Single modality and multimodality treatment of nasal and paranasal sinuses cancer: a single institution experience of 229 patients

Salvage skull base surgery after proton beam therapy for recurrent sinonasal malignancies: A retrospective study

BACKGROUND

This study aimed to examine treatment outcomes and postoperative complications associated with salvage skull base surgery following radical proton beam therapy (PBT).

METHODS

Nine patients who underwent salvage skull base surgery following curative PBT as the initial treatment at our institution between September 2002 and May 2023 were retrospectively reviewed.

RESULTS

The cohort comprised four males and five females with a mean age of 48.1 years. The average proton dose administered during initial therapy was 68.5 Gy (relative biological effectiveness). Among the salvage surgeries, eight were anterior skull base surgeries, and one was an anterior middle skull base surgery. No local recurrences or perioperative deaths were observed. Postoperative complications occurred in three patients (33.3%), all experiencing surgical site infections, with one also having cerebrospinal fluid leakage.

CONCLUSION

The study demonstrates that salvage skull base surgery after PBT effectively achieves local control and safety in patients with recurrent sinonasal malignancies.

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.

Oncology for the rhinologist

PURPOSE OF REVIEW

The purpose of this review is to summarize current evidence regarding the use of induction chemotherapy for a variety of histopathologies of sinonasal malignancy (SNMs) and to review the potential adverse effects of cytotoxic agents.

RECENT FINDINGS

Historically, patients with locally advanced SNMs have had relatively poor prognoses and high morbidity from treatment. The available retrospective data suggests that induction chemotherapy may improve outcomes for patients with sinonasal undifferentiated carcinoma (SNUC), neuroendocrine carcinoma, squamous cell carcinoma (SSCC), and esthesioneuroblastoma. For SNUC and SSCC, response or nonresponse to induction chemotherapy may prognosticate outcomes and for SNUC specifically, drive selection of definitive therapy. In chemosensitive pathologies, induction chemotherapy appears to improve organ preservation.

SUMMARY

Induction chemotherapy may improve functional and oncologic outcomes for patients with SNMs. Because of the rarity of these pathologies, the available data is primarily retrospective. Future randomized, prospective studies should be performed to further optimize and elucidate the role of induction chemotherapy for SNMs.

Failure Patterns Within Different Histological Types in Sinonasal Malignancies: Making the Complex Simple

OBJECTIVE

To analyze the failure patterns in patients with different histological subtypes of sinonasal malignancies (SNMs).

STUDY DESIGN

Retrospectively gathered data.

SETTING

Academic university hospital.

METHODS

Patients with SNMs treated at a tertiary referral center between January 1999 and January 2019 were included. We assessed the failure patterns within different histological subtypes.

RESULTS

The study included 897 patients. The median follow-up time was 100 months. Adenoid cystic carcinoma (ACC) had a moderate risk of developing local recurrence (LR) and distant metastasis (DM). Compared with ACC, squamous cell carcinoma (SCC), adenocarcinoma (AC), soft tissue sarcoma (STS), and mucosal melanoma (MM) were classified as a high LR risk group. For DM, neuroendocrine carcinoma (NEC), STS, and MM were in the high-risk group.

CONCLUSIONS

ACC had intermediate local and distant failure risks, while SCC, AC, STS, and MM were at high LR risks. NEC, STS, and MM were at high DM risk.

Clinical Characteristics and Long-Term Outcomes following Surgery Combined with Adjuvant Radiotherapy for Patients with Frontal Sinus Malignancies

Objectives  Primary frontal sinus malignancies (FSMs) are the rarest sinonasal cancers. This study aimed to determine clinicopathologic characteristics of primary FSMs and provide long-term survival outcomes. Design  This study is a retrospective review. Setting  The study was conducted at a tertiary medical center. Participants  Patients who participated in this study were diagnosed with primary FSMs. Main Outcome Measures  Median survival time is the primary outcome measure of this study. Results  In this series, the median age was 48 years (30-53 years) and all patients were male. There were five cases with squamous cell carcinoma and one with osteosarcoma. All cases presented with locally advanced disease without regional lymphatic metastasis, including five cases of stage III and one case of stage II. The two most common pathways of tumor invasion were as follows: local tumor broke posteriorly through bone wall and invaded dura mater, followed by frontal lobe; local tumor infiltrated downward through the floor of frontal sinus into ethmoid sinus, thereafter invaded laterally orbit and orbital contents. All patients received surgery followed by postoperative radiotherapy at the total doses of 50 to 75.95 Gy. Among them, only one patient underwent R0 resection, the rest of patients underwent R1/R2 resection. With a median survival time of 56 months (32-76 months), two patients receiving R1/R2 resection developed treatment failure and died within 5 years, including one case with local recurrence and one with local recurrence, thereafter distant metastasis. Conclusion  The majority of FSMs presented with peripherally invasive progression lesions which led to a high ratio of R1/R2 resection. Surgery combined with postoperative radiotherapy might result in satisfactory efficacy.

Low-dose nivolumab and cabozantinib in recurrent intestinal-type papillary adenocarcinoma of the sinonasal region

Intestinal-type sinonasal adenocarcinoma is a rare epithelial malignancy primarily treated with surgery and chemoradiation. The combination of low-dose immunotherapy and a tyrosine kinase inhibitor in recurrent disease has not been previously studied.A man in his 20s with papillary adenocarcinoma of the sinonasal region, following surgical resection, was treated with six cycles of concurrent chemoradiotherapy, followed by four cycles of docetaxel, cisplatin and capecitabine. While on treatment, he was found to have extensive residual disease and he was started on low-dose nivolumab and cabozantinib. Repeat imaging after ten months of treatment revealed a significant reduction in lesions.Non-squamous head and neck cancers are often excluded from major trials, and the effect of immunotherapy in these histologies is poorly understood. The response seen with low-dose immunotherapy underscores the need for further research in this setting.

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.

The SINTART 1 study. A phase II non-randomised controlled trial of induction chemotherapy, surgery, photon-, proton- and carbon ion-based radiotherapy integration in patients with locally advanced resectable sinonasal tumours

PURPOSE

Sinonasal tumours are rare diseases with poor prognosis. Multimodal approach including surgery is widely used, although no standard therapy has been established in prospective trials. This study assessed activity and safety of an innovative integration of multimodality treatment-induction chemotherapy (ICT), surgery and radiotherapy (RT)-modulated by histology and response to ICT.

METHODS

Patients with untreated, operable sinonasal tumours with selected histotypes (squamous cell carcinoma, intestinal-type adenocarcinoma, sinonasal undifferentiated and neuroendocrine carcinoma, olfactory neuroblastoma) were enrolled in a single-arm, phase II, multicenter clinical trial. Patients were treated with up to 5 ICT cycles, whose regimen was selected according to histotype, followed either by curative chemo-RT for pts with ≥80% reduction of initial tumour diameter or surgery and adjuvant (chemo)RT. Photon and/or proton/carbon ion-based RT was employed according to the disease site and stage. Primary end-point was 5-year progression-free survival (PFS), secondary end-points were overall survival (OS), ICT objective response rate (ORR) per RECIST 1.1 and safety.

