Sino nasal malignancies

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Sino nasal malignancies

  1. 1. Nasal Cavity and Para nasal Sinuses Cancer by Osama El-Zaafarany
  2. 2. Incidence:      3% of aerodigestive malignancies 1% of all malignancies Males : females = 2 : 1. Sixth to seventh decades The maxillary sinus is most commonly involved with tumor, followed by the nasal cavity, the ethmoids, and then the frontal and sphenoid sinuses.
  3. 3. Anatomy
  4. 4. Maxillary antrum: Superior : orbit, ethmoids Posterior : pterygoids, infratemporal fossa. Ethmoid sinus: Superior : fovea, cribiform Medial : lamina papyracea
  5. 5. Sphenoid sinus Superior : optic nerve, pituitary Lateral : ICA, cavernous sinus Inferior : nasopharynx.  Frontal sinus Inferior: orbit. Posterior: anterior cranial fossa 
  6. 6. Lymphatic Drainage   The anterior nose has the same lymphatic drainage as the external nose. These tend to spread to the submental or level I area. The posterior nose tends to drain to the retropharyngeal nodes as well as the lateral pharyngeal nodes, which eventually drain into the level II.
  7. 7. Etiological Factors:  Exposure: Wood, nickel-refining processes  Industrial fumes, leather tanning  Specific asssociations found include squamous cell carcinoma in nickel workers and adenocarcinoma in workers exposed to hardwood dusts and leather tanning.   Cigarette and Alcohol consumption  No significant association has been shown
  8. 8. Pathologic classification: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Adenocarcinoma Hemangiopericytoma Melanoma Olfactory neuroblastoma Sarcoma: osteogenic, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma Lymphoma: (NHL, NK/T-cell lymphoma=lethal midline granuloma). Metastatic tumors (RCC is the most common). Sinonasal undifferentiated carcinoma
  9. 9. Natural History:  Squamous cell carcinoma:  Most common tumor (80%), Males, Sixth decade.  Location: Maxillary sinus (70%) • Nasal cavity (20%), lateral nasal wall is the most common site 88% present in advanced stages (T3/T4). 90% have eroded walls of sinuses. Regional lymph node metastasis is about 10% to 20% of cases. Local recurrence rate 30% to 40%. •    
  10. 10.  Adenocarcinoma: 2nd most common, 5-20%  Ethmoids.  Strong association with occupational exposures.  High grade subtype: 30% present with metastasis 
  11. 11.  Adenoid Cystic Carcinoma:  3rd most common (3-15%).  occurs most frequently in women, and in the fifth and sixth        decades. Palate > major salivary glands > sinuses. Neck metastasis is rare. Multiple recurrences, distant mets. Perineural spread Resistant to tx. Postoperative RTx is very important. Long-term followup necessary
  12. 12.  Olfactory Neuroblastoma Esthesioneuroblastoma:   Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. Kadish staging system: • • •     A: confined to nasal cavity B: involving the paranasal cavity C: extending beyond these limits Aggressive behavior Local failure: 50-75% Metastatic disease develops in 20-30% Treatment is en bloc surgical (craniofacial) resection with postoperative RTx.
  13. 13.  Sinonasal Undifferentiated Carcinoma: • It is rare type, believed to arise from Schneiderian epithelium, the • • • • • • • • Sionasal ectodermn. Risk factors: Smoking and radiation. The median age 6th decade, male predominance. Aggressive locally destructive lesion. Frequent orbital invasion and intracranial extension. Greater tendency to metastasize than squamous carcinoma. DD: melanoma, lymphoma, olfactory neuroblastoma, rhabdomyosarcoma, neuroendocrine carcinoma, and poorly differentiated squamous cell carcinoma. Prognosis is usually poor, with a median survival of 18 months. Overall survival is a bout 20% at 5 years. Preoperative chemotherapy and radiation may offer improved survival if combined with radical surgery.
  14. 14. Staging:
  15. 15. Ohngren’s Line a line that is drawn from the angle of mandible to the medial canthus. Ohngren indicated that tumors that presented above this line (suprastructure); both superiorly and posteriorly, tended to have a worse prognosis
  16. 16. Clinical Presentation: (delayed diagnosis)  Oral symptoms: 25-35%; Pain, trismus, alveolar ridge fullness, erosion  Nasal findings: 50% Obstruction, epistaxis, rhinorrhea  Ocular findings: 25% Epiphora, diplopia, proptosis  Facial signs: Paresthesias, asymmetry  Classic Triad of advanced disease: • • • facial asymmetry tumor bulge in oral cavity nasal mass
  17. 17. Diagnostic workup:     Physical exam Nasal endoscopy Biopsy Radiography (CT, MRI).
  18. 18. Computed Tomography    Bone erosion 85% accuracy Difficult to differentiate between: Tumor vs. inflammation vs. secretions
  19. 19. MRI     94% accuracy Inflammatory tissue & secretions: intense T2 Tumor: intermediate T1 & T2, Enhancement with Gadolinium If there is a question of neural involvement, MRI is excellent for determining perineural spread, involvement of the dura, or involvement intracranially.
