Post on 17-Jul-2015
Dr J. Daele
Les Pathologies tumorales malignes des cavités nasales et des sinus
Dr J. Daele
The Challenge
Anatomic complexity
High frequency of unresectability
Patient refusal of mutilating resection
Proximity to vital structure
Surgical resection are often piecemeal
50% local recurrence after surgery alone
Multimodal approach ( Surg; RxT;Chemo)
Dr J. Daele
EPIDEMEIOLOGY
• 3 to 4 % of head and neck cancer
• 3 males / 2 females
Dr J. Daele
Clinical features
Dr J. Daele
Clinical features
Symptoms indistinguishable from sinusitis
Nasal obstruction
Pain
Rhinorrhea
More suggesting
Unilat. recurrent Epistaxis
Abnormal sensitivity V1 /2
Unilateral symptoms
Dr J. Daele
Dr J. Daele
(Fiber) Optic Examination
• 30-degree rigid fiber-optic nasendoscope
• Topical decongestant – anaesthetic
• Flexible N.Ph.scope less suitable
• 90-degree laryngopharyngoscope
Dr J. Daele
Investigations
Septum
Dr J. Daele
Neck Examination
• Bimanuel examination of submandibula
• Bimanuel palpation of the cheek (Vest.C)
• Posterior neck triangle V (N.Pharyngeal C)
Dr J. Daele
QOL
• Karnofsky Index
• Generic Multidimensional questionnaires
Physical well- being
Psychological
Social
• Head and Neck Cancer Module EORTC QLQ-C30 is designed to be used in conjunction with generic muldimensonal QOLmeasure (EORTC)
Dr J. Daele
Karnofsky IndexSpecific criteria
Able to carry on normal activity No special care needed
100% Normal general status - No complaint - No evidence of disease
90% Able to carry on normal activity - Minor sign of symptoms of disease.
80% Normal activity with effort, some signs or symptoms of disease.
Unable to work /Able to live at home and care for most personal needs
Various amount of assistance needed
70% Able to care for self, unable to carry on normal activity or do work
60% Requires occasional assistance from others, frequent medical care
50% Requires considerable assistance from others; frequent medical care. Unable to care for self, Requires institutional or hospital care or equivalent, Disease may be rapidly progressing
40% Disabled, requires special care and assistance
30% Severely disabled, hospitalization indicated, death not imminent
20% Very sick, hospitalization necessary, active supportive treatment necessary, Terminal states
10% Moribund
0% Dead
Dr J. Daele
QOL
• Karnofsky Index
• Generic Multidimensional questionnaires
Physical well- being
Psychological
Social
• Head and Neck Cancer Module EORTC QLQ-C30 is designed to be used in conjunction with generic multidimensional QOLmeasure (EORTC)
Dr J. Daele
EORTC QOL-30
A well- validated scale that assesses symptoms prevalent in head and neck cancer and some functional concerns
Dr J. Daele
Advanced clinical evaluation
Ophtalmologic evaluation
Dental evaluation by a oral surgeon
Prosthetic rehabilitation (if maxillectomy)
Neurosurgery examination
Plastic surgery examinationDepending on the surgical approach
Dr J. Daele
Ophtalmologic signs
Exophtalmos
Visual loss
Eye motility impairment.
Tearing
Dr J. Daele
Diagnostic Imaging
• CT Paranasal Sin. and neck (Ax. Cor. Sag.)
• MRI Paranasal Sinus and Brain
Contrast
High Spatial Resolution Algorithm
Dr J. Daele
Diagnostic Imaging
• CT ++ Detecting Cervical Lymph N
Metastasis
Bone destruction• MR ++ Extent intra. cranial.or brain involvem.
