Radiotherapy and Oncology, 21 (1991) 193-200

© 1991 Elsevier Science Publishers B.V. 0167-8140/91/$03.50

193

RADION 00854

Maxillary sinus carcinomas" natural history and results of postoperative radiotherapy G . L. J i a n g 1, K . K i a n A n g 1, L. J. P e t e r s 1, C. D . W e n d t 1, M . J. O s w a l d ~ a n d H . G o e p f e r t 2 Departments of lClinical Radiotherapy and 2Head and Neck Surgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, U.S.A.

(Received 30 October 1990, revision received 19 December 1990, accepted 13 march 1991)

Key words: Maxillary sinus carcinoma; Surgical excision; Palpable lymphadenopathy; Postoperative radiotherapy

Summary Between 1969 and 1985, 73 patients with maxillary sinus cancers underwent surgical excision and postoperative radiotherapy. The clinical stage distribution by the AJC system was 3 T 1, 16 T2, 32 T3, and 22 T 4. Six patients had palpable lymphadenopathy at diagnosis. Surgery for the primary tumor consisted of partial or radical maxillectomy, and if disease stage indicated it, ipsilateral orbital exenteration. This was followed by radiation treatment delivered through a wedge-pair or three-field technique. All but three patients received 50-60 Gy in 2 Gy fractions to an isodose line defining the target volume. Elective neck irradiation was not routinely given. Clinically involved nodes were treated with definitive radiotherapy (five patients) or combined treatment (one patient). Forty-five patients had no evidence of disease at the last follow-up. The 5-year relapse-free survival for the whole group was 51% The overall local control rate was 78 %. Patients with larger tumors, particularly if they also had histological signs of nerve invasion, had a higher recurrence rate than others. The overall nodal recurrence rate without elective neck treatment was 38 To for squamous and undifferentiated carcinoma, and only 5 % for adenoid cystic carcinomas. Therefore, our current recommendation is to deliver elective nodal irradiation routinely to patients with squamous or undifferentiated carcinoma, except for those who have T 1 lesions. Treatment complications were vision impairment, brain and bone necrosis, trismus, hearing loss, and pituitary insufficiency. The incidence of major side effects was determined by disease extent and treatment technique. Many technical refinements were introduced in order to limit the dose to normal tissues in an attempt to reduce the complication rate. To what extent such practice influences the outcome will be determined from subsequent analysis.

Introduction Carcinomas of paranasal sinuses are u n c o m m o n . The annual incidence in the United States is about 1/100 000 [16]. Clinical experience on this disease is thus relatively limited. In general, cancers o f p a r a n a s a l sinuses present a difficult therapeutic challenge because their indolent course leads most to be diagnosed at advanced stages. This problem is c o m p o u n d e d by proximity of critical structures such as the eye, the brain, and cranial nerves to the primary lesion that compromise wide surgical excision and radiotherapy plans. As a conse-

quence o f these factors, uncertainties and controversies exist with regard to the appropriate treatment strategy for this disease. Therefore, this retrospective study was undertaken to analyze the results o f postoperative radiotherapy for carcinomas o f the maxillary sinus in 73 patients treated over a span o f 16 years. Attention was paid to reviewing the pattern of failure as a function of stage and histology of the primary lesion, and the toxicity o f treatment. The outcome of this analysis has led to a change in the treatment policy in subsets of patients.

Address for correspondence and reprint requests: K. Kian Ang, M,D., Department of Clinical Radiotherapy, M.D. Anderson Cancer Center, 1515

Holcombe Blvd., Houston, TX 77030, U.S.A.

