- Email: [email protected]
Squamous carcinoma of the nasal cavity and paranasal sinuses
Squamous
Carcinoma of the Nasal Cavity and Paranasal Sinuses
Jeffrey D. Spiro,
MD,
Kee Chee Soo,
MD,
This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 ( 10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital eontents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.
0 paranasal sinuses remains uncertain. Treatment decisions are complicated by the fact that tumors are often ptimal management of cancers of the nasal cavity and
locally advanced when first seen and are difficult to accurately assess. Interpretation of results is complicated by the lack of uniformity in clinical staging systems and the tendency to lump together different tumor types. Some years ago, we reported that 28 percent of determinate patients with nasal or paranasal sinus cancer were alive and well 5 years postoperatively [I]. Unfortunately, this study did not utilize clinical staging, and there was no analysis by histologic diagnosis. We have reviewed our experience with patients treated for carcinoma of the nasal cavity and paranasal sinuses during a more recent period, when we were increasingly committed to the use of surgery and radiotherapy in combination. Our goals were to compare our results and to assess the impact of combination therapy. MATERIAL
AND METHODS
The records of all patients with malignant neoplasms of the nasal cavity and paranasal sinuses seen at MemoriFrom the Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York. Requests for reprints should be addressed to Ronald H. Spiro, MD, 1275 York Avenue, New York, New York 10021. Presented at the 35th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 21-24,1989. 328
THE AMERICAN JOURNAL OF SURGERY
Ronald H. Spiro,
MD, NW
York,NW
York
al Sloan-Kettering Cancer Center between January 1966 and December 1982 were retrospectively reviewed. After excluding 16 patients with incomplete records, 224 patients remained for analysis. Of this group, 105 patients who received definitive therapy for squamous carcinoma were selected for this report. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). There were 70 men and 35 women, whose ages ranged from 27 to 8 1 years (median 60 years). Of the 65 patients with maxillary sinus cancer, 10 (15 percent) had recurrent tumor after treatment elsewhere, whereas this was true for 17 of 40 patients (43 percent) with primary tumors in the nasal cavity or ethmoid or sphenoid sinuses. For the purpose of this study, patients who underwent a Caldwell-Luc procedure or a polypectomy were considered to be previously untreated. Previously untreated patients with maxillary sinus lesions were retrospectively staged according to the TNM staging system. Two, 8,32, and 13 patients had T1 through T4 primary lesions, respectively. Only five patients had clinical evidence of nodal involvement initially, all of whom had T3 or Tq disease. The most common presenting complaints of those patients with maxillary sinus cancer were pain and nasal obstruction, and the most frequent physical finding was a mass in the cheek. Among the patients with tumors located at other sites, epistaxis and nasal obstruction were the most common symptoms, and a mass in the nasal cavity was the most frequent finding on examination. All patients were eligible for a minimum of 60 months follow-up. Comparison of the alive and well patients to the total eligible for follow-up yielded absolute cure rates. More relevant net, or determinate, cure rates were calculated by excluding as indeterminate any eligible patients who were free of disease when they either died from other causes or were lost to follow-up. In addition, cumulative survival rates were calculated according to the productlimit method of Kaplan and Meier [2]. Treatment: Maxillary sinus. Among the total of 65 patients, 11 were treated with radiotherapy only, 19 had surgery only, and 35 received surgery and adjunctive radiotherapy. Surgery alone was used in most previously treated patients (8 of 10). Most of the 55 patients receiving primary therapy were treated with combinations of surgery and radiotherapy (34 of 55), whereas single modality treatment was used in the remainder (radiotherapy alone in 10 patients; surgery alone in 11 patients). It was clear that the treatment groups were not comparable; 7 of the 10 patients treated with radiotherapy alone had Tq primary lesions, and 7 of the 11 patients treated with surgery alone had Ti or TZ primary tumors. Most of the patients who received combination therapy had T3 lesions.
