Rhabdomyosarcoma of the middle ear and mastoid

Treatment, Survival, and Demographics in Temporal Bone Malignancies: A Pooled Data Analysis

Temporal bone malignancies are relatively uncommon tumors. Their location adjacent to vital structures such as the carotid artery, jugular vein, otic capsule, and temporal lobe can make their treatment potentially challenging. The purpose of this study was to compare outcomes in temporal bone malignancies obtained via pooled literature data. The study sought to examine factors affecting survival in temporal bone malignancies based on the studies in the existing published literature. A systematic search was conducted on the PubMed (Medline), Embase, and Google Scholar databases to identify relevant studies from 1951 to 2022 that described the treatment of temporal bone malignancies. Articles that fulfilled the inclusion criteria were assessed and analyzed by the author. The literature search identified 5875 case series and case reports, and 161 of them contained sufficient data to be included in the pooled data analysis, involving a total of 825 patients. Multivariate analysis of the pooled literature data showed that overall stage, presence of facial palsy, and surgical margin status significantly affected overall survival (OS), while overall stage and presence of facial palsy significantly affected disease-free survival (DFS). To summarize, this study examined pooled survival data on demographics, treatment, and survival of patients with temporal bone malignancies utilizing an extensive literature-based pooled data meta-analysis. Overall stage, facial nerve status, and surgical margin status appeared to most strongly affect survival in patients with temporal bone malignancies.

Rare Diseases of the Middle Ear and Lateral Skull Base

Otalgia, otorrhea and hearing loss are the most common ear-related symptoms that lead to the consultation of an otolaryngologist. Furthermore, balance disorders and affections of the cranial nerve function may play a role in the consultation. In large academic centres, but also in primary care, the identification of rare diseases of the middle ear and the lateral skull base is essential, as these diseases often require interdisciplinary approaches to establish the correct diagnosis and to initiate safe and adequate treatments. This review provides an overview of rare bone, neoplastic, haematological, autoimmunological and infectious disorders as well as malformations that may manifest in the middle ear and the lateral skull base. Knowledge of rare disorders is an essential factor ensuring the quality of patient care, in particular surgical procedures. Notably, in untypical, complicated, and prolonged disease courses, rare differential diagnoses need to be considered.

Cranial Rhabdomyosarcoma Masquerading as Infectious Mastoiditis: Case Report and Literature Review

BACKGROUND

Rhabdomyosarcoma originating in the mastoid is rare and may be misdiagnosed as an infectious mastoiditis due to overlapping clinical and imaging features. We aimed to identify distinguishing characteristics to facilitate earlier diagnosis and treatment.

METHOD

Here we describe a case report and a systematic review of 23 reports describing previous cases of mastoid rhabdomyosarcoma. We compare these patients to a systematic review of patients with infectious mastoiditis and identify distinguishing clinical features.

RESULTS

A total of 43 patients with rhabdomyosarcoma of the mastoid were identified and compared with patients with mastoiditis. Rhabdomyosarcoma patients were more likely to present with a mass (86%) or cranial nerve dysfunction (83.7%), while mastoiditis patients were more likely to have fever (72.4%), pain (48.2%), and present at a younger age (4.4 vs. 6.1 years). The average lifespan with rhabdomyosarcoma of the mastoid was 7.1 months after diagnosis, with 41.7% of patients alive at the time of report.

CONCLUSIONS

Based on abstracted and aggregated information, we identified unique features observed more frequently in each of rhabdomyosarcoma and mastoiditis. These predictive features allow for the differentiation of each diagnosis and avoid the delay of proper treatment.

Head and neck rhabdomyosarcoma in children: a 20-year retrospective study at a tertiary referral center

OBJECTIVE

The purpose of this study was to assess rhabdomyosarcomas (RMS) of the head and neck in pediatric patients with regard to clinical presentation, treatment, and survival.

METHODS

Data were retrospectively obtained from patient charts with regard to RMS of the head and neck diagnosed between 1996 and 2016 at a tertiary referral center. Clinical course, treatment modalities, and side effects were analyzed. Survival analysis was carried out using the Kaplan-Meier method.

