Esthesioneuroblastoma: a meta-analysis and review

Small cell carcinoma of the submandibular gland: a rare small round blue cell tumor

The presence of small cell carcinoma within the submandibular gland is an uncommon clinical entity. However, other small round blue cell tumors are encountered in the head and neck with greater frequency. These include lymphoma, Ewing's sarcoma, melanoma, esthesioneuroblastoma, and neuroblastoma. A basic knowledge of the immunohistochemical studies available to distinguish each these tumors from one another significantly improves the frequency of accurate and timely initial diagnosis. We report a case of small cell carcinoma of the submandibular gland and review the other common small round blue cell tumors that occur within the head and neck. We utilize an acronym, LEMONS, to organize our review and facilitate improved retention of the differential diagnosis for small round blue cell tumors of the head and neck.

Endoscopic treatment of esthesioneuroblastoma: a minimally invasive approach combined with radiation therapy

OBJECTIVE

In a retrospective analysis we discuss our experience in the treatment of olfactory neuroblastoma (ON), a rare tumor of the sinonasal tract.

STUDY DESIGN AND SETTING

Nine patients with olfactory neuroblastoma were treated at the Bolognini Hospital of Seriate and at the Department of Otolaryngology of "La Sapienza" University of Rome combining endoscopic surgery and postoperative radiation therapy. All patients were staged according to Kadish criteria. No chemotherapy was administered in any cases. Local radiation therapy was started postoperatively in all the cases.

RESULTS

All patients, over an average follow-up which ranged from 26 through 60 months, are actually alive with non evidence of disease (NED).

CONCLUSIONS

Despite the short follow-up in this small series of patients, we suggest endoscopic surgery combined with postoperative radiation therapy as an alternative to the conventional modalities of treatment for esthesioneuroblastoma in selected cases.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience

BACKGROUND

Craniofacial resection is the established "gold standard" for surgical treatment of tumors affecting the anterior skull base.

METHODS

This study analyzed 308 patients (220 males, 88 females) who had undergone craniofacial resection for sinonasal neoplasia with up to 25-year follow-up.

RESULTS

An overall actuarial survival of 65% at 5 years and 47% at 10 years was found for the cohort as a whole. For patients with malignant tumors, the 5-year actuarial survival was 59%, falling to 40% at 10 years. For patients with benign pathology, the actuarial survival was 92% at 5 years falling to 82% at 10 years. Statistical analysis again identified brain involvement, type of malignancy, and orbital involvement as the 3 most significant prognostic factors.

CONCLUSION

Analysis of one of the largest single institution cohorts over a 25-year period provides a baseline against which other approaches such as an entirely endoscopic skull base resection must be judged.

Intracavitary chemotherapy (Gliadel) for recurrent esthesioneuroblastoma: case report and review of the literature

Esthesioneuroblastoma is an uncommon malignancy of the nasal vault with a treatment regimen consisting of surgical resection followed by radiotherapy for primary lesions and addition of chemotherapy for patients with advanced, recurrent or metastatic lesions. We report a case of a 39-year-old female with a history of esthesioneuroblastoma, previously treated with resection, radiation and chemotherapy, presenting with a recurrent disease that was successfully treated with re-resection and placement of Gliadel) wafers in the surgical resection cavity. The novel option of controlled-release and local delivery of a chemotherapeutic agent for treatment of recurrent esthesioneuroblastoma should be recognized and considered.

Clinical utility of somatostatin receptor scintigraphic imaging (octreoscan) in esthesioneuroblastoma: a case study and survey of somatostatin receptor subtype expression

BACKGROUND

For tumors that express somatostatin receptors (SSTR), radiolabeled somatostatin analogs, such as 111In-pentetreotide, can demonstrate the presence of tumor by radioligand uptake using somatostatin receptor scintigraphy (SRS). The use of 111In-pentetreotide for SRS depends on the specific high affinity of octreotide for SSTR subtypes 2, 3, and 5. Of these, SSTR2 has the greatest affinity for octreotide and the greatest relevance for tumor detection with Octreoscan imaging. Discriminating between postoperative changes and residual or recurrent tumor after extensive skull base surgery is often difficult, but in a case of recurrent esthesioneuroblastoma (ENB) we found the use of Octreoscan imaging clinically useful. To better define the general relevance of this imaging technique in this setting, we analyzed SSTR subtype expression in a panel of ENB tumors.

