Sinonasal small cell neuroendocrine carcinoma: a systematic review of 80 patients

Small cell neuroendocrine carcinoma in maxillary sinus: a case report and literature review

INTRODUCTION

Small cell neuroendocrine carcinoma is a rare and aggressive pathology with significant diagnostic challenges. Treatment typically involves multimodal therapy, including surgery and chemotherapy, but outcomes vary. The objective of this study is to describe and report a case of small cell neuroendocrine carcinoma.

CASE PRESENTATION

A case study illustrates the follow-up of a 36-year-old female patient from diagnostic biopsy to maxillectomy, followed by adjuvant chemotherapy with cisplatin and etoposide. Small cell neuroendocrine carcinoma poses significant challenges due to its rarity and aggressive behavior.

DISCUSSION

Multimodal therapy remains the mainstay, but the prognosis is unfavorable. Despite advances, managing small cell neuroendocrine carcinoma remains challenging.

CONCLUSIONS

Integrated approaches are crucial, underscoring the need for ongoing research to improve outcomes in this rare malignancy.

Primary Small Cell Carcinoma in Nasal Cavity and Paranasal Sinuses: 15 Cases From a Single Center

Small cell carcinoma (SCC) in the nasal cavity and sinuses is extremely rare. The clinical data of 15 patients with primary SCC in nasal cavity and sinuses were analyzed retrospectively. All patients were treated with surgery, radiotherapy, and chemotherapy. Of the 15 patients, 2 patients are alive for more than 6 years, and 5 patients died after the median follow-up period (11 months). Most of our patients represent the later stage (73% presented at stage III or IV) and had surgery combined with radiotherapy and chemotherapy; however, nearly half of patients have tumor recurrence and/or distant metastasis. SCC of nasal cavity and sinuses often invades surrounding tissues, and the long-term curative rate is generally low. Early diagnosis and comprehensive treatment are key to improve survival. Although the overall survival time of SCC is not optimistic, it is still recommended that patients take comprehensive treatment.

Sinonasal Neuroendocrine Carcinoma: A Case report

Neuroendocrine carcinoma are rare tumor which begin in specialized cells called neuroendocrine cells. It can occur anywhere in the body. Most neuroendocrine tumors occur in the lungs, appendix, small intestine, rectum and pancreas. We reported a case of sinonasal neuroendocrine carcinoma in a 65 year old lady who had presented with a history of right nasal obstruction, bloody nasal discharge, and recurrent epistaxis. On examination, a red, friable, polypoid mass with a tendency to bleed was seen in the right nasal cavity. Computed tomography revealed there was a enhancing expansile necrotic mass in right nasal cavity abutting the medial nasal wall. There was presence of mucosal thickening with inspissated secretion in all sinuses except left maxillary sinus. The patient underwent endoscopic removal of the tumour. Biopsy revealed poorly differentiated carcinoma of right nasal cavity. Immunohistochemistry revealed small cell neuroendocrine carcinoma. After that, the patient had postoperative external radiation treatment with a 6600 cGy dosage administered over 33 fractions. The patient had routine follow-up at the radiation oncology and otolaryngology outpatient departments throughout a 12-month period. During the postoperative month-to-month follow-up, there was no evidence of a local tumour recurrence in the endoscopy.

Improved survival for stage IV sinonasal small cell neuroendocrine carcinoma treated with chemotherapy and anti-PD-L1 therapy

Small cell carcinoma neuroendocrine type (SCCNET) is a rare tumour of the head and neck. Due to its infrequency, a paucity of data exists on optimal treatment, and the current paradigm for advanced SCCNET mirrors that of extensive small cell lung cancer. Increasingly, the treatment for extrapulmonary small cell carcinomas like SCCNET has incorporated immune checkpoint inhibitors (ICIs), although the utility of ICIs is not fully understood. We present a case of stage IVC sinonasal SCCNET in a woman in her 90s, who experienced eyelid swelling and unintentional weight loss. After diagnostic work-up, she was treated with etoposide, carboplatin and atezolizumab with a complete response to therapy. The patient had one episode of inflammatory polyarthropathy which resolved with steroids but otherwise tolerated treatment well and is now living with an overall survival of greater than 27 months. This case highlights the long-term efficacy of combination ICIs and chemotherapy in the treatment of SCCNET.

