Adenoid cystic carcinoma: use of cell proliferation, BCL-2 expression, histologic grade, and clinical stage as predictors of clinical outcome

Post-operative radiotherapy in adenoid cystic carcinoma of salivary glands versus surgery alone: what is the evidence about survival and local control? A systematic review and meta-analysis

BACKGROUND

Adenoid cystic carcinoma of the salivary glands is a relatively rare malignancy characterized by slow growth and a poor prognosis, and effective treatments remain challenging to identify. This systematic review, following the PRISMA guidelines, aimed to analyze the potential benefits of post-operative radiotherapy in terms of local control of recurrences and survival advantages when compared with surgery alone in patients with adenoid cystic carcinoma.

METHODS

A comprehensive systematic review was conducted by searching the MEDLINE, Cochrane, EMBASE, and OVID databases from January 1999 to July 2022. The goal was to identify articles comparing surgery alone with surgery plus postoperative radiotherapy for adenoid cystic carcinoma of the salivary glands. Downs and Black Checklist was used to assess the methodological quality and risk of bias of each included study. The data analysis was performed using Review Manager version 5.4.1.

RESULTS

This review included 8 studies comprising a total of 3103 patients, divided based on the analyzed outcomes. The pooled odds ratio for overall survival at 5 years was 0.87 (95% confidence interval 0.43-1.76, p = 0.70), and at 10 years was 1.23 (95% confidence interval 0.69-2.16, p = 0.48). In both cases, no statistically significant differences were observed. However, the pooled odds ratio for local control at 5 years was 3.37 (95% confidence interval 1.35-8.42, p = 0.009), providing strong support for the use of post-operative radiation.

CONCLUSIONS

The findings from the meta-analysis suggest that post-operative radiotherapy significantly improves local control in patients with adenoid cystic carcinoma. However, there was no statistically significant increase in survival at 5 and 10 years. It is essential to note that the quality of the studies included in this meta-analysis ranged from fair to poor. To better clarify the indications for post-operative radiotherapy, future high-quality research is needed, particularly with improved stratification of patient groups. Additionally, it is important to recognize that achieving local control in adenoid cystic carcinoma is crucial for enhancing the overall quality of life for patients. We acknowledge that this review was not registered in the PROSPERO database, and the data pooling was conducted using a random effects model.

Primary cutaneous adenoid cystic carcinoma: a clinicopathologic, immunohistochemical, and fluorescence in-situ hybridisation study of 13 cases

AIMS

This study aimed to investigate the clinical, histological, immunohistochemical and chromosomal features of primary cutaneous adenoid cystic carcinoma (PCACC).

METHODS AND RESULTS

We retrospectively analysed 13 cases identified on their clinicopathological features and performed fluorescence in-situ hybridisation (FISH) on six available cases. Head and neck (46.2%) were most commonly involved. The median age was 53 years, with a male predilection. Histologically, tumours were classified as grