xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

Benefit–harm assessment

Preponderance of benefits over harms.

Policy level Recommendation. Intervention Chemotherapy in the induction or adjuvant

setting is associated with decreased QOL, with specific AEs varying by specific agent. While many of the AEs are short term, long-term toxicities that impact QOL are common. It is important to weigh the effects of chemotherapy on QOL against the potential benefits for disease control.

Value

Treatment of SNM with RT is frequently indicated for improved disease control; however, it does cause both short- and long-term morbidities. Proton beam RT may be considered to reduce side effects. For ORN, medical management may be attempted but management is typically surgical.

judgments

Surveillance To date, much of the literature on surveillance has been based on principles abstracted from mucosal cancers of the head and neck. In contrast, sinonasal tumors represent a highly diverse group of diseases with variable biologic behavior. Late recurrences ( > 5 years) are possible with many tumors, specifically IP, ONB, and ACC. Surveillance is conducted using a combination of patient history and exam, endoscopy, and imaging, with long-term monitor ing (perhaps even lifelong) a strong consideration for many tumors at high risk for recurrence. Role of assessment based on physical exam, signs, and symptoms

Policy level Recommendation. Intervention RT is associated with improved local control and survival for many tumors but leads to impaired QOL, principally affecting

sinonasal symptoms. Acute symptoms are common, as are long-term toxicities. Proton therapy can be considered for a reduction in morbidity. Skull base ORN can be managed medically or surgically, with growing evidence suggesting safety and efficacy.

Morbidity following chemotherapy and immunotherapy

Aggregate level of evidence

B (Level 1: two studies; Level 2: nine studies. Level 3: eight studies) Chemotherapy, either in the induction or adjuvant setting, is indicated for many sinonasal malignancies (SNMs) to improve disease control. Immunotherapy and intra-arterial chemotherapy both attempt to reduce toxicity while improving disease control. Adverse events (AEs) from systemic chemotherapy are very common, with almost all patients having at least low-grade AEs and more severe AEs occurring in approximately half of patients, depending on the study and agent. Intra-arterial chemotherapy spares some systemic toxicity but may increase local toxicity. Immunotherapy has less side effects than conventional chemotherapy and can have both immune-related side effects and non-immune-related side effects. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. Chemotherapy may improve survival in many SNMs but is associated with adverse side effects that impact QOL. Specific side effects vary by agent. (Continued)

Benefit

Aggregate grade of evidence

C (Level 3: three studies)

Benefit

Early detection of recurrent tumors with possibility of timely intervention. Missing a diagnosis of a recurrent or persistent tumor given relatively low rates of detection. Direct costs: consultation fees and travel costs. Preponderance of benefits over harms. Physical examination of the paranasal sinuses is difficult given the anatomic location. Exam findings should focus on cranial neuropathies, ocular findings, and new-onset lymphadenopathy. present in advanced disease. A complete history and physical examination should be performed at each posttreatment examination. Screening of symptoms should include presence of new onset epistaxis, intractable facial pain, and cranial neuropathies.

Harm

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Symptoms and physical exam findings often

Cost

Benefits–harm assessment

Value

judgments