Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative setting--the MSKCC experience

Surgical Outcomes of Endoscopic Versus Open Resection for Primary Sinonasal Malignancy: A Meta-analysis

Background

Endoscopic resection (ER) for uncommon sinonasal malignancies (SNMs) has been reported to confer superior surgical outcomes compared to open resection (OR) based on indirect comparisons of limited evidence.

Objective

The aim of this study was to pool all direct comparative studies in the literature to validate this potential superior association.

Methods

Systematic searches of 7 electronic databases from their inception to April 2019 were conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. There were 1001 articles identified for screening. Outcomes of interest were pooled as risk ratios (RRs) and mean difference (MD) and analyzed using a random-effects model.

Results

There were 10 studies included in this meta-analysis, with 900 SNM patients in total where ER and OR were utilized in 399 (44%) and 501 (56%) cases, respectively. Compared to OR, random-effects (RE) modeling indicated ER resulted in statistically comparable complications (RR = 0.68; P-effect = .12) and recurrence (RR = 0.84; P-effect = .35). ER was associated with significantly shorter length of stay (LOS) compared to OR (MD = −2.9 days; P-effect <.01).

Conclusions

The use of ER to manage SNM was associated with significantly favorable reduction in LOS compared to OR. However, with respect to other surgical outcomes and recurrence, the current literature does not indicate either ER or OR as statistically superior. Therefore, until greater validation of these associations can be proven, expectations that ER for SNMs confers superior surgical outcomes compared to OR should be tempered.

Organ preservation for patients with anterior mucosal squamous cell carcinoma of the nasal cavity: Rhinectomy-free survival in those refusing surgery

BACKGROUND

Standard treatment of squamous cell carcinoma (SCC) of the anterior nasal mucosa is surgical resection with or without postoperative radiation.

METHODS

Retrospective review of patients diagnosed with SCC of the nasal cavity between January 2000 and July 2018 who refused total rhinectomy and who were treated with radiation with or without chemotherapy with curative intent.

RESULTS

Eleven patients were identified, 73% had stage III or stage IV disease. Four patients were treated with intensity-modulated radiotherapy and seven with intensity-modulated proton radiotherapy. Concurrent chemoradiotherapy was used in nine patients (82%). With a median follow-up of 15 months (3-124 months), two patients experienced recurrence and one developed distant metastasis and died from disease. The 2-year rhinectomy-free survival rate was 88%. Two-year overall survival and recurrence-free survival were 100% and 75%, respectively.

CONCLUSION

A radiation-based approach for SCC of the nasal cavity mucosa is a valid option for selected patients who refuse up-front surgery.

＜Editors' Choice＞ Maxillary sinus carcinoma outcomes over 60 years: experience at a single institution

Advances in the diagnosis and treatment of patients with maxillary sinus carcinoma have improved patient prognosis. This study investigated changes in demographic and clinical characteristics, treatment methods, and outcomes of patients with maxillary sinus carcinomas during three different 10-year periods spanning 60 years at our university hospital. Of the 233 patients with maxillary sinus carcinomas managed at Nagoya University Hospital, 135 were treated between 1951 and 1960 (first period), 35 between 1981 and 1990 (second period), and 63 between 2003 and 2012 (third period). Patient age, sex, TN classifications, treatment methods, and survival rates were compared among patients treated during these time periods. Of the 135, 35, and 63 patients with maxillary sinus carcinomas treated during these time periods, 86 (63.7%), 21 (51.4%), and 48 (76.2%), respectively, were men; 14 (10.4%), six (17.1%), and 14 (22.2%), respectively, were aged ≥70 years; and 135 (100%), 28 (80.0%), and 43 (68.3%), respectively, were treated surgically. The 5-year overall survival rates in patients treated during the first, second, and third periods were 29.7%, 44.3%, and 57.5%, respectively. These findings indicated that advances in the diagnosis and treatment of patients with maxillary sinus carcinoma, including computed tomography and craniofacial resection, have contributed to improvements in patient survival rates.

Survival Outcomes for Induction vs Adjuvant Chemotherapy in Squamous Cell Carcinoma of the Maxillary Sinus

OBJECTIVE

In advanced maxillary sinus cancers treated with surgery and radiotherapy, poor local control rates and the potential for organ preservation have prompted interest in the use of systemic therapy. Our objective was to present outcomes for induction compared to adjuvant chemotherapy in the maxillary sinus.

STUDY DESIGN

Secondary database analysis.

SETTING

National Cancer Database (NCDB).

SUBJECTS AND METHODS

In total, 218 cases of squamous cell maxillary sinus cancer treated with surgery, radiation, and chemotherapy between 2004 and 2012 were identified from the NCDB and stratified into induction chemotherapy and adjuvant chemotherapy cohorts. Univariate Kaplan-Meier analyses were compared by log-rank test, and multivariate Cox regression was performed to evaluate overall survival when adjusting for other prognostic factors. Propensity score matching was also used for further comparison.

RESULTS

Twenty-three patients received induction chemotherapy (10.6%) and 195 adjuvant chemotherapy (89.4%). The log-rank test comparing induction to adjuvant chemotherapy was not significant ( P = .076). In multivariate Cox regression when adjusting for age, sex, race, comorbidity, grade, insurance, and T/N stage, there was a significant mortality hazard ratio of 2.305 for adjuvant relative to induction chemotherapy (confidence interval, 1.076-4.937; P = .032).

CONCLUSION

Induction chemotherapy was associated with improved overall survival in comparison to adjuvant chemotherapy in a relatively small cohort of patients (in whom treatment choice cannot be characterized), suggesting that this question warrants further investigation in a controlled clinical trial before any recommendations are made.

A retrospective dosimetry study of intensity-modulated radiotherapy for nasopharyngeal carcinoma: radiation-induced brainstem injury and dose-volume analysis

Background

Radiation therapy is the standard radical treatment for nasopharyngeal carcinoma (NPC) but also causes transient as well as long-term complications. Patients who develop severe radiation-induced brainstem injuries have a poor prognosis due to the lack of effective medical therapies. However, the relationship between brainstem injury and radiation volume dose is unknown. In this study, we found that radiation-induced brainstem injury was significantly associated with brainstem dose per unit volume.

Methods

A retrospective analysis was performed on a consecutive cohort of 327 patients with NPC receiving IMRT from May 2005 to December 2014. Dose-volume data and long-term outcome were analyzed.

Results

The median follow-up duration was 56 months (range, 3–141 months), and six with T₄ and two with T₃ patients had radiation-induced brainstem injuries. The 3-year and 5-year incidences were 2.2% and 2.8%, respectively. The latency period of brainstem injury ranged from 9 to 58 months, with a median period of 21 months. The Cox regression analysis showed that brainstem radiation toxicity was associated with the T₄ stage, D_2% of gross tumor volume of nasopharyngeal primary lesions and their direct extensions (GTVnx), D_max (the maximum point dose), D_1%, D_0.1cc (the top dose delivered to a 0.1-ml volume), and D_1cc (the top dose delivered to a 1-ml volume) of the brainstem (p < 0.05). Receiver operating characteristic (ROC) curves showed that GTVnx D_2% and the D_max, D_1%, D_0.1cc, and D_1cc of the brainstem were significant predictors of brainstem injury. The area under the ROC curve for these five parameters was 0.724, 0.813, 0.818, 0.818, and 0.798, respectively (p < 0.001), and the cutoff points 77.26 Gy, 67.85 Gy, 60.13 Gy, 60.75 Gy, and 54.58 Gy, respectively, were deemed as the radiation dose limit.

