Meta-analysis of treatment outcomes for sinonasal undifferentiated carcinoma

Sinonasal Tumors: What the Multidisciplinary Cancer Care Board Wants to Know

Sinonasal neoplasms are a remarkably heterogeneous group, reflecting the numerous tissue types present in the nasal cavity and paranasal sinuses. These entities can be relatively benign (ie, respiratory epithelial adenomatoid hamartoma) or can be exceedingly aggressive (ie, NUT carcinoma). Certain sinonasal tumors have a propensity to spread through local invasion and destruction, while others have a high likelihood of perineural spread. The genetic and molecular mechanisms underlying sinonasal tumor behavior have recently become better understood, and new tumor types have been described using these genetic and molecular data. This has prompted an expansion in the number of tumors included in the World Health Organization fifth edition classification system for head and neck tumors, along with a new classification structure. Radiologists' familiarity with this classification structure is crucial to understanding the expected behavior of these tumors and to collaboration with the multidisciplinary cancer care board in making decisions for optimal patient care. ©RSNA, 2024.

SMARCB1-deficient sinonasal adenocarcinoma: a rare variant of SWI/SNF-deficient malignancy often misclassified as high-grade non-intestinal-type sinonasal adenocarcinoma or myoepithelial carcinoma

SMARCB1-deficient sinonasal adenocarcinoma is a rare variant of SWI/SNF-deficient malignancies with SMARCB1 loss and adenocarcinoma features. More than 200 high-grade epithelial sinonasal malignancies were retrieved. A total of 14 cases exhibited complete SMARCB1 (INI1) loss and glandular differentiation. SMARCA2 and SMARCA4 were normal, except for one case with a loss of SMARCA2. Next-generation sequencing (NGS) and/or fluorescence in situ hybridization (FISH) revealed an alteration in the SMARCB1 gene in 9/13 cases, while 2/13 were negative. Two tumors harbored SMARCB1 mutations in c.157C > T p.(Arg53Ter) and c.842G > A p.(Trp281Ter). One harbored ARID1B mutations in c.1469G > A p.(Trp490Ter) and MGA c.3724C > T p.(Arg1242Ter). Seven tumors had a SMARCB1 deletion. One carried an ESR1 mutation in c.644-2A > T, and another carried a POLE mutation in c.352_374del p.(Ser118GlyfsTer78). One case had a PAX3 mutation in c.44del p.(Gly15AlafsTer95). Histomorphology of SMARCB1-deficient adenocarcinoma was oncocytoid/rhabdoid and glandular, solid, or trabecular in 9/14 cases. Two had basaloid/blue cytoplasm and one showed focal signet ring cells. Yolk sac tumor-like differentiation with Schiller-Duval-like bodies was seen in 6/14 cases, with 2 cases showing exclusively reticular-microcystic yolk sac pattern. Follow-up of a maximum of 26 months (median 10 months) was available for 8/14 patients. Distant metastasis to the lung, liver, mediastinum, bone, and/or retroperitoneum was seen in 4/8 cases. Locoregional failure was seen in 75% of patients, with 6/8 local recurrences and 3 cervical lymph node metastases. At the last follow-up, 5 of 8 (62%) patients had died of their disease 2 to 20 months after diagnosis (median 8.2 months), and 3 were alive with the disease. The original diagnosis was usually high-grade non-intestinal-type adenocarcinoma or high-grade myoepithelial carcinoma. A correct diagnosis of these aggressive tumors could lead to improved targeted therapies with potentially better overall disease-specific survival.

The role of radiotherapy in the treatment of sinonasal undifferentiated carcinoma: A population-based analysis

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is a rare, aggressive disease with ambiguous management and poor prognosis. This study aimed to evaluate the role of radiation therapy (RT) and explore the optimal treatment sequence.

METHODS

Retrospective analysis of survival trends of 410 SNUC patients between 1973 and 2015.

RESULTS

The 5-year cancer-specific survival (CSS) rate (45.1%) and overall survival (OS) rates (38.1%) were reported in the 84-month median follow-up. Radiotherapy was a prognosticator for improving CSS (hazard ratio [HR] = 0.425, 95% confidence interval [CI]: 0.299-0.603, p = 0.000) and OS (HR = 0.415, 95% CI: 0.303-0.570, p = 0.000), either with surgery (p = 0.000) or without surgery (p = 0.000). However, in a combined therapy of surgery and RT, preoperative and postoperative RT (5-year OS rates were 47.1% and 45.6%, respectively, p = 0.486) were not significantly different.

CONCLUSIONS

Radiotherapy plays a key role in improving SNUC survival rates. No significant difference in survival rates was observed in preoperative and postoperative RT treatment.

Assessment of targeted therapy opportunities in sinonasal cancers using patient-derived functional tumor models

Malignant tumors derived from the epithelium lining the nasal cavity region are termed sinonasal cancers, a highly heterogeneous group of rare tumors accounting for 3 - 5 % of all head and neck cancers. Progress with next-generation molecular profiling has improved our understanding of the complexity of sinonasal cancers and resulted in the identification of an increasing number of distinct tumor entities. Despite these significant developments, the treatment of sinonasal cancers has hardly evolved since the 1980s, and an advanced sinonasal cancer presents a poor prognosis as targeted therapies are usually not available. To gain insights into potential targeted therapeutic opportunities, we performed a multiomics profiling of patient-derived functional tumor models to identify molecular characteristics associated with pharmacological responses in the different subtypes of sinonasal cancer.

METHODS

Patient-derived ex vivo tumor models representing four distinct sinonasal cancer subtypes: sinonasal intestinal-type adenocarcinoma, sinonasal neuroendocrine carcinoma, sinonasal undifferentiated carcinoma and SMARCB1 deficient sinonasal carcinoma were included in the analyses. Results of functional drug screens of 160 anti-cancer therapies were integrated with gene panel sequencing and histological analyses of the tumor tissues and the ex vivo cell cultures to establish associations between drug sensitivity and molecular characteristics including driver mutations.

RESULTS

The different sinonasal cancer subtypes display considerable differential drug sensitivity. Underlying the drug sensitivity profiles, each subtype was associated with unique molecular features. The therapeutic vulnerabilities correlating with specific genomic background were extended and validated with in silico analyses of cancer cell lines representing different human cancers and with reported case studies of sinonasal cancers treated with targeted therapies.

