Malignant tumors of major salivary gland origin. A matched-pair analysis of the role of combined surgery and postoperative radiotherapy

Establishment of prognostic nomogram for high-grade parotid gland mucoepidermoid carcinoma based on the SEER database

Purpose: We aim to investigate the clinical factors that affect the prognosis of overall survival (OS) for patients with high-grade parotid gland mucoepidermoid carcinoma (high-grade pMEC) and construct a nomogram for prognosis prediction. Subjects and method: Totally, 519 patients diagnosed as high-grade pMEC from the surveillance, epidemiology, and end results (SEER) database between 2004 and 2015 were reviewed. Independent prognostic factors for OS were identified by univariate and multivariate Cox regression analyses. Nomogram was generated to predict the individual's 3- and 5- year OS rates by using R software. Prediction ability was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC) and model calibration was evaluated through calibration plots. Decision curve analysis (DCA) was used to assess the clinical usefulness and net benefit. Results: The results of univariate analysis demonstrated that age, AJCC stage, T stage, N stage, M stage, extraparenchymal lesions, regional lymph nodes status, lymph node dissection status, radiotherapy, chemotherapy, and surgery were significantly correlated with the OS (P < 0.05). Multivariate Cox regression analyses showed that older age at diagnosis, advanced AJCC stage, and positive regional lymph nodes were independent risk factors for OS. In addition, the present study revealed that radiotherapy and surgery were independent protective factors for OS (P < 0.05). The nomograms showed accurate prognostic ability that individually predict 3-years and 5-years overall survival (OS) rates based on age, AJCC stage, regional lymph nodes status, radiotherapy, and surgery. The area under the receiver operating characteristic (ROC) curve (AUC) of the nomogram used to predict the 3-year and 5-year overall survival rate were 0.779 and 0.793, indicating that the model had a good predictive power for the overall survival in high-grade pMEC patient. Conclusions: Using the SEER database, we performed univariate and multivariate analyses to determine independent prognostic factors in high-grade pMEC patients. Subsequently, we constructed and validated a prognostic nomogram to predict 3-and 5-year OS rates based on the SEER database and can assist clinicians to intuitively evaluate prognosis of high-grade pMEC patients.

Management of Clinically Node-Negative Salivary Gland Cancer: Observation, Neck Dissection, or Neck Irradiation?

INTRODUCTION

Salivary gland malignancies are heterogeneous tumors with highly variable outcomes. Elective neck management options include observation, neck dissection (ND), and neck irradiation (NI). We sought to compare outcomes of cN0 salivary gland cancer by elective neck management.

METHODS

An IRB-approved registry was queried for cN0 salivary gland cancers and categorized based on neck management into observation, ND, NI, and ND + NI groups. cN0 included no evidence of clinical or radiographic metastatic lymphadenopathy.

RESULTS

A total of 445 patients were included with 203 in observation, 83 ND, 71 NI, and 88 ND + NI. Median follow-up was 60.8 months (range 0.4-258). There were 47% clinical T1 tumors, 29% T2, and 12% of each T3 and T4. Exactly 90% were cN0 and 10% with borderline lymph node(s). The major salivary gland was the most common site (74%) and the most common histologies included 28% mucoepidermoid and 20% adenoid cystic. Risk factors associated with regional recurrence include age, borderline lymph node features, pathologic T and N stage, poorly differentiated, positive margin, lymphovascular space invasion, and extranodal extension (all p < 0.05). There was no significant difference in local (9.9%-16.7%, p = 0.6) or regional (3.9%-9.4%, p = 0.76) recurrence between all four groups. Five-year distant recurrence was significantly different at 7% for observation, 16% in ND, 25% in NI, and 37% in ND + NI (p < 0.001). Ten-year OS estimates were 78% for observation, 66% for ND, 69% for NI, and 52% in ND + NI (p < 0.001).

CONCLUSION

For patients with cN0 salivary gland cancer, ND and NI yield similar regional control in appropriately selected patients. In high-risk patients with several adverse risk features ND + NI results in favorable regional control but distant metastasis is a driving factor affecting overall survival.

Facility Volume and Changing Facilities for Postoperative Radiotherapy in Salivary Gland Cancer

OBJECTIVES

Changing location of postoperative radiotherapy (PORT) after treatment at a high-volume facility (HVF) is associated with worse survival in various head and neck cancers. Our study investigates this relationship in salivary gland cancer (SGC).

METHODS

The 2004-2016 National Cancer Database was queried for all cases of adult SGC treated with surgery and PORT with or without adjuvant chemotherapy. Patients with multiple cancer diagnoses, metastatic disease, or unknown PORT facility were excluded. Reporting facilities with >95th percentile annual case volume were classified as HVFs, the remainder were classified low-volume facilities (LVFs).

RESULTS

A total of 7885 patients met inclusion criteria, of which 418 (5.3%) were treated at an HVF. Patients treated at an HVF had higher rates clinical nodal positivity (18.2% vs. 14.0%, p < 0.001) and clinical T3/T4 (27.3% vs. 20.7%, p = 0.001) disease. Patients at HVFs changed facility for PORT at lower rates (18.9% vs. 24.5%, p = 0.009). Patients treated at an HVF had higher 5-year overall survival (5-OS) than those treated at an LVF (79.0% vs. 72.0%, p = 0.042). Patients treated at an HVF that changed PORT facility had worse 5-OS (60.8% vs. 83.2%, p < 0.001). Radiation facility change was an independent predictor of worse survival in patients treated at an HVF (HR: 8.99 [3.15-25.67], p < 0.001) but not for patients treated at a LVF (HR: 1.11 [0.98-1.25], p = 0.109).

CONCLUSIONS

Patients treated at an HVF changing facility for PORT for SGC experience worse survival. Our data suggest patients treated surgically at an HVF should be counseled to continue their PORT at the same institution.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:4935-4946, 2024.

Prognostic factors for development of distant metastases in surgically treated high-grade salivary gland carcinomas: results of retrospective single center study with 213 patients

PURPOSE

Distant metastases (DM) are the primary cause of treatment failure and death of patients with salivary gland carcinomas (SGC). The purpose of present study was to evaluate factors predictive on DM development in a cohort of patients with high-grade salivary gland carcinomas.

METHODS

This was a retrospective cohort study of consecutive patients surgically treated with curative intention at the authors' institution from January 1993 to December 2018. Outcomes evaluated were overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DMFS).

RESULTS

A total of 213 patients, 117 males (55%) and 96 females (45%), were included in the study. Parotid gland malignancies accounted for 56% of all cases. Adenoid cystic carcinoma (119 cases; 56%) was the most common tumor type. Cumulative OS for the 5-and 10-year follow-up period was 80% and 58% respectively. DM occurred with 75 patients (35%). The most common locations for DM were lung (55 cases; 73%) and liver (12 cases; 16%). Pathological nodal status, particularly the number of metastatic nodes, was the independent prognostic factor for OS, DSS, RFS and DMFS.

CONCLUSION

Number of metastatic lymph nodes, instead of extranodal extension and largest nodal diameter, was the contributing factor related to DMFS. Since the main function of staging system is to predict outcomes, the significance of extranodal extension and nodal dimension in salivary gland cancer staging system requires further clarification. The elective neck dissection could be considered therapeutic approach for high-grade SGC since occult metastases were detected in 33% of cases.

Patterns and Trends in Adjuvant Therapy for Major Salivary Gland Cancer

OBJECTIVE

To investigate adjuvant therapy indications, utilization, and associated survival disparities in major salivary gland cancer (MSGC).

STUDY DESIGN

Retrospective cohort study.

