Intra-arterial cisplatin and concomitant radiation therapy followed by surgery for advanced paranasal sinus cancer

Veterinary Interventional Oncology

Interventional oncology (IO) is a rapidly growing field in veterinary medicine and has been accepted as a fourth pillar of treatment of neoplastic disease with other modalities including surgery, chemotherapy, and radiation therapy. The major categories of IO therapies in companion animals are focused on the use of locoregional therapies and stenting of malignant obstructions. Although significant assessment of veterinary IO techniques is still necessary, early evaluation of these varying techniques is demonstrating promising results.

Dose-Finding and Efficacy Confirmation Trial of the Superselective Intra-arterial Infusion of Cisplatin and Concomitant Radiation Therapy for Locally Advanced Maxillary Sinus Cancer (JCOG1212): Results of the Efficacy Confirmation Phase in Patients with T4aN0M0

PURPOSE

Locally advanced maxillary sinus cancers require radical surgery as a standard treatment, but this often results in significant disfigurement and impairment of function. JCOG1212 seeks to evaluate the safety and efficacy of the superselective intra-arterial infusion of cisplatin and concomitant radiation therapy (RADPLAT) for T4aN0M0 and T4bN0M0 maxillary sinus squamous cell carcinomas. We herein report the results of the efficacy confirmation phase in the T4a cohort.

METHODS AND MATERIALS

Patients received 100 mg/m2 cisplatin intra-arterially weekly for 7 weeks with concomitant radiation therapy (total 70 Gy) as determined by the results of the preceding dose-finding phase. The trial aimed to evaluate the primary endpoint of 3-year overall survival (OS), comparing RADPLAT with the historical control for 3-year OS in surgery (80%).

RESULTS

From April 2014 to August 2018, 65 patients were registered in the T4a cohort from 18 institutions, consisting of 54 men and 11 women with a median age of 64 years (range, 40-78 years) and Eastern Cooperative Oncology Group performance status 0/1 (58/7). After excluding 1 ineligible patient, 64 patients were included in the primary analysis of efficacy and safety. The median follow-up was 4.5 years in all eligible patients, and the primary endpoint for 3-year OS was 82.8% (90% CI, 73.4%-89.2%). With regard to acute adverse events, mucositis (grade ≥3), neutropenia (grade ≥3), increased creatinine (grade ≥2), hearing impairment (grade ≥2), and stroke (grade ≥2) were observed in 20.3%, 14.1%, 3.1%, 3.1%, and 1.6% of patients, respectively. One treatment-related death due to a thromboembolic event was reported.

CONCLUSIONS

We demonstrated that RADPLAT showed favorable results for patients with T4aN0M0 maxillary sinus squamous cell carcinomas compared with the historical control for 3-year OS in surgery, which was from an earlier period, and showed some specific toxicities. Therefore, RADPLAT, as well as surgery, can be regarded as a possible treatment option for these patients.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Progress and emerging strategies to preserve function in the treatment of sinonasal cancer

The sinonasal structures and their adjacent organs host several functions including vision, olfaction, nasal respiration and filtration, secretory immunity, facial expression, articulation, and oral deglutition. We reviewed the current evidence supporting functional preservation in sinonasal cancer treatment. Primary surgery with or without adjuvant modalities continues to be the standard of care for sinonasal cancer. Unfortunately, functional compromise remains a dominant negative feature of this approach. More recently, through advances in therapeutic techniques and improved understanding of the relevant tumor biology, treatments aimed at preserving function and cosmesis are emerging. The evidence for such progress involving minimal access surgery, surgical reconstruction for rehabilitation, new techniques in radiation therapy, inclusion of systemic and locally enhanced chemotherapy, and therapeutic agents based on molecular targets are highlighted. This multi-prong approach bodes well for future patients with sinonasal cancer to undergo successful treatment that includes maximal preservation of associated functions.

The superselective intra-arterial infusion of cisplatin and concomitant radiotherapy (RADPLAT) is effective for metastatic lymph nodes in head and neck squamous cell carcinoma

BACKGROUND

Superselective intra-arterial infusion of cisplatin and concomitant radiotherapy (RADPLAT) is a very promising treatment modality for locally advanced head and neck squamous cell carcinoma. However, there are some concerns regarding its potential for the control of neck lymph node metastasis. The objective of this study was to investigate whether RADPLAT provided inferior regional control compared to intravenous chemoradiotherapy (IV-CRT).

METHODS

A total of 172 patients with neck lymph node metastases, 66 of whom underwent RADPLAT and 106 IV-CRT, were enrolled in this study. We retrospectively compared regional control rates between RADPLAT and IV-CRT. Furthermore, to adjust for differences in factors related to patient background between the groups, we conducted inverse probability weighting (IPW) analysis using the propensity score.

RESULTS

A comparison between the two groups revealed that the regional control rates were almost equal under unadjusted conditions; however, after adjustment by IPW analysis, the RADPLAT group had a relatively better regional control rate than did the IV-CRT group (1 year regional control rate: 86.6% vs. 79.4%). In addition, the analysis of relative risk factors for regional control in the RADPLAT group showed that the absence of intra-arterial cisplatin infusion into metastatic lymph nodes was the only independent risk factor (Hazard ratio: 4.23, p = 0.04).

CONCLUSION

This study showed that the regional control rate in patients treated with RADPLAT was noninferior to that for IV-CRT. Locally advanced head and neck cancers is a good indication for RADPLAT, even if the patients have neck lymph node metastases.