VOLUME 158 OCTOBER 1989
Most resections included exe&rations of the nasal contents, ethmoid contents, or both, either alone (seven of 54). Total maxillectomy, which included removal of patients), in conjunction with a partial maxikctomy the entire maxiha with preservation of the orbital con- (eight patients), or as part of combined craniofacial excitents, was performed in eight patients. Partial maxilleo sion (six patients). Radical maxillectomy with orbital and tomy, which preserved the orbital floor, was used in six ethmoid exenteration was performed in four patients and patients. wide local excision in five patients. The orbital contents Only 10 patients were treated with radiotherapy were sacriticed in 6 of 33 surgically treated patients (18 alone, 7 of whom received at least 6,000 cGy. Most pa- percent). Of the seven patients treated with radiotherapy tients treated with combination of surgery and radiother- alone, six received at least 6,000 cGy. apy received the radiotherapy postoperatively(27 of 35), In the small group of patients treated with combinaand 18 of these patients received at least 5,000 cGy. tion therapy, five patients received radiotherapy preoperSeven patients receivedpreoperative radiotherapy, which atively, six postoperatively, and one both preoperatively consisted of no more than 4,000 cGy. One patient re and postoperatively. Preoperative doses ranged widely, ceived both preoperative and postoperativetreatment. In and all patients treated postoperatively received at least general, the reasons for adjunctive radiotherapy could not 5,ooo cGy. be ascertained in this retrospective review. Other sites. Patients with primary tumors in the nasal RESULTS There were no postoperative deaths. Minor wound cavity, ethmoid sinuses, and sphenoid sinuses were treated with radiotherapy alone and surgery alone in 7 and 2 1 complications occurred in nine patients, including slough instances, respectively. Twelve patients received combi- of a skin graft in four patients and infection in three. nations of surgery and radiotherapy. As with antral pri- There were four cases of meningitis and two of brain mary lesions, the majority of previously treated patients abscess. These problems occurred with similar frequency ( 12of 17) receivedsurgery only. Most previouslyuntreat- in irradiated and nonirradiated patients. Pulmonary emed patients in this group were treated with singlemodality bolus occurred in one patient, and another patient had therapy as well (14 of 23). Lacking accepted staging sign&ant aspiration. Other complications included concriteria for these nasal, ethmoid, and sphenoid tumors, it gestive heart failure (two patients), parotitis (one pawas diftlcult to compare the different treatment groups. tient), and hypercalemia (one patient). More than two-thirds of surgically treated patients had a radical maxillectomyand orbital exenteration (39
1. -
ANTRUM
(nm66)
NASAL hm27)
0.8
ETHWSPHEN
(nmll)
0.6
0.4
0.2
0 0
I
I
I
I
I
1
2
3
4
5
Time in Yrs THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 OCTOBER 1989
329
-
0
1
2
3
4
STAGES $2 MO)
+
STAGE 3 h32)
+I+
STAGE 4 (n=l3)
5
Time in Yrs
0.2 -
0
NO PREV RX h78)
-i-
PREV RX’D h=27)
I
I
0
-
1
I
I
I
I
2
3
4
5
Time in Yrs
The 5-year determinate cure rate for the entire group was 37 percent. When analyzed by site, patients with nasal cavity lesions had the highest cure rate (43 percent), followed by those with maxillary sinus cancer (38 percent). Patients with ethmoid sinus lesions had the lowest cure rate (13 percent). One of two patients with sphe noid sinus cancer remained alive and well 5 years postoperatively. Patients treated for recurrent tumors had a 5-year determinate cure rate of only 20 percent. Cure rates were substantially higher in those patients with nasal cavity or maxillary sinus cancer who received their primary treatment at Memorial Hospital, with 62 percent and 42 percent, respectively, alive and well 5 years postoperatively. 330
THE AMERICAN JOURNAL OF SURGERY
Determinate cure rates were 100 percent, 86 percent, 39 percent, and 25 percent 5 years postoperatively for stage 1 through 4 lesions, respectively, but the subsets were too small for statistical significance. Similarly, actuarial analysis showed a trend toward better survival in patients with nasal lesions (Figure l), stage I or II disease (Figure 2), and no previous treatment (Figure 3), but the diierences were not statistically significant. The pattern of treatment failure for patients with maxillary sinus cancer is illustrated in Figure 4. Isolated local recurrence was most common, followed by isolated distant recurrence. Neck metastases in the absence of local treatment failure were unusual. The sites of recurrence in patients with nasal cavity, ethmoid, or sphenoid
