Update from the 4th Edition of the World Health Organization Classification of Head and Neck Tumours: Tumors of the Nasal Cavity, Paranasal Sinuses and Skull Base

Primary cutaneous adenoid cystic carcinoma metastasising to the kidney

Adenoid cystic carcinoma (ACC) is a rare head and neck cancer; even more infrequently, it presents as a primary lesion at other sites. Due to ACC's usual pattern of perineural and perivascular spread, it often manifests in delayed local recurrence and distant metastases. Metastasis to the kidney is very rare with as few as 15 cases reported in the literature. This report presents the case of a woman in her 60s with a history of a cutaneous ACC and a singular lesion in her left kidney that was treated with radical nephrectomy. Histopathology showed complete resection of metastatic ACC. To the best of the authors' knowledge, this is the only documented case of primary cutaneous ACC metastasising to the kidney.

SMARCB1/INI-1-Deficient sinonasal carcinoma demonstrates a poor prognosis but favorable clinical outcomes after PD-1/PD-L1 inhibitor therapy: A case series

Despite advances in multimodal cancer therapy, such as combining radical surgery with high-intensity chemoradiotherapy, for SMARCB1/INI-1-deficient sinonasal carcinoma (SDSC), the prognosis of patients remains poor. Immunotherapy is gaining increasing popularity as a novel treatment strategy for patients with SMARCB1/INI-1-deficient tumors. Herein, we report on the management of three patients with SDSC who received PD-1/PD-L1 inhibitor therapy as a part of multimodal therapy based on surgery and chemoradiotherapy. All three patients survived and demonstrated good clinical remission and disease control. To our knowledge, this is the first case series reporting the use of immunotherapy to improve clinical outcomes in neoadjuvant, adjuvant, and late first-line stages of treatment in patients with SDSC. Furthermore, we reviewed the relevant literature and further explored the correlation between SMARCB1/INI-1 deletion and immunotherapy.

Biphenotypic Sinonasal Sarcoma: Literature Review of a Peculiar Pathological Entity-The Neurosurgical Point of View

BACKGROUND

Biphenotypic sinonasal sarcoma (BSNS) is a low-grade tumor of the sinonasal tract with frequent extension to the orbit and skull base. Due to its rare incidence and recent histopathological and molecular characterization, little data are available in regard to its natural history, treatment and surveillance protocol.

METHODS

A comprehensive literature review in Embase online electronic databases on BSNS was made. The analyzed factors included the patients' sex and age, presenting symptoms and signs, anatomical origin and pattern of growth of the tumor, immunohistochemical and molecular features, time to treatment, type of treatment, surgical approach, extent of resection, peri- and post-operative complications, adjuvant therapies, clinical outcome, recurrence and overall survival rates.

RESULTS

This literature review involved 34 studies for an overall series of 149 cases of BSNS. The female (66.9%) and middle-aged populations (median 54.88 years old) were mainly affected. The most frequent clinical onset was nasal obstruction (81%), followed by facial discomfort (44%), epistaxis (15.5%) and ocular impairment (14.3%). Ethmoid sinus (67.8%) and nasal cavity (45.4%) were the most common anatomical site of tumor origin, while an extension to the orbit and skull base was registered in 28.7% and 24.5% of cases. Surgery was the main treatment, especially in the form of endoscopic endonasal approach (56.9%), and allowed for gross total resection in 79% of cases. The recurrence rate was 26.2%; three cases of tumor-related death were reported. Median follow-up was 4.6 years.

CONCLUSIONS

Biphenotypic sinonasal sarcoma is a rare and unique tumoral entity in terms of biological and clinical behavior. Based on the current knowledge, surgery plays the leading role in treatment, accounting for gross total tumor resection in most cases, allowing for clinical symptom and sign resolution and presenting a low rate of perioperative complications. The type of approach and the aim of surgery should be assessed case by case according to patient and pathology features and the surgeon's experience, as well as the aim of the treatment. Further studies including large surgical series and with long follow-up are required to define prognostic factors and guidelines of treatment for this peculiar pathological entity.

Sinonasal Tumors: What the Multidisciplinary Cancer Care Board Wants to Know

Sinonasal neoplasms are a remarkably heterogeneous group, reflecting the numerous tissue types present in the nasal cavity and paranasal sinuses. These entities can be relatively benign (ie, respiratory epithelial adenomatoid hamartoma) or can be exceedingly aggressive (ie, NUT carcinoma). Certain sinonasal tumors have a propensity to spread through local invasion and destruction, while others have a high likelihood of perineural spread. The genetic and molecular mechanisms underlying sinonasal tumor behavior have recently become better understood, and new tumor types have been described using these genetic and molecular data. This has prompted an expansion in the number of tumors included in the World Health Organization fifth edition classification system for head and neck tumors, along with a new classification structure. Radiologists' familiarity with this classification structure is crucial to understanding the expected behavior of these tumors and to collaboration with the multidisciplinary cancer care board in making decisions for optimal patient care. ©RSNA, 2024.

Biphenotypic Sinonasal Sarcoma with Orbital Invasion: A Literature Review and Modular System of Surgical Approaches

Background: Biphenotypic sinonasal sarcoma is a rare low-grade tumor arising from the sinonasal tract, featuring locally aggressive biological behavior, with a tendency to invade the orbit and skull base. There are no defined guidelines of treatment; thus, the management varies among different institutions. The aim of the present study is to provide a modular system of surgical approaches according to the lesion pattern of growth from a literature review. Materials and Methods: A comprehensive and detailed literature review on the PubMed and Embase online electronic databases on biphenotypic sinonasal sarcoma with orbital invasion was conducted. A personal case exhibiting peculiar features was also added. Demographic (patient's sex and age), clinical (presenting symptoms and time to treatment), neuroradiological (anatomical origin and pattern of growth), and treatment (type of treatment, surgical approach, extent of resection, peri- and postoperative complications, and adjuvant therapies) data, as well as clinical outcome, recurrence rates, and overall survival, were analyzed. Results: Thirty-one patients harboring biphenotypic sinonasal sarcoma with orbital invasion were identified. Tumors mainly affected female patients (66.7%) and a middle-aged population (median 55.2 years old). Simultaneous skull base involvement occurred in most cases (80.6%). Surgery was performed in all but one case (97%), as unique treatment (59%) or in association with radio-(23.5%) and/or chemotherapy (5.9%/2.9%), allowing for gross total tumor resection in most cases (66.7%). The endoscopic endonasal approach was the most adopted surgical corridor (51.7%). The local recurrence rate was 19.3%, and only two cases of tumor-related mortality occurred. Conclusions: Surgery is the only curative treatment, with the main goal to restore/improve/arrest progression of clinical manifestations. The endoscopic endonasal route represents the master approach for lesions confined to the midline. Microsurgical transcranial and endoscopic transorbital approaches have a complementary role for addressing the lesion's component with large intracranial extension or affecting the paramedian aspect of the anterior cranial fossa and superior-lateral orbital compartment, respectively. The approach selection should be made case by case according to the tumor pattern of growth.

Integrated Molecular and Histological Insights for Targeted Therapies in Mesenchymal Sinonasal Tract Tumors

PURPOSE OF REVIEW

This review aims to provide a comprehensive overview of mesenchymal sinonasal tract tumors (STTs), a distinct subset of STTs. Despite their rarity, mesenchymal STTs represent a unique clinical challenge, characterized by their rarity, often slow progression, and frequently subtle or overlooked symptoms. The complex anatomy of the sinonasal area, which includes critical structures such as the orbit, brain, and cranial nerves, further complicates surgical treatment options. This underscores an urgent need for more advanced and specialized therapeutic approaches.

