hanna - sinonasal-skullbase - ahns · 10/4/2013 3 patient evaluation oobbjjectiectivveses...

10/4/2013

1

Sinonasal and Skull Base Cancer

Progress, Challenges, and Future

Directions

Ehab Hanna, M.D.

Head and Neck SurgeryMD Anderson Cancer Center

ContextContext��Advances in DiagnosisAdvances in Diagnosis

��Office endoscopyOffice endoscopy

��High Resolution Imaging High Resolution Imaging ��Better Histopathologic ClassificationBetter Histopathologic Classification

��Advances in TreatmentAdvances in Treatment��SurgerySurgery

��Craniofacial and skull base surgeryCraniofacial and skull base surgery

��Endoscopic and Robotic surgeryEndoscopic and Robotic surgery

��Conformal Radiation: IMRT and ProtonConformal Radiation: IMRT and Proton

��Active chemotherapeutic agents and treatment Active chemotherapeutic agents and treatment intensificationintensification

ETIOLOGYETIOLOGY

��OccupationalOccupational��Furniture and hardwood Furniture and hardwood

��Nickel refining Nickel refining

��Leather and boot Leather and boot

��RadioRadio--active paintactive paint

��Previous irradiationPrevious irradiation

��Chronic infectionChronic infection

��Tobacco and alcoholTobacco and alcohol

Sinonasal Cancer Sinonasal Cancer

MDACC ExperienceMDACC Experience

�� Department DatabaseDepartment Database

�� 2698 patients with sinonasal cancer 2698 patients with sinonasal cancer

�� 19441944--April 2007April 2007

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2

0

200

400

600

800

1000

1200

1400

Number of

Patients

Paranasal

Sinus,

NOS

Antrum

(Maxillary

Sinus)

Nasal

Cavity

Ethmoid

Sinus

Sphenoid

Sinus

Frontal

Sinus

Site

Site Distribution of Sinonasal Malignancies in

Patients Seen at MDACC

6.3%

44.9%

34.3%

11.3%

2.0% 1.3%

N=2698 patients

Histologies of Sinonasal Malignancies

in Patients Seen at MDACC

Squamous

Carcinoma

45%

Unclassified

Carcinoma

9%

Other

Neoplasms

5%

Adenoid Cystic

Carcinoma

8%

Adenocarcinoma

6%

Other

Carcinoma

7%

Malignant

Melanoma

6%

Neuroblastoma

4%

Sarcoma

10%

N=2698 patients

SPREADSPREAD

�� LocalLocal

��Direct extensionDirect extension

��Perineural Perineural

��Fissures and foraminaFissures and foramina

�� RegionalRegional

��LymphaticLymphatic

��DistantDistant

��HematogenousHematogenous

0

20

40

60

80

100

120

140

160

Number of

Patients

I II III IV

AJCC Stage

AJCC Stages of Sinonasal Malignancies

Seen at MDACC

9.7% 11.7%

20.2%

58.5%

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Patient EvaluationPatient Evaluation

��ObjectivesObjectives

��Establishing the diagnosisEstablishing the diagnosis

��Determining the extent of tumorDetermining the extent of tumor

��Planning a treatment strategyPlanning a treatment strategy

Symptoms and Signs of Early DiseaseSymptoms and Signs of Early Disease

Office EndoscopyOffice Endoscopy

Signs and Signs and SymptomsSymptoms

Advanced DiseaseAdvanced Disease��Of Of extension beyond the sinonasal extension beyond the sinonasal tracttract

��OrbitalOrbital

��FacialFacial

��Oral Oral

��NeurologicNeurologic

NasalNasal

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FacialFacial OralOral

OrbitalOrbital

NeurologicNeurologic

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ImagingImaging

�� IndicationsIndications

��Suspicion of a Suspicion of a neoplasticneoplastic processprocess

��Evaluation of site and extent of diseaseEvaluation of site and extent of disease

��Type of imaging studyType of imaging study

��Most commonly usedMost commonly used (CT/(CT/MRI/PET)MRI/PET)

��Selectively usedSelectively used (Angiography)(Angiography)

��Specific information for treatment planningSpecific information for treatment planning

