The lateral wall of nasal cavity, maxillary sinus and septal sinus are anatomically adjacent to each other, so it is usually difficult to distinguish the primary location of tumors in these areas except for early stage cancer. Most malignant tumors of the nasal cavity are primary carcinomas, mostly located in the lateral wall of the nasal cavity, with a few occurring in the nasal septum, nasal vestibule and nasal floor. Malignant tumors of the sinuses and nasopharynx may extend directly into the nasal cavity. Metastatic cancer of the nasal cavity is less common. Most of the malignant tumors of nasal cavity are of epithelial origin, mostly squamous cell carcinoma, other adenocarcinoma, adenoid cystic carcinoma, undifferentiated carcinoma, basal cell carcinoma, etc. The non-epithelial ones are lymphoma, olfactory neuroblastoma, malignant melanoma, smooth muscle sarcoma, chondrosarcoma and other sarcomas, etc. The so-called necrotizing sarcoma, which used to be common in clinical practice, has been classified as T-cell lymphoma. Surgical pathology 1.Squamous epithelial cell carcinoma: It accounts for the majority of patients, and almost every patient with nasal carcinoma has bone destruction at the initial diagnosis. The tumor can enter the maxillary sinus and septal sinus from the nasal cavity, cross the paper plate into the orbit, invade the anterior wall to the dorsum of the nose or the soft tissue of the cheek, or penetrate the hard palate and invade the mouth. 2.Adenocarcinoma: including small salivary gland origin tumor. Adenocarcinoma has similar bone destruction and clinical symptoms and course as squamous cell carcinoma. Pathologically, it is divided into two categories: highly malignant and low malignant, and the former has a very poor prognosis. Among salivary gland tumors, adenoid cystic carcinoma is the most common, which is located in the upper part of the nasal cavity and mainly expands to the orbit and septal sinus, and is easy to metastasize distantly due to vascular nerve invasion. 3.Malignant melanoma: it accounts for about 1% of paranasal sinus cancer in the nasal cavity. It is mostly found in 25-50% of nasal septum, or middle and lower turbinates, and often extends to maxillary sinus or protrudes outside the nose. The ratio of male to female incidence is equal, and the peak age is 40-60 years. Melanoma often presents as gray, blue, or black polypoid masses, often with peripheral satellite foci and cervical lymph node metastases. Anaplastic melanoma often presents as unilateral polypoid changes; therefore, all polypoid material should be sent for pathological examination after surgery. The biological behavior of melanoma is difficult to predict. Some do not recur after excision, while others spread extremely widely and can die within a few months. Others, after treatment, appear to suppress the tumor for several years with an effective immune system. 50% survive for 3 years. About 20% develop cervical lymph node metastases, mostly to the submandibular lymph nodes and then to the internal jugular vein lymph node chain. It can invade into the skull via skull base, and distant metastasis is more common. 4. Olfactory neuroblastoma: It is less common and also called as sensory neuroblastoma or neuroendocrine tumor. The tumor occurs in the upper nasal cavity and originates from the olfactory cells of the neural spine stem cells. The tumor appears to have two peak incidences in the age group 11-20 years and 51-60 years, and in the older age group it is called neuroendocrine tumor. Local recurrence rates are low and distant metastasis rates are high in the age group of 20 years; the opposite is true in the age group of 50 years. The tumors are slow growing and often involve the sieve plate in larger cases. Pathologically, it resembles undifferentiated carcinoma and the diagnosis requires specific tumor markers. Kadish staging is generally used to classify the lesions into three stages according to the extent of tumor involvement: stage A, where the tumor is confined to the nasal cavity; stage B, where the tumor involves one or more paranasal sinuses; and stage C, where the tumor extends beyond these areas. 5.Lymphatic reticular cell tumor: malignant lymphoma mostly occurs from the posterior part of the nasal cavity, with larger masses, often extending to the soft palate and pharynx. They include three types: lymphomatous granuloma multiforme, extramedullary plasmacytoma, and non-Hodgkin’s lymphoma. 6. Inverted papilloma: Papilloma of the nasal cavity and paranasal sinuses is an uncommon junctional tumor with potential malignancy. Especially after repeated incomplete surgery recurrence often becomes malignant or becomes squamous cell carcinoma. The histopathologic subdivisions are involute papilloma, mycotic papilloma, and cylindrical cell papilloma, the latter two being much rarer. One of the characteristics of involute papilloma is that it is prone to recurrence, especially after minor local surgical excision. The most common symptom is nasal congestion in 71% of cases, followed by epistaxis in 27% of cases, and in 17% of cases there is a combination of squamous cell carcinoma of the sinuses or nasal cavity, or papillary malignancy. Involutional papillomas often originate in the lateral wall of the nose and occasionally in the septal sinus, superior sinus, pterygoid sinus, and frontal sinus. Intracranial invasion or invasion of the dura mater is rare and is often associated with postoperative recurrence and malignancy, and in very rare cases, the middle ear and temporal bone may be involved by direct extension of the eustachian tube. Clinical manifestations (a) Symptoms 1. Bloody or purulent discharge from nasal cavity. It is the early symptom of nasal carcinoma, and epistaxis may occur occasionally. Squamous carcinoma has more purulent discharge and odor because of superficial tumor necrosis and infection; malignant melanoma has more bloody discharge; malignant lymphoma, adenocarcinoma and soft tissue sarcoma have less abnormal discharge. 