Conclusions

Radiotherapy-induced brainstem injury was uncommon in patients with NPC who received definitive IMRT. Multiple dose-volume data may be the dose tolerance of radiation-induced brainstem injury.

Intensity-modulated radiotherapy for paranasal sinuses and base of skull tumors

Paranasal sinus and skull base tumors are rare aggressive head and neck cancers, and typically present in the locally advanced stages. As a result, achieving wide surgical resection with clear margins is a challenge for these tumors, and radiotherapy is thus usually indicated as an adjuvant modality following surgery to optimize local control. Given the integral role of radiotherapy in the management of this subgroup of head and neck tumors, the advent of intensity-modulated radiotherapy (IMRT) has led to substantial improvement of clinical outcomes for these patients. This is primarily driven by the improvement in radiation dosimetry with IMRT compared to conventional two dimensional (2D)- and 3D-techniques, in terms of ensuring dose intensity to the tumor target coupled with minimizing dose exposure to critical organs. Consequently, the evident clinical benefits of IMRT have been in reduction of normal tissue toxicities, ranging from critical neurological symptoms to less debilitating but bothersome symptoms of eye infections and radiation-induced skin changes. Another domain where IMRT has potential clinical utility is in the management of a subset of non-resectable T4 paranasal sinus and skull base tumors. For these inoperable lesions, the steep dose-gradient between tumor and normal tissue is even more advantageous, given the crucial need to maintain dose intensity to the tumor. Innovative strategies in this space also include the use of induction chemotherapy for patient selection. In this review, we summarized the data for the aforementioned topics, including specific discussions on the different histologic subtypes of paranasal sinus and skull base tumors.

Radiation dose constraints for organs at risk in neuro-oncology; the European Particle Therapy Network consensus

PURPOSE

For unbiased comparison of different radiation modalities and techniques, consensus on delineation of radiation sensitive organs at risk (OARs) and on their dose constraints is warranted. Following the publication of a digital, online atlas for OAR delineation in neuro-oncology by the same group, we assessed the brain OAR-dose constraints in a follow-up study.

METHODS

We performed a comprehensive search to identify the current papers on OAR dose constraints for normofractionated photon and particle therapy in PubMed, Ovid Medline, Cochrane Library, Embase and Web of Science. Moreover, the included articles' reference lists were cross-checked for potential studies that met the inclusion criteria. Consensus was reached among 20 radiation oncology experts in the field of neuro-oncology.

RESULTS

For the OARs published in the neuro-oncology literature, we summarized the available literature and recommended dose constraints associated with certain levels of normal tissue complication probability (NTCP) according to the recent ICRU recommendations. For those OARs with lacking or insufficient NTCP data, a proposal for effective and efficient data collection is given.

CONCLUSION

The use of the European Particle Therapy Network-consensus OAR dose constraints summarized in this article is recommended for the model-based approach comparing photon and proton beam irradiation as well as for prospective clinical trials including novel radiation techniques and/or modalities.

Proton Therapy for Head and Neck Cancer

OPINION STATEMENT

The application of proton beam radiation therapy in the treatment of head and neck cancer has grown tremendously in the past few years. Globally, widespread interest in proton beam therapy has led to multiple research efforts regarding its therapeutic value and cost-effectiveness. The current standard of care using modern photon radiation technology has demonstrated excellent treatment outcomes, yet there are some situations where disease control remains suboptimal with the potential for detrimental acute and chronic toxicities. Due to the advantageous physical properties of the proton beam, proton beam therapy may be superior to photon therapy in some patient subsets for both disease control and patient quality of life. As enthusiasm and excitement for proton beam therapy continue to increase, clinical research and widespread adoption will elucidate the true value of proton beam therapy and give a greater understanding of the full risks and benefits of proton therapy in head and neck cancer.

Outcomes of Patients With Sinonasal Squamous Cell Carcinoma Treated With Particle Therapy Using Protons or Carbon Ions

PURPOSE

This retrospective study aimed to determine the clinical outcomes following particle monotherapy (ie, proton therapy [PT] or carbon ion therapy [CIT]) in patients with sinonasal squamous cell carcinoma at a single institution.

METHODS AND MATERIALS

Between August 2001 and March 2012, 59 patients were treated with definitive PT or CIT; none underwent chemotherapy or surgery. Of the patients, 22 (37%) had unresectable disease. PT was used in 38 patients (64%); CIT, 21 patients (36%). Almost half of the patients (n = 29, 47%) received 65.0 Gy (relative biological effectiveness) in 26 fractions.

RESULTS

The median follow-up period was 30 months (range, 8-127 months) for all patients and 65 months (range, 9-127 months) for the survivors. The 3- and 5-year overall survival rates were 56.2% and 41.6%, respectively; progression-free survival rates, 42.9% and 34.7%, respectively; and local control rates, 54.0% and 50.4%, respectively. Late toxicities of grade ≥3 occurred in 13 patients (22%).

CONCLUSIONS

To our knowledge, this is the largest retrospective study of sinonasal squamous cell carcinoma treated with particle therapy alone. The efficacy of PT and CIT indicated that particle therapy can serve an important role in treating this disease.

Results of preoperative chemoradiotherapy for patients with advanced cancer of the nasal cavity and paranasal sinuses

OBJECTIVES

Curative treatment of nasal cavity and paranasal sinus cancer is challenging due to the proximity to critical anatomical structures. The purpose of this study was to analyze the impact of trimodality therapy with preoperative chemotherapy and reduced-dose radiotherapy followed by organ-preserving surgery for treating patients with nasal cavity and paranasal sinus cancer.

METHODS

This retrospective study included all 156 patients diagnosed with sinonasal cancer in western Sweden between 1986 and 2009. We determined the treatment selection pattern and treatment outcomes for 79 patients treated with preoperative chemoradiotherapy.

RESULTS

Squamous cell carcinoma was the most common histology. The five-year overall survival was 54%, and 85% of these patients had T3 or T4 tumors. The five-year cumulative incidence rate of local recurrence was 32%. The five-year overall survival in patients with squamous cell carcinoma and adenocarcinoma was 45% and 76%, respectively. The median preoperative radiation dose was 48 Gy. Orbital exenteration was performed in 7% of patients.

CONCLUSIONS

Preoperative chemoradiotherapy may be beneficial for patients with advanced sinonasal cancer when primary radical surgery is challenging. Survival outcomes were comparable to outcomes reported in the literature despite conservative surgery and relatively low radiation doses in patients with locally advanced tumors.

Outcome by treatment modality in sinonasal undifferentiated carcinoma (SNUC): A case-series, systematic review and meta-analysis

OBJECTIVE

Sinonasal undifferentiated carcinoma (SNUC) is an aggressive malignancy first described by Frierson et al. in 1986. As the tumor is very rare, current treatment recommendations are based on institutional case reports. We thus felt the need to perform a comprehensive systematic review and meta-analysis to investigate how treatment modalities are associated with survival.

