Dose-Finding and Efficacy Confirmation Trial of the Superselective Intra-arterial Infusion of Cisplatin and Concomitant Radiation Therapy for Locally Advanced Maxillary Sinus Cancer (JCOG1212): Results of the Efficacy Confirmation Phase in Patients with T4aN0M0

PURPOSE

Locally advanced maxillary sinus cancers require radical surgery as a standard treatment, but this often results in significant disfigurement and impairment of function. JCOG1212 seeks to evaluate the safety and efficacy of the superselective intra-arterial infusion of cisplatin and concomitant radiation therapy (RADPLAT) for T4aN0M0 and T4bN0M0 maxillary sinus squamous cell carcinomas. We herein report the results of the efficacy confirmation phase in the T4a cohort.

METHODS AND MATERIALS

Patients received 100 mg/m2 cisplatin intra-arterially weekly for 7 weeks with concomitant radiation therapy (total 70 Gy) as determined by the results of the preceding dose-finding phase. The trial aimed to evaluate the primary endpoint of 3-year overall survival (OS), comparing RADPLAT with the historical control for 3-year OS in surgery (80%).

RESULTS

From April 2014 to August 2018, 65 patients were registered in the T4a cohort from 18 institutions, consisting of 54 men and 11 women with a median age of 64 years (range, 40-78 years) and Eastern Cooperative Oncology Group performance status 0/1 (58/7). After excluding 1 ineligible patient, 64 patients were included in the primary analysis of efficacy and safety. The median follow-up was 4.5 years in all eligible patients, and the primary endpoint for 3-year OS was 82.8% (90% CI, 73.4%-89.2%). With regard to acute adverse events, mucositis (grade ≥3), neutropenia (grade ≥3), increased creatinine (grade ≥2), hearing impairment (grade ≥2), and stroke (grade ≥2) were observed in 20.3%, 14.1%, 3.1%, 3.1%, and 1.6% of patients, respectively. One treatment-related death due to a thromboembolic event was reported.

CONCLUSIONS

We demonstrated that RADPLAT showed favorable results for patients with T4aN0M0 maxillary sinus squamous cell carcinomas compared with the historical control for 3-year OS in surgery, which was from an earlier period, and showed some specific toxicities. Therefore, RADPLAT, as well as surgery, can be regarded as a possible treatment option for these patients.

Invasion of the pterygoid plates: an indicator for regional lymph node failure in maxillary sinus cancer

BACKGROUND

The aim of this study was to evaluate the long-term treatment results of combined superselective intraarterial chemotherapy and radiation therapy for advanced maxillary sinus cancer (MSC) and the incidence of regional lymph node failure, and to reveal the clinical and anatomical predictive factors for metastasis.

METHODS

We retrospectively evaluated 55 consecutive patients with locally advanced squamous cell carcinoma of the maxillary sinus who were treated with external radiotherapy and superselective intraarterial chemotherapy. Elective nodal irradiation (ENI) was performed only in the clinical node-positive (cN+) cases and not in the clinical node-negative (cN0) cases.

RESULTS

Thirty-eight patients were cN0, and 17 were cN+ at diagnosis. Regional lymph node metastases occurred in 7 of 38 patients with cN0, and 2 of 17 with cN+ during the median follow-up period of 36 months. There were more cases of high-grade (3 or 4) late adverse events in the ENI group than in the non-ENI group (13% vs. 41%, respectively; p = 0.03). In cN0 cases without ENI, invasion of the pterygoid plates (57% vs. 90%; p < 0.01) and oral cavity (35% vs. 92%, with invasion vs without invasion, respectively; p = 0.02) was significantly correlated with a low 5-year regional recurrence-free rate.

CONCLUSIONS

Patients with MCS and invasion of the pterygoid plates and oral cavity can be considered appropriate candidates for ENI.

Clinical study of cetuximab combined with radical radiotherapy in the treatment of locally advanced sinonasal squamous cell carcinoma

PURPOSE

To observe the efficacy and side effects of cetuximab combined with radical radiotherapy in the treatment of sinonasal squamous cell carcinoma (SCC), and to investigate the underlying mechanism of cetuximab.

METHODS

62 patients with locally advanced sinonasal SCC diagnosed in our hospital from January 2013 to January 2014 were enrolled. Cetuximab and radical radiotherapy were simultaneously given to patients in the combination group, while only radical radiotherapy was given to patients in the radiotherapy group. Cetuximab was administered weekly until the end of radiotherapy. Patients intolerant to cetuximab or withdrawn the informed consent were excluded. On first administration, cetuximab was given i.v. at a dose of 400 mg/m² for more than 120 min, with maximum drop rate of 5 mL/min. Afterwards, cetuximab was given i.v. per week at a dose of 250 mg/m² for more than 60 min.

RESULTS

(1) The objective response rate (ORR) and disease control rate (DCR) in the combination group was 77.42% and 93.54%, respectively, while the ORR and DCR in the radiotherapy group were only 45.61% and 70.97%, respectively (p<0.05). (2) The progression free survival (PFS) and the median overall survival (OS) in the combination group were 19.5 and 26.6 months, respectively, while in the radiotherapy group were only 13.8 and 18.9 months, respectively (p<0.05). (3) The incidence of rash in the combination group was significantly higher than that of the radiotherapy group (p<0.05). However, there were no significant differences in other adverse reactions between the two groups.

CONCLUSIONS

Combination of cetuximab with radical radiotherapy is safe and effective for advanced local sinonasal SCC and improves the survival rate and the prognosis of patients with sinonasal SCC.

Late Effect of External Eye Irradiation on Choroidal Circulation

PURPOSE

To report two cases of atypical late onset radiation chorioretinopathy occurring 15 and 25 years post exposure and the indocyanine green (ICG) angiographic findings in these patients.

METHODS

Clinical examination and imaging including fluorescein and ICG angiography were performed.

