506
I. J. Radiation
Oncology
0 Biology 0 Physics
to factors other than irradiation: tumor size, closing wound under tension, periosteal stripping, and so on (1). An evaluation of knee function is currently underway. Among 76 patients with soft tissue sarcomas of the thigh who received preoperative rapid fraction irradiation to the knee joint and remain alive disease-free 35 have been evaluated. After a median of 5 years from irradiation 90% have good to excellent function. These preliminary findings plus the functional results noted in our review of foot sarcomas attest to the paucity of late effects following 3.5 Gy fractions when the total dose is 17.5-35 Gy. Dr. Kinsella is correct in his desire for a randomized trial of the various methods for limb salvage. Until such a trial is available we will continue to pursue preoperative chemoradiotherapy for extremity soft tissue sarcomas. We believe this is an extremely effective strategy for managing patients with these challenging malignancies. MICHAEL T. SELCH, M.D. University of California, Los Angeles 10833 Le Conte Ave. Los Angeles, CA 90024 I. Eilber, F. R.; Giullano, A. E.; Huth, J.; Mirra, J.; Morton, D. L. Limb salvage for high grade soft tissue sarcomas of the extremity: Experience at the University of California, Los Angeles. Cancer Treatment Symp. 3:49-57; 1985. 2. Gerner, R. E.; Moore, G. E.; Pickren, J. W. Soft tissue sarcomas. Ann. Surg. 18 1:803-808; 1975. 3. Haskell, C. M.; Silverstein, M.; Rangel, D. M.; Hunt, J. S.; Sparks, F. C.; Morton, D. L. Multimodality cancer therapy in man: a pilot study of Adriamycin by arterial infusion. Cancer 33:1485-1490; 1974. 4. Huth, J. F.; Mirra, J. J.; Eilber, F. R. Assessment of in vivo response to preoperative chemotherapy and radiation therapy as a predictor of survival in patients with soft tissue sarcoma. Am. J. Clin. Oncol. 8:497-503; 1985. 5. Mandard, A. M.; Chasie, J.; Mandard, J. C.; Rousselot, P.; Bouller, N.; Vernhes, J. C.; Wyplosz, J.; Alperine, S.; Tanguy, A.; Abbatucci, J. S. The pathologists role in a multidisciplinary approach for soft part tissue sarcoma: a reappraisal (39 cases). J. Surg. Oncol. 17:6981; 1981. 6. Morton, D. L.; Eilber, F. R.; Townsend, C. M.; Grant, T. T.; Mirra, J.; Weisenburger, T. H. Limb salvage from a multidisciplinary treatment approach for skeletal and soft tissue sarcomas ofthe extremity. Ann. Surg. 184:268-278; 1976. 7. Willett, C. G.; Schiller, A. L.; Suit, H. D.; Mankin, H. J.; Rosenberg, A. The histologic response of soft tissue sarcoma to radiation therapy. Cancer 60: 1500-I 504; 1982.
A LIP SPARING TECHNIQUE FOR EXTERNAL IRRADIATION OF ORAL LESIONS
BEAM
To the Editor: It is difficult to irradiate an anterior floor of the mouth tumor with external beam techniques without causing mucositis of the posterior surfaces of the lips of such magnitude that treatment must be interrupted. Some patients can be taught to hold air in their mouths by puffing the cheeks and lips for long enough periods of time to permit treatment. This simple maneuver produces 1 cm or more of separation of the posterior surface of the lips from the anterior mandible permitting inclusion of the mandible in lateral fields while excluding the posterior lip surfaces. The patient is cautioned not to overdistend the mouth with air since the attendant discomfort usually results in involuntary expulsion. Explaining to the patient what you are trying to accomplish helps, and close monitoring during treatment is essential. It is apparent that the patient must be able to breath through his/her nose and that the mouth must be reasonably anatomically and physiologically intact. Self-inflation of the mouth has also proved to be useful in treating lesions of the lips and cheeks with superficial X my or electron beam as a means of lessening reactions within the mouth. THOMAS P. HAYES, M.D.
