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Oncologic Safety of Endoscopic Removal of Infiltrated Tumor Onto the Periorbita Using Bipolar Cauterization Technique in Sinonasal Malignancy

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Oncologic Safety of Endoscopic Removal of Infiltrated Tumor Onto the Periorbita Using Bipolar Cauterization Technique in Sinonasal Malignancy 臨床耳鼻：第 28 卷 第 1 號 2017 ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• J Clinical Otolaryngol 2017;28:67-75 원 저 Oncologic Safety of Endoscopic Removal of Infiltrated Tumor Onto the Periorbita Using Bipolar Cauterization Technique in Sinonasal Malignancy Sue Jean Mun, MD1, Jaehoon Jung, MD1, Sung-Dong Kim, MD2, Kyu-Sup Cho, MD, PhD2 and Hwan-Jung Roh, MD, PhD1 1Department of Otorhinolaryngology-Head & Neck Surgery, Pusan National University Yangsan Hospital, Yangsan; and 2Department of Otorhinolaryngology-Head & Neck Surgery, Pusan National University Hospital, Busan, Korea - ABSTRACT - Background：The periorbita has been regarded as the crucial structure in decision of orbital exenteration in the patients with sinonasal malignancies. The purpose of this study is to evaluate the oncological safety of endoscopic removal using bipolar cauterization in tumor encroaching on the periorbita without orbital sacrifice through analy- sis of long-term follow-up results of 5 cases. Methods：Retrospective review including demographic data, follow- up results, and local recurrence were performed on the 5 patients of advanced sinonasal cancer who showed bony orbital wall destruction and infiltration onto the periorbita but not transgressing into the orbital fat. Partial or total maxillectomy with orbital preservation was conducted in each patient. The tumor was dissected along the perior- bita using bipolar nasal coagulation forceps by one senior surgeon under the endoscope. Preoperative CT and MRI scan were performed in all cases and retrospectively compared with intraoperative and permanent pathologic reports. Results：The mean age of tumor onset was 51.8 (39-74) years. Histopathology included four squamous cell carcinomas and one adenoid cystic carcinoma. Follow-up period ranged from 31 to 219 months (mean 112.6 months). All cases showed no local recurrence in the orbit but one patient had local recurrence in the pterygopalatine fossa and the other had local recurrence in the neck. Conclusions：Endoscopic removal of infiltrated tumor onto the periorbita using bipolar cauterization technique might be oncologically safe technique in advanced maxillary cancer infiltrated onto the periorbita which is not invading the orbital fat.( J Clinical Otolaryngol 2017;28:67-75) KEY WORDS：EndoscopeㆍOrbitㆍPeriorbitaㆍNasal cavityㆍParanasal sinusㆍNeoplasms. Introduction cision with orbital exenteration was the main stream of treatment in sinonasal malignancy close to the orbit.1,2) In the management of advanced carcinoma (T3- Increased sensitivity of recognizing tumor with high- T4) of the sinonasal tract, the extension of the tumor resolution computed tomography (CT) scan, magnetic into the orbit is very important for oncological safety resonance imaging (MRI) and proven outcomes of com- and quality of life. Before the 1970s, the size and ex- bined surgery with radiotherapy have resulted in orbit- tent of the cancer could not be adequately judged us- al preservation surgery possible since the 1970s.3,4) As ing the earliest sinus tomogram. Therefore, radical ex- a yardstick of actual orbital invasion, a variety of indica- 논문접수일： 2017년 3월 24일 tion of exenteration have been proposed based on in- 논문수정일： 2017년 4월 28일 volvement of bone, periorbita, orbital fat, extraocular 심사완료일： 2017년 5월 24일 muscles, orbital apex, or eyelid. Most of all, periorbita 교신저자：노환중 , 50612 경남 양산시 물금읍 금오로 20 has been considered to be an effective barrier to tumor 부산대학교 의학전문대학원 양산부산대학교병원 이비인후과 학교실 extension into the orbit and has been regarded as the 전화： (055) 360-2132·전송：(055) 360-2930 critical structure in decision of preservation of the eye E-mail：[email protected] in patients with sinonasal malignancy,5-7) but actual in- 67 J Clinical Otolaryngol 2017;28:67-75 A B Fig. 1. 120° Bipolar coagulation nasal forcep (A) and tumor forcep (B). During surgery, infiltrated tumor onto the peri- orbita was removed by stripping the tumor and periorbita with an adequate margin after coagulation using bipolar coagulation nasal forceps. volvement of the periorbita cannot be determined until surgical exploration. 