Management of Malignant Tumours of the Paranasal Sinuses SUDHIR BAHADUR, S. K. KACKER Cr H. PRAKASH
Malignant tumours of the nose and
Observations
stasis.
paranasal sinuses are fortunately uncommon.
Age and sex
Lewis (1972) mentioned
from
that cancer of the nasal cavity and
varied
paranasal sinuses comprise about 2%
(Table I).
of
cancers
According (1981),
of to
the
human
body.
Sisson
and
Becker
malignant
tumours
of
the
nose and paranasal sinuses make up 0.5% of all body tumours and 3% of all tumours of the respiratory tract.
8
:
The age of patients
years
tumour
has
already
destroyed
the
bony confines of the sinus and has The fundamental factors
underlying
8
—
26 51 15
the
diagnosis degree is high g g g suspicion (Harrison, 1973). Aim
of the present
of
modalities of treatment in advanced
Materials and Methods This study is based on experience of 100 cases of various
Delhi,
1983.
between
1. 2. 3. 4. 5. 6.
malignant
1973—June
However, only those
cases
have been included where the cornplete
records
were
available
and
malignant
7. 8. 9.
tumours
are
shown
in
Histopathology
No. of cases
Squamous cell carcinoma Adenoid cystic carcinoma Adeno carcinoma Muco-epidermoid carcinoma Malignant melanoma Sarcomas —Leiomyosarcoma —Osteosarcoma —Chondrosarcoma —Rhabdomyosarcoma —Angiosarcoma Non-Hodgkin's lymphoma Olfactory neuroblastoma Osteoclastoma (giant-cell tumour)
65 12 6
4
65%
2 1
1 1 1
2 2 1
100
Total No. of cases
Sinus involvement: Table 3 described involvement by the disease of
the septum and the vestibules have
the individual sinus.
included
in
the
present
study. Sudhir Bahadur, S. K. Kacker and H. Prakash, from the Department of Otolaryngology and Dental Surgery, All India Institute of Medical Sciences, New Delhi-110 029. 80
Modalities
of treatment—Table regimes
ment followed in
this series.
policy
in
4
of treatLack
management
e.g., advanced disease, relative radio TABLE S Site of primary lesion -
Sinus involvement
No. of cases 81
Maxillary sinus Ethmoid sinus Frontal and ethmoid sinus
15 4
Total No. of cases
100
TABLE 4
2
Lesions of the hard palate and
been
Of
22%
the nasal cavity such as arising from not
disease.
describes various
Other
which have had a reasonable followup.
their
noma.
lesion.
TABLE 2
--
in the Department of Otolaryngology, New
seen
of
may be because of several factors,
Table 2.
lesions of the paranasal sinuses seen All-India Institute of Medical Sciences,
64 36
100
It was found in 65 patients.
malignant tumours of the paranasal sinuses.
Males Females
Squamous-cell carcinoma was the
review results obtained with different
Thus,
carcinoma and one had adenocarci-
Histopathology
malignant
paper is to
stage
of standard
commonly
case
a few
these, eight cases had squamous-cell
No. of cases
20 years 21 40 years 60 years 41 Above 60 years Total No. of patients
spread to the surrounding structures.
more
lesion in the maxillary sinus. some
Age groups
0
one
metastasis
months after the treatment of primary
years
Age and sex prevalence
—
Nearly all cases in our country are
75
nodal
nine cases had nodal involvement at
—
diagnosed at a late stage when the
to
TABLE I —_
Besides,
developed
Lymph node involvement There were only eight patients in the present series which when first seen presented with neck node meta-
Modes of treatment
Therapy used
No. of cases
Surgery alone Radiotherapy and surgery Chemotherapy and surgery Radiotherapy alone Chemotherapy alone
29
30
11
22
8
TABLE 5 Surgical procedures employed Types of surgery
Total maxillectomy alone Total maxillectomy with orbital exenteration Total maxillectomy with radical neck dissection Total maxillectomies performed Partial maxillectomy Lateral rhinotomy No. of surgical procedures
No. of cases 36
14
—
54
4 10 6
70
Indiai Journal of Otoloryngology, Volume 36, No. 3, September, 1984
MANAGEMENT OF MALIGNANT TUMOURS OF THE PARANASAL SINUSES—BAHADUR, eta!. resistance of some tumours, various Surgical procedures excluded from this age groups and the fact that many of the patients came from long disTable 5 describes the surgical tances and could not afford to stay procedures carried out in this study. on for prolonged treatment. Total maxillectomy was done in 54
A policy of combined treatment with radiotherapy and radical surgery has been followed in 30 cases, 26 of these received a full course of prooperative radiotherapy whereas the remaining four received post-operative radiotherapy. A majority of these 30 cases were squamous-cell carcinomas.
