M1 stage subdivisions based on 18F-FDG PET-CT parameters to identify locoregional radiotherapy for metastatic nasopharyngeal carcinoma.

Purpose: To establish a risk classification of de novo metastatic nasopharyngeal carcinoma (mNPC) patients based on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET-CT) radiomics parameters to identify suitable candidates for locoregional radiotherapy (LRRT). Methods: In all, 586 de novo mNPC patients who underwent 18F-FDG PET-CT prior to palliative chemotherapy (PCT) were involved. A Cox regression model was performed to identify prognostic factors for overall survival (OS). Candidate PET-CT parameters were incorporated into the PET-CT parameter score (PPS). Recursive partitioning analysis (RPA) was applied to construct a risk stratification system. Results: Multivariate Cox regression analyses revealed that total lesion glycolysis of locoregional lesions (LRL-TLG), the number of bone metastases (BMs), metabolic tumor volume of distant soft tissue metastases (DSTM-MTV), pretreatment Epstein-Barr virus DNA (EBV DNA), and liver involvement were independent prognosticators for OS. The number of BMs, LRL-TLG, and DSTM-MTV were incorporated as the PPS. Eligible patients were divided into three stages by the RPA-risk stratification model: M1a (low risk, PPSlow + no liver involvement), M1b (intermediate risk, PPSlow + liver involvement, PPShigh + low EBV DNA), and M1c (high risk, PPShigh + high EBV DNA). PCT followed by LRRT displayed favorable OS rates compared to PCT alone in M1a patients (p < 0.001). No significant survival difference was observed between PCT plus LRRT and PCT alone in M1b and M1c patients (p > 0.05). Conclusions: The PPS-based RPA stratification model could identify suitable candidates for LRRT. Patients with stage M1a disease could benefit from LRRT.

Geriatric nutritional risk index as an independent prognostic factor in locally advanced nasopharyngeal carcinoma treated using radical concurrent chemoradiotherapy: a retrospective cohort study.

BACKGROUND: Nutritional status is a key factor influencing the prognosis of patients with cancer. The Geriatric Nutritional Risk Index (GNRI) has been used to predict mortality risk and long-term outcomes. In this study, we aimed to evaluate the predictive value of pretreatment GNRI in patients with nasopharyngeal carcinoma (NPC). METHODS: A total of 1,065 patients with biopsy-proven non-disseminated nasopharyngeal carcinoma were included. Based on a cutoff value of pretreatment GNRI, patients were divided into two groups (low ≤107.7 and high >107.7). Combining GNRI and baseline Epstein-Barr virus (EBV) DNA, all patients were further stratified into three risk groups, namely, high-risk (high EBV DNA and low GNRI), low-risk (low EBV DNA and high GNRI), and medium-risk (except the above) groups. Multivariate analyses were performed using the Cox proportional hazards model to assess the predictive value of the GNRI. RESULTS: Among the 1,065 patients, 527 (49.5%) and 538 (50.5%) were divided into low and high GNRI groups, respectively. Within a median follow-up of 83 months, patients with a high GNRI score exhibited significantly higher overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) compared to those with low GNRI scores (P<0.05). Multivariate analyses revealed that high GNRI is an independent prognostic factor for OS and PFS (hazard ratio, HR, 0.471, 95% CI, 0.270-0.822, P=0.008; HR 0.638, 95% CI, 0.433-0.941, P=0.023, respectively). Using a combination of baseline GNRI and EBV DNA, a satisfying separation of survival curves between different risk groups for OS, PFS, DMFS was observed. The survival rates of patients in the high-risk group were significantly lower than those in the low- and medium-risk groups (all P<0.001). The combined classification was demonstrated to be an independent prognostic factor for OS and PFS after adjustment using multivariate analysis. CONCLUSIONS: Pretreatment GNRI is an independent prognostic factor for NPC patients. The combination of baseline GNRI score and EBV DNA level improved the prognostic stratification of NPC patients.

Establishment and validation of a prognostic nomogram to predict early metastasis in nasopharyngeal carcinoma patients within six months after radiotherapy and to guide intensive treatment.

