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Advances in nasopharyngeal carcinoma — “West meets East”

2019; Wiley; Volume: 92; Issue: 1102 Linguagem: Inglês

10.1259/bjr.20199004

1748-880X

Melvin L.K. Chua, Ying Sun, S. Supiot,

Cancer-related molecular mechanisms research

Free AccessNasopharyngeal carcinoma special feature: editorialAdvances in nasopharyngeal carcinoma—“West meets East”Melvin LK Chua, Ying Sun and Stéphane SupiotMelvin LK ChuaSearch for more papers by this author, Ying SunSearch for more papers by this author and Stéphane SupiotSearch for more papers by this authorPublished Online:17 Sep 2019https://doi.org/10.1259/bjr.20199004SectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations AboutNasopharyngeal carcinoma (NPC) is a distinct malignancy from other epithelial head and neck cancers. The endemic variant is invariably associated with the Epstein-Barr virus (EBV), and typically presents as an undifferentiated histologic subtype. In the rest of the world where this malignancy is much less frequent (age-standardized incidence rate of <3 per 100,000 person-year), NPC tends to be associated with a keratinising squamous histomorphology.1 EBV-associated NPC also has a specific geographical and demographic distribution, with a predisposition for Eastern and Southeastern Asia, and Northern and Eastern Africa, and is more common in males than females (3:1 ratio). These tumours also demonstrate a unique treatment phenotype in contrast to the non-endemic variants, whereby EBV-associated NPC is exquisitely sensitive to radiotherapy and platinum-based chemotherapy, while the squamous histological subtype (for which a linkage to the human papilloma virus has been suggested)2,3 is much less radiosensitive and more aggressive clinically. Even among the undifferentiated and squamous variants of NPC, there is substantial clinical diversity in presentation and treatment response. Nonetheless, there is a convergence in the treatment concepts regardless of the Eastern or Western origin of the disease. With this in mind, we (as the guest editors) designed this special feature on NPC along the theme of “West meets East” by collating a series of review and original research articles that narrate and report on clinical and translational research advances in NPC from both the Eastern and Western parts of the world.Unlike other head and neck cancers, radiotherapy is the treatment backbone of NPC. The implementation of intensity-modulated radiotherapy as the standard of care has led to superior local control, even for advanced T3-4 tumours. However, there are instances where radiotherapy can be further optimised, like in T4 tumours for which local control is inferior compared to the less bulky lesions; and acute and late radiotherapy toxicities remain a perennial issue in these patients, especially with combinatorial chemoradiotherapy. In this BJR special feature on NPC, Sun et al therefore nicely summarise the past and potential future advances that seek to improve the therapeutic ratio of this primary treatment modality, which is balanced by superior tumour targeting and reduction of radiation exposure to normal tissue organs.4 Specific to the latter, late radiotherapy-induced adverse effects, especially neurological complications are debilitating, and it is crucial to not exceed dosimetric constraints of the respective organs at risk. In this regard, Li et al compared the dosimetry to the brachial plexus as outlined by different guidelines, and observed that dose parameters differ depending on the contouring methods.5 This emphasises the need to harmonise the contouring of the individual organs at risk, in order to ensure quality standards in radiotherapy planning and delivery.Another treatment strategy that has advanced cure rates in locoregionally advanced NPC is the combination of platinum- and flupyrimidine-based chemotherapy with radiotherapy. Different combinations have proven efficacy in this disease, and these chemotherapy regimes emerged following investigations as induction, concurrent and adjuvant sequencing in several randomised controlled Phase III clinical trials.6 Peng et al provide a nice summary of the scientific rationale underpinning the designs of past and present trials, and how the trial landscape will evolve for this disease, whereby distant metastasis remains a problem.7 On this note, risk stratification of patients for occult distant metastasis continues to evolve with the refinement of the Tumour (T)- and Node (N)-classification, as well as the integration of liquid biopsy biomarkers like cell-free EBV DNA. Guo et al highlighted some key proposals that could be integrated in future TNM stage classifications, as outcomes of NPC patients continue to improve with time.8The advent of modern imaging techniques has also contributed to stage migration in NPC. For example, 18F-flurodeoxygenase positron emission tomography (18F-FDG-PET) is a superior modality to conventional CT and skeletal scintigraphy in the detection of distant metastases at diagnosis.9 Additionally, 18F-FDG-PET has been investigated as a molecular imaging for the assessment of post-treatment response, but the timing of scan and accuracy for the primary and nodal tumour lesions are less clear. On this note, Jeong et al found that 18F-FDG-PET at 6 months post-treatment harboured a high specificity for residual disease in the nasopharynx.10 This is a useful indication for a viral-associated tumour, for which time to complete response can be prolonged in some cases. More recently, there is an enthusiasm to investigate the association of radiomics indices with tumour characteristics in