Sinonasal malignancies

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.

Multi-parametric MRI-based radiomics signature for preoperative prediction of Ki-67 proliferation status in sinonasal malignancies: a two-centre study

OBJECTIVE

To assess the predictive ability of a multi-parametric MRI-based radiomics signature (RS) for the preoperative evaluation of Ki-67 proliferation status in sinonasal malignancies.

METHODS

A total of 128 patients with sinonasal malignancies that underwent multi-parametric MRIs at two medical centres were retrospectively analysed. Data from one medical centre (n = 77) were used to develop the predictive models and data from the other medical centre (n = 51) constitute the test dataset. Clinical data and conventional MRI findings were reviewed to identify significant predictors. Radiomics features were determined using maximum relevance minimum redundancy and least absolute shrinkage and selection operator algorithms. Subsequently, RSs were established using a logistic regression (LR) algorithm. The predictive performance of RSs was assessed using calibration, decision curve analysis (DCA), accuracy, and AUC.

RESULTS

No independent predictors of high Ki-67 proliferation were observed based on clinical data and conventional MRI findings. RS-T1, RS-T2, and RS-T1c (contrast enhancement T1WI) were established based on a single-parametric MRI. RS-Combined (combining T1WI, FS-T2WI, and T1c features) was developed based on multi-parametric MRI and achieved an AUC and accuracy of 0.852 (0.733-0.971) and 86.3%, respectively, on the test dataset. The calibration curve and DCA demonstrated an improved fitness and benefits in clinical practice.

CONCLUSIONS

A multi-parametric MRI-based RS may be used as a non-invasive, dependable, and accurate tool for preoperative evaluation of the Ki-67 proliferation status to overcome the sampling bias in sinonasal malignancies.

KEY POINTS

• Multi-parametric MRI-based radiomics signatures (RSs) are used to preoperatively evaluate the proliferation status of Ki-67 in sinonasal malignancies. • Radiomics features are determined using maximum relevance minimum redundancy (mRMR) and least absolute shrinkage and selection operator (LASSO) algorithms. • RSs are established using a logistic regression (LR) algorithm.

Prognostic Impact of Adverse Pathologic Features in Sinonasal Squamous Cell Carcinoma

Objective  This study aimed to describe the impact of adverse clinical and pathologic features in sinonasal squamous cell carcinoma (SCC). Design  This study is designed with retrospective chart review. Setting  The present study is conducted at a tertiary care institution. Participants  All patients treated surgically for sinonasal SCC at our tertiary care institution between January 2006 and December 2013. Main Outcome Measures  Overall survival (OS) and disease free survival (DFS) are the final measurement of this study. Results  Forty-eight patients were identified. Mean age at surgery was 65.8 years, and mean follow-up time was 40.7 months. Eighteen patients (38%) had T1-T3 disease, while 30 patients (63%) had T4 disease. Seven patients (8.3%) had nodal disease at presentation. At 2, 5, and 10 years, OS was 71, 54, and 48%, respectively, while DFS was 64, 51, and 45%, respectively. Twelve patients (25%) experienced local recurrences with mean time to recurrence of 15.3 months. Twenty-five patients (52%) had positive margins, 24 (50%) had high-grade tumors, 18 (38%) had perineural invasion (PNI), and 15 (31%) had lymphovascular invasion (LVI). In the univariate analysis, T4 disease (risk ratio [RR] = 2.7) and high grade (RR = 2.4) had a significant association with DFS. In the multivariate analysis, high grade (RR = 4.0 and 4.5) and LVI (RR = 4.1 and 4.7) had a significant association with OS and DFS. Conclusion  Our single-institution experience of 48 patients suggests that high grade and LVI are independently associated with survival outcomes in sinonasal SCC, while PNI and microscopically positive margins do not have a significant impact.

Three-year results after radiotherapy for locally advanced sinonasal adenoid cystic carcinoma, using highly conformational radiotherapy techniques proton therapy and/or Tomotherapy

PURPOSE

We report the patient outcomes of a treatment combining proton therapy and Tomotherapy in sinonasal adenoid cystic carcinoma involving skull base.

MATERIALS AND METHODS

We included patients treated at Curie Institute, Paris, France, between March 2010 and February 2014 for an advanced adenoid cystic carcinoma involving skull base. Patients received Tomotherapy, proton therapy or both. We evaluated treatment toxicity (according to CTCAE V4), local control, distant metastasis-free survival and overall survival.

