Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country

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The therapeutic approach for metastatic forms has evolved with the concept of oligometastasis. Our study aims to evaluate the effectiveness of curative locoregional radiotherapy in these cases, with the objectives of estimating overall and progression-free survival and identifying prognostic factors. Methods This was a retrospective study, including 50 patients treated with curative radiotherapy for oligometastatic nasopharyngeal cancer from January 1st, 2015, to December 31, 2021, at the Salah Azaiez Institute. Results The mean age was 49.6 years, with a male predominance (72%). Initial symptoms were mainly rhinological (38%) and cervical lymphadenopathy (34%). Most patients presented with an advanced stage (T3-T4: 60%, N3: 52%). Metastases were most often osseous (46%), pulmonary (38%), or visceral (liver, extra-cervical lymph nodes: 16%). Thirty-six percent of patients had a single metastatic site, while 30% had more than two. All patients received platinum-based chemotherapy (3 cycles on average), followed by locoregional radiotherapy (70 Gy in 33-35 fractions), mainly with IMRT (76%). Concomitant chemotherapy was associated in 98% of cases. These treatments were associated with adverse effects, including radiodermatitis (100%) and mucositis (98%, including 18% grade 3). Twenty-four percent of patients received maintenance chemotherapy with capecitabine, and 44% received local treatment of metastases. At 3 years, progression-free survival (PFS) was 18% and overall survival (OS) was 44%. Univariate analysis showed a significant impact of several factors on PFS (gender, T stage, interruption of radiotherapy, maintenance chemotherapy). Multivariate analysis did not identify any independent prognostic factor for PFS. However, for OS, T stage (p = 0.024) and metastatic site (p = 0.001) emerged as independent prognostic factors. Conclusion This study served to evaluate radiotherapy practices; it would be even more interesting to conduct a larger-scale study. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-786/v1", "name": "Radiation therapy for synchronous oligometastaticNasopharyngeal cancer..." } } ] } Home Browse Radiation therapy for synchronous oligometastaticNasopharyngeal cancer... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Attia N, Mousli A, Ben zid K et al. Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.12688/f1000research.164478.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] Najla Attia https://orcid.org/0009-0005-5936-4049 1 , Alia Mousli 1 , Khedija Ben zid 1 , [...] Cyrine Mokrani https://orcid.org/0009-0003-2765-8937 1 , Rami Hammami https://orcid.org/0009-0000-6030-1372 2 , Hadhemi Ayadi 1 , Asma Ghorbel 1 , Amani Yousfi 1 , Skander Kedous https://orcid.org/0000-0003-2811-5777 3 , Jebali Souheil 3 , Semia Zaraa 1 , Rim Abidi 1 , Chiraz Nasr 1 Najla Attia https://orcid.org/0009-0005-5936-4049 1 , Alia Mousli 1 , [...] Khedija Ben zid 1 , Cyrine Mokrani https://orcid.org/0009-0003-2765-8937 1 , Rami Hammami https://orcid.org/0009-0000-6030-1372 2 , Hadhemi Ayadi 1 , Asma Ghorbel 1 , Amani Yousfi 1 , Skander Kedous https://orcid.org/0000-0003-2811-5777 3 , Jebali Souheil 3 , Semia Zaraa 1 , Rim Abidi 1 , Chiraz Nasr 1 PUBLISHED 13 Aug 2025 Author details Author details 1 Department of radiotherapy, Salah Azaiez's Institute, Tunis, Tunisia 2 Faculty of medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia 3 Otolaryngology Department, Salah Azaiez's Institute, Tunis, Tunisia Najla Attia Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation Alia Mousli Roles: Conceptualization, Project Administration Khedija Ben zid Roles: Supervision, Writing – Original Draft Preparation Cyrine Mokrani Roles: Data Curation Rami Hammami Roles: Formal Analysis Hadhemi Ayadi Roles: Data Curation Asma Ghorbel Roles: Data Curation Amani Yousfi Roles: Conceptualization Skander Kedous Roles: Visualization Jebali Souheil Roles: Writing – Review & Editing Semia Zaraa Roles: Supervision Rim Abidi Roles: Supervision, Validation, Writing – Review & Editing Chiraz Nasr Roles: Validation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Oncology