Sei sulla pagina 1di 7

AUGUST,

TREATMENT

OF

A. 0. BADIB,

By

M.D.,t

CANCER

S. S. KUROHARA,
and

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OF
M.D.,

nasal
usually

reported

sis.37b0

Most

dude

malignant
tumors
are relatively
rare

cavity

these

tumors

to
of

and

The

as benign

the

Roswell

prognostic

on

discussed

with

the

the

experiences
in

the

tum,

cancer
of the
of different

results

and/or
an

re-

of pa-

Institute

of patients
with
The
influence
factors

the

compared

in selection

Memorial

irradiation

radiation
and

easily

we present

Park

management
nasal
cavity.

not

in

literature,

or

defined

difference

of

treat-

surgery

will

be

tive

the

January,

period

of

23

years,

1942,

weeks
to more
ing
8 months.
(Table

Radiation

years,
common

were

i)

(77
the

than
The
per

the

unilateral
cent),

Therapy

vestibule,

No

factors,

atrophic

nasal
Department,t

node

rhinitis

such
or pre-

Head

ob-

and

and

floor.

in

19

cases

(3,

per

cent).

metastases

were
distant

found

in

metastases

8 cases
in

(.

(14

cases

Roentgenologic
examination
of the nose
and nasal sinuses showed
bone destruction
in 18 cases,
nasal
opacity
or mass
in 14
cases,
and both in I I cases.
Ethmoidal
and
maxillary
sinusitis
was
seen
in 10 cases
(Table i).
To assess
the importance
of the extent of
tumor
as a prognostic
factor,
a clinical
staging
was devised
(Table
III),
based
on
TNM
classification
used by Cocchi.
Stage

discharge
and

choana

410

cases
showed
extension
outside
cavity,
mainly
to the maxillary
(9
cases),
ethmoidal
sinuses
and nasopharynx
( cases). Lymph

per cent)
and
(4 per cent).

average
beearly
sympnasal

posterior

lesions

antrum
cases),

between

and December,
1964,
a total of 57 patients
with malignant
tumors
of
the nasal
fossa
were
treated
at Roswell
Park
Memorial
Institute,
Buffalo,
New
York.
The clinical
features
in the series
are
presented
in Table
i.
Males
were
more
frequently
afflicted
than females.
The average age incidence
was 6i years
and 77 per
cent
of the
cases were
above
50 years
of age.
The
duration
of
symptoms
varied
from

* From

cent).

9 on the
tubinates
(2-upper,
and 3-lower
turbinate)
and

Eighteen
the nasal

MATERIAL

toms

pre-

5 per

(i

site of origin
could
not be determined
in 10 cases
with
cancer
filling
the entire
nasal
cavity
(Table
II).
These
tumors
were
either
polypoidal
masses
in 38 cases
(67 per cent)
or ulcera-

evaluation
of the indicaand
results of radiation

techniques

struction

polyps

nasal

in 8 cases
predisposing

growths,

and

The

therapy.

Over

and

frequent

study,

clearly

of the
for

for

the tumor
potential

less

on
wall.
Other
sites,
in
frequency
were:
sep-

not

the

surgery

are

by

ceded
other

of diagof

were

I)

cent),
and
remaining

the rest of the lateral


order
of decreasing

reviewing

for

of treatment

In this

other

cancer

(Table

per
The

(40

middle,

In

are

tients

tion

of

epistaxis
per
cent).

(28

usually
late.
Chronic
sinusitis

si-

problems

cent),

treatment.

indications

ment

special

per

irradiation,
were found.
tumors
were limited
to the right side
nasal cavity
in 33 cases
(8
per cent),
left side in 2! cases
(,7 per cent),
and
bilateral
in 3 cases
( per cent). The
wall was the most
frequent
site of

desirable.1

because

with

paranasal

C.M.,t

YORK

(54

in-

M.D.,

vious
The
ofthe
to the
were
lateral
tumor:

the
sults

group

J. H. WEBSTER,

local
pain
symptoms

prognoreports

CAVITY*

M.D4

NEW

the
are

and the apparent


difference
made
their separate
presenta-

tion
therapy

poor

the

management

nasal
fossae6
the prognosis

at

in one
of

nuses.35-8#{176}4

published

tumors
mainly

nosis

have

the

of
and

NASAL

PH.D.,t

D. P. SHEDD,
BUFFALO,

P RIMARY

THE

1969

Neck

York.

