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Table 15.1: Tumor, node and metastasis (TNM)
staging for maxillary sinus malignancy.
TX: Primary tumor cannot be evaluated
T0: No primary tumor
Tis: Carcinoma in situ
T1:Tumorconnedtomaxillarysinusmucosa
T2: T1+ hard palate bone erosion or destruction and/or extension of tumor in the middle
meatus
T3: T2+ involvement of posterior bony wall of maxillary sinus or subcutaneous tissues or
medialandoorwalloforbitorpterygoidfossaorethmoidsinuses
T4a: T3+ involvement of anterior orbital contents/cheek skin/pterygoid plates/infratemporal
fossa/cribriform plate/sphenoid or frontal sinuses
T4b: T4a+ involvement of orbital apex/dura/brain/middle cranial fossa/cranial nerves other
than V2, nasopharynx/clivus
Table 15.2: Tumor, node and metastasis (TNM)
staging for nose and ethmoid sinuses.
TX: Primary tumor cannot be evaluated
T0: No primary tumor
Tis: Carcinoma in situ
T1:Tumorconnedtoanyonesubsite,withorwithoutbonyinvasion
T2: T1+ one other subsite in a single region or involvement of an adjacent region within
the nasoethmoidal complex
T3:T2+involvement of the medialwall or oor of theorbit/maxillary sinus/hard palate/
cribriform plate
T4a: T3+ involvement of anterior orbital contents/nose or cheek skin/ minimal extension to
anterior cranial fossa/pterygoid plates/sphenoid or frontal sinuses
T4b: T4a+ involvement of orbital apex/dura/brain/middle cranial fossa/cranial nerves
except V2/nasopharynx/clivus
203Chapter 15 Malignant Tumors of Nose and Paranasal Sinuses: Surgical Perspective
■ For nose and ethmoid sinuses (TNM Staging) (Table 15.2).
■ For regional neck nodes (Table 15.3):
Based upon the TNM stage, nal stage of the tumor is assigned for
treatment planning (Tables 15.4 to 15.6).
■ Neck dissection can be combined with stage-wise treatment, if regional
lymph node metastasis is present.
■ e indications for combination of chemotherapy are involvement of
resection limit, perineural invasion and distal metastasis.
Section 3 Tumor and Tumor-like Conditions204
Table 15.3: Tumor, node and metastasis (TNM) staging for regional neck nodes.
NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1:Singleipsilateralmetastaticlymphnode,≤3cminsize
N2a:Singleipsilateralmetastaticlymphnode,>3cmbut≤6cminsize
N2b:Multipleipsilateralmetastaticlymphnode,≤6cminsize
N2c:Bilateralorcontralateralmetastaticlymphnodes,≤6cminsize
N3:Metastaticlymphnode>6cminsize
Table 15.4: Tumor, node and metastasis (TNM) staging for tumor.
Stage 1 T1N0M0
Stage 2 T2N0M0
Stage 3 T3N0M0, T1-3N1M0
Stage 4a T4aN0-2M0, T1-3N2M0
Stage 4b T4b any N, M0, any T, N3, M0
Stage 4c Any T, Any N, M1
Table 15.5: Staging system and treatment options for maxillary sinus malignancy.
Stage Treatment plan
Stage 1 Wide local excision
Stage 2 Infrastructural maxillectomy
Stage 3 Total maxillectomy or extended total maxillectomy followed by radiotherapy
Stage 4a Extended total maxillectomy with orbital exenteration followed by radiotherapy
Stage 4b Palliative care or supportive care
Stage 4c Palliative care or supportive care
Table 15.6: Staging system and treatment options for nose and ethmoid sinuses
malignancy.
Stage Treatment plan
Stage 1 Endoscopic excision/Lateral rhinotomy excision
Stage 2 Endoscopic excision/Lateral rhinotomy excision
Stage 3 Excision by open approach-extended ethmoidectomy follow by radiotherapy
Stage 4a Extended ethmoidectomy with orbital exenteration follow by radiotherapy
Stage 4b Palliative care or supportive care
Stage 4c Palliative care or supportive care
CLASSIFICATION OF SURGICAL PROCEDURES
Medial Maxillectomy (Fig. 15.1)
■ is surgical procedure entails removal of medial wall of maxilla from
oor of orbit to oor of nose.
