Craniofacial resection for malignant tumors involving the skull base in the elderly

BACKGROUND:

In this study by the International Collaborative Group, the authors examined a large cohort of patients accumulated from multiple institutions that had experience in craniofacial surgery with the objective of reporting outcomes and complications for craniofacial resection (CFR) in the elderly.

METHODS:

One hundred seventy patients aged ≥70 years were included in the study. The median age was 75 years (range, 70‐98 years). One hundred four patients (61%) had received previous single‐modality or combined treatment, which included surgery in 79 patients (46%), radiation in 47 patients (28%), and chemotherapy in 13 patients (8%). The most common histology was squamous cell carcinoma (67 patients; 39%). The margins of resection were close or microscopically positive in 56 patients (33%). Sixty‐eight patients received adjuvant radiotherapy (40%), and 3 patients received chemotherapy (2%). Complications were classified into overall, local, central nervous system (CNS), systemic, and orbital. Overall survival (OS), disease‐specific survival (DSS), and recurrence‐free survival (RFS) were determined by using the Kaplan‐Meier method. Outcomes were compared with patients aged <70 years. Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics (including histology and extent of disease), surgical resection margins, previous radiation, and previous chemotherapy to determine predictive factors.

RESULTS:

Postoperative mortality occurred in 16 patients (9%), and postoperative complications occurred in 72 patients (42%). Local wound complications occurred in 40 patients (24%), CNS complications occurred in 24 patients (14%), systemic complications occurred in 19 patients (11%), and orbital complications occurred in 4 patients (2%). Postoperative mortality and complications were significantly more frequent in elderly patients compared with patients aged <70 years (postoperative mortality: 9% vs 3%; P = .04; complications: 42% vs 32%; P = .0009). The 5‐year OS, DSS, and RFS rates were significantly poorer than those for patients aged <70 years (OS: 42% vs 56%; P < .0001; DSS: 53% vs 61%; P = .04; RFS: 46% vs 54%; P = .03). Surgical margin status and primary tumor histology were independent predictors of OS, DSS, and RFS in multivariate analysis.

CONCLUSIONS:

CFR for malignant skull base tumors in elderly patients (aged ≥70 years) was associated with increased mortality, complications, and poorer outcomes compared with patients aged <70 years. Cancer 2011. © 2010 American Cancer Society.     

Anterior craniofacial resection — for paranasal sinus tumors involving anterior skull base

Management of anterior skull base tumors is complex due to the anatomic detail of the region and the variety of tumors that occur in this area. Currently, the “gold standard” for surgery is the anterior craniofacial approach. Craniofacial resection represents a major advance in the surgical treatment of tumors of the paranasal sinuses involving anterior skull base. It allows wide exposure of the complex anatomical structures at the base of skull permitting monobloc tumor resection. This study presents a series of 18 patients with anterior skull base tumors, treated by a team of head-neck surgeons and neurosurgeons. The series included 15 malignant tumors of the nose and paranasal sinuses and 3 extensive benign lesions. All tumors were resected by a combined bi-frontal craniotomy and rhinotomy. The skull base was closed with a pediculated pericranial flap and a split-thickness free skin graft underneath. There were no postoperative problems of wound infection, cerebrospinal fluid-leakage or meningitis. Recurrent tumor growth or systemic metastasis occurred in 3 out of 15 patients with malignant tumors, 6 months to 2 years postoperatively. Craniofacial resection was thus found to give excellent results with low morbidity in malignant lesions and can also be adapted for benign tumors of anterior skull base.     

肿瘤累及前颅底行颅面切除的预后及影响因素

肿瘤侵犯前颅底行前颅底-颅面切除术后,影响预后的有关因素主要有肿瘤恶性程度和组织学类型,肿瘤浸润范围,脑膜、脑侵犯、眶侵犯,切缘阳性等.     

Neuronavigational guidance in craniofacial approaches for large (para)nasal tumors involving the anterior skull base and upper clival lesions

Objective

Due to the destruction of osseous landmarks of the skull base or paranasal sinuses, the anatomical orientation during surgery of frontobasal or clival tumors with (para)nasal extension is often challenging. In this relation computer assisted surgical (CAS) guidance might be a useful tool. Here, we explored the use of CAS in an interdisciplinary setting.

Methods

The surgical series consists of 13 patients who underwent a lateral rhinotomy combined with a subfrontal craniotomy in case of significant intracranial tumor extension. The procedures were planned and assisted by advanced CAS techniques with image fusion of CT and MRI. Tumors included carcinomas (one case associated with an olfactory groove meningioma), esthesioneuroblastoma, chordoma, chondrosarcoma and ganglioglioma.

