Nasal+Cavity

NOT related to smoking [1] 2:1 male to female occurrence [1] Peak age incidence 10-20yrs of age and 50-60 yrs of age [1] Present at advanced stages [1] 30% to 40% occur in the maxillary sinus 40% to 50% in the nasal cavity 10% in the ethmoid sinuses 5% in the frontal and sphenoid sinuses || Exposure to Mustard Gas [1,2] Exposure to Radium [2] History of Retinoblastoma – when treated with radiation therapy Smoking Increase risk for Nasal cavity cancer || IMAGING: CT/MRI of the primary site and neck. Chest X-ray, CT of thorax if adenoid cystic or neuroendocrine carcinoma. PET/CT may also be ordered. LABS: Complete count.[4] || Other types include minor salivary gland tumors, malignant melanoma, lymphoma, esthesioneuroblastoma, sarcoma, and inverted papilloma [5,4] || Subdigastric (Jugulodigastric) and Submandibular most commonly involved lymph nodes[5,4] || Below are the sites where the tumor may spread. -The lining of the maxillary sinus - Bones around the maxillary sinus, including the roof of the mouth and the nose. - Tissues under the skin. - The eye socket. - The base of the skull - The ethmoid Sinuses. - The front of the eye - The skin of the cheek - Behind the jaw -The bone between the eyes ||
 * Epidemiology: || Rare Tumors – approx. 3% of all upper respiratory tumors [1]
 * Sites of occurrence for nasal cavity and paranasal sinuses **
 * Etiology: || Industrial Exposure – dusts inhaled while working, such as wood, nickel, flour, fabric dusts [1,2]
 * Signs & Symptoms: || Signs and symptoms associated with nasal cavity carcinoma include: [3]
 * Nasal obstruction
 * Nasal discharge
 * Nosebleeds
 * Numbness or tingling
 * Problems with vision
 * Sinus congestion
 * Mass in the nose
 * Mass on the face or the roof of the mouth
 * Pain in the ear and or upper teeth
 * Neck or face swelling ||
 * Diagnostic Procedures: || GENERAL: Complete history and physical. Fiberoptic endoscopic examination with biopsies. Patient should have a dental evaluation before the start of radiation. A baseline ophthalmologic exam, as well as a baseline speech and swallowing assessment if surgery is planned.
 * Histology: || Squamous cell most common;
 * Lymph Node Drainage: || Drainage is mainly ipsilateral;
 * Metastatic Spread: || Lymph node metastasis from the nasal cavity and paranasal sinuses usually does not happen unless the tumor has expanded to areas that contain capillary lymphatics. According to Chao, “approximately 5% of patients have clinically positive lymph nodes on initial presentation; lymph node metastases develop in another 15% of patients after treatment has controlled the primary tumor. However, spread to the retropharyngeal and cervical lymphnodes are possible. According to Perez, Lymph node involvement and distant metastasis are infrequent at diagnosis (11% and 1% respectively).” [4,6]
 * Grading: || Primary tumor described by its grade, by histological examination. Histological grade describes how closely the cancer cells resemble normal tissue under a microscope. Normal tissue contains many different types of cells grouped together, which is called differentiated. Tissue from a tumor usually has cells that look more alike each other (called poorly differentiated). Generally, the more differentiated the tissue, the better the prognosis. A tumor's grade is described using the letter "G" and a number. GX: Indicates the grade cannot be evaluated.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.5in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">G1: Indicates the cells look more like normal tissue (well differentiated).  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.5in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">G2: The cells are only moderately differentiated.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.5in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">G3: The cells don’t resemble normal tissue (poorly differentiated).  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none; text-indent: 0.5in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Recurrent: Recurrent cancer is cancer that comes back after treatment.[7]  ||
