Factors Influencing Surgical Management of Patients With T4b Sinonasal Cancer

OBJECTIVE: 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. METHODS: 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. RESULTS: 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). CONCLUSION: 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.