METHODS

The case history and correlations between MRI and 111In-pentetreotide SRS of a patient with recurrent ENB were reviewed. The expression pattern of the SSTR subtypes in a panel of ENB tumors was then analyzed by reverse transcriptase-polymerase chain reaction (RT-PCR) to better define the potential of more general use of Octreoscan for imaging ENB. To correlate SSTR2 protein expression with 111In-pentetreotide uptake, immunohistochemistry to detect SSTR2 was performed on tumor samples from regions of increased uptake on Octreoscan.

RESULTS

The SSTR2 message was expressed at high levels in all five ENB tumor samples, and either SSTR2 protein or histologic findings typical for ENB were found in all tumor tissue obtained from regions of increased 111In-pentetreotide uptake. Furthermore, Octreoscan imaging in this case proved useful in clinical decision making.

CONCLUSION

The expression pattern of SSTR2 and the specificity of the Octreoscan for regions of active tumor growth support further investigation of the utility of Octreoscan imaging in the diagnosis and surveillance of ENB. Recent advances in novel therapies based on SSTR ligand binding also provide the rationale to consider such novel therapeutic approaches in patients with ENB.

Esthesioneuroblastoma

Esthesioneuroblastoma is a rare tumor for which the published literature does not provide an evidence-based consensus treatment approach. Multimodality therapy including a combination of surgery and radiation appears to provide the best disease-free and overall survival. Surgical resection should proceed through a craniofacial approach if possible. The role of chemotherapy in the initial treatment paradigm is less clear. Chemotherapy should not be used as single-modality therapy for initial treatment but may provide additional benefit when used in combination with radiation and surgery, particularly in advanced-stage disease. Combination chemotherapy should be considered as initial therapy for unresectable tumors and metastatic disease, and as salvage therapy in disease recurrence.

[Esthesioneuroblastoma treatment]

INTRODUCTION

Esthesioneuroblastoma is an uncommon malignancy of the olfactory neuroepithelium. The best treatment has yet to be defined. The purpose of this study is to analyze the tumors's behaviour to choose the ideal treatment, the therapeutic strategy and the patterns of failure.

MATERIALS AND METHODS

We carry out a revision of the series published between 1994 to 2004. In these series, we found 39 papers with 713 patients.

DISCUSSION

CONCLUSIONS

In this review the 5-years survival rate is 51.2%. Through the analysis of 583 partients found in 34 publications, surgery (alone or combined) is the treatment most used (78%). The commonly management is surgical in combination with radiotherapy (47%).

Olfactory neuroblastoma causing ectopic ACTH syndrome

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

Esthesioneuroblastoma of the pituitary gland: a clinicopathological entity? Case report and review of the literature

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare, malignant neoplasm that typically arises in the nasal vault, invades adjacent tissues, and causes locoregional (cervical lymph nodes) and distant metastases. Only two cases of tumors arising in the sellar region that had the histological characteristics of esthesioneuroblastoma have been reported in the literature to date. The authors present the case of a 35-year-old woman with secondary amenorrhea and a rapidly growing tumor located in the adenohypophysis. After total removal of the lesion through a transseptal-transsphenoidal approach, the histological examination revealed an esthesioneuroblastoma Grade II/III according to Hyams. Considering the particular location of the lesion and the absence of residual tumor on postoperative magnetic resonance imaging, no adjuvant therapy was performed. The patient remained free from tumor recurrence 2 years postoperatively. Because all published cases of this esthestoneuroblastoma have been large neuroblastic tumors of the pituitary gland arising in middle-aged women, pituitary neuroblastoma might represent a rare, specific clinicopathological entity.

Sellar neuroblastoma mimicking pituitary adenoma

OBJECTIVE AND IMPORTANCE

Primary intracranial neuroblastomas are rare. They generally arise in the supratentorial parenchyma or paraventricular region. Even more rare are primary sellar neuroblastomas. We present a neuroblastoma that arose in the sellar region and mimicked a non-functioning pituitary adenoma.

