Epidemiology of Sinonasal Squamous Cell Carcinoma: A Comprehensive Analysis of 4994 Patients

Transcription

1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Epidemiology of Sinonasal Squamous Cell Carcinoma: A Comprehensive Analysis of 4994 Patients Saurin Sanghvi, MD; Mohemmed N. Khan, MD; Neal R. Patel, BS; Swetha Yeldandi, BS; Soly Baredes, MD, FACS; Jean Anderson Eloy, MD, FACS Objectives/Hypothesis: To examine the incidence and survival of patients with sinonasal squamous cell carcinoma (SNSCC) between the years of 1973 and 2009 using the Surveillance, Epidemiology, and End Result (SEER) database. Study Design: Retrospective cohort study using a national database. Methods: The SEER registry was utilized to calculate incidence and survival trends for patients with SNSCC between 1973 and Patient data were then analyzed according to age, sex, and race. Results: A total of 4,994 cases of SNSCC were identified, composed of 64.44% males and 35.56% females. Incidence trend analysis revealed a significant decrease in yearly rates from 1973 to 2009 for the overall population, females, whites, blacks, and others (P <.05). Overall 5-, 10-, and 20-year survival for SNSCC was 52.95%, 44.67%, and 29.37%, respectively. No significant differences (P >.05) were found when comparing survival between the last three decades. Differences in longterm survival were noted between whites, blacks, and others, with whites displaying the highest 20-year survival. Males and females were found to have similar long-term survival curves, with 20-year survival of 30.68% and 26.35%, respectively. Conclusions: The overall incidence of SNSCC is declining. However, survival has not significantly improved in the last 3 decades. Race seems to influence the overall survival of this tumor. Future studies need to be conducted to investigate these dynamic trends related to SNSCC. Key Words: Squamous cell carcinoma, sinonasal cancer, malignancy, incidence, survival, long-term survival, epidemiology, Surveillance, Epidemiology, and End Result (SEER) database, nasal cancer, paranasal sinus cancer. Level of Evidence: 2b. Laryngoscope, 124:76 83, 2014 INTRODUCTION Sinonasal cancers make up 5% of head and neck cancers and less than 1% of malignancies overall. 1 The most common histologic type of sinonasal tumor is squamous cell carcinoma (SCC), with its incidence cited anywhere from 35% to 58% and accounting for 60% to 75% of malignancies in the paranasal sinuses. 2,3 Sinonasal SCC (SNSCC) most commonly originates in the maxillary sinus, with the nasal cavity being the second most common location. 4 SCC of the paranasal sinuses tends to be more difficult to diagnose owing to the relatively asymptomatic From the Department of Otolaryngology Head and Neck Surgery (S.S., M.N.K., N.R.P., S.Y., S.B., J.A.E.), Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey (S.B., J.A.E.), and Department of Neurological Surgery (J.A.E.), University of Medicine and Dentistry of New Jersey New Jersey Medical School, Newark, New Jersey, U.S.A Editor s Note: This Manuscript was accepted for publication May 30, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Jean Anderson Eloy, MD, FACS, Associate Professor and Vice Chairman, Director of Rhinology and Sinus Surgery, Department of Otolaryngology Head and Neck Surgery, UMDNJ-New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ jean.anderson.eloy@gmail.com DOI: /lary nature of the tumor. 5 Published 5-year survival rates for paranasal sinus malignancies range from 30% to 40%. 6,7 There have been studies linking viruses, such as Epstein- Barr virus, and different environmental exposures to the development of SNSCC. 8,9 Environmental exposures include smoking, glues, and adhesives, and many more industrial exposures have been hypothesized to effect the development of SNSCC. 10,11 A previous analysis of all sinonasal cancers using the United States National Cancer Institute s Surveillance, Epidemiology, and End Results (SEER) database was performed in However, that study had a broad focus encompassing all sinonasal cancers, without an in-depth analysis of any specific sinonasal malignancy. The current study is the first large-scale population-based study focusing solely on SNSCC. Our goal was to use the SEER database to analyze the trends of survival and incidence of SNSCC in the past 3 decades. This current study serves as a complement to the previous work of Turner and Reh 12 by focusing on additional variables regarding SNSCC not previously reported in the literature. MATERIALS AND METHODS Incidence and survival rates were obtained from the SEER registry from 1973 to Data were categorized for SCC (ICD-O-3 histologic code ) of the nasal cavity

