RECENT ADVANCES IN RADIOTHERAPY FOR SINONASAL MALIGNANCIESPresenter: Dr. Rituraj Upadhyay

Moderator: Dr. Ahitagni Biswas

09-02-2017

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OUTLINE

• Introduction to Sino-nasal tumors

• Clinical presentation and histological types

• Treatment protocols

• Radiotherapy dosage, volumes and techniques

• Precision radiotherapy techniques and its evidence

• Radiotherapy: Acute and Late effects

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SINONASAL MALIGNANCIES

• Uncommon neoplasms involving the nasal cavity and paranasal sinuses

• Encompass broad range of anatomical sites and differing histologies

• The overall 5-year survival from sinonasal cancers improved by 20% in last two decades

• Treatment failures are mostly local, with 81% failures in primary site, 24% nodal and 14% distant

• Management is complicated because of close proximity to multiple critical structures (the eye, brain, optic nerves and chiasm, brainstem, and cranial nerves)

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SINONASAL MALIGNANCIES

• Surgery and radiotherapy are the mainstay of treatment

• Advances have been made in surgical methods including endoscopic resections and highly conformal proton and photon techniques enabling avoidance of adjacent critical structures

• The role of chemotherapy for most of these neoplasms has yet to be clearly defined

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SITES

• Nasal vestibule

• Nasal cavity

PARANASAL SINUSES

• Maxillary sinuses

• Frontal sinuses

• Ethmoid sinuses

• Sphenoid sinus

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HISTOLOGICAL CLASSIFICATION*

HISTOLOGY % n = 3861. Squamous Cell Carcinoma

(squamous cell, transitional, and

32.6

2. Sarcoma (incl RMS) 13.5

3. Esthesioneuroblastoma 10.9

4. Glandular(adenoid cystic carcinoma andmucoepidermoid carcinoma)

10.1(9.1)

5. Lymphomas 9.8

6. Melanoma 8.8

7. Undifferentiated 7.8

8. Adenocarcinoma 6.5

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Dulguerov et al: Nasal and paranasal sinus carcinoma. Cancer 2001.

CLINICAL SPECTRUM

• Nasal findings:(50%) obstruction, epistaxis, rhinorrhea, discharge, extension into nasal cavity

• Oral symptoms:(25-35%) pain, trismus, alveolar ridge fullness, erosion

• Ocular findings:(25%) epiphora, diplopia, proptosis

• Facial signs: paresthesias, facial asymmetry, cheek swelling

• Auditory symptoms: hearing loss

• Neurological: cranial nerve deficits II,III,IV.V1,V2,VI

• Nodal involvement: Seen in about 10%

• Distant mets: rare

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RADIOLOGICAL EXAMINATION

• Modern fiberoptic technology, CT scan &/or MRI are needed to delineate the extent of tumor extracranially and intracranially.

• CT: • Has 85% accuracy.• Good for bone erosion in orbital walls, cribiform plate, fovea

ethmoidalis, etc• Difficult to see periorbital involvement, differentiate tumor,

inflammation and secretions.

• MRI:• 94% accuracy• Excellent for determining perineural spread, involvement of the dura,

or intracranial involvement. 09-02-2017

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IMAGING

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STAGINGPRIMARY TUMOR (T) for Maxillary Sinus tumors

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone

T2 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 plates

T3 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 sinuses

T4a Moderately Advanced Local DiseaseTumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid or frontal sinuses

T4b Very Advanced Local DiseaseTumor 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 09-02-2017

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AJCC 8th edition

N1, N2a, N2b and N2c unchanged other than specify without Extranodal extension (ENE)

• N3a: Metastasis in a lymph node more than 6 cm in greatest dimension without ENE

• N3b: Metastasis in a single or multiple lymph nodes with clinical ENE*

* The presence of skin involvement or soft tissue invasion with deep fixation/tethering to underlying muscle or adjacent structures or clinical signs of nerve involvement is classified as clinical ENE

N-STAGING: 7TH VS 8TH EDITION

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SQUAMOUS CELL CARCINOMA

• Most common type(80%)

• Location: Maxillary sinus (70%) and lateral nasal wall(20%)

• 90% have local invasion and present in advanced stages(T3/4)

• Lymph node metastases is more common than most other paranasal sinus malignancies(10-20%)

• Local recurrence rates are quite high, as high as 30% to 40%

• Complex 3-D anatomy makes clear margins difficult to achieve.