The Evansville Cancer Center 700 N. Burkhardt Rd. Evansville, IN 477 15
August
1990, Volume
BILATERAL
19, Number
2
SQUAMOUS CELL CARCINOMA OF THE MIDDLE EAR
Introduction The stratified squamous epithelium lining the various parts of the upper aero-digestive tract is expected to react in a similar fashion to the same carcinogenic influence. Multicentric occurrence of squamous carcinoma of the head and neck region is well documented. As only a few cases of bilateral middle ear carcinoma have been documented in the literature it was found of interest to report on a patient with long standing otorrhea who within a 4-year interval developed bilateral squamous cell carcinomas of the tympanic and mastoid cavities. This case is discussed in relation to earlier findings in the literature. Case Report A 75-year old man had suffered from intermittent bilateral otorrhea and moderate hearing impairment since early childhood. A mucosal polyp from the left middle ear was extirpated and histopathological examination revealed a low differentiated squamous cell carcinoma. The patient was treated in March 1983 with radiotherapy. It was a combination of equal weights of electron and photon fields with size 6.5 cm X 6.5 cm directed horizontally against the left ear. The electron beam had an energy of 20 MeV and the photon beam 6 MV. The total target dose was 68.2 Gy, which corresponds to CRE = 18.5 Gy. Five months after completion of radiation therapy a new biopsy was taken, showing residual tumor growth. An extended radical mastoidectomy and petrosectomy was performed including resection of the facial nerve. One month after operation a neck node metastasis developed and the patient was treated with a lateral electron field with the energy 16 MeV against the left side of the neck adjacent to the earlier treatment. The total dose was 50 Gy (CRE = 17.0 Gy). The patient has remained free of disease in his left ear 5 years post treatment. Four years after the diagnosis of first tumor, squamous cell carcinoma was diagnosed in a polyp removed from his right ear. No certain bone destruction was found in the CT scans, but the middle ear cavity was filled with soft tissue. A radical operation of the right ear was performed and destruction of the bone was found to be extensive; postoperative radiotherapy followed. Because of the earlier treatment ofthe left middle ear with a dose contribution to the right side, the treatment had to be given strictly on the right side. A horizontal electron field (6.0 cm X 6.0 cm) with the energy 20 MeV was directed against the right ear (weight 100%). Two oooosed ohoton fields. 6 MV. SSD = 100 cm and wedae filter No 3, were given in the AP (anteroposterior) direction with the weight 70%. The total dose with this treatment was 44.4 Gy and CRE = 14.9. In an attempt to consider the earlier treatment of the left side that dose distribution has been added to the radiotherapy treatment of the right ear. Because of a >3-year interval, a reduction of 20% has been applied in Figure 1, where the distribution is given in Gy. In a follow-up in June 1989 the patient was free from tumor in both ears. He suffers from left sided facial palsy. The cavities on both sides were almost clean with only little discharge. Comparatively little is known about the detailed tissue structure and natural history of squamous cell carcinoma of the external auditory canal and middle ear (3). Stell (10) has reviewed the literature regarding malignancies involving these sites and notes that the first systematic description of the disease was presented by Politzer in his 1883 textbook (9). The incidence of middle ear carcinoma is difficult to predict, and has variously been estimated at between 6/ 1.OOO.OOO(6) and l/25.000 (7). The number of middle ear cancers seen at the Department of Oncology, University of UmeH, (covering a population of roughly 900,000 people) between 1966-1985 was 8, four women and four men. The total number registrated in Sweden during the period was 67, 34 women and 33 men. There is general agreement that the high resolution CT scan with a bone algorithm reconstruction is the best tool to evaluate the temporal bone involvement. However, Kinney and Wood (5) reported that CT scan was not able to reliably detect minimal bone invasion of the ear canal, or differentiate solid tumor involvement from mucosal thickening of the middle ear. Also in the present case, no certain bone destruction was found on the CT scans. At operation, however, bone invasion as well as areas of necrotic bone were found in the hypotympanic region on both sides. In the case of the middle ear, two factors are known to be closely associated with the development of cancer (8)-firstly chronic infection and secondly irradiation (1). The patient of the present study revealed
