Malignant Sinonasal Tumors Research Articles

Radionecrosis of the Anterior Skull Base as a Consequence of Sinonasal Malignant Tumor Management: Diagnosis, Prevention, and Management

Objectives: Treatment of sinonasal malignant tumors is based on surgery followed by radiotherapy, and eventually combined with chemotherapy. A late complication of this treatment is cerebral radionecrosis. The aims of this study are to: (1) highlight the main diagnosis criteria of radionecrosis, (2) identify any risk factors, and (3) determine methods of prevention.

Patterns of dural involvement in sinonasal tumors: prospective correlation of magnetic resonance imaging and histopathologic findings

The presence of dural invasion serves as an important negative predictive factor for survival in sinonasal and skull-base neoplasms. The objective of this study was to prospectively correlate preoperative magnetic resonance imaging (MRI) findings with intraoperative surgical findings and histopathology to establish key correlates for dural involvement in sinonasal tumors. Prospective blinded MRI review of 50 sinonasal and anterior skull-base neoplasms was performed by a staff neuroradiologist. Retrospective chart review was performed to accrue salient patient and tumor data. The mean patient age was 54.6 years with a male:female ratio of 1.8:1. The most common tumor histology included adenocarcinoma (18%), squamous cell carcinoma (18%), mucosal melanoma (8%), and olfactory neuroblastoma (8%). MRI demonstrated dural enhancement in 20 patients (40%), with 1 mm and ≥2 mm thickening being noted in 14 (70%) and 6 (30%) cases, respectively. Spectrum of MR findings in these 20 patients included linear enhancement in 15 (75%), nodular thickening in 5 (25%), and loss of hypointense zone in 13 (65%) cases. Intraoperative findings and histology confirmed dural invasion in 12 of 20 cases (60%). Positive predictive value (PPV) of linear and nodular dural enhancement for dural invasion was 46.7% and 100%, respectively. One millimeter (1 mm) and ≥2 mm of dural thickening demonstrated PPV of 42.9% and 100%, respectively. Loss of the hypointense zone had PPV of 92.3% for dural invasion. Fisher's exact test demonstrated that loss of hypointense zone and dural thickening ≥2 mm were statistically associated with dural involvement (p < 0.05). The presence of ≥2 mm of dural thickening, loss of hypointense zone, and nodular dural enhancement were highly predictive for presence of dural invasion by sinonasal malignant tumors. Preoperative knowledge of these MRI patterns may better guide surgical planning and patient counseling.

Imaging of sinonasal tumours

More than 70 benign and malignant sinonasal tumours and tumour-like conditions have been described. However, sinonasal tumours are rare, and sinonasal cancers comprise only 3% of all head and neck cancers and 1% of all malignancies, with a peak incidence in the 5th to 7th decades and with a male preponderance. The early symptoms and imaging findings of sinonasal tumours are similar to rhinosinusitis with runny and stuffy nose, lacrimation and epistaxis and therefore neglected both by the patients and doctors. When late symptoms such as anosmia, visual disturbances, cranial neuropathy (Cn II, IV, V, VI) or facial swelling appear, the patient is referred to sinonasal endoscopy or imaging. At the time of correct diagnosis more than half of the tumours have reached an advanced stage with a poor prognostic outcome. Even if imaging is performed in the early stages, a radiologist inexperienced with sinonasal anatomy and tumour features may easily interpret early signs of a malignant tumour as rhinosinusitis or a lesion that does not require follow-up. This article presents the imaging findings in some of the most common benign and malignant sinonasal tumours, and the TNM classification and staging of sinonasal carcinomas.

Endoscopic Removal of Infected Necrosis after Particle Therapy for Sinonasal Malignant Tumor

Endoscopic Removal of Infected Necrosis after Particle Therapy for Sinonasal Malignant Tumor

Anatomical correlates of endonasal surgery for sinonasal malignancies

In recent years, endoscopic endonasal techniques have been applied to the treatment of sinonasal malignancies. Comprehensive anatomical knowledge is essential to preserve oncological principles and minimize surgical morbidity. The bones that form the anterior cranial base are pneumatized and the sinuses provide surgical corridors for the endoscopic endonasal approach to the skull base. During endoscopic endonasal resection of sinonasal malignancies, usually, the intranasal portion of the tumor is first debulked to provide visualization of the margins and assess the extent of the tumor. Afterwards the tumor is completely removed and the margins of resection are defined. In case of dural resection, the reconstruction is done with vascularized tissue (septal flap or pericranial flap). Sinonasal malignant neoplasms that invade the skull base can be resected accordingly to oncological principles using endoscopic endonasal techniques. Profound knowledge of the endoscopic anatomy of the ventral cranial base is paramount in order to perform a safe resection and reconstruction.

