KISEP Otology Korean J Otolaryngol 2005;48: 외이도편평상피암종의치료경험 연세대학교의과대학이비인후과학교실, 1 한림대학교의과대학이비인후과학교실, 2 이화여자대학교의과대학이비인후과학교실 3 정상호 1 김창우 2 김한수 3 이원상

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1 KISEP Otology Korean J Otolaryngol 2005;48: 외이도편평상피암종의치료경험 연세대학교의과대학이비인후과학교실, 1 한림대학교의과대학이비인후과학교실, 2 이화여자대학교의과대학이비인후과학교실 3 정상호 1 김창우 2 김한수 3 이원상 1 Squamous Cell Carcinoma of the External Auditory Canal: Treatment Results of 15 Cases Sang Ho Jung, MD 1, Chang Woo Kim, MD 2, Han Su Kim, MD 3 and Won-Sang Lee, MD 1 1 Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul; and 2 Department of Otorhinolaryngology, Hallym University College of Medicine, Seoul; and 3 Department of Otolaryngology, Ewha Woman s University College of Medicine, Seoul, Korea ABSTRACT Background and Objectives:The management of external auditory canal (EAC) squamous cell carcinoma (SCC) is very difficult because the structure of the temporal bone is complicated. We aimed to analyze the surgical results of EAC SCC and propose a treatment protocol. Subjects and Method:Fifteen patients with EAC SCC who underwent operations between July 1984 and June 2001 were analyzed. We divided the patients into five classes according to the extent of tumor progression. In patients classified under Class I, the tumor involved the cartilaginous ear canal. Tumors of patients within Class II involved the bony ear canal or mastoid cortex. Tumors that involved the deep structures of the temporal bone but limited involvement of within the middle ear cavity were classified under Class IIIA. In Class IIIB, tumors involved the facial canal, the base of the skull, or mastoid air cells. In Class IIIC, tumors involved the cochlea, the medial wall of middle ear, dura, sigmoid sinus, or other structures such as the parotid gland, carotid canal, or petrous apex. We analyzed data concerning patients and tumors, surgical methods, and surgical outcomes. Results:The number of patients classified under Class I, Class II, Class IIIA, Class IIIB and Class IIIC were 3, 3, 2, 1, and 6, respectively. Surgical approaches were local canal resection, partial temporal bone resection (TBR), subtotal TBR, and total TBR. Follow up period was 5 to 138 months with a mean (±SD) of 40 months (±37.5), and the five-year disease free survival rate was 40.6%. Conclusion:From this study, we suggest the treatment modality for the EAC SCC. We recommend a partial TBR for surgery of Class I or Class II EAC SCC cancers, a subtotal TBR for Class IIIA, and a total TBR when it is close to Class IIIB or Class IIIC. (Korean J Otolaryngol 2005;48:136-41) KEY WORDS:External auditory canal Squamous cell carcinoma Temporal bone resection. 136

정상호 외 병원 이비인후과에서 외이도 악성종양으로 수술적 치료를 종양의 병기(Yonsei staging system for EAC cancer, 받은 환자 중 조직병리학적 검사에서 편평상피암종으로

평균 연령은 56세, 분포는 병기 분류는 완벽하지는 않으나 Goodwin의 제안3)을 기 35세에서 67세까지였으며 60대가 8명(53%)으로 가장 많 본으로 하고 Pittsburgh staging

술 후 평균 추적 관찰 기간은 40개월(5~ 로 세 개 부위로 나누었다.

자료를 수집하 였으며, 4예는 사망 상태였다(Table 1). Table 1.

II 방 법 후향적으로 의무 기록 및 CT나 MRI 등의 치료 전 방사 선학적 소견을 확인하여 발생 부위별 분포, 발생 부위에 따 른 치료법과 이의 결과를 살펴보았으며 5년 무병생존율을

Class IIIA Class IIIB Class IIIC 종양의 범위 종양이 연골성 외이도를 침범하고 골성 외이도나 주변 연부 조직으로의 침윤이 없는 경우 종양이 골성 외이도를 침범했으나 외이도

침윤 없이 중이강에만 국한된 경우 종양이 외이도 골부의 전층을 파괴하고 중이강을 넘어 서 안면신경관, 유양동을 침범한 경우로 내이나 뇌 경막의 침윤은 없는 경우 종양이 뇌경막과 S자형정맥동, 와우를

Tumor extent of EAC* squamous cell carcinoma by imaging study, A (Class I) The tumor (arrow) is confined to

ear involvement, C (Class IIIA) The tumor (arrow) involved EAC, tympanic membrane and ossicular chain without