  20. 20. Treatment Recommendations:
  21. 21. Surgery: • Surgical resection is the primary treatment modality for cancers involving the maxillary or ethmoid sinuses. • Resection is often limited by tumor involvement of the base of skull which can result in damage to critical structures such as brain, and the cranial nerves. • In the past, contraindications to surgical resection included tumor extension to the lateral skull base, intracranial contents, or cavernous sinus. However, with advances in surgical technique and reconstruction, the decision of more extensive surgery, such as a craniofacial resection via craniotomy or transglabellar/subcranial approach can be considered in ethmoid sinus tumors involving cribriform plate for example.
  22. 22.  Unresectability:      extension to frontal lobes invasion of prevertebral fascia bilateral optic nerve involvement cavernous sinus extension Surgical approaches: • • • • • Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Combined craniofacial approach
  23. 23. Surgical procedures:      The goal of surgery for nasal cavity and paranasal sinus tumors is to achieve en bloc resection of all involved bone and soft tissue with clear margins while maximizing the cosmetic and functional outcome. Limited nasal cavity lesions may be resected with medial maxillectomy. Ethmoid lesions usually require medial maxillectomy and en bloc ethmoidectomy. combined craniofacial procedure for lesions involving the inferior surface of the cribriform plate and the roof of the ethmoid. The bony defect in the anterior cranial floor is closed with a vascularized pericranial or temporal muscle flap.
  24. 24.     maxillary antral cancers: radical maxillectomy that removes en bloc the entire maxilla and ethmoid sinus. Suprastructure lesions may involve the orbit, necessitating orbital exenteration. Resection of involved periosteum and frozen-section control of adjacent orbital contents with preservation of the eye may be possible in select lesions with involvement of the periorbita without intraorbital extension Orbital preservation surgery in select patients with involvement of the bony orbit but not soft tissue does not appear to result in poorer survival or local control than those undergoing exenteration.
  25. 25.   Inferior medial maxillectomy Medial maxillectomy   Cranio-facial resection Radical maxillectomy with excentration
  26. 26. Indications for orbital exenteration:      Involvement of the orbital apex Involvement of the extraocular muscles Involvement of the bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through the periorbita into the retrobulbar fat
  27. 27.  Reconstruction after surgery: Surgery for sinonasal cancers leaves major defects in the skull and needs to be reconstructed. Advances in tissue transfer techniques (particularly microvascular free flaps) provide reconstructive options in addition to maxillofacial prostheses.
  28. 28. Types (Stages) of obturator prostheses: (I) Immediate (surgical) obturator prostheses: • • • • initiated at the time of surgery fabricated on a cast obtained from an impression made at the time of the pretreatment dental examination. fabricated using autopolymerizing acrylic resin (methyl methacrylate) ligated into position following tumor resection but before flap closure. (II) Transitional obturator prosthesis: • a minimum of 7 to 10 days after surgery. (III) Definitive (permanent) obturator prosthesis: • begin once adequate healing has occurred, and radiation therapy is completed (usually after three to four months).
  29. 29. Radiotherapy:   Addition of Rtx. to surgery improve 5-years survival (44%) when compared to RTx. alone (23%) or surgery alone. Indications: • •   Adjuvant (standard of care). Definitive: medically inoperable or who refuse radical surgery pre- and postoperative radiation may result in similar control rates. But post-operative RTx preffered: • • Preoperative radiation increases the infection rate and the risk of postoperative wound complications. Preoperative radiation may obscure the initial extent of disease=surgery can not remove the microscopic extensions of the tumor.  Postoperative radiation therapy is started 4 to 6 weeks after surgery.
  30. 30. Indications of elective nodal irradiation:   Not routinely recommended in nasal cavity nor ethmoid sinus tumors. In maxillary tumors: include ipsilateral submandibular and subdigasteric nodes in: Squamous cell carc. • Poor differ carc. • T4 lesions. ‫ــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬ • N.B. The neck is irradiated after neck dissection for nodal involvement at presentation according to the usual guidelines for postoperative neck irradiation in other head & neck cancers.
  31. 31. Target & Dose for 3D-CRTx. (I) Definitive RTx:  Recommend 3D-CRT or IMRT planning to increase sparing of normal structures.  GTV = clinical and/or radiographic gross disease.  CTV1 = 1 cm margin on primary and/or nodal GTV= 66-70 Gy; (1.8-2Gy/Fx.) CTV2 = high-risk regions (depending on the presence or absence of anatomic boundaries to microscopic spread)= 60-63 Gy. CTV3 = elective neck= 54-57 Gy  
  32. 32. (II) Post-operative RTx :  A typical target volume in a postoperative setting encompasses: 60-66 Gy • Both halves of the nasal cavity. • Ipsilateral maxillary sinus. • If the tumor extends superiorly into the ethmoid air cells: Ethmoid sinuses and the ipsilateral medial orbital wall are included • bony orbit after orbital exenteration
  33. 33.  Field Margins: a three-field technique for maxillary antrum: 1 anterior and 2 lateral fields. Anterior field: superior border: above the crista galli to encompass the ethmoids. in the absence of orbital invasion, at the lower edge of the cornea to cover the orbital floor. inferior border: 1 cm below the floor of the sinus. medial border: 1 to 2 cm (or more if necessary) across the midline to cover contralateral ethmoidal extension. lateral border: 1 cm beyond the apex of the sinus or falling off the skin. Lateral fields: superior border: follows the floor of the anterior cranial fossa. anterior border: behind the lateral bony canthus parallel to the slope of the face. posterior border: covers the pterygoid plates.
