Prognostic factors in maxillary sinus and nasal cavity carcinoma

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.

Automated Prediction of Early Recurrence in Advanced Sinonasal Squamous Cell Carcinoma With Deep Learning and Multi-parametric MRI-based Radiomics Nomogram

RATIONALE AND OBJECTIVES

Preoperative prediction of the recurrence risk in patients with advanced sinonasal squamous cell carcinoma (SNSCC) is critical for individualized treatment. To evaluate the predictive ability of radiomics signature (RS) based on deep learning and multiparametric MRI for the risk of 2-year recurrence in advanced SNSCC.

MATERIALS AND METHODS

Preoperative MRI datasets were retrospectively collected from 265 SNSCC patients (145 recurrences) who underwent preoperative MRI, including T2-weighted (T2W), contrast-enhanced T1-weighted (T1c) sequences and diffusion-weighted (DW). All patients were divided into 165 training cohort and 70 test cohort. A deep learning segmentation model based on VB-Net was used to segment regions of interest (ROIs) for preoperative MRI and radiomics features were extracted from automatically segmented ROIs. Least absolute shrinkage and selection operator (LASSO) and logistic regression (LR) were applied for feature selection and radiomics score construction. Combined with meaningful clinicopathological predictors, a nomogram was developed and its performance was evaluated. In addition, X-title software was used to divide patients into high-risk or low-risk early relapse (ER) subgroups. Recurrence-free survival probability (RFS) was assessed for each subgroup.

RESULTS

The radiomics score, T stage, histological grade and Ki-67 predictors were independent predictors. The segmentation models of T2WI, T1c, and apparent diffusion coefficient (ADC) sequences achieved Dice coefficients of 0.720, 0.727, and 0.756, respectively, in the test cohort. RS-T2, RS-T1c and RS-ADC were derived from single-parameter MRI. RS-Combined (combined with T2WI, T1c, and ADC features) was derived from multiparametric MRI and reached area under curve (AUC) and accuracy of 0.854 (0.749-0.927) and 74.3% (0.624-0.840), respectively, in the test cohort. The calibration curve and decision curve analysis (DCA) illustrate its value in clinical practice. Kaplan-Meier analysis showed that the 2-year RFS rate for low-risk patients was significantly greater than that for high-risk patients in both the training and testing cohorts (p < 0.001).

CONCLUSION

Automated nomograms based on multi-sequence MRI help to predict ER in SNSCC patients preoperatively.

Population-based Long-term Outcomes for Squamous Cell Carcinoma of the Nasal Cavity

BACKGROUND

This study evaluates population-based outcomes of patients with squamous cell carcinoma (SCC) of the nasal cavity treated in British Columbia.

METHODS

A retrospective review of nasal cavity SCC treated from 1984 to 2014 was performed (n = 159). Locoregional recurrence (LRR) and overall survival (OS) were evaluated.

RESULTS

The 3-year OS was 74.2% for radiation alone, 75.8% for surgery alone, and 78.4% for surgery and radiation ( P = 0.16). The 3-year LRR was 28.4% for radiation alone, 28.2% for surgery alone, and 22.6% for surgery and radiation ( P = 0.21). On multivariable analysis, surgery and postoperative radiation relative to surgery alone was associated with a lower risk of LRR (hazard ratio: 0.36, P = 0.03). Poor Eastern Cooperative Oncology Group status, node-positive, orbital invasion, smoking, and advanced age were associated with worse OS (all P <0.05).

CONCLUSION

In this population-based analysis, multimodality treatment with surgery and adjuvant radiation were associated with improved locoregional control for SCC of the nasal cavity.

Ligation of the ethmoid arteries in superselective intra-arterial infusion of cisplatin for advanced maxillary sinus cancer fed by the ophthalmic artery

BACKGROUND

Superselective cisplatin (CDDP) infusion via the external carotid artery system and concomitant radiotherapy (RADPLAT) provides favorable oncological and functional outcomes in patients with maxillary sinus cancer. However, targeted lesions are occasionally fed by the branch of the internal carotid artery.

METHODS

In RADPLAT for maxillary sinus cancer partly fed by the ophthalmic artery, the ethmoid arteries were ligated in two patients without medial orbital wall involvement. In four patients with that, CDDP was administered via the ophthalmic artery.

RESULTS

A complete response was obtained in all six patients. Locoregional recurrence was not observed in any cases. However, visual acuity was lost in four patients who received the ophthalmic artery infusion.

CONCLUSIONS

Ligation of the ethmoid arteries is recommended in RADPLAT for maxillary sinus cancer with lesions fed by the ophthalmic artery. CDDP administered via the ophthalmic artery may be considered if a patient accepts the possibility of visual loss.

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.

Classification of maxillectomy in edentulous arch defects, algorithm, concept, and proposal classifications: A review

OBJECTIVES

Aramany's classification of postsurgical maxillectomy defects was introduced for partially edentulous situations, and has been widely used for education and effective communication among practitioners. Numerous classifications of maxillofacial defects, based on surgical procedure, resultant defects, or prosthodontist's perspective after rehabilitation, exist in the literature. However, no single classification has incorporated all these factors. The purpose of this review was to highlight the classification systems and describe a pragmatic classification series for edentulous maxillary arch defects (maxillectomy) by applying the Aramany classification criteria, to enhance treatment outcomes and communication among practitioners.

MATERIAL AND METHODS

An electronic search of the literature published in English was conducted using the PubMed/MEDLINE and Google Scholar database. Keywords used were "maxillectomy classification" AND "surgical resection," "maxillectomy classification" AND "complete edentulous." In addition, a manual search was also performed followed the same criteria in the following journals: Journal of Prosthetic Dentistry and Journal of Prosthodontics.