RESULTS

Twenty-eight patients (17 male, 11 female) with a mean age at diagnosis of 6.8 ± 5.0 years have been included. Fourteen patients (50%) presented with painless swelling in the head and neck region and nine patients (32.1%) presented with cranial nerve deficit at initial diagnosis. The location of the majority of rhabdomyosarcomas was orbital (N = 9; 32.1%), followed by parapharyngeal (n = 4; 14.2%) and sinonasal (n = 3; 10.7%). All patients (n = 28; 100%) received polychemotherapy, additional adjuvant radiation therapy was carried out in 24 patients (85.7%), and surgery was performed in 12 cases (42.9%). The 5-year overall survival was 91.3%, and median progression-free survival was 46 ± 67.4 months. Common side effects resulting from chemotherapy and radiation therapy included neutropenia, mucositis, nausea and vomiting, and radiodermatitis, long-term side effects included microsomia and facial mutilation.

CONCLUSION

Multimodality treatment of rhabdomyosarcomas of the head and neck in pediatric patients may lead to a 5-year overall survival of up to 91.3%.

Orbito-ethmoidal rhabdomyosarcoma in an adult patient: a case report and review of the literature

We report a patient who presented to the ENT service complaining of nasal obstruction, exophthalmos, edema and ipsilateral facial congestion. Imaging studies revealed an aggressive noncalcified solid mass centered in the left nasoethmoidal region and heterogeneous avid enhancement following contrast media injection. Subsequently, a biopsy confirmed the presence of solid alveolar rhabdomyosarcoma. The patient was treated with chemoradiation therapy for 7 weeks. Due to the advanced stage of the disease, the patient was enrolled in a palliative care and pain control program.

Temporal bone rhabdomyosarcoma in children

OBJECTIVE

Rhabdomyosarcoma is the most frequent soft tissue sarcoma in the pediatric age group. The authors present their series of rhabdomyosarcoma of the temporal bone in children at Saint Justine Hospital. The twofold objective of this study is to illustrate the clinical presentation, management, and prognosis of this malignant striated muscle tumor, and to compare these results with previously reported series.

METHODS

A retrospective study was conducted of patients diagnosed and treated for rhabdomyosarcoma of the head and neck at Saint Justine Hospital, a tertiary pediatric center, between 1970 and 2005. Only cases of temporal bone rhabdomyosarcoma were included in the study. A thorough review of medical and surgical charts was performed to obtain demographic, clinical, paraclinical, and therapeutic data, which were subsequently analyzed and compared to published results. A MEDLINE search yielded 34 studies dealing with temporal bone rhabdomyosarcoma since the year 1966.

RESULTS

Thirty-nine patients with rhabdomyosarcoma of the head and neck region were identified, among which only six children had temporal bone rhabdomyosarcoma. The mean age at the time of diagnosis was 4.15 years. Chronic otitis media was the most common clinical presentation. Five children had the embryonal subtype and one had the botryoid subtype on histology. All patients except two received combined chemotherapy and radiotherapy as treatment. Five-year survival rate was 66%. Our results match those reported in the literature 41-81%.

CONCLUSION

Rhabdomyosarcoma of the temporal bone is an aggressive tumor that clinically simulates chronic otitis media. A high index of suspicion should be raised in the context of otitis media that is unresponsive to ordinary medical treatment. A biopsy is hence recommended in the presence of polyps in the external auditory canal that are resistant to medical treatment. Early diagnosis and the adoption of multimodal therapy offer the best outcome.

Auricular Rhabdomyosarcoma in a Rat

An ear (auricular) neoplasm from a 1-year-old male rat was removed surgically and examined histologically. Macroscopically, the neoplasm was firm, white and measured (0.5 x 0.5 cm). Microscopically, the neoplasm was expansile, non-encapsulated, and composed of large, pleomorphic, polygonal to spindle-shaped cells containing multiple nuclei. Using immunohistochemical and chemical stains, the neoplastic cells were positive for vimentin, myoglobin, phosphotungstic acid haematoxylin and desmin, but had no immunoreactivity for cytokeratin or alpha-smooth muscle actin. On the basis of histopathological, immunohistochemical and histochemical stains, a diagnosis of auricular rhabdomyosarcoma was made. Although reported infrequently in human, this is, to the author's knowledge, the first report that describes the detailed gross, histopathological, histochemical and immunohistochemical findings of auricular rhabdomyosarcoma in a rat.

