Management Carcinoma Nose & PNS

1. Management overview in
carcinoma of Nasal cavity
and Paranasal Sinuses
By – Dr. Satyajeet Rath
Moderator – Prof. Kamal Sahni

2. Lymphatics
• Lymphatics of frontal, ethmoid and maxillary sinuses – sparse,
connect with those of nasal cavity
• Once tumour has extended beyond PNS – Increased nodal
incidence
• Incidence of LN involvement -
• 10-15% for maxillary & ethmoid sinus
• 5-10% for nasal cavity

3. Histologic subtypes
• SCC (80-85%)
• Adenoca (adenocystic ca)
• Malignant melanoma
• MFH
• Sarcoma –Osteogenic sarcoma, RMS
• Lymphoma, extramedullary plasmacytoma
• Esthesioneuroblastoma
• Metastatic
• TCC
• Benign variants – angiofibroma, lethal midline granuloma

4. Treatment options
• Surgery
• Radiotherapy
• Surgery + adjuvant Radiotherapy
• Concurrent chemo radiotherapy
• Neo adjuvant chemotherapy

5. 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

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

7. Inferior medial
maxillectomy
Medial maxillectomy
Radical maxillectomy with
exentration
Cranio-facial resection

8. Ethmoid sinus
• Ethmoid sinus lesions are usually extensive when first diagnosed.
• Localized lesions require resection of the ethmoids and the ipsilateral maxilla
and orbit.
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.

9. Surgery complication
• 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

10. Radiotherapy
• Addition of RT to surgery improves 5-years survival when compared to RT alone
or surgery alone.
Indications:
• Adjuvant (standard of care).
• Definitive: medically inoperable or who refuse radical surgery
• Pre- and postoperative radiation may result in similar control rates.
• But post-operative RT prefered:
• Preoperative radiation increases the infection rate and the risk of post-
operative wound complications.
• Preoperative radiation may obscure the initial extent of disease surgery
can not remove the microscopic extensions of the tumor.
• Postoperative radiation therapy is started 4 to 6 weeks after surgery.

11. Indications for postoperative radiation therapy include
• Positive or close margins,
• Extracapsular extension,
• Perineural invasion,
• Advanced T stage
• Multiple cervical metastases
Post op radiotherapy dose
• - ve margin – 60 Gy in 30 #
• +ve/close margin - 66 Gy in 33 #
• Gross residual disease – 70 Gy in 35 #

12. Bristol et al. (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 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.
Bristol IJ, IJROBP;68:719-730.

13. Role of chemotherapy
• Neoadjuvant chemotherapy is sometimes offered in order to
reduce tumor volume, which may permit removal of tumor with a
less morbid resection or facilitate radiotherapy planning if shrinkage
pulls away tumor from critical structures.
• Chemotherapy may be given concurrent with radiotherapy in the
management of inoperable tumors on the basis of improved results
in more frequent head and neck carcinomas.
• Some recent studies give encouraging results for NACT for Ca PNS

14. Radiotherapy

15. Treatment Planning
OBJECTIVE :
• To attain adequate tumor coverage
• Deliver uniform dose distribution throughout target volume
• Minimize doses to normal tissue

16. Simulation
• Position: supine, straight , head extended
• Head Immobilisation: with thermoplastic mask fixed to the couch
• Shoulders :positioned as caudally as possible
• 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
• Preferably CT based RTP scan with 3mm cuts to accurately define GTV
• Image should be taken from above the calvarium to the carina
• IV contrast should be used to help delineation
• For Post Operative Patients: all surgical scar, drain sites, and stoma should be
wired on skin

17. Nasal Vestibule
• Radiation therapy is usually the preferred treatment because of the deformity
produced by excision.
• Nasal cavities are filled with bolus during simulation and treatment to reduce
dose heterogeneity
• Target Volumes for small, well-differentiated lesions measuring
< 1.5-2 cm, small fields with a 1- to 2-cm margin are appropriate.
• The initial target volume for 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.

18. Borders- Anterior Portals
• 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

19. Lateral Portals
• 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.
• 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

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

21. Dose
• Small lesions- (<1.5-2 cm)- 50 Gy in 25 # f/b 10-16 Gy
boost by EBRT
• 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

22. Nasal septum tumor
may be treated using a
customized bee wax
and lead skin
collimation.
Mixed electron and
photon beams being
used in 3-5:1 ratio.

