Franco DeMonte

Endoscopic Resection of Sinonasal Cancers With and Without Craniotomy: Oncologic Results

OBJECTIVE To evaluate the oncologic outcomes of patients with sinonasal cancer treated with endoscopic resection. DESIGN Retrospective review. SETTING Tertiary care academic cancer center. PATIENTS All patients with biopsy-proved malignant neoplasm of the sinonasal region who were treated with endoscopic resection between 1992 and 2007 were included in the study, and their charts were reviewed for demographics, histopathologic findings, treatment details, and outcome. MAIN OUTCOME MEASURES Oncologic outcomes, including disease recurrence and survival. RESULTS Of a total of 120 patients, 93 (77.5%) underwent an exclusively endoscopic approach (EEA) and 27 (22.5%) underwent a cranioendoscopic approach (CEA) in which the surgical resection involved the addition of a frontal or subfrontal craniotomy to the transnasal endoscopic approach. Of the 120 patients, 41% presented with previously untreated disease, 46% presented with persistent disease that had been partially resected, and 13% presented with recurrent disease after prior treatment. The most common site of tumor origin was the nasal cavity (52%), followed by the ethmoid sinuses (28%). Approximately 10% of the tumors had an intracranial epicenter, most commonly around the olfactory groove. Tumors extended to or invaded the skull base in 20% and 11% of the patients, respectively. An intracranial epicenter (P < .001) and extension to (P = .001) or invasion of (P < .001) the skull base were significantly more common in patients treated with CEA than in those treated with EEA. The primary T stage was evenly distributed across all patients as follows: T1, 25%; T2, 25%; T3, 22%; and T4, 28%. However, the T-stage distribution was significantly different between the EEA group and the CEA group. Approximately two-thirds (63%) of the patients treated with EEA had a lower (T1-2) disease stage, while 95% of patients treated with CEA had a higher (T3-4) disease stage (P < .001). The most common tumor types were esthesioneuroblastoma (17%), sarcoma (15%), adenocarcinoma (14%), melanoma (14%), and squamous cell carcinoma (13%). Other, less common tumors included adenoid cystic carcinoma (7%), neuroendocrine carcinoma (4%), and sinonasal undifferentiated carcinoma (2%). Microscopically positive margins were reported in 15% of patients. Of the 120 patients, 50% were treated with surgery alone, 37% received postoperative radiation therapy, and 13% were treated with surgery, radiation therapy, and chemotherapy. The overall surgical complication rate was 11% for the whole group. Postoperative cerebrospinal fluid leakage occurred in 4 of 120 patients (3%) and was not significantly different between the CEA group (1 of 27 patients) and the EEA group (3 of 93 patients) (P > .99). The cerebrospinal fluid leak resolved spontaneously in 3 patients, and the fourth patient underwent successful endoscopic repair. With a mean follow-up of 37 months, 18 patients (15%) experienced local recurrence, with a local disease control of 85%. Regional and distant failure occurred as the first sign of disease recurrence in 6% and 5% of patients, respectively. The 5- and 10-year disease-specific survival rates were 87% and 80%, respectively. Disease recurrence and survival did not differ significantly between the EEA group and the CEA group. CONCLUSIONS To the best of our knowledge, this is the largest US series to date of patients with malignant tumors of the sinonasal tract treated with endoscopic resection. Our results suggest that, in well-selected patients and with appropriate use of adjuvant therapy, endoscopic resection of sinonasal cancer results in acceptable oncologic outcomes.

Mucosal melanoma of the nose and paranasal sinuses, a contemporary experience from the M. D. Anderson cancer center

Sinonasal mucosal melanoma is a rare disease associated with a very poor prognosis. Because most of the series extend retrospectively several decades, we sought to determine prognostic factors and outcomes with recent treatment modalities.

