Nasopharyngeal endoscopic resection in the management of selected malignancies: ten-year experience

Salvage endoscopic nasopharyngectomy for recurrent nasopharyngeal carcinoma in a non-endemic area

PURPOSE

To analyze oncological outcomes of endoscopic surgical treatment of locally recurrent EBV-related undifferentiated non-keratinizing nasopharyngeal carcinoma (uNK-NPC) in a non-endemic area.

METHODS

Retrospective review of patients affected by recurrent uNK-NPC treated with nasopharyngeal endoscopic resection (NER) in a tertiary-care referral center from 2003 to 2022, by evaluating survival rates, prognostic factors, and follow-up strategies.

RESULTS

The oncological outcomes of 41 patients were analyzed, over a mean follow-up period of 57 months. The 5-year overall, disease-specific, and disease-free survival of the cohort were 60.7% ± 8.9%, 69% ± 9%, and 39.7% ± 9.2%, respectively. The local (rT) and regional (rN) extension of recurrent disease, stage of disease, and status of resection margins appeared to significantly influence survivals. After a mean follow-up period of 21 months, a further recurrence after NER was observed in 36.6% of cases. Skull base osteonecrosis induced by previous irradiation and post-surgical bone remodeling represent the major challenges for early detection of further local relapses during postoperative follow-up.

CONCLUSION

NER appeared as a safe and effective treatment for recurrent uNK-NPC. The adequate selection of patients eligible for NER is essential, to maximize the chances to cure and minimize the risk of local complications.

Interventional radiotherapy (brachytherapy) for re-irradiation of recurrent head and neck malignancies: oncologic outcomes and morbidity

Objective

Management of recurrent head and neck cancer (HNC) is challenging. One option in previously irradiated patients is re-irradiation using interventional radiotherapy (IRT), the modern form of brachytherapy. Re-irradiation using IRT can be delivered as an exclusive strategy for salvage or through a postoperative or perioperative approach after salvage surgery. The aim of the present study is to analyse a bicentric Italian series focusing on the use of IRT as a re-irradiation modality and assess the resulting evidence concerning oncologic outcomes and morbidity.

Methods

This is a retrospective study performed in two referral centres in Italy: Policlinico Universitario Agostino Gemelli in Rome and Azienda Ospedaliera Universitaria in Sassari. All patients who had previously received a full course of external beam RT and have been re-irradiated using high-dose-rate IRT between December 2010 and June 2023 were included. Patients were retreated either by a combination of surgery and perioperative (either endocavitary or interstitial) IRT or by exclusive interstitial IRT.

Results

Thirty-four patients were included in the present series, 2 of whom underwent more than one IRT re-irradiation. Notably, no patient reported specific IRT-related toxicities. Median follow-up, excluding patients who died of HNC, was 24.5 months. Two-year local relapse-free survival was 26%, disease-specific survival 39.1%, and overall survival 36.6%.

Conclusions

The present series is the largest reported experience of re-irradiation by IRT for HNC in Italy. The very low rate of toxicity confirms IRT as the safest re-irradiation modality. It is noteworthy to underline that IRT is a multidisciplinary strategy based on the close cooperation between surgeons and radiation oncologists during every phase, from the recommendation of treatment and implantation in the operating theatre, to its prescription and dose painting.

Outcomes of Recurrent Nasopharyngeal Carcinoma Patients Treated With Salvage Surgery: A Meta-Analysis

Objective

To assess the efficacy of treatment outcomes of salvage surgery for recurrent nasopharyngeal carcinoma (rNPC).

Methods

We conducted a detailed search of the literatures in biomedical databases published from January 1990 to December 2020. The main research features and results of interest were retrieved from the articles that met the selection criteria for meta-analysis.

Results

A total of 21 articles with 778 patients were included, 17 of which met the meta-analysis inclusion criteria. The pooled 2-year overall survival (OS), 5-year OS, and 2-year disease-free survival (DFS) were 71%, 50% and 61%, respectively. Subgroup analysis was conducted with postoperative adjuvant therapy. The pooled 2-year OS, 5-year OS and 2-year DFS of the postoperative adjuvant therapy group compared with the surgery alone group were 69% vs 72%, 44% vs 56%, and 77% vs 54%, respectively. Univariate and multivariate analyses were performed on 178 patients with detailed individual postoperative survival data in 10 articles. On multivariate analysis, recurrent T (RT) stage and adjuvant therapy were independent predictors of outcomes.

