Contemporary clinical commentary: Esthesioneuroblastoma: An update on management of the neck

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.

Treatment Outcomes of Olfactory Neuroblastoma: A Multicenter Study by the Korean Sinonasal Tumor and Skull Base Surgery Study Group

OBJECTIVES

Due to the rarity of olfactory neuroblastoma (ONB), there is ongoing debate about optimal treatment strategies, especially for early-stage or locally advanced cases. Therefore, our study aimed to explore experiences from multiple centers to identify factors that influence the oncological outcomes of ONB.

METHODS

We retrospectively analyzed 195 ONB patients treated at nine tertiary hospitals in South Korea between December 1992 and December 2019. Kaplan-Meier survival analysis was used to evaluate oncological outcomes, and a Cox proportional hazards regression model was employed to analyze prognostic factors for survival outcomes. Furthermore, we conducted 1:1 nearest-neighbor matching to investigate differences in clinical outcomes according to the use of neoadjuvant chemotherapy.

RESULTS

In our cohort, the 5-year overall survival (OS) rate was 78.6%, and the 5-year disease-free survival (DFS) rate was 62.4%. The Cox proportional hazards model revealed that the modified Kadish (mKadish) stage and Dulguerov T status were significantly associated with DFS, while the mKadish stage and Hyams grade were identified as prognostic factors for OS. The subgroup analyses indicated a trend toward improved 5-year DFS with dural resection in mKadish A and B cases, even though the result was statistically insignificant. Induction chemotherapy did not provide a survival benefit in this study after matching for the mKadish stage and nodal status.

CONCLUSION

Clinical staging and pathologic grading are important prognostic factors in ONB. Dural resection in mKadish A and B did not show a significant survival benefit. Similarly, induction chemotherapy also did not show a survival benefit, even after stage matching.

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.

Clinical Outcomes and Patterns of Failure in Esthesioneuroblatoma: A Single Institutional Experience

Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy that is typically managed with a combination of surgical resection, radiotherapy and chemotherapy. Data used to guide therapeutic decision making are scant and typically obtained from small retrospective series due to the relative infrequency of the diagnosis. Here, we report our own institutional experience in the management of patients with ENB to help compliment these prior single institutional reports. Records from patients receiving treatment for ENB at the University of Minnesota Medical Center were obtained from 1994 to 2019. A total of 17 patients were identified from our retrospective review. Kadish stage at initial presentation was A in 2 (12%), B in 5 (29%), C in 9 (53%) and D in 1 (6%). All patients underwent surgical resection. Adjuvant radiotherapy was utilized in 12 (71%) patients with concurrent chemotherapy administered in 3 (18%) patients. One patient received neoadjuvant chemoradiotherapy followed by surgical resection. Four patients developed recurrent disease with locoregional failure presenting as the most common site of initial relapse within our study population. Isolated local recurrence occurred in 2 patients, one patient developed combined local and regional failure, while another had combined regional and distant failure with osseous metastases. Recurrent disease was managed by either combined salvage surgery and radiotherapy (RT) or RT alone. Three of the 4 patients who developed recurrence eventually succumbed to their disease. Estimates for 5-year DFS and OS were 65% and 90%, respectively, for the entire cohort.

Recurrent Esthesioneuroblastoma: Long-Term Outcomes of Salvage Therapy

INTRODUCTION

Esthesioneuroblastoma (ENB) is a rare malignant neoplasm arising from the olfactory epithelium of the cribriform plate. Although survival is excellent with a reported 5-year overall survival (OS) of 82%, recurrence is frequent and occurs in 40-50% of cases. This study investigates the characteristics of ENB recurrence and the subsequent prognosis of patients with recurrence.

METHODS

The clinical records of all patients diagnosed as having ENB with subsequent recurrence at a tertiary hospital from 1 January 1960 to 1 January 2020 were retrospectively reviewed. Overall survival (OS) and progression-free survival (PFS) were reported.

RESULTS

A total of 64 out of 143 ENB patients had recurrences. In total, 45 out of 64 recurrences met the inclusion criteria and were included in this study. From these, 10 (22%) had a sinonasal recurrence, 14 (31%) had an intracranial recurrence, 15 (33%) had a regional recurrence, and 6 (13%) had a distal recurrence. The average interval from initial treatment to recurrence was 4.74 years. There were no differences in rates of recurrence with respect to age, sex, or types of surgery (endoscopic, transcranial, lateral rhinotomy, and combined). The time to recurrence was shorter for Hyams grades 3 and 4 compared to Hyams grades 1 and 2 (3.75 years vs. 5.70 years, p < 0.05). Patients with recurrence limited to the sinonasal region had a lower overall primary Kadish stage compared to recurrences beyond the sinonasal region (2.60 vs. 3.03, p < 0.05). A total of 9 (20%) out of 45 patients developed secondary recurrence. Following recurrence, the subsequent 5-year OS and PFS were 63 and 56%, respectively. The mean time to secondary recurrence after treatment of the primary recurrence was 32 months, which was significantly shorter than the time to primary recurrence (32 months vs. 57 months, p = 0.048). The mean age of the secondary recurrence group is significantly older than the primary recurrence group (59.78 years vs. 50.31 years, p = 0.02). No statistically significant differences were observed between the secondary recurrence group and the recurrence group in terms of their overall Kadish stages or Hyams grades.

CONCLUSIONS

Following an ENB recurrence, salvage therapy appears to be an effective therapeutic option with a subsequent 5-year OS of 63%. However, subsequent recurrences are not infrequent and may require additional therapy.

Dramatic response to targeted therapy in an aggressive olfactory neuroblastoma: illustrative case

BACKGROUND

Olfactory neuroblastomas are rare sinonasal tumors that arise from the olfactory epithelium. The authors presented a case of an olfactory neuroblastoma with extensive cranial invasion that demonstrated dramatic response to sorafenib, a tyrosine kinase inhibitor.

OBSERVATIONS

A 54-year-old man with history of prostate cancer and melanoma presented with left-sided proptosis and was found to have a 6.5-cm Kadish stage D olfactory neuroblastoma with cranial invasion that was refractory to chemotherapy and everolimus. However, it demonstrated dramatic response to sorafenib, causing extensive skull base defects that prompted operative repair. Genomic analysis of the tumor revealed mutations in TSC1 and SUFU. The patient developed disease progression with liver metastases 35 months after starting sorafenib, prompting a change to lenvatinib. He experienced progression of his olfactory neuroblastoma 10 months following this change and died in hospice 1 month later.

