Sino-nasal Tumours

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Sino-nasal Tumours
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• Tumors of the nasal cavity proper are
  approximately evenly divided between benign and
  malignant neoplasia, with inverting papilloma
  predominating in the benign group and squamous
  cell carcinoma in the malignant.

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• On the other hand, most sinus tumors are
  malignant with squamous cell carcinoma being the
  most prevalent.
• The maxillary sinus is most commonly involved
  with tumor, followed by the nasal cavity, the
  ethmoids, and then the frontal and sphenoid
  sinuses. 

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Inverted papillomas

• Their etiology is unclear.
• They are known to have high recurrence rates.
• They are associated with malignancy and also have
  locally aggressive growth patterns, which makes
  them technically difficult to remove.
• There is also controversy over the appropriate
  surgical approach for tumor removal.
• There is a role for radiation therapy.

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Inverted papillomas

• Papillomas differ from inflammatory polyps, which
  are more common, in that inflammatory polyps are
  associated with allergic rhinitis and are
  actually reactive lesions, not a tumor.
• Nasal papillomas are true neoplasms and, while
  their etiology is unclear, they are known to
  arise from the nasal respiratory epithelium,
  which undergoes metaplastic change and
  proliferation.

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• Inverted papillomas arise from the Schneiderian
  membrane, which is an invagination of the
  olfactory ectoderm that occurs during the fourth
  week of embryonic development. The mucosa creates
  a transitional zone between the
  endodermally-derived respiratory epithelium of
  the nasopharynx and keratinizing squamous
  epithelium with the nasal vestibule.
• Three types Fungiform papillomas, cylindrical
  papillomas and inverted papillomas.

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• Grossly, inverted papillomas appear more opaque
  than inflammatory polyps, and this is because
  they have a thick epithelial layer.
• Inverting papilloma traces its name to the
  histologic appearance with squamous epithelium
  inverted in the polyps

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• They are commonly located in the nasal cavity and
  they typically involve an adjacent sinus.
• The most common location is the middle turbinate,
  but other common locations include the ethmoid
  sinus and maxillary sinus.
• They have even been found in the nasopharynx.

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• Most common symptoms are unilateral and include
  nasal obstruction, nosebleed and nasal discharge.
  It can be an incidental finding on examination.
• These tumors are rare. They occur about 0.6 cases
  per 100,000 per year and they occur approximately
  1/25th as often as inflammatory polyps.
• The average age at diagnosis is 53, but can range
  anywhere from the pediatric age of 6 to the
  elderly age of 89.
• They are known to have a male predominance of
  (13)
• The recurrence rates cited in the literature
  varies anywhere from 11 to 78, and this depends
  a lot on the treatment modality used.

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• They are associated with malignancy, 5 to 15
  malignancy rates are most generally accepted.
  Inverted papillomas are more commonly associated
  with squamous cell carcinomas.
• There are four types of association
• Metachronous squamous cell carcinoma.
• Carcinoma in situ within the IP
• Synchronous lesions
• Malignant transformation

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The mainstay of treatment is surgery, although
radiation therapy can be involved.

• Traditionally procedures have been either a
  transnasal procedure with polypectomy or confined
  transnasal polypectomy with additional sinus
  procedure, such as Caldwell-Luc. The gold
  standard was lateral rhinotomy with medial
  maxillectomy.
• Radiation therapy can be used as the sole therapy
  for inverted papilloma or it can be used
  postoperatively. The absolute indication for
  radiation therapy is when an inverted papilloma
  is associated with squamous cell carcinoma
• The patients who should get radiation therapy are
  those who had advanced incompletely resected or
  unresectable lesions that are biologically
  aggressive, or patients where morbidity in
  resection would be more pronounced that morbidity
  of tumor radiation.

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Sinonasal neoplasms

• These are rare, comprising less than 3 of all
  malignant aerodigestive tumors and less than 1
  of all malignancies.
• Despite their infrequence, they represent both a
  diagnostic and therapeutic challenge because the
  presenting signs and symptoms may be
  indistinguishable from benign or inflammatory
  disorders.
• These malignancies typically affect Caucasion
  males in the fifth to seventh decades of life and
  have a 21 male preponderance.

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Sinus Anatomy

• Maxillary antrum
• Significance
• Superior orbit, ethmoids
• Posterior pterygoids, infratemporal fossa
• Ethmoid sinus
• Significance
• Superior fovea, cribiform
• Medial lamina papyracea

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Sinus Anatomy

• Sphenoid sinus
• Significance
• Superior optic nerve, pituitary
• Lateral ICA, cavernous sinus
• Lateral wall lt 0.5mm
• Inferior NP, vidian nerve

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• Frontal sinus
• Significance
• Inferior orbit
• Posterior anterior cranial fossa

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Lymphatic Drainage

• The anterior nose has the same lymphatic drainage
  as the external nose.  These tend to spread to
  the submental or level I area. 
• The posterior nose tends to drain to the
  retropharyngeal nodes as well as the lateral
  pharyngeal nodes, which eventually drain into the
  level II. 