• Surgical resection with postoperative radiation is the treatment of choice. Some role of chemo, as extrapolated from HNSCC.

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ADENOCARCINOMA

• Most often seen in ethmoid sinuses

• Present most often in the superior portions

• Strong association with occupational exposures esp. wood dust workers

• High grade: solid growth pattern with poorly defined margins. 30% present with metastasis

• Low grade: uniform and glandular with less incidence of perineuralinvasion/metastasis.

• Treatment : Surgery followed by PORT

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ADENOID CYSTIC CARCINOMA

• 3rd most common site of ACC is the nose/paranasal sinuses

• Perineural spread upto the base of the skull

• It is occurs most frequently in women, and in the fifth and sixth decades.

• Anterograde and retrograde growth

• Despite aggressive surgical resection and radiotherapy, most grow insidiously.

• Postoperative XRT is very important.

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MUCOEPIDERMOID CARCINOMA

• Extremely rare

• Most patients present with low stage disease (stage I and II), although invasive growth is common with higher grade disease.

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OLFACTORY NEUROBLASTOMA/ESTHESIONEUROBLASTOMA

• Originate from stem cells of neural crest origin that differentiate into olfactory sensory cells.

• Aggressive behavior, with • 50-75% local failure and • 20-30% distant mets.

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STAGING

• Most commonly used is the modified Kadish staging

Stage Group Description

A Confined to nasal cavity

B Extends into the paranasal sinuses

C Extends beyond the nasal cavity and paranasal sinuses including involvement of the cribriform plate, skull base, orbit, or intracranial cavity

D Nodal/ Distant Metastasis09-02-2017

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ESTHESIONEUROBLASTOMAS

• Kadish A• Surgery / radiotherapy alone• Adjuvant RT is indicated in close and positive margins or with residual disease• No adjuvant chemotherapy

• Kadish B• Surgery followed by adjuvant RT

• Kadish C• Craniofacial resection post op chemoradiation• NACT -> surgery (craniofacial resection) post op chemoradiation or

chemoradiation (unresectable cases)

• Kadish D• Systemic chemotherapy and palliative RT to local and metastatic sites

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MELANOMA

• 0.5- 1.5% of melanoma originates from the NC and PNS

• Anterior Septum: most common site

• IHC markers include S-100 protein, HMB-45, melan-A, tyrosinase, etc.

• Treatment is wide local excision with/without postoperative radiation therapy

• Prophylactic neck nodal dissection at N0 is not recommended, since the incidence of occult nodal metastases is relatively low.

• Local, regional, and systemic recurrence rates of 20%, 50%, and 80%, respectively seen with lung involvement most common

• Classically poor prognosis with 5yr survival of about 11%09-02-2017

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RHABDOMYOSARCOMA

• Most common paranasal sinus malignancy in children

• Usually: Non-orbital, parameningeal, Alveolar subtype mostly

• Surgical resection is difficult and ChemoRT is the treatment of choice

• Commonly used chemotherapy drugs include Vincristine, Actinomycin D, Cyclophosphamide, Ifosfamide, and Etoposide

• A radiation dose of 50.4 GY/28#/5.5 wks is recommended.

