Squamous cell carcinoma of the external auditory canal. Therapeutic prognosis based on a proposed staging system

Carcinomas of the external auditory canal: Management and results: A multicenter REFCOR propensity score matching study

OBJECTIVES

To analyse prognostic factors and survival outcomes of malignant tumors of the external auditory canal, to investigate the role of regional surgery, and adjuvant radiotherapy in early stages and to investigate the role of surgery in operable T4 stage.

SETTING

A retrospective analysis was conducted on all patients prospectively included in the national database of the French Expertize Network for Rare ENT Cancers (REFCOR) from January 2000 to December 2016.

PARTICIPANTS

103 patients from 19 reference centers were included. A propensity score matching analysis was applied to enable comparisons between treatments.

MAIN OUTCOMES AND MEASURES

Event-free survival, overall survival and factors of poor prognosis of the cohort were described. The interest of local and regional surgery and postoperative radiotherapy were evaluated.

RESULTS

The factors of poor prognosis on event-free survival were immunosuppression (p = 0.002), Karnofsky status less than 90% (p = 0.02), body mass index less than 19 Kg / m2 (p = 0.0009), peripheric facial palsy (p = 0.0016), and positive margin (p = 0.0006). In early stages, locoregional surgery was associated with an increase in event-free survival (p = 0.003, HR = 0.21) versus local surgery alone, while postoperative radiotherapy was not associated with an increase in event-free survival (p = 0.86, HR = 0.91) or overall (p = 0.86, HR = 0.91). In locally advanced stages, locoregional surgery followed by radiotherapy was associated with an increase in event-free survival (p = 0.03, HR = 0.39) and overall (p = 0.02, HR = 0.34) versus chemoradiotherapy alone.

CONCLUSION AND RELEVANCE

Regional surgery is recommended for early stages of cancers of the external auditory canal. In operable cases, locoregional surgery followed by radiotherapy is recommended.

Temporal bone management in external and middle ear carcinoma

PURPOSE OF REVIEW

The purpose of this review is to outline the temporal bone management of external and middle ear carcinoma. The review will outline the current evidence involved in deciding which surgical approach to take, as well as new advances in auditory rehabilitation and immunotherapy.

RECENT FINDINGS

Traditional surgical approaches include lateral temporal bone resection, subtotal temporal bone resection and total temporal bone resection. They can also involve parotidectomy and neck dissection depending on extension of disease into these areas. Options for auditory rehabilitation include osseointegrated hearing aids, transcutaneous bone-conduction implants, and active middle ear implants. Recent advances in immunotherapy have included the use of anti-PD-1 monoclonal antibodies.

SUMMARY

The mainstay of management of temporal bone disease involves surgical resection. Early-stage tumours classified according to the Pittsburgh staging tool can often be treated with lateral temporal bone resection, whereas late-stage tumours might need subtotal or total temporal bone resection. Parotidectomy and neck dissection might also be indicated if there is a risk of occult regional disease. Recent advances in immunotherapy have been promising, particularly around anti-PD-1 inhibitors. However, larger clinical trials will be required to test the extent of efficacy, particularly around combination use with surgery.

Analysis of Prognostic Factors For External Auditory Canal Carcinoma: A 22-Year Experience

OBJECTIVE

This study aimed to investigate the prognostic factors and treatment outcomes in patients with the external auditory canal (EAC) squamous cell carcinoma (SCC).

METHODS

All patients diagnosed with EAC SCC and treated with curative intent at a single tertiary institution were retrospectively reviewed over a 22-year period. Treatment modalities included surgery with adjuvant treatment or definitive radiotherapy. The primary endpoints were overall survival (OS) and disease-specific survival (DSS).

RESULTS

There were 51 patients in our cohort. The 5-year OS and DSS were 64.0% ± 7.0% and 72.0% ± 7.0% respectively. Patients in the surgical arm and RT arm showed no significant difference in OS, DSS, and LRFS (p = 0.075, 0.062, 0.058 respectively). Compared to other routes of spread within the temporal bone, pattern of posterior disease invasion (involving mastoid/sigmoid sinus) showed poorer OS and DSS on multivariate analysis (hazard ratio, HR4.34 and 5.88; p = 0.006 and 0.009). On multivariate analysis, the following factors were independently prognostic of poorer OS and DSS: Previous radiotherapy (HR 3.29 and 4.81, p = 0.021 and p = 0.029); Presence of facial nerve palsy (HR 3.80 and 7.63, p = 0.013 and p = 0.003); Posterior pattern of invasion (HR4.05 and 3.59, p = 0.013 and p = 0.043). Advanced modified Pittsburgh stage was not predictive of poor OS and DSS (HR1.17 and 1.17 E+5, p = 0.786 and p = 0.961).

CONCLUSION

Presence of previous radiotherapy, facial nerve palsy and posterior pattern of disease invasion were independent prognostic factors of poorer survival in patients with EAC SCC.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2203-2210, 2023.

Treatment outcomes of the external auditory canal and temporal bone malignancy with dura invasion

Objectives

This study aimed to evaluate the characteristics and surgical outcomes of patients with external auditory canal (EAC) and temporal bone (TB) malignancy with dura invasion.

Methods

The medical records of patients with EAC and TB malignancy with dura invasion were retrospectively reviewed. Survival outcomes (overall survival [OS], disease-specific survival [DSS], recurrence-free survival [RFS], and distant metastasis-free survival [DMFS]) were analyzed using the Kaplan-Meier method.

Results

A total of eight patients were included in this study. The median age at diagnosis was 49.5 years (range 12-74 years). The median follow-up periods were 46.5 months. Histologically, four out of eight patients were diagnosed with squamous cell carcinoma (SCC; 50%). The 2-year OS and DSS rates of all patients were 62.5%, and those of EAC SCC patients were 50% and 66.7%, respectively; while the 2-year RFS and DMFS rates of all patients were 37.5%. There was one local recurrence at the resection site (12.5%), two regional neck nodal recurrences (25%), and two distant metastases (25%). Dura resection and duroplasty areas were not involved in the local recurrence case.

Conclusion

In EAC and TB cancer with dura invasion, radical surgery with dura resection may show similar survival outcomes to previous studies without recurrence at the dura resection site.Level of evidence: IV.

Temporal Bone Resection for Squamous Cell Carcinoma of the Lateral Skull Base: Systematic Review and Meta-analysis

OBJECTIVE

Temporal bone squamous cell carcinoma (TBSCC) is rare and often confers a poor prognosis. The aim of this study was to synthesize survival and recurrence outcomes data reported in the literature for patients who underwent temporal bone resection (TBR) for curative management of TBSCC. We considered TBSCC listed as originating from multiple subsites, including the external ear, parotid, and external auditory canal (EAC), or nonspecifically from the temporal bone.

DATA SOURCES

PubMed, Cochrane Library, Embase, and manual search of bibliographies.

