Primary tumor of nasal columella is extremely rare. We did not find any information about columellar cancer from snuff in literature except two case reports. Dry snuff is powdered tobacco that is inhaled through the nose. This habit is not widespread in Turkey. Snuff (oral and nasal) usage represents about 1% of total tobacco consumption in Britain and 40% in India
8,9. Dry snuff contain tobacco-specific N–nitrosonornicotine, N-nitrosamines (TSNA) and 4-(methylnitrosamino)- 1- (3-pyridyl) -1 –butanone
10. TSNA has been found to give rise to cancers in the nasal cavity, after applied systemically in rats
11. The carcinogenic effects in the nasal cavity are partially attributed to substances of TSNA in nasal cells
10. Dry tobacco snuff may induce nasal vestibul tumors, over a long period.
There are various opinions about behavior of these tumors, staging, treatment modalities and prognostic factors. But, authors have consensus on high aggressivity of this tumor. Therefore; in case of inadequate resection of columellar cancers, spreading to septum, nasal base and premaxilla are inevitable 6. Spreading of these tumors are difficult to detect only by physical examination. For this purpose, CT and magnetic resonance imaging (MRI) is useful in determining the dissemination of the local tumor. It has been shown that tumors in the vestibular and columellar area are more prone to lymphatic metastasis in some studies 2. Approximately 10% of patients have lymph node metastases in the neck at initial diagnosis. In our patient, any lymphatic metastasis was not detected by physical examination, ultrasonography and computed tomography.
There is no standart staging model for determining of dissemination of the tumor. The size of the lesion has not been included as a reference in Wang's classification 12. Fornelli et al. also have used this classification in their study 3. GETTEC study group has taken the tumor size as a reference for staging (UICC - international union against cancer) 4. This group recommends surgery for T1 tumors, radiotherapy for T2 and T3 tumors, combination of surgery and radiotherapy for T4 tumors 4. Because of the difficulties of reconstruction in T2 and T3 tumors radiotherapy is recommended primarily. According to UICC, the presented case was classified as T1N0M0. Various musculocutaneous flaps are available for reconstruction of the defect such as unilateral nasolabial sulcus, oblique frontal, anguli oris, bilateral nasolabial and Washio’s flap. The defect was reconstructed with left nasolabial sulcus flap in this case.
Neck dissection is still controversial. Upper lip and columella lymphs drains to submandibuler lymph nodes. Therefore, neck dissection should include both submandibuler nodes. Neck dissection was not performed, because both clinic and radiologic evaluation did not reveal any metastatic lymph nodes in our case. On average 10-15% patients have lymph node metastases in the neck after treatment of primary lesion during follow up 4. Fornelli et al. reported that second primary tumors of head and neck are seen approximately 10% of patients in their follow-up 3. Therefore, these patients should be followed by endoscopic examination.
Greater than 2 cm tumor, the invasion of the skin, cartilage, bone, or lips represent poor prognosis 13. Nasal region tumors have the most common recurrence and metastasis rate among cancers originating from the mid-fascial area 6. Recurrence rates have been reported ranging between 16% and 41% in the literature 3,4,6. The most common causes of recurrence are incomplete resected tumors and false-negative surgical margins 6. Early stage columellar tumors have approximately 80% 5-year survival rate 3. However, this rate is 50% in advanced columellar tumors 6.
Long term snuff abuse may cause malign transformation in the nose. Diagnosis and treatment may be delayed because of nonspecific signs and symtoms. These tumors should be treated radically. Close follow-up is required because of high recurrence rate, and in follow-ups endoscopic examinations are recommended to detect second primary tumors which are not uncommon.
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