Long-term radiotherapy outcomes for nasal cavity and septal cancers

Molecular targeted therapies for cutaneous squamous cell carcinoma: recent developments and clinical implications

Cutaneous Squamous Cell Carcinoma (cSCC) is a common and potentially fatal type of skin cancer that poses a significant threat to public health and has a high prevalence rate. Exposure to ultraviolet radiation on the skin surface increases the risk of cSCC, especially in those with genetic syndromes like xerodermapigmentosum and epidermolysis bullosa. Therefore, understanding the molecular pathogenesis of cSCC is critical for developing personalized treatment approaches that are effective in cSCC. This article provides a comprehensive overview of current knowledge of cSCC pathogenesis, emphasizing dysregulated signaling pathways and the significance of molecular profiling. Several limitations and challenges associated with conventional therapies, however, are identified, stressing the need for novel therapeutic strategies. The article further discusses molecular targets and therapeutic approaches, i.e., epidermal growth factor receptor inhibitors, hedgehog pathway inhibitors, and PI3K/AKT/mTOR pathway inhibitors, as well as emerging molecular targets and therapeutic agents. The manuscript explores resistance mechanisms to molecularly targeted therapies and proposes methods to overcome them, including combination strategies, rational design, and optimization. The clinical implications and patient outcomes of molecular-targeted treatments are assessed, including response rates and survival outcomes. The management of adverse events and toxicities in molecular-targeted therapies is crucial and requires careful monitoring and control. The paper further discusses future directions for therapeutic advancement and research in this area, as well as the difficulties and constraints associated with conventional therapies.

Nasal Cavity Squamous Cell Carcinoma: Factors Associated With Treatment Outcomes and Potential Organ Preservation

Background

Squamous cell carcinoma of the nasal cavity (NCSCC) is a rare, challenging malignancy. Surgical resection of this tumor can cause significant facial deformity, and indications for adjuvant or organ preservation therapies are not well-described.

Objective

To examine the impact of treatment regimen on survival outcomes in NCSCC and to compare surgical to non-surgical based therapies.

Methods

The National Cancer Database was queried for NCSCC from 2004 to 2014. Patient demographics, tumor characteristics, and treatment regimen were compared for the entire cohort. Multivariable Cox proportional hazards regression was performed for statistical analysis of treatment regimen and surgical margins on overall survival (OS) for early and late-stage disease.

Results

A total of 1883 NCSCC patients were identified. The OS for the cohort was 83 months, and median age at diagnosis was 65 years. NCSCC patients who underwent surgery followed by adjuvant radiation therapy (RT) had a better OS compared to definitive RT (HR: 0.58, P < .001). In early stage NCSCC (T1/T2, N0), there was no significant difference in OS between patients treated with surgery only or surgery with adjuvant RT compared to definitive RT. In advanced stage NCSCC, surgery with adjuvant RT had a better OS compared to definitive chemoradiation. Having positive margins was shown to predict a worse OS when compared to negative margins in surgical patients despite adjuvant RT or chemoradiation.

Conclusions

NCSCC appears to be best treated with surgery followed by adjuvant RT in advanced-stage disease whereas in early-stage disease, surgery does not improve OS compared to definitive RT.

Is prophylactic neck irradiation indicated for patients with cN0 Adenoid cystic carcinoma of the paranasal sinuses?

PURPOSE

To study the prevalence of nodal metastases in sinonasal adenoid cystic carcinoma (SNACC) and to evaluate whether prophylactic neck irradiation (PNI) should be performed in patients with clinical N0 (cN0) disease.

PATIENTS AND METHODS

Between April 1992 and November 2020, 166 patients with SNACC who had undergone radiotherapy at our department were retrospectively analyzed. The median follow-up time was 71.3 months.

RESULTS

Among 166 cases of SNACC, a total of 13 (7.8%) had retropharyngeal or cervical nodal metastasis and 93% (12/13) cases occurred in patients with advanced T stage (T3-T4). Levels VIIa, Ib, and IIa were the most common sites of initial nodal involvement. Only 1.2% (2/166) of patients presented late neck recurrence. Lymph node metastasis independently predicted a poor progression-free survival (PFS) (P = 0.017) but had no impact on overall survival (OS) (P = 0.38). PNI was performed on 36% (55/153) of cN0 patients. The OS (P = 0.42), PFS (P = 0.59), nodal recurrence-free survival (NRFS) (P = 0.46) and distant metastasis-free survival (DMFS) (P = 0.63) rates showed no significant difference between cases with and without PNI. Furthermore, cN0 patients with T4b (P = 0.53; P = 0.61), tumor origin from maxillary sinus (P = 0.55; P = 0.53) or nasopharynx involvement (P = 0.56; P = 0.60) showed no extended OS or PFS associated with PNI.

CONCLUSIONS

Regardless of the T stage or the site of origin, prophylactic neck irradiation (PNI) for cN0 patients did not provide any benefit on OS and PFS, suggesting that its application on such patients is not warranted unless there is clinical suspicion.

Clinical assessment of anatomic origin effect on the clinical outcomes in primary squamous cell carcinomas affecting nasoethmoidal complex

Background:

Sinonasal squamous cell carcinomas (SCCs) present a great challenge in their diagnosis and management owing to their rapid growth, regional recurrence, local recurrence, and aggressive spread locally.

