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157

ICAR SINONASAL TUMORS

TABLE XVII.A.1 (Continued)

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusion

1. Length of stay 2. Hospital cost

JNA was associated with $59,915 in-hospital cost; average LOS was 3.3 days postoperatively

Stapleton et al. 781

2015 4

Retrospective case series

Cost analysis of patients who underwent

endoscopic resection of JNA( n = 6)

Abbreviations: GTR, gross total resection; JNA, nasopharyngeal angiofibroma (formerly juvenile nasopharyngeal angiofibroma).

Staging systems in JNA

Benefits–harm assessment

Preponderance of benefits over harms.

Value

Endoscopic intervention requires familiarity with endoscopic surgery and endoscopic equipment including tools for hemostasis.

judgments

Aggregate grade of evidence

C (Level 4: two studies)

Policy level Recommendation. Intervention In experienced institutions, endoscopic and

Benefit

Use of staging system that incorporates residual vascularity may better predict intraoperative bleeding and tumor recurrence. Numerous staging systems may provide overlapping information and inconsistent correlation of stage with outcomes or biological behavior. No specific studies dedicated to assessing cost related to staging systems. Preponderance of benefits over harms. Staging systems should help prognosticate pathology as well as facilitate communication about specific pathology by providing a common language between providers managing the disease process.

combined approaches are the preferred surgical approaches for management of JNA.

Harm

2 Staging systems Numerous systems have been used to stage JNA, includ ing Sessions et al. in 1981, Fisch et al. in 1983, Chandler et al. in 1984, Bremer et al. in 1986, Antonnelli et al. in 1987, Andrews et al. in 1989, Radkowski et al. in 1996, Onerci et al. in 2006, and Snyderman et al. in 2010 (Table XVII.A.2). 782–790 The University of Pittsburgh Medi cal Center (UPMC) staging system proposed by Snyderman et al. in 2010 incorporated residual vascularity from the ICA after embolization and was found to have better abil ity to predict blood loss, need for multiple operations, and tumor recurrence. 773 In 2019, Abdelwahab proposed a staging system that incorporated the following factors: nose/nasopharynx, sinus, fossae, cranium, orbit, and resid ual ICA vascularity (NSF-COR). 773 The goal of the system was to create a method for mapping anatomic involvement, allowing for site- and stage-specific recommendation of endoscopic approaches, and incorporating residual ICA vascularity. NSF-COR was applied to a cohort of 54 patients and on analysis correlated significantly with the UPMC system for prognostic ability. Moreover, the COR compo nent of the staging system correlated significantly with blood loss and recurrence. Study details for the UPMC staging system and NSF-COR system are presented in Table XVII.A.3.

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention The use of a staging system that incorporates

residual vascularity has better predictive and prognostic impact than systems that exclusively grade anatomic involvement.

3 Patterns of recurrence and natural history The definition of recurrent, residual, and persistent dis ease varies across the JNA literature. Some authors define residual disease as radiographic evidence of disease within 6 months of surgery and recurrent disease as new radio graphic evidence of disease more than 6 months after surgery. 351 Others contend that there is no true de novo recurrent disease in JNA and that “recurrence” is the interval growth of unintentional residual disease (i.e., tumor left behind after surgery). 791 Moreover, many sur geons will intentionally leave disease intraoperatively to