Paranasal+Sinuses

LABS: Complete blood count.[3] || GX: Grade cannot be evaluated. G1: The cells appear like normal cells (well differentiated). G2: The cells moderately differentiated. G3: The cells do not resemble normal cells (undifferentiated). ||
 * **Epidemiolgy:** || A rare cancer more commonly found in males in Japan and South Africa. Usually between the ages of 10-20 and 50-60 years of age.[1] ||
 * **Etiology:** || People who work in the wood or furniture industry and are exposed to wood dust may develop this disease. May also be linked to smoking as well. ||
 * **Signs & Symptoms:** || Blocked sinuses that do not clear, pain behind the nose or upper teeth, swelling around the eyes. Other symptoms may include numbness of the cheek, upper lip, upper teeth or side of nose, headaches and nosebleeds.[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 type;Other types include malignant melanoma, lymphoma, inverted papilloma, sarcoma, and benign tumors [3,1] ||
 * **Lymph node drainage:** || Drainage is mainly ipsilateral and few or no lymphatic vessels in paranasal sinuses; If lymph nodes are involved some common nodes include the Submandibular, Subdigastric (Jugulodigastric), Retropharyngeal, and Superior Cervical lymph nodes[3,1] ||
 * **Metastatic spread:** || Tumors can spread by three pathways: local extension through adjacent tissue, through the lymphatic system, and through the blood stream.[7] Nasal cavity and paranasal sinus tumors spread mainly by local extension and the lymphatic system. Tumors may extend into the nasal cavity, septum, nasopharynx, orbits, oral cavity or the bones of the base of the skull.[1] The lymphatic chain involved with nasal cavity and paranasal sinuses include levels I-III and the retropharyngeal lymph chain. [4] ||
 * **Grading:** || Grade describes how closely the cancer cells resemble normal cells microscopically. In general, lower grade tumors have a better prognosis.
 * **Staging:** || TNM staging system is limited to the maxillary and ethmoid sinuses.[1,5]

Primary Tumor (maxillary sinus) 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 limited to the antral mucosa (tissue lining the sinus) 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 maxillary sinus, subcutaneous tissues, skin of the 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, cribriform plate, base of skull, nasopharynx, sphenoid, frontal sinuses.

Regional Lymph Nodes (maxillary and ethmoid) 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 [6]

STAGE I: T1, N0, M0 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageI.jpg [6]

STAGE II: T2, N0, M0 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageII.jpg [6]

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 [6]

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 [6]

STAGE IVB: Any T, N3, M0 or (T4B, Any N, M0) http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIVB.jpg [6]

STAGE IVC: Any T, Any N, M1 http://www.cancer.net/patient/Multimedia/Medical%20Illustrations%20Gallery/Web/sinuses_stageIVC.jpg [6]

The University of Florida has developed a staging system that is defined for the nasal cavity and paranasal sinuses:[1] Stage I: limited to the site of origin. Stage II: extension to adjacent sites such as orbit, nasopharynx, paranasal sinuses, skin, pterygomaxillary fossa. Stage III: base of skull or pterygoid plate destruction; intracranial extension. || Stage 5 year survival I 63% II 61% III 50% IV 35% [3] || Stage T1-2 N0: Surgical resection followed by radiation therapy or definitive radiation therapy. Stage T3-4 N0: Surgical resection followed by radiation therapy. For inoperable tumors, definitive radiation therapy or combined chemo and radiation therapy.
 * **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.[7] ||
 * **Prognosis:** || Prognostic factors for survival include age and performance status and for tumor control include tumor location, histology and extension of the disease.[3] Maxillary Sinus 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 live-year relative survival rate of people with nasal cavity and/or paranasal sinus cancer is 54%.[3]Ethmoid Sinus
 * **Treatments:** || The most favorable choice for the carcinoma of the paranasal sinuses is surgery. Some early stage tumors can be treated with surgery alone. However, post-operative radiation therapy treatment is recommended for all cases. Advanced malignancies, tumors that invade the wall of nasopharynx or the base of the skull, are usually inoperable and treated only with radiation. [8]

Ethmoid Sinus The tumor is removed by surgical resection followed by post-operative radiation therapy.

Maxillary Sinus Most tumors require surgical resection, which includes the entire maxilla and ethmoid sinus. Radiation is given post operatively. Early stage tumors can be cured by either surgical resection or radiation treatment.

Sphenoid Sinus Radiation therapy is the treatment of choice.

Nasal Vestibule Radiation therapy can provide 90% local tumor control. Surgical resection followed by post-operative radiation can be given. However, due to some distortion from the surgery, radiation therapy is the choice of treatment.

External Beam radiation therapy From the technical aspects, radiotherapy of the paranasal sinuses is similar. The three treatment fields, which include wedge paired parallel, opposed with anterior-posterior portals are used. The treatment dose of 45Gy to 50Gy is delivered initially. Then, the gross disease is boosted to 60Gy to 66Gy. For definitive radiation therapy, the total dose of 66-70Gy is used. [1]

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. [8]

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. [8] ||
 * **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.[1]

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]. [|http://emedicine.medscape.com/article/847189-overview#a04] Last revised September 14, 2011. Accessed May 24, 2012. [5]. American Cancer Society website. [] Last revised January 11, 2012. Accessed May 23, 2012. [6]. [] Last revised May, 2011. Accessed May 24, 2012. [7]. American Cancer Society website. [] Last revised January 11, 2012. Accessed May 24, 2012. [8] Hoppe TR, Phillips LT, Roach M. Leibel and Phillips Textbook of Radiation Oncology. 3rd Edition. Philadelphia: Saunders, Elsevier. 2010 [9]. [][| Accessed May 24, 2012.]
 * **References:** || [1] Chao KS, Perez CA, Brady KW. //Radiation Oncology-Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.



// Figure 1: Description of Lymph Node Chains in the Neck. [9] // I: Submental and submandibular nodes II: Upper Jugulodigastric groupIII: 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. Simulation films of a patient undergoing postpoerative radiation therapy of the paranasal cavity.[8]

Figure 3. Intersity modulated radiation therapy isodoe plans of the paranasal sinuses in axila views.[8] ||

Back to week 1