VOLUME 158 OCTOBER 1989
NASALCAVITYANDPAllANASALSlNUSCAMXNOMA
cancer were similar to those seen with anti-al cancer. Previous treatment appeared to have little impact on the site of treatment failure. COMMENTS The problems encountered in treating cancer of the nasal cavity and paranasal sinuses are well established. Early symptoms are often ignored, and the majority of patients present with locally extensive disease. In this report, 82 percent of the patients with previously untreated antral lesions had stage III or Iv disease. The complex anatomy of the nasal cavity and paranasal sinuses and their proximity to the orbit and skull base pose major problems in staging and treatment planning. It should be noted that this study antedated the use of computed to mography scanning, which has already demonstrated its value in assessing tumor extent. Additional improve merits can be expected as threedimensional imaging is perfected. Treatment results were difficult to compare. To simplify the analysis, we included only patients with squamous carcinoma and attempted to group them according to the site of origin. Obviously, this can be diff&zultwhen tumors are extensive, because the nasal cavity and sinuses are contiguous. Notwithstanding the variety of treatments used, the inconsistency in staging, and the limited number of patients, we believe that the cure rate has improved some what since our last report, particularly in our patients with maxillary sinus cancer. Moreover, our results for maxillary sinus and nasal cavity cancer are comparable to those reported by others [ 3-101. The exception concerns recent reports from Japan, which claim fewer recurrences after treatment incorporating combinations of intraarterial chemotherapy, moderate doses of radiotherapy, and conservative surgical procedures. Local control rates of 55 to more than 90 percent have been reported using such trimodal treatment, which has resulted in improved survival rates [ 2 1-231. Although such protocols have not been popular in the United States, one recent report has demonstrated encouraging response rates to superselective intraarterial infusion of cisplatin, bleomycin, and 5fluorouracil [ 141. Local recurrence remains our most frequent site of treatment failure, despite an aggressive surgical ap preach. In our study, neck metastases at presentation were uncommon (10 percent), which is consistent with other studies showing a 7 to 17 percent incidence for antral cancer [3,5,9,10,13]. Subsequent treatment failure in the neck in the absence of local recurrence was also uncommon in this study; a finding reported by others as well [7,8,15,16J. In this study, the incidence of orbital exentration was even higher than previously reported from our hospital (51 percent versus 46 percent of all surgically treated patients) [I]. It should be noted that there were only six patients who had skull base resections, a procedure which is gaining in popularity. We doubt that extended surgery for locally advanced squamous cancer of the nasal cavity or sinuses will result in significant improvement in local control rates.
We have focused on adjunctive radiotherapy in an effort to enhance local disease control, with a strong preference that the treatment is given postoperatively. Almost the entire group of patients with stage III antral lesions were treated with the combination of aggressive surgery and adjunctive radiotherapy. Therefore, this retrospective study offers no basis for comparison of results with other treatment plans. Our most recent experience indicates that less than 20 percent of patients with antral cancer had surgery, which includes orbital exenteration [171. This probably reflects a trend towards reliance on radiotherapy for local control when tumor encroaches on, but does not obviously involve, the orbital contents [ 17,181. Our results suggest the need for prospective, cooperative trials incorporating aspects of trimoclality treatment, with the goal being comparable, or even improved, survival with less treatment morbidity.
