Surgical resection of esthesioneuroblastoma metastasis to the chest wall

A 51-year-old female patient was evaluated for a painful chest wall mass causing atelectasis of the right lung, pleural effusion, and dyspnea. The patient's history was significant for esthesioneuroblastoma at the age of 24; multiple recurrences of the tumor had been treated with surgery, radiotherapy, and chemotherapy. Surgical resection of the chest wall mass relieved her symptoms and improved her quality of life. Histologic examination confirmed metastatic esthesioneuroblastoma. The patient developed generalized disease and finally died 2 years after surgery. This case demonstrates the long natural history of this rare neoplasm and the need for close follow-up of patients so that they can be treated early.

Endoscopic Techniques in Resection of Anterior Skull Base/Paranasal Sinus Malignancies

OBJECTIVE

The objective of this study was to examine the role of endoscopic approaches to the resection of anterior skull base and paranasal sinus malignancies at one tertiary care medical center.

STUDY DESIGN

The authors conducted a retrospective chart review over a period of 17 years.

METHODS

Patients undergoing anterior skull base resections for malignancies over a 17-year period were reviewed. Data were collected on each patient with respect to the pathology of the tumor and approach used as well as demographic and follow-up information.

RESULTS

A total of 78 patients were treated at a tertiary care medical center for malignancies of the paranasal sinuses and anterior skull base. The most common diagnosis was squamous cell carcinoma occurring in 33% of the cases. The remaining pathologies included esthesioneuroblastoma (23%), adenoid cystic carcinoma (15%), melanoma (3%), sinonasal undifferentiated carcinoma (3%), lymphoma (5%), nasopharyngeal carcinoma (4%), and other tumor types (14%). Endoscopic techniques were used extensively in this population of patients. Combined approaches using a sublabial/transmaxillary approach and coronal approaches were used when indicated and complemented the endoscopic approach. A majority of patients were without evidence of disease at the end of this review. Using endoscopic techniques allowed for acceptable cosmetic results and facial incisions were used minimally.

CONCLUSION

With complete endoscopic surgical resection followed by radiation therapy, local recurrence, morbidity, and cosmetic deformity have been minimized. The microscopic view provided by endoscopic techniques, with or without complementary approaches, allows for complete tumor removal.

Intracavitary chemotherapy (Gliadel) for recurrent esthesioneuroblastoma: case report and review of the literature

Esthesioneuroblastoma is an uncommon malignancy of the nasal vault with a treatment regimen consisting of surgical resection followed by radiotherapy for primary lesions and addition of chemotherapy for patients with advanced, recurrent or metastatic lesions. We report a case of a 39-year-old female with a history of esthesioneuroblastoma, previously treated with resection, radiation and chemotherapy, presenting with a recurrent disease that was successfully treated with re-resection and placement of Gliadel) wafers in the surgical resection cavity. The novel option of controlled-release and local delivery of a chemotherapeutic agent for treatment of recurrent esthesioneuroblastoma should be recognized and considered.

Esthesioneuroblastoma treated with non-craniofacial resection surgery followed by combined chemotherapy and radiotherapy: An alternative approach in limited resources

BACKGROUND

Esthesioneuroblastoma (ENB) is a rare and aggressive malignant tumor arising from olfactory epithelium. Surgical excision in the form of craniofacial surgical resection (CFR) has shown encouraging results. The purpose of the study is to analyze the outcome of this disease when managed by non-craniofacial resection (NCFR) surgery in limited resources.

METHODS

Between October 1998 and January 2004, eight patients with ENB were treated in the Department of Radiotherapy at KGMU, Lucknow. None of these eight patients underwent CFR surgery. All patients received six cycles of vincristine, adriamycin and cyclophosphamide (VAC) based chemotherapy followed by radiotherapy.

RESULTS

All the patients registered during this period had undergone operative procedures in the form of NCFR surgery except two. Complete response was present in five (62.5%) patients and three (37.5%) patients had partial response. Locoregional relapse-free survival at 3 years was 62.5% and median survival time was 38 months. Disease-free survival and overall survival at 3 years was 72.9 and 71.4%, respectively, and median disease-free survival time was 43 months, while mean overall survival time was 40.7 months as median overall survival time was not reached.