Factors Contributing to Diagnosis and Prognosis in Sinonasal Malignancies

Objectives. This study was intended to explore and analyze the factors which affect the survival and prognosis of patients with malignant tumors of nasal cavity and sinus. Methods. Retrospective analysis was performed on the clinical data of 39 cases of malignant tumors of nasal cavity and sinus that met the requirements of the study. A follow-up study was performed on the patients for more than 36 months. Survival analysis was conducted via the Kaplan-Meier method and log-rank test. Cox regression model was used for multivariate analysis. Results. Gender, pathological type, treatment plan, clinical stage, and survival time of patients were different. Clinical stage was substantially related to the survival of patients ( $P<0.05$ ), which was an independent factor affecting prognosis. Conclusions. Early detection and comprehensive treatment of sinonasal malignancies can improve the prognosis and prolong the survival time of patients.

Therapeutic efficacy of regional and systemic chemotherapy in advanced maxillary sinus cancer

BACKGROUND

To compare the efficacy of regional chemotherapy through the superficial temporal artery and systemic chemotherapy in patients with advanced maxillary sinus cancer.

METHODS

Nine of 22 patients with over TNM stage III maxillary sinus cancer received regional chemotherapy and 13 received systemically. The change of tumor volume, the degree of response according to the tumor location, and side effects after chemotherapy were analyzed.

RESULTS

Tumor volume reduction was significantly higher in the regional than systemic chemotherapy. Tumor response to chemotherapy was greater in regional than systemic chemotherapy in most maxillary sinus wall. The tumor response in anterior, posterior, and lateral wall of maxillary sinus was greater more than two times in the regional than systemic chemotherapy. There were no severe side effects related to regional chemotherapy.

CONCLUSION

Regional chemotherapy was superior to systemic chemotherapy regarding tumor volume reduction, especially located in the anterior, posterior, and lateral wall of maxillary sinus.

Data Set for the Reporting of Carcinomas of the Nasal Cavity and Paranasal Sinuses: Explanations and Recommendations of the Guidelines From the International Collaboration on Cancer Reporting

The International Collaboration on Cancer Reporting was established to internationally unify and standardize the pathologic reporting of cancers based on collected evidence, as well as to allow systematic multi-institutional intercountry data collection to guide cancer care in the future. This data set has been developed by the collaborative efforts of an international multidisciplinary panel of experts involved in the care of patients with carcinomas of the nasal cavity and paranasal sinuses (sinonasal tract). The nasal cavity and paranasal sinuses (including frontal, sphenoid, ethmoid, and maxillary sinuses) comprise a very complex anatomic area of the head and neck, affected by a sometimes bewildering array of neoplasms. Management of malignancies in this anatomic region involves complex surgery because of the anatomic confines and close proximity to many vital structures. Given a multidisciplinary approach, the standardized reporting of the carcinomas that develop in this anatomic region include both required (core) and recommended (noncore) elements in pathology reporting in order to be able to identify critical prognostic factors, often requiring clinical and radiologic correlation. A summary of the International Collaboration on Cancer Reporting guidelines and clinically relevant elements, along with additional explanatory notes, are provided, based on evidentiary support from the literature, set in the context of practical application.

The Role of Chemotherapy in the Management of Sinonasal and Ventral Skull Base Malignancies

In most cases of advanced sinonasal and ventral skull base cancer, a multimodal treatment approach provides the best chance for improved outcomes. Depending on the tumor type and extent of disease, systemic chemotherapy has been shown to play an important role in neoadjuvant, concomitant, and adjuvant settings. The lack of randomized trials continues to limit its indications. Further high-quality studies are needed to understand ideal chemotherapeutic regimens and their role and sequential timing in sinonasal and ventral skull base cancer.

ACR appropriateness criteria® nasal cavity and paranasal sinus cancers

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.

Prognostic impact of pathological response to neoadjuvant chemotherapy followed by definitive surgery in sinonasal squamous cell carcinoma

BACKGROUND

The significance of neoadjuvant chemotherapy followed by definitive surgery for sinonasal squamous cell carcinoma (SCC) was investigated using surgical specimens.

METHODS

Surgery was performed in 58 patients, including 43 patients who had received neoadjuvant chemotherapy. The pathological response was classified as grades 0 (no effect), 1 (slight effect), 2 (moderate effect), and 3 (marked effect), and its correlation with prognosis was investigated.

RESULTS

Grade 2 or 3 response was observed in 34.9% of cases that received neoadjuvant chemotherapy. Overall survival (OS), disease-free survival (DFS), locoregional control, and freedom from distant metastasis were significantly better in the effective neoadjuvant chemotherapy group (grades 2 and 3) than in the less effective neoadjuvant chemotherapy group (grades 0 and 1) and the non-neoadjuvant chemotherapy group combined.

CONCLUSION

Pathological response to neoadjuvant chemotherapy in sinonasal SCC was related to disease prognosis. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1305-E1311, 2016.

SUVmax on FDG-PET is a predictor of prognosis in patients with maxillary sinus cancer

PURPOSE

Our aim was to determine whether the maximum standardized uptake value (SUVmax) of the primary lesion demonstrated by [(18)F]-fluoro-2-deoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) is associated with the prognosis of maxillary sinus cancer.

MATERIALS AND METHODS

The relationships of clinicopathological factors including age, T stage, N stage, histologic type, treatment strategy, and primary tumor SUVmax with progression-free (PFS) and overall (OS) survival were evaluated using the log-rank test and Cox method in 31 patients with maxillary sinus cancer before combined superselective intra-arterial chemotherapy using high-dose cisplatin with concurrent radiotherapy, or radiotherapy alone.

RESULTS

The median duration of follow-up was 55.4 (range 9.7-72.6) months. PFS and OS of patients exhibiting a high SUVmax (≥16 and ≥17, respectively) for the primary tumor were significantly lower than those of patients for whom the primary tumor SUVmax was low (p = 0.0010 and p = 0.033, respectively). Multivariate analyses showed that T stage (p = 0.0049) and primary tumor SUVmax (p = 0.026) were independently prognostic of poorer PFS and that only primary tumor SUVmax (p = 0.049) was independently prognostic of poorer OS.

