Clinical Investigation
Unresectable Carcinoma of the Paranasal Sinuses: Outcomes and Toxicities

https://doi.org/10.1016/j.ijrobp.2008.01.038Get rights and content

Purpose

To evaluate long-term outcomes and toxicity in patients with unresectable paranasal sinus carcinoma treated with radiotherapy, with or without chemotherapy.

Methods and Materials

Between January 1990 and December 2006, 39 patients with unresectable Stage IVB paranasal sinus carcinoma were treated definitively with chemotherapy plus radiotherapy (n = 35, 90%) or with radiotherapy alone (n = 4, 10%). Patients were treated with three-dimensional conformal radiotherapy (n = 18, 46%), intensity-modulated radiotherapy (n = 12, 31%), or conventional radiotherapy (n = 9, 23%) to a median treatment dose of 70 Gy. Most patients received concurrent platinum-based chemotherapy (n = 32, 82%) and/or concomitant boost radiotherapy (n = 29, 74%).

Results

With a median follow-up of 90 months, the 5-year local progression–free survival, regional progression–free survival, distant metastasis–free survival, disease-free survival, and overall survival were 21%, 61%, 51%, 14%, and 15%, respectively. Patients primarily experienced local relapse (n = 25, 64%), mostly within the irradiated field (n = 22). Nine patients developed neck relapses; however none of the 4 patients receiving elective neck irradiation had a nodal relapse. In 13 patients acute Grade 3 mucositis developed. Severe late toxicities occurred in 2 patients with radionecrosis and 1 patient with unilateral blindness 7 years after intensity-modulated radiation therapy (77 Gy to the optic nerve). The only significant factor for improved local progression–free survival and overall survival was a biologically equivalent dose of radiation ≥65 Gy.

Conclusions

Treatment outcomes for unresectable paranasal sinus carcinoma are poor, and combined-modality treatment is needed that is both more effective and associated with less morbidity. The addition of elective neck irradiation may improve regional control.

Introduction

Cancers of the paranasal sinuses are rare and make up only 5% of all head-and-neck cancers (1). Complete surgical resection followed by postoperative radiotherapy is associated with the best overall survival and local control in patients diagnosed with cancer of the paranasal sinuses, with 5-year local control rates of 40% to 79% compared with 20% to 50% when treated with definitive radiotherapy or chemoradiotherapy 2, 3, 4, 5, 6. Unfortunately some patients are diagnosed with unresectable disease with involvement of the nasopharynx, clivus, middle cranial fossa, dura, brain, or the orbital apex. These patients are not candidates for gross total resection and are typically treated with either definitive radiotherapy or a combination of chemotherapy and radiotherapy.

Outcomes in patients with unresectable paranasal sinus cancers have not been reported adequately in the literature. Most studies are small, single institution retrospective evaluations of heterogenous populations of patients treated over several decades with a variety of histologic findings and disease stages, and with a variety of treatment modalities 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14. As a result, these studies are limited in their analysis and discussion regarding the group of patients with unresectable disease. Furthermore, one must typically infer the results either from the outcomes of patients with AJCC Stage IV disease (which can include both resectable Stage IVA and unresectable Stage IVB disease) or from the outcomes of patients treated with definitive radiotherapy (which could include patients with resectable disease).

At Memorial Sloan-Kettering Cancer Center, all patients diagnosed with carcinoma of the paranasal sinuses are evaluated initially by a head-and-neck physician at the institution to determine resectability. All patients who are believed to be suitable for operation undergo gross total resections and, depending on the stage and margin status, may receive adjuvant radiation with or without chemotherapy. Only patients with unresectable disease are offered definitive treatment with radiation, with or without chemotherapy.

The present study describes our experience over the last 18 years treating patients with unresectable carcinoma of the paranasal sinuses. To our knowledge, this is the first study to include this patient subgroup only.

Section snippets

Study patients

Between January 1990 and December 2006, 164 patients with diagnoses of paranasal sinus or nasal cavity carcinoma (identified by ICD-9 codes) who were treated at our institution were evaluated in the Department of Radiation Oncology. Only those patients with biopsy-proven histologic findings for carcinoma were included. Patients with melanoma, sarcoma, lymphoma, rhabdomyosarcoma, esthesioneuroblastoma, plasmacytoma, metastatic disease, or noninvasive disease (in situ) were excluded. Patients

Treatment outcomes

The median follow-up time for surviving patients was 90 months and for all patients was 20 months. The 5-year LPFS, RPFS, and DMFS were 20%, 61%, and 51%, respectively (Fig. 1a). The 5-year DFS and OS were 14% and 15%, respectively (Fig. 1b).

Local recurrence developed in 25 patients and was the first site of relapse in 23 of the patients. The median time to local relapse was 10 months (range, 3–62 months). Relapses occurred within the irradiated region in 22 patients, on the margin of the

Discussion

Patients with cancer of the paranasal sinuses have been shown to have optimal outcomes when treated with a multimodality approach including surgery and radiotherapy 2, 3, 4, 5. However these outcomes are based on small retrospective series, and those patients who did not undergo surgery typically had diffusely infiltrating disease that could not be completely resected. To avoid confusion and in light of prior data, recent modifications to the AJCC staging system for carcinomas of the paranasal

Conclusions

Long-term outcomes for patients with unresectable paranasal sinus carcinoma are poor. More aggressive therapy, including high-dose radiotherapy to ≥65 Gy in combination with concurrent cisplatin, may improve outcomes. A reduction in treatment-related morbidity in the face of dose escalation may be possible by the integration of image-guided radiotherapy or by the use of either proton therapy or intensity-modulated proton therapy.

References (33)

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Portions of this project were presented at the 18th annual meeting of the American College of Radiation Oncology (ACRO), February 21–23, 2008, Miami, FL.

Conflict of interest: none.

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