Skull Base Malignancies Research Articles

Reconstruction after endoscopic surgery for skull base malignancies.

The ability to resect malignancies of the ventral skull base using endoscopic endonasal approaches has created a need for effective endoscopic reconstructive techniques. The purpose of this review is to summarize current techniques for reconstruction of large skull base defects during endoscopic endonasal surgery. Recent medical literature was reviewed to identify techniques and best practices for repair of skull base defects during endoscopic endonasal surgery. Preference was given to evidence-based recommendations. Superior results are observed with multilayer inlay/onlay grafts supplemented with vascularized flaps. The nasoseptal flap is the primary reconstructive flap for most defects; secondary choices include the lateral nasal wall flap and extracranial pericranial flap. Clival defects are particularly challenging and are further augmented with adipose tissue to prevent pontine herniation. Perioperative management including the use of lumbar cerebrospinal fluid drainage minimizes the risk of a postoperative leak in high-risk patients. Postoperative cerebrospinal fluid leaks are managed similarly to primary leaks and may require use of a secondary vascularized flap. Complications of reconstructive flaps include flap necrosis and cosmetic nasal deformity. Large defects of the anterior, middle, and posterior cranial fossae can be managed similarly by adhering to basic principles of reconstruction. Future developments will improve stratification of patients into reconstructive groups and allow tailored reconstructive algorithms. New biomaterials may replace autologous tissue and facilitate endoscopic repair. Improved monitoring will allow for assessment of the reconstructive site with early detection and repair of postoperative cerebrospinal fluid leaks.

Temporal bone resection for lateral skull-base malignancies.

Malignancies involving the temporal bone are increasingly common and require specialized multi-disciplinary care. Given this complex location, involvement of the lateral skull base and local neurovascular structures is common. In this review we discuss general principles for temporal bone resection, as well as alternative and complementary surgical approaches that should be considered in the management of patients with temporal bone cancer. A comprehensive review on literature pertaining to temporal bone resection was performed. The primary surgical strategy for malignancies of the temporal bone is temporal bone resection. This may be limited to the ear canal and tympanic membrane (lateral temporal bone resection) or may include the otic capsule and its contents (subtotal temporal bone resection), and/or the petrous apex (total temporal bone resection). Management of adjacent neurovascular structures including the facial nerve, the carotid artery, and the jugular bulb/sigmoid sinus should be considered during surgical planning. Finally, adjunctive procedures such as parotidectomy and neck dissection may be required based on tumor stage. Temporal bone resection is an important technique in the treatment of lateral skull-base malignancies. This strategy should be incorporated into a multi-disciplinary approach to cancer.

Reconstruction after open surgery for skull-base malignancies

Resection of skull base malignancies that would have been associated with unacceptable morbidity and mortality in the past are now performed with reliable results due in large part to advancements in reconstructive surgery. The goal of this review is to describe the best evidence-based methods of reconstruction following open surgery for skull base tumors in order to attain improved outcomes for patients. A review of recent studies involving reconstruction following open skull base surgeries was performed. Free flaps are now the most commonly recommended method for reconstruction following open skull base surgery, although pedicled regional flaps such as the temporalis muscle, supraclavicular, and submental flaps may be good alternatives in specific cases. Recent series suggest high reconstructive free flap survival rates and low levels of recipient site complications, including neurosurgical complications such as cerebrospinal fluid leak. The location of the resection defect predicts the reconstructive challenges and guides pedicled and free flap selection. Refinements in flap selection and reconstructive technique continue to improve patient outcomes and decrease complication rates following open surgery for skull base malignancies.

