The VX2 carcinoma in the rabbit auricle as an experimental model for intra-arterial embolization of head and neck squamous cell carcinoma with dextran microspheres

A head and neck cancer model is developed using the VX2 carcinoma cell line injected s.c. in both ears of New Zealand White (NZW) rabbits. The study is focused on the effects of intraarterial embolization of the carcinomas with a new type of dextran hydrogel microspheres. During the phase of exponential growth the tumour-surface doubling-time was 7.1+/-2.0 days. Standard deviation in growth of the tumours was significantly larger between separate animals than between tumours growing in the left and right auricle of each individual animal (2.0 versus 0.65 days). A fresh cell suspension containing at least 10 x 10(6) vital tumour cells was necessary to yield a tumour-take of 85%. The caudal auricular artery perfuses the caudal half of the external ear and is very suitable for macroscopic cannulation. Histological evaluation shows, that the use of dextran hydrogel microspheres of at least 25 microm in combination with ligation of non-tumour perfusing branches of the central auricular artery yields diffuse embolization of the VX2 carcinoma. This tumour model can be of use in further studies to optimize particle size and dosage for embolization as well as to evaluate the effect of different anti-neoplastic drugs, slowly released by controlled degradation of dextran microspheres.

ENT malignancies. What the GP needs to know

BACKGROUND

The head and neck are sites that are accessible to examination, therefore early detection of cancers in these sites should be simple.

OBJECTIVE

This article discusses the commoner malignant tumours encountered in the various head and neck subsites. It gives an overview of the types of tumours that occur and the presenting features which allow us to distinguish them from benign disorders and facilitate much earlier diagnosis. Recent advances in diagnostic imaging and treatment are discussed.

DISCUSSION

Improved outcomes for patients with head and neck cancers will occur with earlier detection and community education about risk factors.

Bilateral middle ear squamous cell carcinoma and clinical review of an additional 5 cases of middle ear carcinomas

We reported a retrospective review of the clinical records for a 64 year old male patient with bilateral middle ear squamous cell carcinoma (MESCC), and for the five other patients with MESCC treated at our institution during the last 20 years. The patient with bilateral MESCC has survived and remained tumor free for more than 1.5 years after extended radical resection of the secondary tumor combined with intra-arterial and systemic chemotherapy, radiotherapy and immunotherapy. Four patients with unilateral MESCC were treated with multidisciplinary treatment (induction chemotherapy, surgery and radiotherapy), and the remaining patient was treated with radiotherapy and mastoidectomy. Five of the six patients are alive with no evidence of disease. The patient treated with radiotherapy and radical mastoidectomy died of local recurrence 3 years after diagnosis. We suggest that MESCC should be considered when refractory granulation, long-standing otorrhea, otalgia and facial paralysis are observed. Multidisciplinary treatment, including intra-arterial chemotherapy and en bloc resection of the temporal tumor is useful for the treatment of MESCC and will improve the prognosis of patients with this disease.

Facial paralysis: a presenting feature of rhabdomyosarcoma

The purpose of this paper is to present a child with embryonal rhabdomyosarcoma involving the left middle ear, who initially presented with unilateral facial paralysis. A 5-year-old boy presented with a 4-week history of left-sided facial weakness, associated with persistent otitis media on that side. Examination revealed complete left lower motor neuron facial weakness and hearing loss. A myringotomy revealed a soft tissue mass behind the tympanic membrane. Biopsy and oncologic assessment confirmed a stage II, group III left middle ear embryonal rhabdomyosarcoma. Despite debulking surgery, local irradiation and multiple chemotherapeutic courses the child deteriorated quickly. He developed carcinomatous meningitis and died 9 months after his initial presentation. In conclusion, middle ear tumors should be considered in the differential diagnosis of unresolving otitis media, particularly when associated with persistent ipsilateral facial paralysis. An ear mass, discharge, facial swelling, or systemic symptoms may be initially absent despite the presence of this aggressive malignancy. Careful examination of the middle ear is recommended in children with facial weakness. A myringotomy incision may be necessary including a complete assessment of the middle ear cavity, particularly when there is no fluid return.

An unusual localisation of Kaposi's sarcoma: the external auditory canal

The epidemic form of Kaposi's sarcoma is associated with human immunodeficiency virus infection. Cutaneous and mucosal manifestations are frequently reported in the ENT sphere, mostly involving the oral cavity. The external and middle ear are only rarely concerned with only one case of a mastoid lesion without extension to the external auditory canal (EAC) being reported to this day. The present article describes the first case of involvement of the EAC with extension to adjacent structures. This patient presented other Kaposi lesions and had been treated by systemic hormonal therapy. Thereafter local injection of a cytotoxic agent was given without effect. Finally, radiotherapy resulted in a 50% regression of the tumour mass. The epidemiologic factors and therapeutic modalities with their results are described.