CLINICAL PRESENTATION

This 33-year-old man presented with bitemporal hemianopsia. MRI showed a sellar mass with suprasellar extension mimicking a pituitary adenoma.

INTERVENTION

Because of tumor recurrence and dissemination to the cervical region, he underwent 6 operations and radiosurgery. Detailed histologic examination confirmed the diagnosis of neuroblastoma. Postoperative conventional radiotherapy was effective in reducing the size of the tumor.

CONCLUSION

Neuroblastoma should be considered in the differential diagnosis of patients with sellar lesions.

Basic and clinical aspects of olfaction

Disturbances of olfaction are a common occurrence in many neurological and neurosurgical patients and their correct diagnosis might be helpful in management and enhancement of quality of life. However, olfaction is seldom checked in most neurosurgical units and the "smell bottles" are often either absent or out of date. This chapter reviews systematically recent advances in our understanding of the anatomy, physiology (olfactory coding) and measurement of olfactory function in the human. The causes and symptoms of smell disorders, risk of damage to the olfactory system by various surgical procedures and, finally, the natural history of recovery and treatment of smell disorders, for example after trauma, are discussed.

Combination chemotherapy (cyclophosphamide, doxorubicin, and vincristine with continuous-infusion cisplatin and etoposide) and radiotherapy with stem cell support can be beneficial for adolescents and adults with estheisoneuroblastoma

BACKGROUND

Adolescent-onset and adult-onset esthesioneuroblastoma is a rare disease and is considered incurable. In many patients, local resection and radiation are chosen as clinical therapy with or without chemotherapy. It was reported previously that local resection and radiotherapy led to temporary remission and, in many patients, recurrent disease. Although combination with chemotherapy has been regarded as promising, an effective regimen has not been established. In the current study, the authors investigated the effect and tolerability of the combination of chemotherapy, radiotherapy, and peripheral blood stem cell transplantation (PBSCT).

METHODS

The study population included 12 patients with adolescent-onset and adult-onset esthesioneuroblastoma classified as Kadish Stage A-D. The patients received two cycles of combination chemotherapy, which consisted of cyclophosphamide, doxorubicin, and vincristine (CAD) with continuous-infusion cisplatin and etoposide (CVP). This was combined with radiotherapy with or without PBSCT.

RESULTS

Nine of 12 patients (75%) obtained more than a partial response after only 2 cycles of chemotherapy. After radiation with or without PBSCT, six patients obtained a complete remission (CR). The longest survival was > 3 years. All patients who underwent PBSCT obtained a CR. The most severe side effects were loss of sodium and potassium induced by cisplatin-related renal tubular distress. Those abnormalities were temporary, and all patients recovered.

CONCLUSIONS

The chemotherapy regimen with CADO and CVP does not require continuation for a long time and is very effective and tolerable for patients with adolescent-onset and adult-onset esthesioneuroblastoma. The combination with radiotherapy and PBSCT may lead to a CR without facial disfigurement. In this report, the authors discuss the feasibility and efficacy of this multidisciplinary approach.

Cancer of the nasal cavity and paranasal sinuses

Sinonasal malignancies continue to have poor survival rates. Disease-related mortality is usually the result of disease recurrence and progression at the primary site despite aggressive therapy. Complete surgical excision with postoperative radiation therapy remains the standard of care for resectable lesions. Improved reconstructive techniques have increased our ability to aggressively clear locally advanced disease in this anatomically challenging region, while reducing associated functional and cosmetic morbidity. Intensive multimodality treatment regimens coupled with newer medical technology may ultimately improve the long-prevailing poor prognosis of these tumors.

