treatment of cancer of the nasal cavity
Post on 02-Jun-2018
215 Views
Preview:
TRANSCRIPT
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
1/7
* F rom the R adiation T herapy D epartm ent,t and H ead and N eck D epartm ent, R oSw ell P ark M em oria l Institute, B uffalo ,
York .
A U G U S T , 19 69
824
T R E A T M E N T O F C A N C E R O F T H E N A SA L C A V IT Y *
B y A . 0. BA DIB , M .D .,t S . S. K U ROH A RA , M .D., PH.D .,tJ . H . W EB ST ER , M .D ., C .M .,tan d D . P. SH E D D , M.D4
B U F FA LO , N E W Y O R K
P R IM A R Y m alignant tum ors of thenasal cavity are relatively rare and are
usually reported to have a poor progno-
sis.37b0 M ost of the published reports in-
dude these tum ors in one group w ith other
tum ors m ainly of the paranasal si-
nuses.35-8#{176}4 The special problem s of diag-
nosis and m anagem ent of cancer of the
nasal fossae6 and the apparen t difference in
the prognosis m ade their separate presenta-
tion desirable.1 In review ing the litera ture,
the indications for surgery or rad iation
therapy are not c learly defined and the re-
sults of treatm ent are not easily com pared
because of the difference in selection of pa-
tients for treatm ent.
In this study, w e present the experiences
at R oswell Park M em orial Institu te in the
m anagem ent of patients w ith cancer of the
nasal cav ity . T he influence of differen t
prognostic factors on the results of treat-
m ent by irradia tion and/or surgery w ill be
discussed with an evaluation of the indica-
t ion for techni ques an d r es ul ts o f r ad ia ti on
therapy.
M AT E R I A L
Over the period of 23 years, betw een
January, 1942, and D ecem ber, 1964, a to-
ta l of 57 patients w ith m alignant tum ors of
the nasal fossa w ere treated at R osw ell
Park M em orial Institu te, B uffalo, N ew
Y ork . The clinical featu res in the series are
presen ted in T able i. M ales w ere m ore
frequently afflicted than fem ales. T he aver-
age age incidence w as6i years and 77 pe r
c ent of the cases w ere above 50 years of age.
The duration of sym ptom s varied from
w eeks to m ore than 2 years, the average be-
ing 8 m onths. The com m on early sym p-
tom s (Table i) w ere unila tera l nasal ob-
struction (77 per cent), nasal discharge
(5 4 per cent), epistaxis (4 0 per cent), and
local pain (2 8 per cent). The rem aining
sym ptom s (Table I) w ere less frequen t and
usually la te.
Chronic sinusitis and nasal polyps pre-
ceded the tum or in 8 cases(i 5 per cent). N o
other po ten tial predisposing facto rs, such
as benign grow ths, a trophic rhinitis or pre-
vious irradiation , w ere found .
The tum ors w ere lim ited to the right side
ofthe nasal cav ity in33 cases (8 per cent),
to the left side in2 cases (,7 per cent), and
w ere bilateral in3 cases ( per cen t). Thelateral w all w as the m ost frequen t site of
tumor: 9 on the tubinates (2-upper, 4-
m iddle, and 3-low er turbinate) and10 on
the rest o f the lateral w all. O ther sites, in
order of decreasing frequency w ere: sep-
tum , vestibule, posterior choana and floor.
The site of origin cou ld not be determ ined
in 10 cases w ith cancer filling the entire
nasal cav ity (Tab le II).
These tum ors w ere either polypoidal
m asses in 38 cases (67 per cent) or ulcera-
tive lesions in 19 cases (3, per cent).
Eigh teen cases show ed extension outside
the nasal cavity , m ainly to the m axillary
antrum (9 cases), ethm oidal sinuses (
cases), and nasopharynx ( cases). Lym phnode m etastases were found in 8 cases 1 4
per cent) and distant m etastases in2 cases
(4 per cent).
