Esthesioneuroblastoma--what is the optimal treatment?

Clinical outcomes for olfactory neuroblastoma

Background

Olfactory neuroblastoma (ONB) is a rare malignant tumor arising from the olfactory neuroepithelium. The standard of care for ONB is surgical resection; however, detailed treatment protocols vary by institution. Our treatment protocol consists of endoscopic skull base surgery (ESBS) for endoscopically resectable cases and induction chemotherapy followed by craniotomy combined with ESBS for locally advanced cases, with postoperative radiotherapy performed for all cases. Chemoradiotherapy (CRT) is performed in unresectable cases. In this study, we evaluate our treatment protocol and outcomes for ONB.

Methods

A retrospective review of patients with ONB was conducted. Outcomes included survival outcomes and perioperative data.

Results

Fifteen patients (53.6%) underwent ESBS, 12 (42.9%) underwent craniotomy combined with ESBS, and 1 (3.6%) received CRT. The 5- and 10-year overall survival rates for all patients were 92.9% and 82.5%, respectively, with a median follow-up period of 81 months. The 5- and 10-year disease-free survival rates were 77.3% and 70.3%, respectively, and the 5- and 10-year local control rates were 88.2% and 80.2%, respectively. Patients undergoing ESBS demonstrated a significantly shorter operating time, period from operation to ambulation, hospitalization period, and less blood loss than those undergoing craniotomy combined with ESBS.

Conclusion

Our treatment protocol was found to afford favorable outcomes. Patients who underwent endoscopic resection showed lower complication rates and better perioperative data than those who underwent craniotomy combined with ESBS. With appropriate case selection, ESBS is considered a useful approach for ONB.

Update on olfactory neuroblastoma

Olfactory neuroblastomas are uncommon malignancies that arise from olfactory receptor cells located high in the nasal cavity. Accurate diagnosis plays a crucial role in determining clinical results and guiding treatment decisions. Diagnosis can be a major challenge for pathologists, especially when dealing with tumours with poor differentiation. The discovery of several molecular and immunohistochemical markers would help to overcome classification difficulties. Due to the paucity of large-scale studies, standardisation of diagnosis, treatment and prediction of outcome remains a challenge. Surgical resection by endoscopic techniques with the addition of postoperative irradiation is the treatment of choice. In addition, it is advisable to consider elective neck irradiation to minimise the risk of nodal recurrence. Molecular characterisation will help not only to make more accurate diagnoses but also to identify specific molecular targets that can be used to develop personalised treatment options tailored to each patient. The present review aims to summarise the current state of knowledge on histopathological diagnosis, the molecular biology and management of this disease.

Long-Term Outcomes of Olfactory Neuroblastoma: MD Anderson Cancer Center Experience and Review of the Literature

OBJECTIVES/HYPOTHESIS

Olfactory neuroblastoma (ONB) is a rare sinonasal malignant neoplasm that is known to develop late recurrence. The aim of this study is to evaluate the long-term outcomes of patients with ONB and to determine the factors associated with prognosis.

STUDY DESIGN

Retrospective study.

METHODS

A retrospective review of the medical records of 139 patients diagnosed with ONB at MD Anderson Cancer Center was performed between 1991 and 2016. Descriptive statistics were calculated, and Kaplan-Meier curves were utilized to assess survival.

RESULTS

Median follow-up time was 75 months. Overall, 129 patients (92.8%) had surgery as part of their treatment and 82 (58.9%) patients received postoperative radiation therapy (PORT) or concurrent chemoradiotherapy. Endoscopic approaches were utilized for 72 patients, 69.4% of whom had pure endoscopic endonasal approaches. Five-year overall survival and disease-specific survival were 85.6% and 93.4%, respectively. Recurrence rate was 39.6% with a median time to recurrence of 42 months. Among the 31 patients who received elective nodal irradiation (ENI), two patients developed neck recurrence (6.4%) compared with 20 who developed neck recurrence when ENI was omitted (34.4%) (P = .003). Advanced Kadish stage, orbital invasion, intracranial invasion, and presence of cervical lymphadenopathy at the time of presentation were significantly associated with poor survival.

CONCLUSION

ONB has an excellent survival. Surgical resection with PORT when indicated is the mainstay of treatment. Endoscopic approaches can be used as a good tool. Elective neck irradiation reduces the risk of nodal recurrence among patients with clinically N0 neck. Despite the excellent survival, recurrence rate remains high and delayed, highlighting the need for long-term surveillance.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 2021.

Consolidating the Hyams grading system in esthesioneuroblastoma - an individual participant data meta-analysis

INTRODUCTION

Esthesioneuroblastoma (ENB) is an uncommon primary sinonasal tumor which can extend intracranially. Exactly how to classify them pathologically still remains discrepant; the Hyams grading system, for example, has not been universally adopted. This individual patient data (IPD) meta-analysis aimed to investigate the prognostic implication of each Hyams grade on patient outcomes.

METHODS

We accessed two electronic databases including PubMed and Web of Science. Raw patient data from potential articles were extracted. To examine the associations of various clinicopathological factors with the Hyams grades, we utilized Chi-square, t-test, and Mann-Whitney, as appropriate. Log-rank test and Cox regression analysis were used to elucidate the impact of the Hyams grades on recurrence-free survival (RFS), metastasis-free survival (MFS), and overall survival (OS) of ENB patients.

RESULTS

We included 33 studies with 492 ENB patients. We found significant associations of Kadish stages, Dulguerov stages, rates of recurrence, metastasis, and patient mortality with Hyams grade. Log-rank tests and Cox regression models demonstrated significant differences in RFS and OS of Hyams grade I - II, grade III, and grade IV patients. There was no statistical difference in RFS and OS of Hyams grade I and II. Radiotherapy was only effective in grade III - IV ENBs and chemotherapy showed no benefits to patients.

CONCLUSION

We verify that the Hyams grading system appears to be a reliable prognostic indicator to assess ENB patient outcomes. Consolidating the Hyams grading system into a three-tier system based on similar clinical outcomes of grades I and II may simplify this classification schema.

