CARCINOMA MAXILLAMANAGEMENT

Dr. Paul George Radiation Oncology Regional Cancer center

Trivandrum

NASAL CAVITY & PARANASAL SINUSES

Epidemiology

Incidence 0.5-1/100,000 per year0.2-0.8% of all malignancies3% of upper aerodigestive tract neoplsm

5th-6thdecadeWhite raceM:F=2:1 – 4:1

SQUAMOUS CELL CARCINOMA

Most common histological type70% maxillary sinusMale predominanceOlder age groupEnviornmental exposure: leather tanner, nickel refinery, thorotrast

Adenoca(10-20%), adenocystic ca(<10%), sinonasal melanoma(<4%), esthesioneuroblastoma, sinonasal undifferentiated carcinoma, lymphoma,sarcoma , plasmacytoma

How to Proceed

1.HISTORY & Physical exam2.Radiography (CT, MRI)complete head & neck.3.BIOPSY4.Chest imaging5.dental/prosthetic consultation as indicated

STAGING

HISTORY & PHYSICAL EXAMINATION

Anatomy of maxillary antrum

• Anterior : soft tissue of face .

• Posterolateral : ITF , pterygopalatine F

• Superior : Inferior orbital plate .

• Inferiorly : hard palate ,superior alveolar ridge

PATTERN OF TUMOUR SPREAD

Patterns of tumour spreadAnteriorly: cheek, skinPosteriorly: pterygopalatine fossa, infra temporal fossa, temporal bone middle cranial fossaMedially: nasal cavity,NLDLaterally: cheek, skinSuperiorly: orbit, ethmoid sinusesInferiorly: palate, buccal sulcus

CLINICAL PRESENTATION• Nasal findings:(50%) obstruction, epistaxis,

rhinorrhea,discharge,extension into nasal cavity

• Oral symptoms:(25-35%) pain, trismus, alveolar ridge fullness, erosion

• Ocular findings:(25%) epiphora, diplopia, proptosis

• Facial signs: paresthesias, facial asymmetry, cheek swelling

• Auditory symptoms: hearing loss (OME)• Neurological: cranial nerve deficits II,III,IV.V1,V2,VI• 10% nodal• Distant mets: rare

H & P examination• The sinonasal, ocular, and neurologic systems

should be studied in detail• Ant & post rhinoscopy• Nasal endoscopy

RADIOLOGICAL EXAMINATION

Radiographic studies are essential as the fullextent of a sinonasal neoplasm cannot beestablished even with modern fiberoptictechnology. Both CT& MRI are the effective ways todelineate the extent of tumor extracranially andintracranially.

Computed Tomography

Bone erosionKey areas include the bony orbital walls,cribiform plate, fovea ethmoidalis, posterior wallof the maxillary sinus, pterygopalatine fossa, thesphenoid sinus, and the posterior table of thefrontal sinus.85% accuracy

Difficultperiorbital involvementDifficult to differentiate between: Tumor vs. inflammationvs. secretions

MRI• 94% accuracy

• Inflammatory tissue & secretions: intense T2

• Tumor: intermediate T1 & T2, Enhancement with Gadolinium

• MRI is excellent for determining perineural spread, involvement of the dura, or involvement intracranially.

BIOPSY

Transnasalmedial wall of maxilla is the preferred routeNeedle biopsy is sufficient

Biopsy via Caldwell-Luc approach (canine fossa puncture) is not recommended because of the potential to seed the gingivobuccal sulcus andcheek skin with tumor.

STAGING

Ohngren’s Line

a line that is drawn from the angle of mandible to the medial canthus.Ohngren indicated that tumors that presented above this line (suprastructure); both superiorly and posteriorly, tended to have a worse prognosis

MANAGEMENT

1.SURGERY2.RADIOTHERAPY3.CHEMOTHERAPY:VERY LIMITED ROLE

SURGERY

Surgical approaches:• Endoscopic• Lateral rhinotomy• Transoral/transpalatal• Weber fergussen• Midfacial degloving• Combined craniofacial approach

Extent of resection• Medial maxillectomy• Inferior maxillectomy• Total maxillectomy

Weber fergussen approach tumors involving the maxilla extending superiorly to the infraorbital nerve and into the orbit.Wide access to all areas of the maxilla and orbital floor.