Surgical management of anterior skull-base malignancies (endoscopic vs. craniofacial resection)

Anterior skull base (ASB) malignancies are rare entities characterized by delayed diagnosis and comprise a variety of distinct histological types. Their treatment involves clinical and surgical management, with the latter encompassing open and, more recently, endoscopic approaches. The craniofacial resection, as an open approach, has revolutionized the treatment of such diseases and is the gold standard, although significant morbidity and facial scars are a shortcoming. Seeking a less invasive alternative, many surgeons have approached these pathologies using the endoscopic endonasal approach, with the theoretical advantage of reduced morbidity and no facial scars. In this manuscript, we aim to review the current state-of-art in the surgical management of the ASB malignancies. As such, indications, limitations and future perspectives of different surgical techniques are discussed.

Quality of life considerations for patients with anterior and central skull base malignancies.

The extirpation of skull base malignancies may be associated with significant morbidity and can profoundly impact health related quality of life (HRQOL). In this review, we sought to provide an overview of HRQOL and the factors that influence it for patients with skull base malignancies. Narrative review. HRQOL tends to improve in the months to years following treatment and is profoundly impacted by both tumor location and treatment approach. Wherever possible, HRQOL should always be elicited from the patient directly. Several HRQOL instruments have been used in this population including generic, site-specific and disease specific measures. Given that HRQOL is a multidimensional concept with several important facets, validated disease-specific instruments are generally preferred.

Treatment Options for Recurrent Anterior Skull Base Tumors.

Malignancies of the anterior skull base are rare and recur in 40-80% of treated cases, varying with substantial variance according to histology, stage at primary diagnosis, and other factors. Most recurrences manifest within 2-5 years after primary treatment, but some histologies can relapse even decades after the first presentation. Management of recurrent anterior skull base tumors is challenging and a wide variety of treatment options are available. Similar to the primary setting, surgery is the mainstay of treatment. However, only few patients are likely to be suitable for salvage surgery after restaging. In this scenario, non-surgical options such as re-irradiation with photon or heavy particles may play a role, although the potential toxicity and benefits of treatment needs to be considered on a case-by-case basis. Moreover, stereotactic technologies are emerging as an adjunct valuable tool to minimize side effects. Chemotherapy is acquiring a relevant role in the primary treatment of sinonasal malignant lesions involving the anterior skull base in the neoadjuvant setting or in combination with radiotherapy, but evidence of its efficacy in the treatment of the recurrent/metastatic disease is very limited. The specific drugs employed vary considerably and need to be paralleled with the biology of the different histologies.

Clinical profiling and management outcome of atypical skull base osteomyelitis

Background: Malignant otitis externa or skull base osteomyelitis arises as a complication of otological infection in immunocompromised individuals, especially elderly diabetics. With increasing awareness of the disease and better diagnostic modalities, there has been an increased reporting of atypical osteomyelitis of skull base (AOSB). Atypical osteomyelitis of skull base is a relatively rare yet an emerging clinical entity that also occurs in immunocompromised elderly individuals, however, in the absence of a pre-existing otological or rhinological infection. The purpose of this study was to review the clinical presentation and treatment protocol followed in patients diagnosed with atypical skull base osteomyelitis.Methods: A retrospective audit of medical records of patients diagnosed with AOSB between 2014 and 2018 was done. Clinical presentation and radiological assessment done prior to intervention was noted. All patients underwent transnasal endoscopic biopsy of tissue from clivus. Histopathological and microbiological profiling of biopsied tissue and treatment protocol followed was noted.Results: A total of 10 patients were included in the study out of which eight were male and two female. Eight patients were known diabetics and one patient had been on chronic oral steroid use. Majority presented with a vague dull aching headache and with one or more cranial nerve (CN) palsy(s). Radiological imaging showed clival involvement for all. All were managed conservatively with appropriate antibiotics. Disease resolution was defined as either complete resolution of symptoms and/or no residual lesion noted on follow-up MRI of skull base.Conclusions: Individuals presenting with non-specific symptoms of headache with CN palsy(s) with no obvious otological/rhinological infections, should raise suspicion of atypical skull base osteomyelitis. Histopathological diagnosis and microbiological assessment are an essential aid in conservative management with higher antibiotics. Patient compliance and long-term follow-up is essential for adequate and complete resolution of disease.

