Nasal cavity & sinus cancer

Persistent one-sided nasal blockage, blood-stained discharge, facial numbness, upper-tooth discomfort or changing vision can prompt assessment. These symptoms often have non-cancer causes, but repeated treatment for presumed sinusitis should not replace examination of a persistent or worsening problem.

Nasal endoscopy and a planned biopsy establish the diagnosis. Imaging helps identify the lesion’s extent and the safest approach to obtaining tissue. Bring the original pathology and scans if seeking another opinion, rather than only a short report saying ‘sinus cancer’.

Squamous carcinoma and intestinal-type or non-intestinal-type adenocarcinoma are distinct diagnoses. Poorly differentiated tumors may need specialist testing for NUT carcinoma, SMARCB1/SMARCA4-deficient carcinoma or other entities before being labeled sinonasal undifferentiated carcinoma (SNUC). Expert pathology review is particularly valuable when the initial diagnosis is uncertain.

Olfactory neuroblastoma, also called esthesioneuroblastoma, starts in the upper nasal region and has its own grading and treatment considerations. Lymphoma, mucosal melanoma and salivary-type tumors can also arise here; they should follow their own disease-specific pathways rather than a generic sinonasal carcinoma plan.

CAP recommends high-risk HPV testing for newly diagnosed sinonasal squamous cell carcinoma. HPV-specific testing is preferred; p16 screening followed by HPV-specific testing in positive tumors is an acceptable route. This does not make p16 alone a universal diagnosis or justify using the favorable-stage rules of HPV-associated oropharyngeal cancer.

The current AJCC nasal-cavity/paranasal-sinus system remains the 8th edition. CT and MRI help map bone, orbital, skull-base and nerve involvement. Ask which staging system applies to the exact histology and site; a lesion touching an orbital wall is not the same as one invading deeper orbital structures.

An endoscopic, open or combined operation is chosen according to tumor extent and the chance of clear margins. An endoscopic approach is not automatically sufficient because a tumor is inside the nose. Conversely, skull-base involvement does not automatically rule out specialist surgery.

Discuss expected effects on the eye, palate, teeth, face, smell and swallowing before choosing treatment. Reconstruction may use tissue flaps or a prosthesis such as an obturator to close a palatal defect. The need for neck treatment depends on nodal findings and risk, not one rule for every histology.

Radiation is often used after surgery for recurrence risk, or as a main treatment when surgery is unsuitable. Modern planning aims to cover the tumor while limiting dose to the optic structures, brain and other nearby tissues. Previous radiation records are essential if another course is considered.

IMRT is a standard technique. Proton therapy can be considered when a comparative plan offers meaningful dose or toxicity advantages; carbon-ion treatment has a role in selected unresected radioresistant histologies. The technology name alone does not establish better survival or freedom from visual and neurologic side effects.

Induction chemotherapy may be used for selected aggressive tumors to assess response or make local treatment more feasible. Concurrent chemotherapy can also accompany radiation. The regimen depends on histology, fitness and treatment intent; a platinum-based squamous-cancer regimen should not simply be copied to lymphoma or another distinct tumor.

In SNUC, specialist series support using induction response to help choose definitive chemoradiation or surgery. This is a response-adapted strategy with limitations in the evidence, not a guarantee of avoiding major surgery. The team should explain when response will be assessed and what happens if the tumor does not shrink.

A local recurrence should first be assessed for salvage surgery or carefully selected reirradiation. For squamous tumors requiring systemic therapy, pembrolizumab-based treatment may be considered within applicable head-and-neck indications. US first-line monotherapy requires PD-L1 CPS at least 1; the platinum/fluorouracil combination has no such threshold.

The US perioperative indication for resectable locally advanced head-and-neck squamous cancer also requires CPS at least 1. However, the pivotal surgical trial enrolled oral-cavity, oropharyngeal, hypopharyngeal and laryngeal cancers, not a dedicated sinonasal population. Discuss the site-specific evidence gap rather than assuming every nasal tumor shares those results.

A small prospective phase II study of pembrolizumab with nab-paclitaxel and platinum reported activity in recurrent/metastatic sinonasal squamous cancer. Its 20-patient, single-arm design cannot prove superiority to another regimen. Molecular testing may identify a trial or a tumor-agnostic option in selected cases; eligibility must match the alteration and drug label.

Endoscopy and imaging, often MRI, help assess local recurrence. Routine repeated PET/CT is not automatically the best surveillance approach; inflammation can complicate interpretation. Follow-up should reflect the exact tumor type, previous treatment and risk of late recurrence.

Nasal crusting, altered smell, dry mouth, dental problems, visual changes and difficulties with chewing or swallowing need active management. The team should teach nasal care appropriate to the operation and arrange eye, dental, nutritional and rehabilitation support. New visual loss, substantial bleeding or severe new neurologic symptoms require prompt assessment.

• Full pathology, slides or tissue blocks, and any HPV or molecular results.
• Original CT/MRI showing orbital, skull-base and nerve relationships; endoscopy findings.
• Operative and margin reports, reconstruction details and prior radiation plans.
• Current vision, hearing, smell, dental, eating and weight concerns.