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Malinant Tumors of the Paranasal sinuses & skull base by D. Fliss
This document discusses malignant tumors of the paranasal sinuses and skull base. It covers: 1) Epidemiology, risk factors, histology, clinical presentation and staging of these tumors. 2) Preoperative evaluation including imaging, biopsy and the role of PET-CT in accurate staging. 3) Treatment approaches including surgery, radiation therapy and chemotherapy, both as single modalities and in combination. 4) Post-treatment outcomes and factors influencing survival. Management of the neck is also addressed.
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Malinant Tumors of the Paranasal sinuses & skull base by D. Fliss
- 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012 Malignant Tumors of the Paranasal Sinuses and Skull Base Dan M Fliss
- 2. Epidemiology • Incidence 1:200,000 (USA) • 3% of H&N malignancies • Male predominance 1.8:1 • Age: 55-69 years • Common histology: SCC (51%) • Common site: Nasal cavity (44%), 2012 maxillary sinus (36%) Turner et al. Head and Neck 2011
- 3. Risk Factors • Environmental/Occupational Aflatoxin, formaldehyde, chromium, nickel, mustard gas, polycyclic hydrocarbons, mesothorium (Thorotrast), wood dust (AdenoCa) • Smoking (SCC) • Smoked food 2012 • HPV 6,11,18 (inverted papilloma) Luce et al. Int J Cancer 1993 Katori et al. Eur J Surg Oncol 2005
- 4. Histology • Epithelial (70-80%) – SCC, verrucous ca, adenoCa, ACC, acinic cell ca, mucoepidermoid ca, SNUC • Neuroectodermal – Melanoma, ENB, Ewing sarcoma/PNET • Mesenchymal – MFH, fibrosarcoma, RMS, osteosarcoma, chondrosarcoma, angiosarcoma, hemangiopericytoma 2012 • Other – Lymphoma, plasmacytoma, metastasis (RCC #1)
- 5. Clinical Presentation • LATE • Nasal (50%) – Obstruction, bleeding, mass, sinusitis • Oral (25-30%) – Loose teeth, trismus, pain • Ocular (25%) – Proptosis, diplopia, epiphora • Facial – Distortion, anesthesia V2 2012 • Skull Base/Brain – Headache, CN palsy -> anosmia
- 6. Clinical Examination • Facial symmetry, sensation (V2) • Eye – Ocular motion, globe position, proptosis • Ear – Eustachian tube dysfunction, SOM • Oral – Trismus, ulcer/bulging, loose teeth • Nose - FO endoscopy 2012 • Neck – LN enlargement
- 7. Preoperative Evaluation • Endonasal endoscopy • CT- Axial, coronal, contrast, 3D • Bone erosion • MR - Contrast, fat suppression • Inflammatory vs. neoplastic • Angiography, balloon occlusion test, embolization • Biopsy 2012
- 8. Preoperative Evaluation PET-CT • TNM Staging • Residual disease • Recurrence • Second primary 2012 Gil and Fliss et al. Head and Neck 2007
- 9. Preoperative Evaluation PET-CT • PET/CT offers accurate staging for skull base neoplasms • Accurate preoperative staging can change treatment modality and prevents unnecessary procedures in patients with distant metastases • During follow-up PET/CT enables early detection of tumor recurrence, guides biopsies and allows selection of proper treatment 2012 Gil and Fliss et al. Head and Neck 2007
- 10. Staging Ohngren s Line 2012
- 11. AJCC TNM Staging2011 Maxillary Sinus 2012
- 12. AJCC TNM Staging2011 Ethmoid Sinus and Nasal Cavity 2012
- 13. AJCC TNM Staging2011 Neck and Distant Sites, Prognostic Groups 2012
- 14. Treatment • Surgery • XRT • Chemo • Combinations No RCTs available 2012
- 15.
