Rinectomia total para carcinomas nasais

BrazJOtorhinolaryngol.2020;86(6):763---766

www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Total

rhinectomy

for

nasal

carcinomas

夽

Fábio

Muradás

Girardi

,

Luiz

Alberto

Hauth

,

Aliende

Lengler

Abentroth

Received19February2019;accepted2June2019 Availableonline2July2019

KEYWORDS Carcinoma,squamous cell; Lymphatic metastasis; Noseneoplasms; Skinneoplasms; Survival Abstract

Introduction:Totalrhinectomyisanuncommonprocedureforthetreatmentofnasal malig-nancies,usuallyreservedforlocallyadvancedtumors.Therearefewcaseseriesstudyingtotal rhinectomyintheliterature,reportingconflictingresultsaboutrecurrenceandmetastasis.

Objective: Evaluateprognosisoftotalrhinectomycasesformalignantneoplasiainour institu-tion.

Methods:RetrospectivereviewfromJanuary2013toSeptember2018,includingallpatients undergoingtotalrhinectomyinourInstitution,underthecareoftheHeadandNecksurgical team.

Results:Tenpatientswereincluded, twomenandeightwomen.Themeanpatientagewas 71.6yearsold.Themajorityhadnasalskin(8cases)carcinomas.Squamouscellcarcinomawas presentinsevencases.Intotal,sixcaseshadregionalmetastasis,inamedianperiodof14.3 months.Theoverallmortalityanddiseasespecificmortalitywas50%and30%,respectively,in amedianfollow-upof45.7months.

Conclusion: Weobservedhighoverallanddisease-specificmortalityamongcaseswithadvanced nasalmalignanciesundergoingtotalrhinectomy.

© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Carcinoma espinocelular; Metástaselinfática; Neoplasiasnasais; Neoplasiascutâneas; Sobrevida

Rinectomiatotalparacarcinomasnasais

Resumo

Introduc¸ão: Arinectomiatotaléumprocedimentoincomumparaotratamentodeneoplasias nasais,geralmentereservadoparatumoreslocalmenteavanc¸ados.Hápoucassériesdecasos queestudamarinectomiatotalnaliteratura,asquaisdescrevemresultadosconflitantessobre recorrênciaemetástase.

夽 _{Please cite thisarticle as: Girardi FM, Hauth LA, Abentroth AL. Total rhinectomy for nasal carcinomas.Braz JOtorhinolaryngol.} 2020;86:763---6.

∗_{Correspondingauthor.}

E-mail:fabiomgirardi@gmail.com(F.M.Girardi).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileirade OtorrinolaringologiaeCirurgiaCérvico-Facial.

https://doi.org/10.1016/j.bjorl.2019.06.002

1808-8694/©2019Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

764 GirardiFMetal.

Objetivo:Avaliar o prognóstico de pacientes submetidos a rinectomia total por neoplasia malignaemnossainstituic¸ão.

Método: Revisão retrospectiva de janeiro de 2013 a setembro de 2018, incluiu todos os pacientessubmetidosarinectomia totalemnossainstituic¸ão,soboscuidadosdaequipede cirurgiadecabec¸aepescoc¸o.

Resultados: Dezpacientesforamincluídos,doishomens eoito mulheres.Amédiade idade dospacientesfoide71,6anos.Amaioriaapresentavacarcinomadapelenasal(oitocasos).O carcinomaespinocelularestavapresenteemsetecasos.Seiscasostiverammetástaseregional em um períodomedianode 14,3meses.A mortalidade geraleamortalidade específicada doenc¸aforamde50%e30%,respectivamente;oacompanhamentomédiofoide45,7meses.

Conclusão:Observamosaltamortalidadegeraleespecíficadadoenc¸aentreoscasoscom neo-plasiasnasaisavanc¸adassubmetidasàrinectomiatotal.

