Malinant Tumors of the Paranasal sinuses & skull base by D. Fliss

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Malinant Tumors of the Paranasal sinuses & skull base by D. Fliss

  1. 1. The International Federation of Head and Neck Oncologic Societies Current Concepts in Head and Neck Surgery and Oncology 2012 Malignant Tumors of theParanasal Sinuses and Skull Base Dan  M  Fliss  
  2. 2. Epidemiology •  Incidence 1:200,000 (USA) •  3% of H&N malignancies •  Male predominance 1.8:1 •  Age: 55-69 years •  Common histology: SCC (51%) •  Common site: Nasal cavity (44%),2012 maxillary sinus (36%) Turner et al. Head and Neck 2011
  3. 3. Risk Factors •  Environmental/Occupational Aflatoxin, formaldehyde, chromium, nickel, mustard gas, polycyclic hydrocarbons, mesothorium (Thorotrast), wood dust (AdenoCa) •  Smoking (SCC) •  Smoked food2012 •  HPV 6,11,18 (inverted papilloma) Luce et al. Int J Cancer 1993 Katori et al. Eur J Surg Oncol 2005
  4. 4. Histology •  Epithelial (70-80%) –  SCC, verrucous ca, adenoCa, ACC, acinic cell ca, mucoepidermoid ca, SNUC •  Neuroectodermal –  Melanoma, ENB, Ewing sarcoma/PNET •  Mesenchymal –  MFH, fibrosarcoma, RMS, osteosarcoma, chondrosarcoma, angiosarcoma, hemangiopericytoma2012 •  Other –  Lymphoma, plasmacytoma, metastasis (RCC #1)
  5. 5. Clinical Presentation •  LATE •  Nasal (50%) –  Obstruction, bleeding, mass, sinusitis •  Oral (25-30%) –  Loose teeth, trismus, pain •  Ocular (25%) –  Proptosis, diplopia, epiphora •  Facial –  Distortion, anesthesia V22012 •  Skull Base/Brain –  Headache, CN palsy -> anosmia
  6. 6. Clinical Examination •  Facial symmetry, sensation (V2) •  Eye –  Ocular motion, globe position, proptosis •  Ear –  Eustachian tube dysfunction, SOM •  Oral –  Trismus, ulcer/bulging, loose teeth •  Nose - FO endoscopy2012 •  Neck – LN enlargement
  7. 7. Preoperative Evaluation •  Endonasal endoscopy •  CT- Axial, coronal, contrast, 3D •  Bone erosion •  MR - Contrast, fat suppression •  Inflammatory vs. neoplastic •  Angiography, balloon occlusion test, embolization •  Biopsy2012
  8. 8. Preoperative Evaluation PET-CT •  TNM Staging •  Residual disease •  Recurrence •  Second primary2012 Gil and Fliss et al. Head and Neck 2007
  9. 9. Preoperative Evaluation PET-CT •  PET/CT offers accurate staging for skull base neoplasms •  Accurate preoperative staging can change treatment modality and prevents unnecessary procedures in patients with distant metastases •  During follow-up PET/CT enables early detection of tumor recurrence, guides biopsies and allows selection of proper treatment2012 Gil and Fliss et al. Head and Neck 2007
  10. 10. Staging Ohngren s Line2012
  11. 11. AJCC TNM Staging 2011 Maxillary Sinus2012
  12. 12. AJCC TNM Staging 2011Ethmoid Sinus and Nasal Cavity2012
  13. 13. AJCC TNM Staging 2011Neck and Distant Sites, Prognostic Groups 2012
  14. 14. Treatment•  Surgery•  XRT•  Chemo•  Combinations No  RCTs  available2012
  15. 15. Levels of Evidence2012
  16. 16. Factors Influencing Treatment Choice •  Histology •  Stage •  Resectability •  Reconstruction •  Surgical expertise/ multidisciplinary team •  Comorbidity2012
  17. 17. Management Radiation Tx Technology: •  Stereotactic •  Proton/Neutron •  IMRT –  Intensity-modulated radiotherapy enables to create concave dose distributions allowing better sparing of the optic structures without compromising the dose in the target volume and local control2012 Duthoy et al. Cancer 2005
