Analysis of Plasma Epstein-Barr Virus DNA to Screen for Nasopharyngeal Cancer.

BACKGROUND: Circulating cell-free Epstein-Barr virus (EBV) DNA is a biomarker for nasopharyngeal carcinoma. We conducted a prospective study to investigate whether EBV DNA in plasma samples would be useful to screen for early nasopharyngeal carcinoma in asymptomatic persons. METHODS: We analyzed EBV DNA in plasma specimens to screen participants who did not have symptoms of nasopharyngeal carcinoma. Participants with initially positive results were retested approximately 4 weeks later, and those with persistently positive EBV DNA in plasma underwent nasal endoscopic examination and magnetic resonance imaging (MRI). RESULTS: A total of 20,174 participants underwent screening. EBV DNA was detectable in plasma samples obtained from 1112 participants (5.5%), and 309 (1.5% of all participants and 27.8% of those who initially tested positive) had persistently positive results on the repeated sample. Among these 309 participants, 300 underwent endoscopic examination, and 275 underwent both endoscopic examination and MRI; of these participants, 34 had nasopharyngeal carcinoma. A significantly higher proportion of participants with nasopharyngeal carcinoma that was identified by screening had stage I or II disease than in a historical cohort (71% vs. 20%, P<0.001 by the chi-square test) and had superior 3-year progression-free survival (97% vs. 70%; hazard ratio, 0.10; 95% confidence interval, 0.05 to 0.18). Nine participants declined to undergo further testing, and 1 of them presented with advanced nasopharyngeal carcinoma 32 months after enrollment. Nasopharyngeal carcinoma developed in only 1 participant with negative EBV DNA in plasma samples within 1 year after testing. The sensitivity and specificity of EBV DNA in plasma samples in screening for nasopharyngeal carcinoma were 97.1% and 98.6%, respectively. CONCLUSIONS: Analysis of EBV DNA in plasma samples was useful in screening for early asymptomatic nasopharyngeal carcinoma. Nasopharyngeal carcinoma was detected significantly earlier and outcomes were better in participants who were identified by screening than in those in a historical cohort. (Funded by the Kadoorie Charitable Foundation and the Research Grants Council of the Hong Kong government; ClinicalTrials.gov number, NCT02063399 .).

Early detection of nasopharyngeal carcinoma: performance of a short contrast-free screening magnetic resonance imaging.

BACKGROUND: Although contrast-enhanced magnetic resonance imaging (MRI) detects early-stage nasopharyngeal carcinoma (NPC) not detected by endoscopic-guided biopsy (EGB), a short contrast-free screening MRI would be desirable for NPC screening programs. This study evaluated a screening MRI in a plasma Epstein-Barr virus (EBV)-DNA NPC screening program. METHODS: EBV-DNA-screen-positive patients underwent endoscopy, and endoscopy-positive patients underwent EGB. EGB was negative if the biopsy was negative or was not performed. Patients also underwent a screening MRI. Diagnostic performance was based on histologic confirmation of NPC in the initial study or during a follow-up period of at least 2 years. RESULTS: The study prospectively recruited 354 patients for MRI and endoscopy; 40/354 (11.3%) endoscopy-positive patients underwent EGB. Eighteen had NPC (5.1%), and 336 without NPC (94.9%) were followed up for a median of 44.8 months. MRI detected additional NPCs in 3/18 (16.7%) endoscopy-negative and 2/18 (11.1%) EGB-negative patients (stage I/II, n = 4; stage III, n = 1). None of the 24 EGB-negative patients who were MRI-negative had NPC. MRI missed NPC in 2/18 (11.1%), one of which was also endoscopy-negative. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of MRI, endoscopy, and EGB were 88.9%, 91.1%, 34.8%, 99.4%, and 91.0%; 77.8%, 92.3%, 35.0%, 98.7%, and 91.5%; and 66.7%, 92.3%, 31.6%, 98.1%, and 91.0%, respectively. CONCLUSION: A quick contrast-free screening MRI complements endoscopy in NPC screening programs. In EBV-screen-positive patients, MRI enables early detection of NPC that is endoscopically occult or negative on EGB and increases confidence that NPC has not been missed.