• Aggressive chemo/XRT has improved survival from 51% to 81% in patients with cranial nerve deficits/skull/intracranial involvement

• Other sarcomas: Osteogenic Sarcoma is the most common• Mandible > Maxilla

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LYMPHOMA

• Usually Non-Hodgkins type

• DLBCL are the most common followed by NK-T cell lymphomas

• Highly Radio and chemosensitive

• NK-T cell Lymphoma: often EBV positive. More common in NC• SMILE/GELOX chemo f/b RT 45-60 Gy

• DLBCL: More common in PNS• R-CHOP f/b IFRT 30-36Gy/15-20#

• Survival: Around 50-65% at 5 years.

• Survival drops to 10% in case of recurrent lesions

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HEMANGIOPERICYTOMA

• Originate from pericytes of Zimmerman

• Present as rubbery, pale/gray, well circumscribed lesions resembling nasal polyps

• Treatment is surgical resection with postoperative XRT for positive margins

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SINONASAL UNDIFFERENTIATEDCARCINOMA

• Presents with aggressive, locally destructive lesion

• Diagnosed on pathological differentiation after ruling out melanoma, lymphoma, and olfactory neuroblastoma

• IHC can help in diagnosis: CK-8, p16 positive and EBV and HPV-DNA negative.

• Surgery, when feasible, may improve local control (Reiersen et al)

• Resectable or marginally resectable: • Primary surgery followed by adjuvant chemo-radiotherapy may be preferable• May consider induction chemotherapy (Cyclophosphamide/Doxorubicin/Vincristine)

followed by reassessment for surgery (Musy et al)

• Unresectable: • Concurrent chemoradiation• Induction chemotherapy followed by concurrent chemoradiation (Rischen et al)

• Optimal sequence of modalities and choice of chemotherapy regimen is still unclear09-02-2017

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TREATMENT ALGORITHM

• T1-2N0• Resection → post-op RT for close margin, PNI, adenoid cystic. • For + margin, re-resect (if possible) → post-op RT

• T3-4N0 • Resectable: Resection → post-op RT or chemo-RT*• Unresectable: Definitive RT or chemo-RT*

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*Chemotherapy as extrapolated from Head and neck Squamous Cell Ca

TREATMENT ALGORITHM

• N+• Resection + neck dissection → post-op RT or chemo-RT*. • Alternatively, definitive chemo-RT*

• Elective Nodal Irradiation• In T3/T4 tumors, Histology: Squamous cell Ca or Undifferentiated

carcinomas • Level Ib, II and Retropharyngeal LNs are included.

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*Chemotherapy as extrapolated from Head and neck Squamous Cell Ca

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RADIOTHERAPY09-02-2017

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• Because these cancers are usually diagnosed at a locally advanced stage and surgery is the primary therapy, most patients receive postoperative radiation therapy.

• Addition of RT to surgery improves 5-years survival (44%) when compared to RT alone (23%) or surgery alone.

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Cengiz et al. Sinonasal Tract Malignancies: Prognostic Factors and Surgery Outcomes

INDICATIONS

• Definitive: Medically inoperable or who refuse radical surgery or early lesions

• Adjuvant: High risk features, close or positive margin, R1/R2 resection

• PalliativeMetastatic disease

• Preoperative: In Borderline resectable tumorsIt may increase the infection rate and the risk of postoperative

wound complications.

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TIME DOSE FRACTIONATION

• Pre-op RT• 50 Gy/25#/5weeks

• Post-op RT: • 65 Gy/30#/6 wks to post op residuum• 60 Gy/30#/6wks to tumour bed

• Definitive RT:• 65 Gy/30#/6wks to primary disease• 60 Gy/30#/6wks to local microscopic disease

• Elective Nodal Irradiation• 54 Gy/30#/6wks to Level Ib, II, RPLNs

• Palliative RT• 30 Gy/10#/2wks or 20 Gy/5#/1wk 09-02-2017

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TARGET VOLUMES

• Volumes• GTV: Gross primary plus nodal disease or Post-op residual disease• CTV:

• HR-CTV (CTV65) – GTV + 1cm anatomically constrained margin• IR-CTV (CTV60) – Expansion to include tumour bed & all tissues

which have been surgically handled; entire involved sinus cavity, all areas at risk of harbouring microscopic disease.

