Nasal Septal Squamous Cell Carcinoma:
A Chart Review and Meta-analysis
Michael D. DiLeo, MD; Robert H. Miller, MD; Janet C. Rice, PhD; R. Brent Butcher, MD
Squamous cell carcinoma of the nasal septum oc-
curs infrequently and is often misdiagnosed because
its symptoms are similar to everyday rhinologic com-
plaints. The published series have been too small to
determine the best form of treatment for this cancer.
The authors of this study retrospectively reviewed
nasal septal squamous cell carcinomas treated at
three university-affiliated hospitals over a 30-year
period. Sixteen primary tumors were identified and
reviewed for presentation, staging, treatment, recur-
rence patterns, and risk factors. The authors then
combined their findings with those of suitable litera-
ture series and performeda meta-analysisto evaluate
predictors of survival.
There were too few patients in each stage and
treatment group to significantly determine the opti-
mal treatment for nasal septal squamous cell carcino-
ma. However, based on the present study and the lit-
erature series, the authors suggest that small lesions
may be confidently treated with either radiation or
surgery and that combined therapy may be reserved
for more advanced tumors.
LARYNGOSCOPE,
106:1218-1222,1996
INTRODUCTION
The precise treatment for nasal septal squamous
cell carcinoma has yet to be determined. This uncer-
tainty concerning therapy stems from two sources: the
rarity of this cancer and the lack of proper therapeutic
trials. Although squamous cell carcinoma accounts for
two-thirds of the primary carcinomas of the nasal sep-
tum, these lesions comprise only 9% of malignant tu-
mors of the nasal cavity, which, in turn, represent only
1%of all human rnalignancies.*a Squamous cell car-
cinoma of the nasal septum has been reported infre-
quently in the literature, with only 97 cases listed
through 1978.5 Since 1978, there have been only six
Presented a t the Meeting of the Southern Section of the American
Laryngological, Rhinological and Otological Society, Inc., Naples, Fla., Janu-
ary 6,1996.
From the Ikpartment of Otolaryngology-Head and Neck Surgery
lxi).i)..H . H . M . ) . ' M a n e University School of Medicine, the Department of
Biostatisticb: and EpidemioloLy l J . c . K . ) , Tulane School of Public Health and
Tropical Medicine, and the Department of Otolaryngology-Head and Neck
Surgery ( R . R . H . ) , Ochsner Foundation Hospital, New Orleans.
Reprints not available.
Laryngoscope106: October 1996
1218
reported series with 11 or more patients, for an addi-
tional 143 cases.1.2.4-7
Although no unique staging system exists, prima-
ry nasal septal squamous cell carcinomas can be sepa-
rated from other lesions of the nasal cavity and
paranasal sinuses by their improved prognosis. Com-
pared with lesions of adjacent nasal sites, septal le-
sions have a better outcome because they present ear-
lier and at a smaller size and because they are more
radiosensitive.6 This variable behavior of nasal cavity
lesions is less than adequately accounted for by the
numerous proposed staging systems that only make
distinctions according to tumor size and extension.7-11
Lesions in an advanced state can create even more
problems in staging, in that it is difficult to differenti-
ate between the epicenter of the tumor and an area of
extension.
Classically, certain occupations (e.g., woodwork-
ing, leathenvorking, nickel refining) and exposures
(e.g., solvents, petroleum products, bakery products,
tobacco) have been identified in relationship to malig-
nant lesions of the nasal cavity and paranasal sinuses.
Their contribution to the development of nasal septal
squamous cell carcinomas is unknown, and several se-
ries have found little association with these risk fac-
t o r ~ .The
~ . ~rarity of these tumors may never allow iso-
lation of the inciting events.
The symptoms of squamous cell carcinoma of the
nasal septum often are those of everyday rhinologic
complaints. Consequently, patients may delay seeking
medical care for up to 6 years."7 Patients most fre-
quently present with complaints of nasal obstruction,
epistaxis, nasal mass, ulceration, pain, and rhinor-
rhea.' More advanced disease may present as nasal
swelling, epiphora, diplopia, or palatal ulceration. Un-
fortunately, the diagnosis may be delayed even more if
the nasal cavity is not adequately examined.
Common physical findings include mucosal ul-
ceration, mass lesion, polyp, nasal swelling or deformi-
ty, and septal perforation. 1 Septal carcinoma should
be strongly suspected in a patient with persistent
nasal crusting and intermittent bleeding.5 Rarely is a
biopsy performed on the first physical contact with a
patient. 12
DiLeo et al.: Nasal Septal Cancer
 TABLE I.
