Endoscopic Approach to Remove Intra-extracranial Tumors in Various Skull Base Regions: 10-year Experience of a Single Center.

BACKGROUND: Some problems have been found in the usually adopted combined approach for the removal of intra-extracranial tumors in skull base. Herein, we described a pure endoscopic transnasal or transoral approach (ETA) for the removal of intra-extracranial tumors in various skull base regions. METHODS: Retrospectively, clinical data, major surgical complications, pre- and postoperative images, and follow-up information of a series of 85 patients with intra-extracranial tumors in various skull base regions who were treated by surgery via ETA in our skull base center during the past 10 years were reviewed and analyzed. RESULTS: Gross total tumor removal was achieved in 80/85 cases (94.1%) in this study. All 37 cases with tumors in anterior skull base and all 14 cases with tumors in jugular foramen received total tumor removal. Thirteen and three cases with tumors in clivus received total and subtotal tumor removal, respectively. Total and subtotal tumor removal was performed for 16 cases and 2 cases in lateral skull base, respectively. The complications in this study included: cerebrospinal fluid leakage (n = 3), meningitis (n = 3), and new cranial nerve deficits (n = 3; recovered in 3 months after surgery). In the follow-up period of 40-151 months (median: 77 months), seven patients (8.8%) out of the 80 cases of total tumor removal experienced recurrence. CONCLUSIONS: Complete resection of intra-extracranial growing tumors in various skull base regions can be achieved via the pure ETA in one stage in selected cases. Surgical procedure for radical removal of tumors is feasible and safe.

Clinicopathological significance of p16, cyclin D1, Rb and MIB-1 levels in skull base chordoma and chondrosarcoma.

OBJECTIVE: To investigate the expression of p16, cyclin D1, retinoblastoma tumor suppressor protein (Rb) and MIB-1 in skull base chordoma and chondrosarcoma tissues, and to determine the clinicopathological significance of the above indexes in these diseases. METHODS: A total of 100 skull base chordoma, 30 chondrosarcoma, and 20 normal cartilage tissue samples were analyzed by immunohistochemistry. The expression levels of p16, cyclinD1, Rb and MIB-1 proteins were assessed for potential correlation with the clinicopathological features. RESULTS: As compared to normal cartilage specimen (control), there was decreased expression of p16, and increased expression of cyclin D1, Rb and MIB-1 proteins, in both skull base chordoma and chondrosarcoma specimens. MIB-1 LI levels were significantly increased in skull base chordoma specimens with negative expression of p16, and positive expression of cyclin D1 and Rb (P < 0.05). Significantly elevated MIB-1 LI was also detected in skull base chondrosarcoma tissues, while there was negative expression of p16, cyclin D1 and Rb (P < 0.05). In skull base chordoma, p16 negatively correlated with cyclin D1 and Rb, while cyclin D1 positively correlated with Rb. Additionally, p16, cyclin D1, Rb, or MIB-1 expression showed no correlation with age, gender, or pathological classification of patients with skull base chordoma (P > 0.05). However, p16 and MIB-1 levels correlated with the intradural invasion, and expression of p16, Rb and MIB-1 correlated with the number of tumor foci (P < 0.05). Further, the expression of p16 and MIB-1 appeared to correlate with the prognosis of patients with skull base chordoma. CONCLUSIONS: The abnormal expression of p16, cyclin D1 and Rb proteins might be associated with the tumorigenesis of skull base chordoma and chondrosarcoma.

Anatomical study of endoscope-assisted far lateral keyhole approach to the ventral craniocervical region with neuronavigational guidance.

BACKGROUND: Image-guided neurosurgery, endoscopic-assisted neurosurgery and the keyhole approach are three important parts of minimally invasive neurosurgery and have played a significant role in treating skull base lesions. This study aimed to investigate the potential usefulness of coupling of the endoscope with the far lateral keyhole approach and image guidance at the ventral craniocervical junction in a cadaver model. METHODS: We simulated far lateral keyhole approach bilaterally in five cadaveric head specimens (10 cranial hemispheres). Computed tomography-based image guidance was used for intraoperative navigation and for quantitative measurements. Skull base structures were observed using both an operating microscope and a rigid endoscope. The jugular tubercle and one-third of the occipital condyle were then drilled, and all specimens were observed under the microscope again. We measured and compared the exposure of the petroclivus area provided by the endoscope and by the operating microscope. Statistical analysis was performed by analysis of variance followed by the Student-Newman-Keuls test. RESULTS: With endoscope assistance and image guidance, it was possible to observe the deep ventral craniocervical junction structures through three nerve gaps (among facial-acoustical nerves and the lower cranial nerves) and structures normally obstructed by the jugular tubercle and occipital condyle in the far lateral keyhole approach. The surgical area exposed in the petroclival region was significantly improved using the 0° endoscope (1147.80 mm(2)) compared with the operating microscope ((756.28 ± 50.73) mm(2)). The far lateral retrocondylar keyhole approach, using both 0° and 30° endoscopes, provided an exposure area ((1147.80 ± 159.57) mm(2) and (1409.94 ± 155.18) mm(2), respectively) greater than that of the far lateral transcondylar transtubercular keyhole approach ((1066.26 ± 165.06) mm(2)) (P < 0.05). CONCLUSIONS: With the aid of the endoscope and image guidance, it is possible to approach the ventral craniocervical junction with the far lateral keyhole approach. The use of an angled-lens endoscope can significantly improve the exposure of the petroclival region without drilling the jugular tubercle and occipital condyle.

