Craniofacial resection for malignant melanoma of the skull base: report of an international collaborative study.

OBJECTIVE: To report postoperative mortality, complications, and outcomes in a subset of patients with the histologic diagnosis of malignant melanoma extracted from an existing database of a large cohort of patients accumulated from multiple institutions. DESIGN: Retrospective outcome analysis. SETTING: Seventeen international tertiary referral centers performing craniofacial surgery for malignant skull base tumors. PATIENTS: A total of 53 patients were identified from a database of 1307 patients who had craniofacial resection for malignant tumors at 17 institutions. The median age was 63 years. Of the 53 patients, 25 (47%) had had prior single modality or combined treatment, which included surgery in 22 (42%), radiation in 11 (21%), and chemotherapy in 2 (4%). The margins of resection were close or microscopically positive in 7 (13%). Adjuvant radiotherapy was given in 22 (42%), chemotherapy in 3 (6%), and vaccine or interferon therapy in 2 (4%). Complications were classified into overall, local, central nervous system, systemic, and orbital. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined using the Kaplan-Meier method. Predictors of outcome were identified by multivariate analysis. RESULTS: Postoperative mortality occurred in 3 patients (6%) and postoperative complications were reported in 14 patients (26%). Local wound complications occurred in 6 patients (11%), central nervous system in 7 (13%), systemic in 3 (6%), and orbital in 1 (2%). With a median follow-up of 10 months (range, 1-159 months), the 3-year OS, DSS, and RFS rates were 28.2%, 29.7%, and 25.5%, respectively. The extent of orbital involvement and adjuvant postoperative radiation therapy (PORT) were independent predictors of DSS and OS on multivariate analysis, whereas only PORT was an independent predictor of RFS. Patients treated with PORT had significantly better 3-year OS (39% vs 18%; relative risk, 2.9; P = .007), DSS (41% vs 19%; relative risk, 3.0; P = .007), and RFS (39% vs 15%; relative risk, 4.2; P = .001). CONCLUSIONS: Craniofacial resection in patients with malignant melanoma of the skull base has mortality (6%) and complication rates (26%) comparable to other malignant tumors of the skull base. However, malignant melanoma is associated with a much poorer OS, DSS, and RFS. Adjuvant PORT correlated with improved 3-year OS, DSS, and RFS on multivariate analysis. These factors must be taken into account when considering craniofacial resection in a patient with malignant melanoma invading the skull base.

Orbital preservation in surgical management of sinonasal malignancy.

OBJECTIVE: To determine the oncological and functional outcome when applying defined criteria for orbital preservation during surgical treatment of sinonasal malignancy encroaching on the orbital structures. STUDY DESIGN: Retrospective consecutive review of patients in tertiary care center setting. METHODS: Analysis of 66 patients undergoing surgical treatment for sinonasal malignancy encroaching on the orbit. Orbital preservation was performed in all patients with tumor extension up to and including resectable periorbital involvement. Minimum follow-up was 2 years. Detailed analysis of oncological and functional outcomes is included. RESULTS: Of 66 tumors abutting or invading into the orbit, 54 were amenable for surgical treatment with orbital preservation and the remaining 12 underwent orbital exenteration. Histopathological findings were divided into five subgroups: squamous cell carcinoma, adenomatous carcinomas, sinonasal undifferentiated carcinoma, sarcoma, and other. Squamous cell carcinoma represented the largest subgroup (24 patients), and 5-year overall actuarial survival was not statistically different (P = 1.4; relative risk, 0.713) between patients treated with orbital preservation (53%) versus those undergoing exenteration (46%). Similarly, no difference in survival was found in the adenomatous carcinoma subgroup. Within the orbital preservation group as a whole, local recurrence occurred in 30% patients (16 of 54) compared with 33% patients (4 of 12) treated with orbital exenteration. Of note, eye-sparing surgery was associated with local recurrence at the original site of orbital involvement in only 7.8% of cases (4 of 54). Overall eye function was graded as functional without impairment in 54% of patients (29 of 54), functional with impairment in 37% (20 of 54), and nonfunctional in 9% (5 of 54). The most common abnormality was globe malposition (enophthalmos or hypophthalmos) that was seen in 34 patients (63%) and was associated with the lack of adequate rigid reconstruction of subtotal or total orbital floor or multisegment orbital defects. However, enophthalmos was asymptomatic in the majority of cases, and persistent diplopia occurred in only five patients (9%). Various ocular sequelae were present in 20 of the 49 patients (41%) with functional eyes. Radiation therapy increased the risk of ocular complications, in particular, optic atrophy, cataract formation, excessive dryness, and ectropion. CONCLUSIONS: Selective orbital preservation is oncologically safe and is a worthwhile undertaking in attempting to maintain a functionally useful eye with surgical management of sinonasal malignancy encroaching on the orbit. Consideration should be given to rigid orbital reconstruction in larger defects resulting from subtotal or total orbital floor resection or resections involving two or more orbital walls.

