Published online December 17, 2007
PEDIATRICS Vol. 121 No. 1 January 2008, pp. e141-e145 (doi:10.1542/peds.2007-1319)
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Benoit, M. M.
Right arrow Articles by Cunningham, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Benoit, M. M.
Right arrow Articles by Cunningham, M.
Related Collections
Right arrow Tumors
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?

ARTICLE

Cancer of the Nasal Cavity in the Pediatric Population

Margo McKenna Benoit, MDa,b, Neil Bhattacharyya, MD, FACSb,c, William Faquin, MDd and Michael Cunningham, MD, FACS, FAAPa,b

a Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
b Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts
c Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts
d Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The purpose of this work was to investigate the clinical manifestations and diagnostic range of malignant entities presenting as a nasal mass in the pediatric population.

PATIENTS AND METHODS. A retrospective cohort analysis was conducted at a specialty hospital and a tertiary care university hospital. Patients aged between birth and 18 years and diagnosed with a malignancy that arose within the nasal cavity between the years 1991 and 2006 were included. This institution-specific patient group was compared with a similar cohort of patients extracted from the national Surveillance Epidemiology and End Results database. The main outcome measures were the incidence, presentation, and diagnoses of nasal cancer presenting in this population.

RESULTS. Sixteen patients with nasal malignancies presented institutionally in the defined pediatric age group. Patient age at the time of diagnosis ranged from 7 months to 17 years, with a slight male predominance. The main presenting symptoms were unilateral nasal congestion and ophthalmologic complaints. The median time from presentation to diagnosis was 7 weeks; patients who presented with nonspecific complaints, such as nasal obstruction, headache, and fatigue, were given a diagnosis, on average, later than those who presented with focal manifestations. Nationwide, 47 patients were identified from the Surveillance Epidemiology and End Results database. In both subject groups, the most common diagnoses were rhabdomyosarcoma (37.5% institutionally and 23% in the Surveillance Epidemiology and End Results group) and esthesioneuroblastoma (25% institutionally and 28% Surveillance Epidemiology and End Results). In the Surveillance Epidemiology and End Results cohort, the overall mean survival rate was 188 months.

CONCLUSIONS. Nasal cancer in the pediatric population often presents with nonspecific signs and symptoms, and a high index of suspicion is necessary for a timely diagnosis. Soft tissue sarcomas are expectedly common. The relative high frequency of esthesioneuroblastoma is particularly noteworthy.

Key Words: esthesioneuroblastoma • rhabdomyosarcoma • nasal obstruction • neoplasm

Abbreviations: MGH—Massachusetts General Hospital • SEER—Surveillance Epidemiology and End Results • PNET—primitive neuroectodermal tumor • AJCC—American Joint Commission on Cancer • ACR—anterior craniofacial resection

Cancer of the nasal cavity is a rare but serious problem in the pediatric population. Nonspecific symptoms such as nasal congestion and rhinorrhea may persist for months to even years before a nasal mass is suspected. Although the more frequent use of computed tomography scanning in the evaluation of presumed sinusitis in children is facilitating the diagnosis of these lesions,1 a high level of suspicion is often required before the appropriate diagnostic imaging tests are ordered or an otolaryngology referral is made. The differential diagnosis relative to benign and malignant etiologies of a nasal mass in a child is broad, and surgical biopsy for definitive pathologic diagnosis is required. Malignant lesions in this region in children tend to be locally aggressive, often presenting at an advanced stage. An additional dilemma in this age group is the morbidity associated with the adjuvant treatment of malignant disease, including the subsequent increased risk of developing a second primary cancer.2 Consideration of these issues, in light of the limited available data regarding incidence, prevalence, and treatment, prompted this investigation of our joint institutions' experience with pediatric nasal cancer.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
After approval of this study by the internal review boards at both the Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital (MGH), a retrospective pathology PowerPath (IMPAC Medical Systems, Inc., Sunnyvale, CA) database search was conducted covering both hospitals for the years 1991–2006. Inclusion criteria were defined as age ≤18 years at the time of diagnosis, nasal cavity origin, and malignant disease. Exclusion criteria were nasopharyngeal lesions, benign disease, and nasal or sinonasal metastases from a distant site. Thirteen patients met these criteria.

