The role of elective neck dissection in the treatment of maxillary sinus squamous cell carcinoma

Paranasal Sinus and Nasal Cavity Cancers: Systematic Review and Executive Summary of the American Radium Society Appropriate Use Criteria

Tumors of the paranasal sinus and nasal cavity (PNS/NC) are rare and exhibit diverse histology, anatomic subsite, and malignant potential. Early-stage disease is typically managed with surgery, and locally advanced disease is treated with a combination of surgery, radiotherapy, and chemotherapy. Clinical decision-making is commonly guided by limited retrospective evidence. To address this limitation, we performed a systematic review to inform evidence-based consensus for the management of common clinical scenarios, including the potential roles of radiation and systemic therapy to promote structural preservation, elective neck management, and radiation technique considerations. A librarian-mediated literature search identified 39 studies of adult patients with PNS/NC tumors treated with curative intent that met the study inclusion criteria. Search results were reported using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) methodology. A modified-Delphi process was used to guide consensus for the appropriate use of various management strategies. Strong consensus existed for the appropriateness of primary surgery for early-stage disease, approaches to locally advanced disease with minimal periorbital fat invasion, and the use of induction chemotherapy with response-directed local therapy. Consensus regarding nodal treatment and the use of proton therapy in the adjuvant setting was less robust. The rarity and diversity of PNS/NC tumors limit randomized phase III trials to guide management. As such, this systematic review and appropriate-use consensus statements provide clinical guidance for the management of this challenging disease spectrum.

Patterns of Initial Lymph Node Involvement and Recurrence in Patients With Maxillary Sinus Squamous Cell Carcinoma

BACKGROUND

Determining whether to treat the elective cervical lymph node (LN) area remains a dilemma in maxillary sinus squamous cell carcinoma (SCC). This study analyzed the patterns of initial LN involvement and recurrence to guide treatment strategies.

METHODS

We retrospectively reviewed 119 patients with maxillary sinus SCC treated between 2005 and 2023. Patients received definitive concurrent chemoradiotherapy, neoadjuvant therapy followed by local treatment, or upfront surgery with or without adjuvant radiotherapy.

RESULTS

Among 119 patients, 28 (23.5%) had clinical LN involvement at diagnosis, primarily at ipsilateral neck levels I and II. Regional failure occurred in 18 (19.8%) cN0 and 9 (32.1%) cN+ patients, with ipsilateral level II being the most common site. Contralateral failures were frequent in cN+ patients. Distant metastases occurred in 17 patients (14.3%), predominantly in the lungs.

CONCLUSION

Understanding LN involvement and recurrence patterns can refine radiation field design and follow-up strategies in maxillary sinus SCC.

Elective Neck Dissection in cT1-4 N0M0 Head and Neck Spindle Cell Carcinoma

OBJECTIVE

To investigate the survival benefit of elective neck dissection (END) over neck observation in surgically resected cT1-4 N0M0 head and neck spindle cell carcinoma (HNSpCC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2018 hospital-based National Cancer Database (NCDB).

METHODS

Patients with surgically resected cT1-4 N0M0 HNSpCC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were implemented.

RESULTS

Of 815 patients satisfying inclusion criteria, a high proportion were male (72.4%) and white (86.0%) with disease of the larynx (43.8%) classified as high grade (87.7%) and cT1-2 (74.8%). In total, 235 (28.8%) patients underwent END. END utilization between 2006 and 2018 increased for cT1-2 disease (4.0% vs 30.5%, R2 = 0.731) and for cT3-4 disease (15.4% vs 84.6%, R2 = 0.606). In total, 58 (24.7%) ENDs detected occult nodal metastases (ONMs). The 5-year overall survival (OS) of patients undergoing neck observation and END was 62% and 54%, respectively (P = .215). Among patients undergoing END, patients with ONM had worse 5-year OS than those without ONM (38% vs 60%, P < .001). On multivariable Cox regression, END was not associated with OS (adjusted hazard ratio [aHR] 0.74, 95% CI 0.68-1.32, P = .735); ONM (hazard ratio [HR] 2.01, 95% CI 1.29-3.12, P = .002) was associated with worse OS.

