Definitive Radiotherapy for Juvenile Nasopharyngeal Angiofibroma

Proton Therapy for Advanced Juvenile Nasopharyngeal Angiofibroma

PURPOSE

To provide the first report on proton radiotherapy (PRT) in the management of advanced nasopharyngeal angiofibroma (JNA) and evaluate potential benefits compared to conformal photon therapy (XRT).

METHODS

We retrospectively reviewed 10 consecutive patients undergoing PRT for advanced JNA in a definitive or postoperative setting with a relative biological effectiveness weighted dose of 45 Gy in 25 fractions between 2012 and 2022 at the Heidelberg Ion Beam Therapy Center. Furthermore, dosimetric comparisons and risk estimations for short- and long-term radiation-induced complications between PRT plans and helical XRT plans were conducted.

RESULTS

PRT was well tolerated, with only low-grade acute toxicities (CTCAE I-II) being reported. The local control rate was 100% after a median follow-up of 27.0 (interquartile range 13.3-58.0) months. PRT resulted in considerable tumor shrinkage, leading to complete remission in five patients and bearing the potential to provide partial or complete symptom relief. Favorable dosimetric outcomes in critical brain substructures by the use of PRT translated into reduced estimated risks for neurocognitive impairment and radiation-induced CNS malignancies compared to XRT.

CONCLUSIONS

PRT is an effective treatment option for advanced JNA with minimal acute morbidity and the potential for reduced radiation-induced long-term complications.

Radiation Therapy Improves Local Control in Juvenile Nasopharyngeal Angiofibroma following Disease Progression after Embolization and Surgical Resection: A Case Report

Juvenile nasopharyngeal angiofibroma (JNA) is a relatively uncommon, benign neoplasm of the nasopharynx that can be very difficult to diagnose early due to inconspicuous and seemingly harmless presenting symptoms. Early diagnosis and treatment of JNA are essential for a good prognosis. JNA typically responds well to radiation therapy (RT), but when it does not, the most appropriate next course of action has not been readily defined due to the limited occurrence and experience with this neoplasm. Herein, we describe a JNA patient, who continued to progress after surgery and 36 Gy of adjuvant radiation, but after an additional 14.4 Gy, he has remained in remission for over 2 years. An 11-year-old boy who presented with JNA underwent treatment with embolization and surgical resection. Unfortunately, the tumor progressed within 2 months of surgical intervention and he required RT for adequate local control. While undergoing RT, he again demonstrated signs of progression; so his radiation regimen was increased from 3,600 cGy in 20 fractions to 5,040 cGy in 28 fractions. Since completing RT, the tumor has continued to decrease in size, and the patient is stable and has been without signs of disease progression for over 24 months now. Thus, escalating the radiation regimen to 5,040 cGy may improve local control in rapidly progressive JNA.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Radiation-Induced Sarcoma Originating in Recurrent Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma is a benign disease affecting young males with a propensity to invade intracranially and into the orbit along preformed pathways. Complete surgical excision is the mainstay of management. Patients with multiple recurrences along with tumour extension into skull base and orbit can be considered for external beam radiation as either adjuvant or definitive treatment. Possibility of radiation-induced malignancy has been speculated by many authors, proof of which exists in only two studies so far. This report focuses on radiation-induced leiomyosarcoma in a patient with recurrent juvenile nasopharyngeal angiofibroma.

Juvenile Angiofibroma: Current Management Strategies

Juvenile angiofibroma (JA) is a benign, highly vascular tumor which is diagnosed on the basis of clinical and imaging features. It has a characteristic pattern of spread commonly involving the pterygopalatine fossa and pterygoid base. The mainstay of treatment is surgery, while radiotherapy is rarely used for the treatment of recurrent lesion. Endoscopic endonasal surgery is currently the treatment of choice for small to intermediate size JAs, and is feasible even for advanced lesions; however, this should only be practiced in well-experienced centers.

Nasal juvenile angiofibroma: Current perspectives with emphasis on management

Juvenile angiofibroma is an uncommon, benign, locally aggressive vascular tumor. It is found almost exclusively in young men. Common presenting symptoms include nasal obstruction and epistaxis. More advanced tumors may present with facial swelling and visual or neurological disturbances. The evaluation of patients with juvenile angiofibroma relies on diagnostic imaging. Preoperative biopsy is not recommended. The mainstay of treatment is resection combined with preoperative embolization. Endoscopic surgery is the approach of choice in early stages, whereas, in advanced stages, open or endoscopic approaches are feasible in expert hands. Postoperative radiotherapy (RT) or stereotactic radiosurgery seem valuable in long-term control of juvenile angiofibroma, particularly those that extend to anatomically critical areas unsuitable for complete resection. Chemotherapy and hormone therapy are ineffective. The purpose of the present review was to update current aspects of knowledge related to this rare and challenging disease. © 2017 Wiley Periodicals, Inc. Head Neck 39: 1033-1045, 2017.

