[Treatment of primary craniofacial (sinonasal) malignant tumors affecting the anterior and middle skull base]

Sinonasal malignant tumors are characterized by high histological variability and complexity of the differential diagnosis. Currently, there are classifications of these tumors, which are based on their localization and involvement of various anatomical structures. However, generally accepted algorithms for treatment of this pathology have not yet been developed. This review describes the most important algorithms for treatment of the most common histological variants of sinonasal malignant tumors: squamous cell carcinoma, adenocarcinoma, sinonasal undifferentiated carcinoma, esthesioneuroblastoma, adenoid cystic cancer, and sinonasal adenocarcinoma. The main problems in choosing the approach for treating these tumors are the lack of generally accepted resectability criteria and contradictions between oncological and neurosurgical indications for surgical treatment. Further research is needed to study the role of radiosensitizers and radioprotectors in comprehensive treatment of sinonasal malignant tumors.

Chemotherapy in Esthesioneuroblastoma/Olfactory Neuroblastoma: An Analysis of the Surveillance Epidemiology and End Results (SEER) 1973-2015 Database

OBJECTIVE

Chemotherapy has been proposed as an adjunct to primary local therapy in esthesioneuroblastoma (ENB)/olfactory neuroblastoma (ON), but its role has not been precisely defined. Here, we evaluated its role in ENB treatment.

MATERIALS AND METHODS

The Surveillance Epidemiology and End Results (SEER) database was queried for ENB/ON (International Classification of Diseases-3 9522). Cases met criteria for inclusion if they were unique, had a primary location in the nasal cavity, and had adequate information for Kadish staging derivation. Univariable and multivariable Cox analyses assessed chemotherapy treatment effect on disease-specific survival (DSS) and overall survival (OS). Multiple imputation addressed missing data. A P<0.05 was designated for statistical significance.

RESULTS

In adjusted multivariable analyses, chemotherapy treatment was associated with inferior DSS (hazard ratio [HR], 1.74; 95% confidence interval [CI], 1.21-2.51; P=0.003) and OS (HR, 1.71; 95% CI, 1.26-2.32; P=0.001). Among the subset with local or regional disease treated with surgery and/or radiation therapy, chemotherapy remained associated with inferior outcomes DSS (HR, 2.78; 95% CI, 1.63-4.74; P<0.001) and OS (HR, 2.18; 95% CI, 1.45-3.27; P<0.001). Chemotherapy treatment misclassification did not explain these findings.

CONCLUSIONS

This analysis does not support chemotherapy to improve either DSS or OS in primary ENB/ON treatment, after controlling for known ENB prognostic factors available from SEER. Other prognostic and treatment selection factors could exist which were not controlled in these analyses. Chemotherapy could beneficially affect outcomes other than DSS or OS. Although the concerns have been expressed regarding chemotherapy treatment misclassification in SEER, their analyses did not identify such misclassification as an explanation for our findings.

Protein calorie malnutrition, nutritional intervention and personalized cancer care

Cancer patients often experience weight loss caused by protein calorie malnutrition (PCM) during the course of the disease or treatment. PCM is expressed as severe if the patient has two or more of the following characteristics: obvious significant muscle wasting, loss of subcutaneous fat; nutritional intake of <50% of recommended intake for 2 weeks or more; bedridden or otherwise significantly reduced functional capacity; weight loss of >2% in 1 week, 5% in 1 month, or 7.5% in 3 months. Cancer anorexia-cachexia syndrome (CACS) is a multifactorial condition of advanced PCM associated with underlying illness (in this case cancer) and is characterized by loss of muscle with or without loss of fat mass. Cachexia is defined as weight loss of more than 5% of body weight in 12 months or less in the presence of chronic disease. Hence with a chronic illness on board even a small amount of weight loss can open the door to cachexia. These nutritional challenges can lead to severe morbidity and mortality in cancer patients. In the clinic, the application of personalized medicine and the ability to withstand the toxic effects of anti-cancer therapies can be optimized when the patient is in nutritional homeostasis and is free of anorexia and cachexia. Routine assessment of nutritional status and appropriate intervention are essential components of the effort to alleviate effects of malnutrition on quality of life and survival of patients.

