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Ear carcinoma

Ear carcinoma anatomy to management. Role of radiotherapy in ear carcinoma.

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Ear carcinoma

  1. 1. Ear Carcinoma Anatomy to Management By Dr. Ayush Garg
  2. 2. Learning Objectives for JRs Anatomy of Ear Management of disease Learning Objectives for SRs Recent advances in treatment
  3. 3. Anatomy Epidemiology Clinical presentation Diagnostic workup Pathological classification Prognostic factors Staging General management Radiotherapy techniques Results and sequelae of treatment
  4. 4. Anatomy
  5. 5. • The external, middle, and inner components of the ear develop from the three embryonic layers: ectoderm, mesoderm, and endoderm • The external ear consists of : auricle or pinna, external auditory meatus (canal), tympanic membrane
  6. 6. CN VIII Vestibular apparatus Middle ear cochlea TMJ clivus Mastoid Air cells
  7. 7. • Auricle: composed of elastic cartilage covered with skin. • External auditory meatus : connects the tympanic membrane to the exterior 2.4 cm long. outer 1/3rd - cartilaginous, inner 2/3rd is bony and slightly narrower. related anteriorly to parotid gland at the TM joint; Inferiorly, jugular bulb and facial nerve.  Skin lining is continuous with auricle, outer 1/3rd contains hair follicles, sebaceous and ceruminous glands. • Tympanic membrane: made of multiple layers of squamous epithelium; separates auditory canal from middle ear.
  8. 8. Middle Ear • Middle ear contains: auditory ossicles, tympanic cavity • Opens into the eustachian tube to communicate with the pharynx. • Cavity is lined with mucoperiosteal membrane and eustachian tube is lined with stratified columnar epithelium, has mucous glands in 2/3 rd of the tube closer to the pharynx. • Overall length of eustachian tube is 3.5 cm.
  9. 9. Internal Ear • Lies in petrous portion of temporal bone and consists of : Bony labyrinth Membranous labyrinth. • The membranous labyrinth: holds the organ of hearing, is housed within the bony labyrinth. • Cochlea: responsible for hearing • Vestiblule: responsible for balance Parts of inner ear
  10. 10. Lateral semicircular canal Internal auditory canal Carotid canal Cochlea Facial Canal Sphenoid Sinus Vestibule Mastoid air cells Temporal Lobe (Anterior) Ossicles
  11. 11. Blood Supply • Auricle & external auditory canal: branches of the posterior auricular artery superficial temporal artery, which arise from the external carotid artery. • Middle ear: branches of ascending pharyngeal Artery middle meningeal arteries artery of the pterygoid canal. • Inner ear : internal auditory artery - branch of the basilar artery anterior inferior cerebellar artery.
  12. 12. Nerve supply • The nerves innervating the ear: cranial nerves V, VIII, IX, and X. The VIII or vestibulocochlear nerve: arises at the lateral termination of the internal acoustic meatus and ends in the brainstem between pons and medulla.  responsible for auditory and vestibular function.
  13. 13. Lymphatic drainage • External ear: Lymphatic vessels of the tragus and anterior external portion of the auricle: superficial parotid lymph nodes. posterior and superior aspects of auricle: retroauricular lymph nodes Lobule: superficial cervical group of lymph nodes. • Middle ear and mastoid antrum: sparse lymphatic drainage parotid nodes and upper deep cervical lymph nodes. • Inner ear: no lymphatics.
  14. 14. anteriorly through the cartilaginous canal into the parotid gland 1 through the concha into the postauricular sulcus 2 posteriorly into the mastoid 4 through the tympanic membrane into the middle ear 3 Into the inner ear through the round window or otic capsule 6 Into the anterior mesotympanum to the carotid artery and eustachian tube, 5 Inferomedially into the jugular fossa, carotid artery, and lower cranial nerves 8 Along the extratemporal facial nerve into the infratemporal fossa7
  15. 15. Epidemiology • Malignant disease of the auricle is common but cancers of middle ear and external auditory canal are rare. • Incidence: 1 per million. • External ear: most common are cutaneous malignancies, related to sun exposure. Other predisposing factors: otorrhea, chronic eczema, chronic dermatologic conditions, and chronic ulcerations from trauma. most common in 60 to 70 years of age. More common in males. • Middle ear and the mastoid: more common in 40 to 60 years of age. More common in females.
  16. 16. Clinical presentation • External Ear: • Basal cell carcinomas are more common than squamous cell carcinomas (1.3 :1) • Present as small ulcerations, mostly on helix. • SCC: lymph nodes metastasis in 10-15%. • Common LN metastasis sites: parotid glands, upper deep cervical nodes and postauricular nodes. • Regional metastasis is higher in advanced disease and may involve level V LNs.
