Intensity Modulated Proton Therapy Better Spares Non-Adjacent Organs and Reduces the Risk of Secondary Malignant Neoplasms in the Treatment of Sinonasal Cancers

This study compare dosimetric parameters and secondary malignancy risk (SMN) using intensity modulated proton therapy (IMPT) and volumetric modulated arc therapy (VMAT) plans for the treatment of sinonasal cancer (SC). After IRB-approval, 10 patients previously treated with IMPT for cancers of the ethmoid, sphenoid, maxillary, or frontal sinuses were identified. Dosimetrists blinded to the IMPT plans generated VMAT plans for comparison. Volume coverage and dose to organs at risk (OAR) were recorded and compared. Organ equivalent dose (OED) of tissues outside of the treatment volume was used to define the excess absolute and relative risk of SMNs. In all cases, both VMAT and IMPT provided acceptable target volume coverage and were able to meet OAR constraints. IMPT was superior for brain V10, V30, and mean, brainstem D0.01 ipsilateral cochlea V30, contralateral cochlea mean, contralateral lacrimal gland mean, contralateral parotid mean, spinal cord D0.01 and body outside of the CTV V10, V20, and V30. VMAT was superior for ipsilateral eye mean, ipsilateral lens mean, CTV V100 and maximum hotspot. The relative risk of SMNs with VMAT compared to IMPT is 3.35 (95% CI, 1.92-5.89). For the treatment of SC, IMPT spares OARs that are not immediately adjacent to the treatment volume and reduces the risk of SMNs when compared to VMAT. VMAT spares OARs abutting the target volume better than IMPT and has more homogenous target coverage. Tumors of the ethmoid sinus, benefit more from IMPT, while tumors located elsewhere require application of our findings on a case by case basis.

Radiooncological View on Therapy Outcome after Multidisciplinary Treatment of Sinonasal Tumors

Simple Summary

Tumors of the nasal cavity and paranasal sinus are rare. Most are discovered at a locally advanced stage and require multimodal treatment consisting of surgery and radiotherapy with concomitant chemotherapy. Tumor localization between the eyes and near the brain makes treatment planning difficult due to the necessary consideration of both critical normal tissue with high protection priority and the curative aim of the best radiotherapy dose deposit. Thus, it is noteworthy how tumor volumes impact the five-year survival outcome. Therefore, we investigated initial tumor volumes before any therapy. Patients with larger mean initial tumor volumes of more than 75 cm³ had worse outcomes. There was no additional benefit of upfront surgery. Especially for patients with large tumor burdens of the nasal cavity or paranasal sinus, an interdisciplinary case discussion with the patient is essential in the process of shared decision-making.

Abstract

Purpose: We report the outcome of a mono-institutional retrospective study of sinonasal carcinoma with the primary focus on GTV (gross tumor volume) and the effect of radiotherapy. Methods: 53 patients with sinonasal carcinoma and that of the nasal cavity, paranasal sinus or both except lymphoma were included. All patients were treated between 1999 and 2017. For tumor volume delineation, all pre-therapeutic images were fused to the planning CT (computed tomography). Results: The median follow-up was 17 months [0.3–60], the median age 60 years, 35 males and 18 females were included. Squamous cell carcinoma (SCC) (60.4%) was the predominant histology, followed by adenocarcinoma (15.1%). The mean composite OS (overall survival) time was 33.3 ± 3.5 months. There was no significant difference in the 5 y composite OS between tumor localization or radiotherapy setting. The simultaneous integrated boost concept showed a trend towards improving five-year composite OS compared to the sequential boost concept. The only factor with a significant impact on the 5 y composite OS rate was the pre-therapeutic GTV (cutoff 75 cm³; p = 0.033). The GTV ≥ 100 cm³ has no effect on the 5 y composite OS rate for SCC. Conclusions: The pre-therapeutic GTV is a prognostic factor for five-year composite OS for the entire group of patients with sinonasal tumors, influencing the outcome after completion of all treatment strategies. The GTV seems to not influence five-year composite OS in SCC. For this rare tumor entity, an intensive, multidisciplinary discussion is essential to finding the best treatment option for the patient.

Sinonasal carcinomas - A single-centre experience at Prince of Wales Hospital, Sydney, Australia, from 1994 to 2016

INTRODUCTION

Sinonasal carcinomas (SNCs) are rare neoplasms that are often diagnosed at advanced stages due to asymptomatic growth of tumours in the spaces of the sinonasal complex. Treatment is associated with high morbidity, and outcomes have only improved slightly in the past few decades despite advancements in treatment modalities. The purpose of this study is to evaluate the efficacy and safety of treatment at our institution.

METHODS

This retrospective cohort study analysed patients who received definitive treatment at the Prince of Wales Hospital (POWH), Sydney, for non-metastatic SNC. Patients with non-carcinoma and olfactory neuroblastoma pathology were excluded. Data were collected from the POWH electronic patient database. Survival functions were calculated through Kaplan-Meier analysis, and multivariate analysis for prognostic factors was performed through Cox regression.

