Combined transfacial and neurosurgical approach to malignant tumours of the ethmoid sinus

Trans-Frontal Five-Fluorouracil (TraFFF): a novel technique for the application of adjuvant topical chemotherapeutic agents in sinonasal adenocarcinoma

Sinonasal adenocarcinoma has traditionally been treated with surgery (craniofacial or endoscopic) and adjuvant radiotherapy. Two large series have demonstrated favourable 5-year survival using surgery with adjuvant topical chemotherapy applied repeatedly over several weeks. The authors describe a novel, transnasal application of topical 5-fluorouracil. However, complete coverage of the frontal region of the anterior skull base can be difficult to achieve with a purely transnasal approach in an outpatient setting. We present a novel adjunct method of delivering chemotherapeutic agents into this key area used in a 37-year-old man with T2N0M0 ethmoid adenocarcinoma. The procedure was well tolerated in an outpatient setting and remains disease free at 3 years postoperatively. We suggest that frontal trephination is a useful adjunct to aid accurate placement of adjuvant topical chemotherapeutic agents in the treatment of sinonasal adenocarcinoma.

Treatment Outcomes of Locally Advanced Squamous Cell Carcinoma of the Ethmoid Sinus Treated with Anterior Craniofacial Resection or Chemoradiotherapy

We retrospectively analyzed 14 patients with locally advanced squamous cell carcinoma of ethmoid sinus (LASCC-ES) for the feasibility of anterior craniofacial resection (ACFR). Ethmoid cancer treatment comprised alternating chemoradiotherapy (ALCRT; n = 1), concomitant radiotherapy and intra-arterial cisplatin (RADPLAT; n = 4) and ACFR (n = 9). The 3- and 5-year overall survival (OS) rates of patients were 47.6 and 39.6%, respectively. The 3-year local control (LC) rates of chemoradiotherapy (CRT; ALCRT and RADPLAT) (n = 5) and ACFR (n = 9) groups were 0 and 66.7% (p = 0.012), respectively. The 3-year progression-free survival (PFS) rate of the CRT and ACFR groups were 0 and 55.6% (p = 0.018), respectively. The 3-year OS rate of the CRT and ACFR groups were 0 and 76.2% (p = 0.005), respectively. Postoperative pathological examinations confirmed positive margins in 3 (33%) of 9 cases. The 3-year LC and PFS rates of cases (n = 3) with positive surgical margins were significantly poorer than those of cases (n = 6) with negative surgical margins. Although ACFR for LASCC-ES is a feasible treatment, cases with positive surgical margins were more prone to local relapse. Therefore, surgical safety margins should be thoroughly assessed.

[The clinical evaluation of the effectiveness of anterior craniofacial resection for the treatmentof disseminated tumours and pseudotumour lesions in the nasal cavity, the paranasal sinuses, and the orbit]

The objective of the present work was to evaluate the outcomes of anterior craniofacial resection (ACFR) in the patients presenting with disseminated tumours and pseudotumour lesions in the nasal cavity, the paranasal sinuses, and the orbit based on the results of dynamic clinical observations. A total of 24 patients with tumours and tumour-like lesions of these anatomical structures were involved in the study including 14 ones having benign neoplasms, 2 patients with pseudotumour lesion, and 8 patients having malignant tumours. In all the cases, the pathological processes in the form of destruction and infiltration encompassed the anterior portion of the base of the skull (mostly lamina cribrosae) and spread directly into the anterior cranial fossa. It was shown that ACRF ensured the radical elimination of the pathological process and the enhancement of the five-year survival rate in all the patients with benign tumours and pseudotumour lesions and in half of the patients presenting with disseminated malignant neoplasms.

[Combined Anterior Craniofacial Resection for Locally Advanced Ethmoid Carcinomas]

OBJECTIVE

Carcinoma of the ethmoid sinus is very rare, and treatment for locally advanced tumors remains as a formidable challenge to the clinician. We reviewed cases of ethmoid carcinoma in which anterior craniofacial resection had been undertaken and evaluated the safety and validity of the operative methods.

METHODS

We retrospectively reviewed 13 patients with ethmoid carcinoma who underwent combined anterior craniofacial resection. We evaluated the surgical procedures, complications, outcomes, local recurrence, and the survival rate.

