The role of skull base surgery for the treatment of adenoid cystic carcinoma of the sinonasal tract

BACKGROUND

Adenoid cystic carcinoma (ACC) of the sinonasal tract is an aggressive malignancy associated with a poor 5-year survival rate. The role of skull base surgery for the treatment of patients presenting with sinonasal ACC and its impact upon their survival has not previously been evaluated.

METHODS

A retrospective review of 35 patients with ACC of the sinonasal tract who were treated with surgery and radiation therapy at the University of Pittsburgh Medical Center was performed to evaluate patient outcome.

RESULTS

Local recurrence of tumor following surgery and radiation therapy was observed in 36% of the patients originally treated at the University of Pittsburgh Medical Center. Fourteen percent of these patients developed a regional tumor recurrence, and 21% developed distant metastases. We did not identify any tumor-related factors that predicted patient outcome. Local recurrences were treated with salvage surgical excision, and, despite aggressive management, only 1 of 17 patients with local recurrence was considered cured (NED) at 24 months (follow-up after salvage surgery). Overall, disease-free survival was 46.4%, at a median follow-up of 40 months.

CONCLUSIONS

ACC of the sinonasal tract is an aggressive malignancy. Skull base surgery has facilitated the gross total excision of advanced lesions that were deemed inoperable in the past, but has not resulted in an overall improvement in disease-free survival. Local recurrence portends a very poor prognosis, despite aggressive salvage regimens. Alternative therapies for local recurrences warrant further investigation. Prospective, randomized studies are necessary to evaluate the outcome of patients treated with aggressive multimodal treatment regimens, including chemotherapeutic regimens.

Conformal radiation therapy treatment planning reduces the dose to the optic structures for patients with tumors of the paranasal sinuses

PURPOSE

Compare dose distributions of traditional versus conformal beam orientations in paranasal sinus malignancies.

MATERIALS AND METHODS

Maximum normal tissue doses, dose volume histograms (DVH), normal tissue complication probabilities (NTCP), and the percentage of each normal tissue receiving >80% of the average target dose (V80) were calculated.

RESULTS/CONCLUSIONS

Conformal planning reduced the V80 to the optic nerves and chiasm as well as the normal tissue maximum doses to the ipsilateral and contralateral optic nerves and chiasm, and mean NTCPs.

Surgical salvage after failed radiation for paranasal sinus malignancy

OBJECTIVE

To comment on the role of surgical salvage following failed initial treatment for paranasal sinus malignancy.

DESIGN

A retrospective analysis of one hundred eighty patients treated at The Princess Margaret Hospital, Toronto, from 1976 to 1993.

MATERIALS AND METHODS

Thirty-four of 95 patients (36%) who failed initial treatment underwent surgical salvage. Initial therapy in this group was radiation only (n = 27) and combined therapy (n = 7). Patient, tumor, and surgical data were recorded. There were 23 T4, three T3, six T2, and two T1 carcinomas. Survival, recurrence rates, and the influence of a variety of variables on outcome were analyzed.

RESULTS

Two- and 5-year overall actuarial survival calculated from the date of diagnosis was 54% and 35%, respectively. Two- and 5-year overall actuarial survival calculated from the date of salvage surgery was 44% and 22%, respectively. Advanced age (P < .004), patients with T4 category disease (P < .04), and squamous cell carcinomas (P < .049) correlated with poorer outcome on univariate analysis. Local failure was the most common cause of death (n = 13; 65%).

CONCLUSION

Salvage surgery has a limited role in the management of persistent or progressive disease following failure of initial treatment. Careful postradiation surveillance with endoscopic biopsy under general anesthesia and immediate surgical resection when appropriate may improve the salvage rate.

Studies of the anatomy and pathology of the orbit in carcinoma of the maxillary sinus and their impact on preservation of the eye in maxillectomy

BACKGROUND

The periorbita has been traditionally regarded as the decisive layer whose involvement in carcinoma of maxillary sinus indicates orbital exenteration. Anatomic texts depict that the orbital fat rests on the periorbita. Our experience at surgical dissections has been different.

