xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

margins or surgical complications. Indeed, it appears that successful achievement of negative margins when resecting tumors involving the skull base is predictive of improved survival regardless of the extent of intracranial extension. 130,132,174,178,181–185 However, it should be noted that, in the studies examined, patients with extensive brain parenchymal involvement were often excluded from surgical therapy and therefore an assessment of their resectability is not feasible. Sinonasal tumors may invade the cavernous sinus along several pathways: through the orbital apex (via superior or inferior orbital fissures), through the paranasal sinuses or pterygopalatine fossa (PPF) (via foramen rotundum or ovale), along the course of the ICA, or by direct invasion. Therefore, evaluating resectability of tumors involving the cavernous sinus is frequently considered in tandem with involvement of the orbital apex, carotid artery, or PPF. Data from 40 patients with maxillary sinus carcinomas found that invasion of the cavernous sinus was an indepen dent predictor of poor OS and led to a decrease in 5-year OS from 72.4% to 20% ( p = 0.012), even with attempted en bloc resection. 186 Once tumors involve the cavernous sinus, en bloc or negative margin resection may require sacrifice of the cavernous ICA or multiple cranial nerves, first described by Saito et al. in 1999. 187 However, the rate of severe complications may be unacceptably high. Studies by Saito et al. and Couldwell et al. both report two surgery related deaths among other morbid AEs (stroke, sepsis, CSF leak) in small case series. 187,188 No large-scale stud ies evaluating the resectability of sinonasal tumors with cavernous sinus involvement were found (Table VIII.4). Aggregate grade of evidence : C (Level 3: three studies; Level 4: 12 studies) The proximity to cranial nerves and other vital structures has made the PPF and infratemporal fossa (ITF) histor ically challenging to access and resect. Several authors have reported that the rate of negative margin resection of tumors involving the PPF and ITF ranges from 56% to 77%. 189–192 He et al. found that close or positive mar gins within the PPF or ITF were associated with worse 5-year RFS (hazard ratio [HR] 6.158, p = 0.001) and OS (HR 21.961, p = 0.006). 191 Similar effects were reported by Konig et al., where retromaxillary involvement was associated with worse survival at 2, 5, and 10 years (35%, 29%, and 17%, respectively). 193 In contrast, others found that PPF or ITF involvement was not an independent risk factor for worse outcome when compared to T4b tumors. 194 Based on the limited data available, tumors involving the PPF or ITF E Pterygopalatine and infratemporal fossa involvement

may be accessible surgically and their isolated involvement may not be an independent risk factor for worse progno sis, but in keeping with other subsites, positive surgical margins portend a poorer OS (Table VIII.5). Aggregate grade of evidence : C (Level 3: one study; Level 4: five studies) In nearly all subsections above, there were no high quality, prospective studies evaluating the feasibility of GTR as a primary treatment paradigm for nonrecurrent, very advanced SNM. The preponderance of literature eval uating T4b sinonasal tumors addresses patient outcomes undergoing primary nonsurgical therapy, surgery follow ing neoadjuvant systemic therapy, or the role of surgical debulking prior to definitive radiation. For the purposes of this consensus statement, this review excluded histo logic subtypes in which surgery is not considered first-line treatment. Lymphoma and NPC, for example, are consid ered curable utilizing nonsurgical therapy. In addition, the examination of (1) the role of neoadjuvant systemic therapy prior to surgical extirpation and (2) the role of surgi cal debulking prior to definitive radiotherapy is discussed in other sections of this consensus statement. Overall, the constraints of resectability continue to evolve and are driven by a complex interplay of patient character istics, tumor histology and invasion, surgeon experience, institutional preference, and adjuvant or neoadjuvant therapy. Staging in head and neck malignancies is essential to guide surgical oncologists, radiation oncologists, and medical oncologists toward the most successful treatment options for these tumors. Status of regional and distant metastasis prior to treatment is essential after establishing diagnosis of a malignant primary lesion, as it helps determine prog nosis and may change treatment options. Presence of nodal metastasis has been associated with up to 50% decrease in survival. 195 Although cervical metastasis can be clinically apparent on physical examination in advanced cancers, metastasis may also be discovered on initial staging radi ological imaging. 195 NCCN Head and Neck guidelines recommend CT or MRI of the neck to evaluate cervical nodal metastasis. 196 They specify using either modality as indicated for evaluation of the primary site. CT chest or PET/CT is recommended for “high-grade tumors, mul tistation, or lower neck nodal involvement.” 196 PET/CT is recommended when available in surgically resectable tumors near midline and in the workup of distant metasta sis in patients with advanced cancer including T3, T4, and N1 or higher nodal status. 196 IX WORKUP OF REGIONAL AND DISTANT DISEASE