Post on 06-Mar-2019
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TREATMENT OF CANCERTREATMENT OF CANCER OF THE OF THE
NOSENOSE AND THE PARANASALAND THE PARANASAL
30th Alexandria International Combined ORL Congress (10-12 April 2013)
NOSENOSE AND THE PARANASAL AND THE PARANASAL
SINUSES SINUSES –– MODERN CONCEPTSMODERN CONCEPTS
Wojciech Golusiński
Department of Head and Neck Surgery
The Great Poland Cancer Centre, Poznan, Poland
University of Medical Sciences, Poznan, Poland
Piotr Pieńkowski
Head and neck surgery, especially surgery of the nose and Head and neck surgery, especially surgery of the nose and
paranasal sinues, is a very specific kind of surgery because paranasal sinues, is a very specific kind of surgery because
of specific anatomical conditionsof specific anatomical conditions
Head and Neck Surgery
of specific anatomical conditions of specific anatomical conditions
sense organs:sense organs:
–– sight sight
–– tastetaste
–– smellsmell
Very good vascularization Very good vascularization
and innervationand innervation
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Restricted surgical fieldRestricted surgical field
Difficult to view some anatomical structures, requires Difficult to view some anatomical structures, requires
Head and Neck Surgery
application of additional visual equipment application of additional visual equipment
(endoscope, microscope)(endoscope, microscope)
Common part of upper respiratory and alimentary tract Common part of upper respiratory and alimentary tract
determines operational and postdetermines operational and post--operational procedureoperational procedure
Head and neck cancers – tumor of the paranasal sinuses and anterior skull base
Crossing the borders of different specializationsCrossing the borders of different specializations
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Within the cooperation in the Department there is a therapeutic team proposing treatment for every single patient individually
Head and neck surgeonHead and neck surgeon
RadiotherapistRadiotherapistSk ll b
pp
AnesthesiologistAnesthesiologist
PathologistPathologist
NeurosurgeonNeurosurgeonTherapeutic Therapeutic meetingmeeting
Skull base team
Clinical oncologistClinical oncologist
Radiologist Radiologist
Psychologist Psychologist
PhysiotherapeutistPhysiotherapeutist
MAXILLARYMAXILLARY ETHMOIDAL COMPLEXETHMOIDAL COMPLEXMAXILLARYMAXILLARY--ETHMOIDAL COMPLEX ETHMOIDAL COMPLEX
TUMORS TUMORS
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MaxillaryMaxillary--ethmoidal complex tumors constitute 3% of ethmoidal complex tumors constitute 3% of
all neoplasms of the upper gastroall neoplasms of the upper gastro--pulmonary tract. pulmonary tract.
7 : 100 000 cases7 : 100 000 cases
M : FM : F M : F M : F
2:1 3:12:1 3:1
Head & Neck Oncology P. Evans 2003
Exposure to industrial fumes and wood dust has been
associated with an increased incidence of certain types
of sinonasal malignant tumorsof sinonasal malignant tumors.
Nickel workers show an incidence 250 times greater
than the general population with a latent period of 3 to
18 months.
Furniture workers, who are exposed to hardwood dust,
suffer an increased incidence of adenocarcinoma of the
ethmoid sinus.Head & Neck Oncology P. Evans 2003
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Sinuses & skull base
The most common clinical presentation of tumors of the
sinonasal tract includes nasal airway obstruction, pain,
epistaxis, nasal discharge, or swelling of the cheek.
9% to 12% of patients with sinonasal tumors are
asymptomatic
Weisberger and Dedo reported that paranasal tumors are
associated with a high incidence of cranial neuropathies
(34%) as compared to inflammatory disease (4% to 8%).
