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LATERALISATION OF TUMOURS OF THE NASAL CAVITY AND PARANASAL SINUSES AND ITS RELATIONSHIP TO ÆTIOLOGY
695
LATERALISATION OF TUMOURS OF THE NASAL CAVITY AND PARANASAL SINUSES AND ITS RELATIONSHIP TO ÆTIOLOGY
Dudley Road Hospital, Birmingham, B18 7QH R. T.
J. SHORTRIDGE West Midlands Regional Health Authority Lateralisation was studied in 601
tumours
of the ethmoid sinuses
Methods
P. E. ROBIN
Summary
ance in lateralisation of and nasal cavity.
cases
of
624 cases of carcinoma of the nose and paranasal sinuses, recorded at the Birmingham Regional Cancer Registry between 1957 and 1972 inclusive, were available for study. After exclusion of 16 cases which were bilateral and 7 cases where the side of the lesion was not clearly stated, 601 cases remained. 295 were right-sided and 306 were left-sided. The group was then analysed by site and histology (table I).
carcinoma of the nasal cavity and paranasal sinuses. Squamous and anaplastic carcinomata and adenocarcinoma had a pronounced left-sided predominance in the ethmoid and to a much lesser extent in the nose. The results of a study of 298 cases of septal defection are invoked in support of the hypothesis that squamous and anaplastic carcinomata, as well as adenocarcinoma, are caused by exogenous factors. Introduction
UNEQUAL lateralisation has been noted in tumours of some bilateral organs, such as breast, kidney, lung, testis, ovary, and adrenals. Various theories have been proposed to explain why, for instance, the left female breast should be
more
prone to carcinoma than the
right. For many differences there are anatomical reasons which do not require the invocation of factors of aetiological significance. For instance, carcinoma occurs more commonly in the left main bronchus than the right, in a ratio of 1:16; and the left main bronchus is 1.8 times as long as the right.’ The ratio (right/left) of carcinoma of the lung is 1:13, and the ratio of lung weight is 1:10. These differences, however, are dwarfed by the imbal-
Results Of immediate note is the strong predominance (2/1) of left-sided carcinoma in the ethmoid sinuses and a smaller imbalance in squamous carcinoma of the nasal cavity. The essentially equal distribution of neoplasms in the antrum is by contrast just as worthy of note. Frontosphenoid and vestibule cancers are too few to be evaluated, but the latter seem to be evenly distributed. The various histological types of tumour differ in their tendency to show lateral disparity. Squamous and anaplastic carcinoma and adenocarcinoma all show a strong (5/2) left-sided predominance in the ethmoid region, and there is some suggestion of this predominance in the nasal cavity with squamous carcinoma (4/3). There is an unexpected and otherwise uncharacteristic left predominance of carcinoma in the antrum. Examination of the data for ethmoid tumours by sex shows that (with the exception of adenocarcinoma, of which there are only 2 cases in females) the trends are similar in the two sexes (table 11). Thus, there is left-sided predominance of squamous and anaplastic carcinoma and adenocarcinoma particularly in the ethmoid, a lesser one of squamous carcinoma of the nasal cavity, and none’ at all in the antrum. Other
salivary
TABLE I-LATERALISATION OF TUMOURS OF THE NASAL CAVITY AND PARANASAL SINUSES
696 TABLE IV-SIDE OF DEFLECTION IN
types show no significant lateral preference, that salivary carcinoma appears most frequently except in the left antrum.
