Treatment strategies for primary early-stage sinonasal adenocarcinoma: A retrospective bi-institutional case-control study

The Search for an Ideal Definitive Treatment of Sinonasal Squamous Cell Carcinoma With Orbit Invasion

OBJECTIVES

Sinonasal squamous cell carcinoma (SqCC) often invades the orbit. The treatment approach for sinonasal cancer that has spread to the orbit varies across medical centers and depends on the extent of the invasion. The decision to preserve the orbit in the treatment strategy is made on a case-by-case basis and.

RESULTS

in varying outcomes. Currently, a multimodal treatment regimen, which may include surgery, chemotherapy, radiotherapy (RT), or concurrent chemoradiotherapy (CCRT), is commonly adopted for managing sinonasal cancers. This study aims to assess the prognosis of sinonasal SqCC with orbital invasion from various perspectives.

METHODS

We conducted a retrospective review of patients with primary sinonasal SqCC invading the orbit who were treated at Seoul National University Hospital and Seoul National University Bundang Hospital between 2009 and 2018. The extent of the tumor, orbital invasion, treatment strategies, recurrence rates, and survival rates were analyzed.

RESULTS

Overall survival and disease-free survival (DFS) rates showed no significant differences based on the grade of orbital invasion. When tumor resection with orbit preservation was employed as the definitive treatment, DFS was significantly extended compared to cases where surgery was not the definitive treatment (RT or CCRT). Additionally, there was no significant difference in DFS between patients who underwent orbit exenteration and those who underwent tumor resection with orbit preservation as the definitive treatment.

CONCLUSION

Tumor resection with orbit preservation as the definitive treatment appears to be the preferred approach, prolonging DFS and increasing the likelihood of longer-term survival in cases of SqCC with orbital invasion.

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.

Adjuvant Radiation and Survival Following Surgical Resection of Sinonasal Adenocarcinoma

OBJECTIVES

This study aims to investigate the utility of adjuvant radiation in patients who undergo surgical resection for the management of node-negative sinonasal adenocarcinoma (SNAC).

STUDY DESIGN

Retrospective database review.

METHODS

The 2004-2016 National Cancer Data Base (NCDB) was used to extract patients with surgically resected node-negative SNAC. Kaplan-Meier survival analysis and Cox-Proportional Hazards Modelling were used to analyze the impact of adjuvant radiation on overall survival (OS) following surgery.

RESULTS

349 patients with SNAC underwent surgical resection. Of these patients, 154 (44.1%) received adjuvant radiotherapy (RT). Although there was no significant difference in race, age, or sex of those receiving RT, those receiving RT have more advanced diseases and are more likely to have positive margins. Kaplan Meier analysis showed no significant difference in 5-year OS in patient who received adjuvant RT in comparison to those who underwent surgical resection alone (65.7% vs. 72.6%, respectively; p = 0.378). In addition, when looking at only patients with positive margins, 5-year OS still did not have a significant difference (73.8% vs. 61.6%, respectively; p = 0.101). Only patients with clinical AJCC T4 showed a statistically significant survival benefit with adjuvant RT (56.9% vs. 29.9%, respectively; p = 0.009).

CONCLUSIONS

Adjuvant RT does not appear to provide a significant survival benefit in patients with resected SNAC, with the exception of those with clinically AJCC T4 disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2603-2612, 2023.

PET/CT Imaging in Treatment Planning and Surveillance of Sinonasal Neoplasms

Sinonasal cancers are uncommon malignancies with a generally unfavorable prognosis, often presenting at an advanced stage. Their high rate of recurrence supports close imaging surveillance and the utilization of functional imaging techniques. Whole-body 18F-FDG PET/CT has very high sensitivity for the diagnosis of sinonasal malignancies and can also be used as a "metabolic biopsy" in the characterization of some of the more common subgroups of these tumors, though due to overlap in uptake, histological confirmation is still needed. For certain tumor types, radiotracers, such as 11C-choline, and radiolabeled somatostatin analogs, including 68Ga-DOTATATE/DOTATOC, have proven useful in treatment planning and surveillance. Although serial scans for posttreatment surveillance allow the detection of subclinical lesions, the optimal schedule and efficacy in terms of survival are yet to be determined. Pitfalls of 18F-FDG, such as post-surgical and post-radiotherapy crusting and inflammation, may cause false-positive hypermetabolism in the absence of relapse.

