TUMORS OF MAXILLA AND THEIR MANAGEMENT DR KAMLESH DUBEY

TUMORS OF MAXILLA AND THEIR TUMORS OF MAXILLA AND THEIR MANAGEMENTMANAGEMENT

DR KAMLESH DUBEYDR KAMLESH DUBEY

INTRODUCTIONINTRODUCTION

Nose and PNS are rarest sites of origin of head Nose and PNS are rarest sites of origin of head & neck tumors.& neck tumors.Accounts for < 1% of all malignancies.Accounts for < 1% of all malignancies.More common in 5More common in 5thth & 6 & 6thth decade. decade.M:F = 2:1M:F = 2:1Late presentation with advanced disease is Late presentation with advanced disease is more common.more common.Great variety of different histological types.Great variety of different histological types.Overall prognosis is poor.Overall prognosis is poor.Distal mets is seen in 10 % at presentationDistal mets is seen in 10 % at presentation

ANATOMYANATOMY

Maxillary tumors because of its close Maxillary tumors because of its close proximity to orbit, ethmoids, skull base, proximity to orbit, ethmoids, skull base, ITF always challenging to treat.ITF always challenging to treat.

ANATOMYANATOMY

Orbit is the key to management of tumors Orbit is the key to management of tumors of maxilla always work in subperiosteal of maxilla always work in subperiosteal plane.plane.

ANATOMYANATOMY

Ohngren line-Ohngren line- imaginary line between imaginary line between medial canthus ligament and angle of medial canthus ligament and angle of mandible.mandible.

ANATOMYANATOMY

Lymphatics ;Lymphatics ;Anterior pathway;Anterior pathway;

– Facial , parotid, submandibular nodeFacial , parotid, submandibular node- upper deep cervical nodes.- upper deep cervical nodes.

Post pathway; Post pathway; – retro/ lateral pharyngeal nodes- upper deep cervical retro/ lateral pharyngeal nodes- upper deep cervical

nodes.nodes.

Primary lymph drainage is to retropharyngeal nodes , Primary lymph drainage is to retropharyngeal nodes , clinical e/o early mets is absent clinical e/o early mets is absent Only 10 % have nodal mets at presentation.Only 10 % have nodal mets at presentation.Clinically palpable node is poor prognosis. Clinically palpable node is poor prognosis.

AETIOLOGYAETIOLOGY

Inhalant carcinogensInhalant carcinogens- 40% sinonasal malignancies.- 40% sinonasal malignancies.– Wood dust – adenocarcinoma (1000 times )Wood dust – adenocarcinoma (1000 times )– Hard wood- adenocarcinomaHard wood- adenocarcinoma– Soft wood – SCCSoft wood – SCC– Nickel – SCCNickel – SCC

ChemicalsChemicals– ChromiumChromium– polycyclic hydrocarbonspolycyclic hydrocarbons– aflatoxinaflatoxin– mustard gasmustard gas

RadiationRadiation – thorotrast – thorotrastViruses Viruses - HPV- HPV

24 % inverted papilloma24 % inverted papilloma4 % SCC4 % SCC

TUMORS OF MAXILLATUMORS OF MAXILLA

BenignBenignInverted papillomaInverted papilloma

Osteoma ( Gardner’s syndrome )Osteoma ( Gardner’s syndrome )

ChondromaChondroma

Fibrous dysplasiaFibrous dysplasia

HemangiomaHemangioma

LeiomyomaLeiomyoma

SchwannomaSchwannoma

TUMORS OF MAXILLATUMORS OF MAXILLAMALIGNANT;MALIGNANT;

– Squamous cell carcinoma (80%)Squamous cell carcinoma (80%)– Adeno carcinoma (5%)Adeno carcinoma (5%)– Adenoid cystic carcinoma (5%)Adenoid cystic carcinoma (5%)– HemangiopericytomaHemangiopericytoma– MelanomaMelanoma– Undifferentiated carcinomaUndifferentiated carcinoma– PNETPNET– Malignant fibrous dysplasiaMalignant fibrous dysplasia

Dental origin;Dental origin; – AmeloblastomaAmeloblastoma

Sarcoma;Sarcoma;– RhabdomyosarcomaRhabdomyosarcoma– Fibro sarcomaFibro sarcoma– AngiosarcomaAngiosarcoma– Chondro / osteo sarcomaChondro / osteo sarcoma

Others;Others; lymphoma lymphoma

PATTERNS OF TUMOR SPREADPATTERNS OF TUMOR SPREAD

Maxillary sinusMaxillary sinusAnterior- cheek , skinAnterior- cheek , skin

Posterior- PPF, Posterior- PPF, ITF,MCF, temporal ITF,MCF, temporal bonebone

Medial – nasal cavity, Medial – nasal cavity, ethmoidsethmoids

Superiorly- orbitSuperiorly- orbit

Inferiorly- palate, Inferiorly- palate, alveolus.alveolus.

