Management options and survival in malignant melanoma of the sinonasal mucosa

[Diagnosis and therapy of sinonasal mucosal melanoma]

Sinonasal mucosal melanoma (SNMM) is a rare and aggressive disease representing only 4% of all sinonasal malignancies and 1.4% of all melanomas. With an incidence of approximately 0.2 to 2 cases per million, the disease represents a very rare cancer type. As a result, there is a lack of data and most of the evidence for this highly aggressive disease is based on retrospective observations and analyses. The standard of care is radical tumor resection followed by an adjuvant radiotherapy. Nevertheless, the rate of local recurrence is high, up to 50%. In addition, the majority of patients (up to 70%) develop distant metastases during the course of their disease. Both contribute to the extremely poor prognosis of the disease. Mucosal melanomas (SM) and cutaneous melanomas (CM) behave differently with respect to biology, clinic presentation and prognosis. Compared to CM, survival rates are significantly lower for SM. The 5-year survival rate is around 25% in SNMM but 39-97% in cutaneous melanoma. Similar to CM, immune checkpoint inhibitors achieve promising results in SM. However, response rates are lower in SM compared to CM. The goal of this CME article is to provide an overview on biology, diagnosis, therapy, and prognosis of SNMM.

PET/CT Imaging in Treatment Planning and Surveillance of Sinonasal Neoplasms

Sinonasal cancers are uncommon malignancies with a generally unfavorable prognosis, often presenting at an advanced stage. Their high rate of recurrence supports close imaging surveillance and the utilization of functional imaging techniques. Whole-body 18F-FDG PET/CT has very high sensitivity for the diagnosis of sinonasal malignancies and can also be used as a "metabolic biopsy" in the characterization of some of the more common subgroups of these tumors, though due to overlap in uptake, histological confirmation is still needed. For certain tumor types, radiotracers, such as 11C-choline, and radiolabeled somatostatin analogs, including 68Ga-DOTATATE/DOTATOC, have proven useful in treatment planning and surveillance. Although serial scans for posttreatment surveillance allow the detection of subclinical lesions, the optimal schedule and efficacy in terms of survival are yet to be determined. Pitfalls of 18F-FDG, such as post-surgical and post-radiotherapy crusting and inflammation, may cause false-positive hypermetabolism in the absence of relapse.

Nasal Malignant Melanoma With an Inverted Papilloma in the Contralateral Nasal Cavity: A Case Report

Background: We describe a patient with sinonasal mucosal melanoma (SNMM) and an inverted papilloma, which existed independently in both nasal cavities. Case presentation: We describe an unusual case of a 74-year-old male patient with SNMM and an inverted papilloma. He presented with symptoms of coughing up blood and pain in the left forehead. The patient underwent surgical resection of the lesion, and the SNMM and inverted papilloma were confirmed by histopathology. The patient refused further treatment after surgery, but was re-admitted 7 months later with local recurrence of the left tumor and systemic metastases. Conclusions: Nasal malignant melanoma with an inverted papilloma in the contralateral nasal cavity is rare and can easily be misdiagnosed as the same tumor by imaging. Simultaneous histopathology of bilateral nasal masses is very necessary. The recommended treatment is surgery for the inverted papilloma. An SNMM is a devastating tumor with poor outcomes.

Differentiating sinonasal malignant melanoma from squamous cell carcinoma using DWI combined with conventional MRI

PURPOSE

This study aimed to investigate the feasibility of diffusion-weighted imaging (DWI) in combination with conventional MRI features to differentiate sinonasal malignant melanoma (SNMM) from sinonasal squamous cell carcinoma (SNSCC).

METHODS

A total of 37 patients with SNMM and 44 patients with SNSCC were retrospectively reviewed. Conventional MRI features and apparent diffusion coefficients (ADCs) were evaluated independently by two experienced head and neck radiologists. ADCs were obtained from two different regions of interest (ROIs) including maximum slice (MS) and small solid sample (SSS). Multivariate logistic regression analysis was performed to identify significant MR imaging features in discriminating between SNMM and SNSCC. Receiver operating characteristic (ROC) curves were used to assess the diagnostic performance.

RESULTS

SNMMs were more frequently located in the nasal cavity, with well-defined border, T1 Septate Pattern (T1-SP) and heterogeneous T1 hyperintensity, whereas SNSCCs were more frequently located in the paranasal sinus, with homogenous T1 isointensity, ill-defined border, reticular or linear T2 hyperintensity, and pterygopalatine fossa or orbital involvement (all p < 0.05). The mean ADCs of SNMM (MS ADC, 0.85 × 10^-3mm²/s; SSS ADC, 0.69 × 10^-3mm²/s) were significantly lower than those of SNSCC (MS ADC, 1.05 × 10^-3mm²/s; SSS ADC, 0.82 × 10^-3mm²/s) (p < 0.05). With a combination of location, T1 signal intensity, reticular or linear T2 hyperintensity, and a cut-off MS ADC of 0.87 × 10^-3mm²/s, the sensitivity, specificity, and AUC were 97.3%, 68.2%, and 0.89, respectively.

CONCLUSION

DWI combined with conventional MRI can effectively improve the diagnostic performance in differentiating SNMM from SNSCC.

Oral melanoma: a multicenter study of 69 patients from Japan

OBJECTIVES

The purpose of this multicenter retrospective study was to investigate the demographic characteristics and treatment outcomes of patients with mucosal malignant melanoma (MM) of the oral cavity.

MATERIALS AND METHODS

This was a multicenter study involving 8 Japanese universities. The medical records of 69 patients who were diagnosed with primary oral MM between January 2000 and December 2020 were retrospectively analyzed. Overall survival (OS) and prognostic factors for OS were analyzed statistically.

RESULTS

There were 40 (58.0%) males and 29 (42.0%) females, and their mean (range) age was 69.8 ± 14.6 (22-96) years old. The most common primary site was the palate (30 patients, 43.5%). Stage IVA was the most common disease stage (36 patients, 52.2%). Radical therapy was performed in 55 patients (79.7%). The 2-year and 5-year OS rates of the 69 patients were 64.6% and 42.5%, respectively. The 2-year and 5-year OS rates of the stage III patients were 85.9% and 72.5%, respectively, and those of the stage IVA patients were 56.3% and 26.0%, respectively. The 1-year OS rate of the stage IVB/IVC patients was 26.7%. The 2-year and 5-year OS rates of the radical therapy group were 74.1% and 50.5%, respectively, whereas the 2-year OS rate of the non-radical therapy group was 26.0%. An advanced T classification was the only identified prognostic factor for OS (hazard ratio: 6.312, 95% confidence interval: 1.133-38.522, p < 0.05).

