Advanced squamous cell carcinoma of the maxillary sinus. Results of combined regional infusion chemotherapy, radiation therapy and surgery

Factors in the pathogenesis of tumors of the sphenoid and maxillary sinuses: a comparative study

OBJECTIVES/HYPOTHESIS

To explain the processes that lead to the development of tumors in the maxillary and sphenoid sinuses.

STUDY DESIGN

A 32-year review of the world's literature on neoplasms of these two sinuses and a randomized case-controlled study comparing the normal mucosal architecture of the maxillary to the sphenoid sinus.

METHODS

Analysis of a 32-year world literature review reporting series of cases of maxillary and sphenoid sinus tumors. Tumors were classified by histological type and separated into subgroups if an individual incidence rate was reported. Histomorphometry of normal maxillary and sphenoid sinus mucosa was performed in 14 randomly selected patients (10 sphenoid and 4 maxillary specimens). Specimens were fixed in 10% formalin, embedded in paraffin, and stained with periodic acid-Schiff (PAS) and hematoxylin. Histomorphometric analysis was performed with a Zeiss Axioscope light microscope (Carl Zeiss Inc., Thornwood, NY) mounted with a Hamamatsu (Hamamatsu Photonics, Tokyo, Japan) color-chilled 3 charge coupled device digital camera. The images were captured on a 17-inch Sony (Sony Corp., Tokyo, Japan) multiscan monitor and analyzed with a Samba 4000 Image Analysis Program (Samba Corp., Los Angeles, CA). Five random areas were selected from strips of epithelium removed from each sinus, and goblet and basal cell measurements were made at magnifications x 100 and x 400.

RESULTS

The literature review revealed that the number and variety of tumors in the maxillary sinus are much greater than those in the sphenoid. The incidence of metastatic lesions to each sinus is approximately equal. No recognized pattern of spread from any particular organ system could be determined. On histomorphometric study there were no statistically significant differences between the sinuses in the concentration of goblet cells, basal cells, or seromucinous glands.

CONCLUSIONS

Factors involved in the pathogenesis of tumors of the maxillary and sphenoid sinuses include differences in nasal physiology, embryology, morphology, and topography. There are no significant histological differences in the epithelium and submucous glands between the two sinuses to explain the dissimilar formation of neoplasms.

Neoadjuvant chemotherapy and radiation for inoperable carcinoma of the maxillary antrum: a matched-control study

A matched-control study comparing standard radiotherapy versus neoadjuvant chemotherapy and radiation was undertaken to clarify the effects of neoadjuvant systemic chemotherapy for locally advanced squamous cell carcinoma of the maxillary antrum. Thirty-four patients with inoperable maxillary cancer were treated with neoadjuvant chemotherapy and radiotherapy (Group II). Before starting radiotherapy, all patients in Group II received two or three cycles of neoadjuvant chemotherapy consisting of cisplatin and a 5-day continuous infusion of 5-fluorouracil with or without intravenous injection of vinblastine. Radiation doses ranged from 66 Gy to 75 Gy (median, 70 Gy). The response rate, patterns of failure, toxicity, and survival for Group II were compared with those for 34 stage-matched patients treated with radiation alone (Group I). Despite a higher response rate to neoadjuvant chemotherapy, the recurrence rate and patterns of treatment failure were not influenced by the addition of neoadjuvant chemotherapy. In most cases, neoadjuvant chemotherapy did not interfere with subsequent radiotherapy, and radiation-induced late complications occurred equally in both treatment groups. After a median follow-up of 48 months, there was no significant difference in 5-year actuarial survival or disease-free survival between the two treatment groups. Radiation alone for inoperable maxillary cancer was clearly suboptimal for improving local control and survival rate, but neoadjuvant chemotherapy in addition to standard radiotherapy failed to demonstrate any therapeutic advantage over radiation alone.

Superselective intraarterial chemotherapy in combination with irradiation: preliminary report

Since 1984, a new method for the intraarterial administration of antineoplastic drugs, termed "superselective intraarterial chemotherapy," has been used in combination with simultaneous irradiation in the treatment of 49 patients with squamous cell carcinoma of the head and neck. Under the fluoroscope, a retrograde catheter is inserted into the superficial temporal artery and the tip is led selectively into the main feeding artery of the tumor. In our series of 49 patients, catheter-related complications occurred in only 12.5%. Forty-five patients (91.8%) completed more than 80% of the planned irradiation dosage. The therapeutic effect was excellent. The initial response rate was 100%. Systemic toxicity was uncommon, but local mucositis was frequent in the infused area. These results demonstrate that this new combined therapy is easy, safe, effective, and confers the highest possible initial response rate.

