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Nasal Cancer

Diagnosing Nasal Cancer

Getting to a diagnosis begins with a history and physical examination. If the symptoms haven’t been present for very long, or if the history and physical examination make the doctor less suspicious that your lesion is cancer, your doctor might try some medications and rehabilitation before jumping to a diagnosis of cancer.

At some point, if your doctor is not certain of a diagnosis, and if symptoms aren’t getting better (and definitely if symptoms are getting worse), your doctor should raise the possibility of starting a cancer work-up. Like most cancers in the head and neck, this will include some combination of biopsy and imaging tests, which is the term that doctors use to refer to X-rays, MRIs, CT scans, etc.

If you came to a head and neck cancer specialist after having something small removed from your nasal cavity and found it was cancer only afterwards, your doctor might skip some of the tests and jump to close follow-up or additional treatment. Be sure to bring all the reports and images from any prior treatment with you to your appointment with your head and neck cancer specialist.

Imaging

Imaging refers to radiologic studies, or scans, that create pictures of the structures inside your head and neck. In general, for small tumors that are easily evaluated on physical examination, imaging might not be necessary. For larger tumors, or tumors in locations that are difficult to examine, your doctor will probably order some sort of imaging to get more information about the tumor location and possible spread to regional lymph nodes. An important reason to get a scan for sinonasal tumors is to see if there is any evidence of spread into nearby structures. Spread into other structures will influence what treatment your doctor recommends for you.

For most head and neck cancers, if imaging is required, your doctor will most likely start with a computed tomography (CT) scan with contrast. Other tests might include magnetic resonance imaging (MRI) and/or a positron emission tomography (PET) scan.

Biopsy

A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. At some point, you will need a biopsy of the suspicious lesion in your nasal cavity (or a mass in your neck).

Nose biopsy

There are a few different techniques your doctor might use to biopsy a lesion in your nasal cavity. In general, it can be done in the office or in the operating room, depending on a variety of factors that your doctor will discuss with you.

You will probably get some sprays and/or pads placed inside your nose to decongest and numb the area. The doctor may use an injection as well for this purpose. Then, your doctor will likely use one of the techniques described below to remove a piece of the suspicious lesion in your sinonasal area. After the biopsy, you will probably have more pads or sprays placed inside your nose to control any small amount of bleeding that will result. The bleeding will usually stop on its own.

  • Endonasal biopsy: In this technique, your doctor will use a nasal speculum and a good light to look inside your nose. He or she will take a piece of the suspicious tissue using a forcep.
  • Direct rigid nasal endoscopy: Here, your doctor will place a steel rod telescope into your nose. Then, either through a video projection or looking directly through the telescope, he or she will place a forcep into your nose, nasopharynx or sinus to take a piece of any suspicious tissue for analysis.

Neck biopsy

If there is also a lump in the neck, your doctor might decide to biopsy that as well. There are a few different ways to do a biopsy of the neck:

  • Fine needle aspiration biopsy: The most common and easiest way to biopsy is fine needle aspiration biopsy (FNAB), in which a tiny needle is placed into the tumor and some cells are drawn out through a syringe. The pathology doctor, known as a cytologist or cytopathologist, will then immediately look at the cells under the microscope and let your doctor know if there were enough cells to make a diagnosis. A number of “passes” with the needle might be done to increase the likelihood that there are enough cells to make a diagnosis. The final diagnosis may take a few days to come back, so be patient.

 

