Transnasal endoscopic surgery in selected nasal-ethmoidal cancer with suspected brain invasion: Indications, technique, and outcomes

Surgical resection and overall survival in cT4b sinonasal non-squamous cell carcinoma

Objective

Surgical resection is associated with higher overall survival (OS) than definitive radiotherapy (RT) or chemoradiotherapy (CRT) in cT4b sinonasal squamous cell carcinoma (SCC). Our study investigates the survival benefit of surgical resection in cT4b sinonasal non-SCC.

Methods

The 2004 to 2019 National Cancer Database was queried for patients with cT4b sinonasal non-SCC undergoing definitive treatment with (1) surgical resection + additional therapy (RT, chemotherapy, or both), (2) RT alone, or (3) CRT. Surgical resection + additional therapy and definitive RT/CRT were compared with Kaplan-Meier and multivariable Cox regression models.

Results

Of 629 patients satisfying inclusion criteria, 513 (81.6%) underwent surgical resection + additional therapy and 116 (18.4%) underwent definitive RT/CRT. The most frequent histologic types were undifferentiated carcinoma (23.7%), adenoid cystic carcinoma (22.6%), and adenocarcinoma (20.7%). Few patients presented with clinical nodal metastasis (15.7%). There were 4 (0.8%) mortalities within 90 days of surgical resection. Patients undergoing surgical resection with positive surgical margins had higher 5-year OS than those undergoing definitive RT/CRT (56.3% vs. 39.4%, p = .039) and similar 5-year OS as those with negative margins (56.3% vs. 63.9%, p = .059). Patients undergoing neoadjuvant chemotherapy had similar 5-year OS as those undergoing definitive RT/CRT (60.9% vs. 39.5%, p = .053). Age at diagnosis, tumor diameter, and surgical resection + additional therapy (aHR 0.64, 95% CI 0.45-0.91) were associated with OS (p < .05).

Conclusion

Surgical resection + additional therapy was associated with higher OS than definitive RT/CRT in cT4b sinonasal non-SCC. Surgical resection may benefit select patient with cT4b sinonasal non-SCC.

Level of Evidence

4.

Endoscopic-assisted transorbital extended orbital exenteration: A multi-institutional preclinical study

BACKGROUND

Sinonasal malignancies with orbital invasion have dismal prognosis even when treated with orbital exenteration (OE). Sugawara et al. developed a surgical strategy called "extended-OE (EOE)," showing encouraging outcomes. We hypothesized that a similar resection is achievable under endoscopic guidance through the exenterated orbit (endoscopic-EOE).

METHODS

The study was conducted in three institutions: University of Vienna; Mayo Clinic; University of Insubria; 48 orbital dissections were performed. A questionnaire was developed to evaluate feasibility and safety of each step, scoring from 1 to 10, ("impossible" to "easy," and "high risk" to "low risk," respectively), most likely complication(s) were hypothesized.

RESULTS

The step-by-step technique is thoroughly described. The questionnaire was answered by 25 anterior skull base surgeons from six countries. Mean, median, range, and interquartile range of both feasibility and safety scores are reported.

CONCLUSIONS

Endoscopic-EOE is a challenging but feasible procedure. Clinical validation is required to assess real-life outcomes.

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.

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.

The SINTART 1 study. A phase II non-randomised controlled trial of induction chemotherapy, surgery, photon-, proton- and carbon ion-based radiotherapy integration in patients with locally advanced resectable sinonasal tumours

PURPOSE

Sinonasal tumours are rare diseases with poor prognosis. Multimodal approach including surgery is widely used, although no standard therapy has been established in prospective trials. This study assessed activity and safety of an innovative integration of multimodality treatment-induction chemotherapy (ICT), surgery and radiotherapy (RT)-modulated by histology and response to ICT.

METHODS

Patients with untreated, operable sinonasal tumours with selected histotypes (squamous cell carcinoma, intestinal-type adenocarcinoma, sinonasal undifferentiated and neuroendocrine carcinoma, olfactory neuroblastoma) were enrolled in a single-arm, phase II, multicenter clinical trial. Patients were treated with up to 5 ICT cycles, whose regimen was selected according to histotype, followed either by curative chemo-RT for pts with ≥80% reduction of initial tumour diameter or surgery and adjuvant (chemo)RT. Photon and/or proton/carbon ion-based RT was employed according to the disease site and stage. Primary end-point was 5-year progression-free survival (PFS), secondary end-points were overall survival (OS), ICT objective response rate (ORR) per RECIST 1.1 and safety.