gateway. Abstract Introduction Nasopharyngeal cancer, prevalent in Tunisia, is often diagnosed at an advanced stage. The therapeutic approach for metastatic forms has evolved with the concept of oligometastasis. Our study aims to evaluate the effectiveness of curative locoregional radiotherapy in these cases, with the objectives of estimating overall and progression-free survival and identifying prognostic factors. Methods This was a retrospective study, including 50 patients treated with curative radiotherapy for oligometastatic nasopharyngeal cancer from January 1st, 2015, to December 31, 2021, at the Salah Azaiez Institute. Results The mean age was 49.6 years, with a male predominance (72%). Initial symptoms were mainly rhinological (38%) and cervical lymphadenopathy (34%). Most patients presented with an advanced stage (T3-T4: 60%, N3: 52%). Metastases were most often osseous (46%), pulmonary (38%), or visceral (liver, extra-cervical lymph nodes: 16%). Thirty-six percent of patients had a single metastatic site, while 30% had more than two. All patients received platinum-based chemotherapy (3 cycles on average), followed by locoregional radiotherapy (70 Gy in 33-35 fractions), mainly with IMRT (76%). Concomitant chemotherapy was associated in 98% of cases. These treatments were associated with adverse effects, including radiodermatitis (100%) and mucositis (98%, including 18% grade 3). Twenty-four percent of patients received maintenance chemotherapy with capecitabine, and 44% received local treatment of metastases. At 3 years, progression-free survival (PFS) was 18% and overall survival (OS) was 44%. Univariate analysis showed a significant impact of several factors on PFS (gender, T stage, interruption of radiotherapy, maintenance chemotherapy). Multivariate analysis did not identify any independent prognostic factor for PFS. However, for OS, T stage (p = 0.024) and metastatic site (p = 0.001) emerged as independent prognostic factors. Conclusion This study served to evaluate radiotherapy practices; it would be even more interesting to conduct a larger-scale study. READ ALL READ LESS Keywords Carcinoma, Nasopharynx, Metastasis, Radiotherapy, Chemotherapy, Survival, Prognosis. Corresponding Author(s) Najla Attia ( [email protected] ) Close Corresponding author: Najla Attia Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Attia N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Attia N, Mousli A, Ben zid K et al. Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.12688/f1000research.164478.1 ) First published: 13 Aug 2025, 14 :786 ( https://doi.org/10.12688/f1000research.164478.1 ) Latest published: 13 Aug 2025, 14 :786 ( https://doi.org/10.12688/f1000research.164478.1 ) Introduction Nasopharyngeal cancer ranks 23rd globally in terms of occurrence. In North Africa, its prevalence is significant, with an annual incidence rate of 24 cases per 100,000 inhabitants. 1 In Tunisia, it is the second most common head and neck cancer, following laryngeal tumors. 2 Due to its location within the nasopharynx and the often-non-specific nature of its early symptoms, diagnosis frequently occurs late, leading to a poorer prognosis. 3 Metastases are present at the time of diagnosis in 4 to 10% of cases. 4 For localized tumors, radiotherapy is the standard treatment, which may or may not be combined with chemotherapy. 5 For metastatic tumors, polychemotherapy is often recommended. 5 Indeed, the concept of oligometastasis has revolutionized the treatment of many solid tumors; it describes a state between localized disease and disseminated cancer, characterized by a limited number of metastases. 7 Numerous studies have demonstrated that aggressive treatment, including curative intent therapy for the primary tumor, can significantly improve survival rates in cancers such as prostate, colorectal, and lung cancer. 