23. Brachytherapy
Criteria –
1. lesions of nasal cavity and external nares
2. lesions on the septum or the mucosa medial to ala nasi –
distal 1/3 of nasal cavity
3. Preferable for relatively smaller lesion.

24. Role of Brachytherapy
• For small lesions of nasal vestibule.
• Using Ir 192 wire implant or intracavitary mold.
• The recommended doses for low-dose-rate brachytherapy range
from 60 to 65 Gy delivered during 5 to 7 days.
• In patients with T1 or T2 a boost of 20 to 25 Gy (LDR) over 2 days
or 18 Gy (HDR; 3 Gy twice daily), following EBRT after 50 Gy, if
there is good reduction of tumor volume.
• This technique has been reported as yielding a 2-year local control
of 86%.
Mazeron JJ et al the Groupe Europeen de Curietherapie. Radiother Oncol 1988;13:165-173.

25. • Either brachytherapy or external-beam radiotherapy cures up
to 95% to 100% of small (up to 2 cm) tumors.
• When adequate doses of radiation are used, 70% to 80% of
lesions >2 cm can be controlled.
• As many as 40% of patients with larger lesions who do not
receive elective nodal irradiation will fail in the neck, most
can be salvaged and ultimate regional control is excellent.

26. Nasal Cavity
• 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
• If combined treatment is planned operation first followed by irradiation is
started 4 to 6 weeks afterward.
• The dose is usually 60 to 66 Gy for clear margins; patients with positive
margins or for gross residual tumor after operation receive 70 Gy.
• In altered fractionation dose upto 74.4 may be given(twice daily at 1.2 Gy
per fraction)

27. Ethmoid Sinus Ca Radiotherapy
• Radiotherapy is indicated in medically inoperable disease or in post op
setting With/Without chemotherapy
• Radiation treatment is entirely by external beam, emphasizing treatment
through an anterior field combined with one or two lateral fields.
• 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
• IMRT should be considered if a more conformal dose distribution can be
achieved with this technique.

28. Maxillary Sinus Carcinoma
Patterns of tumour spread
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

29. Maxillary sinus Tumors
• Surgery is preferred treatment in T1 and T2 tumors with post op
RT indicated if margin is close or positive.
• Surgery f/b post op RT is preferred in T3 and T4 lesions
• Medically inoperable or where there is contraindication for
surgery upfront RT can be given .

30. Maxillary sinus tumor
Tumor of infrastructure
• Anterior and I/L wedge pair photon fields are usually
used
• Borders- Anterior portals
• superior– just above floor of orbit below the cornea
• Lateral– 1 cm beyond the lateral wall of maxillary sinus
• Medial – 1-2 cm across midline
• Inferior– 1 cm below floor of maxillary
sinus or below surgical bed

31. Infrastructure
Maxillary sinus tumor
• Latreral portals border:
• Superior and inferior same as anterior Portal
• Anterior – in front of anterior wall
• Posterior- behind the pterygoid plates or more posteriorly
depending on the extent of tumor spread
Use of half beam block with isocenter at the level of orbital
floor and shielding upper half of field prevent exposure to C/L
eye by beam divergence.
• Three field technique with Rt and Lt lateral portals and anterior
portal are preferred in these cases

32. Three field technique -Tumor of suprastructure
Borders - anterior portals
• Superior – Above crista galli to cover ethmoids
In the absence of orbital invasion at lower
edge of cornea
• Inferior –1 cm below the floor of the maxillary sinus or
below surgical bed
• Medial– 1 to 2 cm across midline to cover C/L ethmoid
extension
• Lateral – Depend on tumor extent
1 cm beyond lateral
orbital wall when the
structure is intact

33. Lateral portals
• Superior – Follows the contour of floor
of ant. Cranial fossa
• Inferior – same as anterior portals
• Anterior - Behind lateral bony canthus parallel to slope
of face
• Posterior– Behind the Pterygoid plates or more
posteriorly depending on extent of spread
or surgey
For boost The portal size is reduced to encompass the tumor bed
and to exclude as much of optic pathway as possible.

