TREATMENT OF CANCERTREATMENT OF CANCER OF THE … · TREATMENT OF CANCERTREATMENT OF CANCER OF THE...

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TREATMENT OF CANCERTREATMENT OF CANCER OF THE OF THE

NOSENOSE AND THE PARANASALAND THE PARANASAL

30th Alexandria International Combined ORL Congress (10-12 April 2013)

NOSENOSE AND THE PARANASAL AND THE PARANASAL

SINUSES SINUSES –– MODERN CONCEPTSMODERN CONCEPTS

Wojciech Golusiński

Department of Head and Neck Surgery

The Great Poland Cancer Centre, Poznan, Poland

University of Medical Sciences, Poznan, Poland

Piotr Pieńkowski

Head and neck surgery, especially surgery of the nose and Head and neck surgery, especially surgery of the nose and

paranasal sinues, is a very specific kind of surgery because paranasal sinues, is a very specific kind of surgery because

of specific anatomical conditionsof specific anatomical conditions

Head and Neck Surgery

of specific anatomical conditions of specific anatomical conditions

sense organs:sense organs:

–– sight sight

–– tastetaste

–– smellsmell

Very good vascularization Very good vascularization

and innervationand innervation

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Restricted surgical fieldRestricted surgical field

Difficult to view some anatomical structures, requires Difficult to view some anatomical structures, requires

Head and Neck Surgery

application of additional visual equipment application of additional visual equipment

(endoscope, microscope)(endoscope, microscope)

Common part of upper respiratory and alimentary tract Common part of upper respiratory and alimentary tract

determines operational and postdetermines operational and post--operational procedureoperational procedure

Head and neck cancers – tumor of the paranasal sinuses and anterior skull base

Crossing the borders of different specializationsCrossing the borders of different specializations

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Within the cooperation in the Department there is a therapeutic team proposing treatment for every single patient individually

Head and neck surgeonHead and neck surgeon

RadiotherapistRadiotherapistSk ll b

pp

AnesthesiologistAnesthesiologist

PathologistPathologist

NeurosurgeonNeurosurgeonTherapeutic Therapeutic meetingmeeting

Skull base team

Clinical oncologistClinical oncologist

Radiologist Radiologist

Psychologist Psychologist

PhysiotherapeutistPhysiotherapeutist

MAXILLARYMAXILLARY ETHMOIDAL COMPLEXETHMOIDAL COMPLEXMAXILLARYMAXILLARY--ETHMOIDAL COMPLEX ETHMOIDAL COMPLEX

TUMORS TUMORS

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MaxillaryMaxillary--ethmoidal complex tumors constitute 3% of ethmoidal complex tumors constitute 3% of

all neoplasms of the upper gastroall neoplasms of the upper gastro--pulmonary tract. pulmonary tract.

7 : 100 000 cases7 : 100 000 cases

M : FM : F M : F M : F

2:1 3:12:1 3:1

Head & Neck Oncology P. Evans 2003

Exposure to industrial fumes and wood dust has been

associated with an increased incidence of certain types

of sinonasal malignant tumorsof sinonasal malignant tumors.

Nickel workers show an incidence 250 times greater

than the general population with a latent period of 3 to

18 months.

Furniture workers, who are exposed to hardwood dust,

suffer an increased incidence of adenocarcinoma of the

ethmoid sinus.Head & Neck Oncology P. Evans 2003

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Sinuses & skull base

The most common clinical presentation of tumors of the

sinonasal tract includes nasal airway obstruction, pain,

epistaxis, nasal discharge, or swelling of the cheek.

9% to 12% of patients with sinonasal tumors are

asymptomatic

Weisberger and Dedo reported that paranasal tumors are

associated with a high incidence of cranial neuropathies

(34%) as compared to inflammatory disease (4% to 8%).

