Sinonasal cancer

• Consider flexible nasoendoscopy/EUA and biopsy.
  
  
• Primary surgery is the recommended definitive treatment for resectable sinonasal cancers. Irrespective of whether the surgery is performed with an open craniofacial approach or endoscopically, the surgical plan will involve achieving removal of the clinically and radiologically assessed gross tumour volume with an additional margin (aiming to achieve pathological R0 margin status).
  
  
• Where neoadjuvant systemic therapy has been deployed and a response achieved, consider continuing with the surgical plan (unmodified and including the pre-treatment gross tumour volume).
  
  
• Consider suitability of endoscopic surgery in sinonasal malignancies and discuss with relevant surgical teams. Consider the pre-operative grade and extent of the tumour when planning the surgical technique.
  
  
• If resectable, consider open surgery if the following are required: orbital exenteration, maxillectomy (radical maxillectomy including palate skin etc), skin excision, nasal bone excision, if disease involves anterior, superior +/or lateral frontal sinus, dura or brain lateral to mid orbital roof or lateral to optic nerve, or brain parenchyma. Open surgery may be combined with endoscopic approaches to optimise resection.
  
  
• All locally advanced and some early malignancies present with anterior and/or central skull base disease and therefore require appropriate expertise for dural resection and repair involving neurosurgery.
  
  
• Assess the need for orbital exenteration by specialist surgical team and MDT following full staging including radiology and endoscopic examination. 

• For loco-regionally advanced disease (T3/4 N_any or T_any N+) when multi-modality treatment (surgery then adjuvant (chemo) radiotherapy) is indicated, consider prior to initiating any management:

1. 1. Balance long term control/cure with acute and late morbidity from treatment.
   2. Patient suitability and likelihood of completing whole package of treatment.
   3. Alternative non-curative options.

• Counsel patients carefully on all these factors prior to commencing radical treatment pathway.

• Lymphatic drainage is to the facial, level I and II as well as retropharyngeal lymph nodes and may be bilateral. Consider regional lymph node involvement is predicated on site, stage, and histological type in making a judgment on elective neck treatment. When neck access is required for free flap reconstruction consider ipsilateral elective selective lymphadenectomy.
  
  
• In the presence of N+ve disease consider therapeutic neck dissection.

Consider prior to initiating any management for salvage:

1. Balance of chance of long term control/cure versus.
2. Likely acute and late morbidity from additional treatment.
3. Likelihood of requiring adjuvant treatment to achieve disease control/cure and patient suitability and likelihood to be offered this depending on patient factors and previous treatment.
4. Alternative non-curative options.

Counsel patients carefully on all these factors prior to commencing salvage treatment pathway.

• Consider salvage neck dissection to the affected nodal basin to patients with N+ve disease who have undergone (chemo)radiotherapy and who have FDG PET-CT residual avidity in neck nodes at 3 months post-treatment, with the primary controlled.

• Patients with recurrent/persistent resectable disease at the primary site may be considered for salvage surgery in the absence of distant disease. Consider salvage surgery in the event of recurrence taking into account patient factors including age, co-morbidities, and preferences. Skull base resection is often necessary. Reconstructive flap surgery is usually required.
  
  
• Patients with relapse at the primary site as well as regional recurrence have a poor prognosis.
  
  
• Patients with a short disease-free interval have a poor prognosis

Consider early endoscopic debulking for inoperable cases for palliation.