CONCLUSION

END is performed in a high proportion (30%) of patients with cN0M0 HNSpCC but is not associated with higher OS. The rate of ONM approaching 25% and the association between ONM and worse OS, however, justify consideration of END in HNSpCC.

LEVEL OF EVIDENCE: 4

Prognostic analysis of elective neck dissection in cT3/T4a/T4bN0 maxillary sinus squamous cell carcinoma

PURPOSE

This study aimed to examine the effect of elective neck dissection (END) on the prognosis of patients with cT3/T4N0 maxillary sinus squamous cell carcinoma (MSSCC).

METHODS

Data were obtained from the SEER database. Patients with cT3/T4a/T4bN0 MSSCC were included in the study and divided into two groups: those who received END treatment and those who did not. Differences between the two groups were assessed using propensity score matching. Cox regression was used to screen patients for independent risk factors. The effect of END on cancer-specific survival (CSS) and overall survival (OS) was explored, and subgroup analyses were performed.

RESULTS

A total of 327 patients with cT3/T4N0 MSSCC were enrolled. After propensity score matching (PSM), patients treated with END showed significant improvement in overall survival (OS) and cancer-specific survival (CSS) compared with those who did not receive END (P < 0.05). In subgroup analyses, the hazard ratio was 0.729 (95% confidence interval: 0.549-0.967), indicating a favourable prognosis for patients receiving END. Certain subgroups of patients benefited significantly from END. These subgroups included patients older than 65 years, Caucasian, male, not receiving radiotherapy, stage T3, grade II and MSSCC with a tumour size of 3-5 cm.

CONCLUSION

END improves survival time and survival outcomes in patients with cT3/T4a/T4bN0 MSSCC, especially in cT3 patients.

Advanced reconstructive techniques following orbital exenteration: The role of LCFA free flaps

BACKGROUND

Orbital exenteration is a severe and disabling surgical procedure that involves the removal of all orbital contents. Effective reconstruction is crucial to managing the resulting defects. This study aims to propose a reconstructive algorithm utilizing free flaps derived from the lateral circumflex femoral artery (LCFA) system for orbital exenteration defects, based on our clinical experience.

PATIENTS AND METHODS

Patients who underwent orbital exenteration and subsequent reconstruction using LCFA-based free flaps between January 2013 and January 2022 were included in this study.

RESULTS

A total of 44 patients underwent orbital exenteration, followed by LCFA free flap reconstruction. The choice of reconstructive technique depended on defect type and dura mater exposure, adhering to the proposed algorithm. The procedures included 20 standard ALT (Anterolateral thigh) flaps, 13 chimeric ALT flaps, 1 SALT chimeric flap with skin grafting, 7 SALT flaps with skin grafting, and 3 buried SALT flaps. Complications were recorded in 10 cases at the recipient site and 2 cases at the donor site.

CONCLUSION

Orbital exenteration presents significant challenges both surgically and reconstructively, with a high risk of local recurrence and postoperative mortality. The reconstruction algorithm using LCFA-based free flaps, as proposed in this study, may guide surgeons in selecting the most appropriate technique, tailored to the specific defect and considering postoperative treatments such as adjuvant radiotherapy.

Recurrent Sinonasal Squamous Cell Carcinoma: Current Insights and Treatment Advances

Squamous cell carcinoma is the most common malignancy affecting the sinonasal tract. Local recurrence is the main pattern of treatment failure, affecting nearly half of patients treated for primary sinonasal squamous cell carcinoma (SNSCC). Due to disease rarity and heterogeneity of practices, there are limited guidelines for how to diagnose and care for these patients. This paper reviews current evidence regarding etiology, pathophysiology, diagnosis, prognostic factors, and treatment modalities of recurrent SNSCC (rSNSCC). Currently, salvage surgery offers the only durable approach for eligible patients. These resections often require robust reconstructive options due to prior surgery or radiation. Chemoradiation is offered as an adjuvant or palliative approach when surgery is not a feasible option. Emerging options such as immunotherapy and particle therapy remain an area of ongoing investigation.

Cancer of the paranasal sinuses in Germany: Data on incidence and survival from a population-based cancer registry

PURPOSE

This study aims to provide a broad overview of the epidemiology of cancer of the paranasal sinuses (PSC) in Germany. The data include information on incidence, staging, clinicopathological features and survival from one of the largest cancer registries in Europe.

