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Case R eport
REVISTA PAULISTA DE MEDICIN AFrontal sinus ade nocarcinoma
Universidade Federal de São Paulo / Escola Paulista de Medicina, São Paulo, Brazil
a b s t r a c t
CO N TEX T: Paranasal sinus cancer is co nsidered rare, with an inci-dence o f less than 1 per 1 0 0 ,0 0 0 per year, with the fro ntal sinus being the primary site in o nly 0 .3 %. W e repo rt a case o f adeno car-cino ma arising in the fro ntal sinus.
DESIGN : Case repo rt.
CASE REPO RT: A 5 9 -yea r-o ld wo ma n, sec reta ry, c a me in Feb ru-a ry 1 9 9 8 with ru-a 4 -mo nth histo ry o f lo w intensity fro ntru-a l heru-a dru-a c he. She denied c o nta c t with wo o d dust. O n exa mina tio n a no n-tender swelling wa s no ted o ver her rig ht fo rehea d next to the media l a s-pec t o f the rig ht o rb it. CT sc a n sho wed a so ft-tissue ma ss invo lving fro nta l sinus with intra c ra nia l inva sio n thro ug h the po sterio r wa ll. The a nterio r ethmo id sinus a nd the media l a spec t o f the rig ht o rb it were a lso invo lved. MRI demo nstra ted dura l thic kening in c o mmu-nic a tio n with the fro nta l ma ss. She underwent a n en-b lo c tumo r resec tio n b y c ra nio to my inc luding o rb ita l c lea ra nc e. Histo lo g y re-vea led a n a deno c a rc ino ma . After surg ery she ha d tumo r rec ur-renc e, a nd c hemo thera py a nd ra dio thera py were sta rted resulting in pa rtia l impro vement.
KEY W O RDS: Fro ntal sinus adeno carcino ma. Head and neck neo -plasm. Paranasal sinus cancer.
• Márcio Abrahão • Ana Paula Vieira G o nçalves • Ro berto Yamashita • Ro g ério Aparecido Dedivitis • Ro drig o O liveira Santo s • Luiz Aug usto N ascimento • Marcelo Luis Mudo • Fernando Anto nio Patriani Ferraz • O nivaldo Cervantes
INTRODUCTION
Cancer o f the nasal cavity and paranasal sinuses is relatively rare with an incidence o f less than 1 per 100,000 perso ns per year,1 and represents o nly 3 % o f
all head and neck malignancies.2, 3 Amo ng paranasal
sinuses, the fro ntal sinus is o ne o f the least affected (to gether with the spheno id sinus) with an incidence o f abo ut 0.3 %.2 The sympto ms are vague, simulating
inflammato ry diseases, which is why these tumo rs are o ften diagno sed at an advanced stage. This, in asso -ciatio n with the co mplex anato my o f the regio n, turns such tumo rs into a therapeutic challenge.
The histo lo gically predo minant type, bo th in the nasal cavity and in paranasal sinuses, is squamo us cell carcino ma (SCC), present in 43%-64% o f the cases,4,5 with
adeno carcino ma (AC) appearing as the seco nd mo re fre-quent type, in 10 to 20 %.2,4-6 Nevertheless, in the fro ntal
sinus, squamo us cell carcino ma is far mo re frequent than adeno carcino ma with a ratio o f abo ut 20:1.7 Malignant
tu-mo rs o f respirato ry tract are stro ngly asso ciated with ex-o genex-o us factex-o rs, especially frex-o m industrial prex-o cesses such as pro ductio n o f chro mium, nickel, mustard gas and po lycyclic hydro carbo ns, and with aflato xins, which are asso ciated with squamo us cell carcino ma. The link be-tween wo o d dust and adeno carcino ma o f ethmo id sinuses is well kno wn.8
We repo rt here a case o f fro ntal sinus ad-eno carcino ma where no o ccupatio nal facto r was fo und.
CASE REPORT
A 59-year-o ld wo man, a secretary, came in Febru-ary 1998 with a 4-mo nth co mplaint o f lo w intensity fro n-tal headache. At first it was attributed to sinusitis but antibio tics o ffered no relief. She denied to bacco abuse o r co ntact with chemicals o r wo o d dust. On
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tio n a no n-tender swelling was no ted o ver her right fo re-head next to the medial aspect o f the right o rbit. Extra-o cular mExtra-o vements and rhinExtra-o scExtra-o py were nExtra-o rmal.
She underwent a bico ro nal cranio to my fo llo wed by shield-shaped fro ntal o steo to my. The fro ntal sinus was co mpletely filled by tumo r with extensio n to the ante-rio r ethmo id cells, right lamina papyracea and dura-mater next to the po sterio r wall. An en-blo c resectio n was do ne including right o rbital clearance. The anato mical defect was repaired with acrylic plate and galea. Histo lo gy re-vealed adeno carcino ma. Po st-o peratively she develo ped wo und infectio n and the acrylic plate had to be remo ved, which po stpo ned the initiatio n o f adjuvant therapy. 45 days after surgery she develo ped recurrence abo ve her left o rbit. Chemo therapy with 5 fluo ro uracil and Taxo l and radio therapy was started which led to the disappear-ance o f the tumo r. Ten mo nths after surgery she was still alive but had recurrence in the nasal cavity.
