Adenocarcinoma de mucosa etmoidal: Abordaje quirúrgico mediante rinotomía lateral

González-García, R.; Escorial Hernández, V.; Martos, P.L.; Mancha de la Plata, M.; Naval Gías, L.; Rodríguez Campo, F.J.; Sastre Pérez, J.; Muñoz Guerra, M.; Hinojar, A.; Gamallo, C.

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Revista Española de Cirugía Oral y Maxilofacial

versión On-line ISSN 2173-9161versión impresa ISSN 1130-0558

Rev Esp Cirug Oral y Maxilofac vol.28 no.1 Madrid ene./feb. 2006

PÁGINA DEL RESIDENTE

What should the diagnosis and the surgical approach be?

¿Cuál es su diagnóstico y abordaje quirúrgico?

Male patient, 73-years-old, a carpenter by trade, ex-smoker for 15 years with a moderate drinking habit, attended our Unit after referral by the Otorhinolaryngology Unit. He had a history of early morning, self-limited epistaxis that had been continuing for five months, and which for the previous month had been associated with a difficulty in breathing through the nose. He had a medico-surgical history of ulcerative colitis, sliding hiatus hernia, duodenal ulcer with bleeding episodes of the upper digestive tract, EPOC for more than 10 years, cerebral aneurysm that had been treated with clips, laryngeal microsurgery for polyps of the vocal cords, and arthroplasty of the right hip for coxarthrosis.

A rhinoscopy was carried out that showed a mass in the upper part of the nasal fossa, where an incisional biopsy was carried out. A contrast-enhanced cervicofacial CAT scan was also carried out that showed a soft-tissue mass that was polylobulated and that extended from the right ethmoidal air cells to the nasal fossa, crossing the midline and the nasal septum. Bone destruction was observed, which suggested a malignant tumor of a carcinoma type. Destruction of the lamina papyracea and the lamina cribrosa was not observed, but extensive destruction was observed from the right nasal fossa to the middle meatus (Fig. 1). The neck region did not show any clinical or radiological changes. Nuclear magnetic resonance (NMR) was not carried out because of the intracranial surgical clips. The incisional biopsy was defined macroscopically as an ovoid-shaped tumor measuring 1.5 x 1 cm that was grayish in color and of a soft consistency.

Adenocarcinoma of Ethmoid Mucosa. Surgical approach by means of a Lateral Rhinotomy

Adenocarcinoma de mucosa etmoidal. Abordaje quirúrgico mediante rinotomía lateral

R. González-García¹, V. Escorial Hernández¹, PL. Martos¹, M. Mancha de la Plata¹, L. Naval Gías¹,
F.J. Rodríguez Campo¹, J. Sastre Pérez¹, M. Muñoz Guerra¹, A. Hinojar², C. Gamallo³

1 Servicio de Cirugía Oral y Maxilofacial
2 Servicio de Otorrinolaringología
3 Servicio de Anatomía Patológica
Hospital de la Princesa, Madrid, España

Dirección para correspondencia

Microscopically, the initial biopsy was classified as a papillary adenocarcinoma. After the Tumor Committee had studied it, surgery was decided on. A paranasal approach of the Weber-Ferguson type was carried out extending the cutaneous incision to the ipsilateral glabellar region and a lateral rhinotomy was performed. The tumor was resected and it was lifted away from the upper part of both fossae and from the medial walls of both orbits. Exposure without perforation of the dura mater was visualized from the lamina cribrosa to the sphenoid sinus. All the mucosa of both nasal fossae, the ethmoidal sinuses and the sphenoid sinus was removed and the tumor was resected en bloc. The cavity was then packed with a filling with a gauze border, after checking for adequate hemostasis. Wire osteosynthesis was performed on the nasal bones and direct skin closure was carried out with monofilament (Fig. 2).

