Staging System For Nasopharyngeal Carcinoma Research Articles

Quantitative Spatial Characterization of Lymph Node Tumor for N Stage Improvement of Nasopharyngeal Carcinoma Patients.

This study aims to investigate the feasibility of improving the prognosis stratification of the N staging system of Nasopharyngeal Carcinoma (NPC) from quantitative spatial characterizations of metastatic lymph node (LN) for NPC in a multi-institutional setting. A total of 194 and 284 NPC patients were included from two local hospitals as the discovery and validation cohort. Spatial relationships between LN and the surrounding organs were quantified by both distance and angle histograms, followed by principal component analysis. Independent prognostic factors were identified and combined with the N stage into a new prognostic index by univariate and multivariate Cox regressions on disease-free survival (DFS). The new three-class risk stratification based on the constructed prognostic index demonstrated superior cross-institutional performance in DFS. The hazard ratios of the high-risk to low-risk group were 9.07 (p < 0.001) and 4.02 (p < 0.001) on training and validation, respectively, compared with 5.19 (p < 0.001) and 1.82 (p = 0.171) of N3 to N1. Our spatial characterizations of lymph node tumor anatomy improved the existing N-stage in NPC prognosis. Our quantitative approach may facilitate the discovery of new anatomical characteristics to improve patient staging in other diseases.

Maximal lymph nodal diameter on N stage of nasopharyngeal carcinoma.

To assess the maximal lymph nodal diameter on the 8th edition American Joint Committee on Cancer staging system of nasopharyngeal carcinoma (NPC).This study extracted NPC patients between 2004 and 2016 in the Surveillance, Epidemiology, and End Results database. Included patients were divided into 3 groups: ≤3 cm, >3–6 cm, and >6 cm based on the maximal lymph nodal diameter. Cumulative survival curves of 5-year overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method between the 3 groups.The 5-year OS (64.0% vs 59.3%, P = .240) and CSS (71.8% vs 67.0%, P = .242) of ≤3 cm and >3–6 cm groups were not different. In contrast, the 5-year OS and CSS were different between >6 cm and ≤3 cm groups, and between >6 cm and >3–6 cm groups. The stratified hazard ratio of OS and CSS was 1.75 (95% confidence interval: 1.25–2.45; P = .001) and 1.77 (95% confidence interval: 1.20–2.60; P = .004) for the >6 cm group in the multivariate regression analysis.It is reasonable that the maximal lymph nodal diameter with >6 cm is classified as stage N3 of the 8th edition American Joint Committee on Cancer staging system for NPC.

Comparing the 7th and 8th editions of UICC/AJCC staging system for nasopharyngeal carcinoma in the IMRT era

BackgroundTo compare the prognostic value of 7th and 8th editions of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system for patients with nonmetastatic nasopharyngeal carcinoma (NPC) treated with intensity-modulated radiotherapy and simultaneous integrated boost– intensity-modulated radiation therapy (SIB-IMRT).MethodsPatients with NPC (n = 300) who received SIB-IMRT were included. Survival by T-classification, N-classification, and stage group of each staging system was assessed.ResultsFor T-classification, nonsignificant difference was observed between T1 and T3 and between T2 and T3 disease (P = 0.066 and 0.106, respectively) for overall survival (OS) in the 7th staging system, whereas all these differences were significant in the 8th staging system (all P < 0.05). The survival curves for disease-free survival (DFS) and locoregional recurrence-free survival (LRRFS) in both staging systems were similar, except for the comparison of T2 and T4 disease for LRRFS (P = 0.070 for 7th edition; P = 0.011 for 8th edition). For N-classification, significant differences were observed between N2 and N3 diseases after revision (P = 0.046 and P = 0.043 for OS and DFS, respectively). For staging system, no significant difference was observed between IVA and IVB of 7th edition.ConclusionThe 8th AJCC staging system appeared to have superior prognosis value in the SIB-IMRT era compared with the 7th edition.

Types of Transnasal Endoscopic Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma: Shanghai EENT Hospital Experience.

