Carcinom de mezostructura: prezentare de caz

Velicu Diana Beatrix, studenta an V, seria II, grupa 26

Pacient: d-na Tamang

Varsta: 53
Sex: Feminin
Profesie: Casnica
Localitate: Makwanpur

S-a prezentat la sectia de ORL, din cauza sindromul de obstructie nazala.

Subiectiv:
 Durere in zona obrazului drept de aprox 7 luni
 Tumefactia obrazului drept de aprox 6 luni
Istoricul afectiunii curente:
 Durerea cu debut insidios, de intensitate moderata, usor progresiva, caracter fulgurant, si
agravata la masticatie
 S-a prezentat la medicul de familie si i s-au prescris analgezice
 Apoi a observat tumefactia obrazului drept pana la dimensiunile actuale
 Si-a pierdut dintii de la nivelul maxilarului drept
 Prezinta istoric de cefalee recurenta si pierderi in greutate
 Nu prezinta febra, epistaxis, rinita, privire incetosata; prezinta diplopie

Antecedente personale patologice

 Nu a prezentat interventii chirurgicale
 Nu prezinta afectiuni cronice precum HTA sau DZ
 Nu prezinta istoric de epistaxis recurent

Conditii de viata si de munca

 Fumatoare, aprox 1 pachet pe zi, de la varsta de 13 ani
 Nu mesteca tutun
 Consuma Jad. aprox 300 de ml pe zi
 Ocupatie: fermier
 Nu a lucrat niciodata in sectorul industrial

Examen obiectiv:
 Stare generala: buna
 Performance status (ECOG-The Eastern Cooperative Oncology Group): 0
 Nu prezinta icter, paloare, cianoza, degete hipocratice
 Puls: 80 bmp, regulat
 Tensiune arteriala: 130/90 mm Hg
 Frecventa respiratorie: 20 respiratii pe minut, regulat
 Presiune venoasa jugulara: nu e crescuta
 Examenul toracelui: cantitate scazuta de aer inspirat in zona superioara, cu crepitatii
 Cardiovascular: Batai normale, fara zgomote adaugate, fara murmur
 Abdomen: fara distensie, fara organomegalie
 Oftalmologic: vedere normala, si miscari ocupare normale
  Rinoscopie anterioara: aspect normal

Diagnostic prezumptiv: carcinom de sinus maxilar

Diagnostic diferential:
 Osteosarcom maxilar
 Ameloblastom
 Rinosinuzita fungica
  Chist osos maxilar
 Chist dentiger

Investigatii de baza:
 Hemoleucograma: normal
 Testarea functiei renale: normal
 Rx toracala: normal
 HIV/ HBs/ HVC: negativ
Raport CT:
 Leziune litica expansiva, interesand podeaua sinusului maxilar si procesul alveolar al
maxilarului drept; de asemenea intereseaza alveolele molarilor si premolarilor
 Distructie osoasa si aparitia reactiei periostale „in raze de soare”
 Leziunea tesuturilor moi de dim. 5.0 x 4.4 x 4.5 cm cu zone de necrotice
 Sunt interesate partea adiacenta a palatului dur si peretii adiacenti ai maxilarului
 Vena angulara dreapta se afla in suprafata afectata

Pacienta este trimisa spre examinare histopatologica.

OVERVIEW: MAXILLARY CARCINOMA

Epidemiology
● Incidence -0.5-1/100,000 per year -0.2-0.8% of all malignancies -3% of upper aerodigestive tract
neoplsm
● 5th-6th decade
● White race
● M:F=2:1 – 4:1 21

Environmental exposures
● Adenocarcinoma -wood dust, leather dust
● Squamous cell carcinoma -Aflatoxin, chromium, asbestos, nickel, mustard gas, polycyclic
hydrocarbons.
● Viral: HPV 22
Squamous cell carcinoma
● Most common histological type
● 70% maxillary sinus
● Male predominance
● 7th decade 23

Ohngrens line (1933):A line from medial canthus of the eye to theangle of the mandible
● Anteroinferior/infrastructure: good prognosis
● Superoposterior/suprastructure: poor prognosis, early extension (eye, skull base, pterygoids, and
infratemporal fossa).