RESULT

Fundus examination of the first patient revealed microangiopathy with intraretinal hemorrhages, lipid exudation, telangiectatic and aneurysmal capillary changes. Indocyanine green angiography showed an apparent chorioretinal anastomosis and delayed perfusion of the choriocapillaris. Fundus examination of the second patient revealed a pigment epithelial detachment and retinal pigment epithelial changes. Indocyanine green angiography showed atypical, tortuous, dilated, choroidal vessels as well as areas of hypoperfusion. Both patients had multiple dot-like hyperfluorescent spots in the midphase of the ICG angiogram.

CONCLUSIONS

External radiation exposure may lead to both retinal and choroidal alterations which may be independent events and which may manifest after a long period of quiescence. Furthermore, ICG angiography appears to be a useful diagnostic tool to study the alterations of the choroid following external eye irradiation.

[Nasal cavity and paranasal sinus cancer]

The nasal cavity and parasinusal cancer are rare (10% of tumors of the head and neck) and are mainly represented by squamous cell carcinoma of the nasal cavity or the maxillary sinus and adenocarcinoma of the ethmoid sinus (occupational disease, wood dust). The most common clinical sign is nasal obstruction, but tumors can also manifest as rhinorrhea and/or epistaxis (usually unilateral signs). A magnetic resonance imaging of the facial structure is systematic for staging before treatment. The treatment consists of a first surgery if the patient is operable with a resectable tumor. If it is not the case, the treatment consists of radiotherapy (RT) associated with chemotherapy (CT) according to the initial data (T3/T4 or N+). After first surgery, RT is indicated (except T1N0 with complete resection) associated with a CT based on postoperative data (capsular effraction or incomplete resection). Lymph node irradiation is considered case by case, but is indicated in any nodal involvement. RT must be an intensity modulated RT (IMRT), static or dynamic, and must be imagery guided (IGRT). According to ICRU 83, doses to organs at risk and target volumes must be carried. Finally, after a post-treatment baseline imaging between 2 and 4 months, monitoring will be alternated with the ENT surgeon every 2 or 3 months for 2 years, then every 4 to 6 months for 5 years.

Case report. Metastatic renal cell carcinoma to the left maxillary sinus

Metastatic tumors in the paranasal sinuses are very rare. The origin of metastatic tumors in the paranasal sinuses is often renal cancer. Renal cell carcinomas are known for their tendency for early metastasis, and symptoms due to the metastatic lesion may be the only initial manifestation. In this paper, we deal with the case of a 35-year-old male patient who presented with a mass in the left maxillary region. The presence of a primary renal cell carcinoma was recognized only after surgical removal of the metastatic tumor. The presentation, diagnosis and treatment of this tumor are discussed with a review of the literature.

A combination of modified transnasal endoscopic maxillectomy via transnasal prelacrimal recess approach with or without radiotherapy for selected sinonasal malignancies

An external approach for resection of sinonasal tumors is associated with increased morbidity. Therefore, we employed a modified transnasal endoscopic maxillectomy combined with pre and/or postoperative radiotherapy for early stage maxillary carcinomas. It aims to evaluate our early experience with endoscopic resection of selected malignant sinonasal tumors. The medical and radiology records of patients who underwent endonasal endoscopic resection of malignant sinonasal tumors between 2008 and 2012 were retrospectively reviewed. Ten cases of selected malignant tumor were performed to resect by modified transnasal endoscopic maxillectomy. All the patients were without evidence of disease at a mean follow-up of 26.8 months. No major complications were recorded. The mean hospitalization stay was 6.6 days. In very carefully selected cases of malignant tumors, modified transnasal endoscopic maxillectomy is acceptable. The postoperative complication rate is low, cosmetic outcome is excellent and patients do not require a long hospitalization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Prominent response with helical tomotherapy in recurrent ameloblastic carcinoma of maxillary sinus: a case report

INTRODUCTION

Ameloblastoma is a benign but locally aggressive tumor of odontogenic epithelial tissue. Reports of radiotherapy treatment modalities are limited in the literature.

CASE PRESENTATION

A thirty-five year old male presented with complaints of headache radiating to his face for about six months and impaired vision. The patient's Positron Emission Tomography (PET) showed a mass in the left maxillary sinus extending to the nasal cavity and invading the adjacent tissues. An R2 (macroscopic residual tumor) surgical resection performed to debulk the tumor. Due to the recurrence and residual mass, the patient was treated with helical tomotherapy. At 2 months post-radiotherapy, patient's vision returned to normal. PET scan showed a significant reduction in lesion size 12 months post-radiation.

CONCLUSION

In cases of ameloblastic carcinoma with, post-surgical recurrence or patients not suitable for surgical treatment, helical tomotherapy can be an effective treatment option.

Late temporal lobe necrosis after conventional radiotherapy for carcinoma of maxillary sinus

Cerebral radiation necrosis is a serious late complication after conventional radiotherapy that can present with focal neurologic deficits or with more generalized signs and symptoms of increased intracranial pressure, depending on the location. The incidence and severity of radionecrosis are dose-volume dependent. We report a case of cerebral radiation necrosis 5 years after radiotherapy for a maxillary sinus carcinoma.

[Adenoid cystic carcinoma of maxillary sinus: diagnosis, treatment and prognostic factors]

OBJECTIVE

To study the clinical characters, the outcomes of treatments and the factors affecting long-term treatment results of adenoid cystic carcinoma (ACC) of the maxillary sinus.

METHODS

The clinical data of 80 patients with ACC of the maxillary sinus treated initially were analyzed retrospectively. Survival rate, local recurrence and distant metastasis were analyzed using Kaplan-Meier method. Prognosis factors were analyzed by Log-rank test and Cox regression.

