Plasma cell granuloma of the maxillary sinus: a case report and literature review

BACKGROUND

Plasma cell granulomas are rare and heterogeneous tumor-like lesions of mixed inflammatory cell infiltrates of unknown etiology. Although they have the potential to occur in sites throughout the body, their occurrence in the paranasal sinuses and nasal cavity is uncommon and often associated with unique clinical characteristics and natural history.

METHODS

We present a case of an aggressive plasma cell granuloma of the maxillary sinus and a review of the literature (28 cases).

RESULTS

The patient was treated with definitive radiotherapy (45 Gy in 25 fractions) and experienced a local recurrence 2 years later. The lesion initially responded to corticosteroids and then progressed. Resection was performed and was followed by another recurrence. The patient was treated with radiosurgery and is disease free 8 years after initial treatment.

CONCLUSIONS

Review of the literature indicates that the optimal first line of treatment is high-dose corticosteroids. Surgery is indicated if the lesion fails to respond. Radiotherapy is indicated if complete resection is not feasible.

Abducens nerve palsy and postganglionic Horner syndrome with or without severe headache

OBJECTIVE

To report the clinical features of 9 patients with both abducens nerve palsy and postganglionic Horner syndrome.

PATIENTS AND METHODS

Nine patients with this symptom combination were examined by our Neuro-ophthalmology Clinic in Nihon University Itabashi Hospital between 1978 and 2004. Patient ages ranged from 28 to 63 years (average 47.2+/-8.7 years). Six patients were males and 3 were females. Primary diseases, accompanying symptoms and prognoses were surveyed.

RESULTS

In primary diseases, neoplasm in the cavernous sinus was observed in 2 patients, sphenoidal sinus cyst in 2, intra-cavernous carotid aneurysm in 2, epipharynx carcinoma in 1, chordoma in the base of the skull in 1, and meningioma in the middle cranial fossa in 1. Five patients with extra-cavernous sinus lesions; sphenoidal sinus cyst, epipharynx carcinoma, chordoma and meningioma, complained of severe headache. However, in patients without severe headache, intra-cavernous sinus lesions such as carotid aneurysm and metastatic carcinoma were detected. After therapy, abducens nerve palsy improved in 5 patients, however, Horner syndrome persisted in all patients.

CONCLUSION

We emphasize that this symptom combination is an important sign of lesions in the posterior portion of the cavernous sinus or in its vicinity. Moreover, the presence or absence of severe headache depends on whether the lesion is in the intra-cavernous or extra-cavernous sinus.

Prognostic factors in maxillary sinus and nasal cavity carcinoma

AIMS

The aim of the present study is to define prognostic factors, particularly the impact of treatment on paranasal sinus and nasal cavity malignancies.

MATERIAL AND METHODS

Retrospective study of patients with maxillary antrum and nasal fossae malignancies. A maxillectomy classification as performed to treat malignancies in our institution is described. Multivariate analysis of prognostic factors was done using the Cox's model.

RESULTS

One hundred and nine patients were evaluated. Squamous cell carcinoma was found in 62 cases and in 95 patients the epicentre of the tumour was located in the maxillary antrum. Ten patients were treated with surgery only, 39 patients with surgery and adjuvant radiation therapy, 37 cases received only radiotherapy, and 18 received radiotherapy followed by surgery; in five cases a combination of chemo-radiotherapy was used. Multivariate analysis identified T classification, orbit invasion, N classification, site of origin of tumour in nasal fossae, and no surgical resection as independent prognostic factors (p=0.0001).

CONCLUSION

T4 tumours with orbit invasion present bad prognosis as compared to other T4 tumours. Surgical resection should be included in the treatment strategy. Because of the high frequency of lymph-node metastasis, neck treatment should be considered in T4 tumours.

Isolated maxillary sinus Ewing's sarcoma

Extraskeletal Ewing's sarcoma is rarely found arising in the head and neck region. Only six cases of extraskeletal Ewing's sarcoma invading the nasal cavity or paranasal sinuses have been reported in the literature. The first described case of that Ewing's sarcoma located in isolated maxillary sinus extending into the orbita without involving the nose is presented. A 16-year-old woman presented with swelling in her right cheek. The nasal examination was normal. A computed tomography (CT) and magnetic resonance imaging (MRI) of the sinuses revealed a large mass in the right maxillary sinus with extension to the orbita. Under general anesthesia biopsies were taken. Based on histopathological analysis, a diagnosis of extraskeletal Ewing's sarcoma was made. The patient did not accept the surgical therapy. The patient was treated with combined chemotherapy and radiotherapy. The patient has done without evidence of recurrence or metastasis for one year.

