Paranasal sinuses carcinoma

Ca PNS presentation & managemment

1. CARCINOMA OF PARANASAL SINUSES Presenter – Dr. Venkatesan Moderator – Prof. Th. Tomcha Singh

2. Anatomy

3. Anatomy – contd … Maxillary sinus Base – lat. Wall of nasal cavity Roof – O rbital floor Floor – alveolar processes Apex – into zygomatic bones Ohngren’s line

4. Anatomy – contd … Ethmoid sinus B/w nasal cavity & orbit Sep from orbital cavity by lamina papyracea & from ACF by fovea ethmoidalis Laterally optic nerves Posteriorly optic chiasma

5. Epidemiology Maxillary sinus ca – 70% Ethmoid , frontal, sphenoid sinus ca – extremely rare M > F ( 2 : 1 ) Age > 40yrs Thorotrast Carpenters, saw mill workers Occupational exposure Smoking Alcohol

6. Histologic subtypes Squamous cell carcinoma ( 80 - 85%) Adenoid cystic carcinoma Adenocarcinoma Melanoma Olfactory neuroblastoma Osteogenic sarcoma, rhabdomyosarcoma Lymphoma Metastatic tumors ( kidney, lungs etc) Sinonasal undifferentiated carcinoma

7. Natural history & spread Maxillary ca

8. Natural history & spread - contd Ethmoidal ca

9. Natural history & spread – contd … Sphenoid sinus ca Frontal sinus ca

10. Lymphatic Drainage Usually sparse If tumor extension into skin of face, nasal cavity, NPX > ↑ ed incidence of LN First echelon: submandibular nodes Second echelon: subdigastric nodes - same side Contralateral mets . extremely rare

11. Clinical features Maxillary sinus ca Facial swelling, pain, paresthesia of cheek Epistaxis , nasal discharge, obstruction Ill fitting dentures, alveolar/palatal mass Proptosis , diplopia , impaired vision, orbital pain Ethmoid sinus ca Headache Referred pain to nasal, retrobulbar region SC mass at inner canthus , nasal obstruction,discharge , diplopia & proptosis

12. Prognostic factors Pt specific - Age - Performance status Disease specific - location - histology - locoregional extent - perineural invasion

13. Work up H & P Routine blood examination CXR CT /MRI Dental evaluation Baseline ophthalmologic examn Baseline speech & swallowing assessment Fiberoptic endoscopic examination & Bx

14. Staging – Maxillary sinus Ca

15. AJCC- Nasal cavity & Ethmoid Sinus Tx - Primary tm cannot be assessed To - no evidence of primary tm Tis - carcinoma in situ T1 - Tm restricted to any one subsite with or without bony invasion T2 - invading two subsite in a single region or extending to involve an adjacent region within the nasoethmoidal complex T3 - invade medial wall/ floor of orbit, maxillary sinus,palate / cribiform plate T4a - invade ant orbital contents, skin of nose /cheek, ant cranial fossa , pterygoid plates,sphenoid / frontal sinus T4b - orbital apex, dura , brain,mid cranial fossa , cr nerves, nasopharynx / clivus

16. Staging – contd … Nx - regional nodal status cannot be assessed, No - No regional lymph node metastasis N1 - single I/L clinically + ve lymph node ≤ 3cm N2 - metastasis in ipsilateral , bilateral, contralateral node N2a - single I/L + ve LN >3cm <6cm N2b - multiple, I/L + ve LN <6cm N2c - B/L or C/L LN <6cm N3 - any LN > 6cm Mx - distant metastasis cannot be assessed Mo - No distant metastasis M1 -distant metastasis multiple, ipsilateral clinically positive node <6cm

17. Staging – contd … Stagewise distribution stage I - T 1 N M stage II – T 2 N M stage III – T 3 N M 0 OR T 1 -T 3 N 1 M stage IV : - IV A -T 4 N 0-1 M any TN 2 M - IV B any TN 3 M - IV C any T any N, M1

18. Treatment options Maxillary sinus ca Surgery Radiotherapy - definitive - pre op RT - post op RT Combined modality ( Sx + RT) Chemotherapy - Neo adjuvant - Concomitant

19. Stagewise Treatment

20. Stagewise Treatment – contd …

21. Surgery 1)Total maxillectomy - Adv. Maxillary sinus Ca. 2)Lateral Rhinotomy & medial maxillectomy – malig . limited to nasal walls ,medial wall of maxillary sinus & adj. Ethmoid sinus 3)Medial maxillectomy with Frontal craniotomy for enbloc resection- malig . Tumors→ minimal intracranial extension 4) Partial horizontal Maxillectomy - tumors localised to hard palate & infrastructure of the antrum

22. EBRT Most – post op RT Target volume - physical exam. - Pre Rx imaging - intra operative findings - pathologic findings

23. EBRT – Setup & field arrangement Supine position Immobilisation Mouthbite Planning - maxilla - adj. nasal cavity - ethmoid sinuses - NPx - pterygopalatine fossa - portion of orbit Techniques - Anterolateral wedge pair tech - 3 field tech

24. RT – field portals Maxillary ca

25. Isodose planning for wedge filtered fields

26. EBRT – contd … Dose prescribed at depth of 5 cm EBRT dose - Pre operative : 45-50 Gy over 5 wks - Post operative : 55-60 Gy over 5.5 – 6 wks