Benign vs. MalignantBenign vs. Malignant

CT vs. MRICT vs. MRI MRI T1 vs. T2MRI T1 vs. T2

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T1 with and without contrastT1 with and without contrast Perineural SpreadPerineural Spread

CS

PET-CT

Angiography / EmbolizationAngiography / Embolization

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BiopsyBiopsy

HistopatholgicHistopatholgic ExaminationExamination

A B C

Olfactory Neuroblastoma

Neuroendocrine Carcinoma

Sinonasal Undifferentiated Carcinoma

Cohen et al: Misdiagnosis of Olfactory Neuroblastoma. Neurosurgical Focus12(5): 1-6, 2002

Neuroendocrine Tumors – Overall Survival

0

.2

.4

.6

.8

1

Ove

rall S

urv

ival

0 60 120 180Time (months)

ENB

NEC

SNUC

SmCCp=0.0029

5y-OS93.1%

64.2%62.5%

28.6%

ENB

NECSNUC

SmCC

Pankeratin

Neuroendocrine:

Chromo/Synap

SNUC/SCC NEC

+

+

-

-

Neuroendocrine:

Chromo/Synap

Muscle:

Desmin

Myogenin +

ENB RMS

CD99 Melanocytic:

PanMel/S100

ES/PNET Melanoma

Cordes et al., 2007

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Surgical TreatmentSurgical Treatment

�� Surgical ApproachSurgical Approach

��EndoscopicEndoscopic

��TransfacialTransfacial��Lateral Lateral rhinotomyrhinotomy

��WeberWeber-- FergussonFergusson

��TransoralTransoral --TranspalatalTranspalatal

�� SublabialSublabial “Facial “Facial DeglovingDegloving””

��TranscranialTranscranial

�� Extent of ResectionExtent of Resection

��EthmoidectomyEthmoidectomy

�� Partial Partial maxillectomymaxillectomy

��Total Total maxillectomymaxillectomy

��Orbital Orbital exentrationexentration

��Anterior cranial base Anterior cranial base resectionresection

�� PterygopalatinePterygopalatine fossafossa

�� InfratemporalInfratemporal fossafossadissectiondissection

External Ethmoidectomy ApproachExternal Ethmoidectomy Approach


��Limited tumors of the ethmoid sinus or medial orbitLimited tumors of the ethmoid sinus or medial orbit

��No significant extension into the maxillary sinus or No significant extension into the maxillary sinus or cribriform platecribriform plate

External Ethmoidectomy: External Ethmoidectomy:

Soft Tissue ApproachSoft Tissue Approach External Ethmoidectomy: External Ethmoidectomy:

Bone Resection Bone Resection

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ClosureClosure


Postoperative AppearancePostoperative Appearance

Medial MaxillectomyMedial Maxillectomy


�� Tumors of the lateral nasal wallTumors of the lateral nasal wall

�� No significant extension into the maxillary sinusNo significant extension into the maxillary sinus

Lateral RhinotomyLateral Rhinotomy

AABB

CC

DD

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Medial Maxillectomy:Medial Maxillectomy:

Soft Tissue ApproachSoft Tissue Approach

Medial Maxillectomy: Medial Maxillectomy:

Management of the Lacrimal SacManagement of the Lacrimal Sac

Medial Maxillectomy: Medial Maxillectomy:

Exposure of the nasal cavityExposure of the nasal cavityMedial Maxillectomy: OsteotomiesMedial Maxillectomy: Osteotomies

A

B

C

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Medial Maxillectomy: ClosureMedial Maxillectomy: Closure Postoperative AppearancePostoperative Appearance

Inferior MaxillectomyInferior Maxillectomy


��Upper alveolar ridge tumorsUpper alveolar ridge tumors

��No significant extension into the maxillary sinusNo significant extension into the maxillary sinus

Inferior MaxillectomyInferior Maxillectomy

�� TechniqueTechnique

�� Soft tissue approachSoft tissue approach

�� SublabialSublabial

�� Facial deglovingFacial degloving

�� OsteotomiesOsteotomies

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Facial Degloving ApproachFacial Degloving Approach


��Bilateral medial or inferior maxillary resectionBilateral medial or inferior maxillary resection

��No significant superior/posterior extensionNo significant superior/posterior extension

