xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Role of concurrent chemoradiation therapy in treatment of advanced-stage NPC Aggregate grade of evidence A (Level 1: one meta-analysis of 4800 patients in 19 trials) Benefit The addition of concurrent chemotherapy to radiation in advanced-stage NPC improves OS (HR 0.79), and absolute increase in OS at 5 years is 6.3%.

Role of induction chemotherapy in treatment of NPC Aggregate grade of evidence A (Level 1: one study; Level 2: five studies) Benefit Induction chemotherapy improves most survival parameters, with GP for three cycles having the best OS followed by TPF.

Harm

Use of IC increases grade 3 and 4 adverse events with TPF having the highest number of adverse events. However, long-term QOL may be similar or even better than CRT alone. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. For patients with high performance status and minimal co-morbidity, IC would improve the survival. However, IC increases the toxicity of treatment and may not be tolerated by patients with less-than-optimal performance status or comorbidities. Nevertheless, IC with gemcitabine and cisplatin (GC) regimen has survival benefits, which justifies the increased cost and toxicity during treatment.

Harm

Increased acute toxicities with CRT.

Cost

Addition of chemotherapy incurs increase in treatment cost. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. Addition of concurrent chemotherapy is justified in advanced-stage NPC, unless patient has reduced performance status.

Cost

Benefits–harm assessment

Benefits–harm assessment

Value

Value

judgments

judgments

Policy level Strong recommendation. Intervention Concurrent chemotherapy with cisplatin is

recommended for advanced-stage NPC. There is no difference in survival outcomes for weekly cisplatin regimen versus every 3 weeks dosing.

Role of concurrent chemoradiation therapy in treatment of early-stage NPC Aggregate grade of evidence A (Level 1: two studies; Level 2: one study) Benefit Addition of concurrent chemotherapy during

Policy level Strong recommendation. Intervention IC with GP or TPF, for three cycles before definitive CRT, should be considered for

advanced-stage NPC (stage III–IVB, excluding T3N0) in patients who can tolerate the treatment.

RT improves survival in advanced-stage NPC, but the benefit is less clear in earlier stage disease. Addition of concurrent chemotherapy significantly increase the risk of acute grade 3–4 neutropenia. Addition of chemotherapy increases treatment cost. Cost comparison analyses have not been undertaken. Preponderance of harms over benefits. Except for T2N1 disease with bulky lymph node metastasis, addition of chemotherapy may not improve survival especially for patients receiving IMRT. Routine CRT is not routinely recommended in stage II NPC as it is associated with increased toxicity with unclear survival benefits.

Lymphoma Sinonasal lymphoma is commonly underrecognized, and accurate classification of disease type through histopathol ogy, immunohistochemistry (IHC), flow cytometry, and molecular studies is important for treatment planning. Dif fuse large B-cell lymphoma (DLBCL) is the most common variety, while extranodal NK/T-cell lymphoma (ENKTL) has worse prognosis. DLBCL is treated primarily with chemotherapy and immunotherapy with or without RT, while ENKTL is treated with chemoradiation. Role of chemotherapy: B-cell lymphoma Aggregate grade of evidence B (Level 3: four studies; Level 4: eight studies) Benefit Chemotherapy has been associated with improved survival in patients with sinonasal BCL. (Continued)

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation against. Intervention CRT with cisplatin should only be considered in stage II patients with bulky nodal disease.