Comprehensive preoperative staging system for endoscopic single and multicorridor approaches to juvenile nasal angiofibromas

Abstract

Background:Juvenile nasal angiofibromas (JNA) is a benign lesion with high vascularity and propensity of bone erosion leading to skull base invasion and intracranial extension. It is known to involve multiple compartments, which are often surgically difficult to access. With evolution in surgical expertise and technical innovations, endoscopic and endoscopic-assisted management has become the preferred choice of surgical management. Over the last four decades, various staging systems have been proposed, which are largely based on the extent of nasal angiofibroma. However, no clear guidelines exist for the stage-appropriate surgical management. In this study, we aim to formulate a novel staging system based on the analysis of high quality preoperative imaging and propose detailed surgical guidelines related to disease stages as observed in 242 primary cases of JNA.Methods:A retrospective analysis of the case records of 242 primary JNA cases was performed at our center. Patients were staged according to various existing staging systems as well as our own new staging system, and outcome variables were compared with respect to intraoperative blood loss, multiple staged operations, and tumor recurrences. Operative records were studied and precise endoscopic surgical guidelines were formulated for each stage.Results:Comparing the intraoperative blood loss seen in stages of various classifications, it was found that intraoperative blood loss correlated best and statistically significantly with stages in the newly proposed Janakiram staging system when compared to the existing staging systems. Staged operations were performed in a total of 7/242 patients, and there was a significant association between the requirement of a staged operation and tumor extent (Fischer's exact test, P < 0.001). Tumor recurrence was seen in 22 cases and the pterygoid wedge was found to be the most frequent site of recurrence initially. As the extent of resection improved with better surgical technique over time, recurrences were only found in superior orbital fissure, around the internal carotid artery, and in the middle cranial fossa.Conclusion:This new Janakiram staging system is based on preoperative imaging data from one of the largest JNA case series reported thus far. Respective guidelines reliably stratify patients into treatment groups with definite surgical approaches and predicts outcome. Improved surgical approaches in the modern endoscopic era have redefined JNA management with improved outcome. This study shows the importance of precise presurgical imaging and the choice of the most suitable surgical approach in reducing morbidity and mortality in JNA surgery.

Juvenile Angiofibroma: What Is on Stage?

“…Mean age of the patients, mean follow-up, need for transfusion, and rate of persistent disease of the present study are comparable to most of the published series, [9][10][11]18,20,21 thus confirming appropriateness of the treatment provided and allowing for such an analysis to be performed. All patients of this series underwent PIAE, which allowed for the UPMC classification to be correctly applied.…”

“…In recent years, suggestions for new classifications were proposed by Snyderman 9 and Janakiram. 10 Both authors provided statistical evidence to support the superiority of their staging systems in terms of stratification. The former was backed up by the concept of "residual vascularity," a novelty never considered in previous classification systems, which could account for better correlation with the considered clinical endpoints (blood loss, need for multiple operations, and postoperative persistence and recurrence).…”

“…The following data were collected: age at surgery, imaging studies, surgical technique, duration of surgery, blood loss, need for perioperative transfusion, intraoperative and postoperative complications, outcomes, and follow‐up. Pre‐ and post‐embolization angiograms were reviewed for evidence of residual vascularity from the internal carotid artery (ICA), which was not quantified but based on identifiable vessels coming from the artery, according to Snyderman et al 9 Based on the analysis of preoperative imaging, angiography, and intraoperative findings, all the lesions were retrospectively classified according to the following staging systems (Table I): Andrews‐Fisch, 7 Radkowski, 8 University of Pittsburgh Medical Center (UPMC), 9 and Janakiram 10 . Exclusion criteria were as follows: 1) JA surgically removed without preoperative embolization; 2) missing relevant data (e.g., preoperative imaging, surgical report, postoperative radiologic control); 3) less than 12 months of follow‐up.…”

“…Given the lack of consensus about this topic, the aim of the present study was to validate four of the most widely used staging systems [7][8][9][10] on a cohort of patients treated for JA, with the intent to identify, if any, the most informative and predictive classification with regard to complications and persistence of disease.…”

Combined endoscopic and transoral resection of a high‐staged juvenile nasopharyngeal angiofibroma: A pictorial essay

“…12,15 Several staging systems have been proposed over the years with Sessions, Chandler, Andrews, and Radkowski predominating in the era of open resection and newer systems such as Onerci, UPMC, and Janakiram based on endoscopic techniques. 16,17 The Andrews-Fisch system, one of the first classification systems created for JNA tumors, is based on its analysis of the tumors growth pattern and extensions, with particular attention to how it extends into the skull base. 18 However, its staging and surgical recommendations have certain disadvantages given the limited surgical techniques available at the time the system was created.…”