  18. 18. Radiation Tx Outcome•  Most patients get XRT (64%)•  Definitive XRT (single modality): –  5y local control 43%•  Better as an adjuvant to surgery –  5y local control 84% –  5y overall survival 67% 2012 Mendenhall et al. Laryngoscope 2009 Hoppe et al. Radiat Oncol Biol Phys 2008
  19. 19. Radiation Tx Who Benefits from Adjuvant XRT ? T1-2 T3-4/N1 T4/M12012 Turner et al. Head and Neck 2011
  20. 20. Radiation Tx Side Effects•  Risk for acute toxicity •     Risk  for  blindness•  Other chronic toxicity –  Osteoradionecrosis –  Frontal lobe necrosis –  Panhypopituitarism 2012 Duthoy et al. Cancer 2005 Mendenhall et al. Laryngoscope 2009
  21. 21. Management Chemotherapy •  Adjuvant chemotherapy Chemotherapy employed after the primary tumor has been removed by surgery •  Neoadjuvant chemotherapy Initial use of chemotherapy in order to decrease the tumor burden prior to treatment by other modalities2012
  22. 22. Management ChemotherapyMeta-analysis of chemotherapy in head and neck cancer - 93 RCTs and 17,346 patients 2012 Bourhis et al. Rad Oncol 2009
  23. 23. Chemotherapy in Sinonasal Ca Adjuvant Systemic •  n=35, T4b unresectable tumors •  Cisplatin + XRT -> No surgery •  Poor outcome: 5y OS 15% Hope et al. Radiat Oncol Biol Phys 2008 •  n=15, T3-T4 •  Induction cisplatin+5FU -> Surgery -> 5FU+hydroxyurea + XRT •  Good results: 10y DFS 65%2012 Lee et al. Cancer J Sci Am 1999
  24. 24. Chemotherapy in Sinonasal Ca Preoperative Intra-arterial (1) •  n=74, T2 T3 T4, maxillary sinus •  Multimodality: Preoperative XRT 50 grey + IA 5FU •  Then partial/total maxillectomy •  Good results: 5y OS 53% 5ys 53%2012 Hayashi et al. Cancer 2001
  25. 25. Chemotherapy in Sinonasal Ca Preoperative Intra-arterial (2) •  Concomitant preoperative XRT 50 grey + IA cisplatin •  Then CFR/ maxillectomy •  n=19, T3 T4 •  Good results: 5y OS 53% 5ys 53%2012 Samant et al. Archives 2004
  26. 26. Surgery Approaches •  Open –  Lateral rhinotomy/ Combinations –  Coronal –  Midfacial degloving –  Per-oral –  Facial translocation –  Subcranial /CFR –  Orbitozygomatic •  Endoscopic •  Combined2012
  27. 27. Surgery Skin Incisions 1.  Lateral Rhinotomy 2.  Weber-Fergusson 3.  WF + Lynch 4.  WF + Subciliary 5.  WF + Subciliary + Supraciliary2012
  28. 28. Surgery Type of Maxillectomy 1.  Medial maxillectomy 2.  Infrastructure maxillectomy 3.  Total maxillectomy +- Orbit 4.  Extended maxillectomy 5.  Bilateral2012 maxillectomy 6.  Subcranial / CFR
  29. 29. Surgery Reconstruction - Goals Function •  Oral competency •  Clarity of speech •  Mastication •  Tactile sensation •  Globe support Cosmesis •  Restoration of bony framework •  Soft tissue contour 2012
  30. 30. Surgery Reconstruction – Soft Tissue •  Free flaps –  Rectus abdominis –  Lateral thigh –  Latissimus dorsi –  Radial Forearm –  Tensor fascia lata –  Osteocutaneus Fibula •  Temporalis muscle system •  Fascia lata / temporalis fascia •  Nasolabial flap2012
  31. 31. Surgery Reconstruction – Bone •  Obturator •  Titanium mesh •  Bone grafts –  Calvarial –  Iliac •  Free flaps –  Fibula –  Scapula –  Iliac crest •  Septal 2012 cartilage
  32. 32. Maxillary  Defect Type  1 Type  2 Type  3 Type  4 Prosthesis   So@  Assue   Free  flap   Prosthesis Orbital  floor   Prosthesis Atanium  +-­‐  coated2012 Brown et al. Lancet Oncology 2010
  33. 33. Surgery Management of the Orbit2012 Weizman, Fliss et al. Arch. Otol. (in press)
  34. 34. SurgeryReconstruction of the Orbit – Partial Resection2012 Weizman, Fliss et al. Arch. Otol. (in press)
  35. 35. SurgeryReconstruction of the Orbit - Exenteration 2012 Weizman, Fliss et al. Arch. Otol. (in press)