METHODS

Population-based data on PSC diagnosed from January 1st, 2009 until December 31st, 2019 were retrieved from the German Centre for Cancer Registry Data (ZfKD). Age standardized incidence was calculated and relative survival estimates were computed by sex, histological subtype, age group and T-, N-, and M-Stage.

RESULTS

In total, 3975 cases were included in this study. The age-adjusted incidence rate (ASR) for PSC was 0.3/100,000 which remained stable during the observation period. The most frequent tumor localization was the maxillary sinus (41.9 %) and the most common histological subtype was keratinizing squamous cell carcinoma (kSCC) (44.3 %). All subtypes were predominantly found in the maxillary sinus except for adenocarcinoma and neuroendocrine carcinomas (SNEC), which were most frequently located in the ethmoidal sinus. The majority of the patients with a known T stage was diagnosed in tumor stage T4 (60.8 %). The overall 5-year relative survival (RS) for all patients with PSC was 52 %. RS dropped from 93 % for T1 stage tumors to 39 % for T4 tumors. RS was 58 % for N0 and 31 % for N+ cases, 54 % for M0 and 27 % for M1 cases.

CONCLUSION

Age-adjusted incidence for PSC is low and has been stable for the observed 11-year period. RS decreases continuously with increasing T-, N- and M-stage.

Elective Neck Dissection in cT1-4 N0M0 Head and Neck Basaloid Carcinoma

OBJECTIVE

To investigate the survival benefit of elective neck dissection (END) over neck observation in surgically resected cT1-4 N0M0 head and neck basaloid carcinoma (HNBC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 hospital-based National Cancer Database.

METHODS

Patients with surgically resected cT1-4 N0M0 HNBC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were implemented.

RESULTS

Of 857 patients satisfying inclusion criteria, the majority were male (77.0%) and white (88.1%) with disease of the oral cavity (21.5%) or oropharynx (42.9%) classified as high grade (76.9%) and cT1-2 (72.9%). 389 (45.4%) patients underwent END. END utilization between 2006 and 2017 increased for cT1-2 disease (33.3% vs 56.9%, R2 = .699) but remained relatively constant for cT3-4 disease (66.7% vs 57.9%, R2 = .062). One-hundred and fifteen (29.6%) ENDs detected occult nodal metastases (ONMs). The 5-year overall survival (OS) of patients undergoing neck observation and END was 65.6% and 66.8%, respectively (P = .652). END was not associated with improved OS in survival analyses stratified by patient demographics, clinicopathologic features, and adjuvant therapy. Compared with surgery alone, adjuvant radiotherapy (adjusted hazard ratio: 0.74, 95% confidence interval [CI]: 0.57-0.97, P = .031) was associated with improved OS. END (hazard ratio [HR]: 0.96, 95% CI: 0.71-1.28, P = .770) and ONM (HR: 1.12, 95% CI: 0.78-1.61, P = .551) were not associated with OS.

CONCLUSION

END is performed in nearly half of patients with HNBC but is not associated with improved OS, even after stratifying survival analyses by patient demographics, clinicopathologic features, and adjuvant therapy. The rate of ONM approaching 30%, however, justifies inclusion of END in the surgical management of HNBC.

Role of elective neck dissection in cT2N0 maxillary sinus squamous cell carcinoma

Our objective was to examine the impact of elective neck dissection (END) on the prognosis of patients with cT2N0 maxillary sinus squamous cell carcinoma (MS-SCC) and to determine factors that predict the occurrence of occult metastasis in this patient population. A retrospective analysis was conducted using data from the SEER database. Patients with cT2N0 MS-SCC were included in the study and divided into two groups: those who received END and those who did not. The impact of END on disease-specific survival (DSS) and overall survival (OS) was assessed using propensity score matching. Multivariate logistic regression analysis was performed to determine predictors for occult metastasis. A total of 180 patients were included in the study, with 40 cases receiving END. Following propensity score matching, patients treated with END and those without showed similar DSS and OS rates. Occult metastasis was observed in 9 patients, corresponding to a rate of 22.5%. High-grade tumors were independently associated with a higher risk of occult metastasis compared to low-grade tumors (hazard ratio 1.52, 95% confidence interval 1.17-2.00). cT2 MS-SCC carries an occult metastasis rate of 22.5%, with histologic grade being the primary determinant of occult metastasis. END does not confer a significant survival benefit in this patient population.