BackgroundTransnasal endoscopic nasopharyngectomy (TEN) has become increasingly used for recurrent nasopharyngeal carcinoma (rNPC); however, there is no report on the definitive resectable contour for TEN according to the latest staging system for nasopharyngeal carcinoma. The aim of this study was to establish the types of TEN for rNPC.Materials and MethodsA total of 101 rNPC patients underwent TEN from January 2016 to April 2019 at the authors’ institution. TEN was categorized into four types, which included type I (n=40) with resection of the nasopharynx and sinuses; type II (n=10) with lateral extension to the parapharyngeal space; type III (n=40) with lateral extension to the floor of the middle cranial fossa and the infratemporal fossa and superior extension to the orbital apex and the cavernous sinus back to the prevertebral region; and type IV (n=11) with the resection of the involved internal carotid artery following type III. The 2-year overall survival rate (OS) and local recurrence-free survival rate (LRFS) were assessed.ResultsThe median time of follow-up was 20 months. Twenty-five patients reoccurred. Nineteen patients died. Independent predictors of outcome on multivariate analysis were recurrent T stage (P = 0.039), types of TEN (P = 0.002) and surgical margin (P = 0.003). The 2-year OS and LRFS was 76.2% and 53.6%, respectively.ConclusionsThe result of TEN in the treatment of rNPC is promising. The types of TEN will provide effective guideline for surgical treatment of rNPC.

Recommendation regarding the cranial upper border of level IIb in delineating clinical target volumes (CTV) for nasopharyngeal carcinoma

PurposeTo recommend a cranial border for level IIb in delineating clinical target volumes (CTV) for nasopharyngeal carcinoma (NPC) patients receiving intensity-modulated radiotherapy and to help reach a consensus on contouring level IIb in CTV.MethodsFrom 2012 to 2016, 331 nonmetastatic NPC patients treated with IMRT were retrospectively enrolled. Based on the AJCC 8th staging system of NPC, there were 15 stage I, 76 stage II, 103 stage III, and 137 stage IV patients. The distribution of cervical lymph nodes in NPC was assessed based on imaging. Comparisons of the safety and parotid dose parameters between patients with and without a reduction in the size of level IIb were conducted using SPSS 25.0 and R 2.14.2 software.ResultsMetastasis rates in the most commonly involved lymph nodes, the lateral retropharyngeal and IIb nodes, were 82.8% and 64.0%, respectively. Among patients with level IIb involvement, the upper borders of the metastatic nodes were beyond the caudal edge of C1 in 13.7% of cases. The parotid gland D50 and V26 values were significantly reduced after modifying the upper bound of level IIb used to delineate the CTV (P = 0.000).ConclusionIn principle, the upper bound of level IIb should reach the lateral skull base during delineation of the cervical CTV for NPC. To protect the parotid glands, however, individualized reduction of the upper bound of level IIb is recommended for patients who meet certain criteria.

Validation of Stage N3 of the Eighth Edition AJCC Staging System for Nasopharyngeal Carcinoma.

To validate stage nodal (N)3 of the 8th edition American Joint Committee on Cancer (AJCC) staging system for nasopharyngeal carcinoma (NPC). This retrospective cohort study extracted NPC patients from the Surveillance, Epidemiology, and End Results database between 2004 and 2016. Pathologically confirmed patients with complete data of level IV, N3a, and N3b lymph node metastasis were investigated. The included patients were divided into level IV, N3a, and N3b groups. Five-year overall survival (OS) and cancer-specific survival (CSS) were compared among the three groups. A total of 693 patients were included: 285 (41.13%) patients in the level IV group, 124 (17.89%) patients in the N3a group, and 284 (40.98%) patients in the N3b group. The 5-year OS (57.1%, 55.0%, and 55.2%) and CSS (64.4%, 63.5%, and 64.4%) were not different among the level IV, N3a, and N3b groups. Multivariate regression analysis revealed that N stage was not an independent prognostic factor for OS (hazard ratio [HR] = 1.03, 95% confidence interval [CI]: 0.91-1.17; P = .65) or CSS (HR = 1.03, 95% CI: 0.89-1.19; P = .70). Stage N3 of the 8th edition AJCC staging system for NPC is reasonable. III Laryngoscope, 131:535-540, 2021.

294P - Validation of the 8th edition of AJCC/UICC staging system for nasopharyngeal carcinoma: Results from a non-endemic cohort with long-term follow-up