Malignant tumors of the skull base

Malignant skull base tumors consist of aheterogeneous group of malignancies that can be divided into primary and secondary (metastatic) skull base tumors. In addition, according their anatomical location, they can be further divided into tumors of the anterior, middle, or posterior cranial fossa. Although malignant skull base tumors do not rigorously respect anatomical borders, their anatomical occurrence can potentially be helpful for possible differential diagnosis. This article is focused on the most common malignant tumors of the skull base and their imaging and clinical presentations.

Minimally invasive endoscopic transcribriform resection of malignant lesions of the skull base

Introduction: Malignant tumours of the sinonasal region - including those with invasion of the skull base - necessitate surgical resection. The majority of the cases give an opportunity to perform the procedure via minimally invasive, endoscopic approach, without external, craniofacial surgery. Aim: To assess our clinical experience in treating anterior skull base malignancies, performing minimally invasive endoscopic transcribriform resection. Method: Between February 2015 and July 2017, four male and one female patient underwent minimally invasive, endoscopic skull base procedure. The mean age was 64.6 years (59-70, median: 66). Every surgery was performed via transnasal, endoscopic transcribriform approach. In two cases Kadish C esthesioneuroblastomas, while in one case a T3N0 sinonasal non-differentiated carcinoma, a T1N0 intestinal type adenocarcinoma and a T4N0 squamous cell carcinoma was the indication of surgery, respectively. Results: The mean follow-up time was 22.8 months, between 14 and 46 months. Intraoperative complications did not occur during the procedures. Regarding the postoperative period, liquorrhoea and pneumocephalus occurred in one case. Complications were solved with lumbar drainage. During follow-up, neither residual nor recurrent tumour was observed in our patients. Conclusion: Endoscopic transcribriform resection of the skull base malignancies is a safe and viable alternative to the traditional open approach. Orv Hetil. 2019; 160(40): 1584-1590.

Anterolateral thigh free flap in reconstruction of lateral skull base defects after oncological resection

PurposeEvaluation of the utility of the free anterolateral thigh flap reconstruction of the defects resulting from radical temporal bone resection in the management of lateral skull base malignancies in a single institution.MethodsAn analysis of 17 en bloc subtotal petrosectomies for removal of malignant tumours was performed. There were 12 squamous cell carcinomas, 4 basal cell carcinomas and 1 adenoid cystic carcinoma. The tumours were staged with the University of Pittsburgh TNM system. In all patients, the lateral temporal bone with the preservation of the petrous apex and carotid artery was performed. All patients had parotid gland resection. The post-resection defect was reconstructed with an ALT free flap.ResultsTumour radical resection and defect reconstruction with an ALT flap was achieved in all patients without intraoperative complications. The transplants were harvested as fasciocutaneous flaps, 11 perfused by musculocutaneous and 6 by septocutaneous perforators. The ALT flaps had a mean pedicle length of 8 cm (6–12 cm), and the flap size ranged between 6 × 15 cm and 15 × 30 cm. The flaps were supplied by nine facial, five occipital and three maxillary arteries. Recipient-site veins included eight internal jugular, seven facial, one retromandibular and one external jugular vein. All arterial pedicles were anastomosed in an end-to-end manner. The veins were anastomosed with interrupted sutures and in 11 cases with Synovis-Coupler® devices. All the flap transfers were performed successfully. Three patients experienced postoperative complications.ConclusionsThe ALT flap proved to be effective for covering large temporal skull base defects resulting from the radical removal of temporal bone malignancies. The functional and cosmetic results were acceptable with a low complication rate.

Prospective Evaluation of Health-Related Quality of Life in Patients Undergoing Anterolateral Craniofacial Resection with Orbital Exenteration.

