Nasal Cancer Health Article

Diagnosis

When otherwise unexplainable symptoms lead a doctor to suspect that a patient may have nasal cancer, often he or she will arrange for endoscopic examination of the nasal cavity (and possibly the sinuses) in order to see if there is a tumor. Definite diagnosis requires a biopsy, in which a small piece of the tumor is cut out and examined to see what types of cells it contains. After a nasal cancer is diagnosed (depending on the type of cancer), many doctors will ask the patient to have an x ray, computed tomography scanning (CT scans), or magnetic resonance imaging (MRI). These techniques visualize the tumor and show the doctor how much the tumor has invaded surrounding tissues. Because treatment for nasal cancer, as well as paranasal sinus cancer, involves surgery in a small, complex space which requires the surgeon to set very precise surgical boundaries, and because most nasal cancers are advanced by the time a patient sees a doctor, it is very important that the doctor evaluate the tumor thoroughly before planning treatment. If the tumor appears to have invaded other tissues, often a doctor will schedule a surgical exploration of the tumor in order to better evaluate the cancer, with the goal of constructing the best possible treatment plan. Sometimes, in addition, surgical exploration is necessary to determine whether the position and invasion of the tumor into surrounding tissue makes surgical removal of the tumor impossible.

Treatment team

As the understanding of cancer grows and new treatment approaches are developed, the complexity of cancer treatment also increases. Today, a multidisciplinary approach to cancer treatment is considered necessary for effective patient care. People involved in the treatment of a nasal cancer will typically include the referring physician, an otolaryngologist, a medical oncologist, a pathologist, and a nurse. If radiation therapy is pursued, a radiation oncologist, radiation therapist, radiation nurse, radiation physicist, and a dosimetrist will also be involved. Treatment will also probably include a psychologist, nutritionist, social worker and chaplain. For nasal cancers, a reconstructive or plastic surgeon may be necessary for optimum cosmetic results after removal of a nasal tumor. If surgical removal of the eye is necessary, specialists in prosthetic eye replacement will be necessary as well.

Clinical staging, treatments, and prognosis

When a cancer develops, the original tumor can spread, usually through the blood or lymph system, to other parts of the body. Since the cancer spreads through the lymph system, often the lymph nodes in the area of the original tumor are the first other sites where cancerous cells can be found. Common other places that metastatic disease may appear are the lungs, the liver, and the bones.

One of the foremost goals of a doctor's assessment of a cancer patient is to determine how far the cancer has already spread and how likely it is to spread further, both of which are key factors in the likelihood that the patient will be cured. The assessment of the tumor's spread is termed staging, and the assessment of how aggressive the cancer cells are is termed grading.

Staging of nasal cancers is performed by visual inspection of tumors (maybe through endoscopy) or visualization of tumors by imaging techniques like x rays, MRIs, or CT scans. The doctor may also attempt to feel for tumors manually. This information will be used to create an official stage for the tumor that is a standardized expression of how much the tumor has already spread.

Because tumors of the nasal vestibule and cavity are rare, and because they are comprised of so many different types, no one staging system has been defined for use with these cancers. Cancers of the paranasal sinuses have a defined staging system based on the TNM system, and this system is often used for describing nasal cancers. The T in the TNM system represents the growth of the local tumor, N describes the spread of the tumor to the lymph nodes, and M describes the spread, or metastasis, of the cancer to distant body sites. The cancer is given various numbered ratings in each letter category, and these are used to create a standardized stage. Generally, tumors with no invasion of local tissues are described as Stage I, while tumors with minimal invasion of local tissues are identified as Stage II. Tumors that have extensive local invasion or that have spread to the lymph nodes but which have not metastasized are described as Stage III or early Stage IV (A and B). Stage IVC tumors are >any tumors which have metastasized.

Most nasal cancers (up to 80%) have already spread to other body sites by the time the symptoms prompt a patient to see their doctor. This fact, combined with the fact that the area is anatomically complex and tightly constructed, makes it very important that the first attempt at treatment is well-planned, with input from a multidisciplinary team and thorough evaluation of the cancer before treatment is begun.

Since cancers of the nasal cavity and vestibule include many different types of cancers, treatment will vary depending on the type of cancer involved, where it is located, and the extent to which it has already spread. Because of this, and because of the complexity of the anatomy in the area and the multitude of other important structures that may be involved in later stages, treatment of nasal cancers is highly individualized, with no firm standard practice guidelines.

