NASAL VESTIBULE

STAGING OF NASAL VESTIBULE AND SKIN

T-stage

T1 ≤ 2 cm
T2 2-5 cm
T3 > 5 cm
T4 invades bone
skeletal muscle
cartilage

N-stage

N0 no regional LN metastasis
N1 Regional LN metastasis

TERMS

"Early" lesions

  • superficial ulcerations of the membranous septum or columella with
  • physical exam findings of little more than a crust or scab

"Advanced" lesions

  • invade cartilage
  • grow through the skin surface
  • invade near by structures
    • upper lip
    • columella
    • nasal cavity
    • ginivolabial sulcus
    • premaxilla

PEARLS

  • Recurrence occurs more often in this site than any other site.
  • Histology at this location is more often SCC than BCC

SURGERY ALONE

  • small, superficial lesions.
  • surgery often results in loss of a major portion of the nose

COMBINED MODALITY

Indications

  • large primaries with extensive tissue destruction and distortion
  • Locally advanced lesions may be considered for resection followed by radiation therapy, the cosmetic loss from rhinectomy is severe, and, therefore surgery usually is reserved for salvage after radiation failure.

Management

  • Resection and post-operative radiation
  • pre-operative radiation followed by salvage resection

RADIATION ALONE

  • RT is generally preferred for carcinoma of the nasal vestibule

NODAL MANAGEMENT

First Echelon

  • advanced
  • recurrent
  • moderately or poorly differentiated

Second Echelon

RADIATION TREATMENT

manchu
40 y.o. man with a 2.5 cm x 1.5 cm ulcerative lesion in the nasal vestibule extending down the upper lip.
A generous biopsy showed SCCA with PNI+.

LOCAL FIELD

  • Local Radiation (Local RT only with 2 cm margin) - (middle field on the nose on the left drawing)
  • Appositional field is used to treat the primary tumor. Field borders are determined clinically by binmanual palpation. Treatment can be given with orthovoltage x-rays or electrons. The electron energy is chosen based on the thickness of the lesion.

FIRST ECHELON NODES

Mustache field (Fu Manchu) - (the two lateral fields in the left drawing)

  • appositional anterior right and left electron field (~ 15 degree gantry angle)
  • matched a mid mandibule

& Upper Neck Field

  • lateral parallel opposed photon beams (shown on the diagram on the right)
  • inferior border is just above the arytenoids.

SECOND ECHELON NODES

Lower Neck Field

  • RT to mid- and lower neck nodes with anterior portal
  • nodal boost with appositional electrons or glancing photon fields.

RT COMPLICATIONS

  • synechiae and occlusion of the nasal passage
  • dry mucous memebranes
  • necroses of cartilage, soft tissue, and bone are uncommon
  • small, asymptomatic defects in the nasal septum do not require surgical repair.
Bibliography
1. Wallace A, Morris CG, Kirwan J, Amdur RJ, Werning JW, Mendenhall WM. Radiotherapy for squamous cell carcinoma of the nasal vestibule.Am J Clin Oncol. 2007 Dec;30(6):612-6.
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