Surgical rescue of recurrent carcinoma of the nasal columella.
BACKGROUND
Tumors involving the nasal columella have been noted for their aggressive behavior. Columellar malignancies exhibit perhaps the highest incidence of recurrence and metastasis of all nasal and midfacial cancers of cutaneous origin. Periosteal invasion of maxillary bone and nasal floor may occur "barrier free." Submucosal infiltration of the nasal septum easily develops, leading to potentially lethal invasion of the anterior cranial base. Rapid extension of cancer to the adjacent bony and cartilaginous facial structures requires extensive oncological resections for control. While tumor histology and biologic behavior remain important prognostic indicators, anatomic location within the columella carries with it a much poorer prognosis than do other nasal cutaneous lesions. Recurrent tumors in this location as a result of inadequate initial treatment present a formidable therapeutic challenge.


METHODS
Fourteen patients who had initially been "adequately" treated for cutaneous malignancies of the nasal columella were seen from 1982 to 1992 by the authors because of local tumor recurrence. Histologically, 4 of the 14 were initially basal cell epithelioma, 7 were squamous cell epithelioma, 1 was squamous/basal cell epithelioma, 1 was melanoma, and 1 was anaplastic. By the time tumor regrowth was recognized (mean 24 months), 100% demonstrated bony involvement of the premaxilla or nasal floor, 57% (8 of 14) nodal metastasis to the parotid or neck, and 43% (6 of 14) extension to the anterior skull base. Thirty-six percent (5 of 14) had undergone unsuccessful radiation therapy in an attempt to control the disease.


RESULTS
All patients underwent radical oncological surgery with or without postoperative radiation therapy in an attempt to control the tumors, including combinations of anterior skull base resection, partial or total rhinectomy, partial maxillectomy, and parotidectomy with radical neck dissection. At 5 years, 5 patients (36%) had no evidence of disease and 1 (7%) was alive with disease; at 54 months, 6 (43%) had no evidence of disease and 1 (7%) was alive with disease; at 42 months, 7 (50%) were alive with no disease.


CONCLUSIONS
In this series, an aggressive surgical approach successfully salvaged 43% of recurrences at 5 years and 50% at 54 months. Although overall prognosis remains poor, radical surgery appears a viable modality for rescue of recurrent malignancies of the columella. In view of the ability to control recurrence, more aggressive initial therapy might improve the prognosis of the early columellar lesion.
D000368:Aged; D000369:Aged, 80 and over; D002277:Carcinoma / Q000473:pathology / Q000532:radiotherapy / Q000556:secondary / Q000601:surgery*; D002280:Basal Cell Carcinoma / Q000473:pathology / Q000601:surgery; D002281:Carcinoma, Basosquamous / Q000473:pathology / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000601:surgery; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005260:Female; D006258:Head and Neck Neoplasms / Q000556:secondary; D006801:Humans; D008207:Lymphatic Metastasis; D008297:Male; D008441:Maxillary Neoplasms / Q000473:pathology / Q000601:surgery; D008545:Melanoma / Q000473:pathology / Q000601:surgery; D008875:Middle Aged; D009300:Nasal Septum / Q000473:pathology; D009361:Neoplasm Invasiveness; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D009669:Nose Neoplasms / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D010307:Parotid Neoplasms / Q000556:secondary; D011379:Prognosis; D016879:Salvage Therapy; D012878:Skin Neoplasms / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D012888:Skull Neoplasms / Q000556:secondary; D015996:Survival Rate