Outcome of Definitive and Postoperative Radiotherapy in Patients with Sinonasal Squamous Cell Carcinomas

The role of histology on the outcome of sinonasal carcinomas treated with radiotherapy: a single institution experience

PURPOSE

Sinonasal malignancies are a rare group of head and neck cancers. We aimed to report the oncological outcomes based on histological types in patients who underwent radiotherapy.

MATERIALS AND METHODS

In this single-institution study, we retrospectively retrieved and analyzed data of patients with sinonasal carcinomas who underwent radiotherapy during 2011-2016 as part of their treatment. The 3-year rate of local, regional, and distant recurrences, and overall survival were evaluated according to the histological type.

RESULTS

A total of 28 patients were evaluated in this study, the majority of whom were male (60%). Squamous cell carcinoma (SCC), adenoid cystic carcinoma (ACC), and adenocarcinoma (ADC) were found in 15 patients (53.5%), 8 (28.5%), and 5 (18%), respectively. The highest rates of local and regional recurrences were observed in ACC and SCC, respectively. Distant recurrences were numerically more common in ADC. The 3-year OS was 48%, 50%, and 73% in SCC, ADC, and ACC, respectively.

CONCLUSION

Different histopathologies of sinonasal cancer seem to have different patterns of failure, and this may be considered in the treatment approach.

Can Definitive Radiation Therapy Substitute Surgical Resection in Locally Advanced T3 or T4 Sinonasal Squamous Cell Carcinoma?

PURPOSE

This study aimed to compare oncologic outcomes between definitive radiation therapy (RT) and upfront surgical resection in patients with sinonasal squamous cell carcinoma (SCC).

METHODS AND MATERIALS

Between 2008 and 2021, 155 patients with T1-4b, N0-3 sinonasal SCC were analyzed. The 3-year overall survival (OS), local progression-free survival (LPFS), and overall progression-free survival (PFS) were evaluated using the Kaplan Meier method and compared using a log-rank test. A pattern of regional neck lymph node (LN) failure and treatment-related toxicity profiles were investigated.

RESULTS

A total of 63 and 92 patients underwent upfront RT (RT group) and surgical resection (Surgery group), respectively. The RT group included significantly more patients with T3-4 disease than the Surgery group (90.5% vs 39.1%, P < .001). The rates of 3-year OS, LPFS, and PFS in the RT and Surgery groups were 68.6% versus 81.7% (P = .073), 62.3% versus 73.8% (P = .187), and 47.4% versus 66.1% (P = .005), respectively. However, the corresponding rates in patients with T3-4 disease were 65.1% versus 64.8% (P = .794), 57.4% versus 56.8% (P = .351), and 43.2% versus 46.5% (P = .638), respectively, demonstrating no statistically significant differences between the 2 treatment modalities. Among the 133 N0 patients, regional neck LN progression was observed in 17 patients, and the most common sites of regional neck LN failure were ipsilateral levels Ib (9 patients) and II (7 patients). The 3-year neck node recurrence-free rate in cT1-3N0 patients was 93.5%, while that in cT4N0 patients was 81.1% (P = .025).

CONCLUSIONS

Upfront RT may be considered in selected patients with locally advanced sinonasal SCC, as we have demonstrated similar oncologic outcomes to those of surgery. Prophylactic neck treatment in T4 disease requires further investigation to evaluate its efficacy.

T4b Sinonasal Squamous Cell Carcinoma: Surgery Plus Radiotherapy May Contribute to Prolonged Survival

PURPOSE

To determine oncologic outcomes for patients with T4b sinonasal squamous cell carcinoma (SNSCC) treated with either surgery plus radiotherapy or definitive radiotherapy.

MATERIALS AND METHODS

Between January 1999 and December 2016, 85 patients with T4b SNSCC were analyzed retrospectively, there were 54 who received surgery plus radiotherapy (S + RT group) ± chemotherapy and 31 with definitive radiotherapy (RT group) ± chemotherapy. A 1: 2 propensity score matching (PSM) was performed to balance clinical factors and match patients. Kaplan-Meier method and Cox proportional hazard model were used to determine risk factors on survival outcomes.