RESULTS

Thirty-five patients were evaluable for primary end-point. Fourteen patients (40%) were treated with definitive (CT)RT and 20 (57%) underwent surgery. Five-year PFS was 38% (95% confidence interval [CI], 21-69), with a median PFS of 26 months. Five-year OS was 46% (95% CI, 28-75), with a median OS of 36 months. Three-year PFS-OS for pts achieving PR/CR versus stable disease (SD)/PD to ICT were 49.8-57% versus 43.2-53%, respectively. Three-year PFS for patients achieving major volumetric partial response (≥80% reduction of initial tumour volume, major partial volumetric response [mPRv]) versus non-mPRv were 82% versus 28% and 3-year OS were 92% versus 36% (p value 0.010 and 0.029, respectively). The ORR to ICT was 54% and 60% across all histotypes and in the sinonasal undifferentiated carcinoma (SNUC) subpopulation, respectively, with 6/15 SNUCs (40%) achieving mPRv.

CONCLUSION

Treatment of advanced sinonasal cancer with histology-driven ICT followed by (CT)RT in responsive patients was feasible. Overall, these findings suggest a possible role of ICT as the primary approach in newly diagnosed, resectable sinonasal tumours-especially SNUC-to select patients with favourable prognosis. Histology heterogeneity limits generalisation of trial results.

The SINTART 2 Study. A phase II non-randomised controlled trial of induction chemotherapy, photon-, proton- and carbon-ion-based radiotherapy integration in patients with locally advanced unresectable sinonasal tumours

PURPOSE

Unresectable, locally advanced sinonasal epithelial tumours are rare diseases with poor prognosis. Multimodal approach is widely used, although no standard therapy has been established in prospective trials. This study assessed activity and safety of an innovative integration of multimodality treatment-induction chemotherapy (ICT), surgery and radiotherapy (RT)-modulated by histology and response to ICT.

METHODS

Patients with untreated, unresectable sinonasal epithelial tumours with selected histotypes (squamous cell carcinoma, intestinal-type adenocarcinoma, sinonasal undifferentiated and neuroendocrine carcinoma, olfactory neuroblastoma) were enroled in a single-arm, open-label, phase II, multicentre clinical trial. Patients were treated with up to 5 ICT cycles, whose regimen was selected according to histotype. Photon and/or proton/carbon-ion-based RT was employed according to disease site, stage and ICT response. Primary end-point was 5-years progression-free survival (PFS), secondary end-points were overall survival (OS), ICT objective response rate per RECIST 1.1 and safety.

RESULTS

Twenty-five patients were evaluable for primary end-point. Five-year PFS was 26.8% (95% confidence interval [CI]: 12.6-57.1), with a median PFS of 18 months. Five-year OS was 23.8% (95% CI: 9.5-59.3), with a median OS of 27 months. The overall response rate to ICT was 40%. Three-year PFS for patients achieving major volumetric partial response (mPRv) versus non-mPRv was 40% (95% CI: 13.7-100%) versus 23.1% (95% CI: 8.3-64.7%) (P = 0.318) and 3-year OS was 53.3% (95% CI: 21.4-100%) versus 37.7% (95% CI: 20.0-71.0%) (P = 0.114).

CONCLUSION

Multimodal combination of ICT and innovative RT did not provide a significant improvement in survival rates with respect to previous experiences. This finding underscores the need for future research in this rare disease, still characterised by a heavy burden and poor prognosis. We observed longer survival in subjects achieving response to ICT. The overall treatment safety is acceptable.

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

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

Factors Contributing to Diagnosis and Prognosis in Sinonasal Malignancies

Objectives. This study was intended to explore and analyze the factors which affect the survival and prognosis of patients with malignant tumors of nasal cavity and sinus. Methods. Retrospective analysis was performed on the clinical data of 39 cases of malignant tumors of nasal cavity and sinus that met the requirements of the study. A follow-up study was performed on the patients for more than 36 months. Survival analysis was conducted via the Kaplan-Meier method and log-rank test. Cox regression model was used for multivariate analysis. Results. Gender, pathological type, treatment plan, clinical stage, and survival time of patients were different. Clinical stage was substantially related to the survival of patients ( $P<0.05$ ), which was an independent factor affecting prognosis. Conclusions. Early detection and comprehensive treatment of sinonasal malignancies can improve the prognosis and prolong the survival time of patients.

The Selective Role of Open and Endoscopic Approaches for Sinonasal Malignant Tumours

Endoscopic endonasal surgery has been demonstrated to be effective in the treatment of selected cases of sinonasal cancers. However, in cases of locally advanced neoplasms, as well as recurrences, the most appropriate approach is still debated. The present review aims to summarize the current state of knowledge on the utility of open approaches to resect sinonasal malignant tumours. Published comparative studies and meta-analyses suggest comparable oncological results with lower morbidity for the endoscopic approaches, but selection biases cannot be excluded. After a critical analysis of the available literature, it can be concluded that endoscopic surgery for selected lesions allows for oncologically safe resections with decreased morbidity. However, when endoscopic endonasal surgery is contraindicated and definitive chemoradiotherapy is not appropriate, craniofacial and transfacial approaches remain the best therapeutic option.

Sinonasal Squamous Cell Carcinoma Survival Outcomes Following Induction Chemotherapy vs Standard of Care Therapy

Objective

To compare oncologic outcomes in sinonasal squamous cell carcinoma (SNSCC) treated with standard of care (SOC) definitive therapy, consisting of surgery or chemoradiotherapy, vs induction therapy followed by definitive therapy.

Study Design

Retrospective review.

Setting

Academic tertiary care hospital.

Methods

The medical records of patients with biopsy-proven SNSCC treated between 2000 and 2020 were reviewed for demographics, tumor characteristics, staging, treatment details, and oncologic outcomes. Patients were matched 1-to-1 by age, sex, and cancer stage according to treatment received. Time-to-event analyses were conducted.

Results

The analysis included 26 patients with locally advanced SNSCC who received either induction therapy (n = 13) or SOC (n = 13). Baseline demographics, Charlson Comorbidity Index, and median follow-up time were well balanced. Weekly cetuximab, carboplatin, and paclitaxel were the most common induction regimen utilized. Tolerance and safety to induction were excellent. Objective responses were observed in 11 of 13 patients receiving induction. No difference in disease-free survival was found between the induction and SOC groups at 1 or 3 years. However, when compared with SOC, induction therapy resulted in significant improvement in overall survival at 2 years (100% vs 65.3%, P = .043) and 3 years (100% vs 48.4%, P = .016) following completion of definitive therapy. Two patients in the SOC group developed metastatic disease, as compared with none in the induction group.

Conclusions

Induction therapy was safe and effective. When compared with SOC, induction therapy improved 3-year overall survival.

