Carcinoma of major salivary glands. Recent trends

Parotid carcinoma: Current diagnostic workup and treatment

In this review we present recent progress in diagnostic workup, prognostic evaluation, treatment options and resulting outcomes. Whenever possible, complete resection remains the mainstay of treatment. Sacrifice of facial nerve branches is reserved for the clinically or electromyographically dysfunctioning facial nerve. Clinical or radiological neck disease demands combined surgery and radiotherapy. Treatment of the N0 neck is indicated for advanced stage-high grade tumors but the question remains unanswered whether this should be surgical or radiotherapeutic elective treatment. Surgery alone will cure low stage, low grade tumors, that show no additional negative prognostic factors following adequate resection. In all other tumors postoperative radiotherapy will improve locoregional control. This approach results in good locoregional control, in a way that distant metastasis remains the typical presentation of treatment failure. In this setting, the results of systemic treatment today remain limited, but a huge effort in the molecular biology field has been done to introduce targeted therapy into this domain of head and neck cancer. Disease control remains variable within the patient population. This variation can increasingly be predicted by systems that incorporate the combined information of multivariately identified and quantified prognostic factors into an individualized prognosis for the parotid carcinoma patient.

Morphometric analysis of CD34-positive vessels in salivary gland adenoid cystic and mucoepidermoid carcinomas

BACKGROUND

Carcinomas of the salivary glands are uncommon and morphologically a diverse group of malignancies. To evaluate the prognostic value of CD34 immunostaining of the vessels in adenoid cystic carcinoma (AdCC) and mucoepidermoid carcinoma (MEC), an automated image analysis method was used.

METHOD

In a nationwide study, covering salivary gland cancer (SGC) patients in Finland 1991-1996, 37 AdCC and 18 MEC patients (M 25, F 30, age 25-90, mean 63) were included. In addition to clinical characteristics the size, shape, staining intensity and vessel density in CD34 immunostained histologic samples were measured.

RESULTS

Altogether 4433 vessels were measured from AdCC and 2615 from MEC tumor. Of the total tumor vessels measured, 2651 were from patients who deceased with disease (Group I) and 4397 were from specimens derived from those who did not die of disease (Group II) during the 10-year follow-up. The staining intensity was significantly higher in MEC than in AdCC tumor (P = 0.0005). In MEC, the Group I patients had a higher staining intensity among high-grade patients compared with patients with low grade disease, whereas the tumors in Group II had a lower staining intensity among the high-grade compared with the low grade tumors (P = 0.018). A higher vessel density was found in patients with MEC in group II compared with group I (P = 0.017).

CONCLUSIONS

The staining intensity of CD34 positive vessels in MEC was higher than in AdCC. In MEC, higher staining intensity of vessels in high-grade tumors and lower vessel density in all MEC patients, predicted poor survival.

Carcinomas arising in the submandibular gland: high propensity for systemic failure

BACKGROUND

Cancers of the submandibular gland are uncommon and only a few small series have reported patient survival and prognosis.

METHODS

We examined the treatment outcomes of 62 patients with surgically treated submandibular gland carcinomas. All patients underwent surgical excision with/without neck dissection, and 41 received postoperative radiotherapy for high-grade, invasive, positive margin, or regionally metastatic tumors. The locoregional control and survival rates were calculated by the Kaplan-Meier method and prognostic factors were calculated from uni- and multivariate analyses.

RESULTS

Of the 62 submandibular gland carcinomas, 19 were adenoid cystic, 11 were mucoepidermoid, and 10 were salivary duct carcinomas, and 8 were carcinomas in pleomorphic adenoma. Actuarial 5-year locoregional control, distant metastasis-free survival, disease-free and overall survival rates were 69.7%, 65.8%, 52.8%, and 56.8%, respectively. In multivariate analysis, T category and histological grading were prognostic for disease-free survival (P < 0.01), and T category and resection margins were prognostic for locoregional control (P < 0.02). Distant metastases were found in 21 patients (33.9%) at initial staging (n = 2) or follow-up (n = 19).

CONCLUSIONS

Despite effective locoregional treatment, approximately one-third of patients with submandibular gland carcinomas may fail systemically, resulting in poor survival. New, more effective therapies may be required for these patients.

Late recurrence from salivary gland cancer: when does "cure" mean cure?

BACKGROUND

The purpose of the current study was to determine the incidence of late recurrences, which were defined as those occurring >or=5 years after initial therapy, among patients treated for salivary gland cancer.

METHODS

Between 1960 and 2000, 145 patients underwent definitive therapy for localized carcinomas of the salivary glands and were clinically without evidence of disease at 5 years of follow-up. Cumulative probabilities for developing a subsequent late recurrence were estimated using the Kaplan-Meier method.

RESULTS

The 10-year and 15-year cumulative probabilities of late recurrence in patients who were free of disease at 5 years were 13% and 18%, respectively. The crude rates of late recurrence by histologic subtype were adenoid cystic carcinoma (26%), mixed malignant tumor (25%), mucoepidermoid carcinoma (17%), adenocarcinoma (10%), and acinic cell carcinoma (8%). Sites of late recurrence included distant metastasis (17 patients), local recurrence (8 patients), and regional recurrence (2 patients). The median time to late recurrence was 7.1 years (range, 5.2-23.1 years) from the date of initial surgery. Salvage treatment varied according to location of disease recurrence and initial treatment characteristics. The 15-year estimate of overall survival was 39% for patients who experienced a late recurrence compared with 71% for those who remained free of disease (P= .001).

CONCLUSIONS

A significant proportion of patients who are presumed to be cured of their disease at 5 years after initial treatment for salivary gland cancer will be found to develop late disease recurrence with additional follow-up.

Prognostic Factors Depicting Disease-Specific Survival in Parotid-Gland Tumors

PURPOSE

To identify significant prognostic factors that can be used in clinical decision-making with regard to parotid cancer, which is characterized by a complex and diverse group of tumors with variable outcomes.