CLINICAL FEATURESCLINICAL FEATURES

Nasal obstructionNasal obstructionEpistaxisEpistaxisFacial painFacial painProtosis, vision disturbanceProtosis, vision disturbanceEpiphoraEpiphoraHearing lossHearing lossCheek swelling, parasthesiaCheek swelling, parasthesiaTrismusTrismusCranial nerve deficitsCranial nerve deficits

INVESTIGATIONSINVESTIGATIONS

EndoscopyEndoscopy– DiagnosticDiagnostic– Biopsy Biopsy

ImagingImagingCT scan;CT scan;– Site & extent Site & extent – Bone, skull base erosionBone, skull base erosion– Orbit invasionOrbit invasion– Neck- nodal statusNeck- nodal status


MRIMRIBetter soft tissue delineationBetter soft tissue delineationDifferentiate between secretions, tumorDifferentiate between secretions, tumorDural / intracranial involvementDural / intracranial involvementVascularity- flow voidsVascularity- flow voidsMRA- great vessel encasement, cavernous extensionMRA- great vessel encasement, cavernous extension

Angiography;Angiography;Proximity to great vessels , sphenoidProximity to great vessels , sphenoidVascular tumorsVascular tumorsEmbolisation.Embolisation.


PETPET– Distant metastasisDistant metastasis– Follow upFollow up

BiopsyBiopsy– endoscopic guidanceendoscopic guidance– Sublabial approachSublabial approach

HPE, ImmunohistochemistryHPE, ImmunohistochemistryFNACFNAC

– Neck NodeNeck Node

USG- B modeUSG- B mode– Assesment of orbitAssesment of orbit

TNM stagingTNM staging

Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ

T1: Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone T2: Tumor causing bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid plates

T3: Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses T4a: Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses T4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus

TNM stagingTNM stagingRegional lymph nodes (N) Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but 6 cm or less in greatest dimension, or in multiple ipsilateral but 6 cm or less in greatest dimension, or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension, or in bilateral or lymph nodes, 6 cm or less in greatest dimension, or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension contralateral lymph nodes, 6 cm or less in greatest dimension – N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or

less in greatest dimension less in greatest dimension – N2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest N2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest

dimension dimension – N2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest N2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest

dimension dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimensionN3: Metastasis in a lymph node more than 6 cm in greatest dimension

TNM stagingTNM staging

Stage 1Stage 1 -- T1 T1 N0N0 M0M0Stage 2Stage 2 - - T2 T2 N0 N0 M0M0Stage 3Stage 3 - - T1,2 T1,2 N1N1 M0M0 T3 T3 N0,N1N0,N1 M0 M0Stage 4a-Stage 4a- T4 T4 N0,N1N0,N1 M0 M0 any T any T N2N2 M0 M0Stage 4b- Stage 4b- any T any T N3N3 M0 M0Stage 4c- Stage 4c- any T any T anyN anyN M1M1

SCCSCC

50 % arise in the antrum50 % arise in the antrum

Advanced disease at presentationAdvanced disease at presentation

Local recurrence, distal metastasis more Local recurrence, distal metastasis more commoncommon

Main treatment modality- Sx- PORTMain treatment modality- Sx- PORT

Primary Irradiation- inoperable tumorsPrimary Irradiation- inoperable tumors

Chemotherpy – palliativeChemotherpy – palliative

ADENOCARCINOMAADENOCARCINOMA

Aetiology; Aetiology; – Wood dust, furniture machinery, leather workWood dust, furniture machinery, leather work

Well defined tumor- better survivalWell defined tumor- better survival

Long term survival poorLong term survival poor

Management; as that of SCCManagement; as that of SCC

ADENOID CYSTIC CARCINOMAADENOID CYSTIC CARCINOMA

Common in antrumCommon in antrum

Perineural spreadPerineural spread

Distal metastasis more commonDistal metastasis more common

HPE;HPE;– High grade- bad prognosisHigh grade- bad prognosis– Low grade- better prognosisLow grade- better prognosis

