Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 1, 2005, pp. 35-35

Journal of Postgraduate Medicine, Vol. 51, No. 1, January-March, 2005, pp. 35

Review Article

Malignant tumors of the sinonasal tract

Goldenberg D., Tufano R.P., Goldstein B.J.

Departments of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine

Correspondence Address:Departments of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, dgolden2@jhmi.edu

Code Number: jp05012

Malignant tumors of the sinonasal tract are extremely rare, accounting for 0.2% of all invasive cancers and 3% of head and neck cancers. The majority arise in the maxillary sinus, approximately 20% arise in the ethmoid sinuses, and the remainder (<1%) originate in the frontal and sphenoid sinuses. Squamous cell carcinoma is the most common histology. For such a rare tumor, a great deal has been documented concerning its etiology. Nickel and chrome refining processes have been implicated in the development of carcinoma of the paranasal sinuses,[1] and exposure to wood dust has been implicated specifically in adenocarcinoma of the ethmoid.[1],[2] Shoe workers, especially those involved in the tanning process, show an increased incidence of epithelial sinonasal malignancies.[3] Other industrial agents associated with sinonasal malignancies are thorium dioxide, isopropyl oils, lacquer paint, solder and welding materials, and radium watch dial paint. Interestingly, tobacco was previously thought to not play a role in sinonasal carcinogenesis. However, up to a 5-fold increased risk of sinonasal carcinoma has been observed with heavy smoking.[4] Rarely, sinonasal cancers may present as a second primary tumor in tobacco users with other head and neck cancers.[5]

As discussed in the present study by Panchal et al, clinical presentation of sinus malignancies is non-specific and often mimics benign disease.[6] Indeed, 9-12% of patients with sinonasal malignancies are asymptomatic.[7] It is not surprising that delay in diagnosis is common; 75% of all paranasal sinus tumors are Stage T3 or T4 at the time of diagnosis. Involvement of cranial nerves is a manifestation of advanced disease and indicates a poor prognosis.[6] A palpable neck mass signifies metastatic adenopathy in the jugular chain and is also a sign of advanced disease.

Patient evaluation should include history, complete head and neck examination with nasal endoscopy, imaging and biopsy. Special attention should be paid to cranial nerve function since malignant paranasal tumors are associated with a high incidence of cranial neuropathies compared with inflammatory or benign sinus disease.

Radiological imaging is essential during the initial evaluation. Patients with risk factors or positive exam findings should undergo CT scanning. MRI is useful to differentiate between mass and inspissated fluid secretions, and also may reveal soft tissue and perineural tumor spread. These two modalities complement each other in evaluating and staging a sinonasal tract mass. FDG expand PET scanning may also be useful in differentiating inflammatory from neoplastic disease, and is under active investigation.

Currently, most Stage T1 or T2 maxillary sinus carcinomas are treated by surgery alone, provided adequate resection margins are obtained, while T3 and T4 lesions are treated by combination therapy with surgery and radiation. The issue regarding whether radiation is more effective before or after surgery remains controversial. Chemotherapy alone is generally used as a palliative measure. Despite improvements in surgical ablative and reconstructive techniques, radiation delivery modalities, and imaging technologies, disease-free survival at five years remains less than 50%, independent of stage. Disease-free survival for patients with advanced stage cancer drops to 25%.[8] The key in the diagnosis and treatment of sinonasal cancers remains a high index of suspicion and early diagnosis.

The retrospective review by Panchal et al provides a nice summary of the ten-year experience with sinonasal tumors at one institution. Although other large series have been reported,[9] this paper does add to that literature and provides histopathological data from an Indian patient population.

REFERENCES

1.	Hernberg S, Westerholm P, Schultz-Larsen K, Degerth R, Kuosma E, Englund A, et al. Nasal and sinonasal cancer. Connection with occupational exposures in Denmark, Finland and Sweden. Scand J Work Environ Health 1983;9:315-26.  Back to cited text no. 1
2.	Klintenberg C, Olofsson J, Hellquist H, Sokjer H. Adenocarcinoma of the ethmoid sinuses. A review of 28 cases with special reference to wood dust exposure. Cancer 1984;54:482-8.  Back to cited text no. 2  [PUBMED]
3.	Bimbi G, Saraceno MS, Riccio S, Gatta G, Licitra L, Cantu G. Adenocarcinoma of ethmoid sinus: An occupational disease. Acta Otorhinolaryngol Ital 2004;24:199-203.  Back to cited text no. 3  [PUBMED]
4.	Elwood JM. Wood exposure and smoking: Association with cancer of the nasal cavity and paranasal sinuses in British Columbia. Can Med Assoc J 1981;124:1573-7.  Back to cited text no. 4  [PUBMED]
5.	Walpoe M, Goldenberg D, Koch WM. Second primary tumors of the Sinonasal Cavity. Submitted for presentation 2005 American Head and neck Society Meeting Boca Raton, Fl  Back to cited text no. 5
6.	Resto VA, Deschler DG. Sinonasal malignancies. Otolaryngol Clin North Am 2004;37:473-87.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.	Goldenberg D, Golz A, Fradis M, Martu D, Netzer A, Joachims HZ. Malignant tumors of the nose and paranasal sinuses: A retrospective review of 291 cases. Ear Nose Throat J 2001;80:272-7.  Back to cited text no. 7
8.	Lee MM, Vokes EE, Rosen A, Witt ME, Weichselbaum RR, Haraf DJ. Multimodality therapy in advanced paranasal sinus carcinoma: Superior long-term results. Cancer J Sci Am 1999;5:219-23.  Back to cited text no. 8  [PUBMED]
9.	Tufano, Mokadam NA, Montone KT, Weinstein GS, Chalian AA, Wolf PF, et al. Malignant tumors of the nose and paranasal sinuses: Hospital of the University of Pennsylvania experience 1990-1997. Am J Rhinol 1999;13:117-23.  Back to cited text no. 9

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