Primary parotid carcinoma: analysis of risk factors and validation of a prognostic index

Frequent Immunohistochemical Expression of Transcriptional Repressor GATA Binding 1 in Salivary Gland Neoplasms: A Sensitive but Nonspecific Marker

CONTEXT.—

Salivary gland (SG) neoplasms (SGNs) display considerable immunophenotypic diversity. A significant proportion of SG carcinomas develop metastases, with increased diagnostic difficulty at metastatic sites. Transcriptional repressor GATA binding 1 (TRPS1), a novel immunohistochemical marker for breast cancer, has been found to stain certain SGNs.

OBJECTIVE.—

To investigate TRPS1 and SRY-related HMG-box 10 (SOX10) immunoexpression in various SGNs and non-SG carcinomas, head and neck paragangliomas, and head and neck mucosal melanomas.

DESIGN.—

TRPS1 immunoreactivity score (IRS) was determined as negative or low, intermediate, or high positive; SOX10 was reported as negative or positive.

RESULTS.—

One hundred forty-eight SGNs, 5 breast carcinomas, 105 nonbreast-non-SG carcinomas, including 33 head and neck squamous cell carcinomas (HNSCCs), 6 head and neck paragangliomas, and 6 head and neck mucosal melanomas, were assessed for TRPS1. All 23 benign SGNs showed TRPS1 positivity, with the majority having high-positive IRS (17 of 23 cases; 74%). Among 125 SG carcinomas, 115 of 125 (92%) were TRPS1 positive, with high-positive IRS in 94 of 125 (75%), intermediate-positive IRS in 15 of 125 (12%), and low-positive IRS in 6 of 125 (5%). Among nonbreast-non-SG carcinomas, HNSCC, lung, thyroid, kidney, and ovarian carcinomas showed frequent TRPS1 staining. Nearly half of HNSCCs had high (11 of 18; 33%) or intermediate (4 of 18; 12%) positive IRS. Mean IRS in SG carcinomas was significantly higher than that in nonbreast-non-SG carcinomas (P < .001). None of the TRPS1-positive nonbreast-non-SG carcinomas expressed SOX10.

CONCLUSIONS.—

TRPS1 is positive in most benign and malignant SGNs. Its expression in several nonbreast-non-SG carcinomas indicates that it lacks specificity for breast and SG carcinomas, even if considering only high-positive IRS. Addition of SOX10 can increase the discriminatory utility of TRPS1.

Predictors of recurrence and survival after salivary gland cancer surgery: A multicenter, retrospective study in northern Japan

OBJECTIVES

Salivary gland cancer is a rare disease composed of more than 20 histological types with different grades of malignancy. The aim of this multicenter, retrospective study was to identify the most important predictors affecting recurrence and survival after surgery.

MATERIAL AND METHODS

A total of 543 patients with salivary gland cancers that underwent curative surgery between 2012 and 2022 in 13 institutions in northern Japan were evaluated in this study. Predictors affecting recurrence and survival were identified by univariate and multivariate Cox regression analyses. Age, sex, primary site, histological type, pathological T status, surgical margin, lymph node metastasis, extranodal extension, and postoperative radiotherapy were the variables evaluated.

RESULTS

Multivariate Cox regression analysis showed that increasing age, submandibular cancer, pathological T status 3 or 4, positive surgical margin, and lymph node metastasis, especially with extranodal extension, were independent risk factors for both recurrence and survival. Sublingual cancer was an independent risk factor for recurrence. Postoperative radiotherapy was associated with a lower risk of recurrence and a good prognosis, and adenoid cystic carcinoma was associated with a good prognosis.

CONCLUSION

Lymph node metastasis with extranodal extension was the most important prognostic factor affecting both recurrence and survival after surgery, adenoid cystic carcinoma was associated with a good prognosis, and postoperative radiotherapy was associated with a lower risk of recurrence and a good prognosis.

An analysis of health-related quality of life in children and adolescents after parotidectomy based on patient-reported outcomes

PURPOSE

To assess health-related quality of life (HRQoL) and its influencing factors in these pediatric patients undergoing parotidectomy.

