Sinonasal squamous cell carcinoma and the prognostic implications of its histologic variants: a population-based study

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Can Definitive Radiation Therapy Substitute Surgical Resection in Locally Advanced T3 or T4 Sinonasal Squamous Cell Carcinoma?

PURPOSE

This study aimed to compare oncologic outcomes between definitive radiation therapy (RT) and upfront surgical resection in patients with sinonasal squamous cell carcinoma (SCC).

METHODS AND MATERIALS

Between 2008 and 2021, 155 patients with T1-4b, N0-3 sinonasal SCC were analyzed. The 3-year overall survival (OS), local progression-free survival (LPFS), and overall progression-free survival (PFS) were evaluated using the Kaplan Meier method and compared using a log-rank test. A pattern of regional neck lymph node (LN) failure and treatment-related toxicity profiles were investigated.

RESULTS

A total of 63 and 92 patients underwent upfront RT (RT group) and surgical resection (Surgery group), respectively. The RT group included significantly more patients with T3-4 disease than the Surgery group (90.5% vs 39.1%, P < .001). The rates of 3-year OS, LPFS, and PFS in the RT and Surgery groups were 68.6% versus 81.7% (P = .073), 62.3% versus 73.8% (P = .187), and 47.4% versus 66.1% (P = .005), respectively. However, the corresponding rates in patients with T3-4 disease were 65.1% versus 64.8% (P = .794), 57.4% versus 56.8% (P = .351), and 43.2% versus 46.5% (P = .638), respectively, demonstrating no statistically significant differences between the 2 treatment modalities. Among the 133 N0 patients, regional neck LN progression was observed in 17 patients, and the most common sites of regional neck LN failure were ipsilateral levels Ib (9 patients) and II (7 patients). The 3-year neck node recurrence-free rate in cT1-3N0 patients was 93.5%, while that in cT4N0 patients was 81.1% (P = .025).

CONCLUSIONS

Upfront RT may be considered in selected patients with locally advanced sinonasal SCC, as we have demonstrated similar oncologic outcomes to those of surgery. Prophylactic neck treatment in T4 disease requires further investigation to evaluate its efficacy.

Sinonasal Adenosquamous Carcinoma - Morphology and Genetic Drivers Including Low- and High-Risk Human Papillomavirus mRNA, DEK::AFF2 Fusion, and MAML2 Rearrangement

BACKGROUND

Sinonasal adenosquamous carcinoma is rare, and there are almost no studies detailing morphology or characterizing their genetic driver events. Further, many authors have termed sinonasal tumors with combined squamous carcinoma and glands as mucoepidermoid carcinoma but none have analyzed for the presence of MAML2 rearrangement.

METHODS

Cases from 2014 to 2020 were collected and diagnosed using World Health Organization criteria. They were tested for p16 expression by immunohistochemistry (70% cut-off), DEK::AFF2 fusion by fluorescence in situ hybridization (FISH) and AFF2 immunohistochemistry, MAML2 rearrangement by FISH, and low- and high-risk HPV by RNA ISH and reverse transcription PCR, respectively. Detailed morphology and clinical features were reviewed.

RESULTS

There were 7 male (64%) and 4 female (36%) patients with a median age of 69 years, most Caucasian (10 of 11 or 91%). Most had tobacco exposure (8/11, 73%) and most presented with epistaxis, a visible nasal mass, and/or facial pain. Several had a precursor papillomas (3 of 11, 27%). The squamous component had variable keratinization, 5 of 11 (46%) of which would be described as keratinizing, 3 non-keratinizing, and 2 with mixed features. All had gland formation, by definition, and 2 of 11 (18%) had ciliated tumor cells. None of the 11 cases had MAML2 rearrangement and one had DEK::AFF2 fusion with associated positive nuclear AFF2 protein immunostaining. Most were p16 positive (7 of 11, 64%) and all 7 of these were hrHPV positive either by RNA ISH or RT-PCR. Two of the p16-negative tumors were positive for lrHPV by RNA ISH. Treatment included surgery alone (4 of 11, 36%), surgery with adjuvant radiation (5 of 11, 45%), and surgery with radiation and chemotherapy (2 of 11, 18%). Four of 11 patients (36%) suffered disease recurrence, two requiring re-operation and who were disease free at last follow-up, one receiving additional chemotherapy and who was alive with disease. The other elected to undergo palliative therapy and died of disease.

CONCLUSION

Sinonasal adenosquamous carcinoma is a somewhat heterogeneous tumor not infrequently arising ex papilloma and having various drivers including high- and low-risk HPV and rarely DEK::AFF2 fusion. The prognosis appears favorable when proper treatment is possible.

Expression, Prognostic Value and Correlation with HPV Status of Hypoxia-Induced Markers in Sinonasal Squamous Cell Carcinoma

(1) Background: In head and neck squamous cell carcinoma, tumor hypoxia has been associated with radio/chemoresistance and poor prognosis, whereas human papillomavirus (HPV)-positive status has a positive impact on treatment response and survival outcomes. The aim of this study was to evaluate the expression and the potential prognostic value of hypoxia-induced endogenous markers in patients treated for squamous cell carcinoma of the nasal cavity and paranasal sinuses (SNSCC), and their correlation with HPV status. (2) Methods: In this monocentric study, patients treated in a curative intent for a SNSCC were screened retrospectively. Protein expression of CA-IX, GLUT-1, VEGF, VEGF-R1, and HIF-1α was determined by immunohistochemical staining, scored, and then correlated with overall survival (OS) and locoregional recurrence free survival (LRRFS). HPV status was assessed and correlated with hypoxic markers. (3) Results: 40 patients were included. A strong expression of CA-IX, GLUT-1, VEGF, and VEGF-R1 was detected in 30%, 32.5%, 50%, and 37.5% of cases, respectively. HIF-1α was detected in 27.5% of cases. High CA-IX expression was associated in univariate analysis with poor OS (p = 0.035), but there was no significant association between GLUT-1, VEGF, VEGF-R1, and HIF-1α expression, and OS/LRRFS. There was no correlation found between HPV status and hypoxia-induced endogenous markers (all p > 0.05). (4) Conclusions: This study provides data on the expression of hypoxia-induced endogenous markers in patients treated for SNSCC and underlines the potential role of CA-IX as a prognostic biomarker for SNSCC.