BackgroundThis study aimed to validate the 8th edition of American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) TNM staging system for nasopharyngeal carcinoma (NPC) in a non-endemic region. MethodsWe recruited 614 patients with histology-proven, previously untreated, non-metastatic NPC treated by intensity-modulated radiotherapy (IMRT) at our center. Harrell’s concordance index (c-index) and time-dependent receiver operating characteristic (TD-ROC) analysis were applied to compare the prognostic discrimination between the 7th and 8th edition staging system. ResultsFor T category, the local recurrence-free survival (LRFS) Kaplan-Meier curves of T1, T2 and T3 were well separated in the 8th edition; however, LRFS did not significantly differ between T3 and T4 (P = 0.15). Moreover, the 7th edition achieved higher c-index (0.703 [95% CI, 0.618-0.788] vs. 0.686 [95% CI, 0.604-0.768]) and area under curve ([AUC], 5-year: 0.681 vs. 0.672; 10-year: 0.645 vs. 0.615) than 8th edition for LRFS. With regard to N category, the 8th edition achieved higher c-index (0.800 [95% CI, 0.755-0.847] vs. 0.757 [95% CI,.0.704-0.811]) and AUC (5-year 0.728 vs. 0.685; 10-year: 0.748 vs. 0.680) for distant metastasis-free survival. In terms of overall stage, the 8th edition also had higher c-index (0.800 [95% CI, 0.755-0.845] vs. 0.724 [95% CI, 0.676-0.773]) and AUC (5-year: 0.730 vs. 0.713; 10-year: 0.734 vs. 0.677) compared with 7th edition for overall survival. ConclusionsThe 8th edition of AJCC/UICC TNM staging system achieved significantly better prognostic discrimination than the 7th edition with regard to N category and overall stage but not T category. Legal entity responsible for the studyDepartment of Radiation Oncology, Jiangsu Cancer Hospital, Nanjing Medical University Affiliated Cancer Hospital, Jiangsu Institute of Cancer Research. FundingThe National Natural Science Foundation of China (No. 81672989; No. 81872192). DisclosureAll authors have declared no conflicts of interest.

Nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: clinical outcomes and patterns of failure among subsets of 8th AJCC stage IVa.

The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for nasopharyngeal carcinoma (NPC) merged T4N0-2 and T1-4N3 to create stage IVa. In the present study, we aimed to assess the difference in clinical outcomes and patterns of failure between 8th AJCC T4N0-2 and T1-4N3 NPC patients treated with intensity-modulated radiotherapy (IMRT). We included 3107 patients with stage IVa NPC disease (1871 with T4N0-2 and 1236 with T1-4N3) according to the 8th AJCC staging system. Overall survival (OS) was the primary endpoint. The clinical outcomes between T4N0-2 and T1-4N3 patients were compared. T1-4N3 patients had significantly worse 3-year OS (84.1% vs. 89.2%; p < 0.001) and distant metastasis-free survival (DMFS; 78.3% vs. 85.9%; p < 0.001), but better local relapse-free survival (LRFS; 94.9% vs. 92.2%; p = 0.003), as compared with T4N0-2 patients. Multivariate analysis showed that T1-4N3 was still an independent adverse prognostic factor for both DMFS (hazard ratio [HR] = 1.517, 95% confidence interval [CI] = 1.274-1.806, p < 0.001) and OS (HR = 1.315, 95% CI = 1.100-1.572, p = 0.003), whereas T4N0-2 was an independent adverse prognostic factor for LRFS (HR = 1.581, 95% CI = 1.158-2.158, p = 0.004). In terms of the OS, T4N0-2 patients had better prognosis compared with T1-4N3 patients, and the patterns of failure differed between T4N0-2 and T1-4N3 patients. We believe that future modifications of the AJCC/UICC staging system should separate T4N0-2 from T1-4N3. • In nasopharyngeal carcinoma, T4N0-2 patients tended to develop local relapse, whereas T1-4N3 patients were more likely to develop distant metastasis. • In terms of overall survival, T4N0-2 patients had better prognosis than T1-4N3 patients. • T4N0-2 should be separated from T1-4N3 in the UICC/AJCC staging system.

Validation of the 8th edition of AJCC/UICC staging system for nasopharyngeal carcinoma: Results from a non-endemic cohort with 10-year follow-up

ObjectivesThis study aimed to validate the 8th edition of American Joint Committee on Cancer/Union for International Cancer Control (AJCC/UICC) TNM staging system for nasopharyngeal carcinoma (NPC) in non-endemic region. Materials and methodsWe recruited 607 patients with histology-proven, previously untreated, non-metastatic NPC treated by intensity-modulated radiotherapy (IMRT) at our center. Harrell’s concordance index (c-index) and Akaike information criterion (AIC) were applied to compare the prognostic discrimination between the 7th and 8th edition staging system. ResultsFor T category, the local recurrence-free survival (LRFS) Kaplan-Meier curves of T1, T2 and T3 were well separated in the 8th edition; however, LRFS did not significantly differ between T3 and T4 (P = 0.166). Moreover, the 7th edition achieved higher c-index (0.702 [95% CI, 0.618–0.787] vs. 0.685 [95% CI, 0.604–0.767]) and lower AIC (766.1 vs. 770.8) than 8th edition for LRFS. With regard to N category, the 8th edition achieved higher c-index (0.796 [95% CI, 0.749–0.843] vs. 0.751 [95% CI, 0.696–0.805]) and lower AIC (1439.4 vs. 1471.9) for distant metastasis-free survival. In terms of overall stage, the 8th edition also had higher c-index (0.798 [95% CI, 0.753–0.844] vs. 0.721 [95% CI, 0.672–0.770]) and lower AIC (1963.9 vs. 2007.2) compared with the 7th edition for overall survival. Furthermore, interval validation by bootstrapping the sample randomly for ~100–1000 times also validated above findings. ConclusionThe 8th edition of AJCC/UICC TNM staging system achieved significantly better prognostic discrimination than the 7th edition with regard to N category and overall stage but not T category.