 * Staging: || <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">The American Joint Committee on Cancer (AJCC) TNM system. <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; text-align: left; text-decoration: none;">Tx Primary tumor cannot be evaluated. <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T0 No evidence of primary tumor present. <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Tis Carcinoma in situ. Cancer cells found only in the innermost epithelium layer of the mucosa.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T1 Confined to nasal cavity with possible extension into the bone of the sinus.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T2 Tumor has grown into other nasal or paranasal cavities.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T3 Tumor grown into the bone of the eye socket, palate, cribiform plate and/or the maxillary sinus.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T4a Tumor grown into other structures: front part of the eye socket, the skin of cheek and/or nose, the sphenoid and/or frontal sinus and or the pterygoid plates.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T4a are resectable.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T4b Tumor extends into the back of the eye socket, brain, dura mater, clivus, middle cranial fossa, nasopharynx and/or certain cranial nerves.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">T4b are not resectable.[8]  <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; text-align: left; text-decoration: none;">Nodes For head and neck cancer the “Regional lymph nodes” <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; margin-left: 0.25in; text-align: left; text-decoration: none;">N0 No evidence of cancer in the regional lymph nodes <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">N1 One lymph node involved on the same side of the neck, not larger than 3cm.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">N2a One lymph node involved on the same side of the neck, larger than 3cm but smaller than 6 cm.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">N2b More than one lymph node involved on the same side of the neck, all of which are smaller than 6cm.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">N2c Contralateral or bilateral lymph node involvement, all of which are smaller than 6cm.  <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; margin-left: 0.25in; text-align: left; text-decoration: none;">N3 One or more lymph nodes involved with at least one greater than 6 cm. <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; text-align: left; text-decoration: none;">Metastatic Stage <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">M0 No evidence that cancer has spread to another anatomical site.  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none; text-indent: 0.25in;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">M1 Evidence that cancer has spread to another anatomical site in the body.[7]

<span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; text-align: left; text-decoration: none;">Stage 0: Carcinoma in situ. Cancer cells only in skin covering the nasal cavity. <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; text-align: left; text-decoration: none;">Stage I: Cancer cells have not spread to lymph nodes or other anatomical site. But may have grown into bones surrounding the nasal cavity. <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; line-height: normal; text-align: left; text-decoration: none;">Stage II: Cancer has spread to one or more parts of surrounding tissue in the nasal cavity. <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Stage III: Cancer has grown into the bones of the eye socket, hard palate. Possible spread to one lymph node on the same side of the neck, however node is smaller than 3cm. <span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 0px; overflow: hidden; text-align: left; text-decoration: none;">﻿ <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; line-height: normal; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Stage IVA: An invasive cancer (T4a) with either no lymph node involvement (N0) or spread to only a single same-sided lymph node (N1), but no metastasis (M0). It is also used for any cancer (T) with more significant nodal involvement (N2), but no metastasis (M0). <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Stage IVB: An invasive cancer (any T) that has spread to lymph nodes (any N) but has no metastasis (M0). It is also used for any cancer (any T) that is found in lymph nodes and is larger than 6 cm (N3), but no metastasis (MO). <span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 0px; overflow: hidden; text-align: left; text-decoration: none;">﻿ <span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; text-align: left; text-decoration: none;">Stage IVC: Any tumor (any T, any N) when there is evidence of distant spread (M1).[8] || Late-xerostomia, chronic keratitis & iritis, optic pathway injury, soft tissue or osteoradionecrosis, cataracts[6] Long term complications of nasal vestibule irradiation have been minimal. Central nervous sytem damage, unilateral or bilateral vision loss, serous otitis media, and chronic sinusitis Radiation retinopathy is rare at 45Gy Some visual acuity changes after 60Gy: Decreased visual acuity after 65Gy, Visual acuity decreased 85-90% at 80Gy Optic nerve injury-the 15 year actuarial incidence reached 11% for doses above 60Gy[9] || <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Nasal Vestibule: The most common form of treatment is radiation therapy. Surgery may be performed if the tumor is relatively small in size and location is optimal. [4]