RESULTS

Several classification systems for partial dentition were found in terms of size, location, dentition, and extension of the defect (isolated or communication defects). The findings revealed a variety of maxillectomy defect classifications for partially dentate, considering surgical factors and rehabilitation. However, no study or classification system exist for the edentulous arch defects.

CONCLUSIONS

Different classification systems for maxillectomy defects exist in the literature, only for partially dentate patients. To the authors best knowledge, no classification system for completely edentulous maxillary arch defects have been proposed till date. A simple classification system with clear characteristics for edentulous maxillectomy dental arch defects has been proposed. This classification was modeled after Aramany classification for easier memorization and application.

The Evaluation of Clinical Signs and Symptoms of Malignant Tumors Involving the Maxillary Sinus: Recommendation of an Examination Sieve and Risk Alarm Score

This observational study was conducted to evaluate the clinical signs and symptoms of maxillary sinus tumors and to propose a clinical examination sieve and a unique risk alarm score to be used for timely patient referral and vigilance. The study consisted of 70 patients between 20 to 82 years of age from both sexes. The clinical information gained was collected from the upper dentoalveolar segment, orbit, and nasal sites. Regarding the early clinical sign and symptoms of patients, nasal obstruction was found in 67 patients (95.7%), facial swelling in 69 patients (98.6%), paresthesia in 41 patients (58.6%), and epistaxis in 50 patients (71.4%). Furthermore, in terms of the late signs and symptoms, a palpable mass in buccal sulcus was observed in 65 (92.9%) of the patients, lymphadenopathy in 24 (34.3%), paresthesia in 38 (54.3%), and diplopia in 22 (31.4%). Furthermore, general sign and symptoms like exophthalmos was present in 35 patients (50%), anosmia was observed in 37 patients (52.9%), and oroantral fistula was noted in 37 patients (55.9%). Additionally, 67 (95.7%) of the patients complained of nasal obstruction. Similarly, facial asymmetry was observed in 69 (98.6%) of the patients and double vision was observed in 24 (34.4%). Tumors of the maxillary sinus have a very insidious course of spread and uncertain clinical signs and symptoms. What makes diagnosis worse is the fact that the symptoms of these tumors are so well hidden in the sponge-like nature of the midfacial region that they are easily misinterpreted by patients. Therefore, diagnoses must be made early, dentists must be vigilant, and patients must be fully investigated at the slightest suspicion of a tumor, albeit benign.

Endoscopic Management of Malignant Tumors of Paranasal Sinus and Nasal Cavity: An Institutional Experience

Malignant tumors of sinonasal region are rare and affect less than 1 in 100,000 people per year. They are histologically diverse group and potentially pose significant management problems due to their proximity to the orbit and intracranial cavity. Although squamous cell carcinoma (SCC) is most common malignant tumor of paranasal cavity, tumors like adenocarcinoma, olfactory neuroblastoma, malignant melanoma, adenoid cystic carcinoma, sarcomas, haemoproliferative tumors, e.g. lymphoma may also occur. Retrospectively study was done in a tertiary care institute from January 2008 to December 2018 in India. Inclusion criteria-all biopsy proven PNS malignancy patients operated by endoscopic approach, irrespective of age and gender. Exclusion criteria- patients diagnosed with nasopharyngeal carcinoma, skin involvement, gross orbital involvement (muscle invasion), metastasis, operated by open approaches. 46 patients who underwent endoscopic tumor removal were reviewed. 36 (78.2%) were males and 10 (4.6%) females. Most common tumor in our study was adenoid cystic carcinoma. Recurrence was seen in 6 patients. Palliative therapy was given to all patients with recurrence. Management of malignant PNS tumor involving anterior skull base is multidisciplinary. R0 resection should be main goal in all malignant PNS malignancy. Tumors invading unresectable areas like cavernous sinus, brain parenchyma, carotids can be left in these places followed by palliation except in cases of squamous cell carcinoma. If R0 cannot be achieved surgically in SCC than patient should be considered inoperable and send for palliation. T1-T3 PNS malignant tumors can be managed by endoscopic approach followed by adjuvant therapy after a period of 6 weeks. Endoscopic excision should be converted to endoscopic assisted open approach in case of T4 tumors. We have tried to give a management protocol for management of malignant PNS tumors. Level of evidence: II.

Treatment Outcomes of Sinonasal Malignancies Involving the Orbit

Objective Orbital invasion is associated with a poor prognosis in cases of sinonasal malignancy. This study aimed to analyze the oncological outcomes of sinonasal malignancies involving the orbit.

Patients and Methods We reviewed the medical records of 116 patients with a sinonasal malignancy who had orbital invasion at initial diagnosis and followed up at least 6 months between June 1991 and October 2017 at a single institute. The overall survival (OS), disease-specific survival (DSS), and progression-free survival (PFS) rates according to the clinicopathological factors, extent to orbit, and treatment modality were compared.

Results Patients were mainly treated with surgery and postoperative radiation (n = 39, 33.6%) and concurrent chemoradiation (n = 72, 62.1%). Only five patients (5.1%) underwent orbital exenteration. The OS, DSS, and PFS rates significantly decreased in patients older than 60 years of age and in patients with a higher Charlson Comorbidity Index Score (each p < 0.001). The OS and DSS rates were higher in patients at clinical T3 and N0 stage than in patients at clinical T4 and N1–2 stage (each p < 0.05). There were no significant differences in survival and local control rates according to the extent of orbital invasion, treatment modalities, and orbital preservation. However, neoadjuvant chemotherapy and adjuvant radiation or concurrent chemoradiation increased survival rates in the patients treated with surgery.

