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Sinus Cancer

If an adult in your life has sinus cancer, you may want to know more about it. This page has information about sinus cancer, its types and what to expect.

First, you should understand what cancer is. Cancer is a disease of unhealthy cells. Our bodies are made of cells so tiny you need a microscope to see them. Cancer cells don’t look or act like normal cells, and they grow much more quickly. There are many different types of cancer that can grow anywhere in the body.

Cancers on the outside skin of the nose are typically skin cancers, so see that section if you’re interested in learning more about cancers on the outside of the nose. This section covers cancers inside the paranasal sinuses (air-filled spaces in the head around the nasal cavity).

Of all sinonasal cancers, maxillary sinus cancers are the most common, followed closely by cancers of the nasal cavity and ethmoid sinus cancer. Sphenoid and frontal sinus cancers are very rare.1Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001Dec 15;92(12):3012-29. Most cancers in this region are squamous cell cancers. However, a number of tumors in this region are benign (non-cancerous), including:

  • Papilloma
  • Pyogenic granuloma
  • Adenoma
  • Dermoid
  • Glioma
  • Fibroma
  • Osteoma
  • Chrondroma
  • Hemangioma
  • Neurofibroma
  • Lymphangioma

Technology has helped us diagnose these cancers better. Doctors can use nasal endoscopy (telescopes and cameras inside the nose) to see areas we can’t just by looking in the front of the nose. Also, advances in MRI and CT scanning help us look at the anatomy inside the head much better. Finally, tests like PET scans may also help with diagnosis and understanding the extent of cancers in this area. We also have many more tools to treat cancers in this complex area, which has several important structures nearby.

Here are some facts about sinonasal cancers:

  • Are less than 1 percent of all cancers
  • Are approximately 3 percent of head and neck cancers
  • Usually affect adults older than 45 years old
  • Affect caucasians more than other races
  • Affect males more than females

Your loved one may have noticed a problem in his or her nose or sinuses and then went to the doctor to get it checked. Not every lump or pain is cancer, but it is a good idea to ask a doctor when you are not sure. The earlier cancer is found, the better the outcome can be.

Understanding the anatomy

To understand sinus cancer, you need a basic understanding of the anatomy (parts) of your head and neck.

The paranasal sinuses are air-filled spaces in the head. The sinuses are closely related to some major structures. They are close to the brain, the eyes, the carotid artery, the teeth and important nerves in the head and neck area.

46_sinus_axial45_1_sinuses2

There are four pairs of sinuses.

  • Maxillary sinus: This is the cheek sinus. This sinus is located above the teeth, below the eye and next to the nose. There is one on each side. This is the biggest sinus. There is a little drainage hole so all the mucous made in the sinus can drain into the nasal cavity just under the middle turbinate. The maxillary sinus is the most common site for a sinonasal cancer.
  • Ethmoid sinuses: This is a group of 10-20 small sinuses with very thin walls that sit between the eyes and the nasal septum. The eye (actually the orbit) is to one side of the ethmoid sinus, and there is just a thin piece of bone that separates the two. This, along with the nasal cavity, is tied for being the second most common site of sinonasal cancer. Mucous from the ethmoid sinuses drains into the nasal cavity, under both the middle and superior turbinates.
  • Frontal sinus: This sinus (also one on each side) is located behind the forehead and over the eye. It drains just below the middle turbinate through a passageway called the nasofrontal duct.
  • Sphenoid sinus: This sinus is located behind the nose at the base of the skull. Many important structures are found just behind the sphenoid sinus, including the brain, the nerve of vision and the main blood vessel to the brain (the carotid artery). The mucous from here empties just below the superior turbinate into the nasal cavity.

The exact functions of the sinuses are not clear, but it is thought that they play a role in:

  • Humidification (dampening) of the air
  • Keeping the head light in weight
  • Possibly preventing major skull damage from hits or falls on the face

Causes of sinus cancer

You may want to know what caused the sinus cancer. The short answer is that we don’t know. You can be sure that you did nothing to cause it. Also, it is not contagious (you can’t catch it).

In most cases, it’s a combination of genetics (inherited traits) and the environment.