DIFFERENT TYPES OF FINE NEEDLE ASPIRATION BIOPSIES

By Feel” FNAB Ultrasound Guided FNAB CT-Guided FNAB
When Your Doctor Might Use This Technique If the lump can be easily felt by your doctor If your doctor thinks it will be difficult to get the needle directly into the lump with certainty If your doctor doesn’t think he or she will be able to get into the tumor by feel or with ultrasound guidance
What to Expect Your doctor will feel the lump and place a tiny needle directly into it to extract some cells. Your doctor will use a gentle probe on your face or neck, identify the tumor with the ultrasound and then watch the needle go directly into the tumor on the ultrasound machine. You will be placed into a CT scanner, and a few low-dose CT scans will be performed—first to localize the tumor and then to make sure the needle that is placed is actually within the tumor.There is new technology known as fluoroscopic CT scanning, in which the radiologist can quickly take a few scans without leaving the room, in order to quickly insert the needle into the right place.
  • Core biopsy: Core biopsy is an alternative to fine needle aspiration. A core biopsy is done in the same way as an FNA biopsy, but it uses a larger needle and removes a core of tissue from the tumor rather than just a few cells. The likelihood of false positives and false negatives is much lower with a core needle biopsy than with a fine needle biopsy.5 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.
  • Open neck biopsy: An open biopsy involves making an incision over the tumor and removing a piece or all of the tumor to make a diagnosis. An open biopsy of a neck mass is performed through an incision over the lump, and either a piece (incisional open neck biopsy) or the entire lump (excisional open neck biopsy) is removed to make a diagnosis. Except in a few special circumstances (such as if the tumor is likely a lymphoma or if other methods of diagnosis have not worked), this method should not be used to find the diagnosis of a neck mass.
References

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2 Leclerc A, Martinez Cortes M, Gérin M, Luce D, Brugère J. Sinonasal cancer and wood dust exposure: results from a case-control study. Am J Epidemiol. 1994 Aug 15;140(4):340-9.

3 Brinton LA, Blot WJ, Becker JA, Winn DM, Browder JP, Farmer Jr JC, Fraumeni Jr JF. A case-control study of cancers of the nasal cavity and paranasal sinuses. Am J Epidemiol. 1984 Jun;119(6):896-906.

4 Battista G, Comba P, Orsi D, Norpoth K, Maier A. Nasal cancer in leather workers: an occupational disease. J Cancer Res Clin Oncol. 1995;121(1):1-6.

5 Spiro RH, Thaler HT, Hicks WF, Kher UA, Huvos AH, Strong EW. The importance of clinical staging of minor salivary gland carcinoma. Am J Surg. 1991 Oct;162(4):330-6.

6 Katz TS, Mendenhall WM, Morris CG, Amdur RJ, Hinerman RW, Villaret DB. Malignant tumors of the nasal cavity and paranasal sinuses. Head Neck. 2002 Sep;24(9):821-9.

7 Wieneke JA, Thompson LD, Wenig BM. Basaloid squamous cell carcinoma of the sinonasal tract. Cancer. 1999 Feb 15;85(4):841-54.

8 Marcus DM, Marcus RP, Prabhu RS, Owonikoko TK, Lawson DH, Switchenko J, Beitler JJ. Rising incidence of mucosal melanoma of the head and neck in the United States. J Skin Cancer. 2012;2012:231693. doi: 10.1155/2012/231693. Epub 2012 Dec 2.

9 Edge SB, et al. The AJCC Cancer Staging Manual – Seventh Edition. American Joint Committee on Cancer 2010. Chapter 9: Mucosal Melanoma of the Head and Neck.

10 Ejaz A, Wenig BM. Sinonasal undifferentiated carcinoma: clinical and pathologic features and a discussion on classification, cellular differentiation, and differential diagnosis. Adv Anat Pathol. 2005 May;12(3):134-43.

11 Perez-Ordonez B, Caruana SM, Huvos AG, Shah JP. Small cell neuroendocrine carcinoma of the nasal cavity and paranasal sinuses. Hum Pathol. 1998 Aug;29(8):826-32.

12 Spiro JD, Soo KC, Spiro RH. Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses. Head Neck. 1995;17:114-118.

13 Referenced with permission from The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Head and Neck Cancers V.2.2016. © National Comprehensive Cancer Network, Inc 2016. All rights reserved. Accessed December 6, 2016. To view the most recent and complete version of the guideline, go online to www.NCCN.org.

14 Piccirillo JF, Costas I, Reichman ME. Chapter 2: Cancers of the Head and Neck. Ries LAG, Young JL, Keel GE, Eisner MP, Lin YD, Horner M-J (editors). SEER Survival Monograph: Cancer Survival Among Adults: U.S. SEER Program, 1988-2001, Patient and Tumor Characteristics. National Cancer Institute, SEER Program, NIH Pub. No. 07-6215, Bethesda, MD, 2007.

15 Jethanamest D, Vila PM, Sikora AG, Morris LG. Predictors of survival in mucosal melanoma of the head and neck. Ann Surg Oncol. 2011 Oct;18(10):2748-56.