Bone Invasion by Adenoid Cystic Carcinoma of the Lacrimal Gland: Preoperative Imaging Assessment and Surgical Considerations

Long-term outcomes and prognostic factors of eye-preserving treatment with particle beam radiotherapy for orbital malignancies

BACKGROUND

This retrospective study report the clinical experience of eye-preserving treatment follow by particle beam radiotherapy (IMPT or CIRT) for orbital malignancies. And to evaluate prognostic factors for orbital and lacrimal gland tumors.

METHODS

Sixty-two patients with orbital malignancies were identified in the records of a single center between 2015 and 2021. Sixty-one patients met inclusion criteria. All of the patients received eye-preserving treatment before PBRT. Majority of the patients (91.8%) were treatment with CIRT. Clinical data, treatment modality, local control, metastases and survivals and visual outcomes, as well as associated prognostic indicators were were assessed.

RESULTS

Sixty-one patients were followed with a median of 40.7 months (44.3 months for surviving patients). The 3- and 5-year DSS and LC rates were 88.1% and 69.9%, and the 3- and 5-year DMC rates were 77.5% and 74.2% for entire orbital malignancies. For lacrimal gland carcinoma, the 5-year DSS, LC, DMC, and PFS rates were 83.3%, 64.8%, 66.8%, and 53.4%. Tumor size, T stage, extraorbital invasion, and bone invasion influenced survivals. No grade 3 or higher acute toxicities were observed. A total of 8 patients experienced grade 3-4 visual impairment.

CONCLUSIONS

Particle radiotherapy following eye-preserving treatment provided a favorable local control and survivals with moderate acute and late toxicities, even in patients with unresectable disease. Particle radiotherapy was a promising strategy for management of orbital tumors.

Imaging of the skull base and orbital tumors

The skull base and orbit have complicated anatomical structures where various tumors can occur. The tumor may present with neurological symptoms; however, its diagnosis is clinically difficult owing to accessibility issues. Therefore, diagnostic imaging is crucial in assessing tumors in the skull base and orbit and guiding subsequent management. Notably, some tumors have a predilection for a specific site of origin, and identifying the site of origin on imaging can help narrow the differential diagnosis. At the skull base, chordomas typically occur in the clivus, chondrosarcomas in the paramedian areas, paragangliomas in the jugular foramen, neurogenic tumors, and perineural spread in the neural foramen. Among orbital tumors, cavernous hemangiomas usually occur in the intraconal space, and pleomorphic adenomas and adenoid cystic carcinomas occur in the lacrimal glands. Some skull base and orbital tumors exhibit distinctive imaging features. Chordomas and chondrosarcomas of the skull base show high signal intensities on T2-weighted images, with chondrosarcomas often displaying cartilaginous calcifications. Paragangliomas are characterized by their hypervascular nature. In the orbit, cavernous hemangiomas and pleomorphic adenomas present unique dynamic patterns. Immunoglobulin G4-related disease forms lesions along the nerves. Identifying the tumor origin and its imaging characteristics can help narrow the differential diagnosis of skull base and orbital tumors.

Molecular Analysis of Salivary and Lacrimal Adenoid Cystic Carcinoma

Adenoid cystic carcinoma (ACC) of head and neck origin is associated with slow but relentless progression and systemic metastasis, resulting in poor long-term survival rates. ACC does not respond to conventional chemotherapy. Determination of molecular drivers may provide a rational basis for personalized therapy. Herein, we investigate the clinical and detailed molecular genomic features of a cohort of patients treated in Ireland and correlate the site of origin, molecular features, and outcomes. Clinical and genomic landscapes of all patients diagnosed with ACC over a twenty-year period (2002-2022) in a single unit in Ireland were examined and analyzed using fluorescence in situ hybridization, DNA sequencing, and bioinformatic analysis. Fourteen patients were included for analysis. Eleven patients had primary salivary gland ACC and three primary lacrimal gland ACC; 76.9% of the analyzed tumors displayed evidence of NFIB-MYB rearrangement at the 6q23.3 locus; 35% had mutations in NOTCH pathway genes; 7% of patients had a NOTCH1 mutation, 14.3% NOTCH2 mutation, and 14.3% NOTCH3 mutation. The presence of epigenetic modifications in ACC patients significantly correlated with worse overall survival. Our study identifies genetic mutations and signaling pathways that drive ACC pathogenesis, representing potential molecular and therapeutic targets.