1. Lewis JS, Castro EB. Cancer of the nasal cavity and parana&
sinuses.J Laryngol Gtol 1972; 86: 255-62. 2. Kaplan EL, Meier P. Nonparametric estimation from incom-
plete observations. J Am Stat &soc 1958; 53: 457-81. 3. Lee F, Ogura JH. Maxillary sinus carcinoma. Iaryngoscope 1981; 91: 133-9. 4. Weymuller EA, Reardon EJ, Nash D. A comparison of treatment modalities in carcinoma of the maxillary antrum. Arch Gtolaryngol 1980; 106: 625-9. 5. St. Pierre S, Baker SR. Squamous cell carcinoma of the maxillary sinus: analyses of 66 cases. Head Neck Surg 1983; 5: 50813. 6. Jackson RT, Fitz-Hugh GS, Constable WC. Malignant neo plasms of the nasal cavity and paranasal sinuses. Laryngoscope 1977; 87: 726-36. 7. Olmi P, Cellai E, Chiavacci A, Fallai C. Pamnasal sinuses and nasal cavity cancer: different radiotherapeutic options, results and late damages. Tumori 1986; 72: 589-95. 8. Ahmad K, Cordoba RB, Fayos JV. Squamous cell carcinoma of the maxillary sinus. Arch Otolaryngol 1981; 107: 48-51. 9. Gadeberg CC, Hjelm-Hansen M, Sogaard H, Elbrond 0. Malignant tumors of the paranasal sinuses and nasal cavity: a series of 180 patients. Acta Radio1 Chtcol 1984; 23: 181-7. 10. Beale FA, Garrett PG. Cancer of the param& sinuses with particular reference to maxillary sinus cancer. J Gtolaryngoll983; 12: 377-82. Il. Konno A, Togawa K, Inoue S. Analysis of the results of our
THE AMERICAN JOURNAL OF SURGERY VOLUME 158 OCTOBER 1989 331
SPIRO ET AL
combined therapy for maxillary cancer. Acta Otolaryngol 1980; 372(suppl): 3-16. 12. Sakai S, Hohki A, Fuchihata H, Tanaka Y. Multidisciplinary treatment of maxillary sinus carcinoma. Cancer 1983; 52: 1360-4. 13. Shibuya H, Horiuchi J, Suzuki S, Shioda S, Enomoto S. Maxillary sinus carcinoma: result of radiation therapy. Int J Radiat Chtcol Biol Phys 1984; 10: 1021-6. 14. Lee Y, Dimery IW, Tassel PV, et al. Superselective intraacterial chemotherapy of advanced paranasal sinus tumors. Arch Otolaryngol Head Neck Surg 1989; 115: 503-11. 15. Knegt TP, DeJong PC, VanAndel JG, DeBoer MF, Eyken-
332
THE AMERICAN JOURNAL OF SURGERY
boom W, Van Der Schans E. Carcinoma of the paranasal sinuses: results of a prospective pilot study. Cancer 1985; 56: 57-62. 16. Parsons JP, Mender&all WM, Mancuso AA, Cassis NJ, Million RR. Malignant tumors of the nasal cavity and ethmoid and sphenoid sinuses. Int J Radiat Gncol Biol Phys 1988; 14: 11-22. 17. Perry C, Levine PA, Williamson BR, Cantrell RW. Preservation of the eye in paranasal sinus cancer surgery. Arch Gtolaryngol Head Neck Surg 1988; 114: 632-4. 18. Larson DL, Christ JE, Jesse RI-I. Preservation of the orbital contents in cancer of the maxillary sinus. Arch Gtolaryngol 1982; 108: 370-2.
VOLUME 158
OCTOBER 1989
Carcinoma of the Nasal Cavity and Paranasal Sinuses
Jeffrey D. Spiro,
MD,
Kee Chee Soo,
MD,
This study retrospectively analyzed 105 patients with squamous carcinoma of the nasal cavity and paranasal sinuses. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 ( 10 percent), and the sphenoid sinus in 2 (2 percent). Over half of the patients with antral cancer were treated with surgery and radiotherapy, whereas one-third of the remaining patients received combination therapy. Most procedures were radical, including sacrifice of the orbital eontents in half of the surgically treated patients. The 5-year determinate cure rate was 45 percent for patients with nasal cavity tumors, 38 percent for those with maxillary sinus lesions, and 13 percent for those with ethmoid tumors. Local recurrence remains a major problem despite aggressive surgery and increased use of adjunctive radiotherapy.
