Treatment of Cancer of the Nasal Cavity

8/10/2019 Treatment of Cancer of the Nasal Cavity

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* F rom the R adiation T herapy D epartm ent,t and H ead and N eck D epartm ent, R oSw ell P ark M em oria l Institute, B uffalo ,

York .

A U G U S T , 19 69

824

T R E A T M E N T O F C A N C E R O F T H E N A SA L C A V IT Y *

B y A . 0. BA DIB , M .D .,t S . S. K U ROH A RA , M .D., PH.D .,tJ . H . W EB ST ER , M .D ., C .M .,tan d D . P. SH E D D , M.D4

B U F FA LO , N E W Y O R K

P R IM A R Y m alignant tum ors of thenasal cavity are relatively rare and are

usually reported to have a poor progno-

sis.37b0 M ost of the published reports in-

dude these tum ors in one group w ith other

tum ors m ainly of the paranasal si-

nuses.35-8#{176}4 The special problem s of diag-

nosis and m anagem ent of cancer of the

nasal fossae6 and the apparen t difference in

the prognosis m ade their separate presenta-

tion desirable.1 In review ing the litera ture,

the indications for surgery or rad iation

therapy are not c learly defined and the re-

sults of treatm ent are not easily com pared

because of the difference in selection of pa-

tients for treatm ent.

In this study, w e present the experiences

at R oswell Park M em orial Institu te in the

m anagem ent of patients w ith cancer of the

nasal cav ity . T he influence of differen t

prognostic factors on the results of treat-

m ent by irradia tion and/or surgery w ill be

discussed with an evaluation of the indica-

t ion for techni ques an d r es ul ts o f r ad ia ti on

therapy.

M AT E R I A L

Over the period of 23 years, betw een

January, 1942, and D ecem ber, 1964, a to-

ta l of 57 patients w ith m alignant tum ors of

the nasal fossa w ere treated at R osw ell

Park M em orial Institu te, B uffalo, N ew

Y ork . The clinical featu res in the series are

presen ted in T able i. M ales w ere m ore

frequently afflicted than fem ales. T he aver-

age age incidence w as6i years and 77 pe r

c ent of the cases w ere above 50 years of age.

The duration of sym ptom s varied from

w eeks to m ore than 2 years, the average be-

ing 8 m onths. The com m on early sym p-

tom s (Table i) w ere unila tera l nasal ob-

struction (77 per cent), nasal discharge

(5 4 per cent), epistaxis (4 0 per cent), and

local pain (2 8 per cent). The rem aining

sym ptom s (Table I) w ere less frequen t and

usually la te.

Chronic sinusitis and nasal polyps pre-

ceded the tum or in 8 cases(i 5 per cent). N o

other po ten tial predisposing facto rs, such

as benign grow ths, a trophic rhinitis or pre-

vious irradiation , w ere found .

The tum ors w ere lim ited to the right side

ofthe nasal cav ity in33 cases (8 per cent),

to the left side in2 cases (,7 per cent), and

w ere bilateral in3 cases ( per cen t). Thelateral w all w as the m ost frequen t site of

tumor: 9 on the tubinates (2-upper, 4-

m iddle, and 3-low er turbinate) and10 on

the rest o f the lateral w all. O ther sites, in

order of decreasing frequency w ere: sep-

tum , vestibule, posterior choana and floor.

The site of origin cou ld not be determ ined

in 10 cases w ith cancer filling the entire

nasal cav ity (Tab le II).

These tum ors w ere either polypoidal

m asses in 38 cases (67 per cent) or ulcera-

tive lesions in 19 cases (3, per cent).

Eigh teen cases show ed extension outside

the nasal cavity , m ainly to the m axillary

antrum (9 cases), ethm oidal sinuses (

cases), and nasopharynx ( cases). Lym phnode m etastases were found in 8 cases 1 4

per cent) and distant m etastases in2 cases

(4 per cent).

R oe n t ge no l og ic e xa mi n a t io n o f th e n os e

a n d n as a l s in u se s s ho we d bo n e destruction

i n 18 cases, nasal opacity or m ass in14

cases, and b o th i n I I cases. Ethmoidal an d

m axillary sinusitis w as seen in10 cases

( Ta b l e i).