METHODS AND MATERIALS

A historical cohort of 184 patients with parotid-gland malignancy, who had been registered in the Province of Manitoba from 1970 to 2003, was examined. Survival analysis was performed using Kaplan-Meier curves and a log-rank test for comparing subgroups. The independent effect of factors that predicted survival at the bivariate level was determined using a Cox proportional hazard model.

RESULTS

The mean age at presentation was 62 years. The mean follow-up was 64 months. Absolute and disease-specific survival at 5 years was 41.70% and 57.94%, respectively. Survival for Stages I-IV at 5 years was 85.35%, 76.9%, 56.1%, and 8.4%, respectively (p < 0.0001). Factors with an independent effect on survival (p < 0.05) included age, tumor size, local invasion (Stages T4 vs. T1), and distant metastasis at presentation, tumor differentiation, and treatment. Adjuvant radiotherapy vs. surgery alone reduced the risk of death from disease at 5 years by 50% (hazard ratio [HR], 0.5; 95% confidence interval, 0.228-0.995; p = 0.0486).

CONCLUSIONS

Despite the variety of malignant parotid tumors, easily identifiable prognostic indicators such as advanced age, tumor size, local invasion, and tumor differentiation have a significant impact on outcome. Patients with adverse prognostic factors benefit from adjuvant radiotherapy. The threshold for the use of adjuvant radiotherapy in managing parotid malignancy should be low.

Transcervical Submandibular Sialoadenectomy

The submandibular glands are subject to several pathologies that require excision. The most common problem that affects these salivary glands is sialadenitis combined with sialolithiasis. This problem occurs in the submandibular gland 10 times more frequently than it does in the parotid gland. Other illnesses frequently involving the submandibular glands are represented by sialadenosis and benign, malign, and intermediate neoplasms. Diagnosis of any disturbance in the submandibular gland involves both a clinical and instrumental (echography, traditional radiography [ortopantomography] and eventually computed tomography (CT) or magnetic resonance imaging) assessment. Surgery is the usual method of treatment of both chronic sialadenitis and neoplasms in the submandibular gland. A submandibular gland surgical approach can be cervical, intraoral, or endoscopic. The authors present their clinical experience with a total of 40 patients with illnesses involving the submandibular gland treated with submandibular gland excision by a transcervical approach. Their experience suggests that this approach entails a relatively simple procedure, involves low risks for the nerve structure around the gland, permits wide resection margins for neoplasms, and incurs little aesthetic damage.

Imaging of salivary gland tumours

Imaging of salivary gland tumours is a major challenge for radiologists due to the great variety of differential diagnoses. This article gives a short overview on the anatomy of the salivary glands, the epidemiology of salivary gland tumours as well as the clinical presentation and the different imaging modalities including new magnetic resonance techniques such as diffusion-weighted magnetic resonance imaging, dynamic contrast-enhanced magnetic resonance imaging and magnetic resonance spectroscopy applied in the work-up of salivary gland masses. The imaging features of different tumour types and their differential diagnoses are also discussed. Finally, staging classification and treatment options are presented.

Patterns of nodal relapse after surgery and postoperative radiation therapy for carcinomas of the major and minor salivary glands: What is the role of elective neck irradiation?

PURPOSE

To evaluate the incidence of nodal relapses from carcinomas of the salivary glands among patients with clinically negative necks in an attempt to determine the potential utility of elective neck irradiation (ENI).

METHODS AND MATERIALS

Between 1960 and 2004, 251 patients with clinically N0 carcinomas of the salivary glands were treated with surgery and postoperative radiation therapy. None of the patients had undergone previous neck dissection. Histology was: adenoid cystic (84 patients), mucoepidermoid (60 patients), adenocarcinoma (58 patients), acinic cell (21 patients), undifferentiated (11 patients), carcinoma ex pleomorphic adenoma (7 patients), squamous cell (7 patients), and salivary duct carcinoma (3 patients); 131 patients (52%) had ENI. Median follow-up was 62 months (range, 3-267 months).

RESULTS

The 5- and 10-year actuarial estimates of nodal relapse were 11% and 13%, respectively. The 10-year actuarial rates of nodal failure were 7%, 5%, 12%, and 16%, for patients with T1, T2, T3, and T4 disease, respectively (p = 0.11). The use of ENI reduced the 10-year nodal failure rate from 26% to 0% (p = 0.0001). The highest crude rates of nodal relapse among those treated without ENI were found in patients with squamous cell carcinoma (67%), undifferentiated carcinoma (50%), adenocarcinoma (34%), and mucoepidermoid carcinoma (29%). There were no nodal failures observed among patients with adenoid cystic or acinic cell histology.

CONCLUSION

ENI effectively prevents nodal relapses and should be used for select patients at high risk for regional failure.

Local-regional recurrence after surgery without postoperative irradiation for carcinomas of the major salivary glands: implications for adjuvant therapy

PURPOSE

To determine factors predictive of local-regional recurrence (LRR) after surgery alone for carcinomas of the major salivary glands in an attempt to evaluate the potential role of postoperative radiation therapy.

METHODS AND MATERIALS

Between 1960 and 2004, 207 patients with carcinomas of the major salivary glands were treated with definitive surgery without postoperative radiation therapy. Histology was: 67 mucoepidermoid (32%), 50 adenoid cystic (24%), 34 acinic cell (16%), 23 malignant mixed (11%), 16 adenocarcinoma (8%), 6 oncocytic (3%), 6 myoepithelial (3%), and 5 other (2%). Distribution of pathologic T-stage was: 54 T1 (26%), 83 T2 (40%), 46 T3 (22%), and 24 T4 (12%). Sixty patients (29%) had microscopically positive margins. Median follow-up was 6.1 years (range, 0.5-18.7 years).