R oe n t ge no l og ic e xa mi n a t io n o f th e n os e
a n d n as a l s in u se s s ho we d bo n e destruction
i n 18 cases, nasal opacity or m ass in14
cases, and b o th i n I I cases. Ethmoidal an d
m axillary sinusitis w as seen in10 cases
( Ta b l e i).
To assess the i mp or t a nc e o f t he ex t en t o f
tum or as a prognostic factor, a clinical
stag ing w as devised (Tab le III), based on
TN M classification used by C occh i. S tage
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
2/7
TA B L E I
C LIN IC A L F EA TU RE S
Se xFemaleMale
V O L . 106, N o. Tr ea t me n t o f Ca nc e r o f th e N asal Cavity 82 5
I (T1_T2, N0, M 0) included i6 cases; Stage
II (T1_T2, N 1, M 0), 6 cases; S tage II I (T1_T,,
N 2, or T ,, NO-N2) , 17 cases; and Stage iv
(T4, N -N 2 or T1-T4 , M ), 18 cases. T1 de-
notes a tum or lim ited to the m ucosa that isI cm . in diam eter or less; T2, m ucosal
lesion m ore than i cm . in diam eter; T,
tum ors invo lving bone or cartilage; and
T4, extension outside the nose.N1 m eans a
m obile, unilateral lym ph node; andN 2
fixed or b ilateral lym ph nodes. M stands
for d istan t m etastases.
The diagnosis w as estab lished h istologi-
cally in all the cases and is given in Table
II . T he predom inan t type w as squam ous
c ell c arc in om a (I 2-w ell differen tiated ,
m edium differentiated, and 8-und iffer-
entiated, w hile 8 w ere ungraded). T his w asfollow ed by adenocarcinom a (i i cases),
m ixed salivary tum or ( cases), anaplasticcarcinoma ( cases) and m alignant m ela-
noma (2 cases).
TREATMENT
In th is series, th ree m odalities w ere used
as in itial treatm ent: irrad iation (3 0 cases);
surgery (13 cases); and com bined surgery
an d irrad iatio n (14 cases) (Table III).
In the irrad iation group, 25 cases (#{231}er
cent) received ex ternal radio therapy alone,10 cases had radium therapy alone and 9
cases w ere g iven external irrad iation p lus
rad ium . Tum ors of the vestibule w ere
treated by a single field using orthovo ltage
rad iation. S ingle anterior fields w ere used
for irradiating other tum ors in the an terior
part of the nasal cavity. P arallel opposing
fields w as the technique em ployed in lesions
of the posterior choana w hile an terior and
lateral w edge pair w as used in som e tum ors
involving the m axillary and ethm oidal
sinuses. In extensive lesions, th ree cross-
f i ri n g f ie ld s w er e p re fe rr ed . O rt ho vo lt a ge ,
supervoltage an d c ob a l t 6 o eq u ip me n t w er e
u se d a n d th e tum or dose w as in the range of
5,000 t o 6,ooo r ad s in 5- 6 w eeks depend ing
o n t h e v o l um e t r e a t ed . In som e cases, it was
n ec es sa r y t o in c l u de t he ip s i l a t e r a l e y e i n
th e t r e a t me n t f i e ld , p r o t ec t i n g th e o th e r
N o . o f
Patients
P e r C e n t o f
Patients
A geUnder 40
40-49
50 59
60-69
70 -79
Over 8o years
Sym p tom D uration
0-2
2-4466-12
Over 12 m onths
Presenting Sym ptomN asal obstruction
N asal dischargeEpistaxisLocal painN asal swelling
EpiphoraV is ua l d is tu rb an ce sN eck m ass
Tumor Extens ionM axillary antrumEthmoid s inusOrbitNasopharynxSphenoid sinusC ribriform plateL ym ph nodes
D istant m etastases
Roentgenologic FindingsB on e d es tr uc tio n
N asal opacity or m assBoth
C hron ic sinu sitisNegative
12 21
45 7 9
5 98 4
7 1222 39
13 23
2 4
17 30
34 25
8 14
JO 17
8 14
44 7731 54
23 40
i6 2832 2
5 9
3 52. 4
9 16
4 7
4 7
3 52 4
I 2.
