Oncology Corner  Le coin de l’oncologie

Radiation therapy for tumors of the nasal cavity and paranasal sinuses
in dogs
Kirsty M. Elliot, Monique N. Mayer

T umors of the nasal cavity and paranasal sinuses (sinonasal

tumors) in dogs account for only approximately 1% of all
neoplasia; however, over 80% are malignant, and they carry a
While the role of various environmental contaminants
remains unclear in the development of canine sinonasal neo-
plasia, it has been shown that dolichocephalic breeds kept
poor long-term prognosis (1). Although these tumors are slow indoors and exposed to environmental tobacco smoke are at an
to metastasize, they are locally invasive, and, without treatment, increased risk (4). Brachycephalic breeds (with the exception of
euthanasia is generally elected within a few months due to pro- the Boston terrier) are at a decreased risk for the development
gression of local disease. Sinonasal tumors usually occur in older of sinonasal cancer (1).
dogs, with the average age at diagnosis between 8.7 to 10.7 y A presumptive diagnosis of neoplasia may be made based on
(1). Of all sinonasal tumors, approximately 2/3 are carcinomas skull radiographs, but a definitive diagnosis requires a biopsy.
and 1/3 are sarcomas (1,2). Round cell tumors of the sinonasal Radiographic signs consistent with sinonasal neoplasia include
cavity, such as lymphoma or mast cell tumors, can carry a better the presence of soft-tissue densities within the nasal cavity
prognosis than carcinomas and sarcomas and are not considered as well as bony destruction and proliferation (3) (Figure 2).
in this article. Tissue samples for histology may be obtained via rhinoscopy,
Dogs are commonly presented for nasal discharge, which rhinotomy, or transnostril blind biopsy (2). Prior to passing any
may be hemorrhagic or mucopurulent. Other presenting com- instrument through the naris, the distance from the naris to the
plaints include facial deformity (Figure 1A), ocular discharge, medial canthus of the eye should be measured externally and
sneezing, stertor, dyspnea, exophthalmos, and, if the tumor has marked with tape on the biopsy instrument, to prevent acciden-
invaded through the cribriform plate, potentially neurologic tal penetration of the cribriform plate (2). Before performing
signs (1–3). Differential diagnoses that should be considered a biopsy, a clotting profile (including buccal mucosal bleeding
include bleeding disorders, fungal or bacterial rhinitis, foreign time, prothrombin time, and activated partial thromboplastin
body, and trauma (2,3). time) should be performed (2,3). A computed tomography

Figure 1.  A 10-year-old Dachshund with facial deformity resulting from a nasal carcinoma (1A). A pre-contrast computed tomographic
transverse image of the nasal cavity (1B) reveals a soft tissue density mass occupying most of the nasal cavity with lysis of the dorsal
right aspect of the nasal and maxillary bones.

Department of Small Animal Clinical Sciences, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan
S7N 4P5.
Address all correspondence to Dr. Monique Mayer; e-mail: [email protected]

CVJ / VOL 50 / MARCH 2009 309

Le co i n d e l’ o n colo g i e

A B
Figure 2.  An intraoral dorsoventral radiograph of the nasal cavities in a dog with a sinonasal carcinoma, showing loss of turbinate bone
detail (2A). A radiograph of a normal dog is shown for comparison (2B).

