Treatment of 125 sinonasal tumors: prognostic factors, outcome, and follow-up

[Proposal for the delineation of postoperative primary clinical target volumes in maxillary sinus and nasal cavity cancers]

In this article, we propose a consensus delineation of postoperative clinical target volumes for the primary tumour in maxillary sinus and nasal cavity cancers. These guidelines are developed based on radioanatomy and the natural history of those cancers. They require the fusion of the planning CT with preoperative imaging for accurate positioning of the initial GTV and the combined use of the geometric and anatomical concepts for the delineation of clinical target volume for the primary tumour. This article does not discuss the indications of external radiotherapy (nor concurrent systemic treatment) but focuses on target volumes when there is an indication for radiotherapy.

Results of Primary Treatment and Salvage Treatment in the Management of Patients with Non-Squamous Cell Malignant Tumors of the Sinonasal Region: Single Institution Experience

Non-squamous cell carcinoma-related malignant sinonasal tract tumors (non-SCC MSTT) are rare and diverse malignancies. In this study, we report our experience in the management of this group of patients. The treatment outcome has been presented, involving both primary treatment and salvage approaches. Data from 61 patients treated radically due to non-SCC MSTT between 2000 and 2016 at the National Cancer Research Institute, Gliwice branch, were analyzed. The group consisted of the following pathological subtypes of MSTT: adenoid cystic carcinoma (ACC), undifferentiated sinonasal carcinoma (USC), sarcoma, olfactory neuroblastoma (ONB), adenocarcinoma, small cell neuroendocrine carcinoma (SNC), mucoepidermic carcinoma (MEC), and acinic cell carcinoma, which were found in nineteen (31%), seventeen (28%), seven (11.5%), seven (11.5%), five (8%), three (5%), two (3%) and one (2%) of patients, respectively. There were 28 (46%) males and 33 (54%) females at the median age of 51 years. Maxilla was the primary tumor localization followed by the nasal cavity and ethmoid sinus in thirty-one (51%), twenty (32.5%), and seven (11.5%) patients, respectively. In 46 (74%) patients, an advanced tumor stage (T3 or T4) was diagnosed. Primary nodal involvement (N) was found in three (5%) cases, and all patients underwent radical treatment. The combined treatment consisted of surgery and radiotherapy (RT) and was given to 52 (85%) patients. The probabilities of overall survival (OS), locoregional control (LRC), metastases-free survival (MFS), and disease-free survival (DFS) were assessed in pathological subtypes and grouped together, along with the ratio and effectiveness of salvage. Locoregional treatment failure was seen in 21 (34%) patients. Salvage treatment was performed in fifteen (71%) patients and was effective in nine (60%) cases. There was a significant difference in OS between patients who underwent salvage and those who did not (median: 40 months vs. 7 months, p = 0.01). In the group of patients who underwent salvage, OS was significantly longer when the procedure was effective (median: 80.5 months) than if it failed (median: 20.5 months), p < 0.0001. OS in patients after effective salvage was the same as in patients who were primary cured (median: 80.5 months vs. 88 months, p = 0.8). Distant metastases developed in ten (16%) patients. Five and ten year LRC, MFS, DFS, and OS were 69%, 83%, 60%, 70%, and 58%, 83%, 47%, 49%, respectively. The best treatment results were observed for patients with adenocarcinoma and sarcoma, while USC gave the poorest results in our set of patients. In this study, we indicate that salvage is possible in most patients with non-SCC MSTT with locoregional failure and that it may significantly prolong their overall survival.

A retrospective review of non‑intestinal‑type adenocarcinoma of nasal cavity and paranasal sinus

Non-intestinal adenocarcinoma of nasal cavity and paranasal sinuses (n-ITAC) is a heterogeneous tumor, which has rarely been reported in previous studies. Most high-grade n-ITAC has poor prognosis and there is a lack of classic therapeutic strategy. The present study examined using the PACS system of Nanfang Hospital of Southern Medical University between January 2000 and June 2020. It searched the keyword 'n-ITAC' and selected pathology. A total of 15 consecutive patients were searched. Finally, the present study analyzed a total of 12 n-ITAC patients. The follow-up time was 47 months on average. For low-grade (G1) tumors, 1 and 3-year overall survival (OS) rate were 100 and 85.7% respectively, while for high-grade (G3) tumors, 1 and 3-year OS rates were 80.0 and 20.0% respectively. Pathological grade may be an adverse prognostic factor (P=0.077). The OS of the surgery group was significantly superior to that of the non-surgery group (3-year OS was 63.6 vs. 0%, P=0.0009). Surgery is an indispensable means of treatment. The OS of patients with positive incisal margin was lower compared with that of patients with negative margin (P=0.186), suggesting that complete resection may be one of the prognostic factors. Patients with high risk factors received radiotherapy. The radiation dose was 66-70 Gy/33F for patients with positive margin or non-operation and was 60 Gy/28F for those with negative margin. Most of the patients received prophylactic irradiation of cervical area. Therefore, the prognosis of pathological high-grade n-ITAC is poor. Surgery is the most effective and an indispensable treatment for n-ITAC. For patients with high risk factors, surgery combined with radiotherapy may be a reasonable treatment. With regard to the cover range of radiotherapy, the primary tumor combined with lymph node drainage area is often used in Nanfang Hospital of Southern Medical University and the total dose of radiotherapy can be reduced if the surgical margin is negative.