194 Material and methods

Patient characteristics The medical records of 124 previously untreated patients with maxillary sinus cancers who underwent treatment between January 1969 and October 1985 were reviewed. Ten patients with very extensive disease (such as intracranial extension) received palliative treatment and seven did not return for follow-up; they were excluded from the series. The data (medical history, physical findings, treatment, and outcome) of the remaining 107 patients were reviewed in detail. Seventy-three patients underwent surgery and postoperative radiotherapy, 3 preoperative radiotherapy, 27 definitive conventional radiotherapy and 4 with fast-neutrons treatment. This paper reports the outcome of surgery and postoperative radiotherapy for the 73 patients. Twenty-six patients (36~o) sought medical attention because of symptoms or signs induced by extension of tumor to the premaxillary region such as facial swelling, pain, and paresthesia of the cheek. Symptoms related to tumor spread to the nasal cavity (e.g. epistaxis, nasal discharge, or obstruction) or oral cavity (e.g. ill-fitting denture, gingival or palatal mass, or unhealed tooth socket after extraction) occurred in 20 (27~o) and 19 (26~o) patients, respectively. Five patients (7~o) presented with symptoms or signs of orbital invasion such as proptosis, diplopia, impaired vision or orbital pain. Nine patients had other presenting symptoms, and six had multiple symptoms. The interval from the first symptoms to diagnosis ranged from 1 to 60 months with a median of 5 months. Only 4~o of patients had a history of chronic sinusitis. The length of follow-up of this group of patients ranged from 9 to 182 months (median 83 months). The age of the patients ranged from 27 to 76 years (median 53 years). There were 41 men and 32 women. The distribution according to the histological type of malignancy was as follows: squamous cell carcinoma, 36; undifferentiated cancer, 9; adenocarcinoma, 6; adenoid cystic carcinoma, 20; and mucoepidermoid carcinoma, 2.

formed. The clinical stage distribution is shown in Table I. The site of origin within the maxillary sinus, supraor infra-structure, could not be determined retrospectively in the majority of patients. The surgical pathologic data for each patient were assessed to determine the pathological stage of the primary lesion. Records were insufficient to determine pathological stage in four patients because the anatomical landmarks were not reported in detail. The pathological nodal stage in 67 clinically No patients was not available since it is not the practice to perform routine elective neck dissections. Of the six patients who presented with clinically palpable nodes, only one (N2) underwent a neck dissection which showed involvement of 3 of 27 recovered nodes. Treatment of the primary tumor All patients underwent surgery at U . T . M . D . Anderson Cancer Center. The types of operations were modifications of partial or radical maxillectomy depending on the stage of the disease. Twenty-nine patients also had orbital exenteration because of evidence of involvement of the orbital wall or tumor extension into the orbital cavity. Review of the results of pathological examination of surgical specimens revealed that resection margins were negative in 54 patients (74~o). Fifteen patients (21 ~o) retained microscopic residue and two cases had gross disease remaining after surgery. The margins could not be assessed in two patients because of incomplete reports. Nerve invasion in surgical specimens were present in 42 of the 71 evaluable patients. The distribution of pathological stage was T~ 1; T 2 11; T 3 28; and T 4 29. Pathological stage could not be determined in four patients because of incomplete reports. Postoperative radiotherapy of the tumor bed was begun as soon as wound healing was judged sufficient. Sixty-three patients started irradiation treatment 3 to 6 weeks after surgery. The remaining patients began treat-

TABLE I

Staging In every patient disease was restaged according to the TNM classification of the American Joint Committee (1983). From 1969 to 1975, work-up consisted of physical examination, plain X-rays, and tomograms of the sinuses. After 1975 computed tomography (CT) scan was added as part of the routine assessment. Occasionally magnetic resonance imagery (MRI) was also per-

Clinical stage by AJC system at diagnosis. No

Nl

N2

Total

T4

3 15 30 19

0 1 2 1

0 0 0 2

3 16 32 22

Tot~

67

4

2

73

Tl T2 T3

195 ment from 7 to 16 weeks after surgery. Therapy was carried out with a telecobalt unit in 64 patients; the remaining patients received part of the treatment with cobalt and the other part (boost dose) with a linear accelerator. A three-field technique (1 anterior and 2 lateral wedged) was used in 50 patients and a wedgepair in 20 patients, in portal arrangements that have been described [6]. The remaining three patients received radiotherapy by slightly modified techniques such as combination of three-field and wedge-pair, anterior field with wedge-pair. Of the 44 patients without orbital exenteration, 14 received radiation treatment to the entire ipsilateral orbit. Lens block (1.5 cm diameter) only was used in four patients and lacrimal gland block (covering superior-lateral quadrant of the orbit) only in two patients. The ipsilateral eye was shielded in the remaining 24 patients. The contralateral eye was shielded in all patients. Patients with negative resection margins received total tumor doses ranging from 42 to 60 Gy and those with positive margins from 50 to 66 Gy (Fig. 1). Treatments were given at 2 Gy per fraction. It was customary to prescribe the dose to the isodose line encompassing the target volume. The maximal dose in part of the tumor bed was 10-20~o higher than the prescribed dose.