Objective This study was aimed to evaluate health-related quality of life in patients undergoing anterolateral craniofacial resection (AL-CFR) with orbital exenteration (OE) for malignant skull base tumors and to investigate the effects of early psychiatric intervention. Design Present study is a prospective, observational study. Setting The study took place at the hospital department. Participants Twenty-six consecutive patients were selected who underwent AL-CFR with OE at our hospital between 2005 and 2015. Main Outcome Measures Health-related quality of life was assessed preoperatively and 3, 6, 12, and 24 months after surgery using the Hospital Anxiety and Depression Scale (HADS) and medical outcomes study 8-items Short Form health survey (SF-8). In all cases, psychiatric intervention was organized by the consultation liaison psychiatry team preoperatively and postoperatively. Results Ten (38.0%) of the 26 patients died and 16 (62.0%) were alive and disease-free at the end of the study. The 3-year overall and disease-free survival rates were 64.9% and 53.3%, respectively. Twenty-one patients (80.8%) developed psychiatric complications after surgery and needed treatment with psychotropic medication. Before surgery, 28% of patients had HADS scores ≥8 for anxiety and 20% had scores ≥8 for depression. Seven of the eight items in the SF-8 were significantly lower than those for the general Japanese population. However, scores for all the SF-8 items gradually improved during postoperative follow-up, reaching approximately 50 points, which is the national standard value, at 2 years after surgery. Conclusions Craniofacial resection with OE was feasible and well tolerated in patients with malignant skull base tumors who received early psychiatric intervention to decrease the considerable psychological impact of this procedure.

Detection of Microbiota in Post Radiation Sinusitis.

A shift in the microbiota of chronic rhinosinusitis has been described after radiotherapy to the sinonasal cavity and skull base. There is a paucity of literature characterizing the bacteriology of post radiation sinusitis using next-generation gene sequencing techniques. This study aims to describe and compare the microbial flora of rhinosinusitis after radiotherapy using both culture and molecular techniques for microbial DNA detection. The medical records of patients treated with external beam radiation for sinonasal, nasopharyngeal, or skull base malignancy were reviewed at a tertiary care facility. Patients' sinonasal cavities were swabbed for routine culture or brushed for molecular gene sequencing. Swab specimens were processed for standard microbial culture, and brush specimens were sent for gene sequencing at Micro GenX Laboratory (Lubbock, Texas, USA). Twenty-two patients were diagnosed with chronic sinusitis after undergoing radiotherapy. Staphylococcus aureus was the most common organism identified by both culture and gene sequencing, followed by Pseudomonas aeruginosa. Several additional organisms were detected by gene sequencing that were not isolated by routine culture techniques. Gene sequencing identified pathogens differing from culture results in 50% of patients examined. The bacteriology of post radiation sinusitis appears to resemble the microorganisms responsible for chronic sinusitis in healthy adults. Next generation gene sequencing techniques may reveal additional organisms responsible for sinusitis and provide complementary results that may impact the medical treatment of post radiation sinusitis.

Mental Health Disorders Associated with Sinonasal and Skull Base Malignancies: A Large Cohort Study.

Objective The main purpose of this article is to examine the prevalence, incidence, sociodemographic, and clinical characteristics of mental health disorders (MHDs) among patients with skull base malignancies. Design Retrospective cohort study. Settings/Participants Six-thousand seven-hundred sixty sinonasal/skull base cancer patients in the MarketScan database between 2005 and 2014. Main Outcome Measures Frequency of MHDs pre- and post-diagnosis in patients harboring sinonasal/skull base malignancies. Results A significant increase in MHDs was noted from pre- to post-cancer diagnosis (22 vs 31%, p < 0.0001). Despite an increase in the prevalence rate, the demographic profile of patients with MHDs post-diagnosis remained similar to pre-diagnosis. Those patients harboring MHDs were, however, more likely to be women (62.7 vs 47.4%), and carry a history of smoking (40.9 vs 26.3%) than those without MHDs. These comparisons were statistically significant ( p < 0.0001). Conclusion The prevalence of MHDs increases following a diagnosis of a sinonasal/skull base malignancy. Patients with MHDs were more likely to be women and smokers.

