Quality of Life following Surgery for Malignancies of the Anterior Skull Base

Determinants of quality of life following resection of skull base tumors: a systematic review

Background

Skull base tumors represent a small subset of intracranial neoplasm. Due to their proximity to critical neurovascular structures, their resection often leads to morbidity. As a result, surgical interventions can exacerbate symptoms or cause new deficits, thereby impacting the patients' perceived quality of life (QoL). The factors influencing QoL in patients with skull base tumors remain underexplored. This systematic review aims to synthesize current research on QoL outcomes and identify potential factors influencing QoL in these patients.

Methods

A systematic literature review was conducted in PubMed using the keywords "Skull Base" AND "Quality of Life." A total of 815 studies published up to January 31, 2024, were screened. After abstract review, 656 studies were excluded, and 159 studies underwent full-text review. The wide variability in study methodologies and utilized QoL instruments made only a descriptive comparison possible.

Results

In total, 113 studies were systematically reviewed. Publications focusing on the same tumor type or localization were compared. The majority of studies addressed tumors of the anterior skull base, with pituitary adenomas, meningiomas and vestibular schwannomas being the most commonly represented. The impact of surgery on QoL is often underestimated by caregivers and has a more profound effect on patients than expected by surgeons. A transient decline in QoL after surgery was observed across almost all studies regardless of localization and entity. Factors influencing QoL included age, gender, tumor localization, surgical approach, tumor type, extent of resection, preoperative clinical status and neurological deficits. Radiotherapy and recurrent surgeries were predictors of poorer QoL. Early psychological intervention in complex tumors appears to enhance QoL. Some successful sealing techniques, such as nasoseptal flaps and lumbar drains, affected QoL. However, variability in study methodologies reduced the validity of the findings.

Conclusion

This review highlights the significant impact of skull base tumor surgery on patients' QoL. Given the major oncological and surgical challenges presented by skull base tumors, their treatment significantly affects QoL, and gross total resection (GTR) should not always be the primary goal. Additionally, recognizing and addressing the modifiable and non-modifiable factors influencing QoL is crucial for improving patient outcomes and providing personalized care.

Functional Outcomes and Quality of Life in Patients with Sinonasal, Nasopharyngeal, and Anterior Skull Base Tumors

PURPOSE OF REVIEW

This article will review functional and QOL outcomes among patients treated predominantly for sinonasal and nasopharyngeal malignancies.

RECENT FINDINGS

Treatment advances and interdisciplinary supportive care help to lessen the functional impairments and the reduction in quality of life (QOL) that were once accepted as inevitable tradeoffs for cure. Recent progress in QOL and Patient-Reported Outcome (PRO) instruments for this population will be covered. Sinonasal and nasopharyngeal tumors affect patients' quality of life, appearance, and critical functions. Tumors arise in proximity of vital structures including the orbit, cranial nerves, carotid artery, brain, cervical spine, and pituitary gland. Surgical morbidity, along with acute and late effects of systemic therapy and radiotherapy on normal tissues in this functionally critical region, may result in wide-ranging symptoms. Patients with skull base tumors report a high symptom burden at presentation, prior to treatment, relative to other malignancies in the head and neck region.

Preliminary cross-sectional reliability and validity of the Skull Base Inventory (SBI) quality of life questionnaire

Background

The Skull Base Inventory (SBI) was developed to assess the quality of life of patients undergoing endoscopic or open approaches for anterior and central skull base pathologies. In this study, we sought to establish the discriminative and evaluative properties for this instrument.

Methods

The SBI was administered in a cross-sectional fashion to patients who previously had skull base surgery after treatment and then again 2 weeks after completing the instrument. Internal consistency, test-retest reliability, and construct validity were determined. Four constructs were evaluated with the following a priori hypotheses: lower scores will be seen in patients with 1.malignant versus benign histology, 2.a history of radiation versus none, and those with 3.recurrences versus no recurrence, and 4.items deemed relevant versus irrelevant by respondents.

Results

Fifty-two patients completed the questionnaire; 32 had endoscopic and 20 open surgeries. Internal consistency was good (>0.7 and <0.95) for all domains except one. Test-retest reliability was good (>0.70) for 38 of 41 items. Four constructs were evaluated and three were consistent with a priori hypotheses (p < 0.05). The instrument failed to confirm the hypothesis that malignant tumours are associated with poorer scores than benign.

Conclusions

The SBI demonstrated preliminary reliability and validity for discriminative use.

Long-term changes in quality of life after endoscopic resection of sinonasal and skull-base tumors

BACKGROUND

Minimally invasive endoscopic resection (MIER) has emerged as the new standard for surgical treatment of sinonasal and skull-base tumors. The objective of the present study was to evaluate quality of life (QOL) 2 years after MIER.