Head & Neck Oncology P. Evans 2003
Diagnosis Diagnosis –– Paranasal TumorsParanasal Tumors
Technique
History and Risk factors/cranial nervephysical deficits
Imaging Bone erosionRadiograms
CT scanning Evaluation of bony boundaries of PNS
MRI Evaluation of soft tissue and evaluation of orbit
Biopsy
Sinus lavage/gcytology
Fine needleaspiration
Transnasal biopsy Direct or endoscopic
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SurgerySurgery
TreatmentTreatment
RadiotherapyRadiotherapy
ChemotherapyChemotherapy
tumor’s histological type
t f l ti
What should be taken into consideration What should be taken into consideration when planning individual treatment? when planning individual treatment?
stage of neoplastic proccess
surgical radicalness
patient’s general condition
possibility of combined therapy
possibility of reconstruction
socio-economic factors
patient’s expectations
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MaxillaryMaxillary--ethmoidal complex tumorsethmoidal complex tumors
EpithelialBenign
Keratotic papilloma
Fungiform papilloma
NonepithelialBenign
Fibroma
Chondroma
NonepithelialMalignant
Soft tissue sarcoma
Rhabdomyosarcoma
Inverted papilloma
Cylindrical papilloma
Adenoma
Malignant
Squamous cell carcinoma
Transitional cell carcinoma
Adenocarcinoma
Ad id ti i
Osteoma
Neurilemmoma
Neurofibroma
Hemangioma
Leiomyosarcoma
Fibrosarcoma
Liposarcoma
Angiosarcoma
Myxosarcoma
Hemangiopericytoma
Connective tissue sarcoma
Ch dAdenoid cystic carcinoma
Melanoma
Olfactory neuroblastoma
Undifferentiated carcinoma
Chondrosarcoma
Osteosarcoma
Lymphoreticular tumors
Lymphoma
Plasmacytoma
Giant cell tumor
Metastatic Carcinoma
Sinuses & skull base
maxillary sinuses 60%
lateral nasal wall 30%
ethmoidal sinuses 10-15%
6060%%30%30%
1010--15%15%
sphenoidal and frontal sinus other6060%%30%30%
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American Joint Committee on CancerAmerican Joint Committee on Cancer
Ohngren lineOhngren line
Sinuses & skull base
infrastructure tumors infrastructure tumors –– better prognosisbetter prognosis
suprastructure tumors suprastructure tumors –– worse prognosisworse prognosis
From simple endoscopic lesion resection to a total From simple endoscopic lesion resection to a total
maxillectomy with exenteration of an orbitmaxillectomy with exenteration of an orbit and and
SurgerySurgery
yy
craniofacial resectioncraniofacial resection
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When to use the conventional surgical When to use the conventional surgical
SurgerySurgery
technique? technique?
When to use the endoscopic technique? When to use the endoscopic technique?
Is the fundamental rule of oncologicalIs the fundamental rule of oncological
SurgerySurgery
Is the fundamental rule of oncological Is the fundamental rule of oncological
surgery, surgery, removal of the whole tumor removal of the whole tumor
with a margin of neoplasmwith a margin of neoplasm--free tissues,free tissues,
possible to fulfill when using possible to fulfill when using p gp g
the endoscopic techniques? the endoscopic techniques?
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Endonasal endoscopic tumor removal:Endonasal endoscopic tumor removal:
Small intraethmoidal tumorsSmall intraethmoidal tumors
can be removed can be removed en blocken block..
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
Endonasal endoscopic tumor removal:Endonasal endoscopic tumor removal:
„Multilayer
centripetal technique”
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
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“Multilayer centripetal technique”
Top of the
Septum
Ethmoid
Top of the
ethmoid
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
„Multilayer centripetal technique”„Multilayer centripetal technique”
Endonasal endoscopic tumor removal:Endonasal endoscopic tumor removal:
Consists of 5 stages:Consists of 5 stages:gg
1.1. Decreasing tumor’ massDecreasing tumor’ mass
2.2. Subperiosteal removing of ethmoidSubperiosteal removing of ethmoid
3.3. Removal of bony structures surrounding the tumor (septum, Removal of bony structures surrounding the tumor (septum, bones of the skull base, lamina papiracea)bones of the skull base, lamina papiracea)
44 R l f th d lf t b lb i bitR l f th d lf t b lb i bit
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
4.4. Removal of the dura, olfactory bulb, periorbitRemoval of the dura, olfactory bulb, periorbit
5.5. Plastic of the dura of the skull basePlastic of the dura of the skull base
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Area of the removal of ethmoid
for intraoper.