Tobacco use may increase a person’s risk of developing sinonasal cancer. Researchers also now believe that exposure to certain chemicals in the workplace may increase the risk as well. Workers who may be at increased risk include2, 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 JC Jr, Fraumeni JF Jr. A case-control study of cancers of the nasal cavity and paranasal sinuses. Am J Epidemiol. 1984 Jun;119(6):896-906.4Battista 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.:

  • Nickel workers (including nickel refineries, cutlery factories and battery manufacturing)
  • Chromium workers (including chrome plating and chromium production)
  • Leather workers
  • Woodworkers

Signs and symptoms of sinonasal cancer

Sinus cancer can appear in many different ways, depending on where the cancer is located. For early cancers, there might not be any symptoms, or symptoms may seem like allergies, sinusitis or nasal polyps. Generally, if a polyp or something unusual is seen on only one side, the doctor might be more worried that it could be cancer and should be further evaluated by a biopsy (testing).

Some common symptoms include:

  • Nasal obstruction (feels like something is in the way)
  • Sinus pain, pressure and infections
  • Change or loss of sense of smell
  • Bleeding from the nose, particularly if only on one side (known as epistaxis)

When cancers in this area get larger, the symptoms will depend on what nearby structures are involved.

  • A tumor growing out of the nose
  • Change in vision or double vision
  • Pain
  • Recurrent sinus infections
  • Numbness in part of the face
  • Growth in the roof of the mouth from cancer growing downwards
  • Brain infection

These symptoms sound scary, but don’t jump to conclusions. The person could have one or more of these symptoms but NOT oral cavity cancer. There are several non-cancerous causes of the same symptoms. That’s why they need to see a specialist.

What will happen at the doctor visit

Step 1: History

First, the doctor will listen to the patient talk about his or her health. The doctor will probably ask many questions, too.

The doctor might ask some of these questions:

  • How long has the problem been there?
  • Is it getting worse, better or staying the same?
  • Does it come and go?
  • Have you tried anything to make it better?
  • Is it painful?
  • Do you have numbness or tingling anywhere in your face or mouth?
  • Do you have any changes in your vision or hearing?
  • Do you have a change in your sense of smell?
  • Do you have any lumps or bumps in your neck?
  • Are you losing weight?
  • Do you have any other medical conditions?
  • Have you had any surgeries in the past?
  • What medications do you take? And do you have any allergies?
  • Have you ever been exposed to radiation in the head and neck?
  • What do you (or did you) do for a living?
  • Do you have a family history of cancer?

Step 2: Physical Exam

Next, the doctor will look at and feel the patient’s head and neck. The nasal cavity and sinuses typically require a specialist to examine them because they are hard for a general doctor to see and feel. In general, the specialist might do some of the following:

  • Look and feel inside the mouth
  • Feel the neck extensively and carefully to check for any lumps or bumps
  • Look inside the ears
  • Look inside the front of the nose
  • Check the cranial nerves, do some simple hearing tests and test sense of touch all over the face

The doctor may also perform some special examinations using a sinonasal endoscope. Sinonasal endoscopy is a way to look far inside and around the nose and into the openings of the different sinuses. This method uses a tiny camera on the end of a long flexible tube. The camera is inserted into one of the nostrils and can go deep into the nasal passages and the sinus cavities.

Step 3: Reviewing Tests

After getting background information and doing a physical exam, the doctor will look at the results of any tests the patient has already had.

Step 4: Suggestions

Finally, the doctor will make suggestions about next steps. This will probably include more tests and doctor visits.

Diagnosing sinus cancer

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

However, if the doctor is suspicious, he or she may choose one or more of the following diagnostic steps.

Imaging

Imaging refers to radiologic studies, or scans, that make pictures of the structures inside the head and neck. In general, imaging might not be necessary for small tumors that can be easily seen by the doctor. For larger tumors, or tumors in locations difficult to examine, the doctor will probably order some sort of imaging to get more information about the tumor location to see if the tumor has spread to nearby 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 the doctor recommends.

Some surgeons also say getting imaging (pictures of the inside of the head and neck) will lower the chance of surprises in the operating room. Imaging will also give some clues about whether the tumor is really cancer. This will prepare the patient and the surgeon for what to expect during surgery.

