2018 Section 5 - Rhinology and Allergic Disorders

Eur Arch Otorhinolaryngol (2016) 273:4343–4350

them. Radiographic findings were used to define clinical T classification (cT) according to the AJCC 7th edition staging system. The subtype diagnosis of ITAC was confirmed after the surgery on the specimen according to the 2005 WHO nomenclature. Pathological margins reports were used postoperatively to define pathological T classification (pT) according to the AJCC 7th edition staging system. All the procedures were conducted by the senior author (G.M.). The transfacial approach was performed as described by Labayle [ 8 ]. After a lateral rhinotomy, a systematic exenteration of the ethmoid labyrinth was car- ried out. For the endoscopic approach, the first step was a debulking with piecemeal excision of the tumour. Subse- quently, a centripetal bilateral removal of the ethmoid labyrinth, a frontal Draf 3 sinosotomy, a septectomy, and a tumour root identification and resection were carried out to achieve complete exenteration of both olfactory clefts. The septectomy was conducted from the sphenoidal rostrum to the roof and the floor of the nasal fossa. The anterior car- tilaginous part of the septum was preserved. In the case of macroscopic infiltration of the cribriform plate without meningeal involvement, the bony roof was drilled out under microscopic (LR) or endoscopic (ESS) vision. The overlaying dura was covered with a mucosal flap or fascia lata. For both LR and ESS procedures, a systematic resection of the mucosal boundaries was performed to achieve a clear histological analysis of the margins. Nasal packing was kept for 1 day. For patients with dural or meningeal involvement, the surgical resection was performed in collaboration with a neurosurgeon either via LR or via ESS. Craniofacial reconstruction was, respectively, carried out with a pedic- ulated galea aponeurotica for LR or a multi-layered patch with fascia lata and fat for ESS. Fibrin glue was applied in both procedures to sustain the patch. Nasal packing was kept for at least 2 days. Adjuvant three-dimensional (3D) conformal radiother- apy was systematically delivered for all the patients of our study on the tumour site whatever the pT stage. The follow-up was based on repeated clinical exams (na- soendoscopy) and sinonasal MRI every 6 months. The distant metastases were researched on clinical signs (neu- rological signs, osseous pain, and hepatic disorders) and X-ray chest. The disease-free survival time was defined as the interval between the date of surgery and the date of recurrence or the last consultation. The overall survival Surgical procedures Outcomes assessment

difference in patient selection from one study to another made it difficult to compare ESS with the gold standard of treatment (i.e., open approach). In accordance with recent approaches focused on more homogenous histological subtypes and treatment protocols characterization, the purpose of this study was to determine the oncologic outcomes of patients with ethmoid ITAC who were treated with exclusive endoscopic resection. The results were compared with a previous series of patients who were treated through transfacial approach for tumours of equivalent size and extensions.

Methods

Study design

A monocentric, retrospective study was carried out from May 2002 to December 2013, where included the patients with a nasal ITAC who underwent surgical resection with a curative attempt. A minimum follow-up of 12 months was required. Patients with non-resectable tumours or with a recurrence were excluded. Informed consent was obtained from all individual participants prior to inclusion in the study. All the treatment decisions were established after a multidisciplinary discussion. The classification of the American Joint Committee on Cancer (AJCC 7th edition) was used to stage each tumour [ 7 ]. Before September 2008, an external approach with lateral rhinotomy (LR) was systematically selected for T2–T4 patients. Since October 2008, with the new trends in the oncological management of the sinonasal malignant tumours, an endoscopic sinus surgery (ESS) was proposed for the patients with sinonasal ADC. However, the patients were aware that intraoperative findings could lead to a transfacial approach if necessary. The patients who would not have been eligible for an endoscopic approach (i.e., T3 with laterally and anteriorly involvement of the bony structure of the maxillary sinus, T4a with superiorly and anteriorly frontal sinus extension, T4a with skin extension, and T4b with orbital invasion requiring exenteration) were excluded from our 12-year study. This selection was mandatory to avoid misinter- pretation in outcomes comparison of the two procedures (LR and ESS).

Preoperative and postoperative assessment

The preoperative workup consisted of a contrast-enhanced computed tomography (CT) scan of the sinuses, the neck, and the thorax for all patients with axial, sagittal, and coronal projections. A magnetic resonance imaging (MRI) of the sinuses and the brain was also performed for all of

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