RECENT FINDINGS

Advancements in molecular diagnostics, particularly in next-generation sequencing, have significantly enhanced our understanding of STTs. Consequently, the World Health Organization has updated its tumor classification to better reflect the distinct histological and molecular profiles of these tumors, as well as to categorize mesenchymal STTs with greater accuracy. The growing understanding of the molecular characteristics of mesenchymal STTs opens new possibilities for targeted therapeutic interventions, marking a significant shift in treatment paradigms. This review article concentrates on mesenchymal STTs, specifically addressing sinonasal tract angiofibroma, sinonasal glomangiopericytoma, biphenotypic sinonasal sarcoma, and skull base chordoma. These entities are marked by unique histopathological and molecular features, which challenge conventional treatment approaches and simultaneously open avenues for novel targeted therapies. Our discussion is geared towards delineating the molecular underpinnings of mesenchymal STTs, with the objective of enhancing therapeutic strategies and addressing the existing shortcomings in the management of these intricate tumors.

Our Experience with Sinonasal Glomangiopericytoma in North India: A Case Series

Glomangiopericytoma (GPC) is a rare benign sinonasal tumor originating from Zimmerman's Pericytes surrounding capillaries and accounting for less than 0.05% of all sinonasal tumors. Glomangiopericytoma has low malignant potential (5-10%) and is mostly diagnosed in the 6th or 7th decade of age with slight female preponderance. We presented here a case series of 5 patients with sinonasal GPC. This research was conducted at a tertiary healthcare centre in North India. In our case series, all the patients were evaluated and underwent endoscopic surgical resection. All patients underwent digital subtraction angiography (DSA) and preoperative embolization. The coblation technique used for haemostasis proved very effective and time-saving. All patients exhibited cytoplasmic SMA positivity (a marker of GPC) and CD34 negativity, while one patient exhibited a high Ki-67 index (> 10%), which is a predictor of aggressive tumor behavior. None of the patients showed any recurrence in follow-up. We recommend performing complete endoscopic surgical excision to prevent recurrence. The use of DSA, preoperative embolization, and intraoperative use of the coblation technique provides a cleaner surgical field and reduced operating time.

Adenoid Cystic Carcinoma of the Minor Salivary Glands: A Systematic Review and Meta-Analysis of Clinical Characteristics and Management Strategies

BACKGROUND

Intraoral adenoid cystic carcinoma (ACC) arising from minor salivary glands (MSG) is a rare malignancy associated with delayed diagnosis and unfavorable outcomes. This study aimed to comprehensively review ACC of MSGs, focusing on clinical characteristics, imaging modalities, treatment approaches, and long-term outcomes.

METHODS

A systematic search was conducted in PubMed, Web of Science, and MEDLINE databases to identify relevant articles reporting cases of ACC of MSGs between January 1997 and March 2023. The study was registered in PROSPERO (ID: CRD42023449478). A total of 10 studies that met the inclusion criteria were selected for critical review. In total, 902 patients were diagnosed with ACC of MSGs with an age range of 44.3 to 63 years, and an average age of 56.6 years. The female to male ratio ranges from 1:1 to 2.4:1. Regarding the primary site of ACC, the palate was the most common location, accounting for 30.5% to 83.3%, followed by the buccal mucosa, floor of the mouth, and lip and the retromolar area. For histology, the solid mass pattern was the most prevalent, seen in 95.2% of patients, followed by the cribriform pattern. Regarding treatment modalities, surgery was the most common approach, applied in 76.3% of cases, with a combination of surgery and radiotherapy used in 29.0% of cases. A smaller fraction, 3.2%, received a combination of surgery, chemotherapy, and radiotherapy, and 8.3% underwent radiotherapy alone. Local recurrence rates varied between 1% and 28.5%, and distant metastasis occurred in 18.2% to 33.3% of cases, predominantly to lymph nodes (14.5%). An analysis of overall survival across various stages and patient numbers indicated a 5-year survival rate of 68.0%. The findings of this study provide valuable insights for physicians in making treatment decisions and emphasize the need for ongoing research and collaborative clinical efforts to improve the management and outcomes of this challenging disease.

CONCLUSION

ACC of MSGs is a multifaceted condition typically manifesting as asymptomatic enlargement and ulceration. This disease is marked by distinct histopathological patterns and perineural invasion (PNI). Recognizing these distinctive aspects is key in shaping the treatment plan, which can range from surgical procedures to radiation therapy, chemotherapy, and evolving targeted treatments. Continuous research and collaborative clinical efforts remain critical for ongoing progress in the treatment and management of this challenging condition.

Biphenotypic Sinonasal Sarcoma with Orbital and Skull Base Involvement Report of 3 Cases and Systematic Review of the Literature

Biphenotypic sinonasal sarcoma (BSNS) is a rare malignant tumour of the upper nasal cavity and ethmoid sinuses that presents predominantly in middle aged female patients and show a characteristic infiltrative and hypercellular proliferation of spindle cells that demonstrate a specific immunoreactivity. We present three cases with BSNS that had different presenting complaints, either sinonasal or orbital problems, underwent endoscopic surgical treatment and/or radiotherapy and have been disease free on long follow up. A systematic review of all published cases was performed to identify all BSNS cases known at present. BSNS requires prompt and correct diagnosis with accurate surgical resection as well as consideration of radiotherapy. Our three cases confirm the findings of the literature and support that BSNS is an aggressive but treatable malignant disease of the sinonasal tract.

Seromucinous Hamartoma of the Sinonasal Cavity

Benign tumors or malignant neoplasms must be evaluated in patients with unilateral nasal cavity mass lesions. The 3 most prevalent unilateral benign mass lesions in such individuals are nasal polyps (NPs) and inverted papillomas (IPs). Although rare, it should be kept in mind that sinonasal hamartomas can be occasionally diagnosed as well. Among sinonasal hamartomas, respiratory epithelial adenomatoid hamartoma is more prevalent, with seromucinous hamartoma (SMH) being the second most common. Unlike NPs, sinonasal hamartomas are benign tumors with growth potential, which means it should not be undertreated and warrants surgical removal for treatment. However, sinonasal hamartomas do not have local invasion or malignant transformation potential like IPs; hence, it is vital not to overtreat them. Therefore, understanding the histopathology of SMH and thereby establishing proper surgical planning prior to the surgery remains crucial in such cases. Here, we present a successfully treated case of SMH with a distinctive radiographic, gross, and pathological clinical image of SMH.

Important Cells and Factors from Tumor Microenvironment Participated in Perineural Invasion

Perineural invasion (PNI) as the fourth way for solid tumors metastasis and invasion has attracted a lot of attention, recent research reported a new point that PNI starts to include axon growth and possible nerve "invasion" to tumors as the component. More and more tumor-nerve crosstalk has been explored to explain the internal mechanism for tumor microenvironment (TME) of some types of tumors tends to observe nerve infiltration. As is well known, the interaction of tumor cells, peripheral blood vessels, extracellular matrix, other non-malignant cells, and signal molecules in TME plays a key role in the occurrence, development, and metastasis of cancer, as to the occurrence and development of PNI. We aim to summarize the current theories on the molecular mediators and pathogenesis of PNI, add the latest scientific research progress, and explore the use of single-cell spatial transcriptomics in this invasion way. A better understanding of PNI may help to understand tumor metastasis and recurrence and will be beneficial for improving staging strategies, new treatment methods, and even paradigm shifts in our treatment of patients.

