2018 Section 5 - Rhinology and Allergic Disorders

Eur Arch Otorhinolaryngol (2016) 273:4343–4350

Postoperative outcomes and follow-up

septum, and/or the cribriform plate) in 39 patients (90 %). The cribriform plate was specifically involved in 26 patients (60 %). The site of tumour origin was the ethmoid sinus in two cases and the sphenoid sinus in two cases. There was no statistical difference in terms of staging distribution between LR and ESS groups (Table 1 ). The cT staging mismatched the pT staging in 22 cases (12 under- estimations and 10 overestimations) in particular for pT3 lesions wherein the anterior skull base involvement was often misinterpreted (Table 2 ). Imaging sensibility and positive predictive value (PPV) for cribriform plate involvement were, respectively, 65.5 and 95 %. Sensibility and PPV for meningeal infiltration were 80 %. Sinus invasion (frontal, maxillary, or sphenoid) was overesti- mated with CT scan and MRI in five cases. The surgical resection was performed as described in the methods section. A drilling-out of the cribriform plate was conducted in 34 patients (6/10 pT2, 26/26 pT3, and 2/2 pT4a) and was covered with a mucosal flap harvested from the contralateral inferior turbinate in 23 patients (1 pT2 and 22 pT3) or with a fascia lata patch in four patients (2 pT3 and 2 pT4a). A meningeal resection was performed for the five pT4b patients with a meningeal involvement (3LR, 2ESS). A pediculated galea aponeurotica (3LR) or a multi- layered patch with fascia lata and fat (2 ESS) were used to repair the dural defect. As all the patients were cN0, no neck dissection was required. The systematic histological analysis of the additional mucosal resection around the tumour ground were staged R0 in all the cases.

The mean postoperative hospital stay was significantly increased for patients treated with LR surgery (Table 1 , p = 0.01). Whether the patient was treated with LR or ESS surgery, the mean hospital stay was also increased when a meningeal reconstruction was performed (7.6 ± 1.5 days with a meningeal plasty versus 5.6 ± 1.9 without a plasty, p = 0.03). No CSF leak was diagnosed in the postoperative course. Persistent crusting considered as a minor compli- cation was observed for all the patients. Two major com- plications occurred for two patients treated with LR surgery: one orbital hematoma and one wound infection with a cutaneous fistula. The mean follow-up was 6.6 ± 3.4 years (from 1 to 12 years). Adjuvant RT was delivered on the primary tumour site in all patients with a mean dose of 58.6 ± 5.2 Gy (from 45 to 66 Gy) with 3D conformal protocols. The clinical target volume assessed on the final histological examination consisted of the whole resection cavity and involved paranasal sinuses. The mean delay between surgery and RT was 47 ± 15 days (from 22 to 86 days). Local recurrences were diagnosed in nine patients (21 %), (five from the LR group and four from the ESS group). They were all ipsilateral to the primary lesion. The mean delay to recurrence was 31.6 ± 15.8 months (from 8.5 to 56.5 months). They originated from the sphenoid region in four patients, the ethmoid roof in four patients, and the maxillary sinus in one patient (Table 3 ).

Table 3 Overview of the 12 recurrences, their treatment, and their final follow-up status

Initial pT classification

Surgical approach

Site of 1st R

Treatment of 1st R Site of 2nd R Treatment of 2nd R

FU (months)

FU status

pT2

LR

M (lung /brain)

CT-RT

–

–

143

DOD

pT4b

LR

T (sphenoid)

ESS

T (sphenoid) ESS

142

DOC

pT3

LR

T (ethmoid roof)

ESS

–

–

127

NED

pT3

LR

T (ethmoid roof)

ESS

T (sphenoid) Sc

113

DOD

pT2

LR

N

MRND-RT

–

–

112

DOC

pT3

LR

T (ethmoid roof) ? M (lung)

ESS-CT

–

–

104

AWD

pT3

LR

T (maxillary sinus)

Maxillectomy- MRND-RT

T ? N

RT

101

DOD

pT2

LR

N ? M (brain)

CT-RT

–

–

71

DOD

pT3

ESS

T (ethmoid roof)

ESS

T (frontal brain)

RT

70

NED

pT4a

ESS

T (sphenoid)

RT

–

–

67

DOD

pT3

ESS

T (sphenoid)

ESS

T (sphenoid) SC

63

DOD

pT2

ESS

T (sphenoid)

ESS

T (sphenoid) RT

62

NED

AWD alive with disease, DOC death other cause, DOD death of disease, CT-RT concomitant chemotherapy and radiation therapy, ESS endo- scopic sinus surgery, FU follow-up, LR lateral rhinotomy, M distant recurrence, MRND-RT modified radical neck dissection followed by radiation therapy, N neck recurrence, NED no evidence of disease, pT pathological staging based on histological analysis of tumour specimen and margins, R recurrence, RT radiation therapy, SC supportive care, T local recurrence

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