Esthesioneuroblastoma. Long-term outcome and patterns of failure--the University of Virginia experience

Update on olfactory neuroblastoma

Olfactory neuroblastomas are uncommon malignancies that arise from olfactory receptor cells located high in the nasal cavity. Accurate diagnosis plays a crucial role in determining clinical results and guiding treatment decisions. Diagnosis can be a major challenge for pathologists, especially when dealing with tumours with poor differentiation. The discovery of several molecular and immunohistochemical markers would help to overcome classification difficulties. Due to the paucity of large-scale studies, standardisation of diagnosis, treatment and prediction of outcome remains a challenge. Surgical resection by endoscopic techniques with the addition of postoperative irradiation is the treatment of choice. In addition, it is advisable to consider elective neck irradiation to minimise the risk of nodal recurrence. Molecular characterisation will help not only to make more accurate diagnoses but also to identify specific molecular targets that can be used to develop personalised treatment options tailored to each patient. The present review aims to summarise the current state of knowledge on histopathological diagnosis, the molecular biology and management of this disease.

Deconstructing Olfactory Epithelium Developmental Pathways in Olfactory Neuroblastoma

Olfactory neuroblastoma is a rare tumor arising from the olfactory cleft region of the nasal cavity. Because of the low incidence of this tumor, as well as an absence of established cell lines and murine models, understanding the mechanisms driving olfactory neuroblastoma pathobiology has been challenging. Here, we sought to apply advances from research on the human olfactory epithelial neurogenic niche, along with new biocomputational approaches, to better understand the cellular and molecular factors in low- and high-grade olfactory neuroblastoma and how specific transcriptomic markers may predict prognosis. We analyzed a total of 19 olfactory neuroblastoma samples with available bulk RNA-sequencing and survival data, along with 10 samples from normal olfactory epithelium. A bulk RNA-sequencing deconvolution model identified a significant increase in globose basal cell (GBC) and CD8 T-cell identities in high-grade tumors (GBC from ∼0% to 8%, CD8 T cell from 0.7% to 2.2%), and significant decreases in mature neuronal, Bowman's gland, and olfactory ensheathing programs, in high-grade tumors (mature neuronal from 3.7% to ∼0%, Bowman's gland from 18.6% to 10.5%, olfactory ensheathing from 3.4% to 1.1%). Trajectory analysis identified potential regulatory pathways in proliferative olfactory neuroblastoma cells, including PRC2, which was validated by immunofluorescence staining. Survival analysis guided by gene expression in bulk RNA-sequencing data identified favorable prognostic markers such as SOX9, S100B, and PLP1 expression.

Significance

Our analyses provide a basis for additional research on olfactory neuroblastoma management, as well as identification of potential new prognostic markers.

Operative Technique and Complication Management in a Case of Giant Esthesioneuroblastoma Resected by a Combined Transcranial and Endonasal Endoscopic Approach: Technical Case Report

BACKGROUND AND IMPORTANCE

Esthesioneuroblastoma (ENB) is a rare anterior skull base tumor derived from olfactory epithelium. There are very few operative videos in the literature demonstrating the surgical resection techniques for giant ENB because of their rarity and complexity. In this technical report, we demonstrate the microsurgical resection of a very large and complex high-grade ENB, initially deemed unresectable, through a bifrontal craniotomy and extended subfrontal approach combined with an endonasal endoscopic approach.

CLINICAL PRESENTATION

A 34-year-old woman presented with headaches, nasal congestion, and bloody nasal drainage. MRI showed a large nasal cavity mass with extension into the anterior cranial fossa and bifrontal lobes. There was significant bifrontal edema causing headaches and abutting the optic nerves. Initial management with surgical resection was offered to the patient for local tumor control and to preserve her vision. A combined bifrontal craniotomy and endonasal transsphenoidal approach was used for resecting this giant tumor. After achieving gross total resection, we reconstructed the anterior skull base in layers. She developed several postoperative complications which were appropriately managed.

CONCLUSION

We demonstrate the surgical resection of a giant ENB through a combined transcranial and endonasal endoscopic approach. We discuss the several postoperative complications in this complex case and the lessons learned.

Severe Thrombocytopenia in a Patient With a History of Olfactory Neuroblastoma

Olfactory neuroblastoma is a rare disease with no randomized clinical trials to guide treatment decision making. Surgery, radiation, and chemotherapy are all used for treatment, and prognosis is mostly determined by the histologic grade and clinical stage. While a neuroendocrine type of neoplasm is similar to small cell carcinoma, metastatic disease in olfactory neuroblastoma is rare. We present a case at our institution of an uncommon clinical course of relapsed olfactory neuroblastoma complicated by severe thrombocytopenia.

Olfactory Neuroblastomas: What Actually Happens in the Long-Term?

Objective: The aim of this study was to investigate the long-term oncologic outcome and review the state of the art in the management of olfactory neuroblastomas. Material and Methods: The records of all patients treated for olfactory neuroblastomas in two academic departments between 1975 and 2012 were evaluated retrospectively. Data on epidemiological parameters were collected (age, gender), along with staging (Kadish, Morita), histologic grading (Hyams), time and form of treatment, locoregional control, and disease-specific and overall survival. Patients with other malignant diseases, distant metastases of olfactory neuroblastomas at the time of initial diagnosis, a follow-up time of less than 5 years, or insufficient clinical-pathological data were excluded from further analysis. Results: In total, 53 cases made up our final study sample (26 men, 27 women; male–female ratio 0.96:1). Their mean age was 48.6 years (range: 10–84 years). The mean follow-up time was 137.5 months (4–336 months, SD: 85.0). A total of 5 out of 53 study cases (9.4%) showed metastatic involvement of the neck at the time of initial presentation. Local recurrence was detected in 8/53 (15.1%) and regional recurrence in 7/53 of our study cases (13.2%). Three patients (42.8%) from the group of cases with surgery as the sole form of management (7/53, 13.2%) died due to the disease. The cumulative disease-specific survival and overall survivalfor the whole group of patients were 88.6% and 63.6%, respectively. The cumulative disease-specific survival stratified by Kadish A/B vs. Kadish C/D as well as Hyams I/II vs. Hyams III/IV showed superior results for limited tumors, albeit without significance, and low-grade tumors (highly significant difference). Conclusion: Craniofacial or sometimes solely endoscopically controlled resection can warrant resection of the olfactory neuroblastoma with wide margins. However, locoregional failures and distant metastases can occur after a long period of time. The non-negligible incidence of regional recurrences, partly in unusual localizations, leads us to consider the need to identify the “recurrence-friendly” cases and to perform individualized elective irradiation of the neck in cases with high-risk features.