Characteristicsof 16 Patients With Primary Nasal Septal Squamous Cell Carcinoma,
Patient No. Sex Age Stage Treatment Recurrence FOIIOW-UP Status
1 F 52 Y T1 Surgery 0 63 mo DNED
2 F 72 Y T1 Radiation Progression 5 rno DWD
3 M 49 Y T1 Radiation Two regional 91 mo ANED
4 M 52 Y T1 N1 Combined 0 6 mo ANED
5 M 68 Y T2 Surgery 0 115rno DNED
6 M 59 Y T2 Surgery 0 26 mo ANED
7 M 64 Y T2 Surgery 0 124mo ANED
8 M 67 Y T2 Surgery 0 70 mo DNED
9 M 50 Y T2 Surgery 0 180 mo DNED
10 F 73 Y T2 Surgery 0 26 rno ANED
11 M 65 Y T2 Radiation 0 240 mo DNED
12 M 70 Y T2 Combined One regional 8 mo DNED
13 M 88 Y T3 Surgery 0 6 mo DNED
14 M 59 Y T3 Surgery Two localhegional 67 mo DWD
15 M 56 Y T3 Combined 0 12 rno ANED
16 F 45 Y T3 Combined 0 54 mo DNED
Combined = both surgery and irradiation: ANED =alive with no evidence of disease:DNED = died with no evidence of disease: DWD = dead with disease.

The literature supports treatment of nasal septal
squamous cell carcinoma with surgery, radiation, or
combined therapy, and the reported survival rates
range from 66% to lOO%.l.",P7 Due to the scant num-
bers of cases, studies have not provided adequate com-
parisons between treatment groups. To extend this
limited experience, we performed a retrospective re-
view of the charts of patients with squamous cell carci-
noma of the nasal septum who were treated at three
university-affiliated hospitals. Suitable literature se-
ries were also reviewed and were combined with our
findings in a meta-analysis to determine the optimal
treatment for this cancer.
MATERIALS AND METHODS
Retrospective Chart Review
The medical records and tumor registries of three uni-
versity-affiliated hospitals were searched for the diagnosis
of nasal cavity carcinoma in order to identify patients with
primary nasal septal squamous cell carcinoma. The institu-
tions were tertiary referral centers, and the cases dated back
14,20,and 30 years, depending on the availability of medical
records and tumor registry data at each location.
Only those patients for whom chart notes, surgical re-
ports, or pathologic descriptions clearly identified the tumor
as a primary squamous cell carcinoma of the nasal septum
were entered into the study. The charts were reviewed for
presenting signs and symptoms, delay in presentation and
diagnosis, smoking history, occupation, tumor stage, treat-
ment, margins, second primary tumors, recurrences, and
survival. Tumors were staged according to the staging sys-
tem for carcinoma of the nasal cavity used at the Indiana
University School of Medicine.8 Survival was calculated us-
ing the Kaplan-Meier method.
Literature Review and Meta-analysis
A search of the English language literature since 1966
was performed to identify all series of nasal septal squamous
cell carcinomas. Only primary tumor series giving individ-
ual patient stage, treatment, survival, and disease status
were included in the analysis. Tumor stage, treatment type,
and study group were evaluated as predictors of survival us-
ing the Cox proportional hazards model.
RESULTS
Chart Review
Sixteen patients were found to have histologically
confirmed squamous cell carcinoma originating from
the nasal septum (Table I). The 12 male and 4 female
patients had a mean age of 62 years (range: 45 to 88
years). The time from first symptom to presentation
averaged 12 months (range: 0 to 48 months), and the
most common initial symptom was a nasal mass
(Table 11). The time from the initial physician visit to
the diagnosis of squamous cell carcinoma of the nasal
septum averaged 6 months (range: 0 to 48 months). On
physical examination, the most common findings were
nasal ulcerations, masses, septal perforations, and
skin changes.
Tumors were staged as T1 in four patients, T2 in
eight patients, and T3 in four patients. The tumor in
one patient with neck disease was initially thought to
be an N1 unknown primary, but a T1 septal lesion was
subsequently identified. Treatment consisted of surgi-
cal excision in nine patients, radiation therapy in
three patients, and combined therapy in four patients
(Table 111). The total radiation dose ranged from 50 to
70 Gy. No neck dissections were performed a t the ini-
tial treatment.

Laryngoscope 106: October 1996 DiLeo et at.: Nasal Septal Cancer

1219
 TABLE 111.
Patient Series bv Tumor Staae and Treatment.
Treatment
Serieslumor Stage Surgery Radiation Combined
Present series
I 1 2 0
II 6 1 1
111 2 0 3
Young (1979)'
I 1 8 2

"1 ,I
II 0 7 1
111 0 3 0
Fradis, et al. (1993)4
, , , , , , , , , I 0 0 11
0% Combined = both surgery and irradiation.
