1. Paranasal sinus cancer
Presenter: 張敬弘
Supervisor: 俞芹英 主任

2. Brief history Left peri-orbital swelling for 2 months
Left nasal obstruction for 10+ days
Epistaxis(+) for 3 episodes
Proptosis(+)
Purulent rhinorrhea(+)
Lower visual field darkness(+)
Bone scan:
Suspicious left maxillary and ethmoid sinus involvement
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3/12 CT
OP:
Lateral rhinotomy
MBD CT

3. Introduction Incidence: 1/500,000 ~ 1/1,000,000
Males : Females = 2 : 1
Peak incidence at 50 to 59 years of age
Maxillary > ethmoid > sphenoid > frontal sinuses

4. Risk factors Occupational or medical exposures Air pollution
Tobacco smoke
Viral exposure
Chronic sinusitis

5. Pathology Squamous cell carcinomas (45~80%) Adenoid cystic carcinomas
Adenocarcinomas
Mucoepidermoid carcinomas
Rare: Angiosarcomas, rhabdomyosarcomas, lymphomas, esthesioneuroblastomas (olfactory neuroblastomas), melanomas, and meningiomas
Salivary gland cancers

6. Clinical presentation
The most common symptoms
Facial or dental pain
Nasal obstruction
Epistaxis

7. Clinical presentation
Symptoms mimic sinusitis and allergic rhinitis
Discharge
Nasal obstruction
Difficulty breathing through the nasal cavity
Pressure sensation in the midface
Epistaxis
Symptoms that are specific to sinonasal cancers included
Loosening and numbness of the upper teeth
Eye bulging
Double or blurred vision
Tearing
For very advanced lesions, loss of vision

8. Ethmoid sinus
In the ethmoid sinus, locally advanced lesions may extend into the anterior cranial fossa via the cribriform plate or into the orbit through the lamina papyracea. This may result in anosmia or displacement (typically upward and/or outward) of the globe

9. Sphenoid sinus
In the sphenoid sinus, disease may directly extend through the lateral bony wall into the cavernous sinus
It may also invade the middle cranial fossa directly or via the infraorbital nerve
Diplopia, blurred vision, proptosis, paresthesias in the distribution of the trigeminal nerve or trismus if the pterygoid musculature is invaded

10. Nodal metastases
Regional nodal metastases are uncommon, occurring in only about 20 percent of patients
The retropharyngeal nodes comprise the first echelon lymphatic drainage for sinus malignancies
Other regional nodes that may be involved with lymphatic spread are the periparotid and level 1b nodes

11. Diagnosis PE/NE for orbital extension and/or cranial nerve involvement
Endoscopic examination (rhinoscopy and nasopharyngoscopy)
Both CT and MRI are utilized to further characterize sinonasal tumors

12. Imaging
CT with thin section cuts (3 mm or less), obtained in both axial and coronal projections, is most useful for evaluating tumor invasion into bony structures such as the floor of the orbit and the infratemporal fossa
MRI offers a better assessment of tumor infiltration into adjacent soft tissues such as dura and cavernous sinus. Sagittal MRI views permit optimal assessment of the cribriform plate, base of the skull, and floor of the middle cranial fossa

13. CT
In general, tumors enhance more than any normal head and neck structures except mucosa, extraocular muscles, and blood vessels
A radiologically heterogeneous appearance or the presence of central low attenuation may indicate pathologic lymphadenopathy, even in small lymph nodes

14. AJCC & UICC staging system

16. Treatment Surgery: en bloc craniofacial resection
Management of the eye: preserved
Reconstruction: improved quality of life
Adjuvant RT: optimizes local control
Preoperative RT: unclear
The optimal management for paranasal sinus cancer is not known
Currently, the majority of patients undergo surgery with postoperative radiation

17. Follow up
Cavity cleaning 2-3 weeks postoperatively and again at 4-6 weeks
After all treatment is completed a general formula which is modified according to the individual patient's characteristics is: 1st year post treatment: 1-3 months 2nd year post treatment: 2-4 months 3rd year post treatment: 3- 6 months 4th and 5th years: 4- 6 months After 5 years: Every 12 months

18. Image follow up
Repeat CT/MRI scan at 3-6 months to establish a baseline exam and then at 6-12 month intervals depending on the clinical findings

19. Prognosis
There are no prospective data demonstrating a survival benefit for any follow-up strategy in patients with treated head and neck cancer
High-grade adenocarcinomas have a reported survival rate of less than 35% at 3 years.
For low-grade adenocarcinoma, the 5-year survival rate is approximately 80%.

20. Sinonasal adenocarcinomas
Most nonsalivary head and neck adenocarcinomas arise in the sinonasal tract
Two main categories: One resembling seromucinous glands and the other showing enteric-type differentiation

21. Two main categories
Low-grade tumors with fusion of glands composed of bland seromucinous cells, to those with cystic or tubulo-papillary growth patterns
Intestinal-type adenocarcinomas (ITAC), resembles metastatic carcinoma from the gastrointestinal tract
ITACs are reported to be more aggressive than seromucinous-type carcinomas

22. Well-differentiated sinonasal adenocarcinoma
Intestinal-type sinonasal adenocarcinoma

23. Thanks for listening

26. Weber-Fergusson incision

27. OP findings
Huge granular tumor with calcification occupying whole left maxillary, eyhmoid, sphenoid sinuses, nasal cavity and medial portion of orbital fossa
Left side partial maxillectomy, anterior and posterior ethmoidectomy, and sphenoidectomy was done

28. Adenocarcinomas of the nasal cavity and paranasal sinuses
Well-differentiated adenocarcinoma
Papillary type of adenocarcinoma
Solid type of adenocarcinoma
Mucinous type of adenocarcinoma
Colonic type of adenocarcinoma
Mixed type of adenocarcinoma