© 2019 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Skincanceris themostcommonheadandneckmalignant neoplasiainthevastmajorityoftheworld.Thenoseisa typ-icalsubsiteofheadandneckskincancers,reachingalmost 50%oftheminsomeseries1_{(15%inourseries----unpublished} data).Themajorityofmalignanciesarediagnosedinearlier stages,requiring limitedexcisions,manytimes performed bydifferentspecialists.Totalrhinectomy(TR)isan excep-tionprocedure,reservedforlocallyadvancedtumors.There arefewcaseseriesstudyingTRintheliterature,2---5_mostof themgroupingdifferenthistologies,andcombiningmucosal andskintumors.

About 75---80%of nasalskinmalignanttumorsareBasal Cell Carcinomas (BCC), similar to other head and neck topographies.1 _{Squamous Cell Carcinomas (SCC) comprise} theother20---25%.Althoughcentralfacetopographyis con-sideredamongNCCN high risk featuresfor cutaneous SCC ofhead andneck,6 _{regionalmetastasis areusually} associ-atedwithlargesize,deeplyinvasivelesionsandhighgrade tumors,oftenwithperineuralandlymphovascularinvasion.7 OurHeadandNeckDepartmentisthereferencecenter forskincancer cases.ManyofourpatientsareofGerman descent, a significant part of them linked toagricultural work.

The purpose of this study was to evaluate diagnosis, treatment, andoutcomes in acase seriesof TRfor nasal carcinomas.

Methods

Alocalinstitutional reviewboard anda regionalResearch Ethics Committee approved the study protocol (CAAE: 93792318.4.0000.5304). We undertook a retrospective reviewfromJanuary2013toSeptember2018,includingall patientsundergoingTRinourInstitution,underthecareof theHeadandNecksurgicalteam.Thecaseswereidentified fromoperatingtheatrerecordsandconsultantdiaries.Case noteswerereviewedtogatherinformationrelatingto

clin-icalfeatures,histopathologicalreports,surgicaltreatment andoutcomes.TumorswereclassifiedaccordingtotheTNM classificationsystemofthe8theditionoftheAmericanJoint CommitteeonCancer.

Results

Duringtheanalyzedperiod,10patients,twomenandeight womenwere underwentTRdue tomalignantneoplasiaof the nose at ourtertiary cancercare center (Fig.1). Only onewasaimmunosuppressedpatient.The meanpatient’s age was71.6 yearsold(range56.4---87.2yo). Pathological informationissummarizedinTable1.In7casestherewere treatmentattempts priortoTR,fiveofthemtreatedwith surgicalresectionswithcompromisedsurgicalmargins,and the tworemainingcases, withliquidnitrogen therapy for several times. The most frequent tumor location wasthe nasalskin(8cases).Thenasalvestibulewasthetumor epi-centerinthetworemainingcases.Thenasaldorsumwasthe mostcommonskinsubsite(5cases).Histologicalanalysisof specimensrevealedadiagnosisofBCCinthreepatientsand SCCinsevenpatientsInallcases,ulceratedlesionsexisted. Themeantumordiameterwas3.6cm(range1.5---6cm).All caseswereclassifiedasClarkV,andinthreeofthem,there wasboneinvasion.Inonecase,finalhistologyshowed com-promisedsurgicalmargins.Insixcasestherewasvascularor perineuralinvasion.TwocaseswithSCChadclinically sus-picious neck lymphnodes at the first consultation in our department,but theother fourSCCcasesrecurredin the neckorparotidsinamedianperiodof14.3months(range 2.3---28.9 months).In total, threecasesshowed extracap-sular spread. Except for the only case with SCC without regionalmetastasisafter18.5monthsoffollow-up,allother patients withSCC receivedadjuvant radiotherapy,two of themassociatedwithchemotherapy.Inthreepatients, adju-vant treatment wasdefinitely interrupted by critical side effects. Since in our department we do not have access to maxillofacialprosthetic rehabilitation, the majority (9 cases) was reconstructed with surgical flaps. The overall

Totalrhinectomyfornasalcarcinomas 765

Figure1 Clinicalimagesofthefirsteightcasessubmittedtototalrhinectomy.

