Multimodal Therapy for Sinonasal Malignancies: Updates and Review of Current Treatment

Treatment and related morbidity of nasal cavity and paranasal sinus cancers

Introduction

Sinonasal malignancies are rare and histologically heterogeneous cancers of the nasal cavity and sinuses. The treatment of choice is usually surgery and, if necessary, adjuvant radiotherapy. In this study, we aimed to investigate treatment modalities and associated morbidity.

Methods

A consecutive case series of solid sinonasal cancer treated at our tertiary referral center was analyzed. We performed a retrospective chart review and statistical analysis.

Results

A total of 156 patients with sinonasal cancer were enrolled in the present study. Male patients were more frequently affected (62%) and the median age was 64 years. Squamous cell carcinoma, adenocarcinoma and malignant melanoma (MM) were the most common histopathological entities. Surgery was the primary treatment modality for 73% of curatively treated patients. Primary radiotherapy alone or in combination with systemic treatment was less frequent. Median overall (OS) and recurrence-free survival (RFS) was 164 months and 71.3 months, respectively. Multivariate analysis revealed negative associations of histology (MM) and skull base involvement on RFS and age, skull base involvement and the type of primary therapy (radiochemotherapy) on OS. Postoperative 30-day morbidity was low, with most patients (84%) experiencing no reported events. Radiotherapy was generally well-tolerated, despite most of patients experienced acute toxicity such as dermatitis (80.6%) or mucositis (72.1%). However, only one event of acute toxicity > grade 3 was reported. Long term morbidity was most frequently reported as pain (23%), dry mucosa (19%) and anosmia (14%).

Conclusion

We observed negative associations of histology (MM) and skull base involvement on RFS and age, skull base involvement and the type of primary therapy (radiochemotherapy) on OS. Acute treatment-related morbidity was generally low for surgical patients and considerable for irradiated patients. Moreover, a consistent part of the cohort displayed long term morbidity.

The role of histology on the outcome of sinonasal carcinomas treated with radiotherapy: a single institution experience

PURPOSE

Sinonasal malignancies are a rare group of head and neck cancers. We aimed to report the oncological outcomes based on histological types in patients who underwent radiotherapy.

MATERIALS AND METHODS

In this single-institution study, we retrospectively retrieved and analyzed data of patients with sinonasal carcinomas who underwent radiotherapy during 2011-2016 as part of their treatment. The 3-year rate of local, regional, and distant recurrences, and overall survival were evaluated according to the histological type.

RESULTS

A total of 28 patients were evaluated in this study, the majority of whom were male (60%). Squamous cell carcinoma (SCC), adenoid cystic carcinoma (ACC), and adenocarcinoma (ADC) were found in 15 patients (53.5%), 8 (28.5%), and 5 (18%), respectively. The highest rates of local and regional recurrences were observed in ACC and SCC, respectively. Distant recurrences were numerically more common in ADC. The 3-year OS was 48%, 50%, and 73% in SCC, ADC, and ACC, respectively.

CONCLUSION

Different histopathologies of sinonasal cancer seem to have different patterns of failure, and this may be considered in the treatment approach.

Can Definitive Radiation Therapy Substitute Surgical Resection in Locally Advanced T3 or T4 Sinonasal Squamous Cell Carcinoma?

PURPOSE

This study aimed to compare oncologic outcomes between definitive radiation therapy (RT) and upfront surgical resection in patients with sinonasal squamous cell carcinoma (SCC).

METHODS AND MATERIALS

Between 2008 and 2021, 155 patients with T1-4b, N0-3 sinonasal SCC were analyzed. The 3-year overall survival (OS), local progression-free survival (LPFS), and overall progression-free survival (PFS) were evaluated using the Kaplan Meier method and compared using a log-rank test. A pattern of regional neck lymph node (LN) failure and treatment-related toxicity profiles were investigated.

