Is craniofacial resection in elderly patients too risky?—a 12-year review from two centres

Introduction

Sinonasal malignancies account for approximately 5% of all head and neck malignancies (1). Common pathologies include adenocarcinoma, which accounts for 13–19% of all sinus malignancies (1), as well as olfactory neuroblastoma, squamous cell carcinoma (SCC), and neuroendocrine tumours (2-4). Surgical resection and radiotherapy are common management options for these cancers. Historically, craniofacial resection (CFR) was performed via an open approach, however in recent years resections have increasingly been performed wholly or partially endoscopically. Combined approach procedures refer to a combination of open and endoscopic approaches, excluding resections where a craniotomy is performed (5,6).

Previous studies have outlined major complications of CFR to include cerebrospinal fluid (CSF) leak, meningitis, pneumocephalus, intracranial haematoma, cardiovascular events, pulmonary events, delirium, venous thromboembolism, blindness, infections, and flap issues (7,8). Rates of complications have been demonstrated to be higher with craniotomies when compared to endoscopic approaches (5).

The safety and efficacy of CFR in the elderly population remains unclear. Age has been previously considered a relative contraindication to CFR due to increased risk of complications. Some studies, including a large international review by Ganly et al. in 2011, have demonstrated poorer outcomes for the elderly, aged ≥70 years, undergoing open CFR (9,10). The research by Ganly et al. was performed prior to the popularisation of the endoscopic approach. With the changes in approach, perhaps there are fewer craniotomies being performed in recent times, which may be an explanation for lower complications, particularly in the elderly population. Another study demonstrated similar rates of complications between patients aged ≥70 years and those younger undergoing endoscopic CFR (8). Comorbidities and increased frailty have been demonstrated to increase perioperative risk in elderly patients (11). The 5-factor modified frailty index (mFI-5) is a risk stratification tool for adverse outcome measures, used by surgical specialties perioperatively (12).

This study aims to assess the safety of CFR in the elderly and compare outcomes with younger patients by analysing 12 years of data on sinonasal malignancies from two centres in Melbourne, Australia, where patients undergo careful selection for surgical intervention by a multidisciplinary team. The findings may inform best practices, guide clinicians and patients in shared decision-making, and support evidence-based recommendations for managing sinonasal malignancies in elderly adults.

The primary outcome measure is the rate of major complications in patients aged ≥70 years compared to those <70 years undergoing CFR. The secondary outcomes of the study are to compare the rates of 28-day operative mortality and the length of hospital stay for elderly patients with younger patients.

Methods

We retrospectively identified all patients who underwent CFR from 2011 to 2023 at two separate centres. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the St Vincent’s Hospital Melbourne Human Research Ethics Committee (No. 2024/PID00162) and the Epworth Health Human Research Ethics Committee (No. EH2024-1156). Because of the retrospective nature of the research, the requirement for informed consent was waived. The study is reported according to the STROBE reporting guidelines (available at https://www.theajo.com/article/view/10.21037/ajo-24-79/rc).

The study’s inclusion criteria consisted of patients who underwent endoscopic, combined approach, or open CFR for sinonasal malignancy between January 1, 2011, and August 31, 2023. All patients underwent a rigorous preoperative evaluation by a multidisciplinary team to guide treatment decisions. Patients were excluded if they had undergone revision surgery or had incomplete clinical data.

Data extracted from the electronic medical records included patient demographics, gender, comorbidities, diagnosis, tumour-node-metastasis (TNM) staging as per the 8^th edition of the American Joint Committee on Cancer (AJCC) Cancer Staging Manual (13), details of the surgery, adjuvant therapies, length of hospital stay, 28-day mortality, and complications. Complications included CSF leak, meningitis, pneumocephalus, intracranial haematoma, cardiovascular events, pulmonary events, delirium, venous thromboembolism, blindness, infections, and flap issues. Utilizing retrospective chart data, the mFI-5 was calculated for each patient. This index assigns a score from 0 to 5, where 0 represents the least frail and 5 represents the most frail. The score is determined based on the presence of the following five comorbidities: (I) congestive heart failure within 30 days before surgery; (II) insulin-dependent or non-insulin-dependent diabetes mellitus; (III) chronic obstructive pulmonary disease (COPD) or pneumonia; (IV) partial or total dependence in functional health status at the time of surgery; and (V) hypertension requiring medication. All data was de-identified and secured with password protection.

Patients were categorised into two groups for analysis: age <70 and ≥70 years. There is contention in the literature about what age is safe for surgery, and 70 years was chosen based on previous studies. Post-hoc power calculations were performed.

