Radiographic predictors of occult intracranial involvement in olfactory neuroblastoma patients

BACKGROUND

Traditional management of olfactory neuroblastoma (ONB) includes margin-negative resection with removal of cribriform plate, dura, and olfactory bulb, regardless of intracranial disease. This approach may be overtreating certain patients. Our investigation examines risk factors associated with occult intracranial disease to optimize therapeutic outcomes.

METHODS

This retrospective, multi-institutional cohort study examined clinical covariates associated with occult intracranial involvement. Patient demographics, staging, Hyam's grade, and pathologic involvement of dura, olfactory bulb/tract, and brain were collected. Diagnostic imaging was reviewed. Positive and negative predictive value (NPV) were estimated along with effect size estimates. Cox hazard regression examined associations with overall survival (OS) and disease-free survival (DFS).

RESULTS

A total of 224 subjects with new diagnoses of ONB (2005-2021) were identified. Skull base bone involvement on computed tomography (CT) had the highest NPV for pathologic dura (88.0%), olfactory bulb (88%), and brain involvement (97.3%). Hyam's grade category was significantly associated with dural involvement (φC  = 0.26; 95% confidence interval [CI]: 0.16, 0.42). Subjects without radiologic skull base involvement (n = 66) had pathologic positivity of 12.1%. Within this subgroup, Hyam's grade was clinically significant for dural positivity (φ = 0.34; 95% CI: -0.12, 0.71) with 28.6% involvement in high grade tumors. Neither clinical nor pathologic positivity of intracranial structures were associated with significantly different OS or DFS.

CONCLUSIONS

Both CT and magnetic resonance imaging (MRI) had reasonably good NPV for involvement of dura and olfactory bulb. Higher Hyam's grade was associated with dural involvement. Patients with low-grade tumors not involving the skull base may be suitable for avoiding skull base resection; however, further investigation is warranted.

Operative Technique and Complication Management in a Case of Giant Esthesioneuroblastoma Resected by a Combined Transcranial and Endonasal Endoscopic Approach: Technical Case Report

BACKGROUND AND IMPORTANCE

Esthesioneuroblastoma (ENB) is a rare anterior skull base tumor derived from olfactory epithelium. There are very few operative videos in the literature demonstrating the surgical resection techniques for giant ENB because of their rarity and complexity. In this technical report, we demonstrate the microsurgical resection of a very large and complex high-grade ENB, initially deemed unresectable, through a bifrontal craniotomy and extended subfrontal approach combined with an endonasal endoscopic approach.

CLINICAL PRESENTATION

A 34-year-old woman presented with headaches, nasal congestion, and bloody nasal drainage. MRI showed a large nasal cavity mass with extension into the anterior cranial fossa and bifrontal lobes. There was significant bifrontal edema causing headaches and abutting the optic nerves. Initial management with surgical resection was offered to the patient for local tumor control and to preserve her vision. A combined bifrontal craniotomy and endonasal transsphenoidal approach was used for resecting this giant tumor. After achieving gross total resection, we reconstructed the anterior skull base in layers. She developed several postoperative complications which were appropriately managed.

CONCLUSION

We demonstrate the surgical resection of a giant ENB through a combined transcranial and endonasal endoscopic approach. We discuss the several postoperative complications in this complex case and the lessons learned.

The role of ADC value and Ki-67 index in predicting the response to neoadjuvant chemotherapy in advanced stages of olfactory neuroblastoma

OBJECTIVES

To investigate the efficacy of pretreatment ADC and Ki-67 index in the prediction of the response to neoadjuvant chemotherapy (NACT) in advanced olfactory neuroblastoma (ONB) patients.

METHODS

A total of 21 advanced ONB patients (mean 43.48 years ± 14.26; range 25-69 years; 13 men and 8 women) with diffusion-weighted imaging (DWI) before NACT between June 2015 and October 2021 were retrospectively analyzed. Patients were categorized into responders and non-responders according to RECIST 1.1 after two cycles of NACT. The clinical data, ADCmean value, and Ki-67 index were analyzed.

RESULTS

Kadish stage, ADCmean value, and Ki-67 index showed statistical significance between responders and non-responders. Patients with Kadish C stage were more likely to respond to platinum-based NACT (p = 0.035). Patients with the lower ADCmean value showed response to NACT (p = 0.002) and the cutoff point was 1.04 × 10-3 mm2/s. Patients with the higher Ki-67 index showed response to NACT (p = 0.003) and the cutoff point was 17.5%. Predictive performance of Ki-67 index and ADCmean value showed no significance between responders and non-responders (p = 0.865). A significant negative correlation was found between ADCmean value and Ki-67 index (r = -0.539, p = 0.038).

CONCLUSIONS

The pretreatment ADCmean value, Ki-67 index and Kadish stage have the potential to predict the response to NACT in advanced ONB patients.