DESIGN

Case-series, systematic review and meta-analysis METHODS: We searched the OvidMedline, OvidEmbase, Web of Science, Biosis, Scopus and the Cochrane Library database libraries. We extracted aggregate and individual patient data for statistical analysis. To study the association between treatment modalities and survival, we used random-effects meta-regression for the aggregate- and cox mixed-effects models.

RESULTS

379 citations were found; 29 case series could be included in the final analysis, including a total number of 390 single patients (34.6% female). Median age at diagnosis was 52 years. 80.9% of patients presented with a T4 tumor and 16.0% with nodal metastasis at diagnosis. In individual patient data (IPD) meta-analysis, single modality (surgery alone or radiation alone) treatment was associated with reduced survival compared to double modality (surgery & radiation or chemoradiation) treatment (adjusted Hazard Ratio [aHR] 2.97, 95% ConfidenceInterval [1.41-6.27]) and compared to triple modality (surgery & radiation & chemotherapy) treatment (aHR 2.80 95%-CI 1.29-6.05 for triple vs. single modality). Triple modality treatment was not superior to double modality treatment. (aHR 1.06, 95%-CI 0.59-1.92).

CONCLUSION

Double and triple modality treatment are associated with improved survival over single modality but there is no evidence that triple modality is superior to double modality treatment.

The Impact of Histologic Phenotype in the Treatment of Sinonasal Cancer

The management of sinonasal cancer is a challenge due to its low occurrence and anatomical and significant diversity of histological types. The therapeutic modality used should be tailored individually according to the histology, tumour stage, molecular profile and previous treatments. The clinical management of sinonasal cancer has improved greatly owing to developments in endoscopic surgery and precision radiotherapy. Complete surgical resection is the mainstay of sinonasal malignancies' management but multimodality therapy is associated with improved outcomes in certain histologies. The recognition of various histological types with biological behaviours more suitable for non-surgical modalities has allowed treatment protocols to become more tailored to the disease. In this review we aim to describe and to summarise the current data guiding the management of sinonasal cancer with emphasis on phenotypic variation.

The Role of Radiation Therapy in the Management of Sinonasal and Ventral Skull Base Malignancies

Sinonasal and ventral skull base malignancies are rare tumors that arise in a complex anatomic location juxtaposed with critically important normal tissues. The standard treatment paradigm for most histologies has been surgery followed by postoperative radiation therapy. Because of their propensity to present at an advanced stage and the presence of nearby critical structures, patients are at risk for severe radiation-induced long-term toxicity. Recent advances in radiotherapy technique have improved the therapeutic ratio between tumor control and normal tissue toxicity. This article reviews issues pertinent to the use of radiotherapy in the management of these tumors.

A systematic review of sinonasal oncocytomas and oncocytic carcinomas: Diagnosis, management, and technical considerations

BACKGROUND

Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with the propensity for local invasion. This report and systematic review details a case of a nasal oncocytoma involving the lacrimal sac and provides an update of the current literature.

METHODS

A systematic literature review was performed using PubMed and Ovid databases. The data obtained from published articles with sinonasal oncocytoma/oncocytic carcinoma as the primary diagnosis included patient demographics, presentation, radiographic and histologic findings, management, and recurrence rates.

RESULTS

Twenty cases were identified. The most common symptoms were epistaxis (n = 11) and nasal obstruction (n = 11). Involvement of the nasal cavity was most common (n = 17), followed by the paranasal sinuses (n = 13) and nasolacrimal apparatus (n = 4). Recurrence occurred in 55% of cases. Recurrence was associated with invasion or infiltration found on histology or the presence of both invasion/infiltration and mitotic figures/pleomorphism (p < 0.05), with no significant relationship between recurrence and age at diagnosis (p = 0.42), sex (p = 0.65), and location of tumor (p = 0.14). The authors present the case of a 73-year-old woman with a 5-month history of worsening epistaxis and biopsy-proven oncocytoma. Complete surgical resection of the tumor using combined endonasal endoscopic and anterior orbitotomy approach is described.

CONCLUSION

Oncocytomas and oncocytic carcinomas are rare tumors of the sinonasal cavity with a high rate of local recurrence and orbital involvement. Surgical resection is the treatment of choice and complete resection can be achieved with an endoscopic endonasal approach.

Preoperative surgical simulation and validation of the line of resection in anterolateral craniofacial resection of advanced sinonasal sinus carcinoma

BACKGROUND

The purpose of this study was to assess the usefulness and accuracy of preoperative 3D virtual simulation of anterolateral craniofacial resection in cases of advanced sinonasal sinus carcinoma.

METHODS

Seven patients with advanced (T4 classification) sinonasal sinus carcinoma who underwent anterolateral craniofacial resection in our hospital between 2011 and 2013 were included in this study. Postsimulation CT images were fused with postoperative CT images and differences between the planned and actual osteotomy were measured in 3 regions of the skull base.

RESULTS

The differences ranged from 0 mm to 5.8 mm (average, 3.1 mm) at the inferior wall of the cavernous sinus, from 0.8 mm to 8.3 mm (average, 3.5 mm) at the inferior wall of the sphenoid sinus, and from 0 mm to 13.6 mm (average, 2.3 mm) in the palatine bone.

CONCLUSION

Preoperative 3D virtual surgical simulation and postoperative feedback can contribute to training for surgeons. © 2016 Wiley Periodicals, Inc. Head Neck 39: 512-519, 2017.

Outcomes of nonsurgical management of locally advanced carcinomas of the sinonasal cavity

OBJECTIVE

To determine the outcome of definitive concurrent chemoradiation with platinum for locally advanced sinonasal carcinomas.

STUDY DESIGN

Retrospective cohort.

METHODS

Twenty-three nonsurgically and definitively treated patients diagnosed between July 1998 and February 2009 were analyzed. Patients with adenoid cystic carcinoma or adenocarcinoma were treated with photons and neutrons; the other histologies received photons alone. The vast majority received chemotherapy. Descriptive statistics were utilized, and Kaplan-Meier estimates were computed.

RESULTS

Female (57%) and Caucasian (74%) preponderance were observed. Eighty-seven percent were unresectable; the maxillary and nasoethmoid sites were equally prevalent. Intensity-modulated radiation therapy (IMRT) and photons alone were utilized in 74% and 70%, respectively. Platinum agents were given in 95% of chemotherapy patients. Complete response was observed in 64% of patients. Median progression-free survival (PFS) and overall survival (OS) were 28.8 and 65.3 months, respectively. Three-year PFS and OS rates were 44% and 72%, respectively; 5-year PFS and OS rates were 30% and 60%, respectively. Intensity-modulated radiation therapy and a maxillary site of origin showed a trend toward superior PFS; higher-dose regimens were associated with somewhat shorter PFS. Relapse was observed in 59% of patients, predominantly local. There were few unanticipated adverse effects, and no grade IV/V events were reported.

CONCLUSION

Advanced sinonasal carcinomas are chemoradiosensitive tumors, albeit with a high propensity for local relapse. There is a definite indication for IMRT and a potential curative role of platinum-based chemoradiation regimens.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:855-861, 2017.

