3. Maxillary sinus
“Maxillary sinus is the pneumatic space that is lodged
inside the body of maxilla and that communicates
with the environment by way of the middle meatus
and nasal vestibule.”
Anatomy of the maxillary sinus was 1st described by
Highmore in 1651.
4. Ohngren’s Line
A line that is drawn
from the angle of
mandible to the medial
canthus.
Ohngren indicated that
tumors that presented
above this line
(suprastructure); both
superiorly and
posteriorly, tended to
have a worse
prognosis
5. Lymphatic Drainage
The lymphatic drains in to submandibular lymph
nodes.
The lymphatic drainage reaches the specialised
cells in the maxillary sinus via infra orbital foramen
or through the anterosuperior wall and then to the
submandibular lymph nodes.
11. History & Physical examination
•The sinonasal, ocular, and neurologic systems
should be studied in detail
•Ant & post rhinoscopy
•Nasal endoscopy
12. Radiological Examination
Radiographic studies are essential as the full extent
of a sinonasal neoplasm cannot be established even
with modern fibreoptic technology.
Both CT & MRI are the effective ways to know the
extent of tumor extracranially and intracranially.
13. Computed Tomography
Bone erosion
Key areas include the bony orbital walls,
cribriform plate, fovea ethmoidalis,
posterior wall of the maxillary sinus,
pterygopalatine fossa, the
sphenoid sinus, and the posterior table
of the frontal sinus.
85% accuracy
Difficult
Periorbital involvement
Difficult to differentiate between: Tumor vs. inflammation
vs. secretions
14. MRI
• 94% accuracy
• Inflammatory tissue & secretions:
intense T2
• Tumor: Intermediate T1 & T2,
Enhancement with Gadolinium
• MRI is excellent for determining
perineural spread, involvement of
the dura, or involvement
intracranially.
15. Biopsy
Transnasal
Medial wall of maxilla is the preferred route
Needle biopsy is sufficient
Biopsy via Caldwell-Luc approach (canine fossa
puncture) is not recommended because of the
potential to seed the gingivobuccal sulcus and
cheek skin with tumor.
19. Prognostic Factors
• Patient-specific
• Age and performance status.
• Disease-specific
• Location,
• Histology,
• Locoregional extent (reflected in TNM stage),
• Perineural invasion.
• Extensive local disease involving the nasopharynx, base of skull, or
cavernous sinuses markedly increases surgical morbidity as well as
the risk of subtotal surgical excision.
• Tumor extension into the orbit may require enucleation, but minimal
invasion of the floor or medial wall may be dealt with through
resection and reconstruction, sparing the globe.
23. •Stage IV B: (T4b/ M1 disease)
•Multidisciplinary input is required even for
very advanced cases
•Palliation may involves limited surgery,
radiation therapy, chemotherapy,
investigational studies, best supportive care.
•Control of pain and discomfort a first priority.
•Chemotherapy can be given as single-agent
therapy in investigational settings.
25. Weber fergussen approach tumors
involving the maxilla extending
superiorly to the infraorbital nerve and into the orbit.
wide access to all areas of the maxilla
and orbital floor.
26. Midfacial Degloving
Nasal cavity tumors with
bilateral involvement
Most suited for inferiorly
located tumors.
Subperichondrial plane of
nasal septum
28. Surgical procedures
The goal of surgery for nasal cavity and paranasal sinus tumors
is to achieve en bloc resection of all involved bone and soft
tissue with clear margins while maximizing the cosmetic and
functional outcome.
Limited nasal cavity lesions may be resected with medial
maxillectomy.
Ethmoid lesions usually require medial maxillectomy and en
bloc ethmoidectomy.
combined craniofacial procedure for lesions involving the
inferior surface of the cribriform plate ,the roof of the ethmoid
& frontal sinus.
Multidisciplinary skull base approach has improved the
outcome
34. Immobilisation:
1. Patients should be immobilised supine in a
thermoplastic cast.
2. If the low neck nodes are to be treated (level III–
V) the neck should be extended to allow
treatment of most of the neck nodes
3. A mouth bite is used to depress the tongue and
oral cavity away from the treated volume and
reduce acute morbidity.
4. Patients should be asked to look straight ahead
to avoid rotating the lens or retina, particularly if
the orbital cavity is included in the treated
volume.
35. Imaging:
1. CT scan is performed with 3 mm slices from 2
cm superior to the superior orbital ridge to the
hyoid bone.
2. Fused CT-MRI images can be useful in the
definition of the optic pathways and skull base.
3. MRI also allows retained secretions to be
differentiated from tumour where resection has
been incomplete.
36. 2D CONVENTIONAL: A three-field technique is
used: 1 anterior and 2 lateral fields.
Patient lies in a supine cast with the head in neutral
position.
Tongue bite is used to depress tongue & lower
alveolus away from the target volume.
37. Anterior field:
Superior border: Above the crista galli to encompass the
ethmoids.
Inferior border: 1 cm below the floor of the sinus.
Medial border: 1 to 2 cm (or more if necessary) across the
midline. Cover contralateral ethmoidal
extension.
Lateral border: 1 cm beyond the apex of the sinus or falling
off the skin.
38. Lateral fields:
Superior border: follows the
floor of anterior cranial fossa.
Anterior border: behind the
lateral canthus parallel to the
slope of face.
Posterior border: covers the
pterygoid plates.
39. Anterior field:
When there is no gross involvement of the orbit, the
cornea, lens & lacrimal gland are shielded from the
anterior field.
If there is disease in the orbit, cornea is spared by
cutting out the cast and treating with the eyes open.
Lateral field:
It is angled 5-10 degree posteriorly so that the exit
beam avoids the opposite eye.
Optic chiasma & hypothalamus are shielded from the
lateral field.
