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C A R C I N O M A O F T H E M A X I L L A R Y

A N T R U M - A 10 Y E A R E X P E R I E N C E

Sanjiv Sharma • S. C. Sharma • Sandeep Singhal • Y. N. Mehra • B. D. Gupta Sushmita Ghoshal • A. P. S. Sandhu

A retrospective analysis was performed of 250 cases of carcinoma of the maxillary antrum seen over a 10 years period (1975-1984). 98.24% patients were seen in T3 and T4 stages (UICC 1985). 40. 7% patients presented with clinically palpable nodes. 42.9% patients were treated by radical radiation and 18.6% by a combination of preoperative radiation followed by surgery. Rest 38.5% patients were treated with palliative intention. Three year disease free survival was 39.58% with radiation alone and 51.91% with combined modality treatment which includes patients salvaged by surgery. Failures were mainly at the local site, 75.86% with radiation alone and 60% with combined modality treatment. Combined modality treatment, preferably preoperative radiation followed by radical surgery, gives the best results

in the management of carcinoma of the maxillary antrum.

C ancer of the maxillary sinus is relatively uncomrnon constituting 0.2% to 2.2% of all malignancies,

5% of all malignant aerodigestive tumours and 80-90% of all paranasal sinus tumours (Ackerman and del Regato, 1985). Most of the cases present in advanced stages and assumption of an inflammatory pathology often contributes

Sanjiv Sharma, Resident S. C. Sharma, Additional Professor Sandeep Singhal, Resident

epartment of Radiotherapy, Y. N. Mehra, Professor & Head, Department Of Otolaryngology B.D. Gupta, Professor & Head Sushmita Ghoshal, Resident A.P.S. Sandhu, Resident Department of Radiotherapy. Post Graduate Institute of Medical Education and Research, Chandigarh, lndia, 160 0]2.

Address for reprints Dr. Sandeep Singhal, 227, Ayurvigyan Nagar, New Delhi-ll O 049, India. Based upon paper read at 8th Congress of Association of Radiation Oncologists of India, Bombay, December 5-8, 1986.

towards delay in the diagnosis. Hence the fundamental factor underlying the diagnosis at an early stage is high degree of suspicion (Mc Nicoll et al, 1984). The usual modern diagnostic methods are inadequate in one third of cases (Robin et al, 1980). Fortunately, despite the fact that majority of patients are advanced at time of presentation, propensity for nodal metastasis is low and distant metastasis is rare. Majority of the turnouts are squamous cell carcinomas of intermediate differentiation.

The present study analyses retrospectively the clinical spectrum of the carcinoma of the maxillary an t rum and results of various t reatment modalities in patients seen over a 10 year period at Depar tment of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh.

Mater ia ls and Methods

From 1975 to 1984, 226 cases of carcinoma of the maxillary an turm were seen. These constituted 1.8% of all

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A6E (~q0UPS (YEARS)

J~ MALER

• FE MALES

Fig. 1. Age and sex distribution of the patients.

hldian Journal of Otolao,t golo~; Volume 43, No. 4, l)ecember 1991 -- 191

Carcinoma of the Marillary Antrum - a 10 Year Erperience - - S h a r m a et al.

malignancies and 9.6% of all head and neck malignancies. Peak incidence was seen in fifth to seventh decades of life (Fig. l ) , with an overall male to female ratio of 1.28 : 1.0. Left side was slightly more commonly involved than the right (1.11 : 1.08); with bilateral involvement in one case.

Table I depicts the clinical spect rum of symptomatology. Cheek swelling was the commones t presentat ion (94.7%). 75.7% patients had mult iple site involvement and only 1.76% patients had disease confined to one site at t ime of presentation. There was high incidence of obvious skin involvement (27.8%) and trismus (7.5%).

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Carcinomma M a x i l l a r y Antrum -- Symptometology

Symptoms Clinical Presentation

Percentage No. Of Cases

Cheek Swleling 94.69 214 Oral Symptoms 73.89 167 Nasal symptoms 59.73 135 Facial pain 54.42 123 Orbital symptoms 34.51 78 Skin involvement 27.87 63 Toothache & Loosening of teeth 25.22 67 Cheek anaesthesia 9.29 21 Involvement of two sites 38.49 87 Involvement of three sites 37.16 84 Involvement of four or more sites 22.56 51

Table II shows the distribution of patients according to histology. Squamous cell carcinomas of varying grades consti tuted the majority (65.48%) followed by undifferentiated carcinoma (11.06%). Other histologies were quite uncommon.