8 , 9 Given the promising outcomes observed in other cancers with oligometastasis, we hypothesized that a similar approach could be beneficial for patients with oligometastatic nasopharyngeal cancer. Therefore, we conducted a retrospective study on patients with oligometastatic nasopharyngeal cancer treated with curative intent radiotherapy to analyze survival outcomes and identify prognostic factors. Materials and methods Study design This was a retrospective, single-center study analyzing data from patients treated for oligometastatic nasopharyngeal cancer with locoregional radiotherapy and concurrent chemotherapy at in Tunisia. The oligometastatic state is defined as the presence of no more than five metastases involving at most two organs. Inclusion and exclusion criteria We included patients aged 18 years or older with histopathologically confirmed nasopharyngeal cancer and a Karnofsky Performance Status (KPS) score ≥ 70. Patients were excluded if they received palliative radiotherapy or if they progressed after primary chemotherapy. Data collection Patient medical records were reviewed retrospectively to collect data. Verbal informed consent was obtained from all patients or their families for the use of their data in this study. Due to the retrospective nature of the data collection and the primary method of communication being telephone contact, verbal consent was determined to be the most suitable approach. This procedure was reviewed and approved by the Ethics Committee of Salah Azaiez Institute. The data supporting the findings of this study are openly available. 10 Study endpoint The primary endpoints are overall survival (OS) and progression-free survival (PFS). OS is defined as the time interval from diagnosis to death from any cause or the last date of follow-up. PFS is defined as the time interval from the completion of radiotherapy to the identification of disease progression or death. The secondary endpoint is to identify prognostic factors that may influence overall survival and progression-free survival. Statistical analysis Data was analyzed using Microsoft Excel 2019 and IBM SPSS version 22. Descriptive statistics were employed to summarize the data. For categorical variables, frequencies and percentages were calculated. For continuous variables, normality was assessed using skewness, kurtosis, and the Kolmogorov-Smirnov and Shapiro-Wilk tests. Means and standard deviations were calculated for normally distributed variables, while medians and interquartile ranges were used for non-normally distributed variables. Inferential statistics were used to assess relationships between variables. Bivariate analyses included chi-square tests or Fisher’s exact tests for categorical variables and t-tests or Mann-Whitney U tests for continuous variables. For multiple group comparisons, ANOVA or Kruskal-Wallis tests were used. Multivariate analysis utilized Cox proportional hazards regression with stepwise selection based on the Wald test to identify predictors of survival. Statistical significance was defined as a p-value less than 0.05. Results Between January 2015 and December 2021, 70 patients were diagnosed with oligometastatic nasopharyngeal cancer at our institution. After excluding 11 patients who received palliative radiotherapy and 9 others who experienced disease progression after primary chemotherapy, a total of 50 patients were deemed eligible for inclusion in our study. The mean age of the patients was 49.6 years, with a male predominance (male-to-female ratio of 2:1). The median delay in consultation was 4 months. Presenting symptoms included rhinologic symptoms in 38% of patients and the presence of lymphadenopathy in 34% of cases. All patients presented with undifferentiated carcinoma nasopharyngeal type. The basic clinical data of the patient cohort are shown in Table 1 . Table 1. Baseline demographics and disease characteristics of patients. Characteristic No (%) Gender Male 34 (68%) Female 16 (32%) Smoking Status Yes 22 (44%) No 28 (56%) Symptoms Rhinological 19 (38%) Lymphadenopathy 17 (34%) Otological 12 (24%) Neurological 2 (4%) locoregional extension work-up Cervical MRI 42 (84%) Cervical CT 8 (16%) assessment of distant extension Whole-body CT 45 (90%) Bone scan 15 (30%) PET CT 1 (2%) Others 4 (8%) EBV serology Yes 21 (42%) No 29 (58%) T stage T1-T2 20 (40%) T3-T4 30 (60%) N stage N0-N1 11 (22%) N2-N3 39 (78%) Pathology of metastases Yes 5 (10%) No 45 (90%) Nº of metastatic lesion 1-2 35 (70%) ≥3 15 (30%) Nº of metastatic organs 1 48 (96%) 2 2 (4%) Metastatic sites Bone 23 (46%) Lung 19 (38%) Liver 6 (12%) Distant