There are many different kinds of imaging scans. The doctor may recommend more than one kind of scan to see a better picture of the tumor.

The two main types of imaging used in the U.S. are CT scans and MRI scans.

CT SCAN MRI
 CT Scan  MRI
Advantages A computed tomography (CT) scan is a quick test that shows a great deal of useful information.A CT scan can show the size of the tumor and how far it has spread. It can help a surgeon plan an operation. Magnetic resonance imaging (MRI) is better at showing how the tumor has spread to body parts around it.The patient will not be exposed to radiation during an MRI.
Disadvantages A CT scan uses radiation, which can be dangerous.The pictures might not be clear if the patient moves or has a lot of dental work.Also, a CT doesn’t show damage to nearby body parts as clearly unless the damage is moderate to severe. An MRI takes a lot longer than a CT scan. It requires the patient to lie perfectly still for almost an hour.The patient can’t have an MRI if he or she has metal implants.

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

Biopsy

A biopsy is the best way to find out if a growth is cancer. For a biopsy, the doctor takes out a small piece of the lump or the entire tumor. Another doctor, called a pathologist, then looks at the sample under a microscope to see if it is cancer. Doctors often do biopsies because they can usually be done quickly and safely. The doctor can sometimes do a biopsy during your the first visit, and there is a very low chance of anything going wrong.

Fortunately, many sinonasal lesions can be biopsied in the office with a little numbing medicine (either a spray or a tiny injection or both). It usually takes just a few minutes to do the biopsy.

In some cases, however, the doctor may want to do the biopsy in the operating room, especially if there is concern that the tumor has spread to the neck or throat.

Sinonasal biopsies can sometimes be performed with forceps inserted into the nose. They can also be done with an endoscope, which is a long flexible camera that can be inserted deeper into the nasal passages or sinus cavities. If there is also a lump in the neck, the doctor may decide to take a sample of that as well to see if cancer has spread to the lymph nodes in the neck. This can be done with a needle (called fine needle aspiration biopsy or FNAB) or during open surgery.

As good as biopsies sound, there are a few problems. First, biopsies are not 100 percent accurate. A biopsy could show that a growth is NOT cancer when it really is; this is called a false-negative biopsy. A false positive is also possible when the biopsy seems to show that a growth is cancer but more testing shows it isn’t. Experienced pathologists are far less likely to give a false positive or negative result as long as they have an adequate sample of tissue. Sometimes doctors can’t be completely sure a tumor is cancerous from a biopsy.6Wieneke JA, Thompson LD, Wenig BM. Basaloid squamous cell carcinoma of the sinonasal tract. Cancer. 1999 Feb 15;85(4):841-54.

Determining the type of sinus cancer

Only after a pathologist analyzes some cells or actual pieces of tissue from the lesion will the doctor be able to tell if it is cancer. The doctor may also want a second opinion from a specialist to be sure. Remember, not all lumps and bumps inside the nose and sinuses are cancer. Some growths are benign (non-cancerous), and some tumors are on the border between benign and malignant (cancerous).

In many cases, borderline growths should be removed with surgery. Examples of these types of tumors are:

  • Schneiderian papillomas: These might be related to human papillomavirus (HPV) infections, and they can be found on the front part of the nasal septum (fungiform-type) or on the lateral nasal wall (inverted and cylindrical types). There is a chance of squamous cell carcinoma within some of these papillomas, so they should be surgically removed.

Other borderline tumors include:

  • Angiofibroma
  • Ameloblastoma
  • Fibrous dysplasia
  • Ossifying fibroma
  • Giant cell tumor
  • Myxoma

However, some lesions in the nasal and sinus cavities are in fact cancer. The best way to categorize these types of tumors is based on the cell type from which the cancer started.1, Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: are we making progress? A series of 220 patients and a systematic review. Cancer. 2001Dec 15;92(12):3012-29.5Katz TS, Mendenhall WM, Morris CG, Amdur RJ, Hinerman RW, Villaret DB. Malignant tumors of the nasal cavity and paranasal sinuses. Head Neck. 2002Sep;24(9):821-9.