SETTING

The 2006 to 2017 National Cancer Database.

METHODS

Patients with surgically resected MSGC were included (N = 11,398). pT3-4 classification, pN2-3 classification, lymphovascular invasion, pathologic extranodal extension (pENE), and positive surgical margin (PSM) were considered indications for adjuvant radiotherapy (aRT). pENE and PSM were considered possible indications for adjuvant chemotherapy. Multivariable logistic and Cox regression models were implemented.

RESULTS

Among 6694 patients with≥ $\ge $ 1 indication for aRT, 1906 (28.5%) received no further treatment and missed aRT. Age, race, comorbidity status, facility type, and distance to reporting facility were associated with missed aRT (P < .025). Among 4003 patients with ≥1 possible indication for adjuvant chemoradiotherapy (aCRT), 914 (22.8%) received aCRT. Patients with pENE only (38.5%) and both pENE and PSM (44.0%) received aCRT more frequently than those with PSM only (17.0%) (P < .001). Academic facility was associated with aCRT utilization (P < .05). aCRT utilization increased between 2006 and 2017 in both academic (14.8% vs 23.9%) and nonacademic (8.8% vs 13.5%) facilities (P < .05). Among 2691 patients with ≥1 indication for aRT alone, missed aRT portended poorer OS (hazard ratio [HR]: 1.61, 95% confidence interval [CI]: 1.28-2.03, P < .001). Among 4003 patients with ≥1 possible indication for aCRT, aRT alone (HR: 1.02, 95% CI: 0.89-1.18, P = .780) and aCRT were associated with similar OS.

CONCLUSION

Missed aRT in MSGC occurs frequently and portends poorer OS. Further studies clarifying indications for aCRT are required.

The protective role of postoperative radiation therapy in low and intermediate grade major salivary gland malignancies: A study of the Canadian Head and Neck Collaborative Research Initiative

BACKGROUND

The objective of this study was to examine the utility of postoperative radiation for low and intermediate grade cancers of the parotid and submandibular glands.

METHODS

The authors conducted a retrospective, Canadian-led, international, multi-institutional analysis of a patient cohort with low or intermediate grade salivary gland cancer of the parotid or submandibular gland who were treated from 2010 until 2020 with or without postoperative radiation therapy. A multivariable, marginal Cox proportional hazards regression analysis was performed to quantify the association between locoregional recurrence (LRR) and receipt of postoperative radiation therapy while accounting for patient-level factors and the clustering of patients by institution.

RESULTS

In total, 621 patients across 14 tertiary care centers were included in the study; of these, 309 patients (49.8%) received postoperative radiation therapy. Tumor histologies included 182 (29.3%) acinic cell carcinomas, 312 (50.2%) mucoepidermoid carcinomas, and 137 (20.5%) other low or intermediate grade primary salivary gland carcinomas. Kaplan-Meier LRR-free survival at 10 years was 89.0% (95% confidence interval [CI], 84.9%-93.3%). In multivariable Cox regression analysis, postoperative radiation therapy was independently associated with a lower hazard of LRR (adjusted hazard ratio, 0.53; 95% CI, 0.29-0.97). The multivariable model estimated that the marginal probability of LRR within 10 years was 15.4% without radiation and 8.8% with radiation. The number needed to treat was 16 patients (95% CI, 14-18 patients). Radiation therapy had no benefit in patients who had early stage, low-grade salivary gland cancer without evidence of nodal disease and negative margins.

CONCLUSIONS

Postoperative radiation therapy may reduce LLR in some low and intermediate grade salivary gland cancers with adverse features, but it had no benefit in patients who had early stage, low-grade salivary gland cancer with negative margins.

[Radiotherapy of rare head and neck tumors]

Management of head and neck tumors is complex because of multiple anatomical locations and histologies possibilities. Rare tumors must be managed in a specialized center and be registered in the French network of expertise on ENT Cancers (Refcor). Despite heterogeneous levels of evidence, radiotherapy plays an essential role in their treatment. Radiation therapy is generally indicated in the adjuvant setting, or in case of non-operability. Dose and target volumes depend on histology, location and extensions of the tumor, and the quality of the excision if applicable. We present here a review of the literature and available guidelines for the management by radiotherapy of rare upper aerodigestive tract 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.

Clinicopathological Predictors of Survival for Parotid Mucoepidermoid Carcinoma: A Systematic Review

OBJECTIVE

Various prognostic factors are associated with the survival of patients with parotid mucoepidermoid carcinoma (MEC). The aim of this systematic review is to summarize the clinical and pathologic prognostic factors on survival outcomes in patients with parotid MEC.

DATA SOURCES

Articles published from database inception to July 2020 on OVID Medline, OVID Embase, Cochrane Central, and Scopus.

REVIEW METHODS

Studies were included that reported clinical or pathologic prognostic factors on survival outcomes for adult patients with parotid MEC. Data extraction, risk of bias, and quality assessment were conducted by 2 independent reviewers.

RESULTS

A total of 4290 titles were reviewed, 396 retrieved for full-text screening, and 18 included in the review. The average risk of bias was high, and quality assessment for the prognostic factors ranged from very low to moderate. Prognostic factors that were consistently associated with negative survival outcomes on multivariate analysis included histologic grade (hazard ratio [HR], 5.66), nodal status (HR, 2.86), distant metastasis (HR, 3.10-5.80), intraparotid metastasis (HR, 13.52), and age (HR, 1.02-6.86). Prognostic factors that inconsistently reported associations with survival outcomes were TNM stage, T classification, and N classification.

CONCLUSION

Histologic grade, nodal status, distant metastasis, intraparotid metastasis, and age were associated with worse survival outcomes. These prognostic factors should be considered when determining the most appropriate treatment and follow-up plan for patients with parotid MEC.

Survival outcomes, prognostic factors, and effect of adjuvant radiotherapy and prophylactic neck dissection in salivary acinic cell carcinoma: A prospective multicenter REFCOR study of 187 patients

BACKGROUND

Acinic cell carcinomas (AciCCs) are malignant tumours of the salivary glands. The aim of this work was to analyse data from the national REFCOR multicenter cohort (i) to investigate the prognostic factors influencing survival outcomes in AciCC, (ii) to assess the impact on survival of postoperative radiotherapy (RT) in patients treated for AciCC without high-grade transformation and (iii) to explore the prognostic impact of prophylactic neck dissection (ND) in patients treated for AciCC of the major salivary glands.

PATIENTS AND METHODS

Data from all the patients treated for salivary AciCC between 2009 and 2020 were extracted from the REFCOR database. Survival outcomes and prognostic factors influencing Disease-Free Survival (DFS) and Overall Survival (OS) were investigated using univariate and multivariate analyses. Propensity score matching was used to assess the impact of postoperative RT and prophylactic ND on DFS.

RESULTS

A total of 187 patients were included. After a median follow-up of 53 months, their 5-year OS and DFS rates were 92.8% and 76.2%, respectively. In multivariate analysis, male sex, older age, higher T and N status, and high grade were independently associated with a worse DFS. In the subpopulation analysed after propensity score matching, patients with cN0 AciCC without high-grade transformation who were treated by surgery and RT did not have an improved DFS compared to patients who were treated by surgery alone (hazard ratio (HR) = 0.87, p = 0.8). Factors associated with nodal invasion were T3-T4 status and intermediate/high histological grade. After propensity score matching, prophylactic ND was associated with a trend toward a better DFS (HR = 0.46, p = 0.16).