Prognostic significance of head and neck spindle cell carcinoma

BACKGROUND

Our study investigates the prognostic significance of spindle cell histology on overall survival (OS) of conventional head and neck squamous cell carcinoma (HNSCC).

METHODS

The 2004 to 2017 National Cancer Database was queried for patients with head and neck spindle cell carcinoma (HNSpCC) (n = 1572) or HNSCC (n = 242 697) of the oral cavity, major salivary glands, sinonasal tract, oropharynx, hypopharynx, and larynx treated with curative intent.

RESULTS

Patients with HNSpCC presented more frequently with higher-grade tumors and cN0 disease than those with HNSCC (p < 0.001). In the oral cavity, the HR for death for SpCC compared with SCC was 1.33 (p < 0.001). In the oropharynx, the HR for death for SpCC compared with SCC was 1.47 (p = 0.028).

CONCLUSIONS

After adjusting for patient, tumor, and treatment characteristics, SpCC histology had an independent adverse prognostic effect on OS in the oral cavity and oropharynx. SpCC histology does not necessarily portend poorer survival in all HNSCC.

LEVEL OF EVIDENCE: 4

Top 10 Significant Spindled Head and Neck Lesions to Scrutinze

BACKGROUND

Spindled lesions are a challenging area in head and neck pathology. This is particularly true in the sinonasal tract, where several uncommon entities with both unique and overlapping morphologic, immunophenotypic, and/or molecular features can occur.

METHODS

Review.

RESULTS

The clinicopathologic characteristics of biphenotypic sinonasal sarcoma and nine important differential diagnostic considerations with one or more overlapping feature are summarized to establish a practical framework for approaching spindled lesions of the sinonasal tract.

CONCLUSION

Morphologic evaluation is central to the work up of sinonasal spindle cell lesions-in particular, cellular morphology, tumor architecture and growth pattern, and the presence of admixed epithelial elements - however, focused immunohistochemical analysis of neural, myogenic, rhabdomyoblastic, epithelial, and/or melanocytic marker expression and/or ancillary tests for tumor-specific molecular alterations may be necessary for definitive diagnosis.

Early-stage glottic cancer of rare squamous cell carcinoma variants: a population-based study

BACKGROUND

Squamous cell carcinoma (SCC) is the most common histological type of laryngeal cancer. Several variants of SCC have been reported. However, how these variants differ from conventional SCC and how they should be treated remain to be elucidated.

OBJECTIVE

To compare the prognosis of early-stage glottic cancer among SCC variants.

METHODS

We obtained data from 12471 cases using the Surveillance, Epidemiology, and End Results database. Disease-specific survival (DSS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. A Cox proportional hazard model was used to estimate hazard ratios (HRs) according to the variants.

RESULTS

HRs for DSS and OS compared with well-differentiated SCC were 3.83 and 3.48 for adenosquamous, 1.42 and 1.42 for basaloid, 1.14 and 1.17 for papillary, 0.85 and 0.94 for spindle, and 0.81 and 1.00 for verrucous SCC. The difference in DSS among the treatment modalities was significant in conventional and papillary SCC (p < .001 and p = .032, respectively).

CONCLUSIONS

The prognosis of SCC variants, except for adenosquamous SCC, is comparable to that of conventional SCC.

Factors Contributing to Diagnosis and Prognosis in Sinonasal Malignancies

Objectives. This study was intended to explore and analyze the factors which affect the survival and prognosis of patients with malignant tumors of nasal cavity and sinus. Methods. Retrospective analysis was performed on the clinical data of 39 cases of malignant tumors of nasal cavity and sinus that met the requirements of the study. A follow-up study was performed on the patients for more than 36 months. Survival analysis was conducted via the Kaplan-Meier method and log-rank test. Cox regression model was used for multivariate analysis. Results. Gender, pathological type, treatment plan, clinical stage, and survival time of patients were different. Clinical stage was substantially related to the survival of patients ( $P<0.05$ ), which was an independent factor affecting prognosis. Conclusions. Early detection and comprehensive treatment of sinonasal malignancies can improve the prognosis and prolong the survival time of patients.

Human Papillomavirus-Related Carcinomas of the Sinonasal Tract

Purpose of review

The sinonasal tract is home to a uniquely heterogenous collection of malignant tumors. Human papillomavirus (HPV) has been detected in a number of these, but the virus' role as an oncogenic driver or coincidental finding remains unclear. We aim to highlight five sinonasal tumor types and synthesize the prevalence, etiologic role, and known clinicopathologic relevance of HPV in each.

Recent findings

The last decade has seen an expansion of investigation into HPV's oncogenic and prognostic significance within sinonasal malignancies. The sinonasal tract poses challenges to HPV detection where p16 lacks value as an accurate surrogate. A growing body of data supports a potentially favorable clinical profile for certain sinonasal HPV-positive lesions.

