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
- OHNGREN’S Classification
- AJCC Classification
- 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