Validation of the 8th Edition of AJCC/UICC Staging System for Nasopharyngeal Carcinoma in the Non-Endemic Area and Proposing a New N-Staging System

Prompt validation of new staging system is crucial for cancer management. Since the publication of the 8th edition of AJCC staging system, few validated studies were published. Till now, it lacks evidence from non-endemic area of China and other area of the world. The aim of this study is to assess the applicability and extrapolation of the 8th edition of AJCC staging system for nasopharyngeal carcinoma (NPC) in non-endemic area. This retrospective study enrolled 781 patients from East China, with non-metastatic NPC treated by definitive IMRT. All patients were restaged according to the 7th and 8th edition of AJCC staging system. Univariate and multivariable models were constructed to evaluate the association between risk factors and survival. Based on the multivariate-analysis, recursive partitioning analysis (RPA) derived new N stages objectively. The performance of each staging system was compared using the Harrell’s concordance index (c-index). For T category, given the overlap of local recurrence-free survival (LRFS) curves across T1-3, both the 7th and 8th edition of T category did not show a good capacity of discriminations of LRFS. However, the separations of Distant metastasis-free survival (DMFS) between T4 to T2/T3 were better in the 8th edition. The 8th edition had a higher C-index than the 7th edition, in terms of DMFS and overall survival (OS). For N category, 4.9% of N1 upgraded to N3 and 19.5% of N2 upgraded to N3, based on the 8th edition. All of the upgraded cases were attributed to the involvement of level IVa and level Vb. Hence, significant stage migration decreased the disparities of N2 and N3 disease and the 8th edition had a lower C-index than 7th edition, in terms of DMFS, Disease-free survival (DFS) and OS. Total number of positive nodal levels (TNL) was an independently prognostic factor for DMFS and OS after adjusting for various risk factors. New N staging system using nodal size and TNL was derived from RPA. The proposed N staging system significantly improved the discriminations of DMFS, DFS and OS, compared with the 7th and the 8th edition (Table 1). Given the significant stage migration, the extrapolation of the 8th edition staging system in the non-endemic area is questioned.Total number of positive nodal levels is a prominent surrogate of metastatic nodal burden, which may be considered in the future refinement of staging system.Abstract 2903; Table 1The comparison of prognostic ability of the 7th , 8th, and the proposed overall stage system to discriminate survival rates.DFS (%)7th edition8th editionProposed editionOS (%)7th edition8th editionProposed editionI89.089.088.0I95.695.695.3II88.287.885.4II92.893.293.2III69.271.268.9III81.784.182.4IVA73.665.862.8IVA83.776.870.4IVB56.5IVB72.4c-index0.62560.62300.6339c-index0.63040.63860.6687p value0.0000.0000.000p value0.0000.0000.000 Open table in a new tab

The evolution of nasopharyngeal carcinoma staging.

The prevalence of nasopharyngeal carcinoma is characterized by an unbalanced distribution: the disease is particularly prevalent in East and Southeast Asia. In this article, we review the evolution of the International Union Against Cancer/American Joint Committee on Cancer staging system for nasopharyngeal carcinoma. With the increasing using of newer imaging methods, more advanced radiotherapy techniques and systemic chemotherapy, we also discuss newer clinical features that might affect staging. Finally, we propose the future direction of staging and potential prognostic factors that have a major influence on the treatment outcomes of this disease.

A simplified T classification based on the 8th edition of the UICC/AJCC staging system for nasopharyngeal carcinoma.

