Nasal+Cavity

Lymph node metastases generally do not occur until the tumor has extended to areas that contain abundant capillary lymphatics. the submandibular and subdigastric lymph nodes are most commonly involved. Lymph node spread from vestibule concer is usually to a solitary ipsilateral submandibular node although bilateral spread is seen on occasions. 4 || G1: Low grade - well differentiated G2: Intermediate grade - moderately differentiated G3: High grade - poorly differentiated 6  || Stage I: limited to site of origin Stage II: extension to adjacent sites (e.g., orbit, nasopharynx, paranasal sinuses, skin, pterygomaxillary fossa). Stage III: base of skull or pterygoid plate destruction; intracranial extension. 5 || Radiation retinopathy is rare at 45Gy Some visual acuity changes after 60Gy Decreased visual acuity after 65Gy Visual acuity decreased 85-90% at 80Gy 15 year actuarial incidence of optic nerve injury = 11% for doses above 60Gy 7 || 56% for surgery 83% for radiation 75% for surgery and radiation 8 || Radiation Therapy Surgery followed by postoperative irradiation No clear role for chemothrapy has been defined
 * Epidemiology: || Incidence of local nasal cavity lesions in the United States is rare. Occurs in males more than females by a ratio of 3:2. Median age of occurence is 40-50. Occurence can be preceeded by nasal polyps and/or chronic sinustitis in 10-20 percent of cases. Bimodal occurrence distribution is possible: 10-20 years of age and 50-60 years of age. 1 ||
 * Etiology: || Employees of woodworking, furniture and nickel industries have a risk factor 40 times greater than the general population. Smoking. 2 ||
 * Signs & Symptoms: || Usual symptoms at presentation are: unilateral nasal obstruction, epitaxsis, bloody discharge. 2  ||
 * Diagnostic Procedures: || **__Physical Examination__** is done carefully and includes a meticulous description of the tumor, including it's location, size, color, texture, and whether it is "fixed" to underlying tissue or can be moved about.**Endoscopic __Examination__** means placing a visualization tube under light local anesthesia into the nose and down the throat. the preferred procedure is a **"triple endoscopy"**, which looks at the nose, esophagus and larynx (voice box). **__Imaging Tests__** are done in the radiology department and standardly include a **Chest X-ray** to look for signs of infection or lung tumors. CT scan, MRI, and Bone scans are sometimes ordered as well. __**Biopsy**__ of the tumor is crucial, since only by examining an actual piece of the tumor under the microscope can a diagnosis of cancer be made, and the particular type known with certainty. 3 ||
 * Histology: || Squamous cell carcinoma is the most common malignancy of the nasal cavity and paranasal sinuses. 10% -15% of neoplasms in this region aare minor salivary gland tumors. Other histologic types are lymphoma, esthesioneuroblastoma, sarcoma, and inverted papilloma. Inverted papilloma is usually histologically benign but is associated with squamous cell carcinoma in 10% - 15% of cases. 4 ||
 * Lymph Node Drainage: || Nodal involvement is infrequent. Although metastases from both the nasal cavity and paranasal sinuses may occur,
 * Metastatic Spread: || Submandibular and subdigastric lymph nodes. 5 ||
 * Grading: || Gx: unable to determine
 * Staging: || University of Florida staging system
 * Radiation Side Effects: || Central nervous system damage, unilateral or bilateral vision loss, serous otitus media, and chronic sinusitis
 * Prognosis: || __5 Year Cure Rate__
 * Treatments: || __Treatment__

