Preservation of the eye in the treatment of sinonasal malignant neoplasms with orbital involvement. A confirmation of the original treatise

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Critical review of multidisciplinary approaches for managing sinonasal tumors with orbital involvement

Orbital invasion is frequently observed in tumors involving the maxillary, ethmoid and frontal sinuses given the proximity of the orbit to the sinonasal tract and ventral skull base. The main objective of the present review is to determine the existing evidences on the frequency, treatment, and outcomes of orbital invasion in benign and malignant sinonasal tumors. A systematic review of the literature published from 1995 to 2020 was performed and data sources included PubMed, Cochrane library, NCBI Bookshelf, National Guideline Clearinghouse. Orbital invasion was reported in 2-4% of inverted papillomas, 12-15% of fibro-osseous lesions, 27-32% of juvenile angiofibromas, 35-45% of low-grade malignancies, and 50-80% of high-grade cancers. Surgical resection with negative margins represents the cornerstone of management for benign and low-grade malignant tumors. Histology-specific induction chemotherapy can be used for high-grade sinonasal cancers in order to downstage the tumor and increase the possibility of orbital preservation. When a significant response to induction chemotherapy is observed, exclusive chemoradiation should be offered to improve overall survival rates. Appropriate reconstruction of any surgical defects is essential in order to minimize complications and optimize functional and aesthetic outcomes. Orbital apex invasion represents a negative prognostic factor. In conclusion, a multidisciplinary teamwork is mandatory to maximize local control, minimize morbidity and improve orbital preservation rates.

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

The term “sinonasal tumours” includes a large spectrum of diseases, which are characterized by heterogeneous biological behavior and prognosis, and located in a critical anatomic area. Diagnosis and treatment of sinonasal tumours require the contribution of different disciplines. A narrative review was performed to highlight the role of surgeons in contributing to a multidisciplinary approach to sinonasal tumours. Diagnosis and staging of sinonasal tumours is challenging and requires collaboration between surgeons, radiologists, and pathologists. The identification and management of critical extensions (orbital or intracranial encroachment, vascular abutment or encasement) is fundamental for successful treatment. Most cases of advanced sinonasal tumours can undergo surgical intervention by an adequately trained otorhinolaryngological team. The contribution of neurosurgeons and oculoplastic surgeons is required in selected scenarios. In rare circumstances, multidisciplinary reconstructive strategies can be indicated for complex tissue defects. Furthermore, a multidisciplinary approach is pivotal in the management of perioperative complications. While surgery remains the mainstay of treatment, the role of non-surgical adjuvant or even exclusive treatments is constantly expanding.

Outcomes of orbital exenteration for craniofacial lesions

BACKGROUND

Orbital exenteration (OE) is an ablative procedure used in the management of malignancies of the orbit of either primary or secondary origin. Publications evaluating this procedure have suffered from small patient numbers, heterogeneity of pathologies, and poor patient follow-up. The purpose of this study was to assess patient outcomes in a large cohort of patients undergoing OE at a tertiary cancer center.

METHODS

A retrospective review was conducted of 180 consecutive patients who underwent OE at the authors' institution. Overall survival (OS) was the primary end point measured in the study. Time to locoregional recurrence (progression-free survival [PFS]) and disease-free survival were secondary end points.

RESULTS

Between the years 1993 and 2011, 180 consecutive patients received OE for craniofacial malignancy at the authors' institution. The median follow-up for the cohort was 9.7 years (116 months). The median OS was 73 months, and the median PFS was 96 months. The presence of perineural invasion was associated with shorter OS (P = .01) and PFS (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter PFS than negative margins (P < .01) but with no change in OS (P = .15). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5), and there was 1 death observed (0.6%).

CONCLUSIONS

Used judiciously in the setting of a multidisciplinary management plan, OE for tumor control is a safe therapy.

LAY SUMMARY

Between the years 1993 and 2011, 180 consecutive patients received orbital exenteration for craniofacial malignancy at the MD Anderson Cancer Center. The median follow-up for the cohort was 9.7 years. The presence of perineural invasion was associated with shorter overall survival (P = .01) and progression-free survival (P < .01). Magnetic resonance imaging was predictive of perineural invasion (P < .01). Positive margins were associated with shorter progression-free survival than negative margins (P < .01). The overall complication rate was 15%. The major complication rate (Clavien-Dindo 3b or greater) was 2.8% (n = 5).

Sinonasal cancer encroaching the orbit: Ablation or preservation?

BACKGROUND

Encroachment on the orbital cavity represents a challenge in the management of sinonasal cancer. Criteria guiding orbital preservation lack univocal consensus. Stage of orbital involvement is best assessed through magnetic resonance imaging (MRI).

METHODS

Patients affected by orbit-encroaching sinonasal cancer with available preoperative MRI, receiving surgery-based treatment at the University of Brescia between May 2005 and October 2018 were included. All cases were reviewed by expert radiologists and pathologists. Diagnostic performance of MRI was calculated using pathological information as reference. Survival analysis was performed.

RESULTS

The study included 123 patients. The orbit was abutted in 53 (43.1%) patients, whereas orbital invasion reached the periorbit in 18 (14.6%), extraconal fat and/or medial lacrimal sac in 29 (23.6%), extrinsic ocular muscles in 7 (5.7%), intraconal compartment in 4 (3.3%), and orbital apex in 12 (9.8%). Seventy-six (61.8%) patients received orbit-sparing surgery, 47 (38.2%) underwent orbital ablation (OA). Accuracy of MRI in detecting involvement by cancer was ≥80.0% for the orbital wall, extraconal fat, and muscles, and <80.0% for the periorbit and intraconal compartment. Previous surgery, neoadjuvant chemotherapy, and perineural invasion decreased MRI accuracy. Age, histology, tumor grade, pT category, N status, perineural invasion, orbital invasion stage, and need for OA were found to affect prognosis. Five-year orbital dysfunction-free survival was 92.8%.

CONCLUSION

Conservative management of sinonasal cancers encroaching the orbit is feasible. MRI is essential to preoperatively stage orbital invasion, yet with some limitation. Given the dismal prognosis despite aggressive surgery, neoadjuvant non-surgical therapies should be considered in patients requiring OA.

