Risk factors for local recurrence of adenoid cystic carcinoma: the role of postoperative radiation therapy

Adenoid Cystic Carcinoma of the Nasopharynx: A Retrospective Study of 12 Cases

Objective: This study aimed to describe the experience of a single institution in China in treating adenoid cystic carcinoma of the nasopharynx. Methods: We reviewed the previous literature and conducted a retrospective analysis of 12 patients who diagnosed with nasopharyngeal adenoid cystic carcinoma (NACC) in clinical data, treatment, and follow-up data during 2019 to 2021. Results: Patients ranged in age from 32 to 68 years (mean 40.7 years, median 48.5 years), with a male to female ratio of 5:7. Most of our patients have T4a and T4b diseases (50% and 25%, respectively). A quarter of patients develop distant metastases. Among the 12 patients, 7 of them have positive margins under the microscope (7/12, 58.3%). The chief clinical manifestations were epistaxis, facial swelling, facial pain, headache ear stuffy, and hearing loss. If the tumors involved with cavernous sinus, brain stem infiltrated, and internal carotid artery circumvented, patients will undertake routine enhanced magnetic resonance imaging with Magnetic Resonance Angiography/Magnetic Resonance Venogram (MRA/MRV) to clearly show the lesion region. All patients underwent endoscopic endonasal approach. Fifty percent of patients received radiotherapy and 25% of patients received chemotherapy. None of the patients was lost and the follow-up time ranged from 16 to 45 months. The mean and median follow-up were 2.08 and 1.58 years. Two patients were dead of distant metastasis within 18 and 20 months after the surgery, and another patient with recurrent NACC died of hemorrhage. Conclusion: NACC is a rare malignant tumor that occurs in the nasopharynx, which can grow along the nerve, destroy the bone of the skull base, and metastasize to other organs. Up to now, there is no standard treatment. Our results show that endoscopic sinus surgery is a better choice for advanced or recurrent NACC.

Malignant Minor Salivary gland neoplasms ofLarynx: Our Experience

<br><b>Introduction:</b> Malignant minor salivary gland tumors are rare, accounting for fewer than 1% of all laryngeal cancers.</br> <br><b>Aim:</b> This study aims to share our experiences regarding clinical, radiological, pathological profiles and their management.</br> <br><b>Materials and methods:</b> The current study reviews 11 cases of malignant minor salivary gland tumors of the larynx treated surgically at our Institute between 2005 and 2019.</br> <br><b>Results:</b> The mean age of the patients was 54 years (range 38-75 years) with six females and five males in the series (1.2:1). Subglottis and trachea were the sites of origin in 54% of the cases, and hoarseness with dyspnea were the most common presenting symptoms. There were nine Adenoid cystic and two Mucoepidermoid carcinoma patients. Surgery was the primary mode of treatment.</br> <br><b>Conclusions:</b> Most of the larynx's malignant minor salivary gland tumors are submucosal in origin. The outcome and prognosis vary considerably based on the tumor's histology, grade, and stage.</br>.

Role of postoperative radiotherapy in resected adenoid cystic carcinoma of the head and neck

PURPOSE

Although postoperative radiotherapy (PORT) is demonstrably effective in local control of head and neck adenoid cystic carcinoma (HNACC), its application is controversial and the subset of patients who would benefit most from PORT is unknown. Herein, we analyzed the data of HNACC patients to clarify the role of PORT.

METHODS

We retrospectively reviewed 187 patients with nonmetastatic HNACC who underwent surgical resection between 2005 and 2019. The study endpoints were locoregional failure-free survival (LRFFS), progression-free survival (PFS), and overall survival (OS). Subgroup analysis and recursive partitioning analysis (RPA) were performed to identify patients most likely to benefit from PORT.

RESULTS

With a median follow-up of 84.7 months, the 5-year LRFFS, PFS, and OS were 70.0%, 52.6%, and 86.4%, respectively. Survival was significantly shorter in patients who experienced local failure than in those who did not (5-year OS: 88.1% vs. 80.5%, P = 0.001). The local failure rate was significantly lower in patients who underwent PORT (16.9% vs. 31.0%, P = 0.021), despite the high frequency of adverse factors. Especially, significant decreases in local failure and similar OS rates could be obtained after PORT among patients with positive margins, T2-4 stage disease, and minor salivary gland tumors. The RPA model for PFS categorized patients into four groups according to three prognostic factors (T-stage, location, and sex). The RPA model for LRFFS and OS suggested three groups based on two factors (T-stage, margin for LRFFS; T-stage, grade 3 for OS).

CONCLUSION

PORT could prevent dismal survival, while significantly reducing local failures in high-risk HNACC patients.

Long-Term Outcomes of Personalized Stereotactic Ablative Brachytherapy for Recurrent Head and Neck Adenoid Cystic Carcinoma after Surgery or External Beam Radiotherapy: A 9-Year Study

The management of recurrent head and neck adenoid cystic carcinoma (HNACC) remains a problematic challenge. This study aims to evaluate the long-term outcomes of personalized stereotactic ablative brachytherapy (SABT) as a salvage treatment for recurrent HNACC after surgery or external beam radiotherapy (EBRT). 21 patients with recurrent HNACC after surgery or EBRT successfully underwent iodine-125 (I-125) seed SABT from May 2011 to November 2019. The objective response rate (ORR), disease control rate (DCR), local control time (LCT), overall survival (OS), symptomatic relief and adverse events (AEs) were analyzed. Following SABT, the ORR and DCR were 85.7% and 100%, respectively. The 3-, and 5-year LCT rates were 68.8% and 55.1%, respectively, and the 3- and 5-year OS rates were 85.9% and 66.2%, respectively. Furthermore, univariate analyses showed that higher D90 (>137.1 Gy) was a strong positive prognostic factor of LCT (p < 0.05). The pain disappeared in one patient 3 months after SABT and partial pain improvement was observed in nine patients 1 to 6 months after SABT. Additionally, dyspnea was relieved in one patient with the tumor involving the trachea. The major AEs were mild intraoperative hemorrhage and skin/mucosal toxicities which were generally graded ≤2 and well-tolerated. Personalized SABT was an effective and safe alternative option for recurrent HNACC after the previous failure of surgery or EBRT. The parameter of D90 may influence the local control.

The endoscopic endonasal approach for sinonasal and nasopharyngeal adenoid cystic carcinoma

OBJECTIVE

To determine factors affecting outcomes for patients with sinonasal and nasopharyngeal adenoid cystic carcinoma (SNACC) treated using the endoscopic endonasal approach (EEA) with preservation of key structures followed by adjuvant radiotherapy (RT).