Outcomes in surgical management of sinonasal malignancy-A single comprehensive cancer center experience

BACKGROUND

Sinonasal malignancies are a complex and diverse group of tumors. Over the past five decades, treatment advances have changed the management paradigms for these tumors. Our aim was to analyze the outcomes of patients from a comprehensive cancer center.

MATERIALS AND METHODS

We retrospectively assessed 400 patients with sinonasal malignancies treated with surgery at our center between 1973 and 2015. Multiple variables were reviewed to assess the influence on 5-year outcomes.

RESULTS

The median age was 56 years (IQR 46.8-68). Two hundred and fifty-nine (65%) were males and 141 (35%) were females. Overall survival (OS) and disease-specific survival (DSS) improved in the last analyzed decade. Orbital invasion, advanced pT-classification and pN-classification, and melanoma histology were associated with poorer outcomes.

CONCLUSION

Treatment outcomes for patients with sinonasal malignancy have improved over time. This is likely multifactorial with advances in surgical technique, adjuvant treatment, and patient selection. pT-classification, pN-classification, orbital invasion, and histology are predictive of survival.

Endoscopic endonasal resection of sinonasal teratocarcinosarcoma with intracranial breakthrough: illustrative case

BACKGROUND

Teratocarcinosarcoma traversing the anterior skull base is rarely reported in literature. The heterogenous and invasive features of the tumor pose challenges for surgical planning. With technological advancements, the endoscopic endonasal approach (EEA) has been emerging as a workhorse of anterior skull base lesions. To date, no case has been reported of EEA totally removing teratocarcinosarcomas with intracranial extensions.

OBSERVATIONS

The authors provided an illustrative case of a 50-year-old otherwise healthy man who presented with left-sided epistaxis for a year. Imaging studies revealed a 31 × 60-mm communicating lesion of the anterior skull base. Gross total resection via EEA was achieved, and multilayered skull base reconstruction was performed.

LESSONS

The endoscopic approach may be safe and effective for resection of extensive teratocarcinosarcoma of the anterior skull base. To minimize the risk of postoperative cerebrospinal fluid leaks, multilayered skull base reconstruction and placement of lumbar drainage are vitally important.

Preliminary Study of Chemoradiotherapy Using Modified Docetaxel, Cis-diaminodichloroplatinum, and 5-Fluorouracil for Sinonasal Squamous Cell Carcinoma

Objective

To examine the safety and efficacy of concomitant chemoradiotherapy using a modified TPF regimen (docetaxel + cisplatin + 5-fluorouracil) in patients with advanced sinonasal squamous cell carcinoma (SNSCC).

Study Design

Retrospective study.

Setting

Tertiary center (university hospital).

Methods

Seven patients with previously untreated T3-T4 SNSCC were enrolled. They underwent radiotherapy once daily (total dose, 70 Gy) with 2 courses of concomitant 120-hour infusion of 5-fluorouracil (600 mg/m²/d), docetaxel (50 mg/m², day 2), and cisplatin (60 mg/m², day 2)

Results

Grade 4 leukopenia, grade 4 neutropenia, and grade 3 lymphopenia were observed in 1, 3, and 4 patients, respectively. Grade 4 creatinine elevation was observed in 1 patient. However, other grade 3 or 4 adverse events were not common. Complete response was obtained in all patients. At 60 months there was 85.7% disease-free survival and 100% overall.

Conclusion

Concomitant chemoradiotherapy with a modified TPF regimen may be feasible and effective in patients with advanced SNSCC.

Rare case of metastatic adenocarcinoma to the maxillary sinus

Colorectal carcinoma metastases to the head and neck are exceedingly rare. Patients may present with vague symptoms that may lead to a delay in diagnosis. We report the case of a 51-year-old man with a known history of stage IIIB colorectal adenocarcinoma who presented with right-sided molar tooth bleeding and right-sided palate swelling that led to difficulty speaking, eating and weight-loss of 15 pounds. Imaging studies revealed a 3.1×4.8×3 cm mass that was centred around the posterior aspect of the maxilla. Pathology revealed moderately differentiated intestinal type adenocarcinoma of colonic subtype, immune histochemistry was positive for CDX2, CK20 and MUC2, thus confirming metastatic disease to the maxilla. The patient is undergoing chemoradiation therapy for palliation of his symptoms. Clinicians should be aware of this potentional site of metastatic disease and suspect the diagnosis in a timely manner to avoid delays in making a diagnosis.

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

Introduction

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

Case Description

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

Summary

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

Predictors of survival outcomes in sinonasal squamous cell carcinoma: an analysis of the National Cancer Database

BACKGROUND

Sinonasal squamous cell carcinoma (SNSCC) is a rare malignancy that poses management challenges. Although surgery and chemoradiation therapy (CRT) remain therapeutic mainstays, induction chemotherapy (IC) has emerged as a useful adjunct with locally advanced disease. This study used the National Cancer Data Base (NCDB) to examine treatment outcomes for patients diagnosed with SNSCC.

METHODS

The NCDB (2004-2015) was queried for cases with SNSCC. Multivariate hazard regression modeling was used to identify significant predictors of 24-month and 60-month overall survival (OS) including treatment modality.

RESULTS

A total of 3516 patients with SNSCC met inclusion criteria, including 1750 patients (49.8%) treated with surgery ± adjuvant therapy, 1352 (38.5%) treated with definitive radiotherapy (RT) or CRT, 300 (8.5%) who underwent IC followed by definitive CRT, and 114 (3.2%) who received IC followed by surgery and adjuvant therapy. Hazard modeling for confirmed treatment modality significantly associated (p < 0.001) with OS after adjustment. Patients who received surgical intervention ± adjuvant therapy had lower 24-month and 60-month mortality risk compared to definitive RT or CRT (hazard ratio [HR] ≥ 1.97; p < 0.001) or IC followed by definitive CRT (HR ≥ 1.73; p < 0.001). Compared to primary surgery ± adjuvant therapy, patients undergoing IC then surgery had similar 24-month and 60-month OS (p ≥ 0.672) after adjustment.

CONCLUSION

Multimodality therapy, including surgical intervention, associates with improved OS after multifactorial adjustments. IC followed by surgery associated with improved OS compared to IC, followed by CRT and CRT alone. Study results highlight the utility of surgery toward optimizing OS in patients with SNSCC and demonstrates the potential utility of IC when primary surgical management is not preferred.

Outcomes of Primary Versus Salvage Surgery for Sinonasal Malignancies: A Population-Based Analysis

OBJECTIVES/HYPOTHESIS

There exists a lack of consensus on the optimal sequence of treatment for many sinonasal malignancies (SNMs). This study compares the overall survival (OS) outcomes for primary surgery (PS) versus salvage surgery (SS) in SNM patients across stage, histology, and primary site.

STUDY DESIGN

Retrospective database review.

METHODS

The National Cancer Database was queried for all SNM cases treated with multimodal surgical and nonsurgical therapy between 2004 and 2015. Logistic regression identified predictors of SS. Cox proportional hazards models evaluated predictors of mortality, and Kaplan-Meier log-rank test assessed OS outcomes.

