xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

TABLE XXXIII.2 Evidence surrounding the use of nasal endoscopy in the surveillance of sinonasal tumors.

Clinical endpoints

Study

Year LOE Study design Study groups

Conclusions

Nyquist et al. 2195 2021

Recurrence was detected by nasal endoscopy in 34.3% of cases

3

Retrospective cohort

231 patients treated for SNM

1. DFS 2. Recurrence rate

Zocchi et al. 419

2020 3

Retrospective cohort Retrospective case series

417 patients treated for SNM

Recurrence rates Endoscopy identified 21% of recurrences Diagnostic utility Endoscopy has comparable specificity and a predilection toward identifying superficial local recurrences highly amenable to salvage therapy

Khalili et al. 418

2016 4

109 patients with

primary SNM that underwent successful definitive treatment

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

D Role of imaging Imaging undoubtedly plays a vital role in tumor surveil lance (Table XXXIII.3). While nasal endoscopy can reveal changes and recurrences in the visible mucosa of the sinonasal tract, imaging provides the advantage of visual izing change deep to the mucosa, as can often been seen in SNM recurrence. This includes structures of the orbit, anterior and middle cranial fossae, and PPF/ITF. 35 Struc tural and functional imaging studies are useful in this scenario with the mainstay of structural imaging being MRI. MRI offers superior soft tissue definition and allows for evaluation of PNI. 19 The use of imaging increases the likelihood of detection of recurrent or residual dis ease compared to endoscopy alone, with rates of detection ranging from 49% to 62.7%. 7,12,14 Khalili et al. demon strated that the PPV for MRI was significantly greater compared to FDG-PET/CT and CT (84% vs. 46% and 44%, respectively). 14 In contrast, FDG-PET/CT has an average NPV of 94.4% ± 7.3%, which is useful in ruling out recur rence at primary, regional, and distant sites. 4,36–40 Despite this, the modality of choice is controversial and largely institutionally dependent. Controversy exists on the appropriate timing of imag ing in tumor surveillance. While data from head and neck malignancy suggest a posttreatment FDG-PET/CT at 12 weeks, there is some evidence to suggest this tim ing may not be appropriate in SNM given differences in sinonasal mucosal inflammation following treatment. Two studies retrospectively evaluated the optimal timing of posttreatment FDG-PET/CT for the diagnosis of recur rence in SNM. 3,41 Schwartz et al. investigated the level of FDG avidity in FDG-PET/CT imaging and reported that inflammation does not resolve until greater than 5 months following completion of treatment. 3 Conversely, Ozturk et al. found that FDG-PET/CT had 100% sensitivity and specificity for detecting recurrence at all sites when per formed between 1 and 3 months following completion of

treatment; however, the population and imaging intervals were heterogeneous. 38,41 There are no studies assessing the optimal time intervals for imaging studies in surveillance of SNT. The type of imaging used for surveillance also depends on the site. MRI provides superior detail for evaluation of the primary site, while FDG-PET/CT provides improved diagnostic information for regional and distant failure. Only one study assessed the diagnostic accuracy of MRI in the diagnosis of recurrence; however, only PPV was reported. The authors noted that PPV was superior for MRI compared to FDG-PET/CT for local recurrence (84% vs.46%). 14 They furthermore concluded that FDG-PET/CT has higher false-negative rates, likely due to the inflam matory nature of the sinonasal mucosa. Despite these findings, the PPV for FDG-PET/CT ranges from 43% to 97% with more consistent sensitivity, specificity, and NPV. 4,14,36–40 These findings suggest that FDG-PET/CT is highly sensitive with a high NPV, making this an invalu able modality to rule out recurrence, though the PPV is variable. A summary of the diagnostic utility measures can

be seen in Table XXXIII.4 for SNM. Role of imaging for surveillance Aggregate grade of evidence

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

Benefit

Detection of recurrent disease that cannot be detected though physical exam or nasal endoscopy (e.g., lateral frontal sinus, submucosal, intracranial, intraorbital). Minimal harm of radiation and allergic reaction from radioisotopes. Potential for unnecessary testing leading to financial consequences. Direct costs: variable cost depending on institution and imaging protocols

Harm

Cost

(Continued)