2 and the paranasal sinuses. The SEER 9 registry was utilized to access incidence data for frequency, patient age at diagnosis, race, and sex. The SEER 18 registry was accessed to gain survival information for the last three decades ( , , and ). The SEER*Stat program (Surveillance Research Program, National Cancer Institute, 2012) was used to estimate frequencies, incidence rates, and relative survival from 1973 to Relative survival analysis was extracted for a total period of 240 months using Kaplan-Meier analysis. The category of others within the race demographic includes American Indian, Alaskan Native, Asian/Pacific Islander, unspecified, or unknown. Relative survival rate is expressed as the observed rate of survival adjusted to the expected survival rate of the population in the United States based on time period and demographic studied. Incidence rate data were adjusted to the year 2000 U.S. standard population and were obtained as incidence per 100,000 people in the population of study. Statistical Analysis Data analysis was completed using SEER*Stat 8.0.1, Microsoft Excel Software (Version 2010; Microsoft Corp., Redmond, WA) and Joinpoint Regression Program (National Cancer Institute, Bethesda, MD). Comparison between survival curves was performed using a log-rank test with significance set at a P <.05. Analyses were computed using JMP Statistical Discovery (SAS Institute, Cary, NC). RESULTS Demographic Analysis A total of 4,994 cases of SNSCC were reported in the SEER database between 1973 and 2009 (Table I). Males accounted for 3,218 (64.44%) cases and females accounted for 1,776 (35.56%) cases, amounting to a 1.81:1 male-to-female prevalence ratio. The majority of SNSCC tends to occur in people 55 years and older, with 3,954 (79.18%) cases reported in patients older than 55. Dividing the data by race showed that 4,120 (82.50%) patients were white, 436 (8.73%) were others, and 438 (8.77%) were black. The majority of cases reported the TABLE I. Characteristics of Sinonasal Squamous Cell Carcinoma Malignancies as per the Surveillance, Epidemiology and End Results Database Between 1973 and Characteristic No. % Sex Male 3, Female 1, Age, yr <55 1, >55 3, Race White 4, Black Other Primary site Nasal cavity 2, Paranasal 2, paranasal sinuses (2,693 cases, 53.92%) as the primary sites with the remainder of cases being in the nasal cavity (2,301 cases, 46.08%). Incidence Analysis Overall SNSCC rate in 2009 was 0.32 cases per 100,000 patients and has declined in the last 30 years (Fig. 1). The overall incidence of SNSCC was 0.41 cases per 100,000 patients in 1973 and reached as high as 0.50 cases per 100,000 in Joinpoint regression model revealed a significantly decreasing incidence of SNSCC with the annual percentage change (APC) being 22.21% (P <.05). Overall average incidence from 1973 to 2009 was 0.36 cases per 100,000 patients. The average incidence in males was 0.52 cases per 100,000 patients, and the average incidence of SNSCC in females was 0.23 cases per 100,000 patients, with a male-to-female incidence ratio of 2.26:1. Trend analysis shows the male SNSCC incidence rate to be significantly and steadily declining for the past 30 years (APC, 22.63%; 95% confidence interval [CI], 23.2% to 22.1%), and there is a relatively smaller, yet significant decline in the incidence for females (APC, 21.69%; 95% CI, 22.3% to 21.0%) for the same time period (Fig. 2). This decline was statistically significant for both sexes. Trend analysis was also conducted to calculate the incidence of SNSCC by race (Fig. 3). Overall incidence in others, blacks, and whites was 0.43, 0.38, and 0.35 cases per 100,000 patients, respectively. There was a significant decline in incidence for all races in the last 30 years. Others showed the greatest overall incidence at 0.43 cases per 100,000 patients, and the greatest decline, with an APC of 26.19% (95% CI, 27.7% to 24.7%, P <.05). The next greatest decline in incidence was seen in blacks, with an incidence of 0.92 cases per 100,000 patients in 1973 and 0.29 cases per 100,000 patients in This decline was significant, with an APC of 24.41% (95% CI, 25.4% to 23.4%, P <.05). The smallest decline was noted in whites with an incidence of 0.36 cases per 100,000 patients in 1973 to 0.30 cases per 100,000 patients in Despite the fact that this was the narrowest decline in incidence among the race categories it was still a significant decline (APC, 21.72%; 95% CI, 22.2% to 21.3%, P <.05). Survival Analysis Overall 20-year SNSCC survival rates have fluctuated between the years of 1973 and 1989 (Fig. 4) was used as the last year of diagnosis to accommodate the timeframe of the dataset and still allow for 20 years of follow-up. Mean overall 20-year survival rate was 29.37%. The lowest long-term survival was seen in patients diagnosed in1980, with a 20-year survival rate of 12.40%, and the highest overall 20-year survival rate was seen in 1977 at 38.17%. A best fit line shows that overall the long-term survival has stayed relatively consistent between the years of 1973 and Survival rates by sex were analyzed, showing very similar relative survival curves for both males and 77

