Commentary “Esthesioneuroblastoma: The Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital Experience with Craniofacial Resection, Proton Beam Radiation, and Chemotherapy”

The authors are to be commended for their work. Although their series is small, the analysis should prompt interesting debate on the optimal treatment for esthesioneuroblastoma. The overall survival and disease-free survival rates compare with the best reported series. A craniofacial resection and negative margins were strong positive predictors for better outcomes. The results also argue against induction chemotherapy in favor of a more aggressive, upfront craniofacial resection. The authors strongly advocate postoperative proton beam radiotherapy because of its unique beam characteristics and relatively low toxicity.

In our experience the morbidity associated with a craniofacial resection can be lessened by combining a transbasal approach with an endoscopic paranasal resection. In this manner, a lateral rhinotomy incision can be avoided entirely. Although some authors even propose performing the entire resection through an endoscope, we believe that skull base and dural margins are best assessed through an open approach. My otolaryngological colleagues are comfortable that they can achieve a margin-free resection with endoscopic access, given that the exposure of the deeper sphenoid and cribriform regions is well assessed through the cranial approach. Because robotic radiosurgery systems can now easily target the paranasal skull base, we also believe that there is a growing role for radiosurgery in the treatment of discrete residual or recurrent tumors.

Overall, the series provides data to the increasing body of evidence that surgery should play a critical role in the care of esthesioneuroblastoma. Long-term follow-up of this cohort will likely strengthen this opinion.