Management of Sinonasal Tumors: Prognostic

Factors and Outcomes: A 10 Year Experience at a

Tertiary Care Hospital
Maliha Kazi • Sohail Awan • Montasir Junaid • Sadaf Qadeer •
Nabeel Humayun Hassan
 ABSTRACT
• Sinonasal malignancies are said to be a highly heterogeneous group of
cancers.

1 % of all cancers
3 % of all upper aerodigestive tract tumors
• Histopathology of sinonasal tumors is diverse

Squamous Cell Carcinoma Undifferentiated Carcinoma

 ABSTRACT

Rhadomyosarcoma Chondrosarcoma

Adenocarcinoma Sinonasal Olfactory Neuroblastoma

 ABSTRACT
• Treatment options vary, surgery being the mainstay in most of them.
• Recurrence rates differs with each histological type of tumor
 ABSTRACT
• Identify the prevalent characteristic of sinonasal malignancies 
prognostic factors affecting the outcome.
• Restrospective study design with a total number of 102 patient
• Patient diagnosed with sinonasal malignancies  Included
• Patient previously operated outside intitute
Excluded
• Having received prioe radiation or chemotherapy
 ABSTRACT
• The patients were selected over a period of 10 years, from 200 to 2010
• Majority of the sinonasal tumors were Squamous cell carcinomas
involving the maxillary sinus.
 ABSTRACT
• Locoregional recurrence  positive neck nodes on final histopathology.
• Sinonasal malignancies are mostly squampus cell in variety and
recurrence of these rare entities is dependent on the histological variety
and the presence of positive neck nodes.
 OBJECTIVE

Identify the characteristic features of malignant

neoplasm of the sinonasal and factors affecting
the loco-regional recurrence
 MATERIALS AND METHODS

Exclude Criteria

109 patients from 2000-2010 at the AgaKhan

University Hospital were included.

1. malignancy from nasopharynx

2. previously treated outside the institute
3. lost to follow up and
4. incomplete documentation

Final sample 102 patients

 FOLLOW UP

Monthly intervals in
first year

2-3 months intervals

for next 2 year
 RESULTS

70 patients were males

32 females

Age ranged from 23 – 88 years (means

: 50)
• Most presenting symptom :
• facial swelling (52 patients)
• Nasal blockage (42 patients)
• Epistaxis (8 patients)
• Visual disturbance (2 patients)
• 16 patients had more than one presenting symptom
•Site effected
• Tumor in Maxillary Sinus : 60 patients
• Nasal Cavity : 20 patients
• Ethmoid : 4 patients
• 18 patients had the tumor in multiple sites
• Squamous Cell Carcinoma : 44 Patients
• Adenoid Cystic Carcinoma In 26 Patients
• Mucoepi-Dermoid Carcinoma In 14 Patients And
• 18 Patients Had Various Other Malignancies
• The Malignancies Were Classified According To The AJCC
Classification.
• Stage I Was Present In 16 Patients,
• Stage II In 58 Patients,
• Stage III In 8 Patients And
• Stage Iv In 20 Patints Individuals.
• About 50 patients were treated with surgery,
• 38 individuals were managed by surgery followed by radiation and
• 14 underwent surgery followed by chemoradiation.
• Based on clinical and radiological exam- ination, twenty patients
underwent neck dissection.
• 14 out of 20 patients underwent neck dissection, had positive neck
nodes.
• 10 of the patients with positive neck nodes had reccurence.
• Sinonasal malignancies have a loco-regional recurrence rate of 39 %.
It was noted that the presence of histologi- cally positive neck nodes
and histology of the tumor was significantly associated with disease
recurrence.
• Sinonasal malignancies are a highly diverse group of cancers
• These lesions may arise from various histologic components of the
sino-nasal tract, such as the Schneiderian mucosa, minor salivary
glands, neural tissue, and lymphatics, all of which give rise to a
heterogeneous group of disease
• Majority of cases present at an advanced stage of disease, with a
massive tumor size and invading surrounding bony structures and
sinuses, leading to a high frequency of local failure and poor
outcome.
• Advanced staged disease presents with proptosis, diplopia,
cerebrospinal fluid leak and epiphora due to invasion intracranially or
the orbit.
 CONCLUSION

