Nasal+Cavity

LABS: Complete count.[3] || Subdigastric (Jugulodigastric) and Submandibular most commonly involved lymph nodes[3,1] || GX: Grade cannot be evaluated.
 * **Epidemiolgy:** || A rare cancer more commonly found in males between the ages of 10-20 and 50-60 years of age.[1] ||
 * **Etiology:** || Associated with occupational exposure to dust or chemicals. ||
 * **Signs & Symptoms:** || Sinus pressure, headaches or pain in the sinus areas, runny nose, nosebleeds, a lump or sore inside the nose that does not heal, a lump on the face or roof of the mouth, numbness or tingling in the face, swelling in the eyes, pain in the upper teeth, pain or pressure in the ear.[2] ||
 * **Diagnostic Procedures:** || GENERAL: Complete history and physical. Fiberoptic endoscopic examination with biopsies. Patient should have a dental evaluation before the start of radiation. A baseline ophthalmologic exam, as well as a baseline speech and swallowing assessment if surgery is planned.IMAGING: CT/MRI of the primary site and neck. Chest X-ray, CT of thorax if adenoid cystic or neuroendocrine carcinoma. PET/CT may also be ordered.
 * **Diagnostic Procedures:** || GENERAL: Complete history and physical. Fiberoptic endoscopic examination with biopsies. Patient should have a dental evaluation before the start of radiation. A baseline ophthalmologic exam, as well as a baseline speech and swallowing assessment if surgery is planned.IMAGING: CT/MRI of the primary site and neck. Chest X-ray, CT of thorax if adenoid cystic or neuroendocrine carcinoma. PET/CT may also be ordered.
 * **Histology:** || Squamous cell most common;Other types include minor salivary gland tumors, malignant melanoma, lymphoma, esthesioneuroblastoma, sarcoma, and inverted papilloma [3,1] ||
 * **Lymph node drainage:** || Drainage is mainly ipsilateral;
 * **Metastatic spread:** || Tumors can spread by three pathways: local extension through adjacent tissue, through the lymphatic system, and through the blood stream.[1] Nasal cavity and paranasal sinus tumors spread mainly by local extension and the lymphatic system. Local extension is commonly seen into the adjacent sinuses, nasopharynx, nasal septum, oral cavity or orbits. [1] ||
 * **Grading:** || Grade describes how closely the cancer cells resemble normal cells microscopically. In general, lower grade tumors have a better prognosis.

G1: The cells appear like normal cells (well differentiated). G2: The cells moderately differentiated. G3: The cells do not resemble normal cells (undifferentiated). || TX: Primary tumor cannot be assessed. T0: No evidence of primary tumor. Tis: Carcinoma in situ (cells are limited to the innermost layer of the mucosa). T1: Tumor confined to the nasal cavity or ethmoid with or without bone erosion. T2: Tumor extends into other nasal or paranasal cavity, with or without bone erosion. T3: Tumor extends to the anterior orbit, roof of the mouth, cribiform plate, and/or maxillary sinus. T4A: Tumor extends to the anterior orbit, skin of nose or cheeks, sphenoid sinus, frontal sinus or pterygoid plates. Also described as moderately advanced local disease. T4A tumors are usually surgically resectable. T4B: Tumor extends to the posterior orbit, intracranial extension, dura involvement, middle cranial fossa, nerve involvement, or nasopharynx. Also described as very advanced local disease. T4B tumors are not surgically resectable.
 * **Staging:** || Primary Tumor (ethmoid sinus and nasal cavity) [1,4]

Regional Lymph Nodes NX: Regional lymph nodes cannot be assessed. N0: No regional lymph node 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 cm 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 cm in greatest dimension. N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N3: metastasis in a lymph node more than 6 cm in greatest dimension.

Metastatic Spread: MX: Distant metastasis cannot be assessed. M0: No distant metastasis. M1: Distant metastasis present.