Sinonasal adenoid cystic carcinoma: a population-based analysis of 694 cases

BACKGROUND

Currently, limited literature exists about sinonasal adenoid cystic carcinoma (SNACC). In this study, we analyze the demographics, survival, and treatment efficacy of this rare entity.

METHODS

Our study was a retrospective population-based analysis of SNACC in the Surveillance, Epidemiology, and End Results (SEER) database assessing the 40-year time-frame of 1973 to 2013.

RESULTS

Six hundred ninety-four SNACC patients were identified; 53.2% were female and 46.8% were male. Caucasians were most commonly affected (77.1%). SNACC most often arose from the maxillary sinuses, followed by the nasal cavity. The majority of SNACC cases presented as stage IV disease. Nodal and distant metastases were present in 3.6% and 7.1% of all cases, respectively. Overall 5-, 10-, and 20-year disease-specific survival (DSS) rates were 66.5%, 41.1%, and 17.6%, respectively. The presence of distant metastasis dropped the 5-year DSS rate from 64.5% to 20.0%. Cases treated with combined surgery and adjuvant radiotherapy had a slightly improved 5-year DSS rate compared with surgery alone (73.5% vs 72.5%). Surgery alone resulted in higher 10- and 20-year DSS rates (54.2% and 36.8%, respectively) when compared with combined therapy (44.2% and 15.5%), radiotherapy alone (10.8% and 0%), and no surgery or radiotherapy (9.3% and 0%).

CONCLUSION

This study represents the largest cohort of SNACC patients to date. Factors that confer a survival benefit in SNACC include M0 disease, and presentation primarily in the nasal cavity. Overall low rates of nodal metastasis may not warrant the use of elective neck dissections, unless there is clinical suspicion. Modalities of therapy that include surgery greatly improve survival. Adjuvant radiotherapy appears to slightly improve 5-year disease-free survival but does not impact long-term survival.

Contemporary Staging and Prognosis for Primary Tracheal Malignancies: A Population-Based Analysis

OBJECTIVE: Determine staging characteristics and survival outcomes for primary malignancies of the trachea.

DESIGN: Cross-sectional analysis of national cancer database.

METHODS: Cases of primary tracheal malignancy were extracted from the Surveillance, Epidemiology, and End Results database for the time period 1988-2000. T-stage, N-stage, and overall stage of presentation were determined. Mean, median, and 5-year survival statistics were computed using Kaplan-Meier survival analysis for each tumor histology and for the overall cohort according to stage.

RESULTS: Ninety-two cases with adequate histologic information were identified. Mean age at presentation was 59.3 years with an equal sex distribution. Squamous cell carcinoma was the most common tumor type (41 cases) followed by adenoid cystic carcinoma (19 cases). Forty-nine cases (53%) presented with stage 3 or stage 4 disease. Squamous cell carcinoma exhibited poorer survival (mean survival, 44.0 month, 5-year survival, 34%) than adenoid cystic carcinoma (mean survival, 115 month, 5-year survival, 78%). Five-year unadjusted survival rates according to overall stage were 52.8%, 70.0%, 75.0%, 15.1%, respectively.

CONCLUSIONS: Primary tracheal malignancies often present with advanced stage. Patients with squamous cell carcinoma of the trachea have poorer prognoses when compared with adenoid cystic carcinoma and other tumor types. Staging tracheal cancer with a TNM-based system helps predict survival. EBM rating: C.

Demographics and survival trends of sinonasal adenocarcinoma from 1973 to 2009

BACKGROUND

The purpose of this work was to study the demographics and survival of patients diagnosed with sinonasal adenocarcinoma (SNAC) within the time period of 1973 to 2009 using the Surveillance, Epidemiology, and End Result (SEER) database.

METHODS

A retrospective cohort study using the U.S. National Cancer Institute's SEER registry was performed to study the demographics and survival for SNAC from 1973 to 2009. Analysis was conducted based on race, gender, and stage.

