Tumours of nasal cavity & paranasal sinuses

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classification, diagnosis , staging & management of sinonasal tumors

classification, diagnosis , staging & management of sinonasal tumors

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  • 1. Tumors ofnasal cavity & paranasal sinuses ByDr, Ibrahim Habib (M.D) ENT consultant
  • 2. ‫بسم هللا الرحمن الرحيم‬
  • 3. ‫{ أقم الصالة لدلوك الشمس إلى غسق الليل وقرآن الفجر إن قرآن الفجر كان مشهودا }‬ ‫اإلسراء : 87‬
  • 4. IntroductionCancers of nose & PNS : 3% of Head & Neck cancers .Age : 5th up to 7th decade .Predominately of older males .Exposure:Wood, nickel-refining processesIndustrial fumes, leather tanningCigarette and Alcohol consumption:No significant association has been shown
  • 5. location 3%1% 20% 70%
  • 6. • Floor : palatine process of maxilla• Roof : cribriform plate .
  • 7. Anatomy of maxillary antrumAnterior : soft tissue of face .Posterolateral : ITF , pterygopalatine FSuperior : Inferior orbital plate .Inferiorly : hard palate , superior alveolar ridge
  • 8. Anatomy of ethmoid sinusesAnterior : lacrimal bone .Medialy : lateral nasal wall.Superior : Fovea ethmoidalis .
  • 9. Anatomy of sphenoid sinus Anteriorly : nasal cavity , ethmoid . Posteriorly : clivus , brainstem . Superiorly : pituitary fossa . Laterally : cavernous sinuses & optic N .
  • 10. Anatomy of frontal sinusAnteriorly :soft tissue of forehead .Inferiorly :orbit .Posteriorly :anterior cranial fossa .
  • 11. 1- frontal sinus2- ant. Ethmoid sinus3- infundibulum4- middle. Ethmoidsinus5- post. Ethmoid sinus6- middle concha7- sphenoid sinus8- inf. concha9- hard palate
  • 12. Drainage of PNSMaxillary sinus : middle meatusEthmoid sinuses “ anterior “ : middle meatus .Ethmoid sinuses “ posterior “ : sphenoethmoid recess .Sphenoid sinus : sphenoethmoid recess .Frontal sinus : frontonasal duct .
  • 13. Classification of sinonasal tumors
  • 14. Benign ( epithelial ) Benign ( non Malignant Malignant (nonsinonasal tumors epithelial ) sinonasal (epithelial ) epithelial ) sinonasal tumours sinonasal tumours tumours- Schneiderian papilloma : Leiomyoma - squamous cell - chondrosarcoma .inverted . chondromyxoid fibroma carcinoma : - Rabdomyosarcoma Papillary ( septal ). Differentiated . .Cylinderical Basaloid squamous . - Squamous papilloma ( Adeosquamousnasal vestibule )- Adenoma . Adenocarcinoma . - lymphoproliferative- Dermoid Adenoid cystic . Lymphoma Mucoepidermoid Midline malignant reticulosis Plasmacytoma - Terato carcinosarcoma- Lobular capillary Neuroendocrine Hemangiopercytomahemangioma . carcinoma . Angiosarcoma- Hemangiopericytoma . Hyallinizing clear cell kaposi’sarcoma- peripheral nerve sheath carcinomatumors- Fibrous histocytoma . myxoma , fibromyxoma. - Melanoma . Fibrosarcoma- fibroma . ameloblastoma - olfactory neuroblstoma Osteogenic sarcoma- osteoma . . Malignant fibrous- fibrosseus lesios . - sinonasal Histocytoma undifferentiated carcinoma (SNUC)N.B. Secondary malignancy – Melanoma ,Thyroid , lung , kidney and G I T
  • 15. Squamous Cell Carcinoma• Most common sinonasalmalignancy• 70% arise in antrum• 30% arise in nasal cavity• 15% with synchronus ormetachronus lesion• Pre or co-existing papilloma isrisk factor• 4-9%• Look for necrosis on imagingN.B. Squamous Cell Carcinoma in Inverted Papilloma
  • 16. Adenocarcinoma• 13-19% of SNmalignancies• Arise from surfaceepithelium andseromucinous glands• Intestinal, salivary,neuroendocrine types• Non-specific imagingfeatures• Predilection forethmoid sinuses
  • 17. Adenoid Cystic Ca• <10% of SN malignancies• 25% of adenocarcinomas• Glandular origin• Perineural growth pattern (60%)• Neural cell adhesion molecule(NCAM) in 93%• Small lesions extend beyondwhat is apparent• Difficult to entirely remove• Late recurrences and mets
