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Endoscopic Endonasal Surgery for Malignancies of the Anterior Cranial Base
Abstract
Data from several centers worldwide have demonstrated that transnasal endoscopic surgery performed with or without a transcranial approach is capable of achieving radical resection of selected sinonasal malignancies. We report our experience with endoscopic management of sinonasal cancers, with emphasis on naso-ethmoidal malignancies encroaching on the anterior skull base.
Major series reporting results concerning the endoscopic endonasal approach with or without craniectomy for treatment of sinonasal and anterior skull base cancers were reviewed. Preoperative work-up, indications and exclusion criteria, surgical techniques, postoperative management, and adjuvant therapy are reported.
In the 2 largest series analyzed, the most common malignancies were adenocarcinoma (28%), olfactory neuroblastoma (14.5%), and squamous cell carcinoma (13.5%). The 5-year disease-specific survival rate ranged from 81.9%-87%, with no major differences in the mean follow-up time (34.1 months vs. 37 months).
Endoscopic endonasal resection performed with or without a transcranial approach, when properly planned and in expert hands, has an accepted role with precise indications in the surgeon's armamentarium for the treatment of sinonasal and skull base malignancies.
Copyright © 2014 Elsevier Inc. All rights reserved.
... Traditionally, because of the complexity of the sinonasal anatomy and close proximity with orbit and brain, craniofacial surgery has been regarded as the standard treatment to obtain 'en-bloc' resection 4,5 . Over the past two decades, with advances in endoscopic endonasal surgical techniques and skull base reconstruction methods, minimally-invasive surgery has emerged as an alternative to an open surgical approach, with the advantages of lower post-operative morbidity and higher quality of life than open surgery 2,6,7 . On the other hand, the appropriateness of endoscopic endonasal surgery has been questioned especially when managing locally-advanced cases, thus opening a diatribe between supporters of the two techniques. ...
... Clinically-positive neck lymph nodes were treated with therapeutic neck dissection. All patients were addressed to standardised clinical-radiological follow-up 6 . ...
... Histology-driven protocols are now recognised as the standard of care, which contributed to the reduction of surgical resection as an upfront treatment strategy, particularly in the case of poorly differentiated neoplasms 1,12 . Moreover, the growing experience acquired in sinonasal endoscopic surgery has prompted a wide diffusion of endoscopic resection in the surgical management of these cancers and the concept of "oriented disassembling" of the lesion has definitely proved its validity in terms of oncological safety, with outcomes comparable to those of the classical "en bloc" resection 6 . In the last decade, the progressive development of endoscopic techniques has allowed to manage difficult regions such as the frontal sinus 13 , various areas of the maxillary sinus 14,15 , the infratemporal fossa 16 and orbit 17 . ...
Objective. Endoscopic endonasal surgery is effective in the treatment of sinonasal cancers. However, in cases of well-differentiated locally advanced neoplasms as well as recurrences, the most appropriate treatment is debated. The purpose of this study is to report a monoinstitutional experience on craniofacial surgery performed in a tertiary-care referral centre. Methods. This was a retrospective analysis of 90 patients treated with transcranial and/ or transfacial resection for sinonasal cancer between 2010 and 2020. Outcome measures included overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and recurrence-free survival (RFS). Results. The 5-year OS, DSS and DFS were 48.2%, 60.6% and 28.7%, respectively. Factors correlated with prognosis were pT-classification (p = 0.002), histotype (p = 0.012) and dural involvement (p = 0.004). Independent prognostic factors were orbital apex infiltration (p = 0.03), age (p = 0.002) and adjuvant therapy (p = 0.03). Conclusions. When endoscopic endonasal surgery is contraindicated and chemoradiotherapy is not appropriate, craniofacial and transfacial approaches still represent an option to consider, despite the non-negligible morbidity.
... It also guides the choice of the surgical approach and the planning of the surgical steps. Currently, endoscopic endonasal resection is preferred to the historical craniofacial resection, considering its reliability with comparable oncologic results and a lower morbidity [3]. The radiological assessment of the tumor origin is a crucial piece of information before endoscopic endonasal surgery, especially for the planification of skull base resection and reconstruction [3]. ...
... Currently, endoscopic endonasal resection is preferred to the historical craniofacial resection, considering its reliability with comparable oncologic results and a lower morbidity [3]. The radiological assessment of the tumor origin is a crucial piece of information before endoscopic endonasal surgery, especially for the planification of skull base resection and reconstruction [3]. Contraindications of this technique are often detected by imaging: orbital involvement requiring exenteration, massive dural invasion over orbital roof, invasion of maxillary sinus walls (except for the medial one) [4,5]. ...
Background:
Pretreatment assessment of local extension in sinonasal cancer is essential for prognostic evaluation and surgical planning. The aim of this study was to assess the diagnostic performance of two common imaging techniques (CT and MRI) for the diagnosis of skull base and orbital invasion by comparing imaging findings to histopathological data.
Methods:
This was a retrospective two-center study including patients with sinonasal cancer involving the skull base and/or the orbit operated on between 2000 and 2019. Patients were included only if pre-operative CT and/or MRI, operative and histopathologic reports were available. A double prospective blinded imaging review was conducted according to predefined radiological parameters. Radiologic tumor extension was compared to histopathological reports, which were considered the gold standard. The predictive positive value (PPV) for the diagnosis of skull base/orbital invasion was calculated for each parameter.
Results:
A total of 176 patients were included. Ethmoidal intestinal-type adenocarcinoma was the most common type of cancer (41%). The PPV for major modification of the bony skull base was 78% on the CT scan, and 89% on MRI. MRI signs of dural invasion with the highest PPVs were: contact angle over 45° between tumor and dura (86%), irregular deformation of dura adjacent to tumor (87%) and nodular dural enhancement over 2 mm in thickness (87%). Signs of orbital invasion had low PPVs (<50%).
Conclusions:
This retrospective study provides objective data about the diagnostic value of pretreatment imaging in patients with sinonasal cancer.
... Currently, endoscopic endonasal approaches have proven to be oncologically safe and effective, with outcomes comparable to those of traditional external approaches, and therefore may be adopted in the large majority of cases [31,32]. The absence of facial incisions and osteotomies, less postoperative pain, decreased hospitalization time, improved visualization of tumor borders, and reduced morbidity and mortality rates are commonly cited as the major advantages of endoscopic resection compared with the traditional external approaches [31][32][33]. Moreover, magnification of the surgical field with easier dissection of small neural structures is specifically useful to explore the possible pattern of spread of sinonasal ACC (submucosal/subperiosteal, invasion of PPF, etc.). ...
... The main contraindications for a purely endoscopic approach are the involvement of the anterior plate of the frontal sinus, massive involvement of the orbit, dural invasion over the orbit, massive infiltration of the brain, massive involvement of the lacrimal pathway, and involvement of the hard palate or nasal bones. In these cases, a combined cranioendoscopic approach or a traditional craniofacial resection are indicated [31][32][33]. ...
Sinonasal adenoid cystic carcinoma is a rare malignancy characterized by an insidious growth pattern and a tendency for perineural spread along major and minor nerves, resulting in invasion of the skull base and intracranial extension. Therefore, many patients present with advanced disease and involvement of critical structures, making treatment difficult and potentially associated with high morbidity. Surgery represents the mainstay of treatment of the primary tumor. Complete resection of the tumor with negative margins, whenever feasible, is associated with better survival outcomes. However, in the case of extensive involvement of vital structures (e.g., carotid artery, cavernous sinus, optic nerve, Meckel's cave) or when radical surgery could seriously affect the patient's quality of life, a function-preserving subtotal removal of the tumor followed by irradiation can be proposed. The role of surgery is limited to a biopsy in unresectable lesions that are more suitable for non-surgical treatments (e.g., exclusive chemoradiation). Given the difficulty in obtaining negative margins and the propensity for submucosal and perineural spread, adjuvant radiotherapy is strongly recommended. Recently, heavy-particle radiotherapy using protons or carbon ions has emerged as a promising treatment with improved local control. Local failures (60%) and distant metastases (40%) are common and can occur even decades after definitive treatment. The 5-year overall survival ranges from 55 to 70% and it exceeds that of other sinonasal malignancies, but dramatically drops down at 10 years (40%) and further decreases at 20 years (15%). Therefore, a prolonged follow-up of at least 15 years, and possibly lifelong, is mandatory.
... A number of different criteria have been considered to be relative contra-indications to an endoscopic approach or indications for a combined approach. The involvement of the nasal bones, lateral frontal sinuses, lacrimal system, orbit, anterior maxillary sinuses, dura, cavernous sinus and brain parenchyma have been suggested as limiting the efficacy or suitability for endoscopic resection [23]. On-going technical innovation has resulted in many of these indications becoming increasingly relative with surgical teams favouring differing criteria [22,24]. ...
... The rarity of skull base SCC results in its inclusion with other histopathologies when assessing outcomes. In one study of skull base malignancy including SCC (13.5%) 5 year survival ranged between 81.9%-87% [23]. Subgroup analysis for SCC was not performed. ...
PurposeThe purpose of this review is to assess the recent evidence regarding the management of squamous cell carcinoma of the skull-base and to discuss the implications of these findings on clinical practice.Method
Free text Medline and MeSH term search of publications relating to Squamous Cell Carcinoma & Skull-base and Skull base, Neoplasm respectively. Multidisciplinary clinical guidelines were also reviewed.ResultsThe primary search yielded a total of 271 papers which following initial review was reduced to 28. Secondary search yielded 56 papers. There were no randomised controlled trials relating to squamous cell carcinoma of the skull-base and as such this review is based on cohort studies, case series and expert opinion.Conclusion
Squamous cell carcinoma (SCC) is the most common cancer occurring in the Head and Neck. Squamous cell carcinoma is also the most common cancer arising within the nose and sinuses of which skull-base squamous cell carcinoma is a rare subgroup.Evidence relating to the management and survival of skull-base SCC is based on expert opinion and. retrospective analyses Clinical examination and biopsy, imaging and a broad multidisciplinary team are key to the management of skull-base SCC. The information gathered should be used to guide informed discussion by suitably trained experts with patients regarding surgical approach, post-operative recovery and adjuvant or neoadjuvant treatments. The standard of care is currently to perform skull base resection with or without additional craniotomy, pedicled or free flap reconstruction in multiple layers and post-operative radiation (usually photons or protons). Open approaches have traditionally been the mainstay, however in certain cases endoscopic approaches can yield equivalent results and offer many advantages. Despite advances in care survival remains poor with a nearly one in five risk of nodal recurrence within two years.
... The operative technique for endoscopic resection of anterior cranial base malignancies has been previously described [9] [10]. Nevertheless, authors describe some modifications, especially during the nasal step, the intradural step and the reconstructive step. ...
... Step Nasal steps are characterized by two phases: "centrifugal removal" and "centripetal removal" of the tumor. Authors suggest a modification of the technique previously described [9] beginning with an anterior septostomy in order to facilitated a binarial approach using a four hands two surgeons technic, especially in bilateral extended tumors that cause posterior nasal septum invasion. Authors noted that with this maneuver overall blood loss are reduced, due to the fastest and dynamic debulking of the lesion. ...
... The medial portion of the tumor (i.e. invading the medial maxillary wall, nasal cavity, ethmoid box, and/or nasal septum) was accurately assessed under endoscopic view and managed according to well-established principles of resection of naso-ethmoidal tumors [18][19][20][21]. The posterior osteotomy (i.e. at the level of the pterygomaxillary junction) was performed transnasally (Videos 1-2), while the remaining osteotomies were performed via a transoral or transfacial-transoral approach (Fig. 2). ...
... The medial maxillary wall must be partially removed to expose the posterior extent of the tumor through the transnasal perspective. Although this maneuver requires a piecemeal resection of a part of the tumor, the safety of multi-bloc excision has been demonstrated by several series of endoscopic transnasal resection for nasoethmoidal malignancies [18][19][20][21][28][29][30][31][32][33][34][35]. Furthermore, the portion of the tumor that is encroached when exposing the posterior maxillary wall is either exophytic or infiltrates the medial maxillary wall, which will be entirely removed via the endoscopic medial maxillectomy [14,15]. ...
Background:
When amenable to radical excision, cancer involving the maxilla is typically treated with maxillectomy followed by adjuvant therapy. Posterior tumor extension beyond the maxillary box leads to the invasion of complex areas, where achieving clear margins may be challenging.
