Endoscopic resection followed by adjuvant radiotherapy for sinonasal intestinal-type adenocarcinoma: Retrospective analysis of 30 consecutive patients

A case of high-grade non-intestinal paranasal sinus adenocarcinoma primary in the maxillary sinus: targeted therapy after postoperative immunocombination with chemotherapy

BACKGROUND

High-grade non-intestinal-type sinonasal adenocarcinoma (non-ITAC) is a rare and aggressive form of adenocarcinoma with poor prognosis. The current standard treatment approach involves surgery combined with radiation therapy. However, there is a need for exploring additional treatment modalities to improve patient outcomes.

CASE PRESENTATION

We present a case of a 65-year-old male patient who presented with pain in the right maxillary sinus and was diagnosed with high-grade non-ITAC following surgery. Postoperative pathology revealed tumor invasion into bone tissue and vascular invasion, necessitating further treatment. The patient underwent radiation therapy, followed by immunotherapy with carilizumab combined with chemotherapy. During the maintenance immunotherapy period, tumor progression was observed, and genetic testing identified EGFR and TP53 mutations. Consequently, the patient was treated with gefitinib, a targeted therapy drug. Notably, the patient's lung metastases showed a gradual reduction in size, indicating a favorable treatment response. The patient is currently undergoing oral treatment with gefitinib.

CONCLUSIONS

This case report highlights the potential benefit of combining immunotherapy and targeted therapy in the treatment of high-grade non-ITAC. Despite the rarity of this cancer type, this approach may offer an alternative treatment strategy for patients with this aggressive disease. We hope that this case can contribute to a deeper understanding of high-grade non-ITAC and promote the application of immunotherapy and targeted therapy in improving survival rates for patients with this condition.

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.

Sinonasal adenocarcinomas: Retrospective analysis from an oncology center

INTRODUCTION AND OBJECTIVES

Sinonasal adenocarcinomas are rare and heterogeneous tumors and for this reason remain understudied. Our purpose is to analyze clinical presentation, outcomes and factors affecting survival of patients with sinonasal adenocarcinomas, treated at our institution.

MATERIAL AND METHODS

Retrospective review of clinical records of patients with sinonasal adenocarcinoma, treated at a tertiary oncology institution (January 2010 to December 2019).

RESULTS

Sixty patients diagnosed with adenocarcinoma were included, with male preponderance (54.90%) and a mean age of 57.5±14.9 years. Adenocarcinoma was the most frequent type of sinonasal cancer, contrary to previous reports from our institution. In most patients, it was detected at an advanced disease stage, significantly decreasing their survival rate when compared to patients diagnosed at initial stages (p<0.029). Intestinal type adenocarcinoma was established in 47 patients, the most frequent being the colonic subtype (24%). Tumors with good/moderate histologic differentiation presented a survival advantage over those that were poorly differentiated (p=0.043). The most common treatment modality was surgery followed by radiotherapy. Endoscopic resection was performed in 53% of the patients and an external approach was used in 40% of the patients. Estimated overall survival rates at 3 and 5-years were 64% and 53%, respectively, and cancer specific survival 72% and 65%, for the same period. Recurrence rate was 32% and occurred mainly locally. Disease Free Survival rate was 71% at 3 years and 65% at 5 years.

CONCLUSIONS

Despite being the most common sinonasal malignancy in our sample, in contrast to other series, sinonasal adenocarcinomas are still rare tumors with a substantial local failure rate of around 30%. Advanced stage at diagnosis and histologic differentiation grade negatively affected prognosis of these tumors.

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

BACKGROUND

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

METHODOLOGY

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

RESULTS

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

CONCLUSIONS

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

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.

MiRNome analysis identifying miR-205 and miR-449a as biomarkers of disease progression in intestinal-type sinonasal adenocarcinoma

BACKGROUND

Patients with intestinal-type sinonasal adenocarcinoma (ITAC) have an unfavorable prognosis, and new diagnostic and therapeutic approaches are needed to improve clinical management.

METHODS

Next-generation sequencing-based miRNome analysis was performed on 43 ITAC patients who underwent surgical resection, and microRNA (miRNA) data were obtained from 35 cases. Four miRNAs were identified, and their expression levels were detected by reverse-transcription quantitative polymerase chain reaction and related to the relevant patient outcome. Overall survival and disease-free survival rates were evaluated through the Kaplan-Meier method and log-rank test, and multivariate analysis was performed by means of Cox proportional hazard analysis.