Patterns of tumour spread

● Anteriorly: cheek, skin
● Posteriorly: pterygopalatine fossa, infra temporal fossa, temporal bone middle cranial fossa
● Medially: nasal cavity,NLD
● Laterally: cheek, skin
● Superiorly: orbit, ethmoid sinuses
● Inferiorly: palate, buccal sulcus

Presentation
● Nasal findings: 50%
● Obstruction, epistaxis, rhinorrhea, discharge,extension into nasal cavity
● Oral symptoms: 25-35%
● Pain, trismus, alveolar ridge fullness, erosion
● Ocular findings: 25%
● Epiphora, diplopia, proptosis
● Facial signs: ● Paresthesias, facial asymmetry, cheek swelling
● Auditory symptoms: hearing loss (OME)
● Neurological: cranial nerve deficits II,III,IV.V1,V2,VI 26

Regional spread
● 10% nodal disease: at presentation
● 25-35% during course of disease.
● Submandibular & jugulodigastric nodes: most common

Distant metastases
● Rare at presentation
● Grave signs
● Poor prognosis
● 18 %: adenocarcinoma
● 10%: SCC
● Common sites: Lungs, bone, brain, liver,skin 28
How to Proceed
· H&P including a complete head and neck exam; mirrorand fiberoptic examination as clinically
indicated
· Complete head and neck CT with contrast and/or MRI
· Dental/prosthetic consultation as indicated
· Chest imaging
↓↓
Biopsy:
· Preferred route is transnasal.
· Needle biopsy may be acceptable.
· Avoid canine fossa puncture or Caldwell-Luc approach.
↓↓
Squamous cell carcinoma / Adenocarcinoma
Minor salivary gland tumor / Sarcoma
↓↓
Proper TNM Staging.
T status mainly radiological.
Nodal status mainly clinical.

Stage I / II (T1-T2, N0)

● Surgical resection is the primary treatment.
● If margins are free (1.5-2cm), kept on regular follow-up without adjuvant therapy.
● If there is perineural invasion by the tumor, Adjuvant Radiotherapy is needed (±Chemo)
● If margins are positive, Re-surgery should be considered, after which, if margins come negative, RT
only; if margins come positive, Chemo+RT is recommended.
The role of Chemotherapy has a 2B evidence. Individual cohort study or low quality randomized
controlled trials.

T3-T4, N0
● Surgical resection is the primary treatment.
● If margins are free, RT to the primary & neck.
● If margins are positive, Chemotherapy and RT to the primary and neck.

Node + Stage
● Surgical excision with neck dissection is the recommended primary treatment.
● Followed by RT to the primary site and neck if margins are negative and there is no extracapsular
extension (of the node mets.)
● If margins positive or extracapsular extension, Chemotherapy along with RT to primary and neck is
added as adjuvant therapy.

Surgery
Surgical approaches:
 Endoscopic
 Lateralrhinotomy
 Transoral/transpalatal
 Midfacial degloving
 Combined craniofacial approach Weber-Fergusson

Extent of resection
 Total maxillectomy
 Inferior maxillectomy
 Medial maxillectomy

Unresectable tumors: Surgery

 Superior extension: frontal lobes
 Lateral extension: cavernous sinus
 Posterior extension: prevertebral fascia
 Bilateral optic nerve involvement
 Distant Metastasis

Radiation Techniques
● Preferred interval between resection and RT ≤ 6 weeks
● Conventional fractionation: 66-70 Gy (2.0 Gy/fraction Monday-Friday) in 7 weeks● Alteration can
be done with 6 fractions/week accelerated; 66-70 Gy
● Neck nodal stations: 44-64 Gy (1.6-2.0 Gy/fraction)
● Intensity-Modulated Radiotherapy (IMRT) has been shown to be useful in reducing long-term
toxicity by reducing the dose to salivary glands, temporal lobes, auditory structures, and optic
structures.

Simulate supine with thermoplastic mask immobilization.

● Tongue blade/cork to depress tongue out of fields.
● Recommend 3DCRT or IMRT planning.
● GTV = clinical and radiologic gross disease.
● CTV = 1 cm margin on primary
● Dose limitation is by Lens <10 Gy (cataracts, Retina <45 Gy (vision).
● Parotid mean dose <26 Gy (xerostomia)
● Brain <60 Gy (necrosis). Mandible <60 Gy (osteoradionecrosis).
● Pituitary and hypothalamus mean dose <40 Gy.

Complications
● Acute: mucositis, skin erythema, nasal dryness, xerostomia
● Late: xerostomia, chronic keratitis and iritis, optic pathway injury, soft tissue or osteoradionecrosis,
cataracts, radiation- induced hypopituitarism

Chemotherapy
● Primary Systemic Therapy + concurrent RT
● Cisplatin alone (preferred)
● 5-FU/hydroxyurea
● Cisplatin/paclitaxel
● Cisplatin/infusional 5-FU
● Carboplatin/infusional 5-FU
● Carboplatin/paclitaxel Cetuximab

RADPLAT
Intra-arterial Cisplatin with systemic neutralization by i.v.sodium thiosulphate and Concomitant
Radiation Therapyfor Advanced Paranasal Sinus CA
● ADVANTAGES:
– Allows very high cisplatin dose to be used
– Minimizing adverse systemic effects.
– Excellent locoregional control rates are achievable in patients with unresectable disease
– Favorable side-effect profile when compared with conventional chemoradiation protocols
Followup
● H&P, labs, and CXR every 3 months for first year,
● Every 4 months for second year,
● Every 6 months for third year, then annually.
● Imaging of the H&N at 3 months post treatment, then as indicated