Sinonasal malignancies of neuroendocrine origin

Combined 177Lu-DOTATATE Peptide Receptor Radionuclide Therapy and Platinum-Based Chemotherapy in Recurrent, Metastatic Sinonasal Neuroendocrine Carcinoma: A Promising Therapeutic Option

Sinonasal neuroendocrine carcinomas (SNCs), in contrast to neuroendocrine carcinomas at other sites, are notorious for their recurrent and locally aggressive nature. The clinical concern is primarily due to their complex anatomy and close proximity to vital structures, compounded by lack of proper understanding of pathogenesis, no definitive classification or staging system, and no established treatment guidelines. We present the promise of combined treatment with ¹⁷⁷Lu-DOTATATE-based peptide receptor radionuclide therapy (PRRT) and platinum-based chemotherapy in a patient with high-grade, recurrent, and metastatic SNC (that demonstrated high uptake on both ⁶⁸Ga-DOTATATE and ¹⁸F-FDG PET/CT), which showed a significant partial response. The case report highlights the feasibility and effectiveness of applying a combined protocol of ¹⁷⁷Lu-DOTATATE and platinum-based chemotherapy in the management of high-grade, recurrent, metastatic SNC.

Sinonasal Undifferentiated Carcinoma

PURPOSE OF REVIEW

To provide a comprehensive review of the literature highlighting the recent advances in the diagnosis and management of sinonasal undifferentiated carcinoma (SNUC) RECENT FINDINGS: SNUC usually presents at advanced stage and the prognosis is usually poor with high rates of locoregional recurrence and tendency to metastasize. Special attention should be made in differentiating SNUC from other sinonasal malignancies in order to guide the appropriate treatment accordingly. Multimodality treatment is usually recommended for treating SNUC. The use of neoadjuvant chemotherapy may be associated with improved outcome and can be used to guide the subsequent treatment selection. Despite the recent advances in chemotherapeutic agents, radiation techniques, and surgical approaches, the prognosis and survival outcomes of SNUC remain poor. The addition of induction chemotherapy to the treatment approach followed by definitive local therapy needs to be further studied as it might improve the outcome.

Sinonasal Carcinomas with Neuroendocrine Features: Histopathological Differentiation and Treatment Outcomes

Objectives Sinonasal cancers with neuroendocrine features share similar clinical, radiological, and histopathological features; however, these tumors often exhibit varying degrees of aggressive behavior presenting significant treatment challenges. The objective of this study was to report our experience with these rare malignancies and to present a review of current literature. Methods Following institutional review board approval, the records of all patients with biopsy-proven sinonasal malignancies over a 5-year period were reviewed. Results The study included 14 patients with olfactory neuroblastomas (ONBs), 7 patients with sinonasal undifferentiated carcinomas (SNUC), and 2 patients with sinonasal neuroendocrine carcinomas (SNEC). Histopathologic markers aided in final diagnosis, but showed variable specificity. In patients with sufficient follow-up, the 2-year disease-free survival rate was 81% (9/11) for ONB and 75% (3/4) for SNUC. Three patients developed a regional or distant recurrence (two with ONBs and one with SNUC). Two patients, one with SNEC and one with ONB, succumbed to brain radionecrosis related to proton radiation therapy. Conclusions Overlapping clinical and histopathological features in poorly differentiated sinonasal cancers with neuroendocrine features continue to present a diagnostic challenge. Individualized assessment and treatment strategies can improve the accuracy of the initial assessment and the treatment outcomes.

Survival Outcomes for Combined Modality Therapy for Sinonasal Undifferentiated Carcinoma

Objective Sinonasal undifferentiated carcinoma is a rare and aggressive malignancy of the nasal cavity and paranasal sinuses. Multi-institutional studies examining outcomes of combined modality treatment versus other treatment modalities have not been performed. The objective of our study was to present outcomes for multimodality therapy through use of the National Cancer Database. Study Design Retrospective cohort study. Setting National Cancer Database. Methods A total of 435 cases of SNUC diagnosed between 2004 and 2012 were identified. Kaplan-Meier analyses were performed to find 5-year cumulative survival rates. Multivariate Cox regression evaluated overall survival based on treatment when adjusting for other prognostic factors (age, primary site, sex, race, comorbidity, insurance, and TNM stage). Within the surgery + chemoradiotherapy group, survival analysis was also performed to compare outcomes for induction and adjuvant chemotherapy. Results The cumulative 5-year survival rate was 41.5%, and 36.1% of patients received surgery with chemoradiotherapy. In multivariate analysis, surgery + chemoradiotherapy was associated with significantly improved overall survival versus surgery + radiotherapy and radiotherapy but not significantly different from chemoradiotherapy. Within the surgery + chemoradiotherapy group, induction and adjuvant chemotherapy groups did not have associated differences in survival. Conclusion Combined modality therapy (chemoradiotherapy or surgery + chemoradiotherapy) is associated with improved survival outcomes versus other treatment modalities in patients with sinonasal undifferentiated carcinoma.

Evidence-based practice: endoscopic skull base resection for malignancy

Successful outcomes of endoscopic approaches to benign sinonasal tumors have launched interest in expanding its use for sinonasal malignancy. Because of the heterogeneity and rarity of sinonasal malignancy, evidence for clinical outcomes of endoscopic approaches versus traditional craniofacial resection is low. Using the Oxford Center for Evidence-based Medicine guidelines, we present the existing evidence comparing both techniques for a variety of sinonasal malignancies.

