Case Presentation: Carcinoma Maxilla

Case Presentation -Abish Adhikari, Resident, Department of Radiotherapy & Oncology, Bir Hospital, Kathmandu Speciality Posting: ENT 1

Mrs Tamang.53/FHousewifeMakwanpurPresentation:ENT OPDComplaints:Pain in the Rightcheek area ~ 7monthsSwelling of the Rightcheek ~ 6 months 2

History of Present Illness● Pain was insidious onset, moderate in intensity, slowly progressive, dull aching type, and aggravated on chewing.● Took local practitioners consultation, was prescribed analgesics.● She then noticed swelling in her cheek, slowly growing in size reaching the current size in months.● She had loosening of teeth on right upper jaw.● She has history of on and off headache, and weight loss.● No fever, No nasal bleed, No recurrent runny nose, No 3 blurring of vision, diplopia.

Past History● No history of any surgical intervensions of oral cavity in the past.● No history of Chronic diseases like Diabetes or Hypertension.● No history of recurrent epistaxis. 4

Personal History● Smoker. Filtered Cigarettes. ~10 cigarettes per day since the age of 13. ~20 Pack Years.● Doesnt chew tobacco.● Regularly consumes Jad. ~300 ml per day.● Farmer by occupation.● Has not worked in industrial area. 5

Examination● General Condition: Fair● Performance Status (ECOG): 0● No icterus, No pallor, No clubbing, No cyanosis● Pulse: 80 bpm, regular● Blood Pressure: 130/90 mm Hg● Respiratory Rate: 20 per minute, regular● JVP : Not raised 6

Examination● Chest: Decreased air entry in the Right upper zone with few coarse crepts.● CVS: Normal heart sounds, no murmurs audible● Abdomen: No distension, No organomegaly● Vision : Normal eye movements and vision. 7

Local Examination Palpation:Inspection: *6 x 8 cm smooth*Visible fullness of surfaced, hard massthe right cheek extending from theextending upto the zygomatic bone,angle of mouth. occluding it to the angle of the mouth.*Skin color normal *Altered sensations on*Nasolabial groove the right cheek.obliterated. *No blunting of* Nasofacial groove Infraorbital ridge.is normal *Rest of the sinuses, non tender. * 2x2 cm Rt. Level II 8LN 1x1 cm Rt Level I b

Oral Examination●Mouth opening Normal●The arch of hard palatebulging on the Right side.●A smooth mass 3 x 6 cm onthe Right upper Gingivo-Labial Sulcus,extending fromthe Canine to the 2nd Molar●Right upper premolar andthe three molars are mobileand tender.●The upper surface of the 9growth cant be felt.

● Anterior Rhinoscopy: Normal 10

Diagnosis● Provisional Diagnosis: ● Carcinoma Maxillary Sinus● Differential Diagnosis: ● Osteosarcoma of Maxilla ● Ameloblastoma ● Fungal Rhinosinusitis ● Bone Cysts from Maxilla ● Dentegerous Cysts 11

Investigations: Baseline● CBC: Normal● RFT: Normal● CXR: Normal● HIV/HBsAg/HCV : Negative 12

Investigations:Orthopantomogram 13

CT Scan 14

CT Reports● “Expansile lytic lesion involving the floor and the alveolar process of the Right maxilla also involving the sockets of molar and premolar.● Bone destruction and sunbrust apperance.● Soft tissue mass lesion measuring 5.0 x 4.4 x 4.5 cm with necrotic areas.● Part of adjacent hard palate and adjacent walls of maxilla is also involved.● Right angular vein over the surface of SOL. 18

HPE to be sent 19

Carcinoma Maxilla: Overview 20

Epidemiology● Incidence -0.5-1/100,000 per year -0.2-0.8% of all malignancies -3% of upper aerodigestive tract neoplsm● 5th-6th decade● White race● M:F=2:1 – 4:1 21

Environmental exposures● Adenocarcinoma -wood dust, leather dust● Squamous cell carcinoma -Aflatoxin, chromium, asbestos, nickel, mustard gas, polycyclic hydrocarbons.● Viral: HPV 22

Squamous cell carcinoma● Most common histological type● 70% maxillary sinus● Male predominance● 7th decade 23

Ohngrens line (1933):A line from medial canthus of the eye to theangle of the mandible● Anteroinferior/infrastructure: good prognosis● Superoposterior/suprastructure: poor prognosis, early extension (eye, skull base, pterygoids, and infratemporal fossa). 24

Patterns of tumour spread● Anteriorly: cheek, skin● Posteriorly: pterygopalatine fossa, infra temporal fossa, temporal bone middle cranial fossa● Medially: nasal cavity,NLD● Laterally: cheek, skin● Superiorly: orbit, ethmoid sinuses● Inferiorly: palate, buccal sulcus 25