CONCLUSION

The results demonstrate the importance of understanding the differential biology and the molecular features associated with the different subtypes of sinonasal cancers. Patient-derived ex vivo tumor models can be a powerful tool for investigating these rare cancers and prioritizing targeted therapeutic strategies for future clinical development and personalized medicine.

International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Meta-analysis of multi-modality therapies in sinonasal undifferentiated carcinoma-A timely update

OBJECTIVES

Sinonasal undifferentiated carcinoma (SNUC) is a rare but aggressive tumour with very poor prognosis. There are currently no well-established clinical trials to guide therapy and the impact of various treatment modalities on survival is not well defined. We aim to provide an updated systematic review on current treatment modalities on survival outcomes.

DESIGN AND SETTING

Individual patient data were extracted, and survival data pooled in a one-stage meta-analysis. Descriptive statistics were analysed using the Kaplan-Meier method. Patient-level comparisons stratified by treatment modalities, adjusted for demographics, were conducted using shared-frailty Cox regression.

PARTICIPANTS AND MAIN OUTCOME MEASURES

Participants include all patients diagnosed with SNUC based on histological evidence. We looked at the overall cumulative survival outcome for different treatment modalities and overall survival by treatment modality in low versus high stage SNUC patients.

RESULTS AND CONCLUSION

Seventeen studies were identified, comprising 208 patients from 1993 to 2020. There was no significant difference in cumulative overall survival in low versus high stage patients, and no significant difference in outcomes by treatment modality. The overall cumulative survival of SNUC is 30% at 95 months. Among patients treated with various combinations of treatment modalities, patients with chemoradiotherapy had the highest cumulative survival of 42% at 40 months. Definitive chemoradiotherapy was associated with improved disease survival rate. Regardless of tumour stage, patients should be treated early and aggressively, with no superiority of one treatment regimen over another. Trimodality treatment does not confer survival advantage over bimodality treatment.

Management of 80 sinonasal undifferentiated carcinomas. Retrospective multicentre study of the French Network of Rare Head and Neck Cancers (REFCOR)

OBJECTIVES

Sinonasal undifferentiated carcinoma (SNUC) is a rare and aggressive disease requiring multimodal treatment, and multiple new entities once included in the spectrum of SNUC, such as SWI/SNF-deficient carcinomas, are emerging. We aimed to provide new data regarding the role of chemotherapy and surgery and the prognostic factors of disease-free survival.

METHODS

This study was based on data from the REFCOR database and included patients with SNUC treated with curative intent from 2007 to 2021 across 22 centres in France.

RESULTS

A total of 80 patients were included in the analysis. Among the entire cohort, the 5-year disease-free survival (DFS) and overall survival (OS) rates were 58% and 63%, respectively. Of 100% of the patients treated with irradiation, 29% underwent surgery, 56% neoadjuvant chemotherapy (82% had either a partial or a complete response) and 76% chemoradiotherapy. No treatment modality was associated with a better OS or DFS, including surgery (p = 0.34). There was a trend for a better DFS for the patients treated with chemotherapy (neoadjuvant or concomitant, p = 0.062). Overall survival at 3 years was 58% for SWI/SNF deficient group and 86% for non deficient group (p = 0.14). The locoregional relapse rate without distant metastases was 21% in the exclusive radiotherapy group and 26% in the surgery group. Grade 3 or higher toxicities concerned 9%, 32% and 29% of patients for surgery, radiotherapy and chemotherapy respectively.

CONCLUSION

In the management of localised SNUC among all patients treated with irradiation, surgery yielded no benefit, whereas the addition of chemotherapy tended to improve disease-free survival.

PET/CT Imaging in Treatment Planning and Surveillance of Sinonasal Neoplasms

Sinonasal cancers are uncommon malignancies with a generally unfavorable prognosis, often presenting at an advanced stage. Their high rate of recurrence supports close imaging surveillance and the utilization of functional imaging techniques. Whole-body 18F-FDG PET/CT has very high sensitivity for the diagnosis of sinonasal malignancies and can also be used as a "metabolic biopsy" in the characterization of some of the more common subgroups of these tumors, though due to overlap in uptake, histological confirmation is still needed. For certain tumor types, radiotracers, such as 11C-choline, and radiolabeled somatostatin analogs, including 68Ga-DOTATATE/DOTATOC, have proven useful in treatment planning and surveillance. Although serial scans for posttreatment surveillance allow the detection of subclinical lesions, the optimal schedule and efficacy in terms of survival are yet to be determined. Pitfalls of 18F-FDG, such as post-surgical and post-radiotherapy crusting and inflammation, may cause false-positive hypermetabolism in the absence of relapse.

Statin Medication Improves Five-Year Survival Rates in Patients with Head and Neck Cancer: A Retrospective Case-Control Study of about 100,000 Patients

INTRODUCTION

The overall survival among head and neck cancer patients is still low, even in a time of new therapy regimes. Regarding cancer patients' survival, statin use has already proven to be associated with favorable survival outcomes. Our objective was to investigate the influence of statin medication on the overall survival of head and neck cancer patients.

METHODS

Retrospective clinical data of patients diagnosed with head and neck cancer (International Classification of Diseases codes: C00-C14) were retrieved from a real-world evidence database. The initial cohort was divided into patients with statin medication, who were assigned to building cohort I, and subjects without statin medication, who were assigned to cohort II, both matched by age, gender, and risk factors (nicotine and alcohol abuse/dependence). Subsequently, Kaplan-Meier and risk analyses were performed, and odds and hazard ratios were calculated.

RESULTS

After matching, each cohort contained 48,626 patients (cohort I = females: 15,409; (31.7%), males 33,212 (68.3%); mean age ± standard deviation (SD) at diagnosis 66.3 ± 11.4 years; cohort II = females: 15,432; (31.7%), males 33,187 (68.2%); mean age ± standard deviation (SD) at diagnosis 66.4 ± 11.5 years). Five-year survival was found to be significantly higher for cohort I, with 75.19%, respectively 70.48% for cohort II. These findings were correlated significantly with a risk of death of 15.9% (cohort I) and 17.2% (cohort II); the odds ratio was 0.91 (95% CI: 0.881-0.942) and the hazard ratio 0.80 (0.777-0.827).

