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.

Ectopic adrenocorticotropic hormone syndrome associated with olfactory neuroblastoma: acquirement of adrenocorticotropic hormone expression during disease course as shown by serial immunohistochemistry examinations

Ectopic adrenocorticotropic hormone (ACTH) syndrome (EAS) is a condition of endogenous hypercortisolism sustained by an extrapituitary ACTH-secreting tumor. Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the sinonasal tract and is derived from the olfactory epithelium. Because the paranasal sinus is not a common site of EAS, the development of ONB in patients with EAS is rare. We herein report the first known case of ONB with acquirement of ACTH production during the clinical course as proven by immunohistochemistry. A 50-year-old man diagnosed with ONB was referred to our department in July 2015 because of hypokalemia, hyperglycemia, decreased eosinophil and granulocyte counts, and elevated serum levels of ACTH and cortisol. Although two previous ONB biopsy specimens (2011 and 2014) showed no ACTH immunoreactivity, a newly obtained specimen in August 2015 clearly showed ACTH immunoreactivity. This is the first case of ectopic ACTH syndrome associated with an ONB that acquired the ability to express ACTH during its clinical course as shown by serial immunohistochemical examinations.

[Clinical analysis of 53 cases of esthesioneuroblastoma]

BACKGROUND AND OBJECTIVE

The prognosis of esthesioneuroblastoma (ENB) patients is poor. This study was to analyze prognostic factors and explore a rational treatment for ENB.

METHODS

Clinical data of 53 ENB patients, treated at Sun Yat-sen University Cancer Center from 1980 to 2003, were analyzed retrospectively. The correlation of prognostic factors to clinical features and treatment approaches were analyzed using the Kaplan-Meier method. Efficacy of different treatment modalities was compared.

RESULTS

The five-year overall survival (OS) was 41% of all ENB patients. The five-year OS of the surgery group, radiotherapy group, chemotherapy group, surgery combined with radiotherapy and (or) chemotherapy group, chemoradiotherapy were 42%, 38%, 0, 56%, 0, respectively, which were statistically significant (p<0.05). The five-year OS of Kadish stage A, B, C patients were 100%, 37%, 31%, respectively, which were statistically significant among these three subgroups which (p<0.05). The recurrence rate over the entire period was 51%. The five-year OS of the recurrence group and recurrence-free group were 42% and 48%, respectively, without significant differences (p>0.05).

CONCLUSIONS

ENB is a malignant tumor with high rates of locoregional recurrence and distant metastasis. Surgery-based multimodality is a relatively reasonable method. The prognosis of ENB is associated with the clinical stage and treatment modalities.

Retrospective review of adjuvant chemotherapy for esthesioneuroblastoma

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare tumor arising from the olfactory epithelium in the upper nasal cavity. Prior reviews have found efficacy of chemotherapy for high grade tumors in the advanced setting. However, little information is available regarding chemotherapy in the adjuvant setting.

METHODS

A retrospective review of 76 patients treated at the Mayo Clinic for esthesioneuroblastoma from 1976 to 2003 was performed to evaluate adjuvant chemotherapy (AC) in these patients. Pathology slides were reviewed to assign Hyam's grade, and modified Kadish staging was available for all patients used in the analysis.

RESULTS

Twelve patients were identified to have had full surgical resection of Stage C, high grade (grade 3 or 4) tumors. Six of these patients received AC, and six did not. Most AC was cisplatin and etoposide based. Median time to relapse for patients who did and did not receive AC is 35 and 10.5 months respectively. The median overall survival (OS) for patients that received AC was 83+ (range 21-119+ months). The median OS for patients not receiving AC is 78 months (range 9-240+ months).

CONCLUSIONS

This small retrospective series suggests that adjuvant therapy for patients with high grade, Stage C esthesioneuroblastoma is of benefit following complete resection. Radiation therapy alone provides an improvement in time to relapse, which may be increased further with the addition of cisplatin and etoposide based chemotherapy.

