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Annals of Surgical Oncology 10:689-696 (2003)
© 2003 Society of Surgical Oncology

ORIGINAL ARTICLES

Changing Surgical Therapy for Melanoma of the External Ear

Barbara A. Pockaj, MD, Dawn E. Jaroszewski, MD, David J. DiCaudo, MD, Joseph G. Hentz, MS, Edward W. Buchel, MD, Richard J. Gray, MD, Svetomir N. Markovic, MD and Uldis Bite, MD

From the Department of Surgery (BAP, DEJ, RJG), Department of Dermatology (DJD), Section of Biostatistics (JGH), and Division of Plastic and Reconstructive Surgery (EWB), Mayo Clinic, Scottsdale, Arizona; and the Division of Medical Oncology (SNM) and the Division of Plastic and Reconstructive Surgery (UB), Mayo Clinic, Rochester, Minnesota.

Correspondence: Address correspondence and reprint requests to: Barbara A. Pockaj, MD, Department of Surgery, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259; E-mail: pockaj.barbara{at}mayo.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The purpose of this study was to evaluate the prognostic variables and clinical ramifications of melanoma of the ear.

Methods: A retrospective chart review of patients treated since 1985 at the Mayo Clinic in Scottsdale, AZ, and Rochester, MN, identified 78 patients with complete follow-up.

Results: Of these 78 patients, 68 (87%) were men; the mean age was 64 years (range, 23–87 years). Melanoma thickness averaged 1.7 mm (range, .2–7.0 mm). Treatment of the primary melanoma included wedge resection (59%), Mohs resection (14%), partial amputation (11%), skin and subcutaneous resection with perichondrium preservation (9%), and total amputation (7%). Nineteen patients underwent an elective lymph node dissection, and lymph node metastases were found in seven (37%). Two patients presented with clinically positive lymph nodes. Sentinel lymph node biopsy was performed in 10 patients. After a mean follow-up of 55.7 months, 10 patients (13%) had local recurrence, 9 patients (12%) had regional recurrence, and systemic metastases had developed in 17 patients (22%). Tumor thickness, lymph node metastases, and local recurrence significantly affected systemic recurrence.

Conclusions: The treatment of malignant melanoma of the external ear should follow current standard guidelines, which require wide local excision with negative margins. Sentinel lymph node biopsy can be used to identify patients with lymph node metastases who are at high risk of recurrence.

Key Words: Ear • Elective lymph node dissection • Malignant melanoma • Prognosis • Sentinel lymph node biopsy • Wide local excision


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Malignant melanoma is the fastest-growing cancer in the United States. In 1996, the lifetime risk of malignant melanoma was 1 in 87, compared with the risk in 1980 of 1 in 250. The risk continues to increase and is expected to reach 1 in 74 during the 21st century.1 Approximately 20% of melanomas are located on the head and neck.2 Of these melanomas, 7% to 15% are on the external ear.2–6 Management of melanoma of the ear is challenging because of the ear’s important role in cosmesis and function. In addition, lesions on the ear often go unnoticed, which leads to later diagnosis and thicker lesions.4,7,8

Fortunately, along with the increasing incidence of melanoma, significant progress has been made in its treatment, but many controversies remain. There has been a shift away from aggressive surgical procedures to those using more directed technological advances. Randomized clinical trials evaluating surgical margins in the trunk and extremities have found that a margin of 2 cm does not compromise prognosis.9 Because of the anatomical nature of head and neck melanomas, including those on the ear, randomized trials evaluating margins are difficult to perform. Early reports on malignant melanoma of the ear observed a poor prognosis.3,4 This finding led many to believe that melanoma of the ear manifested a different biological behavior and warranted an aggressive surgical approach. Subsequent series demonstrated that more narrow margins preserving cosmetic outcome did not compromise local recurrence or overall survival.5,7,8

