Squamous carcinoma of the nasal cavity and paranasal sinuses

OUP accepted manuscript

Adenoid cystic carcinoma (ACC) is a rare cancer of the head and neck that primarily occurs in the salivary glands. Sino-nasal ACC (SNACC) is a much rarer entity; this paper presents an exceedingly rare case of SNACC with both intracranial and intradural extension which was ultimately treated with palliative radiotherapy due to its extensive invasion. In addition to this, a review of the literature has been performed to delineate specific learning points for the management of intracranial SNACC.

Therapeutic efficacy of regional and systemic chemotherapy in advanced maxillary sinus cancer

BACKGROUND

To compare the efficacy of regional chemotherapy through the superficial temporal artery and systemic chemotherapy in patients with advanced maxillary sinus cancer.

METHODS

Nine of 22 patients with over TNM stage III maxillary sinus cancer received regional chemotherapy and 13 received systemically. The change of tumor volume, the degree of response according to the tumor location, and side effects after chemotherapy were analyzed.

RESULTS

Tumor volume reduction was significantly higher in the regional than systemic chemotherapy. Tumor response to chemotherapy was greater in regional than systemic chemotherapy in most maxillary sinus wall. The tumor response in anterior, posterior, and lateral wall of maxillary sinus was greater more than two times in the regional than systemic chemotherapy. There were no severe side effects related to regional chemotherapy.

CONCLUSION

Regional chemotherapy was superior to systemic chemotherapy regarding tumor volume reduction, especially located in the anterior, posterior, and lateral wall of maxillary sinus.

Treatment of Maxillary Sinus Carcinoma: Five-Year Results

Previous treatment methods for maxillary sinus carcinoma generally consisted of dissection of maxilla, full dose irradiation, and/or extensive chemotherapy. However, results of such treatment were often poor. Even if patients recover, quality of life (QOL) is significantly reduced as a result of loss of facial structures and functional disability. A retrospective analysis of 42 patients with maxillary sinus carcinoma between 1975 and 1991 was undertaken. All patients underwent pergingival maxillary sinus surgery combined with a standardized total course of pre and postoperative irradiation of 1,600 cGy, together with regional intra-arterial infusion chemotherapy. During the surgery, all visible tumor tissue was removed, and the surrounding tissues were left when possible to facilitate cellular immunity after the surgery. The 5-year survival rate statistically obtained was 100% in Stage II, 100% in Stage III, and 62% in Stage IV patients.

A clinical study of multimodal treatment for orbital organ preservation in locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus

OBJECTIVE

This study aimed to investigate the efficacy of induction chemotherapy followed by concurrent chemotherapy and helical tomotherapy in patients with T4b squamous cell carcinoma of the nasal cavity and paranasal sinus in regard to orbital organ preservation and quality of life.

METHODS

Clinical data of 28 cases of patients with orbital involvement of T4b squamous cell carcinoma of the nasal cavity and paranasal sinus who received multimodal treatment for orbital organ preservation between May 2008 and September 2015 were retrospectively analysed. The treatment efficacy and side effects were assessed. The study included 18 male and 10 female patients. All patients were treated with induction chemotherapy followed by concurrent chemoradiotherapy and/or epidermal growth factor receptor inhibitor. Helical tomotherapy was applied as radiotherapy. Adverse reactions to the chemotherapy were assessed according to Common Terminology Criteria for Adverse Events, Version 4. The overall survival rate, local control rate and rate of effective orbital preservation were calculated using the Kaplan-Meier method.

RESULTS

All patients completed the planned chemotherapy, and 27 (96.4%) of the patients completed the planned radiotherapy cycle. After the multimodal treatment, the 3-year overall survival, local control rate and rate of effective orbital preservation of the patients were 59.2%, 80.2% and 77.8%, respectively.

CONCLUSIONS

Multimodal treatment could preserve the orbital organs of patients with T4b squamous cell carcinoma of the nasal cavity and paranasal sinus, achieve relatively ideal organ protection and survival rates and improve the quality of life of patients with advanced squamous cell carcinoma of the nasal cavity and paranasal sinus, thus providing a new treatment option for these patients.

Survival outcomes after endoscopic resection for sinonasal squamous cell carcinoma arising on inverted papilloma

BACKGROUND

Sinonasal inverted papillomas (IPs) can be associated synchronously or metachronously to invasive squamous cell carcinoma (SCC) in 5% to 10% of cases. The purposes of the present study were to analyze the outcomes of patients with sinonasal SCC arising from inverted papilloma (IP-SCC) treated through an endoscopic approach and review the pertinent literature.

