Paranasal sinuses and nasopharynx CT and MRI

Development of an evaluation and treatment strategy for olfactory neuroblastoma: a review of evidence from large-scale studies, including population-based and multicenter studies, and meta-analyses

Olfactory neuroblastoma is a rare sinonasal malignancy arising from the olfactory epithelium that is characterized by skull base involvement and a modest natural history. Because of its rarity and long course, identification of independent prognostic factors is dependent on multivariate analysis of large, long-term data. In this review, we outline evidence for the evaluation and treatment of olfactory neuroblastoma obtained from recent large-scale population-based studies, meta-analyses and multicenter studies. Hyams grade is currently the only pathological grade system for olfactory neuroblastoma. The modified Kadish staging and Dulguerov classification are available for clinical staging. The results of large-scale studies have confirmed Hyams, the modified Kadish and Dulguerov as independent prognostic factors. Surgery followed by radiotherapy provides the best overall survival and recurrence-free survival for resectable disease. The question of whether postoperative radiotherapy should be administered for all cases or only for those at risk of recurrence remains unanswered. Exclusively endoscopic resection is indicated for modified Kadish A/B cases without any increase in the risk of death or recurrence, and is also indicated for modified Kadish C cases if a negative surgical margin is ensured. For more advanced cases, such as those with extensive brain infiltration, the open approach is indicated. Elective nodal irradiation prevents late nodal recurrence of N0 patients. Chemotherapy has failed to show a benefit in survival or disease control. Current needs for olfactory neuroblastoma include the development and validation of refined staging systems suitable for current practice; expansion of indications for endoscopic surgery; less invasive surgery; definitive radiotherapy and novel systemic therapy.

Review of olfactory cleft roof anatomy

Progress in skull-base endoscopic surgery has improved our knowledge of olfactory cleft (OC) anatomy. This article presents a review of current knowledge concerning the OC roof: descriptive anatomy, radiological exploration, and endoscopic observation. The OC is a narrow area in the most superior part of the nasal cavity. Its roof is the thinnest structure separating the nasal cavities from the brain; it comprises three superimposed tissues: nasal mucosa, ethmoid cribriform plate (ECP), and dura mater. The ECP comprises the anterior ECP containing the ethmoidal slit (ES) medially and the cribroethmoidal foramen (CEF) laterally; and the posterior ECP, comprising the olfactory foramina. The OC roof is bordered anteriorly by the nasal bone roof, laterally by the lateral ethmoid masses, and posteriorly by the jugum and anterior wall of the sphenoid sinuses. Imaging is crucial for analyzing this wall, providing precise detailed information on conformation and anatomic relations with adjacent structures such as the anterior ethmoidal artery. Understanding OC roof anatomy and correct interpretation of imaging are essential for safety in present-day functional endoscopic sinus surgery and anterior skull-base oncologic surgery.

Post-Irradiation Sinus Mucosa Disease in Nasopharyngeal Carcinoma Patients Treated with Intensity-Modulated Proton Therapy

Simple Summary

Chronic rhinosinusitis (CRS) is a common treatment complication in patients with nasopharyngeal carcinoma (NPC) after radiotherapy. In this study, we aimed to investigate the incidence and severity of CRS in NPC patients who underwent intensity-modulated proton therapy (IMPT) by evaluating the sinus mucosa change in imaging studies, and we compared these patients with those who underwent volume-modulated arc therapy (VMAT). This was a retrospective case–control study in which 53 and 54 patients were treated with IMPT and VMAT, respectively. We noted that patients in the IMPT group had a significantly lower incidence and decreased severity of sinus mucosa abnormality than those with VMAT. Better and faster recovery of sinonasal function after radiotherapy in the IMPT group was also observed. IMPT techniques deposit the bulk of their radiation doses in highly confined areas, allowing lower exposure of non-target organs during irradiation, which results in more sinonasal mucosa being retained.