Inflammatory pseudotumour (plasma cell granuloma) arising in the maxillary sinus

CONCLUSIONS

Inflammatory pseudotumours in the maxillary sinus may present as malignant tumours and manifest locally aggressive features characteristic of such tumours. Despite their locally destructive features, they pursue a benign course after local excision.

OBJECTIVE

Inflammatory pseudotumour (plasma cell granuloma) is an uncommon non-neoplastic lesion comprising a proliferation of spindle myofibroblasts and chronic inflammatory cells. Despite its benign histopathological nature, it may exhibit aggressive behaviour that is yet to be characterized in the head and neck area.

MATERIAL AND METHODS

We present the cases of two adult patients with inflammatory pseudotumour arising from the maxillary sinus. Immunohistochemistry and polymerase chain reaction for immunoglobulin from tissue sections were performed to confirm the polyclonality of the infiltrating plasma cells.

RESULTS

CT and MRI disclosed expansive soft masses eroding surrounding soft and bony tissues. Histopathologically, the lesions were unencapsulated and composed of numerous plasma cells, histiocytes and spindle cells with minimal nuclear pleomorphism.

Treatment Outcome of Nasal and Paranasal Sinus Carcinoma

PURPOSE

Most authors recommend aggressive management for sinonasal carcinoma treatment. In an attempt to determine the optimal treatment, we assessed the treatment results of our patients with nasal cavity and paranasal sinus carcinoma.

MATERIALS AND METHODS

From January 1980 to December 2001, 40 patients with malignant tumours of the nasal cavity and the paranasal sinuses were treated. The median follow-up was 6 years. Thirty-two patients had tumours originating from the maxillary sinus. Thirteen patients had T1-T2 (32.5%) tumours and 27 patients had T3-T4 (67.5%) tumours. The treatment method was surgery plus radiotherapy in 24 patients (60%) and radiotherapy alone in 16 patients (40%).

RESULTS

The 5-year overall survival rate was 61%, whereas it was 65% for T1-T2 disease and 56% for T3-T4 disease. The 5-year local control rate was 58%, whereas it was 75% and 50% (p = .219) for T1-T2 and T3-T4 disease, respectively. In multivariate analysis; localization (p = .016), adjuvant radiotherapy (p = .040), local control (p = .05), and gender (p = .013 for female) were statistically significant factors.

CONCLUSION

The prognosis for patients with tumours of the sinonasal area is dependent on localization, tumour stage, and treatment modality. Because the most common site of treatment failure is the primary site, efforts to maximize local control should be undertaken.

[Prognostic analysis of 151 patients with maxillary sinus malignant neoplasms]

BACKGROUND & OBJECTIVE

Five-year survival rate of patients with maxillary malignant neoplasms is low, the prognostic factors of these neoplasms were unclear. This study was to investigate prognostic factors of maxillary sinus malignant neoplasms.

METHODS

Records of 151 inpatients with malignant neoplasms of maxillary sinus initially treated at Cancer Center of Sun Yat-sen University from Sep. 1983 to Mar. 1999 were reviewed. Of 151 cases, 72 were squamous cell carcinoma (SCC), 44 were adenocarcinoma, 16 were sarcoma, and 19 were other histological types; according to 1997 UICC classification, 7 were stage II, 55 were stage III, and 89 were stage IV; 66 patients received combined therapy of surgery and radiotherapy, 14 received surgery alone, 25 received radiotherapy alone, 39 received other treatments, and 7 gave up treatment. All patients were followed up for more than 5 years. Influences of clinicopathologic factors on prognosis of patients with maxillary sinus malignant neoplasms were analyzed by Kaplan-Meier method, and Cox regression model with SPSS10.0 software.

