PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 1 January – June 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3534 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
Philipp J Otolaryngol Head Neck Surg 2019; 34 (1): 34-37 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Maxillary Sinus Squamous Cell Carcinoma in a
Tertiary Hospital in the Philippines
Anna Kristina M. Hernandez, MD
Arsenio Claro A. Cabungcal, MD
Department of Otorhinolaryngology
Philippine General Hospital
University of the Philippines Manila
Correspondence: Dr. Arsenio Claro A. Cabungcal
Department of Otorhinolaryngology
Philippine General Hospital Ward 10
University of the Philippines Manila
Taft Avenue, Ermita, Manila 1000
Philippines
Phone: (+632) 554 8400 loc. 2152
Email: aacabungcal@up.edu.ph
The authors declare that this represents original material, that
the manuscript has been read and approved by all the authors,
that the requirements for authorship have been met by each
author, and that each author believes that the manuscript
represents honest work.
Disclosures: The authors signed disclosures that there are no
financial or other (including personal) relationships, intellectual
passion, political or religious beliefs, and institutional
affiliations that might lead to a conflict of interest.
Presented at the Philippine Society of Otolaryngology Head
and Neck Surgery Descriptive Research Contest (3rd Place).
October 22, 2018, Maynila Ballroom, The Manila Hotel, Manila.
ABSTRACT
Objective: To establish preliminary demographic and clinicopathologic data on Maxillary Sinus
Squamous Cell Carcinoma (SCC) in the Philippine General Hospital
Methods:
Design: Retrospective Case Series
Setting: Tertiary National University Hospital
Participants: Socio-demographic and clinical data from records of 22 patients
admitted at the Department of Otorhinolaryngology of the Philippine General Hospital from
2013-2016 and histopathologically confirmed to have Maxillary Sinus SCC were collected and
described using means and proportions.
Results: There were 15 males and 7 females with a mean age of 50 years old (range 24 to 77
years old). Maxillary mass/swelling was the most common chief complaint. The mean gap
between initial symptoms and consult was 6.77 months. Initial biopsies were obtained from the
maxillary sinus in 16 patients, with 1 patient noted to have undergone malignant transformation
from a prior intranasal squamous papilloma. Staging was advanced (Stage IVA in 16, IVB in 4,
and III in 2) with no patients with Stage I or II disease. Sixteen (16) patients underwent surgery
and radiotherapy while 6 patients received radiotherapy (RT) with or without chemotherapy.
Regional and distant metastases were uncommon.
Conclusion: In this series, maxillary sinus SCC occurs more in males with a maxillary mass as the
most common chief complaint. Delay in treatment is common with a mean gap of 6 months
between initial symptoms and consult. Neck node metastasis is uncommon and most patients
undergo surgery with radiotherapy as treatment.
Keywords: maxillary sinus cancer; paranasal sinus cancer; squamous cell carcinoma
Maxillary sinus squamous cell carcinoma (SCC) is a rare cancer, comprising about 0.2-0.8%
of all malignant neoplasms1,2 and 3% of all head and neck malignancies.1 It is the most common
histopathologic type among maxillary cancers.1,3,4 This disease is extremely rare in children with
those between the ages of 55 to 65 years old usually affected.1 It usually presents in advanced
stages in patients who are often treated for benign conditions before malignancy is diagnosed
and the overall 5-year survival is at 42%.1
There have been reports of varying clinical behavior among Maxillary SCC in various regions
worldwide through the years. Aggressive presentation and rapid onset of maxillary carcinomas
are rarely seen in western Europe5 while prevalence of cervical metastasis at initial presentation
has been observed in India.3,6 Survival has improved through the years but conflicting results
depending on the modality of treatment have also been reported.3,7-9
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PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 1 January – June 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3534 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
Local studies tend to focus more on head and neck malignancies in
general and a literature search of MEDLINE (PubMed) and HERDIN using
the search terms Maxillary Sinus Cancer (MeSH Term) AND Squamous
Cell Carcinoma (MeSH Term) AND Philippines (All Fields) did not yield
specific studies on maxillary sinus SCC. The rarity of this disease, along
with varying findings in the literature necessitates the establishment
of baseline data for maxillary sinus SCC. This paper aims to establish
preliminary sociodemographic and clinicopathologic data on maxillary
sinus SCC in our institution.