REVIEW METHOD

A systematic literature review conducted in December 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Survival data were collected from 51 retrospective studies, resulting in a pooled cohort of 501 patients with TBSCC. Compared to patients undergoing lateral TBR (LTBR), patients undergoing subtotal (SBTR) or total (TTBR) TBR exhibited significantly higher rates of stage IV disease (P < .001), positive surgical margins (P < .001), facial nerve involvement (P < .001), and recurrent disease (P < .001). A meta-analysis of 15 studies revealed a statistically significant 97% increase in mortality in patients who underwent STBR or TTBR. On multivariate analysis, recurrent disease was independently associated with worse overall survival (P < .001). On univariate analysis, facial nerve involvement was also associated with decreased overall survival (P < .001).

CONCLUSION

Recurrent disease was associated with risk of death in patients undergoing TBR. Larger prospective multi-institutional studies are needed to ascertain prognostic factors for a wider array of postoperative outcomes, including histology-specific survival and recurrence outcomes.

Study of Clinicopathological Presentation and Management of Malignant Tumours of the Ear and Temporal Bone at Tertiary Care Cancer Hospital

Tumors of the ear can be benign or malignant. They can occur on the external ear or in the ear canal, the middle ear, and inner ear. Tumors in different areas of the ear behave differently. They are rare which causes several problems in diagnosis and appropriate treatment. The purpose of this study was to analyze retrospectively the patients with malignant neoplasm of the ear. The main objectives of this study were to study the clinicopathological presentation of ear and temporal bone malignancy and to study the management of different types of malignancy of ear and temporal bone. This study is conducted at our tertiary care cancer hospital from Feb 2015 to Jan 2020. This study includes 15 patients treated for malignancy of the external and middle ear. The entire patient was thoroughly examined for malignancy. Details ENT examination was done. History of smoking and tobacco chewing asked. The patient factors considered in this study were age, sex, diagnosis, treatment (surgery, radiotherapy, and chemotherapy), complications, follow-up, and recurrence. This study includes [n = 15] patients. Due to a variety of malignant lesions of the ear and temporal bone they were classified into two groups, Superficial location lesions [n = 5] 3 of disease limited to pinna and 2 cases of primary of parotid origin involving pinna. Deep location involving external auditory meatus and middle ear [n = 12]. In this study of [n = 15] cases lowest age was 18 years. male and highest age was 75 years. male and most common age group was 56-65 years in which [n = 7] patients present. In this study we studied [n = 11] male patients and [n = 4] female patients. The most common symptom present was ear discharge [n = 8], the next common symptom was hard of hearing [n = 7]. A less common symptom was facial weakness [n = 3]. In sign, mastoid tenderness was commonest in [n = 5], and less common was facial palsy in [n = 3]. In our study of [n = 15] patients we did lateral temporal bone resection in [n = 5] patients, wide local excision of lesion in [n = 4] patients, lateral temporal bone resection with postero-lateral neck dissection with PMMC flap done in [n = 2] patients. In our study of [n = 15] cases of ear malignancy most common histopathology is squamous cell carcinoma [n = 12] cases, least were basal cell carcinoma [n = 1], melanoma [n = 1], and Rhabdomyosarcoma [n = 1]. Malignant tumors of the ear and temporal bone are rare. Neoplasm's of the external and middle ear constitutes a group of various histopathological and clinical tumors that differ in diagnostic difficulties, treatment, and prognosis. Surgery is the mainstay of treatment followed by reconstruction. Radiotherapy and chemotherapy play an adjuvant role in post-operative management in the high-risk category. Prognosis is worst as the tumor stage advances. And most of the cases diagnosis was often made in the advanced stage especially for middle ear tumors that diminished the possibility of effective treatment.

Treatment of advanced squamous cell carcinoma of the external auditory canal: Critical analysis of persistent failures in diagnosis and surgery with a competing-risk model

BACKGROUND

A series of temporal bone squamous cell carcinomas (TBSCCs) was analyzed with the aim of (i) better understanding the causes for the persistent high failure rate in advanced SCCs and (ii) discussing a possible way out from this stalemate in treatment.

METHODS

Forty-five TBSCCs consecutively treated surgically were reviewed.

RESULTS

The 5-year cumulative incidence for postoperative local recurrence was 41.8%. At multivariable analysis, pT3-4 stages were associated with eightfold relative incidence of developing local recurrence during follow-up (sHR = 9.06, 95% confidence interval [CI] = 1.18-69.46, p = 0.034) and cause-specific death (sHR = 7.95, 95%CI = 1.01-62.27, p = 0.048).

CONCLUSIONS

The poor outcome in advanced TBSCC occurred because of local recurrence due to defective resection. The fundamental pitfall of surgery on advanced TBSCC appeared to be the insufficient knowledge of microscopic tumor growth in the different sites and subsites of the temporal bone. The serial histopathological study of the en bloc surgical specimen and autopsy temporal bones seems to represent a way to enhance our understanding of these tumors.

Ear canal and middle-ear tumors: a single-institution series of 87 patients

BACKGROUND

Ear canal and middle ear tumors are rare and exhibit variability in histology and clinical manifestation. Surgical resection remains the treatment of choice, but individualized approach is needed to preserve function when possible.

AIMS/OBJECTIVES

To review the management and outcome of ear canal and middle ear tumors at an academic referral center.

MATERIALS AND METHODS

Helsinki University Hospital (HUS) patient files were searched for clinically and histologically confirmed ear canal and middle ear tumors over a 14-year period. The minimum follow-up time was 2 years.

RESULTS

Eighty-seven patients with 88 tumors were identified. There were 20 (23%) benign external auditory canal (EAC), 36 (41%) benign middle ear space (MES), 29 (33%) malignant EAC, and 3 (3%) malignant MES tumors. Most (92%) tumors were managed with primary resection. Thirty-five percent of the operatively managed patients had a residual or a recurrent tumor.

CONCLUSIONS AND SIGNIFICANCE

EAC and MES tumors show great diagnostic and histologic heterogeneity with need for individualized investigative and treatment approaches. In benign tumors, we advocate aggressive local surgical control without sacrificing vital structures. In malignant tumors, we recommend local surgical control with or without adjunct RT.

A systematic review of the primary squamous cell carcinoma of the external auditory canal: survival outcome based on T-staging and proposal of a new classification

OBJECTIVE

This study aimed to provide a systematic review on survival outcome based on Pittsburgh T-staging for patients with primary external auditory canal squamous cell carcinoma.

METHOD

This study was a systematic review in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines performed until January 2018; pertinent studies were screened. Quality of evidence was assessed using the grading of recommendation, assessment, development and evaluation working group system.

RESULTS

Eight articles were chosen that reported on 437 patients with external auditory carcinoma. The 5-year overall survival rate was 53.0 per cent. The pooled proportion of survivors at 5 years for T1 tumours was 88.4 per cent and for T2 tumours was 88.6 per cent. For the combined population of T1 and T2 cancer patients, it was 84.5 per cent. For T3 and T4 tumours, it was 53.3 per cent and 26.8 per cent, respectively, whereas for T3 and T4 tumours combined, it was 40.4 per cent. Individual analysis of 61 patients with presence of cervical nodes showed a poor survival rate.

CONCLUSION

From this review, there was not any significant difference found in the survival outcome between T1 and T2 tumours. A practical classification incorporating nodal status that accurately stratifies patients was proposed.