8 14
2 4
i 8 32
14 25
II 19
30 17
4 7
eye by lead or by tilting the beam of the
l a te r al f i el d s.
Intracavitary and interstitial radium
w er e us ed ma in ly in sm a l l tum ors lim ited to
the nasal fossa (io cases). Radium appli_
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
3/7
826 A . 0. B adib , S . S . K urohara, J. H . W ebster and D . P . S hedd AU G U sT ,
TA B L E II
PA TH O LO G Y BY A N A T O M IC S1FE S
N asal Sites Total
Latera l Y es- U ndeter-Septum . C hoana Floor . N o. Per Cent
Wai t tiDuie mined
S qu am ous carcinom a 6 32 6 o o 8 32A naplastic carcin om a i 2 0 1 0 0 4 7
Lym phoepithelial carc inom a o o o 2. I 0 3 5Adenocarcinoma 8 o o o i 2 II 19Mixed salivary tum or 3 I I 0 0 0 5 9M alignant m elanom a I I 0 0 0 0 2 4
Total N um ber 39 i6 7 3 2 10 57 10 0Per C ent 3 3 28 12 5 4 i 8 10 0
cators or m olds w ere inserted into the nasal tum or dose w as 6,ooo-7,ooo rads in 7-8
cavity through the nostril for anterior days depending upon tum or size.
lesions or th rough the posterio r naris using External irradiation plus intracav itary
a nasal catheter for les ions in the posterior radium w as used in 9 cases oflocally exten-
part. Partia l excision of the tum or w as sive tum or (Tableiii). F ollow ing external
necessary in som e cases to facilitate radium radiotherapy to a tum or dose of5,000
applica tion. Interstitia l radium needles or rads/5 w eeks, an intracavitary radium
radon seeds were used in 4 patients w ith applica tor w as applied to add3,000 rads at
accessible anterio r tum ors of the sep tum o. cm . from the surface in 4-6 applications.
an d f loor. In cases treated by radium , the The surgical procedures used in25 cases
TA B L E II I
I NITIAL TREATMENT BY CLINICAL STAGES
C lin ical Stages T otal
I II III IV N o. Per Cent
A ll Series x6 6 17 18 57 10 0
TreatmentI r r a d i a t i o n II 2 8 9 30 53S u rg e r y 5 3 3 2 13 23
C o m b i n e d 0 I 6 7 14 2 4
Irradia tion TechniquesExternal irradiation 6 2. 6 I I 25 57Radium 5 I 0 10 23
Combined 0 0 4 5 9 20
S urgic al P roc edure sL oc al rese ction 5 3 6 0 14 52Radical 0 I 3 9 13 48
C om bined w ith SurgeryPreopera tive irradia tion o o I 3 4 29
P o s t o p e r a t i v e i r r a d i a t i o n o I 5 4 10 7
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
4/7
TA B L E IV
RE SUL T S O F T RE A TM E NT BY C LINIC AL ST AG ES, H IST O L O G Y A ND SIT E S
5 Y EA R C R U D E SU R V IV A L
A . C lin ical Stages
TotalStage I Stage II Stage III Stage IV
Irradiation 8/9 (89% ) 1/2 (o% ) 2/ 6 (% ) i/6 (17%) 12/23 52 )Surgery 4/5 (8o% ) 2/3 (67%) 2/3 (67%) 0/I ( o% ) 8/12 (67%)Combined I/I (100% ) 2/4 (50% ) 2/5 (o% ) io (o% )
Total 12 /14 86 ) 4/6 (67% ) 6/13(46%) 3/12(25%)
B . H istology
. Lympho- . . . TotalSquam ous Anaplastic {149}th1 1 A deno- iviixed M aiignant
C arcinom a C arcin om a ep i e ia carcinom a Salivary M elanom aCarcinoma
Irradiation 6/12 (o% ) i/ (25% ) 2/2 (100% ) 1 /3 (% ) 2/2 (100%)
12/23 (52% )Surgery 5/7 (73% ) 1/2 (o% ) 2/3 (67%) 8/12 (67%)
Combined 3/5 (60% ) 2/ 4 (o% ) o/ i (0 ) io ( )
Total 34/24 (6% ) 1/4 (25% ) 2/ 2 (100%) 4/9 (44% ) 4/ 5 (8o%) 0/I (o% )
C . Site
TotalL ateral W all Septum V estibule C hoana U ndeterm ined
Irradia tion 3/6 (o% ) 3/6 (o% ) 2/3 (67%) 2/3 (67%) 2/5 (40% ) 32/23 52 )Surgery 3/ 5 (6o%) 4/ 5 (8o%) 1/2 (o% ) 8/12 (67% )Combined 2/ 3 (67% ) 1/2 (50% ) i/i (100% ) 1/ 4 25 ) i o (50%)
Total 8/14 ( {231} % ) 8/13 (62% ) 4/6 (67% ) 2/ 3 (67% ) 3/9 (% )
