Nose and Sinus Cancers
Nose and Sinus cancers include cancers that occur inside of the nose, or the nasal cavity as well as the sinus, which are air-filled spaces in the face taht are located adjacent to the nasal cavity. Even skins cancers that occur on the face may grow inward to involve this region. These are called sinonasal cancers. Sinonasal cancers often need to be evaluated with nasal endoscopy (cameras that are placed inside the nose) and imaging with either a CT or MRI in order to understand the full extent of the tumour.
Depending on multiple factors, including the type, size and location of the tumour, the treatment will likely involve endoscopic or open surgery and possibly additional treatment with radiation and/or chemotherapy.
Of all sinonasal cancers, maxillary sinus cancers are the most common, followed closely by cancers of the nasal cavity and ethmoid sinus cancer. Most cancers in this region are squamous cell cancers. However, there are several tumours in this region that are benign (non-cancerous), including:
- Papilloma
- Pyogenic granuloma
- Adenoma
- Dermoid
- Glioma
- Fibroma
- Osteoma
- Chrondroma
- Hemangioma
- Neurofibroma
- Lymphangioma
Technology has helped us diagnose these cancers better. Doctors can use nasal endoscopy (telescopes and cameras inside the nose) to see areas we can’t see just by looking in the front of the nose. Also, advances in MRI and CT scanning help us look at the anatomy inside the head much better. Finally, functional tests like PET scans may also help with diagnosis and extent of cancers in this region. We also have many more tools to treat cancers in this complex area, which has several important structures nearby.
Here are some facts about sinonasal cancers:
- Are less than 1 percent of all cancers
- Are approximately 3 percent of head and neck cancers
- Age: Usually older than 45 years old
- Race: Caucasians more than other races
- Gender: Males more than females
Please Read Below for more information regarding Nasal and Sinus Cancer.
Nose and Sinus Anatomy
In order to understand sinonasal cancers, it is important to gain some background knowledge on the anatomy of the region, which includes the nose, nasal cavity, and sinuses. The inside of the nose, called the nasal cavity, is much bigger than it seems and contains many different structures, or sub-sites. The left and right nasal cavity are separated by the nasal septum. The very back of each nasal cavity connects to the nasopharynx through two openings, one on either side, called the choanae. The nasopharynx is an open part of the back of the throat that connects both sides of the nasal cavities with the oropharynx.
It is important to remember that cancers on the skin on the outside of the nose and cheeks are considered skin cancers, that have the capacity to invade deeply into the nose and sinuses and can overlap with various aspects of the discussion that follows, but will not be covered in this section.
The 4 main subsites of the nasal cavity include:
- Vestibule: This is the inner nostril. It starts at the very edge of the outer skin of the nostril and stops where the skin transitions into the inner mucous membrane of the nasal cavity.
- Septum: This is the wall in the middle of the nose that separates the left nasal cavity from the right nasal cavity. It is made up of cartilage and bone. At the top of the nose, it joins with the bones of the skull.
- Floor: This is the bottom part of the nasal cavity. It extends all the way to the back of the nasal cavity, where it meets the nasopharynx.
- Lateral wall: This is the sidewall of the nasal cavity. It contains structures called turbinates (also called conchae), which are responsible for filtering and humidifying the air that comes through the nose. There are inferior (lower), middle, and superior (upper) turbinates. Sometimes there is a fourth, even higher, turbinate, which is called the supreme turbinate. Sinuses open into the nasal cavity through openings in the lateral wall just under the middle turbinate, and the tear duct drains tears that pass down from the eyes, through an opening in the lateral wall just under the inferior turbinate.
Sinus Anatomy
The sinuses, also called the paranasal sinuses, are air-filled spaces in the head that produce mucus. They are located near many important structures in the face and the bones of the skull that envelop the brain. There are 4 different types of sinuses that all come in pairs (one on the right side and one on the left side of the face):
- Maxillary sinuses: These are the cheek sinuses. They are located above the teeth, below the eyes, and next to the nose. Each maxillary sinus has a small hole that allows the mucus made in the sinus to drain into the nasal cavity, just under the middle turbinate. The maxillary sinuses are the biggest sinuses, and are also the most common site for sinonasal cancers.
- Ethmoid sinuses: These are a group of 10-20 small sinuses that sit between the eyes and the nasal septum on both sides. There is a very thin piece of bone that separates the eye (actually the orbit) from the ethmoid sinuses. These sinuses have very thin walls, and the mucus they produce drains into the nasal cavity under both the middle and superior turbinates. The ethmoid sinuses are tied with the nasal cavity as the second most common site of sinonasal cancer.
