Radiotherapy with or without surgery for maxillary sinus squamous cell carcinoma: should the clinical N0 neck be treated?

Feasibility of omitting contralateral neck irradiation in patients with node-negative sinonasal squamous cell carcinoma crossing the midline

BACKGROUND

Identifying the lymph node target volume in patients with node-negative sinonasal squamous cell carcinoma (SNSCC) crossing the midline poses a challenge. This study aims to address this.

METHODS

We retrospectively reviewed clinically N0 patients with tumors crossing the midline who received elective neck irradiation (ENI) from two centers between 1999 and 2019. The main endpoint was regional relapse-free survival (RRFS).

RESULTS

We included 104 patients: 64 received bilateral ENI, and 40 received ipsilateral-only ENI (median follow-up time was 89.99 and 95.01 months, respectively). At 5 years, the RRFS rates were comparable (57.68% vs. 55.83%, p = 0.372), as were the contralateral RRFS (57.68% vs. 61.62%, p = 0.541). Five-year OS, LRFS, and DMFS showed no significant difference between two groups.

CONCLUSIONS

Our findings provide preliminary evidence suggesting the potential for avoiding contralateral ENI in SNSCC patients with midline crossing tumors who undergo ipsilateral ENI, covering at least level II. Validation through future prospective studies is necessary.

Feasibility of ipsilateral elective neck irradiation of levels Ib and II without level III in patients with node-negative sinonasal squamous cell carcinoma

BACKGROUND

The necessity of level III irradiation in patients with node-negative advanced sinonasal squamous cell carcinoma (SNSCC) is unclear.

METHODS

Seventy-eight patients with advanced SNSCC were included. Survival rates were estimated and compared between treatment groups.

RESULTS

Twenty-five patients received ipsilateral levels Ib and II irradiation (group 1) and 53 patients received ipsilateral levels Ib and II plus level III irradiation (group 2). The median follow-up time was 75.56 months. Five-year survival rates (regional relapse-free survival, overall survival, local relapse-free survival, and distant metastasis-free survival) were similar between groups 1 and 2 (all p > 0.05). Irradiation doses to the thyroid and larynx were significantly lower in group 1 than in group 2.

CONCLUSIONS

Ipsilateral irradiation of levels Ib and II neck provides similar regional control and results as irradiation of these levels plus level III, with lower irradiation doses to normal neck tissue, in patients with node-negative advanced SNSCC.

Prognostic Factors and Outcomes of De Novo Sinonasal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis

OBJECTIVE

To review overall survival (OS), recurrence patterns, and prognostic factors of de novo sinonasal squamous cell carcinoma (DN-SCC).

DATA SOURCES

PubMed, Scopus, OVID Medline, and Cochrane databases from 2006 to December 23, 2020.

REVIEW METHODS

The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Articles were required to report either recurrence patterns or survival outcomes of adults with DN-SCC. Case reports, books, reviews, meta-analyses, and database studies were all excluded.

RESULTS

Forty-one studies reported on survival or recurrence outcomes. The aggregate 5-year OS was 54.5% (range, 18%-75%) from 35 studies (n = 1903). Patients undergoing open surgery were more likely to receive radiation therapy and present at an advanced stage compared to those receiving endoscopic surgery (all P < .001). Advanced T stage, presence of cervical nodal metastases, maxillary sinus primary site, and negative human papillomavirus (HPV) status were all correlated with significantly worse 5-year OS. Direct meta-analysis of 8 studies demonstrated patients with surgery were more likely to be alive at 5 years compared to those who did not receive surgery (odds ratio, 2.26; 95% CI, 1.48-3.47; P < .001). Recurrence was reported in 628 of 1471 patients from 26 studies (42.7%) with an aggregate 5-year locoregional control rate of 67.1% (range, 50.4%-93.3%).

CONCLUSION

This systematic review and meta-analysis suggests that the 5-year OS rate for DN-SCC may approach 54.5% and recurrence rate approaches 42.7%. In addition, various tumor characteristics including advanced T stage, positive nodal status, maxillary sinus origin, and negative HPV status are all associated with decreased survival.

