Esthesioneuroblastoma: endoscopic nasal and anterior craniotomy resection

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%.

Esthesioneuroblastoma with recurrent dural metastases: Long-term multimodality treatment and considerations

Background:

Esthesioneuroblastoma (ENB) is a rare malignant disease and treatment protocols have not been standardized, varying widely by disease course and institutional practices. Management typically includes wide local excision through open or endoscopic resection, followed by radiotherapy, chemotherapy, and stereotactic radiosurgery. Tumor control can differ on a case-by-case basis. Herein, the complex management of a rare case of recurrent disease with multiple dural metastases is presented.

Case Description:

A 60-year-old patient was diagnosed with ENB after presenting with anosmia and epistaxis. The patient underwent combined endonasal and transfrontal sinus craniofacial resection, followed by proton beam radiation therapy and chemotherapy. Subsequently, he developed a total of 25 dural metastases that were controlled with repeated Gamma Knife Radiosurgery (GKRS). In spite of post-treatment course that was complicated by radiation necrosis and local vasculopathy, the patient made significant recovery to functional baseline.

Conclusion:

The management of ENB entails multimodality and multidisciplinary care, which can help patients obtain disease control and long-term survival. Recurrent ENB dural metastases can behave as oligometastatic disease manageable with aggressive focal GKRS. As prognosis continues to improve, chronic treatment effects of radiation in such cases should be taken into consideration.

Consolidating the Hyams grading system in esthesioneuroblastoma - an individual participant data meta-analysis

INTRODUCTION

Esthesioneuroblastoma (ENB) is an uncommon primary sinonasal tumor which can extend intracranially. Exactly how to classify them pathologically still remains discrepant; the Hyams grading system, for example, has not been universally adopted. This individual patient data (IPD) meta-analysis aimed to investigate the prognostic implication of each Hyams grade on patient outcomes.

METHODS

We accessed two electronic databases including PubMed and Web of Science. Raw patient data from potential articles were extracted. To examine the associations of various clinicopathological factors with the Hyams grades, we utilized Chi-square, t-test, and Mann-Whitney, as appropriate. Log-rank test and Cox regression analysis were used to elucidate the impact of the Hyams grades on recurrence-free survival (RFS), metastasis-free survival (MFS), and overall survival (OS) of ENB patients.

RESULTS

We included 33 studies with 492 ENB patients. We found significant associations of Kadish stages, Dulguerov stages, rates of recurrence, metastasis, and patient mortality with Hyams grade. Log-rank tests and Cox regression models demonstrated significant differences in RFS and OS of Hyams grade I - II, grade III, and grade IV patients. There was no statistical difference in RFS and OS of Hyams grade I and II. Radiotherapy was only effective in grade III - IV ENBs and chemotherapy showed no benefits to patients.

CONCLUSION

We verify that the Hyams grading system appears to be a reliable prognostic indicator to assess ENB patient outcomes. Consolidating the Hyams grading system into a three-tier system based on similar clinical outcomes of grades I and II may simplify this classification schema.

Comparing Kadish and Modified Dulguerov Staging Systems for Olfactory Neuroblastoma: An Individual Participant Data Meta-analysis

OBJECTIVE

To compare the Kadish and the modified Dulguerov staging of individual participants to determine the impact of stage and other prognostic factors on disease-free (DFS) and overall survival (OS).

DATA SOURCES

Systematic review of EMBASE, MEDLINE, Cochrane Library, and CINAHL databases.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) was followed for this study. Articles including patients with olfactory neuroblastoma (ONB) staged with both Kadish and Dulguerov staging systems were reviewed. The raw data from eligible studies were requested to perform an individual participant data (IPD) meta-analysis.

RESULTS

Pooled data from 21 studies representing 399 patients with ONB undergoing treatment with curative intent showed that increasing age, treatment with chemotherapy, and positive or unreported margin status portended worse DFS (P < .05). Increasing stage for both Kadish and Dulguerov staging systems was prognostic for worse DFS and OS (P < .05), with Kadish C representing a heterogeneous group with regard to outcome and corresponding Dulguerov T stage. Using the Akaike information criterion, the Dulguerov staging system had superior performance to the Kadish system for DFS (1088.72 vs 1092.54) and OS (632.71 vs 644.23).

CONCLUSION

This study represents the first IPD meta-analysis of ONB directly comparing the outcomes of Kadish and Dulguerov staging systems in patients treated with primary surgery. Both systems correlated with DFS and OS, with superior performance in the Dulguerov system. Furthermore, the Kadish C group represented a heterogeneous group with regard to outcomes after stratification by the Dulguerov system. Dulguerov T4 patients had the worst outcome, with most being approached with open resection.

Delaying Postoperative Radiotherapy in Low-Grade Esthesioneuroblastoma: Is It Worth the Wait?

Background  Consensus in timing of radiotherapy is yet to be established in esthesioneuroblastoma (ENB). Objective  This study was aimed to investigate if planned adjuvant radiotherapy improves tumor control after complete margin negative resection of low Hyams' grade (1 or 2) ENB. Methods  A retrospective review of patients with pathologically confirmed negative margin resection of Kadish's stage B or C and Hyams' grade 1 and 2 ENBs was conducted. Seventeen patients meeting the criteria were divided into the following two groups for cohort study: (1) those who underwent planned immediate postoperative adjuvant radiotherapy (IR group) and (2) those who did not (delayed radiotherapy [DR] group). Results  The IR group included nine patients (Kadish's stage B in one and stage C in eight; Hyams' grade 1 in two and grade 2 in seven). Mean follow-up was 140.8 months. Seven patients (78%) had disease progression (DP) at a median of 88 months (four with cervical lymph node metastasis [CLNM], one with distant metastasis, and two with both local recurrence and CLNM). One patient experienced frontal lobe abscess. The DR group included eight patients (Kadish's stage B in six and stage C in two; all Hyams' grade 2). Mean follow-up was 123.3 months. Four (50%) patients who developed DP (all local recurrence) were salvaged with surgery and adjuvant radiotherapy at a median of 37.5 months. There was no statistically significant difference in DP rate ( p  = 0.23), time to DP ( p  = 0.26), or the local tumor control rate ( p  = 0.23). Conclusion  In our limited cohort, immediate postoperative radiotherapy did not demonstrate superiority in tumor control, although risk of radiotherapy toxicity appears low.

Endoscopic Approach to Remove Intra-extracranial Tumors in Various Skull Base Regions: 10-year Experience of a Single Center

Background:

Some problems have been found in the usually adopted combined approach for the removal of intra-extracranial tumors in skull base. Herein, we described a pure endoscopic transnasal or transoral approach (ETA) for the removal of intra-extracranial tumors in various skull base regions.