 * Radiation Side Effects: || Acute-mucositis, skin erythema, nasal dryness, xerostomia
 * Prognosis: || <span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;">Prognotic factors for survival include age and performance status and for tumor control include tumor location, histology and extention of the disease.[8] Each year, about 2,000 people are diagnosed with nasal cavity or paranasal sinus cancer in the United States. Tend to occur between ages 45 and 85 and twice as likely in males. <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: Times New Roman; font-size: 16px; text-align: left; text-decoration: none;">The overall five-year relative survival rate of people with nasal cavity and/or paranasal sinus cancer is 54%. (cancer.net) <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">Stage 5 year survival  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">I 63%  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">II 61%  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">III 50%  <span style="background-color: transparent; color: #000000; display: block; font-family: 'Times New Roman'; font-size: 16px; text-align: left; text-decoration: none;"><span style="background-color: transparent; color: #17365d; font-family: 'Times New Roman','serif'; font-size: 16px; line-height: 115%; text-align: left; text-decoration: none;">IV 35% [10]  ||
 * Treatments: || <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Treatment:

<span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Nasal Cavity: Surgery followed up with radiation therapy is the treatment option of choice. After surgery the radiation dose is 60 Gy when there are positive margins the dose range is 60-68 Gy which is less than the dose given when treating with radiation only to decrease the amount of radiation delivered to the optic nerve. When treating the nasal cavity with radiation only the dose is 74-79 Gy which is treated twice-daily (1.1 to 1.2 Gy/fraction) with a 6-hour interfraction interval. This fractionation scheme is used to decrease the amount of radiation damage to the optic nerve. <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Ethmoid Sinus: Optimal treatment is surgery and radiotherapy. [4] <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Maxillary Sinus: Treatment includes surgery and radiation therapy. Most often a radical maxillectomy is done. Craniofacial resection is done when the ethmoid roof is part of the tumor mass. When the patient has lesions that are inoperable they are treated with radiation. When a tumor is inoperable the physician may treat with radiation therapy initially then assess the patient for surgery. <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Sphenoid Sinus: Most often is treated with radiation therapy. [4] <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Dose: 60-70 Gy If the patient has an increased risk for metastatic disease the treatment may include a dose of 50 Gy to the neck. <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">External radiation therapy for nasal cavity, ethmoid sinus, and maxillary sinus use analogous techniques. The treatment uses anterior portal with an additional one to two posterior titled lateral portals. The plan is then optimized using wedges. After the patient has received 45-50 Gy of the dose the fields may be reduced to a gross tumor volume with margin.[4] <span style="color: #ff00b2; font-family: 'Times New Roman',Times,serif; font-size: 16px;">The patient is instructed to look straight ahead with their eyes open. The anterior portal is 1.5 – 2 centimeters across the midline to ensure the nasal cavity and ethmoid-sphenoid complex and medial contra lateral orbit are included. The cribriform plate and the frontal sinus are included in the superior margin. The floor of the nose, maxillary antrum, and alveolar ridge give the basis for the inferior margin. To remove the mandible and tongue from the line of treatment a tongue blade and cork are utilized. The lateral portals are also similar for nasal cavity, ethmoid, and maxillary sinus tumors. The anterior portion of the lateral portal is located at the lateral bony canthus. The superior border is dependent upon the disease involvement. The inferior border is created to cover the floor of the antrium which is normally at the lip comissure. The posterior borders are designed to remove the spinal cord and brainstem from the fields. [4] || [4,6,7] <span style="color: #008000; font-family: 'Times New Roman',Times,serif; line-height: 27px;"> <span style="color: #008000; font-family: 'Times New Roman',Times,serif; line-height: 27px;"> <span style="color: #008000; font-family: 'Times New Roman',Times,serif;"> <span style="color: #008000; font-family: 'Times New Roman',Times,serif;">
