Treatment of squamous cell carcinoma of external auditory canal: A tertiary cancer centre experience

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.

Neoadjuvant Immunotherapy for Head and Neck Squamous Cell Carcinoma: Expecting Its Application in Temporal Bone Squamous Cell Carcinoma

Temporal bone malignant tumors are characterized by atypical clinical symptoms, and easy recurrence and metastasis. They account for 0.2% of head and neck tumors, and the most common pathological type is squamous cell carcinoma. Patients with squamous cell carcinoma of the temporal bone are often at advanced stages when diagnosed, and lose the chance for surgery. Neoadjuvant immunotherapy has recently been approved as the first-line treatment for refractory recurrent/metastatic squamous cell carcinoma of the head and neck. However, it remains to be determined whether neoadjuvant immunotherapy can be used as the first-line treatment for temporal bone squamous cell carcinoma to reduce the tumor stage before surgery, or as a palliative treatment for patients with unresectable advanced stage carcinoma. The present study reviews the development of immunotherapy and its clinical application in head and neck squamous cell carcinoma, summarizes the treatment of temporal bone squamous cell carcinoma, and prospects the neoadjuvant immunotherapy as the first-line treatment for temporal bone squamous cell carcinoma.

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.

Reconstruction of the external auditory canal: The tragal flap revisited and review of contemporary reconstructive techniques

BACKGROUND

Primary malignancies arising in the external auditory canal (EAC) are rare and usually are treated surgically. We review techniques to reconstruct the EAC following ablative surgery, and introduce a rarely utilized tragal skin flap which has particular advantages for reconstruction of limited anterior EAC defects.

METHODS

The terms "tragal flap", "external auditory canal", "preauricular tragal flap", "reconstructive techniques" were searched on PubMed and Google Scholar.

RESULTS

Our review identified one description of a tragal flap to reconstruct the EAC following resection of a malignancy. We add an additional case of a preauricular tragal flap to reconstruct the anterior EAC following resection of a recurrent basal cell carcinoma located in the EAC that led to a circumferential defect.

CONCLUSION

There are several surgical techniques that can be utilized to reconstruct the EAC. We describe a novel tragal flap used to reconstruct the anterior EAC following resection of a recurrent tumor.

Lateral temporal bone resection for cutaneous carcinomas of the external auditory canal and peri-auricular region

OBJECTIVES

To evaluate the outcomes for patients after lateral temporal bone resection surgery for cutaneous squamous cell carcinoma and basal cell carcinoma, and to ascertain predictors of survival and treatment failure.

METHODS

A retrospective review was conducted of the medical records for all patients who underwent lateral temporal bone resection for cutaneous squamous cell carcinoma or basal cell carcinoma between 2007 and 2019 in Western Australia.

RESULTS

Thirty-seven patients underwent lateral temporal bone resection surgery. Median follow-up duration was 22 months. Twenty-five patients had squamous cell carcinoma and 12 had basal cell carcinoma. The overall survival rate at two years for patients with squamous cell carcinoma was 68.5 per cent. Pre-operative facial nerve involvement (determined via clinical or radiological evidence) was identified as a predictor of mortality (hazard ratio = 3.411, p = 0.006), with all patients dying before two years post-operatively. Locoregional tumour control was achieved in 81 per cent of cases (n = 30).

CONCLUSION

Lateral temporal bone resection offers acceptable local control rates and survival outcomes. Caution should be used in offering this surgery to patients with clinical or radiological evidence of facial nerve involvement because of the relatively poorer survival outcomes in this subgroup.

Management of the temporal bone defect after resection of external auditory canal cancer

OBJECTIVE

To evaluate the surgical procedures used to treat external auditory canal cancer with respect to avoiding postoperative infection of the temporal bone defect.

METHODS

Enrolled in the study were 52 patients with external auditory canal cancer surgically treated between July 2015 and October 2020 (38 lateral temporal bone resections, 12 subtotal temporal bone resections and 2 partial resections, accompanied by various combined procedures). Retrospective chart review was conducted taking into consideration postoperative infection, and univariate analysis of prognostic factors was performed.

