Abstract
Introduction
Sinonasal undifferentiated carcinoma (SNUC) is an exceedingly rare and aggressive tumor that carries a poor prognosis due to its non-specific presentation and advanced stage at time of diagnosis. Early detection and treatment are vital, with chemotherapy, radiation, and surgery all being viable options. The literature is sparse and there is no consensus for optimal treatment. In surgical candidates, the otolaryngologist must have a vast skill set in order to resect the tumor with wide margins and reconstruct the defect in hopes of returning the patient to their pre-morbid state.
Methods
A 74-year-old female presented with a growing left nasal mass which was biopsied and found to be a sinonasal undifferentiated carcinoma originating from the anterior nasal cavity between the septum and upper lateral cartilage. The patient was treated with neo-adjuvant carboplatin with concurrent radiation, followed by resection through a lateral nasal flap. The defect was reconstructed with a contralateral septal hinge flap and septal cartilage graft with primary closure of the lateral nasal flap.
Results
Intraoperatively, no skin or cartilage invasion was noted and as such, nasal skin was spared and utilized for primary closure. At a follow-up of 3 months, the patient had no evidence of recurrence and had a well healing repair site with satisfactory cosmesis.
Conclusions
Despite the aggressive nature of SNUC tumors, neo-adjuvant chemo-radiation and surgical intervention with functionally and aesthetically minded reconstruction can provide patients with improved outcomes and decreased morbidity.
1
Case presentation
A 75-year-old otherwise healthy female presented to the office complaining of an enlarging left nasal mass over the past 1 year. She stated that she was having increasing difficulty breathing from the left nasal passage and also noticed that the left side of her nose was beginning to appear swollen and distorted. She denied weight loss, nasal discharge, epistaxis, changes in vision and cognition, or any other constitutional symptoms.
A complete head and neck examination was performed including fiberoptic nasopharyngolaryngoscopy, revealing a large grayish polypoid mass protruding from the left nasal vestibule. The mass appeared to be originating from the superior vestibular mucosa in the region between the septum and the left upper lateral cartilage. There was no evidence of posterior extension or invasion of regional structures. The remainder of the examination was unremarkable and revealed no adenopathy, masses, or gross abnormalities.
A fine-needle-aspiration of the nasal mass revealed an undifferentiated carcinoma in the background of inflammation. Tumor specific stains were performed and found to be positive for p16, Ki-67, p63, and CK (AE1/AE3), conferring the diagnosis of sinonasal undifferentiated carcinoma. The pathology findings from the biopsy can be seen in Fig. 1 .
The patient was evaluated by medical and radiation oncology, and began treatment with cisplatin and concurrent external beam radiation. After the first week of cisplatin, the patient had an elevation in creatinine so therapy was changed to weekly carboplatin, which was continued for an additional 6 weeks. Following completion of treatment, the tumor was grossly decreased in size and repeat imaging was performed as shown in Fig. 2 . Computed tomography (CT) and magnetic resonance imaging (MRI) revealed residual tumor in the anterior nasal cavity with questionable involvement of the cartilage and nasal skin.
Following a thorough discussion with the patient, the decision was made to surgically extirpate the remaining tumor followed with primary reconstruction. As imaging suggested possible involvement of the nasal skin, the decision was made to access the tumor through a lateral nasal flap and reconstruct with a paramedian forehead flap. Following incision and elevation of the nasal flap, the soft-tissue envelope of the nose appeared to be uninvolved. Repeat examination suggested that the tumor was wedged between the left septal mucosa and upper lateral cartilage. The tumor was resected en bloc with septal cartilage, left septal mucoperichondrium, and the left upper lateral cartilage. Frozen section analysis of the surgical margins was negative.
As nasal skin was not resected, a paramedian forehead flap was not performed. The septal mucosa on the right side was raised as a hinge flap and used to recreate the inner lining of the anterior left nasal cavity. With the remaining septal cartilage, a large graft was taken for dorsal support and secured overlying the hinge flap. The lateral nasal flap was closed primarily, and the surgery was concluded at that time. The steps of the resection and reconstruction are displayed in Fig. 3 .
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