Minor salivary gland tumors of the sinonasal region: Results of a retrospective analysis with review of literature

Outcome-oriented clinicopathological reappraisal of sinonasal adenoid cystic carcinoma with broad morphological spectrum and high MYB::NFIB prevalence

Adenoid cystic carcinoma (AdCC) is a salivary gland neoplasm that infrequently appears in the sinonasal region. The aim of this study was to evaluate the outcome and clinicopathological parameters of sinonasal AdCC. A retrospective analysis was conducted on all cases of AdCC affecting the nasal cavity or paranasal sinuses between 2000 and 2018 at the University Hospital Zurich. Tumor material was examined for morphological features and analyzed for molecular alterations. A total of 14 patients were included. Mean age at presentation was 57.7 years. Sequencing revealed MYB::NFIB gene fusion in 11/12 analyzable cases. Poor prognostic factors were solid variant (p < 0.001), histopathological high-grade transformation (p < 0.001), and tumor involvement of the sphenoid sinus (p = 0.02). The median recurrence-free survival (RFS) and OS were 5.2 years and 11.3 years. The RFS rates at 1-, 5-, and 10-year were 100%, 53.8%, and 23.1%. The OS rates at 1-, 5-, and 10- years were 100%, 91.7%, and 62.9%, respectively. In Conclusion, the solid variant (solid portion > 30%), high-grade transformation, and sphenoid sinus involvement are negative prognostic factors for sinonasal AdCC. A high prevalence of MYB::NFIB gene fusion may help to correctly classify diagnostically challenging (e.g. metatypical) cases.

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 MUSES∗: a prognostic study on 1360 patients with sinonasal cancer undergoing endoscopic surgery-based treatment: ∗MUlti-institutional collaborative Study on Endoscopically treated Sinonasal cancers

BACKGROUND

Over the last 2 decades, transnasal endoscopic surgery (TES) has become the most frequently employed surgical technique to treat sinonasal malignancies. The rarity and heterogeneity of sinonasal cancers have hampered large non-population-based analyses.

METHODOLOGY

All patients receiving TES-including treatment between 1995 and 2021 in 5 referral hospitals were included. A prognostic study was performed, and multivariable models were transformed into nomograms. Training and validation sets were based on results from 3 European and 2 non-European centres, respectively.

RESULTS

The training and validation set included 940 and 420 patients, respectively. The mean age at surgery, primary-versus-recurrent presentation, histology distribution, type of surgery, T category and type of adjuvant treatment were differently distributed in the training and validation set. In the training set, 5-year overall survival and recurrence-free survival with a 95%-confidence interval were 72.7% (69.5-76.0%) and 66.4% (63.1-69.8%), respectively, significantly varying with histology. At multivariable analyses, age, gender, previous treatment, the extent of resection on the cranial, lateral and posterolateral axes, grade/subtype, T category, nodal status, margin status and adjuvant treatment were all associated with different prognostic outcomes, displaying a heterogeneous significance and effect size according to histology. The internal and external validation of nomograms was satisfactory (optimism-corrected C-index >0.7 and cumulative area under curve >0.7) for all histologies but mucosal melanoma.

CONCLUSIONS

Outcomes of TES-based treatment of sinonasal cancers vary substantially with histology. This large, non-population-based study provides benchmark data on the prognosis of sinonasal cancers that are deemed suitable for treatment including TES.

Extranodal Head and Neck Mantle Cell Lymphoma: Characteristics, Treatment, and Survival

OBJECTIVES

To describe disease characteristics and treatment and to analyze survival and mortality for extranodal mantle cell lymphoma (MCL) of the head and neck.

METHODS

Patients with extranodal MCL-excluding primary sites in the salivary glands, eye, and adnexa-were identified from the Surveillance, Epidemiology, and End Results (SEER) 18 Registries (2000-2015). Overall survival (OS) and cumulative incidence of MCL and non-MCL mortality were calculated. Factors associated with MCL and non-MCL mortality were analyzed with cause-specific hazard models.

RESULTS

Five hundred nine patients met criteria for descriptive analysis and 294 patients met criteria for survival analysis, with a median follow-up of 58 months. The most common sites for MCL were the oropharynx (66.0%), nasopharynx (19.1%), and oral cavity (8.4%). The most common treatment received was chemotherapy alone (48.9%), followed by chemoradiation therapy (16.9%), and radiation therapy alone (10.4%). The proportion of cases diagnosed as early-stage disease ranged from 31% of sinonasal MCLs to 83% of laryngeal MCLs. At 5 years, OS was 63% (95% CI: 57%-69%). There was no significant difference in OS (P = .79), cumulative incidence of MCL mortality (P = .76), or cumulative incidence of non-MCL mortality (P = .98) by anatomic site. Comparing early-stage to late-stage disease, there was no significant difference in OS (P = .38), cumulative incidence of MCL mortality (P = .07), or cumulative incidence of non-MCL mortality (P = .14). Multivariate analysis showed increased hazard of MCL mortality for patients that were older or that presented with stage III or stage IV disease.