METHODS

Prospective 20-item Sino-Nasal Outcome Test (SNOT-20) data was accrued on 104 patients over 4 years. The study cohort included 72 patients with sinonasal malignancy, while 32 patients with inverted papilloma (IP) served as controls.

RESULTS

The overall and rhinologic subdomain SNOT-20 scores for cancer patients did not statistically improve at 2 years (p = 0.12). They had statistically significant improvement in the psychological subdomain scores at 1 year (p = 0.03) and 2 years (p = 0.03). Similarly, the sleep subdomain scores improved at 1 year (p = 0.04) and 2 years (p = 0.03). In contrast, IP patients had statistically significant improvement in overall SNOT-20 (p = 0.01), rhinologic (p = 0.01), and sleep (p = 0.05) subdomain scores at 6 months, which remained stable at 2 years. Analysis of various factors demonstrated that history of prior smoking adversely affected QOL scores in cancer patients, with higher total SNOT-20 scores than nonsmokers (p = 0.01). Smokers also had higher psychological (p = 0.04), sleep (p = 0.01), and ear/facial (p = 0.001) domain scores than nonsmokers at 2 years.

CONCLUSION

The long-term effects of MIER for sinus cancer showed improved psychological and sleep scores at both 1 year and 2 years. Unfortunately, rhinologic QOL did not statistically improve at any of the measured time points. History of smoking was noted to be the most important predictor of QOL 2 years after MIER for sinonasal malignancy.

The use of photodynamic therapy as adjuvant therapy to surgery in recurrent malignant tumors of the paranasal sinuses

BACKGROUND

Malignant tumors of paranasal sinuses and anterior skull base recur frequently after surgery and adjuvant radiotherapy. The vicinity of essential structures limits additional treatment options, such as salvage surgery and re-radiation. We report the feasibility of photodynamic therapy (PDT) as an adjuvant treatment to surgery.

METHODS

Fifteen patients with recurrent tumors of the paranasal sinuses were treated with mtetrahydroxyphenylchlorin (mTHPC) mediated PDT as an adjuvant treatment to salvage surgery. All patients had previously curative radiotherapy. The treated tumors were squamous cell cancer (8), adenocarcinoma (3), undifferentiated carcinoma (2), adenoid cystic carcinoma (1) and radiotherapyinduced sarcoma (1). In five cases there was extension to the skull base. Two approaches of surgery where used, namely in eight cases an open approach, in the other seven endoscopic approach. Complete macroscopic resection with microscopic tumor positive margins was possible in three patients. The remaining twelve patients received debulking surgery followed by PDT.

RESULTS

None of the patients had cerebrospinal fluid leak, meningitis, major bleeding or vision loss. Four patients developed temporary diplopia due to edema of the medial rectus muscle, one patient suffered from extensive necrosis leading to oro-nasal fistula. Complete response was observed in five patients.

CONCLUSION

Photodynamic therapy can be used with relative safety as adjuvant therapy to surgery in recurrent tumors of the paranasal sinuses and the anterior skull base where complete resection is not achievable.

Changes Experienced in Quality of Life for Skull Base Surgical Patients: A Qualitative Case Study

Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients' lives. Qualitative study of patient experiences can provide rich information to better understand this disease.

Quality-of-Life after Anterior Skull Base Surgery: A Systematic Review

Background Improved treatment and survival of patients with skull base tumors has made the assessment of quality-of-life (QoL) in this population increasingly important. This article provides a comprehensive systematic review pertaining to QoL assessment in adults undergoing anterior skull base surgery. Methods We performed a literature search using the electronic databases of Ovid Medline and Embase. Additional articles were identified through a search using the phrase anterior skull base. Further articles were sought through hand-searching relevant journals and reference lists of identified articles. Results Our search strategy identified 29 articles for inclusion in our systematic review, with considerable variation between studies in population characteristics, methodological design and quality, follow-up length, and outcome assessment. The most commonly used QoL tools were the Karnofsky Performance Status and the Anterior Skull Base Questionnaire. QoL following anterior skull base surgery appears to improve beyond preoperative levels in the months after surgery. For patients undergoing endoscopic skull base surgery, the gain in QoL appears to be greater and may manifest earlier, with no clear long-term deleterious effect on sinonasal outcomes compared with open surgery. Conclusions QoL after anterior skull base surgery in adults appears to improve within several months of surgery, but earlier and to a larger extent if the endoscopic approach is used. Given the relative paucity and heterogeneity of anterior skull base tumors, large-scale prospective multicentre studies utilizing valid and reliable multidimensional QoL tools are required. This may result in improved patient care, by understanding patients' needs better and facilitating the provision of reliable outcome data for clinical trials.