METHODS

The medical records of all patients treated for IP-SCC between 1997 and 2014 at 2 referral centers following a uniform policy were retrospectively analyzed.

RESULTS

Thirty-four patients fulfilled the inclusion criteria. The 5-year overall survival (OS), disease-specific survival (DFS), and recurrence-free survival (RFS) rates were 66.8 ± 0.99%, 71.2 ± 0.96%, and 73.1 ± 0.82%, respectively. Multivariate analysis revealed that the advanced pT classification (pT3 or greater), the high-grade of tumoral differentiation, the cranioendoscopic approach, and the recurrence of disease impacted negatively on survival rates.

CONCLUSION

The endoscopic approach provides encouraging oncologic outcomes for sinonasal IP-SCC, comparable to those observed with traditional external approaches while minimizing morbidity for patients. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

Prognostic factors in sinonasal sarcomas: analysis of the surveillance, epidemiology and end result database

OBJECTIVES/HYPOTHESIS

Sinonasal sarcomas are rare and often aggressive malignant tumors. Although tumor histology and location are the only reported prognostic indicators for this disease, we sought to determine if additional clinical factors might influence patient survival.

STUDY DESIGN

Retrospective cohort study using a national cancer database.

METHODS

Cases of sinonasal sarcomas from 1973 to 2008 were extracted from the Surveillance, Epidemiology and End Result (SEER) database. The influence of patient age, gender, race, and prior irradiation, as well as tumor histology and subsite, was calculated using the Kaplan-Meier method.

RESULTS

A total of 352 patients with sinonasal sarcomas were identified. Histologic subtype, tumor location, gender, and patient age were found to influence patient survival. Specifically, increased age, male sex, frontal and maxillary sinus subsites, and rhabdomyosarcoma and Kaposi sarcoma histologies were associated with a significant increase in mortality rate (P < .05).

CONCLUSIONS

This study comprises the largest analysis of patients with sinonasal sarcoma in the literature and demonstrates the impact of patient age, tumor histology, and tumor location on the overall survival of individuals with these rare malignancies.

Sphenoid masses in children: radiologic differential diagnosis with pathologic correlation

Childhood central skull base masses are rare, often difficult to diagnose, and have overlapping imaging findings. In this review, we provide an overview of the epidemiology, clinical findings, and management of pediatric sphenoid bone and sphenoid sinus masses with an emphasis on imaging findings that may help to differentiate lesions. Radiologic-pathologic correlation is provided. Finally, an imaging-based algorithm is presented as a guide to help radiologists narrow their differential diagnoses. Some of the entities discussed are virtually unique to the pediatric population; others occur rarely in this age group but should be considered in the appropriate clinical setting. Entities included in the discussion are grouped into 2 categories: those that cause nonaggressive osseous remodeling and those that are more commonly associated with aggressive bone changes. Mucocele, aneurysmal bone cyst, giant cell lesions, meningioma, and fibrous dysplasia tend to remodel bone, while entities such as chordoma, craniopharyngioma, rhabdomyosarcoma, sinonasal carcinoma, and neuroblastoma may cause more aggressive local bone changes.

Treatment outcome of maxillary sinus cancer

The standard treatment in the early stage of maxillary sinus cancer is surgical resection followed by postoperative radiation therapy. However, for locally advanced maxillary sinus cancer, a multimodality treatment approach is strongly recommended to improve the survival rate and quality of life of the patient. We determined the treatment outcomes of induction chemotherapy, concurrent chemoradiation therapy, and surgical resection for locally advanced maxillary sinus cancer. Forty-four patients with locally advanced maxillary sinus cancer, who had been treated between January 1990 and April 2008 at Kangnam St. Mary's Hospital, were retrospectively analyzed. The objective response rates were 70%, 53%, and 57% in the intra-arterial induction chemotherapy, intravenous induction chemotherapy, and concurrent chemoradiation therapy groups, respectively. The orbital preservation rates were 83%, 100%, and 75% in the intra-arterial induction chemotherapy, intravenous induction chemotherapy, and surgical resection groups, respectively. In seven of nine patients in whom the orbit could be preserved after induction chemotherapy, the primary tumors were removed completely. However, although the orbits were preserved in three patients who underwent surgical resection as a primary treatment, all three cases were confirmed to be incomplete resections. We found that active induction chemotherapy for locally advanced cancer of the maxillary sinus increased the possibility of complete resection with orbital preservation as well as tumor down-staging.