TREATMENTTREATMENT

T1/ T2T1/ T2– surgery or radiotherapysurgery or radiotherapy

T3, T4T3, T4 surgery- radiotherapysurgery- radiotherapy

radiotherapy- surgeryradiotherapy- surgery

combined CT+ RTcombined CT+ RT

SURGICAL APPROCAHESSURGICAL APPROCAHES

Lateral rhinotomyLateral rhinotomy

Weber Ferguson incisionWeber Ferguson incision

Mid facial deglovingMid facial degloving

ANASTHESIAANASTHESIA

Orotracheal intubationOrotracheal intubation

Throat Packing in oropharyngxThroat Packing in oropharyngx

Hyperventilation, mannitol- if cranial cavity is Hyperventilation, mannitol- if cranial cavity is openedopened

Adequate arrangement of blood & blood Adequate arrangement of blood & blood productsproducts

PRE OP PREPARATIONPRE OP PREPARATION

Broad spectrum antibiotic cover Broad spectrum antibiotic cover

Dental evaluation ( prosthesis, obturator)Dental evaluation ( prosthesis, obturator)

Neurosurgeon review; intra cranial extension, Neurosurgeon review; intra cranial extension, CFRCFR

Plastic surgeon; pre op decision for flapsPlastic surgeon; pre op decision for flaps

Lateral rhinotomyLateral rhinotomy

Moure`s incision Moure`s incision (1902)(1902)

Excellent exposure to Excellent exposure to nasal cavity, medial nasal cavity, medial maxillary wallmaxillary wall

Indication;Indication; medial medial maxillextomymaxillextomy

Cosmetically Cosmetically acceptableacceptable

Weber Ferguson incisionWeber Ferguson incision

Vertical limb- WeberVertical limb- Weber

Horizontal- Ferguson Horizontal- Ferguson 5mm below lid 5mm below lid marginmargin

Useful in total Useful in total maxillectomy, maxillectomy, combined orbital combined orbital exenteration.exenteration.

Mid facial deglovingMid facial degloving

Denker & Kahler 1926 Denker & Kahler 1926 ( modified CWL approach )( modified CWL approach )

1927 Portmann & Retrouvay – mid facial degloving1927 Portmann & Retrouvay – mid facial deglovingMucosal incision- b/l upper GBS between maxillary Mucosal incision- b/l upper GBS between maxillary tuberosity.tuberosity.Nose- full trans fixation , inter cartilaginous incisionNose- full trans fixation , inter cartilaginous incisionExcellent exposure to nasal cavity, antrum, post nasal Excellent exposure to nasal cavity, antrum, post nasal space, pterygo palatinefossa.space, pterygo palatinefossa.Combined with Le Fort 1 osteotomy – wide exposure to Combined with Le Fort 1 osteotomy – wide exposure to clivus, skull baseclivus, skull base

MID FACIAL DEGLOVINGMID FACIAL DEGLOVING

MAXILLECTOMYMAXILLECTOMY

TypesTypes– TotalTotal– PartialPartial

Infra structureInfra structure

Supra structureSupra structure

medialmedial

Subtotal Subtotal

TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY

It involves removal of entire maxilla along It involves removal of entire maxilla along with pterygoid plateswith pterygoid plates

Indication;Indication;– Tumors from mucosa, filling entire antrumTumors from mucosa, filling entire antrum– Soft tissue & bone sarcomasSoft tissue & bone sarcomas

Approach;Approach;– Weber fergusonWeber ferguson– Mid facial deglovingMid facial degloving


Removal of entire Removal of entire maxilla and pterygoid maxilla and pterygoid platesplates

Supine position, 15 K Supine position, 15 K head extensionhead extension

Ant wall of maxilla Ant wall of maxilla exposed – elevating exposed – elevating cheek flap.cheek flap.


Subciliary incision- Subciliary incision- Orbital periosteum Orbital periosteum elevated from floor of elevated from floor of orbitorbitLacrimal sac retracted Lacrimal sac retracted laterally after cutting laterally after cutting medial canthus medial canthus ligament, NLDligament, NLDPost dissection Post dissection continued upto post continued upto post ethmoidal artery.ethmoidal artery.


