Radiation Oncology/Head & Neck/Sinonasal/Overview

Nasal Cavity and Paranasal Sinuses For now please see individual subpages Epidemiology Tumors of the nasal vestibule are frequently considered separately from nasal cavity and paranasal sinus tumors, because they are essentially skin cancers and as such have a different natural history Primary tumors of the nasal cavity and paranasal sinuses are usually grouped together, because they are frequently advanced at presentation and it's not clear from which site they originated Annual incidence ~1/100,000 Occur more often in men, and age >40 (except salivary gland tumors and esthesioneuroblastoma which are seen earlier) Anatomy Sites Nasal vestibule Nasal cavity Maxillary sinuses Frontal sinuses Ethmoid sinuses Sphenoid sinus Lymphatic drainage Nasal vestibule: submandibular LNs, usually ipsilateral but may be bilateral Nasal cavity: olofactory group and respiratory group with different drainage patterns Olofactory group drains to lateral retropharyngeal LNs, but can also communicate with subarachnoid space and CSF Respiratory group drain lower, in lateral retropharyngeal LNs or in Level II LNs Paranasal sinuses have minimal drainage Pathology Benign: inverting papilloma can be associated with carcinoma in 5-15% of cases Squamous cell carcinoma most common Minor salivary glands account for 10-15% cases Lymphoma accounts for ~5%, and includes NK/T cell variant, which is locally very destructive Esthesioneuroblastoma accounts for 3-4% Mucosal melanoma accounts for ~1% Treatment Overview Combination of radical surgery and postop radiation is a frequently used approach Surgical approaches depend on location, and include lateral rhinotomy, medial maxillectomy, total maxillectomy, or craniofacial resection Extent of surgery correlates with DFS and OS, but not local control if RT is used Higher radiation doses are associated with improved local control, but visual toxicity is common Conversely, using conformal RT reduced toxicity while keeping survival comparable to conventional RT Poor overall survival ~50% at 5 years Outcomes Ghent, Belgium 2005 (1998-2003) 15915466 -- "Postoperative intensity-modulated radiotherapy in sinonasal carcinoma: clinical results in 39 patients." (Duthoy W, Cancer. 2005 Jul 1;104(1):71-82.) Retrospective. 39 patients, surgery + postop RT. AdenoCA 79%, SCC 21%. Cribriform plate invasion 28%, orbital invasion 36%. Median IMRT 70 Gy. Median F/U 2.6 years Outcome: 4-year LC 68%, 4-year OS 59% Toxicity: decreased vision 6%, no blindness Conclusion: Postop IMRT good LC, with low acute toxicity 2009 (1998-2006) 18755554 -- "Intensity-modulated radiotherapy for sinonasal tumors: ghent university hospital update." (Madani I, Int J Radiat Oncol Biol Phys. 2009 Feb 1;73(2):424-32. Epub 2008 Aug 26.) Retrospective. 84 patients. Postop IMRT in 89%, primary 11%. Median F/U 3.3 years Outcome: 5-year LC 71%, DFS 60%, DMFS 82%, DSS 67%, OS 58%. Invasion of cribriform plate negative predictor Toxicity: No radiation blindness, 1 patient radiation retinopathy, 1 patient lacrimal duct stenosis, 3 patients brain necrosis Conclusion: IMRT low rate of toxicity, with high local control and survival Turin, Italy; 2008 (2000-2005) 18705398 -- "Stage III-IV sinonasal and nasal cavity carcinoma treated with three-dimensional conformal radiotherapy." (Gabriele AM, Tumori. 2008 May-Jun;94(3):320-6.) Retrospective. 