Prognostic factors influencing relapse of squamous cell carcinoma of the maxillary sinus

Stereotactic Radiotherapy for Localized External Auditory Canal Carcinomas: Report of Four Cases

External auditory canal carcinoma (EACC) is sometimes diagnosed at an early stage because it arises superficially in the ear canal and may cause ear obstruction symptoms early. In addition, in the early stage of EACCs, involvement of lymph nodes or distant metastases are reported less frequently. And so, stereotactic radiotherapy (SRT) concentrating high-dose radiation on the primary tumor may be an effective option. The aim of this study is to evaluate the preliminary results of upfront SRT for early-stage localized EACCs. Four cases (four females, 84 to 98 years old) with EACC of N0M0 (=no lymph node involvement and no distant metastasis) were treated. All four tumors (0.30 - 11.1 ml in volume) were diagnosed as squamous cell carcinoma histologically. A total dose of 24 - 33 Gy in 3 - 5 fractions (D95 [dose delivered to 95% of the target volume]=100% dose) was delivered by SRT using CyberKnife. All four cases were alive at the end of the follow-up period of 19 to 106 months. In three cases (tumor volume, 0.3 - 3.5 ml) the treated tumors had regressed or disappeared by the end of the follow-up period of 106, 28, and 19 months respectively. In the remaining one case, the treated tumor (11.1 ml) regrew and cervical lymph node metastasis occurred, and both were treated with SRT again 6 months and 20 months after the initial SRT respectively. The tumors were still stable at 39 months after the initial SRT. In conclusion, in three cases the small tumors had regressed or disappeared without lymph node involvement or distant metastasis. In the remaining case, additional SRT was performed for recurrent tumors, after which the patient's condition remained stable. SRT may be an effective option for early-stage EACCs.

Treatment Outcome and Patterns of Failure in Patients with Maxillary Sinus Cancer: Clinical Experience from a Regional Cancer Centre in North India

Treatment of maxillary sinus cancer poses several challenges because of its complex anatomy, close proximity to critical structures and majority of patients presenting at an advanced stage. Despite presence of several treatment approaches, the outcome in these cancers has remained dismal. This article examines its clinical behaviour and treatment outcome of these patients treated at our centre in past 7 years. In this retrospective study, 67 patients with carcinoma of maxillary sinus presented from January 2011 to December 2017 were analysed. All the patients reporting during this period were included except those who did not turn up after first visit. Of all the patients, 64.2% had squamous cell carcinoma. The majority of patients presented with advanced stage (IVA and IVB, 83.58%). Nodal disease at presentation was seen in seven patients (10.4%). Treatment to the primary site comprised of surgery and radiotherapy in 24 patients, radiotherapy alone in 22 patients and surgery alone in 12 patients. Statistical program for social sciences (SPSS) version 16 was used for all statistical analyses. The mean follow-up time was 25 months (range 3-72 months). Overall, 17 out of 41 patients who were treated with curative intent (41.5%) developed recurrence. Patients who underwent surgery followed by adjuvant radiotherapy did fairly better in terms of recurrence. Seven patients out of 17 (41.2%) could be salvaged by surgery or radiation. Only one patient developed distant metastasis to D8 vertebra. Patients who were treated with surgery and radiotherapy (either preoperative/adjuvant setting) had better disease-free survival. The results of the current study regarding the treatment of carcinoma of the maxillary sinus show feasibility and efficacy of multimodal therapy. Radical radiotherapy appears to be a feasible alternative in cases of inoperable tumours. Loco regional relapse remains a significant pattern of failure.

Stereotactic Radiosurgery and Stereotactic Radiotherapy for Malignant Skull Base Tumors

The role of stereotactic radiosurgery/stereotactic radiotherapy (SRS/SRT) for malignant skull base tumors was summarized and discussed. The treatment of skull base tumors remains challenging. Their total resection is often difficult. SRS/SRT is one useful treatment option for residual or recurrent tumors after surgical resection in cases of primary skull base tumors. If skull base metastasis and skull base invasion are relatively localized, they can be candidates for SRS/SRT. Low rates of cervical lymph node involvement in early-stage (N0M0, no lymph node involvement or distant metastasis) nasal and paranasal carcinomas (NpNCa) and external auditory canal carcinomas (EACCa) have been reported in the literature. Such cases might be good candidates for SRS/SRT as the initial therapy. We previously reported the results of SRS/SRT for various malignant extra-axial skull base tumors. In addition, treatment results of early-stage head and neck carcinomas were summarized. Those of our data and those of other reported series were reviewed here to clarify the usefulness of SRS/SRT for malignant extra-axial skull base tumors.