- Frontal sinuses: These sinuses are located behind the forehead and over the eyes. The mucus they produce drains into the nasal cavity through a passageway called the nasofrontal duct, which opens up just below the middle turbinate.
- Sphenoid sinuses: These sinuses are located behind the nose at the base of the skull. Many important structures, including the brain, the nerve that controls vision, and the main blood vessel to the brain (the carotid artery) are all located adjacent to the sphenoid sinuses. The mucus produced by these sinuses empties into the nasal cavity just below the superior turbinate.
The exact function of the sinuses is not entirely understood, but their main roles include:
- Producing mucus that moisturizes the inside of the nasal cavity.
- Humidifying the air.
- Keeping the head light in weight.
- Allowing the voice to resonate.
- Potentially protecting the skull from damage due to hits or falls.
Causes, Signs, and Symptoms of Nasal and Sinus Cancer
Causes of Sinonasal Cancer
Currently, there is no definitive cause of nasal cancer. It’s a combination of genetics and environmental factors. However, listed below are a few known risk factors for developing nasal cancer. Similar to other head and neck cancers, tobacco smoke seems to be a risk factor for sinonasal cancers, although to a lesser extent. Exposure to certain workplace chemicals seems to be the largest risk factor for certain types of sinonasal cancers. Workers who may be at increased risk include:
- Nickel workers (including nickel refineries, cutlery factories and battery manufacturing).
- Chromium workers (including chrome plating and chromium production).
- Leather workers.
- Wood workers.
Signs & Symptoms
Nasal cancer can present in many different ways, depending on where the cancer is located. For early cancers, there might not be any symptoms, or symptoms may seem just like allergies, sinusitis, or nasal polyps. As a general rule, if a doctor sees a nasal polyp or some abnormality on only one side of the nose, he or she might be more suspicious that it could be cancer.
Common Symptoms
- Nasal obstruction.
- Sinus pain, pressure and infections.
- Change or loss of sense of smell.
- Bleeding from the nose, particularly if only on one side.
When cancers in this area get larger, the symptoms will depend on what nearby structures are involved.
- A tumor growing out of the nose.
- Change in vision or double vision.
- Pain
- Recurrent sinus infections.
- Numbness in the cheek and/or upper teeth.
- Growth in the roof of the mouth.
- Brain infection (meningitis or encephalitis).
It is important to note that a patient could have one or more of these symptoms but NOT have a sinonasal cancer. There are several non-cancerous causes of the same symptoms. That’s why it’s important to see a specialist.
Diagnosis of Nasal and Sinus Cancer
Diagnosis
The diagnosis of sinonasal cancer can be difficult and overwhelming. Further testing will be necessary to obtain a diagnosis and determine the best course of treatment.
As described in the anatomy section, the nose and sinus cavities are made up of multiple components that can be difficult to see and examine in an office setting. While a mass on the nasal septum is readily visible with a proper light, a mass in the maxillary sinus may not be visible at all without the help of endoscopy or various imaging studies.
Endoscopy
An endoscope is a device that allows doctors to examine inside the body. It is made up of a thin flexible or rigid tube with a camera and light attached on the end. The lenses inside the endoscope provide magnification, allowing doctors to detect even small changes in the lining of the nasal passageways.
“Endoscopy” is simply the process of using an endoscope to visualise a particular part of the body. Doctors have specific types of endoscopic tools such as laryngoscopes, hypopharyngoscopes, bronchoscopes, and esophagoscopes – each designed to evaluate a different portion of the upper aerodigestive tract or throat. Sinonasal endoscopy is a way to look far inside and around the nose as well as the sinus openings. This procedure is useful for providing information about the size and position of a suspected tumour. However, unless a patient has had prior sinus surgery, it can be challenging to see inside the paranasal sinuses even with an endoscope.
Biopsy
A biopsy is the removal of a small piece of tissue to examine under a microscope to see if it is cancerous. A biopsy of a suspicious growth in the nasal cavity or sinuses is usually needed prior to treatment. There are a few different techniques that can be used to take a biopsy in the nose. These can include:
- Endonasal endoscopic biopsy (in office).
- Endoscopic endonasal biopsy (in the operating room).
- Open surgical biopsy.
- Fine needle aspiration biopsy of a related neck mass.
