# Decoding Temporal Bone Carcinoma: The Role of CT and MRI in Precision Staging
## 4 Discussion  
In the present study, T1-T2 tumors showed 100% 5-year survival, while T3 and T4 tumors had survival rates of 25% and 0%, respectively. [PERSON] et al. found a 5-year survival of 100% for T1-T2 tumors, 69% for T3 tumors, and 20% for T4 tumors, while [PERSON] et al. reported a 2-year survival of 100% for T1-T2 tumors, 50% for T3 tumors, and 15% for T4 tumors [6,7]. These results demonstrate the reliability of the Pittsburgh system in predicting survival based on the extent of the disease. [PERSON] et al. demonstrated that preoperative CT has 98% accuracy in predicting surgical findings. However, it does not always detect spread into soft tissue through structures such as [PERSON]'s incisura and [PERSON]'s foramen. MRI suggested as an adjunct to CT, is useful in determining extension into soft tissues and improving overall assessment. The Pittsburgh system was compared with AJCC, focusing on head and neck skin tumors. While the AJCC shows significant differences only in disease-specific survival (DSS) in T3-T4 tumors, the Pittsburgh system discriminates DSS, disease-free survival (DFS), and overall survival (OS). However, the AJCC system does not consider the anatomical specificities of the EAC, limiting its applicability. Injuries extending toward the parotid gland and temporomandibular joint (TM)) have a better prognosis than those involving the otic capsule or mastoid. [PERSON] et al. suggested dividing the T4 category into T4a: lesions in the peri-auricular soft tissues and parotid space. T4b: lesions involving the temporal and skull base [8,9].  
A retrospective cohort analysis on patients who were treated for their primary EAC SCC pointed out that certain limitations in the predictive performance of the Pittsburgh classification system may be due to cancers classified as T4: more specifically, the Pittsburgh classification and modified PSS do not discriminate extension and invasion vectors in the different directions anterior, posterior, medial, lateral, superior, and inferior, thus creating a bias in the survival analysis and best treatment choice [10]. Evidence suggests that tumors spreading anteriorly, in parotid space and preauricular region, are related to a notably higher DFS compared to other T4-classified tumors with other spreading vectors [11]. A subclassification that considers the spreading direction of the T4-staged tumor was proposed by [PERSON] et al. and subdivided such neoplasm's feature into extracranial extension (T4a), intraperitoneally bone and extradural extension (T4b), and meningeal or intradural extension/involvement (T4c) [12].  
[PERSON] et al. observed that the Pittsburgh system, while effective, has limitations when applied to temporal tumors as a whole. Combining high-resolution CT and MRI allows for improved staging, especially for T1-T2 tumors, where subtle bone changes may be misinterpreted. A subdivision of T2 is proposed for T2a: soft tissue involvement of less than 0.5 mm. T2b: extensive involvement without bone erosion, potentially mediated by [PERSON]'s incisura or [PERSON]'s foramen. This integrated approach improves the diagnostic accuracy and effectiveness of the Pittsburgh system in prognosis prediction and treatment planning.