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3 Peculiar Patterns ofSpread ofNose Vestibule Malignancies

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Fig. 3.8 A less frequent case: the visible lesion on the skin arises from the internal surface of the lateral alar cartilage, and from here it comes to invade the skin

3.4 Typical Patterns ofSpread fromtheMedial Wall

When a primary lesion of the medial wall of the vestibule spreads posteriorly, it typically runs along the septal cartilage (Fig. 3.9). For the above cited cartilage resistance, septal perforation is rare except in very bulky primaries or as a consequence of extensive tissue sampling during a diagnostic biopsy. Such posterior spread is not an issue until it remains within the anatomical limits of the nose vestibule (anterior to the coronal plane of pyriform aperture) (Fig.3.9). Septal/columellar primaries can also share the inferior pattern of spread of inferior wall primaries.

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Fig. 3.9 Posterior spread from the septum leading to a cT3 lesion according to our newly proposed T classication

F. Bussu et al.

3.5 Typical Patterns ofSpread fromtheInferior Wall

The inferior spread of nose vestibule primaries (mainly from the inferior and medial walls) typically involves the superior lip (Figs.3.10 and 3.11). It is therefore another typical route for skin invasion in nose vestibule malignancies.

Primaries of the inferior wall can also spread posteriorly; in this case, as the anteroposterior dimension of the inferior wall is minimal (see Fig.3.2), it is associated to two orders of issues:

– invasion of the nasal spine and/or of the hard palate with bone involvement

(Fig. 3.12), which determines an upstaging according to Wang classication and

to our newly proposed T classication [10–12], and most probably a prognostic

impairment;

– overcoming of the plane of the pyriform opening, the newly proposed posterior

limit of the nose vestibule (Fig.3.9), which in our opinion should determine an

upstaging of the lesion as well (see Chap. 5) as it determines clear issues for

treatment by exclusive interstitial brachytherapy (see Chap. 12), which is being

demonstrated to be a valuable option in this group of malignancies [10–12].

3 Peculiar Patterns ofSpread ofNose Vestibule Malignancies

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Fig. 3.10 A typical route of invasion involving the upper lip

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F. Bussu et al.

Fig. 3.11 The tumor invades the lter and runs to the upper lip

3 Peculiar Patterns ofSpread ofNose Vestibule Malignancies

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Fig. 3.12 Inferior spread: invasion of the nasal spine and/or hard palate

References

1. Jeannon J-P, Riddle PJ, Irish J, O’sullivan B, Brown DH, Gullane P.Prognostic indicators in

carcinoma of the nasal vestibule. Clin Otolaryngol. 2007;32:19–23.

2. Bussu F, Tagliaferri L, Mattiucci G, etal. Comparison of interstitial brachytherapy and surgery

as primary treatments for nasal vestibule carcinomas. Laryngoscope. 2016;126:367–71.

3. Mor N, Blitzer A.Functional anatomy and oncologic barriers of the larynx. Otolaryngol Clin

North Am. 2015;48:533–45.

4. Sandell LJ.Novel functions for type II procollagen. Connect Tissue Res. 2014;55:20–5.

5. Caccialanza M, Piccinno R, Percivalle S, Rozza M.Radiotherapy of carcinomas of the skin

overlying the cartilage of the nose: our experience in 671 lesions. J Eur Acad Dermatol

Venereol. 2009;23:1044–9.

6. Caccialanza M, Piccinno R, Moretti D, Rozza M.Radiotherapy of carcinomas of the skin over-

lying the cartilage of the nose: results in 405 lesions. Eur J Dermatol. 2003;13:462–5.

7. Caccialanza M, Piccinno R, Gaiani F, Contini D.Relevance of dermatologic radiotherapy in the

therapeutic strategy of skin epithelial neoplasms: excellent results in the treatment of lesions

localized on eyelids and skin overlying the cartilage of the nose. G Ital Dermatol Venereol.

2013;148:83–8.

8. Caccialanza M, Bertani E, Piccinno R, Rozza M, Brambilla R, Percivalle S.Radiotherapy of

T4 squamous cell carcinoma of the skin of nasal pyramid. J Eur Acad Dermatol Venereol.

2006;0:060606032107062.

9. Bussu F, Tagliaferri L, De Corso E, et al. Functional results of exclusive interventional

radiotherapy (brachytherapy) in the treatment of nasal vestibule carcinomas. Brachytherapy.

2021;20:178–84.

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10. Bussu F, Tagliaferri L, Piras A, Rizzo D, Tsatsaris N, De Corso E, Parrilla C, Paludetti

G. Multidisciplinary approach to nose vestibule malignancies: setting new standards

approccio multidisciplinare ai tumori maligni del vestibolo del naso: verso la denizione

di nuovi standard. Acta Otorhinolaryngol Ital. 2021;41(1):S158–S165. https://doi.

org/10.14639/0392-100X-suppl.1-41-2021-16.

