Survival, Morbidity, and Quality-of-Life Outcomes for Sinonasal and Ventral Skull Base Malignancies

The Impact of Endoscopic Endonasal Surgery on Quality of Life in Patients with Malignant Tumors of the Anterior Skull Base: A Prospective Study

Objective

To investigate the effects of endoscopic endonasal surgery (EES) on longitudinal quality of life (QoL) in patients with malignant tumors of the anterior skull base.

Methods

Eligible patients prospectively completed the Anterior Skull Base Surgery Questionnaire (ASBQ) and the 22-item Sino-Nasal Outcome Test (SNOT-22) questionnaires in referring to 3 different periods throughout their treatment and recovery.

Results

Forty patients were included. The median volume coronal maximum length of the tumor was 3.6 cm (95% CI 2.7-4.1cm). Overall QoL significantly worsened at 1 month postoperatively but returned to baseline after 1 year. Unrelieved symptoms in specific domains prompted further evaluation of individual items. Transient worsening of taste (p=0.011) and olfaction (p=0.004) lasted for 1 month but gradually relieved within the first postoperative year, but vision consistently worsened over the course of the treatment (p=0.126). Age>50 years (p<0.001), comorbidities (p<0.001), tumor necrosis (p<0.001) and recurrence (p=0.001) were associated with worse preoperative QoL. Poor long-term QoL was noted in those undergoing adjuvant therapy (p=0.032). Overall ASBQ scores (p=0.024), subdomain scores in specific symptoms (p=0.016), and vision scores (p=0.009) were worse only in patients with the greater coronal maximum diameter at 1-month postoperatively. Greater coronal maximum diameter was related to worse preoperative subdomain scores regarding specific symptoms (p=0.030) and decreased postoperative long-term decreased vision scores (p=0.014).

Conclusion

Long-term site-specific and sinonasal QoL eventually stabilized after EES. Greater coronal maximum diameter was significantly associated with worsened vision function. Temporarily worse olfactory, vision, and taste function may be tied to decreased short-term QoL.

Long-term complications associated with the management of sinonasal malignancies: a single center experience

Objective

The aim of this study was to review the long-term complications associated with treatment of patients with sinonasal malignancies (SNMs) and risk factors for these complications.

Methods

A retrospective analysis of all patients treated for SNMs at a tertiary care center between 2001 and 2018. A total of 77 patients were included. The primary outcome measure was post-treatment long-term complications.

Results

Overall, long-term complications were identified in 41 patients (53%), and the most common were sinonasal (22 patients, 29%) and orbital/ocular-related (18 patients, 23%). In a multivariate regression analysis, irradiation was the only significant predictor of long-term complications (p = 0.001, OR = 18.86, CI = 3.31-107.6). No association was observed between long-term complications and tumour stage, surgical modality, or radiation dose/modality. Mean radiation dose ≥ 50 Gy to the optic nerve was associated with grade ≥ 3 visual acuity impairment (100% vs 3%; p = 0.006). Radiation therapy for disease recurrence was associated with additional long-term complications (56% vs 11%; p = 0.04).

Conclusions

Treatment of SNMs has substantial long-term complications, which are significantly associated with radiation therapy.

Quality of Life Considerations in Endoscopic Endonasal Management of Anterior Cranial Base Tumors

Considering quality of life (QOL) is critical when discussing treatment options for patients undergoing endoscopic endonasal skull base surgery (EESBS) for cancers at the base of the skull. Several questionnaires have been developed and validated in the last 20 years to explore QOL in this patient population, including the Anterior Skull Base Questionnaire, Skull Base Inventory, EESBS Questionnaire, and the Sino-Nasal Outcome Test for Neurosurgery. The Sino-Nasal Outcomes Test-22 and Anterior Skull Base Nasal Inventory-12 are other tools that have been used to measure sinonasal QOL in anterior cranial base surgery. In addition to pathology-related perturbations in QOL endoscopic surgical options (transsellar approaches, anterior cranial base surgery, and various reconstructive techniques) all have unique morbidities and QOL implications that should be considered. Finally, we look ahead to new and emerging techniques and tools aimed to help preserve and improve QOL for patients with anterior cranial base malignancies.

