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CASE REPORT
Year : 2014  |  Volume : 41  |  Issue : 3  |  Page : 188-191

Primary antral carcinoma managed by en-bloc radical maxillectomy with orbital exenteration


1 Department of Surgery, Burdwan Medical College, Burdwan, West Bengal, India
2 Department Physiology, Burdwan Medical College and Hospital, Burdwan, West Bengal, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Arunima Chaudhuri
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-5009.141225

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  Abstract 

The prognosis of maxillary sinus carcinomas is not very promising. Maxillary sinus carcinomas are usually diagnosed at advanced stages and the proximity of important organs such as the eyes and cranial nerves makes complete surgical resection difficult. We here present a case that presented late with squamous cell carcinoma and was treated by radiotherapy (RT) followed by radical maxillectomy with en-bloc orbital exenteration. Patients who undergo RT followed by en-bloc radical maxillectomy with orbital exenteration as salvage, in these cases may have promising results. We had raised forehead fascio cutaneous flap and translocated it deep to the upper eyelid to bridge the cutaneous defect. Forehead defect was covered with split-thickness skin taken from left thigh. No microvascular surgery was done, but cosmetic results were comparable. In rural setups of developing countries where facilities for microvascular surgery are lacking flap translocation may have a positive outcome.

Keywords: Fascio cutaneous flap, primary antral carcinoma, radical maxillectomy


How to cite this article:
Sarkar SK, Chaudhuri A, Banerjee C, Banerjee S. Primary antral carcinoma managed by en-bloc radical maxillectomy with orbital exenteration . J Sci Soc 2014;41:188-91

How to cite this URL:
Sarkar SK, Chaudhuri A, Banerjee C, Banerjee S. Primary antral carcinoma managed by en-bloc radical maxillectomy with orbital exenteration . J Sci Soc [serial online] 2014 [cited 2018 Nov 17];41:188-91. Available from: http://www.jscisociety.com/text.asp?2014/41/3/188/141225


  Introduction Top


Maxillary sinus carcinoma is a rare neoplasm, with incidence of 0.2% of malignant tumors. [1],[2],[3] The standard treatment in the early stage of maxillary sinus carcinoma is surgical resection followed by post-operative radiotherapy (RT). In an article in 2010, Ashraf et al. studied the results of various approaches of treatment as given in their hospital in 26 years. There was a difference in survival between patients who underwent surgery (Sx) with RT compared with patients who received RT alone or chemotherapy (CTx) with RT. They concluded that the type of treatment to the primary site being an important determinant of survival and local control. [2] Orbital exenteration is used for treatment of malignancies of ocular tissues, mainly squamous cell carcinoma, sebaceous cell carcinoma and basal cell carcinoma. Most patients with maxillary sinus cancer have no symptoms in the early stage and therefore, many of these patients are diagnosed in the advanced stage of the disease. [1],[2],[3],[4]


  Case Report Top


We present a case of a 25-year-old male unmarried agricultural laborer with history of right hemifacial swelling and nasal discharge for 5 months. Furthermore, had recent onset of diplopia. Incisional biopsy report from palatal extension of right maxillary antral carcinoma showed "moderately differentiated squamous cell carcinoma" [Figure 1]. Computed tomography (CT) scan of the face was done and the report showed maxillary antral carcinoma with orbital floor (lower posterior) involvement causing mass effect. Inferior rectus muscle was involved. Physical examination revealed right sided malar swelling and nasal block. Right hemi palate was involved with the tumor. All other systems were clinically normal. Chest X-ray-posterior-anterior (CXR-PA), ultrasonogram of neck and abdomen, electrocardiogram, complete hemogram, postprandial blood glucose (PPBG), liver function test (LFT), urea and serum creatinine were done and all reports were within normal limits. Karnofsky scale was 90%.

The tumor was staged as T4aN0M0. After completing all formalities "Tumor Board" opined in favor of RT and accordingly he was admitted under RT unit. He received 44GY in 22# as external beam RT from cobalt 60. Clinical response was only partial as per response evaluation criteria in solid tumors criteria. Further CT scan of the face was done. Mild shrinkage was evident [Figure 2] and [Figure 3].

Plan was made for radical maxillectomy with en-bloc orbital exenteration. Counseling of the patient in the presence of guardians on two different days was done. The party was explained about the risks and benefits of surgery. Written informed consent for surgery and removal of one eye was obtained after counseling. Investigations performed were, complete hemogram, LFT, PPBG, blood urea, serum creatinine, CXR-PA. Investigations were repeated as patient had RT. Pre-anesthesiological check-up was carried. Delay of some 4 weeks before operation for long operation list resulted in skin involvement of an area extending from infraorbital margin to about 2.5 cm below it. Therefore, the plan of operation was re-scheduled as "radical maxillectomy with overlying skin and en-bloc orbital exenteration followed by some form of flap coverage [Figure 4] and [Figure 5].
Figure 1: Histopathological specimen showing squamous cell carcinoma

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Figure 2: Post-radiotherary computed tomography scan

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Figure 3: Post-radiotherary computed tomography scan

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Figure 4: Operated specimen

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Figure 5: Forehead fascio cutaneous fl ap surgery