Abstract

In the past decade, patients with nasopharyngeal cancer (NPC) have been deemed candidates for proton radiotherapy, due to the large and comprehensive target volumes and the necessity for the retention of the surrounding healthy tissues. In this study, we aimed to compare the incidence and severity of post-irradiation sinusitis by detecting sinus mucosa diseases (SMDs) via the magnetic resonance imaging (MRI) of patients with NPC after intensity-modulated proton therapy (IMPT) and volume-modulated arc therapy (VMAT). A total of 53 patients in the IMPT group and 54 patients in the VMAT group were enrolled in this study. There were significantly lower endoscopic scores and Lund–Mackay staging scores determined from MRI scans in the IMPT group during different follow-up periods. For the most vulnerable sinuses, the incidence and severity of SMD were the highest during the third post-radiotherapy month in both groups. These decreased steadily, and there was no significant increase in the incidence and severity of SMD during the second post-radiotherapy year in the IMPT group. Our data show that NPC patients with IMPT have a significantly lower incidence and decreased severity of SMD than those with VMAT. A better and faster recovery of sinonasal function after radiotherapy in the IMPT group was also observed.

Detailed comparison of anatomy and airflow dynamics in human and cynomolgus monkey nasal cavity

Nonhuman primates are occasionally used as laboratory models for sophisticated medical research as they bear the closest resemblance to humans in morphometry and physiological functions. A range of nonhuman primate species have been employed in the inhalation toxicity, nasal drug delivery and respiratory viral infection studies, and they provided valuable insight to disease pathogenesis while other laboratory animals such as rodents cannot recapitulate due to the lesser degree of similarity in metabolism, anatomy and cellular response to that of humans. It is anticipated that nonhuman primate models of respiratory diseases will continue to be instrumental for translating biomedical research for improvement of human health, and the confidence in laboratory data extrapolation between species will play a pivotal role. From the morphometry and flow dynamics point of view, this study performed a detailed comparative analysis between human and a cynomolgus monkey nasal airway, with intention to provide high-fidelity qualitative and quantitative linkage between the two species for more effective laboratory data extrapolation. The study revealed that cynomolgus monkey could be a good human surrogate in nasal inhalation studies; however, care should be given for interspecies data extrapolation as subtle differences in anatomy and airflow dynamics were present between the two species.

Diffusion-Weighted Magnetic Resonance Imaging in Maxillary Sinuses Inflammatory Diseases: Report of Three Cases and Literature Review

Background

Magnetic resonance imaging is considered a preferable imaging examination in the diagnosis of inflammatory maxillary sinus disease and can provide precise sinonasal characterization. Diffusion-weighted magnetic resonance imaging and apparent diffusion coefficient are complementary magnetic resonance imaging tools that can be applied to the differentiation of sinus diseases. In this report, 3 cases of inflammatory maxillary sinus diseases imaging findings considering diffusion-weighted magnetic resonance imaging features were described. Additionally, a literature review considering the use of diffusion-weighted magnetic resonance imaging in inflammatory lesions is provided.

Methods

The cases reported were: presence of air-fluid levels, mucosal thickening and a mucous retention cyst. Conventional magnetic resonance imaging and apparent diffusion coefficient (ADC) maps, with ADC values were demonstrated. In the literature review, the studies considering inflammatory lesions were detailed, as well as ADC values established by investigators.

Results

ADC values for presence of air-fluid levels, mucosal thickening and mucous retention cyst were respectively: 1.99 x 10^-3 mm²/s; 1.83 x 10^-3 mm²/s; 2.05 x 10^-3 mm²/s.

Conclusions

It was observed that apparent diffusion coefficient values from the inflammatory lesions described in this report were different and apparent diffusion coefficient may be useful in the differentiation of these maxillary sinus alterations. Further larger sample investigations considering apparent diffusion coefficient values focusing in inflammatory lesions are recommended. The lack of studies considering the use of diffusion-weighted magnetic resonance imaging on inflammatory diseases diagnostic was the major limitation to the literature review.

Repeatability and agreement of ultrasonography with computed tomography for evaluating forefoot structure in the coronal plane

Background

Forefoot structure is important to understand some foot problems such as hallux valgus and metatarsalgia. Ultrasonography (US) is a highly portable, noninvasive, low cost, and fast imaging method, especially when compared to magnetic resonance imaging (MRI), computed tomography (CT), and radiography. As the use of US for evaluating forefoot bony structure has not been validated, except for the presence of synovitis, erosions and bursitis within the forefoot in people with inflammatory arthritis, the purpose of this study was to determine whether US is a reliable method for evaluating forefoot structure.

