Minimally invasive sinus surgery by P. Nicolai

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Minimally invasive sinus surgery by P. Nicolai

  1. 1. The International Federation of Head and Neck Oncologic SocietiesCurrent Concepts in Head and Neck Surgery and Oncology 2012 MINIMALLY INVASIVE SINUS SURGERY Piero Nicolai
  2. 2. MALIGNANT SINONASAL TUMORS Critical issues•  Low incidence•  Non-specific presentingcomplaints•  High histologic variability•  Treatment options not welldefined•  Difficult comparison oftreatment results 2012
  3. 3. EPIDEMIOLOGY • 1% of all malignant neoplasms • 3% of all upper respiratory tract malignancies • 3-5% of head and neck malignant neoplasms • Origin: 60% maxillary sinus 20-30% nasal cavity 10-15% ethmoid sinus 1% sphenoid and frontal sinus • The incidence is low in most populations < 1.5/100000 in men <1.0/100000 in women higher rates in Japan and certain parts of China and India • Squamous cell carcinoma is the most common2012 Barnes L, Eveson JW, Reichart P, Sidransky D. s of the nasal cavity and paranasal sinuses. In Barnes L, Eveson JW, Reichart P, Sidransky D, editors. World Health Organization Classification of s Pathology & Genetics Head and Neck s. Lyon, France: IARCPress; 2005:10.
  4. 4. HISTOLOGYMalignant epithelial tumours Haematolymphoid tumoursSquamous cell carcinomaVerrucous carcinoma Extranodal NK/T cell lymphomaPapillary squamous cell carcinoma WHO classification, 2005 Diffuse large B-cell lymphomaBasaloid squamous cell carcinoma Extramedullary plasmacytomaSpindle cell carcinomaAdenosquamous carcinoma Soft tissue tumours Extramedullary myeloid sarcomaAcantholytic squamous cell Malignant tumours Histocytic sarcomacarcinoma FibrosarcomaLymphoepithelial carcinoma Malignant fibrous histiocytoma NeuroectodermalSinonasal undifferentiatedcarcinoma Leiomyosarcoma Ewing sarcomaAdenocarcinoma Olfactory neuroblastoma AngiosarcomaIntestinal-type adenocarcinoma Malignant peripheral nerve sheath Mucosal malignant melanomaNon-intestinal-typeadenocarcinoma tumours Tumours of bone and cartilageSalivary gland-type carcinomas Chondrosarcoma Borderline and low malignantAdenoid cystic carcinoma Mesenchymal chondrosarcomaAcinic cell carcinoma potential tumours OsteosarcomaMucoepidermoid carcinoma Chordoma Desmoid-type fibromatosisEpithelial-myoepithelial carcinoma Inflammatory myofibrobastic Germ cell tumoursClear cell carcinoma N.O.S. Teratoma with malignantMyoepithelial carcinoma tumour transformationPolymorphous low-grade Sinonasal yolk sac tumour Sinonasal typeadenocarcinoma (endodermal sinus tumour)Neuroendocrine tumours haemangiopericytoma Sinonasal teratocarcinosarcomaTypical carcinoid Extrapleural solitary fibrousAtypical carcinoid 2012 tumour Small cell carcinoma,neuroendocrine type Secondary tumours
  5. 5. HISTOLOGY High-grade SNUC tumors • SNUC • SNEC • Ewing Sarcoma • Poorly differentiated carcinoma EWING SARCOMA2012
  6. 6. HISTOLOGY Intermediate-grade tumorsAdenoid cystic carcinoma Perineural invasion 2012 Distant metastasis
  7. 7. HISTOLOGY Low-grade tumors Well-differentiated ITAC Signet ring-cell2012
  8. 8. IMAGING MSCT and/or MRI Differentiation between tumor and inflammatory changes Soft tissues involvement and bony infiltration Perineural spread PET/CT US of the neck2012
  9. 9. IMAGING2012
  10. 10. ANTERIOR CRANIOFACIAL RESECTION MAJOR ADVANCE IN THE SURGICAL TREATMENT OF SINONASAL MALIGNANCIES2012 Ketcham et al., 1963
  11. 11. EVOLUTION OF OUR INDICATIONS FOR ENDOSCOPIC SURGERY 1991 1996 2010-11 Inverted papilloma CSF leak repair 2004 Parasellar and CVJ ETC lesions 1994 2009 1996 Sellar Juvenile angiofibroma Malignant tumors lesions 2012
  12. 12. EVOLUTION OF OUR INDICATIONS FOR ENDOSCOPIC SURGERY 2012
  13. 13. EVOLUTION OF OUR INDICATIONS FOR ENDOSCOPIC SURGERY 2012
  14. 14. SINONASAL, SELLAR, AND NASOPHARYNGEAL TUMORS (N=1528) (April 1995 - December 2011) BENIGN TUMORS MALIGNANT TUMORS (1118 pts) (418 pts) 2012 Endoscopic Combined Endoscopic Combined (939 pts) (171 pts) (353 pts) (65 pts)
  15. 15. EVOLUTION OF OUR INDICATIONS FOR ENDOSCOPIC SURGERY FACTORS CONTRIBUTING TO EXPAND THE INDICATIONS OF ENDOSCOPIC SURGERY • Increasing expertise • Technological advances • Navigation systems • Haemostatic agents • Introduction of new reconstructive techniques2012
  16. 16. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSSURGICAL OPTIONS Endonasal endoscopic resection (EER) EER with transnasal craniectomy (ERTC) Cranio-endoscopic resection (CER)2012
  17. 17. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSContraindications for EER !!•  Extensive lacrimal pathway involvement•  Involvement of the anterior wall/lateral portion of frontal sinus•  Infiltration of the bony walls of the maxillary sinus (except themedial)•  Involvement of the hard palate•  Erosion of the nasal bones•  Invasion of the orbital content•  Involvement of the anterior skull base 2012
  18. 18. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Endoscopic resection with transnasal craniectomy (ERTC): Indications •  Tumors with a high likelihood of spreading along the olfactory phyla •  Extensive contact with the anterior skull base (ASB) •  Limited infiltration/resorption of the ASB •  Contact, focal infiltration or growth through the dura of the ASB2012
  19. 19. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Cranio-endoscopic resection (CER) Indications • Lateral extension of dural resection over the orbital roof • Brain involvement • Encasement of a major vessel (i.e. ICA) or nerve2012
  20. 20. Two Surgical Teams with the same Philosophy P. Castelnuovo P. Nicolai ENT Dpt. of Varese ENT Dpt. of Brescia2012
  21. 21. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STATISTICAL ANALYSIS Follow-up until dead or at least 12 months after the treatment 1996-2010: 326 ptsMean age=61.3 years (range 4-85), M/F=2.2/1 Mean follow-up=52.7 months (range 12-169)2012
  22. 22. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Histology EER ERTC CER Total (n=139) (n=126) (n=61) (n=326) Adenocarcinoma 42 72 28 142 Squamous cell carcinoma 18 9 11 38 Olfactory neuroblastoma 10 20 4 34 Mucosal melanoma 19 5 3 27 Adenoid cystic carcinoma 15 1 1 17 Hemangiopericytoma 11 5 - 15 Lymphoproliferative 5 2 1 8 disorders 2012 SNUC 2 5 4 11 Miscellanea 17 8 9 34
  23. 23. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS T staging (AJCC 2010) EER ERTC CER Total (n=139) (n=126) (n=61) (n=326) T1 57 20 3 80 (24.5%) T2 35 32 2 69 (21.2%) T3 18 28 13 59 (18.1%) T4a 16 14 12 42 (12.9%) 2012 T4b 13 32 31 76 (23.3%)
  24. 24. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS NOT A PIECEMEAL RESECTION BUT TUMOR DISASSEMBLING2012
  25. 25. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS EER/ERTC: multilayer technique 1) Tumor debulking 2) Septal resection 3) Centripetal removal with subperiosteal resection (Draf III + median sphenoidotomy) 4) Removal of bone in contact with the tumor (skull base, lamina papyracea) 5) Removal of periorbita, dura, olfactory bulb(s)2012 6) Duraplasty and skull base reconstruction
  26. 26. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 1: Tumor debulking2012
  27. 27. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSSTEP 2: In case of complete ethmoidectomy the nasal septum is removed... 2012
  28. 28. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSSTEP 3: Centripetal removal with subperiosteal dissection 2012
  29. 29. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSSTEP 4: Removal and drilling of bone-cartilage 2012
  30. 30. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 5: Removal of periorbita, dura and olfactory bulb(s)2012
  31. 31. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 5: Removal of periorbita, dura and olfactory bulb(s)2012
  32. 32. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 6: Endoscopic duraplasty Fascia lata (Iliotibial tract) Fascia lata2012 Iliotibial tract
  33. 33. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 6: Endoscopic duraplasty2012
  34. 34. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 6: Endoscopic duraplasty Goals of fat tissue: sealing of duraplasty and2012 shock absorber effect
  35. 35. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS STEP 6: Endoscopic duraplasty2012
  36. 36. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Endoscopic resection of lesions with brain involvement (selected cases) 2012
  37. 37. Analysis of complications (16.8%) EER ERTC CER n=9/139 n=23/126 n=19/60 Treatment (6.5%) (18.2%) (37.7.6%) MAJOR COMPLICATIONS: 10.4% Surgical revision (10) CSF-leak - 9 7 and lumbar drainage (6) Pneumocephalus - 2 1 Surgical revision Mucocele 4 - - Endoscopic drainage (4) Brain abscess - 1 2 Surgical drainage Extradural abscess - - 1 Endoscopic drainage Frontal osteomyelitis - - 2 Curettage Ictus cerebri 1 - 1 None Broad-spectrum antibiotic Meningitis - 1 - therapy Hygroma - - 2 Surgical drainage MINOR COMPLICATIONS: 6.4% Diplopia - - 4 Optical correction Epistaxis 1 1 1 Cauterization 2012 Septic fever 1 3 1 Medical therapy Non-septic fever - 4 - None Epiphora 2 2 1 DCR (3)