■ is procedure is best suitable for tumors limited to medial wall of
maxillary sinus and lateral wall of nasal cavity.
■ is procedure can be done either through midfacial degloving approach
or purely endoscopically.
■ Medial maxillectomy can be combined with ethmoidectomy for tumors
extending into ethmoids (Fig. 15.2).
205Chapter 15 Malignant Tumors of Nose and Paranasal Sinuses: Surgical Perspective
Fig. 15.1: Schematic diagram of medial maxillectomy, frontal view. (a: First bony cut; b:
Second bony cut; c: Third bony cut; d: Fourth bony cut).
Fig. 15.2: Extended medial maxillectomy, frontal view. (a: First bony cut; b: Second bony
cut; c: Third bony cut; d: Fourth bony cut; e: Fifth bony cut; f: Sixth bony cut).
Section 3 Tumor and Tumor-like Conditions206
Fig. 15.3: Schematic diagram of total maxillectomy, frontal view. (a: First bony cut; b:
Second bony cut; c: Third bony cut).
Inferior or Infrastructural Maxillectomy
■ is surgical procedure is usually done for tumors limited to hard palate
without gross involvement of maxillary sinus mucosa.
■ It entails removal of part or complete removal of hard palate.
■ e most common tumor resected by this procedure is squamous cell
carcinoma.
■ Others tumors like adenoid cystic carcinoma or mucoepidermoid
carcinoma which are limited to palate only.
Posterior Maxillectomy
■ is procedure is usually done for limited tumors of soft palate with
minimal extension to hard palate.
■ It entails removal of posterior aspect of hard palate, soft palate and part
of posterior maxillary sinus.
■ Usually done for squamous cell carcinoma of soft palate.
Total Maxillectomy (Fig. 15.3)
■ is surgical procedure is indicated for tumors involving primarily the
maxillary sinus mucosa.
■ It entails complete removal of whole of the maxillary sinus in toto.
■ e most common tumors requiring total maxillectomy are squamous
cell carcinoma and adenocarcinoma.
■ e palatal defect after total maxillectomy can be managed either by
palatal prosthesis or free ap.
Craniofacial Resection
■ e most advanced cases of nose and paranasal sinuses extending to
cribriform plate with intracranial extension into anterior cranial fossa
can be dealt with craniofacial resection.
■ It entails complete removal of ethmoids, cribriform plate, and even dura.
■ If required, a part of brain parenchyma can also be resected.
■ Numerous extensions of this procedure can be done for complete disease
removal.
■ ese include total maxillectomy, medial maxillectomy and orbital
exenteration, etc.
OTHER COMMON SINONASAL TUMORS
Adenocarcinoma
■ It is the second most common tumor of sinonasal region.
■ Occupational exposure of wood dust is the risk factor.
■ Upper part of nasal cavity and ethmoid sinuses are the most common
site of origin.
■ Surgery is the treatment of choice. Radiotherapy is required for adjuvant
therapy for locally advanced unresectable/residual tumors.
Adenoid Cystic Carcinoma
■ It accounts for less than 5% of sinonasal malignancies.
■ Maxillary sinus is most common site.
■ It tends to grow slowly and usually present with prolonged history of
facial pain.
■ It spreads by perineural and vascular invasion.
■ Surgery is the treatment of choice.
1
Olfactory Neuroblastoma
■ Basal cell of the olfactory neuroepithelium is the cell of origin.
■ It accounts for 5% of sinonasal malignancies.
■ It has slight female preponderance with bimodal age distribution with
peaks at 20 years and 50 years.
■ It can cause paraneoplastic syndromes, such as Cushing’s syndrome,
syndrome of inappropriate antidiuretic hormone secretion (SIADH) and
hypertension by secreting vasoactive peptides.
■ Surgery is the treatment of choice. Radiotherapy and chemotherapy has
role in adjuvant setting.
1
207Chapter 15 Malignant Tumors of Nose and Paranasal Sinuses: Surgical Perspective
CONCLUSION
Clinical features of malignant sinonasal tumors can be confused for common
benign nasal conditions. High index of suspicion is required for early
diagnosis. Usually patients present in advanced stage. Surgery is the primary
treatment of choice. Radiotherapy and chemotherapy is useful in adjuvant
setting.