CONCLUSIONS

These results suggest that (i) long-term follow-up (>5 years) should be considered in patients with AciCC, (ii) treatment by surgery alone could be an option in selected cN0 patients with AciCC without high-grade transformation and (iii) prophylactic ND may be considered preferentially in patients with T3-T4 status and/or intermediate/high histological grade.

Adjuvant radiotherapy in node-negative salivary malignancies of the parotid gland: A multi-institutional analysis

BACKGROUND AND PURPOSE

To determine the role of adjuvant radiotherapy (ART) in parotid gland cancer without nodal metastasis, we evaluated the survival outcomes, prognostic factors, and dose-response relationships in patients with node-negative parotid gland cancer patients.

MATERIALS AND METHODS

Patients who underwent curative parotidectomy and were pathologically diagnosed with parotid gland cancer without regional or distant metastases between 2004 and 2019 were reviewed. The benefit of ART in terms of locoregional control (LRC) and progression-free survival (PFS) were evaluated.

RESULTS

In total, 261 patients were included in the analysis. Of them, 45.2 % received ART. The median follow-up period was 66.8 months. Multivariate analysis revealed that histological grade and ART were independent prognostic factors for LRC and PFS (all p <.05). For patients with high-grade histology, ART was associated with a significant improvement in 5-year LRC (p =.005) and PFS (p =.009). Among patients with high-grade histology who completed RT, higher biologic effective dose (≥77 Gy10) significantly increased PFS (adjusted hazard ratio [HR], 0.10 per 1-Gy increase; 95 % confidence interval [CI], 0.02-0.58; p =.010). ART significantly improved LRC (p =.039) in patients with low-to-intermediate histological grade as well per multivariate analysis, and subgroup analyses revealed patients with T3-4 stage and close/positive resection margins (<1 mm) would benefit from ART.

CONCLUSION

ART should be strongly recommended for patients with node-negative parotid gland cancer with high-grade histology in terms of disease control and survival. In patients with low-to-intermediate-grade disease, those with high T stage and incomplete resection margin benefit with ART.

Predictive factors for survival and treatment outcomes of patients with minor salivary gland malignancies: a retrospective study

INTRODUCTION

Aim of this study was to explore the incidence, pathology, clinical behaviour and evaluate factors predictive on survival and treatment outcomes in a cohort of patients with minor salivary gland (MiSG) malignancies treated at a single center over a period of 25 years.

MATERIALS AND METHODS

Patients who had received primary treatment for MiSG malignancy during 25 years observation period were identified. Outcomes that were evaluated were overall survival (OS), disease specific survival (DSS), recurrence free survival (RFS), locoregional recurrence free survival (LRFS) and distant metastasis free survival (DFS).

RESULTS

A total of 88 patients with MSG malignancies were included in the study. The most common location for MiSG malignancies was the oral cavity (65 tumors; 77%). Cumulative OS for 5 and 10 year follow up period was 82% and 62% respectively. Cumulative DSS for 5 and 10 year follow up period was 85% and 73% respectively. Twenty one (23%) patients developed distant metastases during follow-up. High-grade pathology and tumor stage were significant variables on multivariate analysis for all survival and treatment outcomes.

CONCLUSIONS

Minor salivary gland malignancies are minor only by name. Tumor histological grade, AJCC tumor stage and pT stage were the strongest predictive factors for survival and treatment outcomes. The elective neck dissection could be considered therapeutic approach for selected cases of high grade MiSG malignancies. Distant metastases were the main cause of death and treatment failure.

The effect of adjuvant radiotherapy on clinical outcomes in early major salivary gland cancer

BACKGROUND

This study investigated the effects of adjuvant radiotherapy on outcomes in early-stage major salivary gland cancers.

METHODS

A total of 655 patients were identified, including 355 (54.2%) received adjuvant radiotherapy and 300 (45.8%) had surgery alone. The effect of adjuvant radiotherapy on 5-year locoregional recurrence and disease-specific survival (DSS) was calculated using the Kaplan-Meier method, Wilcoxon rank sum test, and Cox proportional hazards model.

RESULTS

There were no significant differences in locoregional recurrence and DSS between patients receiving adjuvant radiotherapy and those not in both univariate and multivariable analysis. Although patients with positive margin status had a higher locoregional recurrence and those with moderate/poor differentiation had a worse DSS, stratified analysis still indicated there were no protective effects from the use of adjuvant radiotherapy.

CONCLUSIONS

The use of adjuvant radiation therapy was not associated with improved locoregional recurrence and DSS, even for those with high-risk histopathological factors.

Estimating survival after salvage surgery for recurrent salivary gland cancers: Systematic review

Recurrent salivary gland carcinomas (RSCs) are poorly characterized and their clinical features and treatment options have not yet been fully described. The goal of this study was to analyze the therapeutic strategies and oncological outcomes of RSC patients through a literature review analysis. This systematic review was performed according to the PRISMA statements. Inclusion criteria for the systematic review were based on the population, intervention, comparison, and outcomes according to (PICO) framework. Two thousand seven hundred and four records were selected and 1817 recurrences were studied. Three hundred and sixty-five patients underwent salvage surgery (20.1%) and their 5-year mortality rate, overall survival and disease-free survival were 35%, 70%, and 42%, respectively. RSCs are aggressive neoplasms with a high rate of distant metastases (28.9%). Salvage surgery can be considered in patients with limited local and/or regional recurrences, even in case of single distant relapse, appearing within the first 3 years of follow-up.

[Radiation therapy of malignant salivary gland tumors]

Due to their rarity, histologic heterogeneity, and localization, treatment of malignant salivary gland tumors requires an interdisciplinary approach. First-line treatment includes complete tumor resection. Postoperative radiation therapy is advised in patients with risk factors, i.e., incomplete tumor resection, high-grade tumors, or perineural invasion. Definitive radiation therapy is only advised for inoperable tumors because of significantly lower local control and survival rates when compared to combined surgery and radiation therapy. In radiation oncology, modern techniques such as intensity-modulated radiation therapy (IMRT) or particle therapy with heavy ions (i.e., C12) have led to improved outcomes in the treatment of head and neck tumors, especially of adenoid cystic carcinomas. Given the biological and physical benefits of particles, particle therapy, particularly carbon ion radiation, is a promising therapeutic approach for salivary gland tumors that will be further investigated in prospective clinical studies.

Evaluation of Surgical Margin Status in Patients With Salivary Gland Cancer

Importance

Salivary gland cancer comprises a diverse group of histologic types with different biological behavior. Owing to this heterogeneity, the association of margin status and postoperative adjuvant radiotherapy has been poorly studied.

Objective

To examine the association between surgical margin status and oncologic outcomes and the subsequent outcome of adjuvant radiotherapy in patients with salivary gland carcinomas.

Design, Setting, and Participants

This cohort study analyzed data from institutional records at Memorial Sloan Kettering Cancer Center from 1985 to 2015. Statistical analysis was completed on October 31, 2020. After exclusions, 837 patients with surgically treated salivary gland carcinoma were identified. Surgical margins and histologic characteristics identified from pathology reports were recorded, with margins classified as negative, close, and positive, and individual histologic types classified into 3 risk groups: low, intermediate, and high.

Exposures

The outcome of adjuvant radiotherapy was determined in patients with close margins with low- and intermediate-risk histologic type and overall pathologic stage I/II disease.

Main Outcomes and Measures

Disease-specific survival (DSS) and local recurrence-free survival (LRFS) outcomes were calculated using the Kaplan-Meier method. Multivariable analysis was performed using the Cox proportional hazards regression model. A planned subgroup analysis of patients with close margins was conducted.

