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
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
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
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
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)
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, 991-1005, 2008
Schwartz TH, Fraser JF et al: Neurosurgery 62, 991-1005, 2008
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, 152-160, 2009
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, 152-160, 2009
Present limits in the endoscopic approach to anterior skull base tumors Anatomy Pathology Oncological principles Patient Surgeon Technical Equipment Surgery
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 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
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
(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
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
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 (*)
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 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, 286-300, 2011
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?)
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
AN EXAMPLE: L.P., male, 39 years old NON SECRETING HYPOPHYISEAL MACROADENOMA
NASAL TIME OPTICS: 0 TRANSNASAL ENDOSCOPIC APPROACH NASAL SEPTUM UPPER TURBINATE SPHENOID OSTIUM
INTER-SPHENOIDAL SEPTUM ANTERIOR WALL OF SELLA TURCICA SPHENOIDAL TIME: REMOVAL OF THE SPHENOIDAL SEPTUM AND ACCESS TO ANTERIOR WALL OF SELLA TURCICA
CRESTA INTERSPHEN. ANT. WALL OF SELLA TURCICA
THIN BONY LAYER DURA
DURA OF THE SELLA
DECOMPRESSION AND COLLAPSE OF SELLAR CEILING
DECOMPRESSION OF INTRACRANIAL NERVOUS STRUCTURES
BRAIN MRI 5 MONTHS AFTER SURGERY
GIANT NASOPHARYNGEAL ANGIOFIBROMA WITH SKULL BASE EXTENSION (Extradural Type III acc. to Andrews, 1989) Male, 17 y. old TC imaging
MR imaging
MR imaging
MR imaging
Selective right carotid artery angiography Left carotid artery Right and left vertebral arteries
Pre-operative angiographic embolization of the right internal maxillary artery Post Pre
Surgical navigator
Paralatero-nasal approach through right maxillary bone volet
Uncovered dural lining of the clivus behind the posterior wall of the sphenoidal sinus
Left internal carotid artery sheath uncovered in lateral sphenoidal sinus wall Anterior sphenoidal sinus wall eroded by tumor growth
Post-operative closure of the surgical breach Intraoperative blood loss: 510 ml
Post-operative MRI check (7 PO day) PrePrePost- Post-
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.
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
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