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Carotid blowout syndrome (CBS) is a rare yet life-threatening complication that occurs after radiation therapy (RT). This study aimed to determine the incidence of CBS in patients with head and neck cancer (HNC) undergoing contemporary RT and to explore potential discrepancies in the risk of CBS between nasopharyngeal cancer (NPC) and non-NPC patients. A total of 1084 patients with HNC who underwent RT between 2013 and 2023 were included in the study. All patients were under regular follow-ups at the radio-oncology department, and underwent annual contrast-enhanced computed tomography and/or magnetic resonance imaging for cancer recurrence surveillance. Experienced neuroradiologists and vascular neurologists reviewed the recruited patients' images. Patients were further referred to the neurology department for radiation vasculopathy evaluation. The primary outcome of this study was CBS. Patients were categorized into NPC and non-NPC groups and survival analysis was employed to compare the CBS risk between the two groups. A review of the literature on CBS incidence was also conducted. Among the enrolled patients, the incidence of CBS in the HNC, NPC, and non-NPC groups was 0.8%, 0.9%, and 0.7%, respectively. Kaplan–Meier analysis revealed no significant difference between the NPC and non-NPC groups (p = 0.34). Combining the findings for our cohort with those of previous studies revealed that the cumulative incidence of CBS in patients with HNC is 5% (95% CI = 3–7%) after both surgery and RT, 4% (95% CI = 2–6%) after surgery alone, and 5% (95% CI = 3–7%) after RT alone. Our findings indicate a low incidence of CBS in patients with HNC undergoing contemporary RT. Patients with NPC may have a CBS risk close to that of non-NPC patients. However, the low incidence of CBS could be a potentially cause of selection bias and underestimation bias. [ABSTRACT FROM AUTHOR]

Head and neck cancer (HNC) patients who are unable to return to work after completing treatment might face financial loss and reduced self-esteem. The aim of this study was to identify factors influencing a return to work in HNC cancer patients in the first 6 months after treatment. This cross-sectional study examined HNC patients who completed treatment from the outpatient radiation department of a single cancer center in northern Taiwan. Patients were assessed according to psychological distress, patient-perceived health status, barriers to returning to work, and facilitators of returning to work. Of the 106 HNC patients surveyed, 54.7% successfully returned to work. Barriers to returning to work included poor self-perception of health, greater psychological distress, and age ≥50 years. Patients who had higher psychological distress, returned to work after start of the pandemic, or received reconstruction surgery were less likely to experience a positive environment facilitating a return to work. [ABSTRACT FROM AUTHOR]

Background and purpose: to investigate the frequency of cervical–cranial vascular complications soon after radiation therapy (RT) and identify differences among patients with various types of head and neck cancer (HNC). Methods: We enrolled 496 patients with HNC who had received their final RT dose in our hospital. These patients underwent carotid duplex ultrasound (CDU) for monitoring significant carotid artery stenosis (CAS). Brain imaging were reviewed to detect vertebral, intracranial artery stenosis, or preexisted CAS before RT. Primary outcome was significant CAS at the internal or common carotid artery within first 5 years after RT. We categorized the patients into nasopharyngeal carcinoma (NPC) and non-NPC groups and compared the cumulative occurrence of significant CAS between the groups using Kaplan–Meier and Cox-regression analyses. Results: Compared to the NPC group, the non-NPC group had a higher frequency of significant CAS (12.7% vs. 2.0%) and were more commonly associated with significant CAS after adjusting the covariates (Adjusted hazard ratio: 0.17, 95% confident interval: 0.05–0.57) during the follow-up period. All the non-NPC subtypes (oral cancer/oropharyngeal, hypopharyngeal, and laryngeal cancers) were associated with higher risks of significant CAS than the NPC group (p < 0.001 respectively). Conclusion: Significant CAS was more frequently noted within 5 years of RT among the patients with non-NPC HNC than among the patients with NPC. Scheduled carotid artery surveillance and vascular risk monitoring should be commenced earlier for patients with non-NPC HNC. By contrast, vascular surveillance could be deferred to 5 years after RT completion in NPC patients. [ABSTRACT FROM AUTHOR]