- 16. Factors Influencing Treatment Choice • Histology • Stage • Resectability • Reconstruction • Surgical expertise/ multidisciplinary team • Comorbidity 2012
- 17. Management Radiation Tx Technology: • Stereotactic • Proton/Neutron • IMRT – Intensity-modulated radiotherapy enables to create concave dose distributions allowing better sparing of the optic structures without compromising the dose in the target volume and local control 2012 Duthoy et al. Cancer 2005
- 18. Radiation Tx Outcome • Most patients get XRT (64%) • Definitive XRT (single modality): – 5y local control 43% • Better as an adjuvant to surgery – 5y local control 84% – 5y overall survival 67% 2012 Mendenhall et al. Laryngoscope 2009 Hoppe et al. Radiat Oncol Biol Phys 2008
- 19. Radiation Tx Who Benefits from Adjuvant XRT ? T1-2 T3-4/N1 T4/M1 2012 Turner et al. Head and Neck 2011
- 20. Radiation Tx Side Effects • Risk for acute toxicity • Risk for blindness • Other chronic toxicity – Osteoradionecrosis – Frontal lobe necrosis – Panhypopituitarism 2012 Duthoy et al. Cancer 2005 Mendenhall et al. Laryngoscope 2009
- 21. Management Chemotherapy • Adjuvant chemotherapy Chemotherapy employed after the primary tumor has been removed by surgery • Neoadjuvant chemotherapy Initial use of chemotherapy in order to decrease the tumor burden prior to treatment by other modalities 2012
- 22. Management Chemotherapy Meta-analysis of chemotherapy in head and neck cancer - 93 RCTs and 17,346 patients 2012 Bourhis et al. Rad Oncol 2009
- 23. Chemotherapy in SinonasalCa Adjuvant Systemic • n=35, T4b unresectable tumors • Cisplatin + XRT -> No surgery • Poor outcome: 5y OS 15% Hope et al. Radiat Oncol Biol Phys 2008 • n=15, T3-T4 • Induction cisplatin+5FU -> Surgery -> 5FU+hydroxyurea + XRT • Good results: 10y DFS 65% 2012 Lee et al. Cancer J Sci Am 1999
- 24. Chemotherapy in SinonasalCa Preoperative Intra-arterial (1) • n=74, T2 T3 T4, maxillary sinus • Multimodality: Preoperative XRT 50 grey + IA 5FU • Then partial/total maxillectomy • Good results: 5y OS 53% 5ys 53% 2012 Hayashi et al. Cancer 2001
- 25. Chemotherapy in SinonasalCa Preoperative Intra-arterial (2) • Concomitant preoperative XRT 50 grey + IA cisplatin • Then CFR/ maxillectomy • n=19, T3 T4 • Good results: 5y OS 53% 5ys 53% 2012 Samant et al. Archives 2004
- 26. Surgery Approaches • Open – Lateral rhinotomy/ Combinations – Coronal – Midfacial degloving – Per-oral – Facial translocation – Subcranial /CFR – Orbitozygomatic • Endoscopic • Combined 2012
- 27. Surgery Skin Incisions 1. Lateral Rhinotomy 2. Weber-Fergusson 3. WF + Lynch 4. WF + Subciliary 5. WF + Subciliary + Supraciliary 2012
- 28. Surgery Type ofMaxillectomy 1. Medial maxillectomy 2. Infrastructure maxillectomy 3. Total maxillectomy +- Orbit 4. Extended maxillectomy 5. Bilateral 2012 maxillectomy 6. Subcranial / CFR
- 29. Surgery Reconstruction -Goals Function • Oral competency • Clarity of speech • Mastication • Tactile sensation • Globe support Cosmesis • Restoration of bony framework • Soft tissue contour 2012
