Management of sinonasal tumors: prognostic factors and outcomes: a 10 year experience at a tertiary care hospital

Perineural invasion is a poor prognostic factor for sinonasal squamous cell carcinoma

OBJECTIVES

In this study, our primary objective is to elucidate the correlation between sinonasal squamous cell carcinoma (SCC) and perineural invasion (PNI), a topic that has received limited attention in prior literature. Furthermore, we have undertaken an examination of various other clinicopathological factors.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of patients aged ≥ 20 years with newly diagnosed sinonasal cancer and received treatment and care at a tertiary medical center. We excluded patients who did not have an SCC diagnosis, those who underwent palliative surgery, and individuals with insufficient follow-up data at the study endpoint. Ultimately, a total of 49 eligible participants were included in our further analysis.

RESULTS

PNI and advanced T staging were associated with increased risk of local recurrence (LR). Furthermore, PNI was significantly associated with an adverse prognosis in terms of LR-free survival. Participants with PNI had significantly worse overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS). Patients with LR had significantly worse OS, DFS, and DSS.

CONCLUSION

PNI is associated with an elevated risk of LR and reduced OS, DFS, and DSS in patients with sinonasal SCC. These findings can facilitate the formulation of more targeted and effective treatment strategies for sinonasal SCC in clinical practice.

A Clinical Study of Malignant Sino-Nasal Tumors

The sino-nasal cavities represent an anatomical region affected by a variety of tumors with clinical, etiological, genetic and pathological features, which are distinct from tumors commonly encountered in the area of head and neck cancers. We have undertaken this study with the aim of assessing clinical profile, various treatment modalities and outcome of patients with malignant sino-nasal tumors. In this prospective study of two years, done in a rural tertiary care hospital of India, 40 patients with malignant neoplastic tumors of nasal cavity, sinuses and nasopharynx were analyzed for their clinic-pathological and radiological profile and surgical management. The age range found was 10-78 years. There was a significant male preponderance with 23 (57.5%) male patients. Most common histological type seen in our study was Squamous cell carcinoma amongst 32 (80%) of cases. Maximum number of patients were managed with combination therapy of Surgery and Radiotherapy i.e. in 21 patients (52.5%). Multimodality treatment has been deemed the most efficacious choice of treatment which would improve disease free survival for the patients.

Treatment Outcomes of Maxillary Sinus Squamous Cell Carcinoma at a Dedicated Cancer Institute: A Retrospective Study

Introduction

Squamous cell carcinoma arising at the maxillary sinus is a rare neoplasm, characterized by an aggressive growth pattern and glooming prognosis. The proximity of the maxillary sinus with complex anatomical structures such as the eye, skull base, infratemporal fossa, pterygomaxillary fossa, nasal cavities, and ethmoid sinuses makes the surgical treatment of tumors infiltrating into these structures very challenging. The study's objective was to investigate the prognostic factors of survival and maxillary sinus SCC treatment outcomes.

Methods

We did a retrospective analysis of patients treated for maxillary sinus SCC at our institution between 2004 -2018. The study included all the patients with histologically proven maxillary sinus SCC treated with curative intent. The medical record of 43 patients was reviewed and utilized for the analysis. The Kaplan-Meier curve calculated five-year overall survival.

Results

A total of 43 patients were analyzed. At the presentation time, the mean age was 54.56 years (SD ± 11.65). Smoking (n=13, 30.2%) was the common risk factor. 36 (83.7%) patients presented with stage IV disease. Surgery was performed in 16 (37.2%) patients, whereas 27 (62.8%) patients received radiation and chemotherapy. Treatment failure was seen in 35 (81.4%) patients with locoregional recurrence in 30 (85.7%) patients and distant metastases in 5 (14.3%) patients. The five years overall survival in our study was 22%. Loco-regional recurrence and distant metastasis were the significant factors impacting survival (p=0.01).

Conclusion

Maxillary sinus SCC is rare cancer that is more common in males and usually presents at an advanced stage with a poor outcome. These tumors have a higher rate of treatment failure with a poor prognosis. Locoregional recurrence and distant metastasis adversely impact the overall survival.