The Role of Adjuvant Treatment in Craniofacial Malignancy: A Critical Review

Background: Tumors originating from the craniofacial region usually present in a locally advanced stage with frequent involvement of adjacent sites and have a strong tendency for local recurrence in the absence of adjuvant therapy, even when the original surgical resection was presumed to be radical. In the past decades, several advances in the radiological diagnosis and treatment of craniofacial malignancies have been introduced. There are, however, no randomized trials that define the optimal multimodal treatment of these tumors because of their rarity as well as heterogeneity in both histology and site of origin. The aim of this study was to conduct a critical review of the role of adjuvant therapy in the treatment of craniofacial malignancy. Method: We conducted a critical review of the past and contemporary literature available, focusing on adjuvant oncological treatments of the most common craniofacial malignancies. Results: Preoperative radiotherapy can have a documented role in the treatment of olfactory neuroblastoma and soft tissue sarcoma, while preoperative chemotherapy can be advocated in the treatment of sinonasal undifferentiated carcinoma, neuroendocrine carcinoma, olfactory neuroblastoma, and craniofacial sarcoma (both soft-tissue and high-grade osteosarcoma). Postoperative radiotherapy has a well-established role in the treatment of most craniofacial malignancies. The role of postoperative chemotherapy is unclear in most histologies, but is commonly used during the treatment of well-selected cases of paranasal sinus carcinoma, olfactory neuroblastoma, mucosal melanoma, soft tissue sarcoma and high-grade craniofacial osteosarcoma. Discussion: Alongside developments in surgery, there have also been improvements in diagnostics, radiotherapy, and chemotherapy. Implementation of novel radiation techniques allows delivery of higher radiation doses while minimizing irradiation-related morbidity. Better understanding of tumor biology allows the construction of more complex treatment strategies, incorporating adjuvant chemotherapy either pre- or postoperatively. In the era of personalized targeted therapy, rapid strides are being made to identify specific tumor-targets for use of novel biologic agents, with the potential to change current management paradigms.

Multidisciplinary treatment algorithm for the management of sinonasal cancers with orbital invasion: A retrospective study

BACKGROUND

Sinonasal cancers frequently involve the orbit with resulting controversies on whether to remove or preserve the orbital contents.

METHODS

Retrospective review of patients with primary sinonasal cancer involving the orbit, treated according to a multidisciplinary protocol tailored to tumor histology and extent of orbital invasion in two tertiary care referral centers over a 20-year period.

RESULTS

The oncological and functional outcomes of 163 patients were analyzed. The degree of orbital involvement significantly affected both overall (P < .0001) and disease-free (P < .0001) survival. Orbital apex invasion was an independent negative prognostic factor (5-year overall survival, 14.6% ± 7.5%), with dismal prognosis regardless of the treatment adopted. An appropriate use of induction chemotherapy and endoscopic-assisted surgery allowed for orbital preservation in 76.6% of cases; 96% of patients treated using an orbit-sparing approach maintained a functional eye after treatment.

CONCLUSION

The multimodal treatment algorithm herein proposed was able to maximize orbital preservation rates with acceptable oncological and functional outcomes.

Periorbita: Computed Tomography and Magnetic Resonance Imaging Findings

Purpose

The periorbita has been regarded as the critical structure in decision of exenteration in the patients with paranasal (PNS) malignancies. The purpose of this study is to present the CT and MRI findings of the periorbita with PNS malignancies.

Materials and Methods

Ten patients with PNS cancers were chosen for this study. PNS CT and MRI scans were performed on all patients. The imaging findings were reviewed retrospectively by consensus of two neuroradiologists. Assessment of the defect of the orbital bone and invasion of the orbital fat was made by CT and MRI. The signal intensity (SI), thickness, enhancement, and correlation with the orbital bone of the periorbita were analyzed on MRI. The intraoperative and pathologic reports were used as the gold standard for orbital invasion.

Results

In patients with bone defects, it was impossible to differentiate the periorbita from the mass on CT. The periorbita showed hypointensity on T2-weighted images compared with the SI of mass. On Gd-enhanced T1-weighted images, the periorbita showed less enhancement than the mass in nine patients. Six patients showed two hypointense layers (the outer bony wall and the inner periorbita) between the mass and orbital fat on T2-weighted images. The thickness of the periorbita was 0.79–1.4 millimeter. Orbital invasion was more conspicuous on T2-weighted coronal images than on the CT images.

Conclusions

MRI was more conspicuous for detecting orbital invasion than CT. The mass beyond the thickened periorbita on T2-weighted images was considered to be a positive finding of orbital invasion.

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.

Esthesioneuroblastoma and Olfactory Preservation: Is it Reasonable to Attempt Smell Preservation?

Objective  Olfactory preservation after resection of esthesioneuroblastoma (ENB) has been reported, however, the ability to predict tumor involvement of the olfactory system is critical to this surgical strategy. This study aims to answer the question: Can a surgeon predict, based on preoperative imaging, whether there is unilateral involvement of the olfactory system allowing for safe attempt of olfactory preservation? Methods  This is a retrospective review of post-resection ENB meeting inclusion criteria of having bilateral olfactory tracts and bulbs submitted at the time of primary resection for pathologic margins. Five board-certified skull base surgeons blinded to the pathology individually reviewed the preoperative MRI scans to predict degree of tumor involvement. Results  Olfactory bulb involvement occurred in both bulbs in 35% of cases and unilateral in 39% of cases, and there was no involvement in 26% of cases sampled. When comparing physician prediction of involved tracts or bulbs, involvement was appropriate or over-called (i.e., called positive when pathology was in fact negative) in 96% of cases. Conclusion  This study demonstrates unilateral or no pathologic olfactory involvement of the olfactory system in 65% of cases. Our ability to predict this involvement, which may allow for a management strategy that attempts to preserve olfactory function, was accurate at 96%. Therefore, interpretation of imaging and proceeding with smell preservation in ENB appears reasonable in this cohort.

LEVEL OF EVIDENCE

Level 2b.