CONCLUSIONS

Early detection and radical treatment are essential for improving the prognosis of oral MM patients.

CLINICAL RELEVANCE

Early detection and adequate radical therapy leads to the better prognosis of oral MM patients.

Pattern and prognostic value of lymph node metastasis in sinonasal mucosal melanoma

OBJECTIVE

To analyze the pattern of lymph node (LN) metastasis and its effect on prognosis in sinonasal mucosal melanoma (SNMM).

METHODS

This retrospective study was conducted based on the Surveillance, Epidemiology, and End Results (SEER) Program data. Survival outcomes were analyzed using the Kaplan-Meier method. Factors were compared between groups using log-rank test and Fisher's exact test, and prognostic factors were screened using the Cox proportional hazards model. Propensity score matching (PSM) was conducted to examine the treatment differences after accounting for sex, age, race, T stage, N stage, and M stage.

RESULTS

Level I (57.1%) and level II (53.6%) nodes were the most common sites of lymph node metastasis, followed by level III (17.9%) and IV (17.9%) nodes. T stage, M stage, and tumor size were associated with LN metastasis. The 5-year overall survival rates for patients without and with LN metastasis were 35.2% and 5.3%, respectively.

CONCLUSIONS

Level I and II lymph nodes may be the sentinel nodes of SNMM, Advanced T stage and increasing tumor size could promote LN metastasis. LN metastasis may promote distant metastasis and remains an important prognostic factor for patients with SNMM.

Amelanotic Malignant Mucosal Melanoma of the Nasal Cavity: Case Report and Literature Review

Sinonasal malignant melanoma is a rare but aggressive tumor of the head and neck area. It has a poor prognosis. Common symptoms are nasal obstruction, epistaxis, or purulent rhinorrhea. Diagnosis relies on histopathology with immunohistochemistry (IHC) studies. Surgery is the essential treatment, most often supplemented by radiotherapy or immunotherapy. A 63-year-old female patient, with a history of right dacryocystorhinostomy and Parkinson's disease, consulted for symptoms of right nasal obstruction with increasing intensity accompanied by two episodes of mild unilateral epistaxis. Rigid optic examination showed a white-pinkish right obstructive supra-centimetric endonasal tumor. CT revealed an extensive tissue process of the right nasal cavity invading the maxillary sinus, the inferior and middle conchas. A biopsy of the lesion was conducted under local anesthesia. The immunohistochemical study has shown undifferentiated tumor with positive antibody anti PS100 and anti-melan A evoking malignant sinonasal melanoma. The patient underwent two surgeries for maxillectomies as she presented a first local recurrence. She was started on adjuvant radiotherapy. At one year of follow-up, she does not present any local or general signs of disease. Sinonasal melanoma is a particular entity of head and neck mucosal melanomas. The highest incidence is described to be in the seventh and eighth decades of life with no sex difference. IHC profiling of different melanoma subtypes showed the importance of alterations in the KIT gene, this genetic data may constitute a therapeutic target. After surgery, the important local recurrence rates and regional failure justify adjuvant radiotherapy also for resections in free margins. Most authors consider that prophylactic neck dissection is not necessary. Preoperative imaging features (CT scan) are characteristic and helpful for diagnosis. IHC is essential, has a high sensitivity for differentiating achromic melanomas from other neoplasms. Sinonasal achromic melanoma is a very uncommon tumor, invasive, and frequently associated with distant metastasis. Paraclinic examinations are essential for staging and guiding therapeutic management. Immunotherapy is a promising ground of research as it comes to metastatic and advanced disease.

Predictors of distant metastases in sinonasal and skull base cancer patients treated with surgery

OBJECTIVES

Sinonasal and skull base tumors comprise a heterogeneous group of malignancies with a significant rate of distant recurrence (DR). The aim of this study was to analyze tumor and host factors, including pretreatment neutrophil-to-lymphocyte ratio (NLR), that predict DR in these patients.

MATERIALS AND METHODS

We retrospectively reviewed sinonasal tumors and/or tumors involving the skull base treated with surgery between 1973 and 2015 (n = 473). We stratified NLR using the top 5 percentile as cutoff. Factors predictive of outcome were determined by Cox proportional hazards model.

RESULTS

Most tumors were primary (81%) and 67% had skull base resection. The most common site was the nasal cavity (37%) and the most common histology was squamous cell carcinoma (34%). Most patients presented with advanced primary tumor stage (pT3/T4; 80%) and most had no regional neck disease (pNx/N0; 93%). A total of 104 patients developed DR. The 5-year overall and disease-specific survival for patients who developed DR were 36.4% and 35.8%, compared to 69.0% and 74.9% for patients who did not. Patients with DR had a higher percentage of NLR-high patients compared patients without DR (11% vs 3%, p = .006). In a multivariable analysis, melanoma histology (HR = 5.469, 95% CI 3.171-9.433), pT3/T4 (HR = 2.686, 95% CI 1.150-6.275), pN+ (HR = 6.864, 95% CI 3.450-13.653), and NLR-high (HR = 3.489, 95% CI 1.593-7.639) were independent predictors of DR.

CONCLUSION

Melanoma histology, pT, pN, and high NLR predict DR, suggesting that both tumor and host factors need to be considered. NLR may act as a surrogate marker of the host́s immune system.

Outcomes of endoscopic and open resection of sinonasal malignancies: a systematic review and meta-analysis

OBJECTIVE

To compare the efficacy of endoscopic and open resection of sinonasal malignancies.

METHODS

The search was performed using PubMed (1950-2020), Embase (1974-2020), the Cochrane library, and the website clinicaltrials.gov. The hazard ratio, HR, 95% confidence interval, CI, of the rates of overall survival and disease-free survival and the demographic characteristics of the included studies were extracted and analyzed. Pooled analysis was conducted with the studies' individual patient data, using log-rank test, Kaplan-Meier survival, and Cox regression analysis.

RESULTS

Of 1939 articles retrieved, 23 articles were included. Overall, 1373 cases were incorporated into the final analysis, 653 (47.56%) of which underwent the surgery through an endoscopic approach, whereas 720 (52.44%) cases utilized the open approach. The overall survival was comparable between endoscopic and open resection (HR = 0.84 [95% CI: 0.65-1.07], p = 0.16; random effects analysis). Pooled analysis with Cox regression revealed signifcant differences in overall survival (HR = 0.568 [95%CI:0.380-0.849], p = 0.006) and disease-free survival (HR = 0.628 [95%CI:0.424-0.929], p = 0.02) between endoscopic and open approaches.

CONCLUSION

The aggregated evidence suggests the survival outcome of endoscopic resection is comparable or greater than that of open resection of sinonasal malignancies.