  17. 17. External Auditory Canal • Mostly symptomatic • Pruritus and pain – common • Advanced cases : Swelling behind the ear, decreased hearing and facial paralysis • Spread of the tumor into lymphatic areas: common • Distant metastases rare
  18. 18. Tumors in cartilaginous portion of canal:  invade cartilaginous walls and spread to bony canal. Tumors in bony canal : more effective barrier preventing spread; Progress along main axis of canal, eventually invading middle ear or cartilaginous canal.
  19. 19. Diagnostic Work-Up • A baseline audiology testing should be performed before any treatment. • Both CT and MRI play an important role in vizualizing tumors of ear. • CT scan: • CT can show abnormal soft tissue, soft tissue enhancement, and distortion of the normal tissue planes. • Most importantly, when evaluating EAC tumor, CT can provide accurate prediction of bone erosion, such as wall of the EAC, middle ear, TMJ, carotid artery canal, and jugular fossa and thus can help to determine the extension and the operability of tumors
  20. 20. • MRI: • MRI can differentiate the tumor from mastoiditis and cholesteatomas and provide excellent delineation of soft tissue tumor margins, muscle infiltration, intracranial extension, dural or cerebral involvement, and vessel encasement.
  21. 21. • Note: • Diagnosis is always established by biopsy and occasionally by aspiration of the exudative material or by surgical exploration. • A bone scan may be done to determine the changes in temporal bone around the tumor, but it provides very nonspecific information and is not a recommended method of evaluation.
  22. 22. Pathologic Classification • Approx. 85% of the tumors involving auditory canal, middle ear, and mastoid area are squamous cell carcinomas. • Others: Basal cell carcinomas, Adenocarcinomas, Adenoid cystic carcinomas, Melanomas, Sarcomas, specifically embryonic rhabdomyosarcomas. Ceruminous gland tumors and papillomas (rarely arise in the auditory canal) Carcinoid tumor of the middle ear (50 case reports) Endolymphatic sac tumor or aggressive papillary middle ear tumors: (characterized by slow growth but extensive local invasion and bone destruction)
  23. 23. • Lesions of the external ear are more easily controlled than middle ear or mastoid. • Presence of large lesions involving the middle ear and those with extension into the temporal bone or soft tissue is a poor prognostic sign and more difficult to treat. • No correlation between tumor differentiation, positive margins, or perineural disease and survival, they are predictor for local control in tumors involving the temporal bone. • Seventh cranial nerve palsy associated with middle ear tumors indicates poor survival • Spread of tumors to the lymph nodes usually indicates a poor prognosis Prognostic Factors
  24. 24. STAGING
  25. 25. • The seventh edition of the American Joint Committee on Cancer (AJCC) staging manual includes the external ear in its staging system under Cutaneous Squamous Cell Carcinoma and Other Cutaneous Carcinomas. • A group from the University of Pittsburgh proposed a staging system for squamous cell carcinoma of the external auditory canal and temporal bone, which was updated in 2002. • The primary tumor stage is determined by the level of bony erosion, size, and involvement of the middle ear. • Lymph node disease is considered advanced stage with poor prognosis. This staging system has often been cited in the literature
  26. 26. General Management External Ear • Most often treated with limited surgery or external radiation therapy. • Treatment in early stages: irradiation in form of megavolatage electron beam therapy. • Dose: 66 – 70 Gy in 1.8 to 2 Gy per fraction for 6.5 – 7 weeks • Local control rates: 80 -97% • Surgery : beneficial if lesion has invaded cartilage of ear or extends medially into auditory canal. • If squamous cell carcinoma of external ear is treated with surgery alone: recurrence rate 14- 19% • Advanced lesions involving ear canal- managed with combination of irradiation and surgery.
  27. 27. • Treatment of draining lymphatics : not required for early stages of external ear tumors. • Prophylactic neck dissection indicated in : lesions over 4 cm Lesions with cartilage invasion due to increased risk of nodal spread. Overall chance of lymph node involvement in tumors of external ear: 16%.
  28. 28. • Interstitial irradiation using afterloading 192Ir, particularly for tumors <4 cm: effective method of treatment, affording excellent local control with good cosmesis. • Radical surgery and postoperative radiation therapy are the accepted methods of treatment for more advanced lesions of external auditory canal, middle ear and mastoid. • Post op radiotherapy dose: For negative margins: 54 -60 Gy. For positive margins: upto 66 Gy.