V O L . io6, No. Treatm ent of Cancer of the Nasal Cavity 82 7
in this series w ere sim ple resection or
electrocoagula tion of sm all tum ors in14
cases, and radical resection of the nasal
cavity and m axilla w ith curettage of the
ethm oidal and spheno idal sinuses in the
m ore ex tensive tum ors in13 patients. Orbi-
tal excision w as done in2 cases and radical
neck d issection in4 cases.
In the com bined rad iotherapeu tic and
surg ical treatm ent preoperative irradiation
w as given in 4 cases and postoperative ir-
rad iation in io cases using radium or ex-
ternal radiation therapy. T he dose and the
technique depended on the vo lum e of tissue
irradiated and w ere sim ilar to those de-
scribed above.
RESULTS
Table iv illustrates the resu lts o f treat-
m ent in the various clinical stages, h is-
tology and sites of tum ors. E arly stages of
cancer lim ited to the nasal m ucosa ex-
hib ited the best p rognosis. F igure and
Table Iv show that well differentia ted
squam ous cell carcinom as had the best re-
sults and that adenocarcinom as had better
prognosis than undifferentiated squam ous
cell and anaplastic carcinom as. O ther his-
to log ic groups exh ibiting good results w ere
the lym phoep itheliom as and m ixed salivary
tumors . The w hole series had a crude year
surv ival rate of 56 per cen t, and a h igher
tum or-free actuarial su rvival rate of 67
per cent due to the fact that som e of the
patients w ere free of tum or at death or
f o l l o w - u p .
In the cases w ith early stages of this tu -
m or (S tage and II com bined) treated by
irradiation or surgery , year surv ivals of
82 and 75 per cen t, respectively, w ere ob-
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
5/7
10
Y E A R S A F T E R D IA G N O SIS
82 8 A . 0. B ad ib , S . S . K urohara, J. H . W ebster and D .P . Shedd A U G U S T , 196 9
>
S
FIG . I Su rvival rate cu rves after diagn osis of cancer
of the nasal cavity. (ii) Crude survival and(B )tu m or-free su rvival. T he solid curve is for a ll
cases, the interrupted curve is for the histologicgroup s an d the vertica l bars represent 95 pe rcen t confidence interva l. SC= squam ous cell car-
cin om a, u ngrad ed . SC I, II and III = squamous
cell carc inom a, G rades I, II and III. A napl.=anaplastic carc inom a.
tam ed (Table iv ). In late stages (S tageiii
an d Iv com bined) w hich received rad iation ,
surg ical and com bined treatm ents, the
year survivals were: 25, 50, and per cent,
respectively. S ixteen cases(2 8 per cent)
show ed either failu re of response (4 cases)
o r r ec ur re nc es i 2 cases) after the initial
t reatment . Fo ur o f the recurrent cases de-
veloped regional lym ph node m etastases
an d 2 of them distan t m etastases. E ighty
per cent o f the recurrences appeared w ith in
the first year after treatm ent. The m ean re-
currence tim e w as 10 m onths. The per-
sisten t cases and o f the recurrences fol-
low ed radiation treatm ent, w hile3 recur-
rences appeared after surgery , and after
the com bined treatm ent. A ll the persisten t
and recurren t lesions occurred in the pa-
tients w ith an in itial advanced tum or of
Stages H I and Iv. R ecurrences after in itial
su rg ical or com bined surgery and irradi-
ation w ere treated by irradiation. Four of
the persisten t and recurrent tum ors fo llow -
ing initial irradiation w ere re-irrad iated and
the rem ain ing 5 received surgical treat-
ment .