The Prognostic Role of the Immune Microenvironment in Sinonasal Intestinal-Type Adenocarcinoma: A Computer-Assisted Image Analysis of CD3+ and CD8+ Tumor-Infiltrating Lymphocytes

The prognostic value of conventional histopathological parameters in the sinonasal intestinal-type adenocarcinoma (ITAC) has been debated and novel variables should be investigated. Increasing evidence demonstrated that the evolution of cancer is strongly dependent upon the complex interactions within tumor microenvironment. The aim of this retrospective study was to assess the features of immune microenvironment in terms of CD3⁺ and CD8⁺ cells in a series of ITAC and explore their prognostic role, as well as their relations with clinicopathological variables. A computer-assisted image analysis of CD3⁺ and CD8⁺ tumor-infiltrating lymphocytes (TIL) density was conducted on surgical specimens of 51 patients with ITAC that underwent a curative treatment including surgery. ITAC displays variable TIL density, which is associated with OS. In a univariate model, the density of CD3⁺ TIL was significantly related to OS (p = 0.012), whereas the association with CD8+ TIL density resulted in being non-significant (p = 0.056). Patients with intermediate CD3⁺ TIL density were associated with the best outcome, whereas 5-year OS was the lowest for intermediate CD8⁺ TIL density. CD3⁺ TIL density maintained a significant association with OS in the multivariable analysis. TIL density was not significantly related to demographic and clinicopathological variables. CD3⁺ TIL density was independently associated with OS in a non-linear fashion and patients with intermediate CD3⁺ TIL density had the best outcome. Though based on a preliminary analysis on a relatively small series of patients, this finding makes TIL density a potential independent prognostic factor of ITAC.

Multicenter study to assess surgical treatments of 452 sinonasal intestinal-type adenocarcinomas: A REFCOR study

PURPOSE

The objective was to assess the local oncological outcomes of endoscopic versus external surgical treatment of sinonasal intestinal-type adenocarcinomas (ITAC) and the factors of recurrence.

METHODS

a retrospective non-randomized case-control multicenter study was carried out, including 452 untreated sinonasal ITACs recruited from 10 tertiary referral centers. The tumors were re-classified according to the UICC 2017 (pT). Survival curves were obtained using the Kaplan-Meier method. Univariate analysis was done with the log-rank test. Multivariate analysis was performed with a Cox model adjusted for age, T stage, and radiotherapy. A binary logistic regression compared surgical complications and performed two supplementary analyses on positive margins.

RESULTS

We compared 195 and 257 patients operated by the external and endoscopic approach, respectively. The mean follow-up was 59.2 ± 48.7 months. Post-operative margins were invaded in 30.6 versus 18.9% of patients, respectively (p = 0.007). The overall recurrence rate was 33.8 versus 24.6%, respectively (p = 0.034). There was a significant difference in favor of the endoscopic approach regarding local recurrence-free survival thanks to better surgical margins in univariate and multivariate analysis (Odd Ratio = 2.01 (1.2-3.36) p = 0.0087). The complication rate (Odds Ratio = 3.4 (1.79-6.32) p < 0.001) was significantly lower in the endoscopic group. The histological positivity of signet-ring cells shows a statistically significant difference in recurrence-free survival (p = 0.0028).

CONCLUSION

the oncological control of ITAC is better through the endoscopic approach, with negative margins and the absence of signet-ring-cells, two independent factors of recurrence.

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.

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.

An Updated Review on Head and Neck Cancer Treatment with Radiation Therapy

The complexity of head and neck cancers (HNC) mandates a multidisciplinary approach and radiation therapy (RT) plays a critical role in the optimal management of patients with HNC, either as frontline or adjuvant treatment postoperatively. The advent of both definitive and post-operative RT has significantly improved the outcomes of patients with HNC. Herein, we discuss the role of postoperative RT in different subtypes of HNC, its side effects, and the importance of surveillance. The treatment regions discussed in this paper are the oral cavity, nasopharynx, paranasal sinus cavity, oropharynx, larynx and hypopharynx. Multiple studies that demonstrate the importance of definitive and/or postoperative RT, which led to an improved outlook of survival for HNC patients will be discussed.

Rare Diseases of the Nose, the Paranasal Sinuses, and the Anterior Skull Base

Due to their low incidence and thus resulting limited diagnostic criteria as well as therapeutic options, rare diseases of the nose, the paranasal sinuses, and the anterior skull base are a significant challenge. The value as of which a disease has to be considered as rare amounts to a maximum of 5 patients per 10 000 people. Within these diseases, however, there are extreme differences. Some rare or orphan diseases like for example the inverted papilloma belong to regularly diagnosed and treated diseases of larger departments of oto-rhino-laryngology whereas other rare diseases and malformations have only been described in less than 100 case reports worldwide. This fact emphasizes the necessity of bundling the available experience of diagnostics and therapy. The present article gives an overview about rare diseases of the nose, the paranasal sinuses, and the anterior skull base from the field of diseases/syndromes of the olfactory system, malformations of the nose and paranasal sinuses, ventilation and functional disorders as well as benign and malignant tumors. The classification and data on diagnostic and therapeutic options were established based on the current literature.

