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UncategorisedCARCINOMA MAXILLARY SINUS

CARCINOMA MAXILLARY SINUS

Carcinoma Maxillary Sinus arises from lining of maxillary sinus. It occurs in middle aged male around 40 to 60 years old. Sinus remains silent for a long time or showing only symptoms of sinusitis. It destroys bony walls and invades the surrounding structures.

ETIOLOGY

  • It is occupational – mainly due to inhalation of carcinogens
  • Hard wood exposure increases the relative risk by 70 fold particularly ethmoids
  • Soft wood exposure increases the risk of squamous cell carcinoma
  • Nickel exposure increases the risk for SCC by 250 times
  • Other factors are smoking, aflatoxins, formaldehyde, chromium, mustard gas, polycyclic hydrocarbons and thorotrast

  PATTERNS OF TUMOUR SPREAD

  • Anteriorly – cheek and skin
  • Posteriorly – pterygomaxillary fossa, pterygoid plates, nasopharynx, sphenoid sinus, base of skull
  • Medially – nasal cavity, NLD
  • Superiorly – orbits, ethmoid sinuses
  • Inferiorly – palate, buccal sulcus
  • Intracranial – ethmoid and cribriform plates
  • Lymphatic – submandibular, upper jugular, retropharyngeal nodes
  • Systemic – lungs occasionally

CARCINOMA MAXILLARY SINUS – CLASSIFICATION

  1. OHNGREN’S Classification
  2. AJCC Classification
  3. Lederman’s Classification

OHNGREN’s CLASSIFICATION

Suprastructure: Poor prognosis

Infrastructure: Good Prognosis

LEDERMAN’S CLASSIFICATION

  • 2 horizontal lines of sebileau pass through floors of orbits and maxillary sinus,producing:
  • Supra structure: ethmoid, sphenoid and frontal sinuses: olfactory area of nose
  • Mesostructure: Maxillary sinus and respiratory part of nose
  • Infrastructure: Alveolar processes

TNM STAGING

Primary Tumor (T)

TX: Primary tumor cannot be assessed

TO: No evidence of primary tumor

Tis: Carcinoma in situ

T1: Tumor limited to maxillary sinus mucosa with no erosion or destructionof 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

TNM STAGING OF MAXILLARY CARCINOMAS

Stage I: Limited to mucosa

Stage II: Bone Involvement (Not Posterior Wall)

Stage III: T3 lesion and T1 or T2 lesions with N1

Stage IV: T4 lesion and any T with N2/N3 or M1

STAGING – MAXILLARY SINUS CARCINOMAS

TX – Primary tumor cannot be assessed

T0 – No evidence of primary tumor

Tis – Carcinoma in situ

T1 – Tumor limited to the antral mucosa with no erosion or destruction of bone

T2 – Tumor with erosion or destruction of the infrastructure, including the hard palate and/or the middle nasal meatus

T3 – Tumor invades any of the following: skin of cheek, posterior wall of maxillary sinus, floor or medial wall of orbit, anterior ethmoid sinus

T4 – Tumor invades orbital contents and/or any of the following: cribriform plate, posterior ethmoid or sphenoid sinuses, nasopharynx, soft palate, pterygomaxillary or temporal fossae, or base of skull.

CARCINOMAS MAXILLARY SINUS – CLINICAL FEATURES

  • Nasal stuffiness
  • Blood-stained nasal discharge (These are early C/F)
  • Facial paraesthesia or pain (Often misdiagnosed and treated as Sinusitis
  • Epiphora

TREATMENT

  • Stage 1 and 2 SCC – Surgery or Radiation
  • Stage 3 and 4 SCC – Combined modalities
  • Inoperable tumours – Chemoradiation
  • Intra arterial Infusion of 5-Fluorouracil or Cisplatin

TREATMENT OPTION AVAILABLE FOR MAXILLARY SINUS CARCINOMAS

  • Surgery
  • Radiotherapy – definitive, pre op RT and post op RT
  • Combined modality (Sx + RT)
  • Chemotherapy – Neo Adjuvant and Concomitant

CHEMOTHERAPY

  • Primary Systemic Therapy + Concurrent RT
  • Cisplatin alone (preferred)
  • 5-FU/hydroxyurea
  • Cisplatin/paclitaxel
  • Cisplatin/infusional 5-FU
  • Carboplatin/infusional 5-FU
  • Carboplatin/paclitaxel
  • Cetuximab

ROLE OF CHEMOTHERAPY

  • Neoadjuvant chemotherapy is sometimes offered in order to reduce tumor volume, which may permit removal of tumor with a less morbid resection or facilitate radiotherapy planning if shrinkage pulls away tumor from critical structures
  • Chemotherapy may be given concurrent with radiotherapy in the management of inoperable tumors on the basis of improved results in more frequent head and neck carcinomas

Stage I/II (T1 – T2, N0)

  • Surgical resection is the primary treatment
  • If margins are free (1.5-2cm), Kept on regular follow-up without adjuvant therapy
  • If there is perineural invasion by the tumor, Adjuvant Radiotherapy is needed
  • If margins are positive, Re-surgery should be considered, after which, if margins comes negative, RT only; if margins come positive, Chemo + RT is recommended

SURGERY

Surgical approaches:

  • Endoscopic
  • Lateral rhinotomy
  • Transoral/transpalatal
  • Weber fergussen
  • Midfacial degloving
  • Combined craniofacial approach

Extent of resection

  • Medial maxillectomy
  • Inferior maxillectomy
  • Total maxillectomy

RADIOTHERAPY

  • Addition of RT to surgery improve 5-years survival (44%) when compared to RT alone (23%) or surgery alone
  • Indications;

Definitive: medically inoperable or who refuse radical surgery or early lesions

Adjuvant

Palliative

  • Pre- and postoperative radiation may result in similar control rates.

But post-operative RT preferred:

Preoperative radiation increases the infection rate and the risk of postoperative wound complications

Preoperative radiation may obscure the initial extent of disease-surgery can not remove the microscopic extensions of the tumor

  • Postoperative radiation therapy is started 4 to 6 weeks after surgery

PROGNOSTIC FACTORS

  • Patient-specific – age and performance status
  • Disease-specific – location, histology, locoregional extent (reflected in TNM stage), perineural invasion
  • Extensive local disease involving the nasopharynx, base of skull, or cavernous sinuses markedly increases surgical morbidity as well as the risk of subtotal surgical excision
  • Tumor extension into the orbit may require enucleation, but minimal invasion of the floor or medial wal may be dealt with through resection and reconstruction, sparing the globe.

COMPLICATIONS

  • ACUTE – mucositis, skin erythema, nasal dryness, xerostomia
  • LATE – xerostomia, chronic keratitis and iritis, optic pathway injury, soft tissue or osteoradionecrosis, cataracts, radiation-induced hypopituitarism
Carcinoma Maxillary Sinus
CARCINOMA MAXILLARY SINUS

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