��AdvantageAdvantage

��DisadvantageDisadvantage

�� TechniqueTechnique

Inferior MaxillotomyInferior Maxillotomy

Total MaxillectomyTotal Maxillectomy


�� Tumors originating from Tumors originating from the maxillary sinusthe maxillary sinus

�� Tumors with significant Tumors with significant extension into the extension into the maxillary sinusmaxillary sinus

Total MaxillectomyTotal MaxillectomySoft tissue approachSoft tissue approach

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Total MaxillectomyTotal MaxillectomyOsteotomiesOsteotomies

ReconstructionReconstructionPalate and DentitionPalate and Dentition

Craniofacial Resection Craniofacial Resection

�� IndicationsIndications�� Tumors originating from Tumors originating from the olfactory groovethe olfactory groove

�� Tumors extending to or Tumors extending to or invading the invading the cribriformcribriformplateplate

Cranial Base Resection for MalignancyCranial Base Resection for Malignancy

SURGICAL PRINCIPLESSURGICAL PRINCIPLES

�� Adequate oncologic resection Adequate oncologic resection

�� Minimal brain retractionMinimal brain retraction

�� Protection of critical neurovascular structuresProtection of critical neurovascular structures

�� Meticulous reconstruction of the anterior skull Meticulous reconstruction of the anterior skull

base base

�� Optimal esthetic outcomeOptimal esthetic outcome

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Extracranial ApproachExtracranial Approach

A.A. TransfacialTransfacial

B.B. SublabialSublabial

C.C. EndoscopicEndoscopic

Transfacial ApproachTransfacial Approach

A

B

C

Frontal CraniotomyFrontal Craniotomy

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Osteotomies

Tumor ResectionTumor Resection

Reconstruction of the Cranial BaseReconstruction of the Cranial Base

Pericranial FlapPericranial Flap ClosureClosure

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Postoperative AppearancePostoperative Appearance

Before surgery 7 yr FU

Management of the orbit in Management of the orbit in

sinonasal malignancysinonasal malignancy�� ExenterationExenteration

�� PreservationPreservation

�� Role of RadiationRole of Radiation

�� ReconstructionReconstruction

Orbital Exenteration and OrbitectomyOrbital Exenteration and Orbitectomy

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Orbital Defect ReconstructionOrbital Defect Reconstruction Orbital ExenterationOrbital Exenteration

�� Almost routine in 1950sAlmost routine in 1950s--1960s1960s

�� RationaleRationale

�� Oncologic safetyOncologic safety(Harrison 1976,1985,1989)(Harrison 1976,1985,1989)

�� Emotional impactEmotional impact

Orbital PreservationOrbital Preservation

�� The orbit is preserved unless there is invasion of The orbit is preserved unless there is invasion of

the orbitalthe orbital

�� fat, musclesfat, muscles

�� apex, posterior ethmoids, infraorbital n.apex, posterior ethmoids, infraorbital n.

�� periorbita?periorbita?

Orbital PreservationOrbital Preservation

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Orbital ExentrationOrbital Exentration

19%

81%Orbital Exentration

Orbital Preservation

Orbital ReconstructionOrbital Reconstruction

Function of the preserved orbitFunction of the preserved orbit

�� Radiation induced problemsRadiation induced problems

�� Keratopathy, cataract, optic atrophyKeratopathy, cataract, optic atrophy

�� Surgery induced problemsSurgery induced problems

�� Ectropion, hypoglobus, diplopiaEctropion, hypoglobus, diplopia

�� Poor functional and esthetic outcome of the Poor functional and esthetic outcome of the

preserved eye preserved eye ( Jiang 1991,Stern 1993)( Jiang 1991,Stern 1993)

Extent of Orbital Resection and Bony Extent of Orbital Resection and Bony

Orbital ReconstructionOrbital Reconstruction

Improving Function of the Improving Function of the

Preserved OrbitPreserved Orbit

�� Radiation factorsRadiation factors

�� dose, field, shieldingdose, field, shielding

�� 33--D Conformal TherapyD Conformal Therapy

�� IMRTIMRT

�� Surgical factorsSurgical factors

�� Orbital reconstructionOrbital reconstruction

�� Bone grafts (Calvarial, rib..etc.)Bone grafts (Calvarial, rib..etc.)