[Early experience of resection of meningiomas in anterior skull base with intra-extracranial extension via a pure endoscopic endonasal approach].

OBJECTIVE: The early experience of treating anterior skull base meningiomas with intra-extracranial extension via pure endoscopic endonasal approach (EEA) was presented, the safety, feasibility and preliminary treatment outcomes were investigated. METHODS: Eight patients with intra-extradural meningiomas who were admitted from October 2006 to October 2010 were operated on via EEA in one stage in Xuanwu hospital. In this study, the operative technique was described, the degree of resection, complications and the early clinical outcomes were discussed. RESULTS: The complete resection of meningiomas with intra-extracranial extension was achieved in all patients using EEA in one stage. Preoperative visual symptoms were improved or resolved in all cases who presented with preoperative visual complaints. No patient in our series experienced a new neurological deficit after surgery or recurrence and death related meningiomas in the follow-up period (33-75 months). One patient experienced postoperative cerebrospinal fluid leak, delayed meningitis and secondary hydrocephalus which responded to therapy. After treatment, the patient was cure. CONCLUSION: Our limited experience indicates that EEA is feasible and safe for the complete resection of anterior skull base meningiomas with intra- and extracranial extension in one stage in selected cases.

[Transnasal endoscopic anatomy and approaches to the cavernous sinus].

OBJECTIVE: The goal of the current study is to describe the transnasal endoscopic anatomy of the cavernous sinus and to provide the surgical approaches to this area. METHODS: Six silicon-injected adult cadaveric heads (12 sides) were dissected through endoscopic endonasal approach. The cavernous sinus and adjacent structures were exposed; detailed anatomies were demonstrated. High-quality pictures were produced. RESULTS: The cavernous sinus had four walls, namely medial, lateral, posterior and superior walls. Five venous spaces within the sinus were identified by their relation to the carotid artery; those were the medial, lateral, posterosuperior, posteroinferior and anterolateral compartments. Three branches arising from the cavernous segment of internal carotid artery from proximal to distal were meningohypophyseal trunk, inferolateral trunk and McConnell capsular artery. Cavernous sinuses communicated each other by intercavernous sinuses, as well as basilar sinus in middle line, and connected with superior and inferior petrosal sinuses. The third and fourth nerves coursed in superior part of the lateral wall of the cavernous sinus; Meckel's cave located in the posteroinferior part of the lateral wall of the cavernous sinus; V1 sloped to the superior orbital fissure along the lateral wall; the sixth nerve entered the posteroinferior compartment then passed through the internal carotid artery and reached to superior orbital fissure. The approaches to the cavernous sinus included trans-sphenoid-sellar-medial cavernous sinus (medial to the internal carotid artery) and trans-ethmoid-pterygoid-sphenoid-lateral cavernous sinus (lateral to the internal carotid artery). Trans-sphenoid-sellar-medial cavernous sinus approach was able to expose medial compartment and posterosuperior compartment and part of posteroinferior compartment. Trans-ethmoid-pterygoid-sphenoid-lateral cavernous sinus approach was able to expose anteroinferior compartment, lateral cavernous sinus and cranial nerves in lateral wall. CONCLUSION: An understanding of the complex relationships of the cavernous segment of internal carotid artery and cranial nerves in cavernous sinus is paramount for surgically dealing with the disease involved cavernous sinus and adjacent region.

[Surgery for jugular foramen schwannomas via a pure endoscopic transoral approach].