Primary malignant mucosal melanoma of the maxillofacial area

OBJECTIVES

We aimed to collect and report data from all patients who have been diagnosed with mucosal malignant melanoma to obtain the epidemiology and principles of current treatments.

MATERIALS AND METHODS

Between January 2008 and December 2018, 20 patients underwent surgery or follow-up observations at Yonsei University Dental Hospital. The patients' clinical information was reviewed retrospectively.

RESULTS

Seventeen of 20 patients had undergone definitive surgery, while only 6 patients received adjuvant radiotherapy or systemic therapy. Eight of 20 patients, including those that had recurrent lesions, were provided immunotherapy. The 3-year survival for all stages was 50%, with a local recurrence rate of 75% and a metastasis rate of 65%.

CONCLUSION

The overall survival of patients receiving surgical treatment was longer than that of patients who did not undergo surgical resection. Eight of 20 patients received immunotherapy as the first-line regimen at our clinic, and those patients exhibited longer overall survival compared to patients in reported keynote studies.

Clinicopathologic profile of sinonasal neoplasia in Kano, Northwestern Nigeria: A 10-year single-institution experience

Background

Sinonasal neoplasia comprises approximately 3% of all head-and-neck tumors. However, the incidence of these tumors may be greater in some parts of the world including Asia and Africa.

Aim and Objective

The study aimed to review the clinical and histopathological pattern of sinonasal neoplasms in Kano, Nigeria.

Materials and Methods

The records of patients managed for sinonasal neoplasia at the Department of Otorhinolaryngology, Aminu Kano Teaching Hospital, Kano, Nigeria, over a period of 10 years were reviewed. Information obtained from the case files included demographic characteristics, tumor characteristics, and clinical information. The data obtained were analyzed using SPSS version 23.

Results

A total of 245 patients were reviewed with sinonasal neoplasms. Among these, 168 (68.57%) were males, with a sex ratio (M:F) of 2.18:1. The mean age was 40.2 ± 18.9 years. Malignant sinonasal neoplasm constituted 55.92%% of the sinonasal neoplasia, with peak age at the fifth decade. Squamous cell carcinoma was the most common histological subtypes seen in 50.36% of the patients. Inverted papilloma was the most common benign sinonasal neoplasia (42.59%). The most common symptom presented by the patients was nasal obstruction (77.55%), mostly presented within 6 months of onset of symptoms (63.67%), and farmers were the predominant (27.76%). The most common treatment modality was surgical extirpation (54%), and most of the patients presented with Stage IV disease (88%). The site of tumor was found to statistically correlate with the type of tumor among the patients (P ≤ 0.0001), whereas the type of tumor and site of tumor correlated significantly with the duration of symptoms before the presentation.

Conclusion

Malignant sinonasal disease is the predominant sinonasal neoplasm in this environment, and most of the patients presented with advanced disease.

BRAF Mutations and Dysregulation of the MAP Kinase Pathway Associated to Sinonasal Mucosal Melanomas

Sinonasal mucosal melanoma (SNM) is a rare and aggressive type of melanoma, and because of this, we currently have a limited understanding of its genetic and molecular constitution. The incidence among SNMs of somatic mutations in the genes involved in the main molecular pathways, which have been largely associated with cutaneous melanoma, is not yet fully understood. Through a next-generation sequencing (NGS) approach using a panel of 25 genes involved in melanoma pathogenesis customized by our group, we performed a mutation analysis in a cohort of 25 SNM patients. Results showed that pathogenic mutations were found in more than 60% of SNM cases at a somatic level, with strikingly 32% of them carrying deleterious mutations in the BRAF gene. The identified mutations mostly lack the typical UV signature associated with cutaneous melanomas and showed no significant association with any histopathological parameter. Oncogenic activation of the BRAF-depending pathway, which may induce immune tolerance into the tumour microenvironment (i.e., by increasing the VEGF production) was poorly associated with mutations in genes that have been related to diminished clinical benefit of the treatment with BRAF inhibitors. Screening for mutations in BRAF and other MAPK genes should be included in the routine diagnostic test for a better classification of SNM patients.

Current concepts in advanced sinonasal mucosal melanoma: a single institution experience

PURPOSE

To present outcome measures of sinonasal mucosal melanoma (SMM) patients with particular focus on current radiological and therapeutic options, especially in the non-curative setting (immunotherapy).

METHODS

Retrospective study on SMM patients treated at our institution between January 1992 and December 2018.

RESULTS

FDG-PET/MRI has emerged as the new hybrid imaging modality, addressing the need for high local tissue contrast in the paranasal sinuses and the skull base, while allowing for whole-body staging in search for distant metastases, including the brain. Primary treatment protocols consisted of tumor resection in 30/34 patients (88%), palliative radiation therapy (RT) in 3/34 patients (9%) and best supportive care therapy in 1/34 patient (3%). Of all the initially operated patients, 25/30 patients (83%) received adjuvant RT. A total of 9/34 patients (26%) was treated with immunotherapy after the previous combined therapy. For patients treated in curative intention, we observed a 1-year overall survival (OS) of 60% (18/30 patients) and a 3-year OS of 40% (12/30 patients). For patients treated with immunotherapy, median progression-free survival (PFS) was 5 months (IQR 0-13.75), with a maximum PFS of 16 months (combination of nivolumab and ipilimumab). However, there was no difference in OS in patients treated with immunotherapy vs. no immunotherapy (log rank 0.99).

CONCLUSIONS

Sinonasal mucosal melanoma is a highly aggressive tumor, requiring multimodal therapy and developing a substantial incidence of distant metastases. The introduction of FDG-PET/MRI offers new possibilities in the radiological assessment of the tumor and immunotherapy has altered the management in the non-curative setting, resulting in a substantial progression-free survival in selected cases.

Nodal and distant metastases in sinonasal mucosal melanoma: A population-based analysis

OBJECTIVES/HYPOTHESIS

Sinonasal mucosal melanoma (SNMM) is a rare malignant neoplasm. No study to date has analyzed the impact that nodal metastases and distant metastases at diagnosis have on overall survival (OS) and disease-specific survival (DSS).

STUDY DESIGN

Retrospective database review.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for cases of SNMM. Descriptive statistics were used analyze patient demographic and clinicopathologic variables. The Kaplan-Meier model was used to analyze survival, and the Cox proportional hazards model was used for multivariate analysis.

RESULTS

Three hundred twenty-eight cases of SNMM were identified. The most frequent sinonasal anatomic location was the nasal cavity in 279 (73.0%) patients, followed by the maxillary sinus in 60 (15.7%) patients. Regional nodal metastases at diagnosis occurred in 33 (8.6%) patients, whereas distant metastases at diagnosis occurred in 41 (10.7%) patients. Five-year OS was 22.7%, and 5-year DSS was 26.8%. The presence of positive nodes at diagnosis (OS P < .0001, DSS P < .0001), distant metastases at diagnosis (OS P = .0442, DSS P = .0442), primary tumor site (OS P < .0001, DSS P < .0001), and increasing age (OS P = .0012, DSS P = .0016) were found to be significant as negative predictors of OS and DSS.