Treatment Outcomes of Maxillary Sinus Squamous Cell Carcinoma at a Dedicated Cancer Institute: A Retrospective Study

Introduction

Squamous cell carcinoma arising at the maxillary sinus is a rare neoplasm, characterized by an aggressive growth pattern and glooming prognosis. The proximity of the maxillary sinus with complex anatomical structures such as the eye, skull base, infratemporal fossa, pterygomaxillary fossa, nasal cavities, and ethmoid sinuses makes the surgical treatment of tumors infiltrating into these structures very challenging. The study's objective was to investigate the prognostic factors of survival and maxillary sinus SCC treatment outcomes.

Methods

We did a retrospective analysis of patients treated for maxillary sinus SCC at our institution between 2004 -2018. The study included all the patients with histologically proven maxillary sinus SCC treated with curative intent. The medical record of 43 patients was reviewed and utilized for the analysis. The Kaplan-Meier curve calculated five-year overall survival.

Results

A total of 43 patients were analyzed. At the presentation time, the mean age was 54.56 years (SD ± 11.65). Smoking (n=13, 30.2%) was the common risk factor. 36 (83.7%) patients presented with stage IV disease. Surgery was performed in 16 (37.2%) patients, whereas 27 (62.8%) patients received radiation and chemotherapy. Treatment failure was seen in 35 (81.4%) patients with locoregional recurrence in 30 (85.7%) patients and distant metastases in 5 (14.3%) patients. The five years overall survival in our study was 22%. Loco-regional recurrence and distant metastasis were the significant factors impacting survival (p=0.01).

Conclusion

Maxillary sinus SCC is rare cancer that is more common in males and usually presents at an advanced stage with a poor outcome. These tumors have a higher rate of treatment failure with a poor prognosis. Locoregional recurrence and distant metastasis adversely impact the overall survival.

Outcomes of Management of Sinonasal Malignancies at a Dedicated Cancer Institution: A Retrospective Study

Introduction

Sinonasal malignancies (SNMs) are a rare and heterogeneous group of cancers with an incidence of 3%-5% of all head-and-neck tumours. The aim of the present study was to identify the characteristic features of SNMs and to analyze the treatment outcomes and the prognostic factors affecting it.

Materials and Methods

A retrospective review of patients with SNM treated at a dedicated cancer center of Pakistan between 2004 and 2018 was carried out. All patients with histologically proven diagnosis of malignancy arising from nasal cavity or paranasal sinuses and being treated with curative intent were included. The medical records of 184 cases were utilized for final analysis. Chi-square test was applied to identify significant differences. Five-year disease-specific survival (DSS) was calculated using Kaplan-Meier curve via log-rank test and comparison was made between squamous and nonsquamous histologies. P ≤0.05 was considered statistically significant.

Results

Squamous cell carcinoma was the most common histopathology (n = 62, 33.7%). 130 (70.7%) patients presented with stage IV disease. Nodal metastasis was seen in 24 (13%) patients. Treatment failure was seen in 96 (52.2%) patients and was significantly associated with tumour size and the overall stage. DSS of patients with squamous cell carcinoma was 29% as compared to 52% for patients with nonsquamous histologies (P = 0.001).

Discussion

SNM is a diverse group of cancers presenting in late stages. A higher rate of treatment failure associated significantly with stage of the disease was identified in our study.

