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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