- 30. Surgery Reconstruction –Soft Tissue • Free flaps – Rectus abdominis – Lateral thigh – Latissimus dorsi – Radial Forearm – Tensor fascia lata – Osteocutaneus Fibula • Temporalis muscle system • Fascia lata / temporalis fascia • Nasolabial flap 2012
- 31. Surgery Reconstruction –Bone • Obturator • Titanium mesh • Bone grafts – Calvarial – Iliac • Free flaps – Fibula – Scapula – Iliac crest • Septal 2012 cartilage
- 32. Maxillary Defect Type 1 Type 2 Type 3 Type 4 Prosthesis So@ Assue Free flap Prosthesis Orbital floor Prosthesis Atanium +-‐ coated 2012 Brown et al. Lancet Oncology 2010
- 33. Surgery Management of the Orbit 2012 Weizman, Fliss et al. Arch. Otol. (in press)
- 34. Surgery Reconstruction of theOrbit – Partial Resection 2012 Weizman, Fliss et al. Arch. Otol. (in press)
- 35. Surgery Reconstruction of theOrbit - Exenteration 2012 Weizman, Fliss et al. Arch. Otol. (in press)
- 36. Management of theNeck • n=704, malignant tumors, maxillary and ethmoid, T1-T4 • Low frequency of nodal involvement at diagnosis Ethmoid tumors: 1.6% , Maxillary tumors: 8.3% • Nodal status at baseline affects survival s • Risk for regional recurrence: High Risk Low Risk Site Maxillary (12.5%) Ethmoid (4.3%) T-Stage T2 (18%) Histology SCC (21%) 2012 ElecAve ND for T2+ Maxillary SCC Cantu et al. Archives 2008
- 37. Management of theNeck • Multicenter, n=146, oral (palate, alveolus) maxillary SCC, T2-T4 N0 • Frequency of nodal involvement at diagnosis: 15% • Overall rate of nodal involvement: • N0 managed by observation only: 14.8% regional 2012 failure (only 53% were salvaged) • N0 managed by neck dissection/XRT: n/a al. Head and Neck 2011 Montes et
- 38. Management of theNeck • n=139, oral maxillary SCC, T1-T4 • Frequency of nodal involvement at diagnosis: 8.6% • Regional failure among N0 patients: 29.5% (34%) were salvaged • Predictors of failure: T- stage 2012 Morris et al. Head and Neck 2011
- 39. Management of theNeck • A subgroup of high risk patients: Maxillary sinus, SCC/SNUC, T2-T4 • High regional failure rate: 36% • Reduced to 7% if ipsilateral 2012 neck is radiated Bristol et al. Int J Radiat Oncol Biol Phys 2007 Hoppe et al. Int J Radiat Oncol Biol Phys 2008
- 40. Outcome Factors Influencing Survival • Site Nose > maxillary > ethmoid • T stage T1 > T4 • Histology AdenoCa > SCC > SNUC • Subsite analysis – tumor extension associated with reduced survival: – Maxillary tumor: PPF 2012 – Ethmoid tumor: Cribriform, dura, brain, sphenoid – Nasal tumor: Nasal floor Dulguerov et al. Cancer 2001
- 41. Outcome Factors Influencing Survival Site Histology N+ / M+ Treatment DSS 2012 Dulguerov et al. Cancer 2001 Turner et al. Head and Neck 2011
- 42. Skull Base SurgeryDefinition • Skull base surgery is the interdisciplinary approach to lesions afflicting those areas of the deep facial structures that abut the undersurface of the cranium • Requires a multidisciplinary approach: – Head & Neck surgeon – Neurosurgeon – Plastic and Reconstructive surgeon – Maxillofacial surgeon – Neuroradiologist/interventional arteriographer – Neuro-ophthalmologist – Anesthetist 2012 – Pathologist
- 43.
