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Part 2 Site-Specifi c Indications and Techniques
Case
Study
12-7
tiated carcinoma. MRI revealed residual disease in the right
nasoethmoidal region with extension to the nasopharynx. She
was treated with three cycles of cisplatin and etoposide yielding a partial response. is was followed by IMRT using nine
elds and dynamic multileaf collimation. e gross residual
tumor received 70 Gy, the prechemotherapy volume received
60 Gy, and bilateral upper neck nodes received 56 Gy.
A 43-year-old woman presented with right
periorbital pain and nasal obstruction. She underwent bilateral endoscopic surgery removing a
mass from the right nasal cavity and ethmoids,
which was positive for sinonasal-undi eren-
Figure 12.7 shows axial (Fig. 12.7A) and sagittal
(Fig.12.7B) isodose distributions. e residual tumor and
prechemotherapy tumor (bright red and pale red) and optic
pathways (yellow for chiasm) are shown. Concurrent cispl-
atin was administered every 3 weeks. Posttreatment imaging revealed a residual mass. erefore, a resection was
performed. Histologic examination revealed brotic tissue
only. She developed a solitary larynx metastasis 2 years
later and received radiation and chemotherapy to the larynx only. She is without disease, 4 years from her initial
diagnosis.
A B
Figure 12.7A,B
Case
Study
12-8
noma. CT scan revealed a tumor in the right ethmoid
sinuses and upper part of the right nasal cavity involving the floor of the right orbit. The tumor was resected
through a craniofacial approach. The right antrum
and sphenoid sinus were inspected and found free of
gross disease, but the mucosal lining was removed.
A 56-year-old man sought medical attention because of nasal stuffiness and pressure
discomfort below the right eye. A polypoid
mass was removed from the right nasal cavity, which was diagnosed as adenocarci-
Histologic examination revealed an adenocarcinoma
at the ethmoid sinuses spreading to the mucosa of the
nasal septum.
e patient received postoperative radiotherapy.
Figure 12.8 shows anterior eld (Fig. 12.8A) and right
(Fig.12.8B) and le lateral elds used to treat the surgical
bed with 6 MV photons. e lateral orbital canthi, external
auditory canals, oral commissures, and position of the cornea of the right eye were marked at simulation. e thick,
straight wire indicated the slope of the face. A dose of 56 Gy
was delivered to the isocenter in 28 fractions.
Chapter 12 Paranasal Sinuses
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215
A B
Figure 12.8A,B
Case
Study
12-9
through the oor of the anterior cranial fossa in coronal
view (Fig. 12.9A—blue arrow). She underwent resection
of the mass with an endoscopic approach inferiorly and a
bifrontal craniotomy to address the superior aspect of the
tumor. Histologic examination revealed an esthesioneuroblastoma extended through the cribiform plate to involve
the duramater. Margins were positive.
She was treated with postoperative IMRT delivered in
30 fractions. CTV
structed from the imaging and operative and pathology
reports. A small higher-risk volume, at the right anterior cranial fossa oor where the margin was not cleared,
was de ned and given 63 Gy. CTVID (57 Gy) covered the
additional margin on the cranial fossa oor, as well as the
is 47-year-old woman presented with anosmia and nasal obstruction.
As shown in Figure 12.9, CT scan demonstrates a tumor epicentered in the ethmoid
sinuses (Fig. 12.9A—green arrows) broken
(60 Gy) covered the vGTV as recon-
HD
remaining sinuses that were uninvolved but were in the
surgical bed. Figure 12.9B shows a coronal view through
the posterior orbits with an isodose distribution. Note
the 63-Gy line at the superior aspect of the surgical cavity and the 60-Gy line encompassing the resected ethmoids
between the orbits. e 57-Gy line in this view covers the
bilateral maxillary sinuses and nasal cavity. Figure 12.9C
shows a sagittal view through midline. Again the 63-Gy
line and 60-Gy line are appreciated covering a small portion of the inferior aspect of the anterior cranium and the
resected tumor bed, respectively. e 57-Gy line covers the
sphenoid sinus. Also note the isodose gradient achieved
to keep the optic chiasm within tolerance. Axial isodose
distributions are shown at the level of the orbits and optic
pathways (Fig. 12.9D), the epicenter of the surgical cavity
(Fig. 12.9E), and mid maxillary sinuses (Fig. 12.9F). CTVED
(54 Gy) encompassed the retropharyngeal (Fig. 12.9G) and
the upper neck (Fig. 12.9H) nodes. She remains without
disease 3 years later.
