The MUSES∗: a prognostic study on 1360 patients with sinonasal cancer undergoing endoscopic surgery-based treatment: ∗MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers

Safety and Oncologic Outcomes of Endoscopic Endonasal Transcribriform Approach for Locally Advanced Sinonasal Malignancies

INTRODUCTION

The past two decades have seen a paradigm shift in the surgical treatment of sinonasal malignancies, moving from traditional open approaches to minimally invasive endoscopic techniques. Technological advancements have enabled the use of the endoscopic endonasal transcribriform approach (EETA) for tumors involving the anterior skull base (ASB). This study evaluates the oncologic outcomes of EETA for locally advanced sinonasal malignancies with ASB involvement.

METHODS

We conducted a retrospective cohort study at a tertiary cancer center, including patients treated with EETA for sinonasal malignancies from January 2012 to January 2024. Data on demographic characteristics, clinical presentations, treatment protocols, and survival outcomes were analyzed. Survival probabilities were assessed using Kaplan-Meier curves, and subgroups comparisons were made using the log rank test.

RESULTS

Forty-nine patients were included, predominantly with primary tumors (91.8%) and advanced stages (cT3-T4: 89.8%). EETA achieved R0 resection in 82.1% of cases. All eligible patients (88.9%) underwent postoperative radiotherapy, with 97.5% beginning treatment 6-8 weeks after surgery. The mean follow-up duration was 43.2 months. The 5-year overall survival (OS) was 66.5%, disease-free survival (DFS) was 58.7%, and local relapse-free survival (LRFS) was 75%. Patients with olfactory neuroblastoma had significantly higher OS and DFS compared to intestinal-type adenocarcinoma. Margin status significantly impacted survival, with better outcomes observed in patients with clear margins.

CONCLUSION

EETA offers a viable and effective alternative for treating locally advanced sinonasal malignancies with ASB involvement, achieving acceptable oncologic outcomes with reduced morbidity.

Matching-adjusted indirect comparison of endoscopic and craniofacial resection for the treatment of sinonasal cancer invading the skull base

AIM

The aim of this study was to compare the efficacy and safety of endoscopic endonasal approaches (EEA) with craniofacial resection (CFR) for sinonasal cancers invading the skull base, using an unanchored matching-adjusted indirect comparison (MAIC).

METHODS

A MAIC approach was used to analyse data from two large cohorts: the MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers (MUSES) cohort, comprising sinonasal cancer patients treated endoscopically, and a historical CFR cohort reported by Ganly et al. Individual patient data were available only for the first cohort. Patients with olfactory neuroblastomas were excluded. Key prognostic factors were used to match and adjust the two cohorts, minimising selection bias. The primary endpoint was overall survival (OS), with secondary endpoints including recurrence-free survival (RFS), perioperative mortality, complication rates, and resection margins.

RESULTS

A total of 724 EEA-treated and 334 CFR-treated patients were included. EEA showed significantly improved OS before (HR= 2.33, 95 % CI= 1.88-2.87) and after MAIC adjustment (HR= 1.93, 95 % CI= 1.60-2.34). Observed RFS was higher in the EEA group (HR= 1.39, 95 % CI = 1.14-1.69) but no longer differed after adjustment (HR= 1.06, 95 % CI= 0.91-1.23). EEA was associated with significantly better Disease Specific Survival (HR= 1.71, 95 % CI = 1.39-2.13), lower perioperative mortality (OR= 8.12, 95 % CI= 3.45-36.7) and fewer complications than CFR (OR= 3.68, 95 % CI= 2.47-5.42).

CONCLUSION

In this MAIC study based on the 2 largest cohorts of sinonasal cancer with skull base invasion, EEA offered comparable oncologic outcomes to CFR with reduced morbidity, supporting it as a valid alternative when performed in expert centres.

Surgical margin assessment and prognostic impact in sinonasal cancers: a systematic review and meta-analysis

Objective

Surgery remains a cornerstone in treatment of sinonasal malignancies, but the prognostic role of margin status is controversial. This systematic review and meta-analysis evaluated the prognostic significance of surgical margins in sinonasal cancer and their impact on survival, alongside key challenges in its evaluation.

Methods

A systematic search in PubMed, Scopus, and Web of Science identified 64 studies (34,120 patients).

Results

The overall margin infiltration rate was 33.2%, varying widely across studies (4.5-88.2%) and histotypes, and was the highest in adenoid cystic carcinoma (ACC, 61.5%). Meta-analysis of 31 studies showed positive margins were associated with worse survival (overall survival, odds ratio [OR] 2.61; disease-specific survival, OR 5.89; disease-free survival, OR 4.40). Squamous cell carcinoma, olfactory neuroblastoma, and mucosal melanoma had the strongest correlation with margin status, while for ACC and adenocarcinomas statistical significance was not reached. High heterogeneity was noted across studies, alongside inconsistent margin classification, distance thresholds, and use of frozen sections, limiting cross-study comparability.