41. 3D CRT Radiotherapy Planning
• Delineation of target volumes is based on:
• Physical examination
• Pre-treatment imaging
• Intra-operative findings (tumor extension relative
to critical structures such as orbital wall,
cribriform plate, cranial nerve foramina, and ease
of resection)
• Pathologic findings (such as positive margin or
perineural invasion).
42. Target volume definition
• GTV (Gross Tumor Volume):
• Where resection is not possible or has been
incomplete, the GTV is outlined.
• CTV (Clinical Target Volume):
• Defining the CTV is the most important step for
most patients.
• These tumors need a meticulous CTV definition
due to proximity of these tumours to critical
structures such as the optic nerves and chiasm,
brainstem, and lacrimal glands.
43. The CTV should encompass
• All initial sites of disease(presurgery GTV),
• The mucosa of adjacent compartments of the
sinonasal complex
• A 10 mm margin at least from initial sites of
GTV where no good bony barrier to invasion
exists (E.G. Masticator space, cribriform plate
and infraorbital fissure)
• Bony orbit if involved
For most tumours, the CTV will include the
ipsilateral maxillary sinus and bilateral nasal
cavity and the ethmoid sinuses.
44. Organs at Risk (OAR)
Include the
1. Lenses
2. Lacrimal glands (in the superolateral orbit and
upper eyelid)
3. Optic nerves and chiasm
4. Spinal cord
5. Brainstem
6. Pituitary gland
45. OAR & possible complications of RT
• Lens <10 Gy (cataracts)
• Lacrimal gland <30–40 Gy (dry eye syndrome)
• Retina <45 Gy (blindness)
• Optic chiasm and nerves <54 Gy at standard fractionation.
(Optic neuropathy)
• Brain <60 Gy (necrosis)
• Mandible <60 Gy (osteoradionecrosis)
• Parotid mean dose <26 Gy (xerostomia)
• Pituitary and hypothalamus mean dose <40 Gy.
46. Definition of CTV for a pT4a carcinoma of the maxilla
resected with clear margins. (a) Preoperative T1-
weighted contrast-enhanced MRI showing primary
tumour invading the cheek (C), masticator space (M)
and lateral pterygoid muscle (P). (b) Corresponding
planning CT slice showing CTV.
48. IMRT
• IMRT provides a more conformal dose distribution to the unusual
PTVs in Maxillary cancer.
• Five or seven field coplanar beams have been used but these
arrangements will increase dose to the orbital contents.
• A non-coplanar arrangement of three to five sagittal midline beams
with right and left lateral beams avoids entry or exit of beams
through the eyes and provides a uniform dose distribution
49.
50.
51. • IMRT is the preferred treatment method as it generally yields better dose
distribution in terms of both tumor coverage and sparing of normal
tissues
• IMRT is rapidly becoming the standard of care technique for external
beam therapy for sinonasal malignancies.
•
52. Adjuvant Radiotherapy
Addition of RT to surgery improve 5-years
survival (44%) when compared to RT alone
(23%) or surgery alone.
Postoperative Radiotherapy: Preferred
interval between resection and postoperative
RT is 6 weeks
•60–66 Gy (1.8–2.0 Gy/fraction); daily 5 days
a week in 6–6.5 weeks
55. Concurrent Chemotherapy
•Concurrent chemoradiation therapy can be
used for patients with medical conditions that
preclude surgery if those patients have good
performance status.
•Depending on the patient’s performance status
and renal function, single-agent cisplatin can be
used concurrently with external beam radiation
for locally advanced, unresectable squamous
cell carcinoma.
56. Neo-adjuvant Chemotherapy
• Neoadjuvant chemotherapy (i.e., chemotherapy given
before surgery) can reduce tumor volumes
• May allow a less extensive surgical resection than
would be possible otherwise.
• Can also reduce tumor volumes and facilitate
radiotherapy planning by increasing the distance
between tumor borders and critical organ structures
such as brain, chiasm, optic nerve, or spinal cord.
• Investigations are ongoing to determine whether the
response to neoadjuvant chemotherapy can help in the
choice of definitive treatment.
57. •Concurrent:
•Inj Cisplatin 100mg/m2, triweekly with
radiotherapy or 35mg/m2weekly with
radiotherapy.
•Neo-adjuvant/Induction:
•3-6 cycles induction chemotherapy with
•Inj. Docetaxel 75mg/m2 i.v. day 1
•Inj. Cisplatin 75mg/m2 i.v. day 1
•Inj 5F.U. 750 mg/m2 i.v.Day 1-day 4
•Others: Paclitaxel /cisplatin/ infusional 5-FU
•Following induction, agents to be used with
concurrentchemoradiation typically include
weekly carboplatin or cetuximab
58. Palliative chemotherapy
•Cisplatin or carboplatin + 5-FU + cetuximab
(category 1)
•Cisplatin or carboplatin + docetaxel or
paclitaxel
•Cisplatin/cetuximab (non-nasopharyngeal)
•Cisplatin/5-FU
60. T3-T4a N0, T1-T4a N+, T4b any N
T3-T4a N0
Surgical Resection
Adverse Features
-ve
Radiotherapy To
primary
Adverse Features
+ve
RT or Consider
systemic therapy/RT
to primary
T1-T4a N+
Surgical Resection+
Neck dissection
Adverse Features
-ve
Radiotherapy To
primary and Neck
Adverse Features
+ve
RT or Consider
systemic therapy/RT
to primary and neck
T4b any N
Clinical trial
Definitive R.T. with
systemic therapy
For example, if neoadjuvant chemotherapy produces a complete response, then primary radiation therapy, with or without chemotherapy, can be considered; a less-than-complete response would prompt surgical excision of the lesion followed by adjuvant radiation therapy.