ADVANCES IN KNOWLEDGE

This is the first study that investigated the feasibility of DWI in predicting the response to NACT in ONB patients and showed that Kadish stage, pretreatment ADCmean and Ki-67 index may play an important role in the prediction.

Nasoethmoidal Schwannoma as a Mimicar of Esthesioneuroblastoma: A Case Report and Literature Review

Nasoethmoidal schwannomas are rare lesions and their presentation with intracranial extension is even rarer. Here, a patient presenting with rhinorrhea, epistaxis, and proptosis of left eye was diagnosed with giant nasoethmoidal schwannoma extending to frontal lobe and orbit, which was managed with bifrontal craniotomy with endoscopic transnasal gross total excision. This being predominantly a benign lesion has good prognosis if total excision is achieved.

Cystic Intracranial Recurrence of Olfactory Neuroblastoma without Accumulation on Fluorine-18-fluorodeoxyglucose Positron Emission Tomography

A 66-year-old man underwent multimodal treatment for olfactory neuroblastoma (ONB). When he was 72 years old, a cystic intracranial lesion without accumulation on fluorine-18-fluorodeoxyglucose positron emission tomography was detected. Surgical resection was performed when the patient was 73 years old. The pathological examination revealed recurrence of ONB, and the patient underwent focal irradiation. At age 81, he presented with a second recurrence in the right occipital lobe with radiological and pathological findings similar to the prior recurrence. This case suggests that pathological confirmation should be considered in cases with atypical radiological findings following the treatment of ONB.

Ectopic Primary Olfactory Neuroblastoma: Case Series and Literature Review

OBJECTIVE

Olfactory neuroblastoma (ONB) is a rare malignant tumor arising in the upper nasal cleft. Rarely, ONB may originate in ectopic sites and the impact of this on prognosis and treatment strategies continues to be debated.

METHODS

A retrospective analysis was undertaken of patients with ectopic ONB treated between 2000 and 2020 in a tertiary-care referral center for skull base tumors. Three patients were included in this analysis: a 37-year-old woman with ONB arising from the bulla ethmoidalis; a 28-year-old man with inappropriate secretion of antidiuretic hormone caused by a maxillary sinus ONB; and a 41-year-old man with lacrimal sac ONB. Preoperative workup, surgical approach, adjuvant treatments and postoperative surveillance were analyzed. Relevant literature published between 2000 and January 2021 was fully reviewed to investigate oncologic outcomes and delineate the standard of care for such rare tumors.

RESULTS

All patients were treated via endoscopic endonasal resection with radical intent, followed by adjuvant treatments when required. No recurrences of disease were observed after a mean follow-up time of 32 months (range, 12-60 months). Data emerging from the literature suggest that a multidisciplinary treatment approach, including free-margins surgical resection followed by adjuvant radiotherapy or radiochemotherapy, is recommended. Olfactory bulb and dura preservation should be attempted whenever feasible.

CONCLUSIONS

Endoscopic endonasal surgery should be preferred, when possible, to achieve complete excision to minimize patients' morbidity. The ectopic site of origin affects prognosis and should be considered when selecting the appropriate multimodal treatment strategy.

Comparison of a Hybrid IMRT/VMAT technique with non-coplanar VMAT and non-coplanar IMRT for unresectable olfactory neuroblastoma using the RayStation treatment planning system-EUD, NTCP and planning study

The purpose of this study was to compare hybrid intensity-modulated radiotherapy (IMRT) and volumetric-modulated arc therapy (Hybrid IMRT/VMAT), with non-coplanar (nc) IMRT and nc-VMAT treatment plans for unresectable olfactory neuroblastoma (ONB). Hybrid IMRT/VMAT, nc-IMRT and nc-VMAT plans were optimized for 12 patients with modified Kadish C stage ONB. Dose prescription was 65 Gy in 26 fractions. Dose-volume histogram parameters, conformation number (CN), homogeneity index (HI), integral dose and monitor units (MUs) delivered per fraction were assessed. Equivalent uniform dose (EUD) and normal tissue complication probability (NTCP) based on the EUD model (NTCPLogit) and the Lyman-Kutcher-Burman model (NTCPLKB) were also evaluated. We found that the Hybrid IMRT/VMAT plan significantly improved the CN for clinical target volume (CTV) and planning treatment volume (PTV) compared with the nc-VMAT plan. In general, sparing of organs at risk (OARs) is similar with the three techniques, although the Hybrid IMRT/VMAT plan resulted in a significantly reduced Dmax to contralateral (C/L) optic nerve compared with the nc-IMRT plan. The Hybrid IMRT/VMAT plan significantly reduce EUD to the ipsilateral (I/L) and C/L optic nerve in comparison with the nc-IMRT plan and nc-VMAT plan, but the difference in NTCP between the three technique was <1%. We concluded that the Hybrid IMRT/VMAT technique can offer improvement in terms of target conformity and EUD for optic nerves, while achieving equal or better OAR sparing compared with nc-IMRT and nc-VMAT, and can be a viable radiation technique for treating unresectable ONB. However, the clinical benefit of these small differences in dosimetric data, EUD and NTCP of optic nerves may be minimal.