Proceedings of the 2023 North American Society of Head and Neck Pathology Companion Meeting, New Orleans, LA, March 12, 2023: Navigating New Developments in High Grade Sinonasal Neuroendocrine and Neuroectodermal Neoplasms

Although the definitions of sinonasal neuroendocrine and neuroectodermal neoplasms did not change substantially in the 5th edition WHO Classification of Head and Neck Tumours, the diagnosis of olfactory neuroblastoma (ONB), small cell neuroendocrine carcinoma, and large cell neuroendocrine carcinoma remains quite challenging in practice. Ambiguities surrounding the amount of keratin expression allowable in ONB and the amount of neuroendocrine differentiation seen in sinonasal undifferentiated carcinoma (SNUC) lead to significant diagnostic discrepancies at the high grade end of this tumor spectrum. Furthermore, a group of problematic neuroepithelial tumors that show overlapping features of ONB and neuroendocrine carcinoma have never been recognized in formal classification schemes. Since publication of the 5th edition WHO, two new tumor entities have been proposed that help resolve these problems. Olfactory carcinoma is defined by high grade keratin-positive neuroectodermal cells with frequent intermixed glands and shows recurrent Wnt pathway, ARID1A, and RUNX1 alterations. IDH2-mutant sinonasal carcinoma is a molecularly-defined category that encompasses tumors with undifferentiated (SNUC), large cell neuroendocrine, and neuroepithelial phenotypes. This review will provide a practical overview of these emerging entities and their application to diagnostic challenges in the post-WHO sinonasal neuroendocrine and neuroectodermal tumor classification.

Systematic review of neuroendocrine carcinomas of the oropharynx

Data describing features and management of oropharyngeal neuroendocrine carcinomas (NEC) remain sparse. A systematic review was performed. Patients were stratified by treatment modality and examined for disease progression and survival outcomes. Ninety-four patients from 50 publications were included. Average age at diagnosis was 59.7 years (range 14-83). 73.4% were male. Most studies did not document HPV status. Forty patients (85.1%) were p16 positive, and 34 (85.0%) were HPV-ISH positive. Overall survival was 75.4% at 1 year, and 40.0% at 2 years. Of patients with locoregional disease, 33.8% developed distant metastasis. 12.5% of patients developed locoregional recurrence. Patients who developed distant metastases had worse overall survival (p = 0.0004). No significant difference was found between treatment modalities. Human papilloma virus may be associated with oropharyngeal NEC. Current treatments provide locoregional control, but distant metastases are common and confer low overall survival.

Extrapulmonary Small Cell Carcinoma Presenting as an Orbital Mass: A Case Report

Extrapulmonary small cell carcinomas (ESCCs) are poorly differentiated neuroendocrine tumors that are characterized by an aggressive course and poor survival rates. While these tumors can be found anywhere in the body, presentations of lesions in the orbit are exceedingly rare. We present the case of a 47-year-old man who presented with blurry vision, lacrimation, and tenderness of his right eye, as well as a small but palpable temporal mass. Upon workup, he was diagnosed with ESCC in the orbit as well as lesions in the liver and spine. He received systemic chemotherapy but unfortunately proceeded to have rapid spread of his disease and succumbed to this cancer only a year after presentation. This patient illustrates the importance of developing optimal treatment strategies, which have yet to be delineated, and especially the impact of newer immunotherapy agents remains to be seen.

Recognizing sinonasal cancer in primary care: a matched case-control study using electronic records

BACKGROUND

Cancers of the nasopharynx, nasal cavity, and accessory sinuses ("sinonasal") are rare in England, with around 750 patients diagnosed annually. There are no specific National Institute for Health and Care Excellence (NICE) referral guidelines for these cancers and no primary care research published.

OBJECTIVE

To identify and quantify clinical features of sinonasal cancer in UK primary care patients.

METHODS

This matched case-control study used UK Clinical Practice Research Datalink (CPRD) data. Patients were aged ≥40 years with a diagnosis of sinonasal cancer between January 1, 2000 and December 31, 2009 and had consulted their GP in the year before diagnosis. Clinical features of sinonasal cancer were analysed using conditional logistic regression. Positive predictive values (PPVs) for single and combined features were calculated.