CONCLUSIONS

SNMM is a rare pathologic entity with a poor prognosis. The presence of nodal and distant metastases at diagnosis are negative prognostic factors in OS and DSS. These factors can be used in the development of new models of risk stratification and to inform treatment strategies and surveillance patterns.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:622-627, 2020.

Surgery alone versus post-operative radiotherapy for sinonasal malignant melanoma: a meta-analysis

OBJECTIVE

Sinonasal malignant melanoma is a relatively rare malignancy with poor prognosis, and effective treatments remain elusive. This analysis aimed to explore whether post-operative radiotherapy conferred any survival advantages in patients with this disease when compared with surgery alone.

METHODS

Published studies were identified by searching four electronic databases. The endpoints evaluated were: rates of overall survival, disease-free survival and local control.

RESULTS

Twenty-eight studies including 1392 patients were identified. The results indicated that post-operative radiotherapy led to a significantly better three-year overall survival rate (p = 0.02), and suggested a borderline significant benefit for five-year overall survival (p = 0.05), when compared with surgery alone. However, no statistical advantage was found for disease-free survival, local control or one-year overall survival.

CONCLUSION

This meta-analysis indicated that adjuvant radiotherapy prolonged survival, but showed no benefit for disease-free survival or local control.

Open Versus Endoscopic Approach for Sinonasal Melanoma: A Systematic Review and Meta-analysis

Background

Open resection (OR) of sinonasal mucosal melanoma (SNM) traditionally has been the gold standard for treatment. However, endoscopic resection (ER) has recently become a surgical alternative. The aim of this study was to compare survival outcomes between OR and ER of SNM.

Methods

A literature search encompassing PubMed, Embase, Cochrane Library, Web of Science, ClinicalTrials.gov, and Google Scholar was performed. Two reviewers independently screened for original studies comparing survival outcomes between OR and ER for SNM. Data were systematically collected on study design, patient demographics, outcomes, and level of evidence. Quality assessment was performed using the Newcastle-Ottawa scale (NOS). Meta-analysis of overall survival and disease-free survival was performed using random-effects models.

Results

The initial search yielded 2078 abstracts, of which 9 cohort studies were included for a total of 510 patients from 6 different countries. The average quality of all included studies using the NOS was 7.7 stars. Six out of 7 studies reported no differences in the stages of SNM between patients receiving ER versus OR. Overall survival was longer in the ER group versus OR group (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.49–0.95). There was no significant difference in disease-free survival between groups (HR: 0.59, 95% CI: 0.28–1.25).

Conclusion

Based on the available literature, an endoscopic approach for SNM resection has survival outcomes that are similar or greater compared to an open approach.

Sinonasal Melanoma: A Single Institutional Analysis and Future Directions

Background  Sinonasal melanoma is a rare disease with a high mortality rate. The surgical management paradigm has significantly changed over the past decade with the introduction of expanded endonasal techniques. There have also been advances in management of metastatic and locally advanced disease with the advent of immunotherapy. Methods  Single-institution retrospective review of adult patients with sinonasal melanoma, surgically managed at the University of Michigan over a 9-year period. Thirty-one patients met inclusion criteria. All patients were retrospectively staged according to the 7th Edition AJCC staging system for mucosal melanoma. Parameters that may affect survival were analyzed using Cox's proportional hazard models and survival outcomes were analyzed with the Kaplan-Meier method. Additionally, a review of three patients with distant metastatic disease receiving immunotherapy is presented. Results  Most patients were managed endoscopically (67%), and had stage III disease (71%). However, 57% of stage IVB tumors were successfully managed endoscopically. Stage statistically impacted overall survival whereas distant control was impacted by stage, site of origin, mitotic rate, and necrosis. The 2-year overall survival for all stages was 77% which declined with advanced disease. Two-year locoregional control and distant control showed similar trends. Conclusion  Treatment of sinonasal melanoma has drastically changed over the past decade with increased use of expanded endonasal techniques. Our review revealed excellent 2-year overall survival in stage III disease with an appreciable decline in survival in more advanced disease. Immunotherapy may play a large role is future management given the high-risk of distant metastasis.

Posttreatment surveillance for sinonasal malignancy

PURPOSE OF REVIEW

Sinonasal neoplasms have a high rate of recurrence following treatment, and clinicians utilize a variety of surveillance techniques. Generally, surveillance modality and frequency of follow-up are determined by the guidelines for head and neck cancer as a broad category. However, recent studies have demonstrated that a more tailored approach to follow-up may be necessary.

RECENT FINDINGS

Endoscopy has low sensitivity in recurrence detection, especially in the asymptomatic patient. However, it is able to identify superficial recurrences that may be more amenable to repeat resection. Conversely, imaging [computed tomography (CT), MRI, and F-fluorodeoxyglucose-PET/CT] is useful in ruling out disease, but the inflammatory environment of the posttreatment sinonasal cavity leads to a high number of false positives. This is especially notable in PET/CT, which has worse specificity and positive predictive value in sinonasal malignancy than in head and neck malignancy overall, especially in the early posttreatment period. Little data are available on optimal timing and duration of follow-up, but tumor histology and aggressiveness should be considered when choosing a surveillance approach.

SUMMARY

Sinonasal malignancy surveillance strategies may warrant modifications of current protocols used for head and neck malignancy. This is due to a number of factors, including a greater diversity of sinonasal disorder and increased duration of posttreatment sinonasal inflammation. Clinicians should be aware of the performance parameters of commonly used surveillance techniques and adjust follow-up regimens based on this information.

Contemporary Treatment Approaches to Sinonasal Mucosal Melanoma

Sinonasal mucosal melanoma (SNMM) is a rare oncological entity that comprises most head and neck mucosal melanomas. SNMM has distinctive genetic background, different from cutaneous melanoma. Survival outcomes among SNMM patients are poor; while there is no clear consensus on the optimal management of SNMM, the primary treatment modality is generally considered to be wide surgical excision, and radiation therapy (RT) is often used in the postoperative adjuvant setting to improve locoregional control. Systemic therapies have demonstrated little or no survival benefit, and most SNMM patients die of distant metastatic disease. Owing to the rarity of the disease, the literature describing treatment approaches for SNMM is lacking and largely limited to isolated case reports and retrospective series. Here, we describe contemporary diagnostic and therapeutic approaches to SNMM based on the most recent molecular and outcome data.