507
Correspondence
lesions should be those considered for radical on bloc surgery with adjuvant radiotherapy, whereas those in whom the tumor is of poor differentiation will do equally well with conventional mastoid surgery and radiotherapy. For a recent review of different treatment protocols see Arena and Keen, 1988 (I). DX
BENGTCARLSOO Department of Oto-Rhino-Laryngology Huddinge Hospital Huddinge LARS FRANZBN ROGERHENRIKSSON Departments of Oncology, PER-OLOFLOFROTH Department of Radiophysics STEN HERMANSCHMIDT Department of Oto-Rhino-Laryngology University of Umel UmeH, Sweden
Fig. 1. Summation plan for radiotherapy (in Gy). The distribution for the accumulated dose from the treatment of the left ear with an admitted reduction of 20% and the later treatment of the right ear. “Isodose levels”: 25, 40, 50, 60, and 65 Gy. both factors. Kenyon et al. (4) analyzed 2 1 patients (22 ears: one patient had bilateral cancers with squamous cell carcinoma of the middle ear). Overall 19 patients had had chronic suppuration and, in nine of the cases, cholesteatoma had been seen or suspected at some time in the past. The length of history of the symptoms was long and for the whole group averaged 30 years. In 16 of the patients otalgia was also a prominent symptom. The rarity of malignant tumors of the middle ear makes it difficult to proclaim dicta about management. An aggressive treatment including combined surgery and pre- or postoperative radiotherapy seems to be necessary for the best chance for cure (1 I). The present patient was primarily treated with radiation followed by surgery, and is free of tumor 6 (right ear) and 3 years (left ear) after treatment, respectively. Radical surgery or radiation therapy alone has also been recommended (2). The 5-year NED rates range from 10% to 50%, but without an established staging system it is almost impossible to compare treatment results from various institutions or various treatment modalities (12). According to Kenyon et al. (4) it may well be that patients with well differentiated
1. Beal, D.; Lindsay, J.; Ward, P. Radiation induced carcinoma of the mastoid. Arch. Otolaryngol. 8 1:91-16; 1965. 2. Boland, J. The management of carcinoma of the middle ear. Radiology 80:285; 1964. 3. Johns, M. E.; Headington, J. T. Squamos cell carcinoma of the extema auditory canal: a clinoicophathologic study of 20 cases. Arch. Otolaryngol. 100:45-49; 1974. 4. Kenyon, G. S.; Marks, P. W.; Schohz, C. L.; Dhillon, R. Squamos cell carcinoma of the middle ear. A 25-year retrospective study. Ann. Otol. Rhinol. Laryngol. 94:273-277; 1985. 5. Kinney, E.; Wood, B. G. Malignancies of the external ear canal and temporal bone: surgical techniques and results. Laryngoscope 97(2): 158-164; 1987. 6. Lodge, W. 0.; Jones, H. M.; Smith, M. E. N. Malignant tumors of the temporal bone. Arch. Otolaryngol. 61:535-541; 1955. 7. Mawson, S. R.; Ludman, H. Diseases of the ear. A textbook of otology, 4th edition. London: Edward Arnold; 1979:434. 8. Milford, C. A.; Violaris, N. Bilateral carcinoma of the middle ear. J. Laryngol. Otol. 101:711-713; 1987. 9. Politzer, A. Textbook of diseases of the ear. London: Balliere Tindall & Cox; 1883:650-655. 10. Stell, P. M. Carcinoma of the external auditory meatus and middle ear. Chn. Otolaryngol. 9:281-299; 1984. Il. Stell, P. M.; McCormick, M. S. Carcinoma of the external auditory meatus and middle ear: prognostic factors and a suggested staging svstem. J. Larvnaol. Otol. 99(9):847-850: 1985. 12. Wu, B. T.; Wang, F. T. Long-term observation of temporal bone resection in carcinoma of the middle ear and temporal bone. Chin. Med. J. (Engl.) 97(2):205-210; 1984.
