Post on 16-Apr-2017
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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12/31/13
Otolaryngology online
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12/31/13
Otolaryngology online
12/31/13
Otolaryngology online
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