T he final assessm ent of tum or status
show ed year cure in40 cases and failu re
in 17 cases. The failures include 9 patients
w ith local tum or, 4 w ith m etastases, i with
both , and 3 of unknow n status.
DISCUSSION
T he concepts of treatm ent of nasal can-
ce r differ in the various pub lished studies
and change from tim e to tim e in the sam e
clinic.39 Irrad iation , alone, w as the pri-
m ary m ethod of treatm ent in som e series,59
w hile com bined rad iation and surg ical
treatm ent was advocated in m any
others.35#{176}25 Treatm ent was essentia lly
surgical in som e clinics367 and either surg i-
cal o r radio therapeutic , depending on the
radiosensitivity and extent of tum or, in
others.48 The w ide variations in the re-ported results can be ascribed to the m an-
ner in w hich the various au thors selected
cases for treatm ent and to the type of sub-
sequent analysis.
The treatm ent m ethods used in th is
series depended on the site , ex tent and the
histo logy of tum or. R adiation therapy w as
the m ost com m only used technique in both
early and advanced tum ors including m any
epiderm oid carcinom as and adenocarci-
nom as and all anaplastic and lym phoepithe..
hal carcinom as. Surgery w as used prin-
cipally in som e of the early cases and in tu-m ors w ith bone and cartilage involvem ent
and in a few locally extensive tum ors , in-
c luding squam ous cell carc inom as, adeno-
carcinom as and m ixed salivary tum ors.
C om bined treatm ent w as selected in ad-
vanced lesions of any histologic group.
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
6/7
V O L . io6, No. Treatm ent of C ancer of the N asal C av ity 82 9
In the rad iation treatm ent, radium ther-
apy was selected for sm all accessible
lesions; external rad iotherapy for larger and
less accessible tum ors; and radium plus
ex ternal irradiation in m ore ex tensive dis-.ease. External irrad iation w as com m only
used as it is m ore flexible and satisfactory.
Parker advocated external roen tgen ther-
apy in all his cases. Radium plus external
rad iotherapy w as preferred by D evineet
al.2 in nasal and ethm oidal cancer to
achieve a hom ogeneous high le thal tum or
dose. H ow ever, using supervo ltage and
cobalt 6o radiation, w e can deliver a rad ical
tum or dose w ithout the com plications pre-
viously reported after conventional rad io-
therapy.3 M inor early and la te radia tion
sequelae w ere reported in som e of the casesbu t no m ajor com plications w ere seen in
this series.
C onservative surgery plus irradiation
w as advocated by O liver,0 w hile m ore ag-
gressive surgical procedures have been used
by Frazell and Lew is.3 In our cases, se lec-
tion ofsim ple or radical surgical procedures
depended on the site and extension of the
tumor.
B ecause the ex ten t of involvem ent, site
and histology of tum ors are im portant fac-
tors in determ ining survival; these facto rs
w ill be discussed before the evaluation ofthe treatm ent results. Tum or w ith exten-
sion outside the nasal cav ity has a poor
prognosis.5 90 This is seen in the low survi-
val rates in the advanced stages of th is S e-
ries. R oen tgeno log ic ev idence of bone de-
struction w as considered an unfavorab le
facto r in cancer of the nose and paranasal
sinuses.0 H ow ever, Larsson and M artens-
son5 found no great difference betw een the
resu lts in cases w ith or w ithout bone de-
struction. In this study, the cases with evi-
den t bone destruction and extranasal ex-
tension had a shorter survival in all treat-
m ent groups. In cases w ith tum ors lim ited
to the naval cavity, p resence or absence of
roen tgeno log ic evidence of bone involve-
m ent produced no difference in the results.