Surgical treatment versus concurrent chemoradiotherapy as an initial treatment modality in advanced olfactory neuroblastoma

OBJECTIVE

Olfactory neuroblastomas are very aggressive tumors with a high locoregional recurrence rate and distant metastasis. Surgical treatment, including craniofacial resection, has been the main treatment modality, but treatment outcomes of concurrent chemoradiotherapy remain unclear. We present our experiences regarding the treatment outcome of patients with advanced olfactory neuroblastoma undergoing surgical treatment and concurrent chemoradiotherapy.

METHODS

We retrospectively analyzed 16 patients treated for advanced olfactory neuroblastoma within the past 10 years.

RESULTS

The disease-free 5-year survival rate of the patients (n = 10) who underwent surgical treatment was 68%. The survival rate for patients (n = 6) who received concurrent chemoradiotherapy was 42%. The difference in the survival rate was not statistically significant, and no difference in the recurrence rate between the two groups. In the group having surgical treatment, post-operative radiotherapy and salvage therapy were important to increase the survival rate. In the group having concurrent chemoradiotherapy, no patient experienced primary tumor progression.

CONCLUSION

Complete surgical resection, including craniofacial resection (CFR), and post-operative radiotherapy seem to be essential in the treatment of advanced olfactory neuroblastoma. However, concurrent chemoradiotherapy may be another primary treatment modality.

Intracavitary chemotherapy (Gliadel) for recurrent esthesioneuroblastoma: case report and review of the literature

Esthesioneuroblastoma is an uncommon malignancy of the nasal vault with a treatment regimen consisting of surgical resection followed by radiotherapy for primary lesions and addition of chemotherapy for patients with advanced, recurrent or metastatic lesions. We report a case of a 39-year-old female with a history of esthesioneuroblastoma, previously treated with resection, radiation and chemotherapy, presenting with a recurrent disease that was successfully treated with re-resection and placement of Gliadel) wafers in the surgical resection cavity. The novel option of controlled-release and local delivery of a chemotherapeutic agent for treatment of recurrent esthesioneuroblastoma should be recognized and considered.

Esthesioneuroblastoma treated with non-craniofacial resection surgery followed by combined chemotherapy and radiotherapy: An alternative approach in limited resources

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare and aggressive malignant tumor arising from olfactory epithelium. Surgical excision in the form of craniofacial surgical resection (CFR) has shown encouraging results. The purpose of the study is to analyze the outcome of this disease when managed by non-craniofacial resection (NCFR) surgery in limited resources.

METHODS

Between October 1998 and January 2004, eight patients with ENB were treated in the Department of Radiotherapy at KGMU, Lucknow. None of these eight patients underwent CFR surgery. All patients received six cycles of vincristine, adriamycin and cyclophosphamide (VAC) based chemotherapy followed by radiotherapy.

RESULTS

All the patients registered during this period had undergone operative procedures in the form of NCFR surgery except two. Complete response was present in five (62.5%) patients and three (37.5%) patients had partial response. Locoregional relapse-free survival at 3 years was 62.5% and median survival time was 38 months. Disease-free survival and overall survival at 3 years was 72.9 and 71.4%, respectively, and median disease-free survival time was 43 months, while mean overall survival time was 40.7 months as median overall survival time was not reached.

CONCLUSION

Patients in developing countries often present with advanced stages and because of non-availability of technical advances and surgical expertise one tends to approach these patients with palliative intent. Most of the patients in our series were of stage C disease (75%) and still our response rate and survival were encouraging despite the fact that surgery was not optimal. This combination chemoradiotherapy schedule can be used outside the protocol setting where resources are limited.

[Long-term experiences in the therapy of esthesioneuroblastoma]

BACKGROUND

Esthesioneuroblastoma is a rare and clinically variable tumor of nasal sinus and skull base and challenging for modern multidisciplinary therapy. There are no generally known prognostic factors or generally accepted standard therapy regimens.