Cancer of the Paranasal Sinuses

Sinonasal malignancies rare and pathologically diverse and make up <1% of all malignancies. Due to their anatomical location, they can cause significant morbidity with involvement of surrounding critical structures. They often present at a late stage with insidious onset of symptoms. Treatment of sinonasal malignancies is challenging and they often require a multimodality approach with surgery, radiation, and chemotherapy. Outcomes are poor with 5-year overall survival around 32%, but this varies greatly depending on histologic subtype. There is an urgent need for more randomized controlled trials to better define the appropriate therapeutic regimens and to improve clinical outcomes.

The role of chemotherapy in the management of olfactory neuroblastoma: A 40-year surveillance, epidemiology, and end results registry study

BACKGROUND

In this retrospective surveillance, epidemiology, and end results (SEER) registry analysis, we investigated the role of chemotherapy (CT) in the treatment of olfactory neuroblastoma (ON), an exceedingly rare sino-nasal tumor typically treated with surgery and/or radiation therapy (RT).

METHODS

We analyzed all patients in the SEER registry diagnosed with a single primary malignancy of ON, a primary tumor site within the nasal cavity or surrounding sinuses, sufficient staging information to derive Kadish staging, and >0 days of survival, ensuring follow-up data. Receipt of CT in the SEER registry was documented as either Yes or No/Unknown.

RESULTS

Six hundred and thirty-six patients were identified. One hundred and ninety-five patients received CT as part of their treatment for ON. Following propensity score matching and inverse probability of treatment weighting, there was inferior overall survival (OS) (HR 1.7, 95% CI: 1.3-2.2, P = .001) and cancer-specific survival (CSS) (HR 1.8, 95% CI: 1.3-2.4, P < .001) for patients who received CT compared to those who were not treated with CT or had unknown CT status. On subgroup analysis, the only patient population that derived benefit from CT were patients who did not receive surgery and were treated with CT and/or RT (HR 0.3, 95% CI: 0.14-0.61, P < .001).

CONCLUSIONS

Based on this retrospective SEER registry analysis, the use of CT in the management of ON is associated with decreased OS. Our analysis suggests that patients who are considered nonsurgical candidates may benefit from the addition of CT.

Consolidating the Hyams grading system in esthesioneuroblastoma - an individual participant data meta-analysis

INTRODUCTION

Esthesioneuroblastoma (ENB) is an uncommon primary sinonasal tumor which can extend intracranially. Exactly how to classify them pathologically still remains discrepant; the Hyams grading system, for example, has not been universally adopted. This individual patient data (IPD) meta-analysis aimed to investigate the prognostic implication of each Hyams grade on patient outcomes.

METHODS

We accessed two electronic databases including PubMed and Web of Science. Raw patient data from potential articles were extracted. To examine the associations of various clinicopathological factors with the Hyams grades, we utilized Chi-square, t-test, and Mann-Whitney, as appropriate. Log-rank test and Cox regression analysis were used to elucidate the impact of the Hyams grades on recurrence-free survival (RFS), metastasis-free survival (MFS), and overall survival (OS) of ENB patients.

RESULTS

We included 33 studies with 492 ENB patients. We found significant associations of Kadish stages, Dulguerov stages, rates of recurrence, metastasis, and patient mortality with Hyams grade. Log-rank tests and Cox regression models demonstrated significant differences in RFS and OS of Hyams grade I - II, grade III, and grade IV patients. There was no statistical difference in RFS and OS of Hyams grade I and II. Radiotherapy was only effective in grade III - IV ENBs and chemotherapy showed no benefits to patients.

CONCLUSION

We verify that the Hyams grading system appears to be a reliable prognostic indicator to assess ENB patient outcomes. Consolidating the Hyams grading system into a three-tier system based on similar clinical outcomes of grades I and II may simplify this classification schema.

Surgery as Single-Modality Treatment for Early-Stage Olfactory Neuroblastoma: An Institutional Experience, Systematic Review and Meta-analysis

BACKGROUND

For olfactory neuroblastoma (ONB), the combination of surgical tumor resection and radiation therapy (RT) has been considered the "gold standard" in treatment protocols intended to cure.

OBJECTIVE

To summarize evidence on the treatment of ONB using surgery alone.

METHODS

A retrospective institutional case series, a systematic review of the literature, and an individual patient data (IPD) meta-analysis on only surgically treated ONB patients.

RESULTS

At our institution, a total of 10 patients were treated through surgery alone and remained alive and free of disease at last follow-up. The IPD meta-analysis on 128 patients revealed a disease-free survival (DFS) and overall survival (OS) of 67.7% and 75.4% at 5 years and 57.1% and 71.9% at 10 years, respectively. Univariate analysis showed that Kadish stage C/D and Hyams grading III//IV significantly affected OS (P = 0.000 and P = 0.000) and DFS (P = 0.000 and P = 0.002). For low-risk patients, the DFS was 80.6% at 5 years and 67.8% at 10 years, respectively.

CONCLUSIONS

Surgery alone is an equivalent alternative to combined treatment in carefully selected low-risk ONB patients with better outcome measures than previously reported.

Chemotherapy in Esthesioneuroblastoma/Olfactory Neuroblastoma: An Analysis of the Surveillance Epidemiology and End Results (SEER) 1973-2015 Database

OBJECTIVE

Chemotherapy has been proposed as an adjunct to primary local therapy in esthesioneuroblastoma (ENB)/olfactory neuroblastoma (ON), but its role has not been precisely defined. Here, we evaluated its role in ENB treatment.