Recent Advances, Systemic Therapy, and Molecular Targets in Adenoid Cystic Carcinoma of the Head and Neck

With an incidence of 3-4.5 cases per million, adenoid cystic carcinoma (ACC) of the head and neck is one of the most common tumors of the parotid and sublingual salivary glands. In the clinical course, ACC is shown to have an aggressive long-term behavior, which leads to the fact that radical surgical resection of the tumor with tumor-free margins remains the "gold standard" in treating ACC. Particle radiation therapy and systemic molecular biological approaches offer new treatment options. However, risk factors for the formation and prognosis of ACC have not yet been clearly identified. The aim of the present review was to investigate long-term experience of diagnosis and treatment as well as risk and prognostic factors for occurrence and outcome of ACC.

The contemporary management of cancers of the sinonasal tract in adults

Sinonasal malignancies make up <5% of all head and neck neoplasms, with an incidence of 0.5-1.0 per 100,000. The outcome of these rare malignancies has been poor, whereas significant progress has been made in the management of other cancers. The objective of the current review was to describe the incidence, causes, presentation, diagnosis, treatment, and recent developments of malignancies of the sinonasal tract. The diagnoses covered in this review included sinonasal undifferentiated carcinoma, sinonasal adenocarcinoma, sinonasal squamous cell carcinoma, and esthesioneuroblastoma, which are exclusive to the sinonasal tract. In addition, the authors covered malignances that are likely to be encountered in the sinonasal tract-primary mucosal melanoma, NUT (nuclear protein of the testis) carcinoma, and extranodal natural killer cell/T-cell lymphoma. For the purpose of keeping this review as concise and focused as possible, sarcomas and malignancies that can be classified as salivary gland neoplasms were excluded.

Clinical and histopathological findings of a rare sinonasal glomangiopericytoma

Glomangiopericytoma is a rare vascular neoplasm of the nasal cavity and paranasal sinuses that occurs during the sixth or seventh decade of life. It is categorized as a borderline tumor with low malignant potential and classified as a distinct entity of sinonasal tumors with perivascular myoid phenotype by the World Health Organization (WHO). We report the case of a 50-year-old woman with nasal obstruction and severe epistaxis. The nasal sinuses computed tomography (CT), and magnetic resonance imaging (MRI) demonstrated a 3.1 cm soft tissue mass occupying the upper part of the left nasal cavity invading the left paranasal sinuses and nasal septum, and the left eye medial rectus muscle. A total mass resection was performed by nasal endoscopy. The histological and immunohistochemical examination yielded the diagnosis of glomangiopericytoma. This case report aims to contribute to the knowledge of nasal neoplasms. The need for more data on this entity is the main obstacle to developing standardized treatment guidelines.

Biphenotypic sinonasal sarcoma: European multicentre case-series and systematic literature review

Objective

Biphenotypic sinonasal sarcoma (BSNS) is a rare low-grade cancer that was included from the 4th edition of WHO classification of head and neck tumours. The purpose of this study is to analyse clinical behaviour, pattern of recurrences and survival outcomes of this neoplasm.

Methods

Retrospective review of patients affected by BSNS who were treated via an endoscopic-assisted approach in 6 European tertiary-care referral hospitals. Cases of BSNS described in literature since 2012 to date were fully reviewed, according to PRISMA guidelines.

Results

A total of 15 patients were included. Seven patients were treated via an endoscopic endonasal approach, 4 with endoscopic transnasal craniectomy, and 4 via a cranio-endoscopic approach. Adjuvant treatment was delivered in 2 cases. After a mean follow-up of 27.3 months, systemic metastasis was observed in 1 case; the 5-year overall survival and disease-free survival rates were 100% and 80 ± 17.9%, respectively.

Conclusions

BSNS is a locally aggressive tumour with a low recurrence rate and encouraging survival outcomes if properly treated with surgical resection and free margins followed by adjuvant radiotherapy for selected cases. Endoscopic-assisted surgery is safe and effective as an upfront treatment within a multidisciplinary care protocol.

DNA methylation-based classification of sinonasal tumors

The diagnosis of sinonasal tumors is challenging due to a heterogeneous spectrum of various differential diagnoses as well as poorly defined, disputed entities such as sinonasal undifferentiated carcinomas (SNUCs). In this study, we apply a machine learning algorithm based on DNA methylation patterns to classify sinonasal tumors with clinical-grade reliability. We further show that sinonasal tumors with SNUC morphology are not as undifferentiated as their current terminology suggests but rather reassigned to four distinct molecular classes defined by epigenetic, mutational and proteomic profiles. This includes two classes with neuroendocrine differentiation, characterized by IDH2 or SMARCA4/ARID1A mutations with an overall favorable clinical course, one class composed of highly aggressive SMARCB1-deficient carcinomas and another class with tumors that represent potentially previously misclassified adenoid cystic carcinomas. Our findings can aid in improving the diagnostic classification of sinonasal tumors and could help to change the current perception of SNUCs.

Interdisciplinary challenges and aims of flap or graft reconstruction surgery of sinonasal cancers: What radiologists and radiation oncologists need to know

In sinonasal cancer surgery, a fundamental challenge is to understand the postoperative imaging changes after reconstruction. Misinterpretation of post-operative imaging may lead to a misdiagnosis of tumor recurrence. Because radiotherapy planning is based on imaging, there are many gaps in knowledge to be filled in the interpretation of postoperative imaging to properly define radiotherapy tumor volumes in the presence of flaps. On the other hand, radiotherapy may be responsible for tissue fibrosis or atrophy, the anatomy of the reconstructed region and the functional outcomes may change after radiotherapy compared to surgery alone. This narrative review illustrates the interdisciplinary aims and challenges of sinonasal reconstructive surgery using flaps or grafts. It is particularly relevant to radiologists and radiation oncologists, at a time when intensity modulated radiotherapy and proton therapy have the potential to further contribute to reduction of morbidity.

Effects of CT/MRI Image Fusion on Cerebrovascular Protection, Postoperative Complications, and Limb Functional Recovery in Patients with Anterior and Middle Skull Base Tumors: Based on a Retrospective Cohort Study

Objective. To explore the effect of CT/MRI image fusion on cerebrovascular protection, postoperative complications and limb function recovery in patients with anterior and middle skull base tumors. Methods. During January 2019 to December 2021, a retrospective study was conducted on 50 patients who underwent anterior and middle skull base tumor resection in the same surgeon group in our hospital. According to the different surgical approaches, the patients were assigned to the fusion group (n = 29) and the routine group (n = 21). The routine group was operated with traditional operation, and the fusion group was operated with CT/MRI image fusion technique. The operation time, wound volume, resection rate and Karnofsky performance status (KPS), blood transfusion (vascular protection), tumor resection rate, and postoperative complications were compared. Results. The time of operation in the fusion group was shorter compared to the routine group, and the volume of the wound cavity in the fusion group was smaller compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). Following treatment, the KPS score of the fusion group was remarkably higher compared to the routine group, and the difference was statistically significant ( $P<0.05$ ). The intraoperative blood transfusion rate in the fusion group was 17.24%, and the intraoperative blood transfusion rate in the routine group was 47.62%, and the difference was statistically significant ( $P<0.05$ ). The resection rate in the fusion group (89.66%) was remarkably higher compared to the routine group (61.90%, $P<0.05$ ). The incidence of postoperative complications in the fusion group (6.90%) was remarkably lower compared to the control group (33.33%, $P<0.05$ ). Conclusion. The application of CT/MRI image-fusion technology can effectively enhance the clinical symptoms of patients with tumors in the anterior and middle region of the skull base, which can promote the prognosis, shorten the operation time, reduce unnecessary cerebral neurovascular injuries, and retain more brain functions.