Combined Simultaneous Multiportal Approach via Minimally Invasive Transciliary and Endoscopic Endonasal Approaches for Tumors Invading Both the Skull Base and the Sinonasal Area

BACKGROUND

A combined transcranial and transfacial approach has long been the gold standard for surgical management of large tumors with sinonasal and skull base involvement. The extended endoscopic endonasal approach for such pathologies has its advantages, but it has flaws as well, such as anatomic limitations and more ponderous skull base reconstruction and thus higher risk of postoperative complications. Our primary technique for surgical treatment of these pathologies has been a combination of transfacial and minimally invasive transciliary supraorbital keyhole approaches. With the aim to further minimize invasiveness, potential complications, and unsatisfactory aesthetic outcomes during surgical treatment of large tumors invading both the sinonasal area and the skull base, we abandoned the transfacial approach and simultaneously combined the transciliary supraorbital keyhole approach with the endoscopic endonasal approach.

METHODS

The well-known microscope-assisted minimally invasive approach via a transciliary supraorbital keyhole craniotomy was combined with the endoscopic endonasal approach.

RESULTS

Six patients with different histologic types of tumors affecting the sinonasal area and the skull base were operated on. The mean operative time was 3 hours, there were no unexpected intraoperative or postoperative complications, and total tumor removal was achieved in each patient. None of the patients experienced complications associated with the surgery during follow-up.

CONCLUSIONS

Our combined simultaneous multiportal approach enables total tumor eradication with reduced operative time and is associated with minimal intraoperative and postoperative complications, low mortality rate, and excellent cosmetic results.

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.

Adrenocorticotropic Hormone-Secreting Esthesioneuroblastoma with Ectopic Cushing's Syndrome

Esthesioneuroblastoma as a source of ectopic Cushing's syndrome is rare, and to the best of our knowledge, only 20 cases have been reported worldwide. A 46-year-old healthy man visited a local clinic for general weakness and hyposmia, and underwent examination with serial endocrinological workup and brain imaging. ⁶⁸Gallium-DOTA-TOC positron emission tomography scan was helpful where diagnosis of sellar MRI and inferior petrosal sinus sampling were discordant. Combined transcranial and endoscopic endonasal approach surgery was performed, and a diagnosis of esthesioneuroblastoma was given.

An unusual manifestation of olfactory neuroblastoma

A 62-year-old woman presented with an 11-month history of worsening nasal symptoms of rhinorrhoea, anosmia, nasal congestion and intermittent epistaxis. MRI revealed a large mass in the upper nasal vault. Biopsy of the mass revealed an olfactory neuroblastoma. While waiting resection, she acutely developed severe proximal muscle weakness, lethargy and lower extremity oedema. Blood glucose was elevated, and hypokalaemic metabolic alkalosis was noted. Elevated serum cortisol level of 95.7 µg/dL (8.7-22.4 µg/dL) and markedly elevated 24-hour urinary cortisol level of 6962.3 µg/24 hours (4.0-50.0 µg/24 hours) with concurrent adrenocorticotropic hormone (ACTH) level of 171 pg/mL (6-58 pg/mL) were suggestive of an ACTH-dependent source of hypercortisolism. A subsequent positive high-dose dexamethasone suppression test was consistent with ectopic ACTH production. She underwent near-total resection of the right nasal mass followed by radiotherapy, resulting in complete resolution of signs and symptoms of cortisol excess.

Intranasal Esthesioneuroblastoma: CT Patterns Aid in Preventing Routine Nasal Polypectomy

BACKGROUND AND PURPOSE

Esthesioneuroblastoma is a neuroectodermal tumor that commonly arises in the nasal cavity olfactory recess and, when isolated to the intranasal cavity, can be indistinguishable from benign processes. Because lesional aggressiveness requires a more invasive operation for resection than polypectomy, patients with isolated intranasal lesions were studied to define distinguishing CT characteristics.

MATERIALS AND METHODS

Patients with intranasal esthesioneuroblastoma and controls without esthesioneuroblastoma with olfactory recess involvement were identified by using a report search tool. Studies demonstrating skull base invasion and/or intracranial extension were excluded. The imaging spectrum of these lesions was reviewed on both CT and MR imaging, and CT findings were compared with those of controls without esthesioneuroblastoma. Two blinded readers assessed subjects with esthesioneuroblastomas and controls without esthesioneuroblastoma and, using only CT criteria, rated their level of suspicion for esthesioneuroblastoma in each case.

RESULTS

Eight histologically proved cases of intranasal esthesioneuroblastoma were reviewed. All cases had CT demonstrating 3 main findings: 1) an intranasal polypoid lesion with its epicenter in a unilateral olfactory recess, 2) causing asymmetric olfactory recess widening, and 3) extending to the cribriform plate. Twelve patients with non-esthesioneuroblastoma diseases involving the olfactory recess were used as controls. Using these 3 esthesioneuroblastoma CT criteria, 2 blinded readers evaluating patients with esthesioneuroblastoma and controls had good diagnostic accuracy (area under the curve = 0.85 for reader one, 0.81 for reader 2) for predicting esthesioneuroblastoma.

