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Background  The skeletal system is the most common site of distant metastasis in nasopharyngeal carcinoma (NPC); various prognostic factors have been reported for skeletal metastasis, though most studies have focused on a single factor. We aimed to establish nomograms to effectively predict skeletal metastasis at initial diagnosis (SMAD) and skeletal metastasis-free survival (SMFS) in NPC.    Methods  A total of 2685 patients with NPC who received bone scintigraphy (BS) and/or 18F–deoxyglucose positron emission tomography/computed tomography (18F–FDG PET/CT) and 2496 patients without skeletal metastasis were retrospectively assessed to develop individual nomograms for SMAD and SMFS. The models were validated externally using separate cohorts of 1329 and 1231 patients treated at two other institutions.    Results  Five independent prognostic factors were included in each nomogram. The SMAD nomogram had a significantly higher c-index than the TNM staging system (training cohort,  P  = 0.005; validation cohort,  P  < 0.001). The SMFS nomogram had significantly higher c-index values in the training and validation sets than the TNM staging system ( P  < 0.001 and  P  = 0.005, respectively). Three proposed risk stratification groups were created using the nomograms, and enabled significant discrimination of SMFS for each risk group.    Conclusion  The prognostic nomograms established in this study enable accurate stratification of distinct risk groups for skeletal metastasis, which may improve counseling and facilitate individualized management of patients with NPC.    Electronic supplementary material  The online version of this article (10.1186/s12885-017-3630-9) contains supplementary material, which is available to authorized users.

bmc cancer

Development and external validation of nomograms to predict the risk of skeletal metastasis at the time of diagnosis and skeletal metastasis-free survival in nasopharyngeal carcinoma