Aims:

The present clinical trial was conducted to evaluate anatomic subsites' impact on the outcomes concerning SCCs affecting ethmoid sinuses and nasal cavity.

Materials and Methods:

Medical records for tumor staging, tumor classification, grading (histologic) clinical features, symptoms, anatomic subsite, p16 results, treatment provided, and the Tumor-related outcomes were obtained for 28 subjects. Following staging and grading, p16 assays were evaluated along with disease-specific survival and disease-free survival. The collected data were subjected to the statistical evaluation and the results were formulated by keeping the level of significance at P < 0.05.

Results:

Origin was seen from nasal septum, nasal floor, lateral wall, ethmoid sinus, and edge of naris to mucocutaneous junction in 21.4% (n = 6), 7.14% (n = 2), 35.71% (n = 10), 7.14% (n = 2), and 28.57% (n = 8) subjects, respectively. For tumor staging, Stages I, II, III, and IV tumors were seen in, respectively, 39.28% (n = 11), 21.42% (n = 6), 10.71% (n = 3), and 28.57% (n = 8) study subjects. Node status was N0, N1, N2, and N3 in 78.57% (n = 22), 3.57% (n = 1), 7.14% (n = 2), and 10.71% (n = 3) subjects. Carcinoma arising from nasal septum had statistically significant worse disease-specific survival compared to carcinomas arising from other sites (P < 0.001).

Conclusion:

The present study concludes that anatomic subsites largely govern the outcomes and tumor behavior. Also, squamous cell carcinoma affecting the nasal septum is an aggressive tumor with more compromised outcomes and more lymph node involvement.

Spot Scanning Proton Therapy for Sinonasal Malignant Tumors

Purpose

Treatment of sinonasal malignant tumors is challenging, and evidence to establish a standard treatment is limited. Our objective was to evaluate the efficacy and safety of spot scanning proton therapy (SSPT) for sinonasal malignant tumors.

Patients and Methods

We retrospectively analyzed patients with sinonasal malignant tumors (T1-4bN0-2M0) who underwent SSPT between May 2014 and September 2019. The prescription dose was typically either 60 GyRBE in 15 fractions or 60.8 GyRBE in 16 fractions for mucosal melanoma and 70.2 GyRBE in 26 fractions for other histologic subtypes. Endpoints included local control (LC), progression-free survival, overall survival (OS), and incidence of toxicity. Prognostic factors were analyzed using the Kaplan-Meier method and log-rank test.

Results

Of 62 enrolled patients, the common histologic subtypes were mucosal melanoma (35%), squamous cell carcinoma (27%), adenoid cystic carcinoma (16%), and olfactory neuroblastoma (10%). Locally advanced stages were common (T3 in 42% and T4 in 53%). Treatment-naïve tumors and postsurgical recurrent tumors accounted for 73% and 27%, respectively. No patient had previous radiotherapy. The median follow-up was 17 months (range, 6-66) for all patients and 21.5 months (range, 6-66) for survivors. The 2-year LC, progression-free survival, and OS rates of all patients were 92%, 50%, and 76%, respectively. Univariate analysis revealed histology as a prognostic factor for OS, being higher in adenoid cystic carcinoma and olfactory neuroblastoma than in other tumors. Sixteen grade ≥3 late toxicities were observed in 12 patients (19%), including 11 events resulting in visual impairment; the most common was cataract. There was 1 grade 4 toxicity, and there were no grade 5 toxicities.

Conclusion

SSPT was well tolerated and yielded good LC for sinonasal malignant tumors. Although we consider SSPT to be a leading treatment modality, further studies are required to establish its status as a standard treatment.

Brachytherapy of the head and neck: An University of California Los Angeles guide to morbidity reduction

The head and neck (H&N) region is among the most intricate and functional part of our anatomy. Major functional nerves and blood vessels with importance that affect the entire body emanate from the base of skull. Brachytherapy plays an important role as a single modality therapy in early cancer of the lip and oral cavity and a supplemental role in the pharynx or in advanced or recurrent disease. Morbidity in the H&N is intensely personal and disabling. Its avoidance is critical in determining the success or failure of a treatment program, and it is essential to preservation of quality of life. This article summarizes the current literature regarding morbidity related to H&N brachytherapy to aid patients and physicians to achieve optimal outcomes.

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.

Intraparotid lymph node metastasis from a nasal septal carcinoma: an unusual source of the unknown primary

Metastatic disease to the parotid lymph nodes typically occurs secondary to head and neck and cutaneous squamous cell carcinomas (SCC). Nasal septal SCC is an exceedingly rare primary cancer that rarely spreads to regional lymph nodes. A 39-year-old man presented with left-sided cervical lymphadenopathy and nasal polyposis. Initial assessment suggested that he may have a head and neck SCC of unknown origin with nodal deposits in close proximity to the parotid gland. Cross-sectional imaging did not reveal the primary source. After further review of imaging and examination under anaesthetic, the primary SCC was found on the left nasal septum. The patient ultimately required a type 1 craniofacial resection and adjuvant chemoradiotherapy to treat the disease. Thorough investigation of the 'unknown primary' SCC including cross-sectional imaging and endoscopic examination is essential for the diagnosis of rare and unusual primary SCCs. Nasal septal SCC can be successfully managed with combined modality treatment in the form of surgical resection and chemoradiotherapy.

