Craniofacial Resection for Cranial Base Malignancies Involving the Infratemporal Fossa

Abstract OBJECTIVE: Cranial base malignancies involving the infratemporal fossa have been considered unresectable. Advanced operative techniques have made tumor resection feasible in an en bloc fashion with negative histological margins, but there are limited data regarding outcome analysis in patients who have undergone resection of malignant tumors in this area. METHODS: At Memorial Sloan-Kettering Cancer Center, 25 patients underwent anterolateral cranial base resections for tumors that involved the infratemporal fossa during a 7-year period. The most common tumors were sarcoma (n = 9), squamous cell carcinoma (n = 6), and adenoid cystic carcinoma (n = 3). The median size of the tumors was 6 cm, and 12 tumors involved the anterior cranial base and/or orbit. Tumor resections were divided into three types. Twelve patients underwent Type 1 dissection for tumors involving only the infratemporal fossa and maxillary sinus; 2 patients underwent Type 2 dissections involving the infratemporal fossa and anterior cranial base; and 11 patients underwent Type 3 dissection, which included the infratemporal fossa, anterior cranial base, and orbit. All patients required free flap reconstruction, 22 of which were rectus abdominis free flaps. RESULTS: Complications occurred in seven patients, including a single mortality resulting from a myocardial infarction. The 2-, 3-, and 5-year survival rates were 69, 63, and 56%, respectively. The relapse-free survival rates were 47% at 2 and 3 years and 41% at 5 years. Recurrences were local in nine patients and distant in four patients. CONCLUSION: Despite the extensive nature of many infratemporal fossa tumors, they can be resected with acceptable morbidity. Survival rates approach those of anterior cranial base malignancies without infratemporal fossa involvement.

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Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases

Journal of Neurosurgery ◽

10.3171/2009.3.jns0929 ◽

2010 ◽

Vol 112 (1) ◽

pp. 108-117 ◽

Cited By ~ 49

Author(s):

Bing Zhao ◽

Yu-Kui Wei ◽

Gui-Lin Li ◽

Yong-Ning Li ◽

Yong Yao ◽

...

Keyword(s):

Postoperative Complications ◽

Cavernous Sinus ◽

Pituitary Adenomas ◽

Tumor Resection ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Preoperative Imaging ◽

Surgical Removal ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base

Object The standard transsphenoidal approach has been successfully used to resect most pituitary adenomas. However, as a result of the limited exposure provided by this procedure, complete surgical removal of pituitary adenomas with parasellar or retrosellar extension remains problematic. By additional bone removal of the cranial base, the extended transsphenoidal approach provides better exposure to the parasellar and clival region compared with the standard approach. The authors describe their surgical experience with the extended transsphenoidal approach to remove pituitary adenomas invading the anterior cranial base, cavernous sinus (CS), and clivus. Methods Retrospective analysis was performed in 126 patients with pituitary adenomas that were surgically treated via the extended transsphenoidal approach between September 1999 and March 2008. There were 55 male and 71 female patients with a mean age of 43.4 years (range 12–75 years). There were 82 cases of macroadenoma and 44 cases of giant adenoma. Results Gross-total resection was achieved in 78 patients (61.9%), subtotal resection in 43 (34.1%), and partial resection in 5 (4%). Postoperative complications included transient cerebrospinal rhinorrhea (7 cases), incomplete cranial nerve palsy (5), panhypopituitarism (5), internal carotid artery injury (2), monocular blindness (2), permanent diabetes insipidus (1), and perforation of the nasal septum (2). No intraoperative or postoperative death was observed. Conclusions The extended transsphenoidal approach provides excellent exposure to pituitary adenomas invading the anterior cranial base, CS, and clivus. This approach enhances the degree of tumor resection and keeps postoperative complications relatively low. However, radical resection of tumors that are firm, highly invasive to the CS, or invading multidirectionally remains a big challenge. This procedure not only allows better visualization of the tumor and the neurovascular structures but also provides significant working space under the microscope, which facilitates intraoperative manipulation. Preoperative imaging studies and new techniques such as the neuronavigation system and the endoscope improve the efficacy and safety of tumor resection.