Table1 ClinicalandpathologicalinformationfromTRcases.

Age Sex Histology Diameter DOI TNM Recurrence Follow OS DRD Case1 87.2 F SCC 4.5 NI pT4aNxM0 IV No 27.0 Alive No Case2 77.3 F BCC 6.0 NI pT4aNxM0 IV No 36.2 Alive No Case3 63.8 F SCC 3.0 NI pT3N1M0 III Yes 15.3 Dead Yes Case4 80.3 F BCC 2.8 NI pT3NxM0 III Yes 29.0 Dead No Case5 75.7 F SCC 3.0 2.7 pT3NxM0 III Yes 15.2 Dead No Case6 59.3 M SCC 4.0 2.0 pT3NxM0 III No 18.5 Alive No Case7 67.0 F SCC 3.3 1.3 pT3NxM0 III Yes 48.5 Alive No Case8 74.0 F SCC 4.4 1.8 pT3NxM0 III Yes 5.8 Dead Yes Case9 74.8 F SCC 3.5 NI pT4aNxM0 IV Yes 26.0 Dead Yes Case10 56.4 M BCC 1.5 0.8 pT3NxM0 III No 66.1 Alive No

M,male;F,female;SCC,squamouscellcarcinoma;BCC,basalcellcarcinoma;DOI,depthofinvasion;diameterandDOIareexpressed incm;TNM,8theditionoftheAmericanJointCommitteeonCancer(atfirstpresentation);followisexpressedinmonths;OS,overall survival;DRD,diseaserelateddeath.

mortalitywas50%.Themedianfollow-upwas45.7months (range18.5---66.1months).AlldeathswereamongSCCcases withregionalmetastasis,although inonly threecases the deathsweredirectlyassociatedtothedisease.

Discussion

WedescribedaninstitutionalseriesaboutTRforadvanced cutaneousorvestibularcarcinomas.Mostofourcaseswere skin SCC. Often the procedure was an ‘‘end-stage’’ ther-apy,donefrequentlyaftermultiplepriorsurgicalattempts at tumorablation. Althoughthereareencouraging results intheliteratureforprimarydefinitiveradiotherapyinnasal malignancies,severesideeffectswerealsoreported,8_and long-term controlis generally bestachievedwithsurgical standardapproaches.9

Few case series have been published about this issue. Ourresults show that cases withadvanced nasal carcino-mas,especiallySCC,displayaggressivebehavior,withahigh incidenceofregionalmetastasis,similartootherreportsof advancedskinSCCfromotherheadandnecksubsites10,11_or

inmidfaciallocation.12_{Despitehighprevalenceofregional} disease, most authors recommend conservative measures regarding the cervical region, even in advanced cases.12 Disease-related mortality seems to be associated with regional metastasis and/or recurrence. Overall mortality maybehigh,especiallyinserieslikeours,withhighmean age.

Stanleydescribedthegreatesttotalrhinectomyseriesin 1988:fifty-onecases,most ofthemmiddle-agedpatients, 25ofthemwithSCCcomprisingthelargerlesions.Asfound inotherseries,morethanahalfofthemhadprevious unsuc-cessful surgical attempts to cure their disease, many of themundergoing multiple previous excisions.The authors described an overall survival of 50% and a 21% disease relatedmortalityin ameanfollow-upof 68months, simi-lartoourresults. Recurrencewasobservedin half ofthe patientsand wasapparently relatedtoworse survival, as about50%ofrecurrenttumorpatientsdiedoftheirdisease.4 ConflictingresultswerepublishedbyHarrisonin1982.In hispersonalexperienceinTRover15years,mostofthem withseptal SCC,he reportednonewithnodal metastasis.

