10.14639/0392-100X-N2786
Objective. Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck malignancy for which there is no established consensus on most aspects of clinical management. The purpose of this document is to give updated recommendations that incorporate recent evidence on its clinical characteristics and the high efficacy of brachytherapy as primary treatment modality. Methods. A working group consisting of the members of the Scientific Committee for Oncology and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus. Results. Consensus was reached on a set of recommendations, proposing a refined anatomical definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachytherapy as standard of care, with a new method for catheter implantation. Conclusions. The Committee emphasises the critical role of an accurate classification in clinical practice and encourages further research to validate the novel staging system and further improve treatment strategies. Where appropriate, it is recommended that patients be referred to centres with specific experience in brachytherapy for NV SCC.
text/xml
1827-675X
2786
en
Gabriele Molteni
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
squamous cell carcinoma
Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology – Head and Neck Surgery
Text.Serial.Journal
https://www.actaitalica.it/
44
Head and neck
2024-02-27
2023-10-17
2024-02-28
2024-02-28
13-20
1
Gabriele Molteni
2024/02/27
10.14639/0392-100X-N2786
13
Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy; Otolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
1827-675X
squamous cell carcinoma
en
20
Management of nasal vestibule carcinomas: recommendations by the Oncological Committee of the Italian Society of Otorhinolaryngology – Head and Neck Surgery
https://www.actaitalica.it/article/download/2786/1069
44
ACTA OTORHINOLARYNGOLOGICA ITALICA 2024;44:13-20; doi: 10.14639/0392-100X-N2786




Head and neck


Management of nasal vestibule carcinomas:
recommendations by the Oncological Committee
of the Italian Society of Otorhinolaryngology –
Head and Neck Surgery
Francesco Bussu1,2, Luca Tagliaferri3, Michaele Francesco Corbisiero1, Cecilia Lotto4,5, Raul Pellini6, Pierre Guarino7,
Giuseppe Mercante8,9, Andrea Galuppi10, Francesco Cariti11, Giovanni Almadori12, Francesco Longo13,
Luca Calabrese14, Jacopo Galli15, Livio Presutti4,5, Piero Nicolai16, Gabriele Molteni4,5
1
  Department of Medicine, Surgery and Pharmacy, Sassari University, Italy; 2 Otolaryngology Division, Sassari University Hospital,
Sassari, Italy; 3 Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia, Dipartimento di Scienze Radiologiche,
Radioterapiche ed Ematologiche, Rome, Italy; 4 Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of
Bologna, Bologna, Italy; 5 Otolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy;
6
  Head and Neck Department, IRCCS National Cancer Institute “Regina Elena” Rome, Italy; 7 Otorhinolaryngology Head and Neck
Surgery Unit, “Santo Spirito” Hospital of Pescara, Pescara, Italy; 8 Department of Biomedical Sciences, Humanitas University, Milan,
Italy; 9 Department of Otorhinolaryngology - Head and Neck Surgery, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy;
10
   Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, DIMES, Alma Mater Studiorum, Bologna University,
Bologna, Italy; 11 Department of Otolaryngology Head and Neck Surgery, “Mons. Dimiccoli” Hospital, Barletta, Italy; 12 Unit of Head
and Neck Surgical Oncology, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, Rome,
Italy; 13 Maxillofacial & ENT Surgery Unit, Department of Head and Neck Surgery and Oncology, Istituto Nazionale Tumori IRCCS
Fondazione “G. Pascale”, Naples, Italy; 14 Department of Otorhinolaryngology-Head and Neck Surgery, Hospital of Bolzano (SABES-
ASDAA), Teaching Hospital of Paracelsus Medical University (PMU), Bolzano, Italy; 15 Unit of Otolaryngology, Fondazione Policlinico
Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; 16 Section of Otorhinolaryngology - Head & Neck
Surgery, Department of Neurosciences, University of Padua, Padua, Italy