MATERIALS AND METHODS

The Surveillance Epidemiology and End Results (SEER) database was queried for ENB/ON (International Classification of Diseases-3 9522). Cases met criteria for inclusion if they were unique, had a primary location in the nasal cavity, and had adequate information for Kadish staging derivation. Univariable and multivariable Cox analyses assessed chemotherapy treatment effect on disease-specific survival (DSS) and overall survival (OS). Multiple imputation addressed missing data. A P<0.05 was designated for statistical significance.

RESULTS

In adjusted multivariable analyses, chemotherapy treatment was associated with inferior DSS (hazard ratio [HR], 1.74; 95% confidence interval [CI], 1.21-2.51; P=0.003) and OS (HR, 1.71; 95% CI, 1.26-2.32; P=0.001). Among the subset with local or regional disease treated with surgery and/or radiation therapy, chemotherapy remained associated with inferior outcomes DSS (HR, 2.78; 95% CI, 1.63-4.74; P<0.001) and OS (HR, 2.18; 95% CI, 1.45-3.27; P<0.001). Chemotherapy treatment misclassification did not explain these findings.

CONCLUSIONS

This analysis does not support chemotherapy to improve either DSS or OS in primary ENB/ON treatment, after controlling for known ENB prognostic factors available from SEER. Other prognostic and treatment selection factors could exist which were not controlled in these analyses. Chemotherapy could beneficially affect outcomes other than DSS or OS. Although the concerns have been expressed regarding chemotherapy treatment misclassification in SEER, their analyses did not identify such misclassification as an explanation for our findings.

Clinical Outcomes and Multidisciplinary Patterns of Failure for Olfactory Neuroblastoma: The Ohio State Experience

Purpose  Olfactory neuroblastoma (ONB) is a rare head and neck cancer believed to be originated from neural crest cells of the olfactory membrane located in the roof of the nasal fossa. This study evaluates clinical outcomes and failure patterns in ONB patients of those patients treated with surgical resection at a high-volume tertiary cancer center. Methods and Materials  Thirty-nine ONB patients who underwent surgical resection at our institution from 1996 to 2017 were retrospectively identified. Univariate, multivariate, and survival analysis were calculated using Cox regression analysis and Kaplan-Meier log-rank. Results  Median follow-up time was 59 months (range: 5.2-236 months). The median overall survival (OS) and disease-free survival (DFS) for the entire cohort were 15 and 7.6 years, respectively. The 5-year cumulative OS and DFS were 83 and 72%, respectively. The 5-year OS for low Hyams grade (LHG) versus high Hyams grade (HHG) was 95 versus 61% ( p  = 0.041). LHG was found in 66% of the early Kadish stage patients compared with 28% in the advanced Kadish stage patients ( p  = 0.057). On multivariate analysis, HHG and positive node status predicted for worse OS and only HHG predicted for worse DFS. Of note, five patients (all Kadish stage A) who received surgical resection alone had no observed deaths or recurrences with a median follow-up of 44 months (range: 5-235 months). Conclusion  In this retrospective cohort, patients with positive nodes or HHG have significantly worse clinical outcomes. Future studies should explore treatment intensification for HHG or positive nodes.

Olfactory neuroblastoma pulmonary metastasis presenting as a solitary pulmonary mass in an adult: A case report with pathologic correlation

Pulmonary metastasis of an esthesioneuroblastoma is uncommon. In this report, we present a case of an esthesioneuroblastoma pulmonary metastasis in an adult. A 39-year-old man treated with surgical resection of olfactory neuroblastoma was found to have a solitary pulmonary mass on a surveillance computed tomography scan performed 5 years after undergoing primary surgery and radiation treatment. He underwent lobectomy, and histopathology revealed esthesioneuroblastoma metastasis. To our knowledge, no case of esthesioneuroblastoma metastasis presenting as a solitary pulmonary nodule has been described in peer-reviewed literature.

Induction Therapy Prior to Surgical Resection for Patients Presenting with Locally Advanced Esthesioneuroblastoma

Esthesioneuroblastoma (ENB) is a rare olfactory malignancy that can present with locally advanced disease. At our institution, patients with ENB in whom the treating surgeon believes that a margin-negative resection is initially not achievable are selected to undergo induction with chemotherapy with or without radiotherapy prior to surgery. In a retrospective review of 61 patient records, we identified six patients (10%) treated with this approach. Five of six patients (83%) went on to definitive surgery. Prior to surgery, three of five patients (60%) had a partial response after induction therapy, whereas two of five (40%) had stable disease. Microscopically margin-negative resection was achieved in four of five (80%) of the patients who went on to surgery, while one patient had negative margins on frozen section but microscopically positive margins on permanent section. Three of five patients (60%) recurred after surgery; two of these patients died with recurrent/metastatic ENB. In summary, induction therapy may facilitate margin-negative resection in locally advanced ENB. Given the apparent sensitivity of ENB to chemotherapy and radiotherapy, future prospective studies should investigate the optimal multidisciplinary approach to improve long-term survival in this rare disease.

Utility of adjuvant chemotherapy in patients receiving surgery and adjuvant radiotherapy for primary treatment of esthesioneuroblastoma

BACKGROUND

Past research established that surgery plus adjuvant radiotherapy (S + AR) improves overall survival (OS) in esthesioneuroblastoma (ENB). However, it is unknown if the addition of adjuvant chemotherapy (AC) further improves survival. The primary objective of this study was to compare survival among patients treated with S + AR alone to patients who underwent S + AR + AC.

METHODS

Retrospective review of patient records.

RESULTS

Thirty-eight patients met inclusion criteria for either S + AR or S + AR + AC treatment groups. The S + AR + AC group contained more patients with Kadish stage D disease, dural invasion, and positive histologic margins postsurgery. All S + AR + AC patients received platinum-based regimens, combined with etoposide in 67%. OS and recurrence-free survival did not differ between the two groups, even when restricting the analysis to patients with Kadish stages B and C disease.

CONCLUSION

Patients who received platinum-based AC did not exhibit improved survival compared to S + AR alone. Further investigation, preferably prospective, into the optimal use of systemic therapy in ENB is warranted.