Long-Term Survival Outcomes and Treatment Experience of 64 Patients With Esthesioneuroblastoma

Background: Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy, lacking a unified staging system and treatment. Management at a single center was retrospectively evaluated to inform future treatment options and prognostic factors. Methods: Clinical data of 64 consecutive ENB patients, including prognostic factors and treatment methods, were reviewed retrospectively. Data were collected to calculate overall survival (OS) and progression free survival (PFS). Results: The majority of tumors 84.4% were within Kadish C stage, 79.7% were within T3 or T4, and 64.0% were within Hyams grade III or IV. A total of 50 (78.1%) patients received surgery and combined radiotherapy with or without chemotherapy, 10 (15.6%) received surgery with or without chemotherapy alone, and 4 (6.3%) received radiotherapy with or without chemotherapy alone. The majority of patients (79.7%) underwent endoscopic resection (endoscopic and endoscopically assisted). Surgery combined with radiotherapy with or without chemotherapy resulted in significantly better OS (84.4 vs. 50.6%, 84.4 vs. 37.5%) compared to surgery alone and radiotherapy alone (P = 0.0064). Endoscopic surgery group (endoscopic and endoscopically assisted) resulted in significantly better 5-year PFS (61.7 vs. 22.2%) compared to the open surgery group (P < 0.001). Although endoscopic surgery group was not a statistically significant predictor of 5-year OS (P = 0.54), the 5-year OS was 79.3% for the endoscopic surgery group and 76.2% for the open surgery group. A Cox regression analysis identified intracranial extension and surgery combined with radiotherapy as independent factors affecting 5-year OS while cervical lymph node metastasis and Hyams grade IV as independent factors affecting 5-year PFS. Conclusion: Our findings suggest that surgery combined with radiotherapy is the best treatment approach for ENB. For advanced tumors, endoscopic surgery is an effective treatment, and its survival rate is equal to or better than open surgery.

Hyams grading as a predictor of metastasis and overall survival in esthesioneuroblastoma: a meta-analysis

BACKGROUND

Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, represents up to 3% of all sinonasal neoplasms. Hyams histologic grading is a promising tool in predicting metastases and establishing prognoses for this complex tumor.

METHODS

A systematic literature search was performed in the PubMed, Ovid MEDLINE, and Cochrane databases. ENB patients with Hyams I-II or III-IV were categorized as low-grade Hyams (LGH) or high-grade Hyams (HGH), respectively. Binary and continuous random-effects models were applied to calculate odds ratios (ORs) for the incidences of neck and distal metastases as well as for 5- and 10-year overall survival rates.

RESULTS

Of the 57 screened articles published from 1993 to 2018, 16 (525 patients) and 21 (563 patients) provided data for tumor metastases and overall survival rates, respectively. Neck metastasis was observed in 18.2% of HGH vs 7.9% of LGH patients. Distant metastasis was noted in 20.7% of HGH vs 8.9% of LGH patients. LGH patients had 5- and 10-year overall survival rates of 81.2% and 64.0%, respectively, as compared with 60.9% and 40.6%, respectively, for HGH patients. In comparing HGHs vs LGHs, the collective ORs for neck and distant metastases were 2.08 (95% confidence interval [CI], 1.09-3.99; p = 0.03) and 2.37 (95% CI, 1.07-5.26; p = 0.03), respectively. Moreover, in comparing LGHs vs HGHs, collective ORs for 5- and 10-year overall survival rates were 3.39 (95% CI, 2.09-5.49; p < 0.001) and 3.03 (95% CI, 1.82-5.06; p < 0.001), respectively.

CONCLUSION

HGH ENBs, compared with LGH ENBs, are more likely to metastasize to neck or distal targets and to have lower overall survival rates.

Patient characteristics of olfactory neuroblastoma: experience from a tertiary cancer centre 2000-2016 covering Eastern Denmark

The aim of this study was to report incidence and patient characteristics of olfactory neuroblastoma (ONB) at a tertiary cancer institution during a 16-year period. A retrospective review was conducted on patients with ONB treated at Rigshospitalet, Copenhagen from 2000 to 2016 covering Eastern Denmark. Patient demographics, symptoms, stage, pathology-reports, treatment, and outcome were extracted from the patient records and the Danish pathology register. The tumours were graded both histologically and clinically using Hyam's and Kadish classifications, respectively. We identified a total of 14 patients (ten males, four females, median age 57 years, range 17-81 years). Four patients were in Kadish stage A, one stage B, and seven stage C. According to Hyam's classification, two tumours were grade I, nine grade II, and three grade III. All patients were treated with surgery, eight in combination with radiotherapy, where one received proton therapy, and one a combination with chemotherapy. At a median follow-up time of 58 months, the 5-year overall survival was 90% (95% CI 61; 99). ONB is a rare disease; complete radical surgery alone or combined with radiotherapy offered good oncologic control and outcome. Long-term follow-up of ONB should be mandatory.

Exploration of the optimal treatment regimes for Esthesioneuroblastoma: a single center experience in China

BACKGROUND: Esthesioneuroblastoma (ENB) is an uncommon neoplasm arising from the olfactory mucosa. The optimal treatment regimen for ENB remains unclear. This study aims to evaluate its clinical features, long-term outcomes and explore optimal treatment patterns.

METHODS: Clinical data of consecutive 44 ENB patients were reviewed retrospectively. The correlation between clinical features and treatment approaches were analyzed, with several prognostic factors explored meanwhile.

RESULTS: The age of onset of ENB showed a bimodal distribution, with peaks at 10~20 and 50~60 years. The median follow-up time was 84 months (range, 27~198 months).The 5-year overall and progression free survival rates were 42.7% and 39.1%, respectively, with 10-year rates of 28.9% and 21.7% respectively. Overall, 19 patients developed recurrent disease. Patients undergoing surgery combined with adjuvant radiotherapy had significantly higher 5-year overall survival (67.5% vs. 33.3%, P=0.043) and progress-free survival (60.0%vs. 18.7%, P=0.008) than those receiving other treatment approaches. No-Skin-involved ENB was associated with markedly better 5-year overall survival (45.5%vs.0 %, P=0.038) and progress-free survival (31.3% vs. 0 %, P=0.001) compared with skin-involved tumor.

CONCLUSIONS: ENB is a rarely malignant tumor with high probability of locoregional recurrence and poor survival. Surgical resection followed by radiotherapy has been shown to achieve optimal local control and overall survival.

