This document discusses carcinoma of the maxilla, including epidemiology, histology, clinical presentation, staging, investigations, management, and prognosis. Squamous cell carcinoma is the most common type, presenting more in men in the 5th-6th decade. Clinical evaluation includes imaging like CT and MRI to determine extent. Treatment involves surgery like maxillectomy with clear margins followed by postoperative radiation therapy to improve outcomes. Prognosis remains poor at a 5-year survival of 35-45% even with multimodality treatment. A case example is presented of a 58-year-old female smoker found to have cT2N0M0 carcinoma of the left maxilla who underwent subtotal maxillectomy followed

1. CARCINOMA MAXILLA
MANAGEMENT
Dr. Paul George
Radiation Oncology
Regional Cancer center
Trivandrum

2. NASAL CAVITY & PARANASAL SINUSES
Epidemiology
Incidence
0.5-1/100,000 per year
0.2-0.8% of all malignancies
3% of upper aerodigestive tract neoplsm
5th-6thdecade
White race
M:F=2:1 – 4:1

4. SQUAMOUS CELL CARCINOMA
Most common histological type
70% maxillary sinus
Male predominance
Older age group
Enviornmental exposure: leather tanner, nickel
refinery, thorotrast
Adenoca(10-20%), adenocystic ca(<10%), sinonasal
melanoma(<4%), esthesioneuroblastoma,
sinonasal undifferentiated carcinoma, lymphoma,
sarcoma , plasmacytoma

6. How to Proceed
1.HISTORY & Physical exam
2.Radiography (CT, MRI)complete head & neck.
3.BIOPSY
4.Chest imaging
5.dental/prosthetic consultation as indicated
STAGING

7. HISTORY & PHYSICAL EXAMINATION

9. Anatomy of maxillary antrum
• Anterior : soft tissue
of face .
• Posterolateral : ITF ,
pterygopalatine F
• Superior : Inferior
orbital plate .
• Inferiorly : hard
palate ,superior
alveolar ridge

10. PATTERN OF TUMOUR SPREAD

11. Patterns of tumour spread
Anteriorly: cheek, skin
Posteriorly: pterygopalatine fossa, infra temporal
fossa, temporal bone middle cranial fossa
Medially: nasal cavity,NLD
Laterally: cheek, skin
Superiorly: orbit, ethmoid sinuses
Inferiorly: palate, buccal sulcus

12. CLINICAL PRESENTATION
• 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 (OME)
Neurological: cranial nerve deficits II,III,IV.V1,V2,VI
10% nodal
Distant mets: rare

13. H & P examination
• The sinonasal, ocular, and neurologic systems
should be studied in detail
• Ant & post rhinoscopy
• Nasal endoscopy

14. RADIOLOGICAL EXAMINATION
Radiographic studies are essential as the full
extent of a sinonasal neoplasm cannot be
established even with modern fiberoptic
technology.
Both CT& MRI are the effective ways to
delineate the extent of tumor extracranially and
intracranially.

15. Computed Tomography
Bone erosion
Key areas include the bony orbital walls,
cribiform plate, fovea ethmoidalis, posterior wall
of the maxillary sinus, pterygopalatine fossa, the
sphenoid sinus, and the posterior table of the
frontal sinus.
85% accuracy
Difficult
periorbital involvement
Difficult to differentiate between: Tumor vs. inflammation
vs. secretions

16. MRI
• 94% accuracy
• Inflammatory tissue & secretions:
intense T2
• Tumor: intermediate T1 & T2,
Enhancement with Gadolinium
• MRI is excellent for determining
perineural spread, involvement of
the dura, or involvement
intracranially.

17. BIOPSY
Transnasal
medial wall of maxilla is the preferred route
Needle biopsy is sufficient
Biopsy via Caldwell-Luc approach (canine fossa
puncture) is not recommended because of the
potential to seed the gingivobuccal sulcus and
cheek skin with tumor.

19. STAGING

21. Ohngren’s Line
a line that is drawn
from the angle of
mandible to the medial
canthus.
Ohngren indicated that
tumors that presented
above this line
(suprastructure); both
superiorly and
posteriorly, tended to
have a worse prognosis

23. MANAGEMENT
1.SURGERY
2.RADIOTHERAPY
3.CHEMOTHERAPY:VERY LIMITED ROLE

24. SURGERY
Surgical approaches:
•
•
•
•
•
•
Endoscopic
Lateral rhinotomy
Transoral/transpalatal
Weber fergussen
Midfacial degloving
Combined craniofacial approach
Extent of resection
• Medial maxillectomy
• Inferior maxillectomy
• Total maxillectomy

25. Weber fergussen approach
tumors involving the
maxilla extending
superiorly to the
infraorbital nerve and
into the orbit.
Wide access to all areas
of the maxilla
and orbital floor.