A review of nasal, paranasal, and skull base tumors invading the orbit

Tumors that invade the orbit are uncommon. The majority are meningiomas arising from the sphenoid ridge (66%). Others are bone and cartilage tumors arising from the surrounding bones of the orbit, pituitary adenomas, and epithelial tumors arising from the paranasal sinuses and nasal cavity. Meningiomas occur more often in women, whereas epithelial tumors have a predilection for men. Meningiomas and epithelial tumors typically present in the sixth decade of life, whereas bone tumors tend to affect individuals in their third decade of life. Patients often present with a combination of ophthalmological and otorhinolaryngological symptoms, including proptosis, pain, decreased visual acuity, restrictions in motility of the eye, epistaxis, and nasal obstruction. Sarcomas and benign bone and cartilage tumors arise from surrounding structures, whereas carcinomas usually arise from the paranasal sinuses. Surgery is the mainstay of treatment. Depending on the aggressiveness and histology of the tumor, surgery may be combined with radiation and chemotherapy. The prognosis is generally poor, but varies depending on histology and cell origin, size of the tumor, and degree of invasion. Meningiomas and benign bone tumors have the best prognoses. Sinonasal undifferentiated carcinomas, small-cell neuroendocrine carcinomas, osteosarcomas, and rhabdomyosarcomas have poorer prognoses.

The implications of orbital invasion in sinonasal tract malignancies

In recent decades, the management of sinonasal tumors abutting the orbit has been widely discussed. A real guideline has yet to be proposed, as prospective randomized studies on this topic are very difficult to organize, given the relative rarity of this pathology, the wide spectrum of histologic patterns, and the different clinical behavior of tumors. Nevertheless, in recent years, a better assessment of tumor extension has been obtained thanks to the refinement of preoperative imaging tools and, therefore, more conservative approaches could be adopted, with no worsening of the oncological outcomes and, at the same time, with more attention given to the post-surgical quality of life. Currently, tumors that extend to the bony orbital walls with or without focal infiltration of the periorbit are amenable to orbital preservation. On the other hand, infiltration of extraocular muscles and neurovascular structures are an indication to orbital exenteration. The ideal surgical treatment in cases of limited involvement of orbital fat still remains a matter of debate. We report and discuss the recent English literature on this interesting topic.

Induction chemotherapy in head and neck squamous cell carcinoma of the paranasal sinus and nasal cavity: a role in organ preservation

BACKGROUND/AIMS

The role of induction chemotherapy (IC) for eyeball preservation has not been established in head and neck squamous cell carcinoma (HNSCC) of the paranasal sinus and nasal cavity (PNSNC). Periorbital involvement frequently leads to eyeball exenteration with a margin of safety. We evaluated the treatment outcomes, including survival and eyeball preservation, of patients who received IC for HNSCC of the PNSNC.

METHODS

We reviewed 21 patients diagnosed with HNSCC of the PNSNC who were treated with IC. We analyzed response, eyeball preservation rate, and overall survival.

RESULTS

Tumors were located in the paranasal sinus (n = 14) or nasal cavity (n = 7). Most patients had stage T4a (n = 10) or T4b (n = 7) disease. More than half of the patients received a chemotherapy regimen of docetaxel, fluorouracil, and cisplatin (n = 11). Thirteen patients (61.9%) achieved a partial response after IC and 15 patients (71.4%) achieved T down-staging. Among 17 patients with stage T4 disease, which confers a high risk of orbital exenteration, 14 (82.4%) achieved preservation of the involved eye. The 3-year overall survival (OS) rate of patients who achieved a partial response to IC was 84.6%. The 3-year OS rate of patients with stable disease or disease progression after IC was 25.0% (p = 0.038).

CONCLUSIONS

IC could be considered for down-staging patients with advanced T-stage disease. It could also be a reasonable option for eyeball preservation in locally advanced HNSCC of the PNSNC.

Management of orbital invasion in sinonasal malignancies

BACKGROUND

Indications for preservation of orbital contents in case of malignant sinonasal tumors invading the orbit remain controversial.

METHODS

A retrospective consecutive review was conducted of patients in a tertiary care center over a 15-year period.

RESULTS

Ninety-three patients were diagnosed with a malignant tumor invading the orbit. Eighty-three were treated with curative intent of which 58 underwent surgery. Mean follow-up was 45 months. Orbital preservation was feasible in 66% of cases, whereas orbital clearance was performed in cases of locally advanced disease (invasion of extraocular muscles, ocular globe, or orbital apex). Local control rate was 70% for patients treated with orbital clearance and 74% for those with orbital preservation, with no statistical difference. Five-year survival and 5-year relapse-free survival were similar in both groups.

CONCLUSION

Using our strategy, the eye can be spared in more patients than what is currently proposed, without oncologic or survival disadvantages. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Management of the orbit during endoscopic sinonasal tumor surgery

BACKGROUND

The primary aims of the study were to report preoperative imaging characteristics and intraoperative management of the orbit during endoscopic resection of benign and malignant sinonasal tumors.

METHODS

This study was a case series at an academic tertiary care center. Retrospective chart review and prospective imaging assessment was performed on 159 cases treated between July 2009 and December 2012.

RESULTS

A total of 41 patients met predetermined inclusion criteria. Squamous cell carcinoma (17.1%) and inverted papilloma (31.7%) were the most common malignant and benign histology, respectively. Preoperative computed tomography (CT) scanning most commonly demonstrated erosion of the lamina papyracea (80.5%), whereas magnetic resonance imaging (MRI) most commonly illustrated loss of fat plane between tumor and extraocular muscle (53.1%). Endoscopic procedures to address the orbital interface included lamina papyracea resection (85.4%), dacryocystorhinostomy (26.8%), periorbita resection (26.8%), optic nerve decompression (7.3%), and orbital exenteration (2.4%). Oculoplastic surgery involvement was required in 31.7% of cases. Orbital complications included epiphora in 3 (7.3%) and diplopia in 2 (5.1%) patients. Postoperatively, no recurrences were noted in the benign group, whereas 6 (28.6%) recurrences were noted in 21 patients in the malignant group treated with intent to cure. Two patients died of disease due to distant metastases from mucosal melanoma and squamous cell carcinoma.