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.

Adenocarcinoma of the Sinonasal Tract: A Review of the National Cancer Database

Background  Sinonasal adenocarcinoma (SNAC) is a rare malignancy arising from mucus-secreting glandular tissue. Limited large-scale studies are available due to its rarity. We evaluated SNAC in the National Cancer Database (NCDB), a source that affords multi-institutional, population studies of rare cancers and their outcomes. Methods  The NCDB was queried for adenocarcinoma in the sinonasal tract. Multivariate analyses were performed to evaluate for factors contributing to overall survival (OS). Results  A total of 553 patients were identified. The cohort was composed of 59.3% males. The nasal cavity was the most common primary site, representing 44.1% of cases. About 5.7% of patients presented with nodal disease, while 3.3% had distant metastases. About 40.6% of cases presented with stage IV disease. About 73.5% of patients underwent surgery, 54.2% received radiation therapy, and 27.7% had chemotherapy. Median OS was 71.7 months, while OS at 1, 2, and 5 years was 82, 73.0, and 52%, respectively. On multivariate analysis, advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.02-1.05), Charlson-Deyo score of 1 (HR: 1.99; 95% CI: 1.20-3.30), advanced tumor grade (HR: 2.73; 95% CI: 1.39-5.34), and advanced tumor stage (HR: 2.71; 95% CI: 1.33-5.50) were associated with worse OS, whereas surgery (HR: 0.34; 95% CI: 0.20-0.60) and radiation therapy (HR: 0.55; 95% CI: 0.33-0.91), but not chemotherapy (HR: 1.16; 95% CI: 0.66-2.05), predicted improved OS. Conclusions  SNAC is a rare malignancy with 5-year survival approximating 50%. Surgery and radiation therapy, but not chemotherapy, are associated with improved survival, and likely play a critical role in the interdisciplinary management of SNAC.

[Tumors of the paranasal sinus invading the orbit]

Invasion of the orbit by tumors of the paranasal sinus represents an advanced state of disease. Prognosis has hardly improved in recent decades, despite multimodal therapeutic approaches. Complete resection of the tumor still remains the most promising therapy. Orbital exenteration implies a dramatic event for the patient's psyche and quality of life. If the eye that would have to be exenterated is the only one remaining with sufficient vision, exenteration should be abandoned in consensus with the patient. Aesthetic improvements following exenteration can be achieved by surgical and prosthetic techniques. The method of prosthesis fixation needs to be determined with respect to the patients' individual expectations and manual abilities. The main aspects of functional rehabilitation are good local cleanability and sufficient nasal breathing without encrusted mucus, which can be achieved by restoring the natural laminar airflow. Tumors of the paranasal sinus with orbital invasion represent a diagnostic and therapeutic challenge. The information regarding prognosis, therapeutic approaches, post-therapeutic quality of life, and rehabilitation options should be thoroughly discussed by patients and therapists prior to treatment.

Survival in low-grade and high-grade sinonasal adenocarcinoma: A national cancer database analysis

OBJECTIVES/HYPOTHESIS

The purpose of this study was to investigate survival differences between low-grade and high-grade sinonasal adenocarcinoma (SNAC) by examining demographics, tumor characteristics, and treatment modalities.

STUDY DESIGN

Retrospective database analysis.

METHODS

The National Cancer Database was queried for patients with SNAC between 2004 and 2015. Univariate and multivariate analyses were performed for all cases of SNAC. Subsequent analysis focused on low-grade (grade 1 and grade 2) and high-grade (grade 3 and grade 4) SNAC.

RESULTS

A total of 1,288 patients with SNAC were included in the main cohort and divided into low grade (n = 601) and high grade (n = 370). The 5-year overall survival for all patients, low-grade, and high-grade was 54%, 64%, and 38%, respectively. Prognostic factors associated with decreased survival for the main cohort include advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.03-1.06), Charlson-Deyo score (HR: 1.37; 95% CI: 1.05-1.78), grade 2 (HR: 2.21; 95% CI: 1.26-3.86], grade 3 (HR: 3.67; 95% CI: 2.09-6.45), and grade 4 (HR: 3.31; 95% CI: 1.38-7.91). Radiotherapy was associated with improved overall survival for high-grade SNAC (HR: 0.41; 95% CI: 0.24-0.70) but not for low-grade SNAC (HR: 1.05; 95% CI: 0.59-1.85).

