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.

A retrospective review of non‑intestinal‑type adenocarcinoma of nasal cavity and paranasal sinus

Non-intestinal adenocarcinoma of nasal cavity and paranasal sinuses (n-ITAC) is a heterogeneous tumor, which has rarely been reported in previous studies. Most high-grade n-ITAC has poor prognosis and there is a lack of classic therapeutic strategy. The present study examined using the PACS system of Nanfang Hospital of Southern Medical University between January 2000 and June 2020. It searched the keyword 'n-ITAC' and selected pathology. A total of 15 consecutive patients were searched. Finally, the present study analyzed a total of 12 n-ITAC patients. The follow-up time was 47 months on average. For low-grade (G1) tumors, 1 and 3-year overall survival (OS) rate were 100 and 85.7% respectively, while for high-grade (G3) tumors, 1 and 3-year OS rates were 80.0 and 20.0% respectively. Pathological grade may be an adverse prognostic factor (P=0.077). The OS of the surgery group was significantly superior to that of the non-surgery group (3-year OS was 63.6 vs. 0%, P=0.0009). Surgery is an indispensable means of treatment. The OS of patients with positive incisal margin was lower compared with that of patients with negative margin (P=0.186), suggesting that complete resection may be one of the prognostic factors. Patients with high risk factors received radiotherapy. The radiation dose was 66-70 Gy/33F for patients with positive margin or non-operation and was 60 Gy/28F for those with negative margin. Most of the patients received prophylactic irradiation of cervical area. Therefore, the prognosis of pathological high-grade n-ITAC is poor. Surgery is the most effective and an indispensable treatment for n-ITAC. For patients with high risk factors, surgery combined with radiotherapy may be a reasonable treatment. With regard to the cover range of radiotherapy, the primary tumor combined with lymph node drainage area is often used in Nanfang Hospital of Southern Medical University and the total dose of radiotherapy can be reduced if the surgical margin is negative.

Descriptive analysis of recurrences of nasal intestinal-type adenocarcinomas after radiotherapy

BACKGROUND

Despite adjuvant radiotherapy, rates of recurrences of endoscopically operated nasal intestinal-type adenocarcinomas (ITAC) have not been improved in successive series. To better understand how to improve local control, we aimed to investigate the site of local recurrences of ITACs.

METHODS

Retrospective study in a reference center in sinonasal malignancies. For all patients with a local recurrence, radiotherapy plans were retrieved and compared to the delineation of local recurrences.

RESULTS

Of 63 patients, 54 underwent adjuvant radiotherapy of which 14 (25.9%) had a local recurrence. Eleven of them had their onset in an optimally irradiated area. Difficulty to dissect the cribriform plate and/or the lateral lamina was reported for 11 patients with local recurrences in the operative reports (p <0.0001).

CONCLUSIONS

Most of recurrences arose in an optimally irradiated area. A close cooperation between surgeons and radiotherapists is required to define areas at risk and adapt treatment.

Development and validation of a nomogram for prognosis of sinonasal adenocarcinoma (a nomogram for sinonasal adenocarcinoma)

BACKGROUND

The incidence of sinonasal adenocarcinoma is low, and there are few studies on survival and prognosis. Therefore, we aim to develop and validate a prognostic model for predicting the overall survival of sinonasal adenocarcinoma and provide guidance for clinical management.

METHODS

Patients who were diagnosed as sinonasal adenocarcinoma through Surveillance, Epidemiology, and End Results database between 1975 and 2015 were randomly divided into a training group and validation group. Univariate, multivariate survival analysis was performed to screen independent survival factors. A nomogram was established to predict the overall survival rate of sinonasal adenocarcinoma. Receiver operating characteristic curve and calibration plot were performed to verify the discrimination and accuracy of the model. A decision curve analysis was performed to verify the clinical applicability of the model.

RESULTS

A total of 423 patients with sinonasal adenocarcinoma were randomly divided into training group (n = 299) and verification group (n = 124). We established and verified the Nomo map including age, marriage, grade, surgery and tumour size. The c-index of Surveillance, Epidemiology, and End Results stage, T stage and this model are 0.635, 0.626 and 0.803, respectively. The survival rate of the high-risk group scored by this model was lower than that of the low-risk group (P < 0.001). Decision curve analysis shows that the model has advantages in predicting survival rates.

CONCLUSION

Our model is considered to be a useful tool for predicting the overall survival of sinonasal adenocarcinoma, with good discrimination and clinical applicability. We hope that this model will help rhinologists to make clinical decisions and manage patients diagnosed with sinonasal adenocarcinoma.