Malignant Sinonasal Tumors: Update on Histological and Clinical Management

Tumors of nasal cavity and paranasal sinuses (TuNSs) are rare and heterogeneous malignancies, presenting different histological features and clinical behavior. We reviewed the literature about etiology, biology, and clinical features of TuNSs to define pathologic features and possible treatment strategies. From a diagnostic point of view, it is mandatory to have high expertise and perform an immunohistochemical assessment to distinguish between different histotypes. Due to the extreme rarity of these neoplasms, there are no standard and evidence-based therapeutic strategies, lacking prospective and large clinical trials. In fact, most studies are retrospective analyses. Surgery represents the mainstay of treatment of TuNSs for small and localized tumors allowing complete tumor removal. Locally advanced lesions require more demolitive surgery that should be always followed by adjuvant radio- or chemo-radiotherapy. Recurrent/metastatic disease requires palliative chemo- and/or radiotherapy. Many studies emphasize the role of specific genes mutations in the development of TuNSs like mutations in the exons 4-9 of the TP53 gene, in the exon 9 of the PIK3CA gene and in the promoter of the TERT gene. In the near future, this genetic assessment will have new therapeutic implications. Future improvements in the understanding of the etiology, biology, and clinical features of TuNSs are warranted to improve their management.

[Proposal for the delineation of postoperative primary clinical target volumes in ethmoid cancers]

It is proposed to delineate the anatomo-clinical target volumes of primary tumor (CTV-P) in ethmoid cancers treated with post-operative radiotherapy. This concept is based on the use of radioanatomy and the natural history of cancer. It is supported by the repositioning of the planning scanner with preoperative imaging for the replacement of the initial GTV and the creation of margins around it extended to the microscopic risk zones according to the anatomical concept. This article does not discuss the indications of external radiotherapy but specifies the volumes to be delineated if radiotherapy is considered.

Sinonasal Squamous Cell Carcinoma Presentation and Outcome: A National Perspective

BACKGROUND

examine presentation and outcomes of sinonasal squamous cell carcinoma (SCC).

METHODS

A retrospective study utilizing the National Cancer Database, 2004 to 2015. The study population included adult patients diagnosed with primary sinonasal SCC.

RESULTS

A total of 537 patients were included. The mean age of the study population was 62.6 ± 12.7 years. The median follow-up time was 35.6 months (interquartile range: 8.6-55.9). The histological variants identified are: (i) 66.7% keratinizing SCC, (ii) 21.6% non-keratinizing SCC, (iii) 8.0% papillary SCC, and (iv) 3.7% spindle cell carcinoma. Stage at presentation was: (i) 33.3% T1-2, N0, (ii) 31.8% T3-4a, N0, (iii) 13.8% T1-4a, N+, (iv) 17.0% T4b,N0-3, (v) 4.1% M1. Human papilloma virus (HPV) status was available for 96 patients and tested positive in 24 (25.0%) patients. By histological variants, 5-year survival was lowest for spindle cell carcinoma (40.0%), and highest for papillary SCC (70.1%). HPV negative tumors had a 5-year survival of 26.4%, while HPV positive tumors had a 5-year survival of 57.1% (P = <.001). Of the 255 patients with T1-4a, N0-3, M0 who had surgery of the primary site, 31 (12.2%) patients underwent endoscopic approach. The risk of positive postsurgical margins was not significantly different comparing endoscopic to open approach (23.8% vs 24.1%, P >.99).

CONCLUSIONS

Sinonasal SCC could present at advanced stages in two-thirds of the population and exhibit a variety of histological subtypes. Like other sites of head and neck, HPV positive tumors are associated with a favorable prognosis. Endoscopic approach is comparable to open approach in terms of post-surgical margins.

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.

The role of a post therapeutic surveillance program for sinonasal malignancies: Analysis of 417 patients

BACKGROUND

Post therapeutic surveillance of head and neck neoplasms is a still debated issue in the current literature: although different works tried to establish frequency, modality, and efficacy of a routine follow-up, little evidence has been produced, in particular considering only sinonasal malignancies.

METHODS

A retrospective review of patients treated for sinonasal malignancies in a single tertiary center and followed through a regular program of follow-up was carried out. Rate of recurrence, location, timing, diagnosis, and salvage treatment were the main data analyzed.

RESULTS

Of note, 417 patients were included in the study and 117 experienced at least one relapse. Staging, histological type, and previous treatment represent the main clinical factors to be considered to stratify patient's risk of recurrence.

CONCLUSION

A regular post therapeutic surveillance can provide an early recurrence detection for patients treated for sinonasal malignancies, offering opportunity for salvage treatment in a high percentage of patients.

A Multi-Institutional Experience of Proton Beam Therapy for Sinonasal Tumors

Purpose

To report the outcomes of sinonasal tumors treated with proton beam therapy (PBT) on the Proton Collaborative Group registry study.