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General anesthesia was administered with orotracheal intubation. Patient was placed in the supine position with head resting on doughnut. Injection ceftriaxone 1 g intravenous (IV) was given just before operation with prior negative skin sensitivity reaction. Incision was made as a modification from Weber Ferguson approach (right). Maxilla was detached from the frontal bone and palatine and zygoma. Eye (right) was exenterated en-bloc with maxilla. Hemostasis was secured. Superficial temporal artery pulse was felt before and after the operation and found normal. Forehead fascio cutaneous flap based on superficial temporal artery (RT) was raised with its length one and half times the breadth, which was translocated deep to the upper eyelid to bridge the cutaneous defect. Forehead defect was covered with Split-thickness skin taken from left thigh. Gutta-percha wrapped in gauge was packed from oral aspects over the removed maxillary area for support and elimination of dead space. Tracheostomy was done anticipating naso and oropharyngeal edema in immediate post-operative period. Nasogastric feeding tube passed for enteral feeding. Whole specimen was sent for histopathological examination and report. Amount of blood loss was around 200 ml and 1 bottle of B +ve blood was transfused. Time required for surgery was 1 h 45 min. Recovery was uneventful. Further treatment will be based on future course of the disease during long term follow-up of the patient. We had raised forehead fascio cutaneous flap and translocated it deep to the upper eyelid to bridge the cutaneous defect. Forehead defect was covered with split-thickness skin taken from left thigh. No microvascular surgery was done, but cosmetic results were comparable. In rural setups of developing countries where facilities for microvascular surgery are lacking these flap translocation may give promising results.


  Discussion Top


The prognosis of maxillary sinus cancer is not very promising. It is necessary to acquire complete surgical resection and to secure adequate resection margins. However, maxillary sinus cancers usually are diagnosed at advanced stages and the proximity of important organs such as the eyes and cranial nerves makes complete surgical resection difficult. In addition, functional impairments after surgical resection are the major cause of a decreased quality of life. In the present case the case was operated at a late stage and one sided eye had to be removed but complete resection was possible. [1],[2],[3],[4]

A study by Won et al. [5] concluded that induction chemotherapy (ICT) in locally advanced maxillary sinus cancers increased the possibility of tumor down-staging and complete resection with orbital preservation. One of four different treatment modalities, including intra-arterial (IA)-ICT, IV-ICT, concurrent chemoradiotherapy and surgical resection, was selected as a primary treatment based on the TNM stage, performance status, age and comorbidity. Although there were no significant differences in response rate and toxicity profile between the two groups of ICT, IA-ICT was superior to IV-ICT with respect to tumor down staging and local tumor control.

Ashraf et al. conducted a retrospective study from 1979 to 2005. 379 patients with squamous cell carcinoma of the maxillary antrum managed with curative intent were studied. 28 patients had T2, 237 patients had T3 and 114 had T4 tumors. The N classification was N0 in 316 patients, N1 in 21 patients, N2a in 28 patients and N2b in 14 patients. Treatment to the primary site comprised of surgery and RT in 284 patients, RT alone in 57 patients and CTx with RT in 38 patients. There was a difference in survival between patients who underwent Sx with RT compared with patients who received RT alone or CTx with RT. The most common pattern of recurrence was in the primary site, 187 (49.3%) patients. Local control at 3 and 5 years was 71% and 63.8% respectively in Sx with RT, 31.6% and 28% respectively in RT and 28.9% and 26% in CTx with RT group. [2]

Extension to contiguous structures including the orbit, ethmoid sinus, sphenoid sinus, nasal cavity, nasopharynx, pterygoid fossa, palate and cheek may occur and can be a potential problem in the surgical and/or radiotherapeutic management of this disease. [6],[7] Hu et al. [6] reported a 64% 5-year survival rate in the pre-operative RT group and a 5-year survival rate of 26% in the post-operative RT group. We also used pre-operative radiation in our case.


  Conclusion Top


Patients who undergo RT followed by en-bloc radical maxillectomy with orbital exenteration may have promising results. We had raised forehead fascio cutaneous flap and translocated it deep to the upper eyelid to bridge the cutaneous defect. Forehead defect was covered with split-thickness skin taken from left thigh. No microvascular surgery was done, but cosmetic results were comparable. In rural setups of developing countries where facilities for microvascular surgery are lacking flap translocation may have a positive outcome.

 
  References Top

1.Dulguerov P, Jacobsen MS, Allal AS, Lehmann W, Calcaterra T. Nasal and paranasal sinus carcinoma: Are we making progress? A series of 220 patients and a systematic review. Cancer 2001;92:3012-29.  Back to cited text no. 1
    
2.Ashraf M, Biswas J, Dam A, Bhowmick A, Jha JK, Sing V, et al. Results of treatment of squamous cell carcinoma of maxillary sinus: A 26-year experience. World J Oncol 2010;1:28-34.  Back to cited text no. 2
    
3.Villalon-Lopez JS, Valle-Mejia CA, Patino-Lara A, Moreno-Perez BA, Munoz-Lopez JA, Alcantar-Andrade A. Supraestructure maxillectomy and orbital exenteration for treatment of basal cell carcinoma of inferior eyelid: Case report and review. J Cancer Res Ther 2006;2:140-3.  Back to cited text no. 3
    
4.Ben Simon GJ, Schwarcz RM, Douglas R, Fiaschetti D, McCann JD, Goldberg RA. Orbital exenteration: One size does not fit all. Am J Ophthalmol 2005;139:11-7.  Back to cited text no. 4
    
5.Won HS, Chun SH, Kim BS, Chung SR, Yoo IeR, Jung CK, et al. Treatment outcome of maxillary sinus cancer. Rare Tumors 2009;1:e36.  Back to cited text no. 5
    
6.Hu YH, Tu GY, Qi YQ, Xu GS, Wu XL, Cai WM, et al. Comparison of pre- and postoperative radiation in the combined treatment of carcinoma of maxillary sinus. Int J Radiat Oncol Biol Phys 1982;8:1045-9.  Back to cited text no. 6
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7.Manrique RD, Deive LG, Uehara MA, Manrique RK, Rodríguez JL, Santidrian C. Maxillary sinus cancer review in 23 patients treated with postoperative radiotherapy. Acta Otorrinolaringol Esp 2008;59:6-10.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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