The neurosurgical management of sinonasal malignancies involving the anterior skull base: a 28-year experience at The MD Anderson Cancer Center

Abstract

OBJECTIVE Sinonasal malignancies that extend to the anterior skull base frequently require neurosurgical intervention. The development of techniques for craniofacial resection revolutionized the management of these neoplasms, but modern and long-term data are lacking, particularly those related to the incorporation of endoscopic techniques and novel adjuvant chemotherapeutics into management schema. The present study was performed to better define the utility of surgical management and to determine factors related to outcome. METHODS Patients who underwent surgery between 1993 and 2020 were included in this retrospective cohort study. Only patients with greater than 6 months of clinical and radiological follow-up were included. Outcome measures included progression, survival, and treatment-related complications. RESULTS Two hundred twenty-five patients were included. The mean clinical follow-up was 6.5 years. The most common histological diagnosis was olfactory neuroblastoma (33%). Overall, metastatic disease and brain invasion were present in 8% and 19% of patients, respectively, at the time of surgery. A lumbar drain was used in 54% of patients. When stratified by decade, higher-stage disease at surgery became more frequent over time (15% of patients had metastatic disease in the 3rd decade of the study period vs 4% in the 1st decade). Despite the inclusion of patients with progressively higher-stage disease, median overall survival (OS) remained stable in each decade at approximately 10 years (p = 0.16). OS was significantly worse in patients with brain invasion (p = 0.006) or metastasis at the time of surgery (p = 0.014). Complications occurred after 28% of operations, but typically resulted in no long-term negative sequelae. Use of a lumbar drain was a significant predictor of complications (p = 0.02). Permanent ophthalmological disabilities were observed after 4% of surgical procedures. One patient died during the perioperative period. Finally, major complications (Clavien-Dindo grade ≥ IIIb) decreased from 27% of patients in the 1st decade to 10% in the 3rd decade (p = 0.007). CONCLUSIONS The surgical management of sinonasal malignancies with anterior skull base involvement is effective and generally safe. Surgical management, however, is only one facet of the overall multimodal management paradigms created to optimize patient outcomes. Survival outcomes have remained stable despite more extensive disease at surgery in patients who have presented in recent decades. The safety of such surgery has improved over time owing to the incorporation of endoscopic surgical techniques and the avoidance of lumbar spinal drainage with open resection.

Clinical Outcome in Patients with Large Sinonasal Tumors with Intracranial Extension

“…Overall survival was 50% at a mean follow-up op 49 months. These results are in line with reports in the literature 7,8,16,17,20,21 . The most important predictor of survival is achieving gross total resection, while preserving quality of life 22 .…”

Impact of salvage surgery for recurrent sinonasal cancers with skull base and intracranial involvement

“…Indeed, in a large institutional series that included 225 patients who were treated surgically for SNC over a 28-year period, found that the 5-year PFS rate for SNC was 52% and the 5-year OS rate was 65%. 10 Previous studies have demonstrated the poor prognosis associated with recurrent disease, especially when associated with skull base involvement. 13 The goals of this study were to determine whether skull base resection impacts the outcomes of well-selected patients with RSNC despite first-line therapy failure and to identify ad- ditional factors to be considered in the overall treatmentplanning process.…”

“…Furthermore, endoscopic resection in a piecemeal fashion has been found to provide similar oncological control when compared with open en bloc resections. 10 Orbital involvement poses a particular challenge for patients with RSNC. Previous studies have shown that orbital invasion was associated with increased risk of death in patients with RSNC.…”

“…7,33,36 Although treatments did vary between pathologies, the decision to offer salvage surgery at the time of recurrence was done in a multidisciplinary fashion. 10 A proposed treatment algorithm for RSNC is shown in Fig. 2.…”

“…The 5-year overall survival (OS) rate was 65%. 10 Patients with recurrent SNCs (RSNCs) whose first-line therapy has failed often present with extensive involvement of the skull base and exhibit high rates of subsequent recurrence and death. These are particularly challenging pathologies to treat, with limited data guiding the role of salvage surgery, adjuvant radiation, and/or chemotherapy.…”