Sinus Cancer

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Sinus Cancer

• Reporter clerk ???Supervisor ??? ??

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Background

• The location of the nasal cavity and the
  paranasal sinuses make them extremely close to
  vital structures.
• Sinonasal malignancies (SNM) can grow to
  considerable size before presentation, and
  aggressive therapy may be needed in areas close
  to the skull base, orbits, cranial nerves, and
  vital blood vessels

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• Sinonasal malignancies (SNM)---the initial
  manifestations (eg, unilateral epistaxis, nasal
  obstruction) mimic signs and symptoms of many
  common but less serious conditions.
• The patient and clinician often ignore or
  minimize the initial presentation of these tumors
  and treat early-stage malignancy as a benign
  sinonasal disorder.
• By the time ominous signs and symptoms (such as
  severe intractable headache, visual disturbance,
  or cranial neuropathy) occur, the neoplasm is
  often advanced.

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Epidemiology

• Sinonasal malignancies (SNM) are rare. They are
  more common in Asia and Africa than in the United
  States.
• In parts of Asia, sinonasal malignancies (SNM)
  are the second most common head and neck cancer
  behind nasopharyngeal carcinoma. Men are affected
  1.5 times more often than women, and 80 of these
  tumors occur in people aged 45-85 years.
• Approximately 60-70 ? maxillary sinus
• 20-30 ? nasal cavity
• 10-15 ? ethmoid air
  cells (sinuses)
• the remaining ? frontal
  sphenoid sinuses

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Etiology

• Risk factors for sinonasal malignancies (SNM) are
  complicated, multifactorial, and somewhat
  controversial.
• Squamous cell carcinoma (SCC) and adenocarcinoma
  in this area are associated with exposure to
  nickel dust, mustard gas(dichlorodiethyl
  sulfide), thorotrast(????,??????), isopropyl oil,
  chromium(?) is well established.
• Wood dust exposure, in particular, is found to
  increase the risk of SCC 21 times and the risk of
  adenocarcinoma 874 times.
• Many of these products are found in the
  furniture-making industry, the leather industry,
  and the textile industry.

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Pathophysiology

• Squamous cell carcinoma (SCC)? 80 of all
  malignancies that arise in the nasal cavity and
  paranasal sinuses. Approximately 70 occurs in
  the maxillary sinus, 12 in the nasal cavity, and
  the remainder in the nasal vestibule and
  remaining sinuses.

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• Adenoid cystic carcinoma (ACC)? salivary origin
  and is the second most common sinonasal
  malignancy, accounting for 10 of cases. 
• Three histological subtypes are based on growth
  patters tubular, cribriform, and solid. The
  solid form portends a much worse prognosis than
  either cribriform or tubular.

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• Adenocarcinoma? associated with specific risk
  factors including exposure to wood dust,
  lacquers(???), and other organic compounds.
• Distant metastases are rare. When they do occur,
  the lung, liver, and bone are the sites most
  often involved. Metastases to the cervical lymph
  nodes are uncommon, even with poorly
  differentiated tumors.

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• Malignant melanoma
• Sinonasal neuroendocrine tumors
• Esthesioneuroblastoma (ENB, olfactory
  neuroblastoma)
• Sinonasal undifferentiated carcinoma (SNUC)
• Small cell neuroendocrine carcinoma (SmCC)
• Lymphoma
• Salivary-type neoplasms
• Sarcoma
• Metastatic tumors

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Presentation

• Initial presenting symptoms include epistaxis,
  nasal obstruction, recurrent sinusitis, cranial
  neuropathy, sinus pain, facial paresthesia,
  proptosis, diplopia, or an asymptomatic neck
  mass.
• Often, these mimic signs of conditions more
  common and less serious than malignant tumors of
  the sinuses. The patient often ignores early
  symptoms, or the clinician may minimize them,
  treating early-stage malignancies as infectious
  diseases.

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• The ominous signs and symptoms (eg, severe
  intractable headache, visual disturbances) occur,
  the neoplasms are advanced and require complex
  management.

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Workup

• Laboratory Studies
• As with other head and neck cancers, liver
  enzymes are usually obtained to assess for
  distant disease in addition to a chest radiograph
  or CT scan to evaluate for pulmonary metastasis
• In the case of a nasal cavity or paranasal sinus
  mass or erosion, an antineutrophil cytoplasmic
  antibody (ANCA) test for possible Wegener
  granulomatosis should be considered. This
  condition often mimics a neoplasm.

