International Rhinologic Society Rhinology 0300-0729 2026 06 05 Combining EBV DNA dynamics with RECIST-based radiographic response to improve prognostic stratification of recurrent/metastatic nasopharyngeal carcinoma in the era of immunotherapy EN H.X. Long Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China S.C. Li Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China C.R. Lai School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China C.L. Huang School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China X.S. Sun Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China B.W. ShenDepartment of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China Department of Anaesthesiology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Guan J.Y. ShenDepartment of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China Department of Anaesthesiology, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Guangdong Provincial Clinical Research Centre for Cancer, Guan H.J. Wang Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China Y.F. Li Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China J. Chen Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China H. Cheng Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China L.T. Liu Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China Q.Y. Chen Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China H.Q. Chen Department of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China L.Q. TangDepartment of Nasopharyngeal Carcinoma, Sun Yat-sen University Cancer Centre, State Key Laboratory of Oncology in South China, Collaborative Innovation Centre for Cancer Medicine, Guangdong Key Laboratory of Nasopharyngeal Carcinoma Diagnosis and Therapy, Guangzhou 510060, Guangdong, China School of Biomedical Engineering, Southern Medical University, Guangzhou 510515, China Journal Article 3470 10.4193/Rhin25.511 BACKGROUND: This study assessed the prognostic value of early Epstein–Barr virus (EBV) DNA dynamics combined with Response Evaluation Criteria in Solid Tumours (RECIST)-based radiographic response in patients with recurrent/metastatic nasopharyngeal carcinoma (R/M NPC) receiving immunotherapy, to refine risk stratification. METHODOLOGY: A real-world cohort of 306 patients with R/M NPC and detectable EBV DNA at baseline received PD-1 monoclonal antibodies (PD-1 mAbs), alone or with chemotherapy. EBV DNA and radiological assessments were performed at baseline and after two therapy cycles. Biological responses based on EBV DNA were compared with RECIST evaluations. Survival outcomes were analysed using inverse probability treatment weighting, and a Cox regression model was developed incorporating baseline features and early responses. RESULTS: Among 306 patients, 174 achieved complete biological response (cBR), and 203 achieved complete or partial radiological response (CR/PR). Patients achieving both cBR and CR/PR had the most favourable progression-free survival. Early cBR was the dominant prognostic factor for overall survival, whereas radiological response did not affect overall survival within biological response strata. A prediction model integrating baseline features, radiological, and biological responses achieved an optimismcorrected C-index, surpassing models with baseline features alone, baseline plus radiological response, and baseline with biological response. CONCLUSIONS: Early biological response by EBV DNA was a stronger prognosticator than radiological response in PD-1 mAbs-treated R/M NPC. Combining baseline clinical features with biological and radiological responses improved survival prediction.