Malignant neoplasms of the sinonasal tract: report of 71 patients and literature review and analysis

BACKGROUND

The present study aimed to report the characteristics, prognostic factors, and treatment outcomes of 71 cases of malignant neoplasms of the sinonasal tract and literature review and analysis of major report series.

METHODS

Seventy-one consecutive patients diagnosed with primary malignant neoplasm of the sinonasal tract that were treated and followed up at a university hospital between May 2000 and March 2008 were selected for the present study. Thirty-four patients were treated with surgery followed by a combination of chemotherapy and radiotherapy, 15 with surgery alone, 14 with combined radiotherapy and chemotherapy, six with radiotherapy alone, and two with surgery followed by radiotherapy. To find out the major series of related studies over the last 20 years, a literature review of PubMed was performed. In all, we found 42 major series including 8,164 patients with malignant neoplasms of the sinonasal tract.

RESULTS

There were 35 women and 36 men ranging in age from 5 to 80 years, with a median age of 55 years at diagnosis. The primary sites included were paranasal sinuses in 51 and nasal cavity in 20. There were one case of stage I, 20 of stage II, 27 of stage III, and 23 of stage IV. Epithelial tumors constituted 65% of all neoplasms. After a median follow-up of 39 months for surviving patients, 33 patients are alive and without disease, eight are alive with disease, and 30 patients died due to disease. Local recurrence was the most frequent treatment failure. The 5-year disease-free, local control, and overall survival rates were 42.1%, 59.5%, and 54.5%, respectively. On univariate analysis, cervical lymph nodes involvement, primary tumor size, histologic type, response to therapy, and stage of disease were independent prognostic factors for overall survival. In the literature review and by analyzing the data collection from 42 major reported series, the median age was 57 years and male/female ratio was 1.8. Epithelial tumors consisted of 69% of all malignant neoplasms of sinonasal tract and stages III and IV disease constituted 74.7% of all stages. Local recurrence was the dominant treatment failure in nearly all series. Five-year local control and overall survival rates were 56% and 45.5%, respectively.

CONCLUSIONS

In this review and by analyzing the large data collection of recent major reported series, we found that malignant neoplasms of the sinonasal tract tend to present at locally advanced stage, with a high frequency of local failure and a moderate to poor outcome. More effective local treatment for improving the local control and overall survival is needed.

Imaging of lumps and bumps in the nose: a review of sinonasal tumours

Sinonasal disease is one of the most common clinical head and neck pathologies. The majority of sinonasal pathology is inflammatory with neoplasms comprising approximately 3% of all head and neck tumours. Although sinus tumours are rare, they portend a poor prognosis, often due to advanced disease at diagnosis. Like most neoplasms, early detection improves prognosis, therefore clinicians and radiologists should be aware of features separating tumours from inflammatory sinus disease. This article reviews the anatomy, clinical features, imaging findings, treatment and histopathology of selected sinonasal tumours. Benign neoplasms reviewed include osteoma, inverting papilloma, and juvenile nasal angiofibroma. Malignant neoplasms reviewed include squamous cell carcinoma, the minor salivary gland tumour, adenoid cystic carcinoma, adenocarcinoma, melanoma, lymphoma, and olfactory neuroblastoma (esthesioneuroblastoma).

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation

INTRODUCTION

Malignancies of the nasal and paranasal sinuses are uncommon tumors, accounting for only 3% of all aerodigestive tract neoplasms. Despite advances in surgical techniques and continued evolution of adjuvant therapies, the 5-year mortality remains unusually high at greater than 50%. In 1996, we begin utilizing a novel strategy in the treatment of advanced sinonasal carcinomas. This consisted of neoadjuvant selective intra-arterial cisplatin with concurrent radiation therapy (acronym RADPLAT) followed by a conservative craniofacial resection. We now report our results for 11 patients treated with this regimen.

METHODS

Between July 1996 and April 2003, 11 patients with advanced sinonasal malignancies underwent treatment utilizing the RADPLAT protocol followed by a planned surgical resection via a craniofacial approach. Patient charts, operative notes, follow-up clinic notes, and pre- and post-operative imaging studies were reviewed in detail for each subject.

RESULTS

Histopathological analysis of the tumors revealed seven squamous cell carcinomas (64%), two adenocarcinomas (18%), one adenoid cystic carcinoma (9%), and one sinonasal undifferentiated carcinoma (9%). T4N0M0 disease was present in nine patients (81%), and two patients had T3N0M0 disease (19%). Survival was calculated using the Kaplan-Meier method with an overall survival of 81% at 5 years and a progression-free survival at 5 years of 67%. Mean follow-up is 57.2 months ranging from 12 to 95 months.