The Role of Elective Neck Treatment in the Management of Sinonasal Carcinomas: A Systematic Review of the Literature and a Meta-Analysis

The impact of elective neck treatment (ENT), whether by irradiation or dissection, on the prognosis of patients with cN0 sinonasal carcinomas (SNCs) remains an understudied issue. METHODS: A systematic review and meta-analysis of the literature were performed according to PRISMA guidelines in order to assess regional nodal relapse rate after ENT compared to observation in cN0 SNCs patients. Twenty-six articles for a total of 1178 clinically N0 patients were analyzed. Globally, the 5-year overall survival was 52%; 34.6% of patients underwent ENT and 140 regional recurrences were registered (5.9% in the ENT cohort and 15% in the observation group). ENT appears to confer a lower risk of regional recurrence compared to observation alone, with a cumulative OR of 0.38 (95% CI 0.25-0.58). Our meta-analysis supports the efficacy of ENT for reducing the risk of regional recurrence, but its overall impact on survival remains uncertain.

Treatment outcomes of intensity-modulated radiotherapy versus 3D conformal radiotherapy for patients with maxillary sinus cancer in the postoperative setting

BACKGROUND

In this study, we compared the treatment outcomes of postoperative 3D conformal radiotherapy (RT) and intensity-modulated radiotherapy (IMRT) for patients with maxillary sinus carcinoma.

METHODS

Fifty-four patients underwent surgery and postoperative RT, of whom 27 (50%) had squamous cell carcinoma and 14 (26%) had adenoid cystic carcinoma. Nineteen patients (35%) were treated with IMRT and 35 patients (65%) received 3D conformal RT. The median radiation dose for 3D conformal RT and IMRT were 62.1 and 63 Gy, respectively.

RESULTS

IMRT produced significantly superior radiation dose distribution to planning target volumes (PTVs) than 3D conformal RT. Over a median follow-up of 60 months, IMRT provided better 3-year locoregional recurrence-free survival (89.2% vs 59.5%; p = .035) and distant metastasis-free survival (94.7% vs 55.3%; p = .042) rates than 3D conformal RT.

CONCLUSION

Postoperative IMRT for patients with maxillary sinus carcinoma resulted in excellent disease control, and should be considered as the first treatment option in these cases. © 2015 Wiley Periodicals, Inc. Head Neck 38: E207-E213, 2016.

Management of the neck in maxillary sinus carcinomas

PURPOSE OF REVIEW

To discuss and review the role for elective treatment of the neck in maxillary squamous cell carcinoma. Improvements in survival have been seen because of improved local therapies and control; therefore, the treatment of the neck has become a topic of debate.

RECENT FINDINGS

The risk of occult metastases in neck nodes is higher for T3-4 tumors. The rate of nodal relapse in the N0 neck without elective treatment is 8-15%. With elective irradiation the nodal relapse rate decreases. However, most nodal relapses are accompanied by local failure or distant disease. Local failure remains the most common site of failure and cause of death in this patient population.

SUMMARY

Treatment failure occurs overall in 62% of all patients, with local recurrence by far the most common site of treatment failure, which is rarely amenable to salvage therapy. Therefore, elective neck irradiation is not routinely indicated in the clinically N0 neck; those that recur only in the neck can be surgically salvaged more than 50% of the time.

Elective neck irradiation versus observation in squamous cell carcinoma of the maxillary sinus with N0 neck: A meta-analysis and review of the literature

BACKGROUND

Elective neck irradiation of a clinical node-negative (N0) neck in squamous cell carcinoma (SCC) of the maxillary sinus is a controversial issue.

METHODS

A systematic review of electronic databases and a meta-analysis were conducted to clarify the role of elective neck irradiation in patients with SCC of the maxillary sinus and clinical N0 neck. Regional (neck) nodal recurrence was chosen as the primary endpoint.

RESULTS

Four retrospective studies with a total of 129 patients met the inclusion criteria. The results of the meta-analysis showed that elective neck irradiation reduced the risk of regional nodal recurrence (fixed effects model: odds ratio [OR] = 0.16; 95% confidence interval [CI] = 0.04-0.67; p = .01; random-effects model: OR = 0.17; 95% CI = 0.04-0.76; p = .02) compared to observation.

CONCLUSION

This systemic review and first meta-analysis confirmed that elective neck irradiation can significantly reduce the rate of nodal recurrence in patients with N0 SCC of the maxillary sinus.

Charged particle therapy versus photon therapy for paranasal sinus and nasal cavity malignant diseases: a systematic review and meta-analysis

BACKGROUND

Malignant tumours arising within the nasal cavity and paranasal sinuses are rare and composed of several histological types, rendering controlled clinical trials to establish the best treatment impractical. We undertook a systematic review and meta-analysis to compare the clinical outcomes of patients treated with charged particle therapy with those of individuals receiving photon therapy.

