Endoscopic Sinus Surgery

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Sinus Cancer
Reporter: clerk 柯仁裕
Supervisor: 戴志峰 醫師
Background
• The location of the nasal cavity and the
paranasal sinuses make them extremely close to
vital structures.
• Sinonasal malignancies (SNM) can grow to
considerable size before presentation, and
aggressive therapy may be needed in areas
close to the skull base, orbits, cranial nerves,
and vital blood vessels
• Sinonasal malignancies (SNM)---the initial
manifestations (eg, unilateral epistaxis, nasal
obstruction) mimic signs and symptoms of
many common but less serious conditions.
• The patient and clinician often ignore or minimize
the initial presentation of these tumors and treat
early-stage malignancy as a benign sinonasal
disorder.
• By the time ominous signs and symptoms (such
as severe intractable headache, visual
disturbance, or cranial neuropathy) occur, the
neoplasm is often advanced.
Epidemiology
• Sinonasal malignancies (SNM) are rare. They are more
common in Asia and Africa than in the United States.
• In parts of Asia, sinonasal malignancies (SNM) are the
second most common head and neck cancer behind
nasopharyngeal carcinoma. Men are affected 1.5 times
more often than women, and 80% of these tumors occur
in people aged 45-85 years.
• Approximately 60-70%  maxillary sinus
20-30%  nasal cavity
10-15%  ethmoid air cells (sinuses)
the remaining  frontal & sphenoid sinuses
Etiology
• Risk factors for sinonasal malignancies (SNM) are
complicated, multifactorial, and somewhat controversial.
• Squamous cell carcinoma (SCC) and adenocarcinoma in
this area are associated with exposure to nickel dust,
mustard gas(dichlorodiethyl sulfide), thorotrast(二氧
化釷,放射性顯影劑), isopropyl oil, chromium(鉻) is well
established.
• Wood dust exposure, in particular, is found to increase
the risk of SCC 21 times and the risk of adenocarcinoma
874 times.
• Many of these products are found in the furniture-making
industry, the leather industry, and the textile industry.
Pathophysiology
• Squamous cell carcinoma (SCC) 80%
of all malignancies that arise in the nasal
cavity and paranasal sinuses.
Approximately 70% occurs in the maxillary
sinus, 12% in the nasal cavity, and the
remainder in the nasal vestibule and
remaining sinuses.
• Adenoid cystic carcinoma (ACC)
salivary origin and is the second most
common sinonasal malignancy,
accounting for 10% of cases.
• Three histological subtypes are based on
growth patters: tubular, cribriform, and
solid. The solid form portends a much
worse prognosis than either cribriform or
tubular.
• Adenocarcinoma associated with
specific risk factors including exposure to
wood dust, lacquers(亮光漆), and other
organic compounds.
• Distant metastases are rare. When they
do occur, the lung, liver, and bone are the
sites most often involved. Metastases to
the cervical lymph nodes are uncommon,
even with poorly differentiated tumors.
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Malignant melanoma
Sinonasal neuroendocrine tumors
Esthesioneuroblastoma (ENB, olfactory neuroblastoma)
Sinonasal undifferentiated carcinoma (SNUC)
Small cell neuroendocrine carcinoma (SmCC)
Lymphoma
Salivary-type neoplasms
Sarcoma
Metastatic tumors
Presentation
• Initial presenting symptoms include epistaxis,
nasal obstruction, recurrent sinusitis, cranial
neuropathy, sinus pain, facial paresthesia,
proptosis, diplopia, or an asymptomatic neck
mass.
• Often, these mimic signs of conditions more
common and less serious than malignant tumors
of the sinuses. The patient often ignores early
symptoms, or the clinician may minimize them,
treating early-stage malignancies as infectious
diseases.
• The ominous signs and symptoms (eg,
severe intractable headache, visual
disturbances) occur, the neoplasms are
advanced and require complex
management.
Workup
• Laboratory Studies
– As with other head and neck cancers, liver
enzymes are usually obtained to assess for
distant disease in addition to a chest
radiograph or CT scan to evaluate for
pulmonary metastasis
– In the case of a nasal cavity or paranasal
sinus mass or erosion, an antineutrophil
cytoplasmic antibody (ANCA) test for
possible Wegener granulomatosis should
be considered. This condition often mimics a
neoplasm.
• Imaging Studies
– Magnetic resonance imaging (MRI): determine
resectability such as orbital invasion, perineural
spread, skull base invasion, intracranial
extension
– One of MRI’s greatest uses is in helping to
demonstrate the distinction tumor and retaining
secretions in the multiple sinus cavities.
• CT scan has a higher accuracy at determining both bony
remodeling and erosion of the skull base and sinuses.
• Osteolysis can often be observed with SCC, metastatic
disease, sarcoma, and sinonasal undifferentiated
carcinoma(SNUC).
• Boney remodeling is more often seen with salivary gland
tumors, large cell lymphoma, melanoma, and
esthesioneuroblastoma(ENB).
• CT scanning is slightly more accurate than MRI in
demonstration of orbital invasion due to its ability to
evaluate both the bony orbital wall and adjacent fat.
Diagnostic Procedures
• Biopsy is the only 100% accurate means of
obtaining a tissue diagnosis.
• Remember that the turbinates and the possibility
of a juvenile angiofibroma may both lead to
extensive bleeding.
• A biopsy should be performed on highly
suspicious vascular tumors in the OR under
controlled conditions where bleeding can be more
safely controlled.
Staging
• Staging of nasal cavity and paranasal sinus carcinomas
is not as well established as for other head and neck
tumors.
• Two generally accepted staging systems are currently in
use. The Kadish staging system is used specifically for
Esthesioneuroblastoma because this often involves
the skull base and intracranial extension.
• For cancer of the maxillary sinus, the nasal cavity,
and the ethmoid sinus, the American Joint Committee
on Cancer (AJCC) has designated staging by TNM
classification.
• No broadly accepted staging systems for frontal and
sphenoid sinus cancer currently exist
• Maxillary sinus
– Primary tumor (T)
• T1 - Tumor limited to maxillary sinus mucosa with no erosion or destruction
of bone
• T2 - Tumor causing bone erosion or destruction including extension into the
hard palate and/or the middle of the nasal meatus, except extension to the
posterior wall of maxillary sinus and pterygoid plates
• 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
• T4a - Tumor invades anterior orbital contents, skin of cheek, pterygoid plates,
infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
• T4b - 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
• Nasal cavity and ethmoid sinus
– Primary tumor (T)
• T1 - Tumor restricted to any one subsite, with or without bony
invasion
• T2 - Tumor invading 2 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
• T4a - 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
• T4b - Tumor invades any of the following: orbital apex, dura, brain,
middle cranial fossa, cranial nerves other than (V2), nasopharynx,
or clivus
Regional lymph nodes (N)
• N1 - Metastasis in a single ipsilateral lymph node, 3 cm or less in
greatest dimension
• N2a - Metastasis in a single ipsilateral lymph node more than 3 cm
but 6 cm or less in greatest dimension
• N2b - Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in
greatest dimension
• N2c - Metastasis in bilateral or contralateral lymph nodes, 6 cm or
less in greatest dimension
• N3 - Metastasis in a lymph node more than 6 cm in greatest
dimension
Kadish Staging for esthesioneuroblastoma
• Stage A: The tumor is limited to the nasal
fossa.
• Stage B: The tumor extends to the
paranasal sinuses.
• Stage C: The tumor extends beyond the
paranasal sinuses.
Thanks for your attention!
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