Methods

Sixty feet (30 women, age = 40.1 ± 11.8 years) were examined by US and CT to assess agreement with CT and repeatability of US evaluation of the 2nd metatarsal head height, length between the medial sesamoid bone and 5th metatarsal head, transverse arch height, transverse arch index, sesamoid rotation angle, and area under the transverse arch. The measurement data were evaluated for agreement with CT using the intra-class correlation coefficient (ICC)_{3, 1}, Pearson correlation coefficient, and Bland-Altman plot, and with ICC_{1, 1} for repeatability.

Results

The ICC_{3, 1} values of 0.78–0.89, Pearson correlation coefficient of 0.78–0.90, and Bland-Altman plots showed almost perfect agreements between the US and CT method for all parameters, except the area under the transverse arch (AUTA). The ICC_{1, 1} also showed perfect agreements (0.84–0.92) between two sets of US measurements in all parameters.

Conclusions

The US evaluation of forefoot structure in the coronal plane showed good agreement with CT and repeatability of two ultrasonograms in adult women. This reliable evaluation method of forefoot structure can contribute to a quick clinical assessment screening for risk factors of foot problems such as hallux valgus and metatarsalgia. However, because of some limitations such as a lack of inter-observer reliability, more research is needed to validate US evaluation of forefoot structure.

Trial registration

The current study (trial registration number: R0297) was approved by the Ethical Committee for Human Experiments of Kyoto University (http://www.ec.med.kyoto-u.ac.jp) on December 3, 2015. The first participant in this study was enrolled on November 17, 2015 and retrospectively registered.

Spectral characterization of tissues in high spectral and spatial resolution MR images: Implications for a classification-based synthetic CT algorithm

PURPOSE

To characterize the spectral parameters of tissues with high spectral and spatial resolution magnetic resonance images to be used as a foundation for a classification-based synthetic CT algorithm.

METHODS

A phantom was constructed consisting of a section of fresh beef leg with bone embedded in 1% agarose gel. The high spectral and spatial (HiSS) resolution MR imaging sequence used had 1.0 mm in-plane resolution and 11.1 Hz spectral resolution. This sequence was used to image the phantom and one patient. Post-processing was performed off-line with IDL and included Fourier transformation of the time-domain data, labeling of fat and water peaks, and fitting the magnitude spectra with Lorentzian functions. Images of the peak height and peak integral of both the water and fat resonances were generated and analyzed. Several regions-of-interest (ROIs) were identified in phantom: bone marrow, cortical bone, adipose tissue, muscle, agar gel, and air; in the patient, no agar gel was present but an ROI of saline in the bladder was analyzed. All spectra were normalized by the noise within each voxel; thus, all parameters are reported in terms of signal-to-noise (SNR). The distributions of tissue spectral parameters were analyzed and scatterplots generated. Water peak height in cortical bone was compared to air using a nonparametric t-test. Composition of the various ROIs in terms of water, fat, or fat and water was also reported.

RESULTS

In phantom, the scatterplot of peak height (water versus fat) showed good separation of bone marrow and adipose tissue. Water versus fat integral scatterplot showed better separation of muscle and cortical bone than the peak height scatterplot. In the patient data, the distributions of water and fat peak heights were similar to that in phantom, with more overlap of bone marrow and cortical bone than observed in phantom. The relationship between bone marrow and cortical bone for peak integral was better separated than those of peak heights in the patient data. For both the phantom and patient, there was a significant amount of overlap in spectral parameters of cortical bone versus air.

CONCLUSION

These results show promising results for utilizing HiSS imaging in a classification-based synthetic CT algorithm. Cortical bone and air overlap was expected due to the short T2* of bone; reducing early echo times would improve the SNR in bone and image data from these early echoes could help differentiate these tissue types. Further studies need to be done with the goal of better separation of air and bone, and to extend the concept to volumetric imaging before it can be clinically applied.

Ten years of experience in clinicopathologic characteristics, treatment and outcome of patients with nasopharyngeal pathologies in Yazd, Iran

Introduction

Although there are some studies regarding the clinical characteristics and outcome of nasopharyngeal tumors, one such study from Iran has not been reported to date. This study aimed to evaluate the clinical features, treatment, and consequences of nasopharyngeal lesions.