RESULTS

A total of 63 and 92 patients underwent upfront RT (RT group) and surgical resection (Surgery group), respectively. The RT group included significantly more patients with T3-4 disease than the Surgery group (90.5% vs 39.1%, P < .001). The rates of 3-year OS, LPFS, and PFS in the RT and Surgery groups were 68.6% versus 81.7% (P = .073), 62.3% versus 73.8% (P = .187), and 47.4% versus 66.1% (P = .005), respectively. However, the corresponding rates in patients with T3-4 disease were 65.1% versus 64.8% (P = .794), 57.4% versus 56.8% (P = .351), and 43.2% versus 46.5% (P = .638), respectively, demonstrating no statistically significant differences between the 2 treatment modalities. Among the 133 N0 patients, regional neck LN progression was observed in 17 patients, and the most common sites of regional neck LN failure were ipsilateral levels Ib (9 patients) and II (7 patients). The 3-year neck node recurrence-free rate in cT1-3N0 patients was 93.5%, while that in cT4N0 patients was 81.1% (P = .025).

CONCLUSIONS

Upfront RT may be considered in selected patients with locally advanced sinonasal SCC, as we have demonstrated similar oncologic outcomes to those of surgery. Prophylactic neck treatment in T4 disease requires further investigation to evaluate its efficacy.

Sox2 and βIII-Tubulin as Biomarkers of Drug Resistance in Poorly Differentiated Sinonasal Carcinomas

Poorly differentiated sinonasal carcinomas (PDCs) are tumors that have a poor prognosis despite advances in classical treatment. Predictive and prognostic markers and new personalized treatments could improve the oncological outcomes of patients. In this study, we analyzed SOX2 and βIII-tubulin as biomarkers that could have prognostic and therapeutic impacts on these tumors. The cohort included 57 cases of PDCs: 36 sinonasal undifferentiated carcinoma (SNUC) cases, 13 olfactory neuroblastoma (ONB) cases, and 8 sinonasal neuroendocrine carcinoma (SNEC) cases. Clinical follow-up data were available for 26 of these cases. Sox2 expression was detected using immunohistochemistry in 6 (75%) SNEC cases, 19 (53%) SNUC cases, and 6 (46%) ONB cases. The absence of Sox2 staining correlated with a higher rate of recurrence (p = 0.015), especially distant recurrence. The majority of cases showed βIII-tubulin expression, with strong positivity in 85%, 75%, and 64% of SNEC, ONB, and SNUC cases, respectively. Tumors with stronger βIII-tubulin expression demonstrated longer disease-free survival than those with no expression or low expression (p = 0.049). Sox2 and βIII-tubulin expression is common in poorly differentiated sinonasal tumors and has prognostic and therapeutic utility.

Olfactory neuroblastoma: diagnosis, management, and current treatment options

Olfactory neuroblastoma (ONB) is a rare neoplasm originating from the olfactory neuroepithelium representing 3-6% of tumors of the sinonasal tract. ONB require multi-disciplinary care. Historically, the gold standard surgical procedure for ONB has been open craniofacial resection. In the last years, endoscopic endonasal approaches have been largely introduced with lower complication rates, shorter hospital stay, and similar clinical outcome. Radiotherapy plays an important role in the management of ONB, however there are not generally accepted recommendations for its application. Although there is agreement that multimodal therapy is needed, the optimal use of chemotherapy is still unknown. The rarity of the disease, makes difficult to draw definitive conclusions about the role of systemic treatment in induction and concomitant setting.

Sinonasal malignancies: histopathological entities, regional involvement and long-term outcome

BACKGROUND

To assess a large patient cohort with sinonasal malignancies focusing on regional involvement, recurrence and oncological outcome.

METHODS

Patients (n = 144) with malignant tumors of the nasal cavity and paranasal sinuses were treated at our tertiary referral center between 2008 and 2019. A chart review on patient and tumor characteristics, treatment and long-term outcome was performed.