The anatomopathologic study of the sample reported a laminated fragment with a surface area of 9 x 6 cm and a thickness of 0.4 cm, on a level with the right nasal fossa with an exophytic looking mass in its center that corresponded to an epithelial proliferation composed of papillary structures covered by a pseudostratified epithelium with atypical cytologic features. The existence of cuboid or low-columnar cells was observed. These had regular oval nuclei situated by the base, and they had cytoplasm that was slightly eosinophilic and granular (Fig. 3). No infiltration by the tumor could be seen in the areas where bone fragments could be recognized. The mucosa of the sphenoid sinus did not show evidence of tumor infiltration, nor did the mucosa or the cartilaginous tissue of the left nasal fossa. The definitive diagnosis was of adenocarcinoma of the ethmoid sinus and nasal fossa. During the postoperative period there were no important complications. Coadjuvant radiotherapy treatment was decided on at a dose of 50 Gy given locally. The patients is asymptomatic and 6 months after the surgical procedure he has shown no locoregional signs of relapse.

Discussion

Malignant neoplasms of the nasal cavity and paranasal sinuses are infrequent and, according to Goepfert et al¹ they represent 15% of all tumors of the upper airway. Squamous cell carcinoma and minor salivary gland tumors represent 80-90% of cases. Adenoid cystic carcinoma is the most common of the salivary gland carcinoma in the nasosinusal area, and it is followed distantly by adenocarcinoma, mucoepidermoid carcinoma, carcinoma ex pleomorphic adenoma and epimyoepithelial carcinoma.

Adenocarcinoma of ethmoidal mucosa falls into the category of adenocarcinoma of the sinonasal mucosa. Within these, two groups can be differentiated: those with origins in the surface mucinous epithelium and those with an origin in the seromucinous glands.² These have similar histological characteristics to the tumors of the major salivary glands. The adenocarcinoma can be divided in turn into papillary, mucinous, seromucinous and tubular types.³ In accordance with the histological findings mentioned in this case Neto et al,⁴ in a series of 12 cases, reported the presence of tubular glands composed of single flat cuboid or cylindrical cells with oval or round nuclei located at the base that had prominent nucleoli. Pleomorphism, atypia and increased mitotic activity were observed together with the absence of stroma. The global pattern was tubular-cystic, with the occasional presence of cribiform and papillary areas.

The most frequent clinical characteristics are nasal obstruction and epistaxis. The clinical features in our case were similar, although there was early bleeding and the nasal obstruction only appeared at a later stage. With regard to recurrence, Heffner et al³ reported a rate of 30% in concordance with Neto et al (25%).⁴ Given these facts, the need for a close and prolonged follow-up period is recommended.

The differential diagnosis should be established with the epithelial adenomatoid hamartoma of the respiratory tract, glandular seromucinous hamartoma, inverted papilloma, antrochoanal polyps and other types of adenocarcinomas.

The epithelial adenomatoid hamartoma contains ciliated glands of an epithelial respiratory type. Glandular seromucinous hamartoma contain small seromucinous glands that alternate with cystic cavities and blood vessels. Both types of hamartomas lack the invasive histologic characteristics and cribiform pattern that is typical of the adenocarcinoma. The inverted papilloma of cylindrical cells adopts a stratified pattern of eosinophilic cells with an oncocytoid appearance that are supported by a thick basal membrane. The antrochoanal polyp has infarcted areas, edema, inflammatory cells, proliferation of blood vessels and very few glands. Lastly, in the differential diagnosis we have to consider metastasis.⁴

Tumors of the naso-ethmoidal complex should be accessed surgically by means of a combined craniofacial approach^5-7 or by means of a lateral or total rhinotomy, or via a transpalatal or transantral approach.^8,9 In malignant paranasal sinuses involving the skull-base, a combined craniofacial approach is necessary.¹⁰ In cases with orbital involvement, resection en bloc is necessary together with exenteration. When the midline is affected around the nasoethmoidal complex, but not the orbit nor the meninges, a conservative approach is recommended.¹¹ In these cases a total or lateral rhinotomy can be used. The rotation upward and sideways of the complete nasal pyramid allows complete access to both nasal fossae, the ethmoidal labyrinth, medial walls of both orbits and maxillary sinuses, cribiform plate and floor of the nasal fossae.

With this case we achieved a wide access to these structures by means of a Weber-Fergusson incision that extended to the ipsilateral glabellar region followed by a lateral rhinotomy. The nasal pyramid that had a lateral pedicle was rotated en bloc towards the contralateral side (Fig. 2). One of the inconveniences that has been pointed out of lateral rhinotomies is the lack of control of the tumor extension in the contralateral anterior and ipsilateral posterior zones.

