Background: To explore the prognostic value of radiomics-based and digital pathology-based imaging biomarkers from macroscopic magnetic resonance images and microscopic whole-slide images for patients with nasopharyngeal carcinoma (NPC).

Methods: We recruited 220 NPC patients and divided them into training (n=132), internal testing (n=44), external testing (n=44) cohorts. The primary endpoint was failure-free survival (FFS). Radiomic features were extracted from pretreatment MRI and selected and integrated into a radiomic signature. The histopathological signature was extracted from whole-slide images of biopsy specimens using an end-to-end deep-learning method. Incorporating two signatures and independent clinical factors, a multi-scale nomogram was constructed. We also tested the correlation between the key imaging features and genetic alternations in an independent cohort of 16 patients (biological testing cohort).

Results: Both radiomic and histopathologic signatures presented significant associations with treatment failure in the three cohorts (C-index: 0.689-0.779, all p <0.050). The multi-scale nomogram showed a consistent significant improvement for predicting treatment failure compared to the clinical model in the training (C-index: 0.817 vs. 0.730, p <0.050), internal testing (C-index: 0.828 vs. 0.602, p <0.050) and external testing (C-index: 0.834 vs. 0.679, p <0.050) cohorts. Furthermore, patients were successfully stratified into two groups with distinguishable prognosis (log-rank p <0.0010) using our nomogram. We also found that two texture features were related to the genetic alternations of chromatin remodeling pathways in another independent cohort (n = 16).

Conclusion: The multi-scale imaging features showed a complementary value in prognostic prediction and may improve individualized treatment in NPC.