Esthesioneuroblastoma: reflections of a 21-year experience

CyberKnife Radiosurgery for Spinal Leptomeningeal Metastases Secondary to Esthesioneuroblastoma: A Clinical Case Report

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare malignant tumor of neuroectodermal origin that arises from the olfactory epithelium. We present a case of ENB metastasizing through the leptomeningeal route to the spinal dura, which was treated with CyberKnife (CK) stereotactic radiosurgery (SRS), and aim to assess the safety and effectiveness of SRS in such cases. To the best of our knowledge, this is the first case report in the literature that discusses ENB spinal leptomeningeal metastases treated with CK radiosurgery. We retrospectively review the clinical and radiological outcomes in a 70-year-old female with ENB metastasis to the spine. Progression-free survival (PFS), overall survival (OS), and local tumor control (LTC) are investigated. In our patient, ENB had been diagnosed at the age of 58 years and spinal metastases had been first noted at the age of 65 years. A total of six spinal lesions received CK SRS. Lesions were present at the level of C1, C2, C3, C6-C7, T5, and T10-11. The median target volume was 0.72 cc (range: 0.32-2.54). A median marginal dose of 24 Gy was delivered to the tumors with a median of three fractions to a median isodose line of 80% (range: 78-81). LTC at the 24-month follow-up was 100%. PFS and OS were 27 months and 40 months, respectively. No adverse radiation effects were reported. Even though the treated spinal lesions remained stable, the number of new metastatic lesions had increased with progressive osseous and dural metastatic lesions within the cervical, thoracic, and lumbar spine at the last follow-up. SRS provides relatively good LTC for patients with ENB metastasizing to the spine, with no radiation-induced adverse events.

Elective neck irradiation in the management of esthesioneuroblastoma: a systematic review and meta-analysis

BACKGROUND

There is no consensus about the optimal management of the neck in clinically node negative esthesioneuroblastoma (ENB). The aim of this study is to assess the impact of elective neck irradiation (ENI) in terms of regional disease control and survival.

METHODS

The study was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, and Google Scholar databases. The primary outcome was the regional recurrence rate (RRR), that was reported as odds ratio (OR) and 95% confidence interval (CI). Secondary outcomes were the overall survival (OS), and the distant-metastases free survival (DMFS), that were reported as logarithm of the hazard ratios (logHRs) and 95% confidence intervals (CIs).

RESULTS

A total of 489 clinically node negative patients were included from 9 retrospective studies. ENI significantly reduced the risk of regional recurrence compared to no treatment. No difference was measured between ENI and observation, according to both OS and DMFS. No stratified analysis could be performed based on Kadish stage and Hyams grade.

CONCLUSIONS

ENI should be recommended to improve the regional disease control. No advantage was measured in terms of survival or distant metastases with a low quality of evidence. Further prospective studies should be designed to understand if ENI could be avoided in early stage and low-grade tumors.

Occult olfactory neuroblastoma presenting with multiple bone metastases: a case report

RATIONABLE

Olfactory neuroblastoma (ONB) is a rare malignant tumor of the nasal cavity, the primary local symptoms are usually inconspicuous. Patients are often admitted to various specialties based on different primary symptoms, which may result in delayed diagnosis and even a misdiagnosis.

PATIENT CONCERNS

Here we report a case of ONB that presented initially as multiple ostealgia without any local symptoms of the tumor and primarily misdiagnosed as multiple myeloma. The patient was a 47-year-old female with bone pain at multiple sites. The initial diagnosis was considered as multiple myeloma. However, the morphologic examination of bone marrow suggested that the tumor cells originated from the nervous tissues. After the positron emission computed tomography scan, the primary lesion in the nasal cavity was located, and a biopsy was performed.

DIAGNOSIS

The final diagnosis of ONB was confirmed by histopathological tests.

INTERVENTIONS

The patient was treated with metronomic chemotherapy.

OUTCOMES

The symptoms of bone pain were significantly relieved 3 months later. The emission computed tomography scan of the whole body bones and the magnetic resonance imaging of the head showed that the tumor size did not change significantly and proved a progression-free of the disease.

LESSONS

It is a reasonable strategy to identify the original latent tumor by a prompt positron emission computed tomography scan when the primary diagnosis indicates a metastatic disease, especially for the occult malignancies like ONB.

Surgery as Single-Modality Treatment for Early-Stage Olfactory Neuroblastoma: An Institutional Experience, Systematic Review and Meta-analysis

BACKGROUND

For olfactory neuroblastoma (ONB), the combination of surgical tumor resection and radiation therapy (RT) has been considered the "gold standard" in treatment protocols intended to cure.

OBJECTIVE

To summarize evidence on the treatment of ONB using surgery alone.

METHODS

A retrospective institutional case series, a systematic review of the literature, and an individual patient data (IPD) meta-analysis on only surgically treated ONB patients.

RESULTS

At our institution, a total of 10 patients were treated through surgery alone and remained alive and free of disease at last follow-up. The IPD meta-analysis on 128 patients revealed a disease-free survival (DFS) and overall survival (OS) of 67.7% and 75.4% at 5 years and 57.1% and 71.9% at 10 years, respectively. Univariate analysis showed that Kadish stage C/D and Hyams grading III//IV significantly affected OS (P = 0.000 and P = 0.000) and DFS (P = 0.000 and P = 0.002). For low-risk patients, the DFS was 80.6% at 5 years and 67.8% at 10 years, respectively.

CONCLUSIONS

Surgery alone is an equivalent alternative to combined treatment in carefully selected low-risk ONB patients with better outcome measures than previously reported.

Extraprimary Local Recurrence of Esthesioneuroblastoma: Case Series and Literature Review

OBJECTIVES

Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy arising from olfactory neuroepithelium. Recurrence typically occurs locoregionally at the primary site or in the form of cervical metastasis. Delayed local recurrence away from the initial primary site is exceedingly rare.

METHODS

Retrospective review of 4 patients with histologically confirmed extraprimary local recurrence of ENB was performed with review of the literature.