Stereotactic radiosurgery for trigeminal pain secondary to recurrent malignant skull base tumors.

The objective of this study was to assess outcomes after Gamma Knife radiosurgery (GKRS) re-irradiation for palliation of patients with trigeminal pain secondary to recurrent malignant skull base tumors. From 2009 to 2016, 26 patients who had previously undergone radiation treatment to the head and neck received GKRS for palliation of trigeminal neuropathic pain secondary to recurrence of malignant skull base tumors. Twenty-two patients received single-fraction GKRS to a median dose of 17 Gy (range 15-20 Gy) prescribed to the 50% isodose line (range 43%-55%). Four patients received fractionated Gamma Knife Extend therapy to a median dose of 24 Gy in 3 fractions (range 21-27 Gy) prescribed to the 50% isodose line (range 45%-50%). Those with at least a 3-month follow-up were assessed for symptom palliation. Self-reported pain was evaluated by the numeric rating scale (NRS) and MD Anderson Symptom Inventory-Head and Neck (MDASI-HN) pain score. Frequency of as-needed (PRN) analgesic use and opioid requirement were also assessed. Baseline opioid dose was reported as a fentanyl-equivalent dose (FED) and PRN for breakthrough pain use as oral morphine-equivalent dose (OMED). The chi-square and Student t-tests were used to determine differences before and after GKRS. Seven patients (29%) were excluded due to local disease progression. Two experienced progression at the first follow-up, and 5 had local recurrence from disease outside the GKRS volume. Nineteen patients were assessed for symptom palliation with a median follow-up duration of 10.4 months (range 3.0-34.4 months). At 3 months after GKRS, the NRS scores (n = 19) decreased from 4.65 ± 3.45 to 1.47 ± 2.11 (p < 0.001); MDASI-HN pain scores (n = 13) decreased from 5.02 ± 1.68 to 2.02 ± 1.54 (p < 0.01); scheduled FED (n = 19) decreased from 62.4 ± 102.1 to 27.9 ± 45.5 mcg/hr (p < 0.01); PRN OMED (n = 19) decreased from 43.9 ± 77.5 to 10.9 ± 20.8 mg/day (p = 0.02); and frequency of any PRN analgesic use (n = 19) decreased from 0.49 ± 0.55 to 1.33 ± 0.90 per day (p = 0.08). At 6 months after GKRS, 9 (56%) of 16 patients reported being pain free (NRS score 0), with 6 (67%) of the 9 being both pain free and not requiring analgesic medications. One patient treated early in our experience developed a temporary increase in trigeminal pain 3-4 days after GKRS requiring hospitalization. All subsequently treated patients were given a single dose of intravenous steroids immediately after GKRS followed by a 2-3-week oral steroid taper. No further cases of increased or new pain after treatment were observed after this intervention. GKRS for palliation of trigeminal pain secondary to recurrent malignant skull base tumors demonstrated a significant decrease in patient-reported pain and opioid requirement. Additional patients and a longer follow-up duration are needed to assess durability of symptom relief and local control.

Pituitary Dysfunction after Radiation for Anterior Skull Base Malignancies: Incidence and Screening.

