xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

of eight sinonasal tumors were able to be resected en bloc using a contralateral transseptal approach, but it should be noted that all were benign unilateral pathologies. 133 In cases of extensive tumors where the attachment site cannot be readily visualized, piecemeal resection is often required. Tosun et al. divided 20 patients with SNM treated with EEA into four categories by type of resection: en bloc ( n = 5), piecemeal resection of intranasal and en bloc resection of the tumor origin site ( n = 6), piecemeal resection of both intranasal and tumor origin sites with curative intent ( n = 4), and resection with palliative intent or removal with a positive margin ( n = 5). 134 Local recurrence was observed only in the final group at mean follow-up of 4 years, suggesting that piecemeal resection does not lead to an increase in local recurrence. Perhaps the strongest evidence for the oncologic validity of the piecemeal resec tion method utilized by most surgeons during EEA is large reviews showing similarities in outcomes between open and endoscopic approaches to skull base malignancy. For example, there is a large review of 1483 patients using the NCDB, of which 24% underwent endoscopic resection of sinonasal SCC. 135 Following propensity score matching, there was no significant difference in margin status or OS by surgical approach. However, large series, which mainly consist of database studies at the present, are limited in making conclusions about resection method, particularly for the vastly different pathologies that affect the sinonasal tract. En bloc versus debulking/piecemeal resection

Value

No studies have demonstrated a clear benefit of either en bloc or piecemeal resection. Since no study has found worse outcomes for piecemeal resection and improved visualization is accomplished with piecemeal resection in EEA, it is reasonable to resect sinonasal tumors in a piecemeal fashion when necessary for tumor visualization. an option based on tumor extension and sites of involvement. The decision on whether to proceed with en bloc versus piecemeal resection of sinonasal tumors should be made on a case-by-case basis. En bloc resection of the site of attachment/tumor origin should be attempted whenever possible.

judgments

Policy level Option. Intervention Use of en bloc versus piecemeal resection is

B Treatment of sites of attachment Identifying the attachment site for the treatment of a sinonasal neoplasm was first described for the surgical resection of sinonasal IP, where even advanced and large lesions were often found to have relatively small attach ment sites. 136 Initial identification of these attachment sites allows for more accurate clearance of disease with successful oncologic outcomes while minimizing morbid ity by sparing uninvolved structures (Table VI.2). 136,137 Pedicle-oriented surgery was also found to have shorter operating times and facilitates observation and follow-up aimed at the pedicle attachment site. 137 Furthermore, the use of intraoperative frozen sections to obtain evidence of clear margins at attachment sites was found to significantly reduce rates of recurrence in IP and can likely be inferred for other sinonasal lesions. 138 Castelnuovo et al. describe a multilayer centripetal tech nique to approach the resection of sinonasal malignant tumors with successful oncologic results. 139 Most endo scopic resections for sinonasal lesions begin with tumor debulking in order to identify the tumor attachment sites and any areas of potential tumor involvement or inva sion. During this initial stage, it is important to preserve the surrounding normal anatomic structures if possible for orientation and to minimize the necessary margin sec tions to follow. The tumor is then removed starting from the periphery of the tumor attachment site along with a wide margin and working circumferentially toward the center. Complete resection of all tumor attachment sites is crucial for an adequate oncologic resection. Although the tumor capsule is violated during this process, the

Aggregate grade of evidence

C (Level 3: seven studies; Level 4: two studies)

Benefit

Piecemeal resection has the benefit of improved visualization of the tumor attachment site and determining invasion into surrounding structures. En bloc resection, whenever possible, permits gross visualization of clear margins around the resection Piecemeal resection has the theoretical risk of tumor seeding in the cavity via violation of the tumor capsule. En bloc resection is potentially invasive and disfiguring. Cost comparison analyses have not been undertaken.

Harm

Cost

Benefits–harm assessment

Balance of benefits and harms.

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