A retrospective analysis of radiotherapy in the treatment of external auditory canal carcinoma

External auditory canal carcinoma (EACC) is a rare disease. The current study aimed to evaluate the clinical outcomes of patients treated with external beam radiotherapy (EBRT) for EACC. The present study retrospectively reviewed 34 consecutive patients treated for EACC with EBRT between February 2001 and January 2019 at the University of Tokyo Hospital. Clinical staging was performed according to the modified Pittsburgh classification. Of all the included patients, seven patients were in the early stages (I or II) and 27 in the advanced stages (III or IV) of EACC. A total of 16 patients underwent EBRT and surgery (S+RT) pre- and/or postoperatively, while 18 patients underwent definitive radiotherapy (dRT). The median prescribed doses for the S+RT and dRT groups were 66 and 70 Gy, respectively. The median follow-up period for all patients was 22.4 months (range, 2-205 months). The 5-year overall survival rates of the S+RT and dRT groups were 66.7 and 45.1%, respectively. The progression-free survival rate at 5-year was 55.6% (95% confidence interval: 36.5-71.1%) for the entire cohort. A total of 14 patients experienced disease relapse after treatment, consisting of 11 locoregional recurrences and three distant metastases. The current study revealed the clinical outcomes of EBRT for EACC.

Squamous cell carcinoma of the temporal bone: A current review

OBJECTIVES

The rarity of temporal bone squamous cell carcinoma (TBSCC) precludes a clear understanding of the disease and approach to its management. This review provides general background on the disease and discusses the current and emerging oncologic and rehabilitative management options.

DATA SOURCES

PubMed literature review.

METHODS

A review of the current literature was conducted to assess and collate up-to-date information regarding TBSCC management.

RESULTS

TBSCC is a rare and aggressive disease arising in the ear canal, temporal bone, or extratemporal sites. Prior radiation, chronic ear disease, or habitual ear picking may contribute to primary disease development. Because the symptoms of TBSCC and benign otologic disease are similar, TBSCC diagnosis may be delayed, allowing the tumor time to spread throughout the anatomically intricate temporal bone. The extent of the disease is determined based on imaging and is usually staged with the Pittsburgh Staging System. Temporal bone resection with parotidectomy and neck dissection is the current standard of care. Survival is generally good for early disease and poor for advanced disease, but chemotherapy is emerging as a promising treatment option. Auditory rehabilitation with osseointegrated hearing aids is recommended at initial oncologic resection.

CONCLUSIONS

The knowledge of and outcomes for TBSCC have improved with time, but because of the aggressive nature of the disease and the anatomic intricacy of the temporal bone, TBSCC treatment is complex and should be delivered by a multidisciplinary team. Inter-institutional collaboration may accelerate research for this rare disease.

LEVEL OF EVIDENCE

5.

The Clinical Characteristics and Surgical Outcomes of Carcinoma of the External Auditory Canal: A Multicenter Study

OBJECTIVE

To analyze the clinical characteristics and evaluate the surgical outcomes of carcinoma of the external auditory canal (CEAC).

MATERIALS AND METHODS

Overall, 31 patients from four multicenter hospitals, who were diagnosed and surgically treated for CEAC in 2009-2014, were enrolled for this retrospective study. Medical records were reviewed to determine cancer stage according to the Pittsburgh classification. Clinical data of age, sex, site, initial symptoms, surgery extent, postoperative complications including recurrence, follow-up period, and current patient status were collected for analysis. Five-year cumulative survival rate was obtained using Kaplan-Meier method.

RESULTS

At initial diagnosis, 22 patients were in the early stages (stage I: 15; stage II: 7) and 9 patients were in the advanced stages (stage III: 1; stage IV: 8). Lymph node metastasis was present in 5 patients and distant metastasis in 2. Of the 31 patients, 4 patients died (stage II: 1, stage IV: 3) during the follow-up period. Early-stage patients showed 100% 5-year estimated cumulative survival rate, whereas the advanced-stage patients showed 5-year estimated survival rate of 53.6% (p=.006). The overall survival rate of all enrolled patients was 90.3%. Although 5-year estimated disease-free survival rate of stage I was 100.0%, that for stage II was low at 30.0% because of considerable recurrences.

CONCLUSION

The results of this multicenter study suggest that more aggressive treatment modality, including adjuvant therapy, is necessary for patients with CEAC with Pittsburgh stage II or more.

Prognostic Factors Affecting Surgical Outcomes in Squamous Cell Carcinoma of External Auditory Canal

Objectives

Carcinomas of the external auditory canal (EAC) are rare, and management remains challenging. Previous studies seeking prognostic factors for EAC cancers included cancers other than carcinomas. In this study, we analyzed the treatment outcomes of, prognostic factors for, and survival rates associated with specifically squamous cell carcinoma (SCC) of the EAC.

Methods

A retrospective review of 26 consecutive patients diagnosed with SCCs of the EAC in a 10-year period was performed in terms of clinical presentation, stage, choice of surgical procedure, and adjunct therapy. Overall survival (OS) and recurrence-free survival (RFS) were calculated and univariate analysis of prognostic factors was performed.

Results

The median age of the 26 patients with SCCs of the EAC was 63 years (range, 40 to 72 years), and 16 males and 10 females were included. According to the modified University of Pittsburgh staging system, the T stages were T1 in 11, T2 in six, T3 in four, and T4 in five cases. The surgical procedures employed were wide excision in three cases, lateral temporal bone resection (LTBR) in 17, and extended LTBR in four, and subtotal temporal bone resection in two. Two patients underwent neoadjuvant chemotherapy, and two underwent adjuvant chemotherapy. One patient received preoperative radiation therapy, and eleven received postoperative radiation therapy. Of the possibly prognostic factors examined, advanced preoperative T stage and advanced overall stage were significant predictors of RFS, but not of OS.

Conclusion

The advanced T stage and overall stage were associated with decreased survival after surgical treatment in patients with SCC of the EAC, highlighting the importance of clinical vigilance and early detection.

Effect of Piecemeal vs En Bloc Approaches to the Lateral Temporal Bone on Survival Outcomes

Objectives

Lateral temporal bone resection (LTBR) has traditionally been performed en bloc in accordance with oncologic principles. Occasionally, this is not possible due to a low tegmen or lateralized vasculature. We sought to determine if outcomes of piecemeal and en bloc LTBR are comparable.

Study Design

Retrospective review.

Setting

Two academic medical centers.

Subjects and Methods

Multi-institutional retrospective cohort study. Current Procedural Terminology codes were used to identify patients with T1 to T3 squamous cell carcinoma of the external auditory canal (EAC) who underwent LTBR from 2005 to 2015. Kaplan-Meier curves were constructed to compare total survival between the 2 treatment approaches. Pairwise comparisons were performed using χ2 and Fisher exact tests (significance at P = .05), as appropriate.

