Keywords

Pearls

  • Epidemiology

    • 4500 cases per year in the USA.

    • Maxillary cancers are most common (70%).

    • Incidence higher in Japan and South Africa.

    • More common in males (2:1).

  • Anatomy

    • Nasal cavity borders: base of skull (superior); hard palate (inferior); skin (anterior); choanae (posterior).

    • Nasal cavity subsites: vestibule, lateral walls, floor, septum.

    • Paranasal sinus borders: orbital floor (superior); hard palate (inferior); facial bone/zygomatic arch (anterior/anterior lateral); infratemporal fossa/pterygopalatine fossa (posterior/posterior lateral).

    • Paranasal sinus subsites: ethmoid, maxilla, sphenoid, frontal (named according to bones at the tumor location).

    • Ohngren’s line runs from the medial canthus of the eye to the angle of the mandible.

      • Tumors superior-posterior to Ohngren’s line historically had a poorer prognosis.

    • Lymphatic drainage of maxillary antrum to submandibular, parotid, jugulodigastric, retropharyngeal, and jugular nodes.

  • Histology : most common is SCC (70%). Adenocarcinoma, adenoid cystic, mucoepidermoid carcinoma, neuroendocrine (esthesioneuroblastoma/sinonasal undifferentiated carcinoma (SNUC)/sinonasal neuroendocrine carcinoma (SNEC)/small cell), plasmacytoma, lymphoma, melanoma, and sarcoma also seen.

  • See Chap. 12 for more information on esthesioneuroblastoma.

Workup

  • H&P, nasal endoscopy, CT/MRI, biopsy, CXR. Consider PET/CT for stage III/IV.

  • Consider pretreatment baseline serum blood tests including IGF-1, free thyroxin, cortisol, and prolactin.

Staging: Nasal Cavity and Paranasal Sinus Cancer

Editors’ note: All TNM stage and stage groups referred to elsewhere in this chapter reflect the 2010 AJCC staging nomenclature unless otherwise noted as the new system below was published after this chapter was written.

Table 6.1 (AJCC 7TH ED., 2010 )
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Table 6.2 (AJCC 8TH ED., 2017)
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Nasal Cavity and Ethmoid Sinus

T category

T criteria

TX

Primary tumor cannot be assessed

Tis

Carcinoma in situ

T1

Tumor restricted to any one subsite, with or without bony invasion

T2

Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion

T3

Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate

T4

Moderately advanced or very advanced local disease

T4a

Moderately advanced local disease. Tumor invades any of the following: anterior orbital contents, skin of the nose or cheek, minimal extension to the anterior cranial fossa, pterygoid plates, sphenoid, or frontal sinuses

T4b

Very advanced local disease. Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus

Definition of Regional Lymph Node (N)

Clinical N (CN)

N category

N criteria

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single ipsilateral lymph node, 3 cm or smaller in the greatest dimension and ENE(-)

N2

Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in the greatest dimension and ENE(-) or metastases in multiple ipsilateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-), or in bilateral or contralateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N2a

Metastasis in a single ipsilateral node larger than 3 cm but not larger than 6 cm in the greatest dimension and ENE(-)

N2b

Metastasis in multiple ipsilateral nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N2c

Metastasis in bilateral or contralateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N3

Metastasis in a lymph node larger than 6 cm in the greatest dimension and ENE(-) or metastasis in any node(s) with clinically overt ENE(+)

N3a

Metastasis in a lymph node larger than 6 cm in the greatest dimension and ENE(-)

N3b

Metastasis in any node(s) with clinically overt ENE (ENEC)

  1. Note: A designation of “U” or “L” may be used for any N category to indicate metastasis above the lower border of the cricoid (U) or below the lower border of the cricoid (L)
  2. Similarly, clinical and pathological ENE should be recorded as ENE(-) or ENE(+)

Pathological N (pN)

N category

N criteria

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single ipsilateral lymph node, 3 cm or smaller in the greatest dimension and ENE(-)

N2

Metastasis in a single ipsilateral lymph node, 3 cm or smaller in the greatest dimension and ENE(+) or larger than 3 cm but not larger than 6 cm in the greatest dimension and ENE(-), or metastases in multiple ipsilateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-), or in bilateral or contralateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N2a

