xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

to reduce recurrence rate of IP, yet each of these are obser vational reports not supported by sufficient data to make generalizable claims. 703,704 Some cases report use of neoad juvant chemotherapy for unresectable disease, which can facilitate resection if there is good response to treatment. 705 Overall, medical management strategies cannot be sup ported by substantive evidence at this time to provide recommendations. Role of radiation therapy for inverted papilloma

Harm

Small potential for intracranial and/or dural injury and CSF leak. Baseline risk of epistaxis and postoperative pain.

Cost

Associated costs with surgery.

Benefits–harm assessment

Preponderance of benefits over harms.

Value

Determining involvement of skull base on preoperative imaging is helpful for preoperative planning and patient counseling, especially if at risk for CSF leak. There are limited data comparing judicious cautery (e.g., bipolar) versus direct resection of the skull base. Furthermore, there are limited data to suggest that skull base resection may lead to intracranial seeding/recurrence.

judgments

Aggregate grade of evidence

C (Level 4: four studies)

Benefit

Potential for improved disease control in patients in whom surgery has failed or is not possible. Nearly all patients experience minor (mucositis, conjunctivitis, xerostomia, epiphora, anorexia) adverse effects from toxicity, some with major (CNS, radionecrosis, visual changes, etc.) effects that can be life threatening.

Policy level Recommendation. Intervention Perform endoscopic and/or open resection of skull base IP with bony resection, drilling, or cauterization of mucosal rests to adequately address pedicle. F Role of radiation or medical therapy The primary treatment for IP is surgical, yet there remains a role for radiation and/or medical therapy in limited cir cumstances. RT for IP fell from favor due to anaplastic transformation following irradiation of the tumors. 693–696 More recent literature has dispelled this concern as no such relationship could be confirmed in the majority of IP associated squamous cell carcinoma (IP-SCC) cases. 697–699 To date, there is no consensus as to indications for RT in the treatment of IP, yet associated carcinoma, multiple recurrent disease, and impossibility of resection are widely accepted. While there are limited data, the published stud ies report superior rates of LRC and OS when RT is used as adjuvant therapy for IP-SCC lesions. 409,675,700 Priorpub lished data suggest consideration of moderate RT ( ≤ 60Gy) in patients following GTR or STR can help prevent recur rence, while higher doses (70 Gy) should be used in those unable to undergo resection (Table XVI.5). 675 Medical management of IP is a diverse topic, and obser vational published studies implicate several methods that could be effective but have yet to be established in larger studies. Most forms of medical therapy are experimen tal in nature. In one study, topical 5-fluorouracil applied to the wound bed following excision yielded a statisti cally significant reduction in recurrence rate, although there is some concern for confounding due to patient selection. 701 In another study, Anlotinib, a tyrosine kinase inhibitor, showed some efficacy for IP lesions with malig nant foci. 702 Other studies have suggested use of COX2 inhibitors, HPV vaccines, and other experimental agents

Harm

Cost

Procedural costs, as well as radiation-associated morbidity. Balance of benefits and harms.

Benefits–harm assessment

Value

Role of RT is well established but limited to specific circumstances in management of IP.

judgments

Policy level Option. Intervention Consider RT for patients who meet limited indications or special conditions such as unresectable disease, poor surgical candidates, multiply recurrent lesions, or IP associated with malignancy. G Treatment of site of attachment IPs usually grow in an exophytic, noninvasive way and, as a result, their site of attachment requires resection, or man agement, along with the lesion. 706 CT and MRI can be used as adjuncts for preoperative identification of attachment site. CT has the lowest sensitivity ( ∼ 50%) but high speci ficity (PPV as high as 100%) for identification of attachment site when hyperostosis is present. 706–714 These studies also report that MRI is superior for detecting site of attachment (sensitivity ∼ 80%) when able to detect the classic columnar and cerebriform patterns typical of IP (Table XVI.6). 707,710 If the pedicle is identified preoperatively or intraop eratively, there is clear consensus among the literature that resection of the attachment site is paramount for effective clearance of IP. 137,305 Incomplete removal is thought to be the primary reason for postoperative recur-