Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings

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 squamous cell carcinoma: Aggressive behavior coursing with cerebellar invasion and hydrocephalus

Background

Temporal bone squamous cell carcinoma (TBSCC) is a very rare condition. The prognosis is dismal for advanced tumors. Due to its rarity, information in the literature is scarce. Here, we report a unique case of TBSCC with cerebellar invasion and hydrocephalus.

Case Description

A 46-year-old reported right-sided hearing loss and a painful right retroauricular mass for 4 months. Magnetic resonance imaging revealed a 8.7 × 7.6 × 6.4 cm mass invading the right temporal and occipital bones. After a biopsy and 3 surgical procedures over 6 months, the diagnosis of TBSCC was obtained. Due to invasion of the cerebellar tissue and obstructive hydrocephalus, a ventriculoperitoneal shunt was performed. The patient was referred for adjuvant radiotherapy. However, palliative care was initiated due to tumor progression.

Conclusion

We report a case of advanced TBSCC with poor prognosis despite surgical treatment and radiotherapy. More data are necessary to provide new and better treatment to these patients.

Survival Outcomes of Temporal Bone Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

OBJECTIVE

Temporal bone squamous cell carcinoma (TBSCC) is a rare malignancy with poor prognosis, and optimal treatment for advanced cases is uncertain. Our systematic literature review aimed to assess 5-year survival outcomes for advanced TBSCC across different treatment modalities.

DATA SOURCES

EMBASE, Medline, PubMed, and Web of Science.

REVIEW METHODS

A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for articles published between January 1989 and June 2023.

RESULTS

The review yielded 1229 citations of which 31 provided 5-year survival data for TBSCC. The final analysis included 1289 patients. T classification data was available for 1269 patients and overall stage for 1033 patients. Data for 5-year overall survival (OS) was 59.6%. Five-year OS was 81.9% for T1/2 and 47.5% for T3/4 (P < .0001). OS for T1/T2 cancers did not significantly differ between surgery and radiation (100% vs 81.3%, P  = .103). For advanced-stage disease (T3/T4), there was no statistical difference in OS when comparing surgery with postoperative chemoradiotherapy (CRT) (OS 50.0%) versus surgery with postoperative radiotherapy (XRT) (OS 53.3%) versus definitive CRT (OS 58.1%, P  = .767-1.000). There was not enough data to assess the role of neoadjuvant CRT.

CONCLUSION

Most patients will present with advanced-stage disease, and nodal metastasis is seen in nearly 22% of patients. This study confirms the prognostic correlation of the current T classification system. Our results suggest that OS did not differ significantly between surgery and XRT for early stage disease, and combined treatment modalities yield similar 5-year OS for advanced cancers.

The Role of Parotid Gland Invasion in Adenoid Cystic Carcinoma of the External Auditory Canal

OBJECTIVE

This study aimed to investigate the significance of parotid gland invasion in predicting distant metastasis of adenoid cystic carcinoma in the external auditory canal.

STUDY DESIGN

Single-institution retrospective cohort study.

METHODS

A retrospective review of patients with adenoid cystic carcinoma of the external auditory canal who underwent surgery was performed. Information on patient demographics, parotid gland invasion, tumor stage, perineural invasion, lymphovascular invasion, and follow-up data were collected and analyzed.

RESULTS

One hundred twenty-nine patients were identified for review. Parotid gland invasion was noted in 45 patients (34.9%). Parotid gland invasion was significantly associated with tumor stage, perineural invasion, distant metastasis, and postoperative adjuvant therapy. Distant metastasis was noted in 30 patients (23.3%). Multivariate Cox proportional hazards analysis identified parotid gland invasion as an independent risk factor for predicting distant metastasis. The 5-year distant metastasis-free survival rate was 83.6% for patients without parotid gland invasion and 61.8% for patients with parotid gland invasion (p = 0.010).

CONCLUSIONS

The parotid gland invasion rate is relatively high in adenoid cystic carcinoma of the external auditory canal and is significantly related to tumor stage. Parotid gland invasion is associated with worse distant metastasis-free survival.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:419-425, 2024.

Patterns of spread and anatomical prognostic factors of pre-auricular cutaneous squamous cell carcinoma extending to the temporal bone

BACKGROUND

Improvements can be made in the management and staging of advanced pre-auricular cutaneous squamous cell carcinoma (cSCC). We aimed to analyze radiological patterns of spread and clinico-anatomical prognostic factors.

METHODS

Retrospective review of 54 patients with pre-auricular cSCC (cutaneous/nodal) who underwent temporal bone resection with curative intent.

RESULTS

Involvement of the cartilaginous external auditory canal (EAC) (79.6%) and retromandibular space (63.0%) was common. Styloid process/anterior carotid sheath (ACS) (11.1%) and bony EAC (7.4%) involvement were rare. ACS involvement resulted in high rates of involved surgical margins (100%) and poor outcomes on univariable analysis. Negative prognostic factors on multivariable analysis included salvage surgery and invasion of the bony EAC, mandible, pterygoid muscle(s), and dura.

CONCLUSION

The bony EAC and ACS can form temporary barriers to tumor spread, with the latter representing a potential limit of resectability. Prognostic factors revealed can lead to the development of a more appropriate staging tool.

Comparative study of pre- and postauricular flaps for external auditory canal defect reconstruction

BACKGROUND

Malignancies involving the external auditory canal deserve critical evaluation due to this area's aesthetic and functional importance. Flaps can be very useful for the restoration of the external auditory canal. A variety of flaps available for the surgical treatment of external acoustic meatus defects exist, depending on the precise location and size.

OBJECTIVES

Our study aimed to compare aesthetic and functional results in the postoncological reconstruction of external auditory canal defects using a preauricular flap and postauricular revolving door flap.

METHODS

Sixteen patients treated at our plastic surgery unit for defects involving the external auditory canal between January 2014 and December 2020 were included in the study. All defects were the result of a primary or secondary skin cancer excision. Patients were divided into two groups, one receiving the preauricular flap technique and the other the postauricular revolving door flap technique.

RESULTS

Three separate visual analog scales reported excellent scores for the two procedures, though the postauricular revolving door flap had slightly better results. Both preauricular flap and postauricular revolving door flap reconstructive techniques showed good options for external auditory canal reconstruction in postexcision skin cancer patients. From an aesthetic point of view, the revolving door flap appeared to be a more elegant surgical approach in this type of reconstruction because the scar was hidden in the postauricular sulcus.

