Review: Fine-Tuning Sinonasal Cancer Management Requires Increased Awareness and Further Clinical Studies

Cancers of the sinonasal tract are rare, and outcomes remain dismal despite recent progress in cancer treatment on the whole. A review published in CA: A Cancer Journal for Clinicians, aimed to characterize the incidence of sinonasal malignancies as well as potential causes, diagnostic considerations, and treatments.

The review encompassed a variety of sinonasal cancer types, including those exclusive to the sinonasal tract and malignancies that are likely to be found in the sinonasal tract. The former include sinonasal undifferentiated carcinoma, sinonasal adenocarcinoma, sinonasal squamous cell carcinoma, and esthesioneuroblastoma; the latter include primary mucosal melanoma, nuclear protein of the testis carcinoma, and extranodal natural killer cell/T-cell lymphoma.

The earliest signs of sinonasal cancers typically include nasal obstruction, nosebleeds, facial pain, or persistent rhinorrhea, all of which are nonspecific and can make early diagnosis a challenge. These early symptoms are commonly associated with noncancerous conditions such as allergies. Proptosis, diplopia or cranial neuropathy, chronic rhinosinusitis, or headaches are symptoms of locally advanced disease. Advanced disease symptoms vary depending on the specific type of cancer but can include anosmia or proptosis, neuropathy of cranial nerves, and facial paresthesia. Most patients with sinonasal cancers are diagnosed at later stages due to the nonspecific symptoms of early-stage disease.

Patients with early symptoms should undergo head and neck examination that includes mucosal surfaces. Cranial nerve assessment should also be done, as well as endoscopy to determine the extent of the tumor and retrieve tissue for histopathological examination. Imaging studies should be done to further assess the state of disease.

Across sinonasal cancer types, resection is potentially curative when possible, but complete resection can be challenging or impossible due to the nasal cavity and paranasal sinuses’ proximity to critical structures. Negative surgical margins are crucial for achieving improved outcomes vs nonsurgical treatment.

Due to the rarity of sinonasal malignancies, large-scale studies are lacking. However, using induction therapy to achieve negative surgical margins has shown promise for improving outcomes such as overall survival and organ preservation in various sinonasal cancer types. Still, there is not yet a gold standard for treating these cancers, and surveillance is typically conducted according to guidelines for head and neck cancer in general.

While patients with sinonasal cancers require multidisciplinary care from diagnosis to follow-up for optimal outcomes, survivorship and surveillance strategies specific to sinonasal cancers are currently not clearly defined.

“Immediate issues include rehabilitation after radiation and surgery to the sinonasal cavity. Comprehensive nutritional assessment is necessary to ensure recovery,” the authors wrote. “Delayed issues include the development of radiation-induced soft tissue sarcomas, hypothyroidism, and damage to organs from surgery or radiation. The risk factors for some sinonasal cancer types are also common with several other head and neck malignancies, and smoking cessation is essential to prevent additional primary malignancies.”

Going forward, the authors emphasize the importance of increasing early detection and comprehensive multidisciplinary management of sinonasal cancers. Efforts to form larger databases could also help improve the understanding and treatment of these rare malignancies. Studies including multinational cohorts with larger numbers of patients would also benefit sinonasal cancer research and therapy development.

“A challenge for studies in such rare cancers is the comparison of treatment regime versus a standard of care that does not exist,” they noted. “A possible solution to these problems with cancer registries and clinical studies for rare diseases is to have multinational institutions maintain a well-constructed prospective registry.”

The Trans-Atlantic Australasian Retroperitoneal Sarcoma Working Group is one example of this strategy in retroperitoneal sarcoma, and The Head and Neck Cancer International Group is another that facilitates high-quality clinical studies. There is currently a lack of clinical studies for rare cancers within the International Group, but the platform has potential to allow international collaboration for rare malignancies such as sinonasal cancers, the authors wrote.

The review highlights a need for more research in the realm of sinonasal cancers, as well as a focus on timely diagnosis and management of these malignancies for the best possible outcomes.

Reference

Thawani R, Kim MS, Arastu A, et al. The contemporary management of cancers of the sinonasal tract in adults. CA Cancer J Clin. Published online August 2, 2022. doi:10.3322/caac.21752