Conclusions

This study confirms the prognostic value of surgical margins, but underscores the urgent need for standardised definitions to improve prediction of oncologic outcomes and clinical decision-making.

Consensus for a postoperative atlas of sinonasal substructures from a modified Delphi study to guide radiotherapy in sinonasal malignancies

BACKGROUND

Sinonasal and skull base tumor surgery-related morbidity has been reduced by the use of endoscopic endonasal skull base surgery (EESBS). Postoperative radiation therapy (poRT) requires precise definition of target volumes. To enhance the accuracy of poRT planning, histological and radiological correlations are necessary to locate the tumor attachment on poRT CT scans. An accurate atlas of structures resected or identified during EESBS could serve for the interdisciplinary postoperative management of patients, personalizing poRT by adequate radiation dose delivery. The objective of this study was to achieve a consensual segmentation atlas on CT scan with surgeons practicing EESBS and radiation oncologists.

METHODS

The sinonasal structures relevant for poRT of sinonasal malignancies were determined by a two-round Delphi process. A rating group of 25 European experts in sinonasal malignancies was set up. Consensual structures emerged and were used to determine the anatomical limits of the retained structures to draft an atlas with expert based relevant structures. The atlas was then critically reviewed, discussed, and edited by another 2 skull base surgeons and 2 radiation oncologists.

RESULTS

After the two rating rounds, 46 structures obtained a strong agreement, 7 an agreement, 5 were rejected and 5 did not reach consensus. The atlas integrating all the selected structures is presented attached.

CONCLUSION

Consensual segmentation atlas on CT scan might allow, through careful poRT planning to limit the morbidity of poRT while maintaining good local control. Prospective studies are necessary to validate this potential precision medicine-based approach.

Long-term outcomes of endoscopic resection and tailored adjuvant radiotherapy for sinonasal intestinal-type adenocarcinoma: a historical single-center cohort study in 200 patients

Background

Sinonasal intestinal-type adenocarcinoma (ITAC) is a rare disease entity. In contrast to most previous studies, this cohort study consists of a substantial number of uniformly treated patients undergoing endoscopic surgery and adjuvant radiotherapy and provides updated insights into survival outcomes and tumor and treatment-related prognostic factors.

Material and methods

We retrospectively analyzed the medical records of 200 patients primarily treated for ITAC between 1992 and 2022 in our tertiary referral center. Descriptive statistics were applied using Kaplan-Meier method. Cox models were used for univariable and multivariable data analysis.

Results

The 5-year overall survival (OS), disease-specific survival (DSS), and local recurrence-free survival (LRFS) rates were 71.4%, 85.1%, and 55.2% respectively. At 10 years, the numbers decreased to 48.2%, 76.2%, and 32.2% respectively. Significant differences were found in OS and DSS between T-groups. Poorly differentiated tumors had decreased DSS compared to well-differentiated tumors (HR: 3.38 [95% CI: 1.20-9.51], p=.0209). Signet-cell differentiation was associated with the poorest survival among poorly differentiated tumors although not reaching significance. In 34.0% of patients, there was local recurrence, with half of the cases detected within the first two years of follow-up but over 10% of recurrence occurring after 10 years. Positive surgical margins (HR: 2.95 [95% CI: 1.29-6.74], p=.0106), local recurrence (HR: 12.28 [95% CI: 5.59-26.99], p<.0001), and distant metastasis (HR: 41.17 [95% CI: 21.58-78.55], p<.0001) negatively affected DSS. Distant metastasis occurred more frequently in poorly differentiated tumors (25.6%) compared to moderately differentiated (9.5%) and well-differentiated tumors (2.5%) (p=.002).

Conclusions

This extensive study focusing on sinonasal ITAC primarily managed through endoscopic resection and radiotherapy, demonstrates that T-classification and tumor differentiation are independent prognostic factors influencing survival. Furthermore, local recurrence, distant metastasis, and positive surgical margins negatively affect OS and DSS.