Midfacial Degloving

Nasal cavity tumors withbilateral involvementMost suited for inferiorlylocated tumors.Subperichondrial plane of nasal septum

Inferior medial maxillectomy

Medial maxillectomy Radical maxillectomy

with exentration

Cranio-facial resection

Surgical procedures The goal of surgery for nasal cavity and paranasal sinus

tumors is to achieve en bloc resection of all involved bone and soft tissue with clear margins while maximizing the cosmetic and functional outcome.

Limited nasal cavity lesions may be resected with medial maxillectomy.

Ethmoid lesions usually require medial maxillectomy and en bloc ethmoidectomy.

combined craniofacial procedure for lesions involving the inferior surface of the cribriform plate ,the roof of the ethmoid & frontal sinus.

Multidisciplinary skull base approach has improved the outcome

UNRESECTABILITY

Unresectable tumors:• Superior extension: frontal lobes• Lateral extension: cavernous sinus• Posterior extension: prevertebral fascia• Bilateral optic nerve involvement• Distant Metastasis

Reconstruction after surgery is done with microvascular free flap & maxillofacial obturatorprosthesis

RADIOTHERAPY Addition of RT to surgery improve 5-years survival (44%) when compared to

RT alone (23%) or surgery alone.

Indications:

Definitive :medically inoperable or who refuse radical surgery or early lesions

Adjuant:

Palliative:

Pre- and postoperative radiation may result in similar control rates.

But post-operative RT preferred:

Preoperative radiation increases the infection rate and the risk of postoperative wound complications.

Preoperative radiation may obscure the initial extent of disease=surgery can not

remove the microscopic extensions of the tumor.

• Postoperative radiation therapy is started 4 to 6 weeks after surgery.

RADIOTHERAPY TECNIQUES

1.CONVENTIONAL 2D2.CONFORMAL 3D3.IMRT

2D CONVENTIONAL: 3field tecnique

Patient lies in a supine cast with the head in neutral position.Tongue bite is used to depress tongue & lower alveolus away

from the target volume.

ANTEROR FIELD

LATERAL FIELD

• Field Margins: a three-field technique for maxillary antrum: 1 anterior and 2 lateral

fields.Anterior field:superior border: above the crista galli to encompass the ethmoids.

in the absence of orbital invasion, at the lower edge of the cornea to cover the orbital floor.

inferior border: 1 cm below the floor of the sinus.medial border: 1 to 2 cm (or more if necessary) across the midline cover contralateral ethmoidal extension. lateral border: 1 cm beyond the apex of the sinus or falling off the

skin.

Lateral fields:superior border: follows the floor of anterior cranial fossa.anterior border: behind the lat canthus parallel to the slope of face.posterior border: covers the pterygoid plates.

Anterior field:When ther is no gross involvement of the orbit, the cornea, lens & lacrimal gland are shieldedfrom the anterior fieldIf there is disease in the orbit, cornea is sparedby cutting out the cast and treating with the eyes openLateral field:It is angled 5-10 degree posteriorly so that the exit beam avoids the opposite eyeOptic chiasma & hypothalamus are shielded from the lateral field

Anterior beam is weighed as 2:1 to that of lateral beamDose prescription:65Gy/32# or 55Gy/20#

ISODOSE DISTRIBUTION

3D CONFORMAL

4 Field 1. Anteror 2. two lateral portal3. Intraorbital electron portal to make up the dose to post nasal

cavity, ethmoid sinus & medial orbit

CT SIM

A CT scan is performed with 3 mm slices from2cm superior to the superior orbital ridge to thehyoid bone (but extended to include the lowneck if neck nodes are to be treated).

TARGET VOLUME DELINEATIONThe CTV should encompass• all initial sites of disease(presurgery GTV), • The mucosa of adjacent compartments of the sinonasal

complex and• a 10 mm margin at least from initial sites of GTV where no good

bony barrier to invasion exists(e.g. masticator space, cribriform plate and infraorbital fissure) • Bony orbit if involved

For most tumours, the CTV will include the ipsilateral maxillarysinus and bilateral nasal cavity and the ethmoid sinuses.

The CTV is expanded isotropically (usually by 3–5 mm)to form the PTV

Where a craniofacial excision has been carried out, the CTV should extend 10 mm superior to the cribriform plate or 10 mm superior to Initial sites of disease, whichever is greater

If the primary was close to or invading the nasopharynx, the adjacent Ipsilateral retropharyngeal nodes should be included in the CTV.

When cervical node radiotherapy is indicated, the intraparotid nodes, level Ib and superior level II nodes can be included in the CTV.

