gms | German Medical Science

Malignant sinonasal tumors are uncommon, accounting for less than 1% of all malignancies and 3% of those of the head and neck. The initial presenting symptoms are usually nonspecific, with the results that the majority of these tumors have often reached an advanced stage by the time of presentation [Ref. 1]. Therefore, the cure rates from sinonasal cancers are unsatisfactory. In a series of 102 patients, the overall survival rate for all malignant neoplasms of the nasal cavity was 49%, with most failures being due to local control (recurrence or persistence) post treatment [Ref. 2]. Initially advocated for obstructive inflammatory disease, endoscopic approaches are being used increasingly for the definitive treatment of sinonasal neoplasms previously only resected through more traditional (transfacial or craniofacial) approaches. Endoscopic resection of meningoencephaloceles, inverted papillomas, and variety of other benign neoplasms has been advocated as a reasonable alternative compared to traditional approaches with equivalent efficancy [Ref. 3], [Ref. 4], [Ref. 5], [Ref. 6], [Ref. 7].

There have been a few reports on endoscopic resection of malignant sinonasal disease [Ref. 8], [Ref. 9], [Ref. 10], [Ref. 11], [Ref. 12], [Ref. 13]. Unfortunately all of these studies have involved small number of patients who underwent endoscopically assisted traditional external craniofacial resections or case report of complete endoscopic tumor resection. To evaluate the safety and efficacy of strictly endoscopic radical resection of malignant sinonasal neoplasms, we report the single surgeon’s experience with endoscopic resection of malignant sinonasal neoplasms.

This study selected particular patients whose tumors have a special location. All patients were given computerized tomographic scan or magnetic resonance imaging before operation. Tumors with far lateral extension, intracranial invasion, or orbital infiltration were excluded from the study. All of the selected patients were individually designed minimal approach for extensive endoscopic surgery strictly. Five patients with sinonasal cancers were treated with radical surgery by endoscope from September 2000 to December 2002 at Changhua Christian Hospital by the single surgeon (Mu-Kuan Chen). The patients were four males and one female. Their ages distribute between 33 and 68 years old with the average of 51.6 years old. Their major symptoms are nasal obstruction and nasal bleeding.

All of the tumors have been removed successfully by strictly endoscopic surgery. The histological type was adenocarcinoma in three patients, low graded sarcoma in one patient, and undifferentiated carcinoma in one patient. One (undifferentiated carcinoma) had invaded the base of skull so the tumor was complete resected and the defect repaired by fascia lata endoscopically. After operation, the patient received intensity-modulated radiotherapy; however, the others (80%) did not accept radiotherapy. No complications associated with the operation occurred. The patients were routinely followed up from 24 to 51 months and with the average of 39 months. Only one regional recurrence (undifferentiated carcinoma) was noted after 8 months of operation and the radical neck dissection was performed for salvage surgery. Fortunately, this patient remains disease free at 50 months. We find no local recurrence or distant metastasis in this series up to now. The actuarial local control rate, overall survival rate, and disease-free survival rate are 100% at a mean follow-up duration of 39 (24–51 months) months.

The evolution of sophisticated instrumentation and the advancement of computer-aided skull base surgery have facilitated the consideration of resection of malignant sinonasal neoplasms using advanced endoscopic techniques. Endoscopic resection of sinonasal malignancies offers several key advantages including superior visualization, magnification of key structures, assurance of safety margins, avoidance of cosmetic injuries, and preservation of normal structure. Preliminary reports have suggested the efficacy of the endoscopic approach in the management of malignant sinonasal neoplasm [Ref. 10], [Ref. 11], [Ref. 12], [Ref. 14]. Roh et al [Ref. 14] reported their experience of 19 patients of sinonasal malignancies. Among them, 14 patients were strictly resected with an endoscopic approach at two institutions. Combined radiation with or without chemotherapy pre- or postoperatively was given to 78.9% patients. The local recurrence rate was 26.3% and the disease free survival rate was 68.4% at a mean follow-up duration of 33.1 months [Ref. 14]. In our series, single surgeon experience, the postoperative radiotherapy was given in one patient and the disease-free survival rate is 100% at a mean follow-up duration of 39 months. These reports suggest that strictly endoscopic resection of selected malignant sinonasal neoplasms has been advocated as a reasonable alternative to traditional approaches with equivalent efficacy.

The common misconception about endoscopic sinonasal neoplasms resection is that this method violates principles of surgical oncology; however, the central tenets of oncological resection remain paramount when using the endoscopic approach. Because of the inherent structure of the paranasal sinus and skull base, open surgical approaches (trasfacial or trascraniofacial) do not guarantee en bloc specimens or negative margins [Ref. 15]. Piecemeal delivery is not to be rejected on oncologic grounds because biopsy specimens of patient margins may provide useful information for further resection and /or treatment [Ref. 16]. In my experience, except the dura and lamina papyracea, the resection margin should more than 1 cm for curative intent.

Surgery and postoperative radiation therapy may result in improved local control, and absolute survival for malignant sinonasal neoplasms [Ref. 17]. The management of ethmoid adenocrcinoma aims for complete excision to achieve local control. Radiation therapy has had a limited role in achieving primary cure of adenocarcinoma because the relative radioresistance of sinonasal adenocarcinoma. Radiotherapy is recommended for high-grade lesions with dura or cribriform plate invasion, positive margins after resection, and tumors with large volumes or aggressive histological type [Ref. 16].

In this preliminary report, strictly endoscopic resection of sinonasal malignancy yielded local control rate of 100%. The disease free survival rate and overall survival rate are 100% at a mean follow-up duration of 39 (24–51 months) months. Minimally invasive endoscopic approach for extended surgery of malignant sinonasal neoplasms may be considered an alternative to traditional approaches in selected patients.