Nasal Cavity (Nose) and Paranasal Sinus Cancer: Staging and Treatment

What is staging for cancer?

Staging is the process of learning how much cancer is in your body and where it is. Tests like biopsy, nasoscopy, bone scan, PET scan, CT, and MRI may be done to help stage your cancer. Your providers need to know about your cancer and your health so that they can plan the best treatment for you.

Cancer staging looks at the size of the tumor and where it is, and if it has spread to other organs. The staging system for nasal cavity and paranasal sinus cancers is called the “TNM system.” It has three parts:

• T-describes the size/location/extent of the "primary" tumor.
• N-describes if the cancer has spread to the lymph nodes.
• M-describes if the cancer has spread to other organs (called metastases).

Your healthcare provider will use the results of the tests you had to determine your TNM result and combine these to get a stage from 0 (zero) to IV (four).

Nasal cavity and paranasal sinus cancers are grouped together for staging and treatment because of how close they are to each other and the similarity of their cells. "Nasal" means the "nose," and "paranasal" means "around the nose." There are four types of paranasal sinuses, two of which are included in the staging here: the ethmoid sinus and the maxillary sinus.

How are nasal cavity and paranasal sinus cancers staged?

Staging for nasal cavity and paranasal sinus cancers is based on:

• The size of your tumor seen on imaging tests and what is found after surgery (if you have had surgery).
• If your lymph nodes have cancer cells in them.
• Any evidence of spread to other organs (metastasis).
• Where your tumor is. There are two staging systems for these cancers:
  • Staging for cancer in the nasal cavity (nose) or ethmoid sinus (upper part of the nose, between the eyes).
  • Staging for cancer in the maxillary sinus (cheek area next to your nose).

The staging systems are very complex. Below is a summary of the staging. Talk to your provider about the stage of your cancer.

Nasal Cavity or Ethmoid Sinus Cancer Staging

Stage 0 (Tis, N0, M0): The tumor is only in the top layer of cells lining the inside of the nasal cavity or ethmoid sinus and has not grown any deeper (Tis). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage I (T1, N0, M0): The tumor is deeper but is only in one part of the nasal cavity or ethmoid sinus (T1). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage II (T2, N0, M0): The tumor has grown into more than one part of the nasal cavity or ethmoid sinus, or it is in both the nasal cavity and the ethmoid sinus (T2). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage III (T3, N0, M0): The tumor has grown into the side or bottom of the eye socket, the roof of the mouth (palate), the cribriform plate (the bone that separates the nose from the brain), and/or the maxillary sinus (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0); OR (T1-T3, N1, M0): The tumor might or might not have grown outside of the nasal cavity or ethmoid sinus and into nearby structures (T1 to T3). The cancer has spread to a single lymph node on the same side of the neck as the tumor which is no larger than 3 cm across (N1). The cancer has not spread to distant parts of the body (M0).

Stage IVA (T4a, N0-N1, M0): The tumor has grown into the front part of the eye socket, the skin of the nose or cheek, the sphenoid sinus, the frontal sinus, or bones in the face (pterygoid plates). This is called moderately advanced local disease (T4a). The cancer has not spread to nearby lymph nodes (N0), or it has spread to a single lymph node on the same side of the neck as the tumor, and it is less than 3 cm (N1). The cancer has not spread to distant parts of the body (M0); OR (T1-T4a, N2, M0): The tumor may have grown into structures outside the nasal cavity or ethmoid sinus (T1 to T4a). The cancer is N2 if:

• It has spread to a single lymph node on the same side of the neck as the tumor and it is 3-6 cm, OR
• It has spread to more than one lymph node on the same side of the neck as the tumor and they are smaller than 6cm, OR
• It has spread to at least one lymph node on the other side of the neck and they are all smaller than 6cm, OR
• It has spread to a single lymph node on the same side of the neck as the tumor, which is 3 cm or smaller, and is growing outside of the lymph node.