However, in our opinion, it represents a simple technique that can be used for those cases, such as the one that concerns us, when there is ipsilateral involvement of the nasal fossa and ethmoidal sinuses. The tumor resection can be carried out en bloc as there is access to the posterior areas, including the sphenoid sinuses. According to the reflections of Mann,¹² total rhinotomy should be used for lesions of the midline when there is invasion of the nasal cavity and the entire ethmoidal complex, providing there is no dural or orbital involvement. When there is involvement of the rhinopharynx or the sphenoid sinuses this technique is contraindicated, as adequate margin control cannot be obtained.

We believe that the rhinotomy is a valid approach for medium sized tumors (T1 and T2) when there is no infiltration of the lamina cribrosa. For cases entailing larger sized tumors or when neighboring structures are affected, combined craniofacial approaches should be used. We recommend the lateral rhinotomy for those tumors of a moderate size, with an ipsilateral location, when the orbits, lamina cribrosa, sphenoid sinuses and/or clivus are not affected, in order to obtain a wide exposure, with minimal aesthetic and functional sequelae. As reported previously by Roux et al,¹³ surgery is not recommended for very large carcinoma with intracerebral extension, bilateral orbital involvement and/or posterior invasion through the sphenoid sinus and clivus. In these cases, combined radiochemotherapy treatment is preferred. Independent of the therapeutic option used, a close long-term following is required due to the risk of later relapse.

Dirección para correspondencia
Raúl González García
C/ Los Yébenes 35, 8ºC
28047 Madrid, España.
raugg@mixmail.com

References

1. Goepfert H, Luna MA, Lindberg RD, y cols. Malignant salivary gland tumors of the paranasal sinuses and nasal cavity. Arch Otolaryngol 1983;109:662-8. [ Links ]

2. Manning JT, Batsakis JG. Pathology consultation. Salivary-type neoplasms of the sinonasal tract. Ann Otol Rhinol Laryngol 1991;100:691-4. [ Links ]

3. Heffner DK, Hyams VJ, Hauck VJ, et al. Low-grade adenocarcinoma of the nasal cavity and paranasal sinuses. Cancer 1982;50:312-22. [ Links ]

4. Neto AG, Pineda-Daboin K, Luna MA. Sinonasal tract seromucous adenocarcinomas: a report of 12 cases. Ann Diagn Pathol 2003;7:154-9. [ Links ]

5. Shah JP, Galicich JH. Craniofacial resection for malignant tumors of the ethmoid and anterior skull base. Arch Otolaryngol 1977;103(9):514-7. [ Links ]

6. Ketcham AS, Chretien PB, van Buren JM, Hoye RC, Beazley RM, Herdt JR. The ethmoidal sinuses: a re-evaluation of surgical resection. Am J Surg 1973; 126(4):469-76. [ Links ]

7. Raveh J, Turk JB, Ladrach K, Seiler R, Godoy N, Chen J, et al. Extended anterior subcranial approach for skull base tumors: long-term results. J Neuro surg 1995;82(6):1002-10. [ Links ]

8. Harrison DF. Surgical approach to the medial orbital wall. Ann Otol Rhinol Laryngol 1981;90(5 Pt 1):415-9. [ Links ]

9. Sessions RB, Humphreys DH. Technical modifications of the medial maxillectomy. Arch Otolaryngol 1983;109(9):575-7. [ Links ]

10. Rinehart GC, Jackson IT, Potp AZ. Management of locally aggressive sinus disease using craniofacial exposure and the galeal frontalis fascia muscle flap. Plast Reconstr Surg 1993;92:1219-25. [ Links ]

11. Weymüller EA, Reardon EJ, Nash D. A comparison of treatment modalities in carcinoma of the maxillary antrum. Arch Otolaryngol 1980;106:625-. [ Links ]

12. Mann WJ. Total rhinotomy for midline lesions of the ethmoid and the nose. J Maxillofac Surg 1985;13:273-6. [ Links ]

13. Roux FX, Moussa R, Devaux B, Nataf F, Page P, Laccourreye O, et al. Subcranial fronto-orbito-nasal approach for ethmoidal cancers. Surgical techniques and results. Surg Neurol 1999;52:501-10. [ Links ]