TUMORS OF MAXILLA AND THEIR TUMORS OF MAXILLA AND THEIR MANAGEMENT MANAGEMENT DR KAMLESH DUBEY DR KAMLESH DUBEY
Jan 15, 2016
TUMORS OF MAXILLA AND THEIR TUMORS OF MAXILLA AND THEIR MANAGEMENTMANAGEMENT
DR KAMLESH DUBEYDR KAMLESH DUBEY
INTRODUCTIONINTRODUCTION
Nose and PNS are rarest sites of origin of head Nose and PNS are rarest sites of origin of head & neck tumors.& neck tumors.Accounts for < 1% of all malignancies.Accounts for < 1% of all malignancies.More common in 5More common in 5thth & 6 & 6thth decade. decade.M:F = 2:1M:F = 2:1Late presentation with advanced disease is Late presentation with advanced disease is more common.more common.Great variety of different histological types.Great variety of different histological types.Overall prognosis is poor.Overall prognosis is poor.Distal mets is seen in 10 % at presentationDistal mets is seen in 10 % at presentation
ANATOMYANATOMY
Maxillary tumors because of its close Maxillary tumors because of its close proximity to orbit, ethmoids, skull base, proximity to orbit, ethmoids, skull base, ITF always challenging to treat.ITF always challenging to treat.
ANATOMYANATOMY
Orbit is the key to management of tumors Orbit is the key to management of tumors of maxilla always work in subperiosteal of maxilla always work in subperiosteal plane.plane.
ANATOMYANATOMY
Ohngren line-Ohngren line- imaginary line between imaginary line between medial canthus ligament and angle of medial canthus ligament and angle of mandible.mandible.
ANATOMYANATOMY
Lymphatics ;Lymphatics ;Anterior pathway;Anterior pathway;
– Facial , parotid, submandibular nodeFacial , parotid, submandibular node- upper deep cervical nodes.- upper deep cervical nodes.
Post pathway; Post pathway; – retro/ lateral pharyngeal nodes- upper deep cervical retro/ lateral pharyngeal nodes- upper deep cervical
nodes.nodes.
Primary lymph drainage is to retropharyngeal nodes , Primary lymph drainage is to retropharyngeal nodes , clinical e/o early mets is absent clinical e/o early mets is absent Only 10 % have nodal mets at presentation.Only 10 % have nodal mets at presentation.Clinically palpable node is poor prognosis. Clinically palpable node is poor prognosis.
AETIOLOGYAETIOLOGY
Inhalant carcinogensInhalant carcinogens- 40% sinonasal malignancies.- 40% sinonasal malignancies.– Wood dust – adenocarcinoma (1000 times )Wood dust – adenocarcinoma (1000 times )– Hard wood- adenocarcinomaHard wood- adenocarcinoma– Soft wood – SCCSoft wood – SCC– Nickel – SCCNickel – SCC
ChemicalsChemicals– ChromiumChromium– polycyclic hydrocarbonspolycyclic hydrocarbons– aflatoxinaflatoxin– mustard gasmustard gas
RadiationRadiation – thorotrast – thorotrastViruses Viruses - HPV- HPV
24 % inverted papilloma24 % inverted papilloma4 % SCC4 % SCC
TUMORS OF MAXILLATUMORS OF MAXILLA
BenignBenignInverted papillomaInverted papilloma
Osteoma ( Gardner’s syndrome )Osteoma ( Gardner’s syndrome )
ChondromaChondroma
Fibrous dysplasiaFibrous dysplasia
HemangiomaHemangioma
LeiomyomaLeiomyoma
SchwannomaSchwannoma
TUMORS OF MAXILLATUMORS OF MAXILLAMALIGNANT;MALIGNANT;
– Squamous cell carcinoma (80%)Squamous cell carcinoma (80%)– Adeno carcinoma (5%)Adeno carcinoma (5%)– Adenoid cystic carcinoma (5%)Adenoid cystic carcinoma (5%)– HemangiopericytomaHemangiopericytoma– MelanomaMelanoma– Undifferentiated carcinomaUndifferentiated carcinoma– PNETPNET– Malignant fibrous dysplasiaMalignant fibrous dysplasia
Dental origin;Dental origin; – AmeloblastomaAmeloblastoma
Sarcoma;Sarcoma;– RhabdomyosarcomaRhabdomyosarcoma– Fibro sarcomaFibro sarcoma– AngiosarcomaAngiosarcoma– Chondro / osteo sarcomaChondro / osteo sarcoma
Others;Others; lymphoma lymphoma
PATTERNS OF TUMOR SPREADPATTERNS OF TUMOR SPREAD
Maxillary sinusMaxillary sinusAnterior- cheek , skinAnterior- cheek , skin
Posterior- PPF, Posterior- PPF, ITF,MCF, temporal ITF,MCF, temporal bonebone
Medial – nasal cavity, Medial – nasal cavity, ethmoidsethmoids
Superiorly- orbitSuperiorly- orbit
Inferiorly- palate, Inferiorly- palate, alveolus.alveolus.