RESULTS

The median follow-up time was 76.7 months. The cumulative rates of locoregional control (LRC), distant metastasis-free survival (DMFS), cancer-specific survival (CSS), and overall survival (OS) at 5 years for entire cohort were 44.6%, 33.1%, 38.8%, and 33.9% respectively. After PSM, a total of 50 patients in S + RT group and 25 patients in RT group were analyzed. The 5-year LRC, DMFS, CSS, and OS between S + RT and RT group were 58.6% versus 27.5% (p = 0.035), 42.8% versus 20.0% (p = 0.006), 50.3% versus 22.0% (p = 0.005), 44.5% veruss 20.0% (p = 0.004). The 5-year survival rates with orbital retention between groups were 32.7% and 15.0%, p = 0.080. Multivariate Cox analysis revealed non-surgical therapy (HR = 3.678, 95%CI 1.951-6.933) and invasion of cranial nerves (other than maxillary division of trigeminal nerves) (HR = 2.596, 95%CI 1.217-5.535) were associated with decreased OS.

CONCLUSION

The inclusion of surgery in the multimodal management of T4b SNSCC might confer a survival benefit. Further prospective studies comparing the oncologic outcomes of S + RT with RT are warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2222-2231, 2023.

An MRI-Based Radiomics Nomogram to Assess Recurrence Risk in Sinonasal Malignant Tumors

BACKGROUND

Sinonasal malignant tumors (SNMTs) have a high recurrence risk, which is responsible for the poor prognosis of patients. Assessing recurrence risk in SNMT patients is a current problem.

PURPOSE

To establish an MRI-based radiomics nomogram for assessing relapse risk in patients with SNMT.

STUDY TYPE

Retrospective.

POPULATION

A total of 143 patients with 68.5% females (development/validation set, 98/45 patients).

FIELD STRENGTH/SEQUENCE

A 1.5-T and 3-T, fat-suppressed fast spin echo (FSE) T2-weighted imaging (FS-T2WI), FSE T1-weighted imaging (T1WI), and FSE contrast-enhanced T1WI (T1WI + C).

ASSESSMENT

Three MRI sequences were used to manually delineate the region of interest. Three radiomics signatures (T1WI and FS-T2WI sequences, T1WI + C sequence, and three sequences combined) were built through dimensional reduction of high-dimensional features. The clinical model was built based on clinical and MRI features. The Ki-67-based and tumor-node-metastasis (TNM) model were established for comparison. The radiomics nomogram was built by combining the clinical model and best radiomics signature. The relapse-free survival analysis was used among 143 patients.

STATISTICAL TESTS

The intraclass/interclass correlation coefficients, univariate/multivariate Cox regression analysis, least absolute shrinkage and selection operator Cox regression algorithm, concordance index (C index), area under the curve (AUC), integrated Brier score (IBS), DeLong test, Kaplan-Meier curve, log-rank test, optimal cutoff values. A P value < 0.05 was considered statistically significant.

RESULTS

The T1 + C-based radiomics signature had best prognostic ability than the other two signatures (T1WI and FS-T2WI sequences, and three sequences combined). The radiomics nomogram had better prognostic ability and less error than the clinical model, Ki-67-based model, and TNM model (C index, 0.732; AUC, 0.765; IBS, 0.185 in the validation set). The cutoff values were 0.2 and 0.7 and then the cumulative risk rates were calculated.

DATA CONCLUSION

A radiomics nomogram for assessing relapse risk in patients with SNMT may provide better prognostic ability than the clinical model, Ki-67-based model, and TNM model.

EVIDENCE LEVEL

3.

TECHNICAL EFFICACY

Stage 5.

Proton beam therapy in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus

BACKGROUND

To evaluate proton beam therapy (PBT) in multimodal treatment for locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus (NPSCC).