Complications of Advanced Kadish Stage Esthesioneuroblastoma: Single Institution Experience and Literature Review

INTRODUCTION

In esthesioneuroblastoma, greater disease extent and Kadish staging correlate with greater recurrence, complications, and mortality. These advanced stage malignancies require extensive resections and aggressive adjuvant therapy. This increases the risk of complications such as cerebrospinal fluid leak, neurologic deficits, and osteomyelitis. We present our case series and then analyze the literature to ascertain whether advanced stage tumors corresponds to greater rates of complications.

METHODS

A retrospective review of consecutive patients with histologically-proven esthesioneuroblastoma who were aggressively managed at our institution was performed. This was followed by an extensive literature search of published original data, in large series from 2006-2016, where both surgery and adjuvant therapy were used for the treatment of esthesioneuroblastoma.

RESULTS 

Single institution review revealed eight patients with esthesioneuroblastoma, half with advanced Kadish staging. All Kadish A patients ( Kadish A: confined to nasal cavity) underwent endoscopic approaches alone, while Kadish C patients (Kadish C: extends beyond nasal cavity and paranasal sinuses) and D patients (Kadish D: lymph node or distant metastases) underwent craniofacial approaches, while all patients received post-operative adjuvant therapies. Complications such as cerebrospinal fluid (CSF) leak, seizures, meningitis, and abscess only occurred in high Kadish stage patients. Literature review demonstrated a higher proportion of advanced Kadish stage cases correlated with increasing rates of pneumocephalus, infection, and recurrence. A higher proportion of Kadish C and D tumors was inversely correlated with CSF leak rate and overall survival.

DISCUSSION

Advanced stage tumors are often associated with a higher incidence of adverse events up to 33%, both due to disease burden and treatment effect. There is increasing use of endoscopy and neoadjuvant therapy, which have the potential to decrease complication rates.

CONCLUSION 

Advanced Kadish stage esthesioneuroblastoma necessitates meticulous surgical resection and aggressive adjuvant therapies, together, these increase the likelihood of adverse events, including CSF leak, neurologic deficits, and infections, and may represent the real morbidity cost of radically treating these tumors to achieve an improvement in overall survival. In selected patients, less-invasive approaches or neo-adjuvant therapies can be used without compromising on a curative resection.

Maxillofacial esthesioneuroblastoma: A diagnostic complexity

Esthesioneuroblastoma is a rare malignant tumor of the sinonasal tract. Oral and maxillofacial pathologists rarely encounter this tumor in their daily practice. Because of their complex anatomic location, non-specific symptoms, varied histomorphology and unfamiliarity, most of the times, the tumor is diagnosed as benign tumor and thereby conservative treatment results in multiple recurrences. A recurrent case of esthesioneuroblastoma in a 24-year-old female patient describing the clinical, histopathological and immunohistochemical features along with differential diagnosis is discussed.

Combined modality therapy of esthesioneuroblastoma

Objective

Esthesioneuroblastoma (ENB) is a rare tumor of the olfactory epithelium. The objective of this study was to evaluate treatment modalities including surgery, IMRT, and chemotherapy and patient outcomes.

Patients and Methods

A retrospective analysis was performed on a total of 21 patients. Therapy included craniofacial resection (CFR), radiotherapy, chemotherapy, or a combination of these methods.

Results

The median follow-up period was 47 months. Surgery was performed in 90.4% of cases; radiotherapy was performed adjuvantly in 15 (72.7%) patients. Surgery, radiotherapy, and chemotherapy were administered to 7 (33.3%) patients. Eight (38.3%) patients had local recurrence. The 5-year crude overall survival was 71.4% and actuarial 5-year overall survival was 58% with confidence interval (CI, 25 and 81, respectively). The 5-year crude disease-free survival rate was 59% and the 5-year actuarial disease-free survival rate was 62% (CI, 28 and 83, respectively).

Conclusion

Multidisciplinary therapy of ENB should be considered, especially for Kadish C and high-grade lesions. Craniofacial resection (CFR), Intensity modulated radiation therapy (IMRT), and chemotherapy should be investigated in a multi-institution trial of ENB. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Long-term carcinologic results of advanced esthesioneuroblastoma: a systematic review

Surgical resection followed by radiotherapy can be considered like the optimal treatment modality for limited esthesioneuroblastoma. However, therapeutic management of locally advanced tumors remains a challenge. The aim of our study was to access and compare the oncologic results of the different treatment modalities in advanced esthesioneuroblastoma. We performed a systematic review using the Medline, and Cochrane database in accordance with PRISMA criteria and included all the cases of advanced esthesioneuroblastoma published between 2000 and 2013. We also retrospectively included 15 patients with an advanced esthesioneuroblastoma managed at our tertiary care medical center. Long-term survival rates defined as the time from diagnosis or randomization to the date of death or last follow-up were evaluated for each treatment with Kaplan-Meier survival curve analyses. 283 patients have been included. The mean follow-up was 78 months. Five-year highest survival rates were obtained in patients treated by surgery associated with radiotherapy. Ten-year highest survival rates were obtained in patients treated by the association of surgery, radiotherapy and chemotherapy (p = 0.0008). Within the surgical group, 5-year highest survival rates were obtained in patients treated by endoscopic resection (p = 0.003). Surgical resection combined with radiotherapy offers the gold standard of care. Adjuvant chemotherapy seems to improve the long-term survival in patients with locally advanced esthesioneuroblastoma. Endoscopic resection in advanced tumors should be discussed on a case-by-case basis.

[Esthesioneuroblastoma]

Esthesioneuroblastoma is an uncommon malignancy originating from olfactive epithelium. Men are more frequently affected than women. Nasal symptoms are the most common revealing signs. Immunohistochemistry helps diagnosis. There is no randomized trial evaluating treatment due to the low incidence of this tumor. Radiotherapy and surgery are the standard of care. Radiotherapy is benefic even in early stage disease. Chemotherapy is indicated in case of locally advanced or metastatic disease.

Treatment modalities and outcomes of olfactory neuroblastoma

OBJECTIVES/HYPOTHESIS

To analyze the clinical features of olfactory neuroblastoma (ONB) and compare the treatment results according to various treatment modalities, and to validate various staging systems.

STUDY DESIGN

Retrospective analysis.

METHODS

This study included 35 patients with ONB. Treatment consisted of neoadjuvant chemotherapy and radiation therapy (seven patients), traditional craniofacial resection (TCFR, 12 patients), endoscopic craniofacial resection with craniotomy (ECFR, 11 patients), and transnasal endoscopic resection without craniotomy (five patients). The overall mean follow-up period was 64.9 months and mean disease-free survival (DFS) was 50.2 months.