Early detection of nasopharyngeal carcinoma by plasma Epstein-Barr virus DNA analysis in a surveillance program.

BACKGROUND: Nasopharyngeal carcinoma (NPC) is prevalent in Southeast Asia. Over the last decade, plasma Epstein-Barr virus (EBV) DNA has been developed as a tumor marker for NPC. In this study, the authors investigated whether plasma EBV DNA analysis is useful for NPC surveillance. METHODS: In total, 1318 volunteers ages 40 to 60 years were prospectively recruited. Plasma EBV DNA and serology for viral capsid antigen immunoglobulin A (IgA) were measured. Participants who had detectable plasma EBV DNA or positive IgA serology underwent nasal endoscopic examination and a follow-up plasma EBV DNA analysis in approximately 2 weeks. All participants were followed for 2 years to record the development of NPC. RESULTS: Three individuals with NPC were identified at enrolment. All of them were positive for EBV DNA and remained positive in follow-up analysis. Only 1 of those patients was positive for EBV serology. In 1 patient who had NPC with a small tumor confined to the mucosa, the tumor was not detectable on endoscopic examination. Because of a 2-fold increase in plasma EBV DNA on the follow-up analysis, that patient underwent magnetic resonance imaging, which revealed the tumor. Among the participants who did not have NPC but had initially positive plasma EBV DNA results, approximately 66% had negative EBV DNA results after a median of 2 weeks. CONCLUSIONS: Plasma EBV DNA analysis proved useful for detecting early NPC in individuals without a clinical suspicion of NPC. Repeating the test in those who had initially positive results differentiated those with NPC from those who had false-positive results. Cancer 2013. © 2013 American Cancer Society.

Plasma Epstein-Barr Virus DNA and Risk of Future Nasopharyngeal Cancer.

BACKGROUND: We previously conducted a prospective study to show that nasopharyngeal cancer (NPC) screening with circulating Epstein­Barr virus (EBV) DNA analysis can improve survival. However, the long-term significance of positive results in individuals without cancer was unclear. METHODS: We conducted a second-round screening at a median of 43 months after the initial screening. Participants with detectable plasma EBV DNA were retested in 4 weeks, and those with persistently positive results were investigated with nasal endoscopy and magnetic resonance imaging. RESULTS: Of the 20,174 volunteers who participated in the first-round screening, 17,838 (88.6%) were rescreened. Among them, 423 (2.37%) had persistently detectable plasma EBV DNA. Twenty-four patients were identified as having NPC. A significantly higher proportion of patients had stage I/II cancer than in a historical cohort (67% vs. 20%; chi-square test, P<0.001), and they had superior 3-year progression-free survival (100% vs. 78.8%). Compared with participants with undetectable plasma EBV DNA in the first round of screening, participants with transiently and persistently positive results in the first round were more likely to have a cancer identified in the second round, with relative risks of 4.4 (95% confidence interval, 1.3 to 15.0) and 16.8 (95% confidence interval, 5.7 to 49.6), respectively. CONCLUSIONS: Individuals with detectable plasma EBV DNA but without an immediately identifiable NPC were more likely to have the cancer identified in another round of screening performed 3 to 5 years later. (Funded by Kadoorie Charitable Foundation and others; ClinicalTrials.gov number, NCT02063399.)

Exome and genome sequencing of nasopharynx cancer identifies NF-κB pathway activating mutations.

Nasopharyngeal carcinoma (NPC) is an aggressive head and neck cancer characterized by Epstein-Barr virus (EBV) infection and dense lymphocyte infiltration. The scarcity of NPC genomic data hinders the understanding of NPC biology, disease progression and rational therapy design. Here we performed whole-exome sequencing (WES) on 111 micro-dissected EBV-positive NPCs, with 15 cases subjected to further whole-genome sequencing (WGS), to determine its mutational landscape. We identified enrichment for genomic aberrations of multiple negative regulators of the NF-κB pathway, including CYLD, TRAF3, NFKBIA and NLRC5, in a total of 41% of cases. Functional analysis confirmed inactivating CYLD mutations as drivers for NPC cell growth. The EBV oncoprotein latent membrane protein 1 (LMP1) functions to constitutively activate NF-κB signalling, and we observed mutual exclusivity among tumours with somatic NF-κB pathway aberrations and LMP1-overexpression, suggesting that NF-κB activation is selected for by both somatic and viral events during NPC pathogenesis.

