DOI: https://doi.org/10.25305/unj.183027

Endoscopic endonasal approaches to the skull base tumors: minimally-invasive approach with achievement of radicality. Our experience

Orest I. Palamar, Andriy P. Huk, Ruslan V. Aksyonov, Dmytro I. Okonskyi, Dmytro S. Teslenko

Abstract


Objective: to optimize surgical tactic of endoscopic endonasal transsphenoidal (EET) approaches in cases of tumors with intra- and extracranial extension.

Material and methods. For the period of 2013–2019, we retrospectively reviewed 39 patients with tumors of intra-extra skull base location or just extracranial extension. Tumor location and pathology: tumors in pterygopalatine fossa (paraganglioma, carcinoma, neurilemmoma, neurofibroma, chondrosarcoma) — 10 (25.6 %), pituitary adenomas with sphenoid sinus and/or parasellar extension — 14 (35.9 %), sphenoid sinus tumors (carcinoma, neurilemmoma, fibrous dysplasia, angiofibroma, esthesioneuroblastoma) — 8 (20.5 %), petroclival tumors — 6 (15.4 %): hemangiopericytoma — 1, clival tumors — 5 (chordoma), sella turcica lesion with posterior clinoid recess extension (osteoma) – 1 (2.5 %). The extended EET approaches used were as follows: EET + transpterygoid approach — 22 (56.4 %) (in 4 (18.1 %) cases transmaxillary approach was additionally used), extended EET + transclival approach — 4 (10.2 %), EET + transcavernous approach — 2 (5.1 %), EET + transethmoidal approach — 11 (28.2 %). In all cases, we used Karl Storz rigid 4mm 18cm with 0 and 30-degree angled optics. The extent of resection was determined based on routine postoperative CT scans performed within 24 hours after surgery. The volume of resection was evaluated using gadolinium. Gross total resection was defined as the resection of 100 % of the target lesion, subtotal resection as less than 100 % volumetric reduction of the lesion on postoperative CT scans. Further follow-up was done in three, six months and 1 year after surgery, then annually by MRI scanning with gadolinium.

Results. Gross total resection was achieved in 7 (77.8 %) cases of tumor in pterygopalatine fossa. In cases of pituitary adenomas with Knosp 3, Knosp 4 cavernous sinus extension, gross total resection was achieved in 7 (53.8 %) individuals. Sphenoid sinus tumors were totally removed in 5 (62.5 %) cases. Subtotal resection was achieved in 11 (28.2 %) cases. Partial resection was achieved in 8 (20.5 %) cases. Postoperative complications were observed in 5 (12.1 %) cases.

Conclusions Transethmoidal extended endoscopic endonasal approach is sufficient and good to access the anterior wall of the cavernous sinus improving visualization and better removing of cavernous sinus pathology extension. Transpterygoid extended endoscopic endonasal approach provides sufficient visualization of pterygopalatine fossa, petroclival region. Transmaxillary extension allows reaching the subtemporal region.


Keywords


skull base tumors; extended endoscopic approaches

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References


1. Jane JA Jr, Laws ER Jr. The surgical management of pituitary adenomas in a series of 3,093 patients. J Am Coll Surg. 2001 Dec;193(6):651-9. [CrossRef] [PubMed]

2. Lobo B, Heng A, Barkhoudarian G, Griffiths CF, Kelly DF. The expanding role of the endonasal endoscopic approach in pituitary and skull base surgery: A 2014 perspective. Surg Neurol Int. 2015 May 20;6:82. [CrossRef] [PubMed] [PubMed Central]

3. Apuzzo ML, Heifetz MD, Weiss MH, Kurze T. Neurosurgical endoscopy using the side-viewing telescope. J Neurosurg. 1977 Mar;46(3):398-400. [CrossRef] [PubMed]

4. Hofstetter CP, Shin BJ, Mubita L, Huang C, Anand VK, Boockvar JA, Schwartz TH. Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus. 2011 Apr;30(4):E10. [CrossRef] [PubMed]

5. Jho HD, Carrau RL. Endoscopic endonasal transsphenoidal surgery: experience with 50 patients. J Neurosurg. 1997 Jul;87(1):44-51. [CrossRef] [PubMed]