RESULTS

Five-year overall survival and 5-year DFS rates were 76.0% and 61.8%, respectively. Five-year DFS rates for nonsurgical treatment, TCFR, ECFR, and transnasal endoscopic resection without craniotomy group were 35.7%, 41.7%, 80.8%, and 100%, respectively (P = .01). Neck metastasis negatively affected survival (P = .03). DFS rate of patients in the endoscopic surgery group was higher than the nonendoscopic surgery group on Cox multivariate regression analysis (P = .02). The modified Kadish classification system predicted DFS more accurately than the Biller and Dulguerov classification system (P = .04). Locoregional recurrence occurred in 23% (period of recurrence after treatment, mean 49 months; range, 3-143) of patients with ONB, and distant metastasis in 26%. ECRF group showed lesser perioperative bleeding amount and shorter operation time compared with TCFR. However, the admission period was not statistically different.

CONCLUSIONS

Endoscopic surgery for advanced ONB showed successful survival results compared with nonendoscopic surgery on multivariate analysis, and limited morbidities. Modified Kadish classification best predicted DFS for ONB. Long-term follow-up is necessary due to its late recurrence.

Endoscopic skull base surgery for sinonasal malignancy

Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.

Metastatic esthesioneuroblastoma secreting adrenocorticotropic hormone in pediatric patients

The purpose of this article was to report a pediatric case of secondary cervical esthesioneuroblastoma involving the parapharyngeal lymph nodes. A 3-year-old boy came to our clinical observation because of a right lymphonodal mass evidenced by nuclear magnetic resonance and a diagnosis of Cushing syndrome associated with ectopic adrenocorticotropic hormone secretion, moon face, central obesity, asthenia, and hirsutism. At the age of 10 months, the patient underwent endoscopic surgery for asportation of the World Health Organization stage IV esthesioneuroblastoma. At 38 months of age, the patient underwent right parapharyngeal lymphadenectomy with surgical access by a double mandibulectomy. After surgery, serum ACTH, cortisolemia, and urinary excretion of cortisol were within the reference range. Blood pressure was recorded at 110/70 mm Hg. Moon face disappeared, as well as central obesity and hirsutism. Clinical report is presented together with brief review of literature.

Long-term results of 28 esthesioneuroblastomas managed over 35 years

BACKGROUND

The purpose of our study was to assess the long-term results in the management of patients with esthesioneuroblastoma.

METHODS

A total of 28 patients were retrospectively reviewed to analyze their clinical features, treatment outcomes, pattern of failures, and course of the disease.

RESULTS

The patients were classified as 2 patients with T1, 10 patients with T2, 10 patients with T3, and 6 patients with T4; the results of all were included in this study. Twenty-six patients underwent surgery and 23 had postoperative radiotherapy over the tumor bed, only 9 had radiotherapy over the nodes. The average follow-up was 99.11 months. Fifteen-year and 20-year disease-specific and disease-free survival rates were 88.6% to 66.4% and 59.6% to 29.8%, respectively. Six patients had recurrences and 60% of them occurred more than 10 years after treatment. In the first decade, nodal recurrences appeared earlier than local ones when patients with N0 did not undergo neck irradiation.

CONCLUSION

Surgery on patients with T presentations and adjuvant radiotherapy on T and N0 neck presentations seem to be essential to treat esthesioneuroblastoma. A follow-up for a minimum of 20 years is necessary to ensure complete cure.

Esthesioneuroblastoma presenting with proptosis and bilateral neck metastasis: An unusual presentation

Esthesioneuroblastoma (ENB) presenting simultaneously with proptosis and bilateral neck metastasis is a very rare presentation. ENB is a rare tumor arising from the olfactory epithelium of the nasal vault which frequently invades the cranial base, cranial vault and orbit. ENB has a bimodal age distribution between 11 and 20 years and between 51 and 60 years. ENB accounts for approximately 1 to 5% of intranasal cancers and no consensus has been reached yet regarding the treatment of this tumor. We are reporting a 17-year-old male patient who presented with right eye proptosis with loss of vision and bilateral neck metastasis. Contrast enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) was done which showed Kadish stage C tumor. Nasal biopsy was done to make the diagnosis and the patient was subjected to radiotherapy. Tumor responded to radiotherapy and both the primary lesion and the cervical lymph node metastasis disappeared. The purpose of this study is to report the rare presentation of proptosis along with bilateral cervical lymph node metastasis in this rare sinonasal tumor.

Retained role of surgery for olfactory neuroblastoma

BACKGROUND

Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol.

METHODS

This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted.

RESULTS

There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%.

CONCLUSIONS

There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.

Posttreatment prognosis of patients with esthesioneuroblastoma

OBJECT

There is no Class I evidence to guide the appropriate management of esthesioneuroblastoma (EN). Most data currently guiding treatment come from small- or modest-sized series gathered at individual centers that have concluded that surgery with radiotherapy is the preferred treatment. In this study, the authors summarize the published literature on treatment outcomes in patients with EN. The objective was to ascertain what variables predict prognosis in these patients and to determine the relative effect of different therapies.

METHODS

The authors identified 205 published studies containing treatment outcomes for surgery, radiotherapy, chemotherapy, or multimodal treatment. Using Kaplan-Meier analysis, the survival of patients who received surgery was compared with that in those who received surgery and radiotherapy. Additionally, Kadish staging was compared with low- and high-grade Hyams criteria to assess for subgroup prognostic significance in survival differences.

RESULTS

Nine hundred fifty-six patients met the inclusion criteria, with a median follow-up time of 3 years. Kaplan-Meier analysis demonstrated no difference in survival between patients who underwent surgery alone and those who underwent surgery plus radiotherapy at 5 years (78 vs 75%) or 10 years (67 vs 61%, respectively) (p = 0.3). Univariate analysis demonstrated worse survival in cases involving Kadish Grade C tumors, Hyams Grade 3 and 4 tumors, and in patients older than 65 years of age. Multivariate analysis demonstrated that Hyams Grade 3 and 4 lesions carried significant risk (proportional hazard = 4.83, p < 0.001) with 5- and 10-year survival of 47 and 31%.

CONCLUSIONS

A biopsy should always be obtained in cases suspected of EN because histology is a strong prognostic indicator and will help guide appropriate treatment. Unimodal surgery and combined surgery/radiotherapy appear to be of equivalent efficacy with respect to survival in patients with EN. Chemotherapy should be considered in high-grade EN.