�� Alloplastic implants (Medpor,Marlex,Titanium, Alloplastic implants (Medpor,Marlex,Titanium, Vitallium..etc.)Vitallium..etc.)

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Primary ReconstructionPrimary Reconstruction

of the of the Orbit and Cheek: MedporeOrbit and Cheek: Medpore

Primary Reconstruction of the Primary Reconstruction of the Orbit: Orbit:

Titanium MeshTitanium Mesh

Secondary Orbital Reconstruction:Secondary Orbital Reconstruction:Calvarial Bone GraftCalvarial Bone Graft


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Outcome

Are we making progress?

Overall Survival over Five Years of Patients with Sinonasal Malignancies Seen at MDACC from 1944 - April 2007

Died Last Contact

0 12 24 36 48 60

Months from Presentation at MDACC

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve P

rop

ort

ion

Su

rviv

ing

2698 patients

Overall Survival over Five Years of Patients with Sinonasal Malignancies Seen at MDACC from 1944 - April 2007

Died Last Contact

0 12 24 36 48 60


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

1944 - 1953 1954 - 1963 1964 - 1973 1974 - 1983 1984 - 1993 1994 - 2003 2004 - Apr2007

1944 - 1953 vs. 1964 - 1973 & All Later Periods: p < 0.051954 - 1963 vs. 1974 - 1983 & Later: p < 0.051964 - 1973 vs. 1974 - 1983 & Later: p < 0.051974 - 1983 vs. 1994 - 2003 & Later: p < 0.051984 - 1993 vs. 1994 - 2003: p < 0.05

2698 patients

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Overall Five-Year Survival of Sinonasal Malignancy Patients by Histology (Simpler)

Died Last Contact

0 12 24 36 48 60


-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

SQUAMOUS CARCINOMA

UNCLASSIFIED CARC.

ADENOCARCINOMA

OTHER NEOPLASMS

OTHER CARCINOMA

SARCOMA

MALIGNANT MELANOMA

ADENOID CYSTIC CARC.

NEUROBLASTOMA

Overall Ten-Year Survival of Sinonasal Malignancy Patients by Histology (Simpler)

Died Last Contact

0 24 48 72 96 120


-0.2

-0.1

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

SQUAMOUS CARCINOMA UNCLASSIFIED CARC. ADENOCARCINOMA OTHER NEOPLASMS OTHER CARCINOMA SARCOMA MALIGNANT MELANOMA ADENOID CYSTIC CARC. NEUROBLASTOMA

Craniofacial ResectionsCraniofacial Resections

MD Anderson ExperienceMD Anderson Experience

783Feb. 14, 2007

357

Disease-Specific Survival of Sinonasal Cancer Patients

Who Had Craniofacial ResectionsDied of Disease Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

266 patients

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Overall Survival of Sinonasal Cancer Patients Who Had

Craniofacial Resections by Tumor Stage Died Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

T1 or 2 or 3N = 37

T4N = 131

p = 0.003


Craniofacial Resections by Disease Status at PresentationDied Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

Initial disease - No Previous treatment, n = 170 Recurrent disease - after treatment elsewhere, n = 66 Persistent disease - after treatment elsewhere, n = 27

Initial vs. Recurrent Disease : p = 0.001


Craniofacial Resections by Finding of Perineural InvasionDied Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g No Perineural InvasionN = 217

Perineural Invasion FoundN = 49

p = 0.004


Craniofacial Resections by Finding of AngioinvasionDied Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g No AngioinvasionN = 253

Angioinvasion FoundN = 13

p = 0.0001

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ProgressionProgression--Free Survival Free Survival

subdural vs brainsubdural vs brain

�� Subdural spread Subdural spread

�� Mean PFS 68.7 monthsMean PFS 68.7 months

�� Brain invasion Brain invasion

�� Mean PFS 22.3 monthsMean PFS 22.3 months

�� p=0.005p=0.005

Feiz-Erfan I, Suki D, Hanna EY, DeMonte F. Prognostic significance of transdural invasion of skull base

malignancies in patients undergoing craniofacial resection. Neurosurgery 61:1178-85, 2007.

