INTRODUCTION: Recent scientific evidence has demonstrated how surgical navigation (SN) can contribute to improving the results of oncological nasosinusal and craniofacial ablations. This study analyzes the role of SN in optimizing the state of resection margins, analyzing tumor dispersion and personalizing post-surgical treatment. MATERIALS AND METHODS: The present study prospectively included patients undergoing SN-guided surgery for nasosinusal or craniofacial malignant neoplasms at the Section of Otolaryngology - Head and Neck Surgery, Padua University Hospital (AOUP) from April 2021 to June 2021 and from April 2023 to December 2024. Patients underwent magnetic resonance imaging (MRI) with contrast and high-resolution (≤1 mm) craniofacial computed tomography (CT) without contrast, optimized for SN. Subsequently, the DICOM (Digital Imaging and Communication in Medicine) files were imported into an electromagnetic SN system (Medtronic StealthStation S8). The coordinates of the biopsies recorded intraoperatively through the SN were transferred into the 3D Slicer software and, based on the final pathology report, marked red if positive and green if negative. Macroscopic tumor extension was assessed and segmented by an experienced radiologist. This segmentation was used to calculate the distance between the macroscopically evident tumor surface and the coordinates of the positive intraoperative biopsies, using the “Fiducial-To-Model-Distance” module of the 3D Slicer program. The analysis of the personalization of post-surgical treatment planning was carried out through the DICE function. RESULTS: A total of 120 patients were recruited, of which 60 underwent surgery guided by the SN and 60 operated without the aid of the SN, carrying out a 1:1 case-control matching. 38 patients undergoing surgery via SN were then selected for the analysis of tumor dispersion and 4 patients for the study on the personalization of the post-surgical treatment plan. Analysis of margin status demonstrated a lower rate of positive margins (p = 0.013) in the SN group, especially in case of pT4 tumors (p = 0.034), recurrences (p = 0.024), high-grade tumors (p = 0.043) and endoscopic-assisted open surgery (p = 0.035). For the analysis of tumor dispersion, 229 intraoperative biopsies were recorded. Of these, 29 (12.67%) were positive, 26 of which (89.66%) were external to the tumor surface with an average distance value of 11.81 mm and a maximum distance value of 36 .99 mm. Intestinal-type adenocarcinomas (ITAC) demonstrated lower tumor dispersion (mean distance 3.86 mm and maximum distance 8.24 mm) compared to squamous cell carcinomas (SCC) (mean distance 17.02 mm and maximum distance 36.99 mm , p = 0.024) and adenoid cystic carcinomas (ACC) (mean distance 13.46 mm and maximum distance 28.11 mm, p= 0.019). SCC and ACC demonstrated non-significantly different tumor dispersion (p = 0.460). CONCLUSIONS: SN can help improving the status of resection margins, especially in locally advanced tumors, in case of recurrence, in highly aggressive histologies and in combined surgical approaches. Results on tumor dispersion analysis show a discrepancy between macroscopic extension and microscopic infiltration documented through NCI. ITACs demonstrated statistically significantly lower tumor dispersion compared to the other histologies examined. Finally, NCI represents a promising tool to optimize the personalization of post-surgical treatment planning.
INTRODUZIONE: Evidenze scientifiche recenti hanno dimostrato come la navigazione chirurgica intraoperatoria (NCI) possa contribuire a migliorare i risultati delle ablazioni oncologiche nasosinusali e craniofacciali. Questo studio analizza il ruolo della NCI nell’ottimizzazione dello stato dei margini di resezione, nell’analisi della dispersione tumorale e nella personalizzazione del trattamento post-chirurgico. MATERIALI E METODI: Il presente studio ha incluso prospetticamente pazienti sottoposti a chirurgia NCI-guidata per neoplasie maligne nasosinusali o craniofacciali presso la Sezione di Otorinolaringoiatria – Chirurgia Cervico-Facciale, Azienda Ospedale Università Padova (AOUP) da Aprile 2021 a Giugno 2021 e da Aprile 2023 a Dicembre 2024. I pazienti sono stati sottoposti a risonanza magnetica (RM) con mezzo di contrasto e tomografia computerizzata craniofacciale (TC) ad alta risoluzione (≤1 mm) senza mezzo di contrasto, ottimizzata per NCI. Successivamente i file DICOM (Digital Imaging and Communication in Medicine) sono stati importati in un sistema di NCI elettromagnetica (Medtronic StealthStation S8). Le coordinate delle biopsie registrate intraoperatoriamente attraverso la NCI sono state trasferite nel software 3D Slicer e, sulla base del referto patologico definitivo, contrassegnate in rosso se positive e in verde se negative. L'estensione tumorale macroscopica è stata valutata e segmentata da un radiologo esperto. Tale segmentazione è stata usata per calcolare la distanza tra la superficie tumorale macroscopicamente evidente e le coordinate delle biopsie intraoperatorie risultate positive, sfruttando il modulo “Fiducial-To-Model-Distance” del programma 3D Slicer. L’analisi della personalizzazione della pianificazione del trattamento post-chirurgico è stata effettuata attraverso la funzione DICE. RISULTATI: In totale sono stati reclutati 120 pazienti, di cui 60 sottoposti a chirurgia guidata dalla NCI e 60 operati senza l’ausilio della NCI, effettuando un abbinamento casi-controlli 1:1. Sono stati poi selezionati 38 pazienti sottoposti a chirurgia tramite NCI per l’analisi della dispersione tumorale e 4 pazienti per lo studio sulla personalizzazione del piano di