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371

ICAR SINONASAL TUMORS

TABLE XXXIII.1 Evidence surrounding the use of physical exam and symptoms in the surveillance of sinonasal tumors.

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusions

Nyquist et al. 2195 2021

Recurrence was detected on physical examination in 2.0% of cases

3

Retrospective cohort

231 patients treated for SNM

1. DFS 2. Recurrence rate

Zocchi et al. 419

2020 3

Retrospective cohort Retrospective cohort

417 patients treated for SNM.

Recurrence rates Only 6.3% of recurrences were detected by symptoms

Rates of symptomatology are lower in recurrent SNM than in other recurrent cancers of the head and neck

1. DFS 2. OS 3. Recurrence rate

Workman et al. 421

2019 3

55 patients with

history of definitive treatment of SNM with recurrence

Abbreviations: DFS, disease-free survival; OS, overall survival; SNM, sinonasal malignancy.

Role of surveillance based on physical exam, signs, and symptoms

tumor surveillance (Table XXXIII.2). The rates of diagnosis of primary recurrence using nasal endoscopy ranged from 20.8% to 34.3%. 7,12,14 Khalili et al. demonstrated that nasal endoscopy had a sensitivity and specificity of 25% and 89%, respectively, and a PPV of 13% in asymptomatic patients. In patients with symptoms, the PPV of nasal endoscopy increased to 85%. 14 Nyquist et al. demonstrated that, in the setting of local recurrences, half would be diagnosed via nasal endoscopy and that nasal endoscopy diagnoses more primary recurrences when surgical resection has been performed. 7 Furthermore, in patients with recurrent disease, nasal endoscopy tends to identify smaller, more superficial recurrences that may be more amenable to sal vage surgery, while imaging tends to identify larger sized recurrences. 14 Role of endoscopy for surveillance

Aggregate grade of evidence

C (Level 3: three studies)

Benefit

Early detection of recurrent tumors with possibility of timely intervention. Missing a diagnosis of a recurrent or persistent tumor given relatively low rates of detection. Direct costs: consultation fees and travel costs. Preponderance of benefits over harms. Physical examination of the paranasal sinuses is difficult given the anatomic location. Exam findings should focus on cranial neuropathies, ocular findings, and new-onset lymphadenopathy. present in advanced disease. A complete history and physical examination should be performed at each posttreatment examination. Screening of symptoms should include presence of new onset epistaxis, intractable facial pain, and cranial neuropathies.

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Symptoms and physical exam findings often

Aggregate grade of evidence

C (Level 3: two studies; level 4: one study).

Benefit

Detection of a primary tumor recurrence, assess extent of involvement, and evaluation for feasibility of resection. Risk of local tissue trauma and potential to miss recurrence deep to mucosa. Direct costs: procedure fees and consultation fees. Preponderance of benefits over harms. Direct visualization of the paranasal sinuses with rigid or flexible endoscopes should be performed, especially for postsurgical patients.

Harm

Cost

Benefits–harm assessment

C Role of endoscopy Postoperative nasal endoscopy is generally regarded as the standard of care for surveillance, especially follow ing surgical resection. Given that the most common site of failure in SNM is local and that external visualization of the sinonasal tract is difficult, direct visualization of the primary site using nasal endoscopy is important. 34 Despite this hypothetical advantage, only three studies assessed the impact of nasal endoscopy for sinonasal

Value

judgments

Policy level Recommendation. Intervention Nasal endoscopy should be performed at each

surveillance visit to assess for local tumor recurrence within the sinonasal tract, as well as assess mucosal health and side effects (e.g., crusting).