RESULTS

Coronal incision and anterior craniotomy were performed in all cases. Four out of 13 cases underwent ipsilateral orbital exenteration due to involvement of the orbital contents. There were no potentially fatal complications, except for two cases of epidural abscesses which were successfully cured. Positive surgical margins were observed in 6 patients, and they received postoperative radiotherapy and/or chemotherapy. Local recurrences occurred in 4 cases, and 3 died at 9, 11, and 49 months after the surgery. Distant metastasis was not observed during the observation period. The overall 5-year survival rate was 75.2% (Kaplan-Meier method).

CONCLUSION

These tumors were safely removed without severe complications and postoperative mortality. Combined anterior craniofacial resection is an effective and safe option for treatment of locally advanced ethmoid carcinomas after various preoperative treatments.

Craniofacial Resection for Sinonasal Malignant Tumors: Statistical Analysis of Surgical Outcome over 17 Years at a Single Institution

We present a retrospective analysis of surgical outcome of sinonasal malignant tumors. Overall survival (OS), disease-specific survival (DSS), local control (LC), and disease-free survival (DFS) were calculated in 32 patients. Prognostic factors for survival and functional outcomes were investigated. The median follow-up period was 70 months. At 5 years, OS, DSS, LC, and DFS rates were 0.722, 0.745, 0.851, and 0.707, respectively. Prognostic factors for poor OS were involvement of the frontal sinus (p = 0.023), T classification (T4, p = 0.025), surgical complications (p = 0.029), chemotherapy (p = 0.035) postsurgical infection (p = 0.043), involvement of the orbit (p = 0.048), histology (squamous cell carcinoma, p = 0.049), and radiotherapy (p = 0.043). Prognostic factors for poor DSS were radiotherapy (p = 0.030), chemotherapy (p = 0.036), positive surgical margin (p = 0.034), and T classification (T4, p = 0.050). LC was adversely influenced by surgical procedure (combined frontotemporal resection, p = 0.035) and positive surgical margin (p = 0.049). DFS was adversely influenced by positive surgical margin (p = 0.001). Prognostic factors for poor functional outcome were postsurgical infection (p = 0.039), postsurgical complications (p = 0.040), tumor location (maxillary sinus, p = 0.042, orbit, p = 0.0002), number of sinuses involved (number of sinuses involved was inversely proportional to functional outcome, p = 0.027), T classification (T4 p = 0.007), pathology (squamous cell carcinoma, p = 0.023), and chemotherapy (p = 0.048). Craniofacial resection was an effective surgical option.

Evidence for treatment strategies in sinonasal adenocarcinoma

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

Treatment results for ethmoid sinus carcinoma

OBJECTIVE

The aim of this study was to describe the results of treatment in patients with ethmoid sinus carcinoma.

MATERIALS AND METHOD

We performed a retrospective study of 34 patients with carcinoma of the ethmoid sinus, and collected the following data: age, sex, employment, tobacco and alcohol consumption, tumour-node-metastasis stage, treatment, and survival.

RESULTS

The mean patient age was 64 years. Seventy-six per cent of patients were men and 24 per cent women. Squamous cell carcinoma was the most frequent histological tumour type (44 per cent). Eleven patients were classified as T(2), six as T(3), six as T(4a) and 11 as T(4b). Two patients (6 per cent) had nodal metastasis at the time of diagnosis. The anterior skull base was involved in 17 patients (50 per cent) and the anterior orbital contents were affected in seven patients (21 per cent). The five-year actuarial observed survival rate for all patients was 44 per cent.

CONCLUSIONS

Combined treatment with surgery and post-operative radiotherapy permitted good local control in patients with ethmoid sinus carcinoma. We do not recommend prophylactic neck treatment for ethmoid sinus carcinoma.

Is surgical debridement and topical 5 fluorouracil the optimum treatment for woodworkers' adenocarcinoma of the ethmoid sinuses? A case-controlled study of a 20-year experience

OBJECTIVES

Woodworkers' adenocarcinoma of the ethmoid sinuses is an extremely rare occupational malignancy with a locally aggressive course. Treatment with surgical exenteration and topical 5 fluorouracil (5FU) packs has become standard treatment over the last 10 years in this ENT unit. This study presents level 2 evidence that 5FU provides improved survival over previous management with primary radiotherapy and salvage craniofacial resection.

DESIGN

Retrospective case series with historical control group.

SETTING

District General Hospital.

PARTICIPANTS

The records of 31 consecutive patients with the disease were analysed. Five patients died prior to treatment. One patient was treated with surgery alone and therefore excluded. Twenty-five patients were included in the analysis. Fourteen were treated with primary radiotherapy and 11 with surgery and topical 5FU.

