Conformal three-dimensional photon radiotherapy for paranasal sinus tumors.

BACKGROUND: Tumors in the nasal cavity and paranasal sinus are difficult to treat with radiotherapy. Usually, in addition to a two- or three-field photon technique, an interorbital electron field is required. This may result, however, in severe over- or underdosage, the latter being especially detrimental when occurring in the main tumor bulk. METHODS AND RESULTS: We present a conformal three-dimensional treatment technique that provides sufficient interorbital dose with photons only while sparing the eyes, optic nerves and chiasm, and may be considered for selected tumors in this region.     

Intraoperative high-dose-rate brachytherapy for paranasal sinus tumors

PURPOSE: Advanced and recurrent tumors of the paranasal sinuses can be difficult to irradiate to high doses with standard external beam radiotherapy (EBRT), conventional brachytherapy, or intraoperative electron beams. We, therefore, explored the role of intraoperative high-dose-rate brachytherapy (IOHDR) as a boost to EBRT in primary tumors or as sole adjuvant treatment in recurrent disease. METHODS AND MATERIALS: Between 1992 and 1998, 34 patients with locally advanced tumors arising in the paranasal sinuses were treated with IOHDR after maximal surgical excision. Twenty-seven patients with new primaries underwent gross resection and 10-12.5 Gy IOHDR followed by 45-50 Gy EBRT. Seven previously irradiated (45-63 Gy) patients with recurrent disease were treated with 15-20 Gy of IOHDR alone after gross excision. Local control and overall survival were analyzed using the Kaplan-Meier method and compared using the log-rank test. RESULTS: After a mean follow-up of 6 years (range 34-120 months), the 1-, 3-, and 5-year actuarial survival rate was 80%, 62%, and 44%, respectively. The overall local control rate at 1 and 5 years was 75% and 65%, respectively, and distant failure was documented in 44% of patients. Subgroup analysis revealed that the presence of gross disease after surgical resection was the strongest prognosticator, with a 5-year survival and local control rate of 17% and 50%, respectively, compared with 60% and 68%, respectively, for microscopic disease. The local control rates of patients with new primaries were similar to those of patients treated for recurrent disease (63% vs. 71%), probably because gross residual disease occurred only in the group of patients with new primaries. The addition of EBRT to IOHDR increased the 5-year disease-free survival rate from 27% to 44% but had no effect on local control (64% vs. 65%). CONCLUSION: IOHDR can be safely used to deliver a high radiation dose to locally advanced and recurrent tumors in the paranasal sinuses. In an attempt to improve outcome, we are now adding limited-dose EBRT (20-30 Gy) after 17.5 Gy of IOHDR in previously irradiated patients and increasing the EBRT dose for both microscopic (50-54 Gy) and gross residual disease (60-65 Gy) after 15 Gy of IOHDR in previously unirradiated patients. Chemosensitization should also be considered in previously irradiated patients and in those with gross residual disease. Interstitial boosting techniques, which can deliver higher doses at depth, should also be considered in patients with gross residual disease.     

Non-randomized comparison of surgical modalities for paranasal sinus mycoses with intracranial extension.

Mycotic infections of paranasal sinuses are frequently reported in southern Asia. Aspergillus and Mucor species are the predominant ones. Intracranial extension of paranasal sinus mycoses is a difficult problem to manage. We report 18 cases of paranasal sinus mycoses with intracranial extensions. The commonest manifestations were nasal discharge (67%), nasal obstruction (50%), ocular symptoms such as proptosis (44%), telecanthus (39%) and ophthalmoplegia. Computerized tomography scans were found to be quite informative regarding the nature and extent of the disease (100% sensitivity and 78% specificity). A combined intracranial-extracranial approach (six cases) gave a distinct advantage over only adopting an extracranial approach (12 cases). A 17% incidence of CSF leak was noted by adopting only an extracranial approach as well as a recurrence in four cases out of the 12 that were treated using this method (P < 0.05). A slight increase in morbidity was associated with the combined intracranial-extracranial treatment, but no recurrence or significant complications were noted in this approach.     