METHODS

This was a cross-sectional study that included 37 children and adolescents (≤ 19 years) with parotid gland tumors who were treated in Sichuan Cancer Hospital between January 2006 and November 2021. HRQoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30). The Wilcoxon rank sum test was used to analyze the factors influencing patients' HRQoL.

RESULTS

37 children and adolescents were included in the study, including 22 cases of benign tumors and 15 cases of malignant tumors. All patients underwent surgery, and some patients with malignant tumors received radiotherapy or chemotherapy. Malignancy, permanent facial palsy, and Frey syndrome were associated with worse HRQoL in children and adolescents with parotid gland tumors. Radiotherapy and no cervical lymph node dissection were associated with worse HRQoL in pediatric patients with malignancy. The surgical approach of parotid is not a factor influencing HRQoL.

CONCLUSION

Factors associated with HRQoL in children and adolescents with parotid gland tumors include pathological types, permanent facial palsy, and Frey syndrome. In addition, factors affecting patients with malignancy include lateral lymph node dissection and radiotherapy.

Current management and future challenges in salivary glands cancer

Salivary gland cancers (SGCs) are rare, accounting for less than 5% of all malignancies of the head and neck region, and are morphologically heterogeneous. The diagnosis is mainly based on histology, with the complementary aid of molecular profiling, which is helpful in recognizing some poorly differentiated, borderline, or atypical lesions. Instrumental imaging defines the diagnosis, representing a remarkable tool in the treatment plan. Ultrasound and magnetic resonance are the most common procedures used to describe the primary tumour. The treatment of SGCs is multimodal and consists of surgery, radiotherapy, and systemic therapy; each treatment plan is, however, featured on the patient and disease's characteristics. On 24 June 2022, in the meeting "Current management and future challenges in salivary gland cancers" many experts in this field discussed the state of the art of SGCs research, the future challenges and developments. After the meeting, the same pool of experts maintained close contact to keep these data further updated in the conference proceedings presented here. This review collects the insights and suggestions that emerged from the discussion during and after the meeting per se.

Comparative impact of grade on mortality across salivary cancers: A novel, unifying staging system

BACKGROUND

The comparative impact of histologic variants and grade has not been well described.

METHODS

Salivary cancer histologies were profiled using hospital and population-based cancer registries. Multivariable models were employed to assess relationships between histology, grade, and survival.

RESULTS

On univariate analysis, histologic variants exhibited a wide spectrum of mortality risk (5-year overall survival (OS): 86% (acinic cell carcinoma), 78% (mucoepidermoid carcinoma), 72% (adenoid cystic carcinoma), 64% (carcinoma ex-pleomorphic adenoma), 52% (adenocarcinoma NOS), and 47% (salivary duct carcinoma) (p < 0.001). However, on multivariable analysis these differences largely vanished. Worsening grade corresponded with deteriorating survival (5-year OS: 89% [low-grade], 81% [intermediate-grade], 45% [high-grade]; p < 0.001), which was upheld on multivariable analysis and propensity score matching. Recursive partitioning analysis generated TNM + G schema (c-index 0.75) superior to the existing system (c-index 0.73).

CONCLUSION

Grade represents a primary determinant of salivary cancer prognosis. Integrating grade into stage strengthens current staging systems.

Intraparotid lymph node metastasis affects distant metastasis in parotid adenoid cystic carcinoma

To evaluate the relationship between factors of metastatic intraparotid lymph node (IPLN) and distant metastasis in parotid adenoid cystic carcinoma (ACC). Patients with surgically treated parotid ACC were retrospectively enrolled, and primary outcome variable was distant metastasis free survival (DMFS). The effect of factors of metastatic IPLN on DMFS was evaluated using Cox model. In total, 232 patients were included. Extranodal extension of IPLN and cervical lymph nodes did not impact the DMFS, and the 7th but not 8th AJCC N stage was associated with DMFS. Groups of 0 and 1 metastatic IPLN had comparable DMFS, but presence of 2+ positive IPLN was related to increased worse DMFS (p = 0.034, HR 2.09). A new N stage (0 vs 1-2 vs 3+) based on total positive lymph node number exhibited better C-index than traditional N stage. IPLN metastasis increased the risk of distant metastasis, and the impact was mainly determined by the number of metastatic IPLN. Our proposed N stage provided better DMFS prediction than the 8th AJCC N classification.