Head & Neck Oncology P. Evans 2003

Diagnosis Diagnosis –– Paranasal TumorsParanasal Tumors

Technique

History and Risk factors/cranial nervephysical deficits

Imaging Bone erosionRadiograms

CT scanning Evaluation of bony boundaries of PNS

MRI Evaluation of soft tissue and evaluation of orbit

Biopsy

Sinus lavage/gcytology

Fine needleaspiration

Transnasal biopsy Direct or endoscopic

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SurgerySurgery

TreatmentTreatment

RadiotherapyRadiotherapy

ChemotherapyChemotherapy

tumor’s histological type

t f l ti

What should be taken into consideration What should be taken into consideration when planning individual treatment? when planning individual treatment?

stage of neoplastic proccess

surgical radicalness

patient’s general condition

possibility of combined therapy

possibility of reconstruction

socio-economic factors

patient’s expectations

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MaxillaryMaxillary--ethmoidal complex tumorsethmoidal complex tumors

EpithelialBenign

Keratotic papilloma

Fungiform papilloma

NonepithelialBenign

Fibroma

Chondroma

NonepithelialMalignant

Soft tissue sarcoma

Rhabdomyosarcoma

Inverted papilloma

Cylindrical papilloma

Adenoma

Malignant

Squamous cell carcinoma

Transitional cell carcinoma

Adenocarcinoma

Ad id ti i

Osteoma

Neurilemmoma

Neurofibroma

Hemangioma

Leiomyosarcoma

Fibrosarcoma

Liposarcoma

Angiosarcoma

Myxosarcoma

Hemangiopericytoma

Connective tissue sarcoma

Ch dAdenoid cystic carcinoma

Melanoma

Olfactory neuroblastoma

Undifferentiated carcinoma

Chondrosarcoma

Osteosarcoma

Lymphoreticular tumors

Lymphoma

Plasmacytoma

Giant cell tumor

Metastatic Carcinoma


maxillary sinuses 60%

lateral nasal wall 30%

ethmoidal sinuses 10-15%

6060%%30%30%

1010--15%15%

sphenoidal and frontal sinus other6060%%30%30%

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American Joint Committee on CancerAmerican Joint Committee on Cancer

Ohngren lineOhngren line


infrastructure tumors infrastructure tumors –– better prognosisbetter prognosis

suprastructure tumors suprastructure tumors –– worse prognosisworse prognosis

From simple endoscopic lesion resection to a total From simple endoscopic lesion resection to a total

maxillectomy with exenteration of an orbitmaxillectomy with exenteration of an orbit and and

SurgerySurgery

yy

craniofacial resectioncraniofacial resection

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When to use the conventional surgical When to use the conventional surgical

SurgerySurgery

technique? technique?

When to use the endoscopic technique? When to use the endoscopic technique?

Is the fundamental rule of oncologicalIs the fundamental rule of oncological

SurgerySurgery

Is the fundamental rule of oncological Is the fundamental rule of oncological

surgery, surgery, removal of the whole tumor removal of the whole tumor

with a margin of neoplasmwith a margin of neoplasm--free tissues,free tissues,

possible to fulfill when using possible to fulfill when using p gp g

the endoscopic techniques? the endoscopic techniques?

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Endonasal endoscopic tumor removal:Endonasal endoscopic tumor removal:

Small intraethmoidal tumorsSmall intraethmoidal tumors

can be removed can be removed en blocken block..

Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.


„Multilayer

centripetal technique”


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“Multilayer centripetal technique”

Top of the

Septum

Ethmoid

Top of the

ethmoid


„Multilayer centripetal technique”„Multilayer centripetal technique”


Consists of 5 stages:Consists of 5 stages:gg

1.1. Decreasing tumor’ massDecreasing tumor’ mass

2.2. Subperiosteal removing of ethmoidSubperiosteal removing of ethmoid

3.3. Removal of bony structures surrounding the tumor (septum, Removal of bony structures surrounding the tumor (septum, bones of the skull base, lamina papiracea)bones of the skull base, lamina papiracea)