Reappraisal of Grading in Intestinal-Type Sinonasal Adenocarcinoma: Tumor Budding as an Independent Prognostic Parameter

Since sinonasal intestinal-type adenocarcinomas (ITAC) show resemblance to colorectal adenocarcinomas, we aimed to investigate novel prognostic factors of outcome, with particular focus on the role of tumor budding (TB). Retrospective clinico-pathological single-institution study on consecutive ITAC patients between 1996 and 2020. Histopathological parameters including conventional subtypes and TB features (low, intermediate, high) were evaluated with the aid of pancytokeratin (AE1/AE3) immunohistochemical staining. Parameters were correlated to clinical data and outcome. A total of 31 ITAC patients were included. Overall, 19/31 patients (61.3%) presented with stage III/IV disease. Presence of lymph node or distant metastases was rare (1/31 patient, 3.2%). Treatment protocols consisted of tumor resection in 30/31 patients (96.8%) and primary radiochemotherapy in 1/31 patient (3.2%). Adjuvant radiation therapy was conducted in 20/30 surgically treated patients (66.7%). The 3- and 5-year overall survival (OS) was 83.9% and 78.3% and the 3- and 5-years disease-specific survival (DSS) 83.7% % and 78.5%, respectively. The presence of intermediate/high TB (defined as ≥ 5 buds) was associated with both, worse DSS (log rank p = 0.03) and OS (log rank p = 0.006). No patient with low TB revealed progressive disease or died of the disease. No association between TB and tumor stage or conventional tumor subtype was found. Tumor budding seems to be an independent prognostic factor of worse outcome in ITAC.

Endoscopic, Endonasal Transsphenoidal Surgery for Tumors of the Sellar and Suprasellar Region: A Monocentric Historical Cohort Study of 369 Patients

BACKGROUND

The endoscopic endonasal transsphenoidal approach (EETA) is an established technique for the resection of a large variety of benign sellar and suprasellar lesions, mostly pituitary adenomas. It has clear advantages over the microscopic approach, like a superior close-up view of the relevant anatomy and the tumor-gland interface, an enlarged working angle, as well as an increased panoramic vision inside the surgical area. We have been performing the EETA for over a decade, and this study will focus on perioperative and postoperative outcomes and complications and their association with the learning curve.

MATERIAL AND METHODS

All patients in our tertiary referral center (n = 369) undergoing an EETA for a lesion of the sellar and suprasellar region between January 1st 2008 and December 31st 2018 were included, and data were retrospectively retrieved from the electronic patient records.

RESULTS

Median follow-up after surgery was 55 months. Pituitary adenomas (n = 322) were the most frequent pathology. Headache (43.4%) and loss of vision (29.3%) were the most common presenting symptoms. Median procedure duration was significantly longer during the initial 5 years (106 versus 79 minutes; p <0.0001), but incidence of peri- and postoperative CSF leaks in the early years was not significantly higher. Knosp grade >2 was associated with perioperative CSF leak (p =0.002), and perioperative CSF leak was associated with postoperative CSF leak (p <0.001). Almost all cases of meningitis were preceded by a postoperative CSF leak. In 22.4% of patients, tumor recurrence required additional therapy. Perioperative (iatrogenic) mortality was 0.8%. The overall hospital stay decreased over time from an average of 7 to 5 days, and the case load increased yearly (p =0.015).

CONCLUSION

The EETA is an excellent technique with complication rates comparable to or even lower than those in large microsurgical series in the literature. EETA has a significant learning curve affecting the procedure duration. Throughout the first 10 years following the transition from the microscopic approach to the EETA in our cohort, the caseload increased and hospital stay was reduced, while no increase in peri- and postoperative complications was observed.

Treatment of Sinonasal Adenocarcinoma: A Population-Based Prospective Cohort Study

Objectives  Sinonasal adenocarcinoma (AC) is a potentially curable disease despite being an aggressive malignancy. Long-term survival can be achieved with early diagnosis and adequate multidisciplinary treatment. Our goal was to evaluate outcomes for patients with AC treated at our institution. Design  In a population-based consecutive prospective cohort, we conducted an analysis of all patients treated for surface epithelial AC between 1995 and 2018. Results  Twenty patients were included, and follow-up was 100%. The mean follow-up time was 89 months for the entire cohort (112 months for patients with no evidence of disease). Intestinal-type AC was found in 65%, whereas nonintestinal-type AC was found in 35% of all cases; 75% had stage T3/4 disease. Tumor grade was intermediate/high in 65%. Eighteen patients underwent treatment with curative intent (craniofacial resection [CFR] in 61%, transfacial approach in 39%, adjuvant radiotherapy in 89%), achieving negative margins in 56% of cases. Overall survival (OS) rates were 90, 68, and 54% after 2, 5, and 10 years of follow-up, respectively, and the corresponding disease-specific survival (DSS) rates were 90, 73, and 58%. Age over 60 years, tumor with a maxillary origin, and microscopic bone invasion were negative prognostic factors. Radical CFR was correlated with better OS and DSS. Conclusion  The high probability of achieving radicality with CFR, the low complication rate, the acceptable toxicity of modern irradiation modalities, and the promising survival rates indicate that this strategy might be considered a safe and an effective option for treating patients with very advanced sinonasal AC.

Unilateral endoscopic resection with transnasal craniectomy for sinonasal intestinal-type adenocarcinoma: A bi-institutional case-control study on 54 patients

OBJECTIVES

Intestinal-type adenocarcinoma (ITAC) of the ethmoid mostly affects patients exposed to wood dust and has been traditionally treated with bilateral resection. The aim of the present study was to validate unilateral endoscopic resection with transnasal craniectomy (uERTC) in selected ITACs.