Characterization of the tumor immune microenvironment of sinonasal squamous-cell carcinoma

BACKGROUND

Treatment and prognosis of sinonasal squamous-cell carcinoma (SNSCC) have not significantly improved despite improvements in radical therapy. Characterization of the tumor immune microenvironment (TiME) may identify patient subgroups associated with disease recurrence, and provide new biomarkers for improved patient stratification and treatment.

METHODS

The TiME was quantitatively evaluated by multiplex immunohistochemistry (mIHC) in archived tissue sections from 38 patients with SNSCC, and were assessed for differences between recurrent (n = 20) and nonrecurrent (n = 18) groups. Hierarchical clustering analyses were performed to identify phenotypic TiME subgroups within the cohort and were used to compare survival outcomes.

RESULTS

Our mIHC analysis revealed increased T-cell populations and decreased myeloid-cell populations in SNSCC patients without recurrent disease, as compared with patients with recurrent disease. Within T-cell subsets, there was a significantly higher percentage of granzyme B⁺ , T-bet⁺ , Eomes⁺ T cells, as well as higher proliferation of CD8⁺ T cells within the nonrecurrent group relative to the recurrent group. Furthermore, immune-cell complexity profiles of SNSCC revealed hyper- and hypo-T-cell-inflamed, myeloid-inflamed, B-cell-inflamed, and broadly hypoinflamed subtypes not previously identified by gene expression analyses. Our study revealed that presence of either hyper- or hypo-T-cell-inflamed TiME subtypes were associated with increased survival outcomes as compared with broadly hypoinflamed TiME subtypes (p = 0.035 and 0.0376, respectively).

CONCLUSIONS

The TiME of SNSCC reveals distinct subtypes, which may correlate with recurrence and survival outcomes.

Comparison of clinicopathological and preoperative computed tomography findings of sinonasal masses

Background and objectives: Computerized tomography (CT) scan with contrast can delineate soft tissue pathologies and is now the first choice in diagnosing sinonasal malignancy and inflammatory lesions. The present study compared the diagnostic nasal endoscopy (DNE) and CT scan to diagnose cases presented with sinonasal mass. Materials and methods: This was a descriptive study conducted on patients with sinonasal masses attending at Government TD Medical College, Alappuzha, Kerala from 1/1/2014 to 30/6/2015. Each patient was examined by diagnostic nasal endoscopy and had undergone preoperative CT scan. Histopathological examination of the specimens was carried out and compared with the findings of DNE and CT scan. Results: A total of 72 cases were enrolled in the study. Age group was from 13-85 years with a male to female ratio of 1.3:1. Nasal obstruction was the commonest symptom. Among the 72 cases, 59 belonged to the non-neoplastic group and 13 to the neoplastic group. Sinonasal polyps (65.3%) formed the majority of the non-neoplastic lesions. Vascular lesions (6.9%) were the commonest benign neoplastic mass and malignancy was seen in 6.9% of cases. Diagnosis by DNE and CT scan was same except in 3 cases. Histopathology and radiological scan result correlated well except in 3 cases. Conclusion: Histopathology still remains the gold standard in the diagnosis of sinonasal masses. Clinical, CT scan and histopathology diagnoses were complementary with each other. However, CT scan is indispensible in studying the anatomical variants and providing the route map prior to and during endoscopic sinus surgeries. IMC J Med Sci 2022; 16(1): 008 *Correspondence: Santhi Thankappan Pillai, Department of Otorhinolaryngology, Government TD Medical College, Vandanam, Alappuzha, Kerala 688005, India. Email: sttpillai@gmail.com

Dysregulation of Translation Factors EIF2S1, EIF5A and EIF6 in Intestinal-Type Adenocarcinoma (ITAC)

