Download PDF
J Neurol Surg B Skull Base 2024; 85(05): 445-457
DOI: 10.1055/a-2114-4563
Original Article

Does Time to Initiation of Adjuvant Radiotherapy Affect Reconstruction Outcomes after Endoscopic Resection of Skull Base Malignancies?

Franco Rubino
1   Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Bledi Brahimaj
1   Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Ehab Y. Hanna
2   Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Shirley Y. Su
2   Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Jack Phan
3   Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
David R. Grosshans
3   Division of Radiation Oncology, Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Franco DeMonte
1   Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
,
Shaan M. Raza
1   Division of Surgery, Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Introduction and Objective It is unclear if the length of the time interval to initiation of adjuvant radiation therapy (RT) after endoscopic endonasal surgery affects reconstruction outcomes. In this study we present our experience with adjuvant RT after endoscopic endonasal procedures, to determine if the time to RT after surgery impacts post-RT reconstruction complication rates.

Methods A retrospective cohort study of 164 patients who underwent endoscopic endonasal surgery between 1998 and 2021 was conducted. Using Cox proportional hazard ratios (HRs), we evaluated several variables and the complications that occurred during the 1-year period after starting RT.

Results Seventy-eight (47.5%) and eighty-six patients (52.5%) received RT before and after the sixth postoperative week, respectively. The overall post-RT complication rates were 28%, most of these were severe infections (n = 20, 12.2%) and delayed CSF leak (n = 4, 2.5%). There was no significant difference in the post-RT complications between the patients who received postoperative RT before or after the sixth operative week (HR: 1.13; 95% confidence interval: 0.63–2.02; p = 0.675). Univariate analysis demonstrated negative impact associated with smoking history (p = 0.015), the use of neoadjuvant chemotherapy (p = 0.0001), and the use of photon therapy (p = 0.012); and we found a positive impact with the use of multilayer reconstruction techniques (overall, p = 0.041; with fat, p = 0.038; and/or fascia graft, p = 0.035). After a multivariate analysis only, smoking history was an independent risk factor for post-RT complications (p = 0.012).

Conclusion Delaying RT for more than 6 weeks after endoscopic endonasal surgery does not provide a significant benefit for reconstruction outcomes. However, special attention may be warranted in patients with smoking history who have received neoadjuvant chemotherapy, or in patients who will receive photon-based RT after surgery as these groups were found to have increased complication rates post-RT.

Keywords

endoscopic skull base reconstructions - vascularized flap - radiation therapy - proton therapy - photon therapy


