Acute Vision Loss: A Potential Novel Indication for Intraarterial Chemotherapy in the Treatment of Sinonasal Undifferentiated Carcinoma (Case Report)

Introduction: The combination of radiotherapy and concomitant intraarterial cisplatin (RADPLAT) is well recognized in controlling locally invasive unresectable sinonasal undifferentiated carcinoma (SNUC). However, no reliable data are available for acute administration of intraarterial chemotherapy alone for palliation of acute vision loss in patients with unresectable SNUC involving the optic nerve.

Objective: To suggest a novel indication for compassionate use of intraarterial chemotherapy alone in the acute setting in patients with advanced SNUC associated vision loss.

Case Presentation: A 25-year-old Hispanic man presented with bloody nasal discharge, left proptosis, and decreased visual acuity in the left eye. Both CT and MRI of the head and neck revealed a large 6.2-cm sinonasal mass extending through the cribriform plate to the dural, left maxillary sinus, and left orbit resulting proptosis with involvement of the optic nerve. The patient was not a surgical candidate due to intracranial extension with dural involvement. The patient’s visual acuity in the left eye was 2400/20 on presentation. The patient underwent biopsy, which revealed SNUC. Intensity-modulated radiation therapy (IMRT) planning requires approximately 1 week to orchestrate at our institution. We decided to administer supratherapeutic intraarterial cisplatin acutely, along with thiosulfate infusion without radiation in an attempt to save the patient’s vision. The patient experienced an increase in pain initially. However, over the following 5 days, the degree of proptosis diminished markedly and vision improved substantially without IMRT. The patient’s follow-up vision testing revealed 30/20 vision in the left eye at 1 week and 20/20 vision at 2 weeks following therapy. Subsequent MRI revealed marked necrosis and decrease in size of the mass.

Conclusion: Although we are not specifically advocating intraarterial administration of chemotherapy alone for the treatment of head and neck tumors, it may be effective in the acute setting for palliation of acute vision loss related to compression by head and neck tumors such as SNUC.