Carcinoma of major salivary glands. Recent trends

Reconstructive strategies following surgical resection of malignant sublingual gland tumors: A single institution experience

OBJECTIVE

To investigate the characteristics and treatment modalities of malignant tumors originating from the sublingual gland, as well as evaluate the therapeutic outcomes following free flap reconstruction.

METHODS

A retrospective statistical analysis was conducted on the clinical data of nine patients diagnosed with malignant neoplasms tumor of the sublingual gland.

RESULTS

Nine case of malignant tumors originated from the sublingual glandular tissue, encompassing eight adenoid cystic carcinoma (ACC) and a single case of bipartite differentiated carcinoma-a hybrid of epithelial-myoepithelial carcinoma and adenoid cystic carcinoma. Among the nine patients, four anterolateral thigh flaps were used (three of which were thin flaps), and five forearm flaps were also empoyed. The size of flaps varied, with the lengths ranging from 4 cm to 9 cm, and the widths ranging from 2.5 cm to 6 cm. The vessels chosen for anastomosis were the superior thyroid artery in seven cases, the facial artery in one case, and the lingual artery in one case. Among the eight patients who underwent dissection of cervical lymph nodes, metastasis were found in one case. Two patients underwent adjuvant radiotherapy. Upon postoperative follow-up, there was no recurrence in any of the nine patients .

CONCLUSION

The anterolateral thigh perforator flap thinning technique can be employed for postoperative reconstruction of malignant sublingual gland tumors.

Incidence and spread pattern of lymph node metastasis from submandibular gland cancer

OBJECTIVES

To clarify the indication of neck dissection (ND) for patient with submandibular gland (SMG) cancer.

METHODS

A total of 43 patients with SMG cancer were retrospectively analyzed. Forty-one patients underwent ND: Levels I-V in 19 patients, Levels I-III in 18 patients, and Level Ib in 4 patients. The other two patients did not undergo ND, since preoperative diagnoses were benign. Postoperative radiotherapy was performed in 19 patients with positive surgical margin, high grade cancer or stage IV disease.

RESULTS

LN metastases were pathologically confirmed in all patients with cN + and 6 out of 31 patients with cN-. No patients developed regional recurrence during follow-up periods. Ultimately, LN metastases were pathologically confirmed in 17 of 27 high grade, one out of 9 intermediate grade, but not in 7 low grade.

CONCLUSIONS

Prophylactic neck dissection should be considered in T3/4 and high grade SMG cancers.

Results of 301 Parotidectomies: A Twenty-Year Experience of One Single Institution

To evaluate demographic, clinical, surgical and histopathological results and complications of 301 parotidectomies performed in southern part of Turkey. The results of 297 patients undergoing 301 parotidectomies between 2000 and 2019 were retrospectively reviewed. Four patients underwent bilateral parotidectomy. Age, gender, side and size of lesion, postoperative facial nerve function (FNF) for benign tumors and types of surgery were evaluated. There were 172 male and 125 female patients. The mean age was 52.53 ± 16.67 years (range 11-90 years). Patients with malignant tumor had higher mean age than the patients with benign diseases (p < 0.001) and the mean age of Warthin tumor (WT) patients was significantly higher than pleomorphic adenoma (PA) (p < 0.001). There was a significant male dominancy in WTs than the PAs (p < 0.001). The mean size of the malignant tumors was significantly higher than the benign tumors (p = 0.012). The mean of cigarette smoking value (pack/year) was higher in WTs than the PAs (p < 0.001). WT incidence was slightly higher than PA in between years 2010 and 2019 (p = 0.272) compared to between years 2000 and 2009. Fine needle aspiration biopsy had a sensitivity of 96% and specificity of 78% for the benign tumors. Tumor location (p < 0.001) and tumor size (p = 0.034) had negative effect on the postoperative FNF. The incidence of WT had a significant rise in the last decade. Deep lobe tumors and increased tumor size had effect postoperative FNF. Experience of surgeon is more important than nerve monitoring to prevent facial paralysis. Partial superficial parotidectomy was available methods for small benign tumors in tail of the parotid gland.

Diagnosis and management of malignant sublingual gland tumors: a narrative review

OBJECTIVE

In this article we review the literature on the malignant sublingual gland tumors from a surgical perspective.

BACKGROUND

Sublingual gland tumors occur with a very low incidence and most are malignant tumors. The extent of treatment, clinical outcomes and prognosis of malignant sublingual gland tumors have not been well defined, due to the rarity of this disease.

METHODS

A database search using Web of Science (https://webofknowledge.com/) and PubMed (https://pubmed.ncbi.nlm.nih.gov/) was conducted. The following keywords were used in the search: "sublingual gland tumor", AND "malignancy".

CONCLUSIONS

Although the sublingual glands are among the major salivary glands, they share common anatomical characteristics with minor salivary gland tumors. Therefore, the tumors from the sublingual gland may have different clinical behaviors from the other major salivary gland tumors. The sublingual glands are small without a true surrounding capsule of the glands; the extra-parenchymal extension is very common in sublingual gland tumors. Furthermore, the sublingual glands are located in close proximity to the lingual nerve, the submandibular gland-duct system and the mandible. Thus, the surgical approach to the malignant sublingual gland tumor should include the adequate management of neighboring structures. In addition, adjuvant radiation therapy provides a survival benefit for patients with malignant sublingual gland tumors, which have adverse features. This article summarizes the clinical characteristics and unique features of malignant sublingual gland tumors based on previous reports, and provides clinical information regarding the sublingual gland tumors to increase awareness of primary physicians as well as patients.

Survival and prognostic factors of salivary gland malignant mixed tumor-not otherwise specified: A population-based analysis

OBJECTIVE

Malignant mixed tumors of the salivary gland are a group of neoplasms comprised of carcinoma-ex-pleomorphic adenoma, carcinosarcoma, and metastasizing pleomorphic adenoma. An alternative classification, malignant mixed tumor-not otherwise (MMT-NOS), is a diagnosis of exclusion for neoplasms that do not fit the previous histologically profiled subtypes. The objective was to provide a comprehensive assessment of MMT-NOS and determine prognostic factors.

METHODS

This retrospective cohort study queried the Surveillance, Epidemiology, and End Results database for patient and tumor characteristics of US patients with MMT-NOS of the major salivary glands from 1973 to 2016. Kaplan-Meier and Cox regression analysis were performed to determine 5-year survival and prognostic factors.