RESULTS

In cases managed with subtotal temporal bone resection, no postoperative infections occurred. Cases managed with subtotal temporal bone resection demonstrated increased use of free-flap reconstruction, and longer antibiotic infusion period. On the other hand, analysis of cases managed with lateral temporal bone resection revealed 10 out of 38 patients with postoperative infection (26.3%). However, we couldn't find out any factors that contributed significantly to the prevention of postoperative infection, including the surgical procedures used to manage the defected space, which included free-flap implantation, obliteration with fat tissue, muscular flap rotation, and leaving the space empty without obliteration or reconstruction.

CONCLUSION

In cases managed with lateral temporal bone resection, leaving the resected space empty did not increase the risk of infection. On the other hand, in cases with subtotal temporal bone resection, filling the surgical defect with an autologous bulk, including the free-flap reconstruction and fat obliteration, seems to prevent the infection. Moreover, prolonged antibiotic infusion may suppress postoperative infection of the temporal bone defect.

Temporal bone carcinoma: Treatment patterns and survival

OBJECTIVES/HYPOTHESIS

Carcinomas of the temporal bone are rare, and appropriate treatment, staging, and survival data are limited. This study evaluates clinical characteristics and survival rates for patients with temporal bone carcinoma treated with resection at a single tertiary-care institution, with a focus on the outcomes of patients with locally advanced disease including skull base and/or dural invasion.

STUDY DESIGN

Retrospective chart review.

METHODS

Demographic, tumor-specific, and survival data were collected for patients with primary carcinomas of the external auditory canal with involvement of the temporal bone from 2003 to 2015. All patients were staged according to the modified Pittsburgh system. Kaplan-Meier and logistic regression analysis were used to calculate factor-specific survival outcomes.

RESULTS

Sixty-seven patients met inclusion criteria; 85% were male. There were 43 squamous cell carcinomas (64%) and 24 basal cell carcinomas (BCCs) (36%). Tumor stage was 24 (36%) T2, 12 (18%) T3, and 31 (46%) T4 tumors; 53% had recurrent disease. Surgical management included 49 lateral temporal bone resections and 18 subtotal temporal bone resections. Kaplan-Meier analyses revealed more favorable 5-year survival rates associated with BCC histology (P = .01), lateral temporal bone resection compared to subtotal temporal bone resection (P < .01), lack of immunocompromise (P = .04), and absence of perineural/lymphovascular invasion (P = .01). Multivariate regression analysis did not yield statistically significant results.

CONCLUSIONS

Factors predictive of more favorable survival include lack of immunocompromise, BCC histology, absence of perineural/lymphovascular invasion, and disease extent amenable to lateral temporal bone resection. Dural invasion is not an absolute contraindication to surgery, with a subset of patients surviving >5 years.

LEVEL OF EVIDENCE

3 Laryngoscope, 130:E11-E20, 2020.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Treatment and Outcomes of Carcinoma of the External and Middle Ear: The Validity of En Bloc Resection for Advanced Tumor

Carcinoma of the external and middle ear is a very rare disease. Despite the various treatment modalities available, its prognosis is still poor. We aimed to analyze the treatment modalities, outcomes, and validity of surgical approaches, especially in advanced tumors in the ear. Twenty-five patients with carcinoma of the external and middle ear were retrospectively analyzed. The modified Pittsburgh staging system was used for staging of the patients. Overall and disease-free survival was estimated using of Kaplan-Meier method. In our cohort of 25 patients, the majority (76%) had tumor located in external auditory meatus. The most common histologic subtype was squamous cell carcinoma (80%). More than half of patients (56%) had tumor stage IV. In the stage IV group, five patients underwent subtotal temporal bone resection and ipsilateral neck dissection. Seven patients underwent definitive radiotherapy. The remaining two patients underwent palliative chemotherapy. The 2-year overall and disease-free survival for patients with tumor stage IV was 67.7% and 57.8%, respectively. In patients with tumor stage IV, the 2-year overall survival for patients who underwent surgery was 80.0% versus 53.6% for those who underwent radiotherapy (P = 0.16). The 2-year disease-free survival for patients who underwent surgery was 80.0% versus 28.6% for those who underwent radiotherapy (P = 0.15). In the present study, the outcome of patients who received surgical treatment tended to be better than that of patients who received radiation therapy. Our results suggest that en bloc resection could be the first choice even in the advanced disease stage.

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

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