0 paranasal sinuses remains uncertain. Treatment decisions are complicated by the fact that tumors are often ptimal management of cancers of the nasal cavity and
locally advanced when first seen and are difficult to accurately assess. Interpretation of results is complicated by the lack of uniformity in clinical staging systems and the tendency to lump together different tumor types. Some years ago, we reported that 28 percent of determinate patients with nasal or paranasal sinus cancer were alive and well 5 years postoperatively [I]. Unfortunately, this study did not utilize clinical staging, and there was no analysis by histologic diagnosis. We have reviewed our experience with patients treated for carcinoma of the nasal cavity and paranasal sinuses during a more recent period, when we were increasingly committed to the use of surgery and radiotherapy in combination. Our goals were to compare our results and to assess the impact of combination therapy. MATERIAL
AND METHODS
The records of all patients with malignant neoplasms of the nasal cavity and paranasal sinuses seen at MemoriFrom the Head and Neck Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York. Requests for reprints should be addressed to Ronald H. Spiro, MD, 1275 York Avenue, New York, New York 10021. Presented at the 35th Annual Meeting of the Society of Head and Neck Surgeons, San Francisco, California, May 21-24,1989. 328
THE AMERICAN JOURNAL OF SURGERY
Ronald H. Spiro,
MD, NW
York,NW
York
al Sloan-Kettering Cancer Center between January 1966 and December 1982 were retrospectively reviewed. After excluding 16 patients with incomplete records, 224 patients remained for analysis. Of this group, 105 patients who received definitive therapy for squamous carcinoma were selected for this report. The primary tumor was located in the maxillary sinus in 65 patients (62 percent), the nasal cavity in 27 (26 percent), the ethmoid sinus in 11 (10 percent), and the sphenoid sinus in 2 (2 percent). There were 70 men and 35 women, whose ages ranged from 27 to 8 1 years (median 60 years). Of the 65 patients with maxillary sinus cancer, 10 (15 percent) had recurrent tumor after treatment elsewhere, whereas this was true for 17 of 40 patients (43 percent) with primary tumors in the nasal cavity or ethmoid or sphenoid sinuses. For the purpose of this study, patients who underwent a Caldwell-Luc procedure or a polypectomy were considered to be previously untreated. Previously untreated patients with maxillary sinus lesions were retrospectively staged according to the TNM staging system. Two, 8,32, and 13 patients had T1 through T4 primary lesions, respectively. Only five patients had clinical evidence of nodal involvement initially, all of whom had T3 or Tq disease. The most common presenting complaints of those patients with maxillary sinus cancer were pain and nasal obstruction, and the most frequent physical finding was a mass in the cheek. Among the patients with tumors located at other sites, epistaxis and nasal obstruction were the most common symptoms, and a mass in the nasal cavity was the most frequent finding on examination. All patients were eligible for a minimum of 60 months follow-up. Comparison of the alive and well patients to the total eligible for follow-up yielded absolute cure rates. More relevant net, or determinate, cure rates were calculated by excluding as indeterminate any eligible patients who were free of disease when they either died from other causes or were lost to follow-up. In addition, cumulative survival rates were calculated according to the productlimit method of Kaplan and Meier [2]. Treatment: Maxillary sinus. Among the total of 65 patients, 11 were treated with radiotherapy only, 19 had surgery only, and 35 received surgery and adjunctive radiotherapy. Surgery alone was used in most previously treated patients (8 of 10). Most of the 55 patients receiving primary therapy were treated with combinations of surgery and radiotherapy (34 of 55), whereas single modality treatment was used in the remainder (radiotherapy alone in 10 patients; surgery alone in 11 patients). It was clear that the treatment groups were not comparable; 7 of the 10 patients treated with radiotherapy alone had Tq primary lesions, and 7 of the 11 patients treated with surgery alone had Ti or TZ primary tumors. Most of the patients who received combination therapy had T3 lesions.