CONCLUSIONS

Reconstruction with a postauricular revolving door flap allowed for a more natural movement with no external pedicle.

EVIDENCE-BASED MEDICINE EBM LEVEL

IV.

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.

Survival Outcomes in Squamous Cell Carcinoma of the External Auditory Canal: A Systematic Review and Meta-Analysis

Squamous cell carcinomas (SCC) of the external auditory canal (EAC) are rare tumors representing a surgical challenge. Current knowledge is based largely on case series; thus, the level of evidence is weak. This study sought to systematically review the available SCC of the EAC literature and to identify risk factors for overall survival (OS) and disease-specific survival (DSS). A systematic review and meta-analysis of papers searched up to December 2022 through PubMed, Scopus, Web of Science, and Cochrane Library databases was conducted. Quality assessment of the eligible studies was done according to the Newcastle-Ottawa Scale. Pooled univariate and multivariable analyses and meta-analysis using a random-effects or fixed-effects Mantel-Haenszel model were performed. Fifteen articles (282 patients) met the inclusion criteria and were included in the quantitative analysis. The pooled multivariable analysis revealed cT3 and cT4 as independent prognostic factors for OS (p = 0.005, and p < 0.001, respectively) and DSS (p = 0.002, and p < 0.001, respectively). Local recurrence rate was 32.3%. The meta-analysis estimated significantly higher odds ratios for advanced T categories, than cT1-T2 tumors for OS and DSS (OR = 3.55; 95% CI, 1.93–6.52, and OR = 3.73; 95% CI, 2.00–6.97, respectively). In conclusion, locally advanced tumors were associated with poor prognosis. Poor outcomes mostly occurred due to local recurrence.

Long-term analysis of prognostic risk factors impacting surgical outcomes in patients with external auditory canal carcinoma

BACKGROUND

Malignant neoplasms of the external auditory canal (EAC) are rare. No consensus on management has emerged.

OBJECTIVE

To determine possible risk factors influencing tumorgenesis and prognosis of EAC carcinoma.

MATERIALS AND METHODS

108 patients (87 men/21 women) with an average age of 74 ± 13.8 years were recruited from 2005 to 2019 at Department of Otorhinolaryngology, Head and Neck Surgery Heidelberg. The follow-up interval was 43.62 ± 55.39 months. Partial and (sub)total ablative otis, supplementary surgery (petrosectomy, parotidectomy, neck dissection, mastoidectomy) and adjuvant radio(chemo)therapy belonged to treatment options. TNM status was determined at time of diagnosis using the AJCC staging system.

RESULTS

63.9% of patients underwent a total ablative otis. Tumor recurrence was seen in 24.1%. The 1-year survival rate was 87%, the 5-year survival rate was 52%, the mean overall survival (OS) was 3.82 ± 4.6 years. Male EAC carcinoma patients had a better OS (p < 0.001), PFS (p < 0.001) and DSS (p = 0.02) than females. T1 patients had a better OS (p = 0.01), PFS (p = 0.01) and DSS (p < 0.001) than T4 patients. Lymph node but not distant metastasis, tumor grading, perineural, venous and lymphatic invasion, histology, age and tumor localization influenced the OS in EAC carcinoma patients (p = 0.04). The more radical the ablative otis, the worse the OS (p = 0.002), PFS (p = 0.02) and DSS (p < 0.001). Radio(chemo)therapy did not improve the OS.

CONCLUSIONS

EAC carcinoma are difficult to treat and benefit from early diagnosis so that a radical combined treatment approach does not need to be used.

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.

Pattern of nodal metastasis of cutaneous squamous cell carcinoma involving the temporal bone

Objective

The objective of this study was to explore the pattern of lymph-node spread of SCCs involving the temporal bone.

Methods

We retrospectively reviewed all cutaneous SCCs involving the temporal bone over a 20-year time-period. Forty-one patients were eligible.

Results

Mean age was 72.8 years. The diagnosis was cutaneous SCC in all cases.All patients underwent a temporal bone resection, 70.7% had a neck-dissection and 78.0% a parotidectomy.Level 2 was the most common area of neck metastasis, and occurred in 12.2%. The parotid had disease in 34.1%. 51.2% of patients underwent free-flap reconstruction.Mean overall survival of the cohort was 4.2 years.

Conclusions

Overall, the rate of cervical nodal metastasis was 22.0% and 13.5% in the occult setting. The parotid was involved in 34.1% and 10.0% in the occult setting. Results from the present study support consideration for performing a parotidectomy at the time of temporal bone resection, while a neck dissection can be performed for adequate staging of the nodal basin.

Level of Evidence

3.

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.

Squamous Cell Carcinoma of the Temporal Bone Arising from Cholesteatoma: A Case Report and Review of the Literature

Objective  Present a case of squamous cell carcinoma of the temporal bone (SCCTB) arising in a 61-year-old female with a prior history of cholesteatoma and persistent otologic symptoms and review the current literature regarding this disease presentation.

Setting  Tertiary academic center.

Patient  A 61-year-old female with a history of left ear cholesteatoma for which she had undergone surgery 54 years prior. The patient presented with a persistent history of otorrhea since first surgery and developed exacerbation of symptoms just prior to presentation at our department. The clinical picture was highly suspicious of cholesteatoma recurrence. However, the biopsy was consistent with squamous cell carcinoma.

Intervention  Surgical debulking of the lesion was followed by a brief course of radiation therapy later halted by the patient due to side effect intolerance.

Conclusion  SCCTB may arise from cholesteatoma. A high index of suspicion for SCCTB should be maintained in patients with a prior history of cholesteatoma and evidence of a temporal bone mass with persistent otologic symptoms.

