Head & Neck

Sinus and Nasal Cancer

Sinus and nasal cancers form in the tissues within, around and behind the nose. The nose leads into the nasal cavity and is divided into two nasal passages. Paranasal sinuses are hollow spaces in the bones around the nose. Cells within the sinuses make mucus to prevent the inside of the nose from drying out during breathing. The sinuses and the nasal cavity work together to filter the air you breathe and make it moist before it reaches your lungs.

Several paranasal sinuses are named after the bones that surround them (see figure below):

  • Frontal sinuses: lower forehead above the nose.
  • Maxillary sinuses: cheekbones on either side of the nose.
  • Ethmoid sinuses: beside the upper nose, between the eyes.
  • Sphenoid sinuses: behind the nose, in the center of the skull.

Squamous cell carcinoma is the most common type of sinus and nasal cavity cancer. Cancers in this region are formed in the squamous cells, which are thin, flat cells that line the inside of the paranasal sinuses and nasal cavity.

Diagnosing sinus and nasal cancer

Cancer that is found in the sinuses and nasal cavity is often discovered because of symptoms such as blocked sinuses that do not clear, or sinus pressure; headaches or pain in the sinus areas; a runny nose; nosebleeds; a lump or sore inside the nose that does not heal; a lump on the face or roof of the mouth or neck; swelling or other trouble around the eyes; pain in the upper teeth; loose teeth or dentures that no longer fit well; vision changes or facial numbness.

If your doctor suspects you have sinus or nasal cancer, one or more of the following tests may be ordered:

  • A physical exam and history allows the doctor to check general signs of health, including checking for signs of disease, such as swollen lymph nodes. Your doctor will also examine your nose, face and neck.
  • Endoscopy allows the doctor to see inside the body with a thin, lighted, flexible tube called an endoscope. The tube is inserted through the mouth or nose to examine the head and neck areas. This examination has different names depending on the area of the body that is examined, such pharyngoscopy, which examines the pharynx.
    • Nasal endoscopy or nasopharyngoscopy is when the doctor examines the nasal cavity and nasopharynx with a thin, lighted, flexible tube called an endoscope. The tube is inserted through the mouth or nose to examine the head and neck areas.
    • Laryngoscopy is a procedure in which the doctor checks the larynx with a mirror or with a laryngoscope. A laryngoscope is a thin, tube-like instrument with a light and a lens for viewing. You may have numbing medicine sprayed at the back of your throat to make you more comfortable during the procedure.
  • Computed tomography (CT) involves a scanner that rotates around you that makes a series of detailed cross-sectional images of areas inside the body, taken from different angles. These images are made by a computer linked to an X-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly.
  • Magnetic resonance imaging (MRI) is a procedure that uses radio waves and a powerful magnet linked to a computer to create images, usually in 3D, of the tissues and organs inside your body.

If sinus and nasal cavity cancer is diagnosed, more tests will be done to find out whether cancer cells have spread within the sinuses and nasal cavity or to other parts of the body.

Staging

After diagnosing your sinus or nasal cavity cancer, your doctor will stage it, or determine its location and whether it has spread. Knowing the stage of your cancer will help your health care team recommend the best treatment option for you.

The TNM staging system, developed by the American Joint Committee on Cancer (AJCC), is typically used to stage head and neck cancers. This system classifies the cancer by tumor (T), node (N) and metastasis (M). The T category describes the size and location of the primary tumor. The N category describes lymph node involvement, indicating whether the lymph nodes show evidence of cancer cells. The location of these lymph nodes is important because it shows how far the disease has spread. The pathologic N category (sometimes denoted as pN) describes how many lymph nodes are involved and the amount of tumor cells found in the nodes. The M category describes distant metastasis (spread of cancer to another part of the body), if any. Staging for the M category is mainly clinical; however, a new M subcategory may be given based on the presence of tumor cells that can only be detected using a microscope or molecular testing.

Once the cancer has been classified, an overall stage is assigned. The main stages are Stage 0 (or I) through Stage IV, where Stage 0 (also known as “in situ”) is a precursor of an invasive cancer. Stages I and II are confined to the local area where the cancer is found; Stage III has often spread to the regional lymph nodes or lymphatic channels; and Stage IV has spread to distant sites (such as the lung or bone). Even these basic stages are sometimes further divided into subgroups of tumors that have a similar prognosis (Stage IB, Stage IIIC, etc). This grouping allows doctors to more accurately predict survival outcome according to stage and to adjust the treatment to the stage or substage of the cancer. For certain cancers, the AJCC also recommends tumor genetic testing, which can help determine which treatments are likely to be most effective.