The presence of lym ph node m etastases
(relatively uncom m on in this series,14 per
cent) w as associated w ith poor prognosis in
th is m aterial and in o thers.59
The location of the tum or has been re-
ported to be of param ount im portance.#{176}
T um ors of the upper and posterior part of
the nasal reg ion w ere reported to have a
poor prognosis due to their early infiltra-
tion.5 The influence of a particu lar site w as
reported to depend on the ease w ith w hich
the tum or can ex tend to a surrounding vital
s t ructure ; e.g., tumors of the olfactory re-
gion m ay extend to the ethm oids, orbits
and base of the skull, w hile those of the
posterior choana spread to the nasophar-
ynx.8 In th is m aterial, allow ing for all o ther
possible prognostic facto rs, no difference
ex isted betw een the resu lts in tum ors of
various anatom ic sites.A nother prognostic facto r is the h isto -
log ic type. Larsson and M tensson ,5 and
M acC om b and M artin9 reported bad prog-
nosis in the undifferentia ted carcinom as
and the adenocarcinom as. O n the other
hand, O liver0 stated that the type of can-
cer does not appear to alter the prognosis.
T his series show ed a h igher survival rate
in the differentia ted squam ous cell car-
c inom as than in adenocarcinom as. The un-
differen tiated and anaplastic carcinom as
had the low est survival ra te .
The reported resu lts o f surgery versusradiotherapy in m any publications can not
be considered as criteria for com paring
their respective effectiveness, as surgery
w as m ainly used in early operable cases,
w hile rad iation therapy w as lim ited to pal-
lia tion in inoperable advanced tum ors and
residual or recurrent disease .347 N o sta-
tistical d ifference w as found am ong the
over-a ll results of the3 m ain m ethods to
trea tm ent in this series. H ow ever, the
analysis of the results in each stage show ed
som e poin ts of in terest. In the early m u-
cosal lesions, both irrad iation and surgery
gave equally good resu lts. In tum ors w ith
b o n e or cartilage invo lvem ent or lym ph
node m etastases the com bined and surgical
m ethods apparently y ielded better results.
Frazell and Lew is3 using irradiation in a
secondary role in res idual or recurrent tu-
-
8/10/2019 Treatment of Cancer of the Nasal Cavity
7/7
83 0 A. 0 . B a d i b , S . S . K u ro ha ra , J. H. W ebster and D . P . Sh ed d A U G U S T, 1969
m ors, reported I 8 per cent cure rate after
irradia tion and 6 per cent after surgery.
W hen com paring their resu lts in the surgical
group w ith the results in this series in the
radiotherapeutic group, no difference in the
survival rates can be detected . A lso, the
results in their radiotherapeutic group are
com parable to our resu lts in the advanced
cases. H endrick4 reported 8 cases of nasal
carcinoma; 4 early, trea ted by surgery w ith
4- 7 year survival; and 4 advanced, trea ted
by irradia tion w ith 1- 3 year survival. In
the series of M acC om b and M artin9 8
patients survived out of35 patients w ith
nasal carcinom as treated by irrad iation ,
surgery or com bined m ethods.
Favorable results after radiation treat-
m ent of m alignant tum ors of the nasal fossaw ere reported by Parker. Ini 2 patients,
he reported a 67 per cent con trol rate at3-10 years using external rad iotherapy in
all the cases.
S U M M A RY
F ifty-seven cases of can cer ofthe nasal
cavity w ere treated initially by irradia tion
(30 cases), surgery (1 3 cases) and com binedirradia tion and surgery (14 cases). Irradi-
ation w as given using radium techniques in
sm all accessible lesions, external radia tion
therapy in less accessible tum ors, and ex-ternal rad iation therapy plus radium in
m ore extensive disease . External radiation
therap y is the technique com m only used
and w as considered m ore flexib le and satis-
factory . Sim ple or radical surgical proce-
dures were selected according to the site
and extent o f tum or. In the com bined
treatm ent, surgery w as ord inarily follow ed
by irradiation in the treatm ent of locally
advanced tum or.