RESULTS

All cases initially presented with ENB isolated to the cribriform plate(s) treated with primary surgical resection and adjuvant radiotherapy. The first patient had ENB recurrence 8 years posttreatment involving the right orbit. She later developed metastases to the spine, neck, and mandible requiring composite resection and 4 courses of radiotherapy. The second patient had ENB recurrence of the dorsal septum 9 years posttreatment with cervical metastases requiring septectomy, bilateral neck dissection, and radiotherapy. The third patient had ENB recurrence 7 years posttreatment in the posterior nasopharynx requiring endonasal nasopharyngectomy. Finally, the fourth patient had ENB recurrence 12 years posttreatment in the sphenopalatine foramen, which was endoscopically resected. At the time of this review, all 4 patients were disease free at 32, 21, 4, and 24 months posttreatment follow-ups, respectively.

CONCLUSIONS

This case series describes the rare phenomenon of delayed extraprimary local recurrence of histologically confirmed ENB. Treatment of extraprimary recurrences, analogous to other forms of ENB, should include primary surgical resection with adjuvant radiotherapy for generally favorable outcomes. Long-term close follow-up based on symptoms, endoscopy, and imaging is essential because of the risk of delayed recurrence.

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.

Hyams grading as a predictor of metastasis and overall survival in esthesioneuroblastoma: a meta-analysis

BACKGROUND

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, represents up to 3% of all sinonasal neoplasms. Hyams histologic grading is a promising tool in predicting metastases and establishing prognoses for this complex tumor.

METHODS

A systematic literature search was performed in the PubMed, Ovid MEDLINE, and Cochrane databases. ENB patients with Hyams I-II or III-IV were categorized as low-grade Hyams (LGH) or high-grade Hyams (HGH), respectively. Binary and continuous random-effects models were applied to calculate odds ratios (ORs) for the incidences of neck and distal metastases as well as for 5- and 10-year overall survival rates.

RESULTS

Of the 57 screened articles published from 1993 to 2018, 16 (525 patients) and 21 (563 patients) provided data for tumor metastases and overall survival rates, respectively. Neck metastasis was observed in 18.2% of HGH vs 7.9% of LGH patients. Distant metastasis was noted in 20.7% of HGH vs 8.9% of LGH patients. LGH patients had 5- and 10-year overall survival rates of 81.2% and 64.0%, respectively, as compared with 60.9% and 40.6%, respectively, for HGH patients. In comparing HGHs vs LGHs, the collective ORs for neck and distant metastases were 2.08 (95% confidence interval [CI], 1.09-3.99; p = 0.03) and 2.37 (95% CI, 1.07-5.26; p = 0.03), respectively. Moreover, in comparing LGHs vs HGHs, collective ORs for 5- and 10-year overall survival rates were 3.39 (95% CI, 2.09-5.49; p < 0.001) and 3.03 (95% CI, 1.82-5.06; p < 0.001), respectively.

CONCLUSION

HGH ENBs, compared with LGH ENBs, are more likely to metastasize to neck or distal targets and to have lower overall survival rates.

Esthesioneuroblastoma: A Comprehensive Review of Diagnosis, Management, and Current Treatment Options

INTRODUCTION

Many controversies exist in the diagnosis and management of this aggressively malignant condition, mainly because of limited literature and lack of randomized control trials, resulting in nonstandardized treatment methods. We performed a comprehensive review of the literature to identify management approach and treatment options for esthesioneuroblastoma.

METHODS

An extensive review of the published literature was conducted in PubMed, OVID Medline, and EMBASE journals for studies of esthesioneuroblastoma. Terms for search included esthesioneuroblastoma (ENB) and olfactory neuroblastoma (ONB). No date restrictions were used.

RESULTS

The search yielded 3876 related articles. Cross-checking of articles led to exclusion of duplicate articles. The remaining 1170 articles were screened for their full text and English language availability. Of 609 full-text articles available, animal studies, irrelevant articles, and studies with mixed/confusing data were excluded. We finalized 149 articles pertaining to the topic, including 119 original research articles, 3 book chapters, 11 reviews, 9 case reports, and 7 case series.

CONCLUSIONS

Surgical resection followed by radiotherapy is the standard for treatment for higher-grade lesions. The endoscopic endonasal approach is gaining further recognition with more favorable outcomes and better survival than for open surgery. Postoperative radiotherapy is associated with the highest overall survival and shows benefit for patients with higher-stage disease and those who receive chemotherapy. Recurrence rates after treatment vary drastically in the literature and, therefore, prolonged follow-up with repeated imaging is recommended. Lifelong surveillance is recommended because of late recurrences associated with this tumor.

Esthesioneuroblastoma with distant metastases: Systematic review & meta-analysis

BACKGROUND

The purpose of this study was to determine the clinical outcomes and review the management strategies for metastatic esthesioneuroblastoma.

METHODS

We conducted a systematic review and meta-analysis.

RESULTS

Forty-eight studies totaling 118 patients met inclusion criteria. Chemotherapy in combination with surgery and/or radiation exhibited the best overall survival when compared to monotherapy and no treatment (P < .001). However, most patients (66%) received either monotherapy or no therapy. The number and location of metastases among the 3 treatment groups did not significantly differ (P = .85). Treatment modality remained significantly associated with overall survival on multivariable analysis (P < .001). Platinum-based chemotherapy was most commonly utilized but did not provide a survival benefit when compared with all other regimens (P = .88).

CONCLUSION

Distant metastases with esthesioneuroblastoma portend a poor prognosis. Chemotherapy in combination with surgery and/or radiation was associated with improved overall survival. Further research into the optimal systemic therapeutic regimen for patients with distant metastases is critical.

Endoscopic Management of Sinonasal Tumors: A Preliminary Report

Background

The increased experience with the endoscopic approach to sinonasal inflammatory disease has resulted in the increased use of endoscopes to manage many different sinonasal pathologies.

Methods

A chart review of patients with sinonasal tumors treated with primary endoscopic management, from January, 1993 to November, 2003 was performed.

Results

Forty patients were identified (26 men and 14 women). The mean age was 53.2 years, and the mean follow-up was 31.1 months. For benign tumors, 24 patients were identified with a mean age of 50.7 years, a mean follow-up of 17.5 months, and a recurrence rate of 4.2%. For malignant tumors, 16 patients were identified, with a mean age of 57.3 years, a mean follow-up of 51.5 months, and a recurrence rate of 31.3%. The overall survival rate was 87.5%.

Conclusion

Endoscopic surgical excision of selective sinonasal tumors may be an effective therapeutic modality. In some cases, adjuvant external procedures may be required based on tumor location.

