Cost-effectiveness analysis of proton beam therapy for treatment decision making in paranasal sinus and nasal cavity cancers in China.

BACKGROUND: Cost-effectiveness is a pivotal consideration for clinical decision making of high-tech cancer treatment in developing countries. Intensity-modulated proton radiation therapy (IMPT, the advanced form of proton beam therapy) has been found to improve the prognosis of the patients with paranasal sinus and nasal cavity cancers compared with intensity-modulated photon-radiation therapy (IMRT). However, the cost-effectiveness of IMPT has not yet been fully evaluated. This study aimed at evaluating the cost-effectiveness of IMPT versus IMRT for treatment decision making of paranasal sinus and nasal cavity cancers in Chinese settings. METHODS: A 3-state Markov model was designed for cost-effectiveness analysis. A base case evaluation was performed on a patient of 47-year-old (median age of patients with paranasal sinus and nasal cavity cancers in China). Model robustness was examined by probabilistic sensitivity analysis, Markov cohort analysis and Tornado diagram. Cost-effective scenarios of IMPT were further identified by one-way sensitivity analyses and stratified analyses were performed for different age levels. The outcome measure of the model was the incremental cost-effectiveness ratio (ICER). A strategy was defined as cost-effective if the ICER was below the societal willingness-to-pay (WTP) threshold of China (30,828 US dollars ($) / quality-adjusted life year (QALY)). RESULTS: IMPT was identified as being cost-effective for the base case at the WTP of China, providing an extra 1.65 QALYs at an additional cost of $38,928.7 compared with IMRT, and had an ICER of $23,611.2 / QALY. Of note, cost-effective scenarios of IMPT only existed in the following independent conditions: probability of IMPT eradicating cancer ≥0.867; probability of IMRT eradicating cancer ≤0.764; or cost of IMPT ≤ $52,163.9. Stratified analyses for different age levels demonstrated that IMPT was more cost-effective in younger patients than older patients, and was cost-effective only in patients ≤56-year-old. CONCLUSIONS: Despite initially regarded as bearing high treatment cost, IMPT could still be cost-effective for patients with paranasal sinus and nasal cavity cancers in China. The tumor control superiority of IMPT over IMRT and the patient's age should be the principal considerations for clinical decision of prescribing this new irradiation technique.

The utility of routine polyp histopathology after endoscopic sinus surgery.

BACKGROUND: Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner. METHODS: A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed. RESULTS: Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73. CONCLUSION: Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.

Extramedullary plasmacytoma of the nasal cavity: treatment perspective in a developing nation.

Extramedullary plasmacytomas are uncommon tumors, with a worldwide annual incidence of 3 per 100,000 population. They account for 1% of all tumors of the head and neck and 4% of all nonepithelial tumors of the nasal tract. A variety of treatment options has been suggested. These treatments vary according to the site of presentation, the presence of locoregional spread, and the histologic picture. Radiotherapy has been widely used as a treatment modality, but little has been written about surgery as a single management modality. However, such an option assumes importance in a developing nation, where patient follow-up is erratic and treatment costs must be kept low. We discuss the feasibility of surgery in such a circumstance, and we describe our surgical treatment of a case of extramedullary plasmacytoma in an elderly woman who presented to our hospital in India.

Interstitial radiation therapy for early-stage nasal vestibule cancer: a continuing quest for optimal tumor control and cosmesis.

INTRODUCTION: This article reports on the effectiveness, cosmetic outcome, and costs of interstitial high-dose-rate (HDR) brachytherapy for early-stage cancer of the nasal vestibule (NV) proper and/or columella high-dose-rate (HDR). METHODS AND MATERIALS: Tumor control, survival, cosmetic outcome, functional results, and costs were established in 64 T1/T2N0 nasal vestibule cancers treated from 1991-2005 by fractionated interstitial radiation therapy (IRT) only. Total dose is 44 Gy: 2 fractions of 3 Gy per day, 6-hour interval, first and last fraction 4 Gy. Cosmesis is noted in the chart by the medical doctor during follow-up, by the patient (visual analog scale), and by a panel. Finally, full hospital costs are computed. RESULTS: A local relapse-free survival rate of 92% at 5 years was obtained. Four local failures were observed; all four patients were salvaged. The neck was not treated electively; no neck recurrence in follow-up was seen. Excellent cosmetic and functional results were observed. With 10 days admission for full treatment, hospital costs amounted to euro5772 (7044 US dollars). CONCLUSION: Excellent tumor control, cosmesis, and function of nasal airway passage can be achieved when HDR-IRT for T1/T2N0 NV cancers is used. For the more advanced cancers (Wang classification: T3 tumor stage), we elect to treat by local excision followed by a reconstructive procedure. The costs, admission to hospital inclusive, for treatment by HDR-IRT amounts to euro5772 (7044 US dollars). This contrasts substantially with the full hospital costs when NV cancers are treated by plastic reconstructive surgery, being on average threefold as expensive.

Imaging and surgical approach of nasal dermoids.

OBJECTIVE: Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids. DESIGN: Retrospective chart review. SETTING: Division of Pediatric Otolaryngology, Children's Hospital and Health Center, San Diego, California. PARTICIPANTS: All patients with nasal dermoids evaluated and treated from 1990 to 2000. INTERVENTION: Preoperative radiographic evaluation and surgical excision. OUTCOME MEASURES: Accuracy of CT and MRI correlated with surgical findings and results. RESULTS: Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used. CONCLUSIONS: MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

[Magnetic resonance and computed tomography compared in the staging of rhinosinusal neoplasms. A cost-effectiveness evaluation]. / Risonanza Magnetica e Tomografia Computerizzata a confronto nella stadiazione delle neoplasie rino-sinusali. Valutazione costo-efficienza.

This study was aimed at comparing CT and MRI in the preoperative staging of sinonasal malignancies and at developing the most cost-effective diagnostic strategy to determinate resectability and choice of surgery and to assess surgical demolition extent. Forty-nine patients with sinonasal tumors were examined during a 10 years' period, with CT (20 patients), MRI (13 patients) and combined CT and MRI (16 patients); 42/49 patients underwent surgical resection (16 patients with craniofacial resection and 6 with orbital exenteration). Cost-effectiveness of the two techniques was assessed comparing five protocols using CT and MRI either alone or combined. In 40/98 orbits the tumor was in contact with a bone wall. MRI was more accurate than CT in assessing orbital invasion (100% sensitivity, 94% specificity, 86% positive predictive value and 100% negative predictive value, vs. 50%, 93%, 75% and 82%, respectively, for CT). MRI showed the tumor in contact with the skull base in 24/49 patients and CT in 23/49 patients, with no statistically significant difference between the two techniques. Dural infiltration, however, was better demonstrated with MRI in 3 patients with minimal bone erosion of the nasal vault. In 5 patients CT and MRI showed pterygopalatine fossa invasion (4 true positives and 1 false positive for both techniques). Since the final decision about orbital exenteration needs accurate surgical mapping, CT appears to yield all the pieces of information necessary for surgical planning. The most cost-effective protocol seems to be a CT examination for all patients. MRI is needed only for better prognostic assessment in the patients with minimal bone erosion of the floor of anterior cranial fossa. In fact, dural invasion, which is a markedly negative factor for survival, may be missed by CT.