Minimally invasive sinus surgery by P. Nicolai

The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012

MINIMALLY INVASIVE
SINUS SURGERY

Piero Nicolai

MALIGNANT SINONASAL TUMORS
Critical issues

•  Low incidence
•  Non-specific presenting
complaints
•  High histologic variability
•  Treatment options not well
defined
•  Difficult comparison of
treatment results
2012

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 common
2012
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.

HISTOLOGY
Malignant epithelial tumours
Haematolymphoid tumours
Squamous cell carcinoma
Verrucous carcinoma Extranodal NK/T cell lymphoma
Papillary squamous cell carcinoma
WHO classification, 2005 Diffuse large B-cell lymphoma
Basaloid squamous cell carcinoma
Extramedullary plasmacytoma
Spindle cell carcinoma
Adenosquamous carcinoma Soft tissue tumours Extramedullary myeloid sarcoma
Acantholytic squamous cell Malignant tumours Histocytic sarcoma
carcinoma Fibrosarcoma
Lymphoepithelial carcinoma
Malignant fibrous histiocytoma Neuroectodermal
Sinonasal undifferentiated
carcinoma Leiomyosarcoma Ewing sarcoma
Adenocarcinoma Olfactory neuroblastoma
Angiosarcoma
Intestinal-type adenocarcinoma
Malignant peripheral nerve sheath Mucosal malignant melanoma
Non-intestinal-type
adenocarcinoma tumours Tumours of bone and cartilage
Salivary gland-type carcinomas Chondrosarcoma
Borderline and low malignant
Adenoid cystic carcinoma Mesenchymal chondrosarcoma
Acinic cell carcinoma potential tumours Osteosarcoma
Mucoepidermoid carcinoma Chordoma
Desmoid-type fibromatosis
Epithelial-myoepithelial carcinoma
Inflammatory myofibrobastic Germ cell tumours
Clear cell carcinoma N.O.S.
Teratoma with malignant
Myoepithelial carcinoma tumour transformation
Polymorphous low-grade Sinonasal yolk sac tumour
Sinonasal type
adenocarcinoma (endodermal sinus tumour)
Neuroendocrine tumours haemangiopericytoma Sinonasal teratocarcinosarcoma
Typical carcinoid Extrapleural solitary fibrous
Atypical carcinoid
2012
tumour
Small cell carcinoma,
neuroendocrine type Secondary tumours

HISTOLOGY
High-grade SNUC

tumors

• SNUC
• SNEC
• Ewing Sarcoma
• Poorly differentiated
carcinoma EWING SARCOMA

2012

HISTOLOGY
Intermediate-grade
tumors
Adenoid cystic carcinoma Perineural invasion

2012

Distant metastasis

HISTOLOGY
Low-grade tumors

Well-differentiated ITAC

Signet ring-cell

2012

IMAGING
MSCT and/or MRI
Differentiation between tumor and
inflammatory changes
Soft tissues involvement and bony
infiltration
Perineural spread

PET/CT US of the neck
2012

ANTERIOR CRANIOFACIAL RESECTION
MAJOR ADVANCE IN THE SURGICAL TREATMENT OF SINONASAL
MALIGNANCIES

2012

Ketcham et al., 1963

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

ENDOSCOPIC SURGERY

2012

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)

ENDOSCOPIC SURGERY
FACTORS CONTRIBUTING TO EXPAND THE INDICATIONS OF
ENDOSCOPIC SURGERY
• Increasing expertise
• Technological advances
• Navigation systems
• Haemostatic agents
• Introduction of new reconstructive
techniques

2012

ENDOSCOPIC SURGERY FOR MALIGNANT
SINONASAL TUMORS
SURGICAL OPTIONS

Endonasal endoscopic
resection (EER)
EER with transnasal
craniectomy (ERTC)
Cranio-endoscopic resection
(CER)

2012

ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL
TUMORS
Contraindications 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 the
medial)
•  Involvement of the hard palate
•  Erosion of the nasal bones
•  Invasion of the orbital content
•  Involvement of the anterior skull base

2012

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 ASB

2012

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
nerve

2012

Two Surgical Teams with the same
Philosophy

P. Castelnuovo P. Nicolai
ENT Dpt. of Varese ENT Dpt. of Brescia

2012

SINONASAL TUMORS

STATISTICAL ANALYSIS

Follow-up until dead or at least 12 months after the
treatment

1996-2010: 326 pts

Mean age=61.3 years (range 4-85), M/F=2.2/1
Mean follow-up=52.7 months (range 12-169)

2012

ENDOSCOPIC SURGERY FOR
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

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%)


NOT A PIECEMEAL RESECTION
BUT TUMOR DISASSEMBLING

2012

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

SINONASAL TUMORS
STEP 1: Tumor debulking

2012

SINONASAL TUMORS
STEP 2: In case of complete ethmoidectomy
the nasal septum is removed...

2012

SINONASAL TUMORS
STEP 3: Centripetal removal with subperiosteal
dissection

2012

SINONASAL TUMORS
STEP 4: Removal and drilling of bone-cartilage

2012

SINONASAL TUMORS
STEP 5: Removal of periorbita, dura
and olfactory bulb(s)

2012

SINONASAL TUMORS
STEP 5: Removal of periorbita, dura and olfactory bulb(s)

2012

SINONASAL TUMORS
STEP 6: Endoscopic duraplasty

Fascia lata (Iliotibial tract) Fascia lata

2012
Iliotibial tract

SINONASAL TUMORS

2012

SINONASAL TUMORS

Goals of fat tissue:
sealing of
duraplasty and
2012 shock absorber
effect

SINONASAL TUMORS
Endoscopic resection of lesions with brain involvement (selected cases)

2012

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)

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 =0.08
2012 treatment • 2009-2010 (61): 1.6 %

5-year overall survival (EER-ERTC-CER)

ERTC (82.6±4.34)
EER (79.3±3.81)

CER (49.2±6.6)

p=0.00197
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

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; version
2012 10.0.1, 1999 Chicago, IL.

5-year disease-specific survival (untreated vs recurrence)
DISEASE SPECIFIC SURVIVAL DEPENDING ON PREVIOUS
TREATMENT

U (82±2.96)

R (75.3±5.55)

2012 10.0.1, 1999 Chicago, IL.
performed using log-rank
test

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)

2012 10.0.1, 1999 Chicago, IL.
performed using log-rank
test

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; version
2012 10.0.1, 1999 Chicago, IL.

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

ENDOSCOPIC RESECTION WITH
TRANSNASAL CRANIECTOMY (ERTC)
5-year disease-specific survival (histology)

10.0.1, 1999 Chicago, IL.

ENDOSCOPIC RESECTION WITH
TRANSNASAL CRANIECTOMY (ERTC)
5-year disease-specific survival (T category)

10.0.1, 1999 Chicago, IL.

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

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
2012

MENYNGEAL METASTASES
66-year-old male
Signet ring-cell AC
Previous external surgery
Postop RT

70-year-old male
ITAC
No previous treatment
pT4b (dura invasion)
Postop RT
2012

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 chemotherapy
2012
• Need for a multi-institutional database

ENDOSCOPIC SURGERY FOR MALIGNANT SINONASAL
TUMORS
Endoscopic surgery for
malignancies of the sinonasal tract
should be performed only in
centers where a multidisciplinary
team with experience in the whole
spectrum of the procedures
involving the anterior skull base is
available, keeping in mind that
there are precise limits related to
the extent as well as to the biology
of the tumor.
2012

Minimally invasive sinus surgery by P. Nicolai

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