PI3K/AKT/mTOR pathway and autophagy regulator genes in paranasal squamous cell carcinoma metastasis

Although there are many studies on the role of PI3K/AKT/mTOR pathway and autophagy genes in the mechanism of head and neck cancer formation and prognostic significance, there is no study investigating the role of the genes in paranasal sinus carcinomas. The aim of the study was to assess the role of the PI3K/AKT/mTOR pathway and autophagy related gene expression changes in squamous cell carcinoma of paranasal sinuses with and without neck metastasis. Eight paranasal squamous cell carcinoma patients (five without and three with neck metastasis) were included. Tissues were obtained during the surgery. Total RNA was isolated from the tissues and cDNA synthesis was performed. Expression levels of the genes were determined using qRT-PCR method. The results were evaluated using the 2^-∆∆Ct method, and fold changes of the gene expression levels in primary tumor and neck metastasis tissues were calculated according to the normal tissue. Expression levels of both PI3K/AKT/mTOR pathway and positive regulators of autophagy were significantly increased in metastasis-related two groups, especially in neck metastasis tissues. The increase in PI3K/AKT/mTOR pathway and autophagy related gene expression levels may support the metastatic character in paranasal squamous cell carcinomas. This is the first study to assess autophagy related genes in paranasal sinus cancer at transcriptome-level. Support of the transcriptome-level findings by the further protein analyses will contribute to the illumination of the rare paranasal sinus cancer molecular biology.

Management of the neck in maxillary sinus carcinomas

PURPOSE OF REVIEW

To discuss and review the role for elective treatment of the neck in maxillary squamous cell carcinoma. Improvements in survival have been seen because of improved local therapies and control; therefore, the treatment of the neck has become a topic of debate.

RECENT FINDINGS

The risk of occult metastases in neck nodes is higher for T3-4 tumors. The rate of nodal relapse in the N0 neck without elective treatment is 8-15%. With elective irradiation the nodal relapse rate decreases. However, most nodal relapses are accompanied by local failure or distant disease. Local failure remains the most common site of failure and cause of death in this patient population.

SUMMARY

Treatment failure occurs overall in 62% of all patients, with local recurrence by far the most common site of treatment failure, which is rarely amenable to salvage therapy. Therefore, elective neck irradiation is not routinely indicated in the clinically N0 neck; those that recur only in the neck can be surgically salvaged more than 50% of the time.

Role of positron emission tomography in management of sinonasal neoplasms--a single institution's experience

OBJECTIVE

The objective of the study is to examine the utility of positron emission tomography (PET) for staging and restaging after treatment of paranasal sinus carcinomas.

STUDY DESIGN

Retrospective data review was done.

SUBJECTS AND METHODS

Patients selected underwent PET for sinonasal neoplasms from 2003 to 2008 at a tertiary care referral center.

RESULTS

Seventy-seven scans were reviewed from 31 patients. The pathologies included olfactory neuroblastoma (n = 9), squamous cell carcinoma (n = 6), sinonasal undifferentiated carcinoma (n = 6), sinonasal melanoma (n = 6), and minor salivary gland carcinomas (n = 4). The positive predictive value of studies performed for restaging at the primary, neck, and distant sites were 56%, 54%, and 63%; negative predictive values were 93%, 100%, and 98%, respectively. During restaging, 32% of patients were accurately upstaged secondary to neck or distant site involvement.

CONCLUSION

Positron emission tomography serves as a useful adjunct to conventional imaging in the management of sinonasal malignancies. Negative studies are effective in predicting absence of disease as seen in the consistently high-negative predictive values. Positive studies need to be viewed cautiously given the high rate of false-positive studies. When viewed in conjunction with clinical examination, endoscopic assessment, and focused biopsies, they may effectively result in a more accurate assessment of the extent of disease.