Diagnostic value of dynamic contrast enhancement combined with conventional MRI in differentiating benign and malignant lacrimal gland epithelial tumours

AIM

To establish the diagnostic value of the quantitative parameters of dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) combined with conventional MRI in differentiating of benign and malignant lacrimal gland epithelial tumours.

MATERIALS AND METHODS

A retrospective analysis of primary lacrimal gland epithelial tumours confirmed by histopathology was conducted. Conventional MRI features and DCE-MRI quantitative parameters were collected and subjected to analysis. The diagnostic value was evaluated using receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 53 patients were enrolled of which 29 had malignant, whereas 24 had benign tumours. Conventional MRI revealed statistically significant differences between benign and malignant tumours regarding maximum tumour diameter, posterior margin characteristic, bone destruction, and erosion. The Ktrans and Kep values obtained by DCE-MRI were higher in malignant than in benign tumours, with a statistically significant (p<0.001 and p=0.022). A type I time-signal intensity (TIC) curve was more frequent in benign tumours, whereas a type II TIC curve was prevalent in malignant tumours (p=0.001). ROC analysis showed that Ktrans had the best diagnostic value of the DCE-MRI parameters (area under the ROC curve [AUC] of 0.822, 75.9% sensitivity, and 83.3% specificity, p<0.001). The combination of conventional MRI and DCE-MRI factors had the best diagnostic value and balanced sensitivity and specificity (AUC of 0.948, 93.1% sensitivity, and 91.7% specificity, p<0.001).

CONCLUSIONS

The present findings indicate that the combination of quantitative parameters of DCE-MRI and image characteristics of conventional MRI have a high diagnostic value for the diagnosis of benign and malignant lacrimal gland epithelial tumours.

A Review of the Molecular Landscape of Adenoid Cystic Carcinoma of the Lacrimal Gland

Adenoid cystic carcinoma (ACC) has a worldwide incidence of three to four cases per million population. Although more cases occur in the minor and major salivary glands, it is the most common lacrimal gland malignancy. ACC has a low-grade, indolent histological appearance, but is relentlessly progressive over time and has a strong proclivity to recur and/or metastasise. Current treatment options are limited to complete surgical excision and adjuvant radiotherapy. Intra-arterial systemic therapy is a recent innovation. Recurrent/metastatic disease is common due to perineural invasion, and it is largely untreatable as it is refractory to conventional chemotherapeutic agents. Given the rarity of this tumour, the molecular mechanisms that govern disease pathogenesis are poorly understood. There is an unmet, critical need to develop effective, personalised targeted therapies for the treatment of ACC in order to reduce morbidity and mortality associated with the disease. This review details the evidence relating to the molecular underpinnings of ACC of the lacrimal gland, including the MYB-NFIB chromosomal translocations, Notch-signalling pathway aberrations, DNA damage repair gene mutations and epigenetic modifications.

Frequency and imaging features of the adjacent osseous changes of salivary gland carcinomas in the head and neck region

PURPOSE

The association between salivary gland carcinomas and adjacent osseous changes in the head and neck region is not clear. We evaluated the frequency and imaging features of such changes and investigated the specific characteristics of salivary gland carcinomas associated with them.

METHODS

A total of 118 patients with histologically proven salivary gland carcinomas were retrospectively reviewed. The imaging characteristics of osseous changes were sorted into three categories based on computed tomography images: sclerotic change, erosive change, and lytic change. The frequency of all these osseous changes and any one of them was compared between different pathologies using Fisher's exact test. Odds ratios were calculated to evaluate the association between these changes and perineural spread.

RESULTS

Osseous changes were found in 21 (18%) of 118 cases. Among these, seven (6%) cases were with sclerotic, nine (8%) with erosive, and nine (8%) with lytic changes (four with mixed change). Adenoid cystic carcinoma showed a significantly higher frequency of sclerotic and erosive changes, and either osseous change, than the other salivary gland carcinomas (p < 0.001 for each). Sclerotic changes were only present in the adenoid cystic carcinomas. Perineural spread was a significant factor in showing higher osseous change frequencies (odds ratio = 3.98, p = 0.006).

