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Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan
Auris Nasus Larynx 28 (2001) S71– S75 www.elsevier.com/locate/anl
Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan Satoshi Fukuda a,*, Noboru Sakai a, Shin-Etsu Kamata b, Hideo Nameki c, Seiji Kishimoto d, Kunio Nishikawa e, Shozo Kaneko f, Mamoru Miyata g, Masato Fujii h, Yukio Inuyama a a
Department of Otolaryngology, Hokkaido Uni6ersity School of Medicine, kita 15 nishi 7, kita-ku, Sapporo, 060 -8638 Japan b Di6ision of Head and Neck, Cancer Institute Hospital, Tokyo, 002 -8072 Japan c Department of Otolaryngology & Head and Neck Surgery, Shizuoka Red Cross Hospital, Shizuoka, 420 -0853 Japan d Department of Head and Neck Surgery, Tokyo Medical and Dental Uni6ersity School of Medicine, Tokyo, 113 -8519 Japan e Department of Otolaryngology, Shikoku Cancer Center Hospital, Shikoku, 790 -0007 Japan f Toranomon ENT Clinic, Tokyo, 105 -0001 Japan g Miyata ENT Clinic, Utsunomiya, 320 -0851 Japan h Department of Otolaryngology, Keio Uni6ersity School of Medicine, Tokyo, 160 -0016 Japan Received 4 December 2000; received in revised form 12 January 2001; accepted 15 January 2001
Abstract We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n=78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n =16). The most frequent surgical approach was frontal craniotomy (n= 66), followed by front-temporal craniotomy (n =54) and infratemporal fossa approach (n=8). For repair of dura matter, fascia lata was used in 37 cases, galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan– Meier method of nose and paranasal sinus carcinoma (n= 119) was 48%. As for histological classification, the survival rates were both 65% in adenoid cystic carcinoma (n =12) and bone soft tissue malignancy (n=10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n=11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases, liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Skull base surgery; Craniofacial resection
Prologue
This study was supported by the Grant-in-Aid for Cancer Research (number: 4 – 17) from the Ministry of Health and Welfare of Japan from April 1992 to March 1996. * Corresponding author. Tel.: + 81-11-7073387; fax: + 81-117177566. E-mail address: [email protected] (S. Fukuda).
Surgery for malignant tumors involving or extending to the skull base has matured as a relatively safe operative procedure recently. This fact owed to the advancement in techniques of plastic surgery and imaging. However, no large clinical report over one hundred cases of skull base surgery in otolaryngological field has been published in Japan until now. Shah [1] also
0385-8146/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 0 8 3 - 9
S72
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
pointed out that no one individual or single institution has sufficient number of patients at each site or each histological group as yet to have meaningful data in the skull base. Of the study of skull base surgery for head and neck malignancies carried out by the Group of Cancer Research (Chief: Professor Yukio Inuyama), supported by the Japanese Ministry of Health and Welfare, a midterm report of 93 cases has been published in the Japanese journal [2] and brief conclusive reports of total 143 cases has been published in the book [3,4], both of which were written in Japanese. We consider that the substantial surgical results of 143 skull base surgery in Japan should be available and appealed widely to otolaryngologists, neurosurgeons and plastic surgeons overseas as well. With permission of the Director and Editor-in-Chief of the journal [2] and the Editor and Representative of the publisher of the book [3,4], we would like to present the contents in English here.
1. Introduction Significant technical advances have taken place over the course of the past 35 years. The base of skull, an area considered to be the ‘no man’s zone’ at one time, is now routinely approached for various indications, such as malignant head and neck tumors invading the skull base with the development of newer approaches, imaging and technical refinements [1]. The members of the group for ‘The Study of New Treatment for Head and Neck Cancer in the Border Region (Skull Base and Upper Mediastinum)’, supported by the Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare (from April 1992 to March 1996, Chief: Professor Yukio Inuyama), analyzed 143 cases of skull base surgery performed at their affiliated institutions between April 1985 and December 1995. Those members belonged to, (1) Department of Otolaryngology, Hokkaido University School of Medicine, (2) Division of Head and Neck, Cancer Institute Hospital, Tokyo, (3) Department of Otolaryngology & Head and Neck Surgery, Shizuoka Red Cross Hospital, (4) Department of Otolaryngology, Kochi Medical School, (5) Department of Otolaryngology, Shikoku Cancer Center Hospital, (6) Department of Otolaryngology, Jikei University School of Medicine, (7) Department of Otolaryngology, Jichi Medical School, (8) Department of Otolaryngology, Keio University School of Medicine at that time.