Results

Among the 837 patients identified, 438 were women (52.3%); median age at surgery was 58 years (range, 6-98). A total of 399 tumors (47.7%) originated from major salivary glands, and 438 (52.3%) from minor salivary glands. Margin positivity rates were not different between minor and major salivary gland tumors. Positive surgical margins were identified in 252 patients (30.1%), with nasal cavity/paranasal sinuses and trachea/larynx subsites as the most common sites. Close margins were recorded in 203 patients (24.3%). Adjuvant radiotherapy was administered in 80.5% (103 of 128) of patients with major salivary gland cancer with positive margins, 58.8% (60 of 102) with close margins, and 30.7% (52 of 169) with negative margins and in 70.2% (87 of 124), 36.6% (37 of 101) , and 19.7% (42 of 213) patients with minor salivary gland cancer. With median follow up time of 57 months (range, 1-363 months), patients with positive margins had poorer DSS and LRFS. However, after controlling for overall stage, histologic risk group, and adjuvant radiotherapy, margin status was not a factor associated with poorer DSS or LRFS. In patients with close margins, low-risk and intermediate-risk histologic type, and overall pathologic stage I/II, patients who did not have adjuvant radiotherapy had comparable local control with those who received adjuvant radiotherapy.

Conclusions and Relevance

The findings of this cohort study suggest that patients with salivary gland cancer who have either close or positive surgical margins are at increased risk for poorer local control and survival. After controlling for tumor stage, histologic risk group, and the use of adjuvant radiotherapy, margin status was not an independent factor associated with poorer outcome. Subgroup analyses showed that care for patients with close margins with low-risk or intermediate-risk histologic type who have stage I/II cancers might be managed safely without adjuvant radiotherapy.

Management of Non-High-Risk Salivary Gland Carcinomas With Surgery Alone

Background

Risk stratification and appropriate treatment selection are essential for the management of head and neck malignancies, in order to optimize long-term outcomes. Salivary gland carcinomas (SGCs) pose a particular challenge due to their extensive biologic heterogeneity. Primary surgical resection remains the mainstay of treatment; however, outcomes with single modality therapy for 'non-high-risk' lesions are less elucidated in the literature present on the subject. We present our experience with non-high-risk salivary gland malignancies treated by surgery alone. 

Methods

A retrospective analysis of SGCs from 1998-2011 was completed after receiving Institutional Review Board approval. Patient demographic, tumor, treatment, and outcome data were obtained from chart review. The primary outcomes of interest were overall survival (OS) and recurrence-free survival (RFS).

Results

Of the 62 patients identified, 49 patients underwent resection of the primary tumor alone, while an ipsilateral selective neck dissection was included for 13 patients. The median follow-up was 5.05 years. Of the tumors, 79% were low-intermediate grade, 3% high grade, and 17% poorly classified. The OS and RFS were 91% and 87% at five years and 80% and 79% at 10 years, respectively. The combined failure rate of local, regional, and distance was 13%.

Conclusion

Surgery alone is an appropriate treatment strategy for patients with non-high-risk salivary gland malignancy, affording a high likelihood of long-term RFS and OS.

Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

OBJECTIVES

Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear.

STUDY DESIGN

retrospective study.

SETTING

Multicentric.

SUBJECTS AND METHODS

We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors.

RESULTS

A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors.

CONCLUSIONS

Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

High-grade salivary gland cancer: is surgery followed by radiotherapy an adequate treatment to reach tumor control? Results from a tertiary referral centre focussing on incidence and management of distant metastases

Purpose

Salivary Gland cancer (SGC) is a rare and heterogenous group of tumors. Standard therapeutic options achieve high local but poor distant control rates, especially in high-grade SGC. The aim of this monocentric study was to evaluate patterns of recurrence and its treatment options (local ablative vs. systemic) in a homogenously treated patient population with high-grade SGC after surgery and radio(chemo)therapy.

Methods

Monocentric, retrospective study of patients with newly diagnosed high-grade salivary gland cancer. We retrospectively reviewed clinical reports from 69 patients with high-grade salivary gland cancer in a single-center audit. Survival rates were calculated using the Kaplan–Meier method and prognostic variables were analyzed (univariate analysis: log-rank test; multivariate analysis: Cox regression analysis).

Results

The median time of follow-up was 31 months. After 5 years, the cumulative overall survival was 65.2%, cumulative incidence of local recurrence was 7.2%, whereas the cumulative incidence of distant metastases was 43.5% after 5 years. 30 of 69 patients developed distant metastases during the time of follow-up, especially patients with adenoid cystic carcinoma, salivary duct carcinoma, adenocarcinoma NOS and acinic cell carcinoma with high-grade transformation. The most common type of therapy therefore was chemotherapy (50%). 85.7% of patients with local ablative therapy of distant metastases show disease progression during follow-up afterwards.

Conclusion

With surgery and radio-chemotherapy, a high rate of loco-regional control is reached, but over 40% of patients develop distant metastases in the further follow-up which usually present a diffuse pattern involving in a diffuse metastases. Therefore, in the future, intensified interdisciplinary combination therapies even in the first-line treatment in certain subtypes of high-grade SGC should be investigated.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-07024-9.

Diagnostic discrepancy in second opinion reviews of primary epithelial neoplasms involving salivary gland: An 11-year experience from a tertiary referral center focusing on useful pathologic approaches and potential clinical impacts

AIMS

In the era of precision medicine, accurate pathologic diagnoses are crucial for appropriate management.

METHODS

We herein described the histologic features and clinical impacts of 66 salivary gland epithelial neoplasms in which the diagnosis was altered after expert review.

RESULTS

The most common revised diagnosis was that of salivary duct carcinoma (SDC, n = 12), adenoid cystic carcinoma (n = 12), and myoepithelial carcinoma (n = 10). The most common initial diagnosis was mucoepidermoid carcinoma (n = 19) with SDC being the most common revised diagnosis (7/19). Thirteen salivary gland carcinomas were initially diagnosed as benign entities, whereas five benign tumors were initially interpreted as carcinoma. The change in diagnosis was considered to be clinically significant in 65 (97%) cases.

CONCLUSIONS

Given their rarity, salivary gland neoplasms are prone to diagnostic inaccuracy and discrepancy. A constellation of histologic features and ancillary studies are useful in reaching the correct diagnosis, which can have significant clinical impacts.

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.

The Role of Postoperative Radiotherapy and Prognostic Model in Primary Squamous Cell Carcinoma of Parotid Gland

Background

Primary squamous cell carcinoma of parotid gland (parotid SCC) is a high malignant histologic subtype of parotid cancers with aggressive clinical presentation. However, the clinical features and survival benefit of postoperative radiotherapy (PORT) for primary parotid SCC are not well known.

Methods

A retrospective population-based study was performed to identify the role of PORT in parotid SCC patients diagnosed between 1975 and 2016 from SEER database. A prognostic risk model was established based on patient clinical features, including age, tumor stage, and node involvement status. Patients were stratified into high, intermediate, and low risk according to this model. The survival benefit of radiotherapy was compared in the whole cohort and different risk groups.

Results

Nine hundred thirty-one parotid SCC patients were extracted from SEER database, 634 (68.1%) in the RT group and 286 (30.7%) in the non-RT group. Overall, 503 (54.0%) deaths occurred, with a median follow-up of 84 months, the 5-year OS was 43.6% in the whole cohort, 47.7 vs 35.9% in patients with/without PORT (P = 0.005), and 58.9 vs. 38.8 vs. 27.1% in low-, intermediate-, and high-risk group (P < 0.001). Compared with surgery alone, PORT significantly improved the OS of patients with medium risk (47.5 vs. 20.6, P < 0.001), whereas not in the low risk (61 vs. 54%, P = 0.710) and high (25.6 vs. 28.7%, P = 0.524).

