Results
Overall, 23 patients underwent TR for SCC of the nasal vestibule, of which 69.6% were males and 30.4% were females (gender ratio 2.29:1). The median age was 63 years (range 38 – 87). Twenty patients (87%) had a history of smoking, and alcohol abuse was noted in two patients (8.7%). Four patients (17.4%) were immunocompromised including two cases of haematological malignancy (multiple myeloma, chronic lymphocytic leukaemia) and two patients taking immune suppressant medication. The median time between the initial presentation of symptoms and surgery was 7 months (range 3 – 18). Pre-operative imaging for staging included MRI (100%), CT (86.4%) and/or PET-CT (4.5%). Clinical T staging using the Wang’s classification and the AJCC classification for nasal cavity cancers (thus excluding the three primaries of cutaneous origin) are shown in Table 2. Six patients (26.1%) presented with symptoms of recurrent disease, either following radiotherapy (n=3) or nose-preserving surgery (n=3). The outlines of patients’ presentation and treatment are shown in Figure 1.
Surgery was performed by ENT surgeons (73.9%) or maxillofacial surgeons (26.1%) and consisted of a TR, which was extended in six cases (26.1%) to the maxilla, the orbit or the ethmoid sinus. Seven patients (30.4%) underwent a concurrent neck dissection, due to a clinical suspicion of nodal involvement (cN+) or an extensive tumour requiring free flap reconstruction in two cases (8.7%). All patients were offered prosthetic rehabilitation. Late complications included nasolacrimal duct obstruction (20%) and mucocele (5%). The psychological issues and abutment complications related to the prosthesis were not studied.
On histological analysis, all tumours involved the nasal vestibule and originated from either the septum (n=12), vestibule (n=8) or skin (n=3). The main pathological characteristics are presented in Table 2, alongside statistical comparisons between patients that developed disease recurrence (recurrence group) and those that did not (remission group). Notably, three SCCs from the remission group presented with adenosquamous features. Five patients (21.7%) required re-operation for further surgical excision in the month following the TR. Among the seven patients who underwent neck dissection, only one had a pathological nodal involvement, demonstrating extracapsular extension. Seventeen patients (73.9%) received adjuvant treatment, with 14 patients having radiotherapy and 3 having chemoradiotherapy.
After a median follow-up of 32 months (range 3 – 195), six patients (26.1%) presented with tumour recurrence. The median time to recurrence was 12 months (range 5 – 25). One recurrence at the primary site was treated via a salvage cranio-facial resection, the patient was alive and disease free 15 years after treatment. Three patients developed regional recurrence (13%) and were treated by salvage neck dissection, of which two were also given further radiotherapy treatment. One of these patients subsequently developed metastatic disease to the lung and died. Finally, there was one case of both local and regional recurrence (involving the retropharyngeal lymph nodes) and one case of local recurrence alongside metastatic disease involving the lung, pleura and bone. Both patients received palliative care and died during follow-up. Overall, seven patients (30.4%) died during the study period, because of the disease evolution in three cases (13%) or due to another malignancy in four cases (17.4%). The estimated 5-year OS, DFS and DSS was 67.5% [IC95: 41–84.1], 66.3% [IC95: 49.1–83.4] and 80.7% [IC95: 50.3–93.5] respectively (see figure 2).