117. Anterior cranio-facial resection for ethmoid malignant tumors

Two hundred patients underwent anterior craniofacial resection for ethmoid malignant tumors at the Istituto Nazionale per lo Studio e la Cura dei Tumori of Milan between 1987 and 1999. One hundred and twenty patients were previously untreated (60%), whereas 90 (40%) presented with a recurrence after prior treatments performed elsewhere. The ethmoid was involved in all cases and was the probable site of origin of the tumnr in almost all thp. naflV.nts surgery started with a classical coronal incision. The skin and galea were raised; then an anteriorly pedicled rectangular flap of pericranium was elevated. We performed a small and low craniotomy (3×7 cm) through the frontal sinuses, without burr holes, using an oscillating saw and a chisel. We did not use the spinal catheter to aid in brain retraction, since, with the low craniotomy, the more anterior olfactory nerves are easily reached; when dissecting them a spontaneous outflow of CSF is obtained. Lateral osteotomies of the skull base were tailored to the size of the neoplasm, whereas anterior osteotomy was always conducted through the floor of the frontal sinus and the posterior osteotomy through the roof of the sphenoidal sinus. Skin incision by the facial approach was made according to tumor extension into the paranasal sinuses or in the skin. The ethmoid bone was always totally removed, with the whole cribriform plate, vertical lamina and at least the anterior half of the roof and floor of the sphenoid sinus together with the vomer. In addition to ethmoidectomy, at least a medial maxillectomy was always performed with complete removal of turbinâtes on the side with greater extension of the tumor. The defect in the anterior skull base was always repaired with the pedicled rectangular flap of pericranium revolved intracranially and fixed with 4-6 sutures to the residual roof of the sphenoidal sinus and the orbits. The disease-free survival rate is 45% (58% for untreated patients and 25% for relapses). According to our classification of ethmoid malignant tumors the global disease-free survival is: T2-62%, T3-44% and T4-30%. In untreated patients the rates are: T2-72%, T3-59% and T4-30%.