SUMMARY
Objective. Squamous cell carcinoma of the nasal vestibule (NV SCC) is a head and neck
malignancy for which there is no established consensus on most aspects of clinical manage-
                                                                                               Received: October 17, 2023
ment. The purpose of this document is to give updated recommendations that incorporate
                                                                                               Accepted: November 28, 2023
recent evidence on its clinical characteristics and the high efficacy of brachytherapy as
primary treatment modality.
                                                                                               Correspondence
Methods. A working group consisting of the members of the Scientific Committee for Oncol-
                                                                                               Cecilia Lotto
ogy and Reconstructive Surgery of the Italian Society of Otorhinolaryngology Head and Neck     E-mail: cecilia.lotto@studio.unibo.it
Surgery and radiation oncologists expert in brachytherapy was formed to achieve a consensus.
Results. Consensus was reached on a set of recommendations, proposing a refined anatomi-
cal definition of the nasal vestibule, a novel T staging system of the NV SCC, and brachy-       How to cite this article: Bussu F, Tagliaferri
                                                                                                 L, Corbisiero MF, et al. Management of nasal
therapy as standard of care, with a new method for catheter implantation.
                                                                                                 vestibule carcinomas: recommendations by the
Conclusions. The Committee emphasises the critical role of an accurate classification in         Oncological Committee of the Italian Society of
clinical practice and encourages further research to validate the novel staging system and       Otorhinolaryngology – Head and Neck Surgery.
further improve treatment strategies. Where appropriate, it is recommended that patients be      Acta Otorhinolaryngol Ital 2024;44:13-20. htt-
referred to centres with specific experience in brachytherapy for NV SCC.                        ps://doi.org/10.14639/0392-100X-N2786

KEY WORDS: nasal cancer, nasal vestibule cancer, brachytherapy, radiation therapy,             © Società Italiana di Otorinolaringoiatria
squamous cell carcinoma                                                                        e Chirurgia Cervico-Facciale


                                                                                                              OPEN ACCESS

                                                                                               This is an open access article distributed in accordance with
Introduction                                                                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                               Commercial-NoDerivatives 4.0 International) license. The
Squamous cell carcinoma (SCC) of the nasal vestibule (NV) is considered a                      article can be used by giving appropriate credit and mentio-
                                                                                               ning the license, but only for non-commercial purposes and
relatively rare malignancy, accounting for approximately 1% of all head and                    only in the original version. For further information: https://
neck cancers 1.                                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                         13
F. Bussu et al.




The NV, which is the most anterior part of the nasal cavity,
consists of three walls (medial, lateral, and inferior) and
has a framework made by nasal cartilages. Through these
structures, NV SCC can directly spread to the skin 2, which
results in frequent misdiagnoses with skin primaries. Nota-
bly, the initial onset of a small, inapparent primary lesion in
the NV can easily be a more evident outer skin invasion of
the nasal pyramid (Fig. 1). Furthermore, despite being part
of the nasal cavity, the NV’s inner lining consists of epider-
mis up to the level of the limen nasi, which may contribute
to the confusion with skin primaries. There is no consensus
on the treatment of choice of this tumour, and only a few
series specifically focus on this disease 4-7.
However, in recent years, there has been a growing inter-
est towards the specific features of SCC involving the NV,
and the challenges surrounding its management – from di-
agnosis to classification, staging and treatment 3,8-10 . This
increased focus, primarily driven by Italian and Dutch re-
searchers 8,9,11,12, provided data leading the Scientific Com-
mittee for Oncology and Reconstructive Surgery of the             Figure 1. Predominant skin manifestations of primary nasal vestibule cancer
Italian Society of Otorhinolaryngology Head and Neck              (from Bussu et al., 2023, mod.) 3.
Surgery to produce the present document with a series of
recommendations, which in the authors’ view can establish
a state-of-the-art management of NV SCC.                          After the review, discussion, and revisions, the working
                                                                  group reached a unanimous consensus on the position
Materials and methods                                             statements. The document was submitted to the Scientific
                                                                  Committee for Oncology and Reconstructive Surgery and
A position statement working group (FB, GM, MFC, CL,              formally approved.
LP, PN) was created by the Scientific Committee for On-
cology and Reconstructive Surgery of the Italian Society
of Otorhinolaryngology Head and Neck Surgery, which in-
                                                                  Results
cluded Otolaryngologists with specific interest in the man-
agement of NV SCC. Two radiation oncologists (LT, AG)             Statement 1. A clear anatomic definition
were also included in the group.                                  Data reported in the literature on the incidence of NV SCC
After excluding potential conflicts of interest, the working      are misleading. This is in large part due to the lack of a uni-
group was tasked with the objectives of position statements.      versally accepted definition of NV anatomical boundaries.
A literature search was initiated using PubMed, Cochrane,         This ambiguity contributes to an unclear definition of the
and Google Scholar search engines. Search terms incor-            disease. To address this issue, the Committee agrees to
porated: nasal vestibule cancer, nasal cancer, surgical ap-       adopt a plane tangential to the piriform opening as the
proaches, radiation therapy, brachytherapy, chemotherapy,         posterior boundary, a landmark that is easily identifi-
and immunotherapy. The inquiry included clinical trials,          able through imaging studies 3,9,13. This boundary demar-
cohort studies, and review articles. The review was extend-       cates the NV from the proper nasal cavity (Fig. 2). Addi-
ed to current national and society guidelines and published       tionally, the limen nasi and the edge of the nostril should be
position statements from the gray literature.                     recognized as the boundaries separating the NV from the
Throughout the span of two online meetings and additional         skin of the nose and upper lip, respectively.
electronic group correspondence, the literature search re-
sults were compiled into shared themes and formal position        Statement 2. Nasal vestibule cancer as a distinct entity
statements for the Italian Society of Otorhinolaryngology         The current International Classification of Diseases for On-
Head and Neck Surgery were drafted. Areas of ambiguity,           cology (ICD-O) fails to adequately distinguish NV cancer
controversy, and inconsistency within the literature were         from other nasal and paranasal cancers, as the NV is current-
highlighted for discussion within the working group.              ly considered an unspecified area within the nasal cavity 14.