LESSONS

The authors reviewed the clinical presentation and management of a large olfactory neuroblastoma with dramatic response to sorafenib. They highlighted prior uses of targeted therapy in the management of refractory olfactory neuroblastoma within the context of current standard treatment regimens. Targeted therapies may play a vital role in the management of refractory olfactory neuroblastoma.

Olfactory Neuroblastomas: What Actually Happens in the Long-Term?

Objective: The aim of this study was to investigate the long-term oncologic outcome and review the state of the art in the management of olfactory neuroblastomas. Material and Methods: The records of all patients treated for olfactory neuroblastomas in two academic departments between 1975 and 2012 were evaluated retrospectively. Data on epidemiological parameters were collected (age, gender), along with staging (Kadish, Morita), histologic grading (Hyams), time and form of treatment, locoregional control, and disease-specific and overall survival. Patients with other malignant diseases, distant metastases of olfactory neuroblastomas at the time of initial diagnosis, a follow-up time of less than 5 years, or insufficient clinical-pathological data were excluded from further analysis. Results: In total, 53 cases made up our final study sample (26 men, 27 women; male–female ratio 0.96:1). Their mean age was 48.6 years (range: 10–84 years). The mean follow-up time was 137.5 months (4–336 months, SD: 85.0). A total of 5 out of 53 study cases (9.4%) showed metastatic involvement of the neck at the time of initial presentation. Local recurrence was detected in 8/53 (15.1%) and regional recurrence in 7/53 of our study cases (13.2%). Three patients (42.8%) from the group of cases with surgery as the sole form of management (7/53, 13.2%) died due to the disease. The cumulative disease-specific survival and overall survivalfor the whole group of patients were 88.6% and 63.6%, respectively. The cumulative disease-specific survival stratified by Kadish A/B vs. Kadish C/D as well as Hyams I/II vs. Hyams III/IV showed superior results for limited tumors, albeit without significance, and low-grade tumors (highly significant difference). Conclusion: Craniofacial or sometimes solely endoscopically controlled resection can warrant resection of the olfactory neuroblastoma with wide margins. However, locoregional failures and distant metastases can occur after a long period of time. The non-negligible incidence of regional recurrences, partly in unusual localizations, leads us to consider the need to identify the “recurrence-friendly” cases and to perform individualized elective irradiation of the neck in cases with high-risk features.

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.

Elective neck irradiation in the management of esthesioneuroblastoma: a systematic review and meta-analysis

BACKGROUND

There is no consensus about the optimal management of the neck in clinically node negative esthesioneuroblastoma (ENB). The aim of this study is to assess the impact of elective neck irradiation (ENI) in terms of regional disease control and survival.

METHODS

The study was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, and Google Scholar databases. The primary outcome was the regional recurrence rate (RRR), that was reported as odds ratio (OR) and 95% confidence interval (CI). Secondary outcomes were the overall survival (OS), and the distant-metastases free survival (DMFS), that were reported as logarithm of the hazard ratios (logHRs) and 95% confidence intervals (CIs).

RESULTS

A total of 489 clinically node negative patients were included from 9 retrospective studies. ENI significantly reduced the risk of regional recurrence compared to no treatment. No difference was measured between ENI and observation, according to both OS and DMFS. No stratified analysis could be performed based on Kadish stage and Hyams grade.

CONCLUSIONS

ENI should be recommended to improve the regional disease control. No advantage was measured in terms of survival or distant metastases with a low quality of evidence. Further prospective studies should be designed to understand if ENI could be avoided in early stage and low-grade tumors.

Radiation-induced intracranial osteosarcoma of the anterior skull base after treatment of esthesioneuroblastoma

Esthesioneuroblastoma (ENB) is an uncommon sinonasal cancer of the olfactory neuroepithelium that is typically treated with surgical resection followed by radiation therapy. Radiation-induced intracranial osteosarcoma of the skull base is a rare but devastating long-term complication of radiation therapy in this region. Here, we present a case of an 82-year-old patient who developed radiation-induced osteosarcoma of the anterior skull base and paranasal sinuses 10 years after radiation therapy following resection of an ENB. Older patients may be at risk of developing this complication earlier and with a worse prognosis relative to younger patients. Treating physicians/surgeons should be aware of this devastating complication. Patients who are treated with high-dose radiation therapy in this region should be followed for many years.

Proposal of a TNM classification-based staging system for esthesioneuroblastoma: More precise prediction of prognosis

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare malignant neoplasm. Currently, no consistent and universal staging system for ENB exists. The aim of this study is to propose a TNM-based classification.

SUBJECTS AND METHODS

Hundred and forty-two patients from our institution, with ENB pathologically confirmed between July 1978 and December 2018, were reviewed. All patients were restaged according to the Kadish stage, Morita stage and American Joint Committee on Cancer (AJCC) T classification from clinical and radiological data. Multivariate Cox proportional hazard regression analyses were performed to determine the impact of various factors. The goodness-of-fit and predictive accuracy of the different staging systems were calculated using R software.

RESULTS

The median follow-up time was 57 months (range: 4-229 months). According to the Kadish system, the 5-year overall survival (OS) for patients with stage A, B and C was 100%, 83.6% and 64.2%, respectively (P = .055). With respect to the Morita classification, 5-year OS for stages A, B, C and D was 100%, 83.6%, 70.7% and 50.0%, respectively (P = .004). Analysis based on the proposed staging model demonstrated 5-year OS for stage I, II, III and IV disease was 100%, 88.9%, 75.9% and 49.0%, respectively (P < .001). In separate multivariate Cox regression models, only the novel staging system exhibited independent effects on OS (P = .004); the Akaike information criterion and Harrell's concordance index were also superior to those calculated for the Kadish or Morita systems.

CONCLUSIONS

The proposed TNM-based staging system offers an improved prognostic assessment for patients with ENB. Further verification and refinement from additional dataset application is required.

Radiation therapy strategies for skull-base malignancies

INTRODUCTION

The management of skull base malignancies continues to evolve with improvements in surgical technique, advances in radiation delivery and novel systemic agents.

METHODS

In this review, we aim to discuss in detail the management of common skull base pathologies which typically require multimodality therapy, focusing on the radiotherapeutic aspects of care.

RESULTS

Technological advances in the administration of radiation therapy have led to a wide variety of different treatment strategies for the treatment of skull base malignances, with outcomes summarized herein.

CONCLUSION

Radiation treatment plays a key and critical role in the management of patients with skull base tumors. Recent advancements continue to improve the risk/benefit ratio for radiotherapy in this setting.

