Sinonasal cancer, occupation, and tobacco smoking in European women and men

BACKGROUND

In this analysis of European case-control studies on sinonasal cancer, we examined the risk for occupation and smoking, by gender and histological type.

METHODS

The pooled data included 104 female and 451 male cases, and 241 female and 1,464 male controls. Lifetime smoking and occupational history were recoded following uniform criteria, and job-exposure matrices were applied for wood and leather dust.

RESULTS

Wood dust exposure was associated with an excess risk in men (OR = 2.36, 95% CI 1.75-3.2) but not in women (OR = 1.17, 95% CI 0.31-4.47). Exposure to leather dust was associated with an excess risk in both genders. Both wood and leather dust were associated with adenocarcinomas rather than squamous cell carcinomas. Excess risks for smoking were higher for squamous cell carcinomas and higher in men than in women.

CONCLUSIONS

In these European populations, occupation was associated with about 11% of all sinonasal cancers in women and 39% in men. This difference can, in part, be attributed to variation in exposure patterns between genders.

[Does idiopathic naso-sinusal polyposis exist in children?]

Nasal polyposis, a rare disease in childhood, can present itself as an idiopathic disease. The aim of this study was to describe some of the clinical features of idiopathic nasal polyposis in children and to emphasize this condition as a specific clinical entity.

POPULATION AND METHODS

The study was based on a retrospective analysis of 26 cases of idiopathic nasal polyposis that were studied to our department between 1979 and 1996. In addition, a questionnaire was sent to parents of which 20 were returned completed.

RESULTS

The clinical characteristics of idiopathic nasal polyposis in children (11 males and nine females; median: 12 years; range: 8-15 years) were very similar to those observed in adults (median: 50 years), in particular the relation to asthma (ten of 20 cases) and aspirin intolerance (two Fernand-Widal syndromes of 20 cases). Recurrent ENT infections during the maturing period of the immunological system (0-7 years) did not seem to play a role. There appeared, however, to be a strong genetic component as half of our cases had a family history of nasal polyposis and/or asthma.

DISCUSSION

Idiopathic nasal polyposis should be recognized as an entity among nasal polyps in childhood. Management of idiopathic and secondary nasal polyposis is however different. Although the pathogenesis of nasal polyposis is not well understood, the study of this disease in children leads one to suspect a genetic transmission.

A case study comparing a meta-analysis and a pooled analysis of studies of sinonasal cancer among wood workers

A pooled analysis of raw data from 12 case-control studies of sinonasal cancer has recently been conducted by the International Agency for Research on Cancer; the summary odds ratio for all wood-related occupations was 2.0 (95% confidence interval = 1.6-2.5). We have conducted a meta-analysis of the published results of 14 studies on the same topic, including 11 studies from the pooled analysis, and compared the results for several categories of wood workers. Usable results were available for 12 studies: male wood workers had a summary odds ratio of sinonasal cancer of 2.6 (95% confidence interval = 2.1-3.3). The corresponding value based only on the studies that were also included in the pooled analysis was 2.4 (95% confidence interval = 1.9-3.0). When our meta-analysis was based on a relatively large number of studies, results tended to be higher than those of the pooled analysis. As compared with the meta-analysis, the pooled analysis controlled the effect of publication bias by using data from studies for which no specific result was reported, and it reduced misclassification of exposure; the resources used in the pooled analysis, however, were one order of magnitude greater than those needed for the meta-analysis. Whether a pooled analysis of raw data or a meta-analysis should be carried out depends on the research question; we propose some criteria for this decision.

Second malignancy following treatment of acute lymphoblastic leukemia in children

Second malignancy is one of the serious late effects among long-term survivors of acute lymphoblastic leukemia (ALL) in children. Of 83 newly diagnosed pediatric ALL patients at our hospital between January 1980 and December 1995, four patients were found to have second malignancies. These included MDS/AML after B-ALL, rhabdomyosarcoma after early pre-B ALL, ependymoma after B-ALL, and astrocytoma after early pre-B ALL. The mean duration from initial ALL to second malignancy was 5.2 years. The possible causes of second malignancy in these patients are discussed in this report, along with a review of recent literature.