Esthesioneuroblastoma methods of intracranial extension: CT and MR imaging findings

INTRODUCTION

Esthesioneuroblastoma (ENB) is an aggressive neuroectodermal malignancy in the upper nasal cavity with local infiltration and lymphatic or hematogenous metastasis. The purpose of this paper is to document three types of direct intracranial extensions by ENB using computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS

Eleven patients with pathologically confirmed ENB were admitted in our hospital between December 2002 and December 2008. Their magnetic resonance (MR; n = 10) and CT (n = 8) images were retrospectively reviewed, and particular attention was paid to tumor location and extension, enhancement pattern, cervical lymph node metastasis, and Kadish stage.

RESULTS

The majority of patients were male (8/11) with Kadish stage C tumor (10/11). Three types of direct intracranial extension by ENBs were put forward according to their MR and CT findings. The primary tumors were well-defined soft-tissue masses centered in the roof of the nasal cavity eroding into the paranasal sinuses (11/11), the contralateral nasal cavity (4/11), the cranial cavity (5/11), and the fossa orbitalis (3/11). The tumor parenchyma were hypointensity on T1-weighted images, heterogeneous hyperintensity on T2-weighted images, and isodensity or slight hyperdensity on CT images with scattered necroses (4/11) and marginal cysts(4/11). Their enhancements were significant and inhomogeneous. Cervical lymph nodes metastases were observed in four patients (4/11), but no pathologically proved distant metastasis was observed.

CONCLUSION

Three types of direct intracranial extensions by ENB can be found on CT and MRI: cranio-orbital-nasal-communicating ENB, cranio-nasal-communicating ENB, and orbital-nasal-communicating ENB.

Treatment of esthesioneuroblastoma: a 16-year meta-analysis of 361 patients

OBJECTIVES/HYPOTHESIS

This study reviews the published outcomes related to surgical (open, endoscopic, and endoscopic-assisted) and nonsurgical treatment for esthesioneuroblastoma.

STUDY DESIGN

Literature meta-analysis.

METHODS

A meta-analysis of individual patient data for esthesioneuroblastoma publications between 1992 (the earliest identified description of endoscopic resection) and 2008 was conducted. A total of 49 journal articles, comprising 1,170 cases of esthesioneuroblastoma, were included in the study. Criteria for meta-analysis inclusion were five or more patients in a study with sufficient patient data resolution for analysis. Twenty-three studies comprising 361 patients met all inclusion criteria. The overall treatment and outcome at final follow-up of each patient was recorded. Patients were pooled according to treatment techniques and compared to one another using a Kaplan-Meier survival curve and the Mann-Whitney U test to examine differences in follow-up times and publication years.

RESULTS

Log-rank tests showed a greater published survival rate for endoscopic surgery compared to open surgery (P = .0019), even when stratifying for publication year (P = .0018). There was no significant difference in follow-up time. Review of Kadish tumor staging for each modality showed larger tumors were more often treated with an open approach, but open and endoscopic survival measures were comparable.

CONCLUSIONS

These results suggest that endoscopic surgery is a valid treatment method with comparable survival to open surgery. Further prospective analysis will be beneficial.

Esthesioneuroblastoma: The Princess Margaret Hospital experience

BACKGROUND

Esthesioneuroblastoma is rare. The aim of the study was to review our experience and to evaluate the staging system and treatment that best correlates with the patient outcome.

METHODS

Thirty-nine patients were identified between 1972 and 2006.

RESULTS

At presentation 10% had cervical metastases. None had distant metastasis. Five were treated with surgery, 2 with chemotherapy, 1 with radiotherapy, and 30 with surgery and radiation. Local disease control was 82.6% at 5 years. Recurrence was seen in 33% with local and regional disease recurrence at 15% and 18%, respectively. The 5- and 10-year overall survival rates were 87.9% and 69.2%, respectively. Dulguerov classification correlated most closely to survival and recurrence.

CONCLUSIONS

Dulguerov classification best correlates with the patient's outcome. A combined approach is the preferred treatment. It makes no difference whether radiotherapy is given pre or postsurgical resection. Recurrence can occur even 15 years after treatment. Therefore, long-term follow-up is essential.

Results of salvage therapy after failure of initial treatment for advanced olfactory neuroblastoma

INTRODUCTION

Olfactory neuroblastoma is a very aggressive tumour with high rates of locoregional recurrence and distant metastasis. Therefore, salvage therapy plays an important role in control of these neoplasms. In this study, we present our experience and treatment outcomes for salvage therapy in patients with recurrent olfactory neuroblastoma.

MATERIAL AND METHODS

We retrospectively analysed 17 patients treated for advanced olfactory neuroblastoma during the last 15 years.

RESULTS

The disease-free 5-year survival rate was 48% in all patients and 42% in the 17 patients with recurrence or distant metastasis. Salvage therapy was performed in 6 of 8 patients with recurrence or metastasis and proved successful in 50% of them. In the patients with locoregional recurrence, the success rate of salvage radiotherapy plus neck dissection was superior to salvage chemotherapy alone. In addition, 17% of the patients with distant metastasis after initial treatment died after salvage therapy. In 15% of patients with a clinical stage N0 at initial diagnosis, nodal recurrence developed and was successfully treated with salvage therapy.

CONCLUSION

Complete surgical resection, including craniofacial resection and postoperative radiotherapy without elective neck dissection, is the preferred approach in the treatment of advanced olfactory neuroblastoma. In locoregional recurrence, successful salvage therapy may include selective neck dissection and radiotherapy, but in cases of distant metastasis, the prognosis was poor.

Nonplatinum-based chemotherapy with irinotecan plus docetaxel for advanced or metastatic olfactory neuroblastoma: a retrospective analysis of 12 cases

BACKGROUND

The efficacy and safety of chemotherapy with irinotecan plus docetaxel were retrospectively evaluated for olfactory neuroblastoma.

METHODS

Twelve patients with histologically proven advanced or metastatic olfactory neuroblastoma were treated with chemotherapy with irinotecan plus docetaxel at the study institution between 2001 and 2005. Of these, 7 patients with locoregional disease and no prior radiotherapy received irinotecan plus docetaxel followed by definitive radiotherapy, 1 with photon radiotherapy and 6 with proton radiotherapy, whereas 3 patients with distant metastases and 2 with locoregional disease who had received prior radiotherapy received irinotecan plus docetaxel only.