PURPOSE: This study aimed to establish an effective prognostic nomogram to predict the risk of early metastasis (EM) in nasopharyngeal carcinoma (NPC) patients, as a guide for intensive treatment. MATERIALS AND METHODS: A total of 9021 patients with biopsy-confirmed NPC at our institute were enrolled in this study between December 2006 to December 2016. We randomized these patients using a proportion of 2/3 and 1/3 and selected 6044 and 2977 patients as the training and validation cohorts, respectively. All patients received radiotherapy with or without chemotherapy. Univariate and multivariate logistical regressions were used to identify independent risk factors. The nomogram's predictive value was evaluated by concordance indexes (C-indexes), calibration curves, probability density functions (PDFs), and clinical utility curves (CUCs). ROC analysis using Delong test was used to compare efficiency between the nomogram and other risk factors. RESULTS: In total, 174 (2.9%) and 81 (2.7%) patients in training and validation cohorts, respectively, had EM. Pretreatment plasma EBV DNA, N stage, LDH, ALP, BMI, and sex were independent predictive factors of EM. The C-indexes of nomogram were 0.756 (95% CI = 0.719-0.793) and 0.766 (95% CI = 0.720-0.813), in the training and validation cohorts, respectively. The C-index of the nomogram was significantly superior to any one of independent factors. According to the PDFs and CUCs and considering the balance of the true positive EM patients and true positive non-EM patients, we chose 5.0% as a threshold probability for clinical decision-making, which could distinguish about 85% and 48% of non-EM and EM patients, respectively. CONCLUSION: Our nomogram had good accuracy in predicting EM incidence, and a 5.0% threshold was appropriate for clinical decision-making.

A new T classification based on masticator space involvement in nasopharyngeal carcinoma: a study of 742 cases with magnetic resonance imaging.

BACKGROUND: The aim of this study was to investigate the prognostic significance and various classifications for anatomic masticator space involvement (MSI) in patients with nasopharyngeal carcinoma (NPC). METHODS: This study retrospectively analyzed 742 patients with untreated nondisseminated NPC who underwent magnetic resonance imaging (MRI) scan of the nasopharynx and neck. The MSI was graded according to different anatomic features. The overall survival (OS), local relapse-free survival (LRFS), distant metastasis-free survival (DMFS), and disease-free survival (DFS) of the patients with different MSI grades were analyzed using the Kaplan-Meier method and log-rank tests. RESULTS: The frequency of MSI was 24.1% (179/742). The 5-year OS, LRFS, DMFS, DFS for NPC patients with versus without MSI were 70.9% versus 82.5% (P = 0.001), 94.1% versus 91.4% (P = 0.511), 81.4% versus 88.7% (P = 0.021), and 78.0% versus 83.5% (P = 0.215), respectively. Significant differences in OS were also found among different MSI groups. In the patients with MSI, the OS of the group with medial and/or lateral pterygoid involvement (MLPI) NPC was 73.9% compared to 51.3% (P < 0.0001) in the patients with infratemporal fossa involvement (IFI). CONCLUSIONS: MSI was an independent prognostic factor for OS and DMFS. NPCs invading the masticator space should be separately categorized into MLPI and IFI prognostic groups. We suggest that MLPI should be staged as T3 while IFI is staged as T4 disease in future TNM staging revision.

Elevated serum endostatin levels are associated with poor survival in patients with advanced-stage nasopharyngeal carcinoma.

AIMS: To evaluate the prognostic value of serum endostatin levels in patients with advanced-stage nasopharyngeal carcinoma (NPC). MATERIALS AND METHODS: Between August 2003 and March 2005, 218 patients with advanced-stage NPC were enrolled in this study, including 70 patients in the training cohort and 148 in the validation cohort. The pre-treatment serum endostatin and vascular endothelial growth factor (VEGF) levels were measured using competitive enzyme immunoassays. For the normal control, serums samples from 20 healthy individuals were also collected. RESULTS: Serum endostatin levels in the patients with advanced-stage NPC were significantly higher than those of controls, but VEGF levels were similar in the two groups. Univariate analysis revealed significant differences between the high and low endostatin level groups regarding 5 year overall survival (63.9% versus 90.5%; P = 0.003), progression-free survival (PFS) (50.2% versus 79.3%; P = 0.003) and distant metastasis-free survival (DMFS) (59.1% versus 85.3%; P = 0.01) in the training cohort. Using the same cut-off value generated from the training cohort, there were also significant unfavourable correlations between serum endostatin levels and overall survival (P = 0.001), PFS (P = 0.001) and DMFS (P = 0.002) in the second independent validation cohort. Multivariate analysis using the entire group (n = 218) revealed that the serum endostatin level was an independent unfavourable prognostic factor for overall survival (hazard ratio 4.8; 95% confidence interval 2.48-9.23; P < 0.0001), PFS (hazard ratio 3.44; 95% confidence interval 2.06-5.74; P < 0.0001) and DMFS (hazard ratio 3.65; 95% confidence interval 1.92-6.94; P < 0.0001) in patients with advanced-stage NPC. No associations were observed between the outcomes and the serum VEGF levels in patients with advanced-stage NPC. CONCLUSIONS: High endostatin levels are associated with poor survival and this knowledge may improve the risk stratification of patients with advanced-stage NPC.