CONCLUSION

Among salivary gland carcinomas in the head and neck region, adenoid cystic carcinomas had a significantly higher frequency of adjacent osseous changes, especially sclerotic changes, than other salivary gland carcinomas.

Prognostic impact of Notch1 receptor and clinicopathological High-Risk Predictors in lacrimal gland adenoid cystic carcinoma

PURPOSE

Adenoid Cystic Carcinoma (ACC) is an aggressive malignant lacrimal gland tumour associated with poor prognosis. Aberrant Notch signalling has been investigated in various tumours. However, very few studies on Notch signalling in lacrimal gland ACC are reported. The aim of the present study was to evaluate the status of Notch1 receptor and activated Notch1 (NICD1) in lacrimal gland ACC and to correlate it with high-risk clinicopathological features.

METHODS

A total of 23 cases of histopathologically proven lacrimal gland ACC, who underwent surgical treatment, were included in this study. Expression of Notch1 receptor and NICD1 was evaluated by immunohistochemistry on formalin fixed paraffin embedded tissues. The results obtained were correlated with clinicopathological high-risk features and survival of the patients. Kaplan-Meier survival and multivariate analysis was performed to determine the prognostic significance.

RESULTS

Overexpression of Notch1 receptor and NICD1 was observed in 65% and 39% of lacrimal gland ACC cases, respectively. On Kaplan-Meier survival analysis, patients with Notch1 receptor overexpression had reduced disease free survival. On univariate analysis, male gender, bone erosion, perineural invasion, solid histologic pattern, intracranial extension and advanced tumour stage were also indicators of poor prognosis. On multivariate analysis bone erosion was the most significant poor prognostic indicator.

CONCLUSION

Our study demonstrates that overexpression of Notch1 receptor plays a critical role in the biology and aggressive behaviour of lacrimal gland ACC. Bone erosion, solid histologic pattern, advanced T stage, perineural invasion and intracranial extension are other high-risk clinicopathological predictors of lacrimal gland ACC.

Value of MRI-based radiomics analysis for differentiation of benign and malignant epithelial neoplasms in the lacrimal gland: a retrospective study

BACKGROUND

It is essential to distinguish malignant from benign epithelial neoplasms in the lacrimal gland for different treatment options and prognosis.

PURPOSE

To retrospectively assess the performance of magnetic resonance imaging (MRI)-based radiomics features in the differentiation of benign and malignant epithelial neoplasms in the lacrimal gland.

MATERIAL AND METHODS

Seventy-six consecutive patients with histopathology-proven epithelial neoplasms of the lacrimal gland were enrolled in the study, including 41 benign and 35 malignant neoplasms. Radiomics features were extracted from T2-weighted and post-contrast T1-weighted imaging. The least absolute shrinkage and selection operator method was used to select imaging features and reduce data dimension to discriminate malignant from benign neoplasms in the lacrimal gland. Diagnostic performance of the radiomics model was assessed by receive operation characteristic (ROC) curve and compared with that of radiologists.

RESULTS

Four quantitative image features including inverse difference moment normalized (IDMN), mean deviation (MD), standard deviation (SD), and long-run emphasis (LRE) were selected to distinguish malignant from benign epithelial neoplasms in the lacrimal gland. Area under the curve (AUC) of these four features were 0.88, 086, 0.88, and 0.86, respectively, with 0.93 for the combination model. The model identified malignant epithelial neoplasms from benign group with 89% sensitivity, 93% specificity, and 89% accuracy. There was a significant difference in the diagnostic performance of radiomics model and the radiologists, with AUC of 0.70 for radiologists. The diagnostic performance of radiomics is superior to that of radiologists.

CONCLUSION

MRI-based radiomics analysis has potential for differentiation of benign and malignant epithelial neoplasms in the lacrimal gland.

Adenoid Cystic Carcinoma of Lacrimal Gland with Bone Remodeling

Adenoid cystic carcinoma is the most common type of malignancy seen in the lacrimal glands and is generally characterized by invasive malignant appearance with irregular margins and associated bone erosion or destruction. The authors report an unusual patient with a large expansile, well-circumscribed lacrimal adenoid cystic carcinoma with adjacent bone remodeling, radiologically mimicking a benign lesion.