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Part 2 Site-Specifi c Indications and Techniques
A
C
B
D
E
Figure 12.9A-F
F
Chapter 12 Paranasal Sinuses
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217
G
Figure 12.9G,H
Intensity-Modulated Radiation Therapy Planning
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.
Gross Target Volume
GTV represents all areas determined from clinical examination and imaging studies to contain gross disease. ere is no
actual GTV a er complete surgical tumor resection. However, it can be useful to formulate a vGTV to facilitate target
volume de nition in the postoperative setting. e vGTV is
the best approximation of the tissues having high likelihood
of harboring microscopic tumor reconstructed based on
ndings of preoperative clinical examination, imaging studies, and surgical–pathologic assessment.
Clinical Target Volume
ree CTVs are generally delineated.
H
• CTVHD delineates volumes to receive the highest dose.
is includes the primary and nodal GTVs (or vGTVin
the postoperative setting) with 0.5- to 1-cm margins.
• CTVID delineates volumes to receive an intermediate dose,
which includes a 0.5- to 1-cm margin around CTVHD. In
the node-positive neck, CTVID covers the involved nodal
bed outside CTVHD and additional 1 to 2 cm in cranial–
caudal directions.
• CTVED delineates volumes to receive an elective dose for
subclinical disease. If not already included in higher dose
targets (rare), CTVED should cover the entire sinus, the
medial orbital wall, sphenoid sinus, nasal cavity, medial
aspect of the maxillary sinus (or sinuses for bilateral disease)
and oor of the anterior cranial fossa. In clinically N0 neck
(except for low-grade tumors), CTVED encompasses levels
I and II nodes. If level I or II node is involved, CTVED covers levels III and IV regions. Alternatively, levels III and IV
regions can be irradiated with a separate matched anterior
beam with an isocenter placed above the thyroid cartilage.
Background Data
Table 12.1
Variables No. of Patients Local 5-yr Control (%)
Pathologic T stage
T1 + T2
T3
T4
N stage
N0
N1–N2
Infl uence of Disease and Therapy Variables on the Treatment Outcome
Regional 5-yr
Control (%)
a
22
47
77
126
20
73
84
68
73
79
76
82
84
83
75
5-yr Overall
Survival (%)
66
57
50
56
44
(Continued )
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Part 2 Site-Specifi c Indications and Techniques
Table 12.1
Variables No. of Patients Local 5-yr Control (%)
Infl uence of Disease and Therapy Variables on the Treatment Outcome
(Continued )
Regional 5-yr
Control (%)
5-yr Overall
Survival (%)
Histologic fi ndings
SCC
Undifferentiated
Adenocarcinoma
Adenoid cystic carcinoma
Other
Nerve invasion
a
No
Yes
Margin of resection
a
Negative/close
Positive
Elective nodal treatment
a
Patients with unknown status excluded.
Bristol IJ, Ahamad A, Garden AS, et al. Postoperative radiotherapy for maxillary sinus cancer: long-term outcomes and toxicities of treatment. Int J Radiat
Oncol Biol Phys 2007;68:719, with permission.
