xRead - Nasal Obstruction (September 2024) Full Articles

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tases. That being said, Fakhry et al. did not observe better accuracy of PET in the detection of distant metastases in head and neck SCC when compared to CT and Spector et al. did not show improved life expectancy when PET was used over other imaging modalities to detect distant metastases. 426,427 Surveillance recommendations for SNM were often gen eralized based on research for all head and neck cancers, but it is becoming increasingly clear that SNMs are dis tinct entities requiring different surveillance regimens. First, late recurrences beyond 5 years have been widely reported for SNM, with a recent study showing these to account for 11.7% of all recurrent disease. 428 These figures vary depending on the histology and, in some subtypes as ACC, ONB, and melanoma, recurrences even after 10 years have been described. 428–430 For this reason, surveillance beyond 5 years is recommended for SNM and possibly lifelong follow-up should be considered for specific his tological subtypes. 6,196 Second, recurrences are frequently detected in asymptomatic patients (51%–94%) and con sequently a routine examination and imaging protocol is recommended. 419,431 Finally, the appropriate follow-up interval remains controversial; however, there is a con sensus that it should be more intensive during the first 2–3 years posttreatment, given the high risk of recur rence during this time period. Two experienced teams have assessed their surveillance programs for SNM. Using an intensive surveillance program consisting of (1) clinical follow-up every 2 months for year 1, every 3 months for year 2, every 6 months for years 3–5, and annually there after; (2) surveillance MRI every 4 months for year 1, every 6 months for years 2–5, and annually thereafter; and (3) screening for distant metastases annually with CT/PET, Zocchie et al. demonstrated that 94% of all recurrences could be detected in asymptomatic patients. 419 Seventy four percent of recurrences were detected in the first 3 years posttreatment and, importantly, they showed that 61.5% of recurrences detected in this manner could be treated with curative intent. Khalili et al. found similar results with their surveillance program consisting of initial follow-ups at 1–3 monthly intervals for the first 2 years, 3 to 6-month intervals for the next 3 years, and then annually afterward. 418 At each visit, a standard history and physical examination including nasal endoscopy was performed, with MRI, CT, and/or PET/CT scans performed at 3- to 6 month intervals for the first 2 years, then every 6 months to yearly intervals thereafter. Using this surveillance pro gram, they found that 63% first recurrences were detected in the first 24 months after treatment and 87% of first recur rences could be treated with curative intent. Interestingly, all recurrences diagnosed by endoscopy ( n = 6) underwent retreatment and were alive at last follow-up. Three out of 17 patients with local recurrence diagnosed by imaging were

XIII MANAGEMENT OF RECURRENT MALIGNANCY Advances in surgery, RT, and systemic therapies have improved outcomes of SNM, but recurrences remain com mon. Historically, recurrences have been estimated to occur with an average rate around 50%, although recent series of experienced teams report recurrences in the order of 20%–30%. 22,33,416–419 Local recurrence represents the main form of failure and mortality for all types of SNM. Regional and distant metastases are less frequent and vary according to histological subtype and initial grade and stage. For instance, the rate of regional recurrences is sig nificant in ONB, while distant metastatic rate is significant in SNUC, mucosal melanoma, and ACC. Due to the low incidence of SNM and histological variability, there is a paucity of literature concerning the treatment of recurrent disease. A Diagnosis of recurrent tumor Early detection of recurrent SNM is critical for successful salvage treatment. Posttreatment surveillance is therefore vital to maximize long-term survival. However, identifi cation of recurrent disease in a previously treated region can be challenging. Clinical follow-up and imaging are conventionally used for surveillance after successful treat ment of SNM. In-office endoscopy forms the mainstay of clinical surveillance. Although it has a low sensitivity as it only identifies superficial local recurrences, it is inex pensive and easy to perform. Recurrences identified via endoscopy are often amenable to salvage therapy given their early detection. 418,419 Khalili et al. showed a sensitiv ity of 25%, specificity of 89%, PPV of 43%, and NPV of 78% for endoscopy. 418 Imaging is critical for ongoing surveillance in patients treated for SNM with most recurrences being detected through imaging (Table XIII.1). 418,419 MRI demonstrates the highest PPV (84%) compared to PET/CT (46%) or CT alone (44%) for detecting recurrent disease and should be the mainstay of local surveillance. 418 PET/CT has a signifi cant false-positive rate that is probably the consequence of treatment-related inflammatory changes and the propen sity for the sinonasal cavity to develop inflammatory and infective pathologies. 197,216,420,421 Similar issues have also been identified with PET imaging of the neck, especially following neck irradiation to treat regional disease in head and neck cancer. 422–425 Importantly, evidence shows that PET should be performed no sooner than 3 months after treatment due to the possibility of treatment-induced changes confounding the results. PET/CT is, however, extremely valuable for the detection of distant metas