Paranasal+Sinuses

In some cases, the diagnosis of paranasal sinus cancer will be made during an endoscopic surgery for what is believed to be benign chronic sinusitis. During the endoscopic sinus surgery, it is important for the surgeon to obtain a biopsy sample of normal-looking tissues and confirm the diagnosis in a procedure called a frozen section examination before completing the endoscopic surgery for benign chronic sinusitis. G1: Low grade - well differentiated G2: Intermediate grade - moderately differentiated G3: High grade - poorly differentiated. 8 || Maxillary sinus TX - Primary tumor cannot be assed T0 - No evidence of primary tumor Tis - Carcinoma in situ T1 - Tumor limited to antral mucosa with no erosion or destruction of bone T2 - Tumor causing bone erosion or destruction, except for the posterior antral wall, including extension into the hard palate and/or the middle nasal meatus T3 - Tumor invades any of the following: bone of the posterior wall of the maxillary sinus, subcutaneous tissue, skin of cheek, floor or medial wall of orbit, infratemporal fossa, pterygoid plates, ethmoid sinuses T4 - Tumor invades orbital contents beyond the floor or medial wall including any of the following: the orbital apex, cribiform plate, base of skull, nasopharynx, sphenoid frontal sinuses
 * Epidemiology: || 2 to 1 predominance in men versus women and 95% incidence over age 40. 75% incidence over age 70. There is also a bimodal distribution for occurence: 10 to 20 years old and again at 50 to 60. Occurence is beginning to trend toward younger ages. 1  ||
 * Etiology: || Tobacco use, alcohol use, occupational exposure in the woodworking industry. Possible link to viruses such as human papilloma virus. 2  ||
 * Signs & Symptoms: || Nasal obstruction, bloody discharge, unilateral sinusitis, loose teeth. Facial pain is also possible. With orbital cavity invasion: diplopia, proptosis and epiphora. 3 ||
 * Diagnostic Procedures: || **Physical examination.** The doctor feels for any lumps on the neck, lips, gums, and cheeks. Also, the doctor will inspect the nose, mouth, throat, and tongue for abnormalities, often using a light and/or mirror for a clearer view.
 * Biopsy.** A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease).
 * Endoscopy.** This test allows the doctor to see inside the body with a thin, lighted, flexible tube called an endoscope. The person may be sedated as the tube is inserted through the mouth or nose to examine the head and neck areas. The examination has different names depending on the area of the body that is examined, such as laryngoscopy (larynx), pharyngoscopy (pharynx), or a nasopharyngoscopy (nasal cavity, nasopharynx).
 * X-ray.** An x-ray is a picture of the inside of the body. An x-ray can show if the sinuses are filled with something other than air. If so, it is usually not cancer but instead an infection that is treatable. If treatment doesn’t work to clear the sinuses, then other more specialized x-ray tests may be done to identify the blockage. Signs of cancer on an x-ray may be followed up with a computed tomography (CT) scan.
 * Computed tomography (CT or CAT) scan.** A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. CT scans are very useful in identifying cancer of the nasal cavity and paranasal sinus.
 * Magnetic resonance imaging (MRI).** An MRI uses magnetic fields, not x-rays, to produce detailed images of the body, especially images of soft tissue, such as the eye in its socket and the brain adjacent to the sinuses. A contrast medium may be injected into a patient’s vein to create a clearer picture.
 * Bone scan.** A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. This test may be done to see if cancer has spread to the bones.
 * Positron emission tomography (PET) scan.** A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. 4 ||
 * Histology: || The most common type of tumor in these regions is squamous cell carcinoma. Squamous cells are thin, flat cells resembling fish scales. They are found in the tissue that forms the surface of the skin, the lining of the hollow organs of the body, and the passages of the respiratory and digestive tracts. Commonly these tumors are well defined and slow growing, with a low tendency to spread either locally, regionally or distantly. Other types of nasal cavity and paranasal sinus cancer adenocarcinoms, that start in the gland cells, and are the next most common type of nose and paranasal sinus cancer. Cancers in these areas can also be lymphoms, plastocytomas (closely related to myeloma), melanomas or sarcomas, and rare tumours called neuroendocrine carcinomas. If you are looking for information on any of these types of cancer, this is not the right section for you. You need to go to the section of CancerHelp UK about the type of cancer you have. 5 ||
 * Lymph Node Drainage: || Cancers of the maxillary sinus are the most common of the paranasal sinus cancers. Tumors of the ethmoid sinuses, nasal vestibule, and nasal cavity are less common, and tumors of the sphenoid and frontal sinuses are rare. The major lymphatic drainage route of the maxillary antrum is through the lateral and inferior collecting trunks to the first station submandibular, parotid, and jugulodigastric nodes and through the superoposterior trunk to retropharyngeal and jugular nodes. 6 ||
 * Metastatic Spread: || Submandibular and subdigastric lymph nodes are most common. 7 ||
 * Grading: || Gx: unable to determine
 * Staging: || American Joint Committee TMN Classification