METHOD

Retrospective case series of 30 patients treated at the University of Pittsburgh between 2000 and 2014. Hospital records were reviewed for clinical and pathologic data. Outcome measures included overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates.

RESULTS

The majority of patients had T4a and T4b disease (23.3%, and 63.3%). Microscopically positive margins were present in 21 patients (63.6%). Positive margins were present in nine patients (30.0%). The mean and median follow-up were 3.97 and 3.29 years. Five-year OS, DFS, LRFS, and DMFS were 62.66%, 58.45%, 87.54%, and 65.26%. High-/intermediate-grade tumors had worse DFS (P = .023), and LRFS (P = .026) (HR = 4.837, 95% CI, 1.181-19.812). No factors were associated with significantly worse DMFS. No patient suffered CSF leak, optic nerve, or internal carotid injury. The mean and median length of hospital stay was 4.1 days and 2.0 days (range: 0-32 days).

CONCLUSION

Organ-preserving EEA with adjuvant RT for low-grade SNACC offers 5-year survival similar to that reported by other studies, which include radical, open skull base surgery. Patients with high-grade disease do poorly and may benefit from novel treatment strategies. For low-grade disease, organ-preserving EEA with RT may be the best option, offering a balance of survival, quality of life, and decreased morbidity for patients with this difficult-to-cure disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1414-1421, 2020.

Adenoid cystic carcinoma of trachea: long-term disease control after endoscopic surgery and radiotherapy

Aim: Adenoid cystic carcinoma is a rare tumor of head and neck region and its development in the thoracic region is even less frequent. This implies the absence of guidelines for therapeutic management and a consequent case-by-case approach. The role of radiotherapy is not yet clearly defined, but intensity-modulated radiotherapy allows for improved organ-at-risk sparing. Materials & methods: We have collected the cases of four patients treated at our institutions by the means of intensity-modulated radiotherapy, after endoscopic resection. Results & conclusion: Patients treated achieved long-term disease control of about 5 years, with a minimal acute toxicity. Longer follow-up is needed to drain conclusion on the impact of this treatment on overall survival.

Endoscopic Endonasal Interdural Middle Fossa Approach to the Maxillary Nerve: Anatomic Considerations and Surgical Relevance

BACKGROUND

The maxillary nerve (V2) can be approached via the open middle fossa approach.

OBJECTIVE

To delineate the anatomy of V2 and its specific segments with respect to the endonasal landmarks. We present the endoscopic endonasal interdural middle fossa approach to V2 and its potential application for the treatment of perineural spread in sinonasal/skull base tumors.

METHODS

Five human head silicon-injected specimens underwent bilateral endoscopic endonasal transpterygoid approaches. V2 prominence and the maxillary strut were identified in the lateral recess along with paraclival carotid protruberance. The regions superior and inferior to V2 corresponding to the anteromedial and anterolateral triangles of the middle fossa were exposed.

RESULTS

V2 can be classified into 3 segments: interdural (from the Gasserian ganglion to the proximal part of the maxillary strut), intracanalicular (corresponding to the anteroposterior length of the maxillary strut), and pterygopalatine (distal to the maxillary strut and the site of its divisions). Endonasally, the average length of the interdural and the intracanalicular segments were approximately 9 and 4.4 mm, respectively. V2, following its division distal to the maxillary strut, was successfully dissected off the middle fossa dura and transected just distal to the Gasserian ganglion.

CONCLUSION

Endonasally, the interdural segment can be safely mobilized between the periosteal and meningeal dural layers while ensuring the integrity of the middle fossa dura. This allows transection of infiltrated V2 to facilitate tumor resection without entering the intradural/arachnoidal space. Posteriorly, this is limited by the Gasserian ganglion and superomedially by the dural envelope surrounding the cavernous sinus and the paraclival carotid artery.

Prognostic factors and survival in adenoid cystic carcinoma of the sinonasal cavity

BACKGROUND

Optimal treatment and prognostic factors affecting long-term survival in patients with sinonasal adenoid cystic carcinoma (ACC) have yet to be clearly defined.

METHODS

We conducted a retrospective review of patients treated with curative intent from 1980-2015 at MD Anderson Cancer Center.

RESULTS

One hundred sixty patients met inclusion criteria, including 8 who were treated with radiotherapy alone. Median follow-up time was 55 months. The 5-year overall survival (OS) and disease-free survival (DFS) rates were 67.0% and 49.0%, respectively. The 10-year OS and DFS rates were 44.8% and 25.4%, respectively. Factors that portended for poor survival on multivariate analysis were recurrent disease, any solid type histology, epicenter in the sinus cavity, the presence of facial symptoms, or the original disease not treated with surgery. There was no association between surgical margin status or nodal status and survival.

CONCLUSION

In this large cohort of patients with sinonasal ACC with extended follow-up, long-term survival is better than reported in prior literature. Future research should target patients with adverse risk factors.

Clinicopathological Correlation of Adenoid Cystic Carcinoma: A Notorious Masquerader and Clinical Paradox

Background: Adenoid cystic carcinoma (ACC) is an uncommon tumor with nonspecific clinicoradiological features thereby masquerading other nonneoplastic and neoplastic entities. Materials and Methods: Cases of ACC were retrospectively reviewed over a period of 4 years. The clinical details of these patients including fine-needle aspiration cytology (FNAC) and imaging findings were retrieved. Diagnosis was confirmed on histomorphology and supplemented with immunohistochemistry (IHC). Results:: Thirty cases of ACC were included in the study. Mean patient age was 55.5 years with a slight female preponderance. Among the 30 ACCs, 10 (33.4%) were located in submandibular gland, 7 (23.4%) in parotid gland, 6 (20%) in sublingual gland, 2 (6.7%) in lung and one each (3.33%) in nasal cavity, breast, cervix, lip, and skin of face. Preoperative imaging was suggestive of malignancy in 29 cases while a single case of parotid gland ACC was misdiagnosed as benign salivary gland neoplasm. FNAC was performed in 29 cases with a diagnostic accuracy of 82.7%. Histopathological examination showed characteristic features of ACC in all cases with perineural invasion seen in 7 cases. On IHC, positivity for cytokeratin was seen in all cases, cluster of differentiation 117 in 24 cases, thyroid transcription factor-1 in two cases and human epidermal growth factor receptor/neu in two cases. All cases were negative for estrogen receptor and progesterone receptor IHC. Mean Ki-67 score was 47.8%. Conclusion: ACCs are notorious tumors showing slow growth kinetics with propensity for perineural invasion, late recurrences, and distant metastasis. It should be kept in mind as a differential diagnosis at unusual sites other than salivary glands.

Adenoid cystic carcinoma of head and neck: A retrospective clinical analysis of a single institution

Objective

In this study, patients with head and neck adenoid cystic carcinoma were investigated with respect to disease characteristics, treatments, and potentially prognostic variables.