cases. Fourteen of these (26%) were accompanied by orbital exenteration. Four patients which had nodal metastasis underwent radical neck dissection besides the maxillectomy. In one patient a total maxillectomy on one side and partial maxillectomy on the opposite side was done because of the extension of the tumour. Lateral rhinotomy was carried out
Surgery alone was the treatment
in 6 patients, which had malignancy
used in 29 cases. Twenty of these were malignant tumours of the minor
of ethmoid sinuses. Partial maxillectomy was done in 10 patients in whom the lesion was limited to the infrastructure.
salivary gland involving the maxillary sinus. Of the remaining 9 cases undergoing primary radical surgery, there were four cases of squamouscell carcinoma whereas the five cases were melanoma, osteoclastoma, soft tissue and bony sarcomas, and a case olfactory neuroblastoma.
Twenty-two patients were treated with radiotherapy alone. It is not usually our policy to treat them this way. All the patients had been asked to return for follow-up radical surgery 6 weeks after completing the course of radiotherapy. Unfortunately, many of them returned several months later when they had become inoperable. Some of them never came to us.
Recently, we have been using chemotherapy either alone for palleation in patients with advanced lesions which are not suitable for either radiotherapy or surgery or in combination with radical surgery in cases which subsequently become operable following initial administration of chemotherapy. Multiple drug regime using methotrexate, 5-Flurouracil and endoxan have been used in present study.
Follow-up and results Only 64 cases are available for detailed follow-up and comments regarding efficacy of treatment. Patients with inadequate follow-up or the ones treated recently have been
group. Two patients died in immediate postoperative period. Sixteen patients (25%) have survived disease-free for three years or more in present series, of these seven had been treated with primary surgery and another six by a combined regime of radiotherapy and surgery. Only three of the 22 cases which received radiotherapy survived for more than three years. Including the above cases, overall 38 patients (59%) survived diseasefree for more than 1 year following treatment. Local recurrence of the disease occurred within a year in 26 cases (41%) despite the therapy. Six of them had surgery as the main treatment, seven were treated by radiotherapy alone, eight had received a combined regime of radiotherapy and surgery and five cases were very advanced lesions and had been treated with chemotherapy. Prosthetic rehabilitation All patients prior to maxillectomy were referred to dental unit for dental impression for the preparation of temporary palatal prosthesis to be fitted at the time of surgery. This would help in subsequent rehabilitation because patients had little difficulty in swallowing and speech immediately following surgery. The second prosthesis was given 6 weeks later and a final prosthesis to fit the palatal defect, was given 4-6 months following surgery. Discussion
Fig. 1 Advanced carcinoma of the maxilloethmoid complex. Radical surgery with orbitat exentration was carried out.
Indian Journal of Otoloryngology, Volume 36, No. 3, September, 1984
Malignant tumours of the paranasal sinuses present a problem area of the head and neck surgery. There is only 8% five-year survival and 25% threeyear survival rate in the present series. 81
MANAGEMENT OF MALIGNANT TUMOURS OF THE PARANASAL SINUSES—BAHADUR, eta!. The main difficulty in treatment is local control of the disease. Nearly forty per cent patients developed local recurrences within a year. Metastasis to the cervical lymph nodes was seen in only eight patients (8%). Despite this apparently favourable biological behaviour, these tumours carry a poor prognosis. Several factors may be blamed for disappointing results in malignancy involving this region. Firstly in our country, almost all cases are seen when the disease is far advanced. In the present series all cases were either T3 or T4 lesions. By the time patient is first seen, diagnosis is normally obvious on his or her face. This further complicated by the fact that our patients have a poor nutritional status and poor orodental hygiene, which delay the recovery and increase the morbidity and mortality. Diagnostic methods available include (a) clinical assessment, (b) Radiology—plain X-rays are helpful but do not show the extent of soft tissue involvement, (iii) Tomography and (iv) CAT Scan.