PATIENTS AND METHODS

Between 1975 and 2001 26 patients were treated after the diagnosis of esthesioneuroblastoma was established. The cases were evaluated retrospectively. According to the classification of Kadish 1 patient (4 %) had stage A, 16 patients (53 %) stage B and 11 cases (43 %) had stage C tumors. Hyams grading could be obtained in 22 cases (81 %). Tumors were in 12 patients (52 %) graded I or II and in 10 cases tumors had grade III or IV (48 %). Operative therapy was performed in 23 patients (88.5 %), being in 5 patients a single mode therapy. In 18 cases combined therapy was performed (surgery and radiotherapy or radiotherapy and chemotherapy).

RESULTS

Actuarial survival was 61.5 % (16/26). Disease specific 10- and 15-year-survival according to the estimation of Kaplan-Meier was 76.2 %. Patients with small tumors (Kadish A/B) had a 15-year-survival of 86.7 % compared to 63.6 % in cases with advanced tumors (Kadish C). In 7 cases (26.9 %) recurrences developed. Salvage therapy was performed in 5 cases (71.4 %) with a success rate and a 15-year survival each of 60 %.

CONCLUSIONS

Therapy of esthesioneuroblastoma is challenging because of rarity and biologic variability of the tumor and and because of lack of a standard therapy. An interdisciplinary multimodal therapeutic approach is necessary especially in case of advanced tumors with promising results. Histopathological grading according to Hyams and tumor stage are important factors for survival and prognosis. Although recurrence can occur with high frequency even after prolonged time interval, long time survival can be improved after aggressive salvage therapy. Therefore longterm follow up is mandatory.

Esthesioneuroblastoma in childhood and adolescence. Better prognosis with multimodal treatment?

BACKGROUND AND PURPOSE

Only 3% of all malignant intranasal tumors are esthesioneuroblastomas (ENB) and only 20% of these rare neuroectodermal tumors are diagnosed up to 20 years of age. Radiotherapy and surgery are established treatment modalities for these patients, but the role of chemotherapy, especially in a multimodal approach, is not well defined. To investigate the influence of radio- and chemotherapy, the treatment and course of the disease in children and adolescents with ENB were analyzed retrospectively.

PATIENTS AND METHODS

19 unselected patients (nine male and ten female) diagnosed with ENB < or = 20 years of age were included in this analysis. Median age at diagnosis was 14.0 years (range, 5-20 years). The tumors were Kadish stage B in 4/19 patients and stage C in 15/19 patients. 17 patients underwent surgery, either without further therapy (n = 4), followed by radiotherapy (n = 1) or as part of multimodal regimens (n = 12). Two patients received radio- and chemotherapy without surgery. Complete resection (R0) was achieved in 15 out of 17 patients with surgery including all five patients with preoperative chemotherapy due to unresectable primary at diagnosis.

RESULTS

The 5-year overall survival (OS) for the whole group was 73% +/- 12% and the 5-year event-free survival (EFS) 55% +/- 13%. None of the four patients with stage B experienced tumor progression so far, whereas seven out of 15 patients with stage C did (5-year EFS 47% +/- 14%; not significant). Patients with Kadish stage C and multimodal treatment strategies combing surgery, chemo- and radiotherapy had a significantly better outcome than patients with stage C and less than three treatment modalities (65% +/- 17% vs. 20% +/- 18%; p = 0.02).

CONCLUSION

These data indicate a benefit of multimodal treatment regimens combining surgery, chemo- and radiotherapy for pediatric patients with ENB Kadish stage C. Chemotherapy appears to improve resectability, EFS, and OS. Radiotherapy is an integral part in the management of children and young adolescents with ENB in Kadish stage B and C.

Esthesioneuroblastoma: continued follow-up of a single institution's experience

OBJECTIVES

To analyze outcomes and to provide follow-up for our increasing patient cohort with esthesioneuroblastoma.

DESIGN

Retrospective cohort analysis.

SETTING

Patients were examined from September 1, 1976, to May 30, 2004, in a tertiary care academic hospital.

PATIENTS

Fifty consecutive patients diagnosed as having esthesioneuroblastoma were treated with a standardized protocol during a 28-year period. Patients with tumors staged Kadish A or B received preoperative radiotherapy followed by craniofacial resection, while patients with Kadish stage C disease were treated with preoperative sequential chemotherapy and radiotherapy followed by a craniofacial resection. The mean follow-up is 93 months (range, 1-330 months).