824

Department,

RoSwell

Park

Memorial

Institute,

Buffalo,

New

VOL.

106,

Treatment

No.

of Cancer

(T1_T2,
N0, M0) included
i6 cases;
Stage
II (T1_T2,
N1, M0),
6 cases;
Stage
III (T1_T,,
N2, or T,, NO-N2),
17
cases;
and Stage
iv
(T4, N,-N2
or T1-T4,
M), 18 cases.
T1 denotes a tumor
limited
to the mucosa
that is
I
cm.
in diameter
or less;
T2, mucosal
lesion
more
than
i
cm.
in diameter;
T,
tumors
involving
bone
or cartilage;
and
T4, extension
outside
the nose. N1 means
a
mobile,
unilateral
lymph
node;
and
N2
fixed
or bilateral
lymph
nodes.
M stands
for distant
metastases.
The diagnosis
was established
histologically in all the cases and is given
in Table
II.
The
predominant
type
was squamous
cell carcinoma
(I 2-well
differentiated,
medium
differentiated,
and
8-undifferentiated,
while
8 were ungraded).
This was
followed
by adenocarcinoma
(i i
cases),
mixed
salivary
tumor
( cases), anaplastic
carcinoma
(.
cases)
and malignant
melanoma
(2 cases).

of the

Nasal

825

Cavity

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CLINICAL

Age
Under

surgery

and

(13

irradiation

cases);
(14

and
cases)

combined
(Table

were
(30

12

21

45

79

40

5
8

60-69
70-79

8o

Symptom

years

13

23
4

Duration
17

2-4

34

30
25

Over

14

JO

17

14

12 months

Presenting

Symptom
obstruction

44

Nasal discharge
Epistaxis
Local pain

31

77
54

23

40

i6

28

Nasal

32

2!

swelling

Epiphora
Visual disturbances
Neck mass
Tumor
Extension
Maxillary
antrum
Ethmoid
sinus
Orbit
Nasopharynx
Sphenoid
sinus
Cribriform
plate
Lymph
Distant

Bone

by

2.

16

7
5

4
2.
14

Findings

opacity

or mass

Both

Chronic
Negative

9
5

destruction

Nasal

5
3

nodes
metastases

Roentgenologic

eye

39

0-2

6-12

III).

12

22
2

46

surgery

9
4

50-59

used
cases);

In the irradiation
group,
25 cases
(#{231}
per
cent)
received
external
radiotherapy
alone,
10
cases
had radium
therapy
alone
and 9
cases were
given
external
irradiation
plus
radium.
Tumors
of the
vestibule
were
treated
by a single
field using orthovoltage
radiation.
Single
anterior
fields
were
used
for irradiating
other
tumors
in the anterior
part
of the nasal
cavity.
Parallel
opposing
fields was the technique
employed
in lesions
of the posterior
choana
while
anterior
and
lateral
wedge
pair was used in some tumors
involving
the
maxillary
and
ethmoidal
sinuses.
In extensive
lesions,
three
crossfiring fields were preferred. Orthovoltage,
supervoltage
and cobalt 6o equipment
were
used and the tumor
dose was in the range
of
5,000
to 6,ooo rads in 5-6 weeks
depending
on the volume treated. In some
cases,
it was
necessary to include the ipsilateral eye in
the treatment
field, protecting
the other

Patients

40-49

Over

Per Cent of

Patients

Sex
Female
Male

TREATMENT

series,
three
modalities
treatment:
irradiation

FEATURES

No. of

Nasal

In this
as initial

TABLE

sinusitis

i8

32

14

25

II

19

30

17

lead

or

by

tilting

the

beam

of

the

lateral fields.
Intracavitary

and

were used mainly


the

nasal

fossa

interstitial

radium
limited
to
Radium
appli_

in small tumors
(io

cases).