Summary

HPV represents a potential biologically and clinically relevant factor for some sinonasal malignancies. Definitive conclusions regarding HPV's role as a potential oncogenic agent require routine testing using validated methodologies, genomic interrogation, and large-scale prospective studies.

The MUSES∗: a prognostic study on 1360 patients with sinonasal cancer undergoing endoscopic surgery-based treatment: ∗MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers

BACKGROUND

Over the last 2 decades, transnasal endoscopic surgery (TES) has become the most frequently employed surgical technique to treat sinonasal malignancies. The rarity and heterogeneity of sinonasal cancers have hampered large non-population-based analyses.

METHODOLOGY

All patients receiving TES-including treatment between 1995 and 2021 in 5 referral hospitals were included. A prognostic study was performed, and multivariable models were transformed into nomograms. Training and validation sets were based on results from 3 European and 2 non-European centres, respectively.

RESULTS

The training and validation set included 940 and 420 patients, respectively. The mean age at surgery, primary-versus-recurrent presentation, histology distribution, type of surgery, T category and type of adjuvant treatment were differently distributed in the training and validation set. In the training set, 5-year overall survival and recurrence-free survival with a 95%-confidence interval were 72.7% (69.5-76.0%) and 66.4% (63.1-69.8%), respectively, significantly varying with histology. At multivariable analyses, age, gender, previous treatment, the extent of resection on the cranial, lateral and posterolateral axes, grade/subtype, T category, nodal status, margin status and adjuvant treatment were all associated with different prognostic outcomes, displaying a heterogeneous significance and effect size according to histology. The internal and external validation of nomograms was satisfactory (optimism-corrected C-index >0.7 and cumulative area under curve >0.7) for all histologies but mucosal melanoma.

CONCLUSIONS

Outcomes of TES-based treatment of sinonasal cancers vary substantially with histology. This large, non-population-based study provides benchmark data on the prognosis of sinonasal cancers that are deemed suitable for treatment including TES.

Sarcomatoid carcinoma in the sinonasal cavity: A retrospective case series from a single institution

OBJECTIVES

Sarcomatoid carcinoma (SC) is rare in the sinonasal cavity with poor prognosis. This study aimed to summarize the clinical characteristics, treatment and prognosis of patients with sinonasal SC from a single tertiary medical center.

METHODS

Retrospective review of the clinical data of seven patients diagnosed with sinonasal SC from May 1988 to February 2021.

RESULTS

Seven patients with SC in nasal cavity and paranasal sinus, including six males and one female, aged 34-77 years (mean, 58.3 years), were included in this case series. The common presenting symptoms included epistaxis and nasal obstruction. The tumor usually occurred in nasal cavity, maxillary sinus and ethmoid sinus. Most patients were diagnosed at advanced stages with the involvement of orbit and skull base. Open and endoscopic surgery were performed in five and two patients, respectively. The follow-up period ranged from 3 to 26 months. Four patients died of disease within one year, though two received adjuvant chemotherapy and one received radiotherapy. Two patients survived without recurrence at the end of follow-up, both of them underwent adjuvant radiotherapy. One patient received palliative re-irradiation due to local recurrence of the tumor three months after the surgery, however, this patient was lost to follow-up.

CONCLUSIONS

Sinonasal SC is a rare entity with an aggressive behavior and poor prognosis. Early diagnosis and multimodality treatment are recommended to improve the survival.

EGFR Exon 20 Insertion Mutations in Sinonasal Squamous Cell Carcinoma

Recurrent epidermal growth factor receptor (EGFR)-activating mutations have been identified in a rare form of head and neck cancer known as sinonasal squamous cell carcinoma (SNSCC), a malignant disease with a 5-year mortality rate of ~40%. Interestingly, the majority of EGFR mutations identified in patients with primary SNSCC are exon 20 insertions (Ex20ins), which is in contrast to non-small-cell lung cancer (NSCLC), where the EGFR exon 19 deletion and L858R mutations predominate. These studies demonstrate that EGFR Ex20ins mutations are not exclusive to lung cancer as previously believed, but are also involved in driving SNSCC pathogenesis. Here we review the landscape of EGFR mutations in SNSCC, with a particular focus on SNSCC associated with inverted sinonasal papilloma (ISP), a benign epithelial neoplasm. Taking lessons from NSCLC, we also discuss potential new treatment options for ISP-associated SNSCC harbouring EGFR Ex20ins in the context of targeted therapies, drug resistance and precision cancer medicine. Moving forward, further basic and translational work is needed to delineate the biology of EGFR Ex20ins in SNSCC in order to develop more effective treatments for patients with this rare disease.

Characterization of the tumor immune microenvironment of sinonasal squamous-cell carcinoma

BACKGROUND

Treatment and prognosis of sinonasal squamous-cell carcinoma (SNSCC) have not significantly improved despite improvements in radical therapy. Characterization of the tumor immune microenvironment (TiME) may identify patient subgroups associated with disease recurrence, and provide new biomarkers for improved patient stratification and treatment.

METHODS

The TiME was quantitatively evaluated by multiplex immunohistochemistry (mIHC) in archived tissue sections from 38 patients with SNSCC, and were assessed for differences between recurrent (n = 20) and nonrecurrent (n = 18) groups. Hierarchical clustering analyses were performed to identify phenotypic TiME subgroups within the cohort and were used to compare survival outcomes.