14
                                                                                                               Position paper on nasal vestibule carcinoma




                                                                                 Statement 3. Avoiding misdiagnosis
                                                                                 The frequent misdiagnosis of NV carcinomas as skin pri-
                                                                                 maries not only contributes to underestimate the incidence
                                                                                 of the disease but can also lead to improper treatment of
                                                                                 NV SCC as skin cancer, potentially resulting in both cos-
                                                                                 metic and oncological disasters (Fig. 3). In fact, there are
                                                                                 key differences in tumour spread between NV and skin
                                                                                 cancer. NV cancer preferentially spreads along the carti-
                                                                                 lages, which cannot be spared, whereas skin primaries tend
                                                                                 to remain superficial to the cartilages due to their anatomic
                                                                                 structure and most often allow their sparing 2,4. Notably,
                                                                                 skin involvement by NV cancer can be very early even in
                                                                                 case of small inapparent lesions inside the nose 13. As such,
                                                                                 the Committee strongly recommends that all skin le-
                                                                                 sions in and around the nose tip and nostrils, especially
                                                                                 those diagnosed as SCC, should be evaluated by an oto-
                                                                                 laryngologist to exclude a primary nasal lesion 3,9.
Figure 2. Defining distinct anatomical boundaries for the nasal vestibule
(NV). This figure proposes clear boundaries for the NV also to improve esti-
mation of the incidence of NV carcinoma (from Parrilla et al., 2023, mod.) 14.   Statement 4. A specific nasal vestibule cancer classification
                                                                                 Currently, there is no universally accepted staging system
                                                                                 for NV SCC, particularly concerning T classification. The
Specifically, the ICD code C30.0 groups NV with the nasal                        most utilized staging systems include the Union for In-
cavity, making it difficult to accurately assess and track the                   ternational Cancer Control (UICC)/American Joint Com-
prevalence and incidence of NV cancer among other nose can-                      mittee on Cancer (AJCC) staging system for nose and
cers 15. Consequently, the absence of a specific World Health                    paranasal cancers, the UICC/AJCC staging system for
Organization (WHO) topographic code allegedly leads to un-                       non-melanoma skin cancer (NMSC) of the head and neck,
derestimate NV cancer prevalence. The present Committee                          and the Wang’s classification 15,16. Among these, the Wang’s
strongly advocates for the introduction of a specific topo-                      classification, that was developed specifically for the NV
graphic code for NV within the WHO ICD-O.                                        approximately 50 years ago, has proven to be the most re-




Figure 3. Cosmetic and oncologic consequences of misdiagnosed nasal vestibule cancers treated as primary skin cancer (from Bussu et al., 2023, mod.) 3.