CONCLUSIONS

The treatment of advanced sinonasal malignancies with pre-operative intra-arterial cisplatin and concurrent radiation results in a significant improvement in survival. This can be done safely with high response rates and excellent loco-regional control in T3 and T4 disease. Although are results are encouraging, there is a need for a cooperative, multi-institutional, prospective study.

Sinonasal malignancy: what's new?

Tumors of the nasal cavity are located at a complex anatomic site and show a huge histological diversity. Although dealing with a rare malignancy, the last decade has brought--besides new histological and clinical classifications--a variety of new insights into etiological agents, tumor biology and therapeutic concepts as well as valuable overviews of rare histological subtypes. This review tries to disentangle the different medical and scientific aspects of the most frequently encountered histological types of tumors in the nasal cavity and the paranasal sinuses. We concentrate on epidemiology, classification, etiology, cytogenetics and molecular genetics, outcome and prognosis as well as treatment modalities, as far as the past few years have brought considerable new insights. Our principal aim is to provide the clinician with important data from publications of the last decade.

Sinonasal malignancies

Sinonasal malignancies are highly heterogeneous lesions that are challenging to diagnose, treat, and follow clinically. Outcomes remain relatively poor and are associated with late diagnosis, difficult surgical anatomy, and a lack of effective adjuvant modalities of treatment. New multimodal treatment protocols addressed to specific tumor entities are being assessed with promising results. Because of the relative rarity of these lesions, however, progress is slow. The best therapeutic outcomes are achieved in the setting of early diagnosis combined with a meticulous, comprehensive, multidisciplinary approach to the management of these complex tumors.

Intraarterial cisplatin with intravenous paclitaxel and ifosfamide as an organ-preservation approach in patients with paranasal sinus carcinoma

BACKGROUND

The objectives of this study were to determine the efficacy, organ-preservation rate, and safety of intraarterial (IA) cisplatin in combination with intravenous paclitaxel and ifosfamide in patients with locally advanced carcinoma of the paranasal sinuses who required orbital exenteration or major craniofacial resection for complete tumor resection.

METHODS

Patients were treated with intravenous paclitaxel (135 mg/m(2)) on Day 1, ifosfamide (1000 mg/m(2)) on Days 1-3, sodium mercaptoethanesulfonate (600 mg/m(2)) on Days 1-3, and IA cisplatin (100 mg/m(2)) on Day 1 every 21 days.

RESULTS

Of 24 study participants, 20 patients received at least 1 course of IA cisplatin, 1 patient had an early death, and 19 patients were evaluable for response. Five of those 19 patients (26%) achieved a complete response (CR), 6 patients (32%) achieved a partial response, and 8 patients (42%) had stable disease or developed progressive disease. Eye-sparing surgery followed by radiotherapy (RT) was feasible in 7 of 24 patients, RT was offered to only 7 patients, whereas 3 patients received chemotherapy and RT, 2 patients refused further therapy, 3 patients underwent craniofacial resection with orbitectomy, and 1 patient was treated systemically for metastatic disease. At the completion of treatment, 14 of 23 patients (61%) with locally advanced disease were disease free, and the orbit was preserved in 21 of 24 patients (88%). The overall survival, progression-free survival, and disease-free survival rates at 2 years were 60%, 50%, and 84%, respectively. Toxicity was substantial, with two patients experiencing cerebrovascular ischemia (one transient and one cerebrovascular accident) and three patients experiencing cranial neuropathy, which was reversible in two patients.

CONCLUSIONS

Despite the encouraging organ-preservation rate, the approach studied resulted in substantial toxicity, and more effective adjunctive therapy is needed. Alternative approaches, including the integration of targeted therapy agents in induction chemotherapy regimens followed by concomitant chemotherapy and RT or eye-sparing surgery, need further exploration.

Primary chemotherapy followed by anterior craniofacial resection and radiotherapy for paranasal cancer

BACKGROUND

To study prospectively the activity of primary chemotherapy with cisplatin, fluorouracil and leucovorin (PFL) in patients with paranasal cancer receiving surgery and postoperative radiotherapy.

