Carcinoma of the paranasal sinuses. Results of a prospective pilot study

Topical Application of 5-Fluorouracil for the Treatment of Sinonasal Adenocarcinoma and Inverted Papilloma

BACKGROUND

Sinonasal tumors represent a rare and heterogeneous group of rhinologic neoplasms. Even with advancements in surgical approaches, mortality rates of patients with sinonasal adenocarcinoma (SNAC) have not significantly improved and persistently high rates of recurrence in certain patients with inverted papilloma (IP) are seen. The use of 5-fluorouracil (5-FU) has been successfully described as an adjuvant treatment of SNAC and in the prevention of IP recurrence.

OBJECTIVE

This review aims to present the current evidence on the management of SNAC and IP with topical 5-FU.

METHODS

A three-author independent literature review was conducted to identify research involving the use of topical 5-FU for the treatment of SNAC and IP. A total of nine papers on the treatment of SNAC and IP were collected.

RESULTS

The earliest study looking at the combination of adjuvant low-dose radiation and topical 5-FU for adenocarcinoma of the ethmoid sinus showed a 5-year survival rate of 100%. A follow-up study evaluating a similar protocol reported adjusted disease-free survival at 2, 5, and 10 years of 96%, 87%, and 74%, respectively. Similar results have been demonstrated for adjuvant 5-FU use following endoscopic resection and have even been described in the novel setting of transcutaneous 5-FU delivery following frontal trephination. Topical 5-FU has also been described in the treatment of aggressive IP. The largest case series described the use of 5-FU for eighteen cases and demonstrated only a single recurrence.

CONCLUSION

The use of topical 5-FU currently represents an underutilized therapeutic modality within the treatment of rhinologic neoplasms. Available literature suggests that neoadjuvant use of topical 5-FU can improve survival and decrease recurrence for SNAC and IP. However, the small sample sizes prevent advocation for routine use in the general population and further research on 5-FU is necessary.

Treatment of Maxillary Sinus Carcinoma: Five-Year Results

Previous treatment methods for maxillary sinus carcinoma generally consisted of dissection of maxilla, full dose irradiation, and/or extensive chemotherapy. However, results of such treatment were often poor. Even if patients recover, quality of life (QOL) is significantly reduced as a result of loss of facial structures and functional disability. A retrospective analysis of 42 patients with maxillary sinus carcinoma between 1975 and 1991 was undertaken. All patients underwent pergingival maxillary sinus surgery combined with a standardized total course of pre and postoperative irradiation of 1,600 cGy, together with regional intra-arterial infusion chemotherapy. During the surgery, all visible tumor tissue was removed, and the surrounding tissues were left when possible to facilitate cellular immunity after the surgery. The 5-year survival rate statistically obtained was 100% in Stage II, 100% in Stage III, and 62% in Stage IV patients.

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.

Sinonasal carcinomas: epidemiology, pathology, and management

Sinonasal carcinomas are uncommon neoplasms accounting for approximately 3% to 5% of all upper respiratory tract malignancies. Sinonasal malignancies in most cases do not cause early symptoms and present in an advanced stage of disease. Exact staging necessitates a clinical and endoscopic examination with biopsy and imaging. Tumor resection using an open or endoscopic approach is usually considered the first treatment option. In general, sinonasal carcinomas are radiosensitive, so adjuvant or neoadjuvant radiation treatment may be indicated in advanced disease. Multidisciplinary surgical and medical oncologic approaches, including ablation and reconstruction, have enhanced the survival outcome over the past few decades.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Treatment outcomes between concurrent chemoradiotherapy and combination of surgery, radiotherapy, and/or chemotherapy in stage III and IV maxillary sinus cancer: multi-institutional retrospective analysis

PURPOSE

The incidence of maxillary sinus cancer (MSC) is extremely rare, representing less than 1% of all cancers. Because of its rarity, the management of locally advanced MSC is a challenging issue. The objective of the present study was to retrospectively compare the efficacy of 2 traditional treatment strategies, concurrent chemoradiotherapy (CCRT) versus combination of surgery and radiotherapy and/or chemotherapy (SRCT) in MSC.

PATIENTS AND METHODS

From 1989 to 2010, 65 patients with histologically confirmed stage III or IVA/IVB were retrospectively analyzed.

RESULTS

The median age of our subjects was 60 years (range 36 to 81). The present study involved 18 women (27.7%) and 47 men (72.3%). Of the 65 patients, 52 (80.0%) had squamous cell carcinoma. The TNM stage was stage III, as determined by the American Joint Committee on Cancer, 6th edition, in 27 patients (41.5%). Stage IVA or IVB was observed in 38 patients (58.5%). Of the 65 patients, 41 underwent treatment. Of these 41 patients, 26 and 15 patients underwent SRCT and CCRT, respectively. During the 75.6 months (range 6.4 to 249.4) of median follow-up, the median progression-free survival duration was 45.1 months (95% confidence interval 0.0 to 142.7). The 5-year overall survival rate was 64.8%. However, the patients who had undergone surgery had better progression-free survival (hazard ratio 2.363, 95% confidence interval 1.098 to 5.085, P = .028) and overall survival (hazard ratio 4.989, 95% confidence interval 1.646 to 15.118, P = .004). The SRCT group had a better progression-free survival (P = .043) and overall survival (P = .029) duration than did the CCRT group.

CONCLUSION

SRCT might be superior to CCRT for locally advanced MSC. Additional studies comparing the treatment outcomes of CCRT with SRCT are warranted.

Is surgical debridement and topical 5 fluorouracil the optimum treatment for woodworkers' adenocarcinoma of the ethmoid sinuses? A case-controlled study of a 20-year experience

OBJECTIVES

Woodworkers' adenocarcinoma of the ethmoid sinuses is an extremely rare occupational malignancy with a locally aggressive course. Treatment with surgical exenteration and topical 5 fluorouracil (5FU) packs has become standard treatment over the last 10 years in this ENT unit. This study presents level 2 evidence that 5FU provides improved survival over previous management with primary radiotherapy and salvage craniofacial resection.

DESIGN

Retrospective case series with historical control group.

SETTING

District General Hospital.

PARTICIPANTS

The records of 31 consecutive patients with the disease were analysed. Five patients died prior to treatment. One patient was treated with surgery alone and therefore excluded. Twenty-five patients were included in the analysis. Fourteen were treated with primary radiotherapy and 11 with surgery and topical 5FU.

