Sinonasal Malignancies Involving the Frontal Sinus: A Mono-Institutional Experience of 84 Cases and Systematic Literature Review

Abstract

Frontal sinus involvement by malignant tumors is a rare finding. Therefore, a systematic literature review along with a personal case series may contribute to defining more accurately the epidemiology, treatment options, and outcomes of these neoplasms. This is a retrospective review of patients affected by frontal sinus malignancies surgically treated in a tertiary-care referral center over a period of 20 years. Moreover, a systematic literature review of studies describing frontal sinus cancers from 2000 to date was performed according to PRISMA guidelines in order to analyze current evidence about the treatment and outcomes of such a rare disease. Our retrospective review was basedon 84 cases, treated with an exclusive endoscopic approach in 43 cases (51.2%), endoscopic approach with frontal osteoplastic flap in 6 cases (7.1%), and transfacial or transcranial approaches in 35 cases (41.7%). The five-year overall, disease-specific, disease-free, and recurrence-free survivals were 54.6%, 62.6%, 33.1%, and 59.1%, respectively. Age, dural involvement, type of surgical resection, and surgical margin status were significantly associated with the survival endpoints. In conclusion, the involvement of the frontal sinus is associated with a poor prognosis. Multidisciplinary management, including specific histology-driven treatments, represents the gold standard for improving outcomes and minimizing morbidity.

Keywords: craniofacial resection; draf procedure; endoscopy surgery; frontal sinus; multidisciplinary cancer treatment; osteoplastic flap; sinonasal cancer; skull base.

Figure 1

PRISMA flowchart summarizing the methods used in the present study.

Figure 2

Univariate analysis: Kaplan–Meier curves for overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RFS) according to the status of surgical margins and dural involvement. Bold values are statistically significant.

Figure 3

Contrast-enhanced MRI in coronal (A) and sagittal (B) views showing a left frontoethmoidal INI-1 deficient squamous cell carcinoma. After 3 cycles of induction chemotherapy (TPF regimen) an MRI in the coronal (C) and axial (D) view revealed an incomplete response. Tumor persistence was resected via a combined approach: endoscopic transnasal and osteoplastic flap (E), with an exposition of anterior cranial fossa dura (*) which appeared to be free from tumor infiltration (F). At 12 months, postoperative contrast-enhanced MRI in coronal (G) and axial (H) views revealed no local recurrence.

Figure 4

Flowchart of the study protocol, describing the multimodal treatment algorithm for the management of the malignancies involving the frontal sinus. The response rate to induction chemotherapy was defined according to the RECIST 1.1 criteria [9]. Abbreviations: ACC, adenoid cystic carcinoma; ADC, adenocarcinoma; BSC, best supportive care; CER, cranio-endoscopic resection; CFR, craniofacial resection; CHT, chemotherapy; EER, endoscopic endonasal resection; ERTC, endoscopic resection via transnasal craniectomy; FS, frontal sinus; iCHT, induction chemotherapy; ITAC, intestinal-type adenocarcinoma; OPF, osteoplastic flap; RT, radiotherapy; SCC, squamous cell carcinoma; SNEC, sinonasal neuroendocrine carcinoma; SNUC, sinonasal undifferentiated carcinoma.

Figure 5

Preoperative MRI in coronal (A) and sagittal (B) views showing a frontoethmoidal neoplasm with massive bilateral frontal sinus involvement. After an endoscopic transnasal biopsy, the lesion was histologically defined as biphenotypic sinonasal sarcoma. The lesion (*) was resected via a combined surgical approach: frontal sinus osteoplastic flap (C) and endoscopic transnasal approach (D), achieving free resection margins. A contrast-enhanced coronal (E) and sagittal (F) MRI performed 2 years after treatment proved no evidence of residual disease and ruled out local recurrences.