CONCLUSION

SUVmax of the primary tumor determined by FDG-PET/CT before treatment could be a good surrogate marker for prognostication of maxillary sinus cancer.

Advantage of Extended Craniofacial Resection for Advanced Malignant Tumors of the Nasal Cavity and Paranasal Sinuses: Long-Term Outcome and Surgical Management

OBJECTIVE

Craniofacial resection (CFR) for advanced sinonasal malignant tumors (SNMTs) is mandatory for radical resection. Surgeons must be aware of perioperative complications and long-term outcome because this procedure is extremely invasive, especially when the tumor involves the anterior skull base.

METHODS

Thirty-eight consecutive surgical patients with advanced SNMT of T4 stage or Kadish stage C (31 men and 7 women; mean age, 55 years; range: 19-76 years) treated with CFR in the past 28 years were followed up for 59.4 months. In cases of unilateral orbital extension, en-bloc resection was achieved using several neurosurgical techniques (extended CFR) from 2005 onwards. Herein, we evaluated the safety and effectiveness of surgery by comparing survival data between 2 time periods (first stage: 1984-2004, second stage: 2005-2012).

RESULTS

Squamous cell carcinoma was the most common histological type observed (65.8%), followed by esthesioneuroblastoma (15.8%). Using a combination of adjuvant radiation therapy, the 5-year overall survival and the 5-year disease-specific survival rates were 55.5% and 59.4%, respectively. Sarcomatous histology was a poor prognostic factor. The 5-year disease-specific survival rate was 48.9% in the first stage and improved to 82.1% in the second stage (P = 0.057); this was related to improvements in local control rate.

CONCLUSIONS

CFR and postoperative radiotherapy are safe and effective for treating advanced SNMTs. Extended CFR, including radical orbital exenteration, may contribute to good long-term outcomes. A diverse surgical team may help perform radical resection and reconstruction in patients with advanced tumors.

Intra-arterial chemoradiotherapy for head and neck cancer

Intra-arterial chemotherapy has been used to treat localized malignant neoplasms in patients with head and neck cancer for over 50 years as the head and neck region is particularly well suited to regional chemotherapy. Early intra-arterial chemotherapy did not prove its efficacy. In addition, the additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. Subsequent significant advances in vascular radiology techniques and the development of new devices, such as fluoroscopy units and angiographic catheters, have made possible safe, accurate and repeated superselective intra-arterial chemotherapy. Intra-arterial infusion of high-dose cisplatin with systemic neutralization by intravenous sodium thiosulfate (RADPLAT) is a theoretically attractive approach to the treatment of advanced head and neck cancer. However, a Dutch trial comparing intra-arterial and intravenous chemoradiotherapy for advanced head and neck cancer showed that RADPLAT was not superior to intravenous chemoradiotherapy. Therefore, further investigation of RADPLAT, including the refinement of the indications for its application, is needed.

The role of systemic therapy in the management of sinonasal cancer: A critical review

PURPOSE

Due to the rarity and the variety of histological types of sinonasal cancers, there is a paucity of data regarding strategy for their optimal treatment. Generally, outcomes of advanced and higher grade tumors remain unsatisfactory, despite the employment of sophisticated surgical approaches, technical advances in radiation techniques and the use of heavy ion particles. In this context, we critically evaluated the role of systemic therapy as part of a multidisciplinary approach to locally advanced disease.

RESULTS

Induction chemotherapy has shown encouraging activity and could have a role in the multimodal treatment of patients with advanced sinonasal tumors. For epithelial tumors, the most frequently employed chemotherapy is cisplatin, in combination with either 5-fluorouracil, taxane, ifosfamide, or vincristine. Only limited experiences with concurrent chemoradiation exist with sinonasal cancer. The role of systemic treatment for each histological type (intestinal-type adenocarcinoma, sinonasal undifferentiated carcinoma, sinonasal neuroendocrine carcinoma, olfactory neuroblastoma, sinonasal primary mucosal melanoma, sarcoma) is discussed.

CONCLUSIONS

The treatment of SNC requires a multimodal approach. Employment of systemic therapy for locally advanced disease could result in better outcomes, and optimize the therapeutic armamentarium. Further studies are needed to precisely define the role of systemic therapy and identify the optimal sequencing for its administration in relation to local therapies.

Craniofacial Resection for T4 Maxillary Sinus Carcinoma

Objective

The objective of this study was to clarify the outcomes of craniofacial resection for locally advanced maxillary sinus carcinoma classified as T4 and to present methods for managing cases involving the skull base.

Study Design

Case series with chart review.

Setting

Tertiary university hospital.

Subjects and Methods

We performed anterolateral craniofacial resection in en bloc fashion for locally advanced maxillary sinus carcinoma at stage T4. Participants comprised 40 patients with T4 maxillary sinus carcinoma treated between 1992 and 2011. Surgical outcomes were analyzed retrospectively.

Results

Forty patients with stage T4a (n = 26) or stage T4b (n = 14) were included in this study. Five-year overall and disease-free survival rates for the 40 patients with T4 maxillary sinus carcinoma were 62.7% and 52.6%, respectively. Cavernous sinus involvement correlated significantly with worse prognosis ( P = .012). In 35 cases without cavernous sinus involvement, previous treatment ( P = .017) and positive margins ( P = .019) correlated significantly with worse prognosis, and 5-year overall and disease-free survival rates were 72.4% and 55.3%, respectively.