CLINICAL FEATURESCLINICAL FEATURES
Nasal obstructionNasal obstructionEpistaxisEpistaxisFacial painFacial painProtosis, vision disturbanceProtosis, vision disturbanceEpiphoraEpiphoraHearing lossHearing lossCheek swelling, parasthesiaCheek swelling, parasthesiaTrismusTrismusCranial nerve deficitsCranial nerve deficits
INVESTIGATIONSINVESTIGATIONS
EndoscopyEndoscopy– DiagnosticDiagnostic– Biopsy Biopsy
ImagingImagingCT scan;CT scan;– Site & extent Site & extent – Bone, skull base erosionBone, skull base erosion– Orbit invasionOrbit invasion– Neck- nodal statusNeck- nodal status
INVESTIGATIONSINVESTIGATIONS
MRIMRIBetter soft tissue delineationBetter soft tissue delineationDifferentiate between secretions, tumorDifferentiate between secretions, tumorDural / intracranial involvementDural / intracranial involvementVascularity- flow voidsVascularity- flow voidsMRA- great vessel encasement, cavernous extensionMRA- great vessel encasement, cavernous extension
Angiography;Angiography;Proximity to great vessels , sphenoidProximity to great vessels , sphenoidVascular tumorsVascular tumorsEmbolisation.Embolisation.
INVESTIGATIONSINVESTIGATIONS
PETPET– Distant metastasisDistant metastasis– Follow upFollow up
BiopsyBiopsy– endoscopic guidanceendoscopic guidance– Sublabial approachSublabial approach
HPE, ImmunohistochemistryHPE, ImmunohistochemistryFNACFNAC
– Neck NodeNeck Node
USG- B modeUSG- B mode– Assesment of orbitAssesment of orbit
TNM stagingTNM staging
Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumor Tis: Carcinoma in situ
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 the middle of the nasal meatus, except extension to the 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, pterygoid fossa, ethmoid sinuses T4a: Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses T4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus
TNM stagingTNM stagingRegional lymph nodes (N) Regional lymph nodes (N)
NX: Regional lymph nodes cannot be assessed NX: Regional lymph nodes cannot be assessed N0: No regional lymph node metastasis N0: No regional lymph node metastasis N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension greatest dimension N2: Metastasis in a single ipsilateral lymph node, more than 3 cm N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but 6 cm or less in greatest dimension, or in multiple ipsilateral but 6 cm or less in greatest dimension, or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension, or in bilateral or lymph nodes, 6 cm or less in greatest dimension, or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension contralateral lymph nodes, 6 cm or less in greatest dimension – N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or N2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or
less in greatest dimension less in greatest dimension – N2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest N2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest
dimension dimension – N2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest N2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest
dimension dimension N3: Metastasis in a lymph node more than 6 cm in greatest dimensionN3: Metastasis in a lymph node more than 6 cm in greatest dimension
TNM stagingTNM staging
Stage 1Stage 1 -- T1 T1 N0N0 M0M0Stage 2Stage 2 - - T2 T2 N0 N0 M0M0Stage 3Stage 3 - - T1,2 T1,2 N1N1 M0M0 T3 T3 N0,N1N0,N1 M0 M0Stage 4a-Stage 4a- T4 T4 N0,N1N0,N1 M0 M0 any T any T N2N2 M0 M0Stage 4b- Stage 4b- any T any T N3N3 M0 M0Stage 4c- Stage 4c- any T any T anyN anyN M1M1
SCCSCC
50 % arise in the antrum50 % arise in the antrum
Advanced disease at presentationAdvanced disease at presentation
Local recurrence, distal metastasis more Local recurrence, distal metastasis more commoncommon
Main treatment modality- Sx- PORTMain treatment modality- Sx- PORT
Primary Irradiation- inoperable tumorsPrimary Irradiation- inoperable tumors
Chemotherpy – palliativeChemotherpy – palliative
ADENOCARCINOMAADENOCARCINOMA
Aetiology; Aetiology; – Wood dust, furniture machinery, leather workWood dust, furniture machinery, leather work
Well defined tumor- better survivalWell defined tumor- better survival
Long term survival poorLong term survival poor