CONCLUSION

Patients in developing countries often present with advanced stages and because of non-availability of technical advances and surgical expertise one tends to approach these patients with palliative intent. Most of the patients in our series were of stage C disease (75%) and still our response rate and survival were encouraging despite the fact that surgery was not optimal. This combination chemoradiotherapy schedule can be used outside the protocol setting where resources are limited.

Retropharyngeal lymph node metastasis from olfactory neuroblastoma: A report of two cases

Olfactory neuroblastoma is a rare, malignant neoplasm arising from the olfactory epithelium. It has an aggressive biological behavior that is characterized by local recurrence, atypical distant metastasis, and poor long-term prognosis. The incidence of cervical lymph node metastasis in olfactory neuroblastoma is variable, and treatment modalities are controversial. Moreover, few reports have been published concerning retropharyngeal lymph node metastasis from olfactory neuroblastoma. We present two cases of olfactory neuroblastoma with retropharyngeal lymph node metastasis. In addition, we provided a review of the current literature regarding olfactory neuroblastoma and retropharyngeal lymph node metastasis from olfactory neuroblastoma.

[Long-term experiences in the therapy of esthesioneuroblastoma]

BACKGROUND

Esthesioneuroblastoma is a rare and clinically variable tumor of nasal sinus and skull base and challenging for modern multidisciplinary therapy. There are no generally known prognostic factors or generally accepted standard therapy regimens.

PATIENTS AND METHODS

Between 1975 and 2001 26 patients were treated after the diagnosis of esthesioneuroblastoma was established. The cases were evaluated retrospectively. According to the classification of Kadish 1 patient (4 %) had stage A, 16 patients (53 %) stage B and 11 cases (43 %) had stage C tumors. Hyams grading could be obtained in 22 cases (81 %). Tumors were in 12 patients (52 %) graded I or II and in 10 cases tumors had grade III or IV (48 %). Operative therapy was performed in 23 patients (88.5 %), being in 5 patients a single mode therapy. In 18 cases combined therapy was performed (surgery and radiotherapy or radiotherapy and chemotherapy).

RESULTS

Actuarial survival was 61.5 % (16/26). Disease specific 10- and 15-year-survival according to the estimation of Kaplan-Meier was 76.2 %. Patients with small tumors (Kadish A/B) had a 15-year-survival of 86.7 % compared to 63.6 % in cases with advanced tumors (Kadish C). In 7 cases (26.9 %) recurrences developed. Salvage therapy was performed in 5 cases (71.4 %) with a success rate and a 15-year survival each of 60 %.

CONCLUSIONS

Therapy of esthesioneuroblastoma is challenging because of rarity and biologic variability of the tumor and and because of lack of a standard therapy. An interdisciplinary multimodal therapeutic approach is necessary especially in case of advanced tumors with promising results. Histopathological grading according to Hyams and tumor stage are important factors for survival and prognosis. Although recurrence can occur with high frequency even after prolonged time interval, long time survival can be improved after aggressive salvage therapy. Therefore longterm follow up is mandatory.

Esthesioneuroblastoma in childhood and adolescence. Better prognosis with multimodal treatment?

BACKGROUND AND PURPOSE

Only 3% of all malignant intranasal tumors are esthesioneuroblastomas (ENB) and only 20% of these rare neuroectodermal tumors are diagnosed up to 20 years of age. Radiotherapy and surgery are established treatment modalities for these patients, but the role of chemotherapy, especially in a multimodal approach, is not well defined. To investigate the influence of radio- and chemotherapy, the treatment and course of the disease in children and adolescents with ENB were analyzed retrospectively.

PATIENTS AND METHODS

19 unselected patients (nine male and ten female) diagnosed with ENB < or = 20 years of age were included in this analysis. Median age at diagnosis was 14.0 years (range, 5-20 years). The tumors were Kadish stage B in 4/19 patients and stage C in 15/19 patients. 17 patients underwent surgery, either without further therapy (n = 4), followed by radiotherapy (n = 1) or as part of multimodal regimens (n = 12). Two patients received radio- and chemotherapy without surgery. Complete resection (R0) was achieved in 15 out of 17 patients with surgery including all five patients with preoperative chemotherapy due to unresectable primary at diagnosis.

RESULTS

The 5-year overall survival (OS) for the whole group was 73% +/- 12% and the 5-year event-free survival (EFS) 55% +/- 13%. None of the four patients with stage B experienced tumor progression so far, whereas seven out of 15 patients with stage C did (5-year EFS 47% +/- 14%; not significant). Patients with Kadish stage C and multimodal treatment strategies combing surgery, chemo- and radiotherapy had a significantly better outcome than patients with stage C and less than three treatment modalities (65% +/- 17% vs. 20% +/- 18%; p = 0.02).

