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Endonasal endoscopic resection of esthesioneuroblastoma: the Johns Hopkins Hospital experience and review of the literature

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Abstract

Esthesioneuroblastoma is an uncommon malignant tumor originating in the upper nasal cavity. The surgical treatment for this tumor has traditionally been via an open craniofacial resection. Over the past decade, there has been tremendous development in endoscopic techniques. In this report, we performed a retrospective analysis of patients with esthesioneuroblastomas treated with a purely endonasal endoscopic approach and resection at the Johns Hopkins Hospital between January 2005 and April 2010. A total of eight patients with esthesioneuroblastoma, five men and three women, were identified. Six patients were treated for primary disease, and two were treated for tumor recurrence. The modified Kadish staging was A in one patient (12.5%), B in two patients (25%), C in four patients (50%), and D in one patient (12.5%). All patients had a complete resection with negative intraoperative margins. One patient had intraoperative hypertension; there were no perioperative complications. With a mean follow-up of over 27 months, all patients are without evidence of disease. In addition, we reviewed the literature and identified several overlapping case series of patients with esthesioneuroblastoma treated via a purely endoscopic technique. Our series adds to the growing experience of expanded endonasal endoscopic surgery in the treatment of skull base tumors including esthesioneuroblastoma. Longer follow-up on a larger number of patients is required to further demonstrate the utility of endoscopic approaches in the management of this malignancy.

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Acknowledgements

We thank Christine Hann, MD, PhD for critical review of the manuscript.

Author information

Authors and Affiliations

  1. Department of Neurosurgery, Johns Hopkins Hospital, 600 North Wolfe Street, Phipps Building, Room 118, Baltimore, MD, 21287, USA

    Gary L. Gallia & Vafi Salmasi

  2. Department of Otolaryngology, Johns Hopkins Hospital, Baltimore, MD, 21287, USA

    Douglas D. Reh, Wayne Koch & Masaru Ishii

  3. Department of Radiology, Johns Hopkins Hospital, Baltimore, MD, 21287, USA

    Ari M. Blitz

Authors
  1. Gary L. Gallia
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  2. Douglas D. Reh
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  3. Vafi Salmasi
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  4. Ari M. Blitz
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Correspondence to Gary L. Gallia.

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Comments

Alvaro Campero, Tucumán, Argentina

Gallia et al. have performed a retrospective analysis of eight patients with esthesioneuroblastomas who were treated with a purely endonasal endoscopic approach. Six patients were treated for primary disease and the other two were treated for tumor recurrence. The modified Kadish staging applied in this series was A in one patient, B in two patients, C in four patients, and D in one patient. All the eight patients had a complete resection, and a mean follow-up of 27 months showed all of them without evidence of disease. Despite the fact that there are many research papers describing endoscopic resection of esthesioneuroblastomas, this paper is both quite clear and concise and contributes to our understanding of the gold standard treatment of esthesioneuroblastoma nowadays. Furthermore, the description of the surgical technique, given step by step, will certainly help many surgeons around the world who are actually interested in using this approach. As the authors suggested, further research with longer follow-up as well as with a larger number of patients should be carried out in order to demonstrate the efficacious of purely endonasal endoscopic approaches in the management of esthesioneuroblastomas. Moreover, further research should clarify in which cases is better performing a traditional craniofacial resection rather than endoscopic surgery.

Domenico Solari, Paolo Cappabianca, Naples, Italy

In this manuscript, the authors have demonstrated the experience gained with the endoscopic endonasal approach to deal with pathologies involving the anterior area of the skull base either the extracranial but also of intracranial and intradural compartments. This technique, in last decades, has tremendously boosted the development of endo- and para-sinonasal surgery affording its extension among neurosurgeons on one hand and ENT and head and neck surgeons as well.

Even though not original in regard to the multidisciplinary treatment of esthesioneuroblastoma, the article is well conducted giving an overall comprehensive evaluation of the correct management of such a disease. A quite good case series and literature review are reported with detailed information on the technique, results, advantages, and limitations of the approach for such condition. Their strategy resulted to be winning and this has to be much more highlighted, considering the high rate of morbidity that burdens surgery of this area; indeed, they demonstrated skillfulness in complication prevention as well in their treatment. Finally, we would like to remark, once again, the relevant role played by image-guidance systems in providing surgeon with correct orientation.

Leo F. S. Ditzel Filho, Bradley A. Otto, Ricardo L. Carrau, Daniel M. Prevedello, Columbus, OH, USA

In this interesting and well-written article, Gallia et al. report their experience on the purely endonasal endoscopic approach and resection of esthesioneuroblastomas (ENB), as well as a thorough review of the related literature. Their group of eight patients included six primary lesions and two recurrences, half of which were Kadish stage C at presentation. In all cases, negative margins were successfully achieved with no cerebrospinal fluid leaks, meningitis, or other major complication. At a mean follow-up of 27 months, they encountered no evidence of local recurrences or distant metastases.

This report adds to the existing and increasingly growing literature on the efficacy and limitations of endoscopic surgery for resection of skull base malignancies. We agree with their treatment philosophy and use a similar surgical technique and rationale when dealing with these lesions. However, we should make a couple of observations. We do not advocate the routine use of lumbar spinal drains on these cases or the routine use of antibiotic solution irrigations of the nasal cavity. Our patients receive antibiotics only while the nasal packing is in place, which is usually 5 days after surgery.

In addition, we would like to emphasize the ENB propensity for perineural spread, and; therefore, the need for resection of the overlying dura and olfactory bulb for all ENBs (except for rare tumors that arise from the inferior aspect of the middle turbinate). In our experience, a negative MRI is unreliable predicting the presence of intracranial perineural spread. However, we perform a unilateral resection in select patients with unilateral disease (confirmed histologically). The authors did not make clear why patient number 1 did not undergo a skull base resection, even deviating from their own protocol (as described in Methods).

This study reflects the experience of a seasoned and skillful skull base team, which, like ours, includes neurosurgeons and otolaryngologist—head and neck surgeons. It also confirms our belief and philosophy that properly selected tumors can be safely and efficiently addressed endonasally achieving oncologic outcomes that are comparable, if not superior, to traditional approaches. This is evident on their reported experience as well as on their literature review. To this effect, one must observe that the majority of the authors' patients were Kadish stage C at presentation. Despite this advanced disease status, the authors were capable of yielding excellent resection rates with little to no morbidity.

There are, nonetheless, two shortcomings to this report that must be acknowledged: small number of patients and short period of follow-up. Longer follow-up periods are needed to confirm and validate the efficacy of the endoscopic technique in the management of these challenging lesions. We congratulate the authors on their article and on their results.

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Gallia, G.L., Reh, D.D., Salmasi, V. et al. Endonasal endoscopic resection of esthesioneuroblastoma: the Johns Hopkins Hospital experience and review of the literature. Neurosurg Rev 34, 465–475 (2011). https://doi.org/10.1007/s10143-011-0329-2

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