Intensity-modulated particle beam radiation therapy in the management of olfactory neuroblastoma

Background

To report the clinical experience and short-term efficacy in the management of olfactory neuroblastoma (ONB).

Methods

We performed a retrospective analysis of 12 ONB patients treated with particle beam radiation therapy (PBRT) between 12/2015 and 5/2019 at the Shanghai Proton and Heavy Ion Center. Four (33.3%) patients presented with Kadish B ONB, and 8 (66.7%) presented with Kadish C or D disease. Eleven patients received proton radiotherapy (PRT) followed by a carbon ion radiotherapy (CIRT) boost, one patient received CIRT only. The 2-year survival rates were calculated using the Kaplan-Meier method. Acute and late adverse events were summarized and scored according to the CTCAE (version 4.03).

Results

With a median follow-up of 17.5 (range, 2.53–49.9) months, all patients but 1 were alive. Eight patients were alive without evidence of disease, and 2 additional patients achieved partial response and remained alive with residual disease. One patient died of toxicity associated with salvage chemotherapy for distant metastasis and local failure. Another patient developed distant metastasis only and was alive at the time of the last follow-up. The 2-year OS, PFS, LRPFS, and DMFS rates were 83.3%, 75.8%, 87.5%, and 79.5%, respectively. No acute or late toxicities of ≥ grade 3 was observed.

Conclusions

Intensity modulated PBRT of ONB is well tolerated. While longer follow-up is needed, early outcomes suggested that PBRT is safe and effective for the treatment of ONB with minimal adverse events.

Incisionless facial resection for Kadish stage C olfactory neuroblastoma: Transcaruncular approach with combined endonasal and skull base surgery

This case report describes resection without facial incision for aggressive Kadish stage C olfactory neuroblastoma (ONB). We performed resection via transcaruncular approach with combined endonasal and skull base surgery. This multidisciplinary team surgical approach is expected to lead to a new strategy for this type of tumor in the future.

Advanced olfactory neuroblastoma in a teenager: a clinical case and short review of literature

BACKGROUND

Olfactory neuroblastoma, also called esthesioneuroblastoma (ONB), is a rare neuroectodermal neoplasm that originates from the olfactory epithelium of the nose-sinus tract. It generally occurs with epistaxis, nasal obstruction, diplopia, and anosmia.

METHODS

A 16-year-old female was admitted to our Unit with a complaint of nasal obstruction, recurrent epistaxis, anosmia, and intermittent headache of sixth month's duration. After the ENT consultation, physical examination, endonasal endoscopy, and multiple biopsies were performed. Instrumental images (CT, MRI) have been requested to stage the aforementioned pathology.

RESULTS

Instrumental images (CT, MRI) showed a mass filling the right nasal cavity and the maxillary bone and involving the cribriform plate without evidence of dural invasion. Craniofacial resection by means of a bifrontal craniotomy combined with a modified lateral rhinotomic transfacial route was performed. The reconstruction of the inferior and medial orbital walls with employing split-thickness calvarial grafts, pedicled galea-pericranium flap rotated downwards was performed. The patient received 56 Gy of external beam radiotherapy over a 6-week period.

CONCLUSION

Early diagnosis and treatment coordinated by a multidisciplinary team of ENTs, neurosurgeons, oncologists, pathologists, and radiologists are a prerequisite for a good prognosis. An excellent surgical debulking, negative margins, and subsequent locoregional control of the pathology through radiotherapy is fundamental.

Advanced Radiation Techniques in the Treatment of Esthesioneuroblastoma: A 7-Year Single-Institution's Clinical Experience

(1) Background: Esthesioneuroblastoma (ENB) is a rare tumor entity originating from the olfactory neuroepithelium. There is a scarcity of data about different treatment strategies. Intensity modulated radiotherapy (IMRT) and carbon ion radiotherapy (CIRT) are advanced radiation techniques that might improve local tumor control. (2) Methods: This retrospective analysis contained 17 patients with ENB (Kadish stage ≥ C: 88%; n = 15). Four patients had already undergone previous radiotherapy (RT). The treatment consisted of either IMRT (n = 5), CIRT (n = 4) or a combination of both techniques (n = 8). Median follow-up was 29 months. (3) Results: In patients that had not been irradiated before (n = 13), calculated overall survival (OS) and progression free survival (PFS) rates after 48 months were 100% and 81% respectively (Kaplan-Meier estimates). Two of four patients that underwent reirradiation died after RT, presumably due to tumor progression. Besides common toxicities, five patients (30%) showed mostly asymptomatic radiation-induced brain changes, most likely due to a disturbance of the blood-brain barrier. (4) Conclusions: Our results demonstrate that IMRT, CIRT, a combined approach of IMRT and CIRT as well as reirradiation with CIRT seem to be feasible and effective treatment methods in ENB.

Esthesioneuroblastoma with distant metastases: Systematic review & meta-analysis

BACKGROUND

The purpose of this study was to determine the clinical outcomes and review the management strategies for metastatic esthesioneuroblastoma.

METHODS

We conducted a systematic review and meta-analysis.

RESULTS

Forty-eight studies totaling 118 patients met inclusion criteria. Chemotherapy in combination with surgery and/or radiation exhibited the best overall survival when compared to monotherapy and no treatment (P < .001). However, most patients (66%) received either monotherapy or no therapy. The number and location of metastases among the 3 treatment groups did not significantly differ (P = .85). Treatment modality remained significantly associated with overall survival on multivariable analysis (P < .001). Platinum-based chemotherapy was most commonly utilized but did not provide a survival benefit when compared with all other regimens (P = .88).

CONCLUSION

Distant metastases with esthesioneuroblastoma portend a poor prognosis. Chemotherapy in combination with surgery and/or radiation was associated with improved overall survival. Further research into the optimal systemic therapeutic regimen for patients with distant metastases is critical.

An Atypical Esthesioneuroblastoma of the Inferior Nasal Cavity and Maxillary Sinus: Report of a Case

Esthesioneuroblastoma is a rare malignant tumor of the nasal cavity that originates from the olfactory epithelium. In this paper a very rare clinical presentation of this tumor is described. The tumor originated from the maxillary sinus and alveolar process, and was independent of the olfactory region. The patient was a 14-year-old girl presenting with facial swelling and nasal obstruction. Paranasal computed tomography showed a mass filling the right nasal cavity, infiltrating the alveolar process, eroding the anterior wall of the maxilla and invading the subcutaneous tissues of the cheek. Fine-needle aspiration and incisional biopsies identified an esthesioneuroblastoma. After neoadjuvant chemotherapy, we performed a right subtotal and left inferior maxillectomy and reconstructed the maxillary defect with a permanent obturator. At 2 years’ follow-up the patient is free of recurrence.