RESULTS

434 patients were identified with a mean age at diagnosis of 61.5 years. The majority of neoplasms were high grade and stage (70.8% grade III/IV; 63.8% stage III/IV). Extraparenchymal extension (40.6%) and lymph node involvement (28.5%) were common; distant metastases (2.4%) were rare. Treatment included surgery (93.0%), radiation (51.6%), and chemotherapy (10.4%). Facial nerve sacrifice was common (50.8%). Median survival was 66.5 months. 5-year overall and disease-specific survival were 65.7% and 83.0%, respectively. In multivariate analysis, nodal involvement (HR 7.0; P < 0.001), surgery-radiation-chemotherapy (HR 6.1; P = 0.02), extraparenchymal extension (HR 2.50; P = 0.04), and tumor size >4 cm (HR 1.3; P = 0.03) were prognostic factors.

CONCLUSION

Despite high stage and grade at diagnosis, MMT-NOS portends a good 5-year prognosis and low rate of distant metastasis. Prognostic factors were nodal involvement, tumor size, and extraparenchymal extension.

Factors and Outcomes Associated With Temporal Bone Resection for Primary Parotid Malignancy

OBJECTIVE(S)

Although parotid cancer invading into the temporal bone makes up only a small fraction of all parotid cancers, it is more common and relatively understudied compared with primary cancer of the external auditory canal. The objective of this study was to determine what factors are associated with receiving parotidectomy with temporal bone resection (TBR) and the immediate postoperative outcomes.

METHODS

We reviewed the National Cancer Database (2004-2015) for patients with primary parotid malignancy who received parotidectomy with or without TBR. Patient demographic, clinical, and perioperative variables were collected and then compared. Multivariate logistic regression was performed to determine factors associated with receiving TBR.

RESULTS

We identified 134 patients who received parotidectomy with TBR and 16,595 who received parotidectomy only. Reported in terms of odds ratios (95% confidence interval), our multivariate model showed having surgery at an academic facility (1.91 [1.34-2.71], P < .001), clinical stage III or IV (7.48 [1.65-33.96] and 31.37 [7.61-129.32], P = .009 and P < .001, respectively), histologic grade II to IV (4.36 [1.51-12.57], 4.31 [1.53-12.15], and 6.74 [2.26-20.13], P = .006, .006, and .001, respectively), and adenoid cystic histology (3.23 [2.02-5.17], P < .001) were significantly and independently associated with receiving TBR. There was no significant difference in 30-day readmission, or 30-day or 90-day mortality, but the rate of positive surgical margins was significantly higher in those who underwent TBR.

CONCLUSION

Demographic variables are not significant factors for receiving TBR. Tumor characteristics, such as clinical stage and histologic type, and receiving surgical treatment at an academic facility were more strongly associated with receiving TBR.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E2461-E2468, 2021.

Patterns of care, toxicity and outcome in the treatment of salivary gland carcinomas: long-term experience from a tertiary cancer center

Background

Salivary gland carcinomas (SGC) cover a heterogeneous group of malignancies with a lack of data of high-level evidence.

Methods

Clinical data of 127 patients treated for SGC at a university cancer center between 2002 and 2017 were analyzed retrospectively. The association of clinicopathological characteristics, treatment modalities, adverse events, and outcome was assessed.

Results

Patients received surgery (n = 65), surgery followed by (chemo-)radiotherapy (n = 56), or primary (chemo-)radiotherapy (n = 6). Injury to the cranial nerves or their branches was the most frequent surgical complication affecting 40 patients (33.1%). Ten year overall and progression-free survival rates were 73.2% and 65.4%, respectively. Parotid tumor site, advanced tumor, and positive nodal stage remained independent negative prognostic factors for overall survival, loco-regional and distant tumor control in multivariate analysis.

Conclusions

Optimizing treatment strategies for SGC, depending on distinct clinicopathological factors, remains challenging due to the low incidence rates of the disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06652-5.

Prognostic scoring models in parotid gland carcinoma

BACKGROUND

The aim was to identify prognostic factors and test three prognostic scoring models that predicted the risk of recurrence in patients with parotid gland carcinoma.

METHODS

All Danish patients with parotid gland carcinoma, treated with curative intent, from 1990 to 2015 (n = 726) were included. Potential prognostic factors were evaluated using Cox regression and competing risk analyses. The concordance of each prognostic model was estimated using Harrel's C index.

RESULTS

The study population consisted of 344 men and 382 women, with a median age of 63 years. Age above 60 years, high grade histology, T3/T4 tumor, regional lymph node metastases, and involved surgical margins were all associated with a significant reduction in recurrence-free survival. The prognostic model that agreed best with actual outcomes had a C-index of 0.76.

CONCLUSION

Prognostic scoring models may improve individualized follow-up strategies after curatively intended treatment for patients with parotid gland carcinoma.

Analysis of local invasion and regional spread in malignant sublingual gland tumour: Implications for surgical planning

Malignant tumours arising from the sublingual glands are very rare, and the extent and frequency of local invasion or regional spread in malignant sublingual gland tumour (MSLT) has not been fully studied due to the disease rarity. To provide comprehensive features of local and regional spread of MSLT, we reviewed 20 surgical cases for detailed pathological analyses among 26 cases diagnosed as having primary MSLT. Adenoid cystic carcinoma (ACC) was the most common pathological subtype, followed by mucoepidermoid carcinoma. Disease-free and overall survivals at 5 years were 76.1 % and 77.7 %, respectively. High-grade malignant tumours and grade 2-3 ACC accounted for 41.7 % and 85.7 %. Clinical and pathological extraparenchymal extensions were found in 34.6 % and 80.0 %, respectively. Tumour invasion to the lingual nerve and submandibular gland/ductal system were also detected in 40.0 % and 28.6 %. The incidences of lingual nerve invasion in ACC and ACC ≥4 cm were 30.8 % and 42.9 %. Regional nodal involvement occurred in seven of 26 cases, and all metastatic lymph nodes were found in neck levels Ib and IIa. In summary, a significant portion of MSLT cases consisted of high-grade tumours and grade 2-3 ACC; therefore local invasion into adjacent structures should be cautiously evaluated in cases of MSLT.

Large German Multicenter Experience on the Treatment Outcome of 207 Patients With Adenoid Cystic Carcinoma of the Major Salivary Glands

Introdution

We aimed to evaluate treatment outcome of combined radiotherapy (RT) including photon intensity modulated radiotherapy (IMRT) and carbon ion boost for adenoid cystic carcinomas (ACCs) of the major salivary glands, the currently available largest German collective for this cohort.

