Malignant parotid tumors. Prognostic factors and optimum treatment

Oncologic outcomes of the most prevalent major salivary gland cancers: retrospective cohort study from single center

BACKGROUND

The preoperative diagnosis of salivary gland cancer (SGC) is crucial for the application of appropriate treatment, particularly involving the extension of the resection.

METHODS

Retrospective search of medical database identified 116 patients treated surgically with malignant tumors of salivary gland between 2010 and 2020. Analysis included the demographical data, clinical course, type of surgical and adjuvant treatment, histology type and margin status, perivascular invasion (LVI), perineural invasion (PNI), metastatic lymph nodes (LN). Facial nerve function, recurrence-free and overall survival were evaluated. Adequate statistics were used for data analysis.

RESULTS

The final cohort included 63 SGC patients, with adenoid cystic carcinoma the most common pathological type (27%, n = 17), followed by adenocarcinoma (17.4% n = 11). T1 and T2 patients accounted for majority cases (n = 46). The lymph node metastases were confirmed with the histopathology in 31.7% (n = 20). Distant metastases were observed in 4.8% of cases (n = 3). 38% (n = 24) of SGC were treated selectively with surgery, 49.2% (n = 31) had postoperative radiotherapy and 15.9% (n = 10)-radio-chemotherapy. The final facial nerve function was impaired in 38% of patients. Mean overall survival (OS) for all patients was 108.7 (± 132.1) months, and was the most favorable for acinar cell carcinoma (118.9 ± 45.4) and the poorest for squamous cell carcinoma (44 ± 32). Cox regression analysis of disease-free survival and OS identified significant association only with patients' age over 65 years, the hazard ratio of 7.955 and 6.486, respectively.

CONCLUSIONS

The efficacy of treatment modalities for SGC should be verified with regard to the histopathological type, but also the patients' age should be taken into account.

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

OBJECTIVE

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

DATA SOURCES

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

REVIEW METHODS

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

RESULTS

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

CONCLUSION

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

Facial Reanimation and Reconstruction of the Radical Parotidectomy

Radical parotidectomy may result from treating advanced parotid malignancies invading the facial nerve. Survival is often enhanced with multimodality treatment protocols, including postoperative radiation therapy. In addition to the reconstructive challenge of restoring facial nerve function, patients may be left with a significant cervicofacial concavity and inadequate skin coverage. This should be addressed with stable vascularized tissue that is resistant to radiation-induced atrophy. This article describes a comprehensive strategy, includes the use of the anterolateral thigh free flap, the temporalis regional muscle transfer, motor nerve to vastus lateralis grafts, nerve to masseter transfer, and fascia lata grafts for static suspension.

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

Background

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

Methods

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

Results

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

Conclusion

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

Is There A Role for Limited Parotid Resections for Primary Malignant Parotid Tumors?

(1) Background: Lateral or total parotidectomy are the standard surgical treatments for malignant parotid tumors. However, some authors have proposed a more limited procedure. (2) Methods: We performed a review of the literature on this topic. Studies were included that met the following criteria: malignant parotid tumors, information about the extent of surgical resection, treated with less than a complete lateral lobectomy, and information on local control and/or survival. Nine articles fulfilled the inclusion criteria. (3) Results: Eight of the nine series reported favorable results for the more limited approaches. Most used them for small, mobile, low-grade cancers in the lateral parotid lobe. Most authors have used a limited partial lateral lobectomy for a presumed benign lesion. The remaining study analyzed pediatric patients treated with enucleation with poor local control. (4) Conclusions: There is weak evidence for recommending less extensive procedures than a lateral parotid lobectomy. In the unique case of a partial lateral parotidectomy performed for a tumor initially thought to be benign but pathologically proved to be malignant, close follow-up can be recommended for low grade T1 that has been excised with free margins and does not have adverse prognostic factors.

Postoperative radiotherapy for mucoepidermoid carcinoma of the major salivary glands: long-term results of a single-institution experience

Purpose

This study aimed to evaluate the long-term survival outcomes and prognostic factors that affect the clinical outcomes of patients who underwent surgery and postoperative radiotherapy for major salivary gland mucoepidermoid carcinoma (MEC).

Materials and Methods

We retrospectively reviewed the clinical data of 44 patients who underwent surgery followed by radiotherapy for primary MEC of the major salivary glands between 1991 and 2014. The median follow-up period was 9.8 years (range, 0.8 to 23.8 years).

Results

The overall outcomes at 5 and 10 years were 81.5% and 78.0% for overall survival (OS), 86.2% and 83.4% for disease-free survival, 90.6% and 87.6% for locoregional recurrence-free survival, and both 90.5% for distant metastasis-free survival (DMFS). Histologic grade was the only independent predictor of OS (low vs. intermediate vs. high; hazard ratio = 3.699; p = 0.041) in multivariate analysis. A poorer survival was observed among patients with high-grade tumors compared with those with non-high-grade tumors (5-year OS, 37.5% vs. 91.7%, p < 0.001; 5-year DMFS, 46.9% vs. 100%, p < 0.001).

