Paranasal Sinuses: Neoplastic

Lesions

ESHNR 2017

Lisbon, Portugal

Pravin Mundada

Department of Radiology,

Geneva University Hospital,

Switzerland

Layout of the presentation

• Clinical & imaging features of commonly seen benign & malignant sinonasal tumors

• Role of various imaging modalities in diagnosis & treatment planning

• What does the surgeon expect from a radiological report ?

Clinical overview

• Tumors of paranasal sinuses are rare

• Symptoms of benign & early malignant tumors mimic rhinosinusitis: stuffy nose, rhinorrhea,

epiphora & epistaxis

• Symptoms of advanced malignant tumors are related to tumor spread: pain, facial swelling,

cranial nerve palsies, anosmia & visual disturbances

• Often detected when they are large

• Imaging cannot give histopathological diagnosis in most instances

• Patient demographics & characteristic location of tumor may give diagnostic clue in some

cases

Imaging armamentarium

• CT, MRI, FDG PET-CT, FDG PET-MRI, Angiography

• CT & MR compliment each other

• CT: detects bone remodelling & destruction, provides surgial roadmap

• MRI: soft tissue morphology, diffusion & perfusion parameters, direct & perineural spread

• FDG PET-CT/MRI is a problem solving tool & useful for detection of recurrence

• Angiography is useful for pre-surgical evaluation & embolisation

CT & MRI protocols

CT:

• Pre & post-contrast volume acquisition in axial plane

• Multiplanar reconstructions in soft tissue algorithm (3mm slice thickness) & bone

algorithm (1mm)

MRI:

• T1W in axial & T2W in axial & coronal plane

• Axial T2FS & STIR coronal

• High-resolution post-gadolinium T1W & T1WFS sequences in axial & coronal planes,

• DWI (b-value 500 &1000)

Benign tumors and tumor-like conditions

Osseous & fibrosseous

• Osteoma

• Ossifying fibroma

• Fibrous dysplasia

Epithelial & other soft structures

• Inverted papilloma

• Juvenile angiofibroma

• Hemangioma

• Pleomorphic adenoma

• Nerve sheath tumor

What is your diagnosis?

A 55 year-old male with nasal blockade & rhinorrhea

Inverted papilloma (IP)• Benign but locally aggressive

• M>F, typically 40-70 years

• 13 % bilateral & 4% multifocal IP

• 10% degenerate into or co-exist with SCC

• CT: Bone remodelling, conical focal hyperostosis, entrapped bone sign

• MRI: Post-contrast T1WFS: convoluted cerebriform appearance

• Bone destruction on CT & invasive-necrotic appearane on MRI: malignant degeneration

Inverted papilloma

Dynamic Perfusion MRI can be used as a problem solving tool in certain cases

It is useful in differentiating

• a small multifocal IP from enhancing normal mucosa

• a small recurrent IP from post surgical changes

Treatment: Endoscopic resection/ mid-facial degloving/ medial maxillectomy + rhinotomy

Juvenile angiofibroma (JNA)• Benign, locally invasive, highly vascular tumor

• Almost exclusively adolescent males (10-25 years)

• Centred in posterior nasal cavity near sphenopalatine foramen (SPF)

CT: Avidly enahncing mass centred at SPF, bony remodelling +/- erosion, various

extensions

.

Juvenile angiofibroma• MRI: Heterogeneous, intermediate to high signal on T2W, flow voids +

• Angiography: Tumor blush, internal maxillary artery is feeding artery

• Treatment: Complete surgical resection + pre surgical embolization/ combination of

endoscopic + open resection/ radiation therapy

Osteoma• Benign slow growing tumor

• Frontal & ethmoid sinus are common locations

• Sporadic

• Rarely autosomal dominant (Gardner syndrome)

• 3 grades: ivory, mature and mixed

• < 5% are symptomatic: obstruction to sinus drainage & mass effect

Ossifying fibroma (OF)• Benign fibro-osseous tumor, locally agressive, F>M, 20-40 years

• 4 - subtypes: juvenile, active, agressive & psammomatoid

• CT: Well-defined expansile soft tissue density mass with egg-shell ossified rim

• MRI: Variable appearance, may mimic aggressive pathology/ fibrous dysplasia, may

show fluid-fluid levels

• Treatment: Complete surgical resection

Malignant tumors

Osseous

• Osteogenic sarcoma

• Chondrosarcoma

• Metastasis

Epithelial and other soft tissue structure

• Sqamous cell carcinoma (SCC)

• Esthesioneurobalstoma

• Undifferentiated carcinoma

• Adenoid cystcic carcinoma

• Mucoepidermoid carcinoma

• Non-Hodgkin lymphoma

• Melanoma

Squamous cell carcinoma (SCC)

• SCC accounts for 80% of all sinonasal cancers, of which about 75% are located in

maxillary sinus

• M>F, 50-70 years

• Risk factors: Noxious fume inhalation/ HPV/ inverted papilloma/ previous radiation/

immunosuppression

• 5 - year survival: For T1 stage about 100%, for T4a stage about 34%

• Better prognosis: Ethmoid sinus SCC, low tumor stage, HPV+ve, inverted papilloma

• Poor prognosis: Large tumor size, extension beyond sinus walls, nodal metastases,

perineural spread

Squamous cell carcinoma (SCC)

