Development of the international orbital Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system

Abstract

Background Orbital cavernous hemangiomas (OCH) are the most common adult orbital tumor and represent an ideal index lesion for endonasal orbital tumor surgery. In order to standardize outcomes reporting, an anatomic‐based staging system was developed. Methods An international, multidisciplinary panel of 23 experts in orbital tumor surgery was formed. A modified Delphi method was used to develop the cavernous hemangioma exclusively endonasal resection (CHEER) staging system with a total of 2 rounds being completed. Results Tumors medial to a plane along the long axis of the optic nerve may be considered amenable for an exclusively endonasal resection. In select cases, tumors may extend inferolaterally if the tumor remains below a plane from the contralateral naris through the long axis of the optic nerve (ie, plane of resectability [POR]). This definition reached consensus with 91.3% of panelists in agreement. Five stages were designed based on increasing technical resection difficulty and potential for morbidity. Stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery (IMT), and orbital foramina. Staging by anatomic location also reached consensus with 87.0% of panelists in agreement. Size was not included in the staging system due to the lack of agreement on the contribution of size to resection difficulty. Conclusion Endoscopic orbital tumor surgery is a nascent field with a growing, yet heterogeneous, body of literature. The CHEER staging system is designed to facilitate international, high‐quality, standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH.

Management of Orbital Masses: Outcomes of Endoscopic and Combined Approaches With No Orbital Reconstruction

“…The cavernous hemangiomas were classified according to the recently published Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system noted in Table 2. 6 Cavernous hemangiomas in this series consisted of a stages I, III, IVA, and IVB.…”

“…Significant recent research has focused on delineating endoscopic orbital anatomy to facilitate the expansion of solely endoscopic endonasal approaches for management of these lesions. 6,9 Binarial transseptal approaches have been described to augment endoscopic dissection and retraction using a 4-handed technique. 5,[10][11][12] In 3 of our reported cavernous hemangioma resections, we utilized a cryoprobe device to securely grasp the lesion and facilitate the dissection.…”

Transnasal endoscopic resection of orbital cavernous hemangiomas: our experience with 23 cases

“…According to the Cavernous Hemangioma Exclusively Endonasal Resection (CHEER) staging system (Table ), stage I tumors were found in 7 patients (30.4%), stage II in 2 (8.5%), stage III in 2 (8.5%), stage IVA in 2 (8.5%), and stage IVB in 10 (43.5%) (Table ).…”

“…The CHEER staging system was developed primarily using the location of the tumor relative to critical structures within the orbit to facilitate standardized studies establishing the safety, efficacy, and outcomes of endonasal resection of OCH . In our study, total excision was achieved in 16 patients, including 7 with tumors located outside the muscle cone (CHEER stage I) and 9 with tumors inside the muscle cone (CHEER stage II in 2, stage III in 2, stage IVA in 2, and stage IVB in 3).…”

Evidence‐based medicine in an evolving field

“…The stages were based on the relationship of the tumor to the extraocular muscles, the inferomedial muscular trunk of the ophthalmic artery, and the orbital foramina. The resulting Cavernous Hemangioma Exclusively Endonasal Resection, or CHEER, staging system is reported in this issue with stages from I to VB, and provides a useful guide as to the difficulty of removing such a lesion through an endoscopic approach …”