maxillary carcinoma, nasal cavity and paranasal sinus malignancy.pdf

7/30/2019 Maxillary carcinoma, Nasal cavity and paranasal sinus malignancy.pdf

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Dr. Supreet Singh Nayyar, AFMC 2011

www.nayyarENT.com1

Nasal cavity and paranasal sinus malignancy

(For more topics, visitwww.nayyarENT.com)

EPIDEMIOLOGY

< 1 % of all neoplasms 3% of tumors of upper aero digestive tract Incidence 0.5-1 / 100,000/ yr 5th -6th decade M:F 2:1 Avg delay between the first symptom and diagnosis six mths Origin (Scott Brown)

o Maxillary sinusmost common (55 %)o Nasal cavity 35 %o Ethmoid sinuses 9 %o Frontal and sphenoid sinuses (1 %)

AETIOLOGY

Wood workerso 70 times increased incidence particularly in ethmoido African mahogany most dangerouso Biologically active compounds in wood dust impair mucociliary clearance and

predispose to carcinogenesis

o Hardwood exposureadenocarcinomao Soft wood exposure squamous cell carcinoma

Nickelo Relative risk >250o Interval between exposure to nickel and tumor 18 to 36 years

Chromium

Leather industry Polycyclic hydrocarbons Smokingsynergistic with wood dust Aflatoxin (found in certain foods and dust) Mustard gas Thorotrast (thorium dioxide used in paints for watch dials) Radiation Viral EBV, HPV Use of snuff (cocaine)
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Genetic role suggested but not provenOhngren line

Running from the medial canthus of orbit to angle of mandible Separates tumours into two groups

o Those that developed above the lineo Those that developed below it

Ohngren suggestedo Superiorly based cancers more aggressive and poorly differentiatedo Tumours arising from below line more amenable to treatment

With newer imaging & surgical techniques, no longer used nowLymphatic drainage

Lymphatic drainage of nose and paranasal sinuses relatively scanty Two lymphatic pathways

o Anterior Anteroinferior part of nasal cavity and skin of vestibule Drain to facial, parotid and submandibular lymph nodes - the first

echelon nodes

These drain into the upper deep cervical chaino Posterior

Remainder of nose and the paranasal sinuses Pathway which runs anterior to the Eustachian tube to first echelon

nodes - the retropharyngeal lymph nodes

Further drain to upper deep cervical chainPATTERNS OF TUMOUR SPREAD

Local spreado Tend to fill sinus cavity before eroding bony wallso

Periosteum,perichondrium and dura seem to act as a temporary barrierso Bone of the antronasal wall, canine fossa and orbital floor very thin easily

destroyed

o Only 25 percent of maxillary sinus carcinomas are contained within theantrum at time of presentation

Regional spreado Lymphatic spread apparent in 25-35 % of patients at some time during the

course of their disease

o Only 10 % have nodal disease at time of presentationo Submandibular and jugulodigastric nodes most commonly involved


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o Bilateral lymph node involvement likely when tumor near midline Distant spread

o Adenocarcinomas 18%o Squamous cell carcinomas 10%o Common sites bone, brain, liver, lung, skin

SYMPTOMS

Nasal: 50%o Obstruction, epistaxis, rhinorrhea

Oral symptoms: 25-35%o Pain, trismus, alveolar ridge fullness, malocclusion, erosion

Ocular: 25%o Epiphora, diplopia, proptosis

Facialo Paresthesias, asymmetry

Neck mass Ears

o Hearing loss, serous otitis mediaPHYSICAL FINDINGS

Nasal, facial, or intraoral massoIntranasal mass

Often necrotic, but polypoid mucosa may obscureoFacial swellingantral tumor erodes into cheekoWidening of the upper alveolar ridgeoLoose teethoPalatal mass and ulceration


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ProptosisCranial nerve deficits

oCN II, III, IV, VIoCN V ( V1 and V2)