826

0.

A.

Badib,

J.

S. S. Kurohara,

H. Webster

BY ANATOMIC

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Nasal

Lateral
Wait

Septum

32

D.

P. Shedd

AUGUsT,

II

TABLE
PATHOLOGY

and

S1FES

Sites

Yes-

Total

Choana

.
tiDuie

Undeter.
mined

Floor

No.

Per

Cent

Squamous

carcinoma

Anaplastic

carcinoma

2.

8
3

II

19

39

i6

10

28

12

3
5

33

i8

Lymphoepithelial
Adenocarcinoma
Mixed salivary
Malignant

carcinoma
tumor

melanoma

Total Number
Per Cent

cators
cavity

or molds
through

lesions

were
inserted
the
nostril

or through

a nasal
catheter
part.
Partial
necessary

posterior

for lesions
excision
of

in some

application.
radon
seeds

the

into
for

cases

the nasal
anterior

naris

tumors

of

the

and

In

treated

by

radium,

cases

External

radium

anterior

o.

the

TREATMENT

cm.

from

57

in

tumor

exten-

procedures

external

dose

intracavitary
to add

the surface

7-8

intracavitary
oflocally

Following

iii).

100

rads
size.

plus

in 9 cases

an
applied

surgical

of

5,000

radium

rads
applications.

3,000

in 4-6
used

in 25

cases

III
BY CLINICAL

II

x6

weeks,
was

The

Clinical

All Series

irradiation
used
(Table

100

6,ooo-7,ooo
upon
tumor

to

rads/5
applicator

TABLE

was

radiotherapy

septum

INITIAL

dose
depending

radium
was
sive
tumor

radium
needles
or
in 4 patients
with

accessible
floor.

using

in the posterior
the
tumor
was

to facilitate

Interstitial
were
used

tumor
days

32

STAGES

Stages

Total

III

IV

No.

Per

17

18

57

Cent
100

Treatment

Irradiation

Irradiation
External
Radium
Combined

Techniques
irradiation

Surgical
Procedures
Local resection
Radical
Combined
Preoperative

with

30

53

13

23

3
6

14

24

2.

II

Surgery
Combined

Surgery
irradiation

Postoperative irradiation

25

57

10

23

20

6
3

14

52

13

48

29

10

7!

II

at

VOL.

io6,

Treatment

No.

of Cancer

of the

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OF

TREATMENT

BY

Cavity

827

IV

TABLE
RESULTS

Nasal

CLINICAL

STAGES,

5 YEAR

CRUDE

SURVIVAL

A.

Clinical

Stages

HISTOLOGY

AND

SITES

Total

Stage

Stage

Irradiation

8/9

(89%)

1/2

Surgery

4/5

(8o%)

2/3

Combined

Total

4/6

.
Anaplastic

Carcinoma

Carcinoma

Irradiation
Surgery
Combined
Total

#{149}th1

epi

Stage
i/6

(17%)

0/I

( o%)

8/12

(67%)

2/4

(50%)

2/5

(o%)

/io

(o%)

6/13(46%)

Adeno-

e ia

carcinoma

Carcinoma

1/3

(%)

2/2

1/2

(o%)

2/3

3/5

(60%)

2/4

(o%)

4/9

(44%)

34/24

(6%)

1/4

2/2

(25%)

(100%)

2/2

(100%)

C.

Maiignant

Salivary

(25%)

Melanoma

(100%)

12/23

(67%)

4/5

Total

iviixed

i/

(52%)

Histology

(73%)

(o%)

12/23

3/12(25%)

5/7

6/12

IV

(%)
(67%)

(67%)

Lympho-.

III

2/3

2/6

(100%)

B.