                                                                                                                                                      15
F. Bussu et al.




liable in predicting survival outcomes for NV SCC 7,13,17.                           not only improve the accuracy of disease staging but also
This is because of the unique features of NV malignancies                            contribute to a better understanding of its progression and
(distinct patterns of spread and prognostic factors), which                          prognosis, thereby informing more effective and personal-
result in early skin involvement and late bone involvement.                          ized treatment strategies for patients with NV carcinomas.
This behaviour differentiates NV from other malignancies                             The Committee strongly recommends the routine use of
within the same anatomic region, such as those of the na-                            the validated Wang’s classification and encourages the
sal cavity proper and the ethmoid, classified with the same                          concomitant adoption of this novel classification. This
criteria by UICC/AJCC, where skin involvement is rare,                               will build evidence for validation of the latter, facilitate its
late and with a much more ominous impact on progno-                                  potential future widespread adoption, and eventually sup-
sis. Figure 4 illustrates some of the unique NV patterns of                          port its incorporation into the comprehensive UICC/AJCC
spread to the skin 18. Current UICC/AJCC staging systems                             staging system.
fail to adequately capture these nuances, which emphasises
the necessity for tailored parameters. Applying the same                             Statement 5. Brachytherapy as standard of care
parameters used for nasal cavity proper malignancies does                            Treatment outcomes should be assessed in a hierarchical
not reflect the characteristics of NV malignancies and leads                         manner, prioritising oncological results, followed by func-
to inaccuracies in diagnosis and treatment planning.                                 tional and cosmetic results. Cosmetic outcomes are particu-
However, despite its comparative superiority to the UICC/                            larly significant in the context of the NV. Given that the
AJCC staging system, the Wang’s classification, which is                             nose is centrally located on the face, where both light and
admittedly dated, has its own limitations. It lacks clear ana-                       human gaze often focus, even minimal changes are readily
tomical boundaries for the site, and its three-tiered structure                      noticeable. Significant nasal deformities can greatly affect
makes integration with the UICC/AJCC TNM difficult 16.                               first impressions and social interactions 19,20. Research has
Additionally, it employs an ambiguous terminology (e.g.,                             demonstrated the influence of nasal appearance on self-
“massive” or “large portion”), which hampers standardisa-                            identity and mental health, underlining the critical need to
tion and quantification and can make the discrimination be-                          ensure acceptable cosmetic outcomes 19,20-22.
tween T2 and T3 subjective 16. Therefore, there is an urgent                         Radiation and surgery currently represent the two primary
need to revise the classification and staging of NV cancer                           treatment options for NV carcinomas 8,9,11,13,23-25. Compara-
and develop a new system that better accounts for the unique                         tive studies report disease-specific survival (DSS) rates be-
anatomical and clinical characteristics of such a malignancy.                        tween 52% and 94% across three modalities: surgery, ex-
Recently, an Italian group has proposed a new T classifi-                            ternal beam radiotherapy (EBRT), and brachytherapy (BT)
cation system that aligns with these principles (Tab. I) 9,10.                       which in its modern form is now defined as interventional
This proposal includes clear anatomical landmarks that                               radiotherapy (IRT) 9,11,13. Treatment choice typically de-
can be easily identified on radiological images and spe-                             pends on the resources and expertise available at the treat-
cific prognostic factors that were already present in Wang’s                         ing facility.
classification, and in particular the early skin involvement                         When surgery is selected, in view of the specific pattern of
and the late, ominous bone involvement, both characteris-                            spread of NV SCC among cartilages with early skin inva-
tic of this malignancy. The new classification is four-tiered                        sion (Fig. 4) a thorough resection of the ala/nasal wall is
for T with the perspective of an integration in the global                           most often indicated. This will require complex reconstruc-
UICC/AJCC staging system 9. Such an approach would                                   tive surgeries or the creation and fitting of a bone-anchored


