Predictors of survival outcomes in sinonasal squamous cell carcinoma: an analysis of the National Cancer Database

Complete remission in a patient with sinonasal squamous cell carcinoma receiving neoadjuvant tislelizumab plus chemotherapy: a case report

Sinonasal squamous cell carcinoma (SNSCC) is the most common, high-aggressive sinonasal malignancies that have remained relatively stable poor outcomes over the past decade. As a first-line treatment for SNSCC, surgery plus adjuvant radiotherapy is recommended. However, complete surgical resection may not be appropriate due to the proximity of the nasal cavity and sinuses to key structures such as orbit or intracranial. Currently, immune checkpoint inhibitors (ICIs) have been established as one of the first-line therapies for many solid tumors with unresectable stage. However, evidence on the efficacy of ICIs in sinonasal malignancy is scarce and no ICIs are approved for use in SNSCC up to day. In this report, we report a case of a 64-year-old man with SNSCC treated by multi-protocol exploration. The patient achieved pathological complete response (pCR) after receiving two cycles of Docetaxel and cisplatin combined with tislelizumab. To the best of our knowledge, this is the first case of SNSCC treated with tislelizumab that achieved pCR. This case offers real-world evidence that chemotherapy plus immunotherapy is a promising treatment for SNSCC.

Neoadjuvant chemotherapy for organ preservation in sinonasal squamous cell carcinoma

PURPOSE

In this study, we aimed to evaluate the role of induction chemotherapy (IC) in the treatment of locoregionally advanced sinonasal squamous cell carcinoma (SNSCC).

METHODS

130 patients who accepted IC between 2010 and 2022 were retrospectively reviewed. After IC, all the patients underwent chemoradiotherapy (CRT)/ radiotherapy (RT) or CRT/RT followed by surgery. We investigated the objective response to IC, the optimal treatment strategy, organ preservation, and long-term survival.

RESULTS

 Eighty-seven patients (66.9%) achieved a partial response after IC. 86% (27/43) of the patients who did not respond to the IC still presented a sensitive response to radiotherapy (χ2 = 9.26, p = 0.005). Patients who respond to IC could benefit from CRT/RT followed by surgery over other treatment modalities. The 3-year overall survival (OS), progression-free survival (PFS), locoregional-free survival (LRFS), and distant metastasis-free survival (DMFS) rates of 61.2%, 51.3%, 52.1%, 58.1% for the IC response group were significantly superior to those of 37.3% (HR = 0.58, 95% CI 0.34-1.01, p = 0.030), 33.5% (HR = 0.49, 95% CI 0.30-0.82, p = 0.002), 35.9% (HR = 0.54, 95% CI 0.32-0.91, p = 0.009), 36.1% (HR = 0.60, 95% CI 0.35-1.03, p = 0.040) for the IC non-response group. Patients who responded to IC had a high rate of organ preservation compared with patients who did not respond to IC (90.8% vs. 74.4%, χ2 = 6.19, p = 0.013).

CONCLUSIONS

The results demonstrated a response rate to IC in patients with advanced SNSCC; furthermore, the response to IC indicated better survival. Patients who responded to IC had a high rate of organ preservation.

T4b Sinonasal Squamous Cell Carcinoma: Surgery Plus Radiotherapy May Contribute to Prolonged Survival

PURPOSE

To determine oncologic outcomes for patients with T4b sinonasal squamous cell carcinoma (SNSCC) treated with either surgery plus radiotherapy or definitive radiotherapy.

MATERIALS AND METHODS

Between January 1999 and December 2016, 85 patients with T4b SNSCC were analyzed retrospectively, there were 54 who received surgery plus radiotherapy (S + RT group) ± chemotherapy and 31 with definitive radiotherapy (RT group) ± chemotherapy. A 1: 2 propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan-Meier method and Cox proportional hazard model were used to determine risk factors on survival outcomes.

RESULTS

The median follow-up time was 76.7 months. The cumulative rates of locoregional control (LRC), distant metastasis-free survival (DMFS), cancer-specific survival (CSS), and overall survival (OS) at 5 years for entire cohort were 44.6%, 33.1%, 38.8%, and 33.9% respectively. After PSM, a total of 50 patients in S + RT group and 25 patients in RT group were analyzed. The 5-year LRC, DMFS, CSS, and OS between S + RT and RT group were 58.6% versus 27.5% (p = 0.035), 42.8% versus 20.0% (p = 0.006), 50.3% versus 22.0% (p = 0.005), 44.5% veruss 20.0% (p = 0.004). The 5-year survival rates with orbital retention between groups were 32.7% and 15.0%, p = 0.080. Multivariate Cox analysis revealed non-surgical therapy (HR = 3.678, 95%CI 1.951-6.933) and invasion of cranial nerves (other than maxillary division of trigeminal nerves) (HR = 2.596, 95%CI 1.217-5.535) were associated with decreased OS.

