Carcinoma of major salivary glands. Recent trends

Neck dissection in the treatment of cancer of major salivary glands

The treatment of the neck nodes in salivary gland tumors has changed considerably in the last two decades. The current thinking and the rationale for it are discussed in detail in this article.

Malignant epithelial parotid gland tumours: analysis and results in 65 previously untreated patients

BACKGROUND

Optimal management of malignant epithelial parotid tumours requires knowledge of the available therapeutic modalities and the different biological characteristics. The aim of the study was to review the characteristics of patients at presentation, histological classification, disease-free and overall survival rates, and the results of the applied treatment policy regarding the facial nerve and neck.

METHODS

Between 1974 and 1995 a total of 65 patients was treated with curative intent for a previously untreated malignant epithelial parotid gland tumour. All patients underwent some type of parotidectomy, 20 of whom had an en bloc radical neck dissection. In selected cases the facial nerve or its branches were peeled off the tumour thus violating the objective of tumour-free margins and relying heavily on the efficacy of postoperative radiotherapy. In total 51 patients received postoperative radiotherapy. None of the patients was lost to follow-up.

RESULTS

There were 12 locoregional failures (18 per cent). In only one of these 12 patients was salvage therapy successful; the remaining 11 patients died from the tumour. All but one of the eight patients with distant metastasis only died from the tumour. The estimated 5- and 10-year disease-free rates were 68 and 59 per cent respectively. The corresponding survival rates were 75 per cent and 67 per cent. A significant relationship could be observed between tumour stage and survival. The presence of lymph node metastases proved to be the strongest single prognostic factor.

CONCLUSION

In selected cases a conservative approach towards the facial nerve is justified.

Retrospective analysis of 35 patients with acinic cell carcinoma of the parotid gland

PURPOSE

This retrospective study evaluated data pertaining to the history, symptoms, treatment, and prognosis of a series of patients treated for acinic cell carcinoma (ACC).

PATIENTS AND METHODS

Data were based on the records of 35 patients. Follow-up was done by analyzing their records and contacting the referring doctors.

RESULTS

In 71% of the ACC patients, painful swelling of the lateral region of the face was the main symptom. Facial paralysis occurred in 11% of cases before treatment. Tumor recurrence after therapy was noted in 42% of cases. Highly differentiated ACC was the most frequent histologic subtype (74%). The grade of differentiation of the tumor was decisive for the prognosis. Highly differentiated ACC had a better prognosis (2 years overall survival, 100%; 5 years overall survival, 83%; 10 years overall survival, 50%) than lowly differentiated tumors (2 years overall survival, 70%; 5 years overall survival, 50%; 10 years overall survival, 30%).

CONCLUSION

ACC is a rare tumor located mainly in the parotid gland that is characterized by some special attributes. Surgery is the therapy of choice. Prognosis depends mainly on the histologic subtype.

Adenoid cystic carcinoma of the sublingual salivary gland in a 16-year-old female--report of a case and review of the literature

Tumours of the sublingual salivary gland are exceptionally rare. The present case report describes an adenoid cystic carcinoma of the sublingual salivary gland occurring in a 16-year-old girl, in itself an uncommon event. In addition, an interesting feature of the presentation was obstruction of the ipsilateral submandibular gland due to involvement of Wharton's duct.

Diagnosis and treatment of parotid tumours

Diagnosis and treatment of 51 cases of parotid tumour seen and treated in King Fahad National Guard Hospital, Riyadh, are discussed here. More emphasis is placed on proper clinical history and physical examination of patients with parotid lump because usually this will provide enough information to the clinician about the nature of the swelling. Imaging studies are helpful in supporting the clinical diagnosis and determining the extent of the lesion particularly in cases of malignant tumours. Fine needle aspiration biopsy needs an expert cytologist for salivary gland neoplasm and the need for proper communication between the surgeon and cytologist is stressed. All 51 cases underwent surgical excision which is the treatment of choice. Follow-up periods were variable and short.