Treatment ofneck nodes Of the six patients presenting with palpable nodes at diagnosis, five received definitive radiotherapy for the nodal disease. The dose was 50-60 Gy in 25-30 fractions (5-6 weeks) to the whole neck bilaterally (four patients) or ipsilaterally (one case) followed by a

m

4-20 Gy boost to the involved nodes in 2 Gy fractions. One patient underwent neck dissection and then received 50 Gy in 25 fractions to the ipsilateral neck. Seventeen of the 67 patients (16 with squamous or undifferentiated lesions and one with adenoid cystic carcinoma) presenting with no palpable node received elective nodal irradiation concurrent with postoperative irradiation of the primary tumor bed. The reason for delivering elective irradiation was unclear. The technique and extent of neck irradiation varied during this period. Irradiation was delivered to ipsilateral upper neck using appositional electron beam in two patients, to bilateral upper neck through lateral-opposed cobalt fields in five patients. Three patients received irradiation to ipsilateral upper and lower neck (down to the clavicles) with opposing AP-PA fields (2) or appositional electron fields (1). Seven patients received treatment to both sides of the neck, three with anterior cobalt field with midline block, and four with lateral-opposed cobalt fields to the upper neck matched with anterior cobalt field to the lower neck. The dose of elective neck treatment was 50 Gy in 25 fractions over 5 weeks. The clinical stage of the primary tumor of" patients receiving elective neck treatment was T 2 in 2 patients, T3 in 10 patients, and T4 in 5 patients. The stage was slightly more advanced compared to that of 50 patients not receiving elective neck treatment (T, 3; T 2 13; T 3 20; and T4 14).

Salvage treatment

Margins:

Patients with relapse at the primary site underwent further surgical excision when operable. Patients developing isolated nodal recurrences were treated with radiotherapy alone or surgery and radiotherapy. The technique of radiotherapy in general was as described above.

Positive

Data analysis

Negative

t

42

46

50

54

58

62

66

Dose (Gy)

Fig. 1. Radiation dose to primary tumor bed in patients with negative (open bars) and positive (solid bars) surgical margins.

The endpoints of this study were local and regional tumor control, survival, and incidence (and type) of complications. Disease control was presented as an actuarial relapse-free survival (RFS) and disease-specific survival (DSS) rates. In RFS, patients with recurrences were counted as failures regardless of the outcome of rescue treatments, whereas in D S S patients who had been salvaged were considered successes. Patients dying from intercurrent diseases were censored. The actuarial overall survival of this group of patients was also estimated according to the BerksonGage method [3]. Tests for significance were done by the chi-square or Lee-Desu procedure [14].

196 Results

1.o.

Disease status and survival

0.8.

At the time of analysis, 45 patients (61%) had no evidence of disease. Table II summarizes the pattern of failure after initial therapy and after salvage. The actuarial overall survival at 5 years after completion of treatment was 48~o. The 5-year RFS and DSS was 51 and 64~o, respectively (Fig. 2).

.............. '~

0.4-

"................. " " ' " ' " ' , DR

Disease

Specific

--

Relapse

l~i'ee

................

Overall

0.2--

Local control

\

0.0

--

o

~

i~

Year~

Primary disease control was achieved in 57 patients (78%). Recurrences manifested within 2 years from completion of treatment in 12 of 16 patients (range 2-41 months). The sites of failure in 16 patients were the remaining maxillary cavity (4), orbit (3), cranial fossa (3), pterygomaxillary region (2), nasopharynx (1), sphenoid (1), ethmoid (1), hard palate (1), alveolar ridge (1), and soft palate (1). Two patients had relapses at two sites. The three local recurrences in patients with adenoid cystic carcinomas were all located at the base of skull region. Squamous cell and undifferentiated lesions recurred predominately in the remaining maxillary cavity, orbit and pterygomaxillary space. Recurrence occurred inside the radiation field in 10 patients, at the margin of the port in four cases, and at both locations in two. Table III shows the influence of disease and treatment variables on the primary control rate. Owing to the limited number of patients in each subgroup, none of the parameters influenced the primary control rate significantly except for nerve invasion (p = 0.05). Within the dose range used, no doseresponse relationship was found (data not shown). Salvage surgery was attempted in one patient. This resulted in a temporary (15 month) control. The other 15 patients with local recurrences received supportive care (10) or chemotherapy (5). They died of the disease 1 to 21 months after diagnosis of relapse.

