xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Biopsy In-office biopsies for sinonasal lesions appear to be a safe alternative to operative biopsies in appropriately selected patients, though patient selection is important. There is a moderate risk of a false-negative diagnosis given tumor heterogeneity or surrounding sinonasal inflamma tion obscuring the target. No studies have specifically examined the appropriate order of imaging and biopsy. The level of evidence (LOE) is low in this area and largely based on expert opinion. Resectability ∙ There is variability in the literature regarding what features make tumors resectable based on surgeon experience and institutional preference. ∙ Orbital apex: Orbital apex involvement portends a poor prognosis and is deemed unlikely to be able to obtain true-negative surgical margins. ∙ Carotid artery: Despite increasing experience with treat ment of tumors involving the carotid artery, ranging from nonsurgical therapy to carotid resection, there remains no strong evidence to indicate a survival benefit even with the most aggressive of treatments. ∙ Skull base: Poor prognosis is predicted by brain parenchymal and cavernous sinus involvement even if gross total resection (GTR) may be achieved. ∙ Pterygopalatine and infratemporal fossae: Newer evi dence suggests that involvement of these areas does not independently predict worse prognosis, as long as negative margins can be achieved. Workup for regional and distant disease A complete physical examination with palpation of the neck and imaging with computed tomography (CT) and/or magnetic resonance imaging (MRI) is recommended for evaluation of regional lymphadenopathy. Whole-body positron emission tomography (PET)/CT may be uti lized to assess regional and distant metastases but has known limitations, including false positives (e.g., inflam mation). Retropharyngeal lymphadenopathy is commonly underrecognized and should be considered in the workup. Workup of regional and distant disease

Benefit

CT and MRI are complementary for regional and distant disease workup. Functional imaging such as PET/CT has high sensitivity and negative predictive value (NPV), allows for baseline imaging, and is a single imaging technique for rapid simultaneous qualitative evaluation of the primary, regional, and distant metastasis. CTs expose patients to radiation. Workup of regional and distant metastasis and false-positive PET/CT may lead to additional (and potentially unnecessary) investigations, patient anxiety, and increased costs without a change in treatment. In a healthcare setting with limited resources, this may further increase delays in diagnosis and strain on the system. There is potential cost–benefit of hybrid PET scans since they can combine PET/CT or PET/MRI into a single exam and reduce the number and duration of hospital visits. Preponderance of benefits over harms. CT and MRI are both useful modalities for regional and distant disease assessment. CT is faster, better tolerated, and more readily available than MRI, but does incur radiation exposure. MRI does not subject patients to ionizing radiation, but takes longer to perform, has a risk of motion artifact, and is contraindicated in patients with noncompatible ferromagnetic devices. Hybrid PET imaging allows for more rapid and accurate diagnosis of regional and/or metastatic disease, especially for high-grade tumors and/or those tumors prone to metastases (e.g., sinonasal undifferentiated carcinoma, melanoma). However, there is potential for false-positive results, and thus it may be more useful for restaging than initial staging. It may not be as useful for tumors with low FDG avidity. imaging modalities. Hybrid PET or other full-body imaging should be considered in the investigation of regional and distant metastases in SNM. Presence of enlarged retropharyngeal lymph nodes should always be evaluated on CT or MRI.

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention CT and MRI remain the conventional

Aggregate grade of evidence

C (Level 3: four studies; Level 4: 16 studies; Level 5: 12 studies) (Continued)