Management of paediatric sinonasal rhabdomyosarcoma. J Laryngol Otol. 2009;123:990-996. [PMID: 19393123 DOI: 10.1017/s0022215109005337]

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

Sinonasal neoplasms, whether benign and malignant, pose a significant challenge to clinicians and represent a model area for multidisciplinary collaboration in order to optimize patient care. The International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors (ICSNT) aims to summarize the best available evidence and presents 48 thematic and histopathology-based topics spanning the field.

METHODS

In accordance with prior International Consensus Statement on Allergy and Rhinology documents, ICSNT assigned each topic as an Evidence-Based Review with Recommendations, Evidence-Based Review, and Literature Review based on the level of evidence. An international group of multidisciplinary author teams were assembled for the topic reviews using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format, and completed sections underwent a thorough and iterative consensus-building process. The final document underwent rigorous synthesis and review prior to publication.

RESULTS

The ICSNT document consists of four major sections: general principles, benign neoplasms and lesions, malignant neoplasms, and quality of life and surveillance. It covers 48 conceptual and/or histopathology-based topics relevant to sinonasal neoplasms and masses. Topics with a high level of evidence provided specific recommendations, while other areas summarized the current state of evidence. A final section highlights research opportunities and future directions, contributing to advancing knowledge and community intervention.

CONCLUSION

As an embodiment of the multidisciplinary and collaborative model of care in sinonasal neoplasms and masses, ICSNT was designed as a comprehensive, international, and multidisciplinary collaborative endeavor. Its primary objective is to summarize the existing evidence in the field of sinonasal neoplasms and masses.

Age at diagnosis, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio as prognoticators in pediatric sinonasal rhabdomyosarcoma

BACKGROUND

The relationship between pretreatment blood parameters and clinical outcomes of patients with pediatric sinonasal rhabdomyosarcomas has not been described. The purpose of this study was to determine the prognostic factors and certain laboratory parameters that affect the survival and long-term survival in pediatric sinonasal rhabdomyosarcoma.

METHODS

Medical records of pediatric sinonasal rhabdomyosarcoma cases who were treated and followed up between 2004 and 2020 in Hacettepe University were retrospectively reviewed. The relationship between clinical features, laboratory parameters and survival was investigated.

RESULTS

Age at the time of diagnosis, pretreatment neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) had significant effect on survival (p < 0,004, p < 0,037, p < 0,016, respectively). Survival rate was higher in patients younger than 10 (≤10 years of age) at the time of diagnosis (p = 0,004), patients with a NLR of 2 or below (≤2) (p = 0,037), and patients with a PLR of 150 or below (≤150) (p = 0,016). ≤ 10 years of age at the time of diagnosis was found as an independent prognostic factor affecting survival (hazard ratio [HR], 5382; 95 % confidence interval [CI], 1476- 19,623; P = 0,011). In addition, a pretreatment PLR of 150 or below (≤150) was found as another independent prognostic factor that affects survival (hazard ratio [HR], 4386; 95 % confidence interval [CI], 1161- 16,567; P = 0,029).

CONCLUSIONS

Preoperative NLR and PLR may be important parameters to predict the prognosis of pediatric sinonasal rhabdomyosarcoma. Further research with larger patient groups are warranted.

Unusual association of orbital tumour and rhino-orbital-cerebral mucormycosis

In developing tropical countries, rhino-orbital-cerebral mucormycosis has been a cause of severe morbidity and mortality during the COVID-19 pandemic. Classically, it develops as an aggressive angioinvasive destruction of nasal, orbital and cerebral involvement. Blindness is a major disabling complication. The association of mucor in cancer is linked with immunosuppression caused by radiation and/or chemotherapy. In this case report, we tried to explore the diverse possibilities of neck swelling, nasal discharge, ocular swelling and dimness of vision in a teenage boy. Rhabdomyosarcoma is a rare tumour of the soft tissue, connective tissue or bone. This type of unusual association or coexistence of rhabdomyosarcoma with mucormycetes is rarely seen in literature.

Surgical Management of Rhabdomyosarcoma of the Nasal Cavity and Paranasal Sinuses: Analysis of Operative Indications, Settings, and Outcomes

Objectives The role of surgery in management of sinonasal rhabdomyosarcoma (SNRMS) has traditionally been limited, owing to anatomic and technological challenges and the established role of systemic therapy. Herein, we report our institutional experience with surgical management of SNRMS, with a particular focus on operative approaches, extent and outcomes.

Design This study is a retrospective cohort study.