11. Bussu F. New standards for the management of nose vestibule malignancies. Acta Oto-

Laryngologica. 2023;143(3):215–22. https://doi.org/10.1080/00016489.2023.2179662.

12. Scheurleer WFJ, Tagliaferri L, Rijken JA, Crescio C, Rizzo D, Mattiucci GC, Pameijer FA, de

Bree R, Fionda B, de Ridder M, Bussu F. Evaluation of staging systems for cancer of the nasal

vestibule. Cancers. 2023;15(11):3028. https://doi.org/10.3390/cancers15113028.

F. Bussu et al.

Current Staging Systems forNose

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Vestibule Malignancies

AntonioPiras, DavideRizzo, EmiliaDegni, ClaudiaCrescio, AlessiaRe, GiovanniMariaFadda, GiancarloMattiucci, andAntonioPazzola

4.1 Introduction

4.1.1 Principles ofTNM Classification

In the management of cancer, an accurate and reliable staging of the tumor holds the key to successful treatment strategies, to the prediction of clinical outcomes, and to international communication.

The tumor-node-metastasis (TNM) staging system describes the anatomic extent of the primary tumor (T) as well as the involvement of the regional lymph nodes (N) and distant metastasis (M). It should be based on a thorough knowledge of the natural history of tumors at various sites and subsites and on a clear denition of

A. Piras · D. Rizzo (*) Otolaryngology Division, Sassari University Hospital, Sassari, Italy

Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy e-mail: davide.rizzo@aouss.it; drizzo@uniss.it

E. Degni · C. Crescio Otolaryngology Division, Sassari University Hospital, Sassari, Italy e-mail: emilia.degni@aouss.it; claudia.crescio@aouss.it

A. Re Radiation Oncology Unit, Mater Olbia Hospital, Olbia, Italy

G. M. Fadda · A. Pazzola Medical Oncology Division, Sassari University Hospital, Sassari, Italy e-mail: giovanni.fadda@aouss.it; antonio.pazzola@aouss.it

G. Mattiucci Radiation Oncology Unit, Mater Olbia Hospital, Olbia, Italy

Università Cattolica del Sacro Cuore, Istituto di Radiologia, Rome, Italy e-mail: giancarlo.mattiucci@unicatt.it

https://doi.org/10.1007/978-3-031-32850-3_4

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A. Piras et al.

prognostic parameters, as it is expected, rst of all, to properly stratify prognosis and hence to guide therapeutic decision.

TNM was developed and is periodically updated by the Union for International Cancer Control (UICC). It is also used by the American Joint Committee on Cancer (AJCC) and by the International Federation of Gynecology and Obstetrics (FIGO). In 1987, the UICC and AJCC staging systems were unied into a single TNM staging system. The generation of scientic evidence leads to continuous updates in the TNM system for all the malignancies.

4.1.2 Current UICC/AJCC TNM Classification forNose

andParanasal Sinuses Malignancies

Like many other cancers, a fully satisfying stratication of nose/paranasal malignancies has been challenging, mainly because of the numerous anatomic sites and subsites from which tumors can arise and because of the heterogeneity of histologic types that show different clinical behavior and outcomes.

T classication of nose and paranasal sinuses follows two different orders of criteria for maxillary sinus primaries on the one hand and nasal cavities/ethmoid primaries on the other (Tables 4.1 and 4.2).

Many histotypes exist and are also acknowledged as key factors when determining the prognosis. Melanoma, lymphoma, and sarcoma are not included in the UICC/AJCC staging of nose/paranasal sinuses primaries.

The nasoethmoidal complex is divided into two subsites: the nasal cavity and the ethmoid sinuses. The ethmoids are further subdivided into two subsites: left and right, separated by the nasal septum (perpendicular plate of ethmoid). The nasal

Table 4.1 UICC/AJCC 2017, Eighth Edition. Classication of Primary Tumor (T): Maxillary Sinus

T category T criteria TX Primary tumor cannot be assessed Tis Carcinoma in situ T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone T2 Tumor causing bone erosion or destruction including extension into the hard palate

T3 Tumor invades any of the following: bone of the posterior wall of the maxillary

T4 Moderately advanced or very advanced local disease

• T4a Moderately advanced local disease

• T4b Very advances local disease

and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates

sinus, subcutaneous tissues, oor or medial wall of orbit, pterygoid fossa, ethmoid sinuses

Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx or clivus

4 Current Staging Systems forNose Vestibule Malignancies

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Table 4.2

and ethmoid sinus

T category T criteria TX Primary tumor cannot be assessed Tis Carcinoma in situ T1 Tumor restricted to any one subsite, with or without bony invasion T2 Tumor invading two subsites in a single region or extending to involve an adjacent