Methods

In this cross sectional study, we conducted a retrospective review of patients who were diagnosed with nasopharyngeal pathologies and treated at Shahid Sadoughi Hospital and Shahid Ramazanzadeh Radiotherapy Center in Yazd, Iran, over a period of 10 years (from 2005 to 2014). The variables in the study were the patient’s hospital registration number, date, name, age, gender, address, topography, clinical symptoms, morphology, stage, types of treatment, and survival for each subject. Survival data were analyzed using Kaplan-Meier estimates, and multivariate analysis was performed using the Cox regression method. Statistical analyses were performed using IBM-SPSS, version 22.

Results

In the study, there were 123 patients, 85 males and 38 females, who had nasopharyngeal lesions. The mean age at diagnosis was 41.51 ± 20.33 years. There were 83 patients with malignant neoplasms and 40 patients with non-malignant lesions. The most common malignant tumor was nasopharyngeal carcinoma, and the most common benign lesion was angiofibroma. Survival analysis was performed for the 83 patients who had malignant neoplasms, and survival was found to be 94.5 ± 4.32 months. There were significant differences in survival based on the stage of the disease, histological type, and the type of treatment (p = 0.001, 0.02, and 0.003, respectively).

Conclusion

In our institutional study, malignant tumors were more common than benign lesions. Patients with nasopharyngeal carcinoma presented relatively late and at an advanced stage. Regular follow-up is necessary for early detection, recurrence, or metastases of malignant tumors.

Diagnosis and treatment of a rare sinonasal neuroendocrine tumour: adding to the evidence

Sinonasal neuroendocrine tumours (NETs) are rare, aggressive neoplasms with a high recurrence potential. There are no robust protocols for the management of these tumours. An 81-year-old man presented with an incidental sinonasal mass visualised on CT scan of head. Over the next few weeks he developed new onset, progressively worsening headache, right eye ptosis and restricted extraocular movements. Imaging confirmed a rapidly enlarging tumour involving the right nasal cavity and the orbit. Biopsy showed a large cell neuroendocrine carcinoma of the right ethmoidal sinus. The patient was treated with concurrent cisplatin chemotherapy and radiation. Repeat imaging showed decrease in tumour volume. The patient continues to do well and follows up regularly with our oncology service. Current protocols comprising chemotherapy after radiation are based on limited studies. A regimen involving concurrent chemoradiation also appears to aid in tumour volume reduction. Additional studies are required to formulate robust clinical protocols for management of sinonasal NETs.

Imaging Characteristics of Olfactory Neuroblastoma (Esthesioneuroblastoma)

This presentation outlines the clinical and imaging characteristics of esthesioneuroblastoma.

A Method for Accurate Reconstructions of the Upper Airway Using Magnetic Resonance Images

Objective

The purpose of this study is to provide an optimized method to reconstruct the structure of the upper airway (UA) based on magnetic resonance imaging (MRI) that can faithfully show the anatomical structure with a smooth surface without artificial modifications.

Methods

MRI was performed on the head and neck of a healthy young male participant in the axial, coronal and sagittal planes to acquire images of the UA. The level set method was used to segment the boundary of the UA. The boundaries in the three scanning planes were registered according to the positions of crossing points and anatomical characteristics using a Matlab program. Finally, the three-dimensional (3D) NURBS (Non-Uniform Rational B-Splines) surface of the UA was constructed using the registered boundaries in all three different planes.

Results

A smooth 3D structure of the UA was constructed, which captured the anatomical features from the three anatomical planes, particularly the location of the anterior wall of the nasopharynx. The volume and area of every cross section of the UA can be calculated from the constructed 3D model of UA.

Conclusions

A complete scheme of reconstruction of the UA was proposed, which can be used to measure and evaluate the 3D upper airway accurately.

Sinus mucosa status in patients with nasopharyngeal carcinoma treated with intensity-modulated radiotherapy: A 5-year follow-up

BACKGROUND

Sinus mucosa abnormalities on image studies, which is the major diagnostic measure for sinusitis, were investigated in patients with nasopharyngeal carcinoma (NPC) after intensity-modulated radiotherapy (IMRT).

METHODS

A retrospective review of the MRIs for patients with NPC was conducted. Sinus mucosa abnormalities were staged by the Lund-Mackay system.