Materials and Methods

Overall, 207 patients who were irradiated with combined RT between 2009 and 2019 at Heidelberg University Hospital were analyzed retrospectively for local control (LC), progression-free survival (PFS) and overall survival (OS) using Kaplan-Meier estimates. The majority of patients received postoperative RT (n=176/207, 85%) after previous surgery in large German hospitals mainly Mainz, Freiburg, Mannheim and Heidelberg University Hospitals and 15% received primary RT (n=31/207).

Results

After a median follow-up time of 50 months, 84% of the patients were still alive (n=174/207). Disease progression occurred in 32% of the patients (n=66/207) while local recurrence was diagnosed in 12% (n=25/207), and distant relapse in 27% (n=56/207). Estimated 5-year LC, PFS and OS rates were 84%, 56% and 83% for OS, respectively. In multivariate analysis, we could identify two prognostic subgroups: one subgroup resulting in decreased LC, PFS and OS rates and another subgroup having an additional survival disadvantage in PFS and OS. Patients with a macroscopic tumor disease (yes vs. no; p<0.001 for LC, p=0.010 for PFS and p=0.040 for OS) treated in a definitive setting (vs. postoperative setting; p=0.001 for LC, p=0.006 for PFS, p=0.049 for OS) and tumors of upper T stage (T1-4; p=0.004 for LC, p<0.001 for PFS, p<0.001 for OS) showed significantly more local relapses and a decreased PFS and OS. Upper Age (p<0.001 for both PFS and OS), lower Karnofsky Performance Score (<80% vs. ≥80%; p<0.001 for both PFS and OS) and solid histology (vs. non-solid; p=0.049 for PFS and p=0.003 for OS) were in addition associated with worse survival outcome. Toxicity was moderate with 18% late grade 2 and 3 toxicity.

Conclusions

Combined RT results in superior LC rates compared to photon data with moderate toxicity. In multivariate analysis, upper T stage, the existence of a macroscopic tumor before RT and definitive RT setting were identified as major prognostic factors affecting LC negatively.

Determining the number and distribution of intraparotid lymph nodes according to parotidectomy classification of European Salivary Gland Society: Cadaveric study

BACKGROUND

To investigate the distribution of the parotid gland's intraglandular lymph nodes using the parotidectomy zones determined by the parotidectomy classification of the European Salivary Gland Society (ESGS).

MATERIALS AND METHODS

A total of 128 parotid glands were dissected from 64 fresh cadavers, by bilateral parotidectomy without additional incision within the standard autopsy procedure, and categorized.

RESULTS

Eighty-six percent of the IGLNs were located in the superficial lobe and 14% in the deep lobe. An average of 7.09 ± 3.55 IGLNs were found for each of the gland; there were 6.11 ± 3.28 in the superficial lobe and 0.98 ± 1.46 in the deep lobe. While the most common lymph nodes were found in level 2 with 47.7%, only 5% of IGLNs were at level 4. According to the proposed modification, the most common lymph nodes (35.24%) were located at level 2B.

CONCLUSION

Level 2B was found to contain significantly more lymph nodes than other levels, which has not been evaluated before in literature.

Surgery and Radiotherapy in the Treatment of Malignant Parotid Tumors: A Retrospective Multicenter Study

Aims and background

Major salivary gland cancers are rare, with many histologic types and subtypes. The low incidence and heterogeneity of primary parotid carcinomas makes their outcome difficult to evaluate. Treatment remains primarily surgical, but optimal therapeutic regimens have yet to be fully realized. The present study reviews the experience of three Italian institutions in the treatment of primary parotid carcinomas in order to describe the clinicopathological presentation and treatment options with emphasis on radiotherapy and to analyze the factors influencing survival.

Methods and study design

The records of 110 patients with primary parotid neoplastic lesions treated at three Italian institutions from 1993 to 2004 were retrospectively reviewed. Six patients were excluded from the study: 3 received surgery alone and 3 were not assessable, for a total of 104 assessable patients. Acute and late toxicity of radiotherapy was quantified following the recommendations of the RTOG/EORTC. Survival was analyzed by the actuarial Kaplan-Meier product-limit method. The influence of selected factors on 10-year disease-specific survival was analyzed.

Results

The 104 assessable patients were treated as follows: 11 patients received radiotherapy as their only treatment (3 with a palliative purpose) and 93 had postoperative radiotherapy. Thirty-two patients underwent neck dissection: neck lymph node metastases were found in all them. Their mean age was 60 years (range, 14–92). According to the UICC/2002 TNM Classification, 8 patients were stage I, 19 stage II, 34 stage III, 25 stage IVA, 5 stage IVB, 3 recurrent and 10 not assessable (Tx). The most frequent histologies were adenoid cystic carcinoma (n = 16), mucoepidermoid carcinoma (n = 15), and acinic cell carcinoma (n = 15). Twenty-three patients had recurrences: 10 had local recurrences, 3 neck recurrences, 9 distant metastases, and 1 patient had both local recurrence and distant metastases. No factors were observed that would negatively influence the prognosis. Actuarial 10-year disease-specific survival was 71% and actuarial 10-year local control 82%.

Conclusions

The treatment of salivary gland malignancies remains primarily surgical. Our study confirms the results of the literature with surgery and adjunctive radiotherapy in patients with advanced-stage disease. No variables were observed to influence the prognosis.

Nodal Stage: Is It a Prognostic Factor for Submandibular Gland Cancer?

PURPOSE

Submandibular gland cancer is relatively rare. The purpose of this study was to estimate 5-year overall survival (OS) and disease-free survival (DFS) and to identify prognostic factors associated with OS and DFS for submandibular cancer.

MATERIALS AND METHODS

The authors implemented a retrospective cohort study and enrolled a sample of patients with submandibular gland cancer. The predictor variables were age, gender, tumor stage, nodal stage, margin status, and extracapsular spread. The outcome variables were 5-year OS and 5-year DFS. Kaplan-Meier methods were used to estimate survival and Cox hazards models were used to identify prognostic variables.

RESULTS

The sample was composed of 52 patients with submandibular gland cancer (mean age, 47.4 yr; 51.9% men). The median follow-up was 81 months (range, 11 to 159 months). The 5-year OS and DFS rates were 76.9 and 67.3%, respectively. Fixed mass, positive neck node, and positive margin status were relevant predictors of OS and DFS. Nodal stage was the relevant independent predictor affecting the disease outcome of submandibular gland cancer.

