Lymph node metastases from auricular squamous cell carcinoma. A systematic review and meta-analysis

Tumour Recurrence, Depth of Invasion, and Temple Location as Independent Prognostic Parameters of Lymph Node Metastases of Head and Neck Cutaneous Squamous Cell Carcinomas

The excellent survival rate of cutaneous squamous cell carcinoma (cSCC) exceeding 90% is reduced by the presence of nodal metastases by over 50%. We analysed various risk parameters of cSCC to predict the incidence of nodal metastases. A total of 118 patients with the head cSCC were included in a single-institution retrospective study covering the period from 2008 to 2020. Tumour recurrence, temple location, and tumour infiltration depth were found to be independent predictors of nodal metastases (increasing the probability of metastases by 8.0, 8.1, and 4.3 times, respectively). Furthermore, univariate analysis shows that the tumour size and T stage are significant factors increasing the risk of metastases. Several independent risk factors for the development of metastases in the head cSCC have been confirmed. These findings might help identify at-risk patients who require additional attention for adequate radical treatment and close follow-up. In contrast, elective treatment of lymph nodes is not recommended due to the low incidence of regional metastases.

Surgical outcomes for cutaneous squamous cell carcinoma of the auricle

Background

Cutaneous squamous cell carcinoma (CSCC) on the auricle is believed to carry a higher risk of metastatic spread. The rates of lymphatic metastasis reported in the literature have varied widely. There are no established prognostic criteria to determine which of these tumors are higher risk and warrant prophylactic treatment of the associated lymphatic basins.

Objective

To retrospectively evaluate outcomes after surgical treatment of auricular CSCC in our department, examining excision completeness, tumor recurrence, and lymphatic metastasis. Secondarily, to identify factors associated with lymphatic metastasis.

Methods

One hundred and thirty-eight consecutive cases of auricular SCC were excised from 126 patients in our department over a 7-year period (January 2012-December 2018). Data were retrospectively collected on patient characteristics, tumor histology, surgical procedures, and follow-up.

Results

Incomplete initial excision occurred in 17 cases (12.32%). Six patients (4.76%) had a local recurrence. Lymphatic metastasis occurred in eight patients (6.35%), on average within 10.25 months after primary excision. Six patients with metastasis died during follow-up, with a mean survival of 10.2 months. Older age was associated with lymphatic metastasis (P = 0.0267). Other factors, including tumor recurrence, size, grade, cartilage invasion, and positive margins, were evaluated and not significantly associated with metastasis.

Conclusion

In this study, the metastatic rate of auricular SCC was 6.35%, which is within the previously reported ranges. No histological prognostic factors were identified in this study, which may be due to our limited sample size. In the absence of established prognostic criteria, decisions regarding prophylactic treatment should be made on an individual basis with multidisciplinary support.

Curettage and colour-A technique for defining tumour depth on the ear in the Mohs and non-Mohs setting

For tumours of the ear that are suspected to involve auricular cartilage, precise definition of the extent of involved deep margin can be difficult. As large resections of cartilage can be cosmetically disfiguring with limited repair options, we propose a simple and effective technique to facilitate a targeted deep margin resection using a curette and a surgical marking pen.

Malignant lesions of the ear

The dermatologic lesions of the external ear are quite protean and they encompass pre-malignant, malignant and inflammatory entities. The ear is endowed with functional and cosmetic importance and it is part of the "H-zone", which is the area of the head that generally presents tumors that can be considered high risk regardless of their size. As a matter of fact, skin malignancies of the ear tend to have a less benign course compared to the ones located on other areas of the body and complete excision has proven to be challenging. This mini-review provides an overview on the malignant cutaneous lesions of the external ear with a focus on their dermoscopic and reflectance confocal microscopy features. The most prevalent neoplasms of the auricle are squamous cell carcinoma and basal cell carcinoma followed by melanoma. These malignant lesions appear to be more common in men and to have a worse prognosis compared to when they arise from other body districts. There is a relative dearth of large studies centered on the clinical, dermoscopic and reflectance confocal microscopy features of skin cancers of the ear. Hence, further research inquiring into the specific dermoscopic and reflectance confocal microscopy characteristics of the cutaneous malignant lesions of the external ear, if any, are warranted for the future.

The value of primary and adjuvant radiotherapy for cutaneous squamous cell carcinomas of the head-and-neck region in the elderly

Purpose

To examine treatment patterns, oncological outcomes and toxicity rates in elderly patients receiving radiotherapy for cutaneous squamous cell carcinoma (cSCC) of the head-and-neck region.