Results

Twenty-five patients were identified. Ten patients underwent en bloc LTBR; 15 underwent piecemeal LTBR. Median follow-up time was 11 months (range, 1-60 months). There was not a significant difference in overall survival between en bloc (38.9 months; 95% confidence interval [CI], 22.7-55.2) compared to piecemeal (37.5 months; 95% CI, 21.1-53.9) procedures ( P = .519). Estimates of disease-free survival also did not reveal statistically significant differences: estimated mean disease-free survival was 48.1 months (95% CI, 33.7-62.6) in en bloc patients and 32.5 months (95% CI, 17.1-47.8) in piecemeal patients ( P = .246).

Conclusion

These data suggest that piecemeal resection can be considered for cases of squamous cell carcinoma involving the external auditory canal where anatomic constraints preclude a safe en bloc resection. Larger studies or studies with a longer follow-up time may provide improved insight into survival comparisons.

The Outcomes of Surgery and Chemoradiotherapy for Temporal Bone Cancer

OBJECTIVE

We aimed to evaluate the prognostic factors and efficacy of treatment modalities for patients with temporal bone cancer, and to determine if definitive chemoradiotherapy (CRT) for advanced-stage disease can provide a substitute for highly invasive surgeries.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

Sixty-six patients with previously untreated squamous cell carcinoma of the temporal bone treated with curative intent between April 1997 and March 2015.

INTERVENTION

Surgery alone, radiotherapy (RT) alone, surgery followed by RT or definitive CRT.

MAIN OUTCOME MEASURE

The overall survival (OS) rate.

RESULTS

The 5-year OS rate for each T classification was 100% for T1, 76.2% for T2, 55.6% for T3, and 36.7% for T4. Univariable and multivariable analysis showed that T classification was an independent predictor of the OS rate (hazard ratio 5.66; 95% confidence interval 1.51-27.0; p = 0.015). Analysis by treatment modality revealed that the 5-year OS rate for patients with T1-2 was 100% for surgery and 81.3% for RT alone. The rate for patients with T3-4 was 52.1% for definitive CRT and 55.6% for surgery followed by RT with or without chemotherapy.

CONCLUSIONS

Patients with T1-2 benefited from surgical intervention without significant morbidity or mortality. Our findings also suggested that definitive CRT might be appropriate as the first-line treatment for T3-4, especially in cases with unresectable tumors.

Hypofractionated Stereotactic Radiotherapy for Auditory Canal or Middle Ear Cancer

BACKGROUND

Stereotactic radiotherapy (SRT) may represent a new treatment option for individuals with auditory canal or middle ear cancer.

METHODS

Study participants with pathologically proven ear cancer were treated with SRT (35 Gy for 3 fractions or 40 Gy for 5 fractions) as first-line therapy. When local tumor recurrence developed following SRT, subtotal temporal bone resection and postoperative chemoradiotherapy were performed as salvage treatment. Boluses were used for the initial 14 study patients.

RESULTS

Twenty-nine study participants were enrolled and staged with T1 (n = 3), T2 (n = 7), T3 (n = 14), or T4 disease (n = 5). Three-year overall survival rates were 69% for T1/2 disease, 79% for T3 disease, and 0% for T4 disease. Three-year local control rates were 70% for T1/2 disease, 50% for T3 disease, and 20% for T4 disease. Grade 2 or higher dermatitis or soft-tissue necrosis occurred more frequently in study patients treated with boluses (8/14 vs 2/15; P = .02). Salvage treatment was safely performed for 12 recurrent cases.

CONCLUSIONS

These results suggest that SRT outcomes are promising for patients with ear cancer (? T3 disease). The rate of toxicity was acceptable in the study patients treated without boluses. Outcomes of salvage surgery and postoperative radiotherapy following SRT were also encouraging.

The contribution of CT and MRI in staging, treatment planning and prognosis prediction of malignant tumors of external auditory canal

Carcinomas of external auditory canal (EAC) are rare. Radiological imaging particular in computed tomography (CT) and magnetic resonance imaging (MRI) plays an important role in the staging, treatment planning and follow up of the patients with malignant EAC tumor. This article aims to review the role of CT and MRI in the describing different tumor growth pattern, tumor staging, treatment planning, follow up and predicting the prognosis of malignant tumors of EAC.

Management outcomes following lateral temporal bone resection for ear and temporal bone malignancies

Objective

To evaluate clinical outcomes following lateral temporal bone resection (LTBR) for management of malignancies involving the ear or temporal bone.

Subjects and Methods

A retrospective medical record review was performed on patients receiving LTBR for management of malignancies involving the ear or temporal bone between 1990 and 2007.

Results

In this group of 35 patients, the mean age was 62.7 years, with tumor histopathologies including squamous cell carcinoma (SCC, 20), basal cell carcinoma (BCC, 7), adenoid cystic carcinoma (ACC, 7), and adenocarcinoma (1). The 5-year overall survival (OS), disease-specific survival (DSS), and disease-free survival (DFS) were 77%, 79%, and 52%, respectively. Complete resection resulted in improved OS, DSS, and DFS ( P < 0.004 for each) and reduced local recurrence ( P < 0.001).

Conclusions

In patients with carcinomas of the ear and temporal bone, upfront excision including LTBR is an effective management when combined with postoperative radiation therapy. Complete removal of all disease may improve survival and decrease recurrence.

Detection of Epstein-Barr and Human Papilloma Viruses in the Middle Ear Squamous Cell Carcinoma

The uncommon ear tumor of middle ear squamous cell carcinoma (MESCC) is thought to be associated with the history of long-term chronic otitis media in the most cases. The main etiologic factor of MESCC is still unclear and may be multifactorial. Infections of Epstein-Barr virus (EBV) and Human Papillomavirus (HPV) are considered as one of the etiologic factor of MESCC. Previous studies have shown that the EBV and HPV have been detected in MESCC. Although the EBV and HPV have been implicated in human malignancies, their roles in pathogenesis of MESCC have not been elucidated. There has never been report on the presence of EBV and HPV in Indonesian MESCC. This study aimed to determine the presence of EBV and HPV in MESCC. Seven paraffin-embedded tissues of speciment from biopsy were analyzed for the presence of EBV and HPV by immunohistochemistry, stained using polyclonal antibody anti EBNA1 and anti HPV. The samples consisted of 4 (57 %) males and 3 (43 %) females with age range of 26-87 years old. Immunohistochemistry result demonstrated that EBV was detected in three of seven (43 %) and HPV in two of seven (29 %) samples. Coexistence of the presence of EBV and HPV were found in one of seven (14 %) sample. The presence of EBV and HPV in MESCC suggests that viral infection may play an important etiologic role in the carcinogenesis of middle ear.

Outcomes of 18 cases with squamous cell carcinoma of middle ear who underwent both surgery and post-operative radiotherapy

CONCLUSIONS

Early diagnosis and treatment were critical to prevent recurrence, and the long-term outcomes were satisfactory after surgery and post-operative radiotherapy.

OBJECTIVES

To present outcomes of 18 cases with squamous cell carcinoma of the middle ear who underwent both surgery and post-operative radiotherapy.

METHODS

Eighteen cases with squamous cell carcinoma of the middle ear (two cases of T1, five of T2, and 11 of T3) underwent surgery and post-operative radiotherapy, and a surgical approach was determined by tumour sites. Extended mastoidotympanectomy was performed on two cases, with subtotal temporal bone resection on 12 cases and temporal bone resection on four cases. The patients who had cervical metastasis underwent additional radical neck resection and post-operative radiotherapy at the neck. The patients were followed-up after surgery.