RESULTS

In total, 1270 cases of SNAC were analyzed for demographics and survival. Males accounted for 51.6% of cases, while females accounted for 48.4% of cases, amounting to a male to female ratio of 1.06:1.00. Disease specific survival at 5, 10, 15, and 20 years was 65.2%, 50.9%, 40.9%, and 36.5%, respectively. When analyzed by gender, females had higher survival than males, although this difference was not statistically significant. When analyzed by race, the category of other, which encompasses American Indian, Asian, Hispanic, and unknown or unspecified race, was shown to have the best survival, followed by whites and blacks, respectively.

CONCLUSION

SNAC is a rare tumor classically associated with occupational exposure and carries a variable prognosis. This is the first dedicated large-scale, retrospective analysis of a North American SNAC population. SNAC appears to affect both males and females equally and predominantly affects whites. Patients categorized as other had significantly better survival outcomes, while gender appeared to have no significant effect on survival.

Endonasal endoscopic surgery for squamous cell carcinoma of the sinonasal cavities and skull base: Oncologic outcomes based on treatment strategy and tumor etiology

BACKGROUND

Oncologic outcomes for sinonasal and skull base squamous cell carcinoma (SCC) treated with an endoscopic endonasal approach (EEA) needs investigation.

METHODS

Patients with SCC treated with EEA were stratified by treatment strategy and tumor etiology and reviewed.

RESULTS

Thirty-four patients were treated with EEA, or which 27 had definitive resection and 7 had debulking surgery. In the definitive group, 17 had de novo tumors and 10 had tumors arising from inverted papilloma. Definitive resection was associated with better 5-year disease-free survival (DFS) and overall survival (OS) than debulking (62% vs 17%; p = .02; and 78% vs 30%; p = .03). Patients with de novo tumors had similar 5-year DFS and OS to those arising from inverted papilloma (62% vs 62%; p = .75; and 75% vs 86%; p = .24).

CONCLUSION

Definitive resection of sinonasal SCC with EEA provides sound oncologic outcomes. SCC arising from inverted papilloma does not have prognostic significance.

Sinonasal tract and nasopharyngeal adenoid cystic carcinoma: a clinicopathologic and immunophenotypic study of 86 cases

Primary sinonasal tract and nasopharyngeal adenoid cystic carcinomas (STACC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. Eighty-six cases of STACC included 45 females and 41 males, aged 12-91 years (mean 54.4 years). Patients presented most frequently with obstructive symptoms (n = 54), followed by epistaxis (n = 23), auditory symptoms (n = 12), nerve symptoms (n = 11), nasal discharge (n = 11), and/or visual symptoms (n = 10), present for a mean of 18.2 months. The tumors involved the nasal cavity alone (n = 25), nasopharynx alone (n = 13), maxillary sinus alone (n = 4), or a combination of the nasal cavity and paranasal sinuses (n = 44), with a mean size of 3.7 cm. Patients presented equally between low and high stage disease: stage I and II (n = 42) or stage III and IV (n = 44) disease. Histologically, the tumors were invasive (bone: n = 66; neural: n = 47; lymphovascular: n = 33), composed of a variety of growth patterns, including cribriform (n = 33), tubular (n = 16), and solid (n = 9), although frequently a combination of these patterns was seen within a single tumor. Pleomorphism was mild with an intermediate N:C ratio in cells containing hyperchromatic nuclei. Reduplicated basement membrane and glycosaminoglycan material was commonly seen. Necrosis (n = 16) and atypical mitotic figures (n = 11) were infrequently present. Pleomorphic adenoma was present in 9 cases; de-differentiation was seen in two patients. Immunohistochemical studies showed positive reactions for pan-cytokeratin, CK7, CK5/6, CAM5.2, and EMA, with myoepithelial reactivity with SMA, p63, calponin, S100 protein and SMMHC. CD117, CEA, GFAP and p16 were variably present. CK20 and HR HPV were negative. STACC needs to be considered in the differential diagnosis of most sinonasal malignancies, particularly poorly differentiated carcinoma, olfactory neuroblastoma and pleomorphic adenoma. Surgery (n = 82), often accompanied by radiation therapy (n = 36), was generally employed. A majority of patients developed a recurrence (n = 52) 2-144 months after initial presentation. Overall mean follow-up was 19.4 years (range 0.4-37.5 years): 46 patients died with disease (mean 6.4 years); 5 were alive with disease (mean 5.4 years), and 35 patients were either alive or had died of unrelated causes (mean 16.3 years). ACC of the SNT is uncommon. Recurrences are common. The following parameters, when present, suggest an increased incidence of either recurrence or dying with disease: mixed site of involvement, high stage disease (stage IV), skull base involvement, tumor recurrence, a solid histology, perineural invasion, bone invasion, and lymphovascular invasion.

