gms | German Medical Science

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge
7. Kongress der Europäischen Schädelbasisgesellschaft & 13. Jahrestagung der Deutschen Gesellschaft für Schädelbasischirurgie

18. - 21.05.2005, Fulda

Combined trans-frontal basal craniotomy and lateral rhinotomy in patient with nasopharyngeal carcinoma involving the anterior skull base and right orbit

Meeting Contribution

  • A. de Tommasi - Chair of Neurosurgery, University of Bari, Bari, Italy
  • C. de Tommasi - Chair of Neurosurgery, University of Bari, Bari, Italy
  • N. de Candia - Chair of Otolaryngology, University of Bari, Bari, Italy
  • S. Luzzi - Chair of Neurosurgery, University of Bari, Bari, Italy
  • P. Ciappetta - Chair of Neurosurgery, University of Bari, Bari, Italy

ESBS 2005: Skull Base Surgery: An Interdisciplinary Challenge. 7th Congress of the European Skull Base Society held in association with the 13th Congress of the German Society of Skull Base Surgery. Fulda, 18.-21.05.2005. Düsseldorf: German Medical Science GMS Publishing House; 2009. Doc05esbs08

DOI: 10.3205/05esbs08, URN: urn:nbn:de:0183-05esbs082

Veröffentlicht: 27. Januar 2009

© 2009 de Tommasi et al.
Dieser Artikel ist ein Open Access-Artikel und steht unter den Creative Commons Lizenzbedingungen (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.de). Er darf vervielfältigt, verbreitet und öffentlich zugänglich gemacht werden, vorausgesetzt dass Autor und Quelle genannt werden.


Abstract

Literature stresses the advantages of aggressive multimodality treatment for advanced nasopharyngeal carcinoma. Selection of operative approaches depends on by both the size of the defects in the anterior skull base and the extent of intracranial invasion.

The paper reports a 63 year-old female patient who suffered epistaxis, anosmia, amaurosis and right orbital pain.

Brain M.R.I. showed a giant nasopharyngeal carcinoma involving the anterior skull base and right orbit. No distant metastases were revealed.

A combined trans-frontal basal craniotomy and lateral rhinotomy was performed to achieve both a gross resection of the skull base part of the tumor and a lateral mid-facial decompression. No post-operative complications were detected. The patient underwent fractioned radiotherapy and chemotherapy.

On six month follow-up the patient presented amaurosis in the right eye.


Text

Introduction

To date, lot of salvage surgical strategies have been described in the literature to treat those giant nasopharyngeal carcinoma marked by a large extension in the anterior skull base, but no combined trans-frontal basal craniotomy and lateral rhinotomy have still reported.

According to Ganly I et al. [1], advances in imaging, surgical technique, and perioperative care have made cranio-facial resection an effective and safe option for treating malignant tumors involving the skull base.

The paper reports the case of a 63 year-old female patient diagnosed with nasopharyngeal carcinoma involving the anterior skull base and right orbit as well the surgical strategy adopted by the authors in the salvage surgical concept of the reported case.

Materials and methods

A 63 year-old female patient suffered headache, epistaxis, anosmia, right-sided proptosis, ophtalmoplegia, amaurosis, orbital pain.

An anterior rhinoscopy also revealed a yellowish-grey mass blocking nasal cavities and right nostril.

Brain M.R.I. showed a giant tumour in the anterior skull base involving frontal sinuses, ethmoidal bone, right sphenoidal sinus, right orbit and optic nerve, nasal cavities and right maxillary sinus (Figure 1 a-b [Fig. 1]).

A total body CT-scan revealed no distant metastases.

After neo-adjuvant radiotherapy, the authors decided to perform a combined trans-frontal basal craniotomy and lateral rhinotomy in order to achieve both the intracranial and the facial part removal of the tumour.

Via the trans-frontal basal approach a gross resection of the skull base part of the lesion was obtained (Figure 1 c [Fig. 1]). Furthermore, through the right orbital roof, a partial decompression of the right orbit and optic nerve was achieved. Lateral rhinotomy allowed the removal of the intranasal and maxillary parts of the tumour (Figure 1 d [Fig. 1]).

The patient underwent fractioned radiotherapy (median dose, 6600 cGy), and chemotherapy (cisplatin plus 5-fluorouracil).

Results

Neither post-operative CSF leak, nor wound infection were observed.

On histological examination, the tumour proved to be a squamous cell nasopharyngeal carcinoma (Figure 1 e [Fig. 1]). Immunohistochemical staining for K.i.67/Mib1 revealed a proliferative rate of 75%.

On six month follow-up the patient presented amaurosis in the right eye.

Conclusion

Following Roh [2], the nasopharyngeal carcinoma with skull base invasion should be divided into the groups with, simple skull base erosion, minimal involvement of either anterior or posterior cranial nerves, multiple involvements of both cranial nerves, and intracranial extension.

Salvage surgery is often the only curative chance for the patients newly diagnosed with nasopharyngeal carcinoma of intracranial involvement.

The reported case confirms the effectiveness of combined trans-frontal basal craniotomy and lateral rhinotomy in the treatment of those forms with anterior skull base and facial extension.

The cisplatin-based chemotherapy, adopted in the reported case, is considered useful even if limited by cumulative toxicities [3]. Recently, Chua [4] evaluates the efficacy and safety of docetaxel and cisplatin as first-line chemotherapy in patients with previously untreated metastatic nasopharyngeal carcinoma. He reports an overall response rate of 62.5% with a dose of 60 mg/m2 for both drugs. Following the authors, in the near future, docetaxel and cisplatin should be employed even as neo-adjuvant chemotherapy treatment of those cases however candidate for surgery.

Newer drugs such gemcitabine and vinorelbine have been shown to be active in salvage therapy when cisplatin-containing combinations have failed [3].

Despite its rarity, the finding of orbital invasion confers a particularly poor prognosis to these patients as reported by Hsu [5] on the basis of an observational case series of 406 patients affected by nasopharyngeal carcinoma.


References

1.
Ganly I, Patel SG, Singh B, et al. Complications of craniofacial resection for malignant tumors of the skull base: Report of an International Collaborative Study. Head Neck. 2005;27(6):445-51.
2.
Roh JL, Sung MW, Kim KH, et al. Nasopharyngeal carcinoma with skull base invasion: a necessity of staging subdivision. Am J Otolaryngol. 2004;25(1):26-32.
3.
Chang JT, Ko JY, Hong RL. Recent advances in the treatment of nasopharyngeal carcinoma. J Formos Med Assoc. 2004;103(7):496-510.
4.
Chua DT, Sham JS, Au GK. A phase II study of docetaxel and cisplatin as first-line chemotherapy in patients with metastatic nasopharyngeal carcinoma. Oral Oncol. 2005;41(6):589-95.
5.
Hsu MM, Hong RL, Ting LL, et al. Factors affecting the overall survival after salvage surgery in patients with recurrent nasopharyngeal carcinoma at the primary site: experience with 60 cases. Arch Otolaryngol Head Neck Surg. 2001;127(7):798-802.