Complete H&N exam and EndoscopyDiagnostic Assessment

CT scano Three-dimensional image of the lesiono Bone destruction, orbital & intracranial involvement

MRIo Better soft tissue delineationo Ability to differentiate between tumor bulk and retained secretionso Combined with CT for planning surgery for sinus neoplasms

Angiographyo If the lesion demonstrates enhancement during initial CT studyo If it approximates carotid systemo In evaluation of unusual tumors involving the sphenoid sinus and skull baseo In vascular tumors for assessment of tumor extent, feeding vessels and in

combination with embolization

Ultrasoundo B-mode scanning orbital masses

PETo Follow-up after concomitant chemoradiationo

Assessing presence of metastatic disease Endoscopy and Biopsy

o Punch biopsyo Chances of bleedingo Tumors contained within the sinus cavities should be biopsied transnasally

Dental / prosthetic consultationWorkup for distant metastasis

CXR PA view USG abdomen

Workup for surgery

Hb, TLC, DLC INR, Platelet count Bld Grouping Urine RE,ME BS F/PP LFT, RFT, Electrolytes ECG Lipid profile


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TREATMENT

General principles

Most patients have very advanced disease at presentation

All investigations & accurate staging Choice between treatment for cure and palliation Options for patients potentially curable

o Surgeryo Radiotherpyo Chemoradiotherapyo Combinationso Infusion & perfusion techniques (see combined answer)

Management Algorithms (as per NCCN 2011 guidelines)

Maxillary carcinoma



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Ethmoidal Carcinoma


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Recurrent / Persistent disease

Surgical options

External Ethmoidectomy Inferior Medial Maxillectomy Medial Maxillectomy Radical Maxillectomy Craniofacial Resections Extended Craniofacial Resection Minimally Invasive Approaches

Surgical approaches

Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach


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External Ethmoidectomy

Indicationso Removal of benign tumors of the ethmoidal regiono Approach to biopsy and drainage for tumors of sphenoethmoidal region and

medial orbit Bony Excision medial orbital wall and the ethmoidal labyrinth Surgical Approach incision on the lateral wall of the nose Benefits allows excellent cosmesis and preservation of functional tissue Limitations

o For limited tumors (middle turbinate)o Tendency to form a fistula to nasal cavity on irradiation

Inferior Medial Maxillectomy

Indications

o Resection of medial wall of the antrum and inferior turbinateo Most often used for inverted papilloma

Bony Excision marginso Laterally vertical line dropped from the infraorbital forameno Inferiorlyfloor of the noseo Superiorlylacrimal fossa and the middle meatuso Posteriorlydorsal end of the inferior turbinate

Surgical Approach Lateral rhinotomy Benefits

o Adequate exposure and resection for limited tumorso Preserve functional tissueo Provide a very acceptable cosmetic result

Limitationsprovides en bloc removal of limited areaMedial Maxillectomy

Indication larger benign or intermediate tumors involving theentire lateral nasal wall but without extension to the orbit,

anterior cranial fossa, lateral maxilla, or alveolus

Bony Excision lateral nasal wall, including all turbinatetissue, and the contents of the ethmoid and maxillary sinuses

Surgical Approach WeberFergusson with Lynch extensionand lip split

Bony cutso Removal of ant maxillary wall medial to infra orbital

foramen

o Orbital cut from inferior rim carried medially to lamina papyraceao Nasomaxillary suture line cut extending from cut 2 into pyriform apertureo Cut in lateral nasal wall near floor upto post wall of maxillary sinuso Vertical cut from post. nasal floor to post end of sup turbinate & post

ethmoidal cells


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Benefiten bloc resection with little cosmetic deformity LimitationsRemoval of all turbinate tissue results in an abnormal nasal cavity,

often requiring chronic management of crusting

Total Maxillectomy

Indications advanced carcinoma of maxilla Bony Excision removal of maxilla along with nasal bone, the ethmoid sinus, and in

some instances, the pterygoid plates

Surgical Approach Weber Fergusson with a Defenbach (subciliary) extension Bony cuts

o Zygomatico maxillary suture lineo Orbital floor & medial orbital wallo Naso maxillary suture lineo Hard palateo Pterygoid process