Skull base reconstruction.

Reconstruction of skull base defects following tumor resection is of paramount importance in avoiding serious and life-threatening complications. Cranial base surgery has evolved and outcomes have steadily improved as increasingly reliable reconstructive techniques have been adapted to repair the challenging wounds in this complex anatomic region. The most significant development has been the introduction and refinement of microvascular free tissue transfer to the skull base over the past 15 to 20 years. Free flaps can reliably provide the requisite tissue to not only seal the intracranial space from the subjacent cavities, but also to restore complex craniofacial defects that often result from skull base tumor excision. Advances in alloplast technology have also expanded the armamentarium available to the reconstructive surgeon. In particular, bone substitutes, titanium hardware, and resorbable plate fixation have been shown to be very efficacious when used in carefully selected situations. Finally, tissue sealants and adhesives have become widely used as an adjunctive method to achieve a water-tight dural repair.

Craniofacial surgery for esthesioneuroblastoma: report of an international collaborative study.

Introduction Impact of treatment and prognostic indicators of outcome are relatively ill-defined in esthesioneuroblastomas (ENB) because of the rarity of these tumors. This study was undertaken to assess the impact of craniofacial resection (CFR) on outcome of ENB. Patients and Methods Data on 151 patients who underwent CFR for ENB were collected from 17 institutions that participated in an international collaborative study. Patient, tumor, treatment, and outcome data were collected by questionnaires and variables were analyzed for prognostic impact on overall, disease-specific and recurrence-free survival. The majority of tumors were staged Kadish stage C (116 or 77%). Overall, 90 patients (60%) had received treatment before CFR, radiation therapy in 51 (34%), and chemotherapy in 23 (15%). The margins of surgical resection were reported positive in 23 (15%) patients. Adjuvant postoperative radiation therapy was used in 51 (34%) and chemotherapy in 9 (6%) patients. Results Treatment-related complications were reported in 49 (32%) patients. With a median follow-up of 56 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 78, 83, and 64%, respectively. Intracranial extension of the disease and positive surgical margins were independent predictors of worse overall, disease-specific, and recurrence-free survival on multivariate analysis. Conclusion This collaborative study of patients treated at various institutions across the world demonstrates the efficacy of CFR for ENB. Intracranial extension of disease and complete surgical excision were independent prognostic predictors of outcome.

Outcome of craniofacial surgery in children and adolescents with malignant tumors involving the skull base: an international collaborative study.

BACKGROUND: The aim of the study was to characterize the distribution of anterior skull base (ASB) cancers in the pediatric population and to identify predictors of outcome. METHODS: This was an international study of 1307 patients undergoing craniofacial surgery for malignant tumors; 6.4% (n = 84) among these were

Craniofacial surgery for nonmelanoma skin malignancy: report of an international collaborative study.

BACKGROUND: This study examined the efficacy of craniofacial surgery (CFS) in treating locally advanced nonmelanoma skin cancer (NMSC). METHODS: One hundred twenty patients who underwent CFS for NMSC were identified from 17 participating institutions. Patient, tumor, and treatment information was analyzed for prognostic impact on survival. RESULTS: Surgical margins were negative in 74%, close in 3%, and involved in 23% of patients. Complications occurred in 35% of patients, half of which were local wound problems. Operative mortality was 4%. Median follow-up interval after CFS was 27 months. The 5-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates were 64%, 75%, and 60%, respectively. Squamous cell histology, brain invasion, and positive resection margins independently predicted worse OS, DSS, and RFS. CONCLUSION: CFS is an effective treatment for patients with NMSC invading the skull base. Histology, extent of disease, and resection margins are the most significant predictors of outcome.

Craniofacial resection for malignant paranasal sinus tumors: Report of an International Collaborative Study.