CONCLUSION

These results identified several important prognostic factors associated with survival rate in patients with submandibular gland cancer. These prognostic variables include symptoms at presentation, pathologic nodal status, and margin status. These outcomes suggest that heightening vigilance of clinical characteristics for this disease might provide the impetus for improving the survival rate.

Mucoepidermoid Carcinoma of the Salivary Glands: Survival and Prognostic Factors

OBJECTIVE

The aim of this study was to establish global survival rates and potential prognostic factors for mucoepidermoid carcinoma (MC) of the salivary glands in patients diagnosed at the Dr. Eduardo Cáceres Graziani National Institute for Neoplastic Diseases (INEN), Lima, Peru, between 2002 and 2012.

MATERIALS AND METHODS

This was an observational, analytical and longitudinal (information reconstructed in time) retrospective cohort study. Data were obtained from clinical records and used to determine the overall survival (OS) rate at 2 and 5 years, and the individual percentage survival for each prognostic factor using the actuarial technique. We also performed univariate analysis for each possible prognostic factor using log-rank analysis, and multivariate analysis using Cox's regression model. The study was approved by the institutional review board at Dr. Eduardo Caceres Graziani INEN and conducted in accordance with the 1964 Declaration of Helsinki. For this type of study formal consent was not required.

RESULTS

The OS rate of the 51 patients enrolled in the study was 81 % at 2 years and 78 % at 5 years. In the multivariate analysis, the equation that best explained the survival result contained the variable, clinical stage (p = 0.063).

CONCLUSIONS

The results revealed the importance of clinical stage regarding the survival of patients with a primary diagnosis of MC of the salivary glands.

The rising incidence of major salivary gland cancer in the United States

We performed a population-based historical cohort study using the Surveillance, Epidemiology, and End Results (SEER) database to determine trends in the incidence of major salivary gland cancer and to evaluate the effect of sex, tumor size, histology, primary site, and extent of disease. Participants were men and women with major salivary gland cancer, diagnosed 1973-2009. The incidence of major salivary gland cancer increased from 10.4 per 1,000,000 in 1973 to 16 per 1,000,000 in 2009 (annual percent change [APC] 0.99; 95% confidence interval [CI] 0.78 to 1.20; p < 0.05). The incidence of parotid cancers increased (APC 1.13; 95% CI 0.88 to 1.39; p < 0.05) and paralleled the increase in major salivary gland cancer overall. There was an increase in the incidence of tumors measuring 0 to 2.0 cm (APC 1.99; 95% CI 0.61 to 3.38; p < 0.05), but no change in tumors measuring 2.1 to 4.0 cm (APC 1.02; 95% CI -0.46 to 2.52; p > 0.05) and tumors measuring > 4 cm (APC -0.52; 95% CI -1.72 to 0.69; p > 0.05). There was an increase in the incidence of regional (APC 0.77; 95% CI 0.32 to 1.23; p < 0.05) and distant (APC 2.43; 95% CI 1.43 to 3.45; p < 0.05) disease, but not localized disease (APC 0.35; 95% CI 0 to 0.71; p > 0.05). We conclude that the incidence of major salivary gland cancer is increasing, especially small parotid tumors. The incidence of tumors with regional and distant metastasis is also increasing. These findings highlight the need for further research on the etiology of salivary gland cancer, which may reveal opportunities for further public health efforts aimed at prevention.

Treatment of locally advanced parotid malignancies with parotidectomy and temporal bone resection

PURPOSE

In this study we review our institution's experience and outcomes with temporal bone resection and parotidectomy in the treatment of advanced parotid malignancies.

METHODS

Patients undergoing lateral temporal bone resection and parotidectomy from 2007-2013 were identified in the EPIC electronic medical record. Primary tumor location, staging, surgical procedure, and patient demographic and outcome data were collected retrospectively.

RESULTS

Fifteen patients underwent combined temporal bone resection and parotidectomy for parotid malignancy. Carcinoma ex-pleomorphic and squamous cell carcinoma were the most common pathologies. Two year disease free survival was 40%. Distant metastases were the most common site of disease recurrence. Only nodal disease was predictive of reduced disease free survival, though pre-operative facial paralysis showed a trend towards significance. Margin status and operating for recurrent tumor did not influence outcome in our series.

CONCLUSION

Local and regional tumor controls are attainable with combined skull base approaches to advanced parotid malignancies. Unfortunately these cases have a high rate of distant recurrence despite negative margins and local control.

Tumor Differentiation as a Prognostic Factor for Major Salivary Gland Malignancies

Objective The effect of tumor differentiation on prognosis of major salivary gland malignancies is controversial. The aim of this study was to determine the effect of tumor differentiation on prognosis by stage in patients with major salivary gland malignancies and to analyze which patient factors are associated with tumor differentiation. Study Design and Setting Cross-sectional analysis of Surveillance, Epidemiology, and End Results (SEER) database. Subjects and Methods In total, 9810 patients who had a major salivary gland malignancy from 2004 to 2012 were identified using the SEER database. Patients with no staging information or no information on histologic differentiation were excluded. A total of 5366 patients were included in the study. For analysis, patients were categorized by American Joint Committee on Cancer (AJCC) stage and subdivided by tumor differentiation. Multivariate analysis was used to analyze the impact of tumor differentiation on survival, tumor location (parotid, submandibular, sublingual), and sex within each AJCC stage of disease. Results Data analysis demonstrated a significant difference in histologic differentiation by stage, with P < .0001. Within stages II, III, and IV, tumor differentiation was significantly associated with a decrease in survival. There was no significant difference in tumor differentiation between the parotid and submandibular gland. Conclusion For patients with stage II, III, and IV disease, tumor differentiation was an independent predictor of survival. This information can be useful when discussing prognosis and can potentially influence management of disease.

