CARCINOMA MAXILLARY SINUS MANAGEMENT RADIATION ONCOLOGY

1. CARCINOMA MAXILLA MANAGEMENT Dr. Paul George Radiation Oncology Regional Cancer center Trivandrum

2. NASAL CAVITY & PARANASAL SINUSES Epidemiology Incidence 0.5-1/100,000 per year 0.2-0.8% of all malignancies 3% of upper aerodigestive tract neoplsm 5th-6thdecade White race M:F=2:1 – 4:1

3. SQUAMOUS CELL CARCINOMA Most common histological type 70% maxillary sinus Male predominance Older age group Enviornmental exposure: leather tanner, nickel refinery, thorotrast Adenoca (10-20%), adenocystic ca(<10%), sinonasal melanoma(<4%), esthesioneuroblastoma , sinonasal undifferentiated carcinoma, lymphoma, sarcoma , plasmacytoma

4. How to Proceed 1.HISTORY & Physical exam 2 .Radiography (CT, MRI)complete head & neck. 3.BIOPSY 4.Chest imaging 5.dental/prosthetic consultation as indicated STAGING

5. HISTORY & PHYSICAL EXAMINATION

6. Anatomy of maxillary antrum Anterior : soft tissue of face . Posterolateral : ITF , pterygopalatine F Superior : Inferior orbital plate . Inferiorly : hard palate ,superior alveolar ridge

7. PATTERN OF TUMOUR SPREAD

8. Patterns of tumour spread Anteriorly : cheek, skin Posteriorly : pterygopalatine fossa , infra temporal fossa , temporal bone middle cranial fossa Medially: nasal cavity,NLD Laterally: cheek, skin Superiorly: orbit, ethmoid sinuses Inferiorly: palate, buccal sulcus

9. CLINICAL PRESENTATION Nasal findings:(50%) obstruction, epistaxis , rhinorrhea,discharge,extension into nasal cavity Oral symptoms:(25-35%) pain, trismus , alveolar ridge fullness, erosion Ocular findings:(25%) epiphora , diplopia , proptosis Facial signs: paresthesias , facial asymmetry, cheek swelling Auditory symptoms: hearing loss (OME) Neurological: cranial nerve deficits II,III,IV.V1,V2,VI 10% nodal Distant mets: rare

10. H & P examination The sinonasal , ocular, and neurologic systems should be studied in detail Ant & post rhinoscopy Nasal endoscopy

11. RADIOLOGICAL EXAMINATION Radiographic studies are essential as the full extent of a sinonasal neoplasm cannot be established even with modern fiberoptic technology. Both CT& MRI are the effective ways to delineate the extent of tumor extracranially and intracranially .

12. Computed Tomography Bone erosion Key areas include the bony orbital walls, cribiform plate, fovea ethmoidalis , posterior wall of the maxillary sinus, pterygopalatine fossa , the sphenoid sinus, and the posterior table of the frontal sinus. 85% accuracy Difficult periorbital involvement Difficult to differentiate between: Tumor vs. inflammation vs . secretions

13. MRI 94% accuracy Inflammatory tissue & secretions: intense T2 Tumor : intermediate T1 & T2, Enhancement with Gadolinium MRI is excellent for determining perineural spread, involvement of the dura , or involvement intracranially .

14. BIOPSY Transnasal medial wall of maxilla is the preferred route Needle biopsy is sufficient Biopsy via Caldwell-Luc approach (canine fossa puncture) is not recommended because of the potential to seed the gingivobuccal sulcus and cheek skin with tumor.

15. STAGING

16. Ohngren ’ s 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

17. MANAGEMENT 1.SURGERY 2.RADIOTHERAPY 3.CHEMOTHERAPY:VERY LIMITED ROLE

18. SURGERY Surgical approaches: Endoscopic Lateral rhinotomy Transoral / transpalatal Weber fergussen Midfacial degloving Combined craniofacial approach Extent of resection Medial maxillectomy Inferior maxillectomy Total maxillectomy

19. Weber fergussen approach tumors involving the maxilla extending superiorly to the infraorbital nerve and into the orbit. Wide access to all areas of the maxilla and orbital floor.

