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Original Article |

Role of Radiotherapy in the Treatment of Nasoethmoidal Adenocarcinoma FREE

Olivier Choussy, MD; Christophe Ferron, MD; Pierre-Olivier Védrine, MD; Bruno Toussaint, MD; Bénédicte Liétin, MD; Patrick Marandas, MD, PhD; Emmanuel Babin, MD, PhD; Dominique De Raucourt, MD; Emile Reyt, MD; Alain Cosmidis, MD; Marc Makeieff, MD; Danièle Dehesdin, MD, PhD
[+] Author Affiliations

Author Affiliations: Otorhinolaryngology Departments, Rouen University Hospital, Rouen (Drs Choussy and Dehesdin), Nantes University Hospital, Nantes (Dr Ferron), Comprehensive Cancer Centre, Nancy University Hospital, Nancy (Drs Védrine and Toussaint), Clermont-Ferrand University Hospital, Clermont-Ferrand (Dr Liétin), Comprehensive Cancer Centre, Paris (Dr Marandas), Caen University Hospital, Caen (Dr Babin), Comprehensive Cancer Centre Caen, Caen (Dr De Raucourt), Grenoble University Hospital, Grenoble (Dr Reyt), Lyon University Hospital, Lyon (Dr Cosmidis), and Montpellier University Hospital, Montpellier (Dr Makeieff), France.


Arch Otolaryngol Head Neck Surg. 2010;136(2):143-146. doi:10.1001/archoto.2009.212.
Text Size: A A A
Published online

Objective  To assess the efficacy of radiotherapy in the treatment of nasoethmoidal adenocarcinoma.

Design  Multicenter, retrospective study.

Setting  Eleven French hospitals.

Patients  The medical records of 418 patients who presented with nasoethmoidal adenocarcinoma from January 1, 1976, through December 31, 2001, were evaluated. A total of 324 patients were treated with a combination of surgery and radiotherapy, and 55 were treated with surgery only.

Main Outcome Measures  Survival rates, disease recurrence, and postoperative complications.

Results  The 5-year Kaplan-Meier survey revealed survival rates of 64.5% for the surgery-only group and 70.8% for the combined-treatment group. In the surgery-only group, 28 patients (51%) had disease recurrence (24 local, 2 regional, and 2 distant). Of the 55 patients in the combined-treatment group, 31 patients (56%) had disease recurrence (29 local, 1 regional, and 1 distant). Immediate postoperative complications in the combined-treatment group were hemorrhages in 2 patients, meningitis in 3 patients, and cerebrospinal fluid leakage in 4 patients, but no deaths occurred. In the surgery-only group, 1 patient had meningitis, 2 had cerebrospinal fluid leaking but no hemorrhage, and 5 died postoperatively.

Conclusion  The results of this retrospective study suggest that radiotherapy can be used to treat nasoethmoidal adenocarcinoma, but its usefulness should be confirmed with further prospective studies.

Figures in this Article

Nasoethmoidal adenocarcinomas are rare tumors, yet the risk factors for these tumors have been previously well defined.1 The criterion standard treatment reported in the literature is the combination of surgery and radiotherapy215; however, some authors have reported an alternative approach that does not include radiotherapy.1620 The aims of this study were to evaluate and compare patients treated by surgery only with patients treated by a combination of methods (surgery and radiotherapy) and to assess the role of radiotherapy in this patient population.

Our retrospective study assessed a large patient population with nasoethmoidal adenocarcinoma. This series was previously published with general data reported elsewhere.1 All factors that influenced the survey of this population were presented in a previous article and have now been used in this more updated evaluation, with treatment specifically assessed. The treatment was not analyzed in the first article because of the numerous data analyzed in the initial study.

Eleven French hospitals (the University Hospitals of Caen, Clermont-Ferrand, Grenoble, Lyon, Montpellier, Nancy, Nantes, and Rouen and the Comprehensive Cancer Centers of Caen, Nancy, and Paris, collectively known as the Study Group for Tumors of the Head and Neck) participated in the study. The study spans a 25-year period from January 1, 1976, to December 31, 2001, during which 418 patients presented with an adenocarcinoma of the ethmoid bone. A total of 307 patients were men and 111 were women. The mean age at presentation was 62.8 years (range, 31-91 years).

