Sufang Qiu

PURPOSE: To provide evidence-based recommendations on first- and subsequent-line systemic therapy, maintenance therapy, locoregional consolidation, and salvage local therapy for patients with recurrent and/or metastatic nasopharyngeal carcinoma (NPC). METHODS: A multidisciplinary Expert Panel convened by CSCO and ASCO reviewed evidence from randomized trials, meta-analyses, systematic reviews, prospective and retrospective studies, and clinical experience. The guideline was informed by a systematic literature review and consensus-based interpretation of efficacy, safety, feasibility, and patient-centered outcomes across scenarios. Outcomes included overall and progression-free survival, response and disease control rates, toxicity, and quality of life. RESULTS: Evidence supports platinum-based chemotherapy plus a programmed cell death protein 1 (PD-1) inhibitor as preferred first-line therapy for medically fit patients. Evidence also supports maintenance strategies after disease control, while treatment selection depends on prior treatment, disease extent, patient fitness, resource availability, and preferences. Selected responders may receive locoregional consolidation radiotherapy or oral maintenance chemotherapy. For isolated locoregional recurrence amenable to local therapy, options include salvage surgery and re-irradiation. RECOMMENDATIONS: Chemotherapy plus a PD-1 inhibitor, followed by maintenance PD-1 inhibition for up to 2 years, should be offered first-line to appropriate patients with recurrent and/or metastatic NPC. Chemotherapy alone may be offered when immunotherapy is unsuitable or declined. Selected patients responding to first-line chemotherapy may receive oral maintenance chemotherapy or locoregional consolidation intensity-modulated radiotherapy. Salvage surgery or re-irradiation is recommended for appropriately selected patients with isolated locoregional recurrence. Subsequent-line options include chemotherapy, PD-1 inhibitors, and antibody-drug conjugates. Treatment should be individualized according to disease setting, prior therapy, expected toxicities, availability, local drug approvals, and patient preferences. Early supportive and specialist interdisciplinary palliative care, where available, should accompany active anticancer treatment for advanced, incurable disease. Additional information is available at www.ascopubs.org/topics/asco-guidelines/head-neck-cancer .

Background: MRI‐derived nodal features may improve prognostication beyond TNM staging, but distant‐metastasis risk models remain limited. Purpose: To develop and internally validate an MRI model for distant metastasis prediction in locoregionally advanced nasopharyngeal carcinoma (LA‐NPC). Study Type: Retrospective. Population: One thousand five‐hundred and forty‐one patients with LA‐NPC (1103 men and 438 women; mean age, 48 ± 12 years) were split into a training set ( n = 1079) and an internal validation set ( n = 462). Field Strength/Sequence: 3.0‐T MRI using axial T1‐weighted turbo spin‐echo, axial T2‐weighted short‐tau inversion recovery, diffusion‐weighted imaging ( b = 0 and 800 s/mm ² ) with apparent diffusion coefficient maps, and multiplanar fat‐suppressed contrast‐enhanced T1‐weighted turbo spin‐echo. Assessment: Extranodal extension (ENE), cervical lymph node necrosis (CNN), nodal size, regional lymph node density (RLND), nodal laterality, and clinical variables were assessed. Recursive partitioning analysis (RPA) defined risk groups, which were combined with T and N categories in a nomogram. Statistical Tests: Cox analyses were performed in training. Performance was assessed by the concordance index (C‐index), 3‐year time‐dependent receiver operating characteristic analysis, and calibration. Two‐sided p < 0.05 indicated significance. Results: ENE Grade 3 (HR, 1.92; 95% CI, 1.20–3.07), CNN Grades 3–4 (HR, 2.65; 95% CI, 1.46–4.81), and RLND (per‐unit increase: HR, 1.92; 95% CI, 1.29–2.88) were independently associated with shorter distant metastasis–free survival (DMFS). The multivariable model C‐index was 0.766 (95% CI, 0.721–0.811). RPA assigned 491, 524, and 64 patients to low‐, intermediate‐, and high‐risk groups, with 3‐year DMFS rates of 97.53%, 89.90%, and 60.83%, respectively. Nomogram 3‐year AUCs were 0.777 (95% CI, 0.725–0.828) in training and 0.728 (95% CI, 0.645–0.810) in validation; the difference was nonsignificant ( p = 0.333). Mean absolute calibration errors were 0.009 and 0.012, respectively. Data Conclusion: MRI‐derived nodal features enabled DMFS risk stratification, and the internally validated nomogram showed discrimination and calibration. Evidence Level: 4. Technical Efficacy: Stage 2.