Conclusion Orbit preservation and relatively successful oncological outcome could be obtained with surgery and adjuvant radiation or concurrent chemoradiation.

Sinonasal cancer in Denmark 2008-2015: a population-based phase-4 cohort study from DAHANCA

BACKGROUND

Sinonasal cancer is considered a rare disease with poor survival. Its treatment has changed profoundly in recent years, primarily following the introduction of intensity-modulated radiation therapy (IMRT) and minimally invasive endoscopic surgery. Danish national guidelines on treatment of patients diagnosed with sinonasal carcinoma were introduced in 2007. The aim of this phase-4 study was to assess the effect of the implementation of guidelines by describing treatment outcomes in a consecutive nationwide cohort.

METHODS

All patients diagnosed with sinonasal carcinoma in Denmark from 2008 to 2015 were identified in the nationwide clinical database, DAHANCA, and were followed until May 2020. Overall survival (OS) was analysed using Kaplan-Meier estimator. Cumulative incidence of locoregional failure (LRF) and disease-specific mortality (DSM) were analysed using the Aalen-Johansen estimator. Competing risks were death from other causes (DSM) and distant failure and death (LRF). Analysis of prognostic factors was performed using Cox proportional hazard analysis. Start of follow-up was time of diagnosis. The results are presented as estimates with 95% confidence intervals (95% CIs).

RESULTS

A total of 331 patients were identified. Curatively intended treatment was performed in 264 patients (80%). Non-compliance with treatment guidelines was registered in 24 patients (9%). Non-compliance was associated with LRF (hazard ratio [HR], 2.0 [95% CI: 1.1-3.5]). Among patients qualified for curative treatment, failure occurred in 109 patients (41%), primarily at the primary tumour site (81%). Anatomical tumour site and disease stage were independent prognostic factors. The 5-year OS was 56% in patients treated with curative intent, and a combined treatment strategy showed reduced LRF (HR, 0.53 [95% CI: 0.30-0.92]) in a multivariate analysis.

CONCLUSIONS

Guideline compliance and a combined treatment approach reduced the incidence of LRF and thereby increased OS. Our results confirm those of international studies. Treatment of sinonasal carcinoma remains a challenge that requires multidisciplinary team coordination.

Invasion of the pterygoid plates: an indicator for regional lymph node failure in maxillary sinus cancer

BACKGROUND

The aim of this study was to evaluate the long-term treatment results of combined superselective intraarterial chemotherapy and radiation therapy for advanced maxillary sinus cancer (MSC) and the incidence of regional lymph node failure, and to reveal the clinical and anatomical predictive factors for metastasis.

METHODS

We retrospectively evaluated 55 consecutive patients with locally advanced squamous cell carcinoma of the maxillary sinus who were treated with external radiotherapy and superselective intraarterial chemotherapy. Elective nodal irradiation (ENI) was performed only in the clinical node-positive (cN+) cases and not in the clinical node-negative (cN0) cases.

RESULTS

Thirty-eight patients were cN0, and 17 were cN+ at diagnosis. Regional lymph node metastases occurred in 7 of 38 patients with cN0, and 2 of 17 with cN+ during the median follow-up period of 36 months. There were more cases of high-grade (3 or 4) late adverse events in the ENI group than in the non-ENI group (13% vs. 41%, respectively; p = 0.03). In cN0 cases without ENI, invasion of the pterygoid plates (57% vs. 90%; p < 0.01) and oral cavity (35% vs. 92%, with invasion vs without invasion, respectively; p = 0.02) was significantly correlated with a low 5-year regional recurrence-free rate.

CONCLUSIONS

Patients with MCS and invasion of the pterygoid plates and oral cavity can be considered appropriate candidates for ENI.

Sinonasal carcinomas - A single-centre experience at Prince of Wales Hospital, Sydney, Australia, from 1994 to 2016

INTRODUCTION

Sinonasal carcinomas (SNCs) are rare neoplasms that are often diagnosed at advanced stages due to asymptomatic growth of tumours in the spaces of the sinonasal complex. Treatment is associated with high morbidity, and outcomes have only improved slightly in the past few decades despite advancements in treatment modalities. The purpose of this study is to evaluate the efficacy and safety of treatment at our institution.

METHODS

This retrospective cohort study analysed patients who received definitive treatment at the Prince of Wales Hospital (POWH), Sydney, for non-metastatic SNC. Patients with non-carcinoma and olfactory neuroblastoma pathology were excluded. Data were collected from the POWH electronic patient database. Survival functions were calculated through Kaplan-Meier analysis, and multivariate analysis for prognostic factors was performed through Cox regression.

RESULTS

Seventy-five patients from 1994 to 2016 were eligible for analysis. Overall 5-year local control (LC), ultimate local control (ULC), overall survival (OS) and cancer-specific survival (CSS) were 76 ± 6%, 80 ± 5%, 69 ± 6% and 77 ± 5%, respectively. On multivariate analysis, clinical stage was prognostic for LC and primary site was prognostic for OS and CSS. Lymphovascular invasion and tumour inoperability were also predictive of CSS.

CONCLUSION

Survival and local control rates at our centre were greater than those reported in the literature. Early-stage patients treated with surgery alone had excellent oncologic outcomes. Radical surgery with postoperative radiation provides the best outcome in the setting of advanced disease.

Malignant tumors of the maxillary sinus: Prognostic impact of neurovascular invasion in a series of 138 patients

BACKGROUND

Maxillary sinus cancer is a rare disease with heterogeneous biologic behavior. The pattern of neurovascular invasion is known to be an important prognosticator in head and neck cancers, but has not been studied in maxillary malignancies.