2. Background of the patients The total number was 143 (Table 1), consisting of 86
men and 57 women ranging in age between 20 to 86 years (mean: 57 years). The most frequently encountered primary site was nose and paranasal sinuses in 119 (83%). Among these, the maxillary sinus was in 55 (46%) and ethmoid sinuses in 47 (39%), accounting for 85% of these lesions. The following was ear and temporal bone in nine (6.3%). Histologically, the most frequent type was squamous cell carcinoma (SCC) in 78 (55%), followed by olfactory neuroblastoma (OLF) and adenoid cystic carcinoma (ACC) in 16, adenocarcinoma (ADE) in 11, bone and soft tissue carcinoma (BST) in ten, transitional cell carcinoma in four and malignant melanoma (MM) in three. About 87 (61%) cases have received no earlier treatment and 56 cases (39%) have received some form of previous treatment (Table 1).
3. Results The varieties of technical approaches were available for these lesions. Both intracranial and extracranial approach were carried out in more than half of the cases. The way of intracranial approach (n= 96, Table 2) consisted of frontal craniotomy in 66 cases, fronttemporal craniotomy in 54, transtemporal approach in 14, infratemporal fossa approach in eight and suboccipital approach in three. A frontal craniotomy or frontTable 1 Patient characteristics Number of patients Sex Age
Male Female Median Range
143 86 57 57 20–86
Primary site
Nose and paranasal sinuses Maxillary sinus Ethmoid sinus Frontal sinus Sphenoid sinus Nasal cavity Ear and temporal bone Nasopharynx Parotid gland Miscellaneous
119 55 47 6 4 7 9 6 3 6
Histologic type of 143 cases
Squamous cell carcinoma Olfactory neuroblastoma Adenoid cystic carcinoma Adenocarcinoma Bone and soft tissue tumor Transitional cell carcinoma Malignant melanoma Miscellaneous
78 16 16 11 10 4 3 5
Prior treatment
No Yes
87 56
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75 Table 2 Surgical approach Surgical approach Intracranial approach Frontal craniotomy Fronto-temporal craniotomy with orbito-zygomatic osteotomy without orbito-zygomatic osteotomy Infratemporal fossa approach Temporal approach Suboccipital approach Miscellaneous
Number of cases 96 66 54 27 27 8 14 3 5
Extracranial approach Transfacial approach Lateral rhinotomy Weber–Fergusson incision Mid-facial splitting Miscellaneous
145 113 34 28 13 38
Transoral approach Transantral approach Transpalatal approach Miscellaneous Transnasal approach
28 4 13 11 4
temporal craniotomy was usually carried out in most of the nose and paranasal sinus cases; the former was frequent for ethmoid sinuses lesions and the latter for maxillary sinus lesions. In the cases of ear and temporal bone carcinoma, transtemporal approach was frequent. Infratemporal fossa approach and suboccipital approach were selectively applied depending on the lesion. As for the extracranial approach (n = 145, Table 2), transfacial approach was performed in 113 cases. Among these, lateral rhinotomy was performed in 34 cases, Weber– Fergusson incision in 28 cases and midfacial splitting in 13 cases. For reconstruction of the skull base (Table 3), free rectus abdominis myocutaneous (MC) flap was most frequently used in 85 cases. For repair of dura matter, fascia lata was most frequently used, which was followed by galeopericranial flap, temporal muscle fascia. For reconstruction of face, soft tissue and palate, free rectus abdominis MC flap was most frequently used as in a reconstruction of the skull base. Namely, free rectus abdominis MC flap was simultaneously used for reconstruction of the skull base and the face in many cases. The surgical results were indicated in Fig. 1, Tables 4 –6 and Table 7. The overall 5-year survival rate in the
S73
cases of nose and paranasal sinus carcinoma for those undergoing skull base surgery (n= 119) by Kaplan– Meier method was 48% (Fig. 1). Histologically, the survival rate was best in the cases of ACC (n = 12) and BST (n= 10), marking 65%, which was followed by 46% in SCC cases (n= 62) and 33% in ACC (n=11). All the three cases of MM were dead within 1 year, so we considered skull base surgery to be contraindicated for this disease. The overall 5-year survival rate of the rest site was 67% (n= 24). Among them, the cases of nasopharyngeal carcinoma showed fairly well survival rate of 75% (n= 6) considering the fact that all of these cases had recurrences after radiotherapy. The operation time required for skull base surgery was 14.5 h on an average (range: 4–30 h, Table 4), and the amount of intraoperative blood loss was averaged 2500 ml (range: 150–13 000 ml, Table 5). Postoperative complications were observed in 62 cases out of the 143 cases consisted of local infection in 29 cases, liquorrhea in 18, abscess formation in 16, necrosis of the flap and meningitis in ten, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one
