Management of sinonasal tract tumors 27082018

Management of Sinonasal Tract
Tumors
Dr. Varshu Goel
Second Year Post-Graduate Resident
Department of Radiation Oncology
Maulana Azad Medical College, New Delhi

• Anatomy and Lymphatic Drainage
• Clinical Presentation and Diagnostic Work-up
• Staging and Histology
• Treatment Modalities
• Follow-up
2
Outline

3
ParanasalSinuses
a) Maxillary sinuses - Largest, 15 ml
volume
b) Ethmoidal Sinuses - Anterior,
Middle & Posterior group
c) Frontal Sinuses
d) Sphenoidal Sinus
• Sinuses are lined with
pseudostratified ciliated columnar
epithelium
• The purpose of the paranasal
sinuses is to lighten the bone and
give resonance to the voice
Snell’s Clinical Anatomy by Regions, 9th ed.

4
Atlas of Human Anatomy, 6th ed.
The Medial Wall Of The Nasal Cavity (Nasal Septum)
NasalCavity

The Lateral Wall Of The Nasal Cavity
Atlas of Human Anatomy, 6th ed.

• Sinonasal malignancies are uncommon and heterogenous group
of tumors
• Age > 40 years except esthesioneuroblastoma
• Males > Females
• Cancer of the maxillary sinus is the most common of the
sinonasal malignancies
• Incidence of nodal involvement :
• 10-15 % for maxillary & ethmoid sinus
• 5-10 % for nasal cavity
6
Introduction to SinonasalTumors
Perez & Brady's Principles and Practice of Radiation Oncology, 6th ed.

7
Sites
• Nasal Cavity
• Nasal Vestibule
• Paranasal Sinuses

• Local extension – commonest
• Lymphatic – 10%
• More in SCC & poorly diff ca
• Perineural spread – adenoid cystic ca
• Hematogenous - rare
8
Patternof Spread
Fletcher’s Textbook of Radiotherapy, 3rd edition

9
Patternof Spread
Nasal Cavity – 1 – anterior cranial fossa, ethmoid cells, orbit, sphenoid sinus,
BOS, 2 - upper nasal cavity; 3 – Maxillary sinus; 4 – Antrum, 5 – NPX
Coronal
Section
Sagittal
Section

Patternof Spreadof Maxillary Tumors
• Anteriorly: cheek, skin
• Posteriorly:
pterygopalatine fossa, infra
temporal fossa, temporal
bone middle cranial fossa
• Medially: nasal cavity, NLD
• Laterally: cheek, skin
• Superiorly: orbit, ethmoid
sinuses
• Inferiorly: palate, buccal
sulcus
10

11
Patternof Spread
Frontal – 1-nasion, 2-
ethmoid, 3- frontal
lobe
Sphenoid – 1 - NPX, 2 -
middle cranial fossa,
3- post ethmoid cells &
nasal cavity
Ethmoid :
1- c/l ethmoid, 2- maxilla, 3- orbit, 4- nasal
cavity, 5- sphenoid- BOS- NPX, 6- frontal sinus-
cribriform plate-ant cranial fossa, 7-
frontonasal angle

12
Gray’s Anatomy, 41st ed.
Lymphaticsof the NasalCavity
The lymphatic drainage of the nasal
cavity can be divided into two.
1. The main part of the nasal
cavity drains via the
nasopharynx to the
retropharyngeal nodes and
upper deep cervical nodes
(levels IIA and IIB).
2. The lower anterior portion
drains to the submandibular
(level IB), parotid (preauricular)
and jugulodigastric (level IIA)
nodes.
Walter & Miller’s Textbook of Radiotherapy, 7th ed.

• Lymphatic drainage is typically
towards the retropharyngeal
(Rouviere’s node) and upper
deep cervical nodes (level II)
unless the tumour is
particularly anteriorly placed
when the buccinator, level I
and IIA nodes are at risk.
• The lymph system is
remarkably sparse and, as
such, tumors can be quite
advanced without involved
nodes.
13
Lymphaticsof the ParanasalSinuses
Walter & Miller’s Textbook of Radiotherapy, 7th ed.

