Treatment of Ca Maxilla

1. TREATMENT OF CA MAXILLA
Presenter:- Aaditya Sinha
M.Sc Radiotherapy Technology

2. MAXILLARY SINUS
The maxillary sinus is one of the four paranasal sinuses, which
are located near the nose. The maxillary sinus is the largest of
the paranasal sinuses. The two maxillary sinuses are located
below the cheeks, above the teeth and on the sides of the nose.
Function: Decreasing the relative weight of the front of the skull,
and especially the bones of the face. Increasing resonance of
the voice.

3. ANATOMY
The maxillary sinuses are shaped like a pyramid and each contain three
cavities, which point sideways, inwards, and downwards. The sinuses are
small air-filled holes found in the bones of the face.
They reduce skull weight, produce mucus, and affect the tone quality of a
person's voice.

4. Symptoms of Ca Maxilla
In the early stages of the disease, symptoms may be
totally absent. Another practical problem that makes
an early detection difficult is that, symptoms if present
are not specific.
• Headaches
• Pain in the sinus areas on either sides of the nose
• Runny nose
• Nosebleeds
• Lump or sore inside the nose that does not heal
• Numbness of cheeks
• Pain in the upper teeth
• Loose teeth
• Dentures that no longer fit well
• Swelling or other difficulties with the eyes

5. Risk Factors
The following conditions may predispose a person to increased risk of
developing a maxillary sinus cancer. Exposure to certain workplace chemicals
or dust
• Work in Furniture-making
• Carpentry
• Shoemaking
• Metal-plating
• Flour mill or bakery work
• Age more than 40 years
• Smoking; Tobacco use
• Chronic sinusitis

6. Modes of Investigations
1.HISTORY & Physical exam
2. X-ray
3. Chest imaging
4. CT
5. MRI
6. Endoscopy
7. PET scan
8. Bone Scans

7. AJCC –STAGING SYSTEM

8. MANAGEMENT
• Surgery
• Radiotherapy
- definitive
- pre op RT
- post op RT
• Combined modality ( Sx + RT)
• Chemotherapy

9. RADIOTHERAPY
 Addition of RT to surgery improve 5-years survival (44%) when
compared to RT alone (23%) or surgery alone.
 Indications:
 Definitive : medically inoperable or who refuse radical surgery or
early lesions.
 Pre- and postoperative radiation may result in similar control
rates, but post-operative RT preferred:
 Preoperative radiation increases the infection rate and the risk of
postoperative wound complications.
 It may obscure the initial extent of disease or surgery can not
remove the microscopic extensions of the tumor.
• Postoperative radiation therapy is started 4 to 6 weeks after
surgery.

10. RADIOTHERAPY TECNIQUES
1. CONVENTIONAL
2. 3D- CRT
3. IMRT

11. Setup & field arrangement
• Supine position
• Immobilization
• Mouth bite
• Planning
- maxilla
- adj. nasal cavity
- ethmoid sinuses
- Techniques:
- Anterolateral wedge pair
tech
- 3 field tech

12. • 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.
lateral border: 1 cm beyond the apex of the sinus or falling off the skin.
Lateral fields:
superior border: follows the floor of anterior cranial fossa.
anterior border: behind the lat canthus parallel to the slope of face.
posterior border: covers the pterygoid plates.

13. CONVENTIONAL: 3 field technique
Patient lies in a supine cast
with the head in neutral position.
Tongue bite is used to depress
tongue & lower alveolus away
from the target volume.

14. Ant. field Lat. Field

15. RT Dose
• Dose prescribed at depth of 5 cm
• EBRT dose
- Pre operative : 45-50 Gy over 5 wks
- Post operative : 55-60 Gy over 5.5 – 6 wks

16. 3D-CRT
3 Field tech is used:
1. Anterior 2. two lateral portal
*Electron beam may be used for boost purpose.

17. • Initial target volume – Post op. RT
- Sx bed + 1-2 cm margin
- Boost volume – areas at high risk for recurrence
• Advantage
- spare retina & optic nerve
- Post op dose of 66 Gy can be delivered

18. TARGET VOLUME DELINEATION
The CTV should encompass
• all initial sites of disease(presurgery GTV),
• The mucosa of adjacent compartments of the sinonasal
complex and a 10 mm margin at least from initial sites of GTV
where no good bony barrier to invasion exists (e.g. masticator
space, cribriform plate and infraorbital fissure)
For most tumors, the CTV will include the ipsilateral maxillary
sinus and bilateral nasal cavity and the ethmoid sinuses.
The CTV is expanded isotropically (usually by 3–5 mm)to form
the PTV

19. ORGAN AT RISK
1. Eye Lenses
2. Lacrimal glands
3. Optic nerves and chiasm
4. Spinal cord
5. Brainstem and
6. Pituitary gland

20. OAR & Possible Complications of RT
• Lens <10 Gy (cataracts) during the total dose delivery of 60 Gy.
• Lacrimal gland <30–40 Gy (dry eye syndrome)
• Retina <45 Gy (blindness)
• Optic chiasm and nerves <54 Gy at standard fractionation. (Optic
neuropathy)- It is the damage to optic nerve by an external factor
by damaging it neurons leads to loss of vision, with washed out
color visibilty.
• Brain <60 Gy (necrosis)
• Mandible <60 Gy (osteoradionecrosis)-Bone death due to
radiation, bone dies because radiation damages its blood vessels.
It’s a late effect.
• Parotid mean dose <26 Gy (xerostomia) – Unusual dry mouth
basically from medicines.
• Pituitary and hypothalamus mean dose <40 Gy.

21. IMRT
A non-coplanar arrangement
of three to five sagittal midline
beams with right and left
lateral beams avoids entry or exit of
beams through the eyes and
provides a uniform dose distribution
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

22. Complications of RT
Acute:
mucositis, skin erythema, nasal dryness, Xerostomia.
Late:
xerostomia, chronic keratitis and iritis, optic pathway injury
,cataracts, & radiation induced hypopituitarism.

23. Dose fractionation (D/Fx)
Definitive RT: 70Gy , 2 Gy/# over 7 wks
Adjuvant
60 Gy in 30 daily fractions given in 6 weeks.
66 Gy in 33 daily fractions if possible where there is residual
disease.
Palliative
36 Gy in 6 fractions of 6 Gy treating once weekly.

24. Treatment delivery and patient care
Patients are seen weekly during treatment :
• Exercises to reduce trismus
• Prophylactic feeding tubes should be considered
• Ophthalmic review .
• Lubricating eye ointments.
• If there is a pre-existing facial nerve palsy, the eyelid should
be taped shut at night to avoid a dry eye.
• Pituitary function tests should be carried out annually during
follow-up to evaluate late RT effects to the pituitary gland.

25. CONCLUSION:
• Radiotherapy is a best treatment for Ca maxilla.
• Uniform dose distribution can achieve by RT(3D-CRT & IMRT).
• Minimize dose to the critical organs.
• Minimize set up errors by using immobilization devices.
• During the treatment eyes should be faced toward the gantry.
• Patient specific Q.A. should be done before the IMRT treatment.

26. THANK YOU