For most nasal cancers, treatment will involve surgical removal of the tumor followed by four to five weeks of radiation therapy. In advanced cancers, preoperative radiation therapy may also be employed. However, since radiation therapy has proven very effective for nasal cancers and because radiation has better cosmetic results than surgical removal of a tumor, for many nasal cancers (especially T-cell lymphomas and esthesioneuroblastomas), radiation will be the initial treatment option. If the doctor decides to remove as much of the tumor as possible surgically, radiation therapy (external) will usually be used for four to five weeks after surgery in order to destroy any remaining cancerous tissue. One exception is the case of inverted papillomas, for which surgical excision alone is usually employed. Surgery, because of the tight anatomical area in which a surgeon must work, may also involve more recent techniques like cryosurgery (freezing tissue) or laser surgery.

Tumors initially treated by either radiation or surgery alone may, if they come back, be treated by the untried option or by employing both. External radiation may be supplemented, especially in advanced nasal vestibule cancer, by internal radioactive implants. In addition, advanced stage or recurrent nasal cancer may be treated by chemotherapy, usually involving a combination of drugs. Drugs are used in combination in most chemotherapy because combinations of different drugs (with different side effects) deliver the highest cancer-destroying effect, while minimizing the chance for a serious adverse reaction to the therapy. The drug combinations used in nasal cancer vary on the type of cancer, and may include one or all of the drugs cisplatin, fluorouracil, bleomycin, or methotrexate. In addition, nasal cancers described as Stage III or IV will probably be treated with preventative radiation therapy of the neck area, in order to destroy cancerous cells which may have traveled to the lymph nodes.

Although nasal cancers are made up of many different types of cancer, all types of nasal cancers are considered aggressive. The majority of nasal cancers, because symptoms mimic upper respiratory illnesses and because symptoms often do not occur until the cancer has already filled up the nasal cavity and has invaded surrounding tissues, are already in advanced stages when a patient seeks medical help. For this reason, and because treatment is difficult because of the complexity of the anatomical area, fewer than half of nasal cancer patients survive. If the first treatment attempt is successful, and a patient is cancer-free at two years, however, chances improve greatly.

Nasal cancer is unusual in that, although many patients have metastasis to the lymph nodes or beyond (usually to the lungs), metastasis is not usually the reason for a patient's death. Most nasal cancer patients who succumb to the disease die from invasion of the tumor into vital areas of the brain.

Alternative and complementary therapies

Alternative and complementary therapies are treatments that are not traditional, first-line therapies like surgery, chemotherapy and radiation. Complementary therapies are those that are meant to supplement traditional therapies and usually have the objective of relieving symptoms or helping cancer patients cope with the disease or traditional treatments. Alternative therapies are nontraditional treatments that are chosen instead of traditional treatments in an attempt to cure the disease. Alternative therapies have typically not been proven to be effective in the same way that traditional drugs are evaluated, in clinical trials.

Common complementary therapies that may be employed by patients with nasal cancer are art therapy, massage, meditation, visualization, music therapy, prayer, t'ai chi, and yoga or other forms of exercise, which reduce anxiety and can increase a patient's feeling of well-being.

Numerous alternative therapies exist in cancer treatment, but none has been proven in clinical trials to be effective. Laetril, a product of apricot seeds, is probably one of the most well known. Laetril contains a form of cyanide that may be released by tumor enzymes and may then act to kill cancerous cells. Laetril is not approved for use in the United States, although it is available in Mexico. The National Cancer Institute (NCI) sponsored two trials of Laetril in the late 1970s and early 1980s, but found Laetril to be ineffective and concluded that no further study of the substance was necessary. Vitamins and other nutritional elements like vitamins A, C, and E, and selenium are thought to act as antioxidants. Vitamin E, melatonin, aloe vera, and a compound called beta-1, 3-glucan are reported to stimulate the immune system. Natural substances like garlic, ginger, and shark cartilage are also commonly held to shrink tumors, with less defined modes of action.

Antineoplastons are believed by some to be another alternative approach to a cancer cure. Antineoplastons are small proteins which may act as molecular messengers and which may be absent from the urine and blood of many cancer patients. Proponents believe that replacing these proteins may have beneficial effects. The NCI has been unable to draw definitive conclusions about the usefulness of antineoplastons as a therapy because no large-scale clinical trials of the therapy have been completed.