Sinus cancers are extremely rare — constituting less than 1% of cancers overall and about 3% of head and neck cancers. But they can have a big impact on patients — whether it affects their sense of smell or sight or their brain and appearance. The proximity of these cancers to key organs also makes them very difficult to treat.
As a result, few surgeons specialize in treating patients with these conditions. But that challenge is what drew Duke Head and Neck Surgery & Communication Science’s (HNS&CS) Ralph Abi Hachem, MD, to become an expert in treating sinus cancers.
“I love helping patients during challenging times, and sinus cancers are among the most challenging of all,” he said.
Innovative Treatments for a Complex Cancer
Dr. Abi Hachem became interested in skull base and sinonasal tumors during his residency at University of Miami, which led him to pursue dedicated training in treating sinus and skull base tumors and cancer at the Ohio State University. After completing the fellowship, he came to Duke.
“At Duke, I saw an opportunity to leverage the infrastructure in research and excellence in clinical care for patients,” he said. “These cancers require multidisciplinary teamwork and Duke offers that.”
As an endoscopic endonasal surgery expert, Dr. Abi Hachem has helped change the way sinus cancer is treated. Traditionally, these cancers required open surgery — large incisions in the skull that often needed brain retraction. The open approach also doesn’t offer great visualization of the area for the surgeon.
Building on the work David Jang, MD, initiated at Duke, Dr. Abi Hachem prefers to use minimally invasive endoscopy that approaches the tumors through the nose.
“Now we can access these cancers through the nostril with an endoscope, which prevents brain retraction and provides direct access to the tumor,” Dr. Abi Hachem said.
The high-resolution camera attached to the endoscope provides him with much better visualization. The minimally invasive approach usually results in fewer incisions and faster recovery for patients.
While open surgery is sometimes required, Dr. Abi Hachem only chooses that option when minimally invasive approaches aren’t enough.
“The tumor dictates the approach,” he said.
As one of the few surgeons to specialize in sinus cancer surgery, Dr. Abi Hachem sees patients from throughout North Carolina as well as Virginia, Tennessee, Georgia, and other states. Collaborating with Duke colleagues in neurosurgery, medical oncology, radiation oncology, neuroradiology, and pathology, the Duke team treats all types of sinus cancers.
The results can be life changing for patients. For example, patients with cancer surrounding their carotid artery are often offered palliative care instead of surgery. The Duke team offers an innovative approach: they perform carotid resections to remove all the cancer cells. The patients have recovered well after the procedure.
Leading in Sinonasal Cancer Research
Because of the rarity of these cancers, little research has been done in the area and outcomes haven’t improved over the past three decades. Dr. Abi Hachem is working to improve understanding of sinus cancers and pioneer new treatments.
Through his research, Dr. Abi Hachem has described two new cancers of the nose — mixed adenoneurocrine carcinoma (MANEC) and low-grade papillary Schneiderian carcinoma — and published about them. He’s also performed a systemic review and meta-analysis of induction chemotherapy that helped establish national guidelines.
He also collaborates with faculty throughout Duke as well as at other institutions to further understanding of these cancers.
With Duke HNS&CS Vice Chair of Research Bradley Goldstein, MD, PhD, Dr. Abi Hachem has pursued basicscience research projects to better understand olfactory neuroblastomas (also known as esthesioneuroblastoma). Dr. Goldstein and Dr. Abi Hachem have also partnered with Trudy Oliver, PhD, Professor of Pharmacology and Cancer Biology at Duke; together they developed mouse models and cell lines. They’ve learned that olfactory neuroblastomas are similar to small lung cell carcinomas — one of the most common cancers — and that treatments developed for small cell lung cancers can be used for olfactory neuroblastomas.
In addition, Dr. Abi Hachem is working on a variety of new research projects, including a project with Duke neurosurgeon Patrick Codd, MD, who is developing a tool that uses AI and reflects a laser on tissue to determine if it’s cancerous.
A Promising Future for Sinus Cancer Patients
With all of the activity Duke is engaged in for sinus cancers, Dr. Abi Hachem is excited about future possibilities for treatment. More conservative therapies are being developed, including medications such as targeted therapies, and progress is being made in defining risk factors.
“There's going to be a lot of innovation with immunotherapy, targeted therapy, and surgical approaches — all of which will benefit patients,” he said. “With our research collaborations and surgical experience, we are well positioned at Duke to be pioneers in sinus cancer treatment.”