• MRI: Intermediate-high signal on T2W, moderate enhancement, restricted diffusion, direct

tumor extensions, perineural spread, retropharyngeal lymph nodes

• CT: Moderately enhancing mass/ irregular margins/ bone destruction

Case 1

Case 2

T-stage Maxillary Sinus SCC

Tis In situ

T1 Restricted mucosal lining

T2 Bone destruction, limited to hard palate and

middle meatus

T3 Bone destruction of post wall of maxillary

sinus; flor and medial wall of orbit; tumor

extension to ethmoid sinus and pterygoid

fossa

T4a Tumor growth in anterior orbit; pterygoid

plate; infratemporal fossa; cribriform plate;

frontal-sphenoid sinus; skin

T4b Tumor growth into orbital apex; dura; brain;

middle cranial fossa; cranial nerves other

than V2; nasopharynx; clivus

T-Staging of maxillary sinus SCC

Treatment: Chemoradiotherapy + surgery

Adenoid cystic carcinoma (ACC)• Malignant salivary gland-type adenocarcinoma, M>F, 50-70 years

• Aggressive, high incidence of recurrence, distant metastasis & perineural spread

• Recurrence or metastasis can occur even decades after treatment. Poor prognosis

• MRI: On T2W-intermediate signal with areas of high signal, heterogeneous enhancement,

restricted diffusion, perineural spread,

• CT: Solid or heterogeneously enhancing mass, bone destruction

• Treatment: Chemoradiotherapy + surgery

ACC- Case-1 ACC-Case II

Mucoepidermoid carcinoma (MEC)

• Malignant salivary gland-type adenocarcinoma, rare, M>F, 50-70 years.

• Aggressive & poor prognosis

• MRI: On T2W- intermediate to high signal, diffuse heterogeneous enhancement,

perineural spread

• CT: Solid or heterogeneously enhancing mass, bone destruction

• Treatment: Chemoradiotherapy + surgery

An interesting case:

A middle aged man with previous FESS for sinonasal polyposis underwent NECT at a

private center for recurrent nasal blockade & anosmia

This CT was reported as persistent sinonasal polyposis with rarefication of bones due to

long standing inflammation

Esthesioneuroblastoma (ENB)• Rare malignant neuroectodermal tumor arising from olfactory mucosa

• Bimodal distribution - 2nd & 6th decade

• Kadish Classification: A - nasal tumor, B - involvement of nasal cavity + sinuses, C - beyond

sinuses

• CT: Cribriform plate destruction, bony remodelling of nasal cavity

• MRI: Intermediate-high signal on T2, dumb-bell shaped, avid enhancement, cysts in

intracranial component, T2*GRE- blooming foci

• Treatment: Craniofacial resection + radiotherapy

What is your diagnosis?

An elderly lady with long standing nasal blockade & recurrent epistaxis

Undifferentiated sinonasal

carcinoma• Rare non-squamous cell type tumor

• Elderly > 60 years

• Aggressive & high propensity for distant

metastasis; perineural spread

• Unlike ENB, it extends beyond sinonasal cavity

• CT: Typically large enhancing mass, aggressive

bony destruction, often erode cribriform plate,

dumbbell shape due to intracranial component

• MRI: Low-intermediate T2 signal, areas of necrosis,

heterogenous enhancement

•Treatment: Chemoradiotherapy & surgery

Non-Hodgkin lymphoma• Mimics variety of neoplasms & inflammatory disorders

• Nasal cavity > sinuses, 6th -7th decade

• 3 types: B-cell, T-Cell & natural-killer T- cell (NKTL)

• MRI: Polypoid, Low-intermediate T2 signal, DWI - low ADC, perineural spread

• CT: Iso-hyperdense mass, bone remodelling +/- erosion

• FDG PET-CT: avid FDG uptake

• Treatment: Radiotherapy or chemoradiotherapy

Sinonasal malignant melanoma• Neural crest malignancy arising from melanocytes

• 90% seen in Caucacians, M>F, 50-80 years

• Propensity for systemic metastasis, poor prognosis, mean survival is 24 months

• Melanotic & amelanotic

MRI: Melanotic: T1W-hyperintense, T2W-hypointense

Amelanotic: T1W-intermediate, T2W-variable

Both: T2*GRE +/- blooming

CT: Lobular soft tissue mass, bone remodelling +/- erosion

Treatment: Aggressive radical excision & radiotherapy

What is your diagnosis

A 65-year-old male with recurrent sinusitis & recent episodes of epistaxis

What does the surgeon want to know about the

tumor?

• Malignant or benign

• Tumor margins & direct extensions

• Perineural spread

• TNM staging

Tumor extension & impact on treatment

JAF

ENB (stage T4b)

SCC (stage T4a)SCC (stage T4a)

SCC (stage T4b)

Foramen rotundum + Meckel cave

+ infratemporal fossa

IntraduralIntraorbital + hard palate

Masticator space Cutaneous infiltration

Ectopic ENB( stage T4b)

Skull base --cavernous sinus

Perineural spread & its impact on treatment

• Depiction of perineural spread helps in individualisation of radiation field

• Perineural spread to foramen rotundum & cavernous sinus suggests low

probablity of cure with radiotherapy

Adenoid cystic carcinoma Rhabdomyosarcoma Mucoepidermoid carcinoma

PPF + Maxillary NPPF + Vidian N +GSPN +

Facial N

PPF + Greater palatine

nerve

TNM staging

AJCC Cancer

Staging System,

8th Edition

Take home messages

• CT & MRI complement each other in the diagnosis & management of sinonasal tumors

• An aggressive inverted papilloma may mimic a malignant tumor

• A highly vascular posterior nasal cavity tumor in an adolescent male is typical of a JAF

• Melanotic melanomas are hyperintense on T1

• Otherwise, most malignant tumors have overlapping imaging features & imaging may not

indicate a histopathologic diagnosis

• Description of tumor margins, extensions & perineural spread impacts treatment

Acknowledgements

Prof. Dr. Minerva Becker

Department of Radiology

University Hospital, Geneva

Switzerland

Thank you for your attention

Matterhorn, 4478 metres mundada.pravin@gmail.com