RESULTS

Our SNM cohort consisted of 3,011 patients (PS = 2,804; SS = 207). SS patients had significantly longer postoperative hospital stays (P = .009) and increased rates of 30-day (P < .001) and 90-day mortality (P < .001) compared to PS. On multivariate logistic regression, predictors of undergoing SS included sinonasal undifferentiated carcinoma histology (odds ratio = 2.72; 95% confidence interval [CI]: 1.16-6.66; P = .024). On multivariate Cox proportional hazards analyses among SS patients, late-stage disease (hazard ratio [HR] = 4.80; 95% CI: 1.46-15.8; P = .01) and positive surgical margins (HR = 2.31; 95% CI: 1.29-4.13; P = .005) portended significantly worse OS. In the propensity score-matched cohort controlling for stage and histology, PS had significantly improved OS compared to SS (P = .007). Compared to SS, PS also had improved OS in subgroup analyses for patients with late-stage disease (P = .026) and squamous cell carcinoma histology (P = .006).

CONCLUSIONS

In our SMN cohort, PS resulted in improved OS outcomes compared to SS independent of stage and histology. Consideration may be given to primary surgical resection for SMN whenever feasible, though a targeted, individualized approach is warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E710-E718, 2021.

Adenoid Cystic Carcinoma of Salivary Gland: A Ten-Year Single Institute Experience

Adenoid cystic carcinoma is a rare tumor, accounting for about 7.5% of all salivary gland neoplasms. More frequent developing in minor salivary gland, this is a slow-growing tumor with a long-lasting natural evolution, quite aggressive locally, but which has a tendency toward local recurrence and even for distant metastasis. We conducted a retrospective study limited to a period of 10 years in a single medical institution to investigate the morphoclinical profile of this tumor. Thus, we have established that about 60% of the tumors developed in men, with near 40% of the cases in patients in the sixth decade and, most common, the pathology affected the parotid and minor salivary glands from the hard palate mucosa. Histopathologically, prevailed the solid variant, with 72% cases presenting perineural invasion, and 41% cases showing positive surgical resection margins. Most cases had a long-standing asymptomatic evolution, so that at the time of diagnosis, more than two thirds of the patients were at least in stage II-pTNM, and in one-fifth of the cases histopathology showed lymph nodes disseminations.

Comparison of outcomes between patients with de-novo sinonasal squamous cell carcinoma vs malignant transformations from inverted papillomas

BACKGROUND

The survival difference between de-novo sinonasal squamous cell carcinoma (DN-SNSCC) and SCC arising from inverted papillomas (IPs) is unclear. The purpose of this study was to compare the outcomes between DN-SNSCC and IP-transformed SNSCC (IP-SNSCC) patients.

METHODS

In this retrospective review, we compared IP-SNSCC and DN-SNSCC cases from the Eye and ENT Hospital of Fudan University from 2010 to 2017. A total of 162 patients (39 IP-SNSCC and 123 DN-SNSCC) were included in our study. Demographics, tumor characteristics, treatment, and clinical outcomes were analyzed.

RESULTS

The median follow-up time in all cohorts was 56 (range, 5-109) months. There was no difference in age, sex, smoking history, alcohol consumption, tumor primary site, or disease stage between the IP-SNSCC and DN-SNSCC patients. We also did not find significant differences in overall survival and disease-free survival between IP-SNSCC and DN-SNSCC patients (p = 0.584 and p = 0.238, respectively). The 5-year local failure rate was 52.8% for IP-SNSCC patients, which was significantly higher than for those with DN-SNSCC (31.9%; p = 0.013). The 5-year nodal failure rate was 19.0% for IP-SNSCC patients and 8.5% for DN-SNSCC patients (p = 0.211). The 5-year distant metastasis rate was 8.0% for IP-SNSCC patients and 16.1% for DN-SNSCC patients (p = 0.318).

CONCLUSION

IP-SNSCC and DN-SNSCC patients have similar survival outcomes. IP-SNSCC seems to have exhibited a higher local failure rate in our study. We believe that IP-SNSCC is a highly aggressive disease that requires radical treatment. Prophylactic neck treatment should not be omitted in a subset of IP-SNSCC patients.

Very unusual case of a primary sinonasal germ cell tumour

Sinonasal malignancies are a very rare diagnosis. We present a unique case of a 32-year-old man who presented with symptoms of worsening sinusitis and periorbital cellulitis. Investigation found a sinonasal malignancy and pathology confirmed this to be a primary germ cell tumour. The patient was managed with chemotherapy, surgery and consolidation radiotherapy and has remained well to date. This case report outlines an unusual presentation and diagnostic challenge for the primary care physician, ear, nose and throat surgeon, pathologist and oncologist with review of the surrounding literature.

Multimodal Therapy for Sinonasal Malignancies: Updates and Review of Current Treatment

OPINION STATEMENT

Sinonasal malignancies pose a significant challenge in management due to their low incidence, biologic diversity, and significant symptom burden. Even though surgery remains the primary therapeutic modality, a multi-modality approach has been shown to benefit a significant proportion of patients and its success depends largely on stage and histologic type. Non-surgical approaches such as novel radiation approaches as well as intensification with systemic therapy hold promise in altering the organ preservation rate as well as overall survival for patients. Practice changing randomized trials to test these novel modalities are overdue and desperately needed.

The value of preoperative radiotherapy in the treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinoma: A single institutional experience

OBJECTIVES

This study aimed to explore the value of preoperative radiotherapy in the comprehensive treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinomas (LA-NPSCCs).

MATERIALS

This retrospective study included 140 patients with stage III-IVB NPSCCs treated with pre-/postoperative radiotherapy plus surgery. The complete resection rate, pathologic complete response (pCR) rate, and orbital content retention rate were calculated. The overall survival (OS), local control (LC), distance metastasis free survival (DMFS) and disease-free survival (DFS) between treatment groups were evaluated.

RESULTS

With a median follow-up of 92.3 months, the 5-year OS, LC, DMFS, and DFS of entire cohort were 62.0%, 65.5%, 85.4%, and 57.8%, respectively. The preoperative radiotherapy group achieved similar LC, DFS, DMFS, and OS rates compared to postoperative radiotherapy group, despite higher rates of stage IV and orbital content/apex invasion. The preoperative radiotherapy resulted in significantly improved complete resection rate (93.3% vs 38.0%, p < 0.001). In the preoperative radiotherapy group, one third of patients achieved pathologic complete response. The pCR subgroup achieved statistically higher 5-year OS, LC, DFS (p < 0.05), but similar 5-year DMFS (p > 0.05) compared to non-pCR subgroup. The actual orbital content retention rate in preoperative radiotherapy group was 85.7%, superior to 58.3% in postoperative radiotherapy group (p = 0.049).