Materials and Methods

Between January 1995 and December 2010, 29 patients with ACC of the head and neck treated at our institution were retrospectively reviewed.

Results

The 29 patients had a mean age of 54.7 years. Of the 29 patients, 4 (13.8%) underwent surgical resection only, 21 (72.4%) underwent surgery with radiotherapy, and 4 (13.8%) received postoperative chemoradiotherapy. Of 9 patients (31.0%) who experienced a recurrence within the follow-up period, 3 (10.3%) had local recurrence and 5 (17.2%) had distant metastasis; 1 (3.4%) patient had both local recurrence and distant metastatic spread.

Conclusion

ACC is a relatively rare tumor associated with long survival, even in metastatic settings. Despite aggressive therapy with surgery, radiotherapy, and chemo- therapy, a marked potential for local and distant recurrence still remains.

Clinical Outcomes and Prognostic Factors of Adenoid Cystic Carcinoma of the Head and Neck

BACKGROUND

Adenoid cystic carcinoma (ACC) is a salivary gland malignancy with unpredictable growth and poorly understood prognostic factors.

PATIENTS AND METHODS

A database search of patients treated at a single Institution was used to identify patients with histologically-confirmed ACC. Patient, tumor, and treatment characteristics were examined via review of medical records.

RESULTS

Overall survival of 70 patients identified at 5, 10, and 15 years was 80.4%, 61.3%, and 29.4%, respectively. Disease recurrence was seen in 31.9%; of these, 72.7% developed distant metastasis. Older age, higher stage, skull base involvement, positive margins, and metastatic disease, but not local recurrence, predicted a worse overall survival. Higher stage and skull base disease were also associated with shorter disease-free survival. While lung metastasis was the most common, vertebral metastasis was associated with poorer survival.

CONCLUSION

Disease stage, positive margins, skull base involvement, perineural invasion, time to recurrence, and location of metastasis, but not nodal involvement, could serve as poor prognostic factors in ACC.

Salivary Gland. Photon beam and particle radiotherapy: Present and future

Salivary gland cancers (SGCs) are rare diseases and their treatment depends upon histology, stage and site of origin. Radical surgery is the mainstay of treatment but radiotherapy (RT) plays a key role in both the postoperative and the inoperable setting, as well as in recurrent disease. In the absence of prospective randomized trials, a wide retrospective literature suggests postoperative RT (PORT) in patients with high risk pathological features. SGCs, and adenoid cystic carcinoma (ACC) in particular, are known to be radio-resistant tumors and should therefore respond well to particle beam therapy. Recently, excellent outcome has been reported with radical carbon ion RT (CIRT) in particular for ACC. Both modern photon- and hadron-based treatments are effective and are characterized by a favourable toxicity profile. But it is not clear whether one modality is superior to the other for disease control, due to the differences in patients' selection, techniques, fractionation schedules and outcome measurements among clinical experiences. In this paper, we review the role of photon and particle RT for malignant SGCs, discussing the difference between modalities in terms of biological and technical characteristics. RT dose and target volumes for different histologies (ACC versus non-ACC) have also been taken into consideration.

Expression of Autophagy and Reactive Oxygen Species-Related Proteins in Lacrimal Gland Adenoid Cystic Carcinoma

PURPOSE

To investigate the difference of expression of autophagy and reactive oxygen species (ROS) related proteins in adenoid cystic carcinoma (ACC) of lacrimal gland in comparison with ACC of salivary gland.

MATERIALS AND METHODS

Formalin-fixed, paraffin-embedded tissue samples from patients pathologically diagnosed as lacrimal gland ACC (n=11) and salivary gland ACC (n=64) were used. Immunochemistry was used to measure expression of autophagy related proteins [beclin-1, light chain (LC) 3A, LC3B, p62, and BCL2/adenovirus E1B 19 kDa protein-interacting protein 3 (BNIP3)] and ROS related proteins [catalase, thioredoxinreductase, glutathione S-transferasepi (GSTpi), thioredoxin interacting protein, and manganese superoxide dismutase (MnSOD)]. The prognostic factors related to disease-free and overall survival (OS) in lacrimal gland ACC by log-rank tests, were determined.

RESULTS

GSTpi in stromal cells was more highly expressed in lacrimal gland ACC (p=0.006), however, MnSOD in epithelial cells was expressed more in salivary gland ACC (p=0.046). LC3B positivity and BNIP3 positivity in epithelial component were associated with shorter disease-free survival (both p=0.002), and LC3A positivity in stromal component was the factor related to shorter OS (p=0.005).

CONCLUSION

This is the first study to demonstrate the expression of autophagy and ROS related proteins in lacrimal gland ACC in comparison with the salivary gland ACC, which would provide a basis for further study of autophagy and ROS mechanism as novel therapeutic targets in lacrimal gland ACC.

Adenoid cystic carcinoma of head and neck: A single institutional analysis of 66 patients treated with multi-modality approach

Background:

Adenoid cystic carcinoma (ACC) accounts for 1% of all head and neck (HN) cancers.

Materials and Methods:

Demographic, clinical, treatment, and survival details of 66 patients were collected (1995-2011) and analyzed. Disease-free survival (DFS) was estimated by Kaplan-Meier method.

Results:

Primary disease sites were sinonasal (n = 27), salivary gland (n = 30), and others (n = 9). Median follow-up was 23 months (range: 12-211 months). Estimated DFS at 2- and 5-year were 75% and 67.2%, respectively. On univariate analysis, intra-cranial extension (ICE) (hazard ratio [HR]: 3.59, P = 0.0071), lymph node involvement (HR: 4.05, P = 0.0065), treatment modality (others vs. surgery plus adjuvant radiotherapy, HR: 2.39, P = 0.0286) and T stage (T3/4 vs. T1/2, HR: 3.27, P = 0.007) had significant impact on DFS. Lymph node involvement (P = 0.038) and ICE (P = 0.038) continued to have significant impact on DFS on multivariate analysis.

Conclusion:

Surgery followed by adjuvant radiotherapy remains the treatment of choice for HN ACC. Lymph node involvement and ICE confer poor prognosis.

Proton therapy for head and neck adenoid cystic carcinoma: initial clinical outcomes

BACKGROUND

The purpose of this study was to report outcomes of proton therapy in head and neck adenoid cystic carcinoma.

METHODS

We conducted a retrospective analysis of 26 patients treated between 2004 and 2012. Twenty patients (77%) had base of skull involvement; 19 (73%) were treated for initial disease and 7 (27%) for recurrent disease. Twenty patients were treated postoperatively, 6 after biopsy alone and 24 had positive margins or gross residual disease.Median dose delivered was 72 Gy (relative biological effectiveness[RBE]).