RESULTS

The disease-free survival was 86.5% and 82.6% at 5 and 15 years, respectively. There were 17 patients (34%) who developed recurrent disease, most of which was locoregional (12 patients [71%]). There was a long interval to relapse (mean, 6 years), with the longest time to regional recurrence being 10 years. Distant relapses occurred sooner, with poorer outcomes. Of these 17 patients, 7 (41%) underwent successful salvage surgery, while 3 remain alive with disease.

CONCLUSIONS

Excellent outcomes for esthesioneuroblastoma are achievable. Long-term follow-up is necessary because of the extended interval for recurrent disease; unlike most sinonasal malignancies, surgical salvage is possible.

Neoadjuvant etoposide, ifosfamide, and cisplatin for the treatment of olfactory neuroblastoma

BACKGROUND

The optimal chemotherapy regimen for the treatment of olfactory neuroblastoma has not been clearly defined. The purpose of the current study was to evaluate the efficacy of neoadjuvant chemotherapy with the combination of etoposide, ifosfamide, and cisplatin (VIP) for patients with olfactory neuroblastoma.

METHODS

Eleven consecutive patients with newly diagnosed olfactory neuroblastoma were treated with etoposide (75 mg/m2), ifosfamide (1000 mg/m2), and cisplatin (20 mg/m2) all administered intravenously on Days 1-5. Cycles were repeated every 21 days. Patients were excluded from analysis if they had previously received surgery or radiotherapy.

RESULTS

Nine patients achieved objective responses (objective response rate, 82%; 95% confidence interval, 52-95%), which included 2 complete responses and 7 partial responses. The major side effect was hematologic toxicity, with Grade 3/4 neutropenia observed after the receipt of 37% of all cycles and febrile neutropenia observed after the receipt of 2 cycles. All toxic events were reversible, and no chemotherapy-related deaths were documented. The median survival period was 18 months (range, 3-45 months).

CONCLUSIONS

Neoadjuvant VIP chemotherapy was active in the treatment of olfactory neuroblastoma.

Intracranial metastatic esthesioneuroblastoma responsive to temozolomide

Successful management of a heavily pretreated 58-year-old woman with metastatic esthesioneuoblastoma using temozolomide is reported. There is no standard treatment of this tumors with extra- and intracranial manifestations. The response, long term stability and high quality of life using temozolomide for this tumor entity should be recognized.

Successful treatment of metastatic esthesioneuroblastoma

This case report describes a patient with a metastasised olfactorial esthesioneuroblastoma Hyams grade 4 who has been treated with debulking surgery and radiotherapy. After relapse in lymph node, lung and brain, he received additional irradiation and six cycles of carboplatin, vincristine and cyclophosphamide intravenously every three weeks. The patient has now been disease free for 7.8 years. Our data suggest that metastatic esthesioneuroblastoma is sensitive to platinum-based chemotherapy. This patient illustrates that this tumour is very sensitive to platinum-based chemotherapy and that durable complete response can be achieved, even in a metastatic ENB.

Multimodality therapy including radiotherapy and chemotherapy improves event-free survival in stage C esthesioneuroblastoma

BACKGROUND

To evaluate the efficacy of multimodality therapy in patients with esthesioneuroblastoma (ENB).

PATIENTS AND METHODS

From 01/1979 through 08/2001, 47 patients with ENB (20 men, 27 women, age 5-81 years), were registered from 18 oncologic centers. There were 14 tumors stage B and 33 stage C according to the Kadish classification. Initial treatment included surgery alone in seven patients, radiotherapy (RT) with or without chemotherapy (CTX) in twelve, surgery plus postoperative RT in 15, and multimodality therapy (surgery plus pre- or postoperative CTX plus postoperative RT) in 13.