[Neoplasms of the middle ear behind the intact tympanic membrane]

The authors described 4 cases of neoplasms of middle ear behind the intact tympanic membrane (3 cases of paraganglioma and 1 case of adenocarcinoma). They paid attention to the guileful course of disease and non-characteristic symptoms in its initial stage. Only immediate exploratory operation of the middle ear enables to make early diagnosis and start effective treatment.

Evaluation of dogs and cats with tumors of the ear canal: 145 cases (1978-1992)

OBJECTIVE

To characterize the frequency, clinical signs, biologic behavior, and response to treatment of tumors of the ear canal in dogs and cats.

DESIGN

Retrospective analysis of medical records.

ANIMALS

Medical records of 81 dogs (48 malignant tumors, 33 benign tumors) and 64 cats (56 malignant tumors, 8 benign tumors).

PROCEDURE

Data were analyzed for cats and dogs with malignant tumors, and risk factors were analyzed for their potential impact on survival time.

RESULTS

Malignant tumor types most commonly reported included ceruminous gland adenocarcinoma, squamous cell carcinoma, and carcinoma of undetermined origin. Median survival time of dogs with malignant aural tumors was > 58 months, whereas that of cats was 11.7 months. A poor prognosis was indicated by extensive tumor involvement (dogs) and by neurologic signs at time of diagnosis, diagnosis of squamous cell carcinoma or carcinoma of undetermined origin, and invasion into lymphatics or blood vessels (cats).

CLINICAL IMPLICATIONS

Malignant tumors of the ear canal in dogs and cats have a propensity for local invasion, but tend not to metastasize. Squamous cell carcinoma and carcinoma of undetermined origin were the most locally aggressive tumors. Malignant tumors of the ear canal are best managed by aggressive surgical excision. Radiotherapy may be useful when tumors cannot be completely removed.

Carcinoid tumor of the jugulo-tympanic region

Increased levels of 5-hydroxyindole acetic acid (5-HIAA) were found in a patient with a tumor arising in the middle ear. Iodine-123-metaiodobenzylguanidine ([123I]MIBG) scintigraphy and biochemical analysis showed evidence of serotonin production by the tumor. Immunohistochemistry of the tumor showed reactivity with antibodies directed against serotonin, chromogranin, leu-7 and neuron-specific enolase; S-100, met-enkephalin, leu-enkephalin and glial fibrillary acid protein were negative. This case suggests a close relationship between functioning paragangliomas and carcinoid tumors because a strong clinical and endocrinological resemblance exists. The hormonal activity found is discussed in relation to extra-adrenal paragangliomas. We recommend urinary screening not only for detection of increased levels of catecholamines, but also of 5-HIAA in all patients with paragangliomas of the head and neck. When elevated levels are found, [123I]MIBG scintigraphy should be performed to localize the areas of increased uptake in or outside the head and neck region.

[Combined treatment of malignant tumors of the external auditory canal and the middle ear]

Clinical outcomes have been analyzed for 50 patients with malignant tumors in the external acoustic meatus (EAM) and the middle ear (ME). The patients have received combined therapy with pre- or postoperative radiation. Combined treatment for EAM and ME cancer is a method of choice which increases survival of patients and improves quality of their lives. In primary cancer of the ear preoperative radiation is preferable, while postoperative radiation is required in advanced disease, in moderately or poorly differentiated tumors when the risk of recurrence is especially high.

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

OBJECTIVE

To determine the adequacy of the proposed TNM staging system and evaluate the therapeutic modalities used at our institution in an attempt to synthesize guidelines for therapy of primary squamous cell carcinoma (SCC) of the temporal bone.

DESIGN

Case series of 22 patients with previously untreated or residual SCC of the temporal bone treated between 1970 and 1990. Mean follow-up of the surviving patients was 124.5 months (range, 46 to 210 months).

SETTING

University of Texas M. D. Anderson Cancer Center, Houston, an ambulatory and hospitalized care referral center.

PATIENTS

The hospital charts of 41 patients with carcinoma of the temporal bone seen between 1970 and 1990 were retrospectively reviewed. Twenty-two of these patients had previously untreated or residual SCC of the external auditory canal and were chosen for this study. Information was collected regarding symptoms, tumor location, treatment methods, pathologic diagnosis, and patient outcomes.