Table I. Bussu et al.’s Nasal Vestibule Tumour (T) Staging System.
 T1         The lesion is limited to the nasal vestibule internal surface (skin and or mucosa)
 T2a          The lesion invades superficial structures outside the nasal cavity (skin and/or subcutaneous tissue) and in particular upper lip, philtrum, skin
              of the nose and/or nasolabial fold, but does not destroy cartilage, nor invades bony structures, nor structures beyond the plane of the piriform
              aperture (septum, lateral wall, turbinates, etc.)
 T2b          Disruption of cartilages is evident, without invasion of bony structures, nor of structures beyond the plane of the piriform aperture (septum, lateral
              wall, turbinates, etc.)
 T3           The lesion extends posteriorly beyond the piriform aperture (septum, lateral wall, turbinates, etc.)
 T4a          The lesion invades bony structures as hard palate, nasal bones, frontal process of the maxilla, ethmoid, orbit
 T4b          Tumour invades any of the following: orbital apex, dura, brain, anterior and middle cranial fossa, cranial nerves other than V2, nasopharynx, or
              clivus




16
                                                                                                                       Position paper on nasal vestibule carcinoma




Figure 4. Typical patterns of spread to the skin of nasal vestibule carcinomas. (A) Pathway from the lateral wall of the nasal vestibule to the skin, with the tu-
mour invasion front sliding between the alar and lateral nasal cartilage; (B) Pathway from lateral wall of the nasal vestibule to the skin, with the tumour spreading
between the lateral nasal cartilage and the nasal bone; (C) Direct pathway from the nasal septum/columella (medial wall)/floor of the nasal cavity (inferior wall of
the nasal vestibule) to the skin of the upper lip (from Bussu et al., 2023, mod.) 18.


epithesis26-28. Replicating the nose tip’s shape and structure                       explains the excellent cosmetic results (Fig. 5) of the proce-
through reconstructive surgery after its complete removal                            dure due to the preservation of the nose tip’s cartilaginous
is exceptionally challenging, requiring the restoration of                           structure.
three layers: the inner mucosa, the overlying skin (notably                          The clinical target volume’s accessibility and the simplic-
thin and virtually lacking subdermis), and the somewhat                              ity of tube placement, even under local anaesthesia, render
hard cartilaginous framework, each with varying degrees                              IRT a feasible option for elderly or frail patients as well.
of flexibility and a complex three-dimensional shape, ac-
centuated by reliefs and hollows.
In numerous case series and comparative studies, BT has
demonstrated non-inferiority to upfront surgery in terms of lo-
cal-recurrence-free survival (LRFS) and DSS, while provid-
ing superior local control compared to EBRT6,8,11,12,17,23-25,29-33
(Evidence level: IIA). This evidence is particularly compel-
ling in cases without bone involvement 17,33.
Functional parameter analyses among EBRT, BT, and control
subjects show no significant differences in nasal flows and re-
sistance 24. BT patients are spared the nasal crusting often seen
in EBRT patients, and they maintain unchanged Threshold
Discrimination Identification (TDI) scores, reliable indicators
of the olfactory function, and normal mucociliary clearance,
unlike EBRT patients 24 (Evidence level: IIB).
On the other hand, cosmetic outcomes strongly favour IRT
over surgery 12,34. Consistently, cosmetic satisfaction among
IRT patients has been reported as significantly superior to
that of surgical patients 17 (Evidence level: IIB).
Also, the NV’s anatomical characteristics make it well-suit-
ed for IRT. The absence of adjacent vital structures allows
for the delivery of high radiation doses without causing sig-
                                                                                     Figure 5. Examples of local control, framework preservation and consequent
nificant collateral damage. The cartilaginous framework’s                            cosmetic outcomes after IRT for nasal vestibule carcinomas (from Bussu et al,
natural resistance to radiation further supports IRT use and                         2023, mod.) 3.



