Transcranial approach for cancer of the antroethmoidal area

Exclusively endoscopic surgical resection of esthesioneuroblastoma: A systematic review

Background

Historically sinonasal malignancies were always addressed via open craniofacial surgery for an oncologic resection. Increasingly esthesioneuroblastomas are excised using an exclusively endoscopic approach, however, the rarity of this disease limits the availability of long‐term and large scale outcomes data.

Objective

The primary objective is to evaluate the treatment modalities used and the overall survival of patients with esthesioneuroblastoma managed with exclusively endoscopic surgery.

Methods

In accordance with PRISMA guidelines, PubMed was queried to identify studies describing outcomes associated with endoscopic management of esthesioneuroblastomas.

Results

Forty‐four out of 2462 articles met inclusion criteria, totaling 399 patients with esthesioneuroblastoma treated with an exclusively endoscopic approach. Seventy‐two patients (18.0%) received adjuvant chemotherapy and 331 patients (83.0%) received postoperative radiation therapy. The average age was 50.6 years old (range 6–83). Of the 399 patients, 57 (16.6%) were Kadish stage A, 121 (35.2%) were Kadish stage B, 145 (42.2%) were Kadish stage C, and 21 (6.1%) were Kadish stage D. Pooled analysis demonstrated that 66.0% of patients had Hyams histologic Grade Ⅰ or Ⅱ, while 34.0% of patients had Grade Ⅲ or Ⅳ disease. Negative surgical margins were achieved in 86.9% of patients, and recurrence was identified in 10.3% of patients. Of those with 5‐year follow‐up, reported overall survival was 91.1%.

Conclusion

Exclusively endoscopic surgery for esthesioneuroblastoma is performed for a wide range of disease stages and grades, and the majority of these patients are also treated with adjuvant chemotherapy or radiation therapy. Reported overall recurrence rate is 10.3% and 5‐year survival is 91.1%.

Craniofacial resection of malignant tumors of the anterior skull base: a case series and a systematic review

BACKGROUND

Craniofacial resection (CFR) is still considered as the gold standard for managing sinonasal malignancies of the anterior skull base (ASB), while endoscopic approaches are gaining credibility. The goal of this study was to evaluate outcomes of patients who underwent CFR at our institution and to compare our results to international literature.

METHOD

Retrospective analysis of all patients undergoing CFR between 1995 and 2017, and systematic literature review according to the PRISMA statement.

RESULTS

Forty-one patients with sinonasal malignancy (81% with stage T4) of the ASB were included. There was no operative mortality. Complications were observed in 9 cases. We obtained 100% follow-up with mean observation of 100 months. Disease-specific survival rates were 90%, 74%, and 62% and recurrence-free survival was 85% at two, 72% at five, and 10 years follow-up, respectively. CFR as primary treatment, en bloc resection, and resection with negative margins correlated to better survival. Recursive partition analysis identified the latter as the most important prognostic factor, regardless of surgical technique. The relative risk of non-radicality was significantly higher after piecemeal resection compared to en bloc resection. Compared to 15 original articles, totaling 2603 patients, eligible for review, the present study has the longest follow-up time, the second highest 5-year OS, and the third highest 5-year DSS, despite having a higher proportion of patients with high-stage disease.

CONCLUSION

CFR in true en bloc fashion can still be considered as the treatment of choice in cases of advanced-stage sinonasal malignancies invading the ASB.

Transcranial–facial Approach for Tumours of Superior Paranasal Sinuses and Orbit

A monobloc resection of the fronto-ethmoid sphenoid area may be performed through a combined cranial and facial approach. Osmotic cerebral dehydration increases the exposure of the anterior cranial fossa. The results of treatment in 26 patients (24 with malignant disease of the ethmoid area who had disease recurrence after previous radiotherapy with or without surgery) and the complications encountered are described. The clinical details of 9 of these patients have been included in an earlier report (Clifford 1977).