Objective: This study aimed to establish a simplified T classification based on the 8th edition of the Union for International Cancer Control/American Joint Committee on Cancer (UICC/AJCC) staging system for nasopharyngeal carcinoma (NPC).Methods: In total, 325 patients with NPC were included in this study. All patients underwent magnetic resonance imaging, and the staging criteria were recorded. These patients were subjected to staging with the 8th edition of the UICC/AJCC staging system for NPC.Results: Involvement of the oropharynx, nasal cavity, adjacent soft tissue (medial pterygoid, lateral pterygoid, and prevertebral muscles), cervical vertebra, orbit, and hypopharynx were always accompanied by other equivalently or more advanced T-stage classifications. All cases with involvement of the paranasal sinuses showed skull base erosion. The majority of cases with involvement of the pterygoid structure showed skull base erosion.Conclusion: According to the simplification principle, the following new T classification based on the 8th edition of the UICC/AJCC staging system was established: T1, tumor confined to nasopharynx, or beyond the nasopharynx without parapharyngeal involvement; T2, tumor with extension to the parapharyngeal space; T3, tumor with infiltration to bony structures at the skull base; T4, tumor with intracranial extension, involvement of the cranial nerves or parotid gland, and/or extensive soft tissue infiltration beyond the lateral surface of the lateral pterygoid muscle. Validation with a large series of patients is needed.

Observation on clinical efficacy and prognosis analysis of endoscopic surgery treatment for rT1-rT2 recurrent nasopharyngeal carcinoma

Objective:To investigate the feasibility of endoscopic surgery for treatment of rT1-rT2 recurrent nasopharyngeal carcinoma.Method: The clinical data and of 57 patients who had recurrence of the primary lesion after treatment of nasopharyngeal carcinoma from February 2011 to December 2015 were retrospectively analyzed. The patients were re-staged according to Union for International Cancer Control(UICC, 2010) staging system for nasopharyngeal carcinoma before surgery. Patients suitable for surgery underwent endoscopic surgery to remove nasopharyngeal lesions; those combined with cervical lymph node metastases underwent cervical lymph node dissection at the same time; patients with positive surgical margins of pharyngeal lesions and cervical lymph node extramembranous filtration were treated with radiotherapy combined with chemotherapy; patients unsuitable for surgery were treated with radiotherapy combined with chemotherapy directly. All patients were followed up regularly to observe clinical efficacy and survival. Result:Fifty-seven patients were re-staged according to UICC(2010) staging system for nasopharyngeal carcinoma: 19 cases in stage Ⅰ,30 cases in stage Ⅱ, 6 cases in stage Ⅲ and 2 cases in stage Ⅳ,including 27 cases in stage rT1, 30 cases in stage rT2, and 43 cases in stage rN0,6 cases in stage rN1,6 cases in stage rN2,2 cases in stage rN3. Forty-four cases of primary lesions were sected for endoscopic surgery. Patients combined with cervical lymph node metastases underwent cervical lymph node dissection at the same time, with 6 cases of positive surgical margins of pharyngeal lesions and 4 cases of cervical lymph node extramembranous infiltration, who were treated with radiotherapy combined with chemotherapy after surgery. Thirteen patients received radiotherapy combined with chemotherapy directly. At a median follow-up of 36 months, the 3-year overall survival rate of 57 patients was 61.4%. The 3-year overall survival rates of patients in stage Ⅰ, Ⅱ, Ⅲ and Ⅳ were 73.7%, 63.3%, 33.3%, 0.0% respectively. Kaplan-Meier survival curve analysis showed a significant difference in the overall survival rate of patients in different stages(P=0.002). The 3-year overall survival rates of rT1 and rT2 patients were 63.0%, 60.0% respectively, and KaplanMeier survival curve analysis showed no significant difference in the overall survival rate between rT1 and rT2 patients(P=0.707). The 3-year overall survival rates of patients in stages rN0, rN1, rN2, rN3 were 69.8%, 50.0%, 33.3%, 0.0% respectively, and Kaplan-Meier Survival curve analysis showed a significant difference in overall survival between patients in different rN stages(P=0.002). The 3-year overall survival rate was 68.2% in 44 surgical patients, and 38.5% in 13 non-surgical patients. Kaplan-Meier survival curve analysis showed significant difference in overall survival rate between surgical and non-surgical patients(P=0.014).Conclusion: Endoscopic surgery for recurrent nasopharyngeal carcinoma is a safe and effective treatment to improve survival.

