MANAGEMENT OF

PARANASAL SINUS
TUMOURS

Dr. S. Sachin,
Junior Resident,
Department of Radiotherapy and Radiation Medicine,
IMS, BHU
STAGING
STAGING
 RISK OF NODAL INVOLVEMENT
• 87.1% - no gross nodal involvement at
presentation Risk%
• Isolated skip metastases to levels 3 or 4 - 0.7% 25.00%

• 2.5% - bilateral or contralateral 20.00%

• SCC of nasal cavity:
• T1 vs T4 (4% vs. 23%, P < .001) 15.00%

• Melanoma of nasal cavity - 5% to 10%

10.00%
• SCC of maxillary sinus:
• T1 (11%) vs T2+ (24%) 5.00%

0.00%
Site

Maxillary Frontal/sphenoid Ethmoid Nasal cavity

*Ahn review of SEER database from 2004 to 2009 (1,811 patients)

 RISK OF NODAL INVOLVEMENT

8.00%
Risk in % Risk (%)
7.00% 30

6.00%
25
5.00%
4.00% 20

3.00% 15
2.00%
10
1.00%
0.00% 5
Neck node
levels
0
Histology
Level 1 Level 2 Level 3
Level 4 Level 5 Retropharyngeal Squamous Small cell SNUDC
Parotid Facial Adeno ENB Melanoma

*Ahn review of SEER database from 2004 to 2009 (1,811 patients)

OHNGREN’S LINE
 HISTOLOGICAL SUBTYPES
Epithelial epidermoid Squamous cell ca (spindle cell, verrucous, transitional)

Epithelial non-epidermoid Adenoca, Adenoid cystic ca, Mucoepidermoid, Acinic cell

Malignant melanoma, Olfactory neuroblastoma, Sinonasal undifferentiated ca,

Neuroectodermal
Ewing’s sarcoma, Neuroendocrine carcinoma

Odontogenic Ameloblastoma
Mesenchymal Fibrosarcoma, liposarcoma

Muscular Leiomyosarcoma, Rhabdomyosarcoma

Vascular Angiosarcoma, Kaposi’s

Cartilaginous Chondrosarcoma
Osseous Osteosarcoma
Lymphoreticular NHL, Burkitt’s, etc,.
 WHY HISTOLOGY?

• Lymphomas, rhabdomyosarcomas, Ewing’s sarcomas, malignant midline reticulosis, and

Esthesioneuroblastomas are managed essentially by radiation therapy alone

• Systemic chemotherapy is used as an adjuvant for rhabdomyosarcomas, Ewing's sarcomas and

lymphomas.
 GROUP STAGING
T/M N0 N1 N2 N3 M1
Tis M0 0 - - - -
T1 M0 I III IVA IVB IVC
T2 M0 II III IVA IVB IVC
T3 M0 III III IVA IVB IVC
T4a M0 IVA IVA IVA IVB IVC
T4b M0 IVB IVB IVB IVB IVC
M1 IVC IVC IVC IVC IVC
 CLINICAL
FEATURES

Asymptomatic or nonspecific sinonasal

symptoms (mimic benign disease) until they
invade adjacent structures - most have
advanced disease by the time of diagnosis
 ORBIT
Diplopia
Orbital pain
Vision loss, Proptosis
Inner canthus mass
Tearing
NEUROLOGICAL
Cranial neuropathy
NASAL CAVITY Anosmia (cribriform plate)
Nasal obstruction PARANASA Central or facial headache
Epistaxis L SINUS
Nasal discharge
TUMOURS

OTHERS
ORAL CAVITY
Facial swelling /pain
Ill-fitting dentures Paraesthesia of cheek
Alveolar /palatal mass
Unhealed tooth socket
TUMOUR
SPREAD
TUMOUR
SPREAD
 DIAGNOSTIC WORKUP
HPE If post-op (also note on pack years and alcohol history)

General Complete History and Physical Examination of head and neck

CT/MRI of primary site and neck

Radiographic
Chest x-ray or CT of thorax if adenoid cystic or neuroendocrine carcinoma(lung mets)

Endoscopy Fibre-optic endoscopic examination with biopsies

Laboratory CBC, RFT, LFT, Viral markers, ECG-12 leads, 2D ECHO,..