Conclusion

Surgery and postoperative radiotherapy resulted in excellent survival outcomes for patients with major salivary gland MEC. However, high-grade tumors contributed to poor DMFS and OS. Additional aggressive strategies for improving survival outcomes should be developed for high-grade MEC.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 129:883-889, 2019.

Perineural Invasion in Parotid Gland Malignancies

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

Nodal Stage: Is It a Prognostic Factor for Submandibular Gland Cancer?

PURPOSE

Submandibular gland cancer is relatively rare. The purpose of this study was to estimate 5-year overall survival (OS) and disease-free survival (DFS) and to identify prognostic factors associated with OS and DFS for submandibular cancer.

MATERIALS AND METHODS

The authors implemented a retrospective cohort study and enrolled a sample of patients with submandibular gland cancer. The predictor variables were age, gender, tumor stage, nodal stage, margin status, and extracapsular spread. The outcome variables were 5-year OS and 5-year DFS. Kaplan-Meier methods were used to estimate survival and Cox hazards models were used to identify prognostic variables.

RESULTS

The sample was composed of 52 patients with submandibular gland cancer (mean age, 47.4 yr; 51.9% men). The median follow-up was 81 months (range, 11 to 159 months). The 5-year OS and DFS rates were 76.9 and 67.3%, respectively. Fixed mass, positive neck node, and positive margin status were relevant predictors of OS and DFS. Nodal stage was the relevant independent predictor affecting the disease outcome of submandibular gland cancer.

CONCLUSION

These results identified several important prognostic factors associated with survival rate in patients with submandibular gland cancer. These prognostic variables include symptoms at presentation, pathologic nodal status, and margin status. These outcomes suggest that heightening vigilance of clinical characteristics for this disease might provide the impetus for improving the survival rate.

Malignant Parotid Tumor and Facial Palsy

OBJECTIVE: To evaluate risk factors for postoperative facial palsy in patients with parotid carcinoma.

STUDY DESIGN AND SETTING: We conducted a retrospective chart review of patients with parotid carcinoma who underwent parotidectomy at National Taiwan University Hospital from 1980 to 2000.

RESULTS: Eighty-eight patients with a mean age of 53 ± 17 y were recruited. Sixty patients (68.2%) experienced postoperative facial palsy. Tumor size of larger than 4 cm was associated with an increased incidence of facial palsy ( P = 0.0422). Facial palsy was noted in 95.5 percent of patients with facial nerve involvement and 51.3 percent of patients without facial nerve involvement ( P = 0.0004). Of 42 patients with tumor over the deep lobe, 37 (88.1%) had facial palsy but only 50 percent (23 of 46) of those with tumor over the superficial lobe had facial palsy ( P = 0.0001).

CONCLUSION: There were no significant associations between histopathology and facial palsy. Increasing tumor size, deep lobe tumor location, and tumor invasion of facial nerve increased the incidence of postparotidectomy facial palsy.

SIGNIFICANCE: By paying attention to these risk factors a reduction of postoperative facial nerve palsy my be achieved.

Outcomes and prognostic factors for major salivary gland carcinoma following postoperative radiotherapy

PURPOSE

To report outcomes of postoperative radiotherapy (PORT) for major salivary gland carcinoma (SGC) and identify patients at high risk of distant metastases (DM).

METHODS AND MATERIALS

Patients with major SGC treated between 2000-2012 were identified. All patients underwent initial primary resection, with neck dissection (ND) therapeutically (if N+) or electively in high risk N0 patients. PORT was delivered using 3D-CRT or IMRT. Multivariable analysis (MVA) assessed predictors for DM, cause-specific (CSS) and overall survival.

RESULTS

Overall 304 patients were identified: 48% stage III-IVB, 22% lymphovascular invasion (LVI), 50% involved margins and 64% high risk pathology. ND was performed in 154 patients (51%). Adjuvant chemotherapy was used in 10 patients (3%). IMRT was delivered in 171 patients (56%) and 3D-CRT in 133 (44%). With a median follow-up of 82 months, the 5-(10-) year local, regional, distant control, CSS and OS were 96% (96%), 95% (94%), 80% (77%), 83% (82%) and 78% (75%), respectively. DM was the most frequent treatment failure (n=62). On MVA, stage III-IVB and LVI significantly correlated with DM, CSS and OS, while positive margins predicted DM and CSS, and high risk pathology predicted DM. No grade ⩾ 4 RTOG late toxicity was reported; 9 patients had grade 3, including osteoradionecrosis (n=4), neck fibrosis (n=3), trismus (n=1) and dysphagia (n=1).

CONCLUSIONS

Surgery and PORT with 3D-CRT/IMRT produced excellent long-term outcomes. Further research is required for patients with stage III-IVB, LVI, positive margins and high risk pathology to determine the incremental benefit of systemic therapy in management of SGC.

Primary lymphoepithelioma-like carcinoma of salivary gland: sixty-nine cases with long-term follow-up

BACKGROUND

Lymphoepithelioma-like carcinoma (LELC) in the salivary glands is a rare but unique malignancy.

METHODS

Sixty-nine patients with salivary gland LELC with long-term follow-up were reviewed for this study.