T A B L E II P a t t e r n of failure in 73 patients. Relapse After initial treatment After salvage therapy

L

R

L+R

10

10

1

II

0

1

DM

L+DM

R+DM

8

3

1

11

4

1

L = local; R = regional; D M = distant metastasis.

Fig. 2. Actuarial disease-specific, relapse-free, and overall survival rates for the entire group.

Nodal spread and control

Six of 73 patients (8 ~o) had palpable lymphadenopathy at diagnosis (see Table I). Of the 50 patients without palpable lymphadenopathy who did not receive elective neck treatment, 11 (22~o) developed nodal relapse (Table II). In six patients nodal failure had manifested itself by the end of the course of postoperative radiotherapy to the primary tumor bed, and in the remaining five patients nodal recurrence was detected at 2, 3, 5, 21, and 54 months after treatment, respectively, Combining the patients who presented with nodal disease and those who relapsed in the neck without elective irradiation gives a rate of nodal involvement of 30~o (17/56) for this series of patients. There was no difference in the incidence of nodal spread between patients with clinical stage T 2 (5/14), T 3 (8/22), o r T 4 (4/17) tumors (p = 0.66). None of the three patients with T1 disease developed nodal metastasis. The histological type of the primary, however, was found to be a strong determinant, with the great majority of nodal metastases being associated with squamous cell or undifferentiated primary cancers (Table IV). The grade of differentiation of squamous cell carcinoma had no significant influence on the incidence of nodal metastasis. In six patients presenting with lymphadenopathy (N1 or Nz), nodal disease was controlled by definitive radiotherapy (5) or combined treatment (1). One patient developed a relapse in the contralateral, untreated neck. This was controlled by surgery and postoperative radiotherapy. Subsequently, this patient developed failures at distant sites. In none of the 17 patients receiving elective neck irradiation did failure appear in the draining lymphatics. Eleven of 50 patients not undergoing prophylactic neck

197 TABLE III Influence of disease and therapy variables on the treatment outcome. Variables

( 1) Pathological T-Stage ~ T1 ~2 T3 T4 (2) N-Stage NO Nl_2 (3) Histology Squamous cell carcinoma Undifferentiated Adenocarcinoma Adenoid cystic carcinoma Mucoepidermoid (4) Nerve invasion a No Yes (5) Margin of resection a Negative Positive (6) Elective nodal treatment No Yes

No. of patients

5-Year local control (Yo)

5-Year regional control (yo)

Incidence of D M at 5 yrs ( % )

5-Year RFS (~o)

5-Year DSS (%)

12 28 29

91 77 65

71 80 93

17 25 37

64 57 44

75 69 59

67 6

74 67

84 82

27 c 48 b

53 33

66 c 33

36 9 6 20 2

62 89 80 82 (2/2)

86 67 67 94 (2/2)

17 c 50 39 31 (0/2)

49 53 42 60 (2/2)

53 42 60 84 (2/2)

29 42

90 c 64

86 80

20 36

74 c 37

78 57

54 17

74 77

86 76

17 32

58 38

66 66

50 17

77 61

80 100

31 c 0

51 61

58 68

Excluding patients, whose pathological reports were not complete. b Including 11 patients, who did not receive elective neck treatment, and developed nodal recurrence. c Significant at 0.05 level. DM = distant metastasis; RFS = relapse-free survival; DSS = disease-specific survival.

treatment developed nodal recurrence, 4 at submandibular (3 ipsilateral and one bilateral) and 7 at ipsilateral subdigastric nodes. Nine of these 11 patients had isolated neck recurrences. Four of them underwent definitive radiation therapy (61-70 Gy/30-35 fractions/5-7 weeks), and the other 5 received combined treatment (surgery and radiotherapy). These resulted in regional control in all nine patients. Unfortunately, 5 patients eventually died of the disease (distant

metastases 3; primary recurrence 1; and distant metastasis + local disease 1). Two patients experienced nodal recurrence along with a large primary relapse or distant metastasis. They received palliative care. Distant metastasis