OUTCOME MEASURES

Disease free survival was measured using Kaplan-Meier survival analysis.

RESULTS

Five-year disease free survival improved from 50% with primary radiotherapy to 86% with surgery and 5FU. This improvement is statistically significant (P = 0.03).

CONCLUSION

Topical 5FU treatment improves survival of Woodworker's adenocarcinoma of the ethmoid sinuses. This finding may be useful in the treatment of other locally aggressive sinonasal malignancies.

Preserving olfactory function in anterior craniofacial surgery through cribriform plate osteotomy applied in selected patients

OBJECTIVE

Olfaction is often sacrificed to gain access to the cranial base in anterior craniofacial surgery. We describe the long-term results of olfactory function in patients who underwent anterior craniofacial surgery and a cribriform plate osteotomy to preserve olfaction.

METHODS

Between 1992 and 2004, 28 patients underwent 29 cribriform plate osteotomies in an attempt to preserve olfaction during anterior craniofacial surgery performed through modified extended transbasal approaches. Patients' charts and office notes were reviewed retrospectively. Formal olfactory testing was available in 5 patients, but most data were based on patients' subjective reports of olfaction. Olfactory preservation was defined by the subjective ability to detect fumes such as coffee, chocolate, roses, and orange juice regardless of the intensity of the sensation. Follow-up was based on phone calls to patients.

RESULTS

Four patients were lost to follow-up and excluded. Therefore, follow-up was available in 24 patients after 25 procedures. On the basis of patients' subjective reports, olfaction was spared in 22 patients after 23 procedures (92%) and was confirmed objectively in the five patients formally tested. After surgery, only two patients were anosmic.

CONCLUSION

Olfaction can be preserved in selected patients undergoing anterior craniofacial surgery. At least 1 cm of nasal mucosa should remain attached to the cribriform plate, which can be achieved by including the nasal bone in the osteotomy of the orbital bar. A medial orbital canthopexy is therefore necessary after these procedures.

Long-Term Results of Ethmoid Squamous Cell or Undifferentiated Carcinoma Treated with Radiotherapy with or without Surgery

PURPOSE

Ethmoidal malignant tumors, for which intensity-modulated radiotherapy is expected to improve outcome, consist of heterogeneous pathological types. Reports about their outcome are influenced by the inclusion of favorable histology, such as adenocarcinoma and adenoid cystic carcinoma. We investigated the long-term treatment outcome of squamous cell carcinoma and undifferentiated carcinoma of the ethmoid sinus.

MATERIALS AND METHODS

Between August 1976 and April 2002, 25 patients (20 squamous cell carcinomas and five undifferentiated carcinomas) received radical radiotherapy or preoperative radiotherapy in our institution. One (4%) had stage T2 disease, seven (28%) had stage T3, three (12%) had stage T4a, and 14 (56%) had stage T4b. Surgery was performed in 13 patients. Radiation dose varied from 50.4 Gy in 16 fractions (50.4 Gy/16 Fr) to 65 Gy in 26 fractions with or without stereotactic boost irradiation. Eleven patients received chemotherapy consisting mainly of platinum-based compounds.

RESULTS

The 3- and 5-year overall survival rates for all 25 patients were 34% (95% confidence interval [CI]: 14%-54%) and 24% (CI: 6%-42%), respectively. The 3- or 5-year local progression-free rates for all patients were 48.9% and 36.7%, respectively. Visual acuity of a single eye was impaired in three patients and was lost in five patients as a result of tumor progression, but no patient had visual impairment or loss due to radiotherapy.

CONCLUSION

Ethmoid squamous cell carcinoma or undifferentiated carcinoma was diagnosed at advanced T stages and was treated with radiotherapy; these patients had a poorer outcome than patients with adenocarcinoma or adenoid cystic carcinoma. Prospective trials using advanced technology should be carefully compared with historical controls because pathological types can considerably influence the treatment results.

Ethmoid sinus cancer: results of treatment with surgery and combined therapy

OBJECTIVE

Ethmoid sinus cancer is a rare paranasal sinus malignancy. Its characteristics include a low incidence rate, a great variety of histopathological types and multiple treatment modalities. Currently, there remains no definite consensus regarding its optimal management. The aim of this study was to examine the outcome of a population of Asian patients with advanced ethmoid sinus cancers that had been treated with surgery plus combined therapy.