2 정상호 외 병원 이비인후과에서 외이도 악성종양으로 수술적 치료를 종양의 병기(Yonsei staging system for EAC cancer, 받은 환자 중 조직병리학적 검사에서 편평상피암종으로 확 Table 1, Fig. 1) 진된 15명을 대상으로 하였다. 평균 연령은 56세, 분포는 병기 분류는 완벽하지는 않으나 Goodwin의 제안3)을 기 35세에서 67세까지였으며 60대가 8명(53%)으로 가장 많 본으로 하고 Pittsburgh staging system9)을 변형하여 발 았다. 성별 분포는 남자가 10명, 여자가 5명으로 남자가 많 생 부위와 주변 조직으로의 확장 상태를 기준으로 기본적으 은 양상을 보였다. 술 후 평균 추적 관찰 기간은 40개월(5~ 로 세 개 부위로 나누었다. Class Ⅰ은 종양이 연골성 외이 138개월)이었으며 연구 시점에서 2개월 이내에 병원에 내 원하여 추적관찰을 받은 7예의 경우는 의무기록을 검토하였 고, 그렇지 않은 4예는 전화 면담을 통하여 자료를 수집하 였으며, 4예는 사망 상태였다(Table 1). Table 1. Yonsei staging system proposed for squamous cell carcinoma in the external auditory canal 종양 병기 Class I Class II 방 법 후향적으로 의무 기록 및 CT나 MRI 등의 치료 전 방사 선학적 소견을 확인하여 발생 부위별 분포, 발생 부위에 따 른 치료법과 이의 결과를 살펴보았으며 5년 무병생존율을 SPSS프로그램을 이용한 Kaplan-Meier법으로 분석하였다. 병기의 분류는 기존의 분류법을 검토하였고 본 연구 결과를 적용하여 종양의 병기 분류법을 새로 마련하였다. Class IIIA Class IIIB Class IIIC 종양의 범위 종양이 연골성 외이도를 침범하고 골성 외이도나 주변 연부 조직으로의 침윤이 없는 경우 종양이 골성 외이도를 침범했으나 외이도 골부의 전 층을 파괴시키지 않고 외이도에만 국한되었으며 주변 연부 조직으로의 침윤이 없는 경우 종양이 외이도를 넘어서 고막과 이소골을 침범한 경우 로 외이도 골부의 전 층을 파괴시키지 않고 내이의 침윤 없이 중이강에만 국한된 경우 종양이 외이도 골부의 전층을 파괴하고 중이강을 넘어 서 안면신경관, 유양동을 침범한 경우로 내이나 뇌 경막의 침윤은 없는 경우 종양이 뇌경막과 S자형정맥동, 와우를 침윤시키고 이 하선이나 악관절, 측두하와, 추체첨부, 내경동맥관에 침윤이 있는 경우 Fig. 1. Tumor extent of EAC* squamous cell carcinoma by imaging study, A (Class I) The tumor (arrow) is confined to the cartilaginous EAC without bony erosion, B (Class II) The tumor (arrow) involved bony EAC without middle ear involvement, C (Class IIIA) The tumor (arrow) involved EAC, tympanic membrane and ossicular chain without full thickness erosion of EAC, D (Class IIIB) The tumor (arrow) involved full thickness of anterior and posterior EAC wall. It extends to mastoid cavity, posteriorly, and middle ear cavity without cochlea erosion, medially. In this case, glenoid fossa was free from tumor, E (Class IIIC) The tumor (arrow) involved middle ear, cochlea, sigmoid sinus and middle fossa dura. *EAC external auditory canal. A B C D E 137

3 외이도편평상피암종의치료 수술방법 방사선치료 Table 2. External auditory canal carcinomasummary of cases Patient Sex/age Tumor stage Class Preoperative Postoperative Surgical treatment Radiotherapy Result F/U months 01 M/61 I Same LCR No NED 138* 02 M/37 I Same PTBR No NED F/67 I Same PTBR No NED M/67 II Same PTBR No NED F/67 II Same PTBR No NED F/60 N/A II PTBR No LWD 024* 07 F/64 IIIA Same STBR Yes NED M/52 IIIA Same STBR Yes NED M/62 IIIB Same STBR Yes LWD F/49 IIIB IIIC STBR Yes DWD 032* 11 M/56 IIIB IIIC STBR Yes DWD M/48 IIIC Same STBR Yes DWD 029* 13 M/35 IIIC Same TTBR No DWD M/56 IIIC Same STBR No DWD M/61 IIIC Same STBR Yes DWD 006 LCRlocal canal resection, TTBRtotal temporal bone resection, STBRsubtotal temporal bone resection PTBRpartial temporal bone resection, N/Anot available, NEDno evidence of disease, LWDlive with disease, DWDdied with disease, F/Ufollow up, Interviewed by telephone 138 Korean J Otolaryngol 2005;48:136-41

Class IIIB 1 0 0 Class IIIC 6 2 3 Survival rate ( 100, %) 1.1 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0.0 0 20 40 60 80 100 120 140 Month Fig. 3. This graph shows survival rate of external auditory canal squamous cell carcinoma estimated by Kaplan-Meier method.