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• Imaging Studies
• Magnetic resonance imaging (MRI) determine
  resectability such as orbital invasion,
  perineural spread, skull base invasion,
  intracranial extension
• One of MRIs greatest uses is in helping to
  demonstrate the distinction tumor and retaining
  secretions in the multiple sinus cavities.

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• CT scan has a higher accuracy at determining both
  bony remodeling and erosion of the skull base and
  sinuses.
• Osteolysis can often be observed with SCC,
  metastatic disease, sarcoma, and sinonasal
  undifferentiated carcinoma(SNUC).
• Boney remodeling is more often seen with salivary
  gland tumors, large cell lymphoma, melanoma, and
  esthesioneuroblastoma(ENB).
• CT scanning is slightly more accurate than MRI in
  demonstration of orbital invasion due to its
  ability to evaluate both the bony orbital wall
  and adjacent fat.

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Diagnostic Procedures

• Biopsy is the only 100 accurate means of
  obtaining a tissue diagnosis.
• Remember that the turbinates and the possibility
  of a juvenile angiofibroma may both lead to
  extensive bleeding.
• A biopsy should be performed on highly suspicious
  vascular tumors in the OR under controlled
  conditions where bleeding can be more safely
  controlled.

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Staging

• Staging of nasal cavity and paranasal sinus
  carcinomas is not as well established as for
  other head and neck tumors.
• Two generally accepted staging systems are
  currently in use. The Kadish staging system is
  used specifically for Esthesioneuroblastoma
  because this often involves the skull base and
  intracranial extension.
• For cancer of the maxillary sinus, the nasal
  cavity, and the ethmoid sinus, the American Joint
  Committee on Cancer (AJCC) has designated staging
  by TNM classification.
• No broadly accepted staging systems for frontal
  and sphenoid sinus cancer currently exist

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• Maxillary sinus
• Primary tumor (T)
• 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 and/or
  the middle of the nasal meatus, except extension
  to the posterior wall of maxillary sinus and
  pterygoid plates
• T3 - Tumor invades any of the following bone of
  the posterior wall of maxillary sinus,
  subcutaneous tissues, floor or medial wall of
  orbit, pterygoid fossa, ethmoid sinuses
• T4a - Tumor invades anterior orbital contents,
  skin of cheek, pterygoid plates, infratemporal
  fossa, cribriform plate, sphenoid or frontal
  sinuses
• T4b - 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

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• Nasal cavity and ethmoid sinus
• Primary tumor (T)
• T1 - Tumor restricted to any one subsite, with or
  without bony invasion
• T2 - Tumor invading 2 subsites in a single region
  or extending to involve an adjacent region within
  the nasoethmoidal complex, with or without bony
  invasion
• T3 - Tumor extends to invade the medial wall or
  floor of the orbit, maxillary sinus, palate, or
  cribriform plate
• T4a - Tumor invades any of the following
  anterior orbital contents, skin of nose or cheek,
  minimal extension to anterior cranial fossa,
  pterygoid plates, sphenoid or frontal sinuses
• T4b - Tumor invades any of the following orbital
  apex, dura, brain, middle cranial fossa, cranial
  nerves other than (V2), nasopharynx, or clivus

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Regional lymph nodes (N)

• N1 - Metastasis in a single ipsilateral lymph
  node, 3 cm or less in greatest dimension
• N2a - Metastasis in a single ipsilateral lymph
  node more than 3 cm but 6 cm or less in greatest
  dimension
• N2b - Metastasis in multiple ipsilateral lymph
  nodes, 6 cm or less in greatest dimension
• N2c - Metastasis in bilateral or contralateral
  lymph nodes, 6 cm or less in greatest dimension
• N3 - Metastasis in a lymph node more than 6 cm in
  greatest dimension

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Kadish Staging for esthesioneuroblastoma

• Stage A The tumor is limited to the nasal fossa.
• Stage B The tumor extends to the paranasal
  sinuses.
• Stage C The tumor extends beyond the paranasal
  sinuses.

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Thanks for your attention!