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Lin C, Lu Q, Chen Y, Chen X, Huang Y, Zhong H, Peng X, Hu C, Chen B, Lin S, Zong J. Failure patterns and individualized treatment plans of reirradiation for inoperable locally recurrent nasopharyngeal carcinoma. Sci Rep 2024; 14:17887. [PMID: 39095403 PMCID: PMC11297266 DOI: 10.1038/s41598-024-68676-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/26/2024] [Indexed: 08/04/2024] Open
Abstract
Re-irradiation with intensity-modulated radiotherapy (IMRT) remains the primary treatment modality for inoperable locally recurrent nasopharyngeal carcinoma (NPC). However, the rate of radiation-related late adverse effects is often substantially high. Therefore, we aimed to explore failure patterns and individualized treatment plans of re-irradiation for inoperable locally recurrent NPC. Ninety-seven patients who underwent IMRT were retrospectively analyzed. Sixty-two patients had clinical target volume of recurrence (rCTV) delineated, and thirty-five patients had only gross tumor volume of recurrence (rGTV) delineated. Twenty-nine patients developed second local failures after re-irradiation with IMRT (28 cases available). Among those patients, 64.3% (18/28) of patients and 35.7% (10/28) developed in-field or out-field, respectively. No statistical correlation was observed between target volume (rGTV or rCTV) and the local recurrence rate, local failure patterns, grade ≥ 3 toxicity, and survival. Multivariate analysis showed that recurrent T (rT) stage (HR 2.62, P = 0.019) and rGTV volume (HR 1.73, P = 0.037) were independent prognostic factors for overall survival (OS). Risk stratification based on rT stage and rGTV volume revealed that low risk group had a longer 3-year OS rate (66.7% vs. 23.4%), lower total grade ≥ 3 toxicity (P = 0.004), and lower re-radiation associated mortality rates (HR 0.45, P = 0.03) than high risk group. This study demonstrates that the delineation of rCTV may not be beneficial for re-irradiation using IMRT in locally recurrent NPC. Patients with low risk were most suitable for re-irradiation, with maximizing local salvage and minimizing radiation-related toxicities. More precise and individualized plans of re-irradiation are warranted.
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Affiliation(s)
- Cheng Lin
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Qiongjiao Lu
- Department of Radiation Oncology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Yuebing Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Xiaoqiang Chen
- Department of Otolaryngology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Yiping Huang
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Hangyan Zhong
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Xiane Peng
- Key Laboratory of Ministry of Education for Gastrointestinal Cancer, Fujian Medical University, Fuzhou, Fujian, China
| | - Cairong Hu
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Bijuan Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
| | - Shaojun Lin
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China
- Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, Fujian, China
| | - Jingfeng Zong
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, No. 420 Fuma Road, Fuzhou, 350014, Fujian, China.
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Xiao XT, Zou SQ, Chen YP, Guo R, Tang LL, Sun Y, Ma J, Li WF. Patterns and Prognosis of Local Recurrence of Nasopharyngeal Carcinoma after Intensity-modulated Radiotherapy. J Cancer 2024; 15:456-465. [PMID: 38169541 PMCID: PMC10758024 DOI: 10.7150/jca.88148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 11/12/2023] [Indexed: 01/05/2024] Open
Abstract
Objective: To investigate the patterns of local failure and prognosis in patients with locally recurrent nasopharyngeal carcinoma (rNPC) after primary intensity-modulated radiotherapy (IMRT). Methods: The data of 298 patients with locally rNPC after IMRT were retrospectively analyzed. Magnetic resonance images of the initial and recurrent tumors were reviewed and, for patients with extra-nasopharyngeal local recurrence, the gross tumor volume of local recurrence was transferred to the original IMRT plan for dosimetry analysis. Significant prognostic factors for overall survival (OS) were selected by multivariate Cox regression analysis. Results: The commonest recurrence sites were the nasopharynx (93%, 277/298) and skull base (53.7%, 160/298). Of the 21 patients with extra-nasopharyngeal recurrence (19 cases valid), 12 had in-field failures, 4 had marginal failures, and 3 had out-field failures. The ethmoid sinus (57.1%, 4/7) and nasal cavity (28.6%, 2/7) were the most frequent sites of marginal and out-field failures. After median follow-up of 37 months, the 3-year and estimated 5-year OS rates were 57.3% and 41.7%, respectively. Multivariate analysis showed that age, recurrence interval, plasma Epstein-Barr virus (EBV) DNA level, and recurrent T stage were independent prognostic factors for OS. Conclusions: Local failure after IMRT occurs most commonly in the nasopharynx and skull base. In patients with extra-nasopharyngeal recurrence, in-field failure remains the main failure pattern, and marginal and out-field failures mainly occur in the ethmoid sinus and nasal cavity. Elder age, shorter recurrence interval, detectable plasma EBV DNA, and advanced recurrent T stage are negative predictors of OS in patients with rNPC.
