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Objectives/hypothesis Maxillary cancers are rare and aggressive tumors, which can spread beyond the sinus bony walls. Preoperative assessment of infiltration of maxillary sinus floor (MSF) is paramount for surgical planning, as palatomaxillary demolition significantly impacts patients' quality of life. This study investigates the challenges involved in the preoperative and intraoperative evaluation of MSF infiltration and analyzes its prognostic relevance. Study design Retrospective case series. Methods A retrospective review of patients treated for sinonasal malignancies at a single Institution was performed. Patients receiving surgical-based treatment with curative intent for primary maxillary sinus cancers, between January 2000 and November 2019, were included. Results A cohort of 118 patients was analyzed. By comparing intraoperative findings (endoscopic assessment and frozen sections) with preoperative radiological assessment, diagnostic changes with regard to MSF infiltration were found in 27.1% (32/118 cases). MSF infiltration negatively affected the prognosis in both univariate and multivariate analyses in the overall population. In the subgroup of pT1-T3 tumors, MSF infiltration was significantly associated with reduced overall (P = .012), disease-free (P = .011), and distant recurrence-free (P = .002) survival rates. Conversely, pT classification was not able to stratify patients according to prognosis, mainly because early-staged cancers (pT1-T2) with MSF infiltration showed reduced survival rates, similar to those observed in pT3 cancers. Conclusions Preoperative imaging should be integrated with intraoperative findings based on endoscopic inspection and frozen sections. Future studies are required to investigate the opportunity to incorporate MSF infiltration in the TNM staging system, considering its crucial role in defining the extent of surgery and its potential as prognosticator. Level of evidence 4 Laryngoscope, 2021.

Introduction Anterior skull base cerebrospinal fluid (CSF) leaks are managed successfully with endonasal surgery. Endoscopic closure of CSF leaks from posterior table of the frontal sinus remains challenging. Vascularized Hadad-Bassagasteguy flap (HBF) reconstruction of the skull base has increased CSF closure rates but does not extend to frontal sinus. We describe our technique using septal flap pedicled by anterior ethmoid artery (AEA) for repairing frontal defects. Method Retrospective review of cases of frontal CSF leak repair using the AEA flap reconstruction. Flap design: an anterior vertical septal mucosa incision at posterior border of the frontal sinusotomy is made and extended to nasal floor. Posterior vertical incision is made 1 cm posterior to the projection of the axilla of the middle turbinate on the septum and extended to nasal floor. A horizontal incision along the nasal floor joins the two incisions. The flap is raised and rotated into the frontal sinus over the posterior table reconstructed defect. Results Three patients identified. Two males, one female, aged 11, 33 and 56. Patient histories included recurrent bacterial meningitis following head trauma, recurrent sinusitis and fronto-ethmoidal osteoma, with intraoperative CSF leak and CSF rhinorrhea due to meningoencephalocele. The three posterior wall defects were successfully repaired endoscopically with multilayer reconstruction and the AEA septal flap. Conclusions The anterior ethmoid artery septal flap can be successfully utilised for frontal CSF leak repair. Flap is conveniently located for frontal sinus defects. When the septum is intact it provides an excellent final layer as part of multilayer reconstruction.

Nowadays, surgeons have a wide armamentarium of surgical approaches available to safely treat sinonasal malignancies, which includes open approaches, with the traditional craniofacial resection (CFR), and endoscopic transnasal techniques. The correct choice depends on the features of the pathology. It is well known that endoscopic approaches have a lower morbidity compared with traditional open techniques, due to a shorter hospitalization, absence of facial incisions, and avoidance of brain retraction. Moreover, endoscopic surgery presents clear technical advantages. For example, magnification of the surgical field allows the surgeon to carefully identify tumor margins, the site of origin, and the anatomical structures involved by the lesion. Nevertheless, a purely endoscopic approach cannot always provide successful resection of the tumor; the patient must be informed about the possibility of switching to a combined cranioendoscopic resection or CRF, depending on the effective extension of the disease evaluated intraoperatively. Despite these advantages, postoperative complications can occur after endoscopic endonasal surgery, as in any surgical intervention; however, complications after these procedures are less severe and less frequent compared with traditional open approaches. The most common complications observed include skull base reconstruction failure, intraoperative vascular lesions, and orbital or central nervous system complications. Thus, endoscopic endonasal resection, when properly planned and performed by experienced surgeons, is an acceptable treatment for well-selected skull base malignancies with long-term outcomes comparable to those achieved with traditional external approaches.