[Twenty years of retrospective study of malignant paranasal sinus tumors]

Carcinomas of the nasal cavity and paranasal sinuses represent 3% of tumors of the head and neck. Their histology and location vary widely. We reviewed the case histories of patients with malignant tumors of the nasal sinuses seen by us between 1975 and 1996, a total of 37 suitable cases. The site of origin of the tumor was the maxillary sinus in 16 cases, ethmoid sinus in 15, nasal septum in 3, nasal roof in 2, and nasal floor in 1 case. Fifty percent of the tumors were squamous cell carcinomas, 11% undifferentiated carcinomas, 13% non-squamous carcinomas, 5% melanomas, 5% olfactory neuroblastomas, 3% chondrosarcomas and 8% non-Hodgkin lymphomas. When diagnosed, one patient had carcinoma in situ, 3 stage I, 5 stage II, 12 stage III and 16 stage i.v. The cumulative survival was 63% after 3 years and 47% after 5 years.

Cancer of the nasal cavity and paranasal sinuses: a series of 115 patients

A total of 115 patients with sinonasal cancer was assessed during the period 1978-1995. Ninety-one patients received treatment with curative intent. A combination of irradiation and operation was used. The 5-year crude survival for patients, who were treated with curative intent, was 41%; the disease-specific survival throughout the period was 48%. Primary irradiation followed by maxillectomy was widely used in the first half of the period. Treatment in the last part was changed to primary lateral rhinotomy with post-operative irradiation whenever possible. Twelve maxillectomies were performed during the first half of the period, and during the last part, only two. Disease-specific survival was equal in the first and the second halves of the period.

Sinusonasal polyposis

The histological aspects and general disorders related to nasal polyps are reviewed. The origin and physiopathology of nasal polyposis are discussed. The influence of morphology in polyp classification and the contribution of glycohistochemistry are emphasized.

Sinonasal cancer and occupational exposure to textile dust

Data from a case-control study conducted at 27 hospitals in France in 1986-88 were analyzed to examine the association between exposure to textile dust and sinonasal cancer. The study included 207 cases and 409 controls. Detailed information on occupational history and other potential risk factors for sinonasal cancer was collected. Exposure to textile dust (probability and level of exposure, type of textile fiber) was assessed by an expert in industrial hygiene. Among women, exposure to textile dust was associated with an elevated risk of squamous cell carcinoma (odds ratio (OR) = 2.45, 95% confidence interval (CI) = 0.85-7.06, nine exposed cases) and adenocarcinoma (OR = 3.70, 95% CI = 0.56-24.4, three exposed cases). For squamous cell carcinomas, the risk increased with the duration and the level of exposure (P < 0.05): the ORs for the low, medium, and high level of cumulative exposure were 1.00 (95% CI = 0.10-9.43), 2.43 (95% CI = 0.54-11.1), and 3.57 (95% CI = 0.92-13.8), respectively. There was also a limited evidence of an excess risk of squamous cell carcinomas among men exposed to high levels of textile dust (OR = 2.18, 95% CI = 0.65-7.30, four exposed cases). Because of the strong association between wood-dust exposure and adenocarcinoma, an independent effect of textile dust on this type of cancer could not be studied among men. The risks associated with the different types of textile fibers (cotton, wool, and synthetic fibers) were similar and the results did not permit to incriminate a particular type of textile.

Nasal and sinus polyposis in children

Nasal and sinus polyposis in the pediatric population is uncommon and its etiology is unclear. In this 11-year retrospective study, the authors describe the etiologic features and evaluate the effectiveness of endoscopic sinus surgery in 46 children. Patients were divided into three groups according to whether nasal and sinus polyposis was isolated (n = 14), or associated with either asthma (n = 5) or cystic fibrosis (n = 27). An allergy was present in 10% of patients with isolated polyposis, 80% of patients with polyposis associated with asthma, and 22% of patients with polyposis associated with cystic fibrosis. The indications for surgery were disabling symptoms, especially chronic nasal obstruction, rhinorrhea, and mouth breathing, and failure to respond to medical treatment. No surgical complications were encountered. Most patients reported improvement in quality of life with reduction of nasal obstruction in 83% of cases and rhinorrhea in 61%. Minor asymptomatic recurrence (i.e., a few micropolyps localized on the roof of the ethmoid cavity) was observed in 24% of the cases in this series, and major recurrence with the same functional symptoms as before surgery in 12%. However, recurrences were higher in patients with cystic fibrosis, because minor recurrence with no clinical manifestation was observed in 32% of these cases and major recurrence in 16%. Endoscopic sinus surgery must be decided in collaboration with the pediatric and pulmonary physicians, and must be performed skillfully. With a mean follow-up of 3.7 years, results in this series are encouraging.