RESULTS

Thirteen patients were included, with a median follow-up of 34 months. Radiation therapy followed surgery for 77% of the patients and margins were positive in all those cases. Median dose was 73.8Gy. Local control, distant metastasis-free survival and overall survival at 3 years were respectively 60%, 48% and 60%. One-sided grade 3 hearing impairment occurred in 46% of the patients.

CONCLUSION

Combining high-dose proton therapy and Tomotherapy is effective and has moderate toxicity in the treatment of T4 sinonasal adenoid cystic carcinoma involving skull base.

Endoscopic sinus surgery for chronic rhinosinusitis in patients previously treated for sinonasal malignancy

OBJECTIVES/HYPOTHESIS

Patients with a history of sinonasal malignancy can develop chronic rhinosinusitis (CRS) as a consequence of their oncologic treatment. Some patients will fail medical management and require endoscopic sinus surgery (ESS). This study reviews the use of ESS in the management of CRS in patients previously treated for sinonasal malignancy.

STUDY DESIGN

Retrospective review.

METHODS

All patients with a history of sinonasal malignancy who developed CRS and underwent ESS were reviewed. Preoperative and postoperative imaging and symptoms were collected. Major complications (bleeding, orbital injury, and cerebrospinal fluid leak) and minor complications (adhesion formation) and postoperative healing were reviewed.

RESULTS

Eighteen patients were identified. All patients presented with symptoms of CRS and sinonasal crusting. Additionally, five patients presented with recurrent facial cellulitis, and six patients had mucoceles. No major complications were encountered. Postoperatively, all patients reported a subjective improvement in their sinonasal symptoms. Comparison of pre- and post-ESS imaging revealed a significant improvement in Lund-Mackay scores after ESS (P < 0.001) from 12.8 (range 5-22) to 7 (range). Despite symptomatic improvement, all patients continued to have nasal crusting. All patients who initially presented with recurrent facial cellulitis had no further episodes after ESS. None of the endoscopically drained mucoceles recurred.

CONCLUSION

For patients previously treated for sinonasal malignancy with refractory CRS, ESS appears to be a safe and effective treatment option. ESS in these patients results in subjective improvement in sinonasal symptoms as well as objective improvement in radiographic CRS disease burden, although sinonasal crusting will likely not resolve.

LEVEL OF EVIDENCE

4.

Incidence and survival patterns of sinonasal undifferentiated carcinoma in the United States

Objective To determine trends in sinonasal undifferentiated carcinoma (SNUC) survival patterns in the United States. Design Retrospective review of national database. Participants All cases of SNUC in the National Cancer Institute's Surveillance Epidemiology and End Results program from 1973 to 2010 were examined. Main Outcome Measures Age-adjusted incidence and survival rates were calculated and stratified by demographic information and treatment modality. Cohort analysis was performed to analyze survival patterns over time. Results A total of 318 SNUC cases were identified. Age-adjusted incidence rate (IR) was 0.02 per 100,000. Incidence was greater in males (IR: 0.03) than females (IR: 0.01; p = 0.03). Overall 5- and 10-year relative survival rate was 34.9% and 31.3%, respectively. Overall median survival was 22.1 months. Median survival following surgery combined with radiation was 41.9 months. Five-year relative survival rate following surgery, radiation, or surgery combined with radiation was 38.7%, 36.0%, and 39.1%, respectively. Median survival from 1973-1986 and 1987-2010 was 14.5 and 23.5 months, respectively. Conclusions This study provides new data regarding survival patterns of SNUC in the United States, confirming survival benefit with surgery and radiation as well as identifying a trend toward improved survival in recent decades.

Adenoid cystic carcinoma of the maxillary sinus: a clinical-pathological report of 10 years of experience from a single institution

Adenoid cystic carcinoma (ACC) is the most common malignant salivary gland tumour of the maxillary sinus. The present study describes 24 cases seen over a period of 10 years at the Brazilian National Cancer Institute. Socio-demographic, clinical, pathological, and follow-up data were retrieved from the medical files for the period 1997-2006. The mean age of the patients was 51.1 years. Twenty-one (87.5%) presented advanced tumours. The main signs and symptoms found were a tumour mass (87.5%), pain (50%), nasal obstruction (25%), and epistaxis (20.8%). Most cases (62.5%) were treated with surgery and radiation therapy. Follow-up data showed two patients (8.3%) with residual disease, local recurrences in four (16.7%) patients, and distant metastasis in five (20.8%). The overall 5- and 10-year survival rates were 72.61% and 62.11%, respectively. Maxillary sinus ACC has an aggressive but indolent behaviour, typically presenting at an advanced T stage that reflects a poor prognosis for patients.