RESULTS

A total of 94 patients were enrolled in this study. The rate and severity of sinus abnormalities were highest on the third postradiotherapy month (p < .005, t test). There was no significant increase in the incidence of abnormalities on the fifth postradiotherapy year (t test). The anterior ethmoid and maxillary sinuses were the most affected sinuses before and after radiotherapy (p < .005, chi-square test).

CONCLUSION

Our data showed that the anterior ethmoid and maxillary sinuses were the most vulnerable sinuses for therapeutic toxicity after IMRT in patients with NPC. In the long run, however, the application of IMRT does not significantly increase the incidence of sinus toxicities.

Computed tomographic anatomy of the nasal cavity, paranasal sinuses and tympanic cavity of the koala

OBJECTIVE

To use cross-sectional imaging (helical computed tomography (CT)) combined with conventional anatomical dissection to define the normal anatomy of the nasal cavity and bony cavitations of the koala skull.

METHODS

Helical CT scans of the heads of nine adult animals were obtained using a multislice scanner acquiring thin slices reconstructed in the transverse, sagittal and dorsal planes. Subsequent anatomical dissection permitted confirmation of correct identification and further delineation of bony and air-filled structures visible in axial and multiplanar reformatted CT images.

RESULTS

The nasal cavity was relatively simple, with little scrolling of nasal conchae, but bony cavitations were complex and extensive. A rostral maxillary recess and ventral conchal, caudal maxillary, frontal and sphenoidal paranasal sinuses were identified and characterised. Extensive temporal bone cavitation was shown to be related to a large epitympanic recess.

CONCLUSIONS

The detailed anatomical data provided are applicable to future functional and comparative anatomical studies, as well as providing a preliminary atlas for clinical investigation of conditions such as cryptococcal rhinosinusitis, a condition more common in the koala than in many other species.

The feasibility of omitting irradiation to the contralateral lower neck in stage N1 nasopharyngeal carcinoma patients

Purpose

This study was conducted to analyze the feasibility of omitting irradiation to the contralateral lower neck in stage N1 nasopharyngeal carcinoma (NPC) patients.

Materials and methods

From July 2008 to January 2012, 52 patients with stage N1 NPC were analyzed. All patients were treated with intensity-modulated radiation therapy (IMRT) and received bilateral upper neck irradiation to levels II, III and VA and ipsilateral lower neck irradiation to levels IV and VB. The contralateral lower neck irradiation was omitted.

Results

The median follow-up was 29 months (range, 12–52 months). The 3-year overall survival (OS) rate, progress-free survival (PFS), local failure-free (LFS), nodal recurrence-free survival (NFS) and distant metastasis-free survival (DMFS) rates were 92.2%, 94.1%, 94.3%, 98% and 94.1%, respectively. Only one patient developed a neck recurrence in the irradiation field, while no patients experienced out-of-field nodal recurrence. Univariate analysis suggested that T classification was the only significant prognostic factor for overall survival, and age was significantly associated with PFS. Multivariate analyses indicated that age was also a predictor for overall survival. The elective neck irradiation procedure was not a significant predictor for all of the treatment results.

Conclusion

Selective irradiation to bilateral levels of II, III and VA and unilateral levels of IV and VB, omitted the contralateral lower neck in a proportion of patients with N1 stage NPC was safe and practicable.

Commissioning of a new wide-bore MRI scanner for radiotherapy planning of head and neck cancer

OBJECTIVE

A combination of CT and MRI is recommended for radiotherapy planning of head and neck cancers, and optimal spatial co-registration is achieved by imaging in the treatment position using the necessary immobilisation devices on both occasions, something which requires wide-bore scanners. Quality assurance experiments were carried out to commission a newly installed 1.5-T wide-bore MRI scanner and a dedicated, flexible six-channel phased array head and neck coil.

METHODS

Signal-to-noise ratio (SNR) and spatial signal uniformity were quantified using a homogeneous aqueous phantom, and geometric distortion was quantified using a phantom with water-filled fiducials in a grid pattern. Volunteer scans were also used to determine the in vivo image quality. Clinically relevant T1 weighted and T2 weighted fat-suppressed sequences were assessed in multiple scan planes (both sequences fast spin echo based). The performance of two online signal uniformity correction schemes, one utilising low-resolution reference scans and the other not utilising low-resolution reference scans, was compared.