Conclusion

This prognostic model can separate the patients with parotid squamous cell carcinoma into different risk. PORT significantly improved the OS of patients with intermediate risk, whereas high-risk group may need more intensive treatment strategies.

Treatment outcomes of elderly salivary gland cancer patients undergoing radiotherapy - Results from a large multicenter analysis

BACKGROUND AND PURPOSE

To evaluate oncological outcomes and treatment-related toxicities of elderly salivary gland cancer patients undergoing (chemo)radiotherapy.

MATERIAL AND METHODS

Local/locoregional control (LRC), progression-free survival (PFS) and overall survival (OS) of elderly patients ≥ 65 years with primary salivary gland cancers undergoing (chemo)radiotherapy between 2005 and 2020 at three tertiary cancer centers were calculated. The impact of clinicopathological and treatment parameters on outcomes were analyzed, and acute and chronic toxicities were quantified.

RESULTS

288 elderly salivary gland cancer patients were included in this multicenter analysis, and their median LRC, PFS and OS amounted to 113, 39 and 75 months, respectively. Age, performance status, comorbidities, definitive vs. adjuvant (chemo)radiotherapy as well as locally/locoregionally advanced cancers and distant metastases correlated with reduced outcomes in elderly salivary gland patients. Patients receiving dose-escalated radiotherapy (total doses > 70 Gy_EQD2) with carbon ion boost radiation resulted in improved LRC, but no improvements in PFS or OS. Concomitant chemoradiotherapy did not improve treatment outcomes in elderly salivary gland carcinoma patients. Radiotherapy of elderly salivary gland cancer patients resulted in moderate higher-grade toxicities despite dose escalation with 70 (24.3%) and 48 patients (16.7%) experiencing acute and chronic grade 3 toxicities, respectively. No grade 4/5 toxicities were observed in this patient cohort.

CONCLUSION

Data from the largest multicenter analysis of elderly salivary gland cancer patients undergoing (chemo)radiotherapy demonstrate favorable LRC and tolerable toxicity rates. Decision-making for these vulnerable patients should be based on patient performance rather than chronological patient age.

Rate of Occult Neck Nodal Metastasis in Parotid Cancer: A Meta-Analysis

BACKGROUND

The risk for occult neck nodal metastasis in carcinoma of the parotid gland is inconclusive. Therefore, addressing a negative neck prophylactically and the extent to do so remain controversial. This systematic review aimed to determine the rate of occult nodal metastasis for each neck level, and consequently, to elucidate the proper extent of elective neck dissection (END).

METHODS

A meta-analysis of all studies that included patients with a diagnosis of parotid malignancies who underwent an END was performed. The risk for occult nodal metastasis was calculated for each neck level separately.

RESULTS

The search strategy identified 124 papers from January 1980 to December 2019 in the various databases. Nine retrospective studies (n =548) met the inclusion criteria. The risk for occult neck nodal metastasis ranged from 0.0 to 9.43% with a random-effect model of 2.2% for level 1 (n =459), from 3.4 to 28.38% with a random-effect model of 16.51% for level 2 (n =548), from 0.0 to 21.63% with a random-effect model of 4.23% for level 3 (n =518), from 0.0 to 17.02% with a fixed-effect model of 0.39% for level 4 (n =310), and from 0.0 to 11.63% with a fixed-effect model of 1.7% for level 5 (n =417).

CONCLUSION

The rate of occult neck nodal metastasis in parotid malignancies is low, with neck level 2 the most commonly involved. The results of this meta-analysis prevented the authors from substantiating the appropriate extent of an END in parotid cancer.

An evidence-based analysis of the management of N0 neck in patients with cancer of the parotid gland

Introduction: Management of clinically negative neck (cN0) in patients with parotid gland cancer is controversial. Treatment options can include observation, elective neck dissection or elective radiotherapy. Areas covered: We addressed the treatment options for cN0 patients with parotid gland cancer. A literature review was undertaken to determine the optimal management of this group of patients. Expert opinion: Patients with parotid carcinoma and clinically negative neck have various options for their management. The analysis of tumor stage, histology and grade is essential to better define patients at risk for occult lymph node metastasis. These patients can be managed by surgery, radiotherapy or their combination, depending on the presence of risk factors, the moment at which such risk factors are detected, patient-related clinical conditions, medical provider expertise and institutional facilities.

Proton Beam Therapy for Locally Recurrent Parotid Gland Cancer

The aim of this study was to evaluate the efficacy and safety of proton beam therapy for patients with locally recurrent parotid cancer. Between 2009 and 2012, ten patients with locally recurrent parotid gland cancer were treated with proton beam therapy (70.2 Gy equivalents in 32 fractions) with or without intra-arterial infusion chemotherapy of cisplatin (50 mg/body/week, for a total of 5-8 weeks). The median follow-up was 24 months (range 10-49 months). The 1-year overall survival and local control rates were 80 %, and the 3-year overall survival and local control rates were 60 %. None of the patients experienced grade 3-5 toxicities in the treatment or the follow-up periods. These findings suggest that proton beam therapy could be applied effectively and safely for patients with locally recurrent parotid gland cancer.

Concurrent Chemoradiotherapy in the Adjuvant Treatment of High-risk Primary Salivary Gland Malignancies

OBJECTIVES

Adjuvant radiation therapy (RT) is indicated for patients with salivary gland malignancies with risk factors for recurrence following resection. We analyzed patients treated with adjuvant RT with or without concurrent chemotherapy to determine the impact of prognostic and treatment factors.

MATERIALS AND METHODS

Retrospective analysis was performed of 128 patients treated with surgical resection followed by intensity-modulated radiotherapy. In total, 31 (24.2%) patients were treated with concurrent chemoradiotherapy. The Kaplan-Meier method was used to estimate rates of progression-free survival (PFS), local-regional control, distant control, overall survival. Multivariable Cox regression was performed to evaluate factors significant on univariate analysis.

RESULTS

The 5-year rates of PFS, local-regional control, freedom-from distant metastasis, and overall survival were 61.2%, 85.8%, 76.5%, and 73.7%, respectively. Predictors of decreased PFS on univariate analyses were age, tumor stage, nodal stage, positive surgical margins, histology, high grade, perineural invasion, lymphovascular space invasion, extranodal extension, and use of chemoradiotherapy. On multivariable analysis, elevated T-stage, positive surgical margins, and presence of extranodal extension were predictive of decreased PFS. The acute toxicity rates were 30.3% grade 1, 51.5% grade 2, 11.4% grade 3, and 0.8% grade 4. There was no difference in rates of grade 3 or higher acute toxicity with use of RT alone versus chemoradiotherapy (P=0.183).

CONCLUSIONS

Use of chemoradiotherapy for adjuvant treatment of salivary gland malignancies was well-tolerated, but no improvement in survival was seen with the use of chemoradiotherapy in both the overall study population and a subset with high-risk features. Caution should be used when using this modality until randomized evidence becomes available.

[Delineation of the primary tumour clinical target volumes and neck node levels selection of parotid cancers]

Salivary glands tumours are uncommon tumours showing a large diversity of histological types. This article presents a synthesis of patterns and paths of invasion of parotid glands tumours in order to propose an approach of the delineation of primary tumour clinical target volumes and of the selection of lymph nodes target volumes. This article does not discuss treatment indications but defines clinical target volumes to treat if radiotherapy is indicated. Postoperative situation being the most frequent, the delineation of primary tumour clinical target volume is based on an anatomical approach.

