Maurizio Bignami

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.

Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: nine-year experience.

OBJECTIVE: To describe surgical endoscopic experience in the repair of cerebrospinal fluid leaks treated by transnasal approaches. METHODS: Different surgical approaches and techniques in the repair of cranial base defects are reviewed in a series of 135 patients. RESULTS: Success rate at first attempt was 93.3%. Only 9 patients (6.7%) needed a second surgical repair, and in one patient, a coronal approach with frontal craniotomy was necessary. In the other eight cases, an endoscopic procedure was chosen. Two patients needed a third endonasal endoscopic surgical repair, with successful outcome. CONCLUSION: The target of endoscopic endonasal technique in the repair of cerebrospinal fluid leaks is to ensure a stable duraplasty with the least invasive approach avoiding craniotomy. A correct diagnosis surely allows the choice of the best treatment, surgical approach, graft, and technique. Our multidisciplinary approach to this pathology during these years has been essential to gain our challenging results.

Endonasal Endoscopic Repair of Sternberg's Canal Cerebrospinal Fluid Leaks

Objectives: Management of cerebrospinal fluid leaks or encephaloceles of Sternbergs canal is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of the study was to assess the real effectiveness of an endoscopic endonasal approach for treating cerebrospinal fluid leaks of the lateral recess of the sphenoid sinus.

Endoscopic endonasal skull base surgery: past, present and future.

Endoscopic techniques have undergone tremendous advancement in the past years. From the management of phlogistic pathologies, we have learned to manage skull base lesions and even selected intracranial diseases. Current anatomical knowledge plus computer-aided surgery has enabled surgeons to remove large lesions in the paranasal sinuses extending beyond the boundaries of the sinuses themselves. In this sense, management of benign diseases via endoscopic routes is nowadays well accepted whilst the role of endoscopic techniques in sinonasal malignancies is still under investigation. Nowadays, it is possible to tackle different pathologies placed not only in the ventral skull base, but also extended laterally (infratemporal fossa and petrous apex) and even, in really selected cases, within the orbit. The ability to resect and reconstruct has improved significantly. At the moment, the improvement in surgical techniques, like the four-handed technique, has rendered endoscopic procedures capable of managing complex pathologies, according the same surgical principles of the open approaches. From now onwards, frameless neuronavigation, modular approaches, intraoperative imaging systems and robotic surgery are and will be an increasingly important part of endonasal surgery, and they will be overtaken by further evolution.

Role of endoscopic surgery in the management of selected malignant epithelial neoplasms of the naso-ethmoidal complex

This study reviews the outcome of patients with adenocarcinoma (AC) and squamous cell carcinoma (SCC) of the naso‐ethmoidal complex treated by endoscopic surgery.

ENDONASAL ENDOSCOPIC RESECTION AND RADIOTHERAPY IN OLFACTORY NEUROBLASTOMA: OUR EXPERIENCE

Our aim was to evaluate the efficacy of a bimodal method of treatment consisting in endoscopic resection followed by radiotherapy in patients with olfactory neuroblastoma (ON).

Endoscopic transnasal craniectomy in the management of selected sinonasal malignancies.

Background Because of a better understanding of the anatomy from an endoscopic perspective, the acquisition of surgical experience, and concomitant technological advances, endoscopic resection of the anterior skull base (ASB) and overlying dura has now become a reality, opening new possibilities in the management of sinonasal malignancies. Here, the authors review a series of 62 patients, the largest reported to date, who underwent endoscopic transnasal craniectomy (ETC) and endoscopic dural repair for the management of selected sinonasal malignancies. Special emphasis is placed on the surgical technique, technical tricks, choice of materials for endoscopic dural repair, postoperative management, and complications. Methods From 2004, 62 patients underwent ETC at two referral hospitals, which extended anteroposteriorly from the frontal sinus to planum sphenoidale and laterolaterally from the nasal septum to the lamina papyracea (unilateral resection, n = 28; 45%) or from papyracea to papyracea (bilateral resection, n = 34; 55%). Duraplasty with a three-layer technique was performed using the iliotibial tract and fat tissue. Results The most frequent histotypes were adenocarcinoma (58%) and olfactory neuroblastoma (22%). Forty-five (73%) patients were previously untreated. The incidence of early (T1–2, Kadish A-B) and advanced (T3–4, Kadish C) tumors was similar. The complication rate was 15%, mostly cerebrospinal fluid leaks (13%). Its prevalence did not correlate with patient age, medical comorbidities, previous treatment, presence of ASB involvement, or whether ETC was mono- or bilateral, but tended to correlate with advanced tumor stage, dural involvement, and the period of treatment. After a mean follow-up of 17.5 months (range, 1–54 months), 58 (94%) patients had no evidence of disease. Conclusions In correctly selected patients with sinonasal tumors involving the ASB, ETC offers a less invasive alternative than resection by an open approach with an acceptable morbidity.