Methods:
Patients undergoing endoscopic-assisted maxillectomy for nasoethmoidal, maxillary, or hard palate cancer between 2007 and 2017 were included in the study. Surgical technique, margin status, and recurrences were analyzed. Extension of posterior resection was classified in 3 types (type 1: resection of the pterygopalatine fossa; type 2: resection of the pterygoid plates and related muscles; type 3: resection of the upper parapharyngeal space). The analysis of putative risk factors for involvement of margins and local recurrence was performed with special focus on the posterior and medial margin.
Results:
The study included 79 patients (75 with available follow-up; mean: 20.6 months, range: 6-101 months), 37 (46.8%) of whom underwent type 1 resection, 34 (43.0%) type 2, and 8 (10.1%) type 3. According to pT category, 57 (72.2%) tumors were classified as T4a/T4b. Posterior and medial clear margins were achieved in 76/79 (96.2%) and 75/79 (94.9%) patients, respectively. T4b category, extension to the ethmoid, sphenoid sinus, pterygoid process, orbital cavity, and premaxillary tissues were significantly associated with a higher rate of margin involvement. None of the factors was significantly associated with medial margin involvement.
Conclusion:
Endoscopic-assisted maxillectomy combines several refinements including the facilitated detachment of the maxilla from the skull base and precise delineation of the posterior and medial margins of resection.
... Darüber hinaus können ausgewählte spontane oder posttraumatische Liquorlfisteln über einen maßgeschneiderte transcribriformen Zugang behandelt werden. Die wichtigsten malignen Pathologien, die mit diesem Ansatz behandelt werden, sind Plattenepithelkarzinome, Adenokarzinome (hauptsächlich vom intestinalen oder nicht-intestinalen Typ) und olfaktorische Neuroblastome [1,10,[33][34][35][36][37][38][39][40][41][42], mit guten onkologischen Ergebnissen und minimaler Morbidität im Vergleich zu herkömmlichen offenen transfazialen Verfahren. Zu den Faktoren, die die Wahl des Zugangs beeinflussen, gehören neben dem biologischen Verhalten der Läsion, der lokalen Ausdehnung und den rekonstruktiven Optionen auch der präoperative olfaktorische Status und die Möglichkeit das Riechen zu erhalten [43][44][45]. ...
Zusammenfassung
Zielsetzung Die endoskopische endonasale Schädelbasischirurgie hat sich weltweit durchgesetzt. Vergleichende Analysen haben gezeigt, dass die endoskopische Schädelbasischirurgie bei vielen Pathologien der vorderen Schädelbasis, z. B. bei bösartigen Tumoren der Nasennebenhöhlen, bei Pathologien der zentralen Schädelbasis wie Hypophysenadenomen, Kraniopharyngiomen, ausgewählten Fällen von Meningiomen des Planum sphenoidale und des Tuberculum sellae oder bei clivalen Läsionen, z. B. bei Chordomen, Chondrosarkomen oder bestimmten Meningiomen, Vorteile bieten kann. In den letzten drei Jahrzehnten konnten interdisziplinäre chirurgische Teams bestehend aus HNO-Ärzten und Neurochirurgen detaillierte anatomische Kenntnisse vermitteln, neue Ansätze oder Modifikationen etablierter chirurgischer Techniken vorschlagen und somit zu einer kontinuierlichen chirurgischen Weiterbildung beitragen.
Methode Es wurde eine Übersicht über die einschlägige Literatur erstellt, wobei der Schwerpunkt auf der interdisziplinären endoskopischen Chirurgie von Schädelbasisläsionen lag.
Ergebnisse Auf der Grundlage der chirurgischen Erfahrung der Autoren in zwei verschiedenen interdisziplinären endoskopischen Schädelbasiszentren klassifizieren die Autoren die Ansätze für die endoskopische endonasale Schädelbasischirurgie, beschreiben Indikationen und wichtige anatomische Orientierungspunkte für häufige Pathologien und heben chirurgische Techniken zur Vermeidung von Komplikationen hervor.
Schlussfolgerung Die interdisziplinäre endonasale endoskopische Chirurgie vereint chirurgisches Fachwissen, verbessert die Resektionsraten bei vielen Pathologien und minimiert die Morbidität durch Verringern der Häufigkeit chirurgischer Komplikationen.
... Регионарное метастазирование встречается не так часто. В то же время отдаленные метастазы развиваются у 20-40 % больных, не получавших никакого лечения [10]. Основной причиной смерти в рассматриваемой группе является локальное распространение опухоли с поражением критических нейроваскулярных структур или молниеносное прогредиентное течение местного неопластического процесса с развитием интоксикационного синдрома и раковой кахексии. ...
Aim. To perform a retrospective analysis of the results of surgical treatment of patients with anatomically widespread malignant skull base tumors and evaluate the possibility of using various types of closure of skull base defects.
Materials and methods. The study is based on a retrospective analysis of medical records of 139 patients with midface tumors aged 14 to 77 years, operated from 1995 to 2023. Histological structure of the tumors was different. we divided all methods of reconstruction of midface defects into two groups. In the group 1, plastic closure of the defect was per-formed using flaps from anatomical areas located close to the defect. In the group 2, reconstruction was performed using flaps from distant anatomical areas.
Results. In the postoperative period, we did not observe gross cicatricial face deformities, impaired chewing and swallowing functions due to cicatricial contractures of chewing muscles. Titanium mesh for reconstruction was used in 68 (48.9 %) cases. The osteoperiosteal aponeurotic flap was used in 5 cases, of which in 3 (3.8 % of the total number of patients of the 1 st group) – in combination with the temporal muscle. The thoracodorsal flap was used in 62 (44.6 %) patients. various methods of its movement and combination with the anterior dentate muscle were used. In 41 (66.1 %) cases, good cosmetic and functional results were obtained. These indicators correlated with adequate choice of reconstruction method allowing elimination of most of the impaired functions.
Conclusion. The use of the presented technologies for plastic closure of post-resection defects of various parts of the skull base, including those combined with extensive damage to the midface, leads to leveling of the cosmetic and functional consequences of surgical aggression.
... The piecemeal resection technique was subsequently also applied in the removal of other head and neck tumors, such as those of the ethmoid extending to the anterior skull base [8]. ...
Simple Summary
Resection of a malignant tumor of the head and neck should be radical, i.e., the specimen should be surrounded by healthy tissue at all its margins. The thickness of this layer of healthy tissue has varied over time. From the initial categorical minimum limit of 5 mm, we have moved on to lower thicknesses, but never less than 1 mm. Can these rules be respected in surgery of the salivary glands, especially of the parotid gland? Owing to the complex branching and connections of the facial nerve within the parotid gland, even a medium-sized malignant tumor may be in contact with a branch of the nerve, thus raising the question of its preservation. The same issue concerns the lingual nerve in the resection of a malignant tumor of the submandibular and sublingual glands. In this article, examining the studies published on this topic, the pros and cons of nerve preservation will be analyzed.
Abstract
In primary therapy, a universally recognized surgical indication applies to all tumors of the salivary glands. According to the classic rule, radical resection of a head and neck tumor requires clean margins of at least 5 mm, although recent studies have shown that for certain locations, 1 mm may be sufficient. In the surgical resection of a tumor of the salivary glands, especially of the parotid gland, can these rules be respected? Owing to the complex branching and connections of the facial nerve within the parotid gland, even a medium-sized malignant tumor may be in contact with a branch of the nerve, thus raising the question of its preservation. The facial nerve is so important from a functional and aesthetic point of view that it is commonly believed that it should be preserved unless it is incorporated into the tumor. This is a compromise between an oncological resection, that is, the complete excision of the tumor with no residual cancer cells left behind, and quality of life. Almost all authors try to overcome this lack of radicality by indicating postoperative (chemo)radiotherapy. In this article, the pros and cons of nerve preservation will be analyzed by examining the published studies on this topic.
... Endoscopic resection (ER) was defined as the tumour resection through the nostrils under videoendoscopic guidance, with no surgical transgression of the skull base; ER with transnasal craniectomy (ERTC) was defined as an ER including the anterior skull base and, if needed, the overlying dura mater and part of the frontal lobe of the brain as part of the resection [19,20]. Contraindications for an exclusively ER include: nasal bones and hard palate infiltration; invasion of the frontal sinus; massive involvement of the lacrimal sac or of the bony walls of the maxillary sinus (with the exception of the medial one); extension into the infratemporal fossa involvement of the orbit content; massive infiltration of the dura over the orbital roof or brain parenchyma infiltration [21]. In these cases, the endoscopic approach was combined with an external transcranial and/or transfacial route (cranioendoscopic resection, CER; endoscopic-assisted craniofacial resection, EACFR). ...
Purpose:
Sinonasal tumours are rare diseases with poor prognosis. Multimodal approach including surgery is widely used, although no standard therapy has been established in prospective trials. This study assessed activity and safety of an innovative integration of multimodality treatment-induction chemotherapy (ICT), surgery and radiotherapy (RT)-modulated by histology and response to ICT.
Methods:
Patients with untreated, operable sinonasal tumours with selected histotypes (squamous cell carcinoma, intestinal-type adenocarcinoma, sinonasal undifferentiated and neuroendocrine carcinoma, olfactory neuroblastoma) were enrolled in a single-arm, phase II, multicenter clinical trial. Patients were treated with up to 5 ICT cycles, whose regimen was selected according to histotype, followed either by curative chemo-RT for pts with ≥80% reduction of initial tumour diameter or surgery and adjuvant (chemo)RT. Photon and/or proton/carbon ion-based RT was employed according to the disease site and stage. Primary end-point was 5-year progression-free survival (PFS), secondary end-points were overall survival (OS), ICT objective response rate (ORR) per RECIST 1.1 and safety.
Results:
Thirty-five patients were evaluable for primary end-point. Fourteen patients (40%) were treated with definitive (CT)RT and 20 (57%) underwent surgery. Five-year PFS was 38% (95% confidence interval [CI], 21-69), with a median PFS of 26 months. Five-year OS was 46% (95% CI, 28-75), with a median OS of 36 months. Three-year PFS-OS for pts achieving PR/CR versus stable disease (SD)/PD to ICT were 49.8-57% versus 43.2-53%, respectively. Three-year PFS for patients achieving major volumetric partial response (≥80% reduction of initial tumour volume, major partial volumetric response [mPRv]) versus non-mPRv were 82% versus 28% and 3-year OS were 92% versus 36% (p value 0.010 and 0.029, respectively). The ORR to ICT was 54% and 60% across all histotypes and in the sinonasal undifferentiated carcinoma (SNUC) subpopulation, respectively, with 6/15 SNUCs (40%) achieving mPRv.
Conclusion:
Treatment of advanced sinonasal cancer with histology-driven ICT followed by (CT)RT in responsive patients was feasible. Overall, these findings suggest a possible role of ICT as the primary approach in newly diagnosed, resectable sinonasal tumours-especially SNUC-to select patients with favourable prognosis. Histology heterogeneity limits generalisation of trial results.
... Surgical navigation, together with improved surgical instrumentation and techniques, have helped in decreasing complication rates in skull-base functional surgery [11][12][13], and extended surgical indications in oncologic procedures [14][15][16][17][18][19][20][21][22]. Preclinical studies have been continuing to exploit new navigation technologies to guide tumor ablation and to anatomically orient the surgeon in three-dimensional planes. ...
Surgical navigation technology combines patient imaging studies with intraoperative real-time data to improve surgical precision and patient outcomes. The navigation workflow can also include preoperative planning, which can reliably simulate the intended resection and reconstruction. The advantage of this approach in skull-base surgery is that it guides access into a complex three-dimensional area and orients tumors intraoperatively with regard to critical structures, such as the orbit, carotid artery and brain. This enhances a surgeon’s capabilities to preserve normal anatomy while resecting tumors with adequate margins. The aim of this narrative review is to outline the state of the art and the future directions of surgical navigation in the skull base, focusing on the advantages and pitfalls of this technique. We will also present our group experience in this field, within the frame of the current research trends.
... In clinical practice, to ensure gross total resection of the lesion, a purely endoscopic approach is not always possible although a combined cranioendoscopic approach (eg, massive frontal sinus involvement, dura, and brain infiltration) or a craniofacial resection (eg, intraorbital invasion and involvement of the anterolateral maxillary wall and hard palate) might be necessary. 53,57,58 Therefore, the choice of the best approach for the individual patient depends not only on the objective data of the exposure offered by a specific approach but also on the characteristics of the target lesion and the patient's performance status and comorbidities. ...