RESULTS

Our mIHC analysis revealed increased T-cell populations and decreased myeloid-cell populations in SNSCC patients without recurrent disease, as compared with patients with recurrent disease. Within T-cell subsets, there was a significantly higher percentage of granzyme B⁺ , T-bet⁺ , Eomes⁺ T cells, as well as higher proliferation of CD8⁺ T cells within the nonrecurrent group relative to the recurrent group. Furthermore, immune-cell complexity profiles of SNSCC revealed hyper- and hypo-T-cell-inflamed, myeloid-inflamed, B-cell-inflamed, and broadly hypoinflamed subtypes not previously identified by gene expression analyses. Our study revealed that presence of either hyper- or hypo-T-cell-inflamed TiME subtypes were associated with increased survival outcomes as compared with broadly hypoinflamed TiME subtypes (p = 0.035 and 0.0376, respectively).

CONCLUSIONS

The TiME of SNSCC reveals distinct subtypes, which may correlate with recurrence and survival outcomes.

Preliminary Study of Chemoradiotherapy Using Modified Docetaxel, Cis-diaminodichloroplatinum, and 5-Fluorouracil for Sinonasal Squamous Cell Carcinoma

Objective

To examine the safety and efficacy of concomitant chemoradiotherapy using a modified TPF regimen (docetaxel + cisplatin + 5-fluorouracil) in patients with advanced sinonasal squamous cell carcinoma (SNSCC).

Study Design

Retrospective study.

Setting

Tertiary center (university hospital).

Methods

Seven patients with previously untreated T3-T4 SNSCC were enrolled. They underwent radiotherapy once daily (total dose, 70 Gy) with 2 courses of concomitant 120-hour infusion of 5-fluorouracil (600 mg/m²/d), docetaxel (50 mg/m², day 2), and cisplatin (60 mg/m², day 2)

Results

Grade 4 leukopenia, grade 4 neutropenia, and grade 3 lymphopenia were observed in 1, 3, and 4 patients, respectively. Grade 4 creatinine elevation was observed in 1 patient. However, other grade 3 or 4 adverse events were not common. Complete response was obtained in all patients. At 60 months there was 85.7% disease-free survival and 100% overall.

Conclusion

Concomitant chemoradiotherapy with a modified TPF regimen may be feasible and effective in patients with advanced SNSCC.

Sinonasal Squamous Cell Carcinoma, a Narrative Reappraisal of the Current Evidence

Simple Summary

Sinonasal squamous cell carcinomas are a group of diverse tumors affecting the nasal cavity and paranasal sinuses. As a direct consequence of their rarity and heterogeneity, diagnosis is challenging, and treatment does not follow universally accepted protocols. Though surgery represents the mainstay of treatment, neoadjuvant and adjuvant therapies have pivotal roles in improving outcomes of patients treated with curative intent. Indications to endoscopic surgery have been expanding over the last three decades, but a considerable number of patients affected by sinonasal squamous cell carcinoma still need open surgical procedures. Management of the neck in patients affected by sinonasal squamous cell carcinoma is controversial. Curative-intended treatment of recurrent and/or metastatic tumors, alongside palliation of uncurable cases, represent poorly explored aspects of this disease.

Abstract

Sinonasal squamous cell carcinoma is a rare tumor affecting the nasal cavity and paranasal sinuses. Several aspects of this disease, ranging from epidemiology to biology, pathology, diagnosis, staging, treatment, and post-treatment surveillance are controversial, and consensus on how to manage this sinonasal cancer is lacking. A narrative literature review was performed to summarize the current evidence and provide the reader with available data supporting the decision-making process in patients affected by sinonasal squamous cell carcinoma, alongside the authors’ personal opinion on the unsolved issues of this tumor. The review has highlighted several advances in molecular definition of epithelial cancers of the sinonasal tract. Surgery represents the pivot of treatment and is performed through an endoscopic transnasal approach whenever feasible. Open surgery is required for a large proportion of cases. Reconstruction of the defect follows principles of skull base and cranio-maxillo-facial reconstruction. Chemotherapy is given as neoadjuvant treatment or concomitantly to radiotherapy. Photon-based radiation therapy has a crucial role in the adjuvant setting. Particle therapy is providing promising results. Management of the neck should be planned based on the presence of clinically appreciable metastases, primary tumor extension, and need for recipient vessels. Biotherapy and immunotherapy are still underexplored therapeutical modalities.

Remarkable Response of Toripalimab Combined with Chemotherapy in Sarcomatoid Carcinoma of Palatine Tonsil: A Case Report

Background

Sarcomatoid carcinoma (SaCa) of the palatine tonsil is a rare and aggressive subset of head and neck (H&N) cancer which is characterized by insensitivity to surgery and radiotherapy and a poor prognosis. Immunotherapy has led advances in the treatment of melanoma and H&N cancer, but the combined effects of immunotherapy and chemotherapy have not been sufficiently investigated.

Case Presentation

Herein, we report the case of 29-year-old Chinese women with local advanced non-resectable SaCa of the palatine tonsil who exhibited a substantial partial response to toripalimab and chemotherapy followed by radiation therapy. To the best of our knowledge, this is the first report of its successful application in this context.

Conclusion

Toripalimab combined with chemotherapy may be an effective approach for locally advanced H&N cancer in rare categories of patients, which was the first application as far as we know.

Sinonasal Squamous Cell Carcinoma Presentation and Outcome: A National Perspective

BACKGROUND

examine presentation and outcomes of sinonasal squamous cell carcinoma (SCC).

METHODS

A retrospective study utilizing the National Cancer Database, 2004 to 2015. The study population included adult patients diagnosed with primary sinonasal SCC.