6. Deganello A, Ferrari M, Paderno A, Turri-Zanoni M, Schreiber A, Mattavelli D, Vural A, Rampinelli V, Arosio AD, Loppi A, Cherubino M, Castelnuovo P, Nicolai P, Battaglia P. Endoscopic-assisted maxillectomy: Operative technique and control of surgical margins. Oral Oncol. 2019 Jun;93:29-38. [CrossRef] [PubMed]

7. Arnaout MM, Mazzatenta D, Aziz K. CRAN-33. Endoscopic challenge for sellar and parasellar tumors: from above or below. Neuro Oncol. 2018 Jun;20(Suppl 2):i43. [CrossRef] [PubMed Central]

8. Frank G, Pasquini E, Doglietto F, Mazzatenta D, Sciarretta V, Farneti G, Calbucci F. The endoscopic extended transsphenoidal approach for craniopharyngiomas. Neurosurgery. 2006 Jul;59(1 Suppl 1):ONS75-83; discussion ONS75-83. [CrossRef] [PubMed]

9. Choi KJ, Ackall FY, Truong T, Cheng TZ, Kuchibhatla M, Zomorodi AR, Codd PJ, Fecci PE, Hachem RA, Jang DW. Sinonasal Quality of Life Outcomes After Extended Endonasal Approaches to the Skull Base. J Neurol Surg B Skull Base. 2019 Aug;80(4):416-423. [CrossRef] [PubMed] [PubMed Central]

10. Alsaleh S, Albakr A, Alromaih S, Alatar A, Alroqi AS, Ajlan A. Expanded transnasal approaches to the skull base in the Middle East: Where do we stand? Ann Saudi Med. 2020 Mar-Apr;40(2):94-104. [CrossRef] [PubMed] [PubMed Central]

11. Ravisankar M, Khatri D, Gosal JS, Arulalan M, Jaiswal AK, Das KK. Surgical excision of trigeminal (V3) schwannoma through endoscopic transpterygoid approach. Surg Neurol Int. 2019 Dec 27;10:259. [CrossRef] [PubMed Central]

12. Roxbury CR, Ishii M, Richmon JD, Blitz AM, Reh DD, Gallia GL. Endonasal Endoscopic Surgery in the Management of Sinonasal and Anterior Skull Base Malignancies. Head Neck Pathol. 2016 Mar;10(1):13-22. [CrossRef] Erratum in: Head Neck Pathol. 2017 Jun;11(2):268. [PubMed] [PubMed Central]

13. Ajlan A, Achrol AS, Albakr A, Feroze AH, Westbroek EM, Hwang P, Harsh GR 4th. Cavernous Sinus Involvement by Pituitary Adenomas: Clinical Implications and Outcomes of Endoscopic Endonasal Resection. J Neurol Surg B Skull Base. 2017 Jun;78(3):273-282. [CrossRef] [PubMed] [PubMed Central]

14. Plzák J, Kratochvil V, Kešner A, Šurda P, Vlasák A, Zvěřina E. Endoscopic endonasal approach for mass resection of the pterygopalatine fossa. Clinics (Sao Paulo). 2017 Oct;72(9):554-561. [CrossRef] [PubMed] [PubMed Central]

15. Koutourousiou M, Gardner PA, Fernandez-Miranda JC, Paluzzi A, Wang EW, Snyderman CH. Endoscopic endonasal surgery for giant pituitary adenomas: advantages and limitations. J Neurosurg. 2013 Mar;118(3):621-31. [CrossRef] [PubMed]

16. Chin OY, Ghosh R, Fang CH, Baredes S, Liu JK, Eloy JA. Internal carotid artery injury in endoscopic endonasal surgery: A systematic review. Laryngoscope. 2016 Mar;126(3):582-90. [CrossRef] [PubMed]

17. Solari D, Chiaramonte C, Di Somma A, Dell’Aversana Orabona G, de Notaris M, Angileri FF, Cavallo LM, Montagnani S, Tschabitscher M, Cappabianca P. Endoscopic anatomy of the skull base explored through the nose. World Neurosurg. 2014 Dec;82(6 Suppl):S164-70. [CrossRef] [PubMed]


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