  36. 36. Management of the Neck•  n=704, malignant tumors, maxillary and ethmoid, T1-T4•  Low frequency of nodal involvement at diagnosis Ethmoid tumors: 1.6% , Maxillary tumors: 8.3%•  Nodal status at baseline affects survival s•  Risk for regional recurrence: High Risk Low Risk Site Maxillary (12.5%) Ethmoid (4.3%) T-Stage T2 (18%) Histology SCC (21%) 2012 ElecAve  ND  for  T2+  Maxillary  SCC Cantu et al. Archives 2008
  37. 37. Management of the Neck •  Multicenter, n=146, oral (palate, alveolus) maxillary SCC, T2-T4 N0 •  Frequency of nodal involvement at diagnosis: 15% •  Overall rate of nodal involvement: •  N0 managed by observation only: 14.8% regional2012 failure (only 53% were salvaged) •  N0 managed by neck dissection/XRT: n/a al. Head and Neck 2011 Montes et
  38. 38. Management of the Neck •  n=139, oral maxillary SCC, T1-T4 •  Frequency of nodal involvement at diagnosis: 8.6% •  Regional failure among N0 patients: 29.5% (34%) were salvaged •  Predictors of failure: T- stage2012 Morris et al. Head and Neck 2011
  39. 39. Management of the Neck•  A subgroup of high risk patients: Maxillary sinus, SCC/SNUC, T2-T4•  High regional failure rate: 36%•  Reduced to 7% if ipsilateral2012 neck is radiated Bristol et al. Int J Radiat Oncol Biol Phys 2007 Hoppe et al. Int J Radiat Oncol Biol Phys 2008
  40. 40. Outcome Factors Influencing Survival •  Site Nose > maxillary > ethmoid •  T stage T1 > T4 •  Histology AdenoCa > SCC > SNUC •  Subsite analysis – tumor extension associated with reduced survival: –  Maxillary tumor: PPF2012 –  Ethmoid tumor: Cribriform, dura, brain, sphenoid –  Nasal tumor: Nasal floor Dulguerov et al. Cancer 2001
  41. 41. Outcome Factors Influencing Survival Site Histology N+ / M+ Treatment DSS2012 Dulguerov et al. Cancer 2001 Turner et al. Head and Neck 2011
  42. 42. Skull Base Surgery Definition•  Skull base surgery is the interdisciplinary approach to lesions afflicting those areas of the deep facial structures that abut the undersurface of the cranium•  Requires a multidisciplinary approach: –  Head & Neck surgeon –  Neurosurgeon –  Plastic and Reconstructive surgeon –  Maxillofacial surgeon –  Neuroradiologist/interventional arteriographer –  Neuro-ophthalmologist –  Anesthetist 2012 –  Pathologist
  43. 43. Multidisciplinary Team2012
  44. 44. Skull Base Surgery Indications•  Tumors approaching or involving the skull base•  Intracranial tumors with extracranial extension•  Neurovascular tumors2012
  45. 45. Evolution of SB Surgery QOL   Adjuvant  therapy   Minimally     Invasive     Surgery   Evidence     based  medicine   Aggressive     approaches   Learning  of     surgical  skills  2012 1970                            1980                      1990                      2000                          2010  
  46. 46. Evolution of SB Surgery The Future MulA  center   clinical  trials   Broader     PopularizaAon     indicaAons  for     of  surgical   endoscopic  surgery   techniques     AdopAon  of   ?   novel  targeted   Tx  from  other   Narrowing     New  tools   H&N  cancers   indicaAons     for  minimally     trials   for  open  surgery   RoboAc  surgery     invasive  surgery   ?     ?   2010 20202012
  47. 47. SBS Techniques Craniofacial Resection2012 Ketcham et al. Am J Surg 1963
  48. 48. SBS Techniques The Subcranial Approach2012 Fliss et al. Laryngoscope 1999 Fliss et al. Operative Tech 2000
  49. 49. The Subcranial Approach Combinations•  Subcranial with mid-facial degloving2012 Fliss et al. J Oral Maxillofacial Surg. 2000 Fliss et al. Arch Otolaryngol Head Neck Surg 2007