Outcomes and toxicities of definitive radiotherapy and reirradiation using 3-dimensional conformal or intensity-modulated (pencil beam) proton therapy for patients with nasal cavity and paranasal sinus malignancies

BACKGROUND

Proton therapy (PT) improves outcomes in patients with nasal cavity (NC) and paranasal sinus (PNS) cancers. Herein, the authors have reported to their knowledge the largest series to date using intensity-modulated proton therapy (IMPT) in the treatment of these patients.

METHODS

Between 2013 and 2018, a total of 86 consecutive patients (68 of whom were radiation-naive and 18 of whom were reirradiated) received PT to median doses of 70 grays and 67 grays relative biological effectiveness, respectively. Approximately 53% received IMPT.

RESULTS

The median follow-up was 23.4 months (range, 1.7-69.3 months) for all patients and 28.1 months (range, 2.3-69.3 months) for surviving patients. The 2-year local control (LC), distant control, disease-free survival, and overall survival rates were 83%, 84%, 74%, and 81%, respectively, for radiation-naive patients and 77%, 80%, 54%, and 66%, respectively for reirradiated patients. Among radiation-naive patients, when compared with 3-dimensional conformal proton technique, IMPT significantly improved LC (91% vs 72%; P < .01) and independently predicted LC (hazard ratio, 0.14; P = .01). Sixteen radiation-naive patients (24%) experienced acute grade 3 toxicities; 4 (6%) experienced late grade 3 toxicities (osteoradionecrosis, vision loss, soft-tissue necrosis, and soft tissue fibrosis) (grading was performed according to the National Cancer Institute Common Terminology Criteria for Adverse Events [version 5.0]). Slightly inferior LC was noted for patients undergoing reirradiation with higher complications: 11% experienced late grade 3 toxicities (facial pain and brain necrosis). Patients treated with reirradiation had more grade 1 to 2 radionecrosis than radiation-naive patients (brain: 33% vs 7% and osteoradionecrosis: 17% vs 3%).

CONCLUSIONS

PT achieved remarkable LC for patients with nasal cavity and paranasal sinus cancers with lower grade 3 toxicities relative to historical reports. IMPT has the potential to improve the therapeutic ratio in these malignancies and is worthy of further investigation.

The value of preoperative radiotherapy in the treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinoma: A single institutional experience

OBJECTIVES

This study aimed to explore the value of preoperative radiotherapy in the comprehensive treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinomas (LA-NPSCCs).

MATERIALS

This retrospective study included 140 patients with stage III-IVB NPSCCs treated with pre-/postoperative radiotherapy plus surgery. The complete resection rate, pathologic complete response (pCR) rate, and orbital content retention rate were calculated. The overall survival (OS), local control (LC), distance metastasis free survival (DMFS) and disease-free survival (DFS) between treatment groups were evaluated.

RESULTS

With a median follow-up of 92.3 months, the 5-year OS, LC, DMFS, and DFS of entire cohort were 62.0%, 65.5%, 85.4%, and 57.8%, respectively. The preoperative radiotherapy group achieved similar LC, DFS, DMFS, and OS rates compared to postoperative radiotherapy group, despite higher rates of stage IV and orbital content/apex invasion. The preoperative radiotherapy resulted in significantly improved complete resection rate (93.3% vs 38.0%, p < 0.001). In the preoperative radiotherapy group, one third of patients achieved pathologic complete response. The pCR subgroup achieved statistically higher 5-year OS, LC, DFS (p < 0.05), but similar 5-year DMFS (p > 0.05) compared to non-pCR subgroup. The actual orbital content retention rate in preoperative radiotherapy group was 85.7%, superior to 58.3% in postoperative radiotherapy group (p = 0.049).

CONCLUSION

On the basis of multimodality therapy becoming standard paradigm for LA-NPSCCs, preoperative radiotherapy significantly improved complete resection rate and orbital content retention rate. Therefore, preoperative radiotherapy followed by surgery might be desirable for LA-NPSCCs, especially for those with organ preservation intention.

Adenocarcinoma of the Sinonasal Tract: A Review of the National Cancer Database

Background  Sinonasal adenocarcinoma (SNAC) is a rare malignancy arising from mucus-secreting glandular tissue. Limited large-scale studies are available due to its rarity. We evaluated SNAC in the National Cancer Database (NCDB), a source that affords multi-institutional, population studies of rare cancers and their outcomes. Methods  The NCDB was queried for adenocarcinoma in the sinonasal tract. Multivariate analyses were performed to evaluate for factors contributing to overall survival (OS). Results  A total of 553 patients were identified. The cohort was composed of 59.3% males. The nasal cavity was the most common primary site, representing 44.1% of cases. About 5.7% of patients presented with nodal disease, while 3.3% had distant metastases. About 40.6% of cases presented with stage IV disease. About 73.5% of patients underwent surgery, 54.2% received radiation therapy, and 27.7% had chemotherapy. Median OS was 71.7 months, while OS at 1, 2, and 5 years was 82, 73.0, and 52%, respectively. On multivariate analysis, advanced age (hazard ratio [HR]: 1.04; 95% confidence interval [CI]: 1.02-1.05), Charlson-Deyo score of 1 (HR: 1.99; 95% CI: 1.20-3.30), advanced tumor grade (HR: 2.73; 95% CI: 1.39-5.34), and advanced tumor stage (HR: 2.71; 95% CI: 1.33-5.50) were associated with worse OS, whereas surgery (HR: 0.34; 95% CI: 0.20-0.60) and radiation therapy (HR: 0.55; 95% CI: 0.33-0.91), but not chemotherapy (HR: 1.16; 95% CI: 0.66-2.05), predicted improved OS. Conclusions  SNAC is a rare malignancy with 5-year survival approximating 50%. Surgery and radiation therapy, but not chemotherapy, are associated with improved survival, and likely play a critical role in the interdisciplinary management of SNAC.

