Sinonasal cancer encroaching the orbit: Ablation or preservation?

Sinonasal Squamous Cell Carcinoma, a Narrative Reappraisal of the Current Evidence

“…Structural changes and reabsorption of these thin bone structures are well depicted by CT by virtue of its high spatial resolution and capability of demonstrating bone density alterations [ 42 , 43 , 44 ]. On the other hand, gadolinium-enhanced MRI is the dominant tool for structural imaging and is paramount in describing soft tissues involvement, both at the sinonasal region boundaries (periosteum/periorbit and dura mater) [ 45 , 46 , 47 ] and in the adjacent regions (e.g., brain, orbital content, cavernous sinus, internal carotid artery) [ 48 , 49 ].…”

“…Moreover, despite an increasing number of patients affected by SNSCC being treated through neoadjuvant ChT-(RT), there are no defined and evidence-based principles to guide the delineation of margins following nonsurgical treatments. However, since several authors advocate for neoadjuvant ChT-(RT) as a strategy to spare the orbit in patients otherwise treated through orbital ablation [ 49 , 62 , 63 , 64 , 65 ], it can be deduced that surgeons do reduce the entity of resection in SNSCCs objectively responding to neoadjuvant treatments.…”

When is a multidisciplinary surgical approach required in sinonasal tumours with cranial involvement?

“…Maroldi et al demonstrated that MRI is superior to CT in predicting the absence of orbital invasion (negative predictive value: 100% vs 75%, overall accuracy 96% vs 81%, respectively) 27 . In a recent study, Ferrari et al analyzed the diagnostic performance of MRI in detecting the involvement of single orbital structures: the adjusted diagnostic accuracy was satisfactory (≥ 80.0%) for the bony layer, extraconal fat, and muscular layer, but suboptimal (< 80.0%) for the periorbit and intraconal compartment 28 . Overall, MRI was confirmed to provide precious preoperative information on orbit involvement, though with specific shortcomings the MDT should be aware of.…”

“…The multimodal treatment algorithm maximized the orbital preservation rate (76.6%) in patients with orbit-encroaching sinonasal cancer. According to a recent publication, patients receiving orbital ablation for a sinonasal cancer unamenable to orbit-sparing surgery have a high probability of bearing nodal disease (29.8%), poor chances of surviving (5-year overall and disease-specific survival: 27.8%), and high risk of experiencing a local relapse despite aggressive surgery (5-year local recurrence-free survival: 44.6%) 28 . These data should be considered as a "red flag" for the MDT, with an indication to orbital ablation deserving thoughtful evaluation of potential alternatives.…”

“…Another unsolved challenge of sinonasal oncology is represented by sinonasal cancers macroscopically invading the orbital apex. When invasion of the orbital apex is detected at preoperative imaging, 5-year overall survival probability is as low as 15.0% in patients undergoing multimodal treatment including orbital exenteration/clearance 28 . Sugawara et al reported a 5-year overall survival rate of 86.2% in 15 patients with macroscopic orbital apex involvement treated through an "extended orbital exenteration" 75 .…”