xRead - Nasal Obstruction (September 2024) Full Articles

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of 12.7%. 1100 However, DFS and recurrence data were not reported. In a Triological Society Best Practice summary from 2019 specifically for maxillary sinus SCC, Berger et al. draws attention to heterogenous evidence and conclusions with a lack of prospective trials. Despite this, existing database and retrospective evidence suggest that elective neck treat ment may be appropriate for higher T stage SCC, and if the neck is to be entered for resection or reconstruction pur poses, END should be strongly considered for T3 and T4 tumors. 1101 It is additionally important to consider the extent of elective neck treatment. In a review of 128 patients with T4 SCC of the maxillary sinus, of those with regional metastasis at the time of diagnosis, 96% had ipsilateral upper jugulodigastric and submental disease. However, lower jugular chain, contralateral node, and retropharyn geal node involvement is also reported. 1102 The latter is not easily accessible by surgery and consideration should be given to extending radiotherapy coverage of the primary tumor to include the retropharyngeal node, regardless of if or how the lateral neck is treated. Review of arti cles regarding elective neck treatment can be found in Table XXI.A.3. Elective management of the N0 neck in sinonasal SCC

treatment, while 771 patients were observed. Of the 771 patients observed, there was a 34.6% rate of regional recur rence (140/771), while of the patients who underwent elective neck treatment at the time of initial therapy, there was only a 5.9% rate of regional recurrence (24/407). The ORs for regional recurrences after elective neck treatment ranged from 0.03 to 1.39. The cumulative OR was 0.38, indi cating a 62% lower risk of regional recurrence in patients undergoing elective neck treatment compared to patients who were observed in follow-up. However, relevant limita tions of this study include broad histologies included and no interpretation of impact on outcomes. 1095 In a population-based, concurrent retrospective SEER database analysis of 927 patients with N0M0 SNSCC of the maxillary sinus between 2004 and 2013, Sangal et al. conclude that elective neck dissection (END) sig nificantly and independently reduces the 5-year hazard of death (HR 0.646, p = 0.047). They found that for T1, T2, and T4 tumors, END did not independently improve 5-year survival, but for T3 maxillary sinus SNSCC, END did significantly reduce the 5-year hazard of death (HR 0.471, p = 0.001). 1096 Likewise, in a 2014 meta-analysis of N0M0 maxillary sinus SCC, Abu-Ghanem et al. show that ENI significantly reduces the risk of regional recur rence compared to observation (OR 0.16, p = 0.01). 1097 This was similarly concluded by Le et al. in a review of 97 patients with maxillary sinus malignancy, of which 58 were SCCs. They found a statistically significant difference with respect to nodal recurrence between the 36 patients who received RT (25 cN0) and those who did not receive neck radiation (0% and 20%, respectively). 1098 Dooley and Shah reviewed the role of elective neck treat ment for N0M0 patients with maxillary sinus SCC and found the rate of isolated neck failure to be between 4% and 17%. More commonly, recurrence in the neck was accom panied by local recurrence or distant metastatic spread, both of which are unlikely amenable to salvage therapy. They did find that T3 and T4 primary tumors were more likely to involve the neck, and therefore argue that, while elective neck treatment is not justified for T1 and T2 SCC of the maxillary sinus, it may be considered for T3 and T4 disease. 1093 Contrarily, Cantu et al. report the rate of neck metastasis to be higher for T2 tumors than for high “T” stage tumors, and therefore elective neck treatment should be considered for T2N0 SNSCC but is not indicated in T3 and T4N0 patients. 1099 There is also evidence that elective neck treatment may not improve oncological outcomes. Crawford et al. in a ret rospective study of 1220 patients from the NCDB with T3/4 cN0 SNSCC reported no statistically significant difference in OS with END. A total of 19.6% of their patient cohort underwent END, and there was an occult metastases rate

Aggregate grade of evidence

C (Level 2: two studies, Level 3: two studies; Level 4: two studies) Elective neck treatment may decrease the rate of regional recurrence. There are morbidities associated with elective neck treatment, both for surgical treatment and elective irradiation. Insufficient data to make recommendations regarding long-term costs of elective neck treatment.

Benefit

Harm

Cost

Benefits–harm assessment

Balance of benefits and harms.

Value

Patient with advanced T stage tumors may benefit from elective neck treatment. Maxillary sinus SCC has a higher risk of neck metastasis than nasal cavity SCC.

judgments

Policy level Option. Intervention Strong consideration should be given to elective neck treatment in cases of

advanced T-stage tumors, especially if it is a maxillary sinus primary and if primary surgery is undertaken. Elective treatment may be in the form of elective irradiation or END.