histological
Discussion The degree of left-sided predominance is massive in cancers of the ethmoid compared with other parts of the body cited by Waterhouse2 (table m). The left-sided predominance of adenocarcinoma and squamous and anaplastic carcinoma in the ethmoid is statistically (P=0.01) and is in a category quite distinct from other anatomical sites. Such a finding provokes speculation about the cause of this difference, especially since the majority of adenocarcinomata of the ethmoid are caused by exogenous carcinogens.3 Does some factor which influences the distribution of air-flow in the nose also influence the site of carcinogenic change? Septal deviation is an obvious cause of disparity of nasal air-flow, and we therefore determined the side of deflection from the records of 298 patients treated surgically (by resection or septoplasty) for deviated nasal septum. While many
TABLE II-LATERALISATION AND SEX DISTRIBUTION OF ETHMOID TUMOURS
TABLE III-LATERALISATION AND SEX DISTRIBUTION OF CARCINOMATA IN PAIRED ORGANS
298
CASES OF SEPTAL
DEFORMITY
did not have the side of deflection recorded, number could be evaluated (table iv). The septum was deflected to the left in twice as many cases as to the right. If, in the case of a carcinoma indisputably attributable to exogenous factors, in particular wood-dust, the left/right distribution is governed by abnormal air-flow, can one adopt the reverse theory that, with squamous carcinoma of the ethmoid, the distribution is governed by abnormal air-flow and thus the carcinoma is attributable to exogenous factors, be they wood-dust, fumes, or other air pollutants? Such an argument might, on its own, appear presumptuous; however, ethmoid carcinoma shows another feature characteristic of a cancer caused (at least partly) by exogenous factors-i.e., male predominance (17 males to 12 females). Male predominance is characteristic of other neoplasms in the respiratory tract, reflecting a greater tendency for men to be exposed to air pollutants. Though exogenous factors have on rare occasions been suggested as causative-e.g., nickel,4ionising radiation,5 and thoriumb -in the first the precise site is not clarified, whereas in the last it is an isolated case in the antrum. That women also share this lateralising feature suggests that though the factor is likely to be exogenous it is not invariably industrial. These features which suggest exogenous a’tiological influences in the ethmoid region no doubt operate in the nasal cavity to a lesser extent but in the antrum probably not at all. The nasal airflow has been described as passing mainly through the middle and inferior meatuses with enough turbulence to permit settling of appropriate-sized dust particles on the middle turbinate adjacent to the ethmoid. Studies by Hadfield and Macbeth3 and Black et al. are convincing in their extrapolation of the wood-dust theories and could probably be extended to some squamous and anaplastic lesions. It is interesting that the antrum, which is unlikely to be significantly affected by alterations in nasal air-flow, shows no lateralisation of adenocarcinoma nor squamous carcinoma, and indeed it could be questioned whether even adenocarcinoma of the antrum is due to an exogenous factor at all. such a
cases
significant
Requests
for
reprints
should be addressed
to
P. E. R.
REFERENCES
1. Davies, D. V., Davies, F. Gray’s Anatomy; p. 2. Waterhouse, J. A. H. Cancer Handbook of
1340. London, 1962. Epidemiology and Prognosis
Edinburgh, 1974.
*These figures are from a 6-year study by Waterhouse.2 tFrom a 16-year study by P.E.B.
3. Hadfield, E. H., Macbeth, R. G. Ann. Otol. 1971, 80, 699. 4. Pedersen, E., Hogetvens, A., Andersen, A. Int. J. Cancer, 1973, 32, 41. 5 Hora, J. F., Weller, W. A. Ann. Otol. Rhinol. Lar. 1962, 71, 321. 6. Schmitz, G. L., Peter, R., Lehman, R. H. Laryngoscope, 1970, 80, 1722. 7. Black, A., Evans, J. C., Hadfield, E. H. Br J. ind. Med. 1974, 31, 10.
LATERALISATION OF TUMOURS OF THE NASAL CAVITY AND PARANASAL SINUSES AND ITS RELATIONSHIP TO ÆTIOLOGY
Dudley Road Hospital, Birmingham, B18 7QH R. T.
J. SHORTRIDGE West Midlands Regional Health Authority Lateralisation was studied in 601
tumours
of the ethmoid sinuses
Methods
P. E. ROBIN
Summary
ance in lateralisation of and nasal cavity.
cases
of
624 cases of carcinoma of the nose and paranasal sinuses, recorded at the Birmingham Regional Cancer Registry between 1957 and 1972 inclusive, were available for study. After exclusion of 16 cases which were bilateral and 7 cases where the side of the lesion was not clearly stated, 601 cases remained. 295 were right-sided and 306 were left-sided. The group was then analysed by site and histology (table I).
carcinoma of the nasal cavity and paranasal sinuses. Squamous and anaplastic carcinomata and adenocarcinoma had a pronounced left-sided predominance in the ethmoid and to a much lesser extent in the nose. The results of a study of 298 cases of septal defection are invoked in support of the hypothesis that squamous and anaplastic carcinomata, as well as adenocarcinoma, are caused by exogenous factors. Introduction
UNEQUAL lateralisation has been noted in tumours of some bilateral organs, such as breast, kidney, lung, testis, ovary, and adrenals. Various theories have been proposed to explain why, for instance, the left female breast should be
more
prone to carcinoma than the
right. For many differences there are anatomical reasons which do not require the invocation of factors of aetiological significance. For instance, carcinoma occurs more commonly in the left main bronchus than the right, in a ratio of 1:16; and the left main bronchus is 1.8 times as long as the right.’ The ratio (right/left) of carcinoma of the lung is 1:13, and the ratio of lung weight is 1:10. These differences, however, are dwarfed by the imbal-
Results Of immediate note is the strong predominance (2/1) of left-sided carcinoma in the ethmoid sinuses and a smaller imbalance in squamous carcinoma of the nasal cavity. The essentially equal distribution of neoplasms in the antrum is by contrast just as worthy of note. Frontosphenoid and vestibule cancers are too few to be evaluated, but the latter seem to be evenly distributed. The various histological types of tumour differ in their tendency to show lateral disparity. Squamous and anaplastic carcinoma and adenocarcinoma all show a strong (5/2) left-sided predominance in the ethmoid region, and there is some suggestion of this predominance in the nasal cavity with squamous carcinoma (4/3). There is an unexpected and otherwise uncharacteristic left predominance of carcinoma in the antrum. Examination of the data for ethmoid tumours by sex shows that (with the exception of adenocarcinoma, of which there are only 2 cases in females) the trends are similar in the two sexes (table 11). Thus, there is left-sided predominance of squamous and anaplastic carcinoma and adenocarcinoma particularly in the ethmoid, a lesser one of squamous carcinoma of the nasal cavity, and none’ at all in the antrum. Other
salivary
TABLE I-LATERALISATION OF TUMOURS OF THE NASAL CAVITY AND PARANASAL SINUSES
696 TABLE IV-SIDE OF DEFLECTION IN
types show no significant lateral preference, that salivary carcinoma appears most frequently except in the left antrum.