The latter two mentioned investigations have a clear advantage over the conventional radiography in delineating the soft tissue involvement and precise extent of the tumour. Though they have been done in selected cases in this series, demand of work tends to limit its use. Secondly, complex surgical anatomy of the region hinders complete eradication of the disease either by radiotherapy or surgery in all cases. Radiotherapist is further handicapped because (a) there is difficulty in assessing the precise extent of the tumour (b) many tumours involving this region are relatively radioresistent. Robin and Parel (1981) have emphasised on the former point, saying that usual methods of diagnosis of the extent of the tumour are inadequate in one-third of all cases.
radiotherapy alone. We believe that radiotherapy alone can rarely cure any case of advanced squamous-cell carcinoma involving the maxillary sinus. Only three of 22 cases (13.5%) have survived, three years or more disease-free period, two of these had carcinoma of the ethmoids—a site which is said to be more responsive to radiotherapy than carcinoma of the maxillary sinus. We have followed a policy of combined treatment, with radiotherapy and surgery in 30 cases. All of them showed a residual tumour at the time of surgery. Time interval between radiotherapy and subsequent surgery is important and has a direct bearing on the eventual prognosis of the case. Our experience suggests that radical surgery must be carried out within 4-6 weeks of completion of
For the treatment of squamous-cell carcinoma, combined regime of radiotherapy followed by radical surgery has been advised by numerous workers (Pearlman and Abadir, 1974; Ireland and Bryce, 1966; Lewis and Castro, 1972; Schechter and Ogura,
Fig. 3 Recurrent carcinoma of the ethmoids. Initial radiotherapy and surgery done elsewhere. Obvious recurrence in the eye.
Fig. 2 Post operative photograph of the same patient 10 days after surgery. Skin defect was closed with large forehead flap—patient is alive free of disease 18 months - later.
82
1972; Ireland and Bryce, 1966; Ahmed eta!., 1981). Sisson (1970) advocates radical maxillectomy for T4 and 13 lesions; and planned surgery following radiotherapy in more advanced T4 and T3 lesions. We have found poor results in cases which have been treated with
Fig. 4 Post operative photograph of the same patieht following extended maxillectomy and orbital exenturation. Eye pateh seen above was provided to cover the eye defect.
radiotherapy. Unfortunately, some patients return for surgery several months after completing the radiotherapy and this delay considerably
Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984
MANAGEMENT OF MALIGNANT TUMOURS OF THE PARANASAL SINUSES—BAHADUR, et al. lowers the prognosis. We feel that whereas a sound treatment policy
and were able to carry out their household duties without much
based on combined treatment with
trouble.
radiotherapy and radical surgery is best for a majority of cases of squamous-cell carcinomas involving the region, however, treatment should suit an individual patient's requirement rather than the other way round in our environment. Many of our patients in elderly age group with advanced lesions and coming from far off places, have shown much improvement when treated with radical surgery alone. Radiotherapy in this group of cases would aggravate the severe pain, delay surgery and prolong their hospital stay for treatment. Sometimes palliative surgery may be justified to help these unfortunate patients to get rid of the excruciating pain and agony.
Fourteen patients in this series required orbital exenteration along with the radical maxillectomy or ethmoidectomy. It has been mentioned by Sisson (1970) that with the use of pre-operative radiotherapy, number of orbital exenterations required with radical maxillectomy have been reduced in his series, without significantly altering the overall survival results. It has been noticed by us that if orbital periosteum is found to be frankly involved at surgery, with or without the obvious involvement of the soft tissues, the eye should be sacrificed even though the vision may have been normal pre-operatively. There are four more points worthy of discussion.
Results of our initial experience with a combination of chemotherapy and surgery has been encouraging. Long-term results are, however, still awaited. Six patients are alive disease-free for more than a year. Some of them were considered inoperable earlier. The chemotherapy reduces the bulk of the tumour and helps in reducing the post-operative recurrences.
lesions which are inoperable, and chemotherapy when given regularly also seems to control the disease for fairly long periods. Two such patients in this study remained alive for more than a year in presence of the disease
(b) Involvement of the overlying skin by the tumour of the maxillary sinus is not necessarily, a contraindication for surgery, as was formerly believed. Three cases are alive, disease-free, five years, 2 years and 12 years respectively following surgery.
Disease-free survival for 3 years or more Mode of treatment Histology
Surgery
R.T.
Surgery
Squamous-cell carcinoma
1
2
4
Tumours of minor salivary glands
5
—
2
Melanoma
1
—
Rhabdomyosarcoma
—
1
7
3
No. of cases
6
+ R.T.
+16(25%)
TABLE 7
and radical surgery has also been recommended by Japanese workers (Sato eta!., 1970; Kono eta!., 1980; Sakai et a/., 1976). These authors
rate) using this approach. The chemotherapy has a significant role in the palliation of those advanced
cribriform plate may require it's removal and exposure of the dura. Rhinoneurosurgical approach (Craniofacial resection) has been recommended in cases where cribriform plate is involved (Ketchum eta!., 1963).