Embryonal rhabdomyosarcoma with intracranial extension

A case of embryonal rhabdomyosarcoma of the middle ear presenting with facial paralysis and a polypoidal aural mass who subsequently had convulsions due to intracranial extension is presented for its rarity.

Tumours of the mastoid temporal bone: with interesting cases in the paediatric age group

Tumours of the mastoid temporal bone are interesting clinical entities owing to their rarity. A wide variety of benign and malignant tumours occur in and around the temporal bone reflecting the complicated embryological origin and resultant diversity of tumours found in the area. Friedmann (1974), in a classification of tumours of the ear, has grouped some tumours as intermediate in variety, e.g. glomus jugulare tumour, in addition to various benign and malignant tumours. Metastatic deposits from various distant organs such as the lung, breast and kidney can occur in the mastoid bone (Schucknecht, 1968). Invasive tumours can spread to the mastoid bone from adjacent areas such as neoplasms of the parotid and cranium.

Improved prognosis with intensive treatment of children with cranial soft tissue sarcomas arising in nonorbital parameningeal sites. A report from the Intergroup Rhabdomyosarcoma Study

In the first Intergroup Rhabdomyosarcoma Study (IRS-I), it was found that, of 57 patients with nonorbital cranial parameningeal sarcoma treated from 1972 to 1976, 20 patients (35%) developed meningeal sarcoma and 90% (18/20) died of this complication. Since about half of these 20 patients had received inadequate radiation therapy and all had radiation therapy delayed until week 6, the treatment program was modified in December 1977 to begin radiation therapy on day 0 to the entire neuraxis and the primary tumor for all patients presenting with one or more risk factors indicating a high risk of meningeal involvement, and to administer periodic intrathecal medications to the same patients. The risk factors were intracranial extension of tumor, bony erosion at the cranial base, and cranial nerve palsy. In this report, the prognoses of two groups of patients with nonorbital cranial parameningeal sarcoma are compared: 95 patients treated before modification of the protocol in December 1977 with chemotherapy and nonintensive meningeal radiotherapy (preintensive group) and 68 patients treated subsequently with intensive meningeal radiotherapy and chemotherapy (intensive group). All patients received vincristine and actinomycin D (dactinomycin) with or without cyclophosphamide and Adriamycin (doxorubicin), according to the protocol. Radiation therapy consisted of 4000 to 5500 rad to the primary tumor in 5 to 6 weeks for most patients. The intensively treated patients also received intrathecal drugs via lumbar puncture and whole cranial or craniospinal radiation when one or more meningeal risk factors were present. In the preintensive group, the complete remission rate was 68% (65/95); the percentages of patients tumor free or alive at 3 years were 33% and 41%, respectively. In intensively treated patients, the complete remission rate was 76% (52/68); the percentages of patients tumor free or alive at 3 years were 57% and 68%, respectively. The improvements in the percentages of intensively treated patients tumor free or surviving were highly statistically significant (P less than 0.01 for both comparisons). Within the intensive treatment group, meningeal involvement at diagnosis was an unfavorable prognostic sign, since patients with no meningeal involvement had much better tumor-free survival at 3 years (81% vs. 51%) and survival (90% vs. 57%) than patients with evidence of meningeal involvement; the differences were highly statistically significant (P = 0.01).

Rhabdomyosarcoma of the temporal bone

The temporal bone is the primary site for approximately 10% of rhabdomyosarcomas of the head and neck in children. Until recently it has been a uniformly fatal tumor despite treatment with radical surgery and radiation therapy. Although experience with the Intergroup Rhabdomyosarcoma Study protocol-II is of relatively short duration, treatment of these children with radiation therapy and multiple-drug intravenous and intrathecal chemotherapy holds promise of significantly improved control rates.