Material and methods

In this retrospective single-center analysis, locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) of elderly patients > 65 years with cSCC of the head-and-neck region undergoing radiotherapy between 2010 and 2019 were calculated. The prognostic value of clinicopathological parameters on radiotherapy outcomes was analyzed using the Cox proportional hazards model. In addition, both acute and chronic toxicities were retrospectively quantified according to CTCAE version 5.0.

Results

A total of 69 elderly patients with cSCC of the head-and-neck region with a median age of 85 years were included in this analysis, of whom 21.7% (15 patients) presented with nodal disease. The majority of patients exhibited a good performance status, indicated by a median Karnofsky performance status (KPS) and Charlson Comorbidity Index (CCI) of 80% and 6 points, respectively. Radiotherapy was administered as primary (48%), adjuvant (32%) or palliative therapy (20%). 55 patients (79.7%) completed treatment and received the scheduled radiotherapy dose. Median EQD2 radiation doses were 58.4 Gy, 60 Gy and 51.3 Gy in the definitive, adjuvant and palliative situation, respectively. 2-year LRC, PFS and OS ranged at 54.2%, 33.5 and 40.7%, respectively. Survival differed significantly between age groups with a median OS of 20 vs. 12 months (p < 0.05) for patients aged 65–80 or above 80 years. In the multivariate analysis, positive lymph node status remained the only significant prognostic factor deteriorating OS (HR 3.73, CI 1.54–9.03, p < 0.01). Interestingly, neither KPS nor CCI impaired survival in this elderly patient cohort. Only 3 patients (4.3%) experienced acute CTCAE grade 3 toxicities, and no chronic CTCAE grade 2–5 toxicities were observed in our cohort.

Conclusion

Radiotherapy was feasible and well-tolerated in this distinct population, showing the general feasibility of radiotherapy for cSCC of the head-and-neck region also in the older and oldest olds. The very mild toxicities may allow for moderate dose escalation to improve LRC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13014-021-01832-3.

Squamous cell carcinoma of the external ear: 170 cases treated with Mohs surgery

INTRODUCTION

Squamous cell carcinoma of the ear (SCC-E) shows high rates of local recurrence (LR) and lymph node metastases (NM). SCC-E is the leading cause of death from nonmelanoma skin cancer.

OBJECTIVE

To determine the LR and NM rates and survival after Mohs micrographic surgery (MMS).

PATIENTS AND METHODS

We treated 170 invasive SCC-E with MMS with a mean follow up of 48 months. Mean age was 76 years, 93.2% were male patients, mean size: 1.5 cm, and 61.8% of the tumours were well differentiated.

RESULTS

We observed 5 LRs, 2 locoregional recurrences, and 16 NMs in 23 patients. LR and NM rates were 4.1% and 10.6%, respectively. Only 3/25 recurrences occurred after 2 years of follow up. We observed 1(0.6%) distant metastasis (DM) in a patient who also presented LR + NM. Six out of seven cases with LR and 8/18 with NM died of disease, regardless of aggressive surgical rescue with or without adjuvant radiotherapy. Five-year overall survival, disease-free survival, and disease-specific survival were 81%, 82.6%, and 89.7%, respectively.

CONCLUSIONS

Undeniably, the outcome in SCC-E is determined by locoregional control. DM are sporadic and rarely the cause of death. Systematic reviews and retrospective studies show a solid trend in favor of MMS vs surgical excision. The LR rate of this series (4.1%) is one of the lowest published to date with regard to SCC-E, and confirms this assertion. We observed 10.6% NMs according to other series that treated the whole spectrum of SCC-E. Almost 2/3 of patients with NMs die after therapeutic rescue. We believe that it is essential to identify prognostic factors to select patients for one of the following: close surveillance (ultrasonography) during the first 2 years after surgery, sentinel node biopsy, or elective treatment of the nodes (surgery or radiotherapy).

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.

A Systematic Quality Evaluation of Meta-Analyses Related to Plastic Surgery

INTRODUCTION

Meta-analyses are considered to be an important source of evidence. This review aims to systematically assess the quality of meta-analyses addressing topics in plastic surgery.

METHODS

Electronic databases were selected for systematic review. A search was performed focusing on communication addresses containing terms related to plastic surgery, and detailed inclusion criteria were used. Related data were extracted and recorded according to the items of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. To assess the quality of the meta-analyses over time, studies published before and after PRISMA were evaluated.

