Nasal cavity carcinomas are rare, occuring in about 1 out of every 100,000 people per year in the U.S.1 These tumors occur more commonly in whites, and the ratio of men to women is 2:1. These tumors occur most commonly in two different age periods, between 10 to 20 years old and between 50 to 60 years old. Squamous cell carcinoma is the most common histology
Etiology:
Factors that increase ones risk of nasal cavity carcinoma include:2
Previous radiation therapy for hereditary retinoblastoma
Signs & Symptoms:
Early cancer symptoms are often the same as non-cancerous conditions. Early cancer symptoms that mimic common conditions of the sinuses include:5
A nose bleed from one nostril
Blockage of a nostril
Runny nose on one side
Symptoms that can indicate an advances cancer tumor are:
A persistent headache
Changes in vision or double vision
Diagnostic Procedures:
A biopsy is needed to diagnosis the type of cancer. Tissue is removed and a pathologist examines the cells under a microscope.5
CT scan - A special type of X-ray that makes a series of detailed pictures, with different angles, of areas inside the mouth and neck. A computer is linked to the X-ray machine. A contrast may be injected into a vein or swallowed in a pill to help the organs or tissues show up on the X-ray.
Magnetic resonance imaging (MRI) - A machine that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the mouth and neck. This procedure is also called nuclear magnetic resonance imaging (NMRI).
PET scan - A PET scan helps determine if a tumor has spread to other areas in the body. During a positron emission tomography scan (PET), a small amount of radioactive sugar (glucose) is injected into a vein. The scanner makes computerized pictures of the areas inside the body. Cancer cells absorb more radioactive glucose than normal cells, so the tumor is highlighted on the pictures.
Histology:
Squamous cell carcinoma is most common. Malignant melanoma and minor salivary gland tumors each account for 10-15% of cancers in the nasal cavity. Other types are lymohoma (usually histiocytic), esthesioneuroblastoma, sarcoma, and inverting papilloma. The histologic picture of an inverting papilloma is that of a papilloma growing into, rather than out of, the stroma. Almost all nasal vestibule cancers are squamous in origin.10
Lymph node drainage:
Lymph nodes are usually not involved until the tumor has extended to areas of abundant capillary lymphatics. Drainage to the submandibular and subdigastric nodes would be most common.10
Metastatic spread:
Cancer can spread by directly invading surrounding tissue, lymphatics, or through the blood stream.3 Nasal cancers most commonly spread by direct invasion. My Oncologist says he rarely treats nodes for nasal cavity cancers because it is uncommon for them to spread through the lymphatics, although he was quick to mention that its not impossible.
Grading:
The word differentiation describes how developed the cancer cells are and is also used to when describing the grade of the cancer. Grade 1 or low grade means cancer cells look very much like normal nasal cavity cells. Grade 2 cells look slightly normal, and Grade 3 cells look very abnormal and do not resemble normal nasal cavity cells. Physicians may describe grade 1 cells as well differentiated, grade 2 cells as moderately differentiated, and grade 3 cells as poorly differentiated.2
Staging:
The stage of a cancer is a description of how far the disease has spread. Staging is determined by procedures such as: the physical exam, diagnostic imaging, test results, and surgery results. The most common system is the TNM system created by the American Joint Committee on Cancer (AJCC). This system contains 3 key pieces of information: T, N, and M; which stand for tumor, nodes, and metastasis.
T describes whether the main (primary) tumor has invaded other organs or tissues near the nasopharynx.
N describes whether the cancer has spread to nearby (regional) lymph nodes (bean-sized collections of immune system cells throughout the body).
M indicates whether the cancer has metastasized (spread) to other parts of the body.4
Additional numbers or letters that appear after T, N, and M provide more details about each of these factors:
The numbers 0 through 4 indicate further spread.
The letter X means “cannot be assessed” because the information is not available.