4 정상호외 Table 3. Patterns of parotid node metastasis and direct parotid invasion according to tumor stage Tumor stage Patients n Node metastasis n Parotid invasion n Class I Class II Class IIIA Class IIIB Class IIIC Survival rate ( 100, %) Month Fig. 3. This graph shows survival rate of external auditory canal squamous cell carcinoma estimated by Kaplan-Meier method. Five-year disease free survival rate is 40.6%. A B Fig. 2. Boundaries of surgical resection for external auditory canal EAC carcinoma. 1) These axial A and coronal B views show neighboring structures from the EAC, anteriorly mandibular condyle, posteriorly cerebellum and sigmoid sinus, superiorly middle fossa, inferiorly carotid artery and jugular vein, medially middle & inner ear and carotid artery. Solid lines indicate the limits of a local canal resection that includes excision of all external auditory canal skin and removal of the lateral cartilaginous portion of the canal. Dotted lines indicate the limits of a partial temporal bone resection that includes excision of the entire external auditory canal, tympanic membrane, malleus and incus. Dashed lines indicate the limits of a subtotal temporal bone resection STBR that includes removal of the entire temporal bone. The limits of total temporal bone resection is STBR and further removal of petrous apex and/or carotid artery. 139

5 외이도편평상피암종의치료 Table 4. Patterns of initial treatment failures Patient Sex/age Tumor stage Initial treatment Time to recurrence Mo Recurred or remained site 06 F/60 Class II PTBR 16 Mastoid air cell 09 M/62 Class IIIB STBR, postop RT 15 Posterior fossa dura 10 F/49 Class IIIC STBR, postop RT 19 Mastoid air cell 11 M/56 Class IIIC STBR, postop RT 11 Infratemporal fossa 12 M/48 Class IIIC STBR, postop RT 12 Middle fossa dura 13 M/35 Class IIIC TTBR Remained tumor Carotid artery 14 M/56 Class IIIC STBR Remained tumor Middle fossa dura 15 M/61 Class IIIC STBR, postop RT Remained tumor Posterior fossa dura PTBRpartial temporal bone resection, STBRsubtotal temporal bone resection, TTBRtotal temporal bone resection, Postop RTpostoperative radiation therapy Class I * Evaluation of disease extension Class II Class IIIA Class IIIB & IIIC LCR PTBR STBR TTBR Postoperative radiotherapy Fig. 4. Treatment protocol for external auditory canal squamous cell carcinoma, LCRlocal canal resection, PTBRpartial temporal bone resection, STBRsubtotal temporal bone resection, TTBRtotal temporal bone resection, If surgical margin is positive Korean J Otolaryngol 2005;48:136-41

6 정상호외 REFERENCES 1) Kuhel WI, Hume CR, Selesnick SH. Cancer of the external auditory canal and temporal bone. Otolaryngol Clin North Am 1996;29: ) Conley J, Schuller DE. Malignancy of the ear. Laryngoscope 1976; 86: ) Goodwin WJ, Jesse R. Malignant neoplasms of the external auditory canal and temporal bone. Arch Otolaryngol 1980;106: ) Boland J, Paterson R. Cancer of the middle ear and external auditory meatus. J Laryngol Otol 1955;69: ) Conley J. Cancer of the middle ear. Ann Otolaryngol 1965;74: ) Kim CH, Kwon PJ, Jung HY, Kim JR, Shim YS, Yang HS. A clinical and statistical study of the ear cancers. Korean J Otolaryngol 1981; 24: ) Paaske PB, Witten J, Schwer S, Hansen HS. Results in treatment of carcinoma of the external auditory canal and middle ear. Cancer 1987; 59: ) Pensak MM, Gleich LL, Gluckman JL, Shumrick KA. Temporal bone carcinoma: Contemporary perspectives in the skull base surgical era. Laryngoscope 1996;106: ) Arriaga M, Curtin H, Takahashi H, Hirsch BE, Kamerer DB. Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings. Ann Otol Rhinol Laryngol 1990;99: ) Robinson GA. Malignant tumors of the ear. Laryngoscope 1931;41: ) Towson CE. Carcinoma of the ear. Arch Otol 1950;51: ) Crabtree JA, Britton BH, Pierce MK. Carcinoma of the external auditory canal. Laryngoscope 1976;86: ) Kinney SE. Squamous cell carcinoma of the external auditory canal. Am J Otol 1989;10: ) Moody SA, Hirsch BE, Myers EN. Squamous cell carcinoma of the external auditory canal: An evaluation of a staging system. Am J Otol 2000;21: ) Kim CS, Chang SO, Oh SH, Koo JW, Kim JW, Yu WS. Subtotal temporal bone resection for malignancies of the temporal bone. Korean J Otolaryngol 1998;41: ) Spector JG. Management of temporal bone carcinomas: A therapeutic analysis of two groups of patients and long-term followup. Otolaryngol Head Neck Surg 1991;104: ) Gacek RR, Goodman M. Management of malignancy of the temporal bone. Laryngoscope 1977;87:

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( )Jkstro011.hwp 비인강암의방사선치료결과및생존율에관한예후인자분석 2005 2 1 2005 3 28. :, Tel: 053)250-7665, Fax: 053)250-7984 E-mail: jhkim@dsmc.or.kr 정영연외 2 인 : 비인강암의예후인자분석 정영연외 2 인 : 비인강암의예후인자분석 Carcinoma of the nasopharynx treated by radiotherapy