MATERIALS AND METHODS

Patients undergoing surgery-based treatment with curative intent for a malignancy of the maxillary sinus at the Unit of Otorhinolaryngology - Head and Neck Surgery of the University of Brescia between November 2000 and October 2018 were included. A description of the characteristics of the patients, tumors, and treatments has been performed along with uni- and multi-variate analysis of prognostic factors. Tumors were classified based on the presence of perineural (P₀/P₁) and lymphovascular invasion (V₀/V₁) in 4 categories: P₀V₀, P₁V₀, P₀V₁, and P₁V₁.

RESULTS

One hundred-thirty-eight patients were included. Mean age at surgery was 61.0 years. Most patients (60.1%) were affected by non-salivary carcinomas, and most tumors (73.9%) were high-grade cancers. One hundred-seven (77.5%) tumors were classified as pT4. The large majority of patients received bi- or tri-modality treatment. Sixty-three (45.7%) cases were classified as P₀V₀, 32 (23.2%) as P₁V₀, 7 (5.1%) as P₀V₁, and 36 (26.1%) as P₁V₁. T category, nodal status, and neurovascular invasion were significantly associated with prognosis. Perineural and lymphovascular invasion were associated with the topographical growth of the tumor.

CONCLUSIONS

Maxillary cancer is often diagnosed at an advanced stage and in most cases requires a multimodal approach. Perineural and lymphovascular invasion are frequent and have a different impact on prognosis and topographical extension of the tumor.

Predictors of nodal metastasis in sinonasal squamous cell carcinoma: A national cancer database analysis

Objective

We present the largest population based study of sinonasal squamous cell carcinoma (SCC) to identify risk factors for presentation with nodal metastasis.

Methods

The National Cancer Database (NCDB) was used for this study. Location codes corresponding to the nasal cavity and paranasal sinuses and histology codes representing SCC malignancy were queried. Logistic regression analysis was performed to identify factors associated with presentation with nodal metastasis.

Results

6448 cases met inclusion criteria. Nodal metastasis at presentation was seen in 13.2% of patients, with the sinus subsite (19.3%) being a significant risk factor for nodal metastasis at presentation when compared to the nasal cavity (7.9%). Logistic regression analysis showed black, uninsured and Medicaid patients were more likely than white and privately insured patients, respectively, to present with nodal metastasis.

Conclusions

In sinonasal SCC, the sinus subsite has a significantly increased risk of nodal metastasis compared to the nasal cavity. Black race, uninsured and Medicaid patients are more likely to have nodal metastasis at presentation.

Squamous Cell Carcinoma of the Paranasal Sinuses: A Single Center Experience

Objective  Squamous cell carcinoma (SCC) of the paranasal sinuses is usually diagnosed at an advanced stage, making curative therapy difficult. The goal of this study was to evaluate the management and outcomes of patients with SCC treated at our institution. Methods  In a population-based consecutive prospective cohort, we conducted an analysis of all patients treated for SCC between 1988 and 2017. Results  A total of 72 patients were included, follow-up was 100%. Mean follow-up was 57 months for the entire cohort, and 108 months for patients with no evidence of disease. Eighty-two percent of all patients had high-stage (T4) disease. Fifty-seven patients underwent treatment with curative intent; consisting of surgery with or without oncologic treatment in 34, and of oncologic treatment only in 23 cases. Fifteen patients received palliative treatment. The rates of overall survival for the entire cohort were 55% at 2, 41% at 5, and 32% at 10 years, and corresponding disease-specific survival (DSS) rates were 55, 45, and 34%, respectively. DSS rates after surgical treatment with curative intent were 81% at 2, 65% at 5, and 54% at 10 years. Retromaxillary involvement and nonradical surgery were negative prognostic factors. Best survival was achieved with the combination of radical surgery and adjuvant oncologic treatment. Conclusion  Surgical resection with a curative intent yielded 65% at 5-year DSS even in this cohort of patients with high-stage SCC and is still considered as the treatment of choice, preferably in combination with adjuvant radiation therapy and chemotherapy.

Management of orbital invasion in sinonasal malignancies

BACKGROUND

Indications for preservation of orbital contents in case of malignant sinonasal tumors invading the orbit remain controversial.

METHODS

A retrospective consecutive review was conducted of patients in a tertiary care center over a 15-year period.

RESULTS

Ninety-three patients were diagnosed with a malignant tumor invading the orbit. Eighty-three were treated with curative intent of which 58 underwent surgery. Mean follow-up was 45 months. Orbital preservation was feasible in 66% of cases, whereas orbital clearance was performed in cases of locally advanced disease (invasion of extraocular muscles, ocular globe, or orbital apex). Local control rate was 70% for patients treated with orbital clearance and 74% for those with orbital preservation, with no statistical difference. Five-year survival and 5-year relapse-free survival were similar in both groups.

CONCLUSION

Using our strategy, the eye can be spared in more patients than what is currently proposed, without oncologic or survival disadvantages. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1708-1716, 2016.

The SECONDI MAPZ(©) system: new approach for the classification of oncological defects of the midface

The appearance and function of the midface are crucial physiologically, psychologically, and aesthetically, and defects in the region can be devastating. Most of these defects are caused by operations for cancer, for which surgical access and rehabilitation can be challenging. Clinical evidence in midfacial ablative surgery is limited because differences between existing classifications do not allow a uniform approach to data recording, which makes comparison difficult. We explore the history of the classification of midfacial and maxillary defects, we analyse the shortcomings of those currently in use, and propose a new system that enables defects to be mapped simply, logically, and accurately.