40.7% patients presented with clinically palpable lymphadenopa thy (Tables I l l - - V ) . Commonly involved lymph node groups were upper deep cervical (jugulodigastric), submandibular , preauricular and middle deep cervical nodes in that order . Lower neck node involvement was rare (in one case). Lymph node involvement as a function of histology is depicted in Table IV. Squamous cell carcinomas and

. . . . . . . : : . : : . : : : : : . : . . . . . . . . . : . . . . . . . : . ~ 7 5 ~ 7 = 7 . . 7 ~ ' 7 - - ~ . - : 7

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Carcinoma Maxillary Antrum-Histologic D i s t r i b u t i o n

Histology Percentage

1. Squamous cell carcinoma 65.48 2. Undifferent ialcd carcinoma 11.06 3. Adenoid cystic carcinoma5.30 12 4. Adeno carcinoma 3.53 5. Transitional cell carcinoma 1.76 6. Others and unclassified I2.87

Total

undifferentiated carcinomas showed the highest propensity for lymph node metastasis.

All cases were staged retrospectively, according to staging system proposed by

No. Of Cases

148 25

8 4

29

100.00 226 i . . . . . . . . . . . . . . . . . . . . . . . . . . . I

haternational Union for Cancer Control (UICC, 1985), utilizing all available clinical and radiological data. Because CT became available only in the later p~,.rt of the study, an e lement of understaging in

(A)

Carcinoma Maxillary Abntrum - L )~nph N o d e S t a t u s A n d S i tes At P r e s e n t a t i o n

. . . . . . . . . . . . . . I

Total patients with Clinically palpable Nodes - 92 Site Percentage No. of cases i

Upper Deep Cervical 55.43 51 Submandibular 33.69 31 Preauricular 6.59 6 Middle and Lower Deep Cervical 4.29 4 Side Ipsilate-al 84.78 78 Bilateral 13.18 12 Contralateral 2.04 2

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Histology No. of cases No. of cases Percentage Total) ( +ve nodes) L

1. Squamous cell carcinoma 148 69 46.62- - I 2. Undifferentiated carcinoma 25 8 32.00 3. Adenoid cystic carcinoma 12 2 16.66 4. Adeno carcinoma 8 2 25.00 5. Others 33 11 33.33

Total 226 92 40.70

*Staging According To Uicc 1978

T1 T2 T3 T4 Total

No 0(0) 4(2.98) 59(44.04) 71(52.98) 134(59.3) N + 0(0) 0(0) 39(42.39) 53(57.61) 92(40.7) Total 0(0) 4(1.76) 98(43.36) 124(54.87) 226(100.0)

* Figures in parenthesis indicate percentage.

192 -- hldian Journal o f Otolar),ngolog¢, Volume 43, No. 4, December 1991

Carcinoma o f the Maxillary Antrum - a 10 Year Erperience - - Sharma et aL

many patients cannot be ruled out. 98.24% patients presented in T3 and T4 stages (Table V).

Although it is our policy to treat carcinoma of the maxillary antrum b); combination of radiation and surgery still 42.9% patients received only radical radiation. Included in this group are those patients who showed complete response and surgery was considered unnecessary, those who were technically unfit due to involvement of superior and posterior aspect of maxillary sinus where surgical clearance is usually inadequate, those who refused surgery and patients considered medically unfit for surgery.

18.6% patients were treated by a combination of radiation and surgery. All received pre-operative radiation followed 4-6 weeks later by total maxillectomy, via transfaciai or oral route. Extended maxillectomy or combined craniofascial

38.5% patients presented with too advanced disease and were offered palliative r/~diation only. We have not used chemotherapy electively in cases suitable for radical treatment at t i ne of presentation but used it in few patients suitable only for palliation or those who recurred subsequent to radical treatment. But their number is not significant enough to be commented upon.

Patients were followed up for a minimum period of three years, sometimes utilizing the services of Hospital based Tumour Registery. Maximum follow up was 8 years. All patients who underwent surgery were provided with prosthesis.