Epithelial-based cancers start in the surface layer of skin or the lining of organs and glands. They include:

  • Squamous cell carcinoma: These cancers start in the lining of the nasal cavity and sinuses. There are a few subtypes of squamous cell carcinomas, some more aggressive than others. Examples include verrucous squamous cell carcinomas (which have less tendency to invade deeply), basaloid squamous cell carcinoma and well-to-poorly differentiated squamous cell carcinomas.6Wieneke JA, Thompson LD, Wenig BM. Basaloid squamous cell carcinoma of the sinonasal tract. Cancer. 1999 Feb 15;85(4):841-54.
  • Adenocarcinoma: This type of minor salivary gland cancer arises from gland-like elements in the lining of the sinonasal tract or from salivary glands in the nasal cavity. Adenocarcinoma is the second most common type of sinonasal cancer.
  • Minor salivary gland cancers: These cancers affect minor salivary glands located in the nasal cavity and sinuses. Cancer types in this area include:
    • Adenocarcinoma
    • Adenoid cystic carcinoma
    • Mucoepidermoid carcinoma
  • Melanoma: These cancers come from skin cells that give skin its color. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat; this is called mucosal melanoma.7Marcus 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. Actually, approximately two-thirds of all mucosal melanomas start in the nasal cavity and paranasal sinuses (another one-third arise in the oral cavity, and the rest are in various other mucosal sites of the head and neck, such as the throat).8Edge 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. These are aggressive cancers, even when small.
  • Olfactory neuroblastoma (esthesioneuroblastoma): This very rare cancer is thought to begin from the tissue lining in the roof of the nose that is responsible for smell.
  • Sinonasal undifferentiated carcinoma (SNUC): This is a rare but very aggressive cancer. It is unclear what the cell of origin is. It often involves multiple sites.9Ejaz A, Wenig BM. Sinonasal undifferentiated carcinoma: clinical and pathologic features and a discussion on classification, cellular differentiation, and differential diagnosis. Adv AnatPathol. 2005May;12(3):134-43.
  • Neuroendocrine carcinoma: This is a type of cancer that begins in special cells that are a cross between endocrine cells (which produce hormones) and nerve cells. Neuroendocrine carcinoma can be found anywhere in the body, including the gastrointestinal tract, brain or lungs.10Perez-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.

Non-epithelial based sinonasal cancers include11Spiro JD, Soo KC, Spiro RH. Nonsquamous cell malignant neoplasms of the nasal cavities and paranasal sinuses. Head Neck. 1995;17:114-118.:

  • Sarcoma: These soft tissue tumors start in different types of tissues, including fibrous tissue, cartilage, bone, muscles and blood vessels, to name a few. Some examples of sarcomas found in the sinonasal area include:
    • Fibrosarcoma
    • Hemangiopericytoma
    • Angiosarcoma
    • Kaposi’s sarcoma
    • Rhabdomyosarcoma
    • Malignant fibrous histiocytoma
    • Chrondrosarcoma
    • Osteogenic sarcoma
  • Lymphoma: Lymphoid tissue is located all over the body, so lymphoma might appear as a lump in the sinonasal area.
  • Chordoma: This rare bone tumor occurs along the spine. Even more rarely, spread of cancers from other sites could show up in this area as a metastasis. This includes spread of lung, kidney, breast or ovarian cancer.

Even more rarely, spread of cancers from other sites could show up in this area. This includes spread of lung, kidney, breast or ovarian cancer.

The doctor will determine the treatment for the cancer based on the category (type), grade (abnormality) and stage (severity) of the tumor.

Determining the grade of the tumor

Pathologists will typically report on the grade of the tumor. This is the pathologist’s interpretation of how much the cancerous cells resemble normal tissue from that site. There are a number of different grading systems that might be used. The most common is as follows:

  • GX: Grade cannot be assessed
  • G1: Well differentiated
  • G2: Moderately differentiated
  • G3: Poorly differentiated
  • G4: Undifferentiated

Differentiation refers to how closely the cells taken from a tumor or lesion resemble normal cells from the healthy tissue surrounding the tumor. “Well differentiated” means that the cells look similar to normal cells in that area. “Undifferentiated” means the cells look nothing like normal cells in that area.