Mucoepidermoid Carcinoma of the Parotid: Very Close Margins and Adjuvant Radiotherapy

BACKGROUND/AIMS

The importance of adjuvant radiotherapy in patients with close margin resections for mucoepidermoid carcinoma of the parotid gland remains unclear.

METHODS

Patients who underwent parotidectomy for mucoepidermoid carcinoma with or without adjuvant radiotherapy at a single academic tertiary care center from 2000 to 2014 were identified. Included patients had negative but close (≤2 mm) surgical margins without other high-risk histopathological factors including advanced T-stage, positive nodal disease, lymphovascular or perineural invasion, or high-grade histology.

RESULTS

Nineteen patients were identified, of whom 15 (79%) were observed postoperatively, while 4 (21%) underwent adjuvant radiotherapy. There were no significant differences in extent of parotidectomy, elective neck dissection, T staging, or tumor size between patients who were observed and those undergoing adjuvant radiation. There were no locoregional or distant recurrences in any patients at a mean follow up 74.3 months. Patients undergoing adjuvant radiation, however, had significantly more intermediate-grade as compared to low-grade histology (75% vs. 13%, difference 62%, 95% CI 4% to 100%).

CONCLUSIONS

Patients with negative but close (≤2 mm) surgical margins without other high-risk histopathological factors have excellent long-term locoregional control with surgery alone. The effects of adjuvant radiotherapy for those who have intermediate-grade disease remain uncertain.

Survival Impact of Adjuvant Therapy in Salivary Gland Cancers following Resection and Neck Dissection

Objective

To evaluate the impact of postoperative radiotherapy (PORT) and chemotherapy on survival in salivary gland cancer (SGC) treated with curative-intent local resection and neck dissection.

Study Design

Retrospective population-based cohort study.

Setting

National Cancer Database.

Subjects and Methods

Patients with SGC who were undergoing surgery were identified from the National Cancer Database between 2004 and 2013. Neck dissection removing a minimum of 10 lymph nodes was required. Because PORT violated the proportional hazards assumption, this variable was treated as a time-dependent covariate.

Results

Overall, 4145 cases met inclusion criteria (median follow-up, 54 months). PORT was associated with improved overall survival in multivariable analysis, both ≤9 months from diagnosis (hazard ratio [HR], 0.26; 95% CI, 0.20-0.34; P < .001) and >9 months (HR, 0.75; 95% CI, 0.66-0.86; P < .001). In propensity score–matched cohorts, 5-year overall survival was 67.1% and 60.6% with PORT and observation, respectively ( P < .001). Similar results were observed in landmark analysis of patients surviving at least 6 months following diagnosis. Adjuvant chemotherapy was not associated with improved survival (HR, 1.15; 95% CI, 0.99-1.34; P = .06).

Conclusion

PORT, but not chemotherapy, is associated with improved survival among patients with SGC for whom neck dissection was deemed necessary. These results are not applicable to low-risk SGCs not requiring neck dissection.

The efficacy of neutron radiation therapy in treating salivary gland malignancies

OBJECTIVES

Radiation therapy is commonly used to treat head and neck malignancies. While there is abundant research regarding photon radiation therapy, literature on neutron radiotherapy (NRT) and oral complications is limited. This study aims to determine: (1) the 6-year and 10-year locoregional control and survival rates, (2) factors associated with locoregional control and survival and (3) the frequency of oral complications in patients undergoing NRT for salivary gland malignancies.

MATERIALS AND METHODS

This is a retrospective cohort study. The sample was composed of patients with salivary gland malignancies treated with NRT between 1997 and 2010. Data were extracted from patient charts, telephone surveys, and social security records. Multivariate competing risk and Cox regression models were used to assess predictors of locoregional control and survival.

RESULTS

The sample was composed of 545 subjects with a mean age of 54.2 years (±16). The predominant tumor and location were adenoid cystic carcinoma (47%) and the parotid (56%). Multivariate analysis indicated that positive surgical margins, biopsied/inoperable malignancies, neck involvement, and lymphovascular invasion were prognostic risk factors associated with decreased survival. The 6- and 10-year locoregional control rates were 84% and 79%. The 6- and 10-year survival rates were 72% and 62%. Osteoradionecrosis developed in 3.4% of subjects.

CONCLUSIONS

The 6- and 10-year locoregional control and survival rates compare favorably to rates reported for conventional photon radiation. Osteoradionecrosis rates were comparable to that of photon radiation treatment (2-7%). Given the potential benefits of NRT, healthcare professionals should be educated regarding its indications and oral complications.

Nodal failure patterns and utility of elective nodal irradiation in submandibular gland carcinoma treated with postoperative radiotherapy - a multicenter experience

BACKGROUND

The patterns of nodal relapse in submandibular gland carcinoma (SMGC) patients treated with postoperative radiotherapy (PORT) remain unclear. This study aims to investigate the nodal failure patterns and the utility of elective nodal irradiation (ENI) in SMGC patients undergoing PORT.

METHODS

We retrospectively enrolled 65 SMGC patients who underwent PORT between 2000 and 2014. The nodal failure sites in relation to irradiation fields and pathological parameters were analyzed. ENI regions were categorized into three bilateral echelons (first, levels I-II; second, level III; and third, levels IV-V). Extended ENI was defined as coverage of at least the immediately adjacent uninvolved echelons bilaterally; otherwise, limited ENI was administered.

RESULTS

Thirty patients (46%) were stage III-IV, and 18 (28%) were pN+. Neck irradiation included limited (72%) and extended ENI (28%). With a median follow-up of 79 months, 11 patients (17%) developed nodal failures (ipsilateral, N = 6; contralateral, N = 7), 7 (64%) of whom relapsed in the adjacent uninvolved echelons. We identified pN+ (P = 0.030), extranodal extension (ENE, P = 0.002), pT3-4 (P = 0.021), and lymphovascular invasion (LVI, P = 0.004) as significant predictors of contralateral neck recurrence. Extended ENI significantly improved regional control (RC) in patients with pN+ (P = 0.003), ENE (P = 0.022), pT3-4 (P = 0.044), and LVI (P = 0.014), and improved disease-free survival (DFS) in patients with pN+ (P = 0.034). For patients with ≥2 coincident adverse factors, extended ENI significantly increased RC (P < 0.001), distant metastasis-free survival (P = 0.019), and DFS (P = 0.007); conversely, no nodal recurrence was observed in patients without these adverse factors, even when only the involved echelon was irradiated.

CONCLUSIONS

Nodal failure is not uncommon in SMGC patients treated with PORT if pN+, ENE, pT3-4, and LVI are present. Extended ENI should be considered, particularly in patients with multiple pathological adverse factors.

Adjuvant Chemotherapy Is Associated With Improved Survival for Late-Stage Salivary Squamous Cell Carcinoma

OBJECTIVE

Salivary squamous cell carcinomas (SCCs) represent a unique disease entity because many are thought to represent metastases from primary cutaneous malignancies. Nevertheless, they represent a significant proportion of parotid gland cancers and have a notably poor prognosis. Recently, there has been controversy regarding the utility of adjuvant chemotherapy in the treatment of these malignancies, with most studies concluding that there is no survival benefit. We aim to determine the outcomes associated with the use of adjuvant radiotherapy and chemoradiotherapy in the treatment of early- and late-stage salivary SCC.