The management of the lymph nodes in patients with head and neck melanoma remains controversial. Almost all surgeons agree that the use of radical lymph node dissection is not necessary and prefer to use a modified approach.3,10,11 Several randomized trials12,13 failed to demonstrate a survival advantage for patients undergoing elective lymph node dissection (ELND) except in certain subsets.14 The problem with these trials is that only one included melanomas of the head and neck.14 Lymphatic drainage patterns of the head and neck are notoriously ambiguous, and published studies have identified discordant lymphoscintigrams in as many as 80% of patients with head and neck melanoma.15 Melanoma of the ear has the potential to metastasize to preauricular or postauricular sites, to anterior or posterior cervical chains, and to the parotid gland.10,15,16 Lymphatic mapping and sentinel lymph node (SLN) biopsy may resolve these problems. SLN biopsy helps to direct the lymph node evaluation to the appropriate lymph node basin or basins and allows staging without an ELND. Several medical centers have reported success with SLN biopsy for patients with head and neck melanomas.10,17–19

Few published series have evaluated melanoma of the ear. The largest series was published more than 20 years ago3; recent series usually include fewer than 35 patients.5,7,20,21 We decided to re-evaluate this challenging clinical problem to take into consideration new techniques and an improved understanding of the natural history and biology of melanoma.


   PATIENTS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
This study was designed to review and evaluate the presentation, treatment strategies, and subsequent clinical course of patients treated for malignant melanoma of the external ear. Eighty-four patients were identified through the Mayo Clinic tumor registry database from January 1985 to January 2000; 63 were at Mayo Clinic Rochester, and 21 were at Mayo Clinic Scottsdale. The Mayo Foundation Institutional Review Board approved this retrospective chart review.

Only cases of melanoma located on the external ear were included; melanoma in situ was excluded. The study variables included age, sex, location, thickness of lesion, type of surgical treatment for the primary lesion, surgical margins, lymph node evaluation, adjuvant therapy, locoregional recurrence, systemic metastases, and mortality due to disease. Ulceration was not reported for most patients, so this factor was not used in our evaluation.

Surgical definitions were as follows: perichondrium-preserving, wide local excision removes only the skin and subcutaneous tissue, leaving the perichondrium and cartilage; wedge resection removes a section of tissue that includes skin, subcutaneous tissue, and cartilage with or without primary closure; partial amputation removes a section of the ear that is more than one fourth of the ear but is not a complete amputation; and a full amputation removes the entire ear, including the helix, scapha, concha, and lobule. Mohs micrographic surgery begins with a debulking biopsy specimen taken around the previous biopsy site to determine the depth of the residual tumor. An additional margin is obtained around the entire defect, and the complete surgical margin is examined by horizontal histological sections. To help identify residual tumor at the margins, immunostains for melanocytes may be used with frozen or permanent sections. An ELND is defined as removal of the lymph node basin to which the melanoma is predicted to drain when the lymph nodes are not clinically suggestive. Patients did not undergo preoperative lymphoscintigraphy before ELND. A therapeutic lymph node dissection is performed when clinically suspicious lymph nodes are found during wide local excision of the primary melanoma. A delayed lymph node dissection is performed on clinically suspicious lymph nodes that develop after the initial wide local excision.

Patients undergoing SLN biopsy underwent same-day preoperative lymphoscintigraphy with intradermal injection of 250 to 500 µCi of 99mTc-labeled colloid tracer around the primary site of the malignancy. This determined the primary lymph node drainage basin or basins of the melanoma. The nuclear medicine radiologist marked the location of the SLNs. During surgery, 1 mL of 1% isosulfan blue dye was injected. A handheld gamma counter was used during surgery to localize the SLNs. All SLNs demonstrated increased radioactivity (five or more times background), blue staining, or both. Pathologic evaluation of the SLNs was performed by serial sectioning and with S-100 and HMB-45 immunohistochemical stains. If the SLN was found to contain metastasis, we proceeded with a complete lymph node dissection.

The incidence of recurrence and mortality were calculated with the Kaplan-Meier method. The incidence of recurrence was compared among subgroups of patients by comparing the Kaplan-Meier survival curves, and the statistical significance was calculated by using the generalized Wilcoxon test. The generalized Wilcoxon test was selected because few patients had a lengthy follow-up, and it weights time intervals in proportion to the number of patients who provide data for that interval. Confidence intervals for differences in incidence were calculated by using the Greenwood formula for the standard error of the Kaplan-Meier measures.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Eighty-four patients with a diagnosis of melanoma of the external ear were treated at Mayo Clinic. Two patients had their initial surgical treatment elsewhere, and one patient came only for a second opinion. Six of the 84 patients were excluded because they had no follow-up. Patient characteristics of the remaining 78 are listed in Table 1. The mean age of the study population was 64 years (range, 23–87 years), and the mean follow-up was 55.7 months (range, .4–139.8 months). Most patients were men (87%). The left ear (n = 47) was affected more often than the right ear (n = 31). Location of the melanoma was helix (n = 50), lobule (n = 13), scapha (n = 1), concha (n = 5), and tragus (n = 3). Location was not specified in six patients.


