Esthesioneuroblastoma

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CHAPTER 143 Esthesioneuroblastoma

Esthesioneuroblastoma, first described by Berger, Luc, and Richard in 1924,1 is an uncommon neoplasm that arises from olfactory epithelium high in the nasal vault and frequently invades the skull base, cranial vault, and orbit. Although esthesioneuroblastoma accounts for up to 3% of intranasal neoplasms in some series, fewer than 400 unique cases have been reported in the world literature. The recent apparent increase in incidence is at least in part attributable to improvements in diagnostic imaging and pathologic recognition of this relatively rare entity. Because of the limited number of subjects treated in different eras of medical and surgical practice, in addition to nonuniform treatment schemes and follow-up, management recommendations regarding these tumors have been based largely on anecdotal data and limited series.

Clinical Findings

Patients with esthesioneuroblastoma are typically evaluated by the otolaryngologist for complaints of nasal obstruction or recurrent epistaxis. A fleshy, friable nasal mass is frequently noted, and hyposmia is often detected on formal testing. Other, less common initial symptoms and signs include headache, visual impairment, and rhinorrhea (Table 143-2). Males and females are affected equally.46 The age at diagnosis has been reported to be 3 to 78 years with a bimodal distribution consisting of peaks in the second and fifth decades.7,8 No geographic, environmental, or lifestyle risk factors have been clearly associated with increased risk for esthesioneuroblastoma.

TABLE 143-2 Initial Symptoms and Signs of Esthesioneuroblastoma

Nasal Obstruction
Epistaxis
Nasal mass
Hyposmia
Headache
Rhinorrhea
Visual acuity loss
Proptosis
Mental status changes
Neck mass
Tooth pain
Face pain
Face mass
Diplopia

Metastatic disease is present in 17% to 48% of patients with esthesioneuroblastoma at diagnosis.912 Cervical lymph nodes account for the majority of metastases; other locations include lung, bone, and much less commonly, liver, mediastinum, adrenal gland, ovary, spleen, parotid, central nervous system, and spinal epidural space.6,13 In our experience, 8% of patients in whom esthesioneuroblastoma was detected had metastatic disease in the cervical lymph nodes, with cervical node disease eventually developing in 28%. Metastatic disease ultimately developed in some location in 37% of patients.

Patient Evaluation

Preoperative evaluation includes a thorough history and physical examination to determine the extent of the symptoms and concomitant medical conditions that might limit aggressive management. Evaluation by an otolaryngologist is warranted both to assess the extent of sinus and cervical disease and to provide a diagnostic biopsy specimen. A preoperative neuro-ophthalmologic evaluation should be performed to identify visual acuity or motility deficits and to document baseline function in patients with disease near orbital structures or in whom extensive surgical resection is anticipated (Table 143-3).

TABLE 143-3 Preoperative Evaluation of Patients with a Suspected Sinonasal Mass

Radiographic assessment of tumor begins with contrast-enhanced computed tomography (CT). Sinus disease and bony erosion are well depicted by CT. Erosion of the floor of the anterior fossa or orbital wall is common, and in such cases magnetic resonance imaging (MRI) is of utility in more clearly depicting the extent of soft tissue disease and better visualizing pathology near the orbital apex (Fig. 143-2). However, when the bone erosion depicted on CT is minimal, MRI is still strongly recommended because the extent of intracranial disease may be significant even with little visualized bony involvement. Adequate radiographic assessment allows preoperative classification of the tumor according to the scheme proposed by Kadish and modified by others (Table 143-4).12,14,15 As discussed later, this system has been correlated with outcome with some reliability.

TABLE 143-4 Modified Kadish Staging of Esthesioneuroblastoma

Stage A Tumor confined to the nasal cavity
Stage B Tumor extension to the paranasal sinuses
Stage C Tumor beyond the nasal cavity and paranasal sinuses, including involvement of the cribriform plate, base of the skull, intracranial cavity, and/or orbit
Stage D Tumor with metastases to the cervical lymph nodes and/or distant sites

Patients in whom metastatic disease is suspected should undergo a thorough evaluation for determination of the extent of disease and selection of adjuvant therapy. Such evaluation may include positron emission tomography/CT of the neck, chest, abdomen, and pelvis, as well as a bone scan.

Treatment

The relatively small number of reported cases of esthesioneuroblastoma has made it difficult to determine the impact of individual therapies. This effort has been further hampered by the changes in medical management, surgical technique, and technology over the past 50 years; patients in early reports were treated in a much different era of medicine than those in recent years. With the onset of interest in cranial base surgery, treatment paradigms have shifted from less aggressive surgical resection to more frequent total resections. More recently, interest has begun to shift to less invasive, endoscopic-assisted surgical intervention with adjuvant stereotactic delivery of radiotherapy or radiosurgery. Although experience with adjuvant therapies has been limited, some benefit appears to be gained from the use of radiotherapy and chemotherapy.