METHODS

A retrospective study of 2,285 of surgically resected adult salivary SCC diagnosed from 2004 to 2014 in the National Cancer Database was conducted. Patients were divided into early- (I/II) and late-stage (III/IV) groups. Demographic, facility, tumor, and survival variables were included in the analyses. Multivariate Cox survival regressions, propensity-score matched analyses, and univariate Kaplan-Meier analyses were conducted.

RESULTS

The use of adjuvant chemoradiotherapy for late-stage patients was associated with improved survival compared to the use of adjuvant radiotherapy alone (hazard ratio [HR] 0.774, P = 0.026). Five-year survival for late-stage patients treated with surgery alone, surgery with adjuvant radiotherapy, and surgery with adjuvant chemoradiotherapy was 31.1% (standard error [SE]: 2.5), 45.6% (SE: 2.2), and 58.9% (SE: 3.4). Use of adjuvant therapy (either chemoradiotherapy or radiotherapy alone) was associated with improved survival for early-stage patients (HR 0.746, P = 0.037).

CONCLUSION

The addition of chemotherapy to the adjuvant therapy of late-stage patients with salivary SCC may result in improved long-term survival. Expanded use of adjuvant therapy for early-stage disease may also improve patient outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:883-889, 2019.

AAA+ ATPases Reptin and Pontin as potential diagnostic and prognostic biomarkers in salivary gland cancer - a short report

PURPOSE

Salivary gland cancer (SGC) is a rare and heterogeneous disease with significant differences in recurrence and metastasis characteristics. As yet, little is known about the mechanisms underlying the initiation and/or progression of these diverse tumors. In recent years, the AAA+ ATPase family members Pontin (RuvBL1, Tip49a) and Reptin (RuvBL2, Tip49b) have been implicated in various processes, including transcription regulation, chromatin remodeling and DNA damage repair, that are frequently deregulated in cancer. The aim of this study was to assess the clinical and functional significance of Reptin and Pontin expression in SGC.

METHODS

Immunohistochemical staining of Pontin, Reptin, β-catenin, Cyclin D1, TP53 and MIB-1 was performed on a collection of 94 SGC tumor samples comprising 13 different histological subtypes using tissue microarrays.

RESULTS

We found that Reptin and Pontin were expressed in the majority of SGC samples across all histological subtypes. Patients with a high Reptin expression showed a significantly inferior 5-year overall survival rate compared to patients with a low Reptin expression (47.7% versus 78.3%; p = 0.033), whereas no such difference was observed for Pontin. A high Reptin expression strongly correlated with a high expression of the proliferation marker MIB-1 (p = 0.003), the cell cycle regulator Cyclin D1 (p = 0.006), accumulation of TP53 as a surrogate p53 mutation marker (p = 0.042) and cytoplasmic β-catenin expression (p = 0.002). Increased Pontin expression was found to significantly correlate with both cytoplasmic and nuclear β-catenin expression (p = 0.037 and p = 0.018, respectively), which is indicative for its oncogenic function.

CONCLUSIONS

Our results suggest a role of Reptin and Pontin in SGC tumor progression and/or patient survival. Therefore, SGC patients exhibiting a high Reptin expression may benefit from more aggressive therapeutic regimens. Future studies should clarify whether such patients may be considered for more radical surgery, extended adjuvant therapy and/or targeted therapy.

Management of salivary gland carcinomas - a review

Salivary gland carcinomas are a heterogeneous group of tumors with many histological subtypes which occur in both major and minor salivary glands. However, they have a relatively low of incidence. Their rarity limits study size and the ability to perform phase III trials. Therefore, to date, the entire management is usually varied. Certain published studies have paid more attention to the systemic therapy in the management of metastatic or locally recurrent salivary gland cancer, while little effort has been made to study the entire management for this lesions. Although results of treatment for patients with salivary gland carcinoma have improved in recent years, the treatment of salivary gland cancers is still not standardized. And some patients who haven’t received optimal treatment strategies had a reduced survival. In this review, the topics covered include surgery and radiotherapy, selective neck dissection, chemotherapy, and targeted therapy, which aimed to summarize the optimal management approaches and to develop recommendations for managing this lesions. For these rare cancers, there is also a need for a determined, coordinated effort to conduct high-quality clinical trials.

Clinicopathological Behavior and Oncological Outcomes of Malignant Parotid Tumors in a Pakistani Population

Introduction

The incidence of salivary gland tumors is influenced by geographical and racial factors resulting in diverse histology.  While salivary gland tumors account for a low proportion of head and neck cancers, most malignant tumors of the salivary gland are located in the parotid gland. The goals of this study are to describe the clinicopathological behavior of malignant parotid tumors and explore oncological outcomes related to survival in our Pakistani tertiary care cancer hospital.

Methods

We conducted a retrospective analysis of 209 patients diagnosed with malignant parotid tumors from 2004 to 2016. Data such as demographics, age, gender, histology, grade, clinical and pathological stage, surgical treatment types and adjuvant modalities used were analyzed using SPSS software version 20. We used Kaplan Meier curves to analyze survival data.

Results

The median patient age at diagnosis was 40 years, and the ratio of men to women was 1.2:1. Mucoepidermoid carcinoma was the most common histological variant (with a 50% incidence rate) followed by adenoid cystic carcinoma (13%), and adenocarcinoma (10%). Histology has further categorized these malignant tumors into low (34%), intermediate (28%), and high (21% ) grades. The American Joint Committee on Cancer, seventh edition, clinical staging was Stage I (21%), II (28%), III (15%), and IV (34%). The 5-year survival was 68%, and the 10-year survival was 45%.

Conclusion

Mucoepidermoid carcinoma is the most common malignant parotid histology in our patient population. Advanced age, increased T stage (size > 4 cm), high-grade histology, and cervical nodal involvement decrease overall survival. Open biopsies, piecemeal excisions, and delayed presentation for radiotherapy post-surgery may also have role in adverse outcomes in these malignancies.

Perineural Invasion in Parotid Gland Malignancies

Objectives To investigate the clinical predictors and survival implications of perineural invasion (PNI) in parotid gland malignancies. Study Design Case series with chart review. Setting Tertiary care medical center. Subjects and Methods Patients with parotid gland malignancies treated surgically from 2000 to 2015 were retrospectively identified in the Head and Neck Cancer Registry at a single institution. Data points were extracted from the medical record and original pathology reports. Results In total, 186 patients with parotid gland malignancies were identified with a mean follow-up of 5.2 years. Salivary duct carcinoma (45), mucoepidermoid carcinoma (44), and acinic cell carcinoma (26) were the most common histologic types. A total of 46.2% of tumors were found to have PNI. At the time of presentation, facial nerve paresis (odds ratio [OR], 64.7; P < .001) and facial pain (OR, 3.7; P = .002) but not facial paresthesia or anesthesia (OR, 2.8, P = .085) were predictive of PNI. Malignancies with PNI were significantly more likely to be of advanced T and N classification, be high-risk pathologic types, and have positive margins and angiolymphatic invasion. PNI positivity was associated with worse overall (hazard ratio, 2.62; P = .001) and disease-free survival (4.18; P < .001) on univariate Cox regression analysis. However, when controlling for other negative prognosticators, age, and adjuvant therapy, PNI did not have a statistically significant effect on disease-free or overall survival. Conclusions PNI is strongly correlated with more aggressive parotid gland malignancies but is not an independent predictor of worse survival. Facial paresis and pain were predictive of PNI positivity, and facial paresis correlated with worse overall and disease-free survival.

