The management of tumours arising in the maxillary antrum

Clinical Oncology (1992) 4:240--243 © 1992 The Royal College of Radiologists

Clinical Oncology

Original Article The M a n a g e m e n t of T u m o u r s Arising in the Maxillary A n t r u m A. G. Robertson 1, G. S. Rao 2, A. A1-SammarieI and D. S. Soutar3 tBeatson Oncology Centre, Western Infirmary, Glasgow G l l 6NT, 2Department of Plastic Surgery, Withington Hospital, Manchester M20 8CR, 3West of Scotland Plastic and Maxillofacial Unit, Canniesburn Hospital, Bearsden,

Glasgow G61 1QL, UK

Abstract. Eighty-eight cases of tumours arising in the maxillary antrum undergoing treatment between 1967 and 1989 are reported. The series comprised 34 females and 54 males. Sixty-two patients had squamous cell carcinoma (SCC). Forty of those with SCC were treated by XRT only, four cases by surgery only, while the remaining 18 patients had surgery and post-operative XRT as a combined modality treatment. Early SCC (T2No) was adequately controlled by radical radiotherapy alone with a 5-year survival of 69.1%. In more advanced SCC (T3No and (T4N0) radical radiotherapy alone was less successful with the 5-year survival falling to 19%. Combined modality treatment comprising radical surgery followed by radical postoperative radiotherapy improved 5-year survival in advanced SCC to 61%. It is therefore recommended that if patients are treated for cure, major surgery followed by radical postoperative radiotherapy is preferable in advanced squamous tumours ((T3/T4) of the maxillary antrum. Keywords: Maxillary antrum; Squamous carcinoma surgery

Radiotherapy;

followed by planned radical postoperative radiotherapy. Prior to that, treatment depended upon consultant choice. This has resulted in two groups of patients, one treated by radiotherapy alone, the other by radical surgery followed by planned postoperative radiotherapy. The object of this study is to evaluate our results and to compare the efficacy of the two different treatment approaches.

MATERIALS AND METHODS All patients with tumours arising primarily in the maxillary sinus who had treatment at Canniesburn Hospital and the Beatson Oncology Centre between 1967 and 1989 have been evaluated retrospectively. Eighty-eight patients were treated for tumours arising in the maxillary sinus over that time. There were 54 males and 34 females. The majority of patients were aged 60 years and older (Fig. 1). All patients had an initial biopsy at presentation, 62 patients had squamous cell carcinoma and the remainder a variety of rarer tumours, including malignant melanoma, sarcoma etc. (Fig. 2). These 62 patients with squamous cell carcinoma of

INTRODUCTION 30.

Primary malignant tumours of the maxillary sinus are rare. They constitute about 50% of tumours arising in the paranasal sinuses, and paranasal sinus tumours account for about 1% of all cancer deaths [1]. Diagnosis of these tumours is often delayed. The various modes of spread make diagnosis difficult and symptoms may arise late in the history of the disease. Many of the tumours, therefore, are well advanced at the time of presentation. There is still considerable debate whether definitive treatment should be radiation [2-4] or a combination of surgery and planned radical postoperative radiotherapy [5-9]. Since the establishment of a combined radiotherapy/plastic surgery clinic in 1982, we have adopted the policy of radical surgery Correspondence and offprint requests to: A. G. Robertson, Beatson Oncology Centre, Western Infirmary, Glasgow G11 6NT.

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Fig, 1. Age distribution of 62 patients with SCC of the maxillary antrum.

Management of Tumours Arising in the Maxillary Antrum

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Adeno Lymphoma Cylindroma Ca. Osteosarcoma Fibrosarcoma Plasmacytoma Rhabdomyosarcoma Malignant melanoma ,Aneurysmal bone cyst

RESULTS

Fig. 2. Histopathological classification of the tumours.

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years (range 40-77). Those with T2 lesions had a partial maxillectomy carried out; the tumours were removed with adequate margins. The resulting defects are subsequently sealed by constructing a dental obturator. Those with T 3 o r T 4 disease required more extensive surgery, maxillectomy often including exenteration of the orbit, the defects again being sealed or camouflaged by the prefabrication of an obturator and prosthesis. Over the past 5 years reconstruction has been carried out where possible, using musculocutaneous flaps to seal the palate and orbital cavity. In one or two cases bone grafts and muscle slings have been used to reconstruct the floor of the orbit.