The data were summarized using descriptive statistics, including medians and interquartile ranges (IQRs) for continuous variables. Categorical variables were analysed using the Chi-squared test or Fisher’s exact test, while continuous variables were compared using the Mann-Whitney U test or t-test, as appropriate. In addition to P values, effect sizes were reported to quantify the magnitude of differences, including Cohen’s d for t-tests, odds ratios (ORs) with 95% confidence intervals (CIs) for categorical comparisons, and Cliff’s delta or rank-biserial correlation for Mann-Whitney U tests.

Results

A total of 83 patients who underwent CFR were identified at the two centres. Ten patients were excluded due to incomplete data.

The baseline demographics and type of surgery of the two groups are displayed in Table 1. The age range for the cohort is 31 to 87 years, with a median age of 66 years (IQR, 55–75 years). Twenty-eight patients were aged ≥70 years, while the remaining 45 patients were aged <70 years. The subgroups are similar in terms of gender. A completely endoscopic approach was performed in 28 patients, of which 11 patients aged ≥70 years. Of the 45 patients who underwent an open or combined approach, 29 patients had anterior craniotomies. Sixty-five patients had a mFI-5 (12) of 0 or 1 and no patients had a score of 4 or 5.

The histopathology, management, and outcomes are summarised with respect to age and surgical approach in Tables 2,3, respectively, with comparison of endoscopic resection to open/combined approach resections, and age <70 years with age ≥70 years. Three patients had previously received chemoradiotherapy, while one patient underwent preoperative radiotherapy. No other patients received preoperative treatment. In both age groups, adenocarcinomas were generally managed with endoscopic CFR, while SCC were resected mostly with an open or combined approach. The complication rates were similar for both age groups (P=0.019; OR =2.7; 95% CI: 0.683–10.677). There were no inpatient or 28-day postoperative mortalities captured for either age group. The only death captured was an inpatient death due to complications from a separate cancer. The median length of hospital stay was 12 days (IQR, 10–21 days) for the patients aged <70 years, while it was 11 days (IQR, 9–15.5 days) for patients aged ≥70 years. Six patients in the whole cohort did not receive postoperative radiotherapy. The median follow-up for patients aged <70 years was 45 months (IQR, 17–72 months), while for patients aged ≥70 years it was 20 months (IQR, 12.75–42.75 months).

The complications of the two groups are summarised in Table 4. The complication rates were similar in the group aged <70 years in comparison to the group aged ≥70 years. There were 12 complications in the younger group and seven complications in the elderly group. In both age groups, there were more complications in the open/combined approach resection group, compared with endoscopic. The most frequent complication was CSF leak, with 11 cases identified but only three cases required return to theatre for repair while the others were treated with conservative measures. Four cases of CSF leak were managed with lumbar drain insertion. Of the eight patients with a mFI-5 score of 2 or more, only two patients had complications while of the remaining 65 patients, who had mFI-5 scores of 0 or 1, 17 experienced complications (P=0.944).

The study had a small sample size with 73 patients having complete data sets. The study was underpowered at 0.767, as determined by post-hoc power calculations, limiting interpretation.

Discussion

Our study shows that the rates of significant complications were not increased in those aged ≥70 years (25.0%) when compared to patients <70 years (26.7%). Our cohort had 39.7% craniotomies, while the cohort in the Ganly et al. study had 75.7% craniotomies (10). Of the cohort, 89% of patients had a mFI-5 score of 0 or 1. The patients with a higher mFI-5 score, that is ≥2, did not have an increased risk of complications. Regarding mortality, our study did not identify any inpatient or 28-day postoperative deaths within both age groups undergoing endoscopic CFR resection. Our study demonstrated that older patients had a slightly shorter length of stay in hospital with a median of 11 days in comparison to a median of 12 days in the patients aged <70 years undergoing CFR.