Patients were divided into 2 groups. In the first group, 324 patients (77.5%) received combined treatment. In the second group, 55 patients (13.2%) were treated with surgery only. The other 39 patients (9.3%) treated by another protocol were excluded from the present study. These 2 groups were asymmetric, and more at-risk patients were present in the combined-treatment group. To eliminate this difference, a cross-matched population analysis was performed, and 55 patients treated by surgery and radiotherapy were selected to obtain 2 similar groups. Further analysis was performed to compare the surgery-only group to the cross-matched population of 55 patients treated with surgery and radiotherapy. The risk factors for prognosis were the size of the tumor (T4), the size of the lymph node, and intracranial involvement.1

Staging was performed according to the recommendations of the American Joint Committee on Cancer21 for the staging of tumors of the ethmoid sinuses. Both groups contained 7 patients with T1 tumors, 21 with T2 tumors, 11 with T3 tumors, and 16 with T4 tumors; all tumors were labelled N0 based on the American Joint Committee on Cancer classification. All centers included patients treated by surgery only. During this long period of analysis, combined treatment (surgery and radiotherapy) of these lesions experienced major advancements, but the distribution during this period in patients of the 2 groups subsequently permitted a more specific comparison.

Of the 55 patients in the surgery-only group, surgical resection was transfacial in 42 patients (76%), transcranial only in 3 patients (5%), combined (transfacial and transcranial) in 8 patients (15%), and endoscopic in 2 patients (4%). The 2 endoscopic procedures each revealed a poorly developed lesion in a unilateral polyp discovered fortuitously. The transfacial approach was preferred when the lesion was extensive to the mediofacial area with no dura or brain extension. The extension to the cribriform palate was not a contraindication to a transfacial approach for some surgeons. The transcranial procedure was specifically performed for the lesion with intracranial extension but with a limited extension to the anterior part of the sinonasal area.

Radiotherapy was external in all patients with no intensity-modulated radiotherapy or conformal radiation therapy. Megavoltage photons were used during a once-daily fractionation scheme with a median dose of 61 Gy (range, 50-70 Gy) in 30 fractions.

Statistical analysis was performed to evaluate the survival rate of the 2 populations. For statistical analysis we used log-rank and χ2 tests, and data were analyzed using Statview statistical software, version 5.0 (SAS Institute Inc, Cary, North Carolina).

The epidemiologic data of the 2 groups were similar, with nasoethmoidal adenocarcinoma occurring mostly in men in the sixth decade with a long period (>20 years) of wood particle exposure. The only difference in the data was that more women were in the surgery-only group, but sex was not a prognostic factor in this patient population. Unilateral rhinologic symptoms were routinely found. All patients underwent computed tomography, whereas magnetic resonance imaging was used for more recent patients included in the study. The risk factors of each group are reported in Table 1.

Table Graphic Jump LocationTable 1. Risk Factors of the Patients in the Surgery-Only and Combined-Treatment Groups

The 5-year Kaplan-Meier survey revealed survival rates of 64.5% for the surgery-only group and 70.8% for the combined-treatment group. No statistical difference was found in the survival rate (Kaplan-Meier) between these 2 groups (P = .20), but the rates were asymmetric, and more at-risk patients were present in the combined-treatment group. To eliminate this difference, a cross-matched population was created, and 55 patients treated by surgery and radiotherapy were selected to obtain 2 similar groups with regard to risk factors and general data (Table 2). The 5-year Kaplan-Meier survey revealed a survival rate of 60.9% for the cross-matched group. No statistical difference was found with regard to the survival rate between these 2 comparative groups for risk factors of worse prognosis (P = .60) (Figure). All patients included in this analysis underwent a surgical procedure. The macroscopic and microscopic analyses of the tumor resection are given in Table 3.

Place holder to copy figure label and caption
Figure.

Kaplan-Meier survey of the 2 cross-matched groups.

Graphic Jump Location
Table Graphic Jump LocationTable 2. Characteristics of the Surgery-Only and Combined-Treatment Groups
Table Graphic Jump LocationTable 3. Macroscopic and Microscopic Analysis of the Margins of Tumor Resection

In the surgery-only group, 28 patients (51%) had disease recurrence (24 local, 2 regional, and 2 distant). Of the 55 patients in the combined-treatment group, 31 (56%) had disease recurrence (29 local, 1 regional, and 1 distant). At the end point of this study, 32 patients in the surgery-only group and 31 in the combined-treatment group were disease free.