Metabolic characteristics revealing cell differentiation of nasopharyngeal carcinoma by combining NMR spectroscopy with Raman spectroscopy

BackgroundThe staging system of nasopharyngeal carcinoma (NPC) has close relationship with the degree of cell differentiation, but most NPC patients remain undiagnosed until advanced phases. Novel metabolic markers need to be characterized to support diagnose at an early stage.MethodsMetabolic characteristics of nasopharyngeal normal cell NP69 and two types of NPC cells, including CNE1 and CNE2 associated with high and low differentiation degrees were studied by combining 1H NMR spectroscopy with Raman spectroscopy. Statistical methods were also utilized to determine potential characteristic metabolites for monitoring differentiation progression.ResultsMetabolic profiles of NPC cells were significantly different according to differentiation degrees. Various characteristic metabolites responsible for different differentiated NPC cells were identified, and then disordered metabolic pathways were combed according to these metabolites. We found disordered pathways mainly included amino acids metabolisms like essential amino acids metabolisms, as well as altered lipid metabolism and TCA cycle, and abnormal energy metabolism. Thus our results provide evidence about close relationship between differentiation degrees of NPC cells and the levels of intracellular metabolites. Moreover, Raman spectrum analysis also provided complementary and confirmatory information about intracellular components in single living cells. Eight pathways were verified to that in NMR analysis, including amino acids metabolisms, inositol phosphate metabolism, and purine metabolism.ConclusionsMethodology of NMR-based metabolomics combining with Raman spectroscopy could be powerful and straightforward to reveal cell differentiation development and meanwhile lay the basis for experimental and clinical practice to monitor disease progression and therapeutic evaluation.

Comparison analysis of local invasion between the Chinese 2017 staging system and the 2008 staging system for nasopharyngeal carcinoma

Objective To compare the difference of T-stage between Chinese 2017 staging system and the 2008 staging system for nasopharyngeal carcinoma, and to investigate the optimization of T-stage and provide suggestions for further revision. Methods The MRI data of 183 patients with histology-proven newly diagnosed nasopharyngeal carcinoma in our hospital were enrolled from September 2009 to May 2017. All the anatomic sites mentioned in the two staging systems were marked, and all patients were staged according to the 2017 staging system and the 2008 staging system for nasopharyngeal carcinoma. Comparisons of T-stage were made between the two staging systems. Results Involvement of oropharynx, nasopharynx, prevertebral muscles, cervical vertebra, hypopharynx and orbit were 100% accompanied with other same or more advanced T-stage classifications. The invasion rates of the cervical vertebra, orbit and hypopharynx were very low (all <5.00%). The incidence of involvement of pterygoid structure was 15.30%, most of which incorporated with erosion of skull base, only 1 case was invaded alone. All cases of involvement of paranasal sinuses were incorporated with erosion of skull base. Compared with the 2008 staging system, the consti-tuent ratio of T1+T2 in the 2017 staging system increased from 36.61% to 61.75%, and that of T3+T4 decreased from 63.39% to 38.25%, the constituent ratio of T-stage between the 2017 staging system and the 2008 staging system was significantly diffe-rent (χ2=26.94, P<0.001). There was moderate consistency of T-stage between these two staging systems (Kappa=0.514, P<0.001). Conclusion The T-stage of 2017 staging system still has a larger simplification and optimization space. Therefore, according to the principle of concise, the T-stage parameters including oropharynx, nasopharynx, prevertebral muscles, paranasal sinuses, cervical vertebra, orbit and hypopharynx are recommend to delete, and it does not have an impact on the composition of T-stage. We suggest that the pterygoid structure shall combine with the skull base to be one anatomical structure. Key words: Nasopharyngeal neoplasms; Neoplasm staging

Validation of the 8th Edition of the UICC/AJCC Staging System for Nasopharyngeal Carcinoma From non-Endemic Areas in the Era of Intensity-Modulated Radiation Therapy

The 8th edition of UICC/AJCC staging system for nasopharyngeal carcinoma (NPC) has been validated to have a better prognostication than the 7th edition in endemic areas. However, validation studies from non-endemic areas are limited. We retrospectively evaluated the new edition of staging system for NPC patients from non-endemic areas (Western China) who were treated with intensity-modulated radiotherapy (IMRT). Between July 2011 and December 2013, a total of 494 patients with newly diagnosed, non-metastatic NPC treated with IMRT in Sichuan Cancer Hospital were included. Overall survival (OS), progression-free survival (PFS), distant metastasis-free survival (DMFS) were calculated with the Kaplan-Meier method, and differences were compared by using the log-rank test. Akaike information criterion (AIC) and Harrell's concordance index (c-index) were calculated to compare the performance of various staging systems. The median age was 47 years (range, 14-83 years) with a male-to-female ratio of 1.9 to1 (325:169). The median follow-up time was 51 months (range, 3-74.5months). Over 90% of the patients had loco-regional advanced (III+IVa) diseases according to both editions. The 5-year OS, PFS and DMFS rates for the whole group were 82.6%, 84.0% and 88.7%, respectively. Based on the 8th edition, the OS and PFS curves of different T categories were better separated than 7th edition, except the T2 and T3 categories. The 8th edition had higher AIC and c-index values for OS and PFS than the 7th edition. While, for DMFS, the curves cannot be well separated according to both editions (all pvalues > 0.3). For N category, the survival curves of different groups were close to overlap for all the end points based on both editions. The AIC and c-index values were similar for the N categories of both editions. For clinical stage, the OS curves were better separated according to the 8th edition, while no significant differences could be reached for PFS or DMFS based on both editions. The 8th edition of the UICC/AJCC staging system may not be able to well predict the treatment outcomes for NPC patients from non-endemic areas like Western China. More validation studies from non-endemic areas are needed.