While it is important to report the tumor’s grade, few doctors use this information to make decisions regarding treatment or prognosis for this particular cancer type.

Determining the stage of the cancer

The final step before treatment is identifying the stage or the extent of the cancer. This will be determined by the physical exam, imaging studies, laboratory work and biopsies.

As with all cancers of the head and neck, doctors in the U.S. use the AJCC Cancer Staging Manual (7th Ed) to figure out the stage based on three factors.

Factors that go into determining the stage of the cancer
T Characteristics of the main tumor mass
N Status of the lymph nodes in the neck (i.e., evidence of cancer spread)
M Status of cancer spread to parts of the body outside of the head and neck

Note that there are different staging systems for maxillary sinus cancers versus ethmoid and nasal cavity cancers. Those staging systems apply to all forms of carcinoma (hence, they do not apply to mucosal melanoma, lymphomas and sarcomas). Mucosal melanomas of the head and neck have their own staging system as well.

You may hear people refer to your loved one’s cancer by a stage number. In general, Stage I cancer is limited to one tumor site and has not spread beyond that location. Stage IV usually refers to cancer that has spread to distant sites elsewhere in the body. Treatment of cancer that is caught in lower stages generally has a better outcome than cancer found after it has progressed to later stages.

T stage: the main tumor

Based on a physical examination and review of any imaging, the doctor should be able to assign a T stage that falls within one of the following categories.

47_sinuses_Tstages

Tumors of the Maxillary Sinus

Tumors of the Ethmoid Sinus

Tx The doctor is unable to assess the main tumor. Tx The doctor is unable to assess the main tumor.
T0 The doctor is unable to find the main tumor. T0 The doctor is unable to find the main tumor.
Tis The cancer is in situ, meaning there are cancer type cells, but they have not yet invaded deep into tissue. Tis The cancer is in situ, meaning there are cancer type cells, but they have not yet invaded deep into tissue.
T1 The tumor is totally within the lining of the maxillary sinus. There is no destruction of any of the bone of the maxillary sinus. T1 The tumor is in just one subsite, and there is no bone invasion or destruction.
T2 The tumor is in the maxillary sinus and has caused the bone to become eroded or destroyed. The tumor is in this stage even if it extends into the hard palate or into the nose under the middle turbinate. T2 The tumor is involved in two subsites in a single region or an adjacent site within the nasoethmoid complex, with or without bone invasion.
T3 The tumor invades through bone, any of the following: the bone at the back wall of the maxillary sinus, into the deep layers of the skin, into the inner floor of the eye socket, the pterygoid fossa (a space behind and to the side of the nose on the other side of the sphenoid bone), or the ethmoid sinuses. T3 The tumor has grown to involve the inner wall or floor of the eye socket or the maxillary sinus, hard palate or cribiform plate.
T4a This is moderately advanced local disease. The tumor has invaded into the contents of the eye socket in the front, the outer skin of the cheek, pterygoid plates, infratemporal fossa, the cribiform plate, sphenoid or frontal sinuses. T4a This is moderately advanced local disease. The tumor invades any of the following: the front of the eye socket, skin of the nose or cheek, minor extension into the anterior cranial fossa, pterygoid plates, sphenoid sinus or frontal sinus.
T4b This is very advanced local disease. The tumor has invaded into any of the following: the back part of the eye socket (orbital apex), the dura, brain, middle cranial fossa, cranial nerves (except V2), nasopharynx or clivus. T4b This is very advanced local disease. The tumor has invaded into any of the following: the back part of the eye socket (orbital apex), the dura, brain, middle cranial fossa, cranial nerves (except V2), nasopharynx, or clivus.

N stage: spread of cancer to the lymph nodes in the neck

Next, the doctor will use all the available information to assign an N stage. This is based on the assessment as to whether the cancer has spread to lymph nodes in the neck.