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Assessment of prognostic factors in extracranial germ cell tumors in children

Problems in oncology ◽

10.37469/0507-3758-2021-67-6-829-836 ◽

2021 ◽

Vol 67 (6) ◽

pp. 829-836

Author(s):

Symbat Salieva ◽

Riza Boranbayeva ◽

Bakhram Zhumadullayev ◽

Ergali Sarsekbayev ◽

Oleg Bydanov

Keyword(s):

Overall Survival ◽

Prognostic Factors ◽

Survival Rate ◽

Germ Cell ◽

Malignant Tumors ◽

Survival Rates ◽

Tumor Resection ◽

Germ Cell Tumors ◽

Morphological Structure ◽

High Sensitivity

Germ cell neoplasms in the group of benign and malignant tumors heterogeneous in morphological structure, clinical features and prognosis. A special characteristic of germ cell tumors is their high sensitivity to platinum-containing chemotherapy, which allows cure of up to 80–90% patients. However 20–25% of patients with a common type have overall survival rate of less than 50%. The aim of the study is to assess the survival rate of children with extracranial germ cell tumors and to identify adverse risk factors. Methods. The study includes 116 children with extracranial germ cell tumors treated from 2013 to September 2009. Treatment consisted of tumor resection and platinum based on platinum chemotherapy. Survival rate was assessed by the Kaplan-Mayer method. Prognostic factors are determined according to IGCCCG, MaGIC, MAKEI, RODO. Results. Overall and event free survival rates were 79±5% and 76±4%, respectively. The worst overall survival had patients with extragonadal tumors, advanced stages of a disease, high initial level of AFP (≥10 000 ng/ml), non-seminoma version of state treasury bills and extra pulmonary metastases. Conclusion. Survival rate in children with extracranial germ cell tumors depends on the prognostic factors. Statistically significant predictors of the poor prognosis were extragonadal localization of a tumor and the AFP level ≥10 000 ng/ml.

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Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1721816 ◽

2021 ◽

Author(s):

Jonathan Giurintano ◽

Michael W. McDermott ◽

Ivan H. El-Sayed

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

San Francisco ◽

Middle Turbinate ◽

Cranial Base ◽

Anterior Skull Base ◽

Craniofacial Resection ◽

Skull Base Reconstruction ◽

Pericranial Flap ◽

Anterior Cranial Base

Abstract Importance As the limits of advanced skull base malignancies that can be managed through an endoscopic endonasal approach continue to be expanded, the resultant anterior skull base defects are of increasing size and complexity. In the absence of nasoseptal or turbinate flaps, the vascularized pericranial flap has been employed at our institution with excellent results. Objective The study aimed to review the outcomes of patients who underwent endonasal anterior craniofacial resection with anterior skull base reconstruction using a vascularized pericranial flap. Design Retrospective chart review of patients treated by the University of California – San Francisco minimally invasive skull base service from the years 2011 to 2017. Average duration of follow-up was 16.4 months. Setting This study was conducted at Academic tertiary referral center. Participants A total of nine patients with advanced anterior cranial base malignancies were identified who were treated with a minimally invasive, endoscopic anterior craniofacial resection from the years 2011 to 2017. Due to the nature of the resection in these patients, nasoseptal flaps and inferior/middle turbinate flaps were unavailable or insufficient for anterior skull base defect repair. Each patient underwent reconstruction of the anterior cranial base defect using an anteriorly based pericranial flap harvested by bicoronal incision, and tunneled anteriorly to the nasal cavity through a frontoethmoidal incision.

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Osteomalacia Caused by Skull Base Tumors: Report of 2 Cases

Neurosurgery ◽

10.1227/neu.0b013e31821867f7 ◽

2011 ◽

Vol 69 (1) ◽

pp. E239-E244 ◽

Cited By ~ 12

Author(s):

Takeshi Uno ◽

Kensuke Kawai ◽

Naoto Kunii ◽

Seiji Fukumoto ◽

Junji Shibahara ◽

...