RESULTS

The most common toxicities of >or=grade 3 among the 12 patients receiving irinotecan plus docetaxel were leukopenia (33%), neutropenia (50%), febrile neutropenia (8%), and diarrhea (25%), all of which were manageable. Partial response was achieved in 3 patients, giving an overall response rate of 25%. The response rate was higher in patients aged <50 years (3 of 4 patients) compared with those aged >50 years (0 of 8 patients) (P = .018). With a median follow-up period of 22.2 months, the median progression-free survival and overall survival were 13.6 months and 36.6 months, respectively. Of the 7 patients with locoregional disease also receiving definitive radiotherapy, the 2-year survival rate was 100% and 6 patients were alive at the time of last follow-up.

CONCLUSIONS

Chemotherapy for olfactory neuroblastoma with irinotecan plus docetaxel is safe and manageable. Patients aged <50 years may be sensitive to chemotherapy. Induction chemotherapy followed by definitive radiotherapy may represent a promising option for patients with locally advanced olfactory neuroblastoma.

Esthesioneuroblastoma - a clinicopathologic study and role of DNA topoisomerase alpha

Esthesioneuroblastoma (ENB) differs from adrenal neuroblastomas in its histopathologic and biologic characteristics. Hyams grading and Kadish staging have shown correlation with survival. Scant data are available on proliferation indices and prognosis. We retrospectively reviewed the clinicopathologic characteristics of ENB. Both Kadish and UCLA staging systems were used. Hyams grading was simplified into low and high grade. DNA topoisomerase II alpha labeling index (T2alpha LI) was obtained in 8 cases using immunohistochemistry. Of the 19 cases studied, 14 were males and 5 females. Age range was 2 to 62 years (average 27 years). The mass primarily involved the nose in 12 (63%) and paranasal sinuses in 7 cases (37%). Patients presented with nose block in 19 (100%), epistaxis in 10 (53%), proptosis in 9 (47%) and loss of vision in 6 cases (32%). Bony involvement was seen in 7 cases (37%), and intracranial spread in one case (5%). Thirteen (68%) were low-grade tumors and 6 were (32%) high-grade. There was no statistically significant difference between the low- and high-grade ENB in age (years) (p=0.2882), duration of symptoms (months) (p=0.5636), and either in the Kadish (p=0.5456) or the UCLA staging system (p=0.7771). The difference in DNA topoisomerase alpha labeling index between the low- and highgrade ENB (medians: 10.4 and 22.3, respectively) was not statistically significant (p=0.0714), but it was suggestive of a positive association. The results of this study should be interpreted with caution, because of the limited sample size. Three cases recurred locally, one each stage A, B and C, but all low-grade. This preliminary study suggests the need to combine a simplified histologic grading with accurate staging in a reasonable attempt to assess local progression in esthesioneuroblastoma. Larger studies may clarify the role of T2alpha LI in improving histologic grading.

Surgical treatment versus concurrent chemoradiotherapy as an initial treatment modality in advanced olfactory neuroblastoma

OBJECTIVE

Olfactory neuroblastomas are very aggressive tumors with a high locoregional recurrence rate and distant metastasis. Surgical treatment, including craniofacial resection, has been the main treatment modality, but treatment outcomes of concurrent chemoradiotherapy remain unclear. We present our experiences regarding the treatment outcome of patients with advanced olfactory neuroblastoma undergoing surgical treatment and concurrent chemoradiotherapy.

METHODS

We retrospectively analyzed 16 patients treated for advanced olfactory neuroblastoma within the past 10 years.

RESULTS

The disease-free 5-year survival rate of the patients (n = 10) who underwent surgical treatment was 68%. The survival rate for patients (n = 6) who received concurrent chemoradiotherapy was 42%. The difference in the survival rate was not statistically significant, and no difference in the recurrence rate between the two groups. In the group having surgical treatment, post-operative radiotherapy and salvage therapy were important to increase the survival rate. In the group having concurrent chemoradiotherapy, no patient experienced primary tumor progression.

CONCLUSION

Complete surgical resection, including craniofacial resection (CFR), and post-operative radiotherapy seem to be essential in the treatment of advanced olfactory neuroblastoma. However, concurrent chemoradiotherapy may be another primary treatment modality.

Retropharyngeal lymph node metastasis from olfactory neuroblastoma: A report of two cases

Olfactory neuroblastoma is a rare, malignant neoplasm arising from the olfactory epithelium. It has an aggressive biological behavior that is characterized by local recurrence, atypical distant metastasis, and poor long-term prognosis. The incidence of cervical lymph node metastasis in olfactory neuroblastoma is variable, and treatment modalities are controversial. Moreover, few reports have been published concerning retropharyngeal lymph node metastasis from olfactory neuroblastoma. We present two cases of olfactory neuroblastoma with retropharyngeal lymph node metastasis. In addition, we provided a review of the current literature regarding olfactory neuroblastoma and retropharyngeal lymph node metastasis from olfactory neuroblastoma.

Malignant neoplasms of the head and neck

Head and neck masses represent a common clinical entity in children. In general, these masses are classified as developmental, inflammatory, or neoplastic. Having a working knowledge of lesions within this region and conducting a thorough history and physical examination generally enables the clinician to facilitate an appropriate workup and establish a diagnosis. The differential diagnosis is broad, and expeditiously distinguishing benign from malignant masses is critical for instituting a timely multidisciplinary approach to the management of malignant lesions. Neoplasms of the head and neck account for approximately 5% of all childhood malignancies. A diagnosis of malignancy may represent a primary tumor or metastatic foci to cervical nodes. In this review, we discuss the general approach to evaluating suspicious masses and adenopathy in the head and neck region and summarize the most common malignant neoplasms of the head and neck with regard to their incidence, clinical presentation, diagnostic evaluation, staging, and management. Thyroid, parathyroid, and salivary gland tumors are discussed elsewhere in this issue of Seminars in Pediatric Surgery.

[Esthesioneuroblastoma treatment]

INTRODUCTION

Esthesioneuroblastoma is an uncommon malignancy of the olfactory neuroepithelium. The best treatment has yet to be defined. The purpose of this study is to analyze the tumors's behaviour to choose the ideal treatment, the therapeutic strategy and the patterns of failure.