RESULTS

Geometric distortions, for a ±35-kHz bandwidth, were <1 mm for locations within 10 cm of the isocentre rising to 1.8 mm at 18 cm away. SNR was above 50, and uniformity in the axial plane was 71% and 95% before and after uniformity correction, respectively.

CONCLUSION

The combined performance of the wide-bore scanner and the dedicated coil was adjudged adequate, although superior-inferior spatial coverage was slightly limited in the lower neck.

ADVANCES IN KNOWLEDGE

These results will be of interest to the increasing number of oncology centres that are seeking to incorporate MRI into planning practice using dedicated equipment.

In vitro evaluation of the L-peptide modified magnetic lipid nanoparticles as targeted magnetic resonance imaging contrast agent for the nasopharyngeal cancer

The purpose of this study was to analyze the encapsulation of superparamagnetic iron oxide nanoparticles (SPION) by the lipid nanoparticle conjugated with the 12-mer peptides (RLLDTNRPLLPY, L-peptide), and the delivery of this complex into living cells. The lipid nanoparticles employed in this work were highly hydrophilic, stable, and contained poly(ethylene-glycol) for conjugation to the bioactive L-peptide. The particle sizes of two different magnetic lipid nanoparticles, L-peptide modified (LML) and non-L-peptide modified (ML), were both around 170 nm with a narrow range of size disparity. The transversal relaxivity, r2, for both LML and ML nanoparticles were found to be significantly higher than the longitudinal relaxivity r1 (r2/r1 > 20). The in vitro tumor cell targeting efficacy of the LML nanoparticles were evaluated and compared to the ML nanoparticles, upon observing cellular uptake of magnetic lipid nanoparticles by the nasopharyngeal carcinoma cells, which express cell surface specific protein for the L-peptide binding revealed. In the Prussian blue staining experiment, cells incubated with LML nanoparticles indicated much higher intracellular iron density than cells incubated with only the ML and SPION nanoparticles. In addition, the MTT assay showed the negligible cell cytotoxicity for LML, ML and SPION nanoparticles. The MR imaging studies demonstrate the better T2-weighted images for the LML-nanoparticle-loaded nasopharyngeal carcinoma cells than the ML- and SPION-loaded cells.

Diagnostic value of 2D and 3D imaging in odontogenic maxillary sinusitis: a review of literature

This review aims to explore whether 3D imaging offers an added value in diagnosis of odontogenic sinusitis. Odontogenic maxillary sinusitis accounts for approximately 10-12% of maxillary sinusitis cases. Proper diagnosis of odontogenic sinusitis is based on a thorough dental and medical examination and crucial to ensure therapeutic efficacy. To establish the odontogenic cause of maxillary sinusitis, 2D and 3D imaging modalities may be considered, each presenting distinct advantages and drawbacks. The available research indicates that 2D imaging modalities may often mask the origin of odontogenic maxillary sinusitis. This limitation is particularly evident in the maxillary molar region, stressing the need for 3D cross-sectional imaging. The advent of low-dose cone beam computed tomography in dentistry may be particularly useful when odontogenic maxillary sinusitis is not responsive to therapy. Yet, it seems that more research is needed to validate its use in odontogenic maxillary sinusitis.

Assessment of nasal fibroscopy to explore olfactory cleft

OBJECTIVE

To assess whether flexible nasoendoscopy can be used to visualize all parts of the olfactory cleft (OC) without morbidity.

STUDY DESIGN

Single-center, prospective, observational study.

SETTING

French tertiary referral center.

SUBJECTS AND METHODS

100 consecutive patients were divided in 2 groups of 50. Group 1 underwent nasal fibroscopy without vasoconstriction or local anesthesia with an endosheath- protected endoscope. Group 2 was examined by a fiberscope without an endosheath after application of naphazoline Xylocaine. Each OC was divided in 16 items recorded as visualized or not. Four scores were compared between both groups: out of 16 (1 side), out of 32 (both sides), out of 12 concerning only the narrowest and highest bilateral spaces, and out of 4 to divide these specific areas in anterior, middle, and posterior parts. Length of procedure, pain, epistaxis, blood mark on the endosheath, sneezing, rhinorrhea, and causes of failure were recorded.