Purpose: Primary caregivers (PC) of patients with advanced head and neck cancer (HNC) report stress during caregiving time post‐treatment. We sought to identify the trajectories of resilience from initial completion of treatment to 1‐year post‐treatment in PC of patients with advanced HNC and to determine the factors associated with trajectories of resilience. Design: In this prospective cohort study with convenience sampling, patient–PC dyads were recruited from a medical center in northern Taiwan between August 2015 and July 2020. Methods: We recruited 120 patient–PC dyads and followed up at treatment completion and 1, 6, and 12 months post‐treatment. Generalized estimating equation analysis was performed to identified factors related to resilience. Findings: PCs' overall resilience increased from initial completion of treatment to peak at 1‐year post‐treatment. Patient factors associated with greater overall resilience included older age, higher performance status, and shorter time since cancer diagnosis; PC factors included reporting more social support, better physical health, and better mental health. Conclusions: PC mental health was the most important factor in the resilience trajectory of patients with advanced HNC cancer. Clinical relevance: Quantifying the relevant factors of trajectories of resilience will help to identify vulnerable PCs and guide survivorship care in the early stages of the post‐treatment period. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study of survivors of head and neck cancer was to evaluate the effects of a behavior change program and health education on depression, fear of social interactions, avoidance of social interactions, physical function, and social-emotional function.Methods: This was a randomized controlled trial of 100 subjects, in which changes in the scores of several psychometric scales were recorded for an experimental group (behavior change program and health education) and a control group (routine care only). Assessments were performed at baseline (T0), and at 1 month (T1), 2 months (T2), and 3 months (T3) after completing the intervention.Results: After the intervention, the experimental group reported significantly less fear of social interactions, less avoidance of social interactions, and better physical function than the control group. The experimental group also had less depression at T3 than at T0, although there was no such change in the control group. Analysis of physical function indicated that both groups experienced improvements from T0 to T1, slight declines from T1 to T2, and slight declines from T2 to T3; however, both groups had significantly better physical function at T3 than at T0.Conclusions: Head and neck cancer patients who received a behavior change program and health education reported less fear of social interactions, less avoidance of social interactions, and improved physical function during the 3 months after this intervention. [ABSTRACT FROM AUTHOR]

The present study aimed to evaluate the effects of a nurse-led survivorship care program (SCP) on emotional distress, social support, physical health, mental health, and resilience in primary caregivers of patients with advanced head and neck cancer. A randomized controlled trial was conducted. One hundred patient-primary caregiver dyads were randomized into the nurse-led SCP group (experimental) or the usual care group (control). Participants completed a self-reported questionnaire, including measures of emotional distress, social support, physical health, mental health, and resilience. After 6 months, the experimental group reported a significant improvement in emotional distress, social support, physical health, mental health, and resilience. Compared with the control group, measures of emotional distress, physical health, overall resilience, and the resilience aspects of equanimity and perseverance improved in the experimental group. An SCP may feasibly help alleviate emotional distress, improve social support, increase physical and mental health, and strengthen resilience in the primary caregivers of patients with head and neck cancer. Health care providers should encourage primary caregivers to join an SCP. The nurse-led SCP can be applied before patients complete treatment, which may increase the positive effect on physical health and adaptation. [ABSTRACT FROM AUTHOR]

Purpose: Both head and neck magnetic resonance imaging (MRI) and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) play a crucial role in the staging of primary nasopharyngeal carcinoma (NPC). In this study, we sought to prospectively investigate the clinical utility of simultaneous whole-body 18F-FDG PET/MRI for primary staging of NPC patients.Methods: We examined 113 patients with histologically confirmed NPC who underwent pretreatment, simultaneous whole-body PET/MRI and PET/CT for primary tumor staging. The images obtained with the different imaging modalities were interpreted independently and compared with each other.Results: PET/MRI increased the accuracy of head and neck MRI for assessment of primary tumor extent in four patients via addition of FDG uptake information to increase the conspicuity of morphologically subtle lesions. PET/MR images were more discernible than PET/CT images for mapping tumor extension, especially intracranial invasion. Regarding the N staging assessment, the sensitivity of PET/MRI (99.5%) was higher than that of head and neck MRI (94.2%) and PET/CT (90.9%). PET/MRI was particularly useful for distinguishing retropharyngeal nodal metastasis from adjacent nasopharyngeal tumors. For distant metastasis evaluation, PET/MRI exhibited a similar sensitivity (90% vs. 86.7% vs. 83.3%), but higher positive predictive value (93.1% vs. 78.8% vs. 83.3%) than whole-body MRI and PET/CT, respectively.Conclusions: For tumor staging of NPC, simultaneous whole-body PET/MRI was more accurate than head and neck MRI and PET/CT, and may serve as a single-step staging modality. [ABSTRACT FROM AUTHOR]

