Oncocytic Schneiderian Papilloma of the Sinonasal Tract Treated With Radiotherapy.

A 66-year-old man visited the ophthalmology department due to epiphora and was subsequently diagnosed with oncocytic schneiderian papilloma. Surgical removal was recommended to the patient; however, he refused this option. Therefore, a radiation of 64 gray (Gy) was administered in 32 daily doses (2 Gy daily) over 45 days using intensity-modulated radiotherapy. Four months after radiotherapy, the tumor had disappeared. Two years postradiotherapy, the patient was healthy, without tumor recurrence or the development of orbital complications. The authors suggest that radiotherapy could be an adjuvant or definite treatment modality for patients of oncocytic schneiderian papilloma unsuitable for complete surgical removal, or those associated with a high risk of surgery-related complications.

Lymph node metastasis in sinonasal squamous cell carcinoma treated with IMRT/3D-CRT.

OBJECTIVES: To analyze the patterns of neck and retropharyngeal lymph nodes (RPLNs) metastases with magnetic resonance imaging (MRI) in patients with sinonasal squamous cell carcinoma (SCC), and to explore the patterns of treatment failure treated with intensity modulated radiotherapy (IMRT) or three-dimensional conformal radiotherapy (3D-CRT). We also attempt to discuss the role of elective neck irradiation (ENI) in the treatment of cervical negative patients. MATERIALS AND METHODS: Between July 2004 and February 2011, 59 patients with histopathologically proven sinonasal SCC were treated with curative intent at our hospital. Among them, 18 (30.5%) patients had neck or RPLN lymph node involvement at diagnosis. RPLN, level Ib, and level IIa were the most common sites of initial nodal involvement. All patients received IMRT or 3D-CRT, while 19 patients further received surgical resection, and other 40 patients received cisplatin based chemotherapy. Median follow-up durations were 28 months (range, 6-81 months) for the entire patient population and 40 months (range, 7-81 months) among the surviving patients, respectively. RESULTS: The estimated 3-year local-regional control rate, distant-metastasis free survival rate, disease-free survival rate, and overall survival rate were 63.3%, 81.9%, 60.1%, and 68.9%, respectively. On multivariate analysis, old age (>60 years) significantly influenced the overall survival rate(HR=9.428, p=0.000). As for the pattern of treatment failures developed in 26 patients in the follow-up time, local failure, neck recurrence, and distant metastases were seen in 18, 7, and 9 patients, respectively. Level Ib and level IIa were the most common sites of cervical nodal recurrence. None of the 11 patients who received ENI developed failure in the neck. CONCLUSION: For sinonasal SCC patients treated with IMRT or 3D-CRT, our results were generally consistent with findings of other studies, local failure still remain the predominant pattern of treatment failure. However, RPLN metastasis occurred more frequently than previously recognized through detection by MRI in our study. ENI seems to have effectively prevented regional relapse. We recommend ipsilateral level Ib and level IIa neck irradiation for T3-4 sinonasal SCC patients.

[Post-radiation mucocele in two patients treated for nasopharyngeal cancer]. / Mucocèle après radiothérapie chez deux patients traités pour cancer du nasopharynx.

A 30-year-old woman, with a history of nasopharyngeal carcinoma, which was treated by radiotherapy nine years previously, presented with occasional diplopia and recent headaches. A nasopharyngeal biopsy showed no recurrence. The imaging revealed a sphenoidal sinus mucocele. Endoscopic marsupialization of the mucocele allowed clinical improvement. A 56-year-old woman presented, five years after radiotherapy for nasopharyngeal carcinoma, with a fronto-orbital mass. CT-scan revealed a fronto-ethmoidal mucocele. Nasopharyngeal biopsy showed tumour recurrence. Marsupialization of mucocele was performed. Recurrence of the carcinoma was treated by radiotherapy and chemotherapy. Sphenoidal sinus mucocele developing after radiotherapy for nasopharyngeal carcinoma has rarely been reported. CT scan and MRI are useful tools in making the diagnosis. Biopsy is required to diagnose recurrence or associated radio-induced tumor. Endoscopic approach gives good results.