Maxillary sinus cancer is staged differently than ethmoid sinus and nasal cavity cancers. The TNM values vary depending on where the cancer started, but the stages of sinus and nasal cavity cancer determined by the TNM values are the same. Sinus and nasal cancers are staged from Stage 0, or carcinoma in situ (in which the cancer cells are growing only in the inner lining layer of the sinus, parasinus or nasal cavity), to Stage IVC, in which the cancer has metastasized to distant organs.

Although the original stage at diagnosis does not change, a doctor may reassess an individual’s cancer after treatment or if it has recurred, in a process known as restaging. This is rarely done but will likely involve the same diagnostic tests used for the original diagnosis. If a new stage is assigned, it’s often preceded by an “r” to denote that it’s a restage and different from the original stage given at diagnosis.

TNM classification for sinus and nasal cancer

Classification Definition
Tumor (T)
Tx Primary tumor cannot be assessed.
T0 No evidence of primary tumor.
Tis Carcinoma in situ.
Maxillary
T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone.
T2 Tumor causing bone erosion or destruction, including extension into the hard palate and/or middle nasal meatus, except extension to posterior wall of maxillary sinus and pterygoid plates.
T3 Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit (eye socket), pterygoid fossa, ethmoid sinuses.
T4a Moderately advanced local disease. Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses.
T4b Very advanced local disease. Tumor invades any of the following: orbital apex, dura (membrane covering brain), brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve, nasopharynx or clivus.
Nasal Cavity and Ethmoid
T1 Tumor restricted to any 1 subsite, with or without invasion to bone.
T2 Tumor invades 2 subsites in a single region or extends to involve an adjacent region within the nasoethmoidal complex, with or without invasion to bone.
T3 Tumor extends to invade the medial wall or floor of the orbit (eye socket), maxillary sinus, palate (roof of mouth) or cribriform plate.
T4a Moderately advanced local disease. Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses.
T4b Very advanced local disease. Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than, nasopharynx or clivus.
Node (N)
Nx Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis to a single lymph node on same side as tumor, 3 centimeters (cm) (a little more than 1 inch) or less in diameter.
N2


  N2a

  N2b
  N2c
Metastasis to a single lymph node on same side as tumor, more than 3 cm but not more than 6 cm in diameter, or in multiple lymph nodes on same side, none more than 6 cm in diameter, or in lymph nodes on opposite side or both sides, none more than 6 cm in greatest dimension.
Metastasis to a single lymph node on same side as tumor, more than 3 cm but not more than 6 cm in diameter.
Metastasis to multiple lymph nodes on same side as tumor, none more than 6 cm in diameter.
Metastasis to lymph nodes on opposite side as tumor or on both sides, none more than 6 cm in diameter.
N3 Metastasis to a lymph node, more than 6 cm in diameter.
Metastasis (M)
M0 No distant metastasis, has not spread to distant organs.
M1 Distant metastasis, has spread to distant organs.

 

Stages of sinus and nasal cancer

Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3
T1
T2
T3
N0
N1
N1
N1
M0
M0
M0
M0
IVA T4a
T4a
T1
T2
T3
T4a
N0
N1
N2
N2
N2
N2
M0
M0
M0
M0
M0
M0
IVB T4b
Any T
Any N
N3
M0
M0
IVC Any T Any N M1

Treatment options

Treatment for sinus and nasal cancer may include surgery, radiation therapy, chemotherapy, immunotherapy and targeted therapy.

Surgery

Surgery is often used to treat sinus and nasal cancer by removing the cancer and some surrounding bone or other nearby tissues. Because of the location of these cancers, your eye or eye socket may be affected, although most of the time the eye can be saved. Your doctor will consider the location and stage of your cancer to choose the appropriate surgery for you.

If the cancer is found in the nasal cavity, a wide local excision may be made. This procedure involves removal of the tumor and an area of normal tissue around it. If the tumor is found in the septum (dividing wall of the nose), sometimes the whole septum is removed. If the tumor is in the side wall of the nasal cavity, the wall may need to be removed by a procedure called a medial maxillectomy.