RESULTS

Most frequent histological types were squamous cell carcinoma (SCC) (n = 74), adenocarcinoma (n = 24) and mucosal melanoma (n = 18). Primary therapy was surgery in 66% of patients (n = 95) of which 65.8% (n = 66) received adjuvant radiotherapy. Twenty patients (13.8%) were initially staged as cN + and in seven cases, pN + status was histopathologically confirmed. Fifty-six of 130 patients (43.1%) had a relapse after curative intended therapy, including nine loco-regional (6.9%) and seven isolated regional recurrences (5.4%). Twelve of these 16 patients with (loco-)regional recurrence had SCC. Adenoid cystic carcinoma (87.5%) and SCC (65.3%) showed the best long-term overall survival.

CONCLUSIONS

Regional involvement and regional recurrence are scarce. Because of rarity and heterogeneity, evidence on therapeutic management is sparse resulting in the lack of clinical guidelines.

Diagnostic performance of MRI for the assessment of extraocular muscle invasion in malignant sinonasal tumors

PURPOSE

Preoperative assessment of extraocular muscle invasion is essential for therapeutic strategies and prognostic evaluation. The aim of this study was to assess the diagnostic accuracy of MRI for evaluation of extraocular muscle (EM) invasion by malignant sinonasal tumors.

MATERIALS AND METHODS

Consecutively, 76 patients of sinonasal malignant tumors with orbital invasion were included in the present study. Preoperative MRI imaging features were analyzed by two radiologists independently. The diagnostic performances of MR imaging features for detecting EM involvement were evaluated by comparing imaging findings to histopathology data.

RESULTS

A total of 31 extraocular muscles were involved by sinonasal malignant tumors in 22 patients, including 10 medial rectus muscles (32.2%), 10 inferior rectus muscles (32.2%), 9 superior oblique muscles (29.1%), and 2 external rectus muscles (6.5%). The EM involved by sinonasal malignant tumors usually showed relatively high signal intensity on T2-weighted images, indistinguishable from the tumor, nodular enlargement and abnormal enhancement (p = 0.001, < 0.001, < 0.001 and < 0.001, respectively). Using a combination of EM abnormal enhancement and indistinguishable from the tumor in multivariate logistic regression analysis, sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for detecting orbital EM invasion by sinonasal tumors were 93.5, 85.2, 76.3, 96.3 and 88%, respectively.

CONCLUSION

MRI imaging features show high diagnostic performance for the diagnosis of extraocular muscle invasion by malignant sinonasal tumors.

Molecular Basis and Rationale for the Use of Targeted Agents and Immunotherapy in Sinonasal Cancers

Despite the progress of surgery, radiotherapy, and neoadjuvant chemotherapy, the prognosis for advanced sinonasal cancers (SNCs) remains poor. In the era of precision medicine, more research has been conducted on the molecular pathways and recurrent mutations of SNCs, with the aim of understanding carcinogenesis, helping with diagnosis, identifying prognostic factors, and finding potentially targetable mutations. In the treatment of SNC, immunotherapy is rarely used, and no targeted therapies have been approved, partly because these tumors are usually excluded from major clinical trials. Data on the efficacy of targeted agents and immune checkpoint inhibitors are scarce. Despite those issues, a tumor-agnostic treatment approach based on targeted drugs against a detected genetic mutation is growing in several settings and cancer subtypes, and could also be proposed for SNCs. Our work aims to provide an overview of the main molecular pathways altered in the different epithelial subtypes of sinonasal and skull base tumors, focusing on the possible actionable mutations for which potential target therapies are already approved in other cancer types.