Age distribution and age-related outcomes of olfactory neuroblastoma: a population-based analysis

Objective

The objective of the study was to describe the age distribution and to evaluate the role of prognostic value of age on survival in patients diagnosed with olfactory neuroblastoma (ONB). A population-based retrospective analysis was conducted.

Materials and methods

The population-based study of patients in the Surveillance, Epidemiology, and End Results (SEER) tumor registry, who were diagnosed with ONB from 1973 to 2014, were retrospectively analyzed.

Results

The cohort included 876 patients with a median age of 54 years. There was a unimodal distribution of age and ONBs most frequently occurred in the fifth to sixth decades of life. Kaplan–Meier analysis demonstrated overall survival (OS) and cancer-specific survival (CSS) rates of 69% and 78% at 5 years. Multivariable Cox regression analysis showed that age, SEER stage, and surgery were independent prognostic factors for CSS. The risk of overall death and cancer-specific death increased 3.1% and 1.6% per year, respectively. Patients aged >60 years presented significantly poor OS and CSS compared with patients aged ≤60 years, even in patients with loco-regional disease or in those treated with surgery.

Conclusion

This study highlights the growing evidence that there is a unimodal age distribution of ONB and that age is an important adverse prognostic factor.

An Atypical Esthesioneuroblastoma of the Inferior Nasal Cavity and Maxillary Sinus: Report of a Case

Esthesioneuroblastoma is a rare malignant tumor of the nasal cavity that originates from the olfactory epithelium. In this paper a very rare clinical presentation of this tumor is described. The tumor originated from the maxillary sinus and alveolar process, and was independent of the olfactory region. The patient was a 14-year-old girl presenting with facial swelling and nasal obstruction. Paranasal computed tomography showed a mass filling the right nasal cavity, infiltrating the alveolar process, eroding the anterior wall of the maxilla and invading the subcutaneous tissues of the cheek. Fine-needle aspiration and incisional biopsies identified an esthesioneuroblastoma. After neoadjuvant chemotherapy, we performed a right subtotal and left inferior maxillectomy and reconstructed the maxillary defect with a permanent obturator. At 2 years’ follow-up the patient is free of recurrence.

Esthesioneuroblastoma located in the thoracic extradural space: Case report

Objective

Esthesioneuroblastoma accounted for only 6% of the malignant nasal cavity neoplasms (ENB) is a rare tumor which originates from the olfactory epithelium. ENB’s are locally agresive and can metastasize by lymphatic and hematogenous routes. A patient with the mass on the nasal dorsum was reported in this article.

Case history

A 52–year-old-man admitted to the hospital with a 3 months history of progressive nasal obstruction, epistaxis and mass on the nasal dorsum. On rhinoscopy, a polypoid mass was seen in the both nasal cavity and intranasal biopsy with local anesthesia was performed. Histopathologic diagnosis of the tumor was Kadish stage B esthesioneuroblastoma. Tumor was excised by using bilateral endoscopic endonasal resection and lateral rhinotomy approach and paranasal radiotherapy performed postoperatively. Ten months after surgery, neck metastasis was occured and patient was underwent neck dissection. Twenteeth months after initial treatment, distant metastasis was identified on the T 10 vertebra and following the cranial and spinal radiotherapy to the neck he was free of local recurrence at follow up 13 months after surgery.

Conclusion

It has been known that the metastasis of the ENB to the spinal cord is an uncommon event, and it occurs often years after initial diagnosis. MRI scan is helpful for making the diagnosis, and surgery is the treatment of choice for obtaining diagnostic tissue and debulking the tumor. Radiotherapy is also a mainstay of postoperative treatment.

Risk of Delayed Lymph Node Metastasis in Clinically N0 Esthesioneuroblastoma

Objective To determine both the rate of delayed cervical lymph node metastasis in patients with esthesioneuroblastoma (ENB) and a clinically N0 untreated neck and the effectiveness of salvage treatment. Design Retrospective review. Setting Tertiary academic medical center. Participants All patients from January 1, 1965, to December 31, 2010, who received definitive treatment for ENB. Main Outcome Measures The study involved 52 patients: 27 (52%) patients underwent surgery and adjuvant radiotherapy (SART) to the primary site only and 25 (48%) underwent surgery alone (SA) as treatment of the primary site, without elective neck dissection. Results Median follow-up for the SART group was 10 years versus 15.7 years for the SA group. The 10-year delayed cervical lymph node metastasis estimate is 41%. With median follow-up of 47 months after salvage treatment, the 4-year cervical lymph node recurrence-free survival estimate is 70%; the 5-year overall survival estimate is 39%. Conclusions Delayed cervical lymph node metastases are common, indolent, and salvaged effectively in most patients. We propose that patients with ENB and clinically N0 cervical lymph nodes may choose to forego elective neck dissection or elective neck radiotherapy in favor of neck observation within their initial treatment.

Esthesioneuroblastoma With Poor Outcome Despite Extensive Treatment

Esthesioneuroblastoma is a rare malignant tumor of neuroectodermal origin. It usually presents with nonspecific symptoms, such as nasal obstruction, epistaxis, and pain, but has an aggressive course if the treatment is delayed. The authors report a case of esthesioneuroblastoma in a 47-year-old woman, treated with extensive surgical resection, radiotherapy, and chemotherapy. Despite intensive treatment, the patient developed a local recurrence with systemic metastasis and succumbed 4 months later.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

Long-term outcomes of patients with esthesioneuroblastomas: A cohort from a single institution

OBJECTIVE

Esthesioneuroblastoma is a rare cancer. The purpose of this study was to review the long-term outcomes of patients with esthesioneuroblastomas (ENBs) who were treated at a single institution.

MATERIALS AND METHODS

One hundred thirteen patients with biopsy-proven ENBs between June of 1979 and November of 2014 were retrospectively reviewed. There was 1 patient at stage A, 23 stage B and 89 stage C according to Kadish classifications. The initial treatments included pre-operative radiotherapy (RT) followed by surgery in 11 patients, surgery followed by post-operative RT in 51, primary RT in 47, and surgery in 3, and only a single patient was treated with palliative chemotherapy alone.