Tumor >< Inflamation/Secretions
Retropharyngeal Lymph Nodes
Spine ( signs of Leptomening. spread)
Dr J. Daele
Dr J. Daele
Dr J. Daele
Diagnostic Imaging
• Panoramic dental X ray
• Metastases research
• Thoracic spiral CT
• Abdominal Echography
• Squeletal Scintigraphy
Dr J. Daele
PET SCAN
• Investigational in the preoperative assessment ( Health care context)
• Persistent/Stable abnormalities post treatment
• Recurent disease (edema, scarring, flaps)
Dr J. Daele
Dr J. Daele
Dr J. Daele
Laboratory tests
• Neuron-specific Enolase ( Esthesioneurob.)
not prospectively proven
• EBV serology ( IGA VCA et EA) in NPC
correlate with stage before treatment recurrent disease activity after treatment
Dr J. Daele
Miscellaneous investigations
• Maxillar prosthetic rehabilitation
• Anaplastologist advice
• Anatomopathologist for frozen/fixed section
Dr J. Daele
Dr J. Daele
Pathology• Squamous cell carcinoma 50%• Non squamous cell carcinoma Esthesioneuroblastoma SNUC Small cells carcinoma Adenocarcinoma Adenoïd Cystic Carcinoma Mucoepidermoïd Carcinoma T or B cells Lymphoma Plasmocytoma M.Melanoma Sarcoma Metastatic ( Renal/Lung/ breast)
Dr J. Daele
TNM STAGING
Dr J. Daele
TNM STAGING
• 2002 American Joint Committee Cancer
• University of Florida (Nas. Cav./Sph, Fron.Sin.)
• Massachusetts Gen. Hosp. ( Kadish system)
• 1997 AJCC St. System for skin Cancer Nas Vestibule
Dr J. Daele
2002 American Joint Committee on Cancer Staging
• Primary Tumor (T)
Tx Primary T. can not be assessed
To No evidence of primary tumor
Tis Carcinome in situ
Dr J. Daele
A.J.C.C. 2002Maxillary Sinus
• T1 T.limited to max.S. mucosa. No erosion or destruction of bone
• T2 T.causing bone erosion or destruction / hard palat./ middel n. meatus except.post. wall of M. Sinus and Pteryg. Plate
• T3 T. invades any of the following : bone of the post.wall of the Max.S / Subcut.Tisssues / Floor or medial wall of the orbit / Pteryg. Fossa/ Ethmmoid Sinuses
• T4a T.invades ant.orbital content/skin of cheek/pteryg. Plate / infratemp.fossa / cribrif. plate /sphen.or frontal sinus
• T4b T invades any of the following : orbital apex / dura / brain / middle cranial fossa / cranial nerve (V2) / nasopharynx / clivus
Dr J. Daele
AJCC 2002
• Nasal Cavity and Ethmoïd Sinus
• T1 T.restricted to one subsite, +/- bony invasion• T2 T.invading two subsites in a singel region or extending to
involve an adjacent region within the nasoethmoidal complex, +/- bony invasion
• T3 T. invades the medial wall or floor of the orbit,maxillary sinus, palate or cribriform plate.
• T4a T.invades any of the following : ant. orb. content skin of nose or cheek / ant. cranial fossa( minimun)
pterygo.plate s/ sphen. or frontal sinuses• T4b T. invades any of the following : orb.apex / dura / brain /• middle cranial fossa / cranial n. (V2) / nasoph. / clivus
Dr J. Daele
A.J.C.C. 2002 Stage GroupingStage 0 TIS N0 M0
Stage 1 T1 N0 M0
Stage 2 T2 N0 M0
Stage 3 T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage 4a T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Dr J. Daele
A.J.C.C. 2002
Stage 4b T4b Any N M0
Any T N3 M0
Stage 4c Any T Any N M1
Dr J. Daele
Dr J. Daele
A.J.C.C. 1997
Cancer of the n. Vestibule
• T1 T. < or = 2cm• T2 T. > 2cm but </= 5cm• T3 T. > 5cm• T4 T. invasion of cartilage, bone , nerves
favourable < 4cm no bone invasion unfavourable > or = 4cm + invasion of the
premaxilla and the bony septum
Dr J. Daele
Primary Treatment
Dr J. Daele
Primary Treatment Maxillary Sinus
Dr J. Daele
Dr J. Daele
P. Treatment for Etmoid CancerT1-T2
Surgery +/- RxT (Consider endonasal approach)