VOLUME 158 OCTOBER 1989
Most resections included exe&rations of the nasal contents, ethmoid contents, or both, either alone (seven of 54). Total maxillectomy, which included removal of patients), in conjunction with a partial maxikctomy the entire maxiha with preservation of the orbital con- (eight patients), or as part of combined craniofacial excitents, was performed in eight patients. Partial maxilleo sion (six patients). Radical maxillectomy with orbital and tomy, which preserved the orbital floor, was used in six ethmoid exenteration was performed in four patients and patients. wide local excision in five patients. The orbital contents Only 10 patients were treated with radiotherapy were sacriticed in 6 of 33 surgically treated patients (18 alone, 7 of whom received at least 6,000 cGy. Most pa- percent). Of the seven patients treated with radiotherapy tients treated with combination of surgery and radiother- alone, six received at least 6,000 cGy. apy received the radiotherapy postoperatively(27 of 35), In the small group of patients treated with combinaand 18 of these patients received at least 5,000 cGy. tion therapy, five patients received radiotherapy preoperSeven patients receivedpreoperative radiotherapy, which atively, six postoperatively, and one both preoperatively consisted of no more than 4,000 cGy. One patient re and postoperatively. Preoperative doses ranged widely, ceived both preoperative and postoperativetreatment. In and all patients treated postoperatively received at least general, the reasons for adjunctive radiotherapy could not 5,ooo cGy. be ascertained in this retrospective review. Other sites. Patients with primary tumors in the nasal RESULTS There were no postoperative deaths. Minor wound cavity, ethmoid sinuses, and sphenoid sinuses were treated with radiotherapy alone and surgery alone in 7 and 2 1 complications occurred in nine patients, including slough instances, respectively. Twelve patients received combi- of a skin graft in four patients and infection in three. nations of surgery and radiotherapy. As with antral pri- There were four cases of meningitis and two of brain mary lesions, the majority of previously treated patients abscess. These problems occurred with similar frequency ( 12of 17) receivedsurgery only. Most previouslyuntreat- in irradiated and nonirradiated patients. Pulmonary emed patients in this group were treated with singlemodality bolus occurred in one patient, and another patient had therapy as well (14 of 23). Lacking accepted staging sign&ant aspiration. Other complications included concriteria for these nasal, ethmoid, and sphenoid tumors, it gestive heart failure (two patients), parotitis (one pawas diftlcult to compare the different treatment groups. tient), and hypercalemia (one patient). More than two-thirds of surgically treated patients had a radical maxillectomyand orbital exenteration (39
1. -
ANTRUM
(nm66)
NASAL hm27)
0.8
ETHWSPHEN
(nmll)
0.6
0.4
0.2
0 0
I
I
I
I
I
1
2
3
4
5
Time in Yrs THE AMERICAN JOURNAL OF SURGERY
VOLUME 158 OCTOBER 1989
329
-
0
1
2
3
4
STAGES $2 MO)
+
STAGE 3 h32)
+I+
STAGE 4 (n=l3)
5
Time in Yrs
0.2 -
0
NO PREV RX h78)
-i-
PREV RX’D h=27)
I
I
0
-
1
I
I
I
I
2
3
4
5
Time in Yrs
The 5-year determinate cure rate for the entire group was 37 percent. When analyzed by site, patients with nasal cavity lesions had the highest cure rate (43 percent), followed by those with maxillary sinus cancer (38 percent). Patients with ethmoid sinus lesions had the lowest cure rate (13 percent). One of two patients with sphe noid sinus cancer remained alive and well 5 years postoperatively. Patients treated for recurrent tumors had a 5-year determinate cure rate of only 20 percent. Cure rates were substantially higher in those patients with nasal cavity or maxillary sinus cancer who received their primary treatment at Memorial Hospital, with 62 percent and 42 percent, respectively, alive and well 5 years postoperatively. 330
THE AMERICAN JOURNAL OF SURGERY
Determinate cure rates were 100 percent, 86 percent, 39 percent, and 25 percent 5 years postoperatively for stage 1 through 4 lesions, respectively, but the subsets were too small for statistical significance. Similarly, actuarial analysis showed a trend toward better survival in patients with nasal lesions (Figure l), stage I or II disease (Figure 2), and no previous treatment (Figure 3), but the diierences were not statistically significant. The pattern of treatment failure for patients with maxillary sinus cancer is illustrated in Figure 4. Isolated local recurrence was most common, followed by isolated distant recurrence. Neck metastases in the absence of local treatment failure were unusual. The sites of recurrence in patients with nasal cavity, ethmoid, or sphenoid