CGH pattern of esthesioneuroblastoma and their metastases

Comparative genomic hybridization (CGH) was used to screen 22 esthesioneuroblastomas (ENB) from 12 patients including 12 primary tumors and 10 metastasis/recurrent lesions for chromosomal imbalances being the most extensive study so far. The analysis revealed a characteristic pattern consisting of deletions on chromosomes 3p and overrepresentations on 17q in up to 100% of cases. Other important alterations being detectable in more than 80% of cases were deletions on 1p, 3p/q, 9p, 10p/q along with overrepresentation on 17p13, 20p and 22q. Particularly striking was the pattern for chromosomes 3, 10 and 17q and 20 being affected almost exclusively by deletions or overrepresentations, respectively. Pronounced overrepresentations suggestive for high copy amplifications were seen on 1p34, 1q23-q31, 7p21, 7q31, 9p23-p24, 17q11-q22, 17q24-q25, 19, 20p, 20q13 and 22q13. Comparing tumor pairs from the same patient revealed a high concordance indicating clonality and confirming the genetic homogeneity of the tumor entity. The analysis of metastatic/recurrent lesions indicated a higher percentage of pronounced alterations, e.g., high copy DNA gains at 1q34-qter, 7q11, 9p23-p24, 9q34, 13q33-q34, 16p13.3, 16p11, 16q23-q24 and 17p13. The analysis furthermore suggested specific alterations, e.g., deletions of chromosome 11 and gains of 1p to be associated with metastasis formation and/or worse prognosis. Our results indicate that ENB is a distinct entity and provides criteria for its genetic distinction from other small round cell tumor types.

Human achaete-scute homologue (hASH1) mRNA level as a diagnostic marker to distinguish esthesioneuroblastoma from poorly differentiated tumors arising in the sinonasal tract

Distinction of high-grade esthesioneuroblastomas from other poorly differentiated tumors arising in the nasal cavity is an important diagnostic challenge because it determines patient management and prognosis. The human achaete-scute homologue (hASH1) gene is critical in olfactory neuronal differentiation and is expressed in immature olfactory cells; therefore, it could have potential use as a diagnostic marker The aim of the present study was to determine the value of hASH1 messenger RNA (mRNA) levels in differentiating esthesioneuroblastoma from other poorly differentiated tumors. A real-time polymerase chain reaction assay was developed, permitting the comparative determination of hASH1 mRNA levels in triplicate in a double-blind pilot study including 24 frozen cases of esthesioneuroblastoma and poorly differentiated tumors. All 4 positive cases were esthesioneuroblastomas, and all 19 poorly differentiated tumors were negative. In addition, there was an inverse association between the grade of esthesioneuroblastomas and hASH1 mRNA levels. The hASH1 mRNA level might represent a useful tool for distinguishing esthesioneuroblastoma from poorly differentiated tumors of the sinonasal region.

Diagnosis and management of esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon malignant neoplasm of the nasal vault that in the past was considered benign or low-grade malignant. Surgical approaches in the main were transnasal, with a high recurrence rate and ultimate patient death. With the modern imaging of CT and MRI, should the patient be willing and fit enough, esthesioneuroblastoma currently should be approached using a craniofacial resection. Large tumors should be considered for preoperative chemotherapy and postoperative radiotherapy. Local tumor recurrence is not uncommon and is generally related to the attention to local anatomic dissection. Neck metastases, when they present, should be excised using a modified neck dissection. Distant metastases may present at any time during the course of the disease, generally within 36 months, and may respond to local radiotherapy or systemic chemotherapy. Five-year survival currently appears to be optimized by surgery followed by postoperative radiotherapy and is approximately 65%.

Olfactory neuroblastoma: past, present, and future?

OBJECTIVE

To consider the long-term survival and outcomes in patients with olfactory neuroblastoma undergoing craniofacial resection.

STUDY DESIGN

A single-center prospective cohort study.

METHODS

All patients with olfactory neuroblastoma treated in a 23-year period with craniofacial resection (with or without radiotherapy) were analyzed; a multivariate analysis was included.

RESULTS

Forty-two patients aged 12 to 70 years were assessed, 83% of whom had received no preceding treatment. Craniofacial resection was used in all cases, combined with radiotherapy in 24 patients (57%). Duration of follow-up ranged from 2 to 206 months (mean follow-up period, 57 mo). The disease-free actuarial survival and overall survival were 77% and 61% at 5 years and 53% and 42% at 10 years, respectively. A Cox regression analysis identified intracranial extension and orbital involvement as independent factors affecting outcome.

CONCLUSION

Craniofacial resection combined with radiotherapy offers the gold standard of care against which other approaches such as endoscopic resection must be judged.