OUTCOME MEASURES

Disease free survival was measured using Kaplan-Meier survival analysis.

RESULTS

Five-year disease free survival improved from 50% with primary radiotherapy to 86% with surgery and 5FU. This improvement is statistically significant (P = 0.03).

CONCLUSION

Topical 5FU treatment improves survival of Woodworker's adenocarcinoma of the ethmoid sinuses. This finding may be useful in the treatment of other locally aggressive sinonasal malignancies.

The efficacy and safety of concurrent chemoradiotherapy for maxillary sinus squamous cell carcinoma patients

OBJECTIVE

Combined treatment modality, e.g., definitive surgery followed by radiotherapy (RT) and definitive RT with concurrent chemotherapy, has been applied for advanced maxillary sinus squamous cell carcinoma (MSSCC) patients to obtain a better survival with organ preservation in Japan.

METHODS

The outcome of 40 patients with MSSCC between 1991 and 2007 in our institute was analyzed retrospectively. There were 36 males and 4 females, the average age being 59.5 years (ranging from 34 to 81 years). The median follow-up time was 66.1 months. All the patients had received a combined treatment consisting of definitive surgery, RT, and intra-arterial or systemic chemotherapy. The chemotherapeutic regimen was different depending on the performance status and/or complications of the patients. Since 1998, concurrent chemoradiotherapy with cisplatin, 5-fluorouracil, methotrexate and leucovorin regimen (CCRT-PFML) instead of neo-adjuvant chemotherapy has been applied.

RESULTS

The overall 5-year survival rate was 59.2%, the 5-year disease-specific survival rate was 71.7%, and the 5-year organ preservation survival rate was 42.4%. In the group receiving CCRT-PFML, the overall 5-year survival rate was 60.0%, the 5-year disease-specific survival rate was 76.0%, and the 5-year organ preservation survival rate was 60.3%.

CONCLUSION

CCRT-PFML for advanced MSSCC patients is feasible to preserve the organs without reducing the survival rate.

Adenocarcinoma of Ethmoid: a GETTEC retrospective multicenter study of 418 cases

OBJECTIVE

To determine risk factors and evaluate the treatment of ethmoid adenocarcinoma. Epidemiologic data were recorded and compared with the literature.

MATERIALS AND METHODS

A multicenter and retrospective study. The medical records of 418 patients who had presented with ethmoid adenocarcinoma at 11 French hospitals from 1976 to 2001 were analyzed to determine the clinical characteristics and treatment of the disease.

RESULTS

The gender ratio was 2.8 men per 1 woman. Toxic exposure was classic for this lesion, exposure to wood and leather for most cases. The mean age was 63 years (range 31-91). Symptoms were nonspecific and based on clinical rhinologic signs. Nasal endoscopy after mucosal retraction was found useful to evaluate the extension of the lesion and to perform biopsies. Computed tomography scan and magnetic resonance imagery must be carried out prior to treatment to define extra nasal extension. The survival rate was significantly influenced by the size of the lesion (T4, N+) and extension to brain or dura. Surgery with postoperative radiotherapy remains the treatment of choice. Total excision must be a major priority, as confirmed in our series.

CONCLUSION

This retrospective study was, to our knowledge, the largest ever reported in the literature. This series confirmed the risk factor of this lesion as well as the lesion's influence on the survival rate. Surgery is the most important part of the treatment. Local recurrences were responsible for the poor prognosis of this lesion.

Ethmoido-Orbital Tumors: Our Experience

No data in the literature report the specific invasion of the orbit from ethmoidal tumors, although such a pattern of involvement of the orbit frequently occurs because of the thin lamina papyracea separating the two structures. From January 1986 to January 2003, 38 patients with untreated primary ethmoidal malignancies were observed at the Unit of Maxillo-Facial Surgery of the University "La Sapienza" in Rome. Personal data were obtained from review of the personal clinical file of each. Orbital invasion was present in 24 patients with ethmoidal malignancy. Three stages of orbital invasion were identified. The average overall survival, with the Kaplan-Meyer method, was 61.4% after 1 year and 51.1% at 5 and 10 years. Intracranial involvement is the main element for short-term negative prognosis. Orbital exenteration is fundamental if grade III orbital invasion occurs because it ensures an improvement of the disease-free survival.

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation

INTRODUCTION

Malignancies of the nasal and paranasal sinuses are uncommon tumors, accounting for only 3% of all aerodigestive tract neoplasms. Despite advances in surgical techniques and continued evolution of adjuvant therapies, the 5-year mortality remains unusually high at greater than 50%. In 1996, we begin utilizing a novel strategy in the treatment of advanced sinonasal carcinomas. This consisted of neoadjuvant selective intra-arterial cisplatin with concurrent radiation therapy (acronym RADPLAT) followed by a conservative craniofacial resection. We now report our results for 11 patients treated with this regimen.

METHODS

Between July 1996 and April 2003, 11 patients with advanced sinonasal malignancies underwent treatment utilizing the RADPLAT protocol followed by a planned surgical resection via a craniofacial approach. Patient charts, operative notes, follow-up clinic notes, and pre- and post-operative imaging studies were reviewed in detail for each subject.

RESULTS

Histopathological analysis of the tumors revealed seven squamous cell carcinomas (64%), two adenocarcinomas (18%), one adenoid cystic carcinoma (9%), and one sinonasal undifferentiated carcinoma (9%). T4N0M0 disease was present in nine patients (81%), and two patients had T3N0M0 disease (19%). Survival was calculated using the Kaplan-Meier method with an overall survival of 81% at 5 years and a progression-free survival at 5 years of 67%. Mean follow-up is 57.2 months ranging from 12 to 95 months.

CONCLUSIONS

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation results in a significant improvement in survival. This can be done safely with high response rates and excellent loco-regional control in T3 and T4 disease. Although are results are encouraging, there is a need for a cooperative, multi-institutional, prospective study.

Results of orbital preservation for advanced malignant maxillary sinus tumors

OBJECTIVE

The purpose of the study was to examine the oncological and functional outcomes of multimodality therapy for patients with advanced malignant maxillary sinus tumors that invaded the orbit.

STUDY DESIGN

Retrospective study.

METHODS

The medical records of 26 patients with orbital invasion were retrospectively analyzed. The patient group consisted of 16 men and 10 women, with a median age of 58 years. The mean follow-up period was 73 months. The most common disease was squamous cell carcinoma. Seven patients had nodal disease. All patients underwent simultaneous combined therapy consisting of conservative surgery through a sublabial incision, radiotherapy, and regional chemotherapy. Patients with nodal disease were treated with either irradiation or selective neck dissection.