[Indications and results for protontherapy in cancer treatments]

Purpose was to summarize results for proton therapy in cancer treatment. A systematic review has been done by selecting studies on the website www.pubmed.com (Medline) and using the following keywords: proton therapy, radiation therapy, cancer, chordoma, chondrosarcoma, uveal melanoma, retinoblastoma, meningioma, glioma, neurinoma, pituitary adenoma, medulloblastoma, ependymoma, craniopharyngioma and nasal cavity. There are several retrospective studies reporting results for proton therapy in cancer treatments in the following indications: ocular tumors, nasal tumors, skull-based tumors, pediatric tumors. There is no prospective study except one phase II trial in medulloblastoma. The use of proton therapy for these indications is due to dosimetric advantages offering better tumor coverage and organ at risk sparing in comparison with photon therapy. Clinical results are historically at least as efficient as photon therapy with a better toxicity profile in pediatric tumors (cognitive and endocrine functions, radiation-induced cancer) and a better tumoral control in tumors of the nasal cavity. Clinical advantages of proton therapy counterbalance its cost especially in pediatric tumors. Proton therapy could be used in other types of cancer. Proton therapy showed good outcome in ocular, nasal tumors, pediatric, skull-based and paraspinal tumors. Because of some dosimetric advantages, proton therapy could be proposed for other indications in cancer treatments.

Organ preservation with neoadjuvant chemoradiation in patients with orbit invasive sinonasal cancer otherwise requiring exenteration

Purpose

We sought to determine if organ preservation (OP) with neoadjuvant chemoradiation (CRT) was feasible in patients with sinonasal cancer determined to require exenteration.

Materials and Methods

Twenty patients were determined to require exenteration for definitive treatment from 2005 to 2014. Fourteen patients underwent OP and 6 patients received exenteration with adjuvant CRT. Exenteration free survival (EFS), locoregional control (LRC), progression-free survival (PFS), and overall survival (OS) were estimated.

Results

Five patients (36%) receiving OP had complete disease response at time of surgery. With a median follow-up of 18.8 months, EFS was 62% at 2 years for patients undergoing OP. At 2 years, there were no significant differences in LRC, PFS or OS (all all p > 0.050) between the groups. Less grade 3 or greater toxicity was seen in patients undergoing OP (p = 0.003). Visual function was preserved in all patients undergoing OP.

Conclusion

For patients with sinonasal cancer, OP may avoid exenteration, offering similar disease control and improved toxicity.

Risk of lymph node metastasis and recommendations for elective nodal treatment in squamous cell carcinoma of the nasal cavity and maxillary sinus: a SEER analysis

BACKGROUND

Risk of nodal involvement in patients with squamous cell carcinomas (SCC) of the nasal cavity and maxillary sinus has not been well defined, especially by risk factors beyond local T-stage. Additional criteria defining patients at highest risk, as well as specific nodal levels at highest risk, has been limited in small retrospective series. We describe a population-based assessment of specific nodal involvement in this group.

MATERIAL AND METHODS

The Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2010 identified 1283 eligible patients with SCC of the nasal cavity or maxillary sinus. Neck involvement and individual nodal level involvement at presentation were assessed, and comparison made with a contemporaneous cohort of patients with a borderline clinically significant risk of nodal involvement and recurrence.

RESULTS

Among 1283 patients, 182 (14.2%) had nodal involvement at presentation (4-27% by site and local extension). T-stage alone was associated with higher rates of nodal involvement in maxillary sinus SCC, while higher T-stage and size >2 cm were associated with higher rates of nodal involvement in nasal cavity SCC on multivariable analysis. Facial nodes and cervical nodes at levels 1 and 2 have the highest rates of involvement in T4a nasal cavity SCC, whereas nodal levels 1, 2, and/or 3 have the highest rates of involvement in T2 or higher maxillary sinus SCC when compared with a clinical reference standard.

CONCLUSION

In this population-based study, there are high rates of initial nodal involvement when stratified by local extent determined by T-stage in nasal cavity SCC and maxillary sinus SCC, and independently by size in nasal cavity SCC. Involvement of the facial and nodal levels 1-3 varies depending on site and local extent of tumor involvement. These observations may help guide treatment decision making in the inclusion of and extent of elective nodal treatment fields.

Sinonasal squamous cell carcinoma without clinical lymph node involvement : Which neck management is best?

OBJECTIVES

The purpose of this work was to report outcomes of patients with nonmetastatic sinonasal squamous cell carcinoma (SNSCC) and to discuss the impact of elective neck irradiation (ENI) and selective neck dissection (SND) in clinically negative lymph node (N0) patients.

METHODS

Data from 104 nonmetastatic SNSCC patients treated with curative intent were retrospectively analysed. Uni- and multivariate analyses were used to assess prognostic factors of overall survival (OS) and locoregional control (LRC).

RESULTS

Median follow-up was 4.5 years. Eighty-five percent of tumours were stage III-IV. Treatments included induction chemotherapy (52.9 %), surgery (72 %) and radiotherapy (RT; 87 %). The 5‑year OS, progression-free survival, and LRC rates were 48, 44 and 57 %, respectively. Absence of surgery predicted a decrease of OS (hazard ratio [HR] 2.6; 95 % confidence interval [CI] 1.4-4.7), and LRC (HR 3.5; 95 % CI 1.8-6.8). Regional relapse was observed in 13/104 (13 %) patients and most common sites were level II (n = 12; 70.6 %), level III (n = 5; 29.4 %) and level Ib (n = 4; 23.5 %). Management of the neck in N0 patients (n = 87) included 11 % SND alone, 32 % ENI alone, 20 % SND + ENI and 37 % no neck treatment. In this population, a better LRC was found according to the management of the neck in favour of SND (94 % vs. 47 %; p = 0.002) but not ENI.

CONCLUSION

SND may detect occult cervical positive nodes, allowing selective postoperative RT. ENI (ipsilateral level II, ±Ib and III or bilateral) needs to be proposed in selected patients, especially when SND has not been performed.

Intestinal-type sinonasal adenocarcinomas: The road to molecular diagnosis and personalized treatment

BACKGROUND

Sinonasal intestinal-type adenocarcinomas (ITACs) are epithelial tumors of the nasal cavity and the paranasal sinuses, often related to professional exposure to organic dust, mainly wood or leather. It is a rare cancer. If resectable, surgery is the treatment of choice. Postoperative radiotherapy is often indicated to increase local control. Systemic treatment (chemotherapy, targeted agents, or immunotherapy) of irresectable ITACs and/or metastasized disease is less standardized.

METHODS

Articles on ITAC histopathology, molecular profile, and current treatment options of this specific tumor were identified and reviewed, using the electronic databases Pubmed, Medline, Cochrane, and Web of Science.

RESULTS

This article reviews what is currently known on the histopathology, tumorigenesis, molecular characteristics, and standardized treatment options of ITAC.

CONCLUSION

More translational research is needed to identify druggable targets that may lead to a personalized treatment plan in order to improve long-term outcome in patients with locally advanced and/or metastasized ITAC. © 2016 Wiley Periodicals, Inc. Head Neck 38: First-1570, 2016.