CONCLUSION

This represents the largest series to date on endoscopic management of the orbit in benign and malignant sinonasal tumors. A majority of these cases can be managed by a purely endoscopic approach with low complication and recurrence rates, although a subset still require adjunct open approaches for successful tumor extirpation.

To preserve or not to preserve the orbit in paranasal sinus neoplasms: a meta-analysis

Context The effect on survival of orbital evisceration on patients with paranasal sinus neoplasms has not been well established. Objective To review systematically the available literature concerning survival in patients who undergo surgery for paranasal sinus neoplasm with and without preservation of the eye. Data Source A retrospective meta-analysis of English and non-English articles using Medline and the Cochrane database. Eligibility Criteria Studies analyzing 5-year survival rates in patients who had orbital evisceration compared with orbital preservation for the treatment of paranasal sinus neoplasms were included in the final analysis. Data Extraction Independent review by two authors using predefined data fields. Data Synthesis A meta-analysis of four articles involving 443 patients was performed using the DerSimonian-Laird random-effects method. Results Our analysis revealed a total effect size of 0.964 in favor of preservation of the eye; however, these results are not robust, having a true effect size anywhere from 0.785 to 1.142 with a 95% confidence interval. Limitations Only retrospective observational studies were included because a prospective randomized study cannot be performed in this population. Conclusion Our study supports the notion that in select patients preservation of the eye may yield a different outcome when compared with orbital evisceration.

A study of tumours giving rise to unilateral proptosis

Study of distribution, clinical features, radiological features, histopathological aspects, management and outcomes of tumours giving rise to unilateral proptosis. This is a prospective study including 40 patients with benign and malignant tumours of orbital, paraorbital and other sites giving rise to unilateral proptosis. Final diagnosis was made following detailed radiological and histopathological examination. Then, treatment modality was decided, which included surgery, radiotherapy, chemotherapy or required combination. Proptosis was measured by simple/plastic ruler exophthalmometry method. The maximum number of cases 8(20%) were in age group 31-40 years. The youngest patient was 4 year old and the oldest was 80 years. M:F ratio was 1.85:1. Malignant tumours were 32(80%) and benign tumours were 8(20%). 12 cases were having 3 mm proptosis (minimum) and one case having 18 mm (maximum). Only 4(10%) orbital tumours were responsible for unilateral proptosis. Paraorbital tumours 34(85%) was the major cause for unilateral proptosis and 2(5%) were from distant sites. Surgery was the mainstay of treatment 14(35%), followed by combined (surgery + radiotherapy) 5(12.5%), chemotherapy 4(10%), There was 4(10%) mortality, 16(40%) improved 3(7.5%) had same status and 17(42.5%) deteriorated. Thus nasal obstruction is the commonest ENT presenting complains in these patients. The major cause of unilateral proptosis was found to be paraorbital tumours (34%). Thus, a case of proptosis should never be ignored but a thorough ENT and ophthalmic examination is necessary. As malignancy is one of the major cause of unilateral proptosis catching and treating them early will reduce mortality.

Orbital preservation in patients with esthesioneuroblastoma

Objectives Surgical resection in addition to adjuvant radiation with or without chemotherapy is the mainstay of treatment for esthesioneuroblastoma (ENB). However, management of patients with orbital involvement remains controversial. Historically, orbital exenteration has been advocated when there is evidence of periorbital invasion. Recently, the indications for orbital exenteration have become more selective and orbital preservation has been advocated. We report our experience with anterior craniofacial resection and orbital preservation in patients with ENB. Design Retrospective review of all patients diagnosed with esthesioneuroblastoma who underwent traditional open anterior craniofacial resection at the Massachusetts General Hospital/Massachusetts Eye and Ear Infirmary Cranial Base Center from 1997 to 2008. Results Sixteen patients were identified with a mean follow-up of 76 months. All patients underwent anterior craniofacial resection via an open approach and adjuvant proton beam radiation. Six of the 16 patients had evidence of either periorbital or lacrimal sac involvement at the time of surgery. All of these patients underwent periorbital resection to negative histologic margins with preservation of the orbit. Conclusion In our study, patients with ENB and periorbital invasion-who were treated with anterior craniofacial resection and periorbital resection with orbital preservation-had no evidence of decreased survival. In all patients, negative histologic margins of the periorbital resection were achieved.

Imaging and resectability issues of sinonasal tumors

Sinonasal tumors can invade into the critical structures of the anterior and central skull base. Although the determination of precise tumor histology is difficult with imaging, radiology is important in helping differentiate malignant from benign disease. Imaging helps to map the anatomical extent of intracranial and intraorbital tumor, which has important implications for staging, treatment and prognosis. Imaging also helps to facilitate and plan for craniofacial or endoscopic surgical approaches and radiation planning. This paper will review the locoregional invasion patterns for sinonasal tumors, with emphasis on their imaging features. The authors will discuss the implications for staging, resection potential, choice and details of radiotherapy with or without chemotherapy and prognosis. The imaging assessment of structures and compartments that are critical to the skull base team are highlighted: orbit, cavernous sinus, anterior cranial fossa dura/intracranial tumor, lateral frontal sinus, vascular tumor encasement, perineural tumor spread and tumor effect on the surrounding bony structures.

Oncologic and functional outcome of the preserved eye in malignant sinonasal tumors

BACKGROUND

The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement.

METHODS

In a retrospective study of 19 consecutive patients who underwent craniofacial resection or maxillectomy with preservation of orbital contents and adjuvant radiotherapy, the oncological outcome in terms of local recurrence and survival was analyzed. The functional outcome in the preserved eye was analyzed for the cases that did not recur in the orbit.

RESULTS

Nineteen patients were analyzed for their oncologic and functional outcomes. Fifteen patients underwent immediate reconstruction of the orbital support. Eight patients had local recurrences; 11 patients were disease free at the end of the follow-up. Squamous cell carcinoma has a high propensity for local recurrences (ie, 5 of 8 local recurrences were squamous cell carcinoma). Sixteen patients, in whom a satisfactory orbital tumor clearance was obtained, remained recurrence free in the orbit. All the preserved eyes retained adequate function after adjuvant radiotherapy.