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  		TABLE 1. Characteristics of 78 patients with melanoma of the ear
 
The average thickness of ear melanoma in our series was 1.7 ± 1.4 mm (range, .2–7.0 mm). Unlike many other series, this one included a large proportion of patients with thin melanomas (n = 26; 33%). Most patients presented with intermediate-thickness melanoma (n = 42; 54%). Only four patients (5%) presented with a thick melanoma; in six patients (8%), the thickness was not reported.

The surgical approach to the primary melanoma varied (Table 2). Skin resection only, with preservation of the perichondrium, was performed in seven patients (9%). The skin defect was allowed to close by secondary intention or by skin grafting. Most patients (59%) underwent a full-thickness wedge resection. Other surgical procedures included partial amputation (11%) and complete amputation (7%). Eleven patients (14%) underwent Mohs surgery; most of these resections were allowed to close by secondary intention. Complete medical records were not available for two patients whose resections were performed at outside institutions. Negative margins were achieved in all patients. The extent of the margins was <1 cm in 25 patients (33%), >=1 cm in 29 patients (38%), and not specified in 22 patients (29%).


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  		TABLE 2. Surgical approaches to melanoma of the ear in 76 patientsa
 
Twenty-nine patients (38%) underwent some type of lymph node evaluation at the time of wide local excision. Two patients who presented with palpable lymph nodes underwent a therapeutic lymph node dissection. Positive lymph nodes were found in the parotid gland and the upper and lower cervical lymph nodes. Nineteen patients underwent an ELND (Table 2), which included a superficial parotidectomy. Most surgeons performed a modified neck dissection; only two patients underwent radical neck dissection. Of the 19 patients who underwent an ELND, 7 (37%) were found to have positive lymph nodes. The number of positive lymph nodes found ranged from 1 to 3. These positive lymph nodes were found in the parotid or upper cervical lymph nodes. Ten patients underwent an SLN biopsy; no pathologically positive lymph nodes were found. Five tumors drained to only one lymph node basin, and five drained to two lymph node basins. The location of the SLN included parotid (n = 7), posterior auricular (n = 1), submandibular (n = 1), upper jugular (n = 5), and posterior triangle (n = 1). In four patients who did not undergo surgical evaluation of their lymph nodes at the time of wide local excision, suggestive lymph nodes subsequently developed, and the patients then underwent a delayed lymph node dissection.

Few of our patients underwent adjuvant therapy. Four patients with positive lymph nodes received postoperative radiotherapy. One of these four patients also received adjuvant interferon; another patient received adjuvant chemotherapy.

Local recurrence developed in 10 patients (13%; Table 3). The type of resection performed in these patients included wedge (6 of 45; 13%), partial amputation (2 of 8; 25%), complete amputation (1 of 5; 20%), and Mohs resection (1 of 11; 9%). The thickness of the melanoma influenced the incidence of local recurrence, but the type of resection or the extent of margins did not (Table 4). A recurrence of melanoma in the lymph nodes developed in nine patients (12%). It is interesting to note that melanoma in five of these nine patients recurred in a previously dissected basin. Metastases in the lymph nodes developed in four patients after an ELND and in one patient after therapeutic lymph node dissection. Three of these nine patients also received radiotherapy. The biology of the disease in these patients seems to have been particularly aggressive. Four patients (5%) who had a recurrence in lymph node basins that were not evaluated by an ELND or an SLN biopsy underwent a delayed lymph node dissection. Simultaneous local and regional recurrences developed in four patients. Recurrence in the lymph nodes has not occurred in patients who underwent an SLN biopsy, but follow-up of these patients is short (median follow-up, 38 months).