METHODS

Twenty-five patients underwent total maxillectomy for advanced (T3-T4) carcinoma of the maxillary sinus with postoperative radiotherapy during a 15-year period between 1981 and 1995. In 11 patients, despite radiologic evidence of orbital invasion, and in 5 patients with infiltration of the periorbita, the eye could be preserved without evidence of recurrence. In 6 patients who in addition underwent orbital exenteration, histopathologic evidence of tumor invasion of the orbit was present in only one surgical specimen.

RESULTS

Clinicoanatomic studies have clearly shown the presence of a thin, distinct fascial layer which surrounds the periocular fat and separates it from the periorbita. Neither clinical examination nor imaging could predict orbital invasion with absolute accuracy. Histopathologic examination of the surgical specimens shows that tumor infiltration of the eye is rare.

CONCLUSION

Periocular fat is surrounded by a thin fascial layer and is not in direct contact with the periorbita. Intraoperative decision making with respect to preservation of the eye is sometimes essential.

Adjuvant chemotherapy with oral tegaful and uracil for maxillary sinus carcinoma

We have applied tegaful and uracil (UFT) treatment as adjuvant chemotherapy to patients after the completion of primary therapy. UFT was given per os at a dose of 300 or 400 mg/day for more than 1 year. A retrospective study was conducted on 15 patients, assessed as the UFT-treated group, and 24 patients assessed as the UFT-nontreated group. The 5-year survival rate in patients treated or not treated with UFT was 76.6 and 22.6%, respectively. Among those who underwent surgery in combination with other therapy, the 5-year survival rate was 74.1% with UFT and 27.3% without UFT. In patients receiving chemotherapy plus radiotherapy alone, the 5-year survival rate was 80.0% with UFT and 19.2% without UFT. In 23 patients with proven effects of neoadjuvant chemotherapy comprising 18 PR cases and 5 CR cases, a comparison was made between 10 patients treated with UFT and 13 patients not treated with UFT. As a result, the 5-year survival was 76.2 and 17.9%, respectively. In the patients with T3 disease, who occupied the majority, the 5-year survival rate was 71.4 and 23.8%, respectively. Adjuvant chemotherapy with UFT tends to show a substantial significant difference particularly in patients who were successfully treated with radiotherapy plus chemotherapy as the primary treatment. UFT was clearly shown to have a statistically significant effect, despite a small population. The findings of the present investigation point to the value of conducting further study to ascertain the effect of UFT by a randomized trial in a larger population.

Squamous cell carcinoma of the maxillary sinus treated with radiation therapy and conservative surgery

BACKGROUND

For patients with squamous cell carcinoma of the maxillary sinus, combined modality treatment is usually employed, involving radiation and en bloc radical surgery. In this study, local control was analyzed retrospectively in patients who underwent less aggressive piecemeal surgery.

METHODS

Of the 37 patients irradiated between 1973 and 1992, 62% were classified as having T4 lesions. Thirty-two patients underwent surgery and radiation therapy; conventional fractionation radiation therapy was used in most cases. Thirty of these patients underwent piecemeal debulking of their tumors and simultaneous radiation therapy.

RESULTS

Local recurrence free survival at 5 years was 59%, and orbital exenteration was performed on only 1 patient. T classification, the number of operations, and the presence of macroscopic residual disease each had a statistically significant impact on local recurrence. For the patients with macroscopic residual disease, more than 58 gray administered in conventional fractionation appeared to be necessary to improve local control.

CONCLUSIONS

Combined with radiation therapy, conservative surgery with piecemeal debulking was an effective method of treatment for the patients in this study.