766 GirardiFMetal. Localrecurrenceand uncontrolled disease werethe main

follow-upproblems.3 _{ForBecker etal.,analyzing a single} institutionexperiencewithnasalcavitySCC,regional metas-tasiswerealsorareatinitialclinicalpresentation,withonly oncase.Inthiscase series,14patientsweretreatedwith TR.9_{Subramaniametal.alsoreportedaseriesofninecases} without anydisease -relateddeathin amedian follow-up of5years(although threecaseshadlessthanoneyearof follow-up).5

Unfortunatelyfacialprosthesisrehabilitationisnot rou-tinelyavailableforpublichealthsystem-assistedpatientsin ourcountry.Therefore,themajorityofourcaseswas sub-mitted tosurgical reconstruction. As observed by Stanley etal.4_{TRisnotatechnicallydifficultprocedure.} Neverthe-less,patient rehabilitation is areal problem.Even in the best hands, using new techniques and multiple interven-tions,for many patients, acomplete nasal reconstruction often only succeeds in making a horrible situation look strange.4

Conclusion

We observed high loco-regional uncontrolled disease and highoverallanddiseasespecificmortalityamongcaseswith advancednasalskinandvestibularmalignancies,especially SCC.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.Kilic¸ C, Tuncel U, Comert E, Polat I. Nonmelanoma facial skin carcinomas: methods of treatment. J Craniofac Surg. 2014;25:e113---6.

2.ChippE,PrinslooD,RayattS.Rhinectomyforthemanagement ofnasalmalignancies.JLaryngolOtol.2011;125:1033---7. 3.HarrisonDFN.Total rhinectomy----a worthwhileoperation?J

LaryngolOtol.1982;96:1113---23.

4.Stanley RJ, Olsen KD. Rhinectomy for malignant disease. A 20 year experience. Arch Otolaryngol Head Neck Surg. 1988;114:1307---11.

5.Subramaniam T, Lennon P, O’Neill JP, Kinsella J, Timon C. Totalrhinectomy,aclinicalreviewofninecases.IrJMedSci. 2016;185:757---60.

6.SkulskySL,O’SullivanB,McArdleO,LeaderM,RocheM,Conlon PJ,etal.Reviewofhighriskfeaturesofcutaneoussquamous cellcarcinomaanddiscrepanciesbetweentheAmericanJoint CommitteeonCancerandNCCNClinicalPracticeGuidelinesin Oncology.HeadNeck.2017;39:578---94.

7.OwTJ,WangHR,McLellanB,CioconD,AminB,Goldenberg D,etal.EducationCommitteeoftheAmericanHeadandNeck Society(AHNS).AHNSseries:doyouknowyourguidelines? Diag-nosisandmanagementofcutaneoussquamouscellcarcinoma. HeadNeck.2016;38:1589---95.

8.AngKK,JiangGL,FrankenthalerRA,KaandersJH,GardenAS, DelclosL,etal.Carcinomasofthenasalcavity.RadiotherOncol. 1992;24:163---8.

9.BeckerC,Kayser G, PfeifferJ.Squamous cell cancerofthe nasal cavity:new insightsand implications for diagnosisand treatment.HeadNeck.2016;38Suppl1:E2112---7.

10.HarrisBN,BayoumiA,RaoS,MooreMG,FarwellDG,BewleyAF. Factorsassociatedwithrecurrenceandregionaladenopathyfor headandneckcutaneoussquamouscellcarcinoma.Otolaryngol HeadNeckSurg.2017;156:863---9.

11.PorcedduSV.Prognosticfactorsandtheroleofadjuvant radia-tiontherapyinnon-melanomaskincanceroftheheadandneck. AmSocClinOncolEducBook.2015:e513---8.

12.NettervilleJL, Sinard RJ, Bryant GL Jr, Burkey BB. Delayed regionalmetastasisfrommidfacialsquamouscarcinomas.Head Neck.1998;20:328---33.