Prognostic factors and outcomes in minimal access resections of skull base and sinonasal epithelial malignancy

BACKGROUND

Sinonasal epithelial malignancies are uncommon tumours but represent a challenge to treatment given their close proximity to the orbit, brain and cranial nerves. Traditional external surgical approaches have potential for significant functional and cosmetic morbidity. An endoscopic approach provides the surgeon with good access for tumour removal and enables surveillance postoperatively. This study aimed to assess outcomes of an endoscopic approach to sinonasal epithelial malignancy and evaluate factors that may influence its utility.

METHODS

A case series was performed involving consecutive patients treated with endoscopic or endoscopic-assisted surgery for epithelial sinonasal malignancy. Stratification included TNM staging, histopathology, surgical approach, margin status, perineural involvement and adjuvant or neoadjuvant therapy. At follow-up, complications, local control, nodal status and evidence of distant metastases were recorded. Statistical analyses to identify risk factors for developing recurrence and survival differences were performed.

RESULTS

Thirty-five patients were assessed in this study (59.2 ± 11.4 years, 42.9% female). T stage at presentation was T1 in 11.4%, T2 in 17.1%, T3 in 22.9% and T4 in 48.6%. The 3 and 5 year disease specific survival were 91.3% (SE 5) and 71.1% (SE 10). The only factors to influence survival outcomes were perineural invasion of tumour and positive margins at the time of initial surgery. Large tumours did not limit the utility of an endoscopic approach.

CONCLUSION

Endoscopic approach is a safe and oncologically equitable treatment approach to external approaches in the management of epithelial sinonasal malignancy. As with external approaches, perineural invasion of malignance is a poor prognostic factor.

Effect of p16 Status on Survival Outcomes in Sinonasal Squamous Cell Carcinoma

OBJECTIVE

Evaluate the effect of p16 status on disease-free survival (DFS) and overall survival (OS) in patients with sinonasal squamous cell carcinoma (SCC) undergoing treatment with curative intent; and to assess how p16 status may affect patterns of recurrence.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary medical center.

METHODS

Patients with sinonasal SCC treated with curative intent from 2012 to 2018 were identified. Independent variable of interest was p16 status, which was assessed using immunohistochemistry (IHC) with a 70% staining cutoff for positivity. Kaplan Meier survival curve was plotted to assess correlation between p16 status and DFS and OS. Association between recurrence patterns and p16 status was conducted using chi square and fisher's exact tests. Multivariable Cox proportional hazard analysis was conducted to assess association between independent variables and DFS.

RESULTS

Fifty patients with sinonasal SCC met inclusion criteria. Patients were p16 positive in 28/50 (56%) of cases. Kaplan Meier survival curve revealed no statistically significant association between p16 status and DFS or OS survival (P = .780, P = .474). There was no difference in recurrence patterns in patients with p16 positive versus negative tumors.

CONCLUSION

p16 status did not have prognostic value on DFS and OS in our cohort of patients with sinonasal SCC undergoing treatment with curative intent. There was no difference in recurrence patterns between the 2 populations. Based on the results of this study, p16 status should not impact counseling of patients as it relates to their prognosis from SNM.

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.

Surgical outcomes of endoscopic versus open resection for the management of sinonasal malignancies

The purpose of this review is to assess the surgical outcomes of two different treatment modalities, endoscopic and open resection, for the management of sinonasal malignancies by comparing the effectiveness of these two methods. A wide search was carried out considering various electronic databases for English language articles from 2013 to 2018 using keywords such as sinonasal malignancies, endoscopic surgery, open resection for sinonasal malignancies, and endoscopic versus open surgery. One thousand articles were identified from the literature for screening. After a thorough systematic assessment and based on the selection criteria, 10 articles with 4,642 patients were included in this quantitative analysis. With a total of 4,642 patients, 1,730 patients were operated on using endoscopic resection and 2,912 patients were operated on using open resection. The endoscopic approach was found to have a shorter hospital stay compared to open surgical resection (P<0.05). The rate of positive margins and the recurrence rate for open surgical resection were both smaller compared to those for endoscopic resection (P>0.05), and the endoscopic approach had smaller complication rates and a higher survival rate compared to open resection (P>0.05). Though endoscopic resection and open surgical resection have comparable postoperative benefits, preoperative evaluation of cases presenting with sinonasal malignancies is necessary for determining the right treatment method to obtain the best possible results postoperatively.

