Cavernous sinus involvement from recurrent adenoid cystic carcinoma

Cavernous sinus involvement is not a risk factor for the primary tumor site treatment outcome of Sinonasal adenoid cystic carcinoma

Background

Sinonasal adenoid cystic carcinoma is a rare malignancy of the head and neck. Cavernous sinus invasion from sinonasal adenoid cystic carcinoma and its related management have rarely been investigated. This study evaluated the relationship between treatment outcome and cavernous sinus involvement in addition to other parameters.

Methods

A retrospective case series study was conducted at a tertiary referral center. The medical records of 47 patients diagnosed with primary sinonasal adenoid cystic carcinoma between 1984 and 2015 were retrospectively reviewed. The survival impact of the primary treatment modalities and the anatomic sites of tumor involvement were analyzed.

Results

Cavernous sinus invasion was observed in 8 patients (17%), of whom 7 had ACC tumors originating from the maxillary sinus. The results of univariate analysis revealed that tumor stage, primary surgery, and the absence of skull-base and infratemporal fossa invasion were associated with better overall survival (P = 0.033, P = 0.012, P = 0.011, and P = 0.040, respectively) and better disease-free survival (P = 0.019, P = 0.001, P = 0.017, and P = 0.029, respectively). Multivariate analysis identified primary surgery as the only independent prognostic factor for disease-free survival (P = 0.026). Cavernous sinus invasion by sinonasal adenoid cystic carcinoma was not associated with worse overall survival or disease-free survival (P = 0.200 and P = 0.198, respectively).

Conclusions

Because maxillary adenoid cystic carcinoma is associated with a higher rate of cavernous sinus invasion, such cases warrant caution during preoperative planning. Primary surgery as the initial therapy provides better locoregional control and survival for patients with sinonasal adenoid cystic carcinoma. Cavernous sinus invasion did not significantly impact survival; thus, it should not be regarded as a contraindication for curative treatment.

Adenoid cystic carcinoma of the sublingual gland: A case report

Adenoid cystic carcinoma (ACC) of the sublingual gland is an extremely rare neoplasm. The clinicopathological characteristics of ACC are slow-growing swelling with or without ulceration, perineural spread, local recurrence, and distant metastasis. This report describes a 58-year-old male who had a slowly growing swelling without ulceration on the right side of the mouth floor that had been present for 1 month. In a radiological examination, the mass showed multilocular cystic features and no bony or tongue muscle invasion. No enlarged cervical lymph nodes were detected. Excisional biopsy and histological analysis showed that the lesion was ACC. In addition to reporting a rare case of ACC, this report also discusses the differential diagnosis and treatment of ACC with a review of the relevant literature.

Perineural spread of adenoid cystic carcinoma in the oral and maxillofacial regions: evaluation with contrast-enhanced CT and MRI

OBJECTIVES

The objective of this study was to compare the accuracy of contrast-enhanced CT (CECT) and contrast-enhanced MRI (CEMRI) in the detection of perineural spread (PNS) of adenoid cystic carcinoma (ACC) in the oral and maxillofacial regions.

METHODS

This study consisted of 13 ACCs from 13 patients, all of which were histopathologically diagnosed. Both CECT and CEMRI were performed in all patients before the treatment. The images of each patient were retrospectively evaluated for the detection of PNS. The definitions of PNS included abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal, and enlargement or excessive contrast enhancement of a nerve.

RESULTS

11 out of 13 cases were proven to exhibit PNS histopathologically. 8 of the 11 cases for which PNS was histopathologically proven exhibited PNS on MR images. Six of the eight cases for which PNS was exhibited on MR images also exhibited PNS on CT images. The sensitivity, specificity and accuracy for the detection of PNS were 55%, 100% and 62% on CT images and 73%, 100% and 77% on MR images, respectively. Although the accuracy of PNS on MR images was slightly superior to that on CT images, there were no statistically significant differences between the detection of PNS on CT images and on MR images.

CONCLUSIONS

CT and MR images are equally useful for the detection of PNS of ACC in the oral and maxillofacial regions.

Palatal adenoid cystic carcinoma presenting as perineural spread to the cavernous sinus

Adenoid cystic carcinoma of the hard or soft palate is a slow-growing, insidious disease with a tendency to spread via a perineural mechanism along the palatine branches of the maxillary division of the trigeminal nerve. Such spread may present first as a tumor in the pterygopalatine fossa or cavernous sinus. The purpose of this manuscript is to report three cases of palatal adenoid cystic carcinoma which presented as a mass in the cavernous sinus prior to discovery of the palate primary tumor. The imaging features of these cases are emphasized as is the need to search for a head and neck primary lesion when faced with a cavernous sinus mass.

