|Year : 2022 | Volume
| Issue : 1 | Page : 26-29
Preservation of eye in carcinoma of the nose and paranasal sinuses – A critical review
Sudhir Bahadur1, Arun Sharma2, Junaid Malik3, Seema Monga2
1 Hamdard Institute of Medical Sciences, New Delhi, India
2 Department of Otolaryngology and Head and Neck Surgery, Hamdard Institute of Medical Sciences, New Delhi, India
3 Government Medical College, Srinagar, Jammu and Kashmir, India
|Date of Submission||20-Apr-2022|
|Date of Decision||27-May-2022|
|Date of Acceptance||27-May-2022|
|Date of Web Publication||23-Jun-2022|
6824, DLF Phase 4, Sector 27, Gurgaon - 122 002, Haryana
Source of Support: None, Conflict of Interest: None
Background: Tumor invasion into the orbit by carcinoma is well known and its negative impact on the survival and quality of life has been discussed in the literature. Methods: This article is a narrative review on the preservation of eye in the management of cancers of the nose and paranasal region. Conclusions: The clinical features and modern imaging can help in preoperative planning, aided by the intraoperative assessment in decision-making to preserve the eye or not. Unlike in the past, when even orbital periosteum involvement was considered for orbital sacrifice, more conservative approach has been advocated in recent years in view of anatomic, radiological, and histological studies. Limited involvement of the periorbita or even the small part of intraorbital fat may still be considered for the preservation of the eye in selected patients with frozen section control and without affecting the oncologic outcome.
Keywords: Eye preservation, malignant tumors, nose and paranasal sinus
|How to cite this article:|
Bahadur S, Sharma A, Malik J, Monga S. Preservation of eye in carcinoma of the nose and paranasal sinuses – A critical review. J Head Neck Physicians Surg 2022;10:26-9
|How to cite this URL:|
Bahadur S, Sharma A, Malik J, Monga S. Preservation of eye in carcinoma of the nose and paranasal sinuses – A critical review. J Head Neck Physicians Surg [serial online] 2022 [cited 2022 Nov 29];10:26-9. Available from: https://www.jhnps.org/text.asp?2022/10/1/26/347985
| Introduction|| |
Carcinomas of the nose and paranasal sinuses are uncommon lesions and account for nearly 3% of all head-and-neck cancers. Most patients are diagnosed at an advanced stage of disease because of complex surgical anatomy and a few early clinical symptoms. Proximity of vital structures such as orbit, cranial base, brain, optic nerve, and internal carotid artery make the treatment with surgery and radiotherapy that much more difficult,, Besides, a variety of histological subtypes with different biological behavior and varying response to treatment modalities further add to the dilemma of treatment.
Orbit invasion by the tumor is a frequent finding and its negative impact on survival and functional outcome has been discussed in the literature.[3–6] In the past, if the orbital periosteum was involved and breached by the tumor, the patient was considered for eye sacrifice. However, a consensus is emerging among the surgeons since session's work in 1970's that a more conservative approach is needed based on the clinical, radiological, and intraoperative findings. However, there is gray area about the indications of orbital sacrifice, situations to preserving the eye, and quality of functioning eye after the treatment, which merit discussion.
| Orbital Invasion/Diagnosis|| |
Tumor invasion into the orbit may occur by different mechanisms
Direct infiltration and destruction of the orbital walls, involvement through natural foramina and fissures (inferior/superior), ethmoidal foramina, nasolacrimal duct and through perineural invasion. The orbital invasion is reported to occur in 30%–80% of sinonasal cancers,,,,,, although it is more commonly observed in ethmoidal tumors. The clinical symptoms may be seen in 50% of cases such as limitation of eye movements, orbital displacement, and periorbital swelling. Reduction in the visual acuity may be noted in 20% of patients, although the absence of ocular symptoms does not exclude orbital involvement [Table 1].
| Imaging|| |
Computed tomography (CT) scan can reveal orbital bone involvement, and magnetic resonance imaging (MRI) is complementary to demonstrate orbital soft tissue. The tumor involvement adjacent to the periorbita is the most sensitive predictor of orbital invasion (90%) for both CT and MRI. These authors reported that preoperative imaging can help the surgical planning though may not replace the intraoperative assessment. Similar views have been observed by others.
