Nose_Sino-nasal Malignancies

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Transcript Nose_Sino-nasal Malignancies

 Tumors
of the nasal cavity
proper are approximately
evenly divided between
benign and malignant
neoplasia, with inverting
papilloma predominating in
the benign group and
squamous cell carcinoma in
the malignant.
On the other hand,
most sinus tumors are
malignant with
squamous cell
carcinoma being the
most prevalent.
The maxillary sinus is
most commonly involved
with tumor, followed by
the nasal cavity, the
ethmoids, and then the
frontal and sphenoid
Inverted papillomas
Their etiology is unclear.
They are known to have high recurrence rates.
They are associated with malignancy and also
have locally aggressive growth patterns, which
makes them technically difficult to remove.
There is also controversy over the appropriate
surgical approach for tumor removal.
There is a role for radiation therapy.
Inverted papillomas
Papillomas differ from
inflammatory polyps, which
are more common, in that
inflammatory polyps are
associated with allergic rhinitis
and are actually reactive
lesions, not a tumor.
Nasal papillomas are true
neoplasms and, while their
etiology is unclear, they are
known to arise from the nasal
respiratory epithelium, which
undergoes metaplastic
change and proliferation.
Inverted papillomas arise from the
Schneiderian membrane, which is an
invagination of the olfactory ectoderm that
occurs during the fourth week of
embryonic development. The mucosa
creates a transitional zone between the
endodermally-derived respiratory
epithelium of the nasopharynx and
keratinizing squamous epithelium with the
nasal vestibule.
 Three types: Fungiform papillomas,
cylindrical papillomas and inverted
Grossly, inverted
papillomas appear
more opaque than
polyps, and this is
because they have
a thick epithelial
Inverting papilloma
traces its name to the
histologic appearance
with squamous
epithelium inverted in
the polyps
They are commonly
located in the nasal
cavity and they
typically involve an
adjacent sinus.
The most common
location is the middle
turbinate, but other
common locations
include the ethmoid
sinus and maxillary
They have even been
found in the
Most common symptoms are unilateral and
include nasal obstruction, nosebleed and
nasal discharge. It can be an incidental finding
on examination.
These tumors are rare. They occur about 0.6
cases per 100,000 per year and they occur
approximately 1/25th as often as inflammatory
The average age at diagnosis is 53, but can
range anywhere from the pediatric age of 6 to
the elderly age of 89.
They are known to have a male predominance
of (1:3)
The recurrence rates cited in the literature varies
anywhere from 11% to 78%, and this depends a
lot on the treatment modality used.
They are associated with malignancy, 5%
to 15% malignancy rates are most
generally accepted. Inverted papillomas
are more commonly associated with
squamous cell carcinomas.
There are four types of association:
 Metachronous squamous cell carcinoma.
 Carcinoma in situ within the IP
 Synchronous lesions
 Malignant transformation
The mainstay of treatment is surgery,
although radiation therapy can be involved.
Traditionally procedures have been either a transnasal
procedure with polypectomy or confined transnasal
polypectomy with additional sinus procedure, such
as Caldwell-Luc. The gold standard was lateral
rhinotomy with medial maxillectomy.
Radiation therapy can be used as the sole therapy for
inverted papilloma or it can be used postoperatively. The
absolute indication for radiation therapy is when an
inverted papilloma is associated with squamous cell
The patients who should get radiation therapy are those
who had advanced incompletely resected or
unresectable lesions that are biologically aggressive, or
patients where morbidity in resection would be more
pronounced that morbidity of tumor radiation.
Sinonasal neoplasms
These are rare, comprising less than 3% of all
malignant aerodigestive tumors and less than
1% of all malignancies.
Despite their infrequence, they represent both a
diagnostic and therapeutic challenge because
the presenting signs and symptoms may be
indistinguishable from benign or inflammatory
These malignancies typically affect Caucasion
males in the fifth to seventh decades of life and
have a 2:1 male preponderance.
Sinus Anatomy:
Maxillary antrum
 Superior
– orbit,
 Posterior – pterygoids,
infratemporal fossa
Ethmoid sinus
 Superior
– fovea,
 Medial – lamina
Sinus Anatomy:
Sphenoid sinus
 Superior – optic nerve,
 Lateral – ICA,
cavernous sinus
 Lateral wall < 0.5mm
 Inferior – NP, vidian
Frontal sinus
 Inferior – orbit
 Posterior –
anterior cranial
Lymphatic Drainage
The anterior nose has the
same lymphatic drainage
as the external nose. These
tend to spread to the
submental or level I area.
The posterior nose tends to
drain to the
retropharyngeal nodes as
well as the lateral pharyngeal
nodes, which eventually drain
into the level II.