Microscopic tumor invasion of contralateral mucosa in cancer involving unilateral septum

BACKGROUND

Preservation of contralateral mucosa with microscopic tumor invasion in unilateral septal involvement increases the recurrence risk. The purpose of this study was to analyze the risk of invasion of contralateral mucosa in unilateral septal involvement of cancer and to risk stratify patients.

METHODS

Retrospective chart review of patients with histologically proven malignancy with unilateral septal involvement and absence of gross septal tumor involvement on the contralateral side were included.

RESULTS

Among 40 patients, majority (55%) belonged to sixth and seventh decade. The most common type was squamous cell carcinoma (63%). Approximately one-fourth (23%) showed microscopic contralateral invasion. Females (OR 12; 95% CI 2.01-71.35) and patients with septal bone invasion (OR 28.5; CI 3.35-242.0) had a higher risk of developing contralateral mucosal invasion.

CONCLUSION

Complete resection of contralateral mucosa is preferred in areas along the bony septum. When complete resection is not performed, intraoperative frozen section is strongly recommended.

Organ preservation for patients with anterior mucosal squamous cell carcinoma of the nasal cavity: Rhinectomy-free survival in those refusing surgery

BACKGROUND

Standard treatment of squamous cell carcinoma (SCC) of the anterior nasal mucosa is surgical resection with or without postoperative radiation.

METHODS

Retrospective review of patients diagnosed with SCC of the nasal cavity between January 2000 and July 2018 who refused total rhinectomy and who were treated with radiation with or without chemotherapy with curative intent.

RESULTS

Eleven patients were identified, 73% had stage III or stage IV disease. Four patients were treated with intensity-modulated radiotherapy and seven with intensity-modulated proton radiotherapy. Concurrent chemoradiotherapy was used in nine patients (82%). With a median follow-up of 15 months (3-124 months), two patients experienced recurrence and one developed distant metastasis and died from disease. The 2-year rhinectomy-free survival rate was 88%. Two-year overall survival and recurrence-free survival were 100% and 75%, respectively.

CONCLUSION

A radiation-based approach for SCC of the nasal cavity mucosa is a valid option for selected patients who refuse up-front surgery.

Impact of anatomic origin of primary squamous cell carcinomas of the nasal cavity and ethmoidal sinus on clinical outcome

PURPOSE

Since squamous cell carcinomas (SCCs) of the nasoethmoidal complex are rare and aggressive malignancies, the purpose of this study was to evaluate whether anatomic subsites of SCCs of the nasal cavity and ethmoid sinuses affect clinical outcome.

METHODS

We retrospectively analyzed data from 47 patients with primary SCCs of the nasal cavity and ethmoid sinuses who were treated at the Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Vienna, between 1993 and 2018. The impact of anatomic subsites of nasoethmoidal SCCs was evaluated with respect to tumor and nodal classification, disease-free survival (DFS) and disease-specific survival (DSS).

RESULTS

Of the 47 cases, 17 SCCs (36.2%) originated from lateral nasal wall followed by 13 (27.7%) tumors of the edge of naris to mucocutaneous junction, 11 (23.4%) SCCs of the nasal septum, 3 tumors of the nasal floor (6.4%) and 3 SCCs of the ethmoid sinuses (6.4%), respectively. SCCs of the nasal septum were associated with significantly higher rates of neck node metastasis (p = 0.007), which represented a significantly worse prognostic factor for DSS (HR 7.87; p < 0.001). Moreover, advanced tumor stage (HR 5.38; p = 0.014) and tumor origin of nasal septum (HR 4.05; p = 0.025) were also significantly worse prognostic factors for DSS. Fourteen patients (29.8%) developed recurrent disease, including eight local (17.0%), five regional (10.6%) and one distant (2.1%) recurrence. Elective neck dissection (ND) was associated with lower (0 vs. 20.0%) but not significantly different regional and distant DFS (p = 0.075).

CONCLUSION

Anatomic origin of nasal SCC has significant impact on clinical outcome. SCCs of the nasal septum were associated with higher rates of positive neck nodes and worse outcome.

Combination Intensity Modulated Proton Therapy and Passive Scatter Boost for Rapidly Progressing Nasal Cavity Squamous Cell Carcinoma

Cancers of the nasal cavity and septum are associated with poor prognosis and are usually treated with surgery followed by post-operative radiotherapy with or without concurrent chemotherapy. Definitive radiotherapy is used in cases where the tumor is unresectable, patient is unfit for surgery, and/or the patient declines surgical intervention. Here, we present a case of a patient, who for non-medical reasons, opted to have non-surgical management of his rapidly progressing nasal cavity tumor. He was successfully treated with concurrent chemoradiotherapy utilizing a combination of intensity modulated proton therapy (IMPT) with passive scatter boost to reduce dose to the adjacent critical neural structures. Post-treatment clinical examination and imaging demonstrated complete clinical and metabolic response at the primary site and neck. This case highlights the use of IMPT and passive scatter boost in combination to achieve delivery of therapeutic dose to nasal cavity tumor and neck whilst limiting dose to numerous adjacent organs-at-risk.