Methods and Materials

Sixty-nine patients with sinonasal tumors underwent curative intent PBT between 2010 and 2016. Patients who received de novo irradiation (42 patients) were analyzed separately from those who received reirradiation (27 patients) (re-RT). Median age was 53.1 years (range, 15.7-82.1; de novo) and 57.4 years (range, 31.3-88.0; re-RT). The most common histology was squamous cell carcinoma in both groups. Median PBT dose was 58.5 Gy (RBE) (range, 12-78.3; de novo) and 60.0 Gy (RBE) (range 18.2-72.3; re-RT), and median dose per fraction was 2.0 Gy (RBE) for both cohorts. Survival estimates for patients who received de novo irradiation and those who received re-RT were calculated using the Kaplan-Meier method.

Results

Median follow-up for surviving patients was 26.4 months (range, 3.5-220.5). The 3-year overall survival (OS), freedom from distant metastasis, freedom from disease progression, and freedom from locoregional recurrence (FFLR) for de novo irradiation were 100%, 84.0%, 77.3%, and 92.9%, respectively. With re-RT, the 3-year OS, freedom from distant metastasis, FFDP, and FFLR were 76.2%, 47.4%, 32.1%, and 33.8%, respectively. In addition, 12 patients (17.4%) experienced recurrent disease. Re-RT was associated with inferior FFLR (P = .04). On univariate analysis, squamous cell carcinoma was associated with inferior OS (P < .01) for patients receiving re-RT. There were 11 patients with acute grade 3 toxicities. Late toxicities occurred in 15% of patients, with no grade ≥3 toxicities. No patients developed vision loss or symptomatic brain necrosis.

Conclusions

As one of the largest studies of sinonasal tumors treated with PBT, our findings suggest that PBT may be a safe and efficacious treatment option for patients with sinonasal tumors.

Recurrence patterns of sinonasal cancers after a 5-year disease-free period

OBJECTIVES/HYPOTHESIS

Sinonasal cancers are rare but have a poor prognosis. Most previous studies of these cancers have focused on 5-year disease-free survival, but recurrences are also known to occur after this period. We examined the post-5-year recurrence patterns in sinonasal cancer patients by histologic type to determine the indicators for extended and close follow-up requirements.

STUDY DESIGN

Retrospective chart review.

METHODS

A cohort of 241 sinonasal cancer patients was included. Demographic data, cancer site and stage, pathology and treatment results, and follow-up and survival data were collected.

RESULTS

Of the 241 patients, a complete remission occurred in 163 (72.4%) patients, but 83 (50.9%) of these cases developed recurrence, which occurred beyond the 5-year follow-up period in 19 cases (11.7%). The most common post-5-year recurrences were adenoid cystic carcinoma (six patients, 33.3%), followed by melanoma (three patients, 21.4%), poorly differentiated carcinoma (two patients, 18.2%), squamous cell carcinoma (six patients, 6.7%), and olfactory neuroblastoma (no patients, 0%). Post-5-year local recurrence was highest in adenoid cystic carcinoma (six patients, 33.3%), followed by melanoma (three patients, 21.4%), poorly differentiated carcinoma (two patients, 18.2%), and squamous cell carcinoma (five patients, 5.5%). Post-5-year regional recurrence occurred in one squamous carcinoma patient (1.1%), and distant metastasis was seen in one adenoid cystic carcinoma patient (5.5%).

CONCLUSIONS

Sinonasal cancer shows an 11.7% recurrence rate after a 5-year disease-free period. As this recurrence pattern varies by tumor pathology, a specific follow-up plan is needed for each cancer type.

LEVEL OF EVIDENCE

3 Laryngoscope, 129:2451-2457, 2019.

Sinonasal cancer in the Italian national surveillance system: Epidemiology, occupation, and public health implications

BACKGROUND

Sinonasal cancer (SNC) is a rare tumor with predominant occupational etiology associated with exposures to specific carcinogens. The aim of this study is to describe SNC cases recorded in Italy in the period 2000-2016.

METHODS

Clinical information, occupational history, and lifestyle habits of SNC cases collected in the Italian Sinonasal Cancer Register were examined. Age-standardized rates were estimated.

RESULTS

Overall, 1529 cases were recorded. The age-standardized incidence rates per 100 000 person-years were 0.65 in men and 0.26 in women. Occupational exposures were predominant among the attributed exposure settings, primarily to wood and leather dusts. Other putative causal agents included chrome, solvents, tannins, formaldehyde, textile dusts, and pesticides. Many cases had unknown exposure.

CONCLUSIONS

Epidemiological surveillance of SNC cases and their occupational history is fundamental for monitoring the occurrence of the disease in exposed workers in industrial sectors generally not considered at risk of SNC as well as in non-occupational settings.