14
RiskFactors
• Adenocarcinomas of the nasal cavity and ethmoid sinus - carpenters
and sawmill workers who are exposed to wood dust
• Synthetic wood, binding agents, and glues as cocarcinogens.
• Squamous cell carcinomas of the nasal cavity - nickel workers
• Maxillary sinus carcinomas - radioactive thorium containing contrast
material (Thorotrast) used for radiographic visualization of the
maxillary sinuses
• Occupational exposure in the production of chromium, mustard gas,
isopropyl alcohol, and radium
• Ill-fitting dentures, cigarette smoking and alcohol consumption

15
Histology
• Most common: squamous cell carcinoma 80 to 90 %
• Adenocarcinoma
• Adenocystic carcinoma and minor salivary gland tumour -10 to
15%
• Lymphoma – 5%
• Melanoma – 1%
• Others:
• Esthesioneuroblastoma
• RMS
• Mid line lethal granuloma– NK T cell lymphoma
• Extramedullary plasmacytoma
• Sinonasal Undifferentiated Carcinoma

• Usually present as asymptomatic plaques or nodules.
• Are essentially skin cancers.
• Advanced lesions may extend beyond the vestibule and may cause
pain, bleeding, or ulceration.
• Can spread by direct invasion or lymphatic spread; the latter is
usually to the ipsilateral facial (buccinator and mandibular) and
submandibular nodes.
• Lesions extending across the midline may spread to the contralateral
nodes.
• The incidence of nodal metastasis at diagnosis is approximately 5%.
16
Clinical Presentationof
NasalVestibuleCarcinomas

• Nasal cavity tumors present with symptoms and signs of
nasal polyps, hence delaying the diagnosis.
• In case of advanced tumors, signs and symptoms according
to the extent of involvement seen.
• Tumors arising in the upper nasal cavity and ethmoid cells
can extend to the orbit (lamina papyracea) and to the
anterior cranial fossa (cribriform plate).
17
NasalCavityCarcinomas

• Usually diagnosed at advanced stages.
• Symptoms and signs are :
• facial swelling, pain/paraesthesia, epistaxis, nasal discharge and
obstruction, alveolar or palatal mass, unhealed tooth socket
• proptosis, diplopia, impaired vision, or orbital pain due to
orbital invasion.
• Suprastructure tumors tend to show extensive local spread and
have a poorer prognosis.
• The maxillary sinuses are believed to have a limited lymphatic
supply and a correspondingly low incidence of lymphadenopathy at
diagnosis.
18
Maxillary Sinus Carcinomas

19
• A line from medial canthus of the
eye to the angle of the mandible
• Divides the maxillary sinus into
antero-inferior (infrastructure) &
posterosuperior (suprastructure)
parts.
• Infrastructure:
• Good prognosis
• Suprastructure:
• Early extension (eye, skull
base, pterygoids,
infratemporal fossa)
Ohngren’sLine

• Central or facial headaches
• Referred pain to the nasal or retrobulbar region
• Subcutaneous mass at the inner canthus
• Nasal obstruction and discharge
• Diplopia, and proptosis
20
Clinical Presentationof EthmoidSinus
Tumors

DiagnosticWorkup
21
• General –
• Complete history including occupational exposure
• Physical examination : Inspection and palpation of the orbits, nasal and
oral cavities, and nasopharynx, assessment of cranial nerves
• Laboratory – Complete blood count
• Other –
• Dental evaluation with extractions/restorations as needed
• Baseline ophthalmologic examination
• Baseline speech and swallowing assessment if surgery is planned

22
Inspection
- Done with anterior and posterior rhinoscopes.
- To note the following:
• Deformity – congenital or acquired
• Shape – Deviation of septum
• Colour - Inflammation
• Mass - Size, shape, number, bleeding, discharge, fungation, ulceration
Palpation
• Mass - Size, shape, number , friability, mobility, consistency
Clinical Examination

DiagnosticWorkup
23
• Radiographic –
• Fiberoptic endoscopic examination (after mucosal
decongestion) with biopsies
• CT/MRI of the primary site and neck
• Chest x-ray; X-ray PNS, CT thorax if adenoid cystic or
neuroendocrine carcinoma
• CT:
• 85% accuracy.
• Good for bone erosion in orbital walls, cribriform plate, fovea
ethmoidalis
• Difficult to see periorbital involvement, differentiate tumor,
inflammation and secretions.

DiagnosticWorkup
24
• MRI:
• 94% accuracy
• As a single modality gives more information than CT
• Good for :
Fluid vs inflammation vs tumor
Perineural spread, involvement of cranial nerve foramens &
canals
Intracranial or leptomeningeal spread
Skull base erosion
Better visualize lesions involving the cribriform plate,
basisphenoid and floor of middle cranial fossa
Orbital involvement

DiagnosticWorkup
25
• X-ray PNS
Opacification of sinuses
Soft tissue mass
Bony erosion / destruction
Site of origin
Water’s (Occipitomental) view - maxillary antrum, portion of
sphenoid, oblique portion of frontal sinus, anterior ethmoid
Caldwell (Occipitofrontal) view – frontal, posterior ethmoid
Lateral view – sphenoid sinus

AJCCTNM Staging
26
AJCC Cancer Staging Manual, 8th ed.
• No change from the seventh edition
• Maxillary Sinus :
T
cate
gory
T criteria
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor limited to maxillary sinus
mucosa with no erosion or
destruction of bone