44 R l f th d lf t b lb i bitR l f th d lf t b lb i bit


4.4. Removal of the dura, olfactory bulb, periorbitRemoval of the dura, olfactory bulb, periorbit

5.5. Plastic of the dura of the skull basePlastic of the dura of the skull base

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Area of the removal of ethmoid

for intraoper.

histological

examination


Area of the nasal septum removal


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Area of the medial maxillectomy


Plastics of the dura


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Exclusion criteria in endoscopic approach

Frontal sinus involvement

Orbital content involvement

Massive dura involvement (not merly contact or focal

involvement)

Maxillary sinus bony involvement (except the medial wall)

Extension to nasopharynx but not limited to

h b il f ipharyngobasilar fascia

Lacrimal tract involvement

Hard palate involvement

Nasal pyramid involvement

Smith 1954 Smith 1954 –– malignant tumors developing from upper part of malignant tumors developing from upper part of

“Craniofacial resection” for tumors “Craniofacial resection” for tumors located within cribrumlocated within cribrum and skull baseand skull base

nasal cavities, ethmoidal sinuses (posterior ethmoidal complex) nasal cavities, ethmoidal sinuses (posterior ethmoidal complex)

and structures of orbital cavityand structures of orbital cavity

NonNon--malignant but clinically aggressive tumors: meningioma, malignant but clinically aggressive tumors: meningioma,

chordoma, juvenile adenofibroma penetrating to the inside of the chordoma, juvenile adenofibroma penetrating to the inside of the

skullskull

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Ketchum 1963 Ketchum 1963 –– reported the first series ofreported the first series of patients treated with patients treated with

“Craniofacial resection” for tumors “Craniofacial resection” for tumors located within cribrumlocated within cribrum and skull baseand skull base

an anterior craniofacial resection foran anterior craniofacial resection for tumors arising in the ethmoid tumors arising in the ethmoid

sinusessinuses;;

aann enbloc resection of tumor, including the ethmoid sinuses,enbloc resection of tumor, including the ethmoid sinuses,

superior nasal septum, and floor of the anterior cranialsuperior nasal septum, and floor of the anterior cranial fossa, fossa,

corresponding to the interorbital area (i.e. anteriorcorresponding to the interorbital area (i.e. anterior craniofacial craniofacial

resection) or extended laterally to include partresection) or extended laterally to include part of the bony orbit or of the bony orbit or

its soft tissue contents (anterolateralits soft tissue contents (anterolateral craniofacial resection)craniofacial resection)

“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum

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52 years old woman52 years old woman

Chondrosarcoma

diplopia for two weeks diplopia for two weeks

before hospitalisationbefore hospitalisation

MRI

Pathological mass in sphenoid bone fiiling up sphenoid Pathological mass in sphenoid bone fiiling up sphenoid

sinus,penetrating nasopharynx, nasal cavity and posterior part sinus,penetrating nasopharynx, nasal cavity and posterior part

of ethmoid sinusof ethmoid sinus

Chondrosarcoma

o e o d s uso e o d s us

MRI

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CT

Chondrosarcoma

Tumor fills sella turica and

presses cavernous sinuses

Chondrosarcoma

Surgery

Endoscopic

approachapproach

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Chondrosarcoma

Week after

surgery

Chondrosarcoma

6 months after

surgery and

di thradiotherapy

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Chondrosarcoma

CT week

after

surgery

MRI 6 months after surgery

Chondrosarcoma

after surgery and

radiotherapy

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combined endoscopic transnasal combined endoscopic transnasal

CranioCranio--endoscopic techniqueendoscopic technique

and transcranial approach and transcranial approach

cooperation with neurosurgeoncooperation with neurosurgeon

tumors penetrating in the nasal cavity and anteriortumors penetrating in the nasal cavity and anterior tumors penetrating in the nasal cavity and anterior tumors penetrating in the nasal cavity and anterior

cranial fossacranial fossa

Area of the resection

Area forArea for

neurosurgeon

Area for head &

neck surgeonneck surgeon


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for every patient/tumor?for every patient/tumor?

