Craniofacial malignant tumors, their extensions, and surgical strategy for their treatment

Purpose: To identify extension routes of craniofacial malignancies and formulate a surgical treatment plan based thereupon. Material and Methods: We retrospectively reviewed the medical records of 253 patients with craniofacial malignancies who underwent surgical treatment at the Romodanov Neurosurgery Institute from 2002 through 2022. Of the 253 patients, 112 had a primary tumor, and 141, a secondary tumor. Preoperative Karnofsky performance scores ranged from 50 to 70 points. Patients underwent neurological and ophthalmological status assessment, as per routine protocols. Results: Epithelial malignancies were the most common (53.7%), whereas anaplastic meningioma and embryonal malignancies were rather uncommon (1.2% and 0.4%, respectively) craniofacial malignancies. The presence of certain clinical symptoms was associated primarily with tumor origin and extension. A high rate of general brain and rhinological symptoms in our study sample was caused by a high percentage of intracranial and paranasal sinus tumors. Craniofacial malignancies most commonly originate from the midline (particularly, anterior midline skull base). Ethmoidal labyrinth was the most common site of origin (45.0%), followed by a sphenoid sinus (12.2%), pterygopalatine and infratemporal fossae (9.9%), whereas the cavernous sinus and olfactory fossa were the least common sites of origin (0.4% and 1.2%, respectively). Craniofacial tumors extended most commonly intracranially (transdurally, epidurally, via adhesion to the dura mater, and/or cavernous sinus growth) or intraorbitally. Anterior craniofacial resection (bifrontal craniotomy with combined with either lateral rhinotomy or supraorbital advancement; or a subcranial approach) was the most common surgical treatment. Postoperative cerebrospinal fluid rhinorrhea and infectious complications (meningitis and meningoencephalitis) were the most frequent complications. The overall postoperative mortality rate was 2.0%. Conclusion: First, compared to the transcranial and facial approaches, the craniofacial resection is advantageous in terms of the radicality of tumor excision. Second, the subcranial approach is preferable to the bifrontal approach in the presence of marked extracranial tumor component, whereas the transbasal Derome approach is effective in the presence of marked extracranial and/or intracranial tumor components. Finally, both the orbitozygomatic and infratemporal approaches allow for the radicality of excision of lateral skull base malignancies, but the latter approach is associated with a lower rate of complications.