CONCLUSIONS

The results indicate that the five-year survival of head and neck cancer patients is significantly improved by statin medication. As this study was conducted retrospectively, our data must be interpreted with caution, especially since other potential influencing factors and the initial tumor stage were not available.

Neoadjuvant chemotherapy in a rare type of very locally advanced sinonasal carcinomas - long-term results from a tertiary care centre

Introduction

Sinonasal carcinomas are a rare type of head and neck malignancy with various histologies. The outcomes of patients with unresectable locally advanced sinonasal carcinomas are poor. Hence, we performed this analysis to study the long-term outcomes of sinonasal adenocarcinoma (SNAC) and sinonasal undifferentiated carcinomas (SNUC) where neoadjuvant chemotherapy (NACT) has been given followed by local therapy.

Methods

16 patients with SNUC and adenocarcinoma who received NACT were found eligible for the study. Descriptive statistical analysis was performed for baseline characteristics, adverse events and treatment compliance. Kaplan Meir methods were used for the estimation of progression-free survival (PFS) and overall survival (OS).

Results

Seven (43.75%) adenocarcinoma and nine (56.25%) SNUC patients were identified. The median age of the whole cohort was 48.5 years. The median number of cycles delivered was 3 (IQR 1-8). The incidence of grade 3-4 toxicity (CTCAE version 5.0) was 18.75%. The response was partial response or better in seven patients (43.75%). Post-NACT 11 patients (n = 15, 73%) were eligible for definitive therapy. The median PFS was 7.63 months (95% CI, 3.23 - NA months) and the median OS was 10.6 months (95% CI, 5.2-51.5 months). Median PFS and OS for those who underwent surgery post-NACT versus those who did not undergo surgery were 36.267 versus 3.7 months (p = 0.012) and 51.5 versus 10.633 months (p = 0.190), respectively.

Conclusion

The study shows a favourable role of NACT in improving resectability, significant improvement in PFS and non-significant improvement in OS after surgery.

Top 10 Histological Mimics of Neuroendocrine Carcinoma You Should Not Miss in the Head and Neck

BACKGROUND

The spectrum of neuroendocrine neoplasia (NEN) of the head and neck region is wide-ranging and diverse, including a variety of diagnoses stretching from benign and low-malignant tumor forms to highly proliferative, poor prognosis neuroendocrine carcinoma (NEC). Moreover, there are several non-neuroendocrine differential diagnoses to keep in mind as well, displaying various degree of morphological and/or immunohistochemical overlap with bona fide neuroendocrine lesions.

METHODS

Review.

RESULTS

While the growth patterns may vary, well-differentiated NEN usually display a stippled "salt and pepper" chromatin, a granular cytoplasm, and unequivocal expression of neuroendocrine markers such as chromogranin A and synaptophysin. However, these features are often less pronounced in NEC, which may cause diagnostic confusion-not the least since several non-NEC head and neck tumors may exhibit morphological similarities and focal neuroendocrine differentiation.

CONCLUSION

As patients with NEC may require specific adjuvant treatment and follow-up, knowledge regarding differential diagnoses and potential pitfalls is therefore clinically relevant. In this review, the top ten morphological and/or immunohistochemical mimics of NEC are detailed in terms of histology, immunohistochemistry, and molecular genetics.

The contemporary management of cancers of the sinonasal tract in adults

Sinonasal malignancies make up <5% of all head and neck neoplasms, with an incidence of 0.5-1.0 per 100,000. The outcome of these rare malignancies has been poor, whereas significant progress has been made in the management of other cancers. The objective of the current review was to describe the incidence, causes, presentation, diagnosis, treatment, and recent developments of malignancies of the sinonasal tract. The diagnoses covered in this review included sinonasal undifferentiated carcinoma, sinonasal adenocarcinoma, sinonasal squamous cell carcinoma, and esthesioneuroblastoma, which are exclusive to the sinonasal tract. In addition, the authors covered malignances that are likely to be encountered in the sinonasal tract-primary mucosal melanoma, NUT (nuclear protein of the testis) carcinoma, and extranodal natural killer cell/T-cell lymphoma. For the purpose of keeping this review as concise and focused as possible, sarcomas and malignancies that can be classified as salivary gland neoplasms were excluded.

Human Papillomavirus-Related Carcinomas of the Sinonasal Tract

Purpose of review

The sinonasal tract is home to a uniquely heterogenous collection of malignant tumors. Human papillomavirus (HPV) has been detected in a number of these, but the virus' role as an oncogenic driver or coincidental finding remains unclear. We aim to highlight five sinonasal tumor types and synthesize the prevalence, etiologic role, and known clinicopathologic relevance of HPV in each.

Recent findings

The last decade has seen an expansion of investigation into HPV's oncogenic and prognostic significance within sinonasal malignancies. The sinonasal tract poses challenges to HPV detection where p16 lacks value as an accurate surrogate. A growing body of data supports a potentially favorable clinical profile for certain sinonasal HPV-positive lesions.

Summary

HPV represents a potential biologically and clinically relevant factor for some sinonasal malignancies. Definitive conclusions regarding HPV's role as a potential oncogenic agent require routine testing using validated methodologies, genomic interrogation, and large-scale prospective studies.