RESULTS

The 5-year overall survival (OS) for the whole group was 64 +/- 8% and the 5-year event-free survival (EFS) 50 +/- 8%. Patients with multimodality treatment had a significantly better 5-year EFS (74 +/- 13%) compared to the other patients (41 +/- 9%; p = 0.05), while the 5-year OS was not significantly different between the treatment groups (p = 0.39). For patients with Kadish stage C, multimodality therapy (n = 11) resulted in superior 5-year EFS (72 +/- 14% vs 17 +/- 9%; p = 0.01). These patients tended to have an improved OS (69 +/- 15% vs 47 +/- 12%; p = 0.19) compared to the other treatment groups. None of the patients with multimodality treatment had a metastatic relapse.

CONCLUSION

Multimodality treatment (surgery plus pre- or postoperative CTX plus postoperative RT) appears to be highly efficient in preventing local and systemic relapse in patients with advanced ENB. Timing and optimal agents of CTX need to be further evaluated.

[The value of the proton magnetic resonance spectroscopy (HMRS) of white matter injury in children treated with chemo- and/or radiotherapy. Preliminary report]

THE AIM of this study was to estimate the value of HMRS in the diagnosis of brain lesions observed in children treated with chemo and radiotherapy and to assess the possibility to differentiate these lesions from neoplasm or recurrent disease.

MATERIALS AND METHOD

We examined 6 children, aged from 7 to 15 yrs, 3 with brain tumours, 1 with esthesioneuroblastoma treated with chemo and radiotherapy and 2 patients with chemotherapy only, for other neoplasms (leukemia, Wilms tumor). Indications to perform imaging studies were routine for brain tumour patients (no clinical symptoms) and suspicion of disease recurrence in others. MR with 1.5 T scanner and additionally single voxel HMRS in PRESS sequence were performed.

RESULTS

In all cases MRI showed extensive hyperintensive changes in brain tissue with significant mass effect. In 3 cases HMRS was within normal limits, in other 3 cases moderately elevated peak of choline and peak of lactate and lipids were found. In follow up examinations all lesions regressed and all patients are in good clinical condition.

COMMENTS

It could be difficult to differentiate white matter injury from malignancies on MRI. HMRS in case of doubtful findings on MRI in children treated with chemo and radiotherapy, especially in those without symptoms of their disease, is a helpful method.

[Metastatic esthesioneuroblastoma. Challenge in interdisciplinary combined modality therapy]

Esthesioneuroblastoma is a rare tumor, which in many cases is diagnosed at an advanced stage with an high recurrence rate and incidence of metastases. Regionary metastases predict a poor prognosis. There is no standard therapy approach for these tumors. The most widly accepted primary therapy is radical craniofacial enbloc resection followed by radiation therapy. Today chemotherapy is getting more important and is administered with curative intention. Multidisciplinary management results in significantly longer survival in advanced tumor stages and recurrence. A clinical staging system as well as histopathological grading according of Hyams could be from importance for selection and timing of the different therapeutic modalities. We present a case of a 34-year-old female patient who was diagnosed with an advanced olfactory neuroblastoma of the upper nasal cavity with bilateral cervical lymph node metastasis (modified Kadish-stage D). Craniofacial resection and bilateral neck dissection was performed, followed by postoperative radiotherapy. Reviewing the recent literature the different therapeutic approaches are compared and discussed.

Tumors of the skull base in children: review of tumor types and management strategies

Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. They review management strategies that include radio- and chemotherapy, as well as surgical approaches with emphasis on the modifications and complications associated with the procedures as they apply in children. Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.

Chemotherapy for skull base cancers

This article focuses on treatment options for select skull base problems that have decreased post-treatment morbidity and, in many cases, improved survival. The select skull base cancers covered include nasopharyngeal carcinoma, squamous cell carcinoma of the paranasal sinuses, sinonasal undifferentiated carcinoma, neuroendocrine carcinoma, esthesioneuroblastoma, and salivary gland carcinoma.