RESULTS

The 5- and 10-year overall survival rates were 68% and 51%, respectively. The 5- and 10-year local control rates were 66% and 51%, respectively. Overall survival rates and local control rates were significantly worse in patients with disease other than squamous cell carcinoma. Local control rates were significantly worse in patients with orbital apex disease than in patients without orbital apex disease. All 26 patients, despite orbital involvement, retained their orbital contents. Nineteen of these patients demonstrated adequate ocular function.

CONCLUSIONS

Combined therapy with conservative surgery, radiotherapy, and regional chemotherapy is an effective method for local control and preservation of ocular function. However, performing orbital conservation procedure in patients with disease other than squamous cell carcinoma and with orbital apex disease must be considered carefully.

HPV infections in benign and malignant sinonasal lesions

This review updates the evidence that the human papillomavirus (HPV) is involved in the development of benign and malignant sinonasal lesions. Since the early 1980s, when evidence was provided on the possible involvement of HPV in the aetiology of both benign respiratory papillomas and squamous cell carcinomas, a substantial number of studies have explored this issue. To date, 33.3% of sinonasal papillomas and 21.7% of sinonasal carcinomas analysed have been shown to be positive for HPV. Many elements of the data parallel the observations made in HPV lesions at other mucosal sites, such as malignant transformation and frequent recurrence after radical treatment; the fact that low risk HPV types 6 and 11 are usually confined to benign lesions, whereas the reverse is true for the oncogenic HPV types 16 and 18; and the presence of squamo-columnar junctions and squamous cell metaplasia in the sinonasal system. The discrepancies reported by several studies might result in part from technical reasons, but it is also possible that sinonasal lesions have a heterogeneous aetiology (HPV related and non-related) and/or that some novel (yet unidentified) HPV types exist in these lesions, which are detected by some studies but not by others.

Maxillary cancer in a child: a case report

Cases with maxillary cancer are most frequently found in the 5th to the 7th decades of life, and then rarely occur in adolescence, even less so in a children. One does not expect to encounter this tumor in children, considering that most have a non-epithelial origin. However, we had a case of maxillary squamous cell carcinoma which appeared in a 12-year-old boy. He was initially considered to have sinusitis, and received conservative treatment for a while. After diagnosis, a combination therapy consisting of preoperative irradiation along intra-arterial administration of 5-FU and CBDCA was followed by total maxillectomy and primary reconstruction. Unfortunately about 2 months later, distant metastasis developed along with local recurrence, and the boy died about 1 year 6 months after the initial presentation. The clinical details of this rare case will be discussed in conjunction with some important considerations in dealing with this type of malignancy in a child.

Squamous carcinoma of the external auditory canal: a different approach

Squamous carcinoma of the external ear canal is a rare disease and a challenge to treat. Some controversy exists regarding the best options for treatment. Reported 5-year survival varies between 35% and 63%. Since 1976, we have adopted a conservative approach to these tumours, with patients undergoing a specific protocol of meticulous tumour debulking followed by a course of repeated topical 5-fluoro-uracil (5-FU) cream application and necrotectomy. Data was collected prospectively. From 1976 to 1998, 23 patients underwent primary treatment according to our protocol. Nine patients had T1 disease whereas six had T2 and eight had T3 disease. The 5- and 10-year overall survivals were 74% and 60% respectively. These results compare very favourably with those in the literature and surgical debulking with topical 5-FU and necrotectomy remains our primary treatment of choice for squamous cell carcinoma of the external auditory canal.

Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review

BACKGROUND

The authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review.

METHODS

Two hundred twenty patients who were treated between 1975 and 1994 with a minimum follow-up of 4 years were reviewed retrospectively. A systematic review of published articles on patients with malignancies of the nasal and paranasal sinuses during the preceding 40 years was performed.

RESULTS

The 5-year survival rate was 40%, and the local control rate was 59%. The 5-year actuarial survival rate was 63%, and the local control rate was 57%. Factors that were associated statistically with a worse prognosis, with results expressed as 5-year actuarial specific survival rates, included the following: 1) histology, with rates of 79% for patients with glandular carcinoma, 78% for patients with adenocarcinoma, 60% for patients with squamous cell carcinoma, and 40% for patients with undifferentiated carcinoma; 2) T classification, with rates of 91%, 64%, 72%, and 49% for patients with T1, T2, T3, and T4 tumors, respectively; 3) localization, with rates of 77% for patients with tumors of the nasal cavity, 62% for patients with tumors of the maxillary sinus, and 48% for patients with tumors of the ethmoid sinus; 4) treatment, with rates of 79% for patients who underwent surgery alone, 66% for patients who were treated with a combination of surgery and radiation, and 57% for patients who were treated exclusively with radiotherapy. Local extension factors that were associated with a worse prognosis included extension to the pterygomaxillary fossa, extension to the frontal and sphenoid sinuses, the erosion of the cribriform plate, and invasion of the dura. In the presence of an intraorbital invasion, enucleation was associated with better survival. In multivariate analysis, tumor histology, extension to the pterygomaxillary fossa, and invasion of the dura remained significant. Systematic review data demonstrated a progressive improvement of results for patients with squamous cell and glandular carcinoma, maxillary and ethmoid sinus primary tumors, and most treatment modalities.

CONCLUSIONS

Progress in outcome for patients with nasal and paranasal carcinoma has been made during the last 40 years. These data may be used to make baseline comparisons for evaluating newer treatment strategies.

Treatment outcome of maxillary sinus squamous cell carcinoma

BACKGROUND

Optimal treatment policies of maxillary sinus carcinoma remain to be defined.

METHODS

Seventy-four patients with squamous cell carcinoma of maxillary sinus were treated at Department of Otolaryngology, Asahikawa Medical College between 1983 and 1997. The T classification according to the 1997 International Union Against Cancer was as follows: 9 with T2, 35 with T3, and 30 with T4. Eight patients had lymph node metastasis with N1 at diagnosis. Of 62 patients who started multimodality therapy that comprised preoperative radiochemotherapy including local irradiation with total dose of 50 grays along with concomitant intramaxillary arterial infusion of 5-fluorouracil with total dose of 5000 mg followed by total or partial maxillectomy, 59 received the complete therapy. Eleven patients had to be treated with radiotherapy alone, and 1 patient received postoperative radiotherapy. The median follow-up time for surviving patients was 117 months.