CONCLUSIONS

This investigation is the largest to date analyzing the association of treatment modalities with overall survival in SNAC. Surgery remains paramount to treatment, with radiotherapy offering additional survival benefit for high-grade SNAC. Administration of chemotherapy was not associated with improved survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E1-E10, 2020.

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.

Incidence and survival of sinonasal adenocarcinoma by site and histologic subtype. Acta Otolaryngol 2018;138:415-421. [PMID: 29205085 DOI: 10.1080/00016489.2017.1401229]

OBJECTIVE

To determine the incidence and survival of sinonasal adenocarcinoma (SNAC) by subsite and histologic subtype.

STUDY DESIGN

Retrospective database review.

METHODS

Using the SEER database, we performed a retrospective analysis, identified cases of SNAC diagnosed between 1973 and 2013 and analyzed demographic, histopathology, clinicopathology, and determinants of disease specific survival (DSS).

RESULTS

A total of 746 patients with SNAC were identified. Median age at diagnosis was 64 years. Overall incidence was 0.44 per million, and was higher among blacks (O.R.:1.10-2.07:1) and males (O.R.:1.38-2.06:1). Nasal cavity (41.5%) was the most common site, followed by maxillary (26.5%), and ethmoid (17.4%) sinuses. Intestinal-type adenocarcinoma was less likely than Adenocarcinoma not otherwise specified (ANOS) to be found in the maxillary sinus (8.8% vs. 30.6%, p < .05). Surgery alone (48.56%) was the most common treatment modality, followed by surgery and radiotherapy (RT) (32.5%), and RT alone (11.6%). DSS at 5, 10, and 20 years were 63.8%, 57.6%, and 47.0%, respectively. DSS was higher for nasal cavity SNAC, lower grade, lower stage, and those receiving surgery only.

CONCLUSIONS

SNAC is more common among men and blacks. Incidence has not changed significantly in the past 40 years. Survival varies with grade, stage, histology, subsite, and treatment.

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.

Therapy of sinonasal malignancies invading the orbit-orbital exenteration versus preservation of the orbit plus radiotherapy

INTRODUCTION

Orbital invasion is a strong independent prognostic factor for sinonasal malignancies. While there is consent about preservation of the orbit for tumors limited to the orbital periosteum there is controversy about the optimal management of sinonasal malignancies transgressing this barrier. Therefore the aim of our study was to compare exenteration versus preservation of the orbit.

MATERIAL AND METHODS

52 patients with sinonasal malignancies invading the orbit beyond the orbital periosteum with involvement of the orbital soft tissues were included in the retrospective study. Prognostic factors were identified through univariate analysis.

RESULTS

Univariate analysis revealed a significant impact of N-classification (p = 0.017), and treatment strategy (p = 0.016). Exenteration of the orbit was associated with a significantly better 5-year overall survival rate (65.5%) than preservation of the orbit (14%).

CONCLUSIONS

For patients with invasion of the structures beyond the orbital periosteum, exenteration yields better survival results than preservation of the orbital structures in combination with radiotherapy. In cases where both eyes are affected from the tumor or if only one dysfunctional eye would be left over after therapy, we do not recommend orbital exenteration because life quality would be critically deteriorated.

Comparison of endoscopic and external resections for sinonasal instestinal-type adenocarcinoma

Endoscopic sinus surgery (ESS) is considered as a valid option in the management of nasal adenocarcinoma (ADC). Comparative studies with open approaches are still required. A monocentric retrospective study was carried out from May 2002 to December 2013, including 43 patients with intestinal-type adenocarcinoma of the ethmoid sinus. Non-resectable tumours or recurrences were excluded. Before 2008, open approach with lateral rhinotomy (LR) was performed as the gold standard of treatment. From 2008, ESS was systematically used as a first-line option as long as a complete resection was achievable. Adjuvant radiation therapy was delivered (RT) for all the patients. LR and ESS were performed in, respectively, 23 and 20 patients. The two groups were comparable in terms of age, occupational dust exposure, histopathological subtypes, and T stage based on the pathological assessment of the specimen (10 pT2, 26 pT3, 2 pT4a, and 5 pT4b). The tumour origin was mainly located in the olfactory cleft with the involvement of the cribriform plate in 60 % of patients. No major complication was observed in ESS group with a reduced hospital stay (5.6 vs 7.6 days). The disease-free survival was not different between LR and ESS groups over a mean follow-up period of 6.6 years. Even for local advanced stages with skull base involvement, we confirm the reliability and the advantages of ESS in terms of oncological outcomes and morbidity. We advocate complete excision of the olfactory cleft to ensure an appropriate control of the tumoral origin.