Orthovoltage radiation therapy treatment planning using Monte Carlo simulation: treatment of neuroendocrine carcinoma of the maxillary sinus

Dose distributions that result from treating a patient with orthovoltage beams are best determined with a treatment planning system that uses the Monte Carlo method, and such systems are not readily available. In the present work, the Monte Carlo method was used to develop a computer code for determining absorbed dose distributions in orthovoltage radiation therapy. The code was used in planning treatment of a patient with a neuroendocrine carcinoma of the maxillary sinus. Two lateral high-energy photon beams supplemented by an anterior orthovoltage photon beam were utilized in the treatment plan. For the clinical case and radiation beams considered, a reasonably uniform dose distribution (+/- 10%) is achieved within the target volume, while the dose to the lens of each eye is 4-8% of the prescribed dose. Therefore, an orthovoltage photon beam, when properly filtered and optimally combined with megavoltage beams, can be effective in the treatment of cancers below the skin, providing that accurate treatment planning is carried out to establish with accuracy and precision the doses to critical structures.

Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the maxillary sinus?

PURPOSE

To determine the proportion of patients with squamous cell carcinoma of the maxillary sinus who will fail in regional nodes without elective neck treatment and to identify any prognostic factors that may influence neck control.

METHODS AND MATERIALS

From 1971-1995, 42 consecutive patients with squamous cell carcinoma of the maxillary sinus were seen at our department for curative treatment. There were 35 males and 7 females, with a median age at diagnosis of 63.5 years (range, 42-77 years). One tumor was classified as T1, 5 had T2, 15 had T3, and 21 had T4 disease. Four of 42 patients (9.5%) had cervical lymphadenopathy at initial presentation. Thirty-three patients had surgical resection and radiotherapy and nine had radiotherapy alone. None of the 38 patients with clinical N0 necks received elective treatment to the cervical nodes.

RESULTS

Median overall survival was 30 months for all patients. Of the 38 patients with N0 disease, 11 (28.9%) had neck recurrence. Of the 11 neck failures, 9 were ipsilateral only, 1 was contralateral, and 1 had bilateral neck recurrence. The most common site of neck failure was in the upper neck (submandibular and jugulodigastric lymph nodes). Four of the 38 patients (10.5%) had isolated neck failure. Only tumor stage was found to be significant for neck relapse, with T1 and T2 doing worse compared to T3 and T4 tumors. Location of tumor (infrastructure vs. suprastructure), involvement of the oral cavity/oropharynx, nasal cavity, nasopharynx or orbit did not predict for cervical node relapse. Local control at the primary site was likewise not prognostic. The median overall survival for patients who remained N0 was 80 months and for those with initial cervical involvement or recurred in the neck without elective neck irradiation was 25 months (p = 0.05).

CONCLUSION

Based on the 28.9% rate of neck recurrence and the poor median survival of patients who recur in the neck, we recommend prophylactic ipsilateral neck irradiation in patients with T1-T4 squamous cell carcinoma of the maxillary sinus.

An adjuvant afterloading brachytherapy device for use after orbital exenteration in patients with orbital malignancies

In cases of malignant diseases situated within the orbit and threaten to extend beyond it, removal of the orbit and periorbital contents may be indicated, followed by adjuvant chemotherapy or irradiation. An effective radiotherapy device for treatment of residual or suspicious cancer in the enucleated orbit consists of an external-beam radiation source (60Co) and an intraoperatively fitted mould as a guide for the flexible afterloading tubes using a 192Ir source. Considering the physical dose distribution and the local situation, this therapy permits a high dose with homogeneous dose distribution to the target area of the orbit but also allows significant dose reduction to adjunctive critical structures. Four patients with different orbital malignancies were treated by means of a combination of percutaneous radiotherapy with afterloading brachytherapy following orbital exenteration. The individual mould of the orbital cavity is modeled at the end of the operation. The technique of radiotherapy, dose distribution, and follow-up of the disease are demonstrated. Orbital malignancies with an extremely poor prognosis may profit from the application of this combined radiotherapy to avoid supraradical surgical intervention.