3 Fig. 1. Joinpoint Analysis of incidence trends of sinonasal squamous cell carcinoma (SNSCC) for the overall incidence from 1973 to 2009 as rate of SNSCC per 100,000. APC 5 annual percentage change. females during the course of 20 years (Fig. 5). The 5-, 10-, and 20-year survival rates for males were 54.26%, 46.80%, and 30.68%, respectively. The female 5-, 10-, and 20-year survival rates were 50.52%, 40.60%, and 26.35%, respectively. Survival rates were also examined in the context of race differences, with categorization by black, white, and others (Fig. 6). Whites had the highest long-term survival rates of 30.93% at 20 years. In contrast, blacks had the lowest 5-, 10-, and 20-year survival rates of 37.73%, 32.12%, and 19.23%, respectively. Others had 5-, 10-, and 20-year survival rates of 46.07%, 36.57%, and 22.59%. Survival was also stratified by decades by acquiring 10-year survival for 1980 to 1989, 1990 to 1999, and 2000 to 2009 (Fig. 7). Comparison between the three decades revealed no significant difference in survival (P >.05). Survival analysis was also conducted examining the extent of disease (Fig. 8). Extent of disease was defined as local disease, regional spread, and distant metastasis. Patients with localized disease had 5-, 10-, 15-, and 20-year survival rates of 82.86%, 73.84%, 60.61%, and 43.74%, respectively. Patients with regional spread exhibited 5-, 10-, 15-, and 20-year survival rates of 41.10%, 32.81%, 26.21%, and 22.45%, respectively. Patients with distant metastasis had 5-, 10-, 15-, and 20-year survival rates of 29.17%, 19.84%, 18.32%, and 17.13%, respectively. Combining the treatment protocol with progression of disease allowed for generation of 5-year survival curves for patients receiving surgery, radiation, or a combination of radiation and surgery stratified by local Fig. 2. Joinpoint Analysis of sex-specific incidence trends of sinonasal squamous cell carcinoma from 1973 to APC 5 annual percentage change. 78

4 Fig. 3. Joinpoint Analysis of race-specific incidence trends of sinonasal squamous cell carcinoma from 1973 to Others includes American Indian, Alaskan Native, Asian/Pacific Islander, unspecified, or unknown. APC 5 annual percentage change. Fig. 4. Trends in 20-year survival of sinonasal squamous cell carcinoma for the overall population between 1973 and Fig. 5. Sex-specific relative survival of patients with sinonasal squamous cell carcinoma. 79

5 Fig. 6. Race-specific relative survival of patients with sinonasal squamous cell carcinoma. disease, regional spread, and evidence of metastasis (Fig. 9). Patients with localized disease showed 5-year survival rates of 85.71%, 80.38%, and 78.47% when receiving surgery, radiation and surgery, and radiation alone, respectively. Regional spread exhibited lower survival rates, with 5-year survival of 47.80%, 45.20%, and 40.17% when receiving surgery, radiation and surgery, and radiation alone, respectively. Patients with evidence of metastasis demonstrated the lowest survival, with 5- year survival rates of 39.38%, 37.71%, and 29.99% when receiving surgery, radiation and surgery, and radiation alone, respectively. No significant difference was found in the 5-year survival rates among patients with local disease, regional spread, and distant metastasis when stratifying the data by progression of disease. DISCUSSION SNSCC is the most common tumor of the sinonasal cavity. 3 SNSCC has been associated with many environmental exposures, including textile dust, welding fumes, arsenic, glues, and adhesives. 11,13,14 Welding fumes and textile dust have been shown to have a dose-dependent effect on the development of SNSCC. In addition, exposure to cigarette smoke has also been shown to promote a two- to threefold increase in the incidence SNSCC. 15 Demographic Analysis SNSCC occurs more commonly in males, with a 2.26:1 male-to-female ratio when examining the overall incidence from 1973 to This is in accordance with prior studies, with disparity in incidence of sinonasal malignancies found to be almost twofold higher in males. 2,16 Our results indicate a higher incidence of SNSCC in blacks compared to whites and the highest in the others race category overall. Incidence Analysis Overall SNSCC incidence has been steadily and significantly declining in the past 30 years. This decrease Fig. 7. Trends in 10-year relative survival of sinonasal squamous cell carcinoma for the overall population from 1980 to 1989, 1990 to 1999, and 2000 to