OBJECTIVE: To report a new approach, endoscopic transoral approach for the resection of jugular foramen schwannoma. METHODS: Nine patients with jugular foramen schwannoma (three males and six females, ranging in age from 15 to 61 years old) were treated by direct surgery via a pure endoscopic transoral approach to the jugular foramen. Eight patients complained of hypoglossal nerve palsy with hemiatrophy of the tongue; six cases complained of vagus nerve palsy. Three cases complained of glossopharyngeal nerve palsy, one case complained of facial nerve palsy and hearing loss. RESULTS: The nerves in this area were preserved and radical intracapsular removal of the tumor was performed via endoscopic transoral approach in the nine cases. Tumor removal, as assessed by intraoperative endoscopic inspection, postoperative magnetic resonance imaging and clinical evaluation, revealed all tumors were completely removed. One patient suffered from temporary swallowing difficulties and temporary right vagus palsy 1 day after surgery. There were no others intraoperative and postoperative complications. All patients were followed up for 4 - 29 months, no recurrences were occurred in all these patients and the muscle bulk, motor and the pre-postoperative swallowing function, the vagus palsy, the facial nerve palsy and hearing loss had improved in these patients. CONCLUSION: The endoscopic transoral approach and intracapsular removal of the tumor provided for successful minimally invasive surgery in the jugular foramen schwannomas.

[Salvage management and subsequent treatment after internal carotid artery injury during transnasal endoscopic surgery].

OBJECTIVE: To explore the cause, urgent management, further treatment, outcome and prevention of internal carotid artery (ICA) injury during transnasal endoscopic surgery. METHODS: Five ICA injury happened during transnasal endoscopic surgery of sphenoidal sinus and (or) sellar region, involving 1 case of traumatic optic neuropathy, 1 case of sphenoidal cyst, 1 case of fungal sphenoid sinusitis, 1 case of sellar adenoid cystic carcinoma and 1 case of pituitary tumor. These five cases were from three different hospitals in 1990 - 2009, and the clinical data were collected and retrospectively reviewed. RESULTS: Injury of ICA was related with improper anatomic localization and operative procedures. The locations of injury were in cavernous segment in 3 cases, lacerum segment in 1 case, and clinic segment in 1 case, respectively. The types of injury included 3 cases of bleeding of laceration, 1 case of carotid cavernous fistula and 1 case of pseudoaneurysm. Salvage sphenoid sinus packing with vaseline strip and subsequent intravascular stent graft implantation (2 cases) and endovascular embolization (2 cases) effectively controlled bleeding. Four cases were successfully treated without craniocerebral or ocular complications, only 1 case died of massive blood loss. Among 4 survival cases, 1 patient abandoned further therapy, the other 3 patients were cured of primary disease by reoperation or subsequent treatment. CONCLUSION: Preoperatively, reading carefully the imaging data, intraoperatively, identifying anatomical positions accurately, performing proper operation, and stopping bleeding decidedly, postoperatively, seeking interdisciplinary cooperation to repair vascular damages, all these procedures can effectively reduce the surgical risk of ICA injury.

[Resection of petrous apex cholesteatoma via endoscopic trans-sphenoidal approach].

OBJECTIVE: To introduce our experience of resection of petrous apex cholesteatoma through endoscopic, transnasal, trans-sphenoidal approach in 3 cases, and present a surgical technique of intracystic resection of lesion which yielded a relatively stable long-term outcome. METHODS: Resection of parasellar and petrous apex cholesteatoma via endoscopic transsphenoidal approach was performed in three patients between 2001 and 2006. Surgical technique was as follows: the ethmoid and sphenoid sinuses were opened under endoscope, the petrous apex was accessed by drilling skull base bone at the lateral wall of sphenoid sinus and anterior to the internal carotid artery, the cyst wall of cholesteatoma was incised and expanded, then intracystic removal of cholesteatoma was achieved by the suction, curette and rinsing. RESULTS: The petrous apex cholesteatoma in all 3 patients were removed clearly by endoscopic, transnasal, trans-sphenoidal surgery in one time. Before surgery, two patients with headache and orbital apex syndrome had a remarkable improvement just on the day after operation and completely recovered in 1-4 weeks. No postoperative complications happened in all three patients. All patients had no recurrence in symptoms and no imaging evidences of recurrence at a follow-up of 3 - 7 years. CONCLUSION: The petrous apex cholesteatoma around the parasellar region could be treated by intracystic removal via endoscopic, transnasal, transsphenoidal approach, without the need to strip and remove the cyst wall, and the long-term efficacy was reliable.

[Endoscopic endonasal surgery of trigeminal schwannoma extending into the infratemporal fossa].

