xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

melanoma advocate against END for SNMM. 1514 Con versely, other head and neck sites of mucosal melanoma such as the oral cavity are associated with higher rates of nodal involvement and END are more commonly performed in these cases. 1566,1567 In a large institutional review of regional lymph node metastases in SNMM, Amit et al. reported that therapeutic neck dissection was completed in 23 patients (11.6%). In this cohort, regional nodal recurrence occurred in seven patients who had lymph node metastasis at the time of presentation (30.4%) and in 30 of those who had N0 disease at the time of presentation (17.1%). Delayed metas tases to the contralateral lymph nodes were present in seven patients (3.5%). In contrast to other large population based studies, the authors found that the presence of regional lymph node metastases was not associated with OSorDSS. 1568 In a recent NCDB study, Oliver et al. report that completion of a neck dissection was not associated with OS in a multivariate analysis controlling for several variables, including tumor stage and size. 1503 Paralleling the popularity of sentinel lymph node biopsy (SLNB) for cutaneous melanoma, SLNB has emerged as a potential option for mucosal melanoma. Although injec tion of the primary site by nuclear medicine physician can be technically challenging, preliminary experiences of SLNB have been reported for SNMM. 1569–1571 Conceptually, the role of SLNB for SNMM would be to more accurately stage disease and guide adjuvant therapies. The current UK national guidelines advocate consideration of SLNB for accessible SNMM when positivity will influence adjuvant therapy or inclusion in a clinical trial; however, they do not recommend completion neck dissection when the SLNB is positive. 1514 Treatment of the neck in sinonasal mucosal melanoma

Policy level Option. Intervention Neck dissection for clinically positive cervical

lymph nodes may be considered within the context of the patient’s overall treatment plan.

7 Role of radiation therapy RT has played a prominent role in the treatment of SNMM (Table XXIV.D.5). Across several studies, RT is used in the treatment of SNMM in 44%–58% of cases. 366,1482,1565 In the majority of cases, RT is utilized in an adjuvant set ting following surgery with a typical dose-fractionation schedule of about 60 Gy in 30 fractions or a biologically equivalent regimen. 269,368,1482,1572–1574 Elective neck RT in the clinically N0 neck is infrequently utilized. 1575 However, primary monotherapy with RT or RT with systemic ther apy may be selected in cases of unresectable tumors or metastatic disease. 1403,1485 The efficacy of RT for SNMM with regard to survival has been explored in a number of studies. A systematic review of head and neck mucosal melanoma (all sites) found that patients who underwent surgery and adju vant RT had improved OS and improved local control compared to those who underwent surgery alone. 1573 How ever, other studies focusing specifically on SNMM have shown mixed data. In a large multicenter study, patients who underwent adjuvant RT following surgery demon strated a decreased local recurrence rate ( p = 0.001), but without impact on OS. 269 Mirroring these results, a 2016 NCDB study of 695 SNMM patients found no difference in OS between patients undergoing surgery alone versus surgery with adjuvant RT. 368 Another population-based study of 1373 patients found that negative margin surgery, immunotherapy, and treatment in the modern era were associated with improved OS (controlling for age, sex, co morbidities, tumor size, and stage); however, RT was not associated with OS. 1503 Caspers et al. also reported an institutional experience with 51 patients, of which 84% of patients underwent surgery and adjuvant RT. Adjuvant RT was associated with improved local control but had no effect on OS or DSS. 364 In another single-institutional series, Manton et al. reported no association between RT use and OS, LRC, or distant control. 1576 Moreno et al. report similar results with adjuvant RT being associated with improved LRC but with no effect on OS. 232 Finally, a large international multicenter study of 505 SNMM cases did find an OS benefit in patients receiving both surgery and adjuvant RT compared to surgery alone. 1564 In summary, adjuvant RT is likely associated with local control, but the impact on OS remains unclear.

Aggregate grade of evidence

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

Benefit

Neck dissection may reduce risk of regional recurrence (low level evidence) but has not been shown to be associated with OS. Potential harm of neck dissection includes cranial nerve injury, shoulder dysfunction, and vascular injury. Cost comparison analyses have not been undertaken.

Harm

Cost

Benefits–harm assessment

Balance of benefits and harms.

Value

Neck dissection for clinically positive lymph nodes may be considered but must be weighed against other options including immunotherapy.

judgments

(Continued)