RESULTS

The median follow-up was 75months, 5-year overall survival (OS), loco-regional control rate (LRC) and distant metastasis-free survival were 65%, 73% and 67%, respectively. The OSs at 5years were 91% in the pre-operative RT group, 82% in the post-operative RT group, and 50% in the primary RT group (p<0.001). Regarding the patients in early disease stages (Kadish A/B), no survival differences were observed between primary RT and combination treatment. Regarding the node-negative Kadish C disease patients, combination of surgery and RT elicited superior survival, and pre-operative RT yielded the best prognoses. Distant failure rate is over 60% for N-positive disease, chemotherapy may play a more important role.

CONCLUSIONS

The optimal treatment policy for ENBs remains the combination of surgery and radiotherapy. When choosing the most adequate therapy for ENBs, disease stage, age and lymph nodes status should be taken into consideration.

Possible esthesioneuroblastoma metastasis to paranasal sinuses: Clinical report and literature review

BACKGROUND

Local recurrence, and regional and distant metastases, respectively, develop in 30% and 15% of patients with esthesioneuroblastoma (ENB).

METHODS

This case report includes 3 patients with unusual recurrences of ENB in the sinonasal tract.

RESULTS

Patient 1 developed ENB in the bilateral maxillary sinuses after unilateral endoscopic resection of a left ENB followed by postoperative proton radiotherapy. Patient 2 developed ENB at the left optic-carotid recess 7 years after a craniofacial resection and postoperative radiotherapy. Patient 3 developed ENB over the left zygomatic process of the maxilla 4 years after a cranioendoscopic resection and postoperative radiation therapy for ENB of the ethmoid sinuses with intracranial extension. The possibility of venous tumor emboli must be considered as a likely etiology. However, alternative explanations include the development of a second primary or potential transformation because of tumor signaling.

CONCLUSION

We present 3 cases that may represent metastasis of ENB within the sinonasal tract.

[The results of combined treatment patients with olfactory neuroblastoma in material of Cancer Center in Warsaw]

The results of combined treatment patients with olfactory neuroblastoma in material of Cancer Center in Warsaw

AIM

The analysis of the results of combined treatment patients with olfactory neuroblastoma in material of Cancer Center in Warsaw.

MATERIAL

Authors present material of 27 cases olfactory neuroblastoma treated in Cancer Center of Warsaw from 1965 to 2008. The median age was 44 years (range 10-74). The median observation was 72 months (range 2-235).The tumors were seen in 15 women and 12 men. According to Kadish staging there were one A, eight B, and seventeen C stage tumor. The patients in stage A and B was treated by surgery and radiotherapy (mean dose in whole material was 57.15 Gy range 44-70). Five patients in stage C was treated by surgery, radiotherapy and adjuvant chemotherapy. Five patients were treated by neoadjuvant chemotherapy and radiotherapy. Six patients underwent surgery and radiotherapy. One patient was died during adjuvant chemotherapy. One patient in stage B had local recurrence, one local recurrence and metastases and one had only metastases. In stage C 4 patients was died because of metastases, one had local recurrence and, 3 was died because of other reasons. Patients who was failed, underwent surgery, chemotherapy or radiotherapy, it was dependent of clinical situation.

RESULTS

A complete regression was seen in 100% patients in early stages (A and B) and 82% patients in stage C. The 5-year local progression-free survival rate was 91% in early stages and 60% in stage C. The LPFS in whole group was 66.7%. The 5-year disease-free survival rate was 91% in early stages, 46% in stage C. The DSF rate in whole group was 44.4%. The 5-year overall survival rate was 80% in stages A and B, 41.2% in stage C. The OS in whole group was 55.6%. The 5-year survival rate was 20% for patients who had recurrence and/or metastases.

CONCLUSION

A combination of surgery and radiotherapy appears to be adequate treatment for early stages (A and B) olfactory neuroblastoma. There are still no clear protocols of treatment patients in stage C.

Treatment of esthesioneuroblastomas

OBJECTIVE

To analyze the clinical features, treatment outcomes, pattern of failures, and course of the disease of a cohort of patients treated for esthesioneuroblastoma (ENB) with craniofacial resection (CFR) at a single institution during a 12-year period.

MATERIAL AND METHODS

Retrospective analysis of 11 patients with ENB treated with CFR in a tertiary care academic medical center from 1998 to 2009.

RESULTS

Median age at diagnosis was 51 years (range 41-67 years). The most common presenting symptom was nasal obstruction (91%). Four patients (36%) presented with Kadish stage B, six patients (55%) with Kadish stage C, and one patient (9%) with Kadish stage D. The initial treatment was craniofacial resection (CFR) alone for three patients (23%), CFR followed by postoperative radiation therapy (RT) in seven patients (64%), while one patient (9%) received both neoadjuvant and adjuvant RT in addition to surgery. The mean and median follow-up times were 66 and 58 months, respectively (range 23-158 months). Seven patients are currently alive with no evidence of disease (64%), while two patients are alive with disease (18%). Overall survival was 100% at one year postoperatively and 80% five years after the primary treatment. The progression free survival was calculated to 73% at one year and 64% at five years.

CONCLUSIONS

ENB is an uncommon diagnosis with an incidence of 0.037/100,000 persons/year in the catchment area of our institution. Treatment can be challenging, especially with advanced disease. CFR with RT offers good oncologic disease control with minimal morbidity.

Olfactory neuroblastoma: a 35-year experience and suggested follow-up protocol

OBJECTIVES/HYPOTHESIS

To validate a follow-up protocol based on the long-term outcomes and recurrence rates in patients who have undergone surgical treatment for olfactory neuroblastoma.

METHODS

A prospective review of all patients treated for olfactory neuroblastoma at our institution over a 35-year period.

RESULTS

Ninety-five patients were treated from 1978 to 2013, with craniofacial (65 patients) or endoscopic resection (30 patients). Duration of follow-up ranged from 1 to 309 months (mean, 88.66 months). Fifty-six patients were alive and well, and 13 were alive with recurrent disease. Twenty-one patients had died of disease, and three had died of intercurrent disease. Overall survival was 83.4% at 5 years and 76.1% at 10 years. Disease-free survival at 5 years was 80% and at 10 years was 62.8%. A Cox regression analysis showed orbital extension and intracranial involvement to be significant independent factors affecting outcome. Local and regional recurrence occurred after an average of 49 months but with a range of 3 to 233 months.

