Our study also shows a trend towards an association of GPS with BMI. Based on these reports, GPS, incorporating CRP and serum albumin levels, may reflect both presence of the nutritional depletion and functional decline, resulting in poor survival outcome. Second, a strong association was found between EBV infection and NPC in previous studies. Plasma EBV DNA has been identified to be prognostic in metastatic NPC patients. EBV infection stimulated the release of Lomitapide Mesylate pro-inflammatory cytokine including IL-1, IL-6, and TNF-a from the tumor microenvironment, which results in the induction of CRP synthesis from the liver and the reduction of albumin by hepatocytes. In other words, GPS level may be a marker of inflammation from EBV infection and may indicate the magnitude of inflammation and the prognosis of patients as EBV DNA load. Previous studies have also indicated that inflammation in the tumor microenvironment play an important role in promoting tumor growth, invasion, and metastasis. Our data shows that an elevated GPS is significantly associated with higher EBV-DNA level, which will, to certain extent, add further support to the proposal. In addition to these explanations, because our data find an elevated GPS is also significantly associated with elevated LDH, which has been reported to be an indicator of high tumor burden, an elevated GPS score may indirectly reflect a high tumor burden. In general, these explanations suggest that it is reasonable that GPS is a significant and independent predictor of survival outcome. Recently a study by Wei-xiong Xia et al also showed that elevated CRP and CRP kinetics correlated with poor prognosis in patients with metastatic NPC. This study had similar aims and results compared with our study. However there are still some differences between the two studies. Firstly, the GPS incorporates CRP and hypoalbuminemia and may be more suitable to reflect systemic inflammatory response than CRP alone. Secondly, the eligibility criteria are different. All patients enrolled in current study received first-line cisplatin-based regimens. Thus, it is helpful to exclude the potential confounding effect of different regimens. The GPS test is simple and based on standardized, wildly available protein assays. Therefore assessment of the GPS can be Hexamethonium Bromide routinely in most clinical centers. Based on the present results, the significant value of GPS test is that it can identify patients at high risk of disease progression and death as a clinically convenient and useful biomarker. Thus it not only provides guidance of follow-up care at clinic but also has the potential to be a stratification factor or a selection criterion in randomized clinical trials for metastatic NPC. Moreover, in our study, most of the patients evaluated as disease progression at the end of second cycle of chemotherapy were allocated a score of 2. Patients in the good GPS group had a more prolonged progression-free survival. As a consequence we believe that the presence of a systemic inflammatory response should be evaluated in the pretreatment period and might become the promising new targets of anti-tumor therapy. Nowadays there was an amount of ongoing research into the effect of non-steroidal anti-inflammatory drugs on anti-tumor treatment, including colon cancer, lung cancer, esophagus cancer and so on. Accordingly, it is also interesting and significant to study the modification of the systemic inflammatory response in patients with metastatic nasopharyngeal carcinoma. And the GPS which is inexpensive, reliable, and widely available may have a certain guiding significance for selecting patients who might be candidates for modulation of systemic inflammatory response and provide a well defined therapeutic target for future clinical trials.