34. Neck node
• I/L upper neck irradiation given to patient with
squamous cell carcinoma or undifferentiated stage T3
to T4
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

35. Dose
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

36. Ethmoid sinus and Nasal cavity
• Most patient are treated with surgery and post operative
radiotherapy
• Post op radiotherapy techniques are same for ethmoid sinus
and suprastructure of maxillary sinus.
• It includes 3 field technique with 1 anterior and 2 lateral
fields

37. Anterior Portals
• The anterior portal extends 1.5 to 2.0 cm across the midline to encompass
the entire nasal cavity and ethmoid-sphenoid complex and medial
contralateral orbit.
• The superior margin encompasses the cribriform plate and includes all or
part of the frontal sinus.
• The inferior margin
(usually the lip commissure)
includes the floor of the nose,
maxillary antrum, and alveolar ridge
• The mandible and tongue are displaced
out of the treatment portal by a
tongue blade and cork

38. Lateral portals
• Superior – Follows the contour of floor
of ant. Cranial fossa
• Inferior – same as anterior portals
• Anterior - Behind lateral bony canthus
parallel to slope of face
• Posterior– Behind the Pterygoid plates or
more posteriorly depending on extent of
spread or surgey
For boost The portal size is reduced to
encompass the tumor bed and to exclude as
much of optic pathway as possible.

39. • 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.
• During treatment, the patient is instructed to gaze straight ahead
with eyes wide open. The lateral-gaze or upward-gaze eye
positions were discontinued because they rotate the posterior pole
of the eye and retina into the treatment portal.

40. • 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 nasal cavity, ethmoid, and maxillary sinus lesions
are all similar.
• The anterior border of the lateral portals is at the lateral bony canthus,
which means that a portion of the posterior pole of the ipsilateral
eyeball is included in the lateral fields; the contralateral globe is missed
because of the posterior angulation of the lateral portals.

41. U/L Ethmoid /nasal cavity
invovement
Ethmoid /nasal cavity tumor
with I/L maxillary sinus
invasion

42. Ethmoidal carcinoma
I – 45 degree wedge filtered portal at rt
angle
III- parallel opposed field with an anterior
field with wedge filters for tumors of
ethmoid, nasal cavity, sphenoid or antrum

43. Sphenoid and Frontal sinuses
• Cancers of this region is very rare
• Radiation is often offered as an adjunct to surgery.
• Frontline therapy in patients with inoperable tumor or with
tumor type thought to be chemo &/or radiosensitive.
• IMRT is preferred due to proximity to optic structures.

44. 3D - CRT
• For three-dimensional (3D) conformal radiotherapy,
the initial target volume is either Gross Tumor
Volume or for postoperative radiotherapy consists
of the surgical bed with 1- or 2-cm margins
• It depends on the surgical pathology findings and
the proximity of critical structures.
• The boost volume consists of areas at greatest risk
for recurrence, such as
• close or positive resection margins
• regions of perineural invasion
• with 1- to 2-cm margins.

45. Delineation
• Gross tumor volumes (GTV) – Includes all known
primary and cervical lymph node tumor extension based
on clinical, endoscopic and imaging findings.
• Clinical target volume (CTV) –
• HRCTV: GTV is expanded to include a margin for
microscopic extension forming high dose CTV.
• IRCTV: optional. Includes area adjacent to GTV at high
risk of having occult microscopic spread
• LRCTV: nodal regions at low risk for occult microscopic
spread included in a low-risk CTV
• Planning target volume (PTV)-CTV is expanded with 3-
7 mm margin to account for organ motion & setup error

46. Gross tumor target delineation
Target volume delineation : Nancy Y Lee

47. GTV and CTV for various maxillary sinus tumor

48. Nodal GTV delineation

49. T2 N0M0 ethmoid
sinus tumor
delineation
Maxillary sinus tumor
extending to nasal
cavity

50. • The external-beam radiation schedule is typically 50 Gy in 25
fractions followed by a boost of 10 to 16 Gy in 5 to 8 fractions .
• Larger lesions to be treated by external-beam radiation alone
receive 50 Gy in 25 fractions plus a boost of 16 to 20 Gy in 8 to
10 fractions.
• The schedule for elective nodal irradiation is 50 Gy in 25
fractions.
• Palpable nodes are given a boost to a total dose of 66 to 70 Gy in
33 to 35 fractions, depending on the size

51. IMRT
• Intensity-modulated radiotherapy (IMRT) is preferred for tumors of the
nasal cavity in which the target volume extends >5 cm depth or for tumors
of the ethmoid sinus .
• This technique delivers the desired dose to the target volume while
minimizing the dose to critical organs such as cornea, lens, lacrimal glands,
retina, optic nerve, optic chiasm, brain, and brainstem.
• For postoperative radiotherapy, the CTV1 consists of the primary tumor bed
with a 1.0- to 1.5-cm margin.
• A boost subvolume consisting of high-risk regions (sites of positive margins,
gross macroscopic residual tumor) to be treated to higher dose may be
outlined.
• The CTV2 includes the entire operative bed. For ethmoid sinus tumors, this
might include the frontal sinus, maxillary sinus, and sphenoid sinus.