Intestinal-type adenocarcinoma (ITAC) is a rare cancer of the nasal cavity and paranasal sinuses that occurs sporadically or secondary to exposure to occupational hazards, such as wood dust and leather. Eukaryotic translation initiation factors have been described as promising targets for novel cancer treatments in many cancers, but hardly anything is known about these factors in ITAC. Here we performed in silico analyses, evaluated the protein levels of EIF2S1, EIF5A and EIF6 in tumour samples and non-neoplastic tissue controls obtained from 145 patients, and correlated these results with clinical outcome data, including tumour site, stage, adjuvant radiotherapy and survival. In silico analyses revealed significant upregulation of the translation factors EIF6 (ITGB4BP), EIF5, EIF2S1 and EIF2S2 (p < 0.05) with a higher arithmetic mean expression in ITAC compared to non-neoplastic tissue (NNT). Immunohistochemical analyses using antibodies against EIF2S1 and EIF6 confirmed a significantly different expression at the protein level (p < 0.05). In conclusion, this work identifies the eukaryotic translation initiation factors EIF2S1 and EIF6 to be significantly upregulated in ITAC. As these factors have been described as promising therapeutic targets in other cancers, this work identifies candidate therapeutic targets in this rare but often deadly cancer.

Outcomes of Management of Sinonasal Malignancies at a Dedicated Cancer Institution: A Retrospective Study

Introduction

Sinonasal malignancies (SNMs) are a rare and heterogeneous group of cancers with an incidence of 3%-5% of all head-and-neck tumours. The aim of the present study was to identify the characteristic features of SNMs and to analyze the treatment outcomes and the prognostic factors affecting it.

Materials and Methods

A retrospective review of patients with SNM treated at a dedicated cancer center of Pakistan between 2004 and 2018 was carried out. All patients with histologically proven diagnosis of malignancy arising from nasal cavity or paranasal sinuses and being treated with curative intent were included. The medical records of 184 cases were utilized for final analysis. Chi-square test was applied to identify significant differences. Five-year disease-specific survival (DSS) was calculated using Kaplan-Meier curve via log-rank test and comparison was made between squamous and nonsquamous histologies. P ≤0.05 was considered statistically significant.

Results

Squamous cell carcinoma was the most common histopathology (n = 62, 33.7%). 130 (70.7%) patients presented with stage IV disease. Nodal metastasis was seen in 24 (13%) patients. Treatment failure was seen in 96 (52.2%) patients and was significantly associated with tumour size and the overall stage. DSS of patients with squamous cell carcinoma was 29% as compared to 52% for patients with nonsquamous histologies (P = 0.001).

Discussion

SNM is a diverse group of cancers presenting in late stages. A higher rate of treatment failure associated significantly with stage of the disease was identified in our study.

The abscopal effect in head-and-neck squamous cell carcinoma treated with radiotherapy and nivolumab: a case report and literature review

Introduction

The abscopal effect is a rarely observed outcome of radiotherapy wherein there is a reduction in metastatic disease burden outside of the targeted treatment area. Likely due to an in situ vaccine effect of radiotherapy, the abscopal effect may be augmented by immunotherapy. This report is the first case of the abscopal effect observed in metastatic head-and-neck squamous cell carcinoma (hnscc) treated with concurrent radiotherapy and single-agent nivolumab.

Case Description

An otherwise healthy 57-year-old man underwent craniofacial resection and adjuvant chemoradiotherapy for advanced sinonasal squamous cell carcinoma. Distant metastatic disease developed shortly after primary treatment, and immunotherapy in the form of nivolumab was initiated. Subsequent oligometastatic progression despite immunotherapy prompted palliative radiotherapy to a single metastasis due to pending symptomatology. Post-radiotherapy, the abscopal effect was observed with all distant sites of metastatic disease shrinking. Five months following treatment, a sustained reduction in disease burden has been demonstrated.

Summary

We present the first case of the abscopal effect in a patient with metastatic hnscc treated with palliative radiotherapy concurrent with single-agent nivolumab immunotherapy, and only the third case of the abscopal effect in metastatic head-and-neck cancer. Dual treatment with immunotherapy and radiotherapy may be an important treatment option in the future, mediated through the abscopal effect.

Paranasal sinus lymphoma: Retrospective review with focus on clinical features, histopathology, prognosis, and relationship to systemic lymphoma

BACKGROUND

Paranasal sinus lymphoma is a rare clinical entity.

METHODS

We conducted a retrospective case series of 68 patients with biopsy-confirmed paranasal sinus lymphoma with attention on systemic disease association.