METHODS

We identified studies of nasal cavity and paranasal sinus tumours through searches of databases including Embase, Medline, Scopus, and the Cochrane Collaboration. We included treatment-naive cohorts (both primary and adjuvant radiation therapy) and those with recurrent disease. Primary outcomes of interest were overall survival, disease-free survival, and locoregional control, at 5 years and at longest follow-up. We used random-effect models to pool outcomes across studies and compared event rates of combined outcomes for charged particle therapy and photon therapy using an interaction test.

FINDINGS

43 cohorts from 41 non-comparative observational studies were included. Median follow-up for the charged particle therapy group was 38 months (range 5-73) and for the photon therapy group was 40 months (14-97). Pooled overall survival was significantly higher at 5 years for charged particle therapy than for photon therapy (relative risk 1·51, 95% CI 1·14-1·99; p=0·0038) and at longest follow-up (1·27, 1·01-1·59; p=0·037). At 5 years, disease-free survival was significantly higher for charged particle therapy than for photon therapy (1·93, 1·36-2·75, p=0·0003) but, at longest follow-up, this event rate did not differ between groups (1·51, 1·00-2·30; p=0·052). Locoregional control did not differ between treatment groups at 5 years (1·06, 0·68-1·67; p=0·79) but it was higher for charged particle therapy than for photon therapy at longest follow-up (1·18, 1·01-1·37; p=0·031). A subgroup analysis comparing proton beam therapy with intensity-modulated radiation therapy showed significantly higher disease-free survival at 5 years (relative risk 1·44, 95% CI 1·01-2·05; p=0·045) and locoregional control at longest follow-up (1·26, 1·05-1·51; p=0·011).

INTERPRETATION

Compared with photon therapy, charged particle therapy could be associated with better outcomes for patients with malignant diseases of the nasal cavity and paranasal sinuses. Prospective studies emphasising collection of patient-reported and functional outcomes are strongly encouraged.

FUNDING

Mayo Foundation for Medical Education and Research.

Lymph node metastasis in t4 maxillary sinus squamous cell carcinoma: incidence and treatment outcome

BACKGROUND

The purpose of this study was to evaluate the incidence of lymph node metastasis among patients with T4 maxillary sinus squamous cell carcinoma (MS-SCC) as well as the delayed metastasis rate and the treatment outcome for untreated N0 neck in patients with T4 MS-SCC.

METHODS

Consecutive series of all patients (n = 128) with previously untreated T4 maxillary sinus SCC between 2006 and 2007 were obtained from 28 institutions belonging to or cooperating in the Head and Neck Cancer Study Group of the Japan Clinical Oncology Group.

RESULTS

Of the 128 patients, 28 (21.9 %) had lymph node metastasis, and six patients (4.7 %) had distant metastasis at diagnosis. Among the 111 patients who were treated with curative intent, 98 had clinically N0 neck disease and did not receive prophylactic neck irradiation. A total of 11 patients (11.2 %) subsequently developed evidence of lymph node metastasis, of whom eight were among the 83 patients with an N0 neck and had not received elective neck treatment. There were 15 patients who received an elective neck dissection as part of the initial treatment, of whom three had pathologically positive for lymph node metastases. Of 11 patients, six patients with nonlateral retropharyngeal lymph node metastasis without primary or distant disease were successfully salvaged.

CONCLUSIONS

This study identified the incidence of lymph node metastasis among patients with T4 MS-SCC as well as the delayed metastasis rate and the treatment outcome for untreated N0 neck in patients with T4 MS-SCC. These results will be of assistance in selecting treatment strategy for T4 MS-SCC in the future.

The controversy in the management of the N0 neck for squamous cell carcinoma of the maxillary sinus

Squamous cell carcinoma (SCC) of the maxillary sinus is a relatively rare disease. As the reported incidence of regional metastasis varies widely, controversy exists as to whether or not the N0 classified neck should be treated electively. In this review, the data from published series are analyzed to decide on a recommendation of elective treatment of the neck in maxillary SCC. The published series consist of heterogeneous populations of different subsites of the paranasal sinuses, different histological types, different staging and treatment modalities used and different ways of reporting the results. These factors do not allow for recommendations based on high levels of evidence. Given this fact, the relatively high incidence rate of regional metastasis at presentation or in follow-up in the untreated N0 neck, and the relatively low toxicity of elective neck irradiation, such irradiation in SCC of the maxillary sinus should be considered.