The cancer has not spread to distant parts of the body (M0).

Stage IVB (T4b, Any N, M0): The tumor is growing into the back of the eye socket, the brain, the dura (the tissue around the brain), some parts of the skull (the clivus or the middle cranial fossa), certain cranial nerves, or the nasopharynx (upper throat). This is called very advanced local disease (T4b). The cancer may have spread to nearby lymph nodes (any N). It has not spread to distant parts of the body (M0); OR (Any T, N3, M0): The tumor may have grown outside the nasal cavity or ethmoid sinus (any T). The cancer is N3 if:

• It has spread to at least one lymph node that is bigger than 6 cm, OR
• It has spread to a single lymph node on the same side as the tumor, which is bigger than 3 cm and is growing outside of the lymph node, OR
• It is growing in many lymph nodes.

It has not spread to distant parts of the body (M0).

Stage IVC (Any T, Any N, M1): The tumor may have grown outside the nasal cavity or ethmoid sinus (any T). The cancer may have spread to nearby lymph nodes (any N). The cancer has spread to distant parts of the body (M1).

Maxillary Sinus Cancer Staging

Stage 0 (Tis, N0, M0): The tumor is only in the top layer of cells lining the inside of the maxillary sinus and has not grown any deeper (Tis). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage I (T1, N0, M0): The tumor has grown deeper, but it is only in the tissue lining the sinus (the mucosa) and does not grow into the bone. (T1). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage II (T2, N0, M0): The tumor has begun to grow into some of the bones of the sinus, other than into the bone of the back part of the sinus (T2). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0).

Stage III (T3, N0, M0): The tumor has grown into the bone at the back of the sinus (called the posterior wall) or into the ethmoid sinus, the tissues under the skin, or the side or bottom of the eye socket (T3). The cancer has not spread to nearby lymph nodes (N0) or to distant parts of the body (M0); OR (T1-T3, N1, M0): The tumor might or might not have grown into structures just outside the maxillary sinus (T1 to T3). The cancer has spread to a single lymph node on the same side of the neck as the tumor, which is no larger than 3 cm across (N1). The cancer has not spread to distant parts of the body (M0).

Stage IVA (T4a, N0-N1, M0): The tumor is growing into the skin of the cheek, the front part of the eye socket, the bone at the top of the nose, the sphenoid sinus, the frontal sinus, or parts of the face. This is called moderately advanced local disease (T4a). The cancer has not spread to nearby lymph nodes (N0), or it has spread to a single lymph node on the same side of the neck as the tumor, which is not bigger than 3 cm (N1). The cancer has not spread to distant parts of the body (M0); OR (T1-T4a, N2, M0): The tumor may have grown into structures outside the maxillary sinus (T1 to T4a). The cancer is N2 if:

• It has spread to a single lymph node on the same side of the neck as the tumor, which is 3 to 6cm in size, OR
• It has spread to more than one lymph node on the same side of the neck as the tumor, which are 6cm or less, OR
• It has spread to at least one lymph node on the other side of the neck, which are 6cm or less, OR
• It has spread to a single lymph node on the same side of the neck as the tumor, which is 3 cm or smaller, and is growing outside of the lymph node.

The cancer has not spread to distant parts of the body (M0).

Stage IVB (T4b, Any N, M0): The tumor may have grown outside the maxillary sinus (T1 to T4a). The cancer is N2 if:

• It has spread to a single lymph node on the same side of the neck as the tumor, which is 3 to 6cm, OR
• It has spread to more than one lymph node on the same side of the neck as the tumor, which are smaller than 6 cm, OR
• It has spread to at least one lymph node on the other side of the neck, which are smaller than 6 cm across, OR
• It has spread to a single lymph node on the same side of the neck as the tumor, which is 3 cm or smaller, and is growing outside of the lymph node.