Overall Survival Overall Survival –– Surgical MarginsSurgical Margins

�� Negative margins Negative margins

�� Mean 102.9 monthsMean 102.9 months

�� Positive margins Positive margins


�� p=0.049p=0.049

0.00 20.00 40.00 60.00 80.00 100.00 120.00

Total F/U

0.0

0.2

0.4

0.6

0.8

1.0

Overall Survival

Margins

(1=negative;

2=positive; 3=not

assessed)

1.00

2.00

1.00-censored

2.00-censored



Overall Survival Overall Survival –– Resection method Resection method

�� En bloc resection En bloc resection


�� Piecemeal resection Piecemeal resection


�� NS (p=0.951)NS (p=0.951)

0.00 20.00 40.00 60.00 80.00 100.00 120.00

Total F/U

0.0

0.2

0.4

0.6

0.8

1.0

Cum Survival

Type of Rsx (1=en

block; 2=non-en

block)

1.00

2.00

1.00-censored

2.00-censored

Survival Functions



Improvements/Limitations/Future DirectionsImprovements/Limitations/Future Directions

�� Craniofacial skull base surgeryCraniofacial skull base surgery

�� Endoscopic and Robotic ApproachesEndoscopic and Robotic Approaches

�� Conformal RadiationConformal Radiation

�� Active chemotherapeutic agentsActive chemotherapeutic agents

�� Treatment intensificationTreatment intensification

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Endoscopic Resection

Advantages

� Direct access to the anterior and central skull base with no brain retraction

� Avoiding craniofacial incisions and extensive bone removal commonly used in open surgical approaches.

� Wider angle of vision and angled lenses

� increases the range of the endoscopic visual surgical field

� “seeing around corners” compared to the “line of sight” visual field gained by surgical loupes or microscopes.

MORBIDITY AND MORTALITY OF

ANTERIOR CRANIOFACIAL RESECTION

StudyStudy # of # of

PatientsPatients

MortalityMortality MorbidityMorbidity

Catalano et al

1994

73 2.7% 63%

Shah et al

1997

115 3.5% 35%

Dias et al

1999

104 7.6% 48.6%

Solero et al

2000

168 4.7% 30%

Morbidity of ACFRMorbidity of ACFR

IntracranialIntracranial ExtracranialExtracranial SystemicSystemicEarlyEarly LateLate Early Early LateLate EarlyEarly LateLate

Transient MS Transient MS

changes 15%changes 15%

Diplopia 19%Diplopia 19% 12%12% MI 4%MI 4%

CSF Leak 6%CSF Leak 6% Enophthalmos 4%Enophthalmos 4% 4%4% Pneumonia 2%Pneumonia 2%

Seizure 4%Seizure 4% 2%2% Ptosis 4%Ptosis 4% 2%2% Parotitis 2%Parotitis 2%

Meningitis 2%Meningitis 2% Lagophtalmos 2%Lagophtalmos 2% 2%2%

Pneumoceph. 2%Pneumoceph. 2% Epiphora 2%Epiphora 2%

CVA 2%CVA 2% 2%2% Palatal fistula 2% Palatal fistula 2%

Extradural fluid Extradural fluid

2%2%2%2% Wound dehiscence Wound dehiscence

2%2%

Hanna et al: AHNS 2006

Skull Base SurgerySkull Base Surgery

MDACCMDACC

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HemangiopericytomaHemangiopericytoma

Preop

5 yr.

Postop

Endoscopic Resection of

Malignant Tumors� During the last decade, there has been increasing

adoption of endoscopic approaches for surgical

resection of sinonasal malignancy.

� Despite this growing enthusiasm, the oncologic

outcomes for endoscopic resection of sinonasal

cancers have not been adequately reported.

So What Are The

Oncologic Outcomes

of Endoscopic

Resection of Sinonasal

Cancer?