histological
Discussion The degree of left-sided predominance is massive in cancers of the ethmoid compared with other parts of the body cited by Waterhouse2 (table m). The left-sided predominance of adenocarcinoma and squamous and anaplastic carcinoma in the ethmoid is statistically (P=0.01) and is in a category quite distinct from other anatomical sites. Such a finding provokes speculation about the cause of this difference, especially since the majority of adenocarcinomata of the ethmoid are caused by exogenous carcinogens.3 Does some factor which influences the distribution of air-flow in the nose also influence the site of carcinogenic change? Septal deviation is an obvious cause of disparity of nasal air-flow, and we therefore determined the side of deflection from the records of 298 patients treated surgically (by resection or septoplasty) for deviated nasal septum. While many
TABLE II-LATERALISATION AND SEX DISTRIBUTION OF ETHMOID TUMOURS
TABLE III-LATERALISATION AND SEX DISTRIBUTION OF CARCINOMATA IN PAIRED ORGANS
298
CASES OF SEPTAL
DEFORMITY
did not have the side of deflection recorded, number could be evaluated (table iv). The septum was deflected to the left in twice as many cases as to the right. If, in the case of a carcinoma indisputably attributable to exogenous factors, in particular wood-dust, the left/right distribution is governed by abnormal air-flow, can one adopt the reverse theory that, with squamous carcinoma of the ethmoid, the distribution is governed by abnormal air-flow and thus the carcinoma is attributable to exogenous factors, be they wood-dust, fumes, or other air pollutants? Such an argument might, on its own, appear presumptuous; however, ethmoid carcinoma shows another feature characteristic of a cancer caused (at least partly) by exogenous factors-i.e., male predominance (17 males to 12 females). Male predominance is characteristic of other neoplasms in the respiratory tract, reflecting a greater tendency for men to be exposed to air pollutants. Though exogenous factors have on rare occasions been suggested as causative-e.g., nickel,4ionising radiation,5 and thoriumb -in the first the precise site is not clarified, whereas in the last it is an isolated case in the antrum. That women also share this lateralising feature suggests that though the factor is likely to be exogenous it is not invariably industrial. These features which suggest exogenous a’tiological influences in the ethmoid region no doubt operate in the nasal cavity to a lesser extent but in the antrum probably not at all. The nasal airflow has been described as passing mainly through the middle and inferior meatuses with enough turbulence to permit settling of appropriate-sized dust particles on the middle turbinate adjacent to the ethmoid. Studies by Hadfield and Macbeth3 and Black et al. are convincing in their extrapolation of the wood-dust theories and could probably be extended to some squamous and anaplastic lesions. It is interesting that the antrum, which is unlikely to be significantly affected by alterations in nasal air-flow, shows no lateralisation of adenocarcinoma nor squamous carcinoma, and indeed it could be questioned whether even adenocarcinoma of the antrum is due to an exogenous factor at all. such a
cases
significant
Requests
for
reprints
should be addressed
to
P. E. R.
REFERENCES
1. Davies, D. V., Davies, F. Gray’s Anatomy; p. 2. Waterhouse, J. A. H. Cancer Handbook of
1340. London, 1962. Epidemiology and Prognosis
Edinburgh, 1974.
*These figures are from a 6-year study by Waterhouse.2 tFrom a 16-year study by P.E.B.
3. Hadfield, E. H., Macbeth, R. G. Ann. Otol. 1971, 80, 699. 4. Pedersen, E., Hogetvens, A., Andersen, A. Int. J. Cancer, 1973, 32, 41. 5 Hora, J. F., Weller, W. A. Ann. Otol. Rhinol. Lar. 1962, 71, 321. 6. Schmitz, G. L., Peter, R., Lehman, R. H. Laryngoscope, 1970, 80, 1722. 7. Black, A., Evans, J. C., Hadfield, E. H. Br J. ind. Med. 1974, 31, 10.