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Affiliation(s)
| | | | | | | | | | | | | | - Wen-Fei Li
- State Key Laboratory of Oncology in South China, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou 510060, P. R. China
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Qiu Z, Lin F, Wu Z, Wu T, Wang M, Hu J, Xie D, Lyu S, Ma J, Tao Y, Su Y. Why subclinical involvement is prescribed the same high dose as gross tumor volume: A study on high-dose clinical target volume in intensity-modulated radiotherapy plan of nasopharyngeal carcinoma. Head Neck 2023; 45:1206-1214. [PMID: 36856344 DOI: 10.1002/hed.27334] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Most nasopharyngeal carcinoma (NPC) protocols define primary gross tumor volume (GTVnx) plus a range from 2 to 5 mm as the high-dose clinical target volume (hd-CTV). However, in China, hd-CTV is defined as GTVnx plus 0 mm. METHODS A total of 40 patients with newly diagnosed nonmetastatic NPC (T1-T4 ten cases each) treated with IMRT were consecutively enrolled. Real and virtual treatment plans were designed according to the definitions of hd-CTV recommended by China and Radiation Therapy Oncology Group (RTOG), respectively. RESULTS The hd-CTV in China was significantly smaller than that of RTOG. Exposure doses to 5 mm subclinical involvement and OARs as well as NTCP in the China treatment plan were significantly lower than those of RTOG. CONCLUSION It could be recommended to divide the hd-CTV into GTV and subclinical target volume and to prescribe different doses for the GTV and subclinical involvement in the IMRT plan of NPC.
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Affiliation(s)
- Zichen Qiu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Feifei Lin
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Zheng Wu
- Department of Radiation Oncology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, China
| | - Taihua Wu
- School of Computer Science, Zhuhai College of Science and Technology, Zhuhai, China
| | - Mingli Wang
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Jiang Hu
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Dehuan Xie
- Department of Radiation Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Shaowen Lyu
- Department of Radiation Oncology (MAASTRO), GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jun Ma
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Yalan Tao
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
| | - Yong Su
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou, China
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Xu T, Feng Y, Hong H, Xu Y, Chen J, Qiu X, Ding J, Huang C, Li L, Chen C, Fei Z. Biological target volume based on fluorine-18-fluorode-oxyglucose positron emission tomography/computed tomography imaging: a spurious proposition? Radiat Oncol 2023; 18:32. [PMID: 36810119 PMCID: PMC9942280 DOI: 10.1186/s13014-023-02225-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/12/2023] [Indexed: 02/23/2023] Open
Abstract
PURPOSE To assess whether the high metabolic region of fluorine-18-fluorode-oxyglucose (18F-FDG) in the primary lesion is the crux for recurrence in patients with nasopharyngeal carcinoma (NPC), to assess the feasibility and rationale for use of biological target volume (BTV) based on 18F-FDG positron emission tomography/computed tomography (18F-FDG-PET/CT). METHODS The retrospective study included 33 patients with NPC who underwent 18F-FDG-PET/CT at the time of initial diagnosis as well as the time of diagnosis of local recurrence. Paired 18F-FDG-PET/CT images for primary and recurrent lesion were matched by deformation coregistration method to determine the cross-failure rate between two lesions. RESULTS The median volume of the Vpri (primary tumor volume using the SUV thresholds of 2.5), the Vhigh (the volume of high FDG uptake using the SUV50%max isocontour), and the Vrecur (the recurrent tumor volume using the SUV thresholds of 2.5) were 22.85, 5.57, and 9.98 cm3, respectively. The cross-failure rate of Vrecur∩high showed that 82.82% (27/33) of local recurrent lesions had < 50% overlap volume with the region of high FDG uptake. The cross-failure rate of Vrecur∩pri showed that 96.97% (32/33) of local recurrent lesions had > 20% overlap volume with the primary tumor lesions and the median cross rate was up to 71.74%. CONCLUSION 18F-FDG-PET/CT may be a powerful tool for automatic target volume delineation, but it may not be the optimal imaging modality for dose escalation radiotherapy based on applicable isocontour. The combination of other functional imaging could delineate the BTV more accurately.