Comparison of dose-volume histograms of IMRT treatment plans for ethmoid sinus cancer computed by advanced treatment planning systems including Monte Carlo.

BACKGROUND AND PURPOSE: To recompute clinical intensity-modulated treatment plans for ethmoid sinus cancer and to compare quantitatively the dose-volume histograms (DVHs) of the planning target volume (PTV) and the optic organs at risk. MATERIAL AND METHODS: Ten step-and-shoot intensity-modulated treatment plans were enrolled in this study. Large natural and surgical air cavities challenged the calculation systems. Each optimized treatment plan was recalculated by two superposition convolution (TMS and Pinnacle) and a Monte Carlo system (MCDE). To compare the resulting DVHs, a one-way ANOVA for repeated measurements was performed and multiple pairwise comparisons were made. RESULTS: The tails of the PTV-DVHs were significantly higher for the Monte Carlo system. The DVHs of the critical organs displayed some statistically but not always clinically significant differences. For the individual patients, the three planning systems sometimes reproduced clinically discrepant DVHs that were not significantly different when averaged over all patients. CONCLUSIONS: Dose to air cavities contains computational uncertainty. As this dose is clinically irrelevant and optimizing it is meaningless, we recommended extracting the air from the PTV when constructing the PTV-DVH. The planning systems considered reproduce DVHs that are significantly different, especially in the tail region of PTV-DVHs.

Long-term results of ethmoid squamous cell or undifferentiated carcinoma treated with radiotherapy with or without surgery.

PURPOSE: Ethmoidal malignant tumors, for which intensity-modulated radiotherapy is expected to improve outcome, consist of heterogeneous pathological types. Reports about their outcome are influenced by the inclusion of favorable histology, such as adenocarcinoma and adenoid cystic carcinoma. We investigated the long-term treatment outcome of squamous cell carcinoma and undifferentiated carcinoma of the ethmoid sinus. MATERIALS AND METHODS: Between August 1976 and April 2002, 25 patients (20 squamous cell carcinomas and five undifferentiated carcinomas) received radical radiotherapy or preoperative radiotherapy in our institution. One (4%) had stage T2 disease, seven (28%) had stage T3, three (12%) had stage T4a, and 14 (56%) had stage T4b. Surgery was performed in 13 patients. Radiation dose varied from 50.4 Gy in 16 fractions (50.4 Gy/16 Fr) to 65 Gy in 26 fractions with or without stereotactic boost irradiation. Eleven patients received chemotherapy consisting mainly of platinum-based compounds. RESULTS: The 3- and 5-year overall survival rates for all 25 patients were 34% (95% confidence interval [CI]: 14%-54%) and 24% (CI: 6%-42%), respectively. The 3- or 5-year local progression-free rates for all patients were 48.9% and 36.7%, respectively. Visual acuity of a single eye was impaired in three patients and was lost in five patients as a result of tumor progression, but no patient had visual impairment or loss due to radiotherapy. CONCLUSION: Ethmoid squamous cell carcinoma or undifferentiated carcinoma was diagnosed at advanced T stages and was treated with radiotherapy; these patients had a poorer outcome than patients with adenocarcinoma or adenoid cystic carcinoma. Prospective trials using advanced technology should be carefully compared with historical controls because pathological types can considerably influence the treatment results.

