Case Presentation 1

Disease Site:
Head and Neck

Jess Schwab
 Patient Information

▪ Age - 57
▪ Gender- Male
▪ Id Number – J.T. , 8 A.M. tx. time currently
▪ Clinical Site – James V. 7
 PMHx- Past Medical History

▪ Diabetes Mellitus 2 (10 years)- Resistance to/inadequate secretion of insulin,

managed with insulin gtt (medical abbreviation for “drip”) 4x/day, checks sugars 4-
5x/day
▪ Obesity
▪ Hypertension- could be paraneoplastic -> autonomic issues found in cancer
patients caused by chemotherapy, prolonged bed rest or pressure on certain
nerves. These symptoms are not malignant in nature but are caused by cancer and
its treatments.
▪ Cataracts – noticed during the 2 yrs. of symptoms prior to diagnosis
▪ Chronic Back Pain- ex firefighter
▪ PTSD- former military service, also had blood levels of low vitamin D which could
contribute to depression levels
▪ Former Alcoholic
▪ Maxillary Sinus Mass (June 2017)- Esthesioneuroblastoma
PFSHx- Past Family and Social History

▪ Military service ▪ Hypertension on maternal +

paternal sides
▪ Former firefighter
▪ Mother- deceased, lung cancer
▪ Currently is a volunteer
firefighter in Columbus ▪ Father- deceased, lung cancer
▪ Former alcoholic- recent
nursing visits state he
“consumes no more than a
sip/year”
HPI- History of Present Illness

▪ Nasal Congestion and Nose Bleeds were the chief

complaint-> these occurred for 2 years before the pt.
sought help
▪ Diplopia = ______
▪ Care established at a VA in Cincinnati then transferred to
OSU
– MRI showed large tumor including the anterior skull base
– Biopsied = esthesioneuroblastoma, Kadish grade C
– Chemo (in Cincinnati)  surgery (poor chemo response) 
EBRT & concurrent Carboplatin IV
▪ What is the term for chemotherapy given before radiation?
 ENB: Esthesioneuroblastoma

• Extremely rare cancer of the nasal cavity

• Also known as olfactory neuroblastoma
• Generally begins w/ a tumor in the nasal cavity
and can grow into the orbits/brain
• Can cause difficulty with smell, taste and
vision These are the small, round
• Surgery usually first option followed by EBRT blue cells of ENB. What
• Immediate treatment is essential for a other cancer that we have
favorable prognosis learned about has small,
• Also because of the involvement of the round blue cells too?
nose/eyes there is large focus on the
patient’s quality of life
 Symptoms to Expect
• Nasal obstruction most common (70%
of pt.)
• Epistaxis (50% of pt.) = _____ ?
• Nasal discharge with pain
• The tumor is usually close to the optic
nerves and chiasm, so vision loss can
occur
• A red-brown mass may be seen high in
nasal cavity
• Local extension?
• Cribiform plate- anosmia
• Orbital- pain, diplopia
• Frontal sinus- headache
 Epidemiology
• Initially described in 1924 – 1,000 cases documented since
discovery (700 in the United States in almost 100 years)
• Many differential diagnosis because of limited biological
information
• Less differentiated cells resemble many different
diseases
• 80% of cases diagnosed within the last 25 years
• Mean age of 311 American patients was 53
• Most pt. between 40-70
• 55:45 male to female ratio
• 3-5% of all nasal neoplasms (only 2,000 nasal and sinus
cancers diagnosed/yr)
• Cases have been documented in children and teens
• What problems could arise from radiation treatments to This Photo by Unknown Author is licensed
under CC BY-NC-ND

this subset? (think about the location of disease)

 Etiology

▪ The exact factors responsible for ENB are

unknown at this time
▪ The exact location of where this cancer seems to
originate is up for debate in the medical
community. Anatomic locations include:
autonomic ganglia of the nasal mucosa,
sphenopalatine ganglion (regulate the flow of
blood to the nose) and the olfactory epithelium
(most documented)
▪ Genetics, environmental pollution as well as
smoking are factors that may contribute
▪ Because this tumor tends to grow slowly, there is
an average gap of 6 months between symptoms
and diagnosis (our pt. had a 2 year gap!)
Anatomy and Physiology

This patient’s tumor started in the olfactory epithelium.

