xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

gins and for persistent disease in unresectable sites. 293,1144 Table XXII.A.1 summarizes evidence surrounding the

sinonasal ITAC, even in case of proven occupational expo sure, but suggests to tailor the extent of surgery based on the local extension of the tumor. 16,1152 Role of surgery in ITAC

management of sinonasal ITAC. Role of adjuvant therapy in ITAC

Aggregate grade of evidence

B (Level 2: two studies; Level 3: one study; Level 4: seven studies) Oncologic resection is possible with endoscopic approaches in many cases. Reduced complication rate, improved QOL, and better survival outcomes have been described as direct benefit of a multimodal treatment strategy including surgery. Insufficient tumor excision with positive surgical margins, leading to increased risk of local or distant recurrences, and morbidity and complication risks related to surgery. Although no studies have examined the issue of costs in sinonasal ITAC treatment, short hospitalization period and fast patient recovery associated with minimally invasive surgery could translate to lower costs. Preponderance of benefits over harms. All studies to date have suggested equivalent or better outcomes of endoscopic surgery as compared to traditional craniofacial surgery. There is no significant argument for or against bilateral ethmoid resection as routine procedure for patients with occupational exposure.

Aggregate grade of evidence

C (Level 2: one study; Level 3: one study; Level 4: four studies) Additional oncologic control in cases of positive margins or locally advanced/metastatic tumors. The risk of ORN, mucositis, and other RT and chemotherapy-induced complications should be discussed with the patient when adjuvant treatments are planned. No dedicated studies on cost. Multidisciplinary management with multiple healthcare workers involved in the treatment may increase the economic burden. For patients with functional P53 , neoadjuvant chemotherapy may improve survival rates. Adjuvant RT should be administered in advanced-stage and/or poorly differentiated tumors, though there are no dedicated studies on this. Biological studies to better understand the genetic and molecular profile of such rare cancers will be crucial to better stratify patients according to prognosis and discover potential new drug targets for precision medicine. Balance of benefits and harms.

Benefit

Benefit

Harm

Harm

Cost

Cost

Benefits–harm assessment

Value

judgments

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Multidisciplinary management of sinonasal

Policy level Option. Intervention Adjuvant RT should be considered for ITAC

ITAC with primary surgery and achieving negative margins currently represents the standard of care.

treatment following surgery if pathology demonstrates positive surgical margins, for advanced-stage tumors (pT3–4), and/or for poorly differentiated grade. The role of

chemotherapy and timing of administration is less clear.

1 Role of adjuvant therapy To date, given the rarity of the disease, no RCTs have been possible to define indications for adjuvant treat ments in sinonasal ITAC. Current evidence supports the use of adjuvant RT (conformal three-dimensional RT [3DRT] or IMRT) in case of positive surgical margins, advanced-stage tumors (pT3–4), as well as poorly differ entiated ITAC regardless of the stage of the disease at presentation. 374,1151,1153 While there is limited evidence to support the use of concurrent chemotherapy with RT, adju vant cisplatin-based chemotherapy should be considered with adjuvant radiation in cases of positive surgical mar

2 Surveillance, recurrence, and outcomes Cohort studies of sinonasal cancers, including also ITAC, have demonstrated the efficacy of a strict follow-up proto col that includes nasal endoscopy and contrast-enhanced MRI every 3–4 months for the first year, every 4–6 months from the second to the fifth year, and after, once a year from the sixth to the 10th year. 293,1144 Systemic staging (e.g., total body CT, PET/CT) should be conducted once per year for the duration of the follow-up as ITAC patients may develop