Craniofacial resection and its role in the management of sinonasal malignancies

Sinonasal malignancy is rare, and its presentation is commonly late. There is a wide variety of pathologies with varying natural histories and survival rates. Anatomy of the skull base is extremely complex and tumors are closely related to orbits, frontal lobes and cavernous sinus. Anatomical detail and the late presentation render surgical management a challenging task. A thorough understanding of anatomy and pathology combined with modern neuroimaging and reliable reconstruction within a multidisciplinary team is imperative to carry out skull base surgery effectively. While endoscopic approaches are gaining credibility, clearly, it will be some time before meaningful comparisons with craniofacial resection can be made. Until then, craniofacial resection will remain the gold standard for managing the sinonasal malignancies of the anterior skull base, as it has proved to be safe and effective.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience

BACKGROUND

Craniofacial resection is the established "gold standard" for surgical treatment of tumors affecting the anterior skull base.

METHODS

This study analyzed 308 patients (220 males, 88 females) who had undergone craniofacial resection for sinonasal neoplasia with up to 25-year follow-up.

RESULTS

An overall actuarial survival of 65% at 5 years and 47% at 10 years was found for the cohort as a whole. For patients with malignant tumors, the 5-year actuarial survival was 59%, falling to 40% at 10 years. For patients with benign pathology, the actuarial survival was 92% at 5 years falling to 82% at 10 years. Statistical analysis again identified brain involvement, type of malignancy, and orbital involvement as the 3 most significant prognostic factors.

CONCLUSION

Analysis of one of the largest single institution cohorts over a 25-year period provides a baseline against which other approaches such as an entirely endoscopic skull base resection must be judged.

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.

Esthesioneuroblastoma: clinical presentation, radiological, and pathological features, treatment, review of the literature, and the University of Virginia experience

Esthesioneuroblastoma is a rare and malignant upper nasal cavity neoplasm involving the anterior skull base. Treatment includes surgery, radiotherapy, chemotherapy, or a combination. The ideal treatment modality has yet to be determined. Esthesioneuroblastoma often lies in proximity to the optic nerves, optic chiasm, and the orbit. Resection risks damaging these critical structures, and radiotherapeutic techniques, similar to those applied for paranasal sinus tumors, may damage these vital structures and result in late sequelae such as blindness and cortical necrosis. Management strategies for this neoplasm lack uniformity, and there is no universally accepted staging system. In this paper the authors discuss the clinical presentation, radiological and pathological features, and treatment of this rare, malignant skull base neoplasm, as well as review the literature. They also present their results and treatment regimen, which includes preoperative radio- and chemotherapy or 1) craniofacial resection if the lesion has a significant intracerebral component, or 2) frontal sinus resection if little intracranial extension exists.

Craniofacial resection for paranasal sinus cancers

BACKGROUND

Combined anterior craniofacial resection (CFR) has been in use for more than 25 years. The advent of the free revascularized tissue transfer flap in l980 permitted safe resection of tumors that had spread beyond the confines of the paranasal sinuses with immediate reconstruction of the sino-orbital cranial defect. The purpose of this study was to examine the outcomes and morbidity of a management policy of primary CFR and postoperative radiotherapy for paranasal sinus cancers infiltrating the skull base over a 21-year period.

METHODS

Seventy-three patients with paranasal sinus cancers were treated at the Prince of Wales Hospital between l975 and l996. All were newly diagnosed with the exception of one patient who had received radiotherapy elsewhere 5 years earlier. Only 22% were early lesions and 31% were advanced (more than six sites involved). There were 59 men and 14 women. The mean age was 57 years. All but two patients had a performance status of either 0 or 1. Orbital exenteration was performed in 31 patients. Since l980, all major defects were reconstructed with free tissue transfer flaps.

RESULTS

The 5-year cancer-specific survival (CSS) for the 73 patients was 69%, which was unchanged at 10 years. Twenty two patients died from or with their index cancer. An additional 11 patients died from unrelated causes. The actuarial overall survival (OS) at 5 and 10 years was 61% and 48%, respectively. The 5-year recurrence-free rate was 59%. The CSS for the three dominant pathologic conditions were adenocarcinoma 70%, squamous cancer 51%, and olfactory neuroblastoma 84%. The difference was not significant; however, there was a significant difference in OS, with olfactory neuroblastoma having the best prognosis. Orbital involvement, radiologic evidence of skull base erosion, and involvement of the infratemporal fossa were not poor prognostic indicators. Patients with a performance status of 0 had improved OS. There was no operative mortality.