Dental evaluation with extractions/restorations as needed

Baseline ophthalmologic examination
Others
Baseline speech and swallowing assessment if surgery is planned
MRI vs CT
 CT > MRI MRI > CT CT or MRI

Tumor extending outside of nose and/or

Distinguishing between tumor
Bone erosion of thin walls paranasal sinuses to involve the adjacent
extension and obstructed secretions
and septa of PNS structures, including the orbital apex
(T4a)
(T4b)

Retrograde perineural spread along V2 Posterior spread to pterygopalantine

Involvement of hard palate
through foramen rotundum or V3 fossa

Bone marrow invasion, Dural

Early cortical involvement involvement or other types of -
intracranial extension (T4b)

94% accuracy (98% if gadolinium

85% accuracy -
enhanced)

CT & MRI are complementary for staging cancers involving nasal cavity and/or paranasal sinuses
 PROGNOSTIC FACTORS

Patient – specific Disease – specific

(survival) (loco-regional control)

• Location
• Age • Histology
• Performance status • TNM stage
• Perineural invasion

• Extensive local disease (nasopharynx, base of the skull, or cavernous sinuses) markedly increases
surgical morbidity as well as the risk of subtotal surgical excision
MAXILLARY SINUS – OUTLINE
(Except adenoid cystic)
T1-2, N0

Surgery

LVI / PNI
Margin -ve Margin close / +ve
+ve

Adjuvant RT Re-resection

Margin -ve Margin +ve

RT CCRT

Follow-up
*NCCN consensus guidelines
MAXILLARY SINUS (Adenoid cystic)
T1-2, N0

Surgery

Margin –ve RT preferred

PNI -ve

Consider Follow-up
observation* *NCCN consensus guidelines
 MAXILLARY SINUS – OUTLINE
T3-4a, N0 T1-4a, N+

Complete resection Complete resection

Adverse Pathological Adverse pathological Adverse Pathological

features -ve features +ve features -ve

RT CCRT RT

Follow-up
*NCCN consensus guidelines
 MAXILLARY SINUS – T4b

• PS 0-1: CCRT / NACT- f/b CCRT/surgery

• PS 2: CCRT preferred over RT

• PS >3/ distant metastasis at presentation: Palliative RT / single agent CTH / best supportive care
 NASAL CAVITY AND ETHMOID -
OUTLINE
T1 or T2, N0:

• Surgery ± post-op RT
• Approaches:
• Midfacial degloving or Lateral rhinotomy or Endoscopic Transnasal
• Medial maxillectomy with ethmoidal clearance for localised ethmoidal and nasal cavity
tumors
• RT if margin + or PNI +ve
• Technique: Conventional/3DCRT/IMRT (preferred)
• Postoperative doses of 54- 60Gy depending on the tolerance of critical structures

• Radical RT if surgical resection morbid/patients unfit or unwilling for surgery

• Radical doses of 60-66Gy depending on the tolerance of critical structures.
 NASAL CAVITY AND ETHMOID -
OUTLINE
T3 or T4a, N0:
• Surgery + Adjuvant RT / CCRT
• Total Maxillectomy with ethmoidectomy
• Combined Craniofacial approach for lesions reaching / involving the cribriform plate
• Orbital exenteration if eye involved

T4b, N0:
1. Palliative - RT or CT
• Concurrent CTRT in-patient with good performance status

2. Resection in very select group with favourable histology with low biologically aggressive tumours for
eg. Adenoid cystic carcinoma, basal cell carcinoma.
 ENDOSCOPIC OVER OPEN SURGERY
Advantages:

• Lack of facial incisions, craniotomies, or facial bone osteotomies

• Decreased neurovascular structure manipulation

• Early tumor devascularization

• Access to deeply seated lesions

• Decreased hospital stay and pain

• Faster recovery

• Brain retraction avoidable, so postoperative brain edema and possible encephalomalacia are circumvented
 ABSOLUTE CONTRAINDICATIONS
FOR ENDOSCOPIC RESECTION
• Skin involvement

