xRead - Nasal Obstruction (September 2024) Full Articles

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nasal lesion or with concurrent inflammatory nasal polyposis. 573,575,577–579 In the most recent systematic review of 441 cases of REAH, 34.9% were isolated lesions and 50.1% occurred with nasal polyposis. 580 One pathologic study investigated REAH in 150 patients undergoing surgery for nasal polyposis, and REAH was found in 35% of cases, 575 suggesting that REAH is underdiagnosed clinically, on imaging studies, and on histopathology. The most common location of REAH is in the olfactory cleft, with the posterior septum as the second most com mon site. 573,581–583 REAH in the olfactory cleft has been shown to be significantly associated with longstanding ( > 10 years) nasal polyposis and with comorbid asthma. 584 Interestingly, REAH is found more frequently in cases of revision sinus surgery compared to primary cases. 582,584 Grossly, REAH typically appears as a polypoid mass, usually darker and more indurated than an inflammatory polyp. 571 Histologically, REAH classically demonstrates glandular proliferation and a thickened hyalinized base ment membrane, often within a background of inflamed stroma. 585 On IHC, the glandular component is positive for cytokeratins (including cytokeratin 7), and there is usu ally a retained basal cell layer with positivity for p63 and cytokeratin 34 β E12. 585 On CT, REAH is associated with a characteristic uni lateral or bilateral widening of the olfactory cleft in the coronal plane. 573,577,586–589 The first report to describe this finding found that the mean olfactory cleft width was 12.1 mm in patient with REAH, compared to 5.4 mm in patients with nasal polyposis and 4.2 mm in patients with out sinonasal pathology. 589 Another comparative study found that a width of > 10 mm was characteristic of REAH, with 88% sensitivity and 74% specificity. 588 Typi cally there is no associated bone erosion on CT. 586 OnMRI, REAH is intermediate in signal intensity on T1- and T2 weighted sequences, often with a cerebriform contour and homogeneous postgadolinium enhancement. 576,580,590 Endoscopic surgical resection is the primary treat ment modality for REAH, with excellent outcomes. In cases of isolated REAH, the extent of surgery reported ranges from simple excision to subperiosteal dissec tion and drilling of the bone. 576,577,587,591 In cases of REAH with nasal polyposis, authors report perform ing standard endoscopic sinus surgery, including total ethmoidectomy. 573,576,577,584,586,592–594 Evidence-based rec ommendations regarding extent of surgery for REAH cannot be made, given the limitation of existing evidence to case series. There are no studies assessing medical ther apy for management of REAH. Of all reported surgical patients, the recurrence rate is 4.1% (15/363). 580 The clin ical characteristics and risk factors of these recurrences are not well characterized in the existing literature. Olfac tory outcomes following surgery for REAH are reported

Value

All modalities should be considered for improving LRC rates. The absolute benefit to LRC rates for SNM depends on patient and pathology-specific factors and should be weighed against the risk of treatment toxicitNy.RT/CIRT should be considered for salivary glands or radioresistant histologies with gross residual disease at the time of treatment.

judgments

Policy level Recommendation. Intervention IMRT should be considered for improving LRC, DFS, and OS rates when weighed for

patient-specific and tumor features. Evidence suggests that PT, particularly PBT, could be considered when available.

SECTION II: BENIGN LESIONS AND NEOPLASMS XV BENIGN MASS-OCCUPYING LESIONS A Hamartomas Hamartomas are benign malformations consisting of multiple tissue types. In the sinonasal cavity, hamar tomas can be further classified into four histopathologic entities: respiratory epithelial adenomatoid hamartoma (REAH), chondro-osseous respiratory epithelial adenoma toid hamartoma (COREAH), nasal chondromesenchymal hamartoma (NCH), and seromucinous hamartoma. 571 hamartoma REAH is the most common type of sinonasal hamar toma, with over 600 cases reported, and is characterized by excessive glandular proliferation lined by ciliated respira tory epithelium. 572 The precise etiology of REAH remains controversial, with some postulating that it arises as a nonneoplastic byproduct of sinonasal inflammation given its similar gross pathology and common association with nasal polyposis, 573 while others consider it as a neoplasm given that the extent of allelic loss is unusually high for a nonneoplastic entity. 574 REAH is most commonly seen in the third to ninth decade of life, with a reported preponderance in males. 572,575–578 Similar to other sinonasal masses, patients with REAH can present with symptoms of nasal obstruction, nasal discharge, facial pressure, or olfactory impairment. 578 REAH can present as an isolated 1 Respiratory epithelial adenomatoid