CONCLUSION

On the basis of multimodality therapy becoming standard paradigm for LA-NPSCCs, preoperative radiotherapy significantly improved complete resection rate and orbital content retention rate. Therefore, preoperative radiotherapy followed by surgery might be desirable for LA-NPSCCs, especially for those with organ preservation intention.

Management of orbital invasion in sinonasal squamous cell carcinoma: 15 years' experience

BACKGROUND

This study was intended to review our management strategy for sinonasal squamous cell carcinomas (SNSCCs) with orbital invasion and to explore the role of radiotherapy in orbital preservation.

METHODS

We retrospectively analyzed 93 SNSCC patients with orbital invasion who underwent radiotherapy with or without surgery over the past 15 years. The degree of orbital invasion was classified into 3 grades.

RESULTS

Eighty-eight patients presented with T4 tumors and 36 had grade III orbital invasion. Seventy-two patients received surgery plus radiation and 67 received platinum-based chemotherapy. The median follow-up for surviving patients was 60 months. Five-year overall survival (OS) for the whole group was 57.4%. The patients treated with surgery plus radiation had a 5-year survival rate of 62.2% and orbital preservation was feasible in 90.3% of cases. Twenty-one patients with SNSCCs that extended into the extraocular muscles or eye globe also underwent orbital preservation. Five-year locoregional relapse-free survival (LRFS) was 69.5% for patients treated with orbital preservation and 57.1% for those treated with orbital exenteration, indicating no statistical difference. Five-year survival, 5-year progression-free survival (PFS), and 5-year distant metastasis-free survival (DMFS) were similar between groups. Grade III orbital invasion was independently associated with shorter OS, LRFS, PFS, and DMFS.

CONCLUSION

Orbital invasion in grade III was associated with the worst survival outcomes. Invasion of either the extraocular muscles or eye globe is not a contraindication for eye-sparing surgery. Preoperative chemoradiation continues to offer hope to patients with a strong desire to preserve their eyes.

Surgical Outcomes of Endoscopic Versus Open Resection for Primary Sinonasal Malignancy: A Meta-analysis

Background

Endoscopic resection (ER) for uncommon sinonasal malignancies (SNMs) has been reported to confer superior surgical outcomes compared to open resection (OR) based on indirect comparisons of limited evidence.

Objective

The aim of this study was to pool all direct comparative studies in the literature to validate this potential superior association.

Methods

Systematic searches of 7 electronic databases from their inception to April 2019 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1001 articles identified for screening. Outcomes of interest were pooled as risk ratios (RRs) and mean difference (MD) and analyzed using a random-effects model.

Results

There were 10 studies included in this meta-analysis, with 900 SNM patients in total where ER and OR were utilized in 399 (44%) and 501 (56%) cases, respectively. Compared to OR, random-effects (RE) modeling indicated ER resulted in statistically comparable complications (RR = 0.68; P-effect = .12) and recurrence (RR = 0.84; P-effect = .35). ER was associated with significantly shorter length of stay (LOS) compared to OR (MD = −2.9 days; P-effect <.01).

Conclusions

The use of ER to manage SNM was associated with significantly favorable reduction in LOS compared to OR. However, with respect to other surgical outcomes and recurrence, the current literature does not indicate either ER or OR as statistically superior. Therefore, until greater validation of these associations can be proven, expectations that ER for SNMs confers superior surgical outcomes compared to OR should be tempered.

Performance of whole-body 18F-FDG PET/CT as a posttreatment surveillance tool for sinonasal malignancies

PURPOSE

To determine the diagnostic utility of posttreatment surveillance whole-body ¹⁸F-FDG PET/CT in detecting local tumor recurrence (R), regional lymph-node metastasis (LM), and distant metastasis (DM) in asymptomatic sinonasal cancer patients.

METHODS

Eighty consecutive patients (53 men, 27 women; mean age, 60 years; range, 28-92 years) who had undergone 197 posttreatment whole-body ¹⁸F-FDG PET/CT examinations for sinonasal malignancies between January 2009 and August 2017 were retrospectively reviewed. ¹⁸F-FDG PET/CT findings were categorized as positive or negative for R, LM, and DM, separately. Outcomes of ¹⁸F-FDG PET/CT scans were compared with the final diagnosis confirmed by histological analysis or follow-up period for a minimum 12 months. The diagnostic accuracy of scans was calculated for each site using contingency tables. Impact on the management of ¹⁸F-FDG PET/CT examinations was additionally evaluated.

RESULTS

¹⁸F-FDG PET/CT scans identified 37/44 of local recurrences, 21/23 of LMs, and 30/37 of DMs. For local recurrence, sensitivity, specificity, positive predictive value, and negative predictive value were 84% (68-97%), 95% (80-100%), 84% (68-97%), and 95% (80-100%), respectively. For LM, the respective values were 91% (75-100%), 99% (83-100%), 91% (75-100%), and 99% (83-100%). For DM, the values were 81% (64-97%), 99% (85-100%), 97% (81-100%), and 96% (81-100%), respectively. ¹⁸F-FDG PET/CT accounted for a change in management of 85% patients with recurrences.

CONCLUSIONS

Whole-body ¹⁸F-FDG PET/CT is a suitable surveillance tool for sinonasal malignancies in detecting locoregional and distant recurrences in asymptomatic patients without any evidence of recurrence on regular follow-up and endoscopy during the posttreatment period.

Results of preoperative chemoradiotherapy for patients with advanced cancer of the nasal cavity and paranasal sinuses

OBJECTIVES

Curative treatment of nasal cavity and paranasal sinus cancer is challenging due to the proximity to critical anatomical structures. The purpose of this study was to analyze the impact of trimodality therapy with preoperative chemotherapy and reduced-dose radiotherapy followed by organ-preserving surgery for treating patients with nasal cavity and paranasal sinus cancer.

METHODS

This retrospective study included all 156 patients diagnosed with sinonasal cancer in western Sweden between 1986 and 2009. We determined the treatment selection pattern and treatment outcomes for 79 patients treated with preoperative chemoradiotherapy.

RESULTS

Squamous cell carcinoma was the most common histology. The five-year overall survival was 54%, and 85% of these patients had T3 or T4 tumors. The five-year cumulative incidence rate of local recurrence was 32%. The five-year overall survival in patients with squamous cell carcinoma and adenocarcinoma was 45% and 76%, respectively. The median preoperative radiation dose was 48 Gy. Orbital exenteration was performed in 7% of patients.

CONCLUSIONS

Preoperative chemoradiotherapy may be beneficial for patients with advanced sinonasal cancer when primary radical surgery is challenging. Survival outcomes were comparable to outcomes reported in the literature despite conservative surgery and relatively low radiation doses in patients with locally advanced tumors.

A comprehensive comparative analysis of treatment modalities for sinonasal malignancies

BACKGROUND

Sinonasal malignancies are a rare and heterogeneous group of tumors for which there is a paucity of robust data with which to guide management decisions. The authors used the National Cancer Data Base to better understand the presenting characteristics of these tumors and to compare outcomes by treatment modality.

