xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

C Margin status and survival The literature on the impact of margin status on survival is mixed. This is potentially due to several issues. In general, studies are lower levels of evidence, consisting of retro spective reviews and database analyses. Several studies evaluated a mixed tumor type population, and the hetero geneity of these populations may have led to confounding. Finally, several studies evaluating the impact of margins on SNM are small and likely underpowered. For adenocarcinoma, ONB, and SCC, the majority of studies have demonstrated improved outcomes with neg ative margins. Regarding adenocarcinoma, several series show margin status significantly impacts OS, DFS, DSS, RFS, and LRC. 247,362,363,374 In ONB, margin status appears to significantly impact OS, DSS, and RFS, but the effect on DFS and distant metastasis-free survival (DMFS) is less clear. 181,243,254,372,394,396,397 Finally, for SCC, a majority of studies do show margin status to significantly impact OS with a few studies supporting an impact on DFS, DSS, and LRC. 130,140,160,161,241,247,389 For other pathologies, the literature is less conclusive. The data for ACC are fairly mixed with studies show ing an impact on OS but not DFS. 106,362,363,374–377,389,398,399 For melanoma, the literature is similarly mixed regard ing the impact of margins on OS; however, margin status more consistently does not appear to impact LRC. 232,271,277,364–366,368,373,400–402 IP is yet another pathol ogy where the literature shows conflicting results on the impact of margin status on recurrence. 276,369 Finally, several studies reported on a mixed tumor population, which is problematic for several reasons. As stated above, the inclusion of multiple different tumor types intro duces significant confounding, which limits both the interpretation of the results and the applicability to spe cific tumor types. Overall, in mixed tumor studies, the impact of margin status on OS is unclear; however, there does appear to be a benefit to DSS and RFS but little evidence to suggest a benefit for either LRC or DMFS. 22,163,174,177,186,315,360,370,371,378,395,403–407 In summary, the majority of studies demonstrate margin status to impact various survival metrics for most tumor subtypes. For some pathologies such as adenocarcinoma, ONB, and SCC, the benefit of negative margins is fairly well established. However, for other pathologies such as ACC and SNMM, controversies remain. Further studies could potentially provide clarification and better guidance on the importance of margin status in these tumor types.

Margin analysis in sinonasal tumors

Aggregate grade of evidence

C (Level 2: one study; Level 3: 12 studies; Level 4: 61 studies) Negative margins are associated with significant improvements in OS, DSS, and RFS in a majority of studies for all tumor subtypes. Potential harm of taking aggressive margins includes injury to critical neurovascular structures that would otherwise not be sacrificed, leading to increased morbidity or mortality to the patient. Inaccurate frozen section margins intraoperatively could change the operative plan and either compromise definitive resection requiring a return to the operating room or adjuvant chemoradiation or could lead to more aggressive resection than is truly warranted. The potential harm to not achieving negative margins comes at the cost of survival for several tumor subtypes. Frozen section use is associated with increased costs, but this must be weighed against the potential cost of a second surgery, intensification of adjuvant treatment, and reduced survival that could otherwise have been avoided if complete resection with negative margins had been achieved. Preponderance of benefits over harms. “Wide surgical margins” should be more clearly defined and uniformly reported within the literature. Recommendation for most malignancies. Option for ACC with perineural invasion. All attempts should be made to resect SNM to negative margins except for when resecting to negative margins would put critical neurovascular structures at risk for injury that would otherwise not be at risk. GTR may be acceptable for ACC for local control. Frozen section analysis should not be used on mucosal melanoma due to inaccuracy. For all other tumor types evaluated (SCC, adenocarcinoma, ONB, SNUC), frozen section analysis should be used intraoperatively to define the resection margins and ensure definitive/negative margin resection.

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