온라인 Still, there were several reports opposing the concept 칼라 of conservative surgery in the aspect of local tumor con- trol.5,8-12) Few studies have been reported the surgical outcomes in terms of endoscopic orbital preservation surgery for sinonasal malignancy. The purpose of this study was to analyze our expe- rience on sinonasal malignancy which is encroaching the orbit and to appraise the oncological safety of en- doscopic orbital preservation surgery using bipolar cau- terization technique. Methods Fig. 2. Intraoperative findings. The periorbita (arrow A retrospective study was performed on the patients head) has been partially sacrificed. The periorbital fat is with sinonasal malignancies who were surgically kept in place by a thin “periorbital fascia” (arrow). At one point, there is a minuscule defect of continuity of treated in between 1997 and 2004. Of these, 5 patients this fascia, and a single blob of fat (F) is visible. who were suspected of periorbital invasion without transgression into the orbital fat were included in this 1A) and removed with tumor forceps (Fig. 1B) under study. Preoperative clinical data, imaging studies in- direct endoscopic view. Using this technique, the out- cluding CT and MRI, TNM stage, operative notes, op- er layer of periorbita could be stripped away from the erative video, permanent pathologic reports, adjuvant inner layer (Fig. 2). Preoperative CT and MRI scan chemotherapy or radiotherapy and follow-up medical were performed in all cases and retrospectively com- records were reviewed for each patient. All patients un- pared with intraoperative and permanent pathologic derwent partial or total maxillectomy via external ap- reports. proach combined with endoscopic technique for peri- orbital area. Results The suspicious lesions on the periorbita were cau- terized with bipolar coagulation nasal forceps (Fig. Two patients were male and 3 patients were female. 68 Sue Jean Mun, et al : Oncologic Safety of Endoscopic Removal in Sinonasal Malignancy Histologic findings included 4 squamous cell carcino- up, no signs of local recurrence or metastasis have mas (SCCs) and 1 adenoid cystic carcinoma (ACC). been observed. Follow-up period ranged from 31 to 219 months (mean 112.6 months). All cases showed no local recurrence Case 2 on the orbit after endoscopic removal. One patient had A 42-year-old woman complaining of right tooth- local recurrence in pterygopalatine fossa (case 2) and ache and ocular pain for 2 months was diagnosed as the other had regional recurrence in the neck (case 3) SCC of right maxillary sinus by dentist. She had un- (Table 1). dergone right medial maxillectomy for right sinonasal inverted papilloma 18 months ago. Despite three cy- Case 1 cle of systemic chemotherapy at other university hos- A 53-year-old woman presented with 5-month his- pital, the tumor resisted the chemotherapy and the pa- tory of left nasal obstruction and cheek swelling. Na- tient was transferred to our clinic. Nasal endoscopy, pa- sal endoscopy revealed a huge mass filling entire left ranasal CT and MRI showed a huge mass filling right nasal cavity with biopsy confirming SCC. Preopera- maxillary sinus and extending to right hard palate, tive paranasal CT and MRI revealed a soft-tissue mass pterygoid plate, pterygoid muscles and orbit. Periorbi- filling the left maxillary sinus with extension to left ta, showing the signal intensity slightly lower than tu- middle and inferior turbinate. CT images showed par- mor on T2-WI and equal to that of muscle on Gadolin- tial bony destruction of the inferior wall of the orbit, ium enhanced T1-WI, was clearly distinct from tumor but periorbita was distinct from the tumor mass on T2 mass (Fig. 3A and 3B). CT Images revealed bony de- weighted image (WI). The tumor was judged not to struction of the inferior orbital wall (Fig. 3C). Even transgress the periorbita based on these radiologic after the intensity modulated radiation therapy (IMRT) findings. Intra-arterial infusion chemotheraphy via left (total 6,200 cGy), tumor size was not decreased and superficial temporal artery was performed but changed the total maxillectomy was performed. Though there into systemic chemotherapy due to blockage of the in- was focal (0.5×0.5 cm) periorbital invasion of tumor, fusion line on day 2. After 4-week systemic chemother- the inner layer was not invaded and the outer layer apy, partial maxillectomy via Caldwell-Luc approach could be stripped from the inner layer without difficulty assisted with endoscopy was performed. Suspicious le- (Fig. 3D). The tumor was recurred in pterygoid fossa 1 sion on the outer layer of the periorbita was cauterized month after the surgery and wide excision of the tumor and easily separated from the inner layer under endo- using endoscopy was followed by radiosurgery (cy- scopic view. The patient received postoperative radio- berknife). During the follow-up period, no recurrence therapy (total 5,940 cGy). During 175 months follow- was observed on the orbit (Fig. 3D). However, the Table 1. Summary of cases: clinical and radiological findings of five patients Case Sex/Age Pathology Site stage Tx. modality S name PMP BD F/U (mo) Recur State 1 F/53 SCC Lt. Max. T4aN0M0 CTx→S→RT PM M+, I- + 175 - NED 2 F/42 SCC Rt. Max. T4aN0M0 CTx→RT→S TM M+, I+ + 31 PPF, DM DWD 3 F/39 SCC Lt. Max. T3N0M0 S→RT PM M-, I+ + 94 Neck node NED 4 M/51 SCC Lt. Max. T3N0M0 S→RT PM M+, I- + 106 - NED 5 M/74 ACC Lt. Max. T3N0M0 S→RT PM M+, I+ + 54 DM DWD ACC : adenoid cystic carcinoma, AWD : alive with disease, BD : bone defect on CT image, CTx : chemotherapy, DM : distant metastasis, DWD : death with disease, I : inferior wall of the periorbita, Lt. : left, M : medial wall of the periorbita, Max. : maxillary sinus, MM : medial maxillectomy, NED : no evidence of disease, PM : partial maxillec- tomy, PMP : final pathologic margin of the periorbita, PPF : pterygopalatine fossa, Rt.
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