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KUANetal.

TABLE XXIV.D.1 (Continued)

Clinical endpoints 1. OS 2. RFS 3. Frozen

Study

Year LOE Study design Study groups

Conclusion

1. 5-year RFS 23%, OS 35% 2. Positive margins and

Tajudeen et al. 1502

2014 4

Retrospective case series

SNMM patients at a single institution ( n = 14)

perineural/lymphovascular invasion associated negatively affected RFS and OS 3. Nine patients with frozen path 30 specimens negative on frozen 1. 5-year OS survival 28% and DFS 23.7% 2. 5-year DFS was higher with endoscopic than open but no difference in longer term pathology, confirmed to be negative on final pathology

section and final pathology correlation

Lundet al. 1482

2012 4

Retrospective case series

SNMM patients at a single institution ( n = 115)

1. OS 2. DFS

Dauer et al. 1494 1. 49% 3-year DSS, 22% 5-year DSS 2. Local recurrence increased in patients with skip lesions Abbreviations: DFS, disease-free survival; DSS, disease-specific survival; NCDB, National Cancer DataBase; OS, overall survival; RFS, recurrence-free survival; SEER, Surveillance, Epidemiology, and End Results; SNMM, sinonasal mucosal melanoma. 2008 4 Retrospective case series SNMM patients at a single institution ( n = 61) 1. DSS 2. Local recurrence

However, given the aggressiveness of SNMM, some patients present with locally advanced disease in which a negative margin resection is not possible. In these cases, a variety of approaches have been utilized. IC regimens have been described in cases of unresectable SNMM to allow for tumor bioselection, mirroring such regimens for SNUC and ONB. 1358 In an 18-patient series, those patients who had a partial or complete response to IC had improved 5-year OS compared to those who had no response (39% vs. 8%; HR 2.79, 95% CI: 0.75–10.35). Of these 18 patients, six patients went on to surgery and orbital preservation was achieved in all cases. 1515 Similarly, early experience with induction immunotherapy regimens has also been described for locally unresectable SNMM or patients presenting with metastatic disease. 1516–1518 Role of surgery for sinonasal mucosal melanoma

the cheek/nose, palate involvement, extensive intracranial involvement, dural involvement laterally over the orbit, or when orbital exenteration is necessary. 1499 As noted above, the ability to achieve a negative margin resection is the most key when selecting a surgical approach for a given tumor. Secondary important considerations include associated postoperative morbidity and QOL. 1509–1513 A growing body of literature has demonstrated com parable survival rates between open and endoscopic approaches for SNM. 1085,1508 For SNMM in particular, Lombardi et al. studied 58 patients who underwent surgical resection of SNMM. After correcting for tumor stage, they found no difference in OS or DSS between the endoscopic and open resection groups. 1504 Similarly, Miglani et al. reported their institutional experience with 22 patients undergoing surgical resection of SNMM. In this cohort, there was no difference in OS or DSS for endoscopi cally resected tumor group compared to open resection group. The presenting tumor stage was similar between both groups. However, the endoscopic group had improved local control compared to the open resection group. 272 Ina series of patients treated at MD Anderson, SNMM patients undergoing endoscopic-assisted resection had improved 2-year survival compared to open approaches, although this study was not controlled for tumor stage. 232 Large institutional SNMM cohorts by Lund et al. (115 patients) and Lundberg et al. (58 patients) demonstrated comparable OS for endoscopically resected SNMM compared to open approaches. 274,1482 The UK national guidelines on head and neck mucosal melanomas advocate for an endoscopic endonasal surgery whenever feasible. 1514

Aggregate grade of evidence

C (Level 2: one study; Level 4: 16 studies)

Benefit

Surgical resection with negative margins appears to be associated with improved OS and potentially RFS. When possible, it appears that endoscopic resection has equivalent results to open resection for OS andDSS. Surgical morbidity is largely related to selection of surgical approach and site of the tumor.

Harm

(Continued)