Endoscopic Resection of Esthesioneuroblastoma

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare malignant neoplasm originating from neuroepithelial cells. Treatment for this tumor has traditionally required a craniofacial resection through an external approach. The safety and efficacy of transnasal endoscopic resection is unknown. A series of five patients with Kadish stage A or B lesions of the anterior skull base were resected and immediately reconstructed endoscopically over a nine-year period. There were 2 males and 3 females with a mean age of 64 years. Three patients were treated primarily and two were treated secondarily for recurrences after failing a traditional external craniofacial resection and postoperative radiotherapy. All primary lesions received adjuvant radiotherapy. The mean follow-up time was 31 months. All patients were discharged within 4 days or less. Operative complications included temporary postoperative infraorbital anesthesia (1 patient), unplanned cerebrospinal fluid leak (1 patient), and an orbital hematoma (1 patient). None of these complications resulted in any permanent sequelae. Two patients had prolonged nasal crusting for up to one year due to a variety of factors; large cavities, radiation therapy, and exposed lyophilized dural graft. However, all skull base defects healed without any short- or long-term sequelae. There have been no local recurrences. Two patients (1 primary and 1 secondary) developed regional metastasis to the orbit or cervical lymph nodes managed with primary transorbital excision or modified neck dissection, respectively. All but one patient remain free of disease by clinical, endoscopic, and radiographic (CT or MRI) surveillance. The remaining patient recurred distally as an undifferentiated carcinoma in his temporal bone and lungs 12 months after the initial resection. In experienced hands select cases of esthesioneuroblastoma can be safely excised and reconstructed endoscopically with comparable degrees of tissue removal as with external approaches. Short-term oncologic results in this small series of patients appear to be comparable to traditional methods. Longer follow-up on a larger series of patients is warranted.

Treatment of pediatric esthesioneuroblastoma with smell preservation

Olfactory neuroblastoma is a rare malignant tumor of neuroectodermal origin and represents the most common cancer of the nasal cavity in pediatric age. The gold standard of treatment consists of en bloc resection, numerous studies have shown as the endoscopic approaches permit good control of the disease improving the quality of life after the treatment. Herein we describe the case of a 13-year-old patient referred to our outpatient clinic with a polypoid multi-lobed lesion occupying the left nasal cavity and imaging that confirmed a left-sided nasal mass without cribriform plate involvement (Kadish B). We performed an unilateral endoscopic resection with transnasal craniectomy and anterior skull base reconstruction with a flap from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries (Septal Flip Flap, SFF), that provided a faster healing process with reduction of nasal crusting, improvement in the quality of life of patient in the postoperative period and the preservation of the contralateral olfactory bulb that has allowed to save the smell. This treatment strategy of pediatric esthesioneuroblastoma was analyzed in the context of the current literature.

Staging of Sinonasal and Ventral Skull Base Malignancies

Tremendous pathologic diversity among sinonasal and ventral skull base malignancies complicates development of a uniform and prognostically relevant staging system. Because of the comparatively low incidence of these tumors, comprehensive evaluation and comparison of specific staging systems is difficult. The current American Joint Committee on Cancer TNM staging system for sinonasal malignancies is the most common and widely used system in current clinical practice. Alternative systems have been proposed for use with individual histopathologic subtypes. Many of these staging systems are of great utility and accurately predict patient survival. Further research and adjustment of these current staging systems remains an important area of research.

Complications of Advanced Kadish Stage Esthesioneuroblastoma: Single Institution Experience and Literature Review

INTRODUCTION

In esthesioneuroblastoma, greater disease extent and Kadish staging correlate with greater recurrence, complications, and mortality. These advanced stage malignancies require extensive resections and aggressive adjuvant therapy. This increases the risk of complications such as cerebrospinal fluid leak, neurologic deficits, and osteomyelitis. We present our case series and then analyze the literature to ascertain whether advanced stage tumors corresponds to greater rates of complications.

METHODS

A retrospective review of consecutive patients with histologically-proven esthesioneuroblastoma who were aggressively managed at our institution was performed. This was followed by an extensive literature search of published original data, in large series from 2006-2016, where both surgery and adjuvant therapy were used for the treatment of esthesioneuroblastoma.

RESULTS 

Single institution review revealed eight patients with esthesioneuroblastoma, half with advanced Kadish staging. All Kadish A patients ( Kadish A: confined to nasal cavity) underwent endoscopic approaches alone, while Kadish C patients (Kadish C: extends beyond nasal cavity and paranasal sinuses) and D patients (Kadish D: lymph node or distant metastases) underwent craniofacial approaches, while all patients received post-operative adjuvant therapies. Complications such as cerebrospinal fluid (CSF) leak, seizures, meningitis, and abscess only occurred in high Kadish stage patients. Literature review demonstrated a higher proportion of advanced Kadish stage cases correlated with increasing rates of pneumocephalus, infection, and recurrence. A higher proportion of Kadish C and D tumors was inversely correlated with CSF leak rate and overall survival.

DISCUSSION

Advanced stage tumors are often associated with a higher incidence of adverse events up to 33%, both due to disease burden and treatment effect. There is increasing use of endoscopy and neoadjuvant therapy, which have the potential to decrease complication rates.

CONCLUSION 

Advanced Kadish stage esthesioneuroblastoma necessitates meticulous surgical resection and aggressive adjuvant therapies, together, these increase the likelihood of adverse events, including CSF leak, neurologic deficits, and infections, and may represent the real morbidity cost of radically treating these tumors to achieve an improvement in overall survival. In selected patients, less-invasive approaches or neo-adjuvant therapies can be used without compromising on a curative resection.

Complex Skull Base Reconstructions in Kadish D Esthesioneuroblastoma: Case Report

Introduction Advanced Kadish stage esthesioneuroblastoma requires more extensive resections and aggressive adjuvant therapy to obtain adequate disease-free control, which can lead to higher complication rates. We describe the case of a patient with Kadish D esthesioneuroblastoma who underwent multiple surgeries for infectious, neurologic, and wound complications, highlighting potential preventative and salvage techniques.

Case Presentation A 61-year-old man who presented with a large left-sided esthesioneuroblastoma, extending into the orbit, frontal lobe, and parapharyngeal nodes. He underwent margin-free endoscopic-assisted craniofacial resection with adjuvant craniofacial and cervical radiotherapy and concomitant chemotherapy. He then returned with breakdown of his skull base reconstruction and subsequent frontal infections and ultimately received 10 surgical procedures with surgeries for infection-related issues including craniectomy and abscess evacuation. He also had surgeries for skull base reconstruction and CSF leak, repaired with vascularized and free autologous grafts and flaps, synthetic tissues, and CSF diversion.

