CLINICAL ANALYSIS OF CARCINOMA OF THE EXTERNAL AND MIDDLE EAR
Introduction
Carcinoma of the external and middle ear is an uncommon neoplasm with annual incidence estimated at between one and six per million.1 The incidence of the tumor is as rare as less than 0.2% of head and neck cancers.2 Because of the rarity of the tumor, it has been difficult to formulate an evaluation and a treatment strategy. It is also sometimes difficult to diagnose the carcinoma at an early stage because it often resembles or coexists with chronic inflammatory diseases of the ear.
There is a consensus that an outcome of a treatment is poor for an advanced stage. Therefore it is necessary to find out a reasonable therapeutic strategy how the advanced stage of temporal bone carcinoma can be overcome. This study aims to analyze clinical characteristics and five-year survival of carcinomas of the external and middle ear in our department.
Subjects and methods
From February 2000 to April 2012, 28 patients with carcinomas of the ear were treated at the Department of Otolaryngology, Nagasaki University Hospital. Age and sex of these patients are listed in Table 1. In 25 patients, the carcinoma was mainly located in the external auditory canal and in three patients in the middle ear. Tumors were staged according to the Pittsburgh staging system3 for the external auditory canal (Table 2).3
We have basically tried to select surgery whenever possible; mainly total resection of the tumor was performed. In T1 and T2 cases, we performed lateral temporal bone resection (LTB), preserving the facial nerve. Subtotal temporal bone resection (STB) was performed in T3 or anterolateral development cases of T4. The postoperative additional treatment was given to the patients who had positive margin (Fig. 1). Recently, super-selective arterial infusion (SAI) of cisplatin with concomitant radiotherapy is also chosen as treatment for patients who are considered contra-indicated for surgery. Intra-arterial infusion of cisplatin was delivered via the posterior auricular artery and/or superficial temporal artery.4 The data of treatment and survival rate are summarized in Table 3.
Results
Eight patients had a history of otitis externa, and three had a history of chronic otitis media, respectively. Two had a history of ear surgery and five had a habit of ear-picking. All patients for whom more than one year was needed before the diagnosis could be established, had an advanced cancer. Histopathologically, there were 24 squamous cell carcinomas, two adenoid cystic carcinomas, one adenocarcinoma, and one undifferentiated carcinoma. We gave RT to T2 patients (no. 6) on whom we could not perform en-bloc resection of the tumor. The other T1 and T2 patients had no evidence of disease.
s ND: selective neck dissection, NED: no evidence of disease, DOD: died of disease, P: cisplatin, F: fluorouracil, T: docetaxel hydrate, TS-1: tegafur, SAI: superselective arterial infusion of cisplatin, m: month, w: week, y: year, SCC: squamous cell carcinoma, ACC: adenoid cystic carcinoma
Table 2. University of Pittsburgh TNM staging system proposed for the external auditory canal1
N status |
Involvement of lymph node metastases is a poor prognostic finding ; Any node involvement should automatically be considered as advanced disease, ie, T1N1=stage III and T2, T3, T4, N1=stage IV |
M status |
Distant metastases indicate a very poor prognosis and should be considered as stage IV disease. |
In the absence of metastastic lymph nodes or distant metastases, T status of the tumor defines the clinical stage. |
T status |
T1– Tumor limited to the external auditory canal without bony erosion or evidence if soft-tissue extension |
T2– Tumor with limited external auditory canal bony erosion(not full thickness) or radiographic finding consistent with limited (<0.5cm) soft-tissue involvement |
T3– Tumor eroding the osseous external auditory canal (full thickness) with limited (<0.5cm) soft-tissue involvement, or tumor involving middle ear and/or mastoid, or patients presenting with facial paralysis |
T4– Tumor eroding cochlea, petrous apex, medial wall of middle ear, carotid canal, jugular foramen or dura, or with extensive (>0.5cm) soft-tissue involvement |
Fig. 1. Scheme of temporal bone resection.
Table 3. Treatment and survival
RT: radiotherapy, CHE: chemotherapy, SAI: superselective arterial infusion of cisplatin
Fig. 2. Five-year survival rate of T4 patients.
Fig. 3. Comparison of estimated survival in T4 patients treated with operation versus without operation.
The five-year survival rate revealed by Kaplan Meier survival analysis was 100 % in T1, T2 and T3 cases, and 50.7 % in T4 (Fig. 2). In T4 cases, the survival rate of the patients who underwent surgery was 51.8 %, whereas that of the patients who had chemoradiation or SAI with radiotherapy was 50% (Fig. 3). Three patients who received SAI had a good outcome. Post-operative histopathological examination showed that four of 23 patients who underwent surgery had a positive margin, and all of them were T4. There was a considerable difference between positive and negative margin cases in the five-year survival rate. That is, regardless of the post-operative adjuvant treatment, the rates were 87% and 33%, respectively, as shown in Figure 4.
Fig. 4. Influence of histopathological margin on survival rate.
Conclusion
All the cases of the early-stage T1–3 showed good prognoses, while cases in the advanced stage, especially with T4 disease, showed poor five-year survival. These results suggest that prompt diagnosis and treatment are essential. When we examine a patient with repeated otorrhea for a long period, we should consider further examinations with CT scan and/or biopsy to exclude a neoplasm.
We reached the conclusion that current treatment including surgery with or without radiotherapy can control up to T3 cases. Even in advanced cases, surgical approach or SAI improved the survival rate and prognosis. In our view, this reaffirmed the importance of complete resection. On the other hand, one of four patients with a positive margin after surgery treated post-operatively with chemo-radiation survived more than five years with NED. This suggests that post-operative therapy for positive margin may be nevertheless worth trying. SAI could be an effective treatment for advanced cases.
References
1.Morris LG, Mehra S, Shah JP, BilskyMH, Selesnick SH, Kraus DH. Predictors of survival and recurrence after temporal bone resection for cancer. Head and Neck 34(9):1231–1239, 2012
2.Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: an evaluation of a staging system. Am J Otol 21:582–588, 2000
3.Arriaga M, Curtin H, Takahashi H, Hirsch BE, Kamerer DB. Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol 99:714–721,1990
4.Sugimoto H, Ito M, Yoshida S, Hatano M, Yoshizaki T. Concurrent superselective intra-arterial chemotherapy and radiotherapy for late-stage squamous cell carcinoma of the temporal bone. Ann Otol Rhinol Laryngol 120(6):372–376, 2011
Address for correspondence: Nimpei Yamaguchi, Department of Otolaryngology – Head and Neck Surgery, Nagasaki University Graduate School of Biomedical Sciences 1–7-1, Sakamoto, Nagasaki 852–8501, Japan. y-nimpei@nagasaki-u.ac.jp
Cholesteatoma and Ear Surgery – An Update, pp. 487–490
Edited by Haruo Takahashi
2013 © Kugler Publications, Amsterdam, The Netherlands