RESULTS

The 5-, 10- and 15-year cumulative overall survival rates were 65.2%, 37.1%, 26.3% respectively and 5-, 10-, and 15-year disease-free survival rates 50.7%, 30.7% and 24.5% respectively. The 5-, 10- and 15-year cumulative local control rates were 68.5%, 47.3% and 47.3% respectively and the cumulative distant metastasis rate were 32.8%, 48.8% and 48.8% respectively. Prognostic factors affecting survival included T stage, pathologic grade and the modes of treatment (P < 0.05). Patients with combined therapy composed of surgery and radiation had a better local control, compared with surgery or radiation alone (χ(2) = 18.33, P < 0.01), and surgery combined with postoperative radiation was prior to preoperative radiation combined with surgery (χ(2) = 6.64, P < 0.05). Patients treated with surgery combined with preoperative radiation, either with doses of ≥ 60 Gy or with negative margins, had a better local control, compared with doses < 60 Gy and with positive margins (χ(2) = 5.06, P < 0.05). The most of patients (62.8%) died of local recurrence.

CONCLUSIONS

The most of failure was due to recurrence. Combined therapy composed of surgery and radiation improves the local control and survival in patients with ACC of the maxillary sinus, compared with surgery or radiation alone. Surgery combined with postoperative radiation provides the best overall survival and local control and should be the first choice of treatments.

Mucosal malignant melanoma of the maxillary sinus

Mucosal malignant melanoma (MMM) is an aggressive tumour occurring in the upper respiratory tract. It is rare compared to malignant melanoma of the skin. We report a case of a 53-year-old man with left paranasal swelling. A biopsy showed high-grade spindle cell tumour. Subsequently a subtotal maxillectomy was performed. Histopathological examination revealed a hypercellular tumour composed of mixed spindle and epitheloid cells with very occasional intracytoplasmic melanin pigment. The malignant cells were immunopositive for vimentin, S-100 protein and HMB-45. It was diagnosed as mucosal malignant melanoma (MMM). This article illustrates a rare case of MMM where the diagnosis may be missed or delayed without proper histopathological examination that include meticulous search for melanin pigment and appropriate immunohistochemical stains to confirm the diagnosis. Malignant melanoma can mimic many other types of high-grade malignancy and should be considered as a differential diagnosis in many of these instances.

A case of invasive meningioma involving the maxillary sinus

Meningiomas account for nearly 15% of primary brain tumors, but extracranial meningiomas are very rare. We presented a case of invasive maxillary sinus meningioma. A 50-year-old man presented with facial tenderness and severe pain in the left cheek. He had a prior surgery for a meningioma in the left frontal lobe eight months before. Physical examination and computed tomography showed a mass in the left maxillary sinus. Histopathological result of the biopsy obtained via the Caldwell-Luc approach was invasive meningioma. The mass was removed with the sinus mucosa. The histology of the resected specimen was compatible with invasive angioblastic meningioma. Postoperative radiotherapy was administered because of residual intracranial tumor. No recurrence was detected over an 11-month follow-up period.

Primary malignant myoepithelioma of the left maxillary sinus: a case report

We describe the case of a 41-year-old woman who presented with a malignant myoepithelioma (MME) in her left maxillary sinus. Exploratory biopsy of the left maxillary sinus was performed and pathological examination demonstrated that the tumour was positive for calponin and cytokeratin 14, which are indicative of MME. Lateral rhinotomy and left total maxillectomy were undertaken and the patient received radiotherapy and chemotherapy post-surgery. Primary recurrence and metastasis to the left angle of the mandible occurred 9 months after the surgery. The patient died of cachexia 13 months after the surgery.

[Maxillary sinus cancer review in 23 patients treated with postoperative radiotherapy]

OBJECTIVE

To describe the survival and outcome of maxillary sinus cancer in patients managed with surgery and post-operative radiotherapy during the last 10 years in our hospital.

PATIENTS AND METHOD

Descriptive, retrospective, non-randomized study of 23 patients with cancer of the maxillary sinus managed at the Vigo University Hospital Complex, Spain, with radical surgery and post-operative radiotherapy, between 1995 and 2004.

RESULTS

The 3-year actuarial survival was 47.8% and the adjusted actuarial survival was 60.8%. Permanent local tumour control was achieved in 60.8% of cases (14/23). Local tumour recurrence was the main cause of treatment failure (33.3%; 4/12). The most significant prognostic factors affecting local tumour control and survival were: clinical stage (P< .031), suprastructural location of the tumour (P< .001), and presence of positive resection margins (P< .001).

CONCLUSIONS

Local recurrence was found to be very high and generally the main cause of death. New treatment protocols should be assessed.

Postoperative radiotherapy for maxillary sinus cancer: long-term outcomes and toxicities of treatment

PURPOSE

To determine the effects of three changes in radiotherapy technique on the outcomes for patients irradiated postoperatively for maxillary sinus cancer.

METHODS AND MATERIALS

The data of 146 patients treated between 1969 and 2002 were reviewed. The patients were separated into two groups according to the date of treatment. Group 1 included 90 patients treated before 1991 and Group 2 included 56 patients treated after 1991, when the three changes were implemented. The outcomes were compared between the two groups.

RESULTS

No differences were found in the 5-year overall survival, recurrence-free survival, local control, nodal control, or distant metastasis rates between the two groups (51% vs. 62%, 51% vs. 57%, 76% vs. 70%, 82% vs. 83%, and 28% vs. 17% for Groups 1 and 2, respectively). The three changes were to increase the portals to cover the base of the skull in patients with perineural invasion, reducing their risk of local recurrence; the addition of elective neck irradiation in patients with squamous or undifferentiated histologic features, improving the nodal control, distant metastasis, and recurrence-free survival rates (64% vs. 93%, 20% vs. 3%, and 45% vs. 67%, respectively; p < 0.05 for all comparisons); and improving the dose distributions within the target volume, reducing the late Grade 3-4 complication rates (34% in Group 1 vs. 8% in Group 2, p = 0.014). Multivariate analysis revealed advancing age, the need for enucleation, and positive margins as independent predictors of worse overall survival. The need for enucleation also predicted for worse local control.