Olfactory neuroblastoma treated with minimally invasive surgery and adjuvant radiotherapy: a case report and review of the literature

Olfactory neuroblastoma (ON) is a rare tumour of the olfactory neuroepithelium that is characterized by a pattern of slow growth and local recurrences. Combination of surgery and radiotherapy, with or without chemotherapy, is considered to be the standard of care for primary site disease. Recent literature supports the view that endoscopic resection followed by adjuvant radiotherapy correlates with better outcome. In this short communication, we present a case report of olfactory neuroblastoma arising in the right nasal sinus in a 34-year-old male. This patient was treated with endoscopic resection and external beam radiotherapy to the right nasal sinus with intensity-modulated radiation therapy (IMRT) technique. After 2 years follow-up, the patient is free of tumour without any late effect related to therapies. We believe that, in such patients, a treatment strategy including endoscopic resection followed by adjuvant radiotherapy may be effective and feasible and should be considered the gold standard of care.

Changing Trends in the Management of Esthesioneuroblastoma: Irish and International Perspectives

Objectives  Evaluation of the changing trends in esthesioneuroblastoma in an Irish context and review of management options nationally to clarify the best current therapeutic approach by comparing with international research on this uncommon malignancy. Design  Retrospective review. Setting  Tertiary referral center. Participants  All patients presenting with esthesioneuroblastoma in Beaumont hospital or on the National Cancer Registry of Ireland between 1994 and 2013. Main Outcome Measures  Recurrence-free and overall survival. Results  During the study period, 32 cases of esthesioneuroblastoma were diagnosed (0.4 per million per year). Average age at diagnosis was 57 years; however, two cases were under 20. The majority (62.5%) were male. Patients predominantly presented with epistaxis or nasal congestion (73%), while two cases were identified incidentally on radiological investigations. Twenty-seven cases underwent primary surgical management (two post neo-adjuvant treatment) with seventeen requiring bifrontal craniotomy. Twenty-four of these received postoperative radiation therapy. Overall, 5-year survival was 65%. Kadish A/B patients exhibited 100% 5-year disease-specific survival versus 54% in Kadish C/D ( p  = 0.011). Hyams grade I/II patients exhibited 75% 5-year disease-specific survival versus 63% in Hyams grade III/IV ( p  = 0.005). Patients treated endoscopically exhibited 100% 5-year disease-specific survival versus 51% in those treated via an open approach ( p  = 0.102). Conclusions  Many controversies exist in the diagnosis and management of this condition. Despite this, results from Irish data are mostly concordant with the international literature. The rising incidence of this disease may represent improved pathological recognition. An increasing number of esthesioneuroblastoma cases are being successfully treated via endoscopic surgery.

The Impact of Histologic Phenotype in the Treatment of Sinonasal Cancer

The management of sinonasal cancer is a challenge due to its low occurrence and anatomical and significant diversity of histological types. The therapeutic modality used should be tailored individually according to the histology, tumour stage, molecular profile and previous treatments. The clinical management of sinonasal cancer has improved greatly owing to developments in endoscopic surgery and precision radiotherapy. Complete surgical resection is the mainstay of sinonasal malignancies' management but multimodality therapy is associated with improved outcomes in certain histologies. The recognition of various histological types with biological behaviours more suitable for non-surgical modalities has allowed treatment protocols to become more tailored to the disease. In this review we aim to describe and to summarise the current data guiding the management of sinonasal cancer with emphasis on phenotypic variation.

Volumetric analysis of olfactory neuroblastoma skull base laterality and implications on neck disease

OBJECTIVE

To determine if the laterality of primary tumors in patients with olfactory neuroblastoma (ONB) influenced the pattern and development of neck disease.

METHODS

Using a retrospective cohort study design from 1994 to 2015, the primary tumors of patients who either presented with or developed neck disease were volumetrically analyzed using iPlan software (version 3.0.0, BrainLAB, Feldkirchen, Germany) by two independent observers. Agreement of volume-derived sidedness was assessed with a kappa statistic, whereas agreement in volume-derived degree of tumor laterality was evaluated with an intraclass correlation coefficient. A one-sample t test was used to assess the difference in dominant percentage between the two observers.

RESULTS

Sixty-one patients with histological diagnosis and treatment of ONB at our institution were identified. Twenty-four patients exhibited neck involvement, 13 of whom could be volumetrically analyzed. Tumors that were greater than 75% eccentric to one side all exhibited contralateral disease, whereas the majority of unilateral neck disease was associated with relatively midline masses. Within the entire cohort, ipsilateral level 2 lymph nodes displayed the highest involvement (83%, 20 of 24), followed by ipsilateral level 1 (54%, 13 of 24), contralateral level 2 (46%, 11 of 24), contralateral level 1 (21%, 5 of 24), and ipsilateral level 3 (21%, 5 of 24).

CONCLUSION

Ipsilateral neck involvement frequently was observed; however, the degree of ONB primary site laterality did not appear to have implications on the development of contralateral neck disease. Therefore, when considering elective therapy to the neck, ONB laterality should not be used to justify unilateral neck treatment.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:864-870, 2018.

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.

Complex Skull Base Reconstructions in Kadish D Esthesioneuroblastoma: Case Report

Introduction Advanced Kadish stage esthesioneuroblastoma requires more extensive resections and aggressive adjuvant therapy to obtain adequate disease-free control, which can lead to higher complication rates. We describe the case of a patient with Kadish D esthesioneuroblastoma who underwent multiple surgeries for infectious, neurologic, and wound complications, highlighting potential preventative and salvage techniques.

Case Presentation A 61-year-old man who presented with a large left-sided esthesioneuroblastoma, extending into the orbit, frontal lobe, and parapharyngeal nodes. He underwent margin-free endoscopic-assisted craniofacial resection with adjuvant craniofacial and cervical radiotherapy and concomitant chemotherapy. He then returned with breakdown of his skull base reconstruction and subsequent frontal infections and ultimately received 10 surgical procedures with surgeries for infection-related issues including craniectomy and abscess evacuation. He also had surgeries for skull base reconstruction and CSF leak, repaired with vascularized and free autologous grafts and flaps, synthetic tissues, and CSF diversion.

Discussion Extensive, high Kadish stage tumors necessitate radical surgical resection, radiation, and chemotherapy, which can lead to complications. Ultimately, there are several options available to surgeons, and although precautions should be taken whenever possible, risk of wound breakdown, leak, or infection should not preclude radical surgical resection and aggressive adjuvant therapies in the treatment of esthesioneuroblastoma.