RESULTS

During the follow-up, no cases of T1 recurred, and six cases of T2 or T3 recurred, with the total recurrence rate of 37.5% among the patients of T2 and T3. At the fifth year after surgery, 15 patients were still alive, and the actual 5-year survival rate was 83.3% among all patients.

Radiological Findings of Malignant Tumors of External Auditory Canal: A Cross-Sectional Study Between Squamous Cell Carcinoma and Adenocarcinoma

The primary malignant tumors of external auditory canal (EAC) are rare. The purpose of this study is to compare the imaging features of growth and recurrence pattern between 2 most common carcinomas namely squamous cell carcinoma (SCC) and adenocarcinoma of the EAC.This is a retrospective study involving 41 patients with primary EAC carcinomas of which 22 are SCC and 19 are adenocarcinoma. They were all scanned with high resolution computer tomography (HRCT) and magnetic resonance imaging. Follow-up clinical and imaging studies have also been collected and compared with a median follow-up time of 43 months (range 5-192 months). Necrosis was presented as hypodensity on computed tomography images, hyper-intense on T2WI and heterogeneous enhancement.Eighteen patients were diagnosed to be in T1 and T2 stage, it was found that SCC involved both the cartilaginous part and the bony part of the EAC (11/12), whereas adenocarcinoma involved only the cartilaginous part (6/6) (P < 0.01). Twenty-three patients were diagnosed to be in T3 and T4 stage showed bony involvement and adjacent tissue involvement for both SCC and adenocarcinoma. Parapharyngeal space involvement is much more common in recurrent SCC (P = 0.02). Lymph node metastasis was seen in 6 out of 22 patients with SCC, while 5 out of 19 patients of adenocarcinoma had lung metastasis, even at early stage (1/6; 1/5). Necrosis is more likely to occur in the patients with SCC (9/10) than that of adenocarcinoma (3/13) (P = 0.02).SCC and adenocarcinoma is seen to have different growth pattern at early stage but share similar patterns in the advanced stage. Lymph node metastasis is commonly seen in patients with SCC while adenocarcinoma shows lung metastasis even at early stage.

Primary definitive radiotherapy with or without chemotherapy for squamous cell carcinoma of the temporal bone

We aimed to evaluate the impact of concurrent chemoradiotherapy (CCRT) on the survival of patients with squamous cell carcinoma of the temporal bone. We retrospectively analyzed the data of 13 consecutive patients who were treated by definitive radiation therapy (RT) or CCRT as the initial treatment between 1999 and 2012. There were 5 patients with stage II disease, 5 with stage III, and 3 with stage IV, as classified according to the University of Pittsburgh system. Among these, 2, 4, and 3 patients, respectively, were treated by CCRT; whereas the remaining (3 patients with stage II and 1 with stage III) were treated by RT alone. Median follow-up duration was 39 months (12-106 months) in all cases, and 61.5 months (17-70 months) in censored cases. The 5-year overall survival (OS) rates were 51 % in all patients, and 40, 100, and 0 % in patients with stage II, stage III, and stage IV disease, respectively. In patients with stage II and III disease, the 5-year OS rates were 80 % in the CCRT group and 50 % in the RT-alone group. We found better prognosis in patients with stage II and III disease who were treated by CCRT. Only 2 patients treated by CCRT experienced adverse events more than grade 3, which were neutropenia and dermatitis. There was no late adverse event of bony necrosis. Our study results indicate that CCRT is safe and very effective as a first-line treatment for stage II and III squamous cell carcinoma of the temporal bone.

Factors associated with recurrence of squamous cell carcinoma involving the temporal bone

OBJECTIVE

This study aimed to better identify factors associated with recurrence of squamous cell carcinoma (SCC) involving the temporal bone.

METHODS

A retrospective study was conducted at a tertiary hospital. Sixty patients who were diagnosed over a 10-year period with SCC involving the temporal bone and underwent surgical resection were analyzed. All patients were staged based on the University of Pittsburgh staging system. Demographic, intraoperative, and pathologic data were analyzed with respect to recurrence.

RESULTS

Thirteen (21.7%) patients were T1, 8 (13.3%) T2, 7 (11.7%) T3, and 32 (53.3%) T4. Eighteen patients (30.0%) recurred in the study period. The mean time to recurrence was 5.8 months. Tumors originating in the skin overlying the parotid gland and the external auditory canal had higher recurrence rates than those from the auricle/postauricular skin and temporal bone (P = .05). Direct parotid and perineural spread accounted for 15.0% of all routes of temporal invasion but resulted in 22.2% of all recurrences (P = .04). Increased N stage was statistically associated with increased risk of recurrence (P = .01). Cervical, as compared to perifacial and parotid, lymph node involvement was associated with increased risk of recurrence (odds ratio = 6.91; 95% confidence interval, 1.11-42.87).

CONCLUSION

We have identified multiple factors that are associated with increased recurrence of SCC involving the temporal bone.

Cancer of the external auditory canal

INTRODUCTION

Cancer of the external auditory canal is a rare tumour with an annual incidence of one per one million inhabitants. The objective of this study was to evaluate the 5-year overall survival and disease-free survival rates in a series of patients with carcinoma of the external auditory canal and to compare our results concerning the clinical presentation, management and survival with those of the literature.

PATIENTS AND METHOD

Ten patients were included in this retrospective, single-centre study over a 20-year period. Data concerning age, symptoms, imaging, TNM stage according to the Pittsburgh classification, histology, management, sequelae, recurrences and survival were recorded.

RESULTS

The mean age of the patients of this series was 60.7 years. Seven patients had a squamous cell carcinoma. The other histological types were undifferentiated carcinoma, adenoid cystic carcinoma and neuroendocrine carcinoma. Staging was based on the Pittsburgh classification with one stage I, one stage III and eight stage IV tumours. Five-year overall survival rates were 100%, 50% and 0%, respectively. The mean 5-year overall survival rate was 35% and the mean 5-year disease-free survival rate was 24%.

CONCLUSION

Carcinoma of the external auditory canal is a difficult diagnosis when the tumour does not present as a fungating mass protruding from the external auditory canal. The Pittsburgh classification was used for TNM staging of these tumours, allowing comparison of our results with those of the literature. The clinical findings and survival rates observed in this study are comparable to those reported in the literature. These tumours are associated with a poor prognosis on the basis of our results and published data.

Squamous cell carcinoma of the external auditory canal: A case report and review of the literature

Squamous cell carcinoma of the external auditory canal, middle ear and temporal bone is a rare and unusual malignancy. The lack of a unifying classification system in the past, along with the rarity of the disease has made the development of clear treatment guidelines difficult. In this report, we describe a clinical case of a patient with this rare malignancy, discuss the challenges associated with the diagnosis and treatment of the disease, and review the literature for trends while outlining the most beneficial treatment strategy for this patient population.