To assess the i mp or t a nc e o f t he ex t en t o f

tum or as a prognostic factor, a clinical

stag ing w as devised (Tab le III), based on

TN M classification used by C occh i. S tage


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TA B L E I

C LIN IC A L F EA TU RE S

Se xFemaleMale

V O L . 106, N o. Tr ea t me n t o f Ca nc e r o f th e N asal Cavity 82 5

I (T1_T2, N0, M 0) included i6 cases; Stage

II (T1_T2, N 1, M 0), 6 cases; S tage II I (T1_T,,

N 2, or T ,, NO-N2) , 17 cases; and Stage iv

(T4, N -N 2 or T1-T4 , M ), 18 cases. T1 de-

notes a tum or lim ited to the m ucosa that isI cm . in diam eter or less; T2, m ucosal

lesion m ore than i cm . in diam eter; T,

tum ors invo lving bone or cartilage; and

T4, extension outside the nose.N1 m eans a

m obile, unilateral lym ph node; andN 2

fixed or b ilateral lym ph nodes. M stands

for d istan t m etastases.

The diagnosis w as estab lished h istologi-

cally in all the cases and is given in Table

II . T he predom inan t type w as squam ous

c ell c arc in om a (I 2-w ell differen tiated ,

m edium differentiated, and 8-und iffer-

entiated, w hile 8 w ere ungraded). T his w asfollow ed by adenocarcinom a (i i cases),

m ixed salivary tum or ( cases), anaplasticcarcinoma ( cases) and m alignant m ela-

noma (2 cases).

TREATMENT

In th is series, th ree m odalities w ere used

as in itial treatm ent: irrad iation (3 0 cases);

surgery (13 cases); and com bined surgery

an d irrad iatio n (14 cases) (Table III).

In the irrad iation group, 25 cases (#{231}er

cent) received ex ternal radio therapy alone,10 cases had radium therapy alone and 9

cases w ere g iven external irrad iation p lus

rad ium . Tum ors of the vestibule w ere

treated by a single field using orthovo ltage

rad iation. S ingle anterior fields w ere used

for irradiating other tum ors in the an terior

part of the nasal cavity. P arallel opposing

fields w as the technique em ployed in lesions

of the posterior choana w hile an terior and

lateral w edge pair w as used in som e tum ors

involving the m axillary and ethm oidal

sinuses. In extensive lesions, th ree cross-

f i ri n g f ie ld s w er e p re fe rr ed . O rt ho vo lt a ge ,

supervoltage an d c ob a l t 6 o eq u ip me n t w er e

u se d a n d th e tum or dose w as in the range of

5,000 t o 6,ooo r ad s in 5- 6 w eeks depend ing

o n t h e v o l um e t r e a t ed . In som e cases, it was

n ec es sa r y t o in c l u de t he ip s i l a t e r a l e y e i n

th e t r e a t me n t f i e ld , p r o t ec t i n g th e o th e r

N o . o f

Patients

P e r C e n t o f

Patients

A geUnder 40

40-49

50 59

60-69

70 -79

Over 8o years

Sym p tom D uration

0-2

2-4466-12

Over 12 m onths

Presenting Sym ptomN asal obstruction

N asal dischargeEpistaxisLocal painN asal swelling

EpiphoraV is ua l d is tu rb an ce sN eck m ass

Tumor Extens ionM axillary antrumEthmoid s inusOrbitNasopharynxSphenoid sinusC ribriform plateL ym ph nodes

D istant m etastases

Roentgenologic FindingsB on e d es tr uc tio n

N asal opacity or m assBoth

C hron ic sinu sitisNegative

12 21

45 7 9

5 98 4

7 1222 39

13 23

2 4

17 30

34 25

8 14

JO 17

8 14

44 7731 54

23 40

i6 2832 2

5 9

3 52. 4

9 16

4 7

4 7

3 52 4

I 2.

8 14

2 4

i 8 32

14 25

II 19

30 17

4 7

eye by lead or by tilting the beam of the

l a te r al f i el d s.