Validation and suggestion of eighth T classifications of the UICC/AJCC staging system for nasopharyngeal carcinoma patients: a retrospective analysis.

With the aim to validate the applicability of the eighth T classifications of AJCC/UICC staging system for nasopharyngeal carcinoma patients. We compare the seventh and eighth T classifications of the UICC/AJCC staging system in 382 newly diagnosed nasopharyngeal carcinoma patients without cervical lymph node metastasis who were staged with magnetic resonance imaging and treated by intensity-modulated radiotherapy. Univariate analysis was performed using the log-rank test and multivariate analyses with the Cox proportional hazards model were used to evaluate the prognostic values between adjacent stage categories. The Akaike information criterion and Harrell's concordance index were applied to compare the two systems. The median follow-up time was 61.1 months. For local relapse-free survival and distant metastasis failure-free survival, the eighth editions had superior prognostic value to the seventh edition. The Akaike information criterion value was smaller and Harrell's concordance index value was larger for the eighth edition compared with the seventh edition staging system. Our research also found that the difference in overall survival, local relapse-free survival and distant metastasis failure-free survival rates between T1 and T2 patients was not significant according to the eighth edition of the UICC/AJCC staging system, indicating that the discrimination among T1-2 patients was diminished. Intensity-modulated radiotherapy with elective neck irradiation provides excellent local-regional control for nasopharyngeal carcinoma patients and the eighth T classification seems to be superior to the seventh T classification. Since local control has improved in the modern era, the study considered that the staging system could be further improved and simplified by downstaging the current T2 classification patients to T1 with modern treatment. Researchers are attempting to incorporate individualized prognostic factors, such as Epstein-Barr virus DNA, into nomogram.

Comparison of the seventh and eighth editions of the UICC/AJCC staging system for nasopharyngeal carcinoma: analysis of 1317 patients treated with intensity-modulated radiotherapy at two centers

BackgroundIn the intensity-modulated radiotherapy (IMRT) era, great improvement has been made in survival of nasopharyngeal carcinoma (NPC). The 7th edition of the International Union against Cancer/American Joint Committee on Cancer (UICC/AJCC) staging system seems “outdated ” as it mainly based on the study in 2D/3D era, and thus the 8th edition has made some amendments according to recent studies. We aimed to compare and evaluate these two editions of staging system for NPC in patients treated with intensity-modulated radiotherapy.MethodsA total of 1317 patients with biopsy-proven, non-metastatic NPC treated with IMRT between 2009 and 2014 at two institutions were retrospectively assessed. All patients were assessed by magnetic resonance imaging and restaged according to the 7th and 8th editions. Prognostic factors for local relapse-free survival (LRFS), distant metastasis-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) were assessed and compared using the Kaplan-Meier method and log-rank test. The Cox proportional hazards model was also used to calculate the hazard ratio (HR).ResultsIn both 7th and 8th edition, insignificant difference could be observed between T2 and T3 disease, T2 and T4 disease (all P > 0.05) for LRFS, while the difference of LRFS between T3 and T4 disease was significant in the previous edition (P = 0.001) but insignificant (P = 0.279) after revision. For OS, highly similar survival curve could be seen between T2 and T3 disease in both edition (all P > 0.1). DMFS and OS were not significantly different between N3a and N1-3b categories of the 7th edition (all P > 0.05). In contrast, obvious segregation was observed between N3 and the other N categories after the revision and combination in the 8th edition (all P < 0.05). DFS and OS were not significantly different between stage IVA and IVB of the 7th edition (P = 0.057 and P = 0.365, respectively); therefore, combining these stages in the 8th edition was reasonable.ConclusionThe overall stages and N categories of the 8th edition of the UICC/AJCC staging system provide better segregation of survival outcomes than the 7th edition. The 8th edition is also more clinically applicable as it has reduced ambiguity and revised out-of-date definitions. However, the T categories need further optimizing as the 8th edition failed to solve the problem of similar survival between adjacent T-classification, which has been exited since 7th edition.