  29. 29. Surgery • Lesions of the outer part of the auditory canal require local excision with at least a 1-cm margin between the lesion and the tympanic membrane • Surgery for tumors of the auditory canal is performed through a U-shaped incision with elevation of the flap from below. • A split-thickness skin graft is usually required to cover the deficit along the auditory canal • When the tumor involves the bony auditory canal and impinges on the tympanic membrane but does not involve the middle ear or the mastoid, a partial temporal bone resection may be necessary; in this procedure, the auditory canal, tympanic membrane, malleus, and incus are removed along with the TMJ, and the defect is grafted with a split-thickness skin graft
  30. 30. Middle Ear and Temporal Bone • In management of temporal bone tumors originating from middle ear and mastoid area, the surgical options are : mastoidectomy, lateral temporal bone resection, subtotal temporal bone resection, total temporal bone resection. • Postoperative radiation therapy is essential to increase chance of local tumor control as complete resections with clear margins is difficult to achieve. • Chemotherapy has not been beneficial in tumors of ear.
  31. 31. New RT Technique • Stereotactic ablative radiotherapy (SABR) may represent a new treatment option for organ preservation. • A study used 37.5 Gy/3 fractions or 40 Gy/5 fractions radiotherapy as a first-line treatment, resulting in 3-year OS rates: 69% for T1/2, 79% for T3 (95% CI, 47–93), and 0% for T4 disease with limited toxicities.
  32. 32. Chemotherapy • Chemotherapy has been used in tumors of the ear. • The common regimen includes cisplatin, docetaxel, and mitomycin via intravenous or intra-arterial. • A meta-analysis suggested that preoperative CRT followed by surgery may improve the survival of patients with external auditory canal SCC and that definitive CRT may be equivalent to surgical resection. • However, additional trials are necessary to determine efficacy because there was no control trial in this meta-analysis.
  33. 33. Radiation Therapy Techniques • Tumors involving the pinna can be treated with electron or megavoltage irradiation. • Fields : round or polygonal, drawn around the tumor to spare surrounding normal tissues. • For small superficial tumors: margins of 1 cm are adequate. • For extensive lesions: large portal including entire pinna or external canal with 2- to 3-cm margins around clinically apparent tumor. • Lesions involving pinna: treated with low dose per fraction(1.8 to 2 Gy daily) to prevent cartilage necrosis. • Doses of 65 Gy over a period of 6.5 weeks are required to achieve adequate tumor control.
  34. 34. Lesions of external auditory canal: treated with irradiation alone or combined with surgery. Portals: include entire ear and temporal bone with adequate margin (3 cm). Volume treated: includes ipsilateral preauricular, postauricular, and subdigastric lymph nodes. Treating lymphatics beyond jugulodigastric area is usually not necessary.
  35. 35. IMRT:  Improves target coverage and spares normal critical structures. advanced external auditory canal and middle ear tumors: GTV: clinical and radiographic gross disease. CTV1: GTV with 0.3 -0.5 cms margin to a dose of 66-70 Gy at 2 Gy per fraction. CTV2: CTV1 with 0.5 -0.7 cms margin + preauricular and post auricular LNs with ipsilateral level II LN and parotid gland to a dose of 63 Gy at 1.8 Gy per fraction. CTV3: for ipsilateral level III and IV LNs and contralateral level II to a dose of 56 Gy at 1.6 Gy per fraction. PTV: 3-5 mm margin around CTVs.
  36. 36. Unresectable Tumors: • Treated with:  High-energy ipsilateral electron beam therapy (16 to 20 Mev) alone or  Mixed with photons (4 to 6 MV) or  With wedge pair (superior inferiorly angled beams) techniques using low-energy photons or  IMRT. • Dose: 60 to 70 Gy over 6 to 7 weeks. • Doses higher than this produces osteoradionecrosis of temporal bone. • When electron beam radiation therapy is used, use of water bolus in external auditory canal and concha reduce auricular complications.
  37. 37. Palliative Radiation Therapy  In recurrent or advanced disease.  Pain relief is reported in 61% patients with tumors of auditory canal and middle ear.  Recurrences developing after previous irradiation may be retreated with low-dose radiation therapy: tumor control in 20% patients.  When small-volume local recurrence occurs after previous radiation therapy, fractionated high-dose-rate treatment may be considered.
  38. 38. Normal Tissue Dose Constraints
  39. 39. Results of Therapy Overall 5-year survival rates with combination therapy for :  Patients with earlier-stage tumors achieve 70% survival rate at 5 years with no evidence of disease  Tumors involving the middle ear and external auditory canal -40% to 60%  Negative effect of extent of disease on survival without evidence of tumor
  40. 40. Sequelae of Treatment • Possible sequelae with surgery: Hemorrhage, Infection, Loss of facial nerve function, Rarely, Carotid artery thrombosis. Occasionally, vertigo is reported after temporal bone resection. Permanent deafness on operated side.
  41. 41. Radiation therapy sequelae:  Xerostomia (30% incidence)  Osteoradionecrosis of temporal bone. (10% incidence after 60 to 65 Gy)  Cutaneous and Cartilage necrosis of external auditory canal. ( 4% incidence)  Rarely, secondary infection and meningitis.
  42. 42. THANK YOU