RESULTS

There was no significant difference between both groups concerning score out of 16 or 32. The visibility of the narrower and higher spaces was better in group 2: scores out of 12 were significantly different between the groups (P = .025), as were scores out of 4 for the anterior and middle parts of the OC (P = .02 and .01 respectively). Morbidity was low without differences between the groups. Deviated nasal septum was the only cause of failure and increased the patients' pain during the examination (P = .045).

CONCLUSION

Nasal fibroscopy could be used to explore the different portions of the OC efficiently and with low morbidity.

Contralateral maxillary sinus lesions in patients with nasal cavity and/or paranasal sinus carcinoma: analysis of computed tomography findings

OBJECTIVES

The incidence of bilateral maxillary sinus carcinoma is very low in patients with primary maxillary sinus carcinoma. However, surgeons should perform careful diagnosis of any contralateral maxillary sinus lesions to avoid missing a second primary maxillary sinus carcinoma. We therefore investigated the computed tomography (CT) findings of the contralateral maxillary sinus in patients with nasal cavity and/or paranasal sinus carcinoma.

METHODS

Between August 1994 and September 2006, 66 patients (41 male, 25 female; age range, 22 to 85 years; mean age, 56.9 years) with nasal and/or paranasal sinus carcinoma were treated. Preoperative and follow-up CT scans of their contralateral maxillary sinuses were retrospectively reviewed.

RESULTS

Of the 66 patients, 26 (39.4%) had rhinosinusitis, 6 (9.1%) had retention cysts, and 33 (50.0%) showed normal findings on CT. One patient (1.5%) had bilateral enhanced mass-like lesions. Both masses were diagnosed histologically as poorly differentiated squamous cell carcinoma. The rhinosinusitis findings included mucoperiosteal thickening, sclerotic bone thickening, hyperdense secretion, and an air-fluid level, in order of decreasing frequency. Twenty-three of the 32 patients with benign lesions were included in the follow-up CT analysis, ranging from 24 to 108 months (mean, 45 months). On the final CT scan, rhinosinusitis was aggravated in 5 of 19 cases and improved in 14 cases, and the size of the retention cyst decreased in 4 cases. During the follow-up period, no definite abnormality suggesting tumor development in the contralateral maxillary sinus was detected.

CONCLUSIONS

Even though most contralateral maxillary sinus lesions are benign and the incidence of bilateral maxillary sinus carcinoma is very low, second primary maxillary sinus carcinoma should be kept in mind in the differential diagnosis of contralateral maxillary sinus lesions in patients with nasal cavity and/or paranasal sinus carcinoma.

Nasopharyngeal carcinoma: the impact of CT-scan and of MRI on staging, radiotherapy treatment planning, and outcome of the disease

The present study is a critical review of the role of computed tomography (CT) and magnetic resonance imaging (MRI) in the diagnosis and therapy of nasopharyngeal cancer. It is estimated that following CT-scan/MRI, T,N staging of the disease changes in about half of cases, which results in important adjustments of the radiotherapy treatment planning, both in terms of radiation field dimensions and of dose specifications. The development of novel technology with CT-scan-simulated 3-D conformal or intensity-modulated radiotherapy (IMRT) planning is gradually becoming the standard therapy for nasopharyngeal carcinoma (NPC). CT-scan/MRI is also of value in detecting massive parapharyngeal involvement, low-neck lymphadenopathy or fixation of nodes onto adjacent structures, which are important features indicating the necessity to integrate chemotherapy or surgical neck dissection in the overall treatment policy. CT-positron emission tomography (PET) scan is recently under evaluation for the identification of the most active tumor regions, which will allow a biological radiotherapy planning (RTP) using IMRT techniques.

Phase II study of neoadjuvant carboplatin and paclitaxel followed by radiotherapy and concurrent cisplatin in patients with locoregionally advanced nasopharyngeal carcinoma: therapeutic monitoring with plasma Epstein-Barr virus DNA

PURPOSE

To assess the efficacy of neoadjuvant paclitaxel and carboplatin (TC) followed by concurrent cisplatin and radiotherapy (RT) in patients with locoregionally advanced nasopharyngeal carcinoma (NPC) and to monitor treatment response with plasma Epstein-Barr virus (EBV) DNA.