• LR-CTV (CTV54) - Elective nodes: Ipsilateral or B/L Level Ib, II, RP LN

• PTV: Respective CTVs with 3-5 mm isotropic expansion09-02-2017

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ALTERED FRACTIONATION

• Radiobiological advantage in head and neck cancers because of rapidly proliferating tumors.

• Hyperfractionation• refers to giving the total radiation dose in a larger number of doses• Ex: 2 smaller doses per day instead of 1 larger dose • Less dose per fraction decreases late effects, Total dose can be escalated

• Accelerated fractionation• radiation treatment is completed faster • 6 weeks instead of 7 weeks, for instance• Decreases accelerated repopulation

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2D Conventional Techniques

3D Conformal

RT

IMRT/

Arc Therapy

Image guided IMRT

Proton therap

y

Brachytherapy (with

Image guidance)

RADIATION TECHNIQUES: EVOLUTION

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CONVENTIONAL TECHNIQUES

• 2-field or 3-field technique with wedge pairs used

• Patient lies in a supine

cast with the head in

neutral position.

• Tongue bite is used to

depress tongue &

lower alveolus away

from the target volume.

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Anterior field:

• Superior: Supraorbital ridge

• Inferior: Angle of mouth

• Medial: Contralateral medial canthus

• Lateral: Falling off the skin.

When there is no gross involvement of the orbit, the cornea, lens & lacrimal gland are shielded

If there is disease in the orbit, cornea is spared by cutting out the cast and treating with the eyes open

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Lateral fields:• Superior: Floor of anterior

cranial fossa.

• Anterior: Lateral canthus parallel to the slope of face

• Posterior: covers the pterygoid plates.

It is angled 5-10 degree posteriorly so that the exit beam avoids the opposite eye

Optic chiasma & hypothalamus are shielded from the lateral field

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2D ISODOSE DISTRIBUTION

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• Anterior beam is weighed as 2:1 to that of lateral beam

• Dose prescription:• 65Gy/30#/6w or

55Gy/20#/4w

3D CONFORMAL RADIOTHERAPY

• Multiple fields (3-5) are used with multi leaf collimators to shape the radiation portal in accordance to the disease volume, with adequate margins.

• Mapping and contouring of disease extent based on:• Pretreatment physical examination, • Pretreatment imaging,• Intraoperative findings, and• Histopathological examination (e.g., positive margin, perineural

invasion)

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INTENSITY MODULATED RADIOTHERAPY(IMRT)

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• An advanced form of 3D CRT in which non-uniform fluence(beam intensity) is delivered by coplanar or non-coplanar beams using computer-aided optimization and beam shaping to attain desired doses to target volume with reduced dose to surrounding critical structures.

• A non-coplanar arrangement of three to five sagittal midline beams with right and left lateral beams avoids entry or exit of beams through the eyes and provides a uniform dose distribution

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IMRT: ADVANTAGES

• Irregular tumors in sinonasal region: IMRT is needed to conform accurately to the tumor volume

• Vital structures: Optical, auditory and neural structures in the surroundings

• Relatively less organ motion in head and neck, so less daily setup errors, despite complicated planning

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FIXED FIELD IMRT VS VMAT

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EVIDENCE

• N = 81

• 40 patients with cancer of the paranasal sinuses (n = 34) or nasal cavity (n = 6) received postoperative IMRT to a dose of 60 Gy (n = 21) or 66 Gy (n = 19).

• Retrospectively compared with that of a previous patient group (n = 41) who were also postoperatively treated to the same doses but with three-dimensional conformal radiotherapy without intensity modulation.

• Median follow-up was 30 months (range, 4–74 months).

• Two-year local control, overall survival, and disease-free survival were 76%, 89%, and 72%, respectively.