Management; as that of SCCManagement; as that of SCC
ADENOID CYSTIC CARCINOMAADENOID CYSTIC CARCINOMA
Common in antrumCommon in antrum
Perineural spreadPerineural spread
Distal metastasis more commonDistal metastasis more common
HPE;HPE;– High grade- bad prognosisHigh grade- bad prognosis– Low grade- better prognosisLow grade- better prognosis
TREATMENTTREATMENT
T1/ T2T1/ T2– surgery or radiotherapysurgery or radiotherapy
T3, T4T3, T4 surgery- radiotherapysurgery- radiotherapy
radiotherapy- surgeryradiotherapy- surgery
combined CT+ RTcombined CT+ RT
SURGICAL APPROCAHESSURGICAL APPROCAHES
Lateral rhinotomyLateral rhinotomy
Weber Ferguson incisionWeber Ferguson incision
Mid facial deglovingMid facial degloving
ANASTHESIAANASTHESIA
Orotracheal intubationOrotracheal intubation
Throat Packing in oropharyngxThroat Packing in oropharyngx
Hyperventilation, mannitol- if cranial cavity is Hyperventilation, mannitol- if cranial cavity is openedopened
Adequate arrangement of blood & blood Adequate arrangement of blood & blood productsproducts
PRE OP PREPARATIONPRE OP PREPARATION
Broad spectrum antibiotic cover Broad spectrum antibiotic cover
Dental evaluation ( prosthesis, obturator)Dental evaluation ( prosthesis, obturator)
Neurosurgeon review; intra cranial extension, Neurosurgeon review; intra cranial extension, CFRCFR
Plastic surgeon; pre op decision for flapsPlastic surgeon; pre op decision for flaps
Lateral rhinotomyLateral rhinotomy
Moure`s incision Moure`s incision (1902)(1902)
Excellent exposure to Excellent exposure to nasal cavity, medial nasal cavity, medial maxillary wallmaxillary wall
Indication;Indication; medial medial maxillextomymaxillextomy
Cosmetically Cosmetically acceptableacceptable
Weber Ferguson incisionWeber Ferguson incision
Vertical limb- WeberVertical limb- Weber
Horizontal- Ferguson Horizontal- Ferguson 5mm below lid 5mm below lid marginmargin
Useful in total Useful in total maxillectomy, maxillectomy, combined orbital combined orbital exenteration.exenteration.
Mid facial deglovingMid facial degloving
Denker & Kahler 1926 Denker & Kahler 1926 ( modified CWL approach )( modified CWL approach )
1927 Portmann & Retrouvay – mid facial degloving1927 Portmann & Retrouvay – mid facial deglovingMucosal incision- b/l upper GBS between maxillary Mucosal incision- b/l upper GBS between maxillary tuberosity.tuberosity.Nose- full trans fixation , inter cartilaginous incisionNose- full trans fixation , inter cartilaginous incisionExcellent exposure to nasal cavity, antrum, post nasal Excellent exposure to nasal cavity, antrum, post nasal space, pterygo palatinefossa.space, pterygo palatinefossa.Combined with Le Fort 1 osteotomy – wide exposure to Combined with Le Fort 1 osteotomy – wide exposure to clivus, skull baseclivus, skull base
MID FACIAL DEGLOVINGMID FACIAL DEGLOVING
MAXILLECTOMYMAXILLECTOMY
TypesTypes– TotalTotal– PartialPartial
Infra structureInfra structure
Supra structureSupra structure
medialmedial
Subtotal Subtotal
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
It involves removal of entire maxilla along It involves removal of entire maxilla along with pterygoid plateswith pterygoid plates
Indication;Indication;– Tumors from mucosa, filling entire antrumTumors from mucosa, filling entire antrum– Soft tissue & bone sarcomasSoft tissue & bone sarcomas
Approach;Approach;– Weber fergusonWeber ferguson– Mid facial deglovingMid facial degloving
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
Removal of entire Removal of entire maxilla and pterygoid maxilla and pterygoid platesplates
Supine position, 15 K Supine position, 15 K head extensionhead extension
Ant wall of maxilla Ant wall of maxilla exposed – elevating exposed – elevating cheek flap.cheek flap.
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
Subciliary incision- Subciliary incision- Orbital periosteum Orbital periosteum elevated from floor of elevated from floor of orbitorbitLacrimal sac retracted Lacrimal sac retracted laterally after cutting laterally after cutting medial canthus medial canthus ligament, NLDligament, NLDPost dissection Post dissection continued upto post continued upto post ethmoidal artery.ethmoidal artery.