RESULTS

There were 52 cases in the parotid gland and 17 cases in the submandibular gland. All patients underwent complete tumor excision, 41 underwent neck dissection, and 39 received postoperative radiotherapy. The 5-year, 10-year, and 15-year overall survival (OS) rates were 90%, 75%, and 54%, respectively. Patients with higher neutrophil/lymphocyte ratio (NLR ≥ 4.0) and advanced stage (stage III and IV) had significantly poorer OS. Patients who received postoperative radiotherapy had significantly better relapse-free survival (RFS). In multivariate analysis, stage, NLR, and neck dissection were associated independently with OS, whereas stage and postoperative radiotherapy were associated independently with RFS.

CONCLUSION

Salivary gland LELC is a rare malignancy with a better prognosis that partially attributes to surgery with neck dissection and postoperative radiotherapy. Preoperative NLR is an independent prognostic factor.

Signs and symptoms of parotid gland carcinoma and their prognostic value

The aim of this study was to analyse signs and symptoms present in patients with parotid gland carcinoma and to assess their prognostic value. A retrospective study of data from 131 patients who were treated surgically was performed. Evaluation of prognostic factors was possible in 109 patients who completed a minimum 5 year follow up. The most common sign and symptoms were parotid mass (96.9%), pain (40.4%), enlarged cervical lymph nodes (32.0%), facial nerve palsy (20.6%) and overlying skin infiltration (19.8%). In 20% of all cases there were no symptoms of tumour malignancy. The average duration of symptoms suggesting malignancy was 4 months. In univariate analysis, the strongest prognostic value was found for facial nerve palsy; it reduced nearly tenfold (9.7) the 5-year disease-free survival. The subsequent poor prognostic factors were: skin infiltration, enlarged cervical lymph nodes, tumour fixation and tumour size (>4 cm). Pain and the dynamics of tumour growth were not statistically significant for survival rate. Significant difference in 5-year disease free survival rate was found between the groups of patients, according to the number of symptoms suggesting malignancy. The multivariate analysis showed that only facial nerve palsy and skin infiltration were independent prognostic factors.

Concurrent chemoradiotherapy for locoregionally advanced salivary gland malignancies

BACKGROUND

Locoregionally advanced salivary gland malignancies have a poor prognosis despite aggressive therapy. Herein we report our experience in treating high-risk salivary gland malignancies with concurrent chemoradiotherapy (CRT).

METHODS

Medical records of 15 patients with salivary gland malignancies treated with CRT at our institution between 1997 and 2010 were analyzed.

RESULTS

All patients had high-risk characteristics: 80% were stage IV, 54% were ≥ N2, and 47% were unresectable and were treated with definitive CRT. At 2 years, overall survival (OS) was 67%, disease-free survival (DFS) was 44%, and local control was 76%. There were no treatment-related deaths, and patients experienced expected acute side effects.

CONCLUSION

CRT for salivary gland malignancies has acceptable toxicity, CRT is proven beneficial for many other cancers, and some salivary gland malignancies are clinically responsive to chemotherapy. CRT, therefore, should be considered for treatment of high-risk salivary gland malignancies.

Are all prognostic factors in parotid gland carcinoma well recognized?

The aim of his study was to assess the treatment results and prognostic factors in patients with parotid gland carcinoma. The material consisted of 109 patients treated surgically, with or without complementary radiotherapy, between 1978 and 2008 (follow-up at least 5-years). 5-year overall and disease-specific survival were observed in 57.0% of the patients and 5-year disease-free survival was achieved in 50.0%. Univariate analysis including ten clinical and pathological features to assess their prognostic value was done. Parapharyngeal space invasion, facial nerve palsy, and high grade of tumor malignancy were the factors with the highest influence on the treatment results, because their presence decreased the chance for recovery 9.8, 9.7, and 8.2 times, respectively. Histologically positive cervical lymph nodes and extraparenchymal extension were the other factors connected with poor prognosis (prognosis worse 6.7 and 5.4 times, respectively). Clinically positive cervical lymph nodes, positive/uncertain microscopic margin, involvement of the deep lobe, or the whole gland increased the risk of treatment failure 3.4, 3.1, and 2.8, respectively. The age ≥60 years and male gender were statistically significant factors, correlated with poor prognosis and decreased chance for recovery 2.4 and 2.6 times. T-status and clinical stage had important influence on 5-year disease-free survival rate because there were significant differences in the treatment results between individual stages. Multivariate analysis proved that the independent prognostic value, among anatomic structures involved by the neoplasm, had mandible, facial nerve, and skin infiltration. Among tumor-related factors, T-stage and grade had the statistically significant influence on treatment results, and stage and lymph nodes metastases among clinical and pathological features. These results confirm the value of actually used TNM classification (2002). Although the parapharyngeal space invasion is a factor, which seems to have a significant, poor prognostic value, it was not included in this classification.

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.

Treatment Results of Major Salivary Gland Cancer by Surgery with or without Postoperative Radiation Therapy

OBJECTIVES

This is to report treatment results of major salivary gland cancer by surgery with or without postoperative radiation therapy (PORT).