Parathyroid surgery using monitored anesthesia care as an alternative to general anesthesia

BACKGROUND

Although there have been several reports in the literature describing a renewed interest in performing thyroid surgery under local anesthesia (LA), there has been little information regarding parathyroid surgery under local anesthesia.

METHODS

We retrospectively reviewed our experience of 49 LA parathyroid patients over a 9-year period at a single institution. A bilateral cervical block (C2-C3) was administered by a single surgeon using lidocaine and bupivacaine.

RESULTS

The study included 39 females and 10 males with an average age of 62 years (range, 35-89 years). Every surgery was curative and the final pathology revealed 46 parathyroid adenomas and 3 cases of parathyroid hyperplasia. Forty-seven percent of the patients were discharged within 6 hours of operation and the remaining patients had a 1.4-day average length of hospital stay. A group of age- and sex-matched controls who underwent parathyroid surgery using general anesthesia (GA) served as a control group with 27% of operations performed as outpatients and an average length of stay of 1.6 days. Return to work averaged 6 days for the LA group versus 8 days for the GA. In the LA group, there was one instance of postoperative hemorrhage requiring reoperation and one instance of conversion to GA secondary to an inability to tolerate LA. There were no instances of recurrent laryngeal nerve injury or permanent hypoparathyroidism in either group.

CONCLUSIONS

These data suggest that experienced surgeons can perform parathyroid surgery safely and effectively using LA as an alternative to GA.

Management of the neck in parotid carcinoma

BACKGROUND

Management of the clinically negative neck remains a controversial issue in patients with carcinoma of the parotid gland. Our treatment policy has always been conservative, reserving lymphadenectomy for selected patients.

METHODS

We retrospectively evaluated 121 patients with malignant tumors of the parotid gland who received their definitive treatment at the Memorial Sloan-Kettering Cancer Center between 1966 and 1988.

RESULTS

A total of 35 neck dissections (ND) were performed, 14 of which involved removal of clinically positive nodes (radical in 10, modified in 2, and limited in 3). Twenty-one patients had an elective lymphadenectomy (radical in 14, modified in 2, and limited in 4), usually because of ominous histology or high T stage. In addition to histologically positive regional lymph nodes, facial nerve paralysis, gender, and advanced stage, the decision to perform a ND, whether elective or therapeutic, was significantly predictive of decreased survival (P < 0.001). In the majority of patients (86, or 65%), the neck was observed rather than treated electively, with no impact on overall survival. Only 4 of 121 patients developed neck recurrence following treatment, including 3 who had neck dissection as part of their initial management.

CONCLUSIONS

These data support our policy of reserving elective ND only for those histologic diagnoses that carry the highest risk of nodal metastases, as well as for selected patients whose primary tumor resection might be facilitated by lymphadenectomy.

Long-term follow-up of over 1000 patients with salivary gland tumours treated in a single centre

Between 1947 and 1992, 1403 patients with 1432 salivary gland tumours were treated at the Christie Hospital, Manchester. There were 1194 epithelial neoplasms: parotid, 1082 (91 per cent); submandibular, 47 (4 per cent); minor glands, 65 (5 per cent). The commonest histological diagnoses were pleomorphic adenoma (n = 776) and adenolymphoma (n = 159). A total of 244 carcinomas were seen (adenoid cystic carcinoma, n = 75). Treatment was primarily surgical, conservative where possible, and determined by tumour extent and not histology. Adjuvant radiation therapy was used in over half the definitively treated malignancies. The recurrence rate following the treatment of 551 new parotid pleomorphic adenomas was 1.6 per cent at median follow-up 12.5 (range 1-34) years, increasing to 15 per cent in the secondarily referred group (n = 170). For patients with definitively treated primary salivary carcinomas (n = 148), the disease-free survival rate at 5, 10 and 15 years was 58, 47 and 45 per cent respectively. Using multivariate analysis, clinical stage was the most important predictor of survival; the 10-year survival rate for stages I-IV was 96, 70, 47 and 19 per cent respectively.

