1. The International Federation
of Head and Neck Oncologic Societies
Current Concepts in Head and Neck Surgery and Oncology 2012
Skull Base Surgery
Jatin P. Shah

2. Nasal Cavity
and Paranasal Sinuses
2012

3. Tumors of the Nasal Cavity and
Paranasal Sinuses
Site Histology
2012

4. Tumors of the Maxilla
Routes of Spread
2012
Ohngren’s Line

5. Tumors of the Ethmoid
Routes of Spread
2012

6. Tumors of the Frontal and
Sphenoid Sinuses
Routes of Spread
2012

7. Carcinoma of the Nasal Cavity and
Paranasal Sinuses
2012 Patterns of Failure

8. Tumors of the
Nasal cavity and Ethmoid
2012

9. Chondrosarcoma
C T Scan- Axial View
Soft Tissue and Bone Windows
2012

10. Chondrosarcoma
C T Scan- Coronal View
Soft Tissue and Bone Windows
2012

11. Adenocarcinoma
of Ethmoid
MRI with contrast
Axial, Sagittal
and Coronal Views
2012

12. Complex Anatomy
at the Skull Base
• Fear of CSF Leak
• Fear of
Haemorrhage
• Inadequate
exposure
• Incomplete
Resection
2012

13. Indications for Skull Base Surgery
• Benign & malignant tumors approaching
or involving skull base
• Intracranial tumors with
extracranial extension
• Neurovascular tumors
2012

14. Advantages of
External Skull Base Surgery
• Wide exposure
• Wide resection ( Dura, Brain, Orbit,
Bone)
• Monoblock resection
• Secure margins
• Dural repair / graft
• Reconstruction with free flaps
• Time tested techniques
2012
• Outcomes data available

15. Mucoepidermoid Carcinoma
of the Lacrimal Sac
Monoblock Resection
2012

16. Tumors Involving the Skull Base
Sites
• Mucosa of the nasal cavity &
paranasal sinuses
• Epithelium & glandular tissues
• Skin of the face or scalp
• Bone/cartilage
• Dura
• Blood vessels/nerves
• Orbit
2012 • Notochord

17. 2012

18. 2012

19. 2012

20. 2012

21. Adenocarcinoma of Ethmoid
2012

22. Malignant Fibrous Histiocytoma
2012

23. Carcinoma of the Frontal Sinus
2012

24. Squamous cell Carcinoma of Frontal Sinus
2012

25. Introduc)on
2012
1960
Skep)cism
Enthusiasm
1970
Aggressiveness
1980
Techniques
Experience
Techniques
-­‐
1990
Complica)ons
Surgery
Reali)es
Outcomes
-­‐
QOL
Cost
effec)veness
2000
Ethics
Progress
in
Skull
Base
Endoscopic
2005
Approaches
2012
Where
do
we
go
next?

26. Mortality/Morbidity
From
External
Skull
Base
Surgery
Complica)ons
+40%
Overall
Major
+25%
Complica)ons
Minor
+15%
Complica)ons
Mortality
2012
<
10%

27. Technical Variations
to reduce morbidity and
improve appearance and function
• Incisions
• Craniotomy
• Craniectomy
• Dura
• Brain
• Orbit
2012 • Reconstruction

28. 2012

29. 2012

30. Esthetic Incisions
2012

31. Chondrosarcoma of the Ethmoid
2012

32. Skull Base Reconstruction
• Pericranial flap
• Galeal Pericranial flap
• Fasciocutaneous free flap
• Myucutaneous free flap.
2012

33. 2012

34. Nasal Exenteration and Radial
Forearm
Free Flap Reconstruction
2012

35. Large Volume Three
Dimensional Defect
2012

36. Reconstruction with
Rectus Abdominis Free Flap
2012

37. Minimally Invasive Surgery
Nasal endoscopic resection
RT or Chemo/RT
2012

38. Minimally Invasive Surgery
Problems:
• Case Selection
• Histology
• Expertise
• Benchmark
Criteria
2012
• Benchmark Data