METHODS

Between March 1995 and January 2006, 94 patients with primary major salivary cancer underwent curative surgical resection at Samsung Medical Center. The parotid gland was the most commonly involved (73, 77.7%), followed by the submandibular and the sublingual. Neck dissection was added in 28 patients, and PORT was individually recommended to those with risk factors. Seventy-five (79.8%) patients received PORT. PORT volume included primary tumor bed and pathologically involved regional lymphatics, and no additional effort was made for elective nodal irradiation. The median total doses were 56.0 Gy to primary site and 58.7 Gy to regional lymphatics.

RESULTS

After median follow-up of 49 months, 21 patients had relapsed: 20 in PORT; and one in surgery alone group. As the first site of failure, distant metastasis was the most common (17 patients). Local recurrence occurred in three, and regional relapse in one. The lung was the most common site (10 patients), followed by the bone, and the brain. Five-yr disease free survival (DFS), local control, and overall survival (OS) rates were 74.4% and 94.7%, 96.0% and 100%, and 78.2% and 100% in PORT and surgery alone groups, respectively. On multivariate analysis, DFS was significantly affected by pN+ (hazard ratio [HR], 3.624; P=0.0319), while OS was by pN+ (HR, 7.138; P=0.0034) and perineural invasion (HR, 5.073; P=0.0187).

CONCLUSION

Based on our experience, the patients with early stage major salivary gland cancer with low risk can be effectively treated by surgery alone, and those who with risk factors can achieve excellent local and regional control by adding PORT. Omitting elective neck irradiation in patients with N0 disease seems a feasible strategy under accurate clinical evaluation. An effort is needed to decrease distant metastasis through further clinical trials.

Salivary gland malignancies: the role for chemotherapy and molecular targeted agents

Salivary gland tumors are a rare and clinically diverse group of neoplasms that represent less than 1% of all malignancies. In locoregional recurrent or metastatic disease, systemic therapy is the standard approach. Numerous phase II studies with small sample sizes have assessed the activity of different cytotoxic agents, either alone or in combination. For these agents, the objective response rates are generally modest, ranging from 15% to 50%. Duration of response is typically cited in the range of 6 to 9 months. Further evaluation of novel therapies is mandated in this disease. With the emergence of molecular targeted therapy, these tumors become optimal candidates for trials of investigational drugs and established drugs for new indications. Often, salivary gland carcinomas are indolent. As such, one should wish only to treat patients with progressive disease. Study designs must incorporate stringent inclusion criteria to enable accurate reporting of disease response and stabilization, especially in the evaluation of new drugs and novel combinations. Salivary gland-focused cooperative groups are necessary in order to accrue patients to these clinical trials and establish new treatment guidelines for these patients.

Facial nerve function in carcinoma of the parotid gland

AIM

To analyse, for patients with carcinoma of the parotid gland, the prognostic value for treatment outcome of the function of the facial nerve (NVII), and determining facial nerve dysfunction after treatment.

METHODS AND MATERIALS

In a retrospective study of the Dutch head and Neck cooperative group (NWHHT), data of 324 patients with parotid carcinoma were analysed. The function of N VII before treatment was intact in 77%, partially and completely impaired in 14% and 7%, respectively. Eighty-eight percent of the patients were treated surgically, and 77% of them were treated by a combination of postoperative radiotherapy. In 21% NVII was sacrificed, a reconstruction was performed in one of three.

RESULTS

Independent risk factors for N VII dysfunction before treatment were tumour localisation, positive neck nodes at presentation, pain, increasing age, and perineural invasion. Regional, not local, control was significantly impaired for complete facial paralysis. N VII dysfunction was an independent factor for disease free survival, and was 69%, 37% and 13% for normal, partially and completely impaired function, respectively. After treatment 22% of the patients experienced a partial paralysis, and 13% of the patients experienced a complete paralysis of N VII.

CONCLUSION

For patients with parotid carcinoma, facial nerve function before treatment is a strong prognostic factor for disease free survival.

Salivary gland carcinoma: independent prognostic factors for locoregional control, distant metastases, and overall survival: results of the Dutch head and neck oncology cooperative group

BACKGROUND

We analyzed the records of patients with malignant salivary gland tumors, as diagnosed in centers of the Dutch Head and Neck Oncology Cooperative Group, in search of independent prognostic factors for locoregional control, distant metastases, and overall survival.

METHODS

In 565 patients, we analyzed general results and looked for the potential prognostic variables of age, sex, delay, clinical and pathologic T and N stage, site (332 parotid, 76 submandibular, 129 oral cavity, 28 pharynx/larynx), pain, facial weakness, clinical and pathologic skin involvement, histologic type (WHO 1972 classification), treatment, resection margins, spill, perineural and vascular invasion, number of neck nodes, and extranodal disease. The median follow-up period was 74 months; it was 99 months for patients who were alive on the last follow-up.

RESULTS

The rates of local control, regional control, distant metastasis-free and overall survival after 10 years were, respectively, 78%, 87%, 67%, and 50%. In multivariable analysis, local control was predicted by clinical T-stage, bone invasion, site, resection margin, and treatment. Regional control depended on N stage, facial nerve paralysis, and treatment. The relative risk with surgery alone, compared to surgery plus postoperative radiotherapy, was 9.7 for local recurrence and 2.3 for regional recurrence. Distant metastases were independently correlated with T and N stage, sex, perineural invasion, histologic type, and clinical skin involvement. Overall survival depended on age, sex, T and pN stage, site, skin and bone invasion.