Immediate postoperative complications in the combined-treatment group were hemorrhages in 2 patients, meningitis in 3 patients, and cerebrospinal fluid leaking in 4 patients, but no deaths occurred. In the surgery-only group, 1 patient had meningitis, 2 had cerebrospinal fluid leaking but no hemorrhage, and 5 died postoperatively. Five patients had a T4 lesion and underwent a transcranial procedure.

Although nasoethmoidal adenocarcinoma is rare, it is a well-defined condition. Epidemiologic, clinical, and radiologic findings have been reported in a number of articles.120 Risk factors are now well known, and the most important appear to be the size of the lesion (T4 in TNM classification21), extension to the lymph node, and intracranial involvement.1 With regard to treatment, the criterion standard seems to be combined treatment (ie, combination of surgery and radiotherapy in most reported studies),115 which has a 5-year patient survival rate of 35% to 70%. The use of combination treatment is supported by the risk of local tumor recurrence. However, the effect of radiotherapy remains unclear. For some authors, adenocarcinoma of the sinuses and nasal cavities seems to be moderately radiosensitive,2225 whereas other authors15,20 report radiotherapy as their treatment of choice. Some authors reserved radiotherapy for lesions with a large extension.6,26,27 More focused radiation, such as intensity-modulated radiotherapy, must be evaluated. In some cases, authors2830 reported their experiences. Unfortunately, in those studies, data with regard to different histologic types of nasosinus tumors (such as epidermoid and esthesioneuroblastoma) were pooled. Hence, it was not possible to ascertain which data referred merely to adenocarcinoma of the ethmoid. In 2 recent reports, the 5-year overall survival rates were 45% and 58%, with no significant improvements in disease control but a low incidence of complications. The effect of surgery only was studied by Sisson et al31 but only in 2 patients with nasoethmoidal adenocarcinoma, who had a 5-year survival rate of 86%. For Sisson et al, surgery only was a valid alternative for the treatment of small and selected lesions. In the meta-analysis by Dulguerov et al,12 the comparison between surgery only (70%) and a combination of surgery and radiotherapy (63%) showed no statistical difference, but different types of lesions and various anatomical sites were added in their 2 groups.

In our series1 of exclusive adenocarcinoma of the ethmoid bone, we found a 5-year survival rate of 64%, in accordance with the literature. The 5-year survival rate of the group treated by surgery only was 65.4%. In contrast to cases reported in the literature, no statistical difference was found with regard to a 5-year survival rate of the global population compared with the group treated by combined methods or the cross-matched group. Different hypotheses, depending on the size of the lesion, may explain this result.

With or without postsurgical radiotherapy, the aggressive lesions (T4 or those that involve lymph nodes, brain, or dura) had a poor prognosis, and the quality of life of these patients who forego aggressive treatment must be preserved. For smaller lesions, the use of surgery only may be sufficient to eliminate these small tumors, or postsurgical radiotherapy can be performed to effectively treat the curable lesion. This retrospective study was not able to determine the definitive therapeutic treatment, but our results indicate there is no advantage to the use of radiotherapy. Future major multicenter studies are needed to more precisely define the role of radiotherapy in treating nasoethmoidal adenocarcinoma.

In conclusion, the criterion standard treatment of ethmoid nasal adenocarcinoma is a combination of surgery and postoperative radiotherapy. This study demonstrates that all patients do not require postoperative radiotherapy and selected patients can be treated by surgery only. Prospective studies will be useful to clarify the role of radiotherapy and develop a subsequent therapeutic strategy. New modalities of radiotherapy (eg, intensity-modulated radiotherapy) can perhaps improve the treatment of this condition. New molecules (eg, monoclonal antibody of epidermal growth factor receptor inhibitor) could be of interest in the treatment of these lesions, which are similar to intestinal adenocarcinomas. To our knowledge, no previous studies have examined the role of chemotherapy in the treatment of this condition. The results of this retrospective study suggest that radiotherapy can be used to treat nasoethmoidal adenocarcinoma, but its usefulness should be confirmed with further prospective studies.

