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Sinus Cancer

Deciding on a Treatment Plan

Your doctors will typically use National Comprehensive Cancer Network® (NCCN®) Clinical Practice Guidelines in Oncology(NCCN Guidelines®) for Head and Neck Cancers, as well as their own professional experience, to decide on the appropriate treatment course.13Referenced 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. If these NCCN Guidelines® are not followed, they will discuss it with you and explain why your situation might be special.

Before starting treatment, your doctor will make sure that the following steps are completed.

Pretreatment evaluation

  • A full history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam if needed)
  • An evaluation by the members of a head and neck cancer team
  • A biopsy to confirm a diagnosis of cancer
  • Imaging of the lungs to check for spread, if needed
  • CT with contrast or MRI with contrast of the primary tumor, the neck, and the skull base
  • A dental evaluation, if needed
  • A PET-CT may be considered for advanced disease
  • Pretreatment medical clearance and optimization of medical conditions

For mucosal melanoma, the pretreatment evaluation includes the following:

  • A thorough history and physical examination, including a complete head and neck exam (mirror and fiberoptic exam if needed)
  • Verification of the pathology of the mucosal melanoma
  • CT with contrast and/or MRI with contrast to check how extensive the disease is, particularly for sinus cancers
  • Imaging of the lungs to check for spread, if needed
  • A PET-CT may be considered to look for distant, or metastatic, disease

Then your doctor will recommend a course of treatment for you, depending on a number of factors. Like for all cancers in the head and neck, there are three general therapeutic options to consider:

The NCCN Guidelines are slightly different for maxillary versus ethmoid sinus tumors.13 There are no separate NCCN Guidelines for nasal cavity tumors as yet, so you should discuss with your doctors the best management for these types of tumors.

The NCCN Guidelines for most ethmoid sinus cancers (excluding mucosal melanomas, sarcomas and lymphomas) are as follows:13Referenced 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.

Ethmoid sinus tumors 

Newly diagnosed T1, T2

Surgical removal is the preferred treatment, followed by observation for T1 tumors or postoperative radiation for any tumors. However, if after surgical removal there are positive margins or extension into the skull, then chemotherapy with radiation should be considered.

Alternatively, radiation as definitive treatment is another option.

Ethmoid sinus tumors 

Newly diagnosed T3, T4a

Surgical removal is the preferred treatment for these tumors. Surgery should be followed by either radiation or chemotherapy with radiation if there are adverse features such as positive margins or extension inside the skull.

Alternatively, chemotherapy with radiation as the primary treatment is another option.

Ethmoid sinus tumors 

Newly diagnosed T4b

Or patient declines surgery

Options here are chemotherapy with radiation, radiation alone or a clinical trial, which is actually the preferred treatment if possible.
Ethmoid sinus tumors 

Diagnosed after incomplete removal of a lesion

Evidence of tumor cells on physical exam and/or imaging

This can happen when a tumor inside the nose looks benign and a surgeon removed it. Then, the final results come back and it turns out that there is cancer in the tumor. If it wasn’t completely removed and there is still visible tumor present, then:

Additional surgery is the preferred treatment, if possible. This should be followed by radiation therapy or consideration should be given to chemotherapy with radiation if there are adverse features (such as positive margins or extension into the skull.)

Another option is to give radiation therapy and follow it closely.

A final option is to give chemotherapy and radiation and follow it closely.

Ethmoid sinus tumors 

Diagnosed after incomplete resection

No evidence of tumor cells just by looking inside and/or on imaging

This can happen when a tumor inside the nose looks benign and a surgeon removed it. Then, the final results come back and it turns out that there is cancer. If it wasn’t completely removed but there is no visible evidence of tumor, then:

Surgery, if possible, followed by radiation or observation (for T1 tumors) are two reasonable options.

Alternatively, radiation alone could be considered.

The NCCN Guidelines for most maxillary sinus cancers (excluding mucosal melanomas, sarcomas and lymphomas) are as follows:13Referenced 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.

Maxillary sinus cancer

T1-2, N0

All cancers except adenoid cystic carcinoma

Surgical removal is the first treatment you should receive. If the margins are negative, you just need to be followed. If the margins are positive, you need additional surgery if possible, followed by radiation or chemotherapy with radiation (if the new margins are still positive) or you may consider radiation (if the new margins are negative.) If there is invasion into nerves, then your doctors should consider giving radiation or chemotherapy with radiation.
Maxillary sinus cancer

T1-2, N0

Adenoid cystic carcinoma

Surgical removal is the first treatment here as well. If the resection involves the suprastructure (which is the area of the sinus above a line connecting the inner aspect of your eye to the angle of the mandible), then you should also receive radiation. If the resection involved only the infrastructure (below that same line), then your doctor will recommend either observation or radiation.
Maxillary sinus cancer
T3-T4a, N0 All cancer types
The first line treatment is complete removal of the cancer by surgery. If there are any positive margins, then radiation or chemotherapy with radiation to the primary tumor area and the neck is recommended. If there are no positive margins, then radiation to the primary tumor bed and possibly even the neck is recommended (for squamous cell cancers and sinonasal undifferentiated carcinomas.)
Maxillary sinus cancer
T4b, Any N 

All cancer types 

The first line treatment for this class of tumors is clinical trials, definitive radiation therapy alone or chemotherapy with radiation.
Maxillary sinus cancer
T1-T4a, N+All cancer types
When the cancer has spread to the neck, it should be resected from the maxillary sinus as well as from the neck with a neck dissection. Then, if there are no positive margins or spread of cancer outside the neck lymph nodes, radiation should be given to the primary tumor bed and to the neck. If there are positive margins and/or spread outside of the lymph nodes, then radiation is recommended or chemotherapy with radiation to the primary tumor site and the neck is recommended.

The NCCN Guidelines for mucosal melanoma (most of which start in the sinonasal area) are as follows:13Referenced 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.

Mucosal melanoma (sinonasal)
Stage III
You should undergo wide resection of the main tumor, with strong consideration of post-operative radiation to the primary site.
Mucosal melanoma (sinonasal)

Stage IVA
T4a, N0

You should undergo wide resection of the main tumor, with post-operative radiation to the primary site.
Mucosal melanoma (sinonasal) 

Stage IVA

T3-T4a, N1

You should undergo wide resection of the main tumor, with a neck dissection for cancerous lymph nodes in the neck, followed by post-operative radiation to the primary site and the neck.
Mucosal melanoma (sinonasal) 

Stage IVb

The preferred method is to be enrolled in a clinical trial. Other options include radiation alone or some sort of systemic therapy.
Mucosal melanoma (sinonasal)

Stage IVc

The preferred treatment method is a clinical trial. Other options include best supportive care, radiation, or some sort of systemic therapy.
References

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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.

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