xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

morbidity (described as carotid injury, need for bypass, stroke, fistula, and malocclusions). In a subset analysis of sinonasal primaries within international ACC consor tiumdata ( n = 242 patients), 5-year OS for patients with negative, close, and positive margins was 74%, 72%, and 41%, respectively, and 5-year DSS rates were 77%, 75%, and 40%, respectively, again emphasizing the impact on sur vival when able to achieve negative margins. 1206 In the international consortium study, adjuvant RT was adminis tered to 57% of patients with negative margins and 68% and 78% with close or positive margins, which could obscure the impact of positive margins. Surgical debulking, which is typically discouraged in the head and neck, should also be considered in advanced cases of sinonasal ACC where the tumor involves critical organs (such as skull base, nerves, and orbit), and maximal removal of the tumor should be attempted. The literature does not have signif icant data on debulking, but delivery of RT to smaller field maybe a worthy goal and should be discussed as part of a multidisciplinary team. EEA has become a preferred surgical approach for many cases, with the less aggressive resection aiming to preserve function and critical anatomy. 106,494,1199,1205 EEA may be associated with shorter hospital stay and reduced complications. 494,1199 In a retrospective study by Volpi et al. of 34 patients with sinonasal ACC, all underwent endoscopic resection with intent to cure and to achieve GTR. 106 Due to ASB involvement, five of these patients had extended endoscopic resection with a transnasal cran iotomy. In these patients, the resection of the ASB included the ethmoidal roof and overlying dura from the poste rior wall of the frontal sinus to the planum sphenoidale, and between the medial orbital walls. The defects were reconstructed with a multilayer technique, using autol ogous materials (fascia lata or iliotibial tract). Two out of the 34 patients underwent endoscopic nasopharyngec tomy as well due to nasopharyngeal infiltration. All of the procedures achieved intraoperative clear surgical margins unless there was involvement of vital structures prevent ing further resection (i.e., vidian nerve at skull base and maxillary nerve at foramen rotundum). Eventually, all patients had GTR, but seven had positive surgical mar gins on histological examination. The 5- and 10-year OS were 86.5% and 66.8%, respectively. Positive histological margins were shown to correlate with worse survival out come ( p = 0.014) in this cohort even with GTR. 106 In a different cohort of 30 patients with sinonasal ACC under going EEA with preservation of key structures (orbital contents, optic nerves, carotid arteries, motor CNs) per formed with removal of PPF contents (vidian, descending palatine, and infraorbital nerves) if involved, the majority (86.6%) of the cases were T4 disease and only 44.8% were described as “traditionally resectable.” 1199 The endonasal

approach was supplemented with Caldwell-Luc approach in three patients or a Denker maxillectomy in two. With this organ preservation approach, negative margins and complete resection were achieved in only two patients. Nineteen patients (63.6%) had GTR with positive margins, while the remaining nine had STR with gross positive mar gins. No major complications were observed. All patients were recommended to receive adjuvant RT but two did not complete and four had missing data. While the mean follow-up time was only 3.97 years, this is one of the largest cohorts describing the outcomes of sinonasal ACC patients treated with an endoscopic approach. The OS rates at 5 and 10 years were 62.6% and 54.8%, and DFS rates at 5 and 10 years were 58.4% and 12.6%. Local and distant recur rence rates at 10 years were 36.8% and 69.5%, respectively. Margin status was not a factor in survival, but low-grade tumors did have longer survival. Cohort studies of sinonasal ACC patients suggest that the site of origin is a significant factor affecting prognosis. 75,77,79 A multicenter analysis of 99 patients revealed that in tumors originating from the nasal cavity or maxillary sinus, 5-year DSS was 83% and 64%, respec tively, compared to 25% in patients with tumors originating from the sphenoid and ethmoid sinuses. 75 In another study of 105 sinonasal ACC patients, the nasal cavity and sphenoid subsites were associated with best and worst sur vival outcomes, respectively. 79 An NCDB review of 793 sinonasal ACC patients showed that tumors originating from the frontal sinus held worse prognosis in a multivari ate analysis. 376 Other factors limiting the ability to achieve negative margins are advanced tumor stage at presentation in more than 50% of the patients and the high prevalence ofPNI. 75,376,398,1198,1199 PNI is identified in most studies, but reporting varies in the literature. Volpi et al. identified PNI in 11% of cases, whereas Guazzo et al. found large nerve invasion in 62% and microinvasion in 97% of cases; Kashi wazaki et al. found PNI in 93%. 494,106,1199 Mays et al. found 60% large nerve invasion and stated they do not record small nerve invasion because the finding was considered ubiquitous. 398 The presence of nerve invasion and skip lesions also calls into question whether negative margins are truly ever obtained. These factors reflect the complexity in achieving negative surgical margins and great vari ability reported, with histological negative margins being achieved in only 6%–70% of cases. 106,1199,1205 The lowest rate of positive margins was reported with endoscopic sur gical series that also had a majority of lower stage tumors with 60% from T1–3 disease, and only 30% of patients had PNI. 106 Survival appears improved if gross negative, micro scopic positive, or microscopic negative margins can be attained. In the largest single-institutional series of 160 patients with sinonasal ACC, surgical margins did not demonstrate a survival difference, but this was considered