Methods:

Retrospectively, clinical data, major surgical complications, pre- and postoperative images, and follow-up information of a series of 85 patients with intra-extracranial tumors in various skull base regions who were treated by surgery via ETA in our skull base center during the past 10 years were reviewed and analyzed.

Results:

Gross total tumor removal was achieved in 80/85 cases (94.1%) in this study. All 37 cases with tumors in anterior skull base and all 14 cases with tumors in jugular foramen received total tumor removal. Thirteen and three cases with tumors in clivus received total and subtotal tumor removal, respectively. Total and subtotal tumor removal was performed for 16 cases and 2 cases in lateral skull base, respectively. The complications in this study included: cerebrospinal fluid leakage (n = 3), meningitis (n = 3), and new cranial nerve deficits (n = 3; recovered in 3 months after surgery). In the follow-up period of 40–151 months (median: 77 months), seven patients (8.8%) out of the 80 cases of total tumor removal experienced recurrence.

Conclusions:

Complete resection of intra-extracranial growing tumors in various skull base regions can be achieved via the pure ETA in one stage in selected cases. Surgical procedure for radical removal of tumors is feasible and safe.

Combined Endoscopic and Open Approaches in the Management of Sinonasal and Ventral Skull Base Malignancies

Combined transcranial and endoscopic endonasal approaches remain useful in the treatment of ventral skull base malignancies. The extended bifrontal transbasal approach provides wide access to the anterior ventral skull base and paranasal sinuses without transfacial incisions. In more extensive lesions, the bifrontal transbasal approach can then be combined with an endoscopic endonasal approach (EEA) from below. This article reviews the indications, surgical technique, and operative nuances of combined transbasal and EEA (cranionasal) approaches for the surgical management of ventral skull base malignancies.

Olfactory neuroblastoma: a single-center experience

Olfactory neuroblastoma (ONB) is a potentially curable disease, despite being an aggressive malignancy with a poor natural history. Our goal was to evaluate management outcomes for patients with ONB treated at our institution. Our prospective database for brain tumors and the pathology registry of head and neck cancers at Oslo University Hospital were searched to identify all patients treated for ONB between 1998 and 2016. Variables extracted from these databases, supplemented by retrospective chart reviews, underwent thorough analysis. All cases were formally re-examined by a dedicated head and neck pathologist. Twenty patients were identified. Follow-up was 100%. Mean follow-up was 81.5 months for the entire cohort and 120.3 months for patients with no evidence of disease. Fourteen patients underwent treatment of choice including craniofacial resection (CFR) with or without radiotherapy (XRT). Six patients could only receive less extensive treatment; three patients underwent lateral rhinotomy (LR) with or without XRT after being deemed medically unsuitable for CFR, while another three patients received only supportive, non-surgical treatment (due to positive lymph node status in two and to extensive tumor size in one case). Overall and disease-specific survival rates were 100% after 10 years of follow-up when negative surgical margins were achieved by CFR. Positive margins were associated with poorer outcome with no patients surviving longer than 44 months. Long-term survival was also achieved in two cases among patients not eligible for CFR: one case after radical LR and one case after radio-chemotherapy. Advanced disease at presentation (tumor size ≥40 mm, Kadish grades C and D, or TNM IVa and IVb) and positive surgical margins were correlated to significantly dismal survival. Our study suggests that CFR with or without adjuvant XRT is safe and leads to excellent long-time overall and disease-specific survival. Negative surgical margins, tumor size <40 mm, Kadish stage A/B, and TNM stages I-III are independent prognostic predictors of outcome.

Role of surgical treatment for esthesioneuroblastomas: 31-Year experience at a single institution

OBJECTIVE

This study aimed to re-assess the outcomes of different surgical methods for esthesioneuroblastoma (ENB) in a single institution, with emphasis on changes in surgical treatment with regard to endoscopic approaches in patients with ENB.

SUBJECTS AND METHODS

We retrospectively reviewed the data of 35 patients with ENB treated over the last 31 years.

RESULTS

The 5-year overall and disease-free survival rates were 66.8% and 50.8%, respectively. Disease-free survival in the endoscopic surgery group was significantly higher compared to that of craniofacial surgery group (P = 0.035). In the endoscopic surgery group, nine of 10 patients did not exhibit local failure or regional recurrence over a mean followup period of 64.3 months, which was longer than the mean time to recurrence (22.0 months) observed in this study.

CONCLUSION

Given its significant survival outcomes and high rate of local control, endoscopic surgery could be preferred as a minimally invasive treatment with potentially low morbidity and possible oncological validity for the treatment of ENB.

Endoscopic Resection of Sinonasal Malignancy

Objectives

The use of endoscopic approaches for sinonasal malignancy resection has increased, but survival data are limited secondary to disease rarity and new surgical technique. Here we present a systematic review and meta-analysis of endoscopic endonasal resection of sinonasal malignancy.

Data Sources

MEDLINE, PubMed Central, NCBI Bookshelf, Cochrane Library, clinicaltrials.gov, National Guideline Clearinghouse.

Review Methods

PRISMA/MOOSE guidelines were followed. MeSH terms were “endoscopic” AND (“esthesioneuroblastoma” OR “sinonasal adenocarcinoma” OR “squamous cell carcinoma” OR “sinonasal undifferentiated carcinoma”). For studies in which individual-level data were available, results were obtained by direct pooling. For studies in which only summary Kaplan-Meier curves were available, numerical data were extracted, traced, and aggregated by fitting a Weibull model.

Results

Of 320 studies identified, 35 case series were included (n = 952 patients), with 15 studies analyzed via aggregate modeling and 20 studies analyzed via direct pooling. Two- and 5-year survival rates for patients in aggregate modeling were 87.5% and 72.3%, respectively (mean follow-up: 32.9 months). Two- and 5-year survival for patients in direct pooling were 85.8% and 83.5%, respectively (mean follow-up: 43.0 ± 19.5 months). Significant overall survival difference was found between low- and high-grade cancers ( P = .015) but not between low- and high-stage cancers ( P = .79).

Conclusion

Overall 2- and 5-year survival rates are comparable and sometimes greater than those from open craniofacial resection. Survival rates significantly differ by cancer grade but not stage. Journals and investigators should be encouraged to publish retrospective and prospective case series with staged survival updates based on established guidelines.

Combined modality therapy of esthesioneuroblastoma

Objective

Esthesioneuroblastoma (ENB) is a rare tumor of the olfactory epithelium. The objective of this study was to evaluate treatment modalities including surgery, IMRT, and chemotherapy and patient outcomes.