Recurrent epistaxis leading to diagnosis of primary sinonasal melanoma

A 48-year-old man presented to urgent care with recurrent epistaxis over 6 months. Initially, nosebleeds were controlled with packing or cautery. Ultimately, he was referred to ear, nose and throat department and underwent nasal endoscopy which revealed polypoid tissue. A biopsy of the polyp showed non-specific inflammation with no evidence of malignancy. Follow-up maxillofacial CT revealed a large mass lesion in the right maxillary sinus, right nasal fossa, much of the ethmoids and right sphenoid, with destruction of adjacent bony structures. MRI revealed a mass in the right nasal cavity with extension into the ethmoid and anterior sphenoid sinus, anterior cranial fossa and medial orbits. Staging CT discovered metastatic disease in the adrenal glands and lymphadenopathy in the neck. The patient underwent endoscopic sinus surgery with debulking and tissue diagnosis of malignant melanoma. He completed radiation therapy to sinus and was subsequently enrolled in a clinical trial. Most recent imaging revealed complete metabolic response on positron emission tomography.

Prognostic factors in head and neck mucosal malignant melanoma

OBJECTIVE

Primary mucosal malignant melanoma of the head and neck (HN-PMMM) is an aggressive and uncommon neoplasm. Herein, we present a series of 33 patients and the results of treatment, and aimed to determine prognostic factors in HN-PMMM.

METHODS

Patients who were diagnosed as having HN-PMMM in our reference hospital, between 2005 and 2014 were evaluated. Thirty-three of these patients who had follow-up data were included. Surgical margin status was extracted from the original pathology reports. Archived materials were retrieved for the histopathologic findings: ulceration, necrosis, lymphovascular invasion, perineural invasion, pigmentation, and presence of an in situ component. Mitotic activity was evaluated using phosphohistone H3 (PHH3) immunohistochemical staining.

RESULTS

We found an association of PHH3 mitotic activity with overall survival in a univariate analysis and to our knowledge, this is the first report among the available case series of HN-PMMM to evaluate mitotic activity using immunohistochemical staining. We also investigated the relationship between multicentricity and locoregional recurrence, which the authors believe is also a first.

CONCLUSION

PHH3 mitotic activity can be used a prognostic factor for head and neck mucosal malignant melanoma.

Carbon ion irradiation abrogates Lin28B-induced X-ray resistance in melanoma cells

The Lin28/let-7 axis plays an important role in tumor initiation and developmental processes. Lin28B is upregulated in a variety of cancers, and its overexpression enhances cancer cell proliferation and radioresistance through the suppression of let-7 micro RNA expression. In this study, we investigated the role of the Lin28/let7 axis as a target for radiosensitization of melanoma cancer cells. The overexpression of Lin28B reduced mature let-7 microRNA expression in melanoma cell lines, and enhanced the sphere-forming ability of melanoma cell lines, which is a characteristic of cancer stem cell (CSC) populations. Interestingly, Lin28B-overexpressed melanoma cells were more resistant to X-ray irradiation than control cells, and Lin28B-induced radioresistance was abolished after carbon ion irradiation. Consistent with these results, Lin28B overexpression reduced the numbers of γH2A.X foci after X-ray irradiation, whereas carbon ion irradiation had no such effect. Our results suggest that a carbon ion beam is more effective than an X-ray beam in terms of killing cancer cells, possibly due to elimination of CSC populations.

18FDG PET/CT in Routine Surveillance of Asymptomatic Patients following Treatment of Sinonasal Neoplasms

Objective Sinonasal neoplasms have a high rate of recurrence following treatment, and current guidelines support the use of a variety of surveillance techniques. Recent work demonstrates that performance parameters of surveillance modalities may differ with sinonasal tumors in particular when compared with head and neck tumors overall. This study aims to characterize the value of ¹⁸fluorodeoxyglucose (¹⁸FDG) positron emission tomography/computed tomography (PET/CT) as a screening tool in asymptomatic patients. Study Design Retrospective cohort study. Setting Hospital of the University of Pennsylvania and Pennsylvania hospital. Methods Records of asymptomatic patients without suspicious endoscopy or suspicious imaging other than PET during the first 3 years following definitive treatment for sinonasal malignancy were screened and analyzed for inclusion in the cohort. Disease recurrence was determined by biopsy following suspicious PET evaluation. Results PET/CT scans (n = 111) were performed for 45 disease-free asymptomatic patients with no evidence of disease on endoscopy, and 6.3% were suspicious and prompted biopsy during this period, revealing 3 cases of disease recurrence. Overall specificity for PET/CT alone was 96.3% (95% CI, 90.7%-99.0%), with a negative predictive value of 99% (95% CI, 94.8%-100%). All recurrences were detected between 7 and 12 months, and all patients with true recurrence diagnosed by PET/CT had extrasinonasal involvement of tumor at the time of surgery. Conclusion We examined performance parameters of ¹⁸FDG PET/CT in asymptomatic patients with no evidence of disease on endoscopy during the posttreatment period for sinonasal malignancy. The ability of PET/CT to detect recurrences that may be missed by structural imaging or endoscopy makes it a valuable tool for clinicians.

Sinonasal Melanoma: A Case Report and Literature Review

Purpose. Sinonasal malignant mucosal melanoma is a rare, aggressive tumour. Nasal obstruction and epistaxis are the most commonly reported symptoms, although symptomatology may develop late and be nonspecific, which tends to delay diagnosis, resulting in a poorer prognosis. Case Report. This report describes a 64-year-old male patient with nasal obstruction and epistaxis. Computed tomography of the facial sinuses revealed a large lesion in the right nasal cavity, with infiltration into the left cavity, ethmoidal cells, and erosion of the cribriform plate. Initial incisional biopsy revealed an undifferentiated carcinoma of the right maxillary sinus, staged as T4aN0M0. Induction chemotherapy was initiated with cisplatin and etoposide. Response to treatment was complete. The patient was then submitted to radiotherapy with concomitant cisplatin. Immunochemical analysis revealed positivity for vimentin, S100, and HMB-45 (human melanoma black 45), a result compatible with a diagnosis of malignant melanoma. Discussion. Due to the rarity of the tumour and the patient's complete response to chemotherapy and since no blackened lesion had been found at the previous exam, treatment was continued as planned. The patient remains healthy, with no metastasis or recurrence. He is currently being monitored by the clinical oncology team.