NONO

MRMRII

Carcinoma planoepitheliale

54 years old male

Tumor of the hard palate

for 3 weeks

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CT after surgery

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32 years old male

4 k hi f idl

Leiomyosarcoma

4 weeks history of rapidly

growing tumor in oral cavity

Leiomyosarcoma

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16 years old male

Esthensioneurblastoma

2 years history

– tumor of the right

orbit

History of alternative

treatmenttreatment

T3 Kadish staging

system

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MRI



Surgery

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MRI

4 months

after surgery


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Endoscopic evaluation

Patient qualified for:Patient qualified for:

endoscopicendoscopic--transcranial approach.transcranial approach.endoscopicendoscopic transcranial approach.transcranial approach.

Craniofacial resection. Craniotomia fronto basalis, Craniofacial resection. Craniotomia fronto basalis,

orbitotomia supramedialis, excisio tumoris cavi nasi, orbitotomia supramedialis, excisio tumoris cavi nasi,

septi nasi, sinus ethmoidalis anterior et posterior, septi nasi, sinus ethmoidalis anterior et posterior,

sinus frontalis et sphenoidalissinus frontalis et sphenoidalissinus frontalis et sphenoidalis. sinus frontalis et sphenoidalis.

Lymphadenectomia selectiva colli sin. Lymphadenectomia selectiva colli sin.

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Endoscopic evaluation – 7 days after surgery

Patient qualified for:Patient qualified for:

radiochemiotherapy.radiochemiotherapy.radiochemiotherapy.radiochemiotherapy.

–– radiotherapy: radiotherapy: 6060 Gy, dfGy, df == 2Gy2Gy

–– chemiotherapy: PPD (chemiotherapy: PPD (Cisplatinum 80Cisplatinum 80 mg, mg,

Ondansetronum 8Ondansetronum 8 mgmg))

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70 years old male

Plasmocytoma

70 years old male

Headaches for 3 months

MRI

Plasmocytoma

Surgery

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Treatment Treatment –– Tumors of the Sinonasal TractTumors of the Sinonasal Tract

Modality Indications

Surgery Mainstay treatment

Radiation Unresectable or lymphoreticu-lar tumors, poor surgical can-didates. Usually requires sur-gical drainage/debridement

Combination therapy (+) margins, perineural, peri-vascular invasion(+) lymph nodes, recurrent tumor

Chemotherapy Palliative roleClinical research

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Benign tumorsBenign tumors

SUMMARY

Endoscopic removal is recommended.Endoscopic removal is recommended.

The limitation The limitation –– involvement of the frontal sinus or the involvement of the frontal sinus or the

orbita.orbita.

The point of origin has a greater importance than the The point of origin has a greater importance than the

size of the pathology.size of the pathology.

Endoscopic endonasal skull base surgery: past, present and future. Paolo Castelnuovo et ala. Eur Arch Otorhinolaryngol (2010) 267: 649-663.

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Treatment results (total survival time) using Treatment results (total survival time) using

d i t h i i il t th lt id i t h i i il t th lt i

SUMMARY

endoscopic technique are similar to the results using endoscopic technique are similar to the results using

external approaches.external approaches.

The appropriate qualification for the endoscopic The appropriate qualification for the endoscopic

surgerpy is very importantsurgerpy is very importantsurgerpy is very important.surgerpy is very important.

Endoscopic endonasal skull base surgery: past, present and future. Paolo Castelnuovo et ala. Eur Arch Otorhinolaryngol (2010) 267: 649-663.

Treatment of maxillaryTreatment of maxillary--ethmoidal complex tumors ethmoidal complex tumors

h ld b i t di i li thh ld b i t di i li th

SUMMARY

should be an interdisciplinary therapyshould be an interdisciplinary therapy

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