Adjunctive Treatment in Juvenile Nasopharyngeal Angiofibroma: How Should We Approach Recurrence?

A recent case of advanced, recurrent juvenile nasopharyngeal angiofibroma (JNA) at our institution has highlighted the limited evidence regarding adjunctive treatment. We present the case of a 10-year-old boy who is the first to undergo multiple-staged surgical resections alongside vincristine treatment. We performed a review of the literature analyzing the roles of radiation therapy, cytotoxic drugs, and novel targeted agents in JNA relapse. Small cohort studies suggest radiotherapy and flutamide are the most rational treatment options for residual and recurrent JNA. Our review highlights the need for further research into the management of primary and recurrent JNA.

Endoscopic Radiofrequency Ablation–Assisted Resection of Juvenile Nasopharyngeal Angiofibroma

Objectives

To evaluate the feasibility of radiofrequency surgical instrumentation for endoscopic resection of juvenile nasopharyngeal angiofibroma (JNA) and to test the hypothesis that endoscopic radiofrequency ablation–assisted (RFA) resection will have superior intraoperative and/or postoperative outcomes as compared with traditional endoscopic (TE) resection techniques.

Study Design

Case series with chart review.

Setting

Two tertiary care pediatric hospitals.

Subjects and Methods

Twenty-nine pediatric patients who underwent endoscopic transnasal resection of JNA from January 2000 to December 2014.

Results

Twenty-nine patients underwent RFA (n = 13) or TE (n = 16) JNA resection over the 15-year study period. Mean patient age was not statistically different between the 2 groups ( P = .41); neither was their University of Pittsburgh Medical Center classification stage ( P = .79). All patients underwent preoperative embolization. Mean operative times were not statistically different ( P = .29). Mean intraoperative blood loss and the need for a transfusion were also not statistically different ( P = .27 and .47, respectively). Length of hospital stay was not statistically different ( P = .46). Recurrence rates did not differ between groups ( P = .99) over a mean follow-up period of 2.3 years.

Conclusion

There were no significant differences between RFA and TE resection in intraoperative or postoperative outcome parameters.

Nasopharyngeal angiofibroma: Our experience and literature review

Introduction: Juvenile nasopharyngeal angiofibroma is a rare, highly vascular, and histologically benign tumor, generally observed in male adolescents. It shows very aggressive behavior due to local invasiveness and is associated with various symptoms. Juvenile nasopharyngeal angiofibroma originates in the sphenopalatine forame, causing epistaxes and nasal obstruction.

Objective: To retrospectively describe our experience in the diagnosis and treatment of patients with juvenile nasopharyngeal angiofibroma.

Scientific drawing: Retrospective, descriptive study conducted after approval from the Ethics Committee of the Federal University of Sergipe (protocol 0114.0.107.000 -11).

Methods: We analyzed findings in 20 patients who underwent surgery between 2004 and 2011. Factors analyzed include patient age and gender, symptoms, stages, treatment, length of surgery, intraoperatory bleeding, postoperative need for nasal tampons, hospitalization time, complications, and tumor recurrence.

Results: Patients were aged 10–29 years. All patients were treated surgically, including 17 who underwent endoscopic surgery. The mean operation time was 120 min, and the mean bleeding volume was 300 mL. Seventeen patients required clamping of the external carotids and tumor embolization.

Conclusion: Endoscopic surgery alone or with other conventional techniques was safe for the treatment of angiofibromas of different stages.

Juvenile nasopharyngeal angiofibroma

Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, highly vascular, locally aggressive tumors that primarily affect male adolescents. Historical treatment of these neoplasms has been primarily surgical. In the past decade, endoscopic resection of JNAs has become a viable and promising surgical treatment option. Endoscopic resection has many advantages over traditional open techniques, including better cosmesis, decreased blood loss, shortened hospital stays, and equivalent or improved recurrence rates. Emerging endoscopic technology continues to push the boundaries of resection of skull base tumors and will no doubt become the surgical treatment of choice for most JNAs in the near future.

Juvenile angiofibroma: evolution of management

Juvenile angiofibroma is a rare benign lesion originating from the pterygopalatine fossa with distinctive epidemiologic features and growth patterns. The typical patient is an adolescent male with a clinical history of recurrent epistaxis and nasal obstruction. Although the use of nonsurgical therapies is described in the literature, surgery is currently considered the ideal treatment for juvenile angiofibroma. Refinement in preoperative embolization has provided significant reduction of complications and intraoperative bleeding with minimal risk of residual disease. During the last decade, an endoscopic technique has been extensively adopted as a valid alternative to external approaches in the management of small-intermediate size juvenile angiofibromas. Herein, we review the evolution in the management of juvenile angiofibroma with particular reference to recent advances in diagnosis and treatment.

