A leading endoscopic surgeon said that removing complex esthesioneuro blastomas can be achieved using accepted oncological principles, and that the early results appear comparable to outcomes achieved with conventional surgery.
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October 2008Obviously, this is a work in progress, said Carl H. Snyderman, MD, Professor of Otolaryngology at the University of Pittsburgh Medical Center (UPMC), in delivering the Presidential Lecture at the 111th annual meeting of the Triological Society held in conjunction with the Combined Otolaryngology Spring Meeting.
Looking at our own limited experience, we have now treated 24 patients for esthesioneuroblastomas, Dr. Snyderman said, describing his collaboration with Ricardo Carrau, MD, and Amin Kassam, MD, at the UPMC Center for Skull Base Surgery. He reported on 17 of those patients with at least one year of follow-up.
The early results are very encouraging. We have had only one recurrence in this group of 17 patients. We have had two patients with positive margins, he said, including one patient whose tumor involvement above the orbit required transition to an open approach.
We have followed patients for a mean of 31 months, so we are getting respectable numbers, he said.
Dr. Snyderman said, however, that he was concerned about endoscopic procedures that were not performed using oncologic principles designed to give patients the best possible chance for a cure. I am dismayed to see that many of the reports are doing what I would call a nononcologic resection, he said. They are not resecting the dura in all patients; they are not taking the olfactory bulb and olfactory nerves. They are not striving for the same defect that would be done with an open approach.
The margins of resection should be the same as with open approaches. Endoscopic approaches are not an excuse for performing an incomplete tumor resection. We shouldn’t be cutting corners.
Dr. Snyderman said that a fully endoscopic approach can be employed in resection of the difficult tumors. We can do so with adherence to oncological principles, he said. I want to warn you that you should adhere to oncological resection including the dura and olfactory nerves if the skull base is involved until we have good long-term data. Don’t rely on radiation therapy to sterilize the margins. We do have reconstructive options, the use of vascularized flaps to maximize the healing.
I want to caution that there is a steep learning curve in doing these surgeries. It wasn’t until we had four or five years experience working as a team on less involved cases that we embarked on the more complex tumors, he said in his lecture.
Questions Raised
One cannot be anything but impressed by Dr. Snyderman’s presentation and the facility with which he and his team have been able to remove tumors with potentially less morbidity, commented Paul A. Levine, MD, the Robert W. Cantrell Professor and Chair of the Department of Otolaryngology-Head and Neck Surgery at the University of Virginia Health System in Charlottesville. His presentation demonstrated that a surgeon could expand the technique to all lesions.