0 12 24 36 40 0 72 84 08 108 120
Time (Months)
TABLE IV.
Fig. 1. Kaplan-Meier survival curves for a series of 16 patients with
Cox ProDortionalHazards Model for the Combined Series.
nasal septal squamous cell carcinoma.
Variable Chi-SauaredValue PValue
Tumor stage 0.37 0.55
The mean duration of follow-up was 68 months Treatment group 0.76 0.68
(range: 3 to 240 months). The overall 5-year survival Study Group 0.26 0.61
by the Kaplan-Meier method was 66%, and the re-
lapse-free survival was 51% (Fig. 1).
Three known recurrences and one progression of for a planned definitive surgical excision and died with
disease occurred in the group. One patient in the sur- no evidence of disease at 63 months.
gical group, initially with a T3 tumor, had local recur-
rence 19 months after surgery and had localhegional Substantial smoking histories were reported in
disease a t 67 months. This patient died of disease. One 15of the 16 patients, with 11of these histories quanti-
patient in the radiation group, initially with a T1 tu- tated in pack-years for a mean of 56 pack-years. The
mor, had tumor recurrence in the neck at 12 and 53 few occupations that were mentioned included chemi-
months, was surgically salvaged, and was alive with- cal plant worker, street sweeper, house cleaner, and a
out disease a t 91 months. One patient in the com- firefighter who also refinished furniture. Nine second
bined-therapy group, initially with a T2 tumor, had a primary tumors were found in 7 patients, including
recurrence in the neck a t 1month and died of unrelat- leukemia in 2 patients and oral cancer in 2 patients,
ed causes a t 8 months. There was one patient who had with lung, renal, colon, and skin squamous cell and
progression of disease after radiation therapy for a T1 basal cell carcinoma each occurring once.
lesion. Another patient who had a biopsy of a T1 lesion
and topical 5-fluorouracil therapy was lost to follow-up
Meta-analysis
TABLE II. Since 1966,12 articles in the literature have pre-
Symptoms and Physical Findin s in 16 Patients With sented series of patients with primary nasal septal
Nasal Seotal Sauamous 8ell Carcinoma.
Symptoms and Findings Percentage of Patients
squamous cell ~arcinorna.1-7~~.12-1~ Of these, only 2
~ t u d i e s lprovided
.~ adequate information concerning
InitialSymptom
Mass 40%
stage, treatment, survival, and disease status for each
Ulcer 27% individual patient (Table 111). Both series were retro-
Pain 13% spective studies, with one including 22 patients treat-
Nasal obstruction 13% ed primarily with radiation therapy and the other in-
Nasal drainage 7% cluding 11 patients treated with both surgery and
Physical Findings irradiation. When these patients were combined with
Ulcer 56% those in the present series, a total of 49 cases of squa-
Mass 50% mous cell carcinoma of the nasal septum were re-
Perforation 19% viewed.
Skin Changes 19%
Cellulitis 13% Tumor stage, type of treatment, and study group
Nasal deformity 13% were evaluated using a Cox proportional hazards
Edema 13% model. None of the variables was found to be a signifi-
Septal deviation 7% cant predictor of survival (Table IV).

Laryngoscope 106:October 1996 DiLeo et al.: Nasal Septal Cancer

1220
DISCUSSION
Treatment options for nasal septal squamous cell
carcinoma include surgery, radiation, and combined
therapy. Localized anterior septal lesions are removed
through a lateral rhinotomy incision to obtain ade-
quate exposure. Wide excision with l-cm margins and
the removal of full-thickness mucosa, cartilage, and/or
bone is recommended. Early submucosal spread is
thought to be enhanced by bony and cartilaginous bar-
riers.3 With lesions that advance into the posterior
septum or the nasal floor, a more extended approach,
such as the Weber-Furguson incision, must be em-
ployed, along with removal of the involved palate, col-
umella, and medial maxillary wall. For large tumors,
palatal prostheses play an important role in immedi-
ate rehabilitation.
In nasal septal squamous cell carcinomas requir-
ing excision of all or part of the external nose, immedi-
ate reconstruction has been tempered by the known
indolence of these lesion, and close inspection of the
cavity is required.3 Even in the worst situations, ac-
ceptable cosmetic results have been achieved with ad-
hesive or bone-anchored prosthetics. 1.14
Radiation therapy for these tumors typically em-
ploys 60 to 70 Gy to the nasal cavity.eJoJ1 Nasolabial,
buccal, and submandibular lymphatics are frequently
included in the treatment portals. Radiation therapy
is not without risk, and it may result in abnormalities
in ciliary activity and the mucous blanket, fibrosis, tis-
sue thickening, and, possibly, chondritis.3
The literature review revealed series that support
both radiation therapy and combined therapy as pri-
mary treatment modalities for nasal septal squamous
cell carcinomas. However, due to the paucity of pa-
tients with these lesions, adequately large treatment
groups have not been assembled to establish optimal
therapy. In a 1993 review of 11patients with septal in-
vasive squamous cell carcinomas,* all lesions were
stage I and were treated with combined surgery and
radiation. There were only two heavy smokers in the
group, and no occupational exposures were identified.
