Surgical Resection of Skull Base Malignancy: Perioperative and Long-Term Outcomes

 

Objective Endoscopic and traditional surgical approaches to the skull base are commonly used for resection of a variety of malignant skull base pathologies. However, little has been described regarding both perioperative and long-term outcomes in these patients. The aims of this study are to (1) describe long-term outcomes among patients who have undergone skull base surgery for malignant lesions and (2) evaluate whether endoscopic versus traditional approach is associated with worse long-term outcomes.

Study Design Retrospective review

Methods Seventy patients (46 males, 24 females) who underwent skull base surgery at a tertiary referral medical center with malignant pathology and long-term follow-up were included in the study. Background data collected included patient demographics, surgical approach and pathology. Intraoperative complications included major bleeding, anesthesia, myocardial infarction, and other cardiac complications. Postoperative complications included CSF leak, postoperative bleed and infection, readmission, cranial nerve loss, pneumocephalus, stroke, flap failure, and early and late reoperation. Long-term outcomes included need for revision sinus surgery, secondary therapy and response, osteoradionecrosis, disease recurrence, and death.

Results The mean age was 56.8 years. Average total time of follow-up was 4.2 years (s = 2.76). The most common pathology was squamous cell carcinoma (25/70, 35.7%) followed by sinonasal undifferentiated carcinoma (8/70, 11.4%). Thirty-eight patients (54.3%) received secondary therapy postoperatively. Three patients (4.3%) received chemotherapy, 23 (32.9%) received radiotherapy, and 12 (17.1%) received both chemotherapy and radiotherapy. Five patients (7.1%) are confirmed as deceased in the electronic medical record (EMR). Thirty-seven patients (52.9%) had endoscopic surgery and 33 patients (47.1%) had traditional surgery. Eighteen patients (25.7%) required revision sinus surgery. The average number of revision sinus surgeries was 1.6 (s = 1.12) in the endoscopic group and 1.3 (s=0.59) in the traditional group. Indications for revision sinus surgery were benign sinus disease (11/18, 61.1%), tumor recurrence (5/18, 27.8%), and velopharyngeal insufficiency (2/18, 11.1%). There were six observations (8.6%) of local disease recurrence, three (4.3%) of regional recurrence, and nine (12.9%) of distant recurrence. Between endoscopic and traditional groups, there was no statistically significant difference in intraoperative or postoperative complications, receipt of or response to secondary therapy, or need for revision sinus surgery. Survival analysis showed no significant difference in disease-free survival or overall survival between endoscopic and traditional groups (p = 0.37 and p = 0.34, respectively). The traditional group showed an increased rate of osteoradionecrosis (8/33, 24.2%) compared with the endoscopic group (2/37, 5.4%) (p = 0.038).

Conclusion In patients with skull base malignancy, endoscopic and traditional surgical approaches do not statistically differ with regard to secondary therapy and response, disease-free survival, or overall survival. Traditional resections may be associated with an increased rate of osteoradionecrosis compared with the endoscopic approach. Revision surgery rates are low overall but are an important consideration with regard to patient future quality of life.