Neuroendocrine carcinoma of the paranasal sinus: a morphological and endocrinological study

Four cases of small cell carcinoma of the paranasal sinuses were studied histologically, ultrastructurally, and endocrinologically. All tumors showed features of undifferentiated carcinoma with alveolar patterns but without acinar or squamous differentiation and contained cells possessing endocrine-type small secretory granules, which were indistinguishable from non-neoplastic neurosecretory granules. The three cases also possessed a small number of microtubules, and in one of these fine cytoplasmic filaments were observed. One case showed elevated plasma levels of cortisol and adrenocorticotropic hormone associated with adrenocortical hyperplasia and Crooke's changes of the pituitary gland. Another case showed hypercalcemia with bone metastasis, hypercalcitonemia with a high content of calcitonin in the tumor tissue, calcitonin-positive tumor cells, and C-cell hyperplasia of the thyroid. It was concluded that all four cases should be called neuroendocrine carcinoma, which might be related to neoplasms derived from amine precursor uptake and decarboxylation cell series rarely encountered in the paranasal sinuses.     

Locally advanced paranasal sinus and nasopharynx tumors treated with hyperfractionated radiation and concomitant infusion cisplatin.

Fourteen patients with paranasal sinus complex and nasopharynx tumors were treated at State University of New York Health Science Center at Brooklyn (Brooklyn, NY) with a regimen of split-course hyperfractionated radiation (120 cGy/fraction) and concomitant cisplatin infusion (5 to 7 mg/m2/24 hours). All of the patients had T4 tumors or massively recurrent disease with base of skull or facial bone involvement. Twelve patients were treated with curative intent receiving total doses of 6000 to 6960 cGy (modal 6750 cGy), whereas two patients were treated with less than 5000 cGy as palliation. Eleven of the 12 patients (92%) achieved a complete response, and 7 of 12 (58%) are alive at 35 to 72 months (mean, 47 months). Five patients are alive with no evidence of disease, and two with a local recurrence. Three patients died of distant disease, and two died from a local recurrence. When the response to treatment was analyzed based on tumor volume and radiation dose, only two of nine lesions measuring between 4 to 10 cm failed locally. The two palliative patients had almost complete local clearance of the disease but died at 2 and 8 months, respectively. In nine patients, the eye or optic nerve was included in the treatment field and received between 2000 to 6960 cGy. Only one of these nine patients had ophthalmic complication and this was confined to the cornea.     

Nonepithelial tumors of the nasal cavity, paranasal sinuses and nasopharynx: a clinicopathologic study. X. Malignant lymphomas.

In our series of 256 nonepithelial tumors involving the nasal cavity, paranasal sinuses and nasopharynx, 21 were apparently primary malignant lymphomas, including 17 ordinary lymphomas and 4 cases of "midline malignant reticulosis." Of the 15 patients who had ordinary lymphomas and had adequate follow-up, 8 died of lymphoma, 4 were living with disseminated disease, 1 died of other causes with persistent lymphoma and only 2 (13%) had no evidence of recurrence at 8 and 9 years after diagnosis. The tumor was controlled in its primary site by radiotherapy in 13 of 14 patients; however, all but 2 of these patients eventually developed disseminated disease. Of the 3 patients who had midline malignant reticulosis (MMR) and had adequate follow-up, all died of disease. MMR represents an unusual variant of malignant lymphoma and often produces the clinical picture of lethal midline granuloma.     