Margins status are difficult to asess
T3
External approach(endoscopic) + RxT
Combined CFR if cribrif plate or fovea ethm +/- Orb
exenteration +/- maxillectomy
T4
External approach( endoscopic) + CFR + RxT
( Contra ind extension to bil.orb. apex; bil. periorbita; cavernous sinus; massive infratemp.fossa)
RxT for unresectable tumors for medical or surgical reason
Dr J. Daele
Sinonasal tumors Sinonasal tumors Anterior cranial base surgeryAnterior cranial base surgery
Dr J. Daele
Cranial base / sphenoid surgery
Dr J. Daele
Post-Operative Results
Pre-Op Post-Op (19 months)
Dr J. Daele
Dr J. Daele
Primary Treatment for specific Pathologies
Extranodal Lymphoma Chemo+RxT
Plasmocytoma RxT
Rhabdomyosarcoma
Chemo +RxT+Surg +RxTChemo +Surg +RxT
Dr J. Daele
Dr J. Daele
Specific pathology
• SNUC Neoadjuvant Chemotherapy
• Preop. RT
• Surgical Resect C.F.R
• Elective Neck RT
Dr J. Daele
Primary treatment for neck
N0
Elective treatment (ND or RxT) depending on the treatment of primary T of both side of the neck is indicated when the tumor extends to the nasopharynx or/ and the soft palate
>N0
Appropriate N.D. on both side of the neck+ postoperative RxT
Dr J. Daele
Follow up
Dr J. Daele
Cavity cleaning
Fiberoptic examination
Neck palpation
Every 3 M (2 y) ; 6M( 3Y) ; 12M (5y)
MRI or CT
Every 6 M (5 y)
Laboratory test for Thyroid / pituitary gland( RxT on Neck)
Every 6 M (2y); 12M(5y)
Chest X ray ( or CT)
Every 12 months
Dr J. Daele
Treatment of recurrent
or metastatic disease
Dr J. Daele
Salvage treatment for recurrent disease
Depend onSite and extension (rTNM stage)
Previous treatment
Performance status
Patient wishes
Dr J. Daele
Dr J. Daele
Level of evidence
• Level 3 ( Opinions of the teams )
• Level 1
Proven role of neoadjuvant or concurrent chemotherapy in N.Pharyngeal Carcinoma
• Level 2
1- Elective neck RxT in Max. Carc T2 to T4 or in poorly diff. cancer
Dr J. Daele
Level of evidence
• Level 2
2-Neoadjuvant produces a high response rate in patients with undifferentiated carcinoma of the ethmoid
3-Bilat. elective neck RxT in stage B or C of Kadish ( lymphatic failure 20%)
4- The treatment for malignant melanoma is the same ,stage to stage, as for the squamous cell carcinoma
Dr J. Daele
Level of evidenceLevel 2
5- In SNUC no evidence that chemotherapy improve outcome in patients with limited disease over RxT alone
6- External beam RxT may have to be combined with brachytherapy in nasal vestibule cancers
7-In ethmoid cancers exenteration is not decided preoperatively even if clinical suspicions of orbital invasion
Dr J. Daele
Upgrading
• Sentinel ganglion
• Minimally Invasive ( endoscopic) Surgery
• Regul. Epidermic Growth Factor Receptor
mono human AB Cetuxi-Bevacizumab Chemo agents Sorafenib-Sunitinib
• Inhibition Vascul Endoth Growth F (Erlotinib)
• Multifractionned Radiotherapy
Dr J. Daele
Dr J. Daele
Time (months)
Pro
bab
ility
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0 Overall survival
Dr J. DaeleTime (months)
Pro
ba
bili
ty
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
T1T2T3T4
p=0.3831
Survival vs. staging
Dr J. Daele
Time (months)
Pro
ba
bili
ty
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
Other
Adenocarcinoma
Survival – adenocarcinomas vs. other
Dr J. Daele
Time (months)
Su
rviv
al p
rob
ab
ility
0 20 40 60 80 100
0.0
0.2
0.4
0.6
0.8
1.0
Extern.Endosc.
Survival Endosc. vs. external
Dr J. Daele
Dr J. Daele
Sinonasal tumors Sinonasal tumors Anterior cranial base surgeryAnterior cranial base surgery
Dr J. Daele
Cranial base.Left ethmoid, exposed dura.
Dr J. Daele
I.R.M.