31 patients, locally advanced paranasal sinus and nasal cavity tumors. 3D-CRT. Postop (68%) dose 60 Gy or radical dose 68 Gy (32%). Some use of chemotherapy. Median F/U 3.5 years Outcome: Postop: 5-year LC 74%, 5-year OS 72%. Radical RT 20% and 25%. Local recurrence most common site of failure Toxicity: No radiation-induced blindness; 4 patients enucleation as part of radical surgery Conclusion: Local control remains low; 3D-CRT reduces risk of optical pathways but doesn't modify survival UCSF IMRT; 2007 (1998-2004) 17189068 -- "Intensity-modulated radiation therapy for malignancies of the nasal cavity and paranasal sinuses." (Daly ME, Int J Radiat Oncol Biol Phys. 2007 Jan 1;67(1):151-7.) Retrospective. 36 patients with PNS cancers, 32 after gross total resection. Sites: 13 ethmoid, 10 maxillary, 7 nasal cavity, 6 other. IMRT 70 Gy to GTV, and 60 Gy to CTV. Median F/U 51 months 5-year outcomes: LC 58%; DFS 55%; OS 45% Toxicity: minimal, no decreased vision, 1 xerophalmia, 1 lacrimal stenosis, 1 cataract Conclusion: IMRT no benefit on disease control, but low incidence of complications Historical; 2007 (1960-2005) 17459609 -- "Carcinomas of the paranasal sinuses and nasal cavity treated with radiotherapy at a single institution over five decades: are we making improvement?" (Chen AM, Int J Radiat Oncol Biol Phys. 2007 Sep 1;69(1):141-7. Epub 2007 Apr 24.) Retrospective. 127 patients, sinonasal carcinoma. Conventional 46%, 3D-CRT 39%, IMRT 18% Outcome: 5-year OS: 1960's 46%, 1970's 56%, 1980's 51%, 1990's 53%, 2000's 49% Toxicity: Grade 3-4 late: 53%, 45%, 39%, 28%, 16% (SS) Conclusion: No improvement in disease control or survival, but decreased incidence of complications MSKCC; 2006 (1987-2005) 17161557 -- "Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative setting-the MSKCC experience." (Hoppe BS, Int J Radiat Oncol Biol Phys. 2006 Dec 7) Retrospective. 85 patients with PNS, treated with post-op RT. Median RT 63 Gy. 62% treated with IMRT or 3D-CRT, rest with 2D. Median F/U 60 months 5-year outcomes: LC 62%, DM-free 82%, DFS 55%, OS 67%. Bad prognosis: squamous cell and cribriform plate involvement Toxicity: 1 blindness (but no Grade 3-4 among patients treated with IMRT/3D-CRT) Conclusion: Local recurrence main problem. Modern RT safe. Treatment Technique Utah; 1991 1764170 -- "Graduated block technique for the treatment of paranasal sinus tumors." (Tobler M, Med Dosim. 1991 Dec;16(4):199-204.) 5-field graduated wedge technique. AP beam heavily weighted, prescribed just beyond lens. Lateral wedge fields posteriorly fill-in dose as anterior contribution decreases Proton Therapy Clinical Outcomes Harvard 2008 (1991-2002) 17902164 -- "Extent of surgery in the management of locally advanced sinonasal malignancies." (Resto VA, Head Neck. 2008 Feb;30(2):222-9.) Retrospective. 102 patients, locally advanced, treated with proton therapy with or without surgery (R0 20%, R1 49%, R2/biopsy 31%). Squamous cell 32%, neuroendocrine 29%, adenoid cystic 20%, sarcoma 13%, adenocarcinoma 6%. Median RT dose if R0 resection 67.6 Gy, if R1/R2 resection 75.6 Gy usually given BID. Median proton contribution 57%. Concurrent chemo 33% (typically for neuroendocrine). Median F/U 3.6 years, alive 5.1 years Outcome: 5-year LC R0 95% vs R1 82% vs R2 87% (NS, no difference by histology); 5-year DFMS 95% vs. 69% vs 52% (no difference by histology). 