Biomarkers for Immunotherapy in Poorly Differentiated Sinonasal Tumors

The sinonasal cavities harbor a wide variety of rare cancer types. Histopathological classification can be challenging, especially for poorly differentiated tumors. Despite advances in surgery and radio-chemotherapy, the 5-year survival rate is still very low. Thus, there is an unmet clinical need for new therapeutic options. We retrospectively evaluated poorly differentiated tumors of 9 different histological subtypes from 69 patients who had received conventional treatments for the presence of CD8+ tumor-infiltrating lymphocytes (TILs), as well as the expression of PD-L1 and microsatellite instability (MSI) markers MLH1, MSH2, MSH6 and PMS2, as biomarkers for immunotherapy. CD8+ TILs were present in 23/69 (33%) cases, PD-L1 expression was observed in 23/69 (33%), and markers for MSI positivity in 5/69 (7%) cases. CD8+ TILs correlated with PD-L1 positivity, while both were mutually exclusive with MSI markers. None of the biomarkers were associated with clinical features as age, gender or tumor stage. Cases with CD8+ TILs and PD-L1 positivity showed a tendency toward worse disease-specific survival. Immune checkpoint inhibitors are emerging as new options for treatment of many tumor types. Our results indicate that also a substantial subset of patients with poorly differentiated sinonasal tumors may be a candidate to be treated with this promising new therapy.

Biphenotypic Sinonasal Sarcoma with Intracranial Extension - A Case Report with Review of Literature

Rationale

Biphenotypic sinonasal sarcoma is a rare malignant tumour exclusively involving the sinonasal cavity. These tumours have variable and atypical presentations. Early approach and correct treatment modalities are key factors in the management of such cases.

Patient Concern

A 48-year-old male patient presented with left-sided nasal obstruction and intermittent nasal bleeding for one year.

Diagnosis

Biphenotypic sinonasal sarcoma confirmed on histopathological examination and immunohistochemistry.

Treatment

The patient underwent surgical excision with left lateral rhinotomy and bifrontal craniotomy with skull base repair. The patient also received postoperative radiotherapy.

Outcome

The patient is on regular follow-up with no similar complaints.

Take-Away Lesson

Treating team should keep the diagnosis of biphenotypic sinonasal sarcoma in mind while investigating a patient with nasal mass. Surgical management is the treatment of choice, due to its local aggressive nature and proximity to the brain and eyes. Postoperative radiotherapy is vital to prevent tumour recurrence.

A rare case of glomangiopericytoma in the nasal cavity: A case report in light of recent literature

Introduction and importance

Glomangiopericytoma (GPC) is a rare sinonasal tumor that behaves benignly with a long overall survival rate. It accounts for fewer than 0.5% of all sinonasal tumors.

Case presentation

We report the case of a 64-year-old man who presented with recurrent episodes of epistaxis. Rhinoscopy revealed a left posterior nasal septal mass with active oozing. Computed tomography (CT) showed a well-defined soft tissue lesion in the left nasal cavity measuring 1.95 × 1.51 cm. Complete endoscopic resection was successfully performed. Histopathological findings favored the diagnosis of GPC as it revealed tumor cells positive for smooth muscle actin and β-catenin with immunopositivity for CD34.

Clinical discussion

Presenting symptoms of GPC are predominated by epistaxis and nasal obstruction. Since CT and MRI merely lead to a presumptive diagnosis, histopathological findings are indispensable. Complete surgical excision of GPC remains the treatment of choice with excellent prognosis, especially when immunohistochemistry is positive for actin and CD34 immunostaining is negative.

Conclusion

GPC is a rare indolent tumor of pericytes that has a macroscopic appearance of a nasal polyp, which may result in uncertainty in the initial diagnosis. In most cases, GPC warrants only local excision. This case report adds to the literature and helps galvanize the developing clinical guidelines for diagnosis and treatment.

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Glomangiopericytoma (GPC) is a rare sinonasal tumor that behaves benignly with a long overall survival rate.

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GPC has a macroscopic appearance of a nasal polyp, resulting in uncertainty in the initial diagnosis.

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The utilization of histopathological findings to diagnose GPC is indispensable.

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Complete surgical excision is the mainstay of treatment.

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Regular postoperative lifelong follow-up is strongly recommended.

Analysis of Human Papillomavirus (HPV) and Polyomaviruses (HPyVs) in Adenoid Cystic Carcinoma (AdCC) of the Head and Neck Region Reveals Three HPV-Positive Cases with Adenoid Cystic-like Features

An aetiological role of human papillomavirus (HPV) and/or human polyomaviruses (HPyVs) has been proposed in adenoid cystic carcinoma (AdCC). Moreover, HPV-related multiphenotypic carcinoma (HMSC) was recently introduced as an emerging entity of the sinonasal region. Here, we primarily want to study the role of HPV/HPyV in a large AdCC cohort and, secondly, possibly identify and characterize HMSC. Tumour DNA from 68 patients initially diagnosed with AdCC between 2000 and 2012 was, therefore, tested for 27 HPV types and 10 HPyVs. HPV DNA-positive samples were micromorphologically re-evaluated, further stained for p16^INK4a, S100, p63 and CD117 and tested for the presence of the MYB-NFIB fusion transcript. Notably, no samples were HPyV-positive, while one sinonasal and two tonsillar carcinomas were HPV- and p16-positive. After re-evaluating the micromorphology, immunohistochemistry and presence of fusion transcripts, all tumours had the same appearance and fitted within the diagnosis of HMSC, but in all these three cases, the morphology of the HMSC and basaloid squamous cell carcinoma was overlapping. We conclude that HPV and HPyV have no major role in AdCC. However, based on our data, we also suggest that HMSC should be considered as a basaloid variant of squamous cell carcinoma, and not its own entity, until better characterized.

Trends in HPV Testing for Patients With Sinonasal Squamous Cell Carcinoma: A National Analysis

OBJECTIVE

The objective of this study was to analyze national trends in human papillomavirus (HPV) testing for patients diagnosed with sinonasal squamous cell carcinoma (SNSCC).

STUDY DESIGN

Retrospective database study.

SETTING

National Cancer Database (2010-2016).

METHODS

Cases from 2010 to 2016 with a primary SNSCC diagnosis and known HPV testing status were extracted from the National Cancer Database. Univariate and multivariate analyses were then performed to assess differences in socioeconomic, hospital, and tumor characteristics between tested and nontested patients.