CONCLUSIONS

Adequate local control with preserved visual function can be obtained with surgery and adjuvant radiation in appropriately selected malignant sinonasal tumors with orbital involvement. The preserved eye, if reconstructed appropriately, maintains good overall function with acceptable morbidity.

Esthesioneuroblastomas in an Asian population: similarities and differences

OBJECTIVE

Esthesioneuroblastoma is an uncommon tumor that is described widely among the Caucasians. In Singapore, we see predominantly Asian patients with esthesioneuroblastomas. From our experience, we note significant and interesting differences between our data on Asian patients and the published ones on the Caucasian patients.

METHODS

A retrospective review of all patients who underwent craniofacial resection for esthesioneuroblastomas was conducted from January 1997 to January 2010. Relevant data were collected and statistical analyses were carried out to determine factors that predicted mortality or complications.

RESULTS

Out of a total of 48 patients who underwent craniofacial resections, half had esthesioneuroblastomas (50%). There was a peak age distribution at the sixth decade of life and 62% of our patients were male. Both local and regional recurrence rate was 50%.

CONCLUSION

Majority of our Asian patients who underwent craniofacial resections had esthesioneuroblastomas. There is a male predilection, and we do not see a bimodal age distribution that is commonly reported.

Craniofacial surgery for esthesioneuroblastoma: report of an international collaborative study

Introduction Impact of treatment and prognostic indicators of outcome are relatively ill-defined in esthesioneuroblastomas (ENB) because of the rarity of these tumors. This study was undertaken to assess the impact of craniofacial resection (CFR) on outcome of ENB. Patients and Methods Data on 151 patients who underwent CFR for ENB were collected from 17 institutions that participated in an international collaborative study. Patient, tumor, treatment, and outcome data were collected by questionnaires and variables were analyzed for prognostic impact on overall, disease-specific and recurrence-free survival. The majority of tumors were staged Kadish stage C (116 or 77%). Overall, 90 patients (60%) had received treatment before CFR, radiation therapy in 51 (34%), and chemotherapy in 23 (15%). The margins of surgical resection were reported positive in 23 (15%) patients. Adjuvant postoperative radiation therapy was used in 51 (34%) and chemotherapy in 9 (6%) patients. Results Treatment-related complications were reported in 49 (32%) patients. With a median follow-up of 56 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 78, 83, and 64%, respectively. Intracranial extension of the disease and positive surgical margins were independent predictors of worse overall, disease-specific, and recurrence-free survival on multivariate analysis. Conclusion This collaborative study of patients treated at various institutions across the world demonstrates the efficacy of CFR for ENB. Intracranial extension of disease and complete surgical excision were independent prognostic predictors of outcome.

Periorbital fascia, its significance in total maxillectomy

In the surgical management of T3-T4 carcinoma of the maxillary antrum, involvement of the roof and/or erosion of the orbital floor, raises the possibility of the sacrifice of the orbital contents. While it is evident that the eyeball has to be sacrificed in the presence of gross disease, the indications when it can be preserved are not clear. Radiological assessment requires a minimum thickness of 4mm of the tissue. Standard anatomical texts describe the bony orbital floor and the orbital periosteum. In 1998 this author for the first time described a distinct fascial layer which encapsulates the orbital fat and termed it Periorbital Fascia. The purpose of this article is to draw attention to this anatomical structure and discuss the precise indications when the eyeball may be sacrificed or preserved. The conclusions are based on the experience with eighty two total maxillectomies for cancer performed over a period of 30 years. In the opinion of this author the following conclusions can be drawn. First, the orbital fat does not rest on the orbital periosteum as shown in anatomical texts, but is enclosed in a thin independent fascial layer termed the periorbital fascia. Secondly, in the event of malignant disease eroding the orbital roof, what is crucial is to know whether the orbital periosteum is involved and to know as to whether the disease process has reached the orbital surface of the periosteum. In case the disease is limited to the under surface of the orbital periosteum, the eyeball may still be preserved by a careful dissection between the periosteum and the periorbital fascia.

[Principles of radiation therapy for malignant tumors of the orbit and the periorbital area]

Primary malignant tumors of the orbit and the orbital adnexal area are rare, variform and in the majority of cases need an interdisciplinary treatment. According to tumor entity, tumor localization, and tumor extent the complete spectrum of radiotherapeutic therapy options is necessary. In the majority of malignant tumors, such as those of the eyelids, lachrymal glands, orbit, metastases, sarcoma or lymphoma, radiotherapy is used as a high energy therapy by means of medical linear accelerators as so-called teletherapy. In addition, new therapy methods, such as stereotactic highly conformal radiation or intensity-modulated radiation therapy (IMRT) were developed to achieve a higher local tumor control by a better configuration of the radiotherapy fields to the tumor borders and to contribute to a reduction of acute and chronic side effects in normal tissue by blurring of the dose. The application of ionizing radiation sources, such as so-called interstitial brachytherapy can also be just as carefully as effectively used. Particle beam radiotherapy is limited only to specially licensed centers and light hydrogen ions as proton therapy or carbon ions as heavy ion radiotherapy are in use. This overview will show the options as well as important progress in the field of radiotherapy in the treatment of tumors of the orbit and periorbital area.

Sparing the eye in craniofacial surgery for superior nasal vault malignant neoplasms: analysis of benefit

OBJECTIVE

To evaluate orbital and ophthalmologic function following standardized eye-sparing protocol for treating superior nasal vault malignant neoplasms.

DESIGN

A retrospective review of patients with sinonasal malignant neoplasms who underwent preoperative radiation therapy with or without chemotherapy and craniofacial resection (CFR) with eye preservation. Pretreatment and posttreatment ophthalmologic evaluations were performed.

RESULTS

A total of 59 patients underwent eye-sparing therapy between 1983 and 2005; 36 had invasion of the lamina with or without periorbital resection (61%). The most common abnormality was esthesioneuroblastoma (37 cases; 63%), most of which were Kadish stage C (n = 26). The most common preoperative ophthalmologic findings were motility disturbances (18 cases; 31%), afferent pupillary dysfunction and change in acuity (17 cases; 29%), and proptosis (17 cases; 29%). A total of 36 patients were available for long-term follow-up (mean follow-up, 61 months); 35 of these retained functional vision (97%); and 1 patient had a nonfunctional eye.