RESULTS

Median follow-up was 25 months (range, 7–50 months). The 2-year overall survival was 93% for initial disease course and 57% for recurrent disease (p5.19). The 2-year local control was 95% for initial disease and 86% for recurrent disease (p5.48). The 2-year distant metastatic rate was 25%. Late toxicity of grade 0 or 1 was seen in 17 patients, grade 2 in 5, grade 3 in 2, grade 4 in 1, and grade 5 in 1.

CONCLUSION

Initial outcomes of proton therapy are encouraging. Longer follow-up is required.

MYB rearrangement and clinicopathologic characteristics in head and neck adenoid cystic carcinoma

OBJECTIVES

Salivary gland adenoid cystic carcinoma (ACC) is rare, aggressive, and challenging to treat. Many ACCs have a t(6;9) chromosomal translocation resulting in a MYB-NFIB fusion gene, but the clinical significance is unclear. The purposes of this study were to describe the clinicopathologic factors impacting survival and to determine the prevalence and clinical significance of MYB-NFIB fusion.

STUDY DESIGN

Case series.

METHODS

Medical records of patients treated for ACC of the head and neck from 1974 to 2011 were reviewed and clinicopathologic data recorded. Fluorescence in situ hybridization (FISH) was used to detect MYB rearrangement in archival tumor tissue as a marker of MYB-NFIB fusion.

RESULTS

One hundred fifty-eight patients were included, with median follow-up 75.1 months. Median overall survival was 171.5 months (95% confidence interval [CI] = 131.9-191.6), and median disease-free survival was 112.0 months (95% CI = 88.7-180.4). Advanced stage was associated with decreased overall survival (adjusted ptrend  < 0.001), and positive margins were associated with decreased disease-free survival (adjusted hazard ratio [aHR] = 8.80, 95% CI = 1.25-62.12, P = 0.029). Ninety-one tumors were evaluable using FISH, and 59 (65%) had evidence of a MYB-NFIB fusion. MYB-NFIB positive tumors were more likely than MYB-NFIB negative tumors to originate in minor salivary glands (adjusted prevalence ratios = 1.51, 95% CI = 1.07-2.12, P = 0.019). MYB-NFIB tumor status was not significantly associated with disease-free or overall survival (hazard ratio [HR] = 1.53, 95% CI = 0.77-3.02, P = 0.22 and HR = 0.91, 95% CI = 0.46-1.83, P = 0.80, respectively, for MYB-NFIB positive compared with MYB-NFIB negative tumors).

CONCLUSION

Stage and margin status were important prognostic factors for ACC. Tumors with evidence of MYB-NFIB fusion were more likely to originate in minor salivary glands, but MYB-NFIB tumor status was not significantly associated with prognosis.

LEVEL OF EVIDENCE

4.

Expression of metabolism-related proteins in lacrimal gland adenoid cystic carcinoma

OBJECTIVES

To investigate the expression and the clinical implications of metabolism-related proteins in lacrimal gland adenoid cystic carcinoma (ACC) in comparison with salivary gland ACC.

METHODS

Human tissue samples of lacrimal gland ACC (n = 11) and salivary gland ACC (n = 64) were analyzed. Immunochemistry was used to measure expression of proteins related to glycolysis (glucose transporter 1, hexokinase II, carbonic anhydrase IX, and monocarboxylate transporter 4 [MCT4]), glutaminolysis (glutaminase 1 [GLS1], glutamate dehydrogenase [GDH], and amino acid transporter 2 [ASCT2]), mitochondria (adenosine triphosphate [ATP] synthase, succinate dehydrogenase A [SDHA], and succinate dehydrogenase B), and glycolytic intermediate metabolism (phosphoserine phosphatase [PSPH], serine hydroxymethyl transferase 1 [SHMT1]).

RESULTS

GLS1 and ASCT2 were more highly expressed, and GDH, ATP synthase, and SDHA were expressed to a lesser degree in lacrimal gland ACC than in salivary gland ACC (P < .05). Lacrimal gland ACC showed less of a mitochondrial phenotype than did salivary gland ACC (P = .001). Positivity of MCT4 and PSPH was related to shorter disease-free survival, and SHMT1 was related to shorter overall survival (P < .05).

CONCLUSIONS

Lacrimal gland ACC exhibited higher expression of GLS1 and ASCT2, compared with salivary gland ACC. Overexpression of MCT4, PSPH, and SHMT1 was associated with poorer prognosis.

[Adenoid cystic carcinoma of the head and neck--a 10 years experience]

INTRODUCTION

Adenoid cystic carcinoma (ACC) was first described in 1853 and 1854 by three french scientists, Robin, Lorain and Laboulbène. ACC is a rare cancer of the head and neck (about 1%) and it comprises from 6% to 10% of all malignant tumors of the salivary glands. 15%–30% of these tumors are located in submandibular gland, 30% occur in small salivary glands (in the palate, tongue, mouth, nose, sinuses, mucous membrane of the cheeks) and about 6% in parotid gland. Because of its specificity ACC is a challenge for the doctor – it is usually recognized at an advanced stage, spreads along the nerves, it has a high propensity for recurrence, often gives distant metastases, 10-year survival are very small.

AIMS

Aim of this study is the epidemiological and clinical analysis of patients with adenoid cystic carcinoma.

MATERIAL AND METHODS

Includes a retrospective analysis of 21 cases of patients with ACC of the head and neck were hospitalized at the ENT Clinic of the Warsaw Medical University between 2001 and 2011. Data from medical records contain information about the location of the tumor, symptoms and clinical signs, diagnostic methods, method of treatment and local recurrences and distant metastases.

RESULTS

most cases ACC occurred in the large salivary glands (14 cases), in 5 cases in the nasal cavity and maxillofacial region, in 2 cases in the tongue. In order to accurately determine the extent of the tumor, its relationship to adjacent structures was performed computed tomography and magnetic resonance imaging. Most of patients before treatment have been made biopsy of the tumor or download tissues by forceps for histopathological examination. Reported symptoms depend on the location of the tumor. In 20 cases the patients were treated by surgical therapy and followed by radiotherapy, in one case because of the extent of the tumor was sent to radiotherapy.

CONCLUSIONS

Surgical treatment of ACC requires a wide margin of healthy tissues; For the risk of local recurrences affected positive surgical margins, skull base locations of primary tumor and perineural invasion; Because of unpredictable nature of the tumor (local recurrences, distant metastasis), observation of patients after treatment should be carried out permanently, along with periodic imaging studies.