trattamento post-chirurgico. L'analisi dello stato dei margini ha dimostrato un tasso inferiore di margini positivi (p = 0,013) nel gruppo NCI, soprattutto in caso di tumori pT4 (p = 0,034), recidive (p = 0,024), tumori di alto grado (p = 0,043) e chirurgia open endoscopico-assistita (p = 0,035). Per l’analisi della dispersione tumorale sono state registrate 229 biopsie intraoperatorie. Di queste, 29 (12,67%) sono risultate positive, 26 delle quali (89,66%) sono risultate esterne alla superficie tumorale con un valore di distanza media pari a 11,81 mm e un valore di distanza massimo pari a 36,99 mm. Gli adenocarcinomi di tipo intestinale (ITAC) hanno dimostrato una dispersione tumorale inferiore (distanza media 3,86 mm e distanza massima 8,24 mm) rispetto ai carcinomi squamocellulari (SCC) (distanza media 17,02 mm e distanza massima 36,99 mm, p = 0,024) e ai carcinomi adenoidocistici (ACC) (distanza media 13,46 mm e distanza massima 28,11 mm, p= 0,019). SCC e ACC hanno dimostrato una dispersione tumorale non significativamente differente (p = 0,460). CONCLUSIONI: La NCI può contribuire a migliorare lo stato dei margini di resezione, soprattutto nei tumori localmente avanzati, nei casi di recidiva, nelle istologie altamente aggressive e negli approcci chirurgici combinati. I risultati sull’analisi della dispersione tumorale mostrano una discrepanza tra l'estensione macroscopica e l'infiltrazione microscopica documentata attraverso la NCI. Gli ITAC hanno dimostrato in modo statisticamente significativo una dispersione tumorale inferiore rispetto alle altre istologie prese in esame. Infine, la NCI rappresenta uno strumento promettente per ottimizzare la personalizzazione della pianificazione del trattamento post-chirurgico.
IL RUOLO DELLA NAVIGAZIONE INTRAOPERATORIA ELETTROMAGNETICA NELLA CHIRURGIA ONCOLOGICA DEL DISTRETTO CRANIOFACCIALE ANTERIORE: OTTIMIZZAZIONE DEI MARGINI, RISULTATI PROGNOSTICI, ANALISI DELLA DISPERSIONE TUMORALE, PERSONALIZZAZIONE DEL TRATTAMENTO POST-CHIRURGICO. UNO STUDIO PROSPETTICO SU 108 PAZIENTI
COSTANTINO, PAOLA
2022/2023
Abstract
INTRODUCTION: Recent scientific evidence has demonstrated how surgical navigation (SN) can contribute to improving the results of oncological nasosinusal and craniofacial ablations. This study analyzes the role of SN in optimizing the state of resection margins, analyzing tumor dispersion and personalizing post-surgical treatment. MATERIALS AND METHODS: The present study prospectively included patients undergoing SN-guided surgery for nasosinusal or craniofacial malignant neoplasms at the Section of Otolaryngology - Head and Neck Surgery, Padua University Hospital (AOUP) from April 2021 to June 2021 and from April 2023 to December 2024. Patients underwent magnetic resonance imaging (MRI) with contrast and high-resolution (≤1 mm) craniofacial computed tomography (CT) without contrast, optimized for SN. Subsequently, the DICOM (Digital Imaging and Communication in Medicine) files were imported into an electromagnetic SN system (Medtronic StealthStation S8). The coordinates of the biopsies recorded intraoperatively through the SN were transferred into the 3D Slicer software and, based on the final pathology report, marked red if positive and green if negative. Macroscopic tumor extension was assessed and segmented by an experienced radiologist. This segmentation was used to calculate the distance between the macroscopically evident tumor surface and the coordinates of the positive intraoperative biopsies, using the “Fiducial-To-Model-Distance” module of the 3D Slicer program. The analysis of the personalization of post-surgical treatment planning was carried out through the DICE function. RESULTS: A total of 120 patients were recruited, of which 60 underwent surgery guided by the SN and 60 operated without the aid of the SN, carrying out a 1:1 case-control matching. 38 patients undergoing surgery via SN were then selected for the analysis of tumor dispersion and 4 patients for the study on the personalization of the post-surgical treatment plan. Analysis of margin status demonstrated a lower rate of positive margins (p = 0.013) in the SN group, especially in case of pT4 tumors (p = 0.034), recurrences (p = 0.024), high-grade tumors (p = 0.043) and endoscopic-assisted open surgery (p = 0.035). For the analysis of tumor dispersion, 229 intraoperative biopsies were recorded. Of these, 29 (12.67%) were positive, 26 of which (89.66%) were external to the tumor surface with an average distance value of 11.81 mm and a maximum distance value of 36 .99 mm. Intestinal-type adenocarcinomas (ITAC) demonstrated lower tumor dispersion (mean distance 3.86 mm and maximum distance 8.24 mm) compared to squamous cell carcinomas (SCC) (mean distance 17.02 mm and maximum distance 36.99 mm , p = 0.024) and adenoid cystic carcinomas (ACC) (mean distance 13.46 mm and maximum distance 28.11 mm, p= 0.019). SCC and ACC demonstrated non-significantly different tumor dispersion (p = 0.460). CONCLUSIONS: SN can help improving the status of resection margins, especially in locally advanced tumors, in case of recurrence, in highly aggressive histologies and in combined surgical approaches. Results on tumor dispersion analysis show a discrepancy between macroscopic extension and microscopic infiltration documented through NCI. ITACs demonstrated statistically significantly lower tumor dispersion compared to the other histologies examined. Finally, NCI represents a promising tool to optimize the personalization of post-surgical treatment planning.File | Dimensione | Formato | |
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https://hdl.handle.net/20.500.12608/81494