xRead - Nasal Obstruction (September 2024) Full Articles

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ICAR SINONASAL TUMORS

considered if that would facilitate the clearance of tumor (i.e., negative margins). Treatment of sites of attachment

the need for complete surgical resection should be bal anced with functionality and cosmesis. While no stud ies have directly compared surgical oncological princi ples between benign and malignant sinonasal neoplasms, expert opinion and standard modern practice favor endo scopic approaches for benign lesions whenever possible. Regarding oncologic outcomes, Goudakos et al. performed a systematic review to compare open and endoscopic resection of IP between 1974 and 2016. 140 Recurrence rates were significantly lower in the endoscopic resection group compared to the open resection group (14.9% vs. 18.8%). While this study did not control for disease loca tion or extent, it is likely that endoscopic resection is at least as effective as open approaches at achieving local control. Additionally, in the years since this study was pub lished, cumulative experience with endoscopic resection has exponentially grown, suggesting that recurrence rates following endoscopic resection have likely improved. 142 Namely, complete surgical extirpation offers the patient the best chance of cure and is always the desired outcome. This is particularly true in the case of IP, where there is a small risk of progression to malignancy. However, in the setting of purely benign disease, complete oncologic resec tion with the removal of excess normal surrounding tissue should be balanced with the preservation of aesthetics and function. An additional consideration is the risk of tumor seeding to surrounding cavities. Furthermore, resection of the dura or periorbita theoretically removes a natural bar rier to spread, and recurrence due to seeding in the brain or orbit could necessitate a much more aggressive surgery for a benign process. For these reasons, EEA is recommended for benign tumors unless there is gross involvement of the premaxillary soft tissue or skin or surgically inaccessible territories of the paranasal sinuses. D Risk of tumor seeding Tumor resection carries the theoretical risk of tumor seeding in any site in the body if microscopic (or even macroscopic) fragments are left behind and unrecognized (Table VI.3). Tumor seeding has been reported following both open and endoscopic resection of sinonasal tumors. Nguyen et al. conducted a systematic review of recurrence attributed to tumor seeding of all skull base lesions. 143 Of the 69 reported cases, three (4%) were sinonasal tumors. One was an individual case report and one was a retro spective cohort study. 144 Pathologies were SCC ( n = 2) and ACC ( n = 1). All three recurrences occurred follow ing open approaches. In their review of 70 patients with SNM, Moore et al. found two (3%) of recurrences attributed to seeding. One occurred at the transfacial incision after excision of a maxillary sinus tumor and the other along the

Aggregate grade of evidence

C (Level 2: two studies; Level 3: one study; Level 4: three studies; Level 5: one study) Attachment-oriented surgery allows for accurate clearance of disease with successful oncologic outcomes while sparing uninvolved structures. Minimizing morbidity is an especially important consideration in benign sinonasal tumors. Additionally, this technique may allow for shorter operating times and facilitates observation and follow-up aimed at the pedicle attachment site. Not all tumors are amenable to attachment-oriented surgery and the decision must be done on a case-by-case basis. It is highly surgeon dependent to accurately assess the sites of involvement or attachment. If negative margins are unable to be achieved, an open or combined approach may be necessary, especially in cases of malignant or aggressive pathologies. Cost comparison analyses have not been undertaken. Preponderance of benefits over harms. malignant sinonasal tumors in select cases where adequate surgical margins can be obtained safely. In cases of locally advanced lesions, utilizing an attachment-oriented technique must be balanced with the risk of leaving residual disease or needing to convert to an open or combined approach. Attachment-oriented surgery is beneficial to the treatment of benign as well as

Benefit

Harm

Cost

Benefits–harm assessment

Value

judgments

Policy level Recommendation. Intervention Endoscopic attachment-oriented surgery

should be considered to minimize morbidity when feasible and when

negative margins can likely be achieved. In cases of locally advanced disease, an open or combined approach may be necessary for disease clearance.

C Differences between benign and malignant pathologies In general, the principles of oncologic resection apply to both malignant and benign lesions. In benign lesions,