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The prognosis for sinonasal malignancies has remained poor for the past several decades despite refinements in both surgical technique and radiation therapy. Stern reviewed the M.D. Anderson experi-

Figure 11-16. An intraoral view of a rectus abdominus free flap filling a left total maxillectomy defect. Facial contour following total maxillectomy is improved by the soft-tissue bulk of a rectus abdominus free flap reconstruction.

ence for maxillary squamous cell carcinoma and found no significant improvement in survival when compared to a similar study there 20 years earlier.69 However, another study from M.D. Anderson has shown an improved survival with surgery and postoperative radiation therapy when reviewing all types of malignancies.47

The various chemotherapy and radiation therapy regimens described above have shown survival improvements for advanced stage disease, although some of these reports have been for small numbers of patients with relatively short follow-up periods. Surgery with postoperative radiation therapy remains the standard treatment for resectable sinonasal carcinoma. A brief review of the larger series reporting outcomes for surgery with postoperative radiation therapy is shown in Table 11-1.

Spiro reviewed 105 patients at Memorial Sloan-Kettering Cancer Center with nasal cavity, maxillary, and ethmoid squamous cell carcinoma treated with combination surgery and radiation therapy, radiation therapy alone, or surgery alone. The majority of these patients presented with extensive disease with 82 percent of newly treated patients having stage III or stage IV disease. Survival is correlated to stage at presentation (Figure 11 -17), and the overall 5-year survival was 37 percent. The survival rates for nasal, maxillary, and ethmoid tumors were 45 percent, 38 percent, and 13 percent respectively (Figure 11-18). The local control for maxillary sinus tumors was 49 percent, and local recurrence was the most common site of failure.70

Zaharia reported the outcome of 149 patients treated with surgery and postoperative radiation therapy for a variety of malignant histologies. The 5-year actuarial survival was 36.2 percent overall, while for squamous cell carcinoma alone it was 35 percent.71 Sisson reported a 49 percent 5-year survival after treating 60 patients with sinonasal malignancies with a variety of regimens.26 Jiang reviewed the M.D. Anderson experience of 73 patients with maxillary sinus malignancies of varying histologies treated with surgery and postoperative radiation therapy. Overall 5-year relapse free survival was 51 percent, with a local control rate of 78 percent.47 Lavertu treated 54 patients with squamous cell carcinoma of the sinuses: all received surgery and/or radiation therapy with an overall survival of 38.2 percent for the maxillary sinus group.72

SUMMARY

The overall treatment of sinonasal maligancies has resulted in 5-year survival rates in the 30 to 50 percent range, with most of the larger series near the lower end of this spectrum. Local control is a particularly difficult problem, with the majority of failures occurring at the primary site. These difficulties with sinonasal cancer treatment are linked to the complex anatomy of the paranasal sinus region, and a propen

sity for late presentation due to the absence of symptoms in early stage disease. Complete surgical removal of the tumor with postoperative radiation therapy remains the standard of care for resectable lesions. Improved reconstructive techniques including microvascular free flaps and prosthetic obturators have significantly decreased the functional and cosmetic morbidity from aggressive surgical resection. The orbital contents may be preserved in cases where the orbital fat, musculature, and apex are free of disease. If the orbital floor is resected with orbital preservation, then reconstruction of the orbital floor is essential to maintaining good postoperative ocular function, particularly in the setting of additional planned radiation therapy. The use of chemotherapy and accelerated radiation therapy preliminarily appear to offer a substantial benefit for advanced stage tumors. The addition of these modalities may ultimately improve the long-prevailing poor prognosis of these challenging tumors.

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