Survey of Skull Base Surgeons’ Management of Carcinomas Involving the Cavernous Sinus

Introduction: Carcinomas involving the cavernous sinus present a challenge for skull base surgeons given difficulty in obtaining a complete resection without compromising important neurovascular structures. Due to the morbidity and mortality of these operations, chemotherapy, radiotherapy, immunotherapy, and more rarely, open or endoscopic surgery have been employed in the management of such tumors. Although limited to case reports and small series, radical resection of the cavernous sinus has been presented as an option for some patients. We aimed to study the factors that impact surgeons’ willingness to perform cavernous sinus exenteration (CSE) under different clinical scenarios.

Methods: We conducted an online survey from April to July 2021. We surveyed members of the Skull Base Congress, a global community of skull base surgeons, and the North American Skull Base Society. We included surgeons who had cared for patients with carcinomas involving the cavernous sinus. Descriptive statistics and content analysis were used to analyze quantitative and qualitative questions, respectively.

Results: Of 126 respondents, 112 met inclusion criteria. Of those, 80% (90/112) finished the entire survey. Of these, 54% were otolaryngologists and 43% were neurosurgeons. Also, 86% practiced in an academic setting. A third were in practice for 10 to 20 years, while the remainder were roughly equally distributed among 0 to 5, 5 to 10, and >20 years in practice. Surgeons’ willingness to perform CSE under different scenarios is reported in [Table 1]. Those who would not offer CSE cited not believing they could obtain oncologic margins and not wanting to expose patients to the procedure's morbidity. Further, 45% had at least one patient who underwent CSE with estimated survival of these patients shown in [Fig. 1]. Complications included chronic intractable pain, cerebrospinal fluid leak, cerebrovascular accident, or intraoperative/postoperative death within 30 days. Of them, 60% agreed that the availability of immunotherapy and genomic sequencing has affected their willingness to offer CSE.

Conclusion: Overall, most surgeons surveyed were unwilling to offer CSE. Likelihood of offering CSE increased for cases of persistent or recurrent disease. Given the rarity of carcinomas involving the cavernous sinus and the paucity of data on CSE, the results of this international survey of skull base experts may provide more information for providers and patients when making complex treatment decisions.

Table 1

	Yes, I would offer CSE	No, I would NOT offer CSE	It depends[a]	I would consider reirradiation, chemotherapy, or immunotherapy first
Primary carcinomatous disease with cavernous sinus extension (n = 108)	6 (6)	67 (62)	35 (32)	N/A
Perineural extension of disease into cavernous sinus from a primary carcinoma (n = 100)	6 (6)	67 (67)	27 (27)	N/A
Persistent or recurrent carcinoma in cavernous sinus after prior treatment (n = 97)	16 (16)	22 (23)	29 (30)	30 (31%)

Note: Data presented as n (%) based on respondents for each question.

^aFactors influencing decision: histology, patient characteristics (e.g., age), and status of the internal carotid artery and cranial nerves.

Fig. 1

 

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No conflict of interest has been declared by the author(s).

Publication History

Article published online:
15 February 2022