RESULTS

Thirty-five patients were evaluable for primary end-point. Fourteen patients (40%) were treated with definitive (CT)RT and 20 (57%) underwent surgery. Five-year PFS was 38% (95% confidence interval [CI], 21-69), with a median PFS of 26 months. Five-year OS was 46% (95% CI, 28-75), with a median OS of 36 months. Three-year PFS-OS for pts achieving PR/CR versus stable disease (SD)/PD to ICT were 49.8-57% versus 43.2-53%, respectively. Three-year PFS for patients achieving major volumetric partial response (≥80% reduction of initial tumour volume, major partial volumetric response [mPRv]) versus non-mPRv were 82% versus 28% and 3-year OS were 92% versus 36% (p value 0.010 and 0.029, respectively). The ORR to ICT was 54% and 60% across all histotypes and in the sinonasal undifferentiated carcinoma (SNUC) subpopulation, respectively, with 6/15 SNUCs (40%) achieving mPRv.

CONCLUSION

Treatment of advanced sinonasal cancer with histology-driven ICT followed by (CT)RT in responsive patients was feasible. Overall, these findings suggest a possible role of ICT as the primary approach in newly diagnosed, resectable sinonasal tumours-especially SNUC-to select patients with favourable prognosis. Histology heterogeneity limits generalisation of trial results.

Oncologic outcome of multimodality treatment for sinonasal malignancies: An 18-year experience

Purpose

The aim of this study was to retrospectively evaluate the oncologic outcomes of sinonasal malignancies (SNMs) of various histologic subtypes and investigate the impact of multimodality treatment on prognosis of SNM.

Methods

SNM patients treated with curative-intent surgery from 2000 to 2018 were included. The primary outcomes were overall survival (OS). Survival was then assessed through Cox proportional hazards models.

Results

Three hundred and three patients were eligible for the analysis. The 5-year OS and event-free survival (EFS) were 61.0% (95% CI: 55.4%–67.1%) and 46.2% (95% CI: 40.4%–52.7%). The 5-year OS was the worst for malignant melanoma and the best for adenocarcinoma. Patients who received surgery had better OS than those who only received radiotherapy and/or chemotherapy. Endoscopic surgery had better OS than the open approach (p < 0.05). Microscopically margin-negative resection (R0 resection) significantly benefited OS and EFS (p < 0.001). No significant difference in OS was observed between patients who received macroscopic complete resection (R1 resection) followed by adjuvant therapy and patients who received R0 resection. Older age (HR = 1.02, p = 0.02), R1 resection (HR = 1.99, p = 0.02), sinonasal surgical history of more than 3 months before diagnosis (HR = 2.77, p = 0.007), and radiotherapy history (HR = 3, p = 0.006) are risk factors for worse EFS.

Conclusions

Curative-intent surgery is irreplaceable in the treatment of SNM. The endoscopic approach is an effective alternative to the open approach. EFS is worse among patients with older age, R1 resection, sinonasal surgical history of more than 3 months before diagnosis, and radiotherapy history.

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.

The Selective Role of Open and Endoscopic Approaches for Sinonasal Malignant Tumours

Endoscopic endonasal surgery has been demonstrated to be effective in the treatment of selected cases of sinonasal cancers. However, in cases of locally advanced neoplasms, as well as recurrences, the most appropriate approach is still debated. The present review aims to summarize the current state of knowledge on the utility of open approaches to resect sinonasal malignant tumours. Published comparative studies and meta-analyses suggest comparable oncological results with lower morbidity for the endoscopic approaches, but selection biases cannot be excluded. After a critical analysis of the available literature, it can be concluded that endoscopic surgery for selected lesions allows for oncologically safe resections with decreased morbidity. However, when endoscopic endonasal surgery is contraindicated and definitive chemoradiotherapy is not appropriate, craniofacial and transfacial approaches remain the best therapeutic option.

Endoscopic versus open surgery in patients with malignant sinonasal tumours and brain invasion. A case series study

OBJECTIVES

To determine the safety, effectiveness and perioperative costs of endonasal endoscopic approach in brain invasive malignant sinonsal tumours patients.

MATERIALS AND METHODS

This was a case series bidirectional study; that included 30 brain invasive malignant sinonsal tumours patients treated by endonasal endoscopic approach (2015-2017) and 53 by open surgery (2010-2015). Propensity score matching was used to compensate the prognostic factors; in a sample of 50 patients (25 per group). Primary response variables was local control and 3-years overall survival. Perioperative cost variables were analyzed.

RESULTS

A number of 50 patients were included after matching (25 in each therapeutic group). The age average was 55 years and male proportion was 62%. Squamous cell carcinoma and grade II lesions were the most represented in the sample. Endonasal endoscopic approach reduced surgical time in 1 h 20 min, transfusion needs in 5.5 fold and hospitalization in 19 days; in comparison with open technique. Oncologic control based on surgical free margins, local control, overall survival and progression free survival after three years was higher when the resection was performed endoscopically. Functional status was enhanced and complications diminished by using endoscopic approach. Saving was estimated in $7 355.18 per patient.

CONCLUSIONS

Endonasal endoscopic approach represents a safe, effective and economic procedure in selected patients with malignant sinonasal tumors and brain invasion.