RESULTS

A total of 537 patients were included. The mean age of the study population was 62.6 ± 12.7 years. The median follow-up time was 35.6 months (interquartile range: 8.6-55.9). The histological variants identified are: (i) 66.7% keratinizing SCC, (ii) 21.6% non-keratinizing SCC, (iii) 8.0% papillary SCC, and (iv) 3.7% spindle cell carcinoma. Stage at presentation was: (i) 33.3% T1-2, N0, (ii) 31.8% T3-4a, N0, (iii) 13.8% T1-4a, N+, (iv) 17.0% T4b,N0-3, (v) 4.1% M1. Human papilloma virus (HPV) status was available for 96 patients and tested positive in 24 (25.0%) patients. By histological variants, 5-year survival was lowest for spindle cell carcinoma (40.0%), and highest for papillary SCC (70.1%). HPV negative tumors had a 5-year survival of 26.4%, while HPV positive tumors had a 5-year survival of 57.1% (P = <.001). Of the 255 patients with T1-4a, N0-3, M0 who had surgery of the primary site, 31 (12.2%) patients underwent endoscopic approach. The risk of positive postsurgical margins was not significantly different comparing endoscopic to open approach (23.8% vs 24.1%, P >.99).

CONCLUSIONS

Sinonasal SCC could present at advanced stages in two-thirds of the population and exhibit a variety of histological subtypes. Like other sites of head and neck, HPV positive tumors are associated with a favorable prognosis. Endoscopic approach is comparable to open approach in terms of post-surgical margins.

A rare case of nasal Schneiderian (inverted) papilloma associated with basaloid squamous cell carcinoma

Sinonasal inverted papilloma (IP) is a benign, locally aggressive epithelial neoplasm. In less than 9% of cases it is associated with malignancies, typically conventional squamous cell carcinomas (SCC), while other histological variants have been less frequently reported. We describe the third case of basaloid squamous cell carcinoma (BSCC) arising in nasal IP. An 81-year-old female patient presented with a pinkish irregular lesion on the nasal septum. Biopsy was consistent with IP and carcinoma in situ. Two surgical procedures were needed to obtain radical excision. Histology on the surgical specimen revealed BSCC. Seven months after surgery, there was no evidence of disease recurrence. Although IP is more frequently associated with conventional SCC, other malignancies should be considered. The histological differential diagnosis should be supported by immunohistochemistry. The generally-recommended treatment for sinonasal BSCC is complete surgical resection, although this may be a problem in multifocal distributions, as in the present case.

Sinonasal carcinomas - A single-centre experience at Prince of Wales Hospital, Sydney, Australia, from 1994 to 2016

INTRODUCTION

Sinonasal carcinomas (SNCs) are rare neoplasms that are often diagnosed at advanced stages due to asymptomatic growth of tumours in the spaces of the sinonasal complex. Treatment is associated with high morbidity, and outcomes have only improved slightly in the past few decades despite advancements in treatment modalities. The purpose of this study is to evaluate the efficacy and safety of treatment at our institution.

METHODS

This retrospective cohort study analysed patients who received definitive treatment at the Prince of Wales Hospital (POWH), Sydney, for non-metastatic SNC. Patients with non-carcinoma and olfactory neuroblastoma pathology were excluded. Data were collected from the POWH electronic patient database. Survival functions were calculated through Kaplan-Meier analysis, and multivariate analysis for prognostic factors was performed through Cox regression.

RESULTS

Seventy-five patients from 1994 to 2016 were eligible for analysis. Overall 5-year local control (LC), ultimate local control (ULC), overall survival (OS) and cancer-specific survival (CSS) were 76 ± 6%, 80 ± 5%, 69 ± 6% and 77 ± 5%, respectively. On multivariate analysis, clinical stage was prognostic for LC and primary site was prognostic for OS and CSS. Lymphovascular invasion and tumour inoperability were also predictive of CSS.

CONCLUSION

Survival and local control rates at our centre were greater than those reported in the literature. Early-stage patients treated with surgery alone had excellent oncologic outcomes. Radical surgery with postoperative radiation provides the best outcome in the setting of advanced disease.

Development and validation of a nomogram for prognosis of sinonasal squamous cell carcinoma

BACKGROUND

Sinonasal squamous cell carcinoma (SNSCC) is a rare malignancy with varied outcomes. The aim of this study was to develop a nomogram for predicting survival of patients with SNSCC.

METHODS

From the Surveillance, Epidemiology, and End Results database, we identified 1766 patients diagnosed with SNSCC between 2004 and 2015. Patients were randomly separated into a training set and a validation set in 4:1 ratio. An external validation was also performed by a set of 74 SNSCC patients who had been treated in our department. We used the training set to build a nomogram based on stratified multivariable Cox proportional hazard models for predicting overall survival. The predictive accuracy and discriminative ability of the nomogram were determined by concordance index and calibration curve.

RESULTS

Based on 1412 cases of the training cohort, our Cox regression analysis revealed that age, marital status, primary site, differentiation, T stage, N classification, M stage, and treatment modalities were associated with overall survival. A nomogram was established based on the results of multivariate analysis. The C-index values of the nomogram for predicting survival were superior to those of the tumor-node-metastasis staging system (0.745 vs 0.679 in the training cohort, 0.752 vs 0.656 in the validation set, and 0.678 vs 0.596 in the external validation set). The calibration plots demonstrated good consistency between the predicted and observed results.

CONCLUSION

We have developed a nomogram to accurately predict the clinical outcomes of SNSCC patients. This model was effective and can help clinicians to improve patient counseling.