• Sinonasal malignancies is a diverse group of cancers with a variation

in its presentation, histology, local and distant spread and recurrence
rates. Frequency of recurrences is more in squamous cell carcinomas
with presence of posi- tive neck nodes being an important prognostic
factor.
 Critical Appraisal

Management of Sinonasal Tumors: Prognostic

Factors
and Outcomes: A 10 Year Experience at a
Tertiary Care Hospital

 In accordance with the contents of the study

 Title less than 20 words
ABSTRAK

• Abstract <250 words • Consist of :

and already – Purpose
describes the – Design
contents of the
journal. – Participants
– Methods
– Main Outcome
Measure
– Results
– Conclusion
 METODE PENELITIAN DAN SAMPLING

RESEARCH SAMPLING
METHODS 102 patients with
sinonasal malignancy
Retrospective Study
 Critical Appraisal

POPULATION
P Patient with Sinonasal Malignancy

I INTERVENTION
Histopathology

COMPARATION
C Prognostic factor affecting the outcome

O OUTCOME
Squamous cell carcinomas with presence of
positive neck nodes being an important prognostic factor
SINONASAL TUMOR
Anatomi paranasal sinus

• Maxillary sinuses - Largest, 15 ml volume

• Ethmoidal Sinuses - Anterior, Middle &
Posterior group
• Frontal Sinuses
• 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
CAVITAS NASI
 Sinonasal Malignancies Are Uncommon And
Heterogenous Group Of Tumors

Age > 40 years

Males > Females

MOST COMMON HISTOLOGY
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
 RISK FACTOR

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)

Smoking and alcohol also the risk factor of

carcinomas
Ohngren’s Line

• Divides the maxillary sinus into

antero-inferior (infrastructure) &
posterosuperior (suprastructure)
parts.
• Infrastructure:
• Good prognosis
• Suprastructure:
• Early extension (eye, skull
base, pterygoids,
infratemporal fossa)
SITES
 CLINICAL FINDING
Sinus cancer can appear in many different ways, depending on where
the cancer is located.

For early cancers, there might not be any symptoms, or symptoms

may seem like allergies, sinusitis or nasal polyps.

Generally, if a polyp or something unusual is seen on only one

side, it should be further evaluated by a biopsy (testing).
 SOME COMMON SYMPTOMS INCLUDE:

Nasal obstruction (feels Sinus pain, pressure and Change or loss of sense of
like something is in the infections smell
way)

Bleeding from the nose,

particularly if only on one
side (known as epistaxis)
When cancers in this area get larger, the symptoms will
depend on what nearby structures are involved

A tumor growing out of the nose

Brain infection

Change in vision or double vision

Recurrent sinus infections

Numbness in part of the face

Growth in the roof of the mouth from

cancer growing downwards
AJCC TNM Staging of Maxillaris Sinus
• T1  Tumor limited to the maxillary sinus mucosa with no
erosion or destruction of bone
AJCC TNM Staging of Maxillaris Sinus

• T2  Bone erosion or destruction, including extension into the hard

palate and/or middle nasal meatus
AJCC TNM Staging of Maxillaris Sinus

• T3  Invades bone of the posterior wall of the maxillary sinus,

subcutaneous tissues, floor or medial wall of the orbit, pterygoid
fossa, or ethmoid sinuses
AJCC TNM Staging of Maxillaris Sinus

• T4a (Moderately advanced local disease) 

• Tumor invades anterior orbital contents, skin of cheek, pterygoid
plates, infratemporal fossa, cribriform plate, sphenoid or frontal
sinuses
AJCC TNM Staging of Maxillaris Sinus

• T4b (Moderately advanced local disease) 