METHODS

The cases in this study included T3 and T4 NPSCC without distant metastases that were treated at our center using PBT between July 2003 and December 2020. These cases were classified into 3 groups based on resectability and treatment strategy: surgery followed by postoperative PBT (group A); those indicated to be resectable, but the patient refused surgery and received radical PBT (group B); and those declared unresectable based on the extent of the tumor and treated with radical PBT (group C).

RESULTS

The study included 37 cases, with 10, 9 and 18 in groups A, B and C, respectively. The median follow-up period in surviving patients was 4.4 years (range 1.0-12.3 years). The 4-year overall survival (OS), progression-free survival (PFS), and local control (LC) rates were 58%, 43% and 58% for all patients; 90%, 70% and 80% in group A, 89%, 78% and 89% in group B; and 24%, 11% and 24% in group C. There were significant differences in OS (p = 0.0028) and PFS (p = 0.009) between groups A and C; and in OS (p = 0.0027), PFS (p = 0.0045) and LC (p = 0.0075) between groups B and C.

CONCLUSIONS

PBT gave favorable outcomes in multimodal treatment for resectable locally advanced NPSCC, including surgery followed by postoperative PBT and radical PBT with concurrent chemotherapy. The prognosis for unresectable NPSCC was extremely poor, and reconsideration of treatment strategies, such as more active use of induction chemotherapy, may improve outcomes.

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.

Management of sinonasal cancers: Survey of UK practice and literature overview

INTRODUCTION

Sinonasal malignancy is a rare and heterogenous disease, with limited evidence to guide management. This report summarises the findings of a UK survey and expert workshop discussion which took place to inform design of a proposed UK trial to assess proton beam therapy versus intensity-modulated radiation therapy.

METHOD

A multidisciplinary working group constructed an online survey to assess current approaches within the UK to surgical and non-surgical practice. Head and neck clinical oncologists, ear nose and throat (ENT) and oral-maxillofacial (OMF) surgeons were invited to participate in the 42-question survey in September 2020. The Royal College of Radiologists Consensus model was adopted in establishing categories to indicate strength of response. An expert panel conducted a virtual workshop in November 2020 to discuss areas of disagreement.

RESULTS

A survey was sent to 140 UK-based clinicians with 63 responses (45% response rate) from 30 centres, representing a broad geographical spread. Participants comprised 35 clinical oncologists (56%) and 29 surgeons (44%; 20 ENT and 9 OMF surgeons). There were variations in preferred sequence and combination of treatment modalities for locally advanced maxillary squamous cell carcinoma and sinonasal undifferentiated carcinoma. There was discordant surgical management of the orbit, dura, and neck. There was lack of consensus for radiotherapy in post-operative dose fractionation, target volume delineation, use of multiple dose levels and treatment planning approach to organs-at-risk.

CONCLUSION

There was wide variation across UK centres in the management of sinonasal carcinomas. There is need to standardise UK practice and develop an evidence base for treatment.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

A Multicentre UK Study of Outcomes for Locally Advanced Sinonasal Squamous Cell Carcinoma Treated with Adjuvant or Definitive Intensity-modulated Radiotherapy

AIMS

Sinonasal malignancies are rare; the most common histological subtype is squamous cell carcinoma (SCC). No randomised trial data exist to guide treatment decisions, with options including surgery, radiotherapy and chemotherapy. The role and sequence of a primary non-surgical approach in this disease remains uncertain. The aim of this study was to present treatment outcomes for a multicentre population of patients with locally advanced, stage IVa/b sinonasal SCC treated with radical-intent intensity-modulated radiotherapy, either definitively or postoperatively.

MATERIALS AND METHODS

Consecutively treated patients with locally advanced, stage IVa/b sinonasal SCC at four UK oncology centres between January 2012 and December 2017 were retrospectively identified. Descriptive statistics and survival analyses were carried out. Univariable Cox regression analysis was carried out to evaluate the relationship between patient, disease and treatment factors and survival outcomes.