Intracavitary and interstitial radium

w er e us ed ma in ly in sm a l l tum ors lim ited to

the nasal fossa (io cases). Radium appli_


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826 A . 0. B adib , S . S . K urohara, J. H . W ebster and D . P . S hedd AU G U sT ,

TA B L E II

PA TH O LO G Y BY A N A T O M IC S1FE S

N asal Sites Total

Latera l Y es- U ndeter-Septum . C hoana Floor . N o. Per Cent

Wai t tiDuie mined

S qu am ous carcinom a 6 32 6 o o 8 32A naplastic carcin om a i 2 0 1 0 0 4 7

Lym phoepithelial carc inom a o o o 2. I 0 3 5Adenocarcinoma 8 o o o i 2 II 19Mixed salivary tum or 3 I I 0 0 0 5 9M alignant m elanom a I I 0 0 0 0 2 4

Total N um ber 39 i6 7 3 2 10 57 10 0Per C ent 3 3 28 12 5 4 i 8 10 0

cators or m olds w ere inserted into the nasal tum or dose w as 6,ooo-7,ooo rads in 7-8

cavity through the nostril for anterior days depending upon tum or size.

lesions or th rough the posterio r naris using External irradiation plus intracav itary

a nasal catheter for les ions in the posterior radium w as used in 9 cases oflocally exten-

part. Partia l excision of the tum or w as sive tum or (Tableiii). F ollow ing external

necessary in som e cases to facilitate radium radiotherapy to a tum or dose of5,000

applica tion. Interstitia l radium needles or rads/5 w eeks, an intracavitary radium

radon seeds were used in 4 patients w ith applica tor w as applied to add3,000 rads at

accessible anterio r tum ors of the sep tum o. cm . from the surface in 4-6 applications.

an d f loor. In cases treated by radium , the The surgical procedures used in25 cases

TA B L E II I

I NITIAL TREATMENT BY CLINICAL STAGES

C lin ical Stages T otal

I II III IV N o. Per Cent

A ll Series x6 6 17 18 57 10 0

TreatmentI r r a d i a t i o n II 2 8 9 30 53S u rg e r y 5 3 3 2 13 23

C o m b i n e d 0 I 6 7 14 2 4

Irradia tion TechniquesExternal irradiation 6 2. 6 I I 25 57Radium 5 I 0 10 23

Combined 0 0 4 5 9 20

S urgic al P roc edure sL oc al rese ction 5 3 6 0 14 52Radical 0 I 3 9 13 48

C om bined w ith SurgeryPreopera tive irradia tion o o I 3 4 29

P o s t o p e r a t i v e i r r a d i a t i o n o I 5 4 10 7


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TA B L E IV

RE SUL T S O F T RE A TM E NT BY C LINIC AL ST AG ES, H IST O L O G Y A ND SIT E S

5 Y EA R C R U D E SU R V IV A L

A . C lin ical Stages

TotalStage I Stage II Stage III Stage IV

Irradiation 8/9 (89% ) 1/2 (o% ) 2/ 6 (% ) i/6 (17%) 12/23 52 )Surgery 4/5 (8o% ) 2/3 (67%) 2/3 (67%) 0/I ( o% ) 8/12 (67%)Combined I/I (100% ) 2/4 (50% ) 2/5 (o% ) io (o% )

Total 12 /14 86 ) 4/6 (67% ) 6/13(46%) 3/12(25%)

B . H istology

. Lympho- . . . TotalSquam ous Anaplastic {149}th1 1 A deno- iviixed M aiignant

C arcinom a C arcin om a ep i e ia carcinom a Salivary M elanom aCarcinoma

Irradiation 6/12 (o% ) i/ (25% ) 2/2 (100% ) 1 /3 (% ) 2/2 (100%)

12/23 (52% )Surgery 5/7 (73% ) 1/2 (o% ) 2/3 (67%) 8/12 (67%)

Combined 3/5 (60% ) 2/ 4 (o% ) o/ i (0 ) io ( )

Total 34/24 (6% ) 1/4 (25% ) 2/ 2 (100%) 4/9 (44% ) 4/ 5 (8o%) 0/I (o% )