Clinical outcomes after interstitial brachytherapy for early-stage nasal squamous cell carcinoma

PURPOSE

Radiotherapy of nasal carcinomas results in cure rates comparable to surgery, with anatomic preservation and good cosmesis. Brachytherapy (BT) overcomes difficulties with dosimetric coverage and affords a localized and highly conformal irradiation. We report our experience of BT for early-stage nasal squamous cell carcinomas (SCCs).

METHODS AND MATERIALS

Clinical data, BT parameters, and outcome of consecutive patients treated by interstitial BT in our institute between December 1982 and April 2015 for a localized nasal SCC were examined. A total of 34 patients with newly diagnosed T1-2N0-1 nasal skin (n = 22) or nasal cavity (n = 12) SCC were identified. Implantation and dosimetry were done according to the Paris system rules. Low-dose-rate (n = 30) or pulsed-dose-rate (n = 4) techniques were used. Median dose was 70 Gy (64-75 Gy). Sites of tumor recurrence, toxicity rates, and cosmesis outcome were examined.

RESULTS

Median followup time was 89 months. All patients achieved complete response. Five patients experienced local failure, with a median interval of 9 months (range, 5-12 months). Grade 3 acute reactions were reported in 2 patients (6%). Most delayed complications were mild to moderate, and good or fair cosmesis was achieved in 97%. Estimated local failure-free survival and disease-free survival rates at 5 year were 85% (95% CI = 68-94%) and 76% (95% CI = 58-88%), respectively.

CONCLUSIONS

Interstitial BT is effective for selected nasal SCCs, with durable local control, acceptable toxicity, and good cosmesis.

Mucosal Thickening Occurs in Contralateral Paranasal Sinuses following Sinonasal Malignancy Treatment

Objective  To investigate the incidence and degree of contralateral sinus disease following treatment of sinonasal malignancy (SNM) using radiological findings as an outcome measure. Study Design  Retrospective case series. Setting  Tertiary referral academic center. Participants  Patients with SNM treated with surgical and adjuvant radiotherapy with or without concurrent chemotherapy. Main Outcome Measures  Pre- and posttreatment computed tomography and magnetic resonance imaging scans, Lund-Mackay (LM) score, date of diagnosis, chemotherapy, and dosage of radiation therapy (RT). Results  There was a significant difference between pre- and posttreatment LM scores ( p  < 0.001) of the contralateral paranasal sinuses. There was no statistical significance between the change in pre- and posttreatment LM scores and patient age, gender, chemotherapy, RT dosage, and time lapse between diagnosis and when we performed this study in the univariate and the multivariable analyses. Conclusions  Following treatment of SNM with surgical resection and RT, there was a significant increase in incidence and degree of mucosal thickening of the contralateral sinus by LM grading that persisted after the completion of treatment. This indicates the need for long-term follow-up to monitor for chronic rhinosinusitis as a delayed complication following treatment of SNM.

The Role of Radiation Therapy in the Management of Sinonasal and Ventral Skull Base Malignancies

Sinonasal and ventral skull base malignancies are rare tumors that arise in a complex anatomic location juxtaposed with critically important normal tissues. The standard treatment paradigm for most histologies has been surgery followed by postoperative radiation therapy. Because of their propensity to present at an advanced stage and the presence of nearby critical structures, patients are at risk for severe radiation-induced long-term toxicity. Recent advances in radiotherapy technique have improved the therapeutic ratio between tumor control and normal tissue toxicity. This article reviews issues pertinent to the use of radiotherapy in the management of these tumors.

ACR appropriateness criteria® nasal cavity and paranasal sinus cancers

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.

Outcomes of nonsurgical management of locally advanced carcinomas of the sinonasal cavity

OBJECTIVE

To determine the outcome of definitive concurrent chemoradiation with platinum for locally advanced sinonasal carcinomas.

STUDY DESIGN

Retrospective cohort.

METHODS

Twenty-three nonsurgically and definitively treated patients diagnosed between July 1998 and February 2009 were analyzed. Patients with adenoid cystic carcinoma or adenocarcinoma were treated with photons and neutrons; the other histologies received photons alone. The vast majority received chemotherapy. Descriptive statistics were utilized, and Kaplan-Meier estimates were computed.

RESULTS

Female (57%) and Caucasian (74%) preponderance were observed. Eighty-seven percent were unresectable; the maxillary and nasoethmoid sites were equally prevalent. Intensity-modulated radiation therapy (IMRT) and photons alone were utilized in 74% and 70%, respectively. Platinum agents were given in 95% of chemotherapy patients. Complete response was observed in 64% of patients. Median progression-free survival (PFS) and overall survival (OS) were 28.8 and 65.3 months, respectively. Three-year PFS and OS rates were 44% and 72%, respectively; 5-year PFS and OS rates were 30% and 60%, respectively. Intensity-modulated radiation therapy and a maxillary site of origin showed a trend toward superior PFS; higher-dose regimens were associated with somewhat shorter PFS. Relapse was observed in 59% of patients, predominantly local. There were few unanticipated adverse effects, and no grade IV/V events were reported.

