malignant tumors involving paranasal sinuses

Nose & PNS Malignancy

Current concepts

Balasubramanian Thiagarajan

Otolaryngology online

Drtbalu's otolaryngology online

Introduction

Uncommon tumors - >1% of all neoplasms

Diverse group some unique to nose alone

Produces very little symptoms

Commonly mistaken for rhinosinusitis

Average delay from first symptom to diagnosis is about 6 months

Accurate staging is still not possible Current staging system is only for maxillary & ethmoid sinuses

Reality

Surgery & chemoradiotherapy main trt modalities available

Treatment modalities inflict considerable morbidity

Facial disfigurement / Interference with mastication / loss of sight

Quality of life considered while choosing treatment modality

Epidemiology

Incidence 1% per 100,000 / year

Commonly develop during 5th 6th decades of life

Twice as common in men than women

Common sino-nasal malignancy Primary epithelial tumors followed by non-epithelial malignant tumors

Tumors arising from nose 25% and tumors arising from sinuses 75%

60% of squamous carcinomas arise from maxillary sinus, 20% from nasal cavity rest from ethmoids. 1% arise from sphenoid

Common sinonasal malignancy

Squamous cell carcinoma commonest

Adenocarcinomas

Adenocystic carcinomas

Undifferentiated carcinomas

Non Hodgkin's lymphoma

Melanomas

Adenocarcinoma

Third most common epithelial malignancy next only to sinonasal gland carcinoma.

4 times frequent in men. ? Occupational exposure to wood dust.

Commonly arise from olfactory cleft.

Usually appears polypoidal

Unilateral expansion of olfactory cavity and opacification in imaging - ? suspicion

Adenocarcinoma - Imaging

Etiology

Exposure to carcinogen

Smoking / alcoholism

Viral

Carcinogen

Wood dust

Nickel

Chromium

Polycyclic hydrocarbon

Aflatoxin

Thorotrast (watch dial makers)

Wood dust

Adenocarcinoma

Wood workers 500 times common

Exposure to hard wood dust Ebony, mahogany, oak.

Exposure threshold - > 5mg / m3 / day

Chemicals used in wood processing have been eliminated as a cause

Even short periods of exposure can cause adenocarcinoma (< 5 years)

Industrial risk

Wood industry

Textile industry

Bakery

Textile

Nuclear industry

Farming

Construction

Mining

Human papilloma virus

HPV-6 / HPV-11 demonstrated in 10% of squamous cell carcinoma nose & pns.

HPV 16 / HPV 19 are known to cause more virulent cancers.

Presence of squamo columnar junctions in the nose predisposes to HPV induced cancers.

Tumor spread

Local invasion

Orbital spread common thin walls, nerves and blood vessels cause dehiscence

Roof of frontal sinus is thin perforations + for olfactory nerves to pass

Ohngren's Line

Line running from medial canthus to angle of mandible

Prognosis of suprastructure tumors worse (This was before advent of craniofacial resection)

Lymphatic drainage

Lymphatic drainage of this area is scanty.

Anterior / Posterior pathway

Anterior pathway 1st echelon nodes (facial, parotid, submandibular nodes)

Posterior pathway 1st echelon nodes (retropharyngeal nodes)

Anteroinferior nasal cavity, skin of nasal vestibule anterior pathway

Rest of nose and sinuses drain via posterior pathway

Tumor spread

Clinical features

Oral symptoms Pain, trismus, alveolar ridge fullness, erosion, loosening teeth, ill fitting dentures (25-30%).

Nasal symptoms Obstruction, epistaxis, rhinorrhoea (50%).

Ocular symptoms Epiphora, diplopia, proptosis, blindness (25%).

Facial signs Paresthesias, asymmetry

Clinical

Radiology

MRI

Differentiates tumor from soft tissue

Differentiates secretions from tumor mass

Demonstrates perineural spread

Not affected by dental fillings

Can be imaged in sagittal plane

Coronal MRI Foramen rotundum, vidian canal, foramen ovale and optic canal can be seen

Angiogram

Tumors surround carotid artery

Carotid artery needs to be sacrificed in order to obtain clear surgical margins

Balloon occlusion tests should be performed to estimate the risk of cerebral infarction if carotid needs to be sacrificed.

CT imaging

Squamous cell carcinoma

Most common sinonasal malignancy.