  • 18. Sinonasal Melanoma• < 4% of SN neoplasms• Melanocytes in mucosa• Prefers nasal cavity• Epistaxis• Worse prognosis thancutaneous types• High recurrence andmortality rates
  • 19. Esthesioneuroblastoma• Originate from olfactoryepithelium• Two incidence peaks• Adolescence• 50 - 60 years• Epistaxis• High survival withmultimodality therapy• Ca++ and peripheral cysts
  • 20. Sinonasal Undifferentiated Ca (SNUC)• Separate entity from SCCa,ENB, and others• Rare, high-grade malignancy• 2-3:1 male predominance• Broad age range from 3rd to9th decades• Characterized by aggressivelocal growth, regional anddistant mets, and poorsurvival
  • 21. Sinonasal Lymphoma• 44% of extranodallymphomas arise in SN• Prefers nasal cavity• Types• T-cell (Asian)• B-cell (US, Europe)• T/NK-cell (LMG)• Remodeling or erosion• Homogeneous enhancement
  • 22. Sarcomas and Other Malignancies• Sarcomas• Rhabdomyosarcoma• Liposarcoma• Leiomyosarcoma• Fibrosarcoma• Chondrosarcoma• Osteosarcoma• Plasmacytoma• Metastases
  • 23. symptomsEarly : asymptomatic .Oral symptoms: 25-35%, Toothache , trismus, alveolar ridge fullness, erosion ,malocclosion .Nasal findings: 50%Obstruction, epistaxis, rhinorrhea , post nasal discharge , anosmia .Ocular findings: 25%Epiphora, diplopia, proptosisFacial signsParesthesias, asymmetry
  • 24. Physical examinationNasal mass or polyposis .Mass in the check or medical canthus .Broadening of nasal dorsum .Maxillary sinus involvement : Mass in palate or upper alveolus . Mass in upper gingivobuccal sulcus . Malocclusion or loose teeth .Advanced : Trismus .Orbital :Periorbital swelling , proptosis .Epiphora , impaired occular mobilityUncommon : Neck mass
  • 25. Nasal endoscopy that shows a tumor in the left nasal wall
  • 26. InvestigationsAim : detect the disease & its extention .Extention : orbit , skull base , dura , Intracranial , greatvessels .Presence of regional or distant metastasis
  • 27. Presentation of tumours of nose & PNS Nasal mass or polyposis )mass in check )
  • 28. Broadening of nasal dorsum , proptosis , restricted occular mobility
  • 29. C T scan- Ideal- surrounding bone erosion or destruction .Tum : - ourCalification .Soft tissue denistyNecrosis or hgeVascular tum : enhancem ors ent increase with contrastEntrapped secretion : with low density Lym node : regional L.N. , ( retropharyngeal ) L.N. ph. Staging• Guide biopsy and surgery• Treatm responseDistant m ent etastasis .
  • 30. Coronal section of nose & PNS shows soft tissue mass in region of Rt ethmoid air cellpushing septum to other side with bony erosion of septum and fovea ethmoidalis )B)
  • 31. CT Scan, of paranasal sinus, that shows the tumor( angiosarcoma ) in the left nasal cavity
  • 32. MRIAdvantages :- excellent delineation of tumour fromsurrounding inflammatory soft tissue andretained secretions.- obtained in multiple planes .- no exposure to ionizing radiation .- no artifact in the presence of dental filling .
  • 33. Figures 1 and 2: MR shows a 3.0 x 4.0-cm mass arising from the mucosa of the rightethmoid region with some areas of necrosis; the surrounding bony structure is intact but its growth expands nasal septum and lamina papiracea -
  • 34. Tumour secretion inflammationT1 Intermediate signal No enhancement Low signalT1 with contrast Diffuse enhancement No enhancement Low signalT2 Intermediate signal High signal High signalN.B. flow void --- vascular lesion .With contrast -- perineural invasion, dural or intracranial involvementsL.N. -- Heterogenous on T2 , > 1 cm , peripheral enhancement with contrast using fatsuppresion
  • 35. AngiographyIndications :1- Evaluations of vascular tumours extention , vascular anatomy ,selective embolization .2- Skull base surgery with brain retraction , delineate intracranialarterial and venous anatomy .3- tumour encroaching on carotid a. , assess collaterals , may beused with balloon occlusion testing .