• Anterior wall of maxilla

• Gross brain invasion

• Involvement of floor of nasal cavity

• Involvement of lateral or posterior nasopharyngeal walls

• Involvement of lateral wall of maxilla

• Involvement of posterior wall of frontal sinus

 CHOICE OF SURGERY
Local extension Preferred choice

Nasal septum, ethmoidal complex, anterior sphenoidal wall, sphenoidal floor, nasopharynx,
medial maxillary wall, pterygopalatine fossa, infratemporal fossa (moderate invasion), upper
Endoscopic resection
parapharyngeal space, medial orbital bony wall, periorbit, extraconal fat (minimal invasion),
medial wall of the lacrimal sac, nasolacrimal duct

Bony skull base (ethmoidal roof, cribriform plate, planum sphenoidale, tuberculum sellae,
Endoscopic resection with
anteroinferior sellar wall, clivus), adjacent dura mater, falx cerebri (minimal macroscopic
transnasal craniectomy
invasion), brain (minimal macroscopic invasion)

Falx cerebri (nonminimal invasion), brain (nonminimal invasion), orbital roof, supraorbital
Cranioendoscopic resection
dura

Extraconal fat (nonminimal invasion), ocular muscles, eye, preseptal structures, orbital apex,
Orbital exenteration/clearance
lateral wall of the lacrimal sac
 CHOICE OF SURGERY
Local extension Preferred choice

Nasal bones, frontal process of the maxillary bone, external nose Partial or total rhinectomy

Hard palate, inferior alveolar ridge Inferior maxillectomy

Maxillary sinus lumen (with no invasion of the orbital floor) Subtotal maxillectomy
Orbital floor (even if with periosteum or extraconal fat minimal Total maxillectomy w/o resection of periorbit and inferior
invasion) extraconal fat
Maxillectomy + premaxillary soft tissues and/or
Premaxillary periosteum, subcutaneous tissue, skin
rhinectomy
Buccal space, masticatory space Maxillectomy + infratemporal fossa
Riedel's operation w/o resection of prefrontal soft tissues
Frontal sinus lumen, anterior frontal plate, prefrontal soft tissues
and/or rhinectomy
Osteoplastic flap approach or Riedel's operation with
Posterior frontal plate
posterior frontal craniectomy
 CRITERIA OF UNRESECTIBILITY

• Gross infiltration of infratemporal fossa • Cavernous sinus involvement

• Involvement of sphenoid
• Pterygopalatine fissure involvement

• Extensive soft tissue and skin infiltration

• Involvement of dura and intra-cerebral extension of
squamous carcinoma
• Bilateral orbital involvement
 MAXILLA – SURGICAL APPROACHES

• Endoscopic
• Weber – Fergusson
• Lateral rhinotomy
• Transoral / Transpalatal
• Midfacial degloving
• Combined cranio-facial approach

Extent of resection:
• Medial Maxillectomy
• Inferior Maxillectomy
• Total Maxillectomy
RECONSTRUCTION AND PROSTHESIS

• To prevent contracture of the cheek

• To separate nasal and oral cavities

• To provide support to globe

• An obturator should be made from pre-operatively from the impression of the hard palate
 POST- MAXILLECTOMY
RECONSTRUCTION
• Palatal defect less than 1/3rd - obturator preferred

• Sling if orbital floor excised (prevent post-op diplopia)

• Micro vascular Free tissue transfer for

1. Extensive skin and soft tissue defect
2. More than half of palatal loss
3. Orbit resection
4. Skull Base Reconstruction

• Temporary obturator for 2 –3 months till complete contracture occurs

• Final maxillary prosthesis after 2-3 months

RADIATION THERAPY TECHNIQUES

IMRT Particle
Conventional 3D-CRT
(VMAT) (IMPT)
 RT SIMULATION

• Supine position, arms by side

• Head slightly hyperextended to bring the floor of the orbit

parallel to the axis of the anterior field

• Immobilisation by thermoplastic cast

• Intraoral stent (depress tongue away)

• Delineate neck nodes with wires (conventional technique)

• 3mm slices with i.v. contrast

 RT SIMULATION

• Palatectomy - stent designed to hold a water-filled balloon to

obliterate the large air cavity in surgical defect (improve dose
homogeneity)