A parallel search was performed by using the MGH Research Patient Data Registry, a database that contains >2.1 million encrypted records spanning the past 13 years. Two criteria were entered for this search: age ≤18 years and malignant disease of the nasal cavity. This search returned a list of 22 patients; applying the exclusions listed above, 8 patients met study criteria.

Five of the 8 patients from the Research Patient Data Registry overlapped with the results of the Massachusetts Eye and Ear Infirmary/MGH pathology search, so 3 additional patients were identified, which brought the total number of patients from both institutions to 16. For these 16 patients, further information was accessed from electronic and paper medical charts, including inpatient and outpatient clinic notes, discharge summaries, operative reports, and formal pathology reports.

The Surveillance Epidemiology and End Results (SEER; program public use data 1973–2002, National Cancer Institute, Bethesda, MD; released April 2001; http://seer.cancer.gov) database was queried for the time period 1973–2002, inclusive, extracting all of the cases of primary nasal cavity cancer occurring in patients aged <19 years. Tumors coded as arising in the paranasal sinuses proper were excluded. Data on age at diagnosis, tumor histopathology, and survival rate were obtained.


   RESULTS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Institutional
Of the 16 total pediatric age-range patients identified, there were 9 boys and 7 girls. The median age was 7 years, with a mean of 9.7 years and a range of 7 months to 17 years. Diagnoses were classified into 4 major diagnostic categories encompassing 7 histopathologic subtypes (Table 1). 3 The most common diagnosis was rhabdomyosarcoma (37.5%), followed by esthesioneuroblastoma (25%). Additional diagnoses included nonrhabdomyosarcoma malignant soft tissue tumors (6.25%), malignant tumors of bone and cartilage (18.75%), hematolymphoid tumors (6.25%), and neuroectodermal Ewing sarcoma/primitive neuroectodermal tumor (PNET; 6.25%).


View this table:
[in this window]
[in a new window]

  		TABLE 1 Diagnoses According to World Health Organization Classification

 
Presenting manifestations are outlined in Table 2. The most common clinical complaints were unilateral nasal obstruction (9 patients) and ophthalmologic manifestations (8 patients), including proptosis, diplopia, lid discoloration, and loss of vision. Additional signs and symptoms included epistaxis, headache, weight loss, lethargy, obstructive sleep apnea, anosmia, foul nasal discharge, and cervical lymphadenopathy. The median time from reported onset of symptoms to diagnosis was 7 weeks, with a mean of 37 weeks and range of 3 to 240 weeks.


View this table:
[in this window]
[in a new window]

  		TABLE 2 Presenting Manifestations

 
The site and extent of disease varied considerably. None of the 16 patients had distant metastases. Aggressive local extension and destruction was, however, present in all but 1 patient. In these 15 patients, disease primarily arising within the nasal cavity was found on intraoperative examination and/or imaging to extend to the nasopharynx, ethmoid, maxillary, or sphenoid sinuses; parapharyngeal space; pterygopalatine fossa; infratemporal fossa; orbit; base of skull; cavernous sinus; and anterior cranial fossa. The extent of disease did not correlate with the time from symptom onset to diagnosis or with the cancer type. Patients who presented with nonspecific complaints such as nasal obstruction, headache, and fatigue were diagnosed, on average, later (74 weeks) than those presenting with focal signs and symptoms such as proptosis, vision loss, epistaxis, and anosmia (14 weeks).

The type of treatment received by each patient (Table 3) depended on multiple factors, including the final tissue diagnosis, extent of disease, and potential morbidity associated with the treatment modality. All 6 of the patients diagnosed with rhabdomyosarcoma received chemotherapy; 5 also received either standard radiation or proton beam radiotherapy, and 1 had surgical resection of the lesion. Of the 4 esthesioneuroblastoma patients, 2 underwent anterior craniofacial resection followed by standard or proton beam radiation and 2 had transfacial/transnasal removal of the lesion (without craniotomy) with postoperative proton beam therapy. In the nonrhabdomyosarcoma sarcoma group, 4 patients had surgery (2 anterior craniofacial resections and 2 transfacial/transnasal resections) followed by chemotherapy and/or radiation; 1 patient with Ewing sarcoma was treated with chemotherapy and radiation without surgery. The patient with acute lymphoblastic lymphoma was treated with chemotherapy alone after diagnostic nasal and cervical mass biopsies.


