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Unformatted text preview: Neoplasms of the Nose and Paranasal Sinus
University of Texas Medical Branch
Steven T. Wright, M.D.
Anna M. Pou, M.D.
May 19, 2004
1 Neoplasms of Nose and Paranasal Sinuses Very rare 3%
Delay in diagnosis due to similarity to benign conditions
½ benign ½ malignant Paranasal Sinuses Malignant 2 Neoplasms of Nose and Paranasal Sinuses Multimodality treatment
Minimally invasive surgical techniques 3 Epidemiology Predominately of older males
Exposure: Wood, nickelrefining processes Industrial fumes, leather tanning Cigarette and Alcohol consumption No significant association has been shown 4 Location Maxillary sinus Ethmoid sinus 20% Sphenoid 70% 3% Frontal 1% 5 Presentation Oral symptoms: 2535% Nasal findings: 50% Obstruction, epistaxis, rhinorrhea Ocular findings: 25% Pain, trismus, alveolar ridge fullness, erosion Epiphora, diplopia, proptosis Facial signs Paresthesias, asymmetry
6 Radiography CT Bony erosion Limitations with periorbita involvement MRI 94 98% correlation with surgical findings Inflammation/retained secretions: low T1, high T2 Hypercellular malignancy: low/intermediate on both Enhancement with Gadolinium 7 Benign Lesions Papillomas
Neurogenic tumors 8 Papilloma Vestibular papillomas
Schneiderian papillomas derived from schneiderian mucosa (squamous)
Fungiform: 50%, nasal septum Cylindrical: 3%, lateral wall/sinuses Inverted: 47%, lateral wall 9 Inverted Papilloma 4% of sinonasal tumors
Site of Origin: lateral nasal wall
Malignant degeneration in 213% (avg 10%) 10 Inverted Papilloma
Resection Initially via transnasal resection: Medial Maxillectomy via lateral rhinotomy: 5080% recurrence
1020% Endoscopic medial maxillectomy: Key concepts: Identify the origin of the papilloma
Bony removal of this region Recurrent lesions: Via medial maxillectomy vs. Endoscopic resection
11 Osteomas Benign slow growing tumors of mature bone
Location: Frontal, ethmoids, maxillary sinuses When obstructing mucosal flow can lead to mucocele formation
Treatment is local excision 12 Fibrous dysplasia Dysplastic transformation of normal bone with collagen, fibroblasts, and osteoid material
Monostotic vs Polyostotic
Surgical excision for obstructing lesions
Malignant transformation to rhabdomyosarcoma has been seen with radiation
13 Neurogenic tumors 4% are found within the paranasal sinuses
Treatment via surgical resection
Neurogenic Sarcomas are very aggressive and require surgical excision with post op chemo/XRT for residual disease.
When associated with Von Recklinghausen’s syndrome: more aggressive (30% 5yr survival).
14 Malignant lesions Squamous cell carcinoma
Adenoid cystic carcinoma
Osteogenic sarcoma, fibrosarcoma, chondrosarcoma, rhabdomyosarcoma
Sinonasal undifferentiated carcinoma
15 Squamous cell carcinoma Most common tumor (80%)
Maxillary sinus (70%) Nasal cavity (20%) 90% have local invasion by presentation
First echelon: retropharyngeal nodes Second echelon: subdigastric nodes 16 Treatment 88% present in advanced stages (T3/T4)
Surgical resection with postoperative radiation Complex 3D anatomy makes margins difficult 17 Adenoid Cystic Carcinoma 3rd most common site is the nose/paranasal sinuses
Perineural spread Anterograde and retrograde Despite aggressive surgical resection and radiotherapy, most grow insidiously.
Neck metastasis is rare and usually a sign of local failure
Postoperative XRT is very important
18 Mucoepidermoid Carcinoma Extremely rare
Widespread local invasion makes resection difficult, therefore radiation is often indicated 19 Adenocarcinoma 2nd most common malignant tumor in the maxillary and ethmoid sinuses
Present most often in the superior portions Strong association with occupational exposures High grade: solid growth pattern with poorly defined margins. 30% present with metastasis
Low grade: uniform and glandular with less incidence of perineural invasion/metastasis.