Prognostic factors in sinonasal sarcomas: analysis of the surveillance, epidemiology and end result database

OBJECTIVES/HYPOTHESIS

Sinonasal sarcomas are rare and often aggressive malignant tumors. Although tumor histology and location are the only reported prognostic indicators for this disease, we sought to determine if additional clinical factors might influence patient survival.

STUDY DESIGN

Retrospective cohort study using a national cancer database.

METHODS

Cases of sinonasal sarcomas from 1973 to 2008 were extracted from the Surveillance, Epidemiology and End Result (SEER) database. The influence of patient age, gender, race, and prior irradiation, as well as tumor histology and subsite, was calculated using the Kaplan-Meier method.

RESULTS

A total of 352 patients with sinonasal sarcomas were identified. Histologic subtype, tumor location, gender, and patient age were found to influence patient survival. Specifically, increased age, male sex, frontal and maxillary sinus subsites, and rhabdomyosarcoma and Kaposi sarcoma histologies were associated with a significant increase in mortality rate (P < .05).

CONCLUSIONS

This study comprises the largest analysis of patients with sinonasal sarcoma in the literature and demonstrates the impact of patient age, tumor histology, and tumor location on the overall survival of individuals with these rare malignancies.

Endoscopic skull base surgery for sinonasal malignancy

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

Select Neoplasms of the Sinonasal Tract

The sinonasal tract (SNT) includes the nasal cavity and paranasal sinuses (maxillary, ethmoid, frontal, and sphenoid) and may give rise to a variety of nonneoplastic and neoplastic proliferations, including benign and malignant neoplasms. The benign neoplasms of the SNT include epithelial neoplasms of surface epithelial origin, minor salivary gland origin, and mesenchymal origin. The spectrum of malignant neoplasms of the SNT includes epithelial malignancies, sinonasal undifferentiated carcinoma, malignant salivary gland neoplasms, neuroectodermal neoplasms, neuroendocrine neoplasms, melanocytic neoplasm, and sarcomas. This article concentrates on some of the more common types of benign and malignant neoplasms.

Evidence for treatment strategies in sinonasal adenocarcinoma

Adenocarcinomas of various types account for 10% to 20% of all primary malignant neoplasms of the nasal cavity and paranasal sinuses. There is a general consensus that the optimal treatment of adenocarcinoma is surgery and postoperative radiotherapy. The purpose of this report was to review the results of this combined treatment as well as other treatment strategies and their outcome. Most series present outcome data from a heterogeneous group of patients, with a wide variety of tumor subtypes presenting at differing stages, who received a variety of treatment strategies. Surgical excision remains the treatment of choice. The choice of approach is determined by what will best allow complete excision of the disease. Endoscopic techniques, if feasible for complete removal of the tumor, offer results comparable to those of external approaches with lower morbidity. Although clear evidence to support the use of radiotherapy in sinonasal adenocarcinoma is difficult to obtain, local control rates of combined treatment strategies for advanced cases are comparable to less advanced cases with surgery alone, suggesting a positive role for postoperative radiotherapy. However, the importance of thorough surgical resection should be stressed.

Survival for ethmoid sinus adenocarcinoma in European populations

BACKGROUND

Adenocarcinoma of the ethmoid sinus is rare. EUROCARE data provide a good opportunity to study the survival of this rare disease in a population of continental size.

PATIENTS AND METHODS

A total of 204 cases, age 15 to 99 years, diagnosed with primary ethmoid sinus adenocarcinoma between 1983 and 1994, were analyzed. The data were contributed by 22 population-based cancer registries from the nine countries participating in EUROCARE. Relative survival by sex, age, period of diagnosis, region and stage, and adjusted relative excess risk (RER) of death, were estimated.