RESULTS

In total, 155 cases and 697 controls were studied. Nine symptoms and one abnormal investigation were significantly associated with the cancer: nasal mass; odds ratio, 95 (95% confidence interval 7.0, 1315, P = 0.001); head and neck lumps, 68 (12, 387, P < 0.001); epistaxis, 17 (3.9, 70, P < 0.001); rhinorrhoea, 14 (4.6, 44, P < 0.001); visual disturbance, 12 (2.2, 67, P = 0.004); sinusitis, 7.3 (2.2, 25, P = 0.001); sore throat, 6.0 (2.0, 18, P = 0.001); otalgia, 5.4 (1.6, 18, P = 0.007); headache, 3.6 (1.4, 9.5, P = 0.01); raised white cell count, 8.5 (2.8, 27, P < 0.001). Combined PPVs for epistaxis/rhinorrhoea, epistaxis/sinusitis, and rhinorrhoea/sinusitis were 0.62%.

CONCLUSION

This is the first primary care study identifying epistaxis, sinusitis, and rhinorrhoea as part of the clinical prodrome of sinonasal cancer. Although no PPVs meet the 3% NICE referral threshold, these results may help clinicians identify who warrants safety-netting and possible specialist referral, potentially reducing the number of advanced-stage diagnoses of sinonasal cancer.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Overview of the 2022 WHO Classification of Head and Neck Neuroendocrine Neoplasms

This review article provides a brief overview of the new WHO classification by adopting a question-answer model to highlight the spectrum of head and neck neuroendocrine neoplasms which includes epithelial neuroendocrine neoplasms (neuroendocrine tumors and neuroendocrine carcinomas) arising from upper aerodigestive tract and salivary glands, and special neuroendocrine neoplasms including middle ear neuroendocrine tumors (MeNET), ectopic or invasive pituitary neuroendocrine tumors (PitNET; formerly known as pituitary adenoma) and Merkel cell carcinoma as well as non-epithelial neuroendocrine neoplasms (paragangliomas). The new WHO classification follows the IARC/WHO nomenclature framework and restricts the diagnostic term of neuroendocrine carcinoma to poorly differentiated epithelial neuroendocrine neoplasms. In this classification, well-differentiated epithelial neuroendocrine neoplasms are termed as neuroendocrine tumors (NET), and are graded as G1 NET (no necrosis and < 2 mitoses per 2 mm²; Ki67 < 20%), G2 NET (necrosis or 2-10 mitoses per 2 mm², and Ki67 < 20%) and G3 NET (> 10 mitoses per 2 mm² or Ki67 > 20%, and absence of poorly differentiated cytomorphology). Neuroendocrine carcinomas (> 10 mitoses per 2 mm², Ki67 > 20%, and often associated with a Ki67 > 55%) are further subtyped based on cytomorphological characteristics as small cell and large cell neuroendocrine carcinomas. Unlike neuroendocrine carcinomas, head and neck NETs typically show no aberrant p53 expression or loss of RB reactivity. Ectopic or invasive PitNETs are subtyped using pituitary transcription factors (PIT1, TPIT, SF1, GATA3, ER-alpha), hormones and keratins (e.g., CAM5.2). The new classification emphasizes a strict correlation of morphology and immunohistochemical findings in the accurate diagnosis of neuroendocrine neoplasms. A particular emphasis on the role of biomarkers in the confirmation of the neuroendocrine nature of a neoplasm and in the distinction of various neuroendocrine neoplasms is provided by reviewing ancillary tools that are available to pathologists in the diagnostic workup of head and neck neuroendocrine neoplasms. Furthermore, the role of molecular immunohistochemistry in the diagnostic workup of head and neck paragangliomas is discussed. The unmet needs in the field of head and neck neuroendocrine neoplasms are also discussed in this article. The new WHO classification is an important step forward to ensure accurate diagnosis that will also form the basis of ongoing research in this field.