C . Site

TotalL ateral W all Septum V estibule C hoana U ndeterm ined

Irradia tion 3/6 (o% ) 3/6 (o% ) 2/3 (67%) 2/3 (67%) 2/5 (40% ) 32/23 52 )Surgery 3/ 5 (6o%) 4/ 5 (8o%) 1/2 (o% ) 8/12 (67% )Combined 2/ 3 (67% ) 1/2 (50% ) i/i (100% ) 1/ 4 25 ) i o (50%)

Total 8/14 ( {231} % ) 8/13 (62% ) 4/6 (67% ) 2/ 3 (67% ) 3/9 (% )

V O L . io6, No. Treatm ent of Cancer of the Nasal Cavity 82 7

in this series w ere sim ple resection or

electrocoagula tion of sm all tum ors in14

cases, and radical resection of the nasal

cavity and m axilla w ith curettage of the

ethm oidal and spheno idal sinuses in the

m ore ex tensive tum ors in13 patients. Orbi-

tal excision w as done in2 cases and radical

neck d issection in4 cases.

In the com bined rad iotherapeu tic and

surg ical treatm ent preoperative irradiation

w as given in 4 cases and postoperative ir-

rad iation in io cases using radium or ex-

ternal radiation therapy. T he dose and the

technique depended on the vo lum e of tissue

irradiated and w ere sim ilar to those de-

scribed above.

RESULTS

Table iv illustrates the resu lts o f treat-

m ent in the various clinical stages, h is-

tology and sites of tum ors. E arly stages of

cancer lim ited to the nasal m ucosa ex-

hib ited the best p rognosis. F igure and

Table Iv show that well differentia ted

squam ous cell carcinom as had the best re-

sults and that adenocarcinom as had better

prognosis than undifferentiated squam ous

cell and anaplastic carcinom as. O ther his-

to log ic groups exh ibiting good results w ere

the lym phoep itheliom as and m ixed salivary

tumors . The w hole series had a crude year

surv ival rate of 56 per cen t, and a h igher

tum or-free actuarial su rvival rate of 67

per cent due to the fact that som e of the

patients w ere free of tum or at death or

f o l l o w - u p .

In the cases w ith early stages of this tu -

m or (S tage and II com bined) treated by

irradiation or surgery , year surv ivals of

82 and 75 per cen t, respectively, w ere ob-


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10

Y E A R S A F T E R D IA G N O SIS

82 8 A . 0. B ad ib , S . S . K urohara, J. H . W ebster and D .P . Shedd A U G U S T , 196 9

>

S

FIG . I Su rvival rate cu rves after diagn osis of cancer

of the nasal cavity. (ii) Crude survival and(B )tu m or-free su rvival. T he solid curve is for a ll

cases, the interrupted curve is for the histologicgroup s an d the vertica l bars represent 95 pe rcen t confidence interva l. SC= squam ous cell car-

cin om a, u ngrad ed . SC I, II and III = squamous

cell carc inom a, G rades I, II and III. A napl.=anaplastic carc inom a.

tam ed (Table iv ). In late stages (S tageiii

an d Iv com bined) w hich received rad iation ,

surg ical and com bined treatm ents, the

year survivals were: 25, 50, and per cent,

respectively. S ixteen cases(2 8 per cent)

show ed either failu re of response (4 cases)

o r r ec ur re nc es i 2 cases) after the initial

t reatment . Fo ur o f the recurrent cases de-

veloped regional lym ph node m etastases

an d 2 of them distan t m etastases. E ighty

per cent o f the recurrences appeared w ith in

the first year after treatm ent. The m ean re-

currence tim e w as 10 m onths. The per-

sisten t cases and o f the recurrences fol-

low ed radiation treatm ent, w hile3 recur-

rences appeared after surgery , and after

the com bined treatm ent. A ll the persisten t

and recurren t lesions occurred in the pa-

tients w ith an in itial advanced tum or of

Stages H I and Iv. R ecurrences after in itial

su rg ical or com bined surgery and irradi-

ation w ere treated by irradiation. Four of

the persisten t and recurrent tum ors fo llow -

ing initial irradiation w ere re-irrad iated and

the rem ain ing 5 received surgical treat-

ment .