Epidemiology and survival outcomes of sinonasal verrucous carcinoma in the United States

INTRODUCTION

Verrucous carcinoma (VC) is a rare, variant of squamous cell carcinoma with benign cytohistopathologic features and a generally favorable prognosis. Epidemiologic and clinical outcomes data are lacking as a result of limited cases of sinonasal VC.

OBJECTIVE

To describe the incidence and determinants of survival of patients with verrucous carcinoma of the sinonasal tract between the years of 1973 to 2014 using the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The SEER registry was utilized to calculate survival trends for patients with verrucous carcinoma of the sinonasal tract between 1973 and 2014. Patient data then was analyzed with respect to age, sex, race, and treatment modalities (surgery and radiation therapy). Overall survival (OS) and disease-specific survival (DSS) were calculated.

RESULTS

A total of 86 cases of VC of the sinonasal tract were identified. The cohort was comprised of 69.8% males. The mean age at diagnosis was 67.4 years. The nasal cavity was the most common primary site (51.2%), followed by the maxillary sinus (40.7%) and nasopharynx (5.8%). The median OS was 97.6 months. 89.5% of cases underwent surgery and 20.9% received both surgery and radiation therapy. Overall survival at 2, 5, and 10 years was 73%, 59%, and 36%, respectively. On multivariate analysis, advanced age (P < 0.05) and primary site (P < 0.05) were associated with worse OS and DSS, respectively. Primary nasopharyngeal tumor site was associated with reduced DSS (P < 0.05). Surgery improved OS (P < 0.001) and DSS (P < 0.001).

CONCLUSION

Verrucous carcinoma of the sinonasal tract is associated with a generally favorable prognosis. Age, primary site, and surgical therapy are independent predictors of OS and DSS, respectively. We present the first population-based analysis of sinonasal VC, thus clarifying the prognosis and reinforcing the management of this malignancy.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:651-656, 2017.

Minimally invasive endoscopic resection for the treatment of sinonasal malignancy: the outcomes and risk factors for recurrence

Purpose

The role of minimally invasive endoscopic resection (MIER) in the treatment of sinonasal malignancy is controversial. Herein, we performed a retrospective review of a large case series of sinonasal malignancy patients treated with MIER aimed at evaluating the outcomes and identifying the risk factors for recurrence.

Methods

Patients with sinonasal malignancy who underwent MIER from March 2000 to May 2015 were enrolled, and their clinical data were collected. The clinical outcomes were evaluated by determining the 5-year overall survival (OS) and disease-free survival (DFS). The predictive factors for survival and potential independent risk factors for recurrence were explored.

Results

A total of 120 patients were enrolled, including 62 males and 58 females. The mean follow-up period was 51.4 (95% confidence interval: 44.0–59.1) months. The most frequent histological type was mucosal malignant melanoma. The positive margin rate was 19.2% (23/120). Seventy-one patients had the safety anatomic plane (SAP). Age ≥50 years, nodal metastasis, and not having the SAP were found to be predictive factors for survival, and absence of SAP was found to be an independent risk factor for recurrence.

Conclusion

Our study indicated that MIER is an effective and safe surgical procedure in appropriately selected patients. Tumor resection with a safety anatomic boundary is likely to lead to improved survival and decreased recurrence. However, a larger sample and long-term prospective observation are still required to establish the role of MIER in treatment of sinonasal malignancy.

Expression and clinical significance of TrkB in sinonasal squamous cell carcinoma: a pilot study

Previous studies have confirmed that tropomyosin-related kinase B (TrkB) plays a critical role in the occurrence, development, and metastasis of many kinds of malignant tumour. More recently, TrkB was found to be overexpressed in head and neck squamous cell carcinoma (SCC) and to be involved in multistep tumour progression. In this study, the expression of TrkB was investigated in 27 cases of sinonasal SCC using an immunohistochemical method. The clinical significance and possible role of TrkB as a prognostic marker in these tumours was also explored. The results showed that TrkB was overexpressed in all cases of sinonasal SCC. A high level of expression of TrkB was significantly related with poor-to-moderate differentiation of SCC (P=0.026), high clinical stage (P=0.023), and the presence of local recurrence (P=0.004). Analysis by Kaplan-Meier method indicated that patients with high levels of TrkB expression had shorter overall survival (P=0.006) and disease-free survival (P=0.018). Multivariate analysis revealed that the level of TrkB expression was an independent prognostic factor for both overall and disease-free survival (P=0.019 and P=0.048, respectively). These data suggest that the overexpression of TrkB may play a significant role in sinonasal SCC and that TrkB may be used as a potential prognostic marker for the clinical outcome.