PATIENTS AND METHODS

Forty-nine patients, previously untreated, with resectable paranasal carcinoma were enrolled. PFL (leucovorin 250 mg/m2/day for 5 days as a 120 h continuous infusion (c.i.), 5-fluorouracil 800 mg/m2/day from day 2 as a 96 h c.i. and cisplatin 100 mg/m2 day 2 q 3 weeks) was planned for five courses.

RESULTS

Thirty-two patients (65%) completed three or more chemotherapy courses. Two deaths from thrombotic events were observed after the first cycle. Eight cardiac toxicities were recorded during chemotherapy causing treatment discontinuation. Objective response to PFL was observed in 21 patients [43%; 95% confidence interval (CI) 29% to 58%], including four complete responses (CRs) (8%; 95% CI 2% to 20%) and 17 partial responses (PRs) (35%). Pathological complete remission (pCR) was achieved in eight of 49 patients (16%). At 3 years, overall survival was 69% and event-free survival 57%. Overall and event-free survival in patients achieving pCR is 100%.

CONCLUSIONS

PFL is active in paranasal cancer. Patients who attain a pathological complete remission have a favorable prognosis. Cardiovascular complications represent the limiting toxicity. Primary chemotherapy combined with surgery-sparing treatment approaches deserves further investigation.

Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses: treatment results for 47 patients

PURPOSE

Ethmoid sinus cancer is a rare malignancy. Treatment results are mostly reported together with other sinonasal tumors, grouping a wide range of different histologies and treatment approaches. This study reports on the treatment outcome of 47 patients diagnosed with adenocarcinoma of the ethmoid sinuses and treated with surgery and high-dose postoperative radiation therapy.

METHODS AND MATERIALS

Between September 1985 and October 2001, 51 patients with adenocarcinoma of the ethmoid sinuses were referred to the Ghent University Hospital. Four patients were treated with low-dose palliative radiation because of very extended inoperable disease or distant metastasis at the time of diagnosis. They were not included in this analysis. The other 47 patients, all staged as N0M0, were treated with surgery and postoperative high-dose radiation therapy. The median follow-up was 32 months. The T-stages were T1 for 2, T2 for 17, T3 for 11, and T4 for 17 patients. All 47 patients were staged as N0M0.

RESULTS

The 3-year, 5-year, and 7-year overall survival are respectively 71%, 60%, and 38%. The 3-year and 5-year disease-free survival are respectively 62% and 36%. The 3-year and 5-year disease-free survival for T1-T2 stages are respectively 87% and 55%, for T3 stages 57% and 28%, and for T4 stages 41% and 25%. The locoregional tumor control was 70% and 59% at respectively 3 and 5 years. Patients presenting with intracranial tumor invasion at the time of diagnosis relapsed within 7 months after the end of radiotherapy. Radiation-induced severe dry eye syndrome and optic neuropathy was observed in respectively 7 and 2 of the 47 cases.

CONCLUSION

Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses is associated with good local control rates. Crucial for a favorable prognosis is the absence of intracranial invasion. The rarity of these tumors makes it difficult to evaluate new therapeutic advances.

Results of multimodality therapy for squamous cell carcinoma of maxillary sinus

BACKGROUND

A wide variety of modalities, including surgery, radiation therapy, and chemotherapy, alone or in combination, have been used for the treatment of squamous cell carcinoma (SCC) of the maxillary sinus to obtain better local control and maintain functions. However, there is still much controversy with regard to the optimum treatment.

METHODS

From 1987 to 1999, 33 patients with SCC of maxillary sinus were treated at the Department of Otolaryngology-Head and Neck Surgery, University of Tokyo Hospital. The treatment consisted of 30-40 grays (Gy) of preoperative radiotherapy with concomitant intraarterial infusion of 5-fluorouracil and cisplatin followed by surgery and 30-40 Gy of postoperative radiotherapy, for tumors without skull base invasion. For tumors invading the skull base, preoperative systemic chemotherapy with or without radiotherapy was performed, instead of intraarterial chemotherapy, then followed by skull base surgery. The surgical procedures varied according to the extent of tumor. Results were compared with those of the 108 patients treated in our hospital from 1976 to 1982.

RESULTS

Partial maxillectomy was performed in 2 T2 patients and 12 T3 patients. Total maxillectomy was performed in 1 T2 patient, 3 T2 patients, and 7 T4 patients. Skull base surgery was performed in eight T4 patients. Orbital content and hard palate were preserved in 22 patients and 18 patients, respectively. The overall 5-year survival rates were 86% in T 3 patients and 67 % in T4 patients, respectively.