AJCCTNM Staging
27
T
categ
ory
T criteria
T2 Tumor causing bone erosion or
destruction including extension into the
hard palate and/or middle nasal meatus,
except extension to posterior wall of
maxillary sinus and pterygoid plates

AJCCTNM Staging
28
T T criteria
T3 Tumor invades any of the following:
• Bone of the posterior wall of
maxillary sinus,
• Subcutaneous tissues,
• Floor or medial wall of orbit,
• Pterygoid fossa,
• Ethmoid sinuses

29
T
categ
ory
T criteria
T4a Moderately advanced local disease
Tumor invades anterior orbital contents,
skin of cheek, pterygoid plates,
infratemporal fossa, cribriform plate,
sphenoid or frontal sinuses

30
T T criteria
T4b Very advanced local disease
• Tumor invades any of the
following: orbital apex,
• dura,
• brain,
• middle cranial fossa,
• cranial nerves other than
maxillary division of trigeminal
nerve (V2),
• nasopharynx, or
• clivus
M
category
M criteria
M0 No distant metastasis
M1 Distant Metastasis

31
• Nasal Cavity and Ethmoid Sinus :
T
cate
gory
T criteria
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor restricted to any one
subsite, with or without bony
invasion

32
T
cate
gory
T criteria
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

33
T
cate
gory
T criteria
T3 Tumor extends to invade the
medial wall or floor of the orbit,
maxillary sinus, palate, or
cribriform plate

34
T
cate
gory
T criteria
T4a Moderately advanced local disease
Tumor invades any of the following:
• Anterior orbital contents,
• Skin of nose or cheek,
• Minimal extension to anterior
cranial fossa,
• Pterygoid plates,
• Sphenoid or frontal sinuses

35
T category T criteria
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

RegionalLymphNodes
36
N
category
Clinical N criteria (cN) Pathological N criteria (pN)
Nx Regional lymph nodes cannot be
assessed
Regional lymph nodes cannot be
assessed
N0 No regional lymph node
metastasis
No regional lymph node metastasis
N1 Metastasis in a single ipsilateral
lymph node, 3 cm or smaller in
greatest dimension and ENE (-)
Metastasis in a single ipsilateral
lymph node, 3 cm or smaller in
N2a Metastasis in a single ipsilateral
lymph node, larger than 3 cm but
not larger than 6 cm in greatest
dimension and ENE (-)
Metastasis in a single ipsilateral
lymph node, larger than 3 cm but not
larger than 6 cm in greatest
OR
Metastasis in a single ipsilateral or
contralateral node, 3 cm or smaller in
greatest dimension and ENE (+)

37
N
category
Clinical N criteria (cN) Pathological N criteria (pN)
N2b Metastasis in multiple ipsilateral
lymph nodes, none more than 6
cm in greatest dimension and
ENE (-)
Metastasis in multiple ipsilateral
lymph nodes, none more than 6 cm in
N2c Metastasis in bilateral or
contralateral lymph nodes, none
more than 6 cm in greatest
Metastasis in bilateral or contralateral
lymph nodes, none more than 6 cm in
N3a Metastasis in a lymph node,
Metastasis in a lymph node, larger
than 6 cm in greatest dimension and
ENE (-)
N3b Metastasis in any lymph node(s)
with clinically overt ENE (+)
Metastasis in any lymph node(s) with
clinically overt ENE (+)
OR
Metastasis in single ipsilateral node,
dimension and ENE (+)
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)

AJCCPrognosticStageGrouping
38
T N M Stage
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

• Most commonly used is the modified Kadish staging
Stage Group Description
A Confined to nasal cavity
B Extends into the paranasal sinuses
C Extends beyond the nasal cavity and paranasal sinuses
including involvement of the cribriform plate, skull
base, orbit, or intracranial cavity
D Nodal/ Distant Metastasis
39
Stagingof esthesioneuroblastoma

• T1-2N0
• Resection → post-op RT for close margin, PNI, adenoid
cystic ca.
• For + margin, re-resect (if possible) → post-op RT
• T3-4N0
• Resectable: Resection → post-op RT or chemo-RT
• Unresectable: Definitive RT or chemo-RT
• Concurrent chemo for margin positive ,ECE/PNI
40
Treatmentof SinonasalCarcinoma

• N+
• Resection + neck dissection → post-op RT or chemo-RT.
• Alternatively, definitive chemo-RT
• Elective Nodal Irradiation
• In T3/T4 tumors, Histology: Squamous cell Ca or
Undifferentiated carcinomas
• Level Ib, II and Retropharyngeal LNs are included.
41
Treatmentof SinonasalCarcinoma

• Kadish A
• Surgery / RT alone
• Adjuvant RT is indicated in close and positive margins or with
residual disease
• No adjuvant chemotherapy
• Kadish B
• Surgery followed by adjuvant RT
• Kadish C
• Craniofacial resection  post op chemoradiation
• NACT -> surgery (craniofacial resection)  post op
chemoradiation or
chemoradiation (unresectable cases)
• Kadish D
• Systemic chemotherapy and palliative RT to local and metastatic
sites
42
Esthesioneuroblastoma