Background:
Several microsurgical transcranial approaches (MTAs) and endoscopic transnasal approaches (EEAs) to the anterior cranial fossa (ACF) have been described.
Objective:
To provide a preclinical, quantitative, anatomic, comparative analysis of surgical approaches to the ACF.
Methods:
Five alcohol-fixed specimens underwent high-resolution computed tomography. The following approaches were performed on each specimen: EEAs (transcribriform, transtuberculum, and transplanum), anterior MTAs (transfrontal sinus interhemispheric, frontobasal interhemispheric, and subfrontal with unilateral and bilateral frontal craniotomy), and anterolateral MTAs (supraorbital, minipterional, pterional, and frontotemporal orbitozygomatic approach). An optic neuronavigation system and dedicated software (ApproachViewer, part of GTx-Eyes II-UHN) were used to quantify the working volume of each approach and extrapolate the exposure of different ACF regions. Mixed linear models with random intercepts were used for statistical analyses.
Results:
EEAs offer a large and direct route to the midline region of ACF, whose most anterior structures (ie, crista galli, cribriform plate, and ethmoidal roof) are also well exposed by anterior MTAs, whereas deeper ones (ie, planum sphenoidale and tuberculum sellae) are also well exposed by anterolateral MTAs. The orbital roof region is exposed by both anterolateral and lateral MTAs. The posterolateral region (ie, sphenoid wing and optic canal) is well exposed by anterolateral MTAs.
Conclusion:
Anterior and anterolateral MTAs play a pivotal role in the exposure of most anterior and posterolateral ACF regions, respectively, whereas midline regions are well exposed by EEAs. Furthermore, certain anterolateral approaches may be most useful when involvement of the optic canal and nerves involvement are suspected.
... Nowadays, orbital exenteration represents an option for the management of orbital diseases with relentless progression and dismal prognosis. Orbital and lacrimal gland primary tumors, intraorbital metastasis and sinonasal malignancies with orbital extension are the most frequent indications (Zaoli et al., 1978;Castelnuovo et al., 2014;Amsbaugh et al., 2016;Muscatello et al., 2016;Kesting et al., 2017;Kiratli and Koç, 2018;Baum et., 2021), in addition to fulminant invasive fungal rhinosinusitis with orbital spread (Cinar et al., 2017). As regards paranasal sinus cancers, orbital invasion is frequent and represents an independent negative prognostic factor (De Campora and Marzetti, 2006). ...
The purposes of this study were to describe the endoscopic-assisted orbital exenteration surgical techniques, to report preliminary outcomes and to discuss advantages, indications and limitations of this approach. All patients who underwent endoscopic-assisted orbital exenteration at a single tertiary-care center were retrospectively reviewed. A concomitant reconstruction was performed in all cases. The extent of surgical resection was tailored to the size and location of tumor and was classified into four subtypes. A total of 40 patients were included in this series. Orbital exenteration type 1 was performed in 7 cases, type 2 in 11 cases, type 3 in 19 cases, and type 4 in 3 cases. The reconstruction was performed with a pedicled temporal flap in 5 patients and with a free vascularized flap in 34 cases. A radical resection of disease was obtained in 32 cases. After a mean follow-up of 36 months, 14 patients died of disease, one patient died of other causes, 7 are alive with disease, and 18 patients are currently alive without evidence of disease. The preliminary data emerging from this case-series support the feasibility and safety of endoscopic-assisted orbital exenteration.
... Although endoscopic techniques were traditionally not recommended for malignant tumors, more and more studies have proven their effectiveness and safety. Nowadays, they are considered the gold-standard in many centers [26][27][28][29][30][31]. Although complete resection with negative margins is known to be a critical factor, most studies do not mention the status of surgical margins. ...
Introduction. Although uncommon from a population-based perspective, there is considerable morbidity and mortality associated with malignant tumors of the nose and paranasal sinuses.
The objective of this study was to characterize the presentation, risk factors, management and survival of patients with these tumors treated at a single institution.
Materials and methods. We retrospectively reviewed the clinical records of patients with malignancies of the nose and paranasal sinuses diagnosed between January 2010 and December 2014 at a tertiary cancer center. Univariate and multivariate analysis were performed.
Results. Ninety patients were included in the study. Mean age at diagnosis was 62.8 years (range, 2–95 years) and mean follow-up was 44.5 months (range, 2–113 months). The maxillary sinus (33.3 %) and the nasal cavity (32.2 %) were the most frequent sites of origin. Squamous cell carcinoma (36.7 %), mucosal melanoma (15.6 %) and adenoid cystic carcinoma (10 %) were the most common histologic subtypes. Surgery was the primary treatment for 86.7 % of patients. Recurrence occurred in 45 patients (50 %). The overall 5‑year survival was 39.3 % and disease free-survival was 45.9 %. Survival was significantly decreased in non-smokers ( p = 0.022), T3–4 tumors ( p = 0.007), positive lymph nodes ( p <0.001), nonepithelial tumors ( p = 0.036) and positive margins ( p = 0.032). Survival was not affected by surgical approach between endoscopic, open and combined approaches ( p = 0.088).
Conclusion. Prognosis is poor, with high recurrences and low survival, but clearly histology, location and stage-dependent. Sound oncologic principles, with complete resections and negative margins, result in a better outcome.
... This challenge creates a dilemma for surgical treatment as one is balancing between an adequate margin of resection and potential morbidity. Over the last three decades, the evolution of transnasal endoscopic surgery and improvements in adjuvant treatments have been considerably impacting the management of sinonasal cancer (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). Transnasal endoscopy can be considered the standard of treatment for many adequately selected nasoethmoidal malignancies; in addition, it can effectively aid the delineation of critical margins of resection even in the setting of open approaches for advanced sinonasal cancers (i.e., endoscopicassisted maxillectomy and cranioendoscopic resection) (13,14). ...
Background
The resection of advanced maxillary sinus cancers can be challenging due to the anatomical proximity to surrounding critical anatomical structures. Transnasal endoscopy can effectively aid the delineation of the posterior margin of resection. Implementation with 3D-rendered surgical navigation with virtual endoscopy (3D-SNVE) may represent a step forward. This study aimed to demonstrate and quantify the benefits of this technology.
Material and Method
Four maxillary tumor models with critical posterior extension were created in four artificial skulls (Sawbones®). Images were acquired with cone-beam computed tomography and the tumor and carotid were contoured. Eight head and neck surgeons were recruited for the simulations. Surgeons delineated the posterior margin of resection through a transnasal approach and avoided the carotid while establishing an adequate resection margin with respect to tumor extirpation. Three simulations were performed: 1) unguided: based on a pre-simulation study of cross-sectional imaging; 2) tumor-guided: guided by real-time tool tracking with 3D tumor and carotid rendering; 3) carotid-guided: tumor-guided with a 2-mm alert cloud surrounding the carotid. Distances of the planes from the carotid and tumor were classified as follows and the points of the plane were classified accordingly: “red”: through the carotid artery; “orange”: <2 mm from the carotid; “yellow”: >2 mm from the carotid and within the tumor or <5 mm from the tumor; “green”: >2 mm from the carotid and 5–10 mm from the tumor; and “blue”: >2 mm from the carotid and >10 mm from the tumor. The three techniques (unguided, tumor-guided, and carotid-guided) were compared.
Results
3D-SNVE for the transnasal delineation of the posterior margin in maxillary tumor models significantly improved the rate of margin-negative clearance around the tumor and reduced damage to the carotid artery. “Green” cuts occurred in 52.4% in the unguided setting versus 62.1% and 64.9% in the tumor- and carotid-guided settings, respectively (p < 0.0001). “Red” cuts occurred 6.7% of the time in the unguided setting versus 0.9% and 1.0% in the tumor- and carotid-guided settings, respectively (p < 0.0001).
Conclusions
This preclinical study has demonstrated that 3D-SNVE provides a substantial improvement of the posterior margin delineation in terms of safety and oncological adequacy. Translation into the clinical setting, with a meticulous assessment of the oncological outcomes, will be the proposed next step.
... All patients were addressed to specific follow-up, as already described in previous publications. 15 ...
Objectives/Hypothesis
Maxillary cancers are rare and aggressive tumors, which can spread beyond the sinus bony walls. Preoperative assessment of infiltration of maxillary sinus floor (MSF) is paramount for surgical planning, as palatomaxillary demolition significantly impacts patients' quality of life. This study investigates the challenges involved in the preoperative and intraoperative evaluation of MSF infiltration and analyzes its prognostic relevance.
Study Design
Retrospective case series.
Methods
A retrospective review of patients treated for sinonasal malignancies at a single Institution was performed. Patients receiving surgical-based treatment with curative intent for primary maxillary sinus cancers, between January 2000 and November 2019, were included.
Results
A cohort of 118 patients was analyzed. By comparing intraoperative findings (endoscopic assessment and frozen sections) with preoperative radiological assessment, diagnostic changes with regard to MSF infiltration were found in 27.1% (32/118 cases). MSF infiltration negatively affected the prognosis in both univariate and multivariate analyses in the overall population. In the subgroup of pT1-T3 tumors, MSF infiltration was significantly associated with reduced overall (P = .012), disease-free (P = .011), and distant recurrence-free (P = .002) survival rates. Conversely, pT classification was not able to stratify patients according to prognosis, mainly because early-staged cancers (pT1-T2) with MSF infiltration showed reduced survival rates, similar to those observed in pT3 cancers.
Conclusions
Preoperative imaging should be integrated with intraoperative findings based on endoscopic inspection and frozen sections. Future studies are required to investigate the opportunity to incorporate MSF infiltration in the TNM staging system, considering its crucial role in defining the extent of surgery and its potential as prognosticator.
Level of Evidence
4 Laryngoscope, 2021
... A paradoxical fact on recommendations for margin width lies in the techniquedependent threshold defining "clear margins". A cancer of the upper aerodigestive tract would be defined as completely resected with a threshold of 5 mm of pathologically uninvolved tissue if operated on with open surgery, 2-5 mm if through transoral robotic surgery, 0.5-2 mm if via transoral laser surgery, and regardless of metric measurements provided that adjacent structures are not infiltrated in case endoscopic transnasal resection has been performed [27][28][29][30][31][32][33][34][35][36]. On the one hand, this difference is understandable as it expresses the need to define as either "adequate" or "inadequate" a resection performed with a given technique. ...
The concept of surgical margins was born a long time ago but still lacks a univocal and sound understanding. The current biological rationale behind the recommendations on margins management relies on two pillars: (1) the observation that groups of cancer cells can leave the macroscopic tumor and disseminate throughout adjacent tissues with different degrees of aggressiveness; (2) the belief that removal of all (or most of) cancer cells can cure the patient. However, this background is undermined by some pieces of evidence. For instance, it has been proven that tissues surrounding cancer often bear precancerous traits, which means that cutting through non-cancerous tissues does not equate to cut through healthy tissues. The head and neck exquisitely poses a number of challenges in the achievement of negative margins, with special reference to anatomical complexity, high density in relevant structures, and unique histological heterogeneity of cancers. Currently, intraoperative margins evaluation relies on surgeons’ sight, palpation, ability to map tumor extension on imaging, and knowledge of anatomy, with some optical imaging technologies aiding the delineation of the mucosal margins of excision. Frozen sections are currently used to intraoperatively evaluate margins, yet with debate on whether and how this practice should be performed. Future perspectives on improvement of margins control are threefold: research is oriented towards refinements of understanding of cancers local progression, implementation of technologies to intraoperatively render tumor extension, and employment of optical imaging modalities capable of detecting foci of residual tumor in the surgical bed.
... Endoscopic surgery is usually limited to the nasal cavity and paranasal cavity, but in recent years, the indication of endoscopic surgery is progressively expanding. Previous literatures have well-summarized the indications and contraindications for endoscopic transnasal removal of sinonasal malignancies (30,31). Endoscopic surgery has been standardized (31), and its safety and feasibility have been confirmed. ...
Background: Esthesioneuroblastoma (ENB) is a rare sinonasal malignancy, lacking a unified staging system and treatment. Management at a single center was retrospectively evaluated to inform future treatment options and prognostic factors.
Methods: Clinical data of 64 consecutive ENB patients, including prognostic factors and treatment methods, were reviewed retrospectively. Data were collected to calculate overall survival (OS) and progression free survival (PFS).