CONCLUSIONS

Our multimodal treatment has provided favorable local control and survival outcome with good functional results.

Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review

BACKGROUND

The authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review.

METHODS

Two hundred twenty patients who were treated between 1975 and 1994 with a minimum follow-up of 4 years were reviewed retrospectively. A systematic review of published articles on patients with malignancies of the nasal and paranasal sinuses during the preceding 40 years was performed.

RESULTS

The 5-year survival rate was 40%, and the local control rate was 59%. The 5-year actuarial survival rate was 63%, and the local control rate was 57%. Factors that were associated statistically with a worse prognosis, with results expressed as 5-year actuarial specific survival rates, included the following: 1) histology, with rates of 79% for patients with glandular carcinoma, 78% for patients with adenocarcinoma, 60% for patients with squamous cell carcinoma, and 40% for patients with undifferentiated carcinoma; 2) T classification, with rates of 91%, 64%, 72%, and 49% for patients with T1, T2, T3, and T4 tumors, respectively; 3) localization, with rates of 77% for patients with tumors of the nasal cavity, 62% for patients with tumors of the maxillary sinus, and 48% for patients with tumors of the ethmoid sinus; 4) treatment, with rates of 79% for patients who underwent surgery alone, 66% for patients who were treated with a combination of surgery and radiation, and 57% for patients who were treated exclusively with radiotherapy. Local extension factors that were associated with a worse prognosis included extension to the pterygomaxillary fossa, extension to the frontal and sphenoid sinuses, the erosion of the cribriform plate, and invasion of the dura. In the presence of an intraorbital invasion, enucleation was associated with better survival. In multivariate analysis, tumor histology, extension to the pterygomaxillary fossa, and invasion of the dura remained significant. Systematic review data demonstrated a progressive improvement of results for patients with squamous cell and glandular carcinoma, maxillary and ethmoid sinus primary tumors, and most treatment modalities.

CONCLUSIONS

Progress in outcome for patients with nasal and paranasal carcinoma has been made during the last 40 years. These data may be used to make baseline comparisons for evaluating newer treatment strategies.

Carcinoma of the maxillary antrum: a retrospective analysis of 110 cases

BACKGROUND AND PURPOSE

Cancer of the maxillary antrum is a rare disease with a variety of treatment options. The present study was undertaken to review the outcome of patients with carcinoma of the maxillary antrum managed at a single institution.

MATERIALS AND METHODS

A retrospective analysis of 110 cases of carcinoma of the maxillary antrum managed with curative intent during the time period 1976-1993 was performed. There were 33 females and 77 males; the median age was 64 years (range 38-89). The median follow-up time was 4 years (range from 2 months to 17 years). The majority of patients presented with locally advanced disease (78 T4 tumours); nodal involvement was observed in 17/110 cases. Histologic subtypes included in the analysis were limited to squamous cell carcinoma (95 cases) and undifferentiated carcinoma (15 cases). Patients were managed with either primary radiation therapy with surgery reserved for salvage (83/110) or with a planned combined approach with surgery and either pre or postoperative radiation (27/110).

RESULTS

The actuarial 5-year cause-specific survival rate was 43%. The 5-year local control rate was 42%. Of 63 patients with local failure, 25 underwent salvage surgery with a subsequent 5-year cause-specific survival of 31%. Multiple regression analysis of patient, disease and treatment related variables identified local disease extent and nodal disease at presentation as the only variables independently associated with cause-specific survival.

CONCLUSIONS

This analysis indicates that survival from carcinoma of the maxillary antrum is poor with outcome strongly related to local disease extent. The best treatment strategy for this disease remains undefined. Salvage surgery can result in prolonged survival in selected patients experiencing local failure.

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.

Squamous cell carcinoma of maxillary sinus

BACKGROUND

Medical records of 43 patients with histologically proved diagnosis of squamous cell carcinoma who were treated between the years 1975 and 1994 at the department of Otolaryngology Head Neck Surgery, VU Amsterdam were examined.

METHODS

Tumors were restaged according to UICC classification 1997. Thirty-eight patients were treated for cure, nine were treated with chemotherapy followed by external beam radiotherapy, and 28 patients were treated with surgery followed by postoperative radiotherapy. No patient was lost to follow-up. Data with respect to survival were analyzed.

RESULTS

Eighty-three percent of the tumours were in stage III or stage IV at the time of first presentation. Five-year survival after surgery and postoperative radiotherapy for all patients was 64%. For stages II, III, and IV it was 83%, 49%, and 37%, respectively. Cervical nodal metastases were present in 4.1% at the time of presentation. Thirty-seven percent of the patients survived 2 years after chemotherapy followed by radiotherapy.