Endoscopic-Assisted Maxillectomy: A Combined Approach for the Management of Maxillary Malignant Tumors

Maxillary sinus cancer presents unique challenges due to its slow growth and concealed location, often leading to delayed diagnosis and advanced stage at presentation. Wide resection, including maxillectomy, is frequently necessary for curative treatment. However, achieving clear resection margins while preserving function and aesthetics remains crucial. This article evaluates a combined surgical approach for maxillectomy, aiming to optimize oncological outcomes while minimizing morbidity and preserving function and aesthetics. A retrospective evaluation of patients undergoing endoscopic-assisted maxillectomy was conducted, focusing on demographics, tumor characteristics, surgical techniques, and outcomes. Data including operative time, complications, reconstruction methods, and follow-up were collected and analyzed. Ten patients underwent endoscopic-assisted maxillectomy, with favorable outcomes in terms of oncological radicality and functional preservation. Complications were minimal, and all patients achieved R0 margins. Adjuvant therapies were tailored based on individual patient characteristics, with promising survival outcomes and acceptable morbidity. The combined approach offers advantages over traditional methods by providing precise visualization and control in both endonasal and intraoral aspects of the resection. It allows for en-bloc tumor removal with minimal morbidity. Endoscopic-assisted maxillectomy offers a safe and effective approach for achieving optimal oncological outcomes while preserving function and aesthetics. It represents a significant evolution in the management of maxillary tumors, demanding further investigation and refinement.

Sinonasal malignancy: ESMO-EURACAN Clinical Practice Guideline for diagnosis, treatment and follow-up

•The CPG provides key recommendations and algorithms for managing SMs, excluding mucosal melanoma and soft-tissue sarcomas. •The guideline covers diagnosis, staging, risk assessment, treatment and disease monitoring. •Technological advancements in treatment with RT are discussed with a special focus on particle therapy. •Surgical indications for open and transnasal endoscopic surgery are provided. •Neoadjuvant chemotherapy in high-grade, locally advanced SMs helps to select subjects for conservative treatments.

Intraoperative surgical navigation improves margin status in advanced malignancies of the anterior craniofacial area: A prospective observational study with systematic review of the literature and meta-analysis

The current scientific evidence suggests that surgical navigation (SN) can contribute to improve oncologic outcomes in sinonasal and craniofacial surgery. The present study investigated the feasibility of intraoperative SN and its role in improving the outcomes of surgically treated sinonasal and craniofacial tumors. This prospective study compared navigation-guided surgery for sinonasal or craniofacial malignancies with a pair-matched cohort (1:2 matching) of patients operated without SN. A systematic review of the literature was performed. Thirty-five patients who underwent navigation-guided surgery were included. The pair-matched control cohort included 70 patients operated without SN. The margin status analysis demonstrated a lower rate of positive margins (p = 0.013) in the SN group, especially in pT4 (p = 0.034), recurrent (p = 0.024), high-grade tumors (p = 0.043), and endoscopic-assisted open surgery (p = 0.035). The mean preoperative time did not show a significant difference between surgeries performed with or without SN (1.26 vs. 1.23 h, p = 0.445). However, surgeries utilizing SN had a significantly longer median duration compared to those without (8.10 vs. 6.00 h, p = 0.029). A total of 209 patients were included in the meta-analysis; 91 patients (43.5 %) underwent surgery with SN. The results of the meta-analysis showed an improvement in terms of negative margins rate with the use of SN (OR = 2.62; 95%-confidence interval: 1.33-5.17). In conclusion, intraoperative SN can contribute to achieve a clear margin resection, especially in locally advanced tumors, recurrences, highly aggressive histologies, and when endoscopic-assisted open surgery is employed.

Morbidity of multimodal treatments including endoscopic surgery for sinonasal malignancies: Results of an international collaborative study on 940 patients (MUSES)

INTRODUCTION

In the management of sinonasal malignancies treatment-induced morbidity and mortality is gaining relevance both for surgical approaches (endoscopic and open resection) and non-surgical therapies. The aim of this multicenter study is to assess complications associated with endoscopic surgery and non-surgical treatments (neoadjuvant and/or adjuvant) for malignant sinonasal tumors.

METHODS

All patients with nasoethmoidal malignancies treated with curative intent with endoscopic or endoscopic-assisted surgery at three referral centers with uniform management policies were included. Neo- and/or adjuvant (chemo)radiotherapy was administered according to histology and pathological report. Demographics, treatment characteristics, and complications related both to the surgical and non-surgical approaches were retrieved. The data were analyzed with univariate and multivariate statistics to assess independent predictors of complications.

RESULTS

Nine hundred and forty patients were included, 643 males (68%) and 297 females (32%). A total of 225 complications were identified in 187 patients (19.9%): cerebrospinal fluid (CSF) leak (3.5%), mucocele (2.3%), surgical site bleeding (2.0%), epiphora (2.0%), and radionecrosis (2.0%) were the most common. Treatment-related mortality was 0.4%. Variables independently associated with complications at multivariate analysis were principally dural resection (OR 1.92), cranioendoscopic or multiportal resection (OR 2.93), dural repair with multilayer technique with less than three layers (OR 2.17), and graft different from iliotibial tract (OR 3.29).