Findings Hanna et al. 2009:

MD Anderson Cancer Center

Nicolai et al. 2008: U. Brescia and

U. Pavia/Insubria-VareseNumber of patients

Total

EEA

CEA

120 184

93 (77.5%) 134 (73%)

27 (22.5%) 50 (27%)

Mean follow up 37 months 34 months

Prior treatment 59% 28%

Stage EEA CEA All patients EEA* CEA* All patients*

T1 32% 0% 25% 37% 6% 28%

T2 31% 5% 25% 19% 2% 14%

T3 17% 36% 21% 15% 24% 17%

T4 20% 59% 29% 16% 62% 28 %

Histopathology

Adenocarcinoma 14% 37%

Esthesioneuroblastoma 17% 12%

Melanoma 14% 9%

Squamous cell carcinoma 13% 14%

Adenoid cystic carcinoma 7% 7%

Neuroendocrine Carcinoma 4% 1%

SNUC 2% 3%

Sarcomas 15% 13%

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Finding Hanna et al 2009

MD Anderson

Nicolai et al 2008

Italy

Adjuvant Therapy

None (surgery only) 50% 47%

Radiation 37% 39%

Chemoradiation 13% 3%

Chemotherapy 6% 4%

Recurrence

Local 15% 15%

Regional 6% 1%

Distant 5% 7%

5-year Disease-specific survival

Overall 87% 82%

EEA 86% 91%

CEA 92% 59%

Survival in Patients Who Had Endoscopic

Surgery for Sinonasal Cancers Died Last Contact

0 12 24 36 48 60 72 84 96 108 120


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

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Pro

po

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g

Disease-Specific SurvivalN = 120

Overall SurvivalN = 120

Disease-Specific Survival in Patients Who Had Endoscopic

Surgery for Sinonasal Cancers Died of Disease Last Contact

0 12 24 36 48 60


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

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urv

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g

Cranio-Endoscopic ApproachN = 27

Exclusively Endoscopic ApproachN = 93

p = 0.645

Training and Expertise

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Overall Survival in Patients Who Had Endoscopic Surgery for Sinonasal Cancers by Status at Presentation at MDACC

Died Last Contact

0 12 24 36 48 60


0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g

Initial Disease, N = 49

Recurrent Disease, N = 15

Persistent Disease, N = 55

Initial vs. Persistent Disease: p = 0.002Initial vs. Recurrent Disease: p = 0.215Persistent vs. Recurrent Disease: p = 0.286

Limitations of Endoscopic Approaches

Dural Reconstruction and CSF leaks

While endoscopic resection of sinonasal and skull base tumors is gaining popularity, valid concerns exist regarding the adequacy and

reliability of endonasal reconstruction of major skull base

and dural defects.

Dural Defect Repair? CSF Leak

� A layered reconstruction of the dura with inlay and onlay fascial grafts has been described as an effective technique for repair of large dural defects.

� The CSF leak rate with these techniques is significantly higher than rates reported with standard craniofacial resection.

� In a recent study reporting the combined experience of the U. Miami and U. Pittsburgh with endoscopic endonasal resection of ENB, 4 of 23 patients (17%) had postoperative CSF leak.

Folbe et al, Endoscopic endonasal resection of esthesioneuroblastoma:

a multicenter study. Am J Rhinol Allergy. 2009;23(1):91-94.

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Reconstruction of Large Dural Defects

� Our current policy is to perform CEA in patients who require large dural resections, and because of the high likelihood of delivering postoperative high-dose radiation therapy in these patients, our preference is to use vascularized flaps for reconstruction of the skull base.

� In addition to allowing wider dural resection, CEA in our hands allows us a more reliable reconstruction using water-tight suture duraplasty reinforced with a well vascularized pericranial flap.

CSF leak

� Following these principles, the postoperative

CSF leak was rare (3%) in the current study and

compares favorably with results obtained in

standard open craniofacial resections.

The right approach?

Limits of endoscopic approach

� Facial Soft Tissue

� Deep Orbital Invasion

� Lateral supraorbital extension

� Anterior wall of frontal sinus

� Brain parynchemal invasion

Complete Resection

Adequate Reconstruction

Extent of diseaseExtent of disease

Improvement/Limitations/Future DirectionsImprovement/Limitations/Future Directions






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Local control by era / technique

0.0%

10.0%

20.0%

30.0%

40.0%

local rec

1960 - 80's

1990's: 3D

IMRT - 2000's

60’s-80’s

90’s

2000’s

Ahamad et al, AHNS 2007

Does conformal radiation improve outcomes or reduce toxicity?

92%

66%

Complication Free Rate

Bristol IJ, Ahamad A, Garden AS, Morrison WH, Hanna EY, Papadimitrakopoulou VA, Rosenthal DI, Ang KK.