The cancer has not spread to distant parts of the body (M0); OR (Any T, N3, M0): The tumor may have grown outside the maxillary sinus (any T). The cancer is N3 if:

• It has spread to at least one lymph node that is bigger than 6 cm, OR
• It has spread to a single lymph node on the same side as the tumor, which is bigger than 3 cm and is growing outside of the lymph node, OR
• It is growing in many lymph nodes.

It has not spread to distant parts of the body (M0).

Stage IVC (Any T, Any N, M1): The tumor might or might not have grown into structures outside the maxillary sinus (any T). The cancer is N3 if:

• It has spread to at least one lymph node that is bigger than 6 cm, OR
• It has spread to a single lymph node on the same side as the tumor, which is bigger than 3 cm and is growing outside of the lymph node, OR
• It is growing in many lymph nodes.

It has not spread to distant parts of the body (M0).

How are nasal cavity and paranasal sinus cancers treated?

Treatment for nasal cavity and paranasal sinus cancers depends on many things, like your cancer stage, age, overall health, and testing results. There are steps to take before treatment can begin for any kind of head and neck cancer:

• Multidisciplinary treatment is very important. This means you will have providers from many different specialties involved in your care. Many of these providers will see you before you start cancer treatment during visits called consultations. They will work together and with you to create a plan to treat your cancer.
• If you smoke, quit as soon as possible. Smoking may lessen how well your cancer medications work and can worsen side effects.

Your treatment may include some or all the following:

• Surgery
• Radiation Therapy.
• Chemotherapy.
• Targeted Therapy.
• Immunotherapy.
• Supportive/Palliative Treatment.
• Clinical Trials.

Surgery

The type of surgery you have depends on where your tumor is, the stage, and your overall health. Surgery for head and neck cancer can be quite challenging, including removal of tissue and bone and the use of plastic surgery to rebuild facial features to improve how they work and look. There are a few kinds of surgery used to treat nasal cavity and paranasal sinus cancers.

Surgical procedures to treat nasal cancer are:

• Wide local excision: The cancer and part of the healthy nearby tissue is removed.
• Nasal septum removal: Part or all of the septum is removed (The septum is the bone and cartilage the separates your right nostril from your left nostril).
• Nasal cavity wall removal: The wall of the nasal cavity may be removed if it has been affected by the tumor.
• Nose removal: Part or all of the nose is removed. Reconstructive surgery and a prosthesis (implant) may be needed.
• Endoscopic surgery: A surgical tool attached to a thin tube is placed through the nasal cavity. This is less invasive than an incision (cut).

Surgical procedures to treat paranasal sinus cancer are:

• Endoscopic surgery: The cancer is removed using surgical tools attached to a thin tube, placed into the sinus.
• Maxillectomy: Part or all of the hard palate (roof of the mouth) is removed.
• Craniofacial resection: Used in the treatment of cancer of the ethmoid, frontal, and sphenoid sinuses. The tumor is removed through incisions in the face and skull.

In some cases, a neck dissection may be needed to remove lymph nodes.

Talk with your care team about surgical options you have, any concerns about your body image and function, what you will need to do to heal after surgery, and side effects that you may have.

Radiation Therapy

Radiation therapy is the use of high-energy x-rays to kill cancer cells. Radiation for nasal cavity and paranasal sinus cancers can be used:

• Alone.
• After surgery (called adjuvant therapy).
• Before surgery (called neoadjuvant therapy).
• With chemotherapy at the same time (called chemoradiation).
• For palliative treatment (to ease symptoms).
• If the cancer has come back (recurrence).
• To treat lymph nodes of the neck that have cancer in them, and in some cases, even if it does not seem that there is cancer in the lymph nodes.

