Esthesioneuroblastoma, or olfactory neuroblastoma, is a rare malignant neoplasm of the sinonasal tract originating from the olfactory neuroepithelium with neuroblastic differentiation. It most often presents in the superior nasal cavity. Since its initial description in 1924 by Berger and Luc, there have been reports of more than 1000 cases of esthesioneuroblastoma worldwide. Esthesioneuroblastoma is a locally aggressive neoplasm and metastasizes by both hematogenous and lymphatic routes.
The exact etiology of esthesioneuroblastoma is still unknown, and so are the predisposing factors.
Esthesioneuroblastoma accounts for 2 to 6% of nasal cavity and paranasal sinus cancer cases and 0.3% of all upper aerodigestive tract malignancies. The incidence of esthesioneuroblastoma seems to have increased in the last decade. Esthesioneuroblastoma may occur at any age, although it occurs predominantly in young adults. The mean age at presentation is 40 to 70 years. There is a second peak of incidence in later adult life. Men and women are affected equally.
Esthesioneuroblastoma is thought to arise from specialized sensory neuroepithelial olfactory cells. These cells are normally present in the upper part of the nasal cavity, including the upper part of the septum, superior nasal concha, the roof of the nose, and the cribriform plate of the ethmoid sinus.
Esthesioneuroblastoma demonstrates numerous chromosomal aberrations, deletions, and gains, but with no consistent pattern. In one study, a specific deletion on chromosome 11 and a gain on chromosome 1p correlated with metastasis and a worse prognosis. Gains are more frequent than losses, and high-stage esthesioneuroblastomas show more alterations than low-stage tumors. Gains in 20q and 13q may be significant in the progression of this neoplasm - these regions may harbor genes with functional relevance in esthesioneuroblastoma. The detection of PTCH1, GL/1, and GL/2 in 70%, 70%, and 65%, respectively, of human esthesioneuroblastoma specimens, suggests that the SHH signaling pathway may be involved in the pathogenesis of this neoplasm. Research has found expression of the OMP and RICBB genes in esthesioneuroblastomas.
Esthesioneuroblastomas are usually unilateral, polypoid, glistening, soft, reddish-grey masses with an intact mucosa; the cut surface appears greyish-tan to pinkish-red and hypervascularized. The tumors range from under 1 cm in size to large masses involving the nasal cavity and intracranial region. They frequently expand into the adjacent paranasal sinuses, orbit, and cranial vault.
Low-grade esthesioneuroblastoma form submucosal, sharply demarcated nests, lobules, or sheets of cells, often separated by richly vascular or hyalinized fibrous stroma. Pseudorosettes (Homer-Wright rosettes), with neoplastic cells palisading or cuffed around the central delicate fibrillar neural matrix, may be seen. The tumor cells are often uniform, with sparse cytoplasm and round or ovoid nuclei with punctate salt-and-pepper chromatin and nucleoli that are either small or absent. Esthesioneuroblastoma characteristically demonstrates fibrillary cytoplasm and interdigitating neuronal processes (neuropil), created by a syncytium of cells. Higher-grade tumors show tumor necrosis, pleomorphism, increased mitoses, decreased to absent neuropil, and a less overt lobular growth pattern. The tumor cells can arrange in gland-like rings or tight annular formations with a true lumen (Flexner-Wintersteiner rosettes). Rosettes alone are not diagnostic of esthesioneuroblastoma, although the Homer Wright rosettes are nearly pathognomonic in the nasal cavity when containing true neuropil. The mitotic rate is variable, but is usually low, especially in lower-grade tumors. Calcifications (concretion-like or psammomatous) may be seen, less frequently as the grade increases. Melanin pigment, ganglion cells, rhabdomyoblasts, divergent differentiation as islands of true epithelium (squamous pearls or gland formation), and clear-cell change may occasionally present in esthesioneuroblastoma.
The typical immunohistochemical profile includes diffuse staining for neuron-specific enolase, synaptophysin, chromogranin A, CD56 (NCAM) and beta-tubulin, as well as variable S100 protein reactivity, which is typically in a sustentacular cell pattern highlighting only cells at the periphery of the nests, often limited in higher-grade tumors. Sustentacular cells may also be positive for GFAP. Calretinin staining (nuclear and cytoplasmic) has been reported in esthesioneuroblastoma but can also be seen in other sinonasal tumors. As many as one-third of esthesioneuroblastomas may also stain focally for cytokeratin (CAM5.2, CK18). Negative markers include CD45RB, CD99, p63, and FLl1. Proliferation marker studies reveal a variable Ki-67 proliferation index (2- 50%), and BCL2 expression increases with tumor grade.