Discussion Extensive, high Kadish stage tumors necessitate radical surgical resection, radiation, and chemotherapy, which can lead to complications. Ultimately, there are several options available to surgeons, and although precautions should be taken whenever possible, risk of wound breakdown, leak, or infection should not preclude radical surgical resection and aggressive adjuvant therapies in the treatment of esthesioneuroblastoma.

Remote orbital recurrence of olfactory neuroblastoma (esthesioneuroblastoma)

Olfactory neuroblastoma is a rare and often locally aggressive malignancy that invades the orbit via local destruction. It is known to recur in a delayed fashion, particularly to the neck lymph nodes. This is a case of a 65-year-old gentleman who presents with recurrence in the orbit and a neck lymph node 19 years after treatment for his initial disease. This report describes the longest known interval in orbital recurrence and should alert the monitoring physician that extreme delays in recurrence can occur.

Management of Frontal Sinus Tumors

The most common primary tumors of the frontal sinus are osteomas and inverted papillomas, although a variety of other tumors involving this space have been reported. With the advent of new surgical techniques and instrumentation, an endoscopic approach to this region has become feasible. The preoperative assessment and decision making must take into account the complexity of frontal sinus anatomy, tumor type, tumor location, and associated attachments. These procedures allow adequate visualization, tumor removal, and postoperative monitoring, and preserve fairly normal sinus function. Open techniques may also be required and should be in the surgeon's armamentarium.

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

In most cases of advanced sinonasal and ventral skull base cancer, a multimodal treatment approach provides the best chance for improved outcomes. Depending on the tumor type and extent of disease, systemic chemotherapy has been shown to play an important role in neoadjuvant, concomitant, and adjuvant settings. The lack of randomized trials continues to limit its indications. Further high-quality studies are needed to understand ideal chemotherapeutic regimens and their role and sequential timing in sinonasal and ventral skull base cancer.

Role of surgical treatment for esthesioneuroblastomas: 31-Year experience at a single institution

OBJECTIVE

This study aimed to re-assess the outcomes of different surgical methods for esthesioneuroblastoma (ENB) in a single institution, with emphasis on changes in surgical treatment with regard to endoscopic approaches in patients with ENB.

SUBJECTS AND METHODS

We retrospectively reviewed the data of 35 patients with ENB treated over the last 31 years.

RESULTS

The 5-year overall and disease-free survival rates were 66.8% and 50.8%, respectively. Disease-free survival in the endoscopic surgery group was significantly higher compared to that of craniofacial surgery group (P = 0.035). In the endoscopic surgery group, nine of 10 patients did not exhibit local failure or regional recurrence over a mean followup period of 64.3 months, which was longer than the mean time to recurrence (22.0 months) observed in this study.

CONCLUSION

Given its significant survival outcomes and high rate of local control, endoscopic surgery could be preferred as a minimally invasive treatment with potentially low morbidity and possible oncological validity for the treatment of ENB.

Contemporary management of esthesioneuroblastoma

PURPOSE OF REVIEW

This article provides a contemporary review of the management of esthesioneuroblastoma (ENB) within the context of recent surgical advancements, while highlighting the ongoing limitations and controversies surrounding this uncommon pathologic entity.

RECENT FINDINGS

Surgical management of ENB is continuously evolving with contemporary endoscopic approaches complementing or in many cases replacing open approaches.

SUMMARY

Complete surgical resection remains the mainstay definitive therapy for ENB. Aggressive, combined modality therapy appears to be justified in patients at greatest risk of developing recurrence based on advanced tumor stage and high pathologic grade. ENB requires prolonged surveillance following treatment given its tendency for late recurrence.

Patterns of regional and distant metastasis in esthesioneuroblastoma

OBJECTIVES/HYPOTHESIS

To define the incidence and risk factors of metastatic disease and the effectiveness of salvage therapy in esthesioneuroblastoma (ENB).

STUDY DESIGN

Retrospective analysis of 57 patients presenting from 1979 through 2009.

METHODS

Cumulative incidence of neck failure, distant failure, and survival were assessed using the Kaplan-Meier method.

RESULTS

Overall survival for all patients was 85% at 5 years and 75% at 10 years. Overall survival was negatively impacted by intracranial tumor extension (P < 0.001), positive resection margins (P = 0.05), and neck metastases (P = 0.017). Neck lymph nodes were not routinely electively irradiated during this time period. Nodal metastases developed in 17% of patients at a median time of 60 months. Kadish stage was not associated with a risk of nodal metastasis (P = 0.78). After treatment for nodal recurrence, locoregional control was achieved in 78% of patients. Of patients developing nodal recurrence, more than half developed distant metastases. The cumulative incidence of distant metastasis was 39% at a median time of 40 months. Patients who presented with Kadish stage C or D had a significantly increased risk of distant failure (P < 0.001). In patients developing nodal (P = 0.017) or distant metastasis (P = 0.001), the probability of survival was significantly decreased.

CONCLUSION

Regional and distant metastases in patients with esthesioneuroblastoma occur in a delayed fashion and negatively impact survival. Neck nodal recurrence may be a harbinger of distant metastases. At the Memorial Sloan Kettering Cancer Center, New York, New York, we now treat the majority of ENB patients with elective nodal irradiation. However, the chief obstacle to long-term cure is distant metastases.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1556-1561, 2016.

The role of elective nodal irradiation for esthesioneuroblastoma patients with clinically negative neck

PURPOSE

Although adjuvant radiation to the tumor bed has been reported to improve the clinic outcomes of esthesioneuroblastoma (ENB) patients, the role of elective neck irradiation (ENI) in clinically node-negative (N0) patients remains controversial. Here, we evaluated the effects of ENI on neck nodal relapse risk in ENB patients treated with radiation therapy as a component of multimodality treatment.

METHODS AND MATERIALS

Seventy-one N0 ENB patients irradiated at the University of Texas MD Anderson Cancer Center between 1970 and 2013 were identified. ENI was performed on 22 of these patients (31%). Survival analysis was performed with focus on comparative outcomes of those patients who did and did not receive ENI.