lymph nodes 3 (6%) Ninety-four percent of patients completed 3 to 6 cycles of palliative chemotherapy, including a platinum-based regimen. Eighty-four percent of patients achieved a partial response in the primary tumor, while 42% achieved a partial response in metastatic sites. All patients underwent curative radiotherapy to the primary tumor with a dose of 70 Gy delivered in 35 fractions, and 49 patients received concurrent chemotherapy during radiotherapy. Forty-six percent of patients received curative treatment for metastases, with 6 patients undergoing surgery and 17 receiving radiotherapy. The surgical treatments included 3 wedge resections of pulmonary masses, 1 laminectomy, and 2 axillary dissections for nodal metastases. Twenty-four percent of patients received maintenance chemotherapy with capecitabine. Table 2 summarizes the treatment modalities administered to our patients. Table 2. Treatment modalities and response rates. Treatment regimes No (%) Neoadjuvant chemotherapy PF 25 (50%) TPF 20 (40%) Other 5 (10%) Cycles of NAC 1-3 32 (64%) 4-6 18 (36%) Respond to NAC in the primary tumor CR 1 (2%) PR 42 (84%) Stability 7 (14%) Respond to NAC in the metastatic sites CR 8 (16%) PR 21 (42%) Stability 12 (24%) Technique of radiotherapy 2D 12 (24%) IMRT/VMAT 38 (76%) Concomitant chemotherapy Cisplatin 40 (80%) Carboplatin 9 (18%) Respond to radiotherapy in the primary tumor CR 36 (72%) PR 9 (18%) Stability or progression 3 (6%) Respond to radiotherapy in the metastatic sites CR 21 (42%) PR 17 (34%) Stability or progression 10 (20%) Local treatment of metastatic sites No 27 (54%) Surgery 6 (12%) Radiotherapy 17 (34%) Maintenance treatment No 26 (52%) Chemotherapy 12 (24%) Biphosphonates 12 (24%) During a median follow-up of 39.9 months, we found that 52% of patients with disease progression, and 39 patients died. Median PFS was 14 months (95% CI: 7-24.5 months) and Median OS was 32 months (95% CI: 23.5-49.5 months). The 1-year PFS rate was 56% and the 3-year PFS rate was 18% ( Figure 1 ). The 1-year OS rate was 92% and the 3-year OS rate was 44% ( Figure 2 ). Figure 1. Progression free survival of the entire patient cohort. Figure 2. Overall survival of the entire patient cohort. Univariate analysis indicated that several factors were significantly associated with improved OS: female gender (p=0.046), early-stage tumors (T1-T2, p=0.028), metastases in sites other than bone (p=0.023), treatment with intensity-modulated radiation therapy (IMRT) (p=0.03), and maintenance chemotherapy following radiotherapy (p=0.047). Additionally, factors associated with improved PFS included female gender (p=0.008), early-stage tumors (T1-T2, p=0.021), absence of RT interruption (p=0.043), and maintenance chemotherapy following radiotherapy (p=0.04). Table 3 summarizes the results of the univariate analysis. Table 3. Univariate analysis of prognostic factors of PFS and OS. PFS OS Gender Male (N = 34) 12 [6-21] 0.008 32.3 ± 14.9 0.046 Female (N = 16) 18.5 [13.5-45] 42.4 ± 18.5 Smoking status Yes (N = 22) 13 [6-25] 0.830 36 ± 16 0.746 No (N = 28) 14 [7.3-26.8] 34.4 ± 17 T stage T1-T2 (N = 20) 21.5 [12.3-35.8 0.021 39.5|28.8-51.8] 0.028 T3-T4 (N = 30) 12 [6-15] 24 [20.5-40.5] N stage N0-N1 (N = 11] 14.5 [6.8-30.5] 0.598 37.5 [23.5-51] 0.475 N2-N3 (N = 39) 13 [7-26] 28 [22-51] Metastatic sites Bone (N = 23) 9.5 [5.5-16] 0.058 28 ± 12.1 0.023 Lung (N = 19) 17 [13.5-44] 40 ± 17.6 Others (N = 8) 12 [6.5-29.5] 42.3 ± 18.4 Nº of metastatic lesion 1-2 (N = 36) 14 [8-28] 0.166 36.1 ± 16.5 0.153 >2 (N = 14) 12.5 [6-15<) 28.8 ± 15.7 Technique of radiotherapy 2D (N = 12) 10.5 [6-18] 0.149 25.3 ± 14.9 0.03 IMRT VMAT (N = 38) 14 [8.5-28.5] 37.9 ± 17.3 Interruption of RT Yes (N = 32) 9.5 [6-15.3] 0.043 29.5 ± 13.3 0.053 No (N = 18) 15 [9-29] 38.6 ± 17.3 Maintenance chemotherapy Yes (N = 12) 21 ± 12.1 0.040 37.3 ± 16.9 0.047 No (N = 38) 10.2 ± 5.4 27.5 ± 12.4 Local treatment of metastases Yes (N = 22) 13.5 [7.8-30.5] 0.867 35.7 ± 16.9 0.812 As for the multivariate analysis, no prognostic factors were associated with progression-free survival. However, T1-T2 stage and metastases to sites other than bone were independent prognostic factors for overall survival with p=0.024 and 0.001, respectively. Discussion The concept of oligometastatic cancer was introduced by Hellman and Weichselbaum in 1995, 7 and since then, its definition has varied across different studies. Recently, the WHO published the 9th edition of the nasopharyngeal carcinoma classification, introducing a new subgroup, M1a, for patients with 3 or fewer metastases. 