5-year OS 90% vs 49% vs 39% (worst for squamous cell). Regional failure rate 12% Conclusion: High dose proton RT excellent local control regardless of extent of surgery. However, DFS and DMFS depended on extent of surgery. Can consider observation for regional neck 2006 (1991-2001) 17050017 -- "Visual outcome of accelerated fractionated radiation for advanced sinonasal malignancies employing photons/protons." (Weber DC, Radiother Oncol. 2006 Dec;81(3):243-9. Epub 2006 Oct 16.) Retrospective. 36 patients, advanced stage nasal or paranasal malignant tumors. Treated with aggressive surgery and post-op RT (78%) or radical RT (22%). Median dose 69.6 CGE, usually BID or concomitant boost. Proton contribution 20-85% depending on beam availability. No concurrent chemo. Median F/U 4.4 years Outcome: 3-year OS 90%, 5-year OS 81%. 3-year DFS 77%, 5-year DFS 73% Toxicity: late visual/ocular toxicity Grade 2+ (retinopathy, optic neuropathy, cataract, dry-eye syndroma, or nasolacrimal duct blockage) 22% in median 2.6 years after RT) Conclusion: AFRT enables delivery of 70 CGE with acceptable ophthalmologic complications 2002 (1992-1998) 12173330 -- "Neuroendocrine tumors of the sinonasal tract. Results of a prospective study incorporating chemotherapy, surgery, and combined proton-photon radiotherapy." (Fitzek MM, Cancer. 2002 May 15;94(10):2623-34.) Prospective. 19 patients with olofactory neuroblastoma or neuroendocrine carcinoma. Kadish Stage B 4/19, Kadish Stage C 15/19. Induction cisplatin/etoposide x2 cycles, then proton/photon RT to 69.2 CGE concomitant boost. If response, further 2 cycles of chemo. Median F/U 3.7 years Outcome: 5-year OS 74%; 5-year LC 88% Toxicity: 1 patient unilateral vision loss after induction chemo. 4 patients frontal/temporal lobe damage by MRI. 2 patients soft tissue/bone necrosis. No radiation-induced visual loss Conclusion: This approach is successful, with radical surgery reserved for nonresponders Chiba; 2007 (1999-2005) 17398027 -- "Proton-beam therapy for olfactory neuroblastoma." (Nishimura H, Int J Radiat Oncol Biol Phys. 2007 Jul 1;68(3):758-62. Epub 2007 Mar 29.) Retrospective. 14 patients (Kadish A 2/14, Kadish B 5/14, Kadish C 7/14). Dose 65 GyE in 2.5 Gy/fx. Median F/U 3.3 years Outcome: 5-year LC 84%, 5-year RFS 71%, 5-year OS 93% Toxicity: Liquorrhea 1 patient, no other Grade 3+ Conclusion: Excellent local control and survival outcome, without serious side effects Treatment Planning PSI Paranasal; 2003 12559516 -- "Intensity modulation in radiotherapy: photons versus protons in the paranasal sinus." (Lomax AJ, Radiother Oncol. 2003 Jan;66(1):11-8.) Treatment planning. Paranasal case, three dose levels 76 Gy, 66 Gy, and 54 Gy. IMRT vs IMPT comparison Outcome: Comparable target conformality and sparing of critical structures; low dose regions or target homogeneity trade-off in IMRT plan Conclusion: Comparable target conformality and sparing of critical structures, low dose regions better with IMPT Paraorbital; 2000 10863085 -- "Optimizing radiotherapy of orbital and paraorbital tumors: intensity-modulated X-ray beams vs. intensity-modulated proton beams." (Miralbell R, Int J Radiat Oncol Biol Phys. 2000 Jul 1;47(4):1111-9.) Treatment planning. 4 orbital/paraorbital tumors. IMRT vs IMPT. Outcome: PTV coverage comparable. DVHs for OAR better with IMPT, though predicted severe NTCP equally low Conclusion: Both IMRT and IMPT optimally treated PTV and reduced severe late toxicity; IMPT better at low/mid-dose regions