Quality of life following endoscopic endonasal resection of anterior skull base cancers.

OBJECT For several decades, the exclusive purpose in the management of anterior skull base malignancies has been to increase survival rates. Recently, given the improved prognosis achieved, more attention has been focused on quality of life (QOL) as well. Producing data on QOL in anterior skull base cancers is hampered by the rarity of the neoplasm and the lack of specific questionnaires. The purpose of this study was to assess health-related QOL in a large and homogeneous cohort of patients affected by anterior skull base cancers who had undergone endoscopic endonasal resection. METHODS The authors conducted a retrospective review of patients treated for sinonasal and skull base cancers via an endoscopic endonasal approach at two Italian tertiary care referral centers. All patients were asked to complete the Anterior Skull Base Surgery Questionnaire to evaluate their QOL before and 1 month and 1 year after surgical treatment. To assess which parameters affect QOL, the study population was divided into subgroups according to age, sex, stage of disease, surgical approach, and adjuvant therapy. RESULTS One hundred fifty-three patients were enrolled in this study according to the adopted inclusion criteria. Overall QOL started at a score of 4.68 for the preoperative period, sharply decreased as far as a score of 4.03 during the 1st postoperative month, and rose again to a score of 4.59 over the course of 1 year after treatment, with a significant difference among the 3 values (p < 0.05). The specific symptoms and physical status domains registered poorer results at the 1-year assessment (4.00 and 4.71, respectively) than at the preoperative assessment (both domains 4.86), with a statistically significant reduction in scores (p < 0.05). Worse outcomes were associated with several variables: age > 60 years (difference of 0.21 points between the preoperative and 1-year period, p < 0.05), expanded surgical approaches with transnasal craniectomy (decrease of 0.20 points between the preoperative and 1-year period, p < 0.05), and postoperative radiotherapy (score of 4.53 at the 1-year period vs. 4.70 in patients without any adjuvant treatment, p < 0.05). No statistically significant differences were found when analyzing the study population according to sex (p > 0.1) and T classification of disease at presentation (p > 0.05). CONCLUSIONS Radical endoscopic endonasal resection led to either complete or at least partial recovery of patient QOL within the 1st postoperative year.

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

OBJECTIVE To evaluate the feasibility of endoscopic surgery in the management of selected nasopharyngeal cancers. Three different types of nasopharyngeal endoscopic resections (NER) are described. METHOD OF STUDY From January 1997 to October 2008, 17 consecutive patients (mean age: 50 years) with previously untreated (5) or recurrent nasopharyngeal tumours (12) were treated with curative intent by pure endoscopic resection. The extent of surgical resection was classified as follows: type I NER: resection limited to the postero-superior nasopharyngeal wall; type 2 NER: resection superiorly extended to the sphenoid sinus; type 3 NER: resection with lateral extension including the cartilaginous portion of the Eustachian tube and parapharyngeal space. RESULTS Type 1 NER was performed in 4 cases, type 2 in 6, and type 3 in 7. No intra- or post-operative complications were observed. Mean hospitalization time was 4 days (range: 1-7). Follow-up ranged from 10 to 138 months (mean: 41.2±38). At the time of writing, 12 (71/%) patients were free of disease, 3 (17%) alive with disease, and 2 (12%) dead of disease. CONCLUSIONS NER is a feasible surgical technique that can be tailored in relation to tumour extension. Larger series and longer follow-up are needed to further validate the long-term results.

Endoscopic endonasal surgery for malignancies of the anterior cranial base

OBJECTIVE Data from several centers worldwide have demonstrated that transnasal endoscopic surgery performed with or without a transcranial approach is capable of achieving radical resection of selected sinonasal malignancies. We report our experience with endoscopic management of sinonasal cancers, with emphasis on naso-ethmoidal malignancies encroaching on the anterior skull base. METHODS Major series reporting results concerning the endoscopic endonasal approach with or without craniectomy for treatment of sinonasal and anterior skull base cancers were reviewed. Preoperative work-up, indications and exclusion criteria, surgical techniques, postoperative management, and adjuvant therapy are reported. RESULTS In the 2 largest series analyzed, the most common malignancies were adenocarcinoma (28%), olfactory neuroblastoma (14.5%), and squamous cell carcinoma (13.5%). The 5-year disease-specific survival rate ranged from 81.9%-87%, with no major differences in the mean follow-up time (34.1 months vs. 37 months). CONCLUSIONS Endoscopic endonasal resection performed with or without a transcranial approach, when properly planned and in expert hands, has an accepted role with precise indications in the surgeons armamentarium for the treatment of sinonasal and skull base malignancies.