Complete remission of stage IV sinonasal small cell neuroendocrine carcinoma: A case report

Sinonasal small cell carcinoma (SmCC) is a rare type of neoplasm. The current case report describes the case of a 30-year-old male patient with stage IV SmCC who underwent concurrent radiotherapy (RT) plus etoposide-cisplatin treatment. Positron emission tomography (PET)/computed tomography (CT) and fibroscopy examination showed complete remission at 3 months post-treatment. However, leptomeningeal metastasis (LM) occurred at 9 months. A literature search identified no previous case reports describing LM of SmCC. The patient was treated with concurrent RT plus irinotecan-gemcitabine. During the sixth cycle of irinotecan-gemcitabine, the patient required intensive care admission due to severe acute respiratory syndrome-related coronavirus 2-associated pneumonia. Following clearance of the pneumonia, LM was assessed using PET/CT and MRI at 3 months, which revealed a complete response to irinotecan-gemcitabine. In May 2021, the patient succumbed to LM following disease recurrence. The findings of this case report should encourage other authors to publish their treatment outcomes regarding SmCC. More clinical trials are required to achieve better results in terms of patient outcome.

Small Cell Neuroendocrine Carcinoma Presenting as Recurrent Dacryocystitis: Case Report of a Rare Entity

An 84-year-old man presented with a localized, firm, tender mass over the right lacrimal sac. He had a history of acute dacryocystitis in the same eye 6 months before presentation, which resolved with antibiotics followed by uneventful dacryocystorhinostomy. At repeat presentation, the patient underwent orbital imaging and excisional biopsy of the lesion. Histologic studies revealed a small cell neuroendocrine carcinoma. The patient was subsequently treated with chemotherapy and radiation. Although there are rare reports of small cell neuroendocrine carcinoma originating in the sino-orbital-lacrimal region, this is the first report of tumor presentation with acute dacryocystitis in a patient with prior dacryocystorhinostomy.

[Clinical analysis of 31 patients with sinonasal neuroendocrine carcinoma]

Objective:To investigate the characteristics and prognostic factors of sinonasal neuroendocrine carcinoma （SNEC）. Methods:The clinical data of 31 patients with SNEC were retrospectively analyzed. Among the 31 patients, 3 cases were simply surgically removed, 4 cases were surgery + radiotherapy, 4 cases were surgery + chemotherapy, 10 cases were surgery + chemoradiotherapy, and 10 cases were simply given chemoradiotherapy without surgery. The study follow-up 8-64 months. Results:By the end of follow-up, 2 patients were lost to follow-up, 17 died, 12 survival, 8 relapsed and 5-year survival rate was 36.4％. High TNM stage, lymph node metastasis, skull base infiltration and Ki-67≥55％ were the negative prognostic factors for survival. Conclusion:SNEC is a rare aggressive tumor, with poor prognosis, high local recurrence rate, metastasis tendency, hidden disease. The comprehensive treatment of surgery combined with chemoradiotherapy is still the best treatment.

Radiotherapy of sinonasal cancers

We present the update of the recommendations of the French society of radiotherapy and oncology on the indications and the technical methods of carrying out radiotherapy of sinonasal cancers. Sinonasal cancers (nasal fossae and sinus) account for 3 to 5% of all cancers of the head and neck. They include carcinomas, mucosal melanomas, sarcomas and lymphomas. The management of sinonasal cancers is multidisciplinary but less standardized than that of squamous cell carcinomas of the upper aerodigestive tract. As such, patients with sinonasal tumors can benefit from the expertise of the French expertise network for rare ENT cancers (Refcor). Knowledge of sinonasal tumour characteristics (histology, grade, risk of lymph node involvement, molecular characterization, type of surgery) is critical to the determination of target volumes. An update of multidisciplinary indications and recommendations for radiotherapy in terms of techniques, target volumes and radiotherapy fractionation of the French society of radiotherapy and oncology (SFRO) was reported in this manuscript.

Neuroectodermal tumours of the sino-nasal tract: a clinicopathological study of 18 cases with a newly proposed revised classification and a brief review of literature

AIM

Sino-nasal tract tumours constitute 3% of the head and neck malignancies. Among these tumours, neuroectodermal tumours are rare with histo-morphological and immunohistochemical overlap making them a challenge for the pathologist. We included Ewing's/PNET, olfactory neuroblastoma (OFN), mucosal malignant melanomas (MMM), Melanotic neuroectodermal tumour of infancy (MNTI), small-cell neuroendocrine carcinoma (SNEC), and the newest entity Adamantinoma like Ewing's sarcoma (ALES) as part of the neuroectodermally derived tumours of the sino-nasal tract. The last three entities were added to the existing ones, which also has been emphasized in this paper.

