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Combined craniofacial resection of anterior skull base tumors: long-term results and experience of single institution

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Abstract

In this article, the authors are presenting their experience and the results with combined craniofacial resection of anterior skull base tumors based on a review of 27 constitutive cases. Our data are evaluated in comparison to other major centers in other parts of the world, and possible factors that might influence surgical outcome and survival are discussed. Twenty-seven patients diagnosed with anterior skull base tumors between 1999 and 2009 were treated by combined craniofacial resection. Of these patients, there were 19 males (70, 3%) and eight females (29, 7%). The age ranged between 11 and 75 years (mean = 45.9 ± 17.6 years). The follow-up period ranged between 14 and 123 months (avarage = 74 months). The most common presenting symptoms were nasal obstruction and vision disturbance (11 patients for each −40.7%). Total resection was achieved in 24 patients (89%), while subtotal resection was done in three patients (11%). The most common complication was CSF fistule with rhinorrhea, which occurred in five patients (18.5%). Eight patients had recurrences at the time of this long-term follow-up. There were two mortalities in the early postoperative period and seven deaths in the long-term follow-up (overall mortality, 33.3%). The overall 5-year overall survival for all patients in our series was 70.4%. The 5-year overall survival was 62% for patients with malignant tumors and 100% for patients with benign tumors. Combined craniofacial resection of tumors of the anterior skull base is an effective approach for the management of these pathologies. The effectiveness is clearly demonstrated by the clinical results and outcomes of these patients’ groups. The favorable prognosis is enhanced by significantly by total resection with negative tumor margins.

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Authors and Affiliations

  1. Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Cerrahpasa Street, K.M. Pasa, Fatih, Istanbul, Turkey, PO Box: 34089

    Bashar Abuzayed, Bulent Canbaz, Galip Zihni Sanus & Seckin Aydin

  2. Department of Otorhinolaryngology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey

    Harun Cansiz

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Dattatraya Muzumdar, Mumbai, India

Abuzayed et al. report their experience with tumors of combined craniofacial resection for the treatment of anterior skull base tumors from Turkey. It is the first to be published in the English literature from Turkey.

Combined craniofacial resection is performed with an aim to achieve an oncological cure for tumors straddling the anterior, lateral, or posterior fossa skull base. Excision of the tumor along with negative oncological margins is the paramount to justify the radical nature of surgery. A sound anatomical knowledge of the anterior, lateral, and the posterior skull base is necessary. The surgery is best performed in a tertiary oncology center by a multidisciplinary team comprising of a neurosurgeon and otolaryngologist having exposure to and training in skull base surgery. In anterior skull base tumors, combined craniofacial resection is indicated in patients with suspected cribriform plate involvement or dural invasion. In fact, a good negative margin could be achieved in tumors which involve the cribriform plate but do not erode it.

The authors correctly emphasize that the operative resection margin is an important independent prognostic factor affecting survival in patients with malignant tumor in the skull base. The overall 5-year survival was 54% for malignant tumors and 100% for benign tumors which is comparable with the international literature. However, the pathological and aggressive behavior of the tumor also has an impact on the overall prognosis.

Proper selection of the patient for anterior craniofacial resection is important for an optional outcome. A midfacial degloving approach and a low bifrontal craniotomy can also provide wide exposure of the anterior skull base and help lessen facial osteotomies. Endoscopic resection for malignant anterior skull base tumors is controversial since it defies the oncological definitions of resections with negative margins. Also the rate of CSF leak and resultant morbidity tends to be higher in endoscopic resections since it has a steep learning curve and standardization is yet to occur for it to be included in the standard of care for anterior skull base malignant tumors.

Uğur Türe and Christian Brogna, İstanbul, Turkey

The authors retrospectively analyze a 10-year institutional experience with 27 consecutive patients harboring a benign or malignant tumor of the anterior cranial base. Fourteen patients were newly diagnosed with anterior skull base tumors, and 13 were operated on previously: five through the transcranial approach alone, three with the transfacial approach alone, and five with the combined craniofacial approach. The tumor extended toward the orbit in 12 patients, the middle cranial fossa in eight, and the cavernous sinus in two.

A combined craniofacial resection—a bilateral frontobasal approach combined with a lateral rhinotomy or modified midfacial degloving or the transnasal approach—was the approach used in this series. The authors do not report how many patients underwent each type of transfacial approach.

Total resection was achieved in 24 patients, with subtotal in three patients. The authors state that the most important negative factor influencing the degree of resection was an extension toward the middle fossa, cavernous sinus, orbital apex, or superior orbital fissure and the involvement of the internal carotid artery. Nevertheless, in one of the three patients having subtotal resection, none of these structures was involved.

The series presented is heterogeneous. Histopathological examination revealed two juvenile angiofibromas, two transitional meningiomas, two atypical meningiomas, one anaplastic meningioma, five squamous cell carcinomas, two epidermoid carcinomas, two adenocystic carcinomas, three sinonasal adenocarcinomas, one hemangioendothelioma, one fibroblastic osteosarcoma, one chondrosarcoma, one mesenchymal type chondrosarcoma, one rhabdomyosarcoma, one esthesioneuroblastoma, one malignant desmoplastic small round cell tumor originating in the meninges, and one inverted papilloma.