VOLUME 158 OCTOBER 1989
NASALCAVITYANDPAllANASALSlNUSCAMXNOMA
cancer were similar to those seen with anti-al cancer. Previous treatment appeared to have little impact on the site of treatment failure. COMMENTS The problems encountered in treating cancer of the nasal cavity and paranasal sinuses are well established. Early symptoms are often ignored, and the majority of patients present with locally extensive disease. In this report, 82 percent of the patients with previously untreated antral lesions had stage III or Iv disease. The complex anatomy of the nasal cavity and paranasal sinuses and their proximity to the orbit and skull base pose major problems in staging and treatment planning. It should be noted that this study antedated the use of computed to mography scanning, which has already demonstrated its value in assessing tumor extent. Additional improve merits can be expected as threedimensional imaging is perfected. Treatment results were difficult to compare. To simplify the analysis, we included only patients with squamous carcinoma and attempted to group them according to the site of origin. Obviously, this can be diff&zultwhen tumors are extensive, because the nasal cavity and sinuses are contiguous. Notwithstanding the variety of treatments used, the inconsistency in staging, and the limited number of patients, we believe that the cure rate has improved some what since our last report, particularly in our patients with maxillary sinus cancer. Moreover, our results for maxillary sinus and nasal cavity cancer are comparable to those reported by others [ 3-101. The exception concerns recent reports from Japan, which claim fewer recurrences after treatment incorporating combinations of intraarterial chemotherapy, moderate doses of radiotherapy, and conservative surgical procedures. Local control rates of 55 to more than 90 percent have been reported using such trimodal treatment, which has resulted in improved survival rates [ 2 1-231. Although such protocols have not been popular in the United States, one recent report has demonstrated encouraging response rates to superselective intraarterial infusion of cisplatin, bleomycin, and 5fluorouracil [ 141. Local recurrence remains our most frequent site of treatment failure, despite an aggressive surgical ap preach. In our study, neck metastases at presentation were uncommon (10 percent), which is consistent with other studies showing a 7 to 17 percent incidence for antral cancer [3,5,9,10,13]. Subsequent treatment failure in the neck in the absence of local recurrence was also uncommon in this study; a finding reported by others as well [7,8,15,16J. In this study, the incidence of orbital exentration was even higher than previously reported from our hospital (51 percent versus 46 percent of all surgically treated patients) [I]. It should be noted that there were only six patients who had skull base resections, a procedure which is gaining in popularity. We doubt that extended surgery for locally advanced squamous cancer of the nasal cavity or sinuses will result in significant improvement in local control rates.
We have focused on adjunctive radiotherapy in an effort to enhance local disease control, with a strong preference that the treatment is given postoperatively. Almost the entire group of patients with stage III antral lesions were treated with the combination of aggressive surgery and adjunctive radiotherapy. Therefore, this retrospective study offers no basis for comparison of results with other treatment plans. Our most recent experience indicates that less than 20 percent of patients with antral cancer had surgery, which includes orbital exenteration [171. This probably reflects a trend towards reliance on radiotherapy for local control when tumor encroaches on, but does not obviously involve, the orbital contents [ 17,181. Our results suggest the need for prospective, cooperative trials incorporating aspects of trimoclality treatment, with the goal being comparable, or even improved, survival with less treatment morbidity.
