xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

should be undertaken before surgery to prioritize the goals of resection while selecting the appropriate approach and reconstruction. For ACC with perineural invasion (PNI), gross total resection (GTR) without negative margins may be an acceptable alternative. Frozen sections may be used to guide margin status intraoperatively, although it is not reliable for all histologies (i.e., mucosal melanoma). To date, there is no consistent definition of adequacy or “wideness” of margins. Margin analysis in sinonasal tumors Aggregate grade of evidence C (Level 2: one study; Level 3: 12 studies; Level 4: 61 studies) Benefit

Intervention

All attempts should be made to resect SNM to negative margins except for when resecting to negative margins would put critical neurovascular structures at risk for injury that would otherwise not be at risk. GTR may be acceptable for ACC for local control. Frozen section analysis should not be used on mucosal melanoma due to inaccuracy. For all other tumor types evaluated (SCC, adenocarcinoma, ONB, SNUC) frozen section analysis should be used intraoperatively to define the resection margins and ensure definitive/negative margin resection.

Management of recurrent malignancy Outcomes of salvage surgery are dependent on histol ogy, primary site, and stage. Although there may be a survival benefit, there is a higher risk of morbidity and mortality associated with salvage surgery. Palliative treatments, including surgery, radiation therapy (RT), or chemotherapy, may be considered for symptomatic and QOL management without curative intent. Radiation modalities for treatment of sinonasal malignancies RT is an important definitive and adjuvant modality for management of SNM (and some benign tumors in lim ited indications). Intensity-modulated radiation therapy (IMRT) has become the most commonly utilized modality with demonstrated efficacy and generally acceptable safety profile. Particle beam therapy has an emerging role and should be considered if available. Radiation modalities for treatment of sinonasal malignancies Aggregate grade of evidence IMRT: B (Level 2: three studies; Level 3: one study; Level 4: 50 studies)

Negative margins are associated with significant improvements in overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) in a majority of studies for all tumor subtypes. Potential harm of taking aggressive margins includes injury to critical neurovascular structures that would otherwise not be sacrificed, leading to increased morbidity or mortality to the patient. Inaccurate frozen section margins intraoperatively could change the operative plan and either compromise definitive resection requiring a return to the operating room or adjuvant chemoradiation or could lead to more aggressive resection than is truly warranted. The potential harm to not achieving negative margins comes at the cost of survival for several tumor subtypes. Frozen section use is associated with increased costs, but this must be weighed against the potential cost of a second surgery, intensification of adjuvant treatment, and reduced survival that could otherwise have been avoided if complete resection with negative margins had been achieved. Preponderance of benefits over harms. “Wide surgical margins” should be more clearly defined and uniformly reported within the literature. Recommendation for most malignancies. Option for ACC with perineural invasion. (Continued)

Harm

Cost

Proton beam radiotherapy (PBT): C (Level 2: two studies; Level 3: one study; Level 4: 23 studies); five level 4 carbon ion radiotherapy (CIRT) series include single modality PBT patients Fast neutron therapy (NRT): C (Level 4: 10 studies) CIRT: C (Level 2: two studies; Level 3: two studies; Level 4: 23 studies) (Continued)

Benefits–harm assessment

Value

judgments

Policy level