Large dural defects were repaired with a duraplasty of the temporal muscle or a fascia lata graft. The report does not mention how many patients needed this procedure.

Only two patients had preoperative anosmia, but all patients had postoperative anosmia due to the bilateral frontobasal approach. Of the five patients having a postoperative CSF fistula, three required lumbar drainage while two needed a second surgical look. One patient died after the development of a CSF leak, which caused an abscess and cerebritis.

The 5-year overall survival for patients with benign tumors was 100%. Those with malignant tumors had a 5-year survival of 62%. The median time to recurrence was 17 months. While four patients died of recurrences, three died after progression of the residual tumor.

The authors present a relatively large surgical series of anterior cranial base tumors and we congratulate them for dealing with this complex topic with great success in terms of the percentage of patients having total removal. The best treatment and surgical approach to anterior cranial base tumors are still a matter of debate. We would like to discuss the different philosophies and surgical strategies we use in these cases.

First of all, analyzing benign and malignant tumors in the same series can be confusing. In fact, benign and malignant tumors of the anterior cranial base differ in many fundamental aspects, such as the patient’s age and clinical status at presentation, the tumor’s natural history, and the overall philosophy of the use of surgical and adjuvant treatment.

In our opinion, meningiomas of the anterior cranial base rarely require a combined craniofacial approach to be resected totally. For meningiomas arising from the olfactory groove, tuberculum sella, or the medial or lateral sphenoidal ridge, we prefer a pterional-transsylvian exploration and avoid a bilateral subfrontal approach. A subfrontal approach requires retraction of both frontal lobes and causes bilateral frontal lobe damage and postoperative anosmia because both olfactory nerves are usually damaged during this approach. On the other hand, the pterional approach provides a better orientation for the relationships between the meningioma and adjacent vital structures around the sella, without retraction of the frontal lobes. The pterional approach with dissection of the contralateral olfactory nerve from the capsule of the tumor allows the preservation of olfactory function, even in patients with olfactory groove meningiomas. If a surgeon prefers greater working space, the cranio-orbital zygomatic approach can be used.

Juvenile nasopharyngeal angiofibromas (JNAs) are rare, benign, vascular tumors. The blood supply to these lesions is most commonly from the maxillary artery, but may also come from the external carotid artery, the internal carotid artery, the common carotid artery, or the ascending pharyngeal artery. The case of JNA described by the authors involved the nasopharyngeal cavity with extension towards the left sphenoid bone, cavernous sinus, and optic canal. This patient was previously operated on with a combined craniofacial resection and the authors have chosen the same approach for the second surgery. In this case, however, we would prefer to selectively embolize feeding vessels preoperatively. The authors achieved only a subtotal resection with a combined craniofacial resection. Even though JNAs are benign lesions, the recurrence rate is high with residual pathology.

Malignant tumors, such as squamous cell carcinomas or sinonasal adenocarcinomas, require totally different management than benign tumors. In malignant cases, oncological resection is accomplished when en bloc resection includes at least 5 mm of normal tissue beyond the tumor, as determined through histological examination. Moreover, adjuvant therapies such as radiotherapy or, less commonly, chemotherapy must be administered. Treating patients with malignant tumors more complex than benign tumors. Unfortunately, some patients with malignant lesions of the anterior cranial base have already undergone radiotherapy or only partial surgical removal before the tumor reaches the skull base. Previous radiotherapy is correlated with an overall decrease in the 5-year survival and adjuvant radiotherapy carries a high risk of morbidity and local recurrence. Moreover, a delay of surgical treatment may allow the tumor to progress or invade the dura.

In patients with malignant tumors of the anterior cranial base, the combined craniofacial approach can be useful to effect an oncological resection. The modified midfacial degloving used by the authors provides a more cosmetically acceptable surgical route with respect to the lateral rhinotomy. However, in patients with extensive infiltration of the orbital structures, an orbital exenteration with prosthesis reconstruction may be necessary. We likely would have used a left cranio-orbital zygomatic approach to resect the epidermoid carcinoma presented by the authors as the illustrative case. The use of this approach could have gained the same total oncological resection but avoided retraction of the frontal lobes, sparing the contralateral olfactory nerve and preserving the mucosa of the nasal cavities. Unfortunately, this is the only case for which the authors present images. It would have been useful to have other cases to discuss.

The use of intraoperative lumbar drainage in selected cases, which is not mentioned in this paper, allows a good release of cerebrospinal fluid to minimize the need for brain retraction. We then make every effort to prevent cerebrospinal fluid rhinorrhea, which could be life-threatening. We prefer to close the dural defects with pericranium and fill major sinuses with autologous fat. In patients undergoing radiation therapy preoperatively or if a potential for CSF leakage occurs during surgery, we leave the lumbar drain in place for 5–7 days postoperatively.

We congratulate the authors for their efforts with these formidable lesions. Unfortunately, the controversies concerning their treatment will not be resolved in the near future.

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Abuzayed, B., Canbaz, B., Sanus, G.Z. et al. Combined craniofacial resection of anterior skull base tumors: long-term results and experience of single institution. Neurosurg Rev 34, 101–113 (2011). https://doi.org/10.1007/s10143-010-0286-1

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