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ICAR SINONASAL TUMORS

TABLE XXIV.5 Evidence surrounding unilateral resection and smell preservation in ONB.

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusions

OS

21 out of 22 (95%) alive at last follow-up

Nakagawa et al. 1360

2018 4

Retrospective case series

N = 22 ONB by endoscopic surgery N = 26 ONB imaging review by skull base surgeons to predict olfactory bulb involvement

VanGompel et al. 1362

2018 4

Retrospective case series

Correlation of radiographic

1. Unilateral or no pathologic olfactory involvement in 65% on pathology 2. Surgeon prediction of olfactory bulb involvement was appropriate or overread (96%) 1. Six (43%) patients had residual smell function, with two having near-normal to normal function 2. No cases had disease recurrence

and pathologic olfactory bulb involvement by tumor

1. Olfaction (UPSIT) 2. OS 3. Recurrence

Tajudeen et al. 1361

2016 4

Retrospective case series

N = 14 patients undergoing

unilateral ONB resection (seven received postoperative RT)

Abbreviations: ONB, olfactory neuroblastoma (esthesioneuroblastoma); OS, overall survival.

decreased survival. 1369 Lastly, two studies reported no addi tional benefit to the use of adjuvant RT in the postoperative setting. 488 Liu et al. demonstrated that surgery followed by IMRT did not improve OS. 488 Kiyofuji et al. reported that planned postoperative IMRT after a margin negative surgical resection for low-grade ONB (Hyams I/II) did not

Policy level Option. Intervention Unilateral resection in an attempt to preserve

olfactory function may be an option in select cases of limited extent unilateral tumors with negative margin resections.

provide benefit in tumor control. 1370 Role of radiation therapy in ONB

6 Role of radiation therapy RT has long played an important role in the manage ment of ONB with traditional modalities such as external beam, IMRT, carbon-ion (CIRT), and more recently pro ton beam therapy (PBT) (Table XXIV.A.6). RT has been used in various forms as neoadjuvant, adjuvant, and as definitive therapy for ONB. The most common use of RT is adjuvant therapy after surgical resection. A total of nine studies reported improved OS at 3–5 years for patients who underwent postoperative RT. 253,484,521,1347,1364–1368 All studies found adjuvant RT safe with minimal side effects. When stratified by Kadish staging, two specific studies found that adjuvant RT only improved survival for patients with Kadish C and D tumors. 1364,1365 Two studies exam ined the definitive use of IMRT and one study with PBT for treatment of ONB. 486,526,557 Bao et al. reported acceptable 3 year OS with IMRT alone. 486 Another study by Nakamura demonstrated that PBT as primary therapy was safe and effective, especially for Kadish A tumors where 5-year OS was100%. 526 The use of CIRT was also investigated in three studies and found to be effective with acceptable late toxic ities as definitive therapy, specifically for advanced disease (Kadish C/D). 472,557,558 Another study reported that delays in, or prolonged duration of, RT may be associated with

Aggregate grade of evidence

C (Level 2: two studies; Level 4: 14 studies)

Benefit

Improved OS at 3 and 5 years when used as adjuvant therapy. Generally safe, especially with newer modalities, with some late toxicities. There are no studies investigating cost. Preponderance of benefits over harms. Current conclusions based on limited high-quality studies. Larger studies are needed.

Harm

Cost

Benefits–Harms Assessment

Value

judgments

Policy level Option. Intervention Postoperative adjuvant RT is effective,

especially in cases with positive margins, and higher grade or Kadish stage tumors.

7 Role of systemic therapy Chemotherapy has been explored for the treatment of ONB with variable response rates reported in adults (Table XXIV.A.7). Treatment typically consists of