RESULTS

The 5-year overall survival, disease free survival, and local control (LC) rates for all patients were 58.5%, 63.7%, and 73.6%, respectively. The patients who underwent multimodality therapy showed significantly better 5-year overall survival, disease free survival, and LC rates as compared with those who underwent radiotherapy alone (68.5% vs. 9.1%; 73.2% vs. 18.2%; 84.0% vs. 18.2%; P < 0.0001 each). Multivariate analysis revealed that T classification and treatment modality are independent predictors for disease free survival.

CONCLUSIONS

The authors' treatment method, which did not include any complicated techniques, produced higher survival and LC rates because of high effectiveness of multimodality therapy. They concluded that their multimodality therapy could offer a better chance for cure from maxillary sinus carcinoma at many institutions.

Craniofacial resection for paranasal sinus cancers

BACKGROUND

Combined anterior craniofacial resection (CFR) has been in use for more than 25 years. The advent of the free revascularized tissue transfer flap in l980 permitted safe resection of tumors that had spread beyond the confines of the paranasal sinuses with immediate reconstruction of the sino-orbital cranial defect. The purpose of this study was to examine the outcomes and morbidity of a management policy of primary CFR and postoperative radiotherapy for paranasal sinus cancers infiltrating the skull base over a 21-year period.

METHODS

Seventy-three patients with paranasal sinus cancers were treated at the Prince of Wales Hospital between l975 and l996. All were newly diagnosed with the exception of one patient who had received radiotherapy elsewhere 5 years earlier. Only 22% were early lesions and 31% were advanced (more than six sites involved). There were 59 men and 14 women. The mean age was 57 years. All but two patients had a performance status of either 0 or 1. Orbital exenteration was performed in 31 patients. Since l980, all major defects were reconstructed with free tissue transfer flaps.

RESULTS

The 5-year cancer-specific survival (CSS) for the 73 patients was 69%, which was unchanged at 10 years. Twenty two patients died from or with their index cancer. An additional 11 patients died from unrelated causes. The actuarial overall survival (OS) at 5 and 10 years was 61% and 48%, respectively. The 5-year recurrence-free rate was 59%. The CSS for the three dominant pathologic conditions were adenocarcinoma 70%, squamous cancer 51%, and olfactory neuroblastoma 84%. The difference was not significant; however, there was a significant difference in OS, with olfactory neuroblastoma having the best prognosis. Orbital involvement, radiologic evidence of skull base erosion, and involvement of the infratemporal fossa were not poor prognostic indicators. Patients with a performance status of 0 had improved OS. There was no operative mortality.

CONCLUSIONS

An aggressive policy of combined CFR and postoperative radiotherapy with free-flap reconstruction for large defects gave survival results that were comparable to less-advanced lesions and superior to many other treatment alternatives. There was a high exenteration rate (42%). Squamous cancers were associated with the greatest morbidity and poorest OS.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases

BACKGROUND AND PURPOSE

Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution.

MATERIALS AND METHODS

A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110).

RESULTS

The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival.

CONCLUSIONS

This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

Does the combination of radiotherapy and debulking surgery favor survival in paranasal sinus carcinoma?

PURPOSE

To determine the contribution of debulking surgery on local control and survival in paranasal sinus tumors. As most patients present with locally advanced disease, the possibility of radical surgery is limited. Consequently, radiotherapy is often needed as monotherapy or as an adjunct to surgery.

METHODS AND MATERIALS

Between 1977 and 1996, 73 patients (50 male: 23 female) with a paranasal sinus carcinoma were treated. The histology distribution was as follows: squamous cell carcinoma, 55%; adenocarcinoma, 19%; adenoid cystic carcinoma, 11%; and undifferentiated carcinoma, 15%. The clinical T classification was (UICC/TNM 1997): T2 14%, T3 27%, and T4 59%. Pathological neck nodes were found in 11% of patients. Treatment consisted of surgery only in 3, chemotherapy only in 1, radiotherapy only in 18, both surgery and radiotherapy in 50 patients. One patient did not receive any treatment at all. Three patients had concurrent chemotherapy. Median follow-up was 66 months (range, 1-213 months).

RESULTS

Five-year local control (LC) was 65% with combination of radiotherapy and debulking surgery in comparison with 47% with radiotherapy alone, but this difference was not statistically significant (p = 0.58). However, combination treatment gave significantly better 5-year overall survival (OS) (60% vs. 9%; p = 0.001) and 5-year disease-free survival (DFS) (53% vs. 6%; p < 0. 0001). Cox-regression analysis showed that pathologic N status (p = 0.04), palliative intention of treatment (p = 0.018), clinical orbital invasion (p = 0.003), and orbital wall invasion (p = 0.003) were parameters significantly associated with poor local control. Total radiation dose of greater than 65 Gy (p = 0.05) and treatment consisting of radiotherapy alone (p = 0.002) were associated with worse overall survival; for disease-free survival clinical orbital invasion (p = 0.0005), age of greater than 65 years (p = 0.013) and pathologic T4 classification (p = 0.002) were significant factors for an unfavorable outcome. In 19 of 73 patients, 26 serious (mainly ophthalmological) complications were reported; in the majority of these, the visual tract was (partly) included in the treatment fields because of tumor extension. To analyze on which basis patients were selected for the combination therapy, a logistic regression was performed, concluding that clinical T4 classification (p = 0.05), radiological evidence of skull base invasion (p = 0.005), age of greater than 65 years (p = 0.026), radiological evidence of nasopharynx invasion (p = 0.02), clinical suspicion of palate invasion (p = 0.02), and radiological evidence of skin invasion (p = 0.009) were associated with choosing radiotherapy alone.

CONCLUSION

Debulking surgery of paranasal sinus malignancies followed by high-dose radiotherapy to the involved sites was associated with better survival and (although not statistically significant) local control. Patient selection, based on clinical and radiological impression of tumor extension, was the main factor explaining these favorable results. We favor this combination regimen because the surgery gives quick relief of complaints and, at the same time, offers an excellent histologically proven staging method, enabling radiotherapy to be adjusted to the involved sites, thereby decreasing the risk of complications. This can all be achieved with a very low orbital exenteration rate.