Conclusion

This study only included cases of locally advanced maxillary sinus carcinoma classified as T4. Considering the advanced stage, our study suggests relatively favorable outcomes and the importance of managing the cavernous sinus in en bloc resections of malignant skull base tumors. Craniofacial resection in en bloc fashion achieved good survival rates.

Superselective intra-arterial cisplatin infusion and concomitant radiotherapy for maxillary sinus cancer

Background:

The purpose of this study was to evaluate the efficacy of superselective cisplatin infusion with concomitant radiotherapy (RADPLAT) for previously untreated patients with the squamous cell carcinoma of maxillary sinus (SCC-MS).

Methods:

Between 1999 and 2010, 54 patients were given superselective intra-arterial infusions of cisplatin (100–120 mg m⁻² per week) with simultaneous intra-venous infusions of thiosulfate to neutralise cisplatin toxicity and conventional radiotherapy (65–70 Gy).

Results:

One patient (1.9%) was diagnosed with T2, 14 (25.9%) with T3, 27 (50%) with T4a, and 12 (22.2%) with T4b disease. Lymph-node involvement was present in 12 patients (22.2%). During the median follow-up period of 6.4 years, the 5-year local progression-free and overall survival rates were 65.8 and 67.9% for all patients, respectively. No patient died as a result of treatment toxicity or experienced a cerebrovascular accident. Osteonecrosis (n=5), brain necrosis (n=1), and ocular/visual problems (n=14) were observed as late adverse reactions.

Conclusion:

We have shown excellent overall survival and local progression-free rate in SCC-MS patients treated by RADPLAT with acceptable rates of acute and late toxicity. A multi-institutional trial is needed to prove that this strategy is a feasible and effective approach for the treatment of SCC-MS.

Neoadjuvant intra-arterial chemotherapy combined with radiotherapy and surgery in patients with advanced maxillary sinus cancer

Purpose

The optimal treatment of advanced maxillary sinus cancer has been challenging for several decades. Intra-arterial chemotherapy (IAC) for head and neck cancer has been controversial. We have analyzed the long-term outcome of neoadjuvant IAC followed by radiation therapy (RT) and surgery.

Materials and Methods

Twenty-seven patients with advanced maxillary sinus cancer were treated between 1989 and 2002. Five-fluorouracil (5-FU, 500 mg/m²) was infused intra-arterially, and followed by RT (total 50.4 Gy/28 fractions). A planned surgery was performed 3 to 4 weeks after completion of IAC and RT.

Results

At a median follow-up of 77 months (range, 12 to 169 months), the 5-year rates of overall survival in all patients were 63%. The 5-year rates of overall survival of stage T3/T4 patients were 70.0% and 58.8%, respectively. Seven of fourteen patients with disease recurrence had a local recurrence alone. The 5-year actuarial local control rates in patients with stage T3/T4, and in all patients were 20.0%, 32.3%, and 27.4%, respectively. Overall response rate after the completion of IAC and RT was 70.3%. During the follow-up, seven patients (25.9%) showed mild to moderate late complications. The tumor extent (i.e., the involvement of either orbit and/or base of skull) appeared to be related with local recurrence.

Conclusion

Neoadjuvant IAC with 5-FU followed by RT and surgery may be effective to improve local tumor control in the patients with advanced maxillary sinus cancer. However, local failure was still the major cause of death. Further investigations are required to determine the optimal treatment schedule, radiotherapy techniques and chemotherapy regimens.

Cerebral revascularization and carotid artery resection at the skull base for treatment of advanced head and neck malignancies

Object

Resection of cancer and the involved artery in the neck has been applied with some success, but the indications for such an aggressive approach at the skull base are less well defined. The authors therefore evaluated the outcomes of advanced skull base malignancies in patients who were treated with bypass and resection of the internal carotid artery (ICA).

Methods

The authors retrospectively reviewed the charts of all patients with advanced head and neck cancers who underwent ICA sacrifice with revascularization in which an extracranial-intracranial bypass was used between 1995 and 2010 at the Barrow Neurological Institute.

Results

Eighteen patients (11 male and 7 female patients; mean age 46 years, range 7–69 years) were identified. There were 4 sarcomas and 14 carcinomas that involved the ICA at the skull base. All patients underwent ICA sacrifice with revascularization. One patient died of a stroke after revascularization. A second patient died of the effects of a fistula between the oral and cranial cavities (surgery-related mortality rate 11.1%). Eight months after the operation, 1 patient developed occlusion of the bypass and died. Complications associated with the bypass surgery included 1 case of subdural hematoma (SDH) with blindness, 1 case of status epilepticus, and 1 case of asymptomatic bypass occlusion (bypass-related morbidity 16.7%). Complications associated with tumor resection included 3 cases of CSF leakage requiring repair and shunting, 1 case of hydrocephalus requiring shunting, 1 case of SDH, and 1 case of contralateral ICA injury requiring a bypass (tumor resection morbidity rate 33.3%). In 1 patient treated with adjuvant therapy before surgery, the authors identified only a radiation effect and no tumor on resection. In a second patient the bypass was occluded, and her tumor was not resected. The other 16 patients underwent gross-total resection of their tumor. Excluding the surgery-related deaths, the mean and median lengths of survival in this series were 13.2 and 8.3 months, respectively (range 1.5–48 months). Including the surgery-related deaths, the mean and median lengths of survival were 11.8 and 8 months, respectively (range 17 days–48 months). At last follow-up all patients had died of cancer or cancer-related causes.

Conclusions

Despite maximal surgical intervention, including ICA sacrifice at the skull base with revascularization, patient survival was dismal, and the complication rate was significant. The authors no longer advocate such an aggressive approach in this patient population. On rare occasions, however, such an approach may be considered for low-grade malignancies.

