A Study of 30 Cases of Carcinoma of the Maxilla with Emphasis on the Management

A Study of 30 Cases of Carcinoma of the Maxilla with Emphasis on the Management
By Dr. Rehan A. Kazi M.S. (ENT), Fc.Oncology.
Dept. of Oncology, Masina Hospital, Mumbai, India

ABSTRACT

A study of 30 cases of maxillary sinus tumors was carried out by the Oncology dept. of Masina hospital from July ’98 to July ’00 to determine prognostic factors and study the epidemiology, etiology and management of these tumors using parameters like age, sex, socio-economic status, extent of spread, treatment offered and survival rate. This study revealed that 66% of cases were in the 5th –6th decade. Two-thirds of cases were males with presenting symptoms of cheek swelling and nasal obstruction. Most patients presented in stage 3 with no nodes and combined modality i.e. surgery followed by radiotherapy gave a 50% two year survival rate.

INTRODUCTION

Malignant tumors arising within or involving maxillae were recognized at the time of hypocrites, who distinguished between hard and soft lesions but believed that treatment only shortened the patient’s life.

The constitute 2% of cancers arising within upper aero digestive tract, and in most countries form less than 1% of all malignancies. Consequently, maxillary tumors of all types are uncommon. The intimate relationship of nasal passages to maxillary sinus, orbit and anterior cranial fosse presents formidable problems in both diagnosis and tumor control.

While the role of tobacco and alcohol is well established in areas such as the oral cavity, pharynx & larynx, industrial carcinogens like Nickel, wood dust have been identified as factors in the production of sinus cancer. In this study, an attempt has been made to diagnose early, by looking at the clinical symptoms, signs and investigations. As malignancies of the maxillary sinuses is far too often at an advanced stage when first diagnosed, the most important reason being negligence, the index of suspicion must always be high when treating unexplained and persistent symptoms related to the nose, because the element of time is the chief factor in determining the line of treatment.

AIMS & OBJECTIVES

To determine prognostic factors in malignant tumors of the maxilla particularly in co-relation with staging and histopathology of the lesion.
To compare the pre-operative radiological findings in maxillary involvement and correlate with the histopathological findings of the specimen.
To study the epidemiology and etiology of the tumors.
To educate people regarding the suspicion of the tumor in case of persistent unexplained nasal symptoms.

MATERIAL AND METHODS

The patients attending the Oncology Department of Masina Hospital, Bombay and patients referred from other Dept. were taken up for study.

All the cases suspected as tumors of maxillary sinuses were admitted and detailed study was carried out. Malignant tumors of maxillae were studied in detail and data collected was analyzed with respect to:

The age incidence.
The Sex distribution.
The socio economic distribution.
Symptomatology and clinical presentation.
The extent of tumor spread.
Mode of treatment given.
Response to treatment and follow up

Relevant routine hematological, biochemical and radiological investigations incl. CT Scan were done in all patients to supplement the physical examination.

Biopsy.
A biopsy was taken from all cases and histopathological examination was done. Most of the patients had cheek swelling and palatal ulcer and biopsy was taken from the mass / ulcer.

Treatment:
Depending on the clinical assessment of the extent of the tumor and the condition of patient treatment was planned and executed. Curative therapy was offered for most of patients and palliative therapy was offered for 3 patients. Curative treatment consisted of radical surgery followed by radiotherapy. 9 Patients were sent for radiotherapy. (Cobalt - 60)

Follow Up:
Patients were advised to report for a follow up regularly at intervals of monthly duration initially and in 3 months later on. But it is with granger to write that the co-operation and response were not forth coming.

ANALYSIS
During the period of July '98 to July ' 2000 30 cases of malignant tumours of the maxillary sinuses were studied.

Table-1. Age Incidence:
Maximum age of the patient in this series was 80 years & minimum was 27 years.

Age in Years No. of Patients Percentage %

1-10 0 0

11-20 0 0

21-30 3 10

31-40 1 3.3

41-50 10 33.3

51-60 10 33.3

61-70 5 16.6

71-80 1 3.3

Remarks: In our series the fifth & sixth decade of life had the maximum incidence i.e. 66.6%

Table-2. Sex Incidence:

Sex No. of Patients Percentage %

Male 19 63.3

Female 1 36.6

Remarks: Around 2/3rd of our patients were males.