MATERIALS AND METHODS

Patients affected by ITAC receiving uERTC from 2004 to 2017 at two tertiary referral centers were retrospectively analyzed. A control group of patients treated with bilateral endoscopic resection with transnasal craniectomy (bERTC) was selected. Olfaction, taste, and quality of life were evaluated. Survival and functional outcomes in the two groups were compared.

RESULTS

Fifty-four patients who underwent uERTC (case group: 27/54) or bERTC (control group: 27/54) were enrolled. The two groups were statistically comparable. Five-year overall (OS), disease-specific (DSS), recurrence-free (RFS) survivals, and local recurrence rates were not significantly different between groups. Hospitalization time was significantly shorter in the uERTC group (p = 0.0004) and no significant difference in terms of complications was demonstrated. The rate of subjective olfaction preservation was significantly higher in the uERTC group (45.5%) than in the bERTC group (0.0%) (p = 0.0007). Median 22-Items Sinonasal Outcome Test (SNOT-22) values were not significantly different between groups. No significant association of olfaction and taste preservation/worsening with reconstructive technique, radiation therapy, and chemotherapy was observed.

CONCLUSIONS

uERTC is an adequate surgical procedure for selected unilateral ITAC with similar survival rates and lower morbidity compared to bERTC. A rigorous follow-up of patients with ITAC is crucial and strongly recommended independently of the extent of resection.

Intestinal-type adenocarcinoma of the sinonasal tract: an update

PURPOSE OF REVIEW

Intestinal-type adenocarcinoma (ITAC) is one of the most frequent sinonasal tumors, especially in European countries. The purpose of this article is to review the most recent literature, with special emphasis on biological and genetic profile and treatment guidelines.

RECENT FINDINGS

Results on large series support transnasal endoscopic surgery as the technique of choice in the large majority of patients with ITAC. Adjuvant radiotherapy is recommended in advanced-stage and high-grade lesions. More robust data are required to confirm that early-stage, low-grade lesions can be treated with exclusive surgery. The efficacy of new chemotherapy and biotherapy regimens and the added value of heavy particle radiotherapy are currently under evaluation. With a 5-year overall survival ranging between 53 and 83%, which is mainly impacted by local recurrences, ITAC requires a more detailed understanding of its biology. Genetic and biological studies have identified alterations in the molecular pathways of EGFR, MET, and H-RAS which might be considered as potential targets for biotherapy.

SUMMARY

Surgery still plays a key role in the treatment of ITAC, but multidisciplinary management is mandatory. Although further validation is needed, the role of nonsurgical treatment strategies is rising, in agreement with the progresses made in the biological profiling of the disease.

Sinonasal Non-Intestinal-Type Adenocarcinoma: A Retrospective Review of 22 Patients

OBJECTIVE

To analyze outcomes and prognostic factors of sinonasal nonsalivary non-intestinal-type adenocarcinoma (n-ITAC.) METHODS: A retrospective review of 22 consecutive patients with n-ITAC was performed.

RESULTS

Average follow-up time was 77 months. The 5-year overall survival and disease-specific survival were 95.2%. The 5-year overall survival and disease-specific survival were 100% for pT1, pT2, and pT3 tumors and 83.3% for pT4a and pT4b tumors; 100% for G1 tumors and 87.5% for G3 tumors; and 100% for tumors with negative surgical margin and 50% for tumors with positive surgical margin. Stage, grade, and surgical margins were independent prognostic factors. Adjuvant radiotherapy was performed for high-grade and high-stage tumors.

CONCLUSIONS

Surgery followed by radiotherapy has remained a mainstay for management of n-ITAC, and the endoscopic transnasal approach, when correctly planned and indicated, is the surgery of choice. Adjuvant radiotherapy is recommended in cases of high-stage (T3 and T4) and high-grade tumors. n-ITAC is associated with a favorable outcome. High grade, pT4 stage, and positive surgical margins are independent negative prognostic factors.

AHNS Series: Do you know your guidelines? Principles for treatment of cancer of the paranasal sinuses: A review of the National Comprehensive Cancer Network guidelines

This article is a continuation of the "Do You Know Your Guidelines" series. This was launched as an initiative of the American Head and Neck Society to increase the awareness of current best practices pertaining to head and neck cancer. The National Comprehensive Cancer Network (NCCN) guidelines for managing cancer of the paranasal sinuses are reviewed in a systematic fashion. These guidelines outline the workup, treatment, and surveillance of patients with cancer of the maxillary and ethmoid sinuses.

Compartmentalized endoscopic resection of the olfactory cleft for nasal intestinal adenocarcinomas

BACKGROUND

The purpose of this study was to describe the pathology of the different compartments in endoscopic resection of nasal intestinal-type adenocarcinomas (ITACs) and its relationships with oncologic outcomes.

METHODS

This retrospective study included all patients endoscopically operated for nasal ITACs, followed by radiotherapy in the majority of cases, between 2004 and 2014. The surgery systematically separated 3 compartments: ethmoid lateral mass, olfactory cleft, and anterior cranial fossa (in cases with skull-base invasion) to analyze their pathological "focal" or "massive" invasion by the tumor.