MAIN OUTCOME MEASURE

Accuracy of proposed staging system in predicting 5-year survival. Effect of surgery alone, radiotherapy alone, and surgery combined with radiotherapy on survival.

RESULTS

Using the Pittsburgh staging system, the conditions of eight patients (36%) were staged at T1, four (18%) were staged at T2, six (27%) were staged at T3, and four (18%) were staged at T4. (The 19 patients with either recurrent disease or non-SCC were also treated, but their conditions were not staged). Statistical validation is impossible owing to the small sample sizes. Combination therapy with surgery and radiotherapy provided a higher 5-year survival rate than surgery or radiotherapy alone. Extrapolation of our data confirms that a staging system is useful in planning therapy. Surgical resection followed by radiotherapy is the preferred treatment for SCCs of the external auditory canal.

Intralabyrinthine schwannomas

Intralabyrinthine schwannomas are unusual tumors of the vestibule, cochlea, semicircular canals, or some combination of these three, which in the past have been reported as incidental findings at autopsy or surgery. We summarize eight cases of intralabyrinthine schwannomas diagnosed by magnetic resonance imaging at the House Ear Clinic during the past 3 years. We discuss the typical clinical presentation and treatment of cochlear vs. vestibular intralabyrinthine schwannomas.

Middle ear adenoma and adenocarcinoma

Adenomas and adenocarcinomas originating from the middle ear are few in number and have met with significant controversy in the literature. Our experience with 11 previously described patients is updated and five new cases are added. These tumors were seen in persons whose ages ranged from 7 to 77 years. The most common initial symptom was decreased hearing (11 cases), followed by otorrhea (4 cases), and otalgia (4 cases). At the time of diagnosis, facial nerve weakness was present in several patients (seven), and this was a poor prognostic sign. These glandular tumors engender controversy regarding histologic origin and the pathologic demarcation between adenoma and adenocarcinoma. In this review, we show that otorrhea, bone erosion, facial nerve involvement, and aggressive clinical behavior can be the result of lesions that appear microscopically benign. Furthermore, we present evidence of the similarity of these glandular lesions to paragangliomas and carcinoid tumors. Finally, pathologic data are presented to develop the previously unreported theory that the origin for this group of tumors is paraganglionic tissue.

Localized carcinoma of the external ear is an unrecognized aggressive disease with a high propensity for local regional recurrence

Management problems in patients with recurrent squamous cell carcinoma (SCC) of the external ear (pinna) have prompted a review of the management and treatment outcomes of patients who present with localized disease. Forty patients were seen over a 15-year period (1972 to 1991). Thirty-six were men, and 4 were women, with an age range from 43 to 93 years (average age: 71 years). Presenting TNM status was stage 0 in 2 patients, stage I in 15 patients, stage II in 13 patients, stage III in 2 patients, stage IV in 4 patients, and unknown stage in 4 patients. Thirty-six patients had clinically negative nodes at presentation (N0), and 4 had palpable nodes (N+). The primary treatment was local excision in 13 patients, Mohs' micrographic surgery in 16 patients, local excision plus external beam radiotherapy in 4 patients, and radical resection (parotidectomy/neck dissection/mastoidectomy) with or without radiotherapy in 5 patients. Two patients with stage IV disease died after diagnosis and prior to treatment, and two other patients with stage IV disease received palliative chemotherapy. Twenty patients developed recurrence from 2 months to 8 years. It included nine local recurrences, eight regional recurrences (parotid/neck/mastoid), and three distant metastases (lung or brain). After treatment of the recurrences in 20 patients, 8 are alive 15 months to 16 years later, 2 patients died of other diseases, and 10 patients died of SCC. The recurrences were managed by reoperation, radiotherapy, or chemotherapy. From the results of this study, we conclude that localized carcinoma of the external ear has a high propensity for local and regional failure and merits more aggressive treatment of the primary lesion and elective treatment of the regional lymph nodes and parotid gland in high-risk patients.

Therapeutic effect of intralesional interferon (Roferon) in squamous cell carcinoma

Recombinant alpha-2 interferon (IFN)--Roferon--100,000 IU/ml was intralesionally administered in 8 cases of squamous cell carcinoma (SCC) three times a week during 4-6 weeks in inoculations of 1 ml each. The therapeutic effect was scored as major--more than 60% reduction of the tumor size, moderate--30-60% reduction of the tumor mass and, nonreactive--less than 30% reduction of the tumor size. Three cases showed a major reduction, three showed a moderate reduction and two patients showed no reduction of the tumor volume. Histopathological examination of the surgically removed tumors after completion of the Roferon administration confirmed the clinical diagnosis of squamous cell carcinoma and revealed that an intense leukocyte, mainly lymphocytes, infiltration can be observed along with necrotic centers, progressively surrounding and reducing in size the tumor islets, thus proving an intense activation of the immune effector reactions against tumor cells.