CONCLUSION

Our study shows that modern endoscopic treatments and radiotherapy for sinonasal malignancies are associated with limited morbidity and treatment-related mortality. CSF leak and radionecrosis, although rare, remain the most frequent complications and should be further addressed by future research efforts.

Ectopic olfactory neuroblastoma is associated with increased frequency of syndrome of inappropriate antidiuretic hormone secretion and reduced disease control: Case series with systematic review and pooled analysis

INTRODUCTION

Olfactory neuroblastoma (ONB) is a rare malignant tumor originating from the olfactory neuroepithelium, typically within the sinonasal cavity. Cases of ONB originating outside of the olfactory cleft area are extremely rare and are referred to as "ectopic" (eONB), in contrast to "orthotopic" tumors (oONB). ONB has been associated with paraneoplastic syndromes (PNSs), including the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This study investigate the association between eONB and SIADH and compared the prognosis of eONB to oONB.

METHODS

A systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted, focusing on studies reporting eONB and oONB associated with SIADH. Data from four newly identified eONB cases were reported and a pooled analysis was performed. Statistical analyses were conducted to evaluate the prevalence of SIADH in eONB and oONB and to compare clinical outcomes in the two groups.

RESULTS

eONB had a significantly higher prevalence of SIADH (18.3%) compared to oONB (2.0%; p < 0.0001). Patients with eONB were younger, with a slight predominance of females. Recurrence-free survival and time-to-recurrence of eONB were worse than oONB, independently of other prognosticators.

CONCLUSIONS

eONB is associated with a significantly higher incidence of SIADH than oONB, suggesting distinct biological characteristics. Moreover, patients with eONB had worse prognostic outcomes. Further research is needed to understand the underlying mechanisms and improve management strategies for eONB.

Differentiating Sinonasal Tumor Entities with Fluorescein-Enhanced Confocal Laser Endomicroscopy: A Step Forward in Precision Diagnostics

Background/Objectives: Sinonasal malignancies are rare and highly diverse cancers that pose significant diagnostic challenges due to their variable histological features and complex anatomical locations. Accurate diagnosis is critical for guiding treatment, yet conventional methods often require multiple biopsies. This study aimed to evaluate the potential of confocal laser endomicroscopy (CLE) for real-time imaging of sinonasal tumors to characterize specific features of different entities and improve diagnostic precision. Methods: Ten patients with various sinonasal malignancies, including squamous cell carcinoma, adenocarcinoma, sinonasal undifferentiated carcinoma, olfactory neuroblastoma, sinonasal mucosal melanoma, and endonasal lymphoma, were examined using CLE during diagnostic endoscopy. CLE images were compared descriptively with histopathological cross-sections to identify unique imaging patterns for each tumor type. Results: CLE was feasible across all cases, with high-quality images obtained despite anatomical challenges in some cases. Characteristic features, such as vascular clusters in undifferentiated carcinoma, mucin-filled bubbles in adenocarcinoma, and small round cells in neuroblastoma, were identified and corresponded well with histopathological findings. CLE also helped guide biopsies by revealing areas with diagnostic relevance. Conclusions: CLE demonstrates promise as an adjunct diagnostic tool in sinonasal malignancies, offering real-time imaging that correlates with histopathological findings and aids in targeted biopsies. While this study provides preliminary insights into the utility of CLE, further research with larger cohorts and statistical validation is necessary to establish its diagnostic reliability and broader clinical application.

Intraoperative surgical navigation as a precision medicine tool in sinonasal and craniofacial oncologic surgery

INTRODUCTION

Recent evidence supports the efficacy of surgical navigation (SN) in improving outcomes of sinonasal and craniofacial oncologic surgery. This study aims to demonstrate the utility of SN as a tool for integrating surgical, radiologic, and pathologic information. Additionally, a system for recording and mapping biopsy samples has been devised to facilitate sharing of spatial information.

MATERIALS AND METHODS

SN was utilized for biopsy mapping in 10 sinonasal/craniofacial oncologic procedures. Twenty-five raters with experience in anterior skull base oncology were interviewed to identify 15 anatomical structures in preoperative imaging, relying on topographical descriptions and surgical video clips. The difference in the localization of anatomical structures by raters was analyzed, using the SN-mapped coordinates as a reference (this difference was defined as spatial error).

