LAUSR

Sinonasal malignancies account for approximately 3% of head and neck cancersn with sinonasal squamous cell carcinoma (SNSCC) representing the majority of cases, and a higher frequency observed in Asia and South Africa. There is a scarcity of prospectively collected data addressing the management options and outcomes for patients with SNSCC because most data are based on retrospective singleinstitution or small series. Despite the ongoing interest in exploring therapeutic sequencing modalities, including preoperative intensification with systemic therapy, there have been no witnessed changes in the standard of care or improvement in patient outcomes because overall survival continues to be <50% at 5 years for locally advanced disease; furthermore, the toll exerted on patients’ longterm functional status remains staggering and difficult to ascertain in numbers. Retrospective series, largely from single institutions, have encouraged the use of systemic therapy to improve organ preservation in SNSCC. This is largely based on the noted high responses to preoperative chemotherapy and the seemingly improved survival in responders. Yet, despite these encouraging signals, it is still unclear whether a preoperative intensification approach outweighs the risks incurred by cytotoxic therapy and whether these apparent benefits are influenced by patient selection biases and discrepancies in surgical expertise. This is added to the possibility of delaying a potentially curative surgical intervention and a lack of predictability in surgical outcome. In this issue of Cancer, Abdelmeguid and colleagues report their singleinstitution data of neoadjuvant chemotherapy for locally advanced SNSCC. The authors are to be congratulated on this monumental effort in amassing a large number of cases in a disease as rare and challenging as SNSCC. This is probably the largest reported series in SNSCC, but the Abdelmeguid et al report follows similar prior series and, although it is suggestive, it falls short of delivering a definite answer as to the value of preoperative intensification. Although some patients proceeded to nonsurgical therapy after induction chemotherapy, we are left with an unclear understanding of the factors leading to this decision in some patients given the retrospective nature of the report. Although organ preservation has been deemed successful with preoperative intensification in other squamous cell carcinomas of the head and neck, such as larynx cancers, most of these efforts have focused on avoiding surgery altogether. It is worth noting that, despite efforts spanning decades, total laryngectomy is still the standard of care for a large proportion of patients presenting with locally advanced disease, and it continues to confer possible survival advantages despite the controversy and debate regarding adequate patient selection for organpreservation approaches. Clearly, however, there are some patients who do not benefit from an organpreservation approach. Drawing an exact parallel analogy with SNSCC is not feasible because, unlike SNSCC, patient selection criteria for laryngealpreservation approaches have been better refined since the initial efforts in the Veterans Affairs larynx preservation trial. This is attributable at least partially to the sheer frequency of larynx cancer compared with SNSCC, and the ability (largely through cooperative group mechanisms in the United States and overseas) to complete randomized phase 3 trials examining the question of larynx preservation. In contrast, SNSCC remains plagued by the reality that it is an uncommon disease with a relative lack of prospective multicenter data. In addition, given the complexity of multimodal therapy and its heterogeneity, even within single, large institutions, as illustrated by Abdelmeguid and colleagues’ report, tracking the functional benefit of organ preservation remains urgently needed and would be best achieved within the confines of a prospective clinical trial. The Eastern Cooperative Oncology GroupAmerican College of Radiology Imaging Network (ECOGACRIN) Cancer Research Group ECOG ACRIN