I. J. Radiation
Oncology
0 Biology 0 Physics
to factors other than irradiation: tumor size, closing wound under tension, periosteal stripping, and so on (1). An evaluation of knee function is currently underway. Among 76 patients with soft tissue sarcomas of the thigh who received preoperative rapid fraction irradiation to the knee joint and remain alive disease-free 35 have been evaluated. After a median of 5 years from irradiation 90% have good to excellent function. These preliminary findings plus the functional results noted in our review of foot sarcomas attest to the paucity of late effects following 3.5 Gy fractions when the total dose is 17.5-35 Gy. Dr. Kinsella is correct in his desire for a randomized trial of the various methods for limb salvage. Until such a trial is available we will continue to pursue preoperative chemoradiotherapy for extremity soft tissue sarcomas. We believe this is an extremely effective strategy for managing patients with these challenging malignancies. MICHAEL T. SELCH, M.D. University of California, Los Angeles 10833 Le Conte Ave. Los Angeles, CA 90024 I. Eilber, F. R.; Giullano, A. E.; Huth, J.; Mirra, J.; Morton, D. L. Limb salvage for high grade soft tissue sarcomas of the extremity: Experience at the University of California, Los Angeles. Cancer Treatment Symp. 3:49-57; 1985. 2. Gerner, R. E.; Moore, G. E.; Pickren, J. W. Soft tissue sarcomas. Ann. Surg. 18 1:803-808; 1975. 3. Haskell, C. M.; Silverstein, M.; Rangel, D. M.; Hunt, J. S.; Sparks, F. C.; Morton, D. L. Multimodality cancer therapy in man: a pilot study of Adriamycin by arterial infusion. Cancer 33:1485-1490; 1974. 4. Huth, J. F.; Mirra, J. J.; Eilber, F. R. Assessment of in vivo response to preoperative chemotherapy and radiation therapy as a predictor of survival in patients with soft tissue sarcoma. Am. J. Clin. Oncol. 8:497-503; 1985. 5. Mandard, A. M.; Chasie, J.; Mandard, J. C.; Rousselot, P.; Bouller, N.; Vernhes, J. C.; Wyplosz, J.; Alperine, S.; Tanguy, A.; Abbatucci, J. S. The pathologists role in a multidisciplinary approach for soft part tissue sarcoma: a reappraisal (39 cases). J. Surg. Oncol. 17:6981; 1981. 6. Morton, D. L.; Eilber, F. R.; Townsend, C. M.; Grant, T. T.; Mirra, J.; Weisenburger, T. H. Limb salvage from a multidisciplinary treatment approach for skeletal and soft tissue sarcomas ofthe extremity. Ann. Surg. 184:268-278; 1976. 7. Willett, C. G.; Schiller, A. L.; Suit, H. D.; Mankin, H. J.; Rosenberg, A. The histologic response of soft tissue sarcoma to radiation therapy. Cancer 60: 1500-I 504; 1982.
A LIP SPARING TECHNIQUE FOR EXTERNAL IRRADIATION OF ORAL LESIONS
BEAM
To the Editor: It is difficult to irradiate an anterior floor of the mouth tumor with external beam techniques without causing mucositis of the posterior surfaces of the lips of such magnitude that treatment must be interrupted. Some patients can be taught to hold air in their mouths by puffing the cheeks and lips for long enough periods of time to permit treatment. This simple maneuver produces 1 cm or more of separation of the posterior surface of the lips from the anterior mandible permitting inclusion of the mandible in lateral fields while excluding the posterior lip surfaces. The patient is cautioned not to overdistend the mouth with air since the attendant discomfort usually results in involuntary expulsion. Explaining to the patient what you are trying to accomplish helps, and close monitoring during treatment is essential. It is apparent that the patient must be able to breath through his/her nose and that the mouth must be reasonably anatomically and physiologically intact. Self-inflation of the mouth has also proved to be useful in treating lesions of the lips and cheeks with superficial X my or electron beam as a means of lessening reactions within the mouth. THOMAS P. HAYES, M.D.