T he final assessm ent of tum or status

show ed year cure in40 cases and failu re

in 17 cases. The failures include 9 patients

w ith local tum or, 4 w ith m etastases, i with

both , and 3 of unknow n status.

DISCUSSION

T he concepts of treatm ent of nasal can-

ce r differ in the various pub lished studies

and change from tim e to tim e in the sam e

clinic.39 Irrad iation , alone, w as the pri-

m ary m ethod of treatm ent in som e series,59

w hile com bined rad iation and surg ical

treatm ent was advocated in m any

others.35#{176}25 Treatm ent was essentia lly

surgical in som e clinics367 and either surg i-

cal o r radio therapeutic , depending on the

radiosensitivity and extent of tum or, in

others.48 The w ide variations in the re-ported results can be ascribed to the m an-

ner in w hich the various au thors selected

cases for treatm ent and to the type of sub-

sequent analysis.

The treatm ent m ethods used in th is

series depended on the site , ex tent and the

histo logy of tum or. R adiation therapy w as

the m ost com m only used technique in both

early and advanced tum ors including m any

epiderm oid carcinom as and adenocarci-

nom as and all anaplastic and lym phoepithe..

hal carcinom as. Surgery w as used prin-

cipally in som e of the early cases and in tu-m ors w ith bone and cartilage involvem ent

and in a few locally extensive tum ors , in-

c luding squam ous cell carc inom as, adeno-

carcinom as and m ixed salivary tum ors.

C om bined treatm ent w as selected in ad-

vanced lesions of any histologic group.


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V O L . io6, No. Treatm ent of C ancer of the N asal C av ity 82 9

In the rad iation treatm ent, radium ther-

apy was selected for sm all accessible

lesions; external rad iotherapy for larger and

less accessible tum ors; and radium plus

ex ternal irradiation in m ore ex tensive dis-.ease. External irrad iation w as com m only

used as it is m ore flexible and satisfactory.

Parker advocated external roen tgen ther-

apy in all his cases. Radium plus external

rad iotherapy w as preferred by D evineet

al.2 in nasal and ethm oidal cancer to

achieve a hom ogeneous high le thal tum or

dose. H ow ever, using supervo ltage and

cobalt 6o radiation, w e can deliver a rad ical

tum or dose w ithout the com plications pre-

viously reported after conventional rad io-

therapy.3 M inor early and la te radia tion

sequelae w ere reported in som e of the casesbu t no m ajor com plications w ere seen in

this series.

C onservative surgery plus irradiation

w as advocated by O liver,0 w hile m ore ag-

gressive surgical procedures have been used

by Frazell and Lew is.3 In our cases, se lec-

tion ofsim ple or radical surgical procedures

depended on the site and extension of the

tumor.

B ecause the ex ten t of involvem ent, site

and histology of tum ors are im portant fac-

tors in determ ining survival; these facto rs

w ill be discussed before the evaluation ofthe treatm ent results. Tum or w ith exten-

sion outside the nasal cav ity has a poor

prognosis.5 90 This is seen in the low survi-

val rates in the advanced stages of th is S e-

ries. R oen tgeno log ic ev idence of bone de-

struction w as considered an unfavorab le

facto r in cancer of the nose and paranasal

sinuses.0 H ow ever, Larsson and M artens-

son5 found no great difference betw een the

resu lts in cases w ith or w ithout bone de-

struction. In this study, the cases with evi-

den t bone destruction and extranasal ex-

tension had a shorter survival in all treat-

m ent groups. In cases w ith tum ors lim ited

to the naval cavity, p resence or absence of

roen tgeno log ic evidence of bone involve-

m ent produced no difference in the results.