Abstract: We aimed to investigate the prognostic significance of combined pretreatment lymphocyte counts (LCs) and body mass index (BMI) in patients with head and neck cancer (HNC) treated with radiation therapy (RT). Nine hundred and twelve patients with HNC who were treated with RT were retrospectively reviewed. Survival was analyzed by stratifying the patients according to pretreatment LCs and BMI. Patients with low pretreatment LCs and BMI were characterized by a more advanced T stage, fewer nasopharyngeal subsites, less smoking and drinking, and fewer comorbidities. Patients with low pretreatment LCs and BMI had a significantly poorer overall and distant metastasis‐free survival than those with high pretreatment LCs and BMI. No significant differences were observed in terms of local or regional recurrence‐free survival. Combined pretreatment LCs and BMI may be more effective at predicting overall and distant metastasis‐free survival in patients with HNC treated with RT. [ABSTRACT FROM AUTHOR]

Abstract: We aimed to determine whether body composition assessment before treatment can predict outcomes in patients with head and neck cancer (HNC). All 881 patients with locoregional head and neck cancer treated with curative intent radiotherapy (RT) between 2005 and 2012 were retrospectively investigated. Body composition was analyzed via pre‐RT planning computed tomography (CT) images. Subcutaneous adipose tissue (SAT) and skeletal muscle (SM) indices were measured cross‐sectionally at the level of the third thoracic vertebra. Overall survival (OS), locoregional control (LRC), and distant metastasis‐free survival (MFS) were analyzed by body composition index and body mass index (BMI). Survivors were followed up for a median of 4.68 years. The SAT indices in female patients were significantly higher than those in males (P < 0.001). The median SAT and muscle indices were 18.6 and 34.3 cm2/m2 for women and 6.19 and 51.74 cm2/m2 for men, respectively. The 5‐ and 10‐year MFS, LRC, and OS rates were 83% and 82.1%, 73.4% and 71.4%, and 66.4 and 57.6%, respectively. Higher pretreatment SAT index was associated with MFS (hazard ratio [HR]: 0.65; P = 0.015), LRC (HR: 0.758; P = 0.047), and OS (HR: 0.604; P < 0.001). Higher pretreatment BMI was associated with MFS (HR: 0.642; P = 0.031) and OS (HR: 0.615; P < 0.001). The pretreatment SM index had no significant effect on MFS, LRC, and OS. Multivariate analysis revealed that T‐stage, N‐stage, lesion sites, age, and RT treatment days are independent factors associated with OS; T‐stage, N‐stage, and lesion sites are independent factors associated with MFS; and N‐stage, smoking history, and betel quid chewing history are independent factors associated with LRC. A higher CT‐assessed SAT index predicts superior MSF, LCR, and OS in patients with curative HNC, whereas SM does not predict survival or locoregional control. [ABSTRACT FROM AUTHOR]

Background: To investigate the advantage of concurrent chemotherapy with postoperative radiotherapy (RT) of oral squamous cell carcinoma (OSCC) in patients with three or more minor risk factors.Methods: Minor risk factors included pT4 disease, pN1 disease, margin ≤ 4 mm, poor differentiation, perineural invasion, vessel or lymphatic invasion, and tumor invasion depth ≥ 11 mm. Surgery was the primary treatment, followed by RT or concurrent chemoradiation (CCRT). After propensity score matching, 34 patients in each treatment group were selected for comparison.Results: The median follow-up for living patients was 86.4 months (range: 47-189 months). The 5-year overall survival of the RT and CCRT groups was 35.3% and 67.2% (p = 0.018), respectively. The 5-year recurrence-free survival of the RT group and CCRT group was 42.6% and 75.4% (p < 0.01).Conclusion: Postoperative CCRT for patients with three or more minor risk factors increased recurrence-free and overall survival. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the effects of a skin camouflage program on disfigurement, self-esteem, social interaction, and body image in female head and neck cancer (HNC) survivors.Methods: A prospective, repeated-measures, randomized controlled therapeutic intervention design was used. A total of 66 participants were randomly assigned to each group, with 32 in the experimental group and 34 in the control group. The experimental group received a 4-session skin camouflage program, and the control group received routine care. Patients were assessed at 3 time points: baseline assessment (T0) and then at 1, 2, and 3 months (T1, T2, and T3, respectively) after participating in the skin camouflage program.Results: Patients in the experimental group had significantly less facial disfigurement, depression, fear of social interaction, and anxiety regarding social interaction compared with those in the control group. Participants in both groups had significantly lower levels of facial disfigurement, depression, fear of social interaction, anxiety of social interaction, and body image at the final posttest assessment than at the pretest assessment. There were no differences between the groups and within groups with respect to self-esteem.Conclusions: The 3-month skin camouflage program effectively improved facial disfigurement, fear of social interaction, anxiety of social interaction, and body image of female HNC survivors. A survival care plan should include a skin camouflage program to improve body image perception and decrease anxiety after treatment of HNC. [ABSTRACT FROM AUTHOR]

