Novel Biomarkers in Sinonasal Cancers: from Bench to Bedside

PURPOSE OF REVIEW

Sinonasal cancers are a heterogenous group of rare cancers for which histopathological diagnosis can be very challenging and treatment options are limited for advanced disease in particular. Here, we review the candidacy of novel diagnostic and prognostic biomarkers, and therapeutic targets for sinonasal cancers.

RECENT FINDINGS

Molecular multidimensional analyses of sinonasal cancers have been lagging behind other major cancers, but there are numerous publications describing the discovery of novel candidate biomarkers, e.g. the methylation classifier, originally developed for brain cancers, and gene expression panels for the prediction of response to induction chemotherapy in sinonasal undifferentiated carcinoma. The most promising biomarkers are summarized and discussed further with regard to their clinical applicability and future potential. Many of the described novel biomarkers for sinonasal cancers will eventually overcome the pitfalls associated with the frequently non-specific immunohistological tests. With comprehensive, multidimensional molecular testing of these tumours in collaborative consortia projects, our better understanding of the molecular mechanisms of sinonasal cancers and their carcinogenesis will determine the most useful diagnostic and prognostic biomarkers, allow stringent multi-institutional validation and guide trials on targeted therapies.

A neuroendocrine tumour of the sphenoid sinus and nasopharynx: a case report

It is rare for neuroendocrine tumours to originate in the sphenoid sinus and the nasopharynx. Neuroendocrine tumours can be classified into typical carcinoids, atypical carcinoids and small cell neuroendocrine carcinomas. Here we report the case of a 48-year-old man with a typical carcinoid tumour of the nasopharynx and sphenoid sinus. This is a very rare diagnosis, and only a few cases of a typical carcinoid in this region have been described in the literature.

[Influence of chemotherapy regimen on antioxidant level in patients with locally-advanced tumors of the maxilla, nasal and paranasal sinuses]

The study dealt with effect of chemoradiotherapy on the oxidant/antioxidant system in 57 patients with locally-advanced tumors (stage III-IV) of the maxilla, nasal and paranasal sinuses. Therapy modalities ranged from systemic chemoradiotherapy (22), intraarterial chemoradiotherapy + UHF-hyperthermia (20) and intraarterial chemotherapy + radiotherapy (15). The most frequent regimen of chemotherapy involved cisplatin 15 mg/ m2, total dose of 100 mg; fluorouracil 600 mg/m2, total dose of 2,000-3,000 mg, and doxorubicin 15 mg/m2, total dose of 40-60 mg. As far as telegammatherapy is concerned, all patients received STD of 3 Gy and TTD of 40-60 Gy. Unlike systemic chemoradiotherapy, continuous intraarterial chemoradiotherapy with UHF-hyperthermia or without it was followed by lower incidence of enhanced oxidative reaction response and tumor-related endotoxicosis.

Olfactory neuroblastoma causing ectopic ACTH syndrome

A 39-year-old woman who presented with typical Cushingoid appearance (moon facies, central obesity, purpura) was admitted to our hospital because of pulmonary infection. She was found to have hypertension, severe hypokalemia, and metabolic alkalosis. Endocrine data revealed elevated plasma levels of ACTH and cortisol with lack of circadian rhythm, non-suppressibility to high-dose dexamethasone, and hyperresponsiveness to CRH stimulation. Although no pituitary mass was detected by MRI of the brain, inferior petrosal sinus sampling showed a step-up of central to peripheral ACTH levels; these data are consistent with the diagnosis of Cushing's disease. She was successfully treated with metyrapone to control hypercortisolemia. Ten months later, a mass was detected in the ethmoid sinus, which was surgically removed. After resection of the ethmoid sinus tumor, her Cushingoid features and hypercortisolemia disappeared, but recurred after enlargement of a second mass in the maxillary sinus. After resection of the maxillary sinus tumor, her hypercortisolemia subsided. Histologically, the tumor tissues from both the ethmoid and maxillary sinus were identical and consistent with the diagnosis of olfactory neuroblastoma. Immunohistochemically, the immunoreactivities of ACTH and POMC were positive in the cytoplasm of tumor cells, and immunoreactive ACTH was demonstrated in both tumor tissues. Thus, this is the second rare case with ectopic ACTH syndrome caused by olfactory neuroblastoma thus far reported.