Table-3. Duration of complaints:

Duration No. of Cases Percentage %

1-29 days 0 0

1-3 Months 18 60

4-6 months 8 26

7-12 months 0 0

1-1½ years 3 10

1½ - 2 years 1 3.3

Table-4. Symptoms & Signs:
The common symptoms and signs seen were:

Symptoms & Signs No. of Cases Percentage %

Cheek swelling 23 76.6

Nasal mass 14 46.6

Nasal blockage 13 43.3

Toothache & Dental Extraction 13 43.3

Nasal discharge 10 33.3

Growth in gingivobuccal sulcus 10 33.3

Epistaxis 7 23.3

Neck glands 7 23.3

Palate swelling 6 20

Proptosis 6 20

Trismus 2 6.6

Diplopia 1 3.3

Remarks: In this study the most commons symptoms were:

Cheek swelling in 23 cases, nasal blockage in 13 cases, toothache in 13 cases, Epistaxis in 7 cases, and growth in gingivobuccal sulcus in 10 cases.

More than one sign & symptom were present in all cases.

Site of Lesion:

The site of origin is determined by the clinical findings, X-ray findings, and CT findings.
In six cases, site was determined purely on clinical findings such as growth on palate, growth on cheek, growth in upper gingivolabial sulcus and x-ray findings.
In 24 cases site was determined on clinical findings x-ray findings and CT scan findings.

Table-5. Site

Anatomical site of Lesion No. of cases

With extension

Nasal Cavity 14

Oral Cavity 08

Ethmoids 04

Orbits 04

Table-6. Classification:
Attempts were made to classify these tumors along the UICC Classification.

According to this: No. of cases

T1 Lesions 0

T2 Lesions 8

T3 Lesions 16

T4 Lesions 6

N0 Lesions 26

N1 Lesions 4

M0 Lesions 30

Remarks: Majority of the lesions were T3 lesions having no nodes and no metastases.

Table-7: Histological Classification:

Type No. of cases Percentage

Squamous cell carcinoma 25 84.5

Transitional cell carcinoma 3 9.9

Adenoid Cystic carcinoma 2 6.6

Remarks: Majority of cases i.e. 84 % were squamous Cell carcinoma.

Table-8. Broader's Grading of Squamous cell carcinoma.

Type No. of cases Percentage

Well differentiated 12 48

Moderately differentiated 07 28

Poorly differentiated 04 16

Undifferentiated 02 08

Table-8. Investigation done:

Investigations No. of cases Percentage

Hb less than 10gm % 22 72

X-ray PNS showing bony erosion 26 91

Biopsy positive 30 100

Remarks: X-ray showed bony erosion in 26 cases. In 4 cases in which no erosion was seen there was cloudiness and soft tissue shadow with palatal swelling.

Table-9. Analysis of Surgical procedures:
Surgery was attempted in 18 cases.

Name of Procedure No. of cases Percentage

Total maxillectomy 09 50

1+ exenterating of eyeball 03 16.6

2+ forehead flap reconstruction 01 05.5

1+ Supraomohyoid Block dissection 01 05.5

Partial maxillectomy 02 11

Anterior craniofacial resection with RND 02 11

Table-10. Palliative treatment:
Some patients with advanced disease or those refusing surgery were given radiotherapy. For those patients refusing Radiotherapy & surgery, symptomatic treatment was given.

Treatment offered No. of cases Percentage

Radiotherapy 02 16

Palliative Surgery 02 16

Symptomatic (Analgesics and antibiotics) 07 60

Chemotherapy 01 08

Table-11. Post-operative complications:
The following complications were seen in our series of 30 patients.

Complications No. of cases

Infection 6

Stitch abscess 3

CSF leak from cribriform plate 1

Flap necrosis & wound gap 2

Table-12. Follow Up:
The disease free survival rate at the end of 2 years was around 50%.

Follow up No. of cases Percentage

Disease Free Survival 15 50.0

Disease with Survival 7 23.4

Died with Disease 4 13.3

Died without Disease 2 6.7

Lost of Follow up 2 6.7

Total 30 100.0

DISCUSSION

Malignant tumors of the maxillary sinus form less than 2% of ENT malignancies.30 cases presented to us, during the period from July 1998 to July 2000.

Majority of the cases presented in the later decades of life i.e. in the 5th, 6th and 7th decades. In our series, the 5th & 6th decade of life had 33.3% of the cases each. This compared favorably with studies carried out by other authors. Gallengher & Boles in their study of 60 cases carried out at University of Michigan Hospital found an average age of 62.5 years with maximum incidence in the 6th and 7th decades.