METHODS AND RESULTS

A comprehensive analysis was done on all neuroectodermally derived tumours from 2016 to 2020. A total of 18 cases were collected, which included OFN (10 cases), SNEC (2 cases), MMM (2 cases), Ewing's/PNET (2 cases), MNTI (1 case), and ALES (1 case). The most common presentation in NE tumours was nasal obstruction (80-100%). Except for OFN, all other tumours were confined to the nasal and paranasal sinuses. 4/10 cases of OFN showed orbital extension. Cervical lymph-node metastasis was seen in 50% of cases of SNEC and MMM groups. An array of relevant immune-histochemical markers were performed. The marker expression was very subtle among the groups. On follow-up, recurrence was seen in the OFN and MMM groups in 30 and 50%, respectively. Metastasis was seen in SNEC group (100%) and OFN group (10%).

CONCLUSION

As sino-nasal neuroectodermal tumours pose a diagnostic challenge and have different therapies and are prognostically different, the pathologist must be aware of the subtle morphological, immunohistochemical clues which have been dealt with in-depth in this study.

Primary small cell neuroendocrine carcinoma in the nasal cavity: A CARE-compliant case report

RATIONALE

Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses is a rare but aggressive neoplasm with a poor prognosis and a strong propensity for regional recurrence and distant metastasis. Diagnosis is challenging and relies on immunohistochemical study. Treatment includes surgical resection, radiation therapy, chemotherapy, or a combination of these modalities. However, the optimal therapeutic strategy is still controversial. Due to its rarity, the complexity of the histological diagnosis, and the variety of the treatment regimens, we presented a case of primary small cell neuroendocrine carcinoma in the nasal cavity with description of the clinical manifestation, pathology features, and our treatment regimen.

PATIENT CONCERNS

An 82-year-old female patient with hypertension presented with right epistaxis on and off with nasal obstruction for several days.

DIAGNOSIS

An exophytic mass over the posterior end of the right inferior turbinate was found on nasopharyngoscope. Biopsy was done and the pathology confirmed small cell carcinoma, strongly positive for cytokeratin (AE1/AE3) and insulinoma-associated protein 1 (INSM-1), scatteredly positive for chromogranin A, synaptophysin and CD56. The final diagnosis was small cell neuroendocrine carcinoma of right nasal cavity, pT1N0M0, stage I.

INTERVENTIONS

The patient underwent wide excision of right intra-nasal tumor and post-operative radiotherapy with a dose of 6600 cGy in 33 fractions.

OUTCOMES

No local recurrence or distant metastasis was noted during the 12 months of follow-up.

LESSONS

Multimodality treatment remains the most common therapeutic strategy, although no proven algorithm has been established due to the rarity of this disease. Further investigation is needed for providing evidence to standardize the treatment protocol.

Nomograms Forecasting Long-Term Overall and Cancer Specific Survival of Patients With Head and Neck Neuroendocrine Carcinoma

Background

The purpose of this retrospective analysis was to build and validate nomograms to predict the cancer-specific survival (CSS) and overall survival (OS) of head and neck neuroendocrine carcinoma (HNNEC) patients.

Methods

A total of 493 HNNEC patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2015, and 74 HNNEC patients were collected from the Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University/Hunan Cancer Hospital (HCH) between 2008 and 2020. Patients from SEER were randomly assigned into training (N=345) and internal validation (N=148) groups, and the independent data group (N=74) from HCH was used for external validation. Independent prognostic factors were collected using an input method in a Cox regression model, and they were then included in nomograms to predict 3-, 5-, and 10-year CSS and OS rates of HNNEC patients. Finally, we evaluated the internal and external validity of the nomograms using the consistency index, while assessing their prediction accuracy using calibration curves. A receiver operating curve (ROC) was also used to measure the performance of the survival models.

