Post on 06-Mar-2019
Paranasal Sinuses: Neoplastic
Lesions
ESHNR 2017
Lisbon, Portugal
Pravin Mundada
Department of Radiology,
Geneva University Hospital,
Switzerland
Layout of the presentation
• Clinical & imaging features of commonly seen benign & malignant sinonasal tumors
• Role of various imaging modalities in diagnosis & treatment planning
• What does the surgeon expect from a radiological report ?
Clinical overview
• Tumors of paranasal sinuses are rare
• Symptoms of benign & early malignant tumors mimic rhinosinusitis: stuffy nose, rhinorrhea,
epiphora & epistaxis
• Symptoms of advanced malignant tumors are related to tumor spread: pain, facial swelling,
cranial nerve palsies, anosmia & visual disturbances
• Often detected when they are large
• Imaging cannot give histopathological diagnosis in most instances
• Patient demographics & characteristic location of tumor may give diagnostic clue in some
cases
Imaging armamentarium
• CT, MRI, FDG PET-CT, FDG PET-MRI, Angiography
• CT & MR compliment each other
• CT: detects bone remodelling & destruction, provides surgial roadmap
• MRI: soft tissue morphology, diffusion & perfusion parameters, direct & perineural spread
• FDG PET-CT/MRI is a problem solving tool & useful for detection of recurrence
• Angiography is useful for pre-surgical evaluation & embolisation
CT & MRI protocols
CT:
• Pre & post-contrast volume acquisition in axial plane
• Multiplanar reconstructions in soft tissue algorithm (3mm slice thickness) & bone
algorithm (1mm)
MRI:
• T1W in axial & T2W in axial & coronal plane
• Axial T2FS & STIR coronal
• High-resolution post-gadolinium T1W & T1WFS sequences in axial & coronal planes,
• DWI (b-value 500 &1000)
Benign tumors and tumor-like conditions
Osseous & fibrosseous
• Osteoma
• Ossifying fibroma
• Fibrous dysplasia
Epithelial & other soft structures
• Inverted papilloma
• Juvenile angiofibroma
• Hemangioma
• Pleomorphic adenoma
• Nerve sheath tumor
What is your diagnosis?
A 55 year-old male with nasal blockade & rhinorrhea
Inverted papilloma (IP)• Benign but locally aggressive
• M>F, typically 40-70 years
• 13 % bilateral & 4% multifocal IP
• 10% degenerate into or co-exist with SCC
• CT: Bone remodelling, conical focal hyperostosis, entrapped bone sign
• MRI: Post-contrast T1WFS: convoluted cerebriform appearance
• Bone destruction on CT & invasive-necrotic appearane on MRI: malignant degeneration
Inverted papilloma
Dynamic Perfusion MRI can be used as a problem solving tool in certain cases
It is useful in differentiating
• a small multifocal IP from enhancing normal mucosa
• a small recurrent IP from post surgical changes
Treatment: Endoscopic resection/ mid-facial degloving/ medial maxillectomy + rhinotomy
Juvenile angiofibroma (JNA)• Benign, locally invasive, highly vascular tumor
• Almost exclusively adolescent males (10-25 years)
• Centred in posterior nasal cavity near sphenopalatine foramen (SPF)
CT: Avidly enahncing mass centred at SPF, bony remodelling +/- erosion, various
extensions
.
Juvenile angiofibroma• MRI: Heterogeneous, intermediate to high signal on T2W, flow voids +
• Angiography: Tumor blush, internal maxillary artery is feeding artery
• Treatment: Complete surgical resection + pre surgical embolization/ combination of
endoscopic + open resection/ radiation therapy
Osteoma• Benign slow growing tumor
• Frontal & ethmoid sinus are common locations
• Sporadic
• Rarely autosomal dominant (Gardner syndrome)
• 3 grades: ivory, mature and mixed
• < 5% are symptomatic: obstruction to sinus drainage & mass effect
Ossifying fibroma (OF)• Benign fibro-osseous tumor, locally agressive, F>M, 20-40 years
• 4 - subtypes: juvenile, active, agressive & psammomatoid
• CT: Well-defined expansile soft tissue density mass with egg-shell ossified rim
• MRI: Variable appearance, may mimic aggressive pathology/ fibrous dysplasia, may
show fluid-fluid levels
• Treatment: Complete surgical resection
Malignant tumors
Osseous
• Osteogenic sarcoma
• Chondrosarcoma
• Metastasis
Epithelial and other soft tissue structure
• Sqamous cell carcinoma (SCC)
• Esthesioneurobalstoma
• Undifferentiated carcinoma
• Adenoid cystcic carcinoma
• Mucoepidermoid carcinoma
• Non-Hodgkin lymphoma
• Melanoma
Squamous cell carcinoma (SCC)
• SCC accounts for 80% of all sinonasal cancers, of which about 75% are located in
maxillary sinus
• M>F, 50-70 years
• Risk factors: Noxious fume inhalation/ HPV/ inverted papilloma/ previous radiation/
immunosuppression
• 5 - year survival: For T1 stage about 100%, for T4a stage about 34%
• Better prognosis: Ethmoid sinus SCC, low tumor stage, HPV+ve, inverted papilloma
• Poor prognosis: Large tumor size, extension beyond sinus walls, nodal metastases,
perineural spread
Squamous cell carcinoma (SCC)
• MRI: Intermediate-high signal on T2W, moderate enhancement, restricted diffusion, direct
tumor extensions, perineural spread, retropharyngeal lymph nodes
• CT: Moderately enhancing mass/ irregular margins/ bone destruction
Case 1
Case 2
T-stage Maxillary Sinus SCC
Tis In situ
T1 Restricted mucosal lining
T2 Bone destruction, limited to hard palate and
middle meatus
T3 Bone destruction of post wall of maxillary
sinus; flor and medial wall of orbit; tumor
extension to ethmoid sinus and pterygoid
fossa
T4a Tumor growth in anterior orbit; pterygoid
plate; infratemporal fossa; cribriform plate;
frontal-sphenoid sinus; skin
T4b Tumor growth into orbital apex; dura; brain;
middle cranial fossa; cranial nerves other
than V2; nasopharynx; clivus
T-Staging of maxillary sinus SCC
Treatment: Chemoradiotherapy + surgery
Adenoid cystic carcinoma (ACC)• Malignant salivary gland-type adenocarcinoma, M>F, 50-70 years
• Aggressive, high incidence of recurrence, distant metastasis & perineural spread
• Recurrence or metastasis can occur even decades after treatment. Poor prognosis
• MRI: On T2W-intermediate signal with areas of high signal, heterogeneous enhancement,
restricted diffusion, perineural spread,
• CT: Solid or heterogeneously enhancing mass, bone destruction
• Treatment: Chemoradiotherapy + surgery
ACC- Case-1 ACC-Case II
Mucoepidermoid carcinoma (MEC)
• Malignant salivary gland-type adenocarcinoma, rare, M>F, 50-70 years.
