How is juvenile angiofibroma staged?

Staging of Juvenile Angiofibroma

Juvenile angiofibroma is staged using several classification systems, with the Radkowski and Andrews-Fisch staging systems being the most commonly used, though newer systems (Onerci, INCan, and UPMC) are gaining traction based on advances in endoscopic surgical techniques. 1

Most Commonly Used Staging Systems

Traditional Systems

• Radkowski staging system remains one of the two most widely adopted classification systems for juvenile angiofibroma 1
• Andrews-Fisch staging system is the other most commonly utilized staging approach 1
• These traditional systems were developed before modern endoscopic techniques became standard practice 1

Emerging Modern Systems

• Onerci, INCan, and UPMC staging systems represent newer classifications that incorporate advances in technology and surgical approaches, particularly endoscopic techniques 1
• These newer systems show promising utility and are expected to gain increased popularity in the future 1

Key Anatomic Considerations for Staging

High-Risk Sites for Persistent Disease

• Involvement of the pterygoid process base is the most critical predictor of persistent disease, found in 75% (9/12) of cases with persistent disease versus only 12.5% (3/24) of cases without persistent disease 2
• Infratemporal fossa involvement occurs in 33% of cases with persistent disease 2
• Pterygomaxillary fossa extension is present in 33% of cases with persistent disease 2
• Sphenoid sinus invasion occurs in 17% of cases with persistent disease 2

Evolution of Staging Rationale

• Advances in radiographic imaging, preoperative embolization, and surgical methods have changed which anatomic sites are associated with high risk for persistent disease or morbidity 2
• Modern angled endoscopes have improved surgical exposure, necessitating updated classification systems that reflect current capabilities 2

Clinical Staging Approach

Imaging-Based Assessment

• Diagnostic imaging is the cornerstone of evaluation for juvenile angiofibroma, as preoperative biopsy is contraindicated due to hemorrhage risk 3, 4
• Staging relies entirely on radiographic assessment of tumor extent and anatomic involvement 4

Stage-Based Treatment Selection

• Early stage lesions (Stage I and some Stage II) are typically managed with endoscopic transnasal approaches 5
• Advanced lesions (most Stage II, all Stage III, and some Stage IV) require modified midfacial degloving or combined approaches 5
• Most advanced lesions with intracranial extension (some Stage IV) may necessitate combined midfacial degloving-infratemporal fossa approaches with or without craniotomy 5

Important Staging Pitfalls

• Do not attempt biopsy for staging purposes, as this carries significant hemorrhage risk and diagnosis can be made clinically and radiographically 3
• Recognize that older staging systems may not adequately account for modern endoscopic capabilities and may overestimate surgical difficulty 1, 2
• Pterygoid base involvement is the single most important predictor of persistent disease and must be carefully assessed on imaging 2