Table 3 Material for reconstructiona Material for reconstruction Skull base Free flap Rectus abdominis MC flap Latissimus dorsi MC flap Forearm flap Miscellaneous
Number of cases
85 6 4 55
Dura mater Fascia lata Galeopericranial flap Temporal muscle fascia Calvarial periosteal flap based on temporal muscle pedicle
37 35 16 13
Reconstruction of the face, soft tissue and palate Free rectus abdominis MC flap Free latissimus dorsi MC flap Latissimus dorsi MC flap (pedicled) Free rectus abdominis MC flap+Rib Free latissimus dorsi MC flap+anterior serratus muscle flap+Rib
61 4 5 1 4
a
MC flap: myocutaneous flap.
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S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
Fig. 1. The results of skull base surgery in nose and paranasal sinus carcinoma invading skull base (n = 119, by Kaplan – Meier method).
case (Table 6). Ten cases (7%) were regarded as operative death. The most frequent sequela was impairment of cranial nerves (mostly I– VII N) in 51 cases caused by extraction of oculus or operative resection. Secretory otitis media was observed in 19 cases, articulation disorder in ten, trismus in eight and drooping of flaps in four cases (Table 7).
4. Discussion In the present series, major primary site extended to the skull base was the nose and paranasal sinus (83%) and it should be noted that the 5-year survival rate in this lesion was 48%, in particular survival of 46% was observed in squamous cell carcinoma. Before induction of skull base surgery in Japan, Miyake et al. [5] reported 5-year survival rate of 18% by extracranial approach in case of nose and paranasal sinus carcinoma involving skull base and Ono [6] reported 5year survival rate as 6.7% (n =127) in the cases of maxillary sinus carcinoma staged as IV according to the data of TNM Classification Committee (1979– 1981). These two famous Japanese head and neck surgeons in this lesion observed same results of an unfavorable prognosis. Considering these facts, we believed that the overall 5-year survival rate of 48% in 119 cases of nose and paranasal sinus carcinoma involving skull base was a significant progress by induction of skull base surgery. Among those, olfactory neuroblastoma (n = 16) achieved 62% 5-year survival. Considering the origin of this tumor, it was one of the most appropriate diseases to apply skull base surgery. Shah [1] reported that overall 5-year survival of 60% was observed for those undergoing craniofacial resections for malignant diseases involving anterior skull base and that survival was directly impacted by the extent of disease and the
histological type and grade of tumor. He stressed that the development, availability and applicability of craniofacial surgery for malignant diseases that approach or involve the skull base has opened a new era in the surgical treatment of tumors of the nasal cavity and paranasal sinuses. On the other hand, all the three cases of MM terminated fatally within 1 year. It seems to suggest the limit of surgical treatment in this particular disease. Shah [1] also reported the 5-year survival rate of mucosal MM undergoing skull base surgery as less than 20%, indicating worst survival rate in his skull base surgery series by histopathology. We should also decide the indication for skull base surgery in case of recurrences of nasopharyngeal carcinoma, of radiation low sensitivity tumor such as adenocarcinoma, mucoepidermoid carcinoma and adenoid cystic carcinoma and of recurrent parotid gland carcinoma extended into the skull base. Complications were observed in 43%, which needs to be reduced by improving the operative and reconstruction procedures and pre- and post-operative management. Operative death actually occurred in 7%, but it occurred mostly in earlier cases of this series and has rarely occurred in recent cases. Table 4 Time required for surgerya Hour
Number of cases
B4 5–9 10–14 15–19 20–24 \25
1 21 58 32 12 3
a
Mean time: 14.5 h, range: 4–30 h in reported 127 cases.