~ No N1 Cervical Lymph node Metastases

Fig. 3. Clinical stage of 62 patients with SCC of the maxillary antrum.

the maxillary sinus were staged retrospectively using the UICC classification [10]. The majority had advanced tumours (Fig. 3); six had nodal disease and were excluded from further analysis, and four cases treated by surgery alone were also not included in further study• Of the remaining 52 node negative patients, 34 were treated by radiotherapy alone and the remaining 18 were treated by a combination of radical surgery followed by planned postoperative radiotherapy. Both groups of patients received 6000 cGy in 30 fractions over 6 weeks, using the treatment approach described by Frich [4]. The patients were treated on 4-6 Mev linear Accelerators. Because the numbers are small the patients have been grouped into those with T2 tumours and those with T3 and T4 tumours for analysis. Of the patients receiving radical radiotherapy as the primary radiotherapy, 13 had T2 lesions. These had a male = female ratio of 1.12 = 1.00 and an average age of 69 (range 49-83). Twenty-one patients had T3/T4 disease, a male = female ratio of 1.3 = 1.0 and an average age of 66 years (range 27-94). In the group receiving radical surgery and radical postoperative radiotherapy six had T2 lesions, a male -- female ratio of 1:1, and an average age of 63 years (range 51-78). Twelve patients had T3/T4 disease, a male-female ratio of 2:1, and an average age of 62

Five-year survival was analysed using actuarial survival curves. Early t u r n o u t s (TzNo) were adequately controlled by radical radiotherapy alone, with a 5year survival of 69.1%. In more advanced tumours (T3N0 and T4N0) radical radiotherapy alone was less successful, with the 5-year survival rate falling to 19%. Combined modality treatment comprising radical surgery followed by planned radical postoperative radiotherapy greatly improved the 5-year survival in the advanced group, giving a result of 61% (Fig. 4). If the 1-year survival is considered (Table 1) then patients treated by combined therapy fare much better than those treated by radiotherapy alone, although the confidence limits for the various groups of patients, allowing for the sample sizes, show a

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Time (months) o - - o T2N0 Surgery and postoperative radiotherapy (n=6) o - - o TzN o Radiotherapy (n= 13) & - - & T3NoT4N0 Surgery and postoperative radiotherapy (n = 12) T3NoT4N 0 Radiotherapy (n=21) Fig. 4. Actuarial survival curves for patients with maxillary antrum tumours treated by radiotherapy with or without surgery.

A. G. Robertson et al.

242 Table 1. One-year survival according to TNM Stage and treatment modality Stage

Treatment

TaN0

Surgery and Radiotherapy Radiotherapy alone Surgery and Radiotherapy Radiotherapy alone

T2No T3No/T4N0 T3No/T4No

Alive at 1 year (%)

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80

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large overlap in the T2No patients, but a much smaller one in the more advanced patients. All patients dying of disease had local recurrence. Two of the 11 patients (18%) treated by surgery and radiotherapy who died of disease had bone metastase prior to death. Six of the 21 patients (29%) treated by radiotherapy alone who died of disease had developed bone metastases prior to death. Retrospective evaluation of the significance of tumour extension related to the prognosis was carried out using preoperative clinical symptoms, radiographs and margins of resection of the specimen [11]. Preoperative trigeminal neuralgia proved to be a poor prognostic sign, indicating that tumour extended posteriorly into the base of the skull. Metastasis to the cervical lymph nodes at the time of presentation was also associated with a poor outcome; six patients presented with lymph node metastasis and all died within 22 months despite aggressive treatment involving surgery and radiotherapy.

DISCUSSION Squamous cell carcinoma of the maxillary antrum has often been associated with a poor prognosis [3,4]. This has been attributed to late presentation, since signs and symptoms of cancer are often absent until the tumour invades beyond the confines of the maxillary antrum. The TNM classification of maxillary tumours is based on an anatomical division centred on Ohngren's line, which is the plane passing between the inner canthus and the angle of the mandible [12]. This plane divides the face into two portions, an inferior-anterior area which is termed the infrastructure and a superior-posterior area termed the suprastructure. Tumour extending into the infrastructure can involve the upper alveolus and palate or the nose below the inner canthus. This erosion produces early signs and symptoms and they are classified as T2 tumours. Involvement of the suprastructure can often be extensive before signs and symptoms develop and these are classified according to the areas of involvement as T3 or T4 tumours.