RESULTS

The median follow-up time for our cohort is 80.8 months (range, 6-350 months). Among N0 patients, 13 (18.3%) developed neck nodal relapses, with a median time to progression of 62.5 months. None of these 13 patients received prophylactic neck irradiation. ENI was associated with significantly improved regional nodal control at 5 years (regional control rate of 100% for ENI vs 82%, P < .001), but not overall survival or disease-free survival. Eleven patients without ENI developed isolated neck recurrences. All had further treatment for their neck disease, including neck dissection (n = 10), radiation (n = 10), or chemotherapy (n = 5). Six of these 11 patients (54.5%) demonstrated no evidence of further recurrence with a median follow-up of 55.5 months.

CONCLUSION

ENI significantly reduces the risk of cervical nodal recurrence in ENB patients with clinically N0 neck, but this did not translate to a survival benefit. Multimodality treatment for isolated neck recurrence provides a reasonable salvage rate. The greatest benefit for ENI appeared to be among younger patients who presented with Kadish C disease. Further studies are needed to confirm these findings.

Syndrome of inappropriate antidiuretic hormone secretion associated with olfactory neuroblastoma

This study reports a patient having olfactory neuroblastoma complicated by syndrome of inappropriate antidiuretic hormone secretion. Olfactory neuroblastoma is a rare tumor that begins in the olfactory membrane. Only 10 cases have been reported previously. Because of having nonspecific symptoms, most patients manifest at an advanced stage at the time of diagnosis. Olfactory neuroblastoma may show local invasion and/or distant metastasis. We demonstrated preoperatively clinical and biochemical parameters consistent with antidiuretic hormone syndrome turned to normal ranges after the treatment. Surgery, chemotherapy, and radiotherapy are the choices of treatment; among these, surgery is an indispensible treatment.

Preservation of olfaction after unilateral endoscopic approach for resection of esthesioneuroblastoma

Objectives We present a case of olfactory preservation after a unilateral transcribriform transethmoidal endoscopic resection of esthesioneuroblastoma. We also discuss the oncologic results of endoscopic and transcranial approaches and describe the potential benefits and limitations of an endoscopic approach. Setting Single academic medical center. Participant and Design The clinical course of a 28-year-old patient who underwent endoscopic en bloc resection of esthesioneuroblastoma through a unilateral transcribriform transethmoidal approach was reviewed. Results Imaging demonstrated a left-sided nasal mass with cribriform plate involvement (Kadish C). Intraoperatively, the left olfactory bulb and epithelium were sacrificed. Negative frozen sections were obtained from the right olfactory epithelium and dura surrounding the right olfactory bulb. Reconstruction was performed using a multilayered closure of fascia, rigid buttress, and nasoseptal flap. Histology was consistent with esthesioneuroblastoma. Postoperative clinical evaluation, endoscopy, and magnetic resonance imaging demonstrated no evidence of residual or recurrent tumor at 18 months. The UPSIT smell testing revealed normal olfaction preoperatively, moderate microsomia at 3 months postoperatively, and mild microsomia at 18 months postoperatively. Conclusions Endoscopic resection of esthesioneuroblastoma has demonstrated similar oncologic control while reducing postoperative morbidity and mortality over transcranial approaches. This case reveals the potential to preserve olfaction while achieving en bloc endoscopic resection of early stage esthesioneuroblastoma.

Of mice and men: olfactory neuroblastoma among animals and humans

Olfactory neuroblastoma (ONB) is a rare tumour of nasal cavity and paranasal sinuses that arises from the olfactory neuroepithelium and has unpredictable clinical course. As the sense of smell is phylogenetically one of the first senses and olfactory neuroepithelium is evolutionary conserved with striking similarities among different species, we performed an extensive analysis of the literature in order to evaluate the similarities and differences between animals and humans on the clinical, morphological, immunohistochemical, ultrastructural and molecular level. Our analysis revealed that ONB was reported mainly in mammals and showed striking similarities to human ONB. These observations provide rationale for introduction of therapy modalities used in humans into the veterinary medicine. Animal models of neuroblastoma should be considered for the preclinical studies evaluating novel therapies for ONB.

Esthesioneuroblastoma: updating histologic grading as it relates to prognosis

OBJECTIVE

The Hyams grading system has been extensively used to predict prognosis in patients with esthesioneuroblastoma (ENB). However, most studies showing prognostic correlation group grading into I/II versus III/IV, essentially comparing low versus high grade. In addition, these studies include patients with variable treatment regimens, including some that were treated with chemoradiation alone. We aimed to determine whether additional histologic variables correlate with outcome with regard to disease free and overall survival in a series of patients universally treated with anterior skull base resection and +/- adjuvant chemoradiation.

STUDY DESIGN

A retrospective review of 27 patients with ENB was performed.

METHODS

The sections of tumor from these 27 patients were studied and reviewed with attention to percentage lobularity, degree of pleomorphism, degree of neurofibrillary matrix, and degree of apoptosis. In addition, the presence or absence of rosettes, necrosis, calcification, spindle cells, gland hyperplasia, and bone invasion were noted. Finally, the number of mitoses per high power field and the nature of chromatin (fine vs coarse) were recorded. The histopathologic features of these 27 ENBs were reviewed and correlated with clinical outcome.

RESULTS

There were 11 patients with recurrence (40.7% recurrence). There were 5 deaths (81.5% survival). The study cohort's mean overall survival was 158 months and the mean disease-free survival was 70.6 months. In terms of overall survival, necrosis and mitosis (#/10hpf) were significant but not when multivariate analysis was performed, these were not individually significant. In terms of disease-free survival, mitosis (#/10hpf) was significant but not on multivariate analysis. Gland hyperplasia was found to be a positive prognostic variable, associated with longer overall and disease-free survival, but only in combination with no spindle features and without necrosis.

CONCLUSIONS

An updated histologic grading system may provide more valuable prognostic information in patients with esthesioneuroblastoma treated with a standardized treatment paradigm.

Pathologic collision of inverted papilloma with esthesioneuroblastoma

Background: Inverted papilloma (IP) of the nasal cavity is a benign tumor that represents 0.5–4% of all nasal tumors and have been known to rarely undergo malignant transformation to squamous carcinoma and even more rarely adenocarcinoma. Synchronous association with low-grade esthesioneuroblastoma (ENB) has been reported in only one case report where a small-sized lesion was treated with surgery alone. Here we report the first case of invasion of IP by high-grade ENB with nodal metastasis that was treated with combined modality therapy.