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

The term “sinonasal tumours” includes a large spectrum of diseases, which are characterized by heterogeneous biological behavior and prognosis, and located in a critical anatomic area. Diagnosis and treatment of sinonasal tumours require the contribution of different disciplines. A narrative review was performed to highlight the role of surgeons in contributing to a multidisciplinary approach to sinonasal tumours. Diagnosis and staging of sinonasal tumours is challenging and requires collaboration between surgeons, radiologists, and pathologists. The identification and management of critical extensions (orbital or intracranial encroachment, vascular abutment or encasement) is fundamental for successful treatment. Most cases of advanced sinonasal tumours can undergo surgical intervention by an adequately trained otorhinolaryngological team. The contribution of neurosurgeons and oculoplastic surgeons is required in selected scenarios. In rare circumstances, multidisciplinary reconstructive strategies can be indicated for complex tissue defects. Furthermore, a multidisciplinary approach is pivotal in the management of perioperative complications. While surgery remains the mainstay of treatment, the role of non-surgical adjuvant or even exclusive treatments is constantly expanding.

Surgical Management of Sinonasal Cancers: A Comprehensive Review

Surgery plays an important role in the treatment of sinonasal cancer. Many surgical approaches have been described, including open, endoscopic, or combined approaches. The choice is based on several criteria: general criteria related to the oncological results and morbidity of each technique, specific criteria related to the tumor (tumor extensions, tumor pathology), the patient, or the surgeon himself. The aims of this review are (i) to provide a complete overview of the surgical techniques available for the management of sinonasal malignant tumors, with a special focus on recent developments in the field of transnasal endoscopic surgery; (ii) to summarize the criteria that lead to the choice of one technique over another. In particular, the oncological outcomes, the morbidity of the different techniques, and the specificities of each histologic subtype will be discussed based on a comprehensive literature review.

Endoscopic versus open surgery in patients with malignant sinonasal tumors and brain invasion. A case series study

OBJECTIVES

To determine the safety, effectiveness and perioperative costs of endonasal endoscopic approach in brain invasive malignant sinonsal tumors patients.

MATERIALS AND METHODS

This was a case series bidirectional study; that included 30 brain invasive malignant sinonsal tumors patients treated by endonasal endoscopic approach (2015-2017) and 53 by open surgery (2010-2015). Propensity score matching was used to compensate the prognostic factors; in a sample of 50 patients (25 per group). Primary response variables was local control and 3-years overall survival. Perioperative cost variables were analyzed.

RESULTS

A number of 50 patients were included after matching (25 in each therapeutic group). The age average was 55 years and male proportion was 62%. Squamous cell carcinoma and grade II lesions were the most represented in the sample. Endonasal endoscopic approach reduced surgical time in 1 hour 20 minutes, transfusion needs in 5.5 fold and hospitalization in 19 days; in comparison with open technique. Oncologic control based on surgical free margins, local control, overall survival and progression free survival after three years was higher when the resection was performed endoscopically. Functional status was enhanced and complications diminished by using endoscopic approach. Saving was estimated in $7 355.18 per patient.

CONCLUSIONS

Endonasal endoscopic approach represents a safe, effective and economic procedure in selected patients with malignant sinonasal tumors and brain invasion.

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.

Incisionless facial resection for Kadish stage C olfactory neuroblastoma: Transcaruncular approach with combined endonasal and skull base surgery

This case report describes resection without facial incision for aggressive Kadish stage C olfactory neuroblastoma (ONB). We performed resection via transcaruncular approach with combined endonasal and skull base surgery. This multidisciplinary team surgical approach is expected to lead to a new strategy for this type of tumor in the future.

Management of sinonasal adenocarcinomas with anterior skull base extension

INTRODUCTION

Sinonasal adenocarcinomas (SNAC) are rare and heterogeneous. Management of SNAC follows a rather standardized and internationally accepted paradigm. Several refinements have been introduced during the last decade.

METHODS

A narrative review of most updated literature on SNACs has been conducted.

RESULTS

SNACs are classified as intestinal-type and non-intestinal-type, which are further categorized according to grade. Preoperative work-up should include magnetic resonance imaging (or contrast-enhanced computed tomography as a secondary or complementary choice) and biopsy under general anesthesia, or under local anesthesia in case of a history of exposure to wood and/or leather dust. Positron emission tomography, neck ultrasound, and fine-needle aspiration cytology are indicated in selected cases. Surgery represents the most common upfront modality of treatment and is usually accomplished via a transnasal endoscopic approach. Adjuvant radiation therapy is indicated for high-grade, locally advanced tumors and/or in case of margins involvement. Neoadjuvant chemotherapy with cisplatin, 5-fluorouracil and leucovorin may offer high response rates and long-term control in a subgroup of patients affected by intestinal-type adenocarcinoma, and in particular in those whose tumors harbor a functional p53 protein. Most of the bio- and immune-therapeutic potentials on SNACs still remain theoretical, and no clinical data are currently available.

CONCLUSIONS

Management of SNAC consists of histological diagnosis, radiological staging, radical surgery, and adjuvant radiation therapy. Neoadjuvant chemotherapy can be indicated in selected cases. The role of biotherapy and immune therapy still needs to be elucidated.