Is there an occupational etiology of inverted papilloma of the nose and sinuses?

The etiology of inverted papilloma is believed to be of viral origin, as viruses or viral material is found in these tumors of the nose and paranasal sinuses. As the nose is the first defense line of the respiratory tract, we suspected an etiology of airborne pollution as well, especially occupational pollution. We examined a group of 47 patients treated in our department for nasal inverted papilloma, asking about lifelong professional history and occupational exposure. A matched control group of patients with non-malignant diseases was included in the study. We found a significantly higher degree of occupational exposure to different smokes, dusts, and aerosols in the case group. No similar results have been published to our knowledge. To obtain better proof of the role of possible noxious agents, a study technically investigating exposure is mandatory.

Art glassware and sinonasal cancer: report of three cases

In a multicenter study on the occupational etiology of sinonasal cancer (s.n.c.) carried out in Italy, we collected information about three cases which had arisen among glass workers: an adenocarcinoma, a melanoma, and a squamocellular carcinoma. The three men worked many years as mixers and/or batchers in artistic glass factories in Tuscany (Italy). We propose a possible etiological role of arsenic dust.

Occupational exposure to dust and sinonasal cancer. An analysis of 386 cases reported to the N.C.C.S.F. Cancer Registry

An analysis of 386 sinonasal cancer cases reported during the 1978-1994 period to the registry of the Christian Sickness Fund is presented. The relationship between this tumor and previous occupational exposure to carcinogens is investigated by a descriptive case study. Of 386 cases comprising 294 males and 92 females, 139 were adenocarcinomas which in 88 revealed an occupation as woodworker. In 169 sinonasal cancers the professional history indicates an exposure to dust of different origin, but mainly wood, textile, cereals, cement and leather. The primary tumor of 87 sinonasal adenocarcinomas in woodworkers was in 77% ethmoïdal, 12.2% maxillary, 6.8% nasal and 4-sphenoïdal. These findings confirm the results of previous reports on sinonasal cancer from other European countries.

Wood dust and sino-nasal cancer: pooled reanalysis of twelve case-control studies

In order to examine the relationship between wood dust and sino-nasal cancer, data from 12 case-control studies conducted in seven countries were pooled and reanalyzed. The relative risks associated with wood-related jobs and with exposure to wood dust, measured using a job exposure matrix based on occupation and industry titles, were examined using logistic regression. The combined data set consisted of 680 male cases, 2,349 male controls, 250 female cases, and 787 female controls. A high risk of adenocarcinoma among men was associated with employment in wood-related occupations (odds ratio [OR] = 13.5, 95% confidence interval [CI] = 9.0-20.0) and the risk was greatest among men who had been employed in jobs with the highest wood dust exposure (OR = 45.5, 95% CI = 28.3-72.9) and increased with duration of exposure. The risk of adenocarcinoma also appeared elevated among women employed in wood-related jobs (OR = 2.5, 95% CI = 0.5-12.3), but the small number of exposed cases precluded detailed analysis. Women in wood dust-exposed jobs appeared to have an excess of squamous cell carcinoma (OR = 2.1, 95% CI = 0.8-5.5) which increased with duration of exposure. An increased risk of squamous cell carcinoma in men was seen only among those employed for 30 or more years in jobs with exposure to fresh wood (OR = 2.4, 95% CI = 1.1-5.0). The results of this analysis provide strong support to the association between exposure to wood dust in a variety of occupations and the risk of sino-nasal adenocarcinoma and are consistent with the results of individual participating studies, although the magnitude of the excess risk varied. The evidence in regard to squamous cell carcinomas was ambiguous and there was a great deal of heterogeneity observed in individual study results. This may be due to differences in risk associated with exposure to hardwoods and softwoods or with other, as yet to be identified, aspects of exposure.

Visual loss following treatment of sphenoid sinus carcinoma

A 71-year-old woman developed complete third nerve palsy and total blindness of the right eye one month after completing a course of radiotherapy for sphenoid sinus carcinoma over a 13-month period. Differential diagnosis included recurrence of the tumor, radiation-induced second neoplasm, empty sella with chiasmal prolapse and secondary chiasmal arachnoid adhesions, and radionecrosis. Magnetic resonance imaging demonstrated gadolinium contrast enhancement of the right intracranial optic nerve and chiasm, suggesting a radionecrosis process.

Sinonasal non-Hodgkin's lymphoma in patients infected with human immunodeficiency virus: report of three cases and review

Non-Hodgkin's lymphoma (NHL) is a frequent complication of human immunodeficiency virus (HIV) infection, but involvement of the sinonasal region has only rarely been reported. We report three cases of AIDS-associated sinonasal NHL that occurred at our institution and review eight cases that were reported in the literature. The epidemiological and clinicopathologic features of these cases are described and compared with those of three other groups of patients: non-HIV-infected patients with sinonasal NHL, HIV-infected patients with NHL of any anatomic site, and HIV-infected patients with infectious sinusitis. Patients with AIDS-associated sinonasal NHL more frequently developed bony erosion and presented with signs and symptoms referable to adjacent structures, such as the orbit, than did HIV-infected patients with sinusitis, and patients with AIDS and NHL less frequently had typical sinus symptoms and diffuse sinus involvement than did patients with sinusitis. However, the clinical manifestations of these conditions overlap; thus a high index of suspicion for NHL is imperative for prompt diagnosis. These lymphomas typically are high-grade and disseminate early, and the prognosis is generally poor.

Sinonasal cancer and wood dust exposure: results from a case-control study

A case-control study of occupational risk factors for sinonasal cancer was conducted in France in 1986-1988. The study included 207 histologically confirmed cases and 409 controls. Among the male cases were 59 men with squamous cell carcinoma and 82 with adenocarcinoma. The risk of sinonasal cancer in relation to wood dust exposure was studied in these two groups. The analysis was based on a case-by-case assessment of exposure by an industrial hygienist. Hardwood and softwood were distinguished. An approximate twofold increase in risk for squamous cell carcinomas was observed for cases whose first exposure to either hardwood or softwood occurred before 1945; however, the two types of exposure were highly correlated. An exposure to wood dust--from either hardwood alone or hardwood and other kinds of wood--was found for all but two of the 82 male cases with adenocarcinoma. The effects of different elements of exposure to hardwood (duration, level, period) were studied in detail with a logistic model. Two components of exposure--duration and average level--contributed independently to the overall very elevated risk. Additional exposure to wood other than hardwood did not increase the risk.

Risk factors for cancers of the nasal cavity and paranasal sinuses among white men in the United States

A case-control analysis of cancer of the nasal cavity and sinuses was performed using data from the 1986 National Mortality Followback Survey. Data on cigarette smoking, alcohol consumption, usual diet, and other factors from 147 white men who died from nasal cancer and from 449 controls who died from other causes were compared. Cigarette smoking was related to an increased risk of nasal cancer, with a doubling of risk among heavy or long-term smokers and a reduction in risk among long-term quitters. Among nonsmokers, having a spouse who smoked was associated with a significantly elevated risk of nasal cancer. After adjustment for smoking, a significant dose-response relation was also noted between alcohol drinking and risk of nasal cancer. High consumption of salted/smoked foods was associated with elevated risk, and risk tended to decrease with increasing intake of vegetables. Associations were more pronounced for cigarette smoking and certain dietary items when the analysis was restricted to maxillary sinus cancer. The study confirms that cigarette smoking is a risk factor for nasal cancer, and provides further evidence that dietary factors may play a role in the etiology of this malignancy.

[ORL pathology in cystic fibrosis]

We have studied during 1991 a randomized group of 25 cystic fibrosis children whose ages were between 1 and 18 years, analyzing the disease's ENT signs. We have found polyps in the 20% of the patients points up for its high incidence, and the practical absence of otologic, pharyngeal and laryngeal processes.