Publication History

Received: 08 March 2023

Accepted: 19 June 2023

Accepted Manuscript online:
21 June 2023

Article published online:
28 July 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Larnaudie A, Delaby N, Marcy PY. et al. Radiotherapy of sinonasal cancers. Cancer Radiother 2022; 26 (1–2): 156-167
    CrossrefPubMedGoogle Scholar
  • 2 Huang J, Barbera L, Brouwers M, Browman G, Mackillop WJ. Does delay in starting treatment affect the outcomes of radiotherapy? A systematic review. J Clin Oncol 2003; 21 (03) 555-563
    CrossrefPubMedGoogle Scholar
  • 3 Mackillop WJ. Killing time: the consequences of delays in radiotherapy. Radiother Oncol 2007; 84 (01) 1-4
    CrossrefPubMedGoogle Scholar
  • 4 Mackillop WJ, Bates JH, O'Sullivan B, Withers HR. The effect of delay in treatment on local control by radiotherapy. Int J Radiat Oncol Biol Phys 1996; 34 (01) 243-250
    CrossrefPubMedGoogle Scholar
  • 5 Harris JP, Chen MM, Orosco RK, Sirjani D, Divi V, Hara W. Association of survival with shorter time to radiation therapy after surgery for US patients with head and neck cancer. JAMA Otolaryngol Head Neck Surg 2018; 144 (04) 349-359
    CrossrefPubMedGoogle Scholar
  • 6 Dormand EL, Banwell PE, Goodacre TEE, Goodacre TE. Radiotherapy and wound healing. Int Wound J 2005; 2 (02) 112-127
    CrossrefPubMedGoogle Scholar
  • 7 Devalia HL, Mansfield L. Radiotherapy and wound healing. Int Wound J 2008; 5 (01) 40-44
    CrossrefPubMedGoogle Scholar
  • 8 Gieringer M, Gosepath J, Naim R. Radiotherapy and wound healing: principles, management and prospects (review). Oncol Rep 2011; 26 (02) 299-307
    PubMedGoogle Scholar
  • 9 Huang WH, Liu CM, Chao TK, Hung PK. Middle meatus bacteriology of acute rhinosinusitis in patients after irradiation of nasopharynx. Am J Rhinol 2007; 21 (03) 286-288
    CrossrefPubMedGoogle Scholar
  • 10 Surico G, Muggeo P, Mappa L. et al. Impairment of nasal mucociliary clearance after radiotherapy for childhood head cancer. Head Neck 2001; 23 (06) 461-466
    CrossrefPubMedGoogle Scholar
  • 11 Xiao R, Joshi RR, Husain Q. et al. Timing of surgery and adjuvant radiation therapy for sinonasal malignancies: effect of surgical approach. Head Neck 2019; 41 (10) 3551-3563
    CrossrefPubMedGoogle Scholar
  • 12 Guo S, Dipietro LA. Factors affecting wound healing. J Dent Res 2010; 89 (03) 219-229
    CrossrefPubMedGoogle Scholar
  • 13 Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional wound infection: a randomized controlled trial. Ann Surg 2003; 238 (01) 1-5
    CrossrefPubMedGoogle Scholar
  • 14 Wilson JA, Clark JJ. Obesity: impediment to postsurgical wound healing. Adv Skin Wound Care 2004; 17 (08) 426-435
    CrossrefPubMedGoogle Scholar
  • 15 Kassam AB, Prevedello DM, Carrau RL. et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 2011; 114 (06) 1544-1568
    CrossrefPubMedGoogle Scholar
  • 16 Dehdashti AR, Stofko D, Okun J, Obourn C, Kennedy T. Endoscopic endonasal reconstruction of skull base: repair protocol. J Neurol Surg B Skull Base 2016; 77 (03) 271-278
    PubMedGoogle Scholar
  • 17 Bütof R, Baumann M. Time in radiation oncology - keep it short!. Radiother Oncol 2013; 106 (03) 271-275
    CrossrefPubMedGoogle Scholar
  • 18 Zhang M, Xu F, Ni W. et al. Survival impact of delaying postoperative chemoradiotherapy in newly-diagnosed glioblastoma patients. Transl Cancer Res 2020; 9 (09) 5450-5458
    CrossrefPubMedGoogle Scholar
  • 19 Bese NS, Sut PA, Ober A. The effect of treatment interruptions in the postoperative irradiation of breast cancer. Oncology 2005; 69 (03) 214-223
    CrossrefPubMedGoogle Scholar
  • 20 Thames HD, Kuban D, Levy LB. et al. The role of overall treatment time in the outcome of radiotherapy of prostate cancer: an analysis of biochemical failure in 4839 men treated between 1987 and 1995. Radiother Oncol 2010; 96 (01) 6-12
    CrossrefPubMedGoogle Scholar
  • 21 Jang JW, Chan AW. Prevention and management of complications after radiotherapy for skull base tumors: a multidisciplinary approach. Adv Otorhinolaryngol 2013; 74: 163-173
    PubMedGoogle Scholar
  • 22 Peters LJ, Goepfert H, Ang KK. et al. Evaluation of the dose for postoperative radiation therapy of head and neck cancer: first report of a prospective randomized trial. Int J Radiat Oncol Biol Phys 1993; 26 (01) 3-11
