The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience

T	assessment
T1	Tumour limited to external auditory canal without bony erosion or evidence of soft tissue involvement
T2	Tumour with limited external auditory canal bone erosion (not full thickness) or limited (<0.5 cm) soft-tissue involvement
T3	Tumour eroding osseous external auditory canal (full thickness) with limited (<0.5 cm) soft tissue involvement or tumour involving the middle ear and/or mastoid
T4	Tumour eroding cochlea, petrous apex, medial wall of the middle ear, carotid canal, jugular foramen or dura, or with extensive soft tissue involvement (>0.5 cm) such as involvement of temporomandibular joint or styloid process, or evidence of facial paresis
N	assessment
N0	No regional lymph node metastasis
N1	Regional lymph node metastasis
M	assessment
M0	No distant metastasis
M1	Distant metastasis
Stage	group
I	T1N0M0^*
II	T2N0M0^*
III	T3N0M0^‡, T1N1M0^‡
IV	T4N0M0^‡, T2–4N1M0^‡, T1–4N0–1M1^†

[i] The TNM assessment is based on the clinical examination and imaging findings. This staging system has been applied to assess primary external auditory canal cancer and primary middle ear cancer.¹ Middle ear cancer is assessed as at least T3, therefore always locoregionally advanced.

T = tumour; N = regional lymph node metastasis; M = distant metastasis; ^* = localised cancer; ^‡ = locoregionally advanced cancer; ^† = systemically advanced cancer

Data acquisition flowchart of patients with lateral skull-base cancer. Data of 177 patients were thoroughly analysed using Cancer Registry of the Republic of Slovenia and databases of Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Slovenia and Institute of Oncology Ljubljana, Slovenia. The majority of excluded patients suffered from auricular or parotid cancer without lateral skull-base involvement. Additional analysis was performed on the data of locoregionally advanced cancer.
ICD = International statistical classification of diseases and related Health problems 10^th revision

Table 2

Dataset of patients with lateral skull-base cancer treated between 2011 and 2019

cT	cN	cM	Grade
80^M	2012	aEEC^R	C44.2	SCC	cT4^*	cN1^*	cM0^*	IV^P	CT_SB, US_N	yes	SURG➜RT	WLE	partial	iSND	none	PM	R1	8.1
79^M	2014	EACC^R	C44.2	BCC	cT1^P	cN0^P	cM0^P	I^P	CT_SB	none	SURG	WLE	none	none	yes	skin graft	R0	6.9
52^M	2014	EACC^L	C44.2	SCC	cT4^P	cN0^P	cM0^P	IV^P	MRI_SB, CT_SB, US_N	yes	SURG	LTBR	partial	iSND	none	primary closure	R0	5.7
90^F	2015	EACC^L	C44.2	SCC	T3^P	cN0^P	cM0^P	III^P	CT_SB, US_N	yes	SURG	LTBR	none	none	none	primary closure	R0	5.5
59^M	2017	EACC^L	C44.2	ACC	cT4^P	cN0^P	cM0^P	IV^P	MRI_SB, CT_SB, US_N	yes	SURG➜RT	LTBR	partial	iSND	none	primary closure	R1	5.2
50^M	2017	EACC^L	C44.2	BCC	cT ^P	cN0^P	cM0^P	I^P	MRI_SB	none	ECT»SURG	WLE	partial	none	none	primary closure	R0	4.5
85^F	2017	aEEC^R	C44.2	BCC	cT2^*	cN0^*	cM0^*	II^*	US_N	none	SURG	WLE	none	none	none	primary closure	R0	(†2.9 88)
75^M	2018	aEEC^L	C44.2	BCC	cT1^*	cN0^*	cM0^*	I^*	none	none	SURG	WLE	none	none	none	skin graft	R0	(†2.8 78)
79^M	2018	MEC^R	C30.1	SCC	cT3^P	cN0^P	cM0^P	III^P	MRI_SB, CT_SB, MRI_N	yes	SURG	LTBR	none	none	none	primary closure	R1	(†0.4 80)
67^M	2018	aEEC^R	C44.2	BCC	cT4a^*	cN0^*	cM0^*	IVa^*	MRI_SB, CT_SB	yes	SURG	LTBR⁺	partial	iSND	none	RFFF	R0	2.3
66^F	2019	EACC^L	C44.2	SCC	cT1^P	cN1^P	cM0^P	III^P	MRI_SB, CT_SB	yes	SURG	WLE	none	iSND	none	secondary intention	R0	2.0
76^M	2019	aEEC^R	C44.2	SCC	cT3^*	cN0^*	cM0^*	III^*	MRI_SB, CT_SB	yes	RT»SURG	LTBR⁺	partial	iSND	none	PM	R0	2.4
85^M	2012	MEC^R	C30.1	SCC	cT3^P	cN0^P	cM0^P	III^P	CT_SB, US_N	yes	SURG➜RT	LTBR	none	none	none	primary closure	R0	(†0.5 85)
73^F	2014	aEEC^L	C44.2	BCC	cT4a^*	cN0^*	cM0^*	IVa^*	MRI_SB, CT_SB, US_N	yes	RT»ECT»SURG	LTBR⁺	partial	iSND	none	RFFF	R0	1.6
58^F	2014	aPC^R	C07	MC	cT4a^**	cN0^**	cM0^**	IVa^**	MRI_SB, CT_SB	yes	SURG➜RT»SURG	LTBR⁺	performed previously	iSND	none	ALT	R0	0.6
85^F	2015	aPC^R	C07	AC	cT4a^*	cN2b^*	cM0^*	IVa^*	CT_SB	yes	SURG➜RT	MWLE	total	iMRND	none	ALT	R0	0.3
84^M	2017	aEEC^L	C44.2	SCC	cT2^*	cN0^*	cM0^*	II*	US_N	none	SURG➜RT	WLE	partial	iSND	none	secondary intention	R0	0.8