                                                                                                                                                                 17
F. Bussu et al.




This is particularly relevant considering global demograph-     In the last decades brachytherapy evolved from the direct
ic shifts, including the aging baby-boomer population in        implantation of radioactive sources, with obvious dosimet-
the Western Countries 35,36 .                                   ric and radioprotection issues and poor control on the ef-
Based on these findings, the Committee strongly rec-            fective dose released, to the so called remote – afterloading
ommends considering IRT as a treatment option for               machines, based on the implant of applicators or catheters
primary NV lesions without bone involvement, as it ap-          (plastic tubes in case of NV) in which the source is subse-
pears equivalent to surgery for oncological outcomes            quentely inserted to deliver the dose without exposure to
but offers clear advantages in terms of anatomic pres-          ionising radiation by healthcare staff. By controlling the
ervation and cosmetic results 3.                                dwell time in each position in the catheter using dedicated
                                                                software, it is possible to optimise the dose distribution
Statement 6. Management of nodal metastases                     achieving an intensity-modulated technique.
As in all head and neck malignancies, nodal involvement in      To obtain the best dose distribution the implants for inter-
NV carcinoma is one of the main prognostic determinants         stitial IRT have traditionally been placed following dosim-
and one of the main reasons for oncological failure.            etry systems, the main ones being Manchester and Paris
The lymphatic drainage of the anterior third of the nasal       systems. Paris system is the most popular in case of flex-
cavity primarily feeds into the facial, submandibular, and,     ible implants and is based on the following main principles:
to a much lesser extent, parotid lymph nodes. At diagnosis,     1) the active sources (plastic tubes in modern IRT) should
about 5-10% of patients with NV carcinoma show lymph            be parallel and straight; 2) the sources should be inserted
node metastases 7,37-39, although the detection method is not   equidistant each others. Applying the Paris system to the
always specified in these studies.                              nose implies piercing nasal walls and septum in many
There is currently no agreed-upon elective treatment for N0     points. However, it is well known to otolaryngologists that
neck in NV SCC. Both surgical clearance and elective nod-       piercing the mucoperichondrium leads to the destruction
al irradiation (ENI) are considered potential options. How-     of the cartilage, the risk of which is even higher because
ever, current evidence shows that even if nodal metastases      the points of passage are the ones with the highest dose de-
are clearly associated to impaired survival, most delayed       livered (closest to the tubes). In fact, in the BT series with
nodal relapses can anyway be effectively salvaged 40,41. The    implants done according to the Paris system a high rate of
Committee strongly recommends a careful work up of              septal and even alar perforation is reported 13.
the neck based on morphological imaging (ultrasound,            An Italian group developed a new concept of anatomical
contrast enhanced magnetic resonance [CE MR] and/               implantation for nasal primaries based on the following
or computed tomography [CT]). In case of doubts, the            principles:
Committee outlines the value of positron emission to-           1. The tubes must be interstitial as much as possible;
mography (PET) CT and of ultrasound guided fine nee-            2. Do not pierce the perichondrium, ideally remaining
dle aspiration biopsy (FNAB) 42. Properly staged cN0                along the subperichondral planes of (rhino-)septoplasty.
neck can be observed, while the Committee strongly              These two rules have been shown to avoid perforations 9,13,25
recommends neck dissection in cN+ cases, with possible          and are also associated to the best stability of implants,
adjuvant treatment based upon the final histological re-        which is a fundamental requirement for the reliability of
port. Neck dissection can be performed at the same time of      the treatment plan (Evidence level: III) 9,13,24,43,44.
the implantation of IRT plastic tubes.                          If “fully interstitial/buried” implants are not sufficient for ad-
                                                                equate clinical target volume (CTV) coverage by overreach-
Statement 7. The anatomic implantation in nasal vestibule IRT   ing all the limits of the lesion, other tricks can be used to
As we discuss the benefits and potential challenges of IRT in   stabilize the tubes. One of these situations is determined by
NV SCC treatment, it is essential to provide a clear and con-   the presence of a bulky skin spread; in this case the issue can
cise overview of the technique for otolaryngologists who will   be solved with a “contact” strategy, by placing the tubes on
work closely with radiation oncologists to deliver treatment.   the skin in the area of such superficial spread and stabilising
Brachytherapy is a form of radiation therapy that involves      them with an interstitial course on both sides. The most com-
placing radioactive sources directly into or near a tumor.      mon of these situations is given by the extension of the lesion
This method allows for the delivery of high doses of ra-        posterior to the limit of the nasal vestibule, which is the plane
diation to the tumour while minimising exposure to the          tangential to the piriform opening. In these cases, a fully in-
surrounding healthy tissues. The technique can be either        terstitial implant placement may not be possible because of
interstitial (implanted within the tumour) or endocavitary      the bony structures, thus endocavitary implantation may be
(implanted within a body cavity close to the tumour).           needed. This approach, however, raises concerns about the