Neoadjuvant chemotherapy and radiation for inoperable carcinoma of the maxillary antrum: a matched-control study

A matched-control study comparing standard radiotherapy versus neoadjuvant chemotherapy and radiation was undertaken to clarify the effects of neoadjuvant systemic chemotherapy for locally advanced squamous cell carcinoma of the maxillary antrum. Thirty-four patients with inoperable maxillary cancer were treated with neoadjuvant chemotherapy and radiotherapy (Group II). Before starting radiotherapy, all patients in Group II received two or three cycles of neoadjuvant chemotherapy consisting of cisplatin and a 5-day continuous infusion of 5-fluorouracil with or without intravenous injection of vinblastine. Radiation doses ranged from 66 Gy to 75 Gy (median, 70 Gy). The response rate, patterns of failure, toxicity, and survival for Group II were compared with those for 34 stage-matched patients treated with radiation alone (Group I). Despite a higher response rate to neoadjuvant chemotherapy, the recurrence rate and patterns of treatment failure were not influenced by the addition of neoadjuvant chemotherapy. In most cases, neoadjuvant chemotherapy did not interfere with subsequent radiotherapy, and radiation-induced late complications occurred equally in both treatment groups. After a median follow-up of 48 months, there was no significant difference in 5-year actuarial survival or disease-free survival between the two treatment groups. Radiation alone for inoperable maxillary cancer was clearly suboptimal for improving local control and survival rate, but neoadjuvant chemotherapy in addition to standard radiotherapy failed to demonstrate any therapeutic advantage over radiation alone.

Malignant tumours of the nasal cavity and the paranasal sinuses in a Melanesian population

Malignant tumours of the nasal cavity and paranasal sinuses are usually associated with poor prognosis. From 1986 to 1995, 50 such tumours were managed in Papua New Guinea. Twenty-nine of these arose in the maxillary sinus, 15 in the nasal cavity, four in the ethmoid sinus and two in the frontal sinus. Males were more frequently affected than females. No specific carcinogenic factor was apparent in these patients who were uniformly distributed all over the country. Advanced local disease with multiple symptoms and signs was common during presentation. Systemic and neck node metastases were infrequent. Histopathologically, squamous cell carcinoma was the commonest type of tumour. Satisfactory results were obtained by combination therapy consisting of surgery, irradiation, and systemic chemotherapeutics agents. Better health consciousness and health care delivery system are essential for early diagnosis, regular posttreatment follow-up and improved survival of these patients.

Analysis of long-term results of our combination therapy for squamous cell cancer of the maxillary sinus

Seventy-four patients between 1971 and 1982 in Period I and 32 patients between 1982 and 1987 in Period II with maxillary sinus squamous cell cancer were treated by combination therapy consisting of preoperative LINAC X-ray irradiation with 5-flourouracil intra-arterial chemotherapy followed by maxillectomy and primary reconstruction. In Period II, 21 patients received preoperative cisplatinum (CPPP) microcapsule chemoembolization and pepleomycin (PEP) i.m. and or postoperative CDDP i.v. with PEP i.m. in addition to the combination therapy administered in Period I depending on systemic conditions, tumor stage and histopathological type. Five and 10-year crude survival rates were 68.9% and 55.4%, respectively, for Period I and 71.9% and 56.3% for Period II, with no significant difference between the two trials. In 21 selected patients in Period II, who had additional chemotherapy with preoperative CDDP chemoembolization and/or postoperative i.v. infusion of CDDP with pepleomycin i.m., 5 and 10-year survival rates were 85.7% and 61.9%, respectively.

Surgical salvage after failed radiation for paranasal sinus malignancy

OBJECTIVE

To comment on the role of surgical salvage following failed initial treatment for paranasal sinus malignancy.

DESIGN

A retrospective analysis of one hundred eighty patients treated at The Princess Margaret Hospital, Toronto, from 1976 to 1993.

MATERIALS AND METHODS

Thirty-four of 95 patients (36%) who failed initial treatment underwent surgical salvage. Initial therapy in this group was radiation only (n = 27) and combined therapy (n = 7). Patient, tumor, and surgical data were recorded. There were 23 T4, three T3, six T2, and two T1 carcinomas. Survival, recurrence rates, and the influence of a variety of variables on outcome were analyzed.

RESULTS

Two- and 5-year overall actuarial survival calculated from the date of diagnosis was 54% and 35%, respectively. Two- and 5-year overall actuarial survival calculated from the date of salvage surgery was 44% and 22%, respectively. Advanced age (P < .004), patients with T4 category disease (P < .04), and squamous cell carcinomas (P < .049) correlated with poorer outcome on univariate analysis. Local failure was the most common cause of death (n = 13; 65%).

CONCLUSION

Salvage surgery has a limited role in the management of persistent or progressive disease following failure of initial treatment. Careful postradiation surveillance with endoscopic biopsy under general anesthesia and immediate surgical resection when appropriate may improve the salvage rate.

Ethmoid sinus carcinomas: natural history and treatment results

PURPOSE

This retrospective study was undertaken to assess the clinical features and results of treatment of carcinomas of the ethmoid sinus.

MATERIALS AND METHODS

The records of 34 patients with ethmoid sinus carcinomas treated with curative intent at the U.T.M.D. Anderson Cancer Center (UTMDACC) between January 1969 and December 1993 were reviewed. The age of the patients ranged from 28 to 73 years with a median of 57 years. There were 28 Whites, four Hispanics, one Black and one Asian. A simple staging based on anatomical criteria was used to describe the extent of the disease. Six patients had T1, 13 patients had T2 and 15 patients had T3 disease. Twenty-one patients were treated with surgery plus radiation and 13 patients were treated with radiotherapy alone; nine patients received adjuvant chemotherapy. Radiation was given at approximately 2 Gy per fraction to total doses of 50 Gy preoperatively, 52-66 Gy (median 60 Gy) postoperatively and 50-70 Gy (median 63 Gy) when no surgery was performed.

RESULTS

The actuarial 5-year overall, disease-free and disease-specific survival rates were 55%, 58% and 63%, respectively. The actuarial 5-year local control rate was 71% for the whole group (74% for surgery plus radiation and 64% for radiation alone). Local recurrence occurred in nine patients, nodal relapse occurred in three patients and distant metastases occurred in four patients. Histologically proven dura mater invasion was associated with a poorer local control rate in patients undergoing surgery and radiation. The simple T-staging system used in this study was a good discriminator for local control. Of nine patients receiving chemotherapy, three had complete responses and four had partial responses; six of the seven responders had undifferentiated carcinoma. Severe complications of therapy occurred in patients treated between 1969 and 1984 and consisted mainly of visual impairment and brain necrosis.