Patients and Methods

A retrospective analysis was performed on a total of 21 patients. Therapy included craniofacial resection (CFR), radiotherapy, chemotherapy, or a combination of these methods.

Results

The median follow-up period was 47 months. Surgery was performed in 90.4% of cases; radiotherapy was performed adjuvantly in 15 (72.7%) patients. Surgery, radiotherapy, and chemotherapy were administered to 7 (33.3%) patients. Eight (38.3%) patients had local recurrence. The 5-year crude overall survival was 71.4% and actuarial 5-year overall survival was 58% with confidence interval (CI, 25 and 81, respectively). The 5-year crude disease-free survival rate was 59% and the 5-year actuarial disease-free survival rate was 62% (CI, 28 and 83, respectively).

Conclusion

Multidisciplinary therapy of ENB should be considered, especially for Kadish C and high-grade lesions. Craniofacial resection (CFR), Intensity modulated radiation therapy (IMRT), and chemotherapy should be investigated in a multi-institution trial of ENB. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Endoscopic Endonasal Management of Olfactory Neuroblastoma: A Retrospective Analysis of 10 Patients with Quality-of-Life Measures

OBJECTIVE

Anterior craniofacial resection has served as the traditional surgical treatment of olfactory neuroblastoma (ON). With the development of extended endonasal approaches, the opportunity exists for using minimal access techniques for management of select tumors. This study assesses the impact of endoscopic resection on ON and patient outcomes and quality of life.

METHODS

A retrospective review identified 10 patients with ON (3 women, 7 men; mean age 49.1 years) who underwent endoscopic resection during the period 2010-2013. Modified Kadish staging divided the cohort into 3 stage B patients (30%), 5 stage C patients (50%), and 2 stage D patients (20%). Outcome measures included extent of resection, complications, recurrence, and preoperative and postoperative Sino-Nasal Outcome Test-20 scores.

RESULTS

Gross total resection was achieved in all patients, with negative margins in 9 patients. One patient had negative frozen section pathology but was noted to have a positive posterior dural margin on final pathology. There was a 20% complication rate (pneumocephalus, ethmoid meningoencephalocele). Neoadjuvant chemotherapy and radiation were performed in 2 patients (Kadish stage C and D). Adjuvant chemotherapy and radiation were performed in 5 patients (4 Kadish stage C and 1 stage D). Postoperative radiation alone was administered in 3 patients (Kadish stage B). Analysis of postoperative Sino-Nasal Outcome Test-20 scores demonstrated no significant change relative to preoperative Sino-Nasal Outcome Test-20 scores. At the most recent follow-up examination, there was no evidence of recurrent disease in patients who underwent endoscopic resection. One patient (Kadish stage D) died during the follow-up period. Mean follow-up duration was 21.1 months.

CONCLUSIONS

This series adds to the growing body of literature that suggests equivalent or improved outcomes of purely endonasal resection for select patients. Given the advanced Kadish stage of most of our patients, longer follow-up is required to determine the full applicability of purely endoscopic approaches to the treatment of ON.

Comparison of outcomes for open versus endoscopic approaches for olfactory neuroblastoma: A systematic review and individual participant data meta-analysis

BACKGROUND

Endoscopic approaches have been adopted as an alternative to craniofacial resection in the surgical management of olfactory neuroblastoma.

METHODS

We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, Cochrane, and CINAHL (2000-2014) to compare outcomes for open versus endoscopic approaches.

RESULTS

Thirty-six studies containing 609 patients were included. Meta-analysis of (a) all patients, (b) Kadish C/D only, and (c) Hyams III/IV only, failed to show a difference in locoregional control and metastasis-free survival between approaches. However, endoscopic approaches were associated with improved overall survival (OS) for all 3 groups (p = .001, .04, and .001, respectively), and higher disease-specific survival (DSS) for all patients (p = .004) and Hyams III/IV only (p = .002).

CONCLUSION

The current study suggests that endoscopic approaches have comparable control rates to open approaches for olfactory neuroblastoma. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2306-E2316, 2016.

Esthesioneuroblastoma of the nasal cavity

OBJECTIVES

Esthesioneuroblastoma is an uncommon cancer of the nasal cavity. We describe the outcomes for 26 patients treated with curative intent with photon radiotherapy (RT) at the University of Florida.

METHODS

Between May 1972 and June 2007, 26 patients received RT for previously untreated esthesioneuroblastoma of the nasal cavity. Sixteen patients were males and 10 were females with a median age of 55 years (range, 3 to 82 y). The modified Kadish stage distribution was: B, 7 patients; C, 17 patients; and D, 2 patients. Treatment modalities included the following: definitive RT, 5 patients; preoperative RT, 2 patients; and postoperative RT after resection, 19 patients. Elective neck irradiation (ENI) was performed in 17 (71%) of 24 N0 patients.

RESULTS

Rates of local control, cause-specific survival, and absolute overall survival at 5 years were 79%, 72%, and 69%, respectively. Overall survival among patients treated with definitive RT was 20% at 5 years, compared with 81% among those who underwent surgery and adjuvant RT (P=0.01). One (6%) of 17 patients who received ENI developed a recurrence in the neck and was successfully salvaged. Ultimate neck control was 100% at 5 years for patients who received ENI versus 69% among those not receiving ENI (P=0.0173).

CONCLUSIONS

Resection combined with adjuvant RT is more effective than surgery or RT alone in the treatment of esthesioneuroblastoma. ENI reduces the risk of regional relapse in patients with Kadish stage B and C cancers.

Long-term carcinologic results of advanced esthesioneuroblastoma: a systematic review

Surgical resection followed by radiotherapy can be considered like the optimal treatment modality for limited esthesioneuroblastoma. However, therapeutic management of locally advanced tumors remains a challenge. The aim of our study was to access and compare the oncologic results of the different treatment modalities in advanced esthesioneuroblastoma. We performed a systematic review using the Medline, and Cochrane database in accordance with PRISMA criteria and included all the cases of advanced esthesioneuroblastoma published between 2000 and 2013. We also retrospectively included 15 patients with an advanced esthesioneuroblastoma managed at our tertiary care medical center. Long-term survival rates defined as the time from diagnosis or randomization to the date of death or last follow-up were evaluated for each treatment with Kaplan-Meier survival curve analyses. 283 patients have been included. The mean follow-up was 78 months. Five-year highest survival rates were obtained in patients treated by surgery associated with radiotherapy. Ten-year highest survival rates were obtained in patients treated by the association of surgery, radiotherapy and chemotherapy (p = 0.0008). Within the surgical group, 5-year highest survival rates were obtained in patients treated by endoscopic resection (p = 0.003). Surgical resection combined with radiotherapy offers the gold standard of care. Adjuvant chemotherapy seems to improve the long-term survival in patients with locally advanced esthesioneuroblastoma. Endoscopic resection in advanced tumors should be discussed on a case-by-case basis.