Dental root agenesis secondary to irradiation therapy in a case of rhabdomyosarcoma of the middle ear

There have been only a few published reports on the dental-facial effects of radiation therapy and the subsequent oral management of these patients. A case involving a 13-year-old black male patient with a history of rhabdomyosarcoma is presented. The patient received 4,050 rads of radiation to the right middle ear when he was 2 years of age. His residual medical and dental difficulties are apparently complications from the initial therapy. Examination of the oral cavity revealed bimaxillary micrognathia and marked loss of vertical dimension. A Class II facial profile with Class I molar relationship was observed. The mandible was thin and hypoplastic, with a small knife-edge alveolar ridge. The remaining eighteen erupted permanent teeth were very mobile, and root development had ceased after only initial formation. All of the teeth except the first permanent molars were extracted, and immediate partial dentures were inserted at the time of surgery. A discussion of therapeutic considerations follows the case report.

Diagnosis and behavior of juvenile rhabdomyosarcoma

The main problems in the diagnosis of rhabdomyosarcoma are 1) distinction of undifferentiated examples from other small cell malignancies, especially soft-tissue Ewing's tumor and lymphoma; 2) distinction of spindling examples from fibrosarcoma, leiomyosarcoma, malignant fibrous histiocytoma, polyhistioma, and other sarcomas; 3) recognition of minimal criteria on small samples such as needle biopsy specimens or frozen sections; and 4) recognition of rhabdomyosarcoma in uncommon sites such as bone (mandible), perineum, retroperitoneum, and chest. In 95 pediatric cases diagnosed and treated at Royal Alexandria Hospital for Children--45 after the introduction of combined therapy--minimal diagnostic criteria were assessed. Cross-striations were found in only one third of cases; longitudinal myofibrils were more common and more helpful. There was much overlap between histologic types, and the microscopic patterns had little bearing on prognoses in preadolescent children. Fourteen cases could not be further differentiated ("embryonal sarcoma, probably rhabdomyosarcoma")--nine small-cell tumors; four tumors from genitourinary tract or head for which very small biopsy specimens were available, and one spindling retroperitoneal neoplasm. In all, slight evidence suggested embryonal rhabdomyosarcoma; this evidence included oat-shaped nuclei and, in a few cells, deeply eosinophilic cytoplasm, small elongated processes, or myxoid or alveolar foci--features that exclude lymphoma and Ewing's tumor. In six cases that were originally classified as poorly differentiated or undifferentiated, later material confirmed the presence of rhabdomyosarcoma by showing a predominantly well-differentiated (pleomorphic) or alveolar pattern after therapy. In 14 remaining undifferentiated cases, immunoperoxidase staining with antihuman-myoglobin serum was positive in five. With combined therapy there was 100 per cent survival among patients with paratesticular, limb, and stage I and stage II tumors; considerably improved survival among patients with head and neck, pelvic, and stage III tumors; and 100 per cent mortality among patients with intra-abdominal and stage IV tumors.

Rhabdomyosarcoma of the ear in childhood. A report from the Intergroup Rhabdomyosarcoma Study-I

Twenty-four children with rhabdomyosarcoma of the middle (22 patients) or external ear (two patients) were entered on the Intergroup Rhabdomyosarcoma Study-I protocol from 1972 to 1978. After surgery, treatment consisted of radiotherapy plus vincristine, dactinomycin, and cyclophosphamide, with or without Adriamycin. Nine of 19 patients (47%) who presented with localized sarcoma are free of disease at 2.2 to 6.5 years after diagnosis (median, 3.6 years). One is alive with regional recurrence at 6.7 years; another developed a contralateral cerebellar astrocytoma 4.4 years from diagnosis and died without evidence of rhabdomyosarcoma 2 months later. The other 13 children died of recurrent rhabdomyosarcoma at 5 to 25 months after diagnosis (median duration of survival, 10 months). Outcome was influenced by the presence of diagnosis of signs indicating meningeal extension; death rates were 5 of 5 patients with intracranial tumor, 3 of 4 with petrous bone erosion, 2 of 6 with facial nerve palsy, and 3 of 9 with no initial evidence of meningeal extension.