2. Nasal obstruction. It is the most common symptom. The tumor causes obstruction of the airway in the nasal cavity, usually unilateral, but when the tumor is large, it compresses the nasal septum and causes obstruction of the opposite side of the nose, or even obstructs the pharyngeal cavity, causing difficulty in breathing. 3.Sense of smell obstruction. It can be caused by the tumor invading the olfactory area, and it can also be caused by the obstruction of airway. 4.Pain. It can be manifested as intranasal pain, upper toothache, migraine, etc., which are mostly caused by tumor invasion of nerve. Late stage nasal malignant tumor can invade II, III, IV, V, VI and other nerves in the brain. 5. Neck or submandibular masses. It appears due to lymph node metastasis in the neck or submandibular area. 6.Other. If the tumor invades the surrounding tissues and organs, it may cause lacrimation due to compression of the nasolacrimal duct, eye displacement and diplopia due to invasion of the orbit, or loose teeth due to invasion of the alveolar canal, etc. (2) Signs 1. Change of nasal shape. Due to the extrusion of tumor, the shape of nose changes, i.e. the dorsum of nose becomes wider and protrudes, and in advanced stage, the tumor may penetrate the skin of dorsum of nose. 2. Nasal swelling. Through nasal speculum and indirect nasopharyngoscopy, nasal masses can be found, and sometimes the masses can protrude to the nasal vestibule. Squamous cell carcinoma is mostly cauliflower-like, with ulcerated and necrotic surface, brittle and easy to bleed. Malignant melanoma is mostly black or light brown in color, and a few of them may be non-pigmented, with bloody exudate. Olfactory neuroblastoma is polypoid or gray-red in color with abundant blood vessels. Adenocarcinoma tumors are nodular in shape, with normal mucosa in the early stage, but may ulcerate in the late stage. Malignant lymphoma and soft tissue sarcoma usually have larger tumors with smooth surface mucosa. 3.Eye displacement. In late stage, the tumor invades the orbit and squeezes the eye to shift outward, anterior and superior, with limited eye movement and conjunctival edema. 4. Enlarged lymph nodes in the neck. In patients with lymph node metastasis, enlarged lymph nodes can be palpated, among which enlarged deep upper cervical lymph nodes and submandibular lymph nodes are more common. Diagnosis (a) Clinical manifestations are mainly the symptoms of tumor occupancy, including facial swelling or nasal bloody or purulent discharge, nasal obstruction and craniofacial neuropathic pain. The physical signs are nasal mass, nasal shape change and eye displacement. (2) Diagnostic imaging 1. Plain X-ray: On the X-ray, the soft tissue shadow of the nasal cavity is seen, the nasal cavity on the affected side is enlarged, the bone of the lateral wall of the nasal cavity is commonly destroyed, and the paranasal sinus is clouded if the sinus opening is blocked. Since the availability of CT, the significance of X-ray examination is no longer important. 2. CT scan: CT can well show the scope of nasal mass and its relationship with adjacent structures, and show the destruction of bone structure, which can help determine the nature of the lesion. 3. Magnetic resonance imaging MRI: MRI can directly image in multiple planes and has good soft tissue resolution, which can accurately show the extent of lesions and can also identify some lesions, especially tumors and inflammation. The vast majority of tumors in the nasal cavity show low or moderate signal on T2-weighted images, mainly because these tumors are cell-rich and mostly squamous, followed by small salivary adenomas, especially malignant mucous epithelioid salivary adenomas, where the lower the signal on T2-weighted images, the more aggressive they are. Other tumors include lymphoma, extramedullary plasmacytoma, rhabdomyosarcoma, and glioma. Inflammatory lesions are usually high signal on T2-weighted images. Papillomas are high signal on T2-weighted images, and melanomas are high signal on both T1- and T2-weighted images. Tumors are often associated with inflammation, and tumors are more likely to occur at sites of chronic inflammation, especially squamous carcinomas, but the inflammation shows significant high signal on T2-weighted images. (C) Tissue biopsy For the confirmation of nasal tumor, biopsy is required. When biopsy of nasal tumor, the following points should be noted: 1. There is often a layer of necrotic tissue on the surface of nasal tumor, if the biopsy is superficial, the tumor tissue may not be retrieved, but if the biopsy is done on a large piece of deep tissue, it may cause unnecessary bleeding, therefore, the biopsy should first remove the surface necrotic tissue, and then take the material from the outer layer of the tumor entity, and the tissue piece should be sufficient; 2, 2.Sometimes nasal tumor is accompanied by polyp, papilloma, hemangioma or blood clot, so attention should be paid to find different appearance of tissue biopsy to avoid missing the tumor; 3.Sometimes nasal tumor occurs bilaterally, but not in the same pathological form, so both sides should be sent for pathological examination separately, not mixed to avoid misdiagnosis. For