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KUANetal.

TABLE VI.3 Evidence surrounding risk of tumor seeding.

Clinical endpoints Recurrence

Study

Year LOE Study design Study groups

Conclusion

Nguyen et al. 143

Tumor recurrence attributed to seeding in endonasal approaches is rarely reported

2018 2

Systematic review

69 patients with

attributed to seeding

recurrent skull base lesions attributed to seeding

Yuet al. 146

2018 3

Retrospective cohort

38 ONB patients

1. Dural

Dural recurrence can occur in the absence of local recurrence

recurrence

2. Local

recurrence

Moore et al. 144

Tumor recurrence attributed to seeding is rare

2011

3

Retrospective cohort

70 patients with locally advanced SNM

Recurrence

attributed to seeding

Miller et al. 145

2006 5

Case report

One patient with ACC treated with maxillectomy and RT

Recurrence at the

Distant recurrence following resection may be attributed to locoregional seeding intraoperatively

tracheostoma

Abbreviations: ACC, adenoid cystic carcinoma; ONB, olfactory neuroblastoma; RT, radiation therapy; SNM, sinonasal malignancy.

dura at the site of a craniotomy. Both died due to disease, one secondary to the local recurrence and the other sec ondary to distant metastasis. Miller et al. reported an atyp ical site for recurrence of ACC of the maxillary sinus: at the tracheostoma following a transfacial approach. 145 Yuet al. reviewed a series of 20 ONB patients to identify patterns of recurrence. Recurrence was most common at the dura (65%). 146 There were six cases where isolated dural recur rence occurred in the absence of local recurrence, leading the authors to suggest that the dura was seeded with tumor intraoperatively. In their series, surgical approach was not significantly associated with DFS. Taken together, tumor seeding following resection of sinonasal tumors appears to be a rare event as the literature is limited to small case series. While these reports appear to have a preponderance toward open resection, the small sample size and lack of a true comparator group do not allow any conclusions to be made about risk with certain surgical approaches. Risk of tumor seeding

Cost

Cost comparison analyses have not been undertaken.

Benefits–harm assessment

Balance of benefits and harms.

Value

Since reports are limited to case series, there is no evidence to suggest that tumor seeding is impacted by surgical approach. Piecemeal resection could theoretically have a higher risk of tumor seeding due to tumor capsule violation, while open surgery may expose uninvolved soft tissues to tumor. based on tumor seeding is an option. There is no evidence that an open or endoscopic approach to sinonasal tumors carries a higher risk of tumor seeding. Given the lack of case reports, either approach appears to have a low risk of tumor seeding. Upfront recognition and prevention are key to minimize this risk.

judgments

Policy level Option. Intervention Consideration of approach and technique

VII BIOPSY The necessity of histopathological tissue diagnosis in the management of sinonasal lesions is well established. 147–149 Tissue diagnosis is required to identify appropriate treat ment options for patients with sinonasal tumors. Incorrect or delayed diagnoses adversely affect patient outcomes and survival, highlighting the need for accurate and timely diagnosis. 150–152 Previously, tissue diagnosis often required an operative setting. As rigid endoscopy with high-quality

Aggregate grade of evidence

C (Level 2: one study; Level 3: two studies; Level 5: one study) Careful dissection technique and close inspection can minimize risk of tumor seeding. Spread of tumor via seeding presents a significant challenge in management often requiring aggressive surgery and/or adjuvant treatment of a separate site.

Benefit

Harm

(Continued)