Surgery for paranasal sinus tumors can vary. If the tumor is small and found only in the ethmoid sinuses, an endoscopic ethmoidectomy or external ethmoidectomy may be needed. Both surgeries may involve removal of the bone on the inner side of the eye socket and nose to gain access to the ethmoid sinuses. An endoscopic ethmoidectomy involves the use of an endoscope, a thin, lighted tube, to reach the ethmoid sinuses through the nose. An external ethmoidectomy involves making an incision (cut) between the nasal bridge and the eye to reach the ethmoid sinuses. This procedure may also be done with an endoscope. If the tumor has grown into the maxillary sinus, a maxillectomy may be done. This surgery may involve removal of bone from the roof of the mouth, upper teeth, part or all of the eye socket, part of the cheekbone, and/or the bony part of the upper nose.

When a surgeon needs to remove parts of the eye or the eye socket to remove the cancer near the sinuses, possible surgeries that may be needed include the following:

  • Orbital exenteration is the removal of all eye socket contents, including muscles, the lacrimal gland system and the optic nerve, as well as varying parts of the bone of the orbit. The eyelid may be spared. This procedure is performed for large cancers of the eye, the skin over the eye or eyelid or cancers from areas that extend into the eye socket, such as the paranasal sinuses, maxilla, skin or a part of the eye. This surgery is done after a general anesthetic has been given. Since this procedure is done for the spread of a cancer into the eye socket from another location, it is typically done along with an associated procedure such as a maxillectomy or craniofacial resection.
  • Enucleation is the removal of the eye, including the globe, but it leaves the eye socket contents in place. Orbital contents that may be left include the bones of the orbit, extraocular muscles, fat and conjunctiva, which is the mucous membrane that covers the front of the eye and lines the inside of the eyelids. This surgery is typically done for cancers such as retinoblastoma and other cancers in which vision is already gone. This surgery can be done with a regional nerve block without a general anesthetic. However, a small dose of an anesthetic may be given to keep you motionless. An artificial eye may be placed at a later date.

A craniofacial resection may be done if the cancer is found in the ethmoid sinuses, frontal sinuses and/or the sphenoid sinuses. This surgery is more extensive than a maxillectomy in that it can include removal of the upper parts of the eye socket and front of the skull base.

A neck dissection is often performed to remove lymph nodes, regardless of whether the cancer is in the sinus or nasal cavity. A partial or selective neck dissection involves removal of a few lymph nodes. A modified radical neck dissection involves removal of most of the lymph nodes on one side of the neck between the jawbone and collarbone, in addition to some muscle and nerve tissue. A radical neck dissection involves removal of nearly all of the lymph nodes on one side of the neck and even more muscle, nerves and veins.

Radiation therapy

Radiation therapy is the use of high-energy particles such as X-rays to kill cancer cells. It can be used as the main treatment instead of surgery or if a person’s general health is too poor for surgery. It also can be used after surgery to kill small areas of cancer cells; radiation therapy given after surgery is called adjuvant treatment. If the cancer has spread to the brain or spinal cord, radiation therapy may be used as well.

Radiation therapy is often given with chemotherapy in a combination called chemoradiation therapy.

Radiation therapy is given in two main ways: external and internal.

External-beam radiation therapy (EBRT) is the most common type of radiation therapy for sinus or nasal cancer. With this therapy, radiation is delivered to specific parts of the body from a machine. The therapy is similar to getting an X-ray, but the radiation is much stronger.

Internal radiation, also known as interstitial radiation or brachytherapy, is infrequently used if the cancer comes back after EBRT. Thin, metal rods containing radioactive materials are inserted in or near the cancer. The implants are removed before you leave the hospital.

Chemotherapy

Chemotherapy drugs, also called cytotoxic drugs, kill cells that divide quickly, such as cancer cells. Chemotherapy is considered a systemic treatment because the chemotherapy drugs travel throughout the body in the bloodstream. Treatment may involve the use of a single drug or multiple drugs in combination and is given in cycles. Chemotherapy may be combined with targeted therapy or radiation therapy.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow and kill cancer cells. This treatment approach involves the use of substances — made either by the body or in a laboratory — to identify cancer cells as a threat and target them for destruction.

Targeted therapy

Targeted therapy drugs work by targeting specific proteins and genes that help cancer cells grow. Some of these drugs target the epidermal growth factor receptor (EGFR), a protein on the surface of cancer cells that helps them grow and divide. The drugs block EGFR and stop it from working, which can help slow or stop cancer growth.

Additional Resources

 

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