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
S75
Table 7 Postoperative sequelaea
Table 5 Blood loss during surgerya Volume of blood loss (ml)
Number of cases
Postoperative sequelae
Number of cases
B900 1000–1900 2000–2900 3000–3900 \4000
19 35 33 12 20
Cranial nerve involvement Secretary otitis media Articulation disorder Trismus Double vision Drooping of flaps Miscellaneous
51 19 10 8 5 4 12
a Mean blood loss: 2500 ml, ranging from 150 to 13 000 ml in reported 119 cases.
a
Rate of sequela 64% (87/137), not evaluable: six cases.
Table 6 Postoperative complicationsa Postoperative complications
Number of cases
Local infection Liquorrhea Abscess Flap necrosis Meningitis DIC Hemorrhage due to rupture of ICA Cerebral thrombosis Miscellaneous
29 18 16 10 10 4 2 1 19
lacerum, body of sphenoid, brain and cases with wide dural spread and previous treatment failure.
References
a Rate of complication 43% (62/143), surgery related death 10 cases (7%), ICA: internal carotid artery.
From these results, we propose the following points to improve the outcome of skull base surgery: (1) improvement of pre- and post-operative management, (2) evaluation of the extended application and the limit of resection more precisely, (3) advancement of operative procedure and development of a new approach, (4) shortening the operation time and (5) effort to decrease blood loss in volume during surgery. Finally, we will have to wait for further study for precise indication and contraindication for those invading cavernous sinus, internal carotid artery, foramen
.
[1] Shah JP. The skull base. In: Shah JP, editor. Head and Neck Surgery, 2nd edn. New York, NY: Mosby-Wolfe, 1996:85 –141. [2] Inuyama Y, Sakai N, Fukuda S, Nameki H, Kamata S, Kishimoto S, et al. Skull base surgery-Statistical analysis for 93 cases collected from Study Group of Cancer Research from Japanese Ministry of Health and Welfare. Head Neck Cancer Jpn 1994;20:511 – 5 in Japanese. [3] Inuyama Y. Induction of skull base surgery for the cases of nose and paranasal malignancies involving skull base. In: Inuyama Y, editor. Significance of Chemotherapy in the Treatment of Head and Neck Cancer. Tokyo, Japan: Tokyo Igaku-Sha, 1997:175 –8 in Japanese. [4] Inuyama Y. Statistical analysis of skull base surgery and upper mediastinal dissection collected from Study Group of Cancer Research from Japanese Ministry of Health and Welfare. In: Inuyama Y, editor. Recent Progress in Treatment for Border Region of Head and Neck Cancer. Tokyo, Japan: Kyowa Kikaku Tsushin, 1996:124 – 31 in Japanese. [5] Miyake H. Operative treatment. In: Miyake H, editor. Various problems in the Treatment of Maxillary Cancer. Tokyo, Japan: Kohoku Publ. Co, 1984:77 – 92 in Japanese. [6] Ono S., Unpublished data.