METHODS
With institutional review board approval, this retrospective case
series considered for inclusion the records of patients admitted at the
Philippine General Hospital Department of Otorhinolaryngology public
ward from January 1, 2013 – December 31, 2016 who were diagnosed
with histopathologically-confirmed maxillary sinus SCC. Records of
patients diagnosed with other cancers of the maxillary sinus, residual
or recurrent maxillary sinus SCC, and those with incomplete records
were excluded.
We reviewed the patient database of the Department of
Otorhinolaryngology to determine eligible patients for this study.
Patient records were coded and de-identified socio-demographic data
such as age, sex, location, past medical history, family medical history,
personal social history, as well as clinical data including chief complaint,
time between symptom onset and initial consult, signs/symptoms,
staging (T, N, M), biopsy approach, histopathologic diagnosis/grading,
intraoperative anatomic involvement, regional metastasis and distant
metastasis were extracted from patient records. Data were written in
data collection sheets and subsequently encoded in a Microsoft Excel
Office 365 database. Data were checked for accuracy of encoding. Data
analysis utilized Microsoft Excel version 1903 (Microsoft Corp. Redmond,
WA, USA) to generate descriptive analysis. Means and proportions were
used to describe the study variables.
RESULTS
Out of 25 patient records identified, 22 patients (15 males, 7
females) with ages 24 to 77 years old (mean age 50 years old) were
included. Excluded were one record for incompleteness and 2 for
non-SCC biopsy results. Twenty (20) patients were from Luzon, 2
from Visayas, none from Mindanao. Nineteen (19) of the 22 patients
consulted within 6 months of initial symptoms with a chief complaint
of mass or swelling in 21 and nasal obstruction in 1. Eleven (11)
patients had a history of smoking, 15 had a history of alcohol ingestion
and 11 had a history of both. Only three (3) patients had a history
of Schedule 1 (high abuse potential) drug use. Nine (9) patients
had comorbidities but only one (1) patient had a prior intranasal
(not maxillary) mass while two (2) patients had prior intranasal (not
maxillary) surgeries. The employment of patients varied, 3 were
carpenters/construction workers, 3 were jeepney drivers/dispatchers,
2 each were security guards, fishermen farmers, housewives, or
retired, 1 each was a seamstress, animator, cashier, and mechanic, and
2 listed no occupation.
Initial biopsies were mostly taken from the maxillary sinus (n=16)
and resulted in a diagnosis of squamous cell carcinoma for all patients
with 1 patient noted to have undergone malignant transformation
from a prior intranasal squamous papilloma. Staging was advanced in
all (Stage IVA in 16, IVB in 4, and III in 2) with no patients staged I or II in
this series. Sixteen (16) patients underwent surgery with radiotherapy,
the rest were advised radiotherapy with or without chemotherapy.
Eleven (11) patients with advanced staging underwent maxillectomy
with orbital exenteration.
The most common signs/symptoms are enumerated in Figure 1.
Apart from cheek fullness/maxillary swelling, patients also frequently
presented with a palatal bulge (n=20). Other pertinent signs/symptoms
included are hyposmia (n=3), bleeding mass (n=3), septal deviation
(n=3), and skin changes (n=3).
Areas often grossly involved intraoperatively include the oral cavity
(n=19; usually the palate and the gingiva), the nasal cavity (n=17; from
an intranasal extension of the maxillary mass), and the orbit (n=13;
usually through lysis of the orbital floor).
Nine (9) patients presented with clinically palpable neck nodes. Of
the nine (9), only five (5) underwent neck dissection and had available
post-operative histopathologic results. Three (3) of the five (5) patients
Figure 1. Most Common Signs/Symptoms
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 1 January – June 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3736 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
USA
(St. Pierre & Baker, 1983)
Origin
(Authors,
Year
Published)
USA
(St. Pierre &
Baker, 1983)
Netherlands
(Tiwari, et al.
1999)
Brazil
(Santos, et al. 2014)
Japan
(Kondo, et al.
2016)
India
(Qureshi, et al.