[Intensity modulated radiotherapy (IMRT) of head and neck tumors. Increased biological effectiveness in high-risk situations by "integrated boost" therapy]. / Intensitätsmodulierte Bestrahlung (IMRT) von Kopf-Hals-Tumoren. Höhere biologische Wirksamkeit in Risikosituationen durch "integrierten Boost"

Primary tumors of the paranasal sinuses are rare entities which, because of precarious localization and frequently diffuse propagation into neighbouring cavities and the skull base, pose a significant therapeutic problem. Even after complete surgical resection, local relapses are frequent. Postoperative radiotherapy is therefore usually indicated. Intensity modulated radiotherapy (IMRT) is a new technique that helps creating dose distributions that conform closely to the target volume while maximally sparing the organs at risk. This results in the possibility of applying escalated doses to the target while still keeping the incidence of side effects low. What is especially appealing is the possibility of shaping the dose distribution within the target in such a way that areas with a presumably high tumor cell load receive increased doses, a concept which is best described by the term "integrated boost". We present the case of a patient with a sinunasal carcinoma and describe the implications of the clinical implementation of this technique.

Effect of ethmoid sinus cavity on dose distribution at interface and how to correct for it: magnetic field with photon beams.

Recent work proposed the use of magnetic field as a solution to reduce the undesirable effect of air cavities on dose after the air/tissue interface. In contrast to the published work that looks into the problem with slab geometries, in this work we use actual anatomy based on CT images and the magnetic flux from a Helmholtz coil-pair configuration to investigate the problem and to evaluate the efficacy of the proposed solution. The EGS4 phantom was created using CT scans of the head at the level of the ethmoid sinus. The sinus measures 1.95 x 2.18 x 2.00 cm3. The grid size used is 0.15 x 0.15 x 0.4 cm3. Three different radiation beams, 1 x 1, 2 x 2, and 4 x 4 cm2, all 6 MV irradiate the phantom in two different configurations: single beam and parallel opposed. The magnetic field has three different strengths: 0.0, 0.5, and 1.0 T. These represent the maximum strength achieved in the middle of the configuration, between the two coils. The depth of the second buildup region in the absence of the magnetic field was used as the normalization point for the purpose of analysis. Dose was then scored at 0.23 cm after the air/tissue interface. A second phantom, very similar to the CT-based phantom, was created, but with the sinus cavity filled with unit-density tissue; everything else remained the same. This phantom provides a base to investigate the effect of the air cavity on dose. The phantom was termed the phantom without air, or PWA for short. We use the terms "dose reduction ratio" (DRR), defined as one minus the ratio of the dose in PWA to the dose with the presence of the cavity multiplied by 100% and the "dose improvement ratio" (DIR), defined as the ratio of dose with B to that without B, to evaluate the reduction in dose due to the cavity and the improvement in dose with magnetic field, respectively. For single beam geometry, the reduced dose ranged from 41% (1 x 1 cm2 beam) to less than 2% (4 x 4 cm2 beam). For the same single beam geometry, DIR ranged from 1.13 to 1.00 (DIR = 1 indicates no change) with 0.5 T, whereas it ranged from 1.44 to 1.05 for 1.0 T magnets. When an opposing beam was used, the reduced dose was not as severe, such that DRR ranged from 24% to less than 2%. Whereas the dose improvement ranged from 1.08 to 1.00 for 0.5 T, and from 1.23 to 1.01 for 1.0 T.

[Combined transfacial and neurosurgical approach for the treatment of ethmoid cancers]. / Evaluation de la voie d'abord combinée transfaciale et neurochirurgicale dans le traitement des cancers de l'ethmoïde.

OBJECTIVES: The purpose of this work was to examine the indications for the combined transfacial and neurosurgical approach to ethmoid cancers. PATIENTS AND METHODS: Fifteen patients with ethmoid cancers underwent surgery via the combined approach between 1990 and 2000 at the Amiens University Hospital. The transfacial approach alone was reserved for elderly patients. RESULTS: The histological diagnosis was adenocarcinoma in 10 patients. There was one postoperative death. Mean follow-up was 45 months (range 3 - 129). Six patients died from local or metastatic recurrence. At last follow-up eight patients were disease free, two had local or metastatic recurrence. CONCLUSION: We compared systematic use of the combined approach for curative surgery with surgical strategies adopted by other teams. The combined approach is indicated for T3 or T4 tumors and for all other tumors with a posterior or superior extension. Anterior and unilateral tumors may be treated with the transfacial access alone. Limited tumors without extension to the orbit or cribiform plate may be managed endoscopically. The role of histological diagnosis and the choice of the surgical approach remain to be evaluated.