In vivo 1H MR spectroscopy of thyroid carcinoma.

To determine if proton magnetic resonance spectroscopy (1H MRS) of thyroid carcinoma is feasible and to determine if 1H MRS spectra of malignant tumors differ from that of normal thyroid tissue. We performed 1H MRS at 1.5 T at echo-times (TE) 136 and 272 ms to examine eight patients with thyroid cancer (primary tumour or nodal metastasis) larger than 1 cm3 in size and five volunteers with normal thyroids. Spectra acquired from six primary tumors (three anaplastic carcinomas, two papillary carcinomas and one follicular carcinoma) and two nodes (two papillary carcinoma metastases) were analyzed in the time-domain using a non-linear least squares fitting algorithm with incorporation of prior knowledge. Choline (3.2 ppm) was identified in all solid carcinomas with a mean choline/creatine of 4.3 at TE 136 ms and 5.4 at TE 272 ms. Ratios for malignant tumors at TE 136 ms ranged from 1.6 in well differentiated follicular carcinoma to 9.4 in anaplastic carcinoma. No choline was detected in normal thyroid tissues. Our results showed that 1H MRS is a feasible technique for the evaluation of malignant thyroid tumors larger than 1 cm3 and that proton spectra of malignant tumors differ from that of normal thyroid tissue.

The nuclear localization of NFkappaB and p53 is positively correlated with HPV16 E7 level in laryngeal squamous cell carcinoma.

The interaction between the HPV (human papilloma virus) 16 E7 and other cell growth factors, such as p53 and NFkappaB in laryngeal cancer is not clearly understood. The aim of this study was to examine the expression of these three proteins in tumor and non-tumor laryngeal tissues from patients with laryngeal squamous cell carcinoma. These three proteins were dominantly expressed in the nucleus and their levels were higher in the tumor tissue than in the non-tumor tissue, although the comparison between the tumor and non-tumor tissues of p53 staining did not reach significance. The intensity of the nuclear stain of E7 and p53 was stronger than that of p65, a subunit of NFkappaB. Correlation analysis revealed that there was a positive relationship between the level of HPV16 E7 and the expression of p65. The correlation between E7 and p53 was also significant, although to a lesser degree. The finding of nuclear localization of p65 suggests that NFkappaB is constantly activated in the laryngeal cancer cells, whereas the sequestration of p53 in the nucleus may represent a mutated form of p53, which is probably inactivated by HPV16 oncoproteins. In conclusion, this study suggests that the nuclear localization of NFkappaB and p53 may play a role in the development of human laryngeal squamous cell carcinoma infected with HPV16.

MR imaging features of nasopharyngeal tuberculosis: report of three cases and literature review.

The MR imaging appearances in three cases of nasopharyngeal tuberculosis are reported, and the findings are combined with three additional cases from a review of the literature. Two patterns of nasopharyngeal tuberculosis were identified. The first pattern is a discrete polypoid mass in the adenoids, and the second pattern is a more diffuse soft-tissue thickening of one or two of the walls of the nasopharynx. Extension outside the confines of the nasopharynx was not a feature, except in one case with early involvement of the prevertebral muscles.

In vivo proton MR spectroscopy of primary and nodal nasopharyngeal carcinoma.