CONCLUSION

The three changes in radiotherapy technique improved the outcomes for select patients as predicted. Despite these changes, little demonstrable overall improvement occurred in local control or survival for these patients and additional work must be done.

Combined therapy after superselective arterial cisplatin infusion to treat maxillary squamous cell carcinoma

OBJECTIVE

We sought to assess the efficacy of combined therapy after superselective arterial cisplatin infusion (SACI) therapy to treat the maxillary squamous cell carcinoma.

STUDY DESIGN

We conducted a retrospective chart review of 50 patients. After completion of two courses of SACI, 25 of the patients were successively treated by concurrent SACI and radiotherapy (AR), while the other 25 patients were treated by surgery with postoperative radiotherapy (ASR).

RESULTS

Patients with surgery (ASR) had an 88% local control rate with 75% disease-free survival rate at 60 months by Kaplan-Meier analysis, compared with 62% disease-free survival rate for patients with AR treatment. A particularly good outcome was obtained in T4 cases of the ASR group (n=8) whose 5-year survival rate was 87% and local control rate was 100%.

CONCLUSION/SIGNIFICANCE

Combined SACI therapy is very effective for the treatment of maxillary squamous cell carcinomas and contributes to the improving prognoses of patients and organ preservation rates.

[Is orbital exenteration indicated for extensive primary mucosal melanomas of the sinunasal system?]

Primary mucosal melanomas are most frequently localized in the sinunasal system. Orbital involvement must be excluded in the mostly advanced tumor stage. The aim of our study was to find possible indications for orbital exenteration in the T3-4 sinunasal tumor stage. We evaluated 14 treatment courses at our department from 1988 to 2004. The analysis disclosed orbital involvement in 43 % of the patients. The one patient submitted to orbital exenteration had a survival of only 28 months, which was not relevantly longer than in the other 9 patients with a T3-4 tumor stage (median survival of 27 months) or to the two patients with purely palliative treatment (survival of 10 and 21 months). We conclude that, due to the high generalized metastasis rate, radical surgical procedures can only prolong survival in individual cases of advanced-stage sinunasal tumors. Orbital decompression should be considered with reference to the quality of life.

[Metastasis in maxilar sinus as only manifestation of disseminate renal adenocarcinoma]

Paranasal sinuses and nose metastasis are very uncommon. About 50 have been reported. Renal cell carcinoma is the primary neoplasm which most frequently metastasizes in the nasosinusal region, followed by breast and lug. Symptoms are unspecific, but the epistaxis constitutes the most common sign due to the significant vascularizations of the tumor. Prognosis is poor. The survival rate fluctuates between 15-30% at 5 years. Surgery is the elective treatment.

[Malignant mucous primary sinonasal melanoma. A clinic case]

The melanomas are unusual tumours with a high mortality. The mucosal malignant melanoma type supposes loss than 1% of the total of melanoma. The initial symptoms are unspecific and the regional metastasis are rare. The surgical approach it's the most effective treatment complemented with radiotherapy and or chimiotherapy. We present the case of primary nasal mucosal malignant melanoma and review the litterature of this disease.

Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative setting--the MSKCC experience

PURPOSE

To perform a retrospective analysis of patients with paranasal sinus (PNS) cancer treated with postoperative radiotherapy (RT) at Memorial Sloan-Kettering Cancer Center.

METHODS AND MATERIALS

Between January 1987 and July 2005, 85 patients with PNS and nasal cavity cancer underwent postoperative RT. Most patients had squamous cell carcinoma (49%; n = 42), T4 tumors (52%; n = 36), and the maxillary sinus (53%; n = 45) as the primary disease site. The median radiation dose was 63 Gy. Of the 85 patients, 76 underwent CT simulation and 53 were treated with either three-dimensional conformal RT (27%; n = 23) or intensity-modulated RT (35%; n = 30). Acute and late toxicities were scored according to the Radiation Therapy Oncology Group radiation morbidity scoring criteria.

RESULTS

With a median follow-up for surviving patients of 60 months, the 5-year estimates of local progression-free, regional progression-free, distant metastasis-free, disease-free, and overall survival rates were 62%, 87%, 82%, 55%, and 67%, respectively. On multivariate analysis, squamous cell histology and cribriform plate involvement predicted for an increased likelihood of local recurrence, and squamous cell histologic features predicted for worse overall survival. None of the patients who underwent CT simulation and were treated with modern techniques developed a Grade 3-4 late complication of the eye.

CONCLUSION

Complete surgical resection followed by adjuvant RT is an effective and safe approach in the treatment of PNS cancer. Emerging tools, such as three-dimensional conformal treatment and, in particular, intensity-modulated RT for PNS tumors, may minimize the occurrence of late complications associated with conventional RT techniques. Local recurrence remains a significant problem.

Adenoid cystic carcinoma and mucoepidermoid carcinoma of the maxillary sinus: report of a 44-year experience of 25 cases from a single institution

PURPOSE

The aim of this study was to analyze the clinicopathologic characteristics of all cases of adenoid cystic carcinoma (ACC) and mucoepidermoid carcinoma (MEC) arising in the maxillary sinuses treated in a single institution.

PATIENTS AND METHODS

From 1953 to 1997, 18 ACCs and 7 MECs from the maxillary sinus were studied. Clinical data were obtained from the medical records and microscopic slides were reviewed.

RESULTS

Mean age was 45.9 years (range, 13 to 77 years) and TNM staging revealed 88.9% of ACCs at advanced clinical stages, while 57.1% of the MECs were initial clinical stages. Surgery combined with radiotherapy was the most common treatment. Follow-up showed 88.8% of ACC patients died from the tumor, while 42.8% of patients with MEC are alive without disease.