Results

The application of CAS in the combined approaches was both safe and reliable for delineation of tumors and identification of vital structures hidden or encased by the tumors. There was no perioperative 30-day mortality; however two patients died 5 weeks and 5 months after craniofacial tumor resection due to worsening medical conditions. The most common perioperative morbidity was postoperative wound complication in two cases. Tumors were either removed completely, or subtotal resection was achieved allowing targeted postoperative radiotherapy.

Conclusion

Craniofacial approaches with intraoperative neuronavigational guidance in a multidisciplinary setting allow safe resection of large tumors of the upper clivus and the paranasal sinuses involving the anterior skull base. Complex skull base surgery with the involvement of bony structures appears to be an ideal field for advanced navigation techniques given the lack of intraoperative shift of relevant structures.     

Selective reconstructive options for the anterior skull base

Carcinomas of the ethmoid, frontal, or maxillary sinuses sometimes invade the anterior skull base. It is necessary to perform en-bloc resection for this invasive carcinoma according to the concepts of surgical treatment for head and neck cancer. The anterior skull base consists of two parts, the orbital roof as the lateral portion and the roofs of the frontal sinus, ethmoid sinus, and/or sphenoid sinus as the central portion. Selective reconstructive options for the anterior skull base depend on the size of the defect of the skull base. A dural defect is repaired by a fascia lata or a pericranial flap. After the dura has been tacked up, reconstruction of the anterior skull base is performed simultaneously with augmentation of the defect of extracranial structures. Larger defects that consist of both central and lateral portions with orbitomaxillary structures are reconstructed by a bulky musculocutaneous flap such as a rectus abdominis or latissimus dorsi flap. The bony reconstruction of supraorbital structures is also to be considered esthetically. On the other hand, intraorbital tissues are basically preserved in cases of central defects of the anterior skull base. These defects are reconstructed by a free forearm flap or a local flap such as a de-epithelialized midline forehead flap or a pericranial flap. We have selected and applied these flaps in 37 patients as reconstructive options for the anterior skull base since 1989. Eleven of the 37 patients had larger defects and 26 had central defects. De-epithelialized midline forehead flaps were used in 20 patients and were recognized to be a very useful and reliable reconstructive option for central defects of the anterior skull base.     

Craniofacial surgery for malignant skull base tumors: report of an international collaborative study

BACKGROUND: Malignant tumors of the skull base are rare. Therefore, no single center treats enough patients to accumulate significant numbers for meaningful analysis of outcomes after craniofacial surgery (CFS). The current report was based on a large cohort that was analyzed retrospectively by an International Collaborative Study Group. METHODS: One thousand three hundred seven patients who underwent CFS in 17 institutions were analyzable for outcome. The median age was 54 years (range, 1-98 years). Definitive treatment prior to CFS had been administered in 59% of patients and included radiotherapy in 367 patients (28%), chemotherapy in 151 patients (12%), and surgery in 523 patients (40%). The majority of tumors (87%) involved the anterior cranial fossa. Squamous cell carcinoma (29%) and adenocarcinoma (16%) were the most common histologic types. The margins of surgical resection were reported close/positive in 412 patients (32%). Adjuvant postoperative radiotherapy was received by 510 patients (39%), and chemotherapy was received by 57 patients (4%). RESULTS: Postoperative complications were reported in 433 patients (33%), with local wound complications the most common (18%). The postoperative mortality rate was 4%. With a median follow-up of 25 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 54%, 60%, and 53%, respectively. The histology of the primary tumor, its intracranial extent, and the status of surgical margins were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS: CFS is a safe and effective treatment option for patients with malignant tumors of the skull base. The histology of the primary tumor, its intracranial extent, and the status of surgical margins are independent determinants of outcome.     

