Treatment/Prognosis Flashcards
How are sinonasal/PNS tumors typically managed?
Surgical resection and adj RT +/- chemo. Consider induction chemo in SNUCs, small cell, sinonasal neuroendocrine tumors, very advanced primary squamous carcinomas.
Are there any RCTs that define Tx for sinonasal/PNS tumors?
No. Dz is rare and presents at multiple sites with varying histologies. It would be difficult to appropriately power an RCT
What type of Sg is necessary to manage a maxillary sinus tumor?
Partial (2 walls of maxilla removed) or total maxillectomy to –margins. For smaller tumors, endoscopic sinus surgery, with or without robotic assistance, is replacing open procedures. For larger medial tumors, a medial maxillectomy with a midfacial degloving technique is performed with an incision made under the lip (Caldwell–Luc). For tumors that are mainly inf, an infrastructure maxillectomy is often performed. For larger tumors, access through the nasal crease/upper lip may be necessary. Tumors involving the orbital floor or orbit often require orbital exenteration. Reconstruction is done with skin grafting and obturator placement. Larger defects are filled with free flaps.
How are ethmoid sinus tumors managed surgically?
Ethmoid sinus tumors are surgically managed by either endoscopic sinus surgery for small tumors or craniofacial resection, requiring access both anteriorly through the sphenoethmoid area (through the nose) and superiorly with a craniotomy (neurosurgery) to address the skull base/dura.
When is orbital exenteration necessary in sinonasal/PNS tumors, and when is it not absolutely necessary?
It is necessary if extraocular muscles, optic nerve, bulb, or eyelid are involved. It is not necessary if there is only bone erosion or periorbital fat involvement.
What are some indications for definitive radiotherapy in the management of sinonasal/PNS tumors?
Inoperable tumors (medically and technically).
What are the indications for adj radiotherapy after resection of sinonasal/PNS tumors?
Maxillary sinus T3–T4 lesions or T1–2 adenoid cystic above Ohngren line, ethmoid sinus T2–T4 lesions (can consider omission of adj RT in T1 ethmoid per NCCN 2018), N+, + or close margins, +PNI, +LVSI, high-grade histology.
How is radiotherapy delivered and to what dose?
IMRT, volumetric modulated arc therapy, IGRT, proton beam therapy approaches, to 70 Gy (definitively) or 60–66 Gy (adj), to the tumor bed and margins; 50–56 Gy to low-risk areas. Use image fusion (MRI/PET) for planning purposes.
Per the NCCN (2018), what altered RT fractionation regimens can be employed for maxillary sinus tumors when definitive RT is delivered without chemo?
Per NCCN 2018:
Accelerated (6 fx/wk during wks 2–6): 66–70 Gy for gross Dz and >50 Gy for subclinical Dz
Concomitant boost (bid last 2 wks): 72 Gy over 6 wks (1.8 Gy/fx large field and 1.5 Gy/fx same-day boost over last 2 wks)
Hyperfractionated: 1.2 Gy/fx bid to 81.6 Gy over 7 wks
Is concurrent chemo a standard approach in the definitive management of sinonasal/PNS tumors with RT?
No. Prospective trials are evaluating CRT, and it can certainly be considered based on principles for other H&N cancers for which concurrent chemo is recommended (stages 3–4 treated definitively, or +margins or nodes with ECE in the adj setting).
For which tumors should elective neck management be considered (with Sg or RT)?
Elective neck management should be strongly considered for tumors with squamous or undifferentiated histology and for T3 or T4 tumors of other histologies. It is controversial for ENB, though recommended by many centers. It may be left out for other subsites with N0 Dz.
What studies/data support the use of ENI for maxillary sinus tumors?
Stanford data (Le QT et al., IJROBP 2000): 97 pts (36 RT alone, 61 Sg + RT), 12% nodal failure overall in levels I–II; 5-yr nodal failure risk 20% –ENI, 0% +ENI; 5-yr distant relapse rate 29% with neck control, 81% if neck failure.
MDACC data (Bristol I et al., IJROBP 2007): SCC/undifferentiated histologies nodal failure 36% in 36 pts without ENI vs. 7% in 45 pts with ENI.
What have recent studies demonstrated regarding the use of adj IMRT for sinonasal/PNS tumors?
There was no significant improvement in terms of LC or OS; however, there was a lower incidence of complications with IMRT. (Madani I et al., IJROBP 2009; Dirix P et al., IJROBP 2010)
What did the 2017 NCDB analysis (Robin TP et al., Cancer 2017) show regarding the multimodality management of sinonasal/PNS tumors?
Sup OS with multimodality therapies vs. Sg alone; adj RT (HR 0.658, p < 0.001), adj CRT (HR 0.696, p = 0.002), or neoadj therapy (HR 0.656, p = 0.007); neoadj CRT associated with greater likelihood of achieving –margins (OR 2.641, p = 0.045).