Awake craniotomy for brain tumors near eloquent cortex: Correlation of intraoperative cortical mapping with neurological outcomes in 309 consecutive patients

OBJECTIVEIntraoperative localization of cortical areas for motor and language function has been advocated to minimize postoperative neurological deficits. We report herein the results of a retrospective study of cortical mapping and subsequent clinical outcomes in a large series of patients. METHODSPatients with intracerebral tumors near and/or within eloquent cortices (n = 309) were clinically evaluated before surgery, immediately after, and 1 month and 3 months after surgery. Craniotomy was tailored to encompass tumor plus adjacent areas presumed to contain eloquent cortex. Intraoperative cortical stimulation for language, motor, and/or sensory function was performed in all patients to safely maximize surgical resection. RESULTSA gross total resection (≥95%) was obtained in 64%, and a resection of 85% or more was obtained in 77% of the procedures. Eloquent areas were identified in 65% of cases, and in that group, worsened neurological deficits were observed in 21% of patients, whereas only 9% with negative mapping sustained such deficits (P < 0.01). Intraoperative neurological deficits occurred in 64 patients (21%); of these, 25 (39%) experienced worsened neurological outcome at 1 month, whereas only 27 of 245 patients (11%) without intraoperative changes had such outcomes (P < 0.001). At 1 month, 83% overall showed improved or stable neurological status, whereas 17% had new or worse deficits; however, at 3 months, 7% of patients had a persistent neurological deficit. Extent of resection less than 95% also predicted worsening of neurological status (P < 0.025). CONCLUSIONNegative mapping of eloquent areas provides a safe margin for surgical resection with a low incidence of neurological deficits. However, identification of eloquent areas not only failed to eliminate but rather increased the risk of postoperative deficits, likely indicating close proximity of functional cortex to tumor.

OLFACTORY NEUROBLASTOMA: THE 22-YEAR EXPERIENCE AT ONE COMPREHENSIVE CANCER CENTER

Olfactory neuroblastoma (ONB) is a rare tumor arising from the olfactory neuroepithelium. There is no universally accepted staging system, and treatment approaches lack uniformity. We present one institutions experience with this tumor and the results of therapy.

Vascular considerations and complications in cranial base surgery.

The technical evolution of cranial base surgery has resulted in approaches that allow more radical surgical extirpation of complex cranial base lesions. Our service has extensively applied these cranial base approaches for lesions of the cranial base. A subgroup of 100 patients who had cranial base tumors involving potential manipulation or sacrifice of carotid arteries underwent 20-minute balloon test occlusions coordinated with vascular assessments consisting of a combination of the following: 1) four-vessel cerebral angiogram with compression studies; 2) occlusion transcranial Doppler ultrasonography; 3) occlusion single-photon emission computed tomography perfusion studies; and 4) xenon-133 cerebral blood flow studies. Transient neurological deficits associated with balloon test occlusion occurred in 7 of 100 patients (7%). Subsequently, 18 patients underwent permanent carotid occlusion by endovascular detachable balloons. Delayed ischemic complications (> 72 h) occurred in 4 of 18 (22%) patients. Additionally, a number of vascular complications not predicted by the balloon occlusion tests and vascular assessments were experienced. Repeat vascular assessments defined the causes and guided treatment of ischemic patients. Ischemic complications were caused by hemodynamic insufficiency, embolization, vasospasm, radiation vasculopathy, and venous anomaly. Our experience leads us to believe that no vascular assessment exists today that can predict the occurrence of vascular complications accurately. The current enthusiasm for cranial base surgery must be tempered with the sober reality that management of cerebrovascular anatomy and physiology remain significant limitations. Consideration of potential cerebrovascular complications is paramount to successful outcome and implementation of cranial base surgery.