Table 12.2
Infl uence of Disease and Therapy Variables on the Treatment Outcome of 34 Patients Irradiated for
89
11
6
33
7
82
60
107
37
51
68
91
80
85
64
81
66
74
73
69
80
73
75
96
80
83
82
84
77
93
49
40
37
69
71
61
45
59
41
47
Carcinoma of the Ethmoid Sinuses
Variables No. of Patients
5-yr Actuarial
Local Control (%)
5-yr Actuarial Disease-Specifi c
Survival (%)
T stage
T1
T2
T3
Dura invasion
a
No
Yes
Histologic fi ndings
6
13
15
13
5
b
100
79
53
100
30
100
62
51
83
40
Undifferentiated carcinoma 12 82 72
Squamous cell carcinoma
Adenoid cystic and
8
13
53
73
70
50
adenocarcinoma
Local treatment
Surgery + radiation
Radiation alone
21
13
74
64
68
56
Chemotherapy
No
Yes
a
Patients treated with postoperative irradiation only.
b
Excludes one patient with transitional cell carcinoma.
Modifi ed from Jiang GL, Morrison WH, Garden AS, et al. Ethmoid sinus carcinomas: natural history and treatment results. Radiother Oncol 1998;49:21–27, with
permission.
25
80
9
50
62
67
Chapter 12 Paranasal Sinuses
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219
Table 12.3
Histology Patient No.
Esthesioneuroblastoma 31 4 9 0
Neuroendocrine carcinoma 18 27 13 12
Sinonasal-undifferentiated carcinoma 16 21 16 25
Small cell carcinoma 7 33 44 75
a
5-y actuarial rates.
Data from the M.D. Anderson Cancer Center.
Modifi ed from Rosenthal DI, Barker JL Jr, El-Naggar AK, et al. Sinonasal malignancies with neuroendocrine differentiation: patterns of failure according to
histologic phenotype. Cancer 2004;101:2567, with permission.
Table 12.4
First Author (yr) Patient Number % Patients Treated Postoperatively 2-yr Local Control (%)
Combs (2006) 46 ND 81
Daly (2007) 36 89 62
Hoppe (2008) 37 100 75
Madani (2009) 84 89 71
Dirix (2010) 40 100 76
ND, not described.
Data from Combs SE, et al. Radiat Oncolog 2006;1:23; Daly ME, et al. Int J Radiat Oncol Biol Phys 2007;67:151; Hoppe BS, et al. Head Neck 2008;30:925;
Madani I, Bonte K, Vakaet L, et al. Intensity-modulated radiotherapy for sinonasal tumors: Ghent Univerisity Hospital update. Int J Radiat Oncol Biol Phys
2009;73:424; and Dirix P, et al. Int J Radiat Oncol Biol Phys 2010;78:998.
Patterns of Failure in Patients with Sinonasal Carcinomas with Neuroendocrine Differentiation
Local
a
Failure
Local Control of Paranasal Sinus Malignancies Treated With IMRT
(%)
Regional
Failurea (%)
Distant
Failurea (%)
SPHENOID AND FRONTAL SINUSES
Treatment Strategy
Cancers of the sphenoid sinus and frontal sinuses are very
rare. Treatment is individualized and modalities are chosen based on the extent of disease and the histologic type.
Radiation is o en recommended either as an adjunct to
surgery or as a frontline therapy in patients with inoperable
Case
Study
12-10
chemotherapy yielding a partial response.
He was then treated with IMRT with concurrent
chemotherapy. Target delineation was done by fusing the
prechemotherapy MRI onto the postchemotherapy planning CT set. CTVHD encompassed the prechemotherapy
gross disease. Margin was only added anteriorly into the
ethmoids where it was deemed safe. Figure 12.10 shows
A 66-year-old man presented with headache.
An MRI showed a mass (green arrow)
in the sphenoid sinus (Fig. 12.10A). An
endoscopic biopsy revealed squamous cell
carcinoma. He was treated with induction
tumor or with tumor type that is thought to be (chemo)
radiosensitive.
Nodal disease is uncommon. Radiation targets are the primary site with margin. IMRT is preferred due to the proximity
to the optic structures and brain. Examples of treatment of a
patient with sphenoid sinus cancer with frontline radiotherapy
(Case Study 12-10) and a case with frontal sinus cancer treated
th postoperative radiation (Case Study 12-11) are shown.
wi
a sagittal view of isodose distribution through midline
(Fig.12.10B) with the optic chiasm highlighted by yellow
colorwash and arrow.