Radiotherapy alone or after subtotal resection for benign skull base meningiomas

BACKGROUND: The objective of the current study was to analyze the long-term local control and complications in a series of patients who were treated with radiotherapy for benign skull base meningiomas. METHODS: Between January 1984 and July 2001, 101 patients were treated with radiotherapy alone (n = 66) or after undergoing subtotal resection (n = 35). Sixty-one patients had previously untreated tumors, and 40 patients had tumors that were recurrent after prior surgery. Patients had follow-up from 0.6 years to 19 years (median, 5.1 years). The follow-up of living patients ranged from 1.3 years to 19 years (median, 5.4 years). RESULTS: The long-term local control rates were 95% at 5 years, 92% at 10 years, and 92% at 15 years. Multivariate analysis of local control revealed that none of the parameters evaluated significantly influenced this endpoint. The cause-specific survival rates were 97% at 5 years, 92% at 10 years, and 92% at 15 years; and the absolute survival rates were 86% at 5 years, 71% at 10 years, and 62% at 15 years. Multivariate analysis of cause-specific survival revealed that only gender significantly influenced this endpoint (P = 0.0185). Severe complications were observed in eight patients, and three patients experienced complications that were fatal. CONCLUSIONS: The probability of long-term progression-free survival after radiotherapy exceeded 90% and was comparable to the results of complete resection and radiosurgery. Subtotal resection was useful for decompressing the tumor if improvement in neurologic function was anticipated after surgery. Extensive subtotal resection may result in permanent neurologic deficits and did not improve long-term local control.     

The system of modified transcochlear approaches for intradural skull base lesions

The modified transcochlear approach was used to manage 27 patients with intradural tumours of petroclival region and prepontine cistern. Total tumour removal was possible in 21 cases. Planned subtotal removal was done in 2 elderly patients; one was a chordoma with involvement of the cavernous sinus and extending upto the optic chiasma while the other was a petroclival meningioma involving the cavernous sinus with normal abducent nerve function. The remaining 4 cases are awaiting their second stage. The modified transcochlear approach is systematized and further classified into types A, B, C and D depending upon its extensions. The basic surgical technique with its extensions, details of the classification, indications of each type and results are presented in this report.     

Management of sinonasal adenocarcinomas with anterior skull base extension

Journal of Neuro-Oncology - Sinonasal adenocarcinomas (SNAC) are rare and heterogeneous. Management of SNAC follows a rather standardized and internationally accepted paradigm. Several refinements...     

Craniofacial resection for sinunasal tumors

Introduction Malignant sinunasal tumors are very rare in Mexico. They ussually present as advanced disease because it is extremely difficult to make an early diagnosis; in addition, its treatment is complicated by a variety of lesions. Surgical resection remains the mainstay of treatment, but its relative therapeutic value compared with alternative treatments is controversial. Objective We undertook a retrospective analysis in order to evaluate results of craniofacial resections for sinunasal tumors. Materials and methods A total of 20 patients, 11 men and 9 women were considered, median age was 49 years (18–74). Eleven had received previous treatment elsewhere. In 13 patients tumor was limited to maxilo-etmoidal complex, but in 6 cases tumor involved anteroinferior aspect of esfenoidal sinus, in 7 extended to the orbit, in 3 to dura and two to the brain. One had cervical metastases. Median tumoral size was 5.8 cm (1–10). Results Overall complication rate was 50%. Major surgical complications occurred in 4 patients (20%): one patient developed isolated cerebrobrpinal fluid leakage (CEFL), 1 developed deterioration of mental status, and two developed meningitis associated with CEFL. Late complications occurred in 30% of the patients. There was not any operative death. Eleven patients received postoperative radiotherapy. Fifteen patients recurred. There were 11 local relapses, although one associated with a regional relapse, and another with regional and distant relapse. There were four isolated regional fails and six isolated distant failures. Three year overall survival was 65%, and 3-year disease free survival was 50%. Patients without previous treatment median survival was 28.3 months, meanwhile with previous treatment was 18.2 months. Conclusions Craniofacial resection is a safe and valuable tool in the treatment of advanced sinunasal tumors involving cranial base.     

带蒂额肌帽状腱膜裂层颅骨瓣修复前颅底(英文)

Objective:The aim of our study was to reconstruct soft and hard tissue perforating defects of the anterior skull base in a 1-stage surgical procedure with a combined craniofacial approach. Methods:Soft and hard tissue defects of the anterior skull base were successfully reconstructed in 43 patients during a 1-stage surgery through the use of frontalis muscle galea aponeurotica skull flaps with 1 or 2 vascularized pedicles. The skull flap areas were up approximately 7cm × 14cm. Results:Intracranial infection and cerebrospinal fluid leakage were not observed in the 43 patients, and all incisions healed. Of 33 malignant tumor patients, 25 patients received follow-up examinations for longer than 2 years, and 18 patients survived for 2 years. Conclusion:Frontalis muscle galea aponeurotica skull pedicle flaps provided a constant blood supply and resulted in soft and thin tissue. The pedicle flaps, together with the external cranial bone plate, strengthened the support, but still allowed for bending and shaping. In addition, the flap harvesting approach was consistent with surgery approach, without aesthetic compromises.     