View this table:
[in this window]
[in a new window]

  		TABLE 3 Treatment Modalities

 
The mean follow-up time was 33 months (range: 6–128 months). Of the 16 patients identified in this study, 10 had no evidence of disease at last follow-up, 4 had recurrent disease (2 of these had entered hospice care), 1 had died of disease, and 1 was lost to follow-up.

SEER Database
A total of 47 pediatric patients with nasal malignancies were identified in the SEER database. The diagnoses of these SEER patients are comparatively listed in Table 1. Six major diagnostic categories encompassing 19 histopathologic subtypes were identified.3 In this nationwide group of patients, esthesioneuroblastoma was the most common diagnosis (28%) followed by rhabdomyosarcoma (23%). Other tumor types identified in this larger sample included squamous cell carcinoma, adenocarcinoma, small cell neuroendocrine carcinoma, and yolk sac tumor, in addition to various subtypes of nonrhabdomyosarcoma sarcoma and leukemia/lymphoma. Of these 47 patients, 30 were alive and 17 were deceased at the conclusion of the study period, with an overall mean survival time of 188 months (95% confidence interval: 139–237 months). Actuarial 5- and 10-year survival rates were 61.4% and 51.1%, respectively. Overall survival was similar when hematologic malignancies were excluded from the analysis (mean: 181 months; 95% confidence interval: 127–236 months).


   DISCUSSION
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Pediatric head and neck cancers affect an estimated 550 children per year,4 of which nasal malignancies comprise a very small portion. Cancer of the nasal cavity in children is particularly challenging because of the often nonspecific symptoms and characteristic advanced degree of local destruction at presentation. Tumors of the nasal cavity are often initially misdiagnosed as sinus disease and treated empirically. Treatment failure or the onset of new symptoms eventually prompts further diagnostic workup revealing the true underlying pathology. For esthesioneuroblastoma, ocular presenting symptoms have been reported to occur more commonly in children than in adults because of the tendency for the tumor to lie more posterolaterally in the anterior cranial fossa, encroaching on ocular structures.5 This observation is reflected in our pediatric study, where ocular complaints were the second most common presentation, regardless of tumor type. Patients with more worrisome symptomatology, such as visual disturbance, proptosis, or recurrent unilateral epistaxis, were diagnosed more quickly than those presenting with nonspecific symptoms, such as nasal obstruction or headache. Increasing awareness of pediatric nasal cancer among primary care providers may decrease the time from initial presentation to diagnostic imaging or otolaryngologic referral for endoscopic nasal examination (Fig 1).


Figure 1
View larger version (102K):
[in this window]
[in a new window]

  		FIGURE 1 Endoscopic view of an esthesioneuroblastoma in an 11-year-old boy with a 5-year history of headache and nasal congestion. A firm soft tissue mass with vascular overlying mucosa can be seen arising from the right lateral nasal wall.

 
The experience at our institutions closely parallels that of the national SEER database reporting rhabdomyosarcoma and esthesioneuroblastoma to be the most common diagnoses. Rhabdomyosarcoma accounts for 5% to 8% of pediatric malignancies and roughly 40% of rhabdomyosarcoma tumors present in the head and neck region; rhabdomyosarcoma is typically cited as the most common malignancy arising in the nasal cavity in children.6 Esthesioneuroblastoma is comparatively thought of as a rare clinical entity. The incidence of esthesioneuroblastoma has been estimated at 3% of malignant intranasal tumors, with only 20% to 25% diagnosed in patients <20 years of age.7 The identification of esthesioneuroblastoma as one of the most common diagnoses in both patient groups was unexpected. A comparative study on adult nasal cavity malignancies reported squamous cell carcinoma to be the most common diagnosis (49%), with esthesioneuroblastoma a distant second at 13%.8 The present study reflects the strong bias toward soft tissue sarcomas in children and confirms esthesioneuroblastoma to be an important diagnostic entity in all age groups.