Organ preservation with neoadjuvant chemoradiation in patients with orbit invasive sinonasal cancer otherwise requiring exenteration

Purpose

We sought to determine if organ preservation (OP) with neoadjuvant chemoradiation (CRT) was feasible in patients with sinonasal cancer determined to require exenteration.

Materials and Methods

Twenty patients were determined to require exenteration for definitive treatment from 2005 to 2014. Fourteen patients underwent OP and 6 patients received exenteration with adjuvant CRT. Exenteration free survival (EFS), locoregional control (LRC), progression-free survival (PFS), and overall survival (OS) were estimated.

Results

Five patients (36%) receiving OP had complete disease response at time of surgery. With a median follow-up of 18.8 months, EFS was 62% at 2 years for patients undergoing OP. At 2 years, there were no significant differences in LRC, PFS or OS (all all p > 0.050) between the groups. Less grade 3 or greater toxicity was seen in patients undergoing OP (p = 0.003). Visual function was preserved in all patients undergoing OP.

Conclusion

For patients with sinonasal cancer, OP may avoid exenteration, offering similar disease control and improved toxicity.

Paranasal sinuses malignancies: A 12-year review of clinical characteristics

Background

Inadequate epidemiologic investigations of the paranasal sinuses malignancies prompted this retrospective study with special emphasis on a major group of 111 tumors.

Material and Methods

Clinical records of 111 patients with histologically confirmed malignant tumors of the paranasal sinuses were investigated retrospectively from April 2000 to January 2012. Collection of data included demographic information, clinical manifestations, treatment plans, and histopathology of the tumor.

Results

There were 69 (62.16%) male and 42 (37.83%) female patients (male-to-female ratio of 1.6:1), with a median age of 49±12.2 years (range 21 to 88 years). A high level of occurrence was noticed in the fifth (26.3%) decade of life. The most frequent histological types were squamous cell carcinoma (43.5%) and adenoid cystic carcinoma (19%). Among clinical manifestations, nasal obstruction was the most frequent followed by diplopia, and facial swelling. Fifty three patients (47.74%) were treated with combined approach of surgery and radiation therapy.

Conclusions

Paranasal sinuses malignancies are rare conditions with nonspecific symptoms which make early diagnosis of the lesions more challenging. The optimal therapeutic protocol for patients suffering from these tumors is still a somewhat controversial entity and requires further studies.

Key words:Paranasal sinuses, malignancy, surgery,radiotherapy.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

Surgical outcomes of malignant sinonasal tumours: open versus endoscopic surgical approaches

BACKGROUND

Sinonasal malignancies are rare tumours, which can be resected using an open or endoscopic approach. The current study evaluated the outcome of both approaches.

METHODS

A total of 160 patients with malignant nasal tumours were evaluated in an academic tertiary care hospital. The patients were allocated to 'open' or 'endoscopic' surgery groups, based on the surgical approach employed. The following data were evaluated and compared: patient and tumour characteristics; oncological treatments; and oncological outcomes, including complications, surgical margin, recurrence, overall survival and disease-free survival.

RESULTS

The maxillary sinus was the most common tumour location and squamous cell carcinoma was the most common histopathology-based diagnosis. Younger patients had lower grades of tumour. Higher survival rates were significantly related to lower tumour stages in both surgery groups. There were no differences between the two relatively similar groups in terms of surgical margin, the need for adjunctive therapy, and recurrence and survival rates. In addition, multivariate logistical regression analysis indicated no correlations between the type of surgical approach employed and the rates of recurrence and complications.

CONCLUSION

Endoscopic surgery for sinonasal malignancies is comparable to the conventional open approach in carefully selected patients.

Sinonasal tract malignancies: prognostic factors and surgery outcomes

Background:

Cancers of the sinonasal region are rare and its survival rate remains poor because most of the patients are asymptomatic and diagnosed in advanced stages with surrounding important structures.

Objectives:

This study attempted to analyze the clinical and histological features in addition to survival and prognostic factors of surgical treatment of sinonasal cancers.

Patients and Methods:

A retrospective cohort study, involving 36 patients with sinonasal cancer who were treated with surgery in our hospital between 2000 and 2010, was performed. Patients were selected based on the convenience sampling. Patients treated with radiotherapy and/or chemotherapy were excluded from the analysis. Clinical symptoms and histologic findings of patients as well as malignant tumor staging and its prognosis were collected from archives.