malignant melanoma, early biopsy is generally not recommended, but should wait until the examination is completed and treatment is about to start, and the pathology report should be issued quickly. The tumor is often found in the lateral wall of the nasal cavity and the paranasal sinuses, often multiple, with a granular, papillary or polyp-like appearance, red or purplish red. The histological features are squamous epithelium or metastatic epithelium growing finger-like into the mesenchyme, forming crypt of different sizes, in which there are epithelial cells, leukocytes and necrotic tissue; some crypt disappears, forming cell nests or cell clusters; a large number of glycogen-containing vacuoles and small mucous glandular sacs can be seen between the epithelial cells; the epithelium is separated from its underlying mesenchyme by an intact basement membrane, and the mesenchyme is a fibrous or edematous structure with inflammatory cells between. Infiltration. The clinical manifestations of this disease vary according to the size of the tumor, but the most common manifestations are nasal obstruction and nasal masses, increased nasal discharge, epistaxis and head and facial pain in some patients. The most common manifestations are nasal obstruction, nasal masses, increased nasal discharge, epistaxis, head and facial pain, etc. Endorectal papilloma is locally destructive, easy to recur, and 10%-20% are cancerous. It can be identified by biopsy. The treatment of this disease is mainly surgical treatment. 2, nasal polyps Most common in adults, can occur in one or both nasal cavities, manifested as nasal congestion, increased nasal secretion, loss of smell and headache. Nasal polyps are edematous hypertrophy of the nasal mucosa due to chronic stimulation, and the edematous tissue drops down to form polyps. The polyp is mostly attached to the lateral wall of the nasal cavity, its shape is smooth and shiny, gray-white, such as lychee flesh-like; touch with a probe, the quality is soft and not easy to bleed; after using vasoconstrictor, it is not easy to make it shrink. The polyps can be identified by removing them and sending them for pathological examination. 3, nasal sclerosis Most often occurs in about 30 years old, lesions in the anterior part of the nasal cavity, manifested as hard nodules, accompanied by infection, external nasal and upper lip hardening, deformation. The pathology is characterized by granulomas with plasma cell infiltration and foreign body giant cells, with abundant collagen fibers. It can be identified by biopsy of the mass. 4.Paranasal sinus cancer Late stage paranasal sinus cancer often involves the nasal cavity, and nasal obstruction is its secondary symptom, and radiographs and CT scan show that the lesion is mainly in the paranasal sinus. Comprehensive treatment The treatment of highly differentiated squamous carcinoma of nasal cavity should be preferred to the comprehensive treatment of radiotherapy and surgery. The 5-year survival rate of nasal septal sinus squamous carcinoma can reach 60%. In case of lymph node metastasis in the neck, the comprehensive treatment should include the neck, and when the lymph nodes in the neck are clinically negative, prophylactic neck irradiation is not advocated. Hypofractionated squamous carcinoma and undifferentiated carcinoma are mostly advanced when they are diagnosed, and they are more sensitive to radiotherapy, so radiation therapy alone can achieve more satisfactory results. Surgery still has a chance to save the patient after failure of radiotherapy. Adenoid cystic carcinoma often invades along the nerve sheath, and postoperative radiotherapy should be used when the surgical residue or safe margin is not enough. Malignant melanoma The prognosis of nasal malignant melanoma is better than that of malignant melanoma originating from the trunk, and the main reason for treatment failure is still distant metastasis. Treatment is based on an integrated treatment model of radiotherapy ten surgery ten chemotherapy and biotherapy. Endorectal papilloma The first choice of treatment for endorectal papilloma in the maxillary sinus of the nasal cavity is surgery. For patients who cannot be completely removed by surgery, or who have multiple recurrences, or who have malignant changes, the treatment principle is the same as that for nasal squamous carcinoma, and radiation therapy should be considered. The recurrence rate of lateral nasal wall resection is 30%, and the multiple recurrence rate of small resection cases is as high as 71%. Although more conservative sinus surgery has been reported in the literature in recent years, nasal lateral resection with nasal incision is still advocated for involuted papilloma of the nasal cavity and sinuses. Endoscopic resection is also feasible for relatively limited early lesions. Olfactory neuroblastoma in clinical stage A can be treated with radiotherapy alone or surgical excision alone,. In contrast, a combination of radiotherapy plus surgery is appropriate for stage B olfactory neuroblastoma, and similar results have been reported for single approach treatment and combination treatment. The prognosis of stage A and B olfactory neuroblastoma is better, with 3-year survival rate of 88.9% and 83.3% respectively, while the prognosis of stage C olfactory neuroblastoma is poor, with 3-year survival rate dropping to 52.9%. The 5-year survival rate for nasal septal sinus cancer is about 60% in early stage and 20%-30% in late stage with radiotherapy alone. The 5-year survival rate of combined treatment is 60%-70% in the early stage and 60% in the late stage.