06_Nstages (1)

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 Cancer has spread to a single node on the same side of the main tumor, and it is 3 centimeters or less in greatest size.
N2a Cancer has spread to a single lymph node on the same side as the main tumor, and it is more than 3 centimeters but less than or equal to 6 centimeters in greatest size.
N2b There are multiple lymph nodes that have cancer on the same side as the main tumor, but none are more than 6 centimeters in size.
N2c There are lymph nodes in the neck that have cancer on either the opposite side as the main cancer or on both sides of the neck, but none are more than 6 centimeters.
N3 The cancer has spread to one or more neck lymph nodes, and the size is greater than 6 centimeters.

M stage: spread of cancer outside the head and neck

Finally, the doctor will identify an M stage. The M stage is based on an examination of the entire body.

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

The cancer stage

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
Stage IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
Stage IVB Any T N3 M0
T4b Any N M0
Stage IVC Any T Any N M1

Mucosal melanoma of the head and neck

Because mucosal melanoma of the head and neck is mostly found in the nasal cavity and paranasal sinuses (67 percent), it is worth mentioning the staging of this type of cancer here.

T stage for mucosal melanoma

The lowest T stage for a mucosal melanoma is T3. This indicates that even small tumors of this type can be quite aggressive.

T3 The melanoma is at a mucosal site.
T4a This is moderately advanced local disease. The tumor invades the deep tissue, cartilage, bone or overlying skin.
T4b This is very advanced local disease. The tumor involves the brain, dura, skull base, lower cranial nerves IX to XII, masticator space, carotid artery, prevertebral space or mediastinal structures.

N stage for mucosal melanoma

Nx The neck lymph nodes cannot be assessed.
N0 There is no evidence of any spread to the nodes.
N1 There are cancerous lymph nodes present.

M stage for mucosal melanoma

M0 No evidence of distant (outside the head and neck) spread.
M1 There is evidence of spread outside of the head and neck (i.e., in the lungs, bone, brain, etc.).

Cancer stage for mucosal melanoma

After TNM staging, the doctor can assign a cancer stage based on the following chart.

Stage III T3 N0 M0
Stage IVa T4a N0 M0
T3-4a N1 M0
Stage IVb T4b Any N M0
Stage IVc Any T Any N M1

The clinical stage

Once the tests are completed, and before deciding on a treatment plan, the patient should be given a clinical stage that looks like this:

CLINICAL STAGE
Example
Site Maxillary Sinus
Type Squamous Cell Carcinoma
Grade Well Differentiated
cT cT2
cN cN1
cM cM0
cStage cIII

* The lower-case c indicates that this is a CLINICAL STAGE, the stage assigned based on all information available to your doctor before starting treatment.

After surgery, and after the pathologist has evaluated all of the tumor that was removed, the patient should be given a pathologic stage that looks something like this:

PATHOLOGIC STAGE
Example
Site Maxillary Sinus
Type Squamous Cell Carcinoma
Grade Moderately Differentiated
pT pT2
pN pN0
cM cM0
pStage pII

* The lower-case p indicates that this is a PATHOLOGIC STAGE, the stage assigned after tumor removal and confirmation of cancer by a pathologist.

Deciding on a treatment plan

Like with all cancers in the head and neck, there are three general treatment options, which may be used alone, together, or one after the other:

The guidelines for most ethmoid sinus cancers (excluding mucosal melanomas, sarcomas and lymphomas) are as follows12Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343:

Ethmoid sinus tumors Newly diagnosed T1, T2 Surgical removal is the preferred treatment, followed by observation for T1 tumors or 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 alone as the primary 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 way to go 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 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 intracranial extension).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 looks benign and a surgeon removed it. Then the final results come back and it turns out that there is cancer. If there is no visible evidence of tumor, then:Surgery followed by radiation or observation (for T1 tumors) are two reasonable options.Alternatively, radiation alone could be considered.