Estrogen and progesterone receptors in salivary gland adenoid cystic carcinoma

Adenoid cystic carcinomas of salivary glands occur more frequently in women and bear remarkable similarity to adenoid cystic carcinomas of the breast. In addition, breast carcinomas express estrogen and progesterone receptors that impact prognostic significance. This suggests a possible role for sex steroid hormones in the development and progression of salivary gland adenoid cystic carcinoma. On this basis, 12 samples of formalin-fixed, paraffin-embedded salivary gland adenoid cystic carcinomas and 12 samples of normal salivary gland tissue were immunohistochemically evaluated for estrogen and progesterone receptor protein expression. Estrogen receptors were not detected in either group; however, a significantly higher progesterone receptor level was evident in the neoplastic group compared with normal tissue (p < 0.01). These data confirm the presence of progesterone receptors within normal and neoplastic salivary gland tissue. Progesterone receptor expression may be of possible prognostic and therapeutic value in some cases of adenoid cystic carcinoma.

Changing trends in the management of salivary tumors

Fine-needle aspiration biopsy (FNAB) and computed tomography (CT) or magnetic resonance imaging (MRI) are useful in the evaluation of salivary gland tumors, but they are not essential for treatment planning in every patient. The mainstay of therapy is a well-planned and carefully executed surgical procedure which adequately excises the tumor. Disease-free survival is very likely in patients with early stage malignant tumors. When treatment is delayed until the tumor is extensive (Stage 3,4), local recurrence and distant metastases are common and survival rates are low. Adjunctive postoperative radiation therapy can enhance locoregional control in the latter patients, but does not invariably lead to better survival. No consistently effective chemotherapy agents or combinations are presently available. Early diagnosis and consistent, high quality treatment offer the best hope for improved survival.

Histocytologic grading of mucoepidermoid carcinoma of major salivary glands in prognosis and survival: a clinicopathologic and flow cytometric investigation

BACKGROUND

Controversy exists regarding the role of a 3-tiered grading system for mucoepidermoid carcinoma (MEC) of salivary glands in prognosis and survival. This retrospective investigation evaluated a 3-tiered grading system modified from Healey by Batsakis and Luna and compared various clinical, pathologic, and flow cytometric parameters and overall survival among MECs of differing grades.

METHODS

Forty-eight patients with 7 low-grade (LG), 23 intermediate-grade (IG), and 18 high-grade (HG) MECs of parotid (n = 43) and submandibular (n = 5) glands were studied. Data were analyzed using categorical statistics (Wilcoxon, Kruskal-Wallis and Chi-squared tests where appropriate).

RESULTS

Mean ages were 42 years for patients with LG tumors; 47 years, IG; and 59 years, HG (p = 0.02). Gender ratio (p < 0.001) changed from female predominance in LG (6 F:1 M) and IG (2.1 F:1 M) to male predominance in HG (3.5 M:1 F). Mean tumor stage was 1.4 LG, 2.4 IG, and 3.6 HG (p < 0.005). Tumor size increased from 2.1 cm for LG to 3.8 cm for HG (p = 0.01). Margins were involved by tumor in 0% LG, 44% IG, and 61% HG (p < 0.001). Lymph node involvement was 0% LG, 22% IG, and 72% HG (p < 0.001). DNA aneuploidy (DNA index < 0.9 or > 1.1) was present in 0% LG, 13% IG, and 28% HG (p = 0.05). Proliferative fraction (S + G2M) was 5% LG, 7% IG, and 13% HG (p = 0.008). Radiotherapy was administered in 14% LG, 35% IG, and 61% HG (p = 0.03). Recurrences (local and/or metastatic) occurred in 0% LG, 39% IG, and 61% HG (p = 0.009). Survival was decreased significantly (p < 0.0001) with increasing tumor grade (100% LG, 70% IG, and 22% HG).

CONCLUSION

Histologic grading of mucoepidermoid carcinomas of major salivary glands, using the modified Healey 3-tiered system, correlates well with clinical, pathologic, and flow cytometric factors which influence the prognosis and overall survival in affected individuals.