• AIM : 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.
• 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 outcome
43
Surgery

• Surgical approaches:
• Endoscopic
• Lateral rhinotomy
• Transoral/transpalatal
• Midfacial degloving
• Combined craniofacial
approach
• Unresectability:
• extension to frontal
lobes
• invasion of prevertebral
fascia
• bilateral optic nerve
involvement
• cavernous sinus
extension
44
Surgery

• Maxillary Sinus
• Early infrastructure lesions may be excised and cured by surgery
alone
• Extension of cancer to the base of the skull, nasopharynx, or
sphenoid sinus contraindicates surgical excision.
• If the floor of the orbit is free of disease, then the eye and the orbital
rim may be left undisturbed.
• If there is involvement through the floor of the orbit, then a
maxillectomy with resection of the orbital floor with or without an
orbital exenteration must be performed.
• If the posterior wall or the pterygoid plates are involved, they too
must be included in the resection.
45
Surgery

• Ethmoid Sinus
• Lesions are usually extensive when first diagnosed.
• Localized lesions require resection of the ethmoids and the
ipsilateral maxilla and orbit.
46
Surgery

ORBITAL EXENTERATION
• Involvement of periorbita without intra orbital extension
orbital preservation
• Orbital involvement – orbital exenteration
ROLE OF NECK DISSECTION
• Not practiced routinely
• With palpable LNs – ipsilateral neck dissection
OrbitalExenterationand Neck Node
Dissection

• Complications of maxillectomy include failure of the split-
thickness skin graft to heal, trismus, CSF leak, infection and
hemorrhage.
• Complications of ethmoid sinus surgery include hemorrhage,
meningitis, CSF leak, cellulitis and pansinusitis, brain abscess,
and stroke.
• Complications of the craniofacial procedure include meningitis,
subdural abscess, CSF leak, diplopia, and hemorrhage
48
Surgery: Complications

• Definitive:
• Medically inoperable or who refuse radical surgery or early
lesions
• Adjuvant: standard of care
• High risk features, close or positive margin, ECE/PNI
• Palliative
• Metastatic disease
• Postoperative radiation therapy is started 4 to 6 weeks after
surgery.
49
Radiotherapy: Indications

• Objective:
• To attain adequate tumor coverage
• Deliver uniform dose distribution throughout target volume
• Minimize doses to normal tissue
• Head Immobilization: with thermoplastic mask fixed to the couch
• Shoulders: positioned as caudally as possible
50
Radiotherapy: Planning and Simulation

• Eyes open, straight ahead to keep posterior pole away from high
dose region
• Tongue blade/cork to depress tongue out of fields
• Fill surgical defects with tissue equivalents to reduce dose
heterogeneity
• For Post Operative Patients: all surgical scar, drain sites, and stoma
should be wired on skin
51
Radiotherapy: Planning and Simulation

• Small, well-differentiated lesions measuring  1.5 cm  small fields
with a 1- to 2-cm margin are appropriate.
• All poorly differentiated tumors and well- differentiated primaries
of >1.5 -2 cm without palpable lymphadenopathy  includes both
nasal vestibules with at least 2- to 3-cm margins around the
primary tumor (wider margins for infiltrative tumor) as well as
bilateral facial, submandibular, and subdigastric nodes.
• Position: supine, neck slightly flexed to align anterior surface of
maxilla parallel with the top of the couch
53
Radiotherapy

• Anterior Portal
• Superior- bridge of the nose or higher in large tumor
• Inferior- depends on extent of upper lip invasion( from mid
upper lip to vermillion border)
• Lateral portals- about 1 cm lateral to ala nasi
• Used when tumor size is > 1.5-2 cm
• Anterior right and left appositional electron fields (usually with
an approx. 15-20 degree) are used to treat facial lymphatics.
54
Borders

• Lateral Portals
• Medial - lateral border of
anterior field
• Anterior - oral
commissure to middle of
horizontal ramus of
mandible
• Posterior - upper edge of
anterior field to just above
angle of mandible
• Inferior - split horizontal
ramus of mandible and
adjoins the upper neck
field
• The combination of all three
fields is known as moustache
field
55
Borders

• Upper neck field portal
• Used for tumor > 1.5 -2 cm in size
• Upper neck node are treated by parallel opposed photon field.
• Anterior - 1 cm fall off
• Posterior - just behind mastoid process
• Superior - matched to moustache field
• Inferior - just above arytenoid
56
Borders

