xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

problems. 454 Intra-arterial treatment is technically more difficult to apply, limited to specific centers, and in the absence of a clear advantage in disease control and sur vival, IV treatment is far more commonly used. G Morbidity following immunotherapy Nivolumab and pembrolizumab are the principal immunotherapy agents used in SNM. Both drugs block the PD-1 receptor on lymphocytes, preventing PD-L1 and PD-L2 binding and therefore upregulating T-cell-mediated killing of cancer cells. 2180 Common AEs include fatigue, nausea, rash, pruritus, and depressed appetite. 2181–2186 Immune-related AEs (irAEs) are of particular concern and have been found to occur in 27% of patients, with high-grade irAEs in 6%. 2181 Serious AEs may include pneumonitis, adrenal insufficiency, hypothy roidism, colitis, acute liver injury, and Stevens–Johnson syndrome. 2183–2185,2187,2188 Fatal AEs have been found to occur in 0.4% of patients treated with PD-1 and PD-L1 inhibitors, commonly pneumonitis, hepatitis, colitis, neurologic events, and myocarditis. 2181 Overall, however, the side effects of immunotherapy on average are less than those seen with single-agent chemotherapy agents based on RCT data. 2182,2189 Table XXXII.4 summarizes evidence surrounding QOL after chemotherapy and immunotherapy for SNM. Morbidity following chemotherapy and immunotherapy

Value

Chemotherapy may improve survival in many SNM but is associated with adverse side effects that impact QOL. Specific side effects vary by agent.

judgments

Policy level Recommendation. Intervention Chemotherapy in the induction or adjuvant

setting is associated with decreased QOL, with specific AEs varying by specific agent. While many of the AEs are short term, long-term toxicities that impact QOL are common. It is important to weigh the effects of chemotherapy on QOL against the potential benefits for disease control.

In conclusion, various treatment modalities carry differ ent side effect profiles, and long-term QOL is an important consideration in treatment planning for this group of patients. With the increasing awareness of the importance of long-term QOL for SNM patients, shared decision making must focus not only on oncologic outcomes but also the factors that matter most to patients.

XXXIII SURVEILLANCE A Timing and schedule

Despite the extensive literature published on the tim ing and schedule for the surveillance of head and neck malignancy, there is a paucity of evidence to support a universal schedule for surveillance of SNM and benign dis ease. The most recent guidelines set forth by the NCCN suggest careful and regular follow-up for head and neck malignancies with the option to use FDG-PET/CT for surveillance a minimum of 12 weeks following definitive treatment or contrast-enhanced CT or MRI between 8 and 10 weeks posttreatment. 258 Evaluation with FDG-PET/CT prior to 12 weeks increases the rate of false-positive results due to residual inflammation from RT and/or surgical resection. 2192 In addition to imaging, routine clinical exam ination is recommended every 1–3 months for the first year, then every 2–6 months for the second year, followed by every 4–8 months for years 3 through 5, and then annual exams after year 5. Currently, the accepted standard is to extrapolate these recommendations to encompass sinonasal tumors; however, these tumors generally behave differently. Given this, the presented discussion and rec ommendations largely reflect SNM, though some special consideration is given to IP, where there have been focused studies on this topic. While these principles have generally been adopted for all head and neck malignancies, disease of the sinonasal subsite encompasses a wider breadth of pathology than classically seen in other upper aerodigestive tract sub-

Aggregate level of evidence

B (Level 1: two studies; Level 2: nine studies. Level 3: eight studies) Chemotherapy, either in the induction or adjuvant setting, is indicated for many SNMs to improve disease control. Immunotherapy and intra-arterial chemotherapy both attempt to reduce toxicity while improving disease control. AEs from systemic chemotherapy are very common, with almost all patients having at least low-grade AEs and more severe AEs occurring in approximately half of patients, depending on the study and agent. Intra-arterial chemotherapy spares some systemic toxicity but may increase local toxicity. Immunotherapy has less side effects than conventional chemotherapy and can have both immune-related side effects and nonimmune-related side effects. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms.

Benefit

Harm

Cost

Benefits–harm assessment

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