RESULTS

Survival was 83%, 58% and 46%, 1, 3 and 5 years, respectively after diagnosis. Five-year survival was best (60%) in patients of 55-64 years and worst (33%) in the oldest age group (> or =65 years). Five-year survival differ between European population: in Norway (55%, 95% confidence interval 26.4-80.9) and western Europe that includes populations from Eindhoven, Saarland, Geneva, Italy and France (56%, 95%CI 41.3-68.9) was higher than in the UK (41%, 95% CI 30.8-51.8) and eastern Europe which includes Slovakia and Slovenia, (22%, 95% CI 3.5-54.4). Five-year survival did not improve over time. Due to the rarity of the disease, all the survival differences did not reach the statistical significance.

CONCLUSIONS

Since no survival improvement with time was evident from this study, efforts should be made to improve early diagnosis. GPs and ENT specialists should be alerted to the disease and encouraged to take occupational histories in people with persistent nasal symptoms, which may lead to a reasonable suspicion of malignancy. Monitoring of exposed workers may also improve early diagnosis. Patients with suspected ethmoid cancer should be referred immediately a specialized diagnosis and treatment centre.

Rehabilitation: long-term physical and functional changes following treatment

OBJECTIVES

To describe the life altering issues that survivors of a head and neck cancer report post treatment and discuss multidimensional rehabilitation approaches.

DATA SOURCES

Published journal articles, literature reviews, research reports, book chapters.

CONCLUSION

Survivors and their family caregivers encounter many changes during the first 3 months following treatment for head and neck cancer, placing them at risk of multiple adjustment difficulties. Progressive weight loss, loss of energy, strength, muscle endurance and decreased functioning severely compromise healthy adjustment and quality of life.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can help patients and family identify survivorship issues to be managed at home. Planning, exploring, coaching, practicing skills with survivors and their family caregivers, providing specific information, and linking them with resources can help them bridge this transition into extended survivorship.

Treatment results for ethmoid sinus carcinoma

OBJECTIVE

The aim of this study was to describe the results of treatment in patients with ethmoid sinus carcinoma.

MATERIALS AND METHOD

We performed a retrospective study of 34 patients with carcinoma of the ethmoid sinus, and collected the following data: age, sex, employment, tobacco and alcohol consumption, tumour-node-metastasis stage, treatment, and survival.

RESULTS

The mean patient age was 64 years. Seventy-six per cent of patients were men and 24 per cent women. Squamous cell carcinoma was the most frequent histological tumour type (44 per cent). Eleven patients were classified as T(2), six as T(3), six as T(4a) and 11 as T(4b). Two patients (6 per cent) had nodal metastasis at the time of diagnosis. The anterior skull base was involved in 17 patients (50 per cent) and the anterior orbital contents were affected in seven patients (21 per cent). The five-year actuarial observed survival rate for all patients was 44 per cent.

CONCLUSIONS

Combined treatment with surgery and post-operative radiotherapy permitted good local control in patients with ethmoid sinus carcinoma. We do not recommend prophylactic neck treatment for ethmoid sinus carcinoma.

[Epidemiologic analysis of 72 carcinomas of the nasal cavity and paranasal sinuses]

OBJECTIVE

The aim of this study is to define the epidemiological aspects of carcinoma of the nasal cavity and paranasal sinuses.

MATERIAL AND METHODS

We performed a retrospective study of 72 carcinomas of the nasal cavity and paranasal sinuses. Various sites, age and sex distribution, drug consumption, TNM stage grouping and treatment were reported.

RESULTS

The average age was 63. Seventy- five percent of patients (54/72) were male and 25% (18/72) female. The site of origin was paranasal sinuses in 46 patients (64%), 30 in ethmoid sinus, 15 in maxillary sinus and 1 in sphenoid sinus. Twenty-six patients (36%) were located in nasal cavity. Squamous cell carcinoma was the most frequent histological type in both localizations. The 5-year adjusted survival rate for all patients was 60% (IC: 54-66), 36% (IC: 28-44) for paranasal sinus carcinoma and 86% (IC: 79-93) for nasal cavity carcinoma. The 5-year adjusted survival rate according to the T distribution in 46 carcinomas paranasal sinus was 80% T2, 71% T3, 19% T4a and 6% T4b.(p = 0.0002).