Sinonasal quality of life outcomes after minimally invasive resection of sinonasal and skull-base tumors

BACKGROUND

Minimally invasive endoscopic resection (MIER) has emerged as the standard for surgical management of benign and malignant sinonasal and skull-base neoplasms. The objective of the present study was to assess sinonasal quality of life (QOL) and to analyze factors that impact symptomatology after surgery.

METHODS

This single-institution observational cohort study was performed on 94 patients over a 3-year period.

RESULTS

The mean age was 55.2 years, with male:female ratio of 1.5:1. Benign and malignant tumors were observed in 48% and 52% of patients, respectively. The cohort's mean preoperative 20-item Sino-Nasal Outcomes Test score (SNOT-20) was 1.27, decreasing to 0.91 (p = 0.002) at 6 months postoperatively. Patients with benign neoplasms had a lower mean preoperative SNOT-20 score of 1.11 that decreased to 0.58 (p = 0.002), whereas patients with malignant tumors had a higher mean preoperative SNOT-20 score of 1.27, decreasing to 1.03 (p = 0.134) at 6 months postoperatively. The SNOT-20 scores for females improved 0.53 (p = 0.002) compared to 0.23 (p = 0.154) for males at 6 months. Statistically significant sinonasal QOL improvement was noted in nonsmokers (0.62, p = 0.0006), patients with no prior radiation or chemotherapy (0.59, p = 0.0029), and patients with no prior surgery (0.51, p = 0.0012). Multiple variable regression analysis demonstrated that the 2 strongest predictors for lack of SNOT-20 improvement were previous history of smoking (p < 0.05) and prior radiation and/or chemotherapy (p < 0.01) (R(2) = 0.24).

CONCLUSION

MIER results in overall improvement in SNOT-20 scores, with greater change being noted in females and in patients with benign tumors. Prior smoking and chemoradiation strongly predict decreased improvement in sinonasal QOL after surgery.

Quality of life instruments for skull base pathology: systematic review and methodologic appraisal

BACKGROUND

Several quality of life (QOL) instruments exist for skull base pathology, however, there have been no attempts to appraise and systematically review these instruments.

METHODS

We systematically reviewed MEDLINE, EMBASE, Central, AMED, Health and Psychosocial Instruments, and PsychoInfo for anterior or central skull base QOL instruments to January 2010. We queried experts, bibliographies, and meeting proceedings from the North American Skull Base Society from 2005 to 2009. Included instruments were evaluated for instrument characteristics, item generation and reduction, field testing, and measurement properties using predefined criteria.

RESULTS

We identified 9 QOL instruments: 7 measuring QOL for pituitary pathology, 1 for midface pathology, and 1 for anterior skull base pathology. Eight of the 9 instruments have had some psychometric testing. None demonstrated all of the predefined psychometric properties.

CONCLUSIONS

There are several QOL instruments for patients with skull base pathology. None of these instruments met all predefined requirements, and further instrument development is needed.

Global and disease-specific health-related quality of life after complete endoscopic resection of anterior skull base neoplasms

BACKGROUND

Minimally invasive surgery for neoplasms of the anterior skull base has revolutionized the treatment of these diseases. The relative effect of endoscopic procedures, however, has not been described in terms of disease-specific and global health-related quality of life (QoL).

METHODS

A single-center longitudinal study was performed of patients undergoing complete endoscopic resection of anterior skull base neoplasms. Patients presenting between October 2009 and September 2010 were enrolled. QoL assessments were based on the 22-question Sinonasal Outcomes Test (SNOT-22), Health Utilities Index Mark II (HUI-2), and Short-Form 12 (SF-12) and were completed preoperatively and at 3, 6, and 12 months postoperatively. Comparisons over time were made within subjects.

RESULTS

Fourteen patients were enrolled; 11 completed preoperative and postoperative assessments (79%). Our cohort consisted of five men and six women; mean age was 55 years. Six patients had malignant tumors; four required adjuvant therapy. SNOT-22 scores were stable or improved in 10 cases (91%), with a significant difference for the cohort (mean, -33 points; p < 0.01). Ten (91%) patients had stable or improved HUI-2 scores (mean utility change, +0.13). SF-12 scores were stable for both mental (p = 0.17) and physical (p = 0.26) components. Mean quality-adjusted life year gain over the study period was 0.07.

CONCLUSION

Complete endoscopic resection of anterior skull base neoplasms is oncologically sound with anecdotal QoL improvements relative to open craniofacial resection. We show positive, quantifiable QoL results with validated global and disease-specific instruments. Additional work will help to improve outcomes in this population and will be used in formal cost-effectiveness analysis.