Common during 7th decade / males.

Arises lateral nasal wall. 50% arises from turbinates.

85% are well differentiated and keratinizing.

15% of inverted papilloma turns malignant

Adenocarcinoma

Wood workers

9% of all sino nasal malignancies

Common 6th 7th decades

Common in upper nasal cavity / ethmoidal sinuses

Growth rate slow

Metastasis uncommon

Histological types: Papillary, sessile, mucoid, neuroendocrine, intestinal, undifferentiated.

Adenoid cystic carcinoma

5% of all sinonasal malignancies

Slow growth, perineural spread, vascular spread

Maxillary sinus commonly affected

Long history of facial pain defying diagnosis

Olfactory neuroblastoma

Arises from basal cells of olfactory epithelium

5% of sinonasal malignancies

Bimodal distribution (20 and 50 yrs old peak).

More common in women than men

Paraneoplastic syndrome +

Kadish staging system

Stage A Tumor limited to nasal cavity

Stage B Tumor limited to nose and sinuses

Stage C Tumor extending beyond the confines of nose and sinuses

Stage D distant metastasis

ULCA Staging

StageDescription

T1Tumor involving the nasal cavity or paranasal sinuses (excluding sphenoid) or both, sparing the most superior ethmoidal air cells

T2Tumor involving the nasal cavity or paranasal sinuses (including the sphenoid) or both with extension to or erosion of the cribriform plate

T3Tumor extending into the orbit or protruding into the anterior cranial fossa

T4Tumor involving the brain

Undifferentiated carcinoma

Anaplastic

Aggressive tumor

Produces fewer symptoms

Chemoradiation +

Melanoma

4% of sinonasal malignancies

Common in women than men

Affects elderly

Nasal cavity / septum common sites

Polypoidal / ulceration

Metastasis less frequently to nodes

Lungs / brain metastasis common

Lederman's classification

Lines of Sebileau

Supra, meso and infrastructures

Prognosis worsens from below upwards

Growth maxilla staging TNM

T1Tumor confined to antrum No bone erosion

T2Tumor with bone destruction except posterior wall of antrum

T3Erosion of posterior wall / infratemporal fossa / pterygoid plates / orbit / ethmoid sinus

T4aAnterior orbital contents / cribriform plate / sphenoid / frontal sinus

T4bOrbital apex / dura / brain / middle fossa / nasopharynx / clivus

Ethmoid sinus - TNM

T1Tumor confined to ethmoid / with or without bone erosion

T2Tumor extending into nasal cavity

T3Tumor extending to anterior orbit / maxillary sinus

T4aAnterior orbital contents / Skin of nose or cheek / minimal anterior cranial invasion / pterygoid plates / sphenoid / frontal sinus

T4bOrbital apex / dura / brain / middle cranial fossa / cranial nerves other than V2 / nasopharynx / Nasal cavity

Nasal cavity

Subsites recognized septum / floor / lateral wall / vestibule

T1Tumor involving one subsite

T2Tumor involving two subsites / ethmoid

T3Tumor eroding to anterior orbit / maxillary sinus

T4aAnterior orbit / skin of nose and cheek / minimal anterior cranial fossa extension / pterygoid plates / sphenoid / frontal sinus

T4bOrbital apex / dura / brain / middle cranial fossa / nasopharynx / clivus / cranial nerves other than V2

Treatment

Surgery

Radiotherapy

? Chemotherapy

Combination

Irradiation

Preop irradiation preferable

Post op irradiation is suitable only for slow growing tumors

200 rads x 5 days a week 6 weeks (6000rads)

Surgery

Partial maxillectomy

Total maxillectomy

Extended maxillectomy

Medial maxillectomy

Good access to nasal cavities / ethmoids / nasopharynx / sphenoid / pterygopalatine fossa

Moore's incision

Incision may be continued into nasal cavity

Medial maxillectomy - osteotomy

Anterior craniofacial resections

Type I Craniofacial / transorbital resection. This procedure is extended medial maxillectomy with resection of ethmoid roof and orbital periosteum

Type II Medial maxillectomy with window craniotomy using frown line incision

Type III Neurosurgeon helps. Transfacial with neurosurgical approach like frontolateral craniotomy

Thank you

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malignant tumors involving paranasal sinuses

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