A challenging presentation of invasive nasopharyngeal sarcomatoid carcinoma

Sarcomatoid carcinoma is a rare clinical entity, especially when presenting in the nasopharynx. We describe the first documented case of nasopharyngeal sarcomatoid carcinoma with intracranial extension in a 59-year-old Caucasian man presenting with severe bifrontal headache and diplopia, secondary to left abducens nerve palsy. We highlight some of the major diagnostic challenges and describe its unusual histological appearance. We outline the importance of a multidisciplinary approach to his management, which includes input from the medicine, neurosurgery, Ear, Nose and Throat (ENT), pathology, radiology, oncology and respiratory teams. In the context of limited evidence, we then describe the rationale to proceed with induction chemotherapy followed by concurrent chemoradiotherapy. Although there was a partial response to treatment, it was not sufficient enough to allow subsequent surgical clearance. The plan going forward is to palliate with chemotherapy as and when the disease progresses.

Clinical relevance and significance of programmed death-ligand 1 expression, tumor-infiltrating lymphocytes, and p16 status in sinonasal squamous cell carcinoma

Purpose: Immunotherapy may be a potential alternative for patients with sinonasal squamous cell carcinoma (SNSCC). Data regarding potential immunotherapy targets, such as programmed death-ligand 1 (PD-L1) and tumor-infiltrating lymphocytes (TILs), in SNSCC are limited. In this study, we assessed the prevalence and prognostic value of PD-L1 expression and TILs in p16-negative and p16-positive SNSCC. Patients and methods: Tissues from 96 patients with SNSCC were stained using immunohistochemistry against PD-L1, CD8, and Foxp3 to assess the immune environment. The correlations between PD-L1 expression, TILs, and p16 status were analyzed. Additionally, PD-L1, CD8, and Foxp3 expressions, as well as p16 status, were analyzed in relation to patient clinicopathological variables and prognosis. Results: Twenty-nine (30.2%) patients with SNSCC showed PD-L1 expression in >5% of tumor cells. PD-L1 expression was significantly correlated with poor differentiation and a high level of TILs. PD-L1 expression and the CD8+ and Foxp3+ T-cell infiltrates in p16-negative patients (n=78, 81.2%) and p16-positive patients (n=18, 18.8%) were not significantly different. PD-L1 expression and p16 status were not associated with overall survival (OS) and disease-free survival (DFS). Patients with high CD8+ or Foxp3+ cell infiltration had better clinical outcomes. A multivariate analysis confirmed that CD8 TILs were a significant independent and favorable prognostic factor for OS (p=0.023) and DFS (p=0.008). Conclusion: TILs can play a prognostic role in SNSCC. We did not find differences in immune marker expression between p16-positive and p16-negative SNSCC tissues. The high correlation between PD-L1 expression and TILs indicates that the PD-1/PD-L1 pathway is a promising immunotherapeutic target for SNSCC.

Sarcomatoid Carcinoma: "A Surgeons Nightmare"

Sarcomatoid carcinoma (SC) is a rare and unique disease of the oral cavity. It is a biphasic squamous cell carcinoma with sarcoma-like characteristics. It is a strikingly aggressive lesion with a rapid rate of growth and a high rate of metastasis. Diagnosing a sarcomatoid carcinoma may present a challenge; most can only be ascertained by immunohistochemical study. An aggressive treatment plan should be devised for this uncompromising disease with a readiness to accept the dire outcome. We hereby present a case of a 50-year-old male patient, with no history of deleterious habit, diagnosed with SC of the buccal mucosa that proved to be fatal.

True hypopharyngeal carcinosarcoma: a case report and literature review

Objective

Carcinosarcoma consists of carcinomatous and sarcomatous tissues and is an aggressive malignant tumor. It is rarely reported in the hypopharynx.

Methods

A 72-year-old man presented with dysphagia and dyspnea. Laryngoscopy, computed tomography (CT), and ¹⁸F-fluorodeoxyglucose positron emission tomography/CT (¹⁸F-FDG PET/CT) showed a neoplasm on the left posterior hypopharyngeal wall. The patient underwent bilateral neck dissection and excision of the hypopharyngeal cancer followed by postoperative radiation therapy.

Results

Immunohistochemistry revealed carcinomatous cells with membrane positivity for cytokeratin, glucose transporter-1 (GLUT-1), phosphoinositide-3 kinase (PI3K), hypoxia-inducible factor-1α (HIF-1α), and hexokinase-II as well as sarcomatous cells with membrane positivity for smooth muscle actin, GLUT-1, HIF-1α, and PI3K. Histopathology and immunohistochemistry revealed a true carcinosarcoma of the hypopharynx (pT3N0M0, Stage III).

Conclusions

Thorough immunohistochemistry is required for a correct diagnosis of hypopharyngeal carcinosarcoma. ¹⁸F-FDG PET/CT may help to distinguish hypopharyngeal carcinosarcoma from benign tumors.

