Matching-adjusted indirect comparison of endoscopic and craniofacial resection for the treatment of sinonasal cancer invading the skull base

Aim: The aim of this study was to compare the efficacy and safety of endoscopic endonasal approaches (EEA) with craniofacial resection (CFR) for sinonasal cancers invading the skull base, using an unanchored matching-adjusted indirect comparison (MAIC). Methods: A MAIC approach was used to analyse data from two large cohorts: the MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers (MUSES) cohort, comprising sinonasal cancer patients treated endoscopically, and a historical CFR cohort reported by Ganly et al. Individual patient data were available only for the first cohort. Patients with olfactory neuroblastomas were excluded. Key prognostic factors were used to match and adjust the two cohorts, minimising selection bias. The primary endpoint was overall survival (OS), with secondary endpoints including recurrence-free survival (RFS), perioperative mortality, complication rates, and resection margins. Results: A total of 724 EEA-treated and 334 CFR-treated patients were included. EEA showed significantly improved OS before (HR= 2.33, 95 % CI= 1.88–2.87) and after MAIC adjustment (HR= 1.93, 95 % CI= 1.60–2.34). Observed RFS was higher in the EEA group (HR= 1.39, 95 % CI = 1.14–1.69) but no longer differed after adjustment (HR= 1.06, 95 % CI= 0.91–1.23). EEA was associated with significantly better Disease Specific Survival (HR= 1.71, 95 % CI = 1.39–2.13), lower perioperative mortality (OR= 8.12, 95 % CI= 3.45–36.7) and fewer complications than CFR (OR= 3.68, 95 % CI= 2.47–5.42). Conclusion: In this MAIC study based on the 2 largest cohorts of sinonasal cancer with skull base invasion, EEA offered comparable oncologic outcomes to CFR with reduced morbidity, supporting it as a valid alternative when performed in expert centres.