(CT) scan is strongly recommended to support the diagnosis the Western College of Veterinary Medicine, an abdominal
and evaluate the extent of the tumor, and is essential for tumor ultrasound is performed prior to full course radiation therapy, in
staging. Computed tomographic changes consistent with canine order to screen for concurrent disease that may affect a patient’s
sinonasal neoplasia include destruction of bone and abnormal life expectancy.
soft tissue density (Figure 1B) (2). A CT scan can also assess While the long-term prognosis for canine sinonasal tumors
whether there has been extension of the tumor through the is poor, radiation therapy has been shown to improve survival
cribriform plate. times. On the other hand, with no treatment, or if surgery, che-
Despite the fact that, at time of diagnosis, only approximately motherapy, immunotherapy or cryosurgery is performed as a sole
6% of dogs have detectable regional lymph node metastasis, treatment, the median survival time is 3 to 6 mo, as progressive
and pulmonary metastasis is rare (3), full staging is nonetheless local invasion of the tumor leads to increasingly severe clinical
required prior to initiating treatment. Staging will affect the signs, and owners generally opt for euthanasia (Figure 3) (7).
recommended treatment plan for a patient, and also has been With full-course megavoltage radiation therapy, median sur-
shown in some studies to predict outcome with treatment. vival times ranging from approximately 12 to 16 mo have been
Staging is the assessment of the anatomical extent of disease, reported (6,8). Patients that have undergone full course radia-
and uses the World Health Organization (WHO) TNM clas- tion therapy may still continue to show clinical signs related to
sification system that evaluates the primary tumor (T), regional the tumor (such as nasal discharge or sneezing), although these
lymph nodes (N) and presence or absence of distant metastasis signs are usually less severe than before treatment. One study
(M) (Table 1) (5). Additionally, dogs with sinonasal tumors may found that only 39% of dogs were completely free of clinical
be further classified under Théon’s Modified Staging System, signs after radiation (9).
which is used to indicate the extent of the tumor and the There is conflicting evidence as to various prognostic indica-
degree of bony erosion (6). A complete pretreatment workup tors for canine sinonasal neoplasia. While 1 study reported a
for canine sinonasal tumors involves a CT scan of the nasal relative risk of relapse 3.3-fold higher for dogs with carcinomas
cavities and paranasal sinuses, palpation of the regional lymph than for dogs with sarcomas, other studies have failed to show
nodes, thoracic radiographs, blood work (CBC and serum bio- any difference in median survival times between the 2 histologic
chemistry analysis), and urinalysis. If the regional lymph nodes types (6,10,11). Nonkeratinizing squamous cell carcinomas
are enlarged, cytology and/or histology are recommended. At were found to have a shorter median survival time than those

310 CVJ / VOL 50 / MARCH 2009

Table 1.  Staging systems for canine sinonasal tumors
TNM World Health Organization Staging (5)
T — Primary Tumor
  To No evidence of tumor
  T 1 Tumor ipsilateral, minimal, or no bone destruction