CONCLUSIONS

Several prognostic factors for locoregional control, distant metastases, and overall survival were found. Postoperative radiotherapy was found to improve locoregional control.

Malignant parotid tumors: Presentation, clinical/pathologic prognostic factors, and treatment outcomes

PURPOSE

To determine the important clinical/pathologic prognostic factors and optimal treatment of malignant parotid tumors.

METHODS AND MATERIALS

This study was a retrospective chart review of 163 patients treated for malignant parotid tumors at two institutions. Of the 163 patients, 91 were treated with surgical resection and radiotherapy (RT), 56 were treated with surgery alone, and 13 were treated with RT alone. The median follow-up was 5.1 years (range, 0-37 years).

RESULTS

Locoregional recurrence occurred in 37% of surgery-only, 11% of surgery plus RT, and 15% of RT-only patients (p = 0.001, Pearson's chi-square test). Cox proportional hazard multivariate analysis revealed that increasing age and higher stage were each statistically significantly (p < 0.05) associated with a poorer overall 5-year survival and cause-specific survival. Only increasing age and the absence of adjuvant RT were shown in Cox proportional hazard multivariate analysis to impact negatively on local failure-free survival.

CONCLUSION

In Cox proportional hazards multivariate analysis, only increasing age and stage were statistically significant prognostic factors for survival. The addition of RT to surgery did not improve overall survival but did reduce locoregional recurrence and improve local failure-free survival.

Therapy strategies for locally advanced adenoid cystic carcinomas using modern radiation therapy techniques

BACKGROUND

The authors evaluated whether modern photon techniques, such as stereotactic fractionated radiation therapy (FSRT) or intensity-modulated RT, outweighed the biologic advantages of high-linear-energy transfer RT in the treatment of patients with locally advanced adenoid cystic carcinomas (ACC) that infiltrated the skull base or the orbit.

METHODS

Between June 1995 and December 2003, 63 patients with ACC were treated with modern RT techniques at the University of Heidelberg. The treatment results achieved with modern photon techniques alone were compared with the results achieved with combined photon RT and a carbon ion boost. Twenty-nine patients (Group A) were treated with a combination of photon RT and a carbon ion boost. Thirty-four patients (Group B) received photon RT alone.

RESULTS

The median follow-up was 16 months for Group A and 24 months for Group B. Locoregional control rates at 2 years and 4 years were 77.5% and 77.5% for Group A and 72.2% and 24.6% for Group B, respectively (P = 0.08; log-rank test). Disease-free and overall survival rates at 2 years/4 years were 71.5%/53% and 86.6%/75.8% for Group A and 69.2%/23% and 77.9%/77.9% for Group B, respectively. Rates for severe late toxicity were < 5% for both groups.

CONCLUSIONS

Modern RT techniques allowed the safe delivery of high target doses to patients with locally advanced ACC. Late toxicity rates were kept lower compared with the historic neutron therapy data. A combination of modern photon RT and carbon ion RT seemed to be advantageous, with a trend toward higher locoregional control rates compared with modern photon RT alone.

Lymphoepithelial carcinoma versus large cell undifferentiated carcinoma of the major salivary glands

BACKGROUND

Undifferentiated carcinomas of the major salivary glands are rare malignant neoplasms of the head and neck region, and patients with these lesions have a poor prognosis. Patients with lymphoepithelial carcinoma (LEC), a specific subtype of undifferentiated carcinoma, however, have a better prognosis, and LEC seems to differ from large cell undifferentiated carcinoma (LCUC) clinically.

METHODS

Sixteen patients with LEC and 12 patients with LCUC were retrieved from the records of 295 patients who had malignancies of the major salivary glands. A retrospective study on clinical manifestations, treatments, long-term outcomes, and an association with Epstein-Barr virus (EBV) by EBV-encoded small RNA-1 in situ hybridization was conducted to identify their differences.

RESULTS

The median patient age was 44.5 years in the LEC group and 56 years in the LCUC group. At the time of presentation, patients with LCUC had a history of rapid-growing tumor and more advanced locoregional disease (Stage IV in 75% of patients with LCUC compared with 13% of patients with LEC). All 16 patients with LEC underwent curative surgery and radiotherapy, and their 5-year survival rate was 85.6%. In the LCUC group, only 7 patients were eligible to undergo radical surgery and receive radiotherapy, and their 2-year survival rate was only 36%. Age > 50 years was associated with a significantly worse prognosis for patients with LCUC. Neck metastasis and tumor size > 6 cm tended to be poor prognostic factors. Tumors were positive for harboring the EBV genome in all 16 LEC samples but in none of the LCUC samples.

CONCLUSIONS

The clinicopathologic features of LEC and LCUC of the major salivary glands were different. LEC was associated with EBV, and patients with LEC had a much better prognosis compared with the prognosis for patients with LCUC. Therefore, LEC should be put in an independent group and should not be included in the same category as undifferentiated carcinomas of the salivary gland.