CONCLUSIONS

Standardized treatment for superior nasal vault malignant neoplasms using an eye-sparing CFR remains a sound approach both oncologically and ophthalmologically. Most patients with advanced disease present with ophthalmologic findings, and most posttreatment eye findings are notable only on detailed examination and either resolve spontaneously in the acute-care setting or do not require surgical repair.

Imaging Features and Decision Making in Retrobulbar Neuroendocrine Tumours in Horses ? Case Report and Review of Literature

A 25-year-old Haflinger gelding was evaluated for chronic-progressive unilateral exophthalmos. Ultrasonographic investigation and magnetic resonance (MR) imaging revealed a retrobulbar space-occupying mass to be the cause of eyeball displacement. Ultrasonographic features were not sufficient to specify the type and extension of the lesion. Magnetic resonance scans, however, clearly displayed an infiltrative intracranial growth pattern but sparing of orbital soft tissues. Based on MR appearance, tentative diagnosis of an orbital soft tissue neoplasia was made and subsequently confirmed by histopathological investigation. The latter revealed a poorly differentiated neuroendocrine tumour. Retrospectively, MR changes resembled those seen with neuroendocrine neoplasms of the human skull. Even if histopathology remains to be elucidated by cytological or histological inspection, MR imaging of equine orbital tumours should provide the criteria necessary for evaluating the therapeutic options and associated prognosis.

[Malignant paranasal sinus tumors. Diagnosis, therapy and results]

BACKGROUND

Malignant neoplasmas of the paranasal sinuses are rare and present usually in advanced tumor stage due to the lack of early clinical symptoms.

PATIENTS AND METHODS

In the last 10 years, 63 patients with paranasal malignancies were treated at the Department of Otolaryngology, Head and Neck Surgery of the University of Würzburg. 33% of the patients showed an occupational exposition (wood-processing or metal industry). At the time of the first visit to our institution 95% of the patients presented with an extensive disease, staged T3 and T4. Adenocarcinoma (24%), squamous cell carcinoma (22%) and malignant melanoma (19%) were the most common histologies. Surgery combined with radiotherapy was the treatment strategy in 55 patients (87%).

RESULTS

Patients with a complete surgical resection showed a higher 5-year-survival rate (77%) than patients with an incomplete resection (56%). In 38% (n=21) of the patients treated with surgery and radiotherapy, a local recurrence of the tumor was observed. This recurrence localised in the skull base and/or the orbita/periorbita occurred most frequently in the first (46%) or the second year (31%).

CONCLUSION

The prognosis of malignant paranasal tumors depends mainly on the control of the local tumor growth. Modern strategies of surgical treatment in combination with radiotherapy need to be implemented in an effort to achieve a continuous remission.

Orbital invasion by esthesioneuroblastoma

PURPOSE

Esthesioneuroblastoma is a rare malignancy arising from the olfactory mucosa in the nasal fossa, which can invade the orbit producing ophthalmic symptoms and signs. The purpose of this study was to present a case series and review the literature to assess the characteristics of orbital involvement by esthesioneuroblastoma.

METHODS

Retrospective case series of all patients treated for biopsy-proven esthesioneuroblastoma at the Royal Adelaide Hospital between 1992 and 2004.

RESULTS

Nine patients (5 male, 4 female) with a mean age of 50 years (range, 20 to 66 years) were reviewed. One case was classified as Kadish stage A, 1 as Kadish stage B, and 7 as Kadish stage C. Mean time from onset of symptoms to diagnosis was 17 months (range, 2 to 24 months). Radiologic orbital invasion was present in 4 cases and was associated with ophthalmic symptoms or signs in 3 of these cases. These included proptosis (2 cases), periorbital pain (1 case), decreased visual acuity (1 case), extraocular muscle restriction (1 case), and chemosis (1 case). One patient with symptoms secondary to orbital invasion was initially referred to and assessed by an ophthalmologist. All patients who had or went on to have development of orbital invasion had advanced disease at diagnosis. Treatment was surgical (9/9), with the addition of radiotherapy (6/9) and chemotherapy (2/9). Mean follow-up was 3.6 years (range, 0.5 to 8.5 years). Six of 9 patients had tumor recurrence. Two had metastasis. Five of 9 patients remained alive.

CONCLUSIONS

Orbital invasion by esthesioneuroblastoma is not uncommon. It is important to be aware of this malignancy because a significant proportion of patients will present with ophthalmic signs and symptoms.

Ethmoido-Orbital Tumors: Our Experience

No data in the literature report the specific invasion of the orbit from ethmoidal tumors, although such a pattern of involvement of the orbit frequently occurs because of the thin lamina papyracea separating the two structures. From January 1986 to January 2003, 38 patients with untreated primary ethmoidal malignancies were observed at the Unit of Maxillo-Facial Surgery of the University "La Sapienza" in Rome. Personal data were obtained from review of the personal clinical file of each. Orbital invasion was present in 24 patients with ethmoidal malignancy. Three stages of orbital invasion were identified. The average overall survival, with the Kaplan-Meyer method, was 61.4% after 1 year and 51.1% at 5 and 10 years. Intracranial involvement is the main element for short-term negative prognosis. Orbital exenteration is fundamental if grade III orbital invasion occurs because it ensures an improvement of the disease-free survival.

[Surgical treatment of malignant sinonasal tumors with orbital extension: 20 patients]

OBJECTIVE

The purpose of this work was to assess changes in surgical treatment of malignant sinonasal tumors with orbital extension, with or without orbital exenteration, on the basis of clinical, radiological and preoperative data.

MATERIAL AND METHODS

We conducted a retrospective analysis of twenty patients with malignant sinonasal tumors with orbital extension operated on from 1995 to 2002 in the ENT and head and neck department of the Strasbourg University Hospital. CT-scan and MRI were performed before surgery. When periorbital invasion was observed without orbital extension and confirmed by histological examination in the operative theatre, the orbit was preserved during the surgical procedure. Orbital exenteration was necessary for the other patients. Adjunct postoperative radiotherapy was performed in all patients (n=20). Clinical, radiological and surgical data were compared with patient follow-up to search for correlations between radiological signs and the difficult surgical decision for orbital exenteration.