Parameningeal rhabdomyosarcoma in the young

Forty cases of young patients with embryonal rhabdomyosarcoma or undifferentiated sarcoma in parameningeal sites of the head and neck were reviewed. All 40 were treated with radiation therapy in conjunction with surgery and 16 were also treated with adjuvant chemotherapy. The overall five year survival rate was 35%. A primary tumor dose of at least 5000 rad resulted in a significantly greater survival rate compared with lesser doses. Meningeal involvement at diagnosis was present in 20 patients (50%) and the 30% five year survival rate for this group was no different than that for patients without initial meningeal involvement (41%). At first or second relapse, meningeal involvement was present in six of 37 patients and in two patients this occurred as an isolated event with distant meningeal seeding; in four other patients, meningeal involvement was a manifestation of local recurrence. As of the time of the last follow-up examination, control of the primary tumor had been achieved in 22 of the 40 (55%). It is considered that primary tumor radiation treatment parameters may be critical in determining the incidence of subsequent meningeal relapse.

The pathology of head and neck tumors: fibroadipose tissue and skeletal muscle, Part 8

Benign and malignant tumors originating from mesenchymal cells destined to become lipoblasts and myoblasts affect the head and neck with contrasting frequencies. Lipomas and especially liposarcomas are unusual lesions above the clavicles but when found there behave in a biologic manner identical to that of their counter-parts at other anatomic sites. Myogenic tumors, on the other hand, have a predilection for the head and neck, and for rhabdomyosarcomas this predilection is accentuated in childhood. Combination therapy of rhabdomyosarcomas has obviated radical surgery as a method of treatment, and many sites in the head and neck have benefited prognostically by this treatment. Success, however, is dependent on clinical stage of disease, and rhabdomyosarcomas of the nasopharynx, paranasal sinuses, and middle ear remain more resistant to short-term cures because of the extent of the neoplasm. A review of the clinicopathologic aspects of granular-cell tumors and alveolar soft-part sarcomas is also presented because it has been suggested that these tumors have a myogenous origin.

Increased incidence of brain metastases in sarcoma patients

Eleven cases of brain metastases that developed in 114 sarcoma patients are presented. Two of 11 patients presented with brain metastasis at the time of diagnosis and the other nine developed them later. The high incidence of brain metastases in patients with rhabdomyosarcoma (26%) and malignant fibrous histiocytoma (27%), two types of tumor which supposedly metastasize rarely to the brain, is remarkable. The increased incidence of brain metastases may be related to longer survival of sarcoma patients and to the inability of AMN and other drugs used in the treatment of sarcomas to cross the blood-brain barrier. Preventive treatment of brain metastases with drugs active in the CNS or with radiotherapy following the diagnosis of pulmonary metastases, could be useful, especially in patients with rhabdomyosarcoma and malignant fibrous histiocytoma.

Embryonal rhabdomyosarcoma of the middle ear

An embryonic sarcoma of the middle ear occurring in a child has been described. The mainstay of treatment has been triple therapy. The child is well 4 years and 3 months after diagnosis.

Incidence of meningeal involvement by rhabdomyosarcoma of the head and neck in children: a report of the Intergroup Rhabdomyosarcoma Study (IRS)

141 patients with embryonal rhabdomyosarcoma (RMS) of the head and neck are reviewed. 57/141 had lesions of para-meningeal sites. 20/57 (35%) developed evidence of direct meningeal extension. 18/20 (90%) died of this complication. Radiation portals and doses were limited in 42% and 32%, respectively. All patients had chemotherapy for 6 weeks prior to radiation. The significance of the adequacy of radiation factors and the timing of chemotherapy are reviewed. Recommendations for managing these patients include earlier use of radiation and increased coverage of adjacent meninges by radiation including total craniospinal axis radiation when brain meningeal involvement exists.

