EAR including pinna

STAGING OF EAR (U. PITT)

T1

  • limited to external auditory canal

T2

  • limited to external auditory canal with
    • bony erosion (not full thickness) or
    • soft tissue extension (<0.5 cm) - tympanic membrane

T3

  • Resectable and extends beyond the external auditory canal
  • eroding the osseous external auditory canal (full thickness) with
    • soft tissue extension (<0.5 cm)
  • Involvement of
    • middle ear
    • mastoid, or
  • facial paralysis

T4

  • Unresectable and extends beyond the external auditory canal
  • Tumor eroding
    • the cochlea,
    • petrous apex,
    • medial wall of middle ear,
    • carotid cana
    • jugular foramen
    • or dura,
      * extensive (> 0.5 cm) soft-tissue involvement

WORKUP

  • high-resolution CT to help determine the operability of the tumor
  • MR can be used to delineate soft tissue invasion

TREATMENT

T1

  • Sleeve resection or local radiation therapy alone (60-70 Gy)

T2

  • Extended sleeve resection with or without RT, depending on margin
    • RT for close margin (60 Gy)
    • RT for positive margin (70 Gy)

T3

  • Subtotal temporal bone resection (Local Control Rate of 46%)
  • post-operative radiation therapy regardless of margin (60- 70 Gy)

T4

  • palliative radiation to high doses (60-70 Gy)

LESIONS OF EXTERNAL EAR (PINNA)

LOCAL RADIATION ONLY

Indications

  • tumors involving the pinna

Treatment Fields

  • treat with
    • electrons or
    • superficial or orthovoltage irradiation.
  • The fields can be
    • round or polygonal
  • Small superficial tumor
    • 1 cm margin
  • Tumor which encompass the entire pinna or external canal
    • 2 to 3 cm margin.

Technique

  • scatter plate to flatten the ear
  • water in the concha and external auditory canal

ELECTIVE NODAL TREATMENT

  • controversial for lesions on or around the external ear
  • some advocate elective treatment for
    • cartilage invasion
    • deep invasion
    • or poor differentiation
  • most investigators do not agree with this approach

LESIONS OF EXTERNAL AUDITORY CANAL OR DEEPER

FIRST ECHELON COVERED1

Indication

  • External auditory canal OR more

Treatment areas

  • petrosal bone
  • parotid fossa
  • ipsilateral LN of
    • retroauricular
    • upper jugular
    • upper spinal accessory

Technique

  • CT based

SECOND ECHELON COVERED (REGARDLESS OF PRIMARY)

EXAMPLE TREATMENT

ear
Example of treatment portal for tumor of the middle ear involving the petrous bone. The mastoid is included in irradiated volume.

NODAL AREAS

FIRST ECHELON NODES

  • superficial parotid lymph node
  • upper deep cervical lymph nodes

SECOND ECHELON NODES

Lower Neck Field

  • RT to mid- and lower neck nodes with anterior portal
  • nodal boost with appositional electrons or glancing photon fields.

== SEE PAROTID FOR FIELD PICTURE ==

RESULTS

T-STAGE LOCAL CONTROL RATE
T1 66%
T2 62.5% (100% with PORT)
T3 58% (83% with PORT)
T4 0%
Bibliography
1. Afzelius L-E, Gunnarsson MHN. Guidelines for prophylactic radiacal lymph node dissection in cases of carcinoma of the exteranl ear. Arch Otolaryngol Head Neck Surg 1980;2:361.
2. Avila J, Bosch A, Aristizabal S, et al. Carcinoma of the pinna. Cancer 1977;40:2891.
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