  34. 34. Simulation films of wedged-pair setup for a limited lesion involving the maxillary antrum only. The treatment volume includes the ipsilateral maxillary sinus and the nasal cavity. A, Anterior portal. B, Lateral portal.
  35. 35. OAR & possible complications of RTx.    Lens <10 Gy (cataracts). Lacrimal gland <30–40 Gy. (dry eye syndrome) Retina <45 Gy (blindness). incidence of visual loss with Rtx. 12-20% unilateral, 0-8% bilateral.      Optic chiasm and nerves <54 Gy at standard fractionation. (Optic neuropathy) Brain <60 Gy (necrosis). Mandible <60 Gy (osteoradionecrosis). Parotid mean dose <26 Gy (xerostomia). Pituitary and hypothalamus mean dose <40 Gy.
  36. 36. Measures to protect the eye during treatment planning for RTx.  Using advanced techniques; 3D-CRT, IMRT. can provide bilateral sparing of the globe for most patients, it may be more difficult to spare optic nerves, especially on the ipsilateral side,      Good fixation by immobilization devices. Using nonaxial and noncoplanar fields. The contralateral eye is blocked, and greater than two thirds of the ipsilateral eye are also blocked unless there is intraorbital infiltration. With the four-field technique (with interorbital electron portal) the eyes are blocked from the anterior and lateral photon portals. With the three-field technique, the anterior border of the lateral portal is placed at the bony canthus and the anterior portal is weighted more heavily (2 : 1 to 3 : 1).
  37. 37. Role of IMRT in sinonasal cancers   The dose delivered to the optic pathways can be selectively reduced by IMRT, which has the potential to preserve binocular vision, particularly for patients who have extensive and large-volume disease in the paranasal sinuses. In a longitudinal analysis of 127 patients treated with radiation therapy from 1960 to 2005 at the University of California, San Francisco, the incidence of grade 3 or greater late ocular toxicity among patients treated with 3D-CRT=9% and in IMRT=0%.
  38. 38.  IMRT isodose plans of a patient with locally advanced paranasal sinus undergoing definitive radiotherapy.     A: At the level of the maxillary sinuses/parotid glands; B: at the level of the floor of the orbit/brainstem; C: at the level of ethmoid sinuses/mid-orbit. The bilateral eyes are nicely spared (<45 Gy isodose region) as are the brainstem (<45 Gy isodose region) and the parotid glands (<30 Gy isodose region).
  39. 39. Other RTx. Modalities:   Stereotactic Radiosurgery: could be ued for a boost for gross residual disease in patients who have small residual tumor volume at the skull base Proton Beam Radiation: for deep-seated locations requiring high doses of radiation, but no high level evidence for its use.
  40. 40. Role of Brachytherapy      For small lesions of nasal vestibule. using a192 Ir wire implant or intracavitary192 Ir mold. The recommended doses for low-dose-rate brachytherapy range from 60 to 65 Gy delivered during 5 to 7 days. In patients with T1 or T2 a boost of 20 to 25 Gy (LDR) over 2 days or 18 Gy (HDR; 3 Gy twice daily), following EBRTx. after 50 Gy, if there is good reduction of tumor volume. This technique has been reported as yielding a 2-year local control of 86%.
  41. 41. Role of chemotherapy   Neoadjuvant chemotherapy is sometimes offered in order to reduce tumor volume, which may permit removal of tumor with a less morbid resection or facilitate radiotherapy planning if shrinkage pulls away tumor from critical structures. chemotherapy may be given concurrent with radiotherapy in the management of inoperable tumors on the basis of improved results in more frequent head and neck carcinomas.
  42. 42. Follow-up  H&P, labs, and CXR: • • • •  every 3 months for frst year, every 4 months for second year, every 6 months for third year, then annually. Imaging of the H&N: 3 months post-treatment, then as indicated.
  43. 43. Inverted papillomas       47% of Schneiderian papillomas which derived from schneiderian mucosa (squamous) are inverting papillomas. men, 6th-7th decades, unilateral. lateral nasal wall. Recurrence up to 80%. malignant potential; associated with SCC in 2-13%. Management: • The gold standard was lateral rhinotomy with medial maxillectomy. • Role of RTx.    absolute indication for radiation therapy is when an inverted papilloma is associated with squamous cell carcinoma. those who had advanced incompletely resected or unresectable lesions that are biologically aggressive. patients where morbidity in resection would be more pronounced that morbidity of tumor radiation.

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