The letters “is” after the T stand for “in situ,” which means the tumor is still only in the layer of cells where it started and has not yet invaded deeper.5
American Joint Committee on Cancer (AJCC) TNM Staging System for the nasal cavity:
Primary tumor (T): Nasal cavity4
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
T1: Tumor restricted to any 1 subsite, with or without bony invasion
T2: Tumor invading 2 subsites in a single region or extending to involve an adjacent region within the nasoethmoidal complex, with or without bony invasion
T3: Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
T4a: Moderately advanced local disease
Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to the anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses
T4b: Very advanced local disease
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
Regional lymph nodes (N):4
NX: Regional nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node 3 cm or less in greatest dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N2a: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension
N2b: Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension
N2c: Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension
N3: Metastasis in a lymph node, more than 6 cm in greatest dimension
Dental decay, xerostomia, erythema, retinopathy, fatigue, and nausea.5
Prognosis:
The prognosis of nasal cavity cancers is completely dependent on the type, location, spread, and the speed in which it expands. As an average, 35-60% of people diagnosed with nasal cancer will survive beyond 5 years. If the patient has an early stage tumor, they will almost always live to 5 years after diagnosis. On the other hand, an advanced tumor results in only a 10-20% survival rate 5 years after treatment.[9]
Treatments:
The treatment modalities used for nasal cavity cancers are dependent mostly on the stage of the disease. For early stage tumors with no lymph node involvement, surgery and radiation therapy combined is the most accepted method of treatment. If the lymph nodes in the neck are involved, it is necessary to complete a radical dissection as well as radiation to that region. It seems to be crucial that the radiation treatments not be prolonged as there is often a loss of local control. After surgery the radiation therapy treatments are taken to a dose of 60-68 Gray (Gy), or 74-79Gy if treated without surgery. With the spinal cord potentially being in the fields, it is important to remember to add a block to the treatment at 50Gy. Many times the method of choice for the nasal cavity is intensity modulated radiation therapy (IMRT) to the clinical target volume (CTV). In most cases the CTV consists of the gross tumor volume (GTV) plus a 1-1.5 centimeter (cm) margin.[9]
TD 5/5: Organ
Injury
TD 5/5
Whole or Partial organ
Retina
Blindness
5500cGy
Whole
Lens of eye
Blindness
500cGy
Whole
Cornea
Blindness
5000cGy
Whole
Optic Pathway
Blindness
15cGy
0.2
Optic Chiasma
Blindness
4500cGy
3/3
Brain
Infraction, Necrosis
5000-6000cGy
Whole
Brain Stem
Necrosis
6000cGy
Whole
Spinal Cord
Infraction, Necrosis
4500cGy
10cm2
Ear
Acute serous otitis
3000cGy
3/3
Salivary Glands
Xerostomia
5000cGy
50cm2
Lacrimal Glands
Xerophthalmia
4000cGy
Endocrine Glands
Reduced hormone production
4500cGy
3/3
Oral Cavity and Pharynx
Ulceration
6000cGy
50cm2
Reprinted from Radiation Oncology Management Decisions, 2013.12 The image above shows the nasal cavity and surrounding structures.
Reprinted from Radiation Oncology Management Decisions, 2013.12
The image above shows portals used to treat nasal cavity and paranasal sinuses disease. A: In patients with extensive orbital invasion (palpable orbital mass, proptosis, blindness), all orbital contents are irradiated. B: In patients with limited orbital invasion, the major lacrimal gland is shielded. This portal is used for limited lesions of the nasal cavity. C: Typical lateral portal for treatment of paranasal sinus and nasal cavity tumors. Field is angled 5 degrees posteriorly to avoid exit irradiation to the contralateral eye.
Reprinted from Medical Dosimetry, 2013.13 The above images show the isodose distribution in axial, sagittal, and coronal slices for (A) 9-field IMRT and (B) 3-arc volume Volumetric Modulated Arc Therapy (VMAT). The planning target volume 60 Gray (PTV60), PTV57, and PTV54 are shown in red, blue, and yellow colorwash, respectively. The medium red, blue, and yellow lines are the 100% isodose curves of 60 Gray (Gy), 57Gy, and 54Gy, respectively.13
Lozano RG. Head and neck cancers. In: Washington CM, Leaver D, eds. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Elsevier; 2010:692-744.
Perez CA, Brady LW. Principles and Practice of Radiation Oncology. 3rd ed. Philadelphia, PA:Lippincott-Raven;1998.
Washington CM, Leaver D. Principles and Practice of Radiation Therapy. 3rd ed. St. Louis, MO: Mosby Elsevier; 2010: 80-83.
Chao K, Perez CA, Brady LW. Radiation Oncology Management Decisions. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 20011.
Nguyen K, Cummings D, Garcia J, et al. A dosimetric comparative study: Volumetric modulated arc therapy vs intensity-modulated radiation therapy in the treatment of nasal cavity carcinomas. Med Dos. 2013; doi:10.1016/j.meddos.2013.01.006.
- A nose bleed from one nostril
- Blockage of a nostril
- Runny nose on one side
Symptoms that can indicate an advances cancer tumor are:Additional numbers or letters that appear after T, N, and M provide more details about each of these factors:
American Joint Committee on Cancer (AJCC) TNM Staging System for the nasal cavity:
Primary tumor (T): Nasal cavity4
Regional lymph nodes (N):4
Distant metastasis (M):4
Anatomic Stage for the nasal cavity:4
http://www.nccn.org/professionals/physician_gls/pdf/head-and-nec
Organ
The image above shows the nasal cavity and surrounding structures.
Reprinted from Radiation Oncology Management Decisions, 2013.12
The image above shows portals used to treat nasal cavity and paranasal sinuses disease.
A: In patients with extensive orbital invasion (palpable orbital mass, proptosis, blindness), all orbital contents are irradiated.
B: In patients with limited orbital invasion, the major lacrimal gland is shielded. This portal is used for limited lesions of the nasal cavity.
C: Typical lateral portal for treatment of paranasal sinus and nasal cavity tumors. Field is angled 5 degrees posteriorly to avoid exit irradiation to the contralateral eye.
Reprinted from Medical Dosimetry, 2013.13
The above images show the isodose distribution in axial, sagittal, and coronal slices for
(A) 9-field IMRT and
(B) 3-arc volume Volumetric Modulated Arc Therapy (VMAT). The planning target volume 60 Gray (PTV60), PTV57, and PTV54 are shown in red, blue, and yellow colorwash, respectively. The medium red, blue, and yellow lines are the 100% isodose curves of 60 Gray (Gy), 57Gy, and 54Gy, respectively.13
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