RESULTS

A total of 2308 SNSCC cases were collected, with 1210 (52.4%) HPV tested and 1098 (47.6%) not tested. On univariate analyses, patient age, insurance, income quartile, population density, treatment facility location, and tumor grade were significantly associated with HPV testing status. After multivariate logistic regression modeling, living in a suburban area had lower odds of HPV testing as compared with living in urban areas (odds ratio, 0.74 [95% CI, 0.55-0.99]; P = .041), while tumor grade III/IV had higher odds than grade I (odds ratio, 1.73 [95% CI, 1.29-2.33]; P < .001). HPV-tested patients had a similar 5-year overall survival to nontested patients (48.3% vs 45.3%, log-rank P = .405). A sharp increase in HPV testing rates was observed after 2010 (P < .001).

CONCLUSION

Among patients with SNSCC, those with high-grade tumors were more likely to be tested for HPV, while patients with a suburban area of residence were less likely. Additionally, there was no significant survival benefit to HPV testing, with tested and nontested groups having similar overall survival.

LEVEL OF EVIDENCE

4.

Clinicopathologic features and prognosis of olfactory neuroblastoma with isocitrate dehydrogenase 2(IDH2) mutations

OBJECTIVE

Because of their rarity, it is not known whether isocitrate dehydrogenase 2 (IDH2) mutations are related to olfactory neuroblastoma. We investigated relationships between IDH2 mutations, clinicopathological parameters, and prognosis for olfactory neuroblastoma to establish a molecular classification based on IDH2 mutations.

MATERIALS AND METHODS

An 82-patient cohort was retrospectively screened by immunohistochemistry using a mutation-specific IDH2 antibody and by real-time PCR for IDH2 mutations. We also determined immunohistochemically the expression of chromogranin A, synaptophysin, neuron-specific enolase, CD56, S100, and Ki67.

RESULTS

The two methods for detection of IDH2 mutations had high consistency. Mutation of IDH2 detected by real-time PCR was correlated with higher Kadish stage, Hyams grade, and Ki67 proliferation index. Mutation of IDH2 was negatively correlated with expression of chromogranin A, synaptophysin, CD56, and S100. Kaplan-Meier analysis showed that an IDH2 mutation, high Hyams grade, and Ki67 index were associated with poor overall survival. Hyams grade and IDH2 mutation were independent prognostic factors in multivariable analysis.

CONCLUSIONS

Immunohistochemistry was a reliable method to assess the mutation status of IDH2. Tumors with IDH2 mutations represented a distinct subset with aggressive behavior and poor prognosis. The gene status of IDH2 can be a major molecular classification criterion in olfactory neuroblastoma.

PIK3CA mutation in a case of CTNNB1 mutant sinonasal glomangiopericytoma

Glomangiopericytomas are rare, primary sinonasal tumors. The existing literature is mostly limited to reports describing the clinicopathologic characteristics of these tumors. Comprehensive genetic characterization of glomangiopericytomas remain lacking. Whole exome sequencing of a case of glomangiopericytoma was performed under an institutional review board approved protocol. A 69 year-old female underwent surgical resection of a glomangiopericytoma. Whole exome sequencing revealed somatic mutations in CTNNB1 and PIK3CA, the former previously associated with this pathology but the latter not described. Concurrent dysregulation of Wnt/beta-catenin and PI3K/AKT/mTOR signaling, secondary to mutations in these two oncogenes may be amenable to targeted treatment with existing clinically approved drugs. Genomic characterization of glomangiopericytomas remains lacking. This study reports novel co-existence of PIK3CA and CTNNB1 mutations in a case of glomangiopericytoma that may offer insight into the pathogenesis and potential for targeted medical therapies of this rare tumor.

A Systematic Review of Definitive Treatment for Inverted Papilloma Attachment Site and Associations With Recurrence

OBJECTIVE

Inverted papilloma (IP) is the most common benign neoplasm of the nasal cavity with known risk of recurrence. There is no standardized approach to definitive treatment for attachment sites. This systematic review aims to determine whether surgeon choice of technique differs by anatomic attachment site and whether different surgical techniques contribute to reduced rates of recurrence.

DATA SOURCES

PubMed and Ovid Medline.

REVIEW METHODS

A systematic review was conducted for studies reporting on IP. Those that included IP recurrence rates and primary tumor attachment site were reviewed.

RESULTS

Of 122 published studies, 14 met eligibility criteria, representing 585 patients and a recurrence rate of 5.8%. The maxillary sinus (50.9%) was the most common primary attachment site, and the sphenoid sinus was associated with the highest rate of recurrence (10.4%). The most utilized technique included debulking the tumor, removing mucosa over the attachment site, and drilling the underlying bone. The most common Krouse stage represented was T3 (53.3%). No single technique predicted a propensity for recurrence, but certain techniques are favored depending on IP attachment site. Finally, frozen sections to obtain evidence of clear margins intraoperatively significantly reduced rates of recurrence (3.4% vs 7.3%, P = .045).

CONCLUSION

Based on the current literature, the most common technique to address site of attachment involves resecting mucosa and drilling the tumor base. Choice of technique appears to differ for various sites of attachment. Use of intraoperative frozen section analysis appears to be associated with decreased recurrence overall.

LEVEL OF EVIDENCE

3.

Outcome for sinonasal malignancies: a population-based survey

Purpose

Sinonasal malignancies (SNM) represent a rare and complex group of cancers that includes a wide range of histopathological subtypes. Data from population-based cohorts are scarce but warranted as a basis for randomized controlled treatment trials (RCTs). Our aim was to assess overall and histology subset-specific outcomes for SNM patients treated at a tertiary referral centre.

Methods

A retrospective, population-based, consecutive cohort of patients with SNMs diagnosed from 2001 through 2019 was examined. Outcome was analysed in relation to age, gender, site, stage, histopathology, and treatment.

Results

Two-hundred and twenty-six patients were identified, whereof 61% presented with stage IV disease. 80% completed treatment with curative intent, which comprised surgery with neoadjuvant (29%) or adjuvant (37%) radiotherapy, monotherapy with surgery (22%), definitive chemoradiotherapy (7%), or radiotherapy (5%). Median follow-up was 106 months. The 5- and 10-year overall survival rates were 57% and 35%, respectively. Median overall survival was 76 months (esthesioneuroblastoma: 147 months; adenocarcinoma: 117; salivary carcinoma: 88; mucosal melanoma: 69; squamous cell carcinoma: 51, undifferentiated carcinoma: 42; neuroendocrine carcinoma: 9; and NUT-carcinoma 5). The 5- and 10-year disease-free survival rates were 63% and 54%, respectively, and disease-specific survival 83% and 66%. Increasing age, stage IVB, melanoma histopathology, and treatment with definitive chemoradiotherapy emerged as significant independent prognostic risk factors for disease-specific mortality (p ≤ 0.001).

Conclusion

The results indicate a seemingly good outcome in comparison to previous reports, particularly for mucosal melanoma, adenocarcinoma, and undifferentiated carcinoma. The study provides additional background for future RCTs focusing on histology subset-specific treatment for SNM.

Sinonasal SMARCB1 (INI1) Deficient Carcinoma with Yolk Sac Tumor Differentiation: A Case Report and Treatment Options

SMARCB1 (INI1) deficient carcinoma (SDC) is a newly-described, aggressive, high-grade malignancy of the adult population. Rarely, these tumors demonstrate yolk sac differentiation. Treatment protocols are not defined due to the rarity of this entity. A 55 year-old-male presented with a tumor originating in the maxillary sinus. He was treated with neoadjuvant therapy followed by radical surgery and adjuvant treatment. We review the literature and discuss the course of disease and treatments of sinonasal SDC with yolk sac tumor differentiation. To our knowledge, this is the sixth reported case of sinonasal SDC with yolk sac tumor differentiation. This is the first publication describing the clinical course and efficacy of therapeutic interventions.