ACKNOWLEDGMENT
Authors would like to acknowledge Dr. Smriti Panda for drawing schematic
diagrams for various types of maxillectomies in this chapter.
Section 3 Tumor and Tumor-like Conditions208
REFERENCES
1. Mcmonagle BA, Gleeson M. Nasal cavity and paranasal sinus malignancy. In:
Hibbert J, Gleeson M (Eds.). Scott Brown Otorhinolaryngology Head and Neck
Surgery, 7th Edition. London: Hodder Arnold; 2008. pp. 2417-36.
2. Hermanek P, Hutter RVP, Sobin LH, Wagner G, Witteking C (Eds.). TNM Atlas:
Illustrated Guide to the TNM/pTNM Classication of Malignant Tumors, 4th
Edition. Berlin: Springer-Verlag, 1997.
16
CHAPTER
Radiation and Chemotherapy
in Management of Malignant
Sinonasal Tumors
Dodul Mondal
• Introduction
• Risk Factors
• Routes of Spread
– Local Invasion
– Lymphatic Spread Pathway
• Management
– Indications for Radiotherapy in
Sinonasal Malignancy
– Principles of Radiotherapy
Planning
– Site-specicRadiotherapy
Management and Technical
Details
– Complications and Sequelae of
Treatment
INTRODUCTION
■ Tumors of nasal cavity and paranasal sinuses are complex and
uncommon.
■ Maxillary sinus cancers are most common followed by nasal cavity
cancers.
■ Cancers of frontal, ethmoid and sphenoid sinus are extremely
uncommon.
■ Most sinonasal cancers occur in south Asian countries and in Japan.
RISK FACTORS
ese tumors show interesting association between histology, occupational
exposure and dierent chemical agents (Table 16.1).
Table 16.1: Risk factors for sinonasal cancers.
Histology/Location Chemical exposure/Risk factor
Adenocarcinoma Wood dust, glues
Squamous cell carcinoma Nickel
Maxillary cancer Thorotrast
Nasal cavity Smoking, alcohol, human papillomavirus, Epstein-Barr virus
Section 3 Tumor and Tumor-like Conditions210
ROUTES OF SPREAD
■ Tumors grow to a signicantly large size before detection because of free
space within sinonasal cavity.
■ Most spread by local contiguous invasion. is is important during
radiotherapy planning and deciding radiation treatment volume.
■ Lymphatic spread is uncommon even in advanced stage.
Local Invasion
■ Local spread by sinonasal malignancies is detailed in Table 16.2.
■ Adenoid cystic carcinomas (ADCA) are known to spread thorough nerve
roots and trigeminal nerve is often involved.
Table 16.2: Local invasion by sinonasal malignancies.
Tumor location Local spread
Nasal vestibule Upper lip and nasal cavity are most frequently
involved by local extension; gingivolabial
sulcus,premaxillaryspace,oorofnoseand
nasal septum. Very large tumors can spread to
opposite side of face.
Nasal cavity Roof Spreads thorough ethmoid, cribriform plate
and orbit to involve anterior cranial fossa,
subcutaneous tissue and skin.
Floor Hard and soft palate, maxillary antrum.
Lateral wall Maxillary antrum, ethmoid cells, orbit,
pterygopalatine fossa, and nasopharynx.
Ethmoid sinus Nasal cavity, orbit, maxillary antrum, naso-
pharynx, sphenoid sinus and anterior cranial fossa.
Suprastructure of maxillary antrum Nasal cavity, ethmoid cells, orbit, pterygopalatine
fossa, infratemporal fossa, and base of skull.
Infrastructure of maxillary antrum Palate, alveolar process, gingivobuccal sulcus, soft
tissue of the cheek, nasal cavity, masseter muscle,
pterygopalatine space, and pterygoid fossa.
Sphenoid sinus Most commonly involves cranial nerves (III, IV,
V1, V2, VI) at cavernous sinus, nasal cavity and
brain.
Lymphatic Spread Pathway (Table 16.3)
Lymphatic spread is uncommon and mostly determined by organ or
contiguous structure involvement.
Table 16.3: Lymphatic spread.
Primary site of tumor Possible nodal involvement
Nasal vestibule Ipsilateral IB most common.
Submandibular, facial, preauricular less commonly involved.