RESULTS

High levels of miR-205 and miR-34c/miR-449 cluster expression were associated with an increased recurrence risk and, therefore, a worse prognosis. Multivariate analysis confirmed that miR-205 and miR-449 were significant prognostic predictors.

CONCLUSIONS

A high expression of miR-205 and miR-449 is independent predictors of poor survival for ITAC patients.

Decreasing recurrence and increasing survival rates in patients of ethmoid or sphenoid intestinal-type adenocarcinomas: Systematic review and meta-analysis with 1126 cases

BACKGROUND

Ethmoid or sphenoid intestinal-type adenocarcinomas (ITACs) form a distinct subtype of sinonasal adenocarcinomas that occur less than 1 case/100,000/yr. They have obvious exposure relationship to hardwood or leather dusts, infrequent metastasis, but a relatively high local-recurrence rate. They locate at sinuses close to vital structures listed as high-risk areas in surgeries. Even in expert hands, a craniofacial resection is associated with non-negligible mortality and morbidity. Management of these tumors, first or recurrent, needs to weigh these consequences versus the survival, regional-recurrence, and distant-recurrence rates. Due to the rareness of ethmoid or sphenoid ITACs, accurate overall survival and local- or regional-recurrence rates across diverse treatments are unclear. The aim of this study is to report the overall statistics of this cancer and the relationship between enrollment year versus age, recurrence, and survival.

METHODS

Systemic review and meta-analysis with 1126 cases across various treatments in the literature.

RESULTS

Here, we show that patients of ethmoid or sphenoid ITACs had overall local-, regional-, and distant-recurrence rates of 32.2%, 2.2%, and 10.3%, respectively, with a 5-year overall survival rate of 66.2%. The results present a significant correlation between age, local-recurrent rate, or overall survival rate versus enrollment year.

CONCLUSION

This suggests that recent patients of ethmoid or sphenoid ITACs may present at an older mean age, have a lower local-recurrence rate, and have a better 5-year survival rate than before. There was a shifting trend of treating ethmoid ITACs from external approach to endoscopic resection. Clinicians may want to weigh mortality and morbidity rates of external surgeries and these data to share or decide a solution.

Precision Postoperative Radiotherapy in Sinonasal Carcinomas after Endonasal Endoscopic Surgery

Simple Summary

Sinonasal cancers are rare and heterogeneous tumors, mainly carcinomas, with essentially local evolution and a severe vital and functional prognosis. These tumors are more and more being treated in first intent by a mini-morbid endoscopic approach rather than open surgery as the cornerstone of curative treatment. Adjuvant radiotherapy remains necessary owing to non-optimal local control. This article describes the requirements of radiotherapy to ensure adequate delays, the potential of postoperative radiotherapy to increase local and distant disease control and to decrease morbidity further after mini morbid surgery and dose painting techniques, and reviews the criteria that lead to the choice of one technique over another.

Abstract

Radiotherapy plays an important role in the treatment of sinonasal cancer, mainly in the adjuvant setting after surgical resection. Many technological approaches have been described, including intensity-modulated radiotherapy, concomitant chemoradiotherapy, charged particle therapy or combined approaches. The choice is based on general criteria related to the oncological results and morbidity of each technique and their availability, as well as specific criteria related to the tumor (tumor extensions, pathology and quality of margins). The aims of this review are: (i) to provide an overview of the radiotherapy techniques available for the management of sinonasal malignant tumors and (ii) to describe the constraints and opportunities of radiotherapy owing to the recent developments of endonasal endoscopic surgery. The indication and morbidity of the different techniques will be discussed based on a critical literature review.

[Treatment of primary craniofacial (sinonasal) malignant tumors affecting the anterior and middle skull base]

Sinonasal malignant tumors are characterized by high histological variability and complexity of the differential diagnosis. Currently, there are classifications of these tumors, which are based on their localization and involvement of various anatomical structures. However, generally accepted algorithms for treatment of this pathology have not yet been developed. This review describes the most important algorithms for treatment of the most common histological variants of sinonasal malignant tumors: squamous cell carcinoma, adenocarcinoma, sinonasal undifferentiated carcinoma, esthesioneuroblastoma, adenoid cystic cancer, and sinonasal adenocarcinoma. The main problems in choosing the approach for treating these tumors are the lack of generally accepted resectability criteria and contradictions between oncological and neurosurgical indications for surgical treatment. Further research is needed to study the role of radiosensitizers and radioprotectors in comprehensive treatment of sinonasal malignant tumors.