Results:

We found that overall 3 and 5-year survival rates of subjects were 52.8%, and 41.6%, respectively. There was a negative correlation between the clinical stage and survival. There was a significant difference between infrastructural and suprastructural localization in 5-year survival rate (P = 0.018). In the present study, there was a strong relationship between the local control and overall survival (P < 0.01). Overall 5-year survival rate was similar in patients both in the exenterated orbit and preserved orbit (P > 0.05).

Conclusions:

The present study has demonstrated that clinical stage, suprastructural tumor, and the presence of tumor- positive resection margins are the most significant prognostic factors affecting local tumor control and survival. As a result of this study, these tumors should be treated in early stages by surgical margin of resection followed by adjuvant radiotherapy.

Management of sinonasal tumors: prognostic factors and outcomes: a 10 year experience at a tertiary care hospital

Sinonasal malignancies are said to be a highly heterogeneous group of cancers, accounting for less than 1 % of all cancers and less than 3 % of all upper aerodigestive tract tumors. Originating from any histologic components of the sinonasal cavity, the histopathology of these tumors is diverse. Accordingly, treatment options vary, surgery being the mainstay in most of them. Recurrence rates differs with each histological type of tumor, dependent on various factors. In this article, we have tried to identify the prevalent characteristics of sinonasal malignancies and to outline the prognostic factors affecting the outcome. It is a retrospective study design with a total number of 102 patients. Patients diagnosed with sinonasal malignancies were included and any patient previously operated outside our institute or having received prior radiation or chemotherapy were excluded. The patients were selected over a period of 10 years, from 2000 to 2010. Data was analyzed using SPSS 17. Majority of the sinonasal tumors were squamous cell carcinomas involving the maxillary sinus. Locoregional recurrence was found to be more frequent in patients with positive neck nodes on final histopathology. Sinonasal malignancies are mostly squamous cell in variety and recurrence of these rare entities is dependent on the histological variety and the presence of positive neck nodes.

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.

[Cancers of the nasal cavity and paranasal sinuses: clinicopathological, etiological and therapeutic aspects]

Sinonasal cancers are rare and are often associated with occupational exposure that should be researched. Their diagnosis is often delayed. Carcinomas are the most common histological variety. The aim of the present report is to review the main scientific literature about sinonasal cancer to identify their clinicopathological features, and their main causes and treatment modalities. The treatment of these tumors is surgical, usually followed by radiotherapy.

Nodal recurrence of sinonasal cancer: does the risk of cervical relapse justify a prophylactic neck treatment?

BACKGROUND

Sinonasal cancers are rare and no high-level evidence exists to determine their optimal management. Prophylactic neck treatment issue remains controversial. The aim of this study was to analyze the pattern of neck failure and to identify any prognostic factors that may influence neck control.

METHODS

A retrospective review of 155 consecutive patients treated for sinonasal malignancy, without prophylactic neck treatment, between 1995 and 2005 at tertiary cancer center was performed. Demographic, clinical, morphological and pathological parameters were correlated with oncologic outcomes.

RESULTS

Eight out of 155 patients (5%) presented initially with neck node metastasis. Complete remission was obtained for 133 patients after treatment completion. During follow up, 16 out of 133 patients (12%) were affected with regional recurrence. Neck failure occurred in 8 out of 51 patients with local failure and in 8 out of 82 patients locally controlled. Isolated nodal failure was observed in 5 patients initially cN0 out of 133 (3.8%) representing 7.3% of all recurrences and 3 of them underwent successful salvage therapy. None of the tested factors were significantly associated with neck control (p>0.05). Lymph node at diagnosis time was significantly and independently associated with poor survival (p=0.0012).

CONCLUSION

Isolated neck relapse, when local control is achieved, is rare and salvage treatment is effective. Routine prophylactic neck treatment has little interest. However, this approach could be profitable to few selected patients, who remain to be defined. Further investigations are needed.

Sinonasal carcinomas: epidemiology, pathology, and management

Sinonasal carcinomas are uncommon neoplasms accounting for approximately 3% to 5% of all upper respiratory tract malignancies. Sinonasal malignancies in most cases do not cause early symptoms and present in an advanced stage of disease. Exact staging necessitates a clinical and endoscopic examination with biopsy and imaging. Tumor resection using an open or endoscopic approach is usually considered the first treatment option. In general, sinonasal carcinomas are radiosensitive, so adjuvant or neoadjuvant radiation treatment may be indicated in advanced disease. Multidisciplinary surgical and medical oncologic approaches, including ablation and reconstruction, have enhanced the survival outcome over the past few decades.

