Abstract
Dear Editor,
We read with great interest Preetha and colleagues’ study, which examined the treatment outcomes for 84 patients w ith paranasal sinus (PNS) cancer of different histologies. 1 The study evaluated overall survival (OS), loco-regional failure-free survival (LRFS), and distant metastases-free survival (DMFS) as the measured endpoints. In this study, the authors could not find any correlation between histological type and OS, LRFS, or DMFS. Univariate analysis results indicated that the treatment technique was the unique factor significantly related to LRFS outcomes (p = .002), with none demonstrating a significant association with DFS or OS. Of note, there was a slight trend towards significance for OS (p = .078) based on the treatment modality employed. The median OS times were estimated to be 39, 47, and 56 months with surgery alone, radiotherapy (RT) alone, and surgery plus adjuvant treatment [RT or concurrent RT]. These findings indicate that the combination of surgery and adjuvant treatment may significantly improve the survival outcomes of PNS cancer patients. However, we have two concerns that need to be addressed to better interpret the research findings.
First, contradicting the available literature, Preetha and colleagues could not establish any prognostic significance for the factors they examined, which included tumor histology, T-stage (tumor), and N-stage (nodal) concerning the survival outcomes.2–6 This may be due to the limited number of patients in most groups, which made statistical comparisons difficult. Specifically, only 1–5 patients were present in seven groups. This argument applies to both the T-stage and the N-stage as well, with only three patients in T1 and one patient in N3 stages. Backing this assertion, recently Shi et al., in 164 maxillary sinus tumor patients, demonstrated that five-year OS rates were 74.1%, 48.4%, and 22.1% for adenoid cystic carcinomas (ACC), squamous cell carcinomas (SCC), and sarcomas, respectively. 2 Likewise, Poeschl et al. 3 and Robin et al. 4 found that maxillary sinus SCCs had a better prognosis than non-SCCs at comparable stages, with only ACC in Poeschl et al. and adenocarcinomas and ACCs in Robin et al. studies having higher survival rates than SCCs. Jain et al. analysed the Surveillance, Epidemiology, and End Results database and identified 3,714 PNS cancer patients: 2,895 SCC and 819 adenocarcinoma cases. 5 OS was significantly better in adenocarcinomas than SCCs at five years (p = .001). 5 In multivariate analysis, predictors of worse OS were increased age (p < .001) and stage (p < .001) for SCCs and increased age (p < .001) and grade (p < .001) for adenocarcinomas, respectively. In line, Bhattacharyya reported that male sex, older age, higher T- and N-stage, and poorer tumor grade were all associated with a poor prognosis in nasal cancers. 6 Therefore, like its predecessors, it may be profitable to stratify patients into SCC versus non-SCC, T1–2 versus T3–4, and N0 versus N1–3 categories to facilitate a comparison of outcomes in the study conducted by Preetha and colleagues. Such a methodology could reveal the precise value of these well-established prognosticators in their study cohort, thereby uncovering intriguing insights.
Second, unfortunately, the authors did not stratify patients into comparative groups according to their surgical margin status in those for whom surgery was used as part of or the only form of treatment. The complex location of these tumors poses a formidable challenge in performing R0 resections. However, it is well acknowledged that patients undergoing R0 resections exhibit significantly higher survival rates than those receiving R1/R2 resections.7, 8 For example, in a comprehensive study of 2,698 sinonasal SCCs, Torabi et al. reported that 27.2% of patients had positive margins, which was associated with a 67.2% increased risk of mortality and a 96.6% higher rate of additional treatment administration. Likewise, Jafari and colleagues compared the outcomes of 4,543 surgically treated patients with 3,265 non-surgically treated patients and showed that the survival outcomes of patients with macroscopic positive margins were not superior to those treated with nonsurgical options. 8 Cumulatively, these findings suggest that the status of surgical margins is a significant predictor of patient outcomes in PNS cancers. Thus, analysing surgical margin status is critical for facilitating cross-study comparisons and guiding best-fit treatment options in routine clinical practice.
To conclude, the analyses mentioned above are paramount in the stratification of patients to determine those who will benefit from additional neoadjuvant and adjuvant therapies, like radiotherapy and chemotherapy. Such a methodology may also identify low-risk patients who can avoid futile treatments and their short and long-term toxicities, such as oral mucositis, xerostomia, mucosal/soft tissue fibrosis, periodontitis, tooth decay, tooth loss, radiation-induced trismus, and osteoradionecrosis, all of which can have an impact on almost all domains of quality of life.