Endoscopic Management of Sinonasal Hemangiopericytoma

Sinonasal hemangiopericytomas (SNHPCs) are rare perivascular tumors with low-grade malignant potential. Traditionally, these tumors have been treated with open approaches such as lateral rhinotomy, Caldwell-Luc, or transfacial approaches. Increased experience with endoscopic management of benign and malignant sinonasal tumors has led to a shift in management of SNHPC. The authors present their experience in the largest series of patients with SNHPC managed endoscopically. Case series at a tertiary care medical center. A retrospective chart review of all patients undergoing endoscopic management of SNHPC at the University of Miami between 1999 and 2008 was conducted. All endoscopic resections were performed with curative intent. Twelve patients with the diagnosis of SNHPC were treated endoscopically. Mean age was 62.5 years (range, 51-83 years). There were 6 men and 6 women. The mean follow-up was 41 months (range, 15-91 months). Seven (58.3%) presented with nasal obstruction, whereas 4 (41.6%) had epistaxis as their initial presenting symptom. Preoperative angiography or embolization was not performed in any case. Mean estimated blood loss was 630 mL (range, 100-1500 mL). Six patients underwent endonasal endoscopic anterior skull base resection; 4 had complete endoscopic resection all with negative margins. None underwent postoperative adjuvant treatment. No recurrence or metastatic disease was observed in this patient population. Endoscopic management of SNHPC is a feasible approach and did not compromise outcomes in this experience. In this series, familiarity with advance endoscopic sinus surgery was necessary to manage these patients. Postoperative adjuvant therapy was not necessary in this cohort.

Split-rib reconstruction of the frontal sinus: two cases and literature review

Large defects of the anterior wall of the frontal sinus require closure using either autologous or foreign material. In cases of osteomyelitis, the reconstruction must be resistant to bacterial infection. Split-rib osteoplasty can be used in different sites. Two patients with malignant sinonasal tumours underwent repeated treatment, and subsequently developed osteomyelitis of the frontal bone. After adequate therapy, a large defect of the anterior wall persisted. Reconstruction was performed using the split-rib method. The literature on this topic was reviewed. Both patients' treatment were successful. No complications occurred. A PubMed search on the topic of rib reconstruction of the frontal sinus and skull was performed; 18 publications matched the inclusion criteria. From these sources, we noted that 182 reconstructions yielded good results with few complications. Large defects of the anterior wall of the frontal sinus can be closed successfully using autologous split-rib grafting. Aesthetic outcome is good and donor site morbidity is minimal.

Multiparametric MR Imaging of Sinonasal Diseases: Time-Signal Intensity Curve– and Apparent Diffusion Coefficient–Based Differentiation between Benign and Malignant Lesions

The sinonasal region is a platform for a broad spectrum of benign and malignant diseases, and image-based differentiation between benign and malignant diseases in this area is often difficult. Here, we evaluated multiparametric MR imaging with combined use of TICs and ADCs for the differentiation between benign and malignant sinonasal tumors and tumorlike diseases. TICs obtained from dynamic contrast-enhanced MR imaging and ADCs were analyzed on a lesion-by-lesion (overall TIC and ADC) and pixel-by-pixel (TIC and ADC mapping) basis in patients with benign (n = 21) or malignant (n = 23) sinonasal tumors and tumorlike diseases. The TICs were semiautomatically classified into 5 distinctive patterns (flat, slow uptake, rapid uptake with low washout ratio, rapid uptake with high washout ratio, and miscellaneous). ADCs were determined by using b-values of 500 and 1000 s/mm(2). Malignant sinonasal tumors had small (<25%) areas of the type 1 flat TIC profile as determined by pixel-by-pixel TIC analysis and large (≥50%) areas of low or extremely low ADCs (≤1.2 × 10(-3) mm(2/)s) as determined by ADC mapping. Consequently, stepwise classification on the basis of TICs and ADCs successfully (at 100% accuracy) discriminated malignant from benign sinonasal diseases in the present patient cohort. Multiparametric MR imaging by using TICs and ADCs may help differentiate benign and malignant sinonasal diseases.