Elective neck nodal radiation is not recommended

ORGAN AT RISK

include the 1.lenses,2. lacrimal glands (in the superolateral orbit and upper eyelid), 3.optic nerves and chiasm, 4.spinal cord, 5.brainstem and 6.pituitary gland

OAR & possible complications of RT

• Lens <10 Gy (cataracts)• Lacrimal gland <30–40 Gy (dry eye syndrome) • Retina <45 Gy (blindness)• Optic chiasm and nerves <54 Gy at standard fractionation.

(Optic neuropathy)

• Brain <60 Gy (necrosis)• Mandible <60 Gy (osteoradionecrosis)• Parotid mean dose <26 Gy (xerostomia) • Pituitary and hypothalamus mean dose <40 Gy.

IMRT

A non-coplanar arrangement of three to five sagittal midline beams with right and left lateral beams avoids entry or exit ofbeams through the eyes andprovides a uniform dose distribution

IMRT has been shown to be useful inreducing long-term toxicity by reducing the dose to salivary glands,temporal lobes, auditory structures, and optic structures

IMRT

Complications of RT

Acute:mucositis, skin erythema, nasal dryness, Xerostomia

Late: xerostomia, chronic keratitis and iritis, optic pathway injury , osteoradionecrosis,cataracts, radiation induced hypopituitarism

Dose fractionation

Definitive RT: 70Gy , 2G/# over 7 wksAdjuvant60 Gy in 30 daily fractions given in 6 weeks.66 Gy in 33 daily fractions if possible wherethere is residual disease.Palliative36 Gy in 6 fractions of 6 Gy treating once weekly.

Treatment delivery and patient care

Patients are seen weekly during treatment in a multidisciplinary clinic.

• Exercises to reduce trismus• Prophylactic feeding tubes should be considered • ophthalmic review .Lubricating eye ointments• If there is a pre-existing facial nerve palsy, the eyelid

should be taped shut at night to avoid a dry eye.• Pituitary function tests should be carried out annually

during follow-up to evaluate late radiotherapy effects to the pituitary gland.

Role of chemotherapy

• Neoadjuvant chemotherapy is sometimes offered in order to reduce tumor volume, which may permit removal of tumor with a less morbid resection or facilitate radiotherapy planning if shrinkage pulls away tumor from critical structures.

• chemotherapy may be given concurrent with radiotherapy in the management of inoperable tumors on the basis of improved results in more frequent head and neck carcinomas.

FOLLOW UP

H&P, labs every 3 months for first year, Every 4 months for second year,Every 6 months for third year, then annually. Imaging of the H&N at 3 months post treatment, then as indicated

STAGEWISE MANAGEMENT OF CARCINOMA MAXILLA

Stage I / II (T1-T2, N0)

SINGLE MODALITY TREATMENT

DEFINITIVE RT/SURGERY

• If perineural invasion by the tumor, Adjuvant RT (±Chemo)

LOCALLY ADVANCED

T3-T4a, N0( resectable)

SURGERY POSTOP RT

If margins are positive, ChemoRT tothe primary

Node + Stage

SURGERY WITH NECK DISSECTION POSTOP RT

If margins positive or ECE, ChemoRT

Elective neck nodal irradaition is not routinely recommended

VERY LOCALLY ADVANCED

T4b , unresectable

PS 0,1 : RADICAL CHEMORT/ Induction chemofollowed by chemoRTPS2: RADICAL RTPS3: PALLIATION

Locoregional Reurrence/residual:

Salvage surgery/Reirradiation +/_chemo/clinicaltrial

Distant mets: palliative chemo/Best supportivecare

PROGNOSIS

Even with multimodality treatment average 5year median survival of carcinoma maxilla is only 35-45%

CLINICAL SCENARIO

INDIRA 58/FHOUSE WIFEREPORTED INB CLINIC 3/6/13ComplaintsLeft Nasal discharge 15mnthsLeft nasal block 6monthsECOG PS 1 GC;good

INVESTIGATIONS

Trans nasal biosy left maxilla:Poorly diff carcinoma

CA MAXILLAStaging…….? Management…………….?

cT2N0M0

RT/SURGERY….?ADJUANT Rx…?

Cacinoma maxilla: cT2N0M0 MANAGEMENTSUBTOTAL MAXILLECTOMY on 21/08/13HPE:Non keratinising scc with bone erosion close margin <0.1cm from lateral marginOther margins free

Postop RT 55Gy/20#

Thank you…….

Dr. Paul George