Background: Residual locoregionally advanced nasopharyngeal carcinoma (LA-NPC) after definitive chemoradiation leads to poor outcomes, but current treatments lack standardized, evidence-based guidance for individualized dose escalation, causing varied practices. Objective: To develop a risk-stratification model to personalize boost doses for these patients. Design: A retrospective study. Methods: In this retrospective study, 364 LA-NPC patients with post-radiotherapy (post-RT) residual disease were enrolled. Patients were stratified into high-dose (≥600 cGy, n=201) and low-dose (<600 cGy, n=163) boost groups. Independent prognostic factors were identified via Cox regression. A risk stratification model was constructed using these factors, and its utility in guiding boost dose selection was evaluated. Results: Multivariate analysis confirmed that clinical stage (HR=2.012, 95% CI: 1.100-3.682, p=0.023) and detectable post-RT EBV DNA (HR=1.997, 95% CI: 1.129-3.535, p=0.018) were independent prognostic factors for LA-NPC patients with residual disease after definitive chemoradiotherapy. Based on these variables, a three-tiered risk model was established: low-risk (Stage III with undetectable post-RT EBV DNA), middle-risk (Stage III with detectable post-RT EBV DNA or Stage IVA with undetectable post-RT EBV DNA), and high-risk (Stage IVA with detectable post-RT EBV DNA). This model effectively stratified patients for overall survival (OS) (P<0.05). Crucially, a high-dose boost (≥600 cGy) was associated with improved OS in the high-risk group (HR=0.344, 95% CI: 0.122–0.967, P=0.043), whereas no survival advantage was identified in the low- or middle-risk groups. Among high-risk patients, no statistically significant differences in acute or late toxicities were observed between the high-dose and low-dose boost groups. Conclusion: We developed a clinically applicable risk stratification model integrating clinical stage and post-RT EBV DNA status. Our findings suggest that only high-risk patients may derive an OS benefit from a boost dose of ≥600 cGy, whereas low- and middle-risk patients do not appear to benefit from further dose escalation. This risk-adapted boost strategy provides a preliminary framework requiring prospective validation. Given the retrospective single-center design of this study, prospective multicenter studies are warranted before routine clinical implementation.

Glioma ranks among the most intractable malignancies. Given the intricate anatomy of the brain, complete surgical resection is seldom achievable, making radiotherapy a necessary adjunct. Nevertheless, radioresistance, which is closely linked to recurrence, still represents a critical clinical barrier. Effective tumor biomarkers and novel detection methods are urgently required to predict treatment resistance and monitor therapeutic response. Here, we employed surface-enhanced Raman spectroscopy (SERS) coupled with proteomics to profile, for the first time, the characteristic spectral patterns of exosomes secreted by our established radioresistant glioma cells. We further uncovered specific shifts in protein expression during the development of radioresistance, including glycolysis‑related proteins (ALDOA and GAPDH) and ribosomal proteins (RPS5 and RPLP0). These proteins are correlated with glioma prognosis. Moreover, bioinformatic analysis revealed that expression levels of all four genes positively correlate with tumor malignancy grade. Furthermore, we established a machine learning-based diagnostic model, Principal component analysis and convolutional neural network (PCA-CNN), for the accurate identification of exosomes derived from radioresistant glioma cells. These findings validate exosomes as a strong candidate biomarker for predicting radioresistance. This approach enables rapid and reliable assessment of radiotherapy resistance in glioma, paving the way for personalized and precise clinical management.

Background: Precise delineation of clinical target volume (CTV) in postoperative breast cancer radiotherapy to ensure adequate target coverage while limiting radiation exposure to organs at risk (OARs). Anatomical landmark–based and glandular tissue–based approaches are widely used, but their dosimetric differences and practical implications remain under discussion. Methods: This retrospective dosimetric study included breast cancer patients who underwent breast-conserving surgery with normal bilateral breast morphology. CT simulations (3-mm slice thickness) were imported into the Monaco 5.0 planning system. Two CTV delineation strategies were compared: anatomical landmark–based (CTV _an ) following ESTRO guidelines, and glandular tissue–based (CTV _gl ) using CT visualization. Planning target volume (PTV) was generated by applying a 0.5-cm retraction from the skin and a 0.5-cm uniform expansion. All contours were generated by a single senior radiation oncologist, and treatment plans were created by an experienced physicist. Dosimetric parameters for the heart, left lung, and contralateral breast were evaluated. Results: A total of 48 patients (age 32–67 years; mean 49.35 ± 8.57) were included. CTV _gl volumes were significantly smaller than CTV _an volumes (432.87 ± 184.09 cc vs. 582.59 ± 232.55 cc; P < 0.001). Glandular-based delineation was associated with lower D _max , higher D ₉₈ , and reduced OARs exposure. Left lung V ₂₀ , mean heart dose, heart V ₄₀ , and contralateral breast(CB) D _mean were all significantly lower in the CTV _gl group ( P < 0.001). CTV volume showed significant positive associations with heart and contralateral-breast dose, whereas left-lung dose demonstrated weaker and more variable associations, reflecting the influence of anatomical and planning-related factors. Conclusions: Glandular tissue–based delineation produced smaller target volumes and lower radiation exposure to adjacent organs compared with anatomical landmark–based delineation. These findings provide quantitative dosimetric evidence of differences between the two approaches; however, the clinical implications of these reductions cannot be inferred from this dosimetric analysis alone. Further studies incorporating normal tissue complication probability (NTCP) modeling and clinical outcomes are needed to determine their relevance for long-term toxicity and treatment decision-making.