A case of Basal cell carcinoma of external auditory canal

Malignant tumor originated from external auditory canal (EAC) is very rare with an annual incidence of around 1 per million. Pathologically, squamous cell carcinoma is incidentally most common, and adenoid cystic carcinoma, basal cell carcinoma, and melanoma follow in decreasing order. Due to the rarity of malignant tumor of EAC, there is no widely accepted treatment modality yet. But basal cell carcinoma, known to be less aggressive tumor, can be removed with a minimal safety margin and have better treatment results. Recently we experienced a case of basal cell carcinoma in the EAC, confined in the cartilaginous portion of EAC, presenting with intermittent otorrhea for several years. The patient was treated with a sleeve resection of the EAC with a safety margin reconstructed with a split-thickness skin graft. No tumor recurrence or complication was noted in the first postoperative year.

Concomitant chemoradiotherapy as a standard treatment for squamous cell carcinoma of the temporal bone

We sought to characterize the effectiveness of concomitant chemoradiotherapy (CCRT) for patients with squamous cell carcinoma of the temporal bone. We performed a retrospective chart review of 14 patients with cancer of the temporal bone who were provided initial treatment in our hospital from December 2001 to November 2008. Four patients with stage I tumors were treated by radiation therapy alone or with oral administration of S1. One patient with a stage II tumor was treated by radiation therapy concomitant with low dose docetaxel. Nine patients with stage IV tumors were treated by CCRT using the TPF regimen (docetaxel, cisplatin, and 5-fluorouracil). As an initial treatment, all patients but one were treated by radiation therapy with or without chemotherapy. Grade 4 adverse events of patients who received CCRT using the TPF regimen involved the leukopenia in one patient and the neutropenia in two patients. Local recurrences were observed in three patients including two patients with T4 tumors. Five-year disease-specific survival rates for all patients and for patients with T4 tumors were 78% and 67%, respectively. CCRT using the TPF regimen is safe and effective as the first treatment for patients with cancer of the temporal bone.

Predictors of survival and recurrence after temporal bone resection for cancer

BACKGROUND

The purpose of this study was to identify factors predictive of outcome in patients undergoing temporal bone resection (TBR) for head and neck cancer.

METHODS

This was a retrospective study of 72 patients undergoing TBR. Factors associated with survival and recurrence were identified on multivariable regression.

RESULTS

Most tumors were epithelial (81%), commonly (69%) involving critical structures. Cervical metastases were uncommon (6%). Squamous cell carcinoma (SCC) of the external auditory canal carried a high rate of parotid invasion (25%) and parotid nodal metastases (43%). The 5-year rate of overall survival (OS) was 62%; disease-specific survival (DSS), 70%; recurrence-free survival (RFS), 46%. Factors independently associated with outcome on multivariable analysis were margin status and extratemporal spread of disease to the parotid, mandible, or regional nodes. Recurrence was common (72%) in cT3-4 tumors.

CONCLUSIONS

Margin status and extratemporal disease spread are the strongest independent predictors of survival and recurrence. In SCC of the external auditory canal, high rates of parotid involvement support adjunctive parotidectomy. Risk of recurrence in T3-T4 tumors may support a role for adjuvant therapy.

Malignant tumors of the ear and temporal bone: a study of 27 patients and review of their management

OBJECTIVE

To evaluate the management of patients with malignant tumors of the ear and temporal bone.

DESIGN

Retrospective analysis of data.

SETTING

Radcliffe Infirmary, Oxford, United Kingdom.

PARTICIPANTS

Twenty-seven patients were classified into two groups according to the site of origin of the tumor: (1) superficial (17 tumors): tumors arising from the skin of the pinna, parotid, and temporomandibular joint area; (2) deep (10 tumors): tumors arising in the ear canal and temporal bone.

MAIN OUTCOME MEASURES

Treatment modality, complications, recurrence rate, disease-free interval, and survival.

RESULTS

The mean follow-up period was 25 months (0 to 60), and the median overall survival 46 months (0 to 102). Complications occurred in 6 patients (22%). The 3-year survival was 38% (95% confidence interval [CI], 19 to 58%), and the 5-year survival 19% (95% CI, 3 to 35%).

CONCLUSIONS

There were insufficient data to demonstrate any difference in survival or disease-free interval related to the site of tumor origin (superficial versus deep tumors). There were independent differences in survival in favor of both performing parotidectomy and using postoperative radiotherapy, but neither reached significance at the 0.05 level.

The role of facial palsy in staging squamous cell carcinoma of the temporal bone and external auditory canal: a comparative survival analysis

OBJECTIVES

The role for facial palsy in the Pittsburgh staging system for squamous cell carcinoma (SCC) of the external auditory canal (EAC) is unclear. The objective of this study was to conduct a systematic review of published studies to determine the impact of facial palsy on survival outcomes.

DATA SOURCES

A search of MEDLINE, EMBASE, Cochrane Central Register of Clinical Trials, Cochrane, clinicaltrials.gov, and the National Guideline Clearinghouse databases was supplemented by hand searching.

STUDY SELECTION

Articles selected for final analysis had individual subject data on staging and/or facial nerve function, outcome, and follow-up period.

DATA EXTRACTION

Data extracted included demographics, type and stage of cancer, survival, and facial nerve status.

DATA SYNTHESIS

Of 3,046 citations identified by a systematic literature search, 21 case series including 348 subjects with SCC of the EAC met criteria for analysis. The overall and disease-specific survival for subjects with facial palsy were significantly worse than subjects without facial palsy, regardless of stage (p = 0.006 and p = 0.002, respectively). The overall survival outcome for subjects with facial palsy was significantly worse than subjects with stage PITT-2000 T3-designated cancer (p = 0.027) and demonstrated no statistically significant difference from stage PITT-2000 T4-designated cancer (p = 0.897).

CONCLUSION

This pooled-data survival analysis for SCC of the EAC demonstrates that facial nerve involvement is associated with a poor outcome and that the survival outcomes for subjects with facial palsy more closely parallel the survival curves of advanced stage T4 disease. Disease with facial palsy should be classified as stage T4, in accordance with the PITT-2000 system.

Lateral Temporal Bone and Parotid Malignancy With Facial Nerve Involvement

Objectives. To review our institution’s experience and outcomes in the treatment of lateral temporal bone (LTB) and parotid malignancy with facial nerve (FN) involvement. To identify risk factors for treatment failures and to clarify previously established prognostic factors for this advanced-stage disease.

Study Design. Case series with chart review.

Setting. Tertiary care academic hospital.

Subjects and Methods. A series of 26 patients treated operatively for malignancy of the LTB and parotid gland with FN involvement were reviewed retrospectively. All patients underwent sacrifice of the FN due to intraoperative determination of nerve invasion. Demographic, historical, intraoperative, pathologic, and follow-up data were collected and analyzed to determine survival outcomes and locoregional control. Risk factor analysis was performed.

Results. The FN was found to be grossly involved by tumor at the stylomastoid foramen in 57.7% of patients, resulting in sacrifice more proximally in the vertical segment in 57.7%. Statistical analysis demonstrated a locoregional recurrence rate of 34.6%, with the majority of recurrence occurring within the first 2 years after surgery. The rate of distant failure was 15.4%. Kaplan-Meier and chi-square analysis showed an overall survival of 76.0%, 66.7%, 35.3%, 31.2%, and 28.6% at 1, 2, 3, 4, and 5 years, respectively. Advanced age, the presence of tumor of epithelial origin, and pathologically positive lymph nodes are significantly predictive of poor survival.