CONCLUSIONS

Esthesioneuroblastoma can present as a well-marginated intranasal lesion that unilaterally widens the olfactory recess. CT patterns can help predict esthesioneuroblastoma, potentially preventing multiple operations by instigating the correct initial operative management.

Esthesioneuroblastoma: the complete picture - case report and review of the literature

Esthesioneuroblastoma (ENB), also called olfactory neuroblastoma, is a cancerous tumor originating from the olfactory neuroepithelial cells frequently invading the brain through the cribriform plate. The optimal therapy is the multimodality treatment involving a group of physicians trained in different medical specialties. Establishing a careful histopathological diagnostic and treatment planning based on a multidisciplinary approach is of paramount importance. The treatment of ENB correlates with the extent of the lesion, with surgery being the mainstay of therapy followed by postoperative irradiation. Surgery, when complete, image-verified and associated with radiation therapy results in long-term survival and presents a very low probability of illness recurrence. We present the case of a 46-year-old female with ENB, who was operated on in the Clinic of Neurosurgery of the National Institute of Neurology and Neurovascular Diseases in Bucharest, Romania, through a bifrontal craniotomy approach. Gross total resection of the intracranial extent was performed. The pathological diagnosis revealed an aggressive olfactory neuroblastoma. Three weeks after discharge from hospital, the tumor was completely resected through a lateral rhinotomy performed by an otorhinolaryngologist. Six weeks later, the patient received adjuvant therapy (radiotherapy and chemotherapy). The outcome was favorable, with no tumor recurrence at 20 months postoperatively. Our case demonstrates that even when dealing with a visibly aggressive tumor, a correct diagnosis, accurate classification and grading along with appropriate therapy ensure a favorable outcome.

Minimally invasive resection of olfactory neuroblastoma by transnasal endoscopy

Olfactory neuroblastoma is rare. We conducted a retrospective study to review our experience with minimally invasive resection of olfactory neuroblastomas via a transnasal endoscopic technique, including an analysis of surgical outcomes. Our series included 5 patients-3 men and 2 women, aged 29 to 75 years (mean: 48). Surgical outcomes were evaluated on the basis of each patient's preoperative Dulguerov classification and postoperative evaluation on computed tomography and magnetic resonance imaging. One patient was treated with surgery alone, 3 with surgery plus radiotherapy, and 1 with surgery, radiotherapy, and chemotherapy. During follow-up of 18 to 115 months, all 5 patients remained alive and disease-free. We found that endoscopic resection of olfactory neuroblastoma is a feasible and effective procedure, even in patients with more aggressive stages of disease. We also believe that the Dulguerov classification is more useful than other classifications for clinical management and surgical planning. Long-term follow-up is necessary to look for late recurrence.

Olfactory neuroblastoma presenting as bleeding polyp

Malignant tumours of the nasal cavity are rare. Olfactory neuroblastomas (esthesioneuroblastomas) account for only 6% of these neoplasms. Fewer than 1,000 cases have been reported in the literature since this tumour was first described more than 75 years ago. A 13 year old girl presented with bleeding nasal polyp to ENT Department. She was operated as there were no signs of tumour the histopathology report revealed it to be olfactory neuroblastoma. As there was no intracranial extension she was given postoperative radiotherapy.

Huge sphenoid sinus olfactory neuroblastoma: a case report

Intranasal or paranasal sinus olfactory neuroblastoma is a rare malignant neoplasm of olfactory neuroepithelial origin, accounting for approximately 5% of paranasal sinus cancers. Most of the presenting symptoms include nasal obstruction, nasal bleeding, anosmia, rhinorrhea, and headache. In this present report, we describe a 79-year-old man who presented with bilateral nasal congestion for more than 1 year. Nasoendoscopy showed a huge, smooth, mucosal tumor in the nasopharynx with extension to the posterior nasal septum. The tumor was completely resected under endonasal endoscopy and the pathology revealed olfactory neuroblastoma. Olfactory neuroblastomas usually arise in the cribriform plate and superior turbinate. However, the origin and isolation of olfactory neuroblastomas to the sphenoid sinus is exceedingly rare. Only four cases of olfactory neuroblastoma isolated in the sphenoid sinus have been described in English literature and the frequency of presenting symptoms with cranial neuropathies and headache. We report a case of primary sphenoid sinus olfactory neuroblastoma with the greatest enlargement reported to date.