Keyword(s):

Skull Base ◽

Muscle Power ◽

Cranial Base ◽

Whole Body ◽

Entire Body ◽

Whole Body Imaging ◽

Skull Base Tumors ◽

En Bloc ◽

True Incidence ◽

Anterior Cranial Base

Abstract BACKGROUND AND IMPORTANCE: Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome rarely encountered in neurosurgical practice. We report on 2 cases of TIO caused by skull base tumors. Although the diagnosis of TIO is difficult to make and often is delayed because of the insidious nature of the symptoms, mostly systemic pain and weakness, it is curable once it is diagnosed and properly treated. CLINICAL PRESENTATION: Both patients presented with severe pain developing in the lower extremities and moving out to the entire body, as well as difficulty moving. They were diagnosed with TIO several years after onset. A high level of serum FGF23 was confirmed, and whole-body imaging studies demonstrated tumors in the middle and anterior cranial base, respectively. The patient with the anterior cranial base tumor had a history of hemorrhage into the frontal lobe and partial resection. En bloc resection of tumor with surrounding skull bone was performed. The histological diagnosis for both cases was phosphaturic mesenchymal tumor, mixed connective tissue variant. CONCLUSION: The level of FGF23 normalized immediately after surgery. Both patients experienced a dramatic relief of pain and recovery of muscle power. Although reports of osteomalacia caused by tumors in the neurosurgical field are extremely rare in the literature, its true incidence is unknown. We emphasize the importance of recognition of this syndrome and recommend total resection of tumors when possible.

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COMPARATIVE RISK OF LEPTOMENINGEAL DISSEMINATION OF CANCER AFTER SURGERY OR STEREOTACTIC RADIOSURGERY FOR A SINGLE SUPRATENTORIAL SOLID TUMOR METASTASIS

Neurosurgery ◽

10.1227/01.neu.0000341535.53720.3e ◽

2009 ◽

Vol 64 (4) ◽

pp. 664-676 ◽

Cited By ~ 71

Author(s):

Dima Suki ◽

Mustafa Aziz Hatiboglu ◽

Akash J. Patel ◽

Jeffrey S. Weinberg ◽

Morris D. Groves ◽

...

Keyword(s):

Brain Metastasis ◽

Stereotactic Radiosurgery ◽

Tumor Resection ◽

En Bloc Resection ◽

Bloc Resection ◽

Cancer Center ◽

Leptomeningeal Disease ◽

En Bloc ◽

University Of Texas ◽

The Difference

Abstract OBJECTIVE To test the hypothesis that differential risks of developing leptomeningeal disease (LMD) exist in patients having a single supratentorial brain metastasis resected via a piecemeal or en bloc approach or treated with stereotactic radiosurgery (SRS). METHODS Between 1993 and 2006, 827 patients with a supratentorial brain metastasis underwent resection or SRS at The University of Texas M.D. Anderson Cancer Center. The primary outcome was the incidence of LMD. RESULTS Resection was performed piecemeal in 191 patients and en bloc in 351 patients; 285 patients received SRS. LMD occurred in 33 patients, 29 in the resection group and 4 in the SRS group. Risk of LMD was significantly higher with piecemeal tumor resection than with other procedures (SRS: hazard ratio [HR] for piecemeal, 5.8; 95% confidence interval [CI], 1.9–17.2; P = 0.002; en bloc, HR for piecemeal, 2.7; 95% CI, 1.3–5.6; P = 0.009). The difference between piecemeal and en bloc was particularly pronounced in patients with a melanoma primary (HR, 8.4; 95% CI, 1.8–39.2; P = 0.007). The risk of LMD was not significantly different between en bloc resection and SRS (HR for en bloc, 2.1; 95% CI, 0.7–6.4; P = 0.21). Similar results were obtained when comparing effects of SRS and both resection approaches after limiting the sample to patients with tumors in a specific volume range. CONCLUSION Piecemeal resection of a supratentorial brain metastasis carries a higher risk of LMD than en bloc resection or SRS. Further assessment of the role of the 2 surgical resection approaches and SRS in a controlled prospective setting with large numbers of patients is warranted.