• Small lesions- (<1.5-2 cm) – combination of electrons and photons -
50 Gy in 25 # f/b 10-16 Gy boost in 5 to 8 # (prescribed at 90%
isodose line)
• Larger lesions- 50 Gy in 25 # f/b 10-16 Gy boost by EBRT + elective
treatment to facial (moustache area) and upper node ( 50 Gy)
• Palpable neck node receive a total dose of 66-70 Gy
• Post – op : volume is reduced off the undissected nodal regions
after 50 Gy to deliver an additional 6 Gy to the surgical bed f/b
• 4 Gy to pre-op tumor bed = total 60 Gy
• 10 Gy to pre-op tumor bed in limited excision or positive margins
– total 66 Gy 57
Dose

• Criteria –
• lesions of nasal cavity and external nares
• lesions on the septum or the mucosa medial to ala nasi – distal 1/3 of
nasal cavity
• Preferable for relatively smaller lesion.
• Using Ir 192 wire implant or intracavitary mold.
• Recommended dose
• LDR: 60-65 Gy over 5-7 days
• LDR Boost: 20-25 Gy over 2 days [After EBRT 50 Gy] – median overall
treatment time of 36 days
• HDR : 18 Gy @ 3Gy/# , 2#/d
• Dose prescription:
• 0.5 cm lateral to the tumor for lateral nasal vestibule
• At the center of the tumor for tumors of the septum
58
Brachytherapy

• Yields a 2-year local control of 86% and ultimate LRC of 100%
59
Mazeron JJ et al the Groupe Europeen de Curietherapie. Radiother Oncol 1988;13:165-173
Brachytherapy
Ir-192 wire implant

• Retrospective multicentric analysis
• 1,676 pts of carcinomas of the skin of the nose and nasal vestibule
treated by brachytherapy or external-beam irradiation
• The overall local control rate was 93%.
• Local control was dependent on
• tumor size
• <2 cm, 96%;
• 2 to 3.9 cm, 88%;
• >4 cm, 81%)
• site (external surface 94%; vestibule 75%)
• new versus recurrent tumors (95% vs 88%).
• Local control was independent of histology for tumors <4 cm
• For those >4 cm, basal cell carcinomas were more frequently
controlled than were squamous cell carcinomas.
• There were few complications (necrosis, 2%).
• The local control rate with surgery was approximately 90%.
Mazeron JJ et al the Groupe Europeen de Curietherapie. Radiother Oncol 1988;13:165-173.
FrenchGroupe Europeende Curietherapie

63
Gunderson’s Clinical Radiation Oncology, 4th ed.

Both halves of nasal cavity
Ipsilateral maxillary sinus
Ethmoid sinus and ipsilateral medial orbital wall – if the tumor
extends superiorly into the ethmoid cells
TargetVolumes

• Supine
• Head – slightly
hyperextended
 to bring the floor of the
orbit parallel to the axis of
the field
• Intraoral stent – to open
mouth & depress tongue
• Orbital exenteration defect or
palatal resection defect
filled by a water filled
balloon or tissue
equivalent material to
compensate for tissue
defect
PatientSetup

• Technique – anterolateral wedged pair
fields (45˚ W)
• Anterior field
Sup – supraorbital ridge
Inf – angle of mouth
Med – medial canthus of opp eye
Lat – fall off at edge of face
• Lateral field (5˚ inferior tilt)
Sup & Inf – matched with ant field
Ant – lateral canthus
Post – tip of mastoid
Suprastructure: Borders

Tumorsof Suprastructureand Ethmoid
• Technique – 3 field ( 1 ant & 2
lat)
• Lat fields - 5˚ inf tilt & 60˚ W
• Field weightage
Co- 60  1 : 0.5 : 0.5
6-10 MV  1 : 0.15 : 0.15
Anterior field
Sup – above crista galli to
cover ethmoids
Inf, lat , medial – same
Lateral fields
Sup – floor of anterior cranial
fossa
Inf, lat, post - same

Eye shielding
• Complete eye shielding
No involvement of orbital
floor/ globe
• Partial eye shielding
Involvement of orbital
floor
Pencil shield is used 
covers cornea
• No eye shielding
Involvement of globe
Asked to keep eyes open &
look straight
Spares cornea
Lacrimal shielding
In pts with limited orbital
involvement
Eye and LacrimalShielding

• Technique – anterolateral wedge pair
technique (45˚W)
• Anterior
Sup – just above floor of orbit, just
below cornea
Inf – 1 cm below floor of sinus or
below surgical bed
Med – 1-2 cm across midline
Lat – falling off
• Lateral (5˚ inferior tilt)
Sup & inf – matched with anterior
fields
Ant – just behind lateral canthus
Post – behind pterygoid plates/ tip of
mastoid
Tumorsof Infrastructure

• Technique – lateral opposed fields
• Lateral field borders – same
• Tilts –
5˚ inferior tilt from ipsilateral side
5˚ superior tilt from contra side
• Isocenter is placed at the orbital floor & half beam block is used
to prevent beam divergence
Tumorsof Infrastructurespreading across
the midline