Nasal endoscopic and anterior craniotomy resection for esthesioneuroblastoma: how we did it

The objective of this study was to report and present an approach to combine functional and esthetic technique of endoscopic nasal tumor resection with anterior cranial fossa extension resection in a case of Esthesioneuroblastoma (ENB), a rare slow growing malignant neoplasm of the olfactory mucosa. For this purpose, the mass was excised by nasal endoscopic approach with microdebrider and anterior craniotomy with bi-coronal incision. The cribriform plate defect was reconstructed with temporalis fascia and nasal defect with fascia and rotated middle turbinate. Radiotherapy was given. At 4 years follow up no evidence of tumor locally or systemic metastasis were seen. In conclusion endoscopic excision complimented with anterior craniotomy for the anterior cranial fossa extension of resectable ENB with post-op radiotherapy is an effective treatment modality satisfying both oncosurgical as well as esthetic requirements.

Rhinology

Osteomas are the most common benign sinonasal lesion with the frontal sinus the most common location. On sinus MRI, dried secretions show as hyperintense on T1, hypointense on T2, and polyps show hypointense on T1, hyperintense on T2. Rhinoscleroma is caused by Klebsiella rhinoscleromatis with histopathology showing Mikulicz cells (macrophages containing pathogen) and Russell bodies (plasma cells).

Evaluating endoscopic and endoscopic-assisted access to the infratemporal fossa: a novel method for assessment and comparison of approaches

OBJECTIVES/HYPOTHESIS

Endoscopic infratemporal fossa (ITF) surgery is a growing clinical interest. This study presents a method of analyzing approach access and visualization, identifies relevant anatomy in an endoscopic approach to the ITF, and compares endoscopic medial maxillectomy (MMA) and endoscopic-assisted sublabial transmaxillary (SLT) approaches to the ITF as a model for this paradigm.

STUDY DESIGN

Human cadaver anatomic study.

METHODS

Five human cadaver heads (10 ITF dissections) were used. An SLT and MMA were performed on each side. For endoscopic dissections of the ITF, 0° and 30° endoscopes were used. Key landmarks were the posterior maxillary sinus wall, temporomandibular joint, pterygoid plates, foramen spinosum, and foramen ovale. Open dissection was used to confirm ITF landmarks. A novel measurement method using angles of approach and visualization was used to compare approaches.

RESULTS

Visualization and mobility in SLT and MMA were significantly different. The lateral extent and greatest average depth for dissection was 7.9 cm in MMA and 6.1 cm for SLT. The average angle of mobility in approach was 36.3° for MMA and 57.9° for SLT. Average visualization was 40.2° for MMA and 126.5° for SLT. Despite these differences, both surgical approaches allowed access and visualization to all targeted landmarks.

CONCLUSIONS

This evaluation paradigm provides useful data in evaluating an endoscopic or endoscopic-assisted approach to the ITF. Using this paradigm, the SLT and MMA were analyzed. Each provided adequate access to the ITF, but visualization and maneuverability were better in SLT.

Endoscopic endonasal compared with anterior craniofacial and combined cranionasal resection of esthesioneuroblastomas

OBJECTIVE

Esthesioneuroblastomas represent a surgical challenge because of their anatomical location, the necessity of achieving negative margins, and the often-cosmetically disfiguring transfacial approaches needed. Recently, expanded endonasal endoscopic approaches have been developed, either alone or in combination with a craniotomy. We conducted a systematic review of case series and case reports to compare outcomes between these various surgical approaches.

METHODS

A MEDLINE search was conducted of the modern literature (1985-2010) to identify open and endoscopic surgical series. Tumor and patient characteristics, Kadish stage, extent of resection, and progression-free and overall survival were recorded and analyzed by approach. Kaplan-Meier analysis was used to assess overall survival and progression-free survival.

RESULTS

Forty-seven studies comprising 453 patients were included. The endoscopic cohort had a greater proportion of Kadish Stage A tumors compared with the craniofacial group. Gross total resection was achieved in 98.1% of patients who underwent an endoscopic approach compared with 81.3% for the craniofacial and 100% for the cranionasal cohorts. Local recurrence occurred in 8.0% of patients in the endoscopic group compared with 22.1% in the craniofacial and 16.7% in the cranionasal cohorts.

CONCLUSION

In well-selected cases, cranionasal and endonasal approaches can be safe and effective. An ongoing evaluation of the benefits and limitations are necessary to better define the ideal patient population and patient-specific risk factors for the use of these minimal access techniques.

Treatment modalities and outcomes of olfactory neuroblastoma

OBJECTIVES/HYPOTHESIS

To analyze the clinical features of olfactory neuroblastoma (ONB) and compare the treatment results according to various treatment modalities, and to validate various staging systems.

STUDY DESIGN

Retrospective analysis.

METHODS

This study included 35 patients with ONB. Treatment consisted of neoadjuvant chemotherapy and radiation therapy (seven patients), traditional craniofacial resection (TCFR, 12 patients), endoscopic craniofacial resection with craniotomy (ECFR, 11 patients), and transnasal endoscopic resection without craniotomy (five patients). The overall mean follow-up period was 64.9 months and mean disease-free survival (DFS) was 50.2 months.

RESULTS

Five-year overall survival and 5-year DFS rates were 76.0% and 61.8%, respectively. Five-year DFS rates for nonsurgical treatment, TCFR, ECFR, and transnasal endoscopic resection without craniotomy group were 35.7%, 41.7%, 80.8%, and 100%, respectively (P = .01). Neck metastasis negatively affected survival (P = .03). DFS rate of patients in the endoscopic surgery group was higher than the nonendoscopic surgery group on Cox multivariate regression analysis (P = .02). The modified Kadish classification system predicted DFS more accurately than the Biller and Dulguerov classification system (P = .04). Locoregional recurrence occurred in 23% (period of recurrence after treatment, mean 49 months; range, 3-143) of patients with ONB, and distant metastasis in 26%. ECRF group showed lesser perioperative bleeding amount and shorter operation time compared with TCFR. However, the admission period was not statistically different.

CONCLUSIONS

Endoscopic surgery for advanced ONB showed successful survival results compared with nonendoscopic surgery on multivariate analysis, and limited morbidities. Modified Kadish classification best predicted DFS for ONB. Long-term follow-up is necessary due to its late recurrence.