Endoscopic endonasal approaches for the management of cranial base malignancies: histologically guided treatment and clinical outcomes

Malignancies of the skull base represent a highly diverse and challenging set of pathologies which exhibit a wide array of oncologic behavior. In recent decades, a number of important advances in treatment technique have evolved to improve oncologic outcomes and reduce morbidity in the treatment of these aggressive cancers. Intensity modulated radiation therapy has become the gold standard in radiotherapy owing to its precision planning and reduced morbidity. However heavy ion particle radiation (proton therapy, carbon ion, etc.) are recently emerging with promising results at the skull base related to the reduced exit dose to adjacent structures. Novel systemic therapeutics such as targeted and immunotherapies may dramatically alter the treatment paradigm for many of these pathologies. Nevertheless, most skull base malignancies remain surgical diseases. The evolution of the expanded endonasal approach for a minimally invasive surgical resection has proven validity in treating many of these pathologies when properly selected, and have largely supplanted open approaches owing to the reduced morbidity profile. In spite of these important advances, the most critical aspect in comprehensive treatment is a detailed understanding of the oncologic behavior and outcomes data for each of the specific histopathologies encountered at the skull base. The nuances in management strategy, histologic profile, and surveillance planning can be stratified through the development of a comprehensive, multidisciplinary skull base team to maximize therapeutic effect and minimize morbidity for each patient. This review aims to summarize the key body of data and approaches for each of the histologies frequently encountered in the skull base, while highlighting the value and technique of endonasal approaches.

The Impact of Histologic Phenotype in the Treatment of Sinonasal Cancer

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

Epidemiology and survival outcomes of sinonasal verrucous carcinoma in the United States

INTRODUCTION

Verrucous carcinoma (VC) is a rare, variant of squamous cell carcinoma with benign cytohistopathologic features and a generally favorable prognosis. Epidemiologic and clinical outcomes data are lacking as a result of limited cases of sinonasal VC.

OBJECTIVE

To describe the incidence and determinants of survival of patients with verrucous carcinoma of the sinonasal tract between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The SEER registry was utilized to calculate survival trends for patients with verrucous carcinoma of the sinonasal tract between 1973 and 2014. Patient data then was analyzed with respect to age, sex, race, and treatment modalities (surgery and radiation therapy). Overall survival (OS) and disease-specific survival (DSS) were calculated.

RESULTS

A total of 86 cases of VC of the sinonasal tract were identified. The cohort was comprised of 69.8% males. The mean age at diagnosis was 67.4 years. The nasal cavity was the most common primary site (51.2%), followed by the maxillary sinus (40.7%) and nasopharynx (5.8%). The median OS was 97.6 months. 89.5% of cases underwent surgery and 20.9% received both surgery and radiation therapy. Overall survival at 2, 5, and 10 years was 73%, 59%, and 36%, respectively. On multivariate analysis, advanced age (P < 0.05) and primary site (P < 0.05) were associated with worse OS and DSS, respectively. Primary nasopharyngeal tumor site was associated with reduced DSS (P < 0.05). Surgery improved OS (P < 0.001) and DSS (P < 0.001).

CONCLUSION

Verrucous carcinoma of the sinonasal tract is associated with a generally favorable prognosis. Age, primary site, and surgical therapy are independent predictors of OS and DSS, respectively. We present the first population-based analysis of sinonasal VC, thus clarifying the prognosis and reinforcing the management of this malignancy.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:651-656, 2017.

Prognostic models and nomograms for predicting survival of patients with maxillary sinus carcinomas

BACKGROUND

Maxillary sinus carcinoma is an uncommon malignancy. Most reports on prognosis of this disease are from single institutions and include few patients. We used data from the United States National Cancer Institute's Surveillance Epidemiology and End Results (SEER) program to construct models and nomograms for predicting outcomes of patients with maxillary sinus carcinomas.

METHODS

We used records from 668 patients with primary maxillary sinus carcinomas reported to the SEER program from 2004 to 2013 to build nomograms based on stratified multivariable Cox proportional hazard models for predicting 5-year overall survival (OS) and cause-specific survival (CSS). Model building was internally validated with the bootstrap approach.

RESULTS

Five-year survival was 39.7% (95% confidence interval [CI], 35.5% to 44.5%) and 46.8% (42.3% to 51.8%) for OS and CSS, respectively. The final Cox model included the variables of age at diagnosis, tumor size, histologic type, TNM stage, and surgery. Radiotherapy was a stratification factor in the models. The models demonstrated good accuracy for predicting survival with a bootstrap-corrected Somers D_xy of 0.44 for both OS and CSS models. Calibration curves indicated acceptable model calibration.

CONCLUSION

We developed tools for predicting prognosis that incorporate TNM stage and other readily available variables for patients with maxillary sinus carcinomas. The model performance was validated as good. These models can help clinicians to offer improved patient counseling in terms of clinical outcomes and make optimal treatment plans.

Sphenoid sinus malignancies: a population-based comprehensive analysis

BACKGROUND

Sinonasal malignancies are rare, representing less than 1% of all cancers, with the sphenoid sinus accounting for 1% to 2% of these cases. Sphenoid sinus malignancies exhibit very poor outcomes. There is a paucity of literature describing their histopathological features, incidence trends, treatment, and survival. We seek to elucidate these factors using a national population-based resource.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database was used to identify malignant sphenoid sinus tumors. The results were analyzed for demographics, incidence, and clinicopathologic trends. Survival was calculated using Kaplan-Meier analysis.

RESULTS

The search identified 472 cases. The mean and median age at diagnosis was 60.0 years. Males represented 54.9% of cases. By race/ethnicity, 82.4% were white and 8.5% were black. The four most common histopathologies were squamous cell neoplasms (29.4%), adenocarcinomas (14.4%), non-Hodgkin's mature B-cell lymphomas (13.1%), and unspecified epithelial neoplasms (11.0%). The overall incidence from 2000 to 2012 was 0.030 per 100,000. Kaplan-Meier analysis demonstrated an overall 5-year disease-specific survival (DSS) of 48.1%. Of the most common histopathological subtypes, 5-year DSS was best for mature B-cell NHL (64.0%) and worst for unspecified epithelial neoplasms (25.6%).