SMARCB1 (INI-1)-Deficient Sinonasal Carcinoma: A Systematic Review and Pooled Analysis of Treatment Outcomes

(1) Background: SMARCB1 (INI-1)-deficient sinonasal carcinoma is a rare sinonasal malignancy; since its discovery and description in 2014, less than 200 cases have been identified. It is almost impossible to perform randomized-controlled trials on novel therapy to improve treatment outcomes in view of its rarity. We performed a systematic review of all the published case reports/series and included our patients for survival analysis. (2) Methods: In this systematic review, we searched from PubMed-MEDLINE, EMBASE, Scopus, Cochrane Library, CINAHL, and Google Scholar for individual patient data to identify and retrieve all reported SMARCB1-deficient sinonasal carcinoma. Clarification on treatment details and the most updated survival outcomes from all authors of the published case reports/series were attempted. Survival analysis for overall survival (OS) and identification of OS prognostic factors were performed. This systematic review was registered with PROSPERO (CRD42022306671). (3) Results: A total of 67 publications were identified from the systematic review and literature search. After excluding other ineligible and duplicated publications, 192 patients reported were considered appropriate for further review. After excluding duplicates and patients with incomplete pretreatment details and survival outcomes, 120 patients were identified to have a complete set of data including baseline demographics, treatment details, and survival outcomes. Together with 8 patients treated in our institution, 128 patients were included into survival analysis. After a median follow up of 17.5 months (range 0.3-149.0), 50 (46.3%) patients died. The 1-year, 2-year and 3-year OS rates were 84.3% (95% CI % 77.6-91.0), 62.9% (95% CI 53.1-72.7), and 51.8% (95% CI 40.8-62.8), respectively, and the median OS was 39.0 months (95% CI 28.5-49.5). Males (p = 0.029) and T4b disease (p = 0.013) were significant OS prognostic factors in univariable analysis, while only T4b disease (p = 0.017) remained significant in multivariable analysis. (4) Conclusions: SMARCB1-deficient sinonasal carcinoma is an extremely aggressive sinonasal malignancy with a dismal prognosis. Early diagnosis and a multimodality treatment strategy are essential for a better treatment and survival outcome.

The MUSES∗: a prognostic study on 1360 patients with sinonasal cancer undergoing endoscopic surgery-based treatment: ∗MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers

BACKGROUND

Over the last 2 decades, transnasal endoscopic surgery (TES) has become the most frequently employed surgical technique to treat sinonasal malignancies. The rarity and heterogeneity of sinonasal cancers have hampered large non-population-based analyses.

METHODOLOGY

All patients receiving TES-including treatment between 1995 and 2021 in 5 referral hospitals were included. A prognostic study was performed, and multivariable models were transformed into nomograms. Training and validation sets were based on results from 3 European and 2 non-European centres, respectively.

RESULTS

The training and validation set included 940 and 420 patients, respectively. The mean age at surgery, primary-versus-recurrent presentation, histology distribution, type of surgery, T category and type of adjuvant treatment were differently distributed in the training and validation set. In the training set, 5-year overall survival and recurrence-free survival with a 95%-confidence interval were 72.7% (69.5-76.0%) and 66.4% (63.1-69.8%), respectively, significantly varying with histology. At multivariable analyses, age, gender, previous treatment, the extent of resection on the cranial, lateral and posterolateral axes, grade/subtype, T category, nodal status, margin status and adjuvant treatment were all associated with different prognostic outcomes, displaying a heterogeneous significance and effect size according to histology. The internal and external validation of nomograms was satisfactory (optimism-corrected C-index >0.7 and cumulative area under curve >0.7) for all histologies but mucosal melanoma.

CONCLUSIONS

Outcomes of TES-based treatment of sinonasal cancers vary substantially with histology. This large, non-population-based study provides benchmark data on the prognosis of sinonasal cancers that are deemed suitable for treatment including TES.

Update from the 5th Edition of the World Health Organization Classification of Head and Neck Tumors: Nasal Cavity, Paranasal Sinuses and Skull Base

The World Health Organization Classification of Head and Neck Tumours recently published the 5th edition. There are new entities, emerging entities, and significant updates to the taxonomy and characterization of tumor and tumor-like lesions, specifically in this article as it relates to nasal cavity, paranasal sinuses and skull base. Importantly, the number of diagnostic entries has been reduced by creating category-specific chapters for soft tissue, hematolymphoid, melanocytic, neuroectodermal, and metastatic tumors. Bone and salivary gland tumors are also not separately reported in the sinonasal tract, but included in the jaw and salivary gland sections, respectively. Repetition of characteristic entities in each anatomic site was also reduced, instead highlighting only the unique features in each anatomic site. Two new entities (SWI/SNF complex-deficient sinonasal carcinomas and HPV-related multiphenotypic sinonasal carcinoma) will be highlighted in this review, with a discussion of several emerging entities. There is a short description of updated information for all 24 diagnostic entities included in this edition to allow the reader a snapshot of current state of knowledge, but to encourage more investigation and further broaden understanding of these diverse and rare entities.

Emerging concepts in sinonasal tumor research

PURPOSE OF REVIEW

Sinonasal malignancies are rare and understudied, often diagnosed at late stages, and may behave aggressively. This review explores investigative diagnostic, therapeutic, and scientific advances specific to sinonasal undifferentiated carcinoma (SNUC), intestinal-type adenocarcinoma (ITAC), and olfactory neuroblastoma (ONB).

RECENT FINDINGS

A number of studies have recently contributed more robust knowledge of the genetic and molecular landscapes of SNUC, ITAC, and ONB. These analyses have identified SMARCB1 and IDH2 mutations in SNUC, potentially allowing for the tumor's subdivision. Recent studies have also defined a role for induction chemotherapy in SNUC. Somatic mutations for ITAC have been identified and may be potentially targetable with FDA approved therapies. Studies defining the tumor microenvironment for ITAC and ONB have introduced the possibility of immune checkpoint inhibition for these tumor types.

SUMMARY

Studies reviewed here detail promising results of the most current and novel characterization of SNUC, ITAC, and ONB genetic and molecular landscapes, which have informed ongoing therapeutic discovery. With continued multi-institutional efforts, the field of sinonasal tumor research will achieve higher disease control and improved treatment outcomes for patients afflicted with these rare cancers.

Cancer of the Paranasal Sinuses

Sinonasal malignancies rare and pathologically diverse and make up <1% of all malignancies. Due to their anatomical location, they can cause significant morbidity with involvement of surrounding critical structures. They often present at a late stage with insidious onset of symptoms. Treatment of sinonasal malignancies is challenging and they often require a multimodality approach with surgery, radiation, and chemotherapy. Outcomes are poor with 5-year overall survival around 32%, but this varies greatly depending on histologic subtype. There is an urgent need for more randomized controlled trials to better define the appropriate therapeutic regimens and to improve clinical outcomes.