Background/purpose: Significant ethnic differences in susceptibility to the effects of chemotherapy exist. Here, we retrospectively analyzed the safety and efficacy of induction chemotherapy (ICT) with dose-modified docetaxel, cisplatin, and 5-fluorouracil (TPF) in Asian patients with borderline resectable or unresectable head and neck squamous cell carcinoma (HNSCC).Methods: Based on the incidence of adverse events that occurred during daily practice, TPF90 (90% of the original TPF dosage; docetaxel 67.5 mg/m2 on Day 1, cisplatin 67.5 mg/m2 on Day 1, and 5-fluorouracil 675 mg/m2 on Days 1-5) was used for HNSCC patients who were scheduled to receive ICT TPF.Results: Between March 2011 and May 2014, 52 consecutive patients with borderline resectable or unresectable HNSCC were treated with ICT TPF90 followed by concurrent chemoradiotherapy. Forty-four patients (84.6%) received at least three cycles of ICT TPF90. The most commonly observed Grade 3-4 adverse events included neutropenia (35%), anemia (25%), stomatitis (35%), diarrhea (16%), and infections (13.5%). In an intention-to-treat analysis, the complete and partial response rates after ICT TPF90 were 13.5% and 59.6%, respectively. The complete and partial response rates following radiotherapy and salvage surgery were 42.3% and 25.0%, respectively. The estimated 3-year overall survival and progression-free survival rates were 41% [95% confidence interval (CI): 25-56%] and 23% (95% CI: 10-39%), respectively. The observed median overall survival and progression-free survival were 21.0 months (95% CI: 13.3-28.7 months) and 16.0 months (95% CI: 10.7-21.3 months), respectively.Conclusion: TPF90 is a suitable option for Asian patients with borderline resectable or unresectable HNSCC who are scheduled for ICT. [ABSTRACT FROM AUTHOR]

Objectives: Reliable prognostic factors that serve as a guide to follow-up of patients with locoregionally advanced nasopharyngeal carcinoma (NPC) have not yet been identified. We sought to investigate the prognostic implications of post-therapy PET in patients with NPC treated with chemoradiotherapy. Methods: Patients with locoregionally advanced NPC (stages III and IVa-b) who had completed primary curative treatment for 3 months were eligible. All of the patients underwent F-FDG PET and conventional work-up (CWU) for the assessment of treatment response. Results: A total of 165 patients were enrolled. Over a median follow-up of 58 months, 30 patients died and 41 had disease recurrence. The results of the 3-month post-therapy PET and total lesion glycolysis (TLG) of the primary tumor were independent predictors of overall survival. TNM tumor stage, TLG, and post-therapy PET findings were independently associated with disease-free survival (DFS). The results of post-therapy PET were more predictive of DFS than TNM tumor stage ( P < 0.001 vs. P = 0.005). Among patients with stage IVa-b disease, there was a trend toward better 5-DFS rates in patients with a complete metabolic response (CMR) on PET than in those who showed a complete response in the CWU (5-year DFS = 70.7 vs. 63.1 %). Notably, the 1- and 2-year DFS rates were significantly better in the former group compared with the latter. In contrast, the results of post-therapy CWU were not a reliable predictor for DFS. Conclusion: The results of post-therapy PET are an important independent prognostic factor in locoregionally advanced NPC. CMR on PET is associated with better DFS rates and could serve as a guidance to individualize the surveillance protocols for patients with stage IVa-b disease. [ABSTRACT FROM AUTHOR]