Imaging
Imaging scans, also known as radiologic studies, provide the doctor with an inside view of the body. Imaging of the head and neck will be required to determine the extent as well as the behaviour of a growth, and is a vital step prior to treatment of any tumour in the nose or sinus cavities. The most common imaging tests used are CT and MRI scans. A more advanced imaging study called a PET/CT may also be performed to evaluate if a nasal cancer has spread to other sites in the body, as well as to determine if lymph nodes in the neck are likely to harbour cancer cells.
Type of Nasal and Sinus Cancer
Type
Not all masses or lesions in the nose or sinuses are cancer. In fact, most growths in this area are benign (non-cancerous). There are also some tumours that are on the borderline between benign and malignant (cancerous), so it is best to speak to a doctor about the best treatment for each specific case. In many cases, these growths should be removed with surgery.
Squamous (Schneiderian) Papillomas
These might be related to HPV (human papillomavirus) infections, and they can be found on the front part of the nasal septum (fungiform-type) or on the side nasal wall (inverted and cylindrical types). There is a chance of squamous cell carcinoma within some of these papillomas; therefore, they should be surgically removed.
Other Benign Tumours
- Angiofibroma
- Ameloblastoma
- Fibrous dysplasia
- Ossifying fibroma
- Giant cell tumour
- Lobular capillary hemangioma
Some lesions in the nasal and sinus cavities are, in fact, cancerous. The best way to categorise these types of tumours is by the cell type from which the cancer started.
Epithelial-based Cancers
Squamous cell carcinoma
This is the most common type of sinonasal cancer. These cancers arise from the lining of the nasal cavity and sinuses. There are a few different sub-types of squamous cell carcinomas, some more aggressive than others. Examples of these include verrucous squamous cell carcinomas (which have less of a tendency to invade deeply), basaloid squamous cell carcinoma and well-to-poorly differentiated squamous cell carcinomas.
Adenocarcinoma
This type of cancer arises from gland-like elements in the lining of the sinonasal tract. Adenocarcinoma is the second most common type of sinonasal cancer.
Minor salivary gland cancers
Minor salivary glands are found within the sinonasal cavity, and they can develop tumours. There are many sub-types of salivary gland tumours (described in more detail in the salivary gland section), but the most common types include:
- Salivary-type adenocarcinoma
- Adenoid cystic carcinoma
- Mucoepidermoid carcinoma
- Acinic cell carcinoma
Melanoma
These cancers arise from melanin skin cells that give skin its colour. In rare cases, melanoma can be found in the lining of the mouth, nose and/or throat. This is called mucosal melanoma. Approximately two-thirds of all mucosal melanomas start out in the nasal cavity and paranasal sinuses (another one-third arise in the oral cavity, and the rest are in various other mucosal sites of the head and neck, such as the throat). These are more aggressive behaving cancers, even when small.
Esthesioneuroblastoma (olfactory neuroblastoma)
This is a rare cancer that arises from the neural cells in the roof of the nose that is responsible for the sense of smell.
Sinonasal undifferentiated carcinoma (SNUC)
This is a rare but very aggressive cancer. It is unclear what the cell of origin is. It often involves multiple different sites and carries a poor prognosis.
Small cell neuroendocrine carcinoma (SNEC)
This is also a rare type of tumour that behaves aggressively and has a poor prognosis.
Non-epithelial-based Sinonasal Cancers
Sarcoma
These are soft tissue tumours that arise from different types of tissues, including fibrous tissue, cartilage, bone, muscles and blood vessels, to name a few. Some examples of sarcomas that occur in the sinonasal area include:
- Fibrosarcoma
- Hemangiopericytoma
- Angiosarcoma
- Kaposi’s sarcoma
- Rhabdomyosarcoma
- Malignant fibrous histiocytoma
- Chondrosarcoma
- Osteogenic sarcoma
Lymphoma
Lymphoid tissue is all over the body, including the nasal cavity and sinuses. Rarely, lymphoma can present as a mass in the sinonasal area.
Tumours that spread from another site
Even more rarely, spread of cancers from other sites could show up in this area. This includes spread of lung, kidney, breast or ovarian cancer.