Clinical management of localized undifferentiated sinonasal carcinoma: our experience and review of the literature

Undifferentiated sinonasal carcinoma (SNUC) is defined as a small round blue cell tumor that is immunohistochemically distinct from other sinonasal malignancies, such as lymphoma, mucosal melanoma, nasopharyngeal carcinoma, neuroendocrine carcinoma, and olfactory neuroblastoma. SNUCs are very aggressive malignancies, provoking quick destruction of the splanchnocranium structures. Being a very rare neoplasm, there are no prospective clinical trials assessing their treatment strategies, so lots of data are derived by small retrospective trials. Tri-modality treatments (namely those treatments which use together surgery, radiation therapy and chemotherapy) are now considered the best of care for this category of poor prognosis tumors, and whenever possible they should be employed. Despite the tri-modality treatments and the multidisciplinary management, SNUCs are characterized by poor prognosis with a median overall survival reaching 14 months. Ameliorating radiotherapy techniques and performing therapies adapted to the genetics of the disease could represent a promising strategy of therapy in the near future. In this report, we have presented our experience, describing the treatment and the prognosis of four patients seen at our Institution. Moreover, we have performed a review of the literature analyzing the now available therapy options and the possible future strategies.

The Role of Adjuvant Treatment in Craniofacial Malignancy: A Critical Review

Background: Tumors originating from the craniofacial region usually present in a locally advanced stage with frequent involvement of adjacent sites and have a strong tendency for local recurrence in the absence of adjuvant therapy, even when the original surgical resection was presumed to be radical. In the past decades, several advances in the radiological diagnosis and treatment of craniofacial malignancies have been introduced. There are, however, no randomized trials that define the optimal multimodal treatment of these tumors because of their rarity as well as heterogeneity in both histology and site of origin. The aim of this study was to conduct a critical review of the role of adjuvant therapy in the treatment of craniofacial malignancy. Method: We conducted a critical review of the past and contemporary literature available, focusing on adjuvant oncological treatments of the most common craniofacial malignancies. Results: Preoperative radiotherapy can have a documented role in the treatment of olfactory neuroblastoma and soft tissue sarcoma, while preoperative chemotherapy can be advocated in the treatment of sinonasal undifferentiated carcinoma, neuroendocrine carcinoma, olfactory neuroblastoma, and craniofacial sarcoma (both soft-tissue and high-grade osteosarcoma). Postoperative radiotherapy has a well-established role in the treatment of most craniofacial malignancies. The role of postoperative chemotherapy is unclear in most histologies, but is commonly used during the treatment of well-selected cases of paranasal sinus carcinoma, olfactory neuroblastoma, mucosal melanoma, soft tissue sarcoma and high-grade craniofacial osteosarcoma. Discussion: Alongside developments in surgery, there have also been improvements in diagnostics, radiotherapy, and chemotherapy. Implementation of novel radiation techniques allows delivery of higher radiation doses while minimizing irradiation-related morbidity. Better understanding of tumor biology allows the construction of more complex treatment strategies, incorporating adjuvant chemotherapy either pre- or postoperatively. In the era of personalized targeted therapy, rapid strides are being made to identify specific tumor-targets for use of novel biologic agents, with the potential to change current management paradigms.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Impact of induction chemotherapy and socioeconomics on sinonasal undifferentiated carcinoma survival

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is an uncommon malignancy of the nasal cavity and accessory sinuses with limited available studies evaluating role of induction chemotherapy (IC), demographics, and socioeconomic factors on overall survival (OS).

METHODS

The 2004-2015 National Cancer Database was queried for patients with histologically confirmed SNUC. IC was defined as chemotherapy administered 6 months to 2 weeks before surgery or ≥45 days before radiotherapy.

RESULTS

Of 440 identified patients, 70 (16%) underwent treatments involving IC. This consisted of 52 (12%), 15 (3%), and 3 (1%) patients receiving IC before definitive radiation therapy, surgery and adjuvant radiotherapy, or surgery only, respectively. On univariate analysis, IC (p = 0.34) did not affect OS, whereas having government insurance (hazard ratio [HR], 1.79; 95% confidence interval [CI], 1.37-2.34; p < 0.001) and living in regions with ≥13% of the population without a high school diploma (HR, 1.38; 95% CI, 1.06-1.79; p = 0.02) were associated with worse OS. On log-rank test, patients with advanced stage had similar OS regardless of whether or not they received IC (p = 0.96). Patients who received IC lived closer to their treatment site (p = 0.02) and had worse overall health, with more comorbidities (p = 0.02). The timing of IC before definitive surgery or radiation did not affect OS (p = 0.69).

CONCLUSION

In this SNUC population-based analysis, IC did not appear to provide additional OS benefit regardless of disease stage or timing before definitive treatment. Distance to treatment and level of comorbidities may be associated with receiving IC, whereas type of insurance and residence education level may impact SNUC OS, regardless of treatment.

Multimodal Therapy for Sinonasal Malignancies: Updates and Review of Current Treatment

OPINION STATEMENT

Sinonasal malignancies pose a significant challenge in management due to their low incidence, biologic diversity, and significant symptom burden. Even though surgery remains the primary therapeutic modality, a multi-modality approach has been shown to benefit a significant proportion of patients and its success depends largely on stage and histologic type. Non-surgical approaches such as novel radiation approaches as well as intensification with systemic therapy hold promise in altering the organ preservation rate as well as overall survival for patients. Practice changing randomized trials to test these novel modalities are overdue and desperately needed.

Elective neck treatment in sinonasal undifferentiated carcinoma: Systematic review and meta-analysis

Sinonasal undifferentiated carcinomas (SNUCs), being an aggressive malignancy with dismal survival outcome, have given limited consideration regarding management of regional failures. A total of 12 studies, published between 1999 and 2019, met inclusion criteria. We performed a meta‐analysis assessing regional (neck) relapse after elective neck treatment compared to observation in clinically node negative (N0) necks. Clinical data of 255 patients were used for meta‐analysis. Among them, 83.4% of patients presented with T4 tumors and 14.1% had positive neck nodes. Elective neck treatment was applied in 49.5% of analyzed patients. Regional relapses occurred in 3.7% of patients who have undergone elective neck treatment compared to 26.4% in patients who had not. Elective neck treatment significantly reduced the risk of regional recurrence (odds ratio 0.20; 95% confidence interval 0.08‐0.49; P = .0004). The meta‐analysis indicates that elective neck treatment could significantly reduce the risk of regional failures in patients with SNUCs.