Report of a study on IMRT planning strategies for ethmoid sinus cancer.

AIM: This communication reviews the planning strategies and dose statistics of nine IMRT plans generated for a complex head and neck case. PATIENT AND METHOD: An ethmoid sinus cancer case was sent as an IMRT planning task to all participants of the ESTRO course on "IMRT and Other Conformal Techniques in Practice", held in Amsterdam in June 2001. RESULTS: Nine IMRT plans were generated for the case, the majority of the plans generated with commercial planning systems. The number of beam incidences ranged between four and eleven, while five of the nine beam setups were coplanar. The planning target volume dose homogeneity was inversely correlated with the degree of sparing of the surrounding organs at risk. CONCLUSION: IMRT strategies for complex head and neck cases, such as ethmoid sinus cancer, can be strikingly different in various aspects, such as beam setup, total number of segments, PTV dose coverage and dose statistics for organs at risks.

[Adenoid cystic carcinomas invading the skull base. Apropos of 4 cases and review of the literature]. / Carcinomes adénoïdes kystiques envahissant la base du crâne. A propos de 4 observations et revue de la littérature.

Head and neck adenoid cystic carcinomas may invade the adjacent skull base by bone lysis and/or by perinervous and perivascular spread within the skull base foramina. Neurosurgical decision making is not well defined regarding the extent of intracranial tumor component removal, as neurosurgical expertise is limited for this peculiar type of tumors. The issue is to decide whether a radical supposedly locally curative surgery should be attempted, or if a large non disfigurating surgery is mandatory, keeping in mind the frequency of local recurrences and of distant metastases. Over a 13-year period, four adenoid cystic carcinomas invading the skull base were operated on at our institution: two tumors originated in the parotid gland, one in the sphenoid sinus, and one in the ethmoid sinus. Surgical removal was total in one case, subtotal in three cases. Post-operative irradiation was delivered in the four patients (two neutron irradiation, two conventional). One patient with advanced metastatic disease was submitted to chemotherapy. Three patients died from local tumor progression and distant metastases within three years after the intracranial tumor extension has been diagnosed. The patient with an ethmoid tumor is still alive seven years after surgery without any evidence of local tumor progression nor distant metastases. Surgery remains the gold standard treatment for adenoid cystic carcinomas invading the skull base. However, in our opinion a large tumor removal, without or with bone osteotomies, but without sacrifice of cranial nerves, cavernous sinus, internal carotid artery, and of the orbit allows patient survival with an acceptable comfort and absence of psychological distress due to disfigurating surgery nor surgically induced neurological functional deficit. Post-operative irradiation may sometimes stabilize locally the lesions. The place of chemotherapy has, yet, to be determined.

Effects of radiotherapy for nasopharyngeal carcinoma on the paranasal sinuses: study based on computed tomography scanning.

OBJECTIVE: The purpose of this study was to determine if radiotherapy for nasopharyngeal carcinoma causes mucosal disease of the paranasal sinuses. DESIGN: This study was a retrospective study. SETTING: This study was conducted at a tertiary care centre. METHOD: A series of 69 newly diagnosed patients, without pre-existing sinus disease, who were treated with high-dose radiotherapy participated. MAIN OUTCOME MEASURES: The prevalence, severity, and time course of mucosal abnormalities were analyzed, as judged by consecutive computed tomographies (CTs). RESULTS: The CT study revealed that 58.8% of the postirradiation scans had mucosal disease of the sinuses. The maxillary sinus had the highest prevalence (42.3%) without statistical significance (p = .10). The difference by McNemar test for two follow-up scans was not significant (p = .48) and by Kappa test was significant (p = .04). The relationship between the prevalence and the time course post radiotherapy revealed that it remained a high prevalence until after the 4-year follow-up scans. CONCLUSIONS: The results of this study confirm that chronic sinus disease is a common late complication of radiotherapy and it persists for years. Thus, aggressive treatment is indicated.