RESULTS

A total of 116 meta-analyses were included. There was 1 study that was fully in compliance with the PRISMA items. The main flaws impacting the overall quality of the included studies were in the following areas: structured summary (48%), protocol and registration (2%), full electronic search strategy (35%), risk of bias in individual studies (41%), additional analyses (27%), risk of bias within studies (47%), additional analysis (30%), and funding (47%). Study quality was evaluated using relative risks (RR) with a 95% confidence interval (95% CI); this revealed that there were few significant improvements in adherence to the PRISMA statement after its release, especially in selection (RR, 1.80; 95% CI, 1.08-2.99), results of individual studies (RR, 2.88; 95% CI, 1.41-5.91), synthesis of results (RR, 3.08; 95% CI, 1.32-7.17), and funding (RR, 1.65; 95% CI, 1.21-2.24).

CONCLUSIONS

There have been measurable improvements in the quality of meta-analyses over recent years. However, several serious deficiencies remain according to the PRISMA statement. Future reviewers should pay more attention to not only reporting the main findings but also encouraging compliance with proper standards.

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

INTRODUCTION

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Paradigm change in the treatment of non-melanoma skin cancer of the auricle: reconstruction with full thickness skin grafting instead of wedge excision

Non-melanoma skin cancer (NMSC) has become an epidemic disease and is predominantly located in the head and neck area. While historically auricular NMSCs are treated by means of a wedge excision, we describe a more elegant technique with excellent esthetical results. We conducted a retrospective cohort study of 43 consecutive patients with NMSC of the auricle who underwent reconstruction with a full thickness skin graft (FTSG). All grafts survived. Two patients (5%) showed crust formation, but fully recovered. One patient had an irradical resection for which he required a limited re-excision. All patients showed excellent esthetical results. When treating NMSC of the auricle, reconstruction with a FTSG demonstrates several important advantages. It is a relatively simple but oncological safe technique; it leads to excellent esthetical and functional outcomes, and shows high patient and surgeon satisfaction.

Surgical treatment of auricular malignancies when the anterior or posterior skin is intact

The layers of the auricle from front to back were addressed, respectively, as follows: anterior skin, anterior perichondrium, cartilage, posterior perichondrium, and posterior skin. Thus, if a tumor on the auricle was holding 4 of these 5 layers and not holding the anterior or posterior skin, whether it was marginally located or stabilized in the mid parts, without having to apply complete resection, the intact parts were preserved, and the defect area was repaired with full-thickness skin graft. I practiced this method on a total of 17 patients, and histopathologic analysis showed that 13 of the patients had squamous cell carcinoma, 2 had Bowen disease, 1 had basocellular carcinoma, and 1 had granulomatous chondritis. I observed the patients for 7 years at the most. Auricular amputation, partial or total, is not a pretty decision and should not be made unless certainly necessary.

Tumor location is an independent prognostic factor in head and neck Merkel cell carcinoma

OBJECTIVE

Explore the relationship between tumor location and prognosis among patients with Merkel cell carcinoma (MCC) of the head and neck.

STUDY DESIGN

Retrospective analysis of large population database.

SETTING

Surveillance Epidemiology and End Results (SEER) database/multiple settings.

SUBJECTS AND METHODS

Using the SEER database, the authors identified patients with MCC of the head and neck. They compared clinicopathologic characteristics and disease-specific survival (DSS) between patients with head and neck MCC at different anatomic subsites. DSS was estimated by the Kaplan-Meier method, and a multivariable regression model was constructed so that independent predictors of DSS could be determined.

RESULTS

Of the 2104 patients identified, 61.0% were men. The mean age at diagnosis was 77.5 years. Tumors were most commonly located on the face (61.1%). Scalp tumors were significantly larger (10.4% >5 cm, P = .0001) and more likely to present with distant metastasis (8.7%, P = .07) than other head and neck tumors. Lip tumors had the highest rate of invasion into bone, cartilage, and muscle (13.7%, P = .012), and ear tumors had the highest rate of nodal metastasis (63.2%, P = .011). Patients with scalp/neck and lip primary sites had significantly worse survival on univariable analysis (P = .0054 and P = .0007, respectively); however, the lip was the only site associated with worse survival on multivariable analysis (hazard ratio = 1.8, P = .005).

CONCLUSIONS

This study is the first to report lip location as an independent prognostic factor in head and neck MCC. More aggressive treatment of patients with MCC of the lip may be warranted to improve outcomes.