[Studies on serum protein fractions of patients with maxillary sinus cancer undergoing a combination of radiotherapy and chemotherapy: II. Relationship between changes in serum protein fractions and prognosis]

We examined the correlations between changes in serum protein fractions and the prognosis of the patients. The levels of 21 protein components of the sera of 36 patients with maxillary sinus cancer were determined by a single radial immunodiffusion method before and after radiation therapy. The patients with maxillary sinus cancer were treated with combined intra-arterial infusion of bleomycin and external irradiation of 60 Co gamma-rays, and were concurrently treated with 5-fluorouracil at 200 mg/day p.o. The levels of the same protein components were also measured in 34 normal adult as a control. All patients were observed 5 years and 12 years after radiation therapy. In patients who had survived at least 5 years after radiation therapy, the Alb, Tf, Hx, IgG and IgM levels measured before radiation therapy were elevated significantly compared with those who had died within 5 years. In those who had survived at least 5 years, the Alb, Tf, Hx, IgG, IgM, IgA and I alpha I levels measured after radiation therapy were elevated significantly compared with those who had died within 5 years, and AT III was reduced. In cases of maxillary sinus cancer following a period of 5 to 12 years after radiation therapy, multiple regression analysis was used to determine whether increased concentrations of serum protein fractions were associated with good prognosis for the original disease, alpha 2HS. IgM, HX, alpha 1AT and alpha 1X before radiation therapy were positively correlated with survival, whereas AT III, Pmg, Cp, IgA, and alpha 1AG showed negative correlations. After radiation therapy, Pmg, Hx, Cp, Cl inh and Fib were found to be positive factors of survival rate, whereas alpha 2M, alpha 2Pl, I alpha 1, IgA, alpha 1AG and C3 were negative factors.

Simulation accuracy in radiotherapy for maxillary sinus tumors

PURPOSE

To evaluate the accuracy and clinical importance of beam positioning during simulation of radiation treatment for tumors in the maxillary sinus.

METHODS AND MATERIALS

Five patients were prepared as if they were to be treated for a maxillary sinus tumor. A three-beam computed tomography (CT) scan-based computer plan was made for each patient. The location of the central beam axis of each beam was measured, relative to bony anatomical structures. A simulation was performed using the bony references to position the radiation beams during simulation. After this, the simulation procedure was repeated by the use of a noninvasive external localization frame with a known accuracy and reproducibility within 2 mm margins.

RESULTS

When defining the clinical target volume as the known tumor with a 1 cm margin, three out of five patients would suffer a partial geographical miss throughout the entire radiation treatment due to erroneous beam positioning at the simulation stage when using bony structures as a guide for beam positioning. The influence of these errors is analyzed as normal tissue complication and tumor control probabilities.

CONCLUSION

When defining a planning target volume, one should consider a margin to correct for possible simulation errors. We advise the use of objective, external (and thus nonanatomical) landmarks as a reference during simulation to reduce this extra margin to a minimum. In case of simulation, using bony structures as a reference, an additional margin should be entered, depending on the simulation accuracy that can be obtained.

Fabrication and use of an intracavitary radiotherapeutic applicator for the posterior sinus wall: a case report

The essential features of and the prosthodontic procedures necessary for fabricating a radiation applicator from dental acrylic resin for use in a clinical case of recurrent squamous cell carcinoma treated by intracavitary radiotherapy are described. A method for reducing radiation dose to the optic chiasm using Cerrobend alloy is presented.

A CT-based simulation for head and neck tumors in centers without CT-simulator and 3D-planning system

We present a special CT-based simulation technique to optimize the radiotherapy treatments in head and neck tumors. On an immobilization device, some CT hyperdense markers are placed. Real-size CT slices are performed every 5 mm with the patient in the treatment position with the immobilization system. This study permits a more accurate knowledge of the gross tumoral volume and an optimization of the planning treatment.

[Primary extramedullary plasmacytomas of the upper respiratory tract. A study of four cases with infrequent localization]

OBJECTIVE

Assessment of the incidence, diagnosis and treatment of three patients afflicted of extramedullary plasmacytoma located in the Waldeyer's ring, and one case afflicted of maxillary sinus disease.

PATIENTS

The localization of the masses was the palatine amygdala in two cases, and the rhinopharynx and maxillary sinus in the remaining two patients. Major symptoms were dysphagia respiratory failure with closed rhinolalia, and headache. Diagnosis was made by histological study of biopsied tissue. In every case, general illness or other site of localization were ruled out.