Case Presentation: A case of a 64-year-old African American gentleman presented to the otolaryngology with a 3-month history of recurrent epistaxis. Imaging revealed a large right nasal cavity mass extending into the right sphenoid sinus but without intracranial extension. Surgical pathology revealed high-grade ENB invading IP. An orbitofrontal craniotomy approach was used to achieve complete resection of the mass but with positive margins. Post-operative positron emission tomography/computed tomography showed nodal metastasis. The patient was then treated with adjuvant chemoradiation and remains without evidence of disease at 42 months post-treatment. We discuss the disease presentation, histopathologic features, and disease management with literature support.

Conclusion: In this very rare disease presentation where two extremely rare malignancies collide, we show that aggressive management with trimodality therapy of surgery, adjuvant radiation with stereotactic radiosurgical boost, and adjuvant chemotherapy gives excellent results. Given the natural history of the disease, however, long follow-up is needed to declare complete freedom from the disease.

Esthesioneuroblastoma: an update on the massachusetts eye and ear infirmary and massachusetts general hospital experience with craniofacial resection, proton beam radiation, and chemotherapy

Objectives To update the Massachusetts General Hospital (MGH) and Massachusetts Eye and Ear Infirmary (MEEI) experience in the management of esthesioneuroblastoma (ENB) with multimodality therapy and to reassess treatment outcomes and complications in a larger cohort with longer follow-up times. Design A retrospective chart review. Setting A tertiary referral center. Participants All patients presenting with ENB and managed at the MGH and MEEI from 1997 to 2013. Main Outcome Measures Disease-free and overall survival. Results Twenty-two patients were identified with an average follow-up of 73 months. Ten patients presented with Kadish stage B disease and 12 with stage C disease. A total of six patients (27%) developed regional metastases. Treatment for all patients included craniofacial resection (CFR) followed by proton beam irradiation with or without chemotherapy. The 5-year disease-free and overall survival rates were 86.4% and 95.2%, respectively, by Kaplan-Meier analysis. Negative margins were a significant factor in disease-free survival. One patient experienced severe late-radiation toxicity. Conclusions ENB is safely and effectively treated with CFR followed by proton beam irradiation. The high incidence of regional metastases warrants strong consideration for elective neck irradiation. Proton beam radiation is associated with lower rates of severe late-radiation toxicity than conventional radiotherapy.

A 62-year-old female with an intranasal mass extending into the lamina cribrosa

Malignant tumors with neuroendocrine differentiation of the nasal cavity include neuroendocrine carcinoma, small cell undifferentiated carcinoma, olfactory neuroblastoma (esthesioneuroblastoma), and sinonasal undifferentiated carcinoma (SNUC). The rarity of these tumors and overlapping clinical, histological and immunohistochemical findings make the correct diagnosis difficult. However accurate diagnosis is critical for therapy and the outcome differs significantly between these entities. Here we describe the case of a 62-year-old woman with an intranasal tumor extending into the adjacent anatomical compartments and with infiltration of the meninges. The suspected preoperative diagnosis was olfactory neuroblastoma. Histological and immunohistochemical analysis showed a lobulated tumor with neuroendocrine differentiation and we ultimately diagnosed the process as a SNUC. In this report, we discuss the differential diagnosis at hand and present histological findings found in the specimen indicating that the process originated from local glands present in the nasal mucosa.

Orbital preservation in patients with esthesioneuroblastoma

Objectives Surgical resection in addition to adjuvant radiation with or without chemotherapy is the mainstay of treatment for esthesioneuroblastoma (ENB). However, management of patients with orbital involvement remains controversial. Historically, orbital exenteration has been advocated when there is evidence of periorbital invasion. Recently, the indications for orbital exenteration have become more selective and orbital preservation has been advocated. We report our experience with anterior craniofacial resection and orbital preservation in patients with ENB. Design Retrospective review of all patients diagnosed with esthesioneuroblastoma who underwent traditional open anterior craniofacial resection at the Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center from 1997 to 2008. Results Sixteen patients were identified with a mean follow-up of 76 months. All patients underwent anterior craniofacial resection via an open approach and adjuvant proton beam radiation. Six of the 16 patients had evidence of either periorbital or lacrimal sac involvement at the time of surgery. All of these patients underwent periorbital resection to negative histologic margins with preservation of the orbit. Conclusion In our study, patients with ENB and periorbital invasion-who were treated with anterior craniofacial resection and periorbital resection with orbital preservation-had no evidence of decreased survival. In all patients, negative histologic margins of the periorbital resection were achieved.

Esthesioneuroblastoma: Good Local Control of Disease by Endoscopic and Endoscope Assisted Approach. Is it Possible?

To present a short report on nine patients of esthesioneuroblastoma, managed endoscopically or endoscope assisted. To describe the technique and discuss the results at an average of 36.7 months of follow up. A retrospective study in a tertiary care centre. The present communication describes a series of 9 cases harbouring esthesioneuroblastoma, 6 managed endoscopically and 3 endoscope assisted between January 2005 and December 2009. All the nine patients remained free of disease at the primary site by endoscopic and radiological evaluation on an average of 36.7 months of follow up. One of the patients developed cutaneous and systemic metastasis for which she received chemotherapy and another one died during post-operative period due to unrelated causes. None of the patients showed recurrence or residual disease locally. Endoscopic and endoscope assisted approach provides a cosmetically better and surgically comparable outcome for local control of disease in early stages of esthesioneuroblastoma in expert hands without significant complications.

Esthesioneuroblastoma: a contemporary review of diagnosis and management

Esthesioneuroblastoma (ENB) is a rare malignancy, representing only 3% to 6% of all sinonasal malignancies. A wide array of treatment options for ENB have been described in the literature, but prospective clinical trials are absent given the tumor's rarity and natural history. Delay in diagnosis leading to an initial advanced stage of presentation is common secondary to the clinically hidden primary site at the anterior skull base. This article presents data from the current body of literature and reviews the advocated roles for surgery, radiation therapy and chemotherapy.

Salvage Treatment of Local Recurrence in Esthesioneuroblastoma: A Meta-analysis

Esthesioneuroblastoma has a local recurrence rate of ∼30%, but no standard regimen for salvage of local recurrence has been established. We report data from 678 patients from series published since 1990, with a risk reduction analysis of salvage with surgery, radiation, or combined surgery and radiation therapy. We found a 28.5% rate of local recurrence after treatment, and a 42.6% rate of successful salvage with surgery, radiation, or combined treatment. The odds ratio for successful salvage, defined as disease-free survival for at least 1 year, was not significantly different for combined surgery and radiation versus surgery alone or radiation alone or for surgery alone versus radiation alone. The salvage odds ratio for combined surgery and radiation therapy versus radiation therapy alone, 3.5, approached, but did not reach statistical significance. This study reveals a reasonable rate of successful salvage of local esthesioneuroblastoma recurrence using surgery, radiation, or combined surgery and radiation.