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

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

Extensive and aggressive growth of adenoid cystic carcinoma in the lacrimal gland

Adenoid cystic carcinoma (ACC) in the lacrimal gland is a very rare disease with poor overall prognosis. Its primary treatment is surgical excision, including orbital exenteration and radical orbitectomy, which is combined with radiotherapy and chemotherapy. Age, histopathologic type, bone invasion, and tumor extent are known factors that affect the prognosis of ACC. Furthermore, perineural invasion is highly associated with local tumor recurrence and tumor base invasion. Here, we report a rare case of ACC in the lacrimal gland with superior sagittal sinus invasion that repeatedly recurred after the surgical excision.

Multimodal therapy in the management of lacrimal gland adenoid cystic carcinoma

Background

To evaluate the prognosis of Chinese patients with lacrimal gland adenoid cystic carcinoma treated with eye-sparing surgery and adjuvant multimodal therapy.

Methods

The study included 24 consecutive patients with lacrimal gland adenoid cystic carcinoma treated at the Ninth People’s Hospital of Shanghai from May 2008 to September 2017. All patients underwent eye-sparing surgical tumor resection and 20 (83.3%) of the 24 patients in the cohort received postoperative RT. Eight (41.7%) patients in the cohort received chemotherapy. Each patient’s medical records were reviewed.

Results

The study included 13 male and 11 female patients. The median follow-up time after surgery was 33.5 months. Fifteen (62.5%) patients experienced local recurrence. The 1-, 3-, and 5-year recurrence rates were 27.9, 60.0, and 80.0%, respectively. Eleven (45.8%) patients developed metastasis. The 1-, 3-, and 5-year metastasis rates were 8.7, 48.5, and 66.9%, respectively. Eight (33.3%) patients died of lacrimal gland adenoid cystic carcinoma, with a median survival duration of 34.0 months. The 1-, 3-, and 5-year tumor-related mortality was 4.5, 28.1, and 58.0%, respectively. More advanced T stage (≥ T3a) was a risk factor for local recurrence (hazard ratio [HR]: 5.374, P = 0.02), distant metastasis (HR: 8.585, P < 0.01), and tumor-related survival (HR: 9.654, P < 0.01).

Conclusions

Eye-sparing tumor resection protocol followed by adjuvant therapy seems to be associated with high rates of local recurrence, metastases and death. In addition, greater attention should be paid to patients with lacrimal gland adenoid cystic carcinoma with ≥ T3a tumors.

Survival outcomes of eye-sparing surgery for adenoid cystic carcinoma of lacrimal gland

PURPOSE

To survey adenoid cystic carcinoma of lacrimal glands in Asian population and investigate the predictability in prognosis following the 8^th edition American Joint Committee on Cancer (AJCC) staging guideline.

STUDY DESIGN

Retrospective study.

METHODS

The clinical entities and surgical outcomes of the patients who were histologically confirmed with a diagnosis of lacrimal adenoid cystic carcinoma in National Taiwan University Hospital between January 1995 and December 2015 were retrospectively reviewed.

RESULTS

Enrolled were 11 patients. The median follow-up was 7.2 years. Eight patients (72.7%) were diagnosed as T1 or T2 disease, and three patients (27.3%) were diagnosed as T3 or T4 disease according to the AJCC 8^th edition guideline. Eye-sparing surgery with radiotherapy was performed in nine patients. Local recurrence was noted in six patients (54.5%) with median disease-free interval of 23.5 months. Six patients (54.5%) developed distant metastases, including lung, bone, and cranial invasions. Overall survival rate during the study period was 54.6%. Five-year overall survival was 81.8% and ten-year overall survival was 68.2%. The Log-rank test for overall survival and disease-free survival between patients with less than T3 disease (p=0.001) and patients with T3 or T4 disease (p=0.006) revealed significant differences.

CONCLUSION

This study highlighted the aggressive nature of adenoid cystic carcinoma of lacrimal glands. Eye-sparing surgery with adjunctive radiotherapy may achieve relatively optimal disease control in diseases staged T1 or T2, but in advanced disease metastasis and mortality are usually inevitable.