    CrossrefPubMedGoogle Scholar
  • 23 Adelstein D, Gillison ML, Pfister DG. et al. NCCN guidelines® insights head and neck cancers, version 2.2017 featured updates to the NCCN guidelines. J Natl Compr Canc Netw 2017; 15 (06) 761-770
    CrossrefPubMedGoogle Scholar
  • 24 Kuhar HN, Tajudeen BA, Heilingoetter A. et al. Distinct histopathologic features of radiation-induced chronic sinusitis. Int Forum Allergy Rhinol 2017; 7 (10) 990-998
    CrossrefPubMedGoogle Scholar
  • 25 Hsin CH, Tseng HC, Lin HP, Chen TH. Post-irradiation otitis media, rhinosinusitis, and their interrelationship in nasopharyngeal carcinoma patients treated by IMRT. Eur Arch Otorhinolaryngol 2016; 273 (02) 471-477
    CrossrefPubMedGoogle Scholar
  • 26 Lu YT, Lu YC, Cheng HC. et al. Chronic rhinosinusitis after radiotherapy in patients with head and neck cancer: a population-based cohort study in Taiwan. Int Forum Allergy Rhinol 2020; 10 (05) 692-697
    CrossrefPubMedGoogle Scholar
  • 27 Su YX, Liu LP, Li L. et al. Factors influencing the incidence of sinusitis in nasopharyngeal carcinoma patients after intensity-modulated radiation therapy. Eur Arch Otorhinolaryngol 2014; 271 (12) 3195-3201
    CrossrefPubMedGoogle Scholar
  • 28 Ku PK, Tong MC, Tsang SS, van Hasselt A. Acquired posterior choanal stenosis and atresia: management of this unusual complication after radiotherapy for nasopharyngeal carcinoma. Am J Otolaryngol 2001; 22 (04) 225-229
    CrossrefPubMedGoogle Scholar
  • 29 Shepard PM, Houser SM. Choanal stenosis: an unusual late complication of radiation therapy for nasopharyngeal carcinoma. Am J Rhinol 2005; 19 (01) 105-108
    CrossrefPubMedGoogle Scholar
  • 30 Kamel R, Al-Badawy S, Khairy A, Kandil T, Sabry A. Nasal and paranasal sinus changes after radiotherapy for nasopharyngeal carcinoma. Acta Otolaryngol 2004; 124 (04) 532-535
    CrossrefPubMedGoogle Scholar
  • 31 Wu PW, Huang CC, Lee YS. et al. Post-irradiation sinus mucosa disease in nasopharyngeal carcinoma patients treated with intensity-modulated proton therapy. Cancers (Basel) 2022; 14 (01) 225
    CrossrefPubMedGoogle Scholar
  • 32 Crippen MM, Patel N, Filimonov A. et al. Association of smoking tobacco with complications in head and neck microvascular reconstructive surgery. JAMA Facial Plast Surg 2019; 21 (01) 20-26
    CrossrefPubMedGoogle Scholar
  • 33 Silverstein P. Smoking and wound healing. Am J Med 1992; 93 (1A): 22S-24S
    CrossrefPubMedGoogle Scholar
  • 34 Torres-Bayona S, Velasquez N, Nakassa A. et al. Risk factors and reconstruction techniques for persistent cerebrospinal fluid leak in patients undergoing endoscopic endonasal approach to the posterior fossa. J Neurol Surg B Skull Base 2021; 83 (Suppl. 02) e318-e323
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Thorp BD, Sreenath SB, Ebert CS, Zanation AM. Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 2014; 37 (04) E4
    CrossrefPubMedGoogle Scholar
  • 36 Hutson K, Clark A, Hopkins C. et al; CRES Group. Evaluation of smoking as a modifying factor in chronic rhinosinusitis. JAMA Otolaryngol Head Neck Surg 2021; 147 (02) 159-165
    CrossrefPubMedGoogle Scholar
  • 37 Gottrup F. Oxygen in wound healing and infection. World J Surg 2004; 28 (03) 312-315
    CrossrefPubMedGoogle Scholar
  • 38 Sørensen LT, Toft B, Rygaard J, Ladelund S, Teisner B, Gottrup F. Smoking attenuates wound inflammation and proliferation while smoking cessation restores inflammation but not proliferation. Wound Repair Regen 2010; 18 (02) 186-192
    CrossrefPubMedGoogle Scholar
  • 39 Pisters KM, Vallières E, Crowley JJ. et al. Surgery with or without preoperative paclitaxel and carboplatin in early-stage non-small-cell lung cancer: Southwest Oncology Group Trial S9900, an intergroup, randomized, phase III trial. J Clin Oncol 2010; 28 (11) 1843-1849
    CrossrefPubMedGoogle Scholar
  • 40 Nordlinger B, Sorbye H, Glimelius B. et al; EORTC Gastro-Intestinal Tract Cancer Group, Cancer Research UK, Arbeitsgruppe Lebermetastasen und-tumoren in der Chirurgischen Arbeitsgemeinschaft Onkologie (ALM-CAO), Australasian Gastro-Intestinal Trials Group (AGITG), Fédération Francophone de Cancérologie Digestive (FFCD). Perioperative chemotherapy with FOLFOX4 and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC Intergroup trial 40983): a randomised controlled trial. Lancet 2008; 371 (9617): 1007-1016