MATERIAL AND METHODS

Between January 1989 and December 2002 inclusive, 19 newly diagnosed patients with ethmoid sinus cancers who had undergone surgical intervention were enrolled, T4 being the principal carcinoma stage (68.4%). All participating cases proved to be node-negative and no evidence of any distant metastasis was detected at the time of diagnosis. The major treatment modality was surgery plus postoperative radiotherapy. All but 2 of the 13 patients with T4 cancer underwent craniofacial resection with pericranial flap reconstruction.

RESULTS

The estimated overall and disease-free survival rates 3 years post-treatment were 49.4% and 26.3%, respectively. Local tumor recurrence was more common than regional recurrence and/or distant metastasis. A total of 5/15 T3-T4 patients (33%) developed a neck metastasis, 3 of whom also suffered a distant metastasis. There was no postoperative mortality for the cases treated with craniofacial resection.

CONCLUSIONS

Ethmoid sinus cancer typically demonstrates a propensity for late diagnosis and poor prognosis. This study confirms that craniofacial resection plus combined associated therapy is the optimal approach for the effective management of extensive ethmoid sinus tumors and is associated with an acceptable morbidity rate. More aggressive disease management featuring prophylactic concurrent chemoradiotherapy including neck or elective neck dissection plus chemotherapy should be considered for T3-T4 patients as opposed to T1-T2 patients.

Which Role for Radiation Therapy in Ethmoid Cancer? A Retrospective Analysis of 84 Cases from a Single Institution

Purpose

To define the results of radiotherapy for the treatment of ethmoid carcinoma in a large, retrospective, substantially unselected series from a single institution.

Methods and Materials

A relatively large series of 84 consecutive patients treated at our Institution over a 30-year period (1970-2000) was retrospectively analyzed. Sixteen more patients treated in the same period were affected by a relapse of disease at presentation and were therefore excluded from the analysis. Most of the patients had T3 or T4 disease (76%), and half of them had undifferentiated (G3-G4) tumors. Radical surgery preceded radiotherapy in 60 patients, the remaining had only biopsy or incomplete surgery. Average ICRU dose varied according to the extent of postsurgical residual disease.

Results

The 5-year actuarial overall survival of the entire series was 48.6%, 5-year disease-specific survival 58%, and 5-year relapse-free survival 54.6%. Overall, disease-specific and relapse-free survival were significantly better (logrank test) for early stage patients (T1-T2) and for those with low-grade disease; relapse-free and disease-specific survival were also significantly (or almost significantly) better for patients who had radical surgery and for those with less extended postsurgical residue. Patients treated with radiotherapy after biopsy only or grossly incomplete surgery had 5-year relapse-free, disease-specific and overall survival of 22%, 42% and 37%, respectively. Higher cumulative doses (>60 Gy) were related to a not significantly lower recurrence probability in patients with micro- or macroscopic residual disease after surgery (54% vs 62%). Multivariate analysis (Cox model) showed that only T stage and grading were independent prognostic factors for overall and disease-specific survival, whereas the prognostic impact of radical surgery was limited to relapse-free survival.

Conclusions

Radical radiation therapy alone is able to cure about 25% of the unfavorably selected cases, after biopsy only or partial surgery. Radical surgery is associated with better relapse-free survival rates, but the contribution of postoperative radiotherapy to the primary treatment of these patients cannot be eliminated.

Adénocarcinomes de l’ethmoïde : expérience nantaise (80 cas)

OBJECTIVE

To present results of a retrospective analysis of eighty cases of ethmoid adenocarcinoma. Carcinologic and surgical results of anterior skull base resection via the transfacial approach are presented.

METHODS

Tumors were classified as 5% T1, 23% T2, 31% T3, 21% T4a and 20% T4b. Thirty-four patients were treated via a paralateronasal approach without skull base resection. Anterior skull bas resections were performed via the transfacial approach for 26 patients and by combined neurosurgical approach for 21.

RESULTS

Mean follow-up was 4.8 years. Survival rate was 63.4% at 5 years and 57.9% at 8 years. Forty-two patients were alive and disease-free at last follow-up. Three patients were alive with recurrence. The rate of local recurrence was 38.8%. Complications occurred in 20% of the patients who had a transfacial approach. Complications appeared to be less frequent than with the combined approach.

CONCLUSION

Prognosis is related to local control and could be improved by using skull base resection more systematically. In our experience this can be managed by a transfacial approach with similar carcinological results and less complications than the combined approach.