Clinical value of serum squamous cell carcinoma antigen in the management of sinonasal inverted papilloma

BACKGROUND

Although sinonasal inverted papilloma (IP) is a rare benign tumor, it has a tendency to recur and is sometimes associated with squamous cell carcinoma (SCC). Therefore, postoperative long-term follow-up of these patients is recommended. We previously reported that serum SCC antigen might be a useful tumor marker for sinonasal IP. In this study, we investigated whether serum SCC antigen level has a correlation with disease status and is useful in the early detection of recurrent disease.

METHODS

Blood samples for the analysis of serum SCC antigen were taken from 28 IP patients before and after surgical treatment.

RESULTS

Twenty-five (89%) of 28 cases showed evaluated serum SCC antigen levels above the upper limit. This marker level decreased in all cases after surgical resection. Four of these patients had a recurrence. None of the patients with recurrent tumor showed symptoms at the time of detection of their recurrent tumor, and recurrence was discovered from elevated levels of SCC antigen.

CONCLUSIONS

Serum SCC antigen level has a correlation with disease status of IP and has a potential to serve as a useful tool for monitoring the course of disease. SCC antigen is a reliable tumor marker in the management of sinonasal IPs.

Serum squamous cell carcinoma antigen is a useful biologic marker in patients with inverted papillomas of the sinonasal tract

BACKGROUND

Inverted papilloma (IP) is a frequent benign sinonasal tumor that is characterized histologically by squamous metaplasia, epithelial acanthosis, and hyperplasia of the nasal epithelium. Because of its high recurrence rate and malignant transformation potential, careful long-term follow up is necessary.

METHODS

The purpose of the current report was to study the expression of squamous cell carcinoma (SCC) antigen in sinonasal IPs and to evaluate the usefulness of SCC antigen as a biologic marker for the follow-up of patients with sinonasal IP. The expression of SCCA1 in three sinonasal IP cases, three sinonasal SCC cases, and cases of normal nasal epithelium were examined by Western blot analysis, and the SCCA1 expression pattern in 31 IP specimens and 4 carcinoma in IP specimens were evaluated immunohistochemically. The serum levels of SCC antigen in 11 patients with sinonasal IP also were analyzed.

RESULTS

SCCA1 was overexpressed in all three sinonasal IP tissues compared with sinonasal SCC tissues or normal nasal epithelium. SCCA1 cytoplasmic immunoreactivity was detected in the suprabasal epidermal keratinocytes of all 31 sinonasal IP cases. In the four carcinoma in IP specimens, SCCA1 expression in the papillomatous lesion was more intense than in the cancerous lesion. The serum SCC antigen level was high in 10 of 11 patients with IP (91%) and significantly decreased after surgical resection of the tumors.

CONCLUSIONS

The results of the current study indicate that SCCA1 frequently is overexpressed and may play a biologic role in the development of sinonasal IPs. Serum SCC antigen may be a useful biologic marker in patients with sinonasal IP.

[The concentration of ferritin in blood serum of patients with neoplasms of the larynx and the maxillary-ethmoidal complex]

The increased level of ferritin is known as a nonspecific marker of inflammatory processes and neoplasms. A purpose of the article was to indicate concentration of ferritin in blood serum before treatment of 33 patients with cancer of larynx and 16 patients with malignant neoplasms of maxillo-ethmoid complex. The patients with cancer of larynx were characterized by significantly high level of ferritin in comparison to patients with malignant neoplasms of maxillo-ethmoid complex (p < 0.05) and to healthy people (p < 0.05) (respectively 241.9 +/- 154.9; 106.9 +/- 45.4 and 125.0 +/- 30.4 ng/ml). Contrary to patients with cancer of larynx patients with malignant neoplasms of maxillo-ethmoid complex did not differ in significant level of ferritin from healthy people. The concentration of hemoglobin in blood in both groups of patients was similar and was characteristically lower than values obtained in healthy people. The results achieved suggest that indicating of ferritin can be helpful while making a differentiation between cancer of larynx and malignant neoplasms of maxillo-ethmoid complex.

Concomitant infusion cisplatin and hyperfractionated radiotherapy for locally advanced nasopharyngeal and paranasal sinus tumors

PURPOSE

This is a prospective study to improve the therapeutic ratio in the treatment of patients with locally advanced nasopharyngeal and paranasal sinus tumors by using split-course concomitant infusion cisplatin chemotherapy and hyperfractionated radiotherapy.