- 44. Skull Base SurgeryIndications • Tumors approaching or involving the skull base • Intracranial tumors with extracranial extension • Neurovascular tumors 2012
- 45. Evolution of SBSurgery QOL Adjuvant therapy Minimally Invasive Surgery Evidence based medicine Aggressive approaches Learning of surgical skills 2012 1970 1980 1990 2000 2010
- 46. Evolution of SBSurgery The Future MulA center clinical trials Broader PopularizaAon indicaAons for of surgical endoscopic surgery techniques AdopAon of ? novel targeted Tx from other Narrowing New tools H&N cancers indicaAons for minimally trials for open surgery RoboAc surgery invasive surgery ? ? 2010 2020 2012
- 47. SBS Techniques Craniofacial Resection 2012 Ketcham et al. Am J Surg 1963
- 48. SBS Techniques TheSubcranial Approach 2012 Fliss et al. Laryngoscope 1999 Fliss et al. Operative Tech 2000
- 49. The Subcranial Approach Combinations • Subcranial with mid-facial degloving 2012 Fliss et al. J Oral Maxillofacial Surg. 2000 Fliss et al. Arch Otolaryngol Head Neck Surg 2007
- 50. The Subcranial Approach Combinations • Subcranial with pterional approach 2012 Fliss et al. Operative Tech 2000
- 51. The Subcranial Approach Reconstruction 2012 Fliss et al. Neurosurg Focus 2002 Fliss et al. Skull Base 2007 Gil and Fliss et al. Skull Base 2007
- 52. Reconstruction NFO Segment Wrapping 2012 Gil and Fliss. Plastics and Rec Surg 2005
- 53. Evidence Based Medicinein SBS 2012
- 54. Evidence Based Medicinein SBS Large Single Center Series Level 5 JC Irish et al Head & Neck 1994 n = 73 IP Janecka et al Otolaryngology Head &Neck Surgery 1994 n = 183 JP Shah et al Archives 1997 n= 115 V Lund et al Head & Neck 1998 n = 209 DM Fliss et al Laryngoscope 1999 n= 55 G Cantu et al Head & Neck 2011 n = 366 2012
- 55. Evidence Based Medicinein SBS Large Single Center Series • Data obtained: Survival JC Irish et al OS 71% at 4 years IP Janecka et al OS 67% at 2.5 years JP Shah et al DSS 58% at 5 years V Lund et al OS 44% at 5 years DM Fliss et al OS 66% at 2 years G Cantu et al OS 46% at 5 years 2012
- 56. Evidence Based Medicinein SBS Large Single Center Series • Data obtained: PrognosAc factors Cantu et al. Head & Neck 2011 Lund et al. Head & Neck 1998 2012
- 57. Evidence Based Medicinein SBS Large Single Center Series • Data obtained: Safety 2012 Ganly et al. Head & Neck 2005
- 58. Evidence Based Medicinein SBS Multi Center Collaborations • The problem: No single center treats enough patients to accumulate significant numbers for meaningful analysis of patient related and tumor related variables as predictors of surgical and postoperative outcome • The solution: An international collaborative study group comprised of 17 institutions was set up to report their collective experience with the objective of assessing the safety and efficacy of ASBS 2012
- 59. Evidence Based Medicinein SBS Multi Center Collaborations Level 5 • Retrospective cohort • 17 institutions • n = 1307 patient • Follow-up 2012 – Median 25 months – Range 1-940 months
- 60. Evidence Based Medicinein SBS Multi-Center Collaborations • Survival • Post operative mortality – 4% • Post operative complications – 33% 2012
- 61. • Prognostic factorsfor OS 2012
- 62. Evidence Based Medicinein SBS Multi-Center Collaborations Conclusions • CFR is safe and effective • Histology, intracranial extent and surgical margins are independent determinants of outcome 2012
- 63. Evidence Based Medicinein SBS Multi-Center Collaborations • n= 334 • Prognostic factors for DSS: Surgical Margins Orbital involvement 2012
- 64. Evidence Based Medicinein SBS Multi-Center Collaborations Intracranial involvement Histology • Similar outcome and complication rate 2012