Clinicopathologic predictors of recurrence and overall survival in adenoid cystic carcinoma of the head and neck: a single institutional experience at a tertiary care center

BACKGROUND

The purpose of this study was to determine factors that impact recurrence and long-term survival of head and neck adenoid cystic carcinoma (ACC).

METHODS

We conducted a retrospective review of 87 patients with head and neck ACC who were evaluated between 1992 and 2009. Staining for Ki-67, p53, α-estrogen receptor (αER), and progesterone receptor (PR) was performed.

RESULTS

Forty men (46%) and 47 women (54%) were included in this study. Median follow-up for patients was 98 months. Five-year recurrence-free and overall survival (OS) rates were 56% and 81%, respectively. Ki-67 and p53 expression was observed in 5 (6%) and 2 (2%) patients, respectively. αER and PR were all negative. The most important determinants of disease-free survival (DFS) were perineural invasion (PNI; p = .001) and female sex (p = .027). Disease site (major vs minor salivary gland) was the only predictor of worse OS on multivariate analysis.

CONCLUSION

Perineural invasion, female sex, and disease site were the most consistent predictors of poor outcome in head and neck ACC.

125I brachytherapy alone for recurrent or locally advanced adenoid cystic carcinoma of the oral and maxillofacial region

BACKGROUND AND PURPOSE

This retrospective study was to evaluate the local control and survival of (125)I brachytherapy for recurrent and/or locally advanced adenoid cystic carcinoma (ACC) of the oral and maxillofacial region.

PATIENTS AND METHODS

A total of 38 patients with recurrent and/or locally advanced ACC of the oral and maxillofacial region received (125)I brachytherapy alone from 2001-2010. Twenty-nine were recurrent cases following previous surgery and radiation therapy. The other 9 cases involved primary tumors. Overall, 12 tumors were located in the major salivary glands, 12 in the minor salivary glands, and 14 in the paranasal region, the nasal cavity or the skull base. The prescribed dose was 100-160 Gy.

RESULTS

Patients were followed for 12-122 months (median 51 months). The 2-, 5-, and 10-year local tumor control rates were 86.3, 59, and 31.5 %, respectively. The 2-, 5-, and 10-year overall survival rates were 92.1, 65 and 34.1 %, respectively. Tumors > 6 cm had significantly lower local control and survival rates. No severe complications were observed during follow-up.

CONCLUSION

(125)I brachytherapy is a feasible and effective modality for the treatment of locally advanced unresectable or recurrent ACC.

Recurrent prognostic factors and expression of GLUT-1, PI3K and p-Akt in adenoid cystic carcinomas of the head and neck: Clinicopathological features and biomarkers of adenoid cystic carcinoma

The purpose of this study was to explore the factors associated with the recurrence of adenoid cystic carcinomas (ACCs). We examined the recurrence values of clinicopathological variables and GLUT-1, p-Akt and PI3K expression in 42 patients with ACC. Of the 42 patients, 17 developed recurrence following initial surgery. The positive rates of GLUT-1, PI3K and p-Akt protein expression in ACC were 38.1, 38.1 and 50.0%, respectively. The expression of GLUT-1, p-Akt or PI3K protein in ACC was higher than that in inflammatory lesions or benign tumors. Our study demonstrated that T stage, a positive resection margin, perineural invasion, surgery without postoperative radiotherapy and the expression of GLUT-1, PI3K and p-Akt were factors predictive of recurrence by univariate analyses. In multivariate analyses, perineural invasion, a positive resection margin and p-Akt were significant predictors of recurrence. Initial surgery is very significant in the recurrence of ACC. Overexpression of GLUT-1, PI3K and p-Akt may also play a role in its development and recurrence.

A massive adenoid cystic carcinoma of nasal septum progressed into the skull base

BACKGROUND

Adenoid cystic carcinoma (ACC) is a malignant tumor commonly occurring in the major salivary glands. ACC of the nasal septum is exceeding rare.

METHODS

The case of a 42-year-old woman with ACC of the nasal septum is presented. Her chief complaint was nasal obstruction and dysosmia for two month. CT and MRI demonstrated a massive mass occupying the nasal septum infiltrating the palate, vomeronasal, anterior skull base, and dura mater. Combined anterior cranial surgery, endoscopic intranasal surgery, and transpalatal surgery were selected due to the size and location of the tumor. A negative surgical margin was achieved without cosmetic deformity or functional disorder.

RESULTS

She had postoperative radiotherapy with no recurrence or distant metastasis during the follow-up period.

CONCLUSION

The tumor location and the perineural spread pattern should be considered to determine the treatment plan for septum ACC. Post operative radiation is now generally recommended. ACC has a high incidence of local recurrence and distant metastasis rate; therefore, long-term follow-up is necessary.

[Adenoid cystic carcinoma of the head and neck: a retrospective series of 169 cases]

PURPOSE

Adenoid cystic carcinoma represents 1% of head and neck cancers. Adenoid cystic carcinomas are slow growing tumours with high potential for local recurrence. Treatment usually associates radiotherapy and surgery, but the role of radiotherapy remains unclear. We report a retrospective multicentric study of the management and prognostic factors of 169 adenoid cystic carcinomas of head and neck.

PATIENTS AND METHODS

Between 1982 and 2010, 169 patients with adenoid cystic carcinoma of the head and neck were referred to the Cercle des oncologues radiothérapeutes du Sud departments of radiotherapy either for primary untreated tumour (n=135) or for a recurrence of previously treated tumour (n=34). The site of adenoid cystic carcinoma was: parotid gland (n=48, 28.4%), minor salivary gland (n=35, 20.7%), submandibular gland (n=22, 13%), sinus cavities (n=22, 13%), other (n=42, 24.9%). Tumour stages were: T1 (12.4%); T2 (14.2%); T3 (12.4%); T4 (41.4%) and Tx (19.5%). Lymph node involvement was 13% and distant metastasis 8.9%. For adenoid cystic carcinomas of the parotid gland, major nerve involvement was evaluated. Preferential site of metastasis was the lung (87.5%). Treatments were: surgery alone (n=27), surgery and adjuvant radiotherapy (n=89), surgery and adjuvant chemoradiotherapy (n=12), exclusive chemoradiotherapy (n=13), exclusive radiotherapy (n=14), other associations (n=5) and no treatment (n=7). Radiotherapy was delivered through photons (n=119), neutrons (n=6), both (n=4). Two patients had a brachytherapy boost. Median prescribed doses to T and N were respectively 65 Gy and 50 Gy for the 119 photons treated patients.

