Cancer of the nasal cavity and paranasal sinuses

Radiotherapy Results in Locally Advanced Sinonasal Cancer: Turkish Society for Radiation Oncology, Head and Neck Study Group 01-005

OBJECTIVES

This study aims to examine the treatment outcomes and related factors in locally advanced sinonasal cancer across Turkiye.

METHODS

Twelve centers participants of the Turkish Society for Radiation Oncology Head and Neck Study Group attended the study. One hundred and ninety-four patients treated with intensity-modulated radiation therapy between 2001 and 2021 were analyzed retrospectively. The survival analysis was performed using the Kaplan-Meier method. Acute and late toxicity were recorded per Common Toxicity Criteria for Adverse Events V4.0.

RESULTS

The median age was 58 years and 70% were male. The majority of tumors were located in maxillary sinus (59%). Most of the patients (%83) had T3 and T4A disease. Fifty-three percent of patients were in stage 4A. Radiotherapy was administered to 80% of the patients in the adjuvant settings. Median 66 Gy dose was administered in median 31 fractions. Chemotherapy was administered concomitantly with radiotherapy in 45% of the patients mostly with weekly cisplatin. No grade ≥4 acute and late toxicity was observed. The median follow-up was 43 months. The 5-year and 10-year overall survival (OS); locoregional recurrence-free survival (LRFS); distant metastasis-free survival (DMFS), and progression-free survival (PFS) rates were 61% and 47%; 69% and 61%; 72%, and 69%, and 56% and 49%, respectively. In the multivariate analysis, several factors demonstrated significant influence on OS, such as performance status, surgery, and lymph node involvement. Moreover, surgery was the key prognostic factor for LRFS. For DMFS, lymph node involvement and surgical margin were found to be influential factors. In addition, performance status and lymph node involvement were identified as significantly affecting PFS.

CONCLUSIONS

In our study, the authors obtained promising results with IMRT. Performance status, lymph node involvement, and surgery emerged as the primary factors significantly influencing OS.

Lymphatic drainage of sinonasal malignancies and the role of sentinel node biopsies

BACKGROUND

Locoregional recurrence is a critical factor in the prognosis of sinonasal malignancies. Due to the rarity of these tumours, as well as the heterogeneity of histologies and anatomical subsites, there is little evidence regarding the rate and location of regional metastases in sinonasal malignancies. Elective regional lymph node dissection in the therapy of sinonasal malignancies has become controversial. On the one hand, elective regional lymph node dissection is considered to be an overtreatment in the cN0 cases. On the other hand, undetected occult lymphatic metastases are associated with a poor prognosis. In this study, we discuss the role of sentinel lymph node biopsy as a minimally invasive procedure in the treatment of sinonasal malignancies based on our two years of practical experience and the currently available data.

RESULTS

This is a descriptive, monocentric, retrospective study, including 20 cases of cN0 malignant sinonasal neoplasm, that underwent a surgical therapy between 2020 and 2022. The following aspects were investigated: tumour entity, localisation of the primary tumour, tumoral stage, localisation of the sentinel lymph nodes, and postoperative complications. Squamous cell carcinoma was the most frequently diagnosed tumour entity (50%), followed by adenocarcinoma (20%) and malignant melanoma (15%), adenoid cystic carcinoma and mucoepidermoid carcinoma. Sentinel lymph nodes were most frequently found in the ipsilateral neck region I (45%), followed by the ipsilateral neck region II (40%). In all cases, the removed lymph nodes were free of malignancy. There were no postoperative complications due to lymph node biopsy. There were no recurrences during the study period.

CONCLUSION

Sentinel node biopsy could add more safety to the management of cN0 sinonasal malignancies due to its low morbidity. Whether SNB could provide an alternative to elective neck dissection in the management of SNM should be investigated in further studies.

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.

Reconstruction of maxillectomy and midfacial defects using latissimus dorsi-scapular free flaps in a comprehensive cancer center

BACKGROUND

The standard of care for sinonasal malignancies is a large surgical resection followed by radiotherapy. Midfacial defects resulting from maxillectomy require a complex reconstruction procedure. Given their adaptability, chimeric flaps such as latissimus dorsi-scapular (LDS) free flaps appear to be a good option.

MATERIAL & METHODS

We performed a single-center retrospective study of consecutive patients with sinonasal cancers where a LDS free flap was used for reconstruction. We assessed the postoperative complications and the functional, aesthetic and oncologic outcomes.

