Ca Maxilla

Ca Maxilla

Ca Maxilla

AETIOLOGY

1.Worker in hardwood  furniture industry nickel refining, leather work and manufacture of mustard gas have shown higher incidence of sinunasal cancer
2.Commn in bantus of south africa where locally made snuff is used which is rich in nickel and chromium .
3. Worker of furniture industry

Disease is common in 40-60 age group with preponderance in male .

CLINICAL FEATURES

early features of maxillary sinus malignancy are
1. nasal stiffiness
2.Blood stained nasal discharge
3.Facial paraesthesias or pain and epiphora

DIRECTIN OF SPREAD AND EXTENT OF GROWTH

1.Medial spread to nasal cavity gives rise to nasal obstruction, discharge and epistaxis.
2.Anterior spread  cause swelling of the cheek and later invasion of the facial skin.
3.Inferior spread causes expansion of alveolus with dental pain ,loosening of teeth ,poor fitting of dentures. Ulceration of gingiva  and swelling in the hard palate .
4.Superior spread : invades the orbit causing proptosis ,diplopia,occular pain and epiphora.
5.Posterior spread ir into pterygomaxhllary fossa ,pterygoid plates and the musckes causing trismus. Growth may also spread to the nasopharynx,sphenoid sinus and base of skull
6.Intracranial spread
to ethmoid ,cribriform plate or foramen or foramen lacerum
7.Lymphatic spread  occur in the late stage of disease .
Submandibular and upper jugular nodes are enlarged .Maxillary and ethmoid sinuses drain primarily into retropharyngeal nodes, but these nodes are inaccessible to palpation.
8.Systemic metastases
 may be seen in the lungs and occasionally in bone

CLASSIFICATION

A] Ohngren's clas.
An imaginary line is drawn extending between medial canthus of eye & angle of mandible.
Growths situated above this plane have a poorer prognosis.

B] Lederman's clas.

It uses two lines horizontal lines of Sebileau one passing through the floors of orbits & d other through floors of antra. There r 3 parts.
1. Suprastructure. Ethmoid, sphenoid & frontal sinuses & olfactory area
2. Mesostructure. Maxillary sinus & respiratory part of nose.
3. Infrastructure. Containing alveolar process.
Vertical lines extending down d medial walls of orbit to separate ethmoid sinuses & nasal fossa fm d maxillary sinuses.

C] American Joint Committee on Cancer(AJCC) clas.

Used only 4 squamous cell carcinoma. Histopathologically it is graded as
1. Well differentiated
2. Moderately diff.
3. Poorly diff.

D] TNM Clas. & staging system.

Maxillary sinus
T1
tumor limited to maxillary sinus mucosa with no erosion or destruction of bone.
T2
tumor cousing bone erosion or destruction including extension into d hard palate & or middle nasal meatus, except extension to post. wall of maxillary sinus and pterygoid plates
T3
tumor invades any one of following. Bone of post. wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa & ethmoid sinuses
T4a
tumor invades ant. orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses
T4b
tumor invades any of d following: orbital apex, dura, brain, middle cranial fossa, brain, cranial nerves other than maxillary division of trigeminal, nasopharynx or clivus.

Regional Lymph nodes( N )
Nx
minimum criteria of assessment cannot be met with.
No
No regional LN metastasis
N1
Metastasis in a single ipsilateral LN, 3cm or less in greatest dimension
N2a
Metastasis in a single ipsilateral LN more than 3cm but not more than 6cm in greatest dimenson
N2b
Metastasis in multiple ipsilateral LN none more than 6cm in greatest dimension
N2c
metastasis in bilateral or contralateral LN none more than 6cm in greatest dimension.
N3
Metastasis in a LN more than 6cm in greatest dimension

Distant Metastasis ( M )
Mx Distant metastasis cannot be assessed.
M0 No distant metastasis
M1 distant metastasis

STAGE GROUPING OF CANCER OF MAXILLARY SINUS

StageI. T1 N0 M0
StageII. T2 NO MO
StageIII. T3 N0 M0
          T1 orT2 orT3 with N1 M0
StageIV A. T4 N0 M0
             T4 N1 M0
StageIV B. Any T N2 M0
              Any T N3 M0
StageIV C. Any T Any N M1

DIAGNOSIS

A)Investigations
 Non Invasion
1. x rays water's view,max sinus partly
2. usg
3.CT SCAN with contrast
B)Invasive
1.Antral puncture
2.Biopsy
3.ECG

1.Radiograph of sinuses

opacity of the involved sinus with expansion and destruction  of the bony walls
2.CT scan if available this is the best non invasive method to find the extent of disease . CT scan done both in axial and coronal planes .It also helps in staging of disease.
3.BIOPSY :if growth presents in the more or mouth .Biopsy can be easily taken . In early cases ,with suspicion of malignacy ,sinus should be explored by caldwell luc operatiom .Direct visualisation  of the site of tumour in the sinus also helps in staging of the tumour .0
4.ENDOSCOPY of the nose and maxillary sinus will provide detailed examination ..

TREAMENT.

1.Surgery
2.Radiology
3.Chemotheraphy

1 .SURGERY

Maxillectomy
 two types
PARTIAL  Maxillectomy
1)vertical partial
2)horizontal partial Maxillectomy
TOTAL Maxillectomy
INCISION. 2 to 3 mm below lid margin not too far or not too close.

2. RADIOTHERAPY

a. External beam. X ray, beta rays or gamma rays using elements like co 60 and radium using proper precaution.
b. Interstitial. Beads or needle with radioactive material implanted in tumor by caldwell luc op.

3. CHEMOTHERAPY

a. Local. Through feeding vessels
b. Systemic. Used if there is distant metastasis or radio resistant or palliative care.
EG. Methotrexate, 5 fluro niacin, bleomycin

DIFFERENTIAL DIAGNOSIS

1. Malignant tumors
@lymphoreticular system tumors like lymphoma, extramedullary plasmocytosis
@olfactory neurofibroblastoma
@salivary gland malignant tumors like  adenoidcystic ca, adenocarcinoma etc.
@melanoma
@sarcomas like rhabdomyosarcoma, kaposi

2. Benign tumors
hemangioma, meningioma, chondroma, angiofibroma, amyloblastoma

3. Cherubism