Patients with nasopharyngeal carcinoma (NPC) exhibiting persistent EBV DNA positivity throughout treatment (a “D-D-D” trajectory) represent a high-risk group with undefined management strategies. This study aimed to define critical post-radiotherapy timepoints to establish a precision surveillance strategy for these patients. In a longitudinal cohort of non-metastatic “D-D-D” NPC patients, plasma Epstein-Barr virus (EBV) DNA was quantified at 1.5, 3, 6, 9, and 12 months post-radiotherapy. A time-dependent Cox model was employed to evaluate the dynamic prognostic value of EBV DNA status. Model performance was rigorously compared using Harrell’s C-index, the Akaike information criterion, and net reclassification improvement. Classification metrics, including sensitivity, specificity, and predictive values, were analyzed to identify clinically actionable decision points. Among 295 patients, early clearance by 1.5 months (10.5% of the cohort) conferred favorable survival, comparable to the “D-D-U” subgroup from our previous analysis. The 12-month EBV DNA status emerged as the strongest independent predictor of disease progression (adjusted HR = 2.804, 95% CI: 2.273–3.460, P < 0.001), offering high specificity (98.6%) but delayed intervention. In contrast, the 1.5-month timepoint, while highly sensitive (95.0%), generated an unactionable alert rate (89.0%). The 3-month assessment optimally balanced these parameters, maintaining substantial sensitivity (76.7%) within a clinically actionable alert rate (65.5%). We propose a time-adapted risk stratification framework wherein the 3-month assessment identifies patients for intensified surveillance, while persistent EBV DNA at 12 months identifies a population at high risk of progression. The clinical benefit of timepoint-guided interventions warrants prospective randomized investigation. Not applicable The online version contains supplementary material available at 10.1186/s13014-026-02830-z.

Background: The evolution of nasopharyngeal carcinoma (NPC) involves potential transitions among states of recurrence, metastasis, and/or remission. Understanding the dynamics of NPC progression following radical radiotherapy may help optimize surveillance protocols and patient management. Objectives: To characterize the progression dynamics of NPC following radical radiotherapy. Design: A retrospective study. Methods: The cohort comprised NPC patients who underwent radical intensity-modulated radiotherapy between 2016 and 2022. A multi-state Markov model was employed to estimate transition intensities and probabilities across various disease states, including failure-free, single failure event (recurrence or metastasis, R/M), multi-event progression (recurrence and metastasis, R&M), and death. A Shiny-based web tool was developed to facilitate the clinical translation of the model. Results: A total of 4800 NPC patients were included, yielding 18,641 disease-state assessments, with a median follow-up of 3.3 years. The transition intensity from metastasis to death (0.025, 95% confidence interval (CI), 0.021–0.029) was 2.3 times greater than that from recurrence to death (0.011, 95% CI, 0.009–0.014). The estimated probabilities of remaining failure-free, experiencing R/M, and deteriorating to death were 89.9%, 7.7%, and 2.1% at 2 years, respectively. Among patients with recurrence, the probabilities of progression to metastasis and death were 3.8% and 24.5%; among those with metastasis, the probabilities of progression to recurrence and death were 2.1% and 45.0%, respectively. Increasing age, male sex, advanced TNM stage, higher pre-treatment Epstein-Barr virus (EBV) DNA, and detectable post-treatment EBV DNA were associated with treatment failure. A web tool was developed to predict NPC disease-state transitions at 2 years. Conclusion: These findings provide initial evidence on the dynamic progression of NPC, which may inform clinical management and patient counseling. Risk-stratified screening and targeted interventions could help mitigate disease progression.

This study was designed to assess the prognostic significance of nutritional risk index (NRI) in nasopharyngeal carcinoma (NPC) patients. In this dual-center study, 1,174 patients were enrolled. Kaplan-Meier analysis assessed the association between NRI and prognosis. Independent prognostic factors for nomogram construction were identified using multivariate Cox regression analysis. The predictive nomogram underwent assessment through decision curve analysis (DCA) and calibration curves. The median NRI value was 112.11. Patients with high NRI (≥ 112.11) demonstrated significantly better survival outcomes than those with low NRI (< 112.11) in both cohorts. Multivariate analysis identified that NRI (≥ 112.11 vs. < 112.11) was an independent prognostic factor for distant metastasis-free survival in the training cohort, and for overall survival (OS) and locoregional relapse-free survival in the validation cohort. The constructed nomogram showed strong discriminatory ability (C-index: 0.715 for training; 0.678 for validation) and good calibration. DCA indicated superior clinical net benefit compared to default strategies. Risk stratification revealed that low-risk patients achieved significantly higher 3-year OS (97.8% vs. 81.1%, P < 0.001) and progression-free survival (PFS, 93.0% vs. 69.3%, P < 0.001) than high-risk patients. Within the high-risk group, the induction chemotherapy (IC) plus radiotherapy (RT)/concurrent chemoradiotherapy (CCRT) regimen significantly improved OS and PFS compared to RT/CCRT alone. Among low-risk patients, the two regimens yielded comparable outcomes. The NRI serves as a reliable prognostic indicator for NPC patients. The proposed nomogram enables personalized risk stratification and offers reference for individual treatment regimen selection.