20. Midfacial Degloving Nasal cavity tumors with bilateral involvement Most suited for inferiorly located tumors. Subperichondrial plane of nasal septum

21. Inferior medial maxillectomy Medial maxillectomy Radical maxillectomy with exentration Cranio-facial resection

22. 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 ,the roof of the ethmoid & frontal sinus. Multidisciplinary skull base approach has improved the outcome

23. UNRESECTABILITY Unresectable tumors : Superior extension: frontal lobes Lateral extension: cavernous sinus Posterior extension: prevertebral fascia Bilateral optic nerve involvement Distant Metastasis Reconstruction after surgery is done with microvascular free flap & maxillofacial obturator prosthesis

24. RADIOTHERAPY Addition of RT to surgery improve 5-years survival (44%) when compared to RT alone (23%) or surgery alone. Indications: Definitive :medically inoperable or who refuse radical surgery or early lesions Adjuant : Palliative : Pre- and postoperative radiation may result in similar control rates. But post-operative RT preferred : 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 after surgery .

25. RADIOTHERAPY TECNIQUES 1.CONVENTIONAL 2D 2.CONFORMAL 3D 3.IMRT

26. 2D CONVENTIONAL: 3field tecnique Patient lies in a supine cast with the head in neutral position. Tongue bite is used to depress tongue & lower alveolus away from the target volume .

27. ANTEROR FIELD

28. LATERAL FIELD

29. Field Margins: a three-field technique for maxillary antrum : 1 anterior and 2 lateral fields. Anterior field: superior border : above the crista galli to encompass the ethmoids . in the absence of orbital invasion, at the lower edge of the cornea to cover the orbital floor. inferior border : 1 cm below the floor of the sinus. medial border : 1 to 2 cm (or more if necessary) across the midline cover contralateral ethmoidal extension. lateral border : 1 cm beyond the apex of the sinus or falling off the skin. Lateral fields: superior border : follows the floor of anterior cranial fossa . anterior border : behind the lat canthus parallel to the slope of face . posterior border : covers the pterygoid plates .

30. Anterior field: When ther is no gross involvement of the orbit, the cornea, lens & lacrimal gland are shielded from the anterior field If there is disease in the orbit, cornea is spared by cutting out the cast and treating with the eyes open Lateral field: It is angled 5-10 degree posteriorly so that the exit beam avoids the opposite eye Optic chiasma & hypothalamus are shielded from the lateral field Anterior beam is weighed as 2:1 to that of lateral beam Dose prescription:65Gy/32# or 55Gy/20#

31. ISODOSE DISTRIBUTION

32. 3D CONFORMAL 4 Field Anteror 2. two lateral portal 3. Intraorbital electron portal to make up the dose to post nasal cavity, ethmoid sinus & medial orbit

33. CT SIM A CT scan is performed with 3 mm slices from 2cm superior to the superior orbital ridge to the hyoid bone (but extended to include the low neck if neck nodes are to be treated).

34. TARGET VOLUME DELINEATION The CTV should encompass all initial sites of disease( presurgery GTV), The mucosa of adjacent compartments of the sinonasal complex and a 10 mm margin at least from initial sites of GTV where no good bony barrier to invasion exists (e.g. masticator space, cribriform plate and infraorbital fissure) Bony orbit if involved For most tumours , the CTV will include the ipsilateral maxillary sinus and bilateral nasal cavity and the ethmoid sinuses. The CTV is expanded isotropically (usually by 3–5 mm)to form the PTV

35. Where a craniofacial excision has been carried out, the CTV should extend 10 mm superior to the cribriform plate or 10 mm superior to Initial sites of disease, whichever is greater If the primary was close to or invading the nasopharynx , the adjacent Ipsilateral retropharyngeal nodes should be included in the CTV. When cervical node radiotherapy is indicated, the intraparotid nodes, level Ib and superior level II nodes can be included in the CTV. Elective neck nodal radiation is not recommended

36. ORGAN AT RISK include the 1.lenses,2. lacrimal glands (in the superolateral orbit and upper eyelid), 3.optic nerves and chiasm, 4.spinal cord, 5.brainstem and 6.pituitary gland

37. OAR & possible complications of RT Lens <10 Gy (cataracts ) Lacrimal gland <30 – 40 Gy (dry eye syndrome) Retina <45 Gy (blindness ) Optic chiasm and nerves <54 Gy at standard fractionation. (Optic neuropathy) Brain <60 Gy (necrosis ) Mandible <60 Gy ( osteoradionecrosis ) Parotid mean dose <26 Gy ( xerostomia ) Pituitary and hypothalamus mean dose <40 Gy.