RESULTS

Five-year overall survival rate of patients of </=40 years old was 55.7%, that of patients of >40 years old was 33.3%(P=0.030); that of patients with SCC was 30.2%, of patients with adenocarcinoma was 57.5%, of patients with sarcoma was 24.3%, of patients with tumor of other histological types was 50.7% (P=0.011); that of patients with tumor of stage II, III, and IV were 85.7%, 45.8%, and 32.7%, respectively (P=0.029); that of patients with cervical metastases was 14.4%, of patients without cervical metastases was 44.1% (P=0.005); that of patients with distant metastases was 14.3%, of patients without distant metastases was 41.1% (P=0.011); that of patients without treatment was 14.3%, of patients treated with surgery alone was 42.9%, of patients treated with radiotherapy alone was 32.3%, of patients treated with combined therapy of surgery and radiotherapy was 50.8%, of patients treated with other treatments was 29.1% (P=0.004). Univariate survival analysis showed that the above 6 factors were prognostic factors of patients with maxillary sinus malignant neoplasms. Multivariate analysis showed that combination of surgery and radiotherapy (P=0.004, OR< 1), clinical stage (P=0.025, OR >1), SCC (P=0.016, OR >1), and sarcoma (P=0.003, OR >1) were independent prognostic factors of patients with maxillary sinus malignant neoplasms.

CONCLUSION

For maxillary sinus malignant neoplasms, patients with SCC or sarcoma had poorer survival than patients with adenocarcinoma or other histological types of tumor; patients with sarcoma had poorer survival than patients with SCC. The higher the patient's clinical stage was, the worse his prognosis was. Combination of surgery and radiotherapy may be the best treatment for patients with maxillary sinus malignant neoplasms.

Prognostic factors of maxillary sinus malignancies

BACKGROUND

Analysis of a series of tumors of the maxillary sinus show contradictory outcome data. The purpose of this article was to study the prognostic factors that may have implications for patient management.

METHODS

We present a retrospective review of 57 patients who underwent a maxillectomy over a 20-year period.

RESULTS

At the time of presentation, 86% of patients had advanced local disease (T3-T4). The 5-year disease-specific survival rate of this series was 39%. No significant differences on survival were observed according the histology of the tumor (p = 0.213), extension to the infratemporal fossa (p = 0.314), and postoperative radiotherapy (p = 0.723). Factors that revealed a significant reduction of survival were skull base involvement (p = 0.013), involvement of the orbit (p = 0.043), and recurrent disease (p = 0.048). Multivariate analysis confirmed that the skull base and orbital involvement were significantly associated with disease-specific survival.

CONCLUSION

Advanced T stage, base of skull involvement, orbital extension, and local recurrence are highly predictive of poor survival.

[Change of reactive small round cell infiltration in the stroma after pre-operative 8 Gy irradiation using treatment to maxillary sinus carcinoma with Kitasato method and prognosis according to the change]

PURPOSE

In this paper, we report the results of studying the degree of reactive small round cell infiltration in the stroma as a prognostic indicator of maxillary sinus carcinoma treated with the Kitasato method and the effect of preoperative irradiation at 8 Gy on infiltration in the stroma.

SUBJECTS

Out of 74 patients who had been treated with this method in the 27 years from 1976 to 2002, the following patients were enrolled in this study: (1) 17 patients from whom tissue specimens could be obtained with biopsies or probe antrotomies before preoperative irradiation, and (2) 40 patients from whom tissue specimens could be obtained after preoperative irradiation including those who survived five years and who died of a specific cause.

METHOD

We classified the pattern of distribution of small round cell infiltration in the stroma into three degrees. (1) Stromal infiltration was compared before and after the operation to recognize the prognosis for each patient based on the pattern of distribution of small round cell infiltration in the stroma. (2) The correlation between the degree of stromal infiltration and prognosis was studied statistically.

RESULTS

(1) Both the patients with increased stromal infiltration and those postoperatively preserving a preoperative score of 2+ with irradiation at 8 Gy had a good prognosis. (2) The five-year survival rate for patients was significantly higher in those with a score of 2+ for their tissue specimens.

CONCLUSION

The Kitasato treatment method is effective and improves the QOL of patients with maxillary sinus carcinoma. The prognosis was good in the patients with increased or preserved stromal infiltration. The low-dose irradiation and chemotherapy used in combination seemed to be biological response modifiers.

The potentially fatal vascular anomaly and orthodontic treatment--a case report

Oral vascular lesions are of clinical importance to the dental profession because they pose serious bleeding risks. A case report is presented here where a patient with a complex palatal vascular malformation was successfully treated with fixed appliances. The problems encountered during treatment are discussed.