Grade of Nasal and Sinus Cancer
Grade
The final pathology of a tumour biopsy or surgical excision will determine the grade and stage of the cancer. The grade is usually only determined after the tumour has been completely removed. The grade of cancer relates to how healthy or unhealthy cells look under a microscope. In other words, a pathologist will determine the grade of cancer by comparing the amount of the healthy-looking tissue to the amount of cancerous tissue. If most of the tumour cells look like normal tissue then the cancer is “well differentiated” or “low-grade.” However, if the tumour cells look very different from normal tissue then the cancer is “poorly differentiated” or “high-grade.” The grade of cancer may help to determine how quickly the cancer is likely to spread.
Grades of Nasal & Sinus Cancer
| Grade | Definition |
| GX | The grade cannot be evaluated. |
| G1 | The cells look more like normal tissue and are well differentiated. |
| G2 | The cells are only moderately differentiated. |
| G3 and G4 | The cells don’t look like normal tissue and are poorly differentiated. |
Stage of Nasal and Sinus Cancer
Stage
The stage of a cancer is determined by the TNM staging system:
- The ‘T’ stands for tumour size.
- The ‘N’ stands for lymph node involvement.
- The ‘M’ stands for distant metastases, or cancer spread to other areas of the body.
Staging helps doctors determine how serious the cancer is and how best to treat it. Staging systems often reference very specific anatomical structures. Please reference the anatomy page to learn more about these terms.
Staging is generally based on the American Joint Committee on Cancer (AJCC) 8th edition guidelines. The ‘T’ staging is different depending on what subsite of the sinonasal cavity is involved. It is separated by nasal cavity, maxillary sinus, and ethmoid sinus which are provided below. To learn more, see the AJCC TNM Staging Tables and definitions below.
TNM Staging Table, from the American Joint Committee on Cancer (AJCC)
| T | N | M | Stage |
| Tis | N0 | M0 | 0 |
| T1 | N0 | M0 | I |
| T2 | N0 | M0 | II |
| T3 | N0 | M0 | III |
| T1,2,3 | N1 | M0 | III |
| T4a | N0 or N1 | M0 | IVA |
| T1,2,3,4a | N2 | M0 | IVA |
| Any T | N3 | M0 | IVB |
| T4b | Any N | M0 | IVB |
| Any T | Any N | M1 | IVC |
American Joint Committee on Cancer, 8th Ed. 2017
Nasal Cavity TNM Definitions
| T | Definition |
| TX | The primary tumour cannot be evaluated. |
| Tis | The cancer is in situ, meaning it has not invaded into deeper layers. |
| T1 | The tumour is in just one sub-site, and there is no bone invasion or destruction. |
| T2 | The tumour is involved in two sub-sites in a single region or an adjacent site within the nasoethmoid complex, with or without bone invasion. |
| T3 | The tumour has grown to involve the inner wall or floor of the eye socket, or the maxillary sinus, hard palate or cribriform plate. |
| T4a | This is moderately advanced local disease. The tumour has invaded any of the following: the front of the eye socket, skin of the nose or cheek, minor extension into the anterior cranial fossa, pterygoid plates, sphenoid sinus or frontal sinus. |
| T4b | This is very advanced local disease. The tumour has invaded into any of the following: the back part of the eye socket (orbital apex), the dura, brain, middle cranial fossa, cranial nerves (except V2), nasopharynx or clivus. |
Clinical N (cN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to any lymph nodes with clinical appearance of ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
Pathologic N (pN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-)or Cancer has spread to a single lymph node, on the same side as the main tumour, and it is less than 3 cm in greatest dimension and ENE (+) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to a single lymph node, on the same side as the main tumour, and the size is greater than 3 cm and ENE (+)or There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck with ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
| M | Definition |
| M0 | No evidence of distant spread |
| M1 | Distant spread |
Maxillary Sinus TNM Definitions
| T | Definition |
| TX | The primary tumour cannot be evaluated. |
| Tis | The cancer is in situ, meaning it has not invaded into deeper layers. |
| T1 | The tumour is totally within the lining of the maxillary sinus. There is no destruction of any of the bone of the maxillary sinus. |
| T2 | The tumour is in the maxillary sinus and has caused the bone to become eroded or destroyed. The tumour is in this stage even if it extends into the hard palate or into the nose under the middle turbinate. |
| T3 | The tumour invades through bone or any of the following: the bone at the back wall of the maxillary sinus, into the deep layers of the skin, into the inner floor of the eye socket, the pterygoid fossa (a space behind and to the side of the nose on the other side of the sphenoid bone), or the ethmoid sinuses. |
| T4a | This is moderately advanced local disease. The tumour has invaded into the contents of the eye socket in the front, the outer skin of the cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses. |