Evaluation of the Prognostic Capacity of a Novel Survival Marker in Patients with Sinonasal Squamous Cell Carcinoma

Sinonasal squamous cell carcinoma (SNSCC) is a malignant tumor associated with poor survival, and easily obtainable prognostic markers are of high interest. Therefore, we aimed to assess the prognostic value of a novel survival index (SI) combining prognostic values of clinical (T and N classifications and invasion across Ohngren’s line), inflammatory (neutrophil-to-lymphocyte ratio), and nutritional (albumin and body-mass index) markers. All patients with primarily treated SNSCC between 2002 and 2020 (n = 51) were included. Each of the six SI components was stratified into a low- (0) and high-risk (1) categories. Subsequently, the cohort was stratified into low- (SI of 0–2) and high-risk SI groups (SI of 3–6). Overall survival (OS) and disease-free survival (DFS) were compared between patients with low- and high-risk SI. The log-rank test was used to test for statistical significance. Overall, the mortality rate was 41.2% (n = 21), and the recurrence rate was 43.1% (n = 22). We observed significantly better OS in patients with low-risk SI (n = 24/51, 47.1%, mean OS: 7.9 years, 95% confidence interval (CI): 6.3–9.6 years) than in high-risk SI (n = 27/51, 52.9%, mean OS: 3.4 years, 95% CI: 2.2–4.5 years; p = 0.013). Moreover, we also showed that patients with low-risk SI had a longer DFS than patients with high-risk SI (mean DFS: 6.4, 95% CI: 4.8–8.0 vs. mean DFS: 2.4 years, 95% CI 1.3–3.5, p = 0.012). The SI combines the prognostic capacity of well-established clinical, radiologic, inflammatory, and nutritional prognosticators and showed prognostic potential in our cohort of SNSCC patients.

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.

Morbidity and Oncological Outcome After Curative Treatment in Sinonasal Squamous Cell Carcinoma

OBJECTIVES

Sinonasal squamous cell carcinomas are rare and aggressive tumors. Curative therapy includes surgery and radiotherapy, with high risk for local morbidity and impaired quality of life. The objective of this study was to analyze a large cohort of patients with sinonasal squamous cell carcinoma on treatment morbidity and oncological outcome.

METHODS

Patients with sinonasal squamous cell carcinoma (n = 75) treated at a tertiary referral center between 2008 and 2019 were identified. In patients with curative treatment intent (n = 70), a chart review and analysis on patient and tumor characteristics, morbidity, and oncological outcome was performed.

RESULTS

Mean follow-up was 59 months. Primary curative therapy was surgery alone (n = 18), surgery with radiation (n = 25), and primary (chemo)radiation (n = 27). Forty-two (60%) patients suffered from treatment-related morbidity; most frequent symptoms were dry nasal mucosa (20%), nasal obstruction (14.3%), and vision impairment or loss (11.5%). Patients with early disease had less morbidity (51.4 vs 71.1%; P = 0.09), a lower recurrence rate (27% vs. 48.5%; P = 0.08), and better overall survival (92.5% vs. 71.1%; P = 0.01).

CONCLUSION

Treatment-related morbidity is common after curative treatment of sinonasal squamous cell carcinomas. Early disease is beneficial in terms of occurrence and severity as multimodal treatment and recurrence can more likely be avoided.

Multi-parametric MRI-based radiomics signature for preoperative prediction of Ki-67 proliferation status in sinonasal malignancies: a two-centre study

OBJECTIVE

To assess the predictive ability of a multi-parametric MRI-based radiomics signature (RS) for the preoperative evaluation of Ki-67 proliferation status in sinonasal malignancies.

METHODS

A total of 128 patients with sinonasal malignancies that underwent multi-parametric MRIs at two medical centres were retrospectively analysed. Data from one medical centre (n = 77) were used to develop the predictive models and data from the other medical centre (n = 51) constitute the test dataset. Clinical data and conventional MRI findings were reviewed to identify significant predictors. Radiomics features were determined using maximum relevance minimum redundancy and least absolute shrinkage and selection operator algorithms. Subsequently, RSs were established using a logistic regression (LR) algorithm. The predictive performance of RSs was assessed using calibration, decision curve analysis (DCA), accuracy, and AUC.