26. Midfacial Degloving
Nasal cavity tumors with
bilateral involvement
Most suited for inferiorly
located tumors.
Subperichondrial plane of nasal septum

27. 

Inferior medial
maxillectomy
Medial maxillectomy


Cranio-facial resection
Radical maxillectomy
with exentration

28. Surgical procedures
 The goal of surgery for nasal cavity and paranasal sinus
tumors is to achieve en bloc resection of all involved bone and
soft tissue with clear margins while maximizing the cosmetic
and functional outcome.
 Limited nasal cavity lesions may be resected with medial
maxillectomy.
 Ethmoid lesions usually require medial maxillectomy and en
bloc ethmoidectomy.
 combined craniofacial procedure for lesions involving the
inferior surface of the cribriform plate ,the roof of the
ethmoid & frontal sinus.
 Multidisciplinary skull base approach has improved the
outcome

29. UNRESECTABILITY
Unresectable tumors:
• Superior extension: frontal lobes
• Lateral extension: cavernous sinus
• Posterior extension: prevertebral fascia
• Bilateral optic nerve involvement
• Distant Metastasis
Reconstruction after surgery is done with
microvascular free flap & maxillofacial obturator
prosthesis

30. RADIOTHERAPY


Addition of RT to surgery improve 5-years survival (44%) when
compared to RT alone (23%) or surgery alone.
Indications:
Definitive :medically inoperable or who refuse radical surgery or early lesions
Adjuant:
Palliative:

Pre- and postoperative radiation may result in similar control rates.
But post-operative RT preferred:
Preoperative radiation
increases the infection rate and the risk of postoperative wound complications.
Preoperative radiation may obscure the initial extent of disease=surgery can not
remove the microscopic extensions of the tumor.
• Postoperative radiation therapy is started 4 to 6 weeks after surgery.

31. RADIOTHERAPY TECNIQUES
1.CONVENTIONAL 2D
2.CONFORMAL 3D
3.IMRT

32. 2D CONVENTIONAL: 3field tecnique
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.

33. ANTEROR FIELD

34. LATERAL FIELD

36. • Field Margins:
a three-field technique for maxillary antrum: 1 anterior and 2 lateral
fields.
Anterior field:
superior border: above the crista galli to encompass the ethmoids.
in the absence of orbital invasion, at the lower edge of
the cornea to cover the orbital floor.
inferior border: 1 cm below the floor of the sinus.
medial border: 1 to 2 cm (or more if necessary) across the midline
cover contralateral ethmoidal extension.
lateral border: 1 cm beyond the apex of the sinus or falling off the skin.
Lateral fields:
superior border: follows the floor of anterior cranial fossa.
anterior border: behind the lat canthus parallel to the slope of face.
posterior border: covers the pterygoid plates.

37. Anterior field:
When ther is no gross involvement of the orbit,
the cornea, lens & lacrimal gland are shielded
from the anterior field
If there is disease in the orbit, cornea is spared
by cutting out the cast and treating with the eyes open
Lateral field:
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
Anterior beam is weighed as 2:1 to that of lateral beam
Dose prescription:65Gy/32# or 55Gy/20#

38. ISODOSE DISTRIBUTION

39. 3D CONFORMAL
4 Field
1. Anteror
2. two lateral portal
3. Intraorbital electron portal to make up the dose to post nasal
cavity, ethmoid sinus & medial orbit

40. CT SIM
A CT scan is performed with 3 mm slices from
2cm superior to the superior orbital ridge to the
hyoid bone (but extended to include the low
neck if neck nodes are to be treated).

41. TARGET VOLUME DELINEATION
The CTV should encompass
• all initial sites of disease(presurgery GTV),
• The mucosa of adjacent compartments of the sinonasal
complex and
• a 10 mm margin at least from initial sites of GTV where no
good bony barrier to invasion exists
(e.g. masticator space, cribriform plate and infraorbital fissure)
• Bony orbit if involved
For most tumours, the CTV will include the ipsilateral maxillary
sinus and bilateral nasal cavity and the ethmoid sinuses.
The CTV is expanded isotropically (usually by 3–5 mm)to form
the PTV

