2018 Section 5 - Rhinology and Allergic Disorders

Eur Arch Otorhinolaryngol (2016) 273:4343–4350

the most appropriate surgical approach. The external pro- cedure, long time considered as the mainstay of treatment, is often criticized for higher morbidity. In our study, the only two major complications were reported in LR group. Technical advances with increasing skills in the endoscopic surgery led several authors to introduce this approach as an alternative for the treatment of selected ethmoid ADC [ 6 ]. Recent publications showed the validity of ESS for the removal of selected cases of ADC [ 11 , 12 ]. A multicentric study about 159 patients treated with ESS for sinonasal ADC from nine institutions showed the efficiency and the low morbidity of the procedure [ 13 ]. However, the thera- peutic options in this multicentric study were very heterogeneous. As a consequence, studies aimed to strictly compare outcomes between external and endoscopic approaches are required. We proposed herein to compare the outcomes of two recent consecutive series of patients with ethmoid ADC treated through open and endoscopic approaches in the same institution, both systematically followed with adju- vant RT. To reduce potential heterogeneity induced by specific histological behaviour, we focused our study on patients with ITAC, by far the most frequent in the ethmoid sinus. Noteworthy, the mucinous subtype known to be associated with poor outcome [ 14 ] was equally distributed in the two groups of patients in our study. The period of inclusion for the patients treated through LR was limited at the early 2000s to be sure that all of them received 3D conformal RT. These strict criterions of inclusion explain the relative small size of our population over 12 years. In other studies comparing open and endoscopic approaches, ESS has often been considered as a treatment option for tumours of small size, whereas LR was selected for more advanced disease [ 15 ]. To avoid this bias of selection, the patients who would have anyway required an external approach were beforehand excluded from our population in each period of treatment. Thus, four T4 ITAC with orbital apex or skin invasion were excluded from our comparative analysis. Thereby, we observed that the pT stage distribu- tion even for pT4a and pT4b was comparable in our two groups of patients. As a complete extirpation of the tumour was mandatory, debulking through LR or ESS was also excluded from our study. The 3-year and 5-year survival rates observed for the 43 patients are in accordance with published data [ 2 , 9 , 16 ]. Nodal and distant metastases were exclusively observed in the LR group. As progression to lymph nodes or distant metastases is unfrequent due to the poor drainage to lymph vessels to the nasal cavities [ 9 , 14 ], these findings can be explained by a longer follow-up in the LR group. We showed that 3-year and 5-year DFS were not statistically different between LR and ESS, both associated with adjuvant RT. Grosjean et al. described the same results in

Nodal and distant recurrences were observed, respectively, in two and three patients (5LR). Distant metastases were associated with local failure in one patient and with nodal recurrence in one patient. Treatments of the recurrences are summarized in Table 3 . For T recurrence, where selected an endoscopic revision in seven patients, a maxillectomy through midfacial degloving approach in one patient and an exclusive radiation therapy in one patient. For the 43 patients, the 3-year disease-free survival (DFS), overall survival (all deaths observed), and disease specific-survival (deaths induced by ITAC progression) rates were, respec- tively, 76.3, 93.6, and 96.3 %. The 5-year disease-free survival, overall survival, and specific-survival rates were, respectively, 61.8, 90, and 96.3 %. Among the 13 patients deceased at the end of the follow-up period, 6 were related to disease progression (4LR, 2ESS) (Table 3 ). The 3-year and 5-year DFS were not different between LR and ESS groups ( p = 0.4) (Fig. 1 ). Fig. 1 Comparison of disease-free survival (DFS). The 3-year and 5-year DFS were not different between the lateral rhinotomy (LR) and the endoscopic sinus surgery (ESS) groups ( p = 0.4)

Discussion

With a low incidence preventing any prospective ran- domized study, ADC of the sinonasal tract is difficult to assess in terms of surgical outcomes. Many studies dealing with ADC often compare patients with different origins, different stages or histological subtypes pooled from sev- eral institutions [ 2 ] or included during a long period of time [ 9 , 10 ]. As long as complete extirpation of the tumour is achieved, the current debate in ADC management is about

123

253