Craniofacial surgery for esthesioneuroblastoma: report of an international collaborative study

Introduction Impact of treatment and prognostic indicators of outcome are relatively ill-defined in esthesioneuroblastomas (ENB) because of the rarity of these tumors. This study was undertaken to assess the impact of craniofacial resection (CFR) on outcome of ENB. Patients and Methods Data on 151 patients who underwent CFR for ENB were collected from 17 institutions that participated in an international collaborative study. Patient, tumor, treatment, and outcome data were collected by questionnaires and variables were analyzed for prognostic impact on overall, disease-specific and recurrence-free survival. The majority of tumors were staged Kadish stage C (116 or 77%). Overall, 90 patients (60%) had received treatment before CFR, radiation therapy in 51 (34%), and chemotherapy in 23 (15%). The margins of surgical resection were reported positive in 23 (15%) patients. Adjuvant postoperative radiation therapy was used in 51 (34%) and chemotherapy in 9 (6%) patients. Results Treatment-related complications were reported in 49 (32%) patients. With a median follow-up of 56 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 78, 83, and 64%, respectively. Intracranial extension of the disease and positive surgical margins were independent predictors of worse overall, disease-specific, and recurrence-free survival on multivariate analysis. Conclusion This collaborative study of patients treated at various institutions across the world demonstrates the efficacy of CFR for ENB. Intracranial extension of disease and complete surgical excision were independent prognostic predictors of outcome.

Metastatic esthesioneuroblastoma secreting adrenocorticotropic hormone in pediatric patients

The purpose of this article was to report a pediatric case of secondary cervical esthesioneuroblastoma involving the parapharyngeal lymph nodes. A 3-year-old boy came to our clinical observation because of a right lymphonodal mass evidenced by nuclear magnetic resonance and a diagnosis of Cushing syndrome associated with ectopic adrenocorticotropic hormone secretion, moon face, central obesity, asthenia, and hirsutism. At the age of 10 months, the patient underwent endoscopic surgery for asportation of the World Health Organization stage IV esthesioneuroblastoma. At 38 months of age, the patient underwent right parapharyngeal lymphadenectomy with surgical access by a double mandibulectomy. After surgery, serum ACTH, cortisolemia, and urinary excretion of cortisol were within the reference range. Blood pressure was recorded at 110/70 mm Hg. Moon face disappeared, as well as central obesity and hirsutism. Clinical report is presented together with brief review of literature.

Esthesioneuroblastoma in an HIV-1 Infected Patient: Case Report

Esthesioneuroblastoma (ENB) is an uncommon malignant tumor derived from the specialized neuroepithelium of the upper nasal cavity. The largest case series and meta-analyses suggest the combination of surgery and radiotherapy as the gold standard treatment for ENB. However, an increasing number of case series have reported excellent survival and few complications with minimally invasive endoscopic resection (MIER) in conjunction with radiotherapy of EBN in early stages of the disease. In this case report, the authors describe the first case of ENB in a young adult man who was human immunodeficiency virus (HIV)-1 and Hepatitis C virus (HCV) coinfected. The authors discuss all the aspects of this rare disease, focusing on treatment options and prognosis.

Esthesioneuroblastoma: the massachusetts eye and ear infirmary and massachusetts general hospital experience with craniofacial resection, proton beam radiation, and chemotherapy

OBJECTIVES

To determine the efficacy of craniofacial resection and proton radiation for the management of esthesioneuroblastoma (ENB).

DESIGN

A retrospective chart review was performed of all patients presenting with ENB and completely managed at the Massachusetts General Hospital (MGH) and the Massachusetts Eye and Ear Infirmary (MEEI) from 1997 to 2006.

SETTING

A tertiary referral center.

MAIN OUTCOME MEASURES

Disease-free and overall survival.

PARTICIPANTS

All patients presenting with ENB and completely managed at the MGH and the MEEI from 1997 to 2006.

RESULTS

Ten patients were identified with a median follow-up time of 52.8 months. Average age at presentation was 45 years. Nasal obstruction was the most common presenting symptom. Three patients presented with Kadish stage B disease and seven with stage C. No patient had evidence of cervical or metastatic disease at presentation. Seven patients were treated with craniofacial resections (CFR) followed by proton beam radiation with or without chemotherapy. Three patients were treated with initial chemotherapy with no response. They subsequently underwent CFR followed by proton beam radiation. The 5-year disease-free and overall survival rates were 90% and 85.7%, respectively, by Kaplan-Meier analysis. No patient suffered any severe radiation toxicity.

CONCLUSION

ENB can be safely and effectively treated with CFR followed by proton beam irradiation. Proton irradiation may be associated with less toxicity than photon irradiation. The role of chemotherapy remains unclear.

Transnasal, transfacial, anterior skull base resection of olfactory neuroblastoma

PURPOSE

Using a transnasal, transfacial, anterior skull base approach, we have removed olfactory neuroblastomas (OFN) obviating the need for a frontal craniotomy. The objectives were to present our surgical approach in achieving clear margins, to assess patient survival, and to recommend eligibility criteria.

MATERIALS AND METHODS

A retrospective chart review was done to identify patients diagnosed with OFN who underwent this surgical approach. Thirteen patients were identified who underwent our pictorially described approach. Postoperative assessment of pathologic margins, patient survival, and limitations of surgical approach was determined.

RESULTS

Of the 13 patients, 12 (92%) had clear postsurgical margins. One patient had residual intracranial disease due to coagulopathy preventing further resection. Twelve patients remain alive with 10 patients remaining disease-free (follow-up ranging from 11 to 64 months). Three patients presented with recurrent disease initially, with 2 having had subsequent repeat local and regional recurrences, respectively; one of whom died recently of the re-recurrent disease. One patient had a postoperative cerebrospinal fluid leak repaired via the original surgical approach.

CONCLUSIONS

Although craniofacial resection remains an accepted approach for surgical treatment of OFN, we have adopted a transnasal, transfacial approach eliminating the need for a frontal craniotomy. This approach allows for adequate exposure of the cribriform plate, dura, and anterior skull base. Our technique minimizes dural defects and prevents many craniotomy-associated complications, including frontal lobe retraction. Long-term follow-up is needed to compare survival using this approach; however, our results to date are quite promising.

