Pearls from Your Peers: Updates on Management of Sinonasal Tumors

For this edition of “Pearls from Your Peers,” I am joined by Zara M. Patel, MD, from Stanford University who has published multiple studies on inverted papilloma as senior author and is a co-author on the recent International Consensus Statement on Sinonasal Tumors.¹

Based on your understanding of the evidence, what is the latest data on the role of human papilloma virus (HPV) in pathogenesis of inverted papilloma?

There has been conflicting evidence regarding whether HPV is involved in pathogenesis. Stronger evidence exists regarding epidermal growth factor (EGFR) and there has been more recent investigation into several cell cycle and angiogenic factors such as Ki67, VEGF, and Akt/mTOR. Although low-risk HPV subtypes can be found in both exophytic and inverted types of papillomas, there are more limited data for involvement of high-risk HPV.

When is it helpful to perform a debulking operation for a unilateral nasal mass?

Debulking can be used in different ways, depending on whether the tumor is benign or malignant. For both benign and malignant tumors, debulking first to better visualize attachment sites and improve access to those sites within the sinonasal cavity and skull base, before moving forward with the resection of those sites, can be helpful.

It should be pointed out that there has been no difference in survival or recurrence when comparing piecemeal versus en bloc resection for sinonasal and skull base tumors, so that old dogma should be laid to rest.

However, all surgery for malignancy that is undertaken with curative intent, whether the approach is open or endoscopic, and whether done in a piecemeal or en bloc fashion, should have a goal of complete resection with negative margins. If this does not seem feasible at the outset, the only time debulking may be used instead of that would be in a palliative fashion; that is, to help with breathing or to control bleeding, with the shared understanding between surgeon and patient that the intent of treatment at that point is not curative and only seeking to improve quality of life.

Have there been any significant shifts in treatment paradigms that have impacted survival?

The ever-improving methods and modalities of radiation therapy, the advancing border of resectability at the skull base owing to newer technology and surgical techniques, the addition of immunotherapy, and the combination of these into multimodal treatment plans have all impacted survival, albeit differently depending on tumor type.

Is orbital preservation possible when the patient presents with orbital invasion?

The short answer is yes, sometimes. The longer answer depends on exact tumor type and histology, but generally we are using neoadjuvant induction chemotherapy in more and more tumor types to preserve orbital structure and function despite initial invasion into the orbital fat or musculature. We also know that for some tumor types, if there is only invasion through lamina papyracea or periorbita, that resection of these structures while preserving orbital fat and muscle is appropriate and does not change survival when compared with full orbital exenteration.

References:

Kuan et al. International Consensus Statement on Allergy and Rhinology: Sinonasal Tumors. Int Forum Allergy Rhinol. 2024 Feb;14(2):149-608. doi: 10.1002/alr.23262. Epub 2024 Jan 2. PMID: 37658764.