RESULTS

Mean follow-up was 58 months (range 1-250 months). As of December 1, 2010, 83 patients were alive with no evolutive disease (49%), 35 alive and had recurred, 18 had uncontrolled evolutive disease, 28 had died of adenoid cystic carcinoma and 5 of intercurrent disease. Overall survival and disease free survival were respectively 72% and 72% at 5 years, 53% and 32% at 10 years; 5 and 10-year freedom from local recurrence were 81% and 52% respectively. Nerve involvement was found in 17/48 parotid gland adenoid cystic carcinomas. The Cox model including all patients, showed that surgery (P<0.001), surgical margins (P=0.015), nerve involvement (P=0.0079), length of radiotherapy (P=0.018), and tumour location (P=0.041) were associated with disease free survival.

CONCLUSION

In this large series of adenoid cystic carcinoma of head and neck with a majority of T3-T4 tumours, 10-year survivals were achieved for 50% of patients. Radiotherapy did not impact survival.

Adenoid cystic carcinoma of the head and neck: Incidence and survival trends based on 1973-2007 Surveillance, Epidemiology, and End Results data

BACKGROUND

Adenoid cystic carcinoma (ACC) of the head and neck (ACCHN) is a rare tumor of minor salivary, parotid, and submandibular glands. The biologic behavior of the disease is poorly understood, and nonsurgical treatment strategies have yet to be standardized. The long-term prognosis continues to be guarded, with an estimated 10-year survival of <60%. Population-based studies examining ACC are scarce. The authors aimed to analyze incidence rates and survival outcomes for patients diagnosed with ACCHN using national population-based data.

METHODS

Data were obtained from the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Newly diagnosed ACCHN cases reported to SEER from 1973 through 2007 were categorized according to their sex, race, age, year of diagnosis, marital status, treatment interventions, primary tumor site, and disease stage. Incidence of ACCHN and postdiagnosis survival were examined over time and compared across different demographic and disease-related categories.

RESULTS

The authors identified 3026 patients with ACCHN. The mean age at diagnosis among those cases was 57.4 years (range, 11-99 years). Analyses of incidence data demonstrated a decline in ACCHN rates between 1973 and 2007, noted across all sexes and races with no detectable inflexion points. The overall 5-year, 10-year, and 15-year survival outcomes for ACCHN patients were 90.3%, 79.9%, and 69.2%, respectively. Females, patients with localized disease, and younger patients were found to have significantly better survival across all time periods (all comparison-specific log-rank P values <0.001). Multivariate analyses revealed better prognosis among women compared with men (hazard ratio [HR], 0.73; 95% confidence interval [CI], 0.65-0.82), among married compared with unmarried individuals (HR, 0.81; 95% CI, 0.71-0.91), with certain sites of origin and stage of disease (HR, 2.788; 95% CI, 2.36-3.29), and in those who had surgery of the primary tumor site (HR, 0.45; 95% CI, 0.37-0.54).

CONCLUSIONS

The overall incidence of ACC is declining. The noted differences in survival based on sex, marital status, site of origin, and treatment intervention require further investigation.

Clinicopathological features of salivary and non-salivary adenoid cystic carcinomas

Adenoid cystic carcinoma (ACC), commonly from salivary glands, is known for its insidious local growth and usually protracted clinical course. ACC developing from non-salivary glands (i.e., non-salivary ACC) is heterogeneous, and its clinicopathological features remain poorly defined. Patients treated for ACC in a single institution between 1995 and 2007 were included in this study. Immunohistochemical evaluation of Ki-67, E-cadherin, p16, and cyclinD1 was performed. The prognostic significance of clinical and immunophenotypic markers was evaluated. 83 cases of salivary ACC and 24 cases of non-salivary ACC were included. The expression levels of Ki-67 (54.8%), E-cadherin (90.4%), p16 (32.9%), and cyclinD1 (19.2%) between ACCs present at various sites were not different. Sinonasal, lacrimal, and tracheobronchial ACCs had significantly worse outcomes than those of ACC of the major salivary glands. Postoperative radiotherapy reduced the recurrence rate of patients with a negative resection margin (P=0.028). Older age (age >60 years), advanced stage, positive resection margin, high histological grade, and high expression of Ki-67 were significantly correlated with poor prognosis. In conclusion, the site of origin plays a role in the prognosis of ACC, in which positive resection margin and advanced stage are possible factors underlying the differences in outcomes.

Determinants and patterns of survival in adenoid cystic carcinoma of the head and neck, including an analysis of adjuvant radiation therapy

OBJECTIVES

The effect of adjuvant radiation therapy (RT) on survival in patients with adenoid cystic carcinoma (ACC) is much debated. Studies with large numbers of patients and long follow-up are lacking in the literature.

METHODS

We identified 2286 single-primary ACCs of the head and neck treated with surgery in the National Cancer Institute's surveillance, epidemiology, and end results database. The determinants of survival, including the effect of adjuvant RT, were analyzed with a Cox Proportional Hazards Model.

RESULTS

The overall 5-, 10-, 15-, 20-, and 25-year survival rates for patients receiving surgical resection were 77.3%, 59.6%, 44.9%, 35.0%, 25.5%, respectively. In the interval between 10 and 30 years after diagnosis, 111 patients died of ACC, and 137 died of all competing causes combined. Increasing stage caused a decrease in survival that was proportional over time. On multivariable analysis, distant metastasis, lymph node involvement, higher T classification, increasing age, and submandibular gland, or sinus/nasal cavity subsites were each independently associated with decreased overall and cause-specific survival. Adjuvant RT failed to improve overall or cause-specific survival.

CONCLUSIONS

Cause-specific survival continues to decline up to 30 years after diagnosis in ACC of the head and neck. In the interval between 10 and 30 years after diagnosis, patients are nearly as likely to die of ACC as from all competing causes combined. Certain clinicopathological factors are associated with decreased survival. There is no evidence of increased survival in patients receiving adjuvant RT.

Adenoid cystic carcinoma: a rare clinical entity and literature review

The adenoid cystic carcinoma is a relatively rare epithelial tumor of the major and minor salivary glands, accounting for about 1% of all malignant tumor of the oral and maxillofacial region. Although it presents a widespread age distribution, peak incidence occurs predominantly among women, between the 5th and 6th decades of life. The clinical and pathological findings typical of this tumor include slow growth, perineural invasion, potential local recurrence and distant metastasis. Histopathologically it is composed of basaloid cells with primarily myoepithelial/basal cell differentiation. It presents three patterns, cribriform, tubular and solid; the solid type is related to a poor prognosis contrary to the cribriform type, which has a better prognosis. Surgical excision with wide margins is the treatment of choice, if it metastasizes to lymph nodules, post surgical radiotherapy is recommended. We presented herein the case of a 45 year old female patient who presented a palatal lesion, which was treated with surgery and radiotherapy as an additional treatment. We also described a brief literature review of adenoid cystic carcinoma.