several human cancers.11 Radiomics interrogates the first-order, shape and textural features of a radiological image, and while several pipelines exist, there have been few studies comparing the reliability and reproducibility of the feature extraction processes between pipelines. On this note, Liang et al performed a comparative analysis between two publicly available radiomics softwares in NPC patients, and showed that among the feature clusters, textural indices vary most significantly between pipelines, and this interpipeline heterogeneity potentially affects clinical utility.12Following the theme of technological advances, Lin et al described the implementation and usability of the artificial intelligence-based big data platform at their institution for NPC.13 Given the extremely high number of new cases seen per year at the Sun Yat Sen University Cancer Centre (≈6000 cases/y), this host-secured database facilitates the conduct of research that typically requires the curation of large sample sizes. The design of such a big data platform thus provides an opportunity to aggregate outcomes of NPC cases around the world, even in places where this disease is rare. Such data can help inform on broad efficacy of the treatment regimes that are being used in EBV-associated NPC for the non-endemic squamous histologic subtype and pediatric cases. As raised by Limkin and Blanchard, there is progressive convergence of treatment strategies for NPC between the Western and Eastern countries.14 Likewise for pediatric cases, Claude et al summarised the current protocols for this unique subgroup of patients, whereby long-term treatment-related complications carry equal weightage in treatment considerations.15 With the included pieces of work in this special feature, it is evident that while we have made substantial progress in the understanding and treatment of this unique disease, much more work across the different domains of research is needed to continuously advance the care of NPC patients.References1. Chua MLK, Wee JTS, Hui EP, Chan ATC. Nasopharyngeal carcinoma. The Lancet 2016; 387: 1012–24. doi: https://doi.org/10.1016/S0140-6736(15)00055-0 Crossref Medline ISI, Google Scholar2. Wotman M, Oh EJ, Ahn S, Kraus D, Costantino P, Tham T. Hpv status in patients with nasopharyngeal carcinoma in the United States: a seer database study. Am J Otolaryngol 2019; 40: 705–10. doi: https://doi.org/10.1016/j.amjoto.2019.06.007 Crossref Medline ISI, Google Scholar3. Ruuskanen M, Irjala H, Minn H, Vahlberg T, Randen-Brady R, Hagström J, et al.. Epstein-Barr virus and human papillomaviruses as favorable prognostic factors in nasopharyngeal carcinoma: a nationwide study in Finland. Head Neck 2019; 41: 349–57. doi: https://doi.org/10.1002/hed.25450 Medline ISI, Google Scholar4. Sun X-S, Li X-Y, Chen Q-Y, Tang L-Q, Mai H-Q. Future of radiotherapy in nasopharyngeal carcinoma. Br J Radiol 2019; 92: 20190209. doi: https://doi.org/10.1259/bjr.20190209 Link ISI, Google Scholar5. Li C-H, Wu VW, Chiu G. A dosimetric evaluation on applying RTOG-based and CT/MRI-based delineation methods to brachial plexus in radiotherapy of nasopharyngeal carcinoma treated with helical tomotherapy. Br J Radiol 2018; 92: 20170881. doi: https://doi.org/10.1259/bjr.20170881 Link ISI, Google Scholar6. Chen Y-P, Chan ATC, Le Q-T, Blanchard P, Sun Y, Ma J. Nasopharyngeal carcinoma. The Lancet 2019; 394: 64–806. doi: https://doi.org/10.1016/S0140-6736(19)30956-0 Crossref Medline ISI, Google Scholar7. Peng L, Liu J-Q, Chen Y-P, Ma J. The next decade of clinical trials in locoregionally advanced nasopharyngeal carcinoma. Br J Radiol 2019; 92: 20181031. doi: https://doi.org/10.1259/bjr.20181031 Link ISI, Google Scholar8. Guo R, Mao Y-P, Tang L-L, Chen L, Sun Y, Ma J. The evolution of nasopharyngeal carcinoma staging. Br J Radiol 2019; 92: 20190244. doi: https://doi.org/10.1259/bjr.20190244 Link ISI, Google Scholar9. Chua MLK, Ong SC, Wee JTS, Ng DCE, Gao F, Tan TWK, et al.. Comparison of 4 modalities for distant metastasis staging in endemic nasopharyngeal carcinoma. Head Neck 2009; 31: 346–54. doi: https://doi.org/10.1002/hed.20974 Crossref Medline ISI, Google Scholar10. Jeong Y, Jung I-hye, Kim JS, Chang SK, Lee S-wook. Clinical significance of the post-radiotherapy 18 F-fludeoxyglucose positron emission tomography response in nasopharyngeal carcinoma. Br J Radiol 2019; 92: 20180045. Link ISI, Google Scholar11. Li YQ, Tan JSH, Wee JTS, Chua MLK, YQ L, JTS W. Adaptive radiotherapy for head and neck cancers: fact or fallacy to improve therapeutic ratio? Cancer Radiother 2018; 22: 287–95. doi: https://doi.org/10.1016/j.canrad.2018.01.003 Crossref Medline ISI, Google Scholar12. Liang Z-G, Tan HQ, Zhang F, LKR T, Lin L, Lenkowicz J, et al. Comparison of radiomics tools for image analyses and clinicalprediction in nasopharyngeal carcinoma. Br J Radiol 92: 20190271: 20190271. Link ISI, Google Scholar13. Huang X-D, Lv J-W, Li C-F, Huang X-D, Lv J-W, Peng H, et al.. Development and implementation of a dynamically updated big data intelligence platform from electronic health records for nasopharyngeal carcinoma research. Br J Radiol 2019; 92: 20190255. Link ISI, Google Scholar14. Limkin EJ, Blanchard P. Does East meet West? towards a unified vision of the management of nasopharyngeal carcinoma. Br J Radiol 2019; 92: 20190068. Link ISI, Google Scholar15. Claude L, Jouglar E, Duverge L, Orbach D. Update in pediatric nasopharyngeal undifferentiated carcinoma. Br J Radiol 2019; 92: 20190107. 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Published by the British Institute of Radiology History Published onlineSeptember 17,2019 Metrics Download PDF