Lymph Drainage

There is little research

but the cervical and
retropharyngeal nodes
are most common for
lymph spread.
 Common Diagnostic Studies
• Pt. may see ENT specialist first for initial symptoms; workup to follow if signs of disease
Endoscope Inserted through mouth or nose to view
possible tumor

Biopsy To diagnose ENB. Done if symptoms last >1

month

CT Coronal slice most informative, will show extent

of disease and can help with the staging (ex.
Whether or not tumor goes through skull base)

MRI To study intraorbital or nasal extensions

Eye exam Because the tumor can sit so close to optic
nerves, to evaluate vision baseline pre-op + post
treatment
6-12-17 MRI face C+ Primary sinonasal disease, tumor
protrudes into lt orbit and rt maxillary
sinus, rt side lymph nodes (IB, IIB and
retropharyngeal node invasion) 2/27
nodes involved

6-21-17 Surgery Goal- to remove full tumor volume

6-21-17 CT head C- Post resection of tumor, nasal mass

removed in full
Will there be a GTV? Esthesioneuroblastoma. Coronal CT
scan of the orbits and sinuses shows a
large, enhancing, and expansile mass
occupying the ethmoid air cells that is
6-22-17 MRI brain C+ No suspicious lesions invading the cribriform plate and
breaking through to the left anterior
cranial fossa. Image courtesy of
Michael Lev, MD.
Differential Diagnosis

- Small, round blue cell

tumors like melanoma,
lymphoma,
medulloblastoma and
rhabdomyosarcoma
can cause confusion.
An in-depth
histological exam must
be done
• Proposed in 1976 by Kadish; specific to
this malignancy
• There is not one set staging/grading scale
for this disease
• Kadish A: confined to nasal cavity (18%)
• Kadish B: extends to paranasal sinuses
(32%)
• Kadish C: extends beyond nasal cavity
and paranasal sinuses (49%)
• Kadish D: lymph node or distant
metastases
Patient Adjuvant Tx

▪ Chemo in Cincinnati
(unsure of the drug)
▪ Surgery at OSU and EBRT
currently
▪ Chemo currently
(Carboplatin IV) –
Alkylating agent
The PTV_HighEval (dark red line) has a max dose of 7309cgy and an
average of about 6925 cgy. This is our target volume and the
prescribed dose is 6600cgy.
Treatment Parameters

• Position- supine, 2x1mm shims, B

aquaplast HR, arms at 11, knee
sponge
• Number of fields- 5, all 6X IMRT
• Critical organs-
• Optical nerve
• Optic chiasm
• Spinal cord
• Brain stem
Plan Calculation
Side Effects + Management
• Acute- fatigue, mucositis,
xerostomia, lack of saliva, low
Chronic- thyroid hormone causing
hormone problems, 2nd
malignancy, blood counts may be
altered
 Prognosis + Survival (5 yr)
• Prognosis determined by grade, treatment and age
• Historically, pt. treated w/ surgery and radiation do the best
Stage Description 5 Year Survival
A Nasal cavity only 75-91
B Nasal cavity and sinus 68-71
Tumor extends beyond nasal
cavity and paranasal sinuses,
C 41-47
including skull base, orbit or
cribiform plate
Tumor metastasizes to
D cervical lymph nodes and <40
beyond
Metastatic Sites

• Spreads by lymph + blood

• Most common sites are lungs and bones
• Liver, spleen, breast and adrenal spread has
been documented
• There was one patient in literature who had
mets to the trachea 18 months after surgery
and EBRT
• Our pt. currently has a few (+) nodes
• No other metastasis are noted at this
time
 Patient Difficulties
• Recurrent headaches- 3/10, tx with Tylenol
• Rt eye pain
• Increasing difficulty w/ walking (started using a walker)
• Poor taste, continues to eat and no current need for PEG tube
• Xerostomia – This usually occurs with what dose?
• 9-13-17 – day spent in ER for reduced mental status after being found
collapsed in his home by wife
• High lactate levels in blood indicated low O2 and breakdown of
carbs for energy -> nurses suspicious of sepsis
• Still treated and released that night
• Diagnosis at time of discharge was not specific, could have been a
seizure? Low O2 levels were treated but cause unknown at this
time
• 9-18-17 – pt. seen by nursing after complaining of throat pain during
tx, diagnosed with thrush
Patient Experience

Extremely friendly and easy-going patient. Throughout his

treatment he has had many difficulties and increased troubles in
mobility which seems to be causing him frustration. He
mentioned to me that he was “not a religious man” but since
starting treatment he has been “praying every day and
night…things seem to be working out.” He still continues to keep
in close contact with the volunteer fire department and helps out
when he can. He supports his unit every day by wearing the
shirts to treatment.
 References
1. Nasal Cavity Tumors . Nasal cavity - Olfactory neuroblastoma.
http://www.pathologyoutlines.com/topic/nasalolfactoryneurobl
astoma.html. Accessed September 21, 2017.
2. Communications of. Esthesioneuroblastoma. Department of
Otorhinolaryngology.
https://med.uth.edu/orl/opal/esthesioneuroblastoma/. Published
March 4, 2013. Accessed September 21, 2017.
3. Morita A, Ebersold MJ, Olsen KD, Foote RL, Lewis JE, Quast
LM. Esthesioneuroblastoma: prognosis and management.
Neurosurgery. https://www.ncbi.nlm.nih.gov/pubmed/8492845.
Published May 1993. Accessed September 21, 2017.