CONCLUSION

Advanced sinonasal carcinomas are chemoradiosensitive tumors, albeit with a high propensity for local relapse. There is a definite indication for IMRT and a potential curative role of platinum-based chemoradiation regimens.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:855-861, 2017.

Risk of lymph node metastasis and recommendations for elective nodal treatment in squamous cell carcinoma of the nasal cavity and maxillary sinus: a SEER analysis

BACKGROUND

Risk of nodal involvement in patients with squamous cell carcinomas (SCC) of the nasal cavity and maxillary sinus has not been well defined, especially by risk factors beyond local T-stage. Additional criteria defining patients at highest risk, as well as specific nodal levels at highest risk, has been limited in small retrospective series. We describe a population-based assessment of specific nodal involvement in this group.

MATERIAL AND METHODS

The Surveillance, Epidemiology and End Results (SEER) database from 2004 to 2010 identified 1283 eligible patients with SCC of the nasal cavity or maxillary sinus. Neck involvement and individual nodal level involvement at presentation were assessed, and comparison made with a contemporaneous cohort of patients with a borderline clinically significant risk of nodal involvement and recurrence.

RESULTS

Among 1283 patients, 182 (14.2%) had nodal involvement at presentation (4-27% by site and local extension). T-stage alone was associated with higher rates of nodal involvement in maxillary sinus SCC, while higher T-stage and size >2 cm were associated with higher rates of nodal involvement in nasal cavity SCC on multivariable analysis. Facial nodes and cervical nodes at levels 1 and 2 have the highest rates of involvement in T4a nasal cavity SCC, whereas nodal levels 1, 2, and/or 3 have the highest rates of involvement in T2 or higher maxillary sinus SCC when compared with a clinical reference standard.

CONCLUSION

In this population-based study, there are high rates of initial nodal involvement when stratified by local extent determined by T-stage in nasal cavity SCC and maxillary sinus SCC, and independently by size in nasal cavity SCC. Involvement of the facial and nodal levels 1-3 varies depending on site and local extent of tumor involvement. These observations may help guide treatment decision making in the inclusion of and extent of elective nodal treatment fields.

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.

'Saddle nose' deformity caused by advanced squamous cell carcinoma of the nasal septum

Hidden behind their common garden symptoms, malignant tumours of the nasal cavity are typically advanced when detected. Squamous cell carcinoma (SCC) is the most common histological type of these rare tumours which may simply present with epistaxis or a blocked nose. A 79-year-old woman attended our clinic with a 2-year history of progressive nasal collapse resulting in a 'saddle nose deformity'. Imaging showed a soft tissue mass with absolute destruction of the nasal septum and bones with hard palate and maxillary involvement. Histology confirmed a poorly differentiated SCC. Following discussion at the local head and neck multidisciplinary team meeting, the patient was offered radiotherapy alone due to her advanced presentation. She has had a good response to treatment with no further disease progression. Nasal septal SCC is far more successfully treated in the early stages. A suspicious clinician is the patients best ally.

Charged particle therapy versus photon therapy for paranasal sinus and nasal cavity malignant diseases: a systematic review and meta-analysis

BACKGROUND

Malignant tumours arising within the nasal cavity and paranasal sinuses are rare and composed of several histological types, rendering controlled clinical trials to establish the best treatment impractical. We undertook a systematic review and meta-analysis to compare the clinical outcomes of patients treated with charged particle therapy with those of individuals receiving photon therapy.

METHODS

We identified studies of nasal cavity and paranasal sinus tumours through searches of databases including Embase, Medline, Scopus, and the Cochrane Collaboration. We included treatment-naive cohorts (both primary and adjuvant radiation therapy) and those with recurrent disease. Primary outcomes of interest were overall survival, disease-free survival, and locoregional control, at 5 years and at longest follow-up. We used random-effect models to pool outcomes across studies and compared event rates of combined outcomes for charged particle therapy and photon therapy using an interaction test.

FINDINGS

43 cohorts from 41 non-comparative observational studies were included. Median follow-up for the charged particle therapy group was 38 months (range 5-73) and for the photon therapy group was 40 months (14-97). Pooled overall survival was significantly higher at 5 years for charged particle therapy than for photon therapy (relative risk 1·51, 95% CI 1·14-1·99; p=0·0038) and at longest follow-up (1·27, 1·01-1·59; p=0·037). At 5 years, disease-free survival was significantly higher for charged particle therapy than for photon therapy (1·93, 1·36-2·75, p=0·0003) but, at longest follow-up, this event rate did not differ between groups (1·51, 1·00-2·30; p=0·052). Locoregional control did not differ between treatment groups at 5 years (1·06, 0·68-1·67; p=0·79) but it was higher for charged particle therapy than for photon therapy at longest follow-up (1·18, 1·01-1·37; p=0·031). A subgroup analysis comparing proton beam therapy with intensity-modulated radiation therapy showed significantly higher disease-free survival at 5 years (relative risk 1·44, 95% CI 1·01-2·05; p=0·045) and locoregional control at longest follow-up (1·26, 1·05-1·51; p=0·011).