Malignant tumors of the sinonasal tract in the pediatric population

CONCLUSION

Sarcoma and lymphoma comprised 75% of 20 cases of pediatric sinonasal malignancies. As regards treatment, all 20 patients received chemotherapy and 6 patients (30%) underwent surgery. The overall 5-year survival rate was 52%, with favorable outcome for solid tumors compared with lymphoma.

OBJECTIVE

We aimed to investigate the clinical features and treatment outcomes of sinonasal malignancies in 20 pediatric patients.

METHODS

Clinical features were evaluated and tumors were staged according to the staging system for each histologic type.

RESULTS

The 20 patients consisted of 12 males and 8 females, ranging in age from 1 to 16 years, with a median age of 9.6 years at diagnosis. More than half of the patients presented with nasal obstruction as the primary symptom, and mean symptom duration to diagnosis was 5.4 months. Primary tumor sites included the paranasal sinuses alone in four patients, the nasal cavity alone in eight, and both in eight. Eight tumors were sarcomas and seven were lymphomas. The remaining tumors included three olfactory neuroblastomas and two primitive neuroectodermal tumors. The main treatment modality was chemotherapy rather than surgery. The overall survival rate was 52%, and patients with solid tumors survived significantly longer than those with lymphoma (p = 0.02).

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.

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.

Salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck: an update about rare but challenging tumors

PURPOSE OF REVIEW

This is a review about recent clinical developments in rare cancers of the head and neck.

RECENT FINDINGS

Progress in molecular biology techniques has allowed the identification of new prognostic factors, and potential molecular-targeted therapies. This is of importance since chemotherapy continues to play a role but is still limited in this group of malignancies. New techniques of irradiation such as intensity-modulated radiotherapy and three-dimensional conformal radiotherapy appear to improve the locoregional control of these tumors. Surgery continues to be the cornerstone of treatment, with a growing interest in the technique of sentinel lymph node biopsy.

SUMMARY

As salivary gland carcinomas, paranasal sinus cancers and melanoma of the head and neck are rare malignancies, these tumors must be treated in specialized anticancer centers with access to the latest surgical and irradiation techniques. Moreover, clinical studies with translational research are needed to identify strong prognostic and predictive factors, and effective molecular-targeted therapies.

Cancer of the paranasal sinuses

Carcinoma of the paranasal sinuses is a heterogeneous disease that is frequently locally advanced at presentation. Treatment commonly includes radical surgery followed by adjuvant therapy. Despite such aggressive therapy, the likelihood of locoregional failure is significant, resulting in poor survival, particularly with advanced tumors. In this paper, we review the recent literature in search of advances in treatment optimization. These advances include conformal radiotherapy techniques, chemotherapy, image-guided and endoscopic surgery, and surgical approaches for orbital preservation, all of which have a potential to improve the oncologic outcome as well as cosmetic and functional results. We also outline our approach in using these advances in the management of patients with these cancers.

Single modality and multimodality treatment of nasal and paranasal sinuses cancer: a single institution experience of 229 patients

AIMS

To assess the single and multimodal treatment results and prognostic factors for sinonasal carcinoma.

METHODS

Overall survival (OS), disease-specific survival (DSS), local control (LC), and disease-free survival (DFS) in 229 patients with sinonasal carcinoma treated from 1967 to 2003 were calculated. Prognostic factors were univariately and multivariately analyzed. The median follow-up period for survivors was 126 months.

RESULTS

32% of the patients were operated only, 47% underwent multimodal therapy, and 20% were treated without operation. The 5-year OS rate was 41%, and the DSS rate was 51%. The LC rate was 64%, and the DFS rate was 34%. Prognostic for DSS were M status (p<0.001), UICC stage (p<0.001), T classification (p=0.001), N status (p=0.002), intracranial tumor infiltration (p=0.008), infiltration of the pterygopalatine fossa (p=0.02), infiltration of the skull base (p=0.021), infiltration of the orbita (p=0.041), and the type of therapy (p<0.001): The 5-year DSS rate was 63% for patients operated only, 56% for all operated patients, 46% for patients undergoing surgery and radiotherapy, but only 21% for patients treated with radiotherapy+/-chemotherapy. Multivariate analysis revealed that T classification (p=0.042), N classification (p=0.035), M classification (p=0.007), UICC stage (p=0.038), and type of therapy (p=0.038) were independent prognostic factors for DSS.

CONCLUSIONS

Radical surgery is recommended for stage I/II sinonasal carcinomas. Stage III/IV carcinomas still have a poor prognosis, but multimodal treatment seems to favor the outcome.