High-grade adenoid cystic carcinoma originating from the lacrimal gland

Lacrimal Gland Adenoid Cystic Carcinoma with High Grade Transformation: A Case Report and Current Concepts in Multi Modality Management

Lacrimal gland adenoid cystic carcinoma (AdCC) is associated with an aggressive clinical course and grave prognosis. A high grade transformation within adenoid cystic carcinoma of lacrimal gland is a rare condition which is even more locally aggressive with frequent neck and distant metastasis. We present a case of left lacrimal gland adenoid cystic carcinoma with high grade transformation to adenocarcinoma NOS type presenting with orbital pain and proptosis. After thorough evaluation for locoregional and distant spread of the disease, the patient underwent left orbital exenteration with orbitectomy and neck dissection with free flap reconstruction. Patient received adjuvant radiation therapy and is presently disease free for last 6 months. A multi-modality management protocol involving surgery, radiotherapy and chemotherapy has been proposed for management of lacrimal gland AdCC with high grade transformation. We report the 4th case in the literature of lacrimal gland adenoid cystic carcinoma with high grade transformation.

A Rare Case of Orbital Adenoid Cystic Carcinoma Mimicking as Optic Nerve Glioma

Adenoid cystic carcinoma is an uncommon epithelial cell tumour that usually originates from glands. They arise from the upper respiratory tract, lungs, mammary glands, and skin, but most commonly from the salivary glands and lacrimal glands. Our article reports a 53-year-old individual presenting with a history of diminution of visual acuity over the past one and a half months, also associated with a right-sided headache and throbbing eye pain not relieved by medication. Examination revealed right axial proptosis, ptosis, and visual acuity of 6/36, right afferent pupillary defect (RAPD), restriction of ocular movements in supraduction, dextroelevation, and abduction. The fellow eye was completely normal. MRI revealed an enhancing lesion in the retrobulbar area of the right orbit indicative of optic nerve glioma of stage 2. The patient underwent orbito-zygomatic craniotomy with subtotal excision of the mass by a neurosurgeon. Following surgery, histopathological examination of the excised tumour revealed features consistent with adenoid cystic carcinoma. On the third post-operative day, the subject's vision improved to counting fingers at 3 metres, and extraocular movements were regained.

Primary Intracranial Adenoid cystic carcinoma: report of three cases

Objective: Nasal cavity and paranasal sinuses host a variety of malignant tumors with adenoid cystic carcinoma (ACC) being the most frequent cancer of salivary gland origin. The histological origin of such tumors virtually precludes a primarily intracranial localization. The aim of this study is to report cases of primarily intracranial ACC without evidence of other primary lesions at the end of an exhaustive diagnostic workup. Methods: An electronic medical record search complemented by manual searching was conducted to identify prospective and retrospective cases of intracranial ACCs treated in Endoscopic Skull Base Centre Athens (ESA) at the Hygeia Hospital, Athens from 2010 until 2021 with a mean follow-up time of at least 3 years. Patients were included if after complete diagnostic work up there was no evidence of a nasal or paranasal sinus primary lesion and extension of the ACC. All patients were treated with a combination of endoscopic surgery performed by the senior author followed by radiotherapy (RT) and/or chemotherapy. Results: Three unique illustrative cases (ACC involving the clivus, cavernous sinus and pterygopalatine fossa, one orbital ACC with pterygopalatine fossa and cavernous sinus involvement and one involving cavernous sinus, Meckel’s Cave with extension to the foramen rotundum) were identified. All patients underwent subsequently proton or carbon ion beam radiation therapy. Conclusions: Primary intracranial ACCs constitute an extremely rare clinical entity with atypical presentation, challenging diagnostic workup and management. The design of an international web-based database with a detailed report of these tumors would be extremely helpful.

Primary cutaneous adenoid cystic carcinoma: a clinicopathologic, immunohistochemical, and fluorescence in-situ hybridisation study of 13 cases

AIMS

This study aimed to investigate the clinical, histological, immunohistochemical and chromosomal features of primary cutaneous adenoid cystic carcinoma (PCACC).

METHODS AND RESULTS

We retrospectively analysed 13 cases identified on their clinicopathological features and performed fluorescence in-situ hybridisation (FISH) on six available cases. Head and neck (46.2%) were most commonly involved. The median age was 53 years, with a male predilection. Histologically, tumours were classified as grades 1 (eight), 2 (four) and 3 with high-grade transformation (HGT) (one). The HGT component was demonstrated as poorly differentiated carcinoma with multifocal necrosis and myoepithelial differentiation. Patients with one of the following factors: longest diameter of the lesion (≥ 1 cm), involvement of subcutaneous fat tissue and widely infiltrative border had a relatively higher rate of local recurrence, distant metastasis and death. Five of six cases were confirmed to have MYB translocation, while nuclear staining for MYB proto-oncogene, transcription factor (MYB) protein was found in four cases. During the follow-up (median = 64 months), two patients experienced local recurrences. One patient, who was classified as grade III PCACC with HGT, developed multiple metastases and died of disease. Another patient was alive with multiple metastases.

