Catholic University of Louvain, St - Luc University Hospital Head … · 2008-03-07 · EAC3 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme

EAC1

Catholic University of Louvain, St - Luc University HospitalHead and Neck Oncology Programme

Mar. 2002

Carcinoma of external auditory canal

EAC2


Mar. 2002


•• Work-up procedureWork-up procedure

•• StagingStaging

•• Primary treatmentPrimary treatment

•• Follow-upFollow-up

•• Treatment of recurrent and/orTreatment of recurrent and/or metastatic metastatic disease disease

•• References References

EAC3


Mar. 2002

Clinical evaluation Evidence Option

� Complete history of the disease� Performance status (Karnofsky / WHO scale)� Examination of external auditory canal� Audiogram� Examination of the VII th nerve� Neck examination� Drawing of any lesions

Type CType CType CType CType CType CType C

Std.Std.Std.Std.Std.Std.Std.

EAC4


Mar. 2002

Biopsy Evidence Option

� Biopsy under local anesthesia of chronic (> 3months) external lesion

� Biopsy under local anesthesia of any new lesion ofthe external auditory canal

If negative biopsy, then deep biopsy under generalanesthesia

Type C

Type C

Std.

Std.

EAC5


Mar. 2002

Advanced clinical evaluation Evidence Option

� Dental examination by oral surgeon if RxThscheduled

� Others (if required)

Type C

Type C

Std.

Indiv.

EAC6


Mar. 2002

Laboratory tests Evidence Option

� Hemogram, coagulation tests, liver enzymes, kidney function

� Thyroid function if RxTh scheduled: TSH

Type C

Type C

Std.

Std.

EAC7


Mar. 2002

Loco-regional imaging Evidence Option

� CT scan without contrast enhancement (bonewindow)1

� MRI with gadolinium enhancement1

Type C

Type C

Std.

Std.

1See guidelines for loco-regional imaging

EAC8


Mar. 2002

Pathologic examination Evidence Option

Standards of the British Royal College ofPathologists (endorsed by EORTC)1

Type C Std.

1See pathology guidelines

EAC9


Mar. 2002








EAC10


Mar. 2002

Staging Evidence Option

� Modified Pittsburgh (revision 2002) classification Type C Std.

EAC11


Mar. 2002

� 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 (< 0.5 cm) softtissue involvement

� T3: Tumor eroding the osseous external auditory canal (full thickness) withlimited (< 0.5 cm) soft tissue involvement, or tumor involving middle ear and/or mastoid

� T4: Tumor eroding the cochlea, petrous apex, medical wall of the middle ear, carotid canal, jugular foramen or dura, or with extensive (> 0.5 cm)soft tissue involvement; patients presenting with facial paralysis

- T4a: extracranial extension (> 0.5 cm) in soft tissue or skin

- T4b: Tumor eroding the cochlea, petrous apex, medical wall of the middle ear, carotid canal or jugular foramen

- T4c: extension to the dura

EAC12


Mar. 2002

• N status: - N0: no regional lymph node metastasis

- N1: metastasis in regional lymph node(s)

- Nx: regional lymph nodes cannot be assessed

• M status: - M0: no distant metastasis

- M1: distant metastasis

- Mx: distant metastasis cannot be assessed

EAC13


Mar. 2002








EAC14


Mar. 2002

Primary treatment: general strategy Evidence Option

� T1–T2, N0- Lateral temporal bone resection + parotidectomy + selective ND (level II) ± RxTh1

pN+ on frozen section examination, dissection of levels III-V - RxTh if medical status not suitable for surgery : RxTh� T1-T2, N1

- Lateral temporal bone resection + parotidectomy + ND (selective or radical modified) ± RxTh1

� T3 N0- no extension to middle ear: Lateral temporal bone resection + parotidectomy + selective ND (level II) + RxTh1

- extension to middle ear: subtotal temporal bone resection + dissection of nerve VII + nerve graft + parotidectomy + selective ND (level II) + RxTh1

� T3 N1- no extension to middle ear: Lateral temporal bone resection+ parotidectomy + ND (selective or radical modified) + RxTh1

- extension to middle ear: subtotal temporal bone resection+ dissection of nerve VII + nerve graft + parotidectomy + ND

(selective or radical modified) + RxTh1

Type 3

Type 3

Type 3

Type 3

Type 3

Type 3

Type 3

Std.

