Multidisciplinary approach to nose vestibule malignancies: setting new standards

Abstract

Nose vestibule malignancies, mainly SCCs, are considered rare neoplasms. In the present paper, we review the current state of the art concerning classification and treatment, and describe current evidence supporting a paradigm shift. In the current AJCC classification nose vestibule is considered part of nasal cavity/ethmoid. In daily clinical practice, nose vestibule lesions are often misclassified as skin primaries. This leads to an underestimation of the real incidence and to a mis-management. When nose vestibule primaries are correctly classified as nose primaries, the current AJCC TNM appears inadequate for prognostic stratification and an old staging system described 4 decades ago by Wang has been demonstrated to be more reliable in the literature and is preferred in centers with the largest volume of cases treated. The principles of Wang classification should be applied and nose vestibule acknowledged as a new distinct subsite of nose and paranasal sinuses by the AJCC/ UICC. Surgery, External Beam RadioTherapy (EBRT) and Interventional RadioTherapy (IRT, BrachyTherapy BT) are the current therapeutic options for nose vestibule (NV) SCC. Increasing evidence demonstrates that IRT, with a proper multidisciplinary approach, is at least equivalent to surgery and EBRT for treatment of the primary lesions in terms of oncological outcomes, but markedly superior in terms of cosmetic and functional results, supporting HDR (high dose rate) IRT as the new standard for the treatment of the primary lesion in these malignancies. To optimize the advantages of IRT as primary therapeutic modality we set up a new approach to the implantation phase of IRT exploiting the anatomic planes of esthetic and functional nose surgery and the potential of intensity modulated and image guided brachytherapy to avoid septal and alar perforation (anatomic implantation).

Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology – Head and Neck Surgery

“…This ambiguity contributes to an unclear definition of the disease. To address this issue, the Committee agrees to adopt a plane tangential to the piriform opening as the posterior boundary, a landmark that is easily identifiable through imaging studies 3 , 9 , 13 . This boundary demarcates the NV from the proper nasal cavity ( Fig.…”

“…NV cancer preferentially spreads along the cartilages, which cannot be spared, whereas skin primaries tend to remain superficial to the cartilages due to their anatomic structure and most often allow their sparing 2 , 4 . Notably, skin involvement by NV cancer can be very early even in case of small inapparent lesions inside the nose 13 . As such, the Committee strongly recommends that all skin lesions in and around the nose tip and nostrils, especially those diagnosed as SCC, should be evaluated by an otolaryngologist to exclude a primary nasal lesion 3 , 9 .…”

Rethinking Oncologic Facial Nerve Reconstruction in the Acute Phase Through Classification of the Level of Injury

“…Parotid tumours account for 80% of all salivary gland tumours, and 20% are malignant and often invasive to the facial nerve that passes through the parotid gland. 15 Often, the nerve is resected to mitigate the chance of recurrence and improve prognosis. Tumours at this level involving the facial nerve resulting in complete facial paralysis with or without skin defects and often result in long nerve gaps.…”

Successful Preoperative QUAD SHOT for Bulky Parotid Carcinoma: Potential Preoperative Ultra-Hypofractionated Radiotherapy for Conversion Surgery

“…Intraoperatively, peripheral branches of the facial nerve were identified, with the nerve trunk running through the tumor itself and necrotic tissue from preoperative chemotherapy. Ultimately, the facial nerve was not preserved, considering the preoperative cT4 findings [3, 4], pathological biopsy reports, and the state of incomplete paralysis with a drooping mouth corner.…”