Select Neoplasms of the Sinonasal Tract

The sinonasal tract (SNT) includes the nasal cavity and paranasal sinuses (maxillary, ethmoid, frontal, and sphenoid) and may give rise to a variety of nonneoplastic and neoplastic proliferations, including benign and malignant neoplasms. The benign neoplasms of the SNT include epithelial neoplasms of surface epithelial origin, minor salivary gland origin, and mesenchymal origin. The spectrum of malignant neoplasms of the SNT includes epithelial malignancies, sinonasal undifferentiated carcinoma, malignant salivary gland neoplasms, neuroectodermal neoplasms, neuroendocrine neoplasms, melanocytic neoplasm, and sarcomas. This article concentrates on some of the more common types of benign and malignant neoplasms.

Postoperative radiotherapy for maxillary sinus cancer: long-term outcomes and toxicities of treatment

PURPOSE

To determine the effects of three changes in radiotherapy technique on the outcomes for patients irradiated postoperatively for maxillary sinus cancer.

METHODS AND MATERIALS

The data of 146 patients treated between 1969 and 2002 were reviewed. The patients were separated into two groups according to the date of treatment. Group 1 included 90 patients treated before 1991 and Group 2 included 56 patients treated after 1991, when the three changes were implemented. The outcomes were compared between the two groups.

RESULTS

No differences were found in the 5-year overall survival, recurrence-free survival, local control, nodal control, or distant metastasis rates between the two groups (51% vs. 62%, 51% vs. 57%, 76% vs. 70%, 82% vs. 83%, and 28% vs. 17% for Groups 1 and 2, respectively). The three changes were to increase the portals to cover the base of the skull in patients with perineural invasion, reducing their risk of local recurrence; the addition of elective neck irradiation in patients with squamous or undifferentiated histologic features, improving the nodal control, distant metastasis, and recurrence-free survival rates (64% vs. 93%, 20% vs. 3%, and 45% vs. 67%, respectively; p < 0.05 for all comparisons); and improving the dose distributions within the target volume, reducing the late Grade 3-4 complication rates (34% in Group 1 vs. 8% in Group 2, p = 0.014). Multivariate analysis revealed advancing age, the need for enucleation, and positive margins as independent predictors of worse overall survival. The need for enucleation also predicted for worse local control.

CONCLUSION

The three changes in radiotherapy technique improved the outcomes for select patients as predicted. Despite these changes, little demonstrable overall improvement occurred in local control or survival for these patients and additional work must be done.

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation

INTRODUCTION

Malignancies of the nasal and paranasal sinuses are uncommon tumors, accounting for only 3% of all aerodigestive tract neoplasms. Despite advances in surgical techniques and continued evolution of adjuvant therapies, the 5-year mortality remains unusually high at greater than 50%. In 1996, we begin utilizing a novel strategy in the treatment of advanced sinonasal carcinomas. This consisted of neoadjuvant selective intra-arterial cisplatin with concurrent radiation therapy (acronym RADPLAT) followed by a conservative craniofacial resection. We now report our results for 11 patients treated with this regimen.

METHODS

Between July 1996 and April 2003, 11 patients with advanced sinonasal malignancies underwent treatment utilizing the RADPLAT protocol followed by a planned surgical resection via a craniofacial approach. Patient charts, operative notes, follow-up clinic notes, and pre- and post-operative imaging studies were reviewed in detail for each subject.

RESULTS

Histopathological analysis of the tumors revealed seven squamous cell carcinomas (64%), two adenocarcinomas (18%), one adenoid cystic carcinoma (9%), and one sinonasal undifferentiated carcinoma (9%). T4N0M0 disease was present in nine patients (81%), and two patients had T3N0M0 disease (19%). Survival was calculated using the Kaplan-Meier method with an overall survival of 81% at 5 years and a progression-free survival at 5 years of 67%. Mean follow-up is 57.2 months ranging from 12 to 95 months.

CONCLUSIONS

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation results in a significant improvement in survival. This can be done safely with high response rates and excellent loco-regional control in T3 and T4 disease. Although are results are encouraging, there is a need for a cooperative, multi-institutional, prospective study.

Paranasal sinus malignancies: an 18-year single institution experience

OBJECTIVES

To characterize a single institution experience with management of paranasal sinus malignancies during an 18-year time period, report long-term survival rates, and identify prognostic factors.

STUDY DESIGN

Retrospective chart review.

METHODS

Studied were 141 patients treated for a paranasal sinus malignancy at a single institution from 1980 to 1997 with a minimum 3-year follow-up. Gender, age, TNM stage, anatomic site, pathology, treatment, and recurrence rates were reviewed. Multivariate analysis was performed to determine factors affecting survival.