Results: The majority of tumors 84.4% were within Kadish C stage, 79.7% were within T3 or T4, and 64.0% were within Hyams grade III or IV. A total of 50 (78.1%) patients received surgery and combined radiotherapy with or without chemotherapy, 10 (15.6%) received surgery with or without chemotherapy alone, and 4 (6.3%) received radiotherapy with or without chemotherapy alone. The majority of patients (79.7%) underwent endoscopic resection (endoscopic and endoscopically assisted). Surgery combined with radiotherapy with or without chemotherapy resulted in significantly better OS (84.4 vs. 50.6%, 84.4 vs. 37.5%) compared to surgery alone and radiotherapy alone ( P = 0.0064). Endoscopic surgery group (endoscopic and endoscopically assisted) resulted in significantly better 5-year PFS (61.7 vs. 22.2%) compared to the open surgery group ( P < 0.001). Although endoscopic surgery group was not a statistically significant predictor of 5-year OS ( P = 0.54), the 5-year OS was 79.3% for the endoscopic surgery group and 76.2% for the open surgery group. A Cox regression analysis identified intracranial extension and surgery combined with radiotherapy as independent factors affecting 5-year OS while cervical lymph node metastasis and Hyams grade IV as independent factors affecting 5-year PFS.
Conclusion: Our findings suggest that surgery combined with radiotherapy is the best treatment approach for ENB. For advanced tumors, endoscopic surgery is an effective treatment, and its survival rate is equal to or better than open surgery.
... This is remarkable, first, as the very motivation for introducing treatment guidelines was to improve OS; second, as failure to abide by the current treatment guidelines was associated with LRF. The role of endoscopic endonasal surgery has expanded over the past two decades [13][14][15][16]. This minimally invasive approach has been shown to result in lower post-operative morbidity and mortality than open transcranial surgery in cases of anterior skull base-related tumours [2,[17][18][19][20][21]. Highprecision RT has also evolved over the past decades; however, the critical normal tissue adjacent to the sinonasal tumours poses a major challenge in target dose coverage [22]. ...
Background:
Sinonasal cancer is considered a rare disease with poor survival. Its treatment has changed profoundly in recent years, primarily following the introduction of intensity-modulated radiation therapy (IMRT) and minimally invasive endoscopic surgery. Danish national guidelines on treatment of patients diagnosed with sinonasal carcinoma were introduced in 2007. The aim of this phase-4 study was to assess the effect of the implementation of guidelines by describing treatment outcomes in a consecutive nationwide cohort.
Methods:
All patients diagnosed with sinonasal carcinoma in Denmark from 2008 to 2015 were identified in the nationwide clinical database, DAHANCA, and were followed until May 2020. Overall survival (OS) was analysed using Kaplan-Meier estimator. Cumulative incidence of locoregional failure (LRF) and disease-specific mortality (DSM) were analysed using the Aalen-Johansen estimator. Competing risks were death from other causes (DSM) and distant failure and death (LRF). Analysis of prognostic factors was performed using Cox proportional hazard analysis. Start of follow-up was time of diagnosis. The results are presented as estimates with 95% confidence intervals (95% CIs).
Results:
A total of 331 patients were identified. Curatively intended treatment was performed in 264 patients (80%). Non-compliance with treatment guidelines was registered in 24 patients (9%). Non-compliance was associated with LRF (hazard ratio [HR], 2.0 [95% CI: 1.1-3.5]). Among patients qualified for curative treatment, failure occurred in 109 patients (41%), primarily at the primary tumour site (81%). Anatomical tumour site and disease stage were independent prognostic factors. The 5-year OS was 56% in patients treated with curative intent, and a combined treatment strategy showed reduced LRF (HR, 0.53 [95% CI: 0.30-0.92]) in a multivariate analysis.
Conclusions:
Guideline compliance and a combined treatment approach reduced the incidence of LRF and thereby increased OS. Our results confirm those of international studies. Treatment of sinonasal carcinoma remains a challenge that requires multidisciplinary team coordination.
... In most specialized institutions, open approaches are now indicated for more complicated lesions. Indications for open approaches in this new era include [26,[37][38][39][40]: infiltration of the anterior wall of the frontal sinus or massive frontal sinus involvement; infiltration of the nasal bones; involvement of soft tissue or skin of the face or forehead; involvement of the lateral, inferior, or anterior maxillary walls; palate involvement; lacrimal pathway invasion; massive infratemporal fossa extension; invasion of the orbital content; involvement of dura over the orbital roof lateral to the mid-pupillary line; the presence of a crucial neurovascular structure ventral or medial to the target structure when coming from an endonasal route; the need for microvascular reconstruction; internal carotid artery encasement; massive extension of the tumor through the dura and infiltration of falx/ sagittal sinus and/or brain parenchyma. Focal dural involvement may be excised and reconstructed endoscopically; however, wide dural involvement, especially in proximity to an optic chiasm or with lateral extension, warrants an open approach resection and adequate reconstruction (Fig. 1). ...
Treating malignant tumors of the anterior skull base (ASB) is a challenging task, given their late presentation, diverse histology, and involvement of an intricate anatomical space requiring complex surgery. Advances in imaging, gradual refinement of surgical and reconstruction techniques, and improvement of perioperative care during recent decades have resulted in improved clinical outcomes for patients. In addition, assessing functional outcomes and quality-of-life issues have become a fundamental part in the holistic care of patients with ASB tumors. Once dominated by open procedures, the modern field of skull base surgery is rapidly incorporating endoscopic techniques. These techniques have been previously reserved for sinonasal inflammatory diseases, but in recent years they have sequentially and increasingly been applied to more complex disorders. The list of indications includes intracranial pathologies and malignant sinonasal neoplasms with skull base involvement. Open ASB surgery in this new era is reserved for selected cases, yet it is still considered the "gold standard" for treating ASB malignancy. The paucity of evidence-based data regarding the management of ASB tumors is still a major limit of the discipline of ASB surgery, resulting from the rarity and high degree of heterogeneity of these tumors. Therefore, no guidelines exist and prospective large cohort collaborative studies are required in order to consolidate our knowledge of the behavior of each histology encountered, and to assess the clinical and quality-of-life outcomes of the different treatment modalities currently used.
... En el caso de tumores que comprometen la base del cráneo, se debe considerar la combinación de abordajes cuando hay infiltración tumoral de la duramadre lateralmente por encima de la órbita (usualmente lateral a los nervios ópticos) o cuando se extiende significativamente en el parénquima cerebral (34,28). ...
Los recientes avances en el campo de cirugía endoscópica endonasal (CEE) han permitido disminuir la morbilidad de los abordajes abiertos tradicionales, mejorando o al menos igualando los resultados oncológicos y funcionales que hemos visto en estos procedimientos en el manejo de tumores malignos de senos paranasales y base del cráneo.El manejo oncológico de estas patologías complejas se beneficia de un abordaje multidisciplinario, en donde la decisión quirúrgica se basa en el estadio del tumor, localización, histología y relación con estructuras vecinas.La adecuada y cuidadosa selección de pacientes para este tipo de técnicas es esencial para lograr resultados exitosos.Este artículo pretende hacer una revisión narrativa de la literatura sobre estas técnicas quirúrgicas, discutir sus beneficios y limitaciones y, exponer las indicaciones que utilizamos en nuestra institución para elegir cada uno de estos abordajes.
... Over the last 30 years, the development of endoscopic transnasal surgery along with improvements in radiotherapy, such as intensitymodulated radiation therapy and particle therapy, have revolutionized the management of sinonasal cancer [1][2][3][4][5][6][7][8][9][10][11]. A large majority are now resected endoscopically, considerably reducing the morbidity of surgery compared to the historical craniofacial resections that were once performed routinely for such cancers. ...
Objectives:
To demonstrate and quantify, in a preclinical setting, the benefit of three-dimensional (3D) navigation guidance for margin delineation during ablative open surgery for advanced sinonasal cancer.
Materials and methods:
Seven tumor models were created. 3D images were acquired with cone beam computed tomography, and 3D tumor segmentations were contoured. Eight surgeons with variable experience were recruited for the simulation of osteotomies. Three simulations were performed: 1) Unguided, 2) Guided using real-time tool tracking with 3D tumor segmentation (tumor-guided), and 3) Guided by 3D visualization of both the tumor and 1-cm margin segmentations (margin-guided). Analysis of cutting planes was performed and distance from the tumor surface was classified as follows: "intratumoral" when 0 mm or negative, "close" when greater than 0 mm and less than or equal to 5 mm, "adequate" when greater than 5 mm and less than or equal to 15 mm, and "excessive" over 15 mm. The three techniques (unguided, tumor-guided, margin-guided) were statistically compared.
Results:
The use of 3D navigation for margin delineation significantly improved control of margins: unguided cuts had 18.1% intratumoral cuts compared to 0% intratumoral cuts with 3D navigation (p < 0.0001).
Conclusion:
This preclinical study has demonstrated the significant benefit of navigation-guided osteotomies for sinonasal tumors. Translation into the clinical setting - with rigorous assessment of oncological outcomes - would be the proposed next step.
... As instrumentation and surgical approaches have evolved, surgical indications for these pathologic conditions are expanding and the growing expertise of skull base teams in cranial and endoscopic procedures all have contributed to the gradual improvement of outcomes for patients affected by cranial base pathologic conditions. 1,2 In anterior cranial base (ACB) lesions with intracranial extension, one of the most delicate aspects to keep in mind when planning surgery is the subsequent repair of dura mater defects that may have occurred during the procedure. In fact, surgical closure of the skull base, given the high risk of cerebrospinal fluid (CSF) fistulas, requires specific reconstructive techniques: single or multilayer free tissue grafts and vascularized flaps are used together in attempts to obtain the watertight closure of a cranial base defect. ...
... From the end of the last century, the use of transnasal endoscopic surgery was advocated even for treatment of very selected sinonasal malignancies [56]. In the following years, due to increased surgical expertise and more sophisticated surgical tools, the number of patients treated and the oncologic results led to consider this minimally invasive approach a valid alternative to CFR [57][58][59][60][61][62]. Endoscopy allows to operate within a magnified surgical field, avoiding any facial incision; moreover, this approach has been demonstrated to be very useful in lesions such as AdCC since it allows to precisely assess the status of all the sites and structures potentially involved by the tumor [31]. ...
Malignant tumors of minor salivary glands (MiSGMTs) are rare, the majority of them being located in the oral cavity and oropharynx. Adenoid cystic carcinoma (AdCC) is the most frequently encountered histologic type followed by mucoepidermoid carcinoma (MEC); however, many other malignant salivary tumor types have also been described. Presenting complaints of MiSGMT depend on the anatomic site of origin. A painless submucosal swelling is the most frequent finding, possibly associated with obstructive symptoms when the tumor is located in the sinonasal cavities, pharynx, larynx, or trachea; pain or nerve impairment may also be reported.
The resolution of the naked eye has been a challenge for the neurosurgical endeavor since the very first attempts of cranial surgery, and advances have been achieved over the centuries, driven by a synergism between the application of emerging technology into the surgical environment and the expansion of the capabilities of neurosurgery. The understanding of the principles of the optical properties of lenses by Abbè (1840–1905) led to the introduction of loupes in the surgical practice, increasing the visual performance during macroscopic procedures. Modern neurosurgery began with the possibility of illumination and magnification of the surgical field as provided by the microscope. Pioneering contributions from Donaghy and Yasargil opened the way to the era of minimalism with reduction of operative corridors and surgical trauma through the adoption of the microsurgical technique. Almost at the same time, engineering mirabilia of Hopkins in terms of optics and lenses allowed for introduction of rigid and flexible endoscopes as a viable tool in neurosurgery. Nowadays, neurosurgeons are aware of and confident using effective and modern tools of visualization in their armamentarium. Herein we present a cogent review of the evolution of visualization tools in neurosurgery, with a special glimpse into the current development and future achievements.
Objectives:
Medical device-related pressure ulcer (MDRPU) is a skin or subcutaneous tissue injury caused by medical devices. Skin protectants have been used to prevent MDRPU in other fields. In endoscopic sinonasal surgery (ESNS), rigid endoscopes and forceps can cause MDRPU; however, detailed investigations have not been conducted. This study aimed to investigate the frequency of MDRPU in ESNS and the preventive effects of skin protectants METHODS: Thirty-nine patients who received ESNS and consented to study participation were randomly assigned to the "protective agent" (n = 18) or "control" (n = 21) group. MDRPU presence around the nostril was evaluated for up to 7 days post-surgically based on physical findings and subjective symptoms. The occurrence ratio and severity of MDRPU were statistically compared between the groups to evaluate the efficacy of skin protective agents.