CONCLUSION

Sphenoid sinus malignancies are rare, with high prevalence in white males. The most common histopathology is squamous cell neoplasms. They exhibit significant locoregional extension. Of the common sphenoid sinus malignant subtypes, 5-year DSS is best for mature B-cell NHL and worst for unspecified epithelial neoplasms.

Sinonasal Squamous Cell Carcinoma: A Review with Emphasis on Emerging Histologic Subtypes and the Role of Human Papillomavirus

The sinonasal tract is one of the least frequent sites for squamous cell carcinoma in the head and neck. However, it is still a complex tumor type for pathologists because there are numerous histologic variants with unusual morphologic features, several non-squamous carcinomas in the differential diagnosis that can have similar morphology and even squamous differentiation, and because of the increasing recognition of human papillomavirus (HPV) in a subset of the tumors. In addition, the unique and complex anatomy of the sinonasal tract can make proper staging and management of patients' tumors quite challenging. This article reviews sinonasal tract squamous cell carcinoma in depth and provides the latest data on Schneiderian papillomas and HPV in their pathogenesis.

Spindle cell carcinoma of the head and neck region: treatment and outcomes of 15 patients

Introduction

Spindle cell carcinoma of the head and neck is a rare entity and the evidence of optimal management is lacking. The objective of our study was to report the treatment and outcomes of 15 patients treated in a single institution over a seven year period.

Materials and Methods

A total of 15 patients (12 males and 3 females) with spindle cell carcinoma of the head and neck were treated between July 2007 to June 2014. In six patients the disease developed after previous radiotherapy. Of the 15 patients, five patients had their primary in the tongue, four in the paranasal sinuses, two in the hypopharynx, two in the vocal cords, and one each in the soft palate and the floor of mouth. Eleven patients were treated with radical intent (seven patients required surgery only and four were treated with combined modality). The remaining four patients were treated with palliative intent.

Results

Among 11 patients treated with radical intent eight are alive or died of non-oncological causes. The disease recurred locally in three patients and they died of the disease (two patients with locally advanced disease in the tongue and one patient with T1N0 tumour in the hypopharynx). Median overall survival (OS) was 18 months.

Conclusion

Surgery or surgery combined with radiotherapy has a real impact on the natural cause of spindle cell carcinoma of the head and neck region. Even locally advanced tumours can be controlled with aggressive treatment. The worst outcome is seen with the tongue as the primary site because of a high local recurrence rate.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Retrospective database analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

4.

Sinonasal fibrosarcoma: analysis of the Surveillance, Epidemiology, and End Results database

BACKGROUND

Primary fibrosarcoma of the sinonasal region is an infrequently occurring malignant neoplasm. Fibrosarcomas are most commonly found in the extremities, with only 1% of fibrosarcomas reported in the head and neck region. This study analyzes the demographic, clinicopathologic, and survival characteristics of sinonasal fibrosarcoma (SNFS).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (1973 to 2012) was queried for SNFS cases. Data were analyzed with respect to various demographic and clinicopathologic factors. Survival was analyzed using the Kaplan-Meier model.

RESULTS

Fifty-one cases of fibrosarcoma were identified in the sinonasal region. The mean age at diagnosis was 54.5 years and the mean survival was 119.7 months. There was no gender predilection with a male-to-female ratio of 1.04:1. The maxillary sinus was the most common site of involvement (54.9%), followed by the nasal cavity (23.5%). Five-year survival analysis revealed an overall survival rate of 71.7%, disease-specific survival rate of 77.8%, and relative survival (RS) rate of 78.8%. Disease-specific survival was better among those treated with surgery (with [76.2%] or without [87.5%] adjuvant radiotherapy) than those treated with primary radiotherapy alone (33.3%) (p = 0.0069).

CONCLUSION

SNFS is a rare entity. This study represents the largest series of SNFS to date. The mainstay of treatment for this tumor is surgical resection with or without radiotherapy.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Retrospective database analysis.

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

Sinonasal malignancies: A population-based analysis of site-specific incidence and survival

OBJECTIVES/HYPOTHESIS

Sinonasal malignancies vary in behavior according to histology and anatomical location. Incidence, survival, and optimal treatment for these lesions are thus uncertain in various cases. Our objective was to utilize a national population-based registry to identify the most common sinonasal histopathologies by anatomical site, and subsequently analyze the data by incidence trends, survival rates, patient demographics, and treatment modalities.

STUDY DESIGN

Retrospective analysis of the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry.

METHODS

The SEER database was examined for patients diagnosed with sinonasal malignancies between 1973 and 2011. Data were stratified according to anatomical site, incidence, survival, histology, staging, and patient demographics. Therapy-based outcomes were analyzed for cases from 1983 to 2011.

RESULTS

A total of 13,295 patients were identified, with an incidence of 0.83 per 100,000 people. Males comprised 58.6% of cases. Whites represented 81.5% of cases, while blacks comprised 8.7%. Squamous cell carcinoma was the most common histology (41.9%) across all sites of the sinonasal tract. The most common anatomical site of malignancy was the nasal cavity (45.7%), and least common was the frontal sinus (1.2%). For single sites, 5-year disease-specific survival (DSS) was highest for nasal cavity tumors (67.1%) and lowest for overlapping sinus malignancies (37.6%). The overall 5-year DSS for all sinonasal malignancies was 53.7%.

CONCLUSION

Sinonasal malignancies are rare entities with poor overall prognosis. By anatomical site, prognosis is best for nasal cavity cancers and worst for overlapping lesions.

LEVEL OF EVIDENCE

4.