METHODS

The National Cancer Data Base was queried for sinonasal malignancies diagnosed between 2004 and 2012. Overall survival was assessed using multivariate analyses and propensity score matching.

RESULTS

A total of 11,160 patients were identified for the initial analysis. The majority were male, aged 40 to 69 years, with tumors of the nasal cavity or maxillary sinus. Squamous cell histology was most common. The majority of patients presented with advanced tumor stage but without locoregional lymph node or distant metastases. Treatment modalities were compared for squamous cell carcinomas. In multivariate analysis, compared with surgery alone, patients who received adjuvant radiotherapy (hazard ratio [HR], 0.658 [P<.001]), adjuvant chemoradiotherapy (HR, 0.696 [P = .002]), or neoadjuvant therapy (HR, 0.656 [P = .007]) had improved overall survival. Patients who received radiotherapy alone (HR, 1.294 [P = .001]) or chemotherapy alone (HR, 1.834 [P<.001]) had worse outcomes. These findings were validated in propensity score matching. It is important to note that neoadjuvant chemoradiotherapy was associated with achieving a negative surgical margin (odds ratio, 2.641 [P = .045]).

CONCLUSIONS

Surgery is the mainstay of therapy for patients with sinonasal malignancies, but multimodality therapy is associated with improved overall survival. Cancer 2017;123:3040-49. © 2017 American Cancer Society.

Superior orbitectomy and chemotherapy in a dog with frontal sinus squamous cell carcinoma: a case report and review of the literature

A superior orbitectomy can be a challenging but accomplishable surgical option in dogs with a tumor which involves the dorsal bony part of the orbit. The procedure described in this report can be vision‐sparing and life prolonging even in a case of an aggressive growing frontal sinus squamous cell carcinoma.

The Role of Radiation Therapy in the Management of Sinonasal and Ventral Skull Base Malignancies

Sinonasal and ventral skull base malignancies are rare tumors that arise in a complex anatomic location juxtaposed with critically important normal tissues. The standard treatment paradigm for most histologies has been surgery followed by postoperative radiation therapy. Because of their propensity to present at an advanced stage and the presence of nearby critical structures, patients are at risk for severe radiation-induced long-term toxicity. Recent advances in radiotherapy technique have improved the therapeutic ratio between tumor control and normal tissue toxicity. This article reviews issues pertinent to the use of radiotherapy in the management of these tumors.

ACR appropriateness criteria® nasal cavity and paranasal sinus cancers

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.

Therapy of sinonasal malignancies invading the orbit-orbital exenteration versus preservation of the orbit plus radiotherapy

INTRODUCTION

Orbital invasion is a strong independent prognostic factor for sinonasal malignancies. While there is consent about preservation of the orbit for tumors limited to the orbital periosteum there is controversy about the optimal management of sinonasal malignancies transgressing this barrier. Therefore the aim of our study was to compare exenteration versus preservation of the orbit.

MATERIAL AND METHODS

52 patients with sinonasal malignancies invading the orbit beyond the orbital periosteum with involvement of the orbital soft tissues were included in the retrospective study. Prognostic factors were identified through univariate analysis.

RESULTS

Univariate analysis revealed a significant impact of N-classification (p = 0.017), and treatment strategy (p = 0.016). Exenteration of the orbit was associated with a significantly better 5-year overall survival rate (65.5%) than preservation of the orbit (14%).

CONCLUSIONS

For patients with invasion of the structures beyond the orbital periosteum, exenteration yields better survival results than preservation of the orbital structures in combination with radiotherapy. In cases where both eyes are affected from the tumor or if only one dysfunctional eye would be left over after therapy, we do not recommend orbital exenteration because life quality would be critically deteriorated.

Outcomes of nonsurgical management of locally advanced carcinomas of the sinonasal cavity

OBJECTIVE

To determine the outcome of definitive concurrent chemoradiation with platinum for locally advanced sinonasal carcinomas.

STUDY DESIGN

Retrospective cohort.

METHODS

Twenty-three nonsurgically and definitively treated patients diagnosed between July 1998 and February 2009 were analyzed. Patients with adenoid cystic carcinoma or adenocarcinoma were treated with photons and neutrons; the other histologies received photons alone. The vast majority received chemotherapy. Descriptive statistics were utilized, and Kaplan-Meier estimates were computed.

RESULTS

Female (57%) and Caucasian (74%) preponderance were observed. Eighty-seven percent were unresectable; the maxillary and nasoethmoid sites were equally prevalent. Intensity-modulated radiation therapy (IMRT) and photons alone were utilized in 74% and 70%, respectively. Platinum agents were given in 95% of chemotherapy patients. Complete response was observed in 64% of patients. Median progression-free survival (PFS) and overall survival (OS) were 28.8 and 65.3 months, respectively. Three-year PFS and OS rates were 44% and 72%, respectively; 5-year PFS and OS rates were 30% and 60%, respectively. Intensity-modulated radiation therapy and a maxillary site of origin showed a trend toward superior PFS; higher-dose regimens were associated with somewhat shorter PFS. Relapse was observed in 59% of patients, predominantly local. There were few unanticipated adverse effects, and no grade IV/V events were reported.

CONCLUSION

Advanced sinonasal carcinomas are chemoradiosensitive tumors, albeit with a high propensity for local relapse. There is a definite indication for IMRT and a potential curative role of platinum-based chemoradiation regimens.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:855-861, 2017.

A clinical study of multimodal treatment for orbital organ preservation in locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus

OBJECTIVE

This study aimed to investigate the efficacy of induction chemotherapy followed by concurrent chemotherapy and helical tomotherapy in patients with T4b squamous cell carcinoma of the nasal cavity and paranasal sinus in regard to orbital organ preservation and quality of life.

METHODS

Clinical data of 28 cases of patients with orbital involvement of T4b squamous cell carcinoma of the nasal cavity and paranasal sinus who received multimodal treatment for orbital organ preservation between May 2008 and September 2015 were retrospectively analysed. The treatment efficacy and side effects were assessed. The study included 18 male and 10 female patients. All patients were treated with induction chemotherapy followed by concurrent chemoradiotherapy and/or epidermal growth factor receptor inhibitor. Helical tomotherapy was applied as radiotherapy. Adverse reactions to the chemotherapy were assessed according to Common Terminology Criteria for Adverse Events, Version 4. The overall survival rate, local control rate and rate of effective orbital preservation were calculated using the Kaplan-Meier method.

RESULTS

All patients completed the planned chemotherapy, and 27 (96.4%) of the patients completed the planned radiotherapy cycle. After the multimodal treatment, the 3-year overall survival, local control rate and rate of effective orbital preservation of the patients were 59.2%, 80.2% and 77.8%, respectively.

CONCLUSIONS

Multimodal treatment could preserve the orbital organs of patients with T4b squamous cell carcinoma of the nasal cavity and paranasal sinus, achieve relatively ideal organ protection and survival rates and improve the quality of life of patients with advanced squamous cell carcinoma of the nasal cavity and paranasal sinus, thus providing a new treatment option for these patients.