RESULTS

Sixty-seven patients (aged 69.2 ± 9.8 years) were included. Twenty-nine patients (43.3%) had only pathological focal invasion. At 61.0 ± 41.7 months of mean follow-up, the recurrence rates were 34.2% in the group with massive invasion and 10.3% in the group with focal invasion (P = .023). The disease-specific death rate had a tendency to be higher in the group with massive invasion (23.7% vs 6.9% for the group with focal invasion; P = .097). By Kaplan-Meier analysis, the 5-year disease-specific survival rate was better in the group with focal invasion than the group with massive invasion (P = .01). The 5-year overall survival was not different between the 2 groups (47.4% and 65.5% for focal invasion and massive invasion respectively; P = .14).

CONCLUSION

Compartmentalized endoscopic resection, combined with postoperative radiotherapy, is one way to operate on nasal ITACs with good oncologic outcomes.

Ethmoidal adenocarcinoma treated by exclusive endoscopic approach: Focus on learning curve and modification of management

BACKGROUND

The purpose of this study was to investigate the outcome and recurrences for ethmoidal adenocarcinomas treated by exclusive endoscopic surgery in curative intent and investigate the role of the learning curve.

METHODS

We conducted a single-center retrospective study, including 60 patients separated in 2 groups (2002-2011 n = 28 and 2012-2015 n = 32).

RESULTS

The global survival rate at 5 years was 72.6%, and the global and local recurrence rates were 21.6% and 13.3%, respectively. The learning curve had significant impact on global survival at 2 years (93.8% vs 77.8%) and on overall and local recurrences, despite the higher rate of T4 classifications in the latter group. This learning curve could be explained by the evolution toward large endoscopic resection, bilateral, with resection of the cribriform plate, and eventually medial maxillectomy, and started on the healthy side.

CONCLUSION

For selected cases, exclusive endoscopic resection of ethmoid adenocarcinoma achieves results at least as good as craniofacial resection when performed by an experienced cranial base team and including a large endoscopic resection.

Types of endoscopic endonasal resections for sinonasal malignancies

AIM

The aim of this study was to define the types of endoscopic endonasal resection for sinonasal malignancies according to their origin and extension.

METHODS

Patients who underwent endoscopic endonasal surgery for the removal of malignant tumors of the nasal passages, paranasal sinuses, and the anterior cranial base between 2003 and 2010 were included in the study. Patients' data were collected retrospectively. Patients were grouped according to types of endoscopic tumor resection as follows: type I: en bloc resection, type II: resection of intranasal free part piecemeal and origin of tumor en bloc, type III: resection of intranasal free part and origin of tumor piecemeal with curative intent, and type IV: resection of intranasal free part and origin of tumor piecemeal with palliative intent or removal of tumor with positive margin. The follow-up period varied from 2 to 7 years (mean, 4.35 years).

RESULTS

Twenty patients were included in the study. Five patients underwent type I, 6 patients type II, 4 patients type III, and 5 patients underwent type IV resection. No local tumor recurrence was seen after types I, II, and III resections, whereas 2 patients (10%) with the type IV resection had a local recurrence. Distant metastasis was observed in 4 patients (20%) postoperatively (1 patient in type I, 1 patient in type III, and 2 patients in type IV resection). Disease-specific death was 15% (1 case in type I and 2 cases in type IV).

CONCLUSION

Classification of endoscopic tumor resection used in the present study may help preoperative planning.

Long-term follow-up of 123 patients with adenocarcinoma of the sinonasal tract treated with endoscopic resection and postoperative radiation therapy

BACKGROUND

Most series about endoscopic resection of adenocarcinomas of the sinonasal tract present outcome data from a small heterogeneous group of patients with a relatively short follow-up period and a wide variety of histological subtypes and treatment protocols. This relatively large study with a very homogeneous study population updates our experience with a stable treatment protocol looking at survival rates, surgical technique, and prognostic factors.

METHODS

We conducted a retrospective analysis of the medical records of 123 patients with adenocarcinoma of the intestinal type primarily treated with endoscopic resection and postoperative radiotherapy (RT) in a single tertiary referral center during the period 1992 to 2010.

RESULTS

Mean follow-up was 66 months and median follow-up was 54 months. Mean and median follow-up of the subgroup of patients alive at the end of follow-up was 74 months and 61 months, respectively. At 5-years of follow-up, overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were 68%, 82%, and 62% respectively. At 10-year follow-up, these numbers were 51%, 74%, and 45%, respectively. Prognostic factors for treatment outcome are predominantly local recurrence, development of distant metastasis, T classification, histopathological classification, and the center where the first surgery was performed.

CONCLUSION

This large study of sinonasal adenocarcinoma primarily treated with endoscopic resection and RT confirms that this approach results in good oncologic and functional outcome.

Sinonasal adenocarcinoma: a 16-year experience at a single institution

BACKGROUND

Adenocarcinoma is a rare tumor of the sinonasal tract. The purpose of this study was to characterize a single institution's experience with this malignancy.

METHODS

Retrospective review was performed of patients with adenocarcinoma of the sinonasal tract from 1993 to 2009. Demographic data, disease presentation, treatment, and survival rates were collected and evaluated.