    CrossrefPubMedGoogle Scholar
  • 41 Kaklamanos IG, Walker GR, Ferry K, Franceschi D, Livingstone AS. Neoadjuvant treatment for resectable cancer of the esophagus and the gastroesophageal junction: a meta-analysis of randomized clinical trials. Ann Surg Oncol 2003; 10 (07) 754-761
    CrossrefPubMedGoogle Scholar
  • 42 Turan A, Shao D, Salmasi V. et al. Chemotherapy within 30 days before surgery does not augment postoperative mortality and morbidity. Can J Anaesth 2012; 59 (08) 758-765
    CrossrefPubMedGoogle Scholar
  • 43 Meric F, Milas M, Hunt KK. et al. Impact of neoadjuvant chemotherapy on postoperative morbidity in soft tissue sarcomas. J Clin Oncol 2000; 18 (19) 3378-3383
    CrossrefPubMedGoogle Scholar
  • 44 Crawford J, Dale DC, Kuderer NM. et al. Risk and timing of neutropenic events in adult cancer patients receiving chemotherapy: the results of a prospective nationwide study of oncology practice. J Natl Compr Canc Netw 2008; 6 (02) 109-118
    CrossrefPubMedGoogle Scholar
  • 45 Okano S, Tahara M, Zenda S. et al. Induction chemotherapy with docetaxel, cisplatin and S-1 followed by proton beam therapy concurrent with cisplatin in patients with T4b nasal and sinonasal malignancies. Jpn J Clin Oncol 2012; 42 (08) 691-696
    CrossrefPubMedGoogle Scholar
  • 46 Prestwich RJ, Öksüz DÇ, Dyker K, Coyle C, Şen M. Feasibility and efficacy of induction docetaxel, cisplatin, and 5-fluorouracil chemotherapy combined with cisplatin concurrent chemoradiotherapy for nonmetastatic Stage IV head-and-neck squamous cell carcinomas. Int J Radiat Oncol Biol Phys 2011; 81 (04) e237-e243
    CrossrefPubMedGoogle Scholar
  • 47 Tian H, Ma D, Tan X. et al. Platinum and taxane based adjuvant and neoadjuvant chemotherapy in early triple-negative breast cancer: a narrative review. Front Pharmacol 2021; 12: 770663
    CrossrefPubMedGoogle Scholar
  • 48 Lee CK, Gurney H, Brown C. et al. Carboplatin-paclitaxel-induced leukopenia and neuropathy predict progression-free survival in recurrent ovarian cancer. Br J Cancer 2011; 105 (03) 360-365
    CrossrefPubMedGoogle Scholar
  • 49 Fahy BN, Aloia TA, Jones SL, Bass BL, Fischer CP. Chemotherapy within 30 days prior to liver resection does not increase postoperative morbidity or mortality. HPB (Oxford) 2009; 11 (08) 645-655
    CrossrefPubMedGoogle Scholar
  • 50 Sullivan MC, Roman SA, Sosa JA. Does chemotherapy prior to emergency surgery affect patient outcomes? Examination of 1912 patients. Ann Surg Oncol 2012; 19 (01) 11-18
    CrossrefPubMedGoogle Scholar
  • 51 Welsh FKS, Tilney HS, Tekkis PP, John TG, Rees M. Safe liver resection following chemotherapy for colorectal metastases is a matter of timing. Br J Cancer 2007; 96 (07) 1037-1042
    CrossrefPubMedGoogle Scholar
  • 52 Kam MKM, Leung S-F, Zee B. et al. Prospective randomized study of intensity-modulated radiotherapy on salivary gland function in early-stage nasopharyngeal carcinoma patients. J Clin Oncol 2007; 25 (31) 4873-4879
    CrossrefPubMedGoogle Scholar
  • 53 Holliday EB, Kocak-Uzel E, Feng L. et al. Dosimetric advantages of intensity-modulated proton therapy for oropharyngeal cancer compared with intensity-modulated radiation: a case-matched control analysis. Med Dosim 2016; 41 (03) 189-194
    CrossrefPubMedGoogle Scholar
  • 54 Leeman JE, Romesser PB, Zhou Y. et al. Proton therapy for head and neck cancer: expanding the therapeutic window. Lancet Oncol 2017; 18 (05) e254-e265
    CrossrefPubMedGoogle Scholar
  • 55 Romesser PB, Cahlon O, Scher E. et al. Proton beam radiation therapy results in significantly reduced toxicity compared with intensity-modulated radiation therapy for head and neck tumors that require ipsilateral radiation. Radiother Oncol 2016; 118 (02) 286-292
    CrossrefPubMedGoogle Scholar
  • 56 Lydiatt WM, Patel SG, O'Sullivan B. et al. Head and neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin 2017; 67 (02) 122-137
    CrossrefPubMedGoogle Scholar
  • 57 Thawani R, Kim MS, Arastu A. et al. The contemporary management of cancers of the sinonasal tract in adults. CA Cancer J Clin 2023; 73 (01) 72-112
    CrossrefPubMedGoogle Scholar