xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

A En Bloc versus debulking/piecemeal resection Traditional surgical principles held that tumors should be resected en bloc to prevent tumor spillage into the surrounding environment (seeding) and thereby prevent local recurrence (Table VI.1). 126 In head and neck surgical oncology, the resection of sinonasal carcinoma, frayed with anatomic restrictions due to surrounding critical struc tures within tight confines, challenged this principle. In 1970, a novel trimodality protocol (surgery, RT, chemother apy) was suggested, in which surgery involved debulking of tumors in the maxillary sinus rather than complete max illectomy, as had previously been the standard of care. 127 Nineteen of the initial 57 patients treated with this protocol had residual tumor; however, all were successfully treated with subsequent partial maxillectomy or RT. Compared to the patients previously treated with the standard en bloc resection, the trimodality patients had lower rates of local recurrence and earlier return to function. This marked the beginning of a gradual acceptance of “tumor debulking” or “piecemeal” resection of sinonasal tumors as an accept able alternative. Similar findings have since been reported in several other studies. 128,129 In a recent series, survival was retrospectively compared in 27 patients with definitive en bloc resection to seven patients with debulking surgery (endoscopic endonasal approach [EEA], piecemeal resec tion) performed to minimize the radiation field. 130 The debulking group had lower OS and DFS, although this series is limited by selection bias. Patel et al. described the use of a microdebrider in a variety of anterior skull base malignancies including 14 SNMs. 131 GTR or near-total resection was achieved in nearly 90%, but local recurrence and survival were not reported. Another study reviewed 41 patients treated with craniofacial resection (CFR) for SNM, where a majority of patients were noted to have T4 disease (81%) and 42%, 37%, and 17% invading the orbit, meninges, and brain at presentation, respectively. 132 They found that en bloc resection was significantly associated with improved recurrence-free survival (RFS) compared to piecemeal resection (78% vs. 45% at 10 years). But this dif ference was not significant on recursive partition analysis, suggesting confounding by tumor involvement of adjacent structures. With the advent of EEA, approaches often necessitate piecemeal resection of at least part of the intranasal tumor to fully visualize the attachment site. Based on the historic principles of tumor spillage discussed above, some authors have argued that EEA is substandard treatment for aggres sive skull base malignancies. Omura et al. report that seven

Assessment of risk factors for sinonasal tumors

Aggregate grade of evidence

C for all risk factors ∙ Level 4: eight studies (age) ∙ Level 3: two studies; Level 4: seven studies (genetic sex) ∙ Level 2: one study; Level 3: five studies; Level 4: four studies (occupational exposure) ∙ Level 3: three studies (smoking) ∙ Level 2: two studies; Level 3: one study; Level 4: one study (link to viral infections) ∙ Level 3: two studies; Level 4: nine studies (genetic factors) Understanding and screening of risk factors for tumorigenesis provide prognostic information and opportunities for prevention. Recall bias of risk factors, variable risk of tumorigenesis across different individuals and populations. No studies assessing cost, but likely low costs of screening by history. Molecular testing may be costly. Preponderance of benefits over harms. Many risk factors are nonmodifiable. There is a need for further research into the role of molecular and genomic testing.

Benefit

Harm

Cost

Benefits–harm assessment

Value

Judgments

Policy level Recommendation. Intervention Routine history taking and screening for risk factors such as age, sex, ethnicity, occupational exposure, and smoking may provide clinically useful prognostic

information and prevention opportunities. Testing for genetic and viral etiologies may be considered, especially if there are actionable mutations.

VI PRINCIPLES OF SURGICAL TREATMENT The anatomic complexities of the sinonasal cavity, includ ing its close proximity to important structures, notably the skull base and orbit, make surgical resection and clearance of cancer to negative margins particularly challenging. Traditionally, open craniofacial approaches with the goal of total en bloc resection were considered the standard of care. 125 However, advances in endoscopic sinus and anterior skull base surgery shifted this paradigm toward piecemeal or multibloc resection. 125