In our series out of 30 patients, there were 19 males and 11 females. This compares favorably with other studies carried out worldwide by various authors.

Sr. No. Series Male Female Total

1 Ohngren 101 86 187

2 Windeyer 81 72 153

3 Capps 36 35 71

4 Gallengher 42 20 62

5 Sisson 23 19 42

6 Tabb 52 29 81

7 Das Gupta 44 27 71

8 Present Series 19 11 30

Symptomatology:
All patients had symptoms at presentation sufficient to warrant suspicion of a maxillary neoplasm. In our series most of the patients had symptom duration of 1 to 3months. This accounted for 60 % of the cases. 26% of the cases presented between 3 to 6 months after the onset of symptoms. Very few cases presented after one year of the onset of the symptoms. In our series the most common complaints were cheek swelling and pain seen in 76% of the patients. Nasal mass and blockage was seen in 40% of the patients. Epistaxis was also commonly seen. Some cases also presented as a gingivobucal mass i.e. 33 %.

TNM Staging:
The TNM staging system is a useful parameter on which treatment protocol can be based. It also helps to compare results and standardize disease states. In our study 16 out of 30 patients had T3 lesions i.e. (over 50%). The remaining were T2 & T4 (around 25% each) with no T1 case.

Other series show the following occurrence:

Sr. No. Series T1 T2 T3 T4

1 Bush & Bagshaw 0 1 14 12

2 Lee & Ogura 5 11 18 13

3 St. Pierre & Baker 0 8 21 36

4 Gallengher & Boles 1 12 32 11

5 Present Series 0 8 16 6

Nodes:
Emphasis is placed on the size of the nodes found on clinical examination. Nodes larger than 2 to 3 cms. Are considered metastatic. In our study of 30 cases 7 had clinical evidence of nodes. Of these on 3 patients had histologically positive nodes. This shows a high incidence of false positively of the nodes.7 patients (14%) developed clinical lymph node metastasis on follow up. This overall incidence of 23% with regional metastasis is similar to other reports.

Histopathology:
Histopathologic diagnosis was done in all the cases, which presented to us and malignancy was proven in all these cases (i.e. 100%). Of these 25 patients i.e. 85% had squamous cell carcinoma.

Diagnosis:
X - Ray of the paranasal sinuses was done in all 30 cases in our series. This showed bony erosion in 26 cases. In the remaining 4 cases in which there was no erosion, there was cloudiness & soft tissue shadow with a palatal swelling.

Treatment:
In our series of 30 patients that were operated upon, of these 18 patients 9 underwent radical maxillectomy.
4 patients had orbital involvement and underwent orbital exenteration. 2 patients underwent a radical neck dissection. 12 patients in our series were not operated. These patients either had advanced disease or refused surgery or were unfit for the major procedure. 17 out of our 18 operated patients received post-op. Radiotherapy. In this study average does of radiation given was 7100 rads, in the combined therapy group. Of these 5 patients received pre-op. and 5 received post-op. radiation. The 5 patients with post-op. radiation had incomplete excision at the time of surgery with the radiation directed to the area of residual neoplasm.

Two-year survival rate: As majority of patients were seen in stage 3, a disease free survival rate of 50% with combined modality treatment was seen in our series.

CONCLUSION

Malignant tumors of maxillary sinuses are in a quite advanced stage when the patient first presents for examination, even though the duration of symptoms may be less. The tumor is usually more extensive than the symptomatology and clinical examination suggests and conventional radiography is insufficient to note the tumor extent (especially those spreading posteriorly). The low success rate may be due to the advanced tumor at the time of diagnosis and also inability of the available investigation to clearly show the extent of tumor involvement prior to planning management. In this aspect C. T. Scan and MRI are valuable aid to know the extent of tumor spread and should be used more frequently.

Hence the answer to the problem of malignancy appears to be early diagnosis than radical curative efforts. Early diagnosis could help improving the poor success rate in these tumors. Early diagnosis can be possible. By -

Educating the people regarding the symptomatology and encouraging them to seek medical attention early.
Maintaining a high suspicion while treatment patients with prolonged unexplained nasal problems an screening them with-
- X - Ray PNS. water's view.
- Exfoliative cytology of antral lavage returns.
- Subjecting patients to antrostomy and biopsy.

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