CONCLUSION

These data indicate a benefit of multimodal treatment regimens combining surgery, chemo- and radiotherapy for pediatric patients with ENB Kadish stage C. Chemotherapy appears to improve resectability, EFS, and OS. Radiotherapy is an integral part in the management of children and young adolescents with ENB in Kadish stage B and C.

Esthesioneuroblastoma: continued follow-up of a single institution's experience

OBJECTIVES

To analyze outcomes and to provide follow-up for our increasing patient cohort with esthesioneuroblastoma.

DESIGN

Retrospective cohort analysis.

SETTING

Patients were examined from September 1, 1976, to May 30, 2004, in a tertiary care academic hospital.

PATIENTS

Fifty consecutive patients diagnosed as having esthesioneuroblastoma were treated with a standardized protocol during a 28-year period. Patients with tumors staged Kadish A or B received preoperative radiotherapy followed by craniofacial resection, while patients with Kadish stage C disease were treated with preoperative sequential chemotherapy and radiotherapy followed by a craniofacial resection. The mean follow-up is 93 months (range, 1-330 months).

RESULTS

The disease-free survival was 86.5% and 82.6% at 5 and 15 years, respectively. There were 17 patients (34%) who developed recurrent disease, most of which was locoregional (12 patients [71%]). There was a long interval to relapse (mean, 6 years), with the longest time to regional recurrence being 10 years. Distant relapses occurred sooner, with poorer outcomes. Of these 17 patients, 7 (41%) underwent successful salvage surgery, while 3 remain alive with disease.

CONCLUSIONS

Excellent outcomes for esthesioneuroblastoma are achievable. Long-term follow-up is necessary because of the extended interval for recurrent disease; unlike most sinonasal malignancies, surgical salvage is possible.

[Subcranial resection of malignant tumors infiltrating the anterior skull base]

BACKGROUND

Survival and quality of life after subcranial resection of malignant tumors infiltrating the anterior skull base should be evaluated.

METHODS

Data were acquired retrospectively from patient charts and by telephone interview. Quality of life was assessed with the EORTC QLQ30 and H&N35 modules.

RESULTS

From 1996 to 2004, 19 patients (mean age 52 years, 4 woman, 15 men) were surgically treated via a subcranial approach. Fifteen patients suffered from advanced carcinoma, 3 from advanced esthesioneuroblastoma, and 1 patient had a fibrosarcoma. Fifteen patients received adjuvant radiotherapy. During the mean follow-up period of 44 months (12-109 months), 6 patients died, 1 unrelated to the tumor. The probability to survive 5 years was 50 %, the mean survival time was 72 months. Anosmia was reported by 18 of 19 patients. A tension pneumocephalus was observed in 2 patients, one with lethal outcome, decreased vision in 1 patient, loss of vision in 1, persisting diplopia in 1, deep wound infections in 2, and CSF leak in 2 patients. Quality of life was assessed on the average 36 months following end of therapy and did not differ substantially from other patients with head-neck malignancies.

CONCLUSION

Most, malignant tumors infiltrating the anterior skull base can be treated curatively. The treatment outcome is well comparable to other head and neck tumors of corresponding stage.

[Olfactory neuroblastoma removed under endoscopic guidance]

INTRODUCTION

Olfactory neuroblastoma is a rare tumour associated with high rates of recurrence and mortality. Treatment includes surgery, radiotherapy, chemotherapy, or a combination. The ideal treatment modality has yet to be determined.

MATERIAL AND METHODS

46-years old male underwent bilateral endoscopic ethmoidectomy due to chronic sinusitis. During surgery, a 5 mm in diameter tumour was identified in the left superior nasal meatus. On histopathological examination the diagnosis of esthesioneuroblastoma was established and confirmed by immunohistochemistry. The tumour was classified according to Kadish as stage A, according to Biller as T1. MR scans performed two months later disclosed pathological tissues in the left ethmoid region.

RESULTS

Multiple biopsies taken on subsequent frontosphenoethmoidectomy did not contain tumour cells. The patient declined radiotherapy. He has been asymptomatic over the 12 monthsí follow-up period.