Results:
Stage 1 MDRPU, according to the National Pressure Ulcer Advisory Panel classification, was seen in 20.5% (8/39) of the patients, and no patient had more high-grade ulceration. On postoperative days 2 and 3, skin erythema was predominantly observed on the nasal floor, with a comparatively lower incidence in the protective agent group. Significant pain reduction was observed in the nostril's floor on postoperative days 2 and 3 in the protective agent group.
Conclusions:
MDRPU occurred with a relatively high frequency around the nostrils after ESNS. Protective agent use in the external nostrils was effective especially in reducing post-operative pain on the nasal floor, where tissue damage can easily occur due to device-related friction.
Sinonasal tumours are a heterogenous entity. Surgery however forms an essential component in the management. This chapter highlights the various open and endoscopic techniques available for the management of these tumours. Expanded endonasal endoscopic procedures can provide access to a wide range of tumours arising in the sinonasal tract and extending to the pterygopalatine fossa, infratemporal fossa and the anterior cranial fossa. These approaches avoid facial incision, disassembly of the facial skeletal framework, brain retraction and provide a direct access to the tumour. This translates into reduced complication rates, shorter duration of hospital-stay and better quality of life. In carefully selected cases, oncological outcomes at par with open approaches can be obtained in case of sinonasal malignancies. Contemporary indications for open approaches are: skin involvement, involvement of the nasal bones, extensive involvement of the orbital fat, extraocular muscles, skin of the eyelid and lacrimal apparatus.
Objective:
Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously.
Methods:
All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling.
Results:
Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk.
Conclusion:
Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications.
Level of evidence:
3 Laryngoscope, 2022.
During the past five decades, major technological advances, including availability of imaging techniques such as computed tomography, magnetic resonance imaging, and positron emission tomography scans, have improved accurate assessment of tumors. Major advances in reconstructive surgery with development of microvascular free‐flap reconstruction have made one‐stage resection and reconstruction a reality, leading to a better quality of life. Multimodality treatments combining chemotherapy with radiation have led to development of organ preservation strategies and improved locoregional control of head and neck cancer.
An open transfacial or craniofacial resection is the traditional, gold standard approach for the resection of sinonasal malignancies. Over the last three decades, endoscopic approaches have emerged as a viable alternative in the treatment of select patients with sinonasal malignancies. Studies have demonstrated that in comparison to traditional approaches, endoscopic approaches result in shorter operating room times, decreased hospital and ICU stays, lower rates of postoperative complications, and intraoperative blood loss. The growing body of evidence has shown that endoscopic approaches have decreased perioperative morbidity and mortality, preserved oncologic integrity, with comparable or improved outcomes in carefully selected patients with sinonasal malignancies.KeywordsSinonasal malignancySinonasal tumorSkull base tumorSkull base malignancyEndoscopic approachExpanded endonasal approachCraniofacial resection
Endoscopic endonasal surgery has been demonstrated to be effective in the treatment of selected cases of sinonasal cancers. However, in cases of locally advanced neoplasms, as well as recurrences, the most appropriate approach is still debated. The present review aims to summarize the current state of knowledge on the utility of open approaches to resect sinonasal malignant tumours. Published comparative studies and meta-analyses suggest comparable oncological results with lower morbidity for the endoscopic approaches, but selection biases cannot be excluded. After a critical analysis of the available literature, it can be concluded that endoscopic surgery for selected lesions allows for oncologically safe resections with decreased morbidity. However, when endoscopic endonasal surgery is contraindicated and definitive chemoradiotherapy is not appropriate, craniofacial and transfacial approaches remain the best therapeutic option.
Purpose of review:
Exoscopes are external digital devices that provide enhanced and magnified visualization of the surgical field. They usually have dedicated digital controls and a more compact mechanical structure than operative microscopes and current robotic surgical systems. This technology has significant potential in otolaryngology - head and neck surgery, especially concerning the field of transoral approaches. We herein analysed the overall technical characteristics of currently available exoscopic systems and contextualized their advantages and drawbacks in the setting of transoral surgery.
Recent findings:
The actual advantages of exoscopy are still indeterminate, as it has only been applied to limited surgical series. However, its specific properties are herein compared with conventional transoral microsurgery and transoral robotic surgery, discussing the available literature on such a topic, filtered on the basis of the authors' experience and its possible future evolutions. Finally, a summary of current experiences in the field of three-dimensional (3D) transoral exoscopic surgery is presented, highlighting differences compared with standard approaches.
Summary:
3D-exoscopic transoral surgery will possibly play an essential role in future management of early laryngeal and oropharyngeal lesions, significantly shifting the paradigms of this type of procedures.
Introduction
Sinonasal malignancy is a rare and heterogenous disease, with limited evidence to guide management. This report summarises the findings of a UK survey and expert workshop discussion which took place to inform design of a proposed UK trial to assess proton beam therapy versus intensity-modulated radiation therapy.
Method
A multidisciplinary working group constructed an online survey to assess current approaches within the UK to surgical and non-surgical practice. Head and neck clinical oncologists, ear nose and throat (ENT) and oral-maxillofacial (OMF) surgeons were invited to participate in the 42-question survey in September 2020. The Royal College of Radiologists Consensus model was adopted in establishing categories to indicate strength of response. An expert panel conducted a virtual workshop in November 2020 to discuss areas of disagreement.
Results
Survey was sent to 140 UK-based clinicians with 63 responses (45% response rate) from 30 centres, representing a broad geographical spread. Participants comprised 35 clinical oncologists (56%) and 29 surgeons (44%; 20 ENT and 9 OMF surgeons). There was variation in preferred sequence and combination of treatment modalities for locally advanced maxillary squamous cell carcinoma and sinonasal undifferentiated carcinoma. There was discordant surgical management of the orbit, dura, and neck. There was lack of consensus for radiotherapy in post-operative dose fractionation, target volume delineation, use of multiple dose levels and treatment planning approach to organs-at-risk.
Conclusion
There was wide variation across UK centres in the management of sinonasal carcinomas. There is need to standardise UK practice and develop an evidence base for treatment.
By the end of this chapter, the reader will:
Background
The aim of this study was to describe the potential advantages of the 3D endoscope-assisted craniectomy for tumor of the nasal cavity.
Methods
A 77-year-old man with a 6 month history of persistent progressive right nasal obstruction and iposmia is reported. Physical examination, including nasal endoscopy, revealed a large mass within the right nasal cavity. He had no associated symptoms such as visual complaints, paresthesia, and facial pain. He worked as a carpenter.
Further imaging by CT and MRI revealed a large, expansive nasal-ethmoid lesion that almost completely occupies the right nasal cavity with partial extension posterior to the choana, extensive erosion of the ethmoid. Medially marks the nasal septum with deviation to the left. Laterally it marks the medial wall of the maxillary sinus and at the top it is in contact with the cribriform plate which seems to be interrupted in the right parasagittal seat at the 3rd anterior of the olfactory cleft. Histopathological analysis of the specimen was consistent with sinonasal adenocarcinoma, intestinal type (ITAC) cT4aN0 (Hoeben, A., et al.).
Results
Patient was taken up for surgery by transnasal 3D endoscopic approach for excision of tumor with repair of the skull base defect, using Karl Storz IMAGE1 S D3-Link™ and 4-mm TIPCAM®. The mass could be dissected free of the dura and the entire specimen was removed completely and sent for histopthological examination. We followed our 8 main surgical steps: 1) Tumor disassembling; 2) Nasal septum removal; 3) Centripetal bilateral ethmoidectomy and sphenoidotomy; 4) Draf III frontal sinusotomy 5) Anterior and posterior ethmoidal artery closure 6) Skull base removal; 7) Intracranial work; 8) Reconstruction time. A 4 × 2.3 cm skull base defect was repaired using triple layer of fascia lata (Intracranial intradural, intracranial extradural and extracranial) and was sealed using tissue glue (TisselR).
Post-operative recovery was uneventful, pack were removed on 3rd postoperative day and patient was discharged on the 7th post-operative day. After 2 years of follow up, the patient is free of disease.
Conclusion
We describe 3D endoscopic transnasal craniectomy for Intestinal Type Adeno-Carcinoma (ITAC) of the nasal cavity as a feasible technique for the surgical management of sino-nasal tumors (Castelnuovo, P., et al.). Our experience with this approach has been outstanding. We firmly believe that in the first three steps of the procedure the 3D endoscope is not necessary because it extends the surgical time and induce eyestrain of the main surgeon. Nevertheless, 3D endoscope gives the major advantage during the skull base removal and the intracranial work. It offers an optimal vision and better perception of depth with safe manipulation of the instruments avoiding injuries to healthy tissue (Riley, C. A., et al.). Furthermore, 3D images offer better understanding of the relationship between anatomical landmarks, helping the didactic learning curve of our residents.
Background
The usefulness of apparent diffusion coefficient (ADC) and diffusion‐weighted magnetic resonance imaging (DWI) in the detection of malignant tumors has been reported. The purpose of this study is to clarify the role of ADC and DWI for diagnosis of skull base tumors.
Methods
A total of 27 patients with head and neck tumors with skull base invasions undergoing skull base surgery were enrolled in this study. Pathological findings of dural invasion and bone invasion were compared with the diagnostic imaging.
Results
Advanced magnetic resonance imaging techniques revealed that ADC values in regions of pathological bone and dural invasions were significantly lower than in regions of no invasion. The area under the curve of ADC in bone invasions and dural invasions were 0.957 and 0.894, respectively.
Conclusions
Our findings indicate that ADC and DWI are useful tools for the diagnosis of head and neck tumors with skull base invasion.
Anterior skull base approaches have included endoscopic or open microsurgical approaches for intracranial pathologies. However, discussion of a combined hybrid, cranioendoscopic approach, leveraging the benefits of both techniques, has been limited. Here we describe a case of a combined endoscopic, endonasal, and open microsurgical frontotemporal approach for resection of a complex anterior skull base lesion. A 62-year-old man with a large meningioma extending intradurally through the cribiform plate and sphenoethmoidal sinuses underwent a cranioendoscopic resection. Surgical techniques, including repair of the anterior skull base defect as well as complication avoidance and the coordination of multiple surgeons, are discussed.
The video can be found here: https://youtu.be/Ti9tUUdWgJc .
Endoscopic and open microsurgical approaches for pediatric patients are useful for a wide variety of skull base pathologies. A hybrid, cranioendoscopic approach may be beneficial in improving surgical resection for complex lesions. A case of a 13-year-old boy with a large juvenile nasopharyngeal angiofibroma extending through the nasopharynx and pterygopalatine fossa into the maxillary, sphenoid, and cavernous sinuses is demonstrated via an endoscopic, transnasal and frontotemporal, extended middle cranial fossa microsurgical approach. Management of a large pediatric tumor via narrow nasal passages, safe surgical resection around critical neurovascular structures, and complication avoidance is demonstrated.
The video can be found here: https://youtu.be/1WqvsOnQCxs .
Résumé
Introduction
La chirurgie oncologique basi-crânienne par voie endoscopique endonasale chez le sujet âgé et fragile peut épargner la morbidité d’une chirurgie par voie trans-faciale et/ou transcrânienne, parfois jugée déraisonnable alors que la chirurgie reste le traitement de référence des cancers nasosinusiens.
Objectifs
Évaluer les résultats fonctionnels et carcinologiques de cette chirurgie chez le sujet âgé de plus de 70 ans.
Matériels et méthodes
Cette étude rétrospective monocentrique conduite entre octobre 2008 et octobre 2018 a inclus tous les patients ayant bénéficié d’une exérèse oncologique avec reconstruction de l’étage antérieur de la base du crâne par voie endoscopique endonasale exclusive après 70 ans.
Résultats
Quinze procédures effectuées chez 13 patients correspondaient aux critères d’inclusion. La durée d’hospitalisation médiane était de 7 jours. L’exérèse était considérée R0 dans tous les cas, à l’exception d’une exérèse en marges positives au niveau de la méninge (6,7 %). Tous les patients ont bénéficié d’un protocole radiochirurgical complet et conforme aux recommandations du REFCOR. Deux cas de méningites ont été rapportés (13,3 %). Après un recul médian de 27 mois, quatre patients ont présenté une évolutivité locale, dont un présentait également des métastases pulmonaires. Deux patients sont décédés de leur maladie ou de conséquences du traitement.
