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KUANetal.

TABLE X.5 (Continued)

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Miglani et al. 272

2017 4 a

EEA offers comparable survival outcomes to open surgery with similar rates of complications and negative margins

1. Negative margins 2. Complications 3. LOS 4. OS 5. DFS

Retrospective cohort

22 patients EEA( n = 9)

Open ( n = 13)

Wonet al. 269

2015 4 a

Retrospective cohort

133 patients EEA( n = 59) Combined approach ( n = 11) Open ( n = 63)

1. Recurrence 2. OS

Endoscopic-inclusive surgical approaches exhibited improved local control and survival

Menget al. 273

2014 4 a

OS

OS was similar between surgical approaches

Retrospective cohort

69 patients Open ( n = 41) EEA( n = 28)

Abbreviations: DFS, disease-free survival; DSS, disease-specific survival; EEA, endoscopic endonasal approach; LOS, length of stay; LRC, locoregional control; NCDB, National Cancer DataBase; OS, overall survival; RFS, recurrence-free survival. a LOE downgraded for lack of controlling for confounding factors.

Open versus endoscopic approach for sinonasal tumors

comorbidity index scores between the EEA and open approach groups ( p > 0.05). Jiang et al. performed a systematic review and meta analysis of 23 studies comparing EEA ( n = 653) versus open approaches ( n = 720). 298 The authors performed a pooled analysis that included 130 EEA and 118 open approach patients. The OS in EEA was 31.7% compared to 21.1% in the open approach group ( p < 0.05). DFS for EEA was 19.9% and for open surgery was significantly lower at 15.5% ( p < 0.05). Pooled analysis revealed significant differences in OS, favoring EEA (HR 0.72, 95% CI: 0.58– 0.88, p = 0.002). However, the quality assessment of the included studies was low and the assessment of certainties was very low. The data consistently suggest that survival outcomes for EEA are comparable or, in some cases, bet ter than the open approach. Data for low-stage tumors are stronger than the data for high-grade tumors. All studies included in this review compared an open approach to EEA. The results published by most of the studies currently available are limited due to their small sample sizes, which are often unpowered and without adjustment for comorbidities and covariates, and subject to type 2 error. Nearly all utilize retrospective data with some variability in the outcomes measured. There is also selection bias whereby patients undergoing a more mini mally invasive approach have more favorable tumor stage, histologic types, and prognostic factors. However, there are some conclusions that can be drawn from the cur rently available evidence presented in most of these studies (Table X.6).

Aggregate grade of evidence

C (Level 2: one study; Level 3: nine studies; Level 4: 45 studies) Compared to open surgical approaches, endoscopic surgical approaches generally yield reduced morbidity and shorter recovery times with similar oncologic outcomes in low-stage tumors (stage T1–2; Kadish A–B) and certain high-stage tumors (stage T3–4; Kadish C–D) Failure to achieve GTR with negative margins in extensive or high-stage tumors, which could lead to tumor progression or invasion of surrounding structures. Potential for higher risk of CSF leak. Reduction in cost is possible with EEA related to reduced operative times, shorter hospital LOS, and reduced morbidity. A preponderance of benefit over harm exists for the use of endoscopic surgery approaches in low-stage tumors. For high-stage tumors, benefits of endoscopic surgical approaches when negative surgical margins can be achieved, including reduced morbidity and shorter recovery time, may outweigh potential harms depending on the comfort and experience of the surgical team.

Benefit

Harm

Cost

Benefits–harm assessment

(Continued)

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