Two cases of ectopic adrenocorticotropic hormone syndrome with olfactory neuroblastoma and literature review

Olfactory neuroblastomas are rare, slow-growing malignant tumors, usually diagnosed at advanced stages. Ectopic adrenocorticotropic hormone (ACTH) syndrome caused by an olfactory neuroblastoma is extremely rare. We reported two Korean women who suffered from ectopic ACTH syndrome (EAS) caused by olfactory neuroblastomas. The first patient was a 66-year-old woman who had been diagnosed as olfactory neuroblastoma and refused the management two years before and the second patient was a 37-year-old woman on chemotherapy for olfactory neuroblastoma. In the first case, she presented the Cushingoid appearance with systemic edema and her tumor was removed surgically. ACTH secretion by the tissue was confirmed by immunohistochemistry. By contrast, the second patient presented as severe pneumonia caused by cytomegalovirus and was treated with anti-viral agent followed by chemotherapy and radiotherapy, and her residual mass remained. However, after treatment, both patients' plasma ACTH and cortisol levels returned to normal without any adrenolytic therapy. Considering the causative tumors of EAS can be rarely cured and EAS increases the susceptibility to infections, it is prudent to suppress any hypercortisolemia initially, apart from treating the causal malignancy.

Clinical utility of somatostatin receptor scintigraphic imaging (octreoscan) in esthesioneuroblastoma: a case study and survey of somatostatin receptor subtype expression

BACKGROUND

For tumors that express somatostatin receptors (SSTR), radiolabeled somatostatin analogs, such as 111In-pentetreotide, can demonstrate the presence of tumor by radioligand uptake using somatostatin receptor scintigraphy (SRS). The use of 111In-pentetreotide for SRS depends on the specific high affinity of octreotide for SSTR subtypes 2, 3, and 5. Of these, SSTR2 has the greatest affinity for octreotide and the greatest relevance for tumor detection with Octreoscan imaging. Discriminating between postoperative changes and residual or recurrent tumor after extensive skull base surgery is often difficult, but in a case of recurrent esthesioneuroblastoma (ENB) we found the use of Octreoscan imaging clinically useful. To better define the general relevance of this imaging technique in this setting, we analyzed SSTR subtype expression in a panel of ENB tumors.

METHODS

The case history and correlations between MRI and 111In-pentetreotide SRS of a patient with recurrent ENB were reviewed. The expression pattern of the SSTR subtypes in a panel of ENB tumors was then analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR) to better define the potential of more general use of Octreoscan for imaging ENB. To correlate SSTR2 protein expression with 111In-pentetreotide uptake, immunohistochemistry to detect SSTR2 was performed on tumor samples from regions of increased uptake on Octreoscan.

RESULTS

The SSTR2 message was expressed at high levels in all five ENB tumor samples, and either SSTR2 protein or histologic findings typical for ENB were found in all tumor tissue obtained from regions of increased 111In-pentetreotide uptake. Furthermore, Octreoscan imaging in this case proved useful in clinical decision making.

CONCLUSION

The expression pattern of SSTR2 and the specificity of the Octreoscan for regions of active tumor growth support further investigation of the utility of Octreoscan imaging in the diagnosis and surveillance of ENB. Recent advances in novel therapies based on SSTR ligand binding also provide the rationale to consider such novel therapeutic approaches in patients with ENB.

Endoscopic-assisted cranionasal resection of olfactory neuroblastoma

BACKGROUND

Cranionasal resection was first described in 1997 for the surgical resection of olfactory neuroblastoma. The endoscopic transnasal approach is used in cranionasal resection to replace the more invasive craniofacial resection. It has the advantages of avoiding the facial wound and its associated pain, swelling, and scar. The authors have routinely practiced cranionasal resection since 1996 for resection of all anterior skull base tumors in which the resultant skull base bony defect is limited to the nasal and sinus roof. The aim of this study was to review the results of cranionasal resection for olfactory neuroblastoma.

METHODS

The results of cranionasal resection for olfactory neuroblastoma in six patients from 1996 to 2003 were reviewed.

RESULTS

The Kadesh stages were 3A, 2B, and 1C. None of the patients had postoperative complications. Postoperative radiotherapy was given only to the patient with Kadesh stage C disease. There were no local recurrences. Two patients died of lung metastasis.

CONCLUSIONS

Cranionasal resection is a safe and adequate procedure. Postoperative radiotherapy is not necessary after clear resection of Kadesh A and B tumors.

[Olfactory neuroblastoma in 55 year old woman]

In this article the authors describe a rare case of olfactory neuroblastoma in a 55-year-old woman surgically treated because of nasal polyposis. Three years earlier she had been operated for nasal polyposis on the same side in another ENT department. Unfortunately these lesions may had not been evaluated histologically. One of the surgically removed polyps was atypical. In histopathological examination it was confirmed to be olfactory neuroblastoma. CT scan revealed abnormal thickness of the mucosa in the upper part of the nose and ethmoidal sinuses on the right side. The tumor was classified as stage B in Kadish classification of olfactory neuroblastoma. The histopathologic diagnosis and CT scan made after the surgery resulted in necessity of further oncological treatment. The olfactory neuroblastoma is rare, difficult to diagnose, malignant, slowly growing tumor arising from the olfactory epithelium in the upper nasal cavity. The treatment includes surgery, radiotherapy and chemotherapy. Another objective of this paper is to point out that histopathological examination is crucial in each surgically removed tissue.