Imaging lesions of the cavernous sinus

Our aim was to review the imaging findings of relatively common lesions involving the cavernous sinus (CS), such as neoplastic, inflammatory, and vascular ones. The most common are neurogenic tumors and cavernoma. Tumors of the nasopharynx, skull base, and sphenoid sinus may extend to the CS as can perineural and hematogenous metastases. Inflammatory, infective, and granulomatous lesions show linear or nodular enhancement of the meninges of the CS but often have nonspecific MR imaging features. In many of these cases, involvement elsewhere suggests the diagnosis. MR imaging is sensitive for detecting vascular lesions such as carotid cavernous fistulas, aneurysms, and thromboses.

Imaging of salivary gland tumours

Salivary gland neoplasms account for <3% of all tumors. Most of them are benign and parotid gland is the commonest site. As a general rule, the smaller the involved salivary gland, the higher is the possibility of the tumor being malignant. The role of imaging in assessment of salivary gland tumour is to define intra-glandular vs. extra-glandular location, detect malignant features, assess local extension and invasion, detect nodal metastases and systemic involvement. Image guided fine needle aspiration cytology provides a safe means to obtain cytological confirmation. For lesions in the superficial parotid and submandibular gland, ultrasound is an ideal tool for initial assessment. These are superficial structures accessible by high resolution ultrasound and FNAC which provides excellent resolution and tissue characterization without a radiation hazard. Nodal involvement can also be assessed. If deep tissue extension is suspected or malignancy confirmed on cytology, an MRI or CT is mandatory to evaluate tumour extent, local invasion and perineural spread. For all tumours in the sublingual gland, MRI should be performed as the risk of malignancy is high. For lesions of the deep lobe of parotid gland and the minor salivary glands, MRI and CT are the modalities of choice. Ultrasound has limited visualization of the deep lobe of parotid gland which is obscured by the mandible. Minor salivary gland lesions in the mucosa of oral cavity, pharynx and tracheo-bronchial tree, are also not accessible by conventional ultrasound. Recent study suggests that MR spectroscopy may differentiate malignant and benign salivary gland tumours as well as distinguishing Warthin's tumor from pleomorphic adenoma. However, its role in clinical practice is not well established. Similarly, the role of nuclear medicine and PET scan, in imaging of parotid masses is limited. Sialography is used to delineate the salivary ductal system and has limited role in assessment of tumour extent.

Tumors of the salivary glands

This article reviews the role of imaging in the management of tumors of the salivary glands, discussing tumor localization, extent, and, where possible, characterization. The relative benefits of the different modalities and the typical features of benign and malignant lesions are discussed for each modality. Characteristic appearances of specific tumors are highlighted.

Imaging of sellar and parasellar pathology

This article reviews the complex anatomic relationships between structures in the sellar and parasellar regions. Normal anatomy and the normal imaging spectrum are reviewed, with emphasis on the diversity of pathology that originates from this region. Both CT and MR imaging may be used to evaluate the sellar and parasellar regions. This article discusses how modern imaging techniques enable characterization of the many lesions that alter the structure and function of normal sellar and parasellar anatomy.

MR of malignant nasosinusal neoplasms. Frequently asked questions

This paper focuses on the role of MR imaging of malignant neoplasms through a particular layout that emphasizes: (a) the rationale for the application of imaging; (b) the factors influencing the selection of sequences, planes and their proper arrangement; (c) the correlation between MR findings, imaging staging and clinical decision making. Since in most cases surgery is the treatment of choice, the precise assessment of the local extent and spread of tumour plays a key role in planning the surgical approach and influences either the therapy and the prognosis. However, the degree of spatial/anatomical detail required in treatment planning significantly differs between surgery and radiotherapy. Planning of the examination technique focuses on: (a) assembling sequences and planes in the shortest time possible; (b) the solution of specific problems: distinction between neoplasm and retained secretions within nasosinusal cavities; staging of submucosal spread toward the anterior cranial fossa, the orbit, the pterygo-palatine and superior orbital fissures. Since the most effective barrier to spread of neoplasms beyond sinusal walls does not depend on the mineral content of bone, but on the periosteum, assessment of the integrity of periorbita or dura mater is an essential information. Although MR cannot detect focal erosions of the thin sinusal walls, it reliably demonstrates both residual barriers (periorbita and dura), even though the bone has been completely destroyed. However, the final decision concerning orbital exenteration is made according to intraoperative staging. MR imaging can accurately precise the degree of anterior cranial fossa involvement. Furthermore, since either MR and CT accurately indicate the need to perform an anterior craniofacial resection and adequately exclude neoplastic invasion requiring orbital exenteration, more comparative studies are required to demonstrate that MR preoperative staging of nasosinusal malignancies is cost-effective.