RESULTS

Eighty-four patients were included. Primary tumors were staged as T4a in 68% of cases; 38.3% of the patients received induction chemotherapy and 82.7% received adjuvant radiotherapy. Based on our classification of midfacial and palatal defects, the majority of the patients (69%) had a type IIa with interruption of the three facial pillars. The orbital floor was removed in 55.9% of cases. The median follow-up was 45 months. Total flap necrosis with no possible revascularization occurred in 5.9% of cases. For the orbital reconstruction, a revision procedure was needed for necrosis and/or infection of the costal cartilage graft in eight cases (17%). More than 90% of the patients had no functional disorders regarding speaking, swallowing and chewing. Soft palate involvement was a prognostic factor of speech (p < 10^-4) and swallowing (p = .005) disorders. Dental rehabilitation was realized in 70.2% of the patients. No severe complications were observed in the donor site, except for one seroma.

CONCLUSION

A LDS free flap is a reliable technique for the reconstruction of complex midfacial defects.

[Tumors of the paranasal sinus invading the orbit]

Invasion of the orbit by tumors of the paranasal sinus represents an advanced state of disease. Prognosis has hardly improved in recent decades, despite multimodal therapeutic approaches. Complete resection of the tumor still remains the most promising therapy. Orbital exenteration implies a dramatic event for the patient's psyche and quality of life. If the eye that would have to be exenterated is the only one remaining with sufficient vision, exenteration should be abandoned in consensus with the patient. Aesthetic improvements following exenteration can be achieved by surgical and prosthetic techniques. The method of prosthesis fixation needs to be determined with respect to the patients' individual expectations and manual abilities. The main aspects of functional rehabilitation are good local cleanability and sufficient nasal breathing without encrusted mucus, which can be achieved by restoring the natural laminar airflow. Tumors of the paranasal sinus with orbital invasion represent a diagnostic and therapeutic challenge. The information regarding prognosis, therapeutic approaches, post-therapeutic quality of life, and rehabilitation options should be thoroughly discussed by patients and therapists prior to treatment.

Therapy of sinonasal malignancies invading the orbit-orbital exenteration versus preservation of the orbit plus radiotherapy

INTRODUCTION

Orbital invasion is a strong independent prognostic factor for sinonasal malignancies. While there is consent about preservation of the orbit for tumors limited to the orbital periosteum there is controversy about the optimal management of sinonasal malignancies transgressing this barrier. Therefore the aim of our study was to compare exenteration versus preservation of the orbit.

MATERIAL AND METHODS

52 patients with sinonasal malignancies invading the orbit beyond the orbital periosteum with involvement of the orbital soft tissues were included in the retrospective study. Prognostic factors were identified through univariate analysis.

RESULTS

Univariate analysis revealed a significant impact of N-classification (p = 0.017), and treatment strategy (p = 0.016). Exenteration of the orbit was associated with a significantly better 5-year overall survival rate (65.5%) than preservation of the orbit (14%).

CONCLUSIONS

For patients with invasion of the structures beyond the orbital periosteum, exenteration yields better survival results than preservation of the orbital structures in combination with radiotherapy. In cases where both eyes are affected from the tumor or if only one dysfunctional eye would be left over after therapy, we do not recommend orbital exenteration because life quality would be critically deteriorated.

Sinonasal undifferentiated carcinoma: morphological heterogeneity, diagnosis, management and biological markers

Sinonasal undifferentiated carcinoma is a highly aggressive lesion arising in the superior nasal cavity and paranasal sinuses. Differential diagnosis is wide because a range of similar lesions can present at this site. There is increasing evidence that sinonasal undifferentiated carcinoma is a surface (Schneiderian) epithelial-derived malignancy, with or without concurrent neuroendocrine differentiation. Prognosis is poor; recurrence with metastasis to lymph nodes and distant sites is frequent. A combination of radical surgery, chemotherapy and radiotherapy appears to provide the best chance of survival.

Nodal recurrence of sinonasal cancer: does the risk of cervical relapse justify a prophylactic neck treatment?

BACKGROUND

Sinonasal cancers are rare and no high-level evidence exists to determine their optimal management. Prophylactic neck treatment issue remains controversial. The aim of this study was to analyze the pattern of neck failure and to identify any prognostic factors that may influence neck control.

METHODS

A retrospective review of 155 consecutive patients treated for sinonasal malignancy, without prophylactic neck treatment, between 1995 and 2005 at tertiary cancer center was performed. Demographic, clinical, morphological and pathological parameters were correlated with oncologic outcomes.