CONCLUSIONS

Squamous cell carcinoma continues to be diagnosed late. Surgery followed by radiotherapy remains the treatment of choice. Mandibulotomy should be considered for better clearance of retromaxillary space in T3 -T4 tumors. The eye should be preserved whenever it is oncologically safe to do so.

Sinonasal imaging: malignant disease

The clinical presentation of sinonasal malignancy overlaps that of more common benign inflammatory disease. For this reason, unsuspected malignant lesions are often first recognized on the screening CT exam. We will focus on the initial CT appearance of various malignancies and discuss the goals of imaging including the use of MR.

Squamous cell carcinoma of the sinonasal tract invading the orbit

OBJECTIVE/HYPOTHESIS

The treatment of squamous cell carcinoma (SCC) of the sinonasal tract has evolved from routine exenteration of the orbital contents to sparing of the orbit when the SCC does not transgress the periorbita. Nonetheless, the influence of this change in treatment over the rate of local recurrence or survival has not been clearly elucidated. The objective was to ascertain whether orbital sparing surgery for the treatment of SCC of the paranasal sinuses influences the rate of local recurrence or survival.

STUDY DESIGN

This is a retrospective study of patients presenting with SCC arising in the sinonasal tract, treated primarily at the University of Pittsburgh Medical Center from 1977 to 1990, including meta-analysis of the English literature regarding SCC of the sinonasal tract.

METHODS

Review of medical records regarding demographics, histology, extension of tumor, pathologic results, type of surgery, adjunctive therapy, and outcome. Articles for meta-analysis were identified by Medline search and cross-referencing.

RESULTS

Fifty-eight patients with orbital invasion, including bone and/or soft tissue invasion, were included in the study. Patients presenting with invasion of the bony orbit without soft tissue invasion were treated with maxillectomy and/or ethmoidectomy, sparing the orbital contents. Patients presenting with invasion of the orbital bones and soft tissues were treated with ethmoidectomy or maxillectomy, including orbital exenteration. At 3 years' follow-up, 52% of the patients whose orbit was exenterated were alive and without evidence of disease, compared with 59% of the patients whose orbit was spared. This difference was not statistically significant. Similarly, the rate of local recurrence was not statistically significant (P > .05). A meta-analysis of the literature revealed similar results.

CONCLUSIONS

Our data suggest that sparing of the soft tissues of the orbit when the periorbita has not been transgressed by SCC does not downgrade the rate of cure or local control.

Ethmoid sinus carcinomas: natural history and treatment results

PURPOSE

This retrospective study was undertaken to assess the clinical features and results of treatment of carcinomas of the ethmoid sinus.

MATERIALS AND METHODS

The records of 34 patients with ethmoid sinus carcinomas treated with curative intent at the U.T.M.D. Anderson Cancer Center (UTMDACC) between January 1969 and December 1993 were reviewed. The age of the patients ranged from 28 to 73 years with a median of 57 years. There were 28 Whites, four Hispanics, one Black and one Asian. A simple staging based on anatomical criteria was used to describe the extent of the disease. Six patients had T1, 13 patients had T2 and 15 patients had T3 disease. Twenty-one patients were treated with surgery plus radiation and 13 patients were treated with radiotherapy alone; nine patients received adjuvant chemotherapy. Radiation was given at approximately 2 Gy per fraction to total doses of 50 Gy preoperatively, 52-66 Gy (median 60 Gy) postoperatively and 50-70 Gy (median 63 Gy) when no surgery was performed.

RESULTS

The actuarial 5-year overall, disease-free and disease-specific survival rates were 55%, 58% and 63%, respectively. The actuarial 5-year local control rate was 71% for the whole group (74% for surgery plus radiation and 64% for radiation alone). Local recurrence occurred in nine patients, nodal relapse occurred in three patients and distant metastases occurred in four patients. Histologically proven dura mater invasion was associated with a poorer local control rate in patients undergoing surgery and radiation. The simple T-staging system used in this study was a good discriminator for local control. Of nine patients receiving chemotherapy, three had complete responses and four had partial responses; six of the seven responders had undifferentiated carcinoma. Severe complications of therapy occurred in patients treated between 1969 and 1984 and consisted mainly of visual impairment and brain necrosis.