Infratemporal fossa surgical approaches to primary/recurrent malignancies of salivary origin: paradigm surgical shift, patient selection, and oncologic outcomes

PURPOSE OF REVIEW

To review, the surgical approaches available on diagnosing a patient with salivary gland malignancy in the infratemporal fossa (ITF). To comment on patient evaluation and method of treatment selection. To identify and report on patient outcome data and make recommendations on future needs.

RECENT FINDINGS

There is a need to define the anatomic boundaries contents of the ITF, masticator space, parapharyngeal space (PPS), pterygopalatine fossa, ventral skull base, and paramedian skull base, as evidence from publications. The pathological subtypes identified mainly include adenoid cystic and mucoepidermoid carcinomas. The source of these tumours originates from primary disease in the sinonasal tract and nasopharynx superiorly, and the PPS/deep lobe of parotid inferiorly. Current surgical options available, in suitable selected patient, available in tertiary head and neck cancer hospitals, which have available facilities and staffing is the endoscopic endonasal approach. This approach offers patients a 'complete margin-free surgical excision', minimal complications, shorter hospital stay, and no delay with commencement of any adjuvant treatment compared with the traditional 'open transcutaneous' approach.

SUMMARY

The current evidence specifically to the surgical management of salivary gland malignancy involving the ITF is sparse, with great difficult identifying treated patients and their details among a heterogeneous group of patients with many lesions. There is a need for patient data that have specific pathologic conditions to be amalgamated from such centers and publish on outcome events.

Treatment-related morbidity in patients treated for sinonasal malignancy

BACKGROUND

Sinonasal malignancies are a rare, heterogeneous group of tumors that often present at an advanced stage and require multimodal therapy. The presence of high-grade toxicity and sinonasal complications after treatment can negatively impact quality of life. In this study we aim to describe posttreatment morbidity in patients with sinonasal malignancy.

METHODS

A retrospective analysis of all patients treated for sinonasal malignancy was conducted from 2005 to 2018 at a tertiary referral institution. A total of 129 patients met the inclusion criteria. Primary outcomes were treatment details, pathology, posttreatment complications, and radiation toxicity. Fisher's exact test, chi-square test, and Student t test were used for statistical analysis.

RESULTS

Mean age was 58.4 (median, 61; range, 19-94) years. After diagnosis, 24 patients had surgery alone, 46 had surgery with radiation alone, 47 had surgery with chemoradiation, and 14 received definitive chemoradiation. Overall, 10.4% (n = 12) of patients had postoperative complications, and 21.0% (n = 22) had high-grade (grade 3-5) radiation toxicity. After radiation, 20% (n = 21) of patients had chronic sinusitis requiring functional endoscopic sinus surgery and 20% (n = 21) had symptomatic nasal obstruction requiring operative debridement.

CONCLUSION

Sinonasal complications, including nasal obstruction and chronic sinusitis, occur frequently after definitive treatment of sinonasal malignancy and should be addressed when considering quality of life in survivors. These complications occur more frequently in patients who undergo chemoradiation as opposed to surgery alone.

Quality of life and emotional burden after transnasal and transcranial anterior skull base surgery

OBJECTIVE

To analyze psychopathological outcome and health-related quality of life (QOL) for cohorts of patients undergoing transcranial or transnasal anterior skull base surgery.

METHODS

A prospective study of patients undergoing elective surgery for various entities of the anterior skull base was performed. Evaluation for depression (ADS-K score) and anxiety (PTSS, STAI-S, STAI-T, and ASI-3 scores) was done before surgery, at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative quality of life as measured by the SF-36 and EuroQol questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined and compared between transnasal and transcranial subgroups.