RESULTS

We identified 66 patients with sinonasal adenocarcinoma; 48 were men and 18 women. Average age at time of diagnosis was 57.1 years (range, 20-88 years), and median follow-up was 55.3 months (range, 1-238 months). The ethmoid sinus (38%) and nasal cavity (36%) were the most common sites of origin. Nasal obstruction (36%), epistaxis (30%), and nasal discharge (21%) were the most common presenting symptoms. Fifty-one percent of patients presented with T1 or T2 tumors. Surgery was the primary form of treatment in 81% of patients. Twenty-six percent of surgical patients underwent an endoscopic tumor resection. Adjuvant radiation was utilized in 50% of patients and chemotherapy in 10%. Recurrence was seen in 24 patients (37%): 29% recurred locally and 7.6% recurred distantly. The overall 5-year survival was 65.9%. Survival was decreased significantly in patients with T4 tumors (p < .05), high-grade histology (p < .05), and sphenoid sinus involvement (p < .05). Survival was not affected by surgical approach between endoscopic and open approaches (p = .76).

CONCLUSION

Sinonasal adenocarcinomas are commonly identified in the sinonasal cavity and are associated with a relatively favorable prognosis, despite a substantial local failure rate of 30%. Advanced-stage tumors, sphenoid sinus and skull base invasion, and high-grade histology portend poor prognosis. In our experience, endoscopic resection was not associated with adverse outcomes and suggests that this minimally invasive approach can provide acceptable oncologic outcomes in selected patients.

Demographics and survival trends of sinonasal adenocarcinoma from 1973 to 2009

BACKGROUND

The purpose of this work was to study the demographics and survival of patients diagnosed with sinonasal adenocarcinoma (SNAC) within the time period of 1973 to 2009 using the Surveillance, Epidemiology, and End Result (SEER) database.

METHODS

A retrospective cohort study using the U.S. National Cancer Institute's SEER registry was performed to study the demographics and survival for SNAC from 1973 to 2009. Analysis was conducted based on race, gender, and stage.

RESULTS

In total, 1270 cases of SNAC were analyzed for demographics and survival. Males accounted for 51.6% of cases, while females accounted for 48.4% of cases, amounting to a male to female ratio of 1.06:1.00. Disease specific survival at 5, 10, 15, and 20 years was 65.2%, 50.9%, 40.9%, and 36.5%, respectively. When analyzed by gender, females had higher survival than males, although this difference was not statistically significant. When analyzed by race, the category of other, which encompasses American Indian, Asian, Hispanic, and unknown or unspecified race, was shown to have the best survival, followed by whites and blacks, respectively.

CONCLUSION

SNAC is a rare tumor classically associated with occupational exposure and carries a variable prognosis. This is the first dedicated large-scale, retrospective analysis of a North American SNAC population. SNAC appears to affect both males and females equally and predominantly affects whites. Patients categorized as other had significantly better survival outcomes, while gender appeared to have no significant effect on survival.

Sinonasal malignancies: long term follow up after surgical management-an analysis of outcomes

Sinonasal malignancies are rare and survival analysis in affected patients is arduous and perplexing due to various factors. In this review article, attempt has been made to overcome some of those factors while analysing survival outcomes.

AIMS AND OBJECTIVES

The aim of this study was to share the experience of a tertiary care centre in the surgical management of sinonasal malignancies over 12 years.

MATERIALS AND METHODS

This study is a retrospective chart review, and in this study, hospital records of 58 patients with biopsy proven sinonasal malignancies were studied. Only the patients undergoing primary or salvage surgery at our institution from May-2000 to April-2012 with a minimum follow up of 2 years were included. Statistical analyses such as means, proportions, Kaplan-Meier analysis and Cox's regression model were done.

RESULTS

Majority of the patients were males (n = 43) belonging to fourth and fifth decades. Squamous cell carcinoma was the most common (n = 17) histopathological type, followed by adenoid cystic carcinoma (n = 14). Majority presented with stage IV disease (n = 42). 17 patients were operated for recurrent disease. Over all 5 year survival was 72 % and disease free survival was 44 %. Separate analysis for epithelial and matched non-epithelial group showed poorer prognosis with epithelial group (p = 0.0120). Multivariate analysis showed histopathological type (epithelial) and presence of pathological risk factors (positive margins and/or perineural invasion) affecting survival.

CONCLUSIONS

Advanced stage presentation is the norm for sinonasal malignancies. This study noted a 5 year overall survival of 72 % and disease free survival of 44 %. Epithelial histopathology carries poorer prognosis then other counterparts and incomplete removal is shown to add to poor prognosis independently.

Endoscopic craniofacial resection. Indications and technical aspects

INTRODUCTION

Anterior craniofacial resection (CFR) is a standardised procedure for the treatment of tumours involving the anterior skull base. We present our experience in the endoscopic treatment of these tumours.

MATERIAL AND METHOD

A retrospective analysis was performed of patients treated by endoscopic anterior CFR in our Department from 2004 until 2011.