CONCLUSION

Maxillary sinus ACC and MEC are uncommon tumors and a patient's prognosis depends on the clinical stage and histologic type; MEC has shown a better outcome.

Intensity-modulated radiotherapy (IMRT) for carcinoma of the maxillary sinus: A comparison of IMRT planning systems

The treatment of maxillary sinus carcinoma with forward planning can be technically difficult when the neck also requires radiotherapy. This difficulty arises because of the need to spare the contralateral face while treating the bilateral neck. There is considerable potential for error in clinical setup and treatment delivery. We evaluated intensity-modulated radiotherapy (IMRT) as an improvement on forward planning, and compared several inverse planning IMRT platforms. A composite dose-volume histogram (DVH) was generated from a complex forward planned case. We compared the results with those generated by sliding window fixed field dynamic multileaf collimator (MLC) IMRT, using sets of coplanar beams. All setups included an anterior posterior (AP) beam, and 3-, 5-, 7-, and 9-field configurations were evaluated. The dose prescription and objective function priorities were invariant. We also evaluated 2 commercial tomotherapy IMRT delivery platforms. DVH results from all of the IMRT approaches compared favorably with the forward plan. Results for the various inverse planning approaches varied considerably across platforms, despite an attempt to prescribe the therapy similarly. The improvement seen with the addition of beams in the fixed beam sliding window case was modest. IMRT is an effective means of delivering radiotherapy reliably in the complex setting of maxillary sinus carcinoma with neck irradiation. Differences in objective function definition and optimization algorithms can lead to unexpected differences in the final dose distribution, and our evaluation suggests that these factors are more significant than the beam arrangement or number of beams.

Squamous cell carcinoma of the maxillary sinus: a Tata Memorial Hospital experience

BACKGROUND

The optimal treatment of maxillary sinus carcinoma remains to be defined and there is a paucity of Indian studies on the subject.

AIMS

To present experience of management of squamous cell carcinoma of the maxillary sinus treated with curative intent at a single institution.

SETTINGS AND DESIGN

Retrospective study of patients with squamous cell carcinoma of the maxillary sinus who presented between 1994 to 1999.

MATERIALS AND METHODS

The records of 73 patients with squamous cell carcinoma of the maxillary sinus were analyzed. Sixty-two patients were evaluable. Forty patients (65%) were treated with surgery followed by postoperative radiotherapy, five patients (8%) were treated with radiotherapy alone, five patients (8%) were treated with surgery alone; 12 patients (19%) received chemotherapy.

STATISTICAL ANALYSIS USED

Statistical analysis was done using Kaplan-Meier method.

RESULTS

The majority of patients presented with locally advanced disease (52, 84%); nodal involvement was observed in five patients (8%). The most common site of recurrence was at the primary site, which was observed in 28 patients (45%) and regional failures occurred in 10 (16%). The 3 and 5-year overall survival was 38% and 35% and the disease free survival was 29% and 26% respectively. The 5-year overall survival after surgery and postoperative radiotherapy was 42%.

CONCLUSIONS

The majority of patients present with advanced disease resulting in poor outcomes to conventional treatment modalities. Locoregional tumor progression remains a significant pattern of failure. New approaches such as neoadjuvant or concomitant chemoradiotherapy with aggressive surgery need to be considered and evaluated in prospective studies.

Oncocytic carcinoma of the maxillary sinus: a rare neoplasm

Oncocytic neoplasms are tumors composed of oncocytes (i.e., epithelial cells with a large cytoplasm that is rich in mitochondria). Most cases are benign and originate from the major salivary glands, while the minor salivary glands are rarely involved. Occurrence of oncocytic carcinoma (or malignant oncocytoma) within the sinonasal tract is an unusual event. We report a rare case of maxillary sinus oncocytic carcinoma occurring in a 45-year-old male. Biopsy was consistent with an unspecified salivary gland neoplasm. The patient underwent total maxillectomy through a lateral rhinotomic approach; hard palate reconstruction with temporal myofascial flap was performed. Definitive histology was consistent with oncocytic carcinoma. Due to the local extension of the lesion, postoperative radiotherapy (60 Gy) was delivered. Three years after surgery, the patient is free from disease. A brief analysis of the literature was also accomplished in order to discuss treatment options and prognosis of this unusual neoplasm.

Preoperative Chemotherapy and Radiation Therapy for Squamous Cell Carcinoma of the Maxillary Sinus

OBJECTIVE

This study was undertaken to assess the prognostic factors for the management of squamous cell carcinoma (SCC) of the maxillary sinus, who received preoperative chemotherapy and radiation therapy (RT). We also elucidated the appropriate sequence of chemotherapy.

METHODS

A total of 124 patients (median age 62 years) with SCC of the maxillary sinus were analysed retrospectively. T3 or T4 disease was found in 93% of the patients. Thirty-nine patients received neoadjuvant chemotherapy (NA), 38 patients received concurrent chemoradiotherapy (CRT) and 47 patients received NA followed by CRT. The median dose of RT was 60 Gy. Maxillectomy was undertaken in 98 patients.

RESULTS

The 5 year overall survival (OAS) and local control probability (LCP) were 56.6 and 73.7%, respectively. On univariate analysis, surgery (P < 0.0001) and T classification (P < 0.04) were significant prognostic factors for OAS and LCP. Histological grade and nodal status were also related to OAS. However, any chemotherapy sequence was not associated with the treatment outcome. On multivariate analysis, surgery (P < 0.0005) and T classification (P < 0.05) were identified as significant prognostic factors for LCP and OAS.

CONCLUSIONS

This study suggests that both surgery and T stage are important prognostic factors for LCP and OAS in the management of SCC of the maxillary sinus. The appropriate sequence of chemotherapy remains to be elucidated in the future study.