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
ORAL CAVITY – PALATAL INCISIONORAL CAVITY – PALATAL INCISION
BONE CUTSBONE CUTS
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
Bony cutsBony cuts;;
Frontal process of maxillaFrontal process of maxilla
PalatePalate
ZygomaZygoma
Ethmoidal cells, pterygoidsEthmoidal cells, pterygoids
Brisk hemorrageBrisk hemorrage
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
SSG applied over cheek mucosa defectSSG applied over cheek mucosa defect
Cavity packing over palatal prosthesisCavity packing over palatal prosthesis
Skin closed in 2 layersSkin closed in 2 layers
TOTAL MAXILLECTOMYTOTAL MAXILLECTOMY
POST OP CAREPOST OP CARE
Pack removalPack removal
Cavity irrigationCavity irrigation
Oral exercisesOral exercises
Permanent obturatorPermanent obturator
MEDIAL MAXILLECTOMYMEDIAL MAXILLECTOMY
Enblock resection of lateral wall of nasal cavity Enblock resection of lateral wall of nasal cavity including inf/ mid turbinate, lamina papyraceaeincluding inf/ mid turbinate, lamina papyraceae
Indication;Indication; – Inverted papillomaInverted papilloma– Low grade tumors confined to lateral wall on nasal Low grade tumors confined to lateral wall on nasal
cavitycavity
Approach;Approach;– Lateral rhinotomyLateral rhinotomy– Mid facial deglovingMid facial degloving
MEDIAL MAXILLECTOMYMEDIAL MAXILLECTOMY
Lateral rhinotomy Lateral rhinotomy incisionincision
Antero lateral wall of Antero lateral wall of maxilla exposedmaxilla exposed
Nasal cavity entered, Nasal cavity entered, tumor assesd for tumor assesd for resectability.resectability.
MEDIAL MAXILLECTOMYMEDIAL MAXILLECTOMY
Antero lateral wall opening Antero lateral wall opening mademade
Bony cuts;Bony cuts;
Supt to alveolus , lateral Supt to alveolus , lateral to pyramidto pyramid
Vertical – medial to Vertical – medial to inferior orbital nerveinferior orbital nerve
Fronto ethmoidal sutureFronto ethmoidal suture
Post- post wall of antrumPost- post wall of antrum
MEDIAL MAXILLECTPMYMEDIAL MAXILLECTPMY Bone cuts Bone cuts
MEDIAL MAXILLECTOMYMEDIAL MAXILLECTOMY
Cavity packedCavity packed
Primary closurePrimary closure
Post op – irrigation of Post op – irrigation of cavitycavity
Endoscopic medialEndoscopic medial
maxillextomymaxillextomy
Acheives same Acheives same success ratesuccess rate
Avoids scarAvoids scar
INFRA STRUCTUREINFRA STRUCTURE MAXILLECTOMY MAXILLECTOMY
It involves removal of It involves removal of – alveolus ,alveolus ,– floor of antrum, floor of antrum, – inferior part ofinferior part of
pterygoid platespterygoid plates
Indication;Indication;Tumor limited to alveolus, Tumor limited to alveolus, hard palate with no bony hard palate with no bony erosionerosionNo postero superior No postero superior extensionextension
Approach;Approach;Mid facial deglovingMid facial deglovingLateral rhinotomyLateral rhinotomy
INFRA STRUCTUREINFRA STRUCTURE MAXILLECTOMY MAXILLECTOMY
BONY CUTS;BONY CUTS;Horizontal- midway between alveolus & IONHorizontal- midway between alveolus & IONPalate- midlinePalate- midlineMedial- lateral nasal wall below middle meatusMedial- lateral nasal wall below middle meatusPost- inferior portion of pterygoid platesPost- inferior portion of pterygoid plates
INFRA STRUCTURE INFRA STRUCTURE MAXILLECTOMYMAXILLECTOMY
POST OP CARE;POST OP CARE;
Cavity irrigationCavity irrigation
Palatal prosthesisPalatal prosthesis
MANAGEMENT OF ORBITMANAGEMENT OF ORBIT
Orbit preservation;Orbit preservation;– No e\o tumor in orbital floorNo e\o tumor in orbital floor– Breech in floor with intact periosteumBreech in floor with intact periosteum– Minimal periosteal invasion Minimal periosteal invasion
Orbital exenteration;Orbital exenteration;– Breech in orbital periosteumBreech in orbital periosteum– Orbital apex extensionOrbital apex extension
RADICAL MAXILLECTOMY WITH RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATIONORBITAL EXENTERATION
Indication;Indication;– Tumor invading through orbital periosteumTumor invading through orbital periosteum
Approach;Approach;– Weber Ferguson with sub & supra ciliary Weber Ferguson with sub & supra ciliary
extensionextension
RADICAL MAXILLECTOMY WITH RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATIONORBITAL EXENTERATION
Skin of upper lid elevated upto suprior Skin of upper lid elevated upto suprior orbital rim.orbital rim.
