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KUANetal.

TABLE VI.2 Evidence surrounding treatment of sites of attachment.

Clinical endpoints 1. Anatomic

Study

Year LOE Study design Study groups

Conclusion

Trent et al. 138

1. Most common technique to address attachment involved resecting mucosa and drilling tumor base 2. Use of intraoperative frozen sections is associated with decreased recurrence

2022 2

Systematic review

Patients with IP treated with

attachment sites and techniques

attachment-site oriented surgery

2. Recurrent rates

Goudakos et al. 142

2018 2

Systematic reviewof LOE four studies Prospective cohort

2451 patients with

Recurrence rate Recurrence was higher in the open approach group

resection of IP (1526 endoscopic, 925 open)

1. IPs typically have small attachment sites 2. Identification of attachment sites facilitates efficacious resection with minimal morbidity Endoscopic surgery alone was effective in select cases of SNSCC with adequate visualization of tumor attachment site Pedicle-oriented endoscopic surgery offers adequate control of disease with shorter operating times, avoids unnecessary surgery, and facilitates follow-up aimed at pedicle attachment 2-year OS rate higher than 80% in all histologic types of tumors except for melanomas Indications for the endoscopic approach to sinonasal carcinomas has been expanding and can be effective in select cases

1. Attachment diameter 2. Attachment location 3. Persistent/ recurrent disease

Landsberg et al. 136

2021

3

Patients undergoing endoscopic IP excision via

attachment-oriented approach ( n = 33)

Nakamaru et al. 140

2021

4

Retrospective case series

SNSCC patients

1. OS 2. DSS 3. LRC

( n = 15) undergoing endoscopic surgery without an open approach

Pagella et al. 137

1. Recurrence rates 2. Operative times 3. Postoperative complications

2014 4

Retrospective case series

1. IP patients undergoing

standard ESS ( n = 37)

2. IP patients undergoing

pedicle-oriented endoscopic surgery ( n = 36)

Castelnuovo et al. 139

2006 4

Retrospective case series

Patient with treated

2-year OS rate

malignant sinonasal carcinoma ( n = 67)

Homma et al. 141

1. Recurrence rates 2. Survival times 3. Margin status

2021

5

Literature review

Patients with IP and

sinonasal carcinoma undergoing

endoscopic and open treatment

Abbreviations: DSS, disease-specific survival; ESS, endoscopic sinus surgery; IP, inverted papilloma; LRC, locoregional control; OS, overall survival; SNSCC, sinonasal squamous cell carcinoma; SNM, sinonasal malignancy.

normal tissue planes of the tumor are not affected since the tumor sits in an air-filled cavity. Once the visible tumor is resected, an additional layer of tissue, deep to the involved attachment site, should be resected. For exam ple, mucosal lesions should have the underlying bone or cartilage resected, and tumors abutting the orbit may require resection of the lamina papyracea and periorbita. Extensive frozen margin sections should be performed sys tematically to ensure clearance of disease, especially along

the previously identified attachment sites. Resection is continued until negative margins are obtained. Nakamaru et al. similarly describe an attachment-oriented approach for sinonasal SCC. As this tumor is more aggressive than IP, wider surgical margins should be obtained and addi tional frozen sections utilized prior to resecting the mucosa surrounding the tumor. 140,141 If negative margins are not possible through an endoscopic and attachment-oriented approach, conversion to an open approach should be