Beth Israel Deaconess Medical Center

Although current NCCN guidelines do not recommend surgical resection for T4b sinonasal tumors, recent studies report that up to 80% of patients undergo surgery as part of their treatment. This discrepancy between guideline-based recommendations and real-world clinical practice led us to investigate the clinical, demographic, and institutional factors associated with undergoing surgery among patients with clinically staged T4b sinonasal cancer. We analyzed data from the National Cancer Database (2004-2022) to identify patients diagnosed with clinical T4b sinonasal malignancies. Patients were grouped by treatment approach: surgery with adjuvant therapy vs. definitive chemoradiation. Multivariable logistic regression assessed clinical, demographic, and institutional predictors of surgery. Of 2244 patients, 57.5% received surgery as part of treatment. Surgical management was more likely among patients with private insurance (aOR 1.56, 95% CI 1.17-2.08), those treated in the Northeast (aOR 1.55, 95% CI 1.12-2.16), and patients traveling more than 100 miles for care (aOR 1.89, 95% CI 1.35-2.63). Histologic subtypes such as melanoma (aOR 13.37), neuroectodermal tumors (aOR 11.79), adenoid cystic carcinoma (aOR 2.98), and adenocarcinoma (aOR 2.99) were more likely to receive surgery. Node positivity was negatively associated with surgery (aOR 0.49). Despite guideline recommendations, surgery remains common for T4b sinonasal cancer. Surgical selection appears driven by tumor biology as well as access- and system-level factors. These findings highlight the evolving and context-dependent definition of unresectability in clinical practice.

Kara Stavros: Dr. Stavros has served as a paid consultant for Springer Healthcare. Pushpa Narayanaswami: Research Support: NIH, Alexion, Argenx, Cabaletta-Bio, Dianthus. Advisory boards/Consultation: Alexion, Argenx, Amgen, CVS, Cartesian, Dianthus, EMD-Serono, GSK, Immunovant, Immune-Abs, Janssen, Novartis, UCB, Vor-Bio. Speaker honoraria: UCB, Alexion, WebMD, PeerVoice, Medscape, Academic CME, Med Learning Group. Data Safety Monitoring Boards: Alexion, NMD pharma, Sanofi. Royalties: Springer Nature. Other: Serve as Associate Editor, Muscle and Nerve and Associate Editor, Classification of Evidence, Neurology. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

This study is to determine peripheral sample collection timing impact on selectivity index (SI) and success of unstimulated adrenal venous sampling (AVS) for primary aldosteronism (PA) subtyping. In this study, a retrospective discovery and a prospective validation arm were conducted. 74 patients undergoing AVS before and after-ACTH stimulation were reviewed. Discovery dataset was divided into 1) "pre" group, peripherals collected 30-min before AVS and 2) "post" group, peripherals collected 1-min after AVS. SIs were calculated using 30-min-pre and 1-min-post values. Patients with samples having SIs < 2 and SIs ≥ 5 on before and after-ACTH were classified as false negative and those with SI ≥ 2 and SI ≥ 5 on before and after-ACTH as true positive. Data was analyzed using Chi-squared test. For validation, 27 patients were enrolled prospectively as a paired group. In each, two peripherals were collected approximately 30 min before and 1 min after AVS. Cortisol was compared using Wilcoxon matched-pair signed rank test. Retrospectively, 38% of "30 min-pre" patients had SI < 2 in right adrenals, compared to 14% in "1 min-post" patients (P = 0.007). For the left, 45.9% of "30 min pre" patients had SIs < 2 compared to 13.5% in "1 min-post" patients, (P = 0.002). Prospectively, peripheral cortisol 1 min post decreased by 28% compared to 30-min pre (median, 6.4 to 4.6 μmol/L; P < 0.001). SIs increased 40% bilaterally (P < 0.001). In conclusion, in unstimulated AVS, collecting peripheral samples after sampling the adrenal veins is more likely to give more accurate SI than before sampling the adrenal veins.

The data that support the findings of this study are available from the corresponding author upon reasonable request.