Long-Term Outcomes After Proton Beam Therapy for Sinonasal Squamous Cell Carcinoma

PURPOSE

Squamous cell carcinoma (SCC) is the most common sinonasal cancer and is associated with one of the poor outcomes. Proton therapy allows excellent target coverage with maximal sparing of adjacent normal tissues. We evaluated the long-term outcomes in patients with sinonasal SCC treated with proton therapy.

METHODS AND MATERIALS

Between 1991 and 2008, 54 patients with Stage III and IV SCC of the nasal cavity and paranasal sinus received proton beam therapy at our institution to a median dose of 72.8 Gy(RBE). Sixty-nine percent underwent prior surgical resection, and 74% received elective nodal radiation. Locoregional control and survival probabilities were estimated with the Kaplan-Meier method. Multivariate analyses were performed using the Cox proportional-hazards model. Treatment toxicity was scored using the Common Terminology Criteria for Adverse Events version 4.0.

RESULTS

With a median follow-up time of 82 months in surviving patients, there were 10 local, 7 regional, and 11 distant failures. The 2-year and 5-year actuarial local control rate was 80%. The 2-year and 5-year rates of overall survival were 67% and 47%, respectively. Only smoking status was predictive for worse locoregional control, with current smokers having a 5-year rate of 23% compared with 83% for noncurrent smokers (P=.004). Karnofsky performance status ≤80 was the most significant factor predictive for worse overall survival in multivariate analysis (adjusted hazard ratio 4.5, 95% confidence interval 1.6-12.5, P=.004). There were nine grade 3 and six grade 4 toxicities, and no grade 5 toxicity. Wound adverse events constituted the most common grade 3-4 toxicity.

CONCLUSIONS

Our long-term results show that proton radiation therapy is well tolerated and yields good locoregional control for SCC of the nasal cavity and paranasal sinus. Current smokers and patients with poor performance status had inferior outcomes. Prospective study is necessary to compare IMRT with proton therapy in the treatment of sinonasal malignancy.

Outcomes of Sinonasal Cancer Treated With Proton Therapy

PURPOSE

To report disease outcomes after proton therapy (PT) for sinonasal cancer.

METHODS AND MATERIALS

Eighty-four adult patients without metastases received primary (13%) or adjuvant (87%) PT for sinonasal cancers (excluding melanoma, sarcoma, and lymphoma). Common histologies were olfactory neuroblastoma (23%), squamous cell carcinoma (22%), and adenoid cystic carcinoma (17%). Advanced stage (T3 in 25% and T4 in 69%) and high-grade histology (51%) were common. Surgical procedures included endoscopic resection alone (45%), endoscopic resection with craniotomy (12%), or open resection (30%). Gross residual disease was present in 26% of patients. Most patients received hyperfractionated PT (1.2 Gy [relative biological effectiveness (RBE)] twice daily, 99%) and chemotherapy (75%). The median PT dose was 73.8 Gy (RBE), with 85% of patients receiving more than 70 Gy (RBE). Prognostic factors were analyzed using Kaplan-Meier analysis and proportional hazards regression for multiple regression. Dosimetric parameters were evaluated using logistic regression. Serious, late grade 3 or higher toxicity was reported using the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4. The median follow-up was 2.4 years for all patients and 2.7 years among living patients.

RESULTS

The local control (LC), neck control, freedom from distant metastasis, disease-free survival, cause-specific survival, and overall survival rates were 83%, 94%, 73%, 63%, 70%, and 68%, respectively, at 3 years. Gross total resection and PT resulted in a 90% 3-year LC rate. The 3-year LC rate was 61% for primary radiation therapy and 59% for patients with gross disease. Gross disease was the only significant factor for LC on multivariate analysis, whereas grade and continuous LC were prognostic for overall survival. Six of 12 local recurrences were marginal. Dural dissemination represented 26% of distant recurrences. Late toxicity occurred in 24% of patients (with grade 3 or higher unilateral vision loss in 2%).

CONCLUSIONS

Dose-intensified, hyperfractionated PT with or without concurrent chemotherapy results in excellent LC after gross total resection, and results in patients with gross disease are encouraging. Patients with high-grade histology are at greater risk of death from distant dissemination. Continuous LC is a major determinant of survival justifying aggressive local therapy in nearly all cases.

Intensity modulated radiation therapy (IMRT) for sinonasal tumors: a single center long-term clinical analysis

Background

Radiotherapy has a central role in the treatment of sinonasal malignancies, either as postoperative or as primary therapy. To study the efficacy and safety of intensity modulated radiotherapy (IMRT) for sinonasal tumors a single center retrospective evaluation focusing on survival and therapy related toxicity was performed.

Methods

One hundred twenty two patients with primary (n = 82) or recurrent (n = 40) malignant sinonasal tumors were treated with intensity modulated radiotherapy between 1999 and 2009 at the University Clinic of Heidelberg and the German Cancer Research Center and retrospectively analyzed. Most patients had adenoid cystic carcinomas (n = 47) or squamous cell carcinoma (n = 26). 99 patients received postoperative radiotherapy. The median total dose was 64 Gy in conventional fractionation (1.8–2 Gy). Overall survival (OS), progression free survival (PFS) and local recurrence free survival (LRFS) rates were calculated using the Kaplan-Meier method. The log-rank test and Fishers Exact test were applied for univariate analysis, Cox-regression was used for multivariate analysis.

Results

Median follow up was 36 months. 1-, 3- and 5-year estimated overall survival rates were 90, 70 and 54 % respectively. Median progression free survival and local recurrence free survival was 45 and 63 months respectively. Progression free survival and local recurrence free survival at 1, 3 and 5 years were 76, 57 and 47, and 79, 60 and 51 % respectively. 19 patients (15.5 %) were diagnosed with distant metastases. Univariate analysis revealed significantly improved OS and LRFS for treatment of tumors after primary diagnosis, first series of irradiation and radiation dose ≥60 Gy. Multivariate analysis revealed only treatment in primary situation as an independent prognostic factor for OS and LRFS. Acute CTC grade III mucositis was seen in 5 patients (4.1 %) and CTC grade II dysgeusia in 19 patients (15.6 %). Dysgeusia, dysosmia and ocular toxicity were the most common late adverse events.

Conclusions

Our data support the results of previous studies and indicate that intensity modulated radiation therapy (IMRT) represents an effective and safe treatment approach for patients with sinonasal carcinomas.

Flattening Filter-Free Beams in Intensity-Modulated Radiotherapy and Volumetric Modulated Arc Therapy for Sinonasal Cancer

PURPOSE

To evaluate the dosimetric impacts of flattening filter-free (FFF) beams in intensity-modulated radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) for sinonasal cancer.

METHODS

For fourteen cases, IMRT and VMAT planning was performed using 6-MV photon beams with both conventional flattened and FFF modes. The four types of plans were compared in terms of target dose homogeneity and conformity, organ-at-risk (OAR) sparing, number of monitor units (MUs) per fraction, treatment time and pure beam-on time.

RESULTS

FFF beams led to comparable target dose homogeneity, conformity, increased number of MUs and lower doses to the spinal cord, brainstem and normal tissue, compared with flattened beams in both IMRT and VMAT. FFF beams in IMRT resulted in improvements by up to 5.4% for sparing of the contralateral optic structures, with shortened treatment time by 9.5%. However, FFF beams provided comparable overall OAR sparing and treatment time in VMAT. With FFF mode, VMAT yielded inferior homogeneity and superior conformity compared with IMRT, with comparable overall OAR sparing and significantly shorter treatment time.