CONCLUSIONS

The exclusively surgical treatment proved effective due to early stage of the tumour and no evidence of infiltration of the frontal skull base. This strategy, however, requires frequent follow-up visits.

[Esthesioneuroblastoma. Description of a case and review of the literature]

The esthesioneuroblastoma is a malignant and rare type of the nasal cavity. Affected patients usually present with a progressive nasal obstruction, rhinorrea and epistaxis. Metastasis occurs in about 30% of patiens, the most common sites for metastasis are the cervical lymph nodes, less frequent in anothers organs. The optimum management is probably surgery combined with radiotherapy, the chemotherapy is usually reserved for local advanced tumor

Endoscopic-assisted cranionasal resection of olfactory neuroblastoma

BACKGROUND

Cranionasal resection was first described in 1997 for the surgical resection of olfactory neuroblastoma. The endoscopic transnasal approach is used in cranionasal resection to replace the more invasive craniofacial resection. It has the advantages of avoiding the facial wound and its associated pain, swelling, and scar. The authors have routinely practiced cranionasal resection since 1996 for resection of all anterior skull base tumors in which the resultant skull base bony defect is limited to the nasal and sinus roof. The aim of this study was to review the results of cranionasal resection for olfactory neuroblastoma.

METHODS

The results of cranionasal resection for olfactory neuroblastoma in six patients from 1996 to 2003 were reviewed.

RESULTS

The Kadesh stages were 3A, 2B, and 1C. None of the patients had postoperative complications. Postoperative radiotherapy was given only to the patient with Kadesh stage C disease. There were no local recurrences. Two patients died of lung metastasis.

CONCLUSIONS

Cranionasal resection is a safe and adequate procedure. Postoperative radiotherapy is not necessary after clear resection of Kadesh A and B tumors.

[Prognostic factors and outcome of esthesioneuroblastoma]

OBJECTIVE

To investigate the clinical feature, prognostic factors and the appropriate treatment modality of esthesioneuroblastoma (ENB).

METHODS

The data of 49 patients with ENB treated from Dec. 1978 to Dec. 2001 were retrospectively reviewed and analyzed. In this series, 3 patients had modified Kadish stage A disease, 15 stage B, 22 stage C, and 9 stage D lesion. The treatment modalities included surgery alone in 4 patients, and radiotherapy alone in 11, surgery plus radiotherapy in 19, radiotherapy plus chemotherapy in 8, surgery plus radiotherapy plus chemotherapy in 7. Statistic analysis was performed using software SPSS 10.0. Overall survival (OS) and disease free survival (DFS) were calculated using Kaplan-Meier method. Differences between survival curves were tested by Log rank method.

RESULTS

The 5-year OS and DFS of the whole group was 60.5% and 41.9%, respectively. The 5-year OS of patients with modified Kadish stage A or B disease and those with stage C or D was 78.4% and 49.7% (chi(2) = 2.10, P = 0.15), and the 5-year DFS was 47.1% and 38.4% (chi(2) = 0.08, P = 0.78), respectively. The 5-year OS of patients with or without neck lymph nodal metastasis was 17.8% and 70.8% (chi(2) = 2.32, P = 0.13), and the 5-year DFS was 0 and 53.4% (chi(2) = 11.67, P < 0.01), respectively. For patients with kfs > or = 80 and those with kfs < 80, the 5-year OS was 69.0% and 30.1% (chi(2) = 7.01, P < 0.01), and 5-year DFS was 46.7% and 24.9% (chi(2) = 6.37, P = 0.01), respectively. As regard to the treatment modality, The 5-year OS was 69.7% for the patients treated with combined modalities and 46.3% for those with surgery alone or radiotherapy alone (chi(2) = 3.49, P = 0.06), and the 5-year DFS were 52.2% and 21.8% (chi(2) = 7.03, P < 0.01), respectively. The 5-year OS was 71.1% for patients who received surgical treatment and 44.6% for those without it (chi(2) = 7.99, P < 0.01), and 5-year DFS was 54.0% and 24.1% (chi(2) = 6.41, P = 0.01), respectively. The 5-year OS and DFS of 11 patients who received radiotherapy alone were 47.7% and 30.7%, respectively. For 19 patients treated by radiotherapy with radical purpose (including patients who received combined modality with radiotherapy plus chemotherapy), the 5-year OS were 33.9% for < 70 Gy patients and 48.0% for > or = 70 Gy (chi(2) = 0.89, P = 0.35), and the 5-year DFS was 13.3% and 33.3% (chi (2) = 4.48, P = 0.03), respectively. For those who received chemotherapy or not, the 5-year OS was 50.0% and 64.9% (chi(2) = 0.91, P = 0.34), and the 5-year DFS was 38.9% and 43.1% (chi(2) = 0.01, P = 0.91), respectively.