Craniofacial Resection for Sinonasal Malignant Tumors: Statistical Analysis of Surgical Outcome over 17 Years at a Single Institution

We present a retrospective analysis of surgical outcome of sinonasal malignant tumors. Overall survival (OS), disease-specific survival (DSS), local control (LC), and disease-free survival (DFS) were calculated in 32 patients. Prognostic factors for survival and functional outcomes were investigated. The median follow-up period was 70 months. At 5 years, OS, DSS, LC, and DFS rates were 0.722, 0.745, 0.851, and 0.707, respectively. Prognostic factors for poor OS were involvement of the frontal sinus (p = 0.023), T classification (T4, p = 0.025), surgical complications (p = 0.029), chemotherapy (p = 0.035) postsurgical infection (p = 0.043), involvement of the orbit (p = 0.048), histology (squamous cell carcinoma, p = 0.049), and radiotherapy (p = 0.043). Prognostic factors for poor DSS were radiotherapy (p = 0.030), chemotherapy (p = 0.036), positive surgical margin (p = 0.034), and T classification (T4, p = 0.050). LC was adversely influenced by surgical procedure (combined frontotemporal resection, p = 0.035) and positive surgical margin (p = 0.049). DFS was adversely influenced by positive surgical margin (p = 0.001). Prognostic factors for poor functional outcome were postsurgical infection (p = 0.039), postsurgical complications (p = 0.040), tumor location (maxillary sinus, p = 0.042, orbit, p = 0.0002), number of sinuses involved (number of sinuses involved was inversely proportional to functional outcome, p = 0.027), T classification (T4 p = 0.007), pathology (squamous cell carcinoma, p = 0.023), and chemotherapy (p = 0.048). Craniofacial resection was an effective surgical option.

Treatment of malignant sinonasal tumours with intensity-modulated radiotherapy (IMRT) and carbon ion boost (C12)

BackgroundMost patients with cancers of the nasal cavity or paranasal sinuses are candidates of radiation therapy either due incomplete resection or technical inoperability. Local control in this disease is dose dependent but technically challenging due to close proximity of critical organs and accompanying toxicity. Modern techniques such as IMRT improve toxicity rates while local control remains unchanged. Raster-scanned carbon ion therapy with highly conformal dose distributions may allow higher doses at comparable or reduced side-effects.Methods/designThe IMRT-HIT-SNT trial is a prospective, mono-centric, phase II trial evaluating toxicity (primary endpoint: mucositis ≥ CTCAE°III) and efficacy (secondary endpoint: local control, disease-free and overall survival) in the combined treatment with IMRT and carbon ion boost in 30 patients with histologically proven (≥R1-resected or inoperable) adeno-/or squamous cell carcinoma of the nasal cavity or paransal sinuses. Patients receive 24 GyE carbon ions (8 fractions) and IMRT (50 Gy at 2.0 Gy/fraction).DiscussionThe primary objective of IMRT-HIT-SNT is to evaluate toxicity and feasibility of the proposed treatment in sinonasal malignancies.Trial RegistrationClinical trial identifier NCT 01220752

ADAM-9 Expression in Intestinal-type Adenocarcinoma of the Sinonasal Tract

Malignant tumors of the paranasal fossae and sinuses represent 0.2% to 0.8% of all malignant tumors in the body and 3% to 6% of other head and neck tumors. It is possible to distinguish 4 different histologic types of sinonasal malignant tumors: squamous carcinoma, adenocarcinoma, adenoid cystic carcinoma, and sinonasal undifferentiated carcinoma. According to the WHO classification, there are 2 main types of adenocarcinomas: intestinal-type (ITAC) and nonintestinal type. ITACs are generally connected with professional exposure to wood and leather dust. The metalloproteinase 9 (ADAM-9) is a type 1 transmembrane protein that has been associated with cancer development and metastases. Our case of poorly differentiated sinonasal ITAC showed moderate to strong cytoplasmic positivity for ADAM-9 in association with moderate membrane staining for c-erbB-2 oncoprotein. In our opinion, the expression of these proteins could explain the tumoral growth and together they could represent the most interesting targets when designing any tumor treatment scheme.