In 17 patients (23~o) failures appeared at remote sites (lung 15; brain 3; bone 2; liver 1; and subcutaneous

TABLE IV Incidence of neck node involvement by histological type of the primary tumor (excludes 17 patients who received elective neck irradiation). Histology

No. of patients presenting with positive node ( ~o)

No. of patients who developed nodal recurrence without elective neck treatment (}o)

Squamous cell carcinoma Undifferentiated tumor Adenocarcinoma Adenoid cystic carcinoma Mucoepidermoid

5/23 (22~o) 0/6 1/6 0/19 0/2

6/18 (33~o) 3/6 (50~o) 1/5 1/19 (5%) 0/2

p = 0.007 (overall difference).

198 tissues 1). Sixty percent of the distant metastases manifested within 2 years after completion of treatment. Surgical resection of lung metastasis was attempted in 4 patients (3 with adenoid cystic carcinoma, and 1 with squamous cell carcinoma). One patient with adenoid cystic carcinoma was alive with no evidence of disease 44 months after resection. The remaining patients died of the disease 5, 31, and 60 months after resection, respectively. The influence of disease and treatment variables on the incidence of distant metastases is presented in Table III. Variables that significantly influenced incidence were the nodal status ( p < 0 . 0 1 ) , histology (p = 0.04), and nodal treatment (p = 0.03). There was a marked variation in the timing of occurrence of lung metastasis and the length of survival after its diagnosis. Both parameters were strongly determined by the histology of the primary lesion. Six of the 7 patients with squamous cell carcinoma or undifferentiated cancer developed lung metastasis within a year (median = 9 months) after completion of treatment, whereas only 1 of the 8 patients with adenocarcinoma or adenoid cystic carcinoma did so in the same period (p < 0.01). The length of survival after diagnosis of lung metastasis was 1-19 (median 5) months and 14-81 (median 29) months, respectively.

Treatment complications Radiation-induced ocular complication Ipsilateral radiation-induced vision impairment was assessed in the 44 patients who did not undergo eye enucleation. Of the 24 patients treated with eye shields of various sizes, one developed blindness accompanied by severe conjunctivitis 7 months after treatment. Histological examination of the enucleated eye showed optic nerve necrosis. Of the two patients who received radiation treatment with shielding of the ipsilateral lacrimal gland, one developed ipsilateral blindness because of optic nerve and retinal degeneration 3 years

after treatment, and the other had normal vision 10 months after therapy. Three of four patients treated with small lens block only developed ipsilateral blindness (35-50 months post-therapy) due to keratitis. Fourteen patients received irradiation to the whole ipsilateral orbit, mostly with a wedge-pair technique. Eight patients lost their vision from 1 to 24 months after treatment because of corneal damage or necrosis of the anterior segment of the eye, and 3 developed blindness or severe vision impairment (~< 20/200) as the consequence of retinal degeneration occurring 6 to 19 months after completion of radiation. The remaining three patients died with normal vision shortly after treatment. Four patients developed bilateral blindness. The contralateral vision impairment was due to injury to the chiasm (3) or contralateral optic nerve (1). The causes of loss of ipsilateral vision were exenteration (2) and corneal injury (2). The details of the time-dose parameters of optic pathway injury will be reported in another paper. The incidence of mild cataract could not be determined since no detail record was available.

Other complications Table V summarizes the types and incidences. The diagnosis of brain necrosis was made on clinical findings and CT scan, and confirmed by histological examination. The radiation doses to the area of brain necrosis, estimated retrospectively from the isodose curves were 63 to 72 Gy, delivered in 30 fractions (2.1-2.4 Gy per fraction) over 6 weeks. Four patients underwent resection of necrotic tissue, which improved neurologic symptoms in three. Two of these patients subsequently died of intercurrent disease, one of progression of the neurologic deficit and the other of primary tumor recurrence. The fifth patient received symptomatic treatment after biopsy and was alive with minimal discomfort and no evidence of disease at the last follow-up visit. Bone necrosis occurred at the margin of resection

TABLE V Type and incidence of treatment complications occurring in 73 patients. Type of side effect

No. of patients (%)

Latent period: range (median) in months after RT

(1) (2) (3) (4) (5) (6)

5 (7) 4 (5) 2 (3) 9 (12) 3 (4) 3 (4)

5-73 (10) 1-17 (9) 17, 74 0-4 60-72 3, 7, 48

Brain necrosis Bone necrosis requiring debridement Soft tissue necrosis/fistula Trismus* Pituitary insufficiency Hearing loss

* Excluding patients whose eyes were intentionally irradiated because of orbital invasion (see text).