The SECONDI MAPZ(©) system: a practical guide and proof of concept

The SECONDI MAPZ(©) system is a new, simple, and logical classification of oncological defects of the midface that combines regional anatomy, 3-dimensional visualisation, and the hierarchy of functional priorities. In this paper, we provide clinical and radiographic examples of defects of varying complexity to illustrate the application of the system, to highlight its versatility, and to give practical clinical and radiological guidance on its use. We hope that its introduction will result in better communication of information, and the collection of more uniform data with which to compare outcomes, and ultimately will facilitate evidence-based practice in head and neck oncology.

Clinicopathological and immunohistochemical characteristics of surgically treated primary carcinoma of the nasal vestibule - an evaluation of 30 cases

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma of the nasal vestibule (SCCNV) is a rare tumour entity. Treatment modality, particularly indication of neck dissection, is still a controversial subject of debate. We sought to evaluate the occurrence of lymph node metastases, the prognosis and the immunohistochemical characteristics of SCCNV.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study included 30 consecutive patients with SCCNV treated with primary tumour resection and neck dissection in cases of suspicious lymph nodes between 2003 and 2013. According to therapeutical standard adjuvant radiotherapy or chemotherapy were applied in some cases. Clinicopathological data and immunohistochemical expression of CK5/6, EGFR, Ki-67, MMP-2, MMP-9, p53 and VEGFR were analysed.

RESULTS

The median follow-up period was 47.1 months. Five-year disease-free (5-year DFS) and 5-year overall survival (5-year OS) were 91.7% and 92.3%. Five-year OS in low-grade tumours (G1, G2) was 100.0%, in high-grade tumours (G3) 75.0% (P = 0.028), respectively. We did not detect any lymph node metastases in the neck dissections. Overexpression of p53 showed a trend for better 5-year OS (p53-positive 100% versus p53-negative 77.8%, n.s.). We found a positive correlation between p53 and EGFR (P = 0.0001). There was no significant relationship between the expression rates of the markers and tumour stage and grading.

CONCLUSIONS

We propose no prophylactic neck dissection in small-sized SCCNV. Subtile endoscopic follow-up and periodic ultrasound examination of the cervical lymph nodes after surgical treatment are recommended. Further evaluation of the p53- and EGFR-pathways might pave the way to identify possible molecular targets in an attempt to tailor tumour management.

Squamous cell carcinoma of the nasal cavity: A population-based analysis

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma of the nasal cavity (NCSCC) is an infrequent malignancy that has been historically difficult to characterize. This study provides new insight into NCSCC utilizing a population-based database. We analyze the propensity for cervical and distant metastasis from NCSCC, as well as survival outcomes.

STUDY DESIGN

Retrospective database analysis.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) database (2004-2012) was queried for NCSCC cases. Data were analyzed with respect to various demographic and clinicopathologic factors. The results were further examined for regional and distant metastasis. Survival was analyzed using the Kaplan-Meier model.

RESULTS

A total of 1,180 cases of NCSCC were identified in the SEER database between 2004 and 2012. The mean age at diagnosis was 65.8 years. American Joint Committee on Cancer stage was known in 1,050 cases, of which 53.4% were stage I, 13.3% were stage II, 10.2% were stage III, and 23.0% were stage IV. By tumor (T) stage classification, T1 was the most common (56.6%), followed by T4 (19.3%). Most cases had no nodal (N) involvement at diagnosis (90.8%). Cervical nodal involvement was present in 9.1% of cases, while distant metastasis was seen in 1.9%. Five-year disease-specific survival was 69.5% overall, 39.6% in cases with neck involvement and 0.0% for metastatic cases.

CONCLUSIONS

This study represents the only known population-based investigation of NCSCC. Metastasis to cervical nodes or distant sites, especially with T1 tumors, is rare. However, any cervical involvement or distant metastasis discovered on presentation is a poor prognostic indicator.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:560-565, 2016.

Prognostic value of surgical margins during endoscopic resection of paranasal sinus malignancy

BACKGROUND

Complete tumor resection with intraoperative frozen section control remains a central tenet of head and neck surgical oncology. The purpose of this study was to evaluate the significance of margins in predicting recurrence and disease status following endoscopic resection of sinonasal malignancy.

METHODS

This single-institution observational cohort study was performed on 68 patients over a 5-year period who underwent curative minimally invasive endoscopic resection (MIER) for sinonasal malignancies.

RESULTS

The mean age was 58.8 years and 69.1% were male. The mean follow-up after definitive MIER was 15.9 months. A mean of 10.8 margins were taken per surgery (range, 2 to 27). False-negative frozen section analysis was 22.1% for the entire cohort, but slightly higher at 25.0% for T3 or T4 malignancies. At last follow-up, no evidence of disease (NED) status was noted in 60.0% of those with positive margins vs 83.0% in those with negative margins, respectively (p = 0.0795). Regional or distant recurrences were observed in 39.9% of patients with positive margins and 13.2% of those with negative margins, respectively (p = 0.0299). Disease-free survival (DFS) was 9.7 months for patients with positive margins, whereas it was 15.9 months for patients with negative margins.

CONCLUSION

Disease-free status as a function of residual microscopic disease did not prove to be statistically significant. However, positive margins were correlated with a statistically significant increase in regional or distant recurrence. This suggests that complete resection with clear margins can impact oncologic outcomes in patients managed by MIER for sinonasal cancers.

Elective neck irradiation versus observation in squamous cell carcinoma of the maxillary sinus with N0 neck: A meta-analysis and review of the literature

BACKGROUND

Elective neck irradiation of a clinical node-negative (N0) neck in squamous cell carcinoma (SCC) of the maxillary sinus is a controversial issue.