11 In our study, we considered patients with fewer than 5 metastases and a maximum of two affected organs as oligometastatic. Numerous retrospective studies have demonstrated improved OS in metastatic nasopharyngeal carcinoma (mNPC) patients treated with palliative chemotherapy combined with curative radiotherapy compared to those receiving only palliative chemotherapy. 12 – 17 A large series from the National Cancer Database (NCDB), which included 718 patients newly diagnosed with mNPC, further corroborated these findings. This analysis revealed a significant improvement in OS for patients receiving radiotherapy (median OS: 21.4 months) compared to those who did not receive it (median OS: 15.5 months). Moreover, the study showed a positive correlation between increasing radiotherapy doses and improved OS. 16 A phase 3 prospective study involving 126 patients with mNPC evaluated the impact of curative radiotherapy following palliative chemotherapy. After a median follow-up of 26.7 months, the 24-month OS was significantly higher in patients receiving radiotherapy (76.4%) than in those treated with chemotherapy alone (54.5%). The study also demonstrated an improvement in PFS in patients receiving curative RT (p < 0.01). However, it is important to note that only a limited proportion of patients (19–20%) had oligometastatic disease. 6 A recent phase 2 prospective study by Huang et al. involving 69 patients investigated the efficacy of locoregional RT in patients with oligometastatic nasopharyngeal carcinoma. With a median follow-up of 60 months, the study demonstrated a median PFS of 24.23 months, suggesting a promising role for locoregional RT in this setting. Furthermore, it reported a median OS of 53.87 months in patients treated with chemoradiotherapy, indicating a significant improvement in long-term survival outcomes. 18 In our study, the median OS and PFS were 32 and 14 months, respectively. The 3-year OS and PFS rates were 44% and 18%, respectively. While these results compare favorably with some previously reported outcomes, they fall below those observed in the phase 2 study by Huang et al. Several factors may have contributed to this discrepancy. Firstly, our study included a relatively small patient population. Secondly, the limited availability of initial 18F-FDG PET/CT imaging may have impacted patient selection and treatment planning, potentially influencing overall outcomes. The impact of gender on OS and PFS in mNPC remains controversial, with conflicting findings in the literature. Some retrospective studies reported no significant OS or PFS differences between genders, while others suggested a survival advantage for either men or women. 14 , 19 , 20 Notably, our study found a statistically significant improvement in OS (p=0.046) and PFS (p=0.008) for women. The number of affected organs has been identified as an important factor influencing OS and PFS in several retrospective studies. 14 , 21 This was further confirmed in the study by Huang et al., which found significantly better OS ( p = 0.001) and PFS ( p = 0.037) in patients with only one affected organ. Additionally, it showed that among oligometastatic patients, the exact number of metastases (1, 2, or 3–5) had no impact on survival. 18 The site of metastasis also impacts survival outcomes. The literature suggests that hepatic metastases are associated with poorer survival. 15 , 21 However, our findings differed, showing better survival in patients with visceral metastases (other than bone). These unexpected results may be explained by the limited number of patients with hepatic metastases in our study. The analysis of the NCDB highlighted the importance of the RT dose in the treatment of mNPC, showing that a dose greater than 50 Gy is beneficial, with an optimal dose of 70 Gy or higher. 