Salvage Treatment of Local Recurrence in Esthesioneuroblastoma: A Meta-analysis

Esthesioneuroblastoma has a local recurrence rate of ∼30%, but no standard regimen for salvage of local recurrence has been established. We report data from 678 patients from series published since 1990, with a risk reduction analysis of salvage with surgery, radiation, or combined surgery and radiation therapy. We found a 28.5% rate of local recurrence after treatment, and a 42.6% rate of successful salvage with surgery, radiation, or combined treatment. The odds ratio for successful salvage, defined as disease-free survival for at least 1 year, was not significantly different for combined surgery and radiation versus surgery alone or radiation alone or for surgery alone versus radiation alone. The salvage odds ratio for combined surgery and radiation therapy versus radiation therapy alone, 3.5, approached, but did not reach statistical significance. This study reveals a reasonable rate of successful salvage of local esthesioneuroblastoma recurrence using surgery, radiation, or combined surgery and radiation.

Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches

Little data exists comparing endoscopic endonasal approaches to pathology of the anterior skull base with more traditional transcranial and transsphenoidal microscopic approaches. In order to more fully characterize the role of endoscopy in the management of pathology of the anterior cranial base, we conducted a systematic review of case series and case reports documenting surgical and clinical outcomes. We found that for craniopharyngiomas, clival chordomas, esthesioneuroblastomas and giant pituitary adenomas, the endonasal endoscopic approach can result in equivalent or higher rates of gross total resection than open approaches. For meningiomas, however, open transcranial approaches are still able to achieve higher rates of total resection. CSF leak rates are higher for patients undergoing endoscopic surgery for meningiomas and craniopharyngiomas, but not for chordomas, esthesioneuroblastomas or giant pituitary adenomas. In certain patients, the endonasal endoscopic approach may be a safe and effective alternative for the treatment of a wide variety of skull base pathology, particularly those with small midline tumours.

Olfactory neuroblastoma treated by endoscopic surgery followed by combined external beam radiation and gamma knife for optic nerve and chiasm sparing: a case report

We describe the multimodality treatment regimen of a 53-year-old man diagnosed with olfactory neuroblastoma (Kadish stage C) in the right nasal cavity extending into the ethmoid sinus and across the cribriform plate. Endoscopic surgery for tumor resection was followed by a combination of external beam radiotherapy and stereotactic radiosurgery boost with concurrent chemotherapy. The novel combination of dual radiation therapies allowed for the preservation of the nearby optic structures while providing an adequate dosage to a sufficient volume of the afflicted tissue.

Surgical nuances for removal of olfactory groove meningiomas using the endoscopic endonasal transcribriform approach

Olfactory groove meningiomas represent 10% of intracranial meningiomas and arise in the midline of the anterior cranial fossa along the dura of the cribriform plate and planum sphenoidale. Hyperostosis of the adjacent underlying bone is common, and further extension into ethmoid sinuses and nasal cavity can occur in 15%-25% of cases. Radical tumor resection including the involved dural attachment and underlying hyperostotic bone offers the best chance of a Simpson Grade I resection to minimize recurrence. Incomplete removal of involved hyperostotic bone can result in tumor recurrence at the cribriform plate with extension into the paranasal sinuses. Resection has traditionally been performed using a bifrontal or pterional approach, both of which require some degree of brain retraction or manipulation to expose the tumor. The endoscopic endonasal transcribriform approach offers the most direct and immediate exposure to the tumor without brain retraction and manipulation of neurovascular structures. An endonasal "keyhole craniectomy" is performed in the ventral skull base directly over the basal dural attachment, extending from the posterior wall of the frontal sinus to the planum sphenoidale and tuberculum sellae in the anteroposterior plane, and from one medial orbit to the other in the coronal plane. Excellent panoramic visualization of the keyhole skull base defect can be obtained with a 30° endoscope after performing a modified Lothrop procedure. Because the dural attachment is adjacent to the paranasal sinuses, early devascularization and total Simpson Grade I removal of the tumor including the dural attachment and underlying hyperostotic bone can be achieved in properly selected patients. This approach is also very suitable for meningiomas that have recurred or extended into the paranasal sinuses. Extracapsular, extraarachnoid dissection of the tumor from the frontal lobes and neurovascular structures can be performed using conventional bimanual microsurgical techniques. In this report, we review the surgical technique and describe our operative nuances for removal of olfactory groove meningiomas, including recurrent tumors with extension into the nasal cavity, using a purely endoscopic endonasal transcribriform approach. In addition, we discuss the advantages, limitations, patient selection, and complications of this approach. We specifically highlight our technique for multilayer reconstruction of large anterior skull base dural defects using fascia lata and acellular dermal allograft supplemented by bilateral vascularized pedicled nasoseptal flaps. Three new cases of endoscopically resected olfactory groove meningiomas are also presented.

Endoscopic nasal and anterior craniotomy resection for malignant nasoethmoid tumors involving the anterior skull base

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.

Metastatic olfactory neuroblastoma invading a radiation-induced meningioma

Olfactory neuroblastomas are malignant, neuroectodermal nasal tumours. We describe a 62-year-old patient with a recurrent olfactory neuroblastoma invading a radiation-induced meningioma. Given the temporal and spatial relationship between the primary lesion and the described recurrence, this was due to metastatic rather than direct contiguous spread, fulfilling all the criteria for true tumour-to-tumour metastasis. To our knowledge, this is the first description of an olfactory neuroblastoma metastasising to a meningioma.

Endoscopic resection of sinonasal malignancies

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.

Endonasal endoscopic resection of esthesioneuroblastoma: the Johns Hopkins Hospital experience and review of the literature

Esthesioneuroblastoma is an uncommon malignant tumor originating in the upper nasal cavity. The surgical treatment for this tumor has traditionally been via an open craniofacial resection. Over the past decade, there has been tremendous development in endoscopic techniques. In this report, we performed a retrospective analysis of patients with esthesioneuroblastomas treated with a purely endonasal endoscopic approach and resection at the Johns Hopkins Hospital between January 2005 and April 2010. A total of eight patients with esthesioneuroblastoma, five men and three women, were identified. Six patients were treated for primary disease, and two were treated for tumor recurrence. The modified Kadish staging was A in one patient (12.5%), B in two patients (25%), C in four patients (50%), and D in one patient (12.5%). All patients had a complete resection with negative intraoperative margins. One patient had intraoperative hypertension; there were no perioperative complications. With a mean follow-up of over 27 months, all patients are without evidence of disease. In addition, we reviewed the literature and identified several overlapping case series of patients with esthesioneuroblastoma treated via a purely endoscopic technique. Our series adds to the growing experience of expanded endonasal endoscopic surgery in the treatment of skull base tumors including esthesioneuroblastoma. Longer follow-up on a larger number of patients is required to further demonstrate the utility of endoscopic approaches in the management of this malignancy.