CFR is a complex surgical procedure that involves the removal of a tumour from the base of skull and face (14,15). This procedure may be required for various malignant tumours including adenocarcinoma, SCC, and olfactory neuroblastoma (2,4,16). Overall outcomes of CFR have been favourable in recent years with overall complication rates varying from 33% to 42% in two large cohort studies including a large international collaborative study by Ganly et al. in 2011 (9). Gil et al. identified that patients aged ≥50 years had a complication rate of 38.5% while patients aged <50 years had a complication rate of 23.8% (7). Age itself has been demonstrated to increase risk of poor outcomes including higher complication rates, higher mortality rates, and longer admissions to hospital in various surgical specialties (11,17,18). Some of the complications of CFR include CSF leak, pneumocephalus, intracerebral haematomas, infections, thromboembolic events, blindness, pulmonary events, and cardiovascular events (7,8,19,20). The outcomes for patients aged ≥70 years are often influenced by their overall health status, medical comorbidities, and nutritional status (17). Elderly patients may have a higher risk of postoperative complications, such as bleeding, infection, and respiratory failure, due to age-related decline in physical function and organ reserve. Additionally, elderly patients may have a higher risk of delirium and decreased mobility after surgery (11,17,18). The results of our study are in contrast to the findings of the Ganly et al. study which found patients aged ≥70 years had a 64% complication rate, while in patients aged <70 years the complication rate was 36%. A possible reason for the similar rates between age groups in our study is the careful selection of patients for surgery, with consideration of comorbidities, and multidisciplinary team discussion. Our cohort had 39.7% craniotomies, while the cohort in the Ganly et al. study had 75.7% craniotomies (10). Of our cohort, 89% of patients had a mFI-5 score of 0 or 1, indicating good health and baseline reserve. The patients with a higher mFI-5 score, that is ≥2, did not have an increased risk of complications. Another explanation is the smaller sample size and changing trends in complication of CFR. Gil et al. have demonstrated that in recent times, the rates of postoperative infections have significantly reduced (7). The mortality rates in our study are lower than the mortality rates quoted in the literature of 3% in patients aged <70 years, and 9% in patients aged ≥70 years in the 2011 study by Ganly et al. (9). Again, the lower rates in our study may be attributed to improved case selection for surgery and the smaller sample size. Although 58.9% of patients had a T4 tumour, the majority had low frailty, as assessed by the mFI-5, with only eight patients scoring 2 or higher.

The length of stay results are not consistent with the literature findings which demonstrate increased length of stay in elderly patients, following CFR (9) as well as other major surgeries (17). A possible explanation for this finding is that the elderly subgroup experienced similar rates of complications, and perhaps with lower degrees of severity, leading to quicker recoveries and, consequently, shorter lengths of stay.

Elderly patients may require more careful management of their medical comorbidities and optimisation during the preoperative period to minimise perioperative risks (11). Despite these challenges, with thorough preoperative evaluation and close monitoring during surgery, elderly patients have been demonstrated to achieve favourable outcomes from CFR. This study supports our current policy that advanced age, in isolation, is not a contraindication for CFR. To optimise outcomes, careful patient selection and perioperative optimisation are important. Ultimately, the decision to proceed with surgery should be made after a thorough assessment of individual patient factors, including overall health status, medical comorbidities, and nutritional status. The healthcare team should collaborate closely with patients to evaluate the benefits and risks of this procedure in comparison to other treatment options.

The authors acknowledge this study has limitations. This study was underpowered, with a calculated power of 0.767. Therefore, it may not have been sufficiently powered to detect a true difference between the two age groups, limiting the generalizability of our findings. However, the lack of difference suggests that it is unlikely there is a clinically meaningful difference to exclude elderly patients from potentially curative treatment. All patients undergoing CFR are selected through a multidisciplinary team assessment, which applies to individuals of all ages. This selection process may introduce bias into the outcomes, as healthier patients with lower frailty tend to be preferenced.

Future directions of research based on this study could examine long-term disease-specific survival in this cohort, provided sufficient follow-up. Collaborative studies pooling data from multiple institutes within Australia will help determine outcomes from a national perspective for elderly patients undergoing CFR for sinonasal malignancy.

Conclusions

This study shows that within our two-centre cohort, patients undergoing CFR aged ≥70 years had comparable complication rates to patients aged <70 years, with no difference in operative mortality. Ultimately, the choice to undergo CFR should be based on a comprehensive evaluation of each patient’s unique factors, including age, general health, existing medical conditions, and nutritional status.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://www.theajo.com/article/view/10.21037/10.21037/ajo-24-79/rc

Data Sharing Statement: Available at https://www.theajo.com/article/view/10.21037/ajo-24-79/dss

Peer Review File: Available at https://www.theajo.com/article/view/10.21037/ajo-24-79/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://www.theajo.com/article/view/10.21037/ajo-24-79/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the St Vincent’s Hospital Melbourne Human Research Ethics Committee (No. 2024/PID00162) and the Epworth Health Human Research Ethics Committee (No. EH2024-1156). Because of the retrospective nature of the research, the requirement for informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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