CONCLUSIONS

This retrospective review of a large single institutional experience showed that ethmoid sinus carcinomas have a tendency for extensive local invasion but a low propensity for lymphatic and hematogenous spread. Hence, local recurrence was the main cause of cancer-related death. Combined treatment with surgery and postoperative irradiation yielded the highest local control rate. However, radiotherapy alone eradicated two-thirds of primary tumors and, consequently, is a reasonable alternative treatment for patients with medical contraindications to surgery. For patients who underwent surgery and radiotherapy, the presence of histologically proven dura mater invasion was associated with a higher local recurrence rate. Severe radiation complications have been rare with the contemporary radiotherapy technique. Chemotherapy induced excellent responses in undifferentiated carcinoma but its impact on overall disease control is unclear in this small series of patients.

Combined transfacial and neurosurgical approach to malignant tumours of the ethmoid sinus

In order to understand the risks and benefits of a combined transfacial and neurosurgical procedure for neoplasms of the ethmoid sinus, we reviewed all patients who underwent this surgical approach in our department between 1986 and 1994. The study included 41 patients. Pathological diagnoses included adenocarcinoma (31 patients), squamous cell carcinoma (three patients), aesthesioneuroblastoma (three patients), other (four patients). The overall morbidity rate was 39 per cent, and the post-operative mortality rate was 2.5 per cent. Complications were statistically more likely in patients with bone skull base reconstruction. The main carcinologic failures were local recurrences (24 per cent) and metastases (22 per cent). The one-year, three-year and five-year Kaplan Meir survival rates were respectively 84 per cent, 53 per cent and 36 per cent. In conclusion, the mortality and morbidity were acceptable, especially when no bone skull base reconstruction was performed. Better local control justifies a combined procedure with post-operative radiotherapy when tumours involve or reach the skull base.

Ethmoid sinus cancer: twenty-nine cases managed with primary radiation therapy

PURPOSE

To describe the outcome of patients with carcinoma of the ethmoid sinus managed with a policy of primary radiation therapy with surgery for salvage of persistent or progressive disease.

METHODS AND MATERIALS

A retrospective chart review was undertaken of 29 patients with the diagnosis of carcinoma of the ethmoid complex who underwent treatment in the period between January 1976 and December 1994 at the Princess Margaret Hospital. Analysis was confined to those patients with epithelial invasive histology (squamous carcinoma, adenocarcinoma, or undifferentiated carcinoma) managed with curative intent with primary radiation therapy. The median patient age was 62, with a median follow-up time of 4 years. Staging was assigned according to a modification of the UICC 1997 system with 19 (66%) of patients presenting with T4 category tumors. The most common radiation dose regimes were 60 Gy in 30 daily fractions over 6 weeks, or 50 Gy in 20 daily fractions over 4 weeks. Outcome was analyzed with respect to overall survival, cause-specific survival, and local progression-free survival. The influence of a variety of clinical and therapeutic factors on outcome is discussed, the patterns of disease failure are described, and the rationale for this treatment approach is outlined.

RESULTS

The 5-year rates of overall survival, cause-specific survival, and local progression-free survival were 39%, 58%, and 41%, respectively. A total of 18 of 29 patients died during the period of review. Of these, 12 deaths were due to ethmoid cancer, one was due to a second primary lung cancer, and five were attributed to nononcologic causes. No patients died due to treatment-related toxicity. Increasing T category predicted for worse outcome on univariate analysis. Local progression was the major cause of treatment failure and was documented in 15 of 29 patients treated (52%). Six patients were offered salvage surgery for local progression, of whom two remained disease free at 15 and 17 months follow-up.

CONCLUSIONS

Outcome of patients with ethmoid cancer managed with primary radiation therapy with surgery for salvage is comparable to that achieved with planned combined modality approaches. Nevertheless, outcome remains poor and is dependent on the local extent of tumor, with 40-50% of patients eventually succumbing to disease.

Squamous cell carcinoma of the maxillary sinus treated with radiation therapy and conservative surgery

BACKGROUND

For patients with squamous cell carcinoma of the maxillary sinus, combined modality treatment is usually employed, involving radiation and en bloc radical surgery. In this study, local control was analyzed retrospectively in patients who underwent less aggressive piecemeal surgery.

METHODS

Of the 37 patients irradiated between 1973 and 1992, 62% were classified as having T4 lesions. Thirty-two patients underwent surgery and radiation therapy; conventional fractionation radiation therapy was used in most cases. Thirty of these patients underwent piecemeal debulking of their tumors and simultaneous radiation therapy.

RESULTS

Local recurrence free survival at 5 years was 59%, and orbital exenteration was performed on only 1 patient. T classification, the number of operations, and the presence of macroscopic residual disease each had a statistically significant impact on local recurrence. For the patients with macroscopic residual disease, more than 58 gray administered in conventional fractionation appeared to be necessary to improve local control.

CONCLUSIONS

Combined with radiation therapy, conservative surgery with piecemeal debulking was an effective method of treatment for the patients in this study.

Adenocarcinoma of the ethmoid sinus

BACKGROUND

Carcinoma of the paranasal sinuses is rare. The majority of these originate in the maxillary sinus with primary ethmoid carcinomas occurring in up to 20% of cases. Adenocarcinomas comprise up to 50% of the ethmoid malignancy. The relative rarity of tumors originating in this area has led to their inclusion in series that consist mainly of maxillary antral tumors.

METHODS

A retrospective chart review of all patients presenting with primary ethmoid adenocarcinoma at West Virginia University Hospitals between 1988 and 1993 was undertaken. Only patients whose epicenter was believed to be in the ethmoids were included in this analysis. CT scans, MRIs, operative notes, pathology, and final outcome were all analyzed.

RESULTS

Eight patients with primary ethmoid adenocarcinoma were treated during this time span. The male to female ratio was 1:1 with a mean age of 50 years. Symptoms had been present from 3 to 18 months (mean 8 months). All patients underwent craniofacial resection with 5 patients receiving postoperative radiotherapy. Pathologically 4 patients had cribriform plate erosion, 2 had dural involvement, and 1 had extension into the sphenoid sinus. With a mean follow-up of 45 months (9-71 months) 7 patients are disease free and 1 patient has died of disease.

CONCLUSIONS

Obtaining clear margins by craniofacial resection is essential to the management of adenocarcinoma of the ethmoid sinuses. Radiotherapy is reserved for positive margins, cribriform plate penetration, dural invasion, and high-grade lesions that are close to the cribriform plate. Local control was obtained in 87% of our patients.