OBJECTIVE: To investigate the feasibility of removing extracranial trigeminal schwannomas located in the infratemporal fossa by using a purely endoscopic endonasal approach. METHODS: From November 2004 to July 2009, 8 patients with extracranial trigeminal schwannomas located in the infratemporal fossa (4 male patients and 4 female patients, age ranged 31 - 62 years) were surgically treated by using a purely endoscopic endonasal approach. RESULTS: The maximum diameters of the tumors ranged from 3 to 7 cm. All tumors were completely removed. The operation time was 40 to 120 min, blood loss was 300 to 1500 ml. The clinical symptoms of some patients were relieved or improved. There were no intraoperative and postoperative complications, no deaths in this series. No relapse happened during the follow-up. CONCLUSIONS: The purely endoscopic endonasal approach may provide a minimally invasive and safe approach to remove extracranial trigeminal schwannomas extending into the infratemporal fossa. Radical resection is associated with an excellent long-term outcome in this series.

[Nasal endoscopic resection of extended intradural clival chordoma].

OBJECTIVE: Clival chordoma with intradural extension is very difficult to manage mont. Primary experience of nasal endoscopic surgery for the extra-intra clival chordomas was reported. METHODS: Between 2007 and 2009, 7 patients (4 males and 3 females, ages ranging from 8 to 62 years) with clival extra-intra dural chordoma underwent nasal endoscopic surgeries, 4 of them with combined transoral approach. Charts were reviewed for clinical characteristics, previous therapies, tumor extent, management modalities, complications, and outcome. RESULTS: Total resection of tumor was obtained in 6 cases and subtotal resection in one case. Postoperative follow-up period ranged from 3 to 25 months, median 22 months. One of 6 cases with total resection was recurrent and alive with disease. The patient with subtotal resection died secondary to progression of disease 10 months after the surgery. There was no intraoperative complication. Expect for one case of transient cerebral spinal fluid leakage, no postoperative complication was encountered. CONCLUSIONS: Nasal endoscopic approach may provide a less invasive surgery for clival chordoma with intradural extension. It is safe and effective when it is performed by the surgeons with adequate experience and skills and perioperative managements were taken.

[Nasal endoscopic surgical treatment for chondrosarcoma of paranasal sinus and the skull base].

OBJECTIVE: To discuss the clinical characteristics and treatments for chondrosarcoma of paranasal sinus and the skull base. METHODS: The clinical characteristics of chondrosarcoma of paranasal sinus and skull base in 7 patients underwent endoscopic surgeries between 2001 and 2008 were analyzed. Of the patients, 4 men and 3 women. The patients' age ranged from 18 to 47 years, with a median of 31 years. CLINICAL SYMPTOMS: stuffy, nose bleeding, runny, headache, diplopia, eye outreach limited, blurred vision and even blindness. Surgery methods: under nasal endoscopy, after the attachment sites of the tumors to normal tissues were confirmed, the tumors were peeled off along the clear boundary between the tumors and normal tissues, and the potential residual tumor tissues on bones were cleared by a drill. RESULTS: The patients were followed up postoperatively for 24 to 108 months, with a median of 36 months. Five of 7 patients were no recurrence, 2 were alive with tumor. CONCLUSIONS: Chondrosarcoma of paranasal sinus and skull base can be treated by nasal endoscopic surgery, with good clinical outcome.

[Construction, expression and refolding of recombinant luteinizing hormone releasing hormone-angiogenin toxin].

OBJECTIVE: To express, purify and refold recombinant luteinizing hormone releasing hormone-angiogenin (LHRH-Ang) toxin using E. coli. expression system. METHODS: Recombinant LHRH-Ang expression vector was constructed by replacing of EGF fragment in plasmid pET28a/EGF-Ang with LHRH-PII fragment amplified from plasmid pET28/MSH-PE40. DNA sequencing would be used to verify the correction of fused LHRH-PII-Ang gene. Then, E. coli strain BL21 (DE3) was transformed by pET28a/LHRH-Ang vector. Expression of recombinant LHRH-Ang toxin was induced by Isopropyl-ß-D-Thiogalactoside (IPTG). Refolding effects of gradient dialysis was evaluated by SDS-PAGE. RESULTS: Prokaryotic expression vector pET28a/LHRH-Ang, containing LHRH-PII-Ang fusion gene, was constructed by PCR amplification, restriction enzyme digestion and ligation method. Sequence correction of fusion gene was confirmed by DNA sequencing. After IPGT induction, recombinant LHRH-Ang protein was expressed in BL21 (DE3) as inclusion body, it took 18.43% of total protein. Inclusion body was resolved in 8 mol/L urea and purified by DEAE-Sepharose FF column, the purity was 85%. Recombinant LHRH-Ang toxin was refolded and concentrated by gradient dialysis and PEG 20000, respectively. CONCLUSIONS: Recombinant LHRH-Ang protein was expressed in E. coli and refolded successfully.