Nasal cavity IB, retropharyngeal
Maxilla IB, II
1,2
MANAGEMENT
■ Clinical presentation, staging, diagnosis and surgical perspectives have
already been discussed in Chapter 15.
■ A general guideline involving all anatomical site and stage is unwise and
not recommended.
Indications for Radiotherapy in Sinonasal Malignancy
Indications of dierent types of radiotherapy are described in Table 16.4.
Principles of Radiotherapy Planning
■ Rigid thermoplastic head and neck mask is used for immobilization
during planning and daily treatment.
■ Planning CT scan is usually done in supine position with extended neck.
■ Contrast MRI is highly recommended for better soft tissue and
neuroanatomy details.
■ All available helpful images should be fused with planning CT scan for
better tumor delineation.
■ Important normal organs requiring all precautions to reduce dose to
them are: normal uninvolved brain, temporal lobes, hippocampus,
Table 16.4: Indications of radiotherapy in sinonasal malignancy.
Denitiveradiotherapy • Early tumors usually T1, T2, N0.
• Tumors of nasal vestibule and columella even when
very small are usually treated with nonsurgical
method because of signicant facial deformity
produced by surgery.
• Sphenoid sinus malignancy
• Unresectable tumor due to local inltration or
comorbidities.
Palliative radiotherapy
Concurrent chemoradiotherapy • Stages III and IV unresectable tumor, positive
Adjuvant radiotherapy • All resected tumors other than very early tumors
Elective neck node irradiation • Advanced tumors, squamous or undifferentiated
3
• Patients having extremely poor general condition
or incurable disease may benet from palliative
treatment.
margin, high grade and neuroendocrine tumors.4
• Close margin
• Positive margin
• High T stage
• High grade tumor
• Perineural invasion (PNI)
• Lymphovascular invasion (LVSI)
• Lymph node involvement
• Incomplete resection or tumor spillage
• Concurrent cisplatin can be considered after margin
positive resection.
histology should be treated with elective irradiation.
211Chapter 16 Radiation and Chemotherapy in Management of Malignant Sinonasal Tumors
Section 3 Tumor and Tumor-like Conditions212
Table 16.5: Modes of radiotherapy treatment.
Mode Denition
Brachytherapy Sealed radiation sources are inserted within the tumor or
placed at very close proximity of the tumor
External beam radiotherapy Radiation source remains at a distance from the patient
Intensity-modulated
radiotherapy
5
Type of conformal radiation where multiple radiation
beams are used from different angles to target the tumor.
Each radiation beam is subdivided into multiple beamlets
of different intensity.
brainstem, spinal cord, cochlea, optic chiasm, optic nerves, eyeballs,
retina, lacrimal gland, parotid gland, lens and oral cavity.
■ Modes of radiotherapy are detailed in Table 16.5.
Site-specic Radiotherapy Management and
Technical Details (Table 16.6) (Figs. 16.1A to F)
e site specic management for nasal vestibule and maxillary sinus is
detailed in Table 16.6.
For esthesioneuroblastoma, the treatment recommendations are
discussed in chapter 15.
Nasal
vestibule
Maxillary
sinus
Table 16.6: Site-specic radiotherapy management.
Denitive
Gross tumor with margin, elective nodes 50 Gy
radiation
Boost to primary tumor with margin 16–20 Gy
Boost to gross nodes with margin 16–20 Gy
Adjuvant
radiation
Denitive
Adjuvant
Postoperative6 tumor bed depending on margin
status
Uninvolved nodal region 50 Gy
Gross tumor as determined by clinical examination,
imaging or prechemotherapy tumor extension.
Gross tumor volume (GTV) + 1 – 1.5 cm margin 66–70 Gy
Clinical target volume (CTV)1 + 1 – 1.5 cm margin
around the CTV1. If part of a sinus is involved,
remaining of the sinus should be included in CTV2.
Elective nodal regions, base of skull and nerve tract
till the foramen at the base of skull
Gross residual tumor, sites of positive margin or
extracapsular nodal extension
Tumor bed + 1 – 1.5 cm margin 60 Gy
Entire surgical bed 56–57 Gy
Elective nodal regions, base of skull, nerve tract
till foramen at base of skull, if pathology specimen
shows presence of perineural involvement
60–66 Gy
66–70 Gy
59–63 Gy
54–57 Gy
66–70 Gy
54 Gy
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