The guidelines for most maxillary sinus cancers (excluding mucosal melanomas, sarcomas and lymphomas) are as follows:12Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343

Maxillary sinus cancer
T1-2, N0

All cancers except adenoid cystic carcinoma
Surgical removal should be the first treatment. If the margins are negative, the patient just needs to be followed. If the margins are positive, the patient needs additional surgery if possible, followed by either radiation (if the new margins are negative) or chemotherapy with radiation (if the new margins are still positive). If there is invasion into nerves, then 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 surgical removal involves the suprastructure (which is the area of the sinus above a line connecting the inner aspect of the eye to the angle of the mandible), then the patient should also receive radiation. If the surgical removal involved only the infrastructure (below that same line), then the doctor will recommend either observation or radiation.
Maxillary sinus cancer
T3-4a, N0
 All cancer types
The first line treatment is complete removal of the cancer by surgery. If there are any positive margins, then chemotherapy with radiation to the primary tumor area and the neck is recommended. If there are no positive margins and/or spread outside of the lymph nodes, then radiation to the primary tumor bed and possibly even the neck is recommended (for squamous cell cancers and SNUCs).
Maxillary sinus cancer
T4b, Any N
 All cancer types 
The first line treatment for this class of tumors is clinical trials, radiation therapy alone or chemotherapy with radiation.
Maxillary sinus cancer
T1-4a, N+
All cancer types
When the cancer has spread to the neck, it should be removed 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 chemotherapy with radiation to the primary tumor site and the neck should be considered.

The guidelines for mucosal melanoma (most of which start in the sinonasal area) are as follows:12Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343

Mucosal melanoma (sinonasal)
Stage III
The main tumor should be surgically removed, with strong consideration of radiation to the primary site.
Mucosal melanoma (sinonasal)
T4a, N0
The main tumor should be surgically removed, with radiation to the primary site.
Mucosal melanoma (sinonasal) T3-4a, N1 The main tumor should be surgically removed, with a neck dissection for cancerous lymph nodes in the neck, followed by post-operative radiation to the main tumor 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 systemic therapy.
Mucosal melanoma (sinonasal) Stage IVc The preferred treatment method is a clinical trial. Other options include the best supportive care, radiation alone, or systemic therapy.

 

Determining the prognosis

The prognosis is a prediction of how the treatment will turn out. How likely is it that a person with cancer will be cured? Will the cancer come back? How will life change? These are the big questions on most people’s minds when they find out that someone they love has sinus cancer.

The following characteristics of the cancer may affect the chances of a cure.

Factors That Can Affect the Chances of Being Cured
Stage This is the most important factor that affects the chances of being cured. Cancers in earlier stages usually have better outcomes.
Type and Grade The type and grade of tumor show how aggressive a tumor is.
Spread to Lymph Nodes If there is spread to lymph nodes in the neck, there is a lower chance of a cure.
The Tumor Margins (edges) Some say the ability to completely remove the tumor is the single most important factor in whether a person will be cured.
Spread into Nearby Body Parts Spread into large nerves, skin and bone has been shown to indicate a worse prognosis.

In general, it is very difficult to discuss prognosis (outcomes) without understanding all the details of the cancer; to give a percentage chance of a cure is difficult because cancer research looks at all types of cancers and may include patients from long ago.

What to expect after treatment is completed

When the person in your life who has cancer has completed treatment, he or she will need to follow up closely with the doctor. Follow-up doctor visits and testing are to make sure the cancer doesn’t come back or to catch it quickly if it does. In general, a person who has completed treatment for head and neck cancer should have regularly scheduled doctor’s visits every one to three months for the first year, every two to six months in the second year and every four to eight months in the third to fifth year. In addition, the doctor will order scans to help in the monitoring process. After making it past the first five years, the person can then see the doctor once a year.12Cohen, E. E., LaMonte, S. J., Erb, N. L., Beckman, K. L., Sadeghi, N. , Hutcheson, K. A., Stubblefield, M. D., Abbott, D. M., Fisher, P. S., Stein, K. D., Lyman, G. H. and Pratt‐Chapman, M. L. (2016), American Cancer Society Head and Neck Cancer Survivorship Care Guideline. CA: A Cancer Journal for Clinicians, 66: 203-239. doi:10.3322/caac.21343

*The tables within the page are supported by the following sources

Agrawal S, Kane JM, Guadagnolo BA, Kraybill WG, Ballo MT. The benefits of adjuvant radiation therapy after therapeutic lymphadenectomy for clinically advanced, high-risk, lymph node-metastatic melanoma. Cancer. 2009;115(24):5836-5844. doi:10.1002/cncr.24627

Amin M, Edge S, Greene F, et al. (2017). AJCC Cancer Staging Manual, 8th ed. New York: Springer.

