gms | German Medical Science

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

18. - 21.05.2005, Fulda, Germany

Endoscopic resection of nasal septal chondrosarcoma with skull base extension – preliminary results of a case

Meeting Contribution

  • C. Meco - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
  • K. S. Boynukalin - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
  • M. K. Gökcan - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
  • F. Aydiner - Department of Pathology, Ankara University Medical School, Ankara, Turkey
  • T. Aktürk - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
  • S. Erekul - Department of Pathology, Ankara University Medical School, Ankara, Turkey
  • M. Gerceker - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey
  • B. Kücük - Department of Otorhinolaryngology – Head and Neck Surgery, Ankara University Medical School, Ankara, Turkey

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. Doc05esbs22

DOI: 10.3205/05esbs22, URN: urn:nbn:de:0183-05esbs222

Published: January 27, 2009

© 2009 Meco et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Outline

Text

Introduction

Nasal septal chondrosarcomas are infrequent and malignant tumors that arise from cartilaginous structures. In the literature about 50 nasal septal chondrosarcoma cases were described. Optimal treatment depends on local control of the tumor, as no neck or distant metastases are involved. Therefore, the preferred management is radical surgical resection, which traditionally includes various open procedures like midfacial deglowing or lateral rhinotomies that assure not only good exposure but also complete removal [1]. On the other hand, recent advances in endoscopic sinus surgery techniques and powered instrumentation, as well as consequent experiences gained with them enables otolaryngologists and skull base surgeons to remove selected tumors of the nose, sinuses and skull base through endonasal endoscopic approach with decreased morbidity and comparable results. In the literature successful endoscopic resection of 3 septal chondrosarcoma cases were already described [1], [2], [3]. However, they were all limited and none of them had an extension to the skull base, our case being the first to be reported.

Material and method

The presented nasal septal chondrosarcoma case is a 52-year-old female who had a history of bilateral nasal fullness and congestion since 6 months. Her nasal endoscopy revealed a reddish mass with smooth mucosal surface that fills the nasal cavity bilaterally. The remaining head and neck examination was normal. Imaging showed a mass extending from the anterior part of the septum to the anterior wall of the sphenoid sinuses, which involves the ethmoid sinuses bilaterally as well as the base of the skull at the cribriform plate and crista galli (Figure 1 [Fig. 1]). Crista galli was eroded and destructed by the tumor. Preoperative intranasal biopsy revealed an initial pathologic diagnosis of nasal septal chondroma. Therefore, endonasal endoscopic approach was selected for surgery in the first hand. Surgical specimen pointed out the end diagnosis, after which the patient also had additional radiotherapy. We report the preliminary result of this case, whose nasal septal chondrosarcoma with skull base extension was endoscopically resected. Follow up is being done with bimonthly magnetic resonance imaging (MRI) and endoscopy. Until now, there has been no report of endoscopic resection of nasal septal chondrosarcoma with such an extension.

Result

Through the endonasal endoscopic approach, with the help of angled endoscopes and instruments, as well as microdebrider and nasal high speed drills it was possible to totally resect the mass. During the removal of the skull base extension of the tumor, which was expanding at this location (1.5 x 1 cm) along the cribriform plate and crista galli, the neighboring dura was also totally removed. Dura repair was successfully done by using fat tissue, facia lata, cartilage and fibrin glue endoscopically at the end of the surgery. Lumbar drainage was placed after the procedure and stopped at postoperative day four. At postoperative day ten the nasal packings were removed leaving the spongostane at the duraplasty level. Routine endoscopic controls were performed and watertight closure of the dura repair has been confirmed by Beta-2-Transferrin test revealing no CSF in nasal secretion at postoperative second week. The patient tolerated the procedure well and was discharged with no complications. However, the histopathologic report of the surgical specimen surprisingly revealed a grade II chondrosarcoma. Therefore, the patient also underwent postoperative radiation therapy. Bimonthly MRI and endoscopic examinations were obtained. Up to now, there is no evidence of residual disease or recurrence at one year follow-up.

Discussion

Head and neck chondrosarcomas are 10% of all chondrosarcomas [1]. Their preoperative diagnosis may sometimes be challenging. Radiologic findings may resemble to other pathologies like chondroma, meningioma, osteoma, osteosarcoma and fibro-osseous lesions. Histopathological diagnosis of a chondrosarcoma may also be difficult and its differential diagnosis includes chondroma, osteogenic sarcoma and salivary gland neoplasms [2], [4]. Since 20% of head and neck chondrosarcomas may initially be misdiagnosed as chondromas [5], it is extremely necessary to take adequate biopsy specimens to avoid the sampling errors as in our case.

The minimal invasive endoscopic techniques are already being used for some selected benign tumors of the nose, paranasal sinuses and skull base including juvenile angiofibroma, inverted papilloma, osteoma, etc. [1]. Nowadays, reports on successful endoscopic resection of selected malignant tumors are also repeatedly being reported, together with earlier stated chondrosarcomas.

As mentioned above the preferred treatment consists of radical surgical resection while the aim is to maintain clear surgical margins. External approaches such as midfacial deglowing or maxillectomies have been successfully described and performed in the literature for this aim [1], [5], [6]. Nevertheless, endonasal endoscopic approach has the advantage of avoiding facial incisions and disruption of the facial skeleton, reducing postoperative recovery time. In recent literature, for selected cases endoscopic surgery were repeatedly described, especially for benign tumors such as inverted papilloma or nasopharyngeal angiofibroma. Additionally, a few endoscopic removals of selected malign nasal and sinus neoplasms have been reported. Casiano et al were one of the first to report on a small group of patients with esthesioneuroblastoma [6], [7] Also Matthew et al first reported a case of nasal septal chondrosarcoma, which was successfully removed endoscopically [3]. They found no clinical evidence of recurrence 27 months after surgery [3]. Furthermore until now there has been no report of endoscopic resection of nasal septal chondrosarcoma with skull base extension. Combined with radiotherapy it seems to be effective in one year follow-up. However, there is a definitive need for much longer follow-up periods and more selected case material to evaluate the efficacy of this minimal invasive approach on malignant tumors and on this specific tumor kind. In our case, the benign preoperative diagnosis (chondroma) has encouraged us to utilize endoscopic approach, in spite of the skull base extension. When we get the end diagnosis from the surgical specimen as chondrosarcoma, instead of reoperating and doing a craniofacial resection, we planned additional postoperative radiotherapy as we also believe that we have completely removed the tumor during surgery. In fact, chondrosarcomas are not radiosensitive and chemotherapy results for these tumors have been ineffective. However, there are several reports of successful treatment of residual or recurrent disease with radiation therapy [5]. Mostly; radiation therapy is recommended for patients with positive tumor margins, recurrent and high degree tumors [2].

Conclusion

With the enforcement of this case, we have demonstrated that endoscopic total resection of nasal septal chondrosarcoma is possible even with skull base extension, avoiding potential morbidity of open approaches. Although we do not advocate the use of endoscopic approach for all malignant tumors, in selected patients with the availability of special instrumentation, it is feasible to choose this minimal invasive approach with promising results and reserve more aggressive open approaches for recurrence cases.


References

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