RESULTS

The 5-year and 10-year estimates of local-regional control were 86% and 74%, respectively. A Cox proportional hazard model identified pathologic lymph node metastasis (hazard ratio [HR], 4.8; p = 0.001), high histologic grade (HR, 4.2; p = 0.003), positive margins (HR, 2.6; p = 0.03), and T3-4 disease (HR, 2.0; p = 0.04) as independent predictors of LRR. The presence of any one of these factors was associated with 10-year local-regional control rates of 37% to 63%.

CONCLUSION

Lymph node metastasis, high tumor grade, positive margins, and T3-4 stage predict for significant rates of LRR after surgery for carcinomas of the major salivary glands. Postoperative radiation therapy should be considered for patients with these disease characteristics.

Concurrent chemoradiotherapy with cyclophosphamide, pirarubicin, and cisplatin for patients with locally advanced salivary gland carcinoma

CONCLUSION

This concurrent chemoradiotherapy with CPA, THP, and CDDP showed major antitumor activity with manageable toxicity as treatment of advanced salivary gland carcinoma patients. The high response rate (RR) justifies further evaluation of this chemoradiotherapy combination.

OBJECTIVES

The aim of this study was to evaluate the efficacy and toxicity of a concurrent chemoradiotherapy using cyclophosphamide (CPA), pirarubicin (THP), and cisplatin (CDDP) in patients with locally advanced salivary gland carcinoma.

PATIENTS AND METHODS

Seventeen patients with previously untreated stage III-IV salivary gland carcinoma were entered in this trial between January 2000 and September 2005. Chemotherapy consisted of CPA 400 mg/m2 on day 1, THP 40 mg/m2 by 6-h infusion on day 1, and CDDP 60 mg/m2 by 2-h infusion on day 1. Radiotherapy (2.0 Gy/fraction/day, mean total dose: 67.2 Gy (64.0-72.0 Gy)) administered 5 days per week, was targeted to begin on day 1.

RESULTS

The RR was 76% (13/17) and the pathological complete response (CR) was 24% (4/17). The primary site CR was 29% (5/17) and metastatic lymph node CR was 33% (4/12). The 5-year survival rate was 70%. Neutropenia, leukocytopenia and mucositis were common adverse effects, but all 17 patients were assessable for toxicity.

Facial nerve function in carcinoma of the parotid gland

AIM

To analyse, for patients with carcinoma of the parotid gland, the prognostic value for treatment outcome of the function of the facial nerve (NVII), and determining facial nerve dysfunction after treatment.

METHODS AND MATERIALS

In a retrospective study of the Dutch head and Neck cooperative group (NWHHT), data of 324 patients with parotid carcinoma were analysed. The function of N VII before treatment was intact in 77%, partially and completely impaired in 14% and 7%, respectively. Eighty-eight percent of the patients were treated surgically, and 77% of them were treated by a combination of postoperative radiotherapy. In 21% NVII was sacrificed, a reconstruction was performed in one of three.

RESULTS

Independent risk factors for N VII dysfunction before treatment were tumour localisation, positive neck nodes at presentation, pain, increasing age, and perineural invasion. Regional, not local, control was significantly impaired for complete facial paralysis. N VII dysfunction was an independent factor for disease free survival, and was 69%, 37% and 13% for normal, partially and completely impaired function, respectively. After treatment 22% of the patients experienced a partial paralysis, and 13% of the patients experienced a complete paralysis of N VII.

CONCLUSION

For patients with parotid carcinoma, facial nerve function before treatment is a strong prognostic factor for disease free survival.

Management and Outcome of Patients With Malignant Salivary Gland Tumors

PURPOSE

Refined imaging technology, the use of external beam radiation, neutron beam therapy, and chemotherapy, has altered management strategies for patients with salivary gland malignancies during the past 2 decades. Although treatment remains primarily surgical, optimal therapeutic regimens have yet to be fully realized. The purpose of this investigation is to report our experience with the management of patients with a variety of malignant salivary gland neoplasms that were treated with various combinations of surgery, radiation, and chemotherapy and to review treatment outcome in an effort to identify predictors of survival and locoregional control.

MATERIALS AND METHODS

The records of all patients with malignant salivary gland tumors presenting for treatment at our institution between 1992 and 2002 were retrospectively reviewed. Variables were collected and outcome measures were defined in terms of overall survival, disease-free survival, and locoregional control. Descriptive statistics were compiled and statistically evaluated. Survival was described using the Kaplan-Meier method. Prognostic factors were assessed using the Cox proportional hazards model. Clinical and reconstructive factors were reviewed.

RESULTS

Eighty-five patients (35 males and 50 females) ranging in age from 16 to 89 years (mean, 58.6 years) met the criteria for inclusion in the study. The majority of tumors were located in the parotid gland (n = 42), with a significant minority located in the minor salivary glands (n = 29), followed by the submandibular gland (n = 8) and the sublingual gland (n = 6). Mucoepidermoid carcinoma was the most common neoplasm (n = 40). More than half of the patients presented in early-stage disease (stage I = 36, stage II = 17, stage III = 8, stage IV = 25). All patients were treated with surgery as the primary modality. Neck dissection was performed in 29% of patients, and more than half (56%) were treated with adjuvant external beam radiation therapy to a dose of 50 to 70 Gy. Patients were, in general, immediately reconstructed at the time of ablation using composite free tissue transfer when appropriate, local/regional rotational flaps, or maxillary obturators. The disease-free survival rate and locoregional control rate at 5 years were 77% and 86%, respectively. Stage (P = .0017), grade (P = .00044), cervical lymph node metastasis (P = .03), and age (P = .01) proved to make a statistically significant contribution when describing outcome. Neither site (P = .5), the presence of positive margins (P = .3), nor perineural invasion (P = .7) had a significant impact on survival.

