Clinician-to-Clinician Update Clinician-to-Clinician Update

Middle-aged Male Patient Remains Tumor Free 3 Years After Endoscopic Endonasal Surgery

February 2015

Contributed by Emiro Caicedo-Granados, MD, and Ramu Tummala, MD

In the past decade, the role of endoscopic endonasal surgery has dramatically increased. Here we describe a case in which the patient was initially offered an open surgical approach for sino-nasal mass resection at another center but instead chose to seek a minimally invasive approach at University of Minnesota Medical Center.

Patient

A 56-year-old male presented to his local hospital with mental status changes and seizures. Magnetic resonance imaging revealed a sino-nasal mass extending through the anterior skull base into his brain (Figure 1). The patient was stabilized and offered an open anterior facial resection to resect the mass. Because of the invasive nature of the surgery, the patient sought a second opinion at University of Minnesota Medical Center.

preop 443
— Figure 1. Preoperative T1-weighted, post-contrast MRI showing the extent of the tumor.
PostOp 443-1
— Figure 2. T1-weighted, post-contrast MRI taken 3 years after minimally invasive endoscopic skull base surgery shows complete tumor resection.

Treatment

The patient was offered resection via a minimally invasive endoscopic anterior skull base approach, to which he agreed. The surgical team achieved a total resection of the patient’s tumor, with no facial or skull incisions and no brain retraction. The patient recovered without sequelae and was discharged after 4 days. 

Following surgery, the patient underwent postoperative radiotherapy because of the recurrent nature of the tumor and its invasion into the brain. He received adjuvant intensity-modulated radiotherapy to the tumor bed using state-of-the-art Tomotherapy® equipment (Accuray, Sunnyvale, California). He experienced minimal side effects during treatment.

The patient has been free of tumors for 3 years (Figure 2) and has returned to all of his normal life activities.

Discussion

The endonasal approach often allows resection without damaging adjacent healthy tissues, which is not the case with conventional open surgery in which the skin, bone, and sometimes dura mater are opened to provide access to the tumor, producing a risk of tumor seeding.1 From the patient’s perspective, decreased surgery time, decreased length of stay, increased patient comfort and lack of external incision are significant advantages of the endoscopic endonasal approach.2 Endoscopic methods produce results comparable to those of open surgical approaches for tumors of the paranasal sinuses, the sella, and the skull base while providing increased benefits to the patient.3

References

1. Lund V, et al. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl. 2010;22:1-143.

2. Zada G, Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg. 2003;98:350-358.

3. Wagenmann M, Schipper J. The transnasal approach to the skull base. From sinus surgery to skull base surgery. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2011;10:Doc08. doi: 10.3205/cto000081.

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