CONCLUSIONS

Using FFF beams in IMRT and VMAT is feasible for the treatment of sinonasal cancer. Our results suggest that the delivery mode of FFF beams may play an encouraging role with better sparing of contralateral optic OARs and treatment efficiency in IMRT, but yield comparable results in VMAT.

Prognostic Indicators for Salvage Surgery of Recurrent Sinonasal Malignancy

OBJECTIVE

Identify prognostic factors after salvage surgery for recurrent sinonasal malignancy (SNM).

STUDY DESIGN

Case series with chart review.

SETTING

University of Pittsburgh Medical Center.

SUBJECTS

Forty-two patients who underwent curative surgery for locally recurrent SNM ± adjuvant therapy from June 5, 2000, to December 19, 2012. Patients without follow-up were excluded.

METHODS

Chart review with established prognostic indicators for primary malignancies. Statistical analysis included Kaplan-Meier log-rank test, Fisher's exact test, Student's t test, and Cox regression.

RESULTS

Forty-two patients met inclusion criteria: 38.5% developed a second recurrence, and 21.4% had metastases following treatment. The average disease-free interval (DFI) was 26.9 months (range, 2-90 months). DFI was significantly affected by ethmoid versus nonethmoid site (P = .049), histology (P = .012), carotid artery involvement (P = .008), perineural extension (P = .006), and clival invasion (P = .015). The overall survival rates at 6 months, 12 months, and 5 years following surgery were 83.3%, 69%, and 47.6%, respectively. Survival was affected by histology (P = .014), stratified grade (P = .042), tumor extension into the orbit (P = .019), carotid artery (P = .001), perineural space (P = .028), and clivus (P = .022). Complications occurred in 28.6% of patients and were associated with histology (P = .04). Length of hospital stay related to treatment was affected by histology (P = .009), grade (P = .013), and postoperative complication (P < .001). The median percentage of time hospitalized was 8%, and 43% of patients who died within 12 months spent >10% of their remaining days in the hospital.

CONCLUSION

High-risk histologic subtype (melanoma, sinonasal undifferentiated carcinoma, adenocarcinoma, neuroendocrine cancer, sarcoma, and squamous cell carcinoma), grade, and orbital and skull base involvement negatively affect survival and/or DFI for patients with local recurrence of SNM. Improved stratification of patients can be used to guide decision making for patients with recurrent SNM and to avoid inappropriate surgery.

Outcome of Definitive and Postoperative Radiotherapy in Patients with Sinonasal Squamous Cell Carcinomas

Aims

To evaluate outcomes in patients with sinonasal squamous cell carcinoma (SCC) treated with definitive radiotherapy (DRT) and postoperative radiotherapy (PORT).

Methods

Between 1990 and 2013, 73 patients with sinonasal SCC were treated with radiotherapy. Fifty-two patients (71.2%) were treated with DRT and 21 (28.8%) were treated with PORT. The primary tumor sites were the maxillary sinus in 47 patients (64.4%), the nasal cavity in 18 (24.7%), the ethmoid sinus in 7 (9.6%), and the frontal sinus in 1 (1.4%). Four (5.4%), 11 (15.1%), 24 (32.9%), 17 (23.3%), and 17 (23.3%) patients had T1, T2, T3, T4a, and T4b tumors, respectively. N stage was N0, N1, N2a, N2b, N2c, and N3 in 60 (82.2%), 6 (8.2%), 2 (2.7%), 2 (2.7%), and 3 (4.1%) patients, respectively. The median follow-up period was 23 months (range 3-196).

Results

The 5-year local progression-free survival (LPFS), regional progression-free survival (RPFS), distant metastasis-free survival (DMFS), and overall survival (OS) in the DRT and PORT groups were 50.6%, 82.1%, 91.1%, and 84.4% and 85.7%, 72.1%, 76.1%, and 83.5%, respectively, without any statistically significant differences.

Conclusions

The LPFS, RPFS, DMFS, and OS were not significantly different between the DRT and PORT groups. Given the possibility of functional disability and cosmetic disfigurement with facial surgery, DRT might be considered as a surrogate to surgery followed by PORT for patients with locally advanced sinonasal SCC.

Squamous cell carcinoma of the maxillary sinus: A population-based analysis

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma (SCC) accounts for > 90% of head and neck cancers and 60% to 75% of malignancies of the paranasal sinuses. The most commonly affected paranasal sinus is the maxillary. Epidemiologic, incidence, and survival trends have been studied for maxillary sinus SCC (MSSCC), but far less is known about its metastatic potential.

STUDY DESIGN

Retrospective database analysis.

METHODS

The Surveillance, Epidemiology, and End Results database was used to extract frequency, incidence, and survival data for MSSCC between 2004 and 2012. The resultant cases were stratified according to patient demographics and collaborative stage information, including extent of disease, lymph node involvement, TNM staging, and regional and distant metastasis.

RESULTS

A total of 854 cases of MSSCC were identified. The mean age at diagnosis was 66.6 years, with 87.4% presenting at > 50 years. Most patients (65.1%) were male. Whites accounted for 74.6% of cases. A majority (64.3%) of cases presented with stage IV disease. Overall 5-year disease-specific survival was 23.4%. Neck involvement was seen in 7.6% of T1 tumors, 22.2% of T2 tumors, 18.5% of T3 tumors, and 12.2% of T4 tumors. Distant metastasis was not seen in T1-T3 tumors, but was present in 6.8% of T4 tumors.

CONCLUSIONS

MSSCC is a rare entity with poor overall prognosis. The majority of patients included in this study were white males aged ≥50 years, with most tumors presenting at advanced stages. Nodal involvement and distant metastasis are poor prognostic indicators. T1-T3 tumors did not metastasize to distant sites.

LEVEL OF EVIDENCE

4.

Definitive and adjuvant radiotherapy for sinonasal squamous cell carcinomas: a single institutional experience

BACKGROUND

The aim of this study was to evaluate the disease outcomes of patients treated with definitive and adjuvant radiotherapy for squamous cell carcinomas of the nasal cavity and paranasal sinuses in a single institution.

METHODS

Between 2007-2012 patients were retrospectively identified from electronic databases who had undergone surgery and adjuvant radiotherapy or definitive radiotherapy for sinonasal squamous cell carcinomas with curative intent.

RESULTS

Fourty three patients with sinonasal squamous cell carcinoma were identified (22 nasal cavity, 21 paranasal sinuses). 31/43 (72%) had T3 or T4 disease; nodal stage was N0 in 38, N1 in 4, Na/b in 0 and N2c in 1 patient. Median age was 67 years (range 41-86). 18 (42%) received definitive and 25 (58%) adjuvant radiotherapy. Radiotherapy was delivered using either conventional radiotherapy (n = 39) or intensity modulated radiotherapy (n = 4). Elective neck radiotherapy was delivered to two patients. Chemotherapy was delivered to 6/43 (14%) of patients. Two-year local control, regional control, distant metastases free survival, progression free survival, cause specific survival and overall survival were 81%, 90%, 95%, 71%, 84% and 80% respectively. There was no significant difference in outcome comparing patients who underwent surgery and adjuvant radiotherapy with patients receiving definitive radiotherapy (2 year locoregional disease free survival 75% and 70% respectively, p = 0.98). Pooly differentiated tumours were significantly associated with inferior disease outcomes. Local, regional, combined local and regional, and distant failure occurred in 7 (16%), 3 (7%), 1 (2%) and 2 (5%) of patients; all 3 regional recurrences were in patients with nasal cavity squamous cell carcinomas who had not undergone elective neck treatment.

