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KUANetal.

TABLE XIII.4 Evidence surrounding palliative use of radiotherapy to treat skull base involvement of advanced or recurrent sinonasal malignancies.

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

Phanet al. 450

Symptom/pain palliation

GKRS is useful for the palliation of trigeminal pain secondary to recurrent malignant SB tumors with a significant decrease in patient reported pain and opioid requirement EBRT for SB metastases with CN deficits shows good therapeutic success in neurological outcomes with low toxicity rates SRS for palliation shows improvement in cranial neuropathies and pain with acceptable local control despite poorOS 1. SRS is a viable palliative option for symptomatic treatment of cancers that have invaded the cavernous sinus 2. SRS early after diagnosis was significantly associated with improvement of CN dysfunction 1. Radiosurgery was effective in improving tumor-related trigeminal pain 2. Recurrence of trigeminal pain was frequent and was related to tumor progression Radiosurgery is associated with low risk of worsening cranial

2018 4

Retrospective case series

26 patients with recurrent SB

malignancy treated with GKRS for trigeminal pain palliation 30 patients with SB metastases treated withEBRT 21 SB metastases in 18 patients treated with SRS

Dröge et al. 449

2014 4

Retrospective case series

1. Neurological outcomes 2. OS 3. Toxicity 1. Neurological outcomes

Clump et al. 448

2013 4

Retrospective case series

2. OS 3. LC

Kanoet al. 447

2009 4

Retrospective case series

37 CS invasion

1. 1- and 2-year OS 2. PFS 3. Neurological outcomes Trigeminal neu ralgia/painful trigeminal neuropathy response 1. Clinical response 2. Radiographic response

(metastasis or extension) treated with palliative SRS

Pollock et al. 446

2000 4

Prospective

Eight

case series

recurrent/persistent SB malignancies treated with SRS (GKRS to tumor, not CNV) 12 recurrent/persistent head and neck cancer involving SB treated with SRS

Firlik et al. 445

1996 4

Retrospective case series

neuropathies with effective local control for recurrent cancer of theSB Abbreviations: CNV, cranial nerve 5; CS, cavernous sinus; EBRT, external beam radiation therapy; GKRS, Gamma Knife radiosurgery; LC, local control; OS, overall survival; PFS, progression-free survival; SB, skull base; SRS, stereotactic radiosurgery; SN: sinonasal.

Orlandi et al. reported on the results of palliative chemotherapy for patients with recurrent locally advanced sinonasal epithelial carcinomas (keratinizing and nonker atinizing SCC, SNEC, SNUC) initially treated with multi modal therapy. Of the 14 patients who received palliative chemotherapy, those who objectively responded had a median OS of 29.2 months compared to the nonrespon ders who had a median OS of 4.4 months. 435 Another systemic therapy studied in the setting of palliation is pep tide receptor radionuclide therapy (PRRT) for ONB. In a series of seven recurrent or metastatic ONBs deemed unsuitable for further conventional therapies and high somatostatin receptors expression, PRRT showed some benefit, with four patients showing partial response and two with disease stabilization. 453

Aggregate grade of evidence : C (Level 4: six studies)

E Differences in outcomes between primary and salvage treatment It is well accepted that outcomes of primary treatment are superior to those of salvage treatment. However, review of the literature fails to identify any studies that directly com pare the outcomes of these treatments. Furthermore, the studies that do report on the outcomes of salvage treat ment do not provide a breakdown based on histological subtype, but rather report generally on all SNMs or group them according to their biological behavior due to the low number of cases available for analysis.