| Part â… :Analysis of therapeutic efficacy and rational application of combined-modality approaches for 588 cases of the nasal cavity and paranasal sinus carcinomaObjective:To analyze the treatment outcomes and failure pattern, summarize the rational application of combined-modality approaches for patients with the nasal cavity and paranasal sinus carcinoma.Material and methods:A total of 588 consecutive patients with carcinoma of the nasal cavity and paranasal sinusin in our hospital between 1999 and 2014 were retrospectively reviewed. There were 38 patients stage T1,55 stage T2,126 stage T3 and 369 stage T4 according to the 2010 AJCC staging system. There were 100 patients with positive lymph nodes in neck and 17 distant organs involved at presentation. Initial treatment included pre-operative radiotherapy (RT) followed by surgery in 108, surgery followed by post-operative radiotherapy in 259, RT alone in 126, and surgery alone in 83 and 12 patient treated with chemotherapy alone.Results:The median follow-up was 57 months. Overall, the 5-year local recurrence free survival (LRFS), regional recurrence freesurvival (RRFS), distant metastasisfree survival (DMFS), disease free survival (DFS) and overall survival (OS) were 61.0%,90.2%, 70.7%,42.4% and 52.9%, respectively. In the follow-up time, there were 188 (32.0%) local recurrence,42 (7.1%) regional failure and 155 (26.4%) distant metastases. T1 stage patients with high risk factors of local recurrence treated by surgery combined with radiotherapy had similar LRFS, DFS and OS with patients with no high risk factor treated by radical surgery. T2, T3 stage patients received surgery combined with radiotherapy had higher LRFS than surgery alone (76.5%vs56.3%,p=0.012; 74.7% vs46.1%, p=0.022). T4 stage patients treated by surgery combined with radiotherapy had higher LRFS, DFS and OS than surgery alone or chemotherapy alone (p<0.05). For Tl-3 and T4 stage, the 5-year LRFS were 66.9% and 56.4%(p=0.025),5-year DMFS were 84.9% and 60.7%(p<0.001),5-year DFS were 55.2% and 32.8%(p<0.001),5-year OS were 71.1% and 41.3% (p<0.001), respectively. The 5-year DFS, OS for N+and NO stage were 32.5% and 44.2%(p=0.022),36.3% and 56.2% (p<0.001), respectively. The 5-year OS for M1 and MO stage were 17.6% and 53.9% (p<0.001). For â… -â…¢ and IV stage, the 5-year LRFS were 67.6% and 56.3%(p=0.023), the 5-year DMFS were 85.1% and 61.4%(p<0.001), the 5-year DFS were 56.0% and 33.1%(p<0.001), and the 5-year OS were 73.0% and 41.6%(p<0.001). Multivariate analysis showed T4 stage, age>50years, M1 stage, radiotherapy or surgery alone were risk factors for OS.Conclusion:Local recurrence was the most common failure mode, followed by distant metastases and lymph nodes relapse. Treatment of surgery combined with radiotherapy was recommended to T1 stage patients with high risk factors of local recurrence. For T2, T3 stage, plus radiotherapy on the base of surgery improved LRFS than surgery alone. Surgery combined with radiotherapy had good results in LRFS and OS for T4 stage. TNM stage system was good prognostic indicator for LRFS, DMFS, DFS and OS.Part II:The role of pre-operative and post-operative radiotherapy for carcinoma of the nasal cavity and paranasal sinusObjective:To analyze and compare the treatment efficacy of pre-operative andpost-operative radiotherapy, then generalize the status of pre-operativeradiotherapy in treatment of the nasal cavity and paranasal sinus carcinoma.Material and methods:From 1999 to 2014,367 patients of the nasal cavity and paranasal sinus carcinoma treated with surgery combined with radiotherapy were reviewed retrospectively. Thirteen patients had T1,34 had T2,91 had T3, and 229 had T4 tumors according to the 2010 AJCC staging system. There were 43 patients with positive lymph nodes in neck and 3 patients with distant organs involved at presentation. Treatment included pre-operative radiotherapy (RT) followed by surgery in 108 and surgery followed by post-operative radiotherapy in 259. The median tumor dose for patients treated with pre-operative RT was 60Gy (range:39-80Gy) and 69Gy (range: 26-82Gy) for post-operative