Squamous

Stage

(o%)
(67%)

I/I

12/14(86%)

II

(8o%)

o/i

(0%)

0/I

(o%)

(52%)

8/12

(67%)

/io

(o%)

Site

Total
Lateral

Wall

Septum

Vestibule

Choana

Undetermined

Irradiation
Surgery
Combined

3/6
3/5

(o%)

3/6

(o%)

2/3

(67%)

(6o%)

4/5

(8o%)

1/2

(o%)

2/3

(67%)

1/2

(50%)

i/i

(100%)

1/4

(25%)

Total

8/14

(#{231}%)

8/13

(62%)

4/6

(67%)

2/3

(67%)

3/9

(%)

or

tology

and

sites

14

cancer

in

this

series

were

electrocoagulation

simple
of

small

resection
tumors

in

cases,
and
radical
resection
of the nasal
cavity
and maxilla
with
curettage
of the
ethmoidal
and
sphenoidal
sinuses
in the
more extensive
tumors
in 13 patients.
Orbital excision
was done in 2 cases
and radical
neck dissection
in 4 cases.
In the combined
radiotherapeutic
and
surgical
treatment
preoperative
irradiation
was given
in 4 cases and postoperative
irradiation
in io cases
using
radium
or external
radiation
therapy.
The dose and the
technique
depended
on the volume
of tissue
irradiated
and were
similar
to those
described
above.
RESULTS

Table
iv illustrates
ment
in the various

the results
of treatclinical
stages,
his-

2/3

(67%)

2/5

(40%)

32/23

limited

of tumors.
to

the

Early
nasal

(52%)

8/12
/io

(67%)
(50%)

stages
mucosa

of
ex-

hibited
the best
prognosis.
Figure
and
Table
Iv
show
that
well
differentiated
squamous
cell carcinomas
had the best results and that adenocarcinomas
had better
prognosis
than
undifferentiated
squamous
cell and anaplastic
carcinomas.
Other
histologic
groups
exhibiting
good results
were
the lymphoepitheliomas
and mixed
salivary
tumors.
The whole series had a crude
year
survival
rate of 56 per cent,
and a higher
tumor-free
actuarial
survival
rate
of 67
per cent due to the fact that
some
of the
patients
were
free of tumor
at death
or
follow-up.
In the cases with early
stages
of this tumor (Stage
and II combined)
treated
by
irradiation
or surgery,
year
survivals
of
82 and
75 per cent,
respectively,
were ob-

A. 0.

828

Badib,

S. S. Kurohara,

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J.

H.

Webster

and

D.

P. Shedd

AUGUST,

1969

lowed
radiation
treatment,
while
3 recurrences
appeared
after
surgery,
and
after
the combined
treatment.
All the persistent
and recurrent
lesions
occurred
in the patients
with
an initial
advanced
tumor
of
Stages
HI
and Iv. Recurrences
after
initial
surgical
or combined
surgery
and
irradiation
were
treated
by irradiation.
Four
of
the persistent
and recurrent
tumors
following initial
irradiation
were re-irradiated
and
the
remaining
5 received
surgical
treatment.
The
final
assessment
of tumor
status
showed
year cure in 40 cases and failure
in 17 cases.
The failures
include
9 patients
with local tumor,
4 with metastases,
i with
both,
and 3 of unknown
status.

>

DISCUSSION

The concepts
of treatment
of nasal
candiffer
in the various
published
studies
and change
from time
to time in the same
clinic.39
Irradiation,
alone,
was the pricer

mary

method

while
treatment

10

YEARS

FIG.

Survival

of the

rate

nasal

cavity.

tumor-free

cases,
groups

cent
cinoma,

AFTER

curves

survival.

the

interrupted

and

the

confidence
ungraded.

DIAGNOSIS

after

diagnosis

Crude

(ii)

The

I, II

and

curve

is

(B)
for all

is for the

histologic
represent
95 per

vertical
bars
interval.
SC = squamous
SC I, II and III

cell carcinoma,
Grades
anaplastic
carcinoma.

of cancer

survival

solid

curve

and

of treatment

combined

III.