Most tumor types that arise in the nasal area are indistinguishable on the basis of clinical and radiographic features. Surgical biopsy is necessary for histopathologic diagnosis, with a particular reliance on molecular studies and special staining for immunohistochemical markers. These techniques allow the definitive diagnosis of both rhabdomyosarcoma and esthesioneuroblastoma and the differentiation of esthesioneuroblastoma from other neuroendocrine entities. Early molecular analysis suggested that esthesioneuroblastoma was a member of the Ewing sarcoma/PNET family9; more recent studies, however, have demonstrated that esthesioneuroblastoma cell lines do not have the characteristic t(11;22)(q24;q12) chromosomal translocation.10,11 The World Health Organization classification shown in Table 1 currently groups esthesioneuroblastoma with Ewing sarcoma/PNET under the umbrella of neuroectodermal tumors.

The staging of malignancies that arise in the nasal region has not been as well defined as for other head and neck sites. The American Joint Commission on Cancer (AJCC) only recently developed TNM staging guidelines for tumors of the nasal cavity proper.12 Staging is further complicated by the occurrence of multiple histopathologic types, each with its own characteristic profile of local growth, regional spread, and distant metastases. The AJCC criteria are specifically designed for squamous cell carcinoma; therefore, applicability to the pediatric population given the predominance of rhabdomyosarcoma and esthesioneuroblastoma is debatable. Alternative staging systems based on the TNM model have been proposed.8,13 Other diagnosis-specific staging systems applied to nasal tumors include the Ann Arbor staging system for lymphoma and the Kadish system for esthesioneuroblastoma. It remains to be seen whether the new AJCC criteria or any of the alternative TNM systems will have prognostic significance in the pediatric age group.

From our institutional group, 15 of the 16 patients' conditions qualified as T3 or T4 at the time of diagnosis according to AJCC staging. These data are in agreement with previous work suggesting that nasal malignancies in children are locally aggressive and tend to present at an advanced stage. Only 1 patient presented with cervical lymphadenopathy, and none had evidence of distant metastasis.

As to be expected with multiple tumor types, there is no standard treatment plan for malignancies of the nasal cavity. In general, each lesion is treated according to the guidelines for that particular histopathology, and recommendations continue to evolve.

The role of surgery has historically been limited by the proximity of vital structures and the tendency for local destruction by the aggressive nasal malignancies that occur in children. The multiple transfacial and transnasal approaches used to gain access to the nasal cavity typically provide inadequate access for tumors extending through the anterior skull base.14 A combined transfacial and cranial approach, anterior craniofacial resection (ACR), has expanded the role of surgery in the management of malignant tumors of the nasal cavity.15 Success as measured by disease-free survival after ACR seems to be greatest for esthesioneuroblastoma.16 However, even with esthesioneuroblastoma, locally aggressive disease and the difficulty of achieving negative margins makes ACR alone rarely a definitive treatment.

The use of adjuvant therapies for pediatric tumors of the nasal cavity depends on many factors, including the histolopathologic tumor type, the initial extent of disease, and the status of postoperative margins. Because most treatment failures are secondary to local recurrence, radiation therapy is often favored over chemotherapy.17,18 Postoperative radiation therapy is clearly indicated in patients with a variety of tumor types who have positive margins after ACR19 and for some high-grade tumors even if surgical margins are negative.20 In addition, preoperative radiation therapy has been used to reduce tumor size before surgical resection for multiple histopathologic tumor types.21 In adults, chemotherapy has not been found to be useful in affecting survival rate for nasal malignancies with positive margins22 but has been used as a palliative measure for patients in whom both surgery and radiation have failed to halt disease progression.19 For younger patients, there is some evidence favoring trimodality treatment. In pediatric esthesioneuroblastoma patients, for example, a combination of chemotherapy, radiation therapy, and surgery has shown benefit in terms of disease-free survival rate.23