CONCLUSIONS

The treatment of salivary gland malignancies remains primarily surgical, although adjunctive radiotherapy may play an important role in those patients with advanced-stage disease. This study confirms the contributions of stage, grade, age, and cervical metastasis for describing survival. The benefits of combined modality therapy awaits prospective clinical trials.

[Cancer of the parotid gland]

OBJECTIVE

To review our experience and results in the diagnosis and treatment of a low incidence pathology such as the cancer of the parotid gland.

METHODS

The study reviewed 40 patients with malignant tumors of the parotid gland treated between 1991 and 2002 in our hospital. It was used the staging system TNM (American Joint Committee on Cancer 1997).

RESULTS

The most common histological type in our series is the squamous cell carcinoma, in general unilateral and in the superficial lobe. Rapid tumor enlargement, fixation to the skin, cervical lymphadenopathy, pain and facial palsy are malignancy clinical findings. We obtained a 56% 5-year global survival rate, with a 68% for stages I and II, and 43% for stages III and IV.

CONCLUSIONS

This pathology has a low incidence but high mortality. The staging and histological type are important prognostic factors. The surgery is the election treatment, associated with neck disection or radiotherapy.

Salivary gland carcinoma: independent prognostic factors for locoregional control, distant metastases, and overall survival: results of the Dutch head and neck oncology cooperative group

BACKGROUND

We analyzed the records of patients with malignant salivary gland tumors, as diagnosed in centers of the Dutch Head and Neck Oncology Cooperative Group, in search of independent prognostic factors for locoregional control, distant metastases, and overall survival.

METHODS

In 565 patients, we analyzed general results and looked for the potential prognostic variables of age, sex, delay, clinical and pathologic T and N stage, site (332 parotid, 76 submandibular, 129 oral cavity, 28 pharynx/larynx), pain, facial weakness, clinical and pathologic skin involvement, histologic type (WHO 1972 classification), treatment, resection margins, spill, perineural and vascular invasion, number of neck nodes, and extranodal disease. The median follow-up period was 74 months; it was 99 months for patients who were alive on the last follow-up.

RESULTS

The rates of local control, regional control, distant metastasis-free and overall survival after 10 years were, respectively, 78%, 87%, 67%, and 50%. In multivariable analysis, local control was predicted by clinical T-stage, bone invasion, site, resection margin, and treatment. Regional control depended on N stage, facial nerve paralysis, and treatment. The relative risk with surgery alone, compared to surgery plus postoperative radiotherapy, was 9.7 for local recurrence and 2.3 for regional recurrence. Distant metastases were independently correlated with T and N stage, sex, perineural invasion, histologic type, and clinical skin involvement. Overall survival depended on age, sex, T and pN stage, site, skin and bone invasion.

CONCLUSIONS

Several prognostic factors for locoregional control, distant metastases, and overall survival were found. Postoperative radiotherapy was found to improve locoregional control.

Management of the neck in salivary gland carcinoma

Major salivary gland malignancies are rare. Treatment of the primary tumor involves resection with or without postoperative radiation therapy. When there is clinical neck disease, neck dissection is performed to remove gross disease. Treatment of the N0 neck is controversial. Most centers treat the high-risk patient and perform either elective neck dissection or elective neck irradiation to eradicate residual occult disease.

Gene expression screening of salivary gland neoplasms: molecular markers of potential histogenetic and clinical significance

Salivary gland neoplasms comprise phenotypically and biologically diverse lesions of uncertain histogenesis. The molecular events associated with their development and clinicopathological heterogeneity remain unknown. To reveal these events, we performed microarray expression analysis using a nylon-filter membrane platform on 18 primary lesions representing the most common benign and malignant types. Our study identified a small set of genes that are differentially altered between normal salivary gland tissues and benign and malignant tumors. Of the 5000 genes arrayed, 136 genes were differentially expressed by normal tissue, benign tumors, and various malignant neoplasms. Hierarchical clustering analysis differentiated between adenoid cystic carcinomas (ACCs) and other malignant subtypes. Non-ACC specimens manifested overlapping patterns of gene expression within and between tumors. Most of the differentially expressed genes share functional similarities with members of the adhesion, proliferation, and signal transduction pathways. Our study identified: 1) a set of genes that differentiate normal tissue from tumor specimens, 2) genes that differentiate pleomorphic adenoma and ACCs from other malignant salivary gland neoplasms, and 3) different patterns of expression between ACCs arising from major and minor salivary gland sites. The differentially expressed genes provide new information on potential genetic events of biological significance in future studies of salivary gland tumorigenesis.

Estimation of an optimal external beam radiotherapy utilization rate for head and neck carcinoma

BACKGROUND

Radiotherapy is used commonly in the treatment of patients with head and neck carcinoma. The benchmark radiotherapy utilization rates for head and neck carcinoma largely are unknown. The objective of the current study was to determine the optimal radiotherapy utilization rate for patients with head and neck carcinoma and to compare this optimal rate with actual utilization rates where actual utilization data were available.

METHODS

An optimal radiotherapy utilization tree was constructed that depicted all patients with head and neck carcinoma in whom radiotherapy was indicated according to evidence-based treatment guidelines. The proportions of patients with clinical attributes that indicated possible benefit from radiotherapy were obtained from epidemiological data and were inserted into the utilization tree. The optimal proportion of patients with carcinoma of the head and neck who should receive radiotherapy was calculated by merging the evidence-based recommendations with the epidemiological data in the tree. Optimal rates of radiotherapy utilization were compared with actual rates obtained from population-based studies.

RESULTS

Radiotherapy was indicated at some point during their illness in 74% of all patients with head and neck carcinoma. By subsite, the optimal radiotherapy utilization rates were oral cavity, 74%; lip, 20%; larynx, 100%; oropharynx, 100%; salivary gland, 87%; hypopharynx, 100%; nasopharynx, 100%; paranasal sinuses, 100%; and unknown squamous cell carcinoma of the head and neck, 90%. All treatment recommendations were based on Level III or IV evidence. Assessment of actual radiotherapy utilization rates indicated an increased use of radiotherapy over time for head and neck carcinoma. However, there also were some decreases in the use of radiotherapy for some carcinoma subsites over the past 20 years, despite the lower actual rates compared with the optimal rates. The reasons for these reductions in use were not identified.