199 except in one patient who had received elective neck irradiation and developed osteonecrosis of the mandible. One patient who had soft tissue and bone necrosis died of malnutrition accompanied by chronic infection. Nine patients had severe trismus. Tumor extension, surgery and radiation therapy all contributed to the pathogenesis of this side effect. Pituitary insufficiency and hearing loss occurred in patients with large tumors requiring generous radiation fields. Minor side effects were transient facial cellulitis (4), otitis media (19), and hypothyroidism (1). Discussion There is strong evidence that the combination of surgery and radiotherapy yields the best results in patients with maxillary sinus tumors. The reported 5-year local control and survival rates after recombined treatment are 53-68~o and 39-64~o, respectively [2,4,8,10,11,13,15, 20-23]. The corresponding figures for radiotherapy alone are 22-39~o and 22-40~, [ 1,2,4,7,17,20,22]. The data from a few series on surgery only show a 5-year survival rate of 20-30~o [ 1,10,12,22] ; the local control rate with surgery alone was not provided. The overall 5-year local control and RFS rates of this series were 78~o and 51 ~o, respectively. We found, however, that the local control rate was significantly lower in patients with evidence of nerve invasion than in those without it (64~o vs. 90~o). Since local recurrence was a major cause of death, it is prudent to test whether a more aggressive postoperative radiotherapy (i.e. a wider coverage of the area up to the Gasserian ganglion in adenoid cystic carcinomas or a tumor dose of 64-66 Gy to the boost field given in 2 Gy fractions in squamous cell carcinomas) would result in a better outcome in this subset of patients. The control rate in patients with a T 4 disease was slightly lower than those with earlier stages. In such patients, radiation treatment was usually comprised by the proximity of critical normal tissues to the target volume; therapy had to be individualized in order to deliver the desired dose. Another relevant finding from our analysis was that the histological type of the primary lesion was a strong determinant of the nodal recurrence rate. Without elective lymphatic treatment, only 5~o of patients with adenoid cystic and mucoepidermoid carcinomas developed nodal recurrence. In contrast, the incidence of nodal relapse in patients with squamous cell and undifferentiated carcinomas who did not receive elective neck irradiation was as high as 38 ~o. The recurrences in the latter group were evenly distributed among patients with T2, T3, o r T 4 primaries. Our data are thus in disagreement with the other reports and general belief

that nodal spread is infrequent in maxillary sinus cancers and that it occurs predominantly after tumors have extended into an area rich in capillary lymphatics [4,9,18,19]. Although regional control was obtained in all patients with isolated nodal recurrence with subsequent treatment, the 10-year DS S of this subgroup was 34~o. In contrast, none of the 17 patients who received elective neck irradiation developed nodal recurrence. The 10-year DSS of the latter group was 58%. Based on these data, our recommendation is to deliver elective nodal treatment to patients with T2_4 squamous cell or undifferentiated carcinomas. Distant metastasis occurred in about a quarter of the patients. The lung was the site of predilection. A noteworthy observation was that patients with adenoid cystic carcinomas and adenocarcinomas survived significantly longer than those with squamous cell carcinomas and undifferentiated cancers after detection of lung metastasis. This is particularly true if lung metastasis was evident more than a year after completion of treatment. Resection of lung metastasis should be considered, when possible, in the former patient group since this could result in years of symptom-free survival, and perhaps even occasional cures. One patient was alive without evidence of disease 44 months after removal of a lung nodule. The greatest hazard in treatment of carcinoma of maxillary sinus is injury to the eyes and optic pathway. The overall incidence of contralateral blindness was 5 ~o in this series of patients treated over a time span of 16 years. With advances in radiotherapy technique it should be possible to reduce this incidence by limiting the dose to the chiasm and contralateral optic nerve to less than 60 Gy, and by avoidance of hot spots that result in both a higher total tissue dose and a larger fraction size than prescribed. The fate of the ipsilateral eye depends on the extent of the tumor relative to the orbital cavity. Although the whole orbit must sometimes be irradiated, it is frequently possible to spare the lacrimal gland and part of the globe even when the tumor has invaded the orbital floor. In this series, the complication rate was high when a wedge-pair technique was used mostly during the earlier half of the study period. On the other hand, the incidence was 4~o when a three-field technique was used and the ipsilateral orbital cavity could be shielded. Necrosis of the frontal lobe occurred in five (7~o) patients. This complication developed when a very generous superior margin was taken to encompass possible intracranial spread. Better imaging techniques and documentation of the surgical findings now allow us to avoid such large margins in the great majority of patients. In terms of treatment of brain necrosis, we