BACKGROUND AND PURPOSE: The aim of this study was to determine the feasibility of performing in vivo proton ((1)H) MR spectroscopy of nasopharyngeal carcinoma (NPC) and to document the (1)H spectrum of this cancer. METHODS: Twenty-seven patients with NPC lesions >1 cm(3) underwent localized (1)H MR spectroscopy performed at 1.5 T. Water-suppressed spectra from both primary tumors (nine cases) and metastatic nodes (18 cases) were obtained at TE 136 and 272. Spectra were analyzed in the time domain by using a nonlinear least squares fitting algorithm with incorporation of previous knowledge. Choline (Cho)/creatine (Cr) ratios for primary NPC and metastatic nodes were calculated and compared. Spectra from normal neck muscle of five volunteers were acquired as control data. RESULTS: (1)H MR spectroscopy was successfully obtained in seven (78%) of nine primary tumors and 16 (89%) of 18 metastatic nodes. Intense lipid signals in the range of 0.89 to 2.02 ppm were observed in 95% of spectra at TE 136 and 91% of spectra at TE 272. At TE 136, Cho/Cr for metastatic nodes (5.3 +/- 1.6) was significantly higher than the ratio for primary (2.6 +/- 0.5) NPC lesions (P =.02). Cho/Cr ratios for NPC lesions were higher than those for normal neck muscles, for which values ranged from 0 to 0.97 and 0 to 1.1 at TE 136 and 272, respectively. CONCLUSION: (1)H MR spectroscopy is a feasible technique for the evaluation of NPC tumors >1 cm(3). Cho/Cr ratios for the lesions were high compared with those for normal neck muscle.

Comparison of CT and MR imaging for the detection of extranodal neoplastic spread in metastatic neck nodes.

PURPOSE: To compare computed tomography (CT) and magnetic resonance (MR) imaging for the detection of extranodal neoplastic spread (ENS) in metastatic cervical nodes from head and neck squamous cell carcinoma. MATERIALS AND METHODS: 17 patients with a squamous cell carcinoma of the head and neck underwent CT and MR imaging. The neck nodes were assessed for ENS and the results compared using pathology from the surgical resection. RESULTS: Radiologic-pathologic correlation was performed in 51 malignant nodes. The accuracy, sensitivity and specificity were respectively 73, 65, 93% for CT, and 80, 78, 86% for MR imaging. Comparison of CT and MR imaging showed that there was no significant difference between the two modalities for either sensitivity (P = 0.1317) or specificity (P = 0.3173). CONCLUSION: CT and MR imaging are comparable for the detection of ENS.

Comparison of Rater's reliability on perceptual evaluation of different types of voice sample.

OBJECTIVE/HYPOTHESIS: The objective of this study was to determine whether different types of voice samples affect rater reliability and which type of sample can be rated most reliably, with particular reference to two types of connected speech-passage reading and conversational speech. STUDY DESIGN: Prospective reliability study. METHODS: One hundred fifty voice samples from 40 speakers were presented to 14 speech pathologists experienced in managing voice disorders. Each speaker contributed three types of voice samples: sustained vowels, passage reading, and conversational speech. Ratings were made on four vocal parameters--overall severity, roughness, breathiness, and strain--on a 10-point equal-appearing interval scale. RESULTS: Differences in intrarater reliability across the three types of voice samples were noted. Higher intrarater reliability was achieved with connected speech than with sustained vowel samples. Interrater reliability showed no statistically significant difference across the three types but increased with the severity of dysphonia. CONCLUSIONS: This study reveals that raters give internally more reliable ratings for connected speech samples. Results also indicate that voices with severe disorders appear to be rated more reliably.

The effectiveness of group voice therapy: a group climate perspective.

OBJECTIVES/HYPOTHESIS: Group therapy has frequently been adopted as a service delivery model for providing voice therapy. However, currently no literature has focused on understanding the underlying processes that are unique to group therapy, which contribute to treatment success. This study aimed at investigating the role of group climate in voice group therapy. STUDY DESIGN: Prospective case series. METHODS: Twelve teachers with hyperfunctional dysphonia attended eight sessions of group voice therapy. Treatment comprised both direct and indirect voice therapy. Therapy techniques were introduced and practiced in a large group and small group format. Outcome measures were taken using perceptual evaluation, videostroboscopy measures, voice-related quality-of-life (V-RQOL) measures, and vocal symptom scores. The Group Climate Questionnaire was used to measure the underlying process of group therapy. Treatment outcome was measured immediately posttreatment and at 6-months posttreatment. RESULTS: Results indicated statistically significant improvement in the participants' V-RQOL measures and the vocal symptom scores. Treatment gain was noted to sustain up to 6-months posttreatment. The Group Climate Questionnaire indicated that the treatment group is considered as "engaging" rather than "conflicting," which is considered to be associated with positive treatment outcome. CONCLUSION: Group therapy as a service delivery model possesses many advantages from the psychosocial, clinical, health resources allocation perspective. This study demonstrated that group climate plays a significant role in determining treatment success in group voice therapy.