CONCLUSIONS

Carcinoma of nasal cavity and paranasal sinuses represent a group of tumors that differ from the rest of carcinomas of the head and neck.

Management of paranasal sinus malignancy

Malignancies of the nasal cavity and paranasal sinuses represent a wide spectrum of histologies, tissues of origin, and anatomic primary sites. The inherent difficulty in generalizing treatment approaches is obvious, given the numerous variables associated with the broadly-based term, paranasal sinus malignancy (PNSCa). Nevertheless, the majority of epithelial and salivary malignancies of this region (ie, squamous cell carcinoma, adenocarcinoma, adenoid cystic carcinoma, sinonasal undifferentiated carcinoma, and esthesioneuroblastoma) require surgical intervention as part of any treatment regimen. Recent trends have broadened the indications for chemotherapeutic and radiotherapeutic options in the management of advanced PNSCa. Nonepithelial malignancies, including the wide variety of sarcomas arising in this region, most commonly require multimodality treatment including chemotherapy, radiation, and/or surgery for definitive treatment. Moreover, the proximity of the nasal cavity and paranasal sinuses to structures including the orbit, dura, brain, cranial nerves, and carotid arteries mandates careful radiologic and neurologic evaluations throughout the course of the disease. Surgical advances now permit complex tumor removal and reconstruction surrounding these structures resulting in functional and cosmetic improvements when compared to earlier techniques. However, additional clinical trials are necessary to systematically evaluate the locoregional control, organ-preservation strategies, and survival related to the variety of treatments currently available.

Determinants of survival in parotid gland carcinoma: a population-based study

PURPOSE

To determine survival and factors influencing survival for parotid gland cancer.

METHODS

Cases of parotid gland malignancy were extracted from the SEER database for 1988 to 1998. Kaplan-Meier survival analysis was conducted for the most common tumor histologies. Cox proportional hazards modeling was conducted to determine the influence of age, gender, histopathology, grade, size, regional modal status, extraglandular extension, and radiation therapy on survival. Subset analysis was conducted for mucoepidermoid carcinoma according to grade.

RESULTS

Nine hundred three patients were identified with a mean age of 59.2 years. Mean follow-up was 51.8 months. Mean 5-year and 10-year actuarial survivals for the entire cohort were 87.8 months, 66.6% and 49.7%, respectively. Mean tumor size at diagnosis was 2.7 cm; 38.0% of patients had extraglandular extension of the tumor, 26.8% of patients had positive nodal disease, and 59.4% of patients received radiation therapy. Tumor histology did predict survival, with squamous cell carcinoma and acinar cell carcinoma exhibiting the poorest and best survivals, respectively. Stratified Cox proportional hazards modeling revealed that increasing age, tumor size, grade, extraglandular extension, and nodal positivity significantly negatively influenced survival (all P<or=.001); radiation therapy conferred a survival benefit (P=.090), whereas gender did not significantly affect survival. Increasing tumor grade, nodal disease, and extraglandular extension carried particularly high hazards ratios.

CONCLUSIONS

Survival in parotid gland malignancy is influenced by multiple factors. Patients with multiple poor prognostic features such as extraglandular extension, aggressive tumor histologies, and nodal disease will exhibit poorer survivals and may be candidates for more aggressive treatment protocols.

Sinonasal malignancies

Sinonasal malignancies are highly heterogeneous lesions that are challenging to diagnose, treat, and follow clinically. Outcomes remain relatively poor and are associated with late diagnosis, difficult surgical anatomy, and a lack of effective adjuvant modalities of treatment. New multimodal treatment protocols addressed to specific tumor entities are being assessed with promising results. Because of the relative rarity of these lesions, however, progress is slow. The best therapeutic outcomes are achieved in the setting of early diagnosis combined with a meticulous, comprehensive, multidisciplinary approach to the management of these complex tumors.