M. PIEMONTE SOC O.R.L. Az. Ospedaliero-Universitaria S.M.M., Udine

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1 M. PIEMONTE SOC O.R.L. Az. Ospedaliero-Universitaria S.M.M., Udine LIMITS OF ENDOSCOPIC RESECTIONS IN ANTERIOR SKULL BASE TUMORS Limiti delle resezioni endoscopiche nei tumori della rinobase anteriore

2 The limits of endonasal skull base surgery have not yet been realized The limits of yesterday. have already been overtaken and we are going further

Intraoperative navigator Nerve monitoring High resolution cameras &

3 Improvement in technical instrumentations allowed Expanded Endonasal Approach Modern endonasal drills Ultrasonic aspirator Microdebrider Intraoperative navigator Nerve monitoring High resolution cameras & monitors Hemostatic materials Endonasal bipolar forceps Materials for dural reconstruction

osteotomies Avoidance of brain retraction Decreased pain

4 Advantages of Endoscopic Approaches to Anterior Skull Base Avoidance of facial incisions No craniotomies No facial osteotomies Avoidance of brain retraction Decreased pain Shorter hospital stay Faster recovery Etc. DIRECT APPROACH THROUGH AERIAL SPACES

5 Anterior skull base surgery: the surgical choice The principle of skull base surgery is to choose the best pathway to the pathology The endonasal corridor can provide the best and most direct approach to many tumors Other tumor shall be better approached by external surgery Other tumors shall be better approached by a combined approach (endoscopic+external)

6 Extended Endoscopic Approach (EEA) to anterior skull base shall foresee: 1. A target 2. A skull base approach 3. A nasal corridor Three pre-operative questions: a) Where are we going? b) How will we get there? c) Where do we start? Schwartz TH, Fraser JF et al: Neurosurgery 62, , 2008

7 Schwartz TH, Fraser JF et al: Neurosurgery 62, , 2008

8 Expanded endonasal approach (EEA) can be performed in the sagittal plane 1) Transfrontal 2) Transcribriform 3) Transplanum 4) Transsphenoid 5) Transclival 6) Transodontoid Snyderman CH, Pant H et al.: Keio J Med 58, , 2009

2) Middle Midclival/paraclival Transpterygoid 3)

9 Expanded endonasal approach (EEA) can be performed in the coronal plane 1) Anterior Supraorbital Transorbital 2) Middle Midclival/paraclival Transpterygoid 3) Posterior Snyderman CH, Pant H et al.: Keio J Med 58, , 2009

10 Present limits in the endoscopic approach to anterior skull base tumors Anatomy Pathology Oncological principles Patient Surgeon Technical Equipment Surgery

(parapharyngeal, intrapetrous, parasellar) Vertebral artery

11 ANATOMY Bony wall of paranasal sinuses and bony palate Soft tissues of the face Orbit Major vessels ICA (parapharyngeal, intrapetrous, parasellar) Vertebral artery Optic Nerve and chiasma (Eustachian Tube) Lateral Infratemporal region Dura

Bony wall of paranasal sinuses and bony palate Only maxillary sinus medial wall, sphenoidal sinus anterior wall and lateral ethmoid wall can be properly resected by endoscopy Tumor invasion of all

12 Bony wall of paranasal sinuses and bony palate Only maxillary sinus medial wall, sphenoidal sinus anterior wall and lateral ethmoid wall can be properly resected by endoscopy Tumor invasion of all other bony wall of paranasal sinuses and of bony palate are still considered specific contraindications to endoscopy Invasion of soft tissues of the face cannot be treated by endoscopy Orbit Limited periorbital tissue invasion can be endoscopically treated Invasion of soft tissues of the orbit, with need for Exenteratio Orbitae, requires open surgery

13 Major vessels Internal Carotid Artery ICA (parapharyngeal, intrapetrous, parasellar) It is a major limit to endoscopic surgery of the anterior skull base, with main importance in specific approaches (transplanum, transphenoid, etc.) highly dangerous for vascular break Vertebral artery Cavernous Sinus Optic Nerve and chiasma CAROTID (INTRACAVERN. TRACT) CAROTID A. UNCOVERED IN SPHEN. SINUS CAVERNOUS SINUS

14 (Eustachian Tube) Can be resected to gain full access to the infrapetrous area Lateral Infratemporal region Cannot be reached by endoscopic approach alone Dura A wide tumoral invasion of the dura (which cannot entirely and safely exposed by endoscopic approach) is a contraindication to endoscopic removal of the tumor

15 PATHOLOGY Location of the tumor Most part of the tumors of the nasoparanasal cavities and the anterior skull base show a medial to lateral growth, facilitating an endoscopic treatment Diagnosis Imaging Histotype Vascularity NON SECRETING MACROADENOMA