Setting This study was conducted at a single-institution, academic center.

Participants Patients of any age with histologically confirmed RMS of the nasal cavity, maxillary, ethmoid, frontal, or sphenoid sinus, nasolacrimal duct, or nasopharynx presenting between 1994 and 2020 were included in this study.

Main Outcome Measures Demographics, tumor characteristics, operative settings, complications and recurrence, and survival outcomes were the primary outcomes of this study.

Results Our study cohort comprised of 29 patients (mean [range] age: 27.0 [3.1–65.7], n = 12 [41%] female). Tumors of the nasal cavity (n = 10, 35%) and ethmoid sinuses (n = 10, 35%) and those with alveolar histology (n = 21, 72%) predominated. Patients who had surgery as part of their treatment (n = 13, 45%) had improved distant metastasis-free survival (DMFS) overall (hazard ratio [HR]: 0.32, 95% CI: 0.11, 0.98, p = 0.05) as compared with those who did not have surgery. Surgical approaches included open (n = 7), endoscopic (n = 4), and combined (n = 2). Eight of these 13 patients (62%) had an R0 resection. Additionally, surgical salvage of recurrent disease was employed in five patients (17%).

Conclusion SNRMS is an aggressive malignancy with a high rate of recurrence and spread requiring a multidisciplinary approach for optimal outcomes. Our data supports an expanding role for surgery for SNRMS given its feasibility, tolerability, and potential to improve outcomes.

Nasal Embryonal Rhabdomyosarcoma in the Pediatric Population: Literature Review and Report of Midline Presentation

Background:

Congenital midline nasal masses are rare anomalies and are typically benign nasal dermoid sinus cysts (NDSCs). Rhabdomyosarcomas (RMSs) are even less common, and only a fraction affect sites like the external nose, nasal cavity, nasopharynx, and paranasal sinuses. We review the clinical presentation and treatment of nasal, nasopharyngeal, and paranasal RMSs and report the first documented midline presentation.

Methods:

We queried PubMed for articles with titles containing the terms rhabdomyosarcoma or sarcoma botryoides and nose, nasal, paranasal, sinonasal, nasopharynx, or nasopharyngeal. We then searched the references of each included article using the same parameters and continued this process iteratively until no new articles were found.

Results:

The paranasal sinuses were the most commonly affected site, followed by the nasopharynx, nasal cavity, and external nose. Two patients presented with involvement of the external nose, but each presented with involvement of the right ala rather than a midline mass. The rates of intracranial extension and/or skull base involvement were comparable to those of NDSCs. The alveolar subtype was most common, followed by the embryonal subtype.

Conclusions:

Most midline nasal masses are benign; however, we report the first documented presentation of an RMS as a midline nasal mass. Accordingly, RMS should be included in the differential diagnosis of midline nasal masses in the pediatric population. Surgery for midline nasal masses is sometimes delayed due to the risks of interfering with developing structures and early anesthesia. However, early surgical treatment should be considered given this new differential and its predilection for early metastasis.

Therapeutic outcome and prognostic factors in sinonasal rhabdomyosarcoma: a single-institution case series

BACKGROUND

The purpose of this study was to explore the demographics, multimodality therapeutic outcomes*** and prognostic factors in sinonasal rhabdomyosarcoma (SNRMS).

METHODS

We conducted a retrospective analysis of 40 patients who underwent treatment of SNRMS from March 2007 to March 2018. The Kaplan-Meier method and the log-rank test were used to assess survival rates. The Cox regression model was used for multivariate survival analysis.

RESULTS

In total, 25 males and 15 females were included in the study; the median age was 33 years (range, 2-67 years). All patients underwent surgical resection, and surgery prior to or after adjuvant therapy (chemotherapy and radiotherapy) was performed in 91.4% of the patients. The overall 1-, 3- and 5-year survival rates were 77.0%, 46.5% and 46.5%, respectively, during a mean follow-up time of 27.9 (range, 2-128) months in all patients. The log-rank test showed Intergroup Rhabdomyosarcoma Study (IRS) group and infiltration of the skull base influenced overall survival (p = 0.001; p = 0.022). Advanced IRS stage, lymph node metastasis and tumor size ≥ 5 cm were also associated with an unfavorable outcome on overall survival (p = 0.01; p = 0.035; p = 0.02). The results of multivariate regression analysis showed patients with IRS group I were associated with better prognosis outcome on overall survival.

CONCLUSION

Patients with SNRMS have poor 5-year overall survival, and IRS group is the independent prognostic factor for overall survival.

