Epidermoid carcinoma of the nasal cavity: a report of two cases

¹Department of Otolaryngology and Head and Neck Surgery, Hassan II University Hospital Center Fes, Fes, Morocco

^&Corresponding author
Ameziane Hassani Mariam, Department of Otolaryngology and Head and Neck Surgery, Hassan II University Hospital Center Fes, Fes, Morocco

Introduction    

Tumors of the nasal cavities represent less than 1% of all malignant tumors and less than 3% of head and neck tumors [1]. Squamous cell carcinoma (SCC) is the most common histological type. Due to its local aggressiveness, rapid growth, and frequent recurrences, the management of SCC of the nasal cavities poses a challenge. Radical tumor resection followed by adjuvant radiotherapy is the cornerstone of treatment for this tumor [2,3]. We report two cases of locally advanced squamous cell carcinoma of the nasal cavity with two different treatment modalities.

Patient and observation     

Observation 1

Patient information: a 43-year-old patient, with no notable medical history, was admitted for management of a right nasal mass associated with epistaxis evolving over the past five months.

Clinical findings: the clinical examination reveals a deformity of the dorsum of the nose with anterior rhinoscopy showing an ulcerated and budding mass filling the right nasal cavity bleeding on contact (Figure 1, Figure 2). Cervical lymphadenopathy was absent at the time of diagnosis.

Diagnostic and assessment: a cervicofacial CT scan was performed, revealing the presence of tissue mass involving the septal cartilage measuring forty-four millimeters, locally advanced with intra orbital invasion coming into contact with the eyeball, with persistent separation noted. A biopsy was performed, indicating well-differentiated squamous cell carcinoma. The staging assessment, including thoraco-abdominal CT scan, did not reveal regional or distant metastases.

Therapeutic interventions: the case was discussed in a multidisciplinary team meeting; given the intra orbital extension, the difficulty in achieving clear margins, and the complexity of reconstruction, the patient underwent concurrent radio chemotherapy with a dose of 70 Gy at the tumor site and received six cycles of cisplatin, resulting in a good response and disappearance of the lesion.

Follow-up and outcome of interventions: the course was marked by tumor recurrence at the same initial site after one year of surveillance (Figure 3). The patient underwent a facial and cervico-thoraco-abdominal CT scan revealing the reappearance of the lesion with an increase in tumor infiltration, without signs of regional or distant metastasis. The patient was placed on a second-line chemotherapy protocol (docetaxel 75 mg). With a follow-up of three years, the patient showed lesion stability.

Patient perspective: the patient was very grateful to have received a correct diagnosis with appropriate management and pain control.

Informed consent: the patient gave his approval for the publication.

Observation 2

Patient information: a 51-year-old chronic smoker, not currently abstaining, admitted for management of unilateral nasal obstruction associated with epistaxis evolving over the past year.

Clinical findings: the clinical examination reveals the presence of tissue mass filling the right nasal cavity (Figure 4) without palpable cervical lymphadenopathy.

Diagnostic and assessment: cervicofacial and thoraco-abdominal computed tomography shows a lesion process in the right nasal cavity measuring five centimeters, filling the right maxillary sinus with lysis of the orbital floor without signs of regional or distant metastasis (Figure 5). A biopsy was performed, indicating a well-differentiated squamous cell carcinoma.

Therapeutic interventions: the patient underwent tumor resection via a combined approach (external and endoscopic) with lateral rhinotomy and maxillectomy. Cervical lymph node dissection was not performed due to the absence of clinical and radiological lymphadenopathy. Adjuvant radiotherapy was administered at a dose of 66 Gy to the tumor site.

Follow-up and outcome of interventions: the evolution was favorable with tumor regression and no signs of recurrence or distant metastases were observed during a five-year follow-up period.

Patient perspective: he was grateful for the surgical treatment, which enabled him to have a diagnosis and additional treatment with radiotherapy and pain control.

Informed consent: the patient gave his approval for the publication of his case.

Discussion     

Squamous cell carcinoma (SCC) of the nasal cavity represents 3% of head and neck SCCs and 50% of malignant nasosinonasal tumors [2]. The main reported risk factors in the literature are smoking, wood dust exposure [2], and HPV [3]. Clinical signs of nasal SCC include epistaxis, nasal obstruction, facial pain, and ulceration of the affected area. Late symptoms include changes in the contour of the nose and extension to neighboring structures. Unlike sinonasal sinus carcinoma, symptoms develop early while tumors are still small. Clinical diagnosis is relatively easy, and biopsy should be systematic in the presence of a suspicious clinical picture. Due to the non-specific nature of its symptoms, nasal cavity SCCs are often diagnosed at a late stage [2]. In our patients, a mass on the dorsum of the nose, nasal obstruction, and epistaxis were revealing clinical signs of the pathology. Nodal metastases are rare at the time of diagnosis of nasal cavity SCC, occurring in 6% of cases [2]. Nasal cavity lymphatic drainage can be roughly divided into two parts. The anterior part, including the vestibule, drains to the submaxillary lymph nodes, while the posterior part drains to the sub-diaphragmatic lymph nodes and the Rouvière's node. Nodal status is evaluated preoperatively with a cervical ultrasound. Distant metastases of nasal cavity SCC are rare [3]. Nodal and distant metastases were absent in our patients.