The presence of lym ph node m etastases

(relatively uncom m on in this series,14 per

cent) w as associated w ith poor prognosis in

th is m aterial and in o thers.59

The location of the tum or has been re-

ported to be of param ount im portance.#{176}

T um ors of the upper and posterior part of

the nasal reg ion w ere reported to have a

poor prognosis due to their early infiltra-

tion.5 The influence of a particu lar site w as

reported to depend on the ease w ith w hich

the tum or can ex tend to a surrounding vital

s t ructure ; e.g., tumors of the olfactory re-

gion m ay extend to the ethm oids, orbits

and base of the skull, w hile those of the

posterior choana spread to the nasophar-

ynx.8 In th is m aterial, allow ing for all o ther

possible prognostic facto rs, no difference

ex isted betw een the resu lts in tum ors of

various anatom ic sites.A nother prognostic facto r is the h isto -

log ic type. Larsson and M tensson ,5 and

M acC om b and M artin9 reported bad prog-

nosis in the undifferentia ted carcinom as

and the adenocarcinom as. O n the other

hand, O liver0 stated that the type of can-

cer does not appear to alter the prognosis.

T his series show ed a h igher survival rate

in the differentia ted squam ous cell car-

c inom as than in adenocarcinom as. The un-

differen tiated and anaplastic carcinom as

had the low est survival ra te .

The reported resu lts o f surgery versusradiotherapy in m any publications can not

be considered as criteria for com paring

their respective effectiveness, as surgery

w as m ainly used in early operable cases,

w hile rad iation therapy w as lim ited to pal-

lia tion in inoperable advanced tum ors and

residual or recurrent disease .347 N o sta-

tistical d ifference w as found am ong the

over-a ll results of the3 m ain m ethods to

trea tm ent in this series. H ow ever, the

analysis of the results in each stage show ed

som e poin ts of in terest. In the early m u-

cosal lesions, both irrad iation and surgery

gave equally good resu lts. In tum ors w ith

b o n e or cartilage invo lvem ent or lym ph

node m etastases the com bined and surgical

m ethods apparently y ielded better results.

Frazell and Lew is3 using irradiation in a

secondary role in res idual or recurrent tu-


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83 0 A. 0 . B a d i b , S . S . K u ro ha ra , J. H. W ebster and D . P . Sh ed d A U G U S T, 1969

m ors, reported I 8 per cent cure rate after

irradia tion and 6 per cent after surgery.

W hen com paring their resu lts in the surgical

group w ith the results in this series in the

radiotherapeutic group, no difference in the

survival rates can be detected . A lso, the

results in their radiotherapeutic group are

com parable to our resu lts in the advanced

cases. H endrick4 reported 8 cases of nasal

carcinoma; 4 early, trea ted by surgery w ith

4- 7 year survival; and 4 advanced, trea ted

by irradia tion w ith 1- 3 year survival. In

the series of M acC om b and M artin9 8

patients survived out of35 patients w ith

nasal carcinom as treated by irrad iation ,

surgery or com bined m ethods.

Favorable results after radiation treat-

m ent of m alignant tum ors of the nasal fossaw ere reported by Parker. Ini 2 patients,

he reported a 67 per cent con trol rate at3-10 years using external rad iotherapy in

all the cases.

S U M M A RY

F ifty-seven cases of can cer ofthe nasal

cavity w ere treated initially by irradia tion

(30 cases), surgery (1 3 cases) and com binedirradia tion and surgery (14 cases). Irradi-

ation w as given using radium techniques in

sm all accessible lesions, external radia tion

therapy in less accessible tum ors, and ex-ternal rad iation therapy plus radium in

m ore extensive disease . External radiation

therap y is the technique com m only used

and w as considered m ore flexib le and satis-

factory . Sim ple or radical surgical proce-

dures were selected according to the site

and extent o f tum or. In the com bined

treatm ent, surgery w as ord inarily follow ed

by irradiation in the treatm ent of locally

advanced tum or.

The degree of extension and the histo logy

of tum or w ere the m ost significant prog-

nostic factors. Early w ell differentia ted

squam ous cell carcinom as have the bestprognosis. The 5 year surv ival in the w hole

series w as 6 per cent. In the early tum ors,radiotherapy and surgery gave equally good

results. In tum ors with bone or cartilage

i n va s io n o r ly mp h n od e metastases,

50 p e r c en t y ea r su rv iv a l fo l l o we d th e

c om b in ed a nd s u r g i c a l t r ea tm e n t .

A . 0. B adib , M .D .

Roswell Park M em oria l Institute

666 Elm StreetBuffa lo, New Y ork14203

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Treatment of Cancer of the Nasal Cavity

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