[Olfactory neuroblastoma in an old patient. Report of a case]

Olfactory neuroblastoma or esthesioneuroblastoma is a rare embrionary tumor, much more in old patients, which uses to present as a pollipoid mass with nasal obstruction, epistaxis and anosmia of long evolution. We report the case of a 82-year-old male with such symptoms diagnosed by biopsy as neuroblastoma class III according the histologic Hyams grading. Due to the age of the patient and grade of the tumor we did not perform surgery and, although a chemotherapy-radiotherapy treatment was suggested, the patient was not agree with it and he has not been attended or followed in our consulting rooms.

Isolated esthesioneuroblastoma of sphenoid sinus

Esthesioneuroblastoma is a rare neuroendocrine tumor that arises from the olfactory epithelium and accounts for approximately 3% of all intranasal tumors. The tumor involvement in the nasal cavity with extension to paranasal sinuses, orbit, and anterior cranial fossa, is reported in the literature. In this report, we present an interesting case of isolated sphenoid sinus esthesioneuroblastoma, which is the first case to be reported in the literature, and discuss the pathology, clinical manifestations, and various treatment options for this tumor.

[Esthesioneuroblastoma. Description of a case investigated with CT and MR]

Esthesioneuroblastoma, also known as olfactory neuroblastoma, is a rare neuroendocrine tumor originating from the olfactory epithelium of the upper nasal cavity and representing < 3% of all tumors of the nasal cavities. This malignant tumor is characterized by a slow growth and local recurrencies and has a more favorable prognosis as compared with other more frequent forms of neuroblastomas originating from the suprarenal medulla and the sympathetic nervous system. Affected patients usually present with a history of progressive nasal obstruction, rhinorrhea, and severe epistaxis--sign of the conspicuous vascularity of this type of tumor. The combined use of CT and MR techniques allows the diagnostic suspicion of esthesioneuroblastoma and is of vital importance in the accurate staging of the disease and in the treatment planning.

Esthesioneuroblastoma: clinical presentation, radiological, and pathological features, treatment, review of the literature, and the University of Virginia experience

Esthesioneuroblastoma is a rare and malignant upper nasal cavity neoplasm involving the anterior skull base. Treatment includes surgery, radiotherapy, chemotherapy, or a combination. The ideal treatment modality has yet to be determined. Esthesioneuroblastoma often lies in proximity to the optic nerves, optic chiasm, and the orbit. Resection risks damaging these critical structures, and radiotherapeutic techniques, similar to those applied for paranasal sinus tumors, may damage these vital structures and result in late sequelae such as blindness and cortical necrosis. Management strategies for this neoplasm lack uniformity, and there is no universally accepted staging system. In this paper the authors discuss the clinical presentation, radiological and pathological features, and treatment of this rare, malignant skull base neoplasm, as well as review the literature. They also present their results and treatment regimen, which includes preoperative radio- and chemotherapy or 1) craniofacial resection if the lesion has a significant intracerebral component, or 2) frontal sinus resection if little intracranial extension exists.

Olfactory neuroblastoma visualized by Technetium-99m-ECD SPECT

We describe a case of olfactory neuroblastoma diagnosed by 99mTc-ECD SPECT. Although MRI and CT are very important for delineating these tumors, they are, by no means, specific for neuroblastomas. 131I-MIBG scintigraphy, the standard method for imaging tumors of neural crest origin, also failed to detect a histologically proven esthesioneuroblastoma.

[Olfactory esthesioneuromas]

Olfactory neuroblastomas are rare malignant tumours of the nose arising from the olfactory epithelium. In a retrospective series of 18 cases and a review of the literature, the authors establish the main features of this tumour. They emphasise the difficulties of histological examination, often requiring immuno-cyt-chemistery and electron microscopy. They point out the value of a new classification, and confirm treatments being radio-surgical, with use of the combined rhino-neurosurgical approach when there is extension to the cribriform plate. They report a 5-year survival of 91.5%, with 87.5% at 10 years. The high incidence of lymph gland metastases (16.6%) is greater than that of local recurrence (11%) especially in the more advanced cases. The question of prophylactic treatment of the neck nodes is one to be considered.

Imaging of recurrent esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon neoplasm arising from the olfactory epithelium and characterized by frequent local recurrences. The purpose of this study was to determine the role of CT and MRI in the diagnosis of recurrent esthesioneuroblastoma. A total of 14 histologically confirmed recurrent esthesioneuroblastomas referred to our institution between 1986 and 1998 was retrospectively reviewed. All patients underwent both CT and MRI. The tumour recurrences displayed a variety of imaging characteristics and aggressiveness. They were typically expansile and destructive in their growth patterns. Erosion of the cribriform plate and involvement of the anterior cranial fossa were common findings. The CT and MRI appearances of recurrent esthesioneuroblastoma do not differ significantly from tumours imaged at initial presentation. Patients should receive close follow-ups and CT/MRI examinations for several years beyond diagnosis, as early diagnosis of recurrent disease predicts survival.

