24 Neoplastic - Nose/NP Flashcards
NP CA accounts for what % of all CA dx in Kwangtung province of southern China
20%
Incidence of NP CA among native born Chinese vs Caucasians
118x higher
Incidence of NP CA among North American born Chinese vs Caucasians
7x higher
What EBV product is likely to play a role in malignant transformation of NP epithelium
Latent membrane protein (LMP-1)
What environmental factor is most strongly linked to NP CA
Frequent consumption of dried salted fish
What is the 5 yr survival of pts with WHO II or III dz
70%
5 yr survival of pts with WHO I dz
30%
M/c site of origin of NP CA
fossa of rosenmuller
Which nodal groups does NP CA spread to
Retropharyngeal nodes of Rouviere, jugulodigastric nodes, spinal accessory chain
In the staging system described by Ho, poorer prognosis is associated with cervical mets to which area of the neck
Inferior to a plane spanning from CONTRA sternal head of clavicle to IPSI superior margin of trapezius
T/F: The presence of unilateral vs b/l nodal dz in pts with NP CA has no prog significance
True
Incidence of skull base erosion on pts w/ NP CA
25%
M/c site of distant mets from NP CA
bone
Smooth, submucosal NP masses located in the midline are most often what
Embryologic remnants (Thornwaldt’s cysts, pharyngeal bursa remnants)
What factors described by Ho and Neel are regarded as important adverse prognostic indicators in pts with NP CA
- Length and symptomatology of dz
- extension of tumor outside of NP
- presence of inferior cervical nodes
- keratinizing histo architecture (WHO I)
- cranial nerve and skull base extension
- distant mets
- low ADCC titers
Extension into which space is a/w worst prog in pts with NP CA
Anterior masticator space
What is the primary tx modality for NP CA
RT to the NP (66-70 Gy) and neck (60 Gy)
Why is the clinically negative neck treated in NP CA
Studies have shown improved local control and dz-free survival for ppx irradiation of the clinically negative neck in pts w/ NP CA
What are the complications from RT over-dosage in the tx of NP CA
Osteoradionecrosis, brain necrosis, transverse myelitis (45 Gy), hearing loss, hypopituitarism, hypoT, optic necrosis
What is the role of induction chemo for tx of NP CA
No survival advantage has been proven
What is the standard tx protocol for stage III and IV NP CA
Concomitant cisplatin and RT followed by adjuvant chemo with cisplatin and 5-FU
How does tx failure usu manifest in NP CA
Dz at both primary site and cervical LN
What is m/c site of recurrent/persistent NP CA
Lateral wall of NP
What are the tx options for recurrent/persistent NP CA at primary site
Reirradiation w/ larger therapeutic dose that initial tx; stereotactic RT; brachytherapy w/ split plate implantation of radioactive gold grains; surgical resection
What is m/c benign sinonasal neoplasm
Inverting papilloma
What is m/c malig sinonasal neoplasm
SCCa (80%)
What is 2nd m/c malign sinonasal neoplasm
Adenocarcinoma
M/c location of sinonasal SCCa
Maxillary sinus > nasal cavity > ethmoids
Are elective ND warranted in pts with sinonasal SCCa
No, incidence of occult cervical mets is 10%
Percent of sinonasal tumors attributable to occupational exposures
44%
Where do these tumors most often originate
Lateral nasal wall, adjacent to MT
Which substances are thought to predispose to sinonasal neoplasms
Nickel, chromium, isopropyl oils, volatile hydrocarbons, organic fibers from wood, shoe, and textile refineries
Which of these is classically a/w SCCa
Nickel
Which of these are classically a/w adenoCA
Hardwood dust and leather tanning substances
Which virus is thought to play a role in etiology of sinonasal tumors
HPV, 6 and 12
T/F: Smoking by itself is not a significant etiologic factor for sinonasal tumors
True
Which nasal masses should not be biopsied in clinic
Masses in kids or adolescents and masses suspicious for angiofibroma
some recommend delaying bx of any nasal mass until after imaging has been obtained
What are the 3 subtypes of Schneiderian papillomas
Fungiform, inverting, and cylindrical
Where do inverting papillomas most commonly arise
Lateral nasal wall
What factor is most related to the chance of recurrence for IP
Method of removal
What is incidence of recurrence after resection of IP via lateral rhinotomy/medial maxillectomy
13-15%
In pts who undergo resection of IP via lateral rhinotomy/medial maxillectomy, what is most imp factor related to risk for recurrence?