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doi:10.1016/j.ijrobp.2009.09.067

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Compared to the three-dimensional conformal radiotherapy treatment, IMRT resulted in significantly improved disease-free survival (60% vs. 72%; p = 0.02).

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No grade 3 or 4 toxicity was reported in the IMRT group, either acute or chronic.

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The use of IMRT significantly reduced the incidence of acute as well as late side effects, especially regarding skin toxicity, mucositis, xerostomia, and dry-eye syndrome.

IMRT:EVIDENCES.No

Series n Period Site Histology Treatment RT dose

Median f/u

LocalControl

OS Toxicity

1. Duprez, Madani et al(Ghent)

130 1998-2009

Eth:74Max:24NC:31Sph:1

AdCa:82SqCC:23ENB:10SNUC:8

AdjRT:101Def:20ReRT:9Chemo:7

66-70 Gy

52m 5y:59% 52% G3 Ocular:11Brain Nec:6ORN:1

2. Hoppe et al (MSKCC)

85 1987-2005

Max:45NC:24Eth:14

SqCC:42ACC:11END:7

62%IMRT63Gy

62% 67% No>G2 in IMRT,1 blindness

3. Chen et al (UCSF)

127 1960-2005

Max:54NC:35Eth:26Sph:8F:4

SqCC:83ACC:28Adeno:16

Conv:46%3DCRT:36%IMRT:18%

60-72 Gy

49 55%62%61%57%59%

60s:4670s:5680s:5190s:5300s:49

G>2:53%45%39%28%16%

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Chen et al. IJROBP 2007. RT in PNS:Are we making improvement?

IMRT:EVIDENCES.No

Series n Period Site Histology Treatment RT dose

Median f/u

LocalControl

OS Toxicity

4. Claus et al(Belgium)

32 1999-2001

Ethm:21 Max:6NC:5

Adeno:17SqCC:8ENB:3 ACC:2TCC:1 Lepa:1

Sx-Adj RT:31ReRT(2)Definitive RT (1)

66-70 Gy

15m - 80% Mucositis G1–2:28 G3:4No Ocular G3/4 tox.Dry eye:0

5. Daly et al(UCSF)

36 1998-2004

Ethm:13Max:10NC: 7 Oth:6

SqCC:12ENB:7ACC:5SNUC:5AdCa:5Other:2

Sx-RT:32Def RT:4

70 Gy

51m 2y:62%5y:58%

5y:45%

No decreavision.Late:xerophth:1, lacrimal stenosis:1cataract:1

6. Duthoy et al (Ghent)

39 1998-2003

-- AdCa:79%SqCC:21%

Sx+PORT 70 Gy

2.6yrs 4y:68% 59% Decrvision 6%, No blinds

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IMAGE GUIDED RADIOTHERAPY

• Use of imaging during radiation therapy to improve the precision and accuracy of treatment delivery to the designated target volume.

• Compares images taken during treatment to the reference images taken during simulation,

• Appropriate real-time corrections to patient positioning and setup is made

• Imaging technologies used include • Orthogonal X-rays(2-D kV),• Cone beam computed tomography (CBCT),• MV imaging mounted on the treatment head itself

• Eliminates random and systematic treatment errors

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PARTICLE THERAPY

• Includes Proton therapy and Heavy ions like Carbon Ion therapy (CIT)

• These have high LET, which increases steadily from the point of incidence with increasing depth to reach a maximum in the peak region.

• Less dose is delivered to tissues proximal to the tumor and rapid dose fall off at the distal edge of the tumor (Bragg-Peak effect).

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PARTICLE THERAPY

• Dose escalation

• Minimizing exposure of normal tissues and decreasing toxicity

• Useful for deep-seated tumours.