Induction chemotherapy in head and neck squamous cell carcinoma of the paranasal sinus and nasal cavity: a role in organ preservation

BACKGROUND/AIMS

The role of induction chemotherapy (IC) for eyeball preservation has not been established in head and neck squamous cell carcinoma (HNSCC) of the paranasal sinus and nasal cavity (PNSNC). Periorbital involvement frequently leads to eyeball exenteration with a margin of safety. We evaluated the treatment outcomes, including survival and eyeball preservation, of patients who received IC for HNSCC of the PNSNC.

METHODS

We reviewed 21 patients diagnosed with HNSCC of the PNSNC who were treated with IC. We analyzed response, eyeball preservation rate, and overall survival.

RESULTS

Tumors were located in the paranasal sinus (n = 14) or nasal cavity (n = 7). Most patients had stage T4a (n = 10) or T4b (n = 7) disease. More than half of the patients received a chemotherapy regimen of docetaxel, fluorouracil, and cisplatin (n = 11). Thirteen patients (61.9%) achieved a partial response after IC and 15 patients (71.4%) achieved T down-staging. Among 17 patients with stage T4 disease, which confers a high risk of orbital exenteration, 14 (82.4%) achieved preservation of the involved eye. The 3-year overall survival (OS) rate of patients who achieved a partial response to IC was 84.6%. The 3-year OS rate of patients with stable disease or disease progression after IC was 25.0% (p = 0.038).

CONCLUSIONS

IC could be considered for down-staging patients with advanced T-stage disease. It could also be a reasonable option for eyeball preservation in locally advanced HNSCC of the PNSNC.

Advantage of Extended Craniofacial Resection for Advanced Malignant Tumors of the Nasal Cavity and Paranasal Sinuses: Long-Term Outcome and Surgical Management

OBJECTIVE

Craniofacial resection (CFR) for advanced sinonasal malignant tumors (SNMTs) is mandatory for radical resection. Surgeons must be aware of perioperative complications and long-term outcome because this procedure is extremely invasive, especially when the tumor involves the anterior skull base.

METHODS

Thirty-eight consecutive surgical patients with advanced SNMT of T4 stage or Kadish stage C (31 men and 7 women; mean age, 55 years; range: 19-76 years) treated with CFR in the past 28 years were followed up for 59.4 months. In cases of unilateral orbital extension, en-bloc resection was achieved using several neurosurgical techniques (extended CFR) from 2005 onwards. Herein, we evaluated the safety and effectiveness of surgery by comparing survival data between 2 time periods (first stage: 1984-2004, second stage: 2005-2012).

RESULTS

Squamous cell carcinoma was the most common histological type observed (65.8%), followed by esthesioneuroblastoma (15.8%). Using a combination of adjuvant radiation therapy, the 5-year overall survival and the 5-year disease-specific survival rates were 55.5% and 59.4%, respectively. Sarcomatous histology was a poor prognostic factor. The 5-year disease-specific survival rate was 48.9% in the first stage and improved to 82.1% in the second stage (P = 0.057); this was related to improvements in local control rate.

CONCLUSIONS

CFR and postoperative radiotherapy are safe and effective for treating advanced SNMTs. Extended CFR, including radical orbital exenteration, may contribute to good long-term outcomes. A diverse surgical team may help perform radical resection and reconstruction in patients with advanced tumors.

Neoadjuvant Chemotherapy in Locally Advanced and Borderline Resectable Nonsquamous Sinonasal Tumors (Esthesioneuroblastoma and Sinonasal Tumor with Neuroendocrine Differentiation)

INTRODUCTION

Sinonasal tumors are chemotherapy responsive which frequently present in advanced stages making NACT a promising option for improving resection and local control in borderline resectable and locally advanced tumours. Here we reviewed the results of 25 such cases treated with NACT.

MATERIALS AND METHODS

Sinonasal tumor patients treated with NACT were selected for this analysis. These patients received NACT with platinum and etoposide for 2 cycles. Patients who responded and were amenable for gross total resection underwent surgical resection and adjuvant CTRT. Those who responded but were not amenable for resection received radical CTRT. Patients who progressed on NACT received either radical CTRT or palliative radiotherapy.

RESULTS

The median age of the cohort was 42 years (IQR 37-47 years). Grades 3-4 toxicity with NACT were seen in 19 patients (76%). The response rate to NACT was 80%. Post-NACT surgery was done in 12 (48%) patients and radical chemoradiation in 9 (36%) patients. The 2-year progression free survival and overall survival were 75% and 78.5%, respectively.

CONCLUSION

NACT in sinonasal tumours has a response rate of 80%. The protocol of NACT followed by local treatment is associated with improvement in outcomes as compared to our historical cohort.

Endoscopic sinus surgery for chronic rhinosinusitis in patients previously treated for sinonasal malignancy

OBJECTIVES/HYPOTHESIS

Patients with a history of sinonasal malignancy can develop chronic rhinosinusitis (CRS) as a consequence of their oncologic treatment. Some patients will fail medical management and require endoscopic sinus surgery (ESS). This study reviews the use of ESS in the management of CRS in patients previously treated for sinonasal malignancy.

STUDY DESIGN

Retrospective review.

METHODS

All patients with a history of sinonasal malignancy who developed CRS and underwent ESS were reviewed. Preoperative and postoperative imaging and symptoms were collected. Major complications (bleeding, orbital injury, and cerebrospinal fluid leak) and minor complications (adhesion formation) and postoperative healing were reviewed.

RESULTS

Eighteen patients were identified. All patients presented with symptoms of CRS and sinonasal crusting. Additionally, five patients presented with recurrent facial cellulitis, and six patients had mucoceles. No major complications were encountered. Postoperatively, all patients reported a subjective improvement in their sinonasal symptoms. Comparison of pre- and post-ESS imaging revealed a significant improvement in Lund-Mackay scores after ESS (P < 0.001) from 12.8 (range 5-22) to 7 (range). Despite symptomatic improvement, all patients continued to have nasal crusting. All patients who initially presented with recurrent facial cellulitis had no further episodes after ESS. None of the endoscopically drained mucoceles recurred.

CONCLUSION

For patients previously treated for sinonasal malignancy with refractory CRS, ESS appears to be a safe and effective treatment option. ESS in these patients results in subjective improvement in sinonasal symptoms as well as objective improvement in radiographic CRS disease burden, although sinonasal crusting will likely not resolve.

LEVEL OF EVIDENCE

4.

Impact of tumour volume on prediction of progression-free survival in sinonasal cancer

Background

The present study aimed to analyse potential prognostic factors, with emphasis on tumour volume, in determining progression free survival (PFS) for malignancies of the nasal cavity and the paranasal sinuses.