OBJECTIVES Squamous cell carcinoma of nasal vestibule and pyramid is rare, thus classification, treatment protocol, and indications for elective neck treatment are still controversial. Nasal reconstruction is challenging, as well, and prosthesis is still used. STUDY DESIGN Retrospective cohort study. METHODS Retrospective review of patients surgically treated from 2010 to 2018 in a single Institution. Advanced tumors were further treated with adjuvant irradiation. Reconstruction strategy included grafts, locoregional and free flaps, and was customized on layers removed. RESULTS Forty-five patients were enrolled. The 5-year overall survival and disease-free survival were 81.9% ± 7.45% and 61.9% ± 9.09%, respectively. Wang's classification, site of origin, extent of surgery and margins status significantly correlated with prognosis and recurrence rate. Regional recurrences occurred in patients affected by advanced tumors who did not receive any form of elective neck treatment. CONCLUSION Multidisciplinary management and a proper reconstructive algorithm are recommended. Adjuvant irradiation and elective neck treatment should be advocated for advanced stage high-risk patients. LEVEL OF EVIDENCE 4. Laryngoscope, 131:E1198-E1208, 2021.

Simple Summary Poorly differentiated sinonasal carcinomas (PDSNCs) are rare neoplasms that include a wide spectrum of malignancies characterized by alteration in different epigenetic mechanisms (SWI/SNF complex, IDH2, NUT). The aim of our study was to verify if the identification of specific genetic and epigenetic alterations can be useful to recognize different clinico-pathological subsets of PDSNCs to guide treatment decisions. In our cohort, 14 cases showed alterations in SWI/SNF complex or IDH2 genes, which were associated with a higher global DNA methylation level and worst prognosis. The integration of genetic and epigenetic features appears to be a good strategy to improve the clinico-pathological classification of these tumors and to recognize distinct prognostic entities that deserve tailored clinical management. Abstract Background: Poorly differentiated sinonasal carcinomas (PDSNCs) are rare and aggressive malignancies, which include squamous cell carcinoma (SCC), sinonasal undifferentiated carcinoma (SNUC), and neuroendocrine carcinomas (NEC). Several epigenetic markers have been suggested to support the histopathological classification, predict prognosis, and guide therapeutic decision. Indeed, molecularly distinct subtypes of sinonasal carcinomas, including SMARCB1-INI1 or SMARCA4 deficient sinonasal carcinoma, isocitrate dehydrogenase (IDH)-mutant SNUC, ARID1A mutant PDSNCs, and NUT carcinomas, have recently been proposed as separate entities. Identification of aberrant DNA methylation levels associated with these specific epigenetic driver genes could be useful for prognostic and therapeutic purpose. Methods: Histopathological review and immunohistochemical study was performed on 53 PDSNCs. Molecular analysis included mutational profile by NGS, Sanger sequencing, and MLPA analyses, and global DNA methylation profile using LINE-1 bisulfite-PCR and pyrosequencing analysis. Results: Nine SWI/SNF complex defective cases and five IDH2 p.Arg172x cases were identified. A significant correlation between INI-1 or IDH2 defects and LINE-1 hypermethylation was observed (p = 0.002 and p = 0.032, respectively), which were associated with a worse prognosis (p = 0.007). Conclusions: Genetic and epigenetic characterization of PDSNCs should be performed to identify distinct prognostic entities, which deserved a tailored clinical treatment.