Orbital Involvement by Biphenotypic Sinonasal Sarcoma With a Literature Review

PURPOSE

To document a case of a biphenotypic sinonasal sarcoma that impinged on the orbit via a tumor-induced mucocele and review the previous literature devoted to this condition.

METHODS

A clinicopathologic case report with detailed histopathologic, immunohistochemical, and radiological studies with tabulations of previously reported cases and immunohistochemical stains for ruling out mimicking lesions.

RESULTS

A biphenotypic sinonasal sarcoma arose from the ethmoid sinus in a middle-aged man. The tumor induced a mucocele that bowed the medial orbital lamina papyracea into the orbit and caused diplopia and mild proptosis. The biopsy's dual positivity for S100 and smooth muscle actin together with positive paired box 3 immunohistochemical staining established the diagnosis of biphenotypic sinonasal sarcoma.

CONCLUSION

Biphenotypic sinonasal sarcoma, which can involve the orbit in 25% of cases, is a rare head and neck malignancy that has only recently been described. Biphenotypic sinonasal sarcoma is a low-grade, locally aggressive, nonmetastasizing sarcoma displaying both neural and muscle differentiation. It is further characterized by rearrangements of the PAX3 gene with multiple fusion partners, most commonly MAML3 (Mastermind like transcriptional coactivator 3). It occurs predominantly in middle-aged women and exclusively in the sinonasal tract. However, it can spread throughout the central facial structures to invade the brain if not detected early. Ophthalmologists should be aware of this new entity to avoid delays in diagnosis and treatment. The previous literature devoted to this condition was reviewed and analyzed for clinical, radiological, histopathological, and immunohistochemical features. In circumstances where molecular testing is not available, paired box 3 immunohistochemical staining can be used as an alternative diagnostic marker. The current case is most unusual because the orbital findings were induced by a mucocele caused by the tumor that obstructed the sinus ostium. This produced diplopia without direct tumor invasion into the orbital fat.

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.

The prognostic significance of race in nasopharyngeal carcinoma by histological subtype

BACKGROUND

Race has been shown to have variable prognostic importance in nasopharyngeal carcinoma (NPC). However, previous studies are limited by a lack of comprehensive treatment, epidemiologic, and comorbidity data.

METHODS

This was a retrospective cohort study utilizing the National Cancer Database from 2004 to 2016. Multivariable Cox proportional hazards regressions were used to calculate adjusted hazard ratios (aHR) for overall survival.

RESULTS

A cohort of 9995 patients met inclusion and exclusion criteria. Race, insurance, comorbidity, treatment, stage, age, and histology were independent prognosticators. Among patients with keratinizing NPC, Asians and Hispanics had superior survival (aHR 0.58 [95% confidence interval (CI) 0.48-0.69], aHR 0.76 [95% CI 0.61-0.96]) compared to white patients. Among patients with non-keratinizing differentiated NPC, Asians and black patients had improved survival (aHR 0.71 [95% CI 0.56-0.91], aHR 0.72 [95% CI 0.54-0.95]) compared to white patients. Race was not prognostic in non-keratinizing undifferentiated NPC.

CONCLUSION

The prognostic significance of race varies across histological subtypes of NPC.

Biphenotypic Sinonasal Sarcoma: A Case Report and Review of Literature

OBJECTIVES

Biphenotypic sinonasal sarcoma (BSNS), previously low-grade sinonasal sarcoma with neural and myogenic features, is a rare tumor of the sinonasal tract first described in 2012. Due to its rarity, limited literature is available in providing clinicians with a standardized treatment regimen, particularly in cases of positive surgical margins. This article aims to provide a clinical review of the currently available reported cases of BSNS, as well as presenting clinical, radiologic, and pathologic details of 2 novel cases.

METHODS

Online electronic databases include PubMed and Embase where queried for reports of biphenotypic sinonasal sarcoma or low-grade sinonasal sarcoma with neural and myogenic features. Two previously unpublished cases were included in the results. Data including clinical presentation, epidemiologic data, radiologic evaluation, intraoperative details, histopathology, treatment modality, and postoperative follow-up information were included.

RESULTS

A total of 100 previously published cases were identified in 12 prior articles. Mean age at presentation was 52.9 years. Extrasinonasal extension was observed in 27.4% of cases with most common site of extension being cribriform plate. Forty-seven cases included treatment details with surgical excision being the most common modality. Recurrence rates were identical for both surgical excision alone and surgical excision with adjuvant radiotherapy (33.3%).

CONCLUSIONS

Biphenotypic sinonasal sarcoma is a slow-growing tumor that is amenable to surgical resection. Recurrence rates are similar between surgical excision and surgical excision with adjuvant radiation therapy, but limited data in reported cases preclude a determination of treatment superiority.

The role of Narrow Band Imaging (NBI) in the diagnosis of sinonasal diseases

BACKGROUND

Narrow band imaging (NBI) endoscopy is an optical method that helps to characterise tissue vasculature. Its appli- cation in sinonasal pathology remains scarce and a systematic study of its application to rhinology is lacking. The aim of this study is to analyse and describe the normal sinonasal mucosa under NBI light and to characterise the microvascular features of various sinonasal pathologies. We also want to suggest a classification of the patterns, peculiar to this district, and to evaluate whether they can be indicative of a specific physiological or pathological condition.

METHODS

Digital videos and images under white light and NBI of 103 patients (82 evaluated) with 29 sinonasal pathologies and 55 controls (33 evaluated). were independently analysed by three otolaryngologists and the final pattern was then arranged for each image, reaching an agreement between the individual evaluations.

RESULTS

Once the appearance of normal sinonasal (SN) mucosa was established (SN1), four patterns for the pathological mucosa were described and a working classification was proposed (SN2, SN3, SN4, SN5). We calculated specificity (80.6% vs 90.6%), sensi- tivity (20% vs 38.5%), PPV (46.1% vs 50%), NPV (54.7% vs 85.7%) and accuracy (53% vs 80.3%) of the ability of SN4 and SN5 pattern to discriminate between benign and malignant nasal neoformations.

CONCLUSIONS

This is the first study to propose a systematic NBI description and a classification of the vasculature of healthy and pathological mucosa in the sinonasal tract. Our preliminary results show that this technique can help in the workup of several rhinologic conditions and especially in distinguishing benign from malignant tumors.

Challenges in plain film radiographic diagnosis for the dental team: a review of the maxillary sinus

The maxillary sinus is the largest of the paranasal sinuses, with its structure and contents commonly visualised on dental radiographs. Dental practitioners are required to evaluate the entire radiograph, and it is likely there is limited exposure to maxillary sinus pathoses and radiological interpretation in the undergraduate curriculum and routine continuing professional development courses. This review covers radiological features of common benign and malignant sinus disease. Identification of normal anatomical features, common variations and pathoses can facilitate holistic patient management and potentially early detection of neoplastic disease.