Maxillary squamous cell carcinomas staged by computed tomography

In 72 patients with maxillary squamous cell carcinoma, computed tomography (CT) alone was used for T-staging according to the AJC classification. Five, 31, and 36 tumors were diagnosed as T2, T3, T4, respectively. In N0 patients with a minimum follow-up of 2 years, local control rates for T2, T3, and T4 tumors were 33% (1/3), 64% (16/25) and 38% (9/24), respectively. Addition of maxillectomy to treatment seemed to have improved the local prognoses in T3 and T4 tumors. High radiation doses of 60 Gy or more seemed to be beneficial for patients with T3 tumors and without maxillectomy. CT will be of great help in classifying tumors objectively. But more importantly, it will reveal resectability and dictate treatment of choice by delineating the tumor extent precisely.

Prognostic factors influencing relapse of squamous cell carcinoma of the maxillary sinus

In 95 surgically staged patients with squamous cell carcinoma of the maxillary sinus, multivariate regression analyses were employed to identify prognostic factors. Possible prognostic factors for local control were TNM stage and type of surgical procedures: T2 or T3 tumors and use of total maxillectomy showed better local control rates (P less than 0.01). High radiation doses of 40 Gy or more also seemed to be of prognostic significance: P less than 0.2 for 40 to 60 Gy, and P less than 0.1 for 60 Gy or more. The risk of cervical relapse increased when the cheek or alveolus was grossly involved (P less than 0.2). However, since cervical relapse frequently accompanied uncontrollable primary recurrence or distant spread, and since cervical relapse alone was frequently salvaged by radical neck dissection, prophylactic irradiation to the neck is not recommended. Sex, age, nodal state, addition of chemotherapy, total doses of bleomycin or 5-fluorouracil (5-FU), or intra-arterial administration of chemotherapeutic agents did not appear to be of prognostic significance.

Reassessment of technical and biological factors in paranasal sinus carcinoma

Twenty-seven patients with paranasal sinus carcinoma were analyzed. Local control with radiation alone was poor, with most patients failing centrally within the primary site. With preoperative radiation local control is 60%. Previous reports have emphasized failure at superior sites--particularly the orbit. The pattern of local failure in our series is predominantly various medial sites inclusive of intact or exenterated orbit. The surgically nonremovable medial structures are best encompassed by a three-field radiotherapy technique (weighted anterior and two laterals).

Pharmacokinetics of intra-arterial tumour therapy. An experimental study

Mathematically based pharmacokinetic models confirmed the general belief that intra-arterial (i.a.) cytostatic drug infusion can produce an increase in local tissue levels and a reduction in systemic drug availability. The increase in local drug concentration depends largely on the blood-flow rate of the infused artery and the rate of drug elimination from the rest of the body. In an experimental canine model the pharmacokinetics of i.a. infusion were studied using the femoral artery as the site of infusion and an Anger camera for continuous measurement of drug concentration in the target region. Several radioactively labelled drugs with different kinetics were infused over 80 min. The decay phase after the end of i.a. infusion was also monitored. The results indicate that even the femoral artery with its high blood flow is a suitable site for i.a. infusion, provided the plasma half-life of the drug is short enough. Consequently, arteries with lower blood flow (e.g., lingual artery) are even more suitable for i.a. infusion. The various diagrams obtained from this study provide a quick indication of whether or not a drug is suitable in a certain clinical situation.

Intraarterial chemotherapy for head and neck cancer, Part 2: Clinical experience

Despite almost 3 decades of experience, the use of intraarterial (IA) chemotherapy for the treatment of head and neck cancer is not universally accepted. The overall reported response rates are not substantially different from the therapeutic results obtained with systemic therapy. The additional complications associated with establishing and maintaining arterial access have further dampened enthusiasm for this approach. It is clear that considerable improvement in the techniques and efficacy of IA chemotherapy is necessary. This second and last part of this article considers the past and present clinical experience with IA therapy in the treatment of head and neck cancer and explores future developments.