[i] Locoregionally advanced cancer is shown in bold. Age and survival are depicted in years

AC = adenocarcinoma; ACC = adenoid cystic carcinoma; aEEC = advanced skin cancer of external ear (including auricle, concha or periauricular skin); Age = age at the time of cancer diagnosis; ALT = anterolateral thigh free flap; aPC = advanced parotid cancer; BCC = basal cell carcinoma; CT= skull-base computed tomography; _SB EACC = primary external auditory canal cancer; ECT = electrochemotherapy; ECT»SURG = ECT was performed with primary curative intent and surgery as salvage; ^F = female; HP = histopathological diagnosis; ICD-10 = international classification of diseases, 10^th revision; iMRND = ipsilateral modified radical neck dissection; iSND = ipsilateral selective neck dissection; _L = left; LTBR = lateral temporal bone resection; LTBR⁺ = lateral temporal bone resection with wide local excision; ^M = male; MWLE = mastoidectomy with wide local excision; MC = mucoepidermoid carcinoma; MEC = primary middle ear cancer; MRI_N = neck magnetic resonance imaging; MRI= skull-base MRI; ^P = modified Pittsburgh staging _SB system; PM = pectoralis major myocutaneous flap; PTA = pure tone audiometry performed prior surgery; ^R = right; R0 = no residual tumour; R1 = microscopic residual tumour; RFFF = radial forearm free flap; RT = radiotherapy; RTC = residual tumour classification according to the UICC staging system; SCC = squamous cell carcinoma; SURG = surgery; SURG➜RT = combined surgery and postoperative radiotherapy; TMJ = temporomandibular joint; US= neck ultrasound; WLE = wide local excision; Year = year of _N cancer diagnosis; ^* = Union for International Cancer Control (UICC) staging system for skin carcinoma of the head and neck ^** = UICC staging system for major salivary glands; † with a number = an age at death

Barchart of seventeen patients with lateral skull-base cancer treated with curative intent between 2011 and 2019.

85-year old female with locoregionally advanced parotid adenocarcinoma (*i.e*., parotid metastasis after incomplete temporal skin adenocarcinoma cancer resection) extending to the right external auditory canal and lateral skull-base. The resection margin is outlined **(A)**. Primary surgery involving mastoidectomy with wide local excision, total parotidectomy, modified radical neck dissection, temporary tracheostomy, static suspension of oral commissure with fascia lata and anterolateral thigh free flap reconstruction were performed **(B)**.

73-year old female with locoregionally advanced external ear basal cell carcinoma extending to the left lateral skull-base. The resection margin is outlined **(A)**. Salvage surgery (*i.e*., after primary radical radiotherapy and electrochemotherapy) involving lateral temporal bone resection with fat obliteration, with wide local excision, partial parotidectomy, ipsilateral selective neck dissection **(B)** and radial forearm free flap reconstruction **(C)** were performed.

76-year old male with locoregionally advanced external ear squamous cell carcinoma extending to the right lateral skull-base. The resection margin is outlined **(A)**. Salvage surgery (*i.e*., after primary radical radiotherapy) involving lateral temporal bone resection with wide local excision, partial parotidectomy, ipsilateral selective neck dissection and pectoralis major myocutaneous flap reconstruction (due to recipient vessel insufficiency) were performed **(B, C)**.

Kaplan-Meier analysis of overall survival of 12 patients with locoregionally advanced lateral skull-base cancer treated surgically with curative intent. **(A)** Kaplan-Meier analysis of 12 patients regardless of the reconstruction modality. Cumulative survival remained at 83% after six months. **(B)** Kaplan-Meyer analysis of 6 patients treated with flap reconstruction and six patients with other reconstruction modalities. Cumulative survival remained at 67% after six months.

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DOI: https://doi.org/10.2478/raon-2021-0012 | Journal eISSN: 1581-3207 | Journal ISSN: 1318-2099

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Language: English

Page range: 323 - 332

Submitted on: Jan 14, 2021

Accepted on: Feb 17, 2021

Published on: Aug 10, 2021

Published by: Association of Radiology and Oncology

In partnership with: Paradigm Publishing Services

Publication frequency: 4 issues per year

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© 2021 Domen Vozel, Peter Pukl, Ales Groselj, Aleksandar Anicin, Primoz Strojan, Saba Battelino, published by Association of Radiology and Oncology
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

Volume 55 (2021): Issue 3 (September 2021)

The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience

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