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 warm and moisten it before it reaches your lungs.

The 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, but many other types of cancers can occur as well. Cancer in any of the sinuses is rare, but among these cancers, the maxillary sinus is the most common site, followed by the ethmoid sinuses.

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, tests to confirm the diagnosis will be done. If sinus or 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 assign a stage to it according to its size, location and whether it has spread to other areas of the body. Knowing the stage of your cancer will help your health care team recommend the best treatment option for you.

Maxillary sinus cancer is staged differently than ethmoid sinus and nasal cavity cancers.The TNM (tumor, node, metastasis) staging for maxillary sinus cancer depends on where the cancer started, but the TNM staging of ethmoid sinus and nasal cavity cancer does not. 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.

Treatment Options

Your doctor will consider many factors when exploring treatment options, including the stage of disease, the location and size of the tumor, and your overall health status. Treatment options for sinus and nasal cancer include surgery, radiation therapy, chemotherapy and targeted therapy. Be sure to talk with your doctor and/or health care team about the goal of treatment and the benefits and risks of each option. Understanding these issues will help you become better informed for making shared treatment decisions with your doctor.

Surgery

Surgery may be the only treatment needed for early-stage cancer. The surgeon will remove the cancer and some surrounding bone or other nearby tissues. 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 may be 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 or external ethmoidectomy may be needed. 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. Maxillectomy 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.

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 because it can include removal of the upper parts of the eye socket and front of the skull base.

Surgery often involves removal of lymph nodes in the neck, regardless of whether the cancer is in the sinus or nasal cavity. A selective neck dissection involves removal of lymph nodes from a limited area of the neck. 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. 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 and nasal cancer. With this therapy, radiation is delivered to specific parts of the body from a machine. Receiving radiation therapy is similar to getting an X-ray, but the radiation is much stronger.

Intensity-modulated radiation therapy (IMRT) is a type of EBRT in which radiation is delivered more precisely to an area. IMRT is typically used for paranasal sinus cancer because it helps to minimize the dose of radiation delivered to vital structures in the area, such as the eyes.

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.

Radiation therapy may be used as the main treatment instead of surgery if your general health is too poor for surgery. This treatment is generally used for cancers in the sphenoid sinuses because these sinuses are difficult to reach surgically. Radiation therapy can also be used after surgery to kill any remaining cancer cells. This is called adjuvant treatment. Radiation therapy is often given with chemotherapy in a combination called chemoradiation therapy. With this combination, the chemotherapy drug makes the cancer cells more sensitive to radiation, allowing it to kill them more effectively.

Chemotherapy

Chemotherapy drugs kill cells that divide quickly, such as cancer cells. It 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. Chemotherapy for sinus and nasal cancers is usually given when the disease is advanced (later stage)

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. Targeted therapy is usually used, with or without chemotherapy, after surgery for advanced-stage cancers.

Immunotherapy

Immunotherapy uses the body’s own immune system to slow and kill cancer cells. With this treatment approach, substances – made either by the body or in a laboratory – are used to identify cancer cells as a threat and target them for destruction. Immunotherapy for head and neck cancers involves the use of drugs known as immune checkpoint inhibitors. These inhibitors may be given with or without chemotherapy. Immunotherapy may be an option for recurrent or metastatic sinus and nasal cancers.

Other types of immunotherapy and targeted therapy are being evaluated in clinical trials. Ask your doctor or another member of your health care team if a clinical trial is an option for you.

Classifying Sinus and Nasal Cancer

Classification Definition
Tumor (T)
TX Primary tumor cannot be assessed.
Tis Carcinoma in situ.
Maxillary Sinus
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.
T4 Moderately advanced or very advanced local disease.
  T4a Moderately advanced local disease.
Tumor invades anterior orbital contents (eye socket), 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 (eye socket), dura (membrane surrounding the brain and spinal cord), brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx (upper part of throat) or clivus (bony base of skull).
Nasal Cavity and Ethmoid Sinus
T1 Tumor restricted to any one subsite, with or without bony invasion.
T2 Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion.
T3 Tumor extends to invade the medial wall or floor of the orbit (eye socket), maxillary sinus, palate, or cribriform plate.
T4 Moderately advanced or very advanced local disease.
  T4a Moderately advanced local disease.
Tumor invades any of the following: anterior orbital contents (eye socket), 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 (eye socket), dura (membrane surrounding the brain and spinal cord), brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx (upper part of throat) or clivus (bony base of skull).
Node (N)
NX Regional lymph nodes cannot be assessed.
N0 No regional lymph node metastasis.
N1 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(-).
N2 Metastasis in a single ipsilateral (on the same side) lymph node 3 cm or smaller in greatest dimension and ENE*(+);
or larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-);
or metastases in multiple ipsilateral lymph nodes, none larger than 6 cm in greatest dimension and ENE(-);
or in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE(-).
  N2a Metastasis in single ipsilateral (on the same side) node 3 cm or smaller in greatest dimension and ENE*(+);
or a single ipsilateral node larger than 3 cm but not larger than 6 cm in greatest dimension and ENE(-).
  N2b Metastases in multiple ipsilateral (on the same side) nodes none larger than 6 cm in greatest dimension and ENE*(-).
  N2c Metastases in bilateral (on both sides) or contralateral (on the opposite side) lymph node(s), none larger than 6 cm in greatest dimension and ENE*(-).
N3 Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-);
or metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
  N3a Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE*(-).
  N3b Metastasis in a single ipsilateral (on the same side) node larger than 3 cm in greatest dimension and ENE*(+);
or multiple ipsilateral, contralateral (on the opposite side) or bilateral (on both sides) nodes, any with ENE(+);
or a single contralateral node of any size and ENE(+).
Metastasis (M)
M0 No distant metastasis.
M1 Distant metastasis.

*Extranodal extension (ENE) refers to cancer cells that have spread beyond the lymph node into surrounding tissues.

 

Staging 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
M0
M0
IVA T4a
T1, T2, T3, T4a
N0, N1
N2
M0
M0
IVB Any T
T4b
N3
Any N
M0
M0
IVC Any T Any N M1

Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017) published by Springer Science+Business Media.

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