Differential diagnosis and treatment options in paranasal sinus cancers

Paranasal sinus malignancies are challenging to treat. Most patients present with advanced lesions, often with intracranial or intraorbital extension, and have a poor overall prognosis. Given the low incidence and diverse pathologies of paranasal sinus cancers, it is extremely difficult to perform prospective, randomized clinical trials to compare different treatment approaches. Improving the prognosis of these cancers continues to be a difficult task, even in light of advances in surgical techniques,radiation delivery techniques, and new chemotherapeutic agents. Cranio-facial resection techniques developed in the past few decades have cured many patients with skull base invasion, who would have been considered unresectable in the past. Furthermore, improvements in radiation therapy can allow more accurate administration to the desired region, with decreased damage to surrounding structures such as the orbit and brain. Aggressive and oncologically sound surgical resection combined with radiation therapy remains the treatment of choice for most patients.Finally, advances in the diagnosis and staging by use of molecular or DNA markers of tumor behavior may allow for more directed therapy.

Removal of ethmoidal malignant tumors by the isolated paralateronasal approach with resection of the cribriform plate and the dura mater

OBJECTIVE

A series of ethmoidal tumors was resected by an entirely extracranial approach through a lateral rhinotomy incision, with partial maxillectomy and removal of the cribriform plate and dura mater from below.

METHODS

Thirty-four consecutive patients (32 male, 2 female; mean age 64 years, range 45-78) with malignant tumors of the ethmoid sinus were operated by this technique between July 1998 and February 2002. All had complete tumor resection, including the cribriform plate and the dura mater. Excision was performed en bloc 23 times (68%). Although cerebral involvement was encountered in four cases (T4 IC), this technique was adequate for tumor resection, together with corticectomy when necessary. The method used for tumor resection and rebuilding of the anterior skull base is described in detail.

RESULTS

There were no immediate postoperative deaths. One patient developed pneumococcal meningitis with cerebrospinal fluid leakage as a result of a technical error and required further surgery. Four patients presented a confusion syndrome that regressed during the hospital stay, 2 complained of transient diplopia, and 4 had hematoma of the abdominal wall. Mean follow-up of 10.4 months (1-41 months) is still too short to reach definitive conclusions about oncologic results.

CONCLUSIONS

This approach is particularly suitable for removal of tumors in contact with or invading the cribriform plate. Tumor resection is as extensive as with the traditional mixed approach, but does not require the frontal lobes to be drawn aside.

Pericranial flap for closure of paramedian anterior skull base defects

OBJECTIVE

We sought to examine the position of a pericranial flap reconstruction of anterior skull base defects with respect to the original floor of the anterior cranial fossa.

STUDY DESIGN

A retrospective chart and radiology review of 17 patients (1993-2001) with pericranial flap reconstruction for anterior skull base defects and 17 controls was performed.

RESULTS

At 6 or more months after surgery, the new positions of the pericranial flaps ranged from 5 mm above to 11.3 mm below the positions of the original cribriform plates. There were no complications related to the pericranial flaps such as hemorrhage, flap loss, or brain herniation except for 2 (11.8%) cerebrospinal fluid leaks, 1 of which required operative correction.

CONCLUSION

Pericranial flap reconstruction is a reliable method with low morbidity for closure of the most common skull base defect from the craniofacial resection that entails removal-unilateral or bilateral-of the fovea ethmoidalis, cribriform plate, and/or superior septum. This flap creates a watertight seal between the extradural space and the nasal cavity, prevents clinically significant brain herniation, and is associated with a low rate of cerebrospinal fluid leakage even without postoperative lumbar subarachnoid drainage of the cerebrospinal fluid.

Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses: treatment results for 47 patients

PURPOSE

Ethmoid sinus cancer is a rare malignancy. Treatment results are mostly reported together with other sinonasal tumors, grouping a wide range of different histologies and treatment approaches. This study reports on the treatment outcome of 47 patients diagnosed with adenocarcinoma of the ethmoid sinuses and treated with surgery and high-dose postoperative radiation therapy.

METHODS AND MATERIALS

Between September 1985 and October 2001, 51 patients with adenocarcinoma of the ethmoid sinuses were referred to the Ghent University Hospital. Four patients were treated with low-dose palliative radiation because of very extended inoperable disease or distant metastasis at the time of diagnosis. They were not included in this analysis. The other 47 patients, all staged as N0M0, were treated with surgery and postoperative high-dose radiation therapy. The median follow-up was 32 months. The T-stages were T1 for 2, T2 for 17, T3 for 11, and T4 for 17 patients. All 47 patients were staged as N0M0.