CONCLUSION

Esthesioneuroblastoma is more prevalent in the young male adults than female, usually with locally advanced stage lesion when first diagnosed. Performance status and neck lymph node metastasis are significantly correlated with the prognosis. Combined treatment modality consisting of surgery may help to gain more favorable result. Radiotherapy plays an important role in the management of the disease.

[Olfactory neuroblastoma in 55 year old woman]

In this article the authors describe a rare case of olfactory neuroblastoma in a 55-year-old woman surgically treated because of nasal polyposis. Three years earlier she had been operated for nasal polyposis on the same side in another ENT department. Unfortunately these lesions may had not been evaluated histologically. One of the surgically removed polyps was atypical. In histopathological examination it was confirmed to be olfactory neuroblastoma. CT scan revealed abnormal thickness of the mucosa in the upper part of the nose and ethmoidal sinuses on the right side. The tumor was classified as stage B in Kadish classification of olfactory neuroblastoma. The histopathologic diagnosis and CT scan made after the surgery resulted in necessity of further oncological treatment. The olfactory neuroblastoma is rare, difficult to diagnose, malignant, slowly growing tumor arising from the olfactory epithelium in the upper nasal cavity. The treatment includes surgery, radiotherapy and chemotherapy. Another objective of this paper is to point out that histopathological examination is crucial in each surgically removed tissue.

Pericranial Wrapping of the Frontal Bone after Anterior Skull Base Tumor Resection

BACKGROUND

Classic craniofacial resection and the subcranial approach are well-established techniques for the removal of tumors involving the anterior skull base. These techniques require frontal craniotomy to allow broad exposure of the anterior cranial fossa, a procedure that may be further complicated by local infection and osteomyelitis or because of a reduction in tissue perfusion and direct communication between the osteotomy and the contaminated nasoethmoidal cavity. The authors present a new method for wrapping of the frontal bone segment with a pericranial flap with the intention of preventing these serious complications.

METHODS

By means of this new approach, the frontonaso-orbital bone segment is removed, the frontal sinus bone is cranialized, and the frontonaso-orbital segment is repositioned in its original anatomical place following tumor extirpation. Wrapping is accomplished by a double-sided covering of the bone segment with the pericranial flap. This vascularized tissue is guided underneath the bony segment to cover the intranasal surface and then is externalized over the entire frontal area. The frontonaso-orbital segment and its overlying pericranial flap are fixed with the prebent titanium plates.

RESULTS

To date, the authors have performed 20 subcranial operations for resection of malignant tumors of the anterior skull base using this technique. None of these patients developed bone flap necrosis or osteomyelitis following radiotherapy. In the authors' hands, the rate of osteoradionecrosis was significantly lower in patients undergoing malignant subcranial tumor resection with pericranial wrapping than in those operated on before the study was activated (0 percent versus 20 percent, respectively; p = 0.056).

CONCLUSIONS

Pericranial wrapping is suitable for patients undergoing extirpation of anterior skull base tumors and for whom perioperative radiotherapy is recommended and for patients who have undergone multiple surgical procedures.

Combined endoscopic surgery and radiosurgery as treatment modality for olfactory neuroblastoma (esthesioneuroblastoma)

OBJECT

Treatment of esthesioneuroblastoma (olfactory neuroblastoma) has been considerably improved by microsurgical techniques. Nevertheless, these rare tumours of the frontal skull base are still associated with high rates of tumour recurrence and mortality, thus remaining a challenge even for experienced surgeons. A novel therapeutic approach that combines endoscopic sinus surgery and Gamma Knife radiosurgery is presented here. Taking into account the rarity of the disease the present study comprises a relatively large series of patients treated in a similar manner.

METHODS

14 patients (8 males, 6 females) aged 27-75 years (median 38) were treated between May 1993 and December 2003. This series comprises 12 newly diagnosed esthesioneuroblastomas. Two more patients had already previously undergone surgery (24/39 months earlier). Paranasal and nasal endoscopic sinus surgery was performed. Marginal irradiation doses ranging from 15-34 Gy were given to the residual tumours by means of radiosurgery (Gamma Knife) involving 1-7 isocentres within 3 months after surgery. Median follow-up is 58 months (range 13-128).