Metastasis in single ipsilateral or contralateral node 3 cm or less in the greatest dimension and ENE(+) or a single ipsilateral node larger than 3 cm but not larger than 6 cm in the greatest dimension and ENE(-)

N2b

Metastasis in multiple ipsilateral nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N2c

Metastasis in bilateral or contralateral lymph nodes, not larger than 6 cm in the greatest dimension and ENE(-)

N3

Metastasis in a lymph node larger than 6 cm in the greatest dimension and ENE(-) or in a single ipsilateral node larger than 3 cm in the greatest dimension and ENE(+) or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE(+)

N3a

Metastasis in a lymph node larger than 6 cm in the greatest dimension and ENE(-)

N3b

Metastasis in a single ipsilateral node larger than 3 cm in the greatest dimension and ENE(+) or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE(+)

  1. Note: A designation of “U” or “L” may be used for any N category to indicate metastasis above the lower border of the cricoid (U) or below the lower border of the cricoid (L)
  2. Similarly, clinical and pathological ENE should be recorded as ENE(-) or ENE(+)

Definition of Distant Metastasis (M)

M category

M criteria

M0

No distant metastasis (no pathologic MO, use clinical M to complete stage group)

M1

Distant metastasis

AJCC Prognostic Stage Groups

When T is...

And N is...

And M is...

Then the stage group is...

Tis

N0

M0

0

T1

N0

M0

I

T2

N0

M0

II

T3

N0

M0

III

T1, T2, T3

N1

M0

III

T4a

N0, N1

M0

IVA

T1, T2, T3, T4a

N2

M0

IVA

Any T

N3

M0

IVB

T4b

Any N

M0

IVB

Any T

Any N

M1

IVC

  1. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer International Publishing

TREATMENT RECOMMENDATIONS

Table 6.3 Treatment recommendations
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Studies

Nasal Cavity

  • Allen (IJROBP 2008): 68 patients with nasal cavity or nasal septum cancer. Forty-seven percent received definitive RT. Nineteen percent received neck RT. 5/10-yr LC 86/76%, DFS 86/78%, OS 82/62%.

Paranasal Sinus

  • Le (IJROBP 2000): 97 patients with maxillary sinus tumors. Fifty-six had surgery first and 41 had pre-op or definitive RT. 12% LN relapse at 5 years. T3–4 SCC were associated with a high incidence of initial nodal involvement and nodal relapse. None of the patients presenting with SCC histology and N0 necks had nodal recurrence after elective neck radiation. Recommended elective ipsilateral neck RT for T3–4 SCC.

  • Bristol (IJROBP 2007): 146 patients with maxillary sinus tumors treated with post-op radiotherapy. Group 1 included 90 patients treated before 1991. Group 2 included 56 patients treated after 1991, when radiotherapy technique incorporated coverage of the base of skull for patients with perineural invasion, elective neck RT in SCC or undifferentiated histology, and techniques to improve dose homogeneity to target. No difference in 5-yr OS (51% vs. 62%), RFS, LRC, DM between the two groups, but base of skull and nodal failures reduced in at-risk patients. Advanced age, need for enucleation, and positive margins were independent predictors of worse OS. Need for enucleation predicted worse LRC.

Nasal Cavity and Paranasal Sinus

  • Dulguerov (Cancer 2001): 220 patients with nasal cavity and paranasal sinus cancer. 5-yr OS 40%, LC 59%. Prognostic factors: histology, T stage, primary site, and treatment type. Local extension factors associated with worse survival: extension to pterygomaxillary fossa, extension to frontal and sphenoid sinuses, erosion of cribriform plate, and invasion of the dura. In the presence of an intraorbital invasion, enucleation was associated with better survival.

  • Chen (IJROBP 2007): 127 patients with sinonasal carcinoma. 5-yr OS, LRC, and DFS were 52%, 62%, and 54%, respectively. No significant difference in 5-year OS rates for patients treated in the 1960s, 1970s, 1980s, 1990s, and 2000s. Significantly reduced incidence of severe (Grade 3 and 4) toxicity over the decades.

  • Madani (IJROBP 2009): 73 primary and 11 locally recurrent sinonasal tumors definitively treated by IMRT. No chemo. 64% patients had adenocarcinoma histology. Median follow-up 40 mo with 5-year LRC, OS, and DFS were 71%, 58%, and 59%, respectively.