Quality of life considerations for patients with anterior and central skull base malignancies

Journal of Neuro-Oncology - Pediatric spinal tumors are unique pathologies treated by pediatric neurosurgeons. Special attention is required for the preservation of neural function and bony...     

Modified transcranial approach for resection of tumors involving the anterior cranial fossa

It is not unusual that neoplasms arising in the paranasal sinuses already involve the anterior skull base before any significant symptoms appear. Neither transcranial nor transfacial approach alone can allow enbloc resection of the involved paranasal sinuses in continuity with the cribriform plate area of the anterior skull base. Since the introduction of craniofacial resection in 1953, a number of reports [1-3] have claimed that the preferred approach for resection of the invasive tumors of t…     

Gasket-Seal技术在颅底肿瘤内镜手术颅底重建中应用的荟萃分析

目的 评价Gasket-Seal技术在颅底肿瘤内镜手术颅底重建中应用的效果.方法 在中外文文献数据库中检索2007年10月至2016年10月已发表的关于应用Gasket-Seal技术进行颅底肿瘤内镜手术颅底重建的病例对照研究.利用Review Manager(5.3版)软件进行荟萃分析.结果 按文献入选标准共纳入5篇病例对照研究,共210例颅底肿瘤内镜手术患者纳入荟萃研究.荟萃分析表明,与非GS组相比,GS组患者术后远期脑脊液漏发生率低(OR=0.32,95％CI=0.11～0.89,P=0.03),术后脑膜炎发生率低(OR=0.10,95％CI=0.01～0.67,P=0.02).根据GS组是否联合NSF进行亚组分析,结果表明两亚组术后远期脑脊液漏发生率间比较,差异无统计学意义(P=0.85).在GS组中,采用人工骨组与采用同种骨(包括自体骨和异体骨)组病例术后脑脊液漏发生率比较,差异无统计学意义(P=0.25).结论 应用Gasket-Seal技术能安全有效地完成颅底肿瘤内镜手术中的颅底重建.相较其他颅底重建方法,术后脑脊液漏及脑膜炎的发生率更低.     

前颅底肿瘤的术式选择及颅底重建

目的：探讨前颅底肿瘤的手术方式及术后颅底缺损重建技术。方法：对25例前颅底肿瘤患者根据原发肿瘤的生长部位和颅内外受累的情况，分别采用冠状切口经额颅内入路手术、鼻侧切开或扩大鼻侧切开术或颅面联合手术，采用带蒂骨膜瓣或帽状腱膜骨膜瓣重建颅底缺损。结果：肿瘤全切除23例，近全切除1例，部分切除1例，术后全部病例临床症状改善，无手术死亡、脑脊液漏、颅内感染及其他严重并发症。随访1年至13年，存活1年以上者22例，3年以上者12例，5年以上者9例，10年以上者3例。5、10年生存率分别为56．25％（9／16）、37．5％（3／8）。结论：术式选择取决于原发肿瘤的生长部位和颅内外受累的情况；颅面联合手术是一种安全、有效的手术方式；带蒂帽状腱膜骨膜瓣可用于较大颅底缺损的重建，具有安全、取材方便、效果好等优点，值得推广。     

前颅底肿瘤的术式选择及颅底重建

目的:探讨前颅底肿瘤的手术方式及术后颅底缺损重建技术。方法:对25例前颅底肿瘤患者根据原发肿瘤的生长部位和颅内外受累的情况,分别采用冠状切口经额颅内入路手术、鼻侧切开或扩大鼻侧切开术或颅面联合手术,采用带蒂骨膜瓣或帽状腱膜骨膜瓣重建颅底缺损。结果:肿瘤全切除23例,近全切除1例,部分切除1例,术后全部病例临床症状改善,无手术死亡、脑脊液漏、颅内感染及其他严重并发症。随访1年至13年,存活1年以上者22例,3年以上者12例,5年以上者9例,10年以上者3例。5、10年生存率分别为56.25%(9/16)、37.5%(3/8)。结论:术式选择取决于原发肿瘤的生长部位和颅内外受累的情况;颅面联合手术是一种安全、有效的手术方式;带蒂帽状腱膜骨膜瓣可用于较大颅底缺损的重建,具有安全、取材方便、效果好等优点,值得推广。     

Transfacial nasal approach to paranasal sinuses, nasopharynx and anterior skull base

There are different surgical approaches to remove lesion involving the large central lesions of nasal cavity, sinus and nasopharynx with anterior skull base and retromaxillary extension depending on the site extent and the type of tumor. In this paper, we are describing a method that is rhinological and is a direct approach for removal of such lesions in 6 patients.