MATERIALS AND METHODS

We carry out a revision of the series published between 1994 to 2004. In these series, we found 39 papers with 713 patients.

DISCUSSION

CONCLUSIONS

In this review the 5-years survival rate is 51.2%. Through the analysis of 583 partients found in 34 publications, surgery (alone or combined) is the treatment most used (78%). The commonly management is surgical in combination with radiotherapy (47%).

Orbital invasion by esthesioneuroblastoma

PURPOSE

Esthesioneuroblastoma is a rare malignancy arising from the olfactory mucosa in the nasal fossa, which can invade the orbit producing ophthalmic symptoms and signs. The purpose of this study was to present a case series and review the literature to assess the characteristics of orbital involvement by esthesioneuroblastoma.

METHODS

Retrospective case series of all patients treated for biopsy-proven esthesioneuroblastoma at the Royal Adelaide Hospital between 1992 and 2004.

RESULTS

Nine patients (5 male, 4 female) with a mean age of 50 years (range, 20 to 66 years) were reviewed. One case was classified as Kadish stage A, 1 as Kadish stage B, and 7 as Kadish stage C. Mean time from onset of symptoms to diagnosis was 17 months (range, 2 to 24 months). Radiologic orbital invasion was present in 4 cases and was associated with ophthalmic symptoms or signs in 3 of these cases. These included proptosis (2 cases), periorbital pain (1 case), decreased visual acuity (1 case), extraocular muscle restriction (1 case), and chemosis (1 case). One patient with symptoms secondary to orbital invasion was initially referred to and assessed by an ophthalmologist. All patients who had or went on to have development of orbital invasion had advanced disease at diagnosis. Treatment was surgical (9/9), with the addition of radiotherapy (6/9) and chemotherapy (2/9). Mean follow-up was 3.6 years (range, 0.5 to 8.5 years). Six of 9 patients had tumor recurrence. Two had metastasis. Five of 9 patients remained alive.

CONCLUSIONS

Orbital invasion by esthesioneuroblastoma is not uncommon. It is important to be aware of this malignancy because a significant proportion of patients will present with ophthalmic signs and symptoms.

Diagnosis and management of esthesioneuroblastoma

Esthesioneuroblastoma is an uncommon malignant neoplasm of the nasal vault that in the past was considered benign or low-grade malignant. Surgical approaches in the main were transnasal, with a high recurrence rate and ultimate patient death. With the modern imaging of CT and MRI, should the patient be willing and fit enough, esthesioneuroblastoma currently should be approached using a craniofacial resection. Large tumors should be considered for preoperative chemotherapy and postoperative radiotherapy. Local tumor recurrence is not uncommon and is generally related to the attention to local anatomic dissection. Neck metastases, when they present, should be excised using a modified neck dissection. Distant metastases may present at any time during the course of the disease, generally within 36 months, and may respond to local radiotherapy or systemic chemotherapy. Five-year survival currently appears to be optimized by surgery followed by postoperative radiotherapy and is approximately 65%.

Olfactory neuroblastomas: survival rate and prognostic factor

Olfactory neuroblastomas are known to be rare and clinically malignant tumors. The authors analyzed the clinical features, long-term treatment outcomes, and prognostic factors related to 21 cases of olfactory neuroblastomas, treated between January 1979 and October 2000, retrospectively reviewed with medical records and radiologic findings. The mean follow-up period was 28.7 months (range 4-178). The extent of tumor was classified according to the UCLA staging system. Statistical analysis for survival was done using the Kaplan-Meier method and the log-rank test. The mean age was 27 years (13-62), the peak incidence occurred in the second decade (8/21, 38%), and the male to female ratio was 13:8. According to the UCLA staging system, there were 3 cases of T1, 5 of T2, 6 of T3, and 7 of T4. The 5-year survival rate was 21.3% and the average survival time was 28.9 months. The group (n = 14) undergoing radical surgical resection as the primary modality, registered a higher survival rate than the radiation and chemotherapy group (n = 7), with 2-year survival rates being 76.2% vs. 14.3%, respectively (p = 0.0274). The early stage (T1, T2) groups exhibited a better survival rate than the advanced (T3, T4) groups with 5-year survival rates being 38.1% vs. 9.1%, respectively (p = 0.0336). The mean recurrence free time was 7.8 months (range 1-25). From these findings we could conclude that tumor detection in the early stage, radical surgical resection as the primary treatment modality, and regular follow-up with radiologic evaluation for recurrence or metastasis, represent important factors for an improved outcome.

Esthesioneuroblastoma: the Northwestern University experience

OBJECTIVE

To review our experience with esthesioneuroblastoma, a rare malignancy of the head and neck.

STUDY DESIGN

Retrospective review of Tumor Registry data.

METHODS

We performed a computerized search of the Northwestern Memorial Hospital Tumor Registry database from 1981 to 2000.

RESULTS

Sixteen patients with esthesioneuroblastoma were identified and analyzed. Their mean age was 42 years. Eleven of 16 patients (69%) had Kadish stage C; 8 patients (50%) had brain involvement at presentation. Craniofacial resection was performed in 13 patients (81%). Fourteen patients received either preoperative or postoperative therapy; radiation therapy was employed in 11 cases and chemotherapy in 4. The actuarial 5-year survival was 60%, and the actuarial 5-year disease-free survival was 33%, with a median follow-up of 4.3 years. Recurrences occurred at a median time of 11 months after diagnosis (2.5 mo-18 y). The first site of failure was locoregional alone in 10 of 12 patients who progressed, and in 6 patients involved the brain or the meninges. Two patients were successfully salvaged. Patients with high-grade tumors had a trend toward work survival.

CONCLUSIONS

Esthesioneuroblastoma is a rare tumor that is potentially curable by surgical resection and radiation therapy. However, the rate of local failure is high, and late recurrences are not uncommon. The role of chemotherapy warrants further investigation.

Primary sphenoid esthesioneuroblastoma studied with MR

Esthesioneuroblastoma (ENB) is an uncommon tumor type of neural crest origin, which, in the majority of cases, arises in the nasal cavity. We present a rare primary presentation of ENB in the sphenoidal area studied with computed tomography (CT) and magnetic resonance (MR). To our knowledge, this is the first case in which MR findings are available.