• An orbital exenteration defect can also be filled with a water-

filled balloon (decreased dose to temporal lobe)

• Marking of lateral canthi, oral commissures, external auditory

canals, and external scars facilitates target volume delineation
 FIELD
ARRANGEMENTS
 FIELD
ARRANGEMENTS
 FIELD ARRANGEMENTS IN
CONVENTIONAL / 3D-CRT
3-field technique for tumors involving suprastructure or extending to roof of nasal cavity and ethmoid cells:
1 anterior and right and left lateral fields
Lateral fields - 5-degree posterior tilt and 60-degree wedges

Initial target volume:

Anterior field:

• Superior border: above crista galli (to encompass ethmoids)

• In the absence of orbital invasion, at lower edge of cornea to cover orbital floor

• Inferior border: 1 cm below floor of sinus

• Medial border: 1 to 2 cm across the midline to cover contralateral ethmoids

• Lateral border: 1 cm beyond apex of sinus or falling off the skin

 FIELD ARRANGEMENTS IN
CONVENTIONAL / 3D-CRT
Lateral fields:

• Superior border: follows floor of anterior

cranial fossa

• Anterior border: behind lateral bony

canthus parallel to slope of face

• Posterior border: covers pterygoid plates

• Inferior border: corresponds to that of

anterior portal

Boost volume – tumour bed

 FIELD ARRANGEMENTS IN
CONVENTIONAL / 3D-CRT

3-field technique for tumors involving infrastructure with no extension into the orbit or ethmoids

• Anterior and ipsilateral wedge-pair (usually 45-degree wedges) photon fields

• Lateral-opposed photon fields preferred for tumors of infrastructure spreading across midline through
hard palate

• Fields can be slightly angled (5-degree inferior tilt from the ipsilateral side and 5-degree superior tilt
from the contralateral side) to avoid irradiating the contralateral eye

• Use of a half beam with isocenter placed at level of orbital floor and upper half of fields shielded further
reduces exposure of the eyes by beam divergence
 NECK FIELDS

• Superior border: slopes up from horizontal ramus of mandible anteriorly to match inferior border of primary
portal posteriorly, leaving a small triangle over the cheek untreated

• Anterior border: just behind oral commissure

• Posterior border: at mastoid process

• Inferior border: at thyroid notch (above the arytenoids)

 NECK FIELDS

• If maxillary sinus is being treated with conventional non-IMRT techniques, central axes of primary (sinus)
fields and opposed lateral upper neck fields all are placed in plane of inferior border of maxillary fields (i.e.,
usually 1 cm below the floor of the maxillary sinus)

• An independent collimator jaw is used to shield caudal half of maxillary fields and cephalad half of neck field

• Junction between primary and neck fields can be moved during course of treatment to reduce dose
heterogeneity in this region

• Middle and lower neck is irradiated with an anterior appositional photon field matched to inferior border of
opposed-lateral upper neck fields
 RT VOLUMES

• Maxillary cancers usually diagnosed at a locally advanced stage and surgery is primary therapy, most patients
receive post-op RT

• Delineation of target volumes:

• Physical examination, pretreatment imaging (image fusion / registration)

• Intraoperative findings (tumor relative to critical structures such as orbital wall, cribriform plate, cranial
nerve foramina, and ease of resection)

• Pathologic findings (positive margin or perineural invasion)

 DOSE SOLUTION: 3D-CRT

• Optic nerve course becomes more medial as they exit the

orbit and commonly overlap PTV

• If there is high risk of local recurrence 55gy to one optic

nerve is accepted

• 2-phase technique: whole PTV to 50Gy then MLC moved

to protect optic nerve
 RT VOLUMES & DOSES
Volume Primary RT Dose Post-op RT Dose