Staging of orbital involvement
Staging system has included the orbital involvement. The minimal orbital involvement is focal erosion of lamina papyracea without transgression of periorbita. As tumor progressively invades the orbit, periorbita can become locally involved and finally infiltrating the orbital fat and subsequently the extraocular muscles. Janetti proposed a classification of orbital involvement: (a) bone erosion, (b) extraconal fat involvement, and (c) the involvement of medial rectus muscle, optic nerve, eye globe, or palpebral skin [Table 2].
| Surgical Considerations|| |
Usually, a combination of surgery and radiotherapy is used for the treatment in advanced malignant tumors of the maxilloethmoid complex with orbital involvement. Induction chemotherapy and postoperative chemoradiation may have a role based on final histopathology. There is a suggestion in the literature that preoperative radiotherapy may reduce the chances of orbital sacrifice., However, the major dilemma involves whether the eye can be preserved or would need to be sacrificed in patients with orbital involvement.
Decision-making – orbital exenteration may be considered when there is obvious clinical involvement by the tumor with visual loss and ophthalmoplegia or painful eye. However, the decision may not be straightforward in other situations with few ocular symptoms. Imaging has improved the decision-making preoperatively with regard the tumor invasion into the orbit,,. However, several authors have noted limitations of relying exclusively on imaging. Both false-positive and false-negative cases have been observed on radiology., It is, therefore, more useful to reduce this discrepancy by combining radiological features with intraoperative findings and judicious use of frozen section,,,, Kumar et al. found significant co-relationship between operative findings and the final histopathology in 14 of 15 cases. One case showed false-positive findings. It is thus important to take consent for the eye sacrifice preoperatively in all such patients where orbital involvement is suspected.
Several authors have recommended doing frozen section of the periorbita for assessment and in case it was found to be involved, local resection of the former was carried out.,,,, Frozen section may be useful to evaluate the fascial layers, although it can be difficult to freeze the fat for evaluation. Earlier, authors have suggested orbital sacrifice in case if periorbita was involved. The author preserved 63 eyes and found 27 cases (43%).
Alive at 3–15 years. On the other hand, cases which underwent orbital exenteration only 10% survived.
Tiwari et al. treated 25 cases of maxillary sinus carcinoma with combined therapy. In 11 patients, despite radiologic evidence of orbital invasion (including five cases with infiltration of periorbita), the orbits were preserved without evidence of recurrence. In six other patients who underwent orbital exenteration showed histologic evidence of tumor invasion in one patient. They explained that on an anatomic basis, periocular fat is surrounded by a thin fascial layer which is distinctly separate from the periorbita and is not on direct contact with the latter. It was concluded that these eyes may be preserved even if involved periorbita is sacrificed without compromising the survival results.
| Cure Rates|| |
A study reviewed 209 patients who underwent craniofacial resection, 41 cases (20%) required orbital clearance, whereas 23 (11%) underwent resection of the orbital periosteum with preservation of the eyes. When survival in two groups was compared, preservation of the orbit did not affect the outcome (26% versus 29% at 5 years).
In other study by Perry et al., eyes were preserved in 39 of 44 cases. Frozen section of the periorbita was carried out and if the latter was found to be involved, local resection was performed, only three cases showed subsequently recurrence in the orbit. Similarly, McCary et al. observed only 1 recurrence out of 34 preserved orbits. However, guidelines suggested for selecting patients for preserving the eye versus sacrifice include extensive involvement of the periorbita, orbital apex, infraorbital nerve, posterior ethmoidal cells, morphology, and aggressiveness of the tumor. With this protocol, the authors preserved 27 eyes and had 1 local recurrence requiring orbital exenteration. Roy et al. observed that only 1 of their 20 cases needed orbital exenteration. None of 19 cases where orbits were preserved showed recurrence in the eye though local recurrences occurred elsewhere in three cases.