Surgical Strategy for Squamous Cell Carcinoma of the External Auditory Canal: Management of Locally Advanced Cases with Skull Base Involvement

Objective  Surgical indications for advanced-stage squamous cell carcinoma (SCC) of the external auditory canal (EAC) are highly dependent on the skull base surgery team. The aim of this study was to evaluate the surgical outcomes in patients with SCC of the EAC and to clarify the surgical indication of far advanced cases using the T4 subclassification. Methods  Patients with SCC of the EAC who underwent curative treatment from 2002 to 2021 at our hospital were retrospectively reviewed. Clinical and surgical results, including operative data, overall survival (OS), and disease-specific survival (DSS), were analyzed. To clarify the surgical indication for advanced-stage tumors, we proposed the T4 subclassification. Results  In the 46 patients included in the study, 8 patients had T1 tumors, 10 had T2 tumor, 5 had T3 tumors, and 23 had T4 tumors. The 5-year DSS with T1, T2, T3, and T4 tumors were 100, 85.7, 100, and 61.7%, respectively. No prognostic impacts for margin status were found between the 5-year OS and DSS ( p  = 0.23 and 0.13, respectively). Patients with far-advanced-stage (T4b) tumors were significantly associated with shorter DSS than those with early-stage (T1/T2) and advanced-stage (T3/T4a) tumors ( p  = 0.007 and 0.03, respectively). Conclusion  The present study focused on patients with SCC of the EAC at a university hospital over a period of 20 years, especially with skull base involvement, and a T4 subclassification was proposed. Complete tumor resection in an en bloc fashion could help achieve a good survival rate even in patients with locally advanced tumors.

Primary temporal bone squamous cell carcinoma: Comparing the prognostic value of the American Joint Committee on Cancer TNM classification (8th edition) with the revised Pittsburgh staging system

BACKGROUND

Retrospectively considering a temporal bone squamous cell carcinomas (TBSCCs) series, our aim was to compare the predictive power of the American Joint Committee on Cancer (AJCC) staging system (8th edition) with the revised Pittsburgh staging system (rPSS) in terms of disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS).

METHODS

Forty-three TBSCCs consecutively treated surgically were reviewed. The prognostic performance of AJCC and rPSS was compared.

RESULTS

The areas under the curves for the prediction of DFS, DSS, and OS did not differ significantly between both staging systems (p = 0.518, p = 0.940, and p = 0.910, respectively). Harrel's C-indexes for respectively the AJCC and rPSS were 0.76 and 0.70 for DFS, 0.73 and 0.76 for DSS, 0.66 and 0.63 for OS.

CONCLUSION

Comparable prognostic accuracy was observed between AJCC and rPSS. Levels of prognostic performance were only acceptable for both systems, according to Hosmer-Lemeshow scale. Further efforts are needed to define new TBSCC staging modalities with higher prognostic reliability.

Targeted molecular characterization of external auditory canal squamous cell carcinomas

HYPOTHESIS

Squamous cell carcinomas (SCC) of the external auditory canal (EAC) may harbor unique genomic alterations that may explain aggressive behavior and differentiate these tumors from cutaneous SCCs of other subsites.

BACKGROUND

EAC SCCs arise in a non-ultraviolet-exposed region of the head and neck, are often locally aggressive and may metastasize to lymph nodes or distant sites. The genomic alterations underlying cutaneous SCC of other sites are well-documented; however, mutational profiles of EAC SCC are less well characterized and may contribute to the unique anatomic site, high rates of recurrence and tumor spread. We performed targeted sequencing of a cohort of primary EAC SCCs to identify recurring and potentially targetable genomic alterations.

METHODS

Genomic DNA was extracted from formalin-fixed paraffin-embedded specimens of 7 EAC SCCs and subjected to targeted DNA sequencing using a 227-gene panel. Somatic alterations and gene copy number alterations were annotated using our validated, in-house bioinformatics pipelines.

RESULTS

In our EAC SCCs, we found recurrent alterations in TP53 and genes of receptor tyrosine kinase (eg, EGFR, FGFR) and PI3K pathways (eg, PIK3CA), similar to cutaneous SCCs of other head and neck sites. We also observed a high frequency of telomerase reverse transcriptase amplification and DNA methyltransferase 1 alterations, both of which are rarely observed in cutaneous SCCs of other sites.

CONCLUSION

These data represent the first step toward precise molecular characterization of EAC SCCs that may lead to an enhanced understanding of tumor biology and modernized precision medicine approaches for unique tumors.Level of Evidence: NA.

Evaluating the prognostic contributions of TNM classifications and building novel staging schemes for middle ear squamous cell carcinoma

Background

A universally acknowledged cancer staging system considering all aspects of the T‐, N‐, and M‐classifications for middle ear squamous cell carcinoma (MESCC) remains absent, limiting the clinical management of MESCC patients.

Materials and Methods

A total of 214 MESCC patients were extracted from the SEER (the Surveillance, Epidemiology, and End Results) database between 1973 and 2016. The relationships between patient’s characteristics and prognoses were analyzed by Kaplan–Meier and Cox proportional hazards regression models. Novel staging schemes for MESCC were designed by adjusted hazard ratio (AHR) modeling method according to the combinations of Stell’s T‐classification and the eighth AJCC N‐ and M‐classifications, of which performances were evaluated based on five criteria: hazard consistency, hazard discrimination, explained variation, likelihood difference, and balance.

Results

T‐classification was the most significant prognostic factor for MESCC patients in multivariable analysis (p = 0.021). The N‐ and M‐classifications also had obvious prognostic effect but were not statistically significant by multivariate analysis due to the limited metastasis events. Three novel staging schemes (AHR‐Ⅰ–Ⅲ models, different combination of T‐ and N‐classifications) and ST (solely derived from Stell’s T‐classification) were developed, among which the AHR‐Ⅰ staging scheme performed best.

Conclusions

Tumor extension, quantified by Stell’s T‐classification, is the most significant prognostic factor for MESCC patients. However, our AHR‐Ⅰ staging scheme, a comprehensive staging scheme that integrating T‐, N‐, and M‐classifications, might be an optimal option for clinical practitioners to predict MESCC patients’ prognosis and make proper clinical decisions.

Surgical treatment for squamous cell carcinoma of the temporal bone: predictors of survival

Objective

Evaluation of the management and survival in patients treated for temporal bone squamous cell carcinoma (TBSCC) in a tertiary referral centre.

Methods

Forty-nine patients underwent primary treatment for TBSCC. Thirty-six patients underwent a lateral temporal bone resection (LTBR) or subtotal temporal bone resection (STBR). Overall survival (OS) and disease-specific survival (DSS) analysis were assessed.