Long-Term Prognostic Analysis after Endoscopic Endonasal Surgery for Olfactory Neuroblastoma: A Retrospective Study of 13 Cases

Objectives

To summarize the characteristics and long–term outcomes of olfactory neuroblastoma through the analysis of 13 cases in single institution, with the assessment of treatment modality, prognostic factors.

Method

A retrospective study of thirteen cases diagnosed as olfactory neuroblastoma and underwent combined treatments during the period 2000–2010. Statistical analysis was performed to search for prognostic factors and compared different treatment modalities.

Results

13 patients were enrolled in this study, including 8 male and 5 female, ranging from 15 to 69 (median 43) years old. One patient at stage A was only treated with endoscopic endonasal surgery (EES). Seven patients were treated with preoperative radiotherapy and EES, two with EES and postoperative radiotherapy, and the other three with combined radiotherapy and chemotherapy. The range of follow-up time varied from 23 to 116 months (median 65 months). The 5-year overall survival rate was 46.2% (6/13). To date, these thirteen patients have not suffered local recurrences while two patients had lymph node recurrences and one had distant metastasis in the bone marrow. In 13 patients, 61.5% were diagnosed as late T stage (T3/4), 69.2% late Kadish stage (C/D) and 53.8% were high Hyams grade (I/ II), which indicated poor prognosis. Related prognostic factors were the TNM stage (T stage P = 0.028, N stage P = 0.000, M stage P = 0.007), Kadish stage (P = 0.025) and treatment modality (P = 0.015).

Conclusion

Late stage of TNM and Kadish staging system indicated a poor prognosis. Combined treatment modality, including endoscopic endonasal surgery, achieved a better outcome than non-surgical approach.

Patterns of regional and distant metastasis in esthesioneuroblastoma

OBJECTIVES/HYPOTHESIS

To define the incidence and risk factors of metastatic disease and the effectiveness of salvage therapy in esthesioneuroblastoma (ENB).

STUDY DESIGN

Retrospective analysis of 57 patients presenting from 1979 through 2009.

METHODS

Cumulative incidence of neck failure, distant failure, and survival were assessed using the Kaplan-Meier method.

RESULTS

Overall survival for all patients was 85% at 5 years and 75% at 10 years. Overall survival was negatively impacted by intracranial tumor extension (P < 0.001), positive resection margins (P = 0.05), and neck metastases (P = 0.017). Neck lymph nodes were not routinely electively irradiated during this time period. Nodal metastases developed in 17% of patients at a median time of 60 months. Kadish stage was not associated with a risk of nodal metastasis (P = 0.78). After treatment for nodal recurrence, locoregional control was achieved in 78% of patients. Of patients developing nodal recurrence, more than half developed distant metastases. The cumulative incidence of distant metastasis was 39% at a median time of 40 months. Patients who presented with Kadish stage C or D had a significantly increased risk of distant failure (P < 0.001). In patients developing nodal (P = 0.017) or distant metastasis (P = 0.001), the probability of survival was significantly decreased.

CONCLUSION

Regional and distant metastases in patients with esthesioneuroblastoma occur in a delayed fashion and negatively impact survival. Neck nodal recurrence may be a harbinger of distant metastases. At the Memorial Sloan Kettering Cancer Center, New York, New York, we now treat the majority of ENB patients with elective nodal irradiation. However, the chief obstacle to long-term cure is distant metastases.

LEVEL OF EVIDENCE

4. Laryngoscope, 126:1556-1561, 2016.

Endoscopic Endonasal Management of Olfactory Neuroblastoma: A Retrospective Analysis of 10 Patients with Quality-of-Life Measures

OBJECTIVE

Anterior craniofacial resection has served as the traditional surgical treatment of olfactory neuroblastoma (ON). With the development of extended endonasal approaches, the opportunity exists for using minimal access techniques for management of select tumors. This study assesses the impact of endoscopic resection on ON and patient outcomes and quality of life.

METHODS

A retrospective review identified 10 patients with ON (3 women, 7 men; mean age 49.1 years) who underwent endoscopic resection during the period 2010-2013. Modified Kadish staging divided the cohort into 3 stage B patients (30%), 5 stage C patients (50%), and 2 stage D patients (20%). Outcome measures included extent of resection, complications, recurrence, and preoperative and postoperative Sino-Nasal Outcome Test-20 scores.

RESULTS

Gross total resection was achieved in all patients, with negative margins in 9 patients. One patient had negative frozen section pathology but was noted to have a positive posterior dural margin on final pathology. There was a 20% complication rate (pneumocephalus, ethmoid meningoencephalocele). Neoadjuvant chemotherapy and radiation were performed in 2 patients (Kadish stage C and D). Adjuvant chemotherapy and radiation were performed in 5 patients (4 Kadish stage C and 1 stage D). Postoperative radiation alone was administered in 3 patients (Kadish stage B). Analysis of postoperative Sino-Nasal Outcome Test-20 scores demonstrated no significant change relative to preoperative Sino-Nasal Outcome Test-20 scores. At the most recent follow-up examination, there was no evidence of recurrent disease in patients who underwent endoscopic resection. One patient (Kadish stage D) died during the follow-up period. Mean follow-up duration was 21.1 months.

CONCLUSIONS

This series adds to the growing body of literature that suggests equivalent or improved outcomes of purely endonasal resection for select patients. Given the advanced Kadish stage of most of our patients, longer follow-up is required to determine the full applicability of purely endoscopic approaches to the treatment of ON.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

Olfactory Neuroblastoma: Fate of the Neck--A Long-term Multicenter Retrospective Study

OBJECTIVE

Olfactory neuroblastoma and the management of neck disease has posed considerable challenges to the treating physician. The aims of the study were to determine the incidence and factors influencing neck disease and to identify at-risk patients with cervical node-negative disease at presentation.

STUDY DESIGN

Multicenter case series with retrospective chart review.

SETTING AND SUBJECTS

In sum, 113 patients with a histopathologic diagnosis of olfactory neuroblastoma across 6 tertiary hospitals in Australia and the United States.

METHODS

Treatment modalities for the primary site and neck included surgery, radiotherapy, and combined therapy. Treatment outcomes were measured in relation to date of primary treatment, and long-term follow-up was recorded. Disease-free survival was calculated as time for patients to develop delayed neck disease following primary treatment.