  • 36. P.E.T.- Agent : 18 – F flurodeoxy glucose . C – 11 methionine .- Principle : image metabolic activity of head & neck . Tumors including nose& PNSAssess : Local , regional or systemic metastasis . -. Direct biopsy -• Therapy response• Recurrence vs.treatment change• Re-staging- Result : inferior to C.T. & MRI .
  • 37. BiopsyAim : confirm diagnosis & plan appropriate ttt.Route : 1- transnasl . 2- transoral . 3- direct access to the sinus :Maxillary sinus : Transnasal , medial wall ofmaxillary sinus . Caldwell – Luc . Procedure .Ethmoid sinuses : Endoscopic ethmoidectomy - External ethmoidectomy .Sphenoid sinus : endoscopically Trans – septallyFrontal sinus : its floor .
  • 38. Staging of sinonasal tumours
  • 39. Ohngern 1933 staged maxillary Ohngern 1933 staged maxillary sinus cancers (Infrastructure ) sinus cancers(Suprastructure)Site Infrastructure to Ohngern line Suprastructure to Ohngern lineSymptoms Early LateSpread Oral , nasal , I.T.F Pterygomaxillary fossa , middle & anterior cranial fossaTreatment More amenable to surgical resection Less amenable to surgical resectionprognosis Good BadOhngern line : an imaginary line drawn from maxillary tuberosity to inner canthus .Ohngern 1933 staged maxillary sinus cancers
  • 40. Staging of non maxillary sinonasal malignanciesStage I : tumor confined to site of origin .Stage II : spread to adjacent sinuses , skin , nasopharynx ,ptergomaxillary fossa , and or orbit .Stage III : involvement of skull base , pterygoid plate andor intracranial extension .
  • 41. Staging system for olfactory neuroblastomaStage I : confined to primary site .Stage II : presence of nodal metastasis .Stage III : presence of distant metastasis .
  • 42. AJCC staging for PNS primary tumor ( T ) of maxillary sinus- Tx primary T can’t be assessed .- To : no evidence of primary T.- Tis : carcinoma in situ .- T1 : T limited to antral mucosa with no erosion nordestruction of bone .- T2 Tumour causing erosion or destruction except forposterior antral wall , including extention into m.m. ofhard palate and / or middle nasal meatus .
  • 43. AJCC staging for PNS primary tumor ( T ) of maxillary sinus- T3 Tumour invade any of the following : bone of posterior wall ofmaxillary sinus , subcutaneous tissue , skin of check , floor ormedial wall of orbit , I.T.F. , pterygoid plates , ethmoid sinuses .- T4a (resectable): anterior orbit,skin, infratemporal fossa, pterygoidplates, cribriform plate, frontal orsphenoid sinuses- T4b (unresectable): orbital apex,dura, brain, middle fossa, clivus,nasopharynx, CNs (other than V2)-
  • 44. Staging of ethmoid sinus- T1 tumour confined to the ethmoid with or without boneerosion .- T2 Tumour extends into nasal cavity .- T3 Tumour extends into ant. Orbit and / or maxillarysinus .- T4 Tumour with intracranial extension , orbitalextension including apex , involving sphenoid and / orfrontal sinus and / or skin of external nose .
  • 45. Nodal involvement in sinonasal tumours. Nodal involvement infrequent despite advanced stage• Depends on primary site, extent, and histology• 8-18% with nodes at presentaion. Nodal stage based on: N1: Single ipsilat ≤ 3cm • N2:• Number • a: Single ipsilat 3 – 6cm• Uni- or bilateral • b: Multiple ipsilat ≤• Size 6cm-Nodal drainage • c: Bilat or contralat ≤• Facial, parotid, submandibular 6cm• Retropharyngeal • N3: ≥ 6cm node• Then L II
  • 46. staging- stage o Tis No Mo- stage I T1 No Mo- stage II T2 No Mo- stage III T3 No Mo- T1-T3 N1 Mo- stage IV A T4 No Mo T4 N1 Mo- stage IV B any T N2 Mo any T N2 Mo- stage IV c any T any N M1( N ) lymph node . ( M ) distant metastasis .