RESULTS

There was no mortality. In all patients tumour control was achieved within the treated area. 4 patients underwent a second radiosurgical procedure 6-79 months (median 34 months) after initial radiosurgery. One patients had to undergo an additional craniotomy because of extensive neoplastic infiltration, 1 developed postoperative liquorrhea, 1 case was complicated by bilateral frontal sinusitis. All patients complained of nasal discharge and crusts. Karnovsky Index--preoperatively ranging from 80%-100%--remained stable in 12 patients, an improvement was observed in 2 cases.

CONCLUSIONS

Based on the favourable results recorded so far, the combination of endoscopic sinus surgery and radiosurgery can be considered a promising treatment option for esthesioneuroblastoma that merits further consideration.

Endoscopic management of sinonasal tumors: a preliminary report

BACKGROUND

The increased experience with the endoscopic approach to sinonasal inflammatory disease has resulted in the increased use of endoscopes to manage many different sinonasal pathologies.

METHODS

A chart review of patients with sinonasal tumors treated with primary endoscopic management, from January, 1993 to November, 2003 was performed.

RESULTS

Forty patients were identified (26 men and 14 women). The mean age was 53.2 years, and the mean follow-up was 31.1 months. For benign tumors, 24 patients were identified with a mean age of 50.7 years, a mean follow-up of 17.5 months, and a recurrence rate of 4.2%. For malignant tumors, 16 patients were identified, with a mean age of 57.3 years, a mean follow-up of 51.5 months, and a recurrence rate of 31.3%. The overall survival rate was 87.5%.

CONCLUSION

Endoscopic surgical excision of selective sinonasal tumors may be an effective therapeutic modality. In some cases, adjuvant external procedures may be required based on tumor location.

Primary sellar esthesioneuroblastoma

We describe an extremely rare case of a primary intrasellar esthesioneuroblastoma.

[Olfactory neuroblastoma in an old patient. Report of a case]

Olfactory neuroblastoma or esthesioneuroblastoma is a rare embrionary tumor, much more in old patients, which uses to present as a pollipoid mass with nasal obstruction, epistaxis and anosmia of long evolution. We report the case of a 82-year-old male with such symptoms diagnosed by biopsy as neuroblastoma class III according the histologic Hyams grading. Due to the age of the patient and grade of the tumor we did not perform surgery and, although a chemotherapy-radiotherapy treatment was suggested, the patient was not agree with it and he has not been attended or followed in our consulting rooms.

Primary sphenoid sinus esthesioneuroblastoma

Esthesioneuroblastoma is a rare malignant tumor of undifferentiated neuroectodermal origin. Because these tumors are derived from olfactory epithelium, most cases arise in the superior nasal cavity at the level of the cribriform niche. The development of an esthesioneuroblastoma outside of the region in which olfactory epithelium exists is exceedingly rare. We report a rare case of a primary sphenoid sinus esthesioneuroblastoma and discuss the pathogenesis, clinical presentation, and treatment of this rare entity.

[Endoscopic or endoscope-assisted surgery for sinonasal malignancy]

OBJECTIVE

To discuss the feasibility and therapeutic efficacy of resection of sinonasal malignant tumours through endoscopic or endoscope-assisted surgery.

METHODS

Since 1997, 11 cases of malignant tumours were resected under endoscope or by endoscope-assisted surgery. Among them, 5 patients were followed-up for more than 3 years, including one case of nasal septum squamous cell carcinoma; one case of ethmoid sinus squamous cell carcinoma; one case of maxillary sinus adenoid cystic carcinoma and two cases of olfactory neuroblastoma.

RESULTS

In the patients who were followed-up for more than three years, no local recurrence was found. There was only one case of cervical lymph node metastasis found on a patient with olfactory neuroblastoma 2. 5 years after resection. Four years after operation, this patient was suspected to have extensive metastasis in meninges, and only palliative treatment was suggested.

CONCLUSIONS

By endoscope or by endoscope-assisted surgery, some of selected sinonasal malignant tumours can be thoroughly resected. The advantages are mini-invasive and avoidance of facial scar so as to improve the quality of life (QOL) of patients. Large amount of cases, random clinical study with lone- term follow-up are still needed to verify the feasibility and efficacy of endoscopic or endoscope-assisted surgery.