Prognostic factors in mucoepidermoid carcinomas of major salivary glands: a clinicopathologic and flow cytometric study

Mucoepidermoid carcinomas (MEC) of the major salivary glands from 48 patients who received their treatment at a single institution were studied for prognostic indicators. Uni- and multivariate statistical analyses were performed on several clinicopathologic factors and also on flow cytometric (FCM) DNA content data of the carcinomas. Clinical prognostic factors associated with decreased survival included age > 60 years (P = 0.01), male gender (P = 0.002), symptoms at diagnosis (P = 0.03), stage of disease (P < or = 0.0001), type of surgery (P = 0.0006), and recurrence (P = 0.0001). Histopathological prognostic factors associated with decreased survival included MEC tumour grade (P = 0.0001), tumour size > 3.0 cm (P = 0.02), lymph node involvement (P = 0.0004) and positive surgical margins (P = 0.007). DNA FCM factors associated with decreased survival included aneuploid tumours (P = 0.08) and proliferative activity (S+G2M > 5%, P = 0.07). Multivariate analysis indicated that histological grade, proliferative activity, symptoms at diagnosis, clinical stage of disease and type of surgery were significant (P < or = 0.05) prognostic/survival factors in the biological assessment of this neoplasm.

Dysplastic pleomorphic adenoma of the sublingual salivary gland

All tumours of the sublingual gland are rare and paradoxically the large majority are malignant. A case of pleomorphic adenoma in the sublingual gland is described. The tumour showed areas of dysplasia and the difficulties in distinguishing this from benign pleomorphic adenoma or carcinoma in pleomorphic adenoma are considered, and the literature is reviewed.

Parotid Cancer: Treatment and Results

The records of 74 consecutive patients with primary parotid malignancy were reviewed. The age and sex incidence was comparable to that described in previous studies; we observed a high incidence of adenocarcinoma not reported by other investigators. Stage at the time of examination and histologic grade of tumor were independent statistically significant predictors of clinical outcome. Long survival with low grade disease and late recurrence were common. Radiation therapy has been shown to increase survival in a number of studies; however, it had no demonstrable benefit in our series. Parotid cancer should be managed aggressively and early surgery is indicated for all parotid neoplasms. Neck dissection is indicated for clinically positive nodes and high grade cancers; radiation therapy is indicated for high grade cancers and residual disease.

Epirubicin in patients with advanced or recurrent adenoid cystic carcinoma of the head and neck: a phase II study of the EORTC Head and Neck Cancer Cooperative Group

BACKGROUND

Because of the rarity of salivary gland cancer, little is known about the single-agent activity of most anticancer agents in the different histologic types of these cancers.

PATIENTS AND METHODS

Twenty patients with advanced or recurrent adenoid cystic carcinoma of the head and neck were treated with epirubicin on a low-dose weekly schedule (30 mg/m2/week) for eight weeks and, in instances of no response, a high-dose three-weekly schedule (> or = 90 mg/m2). Thirteen patients had locoregional disease (12 recurrences), seven of them also had distant metastases and seven had distant metastases only. All had documented progressive disease, and 17 were symptomatic.

RESULTS

Two objective responses of 7.5 and 20 months were observed in patients with locally recurrent disease, and ten patients showed disease stabilization. The median time to progression was 16 weeks (range 2-250 weeks) and the median survival 67 weeks (range 13-272+ weeks), with three patients still alive more than five years after the initiation of chemotherapy. Contrary to the rather modest objective response rate, symptomatic improvement occurred more frequently (29.4%) and was evident within 8 weeks of treatment.

CONCLUSIONS

This type of chemotherapy should be reserved for patients with rapidly progressive disease or those with symptomatic disease.

Subtotal petrosectomy in the management of advanced parotid neoplasms

Circumferential growth of parotid neoplasms may involve the external auditory meatus posteriorly, the floor of the middle cranial fossa superiorly, and the neurovascular structures of the jugular foramen medially. Inadequate tumor resection in these anatomically complex regions will result in local disease recurrence at the lateral skull base. A subtotal petrosectomy approach has been combined with a standard total parotidectomy in the management of 27 patients with aggressive parotid tumors. Twenty-two patients had malignant lesions and 10 individuals had recurrent disease. The resultant conductive hearing loss is outweighed by the following advantages of this technique: (1) the ability to obtain tumor-free bony margins, (2) proximal intratemporal facial nerve identification, (3) vascular control of the jugular bulb and petrous carotid artery, and (4) the dissection and protection of cranial nerves IX through XII. Our series of 27 patients will be detailed with an emphasis on surgical technique and overall patient results.

