Staging systems for Juvenile Nasopharyngeal Angiofibroma

Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon, slow growing, benign but locally invasive vascular tumor arising from tissues in the sphenopalatine foramen inside nasal cavity. JNAs are also reported to arise from posterior aspect of middle turbinate and rarely from other sites of nasal cavity and in paranasal sinuses.

JNA tumor was first described by the German surgeon and ophthalmologist Freiherr Maximilian Joseph von Chelius (1794–1846) in 1847 under the name “Fibrous Nasal Polyp”. In 1940 Friedberg introduced the term “angiofibroma”.

Juvenile angiofibroma mostly affects adolescent males of around 14 years of age, also found in children, and some cases reported in elderly.

Radiological characteristics of JNA are described separately in another article.

Staging systems for juvenile angiofibroma (JA) are important to standardize evaluation, management, and prognosis of the disease. Various surgeons have proposed multiple staging systems but each with their own pros and cons. All of them aimed to eliminate confusion among institutions with regard to surgical approaches, morbidity, and cure rates.

The following staging systems are the most commonly accepted ones for juvenile angiofibroma:

Sessions staging

This classification proposed by Sessions et al in 1981 is based on computerized tomographic findings similar to

Stage IATumor limited to posterior nares and/or nasopharyngeal vault, with no paranasal sinus extension
Stage IBSame as IA but with extension into one or more paranasal sinuses
Stage IIAMinimal lateral extension through the sphenopalatine foramen, into and including a minimal part of the medial-most part of the pterygomaxillary fossa (PMF)
Stage IIBFull occupation of the PMF with forward displacement of the posterior wall of the maxillary antrum and lateral and/or anterior displacement of the branches of the maxillary artery (superior extension may occur, eroding the orbital bones)
Stage IICExtension through the PMF into the cheek and temporal fossa
Stage IIIIntracranial extension

Advantages

  • This was considered to be the first staging system which reflect the unique behavior of JNA more accurately.

Disadvantages

  • The classification was based on the number of anatomic sites involved, rather than the actual tumor size which complicates the treatment.
  • The classification was based on nasopharyngeal carcinoma staging and thus may result in inaccurate findings.

Fisch staging

In 1983, Fisch proposed the following classification system for JNA

Type ITumor limited to the nasopharynx and nasalcavity, with no bone destruction
Type IITumor invading the PMF and the maxillary, ethmoid, and sphenoidal sinuses, with bone destruction
Type IIITumor invading the infratemporal fossa, orbit, and parasellar region, remaining lateral to the cavernous sinus
Type IVMassive invasion of the cavernous sinus, optic chiasmal region, or pituitary fossa.

Chandler staging

Based on knowledge of presumed site of origin and the growth patterns of JNA, Chandler et al in 1984 proposed the following classification.

Stage ILimited to nasopharynx
Stage IIExtending to nasal cavity and/or sphenoid sinus
Stage IIIExtending into one or more of the following: antrum, ethmoid sinus, pterygomaxillary and infratemporal fossae, orbit, and/or cheek
Stage IVWith intracranial extension

Advantages

  • Found to be useful in making decisions about the approach and management of JNA by some surgeons

Disadvantages

  • Complexity of intracranial extension not considered
  • Didn’t differentiate extra-nasopharyngeal sites, except the sphenoidal sinus and intracranial cavity.

Andrews-Fisch staging

In 1989, Andrews et al. modified the original Fisch classification, based on the growth pattern of JNA to help surgeons choose access procedures. The modified staging system was named the Andrews–Fisch classification and became the most widely used staging system.

 Class ITumor confined to the site of origin at the sphenopalatine foramen, may extend unimpeded into the nasopharynx and nasal cavity
Class II Involvement of the pterygopalatine fossa or the regional paranasal sinuses (the next major sequence of invasion)
Class IIIInvolvement of the infratemporal fossa or orbital region
Class IIIaWithout intracranial extension
Class IIIbWith extradural intracranial (parasellar) extension
Class IVIntracranial Intradural extension
Class IVaWithout cavernous sinus, pituitary or optic chaisma infiltration
Class IVbWith involvement of cavernous sinus / pituitary fossa / or optic chiasma

Advantages

  • Description of the characteristics of tumor growth and invasion, especially the analysis of extension at the skull base, makes this staging system a practical guide to the surgical approach.

Disadvantages

  • As this staging system does not incorporate advances in radiological imaging and surgical techniques, evaluation of the cure rate, incidence of complications, and local residual and recurrence rates is difficult.

The Fisch system or the Andrews–Fisch system has been recognized as the comprehensive, practical, and applicable guide to surgical approach and prediction of outcome. These systems are the most popular ones used by surgeons and is considered as the most practical and robust one.

Radowski staging

This system proposed by Radkowski et al in 1996 was based on modification of Session’s system to include posterior extension to the pterygoid plates and the extent of skull base erosion.

Stage IaLimited to nasal cavity/nasopharynx
Stage IbExtension into one or more sinuses
Stage IIaMinimal extension into pterygopalatine fossa via pterygomaxillary fissure
Stage IIbFills pterygomaxillary fossa, bowing the posterior wall of the maxillary antrum anteriorly or extending into the orbit via the inferior orbital fissure without orbital erosion
Stage IIcInfratemporal fossa extension without cheek or pterygoid plate involvement
Stage IIIaErosion of skull base (middle cranial fossa or pterygoids) with minimal intracranial spread.
Stage IIIbErosion of skull base with intracranial extension with or without cavernous sinus involvement.

Advantages

  • This staging system takes into account the choice of surgical approach and the risk of recurrence.

Onerci staging

Onerci et al in 2006 proposed this classification system for determining the risk of persistent disease after primary treatment and for choosing the appropriate surgical methods.