RESULTS

In our casuistic, the incidence of primary extramedullary plasmacytoma in Waldeyer's ring is 1.2%. The patient's age were 45, 50, 62, and 73 years respectively, and the male/female ratio was 1. In those cases located in the tonsils, a bilateral tonsillectomy was performed. In the case located at the maxillary sinus, a sinus trepanation was performed according the Caldwell-Luc's technique, followed by local radiotherapy at doses of 40 Gy. In the case located at the rhinopharynx, radiotherapy was the only choice. These three different therapeutical procedures led to the disappearance of the disease, and, after a 12 to 53 month-period, patients remain asymptomatic. A patient died due to other causes not related to the illness.

Management of the orbital contents in radical surgery for squamous cell carcinoma of the maxillary sinus

We reviewed retrospectively 139 patients with squamous cell carcinoma of the maxillary sinus who were treated with planned combinations of preoperative radiotherapy and maxillectomy between 1958 and 1987. The 5-year survival rate of these patients was 30%. In 111 patients who had tumor invasion of the orbital floor 88 underwent radical surgery with orbital exenteration and 23 had their orbital contents preserved. If orbital exenteration was performed, the 5-year survival rate was 27.3% (24/88) and the rate of recurrence within the orbit was 12.5%. In patients with preservation of the orbital contents, the corresponding rates were 34.8% (8/23) and 8.6% respectively (P = 0.65). Histological study after maxillectomy with orbital exenteration showed that in 95% of 65 specimens (62/65) invasion of the orbit was limited. These tumors could be completely resected by total maxillectomy with limited removal of the periorbital tissues after preoperative radiotherapy. We conclude that after preoperative radiation, the eyeball could be safely preserved in most selected patients with maxillary sinus carcinoma invading the orbital floor.

Application of 198Au grains for carcinoma of oral cavity

PURPOSE

The purpose of this study is to analyze the results of the treatment using gold grain implants over the past 9 years and to evaluate the usefulness of this treatment method.

PATIENTS AND METHODS

From January 1985 through April 1993, a total of 45 patients with squamous cell carcinomas of the oral cavity and the oropharynx were treated with 198Au grain (gold grain) at the Department of Radiology, Osaka University Medical School. The initial activity of the grains supplied weekly by the Japan Radioisotope Association was usually 5 mCi (185 MBq), and single implants were usual. In case of combined external irradiation, telecobalt gamma-rays or 4 MV X-rays were used for treatment before implant.

RESULTS

The local control rate for patients with T1 stages was 80% (20/25) and with T2 stages, 59% (10/17). The local control rate was 71% (10/14) for gold grain alone and 72% (13/18) for external irradiation combined with gold grain implants (combined therapy). In combined therapy, the median of the interval between external irradiation and gold grain implants was 21 days. The treatment interval for patients with recurrent diseases was 22 days, 22, 27, 39 and 46, respectively. The progression rate showed a tendency to increase in the patients with longer interval (more than 21 days), and with partial regression after external irradiation (p = 0.0085).

CONCLUSION

Our findings show that the time interval between external irradiation and gold grain implantation is an important factor in combined therapy. Therefore, we emphasize that the time interval should be shorter than 3 weeks.

Squamous cell carcinoma of the maxillary sinus

Eighty-five patients with squamous cell cancer of the maxillary sinus received all of their treatment at The University of Texas M.D. Anderson Cancer Center between the years 1971 and 1986. Their records were evaluated according to stage, disease at presentation, symptoms and signs at presentation, treatment, and outcome. There were no differences in locoregional control or survival between groups treated with surgery alone vs surgery plus radiotherapy. Careful analysis of the data indicates that there was almost certainly some selection bias for the patients undergoing combination therapy, as most of this group had historically adverse prognostic factors identified. Those patients who underwent radiotherapy alone or chemotherapy presented with either metastatic or locally advanced disease and were treated with palliative intent; therefore, comparison between this group and standard therapy groups was impossible in this retrospective review. Although it is tempting to speculate that combination therapy improved locoregional control and survival in patients with more advanced disease, none of the data presented in this review reach statistical significance. Furthermore, there is no difference in survival in this population compared with a study at this institution 20 years ago. Squamous cell cancer of the maxillary sinus continues to be a challenging neoplasm. Radiotherapy may improve locoregional control and survival in a group of patients with more advanced disease and may have its greatest utility in earlier-stage disease. A multi-institutional prospective trial is needed to find ways to improve outcome in this patient population.

