xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

been additional studies that met inclusion criteria per taining to management of the neck in ONB patients (Table XXIV.A.3). 15,412,457,1346,1350–1354 Many of these stud ies supported prior findings that patients who present with positive neck disease have significantly worse outcomes. 412,1346,1351 As with prior reports, neck dissec tion was recommended for patients with clinically node positive disease. 412,1346 Kuan et al. queried 381 cases of ONB in the SEER database and identified an overall cervical nodal metas tasis rate of 8.7%, with a predominance of level II disease (6.6%). 1354 Multiple positive nodes were identified in 4.5% of cases. Male sex ( p = 0.009) and higher tumor grade ( p = 0.009) were found to be predictors of cervical metastases. However, when analyzed through multivari ate regression, the presence of cervical nodal disease was not found to be significantly predictive of OS or DFS, suggesting that other disease and patient characteristics, particularly age and tumor grade, are stronger drivers of survival. In a single-institution study of 39 patients, Wolfe et al. reported pathologically confirmed nodal disease at surgery in eight patients (21%) and delayed nodal recurrences in seven patients (18%). 1346 The time to delayed nodal recur rence was a median of 59 months and one case at 16 years. The most common site of neck recurrence was level II (85%) and level III (42%). They reported a 27% 10-year nodal recurrence rate for patients who did not undergo ENI. 1346 Five of these patients who were treated with surgery alone (all Kadish stage A) did not have any recurrences or deaths with a median follow-up of 44 months. Based on these col lective results and prior studies, this group recommended ENI for patients with Kadish C and D disease. 1346 In a single-institution study of 139 patients, Abdelmeguid et al. reported cervical lymphadenopa thy at presentation in 17 patients (12.2%) and delayed nodal recurrence in 23 patients (16.5%). 412 The most common site of neck recurrence was level II in 13 patients and level I in nine patients. Among 31 patients who underwent ENI, two developed neck recurrence (6.4%), whereas 20 patients (34.4%) who did not undergo ENI developed neck recurrence. Of note, the two patients who received ENI and developed regional recurrence had isolated intraparotid nodal spread, which was outside the radiation field. This group noted that ENI would be the most beneficial option for younger patients with Kadish C stage disease. 412 In a single-institution study of 143 patients, McMil lan et al. reported regional disease in 13.8% of patients at presentation. 1351 Thirty-two patients (22.4%) developed delayed neck recurrence at a median of 57 months with one case at 20 years. 1351 In a multi-institutional study of 404 ONB patients, 11 of 65 patients who had not received

ENI had recurrence in the neck (16.9%) versus zero of 26 patients who received ENI. 15 Among these 11 patients, nine presented with Kadish C disease. 15 However, ENI did not impact OS in this multi-institutional international study. In summary, in these updated studies, cervical lym phadenopathy on presentation has been noted in 9%–21% of ONB patients, and neck dissection followed by adju vant RT is supported for these patients. 1346 Delayed neck recurrence is seen in approximately 20% of patients at a median time of approximately 57–59 months after diag nosis. This delayed presentation of neck recurrence sug gests that neck surveillance should be performed beyond 5 years. Collectively these updated data support ENI administration for patients with Kadish C, Kadish D, or high-grade Hyams (III or IV) disease. The role of ENI for Kadish A, Kadish B, or low-grade Hyams disease is less clear and should be guided by high-risk fea tures and an individualized evaluation with a radiation oncologist. Elective management of the N0 neck in ONB

Aggregate grade of evidence

C (Level 2: two studies; Level 4: eight studies).

Benefit

Treatment of clinically positive neck disease assists in disease control. Delayed regional involvement in the neck is common with a median time to recurrence of approximately 5 years. Elective treatment of the neck with irradiation, particularly in patients with high-stage/grade disease, shows significantly reduced evidence of nodal recurrence but does not significantly impactOS. Neck dissection can lead to complications including hematoma, infection, cranial nerve palsies, chyle leak, among others. RT of the neck is associated with xerostomia, skin changes, and long-term toxicity. There are no studies investigating the costs of upfront or delayed treatment of the N0 neck. Preponderance of benefits over harms (N + neck). Balance of benefits and harms (N0 neck). Elective treatment of the N0 neck is likely to prevent long-term regional recurrence in ONB patients with high-stage/grade disease and may lead to improved DFS. Recommendation for treating N + neck. Option for treating N0 neck.

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level

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