Observations and Results

Disease Free Surv iva l

Table VI depicts the disease free survival at 3 years. Out of 96 evaluable patients treated by radical radiation alone, 38

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Treatment Modality Incidence Cases NED at Evaluated 3 years

Radical Radiation 97(42.9) 96 38(39.58) Radiation + Surgery 42(18.6) 41 21(51.21)

*Figures in paranthesis indicate percentage

approach was resorted to whenever (39.58%) out of 41 evaluable patientswho considered necessary. For clinically were treated by a combination of evident lymphadenopathy, radical neck radiation and surgery were disease dissection was performed, whenever free at 3 years. Again included in this possible with primary surgery. Salvage group are 3 cases who recurred locally neck dissection was resorted to whenever and were salvaged by second surgery needed, successfully.

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Treatmentlncidence Local Nodal Local + Distant Modality Failure Failure Nodal Failure

Failure

Radical 58(60.42) 44(75.86) 4(6.89) 9(15.51) 1(1.74) Radiation

Radiation 30(48.79) 12(60.00) 2(10.00) 6(30.00) 0(0.0) Surgery

Overall 78(56.93) 56(40.87) 6(4.37) 15(10.94) 1(0.75)

* Figures in paranthesis indicate percentage

Re lapse Pat tern : Table VII depicts the failure pattern at 3 years. Failure rate was 60.42% in radiation alone group versus 48.79% in combination group. Local failures accounted for approximately 90% of the total and approximately 2.5% were nodal failures. Failures at distant sites were very rare.

Discussion

Management of tumours of maxillary antrum needs a multi-disciplinary approach. Surgery and radiation, alone or in combination are the mainstay of treatment. Some authors recommend a modified planned combined modality approach where a palatal fenestration is performed "~-8 weeks after radical radiation and surgery performed only if multiple biopsies reveal tumour (Calcaterra et al, 1985). This fenestration also helps in detecting any recurrence at an early stage.

Majority of the patients are already advanced at the time of presentaion and either of the modalities used alone gives very poor results, 5 year survivals being in range of 10-15% only. During the last two decades treatment by combining both the modalities has become the mainstay of treatment and better results have been shown by numerous series, with survival having been almost doubled (Lederman, 1970, Shidnia et al, 1984 and Lee et al, 1981). Lewis (1972) though a proponent of combined approach is of the opinion that though cure rates improve, some patients have to unnecessarily sacrifice sinus or sometime eye in instances where irradiation has achieved a cure. Proper sequence of surgery and radiation remains a bit controversial, with majority of authors favouring preoperative radiation followed by surgery (Lederman 1970, Lewis 1972).

Cure of cancer consists of removal of main tumour mass as well as peripheral microextensions in which surgery has got limitations clue to surrounding vital structures. Hence theoretically, a combination of surgery and radiation should give better results than either modality alone and the morality is largely clue to locally recurrent disease leading to

Indian Journal o]" Otolaryngology, Volume 43, No. 4, December 1991 -- 193

Carcinoma of the Marillary Antrum - a 10 Year F-rperience - - Sharma et al.

base of skull & intracranial invasion. Majority of relapses occur within 2 years of diagnosis (Lee et al, 1981). Hence relapse free survival of 3 years is a good indicator of cure.

With properly planned combined approaches, 5 year survival has imporved from 10-29% (Mc Nicoll et al 1984) to 50-70% (Lewis 1972, Lee et al 1981. Parsons et al 1987). This improvement has resulted from better management and control of primary (Shidnia et al, 1984). Local recurrence rate is markedly less with combined modality approach than with radiation alone. The combined modality, though it gives improved survivals, is still associated with lot of morbidity and cosmetic and functional problems. A new trend is emerging in favour of less aggressive approach, without any compromise of the survival (Chretien, 1975). Contrary to McNicoll 's view (1984) that surgery has always to be radical to be effective, advocate of conservative approach are less aggressive and reserve maxillectomy as a salvage measure, thereby providing better cosmetic and functional results.

Controversy exists regarding the managemen t of nodes because of their profound prognosis lowering effect (Me Nicoll 1984, Robin et al 1980). While some say any t rea tment with positive lymph nodes is futile (Stell et al 1976), but majority advocate that a curative a t tempt must at least be tried if nodes are mobile. Radical dissection has been found to be the method of choice, preferably at the t ime of primary surgery or else whenever they become palpable.