Background Pretreatment hematological markers have emerged as prognostic factors for several cancers. The purpose of this study was to present our investigation of the value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting recurrence and mortality for patients with primary sinonasal cancers (SNCs). Methods We carried out a retrospective review of patients with SNC who had been treated using endoscopic approaches from 2002 to 2014 at a single institute. The endpoints analyzed were overall survival (OS) and disease-free survival (DFS). Results Of 365 patients treated, 215 fulfilled the inclusion criteria. Analysis of epithelial tumors (adenocarcinoma and carcinoma) and advanced-stage cancers (pT3–T4) showed shorter OS and DFS in those patients with higher NLR and PLR. Furthermore, the NLR and PLR were revealed as independent prognostic factors for DFS, with a reduced risk of recurrence in patients with NLR

BACKGROUND Sinonasal cancers frequently involve the orbit with resulting controversies on whether to remove or preserve the orbital contents. METHODS Retrospective review of patients with primary sinonasal cancer involving the orbit, treated according to a multidisciplinary protocol tailored to tumor histology and extent of orbital invasion in two tertiary care referral centers over a 20-year period. RESULTS The oncological and functional outcomes of 163 patients were analyzed. The degree of orbital involvement significantly affected both overall (P

Objective Endoscopic endonasal surgery has evolved in recent decades, requiring comparable advances in reconstructive techniques. This study aimed to retrospectively review outcomes of endoscopic anterior skull base reconstruction and to analyze factors associated with failures. Methods Data from patients who underwent endoscopic endonasal anterior skull base reconstruction in a single institution between 1998 and 2017 were collected. Patients were stratified according to selected risk factors: sex; age; previous surgery; disease treated (cerebrospinal fluid leaks, benign tumors, malignant tumors); single or multiple defects; defect dimension ( 6 cm2) and site (olfactory cleft, ethmoidal roof, planum sphenoidalis, posterior wall of frontal sinus); reconstruction technique (overlay graft, multilayer grafts, pedicled flap) and materials used; postoperative radiotherapy; and year of surgery. Statistical significance was assessed using Fisher exact test. Univariate logistic regression was implemented to analyze the association between risk factors and failures. Results Inclusion criteria were met by 513 cases with median follow-up of 96 months (range, 12–257 months). Success rate for initial repair was 95% (487/513), with 100% success rate for secondary closure after revision surgery. Failures were not significantly related to sex (P = 0.54), reconstruction technique (P = 0.28), location of defect (P = 0.65), dimension (P = 0.69), disease (P = 0.83), or postoperative radiotherapy (P = 0.83). Year of surgery, considered as a continuous variable, was associated with a statistically significant reduction of failures (odds ratio = 0.89, P = 0.005). Conclusions Endoscopic surgery is safe and effective for anterior skull base reconstruction. Refinements in surgical technique and increasing experience have contributed to improved success rates.

Objective To investigate different treatment strategies for primary early-stage (pT1-T2) sinonasal adenocarcinomas. Methods Retrospective case-control study. From 2000 to 2011, 61 cases were radically resected using an endoscopic endonasal approach. Surgery as a single treatment modality was adopted for 33 patients (study group) while it was followed by postoperative radiotherapy (poRT) in 28 patients (control group). Results Median follow-up was 61 and 67 months for the study and control group respectively. Patients were stratified according to the pT classification and no statistically significant differences were found in terms of Overall (OS) and Recurrence-free (RFS) survival. When analyzing the high-grade tumors (47 cases), statistically significant differences were observed between the control and study groups both in terms of OS (90.5% ± 6.5% versus 57.6% ± 15.4%, P = 0.03) and RFS (92.3% ± 7.39% versus 80.2% ± 8.88%, P = 0.05). Using multivariate analysis, OS was independently determined by poRT (Hazard Ratio = 0.16; P = 0.03) thus confirming its protective role for high-grade adenocarcinomas. Conclusion Our preliminary results suggest that endoscopic endonasal surgery could be used as a single treatment modality for primary early-stage low-grade sinonasal adenocarcinoma, resected with negative margins. Surgery followed by poRT offers the best treatment strategy not only for advanced-stage lesions but also for high-grade adenocarcinomas, regardless of the stage of disease at presentation. J. Surg. Oncol. 2015; 112:561–567. © 2015 Wiley Periodicals, Inc.

BACKGROUND The purpose of this study was to report the outcomes of endoscopic transnasal resection for sinonasal and anterior skull-base cancers in elderly patients. METHODS A retrospective review was performed. The patients were divided into 2 groups