Indiv.

Std.

Std.

Std.

Std.

Std.

1 see indication of post-operative RxTH (slide 18)

EAC15


Mar. 2002

Primary treatment: general strategy Evidence Option

� T4a, N0- Subtotal temporal bone resection + parotidectomy + selective ND (level II) + RxTh1

pN+ on frozen section examination, dissection of levels III-V - RxTh if medical status not suitable for surgery : RxTh� T4a, N1

- Subtotal temporal bone resection + parotidectomy + ND (selectif or radical modified) + RxTh1

� T4b, any N- Best supportive care- Chemotherapy- Local palliative surgery- Local palliative RxTh- Temporal bone resection + RxTh1

� T4c, any N- Best supportive care- Chemotherapy- Local palliative surgery- Local palliative RxTh

Type 3

Type 3

Type 3

Type CType CType CType CType C

Type CType CType CType C

Std.

Indiv.

Std.

Std.Std.Std.Std.

Indiv.

Std.Std.Std.Std.

1 see indication of post-operative RxTh (slide 18)

EAC16


Mar. 2002

Primary treatmentPrimary treatment: : pathologic examination pathologic examination Evidence Evidence OptionOption

Standards of the British Royal Standards of the British Royal College College of of Type C Type C StdStd..

Pathalogists Pathalogists ( ( endorsed endorsed by EORTC )by EORTC )

11See See pathology guidelinespathology guidelines

EAC17


Mar. 2002

Indication for post-op RxTh Evidence Option

� Evidence at the "T" level-T2-T4-close margins (< 5mm)-positive margins: R1-macroscopic residual disease: R2-perineural invasion

� Evidence at the "N" level-more than one involved lymph node-extracapsular rupture/soft tissue invasion-more than one involved level-invasion of lymphatic vessels

Type 3Type 3Type 3Type 3Type 3

Type 3Type 3Type 3Type 3

Std.Std.Std.Std.Std.

Std.Std.Std.Std.

EAC18


Mar. 2002

Low risk (LR): no adverse featureLow risk (LR): no adverse feature

Intermediate risk (IR): 1 feature other than ECE/STEIntermediate risk (IR): 1 feature other than ECE/STE

High risk (HR): >1 features or ECE/STEHigh risk (HR): >1 features or ECE/STE

Risk factorsRisk factors

• Extracapsular extension / soft tissue extension (ECE/STE)

• (Oral cavity tumors)

• R1 surgical margins

• Nerve invasion

• >1 positive neck nodes

• Positive node in > 1 levels

• Node size > 3 cm

• > 6 week interval between surgery and RxTh

EAC19


Mar. 2002

RxTh regimen Evidence Option

� Target volumes- Petrous bone, mastoid, parotid, para- pharyngeal space and level II (N0) or level II-V (N1)

� Technique- conformal radiotherapy- IMRT radiotherapy

� Dose- T and positive neck levels: 70 Gy- prophylactic dose (undissected neck): 50 Gy- high risk (ECE or >1 risk factors): 64 Gy- intermediate risk (1 risk factor other than(ECE): 60 Gy

� Fractionation- daily 2Gy/fraction

Type C

Type 3Type 3

Type CType CType CType C

Type 3

Std.

Std.Invest.

Std.Std.Std.Std.