The implications of orbital invasion in sinonasal tract malignancies

In recent decades, the management of sinonasal tumors abutting the orbit has been widely discussed. A real guideline has yet to be proposed, as prospective randomized studies on this topic are very difficult to organize, given the relative rarity of this pathology, the wide spectrum of histologic patterns, and the different clinical behavior of tumors. Nevertheless, in recent years, a better assessment of tumor extension has been obtained thanks to the refinement of preoperative imaging tools and, therefore, more conservative approaches could be adopted, with no worsening of the oncological outcomes and, at the same time, with more attention given to the post-surgical quality of life. Currently, tumors that extend to the bony orbital walls with or without focal infiltration of the periorbit are amenable to orbital preservation. On the other hand, infiltration of extraocular muscles and neurovascular structures are an indication to orbital exenteration. The ideal surgical treatment in cases of limited involvement of orbital fat still remains a matter of debate. We report and discuss the recent English literature on this interesting topic.

Surgical management of skull base tumors

AIM

To present a review of the contemporary surgical management of skull base tumors.

BACKGROUND

Over the last two decades, the treatment of skull base tumors has evolved from observation, to partial resection combined with other therapy modalities, to gross total resection and no adjuvant treatment with good surgical results and excellent clinical outcomes.

MATERIALS AND METHODS

The literature review of current surgical strategies and management of skull base tumors was performed and complemented with the experience of Barrow Neurological Institute.

RESULTS

Skull base tumors include meningiomas, pituitary tumors, sellar/parasellar tumors, vestibular and trigeminal schwannomas, esthesioneuroblastomas, chordomas, chondrosarcomas, and metastases. Surgical approaches include the modified orbitozygomatic, pterional, middle fossa, retrosigmoid, far lateral craniotomy, midline suboccipital craniotomy, and a combination of these approaches. The selection of an appropriate surgical approach depends on the characteristics of the patient and the tumor, as well as the experience of the neurosurgeon.

CONCLUSION

Modern microsurgical techniques, diagnostic imaging, intraoperative neuronavigation, and endoscopic technology have remarkably changed the concept of skull base surgery. These refinements have extended the boundaries of tumor resection with minimal morbidity.

Endoscopy versus imaging: Analysis of surveillance methods in sinonasal malignancy

BACKGROUND

The purpose of this study was to assess the utility of imaging and endoscopy in posttreatment surveillance of sinonasal malignancies.

METHODS

We conducted a retrospective analysis of primary sinonasal malignancies diagnosed between 2000 and 2014. Posttreatment surveillance included nasal endoscopy and imaging (MRI, CT, and positron emission tomography [PET]/CT). Positive predictive value (PPV), negative predictive value (NPV), specificity, and sensitivity were calculated for each modality and compared.

RESULTS

One hundred nine sinonasal malignancies were identified with 30 recurrences. Endoscopy showed a sensitivity and specificity of 24% and 89%, respectively, whereas imaging was 76% and 90%, respectively. Identifying suspicious symptoms significantly improved the PPV of both endoscopy and imaging. MRI demonstrates the highest PPV when compared with other imaging modalities.

CONCLUSION

Both modalities are necessary in posttreatment surveillance. MRI shows the highest PPV, whereas endoscopy trends toward a higher specificity. PET/CT scans have a high false-positive rate and should be reserved for tumors with a high propensity for distant metastases. © 2016 Wiley Periodicals, Inc. Head Neck 38:1229-1233, 2016.

Localized sinonasal mucosal melanoma: Outcomes and associations with stage, radiotherapy, and positron emission tomography response

BACKGROUND

Sinonasal mucosal melanoma is a rare neoplasm with a poor prognosis.

METHODS

Retrospective analysis was conducted on 78 patients with localized sinonasal mucosal melanoma treated at Memorial Sloan Kettering Cancer Center (MSKCC from 1998-2013). Demographic, tumor, imaging, and treatment factors were recorded and survival and disease-control outcomes were analyzed.

RESULTS

Median overall survival (OS) and disease-specific survival (DSS) were 32 and 50 months, respectively. Median locoregional recurrence-free survival (LRFS) and distant recurrence-free survival (DRFS) were 43 and 12 months, respectively. Multivariate analysis demonstrated greater OS in nasal cavity tumors and earlier T classification. Radiotherapy (RT) was associated with significantly greater LRFS (5-years; 35% vs 59%; p = .01), but no difference in OS. Post-RT positron emission tomography (PET) response was associated with greater OS.

CONCLUSION

Distant metastasis is the predominant mode of recurrence in sinonasal mucosal melanoma, but local recurrence remains common. RT is associated with improved local control, but no survival benefit. The prognostic value of post-RT PET imaging warrants further investigation. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1310-1317, 2016.

Survival Outcomes of Mucosal Melanoma in the Head and Neck: Case Series and Review of Current Treatment Guidelines

PURPOSE

Malignant mucosal melanoma of the head and neck (MMHN) is an aggressive and rare neoplasm with poor long-term outcomes. The aim of this study is to evaluate the outcomes of patients treated by a single-institution head and neck multidisciplinary team.

MATERIALS AND METHODS

In this retrospective case series, all MMHN cases treated at the Royal Melbourne Hospital from 1990-2015 were retrospectively reviewed. Patient demographic characteristics (eg, age), treatment offered, pathology, and outcomes were collected, tabulated, and correlated with outcomes. Survival outcomes were calculated by the Kaplan-Meier method. Comparison was made between oral and sinonasal melanomas.

RESULTS

A total of 16 cases were identified. Two were excluded because of inaccessible data. Of the 14 remaining cases, 8 were sinonasal melanomas and 6 were oral cavity melanomas. Sinonasal tumor patients presented with epistaxis or visual impairment. Oral melanoma patients presented with pigmented lesions or ulceration. Follow-up ranged from 4 months to 11 years. In 2 patients, locoregional recurrences developed that were successfully re-excised. Six patients died of distant metastases despite clear surgical margins. Two patients with sinonasal melanomas died of extensive local disease with intracranial invasion. One patient died 4 years after diagnosis without disease. There were no failures in the neck. The 2- and 5-year overall survival rates were 63.3% and 31.7%, respectively, by the Kaplan-Meier method. The difference in survival between oral and sinonasal melanomas was not statistically significant.

CONCLUSIONS

Despite clear surgical margins, MMHN has a poor prognosis and most deaths are due to distant metastases. Systemic therapies such as those used in cutaneous melanoma treatment might be used in the future for MMHN.

Clinicopathological Features and Prognosis of Sinonasal Mucosal Malignant Melanoma: A Retrospective Study of 83 Cases in a Chinese Population

AIMS

Sinonasal mucosal malignant melanoma (SNMMM) is a rare disease. The aim of the present study was to describe its clinicopathological features and prognosis in a Chinese population.

METHODS

Data on 83 SNMMM patients were collected and analyzed. A survival analysis was performed using the Kaplan-Meier method and a log-rank test.