DISCUSSION
In co ntrast to ethmo id sinuses, where adeno carci-no ma is predo minant, and in spite o f the anato mical pro x-imity, adeno carcino ma arising in the fro ntal sinus is an exceptio n. Out o f 772 cases o f nasal sinus tumo rs, Lewis & Castro (1972) fo und 6 cases o f cancer arising in the fro n-tal sinus, all o f which were squamo us cell carcino ma.
Paranasal sinus carcino mas have a stro ng o c-cupatio nal asso ciatio n. In 1992, Nuñez et al. fo und a risk o f de ve lo ping paranasal ade no carcino m a 896 times higher in a po pulatio n expo sed to wo o d dust than in the general po pulatio n. This pro bably explains why its male predo minance is 1.7 times higher than
amo ng females.2,4,6,9 Our patient denied expo sure to
any kind o f exo geno us facto rs fro m industry. The peak incidence is when clo se to the sixth decade.4,10
The case repo rted here is a typical example o f paranasal cancer, with a silent o nset simulating a be-nign disease. The advanced stage o f the tumo rs at pre-sentatio n and the co mplex anato my o f the regio n make it difficult to perfo rm resectio n with adequate margins.
Figures 1 and 2 - MRI demonstrated dural thickening in communication with the frontal mass.
Figure 3 - CT scan showed a soft-tissue mass involving the frontal sinus with intracranial invasion through the posterior wall. Anterior ethmoid air cells and the medial aspect of the right orbit were also involved.
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There are no co ntro lled trials to give assurance abo ut ho w radio therapy o r chemo therapy affects survival, but these treatments are helpful in lo cal co ntro l. The o verall respo nse to chemo therapy is abo ut 82% and regimens based o n cisplatin seem to be mo re effective, especially when asso ciated to 5-fluo ro uracil and bleo mycin.11
It is difficult to evaluate the pro gno stic due to rareness o f nasal sinus tumo rs and diversity o f treat-ment and histo lo gic types. The o verall survival o ver 5 years ranges fro m 31 to 46%.4,5 Apparently, adeno
car-cino ma has a better survival o ver 5 years (65%) than
squamo us cell carcino ma (35%),12 The case we repo rt
here had two predicto rs o f po o r o utco me: intracranial invo lvement13 and o rbital extensio n.
Patients submitted to cranio facial resectio n with-o ut with-o rbital invwith-o lvement have a 5-year survival with-o f 69% co mpared with 29% fo r tho se with invo lvement, includ-ing perio steum alo ne.13 Our patient underwent o rbital
clearance, due to gro ss o rbital extensio n, but preo p-erative radiatio n and fro zen sectio ns o f perio rbital in-vo lvement can in so me instances be useful in preserv-ing the eye witho ut co mpro mispreserv-ing o nco lo gical safety.14
1. Ro bin PE, Po well DJ, Stansbie JM. Carcino ma o f the nasal cavity and paranasal sinuses: incidence and presentatio n o f different histo lo gical types. Clin Oto laryngo l 1974;4:431-56.
2. Frazell EL, Lewis JS. Cancer o f the cavity and accesso ry sinuses: a repo rt o f the management o f 416 patients. Cancer 1963;16:1293-301.
3. Schwaab G, Juliero n M, Jano t F. Epidemio lo gy o f cancers o f the nasal cavities and paranasal sinuses. Neuro chirurgie 1997;43(2):61-3.
4. Lewis JS, Castro EB. Cancer o f the nasal cavity and the paranasal sinuses. J Laryngo lo gy Oto l 1972;86:255-62.
5. Jako bsen MH, Larsen SK, Kirkegaard J, Hansen HS. Cancer o f the nasal cavity and paranasal sinuses- pro gno sis and o utco me o f treatment. Acta Onco lo gica 1997;36(1):27-31.
6. Svane-Knudsen V, Jo rgensen KE, Hansen O, Lindgren A, Marker P. Cancer o f the cavity and paranasal sinuses: a series o f 115 patients. Rhino lo gy 1998;36:12-4.
9. Bro wnso n RJ, Ogura JH. Prim ary carcino m a o f the fro ntal sinus. Laryngo sco pe 1971;81:71-89.
8. Klintenberg C, Olo fsso n J, Hellquist H, Swo kjer H. Adeno carcino ma o f
the ethmo id sinuses: a review o f 28 cases with special reference to wo o d dust expo sure. Cancer 1984;1:482-8.