RESULTS

No independent predictors of high Ki-67 proliferation were observed based on clinical data and conventional MRI findings. RS-T1, RS-T2, and RS-T1c (contrast enhancement T1WI) were established based on a single-parametric MRI. RS-Combined (combining T1WI, FS-T2WI, and T1c features) was developed based on multi-parametric MRI and achieved an AUC and accuracy of 0.852 (0.733-0.971) and 86.3%, respectively, on the test dataset. The calibration curve and DCA demonstrated an improved fitness and benefits in clinical practice.

CONCLUSIONS

A multi-parametric MRI-based RS may be used as a non-invasive, dependable, and accurate tool for preoperative evaluation of the Ki-67 proliferation status to overcome the sampling bias in sinonasal malignancies.

KEY POINTS

• Multi-parametric MRI-based radiomics signatures (RSs) are used to preoperatively evaluate the proliferation status of Ki-67 in sinonasal malignancies. • Radiomics features are determined using maximum relevance minimum redundancy (mRMR) and least absolute shrinkage and selection operator (LASSO) algorithms. • RSs are established using a logistic regression (LR) algorithm.

The Role of Salvage in the Management of Patients with Sinonasal Squamous Cell Carcinoma

Objectives: This paper presents and discusses the rate and outcome of salvage according to various factors for patients with sinonasal squamous cell carcinoma (SNSCC). Methods: Data of 79 patients treated radically due to SNSCC between 2000 and 2016 in the National Cancer Research Institute, Gliwice branch, were analyzed. Surgery was the primary treatment in 63 (79%) of patients. The ratio, type, and effectiveness of salvage was assessed and correlated with prognostic factors. Probabilities of overall survival (OS), local control (LC), nodal control (NC), and locoregional control (LRC) were assessed and compared between the groups. Results: The 5-year LC, NC, and LRC survival rates were 62%, 75%, and 53%, respectively. The 5-year OS rate was 51%. In 34 (43%) patients, treatment failure was reported, and salvage was performed in 17 (50%) of them. It was shown that patients after any salvage had significantly longer 2- and 3-year OS rates when compared to patients with no salvage: 52% vs. 7% and 38% vs. 0%, respectively (p = 0.004). Two- and three-year OS rates for patients after effective and ineffective salvage were 83% vs. 33% and 83% vs. 11%, respectively (p = 0.02). For patients with effective salvage, OS did not differ significantly when compared to the OS of primarily cured patients (p = 0.6). Conclusions: For SNSCC patients after treatment failure, salvage is possible in half of the cases and can improve their overall survival even if not finally successful. Moreover, effective salvage can compensate for the failure and give the same ultimate OS as in primarily cured patients.

Head and neck cancer

Head and neck cancer is the seventh most common type of cancer worldwide and comprise of a diverse group of tumours affecting the upper aerodigestive tract. Although many different histologies exist, the most common is squamous cell carcinoma. Predominant risk factors include tobacco use, alcohol abuse, and oncogenic viruses, including human papillomavirus and Epstein-Barr virus. Head and neck malignancies remain challenging to treat, requiring a multidisciplinary approach, with surgery, radiotherapy, and systemic therapy serving as key components of the treatment of locally advanced disease. Although many treatment principles overlap, treatment is generally site-specific and histology-specific. This Seminar outlines the current understanding of head and neck cancer and focuses on treatment principles, while also discussing future directions to improve the outcomes of patients with these malignancies.

Management of sinonasal cancers: Survey of UK practice and literature overview

INTRODUCTION

Sinonasal malignancy is a rare and heterogenous disease, with limited evidence to guide management. This report summarises the findings of a UK survey and expert workshop discussion which took place to inform design of a proposed UK trial to assess proton beam therapy versus intensity-modulated radiation therapy.

METHOD

A multidisciplinary working group constructed an online survey to assess current approaches within the UK to surgical and non-surgical practice. Head and neck clinical oncologists, ear nose and throat (ENT) and oral-maxillofacial (OMF) surgeons were invited to participate in the 42-question survey in September 2020. The Royal College of Radiologists Consensus model was adopted in establishing categories to indicate strength of response. An expert panel conducted a virtual workshop in November 2020 to discuss areas of disagreement.