Computed tomography and magnetic resonance imaging of the nasosinonasal region are routine ancillary examinations to explore these tumors [4]. They allow for precise analysis of the tumor's location, size, and extension to neighboring structures. A staging assessment by cervico-thoraco-abdominal computed tomography allows for the detection of regional and distant metastases. Several distinct classification systems are currently available. These include the Wang classification developed specifically for the nasal vestibule and the TNM classification (8th edition of the UICC) for tumors of the nasal cavity and paranasal sinuses, wherein the nasal vestibule is considered part of the nasal cavity. Many studies have advocated for the Wang classification due to its relative simplicity and superior prognostic value compared to the UICC classification [4]. In our case, both patients had a T4N0M0 classification.

The gold standard treatment is radical surgery followed by radiotherapy. For early-stage tumors, radiotherapy or surgery is effective in managing SCCs of the nasal fossae. Over the past two decades, several studies have demonstrated the advantage of surgical treatment over radiotherapy for this tumor [2,3,5]. Fornelli et al. [6] reported a retrospective analysis of 32 patients with SCC of the anterior nasal cavity. A group of 9 patients underwent primary radiotherapy, and 8 of them experienced recurrences (2 local, 6 regional). Surgical treatment consists of partial or total rhinectomy. Various approaches are used, including endoscopic approach, conventional surgery, or a combination of both [7]. The types of resection and surgical approach used depend on the tumor's location, size, and extension [8].

Conventional external surgery allows for a wide en-bloc resection with tumor-free margins. Anterior lesions are approached through lateral rhinotomy, while lesions developing in the posterior part of the nasal septum or floor may require a Weber-Ferguson incision or a sublabial approach [8]. In cases of locally advanced tumors, orbital exenteration, maxillectomy, or skull base resection may be necessary [7,8]. Reconstruction can be achieved using a prosthesis or surgical repair [2]. While the principle of en bloc resection may not be achievable with endoscopic resection, and tumor margins cannot be precisely verified, studies have shown that fragmentary resection can yield oncological outcomes comparable to conventional surgery [7,8]. This approach helps avoid scarring and aesthetic sequelae and reduces postoperative morbidity. Endoscopic surgery alone is not indicated in cases of orbital invasion, involvement of the anterior and lateral parts of the frontal sinus, anterior wall of the maxillary sinus, nasal bones, and cutaneous invasion [7,9]. The combination of endoscopy and conventional external surgery has become the standard method for treating nasal cavity tumors [9].

Regional lymph node dissection is indicated in the presence of clinical or radiological lymphadenopathy. The management of clinically and radiologically negative (N0) necks in nasal cavity SCCs is a controversial topic. Elective prophylactic dissection seems necessary for tumors at a high TNM stage, HPV-positive tumors, and tumors with perineural spread and vascular invasion [3]. Lymph node dissection was not performed due to the absence of clinical and radiological lymph node metastasis. Advanced stages (III, IV) require surgical excision combined with adjuvant postoperative radiotherapy [2-5,8]. Indeed, Pavel D et al. conducted a meta-analysis of 220 patients with nasal cavity SCCs and concluded that surgery and surgery combined with radiotherapy offer better local control and higher cure rates than radiotherapy alone [10].

For non-operable patients, concurrent radiochemotherapy remains the last therapeutic option. Mendenhall et al. [5], conducted a study on 109 patients with nasal cavity carcinoma; local control and survival were significantly better after surgical intervention with adjuvant radiotherapy than with definitive primary chemoradiotherapy. In our case, the patient treated with radical surgery followed by radiotherapy showed better progress and therapeutic outcomes compared to the patient treated with radiochemotherapy. The prognosis of these tumors remains unfavorable despite appropriate treatment and primarily depends on the following factors: age (darker outlook in older individuals), tumor stage, and quality of surgical resection [5,10].

Conclusion     

Squamous cell carcinoma of the nasal cavity is a rare and highly aggressive tumor. Its nonspecific clinical presentation often leads to delayed diagnosis and management. In both of our cases, the diagnosis was at the locally advanced tumor stage, revealed by nasal obstruction associated with epistaxis. The patient treated with surgery followed by postoperative radiotherapy showed favorable progress and a better prognosis. Radical surgery remains the treatment of choice for this tumor. Radiotherapy is a cornerstone of management and contributes to improving local control, prognosis, and survival. Thus, early diagnosis, even at a stage still requiring surgery, is associated with a better prognosis.

Competing interests     

The authors declare no competing interest.

Authors' contributions     

Patient management: Ameziane Hassani Mariam, Oumaima Masfioui and Benmansour Najib. Data collection: Ameziane Hassani Mariam and Oumaima Masfioui. Manuscript drafting: Ameziane Hassani Mariam. Manuscript revision: Benmansour Najib and Mohamed Noureddine El Alami El Amine. All the authors have read and agreed to the final manuscript.

Figures     

Figure 1: tumor of the right nasal cavity with deformation of the dorsum of the nose

Figure 2: ulcerative-budding mass filling the right nasal fossa; blue arrow indicates nasal obstruction

Figure 3: ulcerative-budding process of the right nasal cavity with cutaneous extension, consistent with recurrence after concurrent radiochemotherapy

Figure 4: ulcerative-budding mass filling the right nasal fossa; blue arrow indicates nasal obstruction

Figure 5: axial computed tomography of the nasal fossae showing a nasal process with involvement of the ipsilateral maxillary sinus

References