Neoadjuvant chemoradiation in squamous cell carcinoma of the maxillary sinus: a 26-year experience

Background. The aim of our study was to evaluate the effects of neoadjuvant platinum-based radiochemotherapy (RCT) in patients with maxillary sinus squamous cell carcinoma and to compare the results with other multimodality treatment concepts for advanced-stage maxillary sinus carcinoma in the literature. Methods. In total, 53 patients with squamous cell carcinoma of the maxillary sinus were reviewed retrospectively. All patients received a neoadjuvant RCT containing either cisplatin or carboplatin followed by radical surgery. Overall survival and locoregional control were plotted by Kaplan-Meier analysis. Prognostic factors were identified through univariate and multivariate analysis. Results. Five-year overall survival for all patients was 35%. Eleven patients achieved a complete response after radiochemotherapy. The complete response rate was significantly higher for patients treated with cisplatin (P = 0.028); however the 5-year overall survival rates did not differ significantly (P = 0.673) for patients treated with cisplatin (37%) and carboplatin (32%). Orbital invasion (P = 0.005) and complete response to radiochemotherapy (P = 0.021) had a significant impact on overall survival in univariate analysis. Conclusions. Neoadjuvant radiochemotherapy followed by radical surgery is an effective treatment for patients with advanced maxillary sinus squamous cell carcinoma. In terms of treatment response cisplatin seems to be more effective than carboplatin.

An essential dose of cisplatin for super-selective intra-arterial infusion concomitant with radiotherapy in patient with maxillary squamous cell carcinoma

The present study investigated the efficacy and safety of using a lower dose of cisplatin (CDDP) in super-selective intra-arterial concurrent chemoradiotherapy (SSIACRT) to treat maxillary squamous cell carcinoma. 10 patients with maxillary squamous cell carcinoma (T3 n = 6, T4a n = 4) without regional or distant metastasis were treated by SSIACRT. The CDDP dose per course was 100 mg/body, i.e. 50-80 mg/m(2). 6-9 weeks after SSIACRT, partial maxillectomy was performed on all patients. Clinical and histological responses, survival rates, and adverse events were investigated. 10 (100%) of 10 patients achieved both clinical and pathological complete or partial remission. The 3-year overall and disease-free survival rates were 100 and 90%, respectively. Grade 3 toxicity was experienced by two patients. In conclusion, the SSIACRT regimen with a lower dose of CDDP (100 mg/body) had an equivalent therapeutic outcome and lower toxic outcome compared to a higher dose of CDDP. This regimen could be an effective and safe therapeutic modality for maxillary squamous cell carcinoma except T4b and N1/2 disease.

Primary Adenocarcinoma of the Frontal Sinus

When tumor involvement of the frontal sinus occurs, it is usually the result of the direct spread of the mass from the nasal cavity or anterior ethmoid sinuses. Primary frontal sinus tumors are extremely rare. We describe a case of primary adenocarcinoma of the frontal sinus in a 53-year-old man. The patient refused surgery, so he was treated with chemotherapy followed by radiotherapy. At the 1-year follow-up, only a slight reduction of the swelling was noted. Thereafter, he was lost to follow-up. This case represents a typical example of a paranasal cancer extending beyond the bony margins, with a silent onset that simulated benign disease. The best hope for an early diagnosis of such a tumor lies in the greater use of computed tomography to assess chronic rhinosinusitis.

Primary frontal sinus squamous cell carcinoma in three dogs treated with piroxicam combined with carboplatin or toceranib

In human medicine, primary frontal sinus squamous cell carcinoma (pFS-SCC) is not frequently reported. In veterinary medicine, frontal sinus SCC is exclusively described as an extension of nasal cavity SCC. To our knowledge, this is the first publication concerning canine pFS-SCC, diagnosed using histology or cytology and medical imaging, in three dogs. The tumours extended into the orbit or brain cavity, without nasal involvement. Treatment was initiated with piroxicam-carboplatin. Prolongation of carboplatin delivery with a low dose intensity was performed on dogs with a favourable initial response. Dog 1 achieved a complete remission (CR), but was euthanized 344 days after start of therapy. Dog 2, still alive 3 years after start of therapy and in CR, received 14 carboplatin deliveries. In dog 3, after changing the treatment protocol into piroxicam-toceranib, a significant tumour reduction occurred, but the dog was euthanized after 195 days because of a relapse.

Contemporary management of sinonasal cancer

BACKGROUND

Sinonasal cancer is a relatively uncommon entity encountered by head and neck oncologists, rhinologists, and skull base surgeons. Recent innovations in surgical and nonsurgical therapeutic modalities raise the question of whether there has been any measurable improvement for treatment outcomes.

METHODS

A retrospective review of data from recent studies that focus on surgery, radiation, and chemotherapy, or combinations thereof, was conducted.

RESULTS

Surgery continues to be the preferred treatment and provides the best results, albeit with an inherent bias based on patient selection. For advanced disease (T4 lesions), the survival rate remains only modest. Complications of treatment, including both surgical and radiation therapy, have been reduced.

CONCLUSIONS

There is a need to improve the efficacy of treatment for this disease. Recommendations for the future direction of therapeutic investigations are outlined.

Impact of superselective transarterial infusion therapy of high-dose cisplatin on maxillary cancer with orbital invasion

BACKGROUND AND PURPOSE

We have been performing the superselective transarterial infusion of high-dose cisplatin for advanced maxillary cancer since 1998 and the local control rate, disease free survival rate, and organ preservation have improved markedly compared with our former therapy. This study evaluates the effectiveness of superselective transarterial infusion therapy by using high-dose cisplatin on maxillary cancer with orbital invasion.