CONCLUSIONS

Definitive or adjuvant radiotherapy provides an effective treatment for sinonasal malignancies. The main pattern of failure remains local, suggesting the need for investigation of intensified local therapy. Whilst remaining uncommon, the cases of regional failure mean that the merits of elective lymph node treatment should be considered on an individual basis.

Endoscopic sinus surgery for chronic rhinosinusitis in patients previously treated for sinonasal malignancy

OBJECTIVES/HYPOTHESIS

Patients with a history of sinonasal malignancy can develop chronic rhinosinusitis (CRS) as a consequence of their oncologic treatment. Some patients will fail medical management and require endoscopic sinus surgery (ESS). This study reviews the use of ESS in the management of CRS in patients previously treated for sinonasal malignancy.

STUDY DESIGN

Retrospective review.

METHODS

All patients with a history of sinonasal malignancy who developed CRS and underwent ESS were reviewed. Preoperative and postoperative imaging and symptoms were collected. Major complications (bleeding, orbital injury, and cerebrospinal fluid leak) and minor complications (adhesion formation) and postoperative healing were reviewed.

RESULTS

Eighteen patients were identified. All patients presented with symptoms of CRS and sinonasal crusting. Additionally, five patients presented with recurrent facial cellulitis, and six patients had mucoceles. No major complications were encountered. Postoperatively, all patients reported a subjective improvement in their sinonasal symptoms. Comparison of pre- and post-ESS imaging revealed a significant improvement in Lund-Mackay scores after ESS (P < 0.001) from 12.8 (range 5-22) to 7 (range). Despite symptomatic improvement, all patients continued to have nasal crusting. All patients who initially presented with recurrent facial cellulitis had no further episodes after ESS. None of the endoscopically drained mucoceles recurred.

CONCLUSION

For patients previously treated for sinonasal malignancy with refractory CRS, ESS appears to be a safe and effective treatment option. ESS in these patients results in subjective improvement in sinonasal symptoms as well as objective improvement in radiographic CRS disease burden, although sinonasal crusting will likely not resolve.

LEVEL OF EVIDENCE

4.

Squamous cell carcinoma of the nasal cavity: A population-based analysis

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma of the nasal cavity (NCSCC) is an infrequent malignancy that has been historically difficult to characterize. This study provides new insight into NCSCC utilizing a population-based database. We analyze the propensity for cervical and distant metastasis from NCSCC, as well as survival outcomes.

STUDY DESIGN

Retrospective database analysis.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (2004-2012) was queried for NCSCC cases. Data were analyzed with respect to various demographic and clinicopathologic factors. The results were further examined for regional and distant metastasis. Survival was analyzed using the Kaplan-Meier model.

RESULTS

A total of 1,180 cases of NCSCC were identified in the SEER database between 2004 and 2012. The mean age at diagnosis was 65.8 years. American Joint Committee on Cancer stage was known in 1,050 cases, of which 53.4% were stage I, 13.3% were stage II, 10.2% were stage III, and 23.0% were stage IV. By tumor (T) stage classification, T1 was the most common (56.6%), followed by T4 (19.3%). Most cases had no nodal (N) involvement at diagnosis (90.8%). Cervical nodal involvement was present in 9.1% of cases, while distant metastasis was seen in 1.9%. Five-year disease-specific survival was 69.5% overall, 39.6% in cases with neck involvement and 0.0% for metastatic cases.

CONCLUSIONS

This study represents the only known population-based investigation of NCSCC. Metastasis to cervical nodes or distant sites, especially with T1 tumors, is rare. However, any cervical involvement or distant metastasis discovered on presentation is a poor prognostic indicator.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:560-565, 2016.

Head and Neck Cancers, Version 1.2015

These NCCN Guidelines Insights focus on recent updates to the 2015 NCCN Guidelines for Head and Neck (H&N) Cancers. These Insights describe the different types of particle therapy that may be used to treat H&N cancers, in contrast to traditional radiation therapy (RT) with photons (x-ray). Research is ongoing regarding the different types of particle therapy, including protons and carbon ions, with the goals of reducing the long-term side effects from RT and improving the therapeutic index. For the 2015 update, the NCCN H&N Cancers Panel agreed to delete recommendations for neutron therapy for salivary gland cancers, because of its limited availability, which has decreased over the past 2 decades; the small number of patients in the United States who currently receive this treatment; and concerns that the toxicity of neutron therapy may offset potential disease control advantages.

The use of photodynamic therapy as adjuvant therapy to surgery in recurrent malignant tumors of the paranasal sinuses

BACKGROUND

Malignant tumors of paranasal sinuses and anterior skull base recur frequently after surgery and adjuvant radiotherapy. The vicinity of essential structures limits additional treatment options, such as salvage surgery and re-radiation. We report the feasibility of photodynamic therapy (PDT) as an adjuvant treatment to surgery.

METHODS

Fifteen patients with recurrent tumors of the paranasal sinuses were treated with mtetrahydroxyphenylchlorin (mTHPC) mediated PDT as an adjuvant treatment to salvage surgery. All patients had previously curative radiotherapy. The treated tumors were squamous cell cancer (8), adenocarcinoma (3), undifferentiated carcinoma (2), adenoid cystic carcinoma (1) and radiotherapyinduced sarcoma (1). In five cases there was extension to the skull base. Two approaches of surgery where used, namely in eight cases an open approach, in the other seven endoscopic approach. Complete macroscopic resection with microscopic tumor positive margins was possible in three patients. The remaining twelve patients received debulking surgery followed by PDT.

RESULTS

None of the patients had cerebrospinal fluid leak, meningitis, major bleeding or vision loss. Four patients developed temporary diplopia due to edema of the medial rectus muscle, one patient suffered from extensive necrosis leading to oro-nasal fistula. Complete response was observed in five patients.

CONCLUSION

Photodynamic therapy can be used with relative safety as adjuvant therapy to surgery in recurrent tumors of the paranasal sinuses and the anterior skull base where complete resection is not achievable.

Treatment outcomes of intensity-modulated radiotherapy versus 3D conformal radiotherapy for patients with maxillary sinus cancer in the postoperative setting

BACKGROUND

In this study, we compared the treatment outcomes of postoperative 3D conformal radiotherapy (RT) and intensity-modulated radiotherapy (IMRT) for patients with maxillary sinus carcinoma.

METHODS

Fifty-four patients underwent surgery and postoperative RT, of whom 27 (50%) had squamous cell carcinoma and 14 (26%) had adenoid cystic carcinoma. Nineteen patients (35%) were treated with IMRT and 35 patients (65%) received 3D conformal RT. The median radiation dose for 3D conformal RT and IMRT were 62.1 and 63 Gy, respectively.