RESULTS

In total, 56 patients with sinonasal SCC were included (70% maxillary sinus, 21% nasal cavity, 9% ethmoid/frontal sinus). Forty-one patients (73%) were treated by surgery/adjuvant (chemo)radiotherapy and 15 (27%) by definitive (chemo)radiotherapy. The median duration of follow-up was 3.8 years (interquartile range 2.0-4.7 years). Estimates for 5-year overall survival and progression-free survival were 30.2% and 24.2%, respectively. Local, regional and distant treatment failures were seen in 33%, 33% and 16% of patients, respectively. Univariable analysis revealed inferior progression-free survival for patients treated with neck dissection (hazard ratio 2.6, 95% confidence interval 1.2-6.1, P = 0.022) but no other significant association between the studied factors and survival outcomes.

CONCLUSION

We show poor survival outcomes and high rates of locoregional treatment failure for patients with locally advanced stage IVa/b sinonasal SCC. There is a need to investigate improved treatments for this group of patients.

Sinonasal Squamous Cell Carcinoma, a Narrative Reappraisal of the Current Evidence

Simple Summary

Sinonasal squamous cell carcinomas are a group of diverse tumors affecting the nasal cavity and paranasal sinuses. As a direct consequence of their rarity and heterogeneity, diagnosis is challenging, and treatment does not follow universally accepted protocols. Though surgery represents the mainstay of treatment, neoadjuvant and adjuvant therapies have pivotal roles in improving outcomes of patients treated with curative intent. Indications to endoscopic surgery have been expanding over the last three decades, but a considerable number of patients affected by sinonasal squamous cell carcinoma still need open surgical procedures. Management of the neck in patients affected by sinonasal squamous cell carcinoma is controversial. Curative-intended treatment of recurrent and/or metastatic tumors, alongside palliation of uncurable cases, represent poorly explored aspects of this disease.

Abstract

Sinonasal squamous cell carcinoma is a rare tumor affecting the nasal cavity and paranasal sinuses. Several aspects of this disease, ranging from epidemiology to biology, pathology, diagnosis, staging, treatment, and post-treatment surveillance are controversial, and consensus on how to manage this sinonasal cancer is lacking. A narrative literature review was performed to summarize the current evidence and provide the reader with available data supporting the decision-making process in patients affected by sinonasal squamous cell carcinoma, alongside the authors’ personal opinion on the unsolved issues of this tumor. The review has highlighted several advances in molecular definition of epithelial cancers of the sinonasal tract. Surgery represents the pivot of treatment and is performed through an endoscopic transnasal approach whenever feasible. Open surgery is required for a large proportion of cases. Reconstruction of the defect follows principles of skull base and cranio-maxillo-facial reconstruction. Chemotherapy is given as neoadjuvant treatment or concomitantly to radiotherapy. Photon-based radiation therapy has a crucial role in the adjuvant setting. Particle therapy is providing promising results. Management of the neck should be planned based on the presence of clinically appreciable metastases, primary tumor extension, and need for recipient vessels. Biotherapy and immunotherapy are still underexplored therapeutical modalities.

The value of preoperative radiotherapy in the treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinoma: A single institutional experience

OBJECTIVES

This study aimed to explore the value of preoperative radiotherapy in the comprehensive treatment of locally advanced nasal cavity and paranasal sinus squamous cell carcinomas (LA-NPSCCs).

MATERIALS

This retrospective study included 140 patients with stage III-IVB NPSCCs treated with pre-/postoperative radiotherapy plus surgery. The complete resection rate, pathologic complete response (pCR) rate, and orbital content retention rate were calculated. The overall survival (OS), local control (LC), distance metastasis free survival (DMFS) and disease-free survival (DFS) between treatment groups were evaluated.

