内镜经翼突入路切除中颅底恶性肿瘤30例临床分析

Clinical analysis of the endonasal transpterygoid approach to the resection of malignant tumors involving the middle skull base of 30 cases

目的探讨内镜经翼突入路切除中颅底恶性肿瘤的疗效。方法回顾分析30例经鼻内镜翼突入路切除累及中颅底恶性肿瘤患者相关资料,总结该手术相关技巧和经验,用Kaplan-Meier法进行生存分析,探讨肿瘤累及颈内动脉对预后影响。结果手术均为全身麻醉下进行。平均手术时间145 min,平均术中出血470 mL,术中脑脊液漏6例;术后颅内感染2例、脑脊液漏1例,均痊愈。病理分别为复发性鼻咽癌21例、腺样囊性癌3例、黏液表皮样癌2例、脊索瘤1例、癌肉瘤1例、鼻咽滤泡树突状细胞肉瘤1例和颅底淋巴上皮瘤样癌1例。30例颅底恶性肿瘤患者术后1年、2年、3年、5年生存率分别为92.9%、79.6%、48.6%和36.5%;复发性鼻咽癌中位生存期为29.00[35.00,23.00]个月,其他恶性肿瘤38.00[38.00,38.00]个月,生存曲线之间差异有统计学意义(χ^2=4.248;P=0.039);颈内动脉累及和未累及患者中位数分别为16.00[23.00,14.00]个月和36.00[80.00,31.00]个月,生存曲线差异有统计学意义(χ^2=9.421;P=0.002);而且颈内动脉受累是影响患者预后的危险因素,颈内动脉受累及患者的死亡风险是未受累患者的9.678倍(HR=9.678,P=0.011)。结论内镜翼突入路是部分中颅底恶性肿瘤外科治疗的合理方案,颈内动脉累及侵犯是影响疾病预后的危险因素。

Objective To explore the endonasal transpterygoid approach to the resection of malignant tumors involving the middle skull base and its outcomes.Methods The surgery-related data of 30 cases of malignant tumors involving the middle skull base attended to at the Department of Otorhinolaryngology of the Shenzhen People’s Hospital between October 2012 and June 2019 were retrospectively analyzed.The skills and experience of the surgeons and the techniques employed during the surgery were summarized.The Kaplan-Meier method was used for survival analysis.The prognoses of the tumor-involved internal carotid arteries were also explored.Results The surgeries,using the endonasal transpterygoid approach,were performed under general anesthesia;the average duration of surgery was 145 minutes,the average intraoperative blood loss was 470 mL,and intraoperative cerebrospinal fluid leakage occurred in 6 cases.The postoperative intracranial infection in 2 cases and the cerebrospinal fluid leakage in 1 case were cured.Pathologically,there were 21 cases of recurrent nasopharyngeal carcinoma,3 cases of adenoid cystic carcinoma,2 cases of mucoepidermoid carcinoma,1 case of chordoma,1 case of carcinosarcoma,1 case of nasopharyngeal follicular dendritic cell sarcoma,and 1 case of skull base lymphocytic epithelioma-like carcinoma.The 1-year,2-year,3-year,and 5-year survival rates of the 30 patients with malignant tumors were 92.9%,79.6%,48.6%,and 36.5%,respectively.The median survival duration was 29.00(35.00,23.00)months for recurrent nasopharyngeal carcinoma and 38.00(38.00,38.00)months for other malignant tumors.The survival curves of recurrent nasopharyngeal carcinomas and other malignant tumors showed statistical significance(χ^2=4.248;P=0.039).The median durations of survival of patients with and without internal carotid artery invasion were 16.00(23.00,14.00)and 36.00(80.00,31.00)months,respectively,and their survival curves were significantly different(χ^2=9.421;P=0.002).Internal carotid artery involvement is a risk factor for poor prognosis,and the risk of death of patients with internal carotid artery involvement was 9.678 times that of those without involvement(HR=9.678,P=0.011).Conclusion The endoscopic transpterygoid approach is a reasonable option for the surgical treatment of tumors involving the middle skull base;however,the involvement of the internal carotid artery is an important prognostic factor that should always be considered.