43. Where a craniofacial excision has been carried out, the CTV should
extend 10 mm superior to the cribriform plate or 10 mm superior to
Initial sites of disease, whichever is greater
If the primary was close to or invading the nasopharynx, the adjacent
Ipsilateral retropharyngeal nodes should be included in the CTV.
When cervical node radiotherapy is indicated, the intraparotid nodes,
level Ib and superior level II nodes can be included in the CTV.
Elective neck nodal radiation is not recommended

44. ORGAN AT RISK
include the
1.lenses,2. lacrimal glands (in the superolateral
orbit and upper eyelid), 3.optic nerves and
chiasm, 4.spinal cord, 5.brainstem and
6.pituitary gland

45. OAR & possible complications of RT
•
•
•
•
Lens <10 Gy (cataracts)
Lacrimal gland <30–40 Gy (dry eye syndrome)
Retina <45 Gy (blindness)
Optic chiasm and nerves <54 Gy at standard fractionation.
(Optic neuropathy)
•
•
•
•
Brain <60 Gy (necrosis)
Mandible <60 Gy (osteoradionecrosis)
Parotid mean dose <26 Gy (xerostomia)
Pituitary and hypothalamus mean dose <40 Gy.

46. IMRT
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
IMRT has been shown to be useful in
reducing long-term toxicity by
reducing the dose to salivary glands,
temporal lobes, auditory structures,
and optic structures

47. IMRT

49. Complications of RT
Acute:
mucositis, skin erythema, nasal dryness,
Xerostomia
Late: xerostomia, chronic keratitis and iritis,
optic pathway injury , osteoradionecrosis,
cataracts, radiation induced hypopituitarism

50. Dose fractionation
Definitive RT: 70Gy , 2G/# over 7 wks
Adjuvant
60 Gy in 30 daily fractions given in 6 weeks.
66 Gy in 33 daily fractions if possible where
there is residual disease.
Palliative
36 Gy in 6 fractions of 6 Gy treating once weekly.

51. Treatment delivery and patient care
Patients are seen weekly during treatment in a
multidisciplinary clinic.
• Exercises to reduce trismus
• Prophylactic feeding tubes should be considered
• ophthalmic review .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.

52. Role of chemotherapy
• Neoadjuvant chemotherapy is sometimes offered in
order to reduce tumor volume, which may permit
removal of tumor with a less morbid resection or
facilitate radiotherapy planning if shrinkage pulls
away tumor from critical structures.
• chemotherapy may be given concurrent with
radiotherapy in the management of inoperable
tumors on the basis of improved results in more
frequent head and neck carcinomas.

53. FOLLOW UP
H&P, labs every 3 months for first
year,
Every 4 months for second year,
Every 6 months for third year, then annually.
Imaging of the H&N at 3 months post treatment,
then as indicated

54. STAGEWISE MANAGEMENT OF CARCINOMA
MAXILLA

55. Stage I / II (T1-T2, N0)
SINGLE MODALITY TREATMENT
DEFINITIVE RT/SURGERY
• If perineural invasion by the tumor, Adjuvant RT
(±Chemo)

56. LOCALLY ADVANCED
T3-T4a, N0( resectable)
SURGERY
POSTOP RT
If margins are positive, ChemoRT to
the primary

57. Node + Stage
SURGERY WITH NECK DISSECTION
If margins positive or ECE,
POSTOP RT
ChemoRT
Elective neck nodal irradaition is not routinely
recommended

58. VERY LOCALLY ADVANCED
T4b , unresectable
PS 0,1 : RADICAL CHEMORT/ Induction chemo
followed by chemoRT
PS2: RADICAL RT
PS3: PALLIATION

59. Locoregional Reurrence/residual:
Salvage surgery/Reirradiation +/_chemo/clinical
trial
Distant mets: palliative chemo/Best supportive
care

60. PROGNOSIS
Even with multimodality treatment average
5year median survival of carcinoma maxilla is
only 35-45%

61. CLINICAL SCENARIO

62. INDIRA 58/F
HOUSE WIFE
REPORTED IN
B CLINIC 3/6/13
Complaints
Left Nasal discharge 15mnths
Left nasal block 6months
ECOG PS 1 GC;good

63. INVESTIGATIONS
Trans nasal biosy left maxilla:
Poorly diff carcinoma

68. CA MAXILLA
Staging…….?
Management…………….?
cT2N0M0
RT/SURGERY….?
ADJUANT Rx…?

69. Cacinoma maxilla: cT2N0M0
MANAGEMENT
SUBTOTAL MAXILLECTOMY on 21/08/13
HPE:
Non keratinising scc with bone erosion
close margin <0.1cm from lateral margin
Other margins free

70. Postop RT 55Gy/20#

72. Thank you…….
Dr. Paul George