cinomas, three adenocarcinomas, and two adenoid cystic carcinomas. All patients were classified as having T4 le- sions using the American Joint Committee ...
Lanny Garth Close, M.D., and Bruce Mickey, M.D.
Transcranial Resection of Ethmoid Sinus Cancer Involving the
Anterior
Cancer of the paranasal sinuses is rare, accounting for only 3% of head and neck malignancies. I In the past, extension of a malignancy of the sinuses to the skull base was considered a contraindication for curative surgical resection. The advent of the combined craniofacial surgical approach to the anterior skull base has, however, brought surgical resection of such malignancies into the realm of acceptable treatment. The combined intracranial and extracranial approach for the resection of neoplasms involving the floor of the anterior cranial fossa (ACF) was first introduced in 1941 by Walter E. Dandy,2 who recommended the extension of orbital tumor resection into the central nervous system. The first report of a combined transcranial and transfacial resection of neoplasms arising in the paranasal sinuses was published in 1954 by Smith et al.3 Despite the success of Smith and colleagues, their work was viewed with skepticism until Ketcham et a14 reported a series of 17 anterior craniofacial resections in 1963. Reports of surgical treatment of paranasal sinus cancer by a craniofacial approach followed by Sisson et all and Bridger.5 Since then, the combined intracranial and extracranial approach has become an accepted option for the resection of neoplasms involving the ACF floor.6-9 Recently, Blacklock et
Skull Base
al'0 described the resection of paranasal sinus neoplasms using a transcranial technique. Despite the relative success of these surgical procedures in the management of tumors involving the anterior skull base, the selection of initial treatment of cancer involving the ethmoid sinus remains a reflection of the philosophy of the treating physician or individual institution. Traditionally, surgery has been reserved for cancer of the ethmoid sinus which approaches but does not invade the skull base. In many institutions, external irradiation has been the initial treatment of choice for ethmoid sinus cancer with intracranial extension. 11,12 Based on our recent experience utilizing the transcranial approach in the surgical treatment of ethmoid sinus cancer involving the anterior skull base, we propose a reappraisal of the traditional indications for surgery based on a meticulous pretreatment radiologic evaluation and the histopathology of each neoplasm.
MATERIALS AND METHODS Between January 1985 and August 1990, 11 patients ranging in age from 32 to 67 years underwent transcranial
Skull Base Surgery, Volume 2, Number 4, October 1992 Departments of Otolaryngology and of Neurological Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Reprint requests: Dr. Close, Department of Otolaryngology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235-9035 Copyright C) 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
213
SKULL BASE SURGERYNOLUME 2, NUMBER 4 OCTOBER 1992
resection of malignancies arising in the ethmoid sinuses and encroaching on or invading the anterior skull base. Of the options available for the management of these patients, the transcranial approach was utilized in order to provide an oncologically sound tumor resection with the lowest possible risk of developing a postoperative cerebrospinal fluid (CSF) fistula. Unilateral orbital involvement and intracranial extension into the frontal lobes did not exclude this approach, but bone invasion posterior to the suture line between the lesser sphenoid wing and the orbital plate of the frontal bone was considered a contraindication. Of the 11 patients, seven were male and four were female. The various pathologic entities included three squamous cell carcinomas, three undifferentiated carcinomas, three adenocarcinomas, and two adenoid cystic carcinomas. All patients were classified as having T4 lesions using the American Joint Committee Staging System for paranasal sinus carcinomas. 13 Disease was limited to the ethmoid sinus without invasion of the dura or orbit in one patient. In eight patients cancer invaded the orbit and two patients had intracranial invasion through the dura (Table 1). One patient (patient 10) also had metastatic disease in the neck. Only 1 of the 11 patients had received cancer treatment prior to presentation to us. This patient (patient 10) had received 60 Gy external beam radiotherapy to the anterior skull base for attempted cure 10 years earlier. The majority of these patients presented with nasal obstruction and discharge associated with localized pain. Epistaxis had occurred in six patients and four presented with visual complaints. The duration of symptoms prior to initial treatment ranged from 3 to 9 months. No patient presented with complaints or clinical evidence of frontal lobe dysfunction. All patients were evaluated preoperatively with a thorough head and neck, as well as neurologic examination. All underwent computed tomography pretreatment
214
(CT) or magnetic resonance imaging (MRI), or both, to determine the exact extent of cancer involvement. Treatment consisted of surgery followed by postoperative external beam radiation therapy in eight patients. Postoperative chemotherapy was included in an additional patient, and one patient was treated preoperatively with neoadjuvant chemotherapy followed by high-dose radiation therapy. The timing of treatment, doses of radiation therapy, and agents used for chemotherapy are listed in Table 1. The transcranial procedure is similar to that described by previous authors.68,"0 Utilizing a bicoronal incision and a free bifrontal bone graft, the anterior skull base is exposed intradurally. The olfactory tracts are divided and the olfactory bulbs and the dura overlying the cribriform plate are resected with the underlying tumor in as en bloc a fashion as possible. Before the ethmoid sinuses are entered, the dural defect is repaired, primarily with a free pericranial graft harvested from posterior to the coronal suture. Bone cuts in the floor of the anterior cranial fossa and resection of the cancer of the ethmoid sinuses are
then carried out in the manner described by Blacklock et al.10 At the conclusion of the resection, the dural repair is reinforced with a vascularized anterior pericranial flap. Recently, we have routinely used vascularized free flap, such as the rectus abdominis flap described by Urken et al,'4 to support the dural repair when an orbital exenteration is necessary. All patients have been followed postoperatively by the authors in the routine manner for patients with head and neck cancer until the time of death or the date of this report. CT or MRI have been performed every 6 to 12 months during the postoperative follow-up period. Follow-up survival analysis was performed using the Kaplan-Meier product limit method, and comparison between the individual subgroups was done using the logrank test.
RESU LTS Of the 11 patients undergoing transcranial resection of ethmoid sinus cancer, there were no deaths during the 30-day period following surgery. No neurologic deficits were noted following surgery and only one patient developed a CSF leak. This patient (patient 4) required an indwelling lumbar drain followed by a ventricular-peritoneal shunt to resolve the CSF leak. In two patients (patients 7 and 9), postoperative infection in the epidural space developed, necessitating the removal of an infected bone flap. Both patients rapidly recovered and are currently neurologically intact. The orbit proved at the time of surgery to be invaded by cancer in six patients, necessitating orbital exenteration and, thus, surgically created unilateral blindness. The orbit was not exenterated in two additional patients even though a pretreatment CT confirmed orbital invasion in both. In the first patient (patient 3), surgery followed an excellent response to chemotherapy and no orbital invasion was seen intraoperatively. In the second patient (patient 10) orbital exenteration was refused by the patient. In two additional patients (patients 1 and 3), unilateral blindness developed secondary to radiation therapy. Progressive loss of vision in the only seeing eye continues to this date in patient 1 (Table 1). Survival analysis data according to the pathologic diagnosis is shown in Figure 1 and according to sites of involvement is demonstrated in Figure 3. Disease-free survival by pathologic diagnosis is illustrated by Figure 2, and Figure 4 portrays disease-free survival according to sites of tumor invasion. In the entire series, local control as achieved in 7 of 11 patients.
DISCUSSION The results in this series of 11 patients undergoing transcranial resection as primary treatment for ethmoid sinus cancer involving the ACF floor would appear to
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