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. 2025 Apr 29;25(1):802.
doi: 10.1186/s12885-025-14086-z.

Nasopharyngeal necrosis following intensity-modulated radiation therapy of primary nasopharyngeal carcinoma-incidence rate and predictors of risk

Xing-Li Yang #  1 , Li Lin #  2   3 , Sha-Sha He  1 , Dan-Wan Wen  1 , Jia Kou  3   4 , Yan Wang  1 , Xue-Cen Wang  5 , Yong Chen  6
Affiliations

Nasopharyngeal necrosis following intensity-modulated radiation therapy of primary nasopharyngeal carcinoma-incidence rate and predictors of risk

Xing-Li Yang et al. BMC Cancer. .

Abstract

Objectives: This study aimed to investigate the incidence of post radiation nasopharyngeal necrosis (PRNN) in primary NPC after intensity modulated radiation therapy (IMRT) and identify the predictors of risk.

Methods: Data of 5798 NPC patients who received IMRT-based treatment between April 2009 and December 2015 were retrospectively reviewed. PRNN was diagnosed by MRI or nasopharyngoscopy. Dosimetric factors were selected by the least absolute shrinkage and selection operator logistic regression and applied to Cox proportional hazards modeling with clinical predictors.

Results: Among the 5798 patients, 53 developed PRNN-an incidence rate of 0.89%. Age > 55 years, diabetes, LDH > 170 U/L, and tumor volume of nasopharynx > 60.5 cm3,were independently associated with risk of PRNN(all p < 0.05. Dosimetric analysis showed that D0.5ccEQD2 of 80.20 Gy might be the dose constraint for nasopharynx (sensitivity = 62.3%, 33 out of 53; specificity = 84.2%, 4897 out of 5925). Besides, the RTOG dose constraints of V110% (V77.0) should be less than 0.2% in case of increasing risk of PRNN(HR = 2.28, 95% CI: 1.26-4.41, p = 0. 01).

Conclusion: Nasopharyngeal necrosis is rare after primary IMRT. The independent risk factors for this rare complication include age > 55 years, diabetes mellitus, LDH > 170 U/L, tumor volume of nasopharynx > 60.5 cm3, D0.5ccEQD2 > 80.20 Gy, and V77.0 < 0.2% to the planning treatment volume of nasopharynx.

Keypoints: High radiation dose may lead to devastating nasopharyngeal necrosis after primary IMRT. Real world analysis will provide valuable information for prevention.

Findings: The aged, diabetes mellitus, large tumor volume, D0.5ccEQD2 > 80.20 Gy and V77.0 < 0.2% to planning treatment volume increased the risk of nasopharyngeal necrosis.

Clinical relevance: This real-world study provided valuable information for prevention of PRNN. Compared with RTOG protocol, D0.5ccEQD2 > 80.20 Gy is a reliable evidence-based new complement to dose constraint, especially for T3-4 disease, who received high prescribe dose in China.

Keywords: Dose constraint; Intensity modulated radiation therapy; Least absolute shrinkage and selection operator logistic regression; Nasopharyngeal carcinoma; Nasopharyngeal necrosis.

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Conflict of interest statement

Declarations. Consent for publication: This retrospective study was approved by the Institutional Review Board of Sun Yat-sen University Cancer Center and The First Affiliated Hospital of Sun Yat-sen University in accordance with the Declaration of Helsinki, and the requirement for informed consent was waive. Competing interests: The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Study flow chart
Fig. 2
Fig. 2
MRI examination of PRNN and Overall survival in PRNN and non-PRNN groups. A: Transverse T1-weighted image; B: Transverse contrast-enhanced T1-weighted image; C: Transverse T2-weighted image; D: Coronal T1-weighted image; E: Coronal contrast-enhanced T1-weighted image; F: Kaplan–Meier curves of overall survival in PRNN and non-PRNN groups
Fig. 3
Fig. 3
AUC of important dosimetric factor and cut-off value. * Converted to equivalent 2 Gy fractionation (EQD2) using α/β = 10 Gy. **Translated according to the recommend total dose of 70 Gy in protocols
Fig. 4
Fig. 4
Univariate analysis for covariates to estimate the risk of PRNN. Abbreviations: EBV = EpsteineBarr virus; N = node; T = tumor; HGB = hemoglobin, ALB = albumin, CRP = C-reactive protein; LDH = lactate dehydrogenase. * Converted to equivalent 2 Gy fractionation (EQD2) using α/β = 10 Gy
Fig. 5
Fig. 5
Multivariate analysis for covariates to estimate the risk of PRNN. A: Multivariate analysis with clinical covariates and D0.5cc; B: Multivariate analysis with clinical covariates and V77.0(V110%). *: Converted to equivalent 2 Gy fractionation (EQD2) using α/β = 10 Gy
See this image and copyright information in PMC

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