Fibroblast growth factor receptor 1 (FGFR1) as a therapeutic target in adenoid cystic carcinoma of the lacrimal gland

Identification of molecular targets is the first step in developing efficacious therapeutic strategies for tumors. A tumors' biological response to perturbagens yields important information on the molecular determinants for tumor growth. The aim of this study was to characterize the response of adenoid cystic carcinoma of the lacrimal gland (LGACC) to intra-arterial cytoreductive chemotherapy (IACC) in order to identify novel targets to enhance therapy. We performed high-throughput proteomic analysis on paired samples from pre-IACC diagnostic biopsies and post-IACC excised tumor samples from 6 LGACC patients. This proteomic analysis provides a comprehensive landscape of the cellular compartments contained within the excised tumors. Interestingly, we found a strong upregulation across the fibroblast growth factor (FGF) signaling pathway, with FGF receptor 1 (FGFR1) exhibiting a consistent and significant upregulation in all post-IACC samples. We thus evaluated the therapeutic efficacy of a novel FGFR1 selective inhibitor, AZD4547, in combination with cisplatin on LGACC cells in-vitro. The combination index (CI) value (<0.895) demonstrated synergistic effect of AZD4547 and cisplatin in inhibiting cell growth and viability (p<0.02), with a differential response seen in post-IACC cultures when compared to pre-IACC cultures. The combination approach showed synergy of the drugs in the migration assay. Western blot analysis indicated a significant upregulation of cleaved caspase-3 and downregulation the expression of FGFR1 (p<0.05) with the combination treatment as compared to either agent independently. Our findings demonstrate that FGFR1 inhibition potentiates the cytoreductive effects of cisplatin and suggest a potential therapeutic benefit of using AZD4547 in the management of LGACC.

Orbital exenteration: Institutional review of evolving trends in indications and rehabilitation techniques

PURPOSE

To determine the changes in indications for orbital exenteration over 20 years and to assess its impact on patient survival. Evolving techniques of rehabilitation of the orbit in our institution were also evaluated.

METHODS

This was a retrospective review of hospital records of patients who underwent orbital exenteration from 1995 to 2015 in a tertiary care center. Data extracted included primary location of the tumor, preoperative treatments, interval between initial diagnosis and exenteration, status of surgical margins, presence of metastatic disease, and postoperative survival. The types of prosthesis utilized over the years were also reviewed. Cox regression analysis was performed for categorical variables. Kaplan-Meier analysis was used to estimate post-exenteration survival.

RESULTS

Over a 20-year period, orbital exenteration was performed on 100 orbits of 100 patients. The mean age was 39.4 years (range: 2 months to 90 years). The most common indications among 98 malignant causes were retinoblastoma, squamous cell carcinoma, basal cell carcinoma, extraocular extension of uveal melanoma, and conjunctival melanoma. Postoperative survival was significantly related to age and tumor location but independent from gender, surgical margin, histopathological diagnosis, previous treatment modality, and preoperative interval. In the whole cohort, 1-year and 5-year survival rates were 97% and 84%, respectively.

CONCLUSIONS

Exenteration appears to be life-saving in children with orbital extension of retinoblastoma. While patients exenterated for malignant eyelid tumors have the best chance of survival, those with orbital extension of uveal melanoma and adenoid cystic carcinoma of the lacrimal gland have the worst prognosis.

Application of Rose and Wright's algorithm in the diagnosis of lacrimal gland masses: a study of 93 cases

OBJECTIVE

To investigate the application of Rose and Wright's algorithm in diagnosing lacrimal gland masses.

DESIGN

Retrospective observational cases series.

PARTICIPANTS

A total of 93 consecutive patients with primary masses within the orbital lobe of the lacrimal gland were reviewed.

METHODS

Before treatment, patients' detailed history was collected verbally and all patients underwent image examination (computed tomography and magnetic resonance imaging). The clinical and radiological features of every patient were evaluated by experienced orbital surgeons. Based on Rose and Wright's criteria, patients were scored and then treated using surgery with radiotherapy and/or chemotherapy. The final diagnoses were based on the histopathologic results. Based on the histopathologic diagnosis, the data from Rose and Wright's algorithm were evaluated.