O N C O LO GY C O R NE R
  T 2 Tumor bilateral and/or moderate bone destruction
  T 3 Tumor invading neighbouring tissues
N — Regional Lymph Node (RLN)
  No No evidence of RLN involvement
  N1 Movable ipsilateral nodes
  N1a Nodes not considered to contain growth
  N1b Nodes considered to contain growth Figure 3.  A sagittal section of a canine head with a nasal
  N2 Movable contralateral or bilateral nodes carcinoma. The extensiveness and close proximity of nasal
  N2a Nodes not considered to contain growth tumors to critical normal structures limits the role of surgery in
  N2b Nodes considered to contain growth treatment of these tumors.
  N3 Fixed nodes
M — Distant Metastasis (44.7 mo as compared with 19.7 mo with radiation only) (15).
  Mx Distant metastasis cannot be assessed However, the dogs in the group that received post-radiation
  M0 No evidence of distant metastasis
  M1 Distant metastasis detected surgical treatment of recurrence did experience a significantly
higher rate of delayed complications, including chronic rhini-
Théon Modified Staging System (6)
tis, osteomyelitis, and osteonecrosis (15). In the radiation and
  S1 unilateral or bilateral neoplasm confined to the nasal passage surgery group, 5 of the 13 dogs (38%) developed recurrent or
without extension into the frontal sinus
chronic rhinitis that developed into osteomyelitis; in the surgery-
  S2 bilateral neoplasm extending into the frontal sinuses with only group, only 4 of the 40 dogs (10%) developed chronic
erosion of any bone of the nasal passage
rhinitis (15). Further studies need to be done to confirm the
benefit of surgery for recurrent disease after radiation treatment
reported for other histologic types: full-course radiation resulted and to better define the level of risk of severe delayed effects.
in a median survival time of only 5.5 mo (12). Using Théon’s The current recommended treatment for canine sinonasal
modified staging system, dogs with Stage 2 disease had a 2.3-fold tumors at the Western College of Veterinary Medicine is full-
higher risk of relapse after radiation therapy than dogs with course radiation therapy in combination with a slow-release
Stage 1 disease in one study; however, other studies have not cisplatin polymer that is administered intramuscularly on the
found that stage of disease impacted prognosis (6,8,10,11,13). first day of radiation treatment. Radiation generally involves
Additional factors that may adversely affect prognosis include 18–20 fractions, which are given under general anaesthesia
the presence of facial deformity at the time of presentation, age Monday to Friday for 3½ to 4 wk as an out-patient procedure.
over 10 years, and the presence of regional lymph node metas- As with all full-course radiation treatments, acute effects will
tasis at time of diagnosis (9,10). occur to varying degrees. Potential acute effects include oral
Cisplatin is a chemotherapeutic agent known to increase mucositis, skin erythema and desquamation, conjunctivitis,
tumor cell kill when used in conjunction with radiation therapy, and keratoconjunctivitis sicca (8). Pain is controlled through
in part due to decreasing the ability of the tumor cells to repair oral medications such as nonsteroidal anti-inflammatories and
DNA damage caused by ionizing radiation (14). When com- opioids, as well as daily local anaesthetic blocks and oral rinses.
bined with full-course radiation, cisplatin may improve median Acute side effects of radiation usually begin to develop during
survival times for canine sinonasal tumors (7,8). In a 1997 the 2nd to 3rd week of treatment, are at their worst at 2 wk
study involving 13 dogs, Lana et al (7) found that the use of after finishing treatment, and are generally completely healed
a slow-release cisplatin polymer was well tolerated, and that it by 4 wk post-treatment.
may improve the median survival time in dogs with sinonasal With full-course radiation treatment there is a low risk, typi-
tumors treated with radiotherapy. This finding was supported in cally less than 5%, of serious side effects occurring months to
a 2nd, retrospective analysis of 51 dogs with malignant sinona- years after radiation therapy in normal tissues that are included
sal tumors, where the authors found that the use of full course in the radiation field. This risk is accepted in order to administer
radiation therapy in combination with slow-release cisplatin a sufficient dose to the tumor to result in a good probability of
resulted in a median survival time of 15.8 mo (8). Local reaction long-term tumor control. Late effects that may be seen months
to the intramuscular slow release cisplatin polymer may occur. to years after radiation if the eyes are within the treatment field
This can range from a mild reaction that responds to antibiotic include keratoconjunctivitis sicca, keratitis, corneal vasculariza-
therapy to moderate to severe reactions that require removal of tion, and cataract formation (8). Skin pigmentation changes,
the implant and tissue debridement (8). Reactions may occur up alopecia, and coat color changes are also commonly seen within
to 6 mo after implant (8). Other side-effects of cisplatin include the radiation field.
bone marrow suppression and renal toxicity. In conclusion, while sinonasal tumors in dogs are rarely
One recent study involving 53 dogs showed that, if the tumor cured, radiation therapy can significantly improve the expected
recurs after full course radiation therapy, exenteration of the median survival time, and is the treatment of choice. A full
nasal cavity significantly improves the median survival time workup should be performed for any older dog presenting with

CVJ / VOL 50 / MARCH 2009 311

 chronic nasal discharge, and referral to a radiation oncology 13. Adams WM, Withrow SJ, Walshaw R, et al. Radiotherapy of malignant
nasal tumors in 67 dogs. JAVMA 1987;191:311–315.
center is recommended once the diagnosis of sinonasal neoplasia
14. Boeckman HJ, Trego KS, Turchi JJ. Cisplatin sensitizes cancer cells to
has been made. ionizing radiation via inhibition of nonhomologous end joining. Mol
Cancer Res 2005;3:277–285.
Acknowledgments
Le co i n d e l’ o n colo g i e

15. Adams WM, Bjorling DE, McAnulty JF, Green EM, Forrest LJ,
Vail DM. Outcome of accelerated radiotherapy alone or accelerated
The authors thank Dr. Stephen Withrow of the Colorado State radiotherapy followed by exenteration of the nasal cavity in dogs with
University Animal Cancer Center for providing the sagittal intranasal neoplasia: 53 cases (1990–2002). J Am Vet Med Assoc 2005;
227:936–941.
image of a canine head, and Dr. Kimberly Tryon of the Western
College of Veterinary Medicine for providing the radiographic
image of the sinonasal tumor. CVJ

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