xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Ravelo et al. described a lower 18F-FDG-PET uptake in SNEC compared to other sinonasal carcinomas, which might hinder the assessment of tumor sizes using this type of diagnostic measure. 200 With regard to localization, both ScNEC and LcNEC are most often primarily local ized in the nasal cavity and in the ethmoid sinus, but infiltration into the skull base, the cranial fossa, or the orbit is common. 48,1417,1460–1462 The available studies show that SNECs are typically first diagnosed at an advanced stage (70%–80% as IV), whereas initial regional and distant metastases are rare. 48,200,1417,1460,1461,1463,1464,1468–1471 4 Treatment strategies The treatment strategies for sinonasal ScNEC and LcNEC vary immensely between the available studies (Table XXIV.C.1) and are often not given in much detail. Furthermore, the information from the available literature does not help to provide detailed recommendations for each distinct entity, but rather for different histopatholo gies grouped together (e.g., STND or SNEC). In the curative setting, however, a multimodality approach has been commonly applied and seems to be advantageous over single-modality treatment. According to a meta analysis by van der Laan et al., surgery with adjuvant RT is the therapy of choice with regard to improved DSS for SNEC. 1404 In their evaluation, there seemed to be no benefit for the additional use of adjuvant chemotherapy. These results, however, cannot be easily extrapolated to sinonasal ScNEC and LcNEC, as these distinct entities were not defined according to the current WHO classifi cation in this study. In another retrospective analysis on SNEC derived from the SEER database, Patel et al. equally concluded that surgery with or without adjuvant RT showed a significantly better outcome regarding DSS than RTalone. 48 For poorly differentiated neuroendocrine car cinomas, including ScNEC and LcNEC, these conclusions are confirmed in a retrospective single-center analysis by Likhacheva et al. 1468 The role of neoadjuvant chemotherapy has recently been investigated in smaller trials and seems to pro vide favorable results. Following standard treatment reg imens for extrapulmonary neuroendocrine carcinomas, two cycles of a combination of cisplatin and etoposide are typically used. 1472 In an initial, small prospective trial from 2002 that included 10 sinonasal NECs, the use of neoadjuvant chemotherapy showed promising long-term outcomes. 540 Another single-center study investigated the role of neoadjuvant chemotherapy in locally advanced and borderline resectable SNEC and ONB. For SNEC, a response rate of 92.3% was shown, but the intensity of response showed no significant correlation to median PFS,

and the rate of grade III–IV toxicity was close to 75% in the whole group investigated. 1473 In a multicenter retrospec tive analysis from Italy, Turri-Zanoni et al. reported on the value of adding neoadjuvant chemotherapy to multimodal treatment for 98 tumors with neuroendocrine differentia tion, of which 22 were SNECs (12 ScNEC and 10 LcNEC). In this group, neoadjuvant chemotherapy, which was admin istered in 10 out of 22 cases, was associated with improved OS and DFS on multivariate analysis. 1349 In conclusion, a multimodal approach, most likely including neoadjuvant chemotherapy, seems warranted for the treatment of sinonasal ScNEC and LcNEC with curative intent, though high-level evidence is missing. At this time, several prospective trials (e.g., NCT02099175, NCT02099188, NCT00707473) are aiming to shed more light on this topic. Treatment strategies for SNEC

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 4: five studies) In aggregate, surgery and RT confer survival benefit for both ScNEC and LcNEC. Morbidity of treatment should be factored into the clinical decision-making process.

Benefit

Harm

Cost

No cost studies have been performed. Preponderance of benefits over harms.

Benefits–harm assessment

Value

There may be an emerging role for neoadjuvant chemotherapy in management of SNEC, likely in higher grade tumors.

judgments

Policy level Recommendation. Intervention Surgery and RT remain the mainstay for primary management of SNEC. Induction

chemotherapy may be considered for patients with locally advanced disease, metastases, and/or high-grade tumors.

5 Recurrence and survival Recurrences for SNEC are very common and occur both locoregionally as well as systemically. The incidence of recurrence varies widely in the available literature but seems to be higher (up to 73%) than other malignant sinonasal tumors. 1349,1460,1461,1464,1468 Treatment strategies for recurrent tumors have not been addressed in detail in the available literature, so current recommendations correspond to those for other sinonasal tumors. Concerning survival, common grouping of different histopathological entities again makes it difficult to draw coherent conclusions from the available studies. The liter ature suggests that the OS for SNEC varies between 42.6%