[Correlation of GST-pi and PCNA expression to prognosis of advanced maxillary sinus squamous cell carcinoma]

BACKGROUND & OBJECTIVE

Tumor markers which relate to cell proliferation and metabolism have seldom been studied in maxillary sinus cancer. This study was conducted to identify the correlation of glutathione S-transferase pi (GST-pi) and proliferating cell nuclear antigen (PCNA) expression to prognosis of advanced maxillary sinus squamous cell carcinoma (SCC).

METHODS

The expression of GST-pi and PCNA in 54 specimens of maxillary sinus SCC, 29 specimens of benign maxillary tumor, and 20 specimens of normal nasal mucosa was detected by immunohistochemistry. The correlation of GST-pi and PCNA expression to prognosis of advanced maxillary sinus SCC was analyzed by Kaplan-Meier method. The prognosis was analyzed by Cox multivariate model.

RESULTS

The overexpression rates of GST-pi and PCNA were significantly higher in maxillary sinus SCC than in benign maxillary tumor and normal nasal mucosa (74.1% vs. 89.6% and 15.0%, P<0.01; 79.6% vs. 3.4% and 0, P<0.01). The 5-year survival rate was significantly higher in advanced maxillary sinus SCC patients with high expression of GST-pi than in the patients with low expression of GST-pi (34.5% vs. 21.2%, P=0.025); the difference between the patients with high and low expression of PCNA was not significant (18.0% vs. 27.0%, P=0.890). The expression of GST-pi was an independent prognostic factor of advanced maxillary sinus SCC (P=0.039, odds ratio>1).

CONCLUSION

The overexpression of GST-pi is an independent prognostic factor of advanced maxillary sinus SCC, but that of PCNA isn't.

A case of metastatic hepatocellular carcinoma in the nasal cavity

Metastatic hepatocellular carcinoma in the nasal cavity and paranasal sinuses is rare. We report the case of a 71-year-old male afflicted with hepatocellular carcinoma with metastasis in the maxillary sinus and nasal cavity. He underwent radiation therapy with a total dose of 36 Gy, but he died of terminal liver failure. The possible metastatic route and prognosis of metastatic hepatocellular carcinoma in the sinonasal tract are discussed.

Measurements of Characteristics of Time Pattern in Dose Delivery in Step-and-Shoot IMRT

BACKGROUND AND PURPOSE

Although intensity-modulated radiotherapy (IMRT) has already shown its clinical benefit, there are some issues which are not yet fully understood. Among these is the question whether the protracted dose delivery due to the lowered dose rate has any radiobiological consequences. To investigate this question, an exact characterization of dose rate profiles in typical clinical plans is needed. Furthermore, such a characterization may lead to an increased knowledge how to improve IMRT technically.

MATERIAL AND METHODS

A new IMRT phantom which allows precise measurement of up to nine points of interest simultaneously with pin-point ionization chambers was developed. To examine dose rates, a new software tool (GRAYHOUND) was developed which can measure doses in short time intervals of up to 0.5 s. 250 points in four clinical IMRT plans were examined. A set of parameters was defined to describe the dose rate profiles including the effective fraction time (eft, which is the percentage of the fraction time in which any dose is delivered to a specific point), and a quotient of the percentage of dose delivered in high dose pulses (> 0.01 Gy/s) divided by the percentage of fraction time needed to deliver this dose (d(HD)/t(HD)).

RESULTS

These quotients are excellent markers for the inhomogeneity of dose rate delivery in IMRT. In both parameters a wide variance in points of the same plan and between different plans was found. For example, eft ranged between 11.6% and 37.3% in high dose points and the time in which high dose rates are delivered to a single high dose point ranged between 3.6% and 10.1% of total fraction time.

CONCLUSIONS

These data show a great inhomogeneity of dose rates not only between different plans but also between different points in the same plan. Biological investigations are needed to quantify the relevance of these inhomogeneities. The parameters which are introduced in this work may be suitable to compare different optimization algorithms in IMRT.

Radiotherapy and Radiosurgery for Benign Neurofibromas

The purpose of this study was to evaluate the efficacy of radiotherapy (RT) and stereotactic radiosurgery (SRS) for neurofibromas. We studied 4 patients treated with RT (3 patients) or SRS (1 patient) and followed from 1.7 to 14.8 years. The tumor remained locally controlled in all patients. No significant complications related to treatment were observed. RT and SRS are likely to locally control neurofibromas in patients who require treatment and are not good candidates for complete resection.

A customized orofacial brachytherapy carrier: a clinical report

This report describes a method in which a customized carrier was fabricated for a patient experiencing difficulty during initial brachytherapy treatment, while using a conventional radiation carrier. When designing a customized brachytherapy carrier for a maxillary defect, it is imperative to achieve stability and retention to ensure maximal therapeutic radiation to the desired location. The fabrication and benefits of using a customized, retentive, stable, and comfortable orofacial brachytherapy carrier are described.

Mucoepidermoid carcinoma in a young adult: recognition, diagnosis, and treatment and responsibility

Recognizing an abnormality is the first and most essential step when diagnosing a pathosis. All health care providers are responsible for evaluating suspicious symptoms and clinical and laboratory findings. Without a baseline evaluation, dentists cannot guarantee that patients are free of potentially serious disease. This article documents how the prognosis for and morbidity of cancer therapy may have been affected by the failure to recognize abnormal signs. Professional responsibility and liability for recognition of abnormality and subsequent diagnosis is emphasized.

Maxillary sinus carcinoma. Natural history and outcome

OBJECTIVE

To assess natural history, treatment outcome and pattern of relapse in patients with maxillary sinus carcinoma.

METHODS

A review was conducted of the medical records of all adult patients with maxillary sinus carcinoma, who were treated at King Faisal Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia, between January 1990 and December 1999. A total of 60 patients were identified for analysis, 36 men and 24 women; the median age was 58-years (range 23-95). Major presenting symptoms were facial swelling 55%, facial pain 50%, and nasal obstruction 43.4%, with a median duration of 5-months (range 1-24). Histology was squamous cell carcinoma in 71.7% and adenoid cystic in 16.7%. They were restaged according to American Joint Committee on Cancer classification 1997 as II, III and IV in 1, 10 and 49. Thirty patients received treatment with curative intent (surgery in 4 patients, radiotherapy in 2, and combined modality in 24), 6 patients refused treatment and 24 were treated palliatively.