METHODS

A systematic review of electronic databases and a meta-analysis were conducted to clarify the role of elective neck irradiation in patients with SCC of the maxillary sinus and clinical N0 neck. Regional (neck) nodal recurrence was chosen as the primary endpoint.

RESULTS

Four retrospective studies with a total of 129 patients met the inclusion criteria. The results of the meta-analysis showed that elective neck irradiation reduced the risk of regional nodal recurrence (fixed effects model: odds ratio [OR] = 0.16; 95% confidence interval [CI] = 0.04-0.67; p = .01; random-effects model: OR = 0.17; 95% CI = 0.04-0.76; p = .02) compared to observation.

CONCLUSION

This systemic review and first meta-analysis confirmed that elective neck irradiation can significantly reduce the rate of nodal recurrence in patients with N0 SCC of the maxillary sinus.

Endoscopic transnasal management of sinonasal malignancies - our initial experience

INTRODUCTION

Malignant tumors of the paranasal sinuses are traditionally managed through external approaches. Advances in endoscopic transnasal surgery have allowed for the endoscopic treatment of some of these tumors.

AIM

To present the results of treatment of a series of patients with paranasal sinus malignancies treated with an endoscopic approach at a single institution.

MATERIAL AND METHODS

The data on tumor type, operative technique, perioperative complications and postoperative course were analyzed.

RESULTS

Eleven patients meeting the inclusion criteria were identified. The histopathology was as follows: malignant melanoma in 3 patients, squamous cell carcinoma in 2, adenocarcinoma in 2, poorly differentiated carcinoma in 1, hemangiopericytoma in 1, adenoid cystic carcinoma in 1 and fibrosarcoma in 1. There were no severe perioperative complications with the exception of 1 case of cerebrospinal fluid leak, which was successfully closed. The mean observation period was 13.5 months. One of the patients died of disease, another was lost to follow-up, and one was reoperated on due to recurrence. The remaining 8 patients are alive with no signs of recurrence.

CONCLUSIONS

Our initial experience seems to confirm results obtained by other authors indicating that in selected cases endoscopic surgery of sinonasal malignancies is similarly effective as external approach surgery.

Effect of local extension sites on survival in locally advanced maxillary sinus cancer

BACKGROUND

We analyzed the effects of local extension sites on survival in patients with locally advanced maxillary sinus cancer.

METHODS

The criteria for inclusion in this study were as follows: (1) previously untreated maxillary sinus cancer; (2) squamous cell carcinoma; (3) T4 disease; and (4) curative-intent treatment. The data for 118 patients were obtained from 28 institutions across Japan and analyzed for overall survival and local control rates by local extension site.

RESULTS

Sites with a poor prognosis included the cribriform plate, dura, nasopharynx, middle cranial fossa, and cranial nerves other than V2. There was a significant correlation among these sites, except for the cranial nerves. Additionally, the hard palate was the only site that correlated with nodal involvement and showed a poor treatment outcome.

CONCLUSION

Even in cases presenting with similar T4 maxillary sinus cancer, treatment should be performed in consideration of the local extension site.

Sinonasal squamous cell carcinomas: clinical outcomes and predictive factors

This was a retrospective study of 33 patients treated for sinonasal squamous cell carcinoma between 1995 and 2008. Epidemiological, clinical, histological, and therapeutic aspects of this series of patients were analysed, and their impacts on overall survival and disease-free survival established using the Kaplan-Meier method. A search for prognostic factors was made using a log-rank test. There were 27 men. The average age at diagnosis was 64.7 years. Tobacco-smoking was found to be a risk factor in 24 patients (72.7%). The median follow-up was 66 months (range 0-99 months). Tumours were classified as T1 in 18.3%, T2 in 27.3%, T3 in 6%, and T4 in 48.5% of cases. Disease-free survival rates at 1 and 5 years were 58.5% and 46.1%, respectively, and overall survival rates were 70.3% and 40%, respectively. Overall survival was correlated to tumour status (TNM, American Joint Committee on Cancer) (P = 0.010) and involvement of key structures (skull base, dura mater, brain, orbit, cavernous sinus, infratemporal fossa, skin) (P = 0.049). Surgery followed by radiotherapy improved overall survival (P = 0.005) and disease-free survival (P = 0.028) when compared to other treatment modalities. When compared to surgery alone, it improved disease-free survival (P = 0.049) regardless of tumour stage.

Comorbidity, complications, and survival of sinonasal malignancies in young and elderly treated by surgery

OBJECTIVE

Sinonasal malignancies are uncommon neoplasms with several histological subtypes, most commonly treated with surgery and postoperative radiotherapy. The aim of this study was to evaluate complications and survival, focusing on differences between elderly and younger patients undergoing surgery.

STUDY DESIGN

Historical cohort based on medical records.

SETTING

Tertial referral center.

SUBJECTS AND METHODS

Medical charts of 103 surgically treated patients (71 patients younger than 70 years and 32 patients aged 70 years and older) in a tertiary referral center with sinonasal malignancy were retrospectively analyzed. Comorbidity was scored according to the Adult Comorbidity Evaluation 27 system. Treatment outcomes were analyzed by collecting treatment-related complications scores and survival data.

RESULTS

Although comorbidity was more common in elderly patients, no significant differences were recorded in complications. In multivariate analysis, length of surgery was the only predictor for complication. Furthermore, no significant differences were seen in disease-specific survival and recurrence in young and elderly patients. Young patients with malignant epithelial tumors and melanoma had worse overall survival than patients with other histological subtypes. However, in elderly patients, no significant differences were seen in survival between histological subtypes.

