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ICAR SINONASAL TUMORS

TABLE VIII.2 Evidence surrounding resectability of tumors involving the orbital apex.

Clinical endpoints

Author

Year LOE Study design Study groups

Conclusion

Li et al. 164

Survival

Grade 3 orbital invasion was associated with shorter 5-year OS, LRFS, PFS, and DMFS Orbital apex invasion was a negative prognosticator in 5-year OSandDSS Extended orbital apex exenteration via middle cranial fossa approach may be feasible in accomplishing

2020 4

Retrospective case series

88 patients with T4 sinonasal SCC who underwent RT ± surgery sinonasal cancers with orbital invasion 15 patients with orbital apex extension of SNM 163 patients with

outcomes

Turri-Zanoni et al. 165

2019 4

Retrospective case series

1. DSS 2. OS

Sugawara et al. 166

N/A

2015

4

Retrospective case series

a negative-margin GTR with tumors involving orbital apex Abbreviations: DMFS, distant metastasis-free survival; DSS, disease-specific survival; GTR, gross total resection; LRFS, locoregional failure/recurrence-free survival; OS, overall survival; PFS, progression-free survival; RT, radiation therapy; SCC, squamous cell carcinoma; SNM, sinonasal malignancy.

considerable oncologic and operative risks that decrease the feasibility of resection. Surgical attempts to dissect or sacrifice the ICA risk arterial rupture and hemorrhagic or embolic stroke, which may be neurologically devastating or lethal. Therefore, the decision to pursue surgery must consider the probability of NMR against the risk of life threatening AEs. Extrapolating from studies of head and neck cancer patients, several parameters are associated with an inability to separate tumor from the ICA. Several groups have demonstrated that cervical carotid artery encasement by 270 ◦ or greater on preoperative imaging is 83%–88% sensitive and 100% specific for histologic vessel invasion (tumor ≤ 1.8 mm from the elastic lamina). 167,168 In contrast to open approaches to the cervical ICA, visual ization of tumors involving the skull base ICA segments may be impaired by tumor location (posterolateral aspect of the ICA) or in areas of significant bony coverage. In a heterogenous group of ventral skull base tumors with ICA involvement, Zhang et al. found that the rate of GTR was significantly associated with the degree of tumor encasement, a posterior location of tumor relative to ICA, the involvement of two or more ICA segments, and robust enhancement on postcontrast T1-weighted MRI sequences. 169 To address the limitations of resecting tumors invading the ICA, multiple groups have examined the role of cerebral revascularization or ICA bypass to facilitate carotid resection and augment the probability of NMR. Early studies of patients with skull base tumors undergoing ICA revascularization prior to GTR were cautious to recommend this paradigm due to higher vascular complications rates (incidence 20%–33% peripro cedurally), including stroke, subdural hemorrhage, bypass occlusion, and death. 170,171 However, at a high-volume center, Yang et al. found that, in patients with intracranial nonsinonasal tumors, high-flow cerebral revasculariza

tion allowed for 72% GTR rate with fewer periprocedural complications than previously described and mean OS of 46.4 months (range 12–81 months). 172 Furthermore, Ferrari et al. reported 10 patients with skull base cancer invasion of the ICA who were treated with ICA resection (two with bypass), with mean OS 27.2 months and 2-year PFS of 88.9%, and 10% perioperative mortality. 173 With careful evaluation of patient and tumor charac teristics, several strategies are often described to address tumors involving the carotid artery: (1) primary nonsurgi cal therapy (radiation and/or chemotherapy), (2) GTR with separation of tumor from the ICA when vessel invasion is not suspected, or (3) GTR with sacrifice of ICA (with or without perioperative cerebral revascularization in cases with suspected vessel invasion). To date, no long-term, definitive data have demonstrated a survival advantage with radical resection that includes ICA sacrifice com pared to primary nonsurgical therapy for SNM. There is no clear consensus on the benefits of carotid resection; how ever, revascularization of the carotid artery, if feasible, may allow GTR but is associated with significant perioperative risks (Table VIII.3). Aggregate grade of evidence : C (Level 4: seven stud ies) D Skull base involvement The detrimental effects of intracranial extension of SNM on OS, DSS, and RFS compared to tumors without intracranial involvement have been demonstrated across multiple large-scale case series. 174–176 Brain parenchymal invasion, in particular, is a remarkably potent predic tor of worse survival despite aggressive multimodality therapy. 175,177–181 CFR (either via open, endoscopic, or