Std.1See detailled protocol2See guidelines for post-operative radiotherapy

EAC20


Mar. 2002








EAC21


Mar. 2002

Follow-up Evidence Option

� Clinical examination- local examination, audiogram, fiberoptic examination and neck palpation every 2 months (first 2 years), every 6 months (3rd-5th year), then every year (> 5 years)- dental examination every 6 months, if RxTh

� Loco-regional imaging- NMR at 6, 12 and 24 months

� Laboratory tests-thyroid function (TSH) every year, if RxTh

� Evolution of late toxicity (EORTC/RTOG) scale

Type C

Type C

Type C

Type CType C

Std.

Std.

Std.

Std.Std.

EAC22


Mar. 2002






• Treatment of recurrent and/orTreatment of recurrent and/or metastatic metastatic diseasedisease

• References

EAC23


Mar. 2002

Salvage treatment for recurrent disease Evidence Option

� anyT-N0-M0-Surgery ± RxTh-Chemotherapy-Best supportive care

� T0-anyN-M0-ND ± RxTh-RxTh-Chemotherapy-Best supportive care

� AnyT-N1-M0/T4 any NSurgery ± RxThChemotherapyBest supportive care

� MetastasisChemotherapySurgeryBest supportive care

Type 3Type 3Type 3

Type 3Type 3Type 3Type 3

Type 3Type 3Type 3

Type 3Type 3Type 3

Std.Indiv.Indiv.

Indiv.Indiv.Indiv.Indiv.

Indiv.Indiv.Indiv.

Std.Indiv.Indiv.

EAC24


Mar. 2002






• Treatment of recurrent and/orTreatment of recurrent and/or metastatic metastatic disease disease

• References

EAC25


Mar. 2002

ReferencesReferences� ARRIAGA M., CURTIN H, TAKAHASHI H, HIRSCH B and KAMERER DB : Staging proposal for external

auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings.Ann Otol Rhinol Laryngol 1990, 99 : 714-721

� ARRIAGA M, HIRSCH BE, KAMERER DB and MYERS EN : Squamous carcinoma of the external auditory meatus .Otolaryngol Head neck Surg 1989, 101 :330-337

� AUSTIN J, STEWART K. and FAWZI N. : Squamous cell carcinoma of the external auditory canal. Arch otolaryngol Head Neck Surg 1994, 120 :1228 - 1232

� JACKLER R. and DRISCOLL C. , Ed. : Tumors of the ear and temporal bone.Lippincot Williams & Wilkins, Philadelphia, 2000

� KUHEL W., HUME C. and SELESNICK S. : Cancer of the external auditory canal and temporal bone. OtolaryngolClin N Am 1996, 29 : 827-852

� MANOLIDIS S, PAPPAS D, VON DOERSTEN P, JACKSON G and GLASSCOCK M Temporal bone and lateralskul base malignancy results . Am J Otol, 1998, 19 : S 1 - S 15

� MOODY S , HIRSCH B and MYERS E : Squamous cell carcinoma of the external auditory canal : an evaluation of astaging system. Am J Otol 2000, 21 : 582-588

� PRASAD S. and JANECKA I. : Efficacy of surgical treatments for squamous cell carcinoma of the temporal bone, alitterature review. Otolaryngol Head Neck Surg 1994, 110 : 270 - 280

� SPECTOR JG : Management of temporal bone carcinomas : a therapeutic analysis of two groups of patients andlong-term followup. Otolaryngol Head Neck Surg 1991, 104 : 58-66

� SHIH L. and CRABTREE J : Carcinoma of the external auditory canal, an update. Laryngoscope 1990, 100: 1215-1218� TRAISSAC L., Ed : Les cancers de l ’oreille, Masson, Paris, 1995� TESTA J , FUKUDA Y and KOWALSKI L. : Prognostic factors in carcinoma of the external auditory canal . Arch

Otolaryngol Head neck Surg, 1997, 123 : 720-724� ZIESKE L. and MYERS E.N. : Squamous cell carcinoma with positive margins Arch otolaryngol Head neck Surg

1986, 112 : 863-866

Documents

Catholic University of Louvain, St - Luc University Hospital Head … · 2008-03-07 · EAC3 Catholic University of Louvain, St - Luc University Hospital Head and Neck Oncology Programme