histological
examination
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
Area of the nasal septum removal
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
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Area of the medial maxillectomy
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
Plastics of the dura
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
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Exclusion criteria in endoscopic approach
Frontal sinus involvement
Orbital content involvement
Massive dura involvement (not merly contact or focal
involvement)
Maxillary sinus bony involvement (except the medial wall)
Extension to nasopharynx but not limited to
h b il f ipharyngobasilar fascia
Lacrimal tract involvement
Hard palate involvement
Nasal pyramid involvement
Smith 1954 Smith 1954 –– malignant tumors developing from upper part of malignant tumors developing from upper part of
“Craniofacial resection” for tumors “Craniofacial resection” for tumors located within cribrumlocated within cribrum and skull baseand skull base
nasal cavities, ethmoidal sinuses (posterior ethmoidal complex) nasal cavities, ethmoidal sinuses (posterior ethmoidal complex)
and structures of orbital cavityand structures of orbital cavity
NonNon--malignant but clinically aggressive tumors: meningioma, malignant but clinically aggressive tumors: meningioma,
chordoma, juvenile adenofibroma penetrating to the inside of the chordoma, juvenile adenofibroma penetrating to the inside of the
skullskull
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Ketchum 1963 Ketchum 1963 –– reported the first series ofreported the first series of patients treated with patients treated with
“Craniofacial resection” for tumors “Craniofacial resection” for tumors located within cribrumlocated within cribrum and skull baseand skull base
an anterior craniofacial resection foran anterior craniofacial resection for tumors arising in the ethmoid tumors arising in the ethmoid
sinusessinuses;;
aann enbloc resection of tumor, including the ethmoid sinuses,enbloc resection of tumor, including the ethmoid sinuses,
superior nasal septum, and floor of the anterior cranialsuperior nasal septum, and floor of the anterior cranial fossa, fossa,
corresponding to the interorbital area (i.e. anteriorcorresponding to the interorbital area (i.e. anterior craniofacial craniofacial
resection) or extended laterally to include partresection) or extended laterally to include part of the bony orbit or of the bony orbit or
its soft tissue contents (anterolateralits soft tissue contents (anterolateral craniofacial resection)craniofacial resection)
“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
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“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
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“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
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“Craniofacial resection” for tumors located“Craniofacial resection” for tumors locatedwithin cribrumwithin cribrum
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52 years old woman52 years old woman
Chondrosarcoma
diplopia for two weeks diplopia for two weeks
before hospitalisationbefore hospitalisation
MRI
Pathological mass in sphenoid bone fiiling up sphenoid Pathological mass in sphenoid bone fiiling up sphenoid
sinus,penetrating nasopharynx, nasal cavity and posterior part sinus,penetrating nasopharynx, nasal cavity and posterior part
of ethmoid sinusof ethmoid sinus
Chondrosarcoma
o e o d s uso e o d s us
MRI
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CT
Chondrosarcoma
Tumor fills sella turica and
presses cavernous sinuses
Chondrosarcoma
Surgery
Endoscopic
approachapproach
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Chondrosarcoma
Week after
surgery
Chondrosarcoma
6 months after
surgery and
di thradiotherapy
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Chondrosarcoma
CT week
after
surgery
MRI 6 months after surgery
Chondrosarcoma
after surgery and
radiotherapy
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combined endoscopic transnasal combined endoscopic transnasal
CranioCranio--endoscopic techniqueendoscopic technique
and transcranial approach and transcranial approach
cooperation with neurosurgeoncooperation with neurosurgeon
tumors penetrating in the nasal cavity and anteriortumors penetrating in the nasal cavity and anterior tumors penetrating in the nasal cavity and anterior tumors penetrating in the nasal cavity and anterior
cranial fossacranial fossa
Area of the resection
Area forArea for
neurosurgeon
Area for head &
neck surgeonneck surgeon
Endonasal micro-endoscopic treatment of malignat tumors of the paranasal sinuses and anterior skull base. Paolo Castelnuovo et ala.Operative Technique in Otolaryngology (2006) 17, 152-167.