• Upfront radiotherapy
• 50 Gy in 25 # to initial target volume
• 16 to 20 Gy in 8-10 # to the boost volume
• Post op Radiotherapy
• Dose 60 Gy in 30 # for -ve margin
• 66 Gy in 33 # for +ve margin
• Gross residual disease- 70 Gy
71
Dose

72
Khan’s Physics of Radiation Therapy, 5th edition

73
Isodose distribution for two angled beams without and with wedges
4 MV, 10 X 10 cm2 ,SSD 100 cm, wedge angle 45o, each beam weighted 100 at Dmax
Wedge pair technique creates a hot spot (acceptable upto 10%) within the
treatment volume under the thin edges of the wedge and is suitable for tumors 0 to
7 cm deep.
Most desirable feature is the rapid dose fall off beyond the region of overlap
Khan’s Physics of Radiation Therapy, 5th edition

• I/L upper neck irradiation given to patient with squamous cell
carcinoma or undifferentiated carcinoma, and in stage T3 to T4
• Using appositional electron field (12 MeV)
• Borders- lateral portal
• Superior- sloping up from the horizontal ramus of the mandible
to the inferior border of primary portals posteriorly
• Anterior- just behind oral commissures
• Posterior- At the mastoid process
• Inferior– Thyroid notch
• B/L neck node treatment indicated with palpable nodes
74
Neck Node

Nasal Cavity and Ethmoid Sinus

• If the ethmoid sinuses are extensively involved but there is no
clinical or radiographic evidence of orbital involvement, a portion
of the orbit (one-half to three-fourths) is usually irradiated to
approximately 45 Gy for possible microscopic disease extension.
• Portals are then reduced to transect the ipsilateral eye medial to
the limbus.
• This technique usually prevents severe lacrimal or retinal injury,
but does produce a cataract
76
EthmoidSinus Fields

• Advanced orbital invasion requires irradiation of the entire orbital
contents and ethmoid sinus lesions.
• The inferior border must be shaped to cover the lowest extent of
disease.
• If the temporal fossa is grossly invaded, the lateral border of the
anterior portal is usually allowed to fall off for all or part of the
treatment.
• The lateral portals for ethmoid is same as nasal cavity and
maxillary sinus lesions.
77
EthmoidSinus Fields

Post-op RT
50 Gy/25 # / 5 weeks to initial target volume
Boost – 10 Gy/ 5# (-ve margins) ; 10-16 Gy/ 5-8 # (+ve margins)
Definitive RT
50 Gy/ 25 #/ 5 weeks to initial target volume
Boost – 16-20 Gy/ 8- 10 #
Pre-op RT
50-60 Gy/ 25-30 #
Palliative RT
30 Gy/10 # , 20 Gy/ 5#, 8 Gy/ SF
Doses

79
NasalCavityand EthmoidSinus Fields
A. Unilateral ethmoid/nasal cavity involvement
B. Field for ethmoid/nasal cavity tumor with spread to the ipsilateral
maxillary antrum

80
NasalCavityand EthmoidSinus Fields
C. Portal for ethmoid/nasal cavity tumor with invasion of the maxillary antra
bilaterally
D. Portal for bilateral ethmoid/nasal cavity tumor or involvement of sphenoid
sinus (with left corneal eye block)

Why?
• Irregular shaped tumors
• Close proximity to radiosensitive normal tissues
Retina, optic nerve, optic chiasma, brain, brain stem
Advantages
Better target coverage
Dose homogeneity
Dose escalation
Sparing of normal critical structures
ConformalRT and IMRT

• GTV
• CTV1 - primary tumor bed with 1.0- to 1.5-cm margin of
normal tissue.
• CTV2 - operative bed, including the bony orbit after orbital
exenteration and the ethmoid, frontal, or sphenoid sinuses if
explored during surgery.
• CTV3 – encompass the tract of cranial nerve V2 to the foramen
rotundum if perineural invasion is present.
• CTVHR - may also be outlined to cover, for example, gross
macroscopic residual tumor or positive margins to which a
higher dose may be delivered
82
IMRT

Definitive RT
Target Description Dose (33-35#)
GTV Gross tumor volume 66-70 Gy
CTV1 (primary CTV) GTV + 1- 1.5 cm 66-70 Gy
CTV2 (intermediate dose
CTV)
CTV1 + 1-1.5 cm 59-63 Gy
CTV3 (elective CTV) Nodal volume, nerve tract , BOS
margin
56-57 Gy
Post-op RT (adjuvant RT)
Target Description Dose (30 #)
CTV – HR Suspected +ve margin ; residual 66-70 Gy
CTV 1 (primary CTV) Tumor bed + 1-1.5 cm 60 Gy
CTV2 (intermediate dose
CTV)
Surgical bed 56 Gy
CTV3 (low dose CTV) Tract of V2 if perineural invasion +nt ;
BOS margin ; elective nodal (if
indicated)
54 Gy
IMRT