Results

Five-year OS of the 49 patients was 39%. Five-year OS of the 36 patients who underwent LTBR or STBR was 46%. Tumour-free margins were achieved in all patients with T1 and T2 disease, in 59% patients with T3 tumours and 0% patients with T4 disease. Five-year DSS was 85% for all T1/T2 tumours, 53% for T3 tumours and 0% for T4 tumours. Clear resection margins was the only significant predictor of DSS in our cohort.

Conclusions

The mainstay of treatment for TBSCC is temporal bone resection with tumour free resection margins, with or without adjuvant radiotherapy. Survival is negatively influenced by non-radical resection. T1 and T2 tumours can be managed safely with LTBR. More advanced disease requires a more extensive resection, with a higher likelihood of non-radical resections and decreased survival rates.

Exoscopic En Bloc Carotid-Sparing Total Temporal Bone Resection: Feasibility Study and Operative Technique

OBJECTIVE

To delineate the steps of exoscopic en bloc carotid artery-sparing total temporal bone resection for malignancies involving the temporal bone in a cadaveric model.

METHODS

Dissections were performed on 3 right-sided (3 sides) formalin-fixed, latex-injected cadaveric specimens. An exoscopic en bloc carotid artery-sparing total temporal bone resection was performed on each cadaver. In the past 4 years, 8 patients have undergone exoscope-assisted internal carotid artery-sparing total temporal bone resection with the technique described in this report. As an example, we present a representative case of a patient in whom this technique was used.

RESULTS

Exoscope-assisted en bloc total temporal bone resections were performed on 3 right-sided cadaveric specimens. The following steps were described to circumferentially expose the petrous temporal bone: infratemporal fossa exposure, temporal craniotomy for subtemporal middle fossa approach to the petrous bone, retrosigmoid craniotomy, and transjugular approach. Finally, 3 skull base osteotomies were performed to liberate anterior, medial, posterior attachments of the petrous bone for en bloc removal. Possible extensions of these dissections as indicated by tumor pathology were described. A case illustration and operative video utilizing these techniques is presented.

CONCLUSIONS

Exoscope-assisted en bloc carotid artery-sparing total temporal bone resection is a feasible technique for management of malignancies with temporal bone invasion.

HPV Infection in Middle Ear Squamous Cell Carcinoma: Prevalence, Genotyping and Prognostic Impact

Middle ear squamous cell carcinoma (MESCC) is rare. Human Papilloma Virus (HPV) infection has been found in a significant number of cases of MESCC. Despite the emerging role of HPV in oncogenesis, its role in the pathogenesis and prognosis of MESCC is not known. This study aims to identify the prognostic impact of alpha and beta HPV in MESCC and its correlation with p16 protein. We retrospectively investigated 33 patients with MESCC surgically treated between 2004 and 2016. HPV DNA was ascertained by polymerase chain reaction (PCR) and P16INK4a detection was performed. Disease-specific survival (DSS) and cumulative incidence of recurrence were calculated in relation to HPV presence and genotype. p16 sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting HPV infection were calculated. HPV was detected in 66.7% of patients (36.4% alpha HPV, 63.6% beta HPV). Five-year DSS was 55.0% and was not statistically related to HPV presence (p = 0.55) or genotype (p = 0.87). Five-year cumulative incidence of recurrence was 46 %, and was not statistically related to HPV presence (p = 0.22) or genotype (p = 0.44). p16 sensitivity, specificity, PPV, and NPV in predicting HPV infection were 27.3%, 36.4%, 46.2%, and 20.0%, respectively. In our experience, beta HPV was more frequent than alpha HPV in MESCC. Neither HPV presence nor HPV genotypes relate to DSS or cumulative incidence of recurrence. p16 expression was not predictive for HPV infection in MESCC. The role of HPV infection in oncogenesis, maintenance, and prognosis of MESCC seems to be different from that in oropharynx and skin cancer.

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.

Survival in Middle Ear Malignancy: A Population-Based Analysis Based on the SEER Database

OBJECTIVE

The purpose of this study was to investigate the clinical features and survival outcomes of patients with middle ear malignancies at a population level.

STUDY DESIGN

Retrospective cohort study with data from a national database.

SETTING

National database of middle ear malignancy.

METHODS

Records of patients diagnosed with a middle ear malignancy from 1973 to 2016 were extracted from the SEER database (Surveillance, Epidemiology, and End Results). SPSS (version 27; IBM) was used to conduct 5-year survival analysis.

RESULTS

The average survival for all 431 patients was 61.4 months. Five-year disease-specific survival for squamous cell carcinoma (SCCA), adenocarcinoma, other carcinoma, and noncarcinoma subtypes varied significantly at 54.6%, 82.1%, 71.8%, and 82.6%, respectively (P < .0001). There was an improved 5-year survival for patients with adenocarcinoma who received surgery versus those who did not (91.7% vs 65.1%; P = .023, log-rank). Five-year disease-specific survival was significantly better in patients aged <55 years (mean ± SD, 77.8% ± 0.39%) as compared with those >70 years (55.1% ± 5.1%) and those aged 55 to 69 years (60.2% ± 4.9%; P < .01 and P < .001, respectively, log-rank). Patients with SCCA were significantly older than those with adenocarcinoma (P < .0001). Noncarcinoma subtypes were more likely to present with local disease, as opposed to regional or distant disease, when compared with SCCA (P = .0027).

CONCLUSION

Prognosis and treatment outcomes for primary middle ear malignancies depend on histologic subtype and age at diagnosis. The noncarcinoma and adenocarcinoma subtypes carry the best prognoses. Patients with adenocarcinoma were most likely to benefit from surgery.

Management of squamous cell carcinoma of the temporal bone: long-term results and factors influencing outcomes

OBJECTIVE

Temporal bone squamous cell carcinoma (TBSCC) is a rare, aggressive tumor. Surgery, alone or combined with radiotherapy, represent the mainstay of treatment. To report our experience in the treatment of TBSCC and evaluate the disease-specific survival, identifying the factors influencing this outcome.

MATERIALS AND METHODS

A retrospective study was performed on 66 patients between 1993 and 2018. Patients were staged according to the University of Pittsburgh-modified TNM staging system. Nine cases (13.6%) were Stage I, 7 cases (10.6%) Stage II, 20 cases (30.3%) Stage III and 30 cases (45.5%) Stage IV. Twenty-four patients underwent lateral temporal bone resection (LTBR) and 42 patients underwent subtotal temporal bone resection (STBR).

RESULTS

One hundred percent of Stage I and II patients showed no evidence of disease (NED) after a median follow-up of 101 months (range 1-289 months). NED resulted in 88.2% of Stage III (mean follow-up 80.3 months; range 8-257) and 46.4% of stage IV (mean follow-up 50.6 months; range 3-217). Pittsburgh Stage or involvement of mastoid, facial nerve, medial wall of the middle ear, temporomandibular joint and middle fossa dura emerged as negative prognostic factors. The highest mortality rate occurred in the first 2 years after treatment, due to local recurrence.

CONCLUSIONS

Prognosis of TBSCC can be excellent in early stage tumors, employing a LTBR. In more advanced cases, prognosis is poor. STBR with adjuvant radiotherapy represents the treatment of choice, offering acceptable survival rates. Given the rarity of the pathology, many controversies still exist concerning optimal management.

Temporal bone carcinoma: Novel prognostic score based on clinical and histological features

BACKGROUND

This study aimed to develop a novel temporal bone squamous cell carcinoma (TBSCC) prognosis scoring system and compare it with the revised Pittsburgh staging system.

METHODS

Forty-four consecutive TBSCC patients were assessed to identify predictors of recurrence. Each predictor's hazard ratio for recurrence was used to develop our novel scoring system.

RESULTS

Based on variables with P < .10 in Cox's regression model, our score included: revised Pittsburgh stage; non-anterior spread of T4 carcinoma; dural involvement; and histological grade. A higher recurrence rate (P = .000) and shorter disease-free survival (P = .000) were associated with scores of ≥5. The area under the curve of our score was larger than that of the revised Pittsburgh stage for both recurrence and disease-specific mortality (P = .0178 and P = .0193, respectively).

CONCLUSION

Our TBSCC scoring system is based on variables that are obtainable preoperatively from clinical and radiological data and biopsies. Its prognostic value should be validated for published TBSCC series and then in prospective settings.

Clinical experience of 23 cases of adenoid cystic carcinoma of the external auditory canal

Adenoid cystic carcinoma (ACC) of the external auditory canal (EAC) is a rare tumor. The present study aimed to describe the clinical features and survival of patients with ACC of the EAC. The present retrospective study included 23 patients (mean age, 51.4±15.4 years; 12 males) diagnosed with ACC of the EAC between January 2010 and September 2017 at The First Affiliated Hospital of The Third Military Medical University (Chongqing, China). The median disease course was 24 months. The presenting features were earache in 16 patients, otorrhea in 7 patients, hearing loss in 5 patients, feeling of aural fullness in 2 patients and EAC mass in 4 patients. Tumor stage was T1 in 13 patients, T2 in 3 patients, T3 in 3 patients and T4 in 4 patients. Among patients with T1 tumors, 5 underwent en bloc external EAC resection; 3 underwent local EAC resection; 1 underwent en bloc EAC resection and superficial parotidectomy; 1 underwent subtotal temporal bone resection for postoperative recurrence; Among patients with T4 tumors, 1 underwent extended temporal bone resection, right parotidectomy, right resection of middle cranial fossa tumors and right resection of temporomandibular joint capsule. 1 underwent subtotal temporal bone resection. Among these 15 patients who underwent surgery, 2 received postoperative radiotherapy, 1 received postoperative chemotherapy, 5 received postoperative chemo-radiotherapy, and 7 did not receive postoperative chemo-radiotherapy. The 3- and 5-year cumulative survival rates of the 23 patients were 47.8% and 17.4%, respectively. Survival may have been improved in patients who received postoperative chemo-radiotherapy and early diagnosis may be the key to improving survival.

Management of adenoid cystic carcinoma of the head and neck: a single-institute study with over 25-year follow-up

Background

Adenoid cystic carcinoma is a rare malignant tumor arising from exocrine glands such as the major and minor salivary glands of the paranasal sinuses or the external auditory canal. Although multiple retrospective clinical studies of ACC have been reported to date, clinical questions, such as 1) long-term prognosis beyond 20 years, 2) usefulness and suitability for treatment of therapeutic interventions, 3) therapeutic goal to aim for, and 4) prognosis by recurrence sites, are still unclear.

Methods

To improve understanding and management of adenoid cystic carcinoma of the head and neck (ACC), a retrospective study with 58 new ACC cases between 1991 and 2016 was performed. The median observation period was 66.8 months (range 3–316 months). The overall clinical stages were as follows: I, 6.9%; II, 25.9%; III, 19.0%; and IV, 48.2%. Histology was cribriform/tubular type (C-T type) in 62.0% and solid type in 27.5%. The main treatment strategy was definitive surgery, which was performed in 75.2% of cases.

Results

Overall 10-year, 20-year, and 25-year survivals were 63.7, 27.3, and 20.0%, respectively. Similarly, disease-specific survival (DSSs) was 65.7, 51.2, and 38.4%, respectively, and disease-free survival was 25.2, 9.4, and 9.4%, respectively. Conducting surgery (HR: 0.19, 95% CI: 0.06–0.61, p = 0.005) and C-T type (HR: 0.32, 95% CI: 0.11–0.93, p = 0.036) were independent prognostic predictors of DSS. DSS was significantly prolonged after salvage surgery for both locoregional recurrence (p = 0.004) and lung metastatic recurrence (p = 0.012, vs best supportive care).

Conclusions

In ACC cases, both initial surgical treatment and repetitive surgical resection of resectable recurrent lesions, including both locoregional and lung metastases, resulted in longer survival. The major goal of treatment for ACC may be long-term survival including cancer-bearing survival, resulting in either natural death or intercurrent-disease death, since judging cure of ACC is almost impossible.

Trial registration

Retrospectively registered.

Prognostic value of pre-operative peripheral inflammation markers in patients with squamous cell carcinoma of the external auditory canal

Introduction

Squamous cell carcinoma of the external auditory canal is a rare entity. Previous studies have suggested predictors for tumor recurrence. However, most of the prognostic factors were from the clinicopathological aspect.

Objective

This study aims to analyze the correlation between pre-operative peripheral inflammation markers and survival outcomes, in order to identify prognostic biomarkers for patients with squamous cell carcinoma of the external auditory canal.

Methods

We retrospectively analyzed patients diagnosed with squamous cell carcinoma of the external auditory canal who underwent surgery at our institute. The pre-operative circulating inflammatory markers, such as the neutrophil, lymphocyte, platelet, and monocyte counts were measured and their ratios including neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and lymphocyte-to-monocyte ratio were calculated. The prognostic value of the measured hematologic parameters in relation to the survival outcomes was also evaluated.

Results

A total of 83 patients were included, of which 26 patients showed tumor recurrence and 57 without recurrence. Neutrophil counts and neutrophil-to-lymphocyte ratio were closely connected with tumor stage. In the patients with recurrence, neutrophil counts, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were elevated (p < 0.0001, p < 0.0001 and p = 0.001), while lymphocyte counts and lymphocyte-to-monocyte ratio were decreased (p = 0.013 and p = 0.016, respectively). The receiver operating curve analysis indicated that pre-operative neutrophil-to-lymphocyte ratio is a potential prognostic marker for recurrence of squamous cell carcinoma of the external auditory canal (area under curve = 0.816), and the cut-off points was 2.325.

Conclusions

Pre-operative neutrophil and lymphocyte counts, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte are significantly correlated with tumor recurrence in patients with external auditory canal squamous cell carcinoma. Furthermore, neutrophil-to-lymphocyte ratio may be unfavorable prognostic factors of this disease.

Clinical characteristics and treatment outcome of adenoid cystic carcinoma in the external auditory canal

BACKGROUND

This study reviewed the clinical manifestations, pathological findings, and treatment outcomes of adenoid cystic carcinoma (ACC) in the external auditory canal (EAC).

METHODS

This was a retrospective review of 12 patients with a diagnosis of ACC in the EAC seen in a single institution over a 30-year period. Data on the demographics, clinical presentation, treatment strategy, and outcome, as well as the pathological features of ACC, were reviewed and analyzed.

RESULTS

The male-to-female ratio was 1:3 and the mean patient age was 55.9 years. The most common clinical presentation was otalgia (75%). Ten patients underwent surgical interventions, including radical mastoidectomy in five patients, wide excision in three, and lateral temporal bone resection in two. Adjuvant radiotherapy or concurrent chemoradiotherapy (CCRT) was performed in case of incomplete resection. Two patients underwent non-surgical treatments: radiotherapy in one and CCRT in the other. Microscopic perineural invasion was not associated with otalgia or histological subtype. The mean follow-up period was 84.6 months. Local recurrence occurred in 33% of patients. One-quarter of patients had distant metastasis, and all had lung metastasis. The 5-year overall survival rate for these patients was 82.5%.

CONCLUSION

EAC ACC should be included in the differential diagnosis when a patient presents with otalgia and a mass in EAC for more than 6 months, particularly if the patient is a middle-aged female. Otalgia might not be associated with perineural invasion or histological subtype. The lung is the most common site of distant metastasis in patients with EAC ACC. Further studies should determine the optimal treatment protocol for this rare malignancy.

External auditory canal carcinoma: clinical characteristics and long-term treatment outcomes

PURPOSE

Evidence-based treatment recommendations for external auditory canal (EAC) carcinoma are lacking in available literature. This study aims to evaluate the clinical characteristics and long-term outcomes of EAC carcinoma in a tertiary referral centre in a period of 15 years and identify independent prognostic factors.

METHODS

Retrospective observational study enrolling all patients with primary EAC carcinoma who underwent primary surgical treatment at the Portuguese Institute of Oncology (Lisbon) between 2004 and 2018. Epidemiological, clinical, histopathological and surgical data were retrieved from clinical records and analysed.

RESULTS

Twenty-seven patients were identified, with a median age of 77 years (range 29-92 years) and a slight female predominance (59.3%). Squamous cell carcinoma (55.6%) was the most common histological type, followed by basal cell carcinoma (40.7%) and ceruminous adenocarcinoma (3.7%). Pittsburgh tumour staging was distributed as early stage in 51.9% (I: 40.7%; II: 11.1%) and advanced stage in 48.1% (III: 29.6%; IV: 18.5%). Median follow-up period was 21 months (interquartile-range: 47). Four patients (14.8%) showed recurrence; recurrence rate was significantly higher in individuals aged < 60 years (p = 0.025) and with lymphovascular invasion (p = 0.049). Median overall survival was 88 months and estimated 2-year and 5-year overall survival rates were both 66%. Survival rates were higher in early stage patients (p = 0.021) and in those without facial palsy (p = 0.032).

CONCLUSION

Based on the available evidence in this review, individuals aged < 60, facial nerve impairment, advanced stage lesions, presence of lymphovascular invasion and squamous cell carcinoma histology are all associated with poor outcome and may be considered when discussing optimal treatment strategies in patients with EAC carcinoma.

Temporal bone resection for lateral skull-base malignancies

INTRODUCTION

Malignancies involving the temporal bone are increasingly common and require specialized multi-disciplinary care. Given this complex location, involvement of the lateral skull base and local neurovascular structures is common. In this review we discuss general principles for temporal bone resection, as well as alternative and complementary surgical approaches that should be considered in the management of patients with temporal bone cancer.

METHODS

A comprehensive review on literature pertaining to temporal bone resection was performed.

RESULTS

The primary surgical strategy for malignancies of the temporal bone is temporal bone resection. This may be limited to the ear canal and tympanic membrane (lateral temporal bone resection) or may include the otic capsule and its contents (subtotal temporal bone resection), and/or the petrous apex (total temporal bone resection). Management of adjacent neurovascular structures including the facial nerve, the carotid artery, and the jugular bulb/sigmoid sinus should be considered during surgical planning. Finally, adjunctive procedures such as parotidectomy and neck dissection may be required based on tumor stage.

CONCLUSIONS

Temporal bone resection is an important technique in the treatment of lateral skull-base malignancies. This strategy should be incorporated into a multi-disciplinary approach to cancer.

Trends of temporal bone cancer: SEER database

OBJECTIVE

This retrospective review aims to analyze epidemiological trends related to temporal bone cancer, and primarily of the squamous cell subtype. Potential trends analyzed included age, gender, and geographical location.

DATA SOURCES

This retrospective review analyzed data found in the National Cancer Institute's SEER Database for cases of carcinomas of the middle ear. Cases were selected between 1975 and 2016 and using the primary site of Middle Ear (Site code C30.1), and then narrowed using additional variables, which included age, sex, and state-county. Languages covered included English.

DATA EXTRACTION

The extracted data was entered into an Excel spreadsheet for further analysis in SPSS Version 25.

DATA SYNTHESIS

An Analysis of Covariance (ANCOVA) and a Bonferroni correction were applied to the data for further analysis of significant trends. The data was then placed into tables outlining the distribution of cases among select patient characteristics of age and sex, and significant age group pairwise comparisons.

CONCLUSIONS

Age at diagnosis of temporal bone cancer is strongly associated with the prevalence of temporal bone cancer. We urge providers to consider subtypes of temporal bone cancer, including squamous cell carcinoma, when evaluating older adults with risk factors for temporal bone cancer and an abnormal physical exam.

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.

Epidermal Carcinoma of the Conchal Bowl: Creation of a Multidisciplinary Pathway Approach

BACKGROUND

Malignant neoplasms of the auricle make up 6% of all skin cancers. Management of cutaneous neoplasms of the conchal bowl presents a unique challenge in visualizing and defining margins that may extend into the external auditory canal (EAC).

OBJECTIVES

The objective of this study was to create a multidisciplinary pathway for cutaneous carcinoma of the conchal bowl extending into the EAC.

METHODS

We present a series of patients that were referred to dermatology or otolaryngology, with cutaneous neoplasms arising in the conchal bowl. A consensus approach from otolaryngology and dermatology, for evaluation and treatment, was created based on evaluation of these cases, and review of the otolaryngology and dermatology literature, in collaboration between the two specialties.

RESULTS

Initial evaluation should be done by both dermatology and otolaryngology, with otomicroscopic evaluation of the canal. Imaging is recommended for lesions that approach the EAC, for bony and soft tissue spread. Excision of the tumor with Mohs micrographic surgery to achieve clearance in the conchal bowl should be performed initially. If extension into the external auditory meatus is present, otolaryngology would proceed with en bloc resection. Repair is dictated by the defect, with both specialties involved in follow-up.

CONCLUSIONS

In collaboration between dermatology and otolaryngology, and following review of the literature, a pathway was created to manage skin cancer of the conchal bowl. This resulted in a stepwise approach for evaluation and management, ensuring that patients have a streamlined pathway for the treatment of these lesions.

Management of Temporal Bone Malignancy in Ireland

Objectives  Lateral temporal bone malignancy remains a challenging rare disease. We report 17 years of multidisciplinary care of these tumors with univariate and multivariate analyses of key prognostic indicators for consideration in contemporary oncological management. Design  This is a retrospective cohort study. Setting  This is set at a tertiary referral center. Participants  All patients presenting with histopathologically newly diagnosed cases of temporal bone malignancy between 2000 and 2017 were included. Main Outcome Measures  The main outcome measures are disease-specific and recurrence-free survival rates. Results  In this study, 48 cases of temporal bone malignancy were diagnosed. Median age at diagnosis was 69 years (range: 5-88). Fourteen patients were female. Squamous cell carcinoma was the predominant malignancy in 34 cases (71%). Surgical treatment was undertaken in 37 patients. Mean length of follow-up was 32 months (range: 0.7-117). Overall 5-year disease-specific survival was 52.4%, while overall 5-year recurrence-free survival was 53.5%. On univariate analysis, significantly worse survival was seen in females ( p  = 0.008), those with distant metastatic disease ( p  = 0.041), and in middle ear involvement ( p  = 0.012) with no difference for involvement of the external auditory canal ( p  = 0.98) or mastoid ( p  = 0.78). Only middle ear involvement remained significant on multivariate analysis. Conclusion  A wide variety of malignant pathology may present in the temporal bone. Recurrence-free survival is equivalent to international data; however, this figure is low. This emphasizes the need to treat these tumors appropriately with radical resection, where possible, at first presentation. Therefore, multidisciplinary surgical input is recommended. Middle ear involvement was a negative prognosticator for disease-specific and recurrence-free survivals.

Acellular Dermal Matrix Mistaken as Recurrence of Malignancy Following Surgery on Positron Emission Tomography/Computed Tomography: A Case Report

OBJECTIVES

To report a rare clinical presentation of an acellular dermal matrix (ADM) used during lateral temporal bone resection mimicking recurrence of cancer of external auditory canal (EAC) on positron emission tomography/computed tomography (PET/CT) 9 months after surgery.

METHODS

Case report and literature review.

RESULTS

A 71-year-old woman underwent lateral temporal bone resection 9 months earlier for management of squamous cell carcinoma of the EAC. She exhibited recurrence of the tumor on ¹⁸F-FDG PET/CT with an intense uptake value (SUV_max 12.8) at the operated site. Exploration was conducted as the location of the lesion was unfavorable to perform biopsy. However, histopathologic evaluation revealed that the lesion was the ADM implanted during surgery.

CONCLUSIONS

Care should be taken when using an ADM during malignant tumor surgery if the site of surgery is not conducive for fine needle aspiration or biopsy.

Institutional Experience of Treatment and Outcomes for Cutaneous Periauricular Squamous Cell Carcinoma

OBJECTIVES

To report our institutional experience, management, and outcomes of cutaneous periauricular squamous cell carcinoma (SCC).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary academic center.

SUBJECTS

Patients undergoing treatment of cutaneous periauricular SCC from 2000 to 2016.

RESULTS

A total of 112 patients had a median follow-up of 24.5 months, a mean ± SD age of 75.7 ± 10.6 years, and a strong male predominance (93.8%). Site distribution shows 87 (77.7%) auricular, 26 (23.2%) preauricular, and 10 (8.8%) postauricular lesions. Of auricular lesions, tumors involved the tragus (n = 3, 3.4%), helix/antihelix (n = 47, 54.0%), conchal bowl (n = 31, 35.6%), external auditory canal (n = 18, 16.1%), and lobule (n = 3, 3.4%). Most patients presented at stage I (52.7%) versus stages II (28.6%), III (6.3%), and IV (12.5%). Patients were largely treated surgically with primary tumor resection ranging from wide local excision to lateral temporal bone resection (± parotidectomy and neck dissection), with 17.0% and 5.4% receiving adjuvant radiation and chemoradiation, respectively. Metastatic spread was seen to the parotid (25.9%) and neck (26.8%), with most common cervical spread to level II. Overall survival, disease-specific survival, and disease-free survival at 3 years were 62%, 89%, and 56%, respectively. Nodal disease was associated with worse disease-specific survival (P < .001) and disease-free survival (P = .042). Pre- and postauricular sites were associated with worse overall survival (P = .007) relative to auricular sites.

CONCLUSION

Among cutaneous SCC, periauricular subsites pose treatment challenges related to surrounding anatomy and represent a unique tumor population. The reported propensity toward recurrence and patterns of metastasis may better guide treatment of aggressive tumors to include regional nodal dissection.

Effectiveness of chemoradiotherapy for radiation-induced bilateral external auditory canal cancer: A case report and literature review

BACKGROUND

Radiation-induced bilateral external auditory canal cancer is an extremely rare disease that has yet to be fully characterized in the clinical literature.

METHODS

Herein, we present a case study of a 75-year-old man with radiation-induced bilateral external auditory canal cancer. The patient's medical history included left maxillary cancer that had been treated with chemoradiation 19 years earlier and local recurrence with total maxillectomy 10 years earlier. Intracavitary radiation was delivered to the site of postoperative recurrence 8 years before the current presentation. The patient declined radical surgery for the external auditory canal cancer at this time, and a customized combined modality regimen was thus administered.

RESULTS

There was no recurrence of cancer for 22 months, to date, after completing chemoradiotherapy.

CONCLUSIONS

Our finding that radiotherapy can be successfully used for radiation-induced cancer indicates that chemoradiotherapy may be a useful strategy for treating this type of malignancy.

Data Set for the Reporting of Ear and Temporal Bone Tumors: Explanations and Recommendations of the Guidelines From the International Collaboration on Cancer Reporting

The International Collaboration on Cancer Reporting (ICCR) was established to internationally unify and standardize the pathologic reporting of cancers based on collected evidence, as well as to allow systematic multi-institutional intercountry data collection to guide cancer care in the future. Such collaborative efforts are particularly essential for developing an evidence base for rare neoplasms or those with marked geographic variation in incidence, such as the tumors of the ear and the temporal bone. The ear and the temporal bone, including the external auditory canal and the middle and inner ear, with the closely associated facial nerve, internal carotid artery, and internal jugular vein, is one of the most complex anatomic structures in the head and neck. A wide range of benign and malignant neoplasms arise in this region. The management of these neoplasms involves complex surgery because of the anatomic confines, and as such, both benign and malignant tumors are included in this data set, as the oncologically equivalent management requires a multidisciplinary approach and standardized nomenclature and terminology. Surgical procedures at this site result in multifaceted 3-dimensional specimens that can be difficult to handle at macroscopic exam. A comprehensive macroscopic examination is important for identifying critical prognostic factors and often requires clinical and radiologic correlation. Histologic examination is straightforward for basal cell or squamous cell carcinoma but can be quite challenging for other neoplasms. A summary of the ICCR guidelines for ear tumors is presented, along with discussion of the salient evidence and practical issues.

Evidence Based Tailored Parotidectomy in Treating External Auditory Canal Carcinoma

Carcinoma of the external auditory canal (EAC) is a rare tumor and little information is available regarding parotid gland in surgically treating EAC carcinomas. This study aimed to investigate the mode of parotid involvement in EAC carcinoma through staging and histopathological analysis, and to establish surgical guidelines for the parotid gland management when there is no clinical evidence of parotid involvement. Sixty-five patients with EAC carcinoma who underwent temporal bone resection and any type of parotidectomy simultaneously were retrospectively reviewed. The rate of direct parotid invasion and parotid nodal involvement was analyzed according to the stage and histopathological findings. Among the 65 patients, 39 were confirmed to have squamous cell carcinoma (SCC) and 26 were confirmed to have adenoid cystic carcinoma (ACC). Direct parotid invasion occurred in 7 of 39 patients with SCC, only in the advanced stages, and in 15 of 26 patients with ACC, regardless of stage. Metastasis to the parotid node was noted in 6 patients with advanced-stage SCC, whereas no patient with ACC showed parotid nodal metastasis. For adequate tumor control with low risk of surgical complications, evidence based tailored parotidectomy should be applied. With no evidence of parotid involvement, an elective parotidectomy can be excluded in early SCC, whereas a total parotidectomy is recommended for advanced SCC. In ACC, basal resection of the parotid gland rather than a superficial or total parotidectomy should be performed at all disease stages.

Squamous Cell Carcinoma of the External Auditory Canal and Temporal Bone: An Update

Squamous cell carcinoma (SCC) is the most common primary malignancy to affect the temporal bone, including primary cutaneous SCC of the pinna, external auditory canal, middle and inner ear. This anatomically complex region generates complicated three-dimensional specimens that can be a challenge for macroscopic and microscopic pathologic assessment. A universally accepted staging classification for these malignancies is still to be established. A brief summary of the regional anatomy, etiology and epidemiology, presentation and diagnosis, radiologic assessment and treatment follows with a review of the pathologic assessment of the different types of specimens generated and an update on staging for SCC of the temporal bone.

Comparison of the University of Pittsburgh staging system and the eighth edition of the American Joint Committee on Cancer TNM classification for the prognostic evaluation of external auditory canal cancer

BACKGROUND

The purpose was to compare survival differences between patients with external auditory canal (EAC) cancer treated according to the University of Pittsburgh modified TNM staging system and those treated in accordance with the 8th edition of the American Joint Committee on Cancer (AJCC) staging manual on the TNM staging system for cutaneous cancers of the head and neck.

METHODS

We performed a retrospective, single-institution review of 60 patients with EAC cancer treated with curative intent between September 2002 and March 2018. Survival outcomes were measured on the basis of the two staging systems.

RESULTS

The C-index values for the overall survival (OS) rate revealed that the University of Pittsburgh staging system had higher prognostic accuracy than the 8th edition of the AJCC staging system. Univariable and multivariable analysis showed that T classification according to the University of Pittsburgh staging system was an independent predictor of the OS rate (hazard ratio 5.25; 95% confidence interval 1.38-24.9; P = 0.015). Meanwhile, the AJCC staging system could not differentiate T2 from T3-4 cancers.

CONCLUSION

The University of Pittsburgh staging system for patients with EAC cancer is a valuable tool for use in clinical decision-making and predicting survival outcome.