  • 47. TNM Staging of Maxillary Carcinomas• Stage I: Limited to mucosa• Stage II: Bone involvement(NOT posterior wall)• Stage III:• T3 lesion• TI or T2 lesions with N1• Stage IV• T4 lesion• Any T with N2/N3 or M1
  • 48. Management of sinonasal tumours
  • 49. Surgical management Indication Surgical management Indication of early primary of lesion Advanced primary lesionInfrastructure lesions confined to Radical maxillectomy advanced lesionsmaxillectomy floor of maxillary sinus confined to maxillary . sinus advanced lesions confined to maxillary sinusMedial maxillectomy lesions confined to Craniofacial resection extension of disease medial wall of into the frontal maxillary sinus sinuses and / or cribriform platePartial or complete lesions confined to Palliative disease is extendedseptectomy septum radiotherapy into brain , sphenoid rostrum , cavernous sinus & internal carotid a
  • 50. Midfacial degloving approach.. Surgical Treatment of Squamous Cell Carcinoma of the Sinuses.
  • 51. Combined bicoronal approach and Dieffenbach-Weber-Fergusson incision. Surgical Treatment of Squamous Cell Carcinoma of the Sinuses..
  • 52. Management of orbit Indication Orbital complications N.B.in sinonasal tumors where R.T.Resection of a small cases with minimal epiphora , keratitis , complications withportion of the periorbital diplopia , pain , pre-operative R.T. areperiorbita & involvement without exophthalmos , and mostly minor andreconstruct with full penetration into loss of vision . transient .fascial graft the orbital fat .Resection of orbit with invasion of the complications are periorbita , the more frequent when infraorbital nerve , or post operative R.T. is the orbital apex used
  • 53. Reconstruction and Prosthetic Rehabilitation- Aim : - prevent contracture of the check , to separateoral & nasal cavities , and to provide support for theglobe .- An obturator should be made preoperatively from animpression of the hard palate .
  • 54. . Algorithm to depict tissue options for midface reconstruction
  • 55. Treatment of maxillary sinus carcinoma(A) 66-year-old woman with total maxillectomy defectand orocutaneous fistula status after surgery and radiotherapy. (B) Cranial bone grafts used to reconstruct orbitozygomatic structure surrounded by rectus abdominus free flap. (C) 3-year postoperative result. (D) Intraoral view of 3-year postoperative result.
  • 56. Management of tumours of nose & PNS (1) The NeckNo :T1 – T2 :electve ND is not generally performed.T3 – T4 :R.T. post. Operative . Upper neck & retro-ph. L.Ns .N+ve with resectable 1ry :MRND . Or dissect 1-V & retropharyngeal chain .
  • 57. Management of tumours of nose & PNS (1) The Neck )late node metastasis)- 5 – 45% occure after 2-3 yrs .- rarely occurs in absence of synchronous local or distantrecurrence you should search for .- TTT aggressively : R.N.D.- 5 yr survival rate was 39% after ttt of delayed metastasis.- N.B. None with nodes at presentation survived 3 years .
  • 58. Radiotherapy as an adjuvant therapy in management of sinonasal tumours- 1- combined with surgery in advanced resectablelesions . Pre. Or post. Operative .- 2- Single modality for :- advanced unresectable lesions .- patients unwilling or unable to undergo surgery .- Average 5 yrs survival rates 10 – 15 % ( total doses up to 79 Gy ) .
  • 59. chemotherapy as an adjuvant therapy in management of sinonasal tumours- Combination chemotherapy with pre. Or post.Operative R.T. in :- Olfactory neuroblastoma & SN undifferentiated ca.- Japanese researchers use combination of R.T. , intra-arterial 5 – fluorouracil ( 5 FU ) and local debridementor cryosurgery for maxillary sinus cancer .
  • 60. - Knegt ‘s regimen in using topical chemotherapy as an adjuvant Therapy in management of sinonasal tumours.The regimen1-antrostomy and debulking of the tumour . 2-The tumour bed is then packed with topical 5FUemulsion .3- The pack are removed and any residual necroticmaterial is debrided as often as necessary . He reported 5-yr survival of 71% .
  • 61. prognosisThe advancement of skull base surgery , cure rates forpatients with sinonasal tumours ,form 39-76% have been achieved
  • 62. Tumours have good chance of cure :1- early maxillary tumours .2- patients with nasal cavity tumours .3- well differentiated adenocarcinoma 90% .4- low grade minor salivary gland tumour .5- olfactory neuroblastoma : 100% stage A & 75% stage B & 60% stage C . Survival .6- sq. cell ca. arising in inverted papilloma .
  • 63. Tumours with bad prognosis1- Advanced maxillary cancer .2- lesions involving pterygoid plates orpterygopalatine fossa .3- lesions involving brain , dura , nasopharynx ,sphenoid .4- lesions involving orbital contents .