Lymph node and distant metastases in patients with sinonasal carcinoma

A retrospective analysis of 34 cases of sino-nasal squamous cell or undifferentiated carcinoma in patients admitted between 1984 and 1992 was undertaken. Multimodality therapy incorporated radiation, surgery and chemotherapy. The five-year survival rate was 53 per cent. The local control rate was 82 per cent. Patients died of local failure (six), distant metastases (six), lymph node metastases (one) and other causes (three). Twenty-eight patients with local control were separated into groups: G1-2 (well and moderately differentiated) and G3-4 (poorly differentiated and undifferentiated) and evaluated to find the association between differentiation and metastasis. Lymph node metastasis was not related to the degree of differentiation. Distant metastasis was significantly related to the degree of differentiation (Fisher's exact test: p = 0.007). The result of the combination therapy is poor for patients with poorly differentiated or undifferentiated carcinoma because of distant metastases. Adjuvant chemotherapy may be necessary for them to prevent distant metastasis.

Prognostic factors in paranasal sinus cancer

PURPOSE

This study was designed to evaluate the influence of several different prognostic factors in determining both local recurrence rates and survival in patients treated for carcinoma of the paranasal sinuses.

MATERIALS AND METHODS

A retrospective study of patients treated between January, 1975 and December, 1991 was undertaken. Hospital charts were reviewed collecting demographic, clinical, and radiographic findings, which were correlated with treatment and subsequent follow-up.

RESULTS

Carcinoma of the paranasal sinuses was identified in 129 patients. This included 95 men and 34 women with an average of 59 years. The ethmoid sinus was primarily involved in 50 patients, the maxillary sinus and 49, the nasal sinus and 25, sphenoid sinus in three in the frontal sinus and two patients. Advanced stage (T3/T4) was diagnosed in 60% of patients at presentation. The most commonly encountered histologies were squamous-cell carcinoma and adenocarcinoma. The most accurate predictors of poor prognosis were advanced T stage and involvement of the anterior skill base. Involvement of the posterior wall of the maxillary sinus, infratemporal fossa, and erosion of the orbital wall was not associated with the worst prognosis.

CONCLUSION

In spite of advances in imaging technique and surgical therapy, the primary cause of death is inability to control local disease. Diagnosis at an earlier stage is associated with improved outcome.

A correlation of argyrophilic nucleolar organizer regions with prognoses in patients with maxillary sinus squamous cell carcinoma

Argyrophilic nucleolar organizer regions (AgNORs) were determined by a semiautomatic image analyzer in a group of 28 patients with T2 or T3 maxillary sinus squamous cell carcinoma. The group was separated into recurrent and non-recurrent groups, metastatic and non-metastatic groups, as well as groups strongly or weakly positive for epidermal growth factor receptor (EGFR). The mean number and area of AgNOR dots per nucleus and the mean size of each dot were calculated. The mean number and area were significantly greater than those in normal cells (P < 0.001), but not in recurrent and non-recurrent groups, metastatic and non-metastatic groups and groups separated by EGFR. There was also no difference found in the mean sizes of tumor and normal cells. These results suggest that AgNOR is related to malignant transformation, but not prognosis.

Squamous cell carcinoma of the maxillary sinus and the oral part of the upper jaw. Comparison of treatment results

The treatment results were compared in 77 patients with maxillary sinus squamous cell carcinoma (MC) and 53 patients with squamous cell carcinoma arising from the oral part of the upper jaw (OC). Both sets of patients received radiotherapy alone, or radiotherapy combined with surgery and/or chemotherapy. Computerized tomography was useful for the definition of the treatment volume. Intraarterial chemotherapy was given in 89 of 130 patients and in these patients the total radiation dose was reduced by about 10 Gy. No difference was found in the 5-year survival rate between the MC (65%) and the OC (66%) groups. The cumulative incidence of local failure was higher in MC (36%) than in OC (26%), whereas the ultimate incidence of neck node metastasis was higher in OC (43%) than in MC patients (18%). Half of the inoperable patients (9/18) were older than 80 years and had contraindications to anaesthesia and major surgery. The local recurrence rate was high in the inoperable MC patients (6/8). Contralateral sinus cancers occurred in 4 patients in the MC group.

Analysis of the results of combined therapy for maxillary carcinoma

BACKGROUND

Maxillary sinus carcinomas usually are locally advanced. A wide variety of modalities, including surgery, radiation therapy, and intraarterial chemotherapy, alone or in combination, have been used. However, there is still much controversy with regard to the optimum treatment.

METHODS

From 1972 to 1986, 108 patients with squamous cell carcinoma of the maxillary sinus were treated at the Department of Radiology, University of Tokyo Hospital. From 1972 to 1974 (the first period), the treatment consisted of operation for reduction of tumor volume, daily cleaning of the maxillary antrum, 20 Gy of postoperative radiation therapy, and intraarterial infusion of 1500 mg of 5-fluorouracil (5-FU) and 3000 mg of 5-bromodeoxyuridine (BUdR). From 1975 to 1979 (the second period), the radiation dose was reduced to 10 Gy, and intraarterial infusion of 5-FU and BUdR was not performed. Surgery for reduction of tumor volume and daily cleaning of the antrum played a major role in this period. From 1980 to 1982 (the third period), daily cleaning of the antrum was not performed. Instead, the dose of radiation was increased to 50-60 Gy. From 1983 to 1986 (the fourth period), more extensive surgery to resect the tumor en bloc was introduced. The radiation dose was increased to 70 Gy. Intraarterial infusion of 3750 mg of 5-FU and 120 mg of cisplatin also was administered.

RESULTS

The 5-year survival rate was 46% in the first period, 24% in the second period, 7.2% in the third period, and 53% in the fourth period. In the third period, there were more cases in which death resulted from a cause other than local failure, such as distant metastasis, pneumonia, or secondary primary cancer. Since 1984, we planned treatment with computed tomography (CT) and used the linear accelerator with a multileaf collimator to treat patients with an irregular field of irradiation. These have made it possible to administer radiation therapy in doses as high as 70 Gy without severe complications and improve the survival rate, especially for T4 disease.

CONCLUSIONS

Radiation plays an important role in sterilizing malignant cells that cannot be removed by operation. The dose of radiation should be determined according to the volume of residual tumor. Careful treatment planning is required to irradiate the tumor adequately and reduce complications.