Diagnostic traps awaiting the head/neck pathologist: "Cytoplasm-poor" neoplasms

CONTEXT

Beyond squamous carcinoma, a variety of diagnostically challenging neoplasms arise within various head and neck sites. This is particularly the situation with neoplasms where little cellular cytoplasm is present to assist the pathologist in categorizing such lesions.

OBJECTIVE

To highlight diagnostic pitfalls that accompanying neoplasms composed primarily of 'cytoplasmically-poor' cells. These pitfalls include morphologic and immunohistochemical traps that emerge from this class of neoplasms.

DATA SOURCES

Selection of pathologic specimens from the author's personal files, and literature review.

CONCLUSIONS

Interpretative pitfalls regarding the histopathology and immunophenotype of small 'cytoplasmically-poor' neoplasms are a diagnostic hazard in head and neck surgical pathology practice, and require knowledge of histomorphologic plasticity and aberrant immunophenotyping.

Immunohistochemical Detection and Molecular Characterization of IDH-mutant Sinonasal Undifferentiated Carcinomas

Recent studies have identified recurrent isocitrate dehydrogenase 2 (IDH2) mutations in a subset of sinonasal undifferentiated carcinomas (SNUCs); however, the true frequency of IDH mutations in SNUC is unknown. We evaluated the utility of mutation-specific IDH1/2 immunohistochemistry (IHC) in a large multi-institutional cohort of SNUC and morphologic mimics. IHC using a multispecific antibody for IDH1/2 (R132/R172) mutant protein was performed on 193 sinonasal tumors including: 53 SNUCs, 8 poorly differentiated carcinomas (PDCARs) and 132 histologic mimics. Mutant IDH1/2 IHC was positive in 26/53 SNUCs (49%; 20 strongly positive and 6 weak) and 3/8 PDCARs (37.5%; 2 strong; 1 weak) but was absent in all other tumor types (0/132). Targeted next-generation sequencing (NGS) on a subset of SNUC/PDCAR (6 strong and 3 weak positive for IDH1/2 IHC; 7 negative) showed frequent IDH2 R172X mutations (10/16) and a single IDH1 R132C mutation. All 6 cases with strong positive mutant IDH1/2 staining and NGS had IDH2 R172S/G mutations. The 3 IHC-weak cases all had IDH2 R172T mutations. Among the 7 tested cases that were negative for mutant IDH1/2 IHC, NGS detected 1 case each with IDH2 R172T and IDH1 R132C mutation. IDH-mutant carcinomas also had frequent mutations in TP53 (55%) and activating mutations in KIT (45%) or the PI3K pathway (36%). Mutation-specific IDH1/2 IHC identifies IDH mutations in SNUC, however, it lacks sensitivity for the full range of IDH mutations. These findings suggest that IDH-mutant sinonasal carcinoma may represent a distinct pathobiological entity with therapeutic implications that can be identified by a combined approach of multispecific IDH1/2 IHC and sequencing.

Induction chemotherapy with docetaxel, cisplatin and fluorouracil followed by concurrent chemoradiotherapy for unresectable sinonasal undifferentiated carcinoma: Two cases of report

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is a rare aggressive tumor that is often unresectable. Optimal treatment for patients with unresectable, locally advanced SNUC (LA-SNUC) has not been established, and the patient outcome remains poor. We report two cases of unresectable LA-SNUC in which induction chemotherapy with docetaxel, cisplatin and fluorouracil (TPF) followed by radiotherapy with concurrent cisplatin (CCRT), a standard treatment option for locally advanced head and neck cancer, demonstrated promising outcomes.

CASE SUMMARY

A 39-year-old man presented with tearing and pain in the right eye. A biopsy of the tumor invading the sinonasal cavities, right orbit and cranial base confirmed the diagnosis of LA-SNUC. Induction TPF chemotherapy induced remarkable tumor shrinkage and rapidly improved the symptoms. He subsequently received CCRT and achieved complete remission of the disease. The other case is a 21-year-old man who presented with worsening vision. The unresectable tumor involving the nasal septum and cranial base was pathologically diagnosed as SNUC. TPF chemotherapy followed by CCRT yielded complete remission of the disease with preserved visual function. Both patients have been disease-free for 44 mo.

CONCLUSION

Induction TPF chemotherapy followed by CCRT may remarkably improve the outcomes in LA-SNUC patients.

Sinonasal Undifferentiated Carcinoma

PURPOSE OF REVIEW

To provide a comprehensive review of the literature highlighting the recent advances in the diagnosis and management of sinonasal undifferentiated carcinoma (SNUC) RECENT FINDINGS: SNUC usually presents at advanced stage and the prognosis is usually poor with high rates of locoregional recurrence and tendency to metastasize. Special attention should be made in differentiating SNUC from other sinonasal malignancies in order to guide the appropriate treatment accordingly. Multimodality treatment is usually recommended for treating SNUC. The use of neoadjuvant chemotherapy may be associated with improved outcome and can be used to guide the subsequent treatment selection. Despite the recent advances in chemotherapeutic agents, radiation techniques, and surgical approaches, the prognosis and survival outcomes of SNUC remain poor. The addition of induction chemotherapy to the treatment approach followed by definitive local therapy needs to be further studied as it might improve the outcome.

High-Grade Sinonasal Carcinoma: Classification Through Molecular Profiling

High-grade sinonasal carcinomas are a cohort of malignant epithelial neoplasms arising in the sinonasal cavities with distinct, ominous morphologic features or lacking well-differentiated features that might otherwise classify them as less biologically worrisome. Recent advances in molecular profiling have led to the identification of several distinct tumor entities previously grouped together. These molecularly distinct lesions include NUT (midline) carcinoma, INI1 (SMARCB1)-deficient carcinoma, SMARCA4-deficient sinonasal carcinoma, and novel IDH-mutant sinonasal undifferentiated carcinoma, in addition to the previously described lymphoepithelial carcinoma that may also be included in the differential diagnosis. The discovery of these distinct molecular tumor profiles may have significant clinical impact as targeted molecular-based therapeutics continue to evolve, and they may offer some respite for patients who have these highly aggressive cancers.