Treatment planning is additionally influenced by the potential significant associated morbidity of these therapeutic modalities in the pediatric population. This morbidity includes susceptibility to craniofacial growth interference, as well as the risk of secondary malignancies. The availability of proton beam radiation therapy, which can more specifically target the diseased area with significantly less irradiation of surrounding vital structures, may decrease the risk of such complications.24

Long-term surveillance is essential for all children diagnosed with malignancies of the nasal cavity. Recurrence of esthesioneuroblastoma has been reported after a disease-free period of 17 years.25 The recurrence rate for pediatric soft tissue sarcomas of the head and neck (excluding the orbit) is estimated as high as 29% by the Intergroup Rhabdomyosarcoma Study.26 Serial physical examinations and imaging studies should be continued well into adulthood to detect recurrences and to initiate salvage therapy in a timely manner. Such follow-up is required relative to the risk of locoregional secondary malignancies as well.


   CONCLUSIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
A great deal of vigilance on the part of primary care providers and otolaryngologists is necessary to facilitate the prompt diagnosis of nasal cancer in children. Additional research is needed in the development of standardized staging criteria and guidelines for both the treatment and the long-term management of these patients.


   ACKNOWLEDGMENTS
 
We thank Dr Robert Hasserjian for comments on the article.


   FOOTNOTES
 
Accepted Jun 6, 2007.

Address correspondence to Margo McKenna Benoit, MD, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles St, Boston, MA 02114. E-mail: margo_benoit{at}meei.harvard.edu

This work was presented as a poster at the 22nd annual meeting of the American Society of Pediatric Otolaryngology; April 27–29, 2007; San Diego, CA.

Drs Benoit and Cunningham had full access to all of the data in the study and take responsibility for the integrity of the data analysis.