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Affiliation(s)
- Ting Xu
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Ye Feng
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Huiling Hong
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Yiying Xu
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Jiawei Chen
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Xiufang Qiu
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Jianming Ding
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Chaoxiong Huang
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Li Li
- grid.415110.00000 0004 0605 1140Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014 Fujian People’s Republic of China
| | - Chuanben Chen
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014, Fujian, People's Republic of China.
| | - Zhaodong Fei
- Department of Radiation Oncology, Clinical Oncology School of Fujian Medical University, Fujian Cancer Hospital, Fuma Road, Fuzhou, 350014, Fujian, People's Republic of China.
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Yuan X, Yan C, Peng S, Chen Z, Lu T, Gong Q, Qiu Y, Xiong W, Ao F, Li G, Li J, Tu Z. Is a high-risk clinical target volume required? Evaluation of the dosimetric feasibility based on T staging. Front Oncol 2022; 12:800400. [PMID: 36119501 PMCID: PMC9478172 DOI: 10.3389/fonc.2022.800400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
Background Clinical target delineation is a primary focus in the field of radiotherapy. This study aimed to investigate whether high-risk clinical target volume can be removed in nasopharyngeal carcinoma patients with different T stages. Materials and methods We designed a test plan without the high-risk clinical target volume for 111 nasopharyngeal carcinoma patients and further compared the test plans with the treatment plans in the parameters of planning target volumes and the radiation dose to normal organs. Results Our data showed that when high-risk clinical target volume was abnegated, target coverage, conformity indices, and homogeneity indices of planning target volumes and doses of normal organs were not influenced in the T4 nasopharyngeal carcinoma patients, and more than 95% of the high-risk planning target volume area could still be covered by the 60 Gy dose line. However, only some T1–3 patients achieved the ideal dose coverage, and even fewer after induction chemotherapy (62.8% vs. 41.2%, p = 0.018). Gross tumor volume was positively correlated with the target coverage of the original high-risk planning target volume in the test-plan (p = 0.0001). Gross tumor volume can be used to predict whether the target coverage of high-risk planning target volume is more than 95% (area under the curve = 0.868). Conclusion Omitting high risk clinical target volume can be considered in patients with T4 nasopharyngeal carcinoma according to physical evaluations. However, this approach is only suitable for a specific subset of T1–3 patients.