RESULTS

A total of 113 patients (46 females, 49.7 ± 13.2 years) were identified with a median follow-up of 41.5 months (interquartile range, 58.2); 7.1% of patients presented with primary neck disease, while 8.8% of patients presented with delayed neck disease. Neck disease was present in patients with Hyams grade II (22.2%), III (55.6%), and IV (22.2%) lesions (χ(2) = 5.66, P = .13). Histologic grade was higher in patients with primary neck disease (χ(2) = 16.22, P = .001). Positive surgical margins were associated with a higher risk of delayed neck disease as compared with clear surgical margin (17.9% vs 5%, P = .034).

CONCLUSION

Neck metastasis is an important clinical consideration for olfactory neuroblastoma at presentation and in surveillance. Primary treatment of the neck could be considered in select patients. Long-term surveillance of the neck and primary site is essential.

Neck recurrence and mortality in esthesioneuroblastoma: Implications for management of the N0 neck

OBJECTIVES/HYPOTHESIS

To review the literature on neck recurrence in esthesioneuroblastoma.

STUDY DESIGN

PubMed database.

METHODS

A PubMed database search was performed using keywords "esthesioneuroblastoma," "olfactory neuroblastoma," and "esthesioneuroblastoma neck metastasis." Articles written in English with greater than 10 subjects that had data regarding the association of neck recurrence and mortality and/or the association of neck recurrence with Kadish stage were included for analysis.

RESULTS

Thirteen studies met inclusion criteria with information regarding the association of neck recurrence and mortality, and 15 studies had data associating neck recurrence and Kadish stage. The neck recurrence rate was 14.1% in studies analyzing mortality. Among those patients who developed regional metastases, mortality was 60%. Of patients without regional recurrence, the mortality rate from disease was 26% (P < 0.0001) and overall mortality was 32% (P < 0.0001). The rate of neck recurrence within each Kadish stage was 0%, 11%, 21%, and 18% for Kadish stages A, B, C, and D, respectively. The trend toward an increased incidence of neck recurrence from stage A to stage D is statistically significant, with P value 0.003.

CONCLUSION

The rate of neck recurrence in esthesioneuroblastoma is close to 15%. There is a strong association of recurrence with Kadish stage B and C. Mortality from disease in patients with recurrence in cervical lymph nodes is significant when compared to those who never develop neck disease. Prospective studies are needed to evaluate a potential role for elective neck dissection versus elective neck radiation for patients with esthesioneuroblastoma.

LEVEL OF EVIDENCE

N/A. Laryngoscope, 126:1373-1379, 2016.

Spread patterns of lymph nodes and the value of elective neck irradiation for esthesioneuroblastoma

OBJECTIVES

This study was aimed to characterize patterns of lymphatic spread and assess the value of prophylactic elective neck irradiation (ENI) for esthesioneuroblastoma (ENB).

METHODS

A retrospectively analysis of 116 patients with newly diagnosed ENB at our institution over 35-year period was undertaken.

RESULTS

32 patients (28%) presented lymph node metastasis at initial diagnosis, the common sites involved were level II, Ib, level III and VIIa. Among 80 N-negative patients staged in Modified Kadish B/C, 50 patients were delivered with ENI, 30 patients were not. The 5-year regional failure-free survival was 98% in patients treated with ENI and 75% in patients without ENI (p=0.005), regional failure rate decreased significantly from 23% (7/30) to 2% (1/50) after ENI (p=0.002). Multivariate analysis also suggested that ENI was an independent favorable predictor for regional controlling (HR, 0.102; 95% CI: 0.012-0.848; p=0.035).

CONCLUSIONS

This is the largest cohort of ENB so far in a single institute, and also the first detailed description of nodal spread patterns of N-positive ENB. Elective neck irradiation reduced the regional failure significantly and should be recommended as a part of initial treatment strategy for patients staged with Modified Kadish B/C.

Esthesioneuroblastoma of the nasal cavity

OBJECTIVES

Esthesioneuroblastoma is an uncommon cancer of the nasal cavity. We describe the outcomes for 26 patients treated with curative intent with photon radiotherapy (RT) at the University of Florida.

METHODS

Between May 1972 and June 2007, 26 patients received RT for previously untreated esthesioneuroblastoma of the nasal cavity. Sixteen patients were males and 10 were females with a median age of 55 years (range, 3 to 82 y). The modified Kadish stage distribution was: B, 7 patients; C, 17 patients; and D, 2 patients. Treatment modalities included the following: definitive RT, 5 patients; preoperative RT, 2 patients; and postoperative RT after resection, 19 patients. Elective neck irradiation (ENI) was performed in 17 (71%) of 24 N0 patients.

RESULTS

Rates of local control, cause-specific survival, and absolute overall survival at 5 years were 79%, 72%, and 69%, respectively. Overall survival among patients treated with definitive RT was 20% at 5 years, compared with 81% among those who underwent surgery and adjuvant RT (P=0.01). One (6%) of 17 patients who received ENI developed a recurrence in the neck and was successfully salvaged. Ultimate neck control was 100% at 5 years for patients who received ENI versus 69% among those not receiving ENI (P=0.0173).

CONCLUSIONS

Resection combined with adjuvant RT is more effective than surgery or RT alone in the treatment of esthesioneuroblastoma. ENI reduces the risk of regional relapse in patients with Kadish stage B and C cancers.

[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.

Low- and high-grade esthesioneuroblastomas display a distinct natural history and outcome

PURPOSE

Esthesioneuroblastomas, also called olfactory neuroblastomas (ENB) represent a rare sinonasal neurectodermal tumour which prognostic factors are unsteadily described.

PATIENTS AND METHODS

Clinical and pathological characteristics were analysed in patients treated at Gustave Roussy Institute between 1979 and 2009.

RESULTS

Out of 63 patients, 19 patients were reclassified and 44 patients were eligible for the analysis. Multivariate analysis revealed that T staging of the modified Dulguerov TNM staging and Hyams grade>III (that we termed high-grade ENB) were the only independent prognostic factors for overall survival (OS). As compared to patients with low-grade ENB (Hyams grade ≤ III), patients with high-grade ENB have higher T4 staging (p=0.02), have frequent lymph node involvement (p=0.009) and are more often unresectable (p=0.005). Resected patients with high-grade ENB frequently displayed mainly leptomeningeal metastasis (n=4/6) in contrast to patients with low-grade ENB who typically experience late loco-regional recurrence (n=10/25). With a median follow-up of 9.6 years, median DFS and OS for resected low-grade ENB were 5.4 and 20.5 years, respectively. Conversely, median DFS and OS for high-grade ENB were 1.5 and 2.5 years, respectively.

CONCLUSION

Low and high-grade ENB display distinct patterns at presentation and relapse, leading to different prognosis. Therefore, they may be regarded as distinct entities.