RESULTS

IMRT produced significantly superior radiation dose distribution to planning target volumes (PTVs) than 3D conformal RT. Over a median follow-up of 60 months, IMRT provided better 3-year locoregional recurrence-free survival (89.2% vs 59.5%; p = .035) and distant metastasis-free survival (94.7% vs 55.3%; p = .042) rates than 3D conformal RT.

CONCLUSION

Postoperative IMRT for patients with maxillary sinus carcinoma resulted in excellent disease control, and should be considered as the first treatment option in these cases. © 2015 Wiley Periodicals, Inc. Head Neck 38: E207-E213, 2016.

Simultaneous production of mixed electron--photon beam in a medical LINAC: A feasibility study

PURPOSE

The electron or photon beams might be used for treatment of tumors. Each beam has its own advantage and disadvantages. Combo beam can increase the advantages. No investigation has been performed for producing simultaneous mixed electron and photon beam. In current study a device has been added to the Medical Linac to produce a mixed photon-electron beam.

METHODS

Firstly a Varian 2300CD head was simulated by MCNP Monte Carlo Code. Two sets of perforated lead sheets with 1 and 2 mm thickness and 0.2, 0.3, and 0.5 cm punches then placed at the top of the applicator holder tray. This layer produces bremsstrahlung x-ray upon impinging fraction electrons on it. The remaining fraction of electrons passes through the holes. The simulation was performed for 10 × 10, 6 × 6, and 4 × 4 cm(2) field size.

RESULTS

For 10 × 10 cm(2) field size, among the punched targets, the largest penumbra difference between the depth of 1 and 7 cm was 72%. This difference for photon and electron beams were 31% and 325% respectively. A maximum of 39% photon percentage was produced by 2 mm target with 0.2 cm holes diameter layer. The minimum surface dose value was 4% lesser than pure electron beam. For small fields, unlike the pure electron beam, the PDD, penumbra, and flatness variations were negligible.

CONCLUSIONS

The advantages of mixing the electron and photon beam is reduction of pure electron's penumbra dependency with the depth, especially for small fields, also decreasing of dramatic changes of PDD curve with irradiation field size.

Surgical outcomes of malignant sinonasal tumours: open versus endoscopic surgical approaches

BACKGROUND

Sinonasal malignancies are rare tumours, which can be resected using an open or endoscopic approach. The current study evaluated the outcome of both approaches.

METHODS

A total of 160 patients with malignant nasal tumours were evaluated in an academic tertiary care hospital. The patients were allocated to 'open' or 'endoscopic' surgery groups, based on the surgical approach employed. The following data were evaluated and compared: patient and tumour characteristics; oncological treatments; and oncological outcomes, including complications, surgical margin, recurrence, overall survival and disease-free survival.

RESULTS

The maxillary sinus was the most common tumour location and squamous cell carcinoma was the most common histopathology-based diagnosis. Younger patients had lower grades of tumour. Higher survival rates were significantly related to lower tumour stages in both surgery groups. There were no differences between the two relatively similar groups in terms of surgical margin, the need for adjunctive therapy, and recurrence and survival rates. In addition, multivariate logistical regression analysis indicated no correlations between the type of surgical approach employed and the rates of recurrence and complications.

CONCLUSION

Endoscopic surgery for sinonasal malignancies is comparable to the conventional open approach in carefully selected patients.

Sinonasal carcinoma: clinical, pathological, genetic and therapeutic advances

The sinonasal cavities represent an anatomical region affected by a variety of tumours with clinical, aetiological, pathological, and genetic features distinct from tumours at the main head and neck cancer localizations. Together, squamous-cell carcinoma and adenocarcinoma account for 80% of all sinonasal tumours, and are aetiologically associated with professional exposure to wood and leather dust particles and other industrial compounds, and therefore, are officially recognized as an occupational disease. Owing to their distinctive characteristics, sinonasal tumours should be considered as separate entities, not to be included in the miscellany of head and neck cancers. Sinonasal tumours are rare, with an annual incidence of approximately 1 case per 100,000 inhabitants worldwide, a fact that has hampered molecular-genetic studies of the tumorigenic pathways and the testing of alternative treatment strategies. Nevertheless, the clinical management of sinonasal cancer has improved owing to advances in imaging techniques, endoscopic surgical approaches, and radiotherapy. Genetic profiling and the development of in vitro cell lines and animal models currently form the basis for future targeted anticancer therapies. We review these advances in our understanding and treatment of sinonasal tumours.

Induction chemotherapy in technically unresectable locally advanced carcinoma of maxillary sinus

Background. Locally advanced carcinoma of maxillary sinus has been historically reported to have poor prognosis. We evaluated the role of NACT in improving the outcome in these patients. Methods. 41 patients with locally advanced technically unresectable (stage IVa) or unresectable maxillary carcinoma (stage IVb) were treated with induction chemotherapy between 2008 and 2011. The demographic profile, response and toxicity of chemotherapy, definitive treatment received, progression free survival (PFS), and overall survival (OS) were analyzed. Univariate and multivariate analysis were performed to determine factors associated with PFS and OS. Results. The chemotherapy included two drugs (platinum and taxane) in 34 patients (82.9%) and three drugs (platinum, taxane, and 5 FU) in 7 (17.1%). There was no complete response seen in any of the patients, stable disease in 18 (43.9%), partial response in 16 (39%), and progression in 7 (17.1%) patients. After induction, the treatment planned included surgery in 12 (29.3%), CT-RT in 24 (58.5%), radical RT in 1 (2.4%), palliative RT in 1 (2.4%), and palliative chemotherapy in 3 (7.3%) patients. Overall, the median PFS was 10.0 months. The OS at 24 months and 36 months was 41% and 35%, respectively. Conclusion. In unresectable maxillary carcinoma, induction chemotherapy has clinically significant benefit with acceptable toxicity.

Sinonasal tract malignancies: prognostic factors and surgery outcomes

Background:

Cancers of the sinonasal region are rare and its survival rate remains poor because most of the patients are asymptomatic and diagnosed in advanced stages with surrounding important structures.

Objectives:

This study attempted to analyze the clinical and histological features in addition to survival and prognostic factors of surgical treatment of sinonasal cancers.

Patients and Methods:

A retrospective cohort study, involving 36 patients with sinonasal cancer who were treated with surgery in our hospital between 2000 and 2010, was performed. Patients were selected based on the convenience sampling. Patients treated with radiotherapy and/or chemotherapy were excluded from the analysis. Clinical symptoms and histologic findings of patients as well as malignant tumor staging and its prognosis were collected from archives.

Results:

We found that overall 3 and 5-year survival rates of subjects were 52.8%, and 41.6%, respectively. There was a negative correlation between the clinical stage and survival. There was a significant difference between infrastructural and suprastructural localization in 5-year survival rate (P = 0.018). In the present study, there was a strong relationship between the local control and overall survival (P < 0.01). Overall 5-year survival rate was similar in patients both in the exenterated orbit and preserved orbit (P > 0.05).

Conclusions:

The present study has demonstrated that clinical stage, suprastructural tumor, and the presence of tumor- positive resection margins are the most significant prognostic factors affecting local tumor control and survival. As a result of this study, these tumors should be treated in early stages by surgical margin of resection followed by adjuvant radiotherapy.