CONCLUSIONS

An aggressive policy of combined CFR and postoperative radiotherapy with free-flap reconstruction for large defects gave survival results that were comparable to less-advanced lesions and superior to many other treatment alternatives. There was a high exenteration rate (42%). Squamous cancers were associated with the greatest morbidity and poorest OS.

Esthesioneuroblastoma: reflections of a 21-year experience

OBJECTIVES

To evaluate the results of standardized treatment of esthesioneuroblastoma at a single institution during a 21-year period and calculate pertinent parameters, i.e., metastatic disease (local, regional, distant), disease-free survival, and complications of treatment.

STUDY DESIGN

A retrospective review was conducted of all patients treated at a single institution from September 1976 through May 1998.

METHODS

Only those patients who received their complete evaluation and treatment at our institution were included in this analysis. Thirty-five patients met this criterion. In addition, results of epidemiological, pathological, and molecular analyses were evaluated to seek accurate indicators for clinical outcomes.

RESULTS

Six percent of patients presented with cervical metastatic disease, but ultimately 25.7% developed at least one episode of cervical metastases; 14.3% of patients developed a local recurrence an average of 6 years after diagnosis; and 37% of the patients ultimately developed at least one episode of metastatic disease. The disease-free survival for this cohort of 35 patients was 80.4% at 8 years. CNS complications occurred in 25.7% of the patients, 22.9% had orbital complications, 20% had systemic posttreatment problems, 18.2% had chemotoxic sequelae, 8.6% had infectious complications, and 14.3% had cosmetic sequelae. No epidemiological, pathological, or molecular factors appeared to be more accurate clinical indicators than the Kadish staging system.

CONCLUSIONS

This series of esthesioneuroblastoma patients (N=35) reflects an 8-year disease-free survival of 80.4%, representing a significant number of patients treated and followed at one institution for an extended period of time. No valuable pathological or molecular indicators to predict aggressive clinical behavior were found. The average time interval before recurrent disease developed was more than 6 years, far greater than that expected for other sinonasal malignancies. Therefore, extended follow-up is necessary for this patient group.

Anterior craniofacial resection for malignant ethmoid tumors--a series of 91 patients

BACKGROUND

Anterior craniofacial resection is now recognized as the best treatment for ethmoid tumors involving the cribriform plate with or without invasion of anterior cranial fossa.

METHODS

Ninety-one patients underwent an anterior craniofacial resection for ethmoid malignant tumors at the Milan Cancer Institute between 1987 and 1994. The patient population was divided into two sections (30 and 61 patients) based upon some important variants (type of craniotomy, antibiotic treatment, postoperative care).

RESULTS

The mean age was 53.4 years (range, 24 to 78 years). There were 62 men and 29 women. Forty-nine patients had a recurrence after previous treatments (surgery and/or radiotherapy). The subdivision by histology was as follows: 50 cases of adenocarcinoma, 16 cases of epidermoid and undifferentiated carcinoma, 8 cases of esthesioneuroblastoma, 5 cases of adenoid cystic carcinoma, 5 cases of melanoma, and 6 rare tumors. The stages (according to our new staging) were as follows: 37 cases with T2, 27 cases with T3, and 27 cases with T4. The mean follow-up was 47 months. Seven patients died after surgery (6 in the first series). The survival at 3 and 5 years was, respectively, 52% and 47%, and the disease-free survival (DFS) was 30% and 24%, with a statistically significant difference at multivariate analysis in favor of patients without prior treatment (p = .033) or T2 versus T3 and T4 (p<.007).