Figures 12.10C–F show two matched pairs of contours
as shown on the prechemotherapy MRI and isodose distributions on the planning CT. CTVHD (red contour) was
prescribed 70 Gy. A third matched pair (Fig. 12.10G,H)
shows axial views below the optic pathways. CTVED (blue)
provided an additional 0.5-cm margin on the ethmoids and
was prescribed 60 Gy. e patient remains well over 2 years
from treatment without disease, and there was no vision
impairment.
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Part 2 Site-Specifi c Indications and Techniques
A
C
B
D
E
Figure 12.10A-F
F
Chapter 12 Paranasal Sinuses
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221
G
Figure 12.10G,H
Case
Study
12-11
di erentiated squamous cell carcinoma. Restaging revealed
no gross residual disease, so it was elected to treat him with
postoperative IMRT as the multidisciplinary team did not
believe further surgery would be of bene t.
IMRT was designed to address the primary tumor bed
only with two target volumes. Because he had a debulking
A 71-year-old man presented with headache.
An MRI showed changes that were
thought to be consistent with a mucocele of
the le frontal sinus. He underwent resection,
and histologic examination revealed poorly
H
rather than an oncologic surgical approach, CTVHD encompassing the le frontal sinus was prescribed 66 Gy. CTVED
added additional 0.5- to 1-cm margins, more generous
margin into the right frontal sinus, and was prescribed
60Gy.
Figure 12.11 shows contours (orange colorwash for
CTVHD and aqua for CTVED) and isodose distributions on
a coronal view (Fig. 12.11A) and three axial views through
the sinus (Fig. 12.11B–D). e patient is without disease at
the last follow-up.
A
Figure 12.11A,B
B
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Part 2 Site-Specifi c Indications and Techniques
C
Figure 12.11C,D
SUGGESTED READINGS
Bristol IJ, Ahamad A, Garden AS, et al. Postoperative
radiotherapy for maxillary sinus cancer: long-term outcomes and
toxicities of treatment. Int J Radiat Oncol Biol Phys 2007;68:719.
Claus F, De Gersem W, De Wagter C, et al. An implementation strategy for IMRT of ethmoid sinus cancer with bilateral sparing of the optic pathways. Int J Radiat Oncol Biol Phys 2001;51:318.
Demonte F, Ginsberg LE, Clayman GL. Primary malignant
tumors of the sphenoidal sinus. Neurosurgery 2000;46:1084.
Fletcher GH, Goepfert H, Jesse RH. Nasal and paranasal
sinus carcinoma. In: Fletcher GH, ed. Textbook of radiotherapy, 3rd
ed. Philadelphia, PA: Lea & Febiger, 1980.
Jesse RH, Goepfert H, Lindberg RD. Carcinoma of the
sinuses: a review of treatment. In: Chambers RG, Janssen de
Limpens AM, Jaques DA, et al. eds. Cancer of the head and neck.
Amsterdam, e Netherlands: Excerpta Medica, 1975.
Jiang GL, Morrison WH, Garden AS, et al. Ethmoid sinus
carcinomas: natural history and treatment results. Radiother Oncol
1998;49:21.
Klintenberg C, Olofsson J, Hellquist H, et al. Adenocarcinoma of the ethmoid sinuses. A review of 28 cases with special reference to wood dust exposure. Cancer 1984;54:482.
Le QT, Fu KK, Kaplan M, et al. Treatment of maxillary sinus
carcinoma: a comparison of the 1997 and 1977 American Joint
Committee on cancer staging systems. Cancer 1999;86:1700.
Le QT, Fu KK, Kaplan MJ, et al. Lymph node metastasis in
maxillary sinus carcinoma. Int J Radiat Oncol Biol Phys 2000;46:541.
Logue JP, Slevin NJ. Carcinoma of the nasal cavity and paranasal sinuses: an analysis of radical radiotherapy. Clin Oncol 1991;3:84.
