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Sino nasal malignancies

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  • 1. Nasal Cavity and Para nasal Sinuses Cancer by Osama El-Zaafarany

2. Incidence: 3% of aerodigestive malignancies 1% of all malignancies Males : females = 2 : 1. Sixth to seventh decades The maxillary sinus is most commonly involved with tumor, followed by the nasal cavity, the ethmoids, and then the frontal and sphenoid sinuses. 3. Anatomy 4. Maxillary antrum: Superior : orbit, ethmoids Posterior : pterygoids, infratemporal fossa. Ethmoid sinus: Superior : fovea, cribiform Medial : lamina papyracea 5. Sphenoid sinus Superior : optic nerve, pituitary Lateral : ICA, cavernous sinus Inferior : nasopharynx. Frontal sinus Inferior: orbit. Posterior: anterior cranial fossa 6. Lymphatic Drainage The anterior nose has the same lymphatic drainage as the external nose. These tend to spread to the submental or level I area. The posterior nose tends to drain to the retropharyngeal nodes as well as the lateral pharyngeal nodes, which eventually drain into the level II. 7. Etiological Factors: Exposure: Wood, nickel-refining processes Industrial fumes, leather tanning Specific asssociations found include squamous cell carcinoma in nickel workers and adenocarcinoma in workers exposed to hardwood dusts and leather tanning. Cigarette and Alcohol consumption No significant association has been shown 8. Pathologic classification: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11)Squamous cell carcinoma Adenoid cystic carcinoma Mucoepidermoid carcinoma Adenocarcinoma Hemangiopericytoma Melanoma Olfactory neuroblastoma Sarcoma: osteogenic, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma Lymphoma: (NHL, NK/T-cell lymphoma=lethal midline granuloma). Metastatic tumors (RCC is the most common). Sinonasal undifferentiated carcinoma 9. Natural History: Squamous cell carcinoma: Most common tumor (80%), Males, Sixth decade. Location:Maxillary sinus (70%) Nasal cavity (20%), lateral nasal wall is the most common site 88% present in advanced stages (T3/T4). 90% have eroded walls of sinuses. Regional lymph node metastasis is about 10% to 20% of cases. Local recurrence rate 30% to 40%. 10. Adenocarcinoma: 2nd most common, 5-20% Ethmoids. Strong association with occupational exposures. High grade subtype: 30% present with metastasis 11. Adenoid Cystic Carcinoma: 3rd most common (3-15%). occurs most frequently in women, and in the fifth and sixth decades. Palate > major salivary glands > sinuses. Neck metastasis is rare. Multiple recurrences, distant mets. Perineural spread Resistant to tx. Postoperative RTx is very important. Long-term followup necessary 12. Olfactory Neuroblastoma Esthesioneuroblastoma: Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells. Kadish staging system: A: confined to nasal cavity B: involving the paranasal cavity C: extending beyond these limitsAggressive behavior Local failure: 50-75% Metastatic disease develops in 20-30% Treatment is en bloc surgical (craniofacial) resection with postoperative RTx. 13. Sinonasal Undifferentiated Carcinoma: It is rare type, believed to arise from Schneiderian epithelium, the Sionasal ectodermn. Risk factors: Smoking and radiation. The median age 6th decade, male predominance. Aggressive locally destructive lesion. Frequent orbital invasion and intracranial extension. Greater tendency to metastasize than squamous carcinoma. DD: melanoma, lymphoma, olfactory neuroblastoma, rhabdomyosarcoma, neuroendocrine carcinoma, and poorly differentiated squamous cell carcinoma. Prognosis is usually poor, with a median survival of 18 months. Overall survival is a bout 20% at 5 years. Preoperative chemotherapy and radiation may offer improved survival if combined with radical surgery. 14. Staging: 15. Ohngrens Line a line that is drawn from the angle of mandible to the medial canthus. Ohngren indicated that tumors that presented above this line (suprastructure); both superiorly and posteriorly, tended to have a worse prognosis 16. Clinical Presentation: (delayed diagnosis) Oral symptoms: 25-35%; Pain, trismus, alveolar ridge fullness, erosionNasal findings: 50% Obstruction, epistaxis, rhinorrheaOcular findings: 25% Epiphora, diplopia, proptosisFacial signs: Paresthesias, asymmetryClassic Triad of advanced disease: facial asymmetry tumor bulge in oral cavity nasal mass 17. Diagnostic workup: Physical exam Nasal endoscopy Biopsy Radiography (CT, MRI). 18. Computed Tomography Bone erosion 85% accuracy Difficult to differentiate between: Tumor vs. inflammation vs. secretions 19. MRI 94% accuracy Inflammatory tissue & secretions: intense T2 Tumor: intermediate T1 & T2, Enhancement with Gadolinium If there is a question of neural involvement, MRI is excellent for determining perineural spread, involvement of the dura, or involvement intracranially. 