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

Domen Vozel

Domen Vozel

  • Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre LjubljanaLjubljana, Slovenia
  • Faculty of Medicine, University of LjubljanaLjubljana, Slovenia
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Vozel, Domen
, 
Peter Pukl

Peter Pukl

Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre LjubljanaLjubljana, Slovenia
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Pukl, Peter
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Ales Groselj

Ales Groselj

  • Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre LjubljanaLjubljana, Slovenia
  • Faculty of Medicine, University of LjubljanaLjubljana, Slovenia
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Groselj, Ales
, 
Aleksandar Anicin

Aleksandar Anicin

  • Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre LjubljanaLjubljana, Slovenia
  • Faculty of Medicine, University of LjubljanaLjubljana, Slovenia
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Anicin, Aleksandar
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Primoz Strojan

Primoz Strojan

  • Faculty of Medicine, University of LjubljanaLjubljana, Slovenia
  • Institute of Oncology LjubljanaLjubljana, Slovenia
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Strojan, Primoz
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Saba Battelino

Saba Battelino

  • Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre LjubljanaLjubljana, Slovenia
  • Faculty of Medicine, University of LjubljanaLjubljana, Slovenia
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Battelino, Saba
  
Aug 10, 2021
The importance of flaps in reconstruction of locoregionally advanced lateral skull-base cancer defects: a tertiary otorhinolaryngology referral centre experience's Cover Image
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Article Category: Research Article
Published Online: Aug 10, 2021
Page range: 323 - 332
Received: Jan 14, 2021
Accepted: Feb 17, 2021
DOI: https://doi.org/10.2478/raon-2021-0012
Keywords
© 2021 Domen Vozel, Peter Pukl, Ales Groselj, Aleksandar Anicin, Primoz Strojan, Saba Battelino, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Figure 1

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 10th revision
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 10th revision

Figure 2

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

Figure 3

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).
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).

Figure 4

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.
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.

Figure 5

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).
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).

Figure 6

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.
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.

Modified Pittsburgh staging system8,9

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†

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

Age Year Site ICD-10 HP Clinical TNM staging
 Preoperative imaging PTA Treatment modalities Otosurgical resection Parotidectomy Neck dissection TMJ resection Reconstruction RTC Survival
cT cN cM Grade
80M 2012 aEECR C44.2 SCC cT4* cN1* cM0* IVP CTSB, USN yes SURG➜RT WLE partial iSND none PM R1 8.1
79M 2014 EACCR C44.2 BCC cT1P cN0P cM0P IP CTSB none SURG WLE none none yes skin graft R0 6.9
52M 2014 EACCL C44.2 SCC cT4P cN0P cM0P IVP MRISB, CTSB, USN yes SURG LTBR partial iSND none primary closure R0 5.7
90F 2015 EACCL C44.2 SCC T3P cN0P cM0P IIIP CTSB, USN yes SURG LTBR none none none primary closure R0 5.5
59M 2017 EACCL C44.2 ACC cT4P cN0P cM0P IVP MRISB, CTSB, USN yes SURG➜RT LTBR partial iSND none primary closure R1 5.2
50M 2017 EACCL C44.2 BCC cT P cN0P cM0P IP MRISB none ECT»SURG WLE partial none none primary closure R0 4.5
85F 2017 aEECR C44.2 BCC cT2* cN0* cM0* II* USN none SURG WLE none none none primary closure R0 (†2.9 88)
75M 2018 aEECL C44.2 BCC cT1* cN0* cM0* I* none none SURG WLE none none none skin graft R0 (†2.8 78)
79M 2018 MECR C30.1 SCC cT3P cN0P cM0P IIIP MRISB, CTSB, MRIN yes SURG LTBR none none none primary closure R1 (†0.4 80)
67M 2018 aEECR C44.2 BCC cT4a* cN0* cM0* IVa* MRISB, CTSB yes SURG LTBR+ partial iSND none RFFF R0 2.3
66F 2019 EACCL C44.2 SCC cT1P cN1P cM0P IIIP MRISB, CTSB yes SURG WLE none iSND none secondary intention R0 2.0
76M 2019 aEECR C44.2 SCC cT3* cN0* cM0* III* MRISB, CTSB yes RT»SURG LTBR+ partial iSND none PM R0 2.4
85M 2012 MECR C30.1 SCC cT3P cN0P cM0P IIIP CTSB, USN yes SURG➜RT LTBR none none none primary closure R0 (†0.5 85)
73F 2014 aEECL C44.2 BCC cT4a* cN0* cM0* IVa* MRISB, CTSB, USN yes RT»ECT»SURG LTBR+ partial iSND none RFFF R0 1.6
58F 2014 aPCR C07 MC cT4a** cN0** cM0** IVa** MRISB, CTSB yes SURG➜RT»SURG LTBR+ performed previously iSND none ALT R0 0.6
85F 2015 aPCR C07 AC cT4a* cN2b* cM0* IVa* CTSB yes SURG➜RT MWLE total iMRND none ALT R0 0.3
84M 2017 aEECL C44.2 SCC cT2* cN0* cM0* II* USN none SURG➜RT WLE partial iSND none secondary intention R0 0.8
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