xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

peripheral nerve sheath tumor, ACC, adenocarcinoma, and metastatic lesions. 216,223 Maurer et al. demonstrated that use of hybrid PET results in both additional radiological and clinically rel evant information, suggesting that hybrid PET imag ing should be used in staging all sinonasal cancers. 198 If PET/CT is used, it should be combined with addi tional MRI. 198 Thus, further studies on the use of hybrid PET/MRI have the potential to make it the imaging modal ity of choice in the future, combining both high-yield imaging techniques into one test. Gallium-69 Dotatate PET/CT imaging is another func tional imaging modality in somatostatin receptor overex pressing sinonasal tumors, such as ONB and SNEC. 224 It has the potential to be very useful in detecting small tumors and metastasis that may not have been identified with traditional imaging methods due to its strong affinity to the receptor. However, one must be aware that menin giomas, reactive lymph nodes, and other inflammatory processes, as well as some organs (liver, spleen, adrenal glands, pancreas, thyroid, and salivary glands), may also present with uptake despite being benign processes. 224 D Biopsy When cervical adenopathy is identified on physical exam and/or imaging, fine-needle aspiration biopsy (FNAB) should be performed to confirm histopathology and diag nosis of cervical metastasis. FNAB with image guidance (ultrasound or CT) is preferred. 196 The use of FNAB for histopathological diagnosis of primary and distant metas tasis is also described. 196,199,225 FNAB provides a rapid cytopathologic diagnosis of regional and, in many cases, distant metastasis. However, the RPLN can be a challeng ing location for FNAB due to anatomic constraints of the facial bones and the proximity of carotid sheath. Some providers have described endoscopic ultrasound-guided needle biopsy approach to the RPLN, but the value of such a procedure over imaging-based diagnosis has not been fully studied. 226,227 In cases of recurrent/metastatic disease, large vol umes of tissues are required, and core needle biopsy is a useful office-based procedure for this tissue acquisi tion. Advanced genomic sequencing allows providers an opportunity to incorporate targeted therapies as part of a patient’s treatment, but such testing requires a larger vol ume of tissue that can be acquired via core needle biopsy. Based on this review, physical examination with pal pation of the neck and imaging with CT and/or MRI should be requested in search of regional cervical and RPLN metastasis. RPLNs appear to be more prevalent than previously thought and should always be investigated, preferably with MRI. Hybrid PET has shown increased

usefulness in staging of sinonasal tumors and should be considered in primary workup due to its many benefits. However, clinicians should remain aware of the limita tions of this imaging modality. PET/MRI shows promise as an imaging modality that should be further investigated. Table IX.1 summarizes evidence surrounding the workup of regional and distant metastasis. Workup of regional and distant disease

Aggregate grade of evidence

C (Level 3: four studies; Level 4: 16 studies; Level 5: 12 studies) CT and MRI are complementary for regional and distant disease workup. Functional imaging such as PET/CT has high sensitivity and NPV, allows for baseline imaging, and is a single imaging technique for rapid simultaneous qualitative evaluation of the primary, regional, and distant metastasis. CTs expose patients to radiation. Workup of regional and distant metastasis and false-positive PET/CT may lead to additional (and potentially unnecessary) investigations, patient anxiety, and increased costs without a change in treatment. In a healthcare setting with limited resources, this may further increase delays in diagnosis and strain on the system. There is potential cost–benefit of hybrid PET scans since they can combine PET/CT or PET/MRI into a single exam and reduce the number and duration of hospital visits. CT and MRI are both useful modalities for regional and distant disease assessment. CT is faster, better tolerated, and more readily available than MRI, but does incur radiation exposure. MRI does not subject patients to ionizing radiation, but takes longer to perform, has a risk of motion artifact, and is contraindicated in patients with noncompatible ferromagnetic devices. Hybrid PET imaging allows for more rapid and accurate diagnosis of regional and/or metastatic disease, especially for high-grade Preponderance of benefits over harms. tumors and/or those tumors prone to metastases (e.g., SNUC, melanoma). However, there is potential for false-positive results, and thus it may be more useful for restaging than initial staging. It may not be as useful for tumors with low FDG avidity.

Benefit

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level

Recommendation.

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