CONCLUSION

For complications, survival, and recurrence, no differences were seen between young and elderly patients. Based on this study, surgery can also be safely performed in elderly sinonasal cancer patients after careful preoperative evaluation and patient selection.

Patterns of local recurrence after primary resection of cancers that arise in the sinonasal region and the maxillary alveolus

Local recurrence remains the most important sign of relapse of disease after treatment of advanced cancer of the maxilla and sinonasal region. In this retrospective study we describe patterns of recurrence in a group of patients who had had open resection for cancer of the sinonasal region and posterior maxillary alveolus with curative intent. Casenotes and imaging studies were reviewed to find out the pattern of any relapse, with particular reference to local recurrence. The minimum follow-up period was 12 months. Of 50 patients a total of 16 developed recurrences, 11 of which were local. Of those 11, a total of 8 were in posterior and superior locations (the orbit, the infratemporal and pterygopalatine fossas, the traversing neurovascular canals of the body of the sphenoid to the cavernous sinus, the Gasserian ganglion, and the dura of the middle cranial fossa). Advanced cancer of the midface often equates with disease at the skull base. Treatment, including surgical tactics, should reflect that.

Classification of maxillectomy defects: a systematic review and criteria necessary for a universal description

STATEMENT OF PROBLEM

Maxillectomy defects are complex and involve a number of anatomic structures. Several maxillectomy defect classifications have been proposed with no universal acceptance among surgeons and prosthodontists. Established criteria for describing the maxillectomy defect are lacking.

PURPOSE

This systematic review aimed to evaluate classification systems in the available literature, to provide a critical appraisal, and to identify the criteria necessary for a universal description of maxillectomy and midfacial defects.

MATERIAL AND METHODS

An electronic search of the English language literature between the periods of 1974 and June 2011 was performed by using PubMed, Scopus, and Cochrane databases with predetermined inclusion criteria. Key terms included in the search were maxillectomy classification, maxillary resection classification, maxillary removal classification, maxillary reconstruction classification, midfacial defect classification, and midfacial reconstruction classification. This was supplemented by a manual search of selected journals. After application of predetermined exclusion criteria, the final list of articles was reviewed in-depth to provide a critical appraisal and identify criteria for a universal description of a maxillectomy defect.

RESULTS

The electronic database search yielded 261 titles. Systematic application of inclusion and exclusion criteria resulted in identification of 14 maxillectomy and midfacial defect classification systems. From these articles, 6 different criteria were identified as necessary for a universal description of a maxillectomy defect. Multiple deficiencies were noted in each classification system. Though most articles described the superior-inferior extent of the defect, only a small number of articles described the anterior-posterior and medial-lateral extent of the defect. Few articles listed dental status and soft palate involvement when describing maxillectomy defects.

CONCLUSIONS

No classification system has accurately described the maxillectomy defect, based on criteria that satisfy both surgical and prosthodontic needs. The 6 criteria identified in this systematic review for a universal description of a maxillectomy defect are: 1) dental status; 2) oroantral/nasal communication status; 3) soft palate and other contiguous structure involvement; 4) superior-inferior extent; 5) anterior-posterior extent; and 6) medial-lateral extent of the defect. A criteria-based description appears more objective and amenable for universal use than a classification-based description.

Oncologic and functional outcome of the preserved eye in malignant sinonasal tumors

BACKGROUND

The purpose of this study was to analyze the oncologic and functional outcomes of the preserved eye in malignant sinonasal tumors with orbital involvement.

METHODS

In a retrospective study of 19 consecutive patients who underwent craniofacial resection or maxillectomy with preservation of orbital contents and adjuvant radiotherapy, the oncological outcome in terms of local recurrence and survival was analyzed. The functional outcome in the preserved eye was analyzed for the cases that did not recur in the orbit.

RESULTS

Nineteen patients were analyzed for their oncologic and functional outcomes. Fifteen patients underwent immediate reconstruction of the orbital support. Eight patients had local recurrences; 11 patients were disease free at the end of the follow-up. Squamous cell carcinoma has a high propensity for local recurrences (ie, 5 of 8 local recurrences were squamous cell carcinoma). Sixteen patients, in whom a satisfactory orbital tumor clearance was obtained, remained recurrence free in the orbit. All the preserved eyes retained adequate function after adjuvant radiotherapy.

CONCLUSIONS

Adequate local control with preserved visual function can be obtained with surgery and adjuvant radiation in appropriately selected malignant sinonasal tumors with orbital involvement. The preserved eye, if reconstructed appropriately, maintains good overall function with acceptable morbidity.

Recurrent adenocarcinoma of the sinonasal tract

BACKGROUND

Adenocarcinomas arising from the nasal cavity and paranasal sinus are malignant tumours that are not of minor salivary gland origin, and they do not demonstrate histopathological features of sinonasal intestinal-type adenocarcinoma. These adenocarcinomas are divided into low- and high-grade subtypes. We herein present a case to highlight the significance of a correct histological diagnosis for treatment and follow-up.

CASE REPORT

We report a case of a recurrent low-grade adenocarcinoma arising in the left nasal cavity and extending to the ethmoid, maxillary sinus and orbital floor. No facial deformity or proptosis was present. The diagnosis was made by analysis of a sample taken by biopsy and CT-MRI. We performed a radical maxillectomy and reconstruction with a temporalis muscle flap and a titanium mesh for the orbital floor.