RESULTS

With a median follow up of 50-months (range 2-128) in surviving patients treated with a curative intent, 12/30 failed locally, 4/30 in the regional neck nodes and 2/30 had systemic relapse. The actuarial 5-year overall survival (OS), relapse free survival (RFS) and local control rate (LC) were 55%, 39% and 51%. Treatment modality was the only significant prognostic factor for outcome, with 5 year OS, RFS and LC of 72%, 49% and 61%, for combined modality using surgery followed by radiotherapy compared to 0% for single approach (p=0.0003, p=0.0052 and p=0.0098)

CONCLUSION

This study indicates that the majority of our patients presented with advanced disease, resulting in poor outcome to conventional treatment modalities. Efforts should be directed to minimize the delay in diagnosis at the primary care level. Combined modality treatment should be offered to all patients with locally advanced disease. New approaches such as neoadjuvant or concurrent chemoradiotherapy with or without surgery need to be considered and evaluated in prospective studies.

Carcinoma of paranasal sinuses: long-term outcomes with radiotherapy

PURPOSE

To assess the clinical features, prognostic factors, results, and complications of treatment of carcinomas of the paranasal sinus.

METHODS AND MATERIALS

The records of 106 patients (72 men and 34 women) with paranasal sinus carcinoma treated with curative intent at Washington University between January 1960 and August 1998 were analyzed. Patient age ranged from 29 to 91 years (median, 64 years). Most tumors originated in the maxillary (76%) or ethmoid (18%) sinus. Most tumors were locally advanced at presentation. All patients underwent radiotherapy (RT), combined with surgery in 65%; 2% received chemotherapy.

RESULTS

Follow-up ranged from 1.7 months to 24 years (median 5 years). The 5-year local tumor control, locoregional tumor control, disease-free survival (DFS), and overall survival rate was 58%, 39%, 33%, and 27%, respectively. A statistically significant improvement in DFS was noted with the addition of surgical resection to RT (35% vs. 29%, p = 0.05). Nodal status at presentation emerged as a statistically significant predictor for locoregional tumor control and DFS in multivariate analysis. Distant metastases occurred in 29% of patients.

CONCLUSION

This review of a large, single-institution experience of paranasal sinus carcinoma patients who underwent RT showed that locoregional tumor progression and recurrence remain predominant patterns of failure despite aggressive local treatment with combined surgery and RT. DFS improved slightly with combined modality treatment. The overall survival rates remained suboptimal, suggesting a need for more accurate determination of tumor extent, as well as more effective locoregional and systemic therapies.

[Malignomas of the nasal cavity and the paranasal sinuses: clinical characteristics, therapy and prognosis of different tumor types]

BACKGROUND

Malignomas of the nasal cavity and the paranasal sinuses count for less than 3 % of the ENT-malignancies.

PATIENTS AND METHODS

This retrospective chart review reports about 46 patients that were first diagnosed and treated with a nasal cavity or paranasal sinus malignancy between 1998 and 2002 in the ENT department of the Ruhr-Universität Bochum.

RESULTS

18 of 46 malignomas were squamous cell carcinomas. At initial diagnose, already 52 % of malignomas were staged T4. Accordingly the origin in 17 % of malignomas could not be determined anymore. Additional 43 % of malignomas originated from the nasal cavity, another 20 % from the maxillary sinus. 11 of 46 patients (24 %) showed histological proven nodal involvement at initial diagnose. 92 % of patients underwent surgical therapy. 25 patients were radiated postoperatively. Over-all 1-year-survival-rate was 75 %, over-all 2-year-survival-rate was 47 %. Beside patients age, tumor free margins at initial surgery and absence of nodal involvement correlated to improved survival. 16 (76 %) of the 21 patients who died had local recurrence. Maxillary sinus malignomas recurred more often than malignomas of the ethmoid and the nasal cavity.

CONCLUSIONS

Malignancies of the nasal cavity and paranasal sinuses are very often diagnosed in advanced T-stages because of unspecific symptoms. The limited prognosis mainly depends on free surgical margins at the first resection and nodal involvement at the first diagnose. For improvement in outcome of nasal and paranasal sinuses malignancies, prospective multi-center trials are necessary.

Bilateral rhegmatogenous retinal detachment after external-beam radiotherapy: just a coincidence?

PURPOSE

To report an unusual case of almost simultaneous bilateral rhegmatogenous retinal detachment in the context of external-beam radiotherapy for a tumor at a non-ocular target site and in the absence of pre-existing ocular pathology.

METHODS

Observational case report with review of corresponding literature.

RESULTS

A 63-year-old man was referred for bilateral retinal detachment which was associated with many horseshoe tears and proliferative vitreoretinopathy. He had undergone surgery for a carcinoma of the left maxillary sinus 4 months prior to the presentation and had then received external-beam radiotherapy for 3 months. There was no familial history of retinal detachment and/or eye trauma in this hyperopic patient with clear native lenses. No chorioretinal pathology was apparent that could have predisposed the retinas to tearing.

CONCLUSIONS

Simultaneous bilateral retinal detachment is exceptional, especially in a patient with no risk factors. The effect of radiotherapy on the vitreoretinal interface is discussed in the light of existing data and may have been responsible for our patient's retinal detachment.

[Outcomes of radiation therapy for maxillary sinus carcinoma]

PURPOSE

We evaluated the outcome of radiation therapy for maxillary sinus carcinoma treated in our institution.