Postoperative radiation for maxillary sinus cancer: long-term outcomes and toxicities of treatment. Int J Rad Onc Biol Phys

68(3):719-30, 7/2007.

Table 6: Crude complications observed for all patients in group 1 and group 2.

Group 1

(n=90)

Group 2

(n=56)

Grade: 1 2 3 4 1 2 3 4

Ocular 1 3 3 22 1 6 7 0

Auditory 7 11 4 1 2 8 0 0

Bone 0 11 0 4 0 3 1 0

Brain 0 0 0 6 0 1 0 0

Subcut Tissue 2 5 6 2 0 3 4 0

Skin 1 3 0 1 0 0 0 0

Endocrine 0 1 4 0 0 2 0 0

Infection 2 0 0 0 5 0 0 0

Total: 13 34 17 36 8 23 12 0

Complications between the Two Groups

Bristol IJ, Ahamad A, Garden AS, Morrison WH, Hanna EY, Papadimitrakopoulou VA, Rosenthal DI, Ang KK.

Postoperative radiation for maxillary sinus cancer: long-term outcomes and toxicities of treatment. Int J Rad Onc Biol Phys

68(3):719-30, 7/2007.

Proton Therapy

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33 yo female

Adenoid cystic carcinoma

Nasopharynx- ACC

70 CGE + CDDP

33 yo female

Adenoid cystic carcinoma

At presentation One year follow up

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Should the N0 neck be treated

with elective nodal radiation?

Nodal Disease by Histology (%)

0

5

10

15

20

25

30

35

Presenting N+ Recurrent N+

SCC and Undiff (N = 100)Other (N = 47)

P = 0.007P = 0.025

0

20

40

60

80

100

0 1 2 3 4 5

Time (Years)

Per

cen

t N

od

al

Con

trol

Nodal Control Rate in Patients with

SCC or Undifferentiated Histology

± ENI

Elective Neck

Irradiation

No Elective Neck

Irradiation

P = 0.0004

62%

92%

Improvement/Limitations/Future DirectionsImprovement/Limitations/Future Directions






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At presentation

After induction chemotherapy

When do we use it?When do we use it?

�� Significant brain Significant brain parnchemalparnchemal invasioninvasion

�� Orbital invasion requiring Orbital invasion requiring exentrationexentration

�� Facial soft tissue and skin invasionFacial soft tissue and skin invasion

�� Nodal metastasisNodal metastasis

�� Gross cavernous sinus invasionGross cavernous sinus invasion

Before induction chemotherapy

One year after treatment

50 patients with T3/T4 SCC

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Disease-Free Survival in Patients with SNUC

Who Underwent Induction Chemotherapy Had Recurrence or Died Last Contact

0 12 24 36 48 60 72 84 96 108 120

Months from End of Treatment for Initial Disease

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Cu

mu

lati

ve

Pro

po

rtio

n S

urv

ivin

g w

/ou

tR

ec

urr

en

ce

Partial or Complete ResponseN = 17

Stable or Progressive DiseaseN = 10

p = 0.0003

Integrated Multidisciplinary ApproachIntegrated Multidisciplinary Approach

At Presentation Induction ChemotherapyConcurrent

Chemoradiation

Craniofacial

Resection

2 yr. F/U

SummarySummarySummarySummarySummarySummarySummarySummary�� Diagnostic imagingDiagnostic imaging�� Craniofacial Craniofacial skull base surgeryskull base surgery�� Endoscopic and Robotic ApproachesEndoscopic and Robotic Approaches�� Conformal RadiationConformal Radiation�� Active chemotherapeutic agentsActive chemotherapeutic agents�� Treatment intensificationTreatment intensification

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34

SAVE -THE-DATE

24th Annual NASBS Meeting:24th Annual NASBS Meeting:

February 14February 14--16, 2014 16, 2014

in SAN DIEGO, CA in SAN DIEGO, CA

Pre meeting Courses Pre meeting Courses


24th Annual NASBS Meeting:24th Annual NASBS Meeting:


in SAN DIEGO, CA in SAN DIEGO, CA

Pre meeting Courses Pre meeting Courses


Thank youThank you

hanna - sinonasal-skullbase - ahns · 10/4/2013 3 patient evaluation oobbjjectiectivveses...

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