[Olfactory neuroblastoma: own experiences]

The authors present material of 12 cases olfactory neuroblastoma observed in Head and Neck Department of Cancer Center in Warsaw from 1961 to 1998. The tumors were seen in 8 women and 4 men. According to Kadish staging there were one A, three B, and eight C stages tumors. Patient in stage A was treated with surgery and radiotherapy. One patient in stage B was treated with surgery and radiotherapy. Two patients in stage B were treated with radiotherapy alone. Six patients in stage C were treated also with surgery, radiotherapy and chemotherapy. Two patients in stage C were treated with surgery and radiotherapy. Complete regression was observed in 9 of 12 patients. One patient died from olfactory neuroblastoma, two other were died from other reasons.

Chemotherapy for esthesioneuroblastomas

Esthesioneuroblastoma can be regarded as a chemosensitive tumor based on multiple reports of response to treatment. Neoadjuvant therapy is seldom curative, however, and may be of no benefit in some patients. Individuals who respond to preoperative therapy have a greater chance of long-term disease-free survival. Platinum-based therapy has been the mainstay of treatment. Toxicity has been mild, and treatment failures have been treated with postoperative chemotherapy with or without bone marrow transplantation. Given the small number of cases of esthesioneuroblastoma diagnosed annually, it is unlikely that any consensus on this issue is forthcoming. Either post- or presurgical treatment of advanced stage or recurrent disease has become the standard of care, however.

[The experience of treatment of 7 cases of olfactory neuroblastoma]

OBJECTIVE

To improve the treatment result of olfactory neuroblastoma.

METHOD

Introduce the experience of treatment of 7 patients with this disease. Among these 7 cases, 2 of them were stage B while the others were stage C according to the system proposed by Kadish. 3 cases received radiotherapy alone, and 4 others received radiotherapy pre-operation. The radiation dose was 5000-7000 cGy. All the patients were followed-up until December 1997.

RESULT

5 cases are still alive, survival time are 20, 22, 23, 29 and 76 months respectively. The other 2 patients died with the survival time of 6 and 48 months respectively.

CONCLUSION

Radiotherapy seems effective in the treatment of olfactory neuroblastoma; the combination of chemo-radio-therapy is preferable for advanced or metastasis olfactory neuroblastoma. We extrapolate there are different subtypes on pathology in this tumor.

Aesthesioneuroblastoma

Forty patients were treated or followed up for aesthesioneuroblastoma between 1980 and 1995 at Institut Gustave Roussy, France. There were three T1, seven T2, 15 T3 and 15 T4 lesions. The cervical metastatic rate at presentation was 18 per cent. Distant metastases were detected by bone marrow biopsy and bone scan in three patients at presentation. Treatment modalities included surgery alone in eight patients, radiotherapy alone in three patients, combined modality surgery plus radiotherapy in 11 patients, chemotherapy alone in two patients, chemotherapy plus radiotherapy in 10 patients, and multimodality therapy chemotherapy plus surgery plus radiotherapy in six patients. The five-year survival rate was 51 per cent. Multimodality treatment offered better survival (63 per cent at five years) and disease-free interval (54 months). Overall local, regional, and distant failure rates were 58 per cent, 15 per cent and 40 per cent respectively. Distant metastases commonly occurred in bone (82 per cent). Cervical metastasis was an unfavourable prognostic indicator (0 per cent survival at two years). In conclusion, aesthesioneuroblastoma is sensitive to chemotherapy and radiotherapy. Multimodality therapy should be used initially.

The role of preoperative adjuvant treatment in the management of esthesioneuroblastoma: the University of Virginia experience

OBJECTIVE

Multidisciplinary management of esthesioneuroblastoma has effected markedly increased survival during the past 20 years. The potential for radical craniofacial surgery for complete en bloc resection, the availability of advanced neuroimaging modalities, and the incorporation of neoadjuvant therapy into treatment strategies for tumor remission have all contributed to this accomplishment. However, a standard protocol for the management of these lesions has not been accepted; preoperative radiation and chemotherapy have been advocated, but neither radiographic nor clinical response has been quantified.

METHODS

Thirty-four consecutive patients with biopsy-proven esthesioneuroblastoma treated at one institution from 1976 to 1994 were reviewed to determine the effects of preoperative radiation therapy, with or without chemotherapy, on tumor size and long-term survival.