CONCLUSIONS

This is the largest single-institution study, to our knowledge, of PCACC in an Asian population. We describe the first case of scalp PCACC with HGT, which is the only death case in our series. PCACC tends to recur locally and has metastatic potential. PCACC with HGT has a poor prognosis.

Aberrantly expressed GFRα-1/RET in patients with lacrimal adenoid cystic carcinoma is associated with high recurrence risk: a retrospective study of 51 LACC cases

Objective:

Because of the poor prognosis of lacrimal adenoid cystic carcinoma (LACC), we aimed to investigate the effects of perineural invasion (PNI) and consequent aberrations in GDNF/GFRα-1/RET protein expression on LACC recurrence.

Methods:

Clinicopathological data for 51 histologically confirmed patients with LACC enrolled between 2001 and 2017 were retrospectively analyzed. Hematoxylin and eosin staining was applied to assess PNI. Tissue-based immunohistochemistry (IHC) detection of GDNF, GFRα-1, and RET proteins was performed on LACC formalin-fixed, paraffin-embedded specimens. We generated semi-quantitative data of the IHC results and compared them with the clinicopathological data for the 51 patients.

Results:

Of the 51 patients, 19 (37.3%) were PNI positive. Recurrence was more common for LACC with than without PNI (73.7% vs. 37.5%, P = 0.01). GDNF, GFRα-1, and RET proteins were expressed in 62.7%, 62.7%, and 54.9% of the 51 patients with LACC, respectively. The expression of all 3 proteins was more common in patients with than without PNI. In agreement with previous findings, PNI-associated GFRα-1 and RET positivity, as detected by IHC, remained significantly associated with recurrence, whereas GDNF expression, as detected by IHC, was not correlated with LACC recurrence. Specifically, patients with concurrent GFRα-1 and RET expression may have a high risk of PNI (89.5% positivity rate) and recurrence (84.2% positivity rate).

Conclusions:

PNI may contribute to LACC recurrence. The concurrent expression of GFRα-1 and RET proteins, as detected by IHC, may potentially be associated with LACC PNI and recurrence.

Adenoid cystic carcinoma with dedifferentiation/expansion of the luminal cell component and preserved biphasic morphology - Early high-grade transformation

We present two patients (29 and 67 years) with histomorphologic and immunohistochemical evidence of early high-grade transformation of adenoid cystic carcinoma in the nasal cavity and floor of mouth, respectively. The component of early high-grade transformation was characterized by 1) selective expansion of the luminal (CK7+, c-kit+, p63-) cell component with severe cytologic atypia and significantly increased Ki-67 proliferation index, and 2) retained albeit attenuated abluminal (CK7-, c-kit-, p63+) cells, surrounding nests of high-grade luminal cells.

Adenoid cystic carcinoma of the parotid metastasising to the dura fifteen years post primary resection: A case report

Adenoid cystic carcinoma (ACC), regardless of the primary site, is typically characterized by a long clinical course associated with a high rate of distant metastases. Intracranial metastasis of ACC is a very rare entity with only few reported cases in the literature. In this study, we report an unusual case of extra-axial intracranial metastasis of ACC in the dura. The primary parotid gland tumour was resected 15 y back. No recurrence had been detected before the occurrence of extra-axial metastasis. After surgical decompression, palliative radiotherapy was administered. To our knowledge, this is the longest interval for the development of metastases following excision of a parotid adenoid cystic carcinoma. This case can raise awareness across specialties that patients with adenoid cystic carcinoma are still at risk of developing metastases even following specialist discharge.

Late intracranial metastasis from adenoid-cystic carcinoma of the parotid gland: Imaging, histologic and molecular features

We describe the neuroradiologic, histologic, and genetic features of a very unusual intracranial dural metastasis from adenoid cystic carcinoma of the parotid gland detected 27 years after the initial diagnosis.

