IVa patients.

CONCLUSIONS

A prolonged wait time (>75 days) between definite diagnosis and initial radical radiotherapy has negative prognostic effects on patients with LA-NPC receiving IC plus CCRT, particularly those with IVa stage.

Optimize the number of cycles of induction chemotherapy for locoregionally advanced nasopharyngeal carcinoma: a propensity score matching analysis

Background: There is no conclusive on the optimal number of cycles of induction chemotherapy (IC) with the greatest benefit to patient survival. This study aimed to assess the efficiency and acute toxicities of different cycles of IC for patients with locoregionally advanced nasopharyngeal carcinoma (LA-NPC). Methods: We reviewed data from patients with LA-NPC treated with IC plus concurrent chemoradiation (CCRT). Propensity score matching (PSM) was applied to match paired patients. After PSM, survival outcomes of matched patients were compared between two and three cycles of IC groups. Univariate and multivariate Cox regression analysis were carried out to identify potentially independent predictors. Treatment-related acute toxicities between the two groups were compared by Pearson X² test or Fisher's exact test. Results: In total, 189 pairs were selected. The median follow-up time was 60 months (range 5 to 126 months). There was no difference between two and three cycles of IC in terms of 5-year overall survival (87.0% vs. 89.7%, p = 0.991), distant metastasis-free survival (90.1% vs. 86.8%, p = 0.587), locoregional recurrence-free survival (97.0% vs. 93.8%, p = 0.488), or progression-free survival (79.4% vs. 79.3%, p = 0.896). Multivariate Cox analysis showed that T stage, N stage, and clinical stage were independent prognostic factors. Three cycles of IC were associated with a higher incidence of Grade 1-2 acute toxicity than two cycles during IC period. Conclusion: The efficacy of two cycles of IC achieved similar survival outcomes as three cycles and has a lower incidence of treatment-related acute toxicity.

Efficiency of high cumulative cisplatin dose in high- and low-risk patients with locoregionally advanced nasopharyngeal carcinoma

BACKGROUND

The optimal cumulative cisplatin dose (CCD) during radiation therapy for locoregionally advanced nasopharyngeal carcinoma (LA-NPC) patients receiving induction chemotherapy (IC) plus CCRT remains controversial. This study aimed to explore the treatment efficiency of CCD for high-and low-risk patients with LA-NPC.

METHODS

Data from 472 LA-NPC patients diagnosed from 2014 to 2018 and treated with IC plus CCRT were reviewed. After propensity score matching, the therapeutic effects of a CCD > 200 and CCD ≤ 200 mg/m² were evaluated comparatively. Five factors selected by multivariate analysis were incorporated to develop a nomogram. Subgroup analysis was conducted to explore the role of different CCDs in nomogram-defined high- and low-risk groups. Additionally, acute toxicities were evaluated comparatively between the high- and low-CCD groups.

RESULTS

After matching, there was no difference between different CCD groups for all patients in terms of 3-year overall survival (OS), distant metastasis-free survival (DMFS), locoregional recurrence-free survival (LRRFS), or progression-free survival (PFS). A nomogram was built by integrating pretreatment EBV DNA, clinical stage, and post-IC EBV DNA, post-IC primary gross tumor and lymph node volumes obtained a C-index of 0.674. The high-risk group determined by the nomogram had poorer 3-year PFS, OS, DMFS, and LRRFS than the low-risk group. A total of CCD > 200 mg/m² increased the survival rates of 3-year PFS and DMFS (PFS: 72.5% vs. 54.4%, p = 0.012; DMFS: 81.9% vs. 61.5%, p = 0.014) in the high-risk group but not in the low-risk group. Moreover, the high CCD increased treatment-related acute toxicities.

CONCLUSIONS

A high CCD was associated with better 3-year PFS and DMFS rates than a low dose for high-risk patients but could not produce a survival benefit for low-risk patients.