__Doses__ 60-70Gy Reduced field size to exclude spinal cord and brain stem after 50Gy and then boost 10-20Gy

__Treatment Fields__ Anterior portal 1.5-2cm across midline (entire nasal cavity and ethmoid-sphenoid complex and medial contralateral orbit) Superior border - cribriform plate and all or part of the frontal sinus Inferior border - commissure of the lips (floor of the nose, maxillary antrum, and alveolar ridge) Lateral portals Anterior border - lateral boney canthus Superior border - 1cm above the roof of the ethmoid sinuses, may be raised 2-3cm to cover known or expected intracranial extension Inferior border - usually at the level of the lip commissure Posterior border - at or near the tragus and bisects the vertebral bodies (exclude spinal cord and brainstem) Lateral fields are rotated 5 degrees posteriorly to avoid irradiation of contralateral eye 9 || Bodin and Sheline have made suggestions of what the dose tolerance should be for the brain stem, however Emami believes them to be to conservative and has come up with their own theory of what the dose should be. Emami believes it should be 6000cGy for a volume of 1/3 with an ending result of necrosis. 10   __OPTIC CHIASM__ Emami decided that the appropriate TD5/5 is 50Gy due to the article written by Hammer who reported that patients who had pituitary tumors developed chiasmal necrosis after receiving 4250cGy in large fractions of 210-280cGy. 10 __OPTIC NERVE__ Many articles such as Parsons, Brown, and Pezner have written articles on optic nerve and blindness. Blindness was found to have occured at or below 50Gy so Emami could not justify to follow some article with the TD5/5 to be 55Gy, instead they decided to follow the TD5/5 of 50Gy. 10 __RETINA__ The dose response curve for retina is extremely steep between 50Gy and 60Gy, so according to Emami a realistic TD5/5 is 45 Gy with an ending side effect of visual loss. 10 __LENS__ Emami states that 10Gy should be the TD5/5, but this is concluded after a Seattle group known as Deeg who checked TBI patients post irradiation for the incidences of cataracts. 10   __MANDIBLE__ In some cases the end point is necrosis, however Emami uses Osteoradionecrosis as an endpoint for determining the TD5/5 because of its significants in morbidity. Even though there is no reliable data on volume and dose to the mandible Emami believes that 1/3 should recieve 65Gy or less or anything above this volume should recieve 60Gy and below. 10 __PAROTID__ Emami has made an attempt to determine from literature and clinical experience what the TD5/5 should be for the parotid glands before xerostomia occurs, The TD5/5 they determined is 32Gy with the note that no significant change occurs with less than 50% of the parotid being irradiated. 10
 * TD5/5: || __BRAIN STEM__

|| __**References**__ 1. Laramore GE, Colterra MD, Hunt KJ. Tumors of the head and neck. In: Rubin P, ed. //Clinical Oncology: A Multidisciplinary Approach// //for Physicians and Students//. 8th ed.Philadelphia, PA: W.B. Saunders Company; 2001:445-446. 2. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002:203. 3. Lenhard,E. Raymond. Jr.,MD., Osteen, T. Robert, Gansler,Ted,.MD. The American Cancer Society's Clinical Oncology. 1st edition. Atlanta,GA. 2001. 4.Chao KS, Perez CA, Brady LW. Radiation Oncology-Management Decisions. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins. 2002. 5.Chao KS, Perez CA, Brady LW. //Radiation Oncology - Management Decisions//. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins. 2002 . 6.Tumor Grade retrieved January 6, 2010 from the American Society of Clinical Oncology website: www.cancer.net/patient/Cancer+Types/Nasal+Cavity+and+Paranasal+Sinus+Cancer 7. Chao KS, Perez CA, Brady LW//. Radiation Oncology - Management Decisions//. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins. 2002 8. Vincent T. DeVita, Jr., MD, Samuel Hellman, MD, Steven A. Rosenberg, MD, PhD. //Cancer Principals and Practices of Oncology.// 6th edition. Philadelphia, PA: Lippincott, Williams & Wilkins. 2001 9. Rodney R. Million, Nicholas J. Cassisi. //Management of Head and Neck Cancer - A Multidisciplinary Approach.// 2nd edition. Philadelphia, PA: J. B. Lippincott 1994 10. B. Emami et al: Tolerance of Normal Tissue to Therapeutic Irradiation, //Int J. Radiat Oncol Biol Phys// 21:109-122, 1991.