Surgical salvage after failed radiation for paranasal sinus malignancy.

OBJECTIVE: To comment on the role of surgical salvage following failed initial treatment for paranasal sinus malignancy. DESIGN: A retrospective analysis of one hundred eighty patients treated at The Princess Margaret Hospital, Toronto, from 1976 to 1993. MATERIALS AND METHODS: Thirty-four of 95 patients (36%) who failed initial treatment underwent surgical salvage. Initial therapy in this group was radiation only (n = 27) and combined therapy (n = 7). Patient, tumor, and surgical data were recorded. There were 23 T4, three T3, six T2, and two T1 carcinomas. Survival, recurrence rates, and the influence of a variety of variables on outcome were analyzed. RESULTS: Two- and 5-year overall actuarial survival calculated from the date of diagnosis was 54% and 35%, respectively. Two- and 5-year overall actuarial survival calculated from the date of salvage surgery was 44% and 22%, respectively. Advanced age (P < .004), patients with T4 category disease (P < .04), and squamous cell carcinomas (P < .049) correlated with poorer outcome on univariate analysis. Local failure was the most common cause of death (n = 13; 65%). CONCLUSION: Salvage surgery has a limited role in the management of persistent or progressive disease following failure of initial treatment. Careful postradiation surveillance with endoscopic biopsy under general anesthesia and immediate surgical resection when appropriate may improve the salvage rate.

Effect of a topical vasoconstrictor on computed tomography of paranasal sinus disease.

Apparent ethmoid inflammation which resolved with alternation of the nasal cycle or following application of topical vasoconstrictors has been observed with magnetic resonance imaging. A similar phenomenon might occur to a lesser degree with computed tomography (CT), leading to overdiagnosis of limited sinus disease. The degree to which ostiomeatal complex disease is reversible by topical vasoconstrictors was investigated. Ten patients with histories of chronic or recurrent sinusitis underwent coronal CT studies of the paranasal sinuses before and after the application of a topical vasoconstrictor. Mucosal volume or thickness measurements were obtained from the turbinates, infundibulum, ethmoidal cells, and antrum. Vasoconstrictor application markedly reduced turbinate size and appeared to reduce mucosal thickening in the ethmoidal infundibulum. Minimal mucosal changes identified in the paranasal sinuses by computed tomography were not reversed by vasoconstrictors and therefore are likely to be pathologic.

[Ultrasonic ethmoidotomy combined with intracavitary magnetotherapy in chronic polypous ethmoiditis]. / Ul'trazvukovaia étmoidotomiia v sochetanii s vnutripolostnoi magnitoterapiei pri khronicheskom polipoznom étmoidite.

The efficacy of ultrasonic ethmoidectomy combined with magnetic therapy was investigated in 90 patients. Ultrasonic ethmoidectomy was applied with the help of a LORA system consisting of a generator and an acoustic unit connected to a waveguide with a spoon-shaped end (44 Hz frequency and 35-40 microns amplitude). Under visual control the ultrasonic spoon was inserted into the meatus nasi medius, and the injured medial, superior and some anterior cells of the ethmoidal bone were opened. Bone trabecules of the cells were removed together with the polypous mucous membrane and polyps, by moving the concave surface forwards and keeping the long axis of the bent portion of the spoon in the vertical position. Follow-up of the treated patients during 6 months to 4 years revealed the absence of polyps in 79.7%. Repeated application of this treatment in the case of severe recurrent forms of polypous ethmoiditis improved the therapeutic efficacy.

Postirradiation optic neuropathy in antral carcinoma.

A case is described of a patient who developed radiation-induced optic neuropathy 18 months following cobalt-60 irradiation for carcinoma of the left maxillary antrum and ethmoid sinus. This case is unusual because of the early onset of the optic nerve damage following radiation therapy and the ultimate emergence of the eye involved by tumor compression as the better eye in terms of visual acuity.