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Endonasal endoscopic tumor removal:Endonasal endoscopic tumor removal:
for every patient/tumor?for every patient/tumor?
NONO
MRMRII
Carcinoma planoepitheliale
54 years old male
Tumor of the hard palate
for 3 weeks
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CT after surgery
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32 years old male
4 k hi f idl
Leiomyosarcoma
4 weeks history of rapidly
growing tumor in oral cavity
Leiomyosarcoma
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16 years old male
Esthensioneurblastoma
2 years history
– tumor of the right
orbit
History of alternative
treatmenttreatment
T3 Kadish staging
system
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MRI
Esthensioneurblastoma
Esthensioneurblastoma
Surgery
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Esthensioneurblastoma
MRI
4 months
after surgery
Esthensioneurblastoma
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Esthensioneurblastoma
Esthensioneurblastoma
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Endoscopic evaluation
Patient qualified for:Patient qualified for:
endoscopicendoscopic--transcranial approach.transcranial approach.endoscopicendoscopic transcranial approach.transcranial approach.
Craniofacial resection. Craniotomia fronto basalis, Craniofacial resection. Craniotomia fronto basalis,
orbitotomia supramedialis, excisio tumoris cavi nasi, orbitotomia supramedialis, excisio tumoris cavi nasi,
septi nasi, sinus ethmoidalis anterior et posterior, septi nasi, sinus ethmoidalis anterior et posterior,
sinus frontalis et sphenoidalissinus frontalis et sphenoidalissinus frontalis et sphenoidalis. sinus frontalis et sphenoidalis.
Lymphadenectomia selectiva colli sin. Lymphadenectomia selectiva colli sin.
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Endoscopic evaluation – 7 days after surgery
Patient qualified for:Patient qualified for:
radiochemiotherapy.radiochemiotherapy.radiochemiotherapy.radiochemiotherapy.
–– radiotherapy: radiotherapy: 6060 Gy, dfGy, df == 2Gy2Gy
–– chemiotherapy: PPD (chemiotherapy: PPD (Cisplatinum 80Cisplatinum 80 mg, mg,
Ondansetronum 8Ondansetronum 8 mgmg))
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70 years old male
Plasmocytoma
70 years old male
Headaches for 3 months
MRI
Plasmocytoma
Surgery
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Treatment Treatment –– Tumors of the Sinonasal TractTumors of the Sinonasal Tract
Modality Indications
Surgery Mainstay treatment
Radiation Unresectable or lymphoreticu-lar tumors, poor surgical can-didates. Usually requires sur-gical drainage/debridement
Combination therapy (+) margins, perineural, peri-vascular invasion(+) lymph nodes, recurrent tumor
Chemotherapy Palliative roleClinical research
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Benign tumorsBenign tumors
SUMMARY
Endoscopic removal is recommended.Endoscopic removal is recommended.
The limitation The limitation –– involvement of the frontal sinus or the involvement of the frontal sinus or the
orbita.orbita.
The point of origin has a greater importance than the The point of origin has a greater importance than the
size of the pathology.size of the pathology.
Endoscopic endonasal skull base surgery: past, present and future. Paolo Castelnuovo et ala. Eur Arch Otorhinolaryngol (2010) 267: 649-663.
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Treatment results (total survival time) using Treatment results (total survival time) using
d i t h i i il t th lt id i t h i i il t th lt i
SUMMARY
endoscopic technique are similar to the results using endoscopic technique are similar to the results using
external approaches.external approaches.
The appropriate qualification for the endoscopic The appropriate qualification for the endoscopic
surgerpy is very importantsurgerpy is very importantsurgerpy is very important.surgerpy is very important.
Endoscopic endonasal skull base surgery: past, present and future. Paolo Castelnuovo et ala. Eur Arch Otorhinolaryngol (2010) 267: 649-663.
Treatment of maxillaryTreatment of maxillary--ethmoidal complex tumors ethmoidal complex tumors
h ld b i t di i li thh ld b i t di i li th
SUMMARY
should be an interdisciplinary therapyshould be an interdisciplinary therapy