RESULTS

Seventy-five patients from 1994 to 2016 were eligible for analysis. Overall 5-year local control (LC), ultimate local control (ULC), overall survival (OS) and cancer-specific survival (CSS) were 76 ± 6%, 80 ± 5%, 69 ± 6% and 77 ± 5%, respectively. On multivariate analysis, clinical stage was prognostic for LC and primary site was prognostic for OS and CSS. Lymphovascular invasion and tumour inoperability were also predictive of CSS.

CONCLUSION

Survival and local control rates at our centre were greater than those reported in the literature. Early-stage patients treated with surgery alone had excellent oncologic outcomes. Radical surgery with postoperative radiation provides the best outcome in the setting of advanced disease.

Outcomes and toxicities of definitive radiotherapy and reirradiation using 3-dimensional conformal or intensity-modulated (pencil beam) proton therapy for patients with nasal cavity and paranasal sinus malignancies

BACKGROUND

Proton therapy (PT) improves outcomes in patients with nasal cavity (NC) and paranasal sinus (PNS) cancers. Herein, the authors have reported to their knowledge the largest series to date using intensity-modulated proton therapy (IMPT) in the treatment of these patients.

METHODS

Between 2013 and 2018, a total of 86 consecutive patients (68 of whom were radiation-naive and 18 of whom were reirradiated) received PT to median doses of 70 grays and 67 grays relative biological effectiveness, respectively. Approximately 53% received IMPT.

RESULTS

The median follow-up was 23.4 months (range, 1.7-69.3 months) for all patients and 28.1 months (range, 2.3-69.3 months) for surviving patients. The 2-year local control (LC), distant control, disease-free survival, and overall survival rates were 83%, 84%, 74%, and 81%, respectively, for radiation-naive patients and 77%, 80%, 54%, and 66%, respectively for reirradiated patients. Among radiation-naive patients, when compared with 3-dimensional conformal proton technique, IMPT significantly improved LC (91% vs 72%; P < .01) and independently predicted LC (hazard ratio, 0.14; P = .01). Sixteen radiation-naive patients (24%) experienced acute grade 3 toxicities; 4 (6%) experienced late grade 3 toxicities (osteoradionecrosis, vision loss, soft-tissue necrosis, and soft tissue fibrosis) (grading was performed according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 5.0]). Slightly inferior LC was noted for patients undergoing reirradiation with higher complications: 11% experienced late grade 3 toxicities (facial pain and brain necrosis). Patients treated with reirradiation had more grade 1 to 2 radionecrosis than radiation-naive patients (brain: 33% vs 7% and osteoradionecrosis: 17% vs 3%).

CONCLUSIONS

PT achieved remarkable LC for patients with nasal cavity and paranasal sinus cancers with lower grade 3 toxicities relative to historical reports. IMPT has the potential to improve the therapeutic ratio in these malignancies and is worthy of further investigation.

Definitive Radiation Therapy Versus Postoperative Radiation Therapy for Patients With Maxillary Sinus Cancer Invading the Upper Jaw

Maxillectomy following radiation therapy has the strongest local control over maxillary sinus cancer. However, in the advanced stage, complete resection is difficult with adequate margin and has the risk of functional disabilities after surgeries. The objective of the study was to determine the optimal treatment strategy for patients with maxillary sinus cancer invades the upper jaw. A total of 998 histologically confirmed maxillary sinus cancer invades the upper jaw patients were subjected to simple randomization. Patients were subjected to maxillectomy and received 150 mg/m/wk intra-arterial cisplatin for 4 weeks followed by radiotherapy (PR group, n = 499) or received the same chemotherapy and definitive radiotherapy only (DR group, n = 499). Disease status, overall survival, progression-free survival, and treatment-emergent adverse effects were evaluated in the follow-up period of 5 years. At the end of 5 years of follow-up, both the treatments had the same overall survival (P = 0.066). Demographic characters were independent parameters for the overall survival (P ≥ 0.05 for all). Postoperative radiotherapy had a higher progression-free survival than definitive radiotherapy (P = 0.018). Maxillectomy was useful in the reduction of the evidence of local recurrence of cancer (P = 0.027). Dysphagia, palate fistula, incomprehensible voice, and trismus were reported as treatment-emergent effects in the PR group. Definitive radiation therapy is recommended in maxillary sinus cancer that invades the upper jaw (Level of Evidence: I; research registry 4571 dated November 14, 2012).

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

OBJECTIVE

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

STUDY DESIGN

Retrospective cohort.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

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

Outcome of Definitive and Postoperative Radiotherapy in Patients with Sinonasal Squamous Cell Carcinomas

Aims

To evaluate outcomes in patients with sinonasal squamous cell carcinoma (SCC) treated with definitive radiotherapy (DRT) and postoperative radiotherapy (PORT).

