Abstract：
OBJECTIVE: Sinonasal malignancies that extend to the anterior skull base frequently require neurosurgical intervention. The development of techniques for craniofacial resection revolutionized the management of these neoplasms, but modern and long-term data are lacking, particularly those related to the incorporation of endoscopic techniques and novel adjuvant chemotherapeutics into management schema. The present study was performed to better define the utility of surgical management and to determine factors related to outcome.
METHODS: Patients who underwent surgery between 1993 and 2020 were included in this retrospective cohort study. Only patients with greater than 6 months of clinical and radiological follow-up were included. Outcome measures included progression, survival, and treatment-related complications.
RESULTS: Two hundred twenty-five patients were included. The mean clinical follow-up was 6.5 years. The most common histological diagnosis was olfactory neuroblastoma (33%). Overall, metastatic disease and brain invasion were present in 8% and 19% of patients, respectively, at the time of surgery. A lumbar drain was used in 54% of patients. When stratified by decade, higher-stage disease at surgery became more frequent over time (15% of patients had metastatic disease in the 3rd decade of the study period vs 4% in the 1st decade). Despite the inclusion of patients with progressively higher-stage disease, median overall survival (OS) remained stable in each decade at approximately 10 years (p = 0.16). OS was significantly worse in patients with brain invasion (p = 0.006) or metastasis at the time of surgery (p = 0.014). Complications occurred after 28% of operations, but typically resulted in no long-term negative sequelae. Use of a lumbar drain was a significant predictor of complications (p = 0.02). Permanent ophthalmological disabilities were observed after 4% of surgical procedures. One patient died during the perioperative period. Finally, major complications (Clavien-Dindo grade ≥ IIIb) decreased from 27% of patients in the 1st decade to 10% in the 3rd decade (p = 0.007).
CONCLUSIONS: The surgical management of sinonasal malignancies with anterior skull base involvement is effective and generally safe. Surgical management, however, is only one facet of the overall multimodal management paradigms created to optimize patient outcomes. Survival outcomes have remained stable despite more extensive disease at surgery in patients who have presented in recent decades. The safety of such surgery has improved over time owing to the incorporation of endoscopic surgical techniques and the avoidance of lumbar spinal drainage with open resection.
METHODS: Patients who underwent surgery between 1993 and 2020 were included in this retrospective cohort study. Only patients with greater than 6 months of clinical and radiological follow-up were included. Outcome measures included progression, survival, and treatment-related complications.
RESULTS: Two hundred twenty-five patients were included. The mean clinical follow-up was 6.5 years. The most common histological diagnosis was olfactory neuroblastoma (33%). Overall, metastatic disease and brain invasion were present in 8% and 19% of patients, respectively, at the time of surgery. A lumbar drain was used in 54% of patients. When stratified by decade, higher-stage disease at surgery became more frequent over time (15% of patients had metastatic disease in the 3rd decade of the study period vs 4% in the 1st decade). Despite the inclusion of patients with progressively higher-stage disease, median overall survival (OS) remained stable in each decade at approximately 10 years (p = 0.16). OS was significantly worse in patients with brain invasion (p = 0.006) or metastasis at the time of surgery (p = 0.014). Complications occurred after 28% of operations, but typically resulted in no long-term negative sequelae. Use of a lumbar drain was a significant predictor of complications (p = 0.02). Permanent ophthalmological disabilities were observed after 4% of surgical procedures. One patient died during the perioperative period. Finally, major complications (Clavien-Dindo grade ≥ IIIb) decreased from 27% of patients in the 1st decade to 10% in the 3rd decade (p = 0.007).
CONCLUSIONS: The surgical management of sinonasal malignancies with anterior skull base involvement is effective and generally safe. Surgical management, however, is only one facet of the overall multimodal management paradigms created to optimize patient outcomes. Survival outcomes have remained stable despite more extensive disease at surgery in patients who have presented in recent decades. The safety of such surgery has improved over time owing to the incorporation of endoscopic surgical techniques and the avoidance of lumbar spinal drainage with open resection.