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Affiliation(s)
- Xingxing Yuan
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Chao Yan
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Shiyi Peng
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Zhiping Chen
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Tianzhu Lu
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Qiaoying Gong
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Yang Qiu
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Wenming Xiong
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Fenghua Ao
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Guoqing Li
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
| | - Jingao Li
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
- *Correspondence: Ziwei Tu, ; Jingao Li,
| | - Ziwei Tu
- National Health Commission (NHC) Key Laboratory of Personalized Diagnosis and Treatment of Nasopharyngeal Carcinoma (Jiangxi Cancer Hospital of Nanchang University), Nanchang, China
- Department of Radiation Oncology, Jiangxi Cancer Hospital, Nanchang, China
- *Correspondence: Ziwei Tu, ; Jingao Li,
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Xiao X, Wu Y, Chen Y, Liu X, Guo R, Tang L, Ma J, Li W. Patterns and prognosis of regional recurrence in nasopharyngeal carcinoma after intensity-modulated radiotherapy. Cancer Med 2022; 12:1399-1408. [PMID: 35822664 PMCID: PMC9883543 DOI: 10.1002/cam4.5020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE We analyzed the patterns of lymph node (LN) failure and prognosis in patients with regional recurrent nasopharyngeal carcinoma (rNPC) alone after primary intensity-modulated radiotherapy (IMRT). METHODS A total of 175 patients who were treated with IMRT between 2010 and 2015 and who experienced regional recurrence alone were included. Recurrent LNs were re-located in the initial pretreatment imaging and IMRT plan and failures were classified as in-field or out-field based on target volume delineation. All patients underwent curative salvage treatment. Independent prognostic factors for overall survival (OS) were selected by multivariate Cox analysis. RESULTS Level IIb (49.1%, 86/175) was the most frequent recurrence site, followed by level IIa (36%), level III (18.9%), level IVa (12%), the retropharyngeal region (8%), level Va (6.9%), and the parotid region (6.9%). A total of 264 recurrent LNs were recorded: 149 (56.4%) were classified as in-field failure with a prescribed dose ≥66 Gy, 60 (22.7%) with 60 to <66 Gy, 32 (12.1%) with 50 to <60 Gy, and 23 (8.7%) as an out-field failure, which mainly occurred in the parotid region and level Ib. After a median follow-up of 52.8 months, the estimated 5-year OS rate was 66.9%. Multivariate analysis showed that age, plasma Epstein-Barr virus DNA level, extranodal extension, lower neck involvement, and parotid LN recurrence were independent prognostic factors of OS. CONCLUSIONS In-field failure represented the main pattern of regional recurrence and out-field failure mainly occurred in the parotid gland and level Ib. Patients with regional rNPC alone had a good prognosis after salvage treatment.
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Affiliation(s)
- Xiao‐Tang Xiao
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Yi‐Shan Wu
- Department of Nasopharyngeal CarcinomaSun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
| | - Yu‐Pei Chen
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Xu Liu
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Rui Guo
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Ling‐Long Tang
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Jun Ma
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
| | - Wen‐Fei Li
- Department of Radiation OncologySun Yat‐sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer MedicineGuangzhouGuangdongPeople's Republic of China
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Research Value of Intensity Modulated Radiation Therapy in Alleviating Parotid Gland Function Injury in Patients with Stage N0 Nasopharyngeal Carcinoma from Physical and Dosimetric Aspects. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:4651364. [PMID: 35860184 PMCID: PMC9293508 DOI: 10.1155/2022/4651364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022]
Abstract
Objective To study the feasibility of intensity modulated radiation therapy (IMRT) for stage N0 nasopharyngeal carcinoma (NPC) and its parotid gland (PG) function preservation from physical and dosimetric aspects. Methods All the clinical data of 77 patients with pathologically confirmed T1-4N0M0 NPC who received radiotherapy between July 2017 and October 2019 in the Radiotherapy Center of Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University were analyzed retrospectively. Three-dimensional conformal radiotherapy (3D-CRT) and IMRT were used in 35 and 42 cases, respectively. The treatment efficiency and the dosimetry differences of the PG in the intensity modulation plan were compared between groups. Quantitative monitoring of 99mTc radionuclide imaging of PG was performed before, at the end of, and 3, 6, and 12 months after radiotherapy. The degree of PG function injury and xerostomia was compared between groups at the end of radiotherapy and 12 months later. Results Higher minimal, maximal, and average irradiation doses of PG were determined in 3D-CRT-treated patients compared with IMRT-treated cases (P < 0.05). Compared with before radiotherapy, the PG uptake index (UI) and excretion index (EI) of both cohorts of patients decreased to varying degrees at the end of radiotherapy, with PG function injury and xerostomia symptoms observed in all cases but with no obvious difference between groups (P > 0.05). To a certain extent, the PG function recovered and the xerostomia symptoms relieved in both groups 12 months after radiotherapy, with better improvements in IMRT group versus 3D-CRT group. Conclusion IMRT has similar short-term efficacy to 3D-CRT in treating patients with stage N0 NPC, but it can effectively reduce the dose of PG radiotherapy and protect the PG function on the premise of ensuring sufficient tumor coverage and dose, showing certain dosimetry advantages.