Adenoid Cystic Carcinoma with Transformation to High Grade Carcinomatous and Sarcomatoid Components: A Rare Case Report with Review of Literature

Adenoid cystic carcinoma (AdCC) comprises of less than 1% of all head and neck cancers and less than 10% of all salivary gland neoplasms. Dedifferentiation/high-grade transformation (HGT) in AdCC is a rare but well known phenomenon which is associated with aggressive clinical behaviour and poor prognosis. We herein report the clinical, cytologic, histologic and immunohistochemical findings of a left submandibular gland AdCC with transformation to high grade carcinomatous and probable dedifferentiation to sarcomatoid component, occurring in a 64 year old male patient. To the author's best knowledge, this is the first case report of such dual transformation occurring in adenoid cystic carcinoma.

Salivary gland hybrid tumour revisited: could they represent high-grade transformation in a low-grade neoplasm?

Salivary gland hybrid tumour, first described in 1996, is a very rare neoplasm for which exact morphological criteria have not been universally agreed upon. In contrast, the concept of high-grade transformation (HGT) in salivary neoplasms has been widely accepted during the last decade, and the number of reported cases is rapidly increasing. A review of the literature revealed 38 cases of hybrid tumour reported in 22 publications. During approximately the same time period, well over 100 cases of HGT in salivary neoplasms have been reported. There are important histological similarities between hybrid tumours and salivary tumours with HGT. In the latter, containing one tumour component of low-grade malignancy and the other of high grade, the two tumour components are not entirely separated and appear to originate in the same area. Virtually, all cases reported as hybrid tumour had no clear lines of demarcation between the two tumour types. We are inclined to suggest that most of the 38 cases of hybrid tumours described in the literature would today better be called tumour with HGT rather than hybrid tumour. The relative proportion of the two components may vary, and the high-grade component is sometimes very small, which emphasises the importance of very generous sampling of the surgical specimen. The molecular genetic mechanisms responsible for HGT, including what used to be called hybrid tumour, remain largely unknown. Abnormalities of a few genes (including p53, C-MYC, cyclin D1, HER-2/neu) have been documented. As insufficient data exist on gene abnormalities in these lesions, conclusions as to whether or not they have a common origin and which mechanisms are involved in transformation cannot be drawn. Due to the small number of cases reported, many of which lack follow-up details; indicators of prognosis of hybrid tumours are not available, but their behaviour seems to be similar to that of tumours with HGT, i.e. an accelerated aggressive course. HGT of salivary gland neoplasms greatly influences macroscopic and microscopic evaluation of the specimen but also, given the high incidence of metastases and morbidity, carries significant treatment implications.

Cervical Lymph Node Metastasis in High-Grade Transformation of Head and Neck Adenoid Cystic Carcinoma: A Collective International Review

Adenoid cystic carcinoma (AdCC) is among the most common malignant tumors of the salivary glands. It is characterized by a prolonged clinical course, with frequent local recurrences, late onset of metastases and fatal outcome. High-grade transformation (HGT) is an uncommon phenomenon among salivary carcinomas and is associated with increased tumor aggressiveness. In AdCC with high-grade transformation (AdCC–HGT), the clinical course deviates from the natural history of AdCC. It tends to be accelerated, with a high propensity for lymph node metastasis. In order to shed light on this rare event and, in particular, on treatment implications, we undertook this review: searching for all published cases of AdCC-HGT. We conclude that it is mandatory to perform elective neck dissection in patients with AdCC-HGT, due to the high risk of lymph node metastases associated with transformation.

Skull invaders: when surgical pathology and neuropathology worlds collide

Skull and dura serve as effective barriers to penetration by most tumors, often preventing masses originating intracranially from extending into the contiguous bone and soft tissues, or those arising in head and neck regions from extending into the dura and brain tissue. We review our 15-year experience with extracranial tumors that had sufficiently invaded adjacent skull, dura, or brain from the "outside-in" to require a neurosurgeon to participate in the surgical resection and discuss our 40 cases in context with the literature. Sinonasal-origin tumors (n = 17) and cutaneous tumors (n = 10) were the most frequent skull-invaders. Most of the cutaneous tumor types were squamous cellcarcinomas (n = 9); diverse sinonasal-origin types included 4 squamous cell carcinomas, 4 adenoid cystic carcinomas, 2 sinonasal undifferentiated carcinomas, 2 sinonasal adenocarcinomas, and single examples each of sinonasal-origin hemangiopericytoma, solitary fibrous tumor, melanoma, mucocele, and teratocarcinoma. There were 9olfactory neuroblastomas, and middle ear-origin basal cell carcinoma,recurrent glomus jugulare, and orbital malignant hidradenoma were also seen. Unique tumors included a cutaneous cylindroma invasive of skull convexity occurring in familial cylindromatosis and a ganglioneuroma of the middle ear with massive bilateral skull base extension. Convexity dural spread, a seldom-reported pattern of dissemination, was seen in 1 olfactory neuroblastoma and 1 adenoid cystic carcinoma. The ability to show skull/dural invasion did not correlate with specific histopathologic features; even benign tumor types can show skull/dural penetration.

