paranasal sinuses carcinoma
TRANSCRIPT
CARCINOMA OF PARANASAL SINUSES
Presenter – Dr. Venkatesan
Moderator – Prof. Th. Tomcha Singh
Anatomy
Anatomy – contd…
Maxillary sinus
• Base – lat. Wall of nasal cavity
• Roof – Orbital floor
• Floor – alveolar processes
• Apex – into zygomaticbones
• Ohngren’s line
Anatomy – contd…
Ethmoid sinus
• B/w nasal cavity & orbit
• Sep from orbital cavity by
lamina papyracea & from
ACF by fovea ethmoidalis
• Laterally optic nerves
• Posteriorly optic chiasma
Epidemiology• Maxillary sinus ca – 70%
• Ethmoid, frontal, sphenoid sinus ca –extremely rare
• M > F ( 2 : 1 )
• Age > 40yrs
• Thorotrast
• Carpenters, saw mill workers
• Occupational exposure
• Smoking
• Alcohol
Histologic subtypes • Squamous cell carcinoma ( 80 - 85%)
• Adenoid cystic carcinoma
• Adenocarcinoma
• Melanoma
• Olfactory neuroblastoma
• Osteogenic sarcoma, rhabdomyosarcoma
• Lymphoma
• Metastatic tumors ( kidney, lungs etc)
• Sinonasal undifferentiated carcinoma
Natural history & spread
Maxillary ca
Natural history & spread - contd
Ethmoidal ca
Natural history & spread – contd…
Sphenoid sinus ca Frontal sinus ca
Lymphatic Drainage
• Usually sparse
• If tumor extension into skin of face, nasal cavity, NPX > ↑ed incidence of LN
• First echelon: submandibular nodes
• Second echelon: subdigastric nodes - same side
• Contralateral mets. extremely rare
Clinical featuresMaxillary sinus ca
• Facial swelling, pain, paresthesia of cheek
• Epistaxis, nasal discharge, obstruction
• Ill fitting dentures, alveolar/palatal mass
• Proptosis, diplopia, impaired vision, orbital pain
Ethmoid sinus ca
• Headache
• Referred pain to nasal, retrobulbar region
• SC mass at inner canthus, nasal obstruction,discharge, diplopia & proptosis
Prognostic factors
• Pt specific
- Age
- Performance status
• Disease specific
- location
- histology
- locoregional extent
- perineural invasion
Work up• H & P
• Routine blood examination
• CXR
• CT/MRI
• Dental evaluation
• Baseline ophthalmologic examn
• Baseline speech & swallowing assessment
• Fiberoptic endoscopic examination & Bx
Staging – Maxillary sinus Ca
AJCC- Nasal cavity & Ethmoid Sinus
Tx - Primary tm cannot be assessed
To - no evidence of primary tm
Tis - carcinoma in situ
T1 - Tm restricted to any one subsite with or without bony invasion
T2 - invading two subsite in a single region or extending to
involve an adjacent region within the nasoethmoidal complex
T3 - invade medial wall/ floor of orbit, maxillary sinus,palate/
cribiform plate
T4a - invade ant orbital contents, skin of nose /cheek, ant cranial
fossa, pterygoid plates,sphenoid/ frontal sinus
T4b - orbital apex, dura, brain,mid cranial fossa, cr nerves,
nasopharynx/ clivus
Staging – contd…Nx - regional nodal status cannot be assessed,
No - No regional lymph node metastasis
N1 - single I/L clinically +ve lymph node ≤ 3cm
N2 - metastasis in ipsilateral, bilateral, contralateral node
N2a - single I/L +ve LN >3cm <6cm
N2b - multiple, I/L +ve LN <6cm
N2c - B/L or C/L LN <6cm
N3 - any LN > 6cm
Mx - distant metastasis cannot be assessed
Mo - No distant metastasis
M1 -distant metastasis multiple, ipsilateral clinically positive node <6cm
Staging – contd…
Stagewise distributionstage I - T1N0M0
stage II – T2N0M0
stage III – T3N0M0 OR T1-T3N1M0
stage IV : - IVA -T4N0-1M0
any TN2 M0
- IVB any TN3M0
- IVC any T any N, M1
Treatment optionsMaxillary sinus ca
• Surgery
• Radiotherapy
- definitive
- pre op RT
- post op RT
• Combined modality ( Sx + RT)
• Chemotherapy
- Neo adjuvant
- Concomitant
Stagewise Treatment
Stagewise Treatment – contd…
Surgery1)Total maxillectomy - Adv. Maxillary sinus Ca.
2)Lateral Rhinotomy & medial maxillectomy –
malig. limited to nasal walls ,medial wall of maxillary
sinus & adj. Ethmoid sinus
3)Medial maxillectomy with Frontal craniotomy
for enbloc resection- malig. Tumors→ minimal
intracranial extension
4) Partial horizontal Maxillectomy-tumors localised
to hard palate & infrastructure of the antrum
EBRT
• Most – post op RT
• Target volume
- physical exam.
- Pre Rx imaging
- intra operative findings
- pathologic findings
EBRT – Setup & field arrangement• Supine position• Immobilisation• Mouthbite• Planning
- maxilla- adj. nasal cavity- ethmoid sinuses- NPx- pterygopalatine fossa- portion of orbit
• Techniques- Anterolateral wedge pair
tech- 3 field tech
RT – field portals Maxillary ca
Isodose planning for wedge filtered fields
EBRT – contd…
• 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
3D CRT
• Initial target volume – Post op. RT
- Sx bed + 1-2 cm margin
- Boost volume – areas at high risk for
recurrence
• Advantage
- spare C/L retina & optic nerve
- Post op dose of 66 Gy can be delivered
IMRT
• Rigid immobilisation
• Shoulders depressed & fixed
• Target volume delinated
• Multiple gantry angles are utilised
• Beam angle selection based on
- Shortest path to the target
- Avoidance of direct irradiation to critical struct.