RESULTS

Of 63 patients with paranasal sinus lymphoma, 35 (56%) had systemic involvement. Four patient groups were identified: (1) primary paranasal sinus lymphoma (44%); (2) systemic disease occurring concurrently with paranasal sinus lymphoma (25%); (3) paranasal sinus lymphoma with relapse of preexisting systemic lymphoma (22%); and (4) progression to systemic disease after primary paranasal sinus lymphoma (8%). Most of the patients with systemic disease were diagnosed at 50 + years and had positive smoking histories. There was a trend toward disease activity in the neighboring ocular location. For patients with preexisting systemic lymphoma, the mean time to paranasal sinus lymphoma was 65 months. When systemic lymphoma developed after localized paranasal sinus lymphoma, mean time to progression was 23 months. Diffuse large B cell lymphoma was the most common paranasal sinus lymphoma.

CONCLUSION

There is a risk of systemic involvement during the disease course of paranasal sinus lymphoma. Biopsy is the preferred first management step and should precede debulking or mass resection in nonemergent cases. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1065-1070, 2017.

Locally advanced paranasal sinus carcinoma: A study of 30 patients

Sinonasal carcinomas (SNcs) are rare neoplasms arising from the paranasal sinuses and nasal cavity. Although these tumours have a heterogeneous histology, they are commonly diagnosed as a locally advanced disease and are associated with a poor prognosis. The present retrospective study reviewed 30 patients with locally advanced SNc, who were treated with surgery followed by chemoradiotherapy or radiotherapy, or radiotherapy with or without concomitant chemotherapy between January 1999 and January 2013 at the Department of Radiation Therapy, University of Naples 'Federico II' (Naples, Italy). A total of 19 patients were treated with upfront surgery followed by adjuvant radio- or chemoradiotherapy (group A), while the remaining 11 patients received exclusive radiotherapy with or without concomitant chemotherapy (group B). Concurrent cisplatin-based chemotherapy (100 mg/m2, days 1, 22 and 43 for 3 cycles) was administered to 34% of patients in group A and 55% of patients in group B. At a median follow-up of 31 months, 33.3% of patients were alive. Cause-specific survival (CSS) and progression-free survival (PFS) times were 32 and 12 months, respectively. No difference in CSS rate was observed between the two treatment groups. Univariate analysis determined that disease stage was the only factor that significantly affected CSS (P=0.002) and PFS (P=0.0001) rates. Acute and chronic toxicities were mild, with only 23.3% of patients reporting G1-2 side effects and no treatment-related blindness. The present study reported moderate activity and efficacy of surgery followed by adjuvant radio- or chemoradiotherapy, and exclusive radiotherapy with or without chemotherapy in this poor prognosis category of patients.

Carcinoma of Maxillary Sinus Masquerading as Odontogenic Infection

Malignant tumours of maxillary sinus are rare. They are usually diagnosed in the late stages when they perforate the sinus walls. The presence of large air space in the maxillary sinus facilitates asymptomatic growth of the sinus malignancy. The clinical presentation of these tumours depends on the sinus wall involved by the disease. The medial wall is usually the first to become eroded, leading to nasal obstruction, epistaxis or discharge. Rarely, symptoms of maxillary sinus carcinoma can resemble dental infection and the affected patients may visit dental clinic seeking treatment. This report presents a case of carcinoma of maxillary sinus mimicking odontogenic infection. Computed tomographic findings explained the reason for the present lesion to masquerade as an inflammatory condition. The importance of advanced imaging modalities for prompt identification of such lesions is discussed.

The pterygopalatine fossa: imaging anatomy, communications, and pathology revisited

Abstract

The pterygopalatine fossa (PPF) is a small, clinically inaccessible, fat-filled space located in the deep face that serves as a major neurovascular crossroad between the oral cavity, nasal cavity, nasopharynx, orbit, masticator space, and the middle cranial fossa. Due to its inherent complex location and connections, it can potentially act as a natural conduit for the spread of inflammatory and neoplastic diseases across the various deep spaces in the head and neck. This review aims to acquaint the reader with the imaging anatomy of the PPF, its important communications, and to identify some major pathological conditions that can involve the PPF, especially in conditions where its involvement can have serious diagnostic and therapeutic implications, such as in perineural tumour spread.

Teaching points

• The PPF is a small neurovascular junction in the deep face with important to-and-fro connections.

• Awareness of anatomy of the PPF and its communications helps to simplify imaging of its pathology.

• Perineural tumour spread is clinically the most important pathology in this region.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.