Background To investigate the pretreatment copy number and the clearance rate of plasma Epstein-Barr virus (EBV) DNA as novel prognostic outcome markers for metastatic nasopharyngeal carcinoma (NPC). Methods Seventy-three patients with metastatic NPC were treated at outpatient department. Plasma EBV DNA concentrations and half-life values of plasma viral clearance rates, were determined by real-time quantitative polymerase chain reaction. Results Treatment response evaluated after 3 to 6 months of treatment showed that the overall response rate was 53.5%. The pretreatment plasma EBV DNA concentrations and the half-life of plasma EBV DNA clearance rates had significant effects on treatment response and overall survival prediction. In the chemotherapy regimen, gemcitabine plus cisplatin had a better treatment outcome than the cisplatin plus oral UFT and calcium folinate-based regimens. Conclusions The pretreatment plasma EBV DNA copy number and their clearance rates are significant predictors for NPC treatment outcome. © 2011 Wiley Periodicals, Inc. Head Neck, 2012 [ABSTRACT FROM AUTHOR]

Summary: Objectives: To investigate the prognostic value of prepontine cistern invasion (PPCI) in nasopharyngeal carcinoma (NPC) patients treated with intensity-modulated radiotherapy (IMRT). Materials and methods: Five hundred and four non-disseminated NPC patients who underwent magnetic resonance imaging examination before radical IMRT between November 2000 and December 2008 were retrospectively reviewed. The diagnostic criteria for PPCI were tumor invasion through the posterior cortex of clivus and extension into the prepontine cistern. Results: The median follow-up of the patients in this study was 63.5months. PPCI was found in 44 patients (25% of T4 patients). The 5-year progression-free survival (PFS), local control (LC), distant metastasis-free survival (DMFS), and overall survival (OS) of all patients, with and without PPCI, were 44.3% and 70.5% (p <0.001), 84.4% and 89.1% (p =0.376), 66.6% and 87.3% (p <0.001), and 59.6% and 80.2% (p <0.001), respectively. In T4 patients with PPCI and without PPCI, the 5-year PFS, LC, DMFS, and OS were 44.3% and 62.5% (p =0.023), 84.4% and 84.9% (p =0.946), 66.6% and 83.1% (p =0.022), and 59.6% and 71.0% (p =0.045), respectively. Using multivariate analysis, PPCI was found to be an independent poor prognostic factor for PFS (HR=1.816; p =0.007), DMFS (HR=1.928; p =0.045), and OS (HR=1.798; p =0.016). Conclusion: Prepontine cistern invasion was an independent prognostic factor for poor DMFS and OS but not LC in NPC patients treated with IMRT, even within T4 patients. [Copyright &y& Elsevier]

• LMR significantly changed during RT in patients with head and neck cancer. • The dynamic changes in LMR during RT carried prognostic value. • Longitudinal assessment of LMR during RT may serve as a promising biomarker. We sought to investigate whether dynamic changes in lymphocyte-to-monocyte ratio (LMR) occurring during the course of radiotherapy (RT) may have prognostic value in patients with head and neck cancer (HNC). We retrospectively reviewed the clinical records of patients with HNC who underwent RT at our center between 2005 and 2013. Generalized estimating equations were used to longitudinally assess changes in LMR through the course of RT. Delta-LMR was calculated as the difference between LMR measured during treatment and baseline LMR values. Freedom from metastasis (FFM) and overall survival (OS) served as the main outcome measures. A total of 1431 patients with HNC were enrolled. After a median follow-up of 9 years, 636 (44.4%) patients died and 240 (16.8%) had distant metastases. Compared with patients with low delta-LMR at two weeks, those with high delta-LMR experienced less favorable outcomes (five-year OS: 73% versus 59%, respectively, p < 0.001; five-year FFM: 87% versus 80%, respectively, p = 0.015). Similar findings were observed for delta-LMR measured at four weeks (five-year OS: 72% versus 60%, p < 0.001; five-year FFM: 86% versus 79%, respectively, p = 0.002) and six weeks (five-year OS: 72% versus 57%, p < 0.001; five-year FFM: 87% versus 79%, respectively, p = 0.002). Multivariate analysis identified delta-LMR as an independent prognostic factor for both FFM and OS. Delta-LMR is a simple and inexpensive biomarker that may be clinically useful for predicting FFM and OS in patients with HNC treated with RT. [ABSTRACT FROM AUTHOR]