Clinicopathologic traits and prognostic factors associated with pediatric sinonasal rhabdomyosarcoma

BACKGROUND

Pediatric sinonasal rhabdomyosarcoma (RMS) is an aggressive and rare malignancy. This is the first multi-institutional study on the prognostic factors associated with outcomes in this population.

METHODS

The National Cancer Database was queried for the period from 2004 to 2013 for all cases of malignant sinonasal RMS in the pediatric population. The impact of patients' demographics, tumor characteristics, and Intergroup Rhabdomyosarcoma Study Group (IRSG) staging on survival was assessed using chi-square test, Fisher's exact test, Kaplan-Meier test, and Cox regression analyses.

RESULTS

A total of 157 cases of pediatric sinonasal RMS were identified. Mean age at diagnosis was 9.38 years and male patients comprised 48.4% of the cohort. The nasal cavity (31.8%) and maxillary sinus (30.6%) were the most common primary sites. Alveolar was the most common histology (49.7%), followed by embryonal type (32.5%). The majority of patients received solely chemoradiation (52.9%), followed by surgery with adjuvant chemoradiation (30.6%). Five-year overall survival (OS) was 55.2% (±4.5%). Metastatic disease was associated with a poorer 5-year OS rate (24.4% vs 61.5%; p = 0.010). Maxillary sinus site was associated with an improved survival (71.8% vs 47.6%; p = 0.009). On multivariate analysis, chemoradiation with or without surgery was an additional prognostic factor. Although IRSG clinical stages did not correlate with survival, high-risk patients in the IRSG clinical risk groups were associated with poorer survival on multivariate analysis (hazard ratio [HR], 2.005; 95% confidence interval, 1.007-3.993; p = 0.048).

CONCLUSION

To date, this is the largest study on pediatric sinonasal RMS. IRSG clinical risk groups may be useful in stratifying high-risk patients with poor prognosis.

Embryonal rhabdomyosarcoma in the maxillary sinus with orbital involvement in a pediatric patient: Case report

This report presents a case of embryonal rhabdomyosarcoma (eRMS) located in the left maxillary sinus and invading the orbital cavity in a ten-year-old male patient who was treated at a referral hospital. The images provided from the computed tomography showed a heterogeneous mass with soft-tissue density, occupying part of the left half of the face inside the maxillary sinus, and infiltrating and destroying the bone structure of the maxillary sinus, left orbit, ethmoidal cells, nasal cavity, and sphenoid sinus. An analysis of the histological sections revealed an undifferentiated malignant neoplasm infiltrating the skeletal muscle tissue. The immunohistochemical analysis was positive for the antigens: MyoD1, myogenin, desmin, and Ki67 (100% positivity in neoplastic cells), allowing the identification of the tumour as an eRMS. The treatment protocol included initial chemotherapy followed by radiotherapy and finally surgery. The total time of the treatment was nine months, and in 18-mo of follow-up period did not show no local recurrences and a lack of visual impairment.

A Population-Based Analysis of Survival for Sinonasal Rhabdomyosarcoma

Objectives Literature detailing factors affecting survival in sinonasal rhabdomyosarcoma (SNRMS) is limited due to its rarity. We analyze the demographics, potential prognostic factors, overall survival, and treatment efficacy of SNRMS. Study Design and Setting Administrative database study. Methods SNRMS was queried in the SEER database (1973-2013; Surveillance, Epidemiology, and End Results). Data were analyzed for demographic and clinicopathologic trends. Kaplan-Meier model was utilized for assessing survival. Results A total of 286 cases of SNRMS were identified. The median age at diagnosis was 24.5 years, and the mean tumor size was 5.1 cm. Overall 5-, 10-, and 20-year disease-specific survival was 35.1%, 25.4%, and 12.0%, respectively. Regional lymph node involvement was present at diagnosis in more than half of cases (54.3%) and distant metastasis in 32.2% of cases. Alveolar rhabdomyosarcoma (54.9%) and embryonal rhabdomyosarcoma (23.8%) were the primary histologies. Alveolar-type SNRMS was more likely than the embryonal type to metastasize to distant sites (41.7% vs 24.1%), and it possessed poorer 5-year survival (29.2% vs 45.6%). Distant metastasis decreased 5-year survival from 35.1% to 3.8%, whereas lymph node involvement did not significantly affect survival. Patients <10 years old had the highest survival rates. Primary tumor origin by subsite did not significantly affect survival. Smaller tumor sizes and earlier Intergroup Rhabdomyosarcoma Study Group stages were associated with improved outcomes. Surgical therapy had the highest survival rates. Conclusion SNRMS has overall poorer prognosis than all other parameningeal rhabdomyosarcomas studied. Age <10 years, smaller tumor sizes, lack of distant metastasis, localized tumors, earlier Intergroup Rhabdomyosarcoma Study Group stages, and embryonal histology were all associated with improved outcomes.