RESULTS

In a multivariate regression analysis, advanced age was predictive of decreased disease-free survival (P=0.008), whereas advanced Kadish stage was associated with a borderline higher rate of disease-related mortality (P=0.056). Two-thirds of the patients showed a significant reduction in tumor burden with adjuvant therapy. Patients with response to neoadjuvant therapy demonstrated a significantly lower rate of disease-related mortality (P=0.050). In this series, the overall 5- and 10-year survival rates were 81.0 and 54.5%, respectively.

CONCLUSION

Preoperative neoadjuvant therapy provides a valuable complement to radical craniofacial resection, leading to reduction in tumor burden. Patients experiencing reduction in tumor volume by neoadjuvant therapy demonstrate an improved prognosis.

Chemotherapy for advanced esthesioneuroblastoma: the Mayo Clinic experience

OBJECTIVE

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare neuroendocrine tumor that arises in the upper nasal cavity from the olfactory epithelium. Little information is available regarding the treatment of these tumors with chemotherapy in the advanced setting. A retrospective review of patients with recurrent esthesioneuroblastoma treated with chemotherapy between 1970 and 1995 at the Mayo Clinic was undertaken to gain more information regarding the efficacy of chemotherapy treatment for these patients.

METHODS

Ten patients were identified using a computerized data base available at this institution. The clinical and pathological materials, when available, were reviewed, and each tumor reviewed was assigned a Hyams' grade.

RESULTS

There were six men and four women, ranging in age from 22 to 74 years, all of whom had assessable Kadish Stage C disease at the time of chemotherapy treatment. The chemotherapy regimens and clinical follow-up varied during this 25-year time span. The only tumor regression resultant from chemotherapy was observed in patients with high-grade tumors. Two of four patients with high-grade tumors obtained regression from first-line, platinum-based chemotherapy, with a mean duration of regression of 9.3 months (range, 2-13 mo). Survival time from initial diagnosis was 139.5 months (range, 83-168 mo) in patients with low-grade tumors and 32.2 months (range, 5-84 mo) in patients with high-grade tumors. Survival from initial chemotherapy treatment was 44.5 months (range, 3-130 mo) in patients with low-grade tumors and 26.5 months (range, 2-67 mo) in patients with high-grade tumors.

CONCLUSION

Hyams' grading of esthesioneuroblastoma tumors seems to be important in predicting response to chemotherapy. Despite sensitivity to platinum-based chemotherapy, patients with high-grade tumors in this series had a much more aggressive course than did those with lower-grade tumors. This series suggests that cisplatin-based chemotherapy is active in advanced, high-grade esthesioneuroblastoma and is a reasonable choice in the systemic treatment of these patients.

Successful treatment of esthesioneuroblastoma and neuroendocrine carcinoma with combined chemotherapy and proton radiation. Results in 9 cases

OBJECTIVE

To study the efficacy of a newly designed treatment strategy for esthesioneuroblastoma and neuroendocrine carcinoma of the paranasal sinuses.

DESIGN AND SETTING

Nonrandomized prospective study of a case series in a tertiary referral center.

PATIENTS

Nine consecutive patients with newly diagnosed esthesioneuroblastoma or neuroendocrine carcinoma of the paranasal sinuses from June 1992 to October 1995 underwent this treatment protocol.

INTERVENTIONS

After histological diagnosis and detailed imaging, 2 cycles of cisplatin and etoposide chemotherapy were instituted. Chemotherapy responders were treated with combined photon and stereotaxic fractionated proton radiation therapy totaling approximately 68 Gy to the primary site, whereas poor responders were treated with surgical resection followed by postoperative radiation. In both cases, therapy was then concluded with 2 additional cycles of cisplatin and etoposide chemotherapy.

MAIN OUTCOMES MEASURES

Response to therapy, survival, disease-free survival, and complications of therapy were examined.

RESULTS

Nine patients with a median Dulguerov T stage of T3 (range, T2 to T4) completed the treatment protocol, with mean follow-up after diagnosis of 20.5 months. Eight of 9 patients exhibited a dramatic response to therapy with remission of their tumor, and resection was not required. One patient failed to respond to induction chemotherapy and received surgical therapy to be followed by postoperative radiotherapy. There have been no recurrences (mean disease-free interval of 14.0 months). Complications were limited and generally transient.