INTERPRETATION

Compared with photon therapy, charged particle therapy could be associated with better outcomes for patients with malignant diseases of the nasal cavity and paranasal sinuses. Prospective studies emphasising collection of patient-reported and functional outcomes are strongly encouraged.

FUNDING

Mayo Foundation for Medical Education and Research.

Epistaxis in a patient on antiplatelet therapy: not always benign

Epistaxis in patients on antiplatelet and anticoagulant therapy is common and typically benign. We present a case of a rare nasal septal malignancy in a patient on antiplatelet therapy and discuss worrisome symptoms and signs which should prompt early referral to a specialist.

National trends in surgery for sinonasal malignancy and the effect of hospital volume on short-term outcomes

OBJECTIVES/HYPOTHESIS

To characterize trends in the management of sinonasal malignancy with a focus on the impact of hospital volume on surgical outcomes.

STUDY DESIGN

Retrospective cohort study.

METHODS

Time trends were analyzed among patients admitted for surgical resection of sinonasal malignancy in the Nationwide Inpatient Sample (NIS) between 1988 and 2009. Subset analysis was performed on cohorts with skull base or orbital involvement or on cohorts who underwent neck dissection. Patient characteristics and hospital attributes were correlated with morbidity and mortality.

RESULTS

Over 22 years, we identified 3,850 cases from 879 hospitals. A total of 24.3% of patients had complications and 0.8% of hospitalizations resulted in mortality. Cases with skull base or orbital involvement, or cases including neck dissection, had more complications and a longer length of stay. Prevalence of neck dissection increased over time. Thirty-two hospitals averaged more than five cases per year, accounting for 28% of all surgeries. These centers were large (73.3%), urban (96.7%), teaching (90%) institutions and performed more high-risk cases: 32.4% of neck dissections, 44.6% of orbital cases, and 43.1% of skull base cases. Compared to lower-volume centers, these centers had more cardiopulmonary and electrolyte complications, but no difference was observed in the lengths of stay. A greater proportion of cases were recently performed at high-volume centers.

CONCLUSION

Over time, complicated surgeries were more likely to occur at higher-volume hospitals without significant changes in surgical complication rates. High-volume centers had increased rates of cardiopulmonary and electrolyte complications, likely representing complex postoperative management, but these were not associated with higher mortality.

LEVEL OF EVIDENCE

2c.

Follow-up strategies in head and neck cancer other than upper aerodigestive tract squamous cell carcinoma

Post-therapy follow-up for patients with head and neck cancer other than upper aerodigestive tract squamous cell carcinoma should meet several objectives: to detect both local, regional or distant recurrences, to evaluate acute and long-term treatment-related side effects, to guide the rehabilitation process, and to provide psychosocial support when needed. To our knowledge, there are no published reports in the literature dedicated to the follow-up of patients with these tumours. A comprehensive literature search for post-treatment follow-up strategies spanning from 1980 to 2012 was performed on several databases. This review focuses on malignant salivary gland tumors, soft tissue sarcomas, cutaneous squamous cell carcinomas, and sinonasal adenocarcinomas. Given the varying biological behavior and treatment-related factors and based on the literature, different recommendations are made on the follow-up of patients with the above-mentioned tumors.

Nasal septum malignancy

INTRODUCTION

Malignancies of the nasal septum are rare diseases and fewer than 400 cases were reported. The understanding of the disease is limited due to its rarity.

METHODS

We present a series of patients with nasal septum malignancies, who were referred to the Princess Alexandra Hospital, Ear, Nose and Throat Department from 2007 to 2010.

RESULTS

Seventeen patients were found to have nasal septum malignancies. The average age was 59.5 years old (range: 36 to 83 years old). The commonest initial symptom on presentation was nasal obstruction (nine out of 17, 53%), seconded by epistaxis (eight out of 17, 47%). The average time from the initial onset of symptoms to presentation averaged 18.8 months (range: 1 to 48 months). The commonest physical finding on presentation was nasal masses (11 out of 17, 65%), followed by nasal septum ulcers (four out of 17, 24%). The histology of the lesions was predominantly squamous cell carcinoma. The mean duration of follow-up was 24.7 months. The overall 3-year survival was 81.9% with the relapse free survival 66.7%.

DISCUSSION

Nasal septum malignancies are highly treatable with good prognoses when in early stages. They required high degree of suspicion to be detected early. Treatment options include surgical resection and radiotherapy and they offered similar 3-year survival rate. Combined therapy is adopted in larger tumours; however, it is not verified with randomized trials. Vigilant follow-up is vital to detect early recurrence, which is common in advanced stage lesions.

Lymphoepithelial carcinoma of the nasal cavity mimicking juvenile angiofibroma

Juvenile angiofibroma, nasopharyngeal carcinoma (NPC) and lymphoepithelial carcinoma of the nasal cavity (LEC NC) all could be found as a hyper-vascular mass in the nasopharynx area. Performing biopsy for histopathologic confirmation is necessary in the case of NPC or LEC NC but could be fatal in the case of angiofibroma. In our case, a 21-year-old male who was suffering from unilateral nasal stuffiness and frequent epistaxis had a mass with an easily bleeding tendency in his right nasal cavity. Juvenile angiofibroma was suspected by clinical and radiologic examinations. We performed preoperative angiography and the feeding vessel from the right internal maxillary artery was obliterated with polyvinyl alcohol nanoparticle. The mass was completely removed endoscopically, and there was profound hemorrhage in spite of the preoperative embolization. The mass turned out to be LEC NC by postoperative histopathologic examination. To avoid this misdiagnosis, the authors suggest that we should perform biopsy under rigid endoscopy 24h after angiographic embolization. If the result of frozen biopsy is juvenile angiofibroma, we could perform surgery another 24h later. If the result is nasopharyngeal carcinoma or LEC NC, we could avoid unnecessary surgical removal and perform radiotherapy. In terms of treatment strategies, we suggest endoscopic removal of gross tumor and postoperative combination of chemoradiotherapy as the more curative regimen with less complications related with radiotherapy.