Correspondence: Olivier Choussy, MD, ENT Department, Rouen University Hospital, 1 rue de Germont, 76031 Rouen, CEDEX France (olivier.choussy@chu-rouen.fr).

Submitted for Publication: December 4, 2008; final revision received June 26, 2009; accepted June 29, 2009.

Author Contributions: Dr Choussy had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: De Raucourt and Dehesdin. Acquisition of data: Ferron, Védrine, Toussaint, Liétin, Marandas, Babin, Reyt, Cosmidis, and Makeieff. Analysis and interpretation of data: Choussy. Drafting of the manuscript: Choussy. Critical revision of the manuscript for important intellectual content: Ferron, Védrine, Toussaint, Liétin, Marandas, Babin, De Raucourt, Reyt, Cosmidis, Makeieff, and Dehesdin. Obtained funding: Cosmidis. Administrative, technical, and material support: Choussy, Ferron, Toussaint, Marandas, De Raucourt, Reyt, and Makeieff. Study supervision: Védrine, Babin, De Raucourt, and Dehesdin.

Financial Disclosure: None reported.

Additional Contributions: Richard Medeiros, PhD, Medical Editor at Rouen University Hospital, edited the manuscript and Jean François Menard, MD, PhD, Rouen University Hospital, provided expert advice in statistical analysis.