• Aggressive & poor prognosis
• MRI: On T2W- intermediate to high signal, diffuse heterogeneous enhancement,
perineural spread
• CT: Solid or heterogeneously enhancing mass, bone destruction
• Treatment: Chemoradiotherapy + surgery
An interesting case:
A middle aged man with previous FESS for sinonasal polyposis underwent NECT at a
private center for recurrent nasal blockade & anosmia
This CT was reported as persistent sinonasal polyposis with rarefication of bones due to
long standing inflammation
Esthesioneuroblastoma (ENB)• Rare malignant neuroectodermal tumor arising from olfactory mucosa
• Bimodal distribution - 2nd & 6th decade
• Kadish Classification: A - nasal tumor, B - involvement of nasal cavity + sinuses, C - beyond
sinuses
• CT: Cribriform plate destruction, bony remodelling of nasal cavity
• MRI: Intermediate-high signal on T2, dumb-bell shaped, avid enhancement, cysts in
intracranial component, T2*GRE- blooming foci
• Treatment: Craniofacial resection + radiotherapy
What is your diagnosis?
An elderly lady with long standing nasal blockade & recurrent epistaxis
Undifferentiated sinonasal
carcinoma• Rare non-squamous cell type tumor
• Elderly > 60 years
• Aggressive & high propensity for distant
metastasis; perineural spread
• Unlike ENB, it extends beyond sinonasal cavity
• CT: Typically large enhancing mass, aggressive
bony destruction, often erode cribriform plate,
dumbbell shape due to intracranial component
• MRI: Low-intermediate T2 signal, areas of necrosis,
heterogenous enhancement
•Treatment: Chemoradiotherapy & surgery
Non-Hodgkin lymphoma• Mimics variety of neoplasms & inflammatory disorders
• Nasal cavity > sinuses, 6th -7th decade
• 3 types: B-cell, T-Cell & natural-killer T- cell (NKTL)
• MRI: Polypoid, Low-intermediate T2 signal, DWI - low ADC, perineural spread
• CT: Iso-hyperdense mass, bone remodelling +/- erosion
• FDG PET-CT: avid FDG uptake
• Treatment: Radiotherapy or chemoradiotherapy
Sinonasal malignant melanoma• Neural crest malignancy arising from melanocytes
• 90% seen in Caucacians, M>F, 50-80 years
• Propensity for systemic metastasis, poor prognosis, mean survival is 24 months
• Melanotic & amelanotic
MRI: Melanotic: T1W-hyperintense, T2W-hypointense
Amelanotic: T1W-intermediate, T2W-variable
Both: T2*GRE +/- blooming
CT: Lobular soft tissue mass, bone remodelling +/- erosion
Treatment: Aggressive radical excision & radiotherapy
What is your diagnosis
A 65-year-old male with recurrent sinusitis & recent episodes of epistaxis
What does the surgeon want to know about the
tumor?
• Malignant or benign
• Tumor margins & direct extensions
• Perineural spread
• TNM staging
Tumor extension & impact on treatment
JAF
ENB (stage T4b)
SCC (stage T4a)SCC (stage T4a)
SCC (stage T4b)
Foramen rotundum + Meckel cave
+ infratemporal fossa
IntraduralIntraorbital + hard palate
Masticator space Cutaneous infiltration
Ectopic ENB( stage T4b)
Skull base --cavernous sinus
Perineural spread & its impact on treatment
• Depiction of perineural spread helps in individualisation of radiation field
• Perineural spread to foramen rotundum & cavernous sinus suggests low
probablity of cure with radiotherapy
Adenoid cystic carcinoma Rhabdomyosarcoma Mucoepidermoid carcinoma
PPF + Maxillary NPPF + Vidian N +GSPN +
Facial N
PPF + Greater palatine
nerve
TNM staging
AJCC Cancer
Staging System,
8th Edition
Take home messages
• CT & MRI complement each other in the diagnosis & management of sinonasal tumors
• An aggressive inverted papilloma may mimic a malignant tumor
• A highly vascular posterior nasal cavity tumor in an adolescent male is typical of a JAF
• Melanotic melanomas are hyperintense on T1
• Otherwise, most malignant tumors have overlapping imaging features & imaging may not
indicate a histopathologic diagnosis
• Description of tumor margins, extensions & perineural spread impacts treatment
Acknowledgements
Prof. Dr. Minerva Becker
Department of Radiology
University Hospital, Geneva
Switzerland
Thank you for your attention
Matterhorn, 4478 metres mundada.pravin@gmail.com