StagesFeaturesResidual disease
Stage IExtension to the nose, nasopharyngeal vault, and sphenoidal sinus.Low possibility of persistent disease by endoscopic/microscopic approach.
Stage II Extension to maxillary sinus or anterior cranial fossa, full occupation of the PMF, limited extension to infratemporal fossa, or the pterygoid plates posteriorlyRequires more extensive surgery, such as combining Caldwell–Luc or additional endonasal drilling
Stage III Deep extension into cancellous bone at the base of the body and the greater wing of sphenoid, significant extension to the infratemporal fossa or pterygoid plates posteriorly or orbit region, and obliteration of cavernous sinusA high possibility of persistent disease and more extensive surgery
Stage IV Intracranial extension between the pituitary gland and internal carotid artery, extension posterolateral to the internal carotid artery, and extensive intracranial extensionShould be managed via combined extensive (intracranial) surgery

Limitations

  • Cited only in one study.

UPMC staging

With the advancement in endoscopic techniques, along with preoperative image evaluation, and preoperative vascular embolization, tumor size and the extent of sinus disease are less important in predicting complete tumor removal with endonasal surgical techniques. Taking into account of these factors, the University of Pittsburgh Medical Center (UPMC) in 2010 proposed the following classification.

Stage INasal cavity,pterygopalatine fossaCan be considered to be minimal tumors and no embolisation needed prior to surgery
Stage IIParanasal sinuses,lateral pterygopalatine fossa; no residual vascularity
Stage IIISkull base erosion, orbit, infratemporal fossa involvment; but have no residual vascularity following embolizationneeds prior embolisation of the internal maxillary artery and other contributing branches of the external carotid arterial system to devascularize the tumor and facilitate surgery

 

Stage IVSkull base erosion, involvement of orbit, infratemporal fossa; with residual vascularity from the intracranial circulation following embolization
Stage VWith Intracranial extension and residual vascularity following embolization
M – with medial extension (medial cavernous sinus)
L – with lateral extension (middle fossa)

Advantages

  • Reflects changes in surgical approaches (endoscopic), route of intracranial extension, and extent of vascular supply from the internal carotid artery (ICA).
  • more effectively predicts immediate morbidity (including blood loss and the need for multiple operations) and tumor recurrence.

Carillo staging / INCan system

Based on an objective analysis of invasion patterns and tumor size, Carrillo et al proposed a novel and simple classification in 2010.

StagesFeaturesManagement
Stage ITumors located in the nasopharynx, nasal fossae, maxillary antrum, anterior ethmoid cells, and sphenoidal sinusCan be managed via an endoscopic approach
Stage IIaTumors invading to pterygomaxillary fossae or infratemporal fossae anterior to pterygoid plates, with major diameter <6 cm
Stage IIbTumors invading to pterygomaxillary fossae or infratemporal fossae anterior to pterygoid plates, with major diameter >6 cmCombined endoscopic and open approach
Stage IIITumors invading to infratemporal fossae posterior to pterygoid plates or posterior ethmoid cells.
Stage IVTumors having extensive skull base invasion >2 cm or intracranial invasionCombined anterolateral skull base approach

Yi Zixiang staging

Proposed in 2013 by Yi Zixiang et al which divides JNAs into three revised types.

TypesFeaturesApproach
Type ILocalized in nasal cavity, nasopharynx, sinus, pterygomaxillary fossa. Minimal extension in infratemporal fossa, orbit, or cranial fossaTransnasal cavity approach with endoscopic guidance
Type IILocalized in infratemporal fossa, cheek, deep or minimal anterior cranial fossa extension, minimal middle cranial fossa extension. With or without cavernous sinus and internal carotid artery compression, but dura mater intactCombined transantral–infratemporal fossa–nasal cavity approach
Type IIIFrom pterygomaxillary fossa and superior orbital fissure, extending into middle cranial fossa as a large gourd-shaped lobeCombined intra- and extracranial approach

References

  1. Sessions RB, Nick Bryan R, Naclerio RM, et al. Radiographic staging of Juvenile Angiofibroma. Head Neck Surg. 1981;3:279–83.
  2. Fisch U. The infratemporal fossa approach for nasopharyngeal tumors. Laryngoscope. 1983;93:36–44.
  3. Chandler JR, Richard Goulding R, Lee Moskowitz L, Quencer RM. Nasopharyngeal Angiofibromas: staging and management. Ann Otol Rhinol Laryngol. 1984;93(4 Pt 1):322–9.
  4. Andrews JC, Fisch U, Aeppli U, et al. The surgical management of extensive nasopharyngeal angiofibromas with the infratemporal fossa approach. Laryngoscope. 1989;99:429–37.
  5. Radkowski D, Mcgill T, Healy GB, et al. Angiofibroma: changes in staging and treatment. Arch Otolaryngol Head Neck Surg. 1996;122:122–9.
  6. Onerci M, Ogretmenoglu O, Yücel T. Juvenile nasopharyngeal angiofibroma: a revised staging system. Rhinology. 2006;44:39–45.
  7. Snyderman CH, Pant H, Carrau RL, et al. A new endoscopic staging system for angiofibromas. Arch Otolaryngol Head Neck Surg. 2010;136:588–94.
  8. Carrillo JF, Maldonado F, Albores O, et al. Juvenile Nasopharyngeal Angiofibroma: clinical factors associated with recurrence, and proposal of a staging system. J Surg Oncol. 2008;98:75–80.
  9. Yi Z, Fang Z, Lin G, et al. Nasopharyngeal angiofibroma: a concise classification system and appropriate treatment options. Am J Otolaryngol. 2013;34:133–41.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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