Choussy  OFerron  CVédrine  PO  et al. GETTEC Study Group, Adenocarcinoma of ethmoid: a GETTEC retrospective multicenter study of 418 cases. Laryngoscope 2008;118 (3) 437- 443
PubMed Link to Article
Klintenberg  COlofsson  JHellquist  HSokjer  HS Adenocarcinoma of the ethmoid sinuses: a review of 28 cases with special reference to wood dust exposure. Cancer 1984;54 (3) 482- 488
PubMed Link to Article
Liétin  BMom  TAvan  P  et al.  Adenocarcinomas of the ethmoid sinus: retrospective analysis of prognostic factors [in French]. Ann Otolaryngol Chir Cervicofac 2006;123 (5) 211- 220
PubMed Link to Article
Jegoux  FFerron  CHMalard  OCariou  GFaure  ABeauvillain De Montreuil  C Ethmoid adenocarcinoma: trans-facial approach for anterior skull base resection: a series of 80 cases [in French]. Ann Otolaryngol Chir Cervicofac 2004;121 (4) 213- 221
PubMed Link to Article
Choussy  OLerosey  YMarie  JP  et al.  Adenocarcinoma of the ethmoid sinuses: results of a retrospective study in Rouen [in French]. Ann Otolaryngol Chir Cervicofac 2001;118 (3) 156- 164
PubMed
Kraus  DHSterman  BMLevine  HLWood  BGTucker  HMLavertu  PS Factors influencing survival in ethmoid sinus cancer. Arch Otolaryngol Head Neck Surg 1992;118 (4) 367- 372
PubMed Link to Article
Moreau  JJBessede  JPHeurtebise  F  et al.  Adenocarcinoma of the ethmoid sinus in woodworkers: retrospective study of 25 cases [in French]. Neurochirurgie 1997;43 (2) 111- 117
PubMed
Dilhuydy  JMLagarde  PAllal  AS  et al.  Ethmoidal cancers: a retrospective study of 22 cases. Int J Radiat Oncol Biol Phys 1993;25 (1) 113- 116
PubMed Link to Article
George  BSalvan  DLuboinski  BBoissonnet  HLot  G Malignant tumors of the ethmoid sinuses: a homogeneous series of 41 cases operated on by mixed approaches [in French]. Neurochirurgie 1997;43 (2) 121- 124
PubMed
Harbo  GGrau  CBundgaard  T  et al.  Cancer of the nasal cavity and paranasal sinuses: a clinico-pathological study of 277 patients. Acta Oncol 1997;36 (1) 45- 50
Link to Article
Heurtebise  FBessede  JPMoreau  JJ  et al.  Ethmoid adenocarcinoma in woodworkers: a retrospective study of 25 cases [in French]. Rev Soc Française Otorhinolaryngol 1998;51 (5) 21- 26
Dulguerov  PJacobsen  MSAllal  ASLehmann  WCalcaterra  TS Nasal and paranasal sinus carcinoma: are we making progress? a series of 220 patients and a systematic review. Cancer 2001;92 (12) 3012- 3029
PubMed Link to Article
Guillotte-van Gorkum  MLNasser  TMérol  JCLegros  MRousseaux  PChays  A Ethmoid adenocarcinoma: a series of 17 cases [in French]. Ann Otolaryngol Chir Cervicofac 2003;120 (5) 296- 301
PubMed
Heffner  DKHyams  VJHauck  KWLingeman  C Low-grade adenocarcinoma of the nasal cavity and paranasal sinuses. Cancer 1982;50 (2) 312- 322
PubMed Link to Article
Shidnia  HHornback  NBSaghafi  NSayoc  ELingeman  RHamaker  R The role of radiation therapy in treatment of malignant tumors of the paranasal sinuses. Laryngoscope 1984;94 (1) 102- 106
PubMed Link to Article
Roux  FXBrasnu  DMenard  M  et al.  Adenocarcinoma of the ethmoid sinuses: result of a new protocol based on inductive chemotherapy combined with surgery: four years experience. Acta Neurochir (Wien) 1989;98 (3-4) 129- 134
PubMed Link to Article
