OUTCOME AND COMPLICATIONS OF EXTENDED CRANIAL-BASE RESECTION REQUIRING MICROVASCULAR FREE-TISSUE TRANSFER

Objectives: To determine the complications of extensive cranial-base r esection requiring free-tissue transfer (FTT) and the effect of these resections on local control and survival among patients with malignant neoplasms of the skull base. Background: Before the advent of FTT, cr anial-base surgery was often limited by our inability to adequately re pair defects comprising communication between the central nervous syst em and upper aerodigestive tract. The use of FTT in cranial-base resec tions was therefore assessed to determine whether the improved procedu re tie, extensive resections) would improve local control and prolong survival. Design: A retrospective review of 39 consecutive craniofacia l resections with FTT reconstruction in patients with malignant neopla sms involving the cranial base. Patients: All 39 patients had malignan t neoplasms, including 20 squamous cell carcinomas, eight basal cell c ar cinemas, two melanomas, two neuroendocrine carcinomas, two adenoid cystic carcinomas, and various other malignant neoplasms. Resections i nvolved the anterior, middle, or posterior cranial fossa in 19 patient s (49%), 10 patients (26%), and three patients (8%) of cases, respecti vely. The remaining seven surgeries (18%) involved resection of more t han one of these cranial base sites. Results: Early (<14 days after su rgery) complications occurred in 14 (36%) of 39 patients. Major compli cations included failure of microvascular anastomosis (n=1), pneumonit is (n=3),perioperative myocardial infarction (n=1), and cerebrovascula r accident (n=1). The microvascular anastomosis failure was promptly t reated with surgical intervention. Two patients (5%) experienced late postoperative complications; one had cellulitis at the donor site, and the other had pneumonitis. No perioperative deaths or complications s uch as meningitis, epidural abscess, or tension pneumocephalus occurre d. The 2-year disease-specific survival rate was 55%, and the 2-year l ocal control rate, 49%; both were determined by the Kaplan-Meier metho d. The nine patients who died of their disease had a median survival o f 9 months. Log rank testing showed that pathologically positive margi ns and transdural pathology were the most significant predictors of lo cal recurrence and death of disease. Conclusions: Contemporary surgica l approaches provide an opportunity for wide surgical excision of dura and skull-base structures that normally separate the intracranial and extracranial cavities. These major skull-base resections can be recon structed safely and effectively with FTT. Patients with malignant neop lasms of the dura and skull base should be approached with the underst anding that transdural disease portends an increased risk of local rec urrence and death of disease.