[Nose and paranasal sinus malignancies with reference to occupational medicine aspects. A case study]

Asbestos is a well known inhalant cancerogenic substance, causing not only mesothelioma but also cancer of the respiratory mucosa of the bronchi. Exposure can also cause non-malignant alterations of the pleura or lung, which can be assessed radiologically. Since asbestos can also induce malignant tumors of the nose and sinuses, we identified 50 patients from the files of the ENT Department Münster and tried to complete questionnaires concerning occupation and occupational hazards using informations from insurance companies as well as at least one chest x-ray. This material could be obtained in 19 patients. Nine of the 19 patients had x-ray findings that could be associated with asbestos exposure, but in none of these 9 cases was massive occupational exposure to asbestos probable. In only two of the nine cases was definite occupational exposure to asbestos not able to be excluded. A control group was not established, since statistical calculations of significance would have been problematic in a number of the 19 patients even if a control group did exist. From the questionnaires we have found an unexpected incidence of dusty workplaces (as seen with textile workers, wood-dust workers, cement workers, quarrymen and millers). A correlation between various types of sinonasal tumors and asbestos exposure could not be made.

[Cancer mortality according to occupation: implications for prevention]

The implications for the prevention of cancer and for health promotion at work is illustrated with two examples from an analysis of cancer mortality by occupation of Swiss men, 1979-1982. The classical approach of industrial medicine to the reduction of pollutants via legislative, technical and informative measures is applied in the case of sinonasal carcinoma and pleural mesothelioma that is increased with furniture-makers. The fact that a comparable cancer mortality pattern linked to miscellaneous factors like smoking, asbestos, cement dust, alcohol, chemicals, nutrition etc. is observed for the various jobs of the building industry, requires an extensive health promotion effort uniting industrial medicine with organizational and individual approaches.

Ethmoidal cancers: a retrospective study of 22 cases

From April 1978 to June 1990, 22 patients with ethmoidal cancer were treated at Fondation Bergonié by a combination of surgery and radiation therapy. The mean age was 59.6 years (range 34-79 years) and the sex ratio is 2.7 (16 males/6 females). Histologic types were: adenocarcinoma, 13 cases; squamous carcinoma, 4 cases; undifferentiated carcinoma, 3 cases and esthesioneuroblastoma, 2 cases. Exposure to wood dust was encountered in 11 patients, especially in cases of adenocarcinoma: 10/13 (77%). Staging according to the classification of the University of Florida was: Stage I, 10 patients; Stage II, 5 patients and Stage III, 7 patients. Resection was considered as complete in 16 cases and only one orbital exenteration was performed. The postoperative radiation therapy delivered a mean given dose of 55.7 Gy (range 50-70 Gy) expressed to the hot spot using a technique adapted to tumor location and extension. Complete remission was achieved in 20 cases. Median follow-up is 28 months. The 5-year overall and disease-free survival are 44% and 38%, respectively. Analysis of recurrences according to staging gives: 5/10 Stage I, 2/5 Stage II and 5/7 Stage III. Recurrence is pejorative since death occurs in all cases within an average of 6 months following salvage treatment, except for three patients still alive within less than 6 months and in second remission. Prognosis of ethmoidal cancer depends on staging and local control.

A population-based case-control study of cancers of the nasal cavity and paranasal sinuses in Shanghai

A population-based case-control study of cancer of the nasal cavity and sinuses, involving interviews of 60 incident cases and 414 controls, was conducted in Shanghai. Cigarette smoking was associated with a mild elevation in risk of squamous-cell carcinoma but not cancers of other cell types. Occupational exposures to wood and silica dusts and to petroleum products, and the use of wood and straw as cooking fuel, were linked to moderate increases in risk, while 4-fold or greater increases were associated with a history of chronic nasal diseases, including those occurring 10 or more years prior to cancer diagnosis. Dietary analyses revealed a significant protective effect of consumption of allium vegetables, oranges and tangerines, with a 50% reduced risk of nasal cancer among individuals in the highest intake group of these foods. Consumption of salt-preserved vegetables, meat and fish was associated with a significantly increased risk of nasal cancer in a dose-response fashion, with a 5-fold excess observed for the heaviest intake of these salted foods. These findings suggest that dietary factors may contribute to the development of nasal cancer.