Knegt  PPde Jong  PCvan Andel  JGde Boer  MFEykenboom  Wvan der Schans  E Carcinoma of the paranasal sinuses: results of a prospective pilot study. Cancer 1985;56 (1) 57- 62
PubMed Link to Article
Knegt  PPAh-See  KWvd Velden  LAKerrebijn  J Adenocarcinoma of the ethmoidal sinus complex: surgical debulking and topical fluorouracil may be the optimal treatment. Arch Otolaryngol Head Neck Surg 2001;127 (2) 141- 146
PubMed Link to Article
Parsons  JTMendenhall  WMMancuso  AACassisi  NJMillion  RR Malignant tumors of the nasal cavity and ethmoid and sphenoid sinuses. Int J Radiat Oncol Biol Phys 1988;14 (1) 11- 22
PubMed Link to Article
Waldron  JNO'Sullivan  BWarde  P  et al.  Ethmoid sinus cancer: twenty-nine cases managed with primary radiation therapy. Int J Radiat Oncol Biol Phys 1998;41 (2) 361- 369
PubMed Link to Article
Sobin  LHWittekind  CH International Union Against Cancer: paranasal sinus. TNM Classification of Malignant Tumors. New York, NY Wiley-Liss Inc1997;38- 41
Marandas  PLuboinski  BEschwege  FWibault  PCachin  Y Ethmoid adenocarcinomas: retrospective study of 76 cases from the Gustave Roussy Institute of Actuality of Ear, Nose, and Throat Oncology [in French]. Topics in Cervicofacial Carcinology[in French]. Paris, France Masson1992;37- 42
Roux  FXBrasnu  DLaccourreye  HFabre  AChodkiewicz  JP Ethmoidal adenocarcinoma surgically treated in one stage by transfacial and subfrontal approach after inductive chemotherapy: preliminary results of a new therapeutic approach [in French]. Neurochirurgie 1987;33 (5) 365- 370
PubMed
Rafla  S Mucous gland tumors of paranasal sinuses. Cancer 1969;24 (4) 683- 691
PubMed Link to Article
Elner  AKoch  H Combined radiological and surgical therapy of cancer of the ethmoid. Acta Otolaryngol 1974;78 (3-4) 270- 276
PubMed Link to Article
Catalano  PJHecht  CSBiller  HF  et al.  Craniofacial resection: an analysis of 73 cases.  Arch Otolaryngol Head Neck Surg 1994;120 (11) 1203- 1208
Link to Article
Stoll  DBebear  JPDarrouzet  V  et al.  Surgery on malignant nasosinal tumors [in French]. Cahiers Otorhinolaryngol 1998;23 (8) 449- 453
Daly  MEChen  AMBucci  MK  et al.  Intensity-modulated radiation therapy for malignancies of the nasal cavity and paranasal sinuses. Int J Radiat Oncol Biol Phys 2007;67 (1) 151- 157
PubMed Link to Article
Duthoy  WBoterberg  TClaus  F  et al.  Postoperative intensity-modulated radiotherapy in sinonasal carcinoma: clinical results in 39 patients. Cancer 2005;104 (1) 71- 82
PubMed Link to Article
Madani  IBonte  KVakaet  LBoterberg  TDe Neve  W Intensity-modulated radiotherapy for sinonasal tumors: Ghent University Hospital update. Int J Radiat Oncol Biol Phys 2009;73 (2) 424- 432
PubMed Link to Article
Sisson  GA  SrToriumi  DMAtiyah  RA Paranasal sinus malignancy: a comprehensive update. Laryngoscope 1989;99 (2) 143- 150
Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Kaplan-Meier survey of the 2 cross-matched groups.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Risk Factors of the Patients in the Surgery-Only and Combined-Treatment Groups
Table Graphic Jump LocationTable 2. Characteristics of the Surgery-Only and Combined-Treatment Groups
Table Graphic Jump LocationTable 3. Macroscopic and Microscopic Analysis of the Margins of Tumor Resection