Ethmoid sinus T1 - Tumor confined to the ethmoid, with or without bone erosion T2 - Tumor extends into the nasal cavity T3 - Tumor extends to the anterior orbit, and/or maxillary sinus T4 - Tumor with intracranial extension, orbital extension including apex, involving sphenoid, and/or frontal sinus and/or skin of external nose

Regional Lymph Nodes NX - Regional lymph nodes cannot be assessed N0 - No Regional lymph nodes metastasis N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 in greatest dimension N2a - Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension N2b - Metastasis in multiple ipsilateral lymph nodes, none more than 6 in greatest dimension N2c - Metastasis in bilateral or contralateral lymph nodes, none more than 6 in greatest dimension N3 - Metastasis in a lymph node more than 6 cm in greatest dimension. 9 || Radiation retinopathy is rare at 45Gy Some visual acuity changes after 60Gy Decreased visual acuity after 65Gy 85-90% visual acuity changes after 80Gy 15 year actuarial incidence of optic nerve injury = 11% for doses above 60Gy. 10 || Maxillary Sinus - T1 and T2 = 60-70% T3 and T4 = 30-40% Unresectable and advanced disease = 10-15%. 11 || If tumor is resectable, surgery is performed first Post operative radiation is recommended even with negative margins
 * Radiation Side Effects: || Central nervous system damage, unilateral or bilateral vision lose, serous otitis media, and chronic sinusitis
 * Prognosis: || Nasal Vestibule - 5 year absolute survival rate is 77% for stages 1 and 2 and 73% for stages 3 and 4
 * Treatments: || __Ethmoid Sinuses__

__Nasal Vestibule__ Radiation therapy is preferred with 90% local tumor control Surgery if the lesion is small and in a favorable location Surgery plus post operative radiation External beam radiation, interstitial or a combination of the two

__Sphenoid Sinus__ Irradiation is usually the treatment by default

__Maxillary Sinus__ Surgery alone Surgery and postoperative radiation Radiation alone

__Treatment Borders__ Anterior portal Superior margin - encompasses the cribiform plate and includes all or part of the frontal sinus Inferior margin - usually the lip commisure includes floor of nose, maxillary antrum and aveolarridge 1.5 to 2cm across midline (entire nasal cavity and ethmoid-sphenoid complex and medial contralateral orbit) Lateral portal Anterior border - lateral boney canthus (includes posterior pole of ipsilateral eyeball) 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 commisure Posterior border - at or near the tragus and bisects the vertebral bodies Posterosuperior border - is usually drawn 2-3mm posterior to the clivus. 12 || According to RTOG 0619 a volume of spinal cord larger than about 3x3x3 mm cubed would be better off having dose less than 48 Gy. Also, in non-IMRT plans any field recieving more than 40-44Gy are to have a spinal block to reach this goal. 13  Phillips who invented the NSD curve used his formula to postulate that a limit of 5000cGy was appropriate because anything above this threshold would cause radiation myelitis. Boden recognized the need for volume data when evaluating dose to the spine. A recommendation by Emami is 5500cGy to a volume of 5cm for the TD5/5. 14
 * TD5/5: || __SPINAL CORD__

__BRAIN STEM__ 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. 14 According to RTOG the brain stem can recieve, "54Gy or 1% of PTV cannot exceed 60Gy." 15  __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. 16 According to RTOG the optic chiasm can recieve, "54Gy or 1% of PTV cannot exceed 60Gy." 17  __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. 18  According to RTOG the optic nerve can recieve, "54Gy or 1% of PTV cannot exceed 60Gy." 19  __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. 20  __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. 20  __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. 20 According to RTOG the mandible can recieve, "70Gy or 1cc of PTV cannot exceed 75Gy." 21

__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. 22   "Mean dose is less than or equal to 26Gy in at least one gland or at least 20cc of the combined volume of both parotid glands will receive less than 20Gy or at least 50% of the gland will recieve less than 30Gy in at least one gland." 23





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 * References**