Presentation● Nasal findings: 50% ● Obstruction, epistaxis, rhinorrhea, discharge,extension into nasal cavity● Oral symptoms: 25-35% ● Pain, trismus, alveolar ridge fullness, erosion● Ocular findings: 25% ● Epiphora, diplopia, proptosis● Facial signs: ● Paresthesias, facial asymmetry, cheek swelling● Auditory symptoms: hearing loss (OME)● Neurological: cranial nerve deficits II,III,IV.V1,V2,VI 26

Regional spread● 10% nodal disease: at presentation● 25-35% during course of disease.● Submandibular & jugulodigastric nodes: most common 27

Distant metastases● Rare at presentation● Grave signs● Poor prognosis● 18 %: adenocarcinoma● 10%: SCC● Common sites: Lungs, bone, brain, liver,skin 28

Staging 29

Survival vs Stage 32

How to Proceed· H&P including a complete head and neck exam; mirrorand fiberoptic examination as clinically indicated· Complete head and neck CT with contrast and/or MRI· Dental/prosthetic consultation as indicated· Chest imagingBiopsy:· Preferred route is transnasal.· Needle biopsy may be acceptable.· Avoid canine fossa puncture or Caldwell-Luc approach.Squamous cell carcinoma / AdenocarcinomaMinor salivary gland tumor / SarcomaProper TNM Staging.T status mainly radiological. Nodal status mainly clinical. 33

Stage I / II (T1-T2, N0) ● Surgical resection is the primary treatment. ● If margins are free (1.5-2cm), kept on regular follow-up without adjuvant therapy. ● If there is perineural invasion by the tumor, Adjuvant Radiotherapy is needed (±Chemo) ● If margins are positive, Re-surgery should be considered, after which, if margins come negative, RT only; if margins come positive, Chemo+RT is recommended. 34The role of Chemotherapy has a 2B evidence. Individual cohort study or low quality randomizedcontrolled trials.

T3-T4, N0● Surgical resection is the primary treatment.● If margins are free, RT to the primary & neck.● If margins are positive, Chemotherapy and RT to the primary and neck. 35

Node + Stage● Surgical excision with neck dissection is the recommended primary treatment.● Followed by RT to the primary site and neck if margins are negative and there is no extracapsular extension (of the node mets.)● If margins positive or extracapsular extension, Chemotherapy along with RT to primary and neck is added as adjuvant therapy. 36

Surgery Surgical approaches:  Endoscopic  Lateralrhinotomy  Transoral/transpalatal  Midfacial degloving  Weber-Fergusson  Combined craniofacial approach Extent of resection  Medial maxillectomy  Inferior maxillectomy  Total maxillectomy 37

Surgery Unresectable tumors:  Superior extension: frontal lobes  Lateral extension: cavernous sinus  Posterior extension: prevertebral fascia  Bilateral optic nerve involvement  Distant Metastasis 38

Radiation Techniques● Preferred interval between resection and RT ≤ 6 weeks● Conventional fractionation: 66-70 Gy (2.0 Gy/fraction Monday-Friday) in 7 weeks● Alteration can be done with 6 fractions/week accelerated; 66-70 Gy● Neck nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)● Intensity-Modulated Radiotherapy (IMRT) has been shown to be useful in reducing long-term toxicity by reducing the dose to salivary glands, temporal lobes, auditory structures, and optic structures. 39

Simulate supine with thermoplastic mask immobilization.● Tongue blade/cork to depress tongue out of fields.● Recommend 3DCRT or IMRT planning.● GTV = clinical and radiologic gross disease.● CTV = 1 cm margin on primary● Dose limitation is by Lens <10 Gy (cataracts, Retina <45 Gy (vision).● Parotid mean dose <26 Gy (xerostomia)● Brain <60 Gy (necrosis). Mandible <60 Gy (osteoradionecrosis).● Pituitary and hypothalamus mean dose <40 Gy. 41

Complications● Acute: mucositis, skin erythema, nasal dryness, xerostomia● Late: xerostomia, chronic keratitis and iritis, optic pathway injury, soft tissue or osteoradionecrosis, cataracts, radiation- induced hypopituitarism 43

Chemotherapy● Primary Systemic Therapy + concurrent RT● Cisplatin alone (preferred)● 5-FU/hydroxyurea● Cisplatin/paclitaxel● Cisplatin/infusional 5-FU● Carboplatin/infusional 5-FU● Carboplatin/paclitaxel Cetuximab 44 ●

RADPLATIntra-arterial Cisplatin with systemic neutralization by i.v.sodium thiosulphate and Concomitant Radiation Therapyfor Advanced Paranasal Sinus CA ● ADVANTAGES: – Allows very high cisplatin dose to be used – Minimizing adverse systemic effects. – Excellent locoregional control rates are achievable in patients with unresectable disease – Favorable side-effect profile when compared with conventional chemoradiation protocols 45

Maxillary Carcinoma: Flowchart 46 Clinical Radiation Oncology, Gunderson et.al

Followup● H&P, labs, and CXR every 3 months for first year,● Every 4 months for second year,● Every 6 months for third year, then annually.● Imaging of the H&N at 3 months post treatment, then as indicated 47

Thank You ! 48

Case Presentation: Carcinoma Maxilla

by Abish Adhikari

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