Conclusion
Cette technique est une option thérapeutique réalisable chez le sujet de plus de 70 ans, avec de bons résultats fonctionnels et un résultat carcinologique acceptable.
Résumé
Les carcinomes nasosinusiens représentent trois pour cent des cancers ORL. Ils sont subdivisés en carcinomes épidermoïdes (50 %), adénocarcinomes (20 %, majoritairement de type intestinal ITAC), et plus rarement, carcinomes adénoïdes kystiques, neuroblastomes olfactifs (= esthésioneuroblastomes), carcinomes neuro-endocrines ou carcinomes nasosinusiens indifférenciés (SNUC). Les taux de survie à cinq ans sont, par ordre décroissant, 72 % pour les neuroblastomes, 63 % pour les adénocarcinomes, 50–60 % pour les neuro-endocrines à grandes cellules, 53 % pour les épidermoïdes, 25–50 % pour les adénoïdes kystiques, 35 % pour les neuro-endocrines à petites cellules et 35 % pour les SNUC et nouvelles entités. Le traitement est chirurgical ; les voies endoscopiques réduisent la morbidité à contrôle tumoral équivalent. La résection endoscopique, si fragmentée, doit être carcinologique. La radiothérapie adjuvante conformationnelle en modulation d’intensité (RCMI) est quasi systématique. Le risque ganglionnaire est faible dans les adénocarcinomes ethmoïdaux et carcinomes adénoïdes kystiques ; il est intermédiaire et peut justifier une radiothérapie prophylactique pour les cous N0 dans les SNUC, neuroblastomes, épidermoïdes et neuro-endocrines nasosinusiens. Pour les formes non résécables, le traitement est une RCMI ou protonthérapie. Elle peut être optimisée par hadronthérapie par ions carbones pour les carcinomes adénoïdes kystiques, ou par chimiothérapie pour tous les carcinomes, dans le cadre d’essais thérapeutiques ouverts en France. La chimiothérapie néoadjuvante est réservée aux formes rapidement évolutives ou à haut potentiel métastatique comme les carcinomes neuro-endocrines ou les SNUC. Compte tenu de leurs spécificités histologiques, moléculaires et de profils évolutifs différents, une expertise du réseau REFCOR, avec relecture REFCORpath, est susceptible de redresser des diagnostics, rectifier des traitements, avec un impact sur la survie.
Sinonasal malignant tumors are characterized by high histological variability and complexity of the differential diagnosis. Currently, there are classifications of these tumors, which are based on their localization and involvement of various anatomical structures. However, generally accepted algorithms for treatment of this pathology have not yet been developed. This review describes the most important algorithms for treatment of the most common histological variants of sinonasal malignant tumors: squamous cell carcinoma, adenocarcinoma, sinonasal undifferentiated carcinoma, esthesioneuroblastoma, adenoid cystic cancer, and sinonasal adenocarcinoma. The main problems in choosing the approach for treating these tumors are the lack of generally accepted resectability criteria and contradictions between oncological and neurosurgical indications for surgical treatment. Further research is needed to study the role of radiosensitizers and radioprotectors in comprehensive treatment of sinonasal malignant tumors.
Introduction:
Sinonasal adenocarcinomas (SNAC) are rare and heterogeneous. Management of SNAC follows a rather standardized and internationally accepted paradigm. Several refinements have been introduced during the last decade.
Methods:
A narrative review of most updated literature on SNACs has been conducted.
Results:
SNACs are classified as intestinal-type and non-intestinal-type, which are further categorized according to grade. Preoperative work-up should include magnetic resonance imaging (or contrast-enhanced computed tomography as a secondary or complementary choice) and biopsy under general anesthesia, or under local anesthesia in case of a history of exposure to wood and/or leather dust. Positron emission tomography, neck ultrasound, and fine-needle aspiration cytology are indicated in selected cases. Surgery represents the most common upfront modality of treatment and is usually accomplished via a transnasal endoscopic approach. Adjuvant radiation therapy is indicated for high-grade, locally advanced tumors and/or in case of margins involvement. Neoadjuvant chemotherapy with cisplatin, 5-fluorouracil and leucovorin may offer high response rates and long-term control in a subgroup of patients affected by intestinal-type adenocarcinoma, and in particular in those whose tumors harbor a functional p53 protein. Most of the bio- and immune-therapeutic potentials on SNACs still remain theoretical, and no clinical data are currently available.
Conclusions:
Management of SNAC consists of histological diagnosis, radiological staging, radical surgery, and adjuvant radiation therapy. Neoadjuvant chemotherapy can be indicated in selected cases. The role of biotherapy and immune therapy still needs to be elucidated.
Background:
In this study, we evaluate our experience and the outcomes of patients with sinonasal cancer treated with endoscopic resection.
Methods:
Retrospective review of patients with sinonasal cancer who had endoscopic resection was conducted. The outcomes of interest included survival outcomes and surgical complications.
Results:
Overall, 239 patients were included. Median follow up time was 46.6 months. Of the 239 patients, 167 (70%) had a pure endonasal endoscopic approach, while 72 (30%) had an endoscopic-assisted approach. Postoperative cerebrospinal fluid (CSF) leakage occurred in 14 patients (5.9%). Negative margins were achieved in 209 patients (87.4%). There was no significant difference in the margin status between the pure endoscopic and endoscopic-assisted group (P = .682). There was no significant difference in the survival outcomes between both the groups.
Conclusion:
Our data suggest that in properly selected patients, endoscopic approaches have acceptable morbidity with low complication rates and can provide an oncologically sound alterative to open approaches.
I tumori maligni della testa e del collo rappresentano in Italia circa il 5% di tutti i tumori maligni e si trovano al 54° posto come frequenza; ogni anno si diagnosticano circa 12.000 nuovi casi. Il tasso di incidenza (standardizzato sulla popolazione europea) è di 16 casi per 100.000 italiani all’anno, mentre in Europa (paesi dell’Unione Europea) è pari a 18 per 100.000.
I carcinomi a cellule squamose della testa e del collo (HNSCC) rappresentano il 90% di tutti i tumori della testa e del collo e possono essere rilevati in vari siti anatomici. Circa il 75% degli HNSCC è associato all'uso di tabacco e alcol; tuttavia, una minoranza di HNSCCs è causata dall'infezione da papillomavirus umano (HPV). Negli Stati Uniti, il declino dell'uso di sigarette è stato associato a una diminuzione dell'incidenza di HNSCC, ad eccezione del carcinoma a cellule squamose oro-faringee (OPSCC) HPV (HPV +), che ha un'incidenza in rapida crescita.
Introduction:
In old and frail patients, oncologic anterior skull-base surgery through an endonasal endoscopic approach avoids the morbidity incurred by transfacial and transcranial approaches, sometimes considered unreasonable, although surgery remains the gold standard treatment for sinonasal cancer.
Objectives:
To assess the functional and oncologic results of this surgery in over-70 year-olds.
Material and methods:
A single-center retrospective study included all patients aged over 70 years at surgery, who underwent endonasal endoscopic oncologic resection and reconstruction of the anterior skull base, between October 2008 and October 2018.
Results:
Fifteen procedures in 13 patients met the inclusion criteria. Mean hospital stay was 7 days. All resections were considered R0, apart from one case with positive dura-mater margins (6.7%). All patients had complete radio-surgical treatment, in accordance with the REFCOR recommendations. Two cases of meningitis were reported (13.3%). At a median follow-up of 27 months, 4 patients presented local recurrence, 1 of whom also had lung metastases. Two patients died of disease-related or treatment-related causes.
Conclusion:
This technique is a feasible treatment in patients aged over 70 years, providing good functional results, and acceptable oncologic outcome.
Objective
To analyze psychopathological outcome and health-related quality of life (QOL) for cohorts of patients undergoing transcranial or transnasal anterior skull base surgery.
Methods
A prospective study of patients undergoing elective surgery for various entities of the anterior skull base was performed. Evaluation for depression (ADS-K score) and anxiety (PTSS, STAI-S, STAI-T, and ASI-3 scores) was done before surgery, at 3 and 12 months after surgery. The correlation between preoperative psychological burden and postoperative quality of life as measured by the SF-36 and EuroQol questionnaires was analyzed. Incidence and influence of these psychiatric comorbidities on clinical outcome were examined and compared between transnasal and transcranial subgroups.
Results
We included 54 patients scheduled for surgery of a pituitary adenoma or meningioma of the anterior skull base between January 2013 and July 2017. Of these, a cohort of 40 (74.1%) completed follow-up interviews after 3 and 12 months. There were 60.0% female patients, median age was 57 years. 57.5% of patients had a meningioma and were operated transcranially, while 42.5% of patients received transnasal surgery for pituitary adenoma. The proportion of pathological anxiety scores significantly decreased from 75.0 to 45.0% (p = 0.002), without difference between transnasal and transcranial subgroups. After 3 months, mean EuroQol VAS score non-significantly increased by 0.07 (p = 0.236) across the entire cohort without significant difference between transcranial and transnasal subgroups (p = 0.478). The transnasal cohort tended to score higher in anxiety scores, whereas the transcranial cohort demonstrated higher depression scores without significant difference, respectively. The individually declared emotional burden significantly decreased from 6.7 to 4.0 on the ten-point Likert scale (p < 0.001) equally for both subgroups (transnasal, − 2.3; transcranial, − 3.0; p = 0.174). On last examination, about half of the patients in each subgroup (41.2% vs. 52.2%; p = 0.491) expressed a considerable recovery of preoperative bodily complaints such as headaches, dizziness, and unrest defined as a score of at least 8 on the Likert scaled item.
Conclusion
Both transnasal and transcranial approaches yield favorable postoperative QOL and psychopathological outcomes. The postoperative increase in QOL is partly influenced by preoperative expression of mental distress, which tends to resolve postoperatively.
In previous decades, extensive and disfiguring transfacial and/or transcranial approaches were used to reach the sellar and parasellar areas. However, these surgical routes were burdened by severe complications and high mortality rates. Recently, the development of endoscopic endonasal techniques has revolutionized the surgical strategies for approaching the sella and adjacent areas and increased the development of transsphenoidal surgery. With these techniques, surgeons have been able to overcome the visual limitations of the open surgical approaches and access areas previously hidden from view. After the contributions of the Pittsburgh duo, Carrau and Jho, pioneers of pure endoscopic surgery, our school began to implement this technique, introducing technical innovations and variations, describing the anatomical details and defining new routes, and playing a key role in its widespread clinical application.
The aim of this study is to describe the experience of a multidisciplinary skull base team with transnasal endoscopic surgery for anterior cranial base tumors.
A retrospective chart review was conducted on patients who underwent an exclusive expanded transnasal approach to the anterior skull base in the period from December 2014 to November 2015. Data on patient demographics, tumor characteristics, surgical information, imaging, and postoperative complications were collected and analyzed.
From a total of 120 patients with skull base diseases managed by the skull base team, 36 were admitted to this study. The overall complication rate in this series was 16.7%, gross total resection was achieved in 32 cases (88.9%) and postoperative CSF leakage occurred in 5 cases (13.9%).
Our preliminary results confirm that an exclusive endoscopic transnasal approach to the anterior cranial base is a reliable technique with acceptable perioperative morbidity.
During the last years, multiple methods and a wide set of materials for skull base reconstruction have been described. In our experience, the ideal graft for duraplasty is the iliotibial tract due to its favorable characteristics in terms of thickness, pliability, and strength. In this report, we show the iliotibial tract-harvesting technique under endoscopic guidance with a minimally invasive approach using a cadaveric model. Two longitudinal incisions of 1 cm each were made at 4 cm down a line drawn between the anterior-superior iliac spine and the lateral margin of patella at the extremities of the middle third of the thigh. By using a set of instruments for endoscopic face-lifting, the graft was easily set up and harvested. The endoscopic approach is associated with less visible scars, but longer operative time in comparison with open traditional procedure. The pros and cons in terms of morbidity need to be evaluated by further studies on actual cases.
Tumours affecting the nose, paranasal sinuses and adjacent skull base are fortunately rare. However, they pose significant problems of management due their late presentation and juxtaposition to important anatomical structures such eye and brain. The increasing application of endonasal endoscopic techniques to their excision offers potentially similar scales of resection but with reduced morbidity. The present document is intended to be a state-of-the art review for any specialist with an interest in this area 1. to update their knowledge of neoplasia affecting the nose, paranasal sinuses and adjacent skull base; 2. to provide an evidence-based review of the diagnostic methods; 3. to provide an evidence-based review of endoscopic techniques in the context of other available treatments; 4. to propose algorithms for the management of the disease; 5. to propose guidance for outcome measurements for research and encourage prospective collection of data. The importance of a multidisciplinary approach, adherence to oncologic principles with intent to cure and need for long-term follow-up is emphasised.