cell carsquamous

Anapl.=

tamed
(Table
iv). In late stages
(Stage
iii
and Iv combined)
which
received
radiation,
surgical
and
combined
treatments,
the
year
survivals
were:
25, 50, and
per cent,
respectively.
Sixteen
cases
(28
per cent)
showed
either
failure
of response
(4 cases)
or recurrences
(i 2 cases)
after
the initial
treatment.
Four of the recurrent
cases developed
regional
lymph
node
metastases
and 2 of them
distant
metastases.
Eighty
per cent of the recurrences
appeared
within
the first year after treatment.
The mean
recurrence
time
was 10 months.
The
persistent
cases
and
of the recurrences
fol-

was

Treatment

series,59

and

advocated

others.35#{176}25
surgical
in some

cal

in some

radiation

surgical
in

was

many

essentially

clinics367
and either
radiotherapeutic,
depending

or

radiosensitivity

others.48
ported

and

The
results

wide
can

ner in which
the
cases for treatment
sequent

extent

of

surgion the

tumor,

variations

in

be ascribed

to

in

the
the

reman-

various
authors
selected
and to the type of sub-

analysis.

The
treatment
methods
used
in this
series
depended
on the site, extent
and the
histology
of tumor.
Radiation
therapy
was
the most commonly
used technique
in both
early

and

advanced

tumors

including

many

epidermoid
carcinomas
and
adenocarcinomas
and all anaplastic
and lymphoepithe..
hal
carcinomas.
Surgery
was
used
principally
in some of the early cases and in tumors
with
bone and cartilage
involvement
and
in
cluding

carcinomas
Combined
vanced

a few locally
extensive
squamous
cell carcinomas,

tumors,

and
mixed
salivary
treatment
was
selected
lesions
of any
histologic

inadeno-

tumors.
in adgroup.

VOL.

io6,

In the

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apy

Treatment

No.

radiation

was

of Cancer

treatment,

selected

radium

for

small

ther-

accessible

lesions;
external
radiotherapy
for larger
and
less accessible
tumors;
and
radium
plus
external
irradiation
in more
extensive
dis-.
ease.
External
irradiation
was
commonly
used

as

it is more

Parker
apy

in

all

his

achieve

and

external

cases.

radiotherapy
al.2 in nasal

Radium

a homogeneous

However,
6o radiation,

tumor

dose

viously

without

the

Minor

depended

Devine
cancer

lethal

et
to

tumor

and
a radical

complications

pre-

conventional

early

and

surgery
by Oliver,0

radio-

late

radiation

plus
irradiation
while
more
ag-

procedures

and
on

therexternal

reported
in some of the cases
complications
were
seen
in

surgical

by Frazell
tion ofsimple

by

high

after

sequelae
were
but no major
this series.
Conservative
was advocated
gressive

plus

using
supervoltage
we can deliver

reported

therapy.3

satisfactory.

roentgen

was preferred
and
ethmoidal

dose.
cobalt

have

Lewis.3
or radical
the

In our
surgical

site

and

been

used

cases,
selecprocedures

extension

of

the

the

extent

histology

of involvement,

of tumors

are

important

found

results
struction.

Tumors

in

no

great

cases
In

this

difference

with
study,

or

between

without
the

cases

gion

may

and

base

deevi-

dent
bone
destruction
and extranasal
extension
had a shorter
survival
in all treatment
groups.
In cases with
tumors
limited
to the naval
cavity,
presence
or absence
of
roentgenologic
evidence
of bone
involvement
produced
no difference
in the results.
The
presence
of lymph
node
metastases
(relatively
uncommon
in this series,
14 per

and

to

the

posterior

the

skull,

choana

posterior

part

ethmoids,
while

of

spread

various

anatomic

Another
logic type.
MacComb
nosis
and

to

the

cer

sites.