  50. 50. The Subcranial Approach Combinations •  Subcranial with pterional approach2012 Fliss et al. Operative Tech 2000
  51. 51. The Subcranial Approach Reconstruction2012 Fliss et al. Neurosurg Focus 2002 Fliss et al. Skull Base 2007 Gil and Fliss et al. Skull Base 2007
  52. 52. Reconstruction NFO Segment Wrapping2012 Gil and Fliss. Plastics and Rec Surg 2005
  53. 53. Evidence Based Medicine in SBS2012
  54. 54. Evidence Based Medicine inSBS Large Single Center Series Level  5   JC  Irish  et  al Head  &  Neck  1994 n  =  73 IP  Janecka  et  al Otolaryngology  Head  &Neck  Surgery  1994 n  =  183 JP  Shah  et  al Archives  1997 n=  115 V  Lund  et  al Head  &  Neck  1998 n  =  209 DM  Fliss  et  al Laryngoscope  1999 n=  55 G  Cantu  et  al Head  &  Neck  2011 n  =  3662012
  55. 55. Evidence Based Medicine in SBS Large Single Center Series•  Data obtained: Survival JC  Irish  et  al OS            71%  at  4  years IP  Janecka  et  al OS            67%  at  2.5  years JP  Shah  et  al DSS        58%  at  5  years V  Lund  et  al OS            44%  at  5  years DM  Fliss  et  al OS            66%  at  2  years G  Cantu  et  al OS            46%  at  5  years2012
  56. 56. Evidence Based Medicine in SBS Large Single Center Series•  Data  obtained:    PrognosAc  factors                Cantu et al. Head & Neck 2011 Lund et al. Head & Neck 19982012
  57. 57. Evidence Based Medicine in SBS Large Single Center Series•  Data obtained: Safety2012 Ganly et al. Head & Neck 2005
  58. 58. Evidence Based Medicine in SBS Multi Center Collaborations •  The problem: No single center treats enough patients to accumulate significant numbers for meaningful analysis of patient related and tumor related variables as predictors of surgical and postoperative outcome •  The solution: An international collaborative study group comprised of 17 institutions was set up to report their collective experience with the objective of assessing the safety and efficacy of ASBS2012
  59. 59. Evidence Based Medicine in SBS Multi Center Collaborations Level  5   •  Retrospective cohort •  17 institutions •  n = 1307 patient •  Follow-up2012 –  Median 25 months –  Range 1-940 months
  60. 60. Evidence Based Medicine in SBS Multi-Center Collaborations•  Survival•  Post operative mortality – 4%•  Post operative complications – 33% 2012
  61. 61. •  Prognostic factors for OS2012
  62. 62. Evidence Based Medicine in SBS Multi-Center CollaborationsConclusions•  CFR is safe and effective•  Histology, intracranial extent and surgical margins are independent determinants of outcome2012
  63. 63. Evidence Based Medicine in SBS Multi-Center Collaborations•  n= 334•  Prognostic factors for DSS: Surgical Margins Orbital involvement2012
  64. 64. Evidence Based Medicine in SBS Multi-Center Collaborations Intracranial involvement Histology•  Similar outcome and complication rate2012
  65. 65. SBS Techniques Endoscopic ApproachAdvantages•  Improved visualization•  No need for brain retraction•  No facial incisions/osteotomies•  Shorter hospitalizationDisadvantages•  Extension into the orbit or beyond•  Extensive dural resection (CSF leak)•  Piecemeal excision (?)•  Reconstructive issues 2012
  66. 66. Endoscopic Approaches Level of Evidence2012
  67. 67. Endoscopic Approaches Evidence Based Medicine•  RetrospecAve  review   Level  5  •  n=120,  15  years  2012
  68. 68. Endoscopic Approaches Evidence Based Medicine2012
  69. 69. Endoscopic Approaches Evidence Based Medicine2012
  70. 70. Endoscopic Approaches Evidence Based Medicine Level  5  •  n=184, 10 years•  Mean follow-up 34 months (2-123) 2012