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  		TABLE 3. Summary of local, regional, and systemic recurrences
 

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  		TABLE 4. Comparisons of the incidence of local recurrencea
 
The 5-year survival was 65%. Systemic metastases developed in 17 patients (22%; Table 3). Most patients (12 of 17; 71%) with systemic metastases already had a local or regional recurrence. Of note, nine patients died of causes other than melanoma, which reflects the elderly age at diagnosis for most of these patients. The factors that affected systemic recurrence included melanoma thickness, lymph node status, and local recurrence. The effect of local recurrence on the development of systemic metastasis was evaluated only for patients who had >=3 years of follow-up (Table 5). This is consistent with what is found in larger melanoma studies. The type of resection did not influence systemic recurrence (P = .41). It is interesting to note that the rate of systemic recurrence in patients who underwent an ELND was significantly higher than in those who underwent observation (44% vs. 13%; P = .02). Further evaluation of these two groups revealed that the patients who underwent ELND had much thicker melanomas (2.33 ± 1.6 mm) compared with those who did not (1.23 ± 1.2 mm). We believe that this finding reflects the surgeon’s decision to perform more aggressive surgery in those patients with a thicker melanoma.


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  		TABLE 5. Comparisons of the incidence of systemic recurrencea
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Melanoma of the external ear, which is diagnosed typically in elderly men, is an unusual lesion that poses therapeutic challenges. In our series, the left ear was affected more often than the right ear. This may reflect sun exposure from driving a car, because the left side of the face is exposed during this activity. The helix of the ear is affected most often.3,7,8 Although the ear is easily visualized, portions of the helix are less apparent and are not examined as frequently as other skin locations, which may account for late diagnosis.

Historically, patients with melanoma of the ear had a perceived poorer outcome, and an aggressive surgical approach was advocated in the 1970s.22 Studies in the 1980s seemed to confirm the aggressive nature of melanoma of the ear,3,4 possibly because of the thick melanomas being diagnosed then. Although melanoma of the external ear was believed to have an inherently poor prognosis, there was no evidence that an aggressive surgical approach to the primary melanoma was justified, and the utility of ELND was not clear. Subsequently, small series in the 1990s did not demonstrate an unusually aggressive nature of melanoma of the ear, although several series included as many as 30% of patients with a melanoma >4 mm thick (Table 6).5,8,20,21 These studies showed that a less radical approach did not result in a much higher local recurrence. Cole et al.5 even demonstrated that a full soft tissue resection sparing the perichondrium was not associated with a higher rate of local recurrence. Our series confirms these findings. The type of resection did not correlate with local recurrence or prognosis.


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  		TABLE 6. Patient series of melanoma of the eara
 
Although randomized studies provide guidelines for the extent of margins for melanoma excision, applying a 2-cm margin in the head and neck area often makes it difficult to preserve cosmesis.9 Treatment of head and neck melanoma should be individualized to allow an adequate surgical margin to be obtained with acceptable cosmetic results. A variety of surgical options are available, ranging from minimal tissue removal, such as a Mohs resection,23 to radical amputation of the ear.

Local recurrence affected only 13% of our patients, compared with as many as 31% in other series (Table 6). Even though we did not find any statistical difference between margin status and local recurrence, the margin status was <1 cm or was unknown in 80% of our patients who had a local recurrence. This finding suggests that margin status may play a role in local recurrence. Bono et al.8 reported a localized recurrence of 0% in a series in which most patients had a negative margin of 1 cm. Narayan and Ariyan7 did not observe any local recurrences in patients with negative margins. The only local recurrence in Narayan and Ariyan’s series occurred in a patient with a positive margin that was not resected again. Hudson et al.20 did not note any local recurrences in patients with a negative margin of >1 cm. After evaluating these small series, we conclude that negative margins are of critical importance and that margins of >=1 cm seem to be associated with the lowest risk of local recurrence.