RESULTS

The analysis revealed an average spatial error of 9.0 mm (95 % confidence interval: 8.3-9.6 mm), with significant differences between surgeons and radiation oncologists (7.9 mm vs 12.5 mm, respectively, p < 0.0001). The proposed model for transferring SN-mapped coordinates can serve as a tool for consultation in multidisciplinary discussions and radiotherapy planning.

CONCLUSIONS

The current standard method to evaluate disease extension and margin status is associated with a spatial error approaching 1 cm, which could affect treatment precision and outcomes. The study emphasizes the potential of SN in increasing spatial precision and information sharing. Further research is needed to incorporate this method into a multidisciplinary workflow and measure its impact on outcomes.

Preservation of orbit in tumor invasion through the periorbita in sinonasal malignancy

OBJECTIVE

One of the possible risks of sinonasal malignancy is its possible spread in the orbit. However, there is no clear consensus among the different departments as to whether it is necessary to exenterate the orbit in limited tumorous infiltration of periorbital fat. The purpose of the study was to demonstrate that periorbital infiltration and periorbital fat invasion without involvement of deeper orbital tissues are not the indication of orbital exenteration.

MATERIALS AND METHODS

Retrospective analysis was performed over a 17-year period of patients undergoing surgical treatment for sinonasal malignancy with histologically verified periorbital infiltration or deeper invasion into the orbit. A total of 32 patients were included in the study. For each group, the following data were analysed: sex, age, preoperative imaging studies, histological findings, site of origin, stage, surgical reconstruction, oncological treatment, survival, cause of death, number of recurrences in the orbit and functional status of preserved eyes.

RESULTS

Based on our criteria for orbital exenteration, orbital preservation was feasible in 18 patients. Orbital exenteration was performed in 14 patients with deeper tumor infiltration. There was a statistically insignificant difference in survival between the two groups. The 5-year overall survival (OS) was 44% for the orbital preservation group (only 2 patients died from local tumor recurrence) and 34% for the orbital exenteration group. The groups did not differ in other observed factors other than the extent of orbital infiltration. In 11 (61.1%) patients, vision was without significant change after radiation therapy. In 2 (11.1%) patients, visual function was impaired due to diplopia. 5 (27.8%) patients had severely impaired vision due to optic nerve atrophy after radiation therapy.

CONCLUSIONS

Our results show a relatively high survival rate in the group of patients with orbital preservation with a high chance of vision preservation, which justifies our approach to orbital preservation even in some tumors with periorbital infiltration.

Endoscopic-assisted transorbital extended orbital exenteration: A multi-institutional preclinical study

BACKGROUND

Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended-OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic-EOE).

METHODS

The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized.

RESULTS

The step-by-step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported.

CONCLUSIONS

Endoscopic-EOE is a challenging but feasible procedure. Clinical validation is required to assess real-life outcomes.

Next-generation sequencing reveals remarkable genetic stability in primary and corresponding recurrent intestinal-type sinonasal adenocarcinoma

BACKGROUND

Recurrent intestinal-type sinonasal adenocarcinoma (ITAC) can occur several years after primary treatment and with different histology. We aimed to clarify if such recurrences could be second primary tumors and to identify actionable mutations as targets for personalized treatment of recurrent ITAC.

METHODS

Twelve pairs of primary and recurrent ITAC were histologically examined and analyzed by next-generation sequencing.

RESULTS

Histological differences between primary and recurrent tumor pairs were observed in five cases. Frequent mutations included TP53, APC, TSC2, ATM, EPHA2, BRCA2, LRP1B, KRAS, and KMT2B. There was 86% concordance of somatic mutations between the tumor pairs, while four cases carried additional mutations in the recurrence.

CONCLUSIONS

We found all cases to be clonal recurrences and not second primary tumors. Moreover, tumor pairs showed a remarkable genomic stability, suggesting that personalized treatment of a recurrence may be based on actionable molecular genetic targets observed in the primary tumor.

Real-Life Prognosis of Sinonasal Tumors

BACKGROUND

Sinonasal cancer represents a challenging disease because of its difficult diagnosis and different histology. Despite a multidisciplinary evaluation and treatments, a poor prognosis is still present. We retrospectively analyzed patients with sinonasal cancer treated in our institution, paying attention to histology and real-life prognosis.

METHODS

A total of 51 consecutive patients were included in the study. Clinical features were described. Overall, disease-free, and disease-specific survival (OS, DFS, DSS) according to histology were calculated. Kaplan-Meyer estimator curves were reported.