The indications for elective treatment of the neck in cancer of the major salivary glands

To define the indications for elective neck treatment, the cases of 474 previously untreated patients were reviewed who had locally confined major salivary gland cancers treated between 1939 and 1982. Clinically positive nodes were present in 14% (67 of 474). Overall, clinically occult, pathologically positive nodes occurred in 12% (47 of 407). By univariate analysis, several factors appeared to predict the risk of occult metastases; however, multivariate analysis revealed that only size and grade were significant risk factors. Tumors 4 cm or more in size had a 20% (32 of 164) risk of occult metastases compared with a 4% (nine of 220) risk for smaller tumors (P less than 0.00001). High-grade tumors (regardless of histologic type) had a 49% (29 of 59) risk of occult metastases compared with a 7% (15 of 221) risk for intermediate-grade or low-grade tumors (P less than 0.00001). In view of the low frequency of occult metastases in the entire group, routine elective treatment of the neck is not recommended. High-grade tumors and larger tumors have a high rate of occult neck metastases, and treatment should be considered in this group.

The importance of clinical staging of minor salivary gland carcinoma

We reviewed a 45-year experience with 459 patients who had previously untreated minor salivary gland neoplasms, 378 (82%) of which were malignant. Data were adequate for retrospective clinical staging in 353 of the 378 patients with malignant tumors using criteria identical to those for squamous carcinoma in the same sites. Five-, 10-, and 15-year survival rates for the patients with malignant tumors treated after 1966 were 75%, 62%, and 56%, respectively, a significant improvement compared with results reported previously. Multivariate analysis confirms that survival was significantly influenced by the clinical stage and the histologic grade, but the applicability of grading was limited to patients with mucoepidermoid carcinoma or adenocarcinoma. Ten-year overall survival was 83%, 53%, 35%, and 24% for patients with stage I through stage IV, respectively. Results in these patients are similar to those we have recently reported in patients with major salivary gland carcinomas, but we are unable to demonstrate that postoperative radiotherapy improved survival.

Acinic cell carcinoma of the salivary glands. A review of 20 new cases

Twenty patients with acinic cell carcinoma of the salivary glands are presented. Seventeen tumours were located in the parotid and three in minor salivary glands, one being considered intraosseous. According to the growth patterns, they were classified as solid-acinar in 8 patients, microcystic in 5 patients, follicular in 3 patients and papillocystic in 4 patients. 9 cases were considered high grade malignant tumours and among the 11 well-differentiated, 2 suffered dedifferentiation in local recurrences. Local recurrence appeared in 9 cases. Three cases had nodal disease on admission while 5 developed this during the course of the disease. Distant metastasis appeared in 2 cases. Local recurrence and nodal disease correlated with the degree of differentiation and state of the margins in the surgical specimen. We recommend an aggressive surgical approach followed by postoperative radiotherapy for the undifferentiated tumours and extensive ones. For the limited and better differentiated, a more limited excision, such as total parotidectomy preserving the facial nerve is suggested.

Sublingual gland

The smallest of the major salivary glands, the sublingual gland is unusually the origin of a salivary neoplasm. When it is, however, the odds are greatly in favor of the neoplasm's being malignant. The gland is also uniquely associated with two nonneoplastic disorders: The cervical ranula and herniation through the mylohyoid muscle

Diagnosis and pitfalls in the treatment of parotid tumors

Any swelling near the ear is best considered a parotid neoplasm until proved otherwise. The diagnosis is primarily based on the clinical examination. Imaging studies are best reserved for patients who present with palate or tonsil swellings, which must be distinguished from parapharyngeal or minor salivary gland tumors. Almost all benign, and most malignant parotid tumors can be resected with preservation of the facial nerve. Aspiration biopsy can add useful information, but is not essential for treatment planning as the extent of the surgical procedure is primarily determined by the extent of the tumor. Survival rates in patients with malignant tumors are most significantly influenced by tumor stage. Results seem to have improved in recent years, possibly because we are treating a larger proportion with favorable lesions. Another factor may relate to the enhancement of locoregional control now achieved with postoperative radiotherapy, particularly in patients with Stage III or IV tumors.