A new staging system for nasopharyngeal carcinoma based on intensity-modulated radiation therapy (IMRT).

ObjectiveThis study is to establish a new staging system for nasopharyngeal carcinoma (NPC) based on the magnetic resonance imaging (MRI) and intensity-modulated radiation therapy (IMRT).MethodsTotally 492 patients with nasopharyngeal carcinoma were included in this study. These patients were diagnosed by pathological detection (without distant metastasis) and underwent the initial treatment of IMRT. These patients were subjected to the staging with the International Union against Cancer/American Joint Committee on Cancer (UICC/AJCC) staging system. Survival rates were calculated by the Kaplan-Meier method. Log-rank test was used to calculate the single factor prognosis, and the COX risk model was used to analyze the multivariate prognosis.ResultsIn these 492 patients, according to our recommended new T and N staging criteria, there were 290 cases of T1 and 202 cases of T2; there were 64 cases of N0, 159 cases of N1, 226 cases of N2, and 43 cases of N3. Univariate and multivariate analyses showed that the T and N staging combination parameters were independent prognostic factors, which affected the overall survival rates and tumor-free survival rates. According to risk difference and survival curve distribution, the following new clinical staging criteria were established: stage I (T1N0M0), stage II (T1N1M0 and T2N0M0), stage III (T1N2M0 and T2N1-2M0), stage IVa (T1-2N3M0), and stage IVb (TxNxM1).ConclusionA new staging system for NPC based on MRI and IMRT has been recommended, which provides valuable evidence for disease treatment and prognosis prediction.

Comparison Between the 7th and the Proposed 8th Editions of the UICC Staging System for Nasopharyngeal Carcinoma Patients Without Cervical Lymph Node Metastasis: A Retrospective Analysis

To evaluate the prognostic value of the proposed 8th Edition of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC) staging system for nasopharyngeal carcinoma (NPC) patients without cervical lymph node metastasis in comparison with the AJCC/ UICC 7th edition This is a retrospective study of 382 newly diagnosed non-metastatic NPC patients without cervical Lymph node metastasis who were treated with intensity-modulated radiotherapy (IMRT). All received elective neck irradiation to levels II, III, VA. Univariate and multivariate analyses were applied to evaluate the prognostic values between adjacent stage categories of the AJCC/ UICC 7th edition and the proposed 8th edition, including overall survival (OS), local relapse-free survival (LRFS), regional relapse-free survival (RRFS), distant metastasis-free survival (DMFS), and disease–free survival (DFS). The Akaike information criterion (AIC) and Harrell’s concordance index (c-index) were applied to compare the two prognostic systems with different numbers of stages The median follow-up time was 61.1 months, with a range from 1 months to 91 months. The 5-year OS, LRFS, RFFS, DMFS and DFS were 86.9%, 96.7%, 99.1%, 93.3% and 82.6%, respectively. For LRFS and DMFS, the proposed eighth editions had superior prognostic value to the AJCC/ UICC 7th edition (P=0.032 vs. P=0.086 and P=0.013 vs. P=0.112). The 5-year OS and DFS were found to be significant both by the seventh and the proposed 8th editions. The difference between T1 and T3, T1 and T4, T2 and T3 and T2 and T4 by the proposed eighth edition were found to be significant (P=0.042, P=0.041, P=0.000, and P=0.000), however, there was no significant difference between T1 and T3, T2 and T3 by the seventh edition (P=0.204, and P=0.215). In addition, the difference between T1, T2, T3 with T4 were found to be significant in DFS (P = 0.000, P = 0.000, P = 0.037) and there was no significant difference between T1 and T3 (P=0.162) by the seventh edition and there was significantly different between T2 and T4 (P=0.026) by the proposed 8th editions. Multivariate analysis demonstrated that age, T stage of the proposed 8th editions and chemotherapy were independent prognostic factors for OS, LRFS, DMFS and DFS. The AIC value was smaller for the 8th edition compared to the 7th edition staging system. The C-index value was larger for the 8th edition compared to the 7th edition staging system. IMRT with elective neck irradiation provides excellent local-regional control for NPC patients without cervical lymph node metastasis. The proposed eighth editions had superior prognostic value to the AJCC/ UICC 7th edition for LRFS and DMFS and lead a better distinction between adjacent T stages of nasopharyngeal carcinoma patients for OS and DFS. Overall, the proposed 8th UICC T classification seems to be superior to the 7th UICC T classification for nasopharyngeal carcinoma patients without cervical lymph node metastasis.