| T4b | This is very advanced local disease. The tumour has invaded into any of the following: the back part of the eye socket (orbital apex), the dura, brain, middle cranial fossa, cranial nerves (except V2), nasopharynx or clivus. |
Clinical N (cN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to any lymph nodes with clinical appearance of ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
Pathologic N (pN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-)or Cancer has spread to a single lymph node, on the same side as the main tumour, and it is less than 3 cm in greatest dimension and ENE (+) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to a single lymph node, on the same side as the main tumour, and the size is greater than 3 cm and ENE (+)or There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck with ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
| M | Definition |
| M0 | No evidence of distant spread |
| M1 | Distant spread |
Ethmoid Sinus TNM Definitions
| T | Definition |
| TX | The primary tumour cannot be evaluated. |
| Tis | The cancer is in situ, meaning it has not invaded into deeper layers. |
| T1 | The tumour is in just one sub-site, and there is no bone invasion or destruction. |
| T2 | The tumour is involved in two sub-sites in a single region or an adjacent site within the nasoethmoid complex, with or without bone invasion. |
| T3 | The tumour has grown to involve the inner wall or floor of the eye socket, or the maxillary sinus, hard palate or cribriform plate. |
| T4a | This is moderately advanced local disease. The tumour has invaded any of the following: the front of the eye socket, skin of the nose or cheek, minor extension into the anterior cranial fossa, pterygoid plates, sphenoid sinus or frontal sinus. |
| T4b | This is very advanced local disease. The tumour has invaded into any of the following: the back part of the eye socket (orbital apex), the dura, brain, middle cranial fossa, cranial nerves (except V2), nasopharynx or clivus. |
Clinical N (cN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to any lymph nodes with clinical appearance of ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
Pathologic N (pN)
| N | Definition |
| NX | The neck lymph nodes cannot be assessed (for example, they were removed for another reason in the past). |
| N0 | There is no evidence of any spread to the lymph nodes. |
| N1 | There is a single node, on the same side of the main tumour, that is 3 cm or less in greatest size and ENE (-) |
| N2 | N2a – Cancer has spread to a single lymph node, on the same side as the main tumour, and it is more than 3 cm but less than or equal to 6 cm in greatest dimension and ENE (-)or Cancer has spread to a single lymph node, on the same side as the main tumour, and it is less than 3 cm in greatest dimension and ENE (+) N2b – There are multiple lymph nodes that have cancer, on the same side as the main tumour, but none are more than 6 cm in size and ENE (-) N2c – There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck, but none are more than 6 cm and ENE (-) |
| N3 | N3a – There is spread to one or more neck lymph nodes, and the size is greater than 6 cm and ENE (-) N3b – There is spread to a single lymph node, on the same side as the main tumour, and the size is greater than 3 cm and ENE (+)or There are lymph nodes in the neck on either the opposite side as the main cancer, or on both sides of the neck with ENE (+) |
ENE (+) = extranodal extension is present (tumour has spread outside of the lymph node based on examination of tumour under the microscope)
ENE (-) = extranodal extension is absent (tumour has not spread outside of the lymph node based on examination of tumour under the microscope)
| M | Definition |
| M0 | No evidence of distant spread |
| M1 | Distant spread |
Treatment for Nasal and Sinus Cancer
Treatment Plan
After determining a diagnosis and completing a full pre-treatment evaluation, doctors will recommend a course of treatment for their patients. For most sinonasal cancers, the pre-treatment evaluation will likely include a verification of the pathology of the cancer, a CT or MRI scan with contrast, and a PET/CT to see if the cancer has spread. In general, there are three different options for the treatment of sinonasal cancers that can be used alone or in combination.
Surgery
Surgical removal is generally the first line of treatment for sinonasal cancers. The surgery that a doctor recommends will depend on the location of the cancer, as well as the stage. Often, surgery for sinonasal cancers will involve a maxillectomy.
An important part of the surgical management of sinonasal cancers is the reconstruction after the tumor is removed. A variety of reconstructive options are possible; however, sometimes primary reconstruction will be deferred and an obturator designed by a prosthodontist will be placed at the time of surgery and adjusted on an outpatient basis. Patients and their care teams should discuss the types of surgeries that may be required for the treatment of their cancer.
Radiation
The most common use of radiation for the treatment of sinonasal cancer is called adjuvant radiation, which is radiation given after surgery in order to decrease the chances that the tumour will come back.