Prognostic value and differences of the sixth and seventh editions of the UICC/AJCC staging systems in nasopharyngeal carcinoma.

BACKGROUND: The aim of this study was to identify the prognostic value and differences between the 6th and 7th International Union Against Cancer/American Joint Committee on Cancer staging systems in nasopharyngeal carcinoma. METHODS: The magnetic resonance imaging scans and medical records of 903 patients with histologically diagnosed non-disseminated nasopharyngeal carcinoma were reviewed retrospectively. Moreover, the extent of nasopharyngeal carcinoma was restaged according to the 6th and 7th editions of the staging systems. RESULTS: Among the 903 patients, the 5-year survival rates were as follows: overall survival (OS), 81 %; local relapse-free survival (LRFS), 90 %; distant metastasis-free survival, 86 %; and disease-free survival, 77 %. Using the 7th edition of the staging system, significant differences in OS between categories T1 and T3, categories T1 and T4, categories T2 and T3, and categories T2 and T4 were achieved (P < 0.001 for all models). However, LRFS differed only between categories T1 and T3 and categories T1 and T4 (P = 0.008 and P = 0.003). No statistically significant differences in LRFS were observed among the different groups of anatomic masticator space invasion (P = 0.781, P = 0.457 and P = 0.696). Significant differences in DMFS were achieved, except between categories N3a and N3b (P = 0.826). The T category and N category were independent prognostic factors for the major endpoints in the Cox multivariate regression analysis (P < 0.005). CONCLUSION: The revisions of the 7th edition of the staging system are acceptable with regard to the distribution of patient classifications and the separation of survival curves. Moreover, this study will help to develop a better classification system and to better identify the appropriate treatment regimens in nasopharyngeal carcinoma.

Prognostic significance of the various classifications for parapharyngeal space involvement in nasopharyngeal carcinoma.

CONCLUSION: Advanced parapharyngeal space (PPS) involvement showed stronger prognostic value than PPS involvement. The classification of PPS involvement proposed by Min or Sham was the most appropriate classification for parapharyngeal extension in nasopharyngeal carcinoma (NPC). The degree of tumor extension into the PPS should be considered in future TNM staging revisions. OBJECTIVES: This study was conducted to evaluate the prognostic significance of the various classifications for PPS involvement in patients with NPC. METHODS: From January to July 2000, a total of 176 patients with pathologically diagnosed NPC were prospectively enrolled in this study. The extent of PPS involvement was examined by contrast-enhanced computed tomography (CT) scan and graded according to the four previously reported classifications (Min, Sham, Xiao, and Heng). RESULTS: The incidence of PPS involvement was 81.8%. The 5-year overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS), and local relapse-free survival rates (LRFS) of the patients with and without PPS involvement were 68.1% and 90.2% (p = 0.010), 66.1% and 87.2% (p = 0.013), 76.7% and 93.6% (p = 0.032), and 84.9% and 93.1% (p = 0.220), respectively. Multivariate analysis showed that PPS involvement (yes vs no) was not an independent prognostic factor. However, graded PPS involvement was an independent factor affecting the prognosis of NPC. When the four classifications were included in a Cox model, it was shown that PPS involvement based on Min's classification was an independent factor for OS (p = 0.001). PPS involvement based on Sham's classification was an independent factor for PFS (p = 0.010) and DMFS (p = 0.009).