CONCLUSIONS

In our series, olfactory neuroblastoma most commonly recurred within the first 4 years but can recur very late, after 19.4 years in one case. There is currently no universally accepted follow-up regime, but even late recurrence is eminently treatable. We therefore propose a protocol for lifelong follow-up with both clinical examination and serial imaging, including the neck and entire intracranial compartment.

LEVEL OF EVIDENCE

4.

Esthesioneuroblastoma as an unusual cause for dystopia

Abstract Esthesioneuroblastoma, also known as olfactory neuroblastoma, is an uncommon malignant neoplasm arising from the olfactory epithelium in the roof of the nasal cavity. There are very few case reports published worldwide. The common presenting symptoms of Esthesioneuroblastoma are unilateral nasal obstruction (70%), epistaxis (50%), anosmia, rhinorrhoea, facial pain, headache, excessive lacrimation and rarely proptosis and visual disturbance. Apart from being locally aggressive, it metastasizes by haematogenous and lymphatic routes. We report an extremely rare case of esthesioneuroblastoma in a 20-year-old man with orbital involvement presenting as dystopia. This rare tumour should be considered in the differential diagnosis for young patients presenting to ophthalmic outpatient department with dystopia.

Craniofacial resection and its role in the management of sinonasal malignancies

Sinonasal malignancy is rare, and its presentation is commonly late. There is a wide variety of pathologies with varying natural histories and survival rates. Anatomy of the skull base is extremely complex and tumors are closely related to orbits, frontal lobes and cavernous sinus. Anatomical detail and the late presentation render surgical management a challenging task. A thorough understanding of anatomy and pathology combined with modern neuroimaging and reliable reconstruction within a multidisciplinary team is imperative to carry out skull base surgery effectively. While endoscopic approaches are gaining credibility, clearly, it will be some time before meaningful comparisons with craniofacial resection can be made. Until then, craniofacial resection will remain the gold standard for managing the sinonasal malignancies of the anterior skull base, as it has proved to be safe and effective.

Esthesioneuroblastoma

Esthesioneuroblastoma is a rare malignant neoplasm in the olfactory region of the nasal cavity and anterior skull base. Diagnosis and staging require anatomic imaging and careful pathologic assessment. Standard treatment is anterior craniofacial resection with postoperative irradiation. The role for chemotherapy is not defined, but is generally for the most advanced cases and used in the neoadjuvant setting and/or postoperatively with irradiation. Prognosis is favorable; however, metastasis rates remain relatively high. Regional and distant metastasis portends a poor outcome. Intensity-modulated radiation treatment and endoscopic surgery have reduced morbidity, but outcomes with these techniques must be fully evaluated.

Salvage Treatment of Local Recurrence in Esthesioneuroblastoma: A Meta-analysis

Esthesioneuroblastoma has a local recurrence rate of ∼30%, but no standard regimen for salvage of local recurrence has been established. We report data from 678 patients from series published since 1990, with a risk reduction analysis of salvage with surgery, radiation, or combined surgery and radiation therapy. We found a 28.5% rate of local recurrence after treatment, and a 42.6% rate of successful salvage with surgery, radiation, or combined treatment. The odds ratio for successful salvage, defined as disease-free survival for at least 1 year, was not significantly different for combined surgery and radiation versus surgery alone or radiation alone or for surgery alone versus radiation alone. The salvage odds ratio for combined surgery and radiation therapy versus radiation therapy alone, 3.5, approached, but did not reach statistical significance. This study reveals a reasonable rate of successful salvage of local esthesioneuroblastoma recurrence using surgery, radiation, or combined surgery and radiation.

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.

Late occurrence of drop metastasis to the spine in a case of esthesioneuroblastoma

Esthesioneuroblastoma is an aggressive neuroectodermal tumor that originates from the olfactory mucosa and often recurs locally. Distant metastasis of esthesioneuroblastoma has been described, but there are few reports of drop metastasis to the spinal cord. Here, we report a case of multiple drop metastases to the cervical, thoracic, and lumbar regions of the spinal cord that occurred 18 years after resection and radiotherapy of the original anterior cranial fossa lesion. There was no evidence of local recurrence. The symptomatic lesion was treated with resection and adjuvant chemotherapy. The options available for treatment of this disease are summarized with a review of the few reported cases of spinal metastasis of esthesioneuroblastoma.

Long-term results of 28 esthesioneuroblastomas managed over 35 years

BACKGROUND

The purpose of our study was to assess the long-term results in the management of patients with esthesioneuroblastoma.

METHODS

A total of 28 patients were retrospectively reviewed to analyze their clinical features, treatment outcomes, pattern of failures, and course of the disease.

RESULTS

The patients were classified as 2 patients with T1, 10 patients with T2, 10 patients with T3, and 6 patients with T4; the results of all were included in this study. Twenty-six patients underwent surgery and 23 had postoperative radiotherapy over the tumor bed, only 9 had radiotherapy over the nodes. The average follow-up was 99.11 months. Fifteen-year and 20-year disease-specific and disease-free survival rates were 88.6% to 66.4% and 59.6% to 29.8%, respectively. Six patients had recurrences and 60% of them occurred more than 10 years after treatment. In the first decade, nodal recurrences appeared earlier than local ones when patients with N0 did not undergo neck irradiation.

CONCLUSION

Surgery on patients with T presentations and adjuvant radiotherapy on T and N0 neck presentations seem to be essential to treat esthesioneuroblastoma. A follow-up for a minimum of 20 years is necessary to ensure complete cure.