Sinonasal malignancies: long term follow up after surgical management-an analysis of outcomes

Sinonasal malignancies are rare and survival analysis in affected patients is arduous and perplexing due to various factors. In this review article, attempt has been made to overcome some of those factors while analysing survival outcomes.

AIMS AND OBJECTIVES

The aim of this study was to share the experience of a tertiary care centre in the surgical management of sinonasal malignancies over 12 years.

MATERIALS AND METHODS

This study is a retrospective chart review, and in this study, hospital records of 58 patients with biopsy proven sinonasal malignancies were studied. Only the patients undergoing primary or salvage surgery at our institution from May-2000 to April-2012 with a minimum follow up of 2 years were included. Statistical analyses such as means, proportions, Kaplan-Meier analysis and Cox's regression model were done.

RESULTS

Majority of the patients were males (n = 43) belonging to fourth and fifth decades. Squamous cell carcinoma was the most common (n = 17) histopathological type, followed by adenoid cystic carcinoma (n = 14). Majority presented with stage IV disease (n = 42). 17 patients were operated for recurrent disease. Over all 5 year survival was 72 % and disease free survival was 44 %. Separate analysis for epithelial and matched non-epithelial group showed poorer prognosis with epithelial group (p = 0.0120). Multivariate analysis showed histopathological type (epithelial) and presence of pathological risk factors (positive margins and/or perineural invasion) affecting survival.

CONCLUSIONS

Advanced stage presentation is the norm for sinonasal malignancies. This study noted a 5 year overall survival of 72 % and disease free survival of 44 %. Epithelial histopathology carries poorer prognosis then other counterparts and incomplete removal is shown to add to poor prognosis independently.

Advanced Ethmoid Sinus Adenocarcinoma Presenting as Temporary Exudative Retinal Detachment

We describe the case of a 70-year-old male patient with ethmoid sinus adenocarcinoma who developed an exudative retinal detachment (ERD) in the right eye as the first manifestation. Two weeks after presentation, total regression of the ERD was noted. Extensive investigations for local causes of ERD were unrewarding. Finally, we performed a computed tomography scanning of the head that revealed an ethmoidal mass extending to the orbit. The diagnosis of adenocarcinoma was confirmed by biopsy. Neoplastic phenomena should be considered in patients presenting with temporary ERD.

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.

Aggressive inflammatory and neoplastic processes of the paranasal sinuses

Although uncommon, sinonasal malignancies and aggressive inflammatory processes are entities every radiologist will encounter during the evaluation of routine sinus imaging studies. A high index of suspicion is necessary for prompt diagnosis. It is important to consider aggressive inflammatory disease in all patients having routine sinus computed tomography because any delay in diagnosis can adversely affect the patients' care. Magnetic resonance (MR) will often provide a better assessment of the lesion extent, allowing for better surgical treatment. MR is crucial for the accurate assessment of neoplastic lesions. A proficient understanding of the complex anatomy of the region is essential.

A national series of 244 sinonasal cancers in Finland in 1990-2004

Sinonasal cancer is still a somewhat controversial entity because most series are single-center studies. The aim of this study was to give more accurate and generalisable information about treatment of the neck and prognosis of sinonasal cancer. Retrospective, population-based, multicentre study. Altogether 244 patients diagnosed in 1990-2004 were evaluated. The 3- and 5-year disease-specific survival (DSS) rates after treatment with curative intent were 68 and 57%, respectively. Regional status at the time of the diagnosis (P < 0.001, log rank) and local recurrence (P = 0.02, log rank) during the follow-up had a statistically significant effect on DSS. Initially 13% of the patients were diagnosed with neck metastasis. The proportion of regional recurrences during the follow-up was 9%, but it did not have a statistically significant impact on DSS (P = 0.68, log rank). Histopathology had no statistically significant impact on survival in this material of 244 patients. In conclusion, routine elective neck treatment of all sinonasal cancer patients is not recommended, but the importance of the treatment of the primary location is emphasised.

Clinical value of office-based endoscopic incisional biopsy in diagnosis of nasal cavity masses

OBJECTIVE

To evaluate clinical features and the diagnostic accuracy of office-based endoscopic incisional biopsy in patients with nasal cavity masses.