Osteogenic sarcoma after orbital radiation rhabdomyosarcoma

PURPOSE

We describe the occurrence of maxillary and orbital osteogenic sarcoma in a child after treatment of contralateral orbital rhabdomyosarcoma with external beam radiation and chemotherapy.

DESIGN

Interventional case report.

INTERVENTION

Treatment of a maxillary and orbital rhabdomyosarcoma with surgical resection, systemic chemotherapy, and local radiation.

MAIN OUTCOME MEASURES

Occurrence and histology of secondary malignancy after orbital radiation.

RESULTS

An eleven year-old male presented for evaluation of left facial swelling, occurring ten years after successful treatment of a right orbital embryonal rhabdomyosarcoma with chemotherapy and 5040 cGY of external beam radiation. Computerized tomography demonstrated a mass involving the left maxillary sinus and orbital floor. Biopsy demonstrated osteogenic sarcoma. Despite attempted total excision with radical maxillectomy, resection margins were found to have microscopic extension of the tumor. Postoperatively he was treated with systemic chemotherapy and local radiation. Eight months postoperatively he remains alive despite local progression.

CONCLUSIONS

Osteogenic sarcoma can occur as a secondary malignancy years after the successful treatment of orbital rhabdomyosarcoma with external beam radiation and chemotherapy. After orbital radiation, subjects should undergo routine lifelong examinations.

Branch retinal artery occlusion following embolization of a maxillary sinus tumor

Retinal vascular complications following embolization of carotid artery branches have been occasionally reported. Since the result can be catastrophic and is often irreversible, all efforts to prevent this complication should be considered prior to the intervention. We report the occurrence of a branch retinal artery occlusion following embolization of a maxillary sinus tumor. Cerebral angiography pre- and post-embolization; pathology results from the excised tumor; fundoscopic, visual field, and fluorescein angiographic findings are reported. A combination of risk stratification and preoperative evaluation methods which might help in prevention of this serious complication are discussed.

Peripheral primitive neuroectodermal tumour of the left maxillary sinus

Peripheral primitive neuroectodermal tumours (pPNETs) are highly malignant, small-cell neoplasms found mainly in children and young adults. Recent advances in immunohistochemistry and genetic typing have led to reports of a close relationship between pPNET and the previously difficult-to-classify Ewing's sarcoma. We report a case of pPNET involving the left maxillary sinus in a 23-year-old female who presented with a 2-month history of unilateral left-sided nasal obstruction, rhinorrhoea and recurrent bloody nasal discharge. A CT scan of the paranasal sinuses showed a large mass (10 x 7 x 3 cm3) arising from the left maxillary sinus, with signs of bone destruction and invasion of the left orbital floor and pterygomaxillary fossa. MRI revealed a heterogeneous hyperintense signal on a T2-weighted image in the left maxillary sinus. The tumour was surgically removed by means of external lateral rhinotomy. Pathological examination showed a sheet of small cells with irregular nuclei. Immunohistochemical studies demonstrated positive immunoreactivity for neurone-specific enolase, synaptophysin, chromogranin, vimentin, S-100 protein and p30-32 MIC-2 gene product. The patient was treated with chemotherapy consisting of cyclophosphamide, vincristine, adriamycin and actinomycin D, together with radiotherapy to a total tumour dose of 60 Gy. After 59 months of follow-up, the patient remained free of disease and a repeat MRI scan was normalized, with no sign of residual tumour.

Development of chronic myelocytic leukemia after chemotherapy for malignant fibrous histiocytoma

At the age of 28, a 33-year-old male was diagnosed with malignant fibrous histiocytoma (MFH) with a primary lesion in the right maxillary sinus. Although arterial infusion chemotherapy (pirarubicin hydrochloride and carboplatin) was given, no tumor shrinkage was observed, and surgery was therefore performed to remove the tumor. Thereafter, the patient received autologous peripheral blood stem cell transplantation with high-dose chemotherapy (combination of ifosphamide, carboplatin and etoposide) as pretreatment. An increase in the peripheral leukocyte count was noted 56 months after the diagnosis of MFH was made. Cytogenetic study showed translocation (9;22)(q34;q11). Chronic myelocytic leukemia (CML) was therefore diagnosed. MFH was in a state of complete remission. The clinical course of this patient strongly suggests that this was a case of treatment-related CML that developed after chemotherapy for MFH. Treatment-related malignant blood diseases are known to include acute myelocytic leukemia and myelodysplastic syndrome, but reports of treatment-related CML are rare, although there have been some cases of treatment-related CML occurring several years after pretreatment.