The developing management of esthesioneuroblastoma: a single institution experience

Esthesioneuroblastoma remains a challenging disease because of its rarity, the complexity of surrounding structures, missing opinions of optimal treatment protocol, and complications associated with necessary surgery. Our objective was to analyse the management and outcome of a cohort of patients with esthesioneuroblastoma from 1990 to 2009 in a tertiary medical centre. There were 17 eligible patients (8 males and 9 females) with the median age of 53 years (range 20-75 years). An obvious inconsistency was noted in the management of the various tumours of the present series during the two decades due to a lack of a uniform treatment protocol. The median follow-up time was 57.5 months (range 3-158 months). Nine patients (seven with curative treatment intent) died of the disease with the median time from diagnosis to death of 60 months (range 3-161 months). Eight patients had no evidence of the disease at last follow-up visit (median 76 months, range 24-119 months). Recurrences were documented in seven of the patients. The median time from end of primary treatment to a recurrence was 57 months (range 6-110 months). The 5-year overall survival and disease-free survival was 68 and 62%, respectively. The management of ENB should be planned by an experienced head and neck surgeon as part of a multidisciplinary team in a tertiary referral setting. Multimodality therapy with long-term follow-up is preferable and should be set based on the available disease-specific classifications for clinical staging and histopathological grading.

Retained role of surgery for olfactory neuroblastoma

BACKGROUND

Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol.

METHODS

This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted.

RESULTS

There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%.

CONCLUSIONS

There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.

Ectopic olfactory neuroblastoma: report of four cases and a review of the literature

Our objective is to present a short series of four rare cases of ectopic olfactory neuroblastoma. Our methods present four case reports of ectopic olfactory neuroblastoma and a review of the literature for management and treatment of this disease. The results indicate short case series reports of ectopic olfactory neuroblastoma arising from the anterior ethmoidal sinuses, the nasopharynx, the lateral nasal wall and the floor of the nose. The discussion focuses on likely origins of ectopic olfactory neuroblastoma, its clinical features and management. We conclude that ectopic olfactory neuroblastoma is a rare disease. Treatment principles are the same for non-ectopic disease and guided by extension into adjacent structures such as the orbit or anterior cranial fossa and usually involves surgery with or without adjuvant radiotherapy.

Posttreatment prognosis of patients with esthesioneuroblastoma

OBJECT

There is no Class I evidence to guide the appropriate management of esthesioneuroblastoma (EN). Most data currently guiding treatment come from small- or modest-sized series gathered at individual centers that have concluded that surgery with radiotherapy is the preferred treatment. In this study, the authors summarize the published literature on treatment outcomes in patients with EN. The objective was to ascertain what variables predict prognosis in these patients and to determine the relative effect of different therapies.

METHODS

The authors identified 205 published studies containing treatment outcomes for surgery, radiotherapy, chemotherapy, or multimodal treatment. Using Kaplan-Meier analysis, the survival of patients who received surgery was compared with that in those who received surgery and radiotherapy. Additionally, Kadish staging was compared with low- and high-grade Hyams criteria to assess for subgroup prognostic significance in survival differences.

RESULTS

Nine hundred fifty-six patients met the inclusion criteria, with a median follow-up time of 3 years. Kaplan-Meier analysis demonstrated no difference in survival between patients who underwent surgery alone and those who underwent surgery plus radiotherapy at 5 years (78 vs 75%) or 10 years (67 vs 61%, respectively) (p = 0.3). Univariate analysis demonstrated worse survival in cases involving Kadish Grade C tumors, Hyams Grade 3 and 4 tumors, and in patients older than 65 years of age. Multivariate analysis demonstrated that Hyams Grade 3 and 4 lesions carried significant risk (proportional hazard = 4.83, p < 0.001) with 5- and 10-year survival of 47 and 31%.

CONCLUSIONS

A biopsy should always be obtained in cases suspected of EN because histology is a strong prognostic indicator and will help guide appropriate treatment. Unimodal surgery and combined surgery/radiotherapy appear to be of equivalent efficacy with respect to survival in patients with EN. Chemotherapy should be considered in high-grade EN.

Olfactory neuroblastoma: a review and update

Olfactory neuroblastoma (ONB) is a malignant neuroectodermal tumor that typically occurs in the superior nasal cavity. It is a distinct entity with features that include nesting, low-grade stippled nuclei, and neurofibrillary stroma with formation of pseudorosettes. It has a distinctive immunoprofile that includes keratin negativity, neuroendocrine marker positivity, and S100 positive sustentacular cells, which surround the nests of tumor in a supportive manner. Although the typical clinicopathologic features leave little room for misinterpretation, the wide variability in this tumor may cause diagnostic difficulty. This includes immunophenotypic diversity or patchy staining with immunomarkers, wide spectrum of grade and histology, posttreatment changes, and occasional divergent differentiation. In addition, problems in sampling, preservation, and clinical localization may make the diagnosis more challenging. A large group of tumors may show morphologic overlap with ONB, with some mimicking low-grade tumors, whereas others mimic high-grade tumors. This differential diagnosis has important treatment and prognostic implications. Further complicating the issue is that many of the mimics themselves may show great morphologic and immunophenotypic variability. This manuscript will review the typical clinical and pathologic features of ONB, address the great variability of ONB in our experience, will focus on the differential diagnosis and report on recent findings in these tumors including molecular genetics where applicable.

Undifferentiated malignant neoplasms of the sinonasal tract

CONTEXT

The most commonly encountered malignant neoplasms of the sinonasal tract are the keratinizing and nonkeratinizing types of squamous cell carcinoma. However, this complex anatomic region may represent the site of aggressive, non-squamous cell epithelial and nonepithelial malignant neoplasms of varying histogenesis, which are grouped under the term undifferentiated malignant neoplasms. Frequently, these undifferentiated malignancies share clinical and light microscopic features, which makes differentiation of one from the other virtually impossible without the use of adjunct analyses (eg, immunohistochemistry, electron microscopy, or molecular biologic studies). These tumors often are clinically aggressive and usually fatal, despite all attempts at controlling disease. Nevertheless, differentiating these tumors has clinical import because advances in therapeutic intervention may increase survival with good quality of life, and in some instances may achieve a cure.

OBJECTIVE

To compare and contrast the clinical, light microscopic, and immunohistochemical features of sinonasal undifferentiated malignant neoplasms.

DATA SOURCES

Case-derived material and literature review.

