Case Presentation: Carcinoma Maxilla
-
Upload
abish-adhikari -
Category
Health & Medicine
-
view
6.327 -
download
0
description
Transcript of Case Presentation: Carcinoma Maxilla
![Page 1: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/1.jpg)
1
Case PresentationCase Presentation
-Abish Adhikari,Resident,
Department of Radiotherapy & Oncology,Bir Hospital, KathmanduSpeciality Posting: ENT
![Page 2: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/2.jpg)
2
Mrs Tamang.53/FHousewifeMakwanpur
Presentation:ENT OPD
Complaints:Pain in the Right cheek area ~ 7 monthsSwelling of the Right cheek ~ 6 months
![Page 3: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/3.jpg)
3
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.
![Page 4: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/4.jpg)
4
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.
![Page 5: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/5.jpg)
5
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.
![Page 6: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/6.jpg)
6
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
![Page 7: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/7.jpg)
7
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.
![Page 8: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/8.jpg)
8
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
![Page 9: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/9.jpg)
9
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.
![Page 10: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/10.jpg)
10
● Anterior Rhinoscopy: Normal
![Page 11: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/11.jpg)
11
Diagnosis● Provisional Diagnosis:
● Carcinoma Maxillary Sinus● Differential Diagnosis:
● Osteosarcoma of Maxilla● Ameloblastoma● Fungal Rhinosinusitis● Bone Cysts from Maxilla● Dentegerous Cysts
![Page 12: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/12.jpg)
12
Investigations: Baseline● CBC: Normal
● RFT: Normal
● CXR: Normal
● HIV/HBsAg/HCV : Negative
![Page 13: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/13.jpg)
13
Investigations:Orthopantomogram
![Page 14: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/14.jpg)
14
CT Scan
![Page 15: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/15.jpg)
15
![Page 16: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/16.jpg)
16
![Page 17: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/17.jpg)
17
![Page 18: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/18.jpg)
18
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.
![Page 19: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/19.jpg)
19
HPE to be sent
![Page 20: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/20.jpg)
20
Carcinoma Maxilla: Overview
![Page 21: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/21.jpg)
21
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
![Page 22: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/22.jpg)
22
Environmental exposures
● Adenocarcinoma -wood dust, leather dust● Squamous cell carcinoma -Aflatoxin, chromium, asbestos, nickel, mustard gas, polycyclic hydrocarbons.● Viral: HPV
![Page 23: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/23.jpg)
23
Squamous cell carcinoma
● Most common histological type● 70% maxillary sinus● Male predominance● 7th decade
![Page 24: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/24.jpg)
24
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).
![Page 25: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/25.jpg)
25
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
![Page 26: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/26.jpg)
26
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
![Page 27: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/27.jpg)
27
Regional spread
● 10% nodal disease: at presentation● 25-35% during course of disease.● Submandibular & jugulodigastric nodes:
most common
![Page 28: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/28.jpg)
28
Distant metastases
● Rare at presentation● Grave signs● Poor prognosis● 18 %: adenocarcinoma● 10%: SCC● Common sites: Lungs, bone, brain,
liver,skin
![Page 29: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/29.jpg)
29
Staging
![Page 30: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/30.jpg)
30
![Page 31: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/31.jpg)
31
![Page 32: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/32.jpg)
32
Survival vs Stage
![Page 33: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/33.jpg)
33
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.
![Page 34: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/34.jpg)
34
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.
![Page 35: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/35.jpg)
35
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.
![Page 36: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/36.jpg)
36
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.
![Page 37: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/37.jpg)
37
Surgery Surgical approaches:
Endoscopic Lateral rhinotomy Transoral/transpalatal Midfacial degloving Weber-Fergusson Combined craniofacial approach
Extent of resection Medial maxillectomy Inferior maxillectomy Total maxillectomy
![Page 38: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/38.jpg)
38
Surgery
Unresectable tumors:Superior extension: frontal lobesLateral extension: cavernous sinusPosterior extension: prevertebral fasciaBilateral optic nerve involvementDistant Metastasis
![Page 39: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/39.jpg)
39
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.
![Page 40: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/40.jpg)
40
![Page 41: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/41.jpg)
41
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.
![Page 42: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/42.jpg)
42
![Page 43: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/43.jpg)
43
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
![Page 44: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/44.jpg)
44
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
![Page 45: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/45.jpg)
45
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
![Page 46: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/46.jpg)
46
Maxillary Carcinoma: Flowchart
Clinical Radiation Oncology, Gunderson et.al
![Page 47: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/47.jpg)
47
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
![Page 48: Case Presentation: Carcinoma Maxilla](https://reader033.fdocuments.net/reader033/viewer/2022050722/5495b53aac79593b2e8b4f04/html5/thumbnails/48.jpg)
48
Thank You !