Nasal Angiofibromas: A Comparison of Modern Staging Systems in an Endoscopic Era

Introduction: There is an increasing shift toward endoscopic endonasal approaches over external approaches for the treatment of nasal angiofibromas. Despite the changing landscape of surgical approaches, there continue to be multiple staging systems for angiofibromas, most of which were adopted prior to the era of endoscopic removal. While the Radkowski and Andrews staging systems are the most commonly used, the Onerci and UPMC staging systems account for the use of endoscopic approaches. The UPMC staging system is unique in including the vascularity of the tumor following embolization as a prognostic factor. An initial report suggests that the UPMC system is superior to other staging systems for prediction of perioperative morbidities and tumor recurrence. This review aims to compare the clinical utility of these staging systems in a large cohort of patients.

Study Design: Retrospective review

Methods: Retrospective chart review between January 2008 and June 2015. Patient demographics, tumor site and extent, preoperative embolization results, perioperative morbidities and complications were correlated with 4 staging systems. Tumors were staged with the Radkowski, Andrews, Onerci and UPMC staging systems.

Results: 34 patients were identified, all who underwent preoperative embolization of their angiofibroma. 82% (28/34) of patients showed evidence of skull base erosion and 68% (23/34) had preoperative residual vascularity from the internal carotid system. 97% (33/34) of patients underwent an exclusively endoscopic surgical approach with 18% (6/34) of patients requiring planned staged operations. 29% (10/34) of patients had residual disease and 9% (3/34) required further surgical resection. The UPMC staging system was most closely correlated with the requirement for staged operations (p = 0.001), intraoperative blood loss (p < 0.0001) and intraoperative transfusions (p = 0.0001) as well as residual postoperative disease and further surgery for regrowth of disease (p = 0.01) as compared with the other 3 staging systems.

Conclusions: The UPMC angiofibroma staging system accounts for both route of skull base extension and tumor vascularity, two important tumor attributes in the age of preoperative embolization and endoscopic endonasal surgery. The UPMC staging system provides better prognostic information and is more helpful in surgical planning. Discrimination of the different staging systems is hampered by the advanced tumors in this series.