Faculty Bibliography

BACKGROUND:This study reports the combined experience of the University of Miami and University of Pittsburgh with endoscopic endonasal resection of esthesioneuroblastoma (ENB). A retrospective case series review was performed in a tertiary care university hospital. METHODS:Twenty-three patients, 16 men and 7 women, were reviewed. Mean age was 56.6 years (15-79 years). Nineteen patients received primary endoscopic endonasal anterior skull base resection. Of these, the modified Kadish stage at presentation was A in 2 patients, B in 11 patients, C in 5 patients, and D in 1 patient. Three patients had revision surgeries for recurrent tumors. The main outcome measures were complete resection and margin assessment, short-term and long-term complications, and recurrence rate. RESULTS:Complete resection and negative intraoperative resection margins were achieved endoscopically in 17 of the primarily treated cases. The two other cases had one patient that required an additional craniotomy approach to complete the resection of a positive lateral dual margin, another patient had positive margins at the orbital apex. All patients tolerated the endoscopic procedure very well with no meningitis. There were four cerebral spinal fluid leaks. Mean follow-up period for the primarily treated cases was 45.2 months (11-152 months), all were disease free at the most recent available follow-up. CONCLUSION/CONCLUSIONS:In experienced hands and carefully selected patients, endoscopic resection of ENB respects the principles of oncologic surgery, providing an adequate exposure for margin assessment as well as reliable reconstruction of the anterior skull defect with a relatively low morbidity.

OBJECTIVES/OBJECTIVE:We evaluated the efficacy of the application of selective neck dissection to cases of clinically node-positive disease. METHODS:We performed a retrospective review at the University of Pittsburgh Head and Neck Cancer Database. A database of 65 patients was followed for an average of 36 months (range, 2 to 128 months) after they underwent selective neck dissection for clinically node-positive regional disease. RESULTS:Regional failure occurred in 8 patients (12.3%). In-field failure was experienced in 4 patients (6.1%), and failures outside the field of dissection occurred in 4 patients (6.1%). The overall incidence of extracapsular spread was 33.8% (22 of 65). Only 2 of 8 regional recurrences were associated with extracapsular spread at the initial neck dissection; however, both recurrences were in the contralateral, undissected side of the neck. Four regional failures were salvaged with surgery, with eventual overall regional control in the neck of 93.9%. Only 1 of 4 ipsilateral recurrences (25%) was successfully salvaged. In contrast, 3 of 4 contralateral failures (75%) were successfully salvaged. In our study population, 21 of 65 cases (32%) that were initially staged as clinically node-positive had no evidence of nodal metastases on pathologic examination. CONCLUSIONS:The application of selective neck dissection and postoperative irradiation in patients with clinically Nl and limited N2 clinical disease appears to be oncologically efficacious. Clinical overstaging occurred frequently in this sample, and may put patients at risk for more morbid surgical procedures.

Since the landmark publication by Ketcham et al in the early 1960s, the resection of sinonasal tumors involving the anterior skull base combines transcranial and transfacial incisions and osteotomies. Recent technical and technologic advances have allowed the use of endoscopic approaches for the resection of these tumors. We report our technique for the endoscopic resection of tumors involving the anterior skull base. Our technique includes the extirpation of select tumors following critical premises, such as obtaining a complete resection and reestablishment of the separation of the sinonasal tract from the cranial cavity. There were 20 patients with various malignant tumors of the sinonasal tract operated on using an endoscopic technique. There are 19 patients alive and without evidence of disease at short-term follow-up (range 11-46 months) The only patient who presented with a recurrent tumor had a sinonasal undifferentiated carcinoma treated with primary chemoradiation. She died of an aggressive recurrence at 8 months postoperatively. In 20 patients, we did not encounter any intraoperative complication. However, postoperative complications included 1 episode of tension pneumocephalus, cerebrospinal fluid leak in 3 patients, and 1 episode of bacterial meningitis associated with a prior cerebrospinal fluid leak. Short-term results suggest that an endoscopic transnasal anterior skull base resection can be performed safely and effectively. Further experience and follow-up are required to ascertain the outcomes of patients treated with endoscopic techniques. © 2006 Elsevier Inc. All rights reserved.