MATERIALS AND METHODS

We treated 23 patients with maxillary cancer by using superselective transarterial infusion therapy with high-dose cisplatin and concomitant radiation therapy for 10 years. Of all patients, 15 showed orbital invasion, with 11 of these tumors fed by both internal maxillary and ophthalmic arteries. In all patients, we performed superselective transarterial infusion therapy via the internal maxillary artery and/or the other feeding branches from the external carotid artery. After the operation, we determined whether a pCR had occurred by checking for the presence of viable cells. In addition, we calculated the overall survival rate, preservation rate of the eyeball, and disease-free survival rate.

RESULTS

For all 23 patients, pCR and overall survival rates were 95.7% and 78.4%, respectively. To date, 2 of these patients died of lung metastasis without local recurrence. For the 15 patients with orbital invasion, the respective pCR and disease-free survival rates were 93.3% and 87.5%. Eyeballs were preserved in all patients, and local recurrence occurred in only 1 patient, at the inferior wall of the maxillary sinus (not in the orbit).

CONCLUSIONS

Superselective transarterial infusion therapy with high-dose cisplatin remarkably improved the local control rate and disease-free survival rate of maxillary cancer. Even in patients with orbital invasion, a high local control rate was achieved, with preservation of the eyeball, through infusion only into branches of the external carotid artery.

Treatment outcome of maxillary sinus cancer

The standard treatment in the early stage of maxillary sinus cancer is surgical resection followed by postoperative radiation therapy. However, for locally advanced maxillary sinus cancer, a multimodality treatment approach is strongly recommended to improve the survival rate and quality of life of the patient. We determined the treatment outcomes of induction chemotherapy, concurrent chemoradiation therapy, and surgical resection for locally advanced maxillary sinus cancer. Forty-four patients with locally advanced maxillary sinus cancer, who had been treated between January 1990 and April 2008 at Kangnam St. Mary's Hospital, were retrospectively analyzed. The objective response rates were 70%, 53%, and 57% in the intra-arterial induction chemotherapy, intravenous induction chemotherapy, and concurrent chemoradiation therapy groups, respectively. The orbital preservation rates were 83%, 100%, and 75% in the intra-arterial induction chemotherapy, intravenous induction chemotherapy, and surgical resection groups, respectively. In seven of nine patients in whom the orbit could be preserved after induction chemotherapy, the primary tumors were removed completely. However, although the orbits were preserved in three patients who underwent surgical resection as a primary treatment, all three cases were confirmed to be incomplete resections. We found that active induction chemotherapy for locally advanced cancer of the maxillary sinus increased the possibility of complete resection with orbital preservation as well as tumor down-staging.

Malignant neoplasms of the sinonasal tract: report of 71 patients and literature review and analysis

BACKGROUND

The present study aimed to report the characteristics, prognostic factors, and treatment outcomes of 71 cases of malignant neoplasms of the sinonasal tract and literature review and analysis of major report series.

METHODS

Seventy-one consecutive patients diagnosed with primary malignant neoplasm of the sinonasal tract that were treated and followed up at a university hospital between May 2000 and March 2008 were selected for the present study. Thirty-four patients were treated with surgery followed by a combination of chemotherapy and radiotherapy, 15 with surgery alone, 14 with combined radiotherapy and chemotherapy, six with radiotherapy alone, and two with surgery followed by radiotherapy. To find out the major series of related studies over the last 20 years, a literature review of PubMed was performed. In all, we found 42 major series including 8,164 patients with malignant neoplasms of the sinonasal tract.

RESULTS

There were 35 women and 36 men ranging in age from 5 to 80 years, with a median age of 55 years at diagnosis. The primary sites included were paranasal sinuses in 51 and nasal cavity in 20. There were one case of stage I, 20 of stage II, 27 of stage III, and 23 of stage IV. Epithelial tumors constituted 65% of all neoplasms. After a median follow-up of 39 months for surviving patients, 33 patients are alive and without disease, eight are alive with disease, and 30 patients died due to disease. Local recurrence was the most frequent treatment failure. The 5-year disease-free, local control, and overall survival rates were 42.1%, 59.5%, and 54.5%, respectively. On univariate analysis, cervical lymph nodes involvement, primary tumor size, histologic type, response to therapy, and stage of disease were independent prognostic factors for overall survival. In the literature review and by analyzing the data collection from 42 major reported series, the median age was 57 years and male/female ratio was 1.8. Epithelial tumors consisted of 69% of all malignant neoplasms of sinonasal tract and stages III and IV disease constituted 74.7% of all stages. Local recurrence was the dominant treatment failure in nearly all series. Five-year local control and overall survival rates were 56% and 45.5%, respectively.

CONCLUSIONS

In this review and by analyzing the large data collection of recent major reported series, we found that malignant neoplasms of the sinonasal tract tend to present at locally advanced stage, with a high frequency of local failure and a moderate to poor outcome. More effective local treatment for improving the local control and overall survival is needed.

Superselective, intra-arterial, rapid infusion chemotherapy for external auditory canal carcinoma

Previously, the treatment of carcinoma of the external auditory canal has mainly involved surgical resection. In order to enable organ preservation and to obtain cancer-free surgical margins, we introduced the use of superselective, intra-arterial, rapid infusion chemotherapy combined with radiotherapy to treat this condition.

We reviewed our patients' tumour stages, feeding arteries and clinical outcomes. Tumours were staged according to the Pittsburgh staging system. Chemotherapy was administered intra-arterially in the angiography suite via transfemoral catheterisation of the feeding arteries. Four patients underwent superselective, intra-arterial, rapid infusion chemo-radiotherapy. A complete response was obtained in all four patients. The overall toxic side effects were modest.