The degree of extension and the histo logy
of tum or w ere the m ost significant prog-
nostic factors. Early w ell differentia ted
squam ous cell carcinom as have the bestprognosis. The 5 year surv ival in the w hole
series w as 6 per cent. In the early tum ors,radiotherapy and surgery gave equally good
results. In tum ors with bone or cartilage
i n va s io n o r ly mp h n od e metastases,
50 p e r c en t y ea r su rv iv a l fo l l o we d th e
c om b in ed a nd s u r g i c a l t r ea tm e n t .
A . 0. B adib , M .D .
Roswell Park M em oria l Institute
666 Elm StreetBuffa lo, New Y ork14203
REFERENCES
I. C O C C H I, V . D ie Strah ien therapie der m alignen
Tum oren der inneren N ase und der N asenne.
b en hoh len (ohn e O be rk iefe rh ohle n). Oncologia,1960 , 13 , 370-380.
2. D E V IN E, K . D ., S C A N L O N , P. W ., and FIGI, F. A .M alignant tum ors of nose and paranasalsinuses. 7.A.M.il . , 1957, 63 617-621.
3. F R A Z E L L , E. L., and L E w I S , J. S. C ancer of nasalcavity and accessory sinuses: report of m an-
agem ent of 416 patients . Cancer, 1963, i {243},I 2 9 3 -1 3 0 1.
4. H E N D R I C K , J. W . T rea tm ent of cancer of nasa lcavity and paranasal sinuses.Surg., G ynec. &
Obsi. , 1956, 102 , 322-330.
5. L A R S S O N , L. G ., and M A RT E N S S O N , G . C ar-
cinom a ofparanasal s inuses and nasal cavities:clin ical study of379 cases trea ted a t R adium -
hem m et and O tolaryngologic Departm ent ofK arolinska Sjukhuset. 4cta radiol., 1954, 4 2,149-172 . .
6. L E D E R E R , F. L., S N I T M A N , M . F., S K O L N I K ,E. E., and S O B O R O F F, B. J. Tum ors of nasalcavity. Laryngoscope, 1957, 67 , 592-604.
7. L E F FA L L , L. D ., JR. , an d W H I T E , J. E. C ancer ofnasal cavity and paranasal s inuses.A m . 7.Surg., 1966, 112, 43 6 - 4 3 8 .
8. L E N Z , M . Sym posium . M alignant neoplasm s ofnose, nasopharynx and paranasal sinuses: eval-
u ation of radia tion therapy. Tr. A m . 4cad.
O p / i t / i . 1951, 5 5 214-225 .
9. M A C C O M B , W . S., and M A RT I N , H . E . C ancer of
n asal cavity. A M . J. R O E N T G E N O L . & R A D .T H ER A P Y , 1942, 47 , I 1 -2 3.
T O. O LIV ER , P C ancer ofnose and paranasal sinuses.
S . C lin . N orth A m erica, 1967, 47 , 595-600.I I. PA R K ER , R . G . C arcinom a of nasa l fossa.A M . J .
R O E N T G EN O L ., RD . T H E R A PY & N U C L E A RM E D . , 1958 , 8o , 766-774.
12. S CH AL L, L . M alig na nt tumors of nose and nasalaccessory sinuses. 7.I1.M.I1., I 948, 137, I 2 73 -
1276.
33 . Sooy, F . A . Prim ary tumors of nasal sep tum .Laryngoscope 1950 , 60 964-992.
14. W IL L IE , C . M alignan t tum ors in nose and its
a cc es so ry s in us es.A ct a o to -l ar yn g., 1947, Suppl.6 1-58.
: W I N B O R N , C. D . Malignant d iseases of nose an dsinuses. A .M .A . A rch. O to la ryng., 1955 , 61,141-150.
top related