Objective: In this study, we investigated the usefulness and limitations of EBV-DNA follow-up in patients who had treated localized nasopharyngeal carcinoma. Methods: Study subjects comprised 389 patients who had received treatment for localized nasopharyn-geal carcinoma in our department. Copy numbers of EBV-DNA in plasma were assessed by real-time quantitative PCR. Patients in whom disease recurrence was suspected underwent image evaluation, esp. PET scan, and tissue proof if it is feasible. Lesions of undermined nature were confirmed by sequen-tial follow-up. Results: Plasma EBV-DNA was detectable in 60 of 63 (95%) patients with metastatic disease and all had positive PET findings. In addition, of the 45 patients with localized recurrent disease, plasma EBV-DNA was detectable in 23 (51%) patients and positive PET scan results were obtained in 40 (89%) of the patients. Of the 284 patients who were disease free, plasma EBV-DNA was detected in 90 (32%) patients. Of the 19 patients in disease free group who were suspected disease recurrence receiving PET scanning, 7 positive PET images were found including 3 second primary malignancy and 4 non-cancer lesions. Two lymphoma cases with positive EBV-DNA value sequentially attacked before or after their NPC were diag-nosed. With the cutoff value of 400 copies/ml of EBV-DNA, the positive predict value was 73.5% and the negative predict value was 82.1%. The sensitivity was 0.46 and the specificity was 0.94. Conclusions: EBV-DNA was a good marker for detecting metastatic failure in treated localized NPC. How-ever, careful interpretation with complements from image examination was needed for locoregional fail-ure and other false positive or false negative situations. [ABSTRACT FROM AUTHOR]

Summary: Distant failure is an important cause of death in stage M0 primary nasopharyngeal carcinoma (NPC). However, a reliable prognosticator for occurrence of distant failure was lacking. Thus, we conducted this study to investigate prospectively the role of standardized uptake value on 18F-FDG for predicting distant failure in stage M0 NPC. Patients with stage M0 primary NPC diagnosed by both conventional work-up (CWU) and 18F-FDG PET were enrolled. Survival was estimated by the Kaplan–Meier method. Cox proportional hazards models were used to identify independent prognosticators. Between January 2002 and July 2003, 65 NPC patients were investigated. Up to the date of analysis, 12 patients died and 13 patients experienced recurrences, among whom 9 had distant failures. The 5-year overall survival (OS), relapse-free survival (RFS), and distant relapse-free survival (DRFS) were 81.2%, 79.2%, 84.4%, respectively. In multivariate analysis, the following risk factors for poor prognosis were identified: T3–4 (p =0.033) for RFS; and maximal standardized uptake value (SUVmax) of the primary tumor>12.0 (p =0.012), stage IVa–b (p =0.037), and N2–3 disease (p =0.04) for DRFS. The 5-year DRFS in stage IVa–b patients with SUVmax>12.0 was significantly lower than that in stage I–III patients with SUVmax⩽12 (p =0.0001). None of the patients in the latter group developed distant failure. In conclusion, a SUVmax>12.0 of the primary tumor represents a “metabolic phenotype” for occurrence of distant failure in stage M0 NPC patients. And the combined information of SUVmax and tumor staging can guide the use of neoadjuvant/adjuvant therapy and surveillance protocols to improve distant control. [Copyright &y& Elsevier]

Objectives: To investigate the prognostic value of the relative maximum standardized uptake value (SUV) ratio between neck lymph node and primary tumor (NTR) measured by pretreatment 18F-FDG PET in patients with nasopharyngeal carcinoma (NPC).Materials and Methods: We retrospectively reviewed patients with non-disseminated NPC who underwent PET scans before radical intensity-modulated radiotherapy (IMRT). Receiver operating characteristic analysis was performed to identify the optimal cut-off value for NTR. The prognostic value of NTR for distant metastasis-free survival (DMFS) was evaluated using Kaplan-Meier method for survival analyses and Cox regression for multivariable analysis.Results: Among the 437 eligible patients, the median follow-up time was 62.9 (range, 2.1-113.0) months. Patients with high NTR (NTR > 0.9181) experienced significantly worse DMFS (5-year 80.5% vs. 91.6%, P < 0.001). In the subgroup analysis, we found that patients with high NTR had significantly lower DMFS in T1-2 category (5-year 86.1% vs. 98.1%, P = 0.002), T3-4 category (5-year 71.5% vs. 86.2%, P = 0.010), N2-3 category (5-year 75.3% vs. 86.2%, P = 0.048), and stage IVA-B (5-year 69.8% vs. 85.4%, P = 0.012). Multivariable analysis showed that NTR was an independent prognostic factor for DMFS (HR 2.20, 95% CI 1.20-4.03, P = 0.011).Conclusion: Pretreatment NTR is an easily accessible but potential prognosticator for DMFS in NPC patients treated by IMRT, which may help in providing more personalized treatment or designing future clinical trials. [ABSTRACT FROM AUTHOR]