Novel Biomarkers in Sinonasal Cancers: from Bench to Bedside

PURPOSE OF REVIEW

Sinonasal cancers are a heterogenous group of rare cancers for which histopathological diagnosis can be very challenging and treatment options are limited for advanced disease in particular. Here, we review the candidacy of novel diagnostic and prognostic biomarkers, and therapeutic targets for sinonasal cancers.

RECENT FINDINGS

Molecular multidimensional analyses of sinonasal cancers have been lagging behind other major cancers, but there are numerous publications describing the discovery of novel candidate biomarkers, e.g. the methylation classifier, originally developed for brain cancers, and gene expression panels for the prediction of response to induction chemotherapy in sinonasal undifferentiated carcinoma. The most promising biomarkers are summarized and discussed further with regard to their clinical applicability and future potential. Many of the described novel biomarkers for sinonasal cancers will eventually overcome the pitfalls associated with the frequently non-specific immunohistological tests. With comprehensive, multidimensional molecular testing of these tumours in collaborative consortia projects, our better understanding of the molecular mechanisms of sinonasal cancers and their carcinogenesis will determine the most useful diagnostic and prognostic biomarkers, allow stringent multi-institutional validation and guide trials on targeted therapies.

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.

Intensity-modulated radiotherapy for paranasal sinuses and base of skull tumors

Paranasal sinus and skull base tumors are rare aggressive head and neck cancers, and typically present in the locally advanced stages. As a result, achieving wide surgical resection with clear margins is a challenge for these tumors, and radiotherapy is thus usually indicated as an adjuvant modality following surgery to optimize local control. Given the integral role of radiotherapy in the management of this subgroup of head and neck tumors, the advent of intensity-modulated radiotherapy (IMRT) has led to substantial improvement of clinical outcomes for these patients. This is primarily driven by the improvement in radiation dosimetry with IMRT compared to conventional two dimensional (2D)- and 3D-techniques, in terms of ensuring dose intensity to the tumor target coupled with minimizing dose exposure to critical organs. Consequently, the evident clinical benefits of IMRT have been in reduction of normal tissue toxicities, ranging from critical neurological symptoms to less debilitating but bothersome symptoms of eye infections and radiation-induced skin changes. Another domain where IMRT has potential clinical utility is in the management of a subset of non-resectable T4 paranasal sinus and skull base tumors. For these inoperable lesions, the steep dose-gradient between tumor and normal tissue is even more advantageous, given the crucial need to maintain dose intensity to the tumor. Innovative strategies in this space also include the use of induction chemotherapy for patient selection. In this review, we summarized the data for the aforementioned topics, including specific discussions on the different histologic subtypes of paranasal sinus and skull base tumors.

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.

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

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

The Impact of Histologic Phenotype in the Treatment of Sinonasal Cancer

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

Endoscopic Resection of Sinonasal and Ventral Skull Base Malignancies

The transnasal endoscopic resection of ventral skull base lesions represents a safe and effective method for the surgical management of sinonasal and ventral skull base malignancies in carefully selected cases. The goal of surgery is complete removal of all tumor with negative resection margins while maintaining the key oncological principles. Careful selection of cases along with the presence of an experienced surgeon and a fully involved multidisciplinary skull base team trained in the management of ventral skull base neoplasm are essential for excellent outcomes.

Sinonasal Malignancies of Anterior Skull Base: Histology-driven Treatment Strategies

The advances in endoscopy have revolutionized the management of sinonasal and skull base lesions. Many complex cancers that traditionally required open approaches are now amenable to purely endoscopic endonasal resection, providing less invasive surgery with lower morbidity but with comparable oncologic outcomes in terms of survival rates. This article discusses the current evidence for the multimodal management of sinonasal and anterior skull base cancers focusing on the different treatment protocols driven by histologic subtypes.

Endoscopic Resection of Sinonasal Malignancy

Objectives

The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy.

Data Sources

MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse.

Review Methods

PRISMA/MOOSE guidelines were followed. MeSH terms were “endoscopic” AND (“esthesioneuroblastoma” OR “sinonasal adenocarcinoma” OR “squamous cell carcinoma” OR “sinonasal undifferentiated carcinoma”). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model.

Results

Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers ( P = .015) but not between low- and high-stage cancers ( P = .79).

Conclusion

Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines.