52. • The bony orbit is part of the operative bed when orbital exenteration is
performed because of tumor invasion.
• For lesions involving the ethmoid sinuses or olfactory region, the CTV
should also include the cribriform plate.
• A third CTV may be delineated to encompass the tract of cranial nerve V2
to the foramen rotundum if there is perineural invasion.
• For primary radiotherapy using IMRT, the CTV1, consisting of the gross
tumor volume plus a margin of 1 to 2 cm, receives the full dose of 66 to 70
Gy.
• In patients receiving neoadjuvant chemotherapy, target volume definition
is based on the extent of disease before chemotherapy.

53. CTV or Maxillary Ca
Practical essentials of IMRT –K.S. Clifford Chao

54. Organ at risk delineation

55. 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 .
• Lacrimal gland <30–40 Gy.
• Pituitary and hypothalamus mean dose <40 Gy.

56. Toxicity
• Acute = mucositis, skin erythema, nasal dryness, xerostomia
• Late = xerostomia,
chronic keratitis and iritis
optic pathway injury
soft tissue or osteoradionecrosis
cataracts
radiation induced hypopituitarism

57. Toxicity
• The formation of nasal cavity synechiae (fibrous mucosal bands causing
airway stenosis)is common.
• It can be prevented by intermittent dilation of the nasal passages with a
petroleum based jelly-coated cotton swab until mucositis has resolved.
• Dry mucous membranes can be managed symptomatically with saline nasal
spray.
• Soft-tissue or cartilage necrosis is uncommon after therapy with an
estimated incidence of 5% to 10%

58. Eyes and Optic Pathway Toxicity
• 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.

59. Madani et al. (2009):
• 84 sinonasal tumors definitively treated by IMRT.
• Median dose of 70 Gy in 35 fractions
• Sixty-four percent patients had adenocarcinoma histology
• squamous cell carcinoma in 17, esthesioneuroblastoma in 9, and
adenoid cystic carcinoma in 4.
• Postoperative IMRT was performed in 75 patients and 9 patients
received primary IMRT
• No chemotherapy was given
• Median follow-up 40 m
• 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
• Toxicity rates were low
Madani I et al IJROBP 2009 73:424-432

60. Maxillary sinus tumor

63. Esthesioneuroblastoma

64. Esthesioneuroblastoma
• A single modality treatment, either surgery or radiotherapy, yields
>90% ultimate locoregional control for early ENBs (Kadish stage A)
.
• The optimal therapy for stage B disease is unclear, partly because this
group is heterogeneous; a combination of surgery and radiotherapy
may have a slight advantage.
• For patients with stage C lesions, evidence suggests better results
with the combination of surgery and radiotherapy.
• The available data do not justify routine elective nodal treatment
because the incidence of isolated nodal relapse is <15%.
Elkon D et al Cancer 1979;44:1087-1094

65. • Chemotherapy is not routinely used for patients with ENB.
• Although responses to chemotherapy have been reported, they
are usually of limited duration .
• Overall, local therapy with surgery and postoperative
radiotherapy yield excellent results at 5 years with regard to
both overall survival (93.1%) and local control (96.2%).
• Concurrent Cisplatin chemotherapy during radiation may be
considered in inoperable cases
• NACT - Vincristine/Doxorubicin based or Cis/Etoposide
Esthesioneuroblastoma
Rosenthal DI et al Cancer 2004;101:2567-2573

66. • Juvenile Nasopharngeal Angioibroma
• Highly vascular tumour
• Young males – 12-14 yrs
• Posterolateral part of nasal cavity
• Angioembolisation + Sx + RT
• 30-35 Gy(3-3.5 wks) / 45 Gy
• Lethal Midline Granuloma
• Diagnosis of exclusion
• Requires Sx + RT
• 40-45 G (5-5.5 wks)
• 30-70% Local control for 2 mnths-10 yrs
• Also requires constant antibiotics, dressing

67. Thank You