CONCLUSION

The inclusion of surgery in the multimodal management of T4b SNSCC might confer a survival benefit. Further prospective studies comparing the oncologic outcomes of S + RT with RT are warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2222-2231, 2023.

Induction Chemotherapy for Locoregionally Advanced Sinonasal Squamous Cell Carcinoma and Sinonasal Undifferentiated Carcinoma: A Comprehensive Review

Sinonasal squamous cell carcinoma (SNSCC) and sinonasal undifferentiated carcinoma (SNUC) are two of the most common, high-grade malignancies of the sinonasal cavity. The standard of care for resectable lesions per the National Comprehensive Cancer Network (NCCN) guidelines includes surgical resection with negative margins plus adjuvant radiation therapy. However, surgery for locally advanced disease with both orbital and intracranial involvement is associated with significant morbidity and poor overall survival. Over the last decade, induction chemotherapy (IC) has emerged as part of a multimodal treatment strategy to optimize locoregional disease control and minimize substantial surgical morbidity such as orbital exenteration without compromising rates of overall survival. The response to IC both guides additional therapy and helps prognosticate a patient's disease. This narrative review examines the data surrounding the management of patients with SNSCC and SNUC. The pros and cons of upfront surgical management plus adjuvant therapy will be explored, and the case for IC will be presented. The IC-specific regimens and treatment paradigms for SNSCC and SNUC will each be explored in detail. Organ preservation, treatment morbidity, and survival data will be presented, and evidence-based recommendations will be presented for the management of these patients.

Population-based Long-term Outcomes for Squamous Cell Carcinoma of the Nasal Cavity

BACKGROUND

This study evaluates population-based outcomes of patients with squamous cell carcinoma (SCC) of the nasal cavity treated in British Columbia.

METHODS

A retrospective review of nasal cavity SCC treated from 1984 to 2014 was performed (n = 159). Locoregional recurrence (LRR) and overall survival (OS) were evaluated.

RESULTS

The 3-year OS was 74.2% for radiation alone, 75.8% for surgery alone, and 78.4% for surgery and radiation ( P = 0.16). The 3-year LRR was 28.4% for radiation alone, 28.2% for surgery alone, and 22.6% for surgery and radiation ( P = 0.21). On multivariable analysis, surgery and postoperative radiation relative to surgery alone was associated with a lower risk of LRR (hazard ratio: 0.36, P = 0.03). Poor Eastern Cooperative Oncology Group status, node-positive, orbital invasion, smoking, and advanced age were associated with worse OS (all P <0.05).

CONCLUSION

In this population-based analysis, multimodality treatment with surgery and adjuvant radiation were associated with improved locoregional control for SCC of the nasal cavity.

The Role of Induction Therapy for Sinonasal Cancers

OPINION STATEMENT

The role of induction chemotherapy in sinonasal cancers is promising; however, prospective studies with higher grades of evidence are needed. With the currently available literature, the authors would advocate for the use of induction chemotherapy (IC) in locally advanced sinonasal squamous cell carcinoma (T3-T4) for organ preservation and potentially for improved survival outcomes. In sinonasal undifferentiated carcinoma (SNUC), IC should be considered in all patients given its tendency for aggressive invasion and poor outcomes. In SNUC, response to IC may direct the modality of definitive treatment to follow. In responders (partial or complete), chemoradiation therapy should be strongly considered. In non-responders or in those with progression of disease, surgical therapy is favored. For esthesioneuroblastoma, surgical resection with negative margins and adjuvant radiation therapy remains the gold standard. However, IC may be considered for locally advanced disease especially with orbital invasion or in recurrent/distant disease. There is no definite indication for IC in sinonasal adenoid cystic carcinoma or sinonasal adenocarcinoma. Recommendations are summarized in Table 1.

The contemporary management of cancers of the sinonasal tract in adults

Sinonasal malignancies make up <5% of all head and neck neoplasms, with an incidence of 0.5-1.0 per 100,000. The outcome of these rare malignancies has been poor, whereas significant progress has been made in the management of other cancers. The objective of the current review was to describe the incidence, causes, presentation, diagnosis, treatment, and recent developments of malignancies of the sinonasal tract. The diagnoses covered in this review included sinonasal undifferentiated carcinoma, sinonasal adenocarcinoma, sinonasal squamous cell carcinoma, and esthesioneuroblastoma, which are exclusive to the sinonasal tract. In addition, the authors covered malignances that are likely to be encountered in the sinonasal tract-primary mucosal melanoma, NUT (nuclear protein of the testis) carcinoma, and extranodal natural killer cell/T-cell lymphoma. For the purpose of keeping this review as concise and focused as possible, sarcomas and malignancies that can be classified as salivary gland neoplasms were excluded.