NUT Midline Carcinoma of the Sublingual Gland: Clinical Presentation and Review

NUT midline carcinoma (NMC) is a rare and aggressive disease encountered in the midline of the head and neck or mediastinum. Due to its sparse incidence and subtle pathologic features, we aim to increase knowledge and awareness for this pathologic entity. We present an exemplary case of a young, healthy male presenting with oral cavity pain and cervical lymphadenopathy. This patient was initially diagnosed with an unspecified, highly aggressive sublingual gland malignancy and underwent locoregional resection with free flap reconstruction however suffered a rapid local recurrence and widely extensive metastasis within just 1 month. After rigorous analysis, final pathologic diagnosis revealed a poorly differentiated carcinoma with evidence of squamous differentiation that eventually, post-mortem tested positive for NMC. Only one prior case of sublingual gland NMC has been previously reported as we discuss the literature regarding all sublingual gland malignancies as well as the pathologic features and treatment options for NMC. We recommend consideration of testing for the NUT proto-oncogene at the time of biopsy in the clinical setting of a poorly differentiated midline carcinoma, especially with squamous differentiation, of the head or neck in order to identify patients for clinical trial enrollment and appropriately counsel on the poor clinical prognosis. Improving clinician awareness is critical to increase diagnostic accuracy and need to study prospective treatment outcomes as the first step toward improving management of this difficult disease.

Complementary role of the Memorial Sloan Kettering Cancer Center nomogram to the American Joint Committee on Cancer system for the prediction of relapse of major salivary gland carcinoma after surgery

BACKGROUND

The purpose of this study was to test the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram in predicting recurrence risk of major salivary gland carcinoma in an Asian cohort.

METHODS

We retrospectively enrolled 149 patients who had undergone intended curative resections for major salivary gland carcinoma between 2007 and 2012. The performance of the MSKCC nomogram and the American Joint Committee on Cancer (AJCC) seventh staging system in predicting recurrence risk was compared.

RESULTS

The MSKCC nomogram and the AJCC staging system both accurately predicted the 5-year recurrence probabilities, with the concordance index (c-index = 0.82; 95% confidence interval [CI], 0.75-0.89 vs c-index, 0.77; 95% CI, 0.68-0.87; p = .45) in patients with major salivary gland carcinomas after curative surgeries. Comparing to the actual observed events, the calibration plot indicated that the MSKCC nomogram accurately estimated the recurrence in low-risk groups but tended to overestimate in high-risk groups. When using the MSKCC nomogram to predict the 5-year recurrence-free probability in each AJCC stage, the prediction was very good for patients with AJCC stages I and II disease (c-index = 0.92 and 0.90, respectively) and modest for those of AJCC stages III and IVa (c-index = 0.51 and 0.62, respectively).

CONCLUSION

The MSKCC nomogram and the AJCC staging system each had its value in predicting recurrence of major salivary gland cancers. When using the MSKCC nomogram to predict the 5-year recurrence-free probability in each AJCC stage, the MSKCC nomogram was more accurate in predicting recurrence risks in those patients with AJCC stage I and II diseases than those with late-stage diseases. © 2017 Wiley Periodicals, Inc. Head Neck 39: 860-867, 2017.

Management of Salivary Gland Tumours: United Kingdom National Multidisciplinary Guidelines

This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Salivary gland tumours are rare and have very wide histological heterogeneity, thus making it difficult to generate high level evidence. This paper provides recommendations on the assessment and management of patients with cancer originating from the salivary glands in the head and neck. Recommendations • Ultrasound guided fine needle aspiration cytology is recommended for all salivary tumours and cytology should be reported by an expert histopathologist. (R) • Adjuvant radiotherapy (RT) following surgery is recommended for all malignant submandibular tumours except in cases of small, low-grade tumours that have been completely excised. (R) • For benign parotid tumours complete excision of the tumour should be performed and offers good cure rates. (R) • In the event of intra-operative tumour spillage, most cases need long-term follow-up for clinical observation only. These should be raised in the multidisciplinary team to discuss the merits of adjuvant RT. (G) • As a general principle, if the facial nerve function is normal pre-operatively then every attempt to preserve facial nerve function should be made during parotidectomy and if the facial nerve is divided intra-operatively then immediate microsurgical repair (with an interposition nerve graft if required) should be considered. (G) • Neck dissection is recommended in all cases of malignant parotid tumours except for low-grade small tumours. (R) • Where malignant parotid tumours lie in close proximity to the facial nerve there should be a low threshold for adjuvant RT. (G) • Adjuvant RT should be considered in high grade or large tumours or in cases where there is incomplete or close resection margin. (R) • Adjuvant RT should be prescribed on the basis of clinical factors in addition to histology and grade, e.g. stage, pre-operative facial weakness, positive margins, peri-neural invasion and extracapsular spread. (R).

Surgical treatment of salivary malignant tumors

Salivary gland malignant tumors (SGMT) are of key interest for head and neck surgeons since surgery with adjuvant radiotherapy is considered the treatment of choice in most of the cases. Some factors, namely rarity, high histologic heterogeneity, and possible occurrence in all the head and neck subsites, contribute to make this topic very controversial; some unclear aspects pertain surgical treatment. When dealing with major salivary gland malignant tumors (MaSGMT), the most debated issues remain the extent of surgery and management of facial nerve. In minor salivary gland malignant tumors (MiSGMT), conversely, surgical planning is influenced by the specific pattern of growth of the different neoplasms as well as the site of origin of the lesion. Finally, two additional issues, the treatment of the neck (therapeutic or elective) and reconstructive strategy after ablative surgery, are of pivotal importance in management of both MaSGMT and MiSGMT. In this review, we discuss the most relevant and controversial issues concerning surgery of SGMT.

Pediatric malignant salivary gland tumors: 60 year follow up

OBJECTIVE

To evaluate the presentation, treatments and outcomes in pediatric patients with salivary gland malignancies.

STUDY DESIGN

Retrospective chart review (1950-2012), Prospective phone interview.

METHODS

Patients ≤18 years old with a salivary gland malignancy treated at our institution were identified. Patients were also contacted by phone for a follow up survey.

RESULTS

Fifty-six patients were identified. Tumor origin was 88% parotid (n = 49), 5% (n = 3) submandibular and 7% (n = 4) minor salivary glands. Time from onset of symptoms to diagnosis was over one year (mean = 14.4 years). Fifteen out of 52 patients with major gland malignancy had a locoregional recurrence and local recurrences were almost all after initial enucleation. Two of these patients died of disease (overall disease specific survival = 96%). Three out of 4 patients with minor gland malignancy had a local recurrence and two patients with high grade pathology developed metastases and died of their disease (overall survival = 50%). On long term follow up survey in 13 patients (25%), 100% reported normal facial movement and 54% described symptoms of Frey's syndrome, which is higher than other reported series in children. Recurrence was noted up to 45 years after initial treatment.

CONCLUSIONS

The majority of malignant pediatric salivary gland tumors are low grade and have excellent survival, especially if found at an early stage. Minor salivary gland malignancies, particularly high grade, have a worse prognosis. Long term mild Frey's syndrome can be expected in approximately half of patients. We advocate a need for long term follow up and increased awareness among providers to diagnose these patients earlier.