6 Fig. 8. The 5-, 10-, 15-, and 20-year relative survival rates of sinonasal squamous cell carcinoma with extent of disease. may be partially attributable to decreased exposure to textile dust and heightened awareness of the carcinogenic effect of industrial substances. Mastrangelo et. al. 17 found an increase in the pooled relative risk for the development of sinonasal cancers in workers exposed to cotton dust. Lai and Christiani 18 described efforts to decrease exposure to cotton dust with the knowledge of the harmful effect this can have. Other industrial nasal carcinogens include chlorphenols, formaldehyde, and wood dust, traditionally all encountered in wood working. 19,20 Knowledge of this type of harmful exposure may have prompted more safety measures to prevent future development of SNSCC. Another variable that may have contributed to the decrease in overall incidence of SNSCC is the decline in tobacco smoking. Studies have found a correlation in the development of lung cancer and SNSCC, propagating a possible causal relationship between SNSCC and smoking. 10 Further studies have shown that smoking is a risk factor for nasal cancers. 21 The 1950s marked the release of the first scientific reports linking cigarettes to lung cancer, but it was not until the early 1970s that tobacco Fig. 9. The 5-year relative survival rates of patients with varying progression of disease stratified by treatment modality. advertising through electronic media was banned. Public health interventions targeting specific demographic groups were enacted in The result was a more than fivefold increase in the incidence of smoking cessation between 1950 and This decline in smoking may have led to a gradual decline in the incidence of SNSCC. Furthermore, the United States Census Bureau data show a steep increase in the level of education of the general population in the last 40 years. 23 Increased level of education has been shown to strongly correlate with cessation of smoking. 24 This may be positively contributing to the decrease in incidence of SNSCC. Incidence analysis by sex revealed that the incidence in males in 1973 was as high as 0.68 cases per 100,000 patients, compared to the relatively lower incidence rate of 0.20 cases per 100,000 patients for females in that same year. This may be due in some degree to changes in smoking patterns during the last 50 years. Young women were quitting smoking at a higher rate than young men during the late 1960s to mid 1970s. 22 This decline in smoking may have ultimately affected the development of SNSCC in the 1970s, with females showing a lower initial incidence rate of SNSCC in However, while both incidence rates have shown a significant decline during the 36-year period of the SEER database, males have shown a much more precipitous decrease in incidence. Similar reports of higher incidence of sinonasal cancer within males as compared to females have also been shown in a previous SEER database study by Turner and Reh analyzing sinonasal malignancies. 12 Analysis of the incidence curves by race showed a significant decrease in incidence in others, blacks, and whites. Others showed the most dramatic decline. However, even with this decline in incidence, others failed to reach as low a level of incidence as seen in both blacks and whites by The next biggest decline in incidence was seen in blacks and the smallest decrease in incidence was seen in whites. Survival Analysis Survival of sinonasal malignancies has been previously studied, reporting a 5-year survival of 40% for all malignancies and 60% for SNSCC specifically. 24 These rates are similar to what we found, with the 5-year SNSCC survival between 50% and 60% in both males and females. However, long-term survival of SNSCC has not been previously reported. We found an overall increase in long-term survival of SNSCC from 20.03% in 1973 to 27.33% in 1989 (Fig. 3). When analyzing the database for survival per decades, patients in the 1980s seemed to have the lowest survival (Fig. 7). However, this difference in survival between the decades was not found to be statistically significant. This finding is in contrast to previous institutional reports stating significant progress in outcomes over the last several decades Long-term survival was also analyzed by sex. The survival curves for males and females were similar, with males having a 20-year survival of 30.68% and females 81