Evidence for treatment strategies in sinonasal adenocarcinoma

Adenocarcinomas of various types account for 10% to 20% of all primary malignant neoplasms of the nasal cavity and paranasal sinuses. There is a general consensus that the optimal treatment of adenocarcinoma is surgery and postoperative radiotherapy. The purpose of this report was to review the results of this combined treatment as well as other treatment strategies and their outcome. Most series present outcome data from a heterogeneous group of patients, with a wide variety of tumor subtypes presenting at differing stages, who received a variety of treatment strategies. Surgical excision remains the treatment of choice. The choice of approach is determined by what will best allow complete excision of the disease. Endoscopic techniques, if feasible for complete removal of the tumor, offer results comparable to those of external approaches with lower morbidity. Although clear evidence to support the use of radiotherapy in sinonasal adenocarcinoma is difficult to obtain, local control rates of combined treatment strategies for advanced cases are comparable to less advanced cases with surgery alone, suggesting a positive role for postoperative radiotherapy. However, the importance of thorough surgical resection should be stressed.

Lymphoepithelial Carcinoma of the Nasal Cavity With EBV Infection in a North African Man

We report the case of a 58-year-old Tunisian man who presented with a 2 months' history of left nasal obstruction and one episode of epistaxis. Nasal endoscopy revealed a polypoid mass of the left nasal septum. Magnetic resonance imaging showed a left nasal cavity tumor with erosion of the orbit. Diagnosis of nasal cavity lymphoepithelial carcinoma EBV positive was performed on biopsy. The patient was treated by chemotherapy and radiotherapy. No tumor recurrence has been reported with a follow-up of 12 months.

CyberKnife radiosurgery for malignant spinal tumors: characterization of well-suited patients

STUDY DESIGN

A prospective interventional case-series study.

OBJECTIVE

To provide clinical results of CyberKnife fiducial-free spinal radiosurgery. The study focused on patients with no more than 2 malignant spinal tumors.

SUMMARY OF BACKGROUND DATA

Progress in frameless radiosurgical technology has enabled the application of radiosurgery to the spine. The CyberKnife System has been used extensively for spine radiosurgery. Until recently, the system required metallic fiducial implants for precise target tracking. Fiducial-free spinal radiosurgery with the CyberKnife has recently become possible, but until now clinical results obtained with this method had been limited.

METHODS

From August 2005 until October 2007, a consecutive series of 102 patients with a total of 134 malignant spinal tumors were selected for single-fraction, fiducial-free CyberKnife radiosurgery (CKRS). The study was limited to patients with a maximum of 2 tumors. Malignant primaries included breast cancer in 23 (22.6%) patients, renal cancer in 20 (19.6%) patients, gastro-intestinal cancers in 12 (11.8%) patients, prostate cancer each in 12 (11.8%) patients, lung cancer in 9 (8.9%) patients, sarcomas in 7 (6.9%) patients. A variety of other malignant tumors were found in 19 (18.6%) patients. Patients with spinal cord compression or evidence of myelopathy were excluded. The sequential neurologic status was recorded. Tumor-associated spinal pain was prospectively scored according to the visual analogue scale (VAS).

RESULTS

Of 102 individuals, 22 (21.6%) died due to progression of their systemic disease. Mean survival after CKRS was 1.4 years (CI: 1.2-1.6). Karnofsky performance score was the only independent predictor of survival after radiosurgery on log-rank test (P < 0.0001), and on Cox regression analysis (hazard ratio, 0.864, P < 0.0001, CI: 0.809-0.922). Median survival after initial tumor diagnosis was 18.4 years (CI: 15.1-23.4). Two (2%) patients suffered complications after radiosurgery; a tumor hemorrhage occurred in one, and another developed spinal instability. These and 2 other patients were stabilized by kyphoplasty. Neurotoxicity or myelopathy was not observed. Local tumor control 15 months after CKRS was 98% (95% CI: 89-99%). Tumor-associated pain was observed in 52 (51%) patients. In these patients the median pretreatment pain score of VAS = 7 (95% CI: 6-7) was significantly reduced to VAS = 1 (95% CI: 4-6) (P < 0.001) within 1 week after CKRS. Analysis of variance identified the initial pain score as the only significant variable to predict pain reduction after CKRS (P < 0.03). Pain recurrence in correlation with tumor recurrence was observed for 3 (6%) patients.

CONCLUSION

Spinal radiosurgery with the CyberKnife technology is a nonivasive, safe, and effective treatment method for patients with 1 or 2 small spinal malignant tumors. The best benefit of the treatment can be expected in patients with good to excellent clinical condition and patients with severe tumor associated pain.