CARCINOMA OF THE EXTERNAL AUDITORY CANAL AND MIDDLE EAR

1
CARCINOMA OF THE EXTERNAL AUDITORYCANAL AND
MIDDLE EAR

• Z.Bernstein MD
• Rambam Medical CenterRadiotherapy Unit

2
Case Presentation

• A 72-year-old male with a 40-year history of
  recurrent left ear discharge, presented to his
  private otolaryngologist with left ear
  discharge, pruritus, and hearing loss.
• Examination revealed a firm, granular mass
  arising from the posterior half of the external
  auditory canal.
• Biopsy of the mass revealed moderately
  differentiated squamous cell carcinoma.
• CT scan and MRI demonstrated soft tissue changes
  noted in the mastoid and middle ear cleft without
  temporal bone invasion.

3
SYMPTOMATOLOGY (Pensak et. Al)

• Ear pain 74
• Hearing loss 62
• Bleeding 28
• Facial numbness 12
• Vertigo 10

4
Moderately differentiated squamous cell carcinoma
in which some, but not all, of the neoplastic
cells in nests have pink keratin staining.
5
CLINICAL SIGNS

• Ear canal lesion 88
• Aural discharge 84
• Preauricular swelling 25
• Facial paralysis 18
• Abnormal neck nodes 8

6
University of Pittsburgh TNM staging system
proposed for the external auditory canal and
middle ear.

• T1 Tumor limited to the external auditory
  canal without bony erosion or evidence of
  soft-tissue extension
• T2 Tumor with limited external auditory canal
  bony erosion (not full thickness) or radiographic
  finding consistent with limited (lt0.5 cm)
  soft-tissue involvement

7
University of Pittsburgh TNM staging system
proposed for the external auditory canal and
middle ear (cont.)

• T3 Tumor eroding the osseous external auditory
  canal (full thickness) with limited (lt0.5 cm)
  soft-tissue involvement, or tumor involving
  middle ear and/or mastoid, or patients presenting
  with facial paralysis
• T4 Tumor eroding the cochlea, petrous apex,
  medial wall of middle ear, carotid canal, jugular
  foramen or dura, or with extensive (gt0.5 cm)
  soft-tissue involvement

8
University of Pittsburgh TNM staging system
proposed for the external auditory canal and
middle ear (cont.)

• Involvement of lymph nodes is a poor prognostic
  finding and automatically places the patient in
  an advanced stage (i.e., Stage III T1N1 or
  Stage IV T2, T3, T4, N1 disease)
• Distant metastasis indicates a very poor
  prognosis and immediately places the patient in
  the stage IV category.

9
LITERATURE REVIEW

• 1966 - 1996., 96 publications, 144 pts.
• No single institution has sufficient data to
  allow analysis of results.
• No randomized or non-randomized prospective
  studies were identified.
• All studies were case series without control
  subjects.

10
T E R M I N O L O G Y

• MASTOIDECTOMY - all types of modified and radical
  mastoidectomy.
• LATERAL TBR - removal of the osseous and
  cartilaginous EAC, malleus and incus.
• SUBTOTAL TBR - removal of the otic capsule in
  addition to removal of the osseous and
  cartilaginous EAC, malleus and incus.
• TOTAL TBR - removal of the petrous apex in
  addition to all that is removed in subtotal
  resection.

11
Q U E S T I O N S

• 1. What is the survival rate of pts. with EAC,
  treated by surgical resection and what type of
  operation should be performed?
• 2. Once the disease enters the middle ear
  (ME), what is the operation that provides optimal
  survival?
• 3. Is total TBR (Temporal Bone Resection)
  ever indicated?

12
Q U E S T I O N S (cont.)

• 4. How does prognosis change as structures such
  as dura mater, brain, and ICA become involved? Is
  there a role for surgery in these instances?
• 5. Does the addition of preoperative or
  postoperative RT enhance survival?

13
R E S U L T S (1)

• E A C - Patients experience similar survival,
  regardless of whether mastoidectomy, lateral TBR,
  or subtotal TBR is performed ( 50, 38.8, 50
  5-year survival respectively).
• The addition of RT to lateral TBR does not appear
  to improve survival.

14
R E S U L T S (2)

• ME extension - survival of pts. Treated with
  subtotal TBR (41.7 5-year survival) appeared to
  be improved over those treated with lateral TBR
  (28.6) or mastoidectomy (17.1).
• Remains uncertain whether the addition of RT to
  mastoidectomy improves survival.

15
R E S U L T S (3)

• Petrous apex involvement -value of surgical
  resection remains unclear.
• subtotal TBR - 0 1-year survival
• total TBR - 50 1-year survival
• - 0 2-year
  survival

16
R E S U L T S (4)

• Resection of involved dura mater does not appear
  to improve survival.
• Incomplete data regarding margins of resection
  were reported.
• Determination of the value of resection of
  involved brain parenchyma or ICA will require
  further study.

17

• THE ROLE OF RADIOTHERAPY (CURRENT STATUS)

18
Testa JR, et al. San Paulo, BrazilArch Otol.Head
Neck Surg. 1997 Jul 123 (7) 720 - 4

• 79 pts. T1-2 - 34 T3-4 - 43 Tx - 2
• Available - 68 pts.
• 5 - year survival
• Surgery - 65
• Radiotherapy - 29
• Surgery Radiotherapy - 63

19
Hashi N, et al. Hokkaido, Japan. Radiother.
Oncol.2000 Aug56(2) 221-5

• 20 pts.
• 8 (T1) - RT alone 65 Gy in 26 fx. Over 6.5
  weeks.
• 12 (T2) - surgery RT (perioper.) 30 - 75 Gy
  in 12 - 30 fx.
• T1 - 100 5-year survival.
• T2 - 48 5-year survival.

20
Moody SA, et al. Pittsburg, USAAm. J Otol. 2000
Jul 21(4) 582-8

• 32 pts. All pts.underwent surgery of the
  temporal bone and RT (depending on stage and
  surgical margins)
• Results S T A G E 2-YEAR
  SURVIVAL
• T1
  100
• T2
  80
• T3
  50
• T4
  7

21
Perefunder L. et al. Wuerzburg, Germany.Int. J.
Radiation Oncology Biol. Phys. Vol.44 No. 4 pp.
777-88, 1999

• 27 pts.
• 5-year survival
• T1-2 - 86
• T3 - 50
• T4 - 41
• Complete tumor resection - 100
• Positive surgical margins - 66
• 3D CT treatment planing HDR brachytherapy -an
  effective tool in management of local recurrence
  following surgery and full course of EBRT.

22
Radiation technique for treatment of T3N1
carcinoma of the external auditory canal with
involvement of an intraparotideal lymph node and
perineural tumor spread along the facial nerve.
23
Dose distribution for brachytherapy treatment of
EAC recurrence.Treatment was performed after
surgery and a full course of EBRT (70 Gy).
24
Overall survival of 27 patients with carcinoma of
the EAC and middle ear treated at the University
of Wuerzburg, and freedom of local recurrence.
25
Survival of patients with carcinoma of the EAC
and middle ear according to T-stages of
Pittsburgh classification
26
Survival of patients with carcinoma of the EAC
and middle ear influence of margins of resection
and of intracranial tumor infiltration
27
C O N C L U S I O N

• RT -treatment of choice in T1 disease
• (Our patient).
• SurgeryRT recommended as standard of care for
  tumors with bony invasion
• Survival for T3 tumors is 50 with
  postoperative RT compared to 0 with surgery
  alone. (Moody SA et al.)
• HDR brachytherapy is an effective tool in
  management of local recurrence following surgery
  and full course EBRT.