Methods

Between 1990 and 2013, 73 patients with sinonasal SCC were treated with radiotherapy. Fifty-two patients (71.2%) were treated with DRT and 21 (28.8%) were treated with PORT. The primary tumor sites were the maxillary sinus in 47 patients (64.4%), the nasal cavity in 18 (24.7%), the ethmoid sinus in 7 (9.6%), and the frontal sinus in 1 (1.4%). Four (5.4%), 11 (15.1%), 24 (32.9%), 17 (23.3%), and 17 (23.3%) patients had T1, T2, T3, T4a, and T4b tumors, respectively. N stage was N0, N1, N2a, N2b, N2c, and N3 in 60 (82.2%), 6 (8.2%), 2 (2.7%), 2 (2.7%), and 3 (4.1%) patients, respectively. The median follow-up period was 23 months (range 3-196).

Results

The 5-year local progression-free survival (LPFS), regional progression-free survival (RPFS), distant metastasis-free survival (DMFS), and overall survival (OS) in the DRT and PORT groups were 50.6%, 82.1%, 91.1%, and 84.4% and 85.7%, 72.1%, 76.1%, and 83.5%, respectively, without any statistically significant differences.

Conclusions

The LPFS, RPFS, DMFS, and OS were not significantly different between the DRT and PORT groups. Given the possibility of functional disability and cosmetic disfigurement with facial surgery, DRT might be considered as a surrogate to surgery followed by PORT for patients with locally advanced sinonasal SCC.

Induction chemotherapy in technically unresectable locally advanced carcinoma of maxillary sinus

Background. Locally advanced carcinoma of maxillary sinus has been historically reported to have poor prognosis. We evaluated the role of NACT in improving the outcome in these patients. Methods. 41 patients with locally advanced technically unresectable (stage IVa) or unresectable maxillary carcinoma (stage IVb) were treated with induction chemotherapy between 2008 and 2011. The demographic profile, response and toxicity of chemotherapy, definitive treatment received, progression free survival (PFS), and overall survival (OS) were analyzed. Univariate and multivariate analysis were performed to determine factors associated with PFS and OS. Results. The chemotherapy included two drugs (platinum and taxane) in 34 patients (82.9%) and three drugs (platinum, taxane, and 5 FU) in 7 (17.1%). There was no complete response seen in any of the patients, stable disease in 18 (43.9%), partial response in 16 (39%), and progression in 7 (17.1%) patients. After induction, the treatment planned included surgery in 12 (29.3%), CT-RT in 24 (58.5%), radical RT in 1 (2.4%), palliative RT in 1 (2.4%), and palliative chemotherapy in 3 (7.3%) patients. Overall, the median PFS was 10.0 months. The OS at 24 months and 36 months was 41% and 35%, respectively. Conclusion. In unresectable maxillary carcinoma, induction chemotherapy has clinically significant benefit with acceptable toxicity.

Intensity modulated radiotherapy for sinonasal malignancies with a focus on optic pathway preservation

PURPOSE

To assess if intensity-modulated radiotherapy (IMRT) can possibly lead to improved local control and lower incidence of vision impairment/blindness in comparison to non-IMRT techniques when treating sinonasal malignancies; what is the most optimal dose constraints for the optic pathway; and the impact of different IMRT strategies on optic pathway sparing in this setting.

METHODS AND MATERIALS

A literature search in the PubMed databases was conducted in July, 2012.

RESULTS

Clinical studies on IMRT and 2D/3D (2 dimensional/3 dimensional) RT for sinonasal malignancies suggest improved local control and lower incidence of severe vision impairment with IMRT in comparison to non-IMRT techniques. As observed in the non-IMRT studies, blindness due to disease progression may occur despite a lack of severe toxicity possibly due to the difficulty of controlling locally very advanced disease with a dose ≤ 70 Gy. Concurrent chemotherapy's influence on the the risk of severe optic toxicity after radiotherapy is unclear. A maximum dose of ≤ 54 Gy with conventional fractionation to the optic pathway may decrease the risk of blindness. Increased magnitude of intensity modulation through increasing the number of segments, beams, and using a combination of coplanar and non-coplanar arrangements may help increase dose conformality and optic pathway sparing when IMRT is used.

CONCLUSION

IMRT optimized with appropriate strategies may be the treatment of choice for the most optimal local control and optic pathway sparing when treating sinonasal malignancy.

Contemporary management of sinonasal cancer

BACKGROUND

Sinonasal cancer is a relatively uncommon entity encountered by head and neck oncologists, rhinologists, and skull base surgeons. Recent innovations in surgical and nonsurgical therapeutic modalities raise the question of whether there has been any measurable improvement for treatment outcomes.

METHODS

A retrospective review of data from recent studies that focus on surgery, radiation, and chemotherapy, or combinations thereof, was conducted.

RESULTS

Surgery continues to be the preferred treatment and provides the best results, albeit with an inherent bias based on patient selection. For advanced disease (T4 lesions), the survival rate remains only modest. Complications of treatment, including both surgical and radiation therapy, have been reduced.

CONCLUSIONS

There is a need to improve the efficacy of treatment for this disease. Recommendations for the future direction of therapeutic investigations are outlined.