RT.Results:The median follow-up was 59.5 months. Overall, the 5-year local recurrence free survival (LRFS), regional recurrence freesurvival (RRFS), distant metastasis free survival (DMFS), disease free survival (DFS) and overall survival (OS) were 67.7%, 90.6%,71.4%,48.2%, and 56.9%, respectively. Patients treated by pre-operative RT had higher DMFS than patients received post-operative RT (75.7%vs69.4%, p=0.046). For R0 resection and R1/2 resection of patients treated by surgery combined with radiotherapy (pre-operative and post-operative RT), the 5-year LRFS were 75.8%and 64.4% (p=0.015), the 5-year DFS were 56.0% and 38.0% (p=0.003), and the 5-year OS were 62.9% and 48.7% (p=0.003). The rate of R0 resection was 95.4% for pre-operative RT and 36.3% for post-operative RT (p<0.001). Multivariate analysis showed R1/2 resection was risk factor for DFS and OS.Conclusion:Surgery combined with radiotherapy was a suitable treatment modality for local advanced nasal cavity and paranasal sinus carcinoma and patients with R0 surgery had higher DFS and OS than R1/2 surgery. Pre-operative radiotherapy had lower DMFS and higher rate of R0 resection than post-operative radiotherapy. Pre-operative radiotherapy followed by surgery should be recommended in clinical practice.Part III:Orbital content preservation of pre-operative radiotherapy and the prognostic value of pathologic response to pre-operative radiotherapy for the nasal cavity and paranasal sinus carcinomaObjective:To evaluate orbital content preservation of pre-operative radiotherapy and the pathologic response to pre-operative radiotherapy, and assess the value of predict survival of pathologic response for the nasal cavity and paranasal sinus carcinoma.Methods:One hundred and eight patients of the nasal cavity and paranasal sinus carcinoma treated with pre-operative radiotherapy followed by surgery in our hospital were studied respectively between 1999 and 2014. The median tumor dose for 105 patients was 60Gy (range:40-80Gy) with per faction dose was 2Gy (range:1.8-2.3Gy), excluding 1 patient with 39Gy/3Gy/13faction,1 patient with 60Gy/3Gy/20faction, and 1 patient with 69Gy/3Gy/23faction. There were 2 endoscopic surgery and 106 open surgery. Evaluation standard of pathologic response to pre-operative radiotherapy: moderate pathologic response was that tumor cells have different degree degeneration; intermediate pathologic response was part of tumor cells disappear, stromal fibrosis and residual cells with degeneration; severe pathologic response was clusters or scattered of residual tumor cells with degeneration or disappear of tumor cell, stromal fibrosis.Results:The median follow-up was 81.5 months. The 5-yearlocal recurrence free survival (LRFS), distant metastasisfree survival (DMFS), disease free survival (DFS) and overall survival (OS) were 64.4%,75.7%,50.1%, and 56.3%, respectively. The rate of orbital wall invaded was 55.6% and orbital content or apex invaded was 23.1%. After pre-operative radiotherapy,93.5% orbital content was preserved. There were 41 patients (38.0%) achieved severe pathologic response to radiotherapy and 67 ones (62.0%) non-severe pathologic response. For severe and non-severe pathologic response,5-year LRFS were 75.7% and 57.6%(p=0.022),5-year DFS were 66.2% and 39.7%(p=0.007), 5-year OS were 65.8% and 50.3%(p=0.078). General conditions of patients and parameters of treatment were analyzed in Logistic regression analysis, no factor was found to be a predictive parameter related to severe pathologic response. Severe pathologic response was good factor to LRFS and DFS in Cox proportional hazards model (p=0.029, p=0.010).Conclusion:Pre-operative radiotherapy had high rate of orbital content preservation and there was 38.0% severe pathologic response to pre-operative radiotherapy for the nasal cavity and paranasal sinus carcinoma. Severe pathologic response had higher LRFS and DFS than non-severe pathologic response and was prognostic factor to LRFS and DFS in Cox analysis for patients of the nasal cavity and paranasal sinus carcinoma. |
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