SM13: Endoscopic Techniques Evolve As New Treatment for Sinonasal Malignancies

Resection

Alexander Chiu, MD, chief of otolaryngology-head and neck surgery at the University of Arizona in Tucson, said the goals of the endoscopic approach and the open approach are mostly the same—a gross total resection, negative margins, sparing of vital organs and avoidance of neurological complications. But, with the endoscopic approach, another goal is the en bloc resection of the tumor attachment site, rather than of the whole tumor, to prevent recurrence.

In video footage, he showed a microdebrider suctioning away and debulking the tumor, which gives a better view of the attachment site, where the tumor can then be resected with a negative margin. “The first half-hour of the case is the most important part of the case,” he said. “That’s where you really want to debulk quickly in order to limit your blood loss.”

In some cases, it becomes clear that the attachment site can’t be resected endoscopically. “You have to be prepared to do an open procedure,” said Dr. Chiu. “I’m not doing this patient any favors by debulking her tumor without addressing that site of attachment.”

The panelists said that they review with patients the possibility of having to move to a more invasive procedure, and most patients are receptive to that if it means helping them in the long term. “These patients are pretty shell-shocked,” Dr. Chiu said. “They’re scared about their cancer; they just want it taken care of.”

Complications

Adam Zanation, MD, assistant professor of otolaryngology/head and neck surgery at the University of North Carolina Chapel Hill School of Medicine, who reviewed complications with endoscopic skull base surgery and sinonasal malignancy procedures, said that in reading the literature, it’s important to consider whether the outcomes reported are in the context of the “current state” of the field. “Is this really what we’re dealing with today? Is that what we should be telling our patients?” he said.

A review of 800 cases of endonasal skull base surgery published in 2011, for instance, found that data were less relevant because so few of the patients had received nasoseptal flap and vascular reconstructions, which have now become routine. Dr. Zanation is now working on a study that shows a lower rate of post-operation cerebrospinal fluid leaks than was found in the former study. “I think they’re overestimated in the current literature,” he said. “As the reconstructive techniques have advanced, the post-operative complications have continued to get better.” Intra-operative neurovascular injury, although rare, can be devastating, however.