CONCLUSIONS

This retrospective review of a large single institutional experience showed that ethmoid sinus carcinomas have a tendency for extensive local invasion but a low propensity for lymphatic and hematogenous spread. Hence, local recurrence was the main cause of cancer-related death. Combined treatment with surgery and postoperative irradiation yielded the highest local control rate. However, radiotherapy alone eradicated two-thirds of primary tumors and, consequently, is a reasonable alternative treatment for patients with medical contraindications to surgery. For patients who underwent surgery and radiotherapy, the presence of histologically proven dura mater invasion was associated with a higher local recurrence rate. Severe radiation complications have been rare with the contemporary radiotherapy technique. Chemotherapy induced excellent responses in undifferentiated carcinoma but its impact on overall disease control is unclear in this small series of patients.

Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses

BACKGROUND

Nonsquamous cell malignant tumors of the nasal cavity and paranasal sinuses are an uncommon and diverse group of neoplasms. Our goal was to define the relative frequency and distribution of these neoplasms, as well as treatment and outcome.

METHODS

This retrospective study analyzed 106 patients with nonsquamous cell malignant neoplasms of the nasal cavity and paranasal sinuses treated at our institution between 1966 and 1982.

RESULTS

Pathology included: salivary type carcinoma (33 patients); sarcoma (25 patients); melanoma (18 patients); esthesioneuroblastoma (11 patients); lymphoma (11 patients); and anaplastic cancer (9 patients). Most tumors arose in the nasal cavity (50%), followed by the antrum (39%), ethmoid sinus (9%), and frontal sinus (2%). Fifty-four percent of all patients were treated with surgery alone. Determinate 5-year and 10-year cure rates were: esthesioneuroblastoma, 70% and 50%; lymphoma, 45% and 30%; anaplastic, 33% and 25%; salivary, 31% and 18%; sarcoma, 25% and 21%; and melanoma, 19% and 0%.

CONCLUSIONS

Overall survival for patients with nonsquamous cell malignant neoplasms of the nasal cavity and paranasal sinuses is poor, particularly with follow-up extended to 10 years. Local recurrence is the major source of treatment failure. We were unable to demonstrate any survival advantage in the group of patients who received surgery and radiotherapy in combination.

Clinical assessment of squamous cell carcinoma of the nasal cavity proper

The subjects were 14 patients with squamous cell carcinoma or undifferentiated carcinoma of the nasal cavity treated at Nihon University Hospital between October 1984 and November 1991, who were followed for at least 3 years. The site of the tumor origin within the nasal cavity was the lateral wall in 8 patients, the nasal septum in three patients, and unknown in three patients. Histologically, there were 13 squamous cell carcinomas in (3 well differentiated, 7 moderately differentiated, and 3 poorly differentiated) and 1 undifferentiated carcinoma. Treatment was by a combination of radiotherapy, chemotherapy, and surgery in 8 cases, a combination of radiotherapy and surgery in 5 cases, and surgery alone in 1 case. The 3-year and 5-year Kaplan-Meier survival rates were 86 and 69%, respectively. A total of 6 patients suffered a recurrence, with local recurrence occurring in 4 patients and pulmonary metastasis in 2 patients. Tumor control was achieved in 3 of the 4 cases of local recurrence by reoperation, and by surgery in 1 of the 2 cases of pulmonary metastasis. The duration of the recurrence-free interval in the patients who developed local recurrences, 18 to 46 months after the completion of the initial course of therapy, was of considerable interest.

Combined therapy for maxillary sinus carcinoma with special reference to extensive Denker's operation

A statistic analysis of 372 patients with maxillary sinus carcinoma treated between 1972 and 1983 was undertaken. One hundred eight patients were treated with the combined method consisting of 50 Gy irradiation, 2,000 mg 5-FU intraarterial infusion and tumor reduction surgery, the so-called extensive Denker's operation. Two hundred twenty-two patients were treated with the combined method not including extensive Denker's operation, and the other 42 patients with radiotherapy alone. The 5-year survival of these three groups were 48, 43, and 17%, respectively. The cumulative local control of the two groups with and without extensive Denker's operation was 51 and 33%, respectively. Maxillectomy as the second treatment was performed in 24 cases (22%) and 71 cases (32%) of the two groups of the combined method with and without extensive Denker's operation, respectively. On the other hand, 5-year survivors without maxillectomy of the two groups were 41 cases (38%) and 54 cases (24%), respectively. It was concluded that extensive Denker's operation plays an important role to increase the success rate of the initial treatment, decrease the rate of maxillectomy and increase the survival rate although it has a certain limit for the indication.