RESULTS

The most prevalent primary tumor was squamous cell carcinoma, followed by adenocarcinoma. Global 2- and 5-year OS was 68.80% and 54.58%, respectively. Global 2- and 5-year DFS was 48.53% and 29.56%, while global 2- and 5-year DSS was 82.86% and 74.57%, respectively. The median OS was 74 and 43 months for early- and late-stage cancer, respectively. The Cox multivariate regression analysis did not reveal any statistically significant effects of age, stage, or histology on survival outcomes.

CONCLUSIONS

The diagnosis is often late and the prognosis poor. An appropriate treatment, which is always quite multimodal, allows us to achieve a global 5-year OS slightly higher than 50%. An adequate diagnosis to increase the percentage of early-stage tumors is mandatory to improve prognosis.

Survival of Patients with Sinonasal Cancers in a Population-Based Registry, Lombardy, Italy, 2008-2023

Sinonasal cancers (SNCs) are rare malignancies associated with occupational exposures. The aim of this study was to analyse the survival of SNC patients using data from the population-based SNC registry of the Lombardy region (10 million people), Italy. We included epithelial SNC cases registered in 2008-2020 and followed-up for vital status until 31 July 2023. Multivariate flexible parametric models with time-dependent covariates were fitted to calculate excess hazard ratios (EHRs) and 95% confidence intervals (CIs) of death. Based on 827 cases (553 males, 274 females) and 514 deaths (345 males, 169 females), the 5-year observed survival was 49% and the net survival was 57%. Age had a substantial impact on survival, particularly within the first year (EHR, 1.35; 95% CI, 1.12-1.51 per 10 years). Compared with the nasal cavity, the EHR for paranasal sinuses was 4.70 (95% CI, 2.96-7.47) soon after diagnosis. Compared with squamous cell carcinomas, the EHR was 0.69 (95% CI, 0.52-0.91) for adenocarcinomas, 1.68 (95% CI, 1.20-2.35) for undifferentiated and unspecified carcinomas, and 1.78 (95% CI, 1.07-2.95) for neuroendocrine carcinomas. Age and cancer site showed time-dependent effects on prognosis, especially within the first month after diagnosis. Prognosis was also markedly affected by cancer morphology. No associations were found for gender and period of diagnosis.

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.

360 Degrees Endoscopic Access to and Through the Orbit

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Definitive treatment for head and neck mucosal melanoma

Head and neck mucosal melanoma is a rare clinical subtype of melanoma or head and neck cancer. Mucosal melanoma is aetiologically and molecularly distinct from cutaneous melanoma. The therapeutic efficacy of immune checkpoint inhibitors for head and neck mucosal melanoma remains unclear. Surgery is considered as the mainstay of treatment for locally advanced head and neck mucosal melanoma, and adjuvant radiotherapy has a role in local disease control. New treatment modalities, such as targeted therapy and immunotherapy, have changed the treatment of cutaneous melanoma. However, patients with mucosal melanoma have been excluded from most Phase III clinical trials. Due to its rarity, outcome data for locally advanced head and neck mucosal melanoma are scarce and are mainly based on retrospective studies with limited case numbers. The objective of this review was to provide an update and overview of clinical trials, prospective observational studies and retrospective studies and discuss future directions for multimodal treatment of locally advanced head and neck mucosal melanoma.

Treatment and outcomes of minor salivary gland cancers of the larynx and trachea: a systematic review

Objectives

Malignant minor salivary glands carcinomas (MiSGC) of the larynx and trachea are rare tumours and published evidence is sparse. We conducted a systematic review to describe shareable treatment strategies and oncological outcomes of these neoplastic entities.

Methods

Full text English manuscripts published from January 1st 2000 to December 14th 2022 were included. Data on demographics, treatments and outcomes were collected. A pooled analysis of 5-year overall survival (OS) was performed.

Results

Seventeen articles and 365 patients met the inclusion criteria. The most common subsites involved were subglottic and distal trachea. Adenoid cystic carcinoma was, by far, the most frequent histotype. The first-choice treatment strategy was surgery (86.8%), while adjuvant treatments were delivered in 57.4% of patients. Only 12.9% were treated with definitive radiotherapy with/without chemotherapy. The mean follow-up was 68.3 months. One hundred nine (34.9%) deaths were recorded and 62.4% were cancer-related. Five-year OS ranged from 20% to 100% and, at pooled analysis, it was 83% (range, 78-87%).

Conclusions

In case of MiSGC of the larynx and trachea, surgery remains the mainstay of treatment. Adjuvant treatments are frequently delivered. Survival estimates are good overall, but highly heterogeneous.