• High biological efficiency (RBE): Effective in relatively radioresistantcancers (Carbon Ions)

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EVIDENCE

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S.No

Series n Period Site Histology Treatment

RT dose

Median f/u

LocalControl

OS Toxicity

1. Dagan et al (Florida)

84 2007-2013

NC/Eth:80%Max:18%

ENB:23%SqCC:22%ACC:17%

Def:13%Adj:87%26% R2 resectionChemo:75%

73.8 GyE

2.7y 3y:83%

R0:90%R1/2:59%RT:61%

3y:68%

Late: 24%>G3: 2%

2. Fuji et al(Japan)

20 2006-2010

NC:12PNS:8

Mucosal Melanoma

No SxCT:16

70 Gy/20fr

35m 62% 5y:51%

G4:3 (ON involved)

3. Cianchettiet al (Germany)

99 1991-2003

-- -- Sx:67% 70Gy 8.5y 8y:83% 8y:46%

>G3: Sx+RT:29%RT:7%

4. Pommier et al (MGH)

23 1991-2002

-- Adenoid cystic

Sx:39% 75.9cGyE

5y:93% 5y:77%

--

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Dagan et al Outcomes of Sinonasal Cancer Treated With Proton Therapy. IJROBP 2016

65

Fuji et al. High-dose proton beam therapy for sinonasal mucosal malignant melanoma. Radiation Oncology 201409-02-2017

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Fuji et al. High-dose proton beam therapy for sinonasal mucosal malignant melanoma. Radiation Oncology 2014

HEAVY-ION THERAPY

• Use of particles more massive than protons or neutrons, such as carbon ions.

• Higher biological efficiency by a factor 1.5-3: Role in radioresistent tumors such as adenocarcinoma, adenoid cystic carcinoma, malignant melanoma and sarcoma• Due to the higher density of ionization, more DNA damage in cancer cells

• Disadvantage: Beyond the Bragg peak, the dose does not decrease to zero. since nuclear reactions between the carbon ions and the atoms of the tissue lead to production of lighter ions which have a higher range. Therefore, some damage occurs also beyond the Bragg peak.

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CIT plans often show a better dose distribution than the PT plans in head and neck patients due to the superb penumbra, which could lead to less toxicity.

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S.No

Series n Period Site Histology Treatment

RT dose

Median f/u

LocalControl

OS Toxicity

1. Koto et al (Japan)

22 1997-2010

Eth:11Max:5NC:6

Adeno Def: 16Salv:4Adj:2

57.6-64 GyEin 16fr

43 3y:61% 3y: 59%

Acute >G3:6 Late-visual loss:5, Brain necrosis:1

2. Jensen et al(German)

29 2009-10

Max sinus MC

AdCC MC Def:17Salv:9ReRT:2

73GyE (CI boost)

5.1m 50% response

- G3:7, G2:6No vision impairment

3. Yanagi et al (Japan)

72 1994-2004

Maligmelanoma

52.8-64GyE

49.2 85% 27% G3 or more none

4. Ohta et al (Japan)

3 2013 - AdCC:2SqCC:1

Sx+RT:1RT:2

64GyE/16fr

39.6m 100% - Visual loss:1

PROTON VS CARBON ION

70

Demizu et al. Particle therapy for mucosal melanoma of the head and neck:A single-institution retrospective comparison of proton and carbon ion therapy

DOSE DISTRIBUTUION

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CONVENTIONAL RT 3D-CRT

DOSE DISTRIBUTUION

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IMRT PROTON-BASED

73

Mock et al. Treatment planning comparison of conventional, 3D conformal, IMRT and proton therapy for paranasal sinus carcinoma.

STEREOTACTIC BODY RADIOTHERAPY(SBRT)

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• Accurately delivers a high irradiation dose to an extracranial target in one or few treatment fractions.

• Nearby tissues are affected as little as possible.

• Main advantage over IMRT: Shortened treatment time.

• SRS: Intracranial target, usually gives the whole radiation dose in one session.