RESULTS

The most common presenting symptoms of SNMMM were nasal obstruction, epistaxis, and bloody rhinorrhea. Histopathologically, 38 cases (45.78%) were amelanotic. Five cell types (epithelioid, undifferentiated, plasmacytoid, spindle, and clear) were identified. Positive staining for human melanoma black-45 and Melan-A was diagnostic of SNMMM. Advanced age, multiple tumor sites, and amelanotic-type SNMMM indicated a worse outcome (p = 0.008, p = 0.009, and p = 0.013, respectively). Neither adjuvant therapy nor the tumor stage was associated with overall survival.

CONCLUSIONS

SNMMM is an uncommon disease with atypical symptoms. Its histopathological appearance is variable, especially in the amelanotic type. Thus, immunohistochemistry is important in the diagnosis, and it should be performed according to the histology.

Sinonasal mucosal melanoma: A 12-year experience of 58 cases

BACKGROUND

Sinonasal mucosal melanoma is a rare malignancy with poor prognosis.

METHODS

Patients with sinonasal malignant melanoma who underwent surgery by different approaches were included in this study. Overall survival (OS) and event-free survival were calculated, and statistically significant variables by univariate analysis were entered in a multivariate Cox regression model.

RESULTS

Pathological staging was pT3, pT4a, and pT4b in 30 cases (51.7%), 17 cases (29.3%), and 11 cases (19.0%). At 3 and 5 years, OS was 43.5% and 29% and event-free survival was 23.6% and 12.4%, respectively. At univariate analysis, OS was significantly influenced by male sex, advanced pT classification, positive margins, and surgical approach; event-free survival was affected by positive margins. At multivariate analysis, the risk of death was independently associated with male sex (hazard ratio [HR] = 2.27; p = .04) and positive margins (HR = 2.32; p = .03).

CONCLUSION

Male sex and positive margins were negative prognostic factors. Endoscopic resection did not show an increased risk of death compared with more extensive surgical approaches. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1737-E1745, 2016.

Sinonasal malignancy: presentation and outcomes

OBJECTIVE

We wanted to identify the presentation, diagnostic work-up and treatment outcomes of patients with sinonasal malignancy at Derriford Hospital, Plymouth, UK and compare these with the European Position Paper on Endoscopic Management of Tumours of the Nose, Paranasal Sinuses and Skull Base.

MATERIALS AND METHODS

This was a retrospective audit of all patients diagnosed with sinonasal malignancy over a five-year period. The clinical records and picture archiving and communications system data of the patients were reviewed.

RESULTS

Thirty patients with sinonasal malignancy were identified out of 570 head and neck cancer patients. The nasal cavity was the most common site for presentation, followed by the maxillary sinuses. Fifty per cent of patients had a squamous cell carcinoma and 27 per cent had a malignant melanoma. Half of the patients presented at stage IV of the cancer and 20 per cent at stage III. Thirty-seven per cent of patients underwent surgical management and only 20 per cent of the total patient group underwent endoscopic surgery. The mortality in our series was 30 per cent over the studied period.

CONCLUSION

Late-stage presentation of sinonasal malignancy has resulted in increased patient mortality in our case series. Also, we found a high incidence of malignant melanoma with high recurrence and survival rates.

Impact of different surgical and postoperative adjuvant treatment modalities on survival of sinonasal malignant melanoma

Background

The role of postoperative adjuvant treatment for sinonasal malignant melanoma remains unclear. This study evaluates the impact of three different surgical and postoperative adjuvant treatment modalities: surgery alone(open and endoscopic approaches), surgery plus radiotherapy and surgery, radiotherapy plus chemotherapy on survival of patients with primary sinonasal malignant melanoma (SMM).

Methods

The data of 69 patients who underwent primary surgical treatments at Eye & ENT hospital of Fudan University between January 1st, 2000 and December 31st, 2010 were retrospectively reviewed. Survival comparison of different surgical and postoperative adjuvant treatment modalities (surgery alone, surgery plus radiotherapy and surgery, radiotherapy plus chemotherapy), as well as survival comparison between open and endoscopic surgical approaches were performed. Curves depicting survival were performed using Kaplan-Meier method. Statistical analysis was performed using log-rank test software SPSS19 and p < .05 is considered as statistically significant.

Results

The median overall survival time was found to be 18 months for surgery alone (27 cases), 32 months for surgery plus radiotherapy (24 cases), 42 months for surgery, radiotherapy plus chemotherapy (18 cases). The 3 and 5 year survival rates for groups mentioned above were 14.8% and 5.6%, 45.1% and 31.6%, 55% and 32.1%, respectively. Statistical significances were found not only between surgery alone and surgery plus radiotherapy treatment group (P = 0.012), but also surgery alone and surgery, radiotherapy plus chemotherapy group (P = 0.002). There was no statistically significant survival difference found between the two different surgical approaches (41 cases for open approach and 28 cases for endoscopic approach).

Conclusions

Sinonasal malignant melanoma is a disease with a poor prognosis. Patients who underwent surgery plus radiotherapy or surgery, radiotherapy plus chemotherapy had better survival outcomes than those underwent surgery alone. Endoscopic approach provided similar survival outcome as an open approach.

A Case of Werner Syndrome with Three Primary Lesions of Malignant Melanoma

Three primary lesions of malignant melanoma developed in a 44-year-old Japanese woman with Werner syndrome. One lesion was on the right large pudental lip and the others in distinct locations on her left sole. After the wide local excision of these tumors, the wound of the large pudental lip was sutured, and the defects on the sole were covered with skin grafts. After one course of chemotherapy consisting of dacarbazine, nimustine, vincristine sulfate and local injection of Interferon beta were performed, severe myelosupression occurred and continued for two months. Defective production of WRN protein was confirmed by Western blotting, although the three representative mutations in Japanese patients, mutations 1, 4 and 6, which include over 90% of the Japanese patients, were not detected. We also reviewed 26 cases of malignant melanoma associated with Werner syndrome (WS), including ours.

Surgical management of recurrent sinonasal mucosal melanoma: endoscopic or transfacial resection

Sinonasal mucosal melanoma (SNMM) is associated with poor prognosis. Local recurrence is common and represents a major problem in the therapy. Wide resection surgery is usually applied. However, given the almost futile prognosis, optimal symptom control may be preferable to wide resection at all costs. The aim of our study was to analyze the outcome in patients with recurrent SNMM treated by transfacial radical surgery or by a less invasive endoscopically controlled approach. Patients with recurrent grade III or IV staged SNMM who presented to our ENT department between 2000 and 2010 were either treated by transfacial (n = 10) or endoscopically controlled surgery (n = 12). The patients' charts were reviewed for clinical symptoms, relapse-free time and survival time. Clinical symptoms improved after surgery. The morbidity after endoscopic surgery was significantly lower than after transfacial surgery. The chosen surgical technique did neither affect relapse-free nor survival time. When treating recurrent SNMM, the comparatively gentle and less mutilating endoscopic approach proved to be a sufficient surgical procedure, being not inferior to aggressive surgery with respect to recurrence and survival rate.