CONCLUSIONS

The actual radiotherapy utilization rate for patients with head and neck carcinoma corresponded reasonably closely to the optimal rate for some populations but also identified some shortfalls for other patient groups. The results of this study provide a way of assessing shortfalls in radiotherapy.

Cancers primitifs de la parotide : approche anatomo-clinique

BACKGROUND

Carcinoma of the parotid gland presents a wide variety of clinical presentations, behaviors and prognoses. The aim of this study was to define the characteristic clinical presentations and the prognostic factors of these tumors.

MATERIAL AND METHOD

Sixty-six patients with carcinoma of the parotid gland seeing during the 1985-2003 period were included in this study. Mean patient age was 55 years; the sex-ratio was 1.

RESULTS

The most common histological types of this series were mucoepidermoid carcinoma and adenoid cystic carcinoma. Stage I tumors were reported in 59% the series while only 18% the patients of this series had stage III and IV disease. Pain was reported in 45% all patients. Facial nerve clinical involvement was reported in 11% all patients.

DISCUSSION

Both tumoral stage and histological grading are independent prognostic factors influencing the therapeutic strategy. Clinical course and tumor growth distinguished between malignant tumors with benign clinical behavior and malignant tumors with malignant clinical behavior. A preoperative workup with physical examination, fine needle cytology and MRI helps to define the preoperative diagnostic and to adapt the therapeutic strategy.

Management of primary malignant epithelial parotid tumors

Parotid cancers are infrequently encountered. These tumors carry a prolonged risk of recurrence and metastasis. Controversies surrounding pre-treatment evaluation by imaging and fine needle aspiration, utility of operative frozen section are partly resolved. Though surgery remains the mainstay of treatment, radiation is being recognized as a useful adjuvant. Facial nerve preservation is one of the important goals at surgery. The role of chemotherapy is still investigational. The prognosis and necessity of elective neck treatment are mainly guided by the tumor grade and stage.

[Salivary gland tumors--tumor typing and grading]

In addition to staging, histological typing and grading provide important information for prognosis and adequate treatment of salivary gland cancers. Current classification and grading systems for mucoepidermoid carcinoma, adenoid cystic carcinoma, and malignant mixed tumor (carcinoma ex pleomorphic adenoma) are discussed.

Management of malignant sublingual salivary gland tumors

The majority of tumors of the sublingual gland are malignant, with adenoid cystic carcinoma and mucoepidermoid carcinoma being the most frequent. Many other malignant tumor types have also been reported. The sublingual gland anatomically is not a unit organ and while it is described anatomically as being confined to the anterior floor of the mouth, salivary tissue may be located laterally along the submandibular duct and posterior floor of the mouth. Diagnosis should be suspected when any thickening or raised lesion presents in this area and a biopsy performed to confirm malignancy before planning further treatment. Surgery is the treatment of choice, and should include an en-block resection of the anterior floor of mouth as a minimum, and may include a portion of mandible, as well as a supraomohyoid neck dissection. Adjuvant radiotherapy should be considered in most of the patients after surgical excision.

Mucoepidermoid carcinoma expleomorphic adenoma of the submandibular gland

We described a rare case of carcinoma expleomorphic adenoma in which mucoepidermoid carcinoma arise from a previous incompletely excised pleomorphic adenoma of the submandibular gland. The tumor was surgically resected along with a modified radical neck dissection and postoperative radiotherapy. The patient remained disease free 3 years after the last operation. The pathology showed concurrent presence of Warthin's tumor in the specimen. The concurrent presence of mucoepidermoid carcinoma, pleomorphic adenoma, and synchronous Warthin's tumor make this case unique, and such a combination associated with the submandibular gland has not been documented in the literature before.

Carcinoma of the parotid gland

BACKGROUND

The low incidence and heterogeneity of histiotypes of primary parotid carcinomas makes these tumors histologically and epidemiologically difficult to evaluate. The present study reviews a single institution's experience in the treatment of primary parotid carcinomas during the last 10 years.

METHODS

The charts of 98 consecutive patients who had a primary parotid carcinoma and who received primary curative treatment were analyzed retrospectively. The tumors were grouped into high-grade and low-grade malignancies. The effect of treatment modalities on locoregional control, the incidence of locoregional recurrences and distant metastases, and survival rates are evaluated and compared between high- and low-grade malignancies.

RESULTS

High- and low-grade malignant tumors were observed in 50 and 48 cases, respectively. Lymph node metastases were detected in 25 of 98 (25%) patients, of whom 8 of 22 (22%) clinically NO staged patients underwent elective neck dissection. In 24 of 26 resected facial nerves, a histologic tumor infiltration was confirmed, in 14 high-grade and 10 low-grade tumors. Local recurrence developed in 13 patients and was associated in 7 with high-grade and in 6 with low-grade tumors. All but 1 of the low-grade malignancies with local recurrence did not receive postoperative irradiation. Regional recurrence developed in 11 patients and distant metastases developed in 10, 3 in combination with a neck recurrence and 1 with a local recurrence. The survival rate at 5 years for low- and high-grade carcinomas was 87% and 56% and the disease-free survival rate 72% and 48%, respectively.

CONCLUSIONS

The incidence of occult metastases in clinically N0-elective neck dissection was 22%. A routine elective neck dissection in all N0 parotid carcinomas is suggested. There is no statistically significant difference between low- and high-grade tumors as for the rate of local recurrence and, as all except one of the low-grade malignancies with local recurrence did not receive postoperative irradiation, postoperative irradiation is not only suggested for high-grade carcinomas but also for T2 to T4 low-grade carcinomas.