It has been suggested that even an invasion of the intra-orbital fat is not a contraindication of orbital preservation. These authors reported a 66% orbital preservation rate and observed similar control rates whether patients were treated with orbital preservation or orbital clearance, 74% versus 70%, respectively (P = 0.76). In the subgroup of squamous carcinoma, 5-year survival of 46% was noted in the orbital clearance group and 60% in the orbital preservation group. These results are similar to those reported by other workers,, and indicate surgical strategy of preserving the orbit even in patients of intra-orbital fat invasion in terms of local control and overall survival. However, microscopic positive margins are associated with increased recurrences.,,
It is important to realize that functional results in preserved eyes were seen in 95% of the functional eyes.,,
With improved surgical and adjuvant radiation techniques, results of sinonasal neoplasms invading the orbit have improved over the years though orbital involvement remains a poor prognostic factor.
When the result of carcinoma of the maxillary sinus (all stages) is considered irrespective of orbital involvement, a significant difference in the survival has been noted in patients treated with surgery as opposed to radiation alone (50% vs. 20%) at 5 years, respectively (P = 0.003). Similar views in favor of surgery have been made elsewhere. Lisan et al. noted local control rate of 72% in patients treated with surgery as opposed to be 48% in patients treated without surgery (P < 0.05). This may suggest a certain amount of selection bias because patients treated without surgery were mostly advanced and sometimes unresectable tumors.
| Prognostic Significance of Orbital Invasion|| |
There is wide acceptance that orbital invasion represents a negative prognostic factor, at least for the most common histologic types such as squamous cell carcinoma and adenocarcinoma.,,, Patel et al. conducted a multicentric study consisting of 1306 patients showed disease-free survival was better if the orbit was not involved than in cases where there was an invasion of the orbit (58% vs. 51%). Ganly et al. observed disease-specific survival rate with orbital involvement was 41%, whereas it was 75% in patients without the involvement of orbit. Another study describes the preservation of orbit in 66 cases even with limited involvement of orbital fat. Local recurrence rate was 30% after orbital clearance.
Similarly, other authors have also found no significant difference in patient survival whose orbits were preserved as against those where orbital sacrifice was carried out (41% vs. 37%). Janetti et al. observed 5-year overall survival to be 62% and 63% in two groups, respectively. The latter authors performed orbital sacrifice in grade 3 classification of orbital involvement medial rectus, optic nerve, eye globe, or palpebral skin.
| Summary|| |
Orbit invasion by carcinoma of the nose and paranasal sinuses is a frequent observation and its negative impact on survival and functional outcome has been mentioned in the literature. Preoperative assessment of orbital involvement is based on clinical and radiological features, although the absence of clinical symptoms does not exclude it.
Imaging, including the CT scan showing bone involvement and complimented by the MRI indicating soft-tissue invasion, can help in preoperative planning but the actual decision to preserve or sacrifice the eye is taken as per the operative finding. Unlike in the past, when tumor invasion of the orbital periosteum was considered an indication of orbital sacrifice, more conservative approach has been followed in the recent years by most surgeons, though there exist considerable gray zones in decision-making.
In recent years, even limited involvement of periorbita is not considered a contraindication for preserving the eye. This has sound anatomic basis because globe and periocular fat is surrounded by a thin fascial layer which is distinctly separate from the periorbita and is not in contact with the latter. Several authors have suggested frozen section studies of the peri-orbita and in the case of its localized involvement, resection of the latter is recommended.
There is suggestion that the eye may be preserved even in cases of limited involvement of the intra-orbital fat. However, most surgeons would prefer to sacrifice the eye in situations with tumors involving the posterior ethmoidal cells or apex of the orbit or with aggressive histology of the tumor.
This material has never been published and is not currently under evaluation in any other peer-reviewed publication.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]