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Epidemiology

• Despite this, up to 44 are attributed to
  occupational exposures, including nickel,
  chromium, isopropyl oils, volatile hydrocarbons,
  and organic fibers that are found in the wood,
  shoe, and textile industries.
• In addition, human papilloma virus can be a
  cofactor, and in one series, human papillomavirus
  6 or 12 was documented in 24 of inverting
  papillomas and 4 of squamous cell carcinomas.
• Specific asssociations found include squamous
  cell carcinoma in nickel workers and
  adenocarcinoma in workers exposed to hardwood
  dusts and leather tanning.

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• The most common entities are squamous cell
  carcinoma. The lateral nasal wall is the most
  common site of involvement, but SCC can also
  present in the sinuses.
• Regional lymph node metastasis is more common
  with squamous cell than most other paranasal
  sinus malignancies, occurring in about about 10
  to 20. Local recurrence rates are quite high,
  as high as 30 to 40
• Adenocarcinoma is the second most common
  malignancy in this area. It is most often in the
  ethmoids, has a male predominance, and is often
  seen in industrial workers.

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• About 3 to 15 of these paranasal sinus
  malignancies are adenoid cystic carcinoma. It is
  occurs most frequently in women, and in the fifth
  and sixth decades.
• Melanoma is rarely seen, comprising only about 3
  of these paranasal sinus malignancies.
• Olfactory neuroblastoma or esthesioneuroblastoma
  are neural crest in origin, and they arise from
  an olfactory epithelium.

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Signs and symptoms of maxillary sinus carcinoma
fall into several major categories

• Oral
• Nasal
• Ocular, facial
• Auditory

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• Oral presentations occur in 25-35 and include
  pain involving the maxillary dentition, trismus,
  palatal and alveolar ridge fullness, and frank
  erosion into the oral cavity.
• Nasal findings are seen in up to 50 of patients
  and include obstruction, discharge, stuffiness,
  congestion, epistaxis, and extension into the
  nasal cavity.

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• Ocular findings occur in approximately 25 and
  arise from upward extension into the orbit, where
  unilateral tearing, diplopia, fullness of lids,
  pain, and exophthalmos are seen

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• Facial signs include infra-orbital nerve
  hypoesthesia, cheek swelling, pain, and facial
  asymmetry.
• Auditory complaints include hearing loss
  secondary to serous otitis media due to
  nasopharyngeal extension.
• With advanced disease, the classic triad of
  findings for carcinoma of the nasal cavity and
  paranasal sinuses may be present These include
• Facial asymmetry
• A visible or palpable tumor bulge in the oral
  cavity
• Tumor visible in the nose with anterior
  rhinoscopy.

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Staging

• Ohngren line, a line that is drawn from the angle
  of mandible to the medial canthus. Ohngren
  indicated that tumors that presented above this
  line, both superiorly and posteriorly, tended to
  have a worse prognosis

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• American Joint Committee on Cancer Staging System
  is the gold standard used for reporting in most
  professional papers. 
• T1 tumors of the nose and nasal cavity, and
  ethmoid sinuses, are tumors restricted to any one
  sub-site, with or without bony invasion. 
• T2s are tumors invading two sub-sites, single
  region or extending to involve adjacent regions
  of the nasal ethmoid complex. 
• T3 tumors begin to have bony involvement,
  invading the medial wall of the floor of the
  orbit, cribriform or palate. 
• T4-A tumors involve the anterior orbital
  contents, nose, and cheeks, with extension into
  the anterior cranial fossa. 
• T4-B, involve the orbital apex, dura, middle
  cranial fossa, as well as the clivus.

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Investigations

• CT scans are excellent for determining bony
  erosion and extent of invasion.

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• If there is a question of neural involvement, MRI
  is excellent for determining perineural spread,
  involvement of the dura, or involvement
  intracranially.

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• Lastly, confirm diagnosis via biopsy. Most often
  biopsy is performed after imaging rule out
  encephaloceles or other vascular issues.
• PET scan has been used to evaluate for residual
  tumor, recurrent tumor, and radiated treated
  fields.
• Angiography is not initially used, but can be
  used for vascular tumors to determine extent and
  vascularity as well as to allow for embolization
  prior to any surgical interventions.

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Management

• Adenocarcinoma Treatment is controversial, but
  the literature indicates that craniofacial
  resection is the key.

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Management

• SCC For the treatment of early lesions, surgery,
  if the tumor is excised en bloc with good
  margins, and, if there is no evidence of
  perineural spread, then surgery is usually
  sufficient. If there are any questions about the
  margins or perineural invasion, the addition of
  radiation is indicated

External

• Inferior medial

Medial
Radical
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Management

• There has been some literature reporting the use
  of radiation therapy alone for early disease, but
  this is not necessarily recommended since
  radiation of this side of the body has
  significant morbidity, with possible
  osteoradionecrosis and vision loss as well as
  damage to the spinal cord.
• Combined modality generally tends to be the gold
  standard surgery with postoperative radiation
  therapy.

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Management

• Also, the use of chemotherapy is now being added
  with the goal of better local control and
  improvement in survival.
• Chemotherapy does have a role in palliation for
  large tumors that are nonresectable.
• If there is nodal disease of the neck with
  squamous cell carcinoma, a neck dissection is
  generally indicated