Elective neck dissection versus observation in primary parotid carcinoma

OBJECTIVE:

To evaluate the efficacy of elective neck dissection in the clinically negative neck of patients with primary carcinoma of the parotid gland.

STUDY DESIGN AND SETTING:

A retrospective analysis was undertaken at a university Department of Otorhinolaryngology-Head and Neck Surgery on 83 previously untreated patients with primary carcinoma of the parotid gland and a clinically negative neck. The reliability of fine needle aspiration cytology, frozen section, and the clinico-pathologic findings of patients with occult neck metastases were analyzed. The regional recurrence rate and the outcome were compared among 2 groups; one with elective neck dissection (N = 41) and one without elective neck dissection (N = 42).

RESULTS:

The diagnosis of malignancy was known preoperatively in 59 (71%) cases, the exact histologic tumor type in 36 (43%) and the grade in 37 (44%) of 83 cases. Occult metastases were detected in 8 (20%) of 41 cNO patients, in 5 cases associated with a high-grade and in 3 cases with a low-grade carcinoma. Recurrence of disease developed in 5 (12%) patients in the elective neck dissection group and in 11 (26%) patients in the observation group. All of the 7 neck recurrences occurred in the observation group. The 5-year actuarial and disease-free survival rate was 80% and 86% for patients with elective neck dissection and 83% and 69% for patients without neck dissection.

CONCLUSION AND SIGNIFICANCE:

A routine elective neck dissection is suggested in all patients with primary carcinoma of the parotid gland. The efficacy of elective neck dissection, nevertheless, has never been evaluated prospectively.

Postoperative Radiation Therapy for T1 and T2 Primary Parotid Carcinoma: Is it Useful?

OBJECTIVE: The benefit of postoperative radiation for advanced primary parotid carcinoma has been reported previously, whereas studies to evaluate the usefulness of postoperative radiation for T1 and T2 parotid carcinomas have never been performed.

STUDY DESIGN AND SETTING: Retrospective analysis on 58 previously untreated patients with T1 and T2 parotid carcinomas. In 34 patients, postoperative radiation was included in the treatment protocol and in 24 patients, no postoperative radiation was applied.

RESULTS: A local recurrence was observed in 8 of 24 (33%) patients withoht and in 1 of 34 (3%) patients with postoperative radiation ( P < 0.5). The 5-year actuarial and disease-free survival rate was 83% and 70% for patients without postoperative radiation and 93% and 92% for patients with postoperative radiation.

CONCLUSION AND SIGNIFICANCE: Local recurrence was less often observed in patients with postoperative radiation. Nevertheless, prospective randomized studies are needed to confirm the usefulness of postoperative radiation in early carcinomas.

EBM rating: B-3b

Adenoid Cystic Carcinoma of the Submandibular Gland: A 35-Year Review

OBJECTIVES: To evaluate the treatment results of adenoid cystic carcinoma (ACC) of the submandibular gland at a single institution during a 35-year period.

STUDY DESIGN & SETTING: A retrospective review was performed by examining the records and reviewing the pathology of 22 patients with ACC of the submandibular gland treated at UCLA Medical Center from June 1963 to December 1997.

RESULTS: Seven men and 15 women with an age range of 23 to 85 years (median, 48 years) were treated. Surgical intervention was performed in 21 patients. All patients with advanced tumor size, perineural invasion, microscopically positive surgical margins, or regional neck metastases received postoperative adjunctive therapy, primarily radiotherapy. Follow-up varied from 6 months to 181 months (median, 67 months). Disease-free survival at 3, 5, and 10 years was 66%, 57%, and 41% respectively, whereas overall survival was 76%, 70%, and 37%, respectively (note: 5- and 10-year survival rates are not statistically conclusive due to the small sample size).

CONCLUSIONS: We report fairly high disease-free survival rates in this patient population and a number of prognostic trends are evident. Early diagnosis, wide surgical intervention, and postoperative radiation are associated with a favorable prognosis. Advanced tumor size, positive surgical margins, perineural invasion, and local recurrence of the tumor are associated with an unfavorable prognosis. EBM rating: C.

Salivary acinic cell carcinoma: reappraisal and update

Epidemiologic and clinicopathologic features, therapeutic strategies, and prognosis for acinic cell carcinoma of the major and minor salivary glands are critically reviewed. We explore histopathologic, histochemical, electron microscopic and immunohistochemical aspects and discuss histologic grading, histogenesis, animal models, and genetic events. In the context of possible diagnostic difficulties, the relationship to mammary analog secretory carcinoma is probed and a classification is suggested. Areas of controversy or uncertainty, which may benefit from further investigations, are also highlighted.

Incidence, treatment, and outcome of parotid carcinoma, 1996-2011: a population-based study in Thuringia, Germany

PURPOSE

The objective of this study was to examine patterns of care and survival in a population-based sample of patients with parotid cancer who were treated in Thuringia, a federal state in Germany, between 1996 and 2011.

METHODS

Data of 295 patients with primary parotid cancer from the Thuringian cancer registry were evaluated for patient's characteristics, tumor stage, incidence, and trends in treatment, cancer-specific survival (CSS), and overall survival (OS).

RESULTS

Stages IV tumors and the amount of tumors in all age cohorts ≥45 years of age increased significantly during the observation period (p = 0.002; age all p < 0.05, respectively). The highest increase in crude incidence was observed for salivary duct carcinomas [relative risk per decade (RR) 5.46; 95% confidence interval (CI) 1.14-26.14] and rare carcinoma subtypes (RR 9.99; 95% CI 1.85-53.94). CSS at 5 years and at 10 years for all patients was 82.4 and 82.4%, respectively. OS at 5 years and at 10 years for all patients was 60.1 and 48.2%, respectively. CSS and OS did not improve over the time. Salivary duct carcinoma showed the lowest 5-year OS (35.6%). Acinic cell carcinoma had the highest OS rate (85.3%). Multivariate Cox models revealed that higher grading (G3/G4) was a more powerful independent predictor of decreased OS than TNM stage.

CONCLUSIONS

CSS and OS did not improve during the study period. Incidence of parotid cancer increased significantly in elderly patients. It seems that grading is next to patient's age the better predictor of OS than TNM stage.