TABLE 6
An aggressive treatment policy based on chemotherapy, radiotherapy
have also reported the best results of treatment in carcinoma of the maxillary sinus (57% to 71% five-year survival
(a) In cases of ethmoidal malignancies which may be either primary or secondary extension of the tumour from the maxillary sinus, the disease is frequently present on exposed orbital periosteum and in posterior ethmoidal cells. This might require orbital extenteration as a part of radical surgery. Involvement of
Disease-free survival for one year or more Mode of treatment Histopathology Surgery Squamous-cell carcinoma Malignant tumour of minor salivary glands
R.T.
R.T. & Chemotherapy surgery and surgery
1
2
10
6
10
—
6
1
—
—
3
16
6
1
Melanoma
—
Rhabdomyosarcoma
1
Osteoclastoma Total
13
=38 (59%)
(Besides, two patients on chemotherapy alone have survived for one year in presence of disease)
Indian Journal of Otolaryngology, Volume 36, No. 3, September, 1984
83
MANAGEMENT OF MALIGNANT TUMOURS OF THE PARANASAL SINUSES—BAHADUR, et a/. Thus, it appears that it
is extremely
(c) Involvement of the pterygopala-
Similarly in two patients extension
tine fossa as shown clinically by
of the tumour in the infratemporal
unlikely we are going to diagnose
trismus has been regarded as a
fossa necessitated inclusion of the
early lesions involving this region
contraindication for surgery. We feet that the younger patients who are otherwise fit may be given a chance for surgery. Transtemporal approach was used in two cases and one patient
zygomatic bone in the specimen
in our country despite our efforts to
(dividing superiorly the orbital part and
run early detection cancer clinics,
posteriorly the temporal part of the
and therefore the only
zygoma). Temporalis muscle was
malignancies of the paranasal sinuses
way to treat
sacrificed. One patient died after 1
is by an aggressive approach requiring
year, the other developed recurrence
chemotherapy, radiotherapy and
has survived for more than a year
with
following radical surgery.
surgery.
a few months following such a
radical surgery, and to maintain as good a follow-up as possible.
References
1.
Ahmed, K., Cordolia, R. B. and Fayos, 6. J. V. (1981) : Squamous cell carcinoma of the Maxillary sinus. Arch. of Otolaryngology, 107 : 48.
Annals of Otology, Laryngology and Rhinology, 78 : 778.
Harrison. D. F. N. (1973) : Management 7• of malignant tumours affecting the maxillary and ethmoid sinuses. Journal of Laryngology and Otology, 87 : 749.
Lewis, J. S. and Castro, E. B. (1972) : Cancer of the nasal cavity and paranasal sinuses. Joarrnaf of Laryngology and Otology, 86 : 255.
3.
Ireland, P. E. and Bryce, D. P. (1966) : 8. Carcinoma of the accessory nasal sunuses. Annals of Otology and Laryngology, 75 : 698.
Robin, P. E. and Power, D. J. (1980) : Regional lymph node involvement anc distant metastasis in carcinoma of the nasal cavity and paranasal sinuses.
4.
Ketcham, A. S. at al (1963) : A combined intra-cranial facial approach to the paranasal sinuses. American Journal of Surgery, 106 : 698.
Journal of Laryngology and Otology, 94 : 307.
13. Miller, R. H. and Caleaterra, T. C. (1980) : Adenoid cystic carcinoma of the Nose and paranasal sinuses, and the palate. Archieves of Otolaryngology, 106 : 424.
9. Pearlman, A. W. and Abadir, R. (19741 : Carcinoma of the maxillary antrum. Laryngoscope, 84 : 400.
Treatment 14. Sakai, S. at al (1976) : policy for maxillary sinus carcinoma. Acta Otolaryngologica, 82 : 172.
5. Konno, A., Togawa, K. and (none, S. (1980) : Analysis of the results of combined therapy for maxillary cancer. Acta Otolaryngoloicga —Supp. 372.
10. Sisson, G. A. and Becker, S. P. (1981) : Cancer of the nasal cavity and paranasal sinuses. In Cancer of the Head and Neck. Ed. by James Suen and Eugene
15. Sato, S. at af. (1970) : Combined surgery, radiotherapy and regional chemotherapy for carcinoma of paranasal sinuses. Cancer, 25 : 571.
2.
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N. Meyer. page 243.
Lewis, J. S. (1969) : Sarcoma of the nasal cavity and paranasal sinuses.
Churchill Livingstone,
11.
Sisson, G. A. (1970) : Carcinoma of the maxillary sinus. Laryngoscope, 80: 933.
12.
Schechter, G. L. and Ogura, J. (1972) : Maxillary sinus malignancies. Laryngoscope, 82 : 796.
Indian Journal of Otoloryngology, Volume 36, No. 3, September, 1984