Prognostic factors in patients with high-risk locally advanced salivary gland cancers treated with surgery and postoperative radiotherapy

BACKGROUND

This study was designed to identify the factors associated with the outcome after standard treatment with surgery and postoperative radiotherapy (RT) for locally advanced salivary gland cancers.

METHODS

We conducted a retrospective review of patients with salivary gland cancers registered in the University of Pittsburgh databases from 1990 to 2006.

RESULTS

A total of 74 patients were analyzed. Histologic types included salivary duct carcinoma, 24%; adenoid cystic carcinoma, 23%; and adenocarcinoma, 19%; N2, 39%; N0-1, 58%; and major salivary gland origin, 80%. With a median follow-up of 4.1 years, the 5-year recurrence-free survival (RFS) was 49%, and the 5-year overall survival (OS) was 55%. The 5-year local RFS was 76% and the 5-year distant RFS was 60%. Using Cox-regression analysis, advanced N classification (N2) was the only significant predictor of both RFS and OS.

CONCLUSION

The long-term survival of patients with high-risk, locally advanced salivary gland cancers is unsatisfactory. Advanced nodal disease is strongly associated with patient outcome and should be considered as a stratification factor in future trials in locally advanced salivary gland cancers.

Histologic grading and prognostic biomarkers in salivary gland carcinomas

Both the variety and rarity of salivary gland carcinomas pose challenge for using histologic grade and biomarkers to predict outcome. Mucoepidermoid carcinoma is the histologic subtype for which grading is most prognostically and therapeutically relevant. This tumor is graded using standard schemes in a 3-tier manner with the intermediate-grade category shows the most variability between grading systems and thus the most controversy in management. The t(11;19)(q21; p13) MECT1-MAML2 translocation may be an objective marker that can help to further stratify difficult cases. Adenoid cystic carcinomas are graded based on pattern with solid areas correlating with a worse prognosis. Occasionally, adenoid cystic carcinomas may undergo transformation to highly aggressive pleomorphic high-grade carcinomas with frequent nodal metastases. Comparative genomic hybridization has revealed several chromosomal regions (such as 1p32-p36, 6q23-q27) of prognostic interest in adenoid cystic carcinoma. Carcinoma ex-pleomorphic adenoma is actually a category of tumors rather than a single tumor type with both aggressive and indolent versions. These tumors should be further qualified as to type/grade of carcinoma and extent, as intracapsular and minimally invasive tumors behave favorably. Acinic cell carcinomas, although generally considered low grade, can recur, metastasize, or even prove lethal in a significant number of cases suggesting amenability to a grading scheme to separate these biologic groups. Although aggressive histologic parameters (anaplasia, necrosis, and mitoses) are predictive of poor outcome, a standard grading scheme does not yet exists. Acinic cell carcinomas can also undergo high-grade transformation.

Chemotherapy and targeted therapy in adenoid cystic carcinoma of the head and neck: a review

Adenoid cystic carcinoma (ACC) is an uncommon tumor usually arising in the head and neck region, mainly in the salivary glands. It demonstrates an indolent prolonged course and is characterized by perineural invasion. Primary treatment of local and locoregional disease consists mainly of surgery and/or irradiation. During follow-up these patients frequently develop local recurrences and distant metastases, especially in the lung, although long-term survival is possible. The role of chemotherapy in ACC is limited, and studies with only a limited number of patients are performed. In this article we review the literature on chemotherapy regimens, including monotherapy and combination chemotherapy schedules, as well as the new targeted therapies.

Role of radiotherapy in adenoid cystic carcinoma of the head and neck

This study retrospectively reviewed 183 cases of adenoid cystic carcinoma treated over 40 years. The local recurrence free survival rate was 68.2 per cent at five years and 40.8 per cent at 10 years. At 10 years, local recurrence free survival was significantly worse following radiotherapy alone (0 per cent), compared with surgery alone (41.8 per cent, p = 0.004) or combined with post-operative radiotherapy (43.5 per cent, p = 0.001). Neither tumour stage three or four, perineural invasion, solid subtype nor involved margins predicted local recurrence. Treatment with radiotherapy alone resulted in worse survival than surgery alone (p = 0.002) or combined with post-operative radiotherapy (p = 0.001). Survival rates following local recurrence (n = 34) were higher following surgery (p = 0.006) but not significantly improved following radiotherapy (p = 0.139). Chemotherapy for distant metastases did not prolong survival (p = 0.747) but did result in improved eating and aesthetics scores, while decreasing overall physical health. These results indicate that surgery is preferable for primary and recurrent adenoid cystic carcinoma of the head and neck. The incidence of local recurrence following surgery and postoperative radiotherapy was similar to surgery alone cases although the latter had less adverse prognostic features. Contemporary chemotherapy may benefit quality of life but not survival in patients with distant metastases due to adenoid cystic carcinoma of the head and neck.

[Cerebral nerves - perineural tumor spread]

Perineural tumor spread in the course of head and neck tumors is a form of metastatic disease in which the tumor disseminates centrifugally or centripetally along the nerve to (non)contiguous regions. Perineural tumor spread is a potentially devastating complication and has a high impact on the therapeutic management and overall prognosis. In a large proportion of patients the disease remains asymptomatic and imaging (especially MRI) plays a crucial role in the detection of lesions. Familiarity with the pertinent anatomy, knowledge of the common spread pathways and an appropriate imaging strategy allow detection of the perineural spread of the disease in the majority of the cases.

Adenoid cystic carcinoma of the parotid gland: Anastamosis of the facial nerve with the great auricular nerve after radical parotidectomy

Adenoid cystic carcinoma of the parotid gland is a rare and slowly growing, but highly malignant tumor. Surgical resection of a malignant parotid tumor should include resection of the facial nerve when the nerve is involved in the tumor. Facial nerve reconstruction is required after nerve resection. A 14 year-old female presented with complaints of painless enlargement of the right parotid gland and facial asymmetry. Physical examination revealed a firm mass in the region of the parotid gland as well as right facial paralysis. Biopsy obtained from the mass showed an adenoid cystic carcinoma of the parotid gland. A radical parotidectomy with a modified radical neck dissection was carried out. Grafting material for the facial reconstruction was harvested from the great auricular nerve. The proximal main trunk and each distal branch of the facial nerve were coapted with the greater auricular nerve. The patient received radiotherapy after surgery and was seen to achieve grade IV facial function one year after surgery. Thus, the great auricular nerve is appropriate grafting material for coaptation of each distal branch of the facial nerve.

Outcomes and prognostic variables in adenoid cystic carcinoma of the head and neck: a recent experience

PURPOSE

To analyze the recent experience of patients with adenoid cystic carcinoma treated with radiation therapy at Memorial Sloan-Kettering Cancer Center.