CONCLUSIONS

The use of combined cisplatin and etoposide chemotherapy with proton radiation has demonstrated initial success in treatment of these tumors. Dramatic response from chemotherapy is possible even in bulky or unresectable disease. This protocol has an acceptable complication rate and conveys less morbidity than craniofacial resection and conventional radiotherapy. Further follow-up will be required to determine the long-term success rate of this therapeutic protocol.

Olfactory neuroblastoma in northern Thailand

Two cases of olfactory neuroblastoma in women in northern Thailand are described. Original complaints were severe headaches and eye pain; death occurred from intracranial extensions 6 months and 1 year after diagnosis. Results of study with light microscopy, immunohistopathology, and electron microscopy are reviewed, and several management recommendations are discussed.

Esthesioneuroblastoma in the pediatric age-group: the role of chemotherapy and autologous bone marrow transplantation

Esthesioneuroblastoma, a malignant neoplasm arising from olfactory epithelium, is unusual in the pediatric age-group. Management has traditionally involved surgery and radiotherapy, alone or in combination, with chemotherapy reserved for recurrent or high grade disease. We report a single institution experience utilizing chemotherapy and radiotherapy as the initial treatment and successful control of the primary tumor in two patients. In one patient, neck dissection and high dose chemotherapy combined with autologous bone marrow transplantation were used as successful salvage therapy of neck metastasis. Both patients are alive and disease free with a mean follow-up of 56 months. These results support the role of chemotherapy in the treatment of esthesioneuroblastoma and suggest that chemotherapy be used as part of the initial combined modality treatment plan.

[Multidrug chemotherapy in a 8-year old child with advanced olfactory neuroblastoma]

Successful treatment of olfactory neuroblastoma is more often described in less advanced tumors and mostly in adults. Fewer presentations concern successful chemotherapy in advanced stages of the disease.

Recurrent renal salt wasting in a child treated with carboplatin and etoposide

BACKGROUND

Nephrotoxicity of carboplatin is rare, especially in children with normal renal function. A 3-year-old boy had localized esthesioneuroblastoma and received 2 courses of carboplatin (200 mg/m2/day during a 1-hour infusion for 3 consecutive days) associated with etoposide (150 mg/m2/day after carboplatin). Because of a good tumor response, a second course was given 21 days later. Complete surgical excision and local irradiation were performed. However, the tumor recurred a few months later, and the patient subsequently died of the disease.

METHODS

Renal function initially was assessed by standard baseline chemistry and technetium-panetetic acid (Tc-DTPA) clearance. Follow-up included ionic controls and tubular exploration during the episodes of hyponatremia.

RESULTS

Hyponatremia occurred 4 days after completion of the first course and resolved after intravenous supplementation. It recurred 20 days after the second course despite salt and magnesium prehydration and posthydration and resolved 17 days later. No glomerular dysfunction was noticed. The association of urinary bicarbonate loss with elevated N-acetyl-beta-glucosaminidase suggested a proximal tubular damage.

CONCLUSIONS

Standard doses of carboplatin may lead to recurrent renal salt wasting in children with initially normal renal function.

Chemotherapy for cranial base tumors

The tumors I will discuss in this chapter on chemotherapy will be ethesioneuroblastoma, salivary gland tumors, chordoma and nasopharyngeal carcinoma. Due basically to the rarity of these lesions, with the exception of nasopharyngeal carcinoma, there have been no multi-institutional studies of chemotherapy use reported in the literature. As a result, there is no clear-cut consensus on the standard of care as it relates to chemotherapy for these tumors. As with most authors who have previously reviewed these tumor types, I believe it is important for us to propose protocols of therapy and test these in arenas where we can accumulate enough patients for meaningful results. In this way, we can test the apparently active agents and combinations in relapsed or extensive disease. We might also begin to explore concurrent therapy (i.e., concurrent radiation and chemotherapy after the surgical procedure, for example).