Disorders and tumors of the salivary glands in children

Salivary gland neoplasms are rare in children. In infants most tumors are benign hemangiomas, with some notable exceptions, such as sialoblastomas. An asymptomatic swelling in the periauricular region is the most common presenting complaint in older children. Approximately 50% of these lesions are malignant, which dictates a thorough diagnostic evaluation by a head and neck surgeon. Surgical excision is the primary treatment modality. Prognosis is primarily determined by histopathologic findings. This review discusses neoplastic lesions of the salivary glands in children, and malignant epithelial tumors in particular.

The Limitations of Routine Magnetic Resonance Imaging for Long-Term Post-Treatment Locoregional Surveillance of Salivary Carcinoma

BACKGROUND/AIMS

To determine the utility of head and neck magnetic resonance imaging (HN-MRI) for the routine surveillance of patients without concurrent symptoms or signs of recurrence more than 6 months after treatment for salivary gland carcinoma (SGC).

METHODS

This is a retrospective single-institution review of SGC patients from 2000 to 2011 who underwent one or more HN-MRI scans without concurrent suspicious symptoms or signs of recurrence more than 6 months after the completion of treatment, with at least 6 months of follow-up after each scan.

RESULTS

Out of an original 283 SGC patients treated surgically, 41 patients, who were disease free 6 months after treatment, had undergone 96 routine HN-MRIs without concurrent suspicious symptoms or signs. Ten out of the 41 patients (24%) experienced a false-positive finding with routine HN-MRI. None of the 96 HN-MRIs demonstrated a true-positive or false-negative finding.

CONCLUSION

More than 6 months after treatment, routine HN-MRI for the detection of locoregional recurrence of SGC has a low utility in patients without concurrent suspicious symptoms or signs. While these data support the judicious use of routine HN-MRIs, the managing physician should ultimately decide on the best course of surveillance for an individual patient based on the unique risk factors and circumstances present.

Adenoid cystic carcinoma of the head and neck--An update

This article provides an update on the current understanding of adenoid cystic carcinoma of the head and neck, including a review of its epidemiology, clinical behavior, pathology, molecular biology, diagnostic workup, treatment and prognosis. Adenoid cystic carcinoma is an uncommon salivary gland tumor that may arise in a wide variety of anatomical sites in the head and neck, often with an advanced stage at diagnosis. The clinical course is characterized by very late recurrences; consequently, clinical follow-up should extend at least >15 years. The optimal treatment is generally considered to be surgery with postoperative radiotherapy to optimize local disease control. Much effort has been invested into understanding the tumor's molecular biological processes, aiming to identify patients at high risk of recurrence, in hopes that they could benefit from other, still unproven treatment modalities such as chemotherapy or biological therapy.

Adenoid cystic carcinoma of the head and neck: clinicopathologic analysis of 218 cases in a Chinese population

OBJECTIVE

The aim of this study was to analyze the clinicopathologic characteristics and prognostic factors of adenoid cystic carcinoma of the head and neck (ACCHN).

STUDY DESIGN

This was a retrospective study of 218 patients with ACCHN.

RESULTS

The cohort included 110 men and 108 women; the parotid and the palate were the most common site of involvement. Of 203 patients with follow-up information (range 2-132 months), 57 had died of the tumor. Distant metastasis (DM) and local recurrence (LR) were documented in 83 (40.9%) and 34 (16.7%) patients, respectively. Cox regression analysis indicated that a solid pattern was a marker for LR and that positive margins and older age were risk factors for DM. Histologic pattern, T stage, N stage, LR, DM, and patient age contributed to the prediction of disease-specific survival.

CONCLUSIONS

A solid pattern, metastasis, LR, and older age are the most important factors for predicting poor prognosis in Chinese patients with ACCHN.

Salivary gland carcinomas

INTRODUCTION

Salivary gland carcinomas are rare tumours of heterogeneous morphology that require distinctive surgical and adjuvant therapy.

METHODS

Relevant studies were electronically searched in PubMed and reviewed for innovative and important information.

RESULTS

Recent insights in genetic alterations like chromosomal aberrations, expression of receptor tyrosine kinases, malfunction of tumour suppressor genes or DNA promoter methylations increased the knowledge about aetiology and pathogenesis. New histological subtypes are recognised, and a three-tiered grading system seems reasonable. Ultrasound remains the basic diagnostic imaging procedure. New developments comprise the diffusion-weighed magnetic resonance imaging, while fluorodeoxyglucose positron emission tomography/computed tomography shows good diagnostic accuracy in detecting distant metastases and local recurrence. Fine-needle aspiration cytology helps in differentiating a neoplasia from a non-neoplastic lesion while being unreliable in recognising malignancy. In contrast, additional core needle biopsy and/or intraoperative frozen section diagnosis increase the accuracy in diagnosing a malignant lesion. Conservative parotid surgery with nerve monitoring remains state-of-the-art. Free flaps or musculoaponeurotic flaps are proposed for prevention of Frey's syndrome. As parotid cancer often shows skip metastases, complete ipsilateral neck dissection (level I-V) is indicated particularly in high-grade lesions. Adjuvant radio(chemo)therapy increases local tumour control, whereas overall survival is not necessarily improved. Current results of systemic chemotherapy or targeted therapy in advanced tumour stages are disappointing.

CONCLUSION

Despite several developments, salivary gland carcinomas remain a heterogeneous group of tumours challenging both pathologists and clinicians.

Outcomes of temporal bone resection for locally advanced parotid cancer

This study was conducted to report outcomes and identify factors predictive of survival and recurrence in patients undergoing lateral temporal bone resection (LTBR) as part of an extended radical parotidectomy for parotid cancer. This is a retrospective cohort study which includes all patients undergoing LTBR for parotid cancer between 1994 and 2010 at two affiliated academic centers. Survival and recurrence rates were analyzed using the Kaplan-Meier method and Cox multivariate regression. A total of 12 patients with median follow-up duration of 30.6 months were included: 6 de novo cases and 6 patients referred after local recurrence. Actuarial locoregional control at 2 years was 73%. Most patients (11; 92%) developed disease recurrence with distant metastases the most common site of first failure (83%). Overall and disease-specific survival rates were 80% at 2 years and 22.5% at 5 years. Recurrence-free survival (RFS) was 67% at 2 years and 8.3% at 5 years. On multivariate analysis, surgical margin status was an independent predictor of RFS (hazard ratio = 3.85, p = 0.045). In advanced parotid cancer, LTBR with a goal of gross total resection offers good locoregional control with an acceptable complication rate. The benefits of this surgery must be balanced with the morbidity and low likelihood of long-term survival, with most patients ultimately experiencing disease recurrence and death.