RESULTS

The 3-year, 5-year, and 7-year overall survival are respectively 71%, 60%, and 38%. The 3-year and 5-year disease-free survival are respectively 62% and 36%. The 3-year and 5-year disease-free survival for T1-T2 stages are respectively 87% and 55%, for T3 stages 57% and 28%, and for T4 stages 41% and 25%. The locoregional tumor control was 70% and 59% at respectively 3 and 5 years. Patients presenting with intracranial tumor invasion at the time of diagnosis relapsed within 7 months after the end of radiotherapy. Radiation-induced severe dry eye syndrome and optic neuropathy was observed in respectively 7 and 2 of the 47 cases.

CONCLUSION

Postoperative radiotherapy for adenocarcinoma of the ethmoid sinuses is associated with good local control rates. Crucial for a favorable prognosis is the absence of intracranial invasion. The rarity of these tumors makes it difficult to evaluate new therapeutic advances.

Complication avoidance in the treatment of malignant tumors of the skull base

The treatment of malignant skull base tumors has improved with the development of skull base surgical approaches that allow en bloc resection of a lesion and increase the efficacy of adjuvant therapies. The anatomical complexity of these lesions and their surroundings has led to a relatively high complication rate. Infection and cerebrospinal fluid fistulas are the most common serious procedure-related complications. They result from the frequent necessity of working in a contaminated space such as the paranasal sinuses as well as from the creation of large dural and skull base defects. The authors have reviewed the literature regarding complications of surgery for malignant skull base lesions and present several techniques and strategies for minimizing their incidence by performing the craniofacial approach to anterior skull base lesions.

Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review

BACKGROUND

The authors reviewed treatment results in patients with nasal and paranasal sinus carcinoma from a large retrospective cohort and conducted a systematic literature review.

METHODS

Two hundred twenty patients who were treated between 1975 and 1994 with a minimum follow-up of 4 years were reviewed retrospectively. A systematic review of published articles on patients with malignancies of the nasal and paranasal sinuses during the preceding 40 years was performed.

RESULTS

The 5-year survival rate was 40%, and the local control rate was 59%. The 5-year actuarial survival rate was 63%, and the local control rate was 57%. Factors that were associated statistically with a worse prognosis, with results expressed as 5-year actuarial specific survival rates, included the following: 1) histology, with rates of 79% for patients with glandular carcinoma, 78% for patients with adenocarcinoma, 60% for patients with squamous cell carcinoma, and 40% for patients with undifferentiated carcinoma; 2) T classification, with rates of 91%, 64%, 72%, and 49% for patients with T1, T2, T3, and T4 tumors, respectively; 3) localization, with rates of 77% for patients with tumors of the nasal cavity, 62% for patients with tumors of the maxillary sinus, and 48% for patients with tumors of the ethmoid sinus; 4) treatment, with rates of 79% for patients who underwent surgery alone, 66% for patients who were treated with a combination of surgery and radiation, and 57% for patients who were treated exclusively with radiotherapy. Local extension factors that were associated with a worse prognosis included extension to the pterygomaxillary fossa, extension to the frontal and sphenoid sinuses, the erosion of the cribriform plate, and invasion of the dura. In the presence of an intraorbital invasion, enucleation was associated with better survival. In multivariate analysis, tumor histology, extension to the pterygomaxillary fossa, and invasion of the dura remained significant. Systematic review data demonstrated a progressive improvement of results for patients with squamous cell and glandular carcinoma, maxillary and ethmoid sinus primary tumors, and most treatment modalities.

CONCLUSIONS

Progress in outcome for patients with nasal and paranasal carcinoma has been made during the last 40 years. These data may be used to make baseline comparisons for evaluating newer treatment strategies.

[Tumors of the facial sinuses]

Nasal cavity and paranasal sinus carcinomas represent a small number of head and neck tumors (3 to 4%). Their management has been improved by modern imaging techniques to define operative procedures and deliver high-precision radiotherapy. Surgery is one of the most important components of treatment. Postoperative radiotherapy is indicated in all circumstances. A large proportion of patients with unresectable disease must be treated exclusively with radiotherapy. Definition of target volumes should be performed according to the knowledge of the natural outcome of the disease and modern 3D imaging. This is mandatory for treatment planning. Conformal radiotherapy significantly reduces the rate of complications, mainly eye toxicity.