STAGE 0 (in situ): Tis, N0, M0 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stage0.jpg [5]

STAGE I: T1, N0, M0 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageI.jpg [5]

STAGE II: T2, N0, M0 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageII.jpg [5]

STAGE III: T3, N0, M0 or (T1, T2, or T3, N1, M0) http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIII.jpg [5]

STAGE IVA: T1, T2, or T3, N2, M0 or (T4A, N0, N1, or N2, M0) http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIVA.jpg [5]

STAGE IVB: Any T, N3, M0 or (T4B, Any N, M0) http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIVB.jpg [5]

STAGE IVC: Any T, Any N, M1 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIVC.jpg [5] ||
 * **Radiation side effects:** || The most common short-term side effects of radiation treatment of nasal cavity or paranasal sinus tumors include sunburn-like skin changes, nausea and fatigue, all of which should resolve after the end of treatment. Also, mouth and throat pain, or sores in the mouth may be experienced. Long-term side effects that may be encountered include chronic sinusitis, unilateral or bilateral vision changes, central nervous system damage, bone pain or damage, and/or hearing changes.[6] ||
 * **Prognosis:** || Prognostic factors for survival include age and performance status and for tumor control include tumor location, histology and extension of the disease.[3] Each year, about 2,000 people are diagnosed with nasal cavity or paranasal sinus cancer in the United States. Tend to occur between ages 45 and 85 and twice as likely in males. The overall five-year relative survival rate of people with nasal cavity and/or paranasal sinus cancer is 54%. Stage 5 year survival

I 63% II 61% III 50% IV 35% || State T1-2 N0: Surgery followed by radiation therapy to the positive margins or radiation therapy alone. Stage T3-4 N0: If the tumor is ressectable then post-op radiation therapy is used alone. For unrespectable tumors, either definitive radiation therapy or concurrent chemo and radiation therapy is used.[1]
 * **Treatments** || The primary treatment choice for carcinoma of the nasal cavity is surgery. Radiation therapy can be used alone for unresectable tumors. In recent years, surgery followed by post-operative radiation therapy has become the main treatment option for resectable tumors. Combined chemotherapy and radiation therapy is used post-surgery to reduce the risk of recurrences.

Radiation Therapy The treatment dose of 66Gy to 70Gy for definitive radiotherapy or concurrent chemo and radiation is the same. The post-op radiotherapy dose is 60Gy with an optional boost to 66Gy. The three dimensional conformal radiotherapy (3DCRT) or IMRT is recommend for the treatment of the nasal cavity to spare more normal structures.[1] IMRT can result in better sparing of the optic apparatus compared to 3DCRT, especially in definitive radiotherapy treatments that requires higher doses. The wedge pair parallel opposed fields with an anterior-posterior field are used for the 3DCRT.

The treatment field borders Anterior field borders Superior – 2cm above the cribriform plate, including part of the orbit. Inferior – Lateral commissure of the lip. Medial – 1.5 to 2cm across the midline Lateral – Includes the entire maxillary sinus[7]

Lateral field boders Anterior – Behind the contralateral bony canthus Superior – 2cm above the cribriform plate Posterior – Include the pterygopalatine fossa and bisecting vertebral body. Inferior – Lateral commissure of the lip.[7] ||
 * **TD 5/5:** || Normal tissue tolerance doses in terms of TD5/5 represent the normal tissue tolerance dose at 5% complication within 5 years post radiation therapy treatments.[7]

TD5/5 Normal Tissue Tolerances (Gy) || [2] Paranasal Sinuses and Nasal Cavity Cancer Treatment. National Cancer Institute. []. Accessed May 21, 2012. [3] Washington, Charles, and Dennis Leaver. //Principles and Practices of Radiation Therapy//.St. Louis,Missouri: Mosby Elsevier, 2010 [4] American Cancer Society website. [] Last revised January 11, 2012. Accessed May 23, 2012. [5] [] Last revised May, 2011. Accessed May 24, 2012. [6] American Cancer Society website. [] Last revised January 11, 2012. Accessed May 24, 2012. [7] Hoppe TR, Phillips LT, Roach M. Leibel and Phillips Textbook of Radiation Oncology. 3rd Edition. Philadelphia: Saunders, Elsevier. 2010 [8] [][| Accessed May 24, 2012.] Figure 1: Description of Lymph Node Chains in the Neck. [8] I: Submental and submandibular nodes II: Upper Jugulodigastric group III: Middle jugular nodes (draining the nasopharynx and oropharynx, oral cavity, hypopharynx, and larynx) IV: Inferior jugular nodes (draining the hypopharynx, subglottic larynx, thyroid and esophagus) V: Posterior triangle group VI: Anterior compartment group Figure 2. Example of three field treatment plan of the nasal cavity. [7] Figure 3. Three dimentional treatment plan of the nasal caivty. [7] ||
 * **References:** || [1] Chao KS, Perez CA, Bardy KW. //Radiation Oncology-Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.

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