MATERIALS AND METHODS

From 1984 to 2001, 48 patients with maxillary sinus carcinoma were irradiated with or without chemotherapy and surgery. Patients ranged from 20-89 years of age (median, 68 years) and included 29 men and 19 women. The clinical T factors for these patients, according to the UICC classification (1997), were T2(n = 2), T3(n = 13), and T4(n = 29). Lymph node involvement was observed in 13 patients. The follow-upperiod ranged from 2.5 to 150 months (median, 25 months). The total radiotherapy dose ranged from 40 Gy to 72.8 Gy. Forty-three patients underwent surgery. Intra-arterial chemotherapy was delivered in 39 patients, and systemic chemotherapy was delivered in 7 patients. Fourteen patients were classified as "unresected" (radiation therapy with or without antrostomy), and 34 patients as "resected" (partial, total, or extended total maxillectomy with pre- or postoperativeirradiation).

RESULTS

The 5-year overall survival rate(OS), cause-specific survival rate(CSS), and local control rate(LC) of all patients were 52%, 64%, and 75%, respectively. There was no significant difference between the "uaresected" and "resected" groups in OS, CSS, or LC. Local recurrence was observed in 12 patients. In the "resected" group, for local control, it was important to reduce viable tumor before maxillectomy. Preoperative > or = 60 Gy irradiation was considered to be effective to reduce tumor viability.

CONCLUSION

There was no significant difference between the "unresected" and "resected" groups in OS, CSS, or LC. In the "resected" group, preoperative irradiation > or = 60 Gy was considered to be effective for local control. In radical treatment of maxillary sinus carcinoma, maxillectomy is not always necessary. Concurrent chemoradiation therapy with or without antrostomy is a reasonable treatment strategy.

The choice of optimal radiotherapy technique for locally advanced maxillary carcinoma using 3d treatment planning system

Aim. To compare the isodose distribution of three radiotherapy techniques for locally advanced maxillary sinus carcinoma and analyze the potential of three-dimensional (3D) conformal radiotherapy planning in order to determine the optimal technique for target dose delivery, and spare uninvolved healthy tissue structures. Methods. Computed tomography (CT) scans of fourteen patients with T3-T4, N0, M0 maxillary sinus carcinoma were acquired and transferred to 3D treatment planning system (3D-TPS). The target volume and uninvolved dose limiting structures were contoured on axial CT slices throughout the volume of interest combining three variants of treatment plans (techniques) for each patient: 1. A conventional two-dimensional (2D) treatment plan with classically shaped one anterior two lateral opposite fields and two types of 3D conformal radiotherapy plans were compared for each patient. 2. Three-dimensional standard (3D-S) plan one anterior + two lateral opposite coplanar fields, which outlines were shaped with multileaf collimator (MLC) according to geometric information based on 3D reconstruction of target volume and organs at risk as seen in the beam eye's view (BEV) projection. 3. Three-dimensional non-standard (3D-NS) plan: one anterior + two lateral noncoplanar fields, which outlines were shaped in the same manner as in 3D-S plans. The planning parameters for target volumes and the degree of neurooptic structures and parotid glands protection were evaluated for all three techniques. Comparison of plans and treatment techniques was assessed by isodose distribution, dose statistics and dose-volume histograms. Results. The most enhanced conformity of the dose delivered to the target volume was achieved with 3D-NS technique, and significant differences were found comparing 3D-NS vs. 2D (Dmax: p<0,05 Daver: p<0,01; Dmin: p<0,05; V90: p<0,05, and V95: p<0,01), as well as 3D-NS vs. 3D-S technique (Dmin: p<0,05; V90: p<0,05, and V95: p<0,01), while there were no differences between 2D vs. 3D-S technique. 3D-S conformal plans were significantly superior to 2D plans regarding the protection of parotid glands, and the additional improvement of dose conformity was achieved with 3D-NS technique. 3D-NS technique resulted in the decrease of Dmax for ipsilateral retina compared with 3D-S technique, while the level of Dmax for optic nerve was increased (within an acceptable range) with 3D-NS technique. Conclusion. In this study, 3D planning of radiotherapy for locally advanced maxillary sinus carcinoma with noncoplanar fields, which number did not exceed the number of fields for conventional arrangement enabled conformal delivering of the adequate dose to the target volume with the improved sparing of adjacent uninvolved healthy tissue structures.

[A case of a 91-year-old woman with maxillary sinus carcinoma who achieved a complete response to chemoradiotherapy with intra-arterial administration of docetaxel]

We treated a 91-year-old woman with advanced maxillary sinus carcinoma who achieved a complete response to chemoradiotherapy with intra-arterial administration of docetaxel. She received local irradiation with a total dose of 50 grays along with concomitant intramaxillary arterial infusion of docetaxel with a total dose of 80 mg. After treatment, pathological examination of a biopsy specimen from the maxillary sinus revealed no residual tumor, and a posttreatment CT scan showed no tumor. Twenty one months after chemoradiotherapy, she had no recurrence and no metastasis. We conclude that chemoradiotherapy using intramaxillary infusion with docetaxel would be useful for maxillary sinus squamous cell carcinoma.

[The supplement therapy of microwave after endoscopic maxillary sinus surgery]

OBJECTIVE

To observe therapeutic effect of microwave eliminating the remnant lesion located at walls of maxillary sinus after endoscopic maxillary sinus surgery and the effect of postoperative.

METHOD

Twenty-six cases (37 sites) were treated with microwave coagulating through enlarged ostium completely by means of 70 degrees endoscopy-guided.

RESULT

The remnant lesion located at walls of maxillary sinus of 23 cases (33 sites) were eliminated without any complication and the effective eliminating rate was 89.2% (33/37). The infected local secretion of maxillary sinus of 17 cases (22 sites) were disappeared.

CONCLUSION

The therapy of microwave by means of nasal endoscopy-guided can get rid of the lesion which is located at walls of the maxillary sinus to avoid the trauma caused by Caldwell-Luc operation, etc. It can improve the effect of the endoscopic sinus surgery.