CONCLUSION

The oropharynx is the most common subsite of head and neck MCLs, followed by the nasopharynx. Primary head and neck MCLs appear to present at an earlier stage than MCLs of other regions. In particular, laryngeal and hypopharyngeal MCLs may present as stage I or II disease.

MRI of Sinonasal Malignancies

ABSTRACT

Sinonasal cavity is an important subsite in head and neck tumors. There are a myriad of malignancies that present within this area. Adequate staging for treatment planning requires multimodality evaluation. Magnetic resonance imaging (MRI) forms an important component in the evaluation of sinonasal tumors. We sought to review the most common sinonasal tumors, including sinonasal anatomy, clinical features, and common imaging features. A literature review was performed to evaluate common sinonasal tumors. Owing to the different tissue types within the sinonasal cavity, there are multiple different tumor pathologies within the sinonasal compartment. Most present in adults although some present in the young. Many of these tumor types have imaging overlaps, although some have a characteristic appearance. MRI can aid in soft tissue delineation, evaluation of multicompartmental extension, intracranial spread, and perineural spread. Sinonasal tumors are a heterogeneous group for which soft tissue delineation via MRI forms an important role in ensuring adequate treatment planning to improve outcomes, decreasing morbidity, and improve functional outcomes.

Impact of tumor site on the prognosis of salivary gland neoplasms: A systematic review and meta-analysis

In numerous types of cancer, the primary tumor site can show a correlation with disease behavior and survival outcomes. In salivary gland tumors (SGTs) this association remains controversial. This study assessed the association between primary sites of SGTs and prognosis. Studies from five databases were assessed and a meta-analysis was performed using studies that presented 95 % confidence interval (95 % CI), hazard ratio (HR) and survival analysis. Gathered information from 46,361 patients showed that site had a prognostic impact on SGTs. Tumors involving minor salivary glands showed worse overall survival (HR = 1.60; 95 % CI = 1.17-2.19; p = 0.003), disease-specific survival (HR=1.63; 95 % CI = 1.12-2.37; p = 0.01), and cause-specific survival (HR=2.10; 95 % CI = 1.72-2.55; p = 0.00001). Tumors from major salivary glands showed better recurrence-free survival (HR=2.31; 95 % CI = 1.77-3.02; p = 0.00001), and locoregional control of disease (HR=2.66; 95 % CI = 1.20-5.91; p = 0.02). Our results showed that the primary site of SGTs has an impact on patient prognosis.

Imaging of Malignant Minor Salivary Gland Tumors of the Head and Neck

Minor salivary gland carcinomas (MSGCs) are nonminor tumors in the head and neck region and account for about half of all salivary gland carcinomas. Imaging evaluation based on the anatomy of minor salivary and mucous glands in the head and neck region as well as invasion patterns in each site helps in identifying optimal treatment modalities and planning suitable treatment strategies. MSGCs can be divided radiologically into localized and invasive subtypes on the basis of the clinical utility of such categorization. Characteristic invasion patterns of the invasive type include deep submucosal extension, bone marrow infiltration, and perineural spread, which are difficult to assess clinically. MSGCs easily invade adjacent structures because of their submucosal location and may spread along the muscles, nerves, periosteum, and dura mater. Moreover, the tumor may spread into the bone marrow without obvious bone destruction. In addition to imaging classification, examining the anatomy and distribution of the minor salivary glands, including the palatal, lingual, buccal, labial, and retromolar glands, as well as other mucous glands, including the glands of the sinonasal cavity and nasopharynx, lacrimal glands, ceruminous glands, laryngeal glands, and tracheal glands, facilitates MSGC diagnosis and tumor extension assessment. The authors review the precise anatomy of the minor salivary and mucous glands in the head and neck region, discuss the MSGC imaging classifications, and describe how to evaluate the extent of MSGCs in each site on the basis of the imaging classification and invasion patterns. ^©RSNA, 2020.

Multi-modality Treatment and Survival in Sinonasal Minor Salivary Gland Tumors

Objectives  The aim of this study was to analyze the effect of the multimodality treatment on survival in sinonasal minor salivary gland tumors. Methods  Adult clinical American Joint Committee on Cancer (AJCC) tumor (T) 1-4a staged cases of sinonasal minor salivary gland tumors were isolated from the National Cancer Database (2004-2014). Multivariate regressions were performed to analyze the effect of multimodality treatment. A subset analysis was also performed in patients with positive margins following surgical management. Results  We identified 556 cases, of which 293 (52.7%) patients were treated with surgery and radiotherapy (RT), 160 (28.8%) were treated with surgery alone, and 52 (9.4%) were treated with surgery and chemoradiotherapy (CRT). No patients were treated with chemotherapy alone. With surgery and CRT as a reference, the only treatment modality associated with decreased survival was RT alone (hazard ratio [HR]: 3.213 [95% confidence interval (CI): 1.578-6.543]; p  = 0.001). Within a subset analysis of patients with positive margins, surgery was associated with decreased survival (HR: 2.021 [95% CI: 1.401-3.925]; p  = 0.038), but not triple modality therapy (HR: 1.700 [95% CI: 0.798-3.662]) when compared with surgery with RT. Conclusion  The most common treatment was surgery and RT, consistent with National Comprehensive Cancer Network (NCCN) guidelines which recommends chemotherapy (CT) only in the most concerning cases. However, we found no difference in survival among most treatment modalities when compared with triple modality therapy, with the exception of RT alone. Although margins were prognostic within these cancers, we found no evidence that adjuvant CRT provides any survival benefit over surgery and RT, though surgery alone was associated with decreased survival.