RESULTS

The male to female ratio was 1.6:1, and the median patient age was 60 years. Most patients presented with T3/T4 or locally advanced disease (88%), N0 status (96%), and M0 status (96%). The maxillary sinus was the most commonly affected site (70%), followed by the ethmoid sinus (26%). The most common malignancy was squamous cell carcinoma (51%), followed by adenoid cystic carcinoma (12%) and adenocarcinoma (11%). Sixty-two percent of this study group underwent surgery as part of a multimodality curative treatment plan or alone as curative treatment. Eighteen patients (13%) had unresectable local disease and received non-surgical palliative treatment. Kaplan-Meier analysis revealed the 5-year and 10-year disease-specific survival was 52% and 35%, respectively. Multivariate analysis revealed T4 stage (P =.005), N-positive stage (P =.009), and M-positive stage (P =.018) negatively impacted survival. Seventy-two patients (51%) developed recurrent disease at a median time of 336 days after initial treatment.

CONCLUSIONS

Most patients with paranasal sinus malignancies presented with locally advanced disease. Advanced T stage, regional, and distant metastasis are highly predictive of poor survival. Recurrence rate is high and typically occurs within the first year after treatment.

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.

Treatment outcome of maxillary sinus squamous cell carcinoma

BACKGROUND

Optimal treatment policies of maxillary sinus carcinoma remain to be defined.

METHODS

Seventy-four patients with squamous cell carcinoma of maxillary sinus were treated at Department of Otolaryngology, Asahikawa Medical College between 1983 and 1997. The T classification according to the 1997 International Union Against Cancer was as follows: 9 with T2, 35 with T3, and 30 with T4. Eight patients had lymph node metastasis with N1 at diagnosis. Of 62 patients who started multimodality therapy that comprised preoperative radiochemotherapy including local irradiation with total dose of 50 grays along with concomitant intramaxillary arterial infusion of 5-fluorouracil with total dose of 5000 mg followed by total or partial maxillectomy, 59 received the complete therapy. Eleven patients had to be treated with radiotherapy alone, and 1 patient received postoperative radiotherapy. The median follow-up time for surviving patients was 117 months.

RESULTS

The 5-year overall survival, disease free survival, and local control (LC) rates for all patients were 58.5%, 63.7%, and 73.6%, respectively. The patients who underwent multimodality therapy showed significantly better 5-year overall survival, disease free survival, and LC rates as compared with those who underwent radiotherapy alone (68.5% vs. 9.1%; 73.2% vs. 18.2%; 84.0% vs. 18.2%; P < 0.0001 each). Multivariate analysis revealed that T classification and treatment modality are independent predictors for disease free survival.

CONCLUSIONS

The authors' treatment method, which did not include any complicated techniques, produced higher survival and LC rates because of high effectiveness of multimodality therapy. They concluded that their multimodality therapy could offer a better chance for cure from maxillary sinus carcinoma at many institutions.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases

BACKGROUND AND PURPOSE

Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution.

MATERIALS AND METHODS

A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110).

RESULTS

The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival.

CONCLUSIONS

This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

Neoadjuvant chemotherapy and radiation for inoperable carcinoma of the maxillary antrum: a matched-control study

A matched-control study comparing standard radiotherapy versus neoadjuvant chemotherapy and radiation was undertaken to clarify the effects of neoadjuvant systemic chemotherapy for locally advanced squamous cell carcinoma of the maxillary antrum. Thirty-four patients with inoperable maxillary cancer were treated with neoadjuvant chemotherapy and radiotherapy (Group II). Before starting radiotherapy, all patients in Group II received two or three cycles of neoadjuvant chemotherapy consisting of cisplatin and a 5-day continuous infusion of 5-fluorouracil with or without intravenous injection of vinblastine. Radiation doses ranged from 66 Gy to 75 Gy (median, 70 Gy). The response rate, patterns of failure, toxicity, and survival for Group II were compared with those for 34 stage-matched patients treated with radiation alone (Group I). Despite a higher response rate to neoadjuvant chemotherapy, the recurrence rate and patterns of treatment failure were not influenced by the addition of neoadjuvant chemotherapy. In most cases, neoadjuvant chemotherapy did not interfere with subsequent radiotherapy, and radiation-induced late complications occurred equally in both treatment groups. After a median follow-up of 48 months, there was no significant difference in 5-year actuarial survival or disease-free survival between the two treatment groups. Radiation alone for inoperable maxillary cancer was clearly suboptimal for improving local control and survival rate, but neoadjuvant chemotherapy in addition to standard radiotherapy failed to demonstrate any therapeutic advantage over radiation alone.