Multilocular sinonasal malignant melanoma: a poor prognostic subgroup?

Clinical observations show that two subtypes of sinonasal malignant melanoma exist: uni- and multilocular melanoma. The aim of this retrospective study was to determine the prevalence and outcome of multilocular sinonasal malignant melanoma. All patients with sinonasal malignant melanoma treated at our institution between 1992 and 2011 were included. Survival and recurrence data were analyzed related to the distribution pattern of the tumors and other factors. Twenty-five patients were identified and included in the analysis. Seven patients (28 %) suffered from multilocular, the remaining 18 patients (72 %) from unilocular sinonasal malignant melanoma. The first group showed a significantly worse disease-free survival, whereas disease-specific and overall survival did not differ between the two subtypes. Multilocular sinonasal malignant melanoma is associated with an unfavorable disease-free survival compared to its unilocular counterpart.

[Malignant melanoma: a rare tumor of the nasal cavity--about a series of 10 cases]

Le mélanome malin des fosses nasales est une tumeur rare mais très agressive, de traitement complexe et de pronostic défavorable. Son traitement relève en principe d'une prise en charge essentiellement chirurgicale complétée par une radiothérapie. L'objectif de ce travail est de rapporter les caractéristiques cliniques, thérapeutiques et évolutives des mélanomes des fosses nasales. Nous avons analysé rétrospectivement 10 cas de mélanomes des fosses nasales suivis à l'institut national d'oncologie de Rabat. La rhinoscopie avec biopsie a permis la confirmation histologique du diagnostic de mélanome. Le bilan d'extension comprenait une tomodensitométrie ou imagerie par résonnance magnétique du massif facial, une radiographie thoracique et une échographie abdominale. Dans notre série, l’âge médian était de 67.5 ans, avec une prédominance féminine (7femmes et 3hommes). Le délai médian de découverte était de 6 mois. Deux patients étaient métastatiques d'emblée, et toutes les tumeurs étaient localement avancées au moment du diagnostic. Sept patients ont été opérés avec des limites chirurgicales envahies dans 2 cas et 3 patients étaient inopérables. 2 patients ont été irradiés après la chirurgie et 2 patients ont reçu une chimiothérapie arrêtée au moment de la progression. Deux patients ont récidivé après traitement, et un patient était en mauvais état général et a bénéficié uniquement de soins palliatifs. Tous les patients sont décédés avec un délai médian de survie de 12 mois. Le mélanome malin muqueux des fosses nasales, bien que rare, demeure une pathologie de pronostic défavorable et pose des problèmes de prise en charge.

Fast neutron radiotherapy for primary mucosal melanomas of the head and neck

BACKGROUND

Primary head and neck mucosal melanomas (HNMMs) are rare tumors managed with surgery and/or radiotherapy and associated with poor outcomes. Given their radioresistance, high linear energy transfer radiotherapy with neutrons may improve local control.

METHODS

We conducted a retrospective review of 14 patients with HNMM treated with neutrons at the University of Washington from 1990 to 2012. Five patients had T3 disease, 9 had T4 disease, 3 had regional nodal disease, and 4 had distant metastases at diagnosis. Primary sites were sinonasal (n=10), lip (n=2), and palate (n=2). Ten patients had initial surgical resection/debulking.

RESULTS

Nine patients had gross residual disease, 6 had complete response, and 3 had partial response. Local control was achieved in 79% until death or last follow-up, and 50% developed distant metastases. Kaplan-Meier 5-year local control was 66% and overall survival was 21%.

CONCLUSION

High rates of locoregional control were achieved with neutrons, despite the presence of gross disease. Survival was limited by early distant metastases.

Survival in Sinonasal Melanoma: A Meta-analysis

Sinonasal melanoma is an uncommon tumor which carries a poor prognosis and high rates of local and regional recurrence and distant metastasis. While surgical resection is the mainstay of treatment, the utility of multimodality therapy has not been well studied or established. We sought to better evaluate the optimal treatment modality for sinonasal melanoma. We reviewed 39 case reports involving 423 patients with sinonasal melanoma and present a meta-analysis comparing survival by treatment modality. The two-tailed p-value for survival by treatment modality was determined. The number of primary site/local, regional, and distant recurrences was determined where data was available. There was a nonsignificant increase in survival for patients treated with surgery + radiotherapy versus surgery alone. There was a statistically significant increase in survival for surgery + chemotherapy versus chemotherapy alone and versus surgery alone. Patients treated with combined surgery, radiation, and chemotherapy had a statistically shorter survival interval than patients treated with surgery + chemotherapy, which may reflect more advanced disease in patients treated with triple therapy. There was no statistically significant increase in survival found for the addition of radiation to surgery. This meta-analysis demonstrates that multimodality therapy, particularly the addition of chemo-or immunotherapy to surgery, may increase survival in a subset of patients. Radiation therapy did not appear to increase survival. There may be a significant increase in overall survival with combined modality therapy with surgery and chemo/immunotherapy versus single modality therapy.

LEVEL OF EVIDENCE

III. Grade of recommendation: C.

Craniofacial resection and its role in the management of sinonasal malignancies

Sinonasal malignancy is rare, and its presentation is commonly late. There is a wide variety of pathologies with varying natural histories and survival rates. Anatomy of the skull base is extremely complex and tumors are closely related to orbits, frontal lobes and cavernous sinus. Anatomical detail and the late presentation render surgical management a challenging task. A thorough understanding of anatomy and pathology combined with modern neuroimaging and reliable reconstruction within a multidisciplinary team is imperative to carry out skull base surgery effectively. While endoscopic approaches are gaining credibility, clearly, it will be some time before meaningful comparisons with craniofacial resection can be made. Until then, craniofacial resection will remain the gold standard for managing the sinonasal malignancies of the anterior skull base, as it has proved to be safe and effective.

Particle radiotherapy with carbon ion beams

Carbon ion radiotherapy offers superior dose conformity in the treatment of deep-seated malignant tumours compared with conventional X-ray therapy. In addition, carbon ion beams have a higher relative biological effectiveness compared with protons or X-ray beams. The algorithm of treatment planning and beam delivery system is tailored to the individual parameters of the patient. The present article reviews the available literatures for various disease sites including the head and neck, skull base, lung, liver, prostate, bone and soft tissues and pelvic recurrence of rectal cancer as well as physical and biological properties.