EVIDENCE
• N = 81, period 2003-2008
• 40 patients with cancer of the paranasal sinuses (n = 34) or nasal cavity
(n = 6) received postoperative IMRT to a dose of 60 Gy (n = 21) or 66 Gy
(n = 19).
• Retrospectively compared with that of a previous patient group (n = 41)
who were also postoperatively treated to the same doses but with three-
dimensional conformal radiotherapy without intensity modulation.
• Median follow-up was 30 months (range, 4–74 months).
• Two-year local control, overall survival, and disease-free survival were
76%, 89%, and 72%, respectively.
84
doi:10.1016/j.ijrobp.2009.09.067

85
Compared to the three-dimensional conformal radiotherapy
treatment, IMRT resulted in significantly improved disease-free
survival (60% vs. 72%; p = 0.02).

86
No grade 3 or 4 toxicity was reported in the IMRT group, either
acute or chronic.

• Includes Proton therapy and Heavy ions like Carbon Ion therapy (CIT)
• These have high LET, which increases steadily from the point of
incidence with increasing depth to reach a maximum in the peak
region.
• Less dose is delivered to tissues proximal to the tumor and rapid
dose fall off at the distal edge of the tumor (Bragg-Peak effect).
• Advantage
• Dose escalation
• Minimizing exposure of normal tissues and decreasing toxicity
• Useful for deep-seated tumors.
• High biological efficiency (RBE): Effective in relatively radioresistant
cancers (Carbon Ions)
87
ParticleTherapy

88
energy loss of ionizing
radiation during its travel
through matter
SOBP: combining protons of
different energies, scanning
techniques

89
IMPT Plan:
Colors depict the
high-dose area on
the gross tumor
and the mid-dose
area on the
clinical target
volume.

• Use of particles more massive than protons or neutrons, such
as carbon ions.
• Higher biological efficiency by a factor 1.5-3:
• Role in radioresistant tumors such as adenocarcinoma, adenoid
cystic carcinoma, malignant melanoma and sarcoma
• Due to the higher density of ionization, more DNA damage in cancer
cells
• Disadvantage: Beyond the Bragg peak, the dose does not decrease to
zero. since nuclear reactions between the carbon ions and the atoms of
the tissue lead to production of lighter ions which have a higher range.
Therefore, some damage occurs also beyond the Bragg peak.
90
HeavyIon Therapy

91
CIT plans often show a better dose distribution than the PT plans in head and neck patients due to the
better penumbra, which could lead to less toxicity
CarbonIon Therapy

ACUTE MORBIDITY
• Fatigue
• Dermatitis, Skin erythema
• Mucositis – nasal > oral
• Xerostomia
• Conjunctivitis, epiphora,
blurring of vision
• Alopecia
• Raised ICT
LATE MORBIDITY
• Late skin effects – erythema,
fibrosis, telangiectasia
• Atrophic mucositis – septal
perforation
• Cataract, dry eye syndrome, optic
neuritis, Chronic keratitis
• Xerostomia
• Facial asymmetry
• Osteoradionecrosis
• Second malignancies
• Neuro endocrine
abnormalities(Hypopituitarism)
92
Toxicities

93
DoseLimitations
• 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 ≤ 70Gy or 1cc PTV not more than 75Gy
• (osteoradionecrosis)
• Parotid mean dose <26 Gy
• Lacrimal gland <30–40 Gy
• Pituitary and hypothalamus mean dose <40 Gy

• Chronic keratitis and iritis (dry-eye syndrome ) : If tumor extension to the
orbital cavity mandates irradiation of the lacrimal gland to doses of more
than 30 to 40 Gy .
• Without lacrimal irradiation, fewer than 20% of patients treated with up
to 55 Gy to the cornea develop chronic corneal injury .
• There is an approximately 5% risk (at 5 years) of cataract formation after
doses of up to 10 Gy to the lenses using conventional fractionation; this
risk increases to 50% at 5 years after 18 Gy.
• Radiation retinopathy is rare after doses of less than 45 Gy, but the
incidence increases to about 50% after doses of 45 to 55 Gy .
• The reported incidence of optic neuropathy is <5% after 50 to 60 Gy but
increases to around 30% for doses of 61 to 78 Gy 94
Sequelae

95
Followup and Recurrence
• Follow up
• Every 4 months for first three years
• Every 6 months for fourth and fifth year
• Annually for life
• Recurrence :
• Salvage surgery after primary radiation
• Salvage radiation after primary surgery
• Cumulative doses of radiation to neural tissues, namely, spinal
cord, brainstem, brain, optic structures are the main limitation
to re-irradiation