RESULTS

Thirty-two patients were analysed. Mean follow-up was 28 months (range: 6-84 months). The most frequent pathological entity was adenocarcinoma (60%), followed by undifferentiated carcinoma (13%). According to TNM classification, malignant epithelial tumour staging was T3 in 9%, T4a in 53% and T4b in 19% of the malignant epithelial tumours. The complication rate was 6% and the resection was complete in 91% of cases. During follow-up, 9% of patients developed recurrence. The 5-year overall survival rate was 70% and the 5-year disease-free survival rate was 85%

CONCLUSION

These results seem to indicate that properly planned endoscopic CFR may be a valid alternative to traditional open approaches for the management of malignancies of the anterior skull base.

Endoscopic endonasal approach for the treatment of anterior skull base tumours

INTRODUCTION

The increasing expertise of transnasal endoscopic surgery has recently expanded its indications to include the management of tumours affecting the skull base. We report our experience with endoscopic management of these tumours, emphasising the indications and surgical technique used.

MATERIAL AND METHOD

A retrospective analysis was performed of patients treated by an endoscopic endonasal approach (EEA) in our department from 2004 until 2011.

RESULTS

Sixty-three patients were analysed. We performed an endoscopic craniofacial resection in 32 patients (51%), an expanded EEA in 22 (35%), a transclival approach in 6 (9%) and a transpterygoid approach in 3 (5%). The most frequent benign tumour was nasopharyngeal angiofibroma (24%), while adenocarcinoma (30%) was the most common among malignancies. Mean follow-up was 26 months (range: 6 to 84 months). The complication rate was 5% and resection was complete in 56 cases (89%). The 5-year overall-survival was 71% in patients with malignant tumours and the effectiveness was 100% in benign tumours.

CONCLUSION

Our results support that endoscopic surgery, when properly planned, represents a valid alternative to standard surgical approaches for the management of skull base tumours.

Stage grouping in tumors of the ethmoid sinuses and the nasal cavity using the sixth edition of the UICC classification of malignant tumors

BACKGROUND

The purpose of this study was to evaluate the prognostic impact of the sixth edition of the Union Internationale Contre le Cancer (UICC) classification and different TNM-based stage groupings for malignant tumors of the ethmoid sinuses and the nasal cavity.

METHODS

We conducted a retrospective analysis of 98 patients with malignant tumors of the ethmoid sinuses and the nasal cavity between 1967 and 2003. The UICC classification of the sixth edition and the T and N Integer Score (TANIS) and Hart were tested for their prognostic significance.

RESULTS

In univariate analysis, all stage groupings revealed discriminatory power for overall survival (OS; p < .05), however, in multivariate analysis only the UICC-stage grouping (p = .033) and the TANIS-8 scheme (p = .044) predicted OS. The TANIS did not have a better prognostic quality than the sixth edition of the UICC classification.

CONCLUSION

The UICC-stage grouping of the sixth edition is a good prognostic index for malignant tumors of the ethmoid sinuses and the nasal cavity.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Endoscopic vs Transfacial Resection of Sinonasal Adenocarcinomas

Objectives. Compare the survival and the complication rates of 2 comparable groups of patients who underwent either endoscopic or transfacial resection of a sinonasal adenocarcinoma.

Study Design. Historical cohort study.

Setting. Tertiary referral center.

Subjects and Methods. Twenty-four patients with sinonasal adenocarcinomas who recently underwent an endoscopy (the ENDO group, 1999-2009) were compared with 24 patients who underwent a lateral rhinotomy procedure (the LR group, 1993-2007). The present retrospective study included patients who would have had an endoscopic resection in 2011.

Results. The groups were comparable in terms of age and sex ( P = .49), as well as tumor stages; 43 of the 48 patients had undergone postoperative radiotherapy. There were 13 T1-T2 and 11 T3-T4 tumors in the ENDO group compared with 12 T1-T2 and 12 T3-T4 tumors in the LR group ( P = .77). The mean length of follow-up was 38 months for the ENDO group and 89 for the LR group. The overall survival and recurrence-free rates were not significantly different ( P = .3 and P = .87, respectively). The median duration of hospitalization was significantly shorter in the ENDO group than in the LR group (4 vs 8 days, P < .0001). The rate of early complications was identical in both groups (12.5%).

Conclusion. The endoscopic approach is a safe and effective treatment in selected sinonasal adenocarcinoma cases. The early oncological outcome and morbidity associated with the endoscopic approach were comparable with a transfacial approach. Hospitalization was significantly reduced by the endoscopic approach. Although the endoscopic approach is less invasive, it requires an optimal preoperative imaging protocol and an experienced surgical team.

Anatomical correlates of endonasal surgery for sinonasal malignancies

In recent years, endoscopic endonasal techniques have been applied to the treatment of sinonasal malignancies. Comprehensive anatomical knowledge is essential to preserve oncological principles and minimize surgical morbidity. The bones that form the anterior cranial base are pneumatized and the sinuses provide surgical corridors for the endoscopic endonasal approach to the skull base. During endoscopic endonasal resection of sinonasal malignancies, usually, the intranasal portion of the tumor is first debulked to provide visualization of the margins and assess the extent of the tumor. Afterwards the tumor is completely removed and the margins of resection are defined. In case of dural resection, the reconstruction is done with vascularized tissue (septal flap or pericranial flap). Sinonasal malignant neoplasms that invade the skull base can be resected accordingly to oncological principles using endoscopic endonasal techniques. Profound knowledge of the endoscopic anatomy of the ventral cranial base is paramount in order to perform a safe resection and reconstruction.