The Evansville Cancer Center 700 N. Burkhardt Rd. Evansville, IN 477 15
August
1990, Volume
BILATERAL
19, Number
2
SQUAMOUS CELL CARCINOMA OF THE MIDDLE EAR
Introduction The stratified squamous epithelium lining the various parts of the upper aero-digestive tract is expected to react in a similar fashion to the same carcinogenic influence. Multicentric occurrence of squamous carcinoma of the head and neck region is well documented. As only a few cases of bilateral middle ear carcinoma have been documented in the literature it was found of interest to report on a patient with long standing otorrhea who within a 4-year interval developed bilateral squamous cell carcinomas of the tympanic and mastoid cavities. This case is discussed in relation to earlier findings in the literature. Case Report A 75-year old man had suffered from intermittent bilateral otorrhea and moderate hearing impairment since early childhood. A mucosal polyp from the left middle ear was extirpated and histopathological examination revealed a low differentiated squamous cell carcinoma. The patient was treated in March 1983 with radiotherapy. It was a combination of equal weights of electron and photon fields with size 6.5 cm X 6.5 cm directed horizontally against the left ear. The electron beam had an energy of 20 MeV and the photon beam 6 MV. The total target dose was 68.2 Gy, which corresponds to CRE = 18.5 Gy. Five months after completion of radiation therapy a new biopsy was taken, showing residual tumor growth. An extended radical mastoidectomy and petrosectomy was performed including resection of the facial nerve. One month after operation a neck node metastasis developed and the patient was treated with a lateral electron field with the energy 16 MeV against the left side of the neck adjacent to the earlier treatment. The total dose was 50 Gy (CRE = 17.0 Gy). The patient has remained free of disease in his left ear 5 years post treatment. Four years after the diagnosis of first tumor, squamous cell carcinoma was diagnosed in a polyp removed from his right ear. No certain bone destruction was found in the CT scans, but the middle ear cavity was filled with soft tissue. A radical operation of the right ear was performed and destruction of the bone was found to be extensive; postoperative radiotherapy followed. Because of the earlier treatment ofthe left middle ear with a dose contribution to the right side, the treatment had to be given strictly on the right side. A horizontal electron field (6.0 cm X 6.0 cm) with the energy 20 MeV was directed against the right ear (weight 100%). Two oooosed ohoton fields. 6 MV. SSD = 100 cm and wedae filter No 3, were given in the AP (anteroposterior) direction with the weight 70%. The total dose with this treatment was 44.4 Gy and CRE = 14.9. In an attempt to consider the earlier treatment of the left side that dose distribution has been added to the radiotherapy treatment of the right ear. Because of a >3-year interval, a reduction of 20% has been applied in Figure 1, where the distribution is given in Gy. In a follow-up in June 1989 the patient was free from tumor in both ears. He suffers from left sided facial palsy. The cavities on both sides were almost clean with only little discharge. Comparatively little is known about the detailed tissue structure and natural history of squamous cell carcinoma of the external auditory canal and middle ear (3). Stell (10) has reviewed the literature regarding malignancies involving these sites and notes that the first systematic description of the disease was presented by Politzer in his 1883 textbook (9). The incidence of middle ear carcinoma is difficult to predict, and has variously been estimated at between 6/ 1.OOO.OOO(6) and l/25.000 (7). The number of middle ear cancers seen at the Department of Oncology, University of UmeH, (covering a population of roughly 900,000 people) between 1966-1985 was 8, four women and four men. The total number registrated in Sweden during the period was 67, 34 women and 33 men. There is general agreement that the high resolution CT scan with a bone algorithm reconstruction is the best tool to evaluate the temporal bone involvement. However, Kinney and Wood (5) reported that CT scan was not able to reliably detect minimal bone invasion of the ear canal, or differentiate solid tumor involvement from mucosal thickening of the middle ear. Also in the present case, no certain bone destruction was found on the CT scans. At operation, however, bone invasion as well as areas of necrotic bone were found in the hypotympanic region on both sides. In the case of the middle ear, two factors are known to be closely associated with the development of cancer (8)-firstly chronic infection and secondly irradiation (1). The patient of the present study revealed