[Esthesioneuroblastoma. Transcribiform-transfovea ethmoidalis endonasal expanded approach. Technical note]

INTRODUCTION

We report a fully endoscopic transcribiform-transfovea ethmoidalis endonasal expanded approach (EEA) for the treatment of esthesioneuroblastoma and review the literature about this entity available in English, establishing a precise surgical technique and describing our intraoperative experience.

CASE REPORT

Our patient was a 65-year old female with anosmia and cognitive deterioration. Cranial MRI showed a large tumoral lesion with solid and cystic components involving the nasal cavity, with diagnostic suspicion of intracranial malignant sinonasal tumour. The patient underwent a fully endoscopic transcribiform-transfovea ethmoidalis EEA, achieving total resection and tumour-free margins. Surgery was followed by radiotherapy.

DISCUSSION

Craniofacial resection enables total removal of sinonasal malignancies, even when the intracranial cavity is involved, and allows for subarachnoid space isolation from the nasal cavity. New advances in endoscopic skull base surgery have achieved comparable oncological results and sufficient reconstructive capacity, leading to less morbidity and better tolerance.

CONCLUSION

EEA may become the first treatment option for skull base malignancies in an immediate future, provided that the anatomical limits of the extended approach are not exceeded by the lesion.

Nasal and paranasal esthesioneuroblastomas: clinical outcomes

Esthesioneuroblastomas (ENB) are rare tumours derived from the olfactory epithelium. Based on their experience and a review of the literature, the authors tried to identify the epidemiological, clinical, histological and therapeutic factors that influence overall and disease-free survival in their series of ENB.

METHODS

This retrospective study concerned eleven patients treated in a single institution for ENB of the nasal cavity and sinuses between 1978 and 2006. The data collected were submitted to statistical analysis using R 2.0(®) software. Overall survival and disease-free survival were estimated by the Kaplan-Meier method and prognostic factors were identified by Log-Rank test.

RESULTS

This series comprised three women (27.2%) and eight men (72.8%) (sex ratio: 2.6). The mean age at diagnosis was 56 years (range: 37-69 years). No risk factors were identified in this cohort. The mean follow-up was 110.2 months (range: 7-348 months). This series included three T1 (27.3%), one T2 (9.1%), four T3 (36.3%) and three T4 (27.3%) tumours. The 1-year, 5-year and 10-year disease-free survival rates were 81.8%, 54.5% and 18.2%, and the corresponding overall survival rates were 100%, 90% and 60%, respectively. The main prognostic factors reported in the literature are tumour stage at diagnosis, adjuvant radiotherapy and radiation dose.

CONCLUSION

ENB are characterized by a high recurrence rate and recurrences can occur a very long time after the diagnosis, indicating the need for prolonged follow-up of these patients. The 5-year and 10-year overall survival rates are about 90% and 60%, respectively.

Esthesioneuroblastoma: Results and Outcomes of a Single Institution's Experience

OBJECTIVES

Analysis of outcomes of a cohort of patients with esthesioneuroblastoma.

DESIGN

Retrospective cohort analysis.

SETTING

PATIENTS presenting with esthesioneuroblastoma from 1994 to 2006 in a tertiary care academic medical center.

PATIENTS

Fifteen consecutive patients diagnosed as having esthesioneuroblastoma were treated during this time period using a subcranial resection. The mean follow-up is 75 months (range, 2 to 240 mos).

RESULTS

The overall survival was 100% and the overall disease-free survival was 49% and 24% at 5 and 15 years, respectively. PATIENTS treated with radiation therapy following surgical resection had a 5- and 15-year disease-free survival of 83.3% compared with a 5- and 15-year disease-free survival of 26.7% and 0%, respectively, for patients whose initial treatment was surgery alone. The mean time to recurrence was 82.1 months. None of the patients had a decrease in Karnofsky Performance Score following subcranial resection.

CONCLUSIONS

PATIENTS with esthesioneuroblastoma whose initial treatment consists of surgical resection followed by radiation therapy have a longer disease-free survival than patients treated with surgery alone. However, initial treatment modality did not have an effect on survival. Long-term, close follow-up is necessary to identify recurrences, which can be treated with a high degree of success.

Esthesioneuroblastoma: is there a need for elective neck treatment?

PURPOSE

To assess the risk of cervical lymph node metastases after definitive treatment for esthesioneuroblastoma (ENB) that did not include elective neck therapy.

METHODS AND MATERIALS

This was a retrospective analysis of 26 ENB patients treated at the University of Michigan between 1995 and 2007. Tumor stage was Kadish A in 1 patient, B in 19, C in 5, and unknown in 1. Craniofacial or subcranial resection was performed in 24 patients (92%), with negative margins in 22 (92%). Postoperative radiotherapy (RT) to the primary site was given in 12 patients (46%), and 14 patients (54%) had surgery alone. All patients had clinically N0 disease, and no patient underwent elective neck dissection or radiation. Median follow-up was 72 months.

RESULTS

Local relapse-free survival was significantly better for patients who received postoperative RT compared with those who had surgery alone: 100% vs. 29% at 5 years, respectively (p = 0.005). Five-year disease-free survival was 87.5% in the RT group vs. 31% in the surgery-alone group (p = 0.05). Regional failure was observed in 7 patients (27%), 6 with Kadish Stage B and 1 with Stage C disease. The most common site of nodal failure was Level II, and 3 patients failed in the contralateral neck. Only 3 patients with regional failure were successfully salvaged.

CONCLUSION

The high rate of regional failures when the neck is not electively treated justifies elective nodal RT in patients with both Kadish Stages B and C. In addition, our experience confirms the beneficial effect on local control of adjuvant RT to the tumor bed.

Contemporary management of sinonasal cancer

BACKGROUND

Sinonasal cancer is a relatively uncommon entity encountered by head and neck oncologists, rhinologists, and skull base surgeons. Recent innovations in surgical and nonsurgical therapeutic modalities raise the question of whether there has been any measurable improvement for treatment outcomes.

METHODS

A retrospective review of data from recent studies that focus on surgery, radiation, and chemotherapy, or combinations thereof, was conducted.

RESULTS

Surgery continues to be the preferred treatment and provides the best results, albeit with an inherent bias based on patient selection. For advanced disease (T4 lesions), the survival rate remains only modest. Complications of treatment, including both surgical and radiation therapy, have been reduced.

CONCLUSIONS

There is a need to improve the efficacy of treatment for this disease. Recommendations for the future direction of therapeutic investigations are outlined.