ORAL CAVITY – PALATAL INCISIONORAL CAVITY – PALATAL INCISION

BONE CUTSBONE CUTS


Bony cutsBony cuts;;

Frontal process of maxillaFrontal process of maxilla

PalatePalate

ZygomaZygoma

Ethmoidal cells, pterygoidsEthmoidal cells, pterygoids

Brisk hemorrageBrisk hemorrage


SSG applied over cheek mucosa defectSSG applied over cheek mucosa defect

Cavity packing over palatal prosthesisCavity packing over palatal prosthesis

Skin closed in 2 layersSkin closed in 2 layers


POST OP CAREPOST OP CARE

Pack removalPack removal

Cavity irrigationCavity irrigation

Oral exercisesOral exercises

Permanent obturatorPermanent obturator

MEDIAL MAXILLECTOMYMEDIAL MAXILLECTOMY

Enblock resection of lateral wall of nasal cavity Enblock resection of lateral wall of nasal cavity including inf/ mid turbinate, lamina papyraceaeincluding inf/ mid turbinate, lamina papyraceae

Indication;Indication; – Inverted papillomaInverted papilloma– Low grade tumors confined to lateral wall on nasal Low grade tumors confined to lateral wall on nasal

cavitycavity

Approach;Approach;– Lateral rhinotomyLateral rhinotomy– Mid facial deglovingMid facial degloving


Lateral rhinotomy Lateral rhinotomy incisionincision

Antero lateral wall of Antero lateral wall of maxilla exposedmaxilla exposed

Nasal cavity entered, Nasal cavity entered, tumor assesd for tumor assesd for resectability.resectability.


Antero lateral wall opening Antero lateral wall opening mademade

Bony cuts;Bony cuts;

Supt to alveolus , lateral Supt to alveolus , lateral to pyramidto pyramid

Vertical – medial to Vertical – medial to inferior orbital nerveinferior orbital nerve

Fronto ethmoidal sutureFronto ethmoidal suture

Post- post wall of antrumPost- post wall of antrum

MEDIAL MAXILLECTPMYMEDIAL MAXILLECTPMY Bone cuts Bone cuts


Cavity packedCavity packed

Primary closurePrimary closure

Post op – irrigation of Post op – irrigation of cavitycavity

Endoscopic medialEndoscopic medial

maxillextomymaxillextomy

Acheives same Acheives same success ratesuccess rate

Avoids scarAvoids scar

INFRA STRUCTUREINFRA STRUCTURE MAXILLECTOMY MAXILLECTOMY

It involves removal of It involves removal of – alveolus ,alveolus ,– floor of antrum, floor of antrum, – inferior part ofinferior part of

pterygoid platespterygoid plates

Indication;Indication;Tumor limited to alveolus, Tumor limited to alveolus, hard palate with no bony hard palate with no bony erosionerosionNo postero superior No postero superior extensionextension

Approach;Approach;Mid facial deglovingMid facial deglovingLateral rhinotomyLateral rhinotomy

INFRA STRUCTUREINFRA STRUCTURE MAXILLECTOMY MAXILLECTOMY

BONY CUTS;BONY CUTS;Horizontal- midway between alveolus & IONHorizontal- midway between alveolus & IONPalate- midlinePalate- midlineMedial- lateral nasal wall below middle meatusMedial- lateral nasal wall below middle meatusPost- inferior portion of pterygoid platesPost- inferior portion of pterygoid plates

INFRA STRUCTURE INFRA STRUCTURE MAXILLECTOMYMAXILLECTOMY

POST OP CARE;POST OP CARE;

Cavity irrigationCavity irrigation

Palatal prosthesisPalatal prosthesis

MANAGEMENT OF ORBITMANAGEMENT OF ORBIT

Orbit preservation;Orbit preservation;– No e\o tumor in orbital floorNo e\o tumor in orbital floor– Breech in floor with intact periosteumBreech in floor with intact periosteum– Minimal periosteal invasion Minimal periosteal invasion

Orbital exenteration;Orbital exenteration;– Breech in orbital periosteumBreech in orbital periosteum– Orbital apex extensionOrbital apex extension

RADICAL MAXILLECTOMY WITH RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATIONORBITAL EXENTERATION

Indication;Indication;– Tumor invading through orbital periosteumTumor invading through orbital periosteum

Approach;Approach;– Weber Ferguson with sub & supra ciliary Weber Ferguson with sub & supra ciliary

extensionextension

RADICAL MAXILLECTOMY WITH RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATIONORBITAL EXENTERATION

Skin of upper lid elevated upto suprior Skin of upper lid elevated upto suprior orbital rim.orbital rim.