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A case of 18 years disease-free survival after combined pancreatoduodenectomy and hemicolectomy for carcinosarcoma of the transverse colon

Surgical Case Reports ◽

10.1186/s40792-021-01159-x ◽

2021 ◽

Vol 7 (1) ◽

Author(s):

Susumu Ohwada ◽

Amika Moro ◽

Nair Amit ◽

Kazunari Sasaki ◽

Shinji Sakurai ◽

...

Keyword(s):

Transverse Colon ◽

Malignant Tumors ◽

Submucosal Tumor ◽

Tumor Resection ◽

Pancreatic Head ◽

Disease Free Survival ◽

En Bloc ◽

Abdominal Ultrasonography ◽

Cross Sectional ◽

Pancreas Head

Abstract Background Ascertaining the origin of large tumors located in the region of the pancreas head and adjacent mesocolon can pose a challenge preoperatively. En bloc pancreatoduodenectomy with hemicolectomy is often required towards curative tumor resection (R0) of malignant tumors in this region. Case presentation Herein we report a case of a 48-year-old man with two contiguous masses each 5 cm in size, located in the pancreatic head. The masses were detected incidentally by abdominal ultrasonography at an annual health check. Endoscopic biopsies revealed inflammation with no malignancy. Cross-sectional imaging showed the tumor direct invasion of the uncinate process of the pancreas, and the third portion of the duodenum. Based on imaging, a malignant submucosal tumor originating from mesenchymal cells in the mesentery of the transverse colon was made preoperatively. The mass required en bloc pancreatoduodenectomy, right hemicolectomy, and resection of the superior mesenteric vein. The final pathology was carcinosarcoma of the transverse colon. The patient survived 18 years after surgery without recurrence. Conclusions Malignant tumors located in the region of the pancreas head should be considered for an en bloc curative tumor resection and adjuvant chemotherapy treatments offered that might be beneficial for carcinosarcoma.

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PROGNOSTIC SIGNIFICANCE OF TRANSDURAL INVASION OF CRANIAL BASE MALIGNANCIES IN PATIENTS UNDERGOING CRANIOFACIAL RESECTION

Neurosurgery ◽

10.1227/01.neu.0000306095.53388.f1 ◽

2007 ◽

Vol 61 (6) ◽

pp. 1178-1185 ◽

Cited By ~ 25

Author(s):

Iman Feiz-Erfan ◽

Dima Suki ◽

Ehab Hanna ◽

Franco DeMonte

Keyword(s):