Oliver0

to

showed

the

The

the

alter

type

of can-

prognosis.

survival

squamous

lowest

radiotherapy
be
considered

rate.

results

of

surgery

in many
publications
as criteria
for

in inoperable
or recurrent

tistical

difference

over-all

results

treatment

in

un-

carcinomas
versus

can not
comparing

their
respective
effectiveness,
as
was mainly
used
in early
operable
while
radiation
therapy
was limited
liation
residual

car-

The

anaplastic

survival

reported

rate

cell

in adenocarcinomas.

and

histoand
prog-

carcinomas
the
other

the

a higher

differentiated
than

On

that

appear

series
the

had

stated

not

the

nasophar-

for all other


no difference
in tumors
of

the
undifferentiated
adenocarcinomas.

does

This

of

prognostic
factor
is the
Larsson
and Mrtensson,5
and Martin9
reported
bad

in
the

hand,

orbits

those

ynx.8 In this material,


allowing
possible
prognostic
factors,
existed
between
the results

differentiated

bone

upper

extend
of

fac-

with

the

of

cinomas

the

829

Cavity

the nasal
region
were
reported
to have
a
poor
prognosis
due to their
early
infiltration.5
The influence
of a particular
site was
reported
to depend
on the ease with which
the tumor
can extend
to a surrounding
vital
structure;
e.g., tumors
of the
olfactory
re-

site

tors in determining
survival;
these
factors
will be discussed
before
the evaluation
of
the treatment
results.
Tumor
with
extension outside
the nasal
cavity
has a poor
prognosis.590
This is seen in the low survival rates
in the advanced
stages
of this Series. Roentgenologic
evidence
of bone
destruction
was
considered
an unfavorable
factor
in cancer
of the nose and paranasal
sinuses.0
However,
Larsson
and Martensson5

Nasal

cent) was associated


with poor prognosis
in
this material
and in others.59
The location
of the tumor
has been
reported
to be of paramount
importance.#{176}

in

tumor.
Because
and

flexible

advocated

of the

surgery
cases,
to pal-

advanced
tumors
disease.347
No

was

found

and
sta-

among

the
to

of the 3 main
methods
this
series.
However,

the

analysis
of the results
in each stage
showed
some
points
of interest.
In the early
mucosal lesions,
both
irradiation
and surgery
gave
equally
good results.
In tumors
with
bone or cartilage
involvement
or lymph
node

metastases

methods
Frazell
secondary

the

apparently
and
role

Lewis3

combined

and

yielded

better

using

irradiation

in residual

or

recurrent

surgical

results.
in a
tu-

A. 0. Badib,

830

mors,

reported

Downloaded from www.ajronline.org by 114.124.37.82 on 11/24/14 from IP address 114.124.37.82. Copyright ARRS. For personal use only; all rights reserved

irradiation

When

comparing

group

with

cent

per

in

rates
in

can

their

after

H. Webster

series

in

in the

detected.

radiotherapeutic

the

Also,

the

group

are

A. 0.

Roswell

in the advanced
8 cases
of nasal
by

surgery

the

series

of

patients

MacComb

survived

nasal
surgery

or

I.

with

combined

he

reported
years

all

after

the

67

radiation

tumors
Parker.
per

of the
In

1960,

2.

cent

fossa

patients,

control

external

using

i 2

rate

at

radiotherapy

in

cases

were

(30

cases),

irradiation

ation
small
therapy

accessible
in less

ternal

radiation

more
therapy

factory.
dures

or

and
extent
treatment,

The

radium

flexible

radical

the

in

in

and

surgical

according

of tumor.
surgery
was

irradiation

advanced

in

External
radiation
commonly
used

more

selected

the

site

combined
followed

treatment

of extension

squamous

of

The

series
was
radiotherapy

results.

invasion

In

and

the

9.

cent.
In the early
tumors,
surgery
gave
equally
good

or lymph

with

node

bone

or

metastases,

cartilage

LEFFALL,

paranasal

of 379

of nasal
Gynec.
&
G.

and nasal

cases

treated

Car-

cavities:

at Radium-

Department
radiol.,

L.,

cavity

and

1966,

112,

of

of

1954,

cavity.

OLIVER,

S.
I I.

67,

1957,

42,

Malignant
and paranasal

MED.,
SCHALL,

J.

AM.

8o,

L. Malignant

sinuses.

H. E. Cancer

of nasal

RD.

of

7.

neoplasms
of
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evalTr. Am.
4cad.

&

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1958,

of nasal

592-604.

47, I 1-23.
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47,

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SKOLNIK,

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666 Elm Street


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