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Pêtre A, Quivrin M, Briot N, Boustani J, Martin E, Bessieres I, Cochet A, Créhange G. Salvage involved-field and extended-field radiotherapy in PET-positive nodal recurrent prostate cancer: outcomes and patterns of failure. Adv Radiat Oncol 2022; 8:101040. [DOI: 10.1016/j.adro.2022.101040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 07/19/2022] [Indexed: 11/27/2022] Open
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Wei YH, Wang Y, Li H, Wang CJ, Liu SR, Huang ZL, Wang GN, Tao YL, Xia YF. A Nomogram to Predict Survival in Patients With Locoregional Recurrent Nasopharyngeal Carcinoma Receiving Comprehensive Treatment. Front Oncol 2022; 12:892510. [PMID: 35785157 PMCID: PMC9243306 DOI: 10.3389/fonc.2022.892510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/16/2022] [Indexed: 12/24/2022] Open
Abstract
ObjectiveThis study aimed to establish a prognostic stratified model of chemotherapy-based comprehensive treatment for patients with locoregional recurrent nasopharyngeal carcinoma (lrNPC), to help individualized treatment decision-making.Materials and MethodsThis study retrospectively reviewed patients with lrNPC who received chemotherapy-based comprehensive treatment from January 1, 2010, to December 31, 2018. A total of 422 eligible patients were divided into test (n = 338) and validation (n = 84) cohorts. A LASSO cox regression model was used to identify significant prognostic factors for overall survival (OS) in the test cohort. A nomogram was then developed based on a combined consideration of clinically meaningful prognostic factors and statistically significant prognostic factors. The performance of the nomogram was assessed with Harrell’s concordance index (C-index) and calibration plots.ResultsFive significant factors were identified: age, albumin (ALB), T stage after recurrent (rT), neutrophil to lymphocyte ratio (NLR), and systematic immune-inflammation index (SII). The nomogram was established with these five factors. C-index was 0.636 in the test cohort and 0.610 in the validation cohort. The calibration curves for the OS rate at 3, and 5 years showed an excellent agreement in both cohorts. In addition, the corresponding risk classification system successfully classified patients into low- and high-risk groups and performed well in stratification (P < 0.001).ConclusionsThe nomogram shows well prognostic performance for lrNPC patients receiving chemotherapy-based comprehensive treatment.
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Affiliation(s)
- Ying-Hong Wei
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ying Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - He Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Chi-jie Wang
- Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Song-Ran Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Pathology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zi-Lu Huang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Guan-Nan Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Head & Neck Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Ya-Lan Tao
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Yun-Fei Xia, ; Ya-Lan Tao,
| | - Yun-Fei Xia
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Sun Yat-sen University Cancer Center, Guangzhou, China
- Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
- *Correspondence: Yun-Fei Xia, ; Ya-Lan Tao,
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10
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Liu X, Wu B, Huang J, Qin Y, Zhang Z, Shi L, Hong X, Ding Q, Peng G, Yang K. Tumor factors associated with in‐field failure for nasopharyngeal carcinoma after intensity‐modulated radiotherapy. Head Neck 2022; 44:876-888. [PMID: 35067997 DOI: 10.1002/hed.26983] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/24/2021] [Accepted: 01/05/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Xixi Liu
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Bian Wu
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Jing Huang
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - You Qin
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Zhanjie Zhang
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Liangliang Shi
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Xiaohua Hong
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Qian Ding
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Gang Peng
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
| | - Kunyu Yang
- Cancer Center, Union Hospital, Tongji Medical College Huazhong University of Science and Technology Wuhan China
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11