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Kubal W. Sinonasal imaging: malignant disease. Semin Ultrasound CT MR. 1999;20 :402 –425[CrossRef][Web of Science][Medline]
  2. Bassal M, Mertens A, Taylor L, Neglia J, Greffe B, Hammond S. Risk of selected subsequent carcinomas in survivors of childhood cancer: a report from the childhood cancer survivor study. J Clin Oncol. 2006;24 :476 –483[Abstract/Free Full Text]
  3. Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization Classification of Tumours: Pathology and Genetics—Head and Neck Tumours. Lyon, France: IARC Press; 2005
  4. Smith R, Robinson R. Head and Neck Malignancies. St Louis, MO: Mosby; 1998
  5. Kennedy J, Haines S. Review of skull base surgery approaches: with special reference to pediatric patients. J Neurooncol. 1994;20 :291 –312[CrossRef][Medline]
  6. Herrmann B, Sotelo-Avila C, Eisenbeis M. Pediatric sinonasal rhabdomyosarcoma: three cases and a review of the literature. Am J Otolaryngol. 2003;24 :174 –180[CrossRef][Web of Science][Medline]
  7. Eich H, Hero B, Staar S, Micke O, Seegenschmiedt H, Mattke A. Multimodality therapy including radiotherapy and chemotherapy improves event-free survival in stage C esthesioneuroblastoma. Strahlenther Onkol. 2003;179 :233 –240[CrossRef][Web of Science][Medline]
  8. Bhattacharyya N. Cancer of the nasal cavity: survival and factors influencing prognosis. Arch Otolaryngol Head Neck Surg. 2002;128 :1079 –1083[Abstract/Free Full Text]
  9. Sorensen P, Wu J, Berean K, Lim J, Donn W, Frierson H. Olfactory neuroblastoma is a peripheral primitive neuroectodermal tumor related to Ewing sarcoma. Proc Natl Acad Sci USA. 1996;93 :1038 –1043[Abstract/Free Full Text]
  10. Kumar S, Perlman E, Pack S, et al. Absence of EWS/FL11 fusion in olfactory neuroblastomas indicates these tumors do not belong to the Ewing's sarcoma family. Hum Pathol. 1999;30 :1356 –1360[CrossRef][Web of Science][Medline]
  11. Mezzelani A, Tornielli S, Minoletti F, Pierotti M, Sozzi G, Pilotti S. Esthesioneuorblastoma is not a member of the primitive peripheral neuroectodermal tumor: Ewing's group. Br J Cancer. 1999;81 :586 –591[CrossRef][Web of Science][Medline]
  12. Sobin L, Wittekind C. International Union Against Cancer: TNM Classification of Malignant Tumors. 6th ed. New York, NY: Wiley-Liss; 2002
  13. Biller H, Lawson W, Sachdev V, Som P. Esthesioneuroblastoma: surgical treatment without radiation. Laryngoscope. 1990;100 :1199 –1201[Web of Science][Medline]
  14. McCutcheon I, Blacklock J, Weber R, DeMonte F, Moser R, Byers M. Anterior transcranial (craniofacial) resection of tumors of the paranasal sinuses: surgical technique and results. Neurosurgery. 1996;38 :471 –480[CrossRef][Web of Science][Medline]
  15. Smith R, Klopp C, Williams J. Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer. 1954;7 :991 –994[Medline]
  16. Levine P, Debo R, Meredith S, Jane J, Constable W, Cantrell R. Craniofacial resection at the University of Virginia (1976–1992): survival analysis. Head Neck. 1994;16 :574 –577[CrossRef][Web of Science][Medline]
  17. Dulguerov P, Allal A, Calcaterra T. Esthesioneuroblastoma: a meta-analysis and review. Lancet Oncol. 2001;2 :683 –690[CrossRef][Web of Science][Medline]
  18. Dulguerov P, Allal A. Nasal and paranasal sinus carcinoma: how can we continue to make progress? Curr Opin Otolaryngol Head Neck Surg. 2006;14 :67 –72[Medline]
  19. Bulsara K, Fukushima T, Friedman A. Management of malignant tumors of the anterior skull base: experience with 76 patients. Neurosurg Focus. 2002;13 :1 –11
  20. Morita A, Ebersold M, Olsen K, Foote R, Lewis J, Quast L. Esthesioneuroblastoma: prognosis and management. Neurosurgery. 1993;32 :706 –714[Web of Science][Medline]
  21. Sisson GS, Toriumi D, Ayiyah R. Paranasal sinus malignancy: a comprehensive update. Laryngoscope. 1989;99 :143 –150[Web of Science][Medline]
  22. Bentz B, Bilsky M, Shah J, Kraus D. Anterior skull base surgery for malignant tumors: a multivariate analysis of 27 years of experience. Head Neck. 2003:515 –520
  23. Eich H, Muller R, Micke O, Kocher M, Berthold F, Hero B. Esthesioneuroblastoma in childhood and adolescence: better prognosis with multimodal treatment? Strahlenther Onkol. 2005;181 :378 –384[CrossRef][Web of Science][Medline]
  24. Lomax A, Goitein M, Adams J. Intensity modulation in radiotherapy: photons versus protons in the paranasal sinus. Radiother Oncol. 2003;66 :11 –18[Web of Science][Medline]
  25. Shah J, Feghali J. Esthesioneuroblastoma. Am J Surg. 1981;142 :456 –458[CrossRef][Web of Science][Medline]
  26. Raney R, Crist W, Maurer H, Foulkes M; Intergroup Rhabdomyosarcoma Study Committee. Prognosis of children with soft tissue sarcoma who relapse after achieving a complete response. Cancer. 1983;52 :44 –50[CrossRef][Medline]
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Digg Digg   Add to Facebook Facebook   Add to Reddit Reddit   Add to Technorati Technorati   Add to Twitter Twitter    What's this?


This article has been cited by other articles:


Home page
 Arch Otolaryngol Head Neck SurgHome page
Pathology Quiz Case 2: Diagnosis
Arch Otolaryngol Head Neck Surg, September 1, 2009; 135(9): 947 - 948.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrowRequest Permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via CrossRef
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Benoit, M. M.
Right arrow Articles by Cunningham, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Benoit, M. M.
Right arrow Articles by Cunningham, M.
Related Collections
Right arrow Tumors
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Digg   Add to Facebook   Add to Reddit   Add to Technorati   Add to Twitter  
What's this?