Conclusion. Outcomes of malignancy of the LTB with FN involvement treated with primary surgical therapy compare favorably with previously published control rates, and overall prognosis for this condition is likely better than historically established.

The problem of nodal disease in squamous cell carcinoma of the temporal bone

CONCLUSION

The prognosis of the clinically positive neck in temporal bone squamous cell carcinoma is bad and failures never occur in the neck but at the site of the primary. A clinically positive neck at presentation is a sign of aggressiveness of the primary and, in such cases, therapeutic neck dissection is to be performed. The role of elective neck dissection is partially supported by our results, but as prognosis worsens and survival drops when a positive node appears in the neck, elective dissection is still advocated. In our material, no recurrence was recorded in the neck, but it was the resection of the primary tumor that proved to be oncologically inadequate. This led to the conclusion that in cases of clinically positive necks a more extended and adequate approach to the primary is thus advocated.

OBJECTIVE

This work aimed to determine the prognostic role of positive neck nodes in squamous cell carcinoma of the temporal bone.

METHODS

We studied the homogeneous case material of 47 surgical cases of temporal bone squamous cell carcinoma, operated on between the years 1983 and 2004. All the cases were reviewed retrospectively, staged according to the Pittsburgh classification, and the follow-up was updated at June 2008 with MRI. The minimum follow-up was set at 3 years.

RESULTS

All the cases but two were treated with therapeutic or elective neck dissection. The neck was assessed both clinically and pathologically. The cases with clinically positive neck nodes at presentation had unfavorable prognosis. All the failures recurred at the site of the primary and never in the neck. The comparison of outcomes between the cases with clinically positive and negative necks showed a difference in survival. The rate of micrometastasis in the clinically negative neck was investigated as well. Our results indicate that though the necessity of elective neck dissection is still controversial, the bad prognostic value of the clinically positive neck is such to support the indication to treat the clinically negative neck.

Superselective, intra-arterial, rapid infusion chemotherapy for external auditory canal carcinoma

Previously, the treatment of carcinoma of the external auditory canal has mainly involved surgical resection. In order to enable organ preservation and to obtain cancer-free surgical margins, we introduced the use of superselective, intra-arterial, rapid infusion chemotherapy combined with radiotherapy to treat this condition.

We reviewed our patients' tumour stages, feeding arteries and clinical outcomes. Tumours were staged according to the Pittsburgh staging system. Chemotherapy was administered intra-arterially in the angiography suite via transfemoral catheterisation of the feeding arteries. Four patients underwent superselective, intra-arterial, rapid infusion chemo-radiotherapy. A complete response was obtained in all four patients. The overall toxic side effects were modest.

Superselective, intra-arterial, rapid infusion chemotherapy can be an effective, organ-preserving treatment for external auditory canal carcinoma, with a high cure rate.

Treatments and outcomes of malignant tumors of external auditory canal

PURPOSE

Primary cancer of the external auditory canal (EAC) is a rare disease with poor prognosis. Because of the rarity of this entity, there is no large series for staging, treatments, and outcomes. The purpose of this study is to evaluate the treatment modalities and outcomes for malignant tumors of EAC at our institute, comparing with other studies.

METHODS

We retrospectively reviewed the patients treated for primary cancer of EAC between 1991 and 2002 at our hospital, which is a tertiary referral center. Ten males and 2 females were enrolled in this study. The median follow-up period was 56.5 months. The interventions included sleeve resection, radical mastoidectomy, or lateral temporal bone resection combined with neck dissection or parotidectomy. Adjuvant radiotherapy was performed in case of incomplete resection. All patients were staged according to the Pittsburgh staging system.

RESULTS

Ten patients had squamous cell carcinoma and 2 had adenoid cystic carcinoma (ACC). Five patients had stage I disease, 2 with stage II, 1 with stage III, and 4 with stage IV. All patients (n = 7) with early stage (I or II) were disease-free, but only 1 of 5 patients with late stage (III or IV) was disease-free. The recurrences occurred in 50% (2/4) of patients with incomplete resection, despite of the adjuvant radiotherapy. Only one patient with complete resection had recurrence and the histologic diagnosis of this particular patient was ACC.

CONCLUSIONS

Patients with early-stage cancer can benefit from less aggressive surgical interventions without significant morbidity or mortality. No recurrence occurred in patients with complete resection except the one with ACC. The result of our institute was comparable or superior to those of other studies in early-stage disease. However, patients with advanced cancer had high recurrence rate despite of adjuvant radiotherapy, suggesting more aggressive surgical approach for complete resection was necessary.

Long-term outcome following radical temporal bone resection for lateral skull base malignancies: a neurosurgical perspective

OBJECT

Primary temporal bone malignancy is a rare form of tumor for which the therapeutic strategy remains controversial. In this study, the authors reviewed their experience with radical temporal bone resection (TBR) of such lesions and analyzed the long-term results to provide treatment recommendations.

METHODS

Between 1994 and 2006, 17 patients (10 men and 7 women) underwent total or subtotal TBR for primary temporal bone malignancies. Tumors were graded according to the University of Pittsburgh system. The effects of surgical margins and tumor extensions on patient survival were analyzed using the Kaplan-Meier method.

RESULTS

All tumors, except 1, were graded T4 (most advanced). Subtotal TBR was performed in 14 patients, and total TBR was performed in 3. The surgical margin was tumor negative in 10 patients and tumor positive in 7. For large tumors extending into the infratemporal fossa or encroaching on the jugular foramen, orbitozygomatic (3 patients) and posterior transjugular (4 patients) approaches were combined with the standard approach, and en bloc resection with a negative margin was achieved in all cases but 1. The follow-up time ranged from 0.3-11.6 years (mean 3.3 years). The 5-year recurrence-free and disease-specific survival rates were 67.5 and 60.1%, respectively. When a negative surgical margin was achieved, the survival rates improved to 100 and 89%, respectively.

CONCLUSIONS

The neurosurgical skull base technique could improve the probability of en bloc resection with a tumor-free margin for extensive temporal bone malignancies, which would cure a subset of patients. The active participation of neurosurgeons would improve patient care in this field.

Squamous cell carcinoma of the temporal bone

Objective:

The aim of this study was to present the management and survival data of patients with squamous cell carcinoma of the temporal bone, and to discuss whether extensive surgery improves survival.

Patients and methods:

Retrospective, case-series review of 17 patients (18 cases) with temporal bone carcinoma (15 primary and three recurrent tumours), over a period of 20 years.

Setting:

Tertiary referral centre – university hospital.

Main outcome measures:

Disease-specific and overall five-year survival.