Surgical results of skull base surgery for the treatment of head and neck malignancies involving skull base: multi-institutional studies on 143 cases in Japan Satoshi Fukuda a,*, Noboru Sakai a, Shin-Etsu Kamata b, Hideo Nameki c, Seiji Kishimoto d, Kunio Nishikawa e, Shozo Kaneko f, Mamoru Miyata g, Masato Fujii h, Yukio Inuyama a a
Department of Otolaryngology, Hokkaido Uni6ersity School of Medicine, kita 15 nishi 7, kita-ku, Sapporo, 060 -8638 Japan b Di6ision of Head and Neck, Cancer Institute Hospital, Tokyo, 002 -8072 Japan c Department of Otolaryngology & Head and Neck Surgery, Shizuoka Red Cross Hospital, Shizuoka, 420 -0853 Japan d Department of Head and Neck Surgery, Tokyo Medical and Dental Uni6ersity School of Medicine, Tokyo, 113 -8519 Japan e Department of Otolaryngology, Shikoku Cancer Center Hospital, Shikoku, 790 -0007 Japan f Toranomon ENT Clinic, Tokyo, 105 -0001 Japan g Miyata ENT Clinic, Utsunomiya, 320 -0851 Japan h Department of Otolaryngology, Keio Uni6ersity School of Medicine, Tokyo, 160 -0016 Japan Received 4 December 2000; received in revised form 12 January 2001; accepted 15 January 2001
Abstract We analyzed 143 cases of skull base surgery collected from the eight institutions of the Study Group supported by the Grant-in-Aid for Cancer Research from the Ministry of Health and Welfare of Japan. Histologically, the most common type was squamous cell carcinoma (n=78), which was followed by olfactory neuroblastoma (n = 16) and adenoid cystic carcinoma (n =16). The most frequent surgical approach was frontal craniotomy (n= 66), followed by front-temporal craniotomy (n =54) and infratemporal fossa approach (n=8). For repair of dura matter, fascia lata was used in 37 cases, galeopericranial flap in 35 and temporal muscle fascia in 16. The 5-year survival rate by Kaplan– Meier method of nose and paranasal sinus carcinoma (n= 119) was 48%. As for histological classification, the survival rates were both 65% in adenoid cystic carcinoma (n =12) and bone soft tissue malignancy (n=10), 62% in olfactory neuroblastoma (n = 16), 46% in squamous cell carcinoma (n = 62) and 33% in adenocarcinoma (n=11). All the three cases of malignant melanoma died within 1 year, so we considered skull base surgery to be contraindicated for this disease. Complications were observed in 62 out of the 143 cases (43%); local infection was most frequent in 29 cases, liquorrhea in 18, abscess in 16, necrosis of the flap and meningitis in ten cases, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one. Death caused directly by surgery was in ten cases (7%). It is important that a multi-center registry be maintained to have a large enough database for comparison of results, and prognosis for each histological entity and further define the role of multidisciplinary treatment. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Skull base surgery; Craniofacial resection
Prologue
This study was supported by the Grant-in-Aid for Cancer Research (number: 4 – 17) from the Ministry of Health and Welfare of Japan from April 1992 to March 1996. * Corresponding author. Tel.: + 81-11-7073387; fax: + 81-117177566. E-mail address: [email protected] (S. Fukuda).
Surgery for malignant tumors involving or extending to the skull base has matured as a relatively safe operative procedure recently. This fact owed to the advancement in techniques of plastic surgery and imaging. However, no large clinical report over one hundred cases of skull base surgery in otolaryngological field has been published in Japan until now. Shah [1] also
0385-8146/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 0 8 3 - 9
S72
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
pointed out that no one individual or single institution has sufficient number of patients at each site or each histological group as yet to have meaningful data in the skull base. Of the study of skull base surgery for head and neck malignancies carried out by the Group of Cancer Research (Chief: Professor Yukio Inuyama), supported by the Japanese Ministry of Health and Welfare, a midterm report of 93 cases has been published in the Japanese journal [2] and brief conclusive reports of total 143 cases has been published in the book [3,4], both of which were written in Japanese. We consider that the substantial surgical results of 143 skull base surgery in Japan should be available and appealed widely to otolaryngologists, neurosurgeons and plastic surgeons overseas as well. With permission of the Director and Editor-in-Chief of the journal [2] and the Editor and Representative of the publisher of the book [3,4], we would like to present the contents in English here.