Parotidectomy: review of treatment and outcomes

BACKGROUND

Parotidectomy is a common surgical procedure performed for a wide array of benign and malignant tumours. The aim of the present study was to review a single-institution experience with parotidectomy over a 10 year period.

METHODS

We retrospectively reviewed 170 patients who had parotidectomy performed. The preoperative investigations, clinicopathological parameters, perioperative morbidity and mortality were assessed.

RESULTS

One hundred and six (62%) of the patients were men. The mean age was 54 years (range 21-80). Indications for parotidectomy included benign tumour (44%), malignant tumour (42%), inflammatory parotid disease (7%) and miscellaneous (5%). The most common benign tumour was pleomorphic adenoma (25%). The most common malignant tumour was metastatic cutaneous squamous cell carcinoma (SCC) (19%). Fine needle aspiration cytology was performed in 83% patients with a sensitivity and specificity for benign tumours of 76% and 97%, respectively. The sensitivity and specificity for malignant tumours was 90% and 99%, respectively. One (0.6%) patient died in the postoperative period. Postoperative complications included wound infection (2.3%), wound haematoma (3.5%) and seroma (6.6%). Six patients (3.5%) developed temporary complete facial paresis, while 33 patients (20%) developed temporary partial facial palsy in the immediate postoperative period. The 2-year disease-free and disease-specific survival for those patients with metastatic cutaneous SCC were 75% and 76%, respectively.

CONCLUSIONS

The most common indications for parotidectomy were pleomorphic adenoma and metastatic cutaneous SCC. Our perioperative morbidity and survival for patients with malignant parotid disease compare favourably with other institutional series.

Parotid carcinoma: impact of clinical factors on prognosis in a histologically revised series

OBJECTIVE

To analyze clinical data and possible prognostic factors of patients with primary carcinoma of the parotid gland.

STUDY DESIGN

A retrospective study was made of 85 patients with suspected parotid cancer who were admitted to the Center of Head and Neck Oncology at Odense University Hospital (Odense, Denmark) from 1975 to 1994.

METHODS

Patient records were retrospectively reviewed and tabulated for relevant clinical parameters. A complete revision of histological examination was performed by the same pathologist and the tumors were classified according to the 1991 international guidelines from the World Health Organization. Five tumors (6%) did not fulfill the criteria of malignancy and were reclassified as benign. In another five cases the assumed primary parotid carcinomas were found to be metastatic disease from cancers of the breast, prostate, skin, and lungs. Ten patients (12%) were excluded from the analysis, leaving 75 individuals for the study.

RESULTS

Twenty-four percent of patients were classified as T1, 32% as T2, 15% as T3, and 28% as T4. One patient (1%) was not classifiable (TX). Regional lymph node metastases were found in 17 cases (23%). Two of these were classified as N1 (3%), 2 as N2A (3%) and 13 as N2B (17%). Four patients were registered as not classifiable (NX) (5%). No patients were classified as N3. Distant metastases were found in four patients (5%) (one patient had bone and liver metastases and three patients had lung metastases). Five-year recurrence-free survival of the entire study group was 63%, disease-specific survival was 69%, and crude survival was 52%. In univariate analysis, tumor size, histological appearance, T status, stage, the presence of lymph node metastases, distant metastases, pain, and facial nerve dysfunction had a significant influence on survival.

CONCLUSIONS

A thorough histological revision is pivotal in retrospective parotid carcinoma studies, and tumor size; histological appearance; T, N, and M status; stage; facial nerve dysfunction; and pain from the face and/or neck seem to be significant prognostic indicators for patients with primary parotid carcinoma.

Response to paclitaxel and carboplatin in metastatic salivary gland cancer: a case report

BACKGROUND

Malignant tumors of the salivary gland are rare entities that are treated primarily by surgical resection. For patients with recurrent or unresectable disease, options include radiation therapy or chemotherapy; however, responses are few and of short duration. Patients with metastatic disease have been treated with chemotherapy, but, again, response rates have been low and of short duration.

METHODS

A 52-year-old man was seen with a mass on his tongue. A biopsy revealed adenocarcinoma of a minor salivary gland. Ten months after surgical resection, neck dissection, and radiation therapy, the patient was found to have metastatic disease to the lung. Chemotherapy was initiated with carboplatin and paclitaxel.

RESULTS

The patient obtained a complete response after six cycles of carboplatin and paclitaxel.

CONCLUSIONS

The use of carboplatin and paclitaxel in the setting of metastatic salivary gland cancer is a viable option.

[Use of fast neutrons in the treatment of tumors of the salivary glands: rationale, review of the literature and experience in Orleans]

If low LET radiation therapy (photons, electrons), following radical microscopically and complete surgery can improve results in term of local control from 34 to 74% for salivary gland tumors, local control is more difficult to achieve in advanced tumors and only palliative treatment is usually attempted. In this survey, all the patient series treated worldwide were reviewed. They show an overall control rate of 31% with photon vs 64% with neutron therapy. A prospective randomised trial sponsored by the RTOG and the MRC published in 1988 and reviewed in 1993 showed an overall locoregional complete tumor clearance of 67% for neutrons and 17% for photons (P < 0.005), with 68% and 25% survival at two years for neutrons and photons respectively. This study was closed for ethical reasons. In Orleans, since 1987, 59 patients have been treated. At five years the persistent local control probability was 69.5%, the five-year crude survival probability 66% and the five-year tumor free survival probability was 64.5%. This review provides evidence that surgical treatment for salivary gland tumors should be limited to patients presenting a high likelihood of negative surgical margin and a small risk of facial nerve damage. Others patients should receive neutron radiation therapy alone as definitive treatment.