Results:

The mean age at presentation was 63 years, with a range of 39 to 75 years. Twelve cases ofde novotumour were managed by surgical resection followed by adjuvant radiotherapy in 10 cases, while three such patients were considered incurable from the outset and were given a combination of radiotherapy and chemotherapy. Of the three patients referred to our unit with recurrent disease, two were treated elsewhere with radical mastoidectomy and one with chemoradiation; all were subsequently managed by subtotal petrosectomy. The disease-specific and overall five-year survival for the entire cohort was 64.17 per cent (mean 89 months; 95 per cent confidence interval, 62–117) and 47.06 per cent (mean 70 months; 95 per cent confidence interval, 43–98), respectively. The disease-specific and overall survival for patients with advanced T3and T4tumours was 59 per cent (mean 83 months; 95 per cent confidence interval, 53–113) and 40 per cent (mean 62; 95 per cent confidence interval, 33–91 months), respectively. All but one recurrence developed within 12 months of initiating treatment. No deaths occurred after 26 months of follow up.

Conclusions:

A lateral temporal bone resection is adequate treatment for T1and T2tumours. Post-operative radiotherapy should probably be offered for large T2tumours. For T3and T4tumours, a subtotal petrosectomy with parotidectomy followed by post-operative radiotherapy is adequate treatment, as it offers a similar outcome to that of more extensive procedures.

Treatment and Prognosis of Squamous Cell Carcinoma of the External Auditory Canal and Middle Ear: A Multi-Institutional Retrospective Review of 87 Patients

PURPOSE

To examine the relative roles of surgery, radiotherapy, and chemotherapy in the management of patients with squamous cell carcinomas of the external auditory canal and middle ear.

METHODS AND MATERIALS

The records of 87 patients with histologically confirmed squamous cell carcinoma who were treated between 1984 and 2005 were reviewed. Fifty-three patients (61%) were treated with surgery and radiotherapy (S + RT group) and the remaining 34 patients with radiotherapy alone (RT group). Chemotherapy was administered in 34 patients (39%).

RESULTS

The 5-year actuarial overall and disease-free survival (DFS) rates for all patients were 55% and 54%, respectively. On univariate analysis, T stage (Stell's classification), treatment modality, and Karnofsky performance status had significant impact on DFS. On multivariate analysis, T stage and treatment modality were significant prognostic factors. Chemotherapy did not influence DFS. The 5-year DFS rate in T1, T2, and T3 patients was 83%, 45%, and 0 in the RT group (p < 0.0001) and 75%, 75%, and 46% in the S + RT group (p = 0.13), respectively. The 5-year DFS rate in patients with negative surgical margins, those with positive margins, and those with macroscopic residual disease was 83%, 55%, and 38%, respectively (p = 0.007).

CONCLUSIONS

Radical radiotherapy is the treatment of choice for early-stage (T1) diseases, whereas surgery (negative surgical margins if possible) with radiotherapy is recommended as the standard care for advanced (T2-3) disease. Further clarification on the role of chemotherapy is necessary.

Bilateral external auditory canal squamous cell carcinoma: a case report

Squamous cell carcinoma (SCC) of the external auditory canal (EAC) is an extremely rare malignant tumor with a prevalance between 1 and 6 cases per 1 million population. The incidence is higher in patients presenting with otological diseases (1 in 5,000 to 15,000). Certain associating factors have been described in the literature. This malignancy frequently presents with symptoms similar to a case of otitis externa or a chronic suppurative otitis media. In this paper, we present a patient who had bilateral SCC of EAC caused by radiotherapy for nasopharyngeal carcinoma. To our knowledge, our case is the fifth bilateral SCC of the EAC and the first bilateral radiotherapy related SCC of the EAC reported in the literature so far.

Squamous cell carcinoma of the external auditory canal and middle ear: an operation combined with preoperative chemoradiotherapy and a free surgical margin

OBJECTIVE

Treatment outcomes for squamous cell carcinoma of the temporal bone were evaluated regarding stage, therapeutic strategy, and prognostic factors.

STUDY DESIGN

Retrospective case review.

SETTING

University hospital and outpatient clinic.

PATIENTS

Twenty-five patients with primary squamous cell carcinoma of the external auditory canal and middle ear.

INTERVENTION

Preoperative chemoradiotherapy and radiotherapy were used in 7 of 12 patients. Lateral temporal bone resection was performed for the lesions not beyond the tympanic membrane. Subtotal temporal bone resection was chosen for lesions extending to the middle ear cavity when there was no invasion to the pyramidal apex, carotid canal, or dura or metastasis. Others were conservatively treated by chemoradiotherapy. When the performance status was poor or an agreement regarding the operation could not be reached, the treatment was modified.

MAIN OUTCOME MEASURE

Estimated survival rates.

RESULTS

The 3-year estimated survival for T1 and T2 lesions was 100%. The 5-year estimated survival for T3 and T4 lesions was 80% and 35%, respectively. The 5-year estimated survival improved up to 75% for T4 tumors with operation and 16% for those without operation after 47 months. The tumor-free surgical margin is significantly related to patient survival in T3 and T4 lesions. Multivariate analysis predicted that concomitant chronic otitis media and positive lymph nodes were significantly associated with poorer survival.

CONCLUSION

The tumor-free surgical margin was important to survival. When T4 lesions did not involve the pyramidal apex, carotid canal, dura, or any lymph nodes, the surgical intervention improved the estimated survival rate to a level as good as T3 lesions.

Analysis of 95 cases of squamous cell carcinoma of the external and middle ear

OBJECTIVE

To analyze the clinical characteristics, 5-year survival, and prognostic factors of squamous cell carcinoma (SCC) of the external and middle ear.

METHODS

A multi institutional study. Ninety five cases of patients from 10 institutions were reviewed on their age and sex distribution, initial complaints, stages, tumor locations, treatments, and outcomes. Prognostic factors were discussed based on the Pittsburgh staging system.

RESULTS

This disease seems to appear in the elderly with a peak age of 50-69 years. Males appear to be more predisposed than females with an odd ratio of 1.7. The initial complaints were not typical, while 12.6% of patients presented a history of recurrent otitis externa or chronic otitis media. Regional metastasis was recognized in 13.7% of patients, while no distant metastasis was confirmed. SCC located in the external ear could be detected in an earlier stage than that in the middle ear. The overall 5-year survival was 66.8% in total, and decreased significantly with stage. SCC in stages I and II was susceptible to each therapeutic strategy with a 5-year survival of 100%. Operation combined with radiotherapy and/or chemotherapy was the major treatment for stages III and IV SCC, while radiotherapy and chemotherapy were applied mainly for those who had been considered inappropriate for operation. The overall survival was 67.2% for stage III and 29.5% for stage IV, and operation with pathologically tumor free margin could improve the survival to 72.7% when combined with radio- and chemotherapy. Stage, completeness of operation with tumor free margin, recurrence, and metastasis have significant influence on survival.

CONCLUSION

Local infiltration seems to be the main behavior of SCC in the external and middle ear. Early diagnosis and treatment were important because SCC in the earlier stage is susceptible to be cured. For tumors of advanced stage, operation should be performed with pathologically tumor free margin, and operation combined with radiotherapy and chemotherapy could improve the survival. Tumor stage adds more influence on survival than its location. Recurrence and metastasis mainly occur in advanced stages and result in a poor survival.