Prognostic scoring models in parotid gland carcinoma

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The impact of nodal status in major salivary gland carcinoma: A multicenter experience and proposal of a novel N-classification

OBJECTIVES

Despite differences in oncological behavior, the 8th edition of AJCC TNM staging currently proposes the same N-classification for major salivary glands (MSG) carcinoma and squamous cell carcinoma of the upper aerodigestive tract. The present study aims to investigate a more reliable definition of N-categories for MSG carcinoma.

MATERIALS AND METHODS

A retrospective multicenter study was performed, including 307 patients treated for primary MSG carcinoma from 1995 to 2019. Outcome measures included overall survival (OS), disease specific survival, and local, regional, and distant recurrence. Survival analysis was performed using log-rank test and Cox proportional-hazards model. Overall number (ON) and largest diameter (LD) of nodal metastases, including intra-parotid metastases, were considered to develop three novel proposals of N-classification; their performance were compared with the current TNM staging using Akaike information criterion (AIC), Bayesian information criterion (BIC), and Nagelkerke pseudo-R2.

RESULTS

Intra-parotid nodes, ON and LD of nodal metastases emerged as major prognosticators for OS, while extra-nodal extension did not impact on any survival. The current N-classification did not show a satisfactory OS stratification. Three novel N-classifications were developed according to number of metastatic nodes (0 vs 1-3 vs ≥ 4) and/or their maximum diameter (<20 mm vs ≥ 20 mm). They all showed better accuracy in OS stratification, and achieved better AIC, BIC and Nagelkerke pseudo-R2 indices when compared to current N-classification.

CONCLUSION

All the proposed N-classifications improved OS stratification and could help in defining a specific N-classification for MSG carcinoma. Their validation and assessment in an external cohort is needed.

Prognostic role of intraparotid lymph node metastasis in primary parotid cancer: Systematic review

BACKGROUND

The prognostic importance of intraparotid lymph node metastasis (P+) in patients with primary parotid gland carcinoma is unclear.

METHODS

Nineteen retrospective and noncomparative cohort studies, published between 1992 and 2020, met the inclusion criteria and included 2202 patients for this systematic review.

RESULTS

The pooled prevalence of the P in adult patients in the unselected studies was 24.10% (95% confidence interval = 17.95-30.25). The number of P+ lymph nodes per patient was counted in only three studies and ranged from 1 to 11. The 5-year recurrence-free survival rate based on Kaplan-Meier analysis varied from 83% to 88% in P- patients compared to 36% to 54% in P+ patients. The average hazard ratio for tumor recurrence in patients with P+ compared to P- was 2.67 ± 0.58.

CONCLUSIONS

P+ is an independent negative prognostic factor in primary parotid gland cancer and should be included into the treatment planning.

Validated Prognostic Nomograms for Patients With Parotid Carcinoma Predicting 2- and 5-Year Tumor Recurrence-Free Interval Probability

Introduction: Salivary gland malignancies are rare tumors with a heterogenous histological and clinical appearance. Previously, we identified multiple prognostic factors in patients with parotid cancer and developed prognostic indices which have repeatedly been validated internationally, demonstrating their general applicability and lasting relevance. Recently, nomograms gained popularity as a prognostic tool. Thus, in this research we aimed to construct nomograms based on our previous validated prognostic models.

Material and Methods: Nomograms were constructed using the previously reported dataset of 168 patients with parotid cancer which was used to develop pre- and postoperative prognostic scores, PS1 and PS2, respectively. Concordance indices for PS1 and PS2 were previously estimated at 0.74 and 0.71, respectively, and are in line with other, widely accepted oncological nomograms.

Results: Pre- and postoperative nomograms predicting 2- and 5-year tumor recurrence-free survival probability are presented. All previously multivariately identified and validated prognostic factors, are incorporated (T size, N classification, pain, age at diagnosis, skin invasion, facial nerve dysfunction, perineural growth, and positive surgical margins). Examples of clinical application and interpretation are given.

Conclusions: The presented prognostic nomograms for predicting 2- and 5-year tumor recurrence-free probability in patients with parotid cancer are powerful, user-friendly, visual tools and are based on internationally validated prognostic indices. They allow for a reliable prognostic assessment and result in a more individualized estimate of the risk for recurrence than the prognostic grouping based on PS1 and PS2. This facilitates assigning trial-patients to risk groups, and may assist in therapeutic decision making and determining appropriate follow-up intervals in clinical practice.