27. 3D CRT Initial target volume – Post op. RT - Sx bed + 1-2 cm margin - Boost volume – areas at high risk for recurrence Advantage - spare C/L retina & optic nerve - Post op dose of 66 Gy can be delivered

28. IMRT Rigid immobilisation Shoulders depressed & fixed Target volume delinated Multiple gantry angles are utilised Beam angle selection based on - Shortest path to the target - Avoidance of direct irradiation to critical struct . - Use of large beam seperation as possible

29. RT – Target volumes Target Description Dose GTV Pre chemotherapy 66 – 70 CTV1 GTV + 1 – 1.5cm 66 – 70 CTV2 Primary CTV + 1 – 1.5cm 59 – 63 CTV3 Nodal volumes, nerve tract & base of skull 54 – 57 Target Description Dose CTV HR Sites of suspected + ve margins, gross macroscopic residual tumor, extracapsular nodal disease 66 – 70 CTV1 Primary tumor bed + 1 – 1.5 cm margin 60 CTV2 Surgical bed 57 CTV3 Trigeminal n., perineural invasion, additional skull base margin, elective nodal volume if indicated 54 Primary RT Post op RT

30. Ethmoid sinus ca Stage I(A) – Sx or EBRT Stage II(B) – Sx + EBRT ± CT / EBRT ± CT Stage III (c) - Sx + EBRT ± CT / EBRT ± CT SX : Medial maxillectomy En bloc ethmoidectomy Craniofacial approach

31. EBRT - Ethmoid sinus ca Anterolateral wedge fields 3 field tech. Diff. loading with more weightage to ant field with 2:1 or 3:1 Post op – 55 – 60 Gy

32. Treatment of neck nodes In SCC & undiff . Carcinoma I/L upper neck Rx is delivered by lateral appositional electron field ( usually 12 MeV ) Uninvolved – 50 Gy over 5 wks Involved – 60 – 66 Gy

33. Treatment sequelae Vestibulo cochlear - hearing impairment, tinnitus, otitis , vestibular dysfunction Ophthalmologic - retinopathy, xerophthalmia , keratopathy,cataracts , visual impairment Endocrine - multiple endocrine dysfunction Oral - xerostomia , dental caries, dysgeusia , mandible exposure, necrosis & trismus Connective tissue complications - soft tissue necrosis, skin changes, sc fibrosis, nasal dryness, swallowing, voice dysfunction

34. Follow up 3 mths after Rx - baseline physical examn - CT, MRI or PET CT 1 st 3 yrs – every 4 mths 4 th & 5 th yr – every 6 mths Then - annually

35. Results of treatment Local control after Rx – remains problematic MD anderson cancer centre (1991 review – 73 pts ) 5 yr local control in - T1 & T2 - 91 % - T3 – 77 % - T4 – 65 % Sx + RT : 5 yrs LC & SR - 44% - 80% RT alone: 5 yrs LC – 22 – 39% 5yrs SR – 22- 40%

36. Thank you

37. Surgery Contraindications - extension thr ant. Fossa - involvement of both optic n. - post. extension into sphenoid sinus - invasion of middle cranial fossa - extension into NPx - inoperable neck node & distant mets

38. Location Maxillary sinus 70% Ethmoid sinus 20% Sphenoid 3% Frontal 1%

39. Presentation Nasal findings: 50% Obstruction, epistaxis , rhinorrhea , erosion Oral symptoms: 25-35% tooth pain, trismus , alveolar ridge fullness, erosion Ocular findings: 25% Epiphora , diplopia , proptosis Facial signs: - V2 Paresthesias , asymmetry, pain , fullness Auditory : CHL

40. SCCA Most common - 80% Maxillary > nasal cavity > ethmoids Males Sixth decade 90% have eroded walls of sinuses - local invasion by presentation

41. Adenocarcinoma 2 nd most common malignant tumor in maxillary & ethmoid sinuses Present most often in the superior portions Strong association with occupational exposures High grade: solid growth pattern with poorly defined margins. 30%with metastasis Low grade: uniform and glandular with less incidence of perineural invasion/metastasis.

42. Adenoid Cystic Carcinoma 3 rd most common in the nose/ paranasal sinuses Perineural spread Despite aggressive Sx resection & RT, most grow insidiously. Neck metastasis is rare & usually a sign of local failure Widespread local invasion makes resection difficult, therefore RT is often indicated - Postoperative RT Resistant to t/t Multiple recurrences, distant mets Long-term follow up necessary

43. MUCOEPIDERMOID CARCINOMA Extremely rare Widespread local invasion makes resection difficult, therefore RT is often indicated METASTATIC TUMORS Renal cell carcinoma Lungs Breasts Urogenital tract Gastrointestinal tract

44. Computed Tomography Bone erosion orbit, cribiform plate fovea, post max sinus wall sphenoid, post wall of frontal sinus 85% accuracy ? Tumor vs. inflammation vs. secretions Limitation- periorbital involvement

45. MRI Superior to CT - multiplanar - Detect intracranial, perineural & leptomeningeal spread Inflammatory tissue & secretions - intense T2 Tumor - intermediate T1 & T2 (low signal) 94% accuracy gadolinium (enhancement) 98% accuracy