Controversies of Endoscopic Repair of Skullbase Defects

Statement of the Problem: Successful endoscopic resection of benign sinonasal tumors within the last decade has led to the endoscopically assisted removal of malignant sinonasal tumors, which in turn set the stage for the contemporary two-nostril, four-handed resection of anterior skull base (ASB) malignancies. The two main grievances skeptics have regarding endoscopic treatment of malignancies are the inability to perform en bloc resections and the belief that ASB cannot be safely repaired endoscopically.

A modified midfacial degloving approach for the treatment of unilateral paranasal sinus tumours

Purpose The midfacial degloving approach (MFDA) is the primary option for the removal of benign and malignant sinonasal tumours. However, the classic MFDA does not compensate for the fact that most benign and malignant paranasal sinus (PNS) tumours are unilateral and the incisions may lead to some unnecessary complications?. Surgical exposure is limited to the upper and deep part of the PNS. Modifications of the classical MFDA that minimize complications and improve surgical field exposure are warranted. Patients The medical records of 27 consecutive patients who had undergone surgery using a modified MFDA for treatment of unilateral benign or malignant tumours from 2000 to 2006, were reviewed. Results We developed and performed a modified MFDA utilizing a hemigingivobuccal incision, a transfixion incision, mucosal detachment of the pyriform aperture and separation of the upper lateral cartilage from the nasal bone in 27 patients with unilateral benign (85%) or malignant (15%) PNS neoplasms. Adequate surgical exposure was achieved in all cases. No technical problems and no intraoperative complications related to the surgical ?procedure were encountered. Conclusion Our modified MFDA provides sufficient surgical exposure for the removal of unilateral malignant or benign PNS tumours with few surgical or cosmetic complications.

Management of Sinonasal Malignant Neoplasms: Defining the Role of Endoscopy

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

A Case of Amelanotic Malignant Melanoma Misconceived as Nasal Polyp

Mucosal malignant melanomas (MM) within the nose and paranasal sinuses are rare, representing 1-3% of MM and 3-4% of malignant sinonasal tumors. The incidence of amelanotic MM with primary lesions in the sinonasal cavity is also extremely rare. The absence of pigmentation in the tumor may result in diagnostic confusion. Amelanotic MM may masquerade as a variety of other conditions leading to a delay in the diagnosis and worsen the prognosis. In this report, we present, along a brief review of the literature, an interesting case of amelanotic MM misconceived as a nasal polyp. Although paranasal MRI and endoscopy showed no evidence of remnant mass after surgery, positron emission tomography/computed tomography (PET/CT) image showed an area of increaed fluorodeoxyglucose (FDG) uptake. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:366-70 Key WordsZZMelanoma, amelanotic·Nasal cavity·Nasal polyps.

The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave

In this paper the authors' goal was to present their clinical experience with lesions of the pterygopalatine fossa, infratemporal fossa, lateral sphenoid sinus, cavernous sinus, petrous apex, and Meckel cave using simple and extended endoscopic transpterygoid approaches to the lateral skull base. Simple and expanded endoscopic transpterygoid approaches were performed in a series of 13 patients with varying pathology that included lateral sphenoid sinus encephaloceles, benign and malignant sinonasal tumors, and lesions of neural origin. A gross-total resection was achieved in 5 of 9 patients, while a subtotal resection for tissue diagnosis and cytoreduction prior to further adjuvant treatment was performed in the remaining patients. Sphenoid sinus encephaloceles were successfully repaired via a transpterygoid approach in all 4 patients. The skull base defect was reconstructed using a multilayered closure. One patient developed a postoperative CSF leak, which was successfully treated conservatively. The mean follow-up time was 16 months. Five patients complained of recurrent sinusitis. One patient experienced xerophthalmia and palate numbness. Three patients had died by the time of this report. Two patients died of unrelated causes. The third patient died of progression of an aggressive pterygopalatine osteosarcoma despite undergoing cytoreductive surgery and adjuvant chemotherapy. An endoscopic transpterygoid approach is a minimally invasive endoscopic approach for lesions located or extending to the pterygopalatine fossa, infratemporal fossa, petrous apex, Meckel cave, and other regions of the paramedian skull base.