The treatment of recurrent unresectable and malignant meningiomas with interferon alpha-2B

OBJECTIVE Recurrent malignant meningiomas and unresectable meningiomas represent a great therapeutic challenge after the failure of radiation therapy. No effective chemotherapy has been found. We report the preliminary results of the treatment of patients with recurrent unresectable or malignant meningiomas with recombinant interferon alpha-2B (IFN-alpha-2B). METHOD Each of six patients with either a recurrent malignant meningioma or an unresectable meningioma was treated with IFN-alpha, administered subcutaneously at a dosage of 4 mU/m2 per day, 5 days per week. Two of the six meningiomas were regular, one was atypical, and three were malignant. RESULTS Five of six patients exhibited positive response to treatment; with stabilization of the size of the tumor in four patients and slight regression in one. The responses observed lasted from 6 to 14 months. The toxicity associated with prolonged use of IFN-alpha was mild and well tolerated. CONCLUSION These results suggest that IFN-alpha is effective in the treatment of recurrent malignant meningiomas.

Anterior transcranial (craniofacial) resection of tumors of the paranasal sinuses: Surgical technique and results

Transfacial approaches, traditionally used for malignant tumors of the paranasal sinuses, provide limited exposure when several sinuses are involved and are unsuitable for tumors that erode through the floor of the anterior cranial fossa. A transcranial approach may aid in the removal of such lesions. To better understand the risks and benefits of this surgical approach, we reviewed all patients (n = 76) who underwent a transcranial approach as part of the excision of paranasal sinus lesions between 1984 and 1993 at our institution. The spectrum of disease included adenocarcinoma (13 patients), squamous cell carcinoma and olfactory neuroblastoma (11 patients each), adenoid cystic carcinoma and poorly differentiated forms of carcinoma (6 patients each), melanoma (5 patients), and miscellaneous others (24 patients). Most patients had ethmoid sinus involvement; tumors were also commonly found in the cribriform plate, sphenoid sinus, and nasal fossa. In each patient, a bifrontal craniotomy was performed with extradural dissection to the floor of the anterior fossa and osteotomies for resection of involved elements. In 47 patients (62%), disease in the orbit, the anterior nasal cavity, or the soft tissues of the face required transfacial as well as transcranial resections. Bony defect in the anterior fossa floor was repaired with a pedicled pericranial flap. Patients with major complications included six patients with epipericranial and/or epidural hematomas requiring evacuation, three with transient cerebrospinal fluid leaks, two who developed bifrontal cerebral infarcts, and one who died soon after surgery. No meningitis was seen. To date, 26 patients (34%) have died; of those living (mean follow-up, 34 mo), 42 (84%) remain in full remission. The transcranial approach can achieve removal of erosive, invasive tumors from this area with predictable morbidity and may be considered whenever sinus tumors breach the anterior cranial base or extend beyond the reach of conventional transfacial approaches.: Transfacial approaches, traditionally used for malignant tumors of the paranasal sinuses, provide limited exposure when several sinuses are involved and are unsuitable for tumors that erode through the floor of the anterior cranial fossa. A transcranial approach may aid in the removal of such lesions. To better understand the risks and benefits of this surgical approach, we reviewed all patients (n = 76) who underwent a transcranial approach as part of the excision of paranasal sinus lesions between 1984 and 1993 at our institution. The spectrum of disease included adenocarcinoma (13 patients), squamous cell carcinoma and olfactory neuroblastoma (11 patients each), adenoid cystic carcinoma and poorly differentiated forms of carcinoma (6 patients each), melanoma (5 patients), and miscellaneous others (24 patients). Most patients had ethmoid sinus involvement; tumors were also commonly found in the cribriform plate, sphenoid sinus, and nasal fossa. In each patient, a bifrontal craniotomy was performed with extradural dissection to the floor of the anterior fossa and osteotomies for resection of involved elements. In 47 patients (62%), disease in the orbit, the anterior nasal cavity, or the soft tissues of the face required transfacial as well as transcranial resections. Bony defect in the anterior fossa floor was repaired with a pedicled pericranial flap. Patients with major complications included six patients with epipericranial and/or epidural hematomas requiring evacuation, three with transient cerebrospinal fluid leaks, two who developed bifrontal cerebral infarcts, and one who died soon after surgery. No meningitis was seen. To date, 26 patients (34%) have died; of those living (mean follow-up, 34 mo), 42 (84%) remain in full remission. The transcranial approach can achieve removal of erosive, invasive tumors from this area with predictable morbidity and may be considered whenever sinus tumors breach the anterior cranial base or extend beyond the reach of conventional transfacial approaches.