CONCLUSIONS

A variety of undifferentiated malignant neoplasms occur in the sinonasal tract with overlapping clinical and pathologic findings. In limited biopsy material, differentiation of these tumor types can be challenging. The pathologist plays a primary role in establishing the correct diagnosis, which often necessitates the use of adjunct studies that allow for differentiating among these neoplasms.

Transcranial combined neurorhinosurgical approach to the paranasal sinuses for anterior skull base malignancies

OBJECTIVE

Various transcranial and transfacial approaches have been described and each claims to provide the best exposure to the anterior skull base. Similarly, each approach claims the best outcomes following the resection of anterior skull base malignancies. We have always advocated a combined neurorhinological approach for the management of paranasal sinus malignancies that infiltrate the skull base, such as esthesioneuroblastomas.

MATERIALS AND METHODS

At the outset, the technique was developed on cadaver specimens, imitating the limitations that might be imposed in the real-life situation when undertaking endoscopic sinus surgery. Additional exposure of the anterior cerebral fossa was achieved using a classical bifrontal approach. Starting with endoscopic or microscopic unroofing of the ethmoids, all relevant landmarks were identified. The frontal, sphenoid, and maxillary sinuses were then opened using endoscopic techniques.

RESULTS

The dissections proved that a broad exposure of the anterior skull base could be combined with clear endoscopic visualization of the nasal cavity and of all the paranasal sinuses from above. This facilitated complete eradication of lesions from the sinuses cavities, their walls, and the intracranial tumor.

DISCUSSION

The combined neurorhinosurgical transcranial approach to the anterior skull base and nasal and paranasal sinuses, avoiding trans-facial approaches, enables a multidiciplinary team to resect malignant tumors of the anterior skull base directly without unnecessary destruction of facial structures. It appears to provide better access than other more destructive methods like midfacial degloving or subfrontal approaches. Our single-stage approach also facilitates safe and effective reconstruction of the skull base. The technique can be employed for tumors of all sizes and is also used for orbital resections and decompression of the optic nerve and chiasma.

Esthesioneuroblastoma: The Princess Margaret Hospital experience

BACKGROUND

Esthesioneuroblastoma is rare. The aim of the study was to review our experience and to evaluate the staging system and treatment that best correlates with the patient outcome.

METHODS

Thirty-nine patients were identified between 1972 and 2006.

RESULTS

At presentation 10% had cervical metastases. None had distant metastasis. Five were treated with surgery, 2 with chemotherapy, 1 with radiotherapy, and 30 with surgery and radiation. Local disease control was 82.6% at 5 years. Recurrence was seen in 33% with local and regional disease recurrence at 15% and 18%, respectively. The 5- and 10-year overall survival rates were 87.9% and 69.2%, respectively. Dulguerov classification correlated most closely to survival and recurrence.

CONCLUSIONS

Dulguerov classification best correlates with the patient's outcome. A combined approach is the preferred treatment. It makes no difference whether radiotherapy is given pre or postsurgical resection. Recurrence can occur even 15 years after treatment. Therefore, long-term follow-up is essential.

Nasenhöhle und Nasennebenhöhlen

Die Gesichtsmitte (der Bezirk zwischen Oberlippe und Stirn) entwickelt sich zwischen der 4. und 8. Schwangerschaftswoche. [ 220] Der Stirnfortsatz bildet sich währen der 4. postovulatorischen Woche, aus ihm gehen die oberen und mittleren Anteile des Gesichts hervor. Die Oberkiefer- und Nasenwülste entwickeln sich unterhalb des Stirnfortsatzes. Am Ende der 4. Woche bilden zwei oberflächliche Verdickungen der Nasenwülste die Riechplakoden, die ektodermaler Herkunft sind und aus denen der Epithelbelag der Nasenhöhle und Nasennebenhöhlen hervorgeht. Die Plakoden stülpen sich ein und bilden die Riechgruben, aus denen die vorderen Choanen (Nasenlöcher) und weniger oberflächlich die primitiven hinteren Choanen entstehen. Die medialen Nasen- und Stirnfortsätze bilden das Nasenseptum, die Stirnknochen, Nasenknochen, die Siebbeinzellen- Komplexe und die oberen Schneidezähne. Die lateralen Nasen- und Oberkieferfortsätze vereinigen sich zur Bildung des Philtrum und der Columella. Das knorpelige Nasenskelet bildet sich während der 7. und 8. postovulatorischen Woche tief unterhalb der Nasen- und Stirnbeinknochen aus dem Chondrocranium. Die Nasennebenhöhlen entwickeln sich in der 6. Fetalwoche aus den lateralen Nasenwänden, und ihr Wachstum setzt sich nach der Geburt während des gesamten Kindes- und Jugendalters fort.

Sinonasal neuro endocrine carcinoma extending into orbit - a case report

Small Cell Neuroendocrine Carcinomas of the Sinonasal tract are extremely uncommon and distinct neoplasms with aggressive clinical behavior. They have similar morphological and immunohistochemical features to those of small cell carcinomas of the lung. They should be distinguished from Olfactory Neuroblastomas. We report a case of this rare entity.A 46-year-old woman presented with a history of injury to the right eye with facial pain and proptosis as the primary symptoms. Later she developed nasal stuffiness. C.T. Scan revealed a space occupying lesion in the right nostril extending into ethmoid sinus and orbit. Functional endoscopic sinus surgery was done with decompression of the orbit. The biopsy material was obtained from ethmoid sinus and orbit. Histopathological examination of the biopsy specimen along with Immunohistochemical stains confirmed a Small Cell Neuroendocrine Carcinoma. Patient was treated with Radiotherapy and chemotherapy and responded well.

Esthesioneuroblastoma: a case report of diffuse subdural recurrence and review of recently published studies

Esthesioneuroblastoma is a rare malignancy arising from the olfactory epithelium. We present a case history of a 75-year-old man who presented with a Kadish stage C esthesioneuroblastoma and underwent craniofacial surgery and adjuvant radiotherapy. Two years later he was found to have diffuse subdural deposits with distant bone and nodal metastases, treated with further radiotherapy. The patient's condition subsequently deteriorated and he died. Given this unusual pattern of failure, we review the recent published studies regarding the natural history, treatment and outcome for this tumour.