RESULTS

We included 54 patients scheduled for surgery of a pituitary adenoma or meningioma of the anterior skull base between January 2013 and July 2017. Of these, a cohort of 40 (74.1%) completed follow-up interviews after 3 and 12 months. There were 60.0% female patients, median age was 57 years. 57.5% of patients had a meningioma and were operated transcranially, while 42.5% of patients received transnasal surgery for pituitary adenoma. The proportion of pathological anxiety scores significantly decreased from 75.0 to 45.0% (p = 0.002), without difference between transnasal and transcranial subgroups. After 3 months, mean EuroQol VAS score non-significantly increased by 0.07 (p = 0.236) across the entire cohort without significant difference between transcranial and transnasal subgroups (p = 0.478). The transnasal cohort tended to score higher in anxiety scores, whereas the transcranial cohort demonstrated higher depression scores without significant difference, respectively. The individually declared emotional burden significantly decreased from 6.7 to 4.0 on the ten-point Likert scale (p < 0.001) equally for both subgroups (transnasal, - 2.3; transcranial, - 3.0; p = 0.174). On last examination, about half of the patients in each subgroup (41.2% vs. 52.2%; p = 0.491) expressed a considerable recovery of preoperative bodily complaints such as headaches, dizziness, and unrest defined as a score of at least 8 on the Likert scaled item.

CONCLUSION

Both transnasal and transcranial approaches yield favorable postoperative QOL and psychopathological outcomes. The postoperative increase in QOL is partly influenced by preoperative expression of mental distress, which tends to resolve postoperatively.

Timing of surgery and adjuvant radiation therapy for sinonasal malignancies: Effect of surgical approach

BACKGROUND

Timely postoperative radiation therapy (RT) within 50 days of surgery for head and neck cancers provides a survival advantage.

METHODS

Using the National Cancer Database, we performed a propensity score-matched analysis comparing patients undergoing open or endoscopic surgery for squamous cell carcinoma (SCC) of the nasal cavity and paranasal sinuses from 2010 to 2015.

RESULTS

Among 168 pairs, patients undergoing endoscopic surgery had shorter time to surgery (24.2 vs 36.7 days, P < .001) and shorter postoperative time to RT (PTTR, 51.2 vs 58.4 days, P = .02). On multivariable linear regression, endoscopic surgery predicted shorter PTTR (β = -7.6, P = .01). Using the Kaplan-Meier method, patients in the longest PTTR quartile had decreased overall survival (OS; Q1 vs Q4, 3-year OS 76.5% vs 53.3%, P = .007), a durable finding when adjusted for covariates (Q1 vs Q4, HR 0.50, P = .008).

CONCLUSIONS

Patients undergoing endoscopic surgery for sinonasal SCC experience shorter PTTR. Shorter PTTR is associated with extended OS.

Significance of human papillomavirus positivity in sinonasal squamous cell carcinoma

BACKGROUND

The role of human papillomavirus (HPV) in sinonasal squamous cell carcinoma (SNSCC) is not well understood.

METHODS

The National Cancer Database was queried for cases of SNSCC with known HPV status. Demographics, socioeconomic variables, TNM stage, histology, grade, treatment modalities, and overall survival (OS) through 5 years were compared between HPV-positive and HPV-negative tumors. Cox proportional hazard regression analyses were performed.

RESULTS

Seven hundred seventy (770) cases were identified; 526 were HPV-negative (68.3%) and 244 (31.7%) were HPV-positive. Patients with HPV-positive tumors were younger (58.0 vs 63.7 years, p < 0.0001). Nasal cavity (49.4%) tumors were more likely to be HPV-positive (p < 0.05) than maxillary (18.8%), ethmoid (18.8%), and frontal (18.2%) sinus tumors. Large cell nonkeratinizing (42.4%), papillary (42.1%), and basaloid (56.5%) tumors were more likely than keratinizing (25.2%) tumors to be HPV-positive (p < 0.05). Well-differentiated (grade I) tumors (9.0%) were less likely than higher grade tumors to be HPV-positive (p < 0.05). Gender, race, facility type, insurance type, median income, education level, Charlson-Deyo comorbidity score, overall stage, T stage, N stage, M stage, tumor size, treatment modality, surgical approach, and surgical margins did not vary by HPV status (p ≥ 0.05). HPV-positive tumors had higher OS than HPV-negative tumors (p < 0.0001). At 5 years, OS was 68.1% and 51.5% for HPV-positive and HPV-negative tumors, respectively. On multivariate analyses, HPV positivity remained a favorable prognostic factor (hazard ratio, 0.49; 95% confidence interval, 0.34-0.70).

CONCLUSION

HPV positivity is more common in nasal cavity SCC and nonkeratinizing SNSCC. It is also a favorable prognostic factor in SNSCC. Future studies on SNSCC should take HPV positivity into consideration.