Prognostic indicators for malignant tumours of the parotid gland

The best treatment of malignant parotid tumours still remains to be defined, and a better knowledge about the tumour features that predict the treatment result is needed. The histological classification of parotid tumours may present difficulties on account of their great morphological diversity. In a series of 152 patients with a malignant tumour of the parotid gland, the prognostic factors and treatment results were investigated over a 25-year period. Treatment consisted of surgery, radiation therapy or a combination (49%, 13% and 38% respectively). Crude 5-year survival was 50% with significant differences related to stage (stage I, 65%; stage II, 50%; stage III, 21%; and stage IV, 9%). With respect to histopathology, the adenoid cystic carcinomas and the acinic cell carcinomas had the best prognosis (76% and 67% 5-year crude survival and 53% and 67% 10-year crude survival respectively). There was a significant difference in crude survival between well/intermediate and poorly differentiated tumours (P = 0.007). In a Cox hazard regression analysis including 136 patients and using death from cancer as the end-point, the following parameters were independent prognostic predictors: T-classification (P = 0.002), M-classification (P < 0.0001), N-classification (N+versus N0) (P = 0.005), local invasion (P = 0.003) and histological differentiation of the tumour (P = 0.03). The TNM system is a good predictor of treatment outcome for malignant parotid tumours. The use of a combination of clinical and histological factors will assist the design of treatment strategies for parotid gland tumours.

Postoperative radiotherapy for malignant tumors of the submandibular gland

PURPOSE

This retrospective study assessed the outcome and patterns of failure for patients with malignant submandibular tumors treated with surgery and postoperative radiation.

METHODS AND MATERIALS

Between 1965 and 1995, 83 patients aged 11-83 years old received postoperative radiotherapy after resection of submandibular gland carcinomas. The most common radiation technique was an appositional field to the submandibular gland bed using electrons either alone or mixed with photons. Primary tumor bed doses ranged from 50 to 69 Gy (median, 60 Gy). Regional lymph nodes (ipsilateral Levels I-IV) were irradiated in 66 patients to a median dose of 50 Gy. Follow-up time ranged from 5 to 321 months (median, 82 months).

RESULTS

Actuarial locoregional control rates were 90%, 88%, and 88% at 2, 5, and 10 years, respectively. The corresponding disease-free survival rates were 76%, 60%, and 53%, because 27 of 74 patients (36%) who attained locoregional control developed distant metastases. Adenocarcinoma, high-grade histology, and treatment during the earlier years of the study were associated with worse locoregional control and disease-free survival. The median survival times for patients with and without locoregional control were 183 months and 19 months, respectively. Actuarial 2-, 5-, and 10-year survival rates were 84%, 71%, and 55%, respectively. Late complications occurred in 8 patients (osteoradionecrosis, 5 patients).

CONCLUSIONS

High-risk cancers of the submandibular gland have a historic control rate of approximately 50% when treated with surgery alone. In the current series, locoregional control rates for high-risk patients with submandibular gland cancers treated with surgery and postoperative radiotherapy were excellent, with an actuarial locoregional control rate of 88% at 10 years.

Parotid gland carcinoma: surgical strategy based on local risk factors

To evaluate the best surgical strategy in cases of parotid gland carcinoma, local risk factors (T, N, histology, and treatment) were analyzed in a series of 134 patients. The efficacy of the facial nerve sacrifice in case of macroscopic tumor infiltration was tested by means of survival analyses (Kaplan-Meier and Cox algorithms). This study demonstrated that nerve preservation resulted in a better prognostic value when compared with resection only in the group of patients having a T1 or T2. In patients affected by T3 and T4, the different treatment did not show any difference in survival rate. In conclusion, the sacrifice of the facial nerve is not always able to improve the survival rate.

Effects of anatomical constraints on tumor growth

Competition for available nutrients and the presence of anatomical barriers are major determinants of tumor growth in vivo. We extend a model recently proposed to simulate the growth of neoplasms in real tissues to include geometrical constraints mimicking pressure effects on the tumor surface induced by the presence of rigid or semirigid structures. Different tissues have different diffusivities for nutrients and cells. Despite the simplicity of the approach, based on a few inherently local mechanisms, the numerical results agree qualitatively with clinical data (computed tomography scans of neoplasms) for the larynx and the oral cavity.

Prognostic factors in major salivary gland cancer

OBJECTIVE

To identify features of major salivary gland cancers that are prognostic for disease-free survival.

STUDY DESIGN

A retrospective study of 78 patients with major salivary gland cancer (64 parotid and 14 submandibular gland) who underwent surgery for definitive treatment from 1976 to 1996. A select group of patients also received adjuvant radiation (56%) and/or chemotherapy (13%).

METHOD

Clinical and pathological risk factors were obtained from patients' charts and pathology reports. Age, gender, tumor site, T-stage, facial paralysis, histologic neck involvement, perineural invasion, and cancer grade were analyzed with respect to disease-free survival. The role of adjuvant treatment in terms of clinical outcome was also investigated.

RESULTS

In our series, the 5-year disease-free survival was 65%. Examining clinical and histologic features one at a time, we found poorer prognosis was associated with submandibular tumors compared with parotid (P =.02), higher T-stage (P =.001), positive cervical nodes (P <.001), perineural invasion (P =.002), and high-grade or adenoid cystic tumors (P =.002). A multivariable analysis indicated that positive lymph nodes (P =.07) and perineural invasion (P =.03) were important histologic predictors of shorter disease-free survival. Receipt of both adjuvant radiation and cisplatin-based chemotherapy (P =.05) was an independent predictor of longer disease-free survival.

CONCLUSION

Our study indicated that the presence of positive lymph nodes and perineural invasion is important independent predictors of disease-free survival. Our limited data also suggest that adjuvant chemotherapy and radiation therapy may improve disease-free survival.