Induction Chemotherapy Response as a Guide for Treatment Optimization in Sinonasal Undifferentiated Carcinoma

PURPOSE

Multimodal therapy is a well-established approach for the treatment of sinonasal undifferentiated carcinoma (SNUC); however, the optimal sequence of the various treatments modalities is yet to be determined. This study aimed to assess the role of induction chemotherapy (IC) in guiding definitive therapy in patients with SNUC.

METHODS

Ninety-five previously untreated patients diagnosed with SNUC and treated between 2001 and 2018 at The University of Texas MD Anderson Cancer Center were included in the analysis. Patients were treated with curative intent and received IC before definitive locoregional therapy. The primary end point was disease-specific survival (DSS). Secondary end points included overall and disease-free survival, disease recurrence, and organ preservation.

RESULTS

A total of 95 treatment-naïve patients were included in the analysis. For the entire cohort, the 5-years DSS probability was 59% (95% CI, 53% to 66%). In patients who had partial or complete response to IC, the 5-year DSS probabilities were 81% (95% CI, 69% to 88%) after treatment with definitive concurrent chemoradiotherapy (CRT) after IC and 54% (95% CI, 44% to 61%) after definitive surgery and postoperative radiotherapy or CRT after IC (log-rank P = .001). In patients who did not experience at least a partial response to IC, the 5-year DSS probabilities were 0% (95% CI, 0% to 4%) in patients who were treated with concurrent CRT after IC and 39% (95% CI, 30% to 46%) in patients who were treated with surgery plus radiotherapy or CRT (adjusted hazard ratio of 5.68 [95% CI, 2.89 to 9.36]).

CONCLUSION

In patients who achieve a favorable response to IC, definitive CRT results in improved survival compared with those who undergo definitive surgery. In patients who do not achieve a favorable response to IC, surgery when feasible seems to provide a better chance of disease control and improved survival.

Sinonasal Undifferentiated Carcinoma: A 15-Year Single Institution Experience

Objective  Sinonasal undifferentiated carcinoma (SNUC) is an aggressive neoplasm, with conflicting existing literature regarding prognosis and treatment due to the rarity of disease. Characterization of optimal SNUC management is necessary for improved outcomes. Study Design  Case series with planned data collection and analysis. Setting  Hospital of the University of Pennsylvania and Pennsylvania Hospital. Participants  Patients with pathologically confirmed SNUC treated within a 15-year period were identified, and records were obtained and evaluated for several demographic characteristics. Main Outcomes Measures  Disease-specific survival from diagnosis was the primary endpoint, while disease recurrence was a secondary endpoint of the study. Results  Twenty-seven patients with established SNUC were included in this cohort, with a median age of 55 years. Eighty-five percent of patients were surgically treated, and 85% of patients presented with stage IV disease. Two-year disease-specific survival was 66% and 5-year disease-specific survival was 46%. Ninety-six percent of patients received both chemotherapy and radiation as adjuvant treatment. Nodal disease at presentation and disease recurrence both significantly decreased patient survival ( p  < 0.05). Conclusions  The majority of patients at this institution presented with clinically advanced disease, and most were managed with a multimodal approach of surgical resection, chemotherapy, and radiation. Extent of disease at presentation and progression of disease following treatment are poor prognostic signs and may merit a more aggressive approach, while early detection and treatment may improve survival and decrease patient morbidity.

Clinical characteristics and prognostic factors of sinonasal undifferentiated carcinoma: a multicenter study

BACKGROUND

Sinonasal undifferentiated carcinoma (SNUC) is a very rare entity with a poor prognosis. Due to the lack of studies on the subject, evidence is lacking concerning its management.

METHODS

A multicenter collaborative study was conducted to assess treatment strategy, oncological outcome, and prognostic factors.

RESULTS

Definitive analyses focused on 54 patients with a majority of advanced stage; the 3-year overall survival (OS) and 3-year recurrence-free survival (RFS) rates were, respectively, 62.4% and 47.8%. During the follow-up, 18 patients (33.3%) died, 10 (18.5%) developed metastases, 7 had lymph-node involvement (13%), and 12 (22.2%) showed recurrence or local progression. In univariate analyses, treatment modalities associated with improved RFS were induction chemotherapy (p = 0.02) and intensity-modulated radiotherapy (p = 0.007). In the multivariate analyses, only induction chemotherapy (p = 0.047, hazard ratio [HR] = 0.39) was significantly associated with improved RFS.

CONCLUSION

Multimodal therapies including induction chemotherapy and intensity-modulated radiotherapy may improve the prognosis of SNUC; surgery might improve local control. Further multicenter studies are required.

A Case of Sinonasal Undifferentiated Carcinoma with Brain Metastases

Sinonasal undifferentiated carcinoma (SNUC) is a rare aggressive neoplasm arising in the nasal cavity and paranasal sinuses. We report a unique case of an 80-year-old man who presented with a locally advanced SNUC involving the ethmoid, sphenoid, and maxillary sinuses and bilateral lymph nodes, clinical T4N2M0. Given his age and the initial extent of his primary tumour, he was treated with neoadjuvant chemotherapy followed by chemoradiation with a split course of 50 Gray (Gy) in 40 fractions delivered twice a day. Four months after his treatments, he developed a recurrence at the left lower eyelid and left frontal sinus, intrabdominal metastases, and a left cerebellar metastasis. A single fraction of 22 Gy was delivered to the cerebellar lesion using stereotactic radiosurgery. He survived 17 months from the initial presentation. We review the available literature regarding treatment of brain metastases and use of hyperfractionated radiotherapy in this rare head and neck cancer.

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.

Staging of Sinonasal and Ventral Skull Base Malignancies

Tremendous pathologic diversity among sinonasal and ventral skull base malignancies complicates development of a uniform and prognostically relevant staging system. Because of the comparatively low incidence of these tumors, comprehensive evaluation and comparison of specific staging systems is difficult. The current American Joint Committee on Cancer TNM staging system for sinonasal malignancies is the most common and widely used system in current clinical practice. Alternative systems have been proposed for use with individual histopathologic subtypes. Many of these staging systems are of great utility and accurately predict patient survival. Further research and adjustment of these current staging systems remains an important area of research.