Patients and methods

Retrospective analysis of 106 patients with primary sinonasal malignancies treated and followed-up between March 2006 and October 2012. Possible predictive parameters for PFS were entered into univariate and multivariate Cox regression analysis. Kaplan-Meier curve analysis included age, sex, baseline tumour volume (based on MR imaging), histology type, TNM stage and prognostic groups according to the American Joint Committee on Cancer (AJCC) classification. Receiver operating characteristic (ROC) curve analysis concerning the predictive value of tumour volume for recurrence was also conducted.

Results

The main histological subgroup consisted of epithelial tumours (77%). The majority of the patients (68%) showed advanced tumour burden (AJCC stage III–IV). Lymph node involvement was present in 18 cases. The mean tumour volume was 26.6 ± 21.2 cm³. The median PFS for all patients was 24.9 months (range: 2.5–84.5 months). The ROC curve analysis for the tumour volume showed 58.1% sensitivity and 75.4% specificity for predicting recurrence. Tumour volume, AJCC staging, T- and N- stage were significant predictors in the univariate analysis. Positive lymph node status and tumour volume remained significant and independent predictors in the multivariate analysis.

Conclusions

Radiological tumour volume proofed to be a statistically reliable predictor of PFS. In the multivariate analysis, T-, N- and overall AJCC staging did not show significant prognostic value.

The role of systemic therapy in the management of sinonasal cancer: A critical review

PURPOSE

Due to the rarity and the variety of histological types of sinonasal cancers, there is a paucity of data regarding strategy for their optimal treatment. Generally, outcomes of advanced and higher grade tumors remain unsatisfactory, despite the employment of sophisticated surgical approaches, technical advances in radiation techniques and the use of heavy ion particles. In this context, we critically evaluated the role of systemic therapy as part of a multidisciplinary approach to locally advanced disease.

RESULTS

Induction chemotherapy has shown encouraging activity and could have a role in the multimodal treatment of patients with advanced sinonasal tumors. For epithelial tumors, the most frequently employed chemotherapy is cisplatin, in combination with either 5-fluorouracil, taxane, ifosfamide, or vincristine. Only limited experiences with concurrent chemoradiation exist with sinonasal cancer. The role of systemic treatment for each histological type (intestinal-type adenocarcinoma, sinonasal undifferentiated carcinoma, sinonasal neuroendocrine carcinoma, olfactory neuroblastoma, sinonasal primary mucosal melanoma, sarcoma) is discussed.

CONCLUSIONS

The treatment of SNC requires a multimodal approach. Employment of systemic therapy for locally advanced disease could result in better outcomes, and optimize the therapeutic armamentarium. Further studies are needed to precisely define the role of systemic therapy and identify the optimal sequencing for its administration in relation to local therapies.

Treatment outcomes of concurrent chemoradiotherapy for locally advanced sinonasal squamous cell carcinoma: A single-institution study

CONCLUSIONS

CCRT is a potential treatment option for locally advanced sinonasal SCC in terms of organ preservation.

OBJECTIVES

Concurrent chemoradiotherapy (CCRT) is increasingly used for patients with advanced head and neck cancer to preserve organ function and improve survival. In the present study, treatment outcomes were compared between surgery and post-operative radiotherapy (PORT) and CCRT in patients with locally advanced sinonasal squamous cell carcinoma (SCC).

METHODS

The records of 30 patients with non-metastatic stage III and IV sinonasal SCC were retrospectively reviewed. Fifteen patients were treated with CCRT and 15 patients underwent PORT.

RESULTS

The locoregional recurrence-free, distant metastasis-free, disease-free, disease-specific, and overall survival rates did not differ between PORT and CCRT groups. In addition, there were no significant differences in incidence rates of acute and chronic toxicities between the two groups.

Orbital complications:diagnosis of different rhinological causes

To evaluate the clinical course of orbital complication using a standardised diagnostic pathway. Seventy-three patients with orbital complications underwent a multimodal diagnostic pathway comprising ENT examination, leucocytes/CRP, CT-/MRI-scanning and disease-related data. Twenty-nine patients suffered from rhinosinusitis, 28 from mucoceles, 13 patients from neoplasms and three patients from rheumatic disorders. Clinical examination diagnosed 60 patients with eyelid swelling, 55 patients with ocular pain, 14 patients with diplopia, 4 patients with exophthalmus, 29 patients with visual field defect and 4 patients with visual loss. The diagnostic pathway identified acute rhinosinusitis with a sensitivity/specificity of 90 %/90 %, mucoceles with 79 %/100 %, neoplasms with 100 %/96 % and granulomatosis with polyangiitis with 100 %/100 %, respectively. All patients left the hospital in good general condition and with regular ocular motility; two patients suffered persistent visual loss. The standardised application of a widely accepted diagnostic pathway reliably distinguishes different causes of orbital complication.

Surgical outcomes of malignant sinonasal tumours: open versus endoscopic surgical approaches

BACKGROUND

Sinonasal malignancies are rare tumours, which can be resected using an open or endoscopic approach. The current study evaluated the outcome of both approaches.

METHODS

A total of 160 patients with malignant nasal tumours were evaluated in an academic tertiary care hospital. The patients were allocated to 'open' or 'endoscopic' surgery groups, based on the surgical approach employed. The following data were evaluated and compared: patient and tumour characteristics; oncological treatments; and oncological outcomes, including complications, surgical margin, recurrence, overall survival and disease-free survival.

RESULTS

The maxillary sinus was the most common tumour location and squamous cell carcinoma was the most common histopathology-based diagnosis. Younger patients had lower grades of tumour. Higher survival rates were significantly related to lower tumour stages in both surgery groups. There were no differences between the two relatively similar groups in terms of surgical margin, the need for adjunctive therapy, and recurrence and survival rates. In addition, multivariate logistical regression analysis indicated no correlations between the type of surgical approach employed and the rates of recurrence and complications.

CONCLUSION

Endoscopic surgery for sinonasal malignancies is comparable to the conventional open approach in carefully selected patients.

Primary carcinoma of the frontal sinus with extensive intracranial invasion: A case report and review of the literature

Primary carcinoma of the frontal sinus is quite rare, with an incidence of 0.3–1.0% of all paranasal sinus carcinomas. The early diagnosis is often difficult and the condition is often mistakenly considered to involve mucoceles, pyoceles or osteomyelitis. The present study reports the case of a 66-year-old male with squamous cell carcinoma originating in the frontal sinus. The presenting symptoms were a cutaneous nodule on the left side of the forehead and a gradually progressive headache. Magnetic resonance imaging (MRI) demonstrated erosion of the ethmoid sinus, frontal lobe and orbit. The radical resection under frontal craniotomy was performed followed by post-operative radiotherapy. Six months after the surgery, the MRI examinations did not find any recurrence, and the patient currently lives symptom-free. The present study illustrates that frontal sinus cancer should be diagnosed early with caution. Total surgical resection followed by radiotherapy and chemotherapy, used singly or in combination, may result in favorable outcomes. The current study discusses the diagnosis, treatment and prognosis of the present case and reviews the associated literature to emphasize the importance of an early identification of this rare disease.