xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.23262, Wiley Online Library on [02/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

25

ICAR SINONASAL TUMORS

Role of adjuvant therapy in non-ITAC Aggregate grade of evidence

Benefits–harm assessment

Balance of benefits and harms.

C for both RT and chemotherapy ∙ Level 3: two studies (RT) ∙ Level 3: two studies (chemotherapy) There is some evidence that adjuvant RT improves DSS of non-ITAC patients, especially for high-grade tumors. No strong data on chemotherapy outside the palliative setting are available, except in the presence of functional p53 protein. Possible side effects of RT include mucositis, nasal discharge, osteoradionecrosis/ osteomyelitis, and hyposmia. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms (RT). No strong evidence (chemotherapy). Adjuvant RT should be considered to improve DSS of non-ITAC patients. The role of chemotherapy is not established in the management of non-ITAC patients except in presence of functional p53 protein and as part of topical treatment.

Value

For patients with functional P53 , neoadjuvant chemotherapy may improve survival rates. Adjuvant RT should be administered in advanced-stage and/or poorly differentiated tumors, though there are no dedicated studies on this. Biological studies to better understand the genetic and molecular profile of such rare cancers will be crucial to better stratify patients according to prognosis and discover potential new drug targets for precision medicine.

judgments

Benefit

Harm

Cost

Policy level Option. Intervention Adjuvant RT should be considered for ITAC

Benefits–harm assessment

treatment following surgery if pathology demonstrates positive surgical margins, for advanced-stage tumors (pT3–4), and/or for poorly differentiated grade. The role of

Value

judgments

chemotherapy and timing of administration is less clear.

Sinonasal non-ITAC is a diagnosis of exclusion and may represent multiple tumor types. Sinonasal renal cell like adenocarcinoma is an important subtype of non-ITAC and must be distinguished from metastatic renal cell car cinoma. Similar to ITAC, the recommended treatment modalities include surgery with adjuvant RT for high grade and advanced-stage disease. Role of surgery in non-ITAC

Policy level Recommendation for adjuvant RT. Option for adjuvant chemotherapy. Intervention Adjuvant RT should be considered for all patients with high-grade and/or

advanced-stage non-ITAC. Concerning low-grade tumors, the potential benefit should be weighed against the side effects. The role of chemotherapy is established in cases of a functional p53 protein or for palliative therapy.

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 4: four studies Surgical resection, either endoscopic or open approach, with negative margins may be associated with improved OS and DSS. Procedural related, depending on the approach. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms.

Sinonasal adenoid cystic carcinoma Sinonasal ACC is a locally invasive salivary gland malig nancy with propensity for PNI and distant metastasis. Management principles were previously discussed in ICSB 2019 5 and the current section provides an updated liter ature review. Given low likelihood of long-term distant control, surgery with goal of GTR followed by RT may achieve favorable local control rates. Human papillo mavirus (HPV)-related multiphenotypic sinonasal carci noma is a histologic mimic of ACC and must be excluded through additional HPV-specific testing due to the differ ent long-term outcomes. Role of surgery in sinonasal ACC Aggregate grade of evidence C (Level 2: one study; Level 3: two studies; Level 4: 10 studies) Benefit Surgical resection is superior to any other modality in terms of local control and long-term survival. (Continued)

Benefit

Harm

Cost

Benefits–harm assessment

Value

Surgical resection with negative margins is beneficial to improve OS and DSS.

judgments

Policy level Recommendation. Intervention Endoscopic transnasal resection with goal of

negative margins is the primary treatment of choice for non-ITAC. Due to increased morbidity, open (craniofacial) resection should be considered when negative postoperative margins cannot be achieved otherwise.