1. Introduction Significant technical advances have taken place over the course of the past 35 years. The base of skull, an area considered to be the ‘no man’s zone’ at one time, is now routinely approached for various indications, such as malignant head and neck tumors invading the skull base with the development of newer approaches, imaging and technical refinements [1]. The members of the group for ‘The Study of New Treatment for Head and Neck Cancer in the Border Region (Skull Base and Upper Mediastinum)’, supported by the Grant-in-Aid for Cancer Research from the Japanese Ministry of Health and Welfare (from April 1992 to March 1996, Chief: Professor Yukio Inuyama), analyzed 143 cases of skull base surgery performed at their affiliated institutions between April 1985 and December 1995. Those members belonged to, (1) Department of Otolaryngology, Hokkaido University School of Medicine, (2) Division of Head and Neck, Cancer Institute Hospital, Tokyo, (3) Department of Otolaryngology & Head and Neck Surgery, Shizuoka Red Cross Hospital, (4) Department of Otolaryngology, Kochi Medical School, (5) Department of Otolaryngology, Shikoku Cancer Center Hospital, (6) Department of Otolaryngology, Jikei University School of Medicine, (7) Department of Otolaryngology, Jichi Medical School, (8) Department of Otolaryngology, Keio University School of Medicine at that time.
2. Background of the patients The total number was 143 (Table 1), consisting of 86
men and 57 women ranging in age between 20 to 86 years (mean: 57 years). The most frequently encountered primary site was nose and paranasal sinuses in 119 (83%). Among these, the maxillary sinus was in 55 (46%) and ethmoid sinuses in 47 (39%), accounting for 85% of these lesions. The following was ear and temporal bone in nine (6.3%). Histologically, the most frequent type was squamous cell carcinoma (SCC) in 78 (55%), followed by olfactory neuroblastoma (OLF) and adenoid cystic carcinoma (ACC) in 16, adenocarcinoma (ADE) in 11, bone and soft tissue carcinoma (BST) in ten, transitional cell carcinoma in four and malignant melanoma (MM) in three. About 87 (61%) cases have received no earlier treatment and 56 cases (39%) have received some form of previous treatment (Table 1).
3. Results The varieties of technical approaches were available for these lesions. Both intracranial and extracranial approach were carried out in more than half of the cases. The way of intracranial approach (n= 96, Table 2) consisted of frontal craniotomy in 66 cases, fronttemporal craniotomy in 54, transtemporal approach in 14, infratemporal fossa approach in eight and suboccipital approach in three. A frontal craniotomy or frontTable 1 Patient characteristics Number of patients Sex Age
Male Female Median Range
143 86 57 57 20–86
Primary site
Nose and paranasal sinuses Maxillary sinus Ethmoid sinus Frontal sinus Sphenoid sinus Nasal cavity Ear and temporal bone Nasopharynx Parotid gland Miscellaneous
119 55 47 6 4 7 9 6 3 6
Histologic type of 143 cases
Squamous cell carcinoma Olfactory neuroblastoma Adenoid cystic carcinoma Adenocarcinoma Bone and soft tissue tumor Transitional cell carcinoma Malignant melanoma Miscellaneous
78 16 16 11 10 4 3 5
Prior treatment
No Yes
87 56
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75 Table 2 Surgical approach Surgical approach Intracranial approach Frontal craniotomy Fronto-temporal craniotomy with orbito-zygomatic osteotomy without orbito-zygomatic osteotomy Infratemporal fossa approach Temporal approach Suboccipital approach Miscellaneous
Number of cases 96 66 54 27 27 8 14 3 5
Extracranial approach Transfacial approach Lateral rhinotomy Weber–Fergusson incision Mid-facial splitting Miscellaneous
145 113 34 28 13 38
Transoral approach Transantral approach Transpalatal approach Miscellaneous Transnasal approach
28 4 13 11 4
temporal craniotomy was usually carried out in most of the nose and paranasal sinus cases; the former was frequent for ethmoid sinuses lesions and the latter for maxillary sinus lesions. In the cases of ear and temporal bone carcinoma, transtemporal approach was frequent. Infratemporal fossa approach and suboccipital approach were selectively applied depending on the lesion. As for the extracranial approach (n = 145, Table 2), transfacial approach was performed in 113 cases. Among these, lateral rhinotomy was performed in 34 cases, Weber– Fergusson incision in 28 cases and midfacial splitting in 13 cases. For reconstruction of the skull base (Table 3), free rectus abdominis myocutaneous (MC) flap was most frequently used in 85 cases. For repair of dura matter, fascia lata was most frequently used, which was followed by galeopericranial flap, temporal muscle fascia. For reconstruction of face, soft tissue and palate, free rectus abdominis MC flap was most frequently used as in a reconstruction of the skull base. Namely, free rectus abdominis MC flap was simultaneously used for reconstruction of the skull base and the face in many cases. The surgical results were indicated in Fig. 1, Tables 4 –6 and Table 7. The overall 5-year survival rate in the
S73