Radiotherapy

Early lesions (Kadish stage A or B) have been managed successfully with radiation therapy alone in some cases; Elkton and coauthors reported short-term local tumor control with radiation therapy alone in 17 of 21 stage A or B tumors.16 Their findings have been confirmed by others,17 but some have suggested that the use of radiation as a sole treatment modality be reserved for inoperable cases.7,18 Anecdotal, unpublished cases of smaller tumors limited to the nasal cavity and successfully treated exclusively with biopsy and radiosurgery have been reported, although experience with this scheme is inadequately detailed and limited by short-term follow-up. However, based on our experience with the use of radiosurgery for focal areas of recurrent disease, primary definitive radiosurgery may be a valid plan for stage A and selected stage B tumors.

Preoperative radiotherapy has also been recommended. Theoretical benefits of preoperative radiation therapy include decreasing tumor mass and minimizing local tumor dissemination and distant metastases at the time of surgery by decreasing cell viability. Preoperative tumor irradiation has proved useful in sparing the orbital contents during surgery for paranasal sinus carcinoma.19 In doses of 50 to 60 Gy, radiation therapy has also been purported to decrease the likelihood of tumor recurrence. In a series from the Mayo Clinic, the incidence of recurrence of both high- and low-grade tumors was reduced by postoperative radiation treatment.8 A review of the recent literature revealed that just 20% of patients treated by radiotherapy and surgery had recurrence of tumor at 5 years versus 50% who underwent surgery alone. For patients with advanced or metastatic disease, adjuvant therapy may provide additional benefit. Improved outcomes have been reported for patients undergoing neck dissection and radiation therapy for cervical disease.5,20

Chemotherapy

Histologically and ultrastructurally, esthesioneuroblastoma shares features with other chemosensitive tumors such as neuroblastoma, small cell lung carcinoma, and primitive neuroectodermal tumor. Probably for this reason, similar chemotherapeutic regimens found to be effective for these other lesions have been used for esthesioneuroblastoma, with variable results. In one series of 7 patients, chemotherapy induced a partial response in 4 patients and no response in 3.6 Another study reported improvement after chemotherapy in 19 of 20 patients.21 A series from the Mayo Clinic demonstrated regression of disease after chemotherapy in 2 of 4 patients with Hyams’ grade III or grade IV tumors but in none of the 4 with lower grade lesions.22 Gross total tumor resection combined with chemotherapy has produced better outcomes than chemotherapy alone has, but this is confounded by the fact that patients who did not undergo attempted resection had more extensive disease at diagnosis. Typically, regimens include cyclophosphamide and vincristine, although doxorubicin is sometimes included. Platinum-based therapies have also been used with some favorable results. A few centers have used high-dose chemotherapy with bone marrow rescue and intra-arterial chemotherapy with some success as well.2326

Combined Chemoradiation Therapy

At the University of Virginia and Penn State University, we have routinely used preoperative radiation therapy and chemotherapy for our patients with esthesioneuroblastoma. Patients with Kadish stage A or B tumors received 45 to 50 Gy of radiation preoperatively; patients with Kadish stage C lesions underwent the same dose of radiation in addition to six cycles of cyclophosphamide-vincristine (20 patients) or cisplatin-etoposide (3 patients) chemotherapy. We have retrospectively analyzed pretreatment and posttreatment MRI findings in 24 patients. Our treatment regimen was associated with a decrease in total tumor volume of greater than 50% or a reduction in intracranial tumor mass of greater than 90% in 13 patients (54%). Total tumor volume reduction of 20% to 50% was seen in 4 patients (17%). Six patients (25%) showed no response (Fig. 143-3). Interestingly, the only patient with progression of tumor during the period of chemoradiation therapy received methotrexate instead of cyclophosphamide.

The sum of the experience with chemotherapy and radiation therapy for esthesioneuroblastoma suggests that some benefit is afforded by these treatments; however, the limited number of subjects and variability in treatment protocols have limited the development of definitive recommendations.

Surgical Resection

Surgical resection has been the mainstay of therapy for esthesioneuroblastoma despite reports of local tumor control with adjuvant treatment alone. In patients not medically precluded from surgery, resection appears to improve long-term results. Smith and colleagues described a combined transfacial and transcranial approach for resection of paranasal sinus carcinoma in 1954,27 and in 1970, the first craniofacial resection for esthesioneuroblastoma was performed by Drs. Slaughter Fitz-Hugh and John Jane at the University of Virginia. Soon thereafter, boosted by the reports of Ketcham and associates and Clifford, the use of craniofacial resection for tumors in this region became widespread.28,

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