CD73-generated extracellular adenosine in chronic lymphocytic leukemia creates local conditions counteracting drug-induced cell death

Extracellular adenosine (ADO), generated from ATP or ADP through the concerted action of the ectoenzymes CD39 and CD73, elicits autocrine and paracrine effects mediated by type 1 purinergic receptors. We have tested whether the expression of CD39 and CD73 by chronic lymphocytic leukemia (CLL) cells activates an adenosinergic axis affecting growth and survival. By immunohistochemistry, CD39 is widely expressed in CLL lymph nodes, whereas CD73 is restricted to proliferation centers. CD73 expression is highest on Ki-67(+) CLL cells, adjacent to T lymphocytes, and is further localized to perivascular areas. CD39(+)/CD73(+) CLL cells generate ADO from ADP in a time- and concentration-dependent manner. In peripheral blood, CD73 expression occurs in 97/299 (32%) CLL patients and pairs with CD38 and ZAP-70 expression. CD73-generated extracellular ADO activates type 1 purinergic A2A receptors that are constitutively expressed by CLL cells and that are further elevated in proliferating neoplastic cells. Activation of the ADO receptors increases cytoplasmic cAMP levels, inhibiting chemotaxis and limiting spontaneous drug-induced apoptosis of CLL cells. These data are consistent with the existence of an autocrine adenosinergic loop, and support engraftment of leukemic cells in growth-favorable niches, while simultaneously protecting from the action of chemotherapeutic agents.

Applicability of the pittsburgh staging system for advanced cutaneous malignancy of the temporal bone

The objectives are to evaluate the applicability of the Pittsburgh staging system (PSS) (designed for primary temporal bone malignancies) to advanced periauricular cutaneous malignancies with temporal bone involvement and to study treatment outcomes and prognostic factors predicting recurrence-free survival. Ten patients with advanced periauricular cutaneous malignancy with temporal bone involvement were identified. Patients with primary temporal bone or parotid gland malignancies were excluded. All patients were clinically T4 at presentation by the American Joint Committee on Cancer (AJCC) staging system. Using Pittsburgh staging, six were T1 (stage I) and four were T4 (stage III). The mean follow-up was 13.6 months (3 to 24 months). Patients with basal cell carcinoma were managed with wide local excision and lateral temporal bone resection (WLE/LTBR) without adjuvant therapy. Two of three (66%) are alive and free of disease; one patient died of other causes. Treatment for squamous cell carcinoma patients involved multimodality therapy. Kaplan-Meier survival curves show a worse prognosis in terms of disease-specific survival for patients with higher-staged PSS tumors. This did not reach statistical significance. The PSS may provide additional prognostic information on advanced cutaneous malignancies of the temporal bone over the more widely used AJCC staging system. However, further prospective multicenter studies with larger sample size are required to validate our findings. Basal cell carcinoma was well controlled with WLE/LTBR alone without adjuvant therapy, whereas squamous cell carcinoma required multimodality therapy: WLE/LTBR and postoperative radiation with or without chemotherapy.

Guidelines for delineation of lymphatic clinical target volumes for high conformal radiotherapy: head and neck region

The success of radiotherapy depends on the accurate delineation of the clinical target volume. The delineation of the lymph node regions has most impact, especially for tumors in the head and neck region. The purpose of this article was the development an atlas for the delineation of the clinical target volume for patients, who should receive radiotherapy for a tumor of the head and neck region. Literature was reviewed for localisations of the adjacent lymph node regions and their lymph drain in dependence of the tumor entity. On this basis the lymph node regions were contoured on transversal CT slices. The probability for involvement was reviewed and a recommendation for the delineation of the CTV was generated.

What's new in skin cancer? An analysis of guidelines and systematic reviews published in 2008-2009

This review summarizes clinically important findings from 17 systematic reviews and 2 guidelines on skin cancer indexed between April 2008 and April 2009. Melanoma primary-prevention measures, such as education, are more likely to be successful in younger children than adolescents, and general population screening for melanoma by whole-body examination is not currently supported by the evidence. A large systematic review of melanoma and pregnancy concluded that pregnancy does not affect prognosis. Two systematic reviews imply that sunburn later in life also increases the risk of melanoma, and that it is just as important as sunburn early in life. Three systematic reviews discussed the role of positron emission tomography and sentinel lymph-node biopsy for melanoma staging, but produced conflicting results. Superior diagnostic accuracy of dermatoscopy over naked-eye examination for melanoma was found in one review, while a second implied nonsignificantly higher sensitivity of computer-based diagnostic methods over dermatoscopy for melanoma but with reduced specificity. There were no identified randomized controlled trials of treatments for unresectable recurrent melanoma, and a review of immunotherapy with vaccines for melanoma failed to prove improved overall and disease-free survival. Guidelines for the management of basal cell carcinoma call for risk stratification, based on numerous factors including tumour size, site and histological subtype. Squamous cell carcinoma of the ear has been shown to spread to regional lymph nodes more commonly than to other sites, and may be predicted by depth of invasion, tumour size, cellular differentiation and completeness of excision.