Endoscopic resection of sinonasal malignancies

Malignant tumors of the sinonasal tract are rare, accounting for only 1% of all malignancies. Although they are associated with substantial histological heterogeneity, surgery plays a key role in their management. This review addresses the evolution of current treatments in view of the introduction of endoscopic resection techniques. The absence of facial incisions and osteotomies, decreased hospitalization time, better control of bleeding, improved visualization of tumor borders, and reduced morbidity and mortality rate are the major advantages of endoscopic techniques in comparison to traditional external approaches. The major criticisms focus on oncologic results in view of the short/intermediate follow-up of large series, which have commonly grouped together several histologies that may be associated with different prognoses. Since prospective studies contrasting the results of endoscopic and craniofacial resections are difficult to carry out given the rarity of the disease together with ethical issues, the creation of a large database would favor the analysis of several variables related to the patient, tumor, and treatment on survival performed on a large number of patients.

Outcome results of endoscopic vs craniofacial resection of sinonasal malignancies: a systematic review and pooled-data analysis

BACKGROUND

Endoscopic approaches of sinonasal malignancies are now being described. This study aims to conduct a systematic review with a pooled-data analysis to compare outcomes of endoscopic vs craniofacial resection of sinonasal malignancies.

METHODS

A search was conducted of MEDLINE (1966-2008), EMBASE (1980-2008), Cochrane Central Register of Clinical Trials (CENTRAL), Cochrane Database of Systematic Reviews, clinicaltrials.gov, and The National Guideline Clearinghouse databases and supplemented by references in retrieved articles. All authors used a detailed list of inclusion and exclusion criteria to determine articles eligible for final inclusion. The authors extracted data regarding study criteria appraisal, sinonasal malignancy characteristics, survival outcomes, and recurrence. Kaplan-Meier survival and locoregional control rates were calculated and compared using the log-rank test.

RESULTS

Of the 2314 citations reviewed, the search yielded 15 case series with individual data on 226 patients. The most common malignancies were esthesioneuroblastoma (47%), adenocarcinoma (24%), and undifferentiated carcinoma (22%). The overall 5-year survival rate for the sample was 56.5% (standard error [SE] ± 3.8). Because of the paucity of data with endoscopic resection of high-stage malignancies, the outcome results were highly variable and no useful comparison could be made. Among low-stage malignancies (T1-2 or Kadish A-B), the endoscopic and open approaches demonstrated no statistically significant difference in outcome results. The 5-year overall survival was 87.4% (SE ± 5.3) in the endoscopic group vs 76.8% (SE ± 8.3) for open approaches (p = 0.351); disease-specific survival was 94.7% (SE ± 3.7) vs 87.7% (SE ± 6.7; p = 0.258); and locoregional control rate was 89.5% (SE ± 5.0) vs 77.2% (SE ± 10.4; p = 0.251).

CONCLUSION

Transnasal endoscopic resection appears to be a reasonable alternative to craniofacial resection in the management of low-stage sinonasal malignancies.

Evidence for treatment strategies in sinonasal adenocarcinoma

Adenocarcinomas of various types account for 10% to 20% of all primary malignant neoplasms of the nasal cavity and paranasal sinuses. There is a general consensus that the optimal treatment of adenocarcinoma is surgery and postoperative radiotherapy. The purpose of this report was to review the results of this combined treatment as well as other treatment strategies and their outcome. Most series present outcome data from a heterogeneous group of patients, with a wide variety of tumor subtypes presenting at differing stages, who received a variety of treatment strategies. Surgical excision remains the treatment of choice. The choice of approach is determined by what will best allow complete excision of the disease. Endoscopic techniques, if feasible for complete removal of the tumor, offer results comparable to those of external approaches with lower morbidity. Although clear evidence to support the use of radiotherapy in sinonasal adenocarcinoma is difficult to obtain, local control rates of combined treatment strategies for advanced cases are comparable to less advanced cases with surgery alone, suggesting a positive role for postoperative radiotherapy. However, the importance of thorough surgical resection should be stressed.

Ethmoid adenocarcinoma--from craniofacial to endoscopic resections: a single-institution experience over 25 years

OBJECTIVES

To identify factors that influence hospitalization time, complications, and prognosis of patients with ethmoid adenocarcinoma treated with different surgical techniques.

DESIGN

Single-institution retrospective review.

SETTING

Academic tertiary care center.

PATIENTS

Sixty-seven patients with ethmoid adenocarcinoma treated from January 1985 to August 2009 were retrospectively evaluated. Surgical treatment included endoscopic resection (n = 12), endoscopic resection with transnasal craniectomy (n = 17), cranioendoscopic resection (n = 9), external approaches limited to the ethmoid (n = 11), and craniofacial resection (n = 18).

MAIN OUTCOME MEASURES

A Cox model was adopted to relate time to death to previous treatment, pT category, grade, and surgical technique. The impact of the same variables on hospitalization time and risk of complications was assessed by linear regression and logistic regression, respectively.

