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Part 2 Site-Specifi c Indications and Techniques
Case
Study
11-6
mass in the posterior right nasal septum, biopsy positive
for squamous cell carcinoma. e tumor was too deep for
either brachytherapy or electron therapy. Given the previous radiotherapy, which encompassed the entire posterior
pharynx, he was treated with IMRT to a total dose of 66 Gy
delivered in 30 fractions.
Figure 11-6 shows a representative axial isodose
through the tumor. He was without evidence of disease for
both primary tumors.
Case
Study
11-7
magnetic resonance imaging revealing the lesion in the
nasal cavity with secretions in the adjacent maxillary
and sphenoid sinuses. He was treated with neoadjuvant
VP-16 and cisplatin for three cycles with a good response,
with only questionable residual disease in the posterior
nasal cavity. He subsequently received IMRT with two
A 55-year-old male initially presented with T2
N0 squamous cell carcinoma of the oropharynx. He was treated with concomitant boost
fractionation. Approximately 1 year later, a
routine follow-up endoscopy discovered a
A 30-year-old man presented with nasal
obstruction. Examination showed a right nasal
mass, the biopsy of which revealed sinonasal
undi erentiated carcinoma.
Figure 11-7A shows a T2-weighted axial
Figure 11.6
additional cycles of single agent cisplatin. Figures 11.7B,C
show axial dose distributions through the nasal cavity and sagittal view through midline, respectively. e
areas of residual abnormality (yellow) received 66 Gy, the
pretreatment tumor volume received 63 Gy, and areas of
potential microscopic spread including right level I and II
nodes received 54 Gy, all given in 30 fractions. Brain stem
(magenta), optic chiasm (blue), and an oral avoidance
volume (orange) are shown. He was free of recurrence at
the last follow-up, more than 3 years a er completion of
therapy.
AB
Figure 11.7A,B
Chapter 11 Nasal Cavity
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195
C
Figure 11.7C
CTV
encompasses the entire sinus beyond CTVID. In
ED
the N0 neck, CTVED may include retropharyngeal, levels
IB and II nodes depending on the tumor type and stage.
When level IB or II node is involved, CTVED also includes
clinically uninvolved ipsilateral levels III and IV nodes.
Note that ipsilateral levels III and IV nodes can also be
treated with a matching anterior oblique photon portal
with an isocenter placed above the thyroid cartilage.
Dose
• External irradiation: conventional technique delivering
50Gy in 25 fractions to the initial target volume plus 16 to
20 Gy in 8 to 10 fractions to the boost volume depending
on the size. IMRT regimen for T1 and small T2 tumors is
66, 60, and 54 Gy to CTV
, CTVID, and CTVED, respec-
HD
tively, given in 30 fractions. Regimens for larger tumors,
or when combined with concurrent chemotherapy are 70,
60 to 63, and 56 to 57 Gy to CTVHD, CTVID, and CTVED,
respectively, in 33 or 35 fractions.
• Brachytherapy: approximately 60 to 65 Gy in 5 to 7 days
speci ed at the margins of the lesion.
Postoperative Radiotherapy
Target Volume
e initial target volume encompasses the entire surgical
bed. e boost volume encompasses areas of macroscopic
disease with 1- to 2-cm margins.
Intensity-Modulated Radiation Therapy
e technique used is similar to primary radiotherapy presented above. e patient is immobilized in a supine position, with an extended head and shoulder thermoplastic
mask. in-cut CT scans are obtained in treatment position.
e target volumes are outlined for dosimetric planning
(see
Case Studies 11-8 to 11-10).
Virtual Gross Target Volume
ere is no actual GTV a er complete surgical tumor resection. However, it can be useful to formulate a virtual GTV
(vGTV) to guide target volume contouring. e vGTV
represents all areas determined from clinical examination,
preoperative imaging studies, and the surgical–pathologic ndings to likely contain high-density microscopic
disease.
Clinical Target Volume
ree CTVs are generally delineated.
• CTVHD delineates volumes to receive the highest dose,
which includes the primary and nodal vGTVs with 0.5- to
1-cm margins.
• CTVID outlines volumes to receive an intermediate dose,
includes the operative bed outside of CTVHD.
• CTV
delineates volumes to receive an elective dose for
ED
subclinical disease. When the tumor invades the adjacent
sinus, then CTVED encompasses the entire sinus. In theN0
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Part 2 Site-Specifi c Indications and Techniques
Case
Study
11-8
Figure 11.8A shows the tumor (green arrow) in an axial
slice of diagnostic CT scan. She underwent an endoscopic
resection of the tumor. Margins were negative but contained high-grade dysplasia.