Clinically, esthesioneuroblastoma often has a subtle presentation mimicking benign inflammatory or infectious disease and delay in diagnosis is not uncommon. Nasal obstruction and epistaxis are typical early manifestations; however, other more specific symptoms can occur depending on the location and extent of the tumor. Anosmia can precede the diagnosis of esthesioneuroblastoma by several years. Other symptoms are related to extension into paranasal sinuses (facial swelling, medial canthus mass), the orbit (orbital pain, proptosis, epiphora, visual field defects), or anterior cranial fossa (headache), and manifestations of inappropriate antidiuretic hormone secretion.
A thorough physical exam and flexible fiber-optic endoscopic evaluation, complemented with both contrast-enhanced CT scan and MR imaging, are key in the diagnostic workup.
Any patient with a history that is suspicious for a sinonasal tumor requires a thorough neurologic, ophthalmologic, and head and neck examination.
Computed tomography scan:
Radiographic assessment of esthesioneuroblastoma begins with a contrast-enhanced computed tomography (CT) scan. Sinus disease and bony erosion depict well with CT scan.
Magnetic resonance imaging:
Esthesioneuroblastoma is most typically hypointense compared with brain gray matter on T1-weighted MRI and should enhance with gadolinium. T2-weighted images show an isointense or hyperintense mass. MRI provides better discrimination between tumor and secretions and optimal evaluation of orbital and intracranial or brain parenchymal involvement.
Biopsy of the tumor:
Intraoperative biopsy under general anesthesia for the sinonasal mass is the recommended course of action. The biopsy is preferably performed after imaging studies have been reviewed to determine the vascularity of the mass.
The three options used for the treatment of esthesioneuroblastoma are surgery, external beam radiation, and chemotherapy. Often, treatment utilizes a combination of these modalities. For small tumors with no sign of regional or local metastasis, surgical resection is advocated. More extensive surgery, typically an open or open or endoscopic-assisted craniofacial resection is recommended along with postoperative radiation therapy, as the disease becomes more locally advanced. Preoperative radiation is an alternative strategy which may yield equivalent results, and induction chemotherapy, as well as concurrent postoperative chemoradiation, may improve local, regional, and distant control. Patients with distant disease can have palliative therapy. Chemoradiation is an approach for patients with unresectable local disease, which could subsequently improve the resectability for locally-advanced esthesioneuroblastoma.
Hyams et al. developed the most widely used grading system for esthesioneuroblastoma. This system divides the spectrum of esthesioneuroblastoma maturation into four grades, ranging from most differentiated (grade I) to least differentiated (grade IV), based on tumor architecture, mitotic activity, nuclear pleomorphism, fibrillary matrix and rosettes, necrosis, gland proliferation, and calcifications. This grading scheme had independent validation relative to prognosis.
The Kadish staging system is an effective means to predict disease-free survival and is widely accepted. It includes the following groups:
A modified Kadish system includes group D tumors, which have distant metastasis or cervical lymphadenopathy.
Dulguerov also proposed a TNM (tumor/nodes/metastasis) style staging system allowing the inclusion of nodal status. This system was later reported to correlate closely with survival and recurrence.
The prognosis of esthesioneuroblastoma is both stage- and grade-dependent. The 5-year survival of stage A tumors is 75 to 90% whereas stage C has a 45% survival. Likewise, high-grade tumors have a 25% 5-year survival whereas low-grade tumors have an 80% survival.
Poor prognostic indicators of esthesioneuroblastoma include:
Recurrence of esthesioneuroblastoma is common, usually occurs within 2 years of the initial presentation (~30%). Metastasis develops in 35% of cases. The cervical lymph nodes are the most common site of spread. Distant metastasis occurs in approximately 10% of patients (lung, bone, liver, skin).
Patients and their families require education on how to recognize the early signs and symptom of sinonasal tumors. Patients with signs of nasal obstruction, epistaxis or anosmia, should seek early intervention. Health education promoting prompt presentation to hospitals, and efforts at early detection of esthesioneuroblastoma are necessary to achieve the cure.
Esthesioneuroblastoma is a rare disease that requires multi-institutional and international collaboration. Centralized processing of esthesioneuroblastoma cases would offer the most favorable ground to accrue more patients and use a uniform database in collecting information and reporting outcomes. Due to the aggressive nature of esthesioneuroblastoma, prompt diagnosis is critical in determining appropriate treatment options. The primary care provider and nurse practitioner should promptly refer any patient with a suspected nasal mass to the ENT surgeon for further workup. Management of esthesioneuroblastoma is complex and needs a multidisciplinary approach involving a team that consists of an ENT surgeon, a neurosurgeon, a radiation oncologist, a pathologist, a radiologist, and an oncologist, with support from nursing and pharmacy where indicated as treatment moves forward.