RESULTS

Eight out of 155 patients (5%) presented initially with neck node metastasis. Complete remission was obtained for 133 patients after treatment completion. During follow up, 16 out of 133 patients (12%) were affected with regional recurrence. Neck failure occurred in 8 out of 51 patients with local failure and in 8 out of 82 patients locally controlled. Isolated nodal failure was observed in 5 patients initially cN0 out of 133 (3.8%) representing 7.3% of all recurrences and 3 of them underwent successful salvage therapy. None of the tested factors were significantly associated with neck control (p>0.05). Lymph node at diagnosis time was significantly and independently associated with poor survival (p=0.0012).

CONCLUSION

Isolated neck relapse, when local control is achieved, is rare and salvage treatment is effective. Routine prophylactic neck treatment has little interest. However, this approach could be profitable to few selected patients, who remain to be defined. Further investigations are needed.

Management of Sinonasal Malignant Neoplasms: Defining the Role of Endoscopy

Background

Preliminary reports support the role of endoscopic techniques in the management of selected sinonasal malignancies. The objectives of this review are (1) to assess outcomes for patients undergoing definitive endoscopic tumor extirpation and (2) to elucidate the role of endoscopy in the management of sinonasal malignancies.

Methods

Retrospective review of patients with sinonasal malignancy managed via endoscopic techniques from September 1998 to December 2007 was conducted.

Results

Sixty-one patients were identified (38 men and 23 women) with a mean age of 59 years. The five most common pathologies were squamous cell carcinoma (21), melanoma (10), esthesioneuroblastoma (8), adenocarcinoma (7), and sinonasal undifferentiated carcinoma (3). Sixty-nine endoscopic procedures were performed and categorized according to surgical intent: 57 curative resections (82.6%), 8 palliative resections (11.6%), and 4 tumor mappings (5.8%). Adjuvant chemotherapy and/or radiation therapy was used in 29 of the 50 patients (58%). For those patients undergoing definitive treatment, the disease-free and overall survival rates were 69.2 and 84.6% at mean of 34.5 and 42.7 months, respectively. The local and regional recurrence rates were 17 and 10%, respectively.

Conclusion

The endoscope is a versatile tool for management of sinonasal malignant neoplasms. Although the role was once just limited to biopsy, endoscopic approaches allow for definitive resection for curative intent and palliative resection for patient comfort with acceptable survival. Moreover, endoscopy facilitates three-dimensional tumor mapping and posttreatment surveillance in patients undergoing definitive chemoradiation.

Malignant neoplasms of the sinonasal tract: report of 71 patients and literature review and analysis

BACKGROUND

The present study aimed to report the characteristics, prognostic factors, and treatment outcomes of 71 cases of malignant neoplasms of the sinonasal tract and literature review and analysis of major report series.

METHODS

Seventy-one consecutive patients diagnosed with primary malignant neoplasm of the sinonasal tract that were treated and followed up at a university hospital between May 2000 and March 2008 were selected for the present study. Thirty-four patients were treated with surgery followed by a combination of chemotherapy and radiotherapy, 15 with surgery alone, 14 with combined radiotherapy and chemotherapy, six with radiotherapy alone, and two with surgery followed by radiotherapy. To find out the major series of related studies over the last 20 years, a literature review of PubMed was performed. In all, we found 42 major series including 8,164 patients with malignant neoplasms of the sinonasal tract.

RESULTS

There were 35 women and 36 men ranging in age from 5 to 80 years, with a median age of 55 years at diagnosis. The primary sites included were paranasal sinuses in 51 and nasal cavity in 20. There were one case of stage I, 20 of stage II, 27 of stage III, and 23 of stage IV. Epithelial tumors constituted 65% of all neoplasms. After a median follow-up of 39 months for surviving patients, 33 patients are alive and without disease, eight are alive with disease, and 30 patients died due to disease. Local recurrence was the most frequent treatment failure. The 5-year disease-free, local control, and overall survival rates were 42.1%, 59.5%, and 54.5%, respectively. On univariate analysis, cervical lymph nodes involvement, primary tumor size, histologic type, response to therapy, and stage of disease were independent prognostic factors for overall survival. In the literature review and by analyzing the data collection from 42 major reported series, the median age was 57 years and male/female ratio was 1.8. Epithelial tumors consisted of 69% of all malignant neoplasms of sinonasal tract and stages III and IV disease constituted 74.7% of all stages. Local recurrence was the dominant treatment failure in nearly all series. Five-year local control and overall survival rates were 56% and 45.5%, respectively.

CONCLUSIONS

In this review and by analyzing the large data collection of recent major reported series, we found that malignant neoplasms of the sinonasal tract tend to present at locally advanced stage, with a high frequency of local failure and a moderate to poor outcome. More effective local treatment for improving the local control and overall survival is needed.