Feasibility and Safety Issues of Endoscopic Endonasal Surgery for Sinonasal Malignancy in Low Volume Center

Objective: Endoscopic endonasal surgery (EES) for sinonasal malignancy is still controversial and is often compared with open craniofacial resection as the golden standard. Nevertheless, EES offers relative lower morbidity for selected patients and may be used with curative or palliative intent. EES has limited value in patients with soft tissue invasion and in cases where orbital clearance is indicated for oncological reasons. Even though sinonasal malignancy is rare, it can be successfully managed in a low-volume setting. The prerequisites for this are: (1) dedicated head and neck oncology multidisciplinary team, (2) dedicated skull base surgery multidisciplinary team, (3) mentoring relationship with reference center using telemedicine.

Methods: Patients with advanced sinonasal malignancy that were managed in a tertiary University hospital from 2008 to 2014 were analyzed. We managed 30 patients with sinonasal malignancy (10 adenocarcinomas, 5 melanomas, 2 olfactory neuroblastomas, 8 squamous cell carcinomas, 2 SNUCs, 1 high-grade mucoepidermoid carcinoma, 1 adenoid cystic carcinoma, 1 malignant schwannoma). All patients had advanced T3 or T4 tumors. Patients were treated with EES alone in 20/30 (67%), combined in 2/30 (7%) and craniofacial resection with/without orbital clearance in 8/30 (26%). All patients received adjuvant therapy, either radiotherapy alone (27 patients) or combination with chemotherapy (4 patients). Surgical telementoring of EES was employed in two cases (2/22). Preoperative consultation with a high-volume reference center (University of Pittsburgh) was obtained in in all cases after 2012.

Results: Overall survival was 80%. Six patients died from disease progression, 2 patients are alive with disease and distant metastasis. Locoregional control was achieved in 27/31 patients (87%).

Conclusion: Patients with advanced sinonasal malignancy can be successfully managed with EES or combined approach. Endoscopic surgery has a limited value in patients that need orbital clearance or soft tissue involvement. For selected, advanced and technically challenging cases, telementoring as well as consultation with a high-volume reference center is needed.