Clinicopathological Features of Thyroid-Like Low-Grade Nasopharyngeal Papillary Adenocarcinoma: A Case Report and Review of the Literature

Thyroid-like low-grade nasopharyngeal papillary adenocarcinoma (TL-LGNPPA) is an extremely rare neoplasm of the nasopharynx. Accordingly, its clinical and pathological characteristics are not well-known. We report a case of TL-LGNPPA and review the relevant literature on TL-LGNPPA. A 38-year-old Japanese woman presented with a history of nasal obstruction that had persisted for 1 month after symptoms of a common cold (e.g., low-grade fever, sore throat, and fatigue). A pedunculated tumor of ~20 mm in diameter was found on the posterior edge of the nasal septum. The tumor was endoscopically resected. Based on careful histopathological and immunohistochemical examinations, it was diagnosed as TL-LGNPPA. At 5 years after surgery, the patient remained disease-free. TL-LGNPPA has a very good prognosis, and complete resection with a sufficient safety margin is recommended as the first-line treatment. The morphological characteristics and immunohistochemical findings, especially TTF-1 positivity and thyroglobulin negativity, are important for the diagnosis.

NUT midline carcinoma in a young pregnant female: a case report

INTRODUCTION

The NUT midline carcinoma is a rare tumor mostly reported in the midline of upper aerodigestive tract and mediastinum. Children as well as adolescents are affected without a gender distribution. A standard treatment is not established. So far, there exists no reported case of a pregnant female suffering from NUT midline carcinoma with musculoskeletal manifestation.

CASE PRESENTATION

A 34-year-old woman was referred to our outpatient clinic by the general practitioner during her 31st week of pregnancy suffering from shoulder pain and dyspnea. So far, dyspnea was interpreted as a typical pregnancy-related symptom. However, a chest X-ray showed a tumor mass in the right lung in close relation to the scapula. Further examinations found metastases in different areas of the body. No pregnancy-related complications were detected by obstetric examination. After an interdisciplinary perinatal case discussion, cesarean section was directly followed by an open biopsy of the right side scapula tumor lesion. A NUT midline carcinoma was diagnosed by immunohistochemistry. Due to disseminated tumor disease in multiple non-resectable locations, a palliative systemical chemotherapy was started by the oncological outpatient clinic.

CONCLUSION

This report presents the case of the very rare NUT midline carcinoma under pregnancy which made interdisciplinary case discussions indispensable for therapy planning.

Perineural Invasion in Adenoid Cystic Carcinoma of the Salivary Glands: Where We Are and Where We Need to Go

Adenoid cystic carcinoma of the salivary gland (SACC) is a rare malignant tumors of the head and neck region, but it is one of the most common malignant tumors that are prone to perineural invasion (PNI) of the head and neck. The prognosis of patients with SACC is strongly associated with the presence of perineural spread (PNS). Although many contributing factors have been reported, the mechanisms underlying the preferential destruction of the blood-nerve barrier (BNB) by tumors and the infiltration of the tumor microenvironment by nerve fibers in SACC, have received little research attention. This review summarizes the current knowledge concerning the characteristics of SACC in relation to the PNI, and then highlights the interplay between components of the tumor microenvironment and perineural niche, as well as their contributions to the PNI. Finally, we provide new insights into the possible mechanisms underlying the pathogenesis of PNI, with particular emphasis on the role of extracellular vesicles that may serve as an attractive entry point in future studies.

A Potential Link Between Prolonged Cork Exposure and Intestinal-Type Sinonasal Adenocarcinoma - Special Findings of a Retrospective Cohort Analysis

Introduction

intestinal-type sinonasal adenocarcinoma (ITAC) is a rare epithelium tumor of the nasal cavities and paranasal sinuses. Exposure to wood and leather dusts is a strong etiological factor related to its development. Prolonged cork exposure has rarely been associated.

Materials and Methods

thirty-seven-year (1981–2018) retrospective cohort analysis of all consecutive patients with sinonasal cancer (SNC) followed at our institution. Medical records were reviewed to determine patient demographics, occupational/environmental exposure, location and extent of the tumor, stage, histopathology findings, treatment strategies, and oncologic outcomes. Survival analysis was done using Kaplan–Meier method.

Results

we evaluated 379 patients with SNC, including 39 (10.3%) ITAC. Patient median age was 73 years (range 49–87), 56% male and 69% with identified professional occupational exposure (54% for cork; 69.2% considering only those for which an agent has been identified). Seventy-two percent had locally advanced disease (stage III or IVA–B). The initial treatment was surgery in 77%, and 54% received adjuvant radiotherapy. The median time to progression, progression-free survival, and overall-survival was 2.36 years (95% CI 1.54–8.70), 1.96 years (95% CI 1.43–3.74), and 3.51 years (95% CI 2.33–10.02), respectively.

Conclusion

ITAC is an uncommon malignancy that grows silently, which contributes to delayed diagnosis, advanced stage and low survival rates. In our cohort, we observed a high prevalence of cork occupational exposure. This finding may lead to the implementation of protection measures and suggest a potential link to be further studied.

Clinical Implication of Diagnostic and Histopathologic Discrepancies in Sinonasal Malignancies

OBJECTIVES

To evaluate the incidence of histopathologic diagnostic discrepancy for patients referred to our institution, identify pathologies susceptible to diagnostic error, and assess the impact on survival of histopathologic diagnostic discrepancies.

METHODS

Three hundred ninety-seven patients with sinonasal cancers were identified, and discordance between the outside pathologic report and MD Anderson Cancer Center pathologic report was assessed. Overall survival and disease-specific survival were analyzed using Kaplan-Meier and log rank methods.

RESULTS

Discordance of major histopathologic diagnoses was present in 24% (97 of 397) of reports, with sinonasal undifferentiated carcinoma, sarcoma, neuroendocrine carcinoma, and poorly differentiated carcinoma pathologies having the highest change in diagnosis (P < .01). A further 61% (244 of 397) had minor changes such as histologic grade, subtype, or stage, with sarcoma and neuroendocrine carcinoma pathologies being most susceptible to change (P < .02). Overall, the 5-year overall survival (OS) and disease-specific survival (DSS) was reduced in patients with a major change in histopathologic diagnosis (59.2% vs. 70.2% (P = .02) and 72.9% vs. 81.2% (P = .02), respectively). Furthermore, patients with a major change in diagnosis and prior treatment experienced a significant reduction in 5-year OS (61.9% vs. 70.4%, P = .03 < .01) and DSS (72.4% vs. 81.5%, P = .04).

CONCLUSION

Histopathological diagnosis of sinonasal tumors is complex and challenging given the rarity of the disease. Obtaining the correct diagnosis is important for treatment selection and survival. In histologies prone to misdiagnoses, obtaining a second opinion from experienced head and neck pathologists at a high-volume institution may potentially lead to a change in treatment recommendations that could result in improved survival in patients with sinonasal malignancies.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1468-E1475, 2021.

Radiation therapy strategies for skull-base malignancies

INTRODUCTION

The management of skull base malignancies continues to evolve with improvements in surgical technique, advances in radiation delivery and novel systemic agents.

METHODS

In this review, we aim to discuss in detail the management of common skull base pathologies which typically require multimodality therapy, focusing on the radiotherapeutic aspects of care.

RESULTS

Technological advances in the administration of radiation therapy have led to a wide variety of different treatment strategies for the treatment of skull base malignances, with outcomes summarized herein.

CONCLUSION

Radiation treatment plays a key and critical role in the management of patients with skull base tumors. Recent advancements continue to improve the risk/benefit ratio for radiotherapy in this setting.