Pleomorphic adenoma of the sublingual salivary gland: an unusual diagnostic challenge

OBJECTIVES

To describe a rare case of pleomorphic adenoma of the sublingual gland.

CLINICAL PRESENTATION AND INTERVENTION

An 80-year-old patient presented with a painless solid submucosal mass of 4 months' duration in the anterior floor of the mouth, appearing as a distinct homogeneous, radiolucent lesion in CT imaging. Histologic findings after complete removal were suggestive of a pleomorphic adenoma almost completely surrounded by a fibrous capsule. No recurrence was observed after a 12-month follow-up.

CONCLUSION

This case showed the possibility of sublingual salivary gland tumors and highlighted the need to consider them when making a differential diagnosis of masses located in the floor of the mouth.

Postoperative radiation therapy for small, low-/intermediate-grade parotid tumors with close and/or positive surgical margins

BACKGROUND

Patients with small, low-/intermediate-risk parotid cancers, treated with surgery, and who have the single prognostic factor of close and/or positive margins, constitute an unusual subset. This study evaluates local control and morbidity associated with postoperative radiation therapy for low/intermediate grade parotid cancer in these patients.

METHODS

Between 1999 and 2006, 17 patients underwent postoperative radiation therapy at Beth Israel Medical Center for acinic cell carcinoma or low-intermediate-grade mucoepidermoid carcinoma of the parotid with close/positive margins. Pathology, treatment, and follow-up data were retrospectively analyzed for morbidity and local control. Two- and 5-year estimates of survival outcomes were performed followed by an analysis of complications.

RESULTS

There were no local failures and no significant long-term complications.

CONCLUSIONS

Patients with small, low-risk cancer of the parotid gland have excellent local control and low treatment-related morbidity when receiving postoperative radiation therapy for positive or close margins of resection.

Intratemporal Grafting of the Facial Nerve following Lateral Skull Base Tumor Resection

Intratemporal skull base tumors may invade the facial nerve in the horizontal (tympanic) or descending (vertical) segments, while parotid malignancies typically infiltrate the facial nerve at the stylomastoid foramen. This article will describe our results following intratemporal facial nerve grafting in 44 patients.

METHODS

This was a retrospective analysis of 44 patients requiring intratemporal facial nerve repair following lateral skull base tumor resection at our tertiary care, academic medical center.

RESULTS

Tumor histology included 17 parotid cancers, 13 temporal bone malignancies, 9 glomus tumors, 3 facial neuromas, and 2 endolymphatic sac tumors. The greater auricular nerve was used in 25 patients and the sural nerve was used in 19 cases. Forty patients were available for facial function assessment at 2 years. Using the House-Brackmann (H-B) recovery scale, the breakdown of patients by facial function was as follows: Grade I, 0 patients; Grade II, 4 patients; Grade III, 29 patients; Grade IV, 4 patients; Grade V, 3 patients; and Grade VI, 0 patients.

CONCLUSIONS

Facial paralysis may occur from intrinsic or external lateral skull base invasion of the facial nerve. Intratemporal interposition grafting resulted in favorable facial function (H-B II or III) in 33 of the 40 (82.5%) patients at the 2-year assessment.

Clinicopathologic features as stronger prognostic factors than histology or grade in risk stratification of primary parotid malignancies

BACKGROUND

The aim of this study, using a retrospective chart review as the primary study design, was to determine the relative contribution of clinicopathologic risk factors versus low- and high-risk grade histologic groups to assist management of primary parotid cancers.

METHODS

In all, 168 primary parotid malignancies were treated surgically at a tertiary care center from 1982 to 2005. Of these, 115 patients with complete follow-up information were further analyzed. Pathologic updating and reclassification in 28% of cases enabled comparison of tumor histology or grade with current consensus criteria. Clinical outcomes of high- and low-risk histology and grade were compared with the influence of traditional clinicopathologic risk factors.

RESULTS

Of 115 cases, the male:female ratio was equal and the median age was 63 years (range, 15 to 89 years). Mucoepidermoid carcinoma (n = 28) was the most common histology. The median follow-up was 44 months (range, 0–278 months). Of low-risk histology patients who underwent neck dissection 40% had pN+ disease. The median time to recurrence was not reached for low-risk tumors, compared with 29 months for high-risk tumors (p = .0001). Interestingly, extracapsular spread (ECS) and margin status were independent prognostic factors and conferred significantly greater prognostic value than histologic grade risk group. Disease-free survival (DFS) and overall survival (OS) at 5 years for the entire cohort were 51% and 57%, respectively. Risk group was a strong independent predictor of OS but not DFS.

CONCLUSIONS

Risk group defined by histology and grade was associated with DFS. ECS and margin status were independent predictors of DFS. Inclusion of ECS and margin status substantially improved the prediction of disease recurrence, supporting elective neck dissection and postoperative radiotherapy for high-grade tumors or low-risk histologies with positive margins or ECS.

[Clinical analysis of malignant submandibular tumor]

The 14 cases of malignant submandibular tumor whose treatment outcome we analyzed between 1989 and 2008 included 5 of adenoid cystic carcinoma, 3 of squamous cell carcinoma, 2 each of mucoepidermoid carcinoma, and carcinoma ex pleomorphic adenoma, and 1 each of carcinosarcoma and large-cell carcinoma. One subject was diagnosed with T1, 7 with T2, 4 with T3, and 2 with T4. Lymph node involvement occurred in 5, -1 with N1 and 4 with N2. None had distant metastasis on the first visit. Seven were treated by surgery alone, 3 by surgery followed by radiotherapy, 2 by surgery followed by radio-and chemotherapy, and 1 by optimized supportive care. The surgical resection area was decided by tumor extension. Neck dissection was done in 9. Overall 5-year survival for all cases based on the Kaplan-Meier method was 57%. All with carcinoma ex pleomorphic adenoma, carcinosarcoma, or large-cell carcinoma remain alive. For those with adenoid cystic carcinoma 5-year survival is 80%, with mucoepidermoid carcinoma 50%, with squamous cell carcinoma 0%, and with carcinosarcoma 0%, respectively. The 5-year survival for stage I subjects was 100%, for stage II 83%, for stage III 50%, and for stage IV 0%. Surgical resection and postoperative radiotherapy were done in cases of minimal extraglandular extension or microscopically positive margins, with satisfactory results. Treatment efficacy for high-grade and advanced stage, however, requires more improvement.