摘要：
目的：扩展到前颅底的鼻窦恶性肿瘤通常需要神经外科手术。颅面切除技术的发展彻底改变了这些肿瘤的管理，但是缺乏现代和长期的数据，特别是与将内窥镜技术和新型辅助化学疗法纳入管理方案有关的那些。进行本研究是为了更好地定义手术管理的效用并确定与结果相关的因素。
方法：这项回顾性队列研究包括1993年至2020年接受手术的患者。仅包括临床和放射学随访超过6个月的患者。成果指标包括进展，生存,和治疗相关的并发症。
结果：纳入了220名患者。平均临床随访时间为6.5年。最常见的组织学诊断是嗅觉神经母细胞瘤（33％）。总的来说,8％和19％的患者存在转移性疾病和脑侵袭，分别,在手术的时候。54％的患者使用了腰椎引流。当按十年分层时，随着时间的推移,手术时更高阶段的疾病变得更常见(15%的患者在研究期间的第3个10年有转移性疾病,而4%的患者在第1个10年有转移性疾病).尽管包括患有逐渐升高的疾病的患者，中位总生存期(OS)在大约10年时每十年保持稳定(p=0.16).手术时脑浸润(p=0.006)或转移(p=0.014)患者的OS显著恶化。28％的手术后发生并发症，但通常不会导致长期的负面后遗症。使用腰椎引流是并发症的重要预测指标（p=0.02）。在4％的外科手术后观察到永久性眼科残疾。一名患者在围手术期死亡。最后,主要并发症(Clavien-Dindo分级≥IIIb)从第一个十年的27%下降到第三个十年的10%(p=0.007).
结论：手术治疗前颅底受累的鼻窦恶性肿瘤是有效且总体安全的。手术管理，然而,只是为优化患者结果而创建的整体多模式管理范例的一个方面。尽管近几十年来在手术中出现了更广泛的疾病，但生存结果仍保持稳定。随着时间的推移，这种手术的安全性得到了改善，这是由于内窥镜手术技术的结合以及避免了开放式切除术的腰椎引流。
方法：这项回顾性队列研究包括1993年至2020年接受手术的患者。仅包括临床和放射学随访超过6个月的患者。成果指标包括进展，生存,和治疗相关的并发症。
结果：纳入了220名患者。平均临床随访时间为6.5年。最常见的组织学诊断是嗅觉神经母细胞瘤（33％）。总的来说,8％和19％的患者存在转移性疾病和脑侵袭，分别,在手术的时候。54％的患者使用了腰椎引流。当按十年分层时，随着时间的推移,手术时更高阶段的疾病变得更常见(15%的患者在研究期间的第3个10年有转移性疾病,而4%的患者在第1个10年有转移性疾病).尽管包括患有逐渐升高的疾病的患者，中位总生存期(OS)在大约10年时每十年保持稳定(p=0.16).手术时脑浸润(p=0.006)或转移(p=0.014)患者的OS显著恶化。28％的手术后发生并发症，但通常不会导致长期的负面后遗症。使用腰椎引流是并发症的重要预测指标（p=0.02）。在4％的外科手术后观察到永久性眼科残疾。一名患者在围手术期死亡。最后,主要并发症(Clavien-Dindo分级≥IIIb)从第一个十年的27%下降到第三个十年的10%(p=0.007).
结论：手术治疗前颅底受累的鼻窦恶性肿瘤是有效且总体安全的。手术管理，然而,只是为优化患者结果而创建的整体多模式管理范例的一个方面。尽管近几十年来在手术中出现了更广泛的疾病，但生存结果仍保持稳定。随着时间的推移，这种手术的安全性得到了改善，这是由于内窥镜手术技术的结合以及避免了开放式切除术的腰椎引流。