Clinico-pathological profile of head and neck malignancies at University College Hospital, Ibadan, Nigeria

INTRODUCTION

This retrospective study analysed head and neck malignancies seen over a 19-year period at the University College Hospital, Ibadan.

METHODOLOGY

One thousand, one hundred and ninety two patients with head and neck malignancies were analysed according to age, gender, topography and histology.

RESULTS

There was an annual hospital frequency of 62 cases per year. The overall mean age for these malignancies was 43.9 (SD ± 19.3) years. The lesions from the respiratory tract were the most frequent (43.2%) of all cases. The palate was the most frequent intra-oral site (13.8%). Epithelial malignancies constituted 73.4% of all cases with a male: female ratio of 2:1, a mean age of 48.1 (SD ± 17.5) years and were mostly located in the larynx (19.7%). Lymphomas constituted 17.5% of all head and neck cancers with a male: female ratio of 1.6:1, a mean age of 35.1 (SD ± 20.6) years and nodal involvement (39.7%) was most common. Sarcomas constituted 8.9% of all malignancies with a male: female ratio of 1.5:1, mean age of 27.1 (SD ± 16.7) years and the maxillofacial bones (42.5%) were most commonly involved. Neuroendocrine malignancies accounted for 0.2% of head and neck malignancies with a male: female ratio of 1:1, a mean age of 28.5 (SD ± 6.4) years and both cases involved the nose.

CONCLUSION

This study has further confirmed that carcinomas remain the most frequent cancers of the head and neck region in south-western Nigeria.

Outcome results of endoscopic vs craniofacial resection of sinonasal malignancies: a systematic review and pooled-data analysis

BACKGROUND

Endoscopic approaches of sinonasal malignancies are now being described. This study aims to conduct a systematic review with a pooled-data analysis to compare outcomes of endoscopic vs craniofacial resection of sinonasal malignancies.

METHODS

A search was conducted of MEDLINE (1966-2008), EMBASE (1980-2008), Cochrane Central Register of Clinical Trials (CENTRAL), Cochrane Database of Systematic Reviews, clinicaltrials.gov, and The National Guideline Clearinghouse databases and supplemented by references in retrieved articles. All authors used a detailed list of inclusion and exclusion criteria to determine articles eligible for final inclusion. The authors extracted data regarding study criteria appraisal, sinonasal malignancy characteristics, survival outcomes, and recurrence. Kaplan-Meier survival and locoregional control rates were calculated and compared using the log-rank test.

RESULTS

Of the 2314 citations reviewed, the search yielded 15 case series with individual data on 226 patients. The most common malignancies were esthesioneuroblastoma (47%), adenocarcinoma (24%), and undifferentiated carcinoma (22%). The overall 5-year survival rate for the sample was 56.5% (standard error [SE] ± 3.8). Because of the paucity of data with endoscopic resection of high-stage malignancies, the outcome results were highly variable and no useful comparison could be made. Among low-stage malignancies (T1-2 or Kadish A-B), the endoscopic and open approaches demonstrated no statistically significant difference in outcome results. The 5-year overall survival was 87.4% (SE ± 5.3) in the endoscopic group vs 76.8% (SE ± 8.3) for open approaches (p = 0.351); disease-specific survival was 94.7% (SE ± 3.7) vs 87.7% (SE ± 6.7; p = 0.258); and locoregional control rate was 89.5% (SE ± 5.0) vs 77.2% (SE ± 10.4; p = 0.251).

CONCLUSION

Transnasal endoscopic resection appears to be a reasonable alternative to craniofacial resection in the management of low-stage sinonasal malignancies.

Retained role of surgery for olfactory neuroblastoma

BACKGROUND

Olfactory neuroblastoma is a rare paranasal sinus malignancy. The traditional approach was craniofacial resection (CFR) and then postoperative radiotherapy until 1998. This review will chart development of a new protocol.

METHODS

This ethics-approved audit evaluated the number of new patients diagnosed with olfactory neuroblastoma, with information relating to patient, disease, and treatment factors noted.

RESULTS

There were 24 eligible patients, 16 men, 8 women, 7 Kadish stage B, 17 stage C. The planned treatment was: chemotherapy (cisplatin/etoposide) and determine treatment dependent on response in 6 patients, surgery and radiotherapy in 16 patients, and single-modality treatment only (surgery, radiotherapy 1) in 2 patients. Surgery to radiotherapy occurred in 17 patients. With salvage treatment ultimate local control was 79%.

CONCLUSIONS

There was a higher local control in those patients who had surgery; abandoning this may carry a higher risk of local failure. The use of response to chemotherapy to determine local treatment remains experimental.

Endoscopic skull base/sinonasal adenocarcinoma surgery: what evidence exists?

BACKGROUND

This study reviewed the published outcomes literature on endoscopic or endoscopic-assisted treatment of sinonasal and skull base adenocarcinoma (SSBA). A systematic literature review was performed.

METHODS

A PubMed search of English language articles on endoscopic or endoscopic-assisted SSBA was performed. Each article was examined for patient data and outcomes for analysis.

RESULTS

Sixteen articles (150 retrospective cases) using endoscopic or endoscopic-assisted SSBA were identified. Three (19%) reported at least 15 cases of adenocarcinoma with 5-year survival ranging from 53 to 83%. In all identified studies, five (31%) reported adenocarcinoma-specific survival statistics and eight (50%) provided complete patient information. Adjuvant therapy was used in 12 studies (75%), with details outlined in 6 (38%) articles, accounting for 52 of 74 cases (70% of those patients and 35% overall). Adenocarcinoma-specific follow-up was reported in only nine studies (56%); four of these nine articles had a median/mean follow-up time of <3 years. Six articles (38%) used American Joint Committee on Cancer guidelines and four articles (25%) used International Union Against Cancer guidelines. The remaining six articles (38%) did not report on the stage of treated tumors. Four articles (25%) reported length of hospital stay and eight (50%) reported complication data. Three studies comprising 61 cases (41% of overall patients) recorded disease status, tumor stage, site involvement, and complication rates for each patient.

CONCLUSION

From the existing body of data, one can not conclude that endoscopic methods are superior or inferior to open methods, but there is growing evidence that this is an efficacious technique. Future studies should have emphasis on detailed, prospective reporting.

Posttreatment prognosis of patients with esthesioneuroblastoma

OBJECT

There is no Class I evidence to guide the appropriate management of esthesioneuroblastoma (EN). Most data currently guiding treatment come from small- or modest-sized series gathered at individual centers that have concluded that surgery with radiotherapy is the preferred treatment. In this study, the authors summarize the published literature on treatment outcomes in patients with EN. The objective was to ascertain what variables predict prognosis in these patients and to determine the relative effect of different therapies.