GTV GTV (pre-chemo volume) 66-70 Gy Gross residual disease 70Gy

Sites of suspected positive margins, gross

CTV HR - - macroscopic 66 Gy
residual tumor, extracapsular nodal disease

CTV 1 GTV + 1-1.5cm 66-70 Gy Primary tumor bed with 1.0–1.5-cm margin 60 Gy

CTV 2 CTV 1 + 1-1.5cm 59-63 Gy Surgical bed 57 Gy

Trigeminal nerve perineural invasion is

Nodal volumes, nerve
present, additional
CTV 3 tract and base of skull 54-57 Gy 54 Gy
skull base margin, elective nodal volume if
margin
indicated
 RT TECHNIQUE

Photon (VMAT > Non co-planar

IMRT > 3D-CRT >
conventional technique)
IMRT for definitive RT for T4N0 SCC of the maxillary
sinus
A and B: Pretreatment photographs showing skin of
cheek involvement

C and D: MRI scans with tumor indicated by white

arrow

E and F: MRIs following induction chemotherapy

showed progressive disease involving left maxilla,
left nasoethmoid region, extending inferiorly into
premaxillary soft tissues

G–I: IMRT plan with coverage of target volumes

treated using concomitant boost. Primary plan of 57
Gy and concomitant boost of additional 15 Gy

G and H also show normal tissues sparing

J and K: skin reaction during final week of RT

M and N: MRI and patient photo at follow-up,

showing healed skin with hyperpigmentation
The tumor was in complete remission at the last
visit 7 months after therapy.
 ELECTIVE NODAL
IRRADIATION
Le Q et al.
Jan 1959 - Dec1996
N=97

Median FU: 78 months

 ORBIT MANAGEMENT
• Workup: Pre-op CT and MRI

• Tumor adjacent to periorbita (dense periosteum surrounding globe) was the most sensitive predictor of orbital
invasion for both CT and MRI

• Stages of orbital invasion:

• Grade I - destruction of medial orbital wall
• Grade II - invasion of periorbital fat, extraconal
• Grade III - invasion of medial rectus, optic nerve, bulb, or eyelid skin, which implies breaching of
periorbita/periosteum

• Orbital exenteration advocated only for grade III, however, frozen section during surgery is necessary to
confirm whether or not tumor has transgressed the periosteum
 CHEMOTHERAPY – NACT

• NACT can reduce tumor volumes - less extensive surgical resection than would be possible
otherwise

• CTH before primary RT - reduce tumor volumes and facilitate RT planning by increasing distance
between tumor borders and critical organ structures (brain, chiasm, optic nerve, or spinal cord)

• NACT –
• Complete response, then primary RT + chemotherapy
• Less-than-complete response - surgical excision followed by adjuvant RT.
 PALLIATION

• Symptoms are particularly distressing

• Disfiguring masses, proptosis, discomfort
• Neuropathic pain, headache
• Epistaxis or other bleeding, nasal obstruction or discharge, and trismus

• Involves limited surgery, RT, chemotherapy, investigational studies, or best supportive care

• Morbidity of each modality must be balanced with potential benefits in symptom control and improved QOL
 PALLIATION

• Particular attention to address pain and discomfort (first priority), and impact of disfigurement and
dysfunction

• Single-agent Chemotherapy in investigational settings

• Hypofractionated RT to reduce duration of treatment

• Radiation or chemotherapy is often effective in reducing tumor bulk and relieving symptoms associated with.
FOLLOW-UP
 POST TREATMENT SURVEILLANCE

Acute toxicities: Late toxicities:

• Mucositis • Temporal lobe injury

• Dysgeusia • Cranial neuropathies
• Xerostomia • Brachial plexopathy
• Dysphagia • Hearing loss
• Dermatitis • Xerostomia
• Dysphagia
• Soft tissue fibrosis
• Endocrinopathies (thyroid and
pituitary)
 DRY EYE

• Acute: 1month after RT

• Red, painful, itching eye, photophobia and foreign body sensation

• Corneal ulceration (delayed)

• Not seen at D< 30Gy, 100% at 55-60Gy

 RADIATION INDUCED OPTIC
NEUROPATHY
• Sudden painless mono-ocular vision loss

• Onset: 3months – 8 years, peak at 1-1.5 years

• 15-year actuarial risk of RION at 60-70Gy

• 50% (>1.9Gy/#) vs 11% (<1.9Gy/#)
THANK YOU
*Devita Principles and practice of oncology