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Liao W, He J, Liu Z, Tian M, Yang J, Han J, Xiao J. A novel dosimetric metrics-based risk model to predict local recurrence in nasopharyngeal carcinoma patients treated with intensity-modulated radiation therapy. Radiat Oncol 2021; 16:186. [PMID: 34556123 PMCID: PMC8461883 DOI: 10.1186/s13014-021-01911-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/09/2021] [Indexed: 02/08/2023] Open
Abstract
Background To develop a risk model based on dosimetric metrics to predict local recurrence in nasopharyngeal carcinoma (NPC) patients treated with intensive modulated radiation therapy (IMRT). Methods 493 consecutive patients were included, among whom 44 were with local recurrence. One-to-two propensity score matching (PSM) was used to balance variables between recurrent and non-recurrent groups. Dosimetric metrics were extracted, and critical dosimetric predictors of local recurrence were identified by Cox regression model. Moreover, recurrent sites and patterns were examined by transferring the recurrent tumor to the pretreatment planning computed tomography. Results After PSM, 44 recurrent and 88 non-recurrent patients were used for dosimetric analysis. The univariate analysis showed that eight dosimetric metrics and homogeneity index were significantly associated with local recurrence. The risk model integrating D5 and D95 achieved a C-index of 0.706 for predicting 3-year local recurrence free survival (LRFS). By grouping patients using median value of risk score, patients with risk score ˃ 0.885 had significantly lower 3-year LRFS (66.2% vs. 86.4%, p = 0.023). As for recurrent features, the proportion of relapse in nasopharynx cavity, clivus, and pterygopalatine fossa was 61.4%, 52.3%, and 40.9%, respectively; and in field, marginal, and outside field recurrence constituted 68.2%, 20.5% and 11.3% of total recurrence, respectively. Conclusions The current study developed a novel risk model that could effectively predict the LRFS in NPC patients. Additionally, nasopharynx cavity, clivus, and pterygopalatine fossa were common recurrent sites and in field recurrence remained the major failure pattern of NPC in the IMRT era. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-021-01911-5.
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Affiliation(s)
- Wenjun Liao
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinlan He
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zijian Liu
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Maolang Tian
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jiangping Yang
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jiaqi Han
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jianghong Xiao
- Department of Radiation Oncology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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12
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Guo Q, Zheng Y, Lin J, Xu Y, Hu C, Zong J, Lu T, Xu H, Chen B, Liang Q, Xiao Y, Pan J, Lin S. Modified reduced-volume intensity-modulated radiation therapy in non-metastatic nasopharyngeal carcinoma: A prospective observation series. Radiother Oncol 2021; 156:251-257. [PMID: 33418007 DOI: 10.1016/j.radonc.2020.12.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/17/2020] [Accepted: 12/22/2020] [Indexed: 12/08/2022]
Abstract
BACKGROUND AND PURPOSE Although the efficacy of "reduced-volume intensity-modulated radiation therapy (IMRT)" in nasopharyngeal carcinoma (NPC) has been confirmed, two issues regarding the necessity of clinical target volume 1(CTV1) delineation and the optimal margin of CTV2 remained undetermined. The current series, utilized de-intensification technique that omitted the contouring of CTV1 and narrowed the margin of CTV2 from 10 mm to 8 mm, namely "modified reduced-volume IMRT" was initiated to evaluate the efficacy and feasibility of this renew technique in a prospective series. PATIENTS AND MATERIALS Dosimetric analysis was performed in 40 non-metastatic NPC cases to evaluate whether our modification is feasible. Then this de-intensification technique was applied in non-metastatic NPC patients treated in our attending group since late 2014. Survival outcomes focused on local recurrence-free survival (LRFS) and local failure pattern were analyzed. RESULTS Preliminary dosimetric evaluation of "modified reduced-volume IMRT" showed that the 60 Gy isodose curve generated naturally by this technique could well wrap the target area of CTV1. Subsequent observation series, which included a total of 471 patients and had a median follow-up time of 46.2 months(range,3.7-70.8 months), reported that 4-year estimated LRFS, regional recurrence-free survival (RRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were 96.6%, 97.7%, 87.7% and 92.4%, respectively. All local recurrence lesions occurred within 95% isodose lines and were considered in-field failures. CONCLUSIONS Our de-intensification technique "modified reduced-volume IMRT" was feasible and did not compromise therapeutic efficacy, well-designed multicenter prospective trials are needed for further research.