Reasons for Post-Surgical Radiation
A doctor may recommend post-surgical radiation in a few scenarios.
- If the tumour was not completely removed or if the surgical margins were positive for cancer.
- If the type of cancer was determined to be aggressive or of a high grade or T-stage.
- If the cancer had spread to lymph nodes in the neck or to other structures, such as nerves or vessels.
In some cases, complete surgical removal of a sinonasal cancer may be impossible or unsafe, and a doctor may recommend radiation therapy as the primary treatment. In this type of treatment, an external beam of radiation is directed at the tumour in order to destroy the rapidly dividing cancer cells.
Chemotherapy
Depending on the type of sinonasal cancer, chemotherapy may be used as the initial treatment in an effort to shrink the primary tumour in preparation for definitive surgical treatment. This use of chemotherapy is called neoadjuvant treatment. Chemotherapy is also sometimes used concomitantly with radiation in an adjuvant setting after primary surgical treatment. In very advanced cases, doctors may recommend systemic therapy (such as chemotherapy) or enrolment in a clinical trial.
General Treatment Options for Sinonasal Cancer
As mentioned above, treatment strategies will vary depending on the type of sinonasal cancer. As an example, the general treatment plan for sinonasal mucosal melanoma is outlined below. In general, it includes surgical removal with or without radiation.
Mucosal melanoma (sinonasal) Stage I-III
- Wide resection of the main tumour.
- Possible radiation to the primary site following surgery.
Mucosal melanoma (sinonasal) Stage IVA T4a, N0
- Wide resection of the main tumour.
- Radiation to the primary site following surgery.
Mucosal melanoma (sinonasal) Stage IVA T3-4a, N1
- Wide resection of the main tumour.
- Neck dissection to look for cancerous lymph nodes in the neck.
- Radiation to the primary site following surgery.
Mucosal melanoma (sinonasal) Stage IVb
Options include:
- Radiation therapy with or without systemic therapy.
- Enrolment in a clinical trial.
Mucosal melanoma (sinonasal) Stage IVC
Options include:
- Radiation therapy with or without systemic therapy.
- Enrolment in a clinical trial.
Doctors should undergo an extensive discussion with their patients on options for treatment and symptom control.
Prognosis for Nasal and Sinus Cancer
Prognosis
A prognosis is a prediction of the outcome of one’s disease. How likely is survival? Will the cancer come back? These are the big questions on most people’s minds after receiving a diagnosis of sinonasal cancer. In general, there are several characteristics of the tumour that can inform a patient about their chances of being cured.
Factors That Affect Prognosis
Stage
This is the most important factor that affects a patient’s chance of being cured.
Site
The location and extent of the tumour in the nasal and/or sinus cavity can affect the surgeon’s ability to resect the tumour with adequate margins of healthy tissue around it.
Type and Grade
Both the type and grade of the tumour determine the amount of treatment necessary and the ultimate prognosis.
Spread to Lymph Nodes
This helps determine stage, but even without other factors, spread to lymph nodes in the neck decreases the chance of cure, especially if there is evidence of growth of cancer outside of the lymph node.
Tumour Margins
The ability to completely remove the tumour with a margin of normal tissue around it is a very important factor in a patient’s prognosis.
While each of these factors contributes to one’s outcome, patients should have a discussion with their doctor to determine their overall prognosis. Giving a percentage of survival is challenging because cancer research often looks at multiple types of cancer and may include a large range of patients who underwent a variety of treatments.
What to Expect after Nasal and Sinus Cancer Treatment
What to Expect After Treatment
After treatment, patients should follow-up with their doctors on a regular basis.
Patients should visit their head and neck specialist on a regular schedule (or earlier if they have any concerning symptoms). This allows doctors to monitor the patient for any sign that the cancer has returned. The best timeline for follow-up will be determined by the doctor.
Standard Follow-up Schedule
- For the first year, go every 1-3 months.
- For the second year, go every 2-6 months.
- For the third to fifth year, go every 4-8 months.
- After five years, start going once annually.
Doctors may select a scan to be performed in the first 6 months after treatment. The first scan serves as a “baseline” study for the purpose of comparing future studies. This will depend on the type and location of the cancer. Imaging could range from something as simple as a quick chest X-ray to more extensive tests such as a CT, MRI, or PET scan. If something suspicious comes up, a patient may need a biospy. Patients should also seek help from a speech therapist for difficulties with speaking or swallowing. They can help with concerns about diet and nutrition, too.