Results of orbital preservation for advanced malignant maxillary sinus tumors

OBJECTIVE

The purpose of the study was to examine the oncological and functional outcomes of multimodality therapy for patients with advanced malignant maxillary sinus tumors that invaded the orbit.

STUDY DESIGN

Retrospective study.

METHODS

The medical records of 26 patients with orbital invasion were retrospectively analyzed. The patient group consisted of 16 men and 10 women, with a median age of 58 years. The mean follow-up period was 73 months. The most common disease was squamous cell carcinoma. Seven patients had nodal disease. All patients underwent simultaneous combined therapy consisting of conservative surgery through a sublabial incision, radiotherapy, and regional chemotherapy. Patients with nodal disease were treated with either irradiation or selective neck dissection.

RESULTS

The 5- and 10-year overall survival rates were 68% and 51%, respectively. The 5- and 10-year local control rates were 66% and 51%, respectively. Overall survival rates and local control rates were significantly worse in patients with disease other than squamous cell carcinoma. Local control rates were significantly worse in patients with orbital apex disease than in patients without orbital apex disease. All 26 patients, despite orbital involvement, retained their orbital contents. Nineteen of these patients demonstrated adequate ocular function.

CONCLUSIONS

Combined therapy with conservative surgery, radiotherapy, and regional chemotherapy is an effective method for local control and preservation of ocular function. However, performing orbital conservation procedure in patients with disease other than squamous cell carcinoma and with orbital apex disease must be considered carefully.

Cemento-ossifying fibroma of maxillary and sphenoid sinuses: case report and literature review

We report a case of cemento-ossifying fibroma (COF) involving the maxillary and sphenoid sinuses and review the literature in order to study the clinical features, imaging findings and histopathologic characteristics of COF. Special care was taken to distinguish this lesion from cemento-osseous dysplasia (COD). It is almost inevitable that differential diagnosis of COD and COF will be complicated by the fact that some pathologic features are shared by both lesions. A combined study incorporating clinical, radiographic and pathologic findings is important in order to ensure an accurate diagnosis. Postoperative follow-up is essential, especially in cases where incomplete removal of the COF was performed.

Treatment of maxillary sinus carcinoma: clinical results using the Kitasato modality

The conventional therapeutic regimen for maxillary sinus carcinoma consists of dissection of the maxilla, full-dose irradiation and extensive chemotherapy. However, the results obtained with this treatment are often poor. Even when patients recover, their quality of life is significantly reduced as a result of deformity of facial structures and swallowing and articulation dysfunctions. A retrospective analysis of 68 patients with maxillary sinus carcinoma treated with the Kitasato modality between 1975 and 1999 was conducted. All patients underwent pergingival maxillary sinus surgery combined with pre- and postoperative irradiation therapy with standardized total doses of 16 Gy; the postoperative irradiation was given in combination with regional intra-arterial infusion chemotherapy administered via the superficial temporal artery. All visible tumor lesions were removed where possible in order to preserve or facilitate cellular immunity after surgery. The cumulative 5-year survival rates were 85.7% for Stage II patients, 88.1% for Stage III, 76.6% for Stage IVA and 75.% for Stage IVB.

Malignant fibrous histiocytoma of the nasal cavity and paranasal sinuses: review of the last 30 years

The clinical and pathologic features of four patients with malignant fibrous histiocytoma of the maxillary sinus were studied. All patients were male, with an age range of 43-71 years at the time of diagnosis. The main symptoms were pain in the facial region, swelling of the cheek and nasal bleeding. Pathologically, three patients were subclassified with the striform-pleomorphic type of malignant fibrous histiocytoma and one with the myxoid type. All patients were operated on and received various combinations of pre- and postoperative irradiation and intra-arterial chemotherapy given via the temporal artery. In the patient with the best prognosis, tumor extension within the maxillary sinus was minimal. Two patients developed local recurrences and died. None of the patients developed locoregional lymph node or systemic metastases.