Esthesioneuroblastoma: irradiation alone and surgery alone are not enough

PURPOSE

To evaluate the long-term outcome of patients with esthesioneuroblastoma treated with neoadjuvant or definitive radiotherapy (RT).

METHODS AND MATERIALS

Between 1980 and 2001, 28 patients with histologically confirmed esthesioneuroblastoma underwent RT, with a median dose of 60 Gy (range 38-73). The median age was 58 years (range 16-85). According to the Kadish classification, 4 patients had Stage A, 8 Stage B, and 16 Stage C tumors. Radical resection was performed in 13 cases, in 9 before RT and in 4 after RT because of stable or progressive disease. The outcome analyses included the median age (58 years), Kadish stage, skull base penetration, intraorbital extension, resection status, and total dose (<or=60 vs. >60 Gy).

RESULTS

After a mean follow-up of 68 months, 54% of patients were free of tumor progression. The 5- and 10-year local progression-free survival rate was 81% and 51%, respectively, and the disease-free survival rate was 70% and 25%, respectively. Four of ten deaths (4/10) were intercurrent, resulting in a cause-specific survival of 77% and 69% at 5 and 10 years, respectively. Radical resection offered significantly better local progression-free survival and disease-free survival (p <0.02). Skull base penetration (p <0.04), intraorbital extension (p <0.04), and Kadish C stage (p <0.06) were important for impaired disease-free survival.

CONCLUSION

Despite doses up to 73 Gy, radical RT cannot replace radical resection, which classifies esthesioneuroblastoma as rather radioresistant. Because of its biology and the high rates of late recurrence, we recommend a radical strategy with resection, high-dose RT, and simultaneous chemotherapy. We are aware that some tumors qualify for palliative treatment only.

Esthesioneuroblastoma: a Danish clinicopathological study of 40 consecutive cases

Aims. To review all cases of esthesioneuroblastoma in Denmark from 1978 to 2000 with respect to staging, grading, histopathological and immunohistochemical evaluation, and prognostication. Methods and results. Possible cases of esthesioneuroblastoma were retrieved from Danish oncology departments. Patients were included on the basis of review of their files or pathology reports, and/or on the basis of histopathological and immunohistochemical examination. Forty-nine possible cases were retrieved. Nine cases were excluded. Esthesioneuroblastoma is a malignant neuroendocrine tumour originating in the olfactory mucosa. It is a small blue cell neoplasm with a characteristic lobular architecture. It has a neuroendocrine immunophenotype and a sustentacular S-100 staining pattern. The tumours were staged according to Kadish and graded according to Hyams. Kaplan-Meier survival analysis was used to identify prognostic factors. Conclusion. The Kadish staging system was able to group the patients into prognostically relevant groups. Intracranial involvement and metastases at the time of diagnosis were found to be poor prognostic factors. Hyams grading system is difficult to work with and it was not possible to divide patients into prognostically relevant groups. Presence of necrosis, a diffuse growth pattern and a high proliferation index proved to be equally poor prognostic factors.

Esthesioneuroblastoma in children

Esthesioneuroblastoma (olfactory neuroblastoma) is a rare tumor of the olfactory epithelium. Approximately 1,000 cases have been described in the literature since the original description in 1924. It occurs in older individuals and is rare in children. The authors describe the clinicopathologic presentation in a series of five children treated with neoadjuvant/adjuvant chemotherapy and review the English literature for previously described patients younger than 18 years to assess clinical presentation, mode of treatment, and outcome in this age group.

Misdiagnosis of olfactory neuroblastoma

OBJECT

Olfactory neuroblastoma (ON) is a rare neoplasm arising from the olfactory epithelium and found in the upper nasal cavity. The authors studied the frequency with which ON is misdiagnosed with other tumors of the paranasal sinuses such as neuroendocrine carcinoma (NEC), pituitary adenoma, melanoma, lymphoma, and sinonasal undifferentiated carcinoma (SNUC). Based on the belief that misdiagnosis commonly occurs, they emphasized the importance of establishing the correct diagnosis, because the treatment regimens and prognosis of these tumor types are often significantly different.

METHODS

Twelve consecutive patients in whom ON was diagnosed were referred to the Department of Neurosurgery at the M. D. Anderson Cancer Center between January 1998 and March 2000. Demographic data were collected, physical findings and mode of treatments were documented, and neuroimaging studies were assessed. Pathologists at the authors' institute reviewed the histological specimens. Only in two of 12 patients was the diagnosis of ON confirmed. Lesions in 10 patients were misdiagnosed; there were two cases of melanoma, three cases of NEC, three cases of pituitary adenoma, and two cases of SNUC. Eight of 10 patients in whom lesions were misdiagnosed required significant alteration in the initially proposed treatment plan.

CONCLUSIONS

Neurosurgeons should be acutely aware of the variety of neoplasms that occur in the paranasal region. The correct diagnosis should be ensured before initiating treatment to provide the optimum therapy and spare the patients from needless and potentially toxic treatment.

Esthesioneuroblastoma: a meta-analysis and review

Our objective was to review recent developments in diagnosis, staging, and treatment of esthesioneuroblastoma (ENB). A meta-analysis of publications between 1990 and 2000 was carried out, and studies were classified according to their main subject: origin/aetiology of ENB, histopathological diagnosis, and treatment. Data so far point to the basal progenitor cells of the olfactory epithelium as the origin of ENB. Histopathological diagnosis remains difficult and is based on results of antigen expression detected through a panel of antibodies by immunohistochemistry. RT-PCR of HASH expression could be a specific marker of ENB. Overall and disease-free survival at 5 years averaged 45% (SD 22) and 41% (SD 21) in the studies included in the meta-analysis. Survival in Hyams' grades I-II was 56% (SD 20) compared with 25% (SD 20) in grades III-IV (odds ratio 6.2). In patients with metastases in cervical lymph nodes (on average 5% of the total) survival was 29%, compared with 64% for patients with N0 disease (odds ratio 5.1). Survival according to treatment modalities was 65% for surgery plus radiotherapy, 51% for radiotherapy and chemotherapy, 48% for surgery, 47% for surgery plus radiotherapy and chemotherapy, and 37% for radiotherapy alone. The histopathological grading according to Hyams and the presence of cervical lymph-node metastases emerged as prognostic factors. A combination of surgery and radiotherapy seems to be the optimum approach to treatment. The exact role of chemotherapy in treatment protocols is still unclear. The role of elective neck dissection is unclear.