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.
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
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
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
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
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
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