16 The optimal fractionation schedule for RT remains uncertain. A prospective phase 2 study found no significant difference between normofractionated treatment (70 Gy in 33 fractions) and hypofractionated treatment (60 Gy in 25 fractions). 22 It has been shown that interruptions in RT negatively impact local control, even if the delay is brief (>2 days). 23 Our study further confirmed these findings from the literature. The RT technique was established based on studies of localized NPC, with IMRT being the standard of care. 24 , 25 However, no studies have directly compared the impact of different RT techniques on survival in mNPC. Notably, our results showed that patients treated with IMRT had better OS and PFS than those treated with 2D RT. A phase 3 clinical study demonstrated that maintenance chemotherapy with capecitabine improves survival; however, none of these patients received RT. 26 Similarly, in the study conducted by Huang et al., patients receiving maintenance chemotherapy had better PFS. 18 The limited number of patients receiving this adjuvant chemotherapy in our cohort may explain the lack of long-term survival benefits. The value of local treatment for metastases remains controversial. Most retrospective studies suggest that combining systemic therapy with local treatment in mNPC may improve survival outcomes. 27 , 28 One study involving 105 patients with oligometastatic mNPC with a single lung lesion found that combining local treatment - either stereotactic RT or surgery - with chemotherapy significantly improved OS and PFS compared to chemotherapy alone. 29 Furthermore, Huang et al. confirmed the importance of local treatment in improving OS (p = 0.05). 18 In our study, most patients received radiotherapy, but primarily at a palliative dose, which may explain the absence of improved survival rates. The addition of anti-PD-1 therapy to chemotherapy (gemcitabine-cisplatin) has shown promising results in mNPC, with a significant improvement in survival. 30 , 31 Several ongoing studies are evaluating the combination of chemotherapy, immunotherapy, locoregional RT, and local metastasis-directed treatment with SBRT in oligometastatic nasopharyngeal cancer (NCT05385926, NCT05431764, NCT05290194). A more aggressive treatment approach may further enhance survival and quality of life for these patients. Our study has several limitations. First, its retrospective design inherently restricts its value. Second, the absence of PET-CT FDG for initial staging and the lack of circulating EBV DNA assessment hindered our ability to perform accurate initial stratification. Finally, treatment heterogeneity over time, including variations in chemotherapy regimens and radiotherapy techniques, adds another limitation. Nevertheless, it is important to note that, to our knowledge, this is the first north-African study reporting results for this specific patient population. Conclusion Our study examined the treatment outcomes for patients with newly diagnosed oligometastatic nasopharyngeal cancer. It demonstrates that an optimal treatment approach combining chemotherapy, high-dose radiotherapy, and curative local treatment of metastases can improve overall survival and progression-free survival. Further prospective studies evaluating the addition of immunotherapy are needed in order to determine the best treatment strategy for these patients, who have a better prognosis. Ethics statement This study was approved by the ethical committee of Salah Azaiez Institute, on January 9 th , 2025 (Approval N0: ISA/2025/1). The study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Patient data anonymity and confidentiality were ensured throughout the data collection process. Data availability The data supporting the findings of this study are openly available in Figshare at https://doi.org/10.6084/m9.figshare.28839293.v2 . 10 Data are available under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) license. References 1. Cancer Today. Accessed July 9, 2024. Reference Source 2. Azziza - PROJET DE COOPERATION AVEC L’UNION EUROPEENNE.pdf. Accessed November 6, 2024. Reference Source 3. Adham M, Mat Lazim N, Carlos R: Clinical presentation of nasopharyngeal carcinoma. An Evidence-Based Approach to the Management of Nasopharyngeal Cancer. Elsevier; 2020; pp. 93–109. Publisher Full Text 4. Bray F, Ferlay J, Soerjomataram I, et al. : Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J. Clin. 2018; 68 (6): 394–424. PubMed Abstract | Publisher Full Text 5. head-and-neck.pdf. Accessed September 25, 2024. Reference Source 6. 