cases of nose and paranasal sinus carcinoma for those undergoing skull base surgery (n= 119) by Kaplan– Meier method was 48% (Fig. 1). Histologically, the survival rate was best in the cases of ACC (n = 12) and BST (n= 10), marking 65%, which was followed by 46% in SCC cases (n= 62) and 33% in ACC (n=11). All the three cases of MM were dead within 1 year, so we considered skull base surgery to be contraindicated for this disease. The overall 5-year survival rate of the rest site was 67% (n= 24). Among them, the cases of nasopharyngeal carcinoma showed fairly well survival rate of 75% (n= 6) considering the fact that all of these cases had recurrences after radiotherapy. The operation time required for skull base surgery was 14.5 h on an average (range: 4–30 h, Table 4), and the amount of intraoperative blood loss was averaged 2500 ml (range: 150–13 000 ml, Table 5). Postoperative complications were observed in 62 cases out of the 143 cases consisted of local infection in 29 cases, liquorrhea in 18, abscess formation in 16, necrosis of the flap and meningitis in ten, DIC in four, rupture of the internal carotid artery in two and cerebral thrombosis in one
Table 3 Material for reconstructiona Material for reconstruction Skull base Free flap Rectus abdominis MC flap Latissimus dorsi MC flap Forearm flap Miscellaneous
Number of cases
85 6 4 55
Dura mater Fascia lata Galeopericranial flap Temporal muscle fascia Calvarial periosteal flap based on temporal muscle pedicle
37 35 16 13
Reconstruction of the face, soft tissue and palate Free rectus abdominis MC flap Free latissimus dorsi MC flap Latissimus dorsi MC flap (pedicled) Free rectus abdominis MC flap+Rib Free latissimus dorsi MC flap+anterior serratus muscle flap+Rib
61 4 5 1 4
a
MC flap: myocutaneous flap.
S74
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
Fig. 1. The results of skull base surgery in nose and paranasal sinus carcinoma invading skull base (n = 119, by Kaplan – Meier method).
case (Table 6). Ten cases (7%) were regarded as operative death. The most frequent sequela was impairment of cranial nerves (mostly I– VII N) in 51 cases caused by extraction of oculus or operative resection. Secretory otitis media was observed in 19 cases, articulation disorder in ten, trismus in eight and drooping of flaps in four cases (Table 7).
4. Discussion In the present series, major primary site extended to the skull base was the nose and paranasal sinus (83%) and it should be noted that the 5-year survival rate in this lesion was 48%, in particular survival of 46% was observed in squamous cell carcinoma. Before induction of skull base surgery in Japan, Miyake et al. [5] reported 5-year survival rate of 18% by extracranial approach in case of nose and paranasal sinus carcinoma involving skull base and Ono [6] reported 5year survival rate as 6.7% (n =127) in the cases of maxillary sinus carcinoma staged as IV according to the data of TNM Classification Committee (1979– 1981). These two famous Japanese head and neck surgeons in this lesion observed same results of an unfavorable prognosis. Considering these facts, we believed that the overall 5-year survival rate of 48% in 119 cases of nose and paranasal sinus carcinoma involving skull base was a significant progress by induction of skull base surgery. Among those, olfactory neuroblastoma (n = 16) achieved 62% 5-year survival. Considering the origin of this tumor, it was one of the most appropriate diseases to apply skull base surgery. Shah [1] reported that overall 5-year survival of 60% was observed for those undergoing craniofacial resections for malignant diseases involving anterior skull base and that survival was directly impacted by the extent of disease and the
histological type and grade of tumor. He stressed that the development, availability and applicability of craniofacial surgery for malignant diseases that approach or involve the skull base has opened a new era in the surgical treatment of tumors of the nasal cavity and paranasal sinuses. On the other hand, all the three cases of MM terminated fatally within 1 year. It seems to suggest the limit of surgical treatment in this particular disease. Shah [1] also reported the 5-year survival rate of mucosal MM undergoing skull base surgery as less than 20%, indicating worst survival rate in his skull base surgery series by histopathology. We should also decide the indication for skull base surgery in case of recurrences of nasopharyngeal carcinoma, of radiation low sensitivity tumor such as adenocarcinoma, mucoepidermoid carcinoma and adenoid cystic carcinoma and of recurrent parotid gland carcinoma extended into the skull base. Complications were observed in 43%, which needs to be reduced by improving the operative and reconstruction procedures and pre- and post-operative management. Operative death actually occurred in 7%, but it occurred mostly in earlier cases of this series and has rarely occurred in recent cases. Table 4 Time required for surgerya Hour
Number of cases
B4 5–9 10–14 15–19 20–24 \25
1 21 58 32 12 3
a
Mean time: 14.5 h, range: 4–30 h in reported 127 cases.
