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Surgery of the Temporal Bone Carcinoma

M. Arif Sudianto Utama

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Introduction

• Temporal bone carcinoma is a rare disease• Very aggressive course• If diagnosis is delayedBad prognosis• Rapid progression and limited therapeutic success• Squamous cell carcinoma (SCC) : Most common

primary (80%)• 0.2% of all head and neck tumours

Ishak LN, Goh SB, Saim L, 2014; Beyea AJ, Moberly CA, 2015

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Lecture Goals

Temporal bone anatomy

Malignant tumorsSCC and other primary tumorsMetastatic tumors

Surgical technic

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Temporal Bone Anatomy : identifying pathwaysof the spread of cancer

Axial Coronal

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Hirsch EB, Chang JY, Antonio MS, 2009

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1. Anteriorly : cartilaginous ear canal parotid gland2. Concha postauricular sulcus 3. Tympanic membrane middle ear 4. Posteriorly mastoid5. Anterior mesotympanum carotid artery & eustachian tube6. Inner ear round window or otic capsule7. Along the facial nerve infratemporal fossa8. Through the mastoid, posterior fossa dura, & sigmoid sinus 9. Beneath the skull base jugular fossa, carotid artery &

lower cranial nerves

Cancer can spread :

Hirsch EB, Chang JY, Antonio MS, 2009

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PRIMARY MALIGNANCIES OF THE TEMPORAL BONE

Gustafson LM, Pensak LM, 2003

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Metastasis to Temporal Bone:

– Breast carcinoma– Prostatic carcinoma– Renal cell carcinoma– Bronchogenic carcinoma– Lymphoma– Histiocytosis X– Colon carcinoma

Marsh M, Jenkins A, 2010; Beyea AJ, Moberly CA, 2015

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SIGNS AND SYMPTOMSOF TEMPORAL BONE MALIGNANCIES

Gustafson LM, Pensak LM, 2003

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The differential diagnosis of temporal bone malignancies

Leonetti PJ, Marzo JS, 2002

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Squamous cell carcinoma (SCC)

• Most common• No sex prevalence• Most patients have H/O chronic inflammation

of some kind• S/S are otorrhea, HL and deep seated otalgia.

40% have a ME mass.• Direct labyrinthine invasion is rare due to otic

capsuleGustafson LM, Pensak LM, 2003; Noorizan Y, Asma A, 2010; Beyea AJ, Moberly CA, 2015

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Extensive recurrence of a tragal SCC of the left

ear

Beyea AJ, Moberly CA, 2015

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Squamous cell carcinoma

• Facial nerve involvement = advanced Dz– CN VII paresis = 30-50% recurrence rate– Paralysis = >60% recurrence

• Involvement of other CN = “dismal prognosis”• CT and MRI are complimentary• Consider angio with embo if surgery is feasible

Noorizan Y, Asma A, 2010; Beyea AJ, Moberly CA, 2015

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Pittsburgh Staging System:T classification

T1 : Tumor limited to the EAC; no bone erosion or soft tissue extension

T2 : Tumor with limited bone erosion to the EAC or <0.5 cm of soft tissue involvement

T3 : Tumor with full-thickness EAC bone erosion, <0.5-cm soft tissue involvement, or tumor in the middle ear or mastoid

T4 : Tumor eroding the cochlea, petrous apex, medial wall of the middle ear, carotid canal, jugular foramen, or dura; or >0.5-cm soft tissue involvement; or facial nerve paresis

Hirsch EB, Chang JY, Antonio MS, 2009

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N classification• N0 : No regional nodes identified• N1 : Single ipsilateral regional node <3 cm• N2a : Single ipsilateral regional node 3–6 cm• N2b : Multiple ipsilateral regional nodes 6

cm• N2c : Bilateral or contralateral regional

nodes 6 cm• N3 : Regional node >6 cm

Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ, Moberly CA, 2015

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M classification

• M0 : Absence of distant metastatic disease• M1 : Presence of distant metastatic disease

Overall stage• I : T1N0M0• II : T2N0M0• III : T3N0M0• IV : T4N0M0, T1–4N1M0, T1–4N0–3M1

Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ, Moberly CA, 2015

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Algorithm Temporal Bone Carcinoma Therapy ‘high grade’ type

Marsh M, Jenkins A, 2010

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Surgical Technic

• T1 : LTBR or primary radiation, consider SP • T2 : LTBR plus postoperative radiation, consider SP • T3 : STBR or TTBR plus postoperative radiation,

consider SP• T4 : STBR or TTBR plus postoperative radiation,

consider SP• N+ : Add radical parotidectomy and SND to the above• M1: Palliation

Therapeutic guidelines by stage

Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ, Moberly CA, 2015

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Margins of resection

Axial

Coronal

1.LTBR

2.STBR

3.TTBR

1.LTBR

2.STBR

3.TTBR

2.STBR

1.LTBR

3.TTBR

Hirsch EB, Chang JY, Antonio MS, 2009; Beyea AJ, Moberly CA, 2015

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Carotid Management

• T bone resection requires carotid control as vessel passes thru medial to the Eustachian tube before entering the cavernous sinus

• CT will show if the tumor is near the carotid canal.