1. Lewis JS, Castro EB. Cancer of the nasal cavity and parana&
sinuses.J Laryngol Gtol 1972; 86: 255-62. 2. Kaplan EL, Meier P. Nonparametric estimation from incom-
plete observations. J Am Stat &soc 1958; 53: 457-81. 3. Lee F, Ogura JH. Maxillary sinus carcinoma. Iaryngoscope 1981; 91: 133-9. 4. Weymuller EA, Reardon EJ, Nash D. A comparison of treatment modalities in carcinoma of the maxillary antrum. Arch Gtolaryngol 1980; 106: 625-9. 5. St. Pierre S, Baker SR. Squamous cell carcinoma of the maxillary sinus: analyses of 66 cases. Head Neck Surg 1983; 5: 50813. 6. Jackson RT, Fitz-Hugh GS, Constable WC. Malignant neo plasms of the nasal cavity and paranasal sinuses. Laryngoscope 1977; 87: 726-36. 7. Olmi P, Cellai E, Chiavacci A, Fallai C. Pamnasal sinuses and nasal cavity cancer: different radiotherapeutic options, results and late damages. Tumori 1986; 72: 589-95. 8. Ahmad K, Cordoba RB, Fayos JV. Squamous cell carcinoma of the maxillary sinus. Arch Otolaryngol 1981; 107: 48-51. 9. Gadeberg CC, Hjelm-Hansen M, Sogaard H, Elbrond 0. Malignant tumors of the paranasal sinuses and nasal cavity: a series of 180 patients. Acta Radio1 Chtcol 1984; 23: 181-7. 10. Beale FA, Garrett PG. Cancer of the param& sinuses with particular reference to maxillary sinus cancer. J Gtolaryngoll983; 12: 377-82. Il. Konno A, Togawa K, Inoue S. Analysis of the results of our
THE AMERICAN JOURNAL OF SURGERY VOLUME 158 OCTOBER 1989 331
SPIRO ET AL
combined therapy for maxillary cancer. Acta Otolaryngol 1980; 372(suppl): 3-16. 12. Sakai S, Hohki A, Fuchihata H, Tanaka Y. Multidisciplinary treatment of maxillary sinus carcinoma. Cancer 1983; 52: 1360-4. 13. Shibuya H, Horiuchi J, Suzuki S, Shioda S, Enomoto S. Maxillary sinus carcinoma: result of radiation therapy. Int J Radiat Chtcol Biol Phys 1984; 10: 1021-6. 14. Lee Y, Dimery IW, Tassel PV, et al. Superselective intraacterial chemotherapy of advanced paranasal sinus tumors. Arch Otolaryngol Head Neck Surg 1989; 115: 503-11. 15. Knegt TP, DeJong PC, VanAndel JG, DeBoer MF, Eyken-
332
THE AMERICAN JOURNAL OF SURGERY
boom W, Van Der Schans E. Carcinoma of the paranasal sinuses: results of a prospective pilot study. Cancer 1985; 56: 57-62. 16. Parsons JP, Mender&all WM, Mancuso AA, Cassis NJ, Million RR. Malignant tumors of the nasal cavity and ethmoid and sphenoid sinuses. Int J Radiat Gncol Biol Phys 1988; 14: 11-22. 17. Perry C, Levine PA, Williamson BR, Cantrell RW. Preservation of the eye in paranasal sinus cancer surgery. Arch Gtolaryngol Head Neck Surg 1988; 114: 632-4. 18. Larson DL, Christ JE, Jesse RI-I. Preservation of the orbital contents in cancer of the maxillary sinus. Arch Gtolaryngol 1982; 108: 370-2.
VOLUME 158
OCTOBER 1989