Madani I, Bonte K, Vakaet L, et al. Intensity-modulated radiotherapy for sinonasal tumors: Ghent Univerisity Hospital update.
Int J Radiat Oncol Biol Phys 2009;73:424.
D
McNicoll W, Hopkin N, Dalley VM, et al. Cancer of the
paranasal sinuses and nasal cavities. Part II. Results of treatment.
JLaryngol Otol 1984;98:707.
Mendenhall WM, Amdur RJ, Morris CG, et al. Carcinoma
of the nasal cavity and paranasal sinuses. Laryngoscope 2009;
119:899.
Mock U, Georg D, Bogner J, et al. Treatment planning comparison of conventional, 3D conformal and intensity-modulated
photon (IMRT) and proton therapy for paranasal sinus carcinoma.
Int J Radiat Oncol Biol Phys 2004;58:147.
Paulino AC, Fisher SG, Marks JE. Is prophylactic neck irradiation indicated in patients with squamous cell carcinoma of the
maxillary sinus? Int J Radiat Oncol Biol Phys 1997;39:283.
Paulino AC, Marks JE, Bricker P, et al. Results of treatment of
patients with maxillary sinus carcinoma. Cancer 1998;83:457.
Pommier P, Ginestet C, Sunyach M, et al. Conformal
radiotherapy for paranasal sinus and nasal cavity tumors: threedimensional treatment planning and preliminary results in
40patients. Int J Radiat Oncol Biol Phys 2000;48:485.
Rosenthal DI, Barker JL Jr, El-Naggar AK, et al. Sinonasal malignancies with neuroendocrine differentiation: patterns
of failure according to histologic phenotype. Cancer 2004;101:
2567.
Tsien C, Eisbruch A, McShan D, et al. Intensity-modulated
radiation therapy (IMRT) for locally advanced paranasal sinus
tumors: incorporating clinical decisions in the optimization
process. Int J Radiat Oncol Biol Phys 2003;55:776.
Waldron JN, O’Sullivan B, Gullane P, et al. Carcinoma of the
maxillary antrum: a retrospective analysis of 110 cases.
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ncol 2000;57:167.
Waldron JN, O’Sullivan B, Warde P, et al. Ethmoid sinus cancer: twenty-nine cases managed with primary radiation therapy. Int
J Radiat Oncol Biol Phys 1998;41:361.
Radiother
Salivary Glands
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Key points
• Salivary neoplasms originate mostly from major
salivary glands (parotid, submandibular, and sublingual glands) but can arise from thousands of minor
glands spread throughout the mucosa of the head
and neck.
• e most common neoplasm is benign pleomorphic
adenoma. Malignant tumors are uncommon but comprise a wide variety of histologic types, with mucoepidermoid carcinoma, adenoid cystic carcinoma (ACC),
and salivary ductal carcinoma leading the list.
• Histologic grade of di erentiation is a strong prog-
nostic factor. Distant metastases are more common
in patients with high-grade tumors.
• Surgery is the recommended frontline treatment for
resectable salivary gland cancers. Many of these
13
tumors are locally in ltrative with ill-de ned borders.
Surgical section margins are o en close or positive.
• Adjuvant radiation is o en recommended. Indications
for radiation include extraglandular extension, close or
positive surgical margins, nodal involvement, highgrade histology, and perineural spread.
• Due to perineural spread, particularly with ACC,
radiation volumes o en include the nerve pathways
from the primary tumor to the skull base.
• Primary radiotherapy is reserved for inoperable
tumors. Neutron therapy may be advantageous in
this situation, particularly for ACC.
• e role of combination of chemotherapy and radia-
tion for the treatment of high-risk salivary cancers is
being investigated.
Despite the realization of the diverse natural history and
variation of radiation technique by speci c site of origin, the
rarity of salivary cancers led many investigators to report
treatment outcomes in aggregate. erefore, this chapter
begins by summarizing the general background outcome
data before addressing individual subsites.
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