More than meets the eye

We report an extremely rare case of a hybrid tumour of the maxillary sinus. A 51-year-old man presented with a 6-week history of nasal congestion and epiphora. Radiological imaging demonstrated a maxillary sinus tumour, with extensive local invasion. Surgical excision included maxillectomy, left eye exenteration and free flap closure. Histology of the excised specimen showed a rare hybrid tumour containing adenoid cystic carcinoma, salivary duct carcinoma, epithelial-myoepithelial carcinoma and basal cell adenoma. Hybrid tumours are very rare tumour entities which are composed of at least two distinct tumour types. Each tumour entity conforms with a defined tumour type. The tumour entities of a hybrid tumour are not separated but have an identical origin within a definite topographical area. Diagnosis and appropriate management requires high index of suspicion, pathological endeavour to look for a more aggressive accompanying tumour and adequate oncological treatment according to the highest grade of tumour.

Patterns of treatment failure in salivary gland cancers

Aim

The purpose of the study was to publish our experience of salivary gland cancer treatment with large number of patients treated at a single institution.

Background

Salivary gland cancers are rare tumors of the head and neck representing about 5% of cancers in that region and about 0.5% of all malignancies. Due to the rarity of the disease, most of the studies regarding treatment outcome consist of low number of patients, thus making it difficult to draw conclusions.

Material and methods

115 patients with primary salivary gland cancer were included in a retrospective study. The subsites of tumor were the parotid gland (58% patients), submandibular gland (19%) and minor salivary glands (23%). All patients underwent primary surgical resection. The following were collected: age, stage of the disease, T status, N status, grade of tumor, perineurial invasion, lymphovascular invasion, extracapsular spread, final histological margin status and postoperative treatment. Details of local, regional or distant recurrence, disease free survival and overall survival were included.

Results

The majority (65%) of patients presented in early stage, T1 and T2 tumors. 81% of patients were N0. Free surgical margins were achieved in 18% of patients, close in 28% patients and positive surgical margins in 54% (62) patients. Factors that significantly increased the risk of recurrence: T stage (p = 0.0006); N-positive status (p < 0.0001); advanced stage of the disease (p < 0.0001); high grade of tumor (p = 0.0007); PNI (p = 0.0061); LVI (p = 0.0022); ECS (p = 0.0136); positive surgical margins (p = 0.0022). On multivariate analysis, high grade of tumor and positive surgical margins remained significant independent adverse factors for recurrence formation.

Conclusions

This report shows a single institution results of oncological treatment in patients with malignant salivary gland tumors, where positive surgical margins strongly correlate with patients' worse outcome. Whether to extend the procedure, which very often requires sacrificing the nerve is still a question of debate.

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.

Pedunculated carcinoma ex pleomorphic adenoma of the nasal cavity: A unique case report

BACKGROUND

A carcinoma ex pleomorphic adenoma (CXPA) is an epithelial malignancy arising in or from a benign pleomorphic salivary adenoma. The parotid gland is the most common location of CXPAs. Minor salivary gland CXPAs of the nasal cavity are exceedingly rare, with only 6 documented in the literature.

METHODS AND RESULT

We present a 7th case: an unusual pedunculated intranasal CXPA, which had a favorable outcome after a wide endoscopic excision and the longest follow-up period reported to date. The clinical features, immunohistochemical characteristics, treatment choices, and disease outcomes of the intranasal CXPAs reported in previous studies are also reviewed.

CONCLUSION

This case demonstrates the importance of considering the possibility of CXPA in the differential diagnosis of minor salivary gland malignancies in the nasal cavity.

Clear cell carcinoma of the nasal cavity: A case report from histopathological viewpoint

We report an extremely rare case of primary clear cell carcinoma (CCC), not otherwise specified (NOS) of the nasal cavity. An 80-year-old woman was referred to our hospital with left nasal obstruction caused by a nasal cavity tumor. The tumor was resected completely with lateral rhinotomy approach. Histopathological examination revealed CCC. CCC metastasis from renal cell carcinoma (RCC), which is at the top of differential diagnosis, was ruled out by the absence of renal tumor at computed tomography (CT). Also, immunohistochemical results of the specimen with vimentin negative and CK7 focally positive excluded the possibility of RCC metastasis. The patient is free from recurrence 1 year after the surgery, and there is no evidence of RCC. In this report histopathological characteristics, especially immunohistochemical properties of primary CCC, NOS of the nasal cavity are presented together with some clinical features of this rare tumor. Also, we refer to histopathogenesis of primary CCC of nasal cavity in relation to myoepithelial carcinoma. Histopathological discussion is further extended to include other CCC and CCC-resembling histologies to confirm the uniqueness of the present case.