Orbital perioseteum seperated from roof of Orbital perioseteum seperated from roof of orbitorbit
EOM , optic nerve cut at level of orbital EOM , optic nerve cut at level of orbital apexapex
Defect lined with SSGDefect lined with SSG
Facial prosthesis appliedFacial prosthesis applied
ORBIAL EXENTERATIONORBIAL EXENTERATION
POST OP DEFECT PROSTHESIS IN PLACE
RECONSTRUCTIONRECONSTRUCTION
SSGSSGPalatal prosthesisPalatal prosthesisObturatorsObturators
Flaps;Flaps;– Temporo pareital galeal flapTemporo pareital galeal flap– Temporalis Temporalis
Free flapsFree flaps;;– Rectus abdomoinisRectus abdomoinis– Lattissimi dorsi Lattissimi dorsi
Composite flap;Composite flap;– Fibula osteo cutaneous flapsFibula osteo cutaneous flaps
RECONSTRUCTIONRECONSTRUCTION
FOREARM FREE FLAP
DENTAL IMPLANTS
RADIATION IN TUMORS OF MAXILLARADIATION IN TUMORS OF MAXILLA
Various combiationsVarious combiationsPrimary irradiation alonePrimary irradiation alone– T1,2 lesionsT1,2 lesions– In operable tumorsIn operable tumors– Patient unfit for surgeryPatient unfit for surgery
Combined with surgeryCombined with surgery– T3,4 lesionsT3,4 lesions– Surgery – RTSurgery – RT– RT- surgeryRT- surgery
CT+ RTCT+ RT
Areas to be covered;Areas to be covered;
1* site, areas of tumor extension , other 1* site, areas of tumor extension , other routes of local spread (i-e) routes of local spread (i-e)
Maxilla, alveolus, nasal cavity, ethmoids, Maxilla, alveolus, nasal cavity, ethmoids, PPF, often orbit, neckPPF, often orbit, neck
Anterior fieldAnterior field
Lateral fieldLateral field
RADIATION FIELDSRADIATION FIELDS
ANTERIOR FIELD LATERAL FIELD
Protect;Protect;
Contra lateral eyeContra lateral eye
Brain stemBrain stem
Upper cervical cordUpper cervical cord
DoseDose50-55 Gy/ 20#/ 4 wks50-55 Gy/ 20#/ 4 wks60-65 Gy/30-33#/ 6-6.5 wks60-65 Gy/30-33#/ 6-6.5 wksLymphoma;Lymphoma;– 40 GY/20#/4 wks40 GY/20#/4 wks
ComplicationsComplications– MucositisMucositis– EyeEye
CataractCataractKeratitisKeratitisOptic nerve damageOptic nerve damage
– Osteo radio necrosisOsteo radio necrosis– hypopituitarismhypopituitarism
CHEMOTHERAPYCHEMOTHERAPY
Cisplastin & 5- FUCisplastin & 5- FUSNUC, RMS, lymphomaSNUC, RMS, lymphomaIntra arterial infusion – 5- FU along with Intra arterial infusion – 5- FU along with RTRTTopical 5- FU ;Topical 5- FU ;– Surgical debulking + topical 5 FU weeklySurgical debulking + topical 5 FU weekly– Adenocarcinoma- ethmoids Adenocarcinoma- ethmoids (knegt et al, Arch of otolarygology,2007 ).(knegt et al, Arch of otolarygology,2007 ).
Palliation.Palliation.
INOPERABLE TUMORSINOPERABLE TUMORS
Irradiation;Irradiation;
6000 rads- 6 wks6000 rads- 6 wks
Salvage surgerySalvage surgery
CT+ RTCT+ RT
Intra arterial 5-FUIntra arterial 5-FU
PNS TUMORS IN CHILDRENPNS TUMORS IN CHILDREN
Commonest malignant tumor is Commonest malignant tumor is rhabdomyosarcomarhabdomyosarcoma
Treatment; triple modalityTreatment; triple modality
Tumors; radioinsensitiveTumors; radioinsensitive
Rad >3000 rads retards facial skeletal growthRad >3000 rads retards facial skeletal growth
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