Orbital perioseteum seperated from roof of Orbital perioseteum seperated from roof of orbitorbit

EOM , optic nerve cut at level of orbital EOM , optic nerve cut at level of orbital apexapex

Defect lined with SSGDefect lined with SSG

Facial prosthesis appliedFacial prosthesis applied

ORBIAL EXENTERATIONORBIAL EXENTERATION

POST OP DEFECT PROSTHESIS IN PLACE

RECONSTRUCTIONRECONSTRUCTION

SSGSSGPalatal prosthesisPalatal prosthesisObturatorsObturators

Flaps;Flaps;– Temporo pareital galeal flapTemporo pareital galeal flap– Temporalis Temporalis

Free flapsFree flaps;;– Rectus abdomoinisRectus abdomoinis– Lattissimi dorsi Lattissimi dorsi

Composite flap;Composite flap;– Fibula osteo cutaneous flapsFibula osteo cutaneous flaps

RECONSTRUCTIONRECONSTRUCTION

FOREARM FREE FLAP

DENTAL IMPLANTS

RADIATION IN TUMORS OF MAXILLARADIATION IN TUMORS OF MAXILLA

Various combiationsVarious combiationsPrimary irradiation alonePrimary irradiation alone– T1,2 lesionsT1,2 lesions– In operable tumorsIn operable tumors– Patient unfit for surgeryPatient unfit for surgery

Combined with surgeryCombined with surgery– T3,4 lesionsT3,4 lesions– Surgery – RTSurgery – RT– RT- surgeryRT- surgery

CT+ RTCT+ RT

Areas to be covered;Areas to be covered;

1* site, areas of tumor extension , other 1* site, areas of tumor extension , other routes of local spread (i-e) routes of local spread (i-e)

Maxilla, alveolus, nasal cavity, ethmoids, Maxilla, alveolus, nasal cavity, ethmoids, PPF, often orbit, neckPPF, often orbit, neck

Anterior fieldAnterior field

Lateral fieldLateral field

RADIATION FIELDSRADIATION FIELDS

ANTERIOR FIELD LATERAL FIELD

Protect;Protect;

Contra lateral eyeContra lateral eye

Brain stemBrain stem

Upper cervical cordUpper cervical cord

DoseDose50-55 Gy/ 20#/ 4 wks50-55 Gy/ 20#/ 4 wks60-65 Gy/30-33#/ 6-6.5 wks60-65 Gy/30-33#/ 6-6.5 wksLymphoma;Lymphoma;– 40 GY/20#/4 wks40 GY/20#/4 wks

ComplicationsComplications– MucositisMucositis– EyeEye

CataractCataractKeratitisKeratitisOptic nerve damageOptic nerve damage

– Osteo radio necrosisOsteo radio necrosis– hypopituitarismhypopituitarism

CHEMOTHERAPYCHEMOTHERAPY

Cisplastin & 5- FUCisplastin & 5- FUSNUC, RMS, lymphomaSNUC, RMS, lymphomaIntra arterial infusion – 5- FU along with Intra arterial infusion – 5- FU along with RTRTTopical 5- FU ;Topical 5- FU ;– Surgical debulking + topical 5 FU weeklySurgical debulking + topical 5 FU weekly– Adenocarcinoma- ethmoids Adenocarcinoma- ethmoids (knegt et al, Arch of otolarygology,2007 ).(knegt et al, Arch of otolarygology,2007 ).

Palliation.Palliation.

INOPERABLE TUMORSINOPERABLE TUMORS

Irradiation;Irradiation;

6000 rads- 6 wks6000 rads- 6 wks

Salvage surgerySalvage surgery

CT+ RTCT+ RT

Intra arterial 5-FUIntra arterial 5-FU

PNS TUMORS IN CHILDRENPNS TUMORS IN CHILDREN

Commonest malignant tumor is Commonest malignant tumor is rhabdomyosarcomarhabdomyosarcoma

Treatment; triple modalityTreatment; triple modality

Tumors; radioinsensitiveTumors; radioinsensitive

Rad >3000 rads retards facial skeletal growthRad >3000 rads retards facial skeletal growth

THANK YOUTHANK YOU

Documents

TUMORS OF MAXILLA AND THEIR MANAGEMENT DR KAMLESH DUBEY