38. IMRT A non-coplanar arrangement of three to five sagittal midline beams with right and left lateral beams avoids entry or exit of beams through the eyes and provides a uniform dose distribution IMRT has been shown to be useful in reducing long-term toxicity by reducing the dose to salivary glands, temporal lobes, auditory structures, and optic structures

39. IMRT

40. Complications of RT Acute: mucositis, skin erythema , nasal dryness, Xerostomia Late: xerostomia , chronic keratitis and iritis , optic pathway injury , osteoradionecrosis , cataracts, radiation induced hypopituitarism

41. Dose fractionation Definitive RT : 70Gy , 2G/# over 7 wks Adjuvant 60 Gy in 30 daily fractions given in 6 weeks. 66 Gy in 33 daily fractions if possible where there is residual disease. Palliative 36 Gy in 6 fractions of 6 Gy treating once weekly.

42. Treatment delivery and patient care Patients are seen weekly during treatment in a multidisciplinary clinic. Exercises to reduce trismus Prophylactic feeding tubes should be considered ophthalmic review .Lubricating eye ointments If there is a pre-existing facial nerve palsy, the eyelid should be taped shut at night to avoid a dry eye. Pituitary function tests should be carried out annually during follow-up to evaluate late radiotherapy effects to the pituitary gland.

43. Role of chemotherapy Neoadjuvant chemotherapy is sometimes offered in order to reduce tumor volume, which may permit removal of tumor with a less morbid resection or facilitate radiotherapy planning if shrinkage pulls away tumor from critical structures. chemotherapy may be given concurrent with radiotherapy in the management of inoperable tumors on the basis of improved results in more frequent head and neck carcinomas.

44. FOLLOW UP H&P, labs, and CXR every 3 months for first year, Every 4 months for second year, Every 6 months for third year, then annually. Imaging of the H&N at 3 months post treatment, then as indicated

45. STAGEWISE MANAGEMENT OF CARCINOMA MAXILLA

46. Stage I / II (T1-T2, N0) SINGLE MODALITY TREATMENT DEFINITIVE RT/SURGERY If perineural invasion by the tumor, Adjuvant RT (±Chemo)

47. LOCALLY ADVANCED T3-T4a, N0( resectable) SURGERY POSTOP RT If margins are positive, ChemoRT to the primary

48. Node + Stage SURGERY WITH NECK DISSECTION POSTOP RT If margins positive or ECE, ChemoRT Elective neck nodal irradaition is not routinely recommended

49. VERY LOCALLY ADVANCED T4b , unresectable PS 0,1 : RADICAL CHEMORT / Induction chemo followed by chemoRT PS2: RADICAL RT PS3: PALLIATION

50. Locoregional Reurrence /residual: Salvage surgery/ Reirradiation +/_chemo/clinical trial Distant mets: palliative chemo/BCS

51. PROGNOSIS Even with multimodality treatment average 5year median survival of carcinoma maxilla is only 35-45%

52. CLINICAL SCENARIO

53. INDIRA 58/F HOUSE WIFE REPORTED IN B CLINIC 3/6/13 Complaints Left Nasal discharge 15mnths Left nasal block 6months ECOG PS 1 GC;good

54. INVESTIGATIONS Trans nasal biosy left maxilla: Poorly diff carcinoma

55. CA MAXILLA Staging…….? Management…………….? cT2N0M0 RT/SURGERY….? ADJUANT Rx…?

56. Cacinoma maxilla: cT2N0M0 MANAGEMENT SUBTOTAL MAXILLECTOMY on 21/08/13 HPE: Non keratinising scc with bone erosion close margin <0.1cm from lateral margin Other margins free

57. Postop RT 55Gy/20#

58. Thank you……. Dr. Paul George