Navigation-guided osteotomies improve margin delineation in tumors involving the sinonasal area: A preclinical study

Abstract

To demonstrate and quantify, in a preclinical setting, the benefit of three-dimensional (3D) navigation guidance for margin delineation during ablative open surgery for advanced sinonasal cancer. Materials and methods: Seven tumor models were created. 3D images were acquired with cone beam computed tomography, and 3D tumor segmentations were contoured. Eight surgeons with variable experience were recruited for the simulation of osteotomies. Three simulations were performed: 1) Unguided, 2) Guided using realtime tool tracking with 3D tumor segmentation (tumor-guided), and 3) Guided by 3D visualization of both the tumor and 1-cm margin segmentations (margin-guided). Analysis of cutting planes was performed and distance from the tumor surface was classified as follows: "intratumoral" when 0 mm or negative, "close" when greater than 0 mm and less than or equal to 5 mm, "adequate" when greater than 5 mm and less than or equal to 15 mm, and "excessive" over 15 mm. The three techniques (unguided, tumor-guided, margin-guided) were statistically compared. Results: The use of 3D navigation for margin delineation significantly improved control of margins: unguided cuts had 18.1% intratumoral cuts compared to 0% intratumoral cuts with 3D navigation (p < 0.0001). Conclusion: This preclinical study has demonstrated the significant benefit of navigation-guided osteotomies for sinonasal tumors. Translation into the clinical setting-with rigorous assessment of oncological outcomeswould be the proposed next step.

Novel Approaches in Surgical Management: How to Assess Surgical Margins

“…Although most frequently employed to minimize intraoperative complications and optimize precision of reconstruction, cross-sectional imaging-based navigation could also provide the surgical team with a more precise image of tumor extension. This has been shown in a preclinical setting, where the employment of navigation with 3-dimensional rendering of the tumor extension significantly increased the adequacy of margin delineation in models of advanced cancers variably extending within the craniomaxillofacial skeleton [22]. Over a total of 381 simulated osteotomies, the use of surgical navigation decreased the rate of gross margin involvement from 18.1% to 0.0%.…”

“…While often resembling a plaque or a sphere in the early phases of growth, advanced tumors of the head and neck acquire a 3-dimensional morphology that mirrors the complexity of subsite anatomy. This translates into a substantially increased chance of misorienting the plane of dissection with respect to one or other components of the tumor [22].…”

Malignant tumors of the maxillary sinus: Prognostic impact of neurovascular invasion in a series of 138 patients

“…The ablative phase consists of maxillectomy, which can be tailored according to tumor extension. During assessment of tumor margins and osteotomy planning, endoscopy and surgical navigation, respectively, can aid the surgeon in achieving a resection with free margins [13][14][15]. With the infrequent exception of early cancers which are radically excised, treatment also includes adjuvant radiation [16,17].…”

Augmented Reality and Intraoperative Navigation in Sinonasal Malignancies: A Preclinical Study

“…Utilization of IN in open procedures to resect malignant tumors has been less reported, but promising results were obtained in margin status in small cohorts ( 3 , 30 , 31 ). Our group has recently published a preclinical experience utilizing the same advanced IN system used in the present study to assist in open sinonasal approaches ( 4 ). The main novelty is that our advanced IN system allows surgeons not only to track the desired instrument but also to visualize the entire cutting trajectory of a tracked cutting tool in 3D.…”

“…Our group has recently published an advanced IN system for open sinonasal approaches during the resection of locally aggressive cancers ( 4 ). This technology not only allows the surgeon to locate a registered instrument or pointer tool in two dimensions but also introduces planar cutting tool capabilities along with three-dimensional (3D) volume rendering.…”