Endoscopic-assisted craniofacial resection of esthesioneuroblastoma: minimizing facial incisions--technical note and report of 3 cases

The surgical management of esthesioneuroblastoma with anterior skull base involvement has traditionally been craniofacial resection, which combines a bifrontal craniotomy with a transfacial approach. The latter usually involves a disfiguring facial incision, mid-facial degloving, lateral rhinotomy, and/or extensive facial osteotomies, which may be cosmetically displeasing to the patient. The advent of angled endoscopes has provided excellent magnification and illumination for surgeons to remove tumors using minimally invasive techniques. The authors describe their experience with three cases of esthesioneuroblastoma, which were surgically removed using a transnasal endoscopic approach, avoiding transfacial incisions. Preoperative radiographs were reviewed and tumors were staged according to the Kadish staging system. One patient had a recurrent esthesioneuroblastoma (Kadish stage B), which was removed entirely through a transnasal endoscopic approach. Two patients had intracranial extension (Kadish stage C), which were resected with a combined approach, endoscopically from below and a bifrontal craniotomy from above, to remove intracranial disease. All patients underwent reconstruction of the anterior skull base. Esthesioneuroblastomas confined to the nasal and paranasal cavities (Kadish stage A and B) were readily accessible through the transnasal endoscopic approach. If there was significant intracranial disease (Kadish stage C), adding a bifrontal craniotomy provided excellent exposure for complete resection of involved tumor. All patients underwent complete tumor resection with negative margins. None developed a cerebrospinal fluid (CSF) leak. The endoscopic-assisted craniofacial approach for the surgical management of esthesioneuroblastomas provides excellent exposure, adequate visualization, and the cosmetic benefit of avoiding an external facial incision.

Recurrent intracranial esthesioneuroblastoma outside the initial field of radiation with progressive dural and intra-orbital invasion

A 55-year-old man presented with esthesioneuroblastoma in the right paranasal sinuses and orbita, extending into the right anterior and middle cranial fossa. He received a partial resection of tumour and post-operative radiotherapy, which was set with a central focus on the right orbit. Five years later, he came to our hospital with a complaint of left exophthalmos. Neuro-imaging revealed that the tumour recurred on the opposite side of the primary lesion, which was out side the irradiated field, with progressive invasion of the left temporal dura. The residual tumour in the irradiated field had reduced in size. He received gross total resection and post-operative radiotherapy. We would like to emphasize that radiotherapy is an important adjuvant therapy for esthesioneuroblastoma, and that the field setting for radiation therapy is extremely important.

Esthesioneuroblastoma: endoscopic nasal and anterior craniotomy resection

OBJECTIVES/HYPOTHESIS

The objective was to illustrate the use of endoscopic techniques as an evolving surgical modality in excision of esthesioneuroblastoma. The authors advocate this method with excision with anterior craniotomy for removal of cribriform plate or anterior cranial fossa tumor extension.

STUDY DESIGN

A retrospective chart review of patients with esthesioneuroblastoma treated surgically at a tertiary care institution from 1991 to 2002 using this surgical paradigm.

METHODS

Patients were excluded for nonsurgical treatment or nasal and sinus tumor excision by nonendoscopic techniques. Patient demographics, tumor histological findings, presenting signs and symptoms, staging (Kadish and Dulguerov), postoperative complications, adjunct therapy, and recurrence were examined.

RESULTS

Seven of 13 patients with esthesioneuroblastoma met all inclusion criteria. The average patient age was 47 years, with a male-to-female distribution of 4 to 3. Patients were grouped by tumor stage using Kadish (stages A, B, and C included three, one, and three patients, respectively) and Dulguerov (stages T1, T2, and T4 included three, two, and two patients, respectively) methods. Average follow-up was 62.3 months. All patients had an endoscopic excision of the nasal and sinus component with anterior craniotomy. The most common postoperative complication was temporary mental status change, which was seen in two patients. There were no postoperative deaths. All patients received radiation therapy, and one also received chemotherapy. Two of the seven patients had recurrences. At last follow-up, six patients had no evidence of disease and one was alive with disease.

CONCLUSION

Endoscopic excision of the nasal and sinus component with anterior craniotomy for cribriform or anterior cranial fossa extension is an effective treatment of esthesioneuroblastoma.