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