High-grade adenoid cystic carcinoma originating from the lacrimal gland

Among primary lacrimal gland tumors, adenoid cystic carcinoma (ACC) is the most common malignant epithelial neoplasm; it is characterized by local intracranial invasion. A case with unusual dumbbell-type intracranial extension representing cavernous sinus syndrome is described. A 49-year-old woman was admitted to our hospital with right cavernous sinus syndrome. Computerized tomographic (CT) scans and magnetic resonance (MR) imaging demonstrated well-enhanced intraorbital and middle fossa tumors mimicking multifocal mass lesions. Operative findings revealed an ACC originating from the lacrimal gland and extending into the right cavernous sinus and middle fossa along the nerve sheath in the superior orbital fissure. Although MR image findings of intracranial ACC often resemble the image findings for meningiomas, intracranial ACC is very aggressive in comparison with meningioma. It is best treated surgically and aggressively.

Treatment of carcinoma of the parotid gland: the results of a multicenter study

PURPOSE

This study analyzed the prognostic factors for carcinoma of the parotid gland and the role of surgery alone or with radiotherapy in treating these lesions.

METHODS

Forty-five patients with malignant parotid tumors were studied retrospectively. Patients were treated by combined surgery and radiation therapy between 1984 and 1995 at the Maxillo-Facial Departments of the General Hospitals of Bologna and Parma. Resection was conservative when possible, depending on the extent of the tumor. The median follow-up time was 54 months. Data regarding incidence, tumor stage and grade, local control, distant metastases (calculated with the Kaplan-Meier method), and survival were analyzed. Cox's multiple linear regression was used to identify patient and tumor characteristics with the greatest prognostic significance.

RESULTS

The actuarial 5- and 8-year disease-free survival rates were 81% and 62%, respectively. Multivariate analysis showed that tumor stage was a more prognostic variable than tumor grade. Residual microscopic disease at the excision margins was also an important prognostic variable. Laterocervical metastases affected 4 patients (9%), and distant metastases appeared in 8 patients (18%).

CONCLUSIONS

Postoperative irradiation is indicated for patients with stage III and IV disease, patients with positive excision margins, and for patients with lymph node metastases.

Evaluation of the validity of the 1997 International Union Against Cancer TNM classification of major salivary gland carcinoma

BACKGROUND

The TNM classification (International Union Against Cancer) of salivary gland carcinoma was revised in 1997. In this study, the authors have evaluated the validity of this new TNM classification and clinical staging in 1683 patients with parotid gland carcinoma.

METHODS

Reclassification was conducted according to the new classification based on the clinical data of 1683 patients registered to the salivary gland division of the Japanese Joint Committee on TNM classification. The 5- and 10-year survival rates according to TNM classification were calculated for 1074 patients whose prognosis could be followed up. Finally, the distribution of the total patient population was analyzed using the new staging and the survival curves for each disease stage.

RESULTS

The variance of the patients for T1 to T4 was appropriate using the new T classification. The 5- and 10-year survival rates corresponded well to the degree of progression of TNM. However, there were only nine patients with Stage III, and marked nonuniformity in the staging was observed. The separation of the survival curves for each stage was not clear, and no significant differences between the survival curves of Stages II and III and Stages III and IV were observed. When the authors classified T1N1M0, T2N1M0, T3N1N0, and T4N0M0, which have 5- and 10-year survival rates similar to Stage III, distribution of patients and separation of the survival curves in each stage improved markedly.

CONCLUSIONS

The results of the current study confirm that the new TNM classification system is valid. However, a significant problem was observed with respect to the new clinical staging. The authors propose that T1N1M0, T2N1M0, T3N1M0, and T4N0M0 be classified as Stage III.

Treatment of malignant neoplasms of the parotid gland

In this study we evaluated the effects of surgical and radiotherapy treatment on local control in 126 patients with malignant tumors of the parotid gland. The most frequently observed malignant tumors were high-grade tumors (68%). Surgical treatment was performed in 81 patients (83.5%). Total conservative parotidectomy was the most frequent procedure (74%), and radiotherapy was performed in 81 patients (83.5%). The global survival rate was approximately 54% at 5 years, whereas disease-free survival was 47% at 5 years. No statistically significant difference in survival rate was found between conservative (52% at 5 years) and radical treatment of the seventh cranial nerve (43% at 5 years). The incidence of recurrent cancer was 25.7% (25 of 97), of which 88% developed during the first 2 years. We report some of the clinical and histologic factors that can influence the prognosis of the disease.

Carcinoma of the major salivary glands. analysis of the role of radiation therapy

Forty-six patients of major salivary gland tumors were retrospectively studied. There were 40 (87%) parotid and 6 (13%) sub-mandibular tumors. Patients receiving adjuvant radiation therapy after a radical surgery fared much better (86%) complete response (CR) as compared to those treated for recurrent or inoperable disease (50% CR). The 5-year overall and disease free survival rates for the entire group is 70% and 34% respectively. These findings and a review of literature suggests that adjuvant post operative radition therapy is recommended to reduce the risk of post surgical recurrence.

National Cancer Data Base report on cancer of the head and neck: acinic cell carcinoma

BACKGROUND

Management of acinic cell carcinoma is based on reports of small numbers of cases accrued over several decades.

METHODS

The National Cancer Data Base (NCDB) identified 1353 cases of acinic cell carcinoma of the head and neck for the years 1985 to 1995. Chi square analyses of selected contingency tables and Wilcoxon regression analyses of selected survival stratifications are presented.

RESULTS

Five-year survival was 83.3% (observed) and 91.4% (disease specific). Worse survival was associated with high grade (p < .0001), age greater or equal to 30 years (p = .0055), and the presence of metastatic disease (p < .0001).