All patients were free of disease 2.5 to 14.0 years after
treatment.
In a 1992 review of 14 patients collected over a 17-
year period,6 the vast majority of lesions were stage I
and received external-beam or interstitial radiation
therapy. Only two tumors were treated with combined
surgery and irradiation. The 5-year overall survival
rate was 92% after surgical salvage was performed in
4 patients for local or regional recurrences. Two of the
8 patients who did not receive prophylactic neck irra-
diation sustained regional recurrences, as compared
with none of the 6 patients who had neck irradiation.
With these favorable results, the investigators strong-
ly recommended primary radiation therapy for early
lesions of the nasal septum.
A 1984 report discussed 18 patients with nasal
Laryngoscope 106:October 1996
septal squamous cell carcinoma collected over an 18-
year period.7 Seven patients underwent surgery, 2 pa-
tients received radiation therapy, and 9 patients were
treated with both surgery and irradiation. The ab-
solute 5-year survival rate was 66%. Fourteen of these
patients were smokers. Synchronous primary tumors
occurred in 17% of patients. On follow-up, the 44% in-
cidence of neck disease was significantly associated
with primary tumors greater than 2 cm in size. Half of
the patients with neck recurrences died of their dis-
ease. Due to the high incidence of regional recurrences
and the poor prognosis for these tumors, prophylactic
neck irradiation was recommended, along with com-
bined therapy a t the primary site.
A 1982 report covered a large series of 58 patients
with septal squamous cell carcinoma who were treat-
ed over a 61-year period.2 Surgery was used in 69% of
patients, radiation therapy in 5% of patients, and com-
bined therapy in 22% of patients. Of the 58 patients,
80% were smokers. The overall 5-year survival was
67%, but no attempt was made to relate survival to
treatment or stage.
In the present study, the 66% overall 5-year sur-
vival rate is consistent with the survival rates in other
series with comparable proportions of early- and late-
stage lesions.2.7 However, the small number of pa-
tients in each tumor staging and treatment group do
not allow for a n accurate comparison of survival. The
surgically treated group was the largest, with eight of
nine patients (one T3 patient recurred locally and re-
gionally) subsequently free of disease. This outcome
suggests a role for surgery alone in early lesions. The
inordinate delay from initial symptoms to presenta-
tion and diagnosis emphasizes the need for a thorough
examination in patients with chronic, persistent rhi-
nologic complaints.
The known 94% incidence of substantial smoking
histories in the present series strengthens the implica-
tions of several other studies that tobacco is an etiolog-
ic factor in the disease process.2~7This relationship is
h r t h e r intensified by the fact that two of the patients
had oral second primary tumors, suggesting possible
field cancerization as the basis of disease.
In the past, the reconstruction of externally de-
forming excisions was delayed due to the indolent na-
ture of septal tumors and the need for cavity inspec-
t i ~ nIn
. ~the present study, only one surgical case was
known to have a local recurrence. Such a low rate of lo-
cal recurrence should not deter primary reconstruc-
tion, and nasal endoscopes make follow-up easier.
Meta-analysis is a useful tool for achieving a con-
sensus among a group of patient series when there is
inadequate individual experience for analysis. Howev-
er, due to the small sample sizes in each treatment and
stage subgroup and due to the large number of pa-
tients still alive a t the time of final follow-up, the pres-
ent meta-analysis fails to achieve significance. Also,
DiLeo et at.: Nasal Septa1Cancer
1221
because of the rarity of this lesion and the small indi-
vidual treatment groups collected over decades, such
an analysis is plagued by failure of patient randomiza-
tion and inconsistency of treatment methods. A multi-
institutional protocol would more effectively address
the best mode of treatment.
CONCLUSION
The results of the literature series and the pres-
ent study suggest that either radiation therapy or sur-
gery is effective for the treatment of early-stage le-
sions of primary squamous cell carcinoma of the nasal
septum. More advanced lesions require the combined
efforts of surgery and radiation therapy. Because of
the poor prognosis of a regional recurrence, prophylac-
tic radiation therapy for the neck may be beneficial in
more advanced tumors. The usefulness of prophylactic
neck dissection has not been examined. The delay in
diagnosis and the treatable nature of early lesions un-
derscore the importance of a thorough examination in
patients with chronic rhinologic complaints.
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