Patterns of Regional Metastasis in Advanced Stage Cutaneous Squamous Cell Carcinoma of the Auricle

Objective. To determine patterns of regional metastasis in patients with advanced stage cutaneous squamous cell carcinoma of the auricle.

Study Design. Case series with chart review.

Setting. University-based tertiary care hospitals.

Subjects and Methods. We analyzed 41 patients with stage III and IV squamous cell carcinoma of the auricle.

Results. The mean age was 74.2 years (range, 20.6-91.7 years). Thirty-five patients (85.4%) were stage IV. Twenty-nine patients (70.7%) had a prior history of nonauricular, nonmelanotic skin carcinoma. Twenty-four patients (58.5%) had regional metastasis to either the cervical or parotid nodal basin. In patients with cervical metastasis, the involvement by level was 6.7% (n = 1), 80.0% (n = 12), 46.6% (n = 7), 13.3% (n = 2), and 40.0% (n = 6), respectively. Of the 6 patients with a level 5 metastasis, 3 had primaries in the preauricular region, 2 had primaries of the auricle, and 1 had a primary of the postauricular region. Occult disease was present in 2 patients (9.1%) with cervical metastasis and in 4 patients (18.2%) with periparotid lymph node metastasis. Perineural invasion was seen in 84.4% of the study population. The recurrence rate was 46.3% (n = 19). The median time to recurrence was 28.3 months.

Conclusion. Patients with advanced stage auricular cutaneous squamous cell carcinoma have a high rate of regional metastasis and recurrence. When planning neck dissections for these patients, level 5 should be included in the resection. Patients demonstrating locally advanced disease without clinical or radiographic evidence of metastasis to the parotid or cervical drainage basin should undergo a parotidectomy and comprehensive neck dissection.

[Malignant tumors of auricula and periauricular area]

BACKGROUND/AIM

Malignant tumors of auricula and periauricular area represent seven percent of all cutaneous tumors. They appear mostly in the sixth and seventh decade. According to histological type they are basocellular and planocellular carcinomas. The most frequent etiology is the sun exposition. The aim of this study was to analyze clinical and histological characteristics and therapy of malignant tumors of auricular and periauricular area.

METHODS

Totally 155 patients were treated in ORL Clinic, Clinical Center Nis during the period 1990-2006. The patients were treated surgically (59.35%), by radiotherapy (1.94%) and by combination of the two methods (38.71%).

RESULTS

Since the majority of tumors were small and presented on the helix, wedge excision and primary reconstruction were performed (136), while total (9) or partial (10) auriculectomy were done in a small number of the patients. For larger lesions (T4--when lesion is greater than 4.0 cm) and neck metastasis invading cartilage or bone, parotidectomy (15), radical neck dissection (25) and temporal bone resection (9) were performed.

CONCLUSION

Carcinoma of auricular and periauricular area should be confirmed by biopsy and histopathologic evaluation. In all cases an adequate excision, margin examination and observation of appropriate lymph node draining regions should be provided.

Metastatic cutaneous squamous cell carcinoma of the external ear: a high-risk cutaneous subsite

Introduction:

Patients with cutaneous squamous cell carcinoma of the external ear may develop metastatic spread to the nearby ipsilateral parotid and/or upper cervical lymph nodes. The literature suggests that the external ear is a high-risk subsite for such tumours, due to nodal metastasis and its associated morbidity and mortality.

Methods:

Between 1980 and 2007, 43 patients with a diagnosis of metastatic cutaneous squamous cell carcinoma of the external ear were treated with surgery alone, surgery plus adjuvant radiotherapy, or radiotherapy alone.

Results:

Patients comprised 39 men and four women. Their median age at diagnosis was 72 years, with a median follow up of 35 months. The median size of the primary lesion was 21 mm, with a median thickness of 7 mm. Fifteen patients presented concurrently with nodal metastases. Thirty patients developed parotid metastases (with positive cervical nodes in six patients), while 13 developed cervical metastases only. Eight patients underwent surgery alone, 32 underwent surgery plus adjuvant radiotherapy, and three received radiotherapy alone. At the last follow up, 15 patients had relapsed and nine had died of their disease, with a median survival after relapse of 5.5 months.

Conclusion:

Patients with metastatic cutaneous squamous cell carcinoma of the external ear have a relatively poor outcome, with a significant number of patients experiencing nodal relapse and death after treatment.