Tumours involving the infrastructure are very amenable to surgery since the bony projections of the malar are preserved as is the orbit. In essence, only

the upper alveolus and palate need be removed leaving a large intraoral and nasal cavity, which for the most part can be satisfactorily dealt with by obturation using a suitable upper denture. Surgery for T3 and T4 tumours involves much more radical surgery, often with the loss of the eye, loss of cheek skin or the creation of large defects which may involve the cranial base. There has been a natural reluctance to advocate surgery for such maxillary carcinomas because of the mutilating effects that might result. Advances in reconstructive techniques [13,14], particularly the use of free flaps with microvascular anastomosis, have opened up new possibilities for radical surgery. Portions of skull base may be removed and, provided the cavities are scaled with vascularized tissues, the risks of meningitis are minimal. In extensive cases, a combined craniofacial approach involving neurosurgery allows access for radical excision of tumours and vascularized reconstruction can safely and effectively pack off the brain and prevent ascending infection from the oral and nasal cavities. These reconstructive techniques combined with modern prosthetics have made surgical excision of advanced maxillary carcinoma a viable option. Original analysis of the results of treating advanced maxillary carcinoma with radiotherapy alone were extremely disappointing with a 5-year survival of 19%. Our experience in the use of combined modality treatment in intraoral cancer [15] led us to adopt a similar approach for advanced maxillary cancer. Following our first few cases, which appeared to do remarkably well, we have continued this treatment approach. Our initial results look promising and we have effectively improved the survival rate to 61%. Although the series is small and we have not had the opportunity to randomize the cases, we have been encouraged by the apparent improvement in survival from 19% with radiotherapy alone to 61% with combined modality treatment. This finding is in keeping with the results reported by other groups [8,91. With improvements in staging of disease, particularly the use of CT and MRI scanners [16] we are now able to tailor surgery more accurately and limit the mutilation. In addition, such investigations can lead to improvements in radical radiotherapy and, by continuing a combined modality treatment approach, it is our hope to maintain improvements in survival and at the same time decrease the morbidity associated with radical cancer treatment.

References 1. Roush GC. Epidemiology of cancer of the nose and paranasal sinuses: current concepts. Head Neck Surg 1979;2:3-11. 2. Stewart JG. A wedge filter approach with four MV radiation to the treatment of carcinomata of the alveolus and antrum. Proc R Soc Med 1960;53:239-42. 3. Bataini JP, Ennuyer A. Advanced carcinoma of the maxillary antrum treated by cobalt teletherapy and electron beam radiation. Br J Radiol 1971;44:590-8. 4. Frieh JC. Treatment of advanced squamous cell carcinoma of the maxillary sinus by irradiation. Int J Radiat Oncol Biol Phys 1982;8:1453-9. 5. MacComb WS, Fletcher GH. Planned combination of surgery

Management of Tumours Arising in the Maxillary Antrum

6. 7. 8. 9. 10.

and radiation in treatment of advanced primary head and neck cancers. A JR 1957;77:397-414. Konno A, Togawa K, Inoue S. Analysis of the results of our combined therapy for maxillary cancer. Acta Otolaryngol Suppl 1980;372:3-16. Weymuller A, Readon EJ, Nash D. A comparison of treatment modalities in carcinoma of the maxillary antrum. Arch Otolarngol 1980;106:625-9. St-Pierre S, Baker SR. Squamous cell carcinoma of the maxillary sinus. Analysis of 66 cases. Head Neck Surg 1983;5:508--13. Hordijk GJ, Brons EN. Carcinomas of the maxillary sinus. A retrospective study. Clin Otolaryngol 1985;10:285-8. UICC. TNM classification of malignant tumours. 4th ed. Berlin: Springer-Verlag 1987.

243 11. Kondo M, Ogawa K, Inuyama J, et al. Prognostic factors influencing relapse of squamous cell carcinoma of the maxillary sinus. Cancer !985;55:190-6. 12. Lederman M. Cancer of the upper jaw and nasal chambers. Proc R Soc Med 1969;62:65-72. 13. McGregor IA, McGregor FM. Cancer of the face and mouth. Edinburgh: Churchill Livingstone, 1986. 14. Early MJ. Primary maxillary reconstruction after cancer excision. Br J Plast Surg 1989;42:628--37. 15. Robertson AG, McGregor IA, Soutar DS, et al. Postoperative radiotherapy in the management of advanced intraoral cancers. Clin Radiol 1986;37:173-8. 16. Kondo M, Ando Y, Inutama Y, et al. Maxillary squamous cell carcinomas staged by computed tomography. Int J Radiat Oncol Biol Phys 1986;12:111--6.

Received for publication July 1991 Accepted January 1992

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