7 26.35%. These results indicate that even though males have greater incidence of SNSCC compared to females, the survival of SNSCC may not be influenced by sex. This may be due to the fact that factors that affect survival, such as stage at diagnosis, extent of spread, and onset of symptoms, are not affected by sex. Analyzing survival rates by race showed whites having the highest 20-year survival at 30.92%. Others had the next highest 20-year survival at 22.56%, followed by blacks at 19.23%. This was interesting, considering that blacks had a higher incidence rate than whites and a lower survival rate in the same period. Variables that may contribute to the difference in survival between whites and blacks are socioeconomic status and access to health care. 27 Histologic status of tumors was not analyzed in this study. However, previous studies have shown a predilection for more aggressive histologic grades of oropharyngeal squamous cell tumors in minority patients. 28 Our current results point to a possible disparity in SNSCC care and encourage the use of public-health efforts to narrow this potential gap. Improved access to multidisciplinary oncologic care and increased effort from clinicians to make the best oncologic treatment available for minority patients may narrow the disparity. Previously identified differences in histologic subtypes by race may be due to biologically based differences and require further study. 28 Progression of disease was examined for possible differences in survival rates in patients exhibiting localized disease, regional spread, and distant metastasis. The lowest survival rates were found in patients with distant metastasis. Our results are in accordance with previous literature demonstrating lower long-term survival rates for patients with advanced disease. 2 Dulguerov et. al. 24 found the lowest 10-year survival in sinonasal cancers among patients with T4 disease extension. However, this is the first study of its kind to our knowledge to analyze 20-year survival for SNSCC stratified by extent of disease. These long-term survival values for distant disease are significantly limited by the small number of cases remaining in this subgroup. Due to the potential lack of adequate reporting on patients in this subgroup, these long-term survivals should be viewed carefully. We also examined survival in relation to varying treatment protocols in each set of disease extent. Patients with localized disease showed varying 5-year survival rates, depending on the method of treatment, with surgical resection alone boasting the highest 5-year survival rate of 85.71%. However, the difference between the survival rates among the varying treatment modalities was not statistically significantly. Patients with regional spread or evidence of metastasis also did not exhibit significant differences in 5-year survival rates when examining for varying treatment methods. Our present analysis contrasts previous research studying sinonasal malignancies that revealed significant differences in outcome associated with varying treatment modalities. 29 This disparity in survival by differing treatment protocols may be due to a selection bias, because the limitations of the SEER 82 database include lack of information such as surgical margins and the use of chemotherapy. However, to our knowledge, this is the first study of its kind showing no significant difference in survival rates in patients with varying treatment methods in SNSCC. The SEER database provides a useful tool to acquire vast epidemiologic information on head and neck cancers. With patient information encompassing the last 30 years, this database gives a large sample size and provides a high statistical power. However, limitations of the database should be mentioned. The database lacks information on treatment by specific institutions and it does not account for tumor classifications or treatment modalities that have changed over the past 30 years. Despite such limitations, this study represents the highest population cohort as of yet to be analyzed for incidence and survival of SNSCC. CONCLUSION SNSCC is the most common tumor of the sinonasal cavity and is generally associated with advanced stage at presentation due to the insidious growth pattern and nonspecific symptoms. The overall incidence of SNSCC has been declining from 1973 to This includes a decrease in incidence for both sexes and all race groups analyzed. However, there does not seem to be a statistically significant increase in survival over this same time period. Disparity in survival between races may require further biologic and sociodemographic studies. BIBLIOGRAPHY 1. Hoppe BS, Stegman LD, Zelefsky MJ, et al. Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative setting the MSKCC experience. Int J Radiat Oncol Biol Phys 2007;67: Arnold A, Ziglinas P, Ochs K, et al. Therapy options and long-term results of sinonasal malignancies. Oral Oncol 2012;48: Weber AL, Stanton AC. Malignant tumors of the paranasal sinuses: radiologic, clinical, and histopathologic evaluation of 200 cases. Head Neck Surg 1984;6: Lewis JS, Castro EB. Cancer of the nasal cavity and paranasal sinuses. J Laryngol Otol 1972;86: Kermer C, Poeschl PW, Wutzl A, Schopper C, Klug C, Poeschl E. Surgical treatment of squamous cell carcinoma of the maxilla and nasal sinuses. J Oral Maxillofac Surg 2008;66: Waldron J, Witterick I. Paranasal sinus cancer: caveats and controversies. World J Surg 2003;27: Giri SP, Reddy EK, Gemer LS, Krishnan L, Smalley SR, Evans RG. Management of advanced squamous cell carcinomas of the maxillary sinus. Cancer 1992;69: Gaffey MJ, Frierson HF, Weiss LM, Barber CM, Baber GB, Stoler MH. Human papillomavirus and Epstein-Barr virus in sinonasal Schneiderian papillomas. An in situ hybridization and polymerase chain reaction study. Am J Clin Pathol 1996;106: Siew SS, Kauppinen T, Kyyronen P, Heikkila P, Pukkala E. Occupational exposure to wood dust and formaldehyde and risk of nasal, nasopharyngeal, and lung cancer among Finnish men. Cancer Manag Res 2012;4: Kuijpens JH, Louwman MW, Peters R, Janssens GO, Burdorf AL, Coebergh JW. Trends in sinonasal cancer in The Netherlands: more squamous cell cancer, less adenocarcinoma. A population-based study Eur J Cancer 2012;48: Luce D, Gerin M, Leclerc A, Morcet JF, Brugere J, Goldberg M. Sinonasal cancer and occupational exposure to formaldehyde and other substances. Int J Cancer 1993;53: Turner JH, Reh DD. Incidence and survival in patients with sinonasal cancer: a historical analysis of population-based data. Head Neck 2012; 34: Luce D, Gerin M, Morcet JF, Leclerc A. Sinonasal cancer and occupational exposure to textile dust. Am J Ind Med 1997;32: d Errico A, Pasian S, Baratti A, et al. A case-control study on occupational risk factors for sino-nasal cancer. Occup Environ Med 2009;66: Brinton LA, Blot WJ, Becker JA, et al. A case-control study of cancers of the nasal cavity and paranasal sinuses. Am J Epidemiol 1984;119:

8 16. Thorup C, Sebbesen L, Dano H, et al. Carcinoma of the nasal cavity and paranasal sinuses in Denmark Acta Oncol 2010;49: Mastrangelo G, Fedeli U, Fadda E, Milan G, Lange JH. Epidemiologic evidence of cancer risk in textile industry workers: a review and update. Toxicol Ind Health 2002;18: Lai PS, Christiani DC. Long-term respiratory health effects in textile workers. Curr Opin Pulm Med 2013;19: Mirabelli MC, Hoppin JA, Tolbert PE, Herrick RF, Gnepp DR, Brann EA. Occupational exposure to chlorophenol and the risk of nasal and nasopharyngeal cancers among U.S. men aged 30 to 60. Am J Ind Med 2000; 37: Hardell L, Johansson B, Axelson O. Epidemiological study of nasal and nasopharyngeal cancer and their relation to phenoxy acid or chlorophenol exposure. Am J Ind Med 1982;3: Zhu K, Levine RS, Brann EA, Hall HI, Caplan LS, Gnepp DR. Casecontrol study evaluating the homogeneity and heterogeneity of risk factors between sinonasal and nasopharyngeal cancers. Int J Cancer 2002; 99: Gilpin EA, Pierce JP. Demographic differences in patterns in the incidence of smoking cessation: United States Ann Epidemiol 2002;12: United States Census Bureau. Educational attainment. Available from: index.html. Accessed February 13, Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer 2001;92: Hanna E, DeMonte F, Ibrahim S, Roberts D, Levine N, Kupferman M. Endoscopic resection of sinonasal cancers with and without craniotomy: oncologic results. Arch Otolaryngol Head Neck Surg 2009;135: Ganly I, Patel SG, Singh B, et al. Craniofacial resection for malignant paranasal sinus tumors: report of an International Collaborative Study. Head Neck 2005;27: Ragin CC, Langevin SM, Marzouk M, Grandis J, Taioli E. Determinants of head and neck cancer survival by race. Head Neck 2011;33: Chen LM, Li G, Reitzel LR, et al. Matched-pair analysis of race or ethnicity in outcomes of head and neck cancer patients receiving similar multidisciplinary care. Cancer Prev Res (Phila) 2009;2: Blanch JL, Ruiz AM, Alos L, Traserra-Coderch J, Bernal-Sprekelsen M. Treatment of 125 sinonasal tumors: prognostic factors, outcome, and follow-up. Otolaryngol Head Neck Surg 2004;131: