Lymphoscintigraphic drainage patterns of the auricle in healthy subjects

Indications for and extent of elective neck dissection for lymph node metastasis from external auditory canal carcinoma

OBJECTIVES

We aim to clarify the frequency of lymph node metastasis of external auditory canal (EAC) carcinoma, including susceptible locations, adequate extent of elective neck dissection, and the relationship between the tumor infiltration site and lymph node metastasis.

PATIENTS AND METHODS

From 2003 to 2018, 63 patients with EAC carcinoma at Tokyo Medical and Dental University Hospital were enrolled in this study. The T and N stages, locations of clinically positive lymph nodes, prognoses, and anatomic site of tumor infiltration were analyzed after treatment.

RESULTS

Clinically positive lymph node metastasis (cN+) was detected in 18 patients (28.6%), consisting of T1, T2, T3, and T4 disease in 1 (6%), 2 (22%), 8 (38%), and 7 (41%) patients, respectively. The metastatic locations were at level II in 10 patients, parotid gland nodes in 7, preauricular nodes in 5, level Ib in 3, level Va in 3, level III in 1, and superficial cervical nodes in 1. Neck recurrence was determined in two of 45 patients with clinically negative lymph nodes (cN0), with the metastatic locations being levels II, Ib, and III. Among 18 cN+ cases, neck recurrence was noted in 2 of 9 patients who underwent neck dissection. Neck lesions were found to be manageable in all five patients who underwent docetaxel, cisplatin, 5-fluorouracil, and radiation therapy (TPF-RT). No relationship was noted between the tumor infiltration site and lymph node metastasis among T3/4 canrcinoma patients.

CONCLUSIONS

Elective neck dissection could be indicated only in T3/4 patients with free flap reconstruction. Levels Ib to III are considered appropriate for elective neck dissection in cN0 cases. Levels Ib to III and Va indicated favorable sites, even in cases with metastasis in the parotid gland or preauricular area. Furthermore, TPF-RT could be a useful option even in cN+ cases.

A cadaveric study of auricular lymphatics and implications for sentinel lymph node biopsy

Malignant cutaneous tumors of the auricle are known to have a high rate of spread to the regional lymph nodes, and, for this reason, removal of the lymph nodes, for diagnostic or therapeutic purposes, is often required. Recent experience with sentinel node biopsy in cutaneous tumors of the head and neck has questioned the traditional lymphatic pathways and prompted a new study. Lymphatic pathways from the auricle were demonstrated by India ink injection of five auricles in three cadavers followed by block dissection and Spalteholz clearing of en bloc specimens. Lymphatics descend adjacent to the mastoid bone periosteum and lie deep to the insertion of the sternocleidomastoid muscle. There are five different locations for sentinel nodes: superficial parotid, anterior mastoid, infra-auricular parotid, deep to sternocleidomastoid, and lateral mastoid. Two of these nodal locations (anterior and lateral mastoid) may be bypassed by anastomotic pathways. We conclude that, first, echelon lymph nodes lie in five different sites, some bypassed by anastomotic lymphatics. Lymphatics from the ear lie close to the mastoid bone and pass deep to the insertion of sternocleidomastoid where they may be difficult to follow. Sentinel lymph node biopsy for cutaneous tumors of the auricle is possible, but the presence of skip metastases should be considered.

[Squamous cell carcinomas of the ear: factors of gravity and surgical treatment, about 30 cases]

INTRODUCTION

Squamous cell carcinomas (SCC) of the ear are known for their aggressiveness. The aim of this study was to investigate factors of gravity while freeing the therapeutic requirements.

PATIENTS AND METHODS

This is a retrospective study of 28 patients (30 ears) operated for SCC. The characteristics of the lesion, the presence of metastasis, treatment modalities and histologic findings were collected. Local recurrences and metastasis are identified with a mean follow-up time of 37months (17-110months).

RESULTS

The lesion size was less than 2cm in 19 cases (63.3%) and greater than or equal to 2cm in 11 cases (36.7%). Macroscopic resection margins were 5, 7 or 10mm. The resections were histologically incomplete in 4 cases (13%) requiring further surgery. Six cases had local recurrence (20%): three with pulmonary or lymph node metastases (10%) and one death (3.3%). In these 6 cases of recurrence, the surgical margins were 6.3mm on average, the initial lesion measured always greater than 2cm (100%). Three quarters of incomplete resections have recurrent despite a surgical revision in healthy margin.

CONCLUSION

Our study confirms the data of literature, namely the pejorative character of a lesion greater than 2cm and incomplete resection. The HAS recommendations seem minimal regarding the ear. In case of injury by more than 2cm and with a proximal location on the ear pinna, only amputation of the ear allows satisfactory cancer control.

Primary mucosal sinonasal melanoma-Case report and review of the literature. The role of complex treatment-surgery and adjuvant radiotherapy

AIM

The place of adjuvant radiotherapy in the treatment of sinonasal melanoma.

BACKGROUND

Sinonasal mucosal melanoma is a rare disease with poor prognosis and requires a complex treatment. Elective neck dissection in patients with N0 and adjuvant radiotherapy has been a source of controversy. High late regional recurrence rates rise questions about elective irradiation of the neck nodes in patients with N0 stage disease.

METHODS

We present our two years' follow up in a case of locally advanced sinonasal melanoma and literature review of the treatment options for mucosal melanoma.

RESULTS

In locally advanced sinonasal melanoma treated with surgical resection, postoperative radiotherapy and chemotherapy we had local tumor control. Two years later, a regional contralateral recurrence without distant metastasis occurred.

CONCLUSIONS

Literature data for frequent neck lymph nodes recurrences justify elective neck dissection. Postoperative elective neck radiotherapy for patients with locally advanced sinonasal melanoma and clinically N0 appears to decrease the rate of late regional recurrences.

Head and neck melanoma

Nearly 20% of malignant melanoma in the human body occurs in the head and neck. Most studies divide the sites of origin of malignant melanoma in the head and neck into the following areas: the face, the scalp and neck, the external ear, and the eyelid or medial or lateral canthal area. Sixty-five percent of malignant melanomas occur in the facial region. Given that the face represents only 3.5% of total body surface area, the face is overrepresented when compared with other sites in the head and neck. Among the sites of origin in the head and neck, melanoma of the scalp and neck carries the highest mortality, with 10-year survival being only 60%. Melanomas of the ear, face, and eyelid have 10-year survival rates of 70%, 80%, and 90%, respectively.

Cutaneous head and neck squamous cell carcinoma metastatic to parotid and cervical lymph nodes

Nonmelanoma skin cancers occur at an epidemic rate in Australia and are increasing in incidence worldwide. In most patients, local treatment is curative. However, a subset of patients will be diagnosed with a high-risk cutaneous squamous cell carcinoma (SCC) and are defined as patients at increased risk of developing metastases to regional lymph nodes. Patients with high-risk SCC may be identified based on primary lesion and patient factors. Most cutaneous SCC arises on the sun-exposed head and neck. The parotid and upper cervical nodes are common sites for the development of metastases arising from ear, anterior scalp, temple/forehead, or scalp SCC. The mortality and morbidity associated with high-risk cutaneous SCC is usually a consequence of uncontrolled metastatic nodal disease and, to a lesser extent, distant metastases. Patients with operable nodal disease have traditionally been recommended for surgery. The efficacy of adjuvant radiotherapy has previously been questioned based on weak evidence in the early literature. Recent evidence from larger studies has, however, strengthened the case for adjuvant radiotherapy as a means to improve locoregional control and survival. Despite this, many patients still experience relapse and die. Research aimed at improving outcome such as a randomized trial incorporating the addition of chemotherapy to adjuvant radiotherapy is currently in progress in Australia and New Zealand. Ongoing research also includes the development of a proposed new staging system and investigating the role of molecular factors such as the epidermal growth factor receptor.

Lymphoscintigraphic drainage of acral limb skin to interval sentinel lymph nodes in healthy subjects

BACKGROUND AND OBJECTIVES

In the literature, drainage to epitrochlear and popliteal sentinel lymph nodes (SLN) are analyzed for whole or distal extremity (below elbow or knee) melanomas that are not topographically homogeneous with respect to tendency of drainage to interval SLNs. We hypothesize that acral (hand and foot) skin has a uniform frequency of drainage to interval SLNs, which is higher than reported for distal extremity melanomas.

METHODS

One hundred healthy subjects were enrolled. Fifty subjects had standard four extremity lymphoscintigraphies by radiocolloid injection into an interdigital web space as in lymphodynamic studies. On another 50 subjects, either targeted upper (n = 25) or lower (n = 25) extremity lymphoscintigraphies were performed utilizing injection sites that likely drain to interval SLNs. Acral skin drainage to interval SLNs was analyzed for interindividual variability and injection site dependence.

RESULTS

There was considerable interindividual variability in drainage of each injection site to interval SLNs. Hand skin had a uniform 50% frequency of drainage to epitrochlear-midhumeral SLNs with both injection sites. This frequency was higher than the epitroclear SLN frequencies reported for distal extremity melanomas. Foot skin had 10% and 90% frequencies of drainage to popliteal SLNs from standard and targeted injection sites, respectively. Foot skin largely simulates the tendency of drainage reported for distal extremity melanomas while lateral heel represents a limited zone that almost uniformly drains to popliteal SLNs.

CONCLUSIONS

Despite dissimilarities between hand and foot, acral skin drainage to interval SLNs is high enough to obligate a thorough interval SLN exploration in acral primaries.