  38. 38. ENDOSCOPIC RESECTION WITH TRANSNASAL CRANIECTOMY (ERTC) Analysis of CSF leak (Fisher exact / Pearson Chi-Square test) Variable (n) CSF-leak rate p values • Present (76):   9.6 %   Comorbidities • Absent (76): 2.7 % p =0.08 • Brescia (48):   4.2 %   Institution • Varese (98): 7.1 % p =0.718 • T1, T2, T3 (99):   6.1 %   Stage • T4 (47): 6.4 % p =1 Dural involvement • Yes (32)   6.3 %   p =1 (pT4b) • No (114) 6.1 % • monolateral (60):   3.3 %   Dural defect • bilateral (86): 8.1 % p =0.308 • primary (111):   6.3 %   Treatment • salvage (35): 5.7 % p =1 Period of • 1997-2008 (85):   9.4 %   p =0.082012 treatment • 2009-2010 (61): 1.6 %
  39. 39. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS 5-year overall survival (EER-ERTC-CER) ERTC (82.6±4.34) EER (79.3±3.81) CER (49.2±6.6) p=0.001972012 SPSS® for Windows; version 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  40. 40. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS 5-year disease-specific survival (EER-ERTC-CER) EER (86.2±3.26) ERTC (85.7±4.04) CER (59.8±6.96) p=0.00038 SPSS® for Windows; version2012 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  41. 41. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS5-year disease-specific survival (untreated vs recurrence) DISEASE SPECIFIC SURVIVAL DEPENDING ON PREVIOUS TREATMENT U (82±2.96) R (75.3±5.55) p=0.0297 SPSS® for Windows; version 2012 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  42. 42. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS 5-year disease-specific survival (histology) ONB (100) MISCELLANEOUS (91.2±4.98) ADC (82.4±3.95) CARCINOMA GROUP (77±5.85) MELANOMA (31.6±10.7) p=0.00098 SPSS® for Windows; version2012 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  43. 43. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS 5-year disease-specific survival (T category) T2 (94.9±3.84) T2 (94.9±3.84) T1 (94.1±2.86) T4a (86.8±6.25) T3 (69.6±7.36) T4b (55.8±6.93) p=0.000203 SPSS® for Windows; version2012 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  44. 44. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS 5-year recurrence-free survival (EER-ERTC-CER) ERTC (77.9±6.26) EER (77.1±3.87) CER (54.7±7.46) p=0.00101 SPSS® for Windows; version 10.0.1, 1999 Chicago, IL.2012 Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  45. 45. ENDOSCOPIC RESECTION WITH TRANSNASAL CRANIECTOMY (ERTC) 5-year disease-specific survival (histology)2012 SPSS® for Windows; version 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  46. 46. ENDOSCOPIC RESECTION WITH TRANSNASAL CRANIECTOMY (ERTC) 5-year disease-specific survival (T category)2012 SPSS® for Windows; version 10.0.1, 1999 Chicago, IL. Survival calculated by the Kaplan-Meiier method. Univariate comparisons performed using log-rank test
  47. 47. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Standard craniofacial resection•  1307 patients (International collaborative study)•  Preoperative treatment: 59%•  Most common histotypes: SCC (29%), ADC (16%)•  Postoperative treatment: 39%•  5-year overall survival: 54%•  5-year disease-specific survival:60%•  5-year recurrence free survival:53% 2012 Patel, et al. 2003
  48. 48. LOCAL FAILURES 72-year-old male ITAC Previous external surgery and RT pT3 (erosion of cribra) 69-year-old male Signet ring-cell AC First treatment pT3 (erosion of cribra)2012
  49. 49. MENYNGEAL METASTASES 66-year-old male Signet ring-cell AC Previous external surgery pT3 (erosion of cribra) Postop RT 70-year-old male ITAC No previous treatment pT4b (dura invasion) Postop RT2012
  50. 50. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORS Conclusions • Endoscopic surgery for T1-T2 lesions of the naso-ethmoidal complex offers a local control of the disease comparable to that obtained with traditional techniques • The efficacy of endoscopic resection with transnasal craniectomy in the management of lesions involving the anterior skull base (bone, dura) requires validation by further studies with larger cohort of patients and long-term follow up • Indications for adjuvant radiotherapy need to be refined • Possible role of neo-adjuvant chemotherapy2012 • Need for a multi-institutional database
  51. 51. ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL TUMORSEndoscopic surgery formalignancies of the sinonasal tractshould be performed only incenters where a multidisciplinaryteam with experience in the wholespectrum of the proceduresinvolving the anterior skull base isavailable, keeping in mind thatthere are precise limits related tothe extent as well as to the biologyof the tumor. 2012

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