Massive nasal bleeding in nasopharyngeal Carcinoma: Incidence, risk Predictors, and survival impact: Running title: Massive nasal bleeding in NPC

Hao-Shen Cheng; Tian-Yun Lin; Chih-Wen Twu; Po-Ju Lin; Yi-Chun Liu; Rong-San Jiang; Kai-Li Liang; Jin-Ching Lin

doi:10.1016/j.oraloncology.2025.107456

Massive nasal bleeding in nasopharyngeal Carcinoma: Incidence, risk Predictors, and survival impact: Running title: Massive nasal bleeding in NPC

Oral Oncol. 2025 Jun 23:167:107456. doi: 10.1016/j.oraloncology.2025.107456. Online ahead of print.

Authors

Hao-Shen Cheng¹, Tian-Yun Lin², Chih-Wen Twu³, Po-Ju Lin⁴, Yi-Chun Liu¹, Rong-San Jiang², Kai-Li Liang², Jin-Ching Lin⁵

Affiliations

¹ Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan.
² Department of Otorhinolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.
³ Department of Otorhinolaryngology-Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan.
⁴ Department of Radiation Oncology, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan.
⁵ Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan; Department of Radiation Oncology, Changhua Christian Hospital, Changhua, Taiwan; Institute of Clinical Medicine, School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan. Electronic address: 182715@cch.org.tw.

PMID: 40554925
DOI: 10.1016/j.oraloncology.2025.107456

Abstract

Objective: To investigate the incidence, risk predictors, and survival impact of massive nasal bleeding in newly diagnosed nasopharyngeal carcinoma (NPC) patients who received curative radiotherapy (RT).

Methods: We enrolled 1327 patients with previously untreated, biopsy-proven NPC, and no distant metastasis. There are 957 males and 370 females, with a median age of 47 years. Histologically, 1304 patients (98.3 %) exhibited nonkeratinizing carcinoma. Most patients (81.0 %) presented with advanced stage III-IV. The treatment consisted of RT alone (6.9 %), RT combined with concurrent (26.6 %) or neoadjuvant (66.5 %) chemotherapy. We calculated the incidence rate of massive nasal bleeding, analyzed potential predictive factors, and evaluated its survival impact.

Results: Of 1327 NPC patients, 5.3 % experienced massive nasal bleeding, with a median onset time of 34 months post-RT. Competing risk analyses based on the sub-distribution hazard model identified that skull base osteoradionecrosis (ORN) and local recurrence were the strongest predictors, followed by T3-4 stage and RT dose > 70 Gy. IMRT and 3DRT techniques were protective. Overall survival analysis revealed significant differences between patients with and without massive bleeding (5-year rates, 40.0 % vs. 80.9 %; 10-year rates, 14.0 % vs. 65.8 %, P < 0.0001). Subgroup analysis confined to 1183 patients without local recurrence revealed the same risk predictors and survival impact.

Conclusion: We identified a 5.3% incidence rate of massive nasal bleeding among newly diagnosed NPC patients treated with curative RT. Skull base ORN and local recurrence were the major risk factors in predicting massive bleeding. The occurrence of massive bleeding reduced OS significantly.

Keywords: Local recurrence; Massive nasal bleeding; Nasopharyngeal carcinoma; Radiotherapy; Skull base ORN.