METHODS

The authors identified 205 published studies containing treatment outcomes for surgery, radiotherapy, chemotherapy, or multimodal treatment. Using Kaplan-Meier analysis, the survival of patients who received surgery was compared with that in those who received surgery and radiotherapy. Additionally, Kadish staging was compared with low- and high-grade Hyams criteria to assess for subgroup prognostic significance in survival differences.

RESULTS

Nine hundred fifty-six patients met the inclusion criteria, with a median follow-up time of 3 years. Kaplan-Meier analysis demonstrated no difference in survival between patients who underwent surgery alone and those who underwent surgery plus radiotherapy at 5 years (78 vs 75%) or 10 years (67 vs 61%, respectively) (p = 0.3). Univariate analysis demonstrated worse survival in cases involving Kadish Grade C tumors, Hyams Grade 3 and 4 tumors, and in patients older than 65 years of age. Multivariate analysis demonstrated that Hyams Grade 3 and 4 lesions carried significant risk (proportional hazard = 4.83, p < 0.001) with 5- and 10-year survival of 47 and 31%.

CONCLUSIONS

A biopsy should always be obtained in cases suspected of EN because histology is a strong prognostic indicator and will help guide appropriate treatment. Unimodal surgery and combined surgery/radiotherapy appear to be of equivalent efficacy with respect to survival in patients with EN. Chemotherapy should be considered in high-grade EN.

Malignant ethmoidal neoplasms: a cranionasal endoscopy approach

Craniofacial resection has been adopted worldwide as the standard therapy for tumors of the paranasal sinuses involving the anterior skull base. Recent refinements in endoscopic techniques together with the development of related surgical instruments allow complete radical resection of complex anatomic structures through combined transcranial and endonasal approaches without compromising any oncological principles. We use a transcranial nasoendoscopic approach for ethmoid malignant tumors in stage I and II according to the Instituto Nazionale Tumori, Milano staging. With this technique, no cutaneous incisions and no approaching osteotomies of the facial skeleton were performed. This approach reduces the period of hospitalization and speeds recovery. Furthermore, intraoperative endoscopy facilitates placement of the osteotomies in the optimal position and improves the likelihood of achieving a complete en bloc resection with removal of all disease hitherto obscured from vision. It represents the choice indication to increase precocious postsurgery radiotherapy possibilities.

Esthesioneuroblastoma methods of intracranial extension: CT and MR imaging findings

INTRODUCTION

Esthesioneuroblastoma (ENB) is an aggressive neuroectodermal malignancy in the upper nasal cavity with local infiltration and lymphatic or hematogenous metastasis. The purpose of this paper is to document three types of direct intracranial extensions by ENB using computed tomography (CT) and magnetic resonance imaging (MRI).

METHODS

Eleven patients with pathologically confirmed ENB were admitted in our hospital between December 2002 and December 2008. Their magnetic resonance (MR; n = 10) and CT (n = 8) images were retrospectively reviewed, and particular attention was paid to tumor location and extension, enhancement pattern, cervical lymph node metastasis, and Kadish stage.

RESULTS

The majority of patients were male (8/11) with Kadish stage C tumor (10/11). Three types of direct intracranial extension by ENBs were put forward according to their MR and CT findings. The primary tumors were well-defined soft-tissue masses centered in the roof of the nasal cavity eroding into the paranasal sinuses (11/11), the contralateral nasal cavity (4/11), the cranial cavity (5/11), and the fossa orbitalis (3/11). The tumor parenchyma were hypointensity on T1-weighted images, heterogeneous hyperintensity on T2-weighted images, and isodensity or slight hyperdensity on CT images with scattered necroses (4/11) and marginal cysts(4/11). Their enhancements were significant and inhomogeneous. Cervical lymph nodes metastases were observed in four patients (4/11), but no pathologically proved distant metastasis was observed.

CONCLUSION

Three types of direct intracranial extensions by ENB can be found on CT and MRI: cranio-orbital-nasal-communicating ENB, cranio-nasal-communicating ENB, and orbital-nasal-communicating ENB.

Treatment of esthesioneuroblastoma: a 16-year meta-analysis of 361 patients

OBJECTIVES/HYPOTHESIS

This study reviews the published outcomes related to surgical (open, endoscopic, and endoscopic-assisted) and nonsurgical treatment for esthesioneuroblastoma.

STUDY DESIGN

Literature meta-analysis.

METHODS

A meta-analysis of individual patient data for esthesioneuroblastoma publications between 1992 (the earliest identified description of endoscopic resection) and 2008 was conducted. A total of 49 journal articles, comprising 1,170 cases of esthesioneuroblastoma, were included in the study. Criteria for meta-analysis inclusion were five or more patients in a study with sufficient patient data resolution for analysis. Twenty-three studies comprising 361 patients met all inclusion criteria. The overall treatment and outcome at final follow-up of each patient was recorded. Patients were pooled according to treatment techniques and compared to one another using a Kaplan-Meier survival curve and the Mann-Whitney U test to examine differences in follow-up times and publication years.

RESULTS

Log-rank tests showed a greater published survival rate for endoscopic surgery compared to open surgery (P = .0019), even when stratifying for publication year (P = .0018). There was no significant difference in follow-up time. Review of Kadish tumor staging for each modality showed larger tumors were more often treated with an open approach, but open and endoscopic survival measures were comparable.

CONCLUSIONS

These results suggest that endoscopic surgery is a valid treatment method with comparable survival to open surgery. Further prospective analysis will be beneficial.

Endoscopic endonasal resection of esthesioneuroblastoma: a multicenter study

BACKGROUND

This study reports the combined experience of the University of Miami and University of Pittsburgh with endoscopic endonasal resection of esthesioneuroblastoma (ENB). A retrospective case series review was performed in a tertiary care university hospital.

METHODS

Twenty-three patients, 16 men and 7 women, were reviewed. Mean age was 56.6 years (15-79 years). Nineteen patients received primary endoscopic endonasal anterior skull base resection. Of these, the modified Kadish stage at presentation was A in 2 patients, B in 11 patients, C in 5 patients, and D in 1 patient. Three patients had revision surgeries for recurrent tumors. The main outcome measures were complete resection and margin assessment, short-term and long-term complications, and recurrence rate.