METHODS AND MATERIALS

From 1990 to 2004, a total of 59 patients with a diagnosis of primary adenoid cystic carcinoma of the head and neck received radiation therapy at our institution. The subsite distribution was oral cavity, 28% (n = 17); paranasal sinuses, 22% (n = 13); parotid, 14% (n = 8); submandibular, 14% (n = 8); oropharynx, 10% (n = 6); sublingual, 3% (n = 2); nasopharynx, 3% (n = 2); and other, 5% (n = 3). T Stage distribution was T1, 34% (n = 20); T2, 19% (n = 11); T3, 14% (n = 8); and T4, 34% (n = 20). Twenty-nine percent of patients (n = 17) were treated with intensity-modulated radiation therapy; 25% (n =15), with three-dimensional conformal therapy, and the remainder, with conventional techniques. Ninety percent (n = 53) of patients received treatment including the base of skull.

RESULTS

Median follow-up for surviving patients was 5.9 years. Five-year and 10-year rates of local control and distant metastases-free survival were 91%/81% and 81%/49%, respectively. Five-year and 10-year rates of disease-free and overall survival were 76%/40% and 87%/65%, respectively. On univariate analysis, stage T4 (p = 0.004) and gross/clinical nerve involvement (p = 0.002) were associated with decreased progression free survival, whereas stage T4 and lymph node involvement were associated with decreased overall survival (p = 0.046 and p < 0.001, respectively).

CONCLUSIONS

Radiation therapy in combination with surgery produces excellent rates of local control, although distant metastases account for a high proportion of failures. Routine treatment to the base of skull reduces the significance of histologic perineural invasion, but major nerve involvement remains an adverse prognostic factor.

Transmaxillary exploration of the intracranial portion of the maxillary nerve in malignant perineural disease

Object

Achieving microscopically tumor-free margins during resection of skull base malignancies has consistently been identified as a positive prognostic factor for patient survival. When malignancies extend perineurally into the major nerves traversing the skull base and entering the cavernous sinus, achieving tumor-free margins can be challenging and typically necessitates performing a craniotomy to access the lateral wall of the cavernous sinus. This report describes a novel technique used to access and resect malignancy extending perineurally into the intracranial portion of V2 via the maxillary sinus.

Methods

Seven patients with maxillary sinus tumors and perineural extensions along V2, who underwent resection of the primary tumor and transmaxillary intracranial exposure and dissection of the maxillary nerve to achieve maximal tumor resection, were analyzed. Prospectively collected data, including symptoms, clinical signs, diagnostic imaging data, pathological diagnosis, incidence and nature of complications, adjuvant therapies, and oncological outcomes, were retrospectively analyzed.

Results

All patients in this cohort had trigeminal nerve symptomatology as well as abnormal enhancement in the pterygopalatine fissure as noted on magnetic resonance imaging. The transmaxillary exploration of the maxillary nerve technique was used in all seven patients, resulting in gross-total resection of the tumors in every patient. At the last follow-up (mean 30 months, range 13–58 months, in four of seven patients for > 2 years), six patients were alive without evidence of local disease. One patient with squamous cell carcinoma died of progressive infratemporal fossa and regional neck disease 26 months after resection. No intracranial or cavernous sinus disease was present.

Conclusions

This technique extended the limits of resection without the need for a craniotomy and improved local tumor control in this patient cohort.

An unusual presentation of adenoid cystic carcinoma of the minor salivary glands with cranial nerve palsy: a case study

Background

Adenoid Cystic Carcinoma (ACC) is a rare tumor entity and comprises about 1% of all malignant tumor of the oral and maxillofacial region. It is slow growing but a highly invasive cancer with a high recurrence rate. Intracranial ACC is even more infrequent and could be primary or secondary occurring either by direct invasion, hematogenous spread, or perineural spread. We report the first case of the 5^th and 6^th nerve palsy due to cavernous sinus invasion by adenoid cystic carcinoma.

Case presentation

A 49-year-old African American female presented to the emergency room complaining of severe right-sided headache, photophobia, dizziness and nausea, with diplopia. The patient had a 14 year history migraine headaches, hypertension, and mild intermittent asthma. Physical examination revealed right lateral rectus muscle palsy with esotropia. There was numbness in all three divisions of the right trigeminal nerve. Motor and sensory examination of extremities was normal. An MRI of the brain/brain stem was obtained which showed a large mass in the clivus extending to involve the nasopharynx, pterygoid plate, sphenoid and right cavernous sinuses.

Biopsy showed an ACC tumor with a cribriform pattern of the minor salivary glands. The patient underwent total gross surgical resection and radiation therapy.

Conclusion

This is a case of ACC of the minor salivary glands with intracranial invasion. The patient had long history of headaches which changed in character during the past year, and symptoms of acute 5^th and 6^th cranial nerve involvement. Our unique case demonstrates direct invasion of cavernous sinus and could explain the 5^th and 6^th cranial nerve involvement as histopathology revealed no perineural invasion.

Primary tuberculosis of submandibular gland

Salivary gland tuberculosis is a rare pathology and does not always have the diagnostic guidelines led by previous tubercular localizations. Tubercular bacillus can reach the salivary gland in different ways, but the condition that most frequently causes a tubercular infection is the decay of the human organism defensive capacity toward the germ.A 15-year-old Romanian boy presented with a swelling in the left submandibular region. Normal extraoral, intraoral examination, and routine diagnostic examinations were performed. In order to make a final diagnosis, we performed a surgical left submandibular gland sialo-adenectomy operation to enable a histologic examination of the withdrawn tissue. Microscopic examination of the gland and lymph nodes showed a chronic necrotizing phlogosis of tubercular type. Previous routine examinations have been important only after final diagnosis to confirm that the submandibular tubercular localization was a primary infection. Diagnosis of this kind of disease is extremely difficult and is made with certainty only with the histologic examination, as happened in our case.

[Adenoid cystic carcinoma]

Adenoid cystic carcinoma is an uncommon tumor of the head and neck. Although it is mainly located in the salivary gland, a skin location has also been described. Metastases are rare, but 50 % of the cases relapse. A 65-year-old male patient had a lesion in the upper lip. After resection, the histological diagnosis was adenoid cystic carcinoma. Treatment was completed with radiotherapy. Ten years later, a nodule was detected in the neck. Its histological diagnosis was lymphatic metastasis due to adenoid cystic carcinoma. Primary cutaneous adenoid cystic carcinoma is a very uncommon tumor in which treatment consists in extensive local excision with free margins. Radiotherapy is not curative and should be reserved for palliative treatments. Multicenter, prospective studies are necessary to determine the best treatment and especially the adjuvant treatment for adenoid cystic carcinoma.