Nasal Cavity Squamous Cell Carcinoma: Factors Associated With Treatment Outcomes and Potential Organ Preservation

Background

Squamous cell carcinoma of the nasal cavity (NCSCC) is a rare, challenging malignancy. Surgical resection of this tumor can cause significant facial deformity, and indications for adjuvant or organ preservation therapies are not well-described.

Objective

To examine the impact of treatment regimen on survival outcomes in NCSCC and to compare surgical to non-surgical based therapies.

Methods

The National Cancer Database was queried for NCSCC from 2004 to 2014. Patient demographics, tumor characteristics, and treatment regimen were compared for the entire cohort. Multivariable Cox proportional hazards regression was performed for statistical analysis of treatment regimen and surgical margins on overall survival (OS) for early and late-stage disease.

Results

A total of 1883 NCSCC patients were identified. The OS for the cohort was 83 months, and median age at diagnosis was 65 years. NCSCC patients who underwent surgery followed by adjuvant radiation therapy (RT) had a better OS compared to definitive RT (HR: 0.58, P < .001). In early stage NCSCC (T1/T2, N0), there was no significant difference in OS between patients treated with surgery only or surgery with adjuvant RT compared to definitive RT. In advanced stage NCSCC, surgery with adjuvant RT had a better OS compared to definitive chemoradiation. Having positive margins was shown to predict a worse OS when compared to negative margins in surgical patients despite adjuvant RT or chemoradiation.

Conclusions

NCSCC appears to be best treated with surgery followed by adjuvant RT in advanced-stage disease whereas in early-stage disease, surgery does not improve OS compared to definitive RT.

Treatment Outcomes of Maxillary Sinus Squamous Cell Carcinoma at a Dedicated Cancer Institute: A Retrospective Study

Introduction

Squamous cell carcinoma arising at the maxillary sinus is a rare neoplasm, characterized by an aggressive growth pattern and glooming prognosis. The proximity of the maxillary sinus with complex anatomical structures such as the eye, skull base, infratemporal fossa, pterygomaxillary fossa, nasal cavities, and ethmoid sinuses makes the surgical treatment of tumors infiltrating into these structures very challenging. The study's objective was to investigate the prognostic factors of survival and maxillary sinus SCC treatment outcomes.

Methods

We did a retrospective analysis of patients treated for maxillary sinus SCC at our institution between 2004 -2018. The study included all the patients with histologically proven maxillary sinus SCC treated with curative intent. The medical record of 43 patients was reviewed and utilized for the analysis. The Kaplan-Meier curve calculated five-year overall survival.

Results

A total of 43 patients were analyzed. At the presentation time, the mean age was 54.56 years (SD ± 11.65). Smoking (n=13, 30.2%) was the common risk factor. 36 (83.7%) patients presented with stage IV disease. Surgery was performed in 16 (37.2%) patients, whereas 27 (62.8%) patients received radiation and chemotherapy. Treatment failure was seen in 35 (81.4%) patients with locoregional recurrence in 30 (85.7%) patients and distant metastases in 5 (14.3%) patients. The five years overall survival in our study was 22%. Loco-regional recurrence and distant metastasis were the significant factors impacting survival (p=0.01).

Conclusion

Maxillary sinus SCC is rare cancer that is more common in males and usually presents at an advanced stage with a poor outcome. These tumors have a higher rate of treatment failure with a poor prognosis. Locoregional recurrence and distant metastasis adversely impact the overall survival.

Sinonasal Squamous Cell Carcinoma Survival Outcomes Following Induction Chemotherapy vs Standard of Care Therapy

Objective

To compare oncologic outcomes in sinonasal squamous cell carcinoma (SNSCC) treated with standard of care (SOC) definitive therapy, consisting of surgery or chemoradiotherapy, vs induction therapy followed by definitive therapy.

Study Design

Retrospective review.

Setting

Academic tertiary care hospital.

Methods

The medical records of patients with biopsy-proven SNSCC treated between 2000 and 2020 were reviewed for demographics, tumor characteristics, staging, treatment details, and oncologic outcomes. Patients were matched 1-to-1 by age, sex, and cancer stage according to treatment received. Time-to-event analyses were conducted.