BACKGROUND: Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient-related and tumor-related predictors of prognosis after craniofacial resection (CFR). METHODS: Three hundred thirty-four patients from 17 institutions were analyzed for outcome. Patients with esthesioneuroblastoma were excluded and are being reported separately. The median age was 57 years (range, 3-98 years). One hundred eighty-eight patients (56.3%) had had prior single-modality or combined treatment, which included surgery in 120 (36%), radiation in 79 (23.7%), and chemotherapy in 56 (16.8%). The most common histologic findings were adenocarcinoma in 107 (32%) and squamous cell carcinoma in 101 (30.2%). The margins of resection were close or microscopically positive in 95 (30%). Adjuvant radiotherapy was given in 161 (48.2%) and chemotherapy in 16 (4.8%). Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics, including histologic findings and extent of disease, surgical resection margins, prior radiation, and prior chemotherapy to determine predictive factors. RESULTS: Postoperative mortality occurred in 15 patients (4.5%). Postoperative complications occurred in 110 patients (32.9%). The 5-year overall, disease-specific, and recurrence-free survival rates were 48.3%, 53.3%, and 45.8%, respectively. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS: CFR for malignant paranasal sinus tumors is a safe surgical treatment with an overall mortality of 4.5% and complication rate of 33%. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent are independent predictors of outcome.

Complications of craniofacial resection for malignant tumors of the skull base: report of an International Collaborative Study.

BACKGROUND: Advances in imaging, surgical technique, and perioperative care have made craniofacial resection (CFR) an effective and safe option for treating malignant tumors involving the skull base. The procedure does, however, have complications. Because of the relative rarity of these tumors, most existing data on postoperative complications come from individual reports of relatively small series of patients. This international collaborative report examines a large cohort of patients accumulated from multiple institutions with the aim of identifying patient-related and tumor-related predictors of postoperative morbidity and mortality and set a benchmark for future studies. METHODS: One thousand one hundred ninety-three patients from 17 institutions were analyzed for postoperative mortality and complications. Postoperative complications were classified into systemic, wound, central nervous system (CNS), and orbit. Statistical analyses were carried out in relation to patient characteristics, extent of disease, prior radiation treatment, and type of reconstruction to determine factors that predicted mortality or complications. RESULTS: Postoperative mortality occurred in 56 patients (4.7%). The presence of medical comorbidity was the only independent predictor of mortality. Postoperative complications occurred in 433 patients (36.3%). Wound complications occurred in 237 (19.8%), CNS-related complications in 193 (16.2%), orbital complications in 20 (1.7%), and systemic complications in 57 (4.8%) patients. Medical comorbidity, prior radiation therapy, and the extent of intracranial tumour involvement were independent predictors of postoperative complications. CONCLUSIONS: CFR is a safe surgical treatment for malignant tumors of the skull base, with an overall mortality of 4.7% and complication rate of 36.3%. The impact of medical comorbidity and intracranial tumor extent should be carefully considered when planning therapy for patients whose tumors are amenable to CFR.

Craniofacial surgery for malignant skull base tumors: report of an international collaborative study.

BACKGROUND: Malignant tumors of the skull base are rare. Therefore, no single center treats enough patients to accumulate significant numbers for meaningful analysis of outcomes after craniofacial surgery (CFS). The current report was based on a large cohort that was analyzed retrospectively by an International Collaborative Study Group. METHODS: One thousand three hundred seven patients who underwent CFS in 17 institutions were analyzable for outcome. The median age was 54 years (range, 1-98 years). Definitive treatment prior to CFS had been administered in 59% of patients and included radiotherapy in 367 patients (28%), chemotherapy in 151 patients (12%), and surgery in 523 patients (40%). The majority of tumors (87%) involved the anterior cranial fossa. Squamous cell carcinoma (29%) and adenocarcinoma (16%) were the most common histologic types. The margins of surgical resection were reported close/positive in 412 patients (32%). Adjuvant postoperative radiotherapy was received by 510 patients (39%), and chemotherapy was received by 57 patients (4%). RESULTS: Postoperative complications were reported in 433 patients (33%), with local wound complications the most common (18%). The postoperative mortality rate was 4%. With a median follow-up of 25 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 54%, 60%, and 53%, respectively. The histology of the primary tumor, its intracranial extent, and the status of surgical margins were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS: CFS is a safe and effective treatment option for patients with malignant tumors of the skull base. The histology of the primary tumor, its intracranial extent, and the status of surgical margins are independent determinants of outcome.