xRead - Nasal Obstruction (September 2024) Full Articles

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KUANetal.

remains first-line treatment, while there is emerging evi dence regarding the role of immunotherapy and its impact on survival. RT and treatment of the neck appear to impact local and regional disease control, respectively, without clear survival benefit. Role of surgery for sinonasal mucosal melanoma

Harm

Single-modality treatment yields poorer OS and RFS. Greater regional recurrence rates occur in patients without elective neck treatment. Not evaluated in current studies. Preponderance of benefits over harms. While early studies suggested the greatest benefit was associated with surgery with adjuvant therapy, more recent studies have supported trimodality treatment or neoadjuvant chemotherapy followed by CRT in responders, especially in patients who cannot be resected with negative margins or without significant morbidity.

Cost

Benefits–harm assessment

Value

judgments

Aggregate grade of evidence

C (Level 2: one study; Level 4: 16 studies)

Benefit

Surgical resection with negative margins appears to be associated with improved OS and potentially RFS. When possible, it appears that endoscopic resection has equivalent results to open resection for OS andDSS. Surgical morbidity is largely related to selection of surgical approach and site of the tumor. Cost comparison analyses have not been undertaken.

Policy level Recommendation. Intervention Multimodal treatment with elective neck

Harm

treatment for SNUC is recommended. Neoadjuvant chemotherapy response as a guide for treatment can be considered.

Cost

Benefits–harm assessment

Preponderance of benefits over harms.

New classification schemes for sinonasal neuroen docrine carcinoma (SNEC) (i.e., small cell and large cell types) have recently been introduced. However, to date, the evidence suggests that surgery and RT remain the main stay of therapy, though IC may play a larger role over time. Treatment strategies for SNEC

Value

Surgical resection with negative margins is beneficial to improve OS.

judgments

Policy level Recommendation. Intervention Surgical resection is the first-line therapy for

SNMM when resection with negative margins can be achieved; when feasible, endoscopic resection should be considered. In cases of locally advanced or metastatic SNMM, the morbidity of radical surgical resection should be weighed against the poor survivability of this tumor; nonsurgical options may be considered in these cases.

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 4: five studies) In aggregate, surgery and RT confer survival benefit for both small-cell neuroendocrine carcinomas (ScNEC) and large-cell neuroendocrine carcinomas (LcNEC). Morbidity of treatment should be factored into the clinical decision-making process. No cost studies have been performed. Preponderance of benefits over harms. There may be an emerging role for neoadjuvant chemotherapy in management of SNEC, likely in higher grade tumors.

Benefit

Role of immunotherapy in sinonasal mucosal melanoma

Harm

Aggregate grade of evidence

C (Level 1: one study; Level 4: seven studies)

Cost

Benefit

Immunotherapy has proven efficacy as an adjuvant therapy for metastatic cutaneous melanoma. Early experience has also demonstrated efficacy as an adjunctive therapy for advanced or metastatic SNMM and may improve OS, although the robust responses do not equal the efficacy noted for metastatic cutaneous melanoma. The potential harm of immunotherapy includes rash, fever, nausea, and more severe immune-related adverse events including enterocolitis, pneumonitis, and hepatitis, particularly when used in combination therapy. (Continued)

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Surgery and RT remain the mainstay for primary management of SNEC. Induction

Harm

chemotherapy may be considered for patients with locally advanced disease, metastases, and/or high-grade tumors.

Sinonasal mucosal melanoma remains a highly chal lenging disease with overall poor prognosis. Surgery