Malignant Tumors of the Sinuses Workup

Updated: Oct 18, 2022
  • Author: Karen Y Choi, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

As with other head and neck cancers, additional tests are usually obtained to evaluate for distant organ disease (eg, liver enzymes) or pulmonary metastasis (eg, chest radiographs, computed tomography [CT] scans).

In the case of a nasal cavity or paranasal sinus mass or erosion, an antineutrophil cytoplasmic antibody (ANCA) test for possible granulomatosis with polyangiitis should be considered. Although granulomatosis with polyangiitis is an inflammatory disease, it often mimics a neoplasm due to its local destructive properties.

Consultation with multiple specialties should be considered because sinonasal tumors involve complex structures throughout the face and skull base. Neurosurgery consultation is warranted for tumors with any skull base involvement and possible intracranial extension. Ophthalmologic consultation is helpful for documenting visual acuity and evaluating for any extraocular motility disturbances and proptosis. After surgery, the ophthalmologist can also assist with the treatment of epiphora or dry eye syndrome. A dentist may need to be seen prior to radiosurgery for dental extraction. A consultation with a prosthodontist should be considered if a maxillectomy is expected. Speech pathology can be consulted for post-treatment morbidities, such as speech and swallowing difficulties.

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Imaging Studies

Imaging studies depend on the differential diagnosis. Plain radiography, computed tomography (CT) scanning, and magnetic resonance imaging (MRI) all provide information. Each has its own advantages and limitations. With the ubiquitous nature of the acute and chronic inflammation disease in the sinonasal cavity and the complex anatomy of the sinonasal tract, these tumors are often difficult to diagnose and treat.

MRI is vital in the establishing the presence or absence of factors that determine resectability, such as orbital invasion, perineural spread, skull base invasion, intracranial extension, and invasion of the masticator and parapharyngeal spaces by tumor. [89]  The greatest advantage to MRI is in helping to distinguish the tumor and revealing retained secretions in the multiple sinus cavities.

Special emphasis should be placed on MRI evaluation of perineural invasion in adenoid cystic carcinoma because these can track down the nerve in over 60% of cases. [90] Esthesioneuroblastoma (ENB) on MRI often shows peritumoral cysts capping of the intracranial portion of the tumor, which is strongly suggestive of the diagnosis. [91]

CT scanning has a higher accuracy in determining both bony remodeling and erosion of the skull base and sinuses. Osteolysis can often be observed with SCC, metastatic disease, sarcoma, and SNUC. Boney remodeling is more often seen with salivary gland tumors, large cell lymphoma, melanoma, and ENB. In addition, chronic or acute inflammatory sinus disease may also cause boney remodeling. [89] Finally, CT scanning is slightly more accurate than MRI in demonstration of orbital invasion due to its ability to evaluate both the bony orbital wall and adjacent fat.

In the setting of ENB, positron emission tomography (PET)-CT scanning is useful for staging and detecting distant metastases when used in conjunction with conventional imaging. [92]  PET-CT scanning can also help to detect recurrences, but it should not replace the use of nasal endoscopy or MRI. [93]

The authors’ opinion is that both CT scanning and MRI should be performed prior to surgical intervention to help assist in preliminary staging, surgical planning, and defining respectability in close consultation with the neuroradiologist. In addition, as most landmarks and normal anatomy after surgery are disrupted, recurrence is difficult to identify on imaging. Therefore, postoperative baseline imaging is recommended for comparison tumor surveillance. Apparent Diffusion Coefficient (ADC) mapping shows potential as an additional MRI tool to effectively differentiate benign/inflammatory lesions from malignant tumors in the sinonasal area. [94]

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Diagnostic Procedures

See the list below:

  • Biopsy is the only 100% accurate means of obtaining a tissue diagnosis.

  • Remember that the turbinates and the possibility of a juvenile angiofibroma may both lead to extensive bleeding. In addition, patients with midline nasal masses may include intranasal dermoids, gliomas, and meningoencephalocele with direct communication with the anterior cranial fossa. Should the surgeon suspect these neoplasms, proper imaging and other tests should be performed before biopsy.

  • A biopsy should be performed on highly suspicious vascular tumors in the OR under controlled conditions where bleeding can be more safely controlled.

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Histologic Findings

The important histologic features are discussed in detail for the individual neoplasms in the Clinical section.