200 found that surgical removal o f the necrotic debris resulted in a rapid relief o f s y m p t o m s as was observed by E d w a r d s and Wilson [5]. In summary, this retrospective study has p r o d u c e d information contributing to the understanding o f the natural history, pattern o f failure, and toxicity o f treatment o f cancers o f the maxillary sinus. This information has resulted in adjustment o f our treatment policy: in particular, we n o w deliver elective ipsilateral neck irradiation in patients with T2_4 squamous or undifferentiated carcinomas, extend the portals to encompass the base o f skull more generously, including the Gasserian ganglion, in patients with adenoid cystic carc i n o m a and in those having perineural invasion, and

adjust the technique for individual patients to reduce the dose to normal tissues. A water-filled balloon is used to reduce the size o f the air cavity in order to diminish the dose inhomogeneity within the target volume to less than 10%. Further follow-up will show whether the change in the treatment strategy will lead to an improvement o f results.

Acknowledgement This investigation was supported by grant CA06294 awarded by the National Cancer Institute, United States D e p a r t m e n t of Health and H u m a n Services.

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14 Lee, E. and Desu, M. A computer program for comparing k samples with right-censored data. Compr. Prog. Biomed. 2: 315-321, 1972. 15 Lindeman, P., Eklund, U. and Petruson, B. Survival after surgical treatment in maxillary neoplasm of epithelial origin. J. Laryngol. Otol. 101: 564-568, 1987. 16 Million, R. R., Cassisi, N. J. and Hamlin, D.J. Nasal vestibule, nasal cavity and paranasal sinuses. In: Management of Head and Neck Cancer, pp. 407-444. Editor: R. R. Million and N. J. Cassisi. Lippincott Co., Philadelphia, 1984. 17 Olmi, P., Cellai, E., Chiavacci, A. and Fallai, C. Paranasal sinuses and nasal cavity cancer: different radiotherapeutic options, results and late damages. Tumori 72: 589-595, 1986. 18 Parsons, J.T., Mendenhall, W.M., Mancuso, A.A., Cassisi, N. J. and Million, R.R. Malignant tumors of nasal cavity and ethmoid and sphenoid sinuses. Int. J. Radiat. Oncol. Biol. Phys. 14: 11-22, 1988. 19 Pezner, R. D., Moss, W. T., Tong, D., Blasko, J. C. and Griffin, T.W. Cervical lymph node metastases in patients with squamous cell carcinoma of maxillary sinus. Int. J. Radiat. Oncol. Biol. Phys. 5: 1977-1980, 1979. 20 Sakai, S., Hohki, A., Fuchihata, H. and Tanaka, Y. Multidisciplinary treatment of maxillary sinus carcinoma. Cancer 52: 1360-1364, 1983. 21 Schlappack, O. K., Dobrowsky, W., Schratter, M., Grasl, M., Schmid, A.P., Swoboda, H., Mallath, G., Pavelka, R. and Braun, O. Radiotherapy for carcinoma ofthe paranasal sinuses. Strahlenther. Onkol. 162: 291-299, 1986. 22 St-Pierre, S. and Baker, S. Squamous cell carcinoma of the maxillary sinus: analysis of 66 cases. Head Neck Surg. 5: 508-513, 1983. 23 Tsujii, H., Kamada, T, Arimoto, T., Mizoe, J., Shirato, H., Matsuoka, Y. and Irie, A. The role of radiotherapy in the management of maxillary sinus carcinoma. Cancer 57: 2261-2266, 1986.

Maxillary sinus carcinomas: natural history and results of postoperative radiotherapy.

Between 1969 and 1985, 73 patients with maxillary sinus cancers underwent surgical excision and postoperative radiotherapy. The clinical stage distrib...
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