[Esthesioneuroblastoma]

Esthesioneuroblastoma is an uncommon malignancy originating from olfactive epithelium. Men are more frequently affected than women. Nasal symptoms are the most common revealing signs. Immunohistochemistry helps diagnosis. There is no randomized trial evaluating treatment due to the low incidence of this tumor. Radiotherapy and surgery are the standard of care. Radiotherapy is benefic even in early stage disease. Chemotherapy is indicated in case of locally advanced or metastatic disease.

Low- and high-grade esthesioneuroblastomas display a distinct natural history and outcome

PURPOSE

Esthesioneuroblastomas, also called olfactory neuroblastomas (ENB) represent a rare sinonasal neurectodermal tumour which prognostic factors are unsteadily described.

PATIENTS AND METHODS

Clinical and pathological characteristics were analysed in patients treated at Gustave Roussy Institute between 1979 and 2009.

RESULTS

Out of 63 patients, 19 patients were reclassified and 44 patients were eligible for the analysis. Multivariate analysis revealed that T staging of the modified Dulguerov TNM staging and Hyams grade>III (that we termed high-grade ENB) were the only independent prognostic factors for overall survival (OS). As compared to patients with low-grade ENB (Hyams grade ≤ III), patients with high-grade ENB have higher T4 staging (p=0.02), have frequent lymph node involvement (p=0.009) and are more often unresectable (p=0.005). Resected patients with high-grade ENB frequently displayed mainly leptomeningeal metastasis (n=4/6) in contrast to patients with low-grade ENB who typically experience late loco-regional recurrence (n=10/25). With a median follow-up of 9.6 years, median DFS and OS for resected low-grade ENB were 5.4 and 20.5 years, respectively. Conversely, median DFS and OS for high-grade ENB were 1.5 and 2.5 years, respectively.

CONCLUSION

Low and high-grade ENB display distinct patterns at presentation and relapse, leading to different prognosis. Therefore, they may be regarded as distinct entities.

Imaging of sinonasal tumours

More than 70 benign and malignant sinonasal tumours and tumour-like conditions have been described. However, sinonasal tumours are rare, and sinonasal cancers comprise only 3% of all head and neck cancers and 1% of all malignancies, with a peak incidence in the 5th to 7th decades and with a male preponderance. The early symptoms and imaging findings of sinonasal tumours are similar to rhinosinusitis with runny and stuffy nose, lacrimation and epistaxis and therefore neglected both by the patients and doctors. When late symptoms such as anosmia, visual disturbances, cranial neuropathy (Cn II, IV, V, VI) or facial swelling appear, the patient is referred to sinonasal endoscopy or imaging. At the time of correct diagnosis more than half of the tumours have reached an advanced stage with a poor prognostic outcome. Even if imaging is performed in the early stages, a radiologist inexperienced with sinonasal anatomy and tumour features may easily interpret early signs of a malignant tumour as rhinosinusitis or a lesion that does not require follow-up. This article presents the imaging findings in some of the most common benign and malignant sinonasal tumours, and the TNM classification and staging of sinonasal carcinomas.

Meta-analysis of treatment outcomes for sinonasal undifferentiated carcinoma

OBJECTIVES

This study reviews the published outcomes regarding sinonasal undifferentiated carcinoma (SNUC) since the initial description in 1986. This article attempts to (1) understand and better describe the benefit and survival advantages associated with using radiation, chemotherapy, and surgical treatment and (2) support the recommendations of a treatment regimen with current available data in the literature.

DATA SOURCES

Published English-language literature.

REVIEW METHODS

A PubMed search for articles related to SNUC, along with the bibliographies of those articles to avoid missing articles. All articles were examined for an independent patient data meta-analysis. Thirty studies with 167 cases from 1986 to October 2009 were identified. Demographics, disease extent, treatment, follow-up, and survival were analyzed. Patient cohorts mirroring Kadish staging were created. Kaplan-Meier curves were constructed.

RESULTS

Follow-up range was 1 to 195 months (mean 23.4 months, median 15 months). At last follow-up, 26.3% of patients were alive with no evidence of disease, 21.0% were alive with disease, and 52.7% were dead of disease. The use of surgery was found to be the best single modality, but chemotherapy and radiation were important as adjuncts in extensive and aggressive disease. The presence of neck metastases was a poor prognostic sign.

CONCLUSION

This study, containing the largest pool of SNUC patients, confirms a poor overall prognosis. The data suggest that the optimal treatment should include surgery, with radiation and/or chemotherapy as adjunct treatments. Neck disease in advanced local disease is a poor prognostic sign and merits aggressive treatment with multimodality therapy.

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.

Sinonasal neuroendocrine carcinoma: impact of differentiation status on response and outcome

Background

The impact of tumor differentiation on the behavior and response of sinonasal neuroendocrine carcinoma is unknown.

Methods

We performed a retrospective review of the patients treated for neuroendocrine carcinoma (NEC) of the nasal cavity or paranasal sinuses from 1992 to 2008 at MDACC.

Results

The results of our study suggest that pathologic differentiation may not be a critical factor in the clinical management of patients with NEC of the sinonasal tract. This is in contrast to laryngeal and lung NEC for which pathological differentiation has traditionally guided clinical management.

Conclusion

Mutlimodality approach should be the cornerstone of treating sinonasal NEC regardless of their differentiation. Specifically, RT may provide durable local control for patients with moderately differentiated NEC if resection is not feasible or desirable, while surgical resection can benefit patients with chemo-resistant or radio-resistant disease.