2018 Section 5 - Rhinology and Allergic Disorders

Eur Arch Otorhinolaryngol (2016) 273:4343–4350

average 3 days shorter for ESS group, and the mean delay between surgery and RT was 50 days for LR group and 43 days for ESS group. The role of chemotherapy is still being investigated in ADC [ 17 ]. Some authors showed that the additional of topical chemotherapy to endoscopic resection can improve survival [ 15 ]. The validity of this policy needs to be confirmed.

excision with duraplasty may not have been planned with the preoperative radiologic assessment. However, this is a time consuming procedure that requires a skilled and available pathologic team. Unless CT scan and MRI can clearly show tumour extension beyond sinuses boundaries, the endoscopic approach must be considered in first attempt. Given plausible misinterpretation in tumour assessment, we chose to use pathological T staging to compare ADC extension between the LR and ESS groups. Even though the TNM staging system is still the stan- dard of comparison for many studies in terms of onco- logical outcomes [ 26 ], it does not reflect the anatomical difficulties encoutered for some tumours resection with endoscopic techniques. A T3 lesion with lateral involve- ment of the maxillary sinus is more difficult to control than a T4a with limited anterior skull base invasion. Further- more, as demonstrated by Cantu et al., the definitions of sphenoid sinus or frontal sinus involvements are far too general. A tumour eroding the antero-inferior aspect of the sphenoid sinus or the lower part of the frontal sinus are quite easy resectable. A tumour of the frontal sinus may be resected more radically than a tumour extended to the pterygoid plate. Often considered as the last stage of a stepwise learning process, endoscopic removal of sinonasal malignant tumours was all performed by the same senior surgeon with a strong expertise in this field. Thus, we avoided any potential influence of a learning curve on outcomes. Although there is a lack of evidence to support the use of postoperative RT in completely resected cases [ 18 ], we still deliver adjuvant RT on the primary tumour site whatever the T stage. De Gabory et al. [ 10 ] recommended avoiding RT for small tumours with limited extension far from the orbit, the cribriform plate, or the meninges. Nicolai et al. [ 9 ] limited the indications of RT to patients with advanced lesions or positive margins. In a recent multicentric retrospective study comparing patients with pT1 pT2 ITAC treated with or without postoperative RT, Turri-Zanoni et al. showed that postoperative RT could be avoided in selected pT1 low-grade ITAC [ 19 ]. However, the previous studies showed that adjuvant RT improves local control regardless of surgical margins [ 27 ]. In our institution, we did not opt for a step down protocol, as we first wanted to validate the endoscopic approach per se in ADC management. In accordance with a large retrospec- tive study of 123 ITAC treated with ESS [ 20 ], we still not considered ESS as a single treatment modality for primary early stage ITAC. Noteworthy, postoperative RT, which may be delayed by wound healing in open procedures, can be administrated immediately following ESS [ 15 ]. ESS offers better cosmetic outcome and shorter hospital stay which can be considered as advantages for adjuvant ther- apy implementation. In our study, the hospital stay was in

Conclusion

In our comparative study of ITAC treated with open or endoscopic approaches, we showed retrospectively that ESS is a valid option even for local advanced tumours in close vicinity to the anterior skull base. The intraoperative assessment of tumour extensions is more relevant than CT scan and MRI to determine the feasibility of this surgical approach. A complete centripetal removal of the ethmoid labyrinth is mandatory to circumscribe the ADC origin frequently observed in the olfactory cleft. Nevertheless, the external approach remains the procedure of choice for ADC with extrasinusal extension towards the orbit, the anterior part of the frontal sinus, and the lateral portion of the maxillary sinus.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of interest.

Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent Informed consent was obtained from all individ- ual participants included in the study.

References

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