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

Abstract

Background: The aim of the study was to identify the value of extensive resection and reconstruction with flaps in the treatment of locoregionally advanced lateral skull-base cancer.

Patients and methods: The retrospective case review of patients with lateral skull-base cancer treated surgically with curative intent between 2011 and 2019 at a tertiary otorhinolaryngology referral centre was made.

Results: Twelve patients with locoregionally advanced cancer were analysed. Lateral temporal bone resection was performed in nine (75.0%), partial parotidectomy in six (50.0%), total parotidectomy in one (8.3%), ipsilateral selective neck dissection in eight (66.7%) and ipsilateral modified radical neck dissection in one patient (8.3%). The defect was reconstructed with anterolateral thigh free flap, radial forearm free flap or pectoralis major myocutaneous flap in two patients (17.0%) each. Mean overall survival was 3.1 years (SD = 2.5) and cancer-free survival rate 100%. At the data collection cut-off, 83% of analysed patients and 100% of patients with flap reconstruction were alive.

Conclusions: Favourable local control in lateral skull-base cancer, which mainly involves temporal bone is achieved with an extensive locoregional resection followed by free or regional flap reconstruction. Universal cancer registry should be considered in centres treating this rare disease to alleviate analysis and multicentric research.

Keywords: ear; free tissue flaps; microsurgery; neoplasm staging; parotid region; temporal bone.

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 10^th revision

Figure 2

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).

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.

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).

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.