Impact of Dural Resection on Sinonasal Malignancies with Skull Base Encroachment or Erosion

Diagnostic Accuracy of MRI for Orbital and Intracranial Invasion of Sinonasal Malignancies: A Systematic Review and Meta-Analysis

Background/Objectives: In this study, we review the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting orbital and intracranial invasion of sinonasal malignancies (SNMs) using histopathological and surgical evidence as the reference standard. Methods: A systematic search of studies in English was conducted in MEDLINE and Embase, limited to articles published since 1990. We included studies using preoperative MRI to detect the intracranial and orbital invasion of SNMs, with histological or surgical confirmation as the reference standard, and reported patient numbers in each class as required to assess diagnostic accuracy. The outcome measures were sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Heterogeneity was assessed with the Higgins inconsistency test (I2). Results: Seven original articles with 546 subjects were included in the review, with six included in the meta-analysis. The pooled overall accuracy for orbital invasion was higher at 0.88 (95% CI, 0.75-0.94) than that for intracranial invasion at 0.80 (95% CI, 0.76-0.83). The meta-analytic estimates and their 95% confidence intervals were as follows for intracranial/orbital invasion: sensitivity 0.77 (0.69-0.83)/0.71 (0.40-0.90); specificity 0.79 (0.74-0.83)/0.91 (0.78-0.97); PPV 0.76 (0.64-0.85)/0.78 (0.61-0.88); and NPV 0.82 (0.72-0.89)/0.90 (0.63-0.98). Substantial heterogeneity was observed in the Higgins inconsistency test (I2) for orbital invasion (84%, 83%, and 93% for sensitivity, specificity, and NPV, respectively). Conclusions: MRI yielded moderate-to-high diagnostic accuracy for intracranial and orbital invasion, despite some limitations leading to false diagnoses. Loss of the hypointense zone on postcontrast MRI was found to predict dural invasion. Infiltration of the extraconal fat beyond the periorbita was found to be an MRI feature of orbital invasion.

Imaging of Skull Base and Orbital Invasion in Sinonasal Cancer: Correlation with Histopathology

Simple Summary

Pretreatment assessment of local extension in sinonasal cancer is essential for prognostic evaluation and surgical planning. It essentially relies on CT and MRI imaging whose performance is not accurately described in the scientific literature. The aim of this study was to assess the diagnostic performance of CT and MRI for the diagnosis of skull base and orbital invasion in sinonasal cancer by comparing imaging findings to histopathological data. A total of 176 patients were included. Objective data about the diagnostic value of pretreatment imaging in patients with sinonasal cancer were obtained: they suggest that pretreatment assessment of orbital invasion is difficult, even with the combination of CT and MRI.

Abstract

Background: Pretreatment assessment of local extension in sinonasal cancer is essential for prognostic evaluation and surgical planning. The aim of this study was to assess the diagnostic performance of two common imaging techniques (CT and MRI) for the diagnosis of skull base and orbital invasion by comparing imaging findings to histopathological data. Methods: This was a retrospective two-center study including patients with sinonasal cancer involving the skull base and/or the orbit operated on between 2000 and 2019. Patients were included only if pre-operative CT and/or MRI, operative and histopathologic reports were available. A double prospective blinded imaging review was conducted according to predefined radiological parameters. Radiologic tumor extension was compared to histopathological reports, which were considered the gold standard. The predictive positive value (PPV) for the diagnosis of skull base/orbital invasion was calculated for each parameter. Results: A total of 176 patients were included. Ethmoidal intestinal-type adenocarcinoma was the most common type of cancer (41%). The PPV for major modification of the bony skull base was 78% on the CT scan, and 89% on MRI. MRI signs of dural invasion with the highest PPVs were: contact angle over 45° between tumor and dura (86%), irregular deformation of dura adjacent to tumor (87%) and nodular dural enhancement over 2 mm in thickness (87%). Signs of orbital invasion had low PPVs (<50%). Conclusions: This retrospective study provides objective data about the diagnostic value of pretreatment imaging in patients with sinonasal cancer.

[Treatment of primary craniofacial (sinonasal) malignant tumors affecting the anterior and middle skull base]

Sinonasal malignant tumors are characterized by high histological variability and complexity of the differential diagnosis. Currently, there are classifications of these tumors, which are based on their localization and involvement of various anatomical structures. However, generally accepted algorithms for treatment of this pathology have not yet been developed. This review describes the most important algorithms for treatment of the most common histological variants of sinonasal malignant tumors: squamous cell carcinoma, adenocarcinoma, sinonasal undifferentiated carcinoma, esthesioneuroblastoma, adenoid cystic cancer, and sinonasal adenocarcinoma. The main problems in choosing the approach for treating these tumors are the lack of generally accepted resectability criteria and contradictions between oncological and neurosurgical indications for surgical treatment. Further research is needed to study the role of radiosensitizers and radioprotectors in comprehensive treatment of sinonasal malignant tumors.

