Presentation on theme: "TUMORS OF MAXILLA AND THEIR MANAGEMENT"— Presentation transcript:
1TUMORS OF MAXILLA AND THEIR MANAGEMENT DR KAMLESH DUBEY
2INTRODUCTIONNose and PNS are rarest sites of origin of head & neck tumors.Accounts for < 1% of all malignancies.More common in 5th & 6th decade.M:F = 2:1Late presentation with advanced disease is more common.Great variety of different histological types.Overall prognosis is poor.Distal mets is seen in 10 % at presentation
3ANATOMYMaxillary tumors because of its close proximity to orbit, ethmoids, skull base, ITF always challenging to treat.
4ANATOMYOrbit is the key to management of tumors of maxilla always work in subperiosteal plane.
5ANATOMYOhngren line- imaginary line between medial canthus ligament and angle of mandible.
6ANATOMY Lymphatics ; Anterior pathway; Post pathway; Facial , parotid, submandibular node- upper deep cervical nodes.Post pathway;retro/ lateral pharyngeal nodes- upper deep cervical nodes.Primary lymph drainage is to retropharyngeal nodes , clinical e/o early mets is absentOnly 10 % have nodal mets at presentation.Clinically palpable node is poor prognosis.
12INVESTIGATIONS Endoscopy Imaging CT scan; Diagnostic Biopsy Site & extentBone, skull base erosionOrbit invasionNeck- nodal status
13INVESTIGATIONS MRI Better soft tissue delineation Differentiate between secretions, tumorDural / intracranial involvementVascularity- flow voidsMRA- great vessel encasement, cavernous extensionAngiography;Proximity to great vessels , sphenoidVascular tumorsEmbolisation.
14INVESTIGATIONS PET Biopsy HPE, Immunohistochemistry FNAC USG- B mode Distant metastasisFollow upBiopsyendoscopic guidanceSublabial approachHPE, ImmunohistochemistryFNACNeck NodeUSG- B modeAssesment of orbit
15TNM staging Primary tumor (T) TX: Primary tumor cannot be assessed T0: No evidence of primary tumorTis: Carcinoma in situT1: Tumor limited to maxillary sinus mucosa with no erosion or destruction of boneT2: Tumor causing bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus, except extension to the posterior wall of maxillary sinus and pterygoid platesT3: Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial wall of orbit, pterygoid fossa, ethmoid sinusesT4a: Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinusesT4b: Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary division of trigeminal nerve (V2), nasopharynx, or clivus
16TNM staging NX: Regional lymph nodes cannot be assessed Regional lymph nodes (N)NX: Regional lymph nodes cannot be assessedN0: No regional lymph node metastasisN1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimensionN2: Metastasis in a single ipsilateral lymph node, more than 3 cm but 6 cm or less in greatest dimension, or in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimension, or in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimensionN2a: Metastasis in a single ipsilateral lymph node more than 3 cm but 6 cm or less in greatest dimensionN2b: Metastasis in multiple ipsilateral lymph nodes, 6 cm or less in greatest dimensionN2c: Metastasis in bilateral or contralateral lymph nodes, 6 cm or less in greatest dimensionN3: Metastasis in a lymph node more than 6 cm in greatest dimension
17TNM stagingStage 1 - T1 N0 M0Stage 2 - T2 N0 M0Stage 3 - T1,2 N1 M0T3 N0,N1 M0Stage 4a- T4 N0,N1 M0any T N2 M0Stage 4b- any T N3 M0Stage 4c- any T anyN M1
18SCC 50 % arise in the antrum Advanced disease at presentation Local recurrence, distal metastasis more commonMain treatment modality- Sx- PORTPrimary Irradiation- inoperable tumorsChemotherpy – palliative
19ADENOCARCINOMA Aetiology; Wood dust, furniture machinery, leather work Well defined tumor- better survivalLong term survival poorManagement; as that of SCC
20ADENOID CYSTIC CARCINOMA Common in antrumPerineural spreadDistal metastasis more commonHPE;High grade- bad prognosisLow grade- better prognosis
21radiotherapy- surgery TREATMENTT1/ T2surgery or radiotherapyT3, T4surgery- radiotherapyradiotherapy- surgerycombined CT+ RT
29MAXILLECTOMY Types Total Partial Infra structure Supra structure medialSubtotal
30It involves removal of entire maxilla along with pterygoid plates TOTAL MAXILLECTOMYIt involves removal of entire maxilla along with pterygoid platesIndication;Tumors from mucosa, filling entire antrumSoft tissue & bone sarcomasApproach;Weber fergusonMid facial degloving
31TOTAL MAXILLECTOMY Removal of entire maxilla and pterygoid plates Supine position, 15 ̊ head extensionAnt wall of maxilla exposed – elevating cheek flap.
32TOTAL MAXILLECTOMYSubciliary incision- Orbital periosteum elevated from floor of orbitLacrimal sac retracted laterally after cutting medial canthus ligament, NLDPost dissection continued upto post ethmoidal artery.
42MEDIAL MAXILLECTOMY Cavity packed Primary closure Post op – irrigation of cavityEndoscopic medialmaxillextomyAcheives same success rateAvoids scar
43INFRA STRUCTURE MAXILLECTOMY It involves removal ofalveolus ,floor of antrum,inferior part ofpterygoid platesIndication;Tumor limited to alveolus, hard palate with no bony erosionNo postero superior extensionApproach;Mid facial deglovingLateral rhinotomy
45INFRA STRUCTURE MAXILLECTOMY POST OP CARE;Cavity irrigationPalatal prosthesis
46Orbital exenteration; MANAGEMENT OF ORBITOrbit preservation;No e\o tumor in orbital floorBreech in floor with intact periosteumMinimal periosteal invasionOrbital exenteration;Breech in orbital periosteumOrbital apex extension
47RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATION Indication;Tumor invading through orbital periosteumApproach;Weber Ferguson with sub & supra ciliary extension
48RADICAL MAXILLECTOMY WITH ORBITAL EXENTERATION Skin of upper lid elevated upto suprior orbital rim.Orbital perioseteum seperated from roof of orbitEOM , optic nerve cut at level of orbital apexDefect lined with SSGFacial prosthesis applied
49ORBIAL EXENTERATIONPOST OP DEFECTPROSTHESIS IN PLACE
57Intra arterial infusion – 5- FU along with RT Topical 5- FU ; CHEMOTHERAPYCisplastin & 5- FUSNUC, RMS, lymphomaIntra arterial infusion – 5- FU along with RTTopical 5- FU ;Surgical debulking + topical 5 FU weeklyAdenocarcinoma- ethmoids(knegt et al, Arch of otolarygology,2007 ).Palliation.