[Olfactory esthesioneuroblastoma: scintigraphic expression of somatostatin receptors]

Esthesioneuroblastoma is an uncommon tumor originating in the upper nasal cavity and constitutes 3% of all intranasal neoplasms. Few references exist about the expression of somatostatin receptors in these tumors. Our case demonstrates a good correlation between the somatostatin receptor scintigraphy and magnetic resonance imaging.

[Stesioneuroblastoma. A case report]

The esthesioneuroblastoma is a rare type of tumor located in nasal cavity, malignant, that is able to take a very aggressive growth pattern, but it has treatment with cure expectations when it is discovered in its initial stages by surgery or intensive radiotherapy and/or chemotherapy in the more developed ones. Due to its low incidence and its clinic presentation as a benign process that makes the patient takes it as a non important process, the esthesioneuroblastoma, as others malignant diseases of the nasal cavity, is frequently diagnosed at developed stages as this case that we present here.

[Evaluation of CT in the diagnosis of esthesioneuroblastoma]

OBJECTIVE

To assess the role of CT in the diagnosis, staging and post-treatment follow-up of esthesioneuroblastoma.

METHODS

Thirteen cases of pathologically comfirmed esthesioneuroblastoma were analysed retrospectively.

RESULTS

On preoperative check up, according to Kadish staging, no case was in stage A, 4 cases were in stage B, 7 in stage C. Tumor scans showed soft tissue density. In 3 cases, calcification was found inside of the tumor. In the 4 cases on scan and enhanced CT, the tumors were heterogeneously enhanced in 3. On enhanced CT, the tumor density was obviously higher than that of the surrounding soft tissue in 6 cases. Postoperative follow-up CT revealed tumor recurrence within 3 months to 2 years in 4 cases. Tumor invasion involved nasal cavity and ethmoid sinus(13 cases), maxillary sinus (12 cases), sphenoid sinus(10 cases), frontal sinus (2 cases), orbit (7 cases). Intracranial invasion occurred in 3 cases, and lymph node metastases in 4 cases.

CONCLUSION

CT is valuable in pre-operative staging and monitoring recurrence of esthesioneuroblastoma. Although esthesioneuroblastoma has characteristic CT features on enhancement and multiple invasions to neighboring structures, reliable diagnosis is dependent on pathological confirmation.

Primary sphenoid and petrous apex esthesioneuroblastoma: case report

A 62-year-old woman presented with raised intracranial pressure and features of a right cerebellopontine angle tumour with extension into the right middle cranial fossa. The patient died before a surgical excision could be performed. The autopsy revealed a primary esthesioneuroblastoma of the sphenoid sinus eroding the petrous bone and extending into the middle cranial fossa with metastatic tumour in the liver, and paratracheal and hilar lymph nodes. Although rare, esthesioneuroblastoma must be considered in the differential diagnosis of petrous-sphenoid lesions.

[Olfactory esthesioneuroblastoma. Review of seven cases]

Esthesioneuroblastomas are fairly rare malignant tumors: only 20 cases have been reported in Spanish records. It is locally aggressive and produces late recurrences. There is no such thing as a universally accepted treatment model. We describe our experience with 7 cases seen in our hospital from 1980 to 1996. A or B stages can be treated with irradiation, surgery or a combination of both. C stages with the most aggressive tendencies may require the combined use of preoperative irradiation, surgery and chemotherapy. We analyzed the forms of presentation, diagnosis, differential diagnosis, treatment, prognosis, and survival. The 5-year survival rate was 75, 60 and 41% for stages A, B and C, respectively.

[An approach to an esthesioneuroblastoma of the anterior cranial fossa via the anterior wall of the hypertrophied frontal sinus]

A 40-year-old patient with anterior cranial fossa esthesioblastoma was operated on. Surgical approach via anterior wall of enlarged frontal sinus was used. After removal of tumor from anterior cranial fossa, ethmoidal and frontal sinuses, skull base defect was closed with abdominal fat and periosteum. Different approaches to anterior cranial fossa are discussed.