507
Correspondence
lesions should be those considered for radical on bloc surgery with adjuvant radiotherapy, whereas those in whom the tumor is of poor differentiation will do equally well with conventional mastoid surgery and radiotherapy. For a recent review of different treatment protocols see Arena and Keen, 1988 (I). DX
BENGTCARLSOO Department of Oto-Rhino-Laryngology Huddinge Hospital Huddinge LARS FRANZBN ROGERHENRIKSSON Departments of Oncology, PER-OLOFLOFROTH Department of Radiophysics STEN HERMANSCHMIDT Department of Oto-Rhino-Laryngology University of Umel UmeH, Sweden
Fig. 1. Summation plan for radiotherapy (in Gy). The distribution for the accumulated dose from the treatment of the left ear with an admitted reduction of 20% and the later treatment of the right ear. “Isodose levels”: 25, 40, 50, 60, and 65 Gy. both factors. Kenyon et al. (4) analyzed 2 1 patients (22 ears: one patient had bilateral cancers with squamous cell carcinoma of the middle ear). Overall 19 patients had had chronic suppuration and, in nine of the cases, cholesteatoma had been seen or suspected at some time in the past. The length of history of the symptoms was long and for the whole group averaged 30 years. In 16 of the patients otalgia was also a prominent symptom. The rarity of malignant tumors of the middle ear makes it difficult to proclaim dicta about management. An aggressive treatment including combined surgery and pre- or postoperative radiotherapy seems to be necessary for the best chance for cure (1 I). The present patient was primarily treated with radiation followed by surgery, and is free of tumor 6 (right ear) and 3 years (left ear) after treatment, respectively. Radical surgery or radiation therapy alone has also been recommended (2). The 5-year NED rates range from 10% to 50%, but without an established staging system it is almost impossible to compare treatment results from various institutions or various treatment modalities (12). According to Kenyon et al. (4) it may well be that patients with well differentiated
1. Beal, D.; Lindsay, J.; Ward, P. Radiation induced carcinoma of the mastoid. Arch. Otolaryngol. 8 1:91-16; 1965. 2. Boland, J. The management of carcinoma of the middle ear. Radiology 80:285; 1964. 3. Johns, M. E.; Headington, J. T. Squamos cell carcinoma of the extema auditory canal: a clinoicophathologic study of 20 cases. Arch. Otolaryngol. 100:45-49; 1974. 4. Kenyon, G. S.; Marks, P. W.; Schohz, C. L.; Dhillon, R. Squamos cell carcinoma of the middle ear. A 25-year retrospective study. Ann. Otol. Rhinol. Laryngol. 94:273-277; 1985. 5. Kinney, E.; Wood, B. G. Malignancies of the external ear canal and temporal bone: surgical techniques and results. Laryngoscope 97(2): 158-164; 1987. 6. Lodge, W. 0.; Jones, H. M.; Smith, M. E. N. Malignant tumors of the temporal bone. Arch. Otolaryngol. 61:535-541; 1955. 7. Mawson, S. R.; Ludman, H. Diseases of the ear. A textbook of otology, 4th edition. London: Edward Arnold; 1979:434. 8. Milford, C. A.; Violaris, N. Bilateral carcinoma of the middle ear. J. Laryngol. Otol. 101:711-713; 1987. 9. Politzer, A. Textbook of diseases of the ear. London: Balliere Tindall & Cox; 1883:650-655. 10. Stell, P. M. Carcinoma of the external auditory meatus and middle ear. Chn. Otolaryngol. 9:281-299; 1984. Il. Stell, P. M.; McCormick, M. S. Carcinoma of the external auditory meatus and middle ear: prognostic factors and a suggested staging svstem. J. Larvnaol. Otol. 99(9):847-850: 1985. 12. Wu, B. T.; Wang, F. T. Long-term observation of temporal bone resection in carcinoma of the middle ear and temporal bone. Chin. Med. J. (Engl.) 97(2):205-210; 1984.