Esthesioneuroblastoma: is there a need for elective neck treatment?

PURPOSE

To assess the risk of cervical lymph node metastases after definitive treatment for esthesioneuroblastoma (ENB) that did not include elective neck therapy.

METHODS AND MATERIALS

This was a retrospective analysis of 26 ENB patients treated at the University of Michigan between 1995 and 2007. Tumor stage was Kadish A in 1 patient, B in 19, C in 5, and unknown in 1. Craniofacial or subcranial resection was performed in 24 patients (92%), with negative margins in 22 (92%). Postoperative radiotherapy (RT) to the primary site was given in 12 patients (46%), and 14 patients (54%) had surgery alone. All patients had clinically N0 disease, and no patient underwent elective neck dissection or radiation. Median follow-up was 72 months.

RESULTS

Local relapse-free survival was significantly better for patients who received postoperative RT compared with those who had surgery alone: 100% vs. 29% at 5 years, respectively (p = 0.005). Five-year disease-free survival was 87.5% in the RT group vs. 31% in the surgery-alone group (p = 0.05). Regional failure was observed in 7 patients (27%), 6 with Kadish Stage B and 1 with Stage C disease. The most common site of nodal failure was Level II, and 3 patients failed in the contralateral neck. Only 3 patients with regional failure were successfully salvaged.

CONCLUSION

The high rate of regional failures when the neck is not electively treated justifies elective nodal RT in patients with both Kadish Stages B and C. In addition, our experience confirms the beneficial effect on local control of adjuvant RT to the tumor bed.

Long-term results of 28 esthesioneuroblastomas managed over 35 years

BACKGROUND

The purpose of our study was to assess the long-term results in the management of patients with esthesioneuroblastoma.

METHODS

A total of 28 patients were retrospectively reviewed to analyze their clinical features, treatment outcomes, pattern of failures, and course of the disease.

RESULTS

The patients were classified as 2 patients with T1, 10 patients with T2, 10 patients with T3, and 6 patients with T4; the results of all were included in this study. Twenty-six patients underwent surgery and 23 had postoperative radiotherapy over the tumor bed, only 9 had radiotherapy over the nodes. The average follow-up was 99.11 months. Fifteen-year and 20-year disease-specific and disease-free survival rates were 88.6% to 66.4% and 59.6% to 29.8%, respectively. Six patients had recurrences and 60% of them occurred more than 10 years after treatment. In the first decade, nodal recurrences appeared earlier than local ones when patients with N0 did not undergo neck irradiation.

CONCLUSION

Surgery on patients with T presentations and adjuvant radiotherapy on T and N0 neck presentations seem to be essential to treat esthesioneuroblastoma. A follow-up for a minimum of 20 years is necessary to ensure complete cure.

Retained role of surgery for olfactory neuroblastoma

BACKGROUND

Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol.

METHODS

This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted.

RESULTS

There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%.

CONCLUSIONS

There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.

Extended applications of endoscopic sinus surgery and its reference to cranial base and pituitary fossa

Sinus surgery has the potential of allowing ENT surgeons to encroach the boundaries of our colleagues in ophthalmology and neurosurgery. The advent of nasal endoscope and lately powered instrumentation and computer-assisted navigational systems has avoided the use of the conventional and more radical approaches by the ENT surgeon for the treatment of inflammatory pathology or tumors of the orbit and skull base. As rhinologists have gained more experience in endoscopic surgery, more areas related to the orbit and the anterior skull base are accessible and surgery is safer.

Radiotherapy for esthesioneuroblastoma: is elective nodal irradiation warranted in the multimodality treatment approach?

PURPOSE

The role of elective nodal irradiation (ENI) in radiotherapy for esthesioneuroblastoma (ENB) has not been clearly defined. We analyzed treatment outcomes of patients with ENB and the frequency of cervical nodal failure in the absence of ENI.

METHODS AND MATERIALS

Between August 1996 and December 2007, we consulted with 19 patients with ENB regarding radiotherapy. Initial treatment consisted of surgery alone in 2 patients; surgery and postoperative radiotherapy in 4; surgery and adjuvant chemotherapy in 1; surgery, postoperative radiotherapy, and chemotherapy in 3; and chemotherapy followed by radiotherapy or concurrent chemoradiotherapy in 5. Five patients did not receive planned radiotherapy because of disease progression. Including 2 patients who received salvage radiotherapy, 14 patients were treated with radiotherapy. Elective nodal irradiation was performed in 4 patients with high-risk factors, including 3 with cervical lymph node metastasis at presentation.

RESULTS

Fourteen patients were analyzable, with a median follow-up of 27 months (range, 7-64 months). The overall 3-year survival rate was 73.4%. Local failure occurred in 3 patients (21.4%), regional cervical failure in 3 (21.4%), and distant failure in 2 (14.3%). No cervical nodal failure occurred in patients treated with combined systemic chemotherapy regardless of ENI. Three cervical failures occurred in the 4 patients treated with ENI or neck dissection (75%), none of whom received systemic chemotherapy.

CONCLUSIONS

ENI during radiotherapy for ENB seems to play a limited role in preventing cervical nodal failure. Omitting ENI may be an option if patients are treated with a combination of radiotherapy and chemotherapy.

Large olfactory neuroblastoma (esthesioneuroblastoma) surgically treated with an Altemir technique modification: a case report

INTRODUCTION

Olfactory neuroblastomas are rare malignant tumors that usually occur in the upper nasal cavity. The purpose of this paper is to present a case of a large olfactory neuroblastoma filling the entire nasal cavity, treated with an Altemir technique modification.

METHODS

A 39-year-old woman presented with a large tumor of the nasal cavity. After the laboratory examinations, the tumor was classified as a Kadish stage A olfactory neuroblastoma. The selected treatment was the surgical excision after an Altemir technique modification combined with midfacial degloving and additional radiotherapy.

RESULTS

Histopathology revealed a Hyams grade III olfactory neuroblastoma completely removed. Although the patient refused the additional radiotherapy, 18 months postoperatively, there were no signs of recurrence, and the patient shows big improvement on her sense of smell.

CONCLUSIONS

Large olfactory neuroblastomas filling the entire nasal cavity extending back to the postnasal space can be completely removed using a transfacial approach as the Altemir technique modification is.