DISCUSSION

Low-grade adenocarcinomas of the sinonasal tract are a challenge for the pathologist to differentiate from benign adenomas and high-grade adenocarcinomas, but the distinction is important because the treatment and prognosis differ. Treatment success is determined by complete surgical excision. We also suggest the usefulness of PET to detect recurrence during follow-up.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

[A case of maxillary sinus carcinoma of a 24-year-old man, holistic aspects of care]

The aim of this study is to report a carcinoma affecting the maxillary sinus of a 24-years old man. Malignant tumors of the nasal cavity and paranasal sinuses are rare and a very heterogeneous group of tumors. The most common is a squamous cell carcinoma. Sinonasal malignances usually present as a difficult diagnostic and therapeutic problem. The treatment depended on location, extension and histology of the tumor, clinical condition and the patient desire. It consisted of surgery, RT, surgery and postoperatory R, and concurrent QT and RT. The treatment should be assessed individually for each patient. The treatment of patients with paranasal neoplasms requires a multidisciplinary cooperation. High quality care requires the preparation of a team of professionals dedicated to their work. We observe generally human trends to restore well being in difficult situation. Patients transform the information about them or change the values system. Psychooncological help in this field reinforces natural mechanism of restoring well being, increasing positive emotions and patient's own activity.

Management of clinically negative neck in maxillary carcinoma

Maxillary cancers include neoplasms arising in both maxillary sinus and oral cavity (upper alveolar ridge, hard palate) according to the American Joint Committee on Cancer. Although it is universally accepted that the combination of surgery and radiotherapy seems to be the treatment of choice, there is no accordance about the treatment of clinically negative neck. We retrospectively analyzed 20 patients with maxillary sinus cancer and 37 with an upper alveolar ridge or hard palate cancer, evaluating the incidence of N-disease and the recurrence at local site. On the basis of our findings, we can affirm that elective treatment of the neck in maxillary carcinoma is not recommended. Considering only squamous cell carcinoma, cervical node metastases are most frequent in case of tumors staged as T1 o T2. High-grade squamous cell carcinomas seem to be related to a higher incidence of nodal involvement. T recurrence has demonstrated to be the most frequent neoplastic event, so that radical surgery is considered one of the most important prognostic factors. Nevertheless, other prospective studies are necessary.

Carcinoma of the nasal cavity and paranasal sinuses in Denmark 1995-2004

OBJECTIVE

To evaluate the treatment outcome for sino-nasal carcinomas in Denmark from 1995-2004 and compare the results to the previous Danish survey covering 1982-1991.

DESIGN

Retrospective follow-up.

MATERIALS AND METHODS

In the five Danish head and neck oncology centres, charts of all consecutive patients with sino-nasal carcinomas were reviewed and data extracted to a common database. Altogether 242 patients from the period 1995-2004 were identified. Of these 162 (67%) were male and 80 (33%) female. Histologies included squamous cell carcinoma (55%), adenocarcinoma (28.5%), adenoid-cystic carcinoma (5.0%), undifferentiated carcinoma (4.5%), transitiocellular carcinoma (1.7%), mucoepidermoid carcinoma (0.8%), neuroendocrine carcinoma (2.5%), small cell carcinomas (1.2%) and carcinomas not otherwise specified (0.8%). Treatments included radiotherapy alone 79 (33%), surgery alone 29 (12%), combined surgery and radiotherapy 96 (40%), palliative/no treatment 38 (16%). A total of 204 (86%) patients were treated with curative intent.

RESULTS

Of the 204 patients treated with curative intent, 94 (46%) relapsed. Most failures were in T-site (63, 30%). N-site failures were 10 (5%) and M-site failures six (3%). Failure occurring in T+N-site, T+M-site, N+M-site and T+N+M-site were seven (3%), two (1%), one (0.5%) and five (3%) respectively. The 5-year actuarial local, nodal and loco-regional control rates were 55 + or - 4%, 86 + or - 3%, 49 + or - 4%, respectively. The overall 5-year actuarial survival rate for the entire cohort was 47 + or - 3%, and the corresponding cancer-specific 5-year actuarial survival rate was 57 + or - 3%. Female gender, nasal cavity tumour, adenocarcinoma and low clinical stage were significant positive prognostic factors in univariate analysis. A Cox multivariate analysis showed that only tumour site and clinical stage were independent significant prognostic factors.

CONCLUSION

The current series has confirmed stage and tumour site as independent prognostic factors. Compared to the previous Danish survey covering the period 1982-1991, the overall survival and cancer-specific survival rates have improved significantly.

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.

Transmandibular approach for excision of maxillary sinus tumors extending to pterygopalatine and infratemporal fossae

En bloc resection of maxillary sinus tumors that extend through the posterior wall necessitates resection of maxilla along with pterygopalatine and infratemporal fossae contents. This cannot be readily performed by conventional anterior maxillectomy approaches. The objective of this study is to evaluate the effectiveness of transmandibular approach for the excision of maxillary sinus tumors extending to pterygopalatine and infratemporal fossae. This is a retrospective review of 15 consecutive patients who underwent maxillectomy with transmandibular approach for tumors with posterior extension, between January 2004 and February 2008. The principal outcome parameter was the margin status on final histopathology report. In addition, evaluable patients were reviewed to assess the morbidity of the procedure using pre-defined parameters. All the patients had negative margins at the infratemporal fossa region. Varying degree of trismus was present in all patients. The cosmetic outcome of the procedure was excellent. Other anterior and transcranial approaches could be combined with this procedure when indicated. We conclude that transmandibular approach is an effective technique for resection of maxillary tumors with posterior extension to the pterygopalatine and infratemporal fossae. The procedure has acceptable morbidity and the aesthetic and functional results are satisfactory.