Background Management of anterior cranial base malignancies requires multidisciplinary care. Radiation therapy remains a mainstay of definitive or adjuvant treatment. Apart from primary hypothyroidism, the effects of radiation on the hypothalamic-pituitary axis after high-dose treatment of head and neck malignancies remain poorly described. We describe a comprehensive screening protocol for surveillance and characterize the incidence of pituitary dysfunction after radiation for anterior cranial base malignancies. Methods A review of patients prospectively enrolled in a skull base registry at an academic center was performed. Included patients had a history of anterior skull base malignancy and external beam radiation to the primary site, with comprehensive post-treatment pituitary serologies and at least 1 year of post-radiation follow-up. Routine hormonal screening was initiated during the study period for all patients with anterior skull base irradiation. Results Eighty-one patients met inclusion. Fifty-eight patients (71%) demonstrated some laboratory abnormality. Thirty patients (37%) demonstrated evidence of hypopituitarism. Twenty-four (29%) demonstrated central hypogonadism, and 16% of patients showed central hypothyroidism. Ten patients (12%) displayed central adrenal insufficiency with six patients demonstrating panhypopituitarism. Primary tumor location and maximum dose of radiation to the gland appeared to correlate with incidence of hypopituitarism. Conclusion Radiation for malignancies of the anterior skull base resulted in a 37% incidence of hypopituitarism in our study. Given the potential morbidity of hypopituitarism, we recommend annual post-treatment screening in these patients. We describe a comprehensive set of serologies that can be utilized, and recommend updating clinical guidelines to reflect the necessity of this screening.

Utility of first positron emission tomography-computed tomography scan as a prognostic tool following treatment of sinonasal and skull base malignancies.

The prognostic value of the first posttreatment whole body integrated positron emission tomography-computed tomography (PET/CT) scanning in patients with sinonasal/skull base malignancies is undetermined. We retrospectively reviewed the data of all patients that underwent surgery for sinonasal/skull base malignancies in 2000-2015. The results of the pretreatment and posttreatment PET/CT findings and the clinical course were retrieved. Thirty-eight patients (average age 60.6 years, 20 males) were included. Sensitivity and specificity, positive predictive value, and negative predictive value of the first PET/CT scan for predicting persistent/recurrent disease were 85.7%, 87.5%, 80%, and 91.3%, respectively. Overall 5-year survival was significantly lower in the first posttreatment PET/CT-positive group (35%) compared to the PET/CT-negative group (93%) (P = .0008). Posttreatment PET/CT findings are highly prognostic in patients with sinonasal/skull base malignancies. Negative findings on the first posttreatment PET/CT scan predict a significantly better overall survival.

Endoscopic endonasal approaches for the management of cranial base malignancies: histologically guided treatment and clinical outcomes.

Malignancies of the skull base represent a highly diverse and challenging set of pathologies which exhibit a wide array of oncologic behavior. In recent decades, a number of important advances in treatment technique have evolved to improve oncologic outcomes and reduce morbidity in the treatment of these aggressive cancers. Intensity modulated radiation therapy has become the gold standard in radiotherapy owing to its precision planning and reduced morbidity. However heavy ion particle radiation (proton therapy, carbon ion, etc.) are recently emerging with promising results at the skull base related to the reduced exit dose to adjacent structures. Novel systemic therapeutics such as targeted and immunotherapies may dramatically alter the treatment paradigm for many of these pathologies. Nevertheless, most skull base malignancies remain surgical diseases. The evolution of the expanded endonasal approach for a minimally invasive surgical resection has proven validity in treating many of these pathologies when properly selected, and have largely supplanted open approaches owing to the reduced morbidity profile. In spite of these important advances, the most critical aspect in comprehensive treatment is a detailed understanding of the oncologic behavior and outcomes data for each of the specific histopathologies encountered at the skull base. The nuances in management strategy, histologic profile, and surveillance planning can be stratified through the development of a comprehensive, multidisciplinary skull base team to maximize therapeutic effect and minimize morbidity for each patient. This review aims to summarize the key body of data and approaches for each of the histologies frequently encountered in the skull base, while highlighting the value and technique of endonasal approaches.

Mental Health Disorders Associated with Sinonasal and Skull Base Malignancies: A Large Cohort Study

Mental Health Disorders Associated with Sinonasal and Skull Base Malignancies: A Large Cohort Study

Proton Beam Radiation-Induced Skull Base Malignancy

Proton Beam Radiation-Induced Skull Base Malignancy

Surgical Resection of Skull Base Malignancy: Perioperative and Long-Term Outcomes

Surgical Resection of Skull Base Malignancy: Perioperative and Long-Term Outcomes