Management of squamous cell carcinomas of the skull-base

PURPOSE

The purpose of this review is to assess the recent evidence regarding the management of squamous cell carcinoma of the skull-base and to discuss the implications of these findings on clinical practice.

METHOD

Free text Medline and MeSH term search of publications relating to Squamous Cell Carcinoma & Skull-base and Skull base, Neoplasm respectively. Multidisciplinary clinical guidelines were also reviewed.

RESULTS

The primary search yielded a total of 271 papers which following initial review was reduced to 28. Secondary search yielded 56 papers. There were no randomised controlled trials relating to squamous cell carcinoma of the skull-base and as such this review is based on cohort studies, case series and expert opinion.

CONCLUSION

Squamous cell carcinoma (SCC) is the most common cancer occurring in the Head and Neck. Squamous cell carcinoma is also the most common cancer arising within the nose and sinuses of which skull-base squamous cell carcinoma is a rare subgroup. Evidence relating to the management and survival of skull-base SCC is based on expert opinion and. retrospective analyses Clinical examination and biopsy, imaging and a broad multidisciplinary team are key to the management of skull-base SCC. The information gathered should be used to guide informed discussion by suitably trained experts with patients regarding surgical approach, post-operative recovery and adjuvant or neoadjuvant treatments. The standard of care is currently to perform skull base resection with or without additional craniotomy, pedicled or free flap reconstruction in multiple layers and post-operative radiation (usually photons or protons). Open approaches have traditionally been the mainstay, however in certain cases endoscopic approaches can yield equivalent results and offer many advantages. Despite advances in care survival remains poor with a nearly one in five risk of nodal recurrence within two years.

Comparing Kadish and Modified Dulguerov Staging Systems for Olfactory Neuroblastoma: An Individual Participant Data Meta-analysis

OBJECTIVE

To compare the Kadish and the modified Dulguerov staging of individual participants to determine the impact of stage and other prognostic factors on disease-free (DFS) and overall survival (OS).

DATA SOURCES

Systematic review of EMBASE, MEDLINE, Cochrane Library, and CINAHL databases.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was followed for this study. Articles including patients with olfactory neuroblastoma (ONB) staged with both Kadish and Dulguerov staging systems were reviewed. The raw data from eligible studies were requested to perform an individual participant data (IPD) meta-analysis.

RESULTS

Pooled data from 21 studies representing 399 patients with ONB undergoing treatment with curative intent showed that increasing age, treatment with chemotherapy, and positive or unreported margin status portended worse DFS (P < .05). Increasing stage for both Kadish and Dulguerov staging systems was prognostic for worse DFS and OS (P < .05), with Kadish C representing a heterogeneous group with regard to outcome and corresponding Dulguerov T stage. Using the Akaike information criterion, the Dulguerov staging system had superior performance to the Kadish system for DFS (1088.72 vs 1092.54) and OS (632.71 vs 644.23).

CONCLUSION

This study represents the first IPD meta-analysis of ONB directly comparing the outcomes of Kadish and Dulguerov staging systems in patients treated with primary surgery. Both systems correlated with DFS and OS, with superior performance in the Dulguerov system. Furthermore, the Kadish C group represented a heterogeneous group with regard to outcomes after stratification by the Dulguerov system. Dulguerov T4 patients had the worst outcome, with most being approached with open resection.

Pattern of loco-regional relapses and treatment in pediatric esthesioneuroblastoma: The French very rare tumors group (Fracture) contribution

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare neuroectodermal tumor that seldom occurs during childhood. Multimodal treatments are currently proposed, but the place of each therapy is still in debate. Our objective is to describe clinical evolution, especially the pattern of relapses and determine contributors to tumor progression.

PROCEDURE

Medical charts of all children (≤18 years) affected by ENB treated in France from January 1990 to December 2015 were retrospectively analyzed.

RESULTS

Eighteen patients were selected (10 males). Median age at diagnosis was 12.2 years (0.9-18). Tumor extension was Kadish stage A (n = 1), B (n = 3), C (n = 10), and D (n = 4). Hyams histological grades were I (n = 1), II (n = 3), III (n = 6), and IV (n = 6) (in two cases not defined). Initial cervical nodal spread was assessed by magnetic resonance imaging (n = 15), computed tomography scan (n = 16), fluorodeoxyglucose-positron emission tomography-computed tomography (n = 7), and cytological/histological analysis (n = 2). N1 stage was confirmed by imaging in two of 18 cases and one of two cases had cervical node dissection with neck irradiation (58 Gy). After a median follow-up of survivors of 7.6 years (3.8-17.9), 10 patients developed neuromeningeal progression, whereas no cervical nodal relapse occurred and only eight survived. Both 5-year overall and event-free survival rates were 44.4% (±11.7%).

CONCLUSIONS

The poor prognosis is mainly related to neuromeningeal dissemination that should be considered during treatment strategy. However, cervical lymph node relapse is rare.