RESULTS

The accuracy of Rose and Wright's algorithm for benign and malignant tumour diagnoses was 75% and 50%, respectively. The diagnostic sensitivity, specificity, and accuracy of Rose and Wright's algorithm were 64%, 93%, and 86%, respectively. The algorithm demonstrated significant accuracy in the clinicoradiological criterion in differentiating between benign tumours and malignant tumours (p < 0.05).

CONCLUSIONS

Rose and Wright's algorithm has great advantages in distinguishing benign from malignant tumours within the orbital lobe of the lacrimal gland. However, the algorithm should be used with great caution because of its low diagnostic sensitivity for malignant tumours.

Adenoid cystic carcinoma of the lacrimal gland is frequently characterized by MYB rearrangement

PurposeAdenoid cystic carcinoma (ACC) represents ~10-15% of salivary neoplasms and almost universally exhibits a lethal clinical course. ACC is also known to occur in the lacrimal gland. ACC is characterized by its heterogeneous morphology and may demonstrate tubular, cribriform, and/or solid architectural patterns. Unfortunately, these histopathological features are not specific to ACC and can be seen in other salivary gland-type neoplasms, introducing a diagnostic dilemma. The discovery of fusion transcripts has revolutionized the diagnosis, surveillance, and treatment of epithelial malignancies. In several anatomic subsites ACC is frequently characterized by a fusion transcript involving genes MYB and NFIB; more specifically, t(6;9)(q22-23;p23-24). This study explores the incidence of MYB rearrangement in cases of lacrimal gland ACC using fluorescent in situ hybridization.Materials and methodsRetrospective clinical and histopathological review of 12 cases of lacrimal gland ACC seen at Mayo Clinic over a 25-year period (1990-2015) was performed. Demographic and clinical data were obtained from medical records. Surgical pathology archival material including H&E slides and immunostains was re-examined. Formalin-fixed paraffin-embedded material was further evaluated using immunohistochemistry when appropriate. Fluorescent in situ hybridization (FISH) using a MYB break-apart probe was applied to all histologically confirmed cases of ACC and benign salivary gland parenchyma.ResultsThe median patient age was 53.6 years (range 12-64) and distributed equally by gender (six male and six female). Rearrangement of MYB was identified using FISH in seven cases (58%). Twenty-five sections of benign salivary gland parenchyma showed no evidence of MYB rearrangement. Primary surgical resection was most common treatment, and 78% of the patient received adjuvant radiation therapy. Median overall survival (OS) was 11 years. Rearrangement of MYB did not affect OS.ConclusionsIn summary, our results indicate that the MYB rearrangement defines a significant subset of lacrimal gland ACCs. Importantly, FISH for MYB rearrangement may be used as a diagnostic tool during pathological examination of lacrimal gland neoplasms. Our results showed no relationship between rearrangement status and clinical outcome. Lastly, the presence of t(6;9) in ACC may provide a platform for molecular-targeting strategies in the future.

Management of Lacrimal Gland Carcinoma: Lessons From the Literature in the Past 40 Years

PURPOSE

To review the published literature on management strategies for lacrimal gland carcinomas.

METHODS

Review of relevant articles in PubMed published in English from the year of 1970 through September 2014.

RESULTS

A review of literature suggests that treatment strategies for adenoid cystic carcinoma of lacrimal gland are varied, but local control does not necessarily prevent future delayed distant relapse. Tumor size and histologic features of lacrimal gland carcinoma seem to be important prognostic features. With improved imaging modalities providing better tumor diagnosis and staging, and availability of more focused radiation delivery techniques, multimodality globe sparing management of lacrimal gland carcinomas may be possible in selected cases. The availability of targeted drugs based on the molecular signature of an individual lacrimal gland carcinoma may offer possible targeted treatments for patients with nonresectable or metastatic disease.

CONCLUSION

Given the rarity of lacrimal gland carcinoma, multi-institutional studies and consistent reporting of size and histologic type of tumors in the literature may be prudent. Particularly, multimodality globe-sparing treatment strategies should be studied further.

Eye-sparing multidisciplinary approach for the management of lacrimal gland carcinoma

BACKGROUND

We analyzed local control and early ocular toxicity after eye-sparing management of lacrimal gland carcinoma.

METHODS

For consecutive patients with lacrimal gland carcinoma treated during 2007 to 2014, we reviewed tumor characteristics, treatment details, ocular toxic effects, and recurrence.