16 Age PATIENT Pediatric patients Narrow nasal spaces Low tolerance to blood losses Geriatric Patients (*) Most part of elderly people presents at least 1 chronic comorbidity About 33% of geriatric patients present 4 or more comorbidities Medical Comorbidities (*)

17 SURGEON & TECHNICAL EQUIPMENT Surgeon Training Expertise Surgical approach Tumor removal Bleeding and Haemorrhage control Dural reconstruction Technical equipment Full technical equipment Manoeuvre angle of the instruments Direct manouvre capability Pre- Post-

Increase of the risk in endoscopic operations Significant suprasellar extension Lateral extension Retrosellar extension Dural and/or brain invasion with brain oedema Firm tumor

18 Increase of the risk in endoscopic operations Significant suprasellar extension Lateral extension Retrosellar extension Dural and/or brain invasion with brain oedema Firm tumor consistency Involvement or vasospasm of the arteries of the Circle of Willis Encasement of the optic apparatus or invasion of the optic foramina Zada G, Laws ER; J. Neurosurg 114, , 2011

19 ONCOLOGICAL PRINCIPLES Open Block resection vs. Endoscopic Piecemeal resection No difference in results Nicolai P, 2008; Hanna E., 2009; McCaffrey TV, 1994; Goffart Y, 2000; Zimmer LA, 2009 SURGERY PLANNING Duration of Surgery (two stage surgery?)

20 Do not forget! Endoscopic surgery of anterior skull base is not only and always. a radical therapeutic practice a one man/one way surgery It can also be: a part of a combined approach to surgical resection a palliation therapy in radically unoperable tumors

21 AN EXAMPLE: L.P., male, 39 years old NON SECRETING HYPOPHYISEAL MACROADENOMA

22 NASAL TIME OPTICS: 0 TRANSNASAL ENDOSCOPIC APPROACH NASAL SEPTUM UPPER TURBINATE SPHENOID OSTIUM

23 INTER-SPHENOIDAL SEPTUM ANTERIOR WALL OF SELLA TURCICA SPHENOIDAL TIME: REMOVAL OF THE SPHENOIDAL SEPTUM AND ACCESS TO ANTERIOR WALL OF SELLA TURCICA

24 CRESTA INTERSPHEN. ANT. WALL OF SELLA TURCICA

25 THIN BONY LAYER DURA

26 DURA OF THE SELLA

28 DECOMPRESSION AND COLLAPSE OF SELLAR CEILING

29 DECOMPRESSION OF INTRACRANIAL NERVOUS STRUCTURES

30 BRAIN MRI 5 MONTHS AFTER SURGERY

31 GIANT NASOPHARYNGEAL ANGIOFIBROMA WITH SKULL BASE EXTENSION (Extradural Type III acc. to Andrews, 1989) Male, 17 y. old TC imaging

32 MR imaging

33 MR imaging

34 MR imaging

35 Selective right carotid artery angiography Left carotid artery Right and left vertebral arteries

36 Pre-operative angiographic embolization of the right internal maxillary artery Post Pre

37 Surgical navigator

38 Paralatero-nasal approach through right maxillary bone volet

39 Uncovered dural lining of the clivus behind the posterior wall of the sphenoidal sinus

40 Left internal carotid artery sheath uncovered in lateral sphenoidal sinus wall Anterior sphenoidal sinus wall eroded by tumor growth

41 Post-operative closure of the surgical breach Intraoperative blood loss: 510 ml

42 Post-operative MRI check (7 PO day) PrePrePost- Post-

43 The future of endoscopic treatment of Anterior Skull Base Tumors: Where do we will draw the line? The limits of endonasal skull base surgery have not yet been fully realized 3D stereo-endoscopy is already adding new chances to endoscopic surgery, but surely other technical innovations will early enhance and enrich this surgical field in the next future.

44 CONCLUSIONS So we will move the line forward in EEA according to the constant improvements of surgical skill and technical progress Probably, many anterior skull base tumor shall be resected by open techniques also in the future, but the field of EEA is destined to always wider and safer applications

45 THANK YOU FOR YOUR KIND ATTENTION

10/23/2010. Excludes Single Surgeon Pituitary (N=~140) Skull Base Volume 12 Month UC SF. Patients. Anterior/Midline. Pituitary CSF Leak.

10/23/2010. Excludes Single Surgeon Pituitary (N=~140) Skull Base Volume 12 Month UC SF. Patients. Anterior/Midline. Pituitary CSF Leak. Advances in Pituitary Surgery Ivan El-Sayed MD, FACS Director- Otolaryngology Minimally Invasive Skull Base Surgery Program Otolaryngology-Head and Neck Surgery University of California-San Francisco Minimally