Computed tomography of pediatric craniofacial sarcoma

Review of the clinical and roentgenographic findings in 16 children with craniofacial sarcomas has revealed that CT is the most accurate method for delineation of the sarcomas and is indispensable for proper therapy planning and post therapy evaluation. The patients were examined and treated according to a protocol which required a CT examination before any type of therapy and after each mode of therapy, chemotherapy and radiotherapy. Chemotherapy alone was noted to produce marked reduction in tumor volume. The orbital sarcomas, which are most frequent, are small tumors without bone destruction. On the other hand, the nasopharyngeal, paranasal sinus and middle ear sarcomas are large tumors frequently associated with extensive bone destruction.

Embryonal rhabdosarcoma of the middle ear and mastoid

Two cases of embryonal rhabdomyosarcoma, arising from the middle ear, are described. It is a rare mesenchymal tumour of childhood, with a very poor prognosis. The literature is briefly reviewed and the difficulties encountered in diagnosis are outlined.

The radiology of bone changes in rhabdomyosarcoma

Rhabdomyosarcoma usually presents as a soft tissue mass, which may invade adjacent bone. However, the patient presents occasionally with bony metastases. Recognition of these is important for staging and management. Fifty-eight cases have been reviewed; 14 of these had local bone invasion by the soft tissue tumour. All bones involvel were flat bones; 12 showed permeated bone destruction and two showed geographic destruction. Bone expansion was seen in half the involved bones. Twelve of the 58 cases showed secondary bone deposits, which were the presenting feature in five. Although 10 cases had permeated bone destruction, two were very well defined with a wide range of radiological appearances. The radiological differential diagnosis includes neuroblastoma, leukaemic infiltration, lymphoma, histiocytosis X, solitary and multifocal osteosarcoma and other deposits.

Ophthalmic striated muscle neoplasms

Rhabdomyosarcoma, the most common primary malignant childhood orbital tumor, is composed of neoplastic striated muscle cells (rhabdomyoblasts) in various stages of differentiation and in patterns suggestive of neoplastic analogs of normal muscle embryogenesis. Orbital rhabdomyosarcoma is most commonly seen in children and adolescents, the average age of onset of symptoms being 7.8 years. The tumor usually presents as a rapidly evolving exophthalmos, often associated with drooping of the upper eyelid. A mass is palapable in only 25% of cases, loss of central vision at the time of presentation is uncommon, and laboratory studies are often of little help in diagnosis. The best diagnostic aid is a high index of suspicion whenever one sees a rapidly progressive exophthalamos in a child. Orbital rhabdomyosarcoma is almost always of the embryonal type, believed to originate in the orbital soft tissues from undifferentiated pluripotential embryonic mesenchyme. In the past, orbital exenteration has been the primary therapy. Review of 162 literature cases of orbital rhabdomyosarcoma, generally treated by unassisted surgery, revealed that only 25% of the patients survived 3 or more years. Recently, it has been shown that radiation therapy, alone or combined with chemotherapy, can be successful. A multidisciplinary approach, utilizing surgery, radiation therapy and chemotherapy has also been advocated. Both approaches appear to offer greater survival than unassisted orbital exenteration. The possibility of primary radiation therapy is extremely promising; if it becomes increasingly effective, a mutilating surgical procedure may become obsolete.

Rhabdomyosarcoma of the middle ear and mastoid

A case of embryonal rhabdomyosarcoma of the middle ear and mastoid is presented. The patient was treated by irradiation and Actinomycin D, and survived 4-5 months.

Embryonal rhabdomyosarcoma of head and neck in children. Correlation of stage, radiation dose, local control, and survival

Nineteen consecutive children are analyzed according to clinical stay, radiation dose (NSD), local control, and survival. The majority received 1600 to 1750 rets and courses of actinomycin during their radiation treatments. The favorable sites were the orbit, facial soft tissue, and the larynx. The primary site control rate was 89%, and the metastatic neck control rate was 80%. The 2-year survival was 70%, and the 5-year survival was 67%. Five children are alive and well 12 to 15 years after irradiation. Late sequelae are hypoplasia of the orbit and maxillary sinus.

Neurological manifestations of primary rhabdomyosarcoma of the head and neck in children

The authors describe four of their own cases of primary rhabdomyosarcoma (RMS) of the head and neck and summarize an additional 25 cases collected from the world literature, each manifesting neurological involvement. The need for early diagnosis and radical surgery is stressed.