97
• Accurately delivers a high irradiation dose to an extracranial target in
one or few treatment fractions.
• Nearby tissues are affected as little as possible.
• Main advantage over IMRT: Shortened treatment time.
• SRS: Intracranial target, usually gives the whole radiation dose in one
session.
• Offers high biological equivalent dose
• Main problem is complex planning
SBRT

98
• Delivery systems:
• Robotic based Cyber Knife
• Gamma Knife
• LINAC Based
SBRT

106
Demizu et al.
Particle therapy for mucosal melanoma of the head and neck:
A single-institution retrospective comparison of proton and carbon ion therapy
Protonversus CarbonIon Therapy

• 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 years OS (51 vs. 62%), RFS, LRC, DM between
the two groups
• Advanced age, need for enucleation, and positive margins were
independent predictors of worse OS
108
Bristolet al :
Bristol IJ, IJROBP; 2007; 68:719-730

• 73 primary and 11 locally recurrent sinonasal tumors
definitively treated by IMRT.
• Median dose of 70 Gy in 35 fractions
• 64 % patients had adenocarcinoma histology, squamous cell
carcinoma in 17%, esthesioneuroblastoma in 9%, and adenoid
cystic carcinoma in 4%.
• The tumors were located in the
• ethmoid sinus in 47%,
• maxillary sinus in 19%,
• nasal cavity in 16%,
• multiple sites in 2%.
Intensity-Modulated Radiotherapy for Sinonasal Tumors: Ghent University Hospital Update
Madani et al : IJROBP2009

• Postoperative IMRT was performed in 75 patients and 9 patients
received primary IMRT
• No chemotherapy was given.
• Median follow-up 40 months - with 5-year LRC, OS, DFS were 71,
58, and 59%, respectively
• No difference was found in local control and survival between
patients with primary or recurrent tumors.
• On multivariate analysis, invasion of the cribriform plate was
significantly associated with lower local control (p = 0.0001) and
overall survival (p = 0.0001
Madani et al : IJROBP2009
Intensity-Modulated Radiotherapy for Sinonasal Tumors: Ghent University Hospital Update

113Chen et al. IJROBP 2007. RT in PNS: Are we making improvement?
ConventionalRT vs 3DCRT vs IMRT

115
Dagan et al. Outcomes of Sinonasal Cancer Treated With Proton Therapy. IJROBP 2016
ProtonTherapy

117CONVENTIONAL RT 3D-CRT
Dose Distribution
Mock et al. Treatment planning comparison of conventional, 3D conformal, IMRT and proton therapy for paranasal
sinus carcinoma.

118
IMRT PROTON-BASED
Dose Distribution
sinus carcinoma.

119
CRT vs 3DCRTvs IMRT vs Protontherapy
sinus carcinoma.

• Ethmoid sinus and sphenoid sinus
• Both are examined by anterior and posterior rhinoscopy
as both open into lateral nasal wall.
• Ethmoid sinus is additionally examined by palpation over
medial wall of orbit upto root of nose.

• Maxillary sinus
• Inspection and palpation
• Note the soft tissue of cheek, lip, eye
lid and molar region. Also orbit with
contents
• Also inspect the vestibule of mouth,
upper alveolus, teeth, palate and the
nose and nasal cavity.
• Look for any fistula, proptosis, diplopia

• Frontal sinus
• Inspection, palpation of
the forehead
• Root of nose
• Orbital margin and orbit

Water’s (occipitomental)
Caldwell’s (occipitofrontal)
- Frontal sinus
Characterization
of frontal,
maxillary
pathology.
- Sphenoid sinus
- Most commonly used
- Maxillary, frontal &
anterior ethmoidal
sinuses.
123
X-raysof the ParanasalSinuses

Normal
Lateral
View
Normal
Calwell’s
view
Water’s View
- Rt Maxillary sinusitis
124

125
Mold brachy: A custom mold of
the nasal vestibule is made and
2-4 plastic tubes (1.0-cm apart)
inserted in the mold alongside
the tumor.
Brachytherapy

• Nasal cavity synechiae can be prevented by intermittent dilation of
the nasal passages with a petroleum based jelly-coated cotton swab
until mucositis has resolved.
• Dry mucosae can be managed symptomatically with saline nasal
spray.
• Oro-dental hygiene
• Exercises to reduce trismus
• Prophylactic feeding tubes
126
Precautions

• Ophthalmic review and Lubricating eye ointments
• If there is a pre-existing facial nerve palsy, the eyelid should be taped
shut at night to avoid a dry eye.
• Pituitary function tests should be carried out annually during follow-
up to evaluate late radiotherapy effects to the pituitary gland.
• Xerostomia can be an acute as well as late effect and can de
decreased by administering Amifostine.
127
Precautions

Management of sinonasal tract tumors 27082018

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