CONCLUSIONS

An anterior craniofacial resection should be performed in cases of ethmoid tumors reaching or eroding the cribriform plate. A scrupulous intra- and postoperative approach is necessary to avoid severe complications. The patients often survive for a long time with recurrence ongoing. Our new staging identifies the critical extensions of ethmoid tumors.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses--a 17-year experience

BACKGROUND

The rarity of sinonasal tumors has precluded long-term follow-up of large series of craniofacial resections until now.

METHODS

A series of 209 patients suffering from a wide range of histologies who had undergone craniofacial resection for sinonasal neoplasia with up to 17 years' follow-up were analyzed.

RESULTS

An overall actuarial survival of 51% at 5 years and 41% at 10 years was found for the cohort as a whole. For malignant tumors, the 5-year actuarial survival was 44%, falling to 32% at 10 years. For benign pathology, the actuarial survival was 75% at both 5 and 10 years. Statistical analysis identified three factors which significantly affect outcome and survival: malignant histology, brain involvement, and orbital involvement. Few complications are associated with the surgery, with the mean post-operative stay being 16 days.

CONCLUSIONS

The improved survival and minimal morbidity and mortality associated with craniofacial resection make it the optimum approach to sinonasal tumors.

Anterior skull base tumour. The choice between cranial and facial approaches, single and combined procedure. From a series of 78 cases

In order to define the most adequate surgical procedure to apply on anterior skull base lesions, we reviewed 78 cases of either benign (43 cases) or malignant (35 cases) tumours; they were treated either by a single surgical approach including transfacial approach (TF) in 9 cases, transbasal approach (TB) in 15 cases and fronto-orbital ridge deposition (FORD) in 16 cases or by a combined procedure: TB + TF (28 cases), TB + FORD (10 cases). In 7 cases, a pterional approach was associated to one of these combined procedures. A classification is proposed, based on the tumour extension along the anteroposterior axis: I) anterior to the crista galli; II) anterior to the anterior clinoïd process; III) posterior to the anterior clinoïd process; and along the vertical axis A: below the bone level; B: below the dura level; C: at and above the dura level. This classification appears very useful to choose among the surgical procedures which one is the more appropriate. In type A tumour (N = 8), TF is sufficient while in type B (N = 38) and C (N = 32) a cranial route is always necessary; among the latter, a combined procedure is frequently asked for posterior tumours type II (N = 29) and III (N = 24). However, others parameters such as tumour consistency, vascularization and need for en-bloc removal are also relevant in this choice.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses

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.

Craniofacial resection of extensive benign lesions of the anterior skull base

The craniofacial resection operation was developed for the treatment of advanced nasal, paranasal and orbital malignancies. It has been refined in recent years, giving increased cure rates and better palliation when cure is not possible. When used to treat extensive benign lesions involving the anterior skull base, this procedure allows more complete and safer resection with better access for repair and avoidance of major complications of brain damage, cerebrospinal fluid leak and haemorrhage. Presented here is a technique for craniofacial resection. The study demonstrates its effectiveness and low morbidity in treating 10 patients with extensive benign disease.

Rhabdomyosarcoma of pterygoid fossa. Resection for cure utilizing an innervated facial flap and craniofacial reconstruction

Tumors of the pterygoid fossa are often regarded as unresectable because of their anatomic inaccessibility. The rapidly developing techniques of craniofacial surgery have advanced sufficiently to now allow safe ablative surgery in this area and yet preserve the functional status and cosmetic appearance of the patient. A technique utilizing a bicoronal incision that is extended to the angle of the mandible on the involved side is described. This allows wide exposure of the bony structures at the lateral base of the skull while maintaining the integrity of the facial nerve within the cutaneous flap. Temporary removal of the zygomatic arch achieves direct access to and visualization of the contents of the temporal and pterygoid fossae. Skull, mandibular, and maxillary bone adjacent to tumor can easily and safely be resected to obtain complete tumor-free margins. Craniectomy bone is harvested and split into inner and outer tables to reconstruct the bony defects. This approach was successfully utilized in a 5-year-old boy with a Group III rhabdomyosarcoma with residual tumor following combined chemo- and radiotherapy. He remains tumor-free at 15 months, postoperation. The technique can be adapted for a variety of mass lesions located at the anterior base of the skull, both intra- and extracranially. Morbidity and mortality should be minimal with an experienced craniofacial team.