Prognostic factors for local recurrence, metastasis, and survival rates in squamous cell carcinoma of the skin, ear, and lip. Implications for treatment modality selection

We reviewed all studies since 1940 on the prognosis of squamous cell carcinoma (SCC) of the skin and lip. The following variables are correlated with local recurrence and metastatic rates: (1) treatment modality, (2) prior treatment, (3) location, (4) size, (5) depth, (6) histologic differentiation, (7) histologic evidence of perineural involvement, (8) precipitating factors other than ultraviolet light, and (9) host immunosuppression. Local recurrences occur less frequently when SCC is treated by Mohs micrographic surgery. This local recurrence rate differential in favor of Mohs micrographic surgery holds true for primary SCC of the skin and lip (3.1% vs 10.9%), for ear SCC (5.3% vs 18.7%), for locally recurrent (previously treated) SCC (10% vs 23.3%), for SCC with perineural involvement (0% vs 47%), for SCC of size greater than 2 cm (25.2% vs 41.7%), and for SCC that is poorly differentiated (32.6% vs 53.6%).

[Differential diagnosis of an ear canal polyp]

Aural polyps or granulation tissue, though usually due to infection, may represent a neoplasm, the most frequent malignant tumour in childhood being rhabdomyosarcoma. We report a 9-year-old boy from whom an aural polyp was removed 4 years ago, with the histological diagnosis of a botryoid (alveolar type) rhabdomyosarcoma. Surgery and chemotherapy with cyclophosphamide, vincristine, adriamycin and actinomycin D were followed by a local recurrence 2 years later. This was treated by chemotherapy and irradiation with 50 Gy; the child has now been free of disease for 2 years. Rhabdomyosarcoma of the ear has a considerably improved cure rate with newer treatments if the diagnosis is made early by biopsy.

[AIDS and lymphoma of the ear]

The authors describe the circumstances for detection of an AIDS lymphomatous complication revealed by an otological picture in one patient. The lymphomatous pathology not related to HIV is reviewed. The particularity of these lymphomas, when they are related to HIV, is their frequent initial extra-ganglionic location, their high grade histological type and their poor prognosis. The authors emphasize the need to perform a biopsy rapidly when confronted with any external otitis resistant to general and local treatments.

Unusual auricular complications in cutaneous oncology

The anatomic complexity of the pinna predisposes that structure to a variety of unique, site specific postoperative complications following management of skin cancer. We describe four unusual auricular complications: 1) radiochondronecrosis; 2) autonecrosis of skin during second intention healing; 3) hearing loss secondary to tragal retraction over the external auditory canal; and 4) extension of tumor through fenestrated cartilage. Well-known postoperative auricular complications are reviewed and anticipation and recognition of these unusual complications are emphasized.

Interferon therapy for basal cell carcinoma and squamous cell carcinoma

Totally 161 basal cell and squamous cell carcinoma (BCC, SCC) patients were treated with human natural leucocytic interferon (HNLI) and recombinant IFN alpha 2c. After HNLI treatment, 61 out of 86 BCC patients and 29 out of 45 SCC patients were cured according to histopathologic and clinical findings. In 13 BCC and 13 SCC patients, the cancer lesion was reduced 25%-90%. After recombinant IFN alpha 2c treatment, 14 of 20 BCC patients and 4 of 10 SCC patients were cured according to histopathologic and clinical findings. In 6 BCC patients and 5 SCC patients the cancer lesion was reduced 25% to 90%. Both types of interferons are effective in the treatment of BCC and SCC patients. Local application of interferon stimulates immune reaction at the site of the tumor. There is a marked difference between the spontaneous macrophage activity and that induced by interferon. The interferon activated macrophages are significantly larger, the number of lysosomes and the density of macrophages is increased. In difficult locations intralesional therapy can be considered to avoid disfigurement of the patients with or without surgery.

[Undifferentiated carcinoma of the ear: apropos of a case]

A case report of ear undifferentiated squamous cell carcinoma is presented. The patient complained pain and suppurative ear, which lead to us to practise an exploratory atticotomy, and therefore the tumor was detected on its early stages. It is a very interesting case report due to its unusual localization, and to the early diagnosis to improve the prognosis of these patients.