Endoscopic endonasal surgery in the management of selected malignant naso-ethmoidal tumors

Objective The objective of this study was to report the cases of three patients with sinonasal malignant tumors who underwent en bloc tumor resection using endoscopic endonasal approaches, and to discuss the advantages and limitations of endoscopic endonasal tumor resection. Methods Three patients with malignant naso-ethmoidal tumors underwent en bloc resection with endoscopic endonasal approach. Results In very carefully selected cases of naso-ethmoidal malignant tumors that were preoperatively evaluated on endoscopic findings and magnetic resonance imaging to be limited to within the nasal cavity and/or ethmoid sinus and to have some safe margins between the tumor and skull base and/or lamina papyracea, tumors were resected en bloc using endoscopic endonasal approaches. A case of cerebrospinal fluid leakage was safely managed with the endoscopic approach. Conclusions In selected T1–T2 naso-ethmoidal malignant tumors with some safe margins, endoscopic endonasal surgery may offer a satisfactory alternative to external procedures.

Computed tomography in the diagnosis of malignant sinonasal tumours in three horses

SummaryMalignant tumours are uncommon in horses, but when they do occur, they are most frequently found in the head. Clinical findings, such as facial swelling and nasal discharge, are frequently encountered but are nonspecific. To highlight the usefulness of a computed tomography (CT) examination in malignancy in the equine head, this Case Report describes the CT features of a leiomyosarcoma, an osteosarcoma and a sarcoma in 3 horses. CT of the equine head was able to provide more information about the extent and severity of lesions than conventional radiography in these cases.

Ethmoidal Lipid-Rich Carcinoma With Focal Glandular Structures

Sinonasal malignant tumors constitute less than 1% of all neoplasms and approximately 3% of those of the upper aerodigestive tract. 1 Sinonasal malignant neoplasms most commonly affect the maxillary sinuses (approximately 60%), followed by the nasal cavity (approximately 22%), ethmoidal sinus (approximately 15%), and frontal and sphenoid sinuses (3%). 1 Sinonasal neoplasms are diverse, with most being squamous cell carcinoma or variants (55%), followed by nonepithelial neoplasms (20%), glandular tumors (15%), undifferentiated carcinoma (7%), and miscellaneous tumors (3%). 1 We describe an exceedingly unusual case of ethmoidal lipid-rich carcinoma with focal glandular structures. To our knowledge, such a case has not been documented in the literature to date.

What Are the Limits of Endoscopic Sinus Surgery?: The Expanded Endonasal Approach to the Skull Base

The advent of endoscopic technologies and techniques has expanded the limits of conventional endoscopic sinus surgery. The expanded endonasal approach describes a series of surgical modules in the sagittal and coronal planes that allow surgical access to the entire ventral skull base. The sagittal plane extends from the frontal sinus to the second cervical vertebra. The coronal plane extends from the midline to the roof of the orbit, the floor of the middle cranial fossa, and the jugular foramen. Key principles of endonasal skull base surgery are choosing a surgical corridor that minimizes the need for neural and vascular manipulation, team surgery, use of the endoscope to enhance visualization, and bimanual tumor dissection under direct visualization. Particular challenges of the expanded endonasal approach are identification of anatomical structures using unfamiliar landmarks, hemostasis, and dural reconstruction. Over the last decade with more than 1000 completely endonasal skull base surgeries, we have demonstrated that endoscopic endonasal surgery of the skull base can be performed with minimal morbidity and mortality. The introduction of the septal mucosal flap for dural reconstruction has decreased the incidence of postoperative cerebrospinal fluid leaks to less than 5%. Early data suggests that oncological outcomes for malignant sinonasal tumors with skull base involvement are comparable to conventional techniques. Proper training in endonasal surgical techniques is essential to prevent unnecessary morbidity and achieve good outcomes.