What is the rate of occult nodal metastasis in squamous cell carcinomas of the sinonasal tract? A systematic review

OBJECTIVE

The role of elective neck dissection (END) in the management of clinical N0 (cN0) squamous cell carcinomas (SCC) of the sinonasal tract is unclear. In this systematic review, we evaluate the risk of occult nodal metastasis in sinonasal SCCs with cN0M0 tumors to support clinical decision making.

METHODS

A literature search was conducted in the following three electronic databases: Medline/PubMed, ScienceDirect, and Google Scholar. Articles were assessed for eligibility in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Two independent authors extracted the data. The Methodological Items for Non-Randomized Studies (MINORS) tool was used for the assessment of biases of each included study.

RESULTS

Our systematic review included six studies that met the inclusion criteria, all retrospective in design. The rate of histologically proven metastasis of sinonasal SCC to the clinically negative neck is 12.5%. Almost half of the positive cases are pathologically staged as N2 (6.5%).

CONCLUSION

Our systematic review provides the rate of sinonasal SCC occult metastasis to the neck so that the surgeons can discuss with patients the risks and possible merits of adding an elective neck management in the surgical plan.

Elective neck dissection versus elective neck irradiation in cT3/4N0 maxillary sinus squamous cell carcinoma: a propensity score matching analysis

BACKGROUND

Maxillary sinus squamous cell carcinoma (MS-SCC) is an infrequent malignancy, and determining the optimal neck management for patients with cT3/4N0 MS-SCC remains a topic of ongoing debate. The purpose of this study was to compare the prognoses and quality of life outcomes of patients who underwent either elective neck dissection (END) or elective neck irradiation (ENI) for cT3/4N0 MS-SCC.

METHODS

In this retrospective study, we enrolled patients with surgically treated cT3/4N0 MS-SCC, and the impact of different neck management strategies on regional control and disease-specific survival was compared using propensity score matching. The effect of surgical intervention on quality of life was evaluated using the Mann-Whitney U test.

RESULTS

Of the 120 patients included, 36 underwent END. After propensity score matching, our analysis indicated that END did not lead to superior outcomes than ENI, as demonstrated by comparable rates of regional control (p = 0.990) and disease-specific survival (p = 0.999). However, in the 70 returned questionnaires, patients who underwent END reported higher scores in the domains of appearance, chewing, and speech than did patients who underwent ENI.

CONCLUSIONS

Our findings suggest that while END and ENI contribute to similar prognoses, END yields superior functional outcomes.

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.

Role of elective neck dissection in prognosis of N0M0 maxillary sinus squamous cell carcinoma: Insights from SEER database analysis

BACKGROUND

The optimal management of cervical lymph nodes in N0M0 maxillary sinus squamous cell carcinoma (MSSCC) remains a subject of debate. This study aimed to investigate the impact of elective neck dissection (END) on the prognosis of N0M0 MSSCC patients and explore potential prognostic factors.

METHODS

A retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was employed to minimize bias between the END and non-END groups. Cox regression analysis was performed to identify prognostic factors, and subgroup analyses were conducted based on patient characteristics. Furthermore, the optimal number of lymph nodes in END was determined using maximally selected test statistics.

RESULTS

A total of 777 N0M0 MSSCC patients were included in the study. After PSM, patients who underwent END demonstrated significantly improved overall survival (OS) and cancer-specific survival (CSS) compared to those who did not undergo END (p < 0.05). Subgroup analyses revealed a favorable prognosis for patients receiving radiotherapy and END, with a hazard ratio of 0.729 (95% CI: 0.549-0.967; p = 0.029) for OS. Furthermore, patients with a lymph node count greater than 5 in END had significantly better OS and CSS compared to those with 5 or fewer lymph nodes (p = 0.013, p = 0.018, respectively).