She was treated with postoperative IMRT. A mouth opening, tongue depressing stent was used to minimize dose to the
oral structures. As the vGTV was relatively small, it was elected
to omit CTVID but de ne CTVHD fairly generously to include
the septum and right nasal cavity. e remaining le nasal
cavity, medial aspect of the right maxillary sinus, hard palate
A 60-year-old woman presented with nasal
obstruction and epistaxis. She was found to
have a lesion in the posterior right nasal septum. Biopsy was positive for squamous cell
carcinoma.
( oor of the nasal cavity), anterior sphenoid sinus, and ethmoid
sinuses were de ned as CTVED. CTVHD and CTVED were prescribed 60 and 54 Gy, respectively, and treatment was delivered
in 30 fractions. An axial view of the isodose distribution is
shown through the mid nose (Fig. 11.8B) along with CTVHD
(red) and CTVED (yellow). A second axial view (Fig. 11.8C)
through the ethmoids and orbits shows only CTVED at this
level. e doses to the optic nerves and lenses were <45 and <10
Gy, respectively. Isodose distributions in sagittal (Figure 11.8D)
and coronal views through midplane of the head (Fig. 11.8E),
and a coronal view through the neck (Fig. 11.8F) of the head
are also shown. e contour colorwash inside the 60-Gy line is
removed so the underlying resected tissues can be appreciated.
e mouth opening stent can also be seen on these views. e
patient has done well and is without disease 3 years later.
A
C
Figure 11.8A-D
B
D
Chapter 11 Nasal Cavity
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197
E
Figure 11.8E,F
Case
Study
11-9
11.9A showing an axial view of the diagnostic head and
neck CT scan. She was treated with surgery and postoperative IMRT.
Surgery consisted of a radical resection of the so tissue of the face, right medial maxillectomy, partial ethmoidectomy, and lacrimal sac marsupialization. e defect was
reconstructed with an anterolateral thigh-free ap. Histologic examination revealed a poorly di erentiated squamous carcinoma that invaded the connective tissue and
periosteum of the lateral nasal wall and medial maxilla.
ere was also perineural invasion.
Postoperative IMRT was delivered in 30 fractions
starting 1 month later. Figure 11.9B shows an axial
A 74-year-old woman had a squamous cell
carcinoma of the right nasal ala treated with
Mohs surgery.
One year later, the tumor (green arrow)
recurred locally as demonstrated on Figure
F
isodose distribution with contours of CTVHD (tumor
bed—red), CTVID (surgical bed—blue), and CTVED
(perineural route and upper neck nodes at risk—yellow).
The surgical bed and reconstructed tissues can be better appreciated without CTV contours (Fig. 11.9C). The
main nerve at risk was the infraorbital nerve to the maxillary nerve as it exits foramen rotundum. Since poorly
differentiated carcinoma has a higher propensity for
nodal spread, CTVED included the right buccal, facial,
and upper cervical nodes. Also shown are axial isodose
distributions at the level of the ethmoids and orbits (Fig.
11.9D), maxilla (Fig. 11.9E), buccal region (Fig. 11.9F),
facial and upper neck nodes (Fig. 11.9G), and a coronal
view through the orbits and anterior maxillary sinuses
(Fig. 11.9H). The patient developed posttherapy ectropion and epiphora that was helped by removal of scar
tissue and tarsorrhaphy to repair the ectropion 1 year
later. She remains without disease 2 years later.
A
Figure 11.9A,B
B
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Part 2 Site-Specifi c Indications and Techniques
C
E
D
F
G
Figure 11.9C-H
H
Chapter 11 Nasal Cavity
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199
Case
Study
11-10
of staging CT scan revealing a bulky tumor (green arrow)
primarily in the oor of the nasal cavity abutting the anterior maxilla (Fig. 11.10A) and more superiorly the septal
defect with surrounding irregular tissue (Fig. 11.10B).
He underwent a partial rhinectomy, ethmoidectomy,
partial resection of the upper lip, and sphenoidotomy, followed by plastic surgical reconstruction. e tumor was
A 57-year-old man presented with chronic
epistaxis and was found to have a tumor of the
nasal septum. A biopsy revealed poorly di erentiated squamous cell carcinoma.
Figure 11.10 shows representative images
3.5cm in size and invaded the cartilage. Due to the size and
poor di erentiation, postoperative IMRT was recommended
to treat the nose, the remaining upper lip, and draining lymphatics. Tissue equivalent material was placed in the surgical
defect to improve the dose distribution. Figures 11.10C-H
show axial isodose distributions at the level of the ethmoids
(Fig. 11.10C), mid maxillary sinuses and the center of the
rhinectomy defect (Fig.11.10D), maxilla and residual upper
lip (Fig.11.10E), mandible and buccal region (Fig.11.10F),
upper neck (Fig. 11.10G), and a sagittal view through midplane (Fig. 11.10H). e patient was without disease but did
have grade 2 xerostomia, 1 year a er treatment.