Endoscopic techniques have undergone tremendous advancement in the past years. From the management of phlogistic pathologies, we have learned to manage skull base lesions and even selected intracranial diseases. Current anatomical knowledge plus computer-aided surgery has enabled surgeons to remove large lesions in the paranasal sinuses extending beyond the boundaries of the sinuses themselves. In this sense, management of benign diseases via endoscopic routes is nowadays well accepted whilst the role of endoscopic techniques in sinonasal malignancies is still under investigation. Nowadays, it is possible to tackle different pathologies placed not only in the ventral skull base, but also extended laterally (infratemporal fossa and petrous apex) and even, in really selected cases, within the orbit. The ability to resect and reconstruct has improved significantly. At the moment, the improvement in surgical techniques, like the four-handed technique, has rendered endoscopic procedures capable of managing complex pathologies, according the same surgical principles of the open approaches. From now onwards, frameless neuronavigation, modular approaches, intraoperative imaging systems and robotic surgery are and will be an increasingly important part of endonasal surgery, and they will be overtaken by further evolution.
After a brief overview of the most commonly discussed sellar approaches in literature, the authors focus on their "Two Nostrils Four Hands" technique. This approach allows otorhinolaryngologists and neurosurgeons to co-operate and its advantages are described. In the discussion the authors want to demonstrate how this collaboration can favour a true interdisciplinary improvement in the treatment of sellar pathology. They also want to demonstrate how this technique can be microinvasive with the use of the two nostrils at the same time, thus preserving the anatomical structures not involved.
Objectives:
The traditional approach to sinonasal tumors involving the skull base has been the anterior craniofacial resection. The first report by Ketcham et al (American Journal of Surgery, 1963;106:698-703) documented their experience with 17 anterior craniofacial resections for malignant tumors of the sinonasal tract. Later experience with this technique at several centers has resulted in the publication of many refinements of technique and further reduction in the morbidity and mortality associated with this procedure. In our hands, endoscopic techniques have allowed us to approach the intranasal aspect of skull base lesions without external incisions and yet still achieve an en bloc resection. The type of lesions suitable for this approach and the associated technical issues are discussed in this article.
Methods:
Between 1999 and 2004, 18 patients with malignant nasoethmoid tumors underwent endoscopic nasal and anterior craniotomy resections. The average age of the patients 60.2 years, with a male-to-female distribution of 15 to 3. Mean follow-up period was 25.1 months.
Results:
Two patients died from postoperative complications, three died from recurrent disease and two from unrelated causes. Eleven patients are free of disease with a mean survival of 19.8 months.
Conclusions:
Although we do not consider this approach a replacement for the traditional anterior craniofacial resection, it is an important adjunct in the skull base surgeon's armamentarium.
The increasing expertise in the field of transnasal endoscopic surgery recently has expanded its indications to include the management of sinonasal malignancies. We report our experience with the endoscopic management of nasoethmoidal malignancies possibly involving the adjacent skull base.
A retrospective analysis was performed of patients treated by an exclusive endoscopic approach (EEA) or a cranioendoscopic approach (CEA) from 1996 to 2006 managed by two surgical teams at the Departments of Otorhinolaryngology of the University of Brescia, and the University of Pavia/Insubria-Varese, Italy.
One-hundred eighty-four patients were considered eligible for the present analysis. An EEA was performed in 134 patients and the remaining 50 patients underwent the CEA. The most frequent histotypes encountered were adenocarcinoma (37%), squamous cell carcinoma (13.6%), olfactory neuroblastoma (12%), mucosal melanoma (9.2%), and adenoid cystic carcinoma (7.1%). Overall, 86 (46.7%) patients received some form of adjuvant treatment. The patients were followed up for a mean of 34.1 months (range, 2-123 months). The 5-year disease-specific survival was 91.4 +/- 3.9% and 58.8 +/- 8.6% (p = 0.0004) for the EEA and CEA group, respectively.
To the best of our knowledge, this is the largest series reported to date of malignant tumors of the sinonasal tract and adjacent skull base treated with pure endoscopic or cranioendoscopic techniques. A 5-year disease-specific survival of 91.4% and 58.8% for the EEA and the CEA groups, respectively, seem to indicate that endoscopic surgery, when properly planned and in expert hands, may be a valid alternative to standard surgical approaches for the management of malignancies of the sinonasal tract.
Objective: To describe and analyze outcomes of the "multilayer centripetal technique" and "cranioendoscopic technique" in the treatment of malignancies of the sinonasal tract. Materials and methods: From June 1997 to June 2005, 67 patients with malignant tumors of the sinonasal tract were treated. A total of 49 patients underwent a sole endoscopic endonasal treatment and 18 a cranio-endoscopic treatment. The follow-up lasted from 6 to 108 months. American Joint Committee on Cancer-Union Internationale Contre le Cancer staging was: T1 = 17, T2 = 4, T3 = 9, T4a = 11, and T4b = 16. Esthesioneuroblastoma cases were staged according to Kadish: 3 = A, 4 = B, and 3 = C. All patients underwent surgical therapy but with different therapeutic intent: curative, salvage, or palliative. Results: Statistical analysis showed a 2-year survival rate higher than 80% in all histologic types of tumors, except for melanomas, according to other investigators in the literature. Conclusions: In this preliminary study, the endoscopic technique alone or in association with the cranial approach, in select cases, seems to be an effective method in the treatment of sinonasal tumors.
Background:
Primary sinonasal mucosal melanomas are aggressive tumors with a poor clinical control by current treatments, raising the urgent need of novel strategies.
Methods:
By fluorescence in situ hybridization (FISH), direct sequencing, and immunohistochemistry, we investigate the spectrum of molecular abnormalities in a cohort of 32 cases of primary sinonasal mucosal melanomas.
Results:
We found that all primary sinonasal mucosal melanomas lack BRAF V600E mutation; in addition, they are characterized by somatic mutations of NRAS (22%) and KIT (12.5%), together with amplification of RREB1 (100%) and loss of MYB (76%). The large majority of cases showed KIT protein expression (96.9%). Among tumor suppressor genes, primary sinonasal mucosal melanomas showed loss of PTEN (48.1%) and p16/INK4a (55.2%). All tested cases showed expression of pAkt and pErk, suggesting a combined activation of PI3K/Akt and RAS-mitogen-activated protein kinase (MAPK) pathways.
Conclusions:
This molecular fingerprint strongly argues against the clinical efficacy of BRAF-inhibitors, but could candidate primary sinonasal mucosal melanomas to therapeutic strategies targeting RAS and KIT mutations or inhibiting PI3K-Akt-mTOR pathway.
Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient-related and tumor-related predictors of prognosis after craniofacial resection (CFR).
Three hundred thirty-four patients from 17 institutions were analyzed for outcome. Patients with esthesioneuroblastoma were excluded and are being reported separately. The median age was 57 years (range, 3–98 years). One hundred eighty-eight patients (56.3%) had had prior single-modality or combined treatment, which included surgery in 120 (36%), radiation in 79 (23.7%), and chemotherapy in 56 (16.8%). The most common histologic findings were adenocarcinoma in 107 (32%) and squamous cell carcinoma in 101 (30.2%). The margins of resection were close or microscopically positive in 95 (30%). Adjuvant radiotherapy was given in 161 (48.2%) and chemotherapy in 16 (4.8%). Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics, including histologic findings and extent of disease, surgical resection margins, prior radiation, and prior chemotherapy to determine predictive factors.
Postoperative mortality occurred in 15 patients (4.5%). Postoperative complications occurred in 110 patients (32.9%). The 5-year overall, disease-specific, and recurrence-free survival rates were 48.3%, 53.3%, and 45.8%, respectively. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis.
CFR for malignant paranasal sinus tumors is a safe surgical treatment with an overall mortality of 4.5% and complication rate of 33%. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent are independent predictors of outcome. © 2005 Wiley Periodicals, Inc. Head Neck27: XXX–XXX, 2005
Background:
In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients.
Methods:
We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap.
Results:
Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved.
Conclusion:
The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.
Melanomas account for 4% of sinonasal malignancies. We present the largest single institution series reported thus far and analyze the outcome with reference to lymph node involvement, radiotherapy and endoscopic resection.
Survival and recurrence data were analyzed on sinonasal melanoma cases collected from 1963-2010 to compare treatment strategies and to ascertain factors predicting outcome.
115 cases (mean age 65.9) were treated at our institution during this period. All underwent surgical resection of the tumour, 31 (27%) endoscopically, and 51 (44%) also received radiotherapy. Five year overall survival was 28% and disease-free survival was 23.7%. Local control was achieved for a median of 21 months, 5-year disease control rate of 27.7%. Endoscopically resected cases showed a significant overall survival advantage up to 5 years. Radiotherapy did not improve local control or survival. Cervical metastases conferred a dramatically worse outcome.
Endoscopic resection of sinonasal melanoma does not prejudice outcome. The role of radiotherapy is unproven.
Health-related quality of life (QOL) outcomes are frequently used by clinicians, patients, and researchers for assessing the effectiveness of an intervention. Small differences in QOL may be statistically significant but their clinical relevance remains undefined. The smallest changes in QOL scores of the anterior skull base surgery questionnaire (ASBS-Q) which could be considered clinically significant have not been delineated. Here we present a meta analysis and review of the literature of 273 patients undergoing skull base tumor resection. The minimal clinically important difference (MCID), defined as "the smallest change in QOL which patients perceive as beneficial", was calculated using several statistical approaches. The MCID of the ASBS-Q was 0.4 (8%, score range 1-5). Various other instruments for QOL estimations revealed a larger range of MCID score (between 6.2%-17.5%) for the different QOL domains. The statistical analyses reveal that histology (benign vs malignant), time elapsed from surgery (< or ≥6 months), and surgical approach (open vs endoscopic) have significant clinical impact on different QOL domains. This paper brings level 1b evidence which demonstrates the importance of MCID as an adjunct for estimation of QOL in patients undergoing skull base surgery.
Management of malignant neoplasms of the sinonasal tract and skull base is hampered by the relative low incidence and pathologic diversity of patient presentations. Many studies have reported successful outcomes in the endoscopic management of malignancy since 1996, and these are summarized in this article. Nonsurgical adjuvant therapies are important for locoregional control because surgery occurs in a restricted anatomic space with close margins to critical structures, and distant disease is an ongoing concern in these disorders. There remains a need for collaborative consistent multicenter reporting, and international registries have been established to assist in such efforts.
Our aim was to evaluate the efficacy of a bimodal method of treatment consisting in endoscopic resection followed by radiotherapy in patients with olfactory neuroblastoma (ON).
This is a retrospective review on 10 patients with ON treated at a tertiary referral center. All the patients were treated with endonasal endoscopic resection, and 1 refused postoperative radiotherapy.
No mortality was observed. Local tumor control was obtained in all the patients. Follow-up ranged from 15 to 79 months (median, 37 months). One patient developed a regional recurrence and for this was treated with bilateral, modified type III radical neck dissection plus radiotherapy on the neck. All patients regained a good quality of life after the treatment.
This method of treatment causes minimal injury to the patients, reduces side effects, and improves the quality of life of those with olfactory neuroblastoma.
Malignant tumors of the sinonasal tract are rare, accounting for only 1% of all malignancies. Although they are associated with substantial histological heterogeneity, surgery plays a key role in their management. This review addresses the evolution of current treatments in view of the introduction of endoscopic resection techniques. The absence of facial incisions and osteotomies, decreased hospitalization time, better control of bleeding, improved visualization of tumor borders, and reduced morbidity and mortality rate are the major advantages of endoscopic techniques in comparison to traditional external approaches. The major criticisms focus on oncologic results in view of the short/intermediate follow-up of large series, which have commonly grouped together several histologies that may be associated with different prognoses. Since prospective studies contrasting the results of endoscopic and craniofacial resections are difficult to carry out given the rarity of the disease together with ethical issues, the creation of a large database would favor the analysis of several variables related to the patient, tumor, and treatment on survival performed on a large number of patients.