The symptomatology, the histologic distribution and the distribution of cases accordiong to the stage in our series resembles that repor ted in the literature. (Lederman 1970, Robin et al, 1980, Lee et al 1981, Shidnia et al, 1984). But the obviously perplexing observation i3 the very high incidence o f clinically detected lymphadenopathy which is almost double than that ment ioned in the l i terature (Macbeth 1965, Pointon 1969, Lee et al 1981, Shidnia et al 1984). Probable reasons for this high percentage could be advanced stage with high incidence of skin invasion and delay in presentation.

Higher survival rates in our series for patients treated by radiation alone (39.58%) is almost double that ment ioned in literature. We have not been able to attribute any sound reasoning for this observation. Disease free survival rates of 51.21% with combined modality approach at our institution are in confirmity with literature and we also strongly advocate a preoperative dose of 55-60 Gy followed 4-6 weeks later by surgery.

Relapse pattern in our series closely follows that given in literature. (Lee et al, 1981, Shidnia et al, 1984). Overall reported relapse rate is 44-70% out of which 65-80% are local failures, 10-20% are nodal lailures and 3-8% patients have tailed at distant sites. Commones t site of recurrence is posterior wall. In our series, both local as well as nodal failures were less in combined modality group.

Conclusions

From the present study, we arrived at following conclusions that :

1. Majority of the cases were advanced stage turnouts and with higher lymph node incidence.

2. The value of combined irradiation and radical surgery in a planned proper sequence is well recognized.

3. Radiation itself is associated with good cure rates and low morbidity.

4. Relapses are less common with combined therapy and majority of them are local failures.

5. Many patients who relapse 'can be salvaged successfully.

6. Advent of effective cytotoxic chemotherapy protocols used prior to conventional modalities and development of extended resection techniques to include parts of the skull base may give more hope for better future results.

Ret~rences

1. Ackerman and del Regato's Cancer Diagnosis, Treatment and Prognosis (1985) : St Louis, CV Mosby Company : 237-247.

2. Chretien, P.B. (1975) : Unique immunobiological aspects of head and neck carcinoma. Canadian Journal of Otolaryngology,4 : 225-235.

3. Caleaterra, T.C. and Juillard, G. (1985) : Nasal cavity and paranasal sinuses. In : Haskell, C.M. ed. Cancer Treatment, Second edition Philadelphia : WB Saunders Company : 488-491.

4. Jesse, R.H., Goepfert, H. and Lindberg, R.D. (1986) : Squamous cell carcinoma of maxillary and ethmoid sinuses. In : Proceedings of the seventh national cancer conference. Philadelphia, JB Lippincott : 193-197.

5. Lederman, M. (1970) : Turnouts of the upper jaw : Natural history and treatment. Journal of Laryngology and Otology, 84 : 369-401.

6. t,ewis J.S. and Castro E.B. (1972) : Cancer of the nasal cavity and paranasal sinuses. The Journal of Laryngology and Otology 86 : 255-262.

7. Lee, F. and Ogura, J. (1981) : Maxillary sinus carcinoma. Larynggoscope, 91 : 133-139.

8. Macbeth, R. (1965) : Malignant diseases of the paranasal sinuses. Journal of Laryngologl¢ and Urology,79 : 592-612.

9. Mc Nicoll, W., Hopkin, N., Dalley, V. M. and Shaw, H.J. (1984) : Cancer of the paranasal sinuses and nasal cavities - Part II. Journal of Laryngology and Otology, 98 : 707-718.

10. Pointon, R.C.S. (1969) : Neoplasia of the nose and sinuses. Journal of Laryngology, 83: 407-415.

11. Parsons, J.T., Mendenhall, W.M., Mancuso, A.A., Cassissi, N.J. and Million, R.R. (1987) : Malignant tumours of nasal cavity and ethmoid and sphenoid sinuses. International Journal of Raditation Oncology Biology and Physics, 14:11-22.

12.

13.

Robin, P.E. and Powel, D.J. (1980) : Regional node involvement and distant metastasis in carcinoma of the nasal cavity and paranasai sinuses. Journal of Laryngology and Urology, 94: 301-309.

Stell, P.M. and Green, J.R. (1976): Management of metastasis to the lymph glands of the neck. Proceedings of The Royal Society of Medicine, 69: 411-413.

14. Shidnia, H., Hornback, N. B., Saghafi, N., Sayoy, C., Lingeman, R., and ttamaker, R. (1984) : The role of radiation therapy in treatment of malignant turnouts of the paranasal sinuses. Laryngoscope;, 94: 102-106.

15. UICC (1985): TNM classification of malignant turnouts. Geneva : 27-29.

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