A B
C
Figure 11.10A-D
D
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Part 2 Site-Specifi c Indications and Techniques
E F
G
Figure 11.10E-H
neck, CTV
may include retropharyngeal and levels IB
ED
and II nodes. When level IB or II node is involved, CTVED
also includes clinically uninvolved ipsilateral level III and
IV nodes. Note that ipsilateral level III and IV nodes can
also be treated with a matching anterior oblique photon
portal with an isocenter placed above the thyroid cartilage.
Setup and Field Arrangement
is setup is similar to that for the maxillary sinus
(see Chapter 12); the eld borders are adjusted to the location and extent of the tumor.
H
Dose
With conventional technique, 50 Gy in 25 fractions is
delivered to the initial target volume and 10 Gy in 5 fractions
(negative margins) to 16 Gy in 8 fractions (positive margins)
is delivered to the boost volume.
IMRT is delivered in 30 fractions. e doses prescribed are
60, 57, and 54 Gy to CTVHD, CTVID, and CTVED, respectively.
In the case of positive margins or extracapsular nodal extension, an additional 6 Gy can be given, as an integrated boost or
in an additional three fractions, to the high-risk volume.
Background Data
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Chapter 11 Nasal Cavity
201
Table 11.2
Local Control and Regional Relapse for Carcinoma of the Nasal Vestibule Treated with Radiation
Therapy (Literature Review)
Authors Year of Publication No. of Patients Local Control (%) Neck Failure
Wong and Cummings 1986 56 80 (C) 4
Chobe et al. 1988 32 97 (C) 17
Mazeron et al. 1988 64 75 (C) 13
Levendag and Pomp 1990 63 86 (C) 6
Mendenhall et al. 1999 44 82 (C) 12
Wang 2000 54 81—T1
NS
79—T2
53—T3 (5 yr)
Kummer et al. 2002 47 85 (C) 14
Langendijk et al. 2004 56 80 (2 yr) 12
C, crude; NS, not stated.
a
Neck failure in patients who did not receive elective nodal irradiation.
Table 11.3
Pattern of Failure
Primary Site No. of Patients LR RR LR + DM DM
After initial treatment
Nasal septum
Lateral wall and fl oor
14
31
2
9
2
0
0
1
After salvage treatment
Nasal septum
Lateral wall and fl oor
LR, local recurrence; RR, regional relapse; DM, distant metastases.
Modifi ed from Ang KK, Jiang GL, Frankenthaler RA, et al. Carcinomas of the nasal cavity. Radiother Oncol 1992;24:163.
14
31
0
5
0
0
0
2
a
(%)
0
2
0
2
Table 11.4
Survival Rates by Site of Primary Disease
Actuarial Rates Patient Number 5 yr (%) P value
Overall survival
Septum
Cavity
Disease-specifi c survival
Septum
Cavity
Local–regional control
Septum
Cavity
Modifi ed from Allen MW, Schwartz DL, Rana V et al. Long-term radiotherapy outcomes for nasal cavity and septal cancers. Int J Radiat Oncol Biol Phys
2008;71:401–406.
31
37
31
37
31
37
90
78
90
83
79
71
0.04
0.13
0.49
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Part 2 Site-Specifi c Indications and Techniques
SUGGESTED READINGS
Aggar A, von Buchwald C, Madsen AR, et al. Squamous cell
carcinoma of the nasal vestibule 1993–2002: a nationwide retrospective study from DAHANCA. Head Neck 2009;31:1593.
Allen MW, Schwartz DL, Rana V, et al. Long-term radiotherapy outcomes for nasal cavity and septal cancers. Int J Radiat Oncol
Biol Phys 2008;71:401.
Ang KK, Jiang GL, Frankenthaler RA, et al. Carcinomas of
the nasal cavity. Radiother Oncol 1992;24:163.
Bhattacharyya N. Cancer of the nasal cavity: survival and factors
in uencing prognosis. Arch Otolaryngol Head Neck Surg 2002;128:1079.
Chassagne D, Wilson JF. Brachytherapy of carcinomas of the
nasal vestibule. Int J Radiat Oncol Biol Phys 1984;10:761.
Chobe R, McNeese M, Weber R, et al. Radiation therapy for carcinoma of the nasal vestibule. Otolaryngol Head Neck Surg 1988;98:67.
Diaz EM Jr, Johnigan RH 3rd, Pero C, et al. Olfactory neuroblastoma: the 22-year experience at one comprehensive cancer
center. Head Neck 2005;27:138.
Jeannon JP, Riddle PJ, Irish J, et al. Prognostic indicators in
carcinoma of the nasal vestibule. Clin Otolaryngol 2007;32:19.
Kummer E, Rasch CR, Keus RB, et al. T stage as prognostic
factor in irradiated localized squamous cell carcinoma of the nasal
vestibule. Head Neck 2002;24:268.