Anterior craniofacial resection — for paranasal sinus tumors involving anterior skull base

Management of anterior skull base tumors is complex due to the anatomic detail of the region and the variety of tumors that occur in this area. Currently, the “gold standard” for surgery is the anterior craniofacial approach. Craniofacial resection represents a major advance in the surgical treatment of tumors of the paranasal sinuses involving anterior skull base. It allows wide exposure of the complex anatomical structures at the base of skull permitting monobloc tumor resection. This study presents a series of 18 patients with anterior skull base tumors, treated by a team of head-neck surgeons and neurosurgeons. The series included 15 malignant tumors of the nose and paranasal sinuses and 3 extensive benign lesions. All tumors were resected by a combined bi-frontal craniotomy and rhinotomy. The skull base was closed with a pediculated pericranial flap and a split-thickness free skin graft underneath. There were no postoperative problems of wound infection, cerebrospinal fluid-leakage or meningitis. Recurrent tumor growth or systemic metastasis occurred in 3 out of 15 patients with malignant tumors, 6 months to 2 years postoperatively. Craniofacial resection was thus found to give excellent results with low morbidity in malignant lesions and can also be adapted for benign tumors of anterior skull base.     

Nonepithelial tumors of the nasal cavity paranasal sinuses, and nasopharynx: a clinicopathologic study. V. Skeletal muscle tumors (rhabdomyoma and rhabdomyosarcoma).

In a study of nonepithelial tumors involving the nasal cavity, paranasal sinuses, and nasopharynx, 19 lesions (three rhabdomyomas, 16 rhabdomyosarcomas) showed skeletal muscle differentiation. The clinical findings associated with these neoplasms are reviewed, the histologic features are illustrated, results of treatment are presented, and clinicopathologic correlations are discussed. The rhabdomyomas grew as localized masses in the nasopharynx, were excised locally, and behaved clinically like benign tumors. The rhabdomyosarcomas were found predominantly in children and were associated with a poor prognosis; most of the patients died within 2 years following diagnosis.     

Management of paranasal sinus malignancy

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

A dosimetric comparison of non-coplanar IMRT versus Helical Tomotherapy for nasal cavity and paranasal sinus cancer.

PURPOSES: To determine if there are clinically significant differences between the dosimetry of sinus tumors delivered by non-coplanar LINAC-based IMRT techniques and Helical Tomotherapy (HT). HT is capable of delivering highly conformal and uniform target dosimetry. However, HT lacks non-coplanar capability, which is commonly used for linear accelerator-based IMRT for nasal cavity and paranasal sinus tumors. METHODS AND MATERIALS: We selected 10 patients with representative early and advanced nasal cavity and paranasal sinus malignancies treated with a preoperative dose of 50 Gy/25 fractions without coverage of the cervical lymphatics for dosimetric comparison. Each plan was independently optimized using either Corvus inverse treatment planning system, commissioned for a Varian 2300 CD linear accelerator with 1cm multileaf collimator (MLC) leaves, or the HT inverse treatment planning system. A non-coplanar seven field technique was used in all Corvus plans with five mid-sagittal fields and two anterior oblique fields as described by Claus et al. [F. Claus, W. De Gersem, C. De Wagter, et al., An implementation strategy for IMRT of ethmoid sinus cancer and bilateral sparing of the optic pathways, Int J Radiat Oncol Biol Phys 51 (2001) 318-331], whereas only coplanar beamlets were used in HT planning. Dose plans were compared using DVHs, the minimum PTV dose to 1cm3 of the PTV, a uniformity index of planned treatment volume (PTV), and a comprehensive quality index (CQI) based on the maximum dose to optical structures, parotids and the brainstem which were deemed as the most critical adjacent structures. RESULTS: Both planning systems showed comparable PTV dose coverage, but HT had significantly higher uniformity (p<0.01) inside the PTV. The CQI for all organs at risk were equivalent except ipsilateral lenses and eyes, which received statistically lower dose from HT plans (p<0.01). CONCLUSIONS: Overall HT provided equivalent or slightly better normal structure avoidance with a more uniform PTV dose for nasal cavity and paranasal sinus cancer treatment than non-coplanar LINAC-based IMRT. The disadvantage of coplanar geometry in HT is apparently counterbalanced by the larger number of fields.     

Nonepithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. A clinicopathologic study. XIII: Meningiomas

Twelve cases of meningiomas involving the nasal cavity and paranasal sinuses are reported. Meningiomas only rarely involve the upper respiratory tract; these 12 cases were found among the 566,000 surgical pathology cases that have been studied in this laboratory. In this series, five meningiomas probably arose in the cranial cavity and secondarily extended into the nasal cavity and paranasal sinuses. Because radiographs demonstrated hyperostosis or bone destruction, three other tumors could have involved the cranial cavity, but this was never proven. In two other cases, the meningiomas appeared to involve only extracranial tissues and thus probably were primary extracranial lesions. (The data available in two other cases were insufficient to assess the possibility of intracranial involvement). These patients clinically had nonspecific signs and symptoms similar to those produced by other types of neoplasms growing in the upper respiratory tract. The tumor involved the sphenoid area in seven cases, the nasal cavity in six, the maxilla in five, the ethmoid sinus in four, and the frontal sinus in one. The diagnosis was first established when biopsy material was examined, although in several cases the presence of meningioma was first suggested on radiographic examination. Treatment depended upon the size and location of the tumor. In some cases, surgical resection appeared to control the lesion. These tumors did not appear to respond well to radiotherapy. The histologic differential diagnosis is discussed.     

Nonepithelial tumors of the nasal cavity, paranasal sinuses, and nasopharynx. A clinicopathologic study. XIV: Chordomas

Twenty cases of a rare tumor, chordoma involving the nasal cavity, paranasal sinuses, or nasopharynx, are reported. Patients most often had localized headache, nasal obstruction, decreased hearing, or symptoms related to cranial nerve involvement, especially diplopia. A mass bulging into the nasopharynx, posterior nasal cavity, or pharynx was found on physical examination in 13 of these 20 patients, and in another 6 patients on radiologic examination. Paralysis of one or more cranial nerves was identified in the majority of patients who had tumors involving the upper nasopharynx. On radiologic examination, bone destruction was frequently identified in the clivus and sphenoid areas, and less commonly in the cervical vertebrae. Each patient had biopsy-proven tumor in the nasopharynx or sphenoid areas. Patients usually were treated by combinations of surgery and radiotherapy, in some cases leading to prolonged periods of apparent tumor control. Radiotherapy frequently resulted in regression of symptoms, sometimes lasting many months or years. A few tumors that involved mainly the lower nasopharynx were more amenable to surgical resection, in one case leading to apparent tumor control. In those cases with adequate follow-up information, most patients had either died of their disease or were living with recurrent or persistent inoperable tumor. Some patients lived for many months or years between recurrences or with known tumor, indicating that chordomas often are slowly growing neoplasms. The histologic features of these chordomas are described and illustrated, and the histopathologic differential diagnosis is discussed.     

Chondrosarcoma of nose and paranasal sinus - a rare presentation

Chondrosarcoma, the most malignant cartilageneous tumor, constitute only 4% of non-epithelial tumours of the nasal cavity, paranasal sinuses and nasopharynx, making it one of the rarest malignancies. Here we present a case of Grade 1 chondrosarcoma involving nose, maxillary sinus, ethmoids and sphenoid sinus managed surgically by wide excision. 12 months follow-up reveled no recurrence or complication.     

Computed tomography of the paranasal sinus and nasal cavity tumours.

One hundred and thirty seven patients with suspected neoplasms of paranasal sinuses and nasal cavity were studied with conventional radiography and C.T. Scan. Significantly greater tumour extent was detected on C.T. due to 3 - Dimensional demonstration of tumours. C.T.Scan was extremely helpful in diagnosing the primary site of tumour and tumour recurrence in treated cases. This information had pronounced effect on patient management and prognosis determination. C.T. was also helpful in differentiating certain benign conditions such as fibro-osseous lesions and inflammation without bony erosion from malignant tumours. The importance of C.T. scan in these neoplasms is discussed here.