Superselective, intra-arterial, rapid infusion chemotherapy can be an effective, organ-preserving treatment for external auditory canal carcinoma, with a high cure rate.

Selective (intra-arterial), rapid infusion chemo-radiotherapy to preserve the larynx in advanced laryngeal carcinoma: preliminary results

Objectives:

We had previously treated patients with advanced stage laryngeal cancer by laryngectomy with or without post-operative radiotherapy. In order to improve such patients' quality of life, we sought to preserve the larynx by selective (intra-arterial), rapid infusion chemotherapy combined with radiotherapy.

Methods:

Chemotherapy was administered intra-arterially in the angiography suite via transfemoral catheterisation of the superior thyroid artery. Patients received up to four once-weekly infusions of cisplatin (75 mg/patient) with simultaneous intravenous administration of sodium thiosulphate, a neutralising agent. Patients also received external radiation simultaneously at a dose of 1.8 or 2.0 Gy per fraction, once daily for five days a week for 7 weeks.

Results:

Intra-arterial infusion chemo-radiotherapy was performed in eight patients with advanced laryngeal carcinoma (four glottic, three supraglottic and one subglottic type carcinoma). A complete response was achieved at the primary site and at lymph node metastases in all eight patients. Overall toxic side effects were modest. No catheter-related thrombo-embolic complications were observed during any of the chemotherapy sessions.

Conclusions:

Selective (intra-arterial), rapid infusion chemo-radiotherapy may enable laryngeal preservation in patients with advanced laryngeal carcinoma.

Malignant tumors of the nasal cavity and paranasal sinuses: long-term outcome and morbidity with emphasis on hypothalamic-pituitary deficiency

PURPOSE

To evaluate the long-term outcome after surgery and radiotherapy for patients with sinonasal cancer and assess late toxicity, with special emphasis on hypothalamic-pituitary dysfunction.

METHODS AND MATERIALS

A retrospective analysis of 168 patients treated for sinonasal cancer in a single institute between 1986 and 2006. A more detailed analysis was performed on a subgroup of 76 patients with adenocarcinoma or squamous cell carcinoma treated with curative intent. Long-term survivors were evaluated for late toxicity by a multidisciplinary team using the late effects of normal tissues (LENT SOMA) scoring system. Additional endocrinologic tests were performed for assessment of hypothalamic-pituitary function.

RESULTS

Five-year actuarial local control and overall survival rates were 62% and 35% for all patients and 64% and 42% for the subgroup with squamous cell carcinoma and adenocarcinoma. In multivariate analysis, T stage was the only significant factor predicting local relapse (79% at 5 years for T1-T3 vs. 53% for T4; p = 0.006). Sinonasal mucosal melanomas had the highest rate of regional failure (33% at 5 years). Thirteen of 21 patients (62%) evaluated at the late morbidity clinic had hormonal disturbances, of whom 5 (24%) had definitive evidence of hypopituitarism with multiple hormonal deficiencies.

CONCLUSION

Local failure is the dominant cause of treatment failure for patients with sinonasal cancer, with T4 stage the only independent predictor. Because of a high rate of radiation-induced hypopituitarism, we recommend endocrinologic surveillance for these patients.

Superselective intra-arterial chemotherapy for advanced maxillary sinus cancer: an evaluation of arterial perfusion with computed tomographic arteriography and of tumor response

OBJECTIVE

The purpose of our study was to elucidate the relationship between arterial perfusion in advanced maxillary sinus cancer which was opacified by superselective intra-arterial computed tomographic arteriography (IA-CTA) and the tumor response to intra-arterial chemotherapy.

METHODS

Superselective IA-CTA was performed to identify the feeding arteries and their perfusion in advanced maxillary sinus cancer in 10 patients. Cisplatin was selectively infused into these feeding arteries, except for the internal carotid artery.

RESULTS

The results were assessed in 9 of the 10 patients, and a complete response was achieved in 5 patients in whom either the entire tumor, or most of the tumor, was perfused by the branches of the external carotid artery. In 4 patients with a partial response, the residual tumors were seen in the territory of the perfusion defect or in the perfusion territory of the internal carotid artery.

CONCLUSION

Superselective IA-CTA is a useful technique to correctly identify the intratumoral perfusion and to predict tumor response to the intra-arterial chemotherapy of advanced maxillary sinus cancer.

Salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck: an update about rare but challenging tumors

PURPOSE OF REVIEW

This is a review about recent clinical developments in rare cancers of the head and neck.

RECENT FINDINGS

Progress in molecular biology techniques has allowed the identification of new prognostic factors, and potential molecular-targeted therapies. This is of importance since chemotherapy continues to play a role but is still limited in this group of malignancies. New techniques of irradiation such as intensity-modulated radiotherapy and three-dimensional conformal radiotherapy appear to improve the locoregional control of these tumors. Surgery continues to be the cornerstone of treatment, with a growing interest in the technique of sentinel lymph node biopsy.

SUMMARY

As salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck are rare malignancies, these tumors must be treated in specialized anticancer centers with access to the latest surgical and irradiation techniques. Moreover, clinical studies with translational research are needed to identify strong prognostic and predictive factors, and effective molecular-targeted therapies.

Postoperative radiotherapy for maxillary sinus cancer: long-term outcomes and toxicities of treatment

PURPOSE

To determine the effects of three changes in radiotherapy technique on the outcomes for patients irradiated postoperatively for maxillary sinus cancer.

METHODS AND MATERIALS

The data of 146 patients treated between 1969 and 2002 were reviewed. The patients were separated into two groups according to the date of treatment. Group 1 included 90 patients treated before 1991 and Group 2 included 56 patients treated after 1991, when the three changes were implemented. The outcomes were compared between the two groups.