Development of minimally invasive surgery for sinonasal malignancy

Sinonasal malignancies are rare and histologically heterogeneous. Treatment is complicated by tumor aggressiveness and location near critical anatomic structures (orbita, skull base, etc.). This low incidence and histologic diversity make prospective studies unfeasible, and thus therapeutic guidelines difficult to establish. The gold standard for surgery is a transfacial approach, with craniofacial resection in case of skull-base involvement. However, these techniques are associated with non-negligible perioperative morbidity. In the past two decades, endoscopic surgery has made major progress, extending its indications: initially developed for functional sinus surgery, it is now applied in benign skull-base pathologies (CSF leakage, meningocele, etc.) and, more recently, in sinonasal malignancy. Literature analysis shows a significant decrease in morbidity and improved quality of life associated with endoscopic endonasal surgery, with oncologic safety and efficacy in well-selected cases, although dependent on operator experience. Additional studies with longer follow-up and comparison between histologic subtypes will be needed.

Design and rationale of a prospective, multi-institutional registry for patients with sinonasal malignancy

OBJECTIVES/HYPOTHESIS

Assessment of patients with sinonasal malignancy is challenging due to the low disease incidence and diverse histopathology. The current literature is composed mainly of retrospective studies with heterogeneous cohorts, and the rarity of cases limits our understanding of disease characteristics and treatment outcomes. We describe the development of a prospective, multi-institutional registry that utilizes cloud-based computing to evaluate treatment outcomes in patients with sinonasal cancer.

METHODS

A web-based, secure database was built to prospectively capture longitudinal outcomes and quality-of-life (QoL) data in patients diagnosed with sinonasal malignancy. Demographics, tumor staging, and treatment outcomes data are being collected. The Sinonasal Outcome Test-22 and University of Washington Quality of Life Questionnaire are administered at presentation and at recurring intervals. To date, seven institutions are participating nationally.

CONCLUSION

This prospective, multi-institutional registry will provide novel oncological and QoL outcomes on patients with sinonasal malignancy to inform management decisions and disease prognostication. The application of cloud-based computing facilitates secure multi-institutional collaboration and may serve as a model for future registry development for the study of rare diseases in otolaryngology.

LEVEL OF EVIDENCE

2C Laryngoscope, 126:1977-1980, 2016.

Brain Herniation After Endoscopic Transnasal Resection of Anterior Skull Base Malignancies

BACKGROUND

Endoscopic endonasal approaches, when appropriate, allow a less invasive method to remove anterior skull base cancer than traditional external transfacial/craniofacial approaches. The resultant skull base defect can be significantly large, potentially extending from the posterior table of the frontal sinus to the tuberculum sellae in the sagittal plane, and from one lamina papyracea to the other in the coronal plane. However, frontal lobe herniation after such expanded endoscopic resection has been considered more of a theoretical than a practical occurrence.

OBJECTIVE

To report the occurrence of frontal lobe herniation into the sinonasal cavity after expanded endonasal approaches, and to analyze causes and pathogenetic mechanisms of this unusual complication, proposing how it could have been prevented.

METHODS

Two cases have been observed in 2 different skull base referral centers in the United States and Italy. Surgical and perioperative complications, postoperative course, and need for revisions were analyzed.

RESULTS

Available data support the hypothesis that this complication is not attributable to the size of the anterior skull base defect, to the surgical technique, or to the materials used for the reconstruction. We found that 1 possible contributing factor may be the presence of increased intracranial pressure associated with obesity and obstructive sleep apnea, observed in both patients.

CONCLUSION

Frontal lobe herniation must be considered as a possible, albeit rare, complication of expanded endoscopic anterior skull base resection. Preoperative investigations concerning the presence of obstructive sleep symptoms as well as proper identification of neuroimaging signs of intracranial hypertension are recommended for such cases.

Intestinal type adenocarcinoma of the ethmoid: Outcomes of a treatment regimen based on endoscopic surgery with or without radiotherapy

BACKGROUND

The purpose of this study was to assess survival, prognostic factors, and complications in a cohort of patients with intestinal-type adenocarcinoma (ITAC) treated with transnasal endoscopic surgery ± radiotherapy (RT).

METHODS

Patients with ITAC who underwent endoscopic surgery ± RT at 2 tertiary centers were retrospectively reviewed. Overall survival (OS) and event-free survival were calculated, and statistically significant variables were entered in a multivariate Cox regression model. Complications were also analyzed.

RESULTS

One hundred-sixty-nine patients were included. Major complications occurred in 9.5% of patients. Adjuvant RT was delivered in 58.6% of patients. Five-year OS and event-free survival were 68.9% and 63.6%, respectively. Advanced pT classification, high-grade, and positive surgical margins were independently predictive of poor survival.

CONCLUSION

Endoscopic surgery ± RT is a valid treatment option in most cases of ITAC. When compared with series based on external surgery, our results support a definitive paradigm shift in the management of ITAC. © 2015 Wiley Periodicals, Inc. Head Neck 38: E996-E1003, 2016.