9. Bridger MWM, Beale FA, Bryce DP. Carcino ma o f the paranasal sinuses: a review o f 158 cases. J Oto l 1978;7(5):379-88.
10. Nuñe z F, Suare z C, Alvare s I, e t al. Sino -nasal ade no c arc ino m a: epidemio lo gical and clinico -patho lo gical study o f 34 cases. J Oto l 1993;22(2):86-90.
11. Lo Russo P, Tapazo glo u E, Kish JA, et al. Chemo therapy fo r paranasal sinus carcino ma. Cancer 1988;62:1-5.
12. Harbo G, Grau C, Bundgaard T, et al. Cancer o f the cavity and paranasal sinuses: a clinic-patho lo gical study o f 277 patients. Acta Onco lo gica 1997;36:45-50.
13. Lund VJ, Ho ward DJ, Wei WI, Cheesman AD. Cranio facial resectio n fo r tumo rs o f the nasal cavity and paranasal sinuses: a 17-year experience. Head & Neck 1998;20(2):97-105.
14. McCary WS, Levine PA, Cantrell RW. Preservatio n o f the eye in the treatment o f sino nasal malignant neo plasms with o rbital invo lvement. Arch Oto laryngo l Head Neck Surgery 1996;122:657-9.
REFERENCES
r e s u m o
CO N TEX TO : O câncer do s seio s paranasais é co nsiderado raro co m uma incidência meno r que 1 po r 1 0 0 .0 0 0 po r ano . O seio fro ntal é o sítio primário em apenas 0 ,3 % do s caso s. A seg uir relatamo s um caso de adeno carcino ma do seio fro ntal.
TIPO DE ESTUDO : Relato de caso .
RELATO DO CASO : Paciente do sexo feminino , 5 9 ano s, secretária, co m queixa de quatro meses de cefaléia fro ntal de leve intensidade (fevereiro de 1 9 9 8 ). N eg ava co ntato co m serrag em. Ao exame no tava-se um abaulamento fro ntal à direita, adjacente a bo rda me-dial da ó rbita direita, de característica endurecida. A to mo g rafia co mputado rizada mo strava um tumo r co m densidade de partes mo les preenchendo o seio fro ntal co m invasão intracraniana através da parede po sterio r. O seio etmo idal anterio r e a bo rda medial da ó rb ita direita ta mb ém esta va envo lvida . A resso nâ nc ia nuc lea r mag nética demo nstrava espessamento dural em co municação co m o tumo r. A paciente fo i submetida a exérese tumo ral em blo co através de cranio to mia bico ro nal incluindo exenteração o rbitária à direita. O exame histo pato ló g ico revelo u adeno carcino ma. Apó s a cirurg ia a pa c iente a presento u rec idiva tumo ra l c o m respo sta pa rc ia l a radio terapia e quimio terapia.
PALAV RAS-CH AV E: Adeno carcino ma de seio fro ntal. Câncer de seio s paranasais. N eo plasia de cabeça e pesco ço .
Márcio Abrahão. Assistant Pro fesso r, Department o f Oto rhino laryngo lo gy, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Ana Paula Vie ira Gonçalve s. Po stgraduate Student, Department o f Oto rhino laryn-go lo gy and Head & Neck surgery, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Robe rto Yamashita. Po stgraduate Student, Department o f Oto rhino laryngo lo gy and Head & Neck surgery, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Rogé rio Apare cido De divitis. Po stgraduate Student, Department o f Oto rhino laryn-go lo gy and Head & Neck surgery, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Rodrigo Olive ira Santos. Po stgraduate Student, Department o f Oto rhino laryngo l-o gy and Head & Neck surgery, Universidade Federal de Sãl-o Paull-o / Escl-o la Paulista de Medicina, São Paulo , Brazil.
Luiz Augusto Nascime nto. Po stgraduate Student, Department o f Oto rhino laryngo l-o gy and Head & Neck surgery, Universidade Federal de Sãl-o Paull-o / Escl-o la Paulista de Medicina, São Paulo , Brazil.
Marce lo Luis Mudo, MD. Department o f Neuro surgery, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Fe rnando Antonio Patriani Fe rraz. Assistant Pro fesso r, Department o f Neuro surgery, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Onivaldo Ce rvante s. Assistant Pro fesso r, Department o f Oto rhino laryngo lo gy, Universidade Federal de São Paulo / Esco la Paulista de Medicina, São Paulo , Brazil.
Source s of funding: No t declared
Conflict of inte re st: No t declared
Last re ce ive d: 10 September 1999
Acce pte d: 29 September 1999
Addre ss for corre sponde nce :
Márcio Abrahão
Departamento de Oto rrino laringo lo gia R. Bo tucatu, 740 - Caixa Po stal 20207 São Paulo /SP - Brasil - CEP 04023-900 E-mail: mabrahao @ sti.co m.br
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