Results

The 3-, 5-, and 10-year nomograms of this analysis demonstrated that M classification had the largest influence on CSS and OS of HNNEC, followed by the AJCC stage, N stage, age at diagnosis, sex/gender, radiation therapy, and marital status. The training validation C-indexes for the CSS and OS models were 0.739 and 0.713, respectively. Those for the internal validation group were 0.726 and 0.703, respectively, and for the external validation group were 0.765 and 0.709, respectively. The area under the ROC curve (AUC) of 3-, 5-, and 10-year CSS and OS models were 0.81, 0.82, 0.82, and 0.78, 0.81, and 0.82, respectively. The C-indexes were all higher than 0.7, indicating the high accuracy ability of our model's survival prediction.

Conclusions

In this study, prognosis nomograms in HNNEC patients were constructed to predict CSS and OS for the first time. Clinicians can identify patients' survival risk better and help patients understand their survival prognosis for the next 3, 5, and 10 years more clearly by using these nomograms.

Neuroendocrine carcinoma of the nasal cavity with epiphora as the first symptom: A case report

RATIONALE

Neuroendocrine carcinomas (NECs) are rare malignancies that originate from the hormone-producing cells of the neuroendocrine system. They can grow in most organs of the body but are commonly found in the gastrointestinal and respiratory tracts. The nasal cavity is a rare site for NECs.

PATIENT CONCERNS

We report a case of NECs in a 45-year-old woman who presented with epiphora in the right eye for a year owing to an unknown reason.

DIAGNOSES

The diagnosis was initially confirmed via histological and immunohistochemical assays. Postoperatively, computed tomography of the neck revealed C4 vertebral bone metastasis.

INTERVENTIONS

The tumor was endoscopically removed from the right eye. The patient received a full course of adjuvant polychemotherapy.

OUTCOMES

Six months after diagnosis, the patient died due to bone metastasis.

LESSONS

Diagnosing nasal neuroendocrine carcinoma is clinically challenging. It must be distinguished from other orbital masses, such as chronic dacryocystitis or nasal polyps. The treatment should be further investigated for this rare malignancy in near future.

Sinonasal Small Cell Carcinoma-Case Series of a Rare Malignancy

Sinonasal small cell neuroendocrine carcinoma (SNEC) is an extremely rare and aggressive neoplasm that can arise in the sinonasal region. These tumors are associated with high morbidity and mortality, are difficult to diagnose, and are hard to treat. We describe 2 cases of this poorly understood malignancy and review imaging, pathology, and treatment decisions. A 41-year-old male and a 64-year-old female presented to a tertiary center in 2019 after developing nasal obstruction and were found to have sinonasal masses on imaging. Both biopsies showed strong expression of pancytokeratin with dot-like reactivity and expression of neuroendocrine markers chromogranin and synaptophysin. The findings were diagnostic of SNEC. Staging positron emission tomography/computed tomography and brain MRI were performed, and patients were discussed at a multidisciplinary tumor board. Neither had distant metastatic disease at presentation. One patient had no intracranial or orbital disease and underwent a subtotal endoscopic resection with adjuvant chemoradiation. The other patient demonstrated middle cranial fossa, dural, and orbital involvement as well as cranial nerve V palsy. This patient was treated with induction chemotherapy, followed by concurrent chemoradiation. Both patients are presently alive at 4 months follow-up, but one with persistent local disease and the other distant metastasis. Sinonasal small cell neuroendocrine carcinoma is a rare and poorly understood malignancy with an aggressive clinical course. Continued careful review of pathology and study of molecular features are needed for improved understanding of SNEC, and particularly for head and neck SNEC, to establish a staging system and better formulate treatment protocols.

[Diagnosis, prognosis and treatment of sinonasal carcinomas (excluding melanomas, sarcomas and lymphomas)]