RESULTS

For orbital extension, the histological examination performed in the operative theatre did not confirm the results of the preoperative CT-scan in 15% of patients and the preoperative MRI in 11%. In a first group of nine patients with bony wall extension (78%, 7/9) or periorbital extension (22%, 2/9), there were no cases of recurrence at six years follow-up. In a second group of eleven patients with intraorbital extension, orbital exenteration was not performed in two (18%) because of surgically unresectable massive extension. Four of the nine other patients who underwent orbital exenteration were free of local recurrence at ten months follow-up and five were considered to have achieved oncological cure at four years follow-up.

CONCLUSION

Preoperative CT and MRI are essential but the decision for orbital exenteration must be made on the basis of the histological examination performed during the operative procedure because imaging often underestimates tumor extension.

Orbitastabilisierung mit Suprabrow-Periosttranspositionslappen

BACKGROUND

Common reasons for orbital defects are midfacial traumas or defects following tumor resection within the sinu-orbital region. In these cases, reconstruction of the medial or inferior orbital wall often is required. Common materials for orbital reconstruction, such as titanium-mesh, are used where epithelialisation problems are frequently encountered.

METHODS

Three patients with extended resection of malignomas of the medial and inferior orbit wall were reconstructed with a myofascial transposition flap from the suprabrow region.

RESULTS

Orbital tumor infiltration was present in 11 of the 54 patients treated from 1997 to 2003 for tumors of the nasal region. In three cases, tumor extension to the medial and caudal orbital wall required extensive tissue resection, including the periorbit. In these cases, we created a new horizontal fascial flap from the suprabrow-region which stabilized the bulbus by fixation to the lateral maxilla. Follow-up 12 months after surgery showed good epithelialisation of the reconstructed region without functional deficits.

CONCLUSION

This previously undescribed fascial suprabrow-flap constitutes a valuable method in the reconstruction of large combined defects of the medial and caudal orbit wall profiting particularly from the autologous material used.

Imaging of neoplasms of the paranasal sinuses

The assessment of sinonasal malignancies requires a multidisciplinary team approach.Advances in pretherapeutic imaging have significantly contributed to the managementof sinonasal tumors. CT and MR imaging play complementary roles in the assess-mentand staging of these malignancies by determining the presence or absence of exten-sionof disease into the skull base and its foramina, the orbit, and the intracranial compartment.

Head and neck tumors other than squamous cell carcinoma

PURPOSE OF REVIEW

This review deals with classification and treatment of some rare nonsquamous cell carcinomas of the head and neck.

RECENT FINDINGS

Paranasal sinus tumor classification is under evaluation. Contrary to the past, the recent tendency is to build stage classifications on prognostic factors that mainly reflect limitations for adequate surgery, and not simply on dimensional criteria, which are more frequently used in TNM. Among sinonasal tract tumors new pathologic entities have been described. So far, little is known about their natural history and about the need to use pathologic classification to differentiate treatment. Recent advances in radiotherapeutic techniques, such as intensity-modulated radiotherapy, will probably have an impact on future treatment of paranasal sinus tumors. Several molecular targets (c-kit, HER-2/neu, androgen receptors) have been identified in salivary gland cancer. It is interesting to note that among different histotypes there is a trend toward a consistent expression of specific markers in specific cancers, suggesting a possible implication of them in the disease histogenesis. Not surprisingly these findings prompted clinical research with molecular targeted drugs.

SUMMARY

Nonsquamous cell carcinomas of the head and neck are rare neoplasms. A multidisciplinary team treatment plan is needed, in particular for skull base-located tumors. Salivary gland cancer displays several molecular targets that need to be investigated further.

Malignant tumors of the nasal cavity and paranasal sinuses

PURPOSE

To evaluate the role of radiation therapy in patients with nasal cavity and paranasal sinus tumors.

MATERIALS AND METHODS

Between October 1964 and July 1998, 78 patients with malignant tumors of the nasal cavity (48 patients), ethmoid sinus (24 patients), sphenoid sinus (5 patients), or frontal sinus (1 patient) were treated with curative intent by radiation therapy alone or in the adjuvant setting. There were 25 squamous cell carcinomas, 14 undifferentiated carcinomas, 31 minor salivary gland tumors (adenocarcinoma, adenoid cystic carcinoma, and mucoepidermoid carcinoma), 8 esthesioneuroblastomas, and 1 transitional cell carcinoma. Forty-seven patients were treated with irradiation alone, 25 with surgery and postoperative irradiation, 2 with preoperative irradiation and surgery, and 4 with chemotherapy in combination with irradiation with or without surgery.

RESULTS

The 5-year actuarial local control rate for stage I (limited to the site of origin; 22 patients) was 86%; for stage II (extension to adjacent sites (eg, adjacent sinuses, orbit, pterygomaxillary fossa, nasopharynx; 21 patients) was 65%; and for stage III (destruction of skull base or pterygoid plates, or intracranial extension; 35 patients) was 34%. The 5-year actuarial local control rate for patients receiving postoperative irradiation was 79% and for patients receiving irradiation alone was 49% (p =.05). The 5-, 10-, 15-, and 20-year ultimate local control rates for all 78 patients were 60%, 56%, 48%, and 48%, respectively. The 5-, 10-, 15-, and 20-year cause-specific survival rates for all 78 patients were 56%, 45%, 39%, and 39%, respectively. The 5-, 10-, 15-, and 20-year absolute survival rates for all 78 patients were 50%, 31%, 21%, and 16%, respectively. Of the 67 (86%) patients who were initially seen with node-negative disease, 39 (58%) received no elective neck treatment, and 28 (42%) received elective neck irradiation. Of the 39 patients who received no elective neck treatment, 33 (85%) did not experience recurrence in the neck compared with 25 (89%) of 28 patients who received elective neck irradiation. Most patients who received elective neck irradiation (57%) had stage III disease. Twenty-one (27%) of 78 patients had unilateral blindness develop secondary to radiation retinopathy or optic neuropathy; the complication was anticipated in most of these patients, because the ipsilateral eye was irradiated to a high dose. Four patients (5%) unexpectedly had bilateral blindness develop because of optic neuropathy. All four of these patients received irradiation alone.