2006)
Philippines
(Hernandez
& Cabungcal,
2019)*
Number of
Patients
Gender
Distribution,
Age
Stage
Distribution
Percentage of
Lymph Node
Metastasis
Treatment
Outcomes
66 patients
(1964-1975)
42 Male, 24 Female
Average age at 60
years
1 Stage I, 8 Stage
II, 21 Stage III, 36
Stage IV
10.6% of patients
had lymph node
metastasis
Surgery + RT
5-year survival 75%
for T2, 28.5% T3,
19.4% T4
43 squamous cell
carcinoma patients
(1975-1994)
28 Male, 15 Female
Age range at 32-90
years
7 Stage II, 20 Stage
III, 16 Stage IV
Surgery + RT,
Chemotherapy
+ RT
5-year disease-free
survival 64% for
Surgery+RT
2-year survival of
37% for Chemo+RT
58 patients (more
adenocarcinomas
than squamous cell
carcinomas)
35 Male, 23 Female
Median age of 59 years
5 Stage I or II, 53 Stage
III or IV
17.2% of patients had
regional metastasis
Surgery +RT,
Chemotherapy + RT
Overall 5-year survival
rate of 17.7%
26 patients (2002-
2008)
18 Male, 8 Female
Average age at 64.2
years (50-84 years)
4 with T2, 13 with
T3, 9 with T4a
8 patients had
lymph node
metastasis (30.8%)
Chemotherapy + RT
Overall 5-year
survival rate of
71.3%
73 patients
(1994-1999)
39 Male, 23
Female
Median age 55
years
61 Presented
with T3/T4
Disease
6 presented
with lymph
node metastasis
Surgery + RT,
Chemotherapy,
Radiotherapy
Overall 5-year
survival after
Surgery + RT of
43%
22 patients (2013-
2016)
15 Male, 7 Female
Average age at
50 years (24-77
years)
0 Stage I/II, 2
Stage III, 16 Stage
IVA, 4 Stage IVB
3 patients had
lymph node
metastasis
Surgery +
RT, RT +/-
Chemotherapy
Table 1. Comparison of Maxillary Sinus Cancer Data
*data from the present series
yielded positive regional metastasis to the cervical lymph nodes.
Diagnostics for distant metastases were normal for most patients
including liver ultrasound (n=18), chest x-ray (n=16), Aspartate
Aminotransferase (n=16), Alanine Aminotransferase (n=12) and Alkaline
Phosphatase (n=14). Four (4) patients had remarkable liver ultrasound
findings -- 2 had benign findings (hepatic cyst and parenchymal
disease), 1 had a hepatic focus measuring 1.8cm, and another had non-
specific calcifications. Biopsy was not obtained from any of the masses
identified. Four (4) patients had significant x-ray findings suggestive of
infection (pneumonia in 1, pulmonary tuberculosis in 3).
DISCUSSION
The general demographic and clinicopathologic profile of patients
with maxillary SCC in this series is similar with findings in our literature
review from the region. (Table 1) Common symptoms include pain,
nasal discharge, epistaxis and obstruction, commonly affecting males
more than females at a ratio of 1.5:1.1 Other symptoms include: (1)
nasal fullness, stuffiness or obstruction, (2) pain, (3) cheek paresthesia,
(4) cheek fullness or swelling, (5) palatal bulge, (6) persistent, non-
healing nasal/oral sore or ulcer, (7) nasal mass, (8) proptosis, diplopia
or lacrimation.1 Similar to existing literature, our study revealed male
predominance in this disease – with a male: female ratio of 2.1:1. The
presence of a maxillary mass was the most common chief complaint
identified.
The development of maxillary sinus cancer appears to be influenced
by several factors such as: exposure to (1) nickel, (2) chlorophenols, (3)
textile dust, (4) Thorotrast instillation, (5) smoking, (6) formaldehyde, (7)
wood, (8) concurrence of sinonasal (Schneiderian) papilloma, and (9)
Human Papilloma Virus.1,7 However, due to methodological limitations
of this study, we were unable to identify these factors in our sample.
Smoking and alcohol ingestion were observed in at least half of the
patients and were more frequently noted than Schedule 1 drug use.
Employment as a construction worker or jeepney driver was more
common among the patients in our series. Risk for exposure may be
inferred, at best, from the patients’ residence or employment.
