xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23262, Wiley Online Library on [02/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

155

ICAR SINONASAL TUMORS

common presenting symptoms are nasal obstruction (76%– 100%) and recurrent epistaxis (45%–77%). 767,769 Etiology is controversial—some evidence suggests that they are the result of a nonresorbed remnant of the first branchial arch, while other evidence suggests that angiofibromas develop in a specific hormonal and genetic milieu. 770–772 Clinically, they originate from the posterior nasal cavity, near the basisphenoid and the superior mar gin of the sphenopalatine foramen. Patterns of extension are determined by the surrounding foramina: medially into the nasal cavity, nasopharynx, and paranasal sinuses through the sphenopalatine foramen; superior into the orbit via the infraorbital fissure; inferiorly into the greater palatine foramen; and laterally into the infratemporal fossa via the pterygomaxillary fissure. Extension to the skull base and intracranially can be seen in up to 26% of cases. 773 Workup typically includes imaging with CT, MRI, and angiography. Recent advances in CT have allowed for dynamic flow imaging, termed four-dimensional CT. Early studies have demonstrated similar performance and less radiation exposure when compared to gold standard digital subtraction angiography, but additional work is required to define its role in the management of patients with JNA. 774 Biopsy is not routinely performed, especially in the outpatient setting, given the possibility of massive hemor rhage unless radiographic features are atypical and there is concern for malignancy. Histologically, the tumors demonstrate a dense stro mal component with a large population of fibroblasts as well as vessels of varying caliber. Immunohistochem ical stains will demonstrate β -catenin, androgen recep tor, estrogen receptor B, and prostate-specific antigen expression. Genomic analysis has demonstrated fourfold upregulation in vascular endothelial growth factor (VEGF) signaling. 775 High c-Kit expression has been associated with rapid tumor growth and recurrence, while high VEGF signaling has been associated with skull base involvement and hemorrhage. 776 This current section represents an update on the prior evidenced-based review with recommendations published in ICSB 2019 (section V.A) and focuses on studies pub lished from 2018 to 2022. 5,777 For specific outcomes that were not addressed in the ICSB, a complete system atic review and subsequent evidenced-based review with recommendations were performed. 778 Open versus endoscopic approaches JNA is most commonly managed surgically. Historically, open craniofacial approaches were employed; however, EEA has been successfully employed in recent years for management. Current EBRs support the utility and 1

outcomes of EEA in addition to preoperative emboliza tion as the preferred method of tumor resection. 5,777 A more recent meta-analysis of nine studies including 362 patients demonstrated superiority of the endoscopic and/or combined approaches when compared to purely open approaches with respect to recurrence, irrespec tive of tumor stage: 2% versus 17% for low-stage tumors, and 26% versus 32% for high-stage tumors. 351 This sin gle meta-analysis represents the strongest LOE at present comparing endoscopic and open techniques in the man agement of JNA and has increased the aggregate LOE from the ICSB. 5,777 Long-term institutional studies that transitioned initially from open approaches to endoscopic or combined approaches also lend evidence to support the superiority of EEA for management of JNA. Szyfter et al. report a series of 71 patients over 20 years (37 patients with open-only approaches and 34 with endo scopic or combined approaches). They report less blood loss, lower rates of recurrence, and fewer side effects of open approaches (scarring, cranial neuropathies) when employing the endoscopic approach. 779 Similarly, Cohen Cohen et al. report a 22-patient cohort compared to an internal 65-patient historical cohort and found increasing utilization of EEA in recent cases with preservation of tumor control and equivalent recurrence rates. 780 Stapleton et al. performed a cost analysis of 55 pedi atric patients who underwent EEA for skull base lesions; in this cohort, there were six patients with JNA. They found that, on average, surgery accrued $59,915 in-hospital costs with a mean LOS of 3.3 days. JNA was associated with the greatest hospital costs of the pathologies studied. While there was no direct comparison to tumors man aged with open craniofacial approaches, the LOS for the endoscopic management of JNA determined in this series was lower than data published for open approaches; thus, the authors conclude that endoscopic management of JNA was a cost-effective approach in the pediatric population (Table XVII.A.1). 781 Open versus endoscopic approaches for JNA Aggregate grade of evidence B (Level 2: one study; Level 4: seven studies) Benefit Endoscopic approaches demonstrate

comparable and possibly reduced tumor recurrence rates along with lower patient morbidity and intraoperative bleeding. Endoscopic approach is associated with low complication rates and morbidity. Endoscopic management is associated with favorable costs when compared to costs from open surgery.

Harm

Cost

(Continued)