RESULTS

With a median follow-up of 92.3 months, the 5-year OS, LC, DMFS, and DFS of entire cohort were 62.0%, 65.5%, 85.4%, and 57.8%, respectively. The preoperative radiotherapy group achieved similar LC, DFS, DMFS, and OS rates compared to postoperative radiotherapy group, despite higher rates of stage IV and orbital content/apex invasion. The preoperative radiotherapy resulted in significantly improved complete resection rate (93.3% vs 38.0%, p < 0.001). In the preoperative radiotherapy group, one third of patients achieved pathologic complete response. The pCR subgroup achieved statistically higher 5-year OS, LC, DFS (p < 0.05), but similar 5-year DMFS (p > 0.05) compared to non-pCR subgroup. The actual orbital content retention rate in preoperative radiotherapy group was 85.7%, superior to 58.3% in postoperative radiotherapy group (p = 0.049).

CONCLUSION

On the basis of multimodality therapy becoming standard paradigm for LA-NPSCCs, preoperative radiotherapy significantly improved complete resection rate and orbital content retention rate. Therefore, preoperative radiotherapy followed by surgery might be desirable for LA-NPSCCs, especially for those with organ preservation intention.

Definitive Radiation Therapy Versus Postoperative Radiation Therapy for Patients With Maxillary Sinus Cancer Invading the Upper Jaw

Maxillectomy following radiation therapy has the strongest local control over maxillary sinus cancer. However, in the advanced stage, complete resection is difficult with adequate margin and has the risk of functional disabilities after surgeries. The objective of the study was to determine the optimal treatment strategy for patients with maxillary sinus cancer invades the upper jaw. A total of 998 histologically confirmed maxillary sinus cancer invades the upper jaw patients were subjected to simple randomization. Patients were subjected to maxillectomy and received 150 mg/m/wk intra-arterial cisplatin for 4 weeks followed by radiotherapy (PR group, n = 499) or received the same chemotherapy and definitive radiotherapy only (DR group, n = 499). Disease status, overall survival, progression-free survival, and treatment-emergent adverse effects were evaluated in the follow-up period of 5 years. At the end of 5 years of follow-up, both the treatments had the same overall survival (P = 0.066). Demographic characters were independent parameters for the overall survival (P ≥ 0.05 for all). Postoperative radiotherapy had a higher progression-free survival than definitive radiotherapy (P = 0.018). Maxillectomy was useful in the reduction of the evidence of local recurrence of cancer (P = 0.027). Dysphagia, palate fistula, incomprehensible voice, and trismus were reported as treatment-emergent effects in the PR group. Definitive radiation therapy is recommended in maxillary sinus cancer that invades the upper jaw (Level of Evidence: I; research registry 4571 dated November 14, 2012).

Intensity-modulated radiotherapy for paranasal sinuses and base of skull tumors

Paranasal sinus and skull base tumors are rare aggressive head and neck cancers, and typically present in the locally advanced stages. As a result, achieving wide surgical resection with clear margins is a challenge for these tumors, and radiotherapy is thus usually indicated as an adjuvant modality following surgery to optimize local control. Given the integral role of radiotherapy in the management of this subgroup of head and neck tumors, the advent of intensity-modulated radiotherapy (IMRT) has led to substantial improvement of clinical outcomes for these patients. This is primarily driven by the improvement in radiation dosimetry with IMRT compared to conventional two dimensional (2D)- and 3D-techniques, in terms of ensuring dose intensity to the tumor target coupled with minimizing dose exposure to critical organs. Consequently, the evident clinical benefits of IMRT have been in reduction of normal tissue toxicities, ranging from critical neurological symptoms to less debilitating but bothersome symptoms of eye infections and radiation-induced skin changes. Another domain where IMRT has potential clinical utility is in the management of a subset of non-resectable T4 paranasal sinus and skull base tumors. For these inoperable lesions, the steep dose-gradient between tumor and normal tissue is even more advantageous, given the crucial need to maintain dose intensity to the tumor. Innovative strategies in this space also include the use of induction chemotherapy for patient selection. In this review, we summarized the data for the aforementioned topics, including specific discussions on the different histologic subtypes of paranasal sinus and skull base tumors.