Craniofacial resection for tumors of the nasal cavity and paranasal sinuses

The craniofacial approach for resection of tumors of the nose and paranasal sinuses is well established, as are its advantages over previous methods of treatment. The technique has been considerably modified, resulting in an operation that combines excellent access, a sound oncologic resection with excellent cosmesis, and low postoperative morbidity for conditions associated hitherto with an extremely poor prognosis. The 7-yr experience of 60 patients is presented. Results suggest improved survival in a group of patients who are potentially curable by this procedure, while in those with extensive disease good palliation is achieved. In addition, large benign tumors that would previously have been considered inaccessible can be resected. Its many advantages recommend it as the treatment of choice for tumors of the nose and paranasal sinuses.

Treatment of tumors involving the anterior cranial fossa

The potential for a tumor of the upper face, either malignant or nonmalignant, to involve the anterior cranial base is often not appreciated. This leads to inadequate preoperative investigation and to surgery performed by the head and neck surgeon without the help of the neurosurgeon. In this way, complete tumor resection may be compromised or delayed. Neither of these situations is desirable. If the potential for anterior cranial fossa invasion is recognized, there should be prior consultation with the neurosurgeon and a combined operative procedure. Exposure of these lesions has considerably improved with experience in congenital craniofacial deformities: this will allow en bloc resection of most pathologies. Immediate reconstruction after resection of nonmalignant tumors is advocated, but in aggressive--particularly in recurrent--malignancies, delayed reconstruction is advised. Careful combined follow-up with frequent blind biopsies should be carried out as indicated.

Treatment of recurrent carcinoma at the base of the skull with carbon dioxide laser

The extension of carcinoma to the cribriform plate is a poor prognostic finding. Two extremes of treatment approach have been advocated. On the one hand, patients may be abandoned to palliative chemotherapy. On the other hand, heroic and aggressive resections may be advocated including combined neurosurgical transdural and otolaryngologic facial-orbital resection. Armed with the surgical microscope and the CO2 laser there may be a place for a middle ground of therapy. We present our experience with recurrent tumor after full course radiation therapy and maxilloethmoidectomy. The biopsy proven recurrences were found at the cribriform plate but could not be shown to have crossed into the anterior cranial fossa by polytomography or high resolution CT scanning. The CO2 surgical laser delivered through the surgical microscope was used with repeated applications. Recurrent epidermoid carcinoma found to be confined to the nasal side of the cribriform plate can be controlled by careful microscopic stripping of soft tissue from the cribriform plate with a surgical laser.

Malignant fibrous histiocytoma of the ethmoid sinus

Malignant fibrous histiocytomas are soft-tissue tumours of histiocytic origin that occur infrequently in the head and neck region. There are no completely reliable histologic criteria for the diagnosis of malignancy. Only five MFHs arising primarily from the ethmoid sinus have been reported in the literature. A further case is described in which the diagnosis was only definitely established following ultrastructural examination. Local tumour recurrence occurred in both the nasal cavity and nasopharynx eighteen months following primary combination treatment by radiotherapy, cytotoxic chemotherapy and surgery. Multicentric synchronous tumour recurrence has not been previously described in MFH involving the head and neck. This feature may account for the well documented high local recurrence rate following apparently complete surgical ablation.

The diagnosis and surgical management of olfactory neuroblastoma: the role of craniofacial resection

The diagnosis and clinical management of olfactory neuroblastoma are discussed. Computerized tomography is a valuable means of assessing the pre-operative extent of disease and the efficacy of subsequent major surgery. The tissue diagnosis is facilitated by electron microscopy, demonstrating the presence of dense core vesicles and cytoplasmic filaments. Radiotherapy followed by craniofacial resection is the treatment of choice for olfactory neuroblastomas that are locally extensive at presentation.

Massive chondroma of skull base

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