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 13 Aug 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of radiotherapy, Salah Azaiez's Institute, Tunis, Tunisia 2 Faculty of medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia 3 Otolaryngology Department, Salah Azaiez's Institute, Tunis, Tunisia Najla Attia Roles: Conceptualization, Data Curation, Writing – Original Draft Preparation Alia Mousli Roles: Conceptualization, Project Administration Khedija Ben zid Roles: Supervision, Writing – Original Draft Preparation Cyrine Mokrani Roles: Data Curation Rami Hammami Roles: Formal Analysis Hadhemi Ayadi Roles: Data Curation Asma Ghorbel Roles: Data Curation Amani Yousfi Roles: Conceptualization Skander Kedous Roles: Visualization Jebali Souheil Roles: Writing – Review & Editing Semia Zaraa Roles: Supervision Rim Abidi Roles: Supervision, Validation, Writing – Review & Editing Chiraz Nasr Roles: Validation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 13 Aug 2025, 14:786 https://doi.org/10.12688/f1000research.164478.1 Copyright © 2025 Attia N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Attia N, Mousli A, Ben zid K et al. Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.12688/f1000research.164478.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 13 Aug 2025 Views 0 Cite How to cite this report: Bhattacharyya M. Reviewer Report For: Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.5256/f1000research.180999.r408318 ) The direct URL for this report is: https://f1000research.com/articles/14-786/v1#referee-response-408318 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 05 Sep 2025 Mouchumee Bhattacharyya , Dr Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India Approved VIEWS 0 https://doi.org/10.5256/f1000research.180999.r408318 A very well written and well analyzed article. The authors have admitted to the limitations of the study. But, considering the high incidence of cancer nasopharynx in North Africa, a prospective study with adequate sample size will definitely help stake-holders, ... Continue reading READ ALL A very well written and well analyzed article. The authors have admitted to the limitations of the study. But, considering the high incidence of cancer nasopharynx in North Africa, a prospective study with adequate sample size will definitely help stake-holders, policy makers in tackling the problem and this study could guide the designing of the prospective study. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Radiotherapy in 1.Cancer of Nasopharynx, 2.Gynecological cancers, 3.Pediatric malignancies. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Bhattacharyya M. Reviewer Report For: Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.5256/f1000research.180999.r408318 ) The direct URL for this report is: https://f1000research.com/articles/14-786/v1#referee-response-408318 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. 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This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions A very well written and well analyzed article. The authors have admitted to the limitations of the study. But, considering the high incidence of cancer nasopharynx in North Africa, a prospective study with adequate sample size will definitely help stake-holders, policy makers in tackling the problem and this study could guide the designing of the prospective study. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Radiotherapy in 1.Cancer of Nasopharynx, 2.Gynecological cancers, 3.Pediatric malignancies. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Bhattacharyya M. Peer Review Report For: Radiation therapy for synchronous oligometastatic Nasopharyngeal cancer in a low-middle-income country [version 1; peer review: 1 approved] . F1000Research 2025, 14 :786 ( https://doi.org/10.5256/f1000research.180999.r408318) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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