39. Improvement in Local Control
Case Selection:
• Histology
• Extent
• Margins?
• Adjuvant Chemo/RT
2012

40. Results of Skull Base Surgery for Malignant
Tumors
1960 - 2000
Time 1960-1970 1970-1980 1980-1990 1990-2000
Authors Ketcham Sisson Shah International
Cheesman Janecka Study
Gussack
Survival 49% 49% 56-70% 59% cause
specific
2012
Adapted from O’Malley BV, Janecka IP: Seminars in Surg
Onc 1995; 11:221-227

41. International Study of Skull Base Surgery
for Malignant Tumors
2012 Approached
Participated

42. ICSG for CFS Survival
1.0
0.9
0.8
Proportion Surviving
0.7
5-year disease-specific survival 60%
0.6
0.5
0.4
0.3
0.2
0.1
0.0
2012 0 12 24 36 48 60 72 84 96 108 120
Follow up Interval (Months)

43. ICSG for CFS DSS: Impact of
Histology
1.0
0.9
Group I: ENB, Skin,
0.8 79% Low grade sarcoma
Proportion Surviving
0.7
0.6
0.5
0.4 Group 2:Hi grade sarcoma, SCC,
57% Salivary, Other malignancies
0.3
0.2
Group 3:Mucosal melanoma,
0.1 p<.0001 30% Undifferentiated/anaplastic
0.0
0 12 24 36 48 60 72 84 96 108 120
2012
Follow-up Interval (Months)

44. ICSG for CFS DSS: Impact of
Intracranial Extension
1.0
0.9
0.8
Proportion Surviving
0.7 None 66%
0.6 Bone 59%
0.5
Dura 54%
0.4
0.3
0.2 Brain 29%
0.1 p<.0001
0.0
2012 0 12 24 36 48 60 72 84 96 108 120
Follow-up Interval (Months)

45. ICSG for CFS
DSS: Impact of Surgical Margin
Status
1.0
0.9
Proportion Surviving
0.8
Negative 74%
0.7
0.6
0.5
Positive 38%
0.4
0.3
0.2
0.1
0.0
2012 0 12 24 36 48 60 72 84 96 108 120
Follow-up Interval (Months)

46. ICSG for CFS
Prognostic Predictors of Disease-specific Survival
Prognostic covariate RFS DSS OS
Uni Multi Uni Multi Uni Multi
Age NS - NS - NS -
Gender NS - NS - NS -
Medical Comorbidity NS - NS - SIG SIG
Anatomic Location SIG NS SIG NS SIG NS
Histology SIG SIG SIG SIG SIG SIG
Orbital Involvement SIG NS SIG NS SIG NS
Intracranial SIG SIG SIG SIG SIG SIG
Involvement
Surgical Margins SIG SIG SIG SIG SIG SIG
2012

47. Esthesioneuroblastoma
Local Recurrence
2012

48. Craniofacial
Surgery:
1973
–
2000
Site
of
Failure
LOCAL
REGIONAL
39
3
2
3
11
6
No
failure
=
86
(51%)
19
DISTANT
2012

49. 2012

50. Progress in Skull Base
Surgery
Hampered by
Biology Physiology
of the of the
disease Cerebrovascular
system
2012

51. How to Improve Outcomes in
Anterior Skull Base Surgery
• Reduction in Morbidity/ Mortality
• Improvement in Local Control
• Improvement in Survival
• Improvement in Quality of Life
2012

52. Improvement in Survival
Case selection:
• Histology
• Extent
• Induction Chemotherapy
• Concurrent Chemo/Radiotherapy
2012

53. To Improve Outcomes in
Skull Base Surgery
In the future we will need to:
• Integrate Technological Innovations
• Integrate Biological Advances
• Reduce complications and morbidity
• Minimize sequelae of surgery
• Improve cost effectiveness
2012 • Increase cure rates