Potential impact on tumor control and organ preservation with cisplatin and 5-fluorouracil for patients with advanced tumors of the paranasal sinuses and nasal fossa. A prospective pilot study

METHODS

Twelve patients with advanced epithelial nonadenocarcinoma of the paranasal sinuses and nasal fossa were treated with three cycles of cisplatin (100 mg/m2, day 1) and 5-fluorouracil (1000 mg/m2/24 hours on days 1-5 by continuous infusion), followed by preoperative external radiation therapy of 48 Gy and limited surgery, clearing the paranasal sinuses and nasal fossa.

RESULTS

After chemotherapy, 11 of 12 patients were free of the previous symptoms of disease. Clinical response rates were different, however, with an overall response rate of approximately 70% with no complete responses. Histopathologic analysis of resected specimens showed no vital tumor in eight patients, minimal microscopic disease in three patients, and infiltrating tumor in one patient. Local control was achieved in 11 of 12 patients. Ten patients are alive with no evidence of disease (mean follow-up, 27 months). Surgical mutilation was avoided, with no functional or cosmetic loss.

CONCLUSIONS

The results of this small pilot study seem to indicate a high chemosensitivity of carcinomas of the paranasal sinuses and nasal fossa, which, in this study, has meant significant relief of symptoms and an unusually high rate of local control (90%) without mutilation.

Carcinoma of the maxillary antrum treated by pre-operative radiotherapy or radical radiotherapy alone

The results of pre-operative radical radiotherapy and subsequent maxillary resection are reported in 54 consecutive patients with carcinoma of the maxillary antrum treated at The Royal London Hospital from 1965 to 1989. The actuarial two and five year survivals were 50.3 per cent and 38.5 per cent respectively. Patients with adenocarcinomas fared better when compared with squamous and undifferentiated carcinomas (log rank p = < 0.01). Undifferentiated carcinoma and involved regional lymph nodes were both very poor prognostic factors. In those patients who were either unfit for or refused maxillary resection, radical radiotherapy alone was still an effective treatment, with only a slight disadvantage in terms of local control and survival.

Maxillary sinus carcinomas: natural history and results of postoperative radiotherapy

Between 1969 and 1985, 73 patients with maxillary sinus cancers underwent surgical excision and postoperative radiotherapy. The clinical stage distribution by the AJC system was 3T1, 16T2, 32T3, and 22T4. Six patients had palpable lymphadenopathy at diagnosis. Surgery for the primary tumor consisted of partial or radical maxillectomy, and if disease stage indicated it, ipsilateral orbital exenteration. This was followed by radiation treatment delivered through a wedge-pair or three-field technique. All but three patients received 50-60 Gy in 2 Gy fractions to an isodose line defining the target volume. Elective neck irradiation was not routinely given. Clinically involved nodes were treated with definitive radiotherapy (five patients) or combined treatment (one patient). Forty-five patients had no evidence of disease at the last follow-up. The 5-year relapse-free survival for the whole group was 51% The overall local control rate was 78%. Patients with larger tumors, particularly if they also had histological signs of nerve invasion, had a higher recurrence rate than others. The overall nodal recurrence rate without elective neck treatment was 38% for squamous and undifferentiated carcinoma, and only 5% for adenoid cystic carcinomas. Therefore, our current recommendation is to deliver elective nodal irradiation routinely to patients with squamous or undifferentiated carcinoma, except for those who have T1 lesions. Treatment complications were vision impairment, brain and bone necrosis, trismus, hearing loss, and pituitary insufficiency. The incidence of major side effects was determined by disease extent and treatment technique. Many technical refinements were introduced in order to limit the dose to normal tissues in an attempt to reduce the complication rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Carcinoma of the nasal cavity and paranasal sinuses: an analysis of radical radiotherapy

A retrospective analysis was conducted of 152 patients with carcinoma of the nasal cavity and paranasal sinuses who were treated with radical radiotherapy between 1975-1984. Stages at presentation were T1 11%, T2 18%, T3 27%, and T4 44%. The median follow-up was 61 months. The overall corrected 5-year survival was 47% and by T stage, T1 86%, T2 82%, T3 49%, T4 25%. Local control was achieved in 45% of cases following radiotherapy. Salvage surgery was attempted in 20 patients where radiotherapy failed and was successful in eight. Nodal disease was present in 6.5% of patients at presentation and 10.5% developed nodal disease after treatment. Nodal disease as sole relapse occurred in four patients and was associated with prolonged survival following radical salvage treatment. Distant metastatic disease occurred in 25 patients and of these 17 (68%) also had locoregional failure. Osteoradionecrosis occurred in three cases, and a further three cases developed bilateral blindness. We conclude that radical radiotherapy achieves results comparable to published data for combined surgery and radiotherapy with acceptable toxicity.

Combined therapy for maxillary sinus carcinoma with special reference to extensive Denker's operation

A statistic analysis of 372 patients with maxillary sinus carcinoma treated between 1972 and 1983 was undertaken. One hundred eight patients were treated with the combined method consisting of 50 Gy irradiation, 2,000 mg 5-FU intraarterial infusion and tumor reduction surgery, the so-called extensive Denker's operation. Two hundred twenty-two patients were treated with the combined method not including extensive Denker's operation, and the other 42 patients with radiotherapy alone. The 5-year survival of these three groups were 48, 43, and 17%, respectively. The cumulative local control of the two groups with and without extensive Denker's operation was 51 and 33%, respectively. Maxillectomy as the second treatment was performed in 24 cases (22%) and 71 cases (32%) of the two groups of the combined method with and without extensive Denker's operation, respectively. On the other hand, 5-year survivors without maxillectomy of the two groups were 41 cases (38%) and 54 cases (24%), respectively. It was concluded that extensive Denker's operation plays an important role to increase the success rate of the initial treatment, decrease the rate of maxillectomy and increase the survival rate although it has a certain limit for the indication.

Symptoms in patients with maxillary sinus carcinoma

Symptoms at first onset and on initial examination were analyzed in 845 patients with maxillary sinus carcinoma. About 20-30 per cent of the patients became aware of swelling of cheek, nasal obstruction, nasal discharge and epistaxis as first symptoms. About 50-80 per cent of the patients complained of such symptoms on initial examination. Symptoms of maxillary sinus carcinoma are similar to those of chronic sinusitis which results in a delay in diagnosis. Such symptoms should be recognized to improve survival rate. CT and MRI scans are useful for early diagnosis and determination of tumour extension. Sinoscopy with biopsy is most important to detect the earliest tumour stage.