There are two main types of radiation used to treat nasal cavity and paranasal sinus cancer:

• External radiation therapy: A beam of radiation from outside of the body is directed into the body. It may also be called x-ray therapy, 3D conformal radiation, intensity-modulated radiation therapy (IMRT), cobalt, photon, or proton therapy. When this type of radiation is used, you will likely need to wear a mask that is fitted for you to help you keep still during treatments. This mask can cause anxiety and claustrophobia. Your providers will be able to give you advice to help you with wearing the mask during treatment.
• Internal radiation therapy: A radioactive source is placed inside the body, in or near the tumor. This is called brachytherapy or implant therapy. It is used with external beam radiation and is not a commonly used treatment.

Because radiation can affect nearby tissues, there are many potential side effects of radiation for head and neck cancers. Radiation for nasal cavity and paranasal sinus cancers can cause lymphedema (swelling) and narrowing of the nasal cavity which can make it hard to breathe. There are ways to manage these side effects and it is important to talk to your provider about any side effects you are having.

Before you start treatment, you will likely need to be seen by a dentist. Radiation to this area can affect the teeth and gums. It is important to ensure you have proper dental health before starting treatment with radiation.

Chemotherapy

Chemotherapy is the use of anti-cancer medications to kill cancer cells. It can be used before surgery (neoadjuvant), often with radiation therapy (chemoradiation), after surgery, to help with symptoms (called palliative therapy), or to treat cancer that has come back (recurrence) or spread (metastasis).

Chemotherapy medications that may be used are cisplatin, 5-fluorouracil (5-FU), carboplatin, paclitaxel, docetaxel, capecitabine, and methotrexate. These medications can cause side effects. Ask your medical oncologist which medications would be best for you and when during treatment you will receive them.

Targeted Therapy

Nasal cavity and paranasal sinus cancers may be treated with targeted therapies that focus on specific gene mutations or proteins in the tumor. Targeted therapies work by targeting something specific to a cancer cell, which lets the medication kill cancer cells and affecting healthy cells less. Sometimes the “target” is found on a certain type of healthy cell and side effects can happen as a result. An example of a targeted therapy used for this type of cancer is cetuximab.

Immunotherapy

Immunotherapy is the use of a person's own immune system to kill cancer cells. Examples of immunotherapy medications used to treat these types of cancer are pembrolizumab and nivolumab. Your tumor may need to be tested to make sure immunotherapy medications will work for you.

Supportive/Palliative Therapy

Your quality of life is very important during and after treatment for head and neck cancer. Supportive and palliative treatments are used to lessen symptoms or side effects that you may have. Head and neck cancer treatment and the cancer itself can cause:

• Pain: Your care team will help you with medications and other therapies for pain. Radiation, surgery, and a nerve block can help as well.
• Nutrition issues: For some patients, difficulty swallowing, mucositis (sore mouth and throat), loss of taste, or a lack of saliva production may make eating hard or impossible. It is important that you are followed closely by a dietitian to support you in food and supplement choices, and to keep good nutritional status. If needed, a speech and swallowing specialist can test if you can swallow safely without choking or inhaling food. Many patients will need to be fed through a tube placed in their stomach (called a PEG or ‘G' tube). In most cases, this is only temporary (for a short time).
• Changes in Body Image: Social workers and psychologists may be needed to help in dealing with the changes in body image and your role in your family.
• Speech problems: A speech therapist can help you regain as much of your speech as possible, and also give you other ways to communicate.

Clinical Trials

You may be offered a clinical trial as part of your treatment plan. To find out more about current clinical trials, visit the OncoLink Clinical Trials Matching Service.

Making Treatment Decisions

Your care team will make sure you are included in choosing your treatment plan. This can be overwhelming as you may be given a few options to choose from. It feels like an emergency, but you can take a few weeks to meet with different providers and think about your options and what is best for you. This is a personal decision. Friends and family can help you talk through the options and the pros and cons of each, but they cannot make the decision for you. You need to be comfortable with your decision – this will help you move on to the next steps. If you ever have any questions or concerns, be sure to call your team.

You can learn more about head and neck cancers at OncoLink.org.