RESULTS

No differences were found in the 5-year overall survival, recurrence-free survival, local control, nodal control, or distant metastasis rates between the two groups (51% vs. 62%, 51% vs. 57%, 76% vs. 70%, 82% vs. 83%, and 28% vs. 17% for Groups 1 and 2, respectively). The three changes were to increase the portals to cover the base of the skull in patients with perineural invasion, reducing their risk of local recurrence; the addition of elective neck irradiation in patients with squamous or undifferentiated histologic features, improving the nodal control, distant metastasis, and recurrence-free survival rates (64% vs. 93%, 20% vs. 3%, and 45% vs. 67%, respectively; p < 0.05 for all comparisons); and improving the dose distributions within the target volume, reducing the late Grade 3-4 complication rates (34% in Group 1 vs. 8% in Group 2, p = 0.014). Multivariate analysis revealed advancing age, the need for enucleation, and positive margins as independent predictors of worse overall survival. The need for enucleation also predicted for worse local control.

CONCLUSION

The three changes in radiotherapy technique improved the outcomes for select patients as predicted. Despite these changes, little demonstrable overall improvement occurred in local control or survival for these patients and additional work must be done.

Combined therapy after superselective arterial cisplatin infusion to treat maxillary squamous cell carcinoma

OBJECTIVE

We sought to assess the efficacy of combined therapy after superselective arterial cisplatin infusion (SACI) therapy to treat the maxillary squamous cell carcinoma.

STUDY DESIGN

We conducted a retrospective chart review of 50 patients. After completion of two courses of SACI, 25 of the patients were successively treated by concurrent SACI and radiotherapy (AR), while the other 25 patients were treated by surgery with postoperative radiotherapy (ASR).

RESULTS

Patients with surgery (ASR) had an 88% local control rate with 75% disease-free survival rate at 60 months by Kaplan-Meier analysis, compared with 62% disease-free survival rate for patients with AR treatment. A particularly good outcome was obtained in T4 cases of the ASR group (n=8) whose 5-year survival rate was 87% and local control rate was 100%.

CONCLUSION/SIGNIFICANCE

Combined SACI therapy is very effective for the treatment of maxillary squamous cell carcinomas and contributes to the improving prognoses of patients and organ preservation rates.

Cancer of the paranasal sinuses

Carcinoma of the paranasal sinuses is a heterogeneous disease that is frequently locally advanced at presentation. Treatment commonly includes radical surgery followed by adjuvant therapy. Despite such aggressive therapy, the likelihood of locoregional failure is significant, resulting in poor survival, particularly with advanced tumors. In this paper, we review the recent literature in search of advances in treatment optimization. These advances include conformal radiotherapy techniques, chemotherapy, image-guided and endoscopic surgery, and surgical approaches for orbital preservation, all of which have a potential to improve the oncologic outcome as well as cosmetic and functional results. We also outline our approach in using these advances in the management of patients with these cancers.

Clinical characteristics and outcome of non-squamous cell malignancies of the maxillary sinus

BACKGROUND AND OBJECTIVES

A significant paucity of data exists on non-squamous cancers of the maxillary sinus. The purpose of this study was to assess the clinical characteristics and outcomes of these tumors.

METHODS

Retrospective review of 42 patients with complete available data and a diagnosis of non-squamous cancer of the maxillary sinus treated with curative intent between 1994 and 1999 were performed. Information recorded included demography, clinical characteristics, histopathological findings, treatment methods, and outcome. Survival was also compared with that of squamous cancers of the maxillary sinus.

RESULTS

The majority of patients presented with locally advanced disease (83%). Malignancies were 14 sarcomas, 8 adenoid cystic carcinoma, 8 mucoepidermoid carcinoma, 2 adenocarcinoma, and 10 miscellaneous tumors. Fifteen (35.7%) patients developed recurrent disease and six developed distant metastases. The most common site of recurrence was local (32.5%). The overall mean survival was 71.7 months and 5-year overall and disease-free survival was 51% and 48%, respectively. In contrast, the mean survival in the selected 62 patients with squamous cancers was 40 months and 5-year survival was 29% (P = 0.01). Tumor stage, histological, and treatment type was not associated with significant survival advantage.

CONCLUSIONS

Patients with non-squamous cancers of the maxillary sinus present with locally advanced disease. Local tumor progression remains a significant pattern of failure; however, unlike squamous cancers they have a better prognosis.

Management of paranasal sinus malignancy

Malignancies of the nasal cavity and paranasal sinuses represent a wide spectrum of histologies, tissues of origin, and anatomic primary sites. The inherent difficulty in generalizing treatment approaches is obvious, given the numerous variables associated with the broadly-based term, paranasal sinus malignancy (PNSCa). Nevertheless, the majority of epithelial and salivary malignancies of this region (ie, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, sinonasal undifferentiated carcinoma, and esthesioneuroblastoma) require surgical intervention as part of any treatment regimen. Recent trends have broadened the indications for chemotherapeutic and radiotherapeutic options in the management of advanced PNSCa. Nonepithelial malignancies, including the wide variety of sarcomas arising in this region, most commonly require multimodality treatment including chemotherapy, radiation, and/or surgery for definitive treatment. Moreover, the proximity of the nasal cavity and paranasal sinuses to structures including the orbit, dura, brain, cranial nerves, and carotid arteries mandates careful radiologic and neurologic evaluations throughout the course of the disease. Surgical advances now permit complex tumor removal and reconstruction surrounding these structures resulting in functional and cosmetic improvements when compared to earlier techniques. However, additional clinical trials are necessary to systematically evaluate the locoregional control, organ-preservation strategies, and survival related to the variety of treatments currently available.