Orbital preservation in maxillectomy

Twenty-eight previously untreated patients with squamous carcinoma of the maxillary sinus underwent maxillectomy with preservation of the orbital contents at the M. D. Anderson Cancer Center between 1971 and 1986. Eighteen patients had part or all of the orbital floor resected; nine patients were treated with radiotherapy, and nine had surgery only. Only 3 of 18 patients in this group (17%) retained significant function in the ipsilateral eye. Furthermore, local recurrence in this group was common (44%), regardless of whether postoperative radiotherapy was used. Ten patients retained the bony orbital floor; if the radiation fields did not include the eye, problems were minimal. Strong consideration should be given to orbital exenteration at the time of surgery, when the orbital floor is resected--especially if postoperative radiation fields will include the eye.

The utilization of a multi-layer prosthesis to treat recurrent antral carcinoma: a case report and review of the literature

This paper reviews the use of an intracavitary mold in the radiotherapeutic management of recurrent sub-orbital carcinoma of the maxillary sinus. An overview of the clinical features of antral carcinomas and the concept of brachytherapy in the management of these lesions is presented. Brachytherapy is usually reserved for relatively accessible lesions. Post-surgical and radiation-induced trismus can be a complicating factor, as in the case presented, where the inter-incisal distance was less than three millimeters. To circumvent the problem, a multi-layer antral plug was utilized as a carrier for the radioactive sources, and its construction is described.

Visual recovery from radiation-induced optic neuropathy. The role of hyperbaric oxygen therapy

Optic neuropathy resulting in permanent visual loss is an infrequent delayed complication of radiation therapy. Hyperbaric oxygen therapy (HBO) has been used to treat such a complication, but its efficacy is controversial. We report a patient who presented with radiation-induced optic neuropathy 17 months after irradiation for a left maxillary antrum melanoma. HBO fully reversed visual loss in the more recently involved eye, and slightly improved vision in the earlier affected eye.

Atypical aesthesioneuroblastoma: CT and MRI findings

Aesthesioneuroblastoma is an uncommon tumour of the superior nasal cavity, originating from the olfactory mucosa. Usually no specific radiological features indicate the diagnosis; normally these tumours are seen on CT as homogeneous, enhancing, soft tissue masses causing bone remodelling. Typical but quite nonspecific MRI findings include high signal on T2-weighted images and strong enhancement after gadolinium. The extent of tumour in the paranasal sinuses and anterior cranial fossa is best assessed with MRI after intravenous gadolinium, and this is considered as the most accurate method for assessing preoperative resectability. We report an aesthesioneuroblastoma in an atypical location, with extensive calcification.

Carcinoma of the maxillary antrum treated by pre-operative radiotherapy or radical radiotherapy alone

The results of pre-operative radical radiotherapy and subsequent maxillary resection are reported in 54 consecutive patients with carcinoma of the maxillary antrum treated at The Royal London Hospital from 1965 to 1989. The actuarial two and five year survivals were 50.3 per cent and 38.5 per cent respectively. Patients with adenocarcinomas fared better when compared with squamous and undifferentiated carcinomas (log rank p = < 0.01). Undifferentiated carcinoma and involved regional lymph nodes were both very poor prognostic factors. In those patients who were either unfit for or refused maxillary resection, radical radiotherapy alone was still an effective treatment, with only a slight disadvantage in terms of local control and survival.

A non-Hodgkin's lymphoma in the buccal mucosa. A case report

Non-Hodgkin's lymphomas are tumors of the immune system that uncommonly evolve as primary lesions of the oral cavity. A case of a primary lymphoma in the right cheek that had invaded the surrounding tissues is presented.