METHODS AND MATERIALS

From 1983 to 1993, 21 patients with locally advanced nasopharyngeal and paranasal sinus tumors (T3 and T4, or recurrent tumors involving the facial bones and/or the base of the skull) were treated with a regimen of split-course hyperfractioned radiotherapy (1.2 Gy/fraction/bid) and concomitant infusion cisplatin (5-10 mg/m2/24 h). The therapy was given in three separate 2-week sessions with 1 to 2 week breaks between sessions. Seventeen of 21 patients were treated with curative intent with cumulative radiation doses ranging from 64.8 to 70.8 Gy. Four patients were treated with palliative intent to a total dose of less than 60 Gy or to a limited field due to previous irradiation.

RESULTS

Sixteen of 17 patients (94%) treated curatively achieved a complete response. Of the 16 patients who achieved complete response, 7 patients (50%) were alive at the time of analysis (36 to 126 months). One patient was alive at 4 years with no evidence of disease, and died in 10 years at the age of 80 of unknown cause. Two patients died of local recurrence at 21 and 45 months and one patient died of a cerebrovascular accident at 12 months with disease status unknown. Five patients died of distant metastases. The one patient who had a partial response died in 25 months with local disease and metastases to the bone and lung. Four patients that were previously irradiated received a reduced total dose or treated to a limited irradiation field. All had near complete responses, but died within a year of treatment, with the exception of one patient who died at 23 months. Acute reactions included intense erythema of the mucosa in all patients. Five of 21 (23%) developed punctate mucositis and 3 of 21 (14%) developed confluent mucositis. Hematologically, one patient developed neutropenia (1800 WBC/mm3) and one developed thrombocytopenia (38,000/mm3). A rising creatinine was observed in three patients (2.0, 1.7, 1.7) all of whom were treated with the higher 10 mg/m2/day dose of infusional cisplatin. In all three of these cases, the creatinine slowly returned to normal over a 6-month period. Hormonal evaluations were performed in three patients and all were within normal ranges. There was no evidence of neck fibrosis or trismus. One patient with gross recurrent disease of the orbit developed blindness of the involved eye due to corneal opacification. The orbital area had been reirradiated in this patient.

CONCLUSIONS

Concomitant infusion cisplatinum with hyperfractionated radiation improved tumor control, but did not increase normal tissue injury. Acute reactions were minimized by splitting the treatment with a 1- to 2-week break after each 2 weeks of radiation treatment. Late complications were not increased by using a hyperfractionated radiation regimen. The local failure rate was only 18% (3 of 17 patients), but the distant failure rate was 35% (6 patients). Further investigation is needed to prove if adjuvant chemotherapy after concomitant chemoradiation improves survival by decreasing the distant failure in such advanced cases.

Sphenoid sinus localization of multiple myeloma revealing evolution from benign gammopathy

BACKGROUND

Plasma-cell neoplasms of the head and neck include extramedullary plasmacytoma and solitary plasmocytoma of bone or may represent a local manifestation of multiple myeloma. Involvement of sphenoid sinus has been rarely reported in multiple myeloma.

METHODS

We present the case of a 77-year-old man with a 3-year-history of benign monoclonal IgG-lambda gammopathy who developed left sixth-nerve palsy and malaise.

RESULTS

Computed tomography scan and magnetic resonance imaging scan disclosed a large soft-tissue mass of the sphenoid sinus with bone destruction. Sphenoid sinus biopsy revealed an IgG monoclonal plasma cell neoplasm. Diagnosis of multiple myeloma stage IA was then established.

CONCLUSIONS

Diagnosis of plasma-cell neoplasm should be considered in sphenoid sinus tumors and depends upon histologic examination. This case enlightens the relationships between monoclonal benign gammopathy and plasma-cell neoplasms of the head and neck which constitute a continuum of B-cell lymphoproliferative disorders.