The evolution of minimally invasive endoscopic techniques, coupled with advances in surgical instrumentation and computer-aided surgery, has greatly facilitated the management of complex sinonasal and skull-base pathology. This accrued experience has facilitated consideration of the treatment of malignant neoplasms of the paranasal sinuses and skull base via the endoscopic route. This strategy uses the rigid endoscope as the primary surgical modality for resection of neoplasms within the paranasal sinus confines, along with the adjacent orbit and skull base. The endoscopic approach has been demonstrated to be effective, with surgical outcomes approaching the traditional open craniofacial resection, providing unparalleled visualization, avoidance of facial incisions and reduction in morbidity. This article outlines the salient components of the endoscopic paradigm for minimally invasive tumor resection, focusing on requisite technology, surgical techniques and patient outcomes.
Because of a better understanding of the anatomy from an endoscopic perspective, the acquisition of surgical experience, and concomitant technological advances, endoscopic resection of the anterior skull base (ASB) and overlying dura has now become a reality, opening new possibilities in the management of sinonasal malignancies. Here, the authors review a series of 62 patients, the largest reported to date, who underwent endoscopic transnasal craniectomy (ETC) and endoscopic dural repair for the management of selected sinonasal malignancies. Special emphasis is placed on the surgical technique, technical tricks, choice of materials for endoscopic dural repair, postoperative management, and complications.
From 2004, 62 patients underwent ETC at two referral hospitals, which extended anteroposteriorly from the frontal sinus to planum sphenoidale and laterolaterally from the nasal septum to the lamina papyracea (unilateral resection, n = 28; 45%) or from papyracea to papyracea (bilateral resection, n = 34; 55%). Duraplasty with a three-layer technique was performed using the iliotibial tract and fat tissue.
The most frequent histotypes were adenocarcinoma (58%) and olfactory neuroblastoma (22%). Forty-five (73%) patients were previously untreated. The incidence of early (T1-2, Kadish A-B) and advanced (T3-4, Kadish C) tumors was similar. The complication rate was 15%, mostly cerebrospinal fluid leaks (13%). Its prevalence did not correlate with patient age, medical comorbidities, previous treatment, presence of ASB involvement, or whether ETC was mono- or bilateral, but tended to correlate with advanced tumor stage, dural involvement, and the period of treatment. After a mean follow-up of 17.5 months (range, 1-54 months), 58 (94%) patients had no evidence of disease.
In correctly selected patients with sinonasal tumors involving the ASB, ETC offers a less invasive alternative than resection by an open approach with an acceptable morbidity.
To evaluate the oncologic outcomes of patients with sinonasal cancer treated with endoscopic resection.
Retrospective review.
Tertiary care academic cancer center.
All patients with biopsy-proved malignant neoplasm of the sinonasal region who were treated with endoscopic resection between 1992 and 2007 were included in the study, and their charts were reviewed for demographics, histopathologic findings, treatment details, and outcome.
Oncologic outcomes, including disease recurrence and survival.
Of a total of 120 patients, 93 (77.5%) underwent an exclusively endoscopic approach (EEA) and 27 (22.5%) underwent a cranioendoscopic approach (CEA) in which the surgical resection involved the addition of a frontal or subfrontal craniotomy to the transnasal endoscopic approach. Of the 120 patients, 41% presented with previously untreated disease, 46% presented with persistent disease that had been partially resected, and 13% presented with recurrent disease after prior treatment. The most common site of tumor origin was the nasal cavity (52%), followed by the ethmoid sinuses (28%). Approximately 10% of the tumors had an intracranial epicenter, most commonly around the olfactory groove. Tumors extended to or invaded the skull base in 20% and 11% of the patients, respectively. An intracranial epicenter (P < .001) and extension to (P = .001) or invasion of (P < .001) the skull base were significantly more common in patients treated with CEA than in those treated with EEA. The primary T stage was evenly distributed across all patients as follows: T1, 25%; T2, 25%; T3, 22%; and T4, 28%. However, the T-stage distribution was significantly different between the EEA group and the CEA group. Approximately two-thirds (63%) of the patients treated with EEA had a lower (T1-2) disease stage, while 95% of patients treated with CEA had a higher (T3-4) disease stage (P < .001). The most common tumor types were esthesioneuroblastoma (17%), sarcoma (15%), adenocarcinoma (14%), melanoma (14%), and squamous cell carcinoma (13%). Other, less common tumors included adenoid cystic carcinoma (7%), neuroendocrine carcinoma (4%), and sinonasal undifferentiated carcinoma (2%). Microscopically positive margins were reported in 15% of patients. Of the 120 patients, 50% were treated with surgery alone, 37% received postoperative radiation therapy, and 13% were treated with surgery, radiation therapy, and chemotherapy. The overall surgical complication rate was 11% for the whole group. Postoperative cerebrospinal fluid leakage occurred in 4 of 120 patients (3%) and was not significantly different between the CEA group (1 of 27 patients) and the EEA group (3 of 93 patients) (P > .99). The cerebrospinal fluid leak resolved spontaneously in 3 patients, and the fourth patient underwent successful endoscopic repair. With a mean follow-up of 37 months, 18 patients (15%) experienced local recurrence, with a local disease control of 85%. Regional and distant failure occurred as the first sign of disease recurrence in 6% and 5% of patients, respectively. The 5- and 10-year disease-specific survival rates were 87% and 80%, respectively. Disease recurrence and survival did not differ significantly between the EEA group and the CEA group.
To the best of our knowledge, this is the largest US series to date of patients with malignant tumors of the sinonasal tract treated with endoscopic resection. Our results suggest that, in well-selected patients and with appropriate use of adjuvant therapy, endoscopic resection of sinonasal cancer results in acceptable oncologic outcomes.
The combined approach for resection of tumors of the nose and paranasal sinuses is well established. The technique has been considerably modified, resulting in an operation that combines good access, sound oncologic resection with excellent cosmesis, and a low postoperative morbidity rate for conditions that have been associated hitherto with an extremely poor prognosis. A 9 year experience with 92 patients is presented. Long follow-up confirmed the initial results, suggesting an improved survival rate in patients with potentially curable disease. An increasing number of large benign tumors, which would previously have been considered inaccessible, are now being resected. Herein, the role and accuracy of preoperative investigations such as computerized tomography and magnetic resonance imaging are evaluated, and the cosmetic implications associated with long-term survival, particularly in children, is considered. The many advantages of craniofacial resection recommend it as the treatment of choice for tumors of the nose and paranasal sinuses, and the versatility of the technique allows its application to tumors arising in adjacent areas.
Over the last decade, the use of rigid endoscopes in surgery of tumorous lesions of the nose, paranasal sinuses, nasopharynx and anterior skull base has extended and diversified. Endoscopic surgical approaches for malignant lesions are very controversially discussed as of today, yet. From 1989-1999 we have treated 43 patients with invasive/destructive tumors of the paranasal sinuses and the anterior skull base strictly endoscopically, transnasally. These included 5 patients with juvenile angiofibromas and 36 patients with various malignant tumors, one with a large invasive macroadenoma of the pituitary and one case of a craniopharyngeoma. The age range was 3 months to 82 years. Whereas the very first patients were approached endoscopically in a palliative intention, we have started endoscopic surgery for selected malignancies with curative intention in the last years. Histologically, patients with various carcinoma differentiation were operated (n = 18), as well as patients with malignant melanoma (n = 5), esthesioneuroblastoma (n = 8), clivus chordoma (n = 3), immature teratoma (n = 1) and leiomyosarcoma (n = 1). Our first results appear to indicate, that outcome is at least equal to standard external approaches, however with excellent functional terms and significantly better overall quality of life. The limitations result from the anatomical spread of the tumor, when extensive infiltration of orbit, dura/brain and other vital structures exist. However, in experienced hands, endoscopic surgery in this region can be rather radical, bone and even dura of the anterior skull base can be resected as can the periorbit, and all structures reconstructed in the same session. Endoscopic techniques lend themselves very well to cooperation with neighbouring specialities like neurosurgery. In individual cases, gamma-knife therapy has proven an extremely helpful adjunctive. With this combined approach, all 8 patients with esthesioneuroblastoma are alive and free of disease with a mean observation time of 37.2 months. We will therefore continue to use this procedure in selected cases as a reliable alternative to external approaches in the future. However we recommend, that these techniques are only applied at centers, where all other surgical approaches can be performed, should need for this arise.
A combined intracranial facial approach to cancer of the paranasal sinuses has been performed in nineteen patients. One postoperative death occurred due to meningitis. Despite extensive preoperative disease, eleven patients have survived two to seventy-five months free of disease; eight of these having been followed up during thirty-one months.This procedure can be performed with a minimum of complications and allows the surgeon the opportunity to do a true en bloc resection of cancer in an anatomically difficult area. The advantages of the combined procedure are that it allows: (1) evaluation of intracranial disease, (2) protection of the brain, (3) avoidance of spinal fluid fistulas, (4) more adequate hemostasis, (5) facilitation of resection, and (6) en bloc resection.
Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient-related and tumor-related predictors of postoperative morbidity and mortality and set a benchmark for future studies.
One thousand one hundred ninety-three patients from 17 institutions were analyzed for postoperative mortality and complications. Postoperative complications were classified into systemic, wound, central nervous system (CNS), and orbit. Statistical analyses were carried out in relation to patient characteristics, extent of disease, prior radiation treatment, and type of reconstruction to determine factors that predicted mortality or complications.
Postoperative mortality occurred in 56 patients (4.7%). The presence of medical comorbidity was the only independent predictor of mortality. Postoperative complications occurred in 433 patients (36.3%). Wound complications occurred in 237 (19.8%), CNS-related complications in 193 (16.2%), orbital complications in 20 (1.7%), and systemic complications in 57 (4.8%) patients. Medical comorbidity, prior radiation therapy, and the extent of intracranial tumour involvement were independent predictors of postoperative complications.
CFR is a safe surgical treatment for malignant tumors of the skull base, with an overall mortality of 4.7% and complication rate of 36.3%. The impact of medical comorbidity and intracranial tumor extent should be carefully considered when planning therapy for patients whose tumors are amenable to CFR.
This study reviews the outcome of patients with adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the naso-ethmoidal complex treated by endoscopic surgery.
Sixteen patients underwent a purely endoscopic excision of AC (n = 12) or SCC (n = 4) at 2 university hospitals. All patients were prospectively followed by endoscopic and MRI evaluations.
The tumor originated from the ethmoid in 13 cases and the nasal fossa in 3. Lesions were staged as follows: 5 T1, 10 T2, and 1 T3. Adjuvant radiotherapy was delivered in 7 cases. Follow-up (range, 28-70 months; mean, 47.25) was available for all patients. One patient died for brain metastases 28 months after surgery. Another patient required salvage craniofacial resection and radiotherapy for recurrent AC. Five-year disease-specific and disease-free survival rates were 93.3% and 87.0%, respectively.
In selected T1-T2 lesions of the naso-ethmoidal complex, endoscopic surgery seems to offer a satisfactory alternative to external procedures.
FS, frontal sinus; RoE, roof of ethmoid; CG, crista galli; dm, dura mater; FL, frontal lobe; OB, olfactory bulb; 1, intradural layer; 2, intracranial extradural layer; 3, extracranial layer placed overlay
- Ss
SS, sphenoidal sinus; FS, frontal sinus; RoE, roof of ethmoid; CG, crista galli; dm, dura mater; FL, frontal lobe; OB, olfactory bulb; 1, intradural layer; 2, intracranial extradural layer; 3, extracranial layer placed overlay; O, orbit;
Craniofacial resection for malignant paranasal sinus tumors: report of an International Collaborative Study
- I Ganly
- S G Patel
- B Singh
- D H Kraus
- P G Bridger
- G Cantu
- A Cheesman
- De Sa
- G Donald
- P Fliss
- D M Gullane
- P Janecka
- I Kamata
- S E Kowalski
- L P Levine
- P A Medina Dos Santos
- L R Pradhan
- S Schramm
- V Snyderman
- C Wei
- W I Shah
Ganly I, Patel SG, Singh B, Kraus DH, Bridger PG,
Cantu G, Cheesman A, De Sa G, Donald P,
Fliss DM, Gullane P, Janecka I, Kamata SE,
Kowalski LP, Levine PA, Medina Dos Santos LR,
Pradhan S, Schramm V, Snyderman C, Wei WI,
Shah JP: Craniofacial resection for malignant
paranasal sinus tumors: report of an International
Collaborative Study. Head Neck 27:575-584, 2005.
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