Setting New Standards for Nasal Vestibule Malignancies

In this concluding chapter, we outline three fundamental paradigm shifts in the oncology of the nasal vestibule. First, the classification needs to be changed, by defining the nasal vestibule as a subsite of the nose and paranasal sinuses and separating it from the “nasal cavity proper and ethmoid.” The anatomic boundaries should therefore be changed and made reliable and easy to identify, also radiologically. A specific topographic code should be assigned, with specific T-classification criteria derived from specific characteristics of cancers arising in this site. This will improve both prognostic stratification and treatment selection and also provide a better estimation of the real prevalence, which is underestimated due to the absence of a specific topographic code in cancer registries, but also because of frequent misdiagnosis with skin cancers, due to the early straightforward invasion of the skin by these primaries. For this reason, we recommend every lesion of the nasal and perinasal skin to be routinely evaluated by an otolaryngologist, to exclude a nasal vestibule primary. Secondly, there is increasing evidence demonstrating that Interventional Radiotherapy (IRT, Brachytherapy, BT), is at least equivalent to surgery and superior to EBRT for the treatment of early-stage (T1 and T2 according to Wang) primary lesions in terms of oncological outcomes. Moreover, IRT appears superior to both aforementioned modalities in terms of cosmetic and functional results. Considering these findings, we recommend HDR (High Dose Rate) IRT as the new standard for the treatment of the primary lesion in nasal vestibule carcinoma. As for neck treatment in N+ disease, a neck dissection remains the treatment of choice, as it is a safe and effective modality with both a staging and a curative role. Furthermore, it meshes well with IRT for the primary tumor and leaves room for further radical treatment by external beam radiation (see Chap. 14). Elective neck treatment in cN0 disease remains a topic of ongoing discussion, but is not recommended as of today. We believe that ultrasound investigation associated when deemed useful to USguided fine needle aspiration biopsy in a Lump Clinic can be extremely useful for the assessment of the real neck status and the proper definition of cN0 necks. The role of sentinel node biopsy in high-risk node negative nasal vestibule carcinoma is currently being evaluated. Thirdly, to optimize the advantages of IRT as the primary therapeutic modality, we propose an evolved approach to the implantation phase of IRT, for which the main criterion becomes anatomy, that is an exploitation of the anatomic planes of esthetic and functional nose surgery to avoid previously described septal and alar perforation (anatomic implantation). The potential of intensity-modulated and image-guided IRT (IM-IRT and IG-IRT) will be in turn exploited to compensate for dose inhomogeneities.