RESULTS

Complete resection and negative intraoperative resection margins were achieved endoscopically in 17 of the primarily treated cases. The two other cases had one patient that required an additional craniotomy approach to complete the resection of a positive lateral dual margin, another patient had positive margins at the orbital apex. All patients tolerated the endoscopic procedure very well with no meningitis. There were four cerebral spinal fluid leaks. Mean follow-up period for the primarily treated cases was 45.2 months (11-152 months), all were disease free at the most recent available follow-up.

CONCLUSION

In experienced hands and carefully selected patients, endoscopic resection of ENB respects the principles of oncologic surgery, providing an adequate exposure for margin assessment as well as reliable reconstruction of the anterior skull defect with a relatively low morbidity.

Endoscopic versus traditional craniofacial resection for patients with sinonasal tumors involving the anterior skull base

OBJECTIVES

With the advent of microdebriders and image guidance systems, endoscope-assisted surgery is now more widely used for the treatment of tumors involving the base of the skull. The aim of this study was to analyze the clinical features of tumors involving the anterior skull base and to evaluate the treatment outcomes according to the surgical approach, which included the traditional craniofacial resection (TCFR) and the endoscopic craniofacial resection with craniotomy (ECFR).

METHODS

Forty-six patients who underwent craniofacial resection from 1989 through 2006 at Seoul National University Hospital and Seoul National University Bundang Hospital were included in this study. Demographics, histology, surgical management, surgical outcomes, complications, and morbidity were analyzed.

RESULTS

The number of malignant and benign lesions was 40 and 6 cases respectively. The most common diagnosis was olfactory neuroblastoma occurring in 41% of the cases followed by squamous cell carcinoma and malignant melanoma. Thirty-six patients underwent TCFR, while ECFR was performed with or without adjunctive chemotherapy or radiotherapy in 10 patients. The overall five-year survival rate for patients with malignant tumors of the anterior skull base was 47.4%. Out of 19 patients with olfactory neuroblastomas, 10 patients had TCFR and six among them died of their disease. Nine patients underwent ECFR, and none of them died of their disease. The ECFR group had lower morbidity and cosmetic deformity than did the TCFR group.

CONCLUSION

The ECFR may be considered as an alternative option for the treatment of selected tumors with anterior skull base invasion. This approach offers the advantages of avoiding facial incisions with comparable treatment results.

Esthesioneuroblastoma: 25-year experience at a single institution

OBJECTIVES

To evaluate outcomes for patients with esthesioneuroblastoma treated at a single institution during a 25-year period.

DESIGN

Eighteen patients with pathologic diagnosis of esthesioneuroblastoma between 1980 and 2004 were retrospectively identified.

RESULTS

Two patients had Kadish A, seven had Kadish B, and nine had Kadish C disease. The mean follow-up was 71 months. Treatment regimens consisted of surgery alone (four patients), surgery followed by postoperative radiation (six patients), surgery followed by postoperative chemoradiotherapy (three patients), preoperative radiotherapy (two patients), preoperative chemoradiotherapy (one patient), chemoradiotherapy (one patient), and surgery plus chemotherapy (one patient). Surgical approaches (n = 17) consisted of 13 traditional craniofacial resections, one endoscopic-assisted cranionasal resection, and three minimally invasive endoscopic resections. The 10-year disease-specific survival was 80%. The overall recurrence-free survival at five and 10 years was 62% and 46%, respectively. Positive surgical margins and TNM staging predicted survival.

CONCLUSION

Both endoscopic and open surgical approaches have been successful in treating a small number of esthesioneuroblastoma patients with high survival and low rate of surgical complications.

Craniofacial resection for malignant nasal and paranasal sinus tumors assisted with the endoscope

BACKGROUND

Craniofacial resection is regarded as the treatment of choice for paranasal malignant tumors invading the skull base. Even with this approach, the surgical view remains obscured when tumors in the deep nasal and paranasal sinuses are resected. Endoscopy provides a wide and clear surgical view in the deep and narrow nasal cavity. We report two patients who underwent craniofacial resection assisted with endoscope.

METHODS

Two patients with malignant paranasal sinus tumor invading the anterior skull base underwent endoscope-assisted craniofacial resection.

RESULTS

To avoid a limited surgical view in the sinonasal cavity, we performed craniofacial resection with endoscopic osteotomy and several procedures in the nasal cavity. The neurosurgeon performed anterior skull base osteotomy at an appropriate site from above, while the otolaryngologist provided illumination with the endoscope from below and preserved the adjacent structures. The patients recovered uneventfully and the endoscopic examinations of both patients 18 months after the surgery showed no recurrence.

CONCLUSIONS

Endoscopes were useful for the craniofacial resection at osteotomy, providing illumination from below and at the several procedures in the deep part of the nasal cavity. If a lateral rhinotomy incision is made, the combined transfacial and transnasal approaches avoid the limited working angle associated with the transnasal approach alone. Although an endoscopic approach is useful for treating sinonasal tumors, we should recognize its advantages and limitations.

Endoscopic Surgery for Malignant Tumors of the Sinonasal Tract and Adjacent Skull Base: A 10-year Experience

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Olfactory neuroblastoma: long-term clinical outcome at a single institute between 1979 and 2003

CONCLUSIONS

The progression of olfactory neuroblastoma showed a biphasic pattern. As well as Hyams' histopathological grading and neck metastasis at presentation, early phase recurrence should be regarded as an important prognosticator. A high local failure rate suggests that craniofacial resection followed by postoperative radiotherapy should still be the standard treatment for olfactory neuroblastoma.

OBJECTIVE

The aim of this study was to evaluate factors associated with survival and local control of olfactory neuroblastoma in the long run and to estimate treatment strategies.

PATIENTS AND METHODS

Twelve patients (seven men and five women) who had undergone initial curative treatment for olfactory neuroblastoma were retrospectively analyzed.

RESULTS

Cause-specific 10-year survival was 64.8%, while disease-free 10-year survival remained 28.6%. Local failure was found in half of the patients. All of the three patients who did not receive radiotherapy developed local failure. A biphasic pattern of recurrence was observed. The early phase recurrence group showed a significantly poorer survival than the late phase recurrence group. Hyams' histopathological grading and neck metastasis at presentation were also correlated with survival.

Esthesioneuroblastoma

Esthesioneuroblastoma is a rare tumor for which the published literature does not provide an evidence-based consensus treatment approach. Multimodality therapy including a combination of surgery and radiation appears to provide the best disease-free and overall survival. Surgical resection should proceed through a craniofacial approach if possible. The role of chemotherapy in the initial treatment paradigm is less clear. Chemotherapy should not be used as single-modality therapy for initial treatment but may provide additional benefit when used in combination with radiation and surgery, particularly in advanced-stage disease. Combination chemotherapy should be considered as initial therapy for unresectable tumors and metastatic disease, and as salvage therapy in disease recurrence.