Mucoepidermoid Carcinoma: A 23-Year Experience with Emphasis on Low-Grade Tumors with Close/Positive Margins

Objective Describe outcomes for mucoepidermoid carcinoma by histologic grade and evaluate outcomes for patients with low-grade tumors with close/positive margins after initial surgical resection. Study Design Cohort study. Setting Kaiser Permanente Southern California Medical Group from 1993 to 2016. Subjects and Methods Retrospective review of 154 patients with major and minor salivary gland mucoepidermoid carcinoma of the head and neck. Disease-specific and recurrence-free survival were stratified by tumor grade. Subgroup analysis of recurrence-free survival in patients with low-grade disease with close or positive margins was also performed. Results Five-year recurrence-free and disease-specific survival were excellent for both low- and intermediate-grade tumors, while there was there was a high rate of recurrence and mortality among patients with high-grade tumors. Patients with low-grade tumors with close or positive margins who were observed had no difference in recurrence-free survival compared to those who underwent revision surgery and/or adjuvant radiotherapy. Conclusions High-grade mucoepidermoid carcinoma has poor outcomes despite aggressive treatment. Among patients with low-grade tumors with close or positive margins on initial resection, additional treatment had no impact on survival or recurrence. Observation may be a reasonable alternative to additional treatment in this select group of patients.

Survival in patients with parotid gland carcinoma - Results of a multi-center study

BACKGROUND

Parotid gland carcinoma is a rare malignancy, comprising only 1-4% of head and neck carcinomas; therefore, it is difficult for a single institution to perform meaningful analysis on its clinical characteristics. The aim of this study was to update the clinical knowledge of this rare disease by a multi-center approach.

METHODS

The study was conducted by the Kyoto University Hospital and Affiliated Facilities Head and Neck Clinical Oncology Group (Kyoto-HNOG). A total of 195 patients with parotid gland carcinoma who had been surgically treated with curative intent between 2006 and 2015 were retrospectively reviewed. Clinical results including overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), local control rate (LCR), regional control rate (RCR), and distant metastasis-free survival (DMFS) were estimated. Univariate and multivariate analyses were performed to identify prognostic factors.

RESULTS

The median patient age was 63years old (range 9-93years), and the median observation period was 39months. The OS, DFS, DSS, LCR, RCR, and DMFS at 3years were 85%, 74%, 89%, 92%, 88%, and 87%, respectively. Univariate analysis showed age over 74, T4, N+, preoperative facial palsy, high grade histology, perineural invasion, and vascular invasion were associated with poor OS. N+ and high grade histology were independent factors in multivariate analysis. In subgroup analysis, postoperative radiotherapy was associated with better OS in high risk patients.

CONCLUSION

Nodal metastases and high grade histology are important negative prognostic factors for OS. Postoperative radiotherapy is recommended in patients with advanced high grade carcinoma.

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 Prognostic Significance of Facial Nerve Involvement in Carcinomas of the Parotid Gland

IMPORTANCE AND BACKGROUND

Facial nerve (FN) palsy and perineural invasion (PNI) are adverse features in carcinomas of the parotid gland. FN sacrifice at the time of surgery is associated with significant morbidity. The role of adjuvant radiotherapy in patients with high-risk features, including FN involvement, remains unclear.

OBJECTIVE

Analyze the disease-free survival (DFS) and overall survival (OS) and the impact of tumor characteristics, including FN involvement, for patients treated with surgical resection for carcinoma of the parotid gland.

DESIGN

This is a retrospective chart review.

SETTING

University of Utah and Intermountain Healthcare, Utah.

PARTICIPANTS

A total of 129 patients who were treated with primary surgery for nonmetastatic primary malignancies of the parotid gland from 1988 to 2006.

INTERVENTIONS

Parotidectomy with or without adjuvant therapy.

MAIN OUTCOME(S) AND MEASURES

Kaplan-Meier analysis was used to obtain 5-year estimates of DFS and OS. Recurrence risk factors, particularly the impact of FN involvement, were analyzed.

RESULTS

Five-year DFS and OS rates were 79% and 78%, respectively. Thirty-two (28%) patients developed recurrent disease. Disease recurrence occurred in 64% of patients with both FN palsy and PNI, in 43% with FN palsy without PNI, in 27% with only PNI, and in 16% without either feature.

CONCLUSIONS AND RELEVANCE

FN involvement, particularly FN palsy, is a predictor of increased risk of recurrence and death. Radiotherapy cannot substitute for FN sacrifice in high-risk patients.

Androgen Receptor Expression in Primary Nonsquamous Cell Rare-Variant Carcinomas of the Head and Neck

Objective

Androgen receptor (AR) is a diagnostic immunohistochemical marker for salivary gland duct carcinoma (SDC), but other nonsquamous cell head and neck carcinomas (NSCCs) may also express it. The aim of this preliminary study was to investigate the immunohistochemical expression of AR in rare head and neck NSCCs.

Study Design

Retrospective analysis of histologic records.

Setting

A large community hospital.

Subjects and Methods

Twenty-seven patients with NSCC were selected (21 men, 6 women; average age, 69 years). Exclusion criteria were histologically confirmed primary and metastatic head and neck squamous cell carcinomas and thyroid carcinomas. AR immunohistochemistry was done on formalin-fixed, paraffin-embedded tissue blocks.

Results

Variable AR expression was found in 5 of 27 (25%) cases of NSCC. All 7 patients with SDC showed intense and extensive positive immunoreactivity. Of 27 NSCC tumors, 15 (56%) had negative staining.

Conclusion

In the head and neck, expression of AR is not limited to SDCs; other NSCCs also express it. When surgery or radiotherapy is not appropriate for recurrent or metastatic head and neck NSCC, palliative chemotherapy offers poor results. Antiandrogen therapy is well tolerated and is much less toxic than chemotherapy. Since androgen deprivation therapy has been used against SDCs, this therapy may theoretically be used in a small subset of head and neck NSCCs.

Adjuvant radiation for salivary gland malignancies is associated with improved survival: A National Cancer Database analysis

Objective

There are no randomized data to support the use of postoperative radiation for salivary gland malignancies. This study uses the National Cancer Database (NCDB) to describe the epidemiology of salivary gland cancer patients and to investigate whether treatment with adjuvant radiation improves overall survival.

Methods and materials

A total of 8243 patients diagnosed with a major salivary gland cancer were identified from the NCDB. All patients received primary surgical resection of their malignancy. Patients were risk-stratified by adverse features, and overall survival rates were determined. Patients were considered high risk if they had extracapsular extension and/or positive margin after resection. Patients were considered intermediate risk if they did not meet the criteria for high risk but had pT3-T4 disease, pN+ disease, lymphovascular space invasion, adenoid cystic histology, or grade 2-3 disease. Patients who did not meet criteria for high or intermediate risk were considered low risk. Overall patient demographics, disease characteristics, treatment factors, and outcomes were summarized with descriptive statistics and analyzed with STATA.

Results

Median follow-up in this cohort was 42.4 months, with the median age of 58 years. Patients in the high-risk group had greater survival (hazard ratio [HR], 0.76; P = .002; 95% confidence interval [CI], 0.64-0.91) if they received adjuvant radiation therapy. In contrast, patients in the intermediate- (HR, 1.01; P = .904; 95% CI, 0.85-1.20) and low-risk groups (HR, 0.85; P = .427; 95% CI, 0.57-1.26) did not experience a survival benefit with adjuvant radiation therapy.

Conclusions

This large analysis compared survival outcomes between observation and adjuvant radiation alone in risk-stratified patients after resection of major salivary glands using a national database. The use of adjuvant radiation for high-risk major salivary gland cancers appears to offer a survival benefit. Although an overall survival benefit was not seen in low- and intermediate-risk salivary gland cancers, this study could not address impact on local control because of the limitations of the NCDB.