Outcomes in Adult Sinonasal Rhabdomyosarcoma

Objective To describe patient demographics, histology, treatment modalities, and survival associated with adult sinonasal rhabdomyosarcoma. Study Design Retrospective review of a national database. Setting Tertiary medical center. Subjects and Methods Patient demographics, tumor histology, treatment modalities, and survival trends were examined for patients aged ≥18 years who were diagnosed with sinonasal rhabdomyosarcoma between 2004 and 2013 with the National Cancer Database. Kaplan-Meier analysis and the log-rank tests were performed to determine the unadjusted association between overall survival and various patient and disease characteristics. Results A total of 186 patients were identified; 5-year overall survival was 28.4%. Over half of patients were between 18 and 35 years old at diagnosis (53.8%), which was associated with improved 5-year overall survival over patients >35 years old (31.9% vs 24.4%, P = .014). Alveolar sinonasal rhabdomyosarcoma was most common (66.7%). There was no statistical difference in 5-year overall survival between alveolar and embryonal subtypes (30.5% vs 41.6%, P > .05). Metastatic disease was present in 27.7% of patients and was associated with worse 5-year overall survival (14.7% vs 33.9%, P < .0001). The majority of patients were treated with chemotherapy with adjuvant radiation (49.5%). A quarter of patients were treated with surgery plus chemoradiation (25.8%). Conclusion We present the largest analysis of adult sinonasal rhabdomyosarcoma using a standardized national based database. Adult sinonasal rhabdomyosarcoma has a very poor prognosis independent of histologic subtype. The small number of surgical cases limits the ability of the analysis to accurately compare treatment with chemoradiation with and without surgery.

Management of pediatric head and neck rhabdomyosarcoma: A case-series of 36 patients

Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in the pediatric population. In 35% of cases, RMS develops in the head and neck (H&N) region, and only combined therapy is recognized as a curative treatment. However, recent advances in skull base and reconstructive surgery, along with microsurgery and endoscopic surgery, have strengthened the role of surgery as an important part of RMS treatment. In the present study, 36 pediatric RMS cases (24 males and 12 females) were analyzed after surgical treatment. The average age at diagnosis was 7 years. In total, 67% of tumors were localized in the parameningeal region. Alveolar RMS was the most common histopathological type. A total of 16 patients were treated due to disease recurrence or a previous non-radical surgical procedure, while 19 cases had inductive chemotherapy and/or radiotherapy preceding surgical treatment due to locally advanced disease. In 1 case, only diagnostic biopsy was performed. It is recommended that the management of H&N RMS is interdisciplinary from the beginning. Extensive surgical dissection in the H&N region for RMS may result in severe cosmetic defects and functional impairment; thus, these risks should be considered during treatment planning, and the surgical approach should be based on the individual characteristics of each patient.

Indications for open procedures in the endoscopic era

PURPOSE OF REVIEW

Endoscopic sinus surgery became the gold standard in inflammatory disorders of the nose and paranasal sinuses, in cerebrospinal fluid leak and epistaxis management, and established its efficacy in the oncology of the region. However, there are certain limitations which make an external approach mandatory. This article reviews the recent literature describing the cases where an open procedure is still indicated.

RECENT FINDINGS

Despite the evolution of endoscopic surgery external approaches are still indicated. Osteoplastic flap remains an option for the refractory inflammation of the frontal sinus. Benign and malignant tumours with lateral or superior extension, neurovascular involvement, and bony/soft tissue erosion usually require an external approach. Superior and lateral posterior wall defects of frontal sinus with cerebrospinal fluid leak may mandate an open procedure. Management of severe epistaxis may still necessitate in selected cases an external approach when endoscopic surgery fails and embolization setting is not available.

SUMMARY

Although advances in endoscopic instrumentation and techniques steadily decrease the indications for external approaches, they continue to have a role in the management of nasal disorders. This study summarizes the recent literature and provides a comprehensive review of the up-to-date remaining indications for open procedures in the nose and paranasal sinuses.