Solitary extramedullary plasmacytoma of the maxillary sinus. Case report

Solitary extramedullary plasmacytomas are rare tumors that often affect head and neck region. Because of the non-specific associated symptomatology, they frequently are misdiagnosed. We briefly describe a 69-year-old woman who developed solitary plasmacytoma in the left maxillary sinus and was initially treated as having sinusitis. We also report the diagnostic work-up that is necessary to establish a correct diagnosis in such cases. This case highlights that an appropriate investigation for neoplastic disease should be performed in patients presenting with persistent symptoms that resemble those of sinusitis, especially if these do not resolve after conservative medical treatment.

Epithelioid angiosarcoma of the maxillary sinus and the maxilla: a case report and review of the literature

Epithelioid angiosarcoma is a rare malignant tumor that arises from the endothelium of the blood vessels. In the head and neck area, most of these lesions affect the scalp and facial soft tissues, and the maxillary sinus and the maxilla are among the rarest locations involved. In this paper, we present a case of angiosarcoma of the left maxillary sinus, with extension into the left maxilla. We review the literature and discuss the differential diagnosis of endothelial neoplasms and the management and the prognosis of this tumor.

Trimodal combination therapy for maxillary sinus carcinoma

PURPOSE

This study was conducted to evaluate the effectiveness of trimodal combination therapy (radiotherapy, intra-arterial chemotherapy, antrotomy) for the treatment of primary maxillary sinus carcinoma.

METHODS AND MATERIALS

Between 1977 and 1996, 110 patients with maxillary squamous cell carcinoma were treated with trimodal combination therapy at Tokyo Medical and Dental University Hospital. All tumors were classified according to the 1997 UICC TNM staging system. Eighty percent of patients had T3 or T4 tumors. The T3 and T4 tumors were also classified into three groups according to their location, as visualized using computed tomography: the posterior-lateral (P) group, the medial (M) group, and the upper (U) group. Eight patients received additional radiotherapy, and 37 patients underwent a second surgical procedure, in addition to the trimodal combination therapy.

RESULTS

The 5-year cause-specific survival and local control rates were 71% and 65%, respectively. The 5-year local control rate was 80% for the T1+2 tumors, 64% for the T3 tumors, and 52% for the T4 tumors (p = 0.06). Patients in the P+M group who received a 5-fluorouracil (5-FU) dosage of more than 3500 mg had a better 5-year local control rate than patients who received a 5-FU dosage of less than 3500 mg (p = 0.01). No improvement in the local control rate after a second surgical procedure or additional irradiation treatment was observed in any of the groups.

CONCLUSION

Trimodal combination therapy provides good local control, with the final outcome depending on the T stage of the tumor and the dosage of 5-FU.

[Statistical analysis of maxillary sinus squamous cell carcinoma]

Cases of squamous cell carcinoma of the maxillary sinus initially treated at Keio University Hospital between January 1981 and December 1998 studied retrospectively involved 60 untreated cases--46 men and 14 women aged 36 to 86 years (mean: 59.8 years). Of these, 7 had T2, 41 T3 and 12 T4 tumors based on 1997 AJCC TNM classification. Seven (11.7%) had nodal involvement but none had distant metastasis at diagnosis. Of the 60, 53 (88.3%) were stage III or IV. Prognostic factors and survival were statistically analyzed for 59 cases, excluding the 60th who died of another cause. Follow-up was 4 to 227 months, with a median of 59 months and a mean of 38 months. Of the 59, 48 (81.4%) underwent neoadjuvant chemotherapy (NAC). Survival was estimated using the Kaplan-Meier method as univariate analysis. Cause-specific 5-year survival was 56.8% for all stages, 68.2% for T2, 60.0% for T3, and 41.7% for T4. T stage classification was thus a significant independent prognostic factor in multivariate analysis using Cox's proportional hazards model (p = 0.0240). It also identified T stage classification (p = 0.0486) and NAC (p = 0.0419) as significant independent factors affecting survival with organ preservation. We also statistically analyzed 48 cases treated with NAC, which showed complete response (CR) for 11, partial response (PR) for 25, no change (NC) for 11, and progressive disease (PD) for 1. Responders (CR + PR) showed significantly better survival and organ preservation than nonresponders (NC + PD). The NAC response enables us to predict prognosis. T4 cases without NAC response should be treated intensively.