Results

The analysis included 26 patients with locally advanced SNSCC who received either induction therapy (n = 13) or SOC (n = 13). Baseline demographics, Charlson Comorbidity Index, and median follow-up time were well balanced. Weekly cetuximab, carboplatin, and paclitaxel were the most common induction regimen utilized. Tolerance and safety to induction were excellent. Objective responses were observed in 11 of 13 patients receiving induction. No difference in disease-free survival was found between the induction and SOC groups at 1 or 3 years. However, when compared with SOC, induction therapy resulted in significant improvement in overall survival at 2 years (100% vs 65.3%, P = .043) and 3 years (100% vs 48.4%, P = .016) following completion of definitive therapy. Two patients in the SOC group developed metastatic disease, as compared with none in the induction group.

Conclusions

Induction therapy was safe and effective. When compared with SOC, induction therapy improved 3-year overall 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.

Determinants of survival in sinonasal and skull base chondrosarcoma: An analysis of the National Cancer Database

BACKGROUND

Chondrosarcomas are rare, malignant chondroid tumors that can occur in the sinonasal and skull base regions. Surgery is a mainstay of treatment, but complete resection can be challenging because of the close proximity of critical neurovascular structures. Because of their rarity and relatively indolent nature, optimal treatment regimens are not established. Our objective was to assess determinants of survival for sinonasal and skull base chondrosarcomas utilizing the National Cancer Database (NCDB).

METHODS

The NCDB (2004-2017) was queried for cases of sinonasal and skull base chondrosarcoma. Multivariate hazard regression modeling was used to identify significant predictors of 60-month and 120-month overall survival (OS).

RESULTS

Seven hundred thirty-six cases met inclusion criteria. OS for all treatment types was 84.7% [SE±0.02] at 60 months and 75.6% [SE±0.02] at 120 months. Surgery with or without adjuvant treatment was found to associate with highest OS at 60 and 120 months. For patients receiving adjuvant radiation during treatment, proton therapy had significantly better OS at 60 months (95.4% [SE±0.03] vs 82.3% [SE±0.03], -²  = 5.27; p = 0.02) and 120 months (85.1% [SE±0.08] vs 72.8% [SE±0.05], -²  = 4.11; p = 0.04) compared with conventional external beam. After adjustment for primary site, multivariate Cox regression modeling (n = 561) identified cofactors significantly associated with variation in mortality risk at 60 and 120 months, including age, Charlson-Deyo total score ≥ 3, insurance provision status, and tumor grade.

CONCLUSIONS

Sinonasal and skull base chondrosarcoma are primarily treated with surgery with favorable OS. Adjuvant treatment may be required and proton radiation was associated with improved 60-month and 120-month survival compared with conventional radiation.

Induction Chemotherapy for Orbit Preservation in Sinonasal Squamous Cell Carcinoma

Sinonasal squamous cell carcinoma (SNSCC) is a rare and aggressive malignancy which often presents at an advanced stage. The gold-standard treatment includes negative-margin surgical resection plus adjuvant therapy. In cases of orbital invasion, surgery requires orbital exenteration which can carry significant morbidity and result in decreased quality of life. In selected patients, induction chemotherapy (IC) can allow for orbit preservation without compromising oncologic outcomes. The available literature will be briefly discussed.

Outcomes of Management of Sinonasal Malignancies at a Dedicated Cancer Institution: A Retrospective Study

Introduction

Sinonasal malignancies (SNMs) are a rare and heterogeneous group of cancers with an incidence of 3%-5% of all head-and-neck tumours. The aim of the present study was to identify the characteristic features of SNMs and to analyze the treatment outcomes and the prognostic factors affecting it.

Materials and Methods

A retrospective review of patients with SNM treated at a dedicated cancer center of Pakistan between 2004 and 2018 was carried out. All patients with histologically proven diagnosis of malignancy arising from nasal cavity or paranasal sinuses and being treated with curative intent were included. The medical records of 184 cases were utilized for final analysis. Chi-square test was applied to identify significant differences. Five-year disease-specific survival (DSS) was calculated using Kaplan-Meier curve via log-rank test and comparison was made between squamous and nonsquamous histologies. P ≤0.05 was considered statistically significant.

Results

Squamous cell carcinoma was the most common histopathology (n = 62, 33.7%). 130 (70.7%) patients presented with stage IV disease. Nodal metastasis was seen in 24 (13%) patients. Treatment failure was seen in 96 (52.2%) patients and was significantly associated with tumour size and the overall stage. DSS of patients with squamous cell carcinoma was 29% as compared to 52% for patients with nonsquamous histologies (P = 0.001).

Discussion

SNM is a diverse group of cancers presenting in late stages. A higher rate of treatment failure associated significantly with stage of the disease was identified in our study.

Cancer of the Paranasal Sinuses

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

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.