Prognostic Significance ◽

Progression Free Survival ◽

Cranial Base ◽

Cancer Center ◽

Primary Malignancy ◽

Craniofacial Resection ◽

Brain Invasion ◽

University Of Texas ◽

Negative Prognostic Factor ◽

Alive With Disease

Abstract OBJECTIVE Invasion of the brain and/or dura is a known negative prognostic factor for patients undergoing craniofacial resection for cranial base malignancy. However, an evaluation of factors that may affect prognosis in this patient subgroup has not been undertaken. METHODS Between 1993 and 2003, 212 patients underwent craniofacial resection for primary malignancy of the cranial base at the University of Texas M.D. Anderson Cancer Center. Twenty-eight patients (eight women, 20 men; median age, 52 yr; age range, 26–76 yr) had evidence of transdural spread (subdural tumor or brain invasion) of malignancy. These patients were identified and a retrospective review of prospectively collected data was undertaken. RESULTS Subdural tumors were found in 16 of these patients, and brain invasion was detected in 12. Gross total resections were achieved in 22 patients: 13 with microscopically negative margins, eight with positive margins, and one with unspecified margins. Surgical complications occurred in six patients. There was no surgical mortality. The 5-year actuarial overall survival (OS) was 58%. Eleven patients had no evidence of disease, 11 died of disease, and six were alive with disease at the end of the follow-up period. The median actuarial progression-free survival (PFS) was 38 months (95% confidence interval, 4–72 mo). Gross total resection with negative margins was the key positive predictor of OS and PFS. Brain invasion was a negative predictor of survival (significant for PFS; trend only for OS). There was a trend for shorter OS and PFS in patients with high-grade tumors. CONCLUSION Overall OS and PFS in highly selected patients with transdural invasion of cranial base malignancy is similar to what has been historically reported for patients without such invasion. The most important variables positively affecting OS and PFS seem to be the ability to achieve a microscopically margins-negative resection followed by absence of brain invasion. Performing this resection in a piecemeal fashion does not seem to affect survival outcomes.

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Central Bisegmentectomy for Malignant Liver Tumors: Experience in 8 Patients

International Surgery ◽

10.9738/intsurg-d-13-00163.1 ◽

2014 ◽

Vol 99 (5) ◽

pp. 612-615 ◽

Cited By ~ 1

Author(s):

Hiroaki Shiba ◽

Koichiro Haruki ◽

Yasuro Futagawa ◽

Tomonori Iida ◽

Kenei Furukawa ◽

...

Keyword(s):

Liver Function ◽

Liver Tumors ◽

Malignant Tumors ◽

Survival Rates ◽

Liver Volume ◽

Optimal Solution ◽

Disease Free Survival ◽

University Hospital ◽

Remnant Liver ◽

En Bloc

Abstract Central bisegmentectomy (CBS) of the liver is an en bloc hepatic resection of Couiaud segments 4, 5, and 8. The indications for CBS include benign and malignant tumors occupying both the left medial and right anterior segments. However, CBS has rarely been reported. Here, we investigate CBS in patients with suboptimal liver function for whom an extended lobectomy is not an optimal solution. Each case was 1 of 8 patients who underwent CBS for hepatocellular carcinoma (HCC) or colorectal cancer liver metastasis (CRLM) at the Department of Surgery, Jikei University Hospital. Indications for CBS consisted of CRLM in 3 patients and HCC in 5 patients. The median duration of operation was 552 minutes, and median blood loss was 2263 g. No postoperative nor in-hospital mortalities occurred. In this study, 1-, 2-, and 3-year disease-free survival rates were 62.5%, 12.5%, and 12.5%, respectively, and 1-, 2-, and 3-year overall survival rates were 100%, 100%, and 85.7%, respectively. CBS is advocated for central liver tumors in patients with suboptimal liver function for whom extended lobectomy could result in less than optimal remnant liver volume and function.

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Zones of Approach for Craniofacial Resection: Minimizing Facial Incisions for Resection of Anterior Cranial Base and Paranasal Sinus Tumors

Neurosurgery ◽

10.1227/01.neu.0000088802.58956.5a ◽

2003 ◽

Vol 53 (5) ◽

pp. 1126-1137 ◽

Cited By ~ 59

Author(s):

James K. Liu ◽

David Decker ◽

Steven D. Schaefer ◽

Augustine L. Moscatello ◽

Richard R. Orlandi ◽

...

Keyword(s):

Nasal Cavity ◽

Maxillary Sinus ◽

Paranasal Sinuses ◽

Tumor Resection ◽

Blind Spot ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Surgical Approaches ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base