RESULTS

A survey was sent to 140 UK-based clinicians with 63 responses (45% response rate) from 30 centres, representing a broad geographical spread. Participants comprised 35 clinical oncologists (56%) and 29 surgeons (44%; 20 ENT and 9 OMF surgeons). There were variations in preferred sequence and combination of treatment modalities for locally advanced maxillary squamous cell carcinoma and sinonasal undifferentiated carcinoma. There was discordant surgical management of the orbit, dura, and neck. There was lack of consensus for radiotherapy in post-operative dose fractionation, target volume delineation, use of multiple dose levels and treatment planning approach to organs-at-risk.

CONCLUSION

There was wide variation across UK centres in the management of sinonasal carcinomas. There is need to standardise UK practice and develop an evidence base for treatment.

Endoscopic endonasal resection of sinonasal teratocarcinosarcoma with intracranial breakthrough: illustrative case

BACKGROUND

Teratocarcinosarcoma traversing the anterior skull base is rarely reported in literature. The heterogenous and invasive features of the tumor pose challenges for surgical planning. With technological advancements, the endoscopic endonasal approach (EEA) has been emerging as a workhorse of anterior skull base lesions. To date, no case has been reported of EEA totally removing teratocarcinosarcomas with intracranial extensions.

OBSERVATIONS

The authors provided an illustrative case of a 50-year-old otherwise healthy man who presented with left-sided epistaxis for a year. Imaging studies revealed a 31 × 60-mm communicating lesion of the anterior skull base. Gross total resection via EEA was achieved, and multilayered skull base reconstruction was performed.

LESSONS

The endoscopic approach may be safe and effective for resection of extensive teratocarcinosarcoma of the anterior skull base. To minimize the risk of postoperative cerebrospinal fluid leaks, multilayered skull base reconstruction and placement of lumbar drainage are vitally important.

Surgical approach is associated with complication rate in sinonasal malignancy: A multicenter study

BACKGROUND

Management of sinonasal malignancy (SNM) often includes surgical resection as part of the multimodality treatment. Treatment-related surgical morbidity can occur, yet risk factors associated with complications in this population have not been sufficiently investigated.

METHODS

Adult patients with histologically confirmed SNM whose primary treatment included surgical resection were prospectively enrolled into an observational, multi-institutional cohort study from 2015 to 2020. Sociodemographic, disease, and treatment data were collected. Complications assessed included cerebrospinal fluid leak, orbital injury, intracranial injury, diplopia, meningitis, osteoradionecrosis, hospitalization for neutropenia, and subsequent chronic rhinosinusitis. The surgical approach was categorized as endoscopic resection (ER) or open/combined resection (O/CR). Associations between factors and complications were analyzed using Student's t test, Fisher's exact test, and logistic regression modeling.

RESULTS

Overall, 142 patients met the inclusion criteria. Twenty-three subjects had at least 1 complication (16.2%). On unadjusted analysis, adjuvant radiation therapy was associated with developing a complication (91.3% vs 65.5%, p = 0.013). Compared with the ER group (n = 98), the O/CR group (n = 44) had a greater percentage of higher T-stage lesions (p = 0.004) and more frequently received adjuvant radiation (84.1% vs 64.4%, p = 0.017) and chemotherapy (50.0% vs 30.6%, p = 0.038). Complication rates were similar between the ER and O/CR groups without controlling for other factors. Regression analysis that retained certain factors showed O/CR was associated with increased odds of experiencing a complication (odds ratio, 3.34; 95% confidence interval, 1.06-11.19).

CONCLUSIONS

Prospective, multicenter evaluation of SNM treatment outcomes is feasible. Undergoing O/CR was associated with increased odds of developing a complication after accounting for radiation therapy. Further studies are warranted to build upon these findings.