ORLANDO, FL-New endoscopic technology allows skilled surgeons to perform minimally invasive operations such as delicate esthesioneuroblastoma resection-but a leader in the field suggests that just because the procedure can be performed endoscopically doesn’t necessarily mean it should be attempted.
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July 2008
Before endoscopic surgeons declare that the procedure is ready for prime time, Paul A. Levine, MD, the Robert W. Cantrell Professor of Otolaryngology-Head and Neck Surgery and Director of Head and Neck Surgical Oncology in the Department of Otolaryngology-Head and Neck Surgery at the University of Virginia in Charlottesville, said that doctors have to follow the example of famed surgeon Joseph Ogura, MD, by making sure their work conforms to precise scientific and medical and oncologic principles.
Dr. Levine, in delivering the Triological Society Joseph Ogura Lecture at the society’s 111th annual meeting, held during the Combined Otolaryngology Spring Meeting, said these principles include the following:
The doctor-patient relationship, more than ever before, must be based on a mutual trust and understanding to determine a therapeutic decision…. Honesty and integrity are imperative in discussing any therapeutic options, but especially for those options which have not been tested thoroughly enough to support a change from established therapy.
Cancer treatment should be performed by cancer specialists in cancer hospitals where all facilities and support staff are available.
Those who embark upon new treatments must be sure these treatments are based upon solid clinical principles, and reporting outcomes, good or bad, is crucial.
Dr. Levine said that endorsement of endoscopic resection of esthesioneuroblastomas should be withheld until the procedure has secured the long-term results that indicate that the procedure does indeed offer cure rates as high as those achieved with craniofacial resection.
Those of us who have had success in the treatment of esthesioneuroblastoma by performing craniofacial resection agree that this surgery remains the gold standard for treating esthesioneuroblastomas, Dr. Levine said. A review of the outcomes of craniofacial resection of esthesioneuroblastomas show how far we have come in the management of nasal vault malignancies.
The Business of Medicine
He said that the onus to perform minimally invasive endoscopic procedures is fed by the proliferation of a new generation of tools that are pushed by marketing that is part of the business of medicine.
It is clear that the practice of medicine is becoming a business-and a very big one, at that, Dr. Levine said. In terms of dollars spent, health care is the number-one industry in the United States. Individual physicians sometimes reflect this by purchasing and marketing the use of very expensive technological devices-occasionally prior to the approval of the newer technology.
Disease-Free Survival Rates
Dr. Levine demonstrated that the University of Virginia protocol-radiation followed by craniofacial resection and adjunctive chemotherapy based on Kadish staging-has produced impressive disease-free and overall survival practice results.
It is extremely important, in analyzing the remaining studies, to remember that the mean time for recurrence of five years, accepted for most other cancers, is not valid in head and neck cancer. Hence the survival data for 10, 15, and 20 years are important to evaluate treatment efficacy, he said.
We have consistently shared the survival results of our esthesioneuroblastoma group, he said. Recognizing that this was an orphan illness, we knew it would take time and need a concerted data collection effort to assure that our results had significance. It has also been accepted that only follow-up for greater than six years with a substantial cohort size had to be seriously considered as valid evaluated treatment option for this tumor.
Dr. Levine noted that in 2006, the disease-free survival for complete management of 50 consecutive patients was 86.5% at five years. More importantly, we had an 82.6% disease-free survival at 15 years, he said.
In his featured lecture, he provided updated information on 60 patients-treated since 1976-with a 20-year overall disease-free survival of 81.2%. The figures represent only patients for whom the facility has provided complete therapy. It does not include patients who were provided salvage therapy after initial treatment elsewhere.
Dr. Levine cited other major series of esthesioneuroblastoma patients by Lund (2003) noting a five-year disease free survival of 77% and a 10-year survival of 53%; by Broich (1997), who published outcomes of 945 patients treated over a period of more than 70 years and had a five-year survival with radiation and surgery of 72.5%; and by Dulguerov (2001), who performed a meta-analysis of 390 patients between 1990 and 2000 of ethesioneuroblastoma patients in 26 studies and found a five-year disease-free survival of 45%, but when radiation and surgery were combined, there was a 65% survival.
Is Endoscopy the Way to Go?
Given the advances in endoscopic surgery and intraroperative imaging, it is not difficult to understand the tendency to expand the approach with an endoscopic treatment of benign sinonasal disease to that of neoplasm, Dr. Levine said.
He cited a number of series of endoscopic procedures, but the numbers were small (10 to 20 patients), and the follow-up time was relatively short (less than 5 years), which reflects the fact that the procedure has only recently been attempted.
Age and experience may breed some risk aversion, but I hope I am not falling into the trap of slavishly following a conservative approach, he said. As the old conservative has reportedly been quoted: ‘I have seen a lot of progress in my time, and I’ve been against it all.’
Dr. Levine added, In dealing with head and neck cancer for the past 30 years, it has always been my credo that one should continue to maintain an open mind and permit data and outcomes to be one’s guide. Physicians in all professions would do well to maintain and adhere to the axiom of Alexander Pope: ‘Be not the first by whom the new are tried/Nor yet the last to lay the old aside.’
He said that when doctors present options to patients, the first consideration must always be probability of a cure. A second question, especially when dealing with facial tumors, involves morbidity and cosmetic outcomes. He showed examples of several patients who underwent extensive cranial facial resection and had almost no long-term evidence of disfiguring scarring.
Not one patient in our series has been deterred or psychologically prevented from pursuing an active and fruitful life, Dr. Levine said. While no scar is preferable, all things being equal, this should not be a strong selling point or more importantly not be a determining factor in patients’ choice unless the outcomes are comparable.
He said that the decision requires comparisons of cure rates, which for cancer is influenced by the ability to provide clear surgical margins.
Although sometimes difficult during a craniofacial resection or an en bloc dissection, it is possible to have an incised margin that is determined, Dr. Levine said. Going for piecemeal dissection utilizing endoscopic resection, it can be difficult to resect the tumor with surgical margin confidence. Even proponents of this technique have concerns about their confidence in the adequacy of surgical margins obtained utilizing this approach.
A Team Approach
Dr. Levine also said that treatment of complicated tumors requires a team approach. Appropriate treatment requires knowledge of the disease process and the range of other adjuvant therapies and their support staff, he said.
With that in mind, if one proposes to resect these tumors endoscopically, it should be performed by a team that has counseled the patient about the potential need to perform a craniofacial resection-now euphemistically called the open approach-and be prepared to do so while the patient is still on the operating room table during the initial procedure.
Performing the endoscopic approach then finding the tumor to be unresectable via this approach [or] packing the cavity and then referring the patient to a craniofacial team to perform the resection is not appropriate, he asserted.
Surgical resection of rare tumors should always be treated by individuals who have the most experience-whether it be a conventional surgical approach or a microinvasive treatment, said Robert J. Mayer, MD, the Stephen B. Kay Family Professor of Medicine at Harvard Medical School in Boston.
These kinds of surgeries should always be performed at a major cancer hospital because even if there are experienced endoscopic specialists, there is always the possibility that a procedure will turn out to be more complicated than expected and it will need to be converted to a conventional procedure, Dr. Mayer said.
He agreed that doctors and patients need to discuss the options for treatment. These are not usually emergency procedures, he said. There is time to plan and review the procedures, and the patient needs to be involved in the decision.
©2008 The Triological Society