CONCLUSION

Surgery and postoperative radiation therapy may result in improved local control, absolute survival, and complications when compared with radiation therapy alone. Elective neck irradiation is probably unnecessary for patients with early-stage disease.

Imaging of neoplasms of the paranasal sinuses

The assessment of sinonasal malignancies requires a multidisciplinary team approach. Advances in pretherapeutic imaging have significantly contributed to the management of sinonasal tumors. CT and MR imaging play complementary roles in the assessment and staging of these malignancies by determining the presence or absence of extension of disease into the skull base and its foramina, the orbit, and the intracranial compartment.

Orbital preservation in surgical management of sinonasal malignancy

OBJECTIVE

To determine the oncological and functional outcome when applying defined criteria for orbital preservation during surgical treatment of sinonasal malignancy encroaching on the orbital structures.

STUDY DESIGN

Retrospective consecutive review of patients in tertiary care center setting.

METHODS

Analysis of 66 patients undergoing surgical treatment for sinonasal malignancy encroaching on the orbit. Orbital preservation was performed in all patients with tumor extension up to and including resectable periorbital involvement. Minimum follow-up was 2 years. Detailed analysis of oncological and functional outcomes is included.

RESULTS

Of 66 tumors abutting or invading into the orbit, 54 were amenable for surgical treatment with orbital preservation and the remaining 12 underwent orbital exenteration. Histopathological findings were divided into five subgroups: squamous cell carcinoma, adenomatous carcinomas, sinonasal undifferentiated carcinoma, sarcoma, and other. Squamous cell carcinoma represented the largest subgroup (24 patients), and 5-year overall actuarial survival was not statistically different (P = 1.4; relative risk, 0.713) between patients treated with orbital preservation (53%) versus those undergoing exenteration (46%). Similarly, no difference in survival was found in the adenomatous carcinoma subgroup. Within the orbital preservation group as a whole, local recurrence occurred in 30% patients (16 of 54) compared with 33% patients (4 of 12) treated with orbital exenteration. Of note, eye-sparing surgery was associated with local recurrence at the original site of orbital involvement in only 7.8% of cases (4 of 54). Overall eye function was graded as functional without impairment in 54% of patients (29 of 54), functional with impairment in 37% (20 of 54), and nonfunctional in 9% (5 of 54). The most common abnormality was globe malposition (enophthalmos or hypophthalmos) that was seen in 34 patients (63%) and was associated with the lack of adequate rigid reconstruction of subtotal or total orbital floor or multisegment orbital defects. However, enophthalmos was asymptomatic in the majority of cases, and persistent diplopia occurred in only five patients (9%). Various ocular sequelae were present in 20 of the 49 patients (41%) with functional eyes. Radiation therapy increased the risk of ocular complications, in particular, optic atrophy, cataract formation, excessive dryness, and ectropion.

CONCLUSIONS

Selective orbital preservation is oncologically safe and is a worthwhile undertaking in attempting to maintain a functionally useful eye with surgical management of sinonasal malignancy encroaching on the orbit. Consideration should be given to rigid orbital reconstruction in larger defects resulting from subtotal or total orbital floor resection or resections involving two or more orbital walls.

Esthesioneuroblastoma: clinical presentation, radiological, and pathological features, treatment, review of the literature, and the University of Virginia experience

Esthesioneuroblastoma is a rare and malignant upper nasal cavity neoplasm involving the anterior skull base. Treatment includes surgery, radiotherapy, chemotherapy, or a combination. The ideal treatment modality has yet to be determined. Esthesioneuroblastoma often lies in proximity to the optic nerves, optic chiasm, and the orbit. Resection risks damaging these critical structures, and radiotherapeutic techniques, similar to those applied for paranasal sinus tumors, may damage these vital structures and result in late sequelae such as blindness and cortical necrosis. Management strategies for this neoplasm lack uniformity, and there is no universally accepted staging system. In this paper the authors discuss the clinical presentation, radiological and pathological features, and treatment of this rare, malignant skull base neoplasm, as well as review the literature. They also present their results and treatment regimen, which includes preoperative radio- and chemotherapy or 1) craniofacial resection if the lesion has a significant intracerebral component, or 2) frontal sinus resection if little intracranial extension exists.

Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review

BACKGROUND

The authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review.

METHODS

Two hundred twenty patients who were treated between 1975 and 1994 with a minimum follow-up of 4 years were reviewed retrospectively. A systematic review of published articles on patients with malignancies of the nasal and paranasal sinuses during the preceding 40 years was performed.

RESULTS

The 5-year survival rate was 40%, and the local control rate was 59%. The 5-year actuarial survival rate was 63%, and the local control rate was 57%. Factors that were associated statistically with a worse prognosis, with results expressed as 5-year actuarial specific survival rates, included the following: 1) histology, with rates of 79% for patients with glandular carcinoma, 78% for patients with adenocarcinoma, 60% for patients with squamous cell carcinoma, and 40% for patients with undifferentiated carcinoma; 2) T classification, with rates of 91%, 64%, 72%, and 49% for patients with T1, T2, T3, and T4 tumors, respectively; 3) localization, with rates of 77% for patients with tumors of the nasal cavity, 62% for patients with tumors of the maxillary sinus, and 48% for patients with tumors of the ethmoid sinus; 4) treatment, with rates of 79% for patients who underwent surgery alone, 66% for patients who were treated with a combination of surgery and radiation, and 57% for patients who were treated exclusively with radiotherapy. Local extension factors that were associated with a worse prognosis included extension to the pterygomaxillary fossa, extension to the frontal and sphenoid sinuses, the erosion of the cribriform plate, and invasion of the dura. In the presence of an intraorbital invasion, enucleation was associated with better survival. In multivariate analysis, tumor histology, extension to the pterygomaxillary fossa, and invasion of the dura remained significant. Systematic review data demonstrated a progressive improvement of results for patients with squamous cell and glandular carcinoma, maxillary and ethmoid sinus primary tumors, and most treatment modalities.

CONCLUSIONS

Progress in outcome for patients with nasal and paranasal carcinoma has been made during the last 40 years. These data may be used to make baseline comparisons for evaluating newer treatment strategies.