RESULTS

Twenty patients, median age 55 years, were treated for lacrimal gland carcinoma during the study period; 11 had globe-sparing surgery. Seven patients had adenoid cystic carcinoma, 2 had carcinoma ex pleomorphic adenoma, and 1 each had high-grade and low-grade adenocarcinoma. Ten patients underwent postoperative radiotherapy, median 60 Gy (range, 52-64 Gy), 6 with concurrent chemotherapy. At a median of 30 months after radiation, all patients had dry eye syndrome, and 1 patient had severe corneal and conjunctival damage leading to enucleation. All 11 patients were disease free at last contact, median follow-up after surgery of 33 months.

CONCLUSION

An eye-sparing approach with surgery followed by adjuvant radiotherapy or chemoradiotherapy is feasible for selected patients with lacrimal gland carcinoma and is associated with a reasonable locoregional control and ocular toxicity profile. © 2016 Wiley Periodicals, Inc. Head Neck 38:1258-1262, 2016.

Adenoid cystic carcinoma of the skull base: results with an aggressive multidisciplinary approach

OBJECT

Adenoid cystic carcinoma (ACC) is a locally aggressive tumor of salivary gland origin. Little data exist to guide treatment when this tumor extends to involve the structures of the skull base.

METHODS

Fifty-one patients with a diagnosis of ACC affecting the skull base were identified from a prospective database at MD Anderson Cancer Center (from 1992 to 2010).

RESULTS

Median follow-up for study patients was 6.75 years. The 5- and 10-year overall survival (OS) rates were 78% and 50%, respectively. Sixty-six percent of patients had progression of their disease. The 5- and 10-year progression-free survival (PFS) rates were 46.7% and 21.0%, respectively. Gross-total resection was achieved in 75% of patients, with 49% having microscopically negative margins at the time of first operation. On univariate analysis, resections with microscopically negative margins were associated with a significant OS advantage (20.1 ± 3.3 years) compared with resections that left residual disease, even if microscopic (10.3 ± 1.6 years, p = 0.035). In patients who underwent reoperation, the effect persisted, with improved OS in those with negative margins (21.4 ± 0.0 vs 16.7 ± 4.0 years, p = 0.06). The use of adjuvant radiotherapy was associated with an OS advantage (16.2 ± 2.5 vs 5.5 ± 2.2 years, p = 0.03) at initial diagnosis and improved PFS (7.8 ± 1.0 vs 2.1 ± 0.62 years, p = 0.005), whereas repeat irradiation provided no benefit. The use of adjuvant chemotherapy at diagnosis or at recurrence was not associated with any significant advantage. Multivariate analysis revealed margin-negative resection at initial operation and at recurrence retained OS significance, even after controlling for age, radiation therapy, and T stage.

CONCLUSIONS

ACC of the skull base is best treated with a multidisciplinary approach aimed at maximal, safe resection. Adjuvant radiotherapy should be offered, whereas chemotherapy does not confer benefit.

Imaging findings of recurrent tumors after orbital exenteration and free flap reconstruction

PURPOSE

Tumors that recur following orbital exenteration may not be evident on clinical examination, highlighting the need for imaging surveillance. The goal of this study was to report the imaging characteristics of recurrent tumors following orbital exenteration and free flap reconstruction.

METHODS

The authors retrospectively reviewed the records of 48 patients who underwent orbital exenteration for the treatment of orbital malignancy and identified 17 recurrent tumors in 17 patients. The lesions were assessed for the presence of a soft tissue mass, imaging characteristics, and fluorodeoxyglucose avidity.

RESULTS

The recurrent tumors were detected 1 month to 6 years 10 months (median, 1 year 3 month) after orbital exenteration. On both CT and MRI, all 17 lesions were soft tissue masses at presentation. On CT, the lesions demonstrated heterogeneous to homogeneous to centrally necrotic enhancement; on MRI, the lesions were T1 hypointense to isointense and T2 hypointense to hyperintense. Twelve of the 15 recurrent tumors with available preoperative imaging had an enhancing appearance similar to that of the original tumor. Thirteen of the 17 recurrent tumors were at the margin of a flap placed for reconstruction; the other 4 lesions were remote from the operative site.