Management of Frontal Sinus Tumors

The most common primary tumors of the frontal sinus are osteomas and inverted papillomas, although a variety of other tumors involving this space have been reported. With the advent of new surgical techniques and instrumentation, an endoscopic approach to this region has become feasible. The preoperative assessment and decision making must take into account the complexity of frontal sinus anatomy, tumor type, tumor location, and associated attachments. These procedures allow adequate visualization, tumor removal, and postoperative monitoring, and preserve fairly normal sinus function. Open techniques may also be required and should be in the surgeon's armamentarium.

The Role of Chemotherapy in the Management of Sinonasal and Ventral Skull Base Malignancies

In most cases of advanced sinonasal and ventral skull base cancer, a multimodal treatment approach provides the best chance for improved outcomes. Depending on the tumor type and extent of disease, systemic chemotherapy has been shown to play an important role in neoadjuvant, concomitant, and adjuvant settings. The lack of randomized trials continues to limit its indications. Further high-quality studies are needed to understand ideal chemotherapeutic regimens and their role and sequential timing in sinonasal and ventral skull base cancer.

The Role of Radiation Therapy in the Management of Sinonasal and Ventral Skull Base Malignancies

Sinonasal and ventral skull base malignancies are rare tumors that arise in a complex anatomic location juxtaposed with critically important normal tissues. The standard treatment paradigm for most histologies has been surgery followed by postoperative radiation therapy. Because of their propensity to present at an advanced stage and the presence of nearby critical structures, patients are at risk for severe radiation-induced long-term toxicity. Recent advances in radiotherapy technique have improved the therapeutic ratio between tumor control and normal tissue toxicity. This article reviews issues pertinent to the use of radiotherapy in the management of these tumors.

Small round blue cell tumors of the sinonasal tract: a differential diagnosis approach

One of the most challenging diagnostic categories within tumors of the sinonasal tract is the small round blue cell tumors. Biopsies are usually small and limited, resulting in considerable diagnostic difficulty for practicing surgical pathologists. These tumors share several overlapping histologic and immunophenotypic findings while also showing considerable variation within and between cases. Specific tumor site of origin, imaging findings, and clinical findings must be combined with the histology and pertinent ancillary studies if the correct diagnosis is to be reached. Discrimination between neoplasms is critical as there are significant differences in therapy and overall outcome. It is important to have a well developed differential diagnosis for this category of tumors, where each of the diagnoses is considered, evaluated, and either confirmed or excluded from further consideration. In an undifferentiated tumor, showing a small round blue cell morphology, using the mnemonic 'MR SLEEP' helps to highlight tumors to consider: melanoma, mesenchymal chondrosarcoma, rhabdomyosarcoma, sinonasal undifferentiated carcinoma, squamous cell carcinoma (including NUT carcinoma), small cell osteosarcoma, lymphoma, esthesioneuroblastoma (olfactory neuroblastoma), Ewing sarcoma/primitive neuroectodermal tumor, pituitary adenoma, and plasmacytoma. A panel of pertinent immunohistochemistry studies, histochemistries and/or molecular tests should aid in reaching a diagnosis, especially when taking the pattern and intensity of reactions into consideration.

ACR appropriateness criteria® nasal cavity and paranasal sinus cancers

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.

A multimodality approach to sinonasal undifferentiated carcinoma: a single institute experience

BACKGROUND

Sinonasal undifferentiated carcinoma is a rare aggressive tumour arising from the Schneiderian epithelium lining the sinonasal tract. Although considered the cornerstone of therapy, surgical resection can only be performed in a limited number of patients. This report describes the experience of treating sinonasal undifferentiated carcinoma with a multimodality approach.

METHOD

The treatment charts of sinonasal undifferentiated carcinoma patients treated at a tertiary care centre from 2004 to 2012 were retrospectively reviewed.

RESULTS

A total of 16 sinonasal undifferentiated carcinoma patients with a median age at diagnosis of 47.5 years (range 8-65 years) were included: 19 per cent had neck nodal metastasis at presentation. Four patients (25 per cent) underwent surgery: of these, two had post-operative radiotherapy, one had pre-operative radiotherapy and one had adjuvant chemotherapy alone. Six patients (38 per cent) received definitive radiotherapy: five had received neoadjuvant chemotherapy to reduce tumour size and help in radiotherapy planning, while four (25 per cent) received palliative radiotherapy. The median follow up was 10.4 months (range 1-42.5 months). The estimated median progression-free survival time was 29.3 months. One- and three-year progression-free survival rates were 77 per cent and 41 per cent, respectively.

CONCLUSION

Surgery is the best treatment option for sinonasal undifferentiated carcinoma, although most patients require post-operative radiotherapy for advanced disease and close tumour margins. Definitive radiotherapy with or without chemotherapy may be suitable for patients with inoperable locally advanced disease. Elective nodal irradiation to address the high nodal involvement rates should be considered to improve the survival rate.

Sinonasal Carcinomas with Neuroendocrine Features: Histopathological Differentiation and Treatment Outcomes

Objectives Sinonasal cancers with neuroendocrine features share similar clinical, radiological, and histopathological features; however, these tumors often exhibit varying degrees of aggressive behavior presenting significant treatment challenges. The objective of this study was to report our experience with these rare malignancies and to present a review of current literature. Methods Following institutional review board approval, the records of all patients with biopsy-proven sinonasal malignancies over a 5-year period were reviewed. Results The study included 14 patients with olfactory neuroblastomas (ONBs), 7 patients with sinonasal undifferentiated carcinomas (SNUC), and 2 patients with sinonasal neuroendocrine carcinomas (SNEC). Histopathologic markers aided in final diagnosis, but showed variable specificity. In patients with sufficient follow-up, the 2-year disease-free survival rate was 81% (9/11) for ONB and 75% (3/4) for SNUC. Three patients developed a regional or distant recurrence (two with ONBs and one with SNUC). Two patients, one with SNEC and one with ONB, succumbed to brain radionecrosis related to proton radiation therapy. Conclusions Overlapping clinical and histopathological features in poorly differentiated sinonasal cancers with neuroendocrine features continue to present a diagnostic challenge. Individualized assessment and treatment strategies can improve the accuracy of the initial assessment and the treatment outcomes.