An MRI-Based Radiomic Nomogram for Discrimination Between Malignant and Benign Sinonasal Tumors

BACKGROUND

Preoperative discrimination between malignant and benign sinonasal tumors is important for treatment plan selection.

PURPOSE

To build and validate a radiomic nomogram for preoperative discrimination between malignant and benign sinonasal tumors.

STUDY TYPE

Retrospective.

POPULATION

In all, 197 patients with histopathologically confirmed 84 benign and 113 malignant sinonasal tumors.

FIELD STRENGTH/SEQUENCES

Fast-spin-echo (FSE) T₁ -weighted and fat-suppressed FSE T₂ -weighted imaging on a 1.5T and 3.0T MRI.

ASSESSMENT

T₁ and fat-suppressed T₂ -weighted images were selected for feature extraction. The least absolute shrinkage selection operator (LASSO) algorithm was applied to establish a radiomic score. Multivariate logistic regression analysis was applied to determine independent risk factors, and the radiomic score was combined to build a radiomic nomogram. The nomogram was assessed in a training dataset (n = 138/3.0T MRI) and tested in a validation dataset (n = 59/1.5T MRI).

STATISTICAL TESTS

Independent t-test or Wilcoxon's test, chi-square-test, or Fisher's-test, univariate analysis, LASSO, multivariate logistic regression analysis, area under the curve (AUC), Hosmer-Lemeshow test, decision curve, and the Delong test.

RESULTS

In the validation dataset, the radiomic nomogram could differentiate benign from malignant sinonasal tumors with an AUC of 0.91. There was no significant difference in AUC between the combined radiomic score and radiomic nomogram (P > 0.05), and the radiomic nomogram showed a relatively higher AUC than the combined radiomic score. There was a significant difference in AUC between each two of the following models (the radiomic nomogram vs. the clinical model, all P < 0.001; the combined radiomic score vs. the clinical model, P = 0.0252 and 0.0035, respectively, in the training and validation datasets). The radiomic nomogram outperformed the radiomic scores and clinical model.

DATA CONCLUSION

The radiomic nomogram combining the clinical model and radiomic score is a simple, effective, and reliable method for patient risk stratification.

LEVEL OF EVIDENCE

4 TECHNICAL EFFICACY STAGE: 2.

Novel Biomarkers in Sinonasal Cancers: from Bench to Bedside

PURPOSE OF REVIEW

Sinonasal cancers are a heterogenous group of rare cancers for which histopathological diagnosis can be very challenging and treatment options are limited for advanced disease in particular. Here, we review the candidacy of novel diagnostic and prognostic biomarkers, and therapeutic targets for sinonasal cancers.

RECENT FINDINGS

Molecular multidimensional analyses of sinonasal cancers have been lagging behind other major cancers, but there are numerous publications describing the discovery of novel candidate biomarkers, e.g. the methylation classifier, originally developed for brain cancers, and gene expression panels for the prediction of response to induction chemotherapy in sinonasal undifferentiated carcinoma. The most promising biomarkers are summarized and discussed further with regard to their clinical applicability and future potential. Many of the described novel biomarkers for sinonasal cancers will eventually overcome the pitfalls associated with the frequently non-specific immunohistological tests. With comprehensive, multidimensional molecular testing of these tumours in collaborative consortia projects, our better understanding of the molecular mechanisms of sinonasal cancers and their carcinogenesis will determine the most useful diagnostic and prognostic biomarkers, allow stringent multi-institutional validation and guide trials on targeted therapies.

INI-1 (SMARCB1)-Deficient Undifferentiated Sinonasal Carcinoma: Novel Paradigm of Molecular Testing in the Diagnosis and Management of Sinonasal Malignancies

Sinonasal tumors consist of a group of rare heterogeneous malignancies, accounting for 3%-5% of all head and neck cancers. Although squamous cell carcinomas make up a significant portion of cancers arising in the sinonasal tract, there are a variety of aggressive tumor types that can present with a poorly differentiated morphology and continue to pose diagnostic challenges. Accurate classification of these unique malignancies has treatment implications for patients. Recent discoveries have allowed more detailed molecular characterization of subsets of these tumor types, and may lead to individualized treatments. INI-1 (SMARCB1)-deficient sinonasal carcinoma is a recently identified subtype of sinonasal malignancy, which is characterized by deletion of the INI-1 tumor suppressor gene. Loss of INI-1 expression has emerged as an important diagnostic feature in several human malignancies including a subset of sinonasal carcinomas. In this article, we present a case of INI-1 (SMARCB1)-deficient sinonasal carcinoma, provide an overview of recent advances in histological and molecular classification of sinonasal malignancies, and discuss challenges of caring for patients with these rare malignancies, as well as potential treatment implications. KEY POINTS: Clinicians and pathologists should recognize that a variety of sinonasal tumors can present with a poorly differentiated morphology that warrants further workup and molecular classification. Routine workup of poorly or undifferentiated sinonasal tumors should include testing for INI-1/SMARCB1, SMARCA4, and NUT. Patients with these molecularly defined subsets of tumors may benefit from clinical trials that seek to exploit these molecular alterations. The EZH2 inhibitor, tazemetostat, has demonstrated some antitumor activity in INI-1-deficient tumors, and is currently under investigation.

Sinonasal Squamous Cell Carcinoma: Etiology, Pathogenesis, and the Role of Human Papilloma Virus

PURPOSE OF REVIEW

Sinonasal squamous cell carcinoma (SNSCC) is a rare disease with considerable histologic diversity. Currently, there is a poor understanding of the etiology and pathogenesis of SNSCC. Here, we review recent literature to summarize what is known regarding (1) the etiology of SNSCC, (2) the role of Human Papilloma Virus (HPV) in SNSCC, and (2) the molecular underpinnings of SNSCC.

RECENT FINDINGS

1. High risk HPVappears to play a role in the pathogenesis of a subset of SNSCCs. SNSCCs with high risk HPV have improved survival compared with those without HPV and occur in patients who are younger, similar to HPV mediated oropharyngeal cancer. 2. A subset of inverted papillomas have transcriptionally active low-risk HPV and have a higher risk of transformation, while low risk HPV negative inverted papillomas frequently have EGFR mutations.

SUMMARY

SNSCC is a diverse disease with likely multiple etiologies including carcinogen, irritant exposure, and HPV. While not definitively proven, evidence supports a role for high-risk HPV in a subset of SNSCC, and low-risk HPV in a subset of inverted papillomas which transform to SNSCC. In-depth molecular and genomic studies are needed in SNSCC to better understand the genomic underpinnings and oncogenic drivers.

Interventional Management of Head and Neck Tumors

Advancements in medical imaging and device technology allow minimal invasive procedures for the diagnosis and treatment of various disorders. For the management of tumors in head and neck region, these image-guided interventions play essential role in the often used multidisciplinary approach. Tissue sampling under ultrasound or computed tomography guidance is generally the first step to reach a pathological diagnosis. For head and neck tumors with high vascularity, embolization using particulate matter, liquid embolic agents, or coils is used to achieve successful tumor resection with minimal blood loss. Hemorrhage related to head and neck tumors can be evaluated and managed with endovascular techniques with minimal morbidity and mortality. Intra-arterial chemotherapy, radiofrequency ablation, and cryotherapy are new techniques for the management of advanced head and neck cancer which may serve as an alternative to achieve locoregional control and survival when curative resection may not be feasible.