20 Hemangiopericytoma Pericytes of Zimmerman
Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps
Treatment is surgical resection with postoperative XRT for positive margins 21 Melanoma 0.5 1.5% of melanoma originates from the nasal cavity and paranasal sinus.
Anterior Septum: most common site
Treatment is wide local excision with/without postoperative radiation therapy
END not recommended
AFIP: Poor prognosis
5yr: 11% 20yr: 0.5% 22 Olfactory Neuroblastoma
Esthesioneuroblastoma Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells.
A: confined to nasal cavity B: involving the paranasal cavity C: extending beyond these limits 23 Olfactory Neuroblastoma
Esthesioneuroblastoma UCLA Staging system T1: Tumor involving nasal cavity and/or paranasal sinus, excluding the sphenoid and superior most ethmoids T2: Tumor involving the nasal cavity and/or paranasal sinus including sphenoid/cribriform plate T3: Tumor extending into the orbit or anterior cranial fossa T4: Tumor involving the brain 24 Olfactory Neuroblastoma
Esthesioneuroblastoma Aggressive behavior
Local failure: 5075%
Metastatic disease develops in 2030%
Treatment: En bloc surgical resection with postoperative XRT 25 Sarcomas Osteogenic Sarcoma Most common primary malignancy of bone. Mandible > Maxilla Sunray radiographic appearance Fibrosarcoma
Chondrosarcoma 26 Rhabdomyosarcoma Most common paranasal sinus malignancy in children
Triple therapy is often necessary
Aggressive chemo/XRT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement.
Adults, Surgical resection with postoperative XRT for positive margins.
27 Lymphoma NonHodgkins type
Treatment is by radiation, with or without chemotherapy
Survival drops to 10% for recurrent lesions 28 Sinonasal Undifferentiated Carcinoma Aggressive locally destructive lesion
Dependent on pathological differentiation from melanoma, lymphoma, and olfactory neuroblastoma
Preoperative chemotherapy and radiation may offer improved survival 29 Metastatic Tumors Renal cell carcinoma is the most common
Palliative treatment only 30 Staging of Maxillary Sinus Tumors 31 Staging of Maxillary Sinus Tumors T1: limited to antral mucosa without bony erosion
T2: erosion or destruction of the infrastructure, including the hard palate and/or middle meatus
T3: Tumor invades: skin of cheek, posterior wall of sinus, inferior or medial wall of orbit, anterior ethmoid sinus
T4: tumor invades orbital contents and/or: cribriform plate, post ethmoids or sphenoid, nasopharynx, soft palate, pterygopalatine or infratemporal fossa or base of skull
32 Surgery Unresectable tumors: Superior extension: frontal lobes Lateral extension: cavernous sinus Posterior extension: prevertebral fascia Bilateral optic nerve involvement 33 Surgery Surgical approaches: Endoscopic
Combined craniofacial approach Extent of resection Medial maxillectomy
34 Tracheostomy 130 maxillectomies only 7.7% required tracheostomy
Of those not receiving tracheostomy during surgery, only 0.9% experienced postoperative airway complications
Tracheostomy is unnecessary except in certain circumstances (bulky packing/flaps, mandibulectomy)
35 Treatment of the Orbit Before 1970’s orbital exenteration was included in the radical resection
Preoperative radiation reduced tumor load and allowed for orbital preservation with clear surgical margins
Currently, the debate is centered on what “degree” of orbital invasion is allowed. 36 Current indications for orbital exenteration Involvement of the orbital apex
Involvement of the extraocular muscles
Involvement of the bulbar conjunctiva or sclera
Lid involvement beyond a reasonable hope for reconstruction
Nonresectable full thickness invasion through the periorbita into the retrobulbar fat
37 Conclusions Neoplasms of the nose and paranasal sinus are very rare and require a high index of suspicion for diagnosis
Most lesions present in advanced states and require multimodality therapy 38 Bibliography Bhattacharyya N. Cancer of the Nasal Cavity: Survival and Factors Influencing Prognosis. Archives of OtoHNS. Vol 128(9). September 2002. Pp 10791083.
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This note was uploaded on 12/28/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.
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