[Differential proteins analysis among human nasal inverted papilloma and nasal polyposis and normal nasal mucosa].

OBJECTIVE: Proteomics-based approach was applied to analyze and compare the difference of proteins among human nasal inverted papilloma (NIP), nasal polyposis and normal nasal mucosa, in order to screen different proteins as marker. METHODS: The total proteins of NIP, nasal polyposis and normal nasal mucosa were separated by two-dimensional gel electrophoresis (2-DE). Protein image obtained by using the gel of Calibrated GS-800 Densitometer system, and determined different protein spots. RESULTS: Six differential proteins between NIP and nasal polyp tissue were identified, which were galectin-1, Manganese-superoxide dismutase, galectin-7, trichostatin A, prohibitin and transferring. All of them were increased in NIP. CONCLUSIONS: Six differential proteins were possibly involved in NIP, which provided a new way for discriminating NIP from nasal polyposis. The data would be good for the establishment of NIP protein 2-DE map.

[Significance of conservation of the horizontal bony strut of the basal lamellae in endoscopic sinus surgery].

OBJECTIVE: To explore the methods of maintaining the stability of middle turbinate (MT), reducing the incidence of middle meatus synechia formation and improving the treatment effect of endoscopic sinus surgery. METHODS: A prospective study was conducted in 54 consecutive patients with chronic sinusitis. The patients were allocated into two groups. During the operation, the most anterior and superior MT attachments to the agger nasi region were preserved, and anterior and posterior ethmoidectomy were performed in group A (27 cases 47 sides). Besides above structures, the most posterior and inferior aspects of the basal lamellae and the horizontal boney strut structures of the basal lamellae were preserved in group B (27 cases 51 sides). RESULTS: There were no significant differences between the two groups in age, course and preoperation visual analogue scale (VAS) score. The VAS scores in group A before and 1 year after operation were (6.41 +/- 0.25) and (1.70 +/- 0.36), the difference was significant (t = 10.472, P < 0.05). The VAS scores in group B before and 1 year after operation were (6.78 +/- 0.23) and (0.66 +/- 0.16), the difference was significant (t = 17.195, P < 0.05). The Lund-Kennedy scores in group A and group B one year after operation were (1.85 +/- 0.47) and (0.67 +/- 0.16), the difference was significant (t = 2.290, P < 0.05). The MT position was described as stable, slight drifting laterally and synechia formation. And the incidence of stable, slight drifting laterally and synechia between MT and the nasal lateral wall in group A and group B was 57.4%, 23.4%, 19.1% and 88.2%, 3.9%, 7.8% respectively, the differences were significant (chi(2) = 12.511, P < 0.05) CONCLUSIONS: Conservation of the horizontal bony strut of basal lamellae could better maintain the stability of MT, reduce the incidence of MT drifting laterally and synechia formation, and finally improve the curative effect of endoscopic sinus surgery.

[Clinical study on mometasone furoate nasal spray in the treatment of non-allergic rhinitis].

OBJECTIVE: To evaluate the outcome of mometasone furoate nasal spray (MFNS) used for 3 months on non-allergic rhinitis (NAR). METHODS: In this multicenter study, NAR patients were enrolled from eight hospitals and received MFNS 200 microgram once daily for 3 months. The patients were followed-up for three times (at baseline, month 1 and month 3) to record the symptom scores and nasal endoscopic appearances. At the same time, the adverse events frequency was recorded and analyzed. RESULTS: A total of 188 NAR cases were enrolled in the study. The total nasal symptom score assessment descended significantly at month 1 (1.70 ± 0.75) and month 3 (0.95 ± 0.79) visits versus at baseline (2.67 ± 0.68, Z value were from -11.603 to -10.491, all P < 0.01). The individual symptoms, including nasal stuffiness, nasal discharge, nasal stuffiness-related dizziness or headache, hyposmia, sleep quality, daily life activity, work or study efficiency, mental status, and whole body fatigue, also showed less scores at month 1 and month 3 visits versus at baseline (Z value were from -11.313 to -6.802, all P < 0.01). At the same time, nasal mucosal appearances assessed by endoscopy had lower scores at month 1 (1.40 ± 0.62) and month 3 (0.75 ± 0.71) visits versus at baseline (2.27 ± 0.73, Z value were from -11.484 to -10.002, all P < 0.01). Additionally, adverse events were only observed in 5.3% cases with light rhinorrhagia and nasal dryness. No other side effect was found. CONCLUSIONS: A 3-months administration of intranasal mometasone can effectively and safely improve NAR patients' clinical symptom and nasal mucosal appearances.