Bachar G, Loh KS, O’Sullivan B, et al. Mucosal melanomas of the head and neck: experience of the Princess Margaret Hospital. Head Neck. 2008;30(10):1325-1331. doi:10.1002/hed.20878

Burmeister BH, Henderson MA, Ainslie J, et al. Adjuvant radiotherapy versus observation alone for patients at risk of lymph-node field relapse after therapeutic lymphadenectomy for melanoma: a randomised trial. Lancet Oncol. 2012;13(6):589-597. doi:10.1016/S1470-2045(12)70138-9

Chang AE, Karnell LH, Menck HR. The National Cancer Data Base report on cutaneous and noncutaneous melanoma: a summary of 84,836 cases from the past decade. The American College of Surgeons Commission on Cancer and the American Cancer Society. Cancer. 1998;83(8):1664-1678. http://www.ncbi.nlm.nih.gov/pubmed/9781962.

Chen AM, Daly ME, Bucci MK, et al. Carcinomas of the paranasal sinuses and nasal cavity treated with radiotherapy at a single institution over five decades: are we making improvement? Int J Radiat Oncol Biol Phys. 2007;69(1):141-147. doi:10.1016/j.ijrobp.2007.02.031

Chen N-X, Chen L, Wang J-L, et al. A clinical study of multimodal treatment for orbital organ preservation in locally advanced squamous cell carcinoma of the nasal cavity and paranasal sinus. Jpn J Clin Oncol. 2016;46(8):727-734. doi:10.1093/jjco/hyw064

Dirix P, Nuyts S, Geussens Y, et al. Malignancies of the nasal cavity and paranasal sinuses: long-term outcome with conventional or three-dimensional conformal radiotherapy. Int J Radiat Oncol Biol Phys. 2007;69(4):1042-1050. doi:10.1016/j.ijrobp.2007.04.044

Douglas CM, Malik T, Swindell R, Lorrigan P, Slevin NJ, Homer JJ. Mucosal melanoma of the head and neck: radiotherapy or surgery? J Otolaryngol Head Neck Surg. 2010;39(4):385-392. http://www.ncbi.nlm.nih.gov/pubmed/20643003.

Hoppe BS, Stegman LD, Zelefsky MJ, et al. Treatment of nasal cavity and paranasal sinus cancer with modern radiotherapy techniques in the postoperative setting–the MSKCC experience. Int J Radiat Oncol Biol Phys. 2007;67(3):691-702. doi:10.1016/j.ijrobp.2006.09.023

Le QT, Fu KK, Kaplan MJ, Terris DJ, Fee WE, Goffinet DR. Lymph node metastasis in maxillary sinus carcinoma. Int J Radiat Oncol Biol Phys. 2000;46(3):541-549. http://www.ncbi.nlm.nih.gov/pubmed/10701732.

Meleti  M, Leemans CR, de Bree R, Vescovi P, Sesenna E, van der Waal I. Head and neck mucosal melanoma: experience with 42 patients, with emphasis on the role of postoperative radiotherapy. Head Neck. 2008;30(12):1543-1551. doi:10.1002/hed.20901

Ock C-Y, Keam B, Kim TM, et al. Induction chemotherapy in head and neck squamous cell carcinoma of the paranasal sinus and nasal cavity: a role in organ preservation. Korean J Intern Med. 2016;31(3):570-578. doi:10.3904/kjim.2015.020

Patel SG, Prasad ML, Escrig M, et al. Primary mucosal malignant melanoma of the head and neck. Head Neck. 2002;24(3):247-257. http://www.ncbi.nlm.nih.gov/pubmed/11891956.

Porceddu S, Martin J, Shanker G, et al. Paranasal sinus tumors: Peter MacCallum Cancer Institute experience. Head Neck. 2004;26(4):322-330. doi:10.1002/hed.10388

Seetharamu N, Ott PA, Pavlick AC. Mucosal melanomas: a case-based review of the literature. Oncologist. 2010;15(7):772-781. doi:10.1634/theoncologist.2010-0067


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