CONCLUSIONS

An aggressive subset of acinic cell carcinoma which is characterized by high grade and advanced stage rarely occurs in patients younger than 30 years old. Although better outcome was not statistically demonstrated for combined therapy, surgery with irradiation is the most common management in the United States for cases with regional metastases, high grade, and microscopic positive margins.

Clinico-pathological and treatment-related factors influencing survival in parotid cancer

One hundred and three patients with primary parotid cancer treated surgically at the Christie Hospital, Manchester (1952-1992), were analysed to assess the influence on survival of prognostic and treatment-related factors. Thirty-seven patients were treated by surgery alone (SG), 66 received post-operative radiation (SG+RT). Median follow-up was 12 years, minimum 5 years. The 10-year disease-specific survival rates for stage I, II and III/IV were 96%, 61% and 17% respectively (P < 0.0001). The various histological types segregated into three survival patterns: low-, intermediate-and high-grade with 10-year survival rates of 93%, 41% and 50% respectively (P < 0.0001). On multivariate analysis, the factors influencing risk of cancer death in order of importance were: tumour size > 4 cm (P < 0.001), presence of nodes (P = 0.001), histology of adenoid cystic carcinoma (P = 0.01), high-tumour grade (P = 0.02) and perineural involvement (P = 0.01). Neither the extent of surgery nor the operator influenced outcome. Overall, adjuvant RT significantly reduced locoregional recurrence (SG+RT 15% vs SG 43%; P = 0.002) but not survival, although on subanalysis, there was a trend to improved survival with large cancers and high-grade tumours. Long-term survival is determined primarily by tumour characteristics, namely clinical stage and grade. Post-operative RT contributes significantly to locoregional control and probably confers some survival advantage in high-risk patients.

Neutron radiotherapy for the treatment of locally advanced major salivary gland tumors

BACKGROUND

Malignant salivary gland tumors are rare tumors of the head and neck region. The treatment of these tumors has generally consisted of surgical extirpation, with postoperative radiotherapy improving locoregional control and survival in patients with high risk tumors. Neutron radiotherapy has been found to be more efficacious than conventional radiotherapy in the setting of inoperable or subtotally resected salivary gland tumors.

METHODS

One hundred forty-eight patients with malignant salivary tumors of major salivary gland origin were treated at the University of Washington Medical Center with fast neutron radiotherapy between the years 1984 and 1995. One hundred twenty-eight patients were treated with curative intent, and of these, 120 patients had evidence of gross residual disease at the time of treatment. These patients constitute the main analysis of this paper. Of these patients, 19% had recurrent disease, 39% were initially seen with positive lymph nodes, and 11% had previously received full dose conventional radiotherapy. At the time of analysis, the median period at risk of survivors was 26 months.

RESULTS

The 5-year actuarial locoregional control rate for all patients with gross tumor treated with curative intent was 59%. A tumor size < or =4 cm was associated with an excellent locoregional control rate (80%), and cause-specific survival (73%) at 5 years compared with patients with larger tumors (35% and 22%, respectively, p<.001 in both cases). On univariate analysis, there appeared to be an advantage in locoregional control for patients with smaller sized tumors (< or =4 cm) who underwent an attempted surgical extirpation. Locoregional control was excellent (100%) in patients having a complete surgical resection of their tumors and undergoing postoperative neutron radiotherapy because of the presence of other high risk factors. Lymph node status at the time of treatment, base of skull involvement, and male sex were associated with the development of distant metastasis, with 52% of node positive patients developing distant metastases by 5 years, compared with 32% of node negative patients (p = .04).

CONCLUSIONS

Neutron radiotherapy is an effective form of treatment for patients with high risk, locally advanced tumors of major salivary gland origin. An initial surgical resection appears beneficial in patients for whom such an approach is feasible.

Salivary gland carcinomas--prognostic factors

A retrospective study of factors of prognostic significance for clinical course and survival was performed using uni- and multivariate analyses in 251 patients with primary salivary gland carcinoma admitted during the period 1958-1992. Univariate analyses indicated that site of primary tumour, histology, clinical stage, presence of node metastases at primary diagnosis, and status of surgical margins were important prognostic factors for cause-specific survival, locoregional control and distant metastases. Multivariate analyses confirmed that histology was important for both locoregional control and cause-specific survival, whereas primary site was only of importance for locoregional control. Presence of node metastases at diagnosis was more important for locoregional control than clinical stage, whereas clinical stage was the most important factor for cause-specific survival. Status of surgical margins was of major importance for both cause-specific survival and locoregional control. Radiotherapy in addition to surgery improved locoregional control only, whereas survival was not affected.

A clinic for the rapid processing of patients with neck masses

Neck masses are common and may have serious underlying pathology. There is much anxiety and confusion in primary care as to which hospital department will provide the patient with the best service and the swiftest diagnosis. A clinic was set up at Wexham Park hospital to enable patients with neck masses to be seen early, and to undergo a one-stop specialist evaluation, ultrasound scan and fine needle aspiration biopsy. The clinic has yielded a wide variety of benign and malignant pathology. The first 100 patients are discussed and evaluated.

Parotid gland carcinoma: analysis of prognostic factors

The histologic variety of parotid gland carcinomas, their different natural history, and the peculiar anatomy of the parotid region can make prognosis and therapeutic strategy quite controversial. The present study was designed to evaluate those prognostic factors able to affect the long-term results in a group of 167 consecutively treated parotid epithelial malignancies. The continuous or discrete covariants considered as potential prognostic factors are age, sex, histotype, grading, TNM and pTNM classification, facial nerve involvement, type of surgery on the tumor site and on nodes, facial nerve resection, and postoperative radiotherapy. All the material has been statistically analyzed and the results have been compared with the principal data published. According to the analysis, the most relevant prognostic factors in parotid gland carcinomas appear to be pTN staging, tumor grading, facial nerve involvement, and local extension. These factors could reliably predict the patient's chance for survival, and thus influence the therapeutic strategy.