S. Fukuda et al. / Auris Nasus Larynx 28 (2001) S71–S75
S75
Table 7 Postoperative sequelaea
Table 5 Blood loss during surgerya Volume of blood loss (ml)
Number of cases
Postoperative sequelae
Number of cases
B900 1000–1900 2000–2900 3000–3900 \4000
19 35 33 12 20
Cranial nerve involvement Secretary otitis media Articulation disorder Trismus Double vision Drooping of flaps Miscellaneous
51 19 10 8 5 4 12
a Mean blood loss: 2500 ml, ranging from 150 to 13 000 ml in reported 119 cases.
a
Rate of sequela 64% (87/137), not evaluable: six cases.
Table 6 Postoperative complicationsa Postoperative complications
Number of cases
Local infection Liquorrhea Abscess Flap necrosis Meningitis DIC Hemorrhage due to rupture of ICA Cerebral thrombosis Miscellaneous
29 18 16 10 10 4 2 1 19
lacerum, body of sphenoid, brain and cases with wide dural spread and previous treatment failure.
References
a Rate of complication 43% (62/143), surgery related death 10 cases (7%), ICA: internal carotid artery.
From these results, we propose the following points to improve the outcome of skull base surgery: (1) improvement of pre- and post-operative management, (2) evaluation of the extended application and the limit of resection more precisely, (3) advancement of operative procedure and development of a new approach, (4) shortening the operation time and (5) effort to decrease blood loss in volume during surgery. Finally, we will have to wait for further study for precise indication and contraindication for those invading cavernous sinus, internal carotid artery, foramen
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[1] Shah JP. The skull base. In: Shah JP, editor. Head and Neck Surgery, 2nd edn. New York, NY: Mosby-Wolfe, 1996:85 –141. [2] Inuyama Y, Sakai N, Fukuda S, Nameki H, Kamata S, Kishimoto S, et al. Skull base surgery-Statistical analysis for 93 cases collected from Study Group of Cancer Research from Japanese Ministry of Health and Welfare. Head Neck Cancer Jpn 1994;20:511 – 5 in Japanese. [3] Inuyama Y. Induction of skull base surgery for the cases of nose and paranasal malignancies involving skull base. In: Inuyama Y, editor. Significance of Chemotherapy in the Treatment of Head and Neck Cancer. Tokyo, Japan: Tokyo Igaku-Sha, 1997:175 –8 in Japanese. [4] Inuyama Y. Statistical analysis of skull base surgery and upper mediastinal dissection collected from Study Group of Cancer Research from Japanese Ministry of Health and Welfare. In: Inuyama Y, editor. Recent Progress in Treatment for Border Region of Head and Neck Cancer. Tokyo, Japan: Kyowa Kikaku Tsushin, 1996:124 – 31 in Japanese. [5] Miyake H. Operative treatment. In: Miyake H, editor. Various problems in the Treatment of Maxillary Cancer. Tokyo, Japan: Kohoku Publ. Co, 1984:77 – 92 in Japanese. [6] Ono S., Unpublished data.