Abstract OBJECTIVE Anterior cranial base tumors are surgically resected with combined craniofacial approaches that frequently involve disfiguring facial incisions and facial osteotomies. The authors outline three operative zones of the anterior cranial base and paranasal sinuses in which tumors can be resected with three standard surgical approaches that minimize transfacial incisions and extensive facial osteotomies. METHODS The zones were defined by performing dissections on 10 cadaveric heads and by evaluating radiographic images of patients with anterior cranial base tumors. The three approaches performed on each cadaver were transbasal, transmaxillary, and extended transsphenoidal. RESULTS Three zones of approach were defined for accessing tumors of the anterior cranial base, nasal cavity, and paranasal sinuses. Zone 1 is exposed by the transbasal approach, which is limited anteriorly by the supraorbital rim, posteriorly by the optic chiasm and clivus, inferiorly by the palate, and laterally by the medial orbital walls. This approach allows access to the entire anterior cranial base, nasal cavity, and the majority of maxillary sinuses. The limitation imposed by the orbits results in a blind spot in the superolateral extent of the maxillary sinus. Zone 2 is exposed by a sublabial maxillotomy approach and accesses the entire maxillary sinus, including the superolateral blind spot and the ipsilateral anterior cavernous sinus. However, access to the anterior cranial base is limited. Zone 3 is exposed by the transsphenoidal approach. This approach accesses the midline structures but is limited by the lateral nasal walls and intracavernous carotid arteries. An extended transsphenoidal approach allows further exposure to the anterior cranial base, clivus, or cavernous sinuses. The use of the endoscope facilitates tumor resection in the nasal cavity and paranasal sinuses. CONCLUSION The operative zones outlined offer minimally invasive craniofacial approaches to accessing lesions of the anterior cranial base and paranasal sinuses, obviating facial incisions and facial osteotomies. Case illustrations demonstrating the approach selection paradigm are presented.

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Robotic vs. Transsternal Thymectomy: A Single Center Experience over 10 Years

Journal of Clinical Medicine ◽

10.3390/jcm10214991 ◽

2021 ◽

Vol 10 (21) ◽

pp. 4991

Author(s):

Luis Filipe Azenha ◽

Robin Deckarm ◽

Fabrizio Minervini ◽

Patrick Dorn ◽

Jon Lutz ◽

...

Keyword(s):

Tumor Size ◽

Survival Rates ◽

Tumor Resection ◽

Median Sternotomy ◽

Good Alternative ◽

En Bloc ◽

Thymic Tissue ◽

Single Center Experience ◽

Median Tumor Size ◽

Bovine Pericardial Patch

Introduction: Thymomas are the most common tumors of the mediastinum. Traditionally, thymectomies have been performed through a transsternal (TS) approach. With the development of robot-assisted thoracic surgery (RATS), a promising, minimally invasive, alternative surgical technique for performing a thymectomy has been developed. In the current paper, the oncological and surgical outcomes of the TS vs. RATS thymectomies are discussed. Methods: For the RATS thymectomy, two 8 mm working ports and one 12 mm camera port were used. In the transsternal approach, we performed a median sternotomy and resected the thymic tissue completely, in some cases en bloc with part of the lung and/or, more frequently, a partial pericardiectomy with consequent reconstruction using a bovine pericardial patch. The decisions for using the TS vs. RATS methods were mainly based on the suspected tumor invasion of the surrounding structures on the preoperative CT scan and tumor size. Results: Between January 2010 and November 2020, 149 patients were submitted for an anterior mediastinal tumor resection at our institution. A total of 104 patients met the inclusion criteria. One procedure was performed through a hemi-clamshell incision. A total of 81 (78%) patients underwent RATS procedures, and 22 (21.1%) patients were treated using a transsternal (TS) tumor resection. Thymoma was diagnosed in 53 (51%) cases. In the RATS group, the median LOS was 3.2 ± 2.8 days and the median tumor size was 4.4 ± 2.37 cm compared to the TS group, which had a median LOS of 9 ± 7.3 days and a median tumor size of 10.4 ± 5.3 cm. Both differences were statistically significant (p < 0.001). Complete resection was achieved in all patients. Conclusion: While larger and infiltrating tumors (i.e., thymic carcinomas) were usually resected via a sternotomy, the RATS procedure is a good alternative for the resection of thymomas of up to 9.5 cm, and the thymectomy is a strong approach for myasthenia gravis. The oncological outcomes and survival rates were not influenced by the chosen approach.

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