RESULTS

The risk of complications increased for pT4a-b lesions (P = .02) and craniofacial resection (P = .01). Hospitalization time increased by 6.3 days for cranioendoscopic resection (P = .03) and by 11.7 days for craniofacial resection (P < .001). Three- and 5-year overall survivals were 68.0% (standard error = 5.8%) and 48.4% (standard error = 6.9%). Three-year survival was 76.62% and 51.81% for previously untreated and treated patients, respectively, and it was 92.98% and 33.33% in patients treated with endoscopic techniques and craniofacial resection, respectively. Multivariate analysis showed that previous treatment (hazard ratio of death = 3.9, P = .01) and craniofacial resection (HR = 5.16, P = .05) were mainly associated with survival.

CONCLUSIONS

Endoscopic techniques, in properly selected patients, were associated with a favorable oncologic outcome and a statistically significant reduction in both complication rate and hospitalization time. This study supports the role of endoscopic techniques in surgical treatment of ethmoid adenocarcinoma.

Anterior craniofacial resection for malignant paranasal tumors: a monoinstitutional experience of 366 cases

BACKGROUND

The purpose of this study was to evaluate the results of a mono-institutional series of patients treated with anterior craniofacial resection for malignant paranasal sinus tumors.

METHODS

We analyzed all patients with malignant paranasal sinus tumors treated with anterior craniofacial resection at our institution between 1987 and 2007. All tumors were classified according to both the American Joint Committee on Cancer (AJCC)-2002 and the Istituto Nazionale Tumori (INT) classifications.

RESULTS

The sample included 366 patients. There was intraorbital spread in 108 cases. The skull base was eroded in 127 patients, with dura or brain involvement in 93 patients. The 10-year disease-specific survival was 53.1%. Histologic subtype, INT stage, surgical margins, and postsurgical radiotherapy were significant, independent predictors for both local relapse and disease-specific survival (DSS). The AJCC-2002 classification was not significant when tested in place of INT stage.

CONCLUSION

Our data indicated that craniofacial resection and postsurgical radiotherapy remain the primary option for malignant tumors involving the anterior skull base.

Endoscopic skull base/sinonasal adenocarcinoma surgery: what evidence exists?

BACKGROUND

This study reviewed the published outcomes literature on endoscopic or endoscopic-assisted treatment of sinonasal and skull base adenocarcinoma (SSBA). A systematic literature review was performed.

METHODS

A PubMed search of English language articles on endoscopic or endoscopic-assisted SSBA was performed. Each article was examined for patient data and outcomes for analysis.

RESULTS

Sixteen articles (150 retrospective cases) using endoscopic or endoscopic-assisted SSBA were identified. Three (19%) reported at least 15 cases of adenocarcinoma with 5-year survival ranging from 53 to 83%. In all identified studies, five (31%) reported adenocarcinoma-specific survival statistics and eight (50%) provided complete patient information. Adjuvant therapy was used in 12 studies (75%), with details outlined in 6 (38%) articles, accounting for 52 of 74 cases (70% of those patients and 35% overall). Adenocarcinoma-specific follow-up was reported in only nine studies (56%); four of these nine articles had a median/mean follow-up time of <3 years. Six articles (38%) used American Joint Committee on Cancer guidelines and four articles (25%) used International Union Against Cancer guidelines. The remaining six articles (38%) did not report on the stage of treated tumors. Four articles (25%) reported length of hospital stay and eight (50%) reported complication data. Three studies comprising 61 cases (41% of overall patients) recorded disease status, tumor stage, site involvement, and complication rates for each patient.

CONCLUSION

From the existing body of data, one can not conclude that endoscopic methods are superior or inferior to open methods, but there is growing evidence that this is an efficacious technique. Future studies should have emphasis on detailed, prospective reporting.

Intensity-modulated radiotherapy for sinonasal cancer: improved outcome compared to conventional radiotherapy

PURPOSE

To evaluate clinical outcome and toxicity of postoperative intensity-modulated radiotherapy (IMRT) for malignancies of the nasal cavity and paranasal sinuses.

METHODS AND MATERIALS

Between 2003 and 2008, 40 patients with cancer of the paranasal sinuses (n = 34) or nasal cavity (n = 6) received postoperative IMRT to a dose of 60 Gy (n = 21) or 66 Gy (n = 19). Treatment outcome and toxicity were retrospectively compared with that of a previous patient group (n = 41) who were also postoperatively treated to the same doses but with three-dimensional conformal radiotherapy without intensity modulation, from 1992 to 2002.

RESULTS

Median follow-up was 30 months (range, 4-74 months). Two-year local control, overall survival, and disease-free survival were 76%, 89%, and 72%, respectively. Compared to the three-dimensional conformal radiotherapy treatment, IMRT resulted in significantly improved disease-free survival (60% vs. 72%; p = 0.02). No grade 3 or 4 toxicity was reported in the IMRT group, either acute or chronic. The use of IMRT significantly reduced the incidence of acute as well as late side effects, especially regarding skin toxicity, mucositis, xerostomia, and dry-eye syndrome.

CONCLUSIONS

Postoperative IMRT for sinonasal cancer significantly improves disease-free survival and reduces acute as well as late toxicity. Consequently, IMRT should be considered the standard treatment modality for malignancies of the nasal cavity and paranasal sinuses.