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Case PresentationCase Presentation

-Abish Adhikari,Resident,

Department of Radiotherapy & Oncology,Bir Hospital, KathmanduSpeciality Posting: ENT

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Mrs Tamang.53/FHousewifeMakwanpur

Presentation:ENT OPD

Complaints:Pain in the Right cheek area ~ 7 monthsSwelling of the Right cheek ~ 6 months

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History of Present Illness● Pain was insidious onset, moderate in intensity, slowly

progressive, dull aching type, and aggravated on chewing.

● Took local practitioner's consultation, was prescribed analgesics.

● She then noticed swelling in her cheek, slowly growing in size reaching the current size in months.

● She had loosening of teeth on right upper jaw.● She has history of on and off headache, and weight

loss.● No fever, No nasal bleed, No recurrent runny nose, No

blurring of vision, diplopia.

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Past History

● No history of any surgical intervensions of oral cavity in the past.

● No history of Chronic diseases like Diabetes or Hypertension.

● No history of recurrent epistaxis.

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Personal History

● Smoker. Filtered Cigarettes. ~10 cigarettes per day since the age of 13. ~20 Pack Years.

● Doesn't chew tobacco.● Regularly consumes Jad. ~300 ml per day. ● Farmer by occupation.● Has not worked in industrial area.

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Examination

● General Condition: Fair● Performance Status (ECOG): 0● No icterus, No pallor, No clubbing, No cyanosis● Pulse: 80 bpm, regular● Blood Pressure: 130/90 mm Hg● Respiratory Rate: 20 per minute, regular● JVP : Not raised

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Examination

● Chest: Decreased air entry in the Right upper zone with few coarse crepts.

● CVS: Normal heart sounds, no murmurs audible● Abdomen: No distension, No organomegaly● Vision : Normal eye movements and vision.

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Local ExaminationInspection:

*Visible fullness of the right cheek extending upto the angle of mouth.

*Skin color normal

*Nasolabial groove obliterated.

* Nasofacial groove is normal

Palpation:

*6 x 8 cm smooth surfaced, hard mass extending from the zygomatic bone, occluding it to the angle of the mouth.

*Altered sensations on the right cheek.

*No blunting of Infraorbital ridge.

*Rest of the sinuses, non tender.

* 2x2 cm Rt. Level II LN1x1 cm Rt Level I b

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Oral Examination●Mouth opening Normal●The arch of hard palate bulging on the Right side.

●A smooth mass 3 x 6 cm on the Right upper Gingivo-Labial Sulcus,extending from the Canine to the 2nd Molar

●Right upper premolar and the three molars are mobile and tender.

●The upper surface of the growth can't be felt.

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● Anterior Rhinoscopy: Normal

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Diagnosis● Provisional Diagnosis:

● Carcinoma Maxillary Sinus● Differential Diagnosis:

● Osteosarcoma of Maxilla● Ameloblastoma● Fungal Rhinosinusitis● Bone Cysts from Maxilla● Dentegerous Cysts

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Investigations: Baseline● CBC: Normal

● RFT: Normal

● CXR: Normal

● HIV/HBsAg/HCV : Negative

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Investigations:Orthopantomogram

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CT Scan

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CT Reports● “Expansile lytic lesion involving the floor and the alveolar

process of the Right maxilla also involving the sockets of molar and premolar.

● Bone destruction and sunbrust apperance.

● Soft tissue mass lesion measuring 5.0 x 4.4 x 4.5 cm with necrotic areas.

● Part of adjacent hard palate and adjacent walls of maxilla is also involved.

● Right angular vein over the surface of SOL.

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HPE to be sent

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Carcinoma Maxilla: Overview

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Epidemiology

● Incidence -0.5-1/100,000 per year -0.2-0.8% of all malignancies -3% of upper aerodigestive tract neoplsm● 5th-6th decade● White race● M:F=2:1 – 4:1

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Environmental exposures

● Adenocarcinoma -wood dust, leather dust● Squamous cell carcinoma -Aflatoxin, chromium, asbestos, nickel, mustard gas, polycyclic hydrocarbons.● Viral: HPV

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Squamous cell carcinoma

● Most common histological type● 70% maxillary sinus● Male predominance● 7th decade

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Ohngren's line (1933): A line from medial canthus of the eye to the angle of the mandible● Anteroinferior/infrastructure:

good prognosis ● Superoposterior/suprastructure:

poor prognosis, early extension (eye, skull base, pterygoids, and infratemporal fossa).