 * TD5/5: || The 5 % risk of complication within 5 years (TD5/5) are listed below for volumes within the irradiated field. [11] ||  ||   ||   ||   ||   ||
 * ** Organ ** || ** 1/3 Volume ** || ** 2/3 Volume ** || ** 3/3 Volume ** || ** Complications ** ||
 * Brain Stem || 6000 cGy || 5300 cGy || 5000 cGy || Necrosis Infarction ||
 * Ear mid/external || 3000 cGy || 3000 cGy || 3000 cGy || acute serous otitis ||
 * Ear mid/external || 5500 cGy || 5500 cGy || 5500 cGy || chronic serous otitis ||
 * Parotid ||  || 3200 cGy || 3200 cGy || xerostomia ||
 * Optic Chiasma & Optic Nerve || No Partial Volume || No Partial Volume || 5000 cGy || Blindness ||

__**<span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 18px;">Green Group **__ <span style="color: #ff00a5; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Lisa - Signs and Symptoms and Treatment <span style="color: #632423; font-family: 'Times New Roman',Times,serif; font-size: 15px;">Eric - Etiology and Epidemiology <span style="color: #ad14ad; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Kim A - Diagnostic procedures <span style="color: #0a3771; font-family: 'Times New Roman',Times,serif; font-size: 16px;">LaDonna - Staging, Grading and Prognosis <span style="color: #008000; font-family: 'Times New Roman',Times,serif; font-size: 16px;">Curtis - Histology and Lymphatic Drainage <span style="font-family: 'Times New Roman',Times,serif; font-size: 16px;">Shun - TD5/5 and Metastatic Spread References

<span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[1]National Cancer Institute. //Factsheet.// Available at: [] <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">Accessed on May 26, 2011. <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[2]National Cancer Institute. Available at: [|http://www.cancer.org/Cancer/NasalCavityandParanasalSinusCancer/DetailedGuide/index] <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">Accessed on May 26, 2011. Last Medical Review: 08/16/2010, Last Revised: 08/16/2010 <span style="font-family: 'Times New Roman',serif; font-size: 16px; line-height: 24px;">[3] Available at National Cancer Institute [] Accessed May 27, 2011. <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[4] Chaos KS, Perez CA, Brady LW. //Radiation Oncology-Management Decisions//. 2nd edition. Philadelphia:Lippincott, Williams & Wilkins. 2002 <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[5] Washington, Charles, and Dennis Leaver. Principles and Practices of Radiation Therapy. St. Louis,Missouri: Mosby Elsevier, 2010. Print <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[6] Perez CA, Brady LW, Halperin EC; //Principles and Practice of Radiation Oncology.// 5th Edition; Philadelphia PA; Lippincott Williams and Wilkins; 2008; <span style="font-family: 'Times New Roman',serif; font-size: 16px; line-height: 20px;">[7] Cancer Research UK. //Cancerhelp.// Available at: __<span style="color: windowtext; font-family: 'Times New Roman',serif; font-size: 12pt;">[] __ <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">Accessed May 19, 2011. <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[8] WebMD. //Cancer health center//. Available at: __<span style="color: windowtext; font-family: 'Times New Roman',serif; font-size: 12pt;">[] __ <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">Accessed May 20, 2011. <span style="font-family: 'Times New Roman',serif; font-size: 16px; line-height: 20px;">[9] Hansen E, Roach M. //Handbook of Evidence-based Radiation Oncology//. New York:Springer. 2007 <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">[10] American Cancer Society. //Nasal cavity and paranasal sinuses cancer.// Available at: __<span style="color: windowtext; font-family: 'Times New Roman',serif; font-size: 12pt;">[] __ <span style="font-family: 'Times New Roman',serif; font-size: 12pt;">Accessed May 18, 2011.

<span style="background-color: transparent; color: #17365d; display: block; font-family: 'Times New Roman',serif; font-size: 16px; text-align: left; text-decoration: none;"> <span style="background-color: #ffffff; color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 16px;">[11] Emami B, Lyman J, Brown A, et al. Tolerance of normal tissue to therapeutic irradiation. //Int J Radiat Oncol Biol Phys//.1991;21(1):109-122