Development of a disease-specific quality-of-life questionnaire for anterior and central skull base pathology--the skull base inventory

OBJECTIVES/HYPOTHESIS

Anterior and central skull base lesions and their surgical treatment (endoscopic or open approaches) can affect quality of life. A disease-specific instrument is needed to compare quality of life for different surgical approaches.

STUDY DESIGN

Items were generated using a composite strategy consisting of chart review, systematic review of skull base instruments, expert interviews, and qualitative analysis of patient focus groups. A cross-sectional survey study was performed to reduce items based on an item impact score.

METHODS

Charts of 138 patients who underwent skull base surgery were reviewed to identify physical items and domains. Five experts were interviewed for item and domain identification. Thirty-four patients were recruited into eight focus groups based on their surgical approach (open or endoscopic) and tumor location (anterior or central). Items were generated using a composite approach and then reduced into a final questionnaire using item impact scores.

RESULTS

Chart review identified 47 physical items. Systematic review revealed nine relevant instruments with 217 relevant items. Experts identified 11 domains with 69 additional items. Qualitative analysis of focus groups generated 49 items. A total of 382 items were identified and reduced to 77 items after eliminating overlapping and irrelevant items. Further item reduction using item impact scores yielded 41 items.

CONCLUSIONS

The Skull Base Inventory is a disease-specific quality-of-life instrument. Psychometric properties have yet to be tested. It may serve to compare quality of life for endoscopic or open procedures.

Esthesioneuroblastoma: Results and Outcomes of a Single Institution's Experience

OBJECTIVES

Analysis of outcomes of a cohort of patients with esthesioneuroblastoma.

DESIGN

Retrospective cohort analysis.

SETTING

PATIENTS presenting with esthesioneuroblastoma from 1994 to 2006 in a tertiary care academic medical center.

PATIENTS

Fifteen consecutive patients diagnosed as having esthesioneuroblastoma were treated during this time period using a subcranial resection. The mean follow-up is 75 months (range, 2 to 240 mos).

RESULTS

The overall survival was 100% and the overall disease-free survival was 49% and 24% at 5 and 15 years, respectively. PATIENTS treated with radiation therapy following surgical resection had a 5- and 15-year disease-free survival of 83.3% compared with a 5- and 15-year disease-free survival of 26.7% and 0%, respectively, for patients whose initial treatment was surgery alone. The mean time to recurrence was 82.1 months. None of the patients had a decrease in Karnofsky Performance Score following subcranial resection.

CONCLUSIONS

PATIENTS with esthesioneuroblastoma whose initial treatment consists of surgical resection followed by radiation therapy have a longer disease-free survival than patients treated with surgery alone. However, initial treatment modality did not have an effect on survival. Long-term, close follow-up is necessary to identify recurrences, which can be treated with a high degree of success.

A prospective evaluation of short-term health-related quality of life in patients undergoing anterior skull base surgery

We evaluated the health-related quality of life (QOL) of patients undergoing anterior skull base tumor resection. The Anterior Skull Base Surgery QOL questionnaire, a disease-specific multidimensional instrument dedicated to this population, was used to collect and prospectively analyze demographic, medical, and QOL data on 48 patients. Thirty-nine patients completed the questionnaire preoperatively and at 6 and 12 months postoperatively. Seventeen patients (44%) had malignant histology and 22 (56%) had benign tumors. The overall QOL score decreased significantly at 6 months postoperatively (p < 0.05) and improved significantly at 12 months postoperatively (p < 0.04). The emotional domain improved significantly at 12 months postoperatively compared with the preoperative scores (p < 0.03). Patients with malignant tumors had lower scores at 6 months postoperatively compared with patients with benign lesions (p < 0.002), although the scores for both groups at 12 months postoperatively were similar. Adjuvant radiation therapy was associated with a poor QOL (p < 0.005). The results of this prospective study show that the overall deteriorated QOL of patients after anterior skull base tumor resection returns to baseline by 1 year after surgery. Histology and radiotherapy are significant predictors of health-related QOL in this population.

Quality of life following endonasal skull base surgery

The importance of quality of life (QOL) outcomes following treatments for head and neck tumors are now increasingly appreciated and measured to improve medical and surgical care for these patients. An understanding of the definitions in the setting of health care and the use of appropriate QOL instruments and measures are critical to obtain meaningful information that guides decision making in various aspects of patient health care. QOL outcomes following cranial base surgery is only recently being defined. In this article, we describe the current published data on QOL outcomes following cranial base surgery and provide preliminary prospective data on QOL outcomes and sinonasal morbidity in patients who underwent endonasal cranial base surgery for management of various skull base tumors at our institution. We used a disease-specific multidimensional instrument to measure QOL outcomes in these patients. Our results show that although sinonasal morbidity is increased, this is temporary, and the vast majority of patients have a very good QOL by 4 to 6 months after endonasal approach to the cranial base.