18
                                                                                                     Position paper on nasal vestibule carcinoma




stabilization of the tubes and high doses to the mucosal sur-      Ethical consideration
faces can be associated in our experience with synechiae. To       This research was conducted in full accordance with the
address the issue of stabilisation of endocavitary implants,       World Medical Association Declaration of Helsinki (2002).
blind catheters can be fixed to Merocel packing, though            Due to the nature of this study, the Institutional Review
this may result in unpredictable geometry and path of the          Board of the partecipating Hospitals do not perform a for-
tube and consequent undesired issues with CTV coverage.            mal ethical assessment.
Alternatively, blind tubes can be secured to a silicone foil,
maintaining a precise relationship between the catheters. En-      References
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                                                                        of interdisciplinary assessment of interstitial interventional radio-
A proper classification in daily clinical practice is essential         therapy (brachytherapy) for periorificial face cancer. J Pers Med
to bolster evidence. Building on this, the Committee urges              2022;12:1038. https://doi.org/10.3390/jpm12071038
clinicians to diligently pursue the outlined priority research     7
                                                                        Agger A, von Buchwald C, Madsen AR, et al. Squamous cell carci-
areas to enhance NV SCC management 11,12,17. We also en-                noma of the nasal vestibule 1993-2002: a nationwide retrospective
                                                                        study from DAHANCA. Head Neck 2009;31:1593-1599. https://doi.
courage participation in ongoing clinical trials or the incep-          org/10.1002/hed.21132
tion of novel ones to further build evidence.                      8
                                                                        Bussu F, Tagliaferri L, Mattiucci G, et al. Comparison of intersti-
If the best treatment options are not readily available in cer-         tial brachytherapy and surgery as primary treatments for nasal ves-
tain Italian facilities, the Committee strongly recommends              tibule carcinomas. Laryngoscope 2016;126:367-371. https://doi.
                                                                        org/10.1002/lary.25498
referring patients to centers possessing the necessary tech-       9
                                                                        Bussu F, Tagliaferri L, Crescio C, et al. New standards for the manage-
nology and expertise to provide optimal treatment.                      ment of nose vestibule malignancies. Acta Otolaryngol 2023;143:215-
                                                                        222. https://doi.org/10.1080/00016489.2023.2179662
Conflict of interest statement                                     10
                                                                        Bussu F, Gallus R, Rizzo D, et al. A proposal for a consistent classifi-
The authors declare no conflict of interest.                            cation of nasal vestibule carcinomas. In: Bussu F, ed. Malignancies of
                                                                        the nasal vestibule. Cham: Springer; 2023.
                                                                   11
                                                                        Czerwinski MD, Jansen PP, Zwijnenburg EM, et al. Radiotherapy as
Funding                                                                 nose preservation treatment strategy for cancer of the nasal vestibule:
This research did not receive any specific grant from fund-             the Dutch experience. Radiother Oncol 2021;164:20-26. https://doi.
ing agencies in the public, commercial, or not-for-profit               org/10.1016/j.radonc.2021.08.018
sectors.                                                           12
                                                                        Czerwinski MD, van Leeuwen RG, Kaanders JH, et al. Image guided
                                                                        brachytherapy for cancer of the nasal vestibule: local control and cos-
                                                                        mesis. Int J Radiat Oncol Biol Phys 2019;103:913-921. https://doi.
Author contributions                                                    org/10.1016/j.ijrobp.2018.11.018
FB, LT, GM: conceptualization; FB, LT, GM: methodology;            13
                                                                        Bussu F, Tagliaferri L, Piras A, et al. Multidisciplinary ap-
FB, LP, GM: validation; FB, MFC: resources; FB, MFC, CL,                proach to nose vestibule malignancies: setting new standards.
G: writing – original draft preparation; FB, MFC, CL, GM:               Acta Otorhinolaryngol Ital 2021;41(2 Suppl 1):S158. https://doi.
                                                                        org/10.14639/0392-100X-suppl.1-41-2021-16
writing – review and editing; FB, LT, RP, PG, GM, AG, FC,          14
                                                                        Parrilla C, Bussu F, Turra N, et al. Anatomy of the nose vestibule.
GA, FL, LC LP, PN, GB: supervision. All authors have read               In: Bussu F, ed. Malignancies of the nasal vestibule. Cham: Springer;
and agreed to the published version of the manuscript.                  2023.




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