• 4 vessel angiography will show if vessel is involved with tumor

Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010

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Carotid BTO

• Balloon occlusion testing with Xenon/CT– Investigate the collateral blood flow to ipsilateral

hemisphere• 80% will tolerate ICA sacrifice• 10% will not – necessitates prior bypass grafting (ECA to

MCA bypass) before T bone resection• 10% grey zone – intraoperative or preoperative

revascularization

Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010

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Lateral T Bone Resection

• En bloc removal of the entire EAC and TM• Utilizes the extended facial recess approach• May also include parotidectomy, ND and

mandibular condylectomy• Involves resection of concha, may include

variable parts of the pinna and tragus PRNHirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ, Moberly CA, 2015

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Lateral T Bone Resection

• Postauricular and meatal incisions for resection of the temporal bone.

• This illustration demonstrates inclusion of the tragus with the specimen

Hirsch EB, Chang JY, Antonio MS, 2009

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Lateral T Bone Resection

•Closure of the EAC•Complete mastoidectomy•Extended facial recess (sacrifice the chorda)•Disarticulate the IS joint•Fracture the anterior EAC

just lateral to the Eustachian tube with osteotome•Watch out for ICA!

Hypotympanic dissection

Specimen fractured with osteotome

Specimen separated from soft tissue

Marsh M, Jenkins A, 2010

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• The anteriorly based skin flap containing the pinna is separated from the core of the external auditory meatus. The meatus has been oversewn to prevent tumor spillage.

Hirsch EB, Chang JY, Antonio MS, 2009

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Subtotal T Bone Resection

• Used with CA has penetrated into the ME space or mastoid cavities

• Requires resection of the otic capsule• Can be extended toward the ITF, jugular bulb or dura

as prescribed by tumor extent• Should include monitoring of CN 7, 9, 10, 11• If possible spare CN 7 by complete mobilization from

geniculate to foramen and transpose the nerve posteriorly.

Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ, Moberly CA, 2015

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Subtotal T Bone Resection• The tegmen and posterior fossa plates are thinned

and then removed.• A translab drill out of the IAC and jug bulb then done– Allows further mobilization of the FN from the porus if

needed.– The transected end of CN VIII should be sent for frozen

section• Entire tympanic ring drilled out but leaving

periostium over ICA and lower CNs.

Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ, Moberly CA, 2015

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C-shaped incision or Y-shaped incision

• Incisions include a central external auditory canal core, which is sutured closed

• Tragus can be preserved for better cosmesis

• Temporal craniotomy for subtotal temporal bone resection is smaller than for a total temporal bone resection

• Parotid gland with main trunk of facial nerve has been elevated from masseter muscle.

Marsh M, Jenkins A, 2010

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Subtotal T Bone Resection• Neck dissection

preformed for vascular control of IJ and ICA

• Involvement of jugular foramen necessitates IJ sacrifice and ligation of the sigmoid– Avoid injury to vein of

Labbe – drainage of the temporal lobe and can result in venous infarction of temporal lobeBad!!

Marsh M, Jenkins A, 2010

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Subtotal T Bone Resection

• Dural extension can be resected with help of neurosurgeon to close the dural defect.

• Extension into the ITF accomplished by including a Fisch A ITF approach

Marsh M, Jenkins A, 2010

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Total Temporal Bone Resection

Marsh M, Jenkins A, 2010

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Total T Bone Resection

• Used if tumor involves the petrous apex• Mandates proximal and DISTAL control of the

ICA– Distal control accomplished with middle cranial

fossa approach • Requires division of CN 7, 8, 9, 10 and 11– Done through a suboccipital crani

Hirsch EB, Chang JY, Antonio MS, 2009; Marsh M, Jenkins A, 2010; Beyea AJ, Moberly CA, 2015

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• The ICA is completely mobilized or resected if involved with tumor

• Osteotomy completed posterior to the foramen ovale

Marsh M, Jenkins A, 2010

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The temporal and retrosigmoid portions of the dura have been opened.

• N. VII through XI have been transected

• The underlying dura incised as the posterior border of the en bloc resection of the petrous bone

Marsh M, Jenkins A, 2010

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Postoperative

Left Ear, Reconstruction has been performed with a pectoralis major flap (PM)

Beyea AJ, Moberly CA, 2015

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Complication

• Vascular• Cerebrospinal fluid leak• Infection• Intracranial hemmorrhage and hypertension• Wound

Hirsch EB, Chang JY, Antonio MS, 2009

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Outcomes

• Tumors limited to the EAC have 50-80% cure rate after LTBR

• Tumor extending beyond the ME 0-15% survival >2yrs

• Survival increases with dual modality therapy• University of Pittsburg staging system – Increasing T stage is inversely proportional to survival– T1 and T2 have reported 100% 2 yr survival– T3 lesions have 2 yr of 56%– 2 yr survival of T4 tumors at 17%

Hirsch EB, Chang JY, Antonio MS, 2009

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