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Staging

Staging of nasal cavity and paranasal sinus carcinomas is not as well established as for other head and neck tumors. Two generally accepted staging systems are currently in use. The Kadish staging system is used specifically for esthesioneuroblastoma because this malignancy often involves the skull base and intracranial extension. For cancer of the maxillary sinus, the nasal cavity, and the ethmoid sinus, the American Joint Committee on Cancer (AJCC) has designated staging by TNM classification. No broadly accepted staging systems for frontal and sphenoid sinus cancer currently exist. [56]

Maxillary sinus

Primary tumor (T)

  • TX - Primary tumor cannot be assessed

  • Tis - Carcinoma in situ

  • T1 - Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone

  • T2 - Tumor causing bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid plates

  • T3 - Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinuses

  • T4a - Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

  • T4b - 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

Nasal cavity and ethmoid sinus

Primary tumor (T)

  • TX - Primary tumor cannot be assessed

  • Tis - Carcinoma in situ

  • T1 - Tumor restricted to any one 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 - Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior cranial fossa, pterygoid plates, sphenoid or frontal sinuses

  • T4b - Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2), nasopharynx, or clivus

Regional lymph nodes (N)

See the list below for clinical N:

  • NX - Regional lymph 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 and ENE (-)

  • N2 - Metastasis in a single ipsilateral lymph node larger than 3 cm but 6 cm or less in greatest dimension and extranodal extension negative (ENE [-]); or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension and ENE (-); or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

    • N2a - Metastasis in a single ipsilateral lymph node larger than 3 cm but 6 cm or less in greatest dimension and ENE (-)

    • N2b - Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

    • N2c - Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

  • N3 - Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE (-); or in any lymph node(s), with clinically overt ENE (+)

    • N3a - Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE (-)

    • N3b - Metastasis in any lymph node(s), with clinically overt ENE

See the list below for pathological N:

  • NX - Regional lymph 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 and ENE (-)

  • N2 - Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension and ENE (+); or in a single ipsilateral lymph node larger than 3 cm but 6 cm or less in greatest dimension and ENE (-); or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension and ENE (-); or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

    • N2a - Metastasis in a single ipsilateral lymph node 3 cm or less in greatest dimension and ENE (+); or in a single ipsilateral lymph node larger than 3 cm but 6 cm or less in greatest dimension and ENE (-)

    • N2b - Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

    • N2c - Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimension and ENE (-)

  • N3 - Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE (-); or in a single ipsilateral lymph node larger than 3 cm in greatest dimension and ENE (+); or in multiple ipsilateral, contralateral, or bilateral nodes, any of them ENE (+); or a single contralateral lymph node of any size and ENE (+)

    • N3a - Metastasis in a lymph node larger than 6 cm in greatest dimension and ENE (-)

    • N3b - Metastasis in a single ipsilateral lymph node larger than 3 cm in greatest dimension and ENE (+); or in multiple ipsilateral, contralateral, or bilateral nodes, any of them ENE (+); or in a single contralateral node of any size and ENE (+)

Kadish staging for esthesioneuroblastoma  

See the list below [95, 96] :

  • Stage A: The tumor is limited to the nasal fossa

  • Stage B: The tumor extends to the paranasal sinuses

  • Stage C: The tumor extends beyond the paranasal sinuses

  • Stage D: Regional lymph node or distant metastasis [97, 98]

Mucosal melanoma

Primary Tumor (T)

  • T3 - Tumors limited to the mucosa and immediately underlying soft tissue, regardless of thickness or greatest dimension; for example, polypoid nasal disease, pigmented or nonpigmented lesions of the oral cavity, pharynx, or larynx
  • T4 - Moderately advanced or very advanced
    • T4a - Moderately advanced disease; tumor involving deep soft tissue, cartilage, bone, or overlying skin
    • T4b - Very advanced disease; tumor involving the brain, dura, skull base, lower cranial nerves (IX, X, XI, XII), masticator space, carotid artery, prevertebral space, or mediastinal structures

See Mucosal Melanoma of Head and Neck Staging.

Ann Arbor staging for lymphomas

See the list below [99] :

  • Stage I - Involvement of a single lymph node region or of a single extralymphatic organ or site
  • Stage II - Involvement of two or more lymph node regions on the same side of the diaphragm or localized involvement of an extralymphatic organ or site and of one or more lymph node regions on the same side of the diaphragm; an optional recommendation is that the number of node regions involved be indicated by a subscript
  • Stage III - Involvement of lymph node regions on both sides of the diaphragm, which may also be accompanied by localized involvement of an extralymphatic organ or site and/or involvement of the spleen
  • Stage IV - Diffuse or disseminated involvement of one or more extralymphatic organs or tissues with or without associated lymph node enlargement
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