xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

gradient between the tumor volume and adjacent critical OARs. 555 Particle beam RT results in a very encourag ing local control rate in patients with ACC of the skull base. The first report of treatment with high-dose PBRT in ACC patients with skull base extension revealed 5-year local control rate of 93% and 5-year OS and DFS 77% and 56%, respectively. 538 In a more recent retrospective analysis of intensity-modulated PBRT, CIRT, or combination ther apy in 38 patients with sinonasal ACC, of which 94% had locally advanced disease (T3–4), the 3-year local control rate was 90% and 3-year OS and PFS were 96% and 80.6%, respectively. 555 Reported treatment toxicities include optic neuropathy, neurological effects, and xerostomia. 538,555 To conclude, postoperative radiation may be delivered using conventional photon RT (e.g., IMRT) or PBRT. CIRT has shown promising rates of local control as adju vant treatment and also for inoperable cases. 568 In most cases, ACC is radiosensitive but not generally radiocur able disease, making RT an ineffective singular treatment modality. 548,1215 Role of adjuvant radiation therapy in sinonasal ACC Aggregate grade of evidence C (Level 2: one study; Level 3: two studies; Level 4:10 studies) Benefit Postoperative RT improves local control rates and survival outcomes. Harm Acute and late toxicities. Cost No studies directly assessed cost. However, improved local control implies decreased

reserved for palliation in cases of unresectable tumors or metastatic disease; chemotherapeutic agents such as cisplatin, adriamycin, 5-flucouracil, doxorubicin, and car boplatin have been proposed mostly for palliation when tumor resection is difficult or when faced with rapidly progressing tumor. 73,79,377,408,1198 There are no dedicated prospective studies on chemotherapy for sinonasal ACC. Table XXII.C.1 summarizes evidence for treatment in sinonasal ACC. E Other salivary gland malignancies 1 Mucoepidermoid carcinoma Sinonasal mucoepidermoid carcinoma (MEC) is rare, comprising approximately 1.5% of all SNMs. 1216 Patients with sinonasal MEC are mostly middle-aged and White. 411,1217,1218 There is no clear gender predilection. 411 Patients usually present with a nasal mass or symptoms of nasal obstruction. A large proportion of cases originate in the maxillary sinus (45.6%–52.6%) or nasal cavity (31.6%–41.0%), which is thought to reflect the proportion of seromucinous glands present in these areas. 411,1217,1218 Many patients present with advanced-stage disease (Stage 3 or 4) (44.8%%–54.5%). 411,1217 Surgical resection is the primary treatment of sinonasal MEC and has been shown to be a significant predictor of survival. 411 In the included studies, 57%–100% of cases underwent surgical resection. 411,1217–1219 Although achiev ing negative margins is associated with improved 5-year OS and median OS when compared to cases of positive margins, this was not a statistically significant finding in a retrospective review of 239 cases in the NCDB. 411 A significant proportion of patients required preopera tive or postoperative RT (10.5%–61.0%). 411,1217–1219 In cases of surgical resection with negative margins, the addi tion of postoperative RT has been shown to be associated with improved survival. 411 This association is not present, however, in cases of positive surgical margins. Chemother apy is less utilized in the treatment of sinonasal MEC (0%–16.3%). 411,1217–1219 In two small case series, the rate of recurrence was found to range from 28.6% to 31.6%. 1218,1219 Larger retrospective reviews have found the 5-year OS of patients with sinonasal MEC to range from 57.0% to 64.1%. 411,1217 Several patient and tumor characteristics have been identified to influence survival. A review of the NCDB found that insurance status (specifically Med icaid), advanced T stage, and advanced nodal disease were associated with worse OS. 1217 Other factors shown to be associated with worse OS include patient residence in an urban or rural area, primary tumor in the sphenoid sinus, high-grade tumors, and age > 70 years. 411 In a small case

future cost in terms of hospitalization, imaging, systemic therapy, and so forth.

Benefits–harm assessment

Preponderance of benefits over harms.

Value

In patients with adverse features and positive surgical margins, adjuvant RT effect on local control is crucial. While RT as the primary treatment was not extensively studied and was usually reserved for unresectable cases, adjuvant RT shows clear survival benefit and a better local control trend in all patients, especially with positive surgical margins.

judgments

Policy level Recommendation. Intervention Adjuvant postoperative RT should be

recommended in all cases, with special importance in cases of advanced-stage disease, positive margins, and PNI.

3 Role of chemotherapy The role of chemotherapy in the treatment of sinonasal ACC is not well studied, with paucity of cases treated with chemotherapy. Most commonly, chemotherapy is