Conclusions

This meta-analysis indicated that recurrent NPC patients can obtain survival benefits from salvage surgery. Accurately assessing the RT stage of the tumor and choosing the appropriate surgical method are important to the success of the surgery. Although the prognostic factors influencing outcome have been studied, conclusive data on the survival benefits are still lacking. Random controlled trials (RCTs) to compare surgery alone and postoperative adjuvant therapy are needed in patients with positive margin status after salvage surgery.

Types of Transnasal Endoscopic Nasopharyngectomy for Recurrent Nasopharyngeal Carcinoma: Shanghai EENT Hospital Experience

Background

Transnasal endoscopic nasopharyngectomy (TEN) has become increasingly used for recurrent nasopharyngeal carcinoma (rNPC); however, there is no report on the definitive resectable contour for TEN according to the latest staging system for nasopharyngeal carcinoma. The aim of this study was to establish the types of TEN for rNPC.

Materials and Methods

A total of 101 rNPC patients underwent TEN from January 2016 to April 2019 at the authors’ institution. TEN was categorized into four types, which included type I (n=40) with resection of the nasopharynx and sinuses; type II (n=10) with lateral extension to the parapharyngeal space; type III (n=40) with lateral extension to the floor of the middle cranial fossa and the infratemporal fossa and superior extension to the orbital apex and the cavernous sinus back to the prevertebral region; and type IV (n=11) with the resection of the involved internal carotid artery following type III. The 2-year overall survival rate (OS) and local recurrence-free survival rate (LRFS) were assessed.

Results

The median time of follow-up was 20 months. Twenty-five patients reoccurred. Nineteen patients died. Independent predictors of outcome on multivariate analysis were recurrent T stage (P = 0.039), types of TEN (P = 0.002) and surgical margin (P = 0.003). The 2-year OS and LRFS was 76.2% and 53.6%, respectively.

Conclusions

The result of TEN in the treatment of rNPC is promising. The types of TEN will provide effective guideline for surgical treatment of rNPC.

Volumetric Analysis of Endoscopic and Maxillary Swing Surgical Approaches for Nasopharyngectomy

Objectives/Hypothesis  The endoscopic endonasal approach (EEA) for nasopharyngectomy is an alternative to the maxillary swing approach (MSA) for selected recurrent nasopharyngeal carcinomas (NPC). We compare the access between these approaches. Methods  Three cadaver specimens were used to compare access volumes of the EEA and MSA. Exposure volumes were calculated using image guidance registration to cone beam computed tomography and tracking of accessible tissue with volumetric quantification. The area of exposure to the carotid artery was measured. Results  The MSA provided higher volumes for access volume compared with the EEA (66.6 vs 39.1 cm ³ , p  = 0.009). The working area was larger in the MSA (80.2 vs 56.9 cm ² , p  = 0.06). The exposure to the carotid artery was higher in the MSA (1.88 vs 1.62 cm ² , p  = 0.04). The MSA provided larger volume of exposure for tumors of the parapharyngeal space with exposure below the palate. Conclusions  This study suggests that the MSA for nasopharyngectomy provides a larger volume of exposure. However, much of the increased exposure relates to exposure of the parapharyngeal space below the palate. The EEA provides adequate access to superior anatomical structures.

Salvage endoscopic nasopharyngectomy for local recurrent or residual nasopharyngeal carcinoma: a 10-year experience

BACKGROUND

Our aim was to review the outcomes of endoscopic nasopharyngectomy performed on a large series of patients with residual or recurrent nasopharyngeal carcinomas and to identify the prognostic factors.

METHODS

Ninety-one patients with residual (10) and recurrent (81) nasopharyngeal carcinomas who underwent endoscopic nasopharyngectomy were enrolled in our study. Clinical information including gender, age, medical history, symptoms, radiographic findings, tumor stage, treatment, recurrence time, postoperative pathological examination, complications, and outcomes at last follow-up visit was collected. The survival curves and multivariate survival analysis were analyzed using the Kaplan-Meier and Cox proportional hazards model.