Lacrimal gland adenoid cystic carcinoma with high-grade transformation to myoepithelial carcinoma: report of a case and review of literature

Adenoid cystic carcinoma (AdCC) is the most frequent malignant neoplasm of the lacrimal glands. Like its salivary gland counterpart, lacrimal AdCC can rarely undergo high-grade transformation ("dedifferentiation"). We herein report the clinical, radiographic and microscopic findings of a lacrimal gland AdCC with high grade transformation, occurring in a 39-year-old female patient. In contrast to salivary gland AdCC with high-grade transformation, which usually shows a high grade component with "ductal" differentiation, in the case presented, the "dedifferentiated" component showed morphologic and immunohistochemical features of myoepithelial differentiation.

Cytodiagnosis of intracranial metastatic adenoid cystic carcinoma: Spread from a primary tumor in the lacrimal gland

Adenoid cystic carcinoma (ACC) of the lacrimal gland is a rarely encountered orbital tumor. It invades intracranially more frequently than carcinomas of other glands in the head and neck. A 61-year-old man underwent right orbital exenteration for a tumor in the supraorbital region. He had lost all records and presented to us with a diffuse swelling in the right forehead, six years later. Fine-needle aspiration cytology of the right frontal swelling revealed monomorphic population of small, slightly atypical cells, arranged in multilayered groups with abundant fine intercellular metachromatic substance between cell groups. There were hyaline globules of varying size with attached tumor cells. Cytological diagnosis of metastatic intracranial ACC with a lacrimal gland primary was suggested. Biopsy of the swelling confirmed our cytological diagnosis of ACC with perineural, vascular and lymphatic invasion. Thus, the authors report this case of intracranial metastasis of ACC of the lacrimal gland to remind neurosurgeons planning intervention that this disease shows a tendency to invade intracranially.

Skull base invasion of adenoid cystic carcinoma of the lacrimal gland : a case report

Although adenoid cystic carcinoma (ACC) of the lacrimal gland is a rarely encountered orbital tumor, it invades intracranially more frequently than carcinomas of other glands in the head and neck. A 52-year-old man underwent orbital exenteration and resection of intracranially extended tumor via a fronto-orbito-zygomatic approach in combination with a transfacial approach. Histopathologically, the tumor showed perineural, vascular, and lymphatic invasion. Additionally, he received radiotherapy (60 Gy) and adjuvant systemic cisplatin and 5-fluorouracil chemotherapy due to residual tumor in the orbit and systemic metastases (lung, ribs, and spines). He was free of progression and recurrence at 6 months after treatment. The authors report a case of skull base invasion by an ACC of the lacrimal gland to remind neurosurgeons planning intervention that this disease shows a tendency to invade intracranially.

Adenoid Cystic Carcinoma of the Cavernous Region-Case Report-

A 62-year-old Japanese male patient presented with right oculomotor, abducens, and trigeminal nerve disturbances. Neuroimaging revealed a right middle cranial fossa mass lesion with the characteristics of trigeminal schwannoma. The patient underwent a right temporal craniotomy for gross total resection. Histological examination confirmed a metastasis of adenoid cystic carcinoma (ACC). After the operation, no evidence of the primary lesion could be found. The patient was treated with radiation therapy. ACC can be difficult to identify before histological confirmation. The incidence of intracranial invasion of ACC is 4-22%, but in this case no evidence of the primary lesion was found.

Diagnosis and radiologic manifestations of malignant dumbbell tumors of the parotid gland: review and 2 case reports

Primary malignant dumbbell tumors represent a special growth type of deep-lobe parotid neoplasm. Because they are located in an anatomically limited space between the skull base and the mandibular ramus, they do not cause any but a few nonspecific symptoms and may metastasize into the neck or distant organs before the primary tumor has ever been diagnosed. This article describes 2 cases that first presented as asymptomatic carcinoma unknown primary syndrome and were later discovered to be malignant dumbbell tumors of the parotid gland. Because adequate evaluation is essential for the subsequent management, several diagnostic methods available for the differential diagnosis of this tumor are discussed; we compare these according to their relevance to the therapeutic procedure. Magnetic resonance imaging was found to be the most appropriate imaging technique because of its ability to help us better differentiate between tumor and surrounding tissue. Computed tomography and single photon emission computed tomography can help us identify involvement of the skull base and mandibular ramus.