CONCLUSION

Our findings suggest that END provides a survival benefit for N0M0 MSSCC patients. Additionally, a lymph node count greater than 5 in END is associated with improved staging accuracy and better prognosis. Prospective research is needed to validate these findings and inform clinical decision-making for N0M0 MSSCC patients.

Elective Neck Dissection for cT1-4 N0M0 Head and Neck Verrucous Carcinoma

OBJECTIVE

To investigate the survival benefit of elective neck dissection (END) over neck observation in cT1-4 N0M0 head and neck verrucous carcinoma (HNVC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 National Cancer Database.

METHODS

Patients with surgically resected cT1-4 N0M0 HNVC were selected. Linear, binary logistic, Kaplan-Meier, and Cox proportional hazards regression models were utilized.

RESULTS

Of 1015 patients satisfying inclusion criteria, 223 (22.0%) underwent END. The majority of patients were male (55.4%) and white (91.0%) with disease of the oral cavity (67.6%) classified as low grade (90.0%) and cT1-2 (81.8%). The minority of ENDs (4.0%) detected occult nodal metastases. The rate of END increased from 2006 to 2017 for both cT1-2 (16.3% vs 22.0%, p = .126, R2  = 0.405) and cT3-4 (41.7% vs 70.0%, p = .424, R2  = 0.232) disease but these trends were not statistically significant. Independent predictors of undergoing END included treatment at an academic facility (adjusted odds ratio [aOR]: 1.75, 95% confidence interval [CI]: 1.19-2.55), cT3-4 disease (aOR: 3.31, 95% CI: 2.16-5.07), and tumor diameter (aOR: 1.09, 95% CI: 1.01-1.19) (p < 0.05). The 5-year overall survival (OS) of patients treated with and without END was 71.3% and 70.6%, respectively (p = .661). END did not significantly reduce the 5-year hazard of death (adjusted hazard ratio: 1.25, 95% CI: 0.91-1.71, p = .172). END did not significantly improve 5-year OS in univariate and multivariate analyses stratified by several patient, facility, tumor, and treatment characteristics.

CONCLUSION

END does not confer an appreciable survival benefit in HNVC, even after stratifying univariate and multivariate analyses by several patient, facility, tumor, and treatment characteristics.

LEVEL OF EVIDENCE

Level 4.

Sinonasal malignancies: histopathological entities, regional involvement and long-term outcome

BACKGROUND

To assess a large patient cohort with sinonasal malignancies focusing on regional involvement, recurrence and oncological outcome.

METHODS

Patients (n = 144) with malignant tumors of the nasal cavity and paranasal sinuses were treated at our tertiary referral center between 2008 and 2019. A chart review on patient and tumor characteristics, treatment and long-term outcome was performed.

RESULTS

Most frequent histological types were squamous cell carcinoma (SCC) (n = 74), adenocarcinoma (n = 24) and mucosal melanoma (n = 18). Primary therapy was surgery in 66% of patients (n = 95) of which 65.8% (n = 66) received adjuvant radiotherapy. Twenty patients (13.8%) were initially staged as cN + and in seven cases, pN + status was histopathologically confirmed. Fifty-six of 130 patients (43.1%) had a relapse after curative intended therapy, including nine loco-regional (6.9%) and seven isolated regional recurrences (5.4%). Twelve of these 16 patients with (loco-)regional recurrence had SCC. Adenoid cystic carcinoma (87.5%) and SCC (65.3%) showed the best long-term overall survival.

CONCLUSIONS

Regional involvement and regional recurrence are scarce. Because of rarity and heterogeneity, evidence on therapeutic management is sparse resulting in the lack of clinical guidelines.

The role of elective neck dissection in T1 and T2 nasal cavity squamous cell carcinomas

PURPOSE

To evaluate the role of elective neck dissection (END) on oncological outcome in early-stage nasal cavity squamous cell carcinomas (SCCs).

METHODS

In total, 87 patients with T1 (n = 59; 67.8%) and T2 (n = 28; 32.2%) SCCs were evaluated regarding performance of END, regional recurrences (RR) and its impact on cancer-specific survival (CSS). We further created a risk score based on T-classification, tumor subsite and grading to identify patients whom may benefit from END and calculated the corresponding numbers needed to treat (NNT) to prevent RR.

