xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

∙ Dysplasia is a harbinger of progression to malig nant transformation in IP and oncocytic papillomas. Papilloma-associated malignancies tend to be associated with low-risk HPV, while high-risk HPV seems more prevalent in de novo sinonasal SCC.

Benefit

IMRT provides locoregional control (LRC) and benefits in PFS and OS rates as either primary or adjuvant therapy for SNM with absolute benefits dependent on patient and pathology-specific factors. RT morbidity is related to the extent and site of the tumor, including soft tissue, bone, vascular, and neural injury. Aside from IMRT, the other modalities may not be widely available, and patients may need to travel to specialized facilities for care. Limited to two series. PBT provided extra quality-adjusted life-year (QALY) compared to IMRT and was cost-effective in patients ≤ 56 years old, and CIRT increased costs compared to IMRT despite survival benefits. Preponderance of benefits over harms. All modalities should be considered for improving LRC rates. The absolute benefit to LRC rates for SNM depends on patient and pathology-specific factors and should be weighed against the risk of treatment toxicity. NRT/CIRT should be considered for salivary glands or radioresistant histologies with gross residual disease at the time of treatment. LRC, disease-free survival (DFS), and OS rates when weighed for patient-specific and tumor features. Evidence suggests that PT, particularly PBT, could be considered when available.

Harm

Assessment of dysplasia and HPV in sinonasal papillomas

Cost

Aggregate grade of evidence

B (Level 2: seven studies; Level 3: 17 studies; Level 4: 22 studies) Proper histopathologic assessment is crucial to appropriately characterize IP grade and clinical behavior. The surgeon should consider assessment of EGFR and KRAS mutations and HPV in diagnostically challenging cases, particularly when there is concern for dysplasia or malignant transformation. There is potential negative impact to patient care when an incorrect pathologic diagnosis (e.g., understaging) is made. No studies currently discuss healthcare costs related to the diagnostic workup of IP and genomic or viral testing. Preponderance of benefits over harms.

Benefit

Benefits–harm assessment

Value

judgments

Harm

Cost

Benefits–harm assessment

Policy level Recommendation. Intervention IMRT should be considered for improving

Value judgment Appropriate evaluation of tissue specimens allows for improved treatment

stratification. Given the potentially high risk of recurrence and morbidity from inappropriate treatment, a correct diagnosis is critical for sinonasal papillomas.

Policy level Recommendation. Intervention The surgeon should engage with the head

Section 2: Benign lesions and neoplasms Sinonasal papillomas ∙ Exophytic papilloma has a strong association with low risk human papillomavirus (HPV) subtypes, with rare malignant transformation risk. ∙ Oncocytic papillomas have comparable malignant transformation risk as IPs but may be distinguished through pathologic and molecular features. ∙ IPs, which are the most common sinonasal papillo mas, demonstrate somatic mutations in EGFR and association with low-risk HPV subtypes.

and neck pathologist to appropriately diagnose sinonasal papillomas and determine presence of dysplasia. EGFR mutations appear to be the dominant factor in IP development. Although low-risk HPV may be found in exophytic and inverted subtypes, there are limited data to support the involvement of high-risk HPV in sinonasal papillomas.

∙ Whenever possible, all IP sites of attachment should be definitively treated with mucosal resection followed by drilling and/or cauterization of the hyperostotic focus