Histopathologic grading of salivary gland neoplasms: III. Adenoid cystic carcinomas

Histopathologic grading of adenoid cystic carcinomas can provide valuable prognostic information, particularly when the presence or absence of a solid growth architecture is noted. Other growth patterns, exemplified by a tubuloductal or cribriform-cylindromatous differentiation, are associated with a more protracted biologic course and less rapid mortality. A three-tiered grading system based on the three growth patterns of the carcinoma is presented.

Histopathologic grading of salivary gland neoplasms: II. Acinic cell carcinomas

Acinic cell carcinomas display varied cytoarchitectural patterns of growth that should allow for formulation of histopathologic grading. Grading of these carcinomas may serve to identify subsets whose biologic behavior is more aggressive than the usually accepted low-grade behavior of acinic cell carcinomas as a group. To that end, a three-level histopathologic grading scheme is presented.

Histopathologic grading of salivary gland neoplasms: I. Mucoepidermoid carcinomas

Histopathologic grading of salivary gland neoplasms has been done with various degrees of success and hence various degrees of acceptance among pathologists and otolaryngologists-head and neck surgeons. Given their histopathologic diversity, three carcinomas--mucoepidermoid, adenoid cystic, and acinic cell--would seem to be suitable candidates for grading. In this, the first of a three-part series, the authors present a three-level grading scheme for mucoepidermoid carcinomas. It combines histocytologic and growth features of the carcinomas that independently or together, in other grading proposals, have shown prognostic value.

Postoperative radiation therapy for major salivary gland malignancies

Between 1966 and 1982 there have been 46 patients treated with surgery plus post-operative radiation therapy for malignant tumors of salivary gland origin. The indication(s) for radiotherapy included positive margins (42%), advanced local tumor (37%), positive nodes (33%), or high grade histology (48%). Overall actuarial local control at 5 years was 73%, being 100% for T1, 83% for T2, 80% for T3, and 43% for T4. Actuarial survival at 5 years was 80% for T1, 83% for T2, 60% for T3, and 48% for T4. Patients with positive nodes (N+) did worse than those with negative nodes (No), with locoregional control and survival at 5 years being 58% vs. 83%, (P = 0.025) and 38% vs. 80% (P = less than .01), respectively. We found no need for contralateral neck treatment even for those with positive nodes. Also, to date, none of eight patients with adenoid cystic histology has failed locally, as opposed to three of eight failures in patients treated with surgery alone. We believe that post-operative irradiation provides excellent locoregional control for appropriate patients with malignant tumors of major salivary glands.

Observations on the natural history and treatment of recurrent major salivary gland cancer

In an attempt to define the natural history and the indications for postoperative radiotherapy (RT) in locally recurrent major salivary gland cancers, we reviewed 78 patients treated between 1965 and 1982. All patients underwent resection of the tumor. Group 1 (N = 38) had complete resection of tumors, with low or intermediate grade histology and without lymph node spread. Group 2 consisted of the remaining 40 patients who had high-risk features (HR) (high grade histology, lymph node metastases, and close or positive margins of resection). Half of the Group 2 patients received radiation therapy. Overall survival was 63% at 5 years, and 35% at 15 years. Survival of Group 1 was 83% at 5 years and 58% at 15 years. Local control for Group 1 was 69% at 5 years, 54% at 15 years, and was size-dependent. Group 2 survival was 40% at 5 years and 29% at 10 years. Local control at 5 and 10 years was 49% and 35%. Our data indicate that surgery alone yielded good local control in patients with small tumors (less than or equal to 3 cm) and no HR features, suggesting that postoperative RT may be unnecessary for these patients. Other patients have suboptimal local control, and although there is a rationale for the use of postoperative radiotherapy, we cannot assess its impact in this retrospective study.