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Affiliation(s)
- Qiaojuan Guo
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China; Key Laboratory of Systems Biomedicine (Ministry of Education), Shanghai Center for Systems Biomedicine, Shanghai Jiao Tong University, China
| | - Yahan Zheng
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Jinyong Lin
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Yun Xu
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Cairong Hu
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jingfeng Zong
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Tianzhu Lu
- Department of Radiation Oncology, Jiangxi Cancer Hospital of Nanchang University, China
| | - Hanchuan Xu
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Bijuan Chen
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Qiandong Liang
- Department of Radiation Oncology, Fujian Medical University Cancer Hospital & Fujian Cancer Hospital, Fuzhou, China
| | - Youping Xiao
- Department of Radiology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Jianji Pan
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China
| | - Shaojun Lin
- Department of Radiation Oncology, Fujian Cancer Hospital & Fujian Medical University Cancer Hospital, Fuzhou, China; Fujian Key Laboratory of Translational Cancer Medicine, Fuzhou, China.
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13
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Weng JJ, Wei JZ, Li M, Zhang SJ, Wei YZ, Wang HW, Qin DX, Lu JL, Jiang H, Qu SH. Effects of Surgery Combined with Chemoradiotherapy on Short- and Long-Term Outcomes of Early-Stage Nasopharyngeal Carcinoma. Cancer Manag Res 2020; 12:7813-7826. [PMID: 32922081 PMCID: PMC7457865 DOI: 10.2147/cmar.s262567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/07/2020] [Indexed: 01/26/2023] Open
Abstract
Objective The efficacy of surgery as the primary treatment modality for nasopharyngeal carcinoma (NPC) is yet to be clarified. Therefore, we aimed to explore the short- and long-term efficacy of surgery for early-stage NPC. Methods We retrospectively evaluated 341 patients diagnosed with early-stage NPC between September 2010 and December 2015. Among them, 58 patients underwent endoscopic nasopharyngectomy combined with chemoradiotherapy, whereas 283 patients underwent conventional chemoradiotherapy. The patients who underwent concurrent chemoradiotherapy or radiotherapy alone were matched to patients who underwent surgery in a 1:2 ratio using propensity score matching to analyze the clinical efficacy of each therapeutic modality. The primary endpoint was survival, and the secondary endpoints were tumor regression rate and reduction in Epstein–Barr virus (EBV)-DNA levels. Results After matching, 156 patients were enrolled (58 patients in the surgery group; 98 patients in the non-surgery group). The baseline data of the matched patients had good inter-group comparability (All P>0.05). The surgery group had significantly higher 5-year overall survival (98.30% vs. 91.70%), disease-free survival (98.30% vs. 81.40%), and recurrence-free survival (100.00% vs. 90.10%) rates than did the non-surgery group (All P<0.05). In total, 0 and 14 patients in the surgery and non-surgery groups, respectively, had residual cancer at the end of treatment (P=0.001). All patients in the surgery group tested negative for EBV-DNA, whereas two patients in the non-surgery group tested positive. The incidence of hematologic toxicity during treatment was similar between the two groups (All P>0.05). Still, the incidence of severe oral mucositis was lower in the surgery group than in the non-surgery group (37.9% vs. 54.08%, P=0.051). Conclusion Surgery can improve the clearance rate of EB virus and reduce tumor residue. Surgery may be a safe and effective treatment for early NPC.
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Affiliation(s)
- Jing-Jin Weng
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Jia-Zhang Wei
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Min Li
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Shao-Jie Zhang
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Yun-Zhong Wei
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Han-Wei Wang
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Dan-Xue Qin
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Jin-Long Lu
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - He Jiang
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
| | - Shen-Hong Qu
- Department of Otolaryngology & Head and Neck, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning 530021, People's Republic of China
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