CONCLUSION

Recurrent tumors following orbital exenteration and free flap reconstruction demonstrate a wide range of imaging appearances but most often appear as a soft tissue masses often similar in appearance to the primary tumor and arising near the flap margin. Awareness of the imaging features of recurrent disease is important because failure to diagnose recurrence can delay appropriate treatment.

Adenoid cystic carcinoma of the lacrimal gland metastatic to the kidney: case report and review of the literature

INTRODUCTION

Adenoid cystic carcinoma (ACC) is a malignant neoplasm that arises within secretory glands. It rarely occurs in the lacrimal gland. Kidney metastases are very rare.

CASE PRESENTATION

We report a case of a 76-year-old female patient treated with right radical nephrectomy because of the tumour mass of the right kidney. Well-circumscribed, firm, grey mass was found on the lower pole of the kidney. Histologically, tumour was considered to be ACC. Retrospective history data showed ACC of the lacrimal gland surgically treated 14 years before with metastasis to the lung operated seven years before. Our diagnosis was metastatic ACC to the kidney.

CONCLUSION

ACC has a remarkable capacity for recurrence. To our knowledge, in the English-speaking area (PubMed), 10 cases of ACC metastatic to the kidney have been described to date, and this is the second reported case of kidney metastasis from primary lacrimal ACC.

Neutron radiotherapy for adenoid cystic carcinoma of the lacrimal gland

PURPOSE

Lacrimal gland adenoid cystic carcinomas are rare, aggressive orbital tumors that share histopathologic similarities with salivary gland malignancies. Neutron radiotherapy may be useful for treatment due to its high biological effectiveness for salivary malignancies.

METHODS

The authors retrospectively reviewed the outcomes for 11 lacrimal gland adenoid cystic carcinoma patients treated with neutrons from 1988 to 2011. Most had undergone surgery prior to radiation therapy. However, gross residual disease was present in 8 patients. The most common American Joint Committee on Cancer stage was T4cN0M0. Four patients with skull base involvement received a radiosurgery boost and 1 received a proton therapy boost.

RESULTS

Median follow up was 6.2 years. Median overall survival was 11.1 years and median disease-free survival was 6.3 years. Five-year local control was estimated by the Kaplan-Meier method as 80%. Three patients had a local recurrence; 4 developed distant metastases. Six patients died. Seven patients had intact vision in the affected eye before neutron radiation. Two required enucleation for a painful dry eye. Of the 5 who avoided an enucleation, 3 had either severe visual impairment (20/400) or only light perception and 2 were without known vision compromise or complications at the time of their death. One patient developed asymptomatic frontal lobe radionecrosis after 2 courses of radiation therapy.

CONCLUSIONS

Neutron radiation therapy achieved excellent 5-year local control in this series of high-risk patients, with most cases having gross residual disease. Late recurrences and distant metastases remain a challenge. Meaningful ipsilateral vision preservation was not possible in most cases in the long term, although only 2 patients required an enucleation for treatment effects.

Three-Dimensional Multidetector CT for Anatomic Evaluation of Orbital Tumors

Intricate resection and complex reconstructive procedures often required for primary and metastatic orbital tumors are facilitated by accurate imaging. A three-dimensional (3D) image can be reconstructed from source axial multidetector computed tomography (MDCT) images to visualize orbital tumors. To assess the utility of 3D images in this setting, the 3D images were reconstructed retrospectively for 20 patients with an orbital tumor and compared to two-dimensional (2D) orthogonal MDCT studies. Both types of images were assessed for their capacity to show the bony orbital walls and foramina, extraocular muscles, and optic nerve in the orbit contralateral to the tumor and, in the affected orbit, the extent of the tumor and its relationship to normal orbital contents and associated bone destruction. 3D imaging is most informative when axial images are acquired at 1.25 mm collimation. The optic nerve, extraocular muscles, and well-circumscribed orbital tumors were well visualized on 3D images. On 3D imaging, tumor-associated destruction of the lateral and superior orbital walls was fairly well demonstrated and that of the inferior and medial walls was not. The 3D images provide the surgeon with a comprehensive view of well-circumscribed orbital tumors and its relationship to extraocular muscles, exiting foramina, and the superior and lateral walls.