Version 3.2021, 04/27/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Version 3.2021, 04/27/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Maxillary Sinus Tumors
MAXI-2
i For SNUC with neuroendocrine features, small cell, high-grade olfactory esthesioneuroblastoma, or SNEC histologies, systemic therapy should be a part of the overall treatment. Consider a clinical trial and referral to a major medical center that specializes in these diseases. See SYST-A.
j See Principles of Surgery (SURG-A).
k See Principles of Radiation Therapy (MAXI-A).
l See Principles of Systemic Therapy for Non-Nasopharyngeal Cancers (SYST-A).
m For adenoid cystic tumors and minor salivary gland tumors, see SALI-A.
STAGING PRIMARY TREATMENTi ADJUVANT TREATMENTi FOLLOW-UP
T1–2,N0
All histologies except
adenoid cystic
T1–2,N0 Adenoid cystic
Resectionj
Resectionj
Margin negative
Perineural, vascular, or lymphatic invasion
Positive margin
Consider RTk
orConsider systemic therapy/RTk,l (category 2B)
Recurrent or Persistent Disease (See ADV-3) Follow-up
(See FOLL-A) Re-resection,
if feasible
RTk,m (preferred) orConsider observation for margin negative, no perineural spread
Margin negative
Positive margin
Consider RTi RTk
orConsider systemic therapy/RTk,l (category 2B)
Version 3.2021, 04/27/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Maxillary Sinus Tumors
MAXI-3
i For SNUC with neuroendocrine features, small cell, high-grade olfactory esthesioneuroblastoma, or SNEC histologies, systemic therapy should be a part of the overall treatment. Consider a clinical trial and referral to a major medical center that specializes in these diseases. See SYST-A.
j See Principles of Surgery (SURG-A).
STAGING PRIMARY TREATMENTi ADJUVANT TREATMENTi FOLLOW-UP
Recurrent or Persistent Disease (See ADV-3)
Recurrent or Persistent Disease (See ADV-3) Follow-up
(See FOLL-A)
Follow-up (See FOLL-A)
Metastatic disease at initial presentation See Treatment of Very Advanced Head and Neck Cancer (ADV-2) See Treatment of Very
Advanced Head and Neck Cancer (ADV-1) T3–T4a,N0
T4b,N0–3 T1–T4a,N+
Complete resectionj
Resection + neck dissectionj
Adverse featuresn
No adverse featuresn
RTk
or Consider systemic therapy/RTk,l (category 2B) to primary and neck
RTk,m to primary and neck (category 2B for neck for squamous cell carcinoma and undifferentiated tumors)
Adverse featuresn
No adverse featuresn
RTk,m
orConsider systemic therapy/RTk,l to primary and neck (category 2B)
RTk,m to primary + neck
k See Principles of Radiation Therapy (MAXI-A).
l See Principles of Systemic Therapy for Non-Nasopharyngeal Cancers (SYST-A).
m For adenoid cystic tumors and minor salivary gland tumors, see SALI-A.
n Adverse features include positive margins, close margins, or extranodal extension (See Discussion).
Version 3.2021, 04/27/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
Maxillary Sinus Tumors
MAXI-A
1 See Principles of Radiation Techniques (RAD-A) and Discussion.
2 In the paranasal sinus area, care should be taken to avoid critical neural structures; therefore, 1.8 Gy/fraction can be considered.
3 For doses >70 Gy, some clinicians feel that the fractionation should be slightly modified (eg, <2.0 Gy/fraction for at least some of the treatment) to minimize toxicity. An additional 2–3 doses can be added depending on clinical circumstances.
PRINCIPLES OF RADIATION THERAPY1 DEFINITIVE:
RT Alone
• PTV
High risk: Primary tumor and involved lymph nodes [this includes possible local subclinical infiltration at the primary site and at the high-risk level lymph node(s)]
◊Fractionation:
– 66 Gy (2.2 Gy/fraction) to 70–70.2 Gy (1.8–2.0 Gy/fraction) daily Monday–Friday in 6–7 weeks2,3
– Concomitant boost accelerated RT:
▪72 Gy/6 weeks (2 Gy once daily and then 1.8 Gy/fraction, large field; 1.5 Gy boost as second daily fraction during last 12 treatment days)
▪66–70 Gy (2.0 Gy/fraction; 6 fractions/wk accelerated) – Hyperfractionation: 81.6 Gy/7 weeks (1.2 Gy/fraction, twice
daily)
Low to intermediate risk: Sites of suspected subclinical spread
◊44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)4,5 CONCURRENT SYSTEMIC THERAPY/RT:6
• PTV
High-risk: typically 70–70.2 Gy
(1.8–2.0 Gy/fraction); daily Monday–Friday in 7 weeks2
Low to intermediate risk: 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)4,5
POSTOPERATIVE:
RT or Concurrent Systemic Therapy/RT6
• Preferred interval between resection and postoperative RT is ≤6 weeks
• PTV
High risk: Adverse features such as positive margins (See footnote n on MAXI-3)
◊60–66 Gy (1.8–2.0 Gy/fraction); daily Monday–Friday in 6–6.5 weeks2
Low to intermediate risk: sites of suspected subclinical spread
◊ 44–50 Gy (2.0 Gy/fraction) to 54–63 Gy (1.6–1.8 Gy/fraction)4,5
4 Suggest 44–50 Gy in sequentially planned IMRT or 54–63 Gy with IMRT dose painting technique (dependent on dose per fraction).
5 Treatment to sites of suspected subclinical spread is not consistently performed at all institutions. (Le QT, Fu KK, Kaplan MJ, et al. Lymph node metastasis in maxillary sinus carcinoma. Int J Radiat Oncol Biol Phys 2000;46:541-549; and Jeremic B, Nguyen-Tan PF, Bamberg M. Elective neck irradiation in locally advanced squamous cell carcinoma of the maxillary sinus: a review. J Cancer Res Clin Oncol 2002;128:235-238.)
6 See Principles of Systemic Therapy for Non-Nasopharyngeal Cancers (SYST-A).
Either IMRT or proton therapy is recommended for maxillary sinus or paranasal/ethmoid sinus tumors to minimize dose to critical structures.
Version 3.2021, 04/27/21 © 2021 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.