xRead - Nasal Obstruction (September 2024) Full Articles

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acceptable by the authors, with nine grade 3 and six grade 4 toxicities reported. 528 The time to initiation of postopera tive RT is critical. In an NCDB review of SNSCC patients, a shorter postoperative time to radiotherapy was associated with increased OS. This is estimated to be at approximately 61 days. 1087 Evidence for postoperative CRT is extrapolated from the head and neck SCC literature. Positive resection margins or extra-nodal extension are considered indications for platinum-based concurrent chemotherapy. Additionally, in the presence of high-risk features such as high-grade tumors, close resection margins, and nodal metasta sis, concurrent chemotherapy may be considered. 1088,1089 Review of articles regarding the role of adjuvant therapy can be found in Table XXI.A.2. Role of adjuvant therapy in sinonasal SCC

worse outcomes compared to triple-modality therapies and treatment protocols with neoadjuvant therapy. 159 Homma et al. are currently conducting a prospec tive trial investigating the use of intra-arterial high-dose cisplatin with concomitant RT for advanced maxillary sinus cancers (T4a/bN0M0). They published the outcomes of 18 patients for their dose-finding phase in 2018 and reported that seven cycles of intra-arterial high dose cis platin were clinically safe and their recommended cycle number. Further data are expected as they complete their studies. 1090 There may be a role for immunotherapy/targeted ther apy in definitive RT. Qiu et al. showed that definitive RT in combination with immunotherapy/targeted ther apy (cetuximab) demonstrated improved OS, objective response, and PFS compared to RT alone. 1091 In 2018, Toyomasu et al. published a series describ ing the use of IMPT monotherapy in 59 cases of SNSCC. This represents the largest series to date. The majority of their patient cohort (70%) were classified to have T4 disease. They report comparable outcomes with other treatment modalities. Their reported 5-year OS, PFS, and LRC rates are 41.6%, 34.7%, and 50.4%, respectively. They report a grade 3 or 4 toxicity rate in 22% of patients. 559 Mimica et al. report IMPT as an option for organ preser vation for patients with nasal cavity/septum SCC that declined rhinectomy. Seven of the 11-patient cohort was treated with primary IMPT with concurrent chemother apy, the rest were treated with IMRT ± chemotherapy. They report a 2-year survival rate of 100% and only one out of seven (14%) patients who underwent IMPT had local recurrence. 1092 In particular, the role of definitive CRT/RT in the treat ment of early-stage SNSCC is not clearly defined. NCCN guidelines support definitive CRT/RT for T1 and T2 eth moid and nasal cavity SCC; however, there are no trials evaluating this recommendation. Role of definitive chemoradiotherapy in sinonasal SCC

Aggregate grade of evidence

C (Level 4: four studies)

Benefit

Surgery followed by postoperative RT demonstrates improved LRC and OS compared to patients treated with definitive RT/CRT or surgery alone. Associated with treatment-specific toxicities. Insufficient data to make recommendation regarding long-term costs of adjuvant therapy. Preponderance of benefits over harms. The stage of tumor at presentation, the specific histologic subtype, and the goals of the patient should be carefully considered. poorly differentiated histologies would benefit from postoperative RT. The role of CRT is not clearly defined specifically for SNSCC but should be considered when positive margins or extranodal extension is present.

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Patients with locally advanced disease or

Aggregate grade of evidence

C (level 4: four studies)

d Role of definitive chemoradiotherapy Although upfront surgery followed by adjuvant RT has been associated with improved survival outcomes in the treatment of SNSCC, definitive CRT/RT can be considered for patients who have unresectable tumors, are not can didates for surgery or chemotherapy, or have early-stage tumors. Chemotherapy is generally platinum based, and IMRT and IMPT are the two most common radiotherapy options. Definitive CRT has been shown to have similar OS compared to single-modality therapy with surgery, but

Benefit

In cases of unresectable tumors, nonsurgical therapies offer an alternative to palliative treatments. Additionally, in early-stage cancers, nonsurgical therapy may confer equivalent outcomes as compared to surgery ± adjuvant therapy. There are systemic and local toxicities related to nonsurgical therapies.

Harm

(Continued)