Olfactory neuroblastoma: detection of genomic imbalances by comparative genomic hybridization

Olfactory neuroblastoma (esthesioneuroblastoma) is a very rare tumour of the olfactory mucosa. Morphological features and cytogenetic studies strongly suggest a neuro-ectodermal origin. Up to now, cytogenetic studies are inconsistent. Some of them have proposed that the tumour belongs to the pPNET family. In the present study we describe genomic imbalances in olfactory neuroblastoma in a 46-year-old woman by using the molecular cytogenetic technique--comparative genomic hybridization (CGH)--in order to define the spectrum of genetic abnormalities in the tumour. The anatomical location and morphological findings were the basis for the diagnosis of esthesionearoblastoma. Immunohistochemical reactions for NSE, synaptophysin, chromogranin A, HNK-1/Leu-7 and S-100 revealed a characteristic immunophenotype. The CGH analysis showed multiple changes including DNA overrepresentations of chromosomes 4, 8, 11 and 14, partial DNA gains of the long arms of chromosomes 1 and 17, deletions of the entire chromosomes 16, 18, 19 and X, and partial losses of chromosomes 5q and 17p. This study represents an early utilisation of the CGH technique in olfactory neuroblastoma and demonstrates that the tumour carries complex chromosomal aberrations.

Surgical treatment of anterior skull base tumours

Skull base tumours represent a special challenge to surgeons due to the complex anatomy of the area. While small tumours are easy to remove, large lesions can pose complex situations. The most difficult aspects are not only the approach and removal, but specially the repair of the defects created by the resection of the tumour. We present here our experience with the surgical removal of tumours on the anterior skull base. To achieve a good approach, we resort to a bifrontal craniotomy including the cilliar arches. To obtain a skull base bone flap that can be used for repair at the end of the procedure, we remove the roof of the nose and a part of the medial wall and roof of both orbits. While the tumour is removed, the skull base bone flap is autoclaved to kill all tumoural cells. At the end of the procedure this bone flap is replaced, wrapped with a flap of pericranium. Provided no orbit needs to be emptied, no other flap is needed to reconstruct the area. One advantage is that the surgical cavity is not occluded with tissues, thus facilitating early identification of any recurrence. The area can be explored with the aid of an endoscope introduced into the nasal cavities through the nostrils, and in case of doubt, biopsies taken from all suspicious area. Our technique facilitates the repair of the surgical defect, and while not compromising the healing process it has a very low incidence of CSF leaks and infections.

Cardiac metastasis of an esthesioneuroblastoma

Images

Imaging of olfactory neuroblastoma by In-111 bleomycin complex

No other successful nuclear method, besides bone scanning, has been reported in the literature for in vivo imaging of olfactory neuroblastoma. In this article, excellent uptake is reported by an In-111 labeled bleomycin complex (BLMC) in the ethmoid region of a histologically confirmed olfactory neuroblastoma. The uptake of BLMC was 0.7 x 10(-3)% ID/g at 48 hours after injection, and tumor-to-muscle and tumor-to-fat ratios were 6:1 and 11:1, respectively. The authors conclude that BLMC should be considered as a useful imaging agent, and the BLMC has potential as a radiochemotherapeutic agent against an olfactory neuroblastoma.

Pre-operative imaging of esthesioneuroblastoma

The pre-operative images of three patients with biopsy proven esthesioneuroblastoma are presented. The role of computed tomography (CT) and magnetic resonance imaging (MRI) in the pre-operative determination of tumour extent is discussed.

[Neoplastic involvement of the cranial base. Role of computerized tomography and magnetic resonance]

We discussed in this paper the abilities and limits of CT Scan and MR Imaging in the diagnosis of skull base tumors. We stressed the role of computerized neuroimaging in the characterization and evaluation of the extension of these tumor masses involving the skull base.

Esthesioneuroblastoma presenting as an orbital mass in a young child

A 3-year-old boy presented with uniocular proptosis and ophthalmoplegia. Investigation revealed a mass involving the right orbit with extension into the left orbit and paranasal sinuses, and intracranial extension involving both frontal lobes. Biopsy of an enlarged cervical node and the intranasal mass revealed esthesioneuroblastoma. This tumor has been reported rarely in a child this age, and only 12 case reports document patients under 10 years of age. The presentation as an orbital mass is previously unreported and must now be considered in the differential diagnosis of proptosis in childhood. The usual clinical, radiological, and pathological features of olfactory esthesioneuroblastoma are reviewed.

Olfactory neuroblastoma: MR evaluation

PURPOSE

To evaluate MR in the diagnosis and staging of olfactory neuroblastoma.

METHODS

Five patients with histologically proved olfactory neuroblastomas were studied by MR. Four also had CT scans.

RESULTS

The extent of disease delineated by MR agreed with surgical findings and surgical staging of the tumor in all five patients. All cases of olfactory neuroblastomas originated in the nasal cavity and involved the ethmoid sinuses. In three of the five cases, the tumors extended to the anterior skull base. In one case MR correctly suggested skull base involvement missed on CT. Lesions were isointense to hyperintense with muscle on T1-weighted scans. Compared with fat on T2-weighted scans, olfactory neuroblastomas were variable in signal intensity. Enhancement was minimal to moderate in all cases.

CONCLUSION

In the evaluation of olfactory neuroblastoma, MR is most useful in delineating the extent of the tumor and may be more accurate than CT. However, the signal intensity characteristics of olfactory neuroblastomas may overlap other tumors.