Long-term survival outcomes of technically unresectable carcinoma maxilla postinduction chemotherapy.

Dear Editor,

Carcinoma of the maxillary sinus is a rare malignancy.[12] Due to this, there are limited prospective studies that have been reported. As the early stages of this malignancy remain asymptomatic, most patients get diagnosed in a locally advanced stage.[1] Due to its anatomical proximity to vital structures, surgical resection is a challenge, especially in locally advanced stages. However, surgical resection remains the cornerstone of management of this cancer.[3] In a study done by Iyer et al. in resectable locally advanced maxillary sinus cancers, surgical resection was associated with a 5-year disease-specific survival of 71% versus 0% in chemoradiation arm (P = 0.05).[4] However, in very locally advanced borderline resectable maxillary sinus carcinoma, upfront surgery is not possible. We had reported our initial results in 41 patients treated between 2008 and 2011 with induction chemotherapy in these tumors.[5] In this letter, we report the long-term results of patients treated with this strategy.

Forty-one patients with locally advanced technically unresectable maxillary sinus carcinoma were treated with two cycles of induction chemotherapy. All patients had T4 disease. The induction chemotherapy consisted of either three-drug regimen of docetaxel, cisplatin, and 5-fluorouracil or two-drug regimen of taxane (docetaxel or paclitaxel) and platinum (cisplatin or carboplatin). The chemotherapy regimens received were TPF in 7 patients, docetaxel-platinum in 15 patients, and rest received paclitaxel-platinum. The median cycles received were 2. Postinduction regimen, the response rate was 39% (16 patients). These patients were then discussed in a multidisciplinary joint clinic. The further treatment these patients underwent were surgical resection followed by postoperative chemoradiation in 8 patients, radical chemoradiation in 21 patients, radical radiation in 1 patient, palliative radiation in 1 patient, palliative chemotherapy in 4 patients, and best supportive care in 6 patients.

R version 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria) was used for analysis. Kaplan–Meier method was used for the estimation of progression-free survival (PFS) and overall survival (OS). Follow-up was calculated using reverse Kaplan–Meier method. Cox regression analysis was used to identify factors affecting PFS and OS. The median follow-up was 66.3 months. The 5-year progression-free survival rate and OS rate were 15.2% (95% confidence interval [CI] 3.2%–27.2%) and 16.9% (95% CI 4.9%–28.9%), respectively. The factors which were independently associated with an improvement in PFS and OS were grade of tumor and serum albumin level [Table 1].

Table 1

The impact of different factors on progression-free survival and overall survival

The outcomes of T4 carcinoma maxilla reported in the literature are poor.[1] Even resected T4 maxillary sinus carcinomas have a 5-year OS between 20% and 36%.[678] The outcomes of resectable carcinoma maxilla who are treated with chemoradiation are dismal.[4] The 5-year disease-specific survival in these patients is 0%. Considering these outcomes, strategy of providing induction chemotherapy followed local treatment based on response seems reasonable. In view of the rarity of this malignancy, it is unlikely that a prospective randomized study would be conducted in this malignancy. Hence, we opine that, in view of the long-term results seen with induction therapy, induction followed by local treatment should be considered as an option in technically unresectable maxillary sinus carcinomas.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.