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Patterns of tumour spread

● Anteriorly: cheek, skin● Posteriorly: pterygopalatine fossa, infra temporal

fossa, temporal bone middle cranial fossa● Medially: nasal cavity,NLD● Laterally: cheek, skin● Superiorly: orbit, ethmoid sinuses● Inferiorly: palate, buccal sulcus

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Presentation● Nasal findings: 50%

● Obstruction, epistaxis, rhinorrhea,discharge,extension into nasal cavity

● Oral symptoms: 25-35%● Pain, trismus, alveolar ridge fullness, erosion

● Ocular findings: 25%● Epiphora, diplopia, proptosis

● Facial signs:● Paresthesias, facial asymmetry, cheek swelling

● Auditory symptoms: hearing loss (OME)● Neurological: cranial nerve deficits II,III,IV.V1,V2,VI

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Regional spread

● 10% nodal disease: at presentation● 25-35% during course of disease.● Submandibular & jugulodigastric nodes:

most common

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Distant metastases

● Rare at presentation● Grave signs● Poor prognosis● 18 %: adenocarcinoma● 10%: SCC● Common sites: Lungs, bone, brain,

liver,skin

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Staging

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Survival vs Stage

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How to Proceed· H&P including a complete head and neck exam; mirror and fiberoptic examination as clinically indicated· Complete head and neck CT with contrast and/or MRI· Dental/prosthetic consultation as indicated· Chest imaging

Biopsy:· Preferred route is transnasal.· Needle biopsy may be acceptable.· Avoid canine fossa puncture or Caldwell-Luc approach.

Squamous cell carcinoma / AdenocarcinomaMinor salivary gland tumor / Sarcoma

Proper TNM Staging. 'T' status mainly radiological. Nodal status mainly clinical.

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Stage I / II (T1-T2, N0)● Surgical resection is the primary treatment.

● If margins are free (1.5-2cm), kept on regular follow-up without adjuvant therapy.

● If there is perineural invasion by the tumor, Adjuvant Radiotherapy is needed (±Chemo)

● If margins are positive, Re-surgery should be considered, after which, if margins come negative, RT only; if margins come positive, Chemo+RT is recommended.

The role of Chemotherapy has a 2B evidence. Individual cohort study or low quality randomized controlled trials.

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T3-T4, N0● Surgical resection is the primary treatment.

● If margins are free, RT to the primary & neck.

● If margins are positive, Chemotherapy and RT to the primary and neck.

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Node + Stage● Surgical excision with neck dissection is the recommended

primary treatment.

● Followed by RT to the primary site and neck if margins are negative and there is no extracapsular extension (of the node mets.)

● If margins positive or extracapsular extension, Chemotherapy along with RT to primary and neck is added as adjuvant therapy.

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Surgery Surgical approaches:

Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach

Extent of resection Medial maxillectomy Inferior maxillectomy Total maxillectomy

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Surgery

Unresectable tumors:Superior extension: frontal lobesLateral extension: cavernous sinusPosterior extension: prevertebral fasciaBilateral optic nerve involvementDistant Metastasis

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Radiation Techniques● Preferred interval between resection and RT ≤ 6 weeks● Conventional fractionation: 66-70 Gy (2.0 Gy/fraction

Monday-Friday) in 7 weeks● Alteration can be done with 6 fractions/week accelerated;

66-70 Gy● Neck nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)● Intensity-Modulated Radiotherapy (IMRT) has been

shown to be useful in reducing long-term toxicity by reducing the dose to salivary glands, temporal lobes, auditory structures, and optic structures.

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Simulate supine with thermoplastic mask immobilization.

● Tongue blade/cork to depress tongue out of fields.● Recommend 3DCRT or IMRT planning.● GTV = clinical and radiologic gross disease.● CTV = 1 cm margin on primary● Dose limitation is by Lens <10 Gy (cataracts,

Retina <45 Gy (vision).● Parotid mean dose <26 Gy (xerostomia)● Brain <60 Gy (necrosis). Mandible <60 Gy

(osteoradionecrosis).● Pituitary and hypothalamus mean dose <40 Gy.

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Complications

● Acute:

mucositis, skin erythema, nasal dryness, xerostomia

● Late:

xerostomia, chronic keratitis and iritis, optic pathway injury, soft tissue or osteoradionecrosis, cataracts, radiation-induced hypopituitarism

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Chemotherapy

● Primary Systemic Therapy + concurrent RT● Cisplatin alone (preferred)● 5-FU/hydroxyurea● Cisplatin/paclitaxel● Cisplatin/infusional 5-FU● Carboplatin/infusional 5-FU● Carboplatin/paclitaxel

● Cetuximab

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RADPLAT

Intra-arterial Cisplatin with systemic neutralization by i.v. sodium thiosulphate and Concomitant Radiation Therapy for Advanced Paranasal Sinus CA

● ADVANTAGES:– Allows very high cisplatin dose to be used– Minimizing adverse systemic effects. – Excellent locoregional control rates are achievable in

patients with unresectable disease– Favorable side-effect profile when compared with

conventional chemoradiation protocols

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Maxillary Carcinoma: Flowchart

Clinical Radiation Oncology, Gunderson et.al

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Followup

● H&P, labs, and CXR every 3 months for first year,

● Every 4 months for second year,● Every 6 months for third year, then annually. ● Imaging of the H&N at 3 months post treatment,

then as indicated

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Thank You !