20. Treatment Recommendations: 21. Surgery: Surgical resection is the primary treatment modality for cancersinvolving the maxillary or ethmoid sinuses. Resection is often limited by tumor involvement of the base of skull which can result in damage to critical structures such as brain, and the cranial nerves. In the past, contraindications to surgical resection included tumor extension to the lateral skull base, intracranial contents, or cavernous sinus. However, with advances in surgical technique and reconstruction, the decision of more extensive surgery, such as a craniofacial resection via craniotomy or transglabellar/subcranial approach can be considered in ethmoid sinus tumors involving cribriform plate for example. 22. Unresectability: extension to frontal lobes invasion of prevertebral fascia bilateral optic nerve involvement cavernous sinus extensionSurgical approaches: Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Combined craniofacial approach 23. Surgical procedures: The goal of surgery for nasal cavity and paranasal sinus tumors is to achieve en bloc resection of all involved bone and soft tissue with clear margins while maximizing the cosmetic and functional outcome. Limited nasal cavity lesions may be resected with medial maxillectomy. Ethmoid lesions usually require medial maxillectomy and en bloc ethmoidectomy. combined craniofacial procedure for lesions involving the inferior surface of the cribriform plate and the roof of the ethmoid. The bony defect in the anterior cranial floor is closed with a vascularized pericranial or temporal muscle flap. 24. maxillary antral cancers: radical maxillectomy that removes en bloc the entire maxilla and ethmoid sinus. Suprastructure lesions may involve the orbit, necessitating orbital exenteration. Resection of involved periosteum and frozen-section control of adjacent orbital contents with preservation of the eye may be possible in select lesions with involvement of the periorbita without intraorbital extension Orbital preservation surgery in select patients with involvement of the bony orbit but not soft tissue does not appear to result in poorer survival or local control than those undergoing exenteration. 25. Inferior medial maxillectomyMedial maxillectomyCranio-facial resectionRadical maxillectomy with excentration 26. Indications for orbital exenteration: Involvement of the orbital apex Involvement of the extraocular muscles Involvement of the bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through the periorbita into the retrobulbar fat 27. Reconstruction after surgery:Surgery for sinonasal cancers leaves major defects in the skull and needs to be reconstructed. Advances in tissue transfer techniques (particularly microvascular free flaps) provide reconstructive options in addition to maxillofacial prostheses. 28. Types (Stages) of obturator prostheses: (I) Immediate (surgical) obturator prostheses: initiated at the time of surgery fabricated on a cast obtained from an impression made at the time of the pretreatment dental examination. fabricated using autopolymerizing acrylic resin (methyl methacrylate) ligated into position following tumor resection but before flap closure.(II) Transitional obturator prosthesis: a minimum of 7 to 10 days after surgery.(III) Definitive (permanent) obturator prosthesis: begin once adequate healing has occurred, and radiation therapy is completed (usually after three to four months). 29. Radiotherapy: Addition of Rtx. to surgery improve 5-years survival (44%) when compared to RTx. alone (23%) or surgery alone. Indications: Adjuvant (standard of care). Definitive: medically inoperable or who refuse radical surgerypre- and postoperative radiation may result in similar control rates. But post-operative RTx preffered: Preoperative radiation increases the infection rate and the risk of postoperative wound complications. Preoperative radiation may obscure the initial extent of disease=surgery can not remove the microscopic extensions of the tumor. Postoperative radiation therapy is started 4 to 6 weeks aftersurgery. 30. Indications of elective nodal irradiation: Not routinely recommended in nasal cavity nor ethmoid sinus tumors. In maxillary tumors: include ipsilateral submandibular and subdigasteric nodes in: Squamous cell carc. Poor differ carc. T4 lesions. N.B. The neck is irradiated after neck dissection for nodal involvement at presentation according to the usual guidelines for postoperative neck irradiation in other head & neck cancers. 31. Target & Dose for 3D-CRTx. (I) Definitive RTx: Recommend 3D-CRT or IMRT planning to increase sparing of normal structures. GTV = clinical and/or radiographic gross disease.CTV1 = 1 cm margin on primary and/or nodal GTV= 66-70 Gy; (1.8-2Gy/Fx.) CTV2 = high-risk regions (depending on the presence or absence of anatomic boundaries to microscopic spread)= 60-63 Gy. CTV3 = elective neck= 54-57 Gy 32. (II) Post-operative RTx : A typical targ

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