RESULTS

Our study included 71 men and 20 women with a median age of 51 years. The lesions were staged as follows: rT1, 30; rT2, 13; rT3, 29; and rT4, 19. No serious operative or postoperative complication was observed. The median follow-up period was 23 months (range, 4-109 months). Tumor necrosis was identified in 40 of 91 patients. At the last follow-up, 42 patients were free of disease, 10 were alive with disease, and 39 had died. At 2- and 5-year follow-up, the overall survival rates were 64.8% and 38.3%, respectively; the disease-free survival rates were 57.5% and 30.2%, respectively, for the two periods. Multivariate analysis showed that T classification (P = 0.02) and tumor necrosis (P = 0.024) were independent risk factors.

CONCLUSIONS

Endoscopic nasopharyngectomy is a feasible and effective surgical treatment for recurrent and residual nasopharyngeal carcinomas.

Anatomy Relationship around Internal Carotid Artery in the Endoscopic Surgery of Nasopharynx: A Study Based on Computed Tomography Angiography

Objective Anatomic knowledge is needed to avoid injury to internal carotid artery (ICA) during the endoscopic surgery around nasopharynx and its surrounding space. Design We prospectively studied the computed tomography angiography (CTA) data of 28 patients with image processing software. Special attention was given to ICA and various landmarks around nasopharynx. Results The anatomic relationship between ICA and different landmarks around nasopharynx was clearly presented in three-dimension. The fossa of Rosenmuller is the nearest point of the nasopharyngeal cavity to ICA. The opening of the Vidian canal in the middle cranial fossa could be either above, below, or at the level of the horizontal segment of petrous ICA. The pharyngeal trunk of the ascending pharyngeal artery can also be clearly identified in most reconstructed CTA images. Multiple anatomic relationships were also quantified. Conclusions Reconstructed CTA can provide key anatomic information for a safe and accurate endoscopic dissection around nasopharynx.

Endoscopic endonasal resection of sinonasal and skull base malignancies in children: feasibility and outcomes

BACKGROUND

The aim of this study is to present our experience in treating paediatric sinonasal and skull base malignancies with exclusively endonasal endoscopic approach and measure its feasibility.

METHODS

This study is a retrospective review of seven patients under age of 19 years who have sinonasal and skull base malignancies and treated with endoscopic endonasal approach. The main outcome measures are the surgical resection, complications, survival rate, recurrence and gross facial growth.

RESULTS

Radical tumour resection was achieved in all cases with negative margins; no major complications were observed. Mean follow-up was 65 months and no evidence of recurrences. Facial growth assessment showed no gross changes.

CONCLUSION

In selected cases, endoscopic endonasal approach of paediatric sinonasal and skull base malignancies could be an alternative approach. Despite of our few cases, it showed a feasibility of this technique with satisfactory oncological control. A further collaborative study with larger number is needed to have more valid conclusion.

The temporo-parietal fascial flap in extended transnasal endoscopic procedures: cadaver dissection and personal clinical experience

Due to progressively expanded indications of endoscopic transnasal surgery, having different reconstructive options in the armamentarium becomes of paramount importance. We herein report our experience with the use of the temporo-parietal fascial flap after extended endoscopic procedures for malignancies of the clival and nasopharyngeal regions. We focus our report on the surgical anatomy of this flap and the technique for its intranasal transposition through an infratemporal corridor. The main steps of the procedure and anatomic landmarks were highlighted, thanks to previous cadaver dissection. Five patients underwent an extended endoscopic resection for malignant tumors: one with persistent clival chordoma, three with recurrent nasopharyngeal carcinomas, and 1 recurrent nasopharyngeal adenoid cystic carcinoma. In all patients a temporo-parietal fascial flap was harvested to protect critical structures or irradiated denuded bone. The Mean harvesting and hospitalization time were 120 min and 5 days, respectively. No major or minor complications were observed. Whenever local flaps are not available for oncologic reasons or previous surgery, the temporo-parietal fascial flap is a safe and relatively easy option to protect the residual skull base and critical structures such as the internal carotid artery and dura of the posterior cranial fossa, after extended endoscopic resections.

[Interdisciplinary skull base surgery. From explorative crater cavity surgery to predictive tunnel surgery?]

Total endoscopic or endoscopy-assisted surgical procedures are becoming more and more important for skull base surgery. In particular at the frontal skull base endoscopic procedures with planned opening of the subarachnoidal space have mostly replaced the microscope because of the good experiences in functional endoscopic sinus surgery (FESS). The advantages for the patients of endoscopic procedures with planned opening of the subarachnoidal space measured by criteria, such as mortality, morbidity or recurrence rate are unclear due to a lack of valid study data according to the criteria of evidence-based medicine.