PATIENTS AND METHODS

Thirty-one patients with International Union Against Cancer stages III and IV undifferentiated NPC had two cycles of paclitaxel (70 mg/m2 on days 1, 8, and 15) and carboplatin (area under the curve 6 mg/mL/min on day 1) on a 3-weekly cycle, followed by 6 to 8 weeks of cisplatin (40 mg/m2 weekly) and RT at 66 Gy in 2-Gy fractions. Plasma EBV DNA was measured serially using the real-time quantitative polymerase chain reaction method. Results All patients completed planned treatment. Response to neoadjuvant TC was as follows: 12 patients (39%) achieved partial response (PR) and 18 achieved (58%) complete response (CR) in regional nodes; five patients (16%) achieved PR and no patients achieved CR in nasopharynx. At 6 weeks after RT, one patient (3%) achieved PR and 30 patients (97%) achieved CR in regional nodes, and 31 patients (100%) achieved CR in nasopharynx; 29 patients (93%) had EBV DNA level of less than 500 copies/mL. Neoadjuvant TC was well tolerated, and the most common acute toxicity of cisplatin plus RT was grade 3 mucositis (55%). At median follow-up of 33.7 months (range, 7 to 39.3 months), six distant and three locoregional failures occurred. Plasma EBV DNA level increased significantly in eight of nine patients who experienced treatment failure but did not increase in those who did not. The 2-year overall and progression-free survival rates were 91.8% and 78.5%, respectively. CONCLUSION This strategy was feasible and resulted in excellent local tumor control. Serial plasma EBV DNA provides a noninvasive method of monitoring response in NPC.

The unilateral opaque maxillary sinus on computed tomography

Computed tomography (CT) is the imaging method of choice for conditions that affect the paranasal sinuses. We reviewed all paranasal CT scans in the ear nose and throat (ENT) and maxillofacial surgery departments in 1 year. Of these 372 scans, unilateral opacity of the maxillary sinus was seen in 20 cases. Neoplastic disease was diagnosed in six of these, four of which were malignant. We describe the cases of neoplastic disease, particularly features of the history, examination, and scans that should alert the clinician to the possibility of sinister pathology. We emphasise the importance of nasendoscopic examination in the accurate assessment of sinonasal disease.

Irradiation of paranasal sinus tumors, a delineation and dose comparison study

PURPOSE

To determine the influence of observer variation and treatment planner variation on the dose delivered to the target and normal structures when irradiating paranasal sinus carcinomas.

PATIENTS AND METHODS

Nine patients with paranasal sinus tumors underwent debulking surgery and subsequent radiation therapy. Two observers from two different institutions delineated the clinical target volumes (CTVs) for the elective and the boost volumes. These volumes were expanded in three dimensions with a 5-mm margin. At both institutions, a three-dimensional conformal treatment plan of 46 Gy to the elective volumes, plus 20 Gy to the boost target volumes, was designed. The delineated volumes and treatment plans were compared.

RESULTS

The mean volume ratio between institutions of the elective CTVs was 0.9 (standard error = 0.05). The differences were located mainly at the bottom of the nasal cavity and at the frontal border of the target areas. The differences in boost CTVs were large; the mean volume ratio was 2.6 (standard error = 0.58). After expansion of the CTV, the mean distance between the planning target volume (PTV) and the chiasm differed by 0.5 cm between the two institutions. Cases with smaller distances between the PTV and the chiasm had more underdosage to the PTV. This effect was less pronounced for institution A (1 vol.%/cm) than for institution B (10 vol.%/cm) treatment plans, which were less conformal. When the treatment plan was designed for the PTV of institution B, 23 volume % of the PTV of institution A received <95% of the prescribed dose. If the treatment plan was designed for the (on average larger) PTV of institution A, the underdosed volume of PTV at institution B was 17%. The relative underdosage to the "other" PTV was larger when the original treatment plan was more conformal.

CONCLUSION

In the irradiation of paranasal sinus cancer, both the treatment planner and the observer have a significant influence on the dose to the target and organs at risk. Both effects are similar in magnitude. The observer effect increases with more conformal treatment plans. Minimizing the observer variation is important for adequate irradiation of paranasal sinus cancer.