- 65. SBS Techniques Endoscopic Approach Advantages • Improved visualization • No need for brain retraction • No facial incisions/osteotomies • Shorter hospitalization Disadvantages • Extension into the orbit or beyond • Extensive dural resection (CSF leak) • Piecemeal excision (?) • Reconstructive issues 2012
- 66. Endoscopic Approaches Level of Evidence 2012
- 67. Endoscopic Approaches Evidence Based Medicine • RetrospecAve review Level 5 • n=120, 15 years 2012
- 68. Endoscopic Approaches Evidence Based Medicine 2012
- 69. Endoscopic Approaches Evidence Based Medicine 2012
- 70. Endoscopic Approaches Evidence Based Medicine Level 5 • n=184, 10 years • Mean follow-up 34 months (2-123) 2012
- 71. Endoscopic Approaches Evidence Based Medicine 2012
- 72. Endoscopic Approaches Evidence Based Medicine EEA CEA • 5year DSS: 91% 59% (SelecAon bias) 2012
- 73. Evidence Based Medicinein SBS Endoscopic Surgery Summary • Evidence quality -‐ low • Long term follow-‐up -‐ unavailable • Staged tumors (ENB, adenocarcinoma) can be managed with results equivalent to open techniques • Advanced tumors should be approached by minimally invasive open techniques or by a combinaAon of open and endoscopic approaches 2012 • PaAents should be managed by trained surgical oncologists and nasal
- 74. Quality of Lifein SBS Problem • ASBS has been established as safe and effective • The physical and psychological consequences of ASBS on a patient s QOL have not been clarified Solution • To develop a cancer-specific multidimensional instrument to assess the impact of surgery on the QOL of patients 2012 with anterior cranial base tumors
- 75. Quality of Lifein SBS 2012
- 76. Quality of Lifein SBS • Retrospective survey, n = 69 • Generation of questions: review of literature, interview of patients and caregivers • Assessment of reliability and validation of the construct • Domains: – Performance - Pain – Physical function - Influence on emotions 2012 – Vitality - Specific symptoms
- 77. Quality of Lifein SBS Overall QoL Social Activity 60 60 50 50 Patients (%) Patients (%) 40 40 30 30 20 20 10 10 0 0 Worse Same Better Worse Same Better 60 Financial Status 60 Impact Upon emotions 50 50 Patients (%) Patients (%) 40 40 30 30 20 20 10 0 10 Worse Same Better Worse Same Better 2012
- 78. Quality of Lifein SBS 2012
- 79. Quality of Lifein SBS 4.0 3.5 QOL Score 3.0 N=39 P<0.05 2.5 Preoperative 6 months 12 months 2012
- 80. Quality of Lifein SBS Conclusions • The overall QOL in most patients after ASB surgery is good, with significant improvement within 6 months • The worst impact of surgery was on the patients financial and emotional QOL domains. • Negative prognostic factors for QOL: – Old age – Malignancy – Comorbidity Gil and Fliss et al. Arch Otol H&N Surg 2003 2012 – Radiotherapy Gil and Fliss et al. Arch Otol H&N Surg 2004 Gil and Fliss et al. J Neurosurg 2004 – Wide surgery Abergel and Fliss et al. Harefua 2004 Gil and Fliss et al. Skull Base 2010
- 81. Trends in Survivaland Demographics of Patients Undergoing SBS Head & Neck 2011 • Study conducted in order to identify time-related changes in the clinical characteristics and survival of patient undergoing ASB surgery over the last four decades • Pooled data from two cancer centers: Memorial Sloan-Kettering Cancer Center 234 2012 Tel Aviv Sourasky Medical Center 48 Total n = 282
- 82. Trends in Survivaland Demographics of Patients Undergoing SBS • Demographics and clinical characteristics 2012
- 83. Trends in Survivaland Demographics of Patients Undergoing SBS • Survival 2012
- 84. Trends in Survivaland Demographics of Patients Undergoing SBS • Prognostic factors for OS 2012
- 85. Trends in Survivaland Demographics of Patient Undergoing SBS Conclusion • Despite a higher risk for morbidity and tumor recurrence, refinement of surgical technique and the use of adjuvant radiation therapy, contributed to the current improvement in survival of patients 2012 with anterior skull base malignancies