RESULTS

Nine (10.3%) patients experienced RR of whom 3 (5.1%) were T1 and 6 (21.4%) T2 tumors (p = 0.042). All RR originated from moderately or poorly differentiated (G2-G3) SCCs of the nasal septum or vestibule. END was done in 15 (17.2%) patients and none of those experienced RR (p = 0.121). Onset of RR represented the worst prognostic factor for CSS (HR 23.3; p = 0.007) with a 5y-CSS of 44.4% vs. 97.3% (p < 0.001). RR occurred in none of the patients with no or low risk scores compared to 31.6% (6/19) in patients with high-risk scores (p = 0.006). Accordingly, three high-risk patients would need to undergo END (NNT 2.63) to prevent RR compared to a NNT of 8 for the whole cohort.

CONCLUSIONS

Although rare, occurrence of RR significantly deteriorates outcome in early stage nasal cavity SCCs, which could be effectively reduced by performance of END. The importance of END is currently underestimated and our proposed risk score helps identifying those patients who will benefit from END.

Imaging Recommendations for Diagnosis, Staging, and Management of Sinonasal Tumors

Sinonasal tumors are a relatively rare and heterogeneous group of tumors. Owing to their nonspecific presentation and rarity, they can be potentially overlooked resulting in delayed diagnosis and management, and increased patient morbidity. Imaging is crucial for the detection, staging, surgical planning, follow-up as well as surveillance of sinonasal masses, wherein computed tomography (CT) and magnetic resonance imaging (MRI) play complementary roles. CT is better at depicting bony changes, while MRI is useful for delineating the extent of soft tissue lesion, detect perineural, intracranial, or intraorbital spread as well as differentiate trapped sinus secretions from tumor tissue. Other modalities like fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and arteriography can be selectively employed. FDG-PET is useful for metastatic workup and detection of residual/ recurrent disease. Arteriography and endovascular image-guided interventions are useful to delineate supply of vascular tumors and perform preoperative embolization. A systematic evidence-based approach to a possible case of sinonasal tumor can go a long way in streamlining the detection and management of these tumors, while optimizing the use of available healthcare resources.

Ectopic Primary Olfactory Neuroblastoma: Case Series and Literature Review

OBJECTIVE

Olfactory neuroblastoma (ONB) is a rare malignant tumor arising in the upper nasal cleft. Rarely, ONB may originate in ectopic sites and the impact of this on prognosis and treatment strategies continues to be debated.

METHODS

A retrospective analysis was undertaken of patients with ectopic ONB treated between 2000 and 2020 in a tertiary-care referral center for skull base tumors. Three patients were included in this analysis: a 37-year-old woman with ONB arising from the bulla ethmoidalis; a 28-year-old man with inappropriate secretion of antidiuretic hormone caused by a maxillary sinus ONB; and a 41-year-old man with lacrimal sac ONB. Preoperative workup, surgical approach, adjuvant treatments and postoperative surveillance were analyzed. Relevant literature published between 2000 and January 2021 was fully reviewed to investigate oncologic outcomes and delineate the standard of care for such rare tumors.

RESULTS

All patients were treated via endoscopic endonasal resection with radical intent, followed by adjuvant treatments when required. No recurrences of disease were observed after a mean follow-up time of 32 months (range, 12-60 months). Data emerging from the literature suggest that a multidisciplinary treatment approach, including free-margins surgical resection followed by adjuvant radiotherapy or radiochemotherapy, is recommended. Olfactory bulb and dura preservation should be attempted whenever feasible.

CONCLUSIONS

Endoscopic endonasal surgery should be preferred, when possible, to achieve complete excision to minimize patients' morbidity. The ectopic site of origin affects prognosis and should be considered when selecting the appropriate multimodal treatment strategy.