- Use of large beam seperation as possible
RT – Target volumes
Target Description Dose
GTV Pre chemotherapy 66 – 70
CTV1 GTV + 1 – 1.5cm 66 – 70
CTV2Primary CTV +
1 – 1.5cm 59 – 63
CTV3 Nodal volumes, nerve tract & base of skull
54 – 57
Target Description Dose
CTV HRSites of suspected +vemargins, gross macroscopic residual tumor, extracapsularnodal disease
66 – 70
CTV1Primary tumor bed + 1 –
1.5 cm margin60
CTV2 Surgical bed57
CTV3Trigeminal n., perineural
invasion, additional skullbase margin, elective nodal volume if indicated
54
Primary RT Post op RT
Ethmoid sinus ca
• Stage I(A) – Sx or EBRT
• Stage II(B) – Sx + EBRT ± CT / EBRT ± CT
• Stage III (c) - Sx + EBRT ± CT / EBRT ± CT
SX :
1) Medial maxillectomy
2) En bloc ethmoidectomy
3) Craniofacial approach
EBRT - Ethmoid sinus ca
• Anterolateral wedge
fields
• 3 field tech.
• Diff. loading with more
weightage to ant field
with 2:1 or 3:1
• Post op – 55 – 60 Gy
Treatment of neck nodes
• In SCC & undiff. Carcinoma
• I/L upper neck Rx is delivered by lateral
appositional electron field ( usually 12 MeV)
• Uninvolved – 50 Gy over 5 wks
• Involved – 60 – 66 Gy
Treatment sequelae
• Vestibulo cochlear
- hearing impairment, tinnitus, otitis, vestibular dysfunction
• Ophthalmologic
- retinopathy, xerophthalmia, keratopathy,cataracts, visual impairment
• Endocrine
- multiple endocrine dysfunction
• Oral
- xerostomia, dental caries, dysgeusia, mandible exposure, necrosis & trismus
• Connective tissue complications
- soft tissue necrosis, skin changes, sc fibrosis, nasal dryness, swallowing, voice dysfunction
Follow up
• 3 mths after Rx
- baseline physical examn
- CT, MRI or PET CT
• 1st 3 yrs – every 4 mths
• 4th & 5th yr – every 6 mths
• Then - annually
Results of treatment
• Local control after Rx – remains problematic
• MD anderson cancer centre
(1991 review – 73 pts )
5 yr local control in
- T1 & T2 - 91 %
- T3 – 77 %
- T4 – 65 %
• Sx + RT : 5 yrs LC & SR - 44% - 80%
• RT alone: 5 yrs LC – 22 – 39%
5yrs SR – 22- 40%
Thank you
Surgery
Contraindications
- extension thr ant. Fossa
- involvement of both optic n.
- post. extension into sphenoid sinus
- invasion of middle cranial fossa
- extension into NPx
- inoperable neck node & distant mets
Location
• Maxillary sinus
– 70%
• Ethmoid sinus
– 20%
• Sphenoid
– 3%
• Frontal
– 1%
Presentation
• Nasal findings: 50%
– Obstruction, epistaxis, rhinorrhea, erosion
• Oral symptoms: 25-35%
– tooth pain, trismus, alveolar ridge fullness, erosion
• Ocular findings: 25%
– Epiphora, diplopia, proptosis
• Facial signs:
-V2 Paresthesias, asymmetry, pain , fullness
• Auditory : CHL
SCCA
• Most common - 80%
• Maxillary > nasal cavity > ethmoids
• Males
• Sixth decade
• 90% have eroded walls of sinuses - local
invasion by presentation
Adenocarcinoma
• 2nd most common malignant tumor in maxillary
& ethmoid sinuses
• Present most often in the superior portions
– Strong association with occupational exposures
• High grade: solid growth pattern with poorly
defined margins. 30%with metastasis
• Low grade: uniform and glandular with less
incidence of perineural invasion/metastasis.
Adenoid Cystic Carcinoma
• 3rd most common in the nose/paranasal sinuses
• Perineural spread
• Despite aggressive Sx resection & RT, most grow insidiously.
• Neck metastasis is rare & usually a sign of local failure
• Widespread local invasion makes resection difficult,
therefore RT is often indicated - Postoperative RT
• Resistant to t/t
• Multiple recurrences, distant mets
• Long-term follow up necessary
MUCOEPIDERMOID CARCINOMA
• Extremely rare
• Widespread local invasion makes resection difficult, therefore RT is often indicated
METASTATIC TUMORS
• Renal cell carcinoma
• Lungs
• Breasts
• Urogenital tract
• Gastrointestinal tract
Computed Tomography
• Bone erosion
– orbit, cribiform plate
– fovea, post max sinus wall
– sphenoid, post wall of frontal sinus
• 85% accuracy
• ? Tumor vs. inflammation vs. secretions
• Limitation-periorbitalinvolvement
MRI
• Superior to CT
- multiplanar
- Detect intracranial,
perineural & leptomeningeal
spread
• Inflammatory tissue & secretions - intense T2
• Tumor - intermediate T1 & T2 (low signal)
• 94% accuracy
• gadolinium (enhancement) 98% accuracy