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.