Management of Stage IV Carcinoma of Temporal Bone: Institutional Experience

Background The management protocol of stages I to III carcinoma temporal bone yields good outcome in majority of patients. In stage IV lesions, the treatment protocols are guided by multiple factors such as intracranial extension, vascular involvement, nerve involvement, etc. The anticipated complications influence the final treatment plan adversely.

Objective The objective of the review was to analyze our results and assess the outcome of surgery in such cases.

Methodology A retrospective review of patients with stage IV carcinoma temporal bone treated surgically at our institute from June 2014 to July 2017 was done. A total of 13 patients were included in the study. All patients were treated with surgery followed by radiotherapy.

Structures involved preoperatively:

• Facial nerve involvement: two patients (with carotid canal involvement)

• Dural invasion/abutting dura: four patients

• Petrous bone involvement with cochlear erosion: three patients

• Infratemporal fossa and parotid gland involvement: one patient

• Carotid canal erosion: two patients (with facial nerve involvement)

• Jugular foramen involvement: one patient.

Surgery performed:

• Sleeve resection with total conservative parotidectomy and supraomohyoid neck dissection: one patient

• Lateral temporal bone resection with superficial parotidectomy and supraomohyoid neck dissection: one patient

• Subtotal temporal bone resection with superficial parotidectomy and supraomohyoid neck dissection: seven patients

• Lateral temporal bone resection (ICA sparing) with superficial parotidectomy and supra-omohyoid neck dissection: three patients

• One case was abandoned due to ICA injury intraoperatively, which was sutured and packing done.

Results The blood loss ranged from 600 to 1,700 mL, with a mean of 784 mL. The average hospital stay was 7.5 days. Histopathologically margin negative excision was attained in eight patients and a margin positive excision was attained in five patients.

The complications encountered are as follows:

• Facial palsy: three patients

• ICA injury: one patient

• Cerebrospinal fluid otorrhea: two patients

• Meningitis: two patients

• Skin necrosis: two patients

• Swallowing difficulty: one patient.

All patients received postoperative radiotherapy of 30 fractions and 60 gray over a period of 6 to 9 weeks (interrupted radiotherapy in three cases, due to toxic reactions). In five patients with positive margins, concurrent chemotherapy was administered.

The follow-up ranged from 5 months to 3 years.

Disease-free survival for > 3 years: one patient, 2 to 3 years: two patients, 1 to 2 years: four patients, and 6 months to 1 year: two patients. Recurrence of disease was noticed in 5 months period: one patient (residual disease not responsive to radiotherapy), 6 months to 1 year: one patient, and 1 to 2 years: one patient. One patient expired within 3 months of radiotherapy due to progressive disease.

Conclusion The advances in surgical and radiotherapy techniques have overall improved the disease-free survival rate. The margin positive cases traditionally do worse and stand a chance for early recurrence. But with the advent of good radiotherapy techniques, 2-year disease-free survival rate has improved, as in our series (40%). Preservation of lower cranial nerves and ICA, even at the expense of some residual disease improves 2-year quality of life significantly. A larger trial is warranted to evaluate the hypothesis and create protocols for management.