• Tumor invades orbital apex, dura, brain, middle cranial fossa, cranial
nerves other than maxillary division of trigeminal nerve (V),
nasopharynx, or clivus
 AJCC TNM Staging of Ethmoid Sinus or
Nasal Cavity
• T1  Tumor restricted to any one subsite, with or without
bony invasion
 AJCC TNM Staging of Ethmoid Sinus or
Nasal Cavity
• T2  Tumor invades two subsites in a single region or
extending to involve an adjacent region within the
nasoethmoidal complex, with or without bony invasion
 AJCC TNM Staging of Ethmoid Sinus or
Nasal Cavity
• T3  Tumor extends to invade the medial wall or floor of
the orbit, maxillary sinus, palate, or cribriform plate
 AJCC TNM Staging of Ethmoid Sinus or
Nasal Cavity
• T4a (Moderately advanced local disease ) 
• Tumor invades anterior orbital contents, skin of nose or
cheek, minimal extension to anterior cranial fossa,
pterygoid plates, sphenoid or frontal sinuses
 AJCC TNM Staging of Ethmoid Sinus or
Nasal Cavity
• T4b (Very advanced local disease) 
• Tumor invades orbital apex, dura, brain, middle cranial
fossa, cranial nerves other than V, nasopharynx, or clivus
• 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
greatest dimension
• N2a  Metastasis in a single ipsilateral lymph node, larger than 3 cm
but no larfer than 6 cm in greatest dimension
• N2b  Metastasis in multiple ipsilateral lymph nodes, none more
than 6 cm in greatest dimension
• N2c  Metastasis in bilateral or contralateral lymph nodes, none
more than 6 cm in greatest dimension
• N3a  Metastasis in a lymph node, larger than 6 cm in greatest
dimension
• N3b  Metastasis in any lymph nodes(s) with clinically overt ENE
 CHEMOTHERAPY

• What is chemotherapy?
• Chemotherapy is a type of cancer treatment that uses drugs
to destroy cancer cells.
HOW DOES CHEMOTHERAPY WORK?

stopping or
Chemotherapy slowing cell
cancer

harm healthy cells

that divide quickly

or cause your hair

Cell on mouth Cell on intestines Cell on intestines
to grow
WHAT DOES CHEMOTHERAPY DO?

• Cure cancer chemotherapy

No detect and
destroys cancer
not grow back.
cells

• Control cancer
spreading, slows its
Chemotherapy growth, or destroys
cancer cells

• Ease cancer symptoms

shrinks tumors that
are causing pain or
Chemotherapy
pressure.
 HOW IS CHEMOTHERAPY USED?

• Neo-Adjuvant Chemotherapy.
Make a tumor smaller before surgery or radiation
therapy.
• Adjuvant Chemotherapy.
Destroy cancer cells that may remain after surgery
or radiation therapy.
• Destroy cancer cells that have come back
(recurrent cancer) or spread to other parts of your
body (metastatic cancer).
How is chemotherapy given?

• Injection
• Intra-arterial (IA).
• Intraperitoneal (IP).
• Intravenous (IV).
• Topical.
• Oral.
TYPES OF CANCER TREATMENTS
Surgery An operation to remove or repair a part of the body affected
by cancer.

Chemotherapy The use of cytotoxic drugs to treat cancer by

killing cancer cells

Radiotherapy (radiation The use of radiation, usually x-rays or gamma

therapy)
rays, to kill cancer cells

Hormone therapy Treatment that blocks the body’s natural

(endocrine therapy)
hormones, which sometimes help cancer cells
grow

Immunotherapy treatment of disease using substances that

alter the immune system’s response.

Targeted therapy Treatment that attacks specific particles

(molecules) within cells that allow cancer to
grow.
Surgery
 TREATMENT

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

• Complications of maxillectomy include failure of the splitthickness

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
Chemotherapy
Radiotherapy
Radiotherapy : Indications
• 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
Hormone therapy
Side Effects Chemotherapy and how to
managed