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KUANetal.

TABLE XII.2 Evidence surrounding impact of approach on margin status.

Clinical endpoints 1. Impact of

Study

Year LOE Study design Study groups

Conclusions

1. No significant difference in MS between EEA and OR 2. No significant difference in hazard of death between PM and NM No significant difference in MS between EEA and endoscopic-assisted resection

Almutuawa et al. 277

2020 3

Retrospective cohort

Patients with SNMM who underwent either EEA ( n = 10) or open surgery ( n = 10) EEAof SNM( n = 167) versus endoscopic-assisted resection of SNM ( n = 72) Patients with SNMM who underwent either EEA (PM = 2, NM = 25) or open surgery (PM = 3, NM = 24) Patients with ONB treated with either EEA( n = 67; PM = 8,NM = 59) or open surgery ( n = 42; PM = 20, NM = 22) EEA( n = 28) versus open surgery ( n = 55) Patients in the NCDB with SCC treated withEEA( n = 353; PM = 74,NM = 169) versusOR( n = 1130; Patients with SNM who underwent

EEAonMS

2. OS

Abdelmeguid et al. 182

2019 3

Retrospective cohort

MS differences between approaches

Yinet al. 268

No difference in ability to obtain NM via EEA versus open surgery

MS differences between approaches

2018 3

Retrospective cohort

Harvey et al. 243

2017 3

Retrospective cohort

1. MS

1. The ability to achieve NM was better in EEA versus open surgery for both Kadish B and C stage tumors 2. MS was a major predictor of survival for the group as a whole

differences between approaches

2. Five- and

10-year DFS

Arnold et al. 297

MS

No significant difference in PM between EEA and open surgery

2012 3

Retrospective cohort

Kilic et al. 135

2018 4

Retrospective database review (NCDB)

1. MS 2. OS

1. The rate of PM between EEA and OR was comparable when all tumor states were considered 2. There was a significantly greater PM rate in the EEA group for IVB tumors 3. MS was associated with poorer survival No difference between EEA versus open surgery on MS

(PM = 267, NM = 749)

Miglani et al. 272

MS differences between approaches

2017 4

Retrospective case series

Patients with mucosal melanoma who underwent either EEA( n = 9) or open surgery ( n = 13)

Abbreviations: EEA, endoscopic endonasal approach; MS, margin status; NCDB, National Cancer DataBase; NM, negative margins; ONB, olfactory neuroblastoma; PM, positive margins; SCC, squamous cell carcinoma; SNMM, sinonasal mucosal melanoma; SNM, sinonasal malignancy.

in melanoma. 384,392,393 For these reasons, surgeons should consider deferring to permanent pathology for analysis of margins. 271,384 Other instances where it would be rea sonable to defer to permanent pathology are times when intraoperative findings dictate a more aggressive surgical resection that has not previously been discussed with the patient. Several studies have shown the rate of positive mar gins after surgical treatment of SNM to be between 13%

and 30%. 160,161,174 Options for positive margins include returning to the operating room for re-resection versus adjuvant treatment in the form of chemotherapy, RT, or CRT. 140,141,161,289,363–365,372,394–396 The choice of how to address positive margins is complex and depends upon sev eral factors including whether it is feasible for negative margins to be achieved and the volume of tumor that is left behind. This decision must be made on a case-by-case basis.