Salivary gland tumours treated in the stomatological clinics in Bratislava

During the period of 1951-1996 a group of 1021 patients (484 men and 537 women, mean age 53 years, range 2-87 years) with salivary gland tumours were analysed retrospectively. The mean follow-up period was 8 years (range 10 months-25 years). The frequency of benign tumours was 74% (n = 755) and malignant tumours 26% (n = 266). Lesions were sited in the parotid gland 83% (n = 847), in the submandibular gland 10.8% (n = 110), in the sublingual gland 3.2% (n = 33) and in the minor salivary glands 3% (n = 31). The most common benign tumours were pleomorphic adenoma in 53.9% (n = 550) and Warthin's tumour 9.7% (n = 99). Of the malignancies, the adenoid cystic carcinoma was most common (6.4% of cases, n = 65) and mucoepidermoid carcinoma occurred in 5.2% (n = 53). The predominant therapy was surgery alone or in combination with postoperative radiotherapy in 93.7% (957 cases), radiotherapy alone after fine needle aspiration biopsy for 4.7%, and 19 patients remained untreated.

Clinico-pathological and treatment-related factors influencing survival in parotid cancer

One hundred and three patients with primary parotid cancer treated surgically at the Christie Hospital, Manchester (1952-1992), were analysed to assess the influence on survival of prognostic and treatment-related factors. Thirty-seven patients were treated by surgery alone (SG), 66 received post-operative radiation (SG+RT). Median follow-up was 12 years, minimum 5 years. The 10-year disease-specific survival rates for stage I, II and III/IV were 96%, 61% and 17% respectively (P < 0.0001). The various histological types segregated into three survival patterns: low-, intermediate-and high-grade with 10-year survival rates of 93%, 41% and 50% respectively (P < 0.0001). On multivariate analysis, the factors influencing risk of cancer death in order of importance were: tumour size > 4 cm (P < 0.001), presence of nodes (P = 0.001), histology of adenoid cystic carcinoma (P = 0.01), high-tumour grade (P = 0.02) and perineural involvement (P = 0.01). Neither the extent of surgery nor the operator influenced outcome. Overall, adjuvant RT significantly reduced locoregional recurrence (SG+RT 15% vs SG 43%; P = 0.002) but not survival, although on subanalysis, there was a trend to improved survival with large cancers and high-grade tumours. Long-term survival is determined primarily by tumour characteristics, namely clinical stage and grade. Post-operative RT contributes significantly to locoregional control and probably confers some survival advantage in high-risk patients.

Malignant epithelial parotid gland tumours: analysis and results in 65 previously untreated patients

BACKGROUND

Optimal management of malignant epithelial parotid tumours requires knowledge of the available therapeutic modalities and the different biological characteristics. The aim of the study was to review the characteristics of patients at presentation, histological classification, disease-free and overall survival rates, and the results of the applied treatment policy regarding the facial nerve and neck.

METHODS

Between 1974 and 1995 a total of 65 patients was treated with curative intent for a previously untreated malignant epithelial parotid gland tumour. All patients underwent some type of parotidectomy, 20 of whom had an en bloc radical neck dissection. In selected cases the facial nerve or its branches were peeled off the tumour thus violating the objective of tumour-free margins and relying heavily on the efficacy of postoperative radiotherapy. In total 51 patients received postoperative radiotherapy. None of the patients was lost to follow-up.

RESULTS

There were 12 locoregional failures (18 per cent). In only one of these 12 patients was salvage therapy successful; the remaining 11 patients died from the tumour. All but one of the eight patients with distant metastasis only died from the tumour. The estimated 5- and 10-year disease-free rates were 68 and 59 per cent respectively. The corresponding survival rates were 75 per cent and 67 per cent. A significant relationship could be observed between tumour stage and survival. The presence of lymph node metastases proved to be the strongest single prognostic factor.

CONCLUSION

In selected cases a conservative approach towards the facial nerve is justified.

Fine-needle aspiration biopsy of large-cell undifferentiated carcinoma of the salivary glands: presentation of two cases, literature review, and differential cytodiagnosis of high-grade salivary gland malignancies

Primary undifferentiated carcinoma of the salivary glands is a rare, high-grade neoplasm which accounts for a very small number (1-5.5%) of malignant salivary gland tumors. The large-cell variant (LCU) is less well-characterized than the small-cell form. We report on the fine-needle aspiration (FNA) biopsy findings of 2 cases of LCU, one arising in the parotid gland, and the other in a buccal mucosa accessory salivary gland. The 2 cases were similar in composition: isolated and loosely cohesive large cells with abundant cytoplasm, and variability pleomorphic nuclei with prominent nucleoli. One case also featured multinucleated tumor giant cells and macrophage polykaryons; the latter has not previously been described in FNA biopsies of LCU. There was no evidence of squamous, myoepithelial, or widespread mucinous differentiation by morphological, cytochemical, or immunohistochemical analyses (focal rare mucin production identified on special stains in one case). The differential diagnosis is lengthy and consists of other high-grade primary salivary gland malignancies as well as metastatic lesions, including melanoma. The pattern of immunohistochemical reactivity (positive keratin, negative S-100, and HMB-45 antigens), and lack of conspicuous mucin production of significant lymphoidinfiltrate, were useful in establishing the correct diagnosis.