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

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

Signaling Pathways mTOR and ERK as Therapeutic Targets in Sinonasal Intestinal-Type Adenocarcinoma

Despite advances in surgery and radiotherapy, the overall prognosis of sinonasal intestinal-type adenocarcinoma (ITAC) is poor, and new treatment options are needed. Recent studies have indicated alterations in cellular signaling pathways that may serve as targets for modern inhibitors. Our aim was to evaluate the frequency of mTOR and ERK pathway upregulation in a retrospective series of 139 ITAC and to test the efficacy and mechanism of action of candidate targeted inhibitors in cell line ITAC-3. An immunohistochemical analysis on p-AKT, p-mTOR, p-S6, p-4E-BP1, and p-ERK indicated, respectively, a 68% and 57% mTOR and ERK pathway activation. In vitro studies using low doses of mTOR inhibitor everolimus and ERK inhibitor selumetinib showed significant growth inhibition as monotherapy and especially as combined therapy. This effect was accompanied by the downregulation of mTOR and ERK protein expression. Our data open a new and promising possibility for personalized treatment of ITAC patients.

T4b Sinonasal Squamous Cell Carcinoma: Surgery Plus Radiotherapy May Contribute to Prolonged Survival

PURPOSE

To determine oncologic outcomes for patients with T4b sinonasal squamous cell carcinoma (SNSCC) treated with either surgery plus radiotherapy or definitive radiotherapy.

MATERIALS AND METHODS

Between January 1999 and December 2016, 85 patients with T4b SNSCC were analyzed retrospectively, there were 54 who received surgery plus radiotherapy (S + RT group) ± chemotherapy and 31 with definitive radiotherapy (RT group) ± chemotherapy. A 1: 2 propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan-Meier method and Cox proportional hazard model were used to determine risk factors on survival outcomes.

RESULTS

The median follow-up time was 76.7 months. The cumulative rates of locoregional control (LRC), distant metastasis-free survival (DMFS), cancer-specific survival (CSS), and overall survival (OS) at 5 years for entire cohort were 44.6%, 33.1%, 38.8%, and 33.9% respectively. After PSM, a total of 50 patients in S + RT group and 25 patients in RT group were analyzed. The 5-year LRC, DMFS, CSS, and OS between S + RT and RT group were 58.6% versus 27.5% (p = 0.035), 42.8% versus 20.0% (p = 0.006), 50.3% versus 22.0% (p = 0.005), 44.5% veruss 20.0% (p = 0.004). The 5-year survival rates with orbital retention between groups were 32.7% and 15.0%, p = 0.080. Multivariate Cox analysis revealed non-surgical therapy (HR = 3.678, 95%CI 1.951-6.933) and invasion of cranial nerves (other than maxillary division of trigeminal nerves) (HR = 2.596, 95%CI 1.217-5.535) were associated with decreased OS.

CONCLUSION

The inclusion of surgery in the multimodal management of T4b SNSCC might confer a survival benefit. Further prospective studies comparing the oncologic outcomes of S + RT with RT are warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2222-2231, 2023.

Sinonasal Malignancies Involving the Frontal Sinus: A Mono-Institutional Experience of 84 Cases and Systematic Literature Review

Frontal sinus involvement by malignant tumors is a rare finding. Therefore, a systematic literature review along with a personal case series may contribute to defining more accurately the epidemiology, treatment options, and outcomes of these neoplasms. This is a retrospective review of patients affected by frontal sinus malignancies surgically treated in a tertiary-care referral center over a period of 20 years. Moreover, a systematic literature review of studies describing frontal sinus cancers from 2000 to date was performed according to PRISMA guidelines in order to analyze current evidence about the treatment and outcomes of such a rare disease. Our retrospective review was basedon 84 cases, treated with an exclusive endoscopic approach in 43 cases (51.2%), endoscopic approach with frontal osteoplastic flap in 6 cases (7.1%), and transfacial or transcranial approaches in 35 cases (41.7%). The five-year overall, disease-specific, disease-free, and recurrence-free survivals were 54.6%, 62.6%, 33.1%, and 59.1%, respectively. Age, dural involvement, type of surgical resection, and surgical margin status were significantly associated with the survival endpoints. In conclusion, the involvement of the frontal sinus is associated with a poor prognosis. Multidisciplinary management, including specific histology-driven treatments, represents the gold standard for improving outcomes and minimizing morbidity.