Clinical significance of neck node metastasis in squamous cell carcinoma of the maxillary antrum

PURPOSE

To further clarify the clinical significance of neck node metastasis in squamous cell carcinoma of the maxillary sinus (maxillary SCC).

MATERIALS AND METHODS

The medical charts of the 116 patients with maxillary SCC were retrospectively reviewed. Twelve patients (10.3%) presented initially with neck node metastases, and 14 (13.5%) of 104 node-negative patients subsequently developed regional recurrence during the follow-up period. The high-risk factors for neck node metastasis, patterns of regional failure, and survival for node-positive patients were analyzed with the patient cohort that had largely been treated with radiation alone.

RESULTS

Of the various factors, the tumor extension to the nasopharynx or oral cavity was the statistically significant determinants predictive of neck node metastasis at the initial diagnosis. During the follow-up period, regional failure was far less common than local failure (19.0% v 68.1%), and the majority of regional failures were accompanied by local recurrences. The oral cavity extension and control status of local disease were the high-risk factors for subsequent development of regional recurrence in node-negative patients. The overall 5-year survival rate for node-positive patients (16.7%) showed a poorer outcome compared with that for node-negative patients (31.3%), but it was similar to that of T4N0 patients (26.6%). Although patients who subsequently developed neck node recurrence during follow-up represented a dismal prognosis, uncontrolled local diseases in these patients still remained a major problem, resulting in a poor prognosis.

CONCLUSIONS

Despite an unfavorable prognosis of patients with neck node metastasis, an aggressive trial to achieve maximum local control of the primary tumor was considered to be more important than elective neck treatments.

Squamous cell carcinoma of the sinonasal tract invading the orbit

OBJECTIVE/HYPOTHESIS

The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival.

STUDY DESIGN

This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract.

METHODS

Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing.

RESULTS

Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results.

CONCLUSIONS

Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Simulation accuracy in radiotherapy for maxillary sinus tumors

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

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

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

The management of tumours arising in the maxillary antrum

Eighty-eight cases of tumours arising in the maxillary antrum undergoing treatment between 1967 and 1989 are reported. The series comprised 34 females and 54 males. Sixty-two patients had squamous cell carcinoma (SCC). Forty of those with SCC were treated by XRT only, four cases by surgery only, while the remaining 18 patients had surgery and post-operative XRT as a combined modality treatment. Early SCC (T2N0) was adequately controlled by radical radiotherapy alone with a 5-year survival of 69.1%. In more advanced SCC (T3N0 and (T4N0) radical radiotherapy alone was less successful with the 5-year survival falling to 19%. Combined modality treatment comprising radical surgery followed by radical postoperative radiotherapy improved 5-year survival in advanced SCC to 61%. It is therefore recommended that if patients are treated for cure, major surgery followed by radical postoperative radiotherapy is preferable in advanced squamous tumours ((T3/T4) of the maxillary antrum.

Potential improvement of three dimension treatment planning and proton therapy in the outcome of maxillary sinus cancer

Carcinomas arising in the maxillary sinus are challenging technical problems for radiotherapists due to the complexity of the regional anatomy and the close relations of the tumor to dose-limiting critical structures (eyes, optic nerves, optic chiasm, and brain stem). This study shows that an improvement in the dose distribution can be achieved with the use of three dimensional treatment planning and a combination of x-ray and proton beam arrangements. Although tumor coverage was identical when comparing dose distributions of X rays alone to X rays plus proton beam boost, the critical structures received less dose in the X rays plus proton beam plan. Because a superior dose distribution should yield an improved local control and reduced morbidity, a benefit in survival could be expected.

Paranasal sinus cancer

This is a review of 65 patients with paranasal sinus malignancies who were treated by radical surgery. Most patients received either pre- or postoperative radiotherapy. Twenty-nine tumours arose in the maxillary antrum, seventeen in the ethmoid labyrinth and the remainder from the vestibule, nasal septum, lateral nasal wall and vault. There were 58 epithelial cancers. The 5-year survival rate for patients with adenocarcinoma was 78%, and 70% for antral squamous cell cancer and esthesioneuroblastoma. None of the melanoma patients survived free of disease for 5 years. The 5-year survival rate for the 21 patients undergoing orbital exenteration was 50%, compared with 70% when the eye was spared. Twelve free flap revascularized tissue transfer flaps were used to reconstruct large cranial and sino-orbital defects.