Angiocentric T-cell lymphoma of the nose, paranasal sinuses and hard palate

Sixty-five cases of malignant lymphoma of the nose, paranasal sinuses and hard palate were retrospectively analysed to identify the presence or absence of angiocentric lesions. We observed that the 23 patients with angiocentric lesions had a worse prognosis with a shorter duration of response and also a shorter duration of survival, compared with 42 cases of malignant lymphoma of the same anatomical region but without angiocentric lesions. Patients with angiocentric lymphoma were associated with other bad prognostic factors such as elevated levels of lactic dehydrogenase and beta 2 microglobulin, local bone destruction and lymphopenia. Immunophenotyping studies showed that most patients with angiocentric lesions had T cell lymphomas (18 of 23, 78 per cent). We believe that patients with angiocentric T cell lymphomas of the nose, paranasal sinuses and hard palate represent a distinctive clinico-pathological entity with different clinical presentation and outcome. Patients with angiocentric T cell lymphomas had frequent relapse at extranodal sites and combined therapy should be considered as the initial therapeutic approach.

[Analysis of plasma fibrinogen in evaluating the effectiveness and prognosis of polyradiomodifying therapy of malignant tumors of the upper respiratory tract]

Patients with malignant tumors of the upper respiratory tract showed higher concentrations of fibrinogen in plasma the level of which was correlated with the stage of disease. Measurements of the protein in the course of radiation therapy demonstrated that two months after effective treatment fibrinogen concentrations decreased to normal values and remained at that level throughout the remission time. If radiation therapy was ineffective, fibrinogen concentrations remained high during 2 to 4 months after exposure. Metastases and recurrent tumors caused a drastic increase in the fibrinogen content, the change occasionally occurring prior to clinical manifestations. In view of this, plasma fibrinogen can be recommended as an additional measure that can be used to evaluate therapy effectiveness, to prognose the course of disease and to identify metastases in patients with malignant tumors of the upper respiratory tract.

[Prolactin producing adenomas of the pituitary gland with primary localization in the sinus sphenoidalis (author's transl)]

The radio-immuno-assay of the pituitary hormone prolactin represents the basis for a functional differentiation of the so-called chromophobic adenomas. Two thirds of these tumors produce this hormone. For a long period of growth these adenomas are localized in the middle of the sella turcica. Their first direction of growth is towards the sinus sphenoidalis. At the ENT-clinic of the Cologne University two prolactin producing adenomas have been detected as the cause of suspected changes of the sinus sphenoidalis. The need for an endocrinological diagnosis in cases of unknown processes of the sinus sphenoidalis, the indication for surgery, and the medicamental treatment of these tumors with 2-Br-alpha-Ergocriptine (Parlodel) is discussed.

Plasma protein production by human tumors xenotransplanted in nude mice

For detection of plasma proteins produced by human malignant tumors, a survey of blood plasma obtained from nude mice bearing serially transplanted human tumors was performed by immunoelectrophoresis and the double immunodiffusion technique. Among 34 lines including 18 types of human tumors, human specific plasma proteins were demonstrated in the plasma of nude mice transplanted with two lines of renal cell carcinoma, one adenocarcinoma of the colon, and one squamous cell carcinoma of the maxillary sinus. These tumors can be designated as "ectopic" plasma protein-producing tumors since the organs or tissues from which they originated are not considered to be usual sites of plasma protein synthesis. Plasma protein production, as well as that of alpha1-fetoprotein, was also found in one line of hepatoblasotma and three lines of yolk sac tumors. The above tumors were shown to produce one or more of the following 10 of 20 plasma proteins examined: albumin, prealbumin, alpha1-antitrypsin, ceruloplasmin, alpha2-macroglobulin, hemopexin, haptoglobin, C3 and C4 component of complement, and transferrin. An immunochemical demonstration of human specific cancer products observed in human tumors xenotransplanted into nude mice may provide a new approach for investigating the metabolism of neoplastic cells.

[Comparative clinical, histomorphological and immunological investigations into etiological aspects of polyposis nasi et sinuum (author's transl)]

43 patients with polyps affecting the nose and the sinuses were examined for immunological deficiencies on the basis of clinical, histomorphological and immunological findings. Constant histological findings were a chronic non-specific inflammation of varying intensity; immune-histologically a varyingly dense collection of Ig-producing cells with intracellular and extracellular immunoglobulins was observed. A determination of the immunoglobulins in the serum allowed no conclusion to be drawn as to the local condition of the mucosa. Hypertensitivity reactions played no role as a causal pathogenetic factor in the development of polyposis. In a third of the cases, however, polypi led to a secondary bronchial asthma. After the surgical removal of the polypi from the nose and paranasal sinuses, not only an improvement in nasal breathing and in the aeration of the sinuses was regularly achieved, but obstructive disorders of ventilation also disappeared.