Langendijk JA, Poorter R, Leemans CR, et al. Radiotherapy
of squamous cell carcinoma of the nasal vestibule. Int J Radiat Oncol
Biol Phys 2004;59:1319.
LeLiever WC, Bailey BJ, Gri ths C. Carcinoma of the nasal
septum. Arch Otolaryngol 1984;110:748.
Levendag PC, Pomp J. Radiation therapy of squamous
cell carcinoma of the nasal vestibule. Int J Radiat Oncol Biol Phys
1990;19:1363.
Levendag PC, Nijdam WM, van Moolenburgh SE, et al.
Interstitial radiation therapy for early-stage nasal vestibule cancer:
a continuing quest for optimal control and cosmesis. Int J Radiat
Oncol Biol Phys 2006;66:160.
Mazeron JJ, Chassagne D, Crook J, et al. Radiation therapy of
carcinomas of the skin of nose and nasal vestibule: a report of 1676
cases by the Groupe Europeen de Curietherapie. Radiother Oncol
1988;13:165.
Mendenhall WM, Amdur RJ, Morris CG, et al. Carcinoma of
the nasal cavity and paranasal sinuses. Laryngoscope 2009;119:899.
Rosenthal DI, Barker JL Jr, El-Naggar AK, et al. Sinonasal
malignancies with neuroendocrine di erentiation: patterns of failure according to histologic phenotype. Cancer 2004;101:2567.
Schalekamp W, Hordijk GJ. Carcinoma of the nasal vestibule:
prognostic factors in relation to lymph node metastasis. Clin Oto-
laryngol 1985;10:201.
Wallace A, Morris CG, Kirwan J, et al. Radiotherapy for
squamous cell carcinoma of the nasal vestibule. Am J Clin Oncol
2007;30:612.
Wong CS, Cummings BJ.
the treatment of squamous cell carcinoma of the nasal vestibule.
Areview. Acta Oncol 1988;27:203.
e place of radiation therapy in
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Paranasal Sinuses
Key Points
• e paranasal sinuses include the maxillary,
ethmoid, sphenoid, and frontal sinuses.
• Cancers of the paranasal sinuses are uncommon with
the majority originating in the maxillary sinus.
• Carcinomas arising from the sinuses have a wide
range of histologic types. Squamous cell cancer is
most common but neoplasms arising from minor
salivary glands, and respiratory and olfactory cells
can also develop in sinuses.
• Most sinus cancers are treated with surgery.
Radiation with or without chemotherapy is o en
recommended postoperatively.
• Rare neoplasms, including undi erentiated
carcinomas, can be addressed with de nitive radiation in combination with chemotherapy.
• e proximity of the eyes, optic pathways, and brain
makes treatment of these cancers quite challenging because of the complexity of target volumes.
Intensity-modulated radiation therapy (IMRT) can
circumvent some of these challenges.
MAXILLARY SINUS
Treatment Strategy
Surgery alone is the preferred treatment of T1 tumors
(uncommon). Postoperative radiotherapy is only indicated
when the margin is close or positive. Surgery plus postoperative radiotherapy is the standard therapy for T2 to T4 tumors.
Patients with larger T3 and T4 tumors are occasionally
selected for treatment with systemic therapy in an attempt
to reduce the need for orbital exenteration. e response
to chemotherapy determines the type of local–regional
treatment. For complete or near-complete response, the
treatment is radiotherapy with concurrent chemotherapy
(uncommon), and for less than near-complete response, the
treatment is surgery plus postoperative radiotherapy, with
concurrent chemotherapy in case of the presence of positive
margins or nodal disease with extracapsular extension.
Postoperative Radiotherapy
Target Volume
e initial target volume encompasses the entire surgical
bed (see Case Studies 12-1 and 12-2), ipsilateral levels IB
and II (submandibular and subdigastric) nodes for patients
with squamous cell or undi erentiated carcinomas with no
clinical evidence of nodal involvement at diagnosis, or whole
ipsilateral or bilateral neck for patients with N+ at diagnosis.
e boost volume encompasses areas of known disease
with 1- to 2-cm margins.
Setup and Field Arrangement for Conventional
T
echnique
An intraoral stent is used to open the mouth and depress the
tongue. When surgical resection includes removal of the hard
palate, the stent can be designed to hold a water- lled balloon
to occlude the surgical defect (see Chapter 3). Orbital exenteration defect, if present, is lled directly with a water-containing
balloon (see Case Study 12-3) or other types of bolus material.
e patient is immobilized in a supine position with a
slight hyperextension of the head to bring the oor of the
orbit parallel to the axis of the anterior beam. is position
allows delivery of the desired dose to the orbital oor without irradiating through a large volume of the ipsilateral eye.
Marking of lateral canthi, oral commissures, and external
scar facilitates portal design. When there is no external scar
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