Sinonasal adenoid cystic carcinoma: the M. D. Anderson Cancer Center experience.

Adenoid cystic carcinoma of the sinonasal tract is a rare cancer that accounts for 10% of all malignancies at this site. The objective of the current study was to evaluate prognostic factors, treatment outcomes, recurrence patterns, and survival rates for sinonasal adenoid cystic carcinoma.

Surgical treatment of anterior basal meningiomas

Meningiomas of the anterior skull base account for 40% of all intracranial meningiomas. Of these, almost half are sphenoid wing meningiomas; the other half are tuberculum sella tumors or olfactory groove tumors. Anterior clinoidal (medial sphenoid wing) meningiomas are a subcategory of the sphenoid wing meningiomas; they fall into one of three categories according to the presence of an interfacing arachnoidal membrane between the tumor and the cerebral vessels. Meningiomas of the tuberculum sella arise from the tuberculum sella, chiasmatic sulcus, limbus sphenoidale, and the diaphragma sella; they may extend into both optic canals. Olfactory groove meningiomas arise more anteriorly than do the tuberculum sella meningiomas and may be symmetrical around the midline or extend to one side or the other; at least 15% grow into the ethmoid sinuses. This paper addresses the clinical presentation, preoperative evaluation, and surgical procedures used for treating tumors of the tuberculum sella, the olfactory groove, and the anterior clinoid.

Benign nonmeningeal tumors of the cavernous sinus

OBJECTIVE Resection of benign cavernous sinus tumors with minimum morbidity and mortality is increasingly more common. Although meningiomas have dominated most discussions, numerous nonmeningeal tumors also deserve attention because they are generally more amenable to radical surgical resection. METHODS We reviewed the records of 40 patients (19 female and 21 male patients) who were treated surgically during a 15-year period for benign, nonmeningeal tumors of the cavernous sinus. Invasive pituitary adenomas (14 cases) and trigeminal schwannomas (13 cases) comprised the majority of tumors; the remaining tumor types were hemangioma, neurofibroma, juvenile angiofibroma, dermoid tumor, giant cell tumor, chondromyxofibroma, and chondroma. Patient age ranged from 7 to 65 years (mean, 37 yr). RESULTS All patients underwent surgery, the intent being total resection. Total resection was achieved in 33 (82.5%) of the 40 patients. Follow-up was achieved via a combination of direct patient visit or phone interview or via the referring physician. Eight patients had undergone previous surgery elsewhere, which correlated closely with complications and neurophthalmological outcomes but did not affect resectability. Postoperatively, 89.7% of the patients had either stable or improved extraocular muscle function compared with their preoperative statuses. Forty percent of the patients experienced improvement of their preoperative extraocular muscle deficits. Complications included cerebrospinal fluid leak (three cases), postoperative hemorrhage (one case), fat embolism (one case), perforator distribution infarct (one case), hydrocephalus requiring ventriculoperitoneal shunting (two cases), transient hemiparesis (one case), and diabetes insipidus (one case). CONCLUSION We conclude that benign nonmeningeal tumors of the cavernous sinus can be safely and radically removed and result in good long-term neuro-ophthalmological function and low morbidity and mortality. Furthermore, when compared with our previously reported results for cavernous sinus meningiomas, benign nonmeningeal tumors of the cavernous sinus carry a better chance of total removal, a lower incidence of postoperative ocular dysfunction, and a higher rate of recovery of preoperative cranial nerve deficits.