  • Snyers (IJROBP 2009): 178 patients with sinonasal cancer. 62% of long-term survivors had hormonal disturbances and 24% had multiple hormonal deficiencies.

  • Wiegner (IJROBP 2012): 52 patients with tumors of the nasal cavity and paranasal sinuses treated post-op or definitively with IMRT. 2-year LRC, in-field LRC, FFDM, and OS were 64%, 74%, 71%, and 66%. Grade ≥ 3 mucositis 37%, dermatitis 15%, one late optic toxicity.

  • Multiple other published series report that IMRT is safe and effective for sinonasal carcinomas (e.g., Askoxylakis, Radiat Oncol 2016) and that it is often the preferred radiotherapy technique in particular for normal tissue sparing (Chi, J Hematol Oncol 2013).

  • Some physicians extrapolate from the Bernier and Cooper head and neck cancer studies (NEJM 2004, Head and Neck 2005) to support using post-op concurrent chemo and RT in patients with SCC of the paranasal sinuses having positive margins or extranodal extension.

Induction Chemotherapy

  • Hanna (Arch Otolaryngol Head Neck Surg 2011): 46 patients with T3–T4 squamous cell carcinoma of the paranasal sinuses or nasal cavity (maxillary sinus 67%). 26% had clinical evidence of nodal metastasis; 80% had stage IV. Induction chemotherapy was taxane-platinum in 80% or combined with ifosfamide or 5-fluorouracil, or taxane-5-fluorouracil. 67% of patients achieved at least partial response, 24% had progression, and 9% had stable disease. Surgery could be performed in 52% after induction. 2-year survival for stable or responding disease was 77% but was 36% for patients with progression on induction. The authors suggest that a lack of response to induction may indicate an inherently poor prognosis.

Radiation Techniques

Simulation and Field Design

  • Simulate supine with thermoplastic mask immobilization.

  • Eyes open, straight ahead to keep posterior pole away from high dose region inferiorly.

  • Consider tongue blade/cork to depress tongue out of fields.

  • Consider filling surgical defects with tissue equivalent material.

  • Recommend IMRT or 3DCRT planning to increase sparing of normal structures.

  • GTV = clinical and/or radiographic gross disease.

  • CTV1 = 1 cm margin on primary and/or nodal GTV.

  • CTV2 = high-risk regions (depending on the presence or absence of anatomic boundaries to microscopic spread).

  • CTV3 = elective neck.

  • Individualized planning target volumes are used for the GTV, CTV1, CTV2, and CTV3 tailored to subsite and stage.

  • Replanning may be considered during treatment if there is a potential for change in aeration of the sinuses in response to treatment , given the proximity to optic and central nervous system structures.

Dose Prescriptions

  • EBRT 1.8–2 Gy/fx.

  • Definitive RT or chemo-RT: CTV1 to 66–70 Gy, CTV2 to 60–63 Gy, CTV3 to 54–57 Gy.

  • Post-op RT: CTV1 to 60 Gy with optional boost to 66 Gy to high-risk areas (close/+ margins, ECE, PNI). CTV2 to 50–54 Gy.

  • For selected nasal septum tumors, brachytherapy may be appropriate.

Dose Limitations

  • Lens <10 Gy (cataracts).

  • Retina <45 Gy (vision). May go higher if treating bid or partial volume.

  • Optic chiasm and nerves <54 Gy at standard fractionation.

  • Brain <60 Gy (necrosis).

  • Mandible <60 Gy (osteoradionecrosis).

  • Parotid mean dose <26 Gy (xerostomia).

  • Lacrimal gland <30–40 Gy.

  • Pituitary and hypothalamus mean dose <40 Gy.

Complications

  • Acute = mucositis, skin erythema, nasal dryness, xerostomia

  • Late = xerostomia, chronic keratitis and iritis, optic pathway injury, soft tissue or osteoradionecrosis, cataracts, radiation-induced hypopituitarism

Follow-Up

  • H&P, labs, and CXR every 3 months for the first year, every 4 months for second year, every 6 months for third year, and then annually. Imaging of the H&N at 3 months posttreatment and then as indicated.