  71. 71. Endoscopic Approaches Evidence Based Medicine2012
  72. 72. Endoscopic Approaches Evidence Based Medicine        EEA    CEA  •  5year  DSS:    91%    59%                (SelecAon  bias)   2012
  73. 73. Evidence Based Medicine in SBS Endoscopic Surgery Summary   •  Evidence  quality  -­‐  low   •  Long  term  follow-­‐up  -­‐  unavailable   •  Staged  tumors  (ENB,  adenocarcinoma)   can  be  managed  with  results  equivalent   to  open  techniques   •  Advanced  tumors  should  be  approached   by  minimally  invasive  open  techniques  or   by  a  combinaAon  of  open  and   endoscopic  approaches  2012 •  PaAents  should  be  managed  by  trained   surgical  oncologists  and  nasal  
  74. 74. Quality of Life in SBS Problem •  ASBS has been established as safe and effective •  The physical and psychological consequences of ASBS on a patient s QOL have not been clarified Solution •  To develop a cancer-specific multidimensional instrument to assess the impact of surgery on the QOL of patients2012 with anterior cranial base tumors
  75. 75. Quality of Life in SBS2012
  76. 76. Quality of Life in SBS •  Retrospective survey, n = 69 •  Generation of questions: review of literature, interview of patients and caregivers •  Assessment of reliability and validation of the construct •  Domains: –  Performance - Pain –  Physical function - Influence on emotions2012 –  Vitality - Specific symptoms
  77. 77. Quality of Life in SBS Overall QoL Social Activity 60 60 50 50 Patients (%) Patients (%) 40 40 30 30 20 20 10 10 0 0 Worse Same Better Worse Same Better 60 Financial Status 60 Impact Upon emotions 50 50 Patients (%) Patients (%) 40 40 30 30 20 20 10 0 10 Worse Same Better Worse Same Better2012
  78. 78. Quality of Life in SBS2012
  79. 79. Quality of Life in SBS 4.0 3.5 QOL Score 3.0 N=39 P<0.05 2.5 Preoperative 6 months 12 months2012
  80. 80. Quality of Life in SBS Conclusions •  The overall QOL in most patients after ASB surgery is good, with significant improvement within 6 months •  The worst impact of surgery was on the patients financial and emotional QOL domains. •  Negative prognostic factors for QOL: –  Old age –  Malignancy –  Comorbidity Gil and Fliss et al. Arch Otol H&N Surg 20032012 –  Radiotherapy Gil and Fliss et al. Arch Otol H&N Surg 2004 Gil and Fliss et al. J Neurosurg 2004 –  Wide surgery Abergel and Fliss et al. Harefua 2004 Gil and Fliss et al. Skull Base 2010
  81. 81. Trends in Survival and Demographics of Patients Undergoing SBSHead  &  Neck  2011 •  Study conducted in order to identify time-related changes in the clinical characteristics and survival of patient undergoing ASB surgery over the last four decades •  Pooled data from two cancer centers: Memorial Sloan-Kettering Cancer Center 2342012 Tel Aviv Sourasky Medical Center 48 Total n = 282
  82. 82. Trends in Survival and Demographics of Patients Undergoing SBS•  Demographics and clinical characteristics 2012
  83. 83. Trends in Survival and Demographics of Patients Undergoing SBS •  Survival2012
  84. 84. Trends in Survival and Demographics of Patients Undergoing SBS•  Prognostic factors for OS 2012
  85. 85. Trends in Survival and Demographics of Patient Undergoing SBS Conclusion •  Despite a higher risk for morbidity and tumor recurrence, refinement of surgical technique and the use of adjuvant radiation therapy, contributed to the current improvement in survival of patients2012 with anterior skull base malignancies

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