The endoscopic endonasal approach for sinonasal and nasopharyngeal adenoid cystic carcinoma

Abstract

Objective: To determine factors affecting outcomes for patients with sinonasal and nasopharyngeal adenoid cystic carcinoma (SNACC) treated using the endoscopic endonasal approach (EEA) with preservation of key structures followed by adjuvant radiotherapy (RT).Method: Retrospective case series of 30 patients treated at the University of Pittsburgh between 2000 and 2014. Hospital records were reviewed for clinical and pathologic data. Outcome measures included overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates.Results: The majority of patients had T4a and T4b disease (23.3%, and 63.3%). Microscopically positive margins were present in 21 patients (63.6%). Positive margins were present in nine patients (30.0%). The mean and median follow-up were 3.97 and 3.29 years. Five-year OS, DFS, LRFS, and DMFS were 62.66%, 58.45%, 87.54%, and 65.26%. High-/intermediate-grade tumors had worse DFS (P = .023), and LRFS (P = .026) (HR = 4.837, 95% CI, 1. 181-19.812). No factors were associated with significantly worse DMFS. No patient suffered CSF leak, optic nerve, or internal carotid injury. The mean and median length of hospital stay was 4.1 days and 2.0 days (range: 0-32 days).Conclusion: Organ-preserving EEA with adjuvant RT for low-grade SNACC offers 5-year survival similar to that reported by other studies, which include radical, open skull base surgery. Patients with high-grade disease do poorly and may benefit from novel treatment strategies. For low-grade disease, organ-preserving EEA with RT may be the best option, offering a balance of survival, quality of life, and decreased morbidity for patients with this difficult-to-cure disease.

The Role of Elective Neck Treatment in the Management of Sinonasal Carcinomas: A Systematic Review of the Literature and a Meta-Analysis

“…Another study from the US found improved OS only for END performed in T3-T4 major salivary glands ACC; in this large dataset of over 2800 patients, the sinonasal cavity represented the second anatomical subsite in terms of frequency, but it was also the least likely to receive END and to harbor occult metastases [ 46 ]. Finally, in a recently published series of exclusively sinonasal ACC treated by endoscopic endonasal approaches, nodal recurrence occurred in only 1 out of 30 cases, and it was concomitant to distant metastases; again, adjuvant RT was delivered in 83% of patients but the fields were not specified [ 47 ].…”

Surgical Management of Sinonasal Cancers: A Comprehensive Review

“…Two series report the results of 30 and 34 patients treated endoscopically. They report overall survival rates at 5 years of 62.7% and 86.5% and confirm that endoscopy is a valid surgical treatment modality [99,104]. Surprisingly, the study by Kashwazaki et al, which also included patients with adenoid cystic carcinoma of the nasopharynx, reported a clear surgical margin rate of 7% [104] which may seem too low to recommend this surgical strategy.…”

“…They report overall survival rates at 5 years of 62.7% and 86.5% and confirm that endoscopy is a valid surgical treatment modality [99,104]. Surprisingly, the study by Kashwazaki et al, which also included patients with adenoid cystic carcinoma of the nasopharynx, reported a clear surgical margin rate of 7% [104] which may seem too low to recommend this surgical strategy. However, the study by Volpi et al which reported a clear margin rate of 79.4% is in favor of the endoscopic approach with satisfactory carcinological results [99].…”

“…When the extent of the tumor makes the morbidity of the procedure too high, a subtotal resection is possible, associated with adjuvant radiotherapy [103]. Interestingly, obtaining microscopically positive margins did not show superiority in terms of local recurrence compared to macroscopically positive margins in a retrospective study [104]. Invasion of the cavernous sinus does not necessarily contraindicate surgery, but extensions to the base of the skull and the infratemporal fossa remain factors of poor prognosis [105].…”

The Role of Adjuvant Treatment in Craniofacial Malignancy: A Critical Review

“…The role of postoperative radiotherapy in cases of stage T2 tumors is unclear, while some studies show no benefit, others show higher recurrence rates in the absence of radiotherapy, especially in cases of high-risk tumors, such as adenoid cystic carcinoma and undifferentiated carcinoma ( 108 – 111 ). In cases of squamous cell carcinoma with macroscopic or microscopic tumors after surgical treatment, concomitant hypoxic modification with the radiosensitizer nimorazol should be used ( 112 ).…”