When, how and why to treat the neck in patients with esthesioneuroblastoma: a review

Esthesioneuroblastoma is an uncommon tumor that presents in the sinonasal cavity and anterior skull base. Cervical metastases are not frequently found on initial presentation but eventually occur in 20-25% of these patients. This presents the treating physician with the difficult decision as to how and when to treat the neck in this disease. The aims of this study were to provide a comprehensive review of the incidence of N+ disease at presentation, make recommendations about the optimal treatment strategy of patients with N+ disease, explain the role of elective neck treatment in patients with N0 disease, and comment on treatment of patients with late cervical metastases that require salvage therapy, using the literature review of the incidence and treatment of neck disease in patients with esthesioneuroblastoma. This review revealed an approximately 5-8% incidence of cervical nodal metastasis at the time of presentation. Combined modality therapy with surgery and radiotherapy is recommended to treat the N+ neck at the time of diagnosis and later. Chemotherapy may have a role combined with radiation treatment, but there are little data to support this. There is limited evidence to substantiate the use of elective neck dissection or elective radiotherapy in the clinically and radiologically N0 neck. Patients who have late cervical metastases have a clear survival advantage (59 vs. 14%) when treated with combined surgery and radiotherapy relative to single modality methods alone. The results indicate that the management of the neck in esthesioneuroblastoma continues to be a significant challenge in the treatment algorithm of these complex patients.

Radiotherapy for esthesioneuroblastoma: is elective nodal irradiation warranted in the multimodality treatment approach?

PURPOSE

The role of elective nodal irradiation (ENI) in radiotherapy for esthesioneuroblastoma (ENB) has not been clearly defined. We analyzed treatment outcomes of patients with ENB and the frequency of cervical nodal failure in the absence of ENI.

METHODS AND MATERIALS

Between August 1996 and December 2007, we consulted with 19 patients with ENB regarding radiotherapy. Initial treatment consisted of surgery alone in 2 patients; surgery and postoperative radiotherapy in 4; surgery and adjuvant chemotherapy in 1; surgery, postoperative radiotherapy, and chemotherapy in 3; and chemotherapy followed by radiotherapy or concurrent chemoradiotherapy in 5. Five patients did not receive planned radiotherapy because of disease progression. Including 2 patients who received salvage radiotherapy, 14 patients were treated with radiotherapy. Elective nodal irradiation was performed in 4 patients with high-risk factors, including 3 with cervical lymph node metastasis at presentation.

RESULTS

Fourteen patients were analyzable, with a median follow-up of 27 months (range, 7-64 months). The overall 3-year survival rate was 73.4%. Local failure occurred in 3 patients (21.4%), regional cervical failure in 3 (21.4%), and distant failure in 2 (14.3%). No cervical nodal failure occurred in patients treated with combined systemic chemotherapy regardless of ENI. Three cervical failures occurred in the 4 patients treated with ENI or neck dissection (75%), none of whom received systemic chemotherapy.

CONCLUSIONS

ENI during radiotherapy for ENB seems to play a limited role in preventing cervical nodal failure. Omitting ENI may be an option if patients are treated with a combination of radiotherapy and chemotherapy.

Rare nasosinusal tumors: case series and literature review

Tumors of the nasal cavity and paranasal sinuses are unusual pathologies found in clinical practice. Approximately 0.8% of all human cancers are located in this area. Despite being rare, nasosinusal neoplasms usually manifest through nonspecific symptoms that are common to numerous inflammatory pathologies. The aim of this study is to describe a series of rare nasosinusal tumors, including esthesioneuroblastomas, central giant cell granulomas, extramedullary plasmocytomas, nasosinusal hemangiopericytomas, neurofibromas and cemento-ossifying fibromas, diagnosed at the Fortaleza General Hospital. We, hereby, briefly review each of the aforementioned pathologies, stressing the need for a precise histological diagnosis for proper treatment in each case.

Esthesioneuroblastoma: 25-year experience at a single institution

OBJECTIVES

To evaluate outcomes for patients with esthesioneuroblastoma treated at a single institution during a 25-year period.

DESIGN

Eighteen patients with pathologic diagnosis of esthesioneuroblastoma between 1980 and 2004 were retrospectively identified.

RESULTS

Two patients had Kadish A, seven had Kadish B, and nine had Kadish C disease. The mean follow-up was 71 months. Treatment regimens consisted of surgery alone (four patients), surgery followed by postoperative radiation (six patients), surgery followed by postoperative chemoradiotherapy (three patients), preoperative radiotherapy (two patients), preoperative chemoradiotherapy (one patient), chemoradiotherapy (one patient), and surgery plus chemotherapy (one patient). Surgical approaches (n = 17) consisted of 13 traditional craniofacial resections, one endoscopic-assisted cranionasal resection, and three minimally invasive endoscopic resections. The 10-year disease-specific survival was 80%. The overall recurrence-free survival at five and 10 years was 62% and 46%, respectively. Positive surgical margins and TNM staging predicted survival.

CONCLUSION

Both endoscopic and open surgical approaches have been successful in treating a small number of esthesioneuroblastoma patients with high survival and low rate of surgical complications.

Tumores nasossinusais raros: série de casos e revisão de literatura

Os tumores nasossinusais são patologias pouco freqüentes na prática clínica. Aproximadamente 0,8% de todos os cânceres humanos localizam-se nessa região. Apesar de rara, a neoplasia nasossinusal manifesta-se habitualmente através de sintomas inespecíficos e comuns a inúmeras patologias inflamatórias. Este estudo se propõe a descrever uma série de casos de tumores nasossinusais não-epiteliais raros, incluindo estesioneuroblastoma, granuloma central de células gigantes, plasmocitoma extramedular, hemangiopericitoma sinonasal, neurofibroma e fibroma cemento-ossificante, diagnosticados no Hospital Geral de Fortaleza, SESA/SUS. Faz-se uma breve revisão de literatura de cada patologia, salientando-se a necessidade do diagnóstico anatomopatológico preciso para condução adequada de cada caso.

Cancer of the nasal cavity and paranasal sinuses

Sinonasal malignancies continue to have poor survival rates. Disease-related mortality is usually the result of disease recurrence and progression at the primary site despite aggressive therapy. Complete surgical excision with postoperative radiation therapy remains the standard of care for resectable lesions. Improved reconstructive techniques have increased our ability to aggressively clear locally advanced disease in this anatomically challenging region, while reducing associated functional and cosmetic morbidity. Intensive multimodality treatment regimens coupled with newer medical technology may ultimately improve the long-prevailing poor prognosis of these tumors.