Extent of Surgery in the Management of Locally Advanced Sinonasal Malignancies

Introduction: Optimal treatment for malignancies of the sinonasal sinuses involving the anterior skull base remains under evolution. This study evaluates the importance of extent of surgery for patients with locally advanced paranasal sinus cancer treated with combined surgery and proton radiotherapy.

Methods: A retrospective review of 94 cases diagnosed with nonmetastatic, AJCC stage II-IV, paranasal sinus cancer between 1991 and 2002 at the Massachusetts Eye and Ear Infirmary and the Massachusetts General Hospital, who received combined conformal proton and photon radiotherapy after surgery. Extent of surgery and surgical approach were evaluated and correlated with outcome variables of local control, pattern of recurrence, disease-free survival, and overall survival.

Results: Extent of surgery ranged from biopsy only to complete resection via endoscopic, transfacial/extracranial, and craniofacial approaches. The median follow-up was 37 months. Eleven patients developed locoregional and 24 patients developed distant metastasis as their first site of failure. At 3 and 5 years, overall survival rates were 61% and 55%, respectively; disease-free survival rates were 56% and 50%, respectively. The local control rate was 85% at 3 and 5 years. Complete resection was predictive of decreased distant metastasis (p = 0.04) and increased disease-free survival (p = 0.03). Extent of surgery, however, was not predictive of improved local control or overall survival.

Conclusion: Combined proton and photon radiotherapy results in excellent local control rates in patients with locally advanced sinonasal cancer irrespective of extent of surgery. Complete resection, however, is predictive of improved disease-free survival and decreased rate of distant metastasis.