Depth of tumor excision is more complicated in patients with ear melanoma. Skin and subcutaneous tissue need to be excised, but perichondrium should be removed only when there is direct tumor involvement, such as with melanoma in other locations where the fascia is spared.24 We have shown that wide local excision sparing the perichondrium and closing the defect by using a skin graft or secondary intention leads to an acceptable local recurrence rate. Grafting can be accomplished with the use of posterior auricular skin. Care must be taken to obtain complete hemostasis, and careful application of a pressure dressing is needed to prevent hematoma. Because of the thin nature of the skin of the ear, a full-thickness wedge resection is better suited for the intermediate and thick melanomas.25 For larger defects, the use of a tubed retroauricular skin flap26 or a chondrocutaneous advancement flap results in a cosmetically acceptable ear despite a reduced circumference.7,27 Not only is cosmetic appearance important, but radical resection may result in significant functional difficulty for patients who wear eyeglasses.

The use of Mohs surgery in the treatment of malignant melanoma is yet to be established. The reported series generally focused on lentigo maligna and large primary lesions situated near vital structures.28,29 Of our 11 patients who underwent Mohs surgery, only 1 had local recurrence and no systemic disease. Because of the small number of patients in our series, it is not possible to make definitive conclusions about the use of Mohs surgery.

ELND continues to be a controversial procedure. Four large, prospective, randomized trials failed to demonstrate a survival benefit.13,14,30,31 The Intergroup Melanoma Study14 identified a subset of patients who did benefit from the procedure (patients <60 years old; melanoma thickness of 1–2 mm without ulceration). There are limited data evaluating the use of ELND in patients with ear melanoma. Few patients underwent an ELND in published series of melanoma of the ear (Table 6). Byers et al.3 did not observe a difference in survival if an ELND or a delayed lymph node dissection was performed when lymph node metastases appeared. The number of patients who presented with positive lymph nodes, as determined by ELND or therapeutic lymph node dissection, ranged from 0% to 29%. The number of patients in whom lymph node metastases ultimately developed is relatively low, considering the thickness of the melanoma at presentation. In our series, only 12% of patients presented with positive lymph nodes (seven patients on ELND and two patients on clinical examination). Lymph node recurrences developed in nine patients, but five occurred in an already-dissected lymph node basin.

SLN biopsy provides an excellent alternative to ELND. The status of the SLN indicates whether a full lymph node dissection is warranted. The SLN biopsy false-negative rate is low (<5%).32–34 The problem of discordant lymphatic drainage in head and neck melanomas makes the use of SLN biopsy even more attractive because preoperative lymphoscintigraphy is a critical component of this procedure. The combination of blue dye injection with intraoperative handheld gamma-probe evaluation identifies the SLN in >90% of patients with head and neck melanomas.10,18,19 The use of both techniques is crucial because the blue dye staining is not as vivid in the ear as it is in the axilla or groin.11

We have reported on 10 patients who underwent SLN biopsy. The SLNs of all 10 patients were negative, and no further lymph node dissection was performed. With a short follow-up (median, 38 months), there have been no regional recurrences in these patients. Other reports also have noted the success of SLN biopsy in patients with melanoma of the ear.10,16,34

It is not unusual for lymphatic drainage of the ear to localize to the preauricular or parotid lymph nodes. Traditionally, a superficial parotidectomy was performed with an ELND. Two recent studies reported that SLN biopsy of the parotid gland can be performed with a high success rate and low morbidity.35,36 This is because 90% of the lymph nodes within the parotid gland are located in the superficial portion above the parotid duct and facial nerve.37 SLN biopsy allows for biopsy of these parotid nodes without the morbidity of a superficial parotidectomy.

In summary, we found that tumor thickness, lymph node status, and development of local recurrence have a negative effect on prognosis. Even though the number of patients reported in our study and in the literature is small, we believe that the data support the current treatment of malignant melanoma of the external ear, which should follow the current standards of melanoma care established for other parts of the body. Wide local excision with a negative margin is critical. Margins of at least 1 cm seem to result in a lower rate of local recurrence. Radical excision is not indicated because it confers no survival benefit and may even result in significant functional impairment. Detection of lymph node metastases will identify patients at high risk for systemic recurrence, who may derive benefit from adjuvant therapy. SLN biopsy offers an alternative to ELND for lymph node basin evaluation with a high success rate and low morbidity.


   FOOTNOTES
 
A retrospective review of 78 patients with malignant melanoma of the ear revealed that radical surgery does not improve survival. Appropriate surgical treatment and staging involve following standard melanoma treatment guidelines, including wide local excision and sentinel lymph node biopsy.

Received for publication September 27, 2002. Accepted for publication March 18, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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