Sinonasal Squamous Cell Carcinoma, a Narrative Reappraisal of the Current Evidence

Simple Summary

Sinonasal squamous cell carcinomas are a group of diverse tumors affecting the nasal cavity and paranasal sinuses. As a direct consequence of their rarity and heterogeneity, diagnosis is challenging, and treatment does not follow universally accepted protocols. Though surgery represents the mainstay of treatment, neoadjuvant and adjuvant therapies have pivotal roles in improving outcomes of patients treated with curative intent. Indications to endoscopic surgery have been expanding over the last three decades, but a considerable number of patients affected by sinonasal squamous cell carcinoma still need open surgical procedures. Management of the neck in patients affected by sinonasal squamous cell carcinoma is controversial. Curative-intended treatment of recurrent and/or metastatic tumors, alongside palliation of uncurable cases, represent poorly explored aspects of this disease.

Abstract

Sinonasal squamous cell carcinoma is a rare tumor affecting the nasal cavity and paranasal sinuses. Several aspects of this disease, ranging from epidemiology to biology, pathology, diagnosis, staging, treatment, and post-treatment surveillance are controversial, and consensus on how to manage this sinonasal cancer is lacking. A narrative literature review was performed to summarize the current evidence and provide the reader with available data supporting the decision-making process in patients affected by sinonasal squamous cell carcinoma, alongside the authors’ personal opinion on the unsolved issues of this tumor. The review has highlighted several advances in molecular definition of epithelial cancers of the sinonasal tract. Surgery represents the pivot of treatment and is performed through an endoscopic transnasal approach whenever feasible. Open surgery is required for a large proportion of cases. Reconstruction of the defect follows principles of skull base and cranio-maxillo-facial reconstruction. Chemotherapy is given as neoadjuvant treatment or concomitantly to radiotherapy. Photon-based radiation therapy has a crucial role in the adjuvant setting. Particle therapy is providing promising results. Management of the neck should be planned based on the presence of clinically appreciable metastases, primary tumor extension, and need for recipient vessels. Biotherapy and immunotherapy are still underexplored therapeutical modalities.

Elective neck dissection for T3/T4 cN0 sinonasal squamous cell carcinoma

BACKGROUND

In locally advanced sinonasal squamous cell carcinoma (SNSCC), management of the clinically node-negative (cN0) neck is variable and elective neck dissection (END) remains controversial.

METHODS

Patients with surgically treated T3/T4 cN0 M0 SNSCC were identified using the NCDB. Overall survival (OS) was assessed by Cox proportional hazard analysis in propensity score-matched cohorts. Factors associated with END were evaluated with logistic regression.

RESULTS

Two hundred twenty patients underwent END (19.6%). END did not correlated with OS in propensity score-matched cohorts (HR 0.971, 95% CI 0.677-1.392), a maxillary sinus tumor subgroup (HR 1.089, 95% CI 0.742-1.599), or by radiation status [radiation: (HR 0.802, 95% CI 0.584-1.102); no radiation: (HR 0.852, 95% CI 0.502-1.445)]. The occult metastasis rate in the END cohort was 12.7%.

CONCLUSION

END did not significantly improve OS in this study. Further information on disease-free survival is necessary to determine its role in advanced-stage SNSCC.

Prognostic value of the pretreatment albumin:globulin ratio combined with adult comorbidity evaluation 27 and TMN staging in patients with squamous cell carcinoma of the maxillary sinus

The albumin:globulin (A:G) ratio, adult comorbidity evaluation 27 (ACE-27), and TMN staging have been shown to be strong predictive indicators of the survival of patients with many types of tumours. We have investigated the prognostic value of pretreatment based on the A:G ratio combined with TMN staging and ACE-27 in patients with squamous cell carcinoma (SCC) of the maxillary sinus. We studied 196 patients, and the prognostic value was explored by univariate and multivariate Cox's hazards analysis. Multivariate analyses suggested that pretreatment A:G ratio was independently associated with overall survival (hazard ratio (HR) 1.542, 95% CI 1.219 to 1.991, p=0.002); disease-specific survival, (HR 1.499, 95% CI 1.197 to 1.842, p=0.001); and disease-free survival (HR 1.452, 95% CI 1.207 to 1.834, p<0.001). Additional prognostic factors shown in the survival analyses included ACE-27, pathological T stage, and pathological N stage. Pretreatment A:G ratio combined with ACE-27 and TMN staging were powerful prognostic indicators of outcome in patients with SCC of the maxillary sinus, which has potentially important ramifications for stratification of the disease in the future.