xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Benefits–harm assessment

Preponderance of benefits over harms.

Intervention Tumor histology should be taken into consideration when determining the appropriate surveillance protocols. Most tumors recur within the first 5 years;

Value

FDG-PET/CT should be used for evaluation of regional or distant metastases, while MRI is the treatment of choice for surveillance of the primary site (i.e., superior soft tissue definition). CT can be considered but has less sensitivity compared to MRI.

judgments

however, certain pathologies (e.g., IP, ONB) have propensity for recurrence greater than 10 years following definitive treatment.

Policy level Recommendation. Intervention Posttreatment imaging should be performed to detect residual or recurrent disease. MRI and/or FDG-PET/CT should be the

F Surveillance of sinonasal malignancies

While current dogma suggests that FDG-PET/CT is use ful for surveillance of regional or distant metastatic disease, this is generally based on clinical studies for HNSCC, which has a higher propensity for regional failure. In general, SNM tends to fail locally, though this is dependent on the tumor histology. The median recurrence rate for SNM in the included studies was 30.7% (range 17.6%–73.9%), with the majority of recur rences being local. When assessing tumor subtype, HPC had the lowest rates of recurrence and mucosal melanoma had the highest rates. 373,402,419,1417,2197 The DFS is also dependent on tumor subtype, with SNUC, SNEC, and melanoma having the shortest DFS and sali vary gland tumors, adenocarcinomas, and ONB having the longest. 216,373,418,419,431,1086,1153,1161,1166,1397,1417,1931,2195–2197 Other than descriptions of DFS and OS, no studies eval uated differences in surveillance including modalities, timing, and duration based on tumor histology. G Surveillance of inverted papilloma While IP is a benign tumor, there is a risk for malig nant degeneration and recurrence of the primary tumor, necessitating long-term surveillance. 22 Of the included studies, 11 studies assessed long-term follow-up for IP. 369,701,720,721,741,1135,2194,2198–2201 There was a wide range for mean time to recurrence ranging from 8 to 45.5 months, with maximum time to recurrence being 253.2 months. The rates of recurrence were also variable with a mean rate of recurrence of 16.1% ± 9.1%. The method for diagnosis of recurrence was inconsistent across included studies with nasal endoscopy and imaging being used. Many authors advocated the use of nasal endoscopy for surveillance. 216,369,701,2199,2200 Both MRI and CT were used for evaluation of recurrent lesions at variable schedules. Only one compared different surveillance strategies. 741 The authors compared findings from CT, MRI, and nasal endoscopy on patients with recurrent IP and demonstrated that MRI revealed the presence of the recurrent tumor in all cases compared to the other modalities. CT was equiv-

modality of choice. Multiple scans provide for adequate comparison of changes across time. The timing is left to provider discretion, but FDG-PET/CT should be performed 12 weeks following completion of treatment and MRI should be performed within 8–10 weeks following treatment.

E Differences in surveillance practices based on histology There were no studies assessing the impact of tumor histol ogy on the specific intervals or modalities of surveillance; however, based on the pooled evidence, it can be implied that histology is paramount. While tumors of the head and neck generally consist of SCC and its subtypes, sinonasal tumors are vastly different and tumor biology strongly dic tates the necessary follow-up interval and modality for surveillance. Given the paucity of data in the literature, it is necessary to infer recommendations by assessing the natural course of each tumor, benign and malignant. Differences in surveillance practices based on histology Aggregate grade of evidence D (no dedicated studies) Benefit Detection of recurrent or residual sinonasal tumors. Harm Missing late or early recurrence of disease; unnecessary testing or examinations. Cost None. Benefits–harm assessment Insufficient evidence. Value judgments Sinonasal tumors behave differently from other head and neck tumors. Surveillance should be tailored to specific tumor histology and biologic behavior.

Policy level

No recommendation.

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