xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

Role of surgery in non-ITAC

Benefit

There is some evidence that adjuvant RT improves DSS of non-ITAC patients, especially for high-grade tumors. No strong data on chemotherapy outside the palliative setting are available, except in the presence of functional p53 protein. Possible side effects of RT include mucositis, nasal discharge, ORN/osteomyelitis, and hyposmia. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms (RT). No strong evidence (chemotherapy). Adjuvant RT should be considered to improve DSS of non-ITAC patients. The role of chemotherapy is not established in the management of non-ITAC patients except in presence of functional p53 protein and as part of topical treatment.

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 4: four studies) Surgical resection, either endoscopic or open approach, with negative margins may be associated with improved OS and DSS. Procedural related, depending on the approach. Cost comparison analyses have not been undertaken.

Benefit

Harm

Harm

Cost

Cost

Benefits–harm assessment

Preponderance of benefits over harms.

Benefits–harm assessment

Value

Surgical resection with negative margins is beneficial to improve OS and DSS.

judgments

Value

Policy level Recommendation. Intervention Endoscopic transnasal resection with goal of negative margins is the primary treatment of

judgments

choice for non-ITAC. Due to increased morbidity, open (craniofacial) resection should be considered when negative postoperative margins cannot be achieved otherwise.

Policy level Recommendation for adjuvant RT. Option for adjuvant chemotherapy. Intervention Adjuvant RT should be considered for all patients with high-grade and/or

advanced-stage non-ITAC. Concerning low-grade tumors, the potential benefit should be weighed against the side effects. The role of chemotherapy is established in cases of a functional p53 protein or for palliative therapy.

6 Role of chemoradiation therapy Some studies suggest that postoperative RT should be considered regardless of tumor grade or stage. 1193 Other authors emphasize the effectiveness of surgery alone for T1–T2/G1 tumors. 1150,1194 Adjuvant RT is usually reserved for high-grade and/or advanced-stage tumors, since adju vant RT is associated with more favorable prognosis in such tumors. 1178 However, larger studies designed to evalu ate the role of RT are required. There are no data on the use of neoadjuvant RT in the treatment of sinonasal non-ITAC. The role of chemotherapy in treatment of non-ITAC is mainly in the palliative setting. 1195 IC with a regimen of cisplatin, fluorouracil, and leucovorin has shown good results in advanced tumors, where a functional p53 pro tein is present; unfortunately, this is not the case for most (85%) non-ITAC patients. 101,1195 Data on topical application of chemotherapeutic agents have existed since 1970, but not specifically for non-ITAC groups. There are no data on the use of immunotherapy or hormonal therapy in the management of non-ITAC. Table XXII.B.2 contains data on the management of non-ITACs. Role of adjuvant therapy in non-ITAC

7 Recurrence and survival Adenocarcinomas, even low-grade, have shown a ten dency to recur. However, the pleiomorphism of mor phologic patterns of such lesions does not allow for safe conclusions or solid qualitative analyses. 1173 Lesions without salivary gland features have not been shown to metastasize. 1173 As with most sinonasal malignant tumors, high grade, advanced stage, and positive surgical margins seem to be independent negative prognostic factors. 363 Very little survival data coming from small series or short-term follow-up are available. Five-year OS of non ITAC groups of patients varies from 58% to 95.2%. 363,1159 Chen et al. determined a 5-year DSS rate of 71.2% for non-ITAC patients, which is not statistically significantly different from ITAC patients, something that has been sup ported by other authors as well. 1178,1196 On the contrary, Meccariello et al. associated non-ITAC histology with a less favorable prognosis. 259 However, this is probably the result of different case mix of high- and low-grade tumors within the non-ITAC groups. Concerning tumor grade, prognosis of high-grade non-ITAC is poor. 1177 Sphenoid sinus invasion has also been shown to reduce survival,

Aggregate grade of evidence

C for both RT and chemotherapy • Level 3: two studies (RT) • Level 3: two studies (chemotherapy)

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