Despite this, up to 44% are attributed to
occupational exposures, including nickel,
chromium, isopropyl oils, volatile hydrocarbons,
and organic fibers that are found in the wood,
shoe, and textile industries.
In addition, human papilloma virus can be a
cofactor, and in one series, human
papillomavirus 6 or 12 was documented in 24%
of inverting papillomas and 4% of squamous cell
Specific asssociations found include squamous
cell carcinoma in nickel workers and
adenocarcinoma in workers exposed to
hardwood dusts and leather tanning.
The most common entities are
squamous cell carcinoma. The
lateral nasal wall is the most common
site of involvement, but SCC can also
present in the sinuses.
 Regional
lymph node metastasis is more
common with squamous cell than most
other paranasal sinus malignancies,
occurring in about about 10% to 20%.
Local recurrence rates are quite high, as
high as 30% to 40%
Adenocarcinoma is the second most
common malignancy in this area. It is
most often in the ethmoids, has a male
predominance, and is often seen in
industrial workers.
About 3% to 15% of these
paranasal sinus malignancies are
adenoid cystic carcinoma. It is
occurs most frequently in women, and
in the fifth and sixth decades.
Melanoma is rarely seen,
comprising only about 3% of these
paranasal sinus malignancies.
Olfactory neuroblastoma or
esthesioneuroblastoma are neural
crest in origin, and they arise from
an olfactory epithelium.
Signs and symptoms of maxillary sinus
carcinoma fall into several major categories
 Nasal
 Ocular, facial
 Auditory
Oral presentations occur in
25-35% and include pain
involving the maxillary
dentition, trismus, palatal
and alveolar ridge fullness,
and frank erosion into the
oral cavity.
Nasal findings are seen in
up to 50% of patients and
include obstruction,
discharge, stuffiness,
congestion, epistaxis, and
extension into the nasal
Ocular findings
occur in
approximately 25%
and arise from
upward extension
into the orbit,
where unilateral
tearing, diplopia,
fullness of lids,
pain, and
exophthalmos are
Facial signs include infra-orbital nerve
hypoesthesia, cheek swelling, pain, and
facial asymmetry.
Auditory complaints include hearing loss
secondary to serous otitis media due to
nasopharyngeal extension.
With advanced disease, the classic triad
of findings for carcinoma of the nasal
cavity and paranasal sinuses may be
present: These include
 Facial asymmetry
 A visible or palpable
tumor bulge in the oral
 Tumor visible in the nose with anterior
Ohngren line, a line
that is drawn from the
angle of mandible to
the medial canthus.
Ohngren indicated
that tumors that
presented above this
line, both superiorly
and posteriorly,
tended to have a
worse prognosis
American Joint Committee on Cancer Staging System is
the gold standard used for reporting in most professional
 T1 tumors of the nose and nasal cavity, and ethmoid
sinuses, are tumors restricted to any one sub-site, with
or without bony invasion.
 T2s are tumors invading two sub-sites, single region or
extending to involve adjacent regions of the nasal
ethmoid complex.
 T3 tumors begin to have bony involvement, invading the
medial wall of the floor of the orbit, cribriform or palate.
 T4-A tumors involve the anterior orbital contents, nose,
and cheeks, with extension into the anterior cranial
 T4-B, involve the orbital apex, dura, middle cranial fossa,
as well as the clivus.
CT scans are excellent for determining
bony erosion and extent of invasion.
If there is a question of
neural involvement, MRI
is excellent for
determining perineural
spread, involvement of
the dura, or involvement
Lastly, confirm diagnosis via biopsy. Most
often biopsy is performed after imaging
rule out encephaloceles or other vascular
 PET scan has been used to evaluate for
residual tumor, recurrent tumor, and
radiated treated fields.
 Angiography is not initially used, but can
be used for vascular tumors to determine
extent and vascularity as well as to allow
for embolization prior to any surgical
Treatment is
controversial, but the
literature indicates
that craniofacial
resection is the key.
SCC: For the treatment of
early lesions, surgery, if
the tumor is excised en
bloc with good margins,
and, if there is no evidence
of perineural spread, then
surgery is usually
sufficient. If there are any
questions about the
margins or perineural
invasion, the addition of
radiation is indicated
Inferior medial
There has been some literature reporting the
use of radiation therapy alone for early
disease, but this is not necessarily
recommended since radiation of this side of the
body has significant morbidity, with possible
osteoradionecrosis and vision loss as well as
damage to the spinal cord.
Combined modality generally tends to be the
gold standard: surgery with postoperative
radiation therapy.
Also, the use of chemotherapy is now being
added with the goal of better local control and
improvement in survival.
Chemotherapy does have a role in palliation for
large tumors that are nonresectable.
If there is nodal disease of the neck with
squamous cell carcinoma, a neck dissection is
generally indicated