The dilemma with diagnosing Maxillary Sinus SCC is that tumor
growth is usually indolent. Delay in consultation may range from a
month to even years, with some patients in this series first consulting
ophthalmologists for eye symptoms or dentists for dental symptoms,
only to discover that the problem was in the maxillary sinus. Many
patients in our series presented in advanced stages, in contrast to the
rarity of aggressively presenting maxillary carcinomas among patients
PhiliPPine Journal of otolaryngology-head and neck Surgery Vol. 34 no. 1 January – June 2019
PhiliPPine Journal of otolaryngology-head and neck Surgery 3736 PhiliPPine Journal of otolaryngology-head and neck Surgery
ORIGINAL ARTICLES
in western Europe.5 Since the maxillary sinus is an area surrounded by
bone, significant bony involvement usually occurs prior to clinically
apparent symptoms such as a cheek bulge which usually prompts
medical consult. Patients may initially be diagnosed with some areas as
unresectable, profoundly affecting prognosis.
The usual treatment for maxillary sinus SCC in our institution was
surgery with radiotherapy. Radiotherapy with or without chemotherapy
was usually advised for patients who were poor surgical candidates.
It has been established in the literature that histopathologic
diagnosis is a strong factor for nodal metastasis with a primary SCC
or undifferentiated carcinoma being the most likely to result in neck
node metastasis.11 The grading of differentiation (well-differentiated,
moderately-differentiated, and poorly-differentiated) has been found
to have no significant difference in the likelihood for nodal metastasis.11
Only three (3) patients (2 well-differentiated SCC, 1 poorly differentiated
SCC) out of the 22 patients in our study presented with positive cervical
metastasis, relatively low compared to the high (46%) incidence (69
out of 148 patients) noted in India.3,5 This is consistent with findings
in literature that nodal metastasis is uncommon in tumors without
extensive lymphatic involvement, as is the case for the maxillary
sinus.11 Studies such as by Le et al., found an overall incidence of 15.5%
for neck node metastases in patients with Maxillary SCC.12 Due to
this low rate of neck node metastasis, elective neck dissection is not
routinely done for patients with maxillary sinus SCC in our institution.
Fine needle aspiration biopsy (FNAB) is likewise not done for clinically
palpable neck nodes among patients with maxillary sinus SCC as these
patients are treated with an additional neck dissection. Our results may
underestimate the incidence of neck node metastases in our institution.
However, FNAB may be explored as an option to determine neck node
metastasis among patients who are not good candidates for surgical
management.
There have been conflicting reports regarding factors influencing
nodal metastasis, with some studies citing that extension of tumor
outside of the maxillary sinus was closely related to the risk of cervical
lymphadenopathy for maxillary sinus SCC.12,13 Another study reports
that staging (T2 in particular) confers a higher risk for nodal metastasis
than T3 or T4 tumors.4 A study by Ahn et al. found that the increase in
risk begins with T2 tumors and progresses to T3 and T4 tumors as well.15
All three patients who presented with positive cervical metastasis were
staged as T4a tumors and 2 of the 3 patients were positive for tumor
at the area of the pterygoid plates. These findings may be worth
investigating in future research.
There are several limitations to this study. First, the limited sample
size precludes the generalizability of our findings. Our series was also
limited to the patients of one department (otorhinolaryngology) in our
hospital and does not reflect the general surgery census of the same
hospital. It is recommended that more patients with maxillary sinus SCC
be included in future studies to gain more insight from trends observed
in the data. The inclusion of imaging findings and post-treatment follow-
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up in the analysis will make the data more robust. Second, no association
between the variables and the diagnosis of maxillary sinus SCC may be
drawn from this series due to the limited number of patients included.
The authors aimed to establish preliminary data for this condition and
such associations may better be evaluated using other methods of
statistical analysis in future studies with a larger sample size. A longer
study period can also allow us to evaluate outcomes. Third, review of
patient records limits the kind of data available. Clinicians usually do
not ask about (or write down) technical risk factors such as exposure to
substances and these may only be implied based on employment. In
retrospect, broader inclusion criteria—including all types of maxillary
sinus cancers— might have resulted in more patients and may have
provided a more comprehensive understanding of the clinical behavior
and outcomes of various maxillary sinus malignancies in our institution.
In conclusion, our series found that maxillary sinus SCC occurs more
in males, with a maxillary mass as the most common chief complaint.
Delays in treatment are usual, with a mean gap of 6 months between
initial symptoms and consult. Neck node metastasis is uncommon and
most patients undergo surgery with radiotherapy as treatment.