STUDY DESIGN

Diagnostic test assessment with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

From January 1997 to August 2006, preoperative diagnosis was achieved using endoscopic incisional biopsy in 521 patients. Cytopathologic and histologic findings were categorized as malignancy, benign neoplasm, or non-neoplastic lesion. Preoperative imaging was done in 462 patients (computed tomography: 438 cases; magnetic resonance imaging: 24 cases). We investigated the accuracy of endoscopic incisional biopsy and preoperative imaging by comparing it with pathologic results from tumor resection as the "gold standard."

RESULTS

Most of the patients had unilateral nasal symptoms (e.g., nasal obstruction, unilateral epistaxis, unilateral facial pain), and the clinical symptoms were of little diagnostic value in the differentiation of tumor and inflammatory lesion. The sensitivity and specificity of endoscopic incisional biopsy were 43.7 and 98.9 percent, respectively, for the diagnosis of nasal cavity malignancies, and 78.2 and 96.2 percent, respectively, for the diagnosis of benign neoplasms. The sensitivity and specificity of preoperative imaging were 78.3 and 97.5 percent, respectively, for the diagnosis of nasal cavity malignancies and 66.4 and 86.3 percent, respectively, for the diagnosis of benign neoplasms. Combining the two modalities increased diagnostic accuracy in nasal cavity masses.

CONCLUSION

Endoscopic incisional biopsy alone did not ensure accurate diagnosis of nasal cavity tumors, but in combination with preoperative imaging it was helpful for the diagnosis of nasal cavity malignancies.

Treatment monitoring of paranasal sinus tumors by magnetic resonance imaging

Treatment monitoring of paranasal tumors is crucial, given the high rate of local and regional relapses that impairs the overall prognosis of patients. Magnetic resonance imaging (MRI) is the technique of choice to detect changes in the submucosa and deep spaces of the suprahyoid neck, inaccessible at clinical and endoscopic assessment. Correct interpretation of MRI requires detailed knowledge of the treatment applied and of the changes treatments are supposed to produce on macroscopic anatomy and tissue signals. Once such background of information is obtained, detection of recurrences is a less challenging task.

Extent of surgery in the management of locally advanced sinonasal malignancies

BACKGROUND

The relative importance of surgery within multimodality regimens commonly used to treat advanced sinonasal malignancies remains unknown.

METHODS

One hundred two patients with locally advanced sinonasal cancers treated with proton beam radiation therapy with or without surgery were retrospectively reviewed. Extent of surgery and outcome variables of local control, disease-free survival, and overall survival were evaluated. Patterns of failure were also assessed.

RESULTS

Extent of surgery correlated with disease-free survival and overall survival rates. Local control rate, however, was independent of the degree of surgical resection achieved. Overall, treatment failure most commonly resulted from distant metastases, which occurred in 30% of patients and also correlated with extent of surgical resection. Tumor type-specific outcomes reveal differences associated with the extent of surgery achieved.

CONCLUSION

High-dose radiotherapy with proton beam resulted in excellent local control rates in patients with locally advanced sinonasal cancer, irrespective of the extent of surgery. Complete resection, however, was predictive of improved disease-free survival and decreased rate of distant metastasis.

Management of paranasal sinus malignancy

Malignancies of the nasal cavity and paranasal sinuses represent a wide spectrum of histologies, tissues of origin, and anatomic primary sites. The inherent difficulty in generalizing treatment approaches is obvious, given the numerous variables associated with the broadly-based term, paranasal sinus malignancy (PNSCa). Nevertheless, the majority of epithelial and salivary malignancies of this region (ie, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, sinonasal undifferentiated carcinoma, and esthesioneuroblastoma) require surgical intervention as part of any treatment regimen. Recent trends have broadened the indications for chemotherapeutic and radiotherapeutic options in the management of advanced PNSCa. Nonepithelial malignancies, including the wide variety of sarcomas arising in this region, most commonly require multimodality treatment including chemotherapy, radiation, and/or surgery for definitive treatment. Moreover, the proximity of the nasal cavity and paranasal sinuses to structures including the orbit, dura, brain, cranial nerves, and carotid arteries mandates careful radiologic and neurologic evaluations throughout the course of the disease. Surgical advances now permit complex tumor removal and reconstruction surrounding these structures resulting in functional and cosmetic improvements when compared to earlier techniques. However, additional clinical trials are necessary to systematically evaluate the locoregional control, organ-preservation strategies, and survival related to the variety of treatments currently available.