Can be combined with orbital exentration Preformed obturator support for packing Benefits When supplemented by irradiation, cure rate 30% (Cummings) Limitations Even when orbital exenteration is included inadequate resection if

ethmoidal roof, orbital apex or pterygoid region involved

Therefore, careful evaluation & planning required before surgeryCraniofacial Frontoethmoidectomy

Indications en bloc resectionfor tumors of the ethmoidal and

frontal regions

Bony Excisiono Anterior cranium

(including the frontal

sinus)

o Floor of anterior cranialfossa

o Ethmoido +/- Eyeo Nasal septum


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Benefitso Provides direct visualization of the cribriform plate and fovea ethmoidaliso Potential for en bloc removalo Provides wide exposure to allow effective repair of dural tearso Allows intraoperative irradiation or placement of a radioactive implant

LimitationsIf tumor extends to sphenoid sinus, cavernous or transdurally, en blocresection cannot be achieved

Extended Craniofacial Resection

IndicationsExtensive tumors involving the anterior skull base including pterygoidplates

Bony Marginso Posterior limits

Foramen ovale Foramen rotundum ICA

o Remaining margins as for craniofacial frontoethmoidectomy and totalmaxillectomy

o Surgical Approach Bicoronal and anterior or lateral facial incisions Closure split-galea flap to cover dura

o Team neurosurgeon + otolaryngologisto Benefits Thorough exposure and complete excision of otherwise

unresectable tumors

o Contrindicationsclear-cut pterygoid plate erosion and cranial nerveinvasion

Supplemental Management in Extended Craniofacial Resection

Intraoperative iodine seed implantationo Adenoid cystic carcinoma more beneficialo Undifferentiated carcinoma and squamous cell carcinoma less optimistic

Reconstruction (for detailed reconstruction see maxillectomy presentation)o Radial forearmo Rectus abdominis musculocutaneous flapso Latissimus dorsi flap

Radiotherapy

Conventionalo 66-70 Gy (2.0 Gy/fraction; daily Monday-Friday) in 7 weekso Neck Uninvolved nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)

Concurrent chemoradiotherapyo Primary and gross adenopathy: 70 Gy (2.0 Gy/fraction)o Neck Univolved nodal stations: 44-64-Gy (1.6-2.0 Gy/fraction)

Postoperative RT

o Primary 6066 Gy (2.0 Gy / fraction)


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o Neck Involved nodal stations: 60-66 Gy (2.0 Gy/fraction) Uninvolved nodal station: 44-64 Gy (1.6-2.0 Gy/fraction)

o Preferred interval between resection and postoperative RT is


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Intermediate Neoplasmso Inverted Papillomaso Meningiomaso Hemangiomaso Hemangiopericytoma

Malignant lesionso Squamous cell carcinomao Adenocarcinomao Adenoid cystic carcinomao Olfactory neuroblastomao Sinonasal undifferentiated carcinomao Lymphomao Mucoepidermoid carcinomao Melanomao Osteogenic sarcomao Fibrosarcomao Chondrosarcomao Rhabdomyosarcomao Metastatic tumors

Squamous cell carcinoma

Most common tumor (80%) Location:

o Maxillary sinus (70%)o Nasal cavity (20%) 90% have local invasion by presentation Lymphatic drainage:

o First echelon: retropharyngeal nodeso Second echelon: subdigastric nodes

Surgical resection with postoperative radiationAdenocarcinoma

2nd most common malignant tumor Present most often in the superior portions Strong association with occupational exposures High grade

o Solid growth pattern with poorly defined marginso 30% present with metastasis

Low gradeo Uniform and glandular with less incidence of perineural invasion/metastasis


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Adenoid Cystic Carcinoma

3rd most common site

maxillary carcinoma, nasal cavity and paranasal sinus malignancy.pdf

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