Management considerations for malignant tumors of the skull base
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INTRODUCTION
Management considerations for malignant tumors of the skull base Franco DeMonte1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction The last two decades have brought refinements in diagnostic imaging, instrumentation, microvascular reconstruction and an improved overall appreciation of the anatomy of the skull base, both open and endoscopic. These refinements have extended the boundaries of tumor resection and have obviated the need for adjuvant therapies in some patients with benign or low-grade tumors. In patients with high-grade malignancies, however, a carefully constructed multimodal treatment plan, incorporating surgery, radiation therapy and chemotherapy, is necessary in order to maximize patient outcome.
Management paradigms The foundation of all management decisions rests on a representative biopsy of the tumor, properly identified and diagnosed by experts in surgical pathology with experience in head and neck malignancy, neural tumors and sarcoma pathology. Inaccurate diagnoses can lead to both under and over treatment with its attendant toxicity and morbidity. Cohen et al. discuss an example of the problems encountered with misdiagnosis with respect to sinonasal olfactory neuroblastoma. In a series of 12 consecutive patients referred with the “biopsy-proven” diagnosis of olfactory neuroblastoma only two patients, on review by an expert pathologist, did in fact harbor this tumor [1, 2]. Revised diagnoses included pituitary adenoma (3 patients), neuroendocrine carcinoma (3), sinonasal undifferentiated carcinoma (2), and melanoma (2). These revised diagnoses led to significant alterations in the initially proposed treatment plan in 8 of 10 patients including the recommendation of observation alone in the three patients with pituitary adenomas, one of whom had * Franco DeMonte [email protected] 1
Department of Neurosurgery–Unit 442, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
been rendered blind by radiation necrosis of his optic nerves (had been aggressively treated as an olfactory neuroblastoma). A recent review of 397 patients with sinonasal malignancy at M.D. Anderson Cancer Center identified a 24% discordance of major histopathological diagnosis. The 5 year overall survival was reduced in patients with a major change in diagnosis (55% vs 70.8%) highlighting the importance of a correct diagnosis. (Choi et al. unpublished data) Table 1. With the correct pathological diagnosis in hand each patient should be evaluated by members of a multidisciplinary group including medical and radiation oncology, dental oncology, head and neck surgery, neurosurgery and plastic surgery. Additional consultations with speech pathology, audiology, otology, and ophthalmology may be necessary. In this setting the combined expertise of each individual is brought to bear on the patient’s problem and leads to the construction of the optimal management plan for each patient. The skull base neurosurgeon’s main contribution
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