Mitotic index
What is ddx of small cell sinonasal tumor
- Esthesioneuroblastoma
- Plasmacytoma
- Melanoma
- Lymphoma
- Sarcoma
- Poorly differentiated SCCa
- Ewing’s sarcoma
- Peripheral neuroectodermal tumor (PNET)
- SNUC
What is a SNUC
Sinonasal undifferentiated carcinoma – a very aggressive small cell sinonasal tumor
What are the poor prognostic factors for SNUC
Orbital involvement and neck mets
Tumors in the paranasal sinuses have a worse prog than those arising in the nasal cavity
SNUC tumors have Ab’s to what substances
- Cytokeratin
- Epithelial membrane Ag
- Neuron-specific enolase
What is tx for SNUC
Preop CRT followed by surgical resection for those tumors w/o distant mets or extensive intracranial involvement
In what age group is olfactory neuroblastoma usu seen
Bimodal – 20s and 50s
Esthesioneuroblastom involving ethmoids is what Kadish stage
B
What are the 3 m/c malig bone tumors of the paranasal sinuses
Multiple myeloma, osteogenic sarcoma, and chondrosarcoma
Pathophysiology of fibrous dysplasia
Nl medullary bone is replaced by collagen, fibroblasts, and osteoid
Where is fibrous dysplasia most commonly found in H&N
maxilla
Where is ACC of the H&N most commonly found
Palate > major salivary glands > paranasal sinuses
Where is melanoma m/c found in nose and paranasal sinuses
nasal septum
How does nasal melanoma differ from cutaneous melanoma
More aggressive with a worse prognosis and an unpredictable course – local recurrence is the m/c cause of failure
What is the m/c type of lymphoma of nose and paranasal sinuses
Non-hodgkin’s lymphoma
What is Ohngren’s line and how is it significant
Imaginary line from medial canthus to angle of mandible; tumors below the line have a better prognosis than tumors above the line (w/ palate as an exception)
comprises only 3% of schneiderian papillomas
cylindrical
M/c type of schneiderian papilloma, typically seen on nasal septum
Fungiform
2-13% of these benign nasal tumors have malig potential
IP
Has a predilection for mandible and sunray appearance on X-ray
osteogenic sarcoma
More than 90% will have invaded through at least one wall of the involved sinus at presentation
SCCa
Benign tumor m/c seen in pts less than 20 yo and has a ground glass appearance on x-ray
fibrous dysplasia
Benign tumor m/c found in the frontal sinus
osteoma
Encapsulated benign tumor that arises from surface of nerve fibers
neurilemoma
unencapsulated tumor that arises from w/in a nerve; 15% become malig
neurofibroma
2nd m/c malig sinonasal tumor; tend to be located superior to Ohngren’s line
AdenoCA
Arise from pericytes of Zimmerman and considered neither benign nor malig
Hemangiopericytoma
Arise from cells of neural crest that differentiate into olfactory sensory cells; Homer Wright rosettes are characteristic
Esthesioneuroblastoma
May progress to multiple myeloma
extramedullary plasmacytoma
M/c tumor to met to sinonasal area
renal cell
Well circumscribed mobile painless lesion m/c found on tongue that has malig potential and histopath shows poygonal cells w/ abundant eosinophils
Granular cell tumor
Met to the brain more frequently than any other soft-tissue sarcoma
Alveolar soft part sarcoma
What sinonasal neoplasms remodel rather than erode bone
Sarcomas, minor salivary gland carcinomas, hemangiopericytomas, extramedullary plasmacytomas, large cell lymphomas, and olfactory neuroblastomas
Primary modality of tx for extramedullary plasmacytomas
RT
After benign lymphoid hyperplasia, what is m/c benign NP tumor
JNA
From which site in NP does JNA develop
Trifurcation of the palatine bone, horizontal ala of the vomer, and the root of the pterygoid process
What is the stage of a JNA eroding the skull base with minimal intracranial extension
IIIA
Main blood supply to JNA
IMAX or ascending pharyngeal artery