The Prognostic Role of the Immune Microenvironment in Sinonasal Intestinal-Type Adenocarcinoma: A Computer-Assisted Image Analysis of CD3+ and CD8+ Tumor-Infiltrating Lymphocytes

The prognostic value of conventional histopathological parameters in the sinonasal intestinal-type adenocarcinoma (ITAC) has been debated and novel variables should be investigated. Increasing evidence demonstrated that the evolution of cancer is strongly dependent upon the complex interactions within tumor microenvironment. The aim of this retrospective study was to assess the features of immune microenvironment in terms of CD3⁺ and CD8⁺ cells in a series of ITAC and explore their prognostic role, as well as their relations with clinicopathological variables. A computer-assisted image analysis of CD3⁺ and CD8⁺ tumor-infiltrating lymphocytes (TIL) density was conducted on surgical specimens of 51 patients with ITAC that underwent a curative treatment including surgery. ITAC displays variable TIL density, which is associated with OS. In a univariate model, the density of CD3⁺ TIL was significantly related to OS (p = 0.012), whereas the association with CD8+ TIL density resulted in being non-significant (p = 0.056). Patients with intermediate CD3⁺ TIL density were associated with the best outcome, whereas 5-year OS was the lowest for intermediate CD8⁺ TIL density. CD3⁺ TIL density maintained a significant association with OS in the multivariable analysis. TIL density was not significantly related to demographic and clinicopathological variables. CD3⁺ TIL density was independently associated with OS in a non-linear fashion and patients with intermediate CD3⁺ TIL density had the best outcome. Though based on a preliminary analysis on a relatively small series of patients, this finding makes TIL density a potential independent prognostic factor of ITAC.

Sinonasal Cancer: Improving Classification, Stratification and Therapeutic Options

The nasal cavities and paranasal sinuses are the site of origin of a wide spectrum of histologically and clinically distinct disease entities [...].

Patterns of recurrences in sinonasal cancers undergoing an endoscopic surgery-based treatment: Results of the MUSES* on 940 patients: *MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers

OBJECTIVES

The improvements in survival with expansion of the survivors' population, along with evolution of endoscopically-based treatment modalities, have contributed to emphasize the clinical relevance of recurrences in sinonasal cancers. However, at present, literature is scant regarding the pattern of recurrences and the therapeutic strategies available to manage long survivors who experienced single or multiple failures. The aim of the present study was to analyze sinonasal cancers recurrences to provide data regarding rates and patterns of relapse, predictors of failure and prognostic impact of the recurrence.

MATERIALS AND METHODS

All patients receiving multimodal treatments including endoscopic surgery between 1995 and 2021 in three European referral centers were included. Statistical analysis of survival was performed through univariable, multivariable and unidirectional multistate models. Survival after recurrence analysis was implemented for patients experiencing at least one recurrence.

RESULTS

The 5- and 10-year recurrence free survival rates were 34.1% and 38.4% for the whole population. With a mean follow-up time of 60 months, a global recurrence rate of 32.9% was observed. The 5- and 10-year survival after recurrence rates were 27.2% and 21.7%, respectively. Incidence and rates of recurrences were significantly associated with histology subtypes.

CONCLUSION

This study provides valuable oncologic outcomes regarding a large homogenous cohort of patients affected by sinonasal malignances treated within a multimodal framework, emphasizing the strong correlation of histologic type with prognosis, as well as with pattern of recurrences.

Oncologic outcome of multimodality treatment for sinonasal malignancies: An 18-year experience

Purpose

The aim of this study was to retrospectively evaluate the oncologic outcomes of sinonasal malignancies (SNMs) of various histologic subtypes and investigate the impact of multimodality treatment on prognosis of SNM.

Methods

SNM patients treated with curative-intent surgery from 2000 to 2018 were included. The primary outcomes were overall survival (OS). Survival was then assessed through Cox proportional hazards models.

Results

Three hundred and three patients were eligible for the analysis. The 5-year OS and event-free survival (EFS) were 61.0% (95% CI: 55.4%–67.1%) and 46.2% (95% CI: 40.4%–52.7%). The 5-year OS was the worst for malignant melanoma and the best for adenocarcinoma. Patients who received surgery had better OS than those who only received radiotherapy and/or chemotherapy. Endoscopic surgery had better OS than the open approach (p < 0.05). Microscopically margin-negative resection (R0 resection) significantly benefited OS and EFS (p < 0.001). No significant difference in OS was observed between patients who received macroscopic complete resection (R1 resection) followed by adjuvant therapy and patients who received R0 resection. Older age (HR = 1.02, p = 0.02), R1 resection (HR = 1.99, p = 0.02), sinonasal surgical history of more than 3 months before diagnosis (HR = 2.77, p = 0.007), and radiotherapy history (HR = 3, p = 0.006) are risk factors for worse EFS.

Conclusions

Curative-intent surgery is irreplaceable in the treatment of SNM. The endoscopic approach is an effective alternative to the open approach. EFS is worse among patients with older age, R1 resection, sinonasal surgical history of more than 3 months before diagnosis, and radiotherapy history.