xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

Role of surgery in ITAC

Value

Definitive CRT/RT could be considered in the setting of unresectable tumors, for patients who are poor surgical and chemotherapy candidates, and in patients who decline surgery. Additionally, for early-stage tumors, definitive CRT/RT can be considered, although there are limited studies evaluating this.

judgments

Aggregate grade of evidence

B (Level 2: two studies; Level 3: one study; Level 4: seven studies) Oncologic resection is possible with endoscopic approaches in many cases. Reduced complication rate, improved QOL, and better survival outcomes have been described as direct benefit of a multimodal treatment strategy including surgery. Insufficient tumor excision with positive surgical margins, leading to increased risk of local or distant recurrences, and morbidity and complication risks related to surgery. Although no studies have examined the issue of costs in sinonasal ITAC treatment, short hospitalization period and fast patient recovery associated with minimally invasive surgery could translate to lower costs. Preponderance of benefits over harms. All studies to date have suggested equivalent or better outcomes of endoscopic surgery as compared to traditional craniofacial surgery. There is no significant argument for or against bilateral ethmoid resection as routine procedure for patients with occupational exposure.

Benefit

Policy level Option. Intervention Patients with unresectable or early-stage disease, patients who are poor surgical

Harm

candidates, and patients who do not desire surgery may be considered for definitive CRT/RT.

Elective management of the N0 neck in sinonasal SCC Aggregate grade of evidence C (Level 2: two studies, Level 3: two studies; Level 4: two studies) Benefit Elective neck treatment may decrease the rate of regional recurrence. Harm There are morbidities associated with elective neck treatment, both for surgical treatment and elective irradiation.

Cost

Benefits–harm assessment

Value

Cost

Insufficient data to make recommendations regarding long-term costs of elective neck treatment.

judgments

Benefits–harm assessment

Balance of benefits and harms.

Value

Patient with advanced T-stage tumors may benefit from elective neck treatment. Maxillary sinus SCC has a higher risk of neck metastasis than nasal cavity SCC.

judgments

Policy level Recommendation. Intervention Multidisciplinary management of sinonasal

ITAC with primary surgery and achieving negative margins currently represents the standard of care.

Policy level Option. Intervention Strong consideration should be given to elective neck treatment in cases of

advanced T stage tumors, especially if it is a maxillary sinus primary and if primary surgery is undertaken. Elective treatment may be in the form of elective irradiation or END.

Role of adjuvant therapy in ITAC

Aggregate grade of evidence

C (Level 2: one study; Level 3: one study; Level 4: four studies) Additional oncologic control in cases of positive margins or locally advanced/metastatic tumors. The risk of osteoradionecrosis, mucositis, and other RT- and chemotherapy-induced complications should be discussed with the patient when adjuvant treatments are planned. No dedicated studies on cost. Multidisciplinary management with multiple healthcare workers involved in the treatment may increase the economic burden. (Continued)

Benefit

Sinonasal adenocarcinoma Sinonasal adenocarcinomas comprise a group of glandu lar neoplasms, of which intestinal-type adenocarcinoma (ITAC) is more common in European countries and is asso ciated with exposure to hardwood dusts. Certain subtypes (signet ring cell type) and higher tumor grade are asso ciated with worse prognosis. The mainstay of treatment is surgical resection with negative margins, with adjuvant RT considered for positive margins, advanced tumor stage, and high-grade tumor histology.

Harm

Cost