Ethmoid sinus carcinomas: results and prognosis after neoadjuvant chemotherapy and combined surgery--a 10-year experience.

From June 1982 to June 1992, 144 ethmoido-sphenoido-orbital tumors have been referred to the neurosurgical department of Ste Anne Hospital. One hundred five of them were malignant lesions, among which 83 were included into our therapeutic protocol (1) neo-adjuvant chemotherapy (CDDP + 5-FU), (2) combined surgical procedure (subfrontal and transfacial), (3) postoperative radiotherapy. Fifty nine percent of the patients had no response to chemotherapy; 19% had a partial response (reduction of the tumoral volume > 50% and < 100%), 22% had a complete response. One patient had an immediate and transient postoperative rhinorrhea responsible for meningitis (acinetobacter) that was cured after a 3-day treatment. Four patients had postoperative meningitis without any cerebrospinal fluid leakage; they were also cured. Five patients had a local suppuration that was treated by subcutaneous drainage (n = 1) or the removal of the cranial basis graft (n = 4). Oncologic results are presented for only adenocarcinomas (n = 63) because they represent the only population of this series large enough to assure significant statistical figures. The global actuarial survival rate was 53% at 3 years and 42.5% at 5 years. The 5-year actuarial survival rate was 80% for T1 tumors, 60% for T2, 40% for T3, and 25% for T4. Patients with an intracranial extension had a 3-year survival rate of 19%; none survived after 4-year follow-up. Neo-adjuvant chemotherapy seemed to influence the survival: 100% survival rate at 5 and 10 years for the complete responders. We discuss the opportunity of intraorbital exenteration, the indications, and the limits of combined surgery. We emphasize the importance of neo-adjuvant chemotherapy and of combined surgical procedures, even when the patients are complete responders to chemotherapy: complete responders who had only a transfacial approach have a 5-year actuarial survival rate of 80% (instead of 100% when a combined procedure was performed). Those who were not operated primarily recurred within 3 years and then had to be operated. We propose to follow such a combined surgery for all large ethmoidal cancers (T3 and T4) and for small tumors (T1 and T2) developed superiorly and posteriorly. Anterior T1 and T2 tumors should be operated through a single transfacial route.