Salivary gland carcinoma in Denmark: a national update and follow-up on incidence, histology, and outcome

PURPOSE

Salivary gland carcinoma is a rare disease and studies on epidemiology and outcome require data collection over many years. The aim of this study is to present an update of incidence rates, anatomical sites, histological subtypes, and survival rates based on the Danish national cohort of salivary gland carcinoma patients.

METHODS

Data from all Danish patients with salivary gland carcinoma diagnosed from 1990 to 2015 (n = 1601) were included and analyzed following histological reevaluation and reclassification. Overall, disease-specific, and recurrence-free survival were evaluated. Prognostic factors were analyzed with multivariate Cox Hazard Regression.

RESULTS

The study population consisted of 769 men and 832 women, median age 62 years (range 6-102). The most frequent anatomic site was the parotid gland (51.8%). Adenoid cystic carcinoma was the most common subtype (24.7%). The majority had tumor classification T1/T2 (65.3%). The mean crude incidence was 1.2/100.000/year with an increase of 1.5% per year. There was no increase in age-adjusted incidence. The 5-, 10-, and 20-year survival rates were for overall survival 68, 52, and 35%, for disease-specific survival, 77, 69, and 64%, and for recurrence-free survival, 75, 64, and 51%, respectively. Age, high-grade histological subtype, advanced T-classification, cervical lymph node metastases, vascular invasion, and involved surgical margins had significantly negative impact on survival rates.

CONCLUSION

The age-adjusted incidence has been stable for a period of 26 years. Multivariate analysis confirmed that histological grade, advanced stage, involved surgical margins and vascular invasion are independent negative prognostic factors. Survival rates were stationary compared to earlier reports.

Prognostic Value of the Lymphocyte-to-Monocyte Ratio in Patients with Parotid Gland Carcinoma

Objective

Previous studies have evaluated various markers as prognostic predictors in patients with many types of cancers. However, the influence of such factors on the outcomes of patients with parotid gland carcinoma (PGC) is unknown. This study investigated the roles of alternative markers in the prognoses of patients with PGC.

Methods

Overall, 101 patients who underwent curative treatment for PGC were retrospectively evaluated, and their 5‐year overall and disease‐free survival rates were calculated. The prognostic values of clinical and pathologic factors were determined.

Results

The 5‐year overall and disease‐free survival rates were 73.1% and 62.8%, respectively. Multivariate analysis revealed that a low lymphocyte‐to‐monocyte ratio (LMR), high T classification, high N classification, and perineural invasion were independent predictors of poor prognosis.

Conclusions

Thus, we identified LMR as an independent prognostic factor for patients with PGC. Patients with low LMRs who are amenable to treatment may require adjuvant treatment to improve their prognoses.

Level of Evidence

4 Laryngoscope, 131:E864–E869, 2021

Nomograms predictive for oncological outcomes in malignant parotid tumours: recurrence and mortality rates of 228 patients from a single institution

PURPOSE

Malignant parotid tumours are rare and multiple prognostic factors exist.

METHODS

Through a retrospective study we aimed to identify nomograms predicting recurrence and mortality rates in 228 primary parotid cancers. Patients clinical, treatment and tumour characteristics were retrospectively collected between 1980 and 2005 at our Institution. Factors predictive of disease-free-specific-survival (DSS) and overall survival (OS) were calculated by univariate and multivariate analysis. Nomograms were then constructed.

RESULTS

The 5- and 10-year DSS rates were 73% and 71.4%, and nomogram was drawn based on five parameters where perineural invasion showed the most significant predicting influence (p < 0.001). The median follow-up was of 95 months and the 5- and 10-year OS rates were 68.7% and 53.1%; six predictive variables (age, histological grade, perineural invasion, pathological lymph node status, resection margins and distant metastasis) were used to create nomogram.

CONCLUSIONS

Our nomograms provide a tailored outcome to a patient affected by malignant parotid tumour and give him/her a risk assessment for recurrence and mortality based on individual factors by a concordance index > 0.8.