References

Choussy  OFerron  CVédrine  PO  et al. GETTEC Study Group, Adenocarcinoma of ethmoid: a GETTEC retrospective multicenter study of 418 cases. Laryngoscope 2008;118 (3) 437- 443
PubMed Link to Article
Klintenberg  COlofsson  JHellquist  HSokjer  HS Adenocarcinoma of the ethmoid sinuses: a review of 28 cases with special reference to wood dust exposure. Cancer 1984;54 (3) 482- 488
PubMed Link to Article
Liétin  BMom  TAvan  P  et al.  Adenocarcinomas of the ethmoid sinus: retrospective analysis of prognostic factors [in French]. Ann Otolaryngol Chir Cervicofac 2006;123 (5) 211- 220
PubMed Link to Article
Jegoux  FFerron  CHMalard  OCariou  GFaure  ABeauvillain De Montreuil  C Ethmoid adenocarcinoma: trans-facial approach for anterior skull base resection: a series of 80 cases [in French]. Ann Otolaryngol Chir Cervicofac 2004;121 (4) 213- 221
PubMed Link to Article
Choussy  OLerosey  YMarie  JP  et al.  Adenocarcinoma of the ethmoid sinuses: results of a retrospective study in Rouen [in French]. Ann Otolaryngol Chir Cervicofac 2001;118 (3) 156- 164
PubMed
Kraus  DHSterman  BMLevine  HLWood  BGTucker  HMLavertu  PS Factors influencing survival in ethmoid sinus cancer. Arch Otolaryngol Head Neck Surg 1992;118 (4) 367- 372
PubMed Link to Article
Moreau  JJBessede  JPHeurtebise  F  et al.  Adenocarcinoma of the ethmoid sinus in woodworkers: retrospective study of 25 cases [in French]. Neurochirurgie 1997;43 (2) 111- 117
PubMed
Dilhuydy  JMLagarde  PAllal  AS  et al.  Ethmoidal cancers: a retrospective study of 22 cases. Int J Radiat Oncol Biol Phys 1993;25 (1) 113- 116
PubMed Link to Article
George  BSalvan  DLuboinski  BBoissonnet  HLot  G Malignant tumors of the ethmoid sinuses: a homogeneous series of 41 cases operated on by mixed approaches [in French]. Neurochirurgie 1997;43 (2) 121- 124
PubMed
Harbo  GGrau  CBundgaard  T  et al.  Cancer of the nasal cavity and paranasal sinuses: a clinico-pathological study of 277 patients. Acta Oncol 1997;36 (1) 45- 50
Link to Article
Heurtebise  FBessede  JPMoreau  JJ  et al.  Ethmoid adenocarcinoma in woodworkers: a retrospective study of 25 cases [in French]. Rev Soc Française Otorhinolaryngol 1998;51 (5) 21- 26
Dulguerov  PJacobsen  MSAllal  ASLehmann  WCalcaterra  TS Nasal and paranasal sinus carcinoma: are we making progress? a series of 220 patients and a systematic review. Cancer 2001;92 (12) 3012- 3029
PubMed Link to Article
Guillotte-van Gorkum  MLNasser  TMérol  JCLegros  MRousseaux  PChays  A Ethmoid adenocarcinoma: a series of 17 cases [in French]. Ann Otolaryngol Chir Cervicofac 2003;120 (5) 296- 301
PubMed
Heffner  DKHyams  VJHauck  KWLingeman  C Low-grade adenocarcinoma of the nasal cavity and paranasal sinuses. Cancer 1982;50 (2) 312- 322
PubMed Link to Article
Shidnia  HHornback  NBSaghafi  NSayoc  ELingeman  RHamaker  R The role of radiation therapy in treatment of malignant tumors of the paranasal sinuses. Laryngoscope 1984;94 (1) 102- 106
PubMed Link to Article
Roux  FXBrasnu  DMenard  M  et al.  Adenocarcinoma of the ethmoid sinuses: result of a new protocol based on inductive chemotherapy combined with surgery: four years experience. Acta Neurochir (Wien) 1989;98 (3-4) 129- 134
PubMed Link to Article
Knegt  PPde Jong  PCvan Andel  JGde Boer  MFEykenboom  Wvan der Schans  E Carcinoma of the paranasal sinuses: results of a prospective pilot study. Cancer 1985;56 (1) 57- 62
PubMed Link to Article
Knegt  PPAh-See  KWvd Velden  LAKerrebijn  J Adenocarcinoma of the ethmoidal sinus complex: surgical debulking and topical fluorouracil may be the optimal treatment. Arch Otolaryngol Head Neck Surg 2001;127 (2) 141- 146
PubMed Link to Article
Parsons  JTMendenhall  WMMancuso  AACassisi  NJMillion  RR Malignant tumors of the nasal cavity and ethmoid and sphenoid sinuses. Int J Radiat Oncol Biol Phys 1988;14 (1) 11- 22
PubMed Link to Article
Waldron  JNO'Sullivan  BWarde  P  et al.  Ethmoid sinus cancer: twenty-nine cases managed with primary radiation therapy. Int J Radiat Oncol Biol Phys 1998;41 (2) 361- 369
PubMed Link to Article
Sobin  LHWittekind  CH International Union Against Cancer: paranasal sinus. TNM Classification of Malignant Tumors. New York, NY Wiley-Liss Inc1997;38- 41
Marandas  PLuboinski  BEschwege  FWibault  PCachin  Y Ethmoid adenocarcinomas: retrospective study of 76 cases from the Gustave Roussy Institute of Actuality of Ear, Nose, and Throat Oncology [in French]. Topics in Cervicofacial Carcinology[in French]. Paris, France Masson1992;37- 42
Roux  FXBrasnu  DLaccourreye  HFabre  AChodkiewicz  JP Ethmoidal adenocarcinoma surgically treated in one stage by transfacial and subfrontal approach after inductive chemotherapy: preliminary results of a new therapeutic approach [in French]. Neurochirurgie 1987;33 (5) 365- 370
PubMed
Rafla  S Mucous gland tumors of paranasal sinuses. Cancer 1969;24 (4) 683- 691
PubMed Link to Article
Elner  AKoch  H Combined radiological and surgical therapy of cancer of the ethmoid. Acta Otolaryngol 1974;78 (3-4) 270- 276
PubMed Link to Article
Catalano  PJHecht  CSBiller  HF  et al.  Craniofacial resection: an analysis of 73 cases.  Arch Otolaryngol Head Neck Surg 1994;120 (11) 1203- 1208
Link to Article
Stoll  DBebear  JPDarrouzet  V  et al.  Surgery on malignant nasosinal tumors [in French]. Cahiers Otorhinolaryngol 1998;23 (8) 449- 453
Daly  MEChen  AMBucci  MK  et al.  Intensity-modulated radiation therapy for malignancies of the nasal cavity and paranasal sinuses. Int J Radiat Oncol Biol Phys 2007;67 (1) 151- 157
PubMed Link to Article
Duthoy  WBoterberg  TClaus  F  et al.  Postoperative intensity-modulated radiotherapy in sinonasal carcinoma: clinical results in 39 patients. Cancer 2005;104 (1) 71- 82
PubMed Link to Article
Madani  IBonte  KVakaet  LBoterberg  TDe Neve  W Intensity-modulated radiotherapy for sinonasal tumors: Ghent University Hospital update. Int J Radiat Oncol Biol Phys 2009;73 (2) 424- 432
PubMed Link to Article
Sisson  GA  SrToriumi  DMAtiyah  RA Paranasal sinus malignancy: a comprehensive update. Laryngoscope 1989;99 (2) 143- 150
Link to Article

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
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