Malignant tumours of the parotid gland: a 12-year review

Malignant parotid tumours are uncommon and present a significant management challenge. Fifty-one such patients (25 male, 26 female, median age 64 years) operated on in the Newcastle Plastic Surgery Unit between 1983 and 1994 were retrospectively evaluated. Preoperative investigations included FNA cytology (n = 20), and for staging CT and/or MRI scans (n = 21). Of the 35 primary tumours 32 were epithelial and three lymphomatous. Metastatic tumours were squamous cell carcinoma (7), melanoma (6), renal cell carcinoma (2) and sebaceous carcinoma (1). FNA cytology correctly diagnosed malignancy with an 88% sensitivity (false negatives = 2). A total or radical parotidectomy was required in 60% of patients, the rest undergoing superficial parotidectomy. In continuity neck dissection was undertaken in 23 (45%) cases. Postparotidectomy reconstruction included 10 free, 3 myocutaneous, and 4 local transposition/rotation flaps. Thirty-seven patients (73%) received postoperative radiotherapy. Seventy-two per cent of patients are alive after a mean follow-up of 42 months. The crude 5- and 10-year survival rates were 68% and 49% respectively while the loco-regional control rate (Kaplan-Meier method) at 10 years was 79%. Fifteen patients (30%) have permanent facial palsy. It is concluded that radical surgery with appropriate reconstruction followed by planned postoperative adjuvant radiotherapy gives effective control of malignant parotid tumours.

Postoperative radiotherapy for malignant tumors of the parotid gland

PURPOSE

To update our experience using postoperative irradiation in selected patients with carcinomas of the parotid gland. Outcomes of treatment with a focus on the effectiveness of the two primary techniques of radiation used for treating these tumors were evaluated.

METHODS AND MATERIALS

A retrospective analysis of 166 patients with parotid gland malignancies treated in the Department of Radiotherapy at the University of Texas M. D. Anderson Cancer Center between 1965-1989 was performed. All patients were treated following surgery and did not have macroscopic disease at the time of their radiation. The most common histologies were mucoepidermoid carcinoma (28%) and adenocarcinoma (27%). Pathologic features constituting indications for postoperative radiotherapy included: inadequate margins, 104 (63%) cases; extraglandular disease extension, 82 (49%); perineural invasion 57 (34%); and nodal disease 43 (26%). Radiation was delivered through an ipsilateral field of predominantly high energy electrons in 142 patients (86%). Wedged paired 60Co fields were used to treat 19 patients. The median dose was 60 Gy, typically delivered at 2 Gy per fraction. The median follow-up time for surviving patients was 155 months.

RESULTS

Forty-seven (29%) patients had disease recurrence, of whom 15 (9%) had disease recur locally and 10 (6%) regionally (neck). There was no association between the dose of radiation and local failure, except for a trend for patients with positive margins and/or named nerve involvement to have improved local control if they received doses > 60 Gy. There was no difference in failure rates in patients treated with wedged pair techniques or ipsilateral fields, but there was a higher complication rate in the former. Overall, 37 patients (22%) developed chronic sequelae attributed to radiation. Twelve patients developed decreased hearing, and 15 patients developed soft tissue or bone necrosis or exposure.

CONCLUSIONS

Local and regional control rates for high risk patients with parotid gland carcinomas treated with radiation following surgery were excellent. The technique of using an ipsilateral field encompassing the parotid bed and treated with high energy electrons often mixed with photons was effective with minimal severe late toxicity. The moderate complication rate experienced in this series can be further reduced using modern techniques as described.

Malignant epithelial parotid tumours: a rational treatment policy

Formal parotidectomy was undertaken in 271 patients by one surgeon over 11 years. Forty patients were treated for malignant salivary tumours (nine were recurrent). Low-grade tumours (45 per cent) were treated by surgery alone, untreated high-grade tumours (55 per cent) by surgery and radiotherapy, before or after operation, depending on clinical findings. The aims of surgery were to obtain tumour clearance, to preserve the facial nerve if possible, and to perform radical neck dissection for palpable malignant lymphadenopathy proven cytologically and for high-grade tumours when intraoperative jugulodigastric lymph node biopsy confirmed metastasis. Four patients sustained facial weakness as a result of surgery. At a median of 46 months follow-up two patients had developed local recurrence. Eleven patients with high-grade but none with low-grade tumours died from metastases. Patients with high-grade lesions with facial weakness from malignant infiltration and those with lymphatic metastasis have a significantly worse prognosis than those without. Locoregional control of parotid cancers can be achieved by formal parotidectomy and selective irradiation without routine sacrifice of the facial nerve.