|||Arnold PM,Habib A,Newell K,Anderson KK, Esthesioneuroblastoma metastatic to the thoracic intradural and extradural space. The spine journal : official journal of the North American Spine Society. 2009 May; [PubMed PMID: 18805062]|
|||Svane-Knudsen V,Jørgensen KE,Hansen O,Lindgren A,Marker P, Cancer of the nasal cavity and paranasal sinuses: a series of 115 patients. Rhinology. 1998 Mar; [PubMed PMID: 9569435]|
|||Liermann J,Syed M,Held T,Bernhardt D,Plinkert P,Jungk C,Unterberg A,Rieken S,Debus J,Herfarth K,Adeberg S, Advanced Radiation Techniques in the Treatment of Esthesioneuroblastoma: A 7-Year Single-Institution's Clinical Experience. Cancers. 2018 Nov 20; [PubMed PMID: 30463343]|
|||Holland H,Koschny R,Krupp W,Meixensberger J,Bauer M,Kirsten H,Ahnert P, Comprehensive cytogenetic characterization of an esthesioneuroblastoma. Cancer genetics and cytogenetics. 2007 Mar; [PubMed PMID: 17321323]|
|||Riazimand SH,Brieger J,Jacob R,Welkoborsky HJ,Mann WJ, Analysis of cytogenetic aberrations in esthesioneuroblastomas by comparative genomic hybridization. Cancer genetics and cytogenetics. 2002 Jul 1; [PubMed PMID: 12165452]|
|||Bockmühl U,You X,Pacyna-Gengelbach M,Arps H,Draf W,Petersen I, CGH pattern of esthesioneuroblastoma and their metastases. Brain pathology (Zurich, Switzerland). 2004 Apr; [PubMed PMID: 15193028]|
|||Mao L,Xia YP,Zhou YN,Dai RL,Yang X,Wang YJ,Duan SJ,Qiao X,Mei YW,Hu B, Activation of sonic hedgehog signaling pathway in olfactory neuroblastoma. Oncology. 2009; [PubMed PMID: 19738389]|
|||Ow TJ,Bell D,Kupferman ME,Demonte F,Hanna EY, Esthesioneuroblastoma. Neurosurgery clinics of North America. 2013 Jan; [PubMed PMID: 23174357]|
|||Trojanowski JQ,Lee V,Pillsbury N,Lee S, Neuronal origin of human esthesioneuroblastoma demonstrated with anti-neurofilament monoclonal antibodies. The New England journal of medicine. 1982 Jul 15; [PubMed PMID: 7201076]|
|||Wooff JC,Weinreb I,Perez-Ordonez B,Magee JF,Bullock MJ, Calretinin staining facilitates differentiation of olfactory neuroblastoma from other small round blue cell tumors in the sinonasal tract. The American journal of surgical pathology. 2011 Dec; [PubMed PMID: 22020045]|
|||Thompson LD, Olfactory neuroblastoma. Head and neck pathology. 2009 Sep; [PubMed PMID: 20596981]|
|||Mills SE, Neuroectodermal neoplasms of the head and neck with emphasis on neuroendocrine carcinomas. Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc. 2002 Mar; [PubMed PMID: 11904342]|
|||Saade RE,Hanna EY,Bell D, Prognosis and biology in esthesioneuroblastoma: the emerging role of Hyams grading system. Current oncology reports. 2015 Jan; [PubMed PMID: 25416317]|
|||Klironomos G,Gonen L,Au K,Monteiro E,Mansouri A,Turel MK,Witterick I,Vescan A,Zadeh G,Gentili F, Endoscopic management of Esthesioneuroblastoma: Our experience and review of the literature. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2018 Dec; [PubMed PMID: 30340976]|
|||Bernier J,Cooper JS,Pajak TF,van Glabbeke M,Bourhis J,Forastiere A,Ozsahin EM,Jacobs JR,Jassem J,Ang KK,Lefèbvre JL, Defining risk levels in locally advanced head and neck cancers: a comparative analysis of concurrent postoperative radiation plus chemotherapy trials of the EORTC ( [PubMed PMID: 16161069]|
|||Chao KS,Kaplan C,Simpson JR,Haughey B,Spector GJ,Sessions DG,Arquette M, Esthesioneuroblastoma: the impact of treatment modality. Head [PubMed PMID: 11505485]|
|||Nishimura H,Ogino T,Kawashima M,Nihei K,Arahira S,Onozawa M,Katsuta S,Nishio T, Proton-beam therapy for olfactory neuroblastoma. International journal of radiation oncology, biology, physics. 2007 Jul 1; [PubMed PMID: 17398027]|
|||Tajudeen BA,Arshi A,Suh JD,St John M,Wang MB, Importance of tumor grade in esthesioneuroblastoma survival: a population-based analysis. JAMA otolaryngology-- head [PubMed PMID: 25356502]|
|||Dulguerov P,Allal AS,Calcaterra TC, Esthesioneuroblastoma: a meta-analysis and review. The Lancet. Oncology. 2001 Nov; [PubMed PMID: 11902539]|
|||Dulguerov P,Calcaterra T, Esthesioneuroblastoma: the UCLA experience 1970-1990. The Laryngoscope. 1992 Aug; [PubMed PMID: 1495347]|