Sinonasal carcinomas account for 3% of ENT cancers. They are subdivided into squamous cell carcinomas (50%), adenocarcinomas [20%, mostly of intestinal type (ITAC)], and more rarely, adenoid cystic carcinomas, olfactory neuroblastomas (=esthesioneuroblastomas), neuroendocrine carcinomas or undifferentiated sinonasal carcinomas (SNUC). The 5-year survival rates are, in descending order, 72% for neuroblastomas, 63% for adenocarcinomas, 50-60% for large-cell neuroendocrine carcinomas, 53% for squamous cell carcinomas, 25-50% for adenoid cystic, 35% for small-cell neuroendocrine carcinomas and 35% for SNUC and newly discovered histologies. Surgery is the main treatment; endoscopic approaches reduce the morbidity with equivalent tumour control. Intensity-modulated radiation therapy (IMRT) is almost systematic. Nodal involvement is rare in ethmoidal adenocarcinomas and adenoid cystic carcinomas; it is intermediate and may justify prophylactic radiotherapy for N0 necks in SNUC, neuroblastoma, squamous cell carcinomas and sinonasal neuroendocrine carcinomas. IMRT or proton therapy is the mainstay of treatment of unresectable disease. Radiotherapy optimization by carbon ion therapy for adenoid cystic carcinomas, or by chemotherapy for all carcinomas with IMRT or proton therapy, is investigated within clinical trials in France. Neoadjuvant chemotherapy is reserved for rapidly progressive disease or histologies with a high metastatic potential such as neuroendocrine carcinomas or SNUC. Given their histologic and molecular specificities and different relapse patterns, an expertise of the REFCOR network, with REFCORpath review, is likely to correct diagnoses, rectify treatments, with an impact on survival.

Rare cases of head and neck's neuroendocrine carcinomas disease: Case series of 4 patients and review of the literature

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Cervical lymph node SmCC as a primary tumor’s location, was never described in the literature according to what we know.

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AC neuroendocrine carcinoma of the tonsil has never been described in the literature up to our knowledge.

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A review of the literature was performed, indicating treatment and disease’s prognosis.

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In 2012, the 2005 WHO classification of neuroendocrine tumors of the head and neck region was modified by adding the ranges of the Ki-67 and suggested that LCNEC should be considered a distinct disease entity and be separated from AC.

Introduction

Primary neuroendocrine carcinomas are uncommon head and neck malignancies. Their classification is still debated. We report four cases of unusual primary locations of neuroendocrine carcinomas of head and neck region emphasizing two entities and rare sites that were never described in the literature to the best of our knowledge.

Presentation of cases

We reported four different cases of neuroendocrine carcinomas (nasal cavity, larynx, lymph nodes and tonsil) treated in our institution. The diagnosis was made by biopsy and confirmed by Immunohistochemical study. We underscored 2 atypical and rare entities in their location and anatomo histopathological type. Chemotherapy and radiotherapy were proposed for patients with nasal’s and laryngeal locations. This latter had also undergone surgery. For lymph node location, the patient received decompressive radiotherapy alone. The patient diagnosed with neuroendocrine carcinoma of the tonsil didn’t get any treatment except initial tonsillectomy for diagnosis purposes. Regarding the evolution in our case series, 2 patients had a relapse with local and regional metastasis. Among the 4 patients, 50 % passed away, one is still alive with deterioration of his general status and one is lost to follow-up and refused undergoing further investigations.

Discussion

There is confusion in the literature regarding the classification of neuroendocrine carcinomas. According to the 2005 WHO, these lesions, can be subdivided into TC, AC (including LCNEC), SmCC, combined SmCC with nonsmall cell carcinoma, and paraganglioma. Their treatment is still debated. Through an overview of the literature, we have gathered the main studies and 2 meta-analysis summarizing the mainstay treatment and disease’s outcome.

Conclusion

Neuroendocrine carcinomas of head and neck region are aggressive tumors with poor prognosis, low incidence and their diagnosis is not obvious. The treatment protocol depends on the type, the site of the lesions, and metastasis status. It’s still not well codified.

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.

Genetic and molecular alterations in olfactory neuroblastoma: implications for pathogenesis, prognosis and treatment

Olfactory neuroblastoma (ONB, Esthesioneuroblastoma) is an infrequent neoplasm of the head and neck area derived from olfactory neuroepithelium. Despite relatively good prognosis a subset of patients shows recurrence, progression and/or metastatic disease, which requires additional treatment. However, neither prognostic nor predictive factors are well specified. Thus, we performed a literature search for the currently available data on disturbances in molecular pathways, cytogenetic changes and results gained by next generation sequencing (NGS) approaches in ONB in order to gain an overview of genetic alterations which might be useful for treating patients with ONB. We present briefly ONB molecular pathogenesis and propose potential therapeutic targets and prognostic factors. Possible therapeutic targets in ONB include: receptor tyrosine kinases (c-kit, PDGFR-b, TrkB; EGFR); somatostatin receptor; FGF-FGFR1 signaling; Sonic hedgehog pathway; apoptosis-related pathways (Bcl-2, TRAIL) and neoangiogenesis (VEGF; KDR). Furthermore, we compare high- and low-grade ONB, and describe its frequent mimicker: sinonasal neuroendocrine carcinoma. ONB is often a therapeutic challenge, so our goal should be the implementation of acquired knowledge into clinical practice, especially at pretreated, recurrent and metastatic stages. Moreover, the multicenter molecular studies are needed to increase the amount of available data.

Diagnostic reliability of pretreatment biopsy in malignant nasoethmoidal tumors: A retrospective study of 77 cases

OBJECTIVES/HYPOTHESIS

Pretreatment biopsy is crucial in histology-based management of malignant nasoethmoidal tumors, because misdiagnosis can lead to inadequate therapeutic planning. Factors influencing the reliability of biopsy were retrospectively investigated in a tertiary referral center.

STUDY DESIGN

Retrospective case series.

METHODS

All patients who underwent biopsy, staging magnetic resonance, surgery, and histologic diagnosis for nasoethmoidal tumors in our hospital were retrospectively evaluated. Histologic discrepancy, histology, procedure for biopsy (biopsy under local anesthesia [OB], biopsy under local anesthesia and sedation [SB], or under general anesthesia [GB]), site of the lesion, and the biopsy volume were analyzed. Biopsy reliability rate (BRR) (preoperative biopsy confirmed after surgical treatment) and concordance rate (CR) (postoperative diagnosis identified in preoperative biopsy) were calculated. Univariate and multivariate statistical analyses were used to identify factors influencing histologic discrepancies.

RESULTS

Seventy-seven patients were included. Five (6.5%) minor and eight (10.4%) major histologic discrepancies were observed (16.9%). OB and SB showed significantly lower biopsy volumes than GB (P < .0001 and P = .002, respectively). The biopsy volume was significantly lower in cases with histologic discrepancies (P = .045). Squamous cell carcinoma was independently associated with lower BRR. Germ cell tumor, salivary gland carcinoma, and sarcoma showed the lowest CR. Adenocarcinoma, mucosal melanoma, and olfactory neuroblastoma showed the highest BRR and CR.

CONCLUSIONS

The risk of misdiagnosis for nasoethmoidal tumors may be high even in referral centers. Especially when clinical and radiologic findings suggest a diagnosis different from adenocarcinoma, mucosal melanoma, and olfactory neuroblastoma, obtaining abundant material under general anesthesia may reduce the risk of diagnostic error and inadequate treatment.

LEVEL OF EVIDENCE

4. Laryngoscope, 1772-1777, 2018.

Small cell carcinoma of the head and neck: A comparative study by primary site based on population data

OBJECTIVES/HYPOTHESIS

Small cell carcinoma (SmCC) of the head and neck is an extremely rare neuroendocrine malignancy. In this study, we describe the incidence and determinants of survival of patients with SmCC of the head and neck between the years of 1973 and 2012 using the Surveillance, Epidemiology, and End Results database as differed by primary site.

STUDY DESIGN

Retrospective, population-based cohort study.

METHODS

A total of 237 cases of SmCC of the head and neck were identified, which was divided into sinonasal primaries (n = 82) and all other head and neck primaries (n = 155). Clinicopathologic and epidemiologic variables were analyzed as predictors of overall survival (OS) and disease-specific survival (DSS) based on the Kaplan-Meier method.

RESULTS

More than half of sinonasal primaries presented with Kadish stage C or D. On multivariate analysis, surgery was the only independent predictor of improved DSS (P = .008) for sinonasal primaries; in contrast, radiation therapy was a favorable prognosticator for OS (P = .007) and DSS (P = .043) in extrasinonasal sites. Comparison of survival between sinonasal primaries and all other sites demonstrated that sinonasal SmCC had uniformly better OS (P = .002) and DSS (P = .006).

CONCLUSIONS

SmCC in the head and neck remains rare, and sinonasal primaries appear to have improved survival compared to other sites. Based on these results, optimal treatment for sinonasal SmCC appears to be surgical therapy, whereas radiation therapy is the preferred treatment for SmCC of other primary sites, particularly the larynx.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:1785-1790, 2017.