Salivary gland tumors at in vivo proton MR spectroscopy.

PURPOSE: To prospectively evaluate whether proton magnetic resonance (MR) spectroscopy can be used to characterize salivary gland tumors (SGTs). MATERIALS AND METHODS: Ethics committee approval and informed consent were obtained. Hydrogen 1 ((1)H) MR spectroscopy was performed with echo times of 136 and 272 msec at 1.5 T in both SGTs and normal parotid glands. Spectra were analyzed in the time domain by using prior knowledge in the fitting procedure to obtain peak amplitudes of choline (Cho), creatine (Cr), and unsuppressed water. Mean Cho/Cr and Cho/water ratios for each subgroup of SGTs were obtained, and results were compared by using a nonparametric t test. RESULTS: Successful spectra were acquired in 56 patients (35 men, 21 women; mean age, 56 years) with a total of nine malignant tumors and 47 benign SGTs (24 Warthin tumors, 22 pleomorphic adenomas, one oncocytoma). At an echo time of 136 msec, Cho/Cr ratios were obtained in 26 (47%) of 55 spectra, with a mean value (+/- standard deviation) of 1.73 +/- 0.47, 5.49 +/- 1.86, 3.46 +/- 0.84, and 2.45 for malignant tumors, Warthin tumors, pleomorphic adenomas, and oncocytoma, respectively. Differences were significant between Warthin tumors and pleomorphic adenomas (P = .028) and between benign SGTs and malignant tumors (P < .001). At an echo time of 272 msec, Cho/Cr ratios were obtained in 16 (30%) of 53 spectra, with a mean value of 2.27 +/- 0.69, 6.92 +/- 1.47, and 3.67 +/- 1.23 for malignant tumors, Warthin tumors, and pleomorphic adenomas, respectively. Differences were also significant between Warthin tumors and pleomorphic adenomas (P = .041) and benign SGTs and malignant tumors (P = .004). There was a significant difference in mean Cho/water ratio for Warthin tumors versus pleomorphic adenomas at echo times of 136 msec (P = .003) and 272 msec (P = .002) but not for benign SGTs versus malignant tumors. CONCLUSION: (1)H MR spectroscopy may be used to characterize SGTs, but a larger study is required to validate these initial results.

Necrosis in metastatic neck nodes: diagnostic accuracy of CT, MR imaging, and US.

PURPOSE: To compare the diagnostic accuracy of computed tomography (CT), magnetic resonance (MR) imaging, and ultrasonography (US) in the detection of necrosis in metastatic cervical nodes from patients with head and neck squamous cell carcinoma. MATERIALS AND METHODS: Twenty-seven patients (age range, 39-85 years; mean age, 62 years) with squamous cell carcinoma in the head and neck underwent CT, MR imaging, and US. Three radiologists evaluated the images for nodal necrosis. The results of each modality were analyzed for sensitivity, specificity, and accuracy. Pathologic analysis of the surgical resection served as the reference standard. The three modalities were compared for specificity and sensitivity with the McNemar test. RESULTS: Pathologic examination revealed 903 nodes, of which 89 were malignant. Of the malignant nodes, 43 were necrotic. Analysis of the detection of necrosis in the 89 malignant nodes showed an accuracy, sensitivity, and specificity of 92%, 91%, and 93% for CT; 91%, 93%, and 89% for MR imaging; and 85%, 77%, and 93% for US, respectively. All imaging modalities failed to depict necrotic areas of 3 mm or smaller in three nodes, and necrosis was missed in an additional seven nodes with US and in one node with CT. Necrosis could not be distinguished from other components of malignancy, such as viable tumor and scar tissue, in seven nodes (CT, 3; MR imaging, 5; US, 3). The sensitivity of both MR imaging and CT was significantly better than that of US (P =.0082 and P =.0339, respectively). There was no significant difference in sensitivity (P =.3173) between MR imaging and CT, or in the specificity of the three modalities. CONCLUSION: MR imaging is comparable to CT for the detection of necrosis. The sensitivity of MR imaging and CT is better than that of US.