T3 Tumor extends to invade the medial wall or oor of the orbit, maxillary sinus,

T4 Moderately advanced or very advanced local disease

• T4a Moderately advanced local disease

• T4b Very advanced local disease

UICC/AJCC 2017, Eighth Edition. Classication of Primary Tumor (T): Nasal cavity

region within the nasoethmoidal complex, with or without bony invasion

palate, or cribriform plate

Tumor invades any of the following: anterior orbital contents, skin of the nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses

Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx or clivus

cavity is divided into four subsites: the septum, the oor, the lateral wall, and the edge of the naris to the mucocutaneous junction, but without any differences in the denition of c- and/or p-T between such different subsites, which are all included in the same topographic code C30.0 (Tables 4.5 and 4.6).

4.1.3 Evolution ofUICC/AJCC TNM ofNose andParanasal Sinus

The current complete 8th UICC/AJCC staging system (2017) for maxillary sinus and nasoethmoid lesions is therefore shown in Tables 4.1, 4.2, 4.3, and 4.4 [1].

The T category (Tables 4.1 and 4.2) is identical to the UICC/AJCC Cancer Staging Manual 7th edition (2009) [2], according to the changes introduced in the 6th edition (2002) concerning the classication of the nasal cavity and paranasal malignancies [3]. Here a new site, the nasal cavity (C30.0), was added for inclusion into the staging system of nose malignancies. In the 6th UICC/AJCC edition, in addition to maxillary sinus, the nasal cavity was merged with the ethmoid in the same T classication, forming the nasoethmoid complex, divided into two regions: the nasal cavity (four subsites: septum, oor, lateral wall, and vestibule) and the ethmoid sinuses (two subsites: right and left).

The sites in this classication are listed by code numbers of the International Classication of Diseases for oncology (Chapter 2 of the 2019 edition of the ICD-10-CM, World Health Organization) [4] (Tables 4.5 and 4.6).

As shown, the nasal vestibule (NV) is included in C30.0 code, the same “billable” ICD code used to specify a diagnosis of malignant neoplasm everywhere in the nasal cavity, considering NV only an unspecied subsite of the nasal cavity [5, 6].

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A. Piras et al.

Table 4.3

N category N criteria NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3cm or smaller in greatest

N2 Metastasis in a single ipsilateral node larger than 3cm but no larger than 6cm in

• N2a Metastasis in a single ipsilateral node larger than 3cm but no larger than 6cm in

• N2b Metastasis in multiple ipsilateral lymph node, none larger than 6cm in greatest

• N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6cm in

• N3a

• N3b Metastasis in any node(s) with clinically overt ENE (+)

ENE extranodal extension

Table 4.4

N category N criteria NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3cm or smaller in greatest

N2 Metastasis in a single ipsilateral node, 3cm or smaller in greatest dimension and

• N2a Metastasis in single ipsilateral or contralateral node 3cm or less in greatest

• N2b Metastasis in multiple ipsilateral lymph node, none larger than 6cm in greatest

• N2c Metastasis in bilateral or contralateral lymph nodes, none larger than 6cm in

• N3a

• N3b Metastasis in a single ipsilateral node larger than 3cm in greatest dimension and

Denition of regional lymph node (N): Clinical N (cN)

dimension and ENE (−)

greatest dimension and ENE (−); or metastasis in multiple ipsilateral lymph node, none larger than 6cm in greatest dimension and ENE (−); or in bilateral or contralateral lymph nodes, none larger than 6cm in greatest dimension and ENE (−)

greatest dimension and ENE (−)

dimension and ENE (−)

greatest dimension and ENE (−)

Metastasis in a lymph node larger than 6cm in greatest dimension and ENE (−); or metastasis in any node(s) with clinically overt ENE (+)

Metastasis in a lymph node larger than 6cm in greatest dimension and ENE (−)

Denition of regional lymph node (N): Pathological N (pN)

dimension and ENE (−)

ENE (+); or larger than 3cm but no larger than 6cm in greatest dimension and ENE (−); or metastasis in multiple ipsilateral lymph node, none larger than 6cm in greatest dimension and ENE (−); or in bilateral or contralateral lymph nodes, none larger than 6cm in greatest dimension and ENE (−)

dimensión and ENE(+); or a single ipsilateral node larger than 3cm but not larger than 6cm in greatest dimensión and E N E (−)

dimension and ENE (−)

greatest dimension and ENE (−)

Metastasis in a lymph node larger than 6cm in greatest dimension and ENE (−); or in a single ipsilateral node larger than 3cm in greatest dimension and ENE (+); or multiple ipsilateral, contralateral or bilateral node, any with ENE (+)

Metastasis in a lymph node larger than 6cm in greatest dimension and ENE (−)

ENE (+); or multiple ipsilateral, contralateral or bilateral nodes, ant with ENE (+)

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