Pediatric sinonasal rhabdomyosarcoma: A case report

Pediatric sinonasal rhabdomyosarcoma (PSR) is a rare condition, with a limited number of previously reported cases. It is an aggressive malignancy associated with poor outcomes, and no consensus has been reached on the optimal therapeutic strategy. The present study reported the case of embryonal PSR in a 2-year old girl, presenting with unilateral nasal obstruction and a polypoid mass protruding from the left nasal cavity. The pediatric patient was initially treated with surgical resection, followed by adjuvant chemotherapy containing vincristine (1.5 mg/m², weekly) and actinomycin-D (1.5 mg/m², three times weekly). On the 10th month of follow-up, tumor recurrence was detected and a salvage surgery was performed, while the same chemotherapy regimen was resumed. Following the first cycle of chemotherapy, the patient developed a fungal bronchopneumonia and succumbed due to disease progression, acute respiratory distress syndrome and septic shock 12 months after diagnosis.

Incidence trends and long-term survival analysis of sinonasal rhabdomyosarcoma

PURPOSE

Sinonasal rhabdomyosarcoma (SNRMS) is a rare malignancy which often presents with nasal obstruction, rhinorrhea and epistaxis. It is the most common sarcoma in children. In this study, we analyze the incidence and long-term survival for SNRMS using a national population-based database.

METHODS

The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to calculate incidence and survival trends for SNRMS between 1973 and 2009. In addition, data were grouped by age, gender, race, and histopathological subtype.

RESULTS

A total of 181 cases of SNRMS were analyzed for incidence trends, showing a 1.23:1 female to male ratio. While the overall incidence of SNRMS increased by 1.02% annually over the last 20years, this pattern was not equal amongst gender and racial groups. The incidence in males has increased, while in females incidence has decreased. An increase in incidence was noted in white and "others," but decreased in blacks. Using a total of 314 cases for survival analysis, we found that the rate in the white population has been consistently highest with a 5-year survival of 49.45%, 10- and 20-year survival of 48.81%. Survival rates in cases of embryonal SNRMS were also consistently higher than in cases of alveolar SNRMS.

CONCLUSION

Overall incidence of SNRMS is increasing. Histologic subtype and race are important considerations in the long-term prognosis of SNRMS. Future studies will further elucidate gender and race related trends.

Construction of conditional lentivirus-mediated shRNA vector targeting the human Mirk gene and identification of RNAi efficiency in rhabdomyosarcoma RD cells

Rhabdomyosarcoma is the most common malignant soft tissue tumor in children. It has been demonstrated that Mirk as an activated protein kinase is overexpressed in rhabdomyosarcoma cells, which may be correlated with tumorigenesis. The aim of the present study was to explore the possibility of Mirk gene as a therapeutic target for the treatment of rhabdomyosarcoma, and the use of RNA interference in a temporally and spatially restricted manner to study the function of the target gene would be highly beneficial. To address this problem, a conditional lentivirus-mediated short hairpin RNA targeting human Mirk gene was constructed and employed to reduce endogenous Mirk expression in the rhabdomyosarcoma RD cell line in vitro. The expression of Mirk shRNA in RD cells transduced with this recombinant vector could be tracked with the expression of red fluorescent protein by the administration of doxycycline. A stable transgenic RD line was generated by transducing RD lines with the packaging viral particles. Quantitative PCR and western blot analysis indicated that the mRNA and protein levels of Mirk in the transgenic RD cells were significantly lower compared to those in the controls. In addition, the increasing apoptosis of RD cells induced by silencing of the Mirk gene was also observed. Overall, the results demonstrated that this recombinant vector-based RNAi expression system is an efficient approach to knockdown Mirk gene expression in the rhabdomyosarcoma RD cell line, which could, thereby, provide both a protocol to study the role of Mirk gene in tumor cells and a safer gene therapy in the clinic.

Malignant tumors of the sinonasal tract in the pediatric population

CONCLUSION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

A low-grade myofibroblastic sarcoma in the abdominal cavity

Background

Rhabdomyosarcoma is the most common malignant tumor in the nasal and paranasal sinus area at childhood. Multimodal treatment for this disorder has severe side effects due to normal tissue damage. As a result of this treatment, facial growth retardation and oral abnormalities such as malformation of teeth and microstomia can cause esthetic and functional problems.

Case reports

Two cases are presented of patients with severe midfacial hypoplasia and reduced oral function as a result of treatment of rhabdomyosarcoma of the nasopharyngeal and nasal–tonsil region. With a combined surgical (osteotomy, distraction osteogenesis, implants) and prosthetic (implant-based overdenture) treatment, esthetics and function were improved.