Induction Chemotherapy for Sinonasal Tumors in Patients Presenting with Brain Invasion and/or Neurological Deficits

Introduction: Induction chemotherapy (IC) is increasingly utilized in multi-modality treatment of sinonasal cancers. The aim of this study was to report radiographic and neurological outcomes, necessity of urgent surgical intervention, disease control and survival in patients with sinonasal cancers with brain invasion and/or neurologic deficits undergoing IC.

Methods: Retrospective analysis of patients who underwent IC for sinonasal tumors with intracranial brain invasion and/or neurological deficit. Baseline demographics, neurological exam, tumor staging, IC regimen, intracranial invasion was recorded. Comparisons were made to post IC neurological exams, interruption in IC, tumor response, continued surgical, radiation and chemotherapeutic management.

Results: Forty patients with brain invasion (BI) and 31 with a neurological deficit (ND) regardless of extent of intracranial invasion met the inclusion criteria of 341 screened within a database of patients having received induction chemotherapy at our institution. Males represented the majority in both cohorts (BI: 65%, ND: 58%), average age BI of 48.6 and ND of 55.1. Six pathologies were represented in the groups with sinonasal undifferentiated carcinoma being the most prevalent in both (BI 40%, ND 41.9%), followed by esthesioneuroblastoma (BI 27.5%, ND 9.7%) and squamous cell carcinoma (BI7.5%, ND 25.8%). All tumors were stage T4 with majority N0 (BI 72.5%, ND 77.5%). The most common tumor origin was nasal (BI 45%, ND 58%), followed ethmoidal origin (BI 50%, ND 19.4%). The BI group was stratified based on parenchymal mass effect, seen in 24 (60%) or patients, and orbital invasion in 33 (82.5%) of patients. In the ND group, orbital invasion was seen in 83.9%, and brain invasion in 22.6%. The majority received combined platinum-based therapy (95% of BI, and all of ND patients). The average number of IC cycles was 3.2 in BI and 3.1 ND. Radiographic response to IC was complete in 12.5% BI, 9.7% ND, partial in 67.5% BI, 61.3%ND, stable disease or disease progression in 20% BI, and 29.1% ND patients. Five patients (12.5% BI) and 2 (6.5% ND) had interruption in their IC; however, all completed at least two cycles, and none were due to progression of disease, need for urgent surgery, or neurologic decline. Among ND patients, 12.9% were due to frontal brain invasion symptomatology, and 93.5% had an optic neuropathy. Post-IC overall deficits decreased to 54.8% (p < 0.05). All frontal symptoms resolved, and only 22.9% the optic neuropathies persisted (p < 0.05). In the BI cohort, post-IC chemotherapy/radiation was performed on 34 (85%) and surgery in 18 (45%) of patients. Indication for surgery was to either little or no tumor response to IC in 5 (27.8%), good response with residual disease in 10 (55.5%). Gross total resection was obtained in 16 (88.9%), and negative margins in 13 (72.2%). Recurrence occurred in 16 (40%). Progression free survival was 24.8 and overall survival 55.7 months.

Conclusion: In patients with sinonasal carcinomas presenting with brain invasion and/or neurologic deficits, proceeding with histology-specific multimodality treatment protocols based on induction chemotherapy resulted in improvement of neurologic symptoms. IC was safely administered without interruption of IC due to neurological decline or symptom progression.

Publication History

Article published online:
01 February 2023