• Offers high biological equivalent dose

• Main problem is complex planning

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• Delivery systems:• Robotic based Cyber Knife• Gamma Knife• LINAC Based

SBRT: EVIDENCE

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S.No

Series n Histology Treatment RT dose Median f/u

LocalControl

OS Toxicity

1. Vargo et al(Pittsburgh)

34 NonSqCC Reirradiation

40Gy/5# 10m 1y:59% 1y:59% G3 Acute:15%Late:6%

2. Roh et al (Korea)

36 NPx:8Max:8Neck:8NC:4

Reirradiation

18-40Gy/3-5#

17.3m 43%CR37%PR9%SD11%PD

-- G3 Acute:13Late:3 (necrosis)

3. Bourgeois et al (New York)

2 Melanoma R2 resection-SBRT

15Gy/1# - 7yrs8m

7yrs1y

Mild Epistaxis

4. Ozyigit et al (Turkey)

4 Melanoma R2 resection-SBRT

30Gy/3# 2y 50% 75% Nasal regurgitation

BRACHYTHERAPY

• Useful for: • Lesions of nasal cavity and external nares (vestibule)• Lesions on the septum or the mucosa medial to ala nasi• Preferable for relatively smaller lesions (T1/T2)

• Ir-192 wire implant or intracavitary mold is used

• Yields a 2-year local control of 86% and ultimate LRC of 100%*

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*Mazeron JJ et al the Groupe Europeen de Curietherapie. Radiother Oncol 1988;13:165-173

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Ir-192 wire implant

Perez & Brady's Principles and Practice of Radiation Oncology 6th Ed

BRACHYTHERAPY

• Recommended dose • LDR: 60-65 Gy over 5-7 days• LDR Boost: 20-25 Gy over 2 days [After EBRT 50 Gy]• HDR : 18 Gy @ 3Gy/# , 2#/d

• Dose prescription: • 0.5 cm lateral to the tumor for lateral nasal vestibule• At the center of the tumor for tumors of the septum

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Mould brachy: A custom mold of the nasal vestibule is made and 2-4 plastic tubes (1.0-cm apart) inserted in the mold alongside the tumor.

TREATMENT ACCOMPANIMENTS

ACUTE MORBIDITY• Fatigue

• Dermatitis, Skin erythema

• Mucositis – nasal > oral

• Xerostomia

• Conjunctivitis, epiphora, blurring of vision

• Alopecia

• Raised ICT

LATE MORBIDITY• Late skin effects – erythema, fibrosis,

telengectasia

• Atrophic mucositis – septal perforation

• Cataract, dry eye syndrome, optic neuritis, Chronic keratitis

• Xerostomia

• Facial asymmetry

• Osteoradionecrosis

• Second malignancies

• Neuro endocrine abnormalities(Hypopituitarism)

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TREATMENT DELIVERY AND PATIENT CARE

• Nasal cavity synechiae can be prevented by intermittent dilation of the nasal passages with a petroleum based jelly-coated cotton swab until mucositis has resolved.

• Dry mucosae can be managed symptomatically with saline nasal spray.

• Oro-dental hygiene

• Exercises to reduce trismus

• Prophylactic feeding tubes

• Ophthalmic review and Lubricating eye ointments

• If there is a pre-existing facial nerve palsy, the eyelid should be taped shut at night to avoid a dry eye.

• Pituitary function tests should be carried out annually during follow-up to evaluate late radiotherapy effects to the pituitary gland.

• Xerostomia can be an acute as well as late effect and can de decreased by administering Amifostine.

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CONCLUSION

• Sinonasal malignancies are uncommon and heterogenous group of tumors

• They usually present in locally advanced stages and surgery is the mainstay of treatment

• RT is often used in adjuvant settings and sometimes alone as definitive RT

• RT has advanced a long way from era of conventional RT to 3D conformal RT, IMRT and IGRT

• Modern techniques like Proton, IMPT and Carbon ion therapy have enabled dose escalation to tumor tissue and reduced normal organ toxicity

• SBRT/SRS has shown promise in delivering high dose per fraction, thus reducing the treatment time to a few days

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