Measurement of skin dose in primary irradiation of maxillary sinus carcinoma

Subcutaneous involvement frequently occurs in maxillary sinus carcinoma. Radical resection does not include removal of the skin at risk. In standard postoperative wedge-pair treatment plans, the surface dose is dependent upon beam weighting, beam energy, and patient contour. Thermoluminescent dosimetry (TLD) measurements were performed to evaluate the surface dose of patients undergoing postoperative irradiation of maxillary sinus carcinoma following primary resection. When 60 Gy was delivered to isocenter with a 45 degrees wedge pair and 6 MV photons with 1 cm bolus, the subcutaneous tissues at risk received approximately 30 Gy. Based upon presented TLD measurements, supplemental electron beam therapy to the subcutaneous tissues if primarily involved should be considered.

Carcinoma of the nasal cavity and paranasal sinuses: an analysis of radical radiotherapy

A retrospective analysis was conducted of 152 patients with carcinoma of the nasal cavity and paranasal sinuses who were treated with radical radiotherapy between 1975-1984. Stages at presentation were T1 11%, T2 18%, T3 27%, and T4 44%. The median follow-up was 61 months. The overall corrected 5-year survival was 47% and by T stage, T1 86%, T2 82%, T3 49%, T4 25%. Local control was achieved in 45% of cases following radiotherapy. Salvage surgery was attempted in 20 patients where radiotherapy failed and was successful in eight. Nodal disease was present in 6.5% of patients at presentation and 10.5% developed nodal disease after treatment. Nodal disease as sole relapse occurred in four patients and was associated with prolonged survival following radical salvage treatment. Distant metastatic disease occurred in 25 patients and of these 17 (68%) also had locoregional failure. Osteoradionecrosis occurred in three cases, and a further three cases developed bilateral blindness. We conclude that radical radiotherapy achieves results comparable to published data for combined surgery and radiotherapy with acceptable toxicity.

The value of treatment planning using CT and an immobilizing shell in radiotherapy for paranasal sinus carcinomas

This article describes a method which uses CT scans and immobilizing shells radiation treatment planning (CT-assisted planning) for paranasal sinus carcinomas and the value of this method on the treatment outcome. Results of the treatment for 82 patients who had CT-assisted planning were compared with that of 88 patients who had no such treatment planning. It has been concluded that the combined use of CT and the shell in treatment planning permitted a 3-dimensional localization of both the tumor and critical normal structures with great accuracy, leading to an improved long-term survival and a reduced complication rate. The multivariate regression analysis for predicting significant prognostic factors also confirmed the valuable role of CT in terms of survival and primary tumor control. The actuarial 5-year survival rate was 51% in all patients, whereas, by using CT-assisted planning, it was improved to 61%. The improved survival was observed among the patients with tumors of the suprastructures where tumors were located adjacent to the critical organs (brain and eye). Major complications attributable to radiation have included instances of brain and ocular damage. CT-assisted planning, however, has been proven effective in avoiding brain necrosis and preserving eye sight.

Cancer of the paranasal sinuses

Cancers of the paranasal sinuses, although rare, continue to cause the death of more than half of patients afflicted with them. The use of combined therapy (surgery and irradiation) has effected some improvement in control, particularly with better surgical and radiation techniques. Unfortunately, better results will not be obtained until earlier diagnoses can be achieved.

Maxillary squamous cell carcinomas staged by computed tomography

In 72 patients with maxillary squamous cell carcinoma, computed tomography (CT) alone was used for T-staging according to the AJC classification. Five, 31, and 36 tumors were diagnosed as T2, T3, T4, respectively. In N0 patients with a minimum follow-up of 2 years, local control rates for T2, T3, and T4 tumors were 33% (1/3), 64% (16/25) and 38% (9/24), respectively. Addition of maxillectomy to treatment seemed to have improved the local prognoses in T3 and T4 tumors. High radiation doses of 60 Gy or more seemed to be beneficial for patients with T3 tumors and without maxillectomy. CT will be of great help in classifying tumors objectively. But more importantly, it will reveal resectability and dictate treatment of choice by delineating the tumor extent precisely.