The changing surgical management of juvenile nasopharyngeal angiofibroma

The management of juvenile nasopharyngeal angiofibroma (JNA) has changed during the last decades but it still continues to be a challenge for the multidisciplinary head and neck surgical team. The aim of this study was to review the used treatment approach and outcome of JNA in a single institution series of 27 patients diagnosed and treated during the years 1970-2009. All patients were male, with the median age of 17 years (range 11-33 years). Surgery was used as the primary treatment in every case. Surgical approaches varied, transpalatal approach (N = 14) being the most common approach used in this series. During the last decade various other techniques were applied, including endoscopic (N = 3) resection. Two patients were additionally treated with antiangiogenic agents and one patient with stereotactic radiotherapy. The primary recurrence rate was 37% and it seemed to correlate with vascular density of tumour and the surgical approach used. We suggest that the management of JNA should be planned by an experienced head and neck surgeon, as part of a multidisciplinary team, preferably in a tertiary referral setting, and the recent development of the available therapies should be taken into account to minimise the risk of recurrence.

Juvenile nasopharyngeal angiofibroma with intracranial extension: analysis of 23 Egyptian patients

The purpose of this study was to present our experience with definitive surgical management of patients with Juvenile nasopharyngeal angiofibroma with intracranial extension. The study included 23 male adolescents with histologically proven juvenile nasopharyngeal angiofibroma. The mean age was 14.7 years (12-20 years). CT, MRI+/-angiographies were for taken for the patients. Preoperative embolization was done with gel foam before the operation. Two surgical procedures were used; anterior subcranial transfacial transmaxillary approach (21 patients), while craniofacial resection was used in two patients. Middle cranial fossa was affected in 22 patients while anterior cranial fossa was affected in only one patient. Complete resection of the tumor was achieved in 19 patients with residual or recurrence in four patients. Complications of the surgical approaches were reported in 14 patients. The subcranial transfacial transmaxillary approach avoids the complications of craniotomy and provides adequate access for excision of Juvenile nasopharyngeal angiofibroma with intracranial extradural extension.

Juvenile Nasopharyngeal Angiofibroma: The Expanded Endonasal Approach

Background

Juvenile nasopharyngeal angiofibroma (JNA) is a benign but locally aggressively vascular tumor that may involve the skull base and extend intracranially. Endoscopic excision has become the new standard for smaller tumors but remains a challenge for large tumors, leading some to advocate radiation therapy. We reviewed our experience managing JNA, specifically with respect to utility of the expanded endonasal approach (EEA) for lesions with skull base and intracranial extension.

Methods

All cases of JNA at the University of Pittsburgh Medical Center from 1995 to 2006 were reviewed with respect to tumor size and location, vascular supply and results of embolization, skull base involvement and intracranial extension, surgical approach, blood loss, intraoperative and postoperative complications, and recurrence.

Results

Thirty-one cases of JNA were identified. The majority of tumors were completely excised using the EEA, regardless of size or extension into adjacent compartments. Surgical excision of some tumors with intracranial blood supply was staged. Recurrence rates were not associated with extent of tumor or surgical technique. Long-term morbidity was minimal.

Conclusion

Most JNA, regardless of tumor extent, may be completely excised using EEA alone or in combination with minor sublabial incisions avoiding the morbidity associated with larger open approaches or postoperative radiation therapy.

Critical look at the surgical approaches of nasopharyngeal angiofibroma excision and "total maxillary swing" as a possible alternative

OBJECTIVES

We critically analyzed different surgical approaches used for the excision of nasopharyngeal angiofibroma (NPA) at our hospital in a 10-year period and proposed "total maxillary swing" as a possible alternative approach.

METHODS

Retrospective review of the clinical and operative records was done regarding 39 cases of NPA that were surgically managed from 1995 to 2005. The duration of the surgical procedures, amount of blood loss and transfusion, time to recurrence, frequency of recurrence, functional and cosmetic deformity, and complications of all surgical procedures were thoroughly analyzed. These parameters were compared with total maxillary swing, a new approach recently being used by us, for the one-time excision of NPA.

RESULTS

A total of 61 operations including revision surgeries for recurrences were done in the 39 cases of NPA. Conventional surgical approaches were performed in 37 cases, and the total maxillary swing approach was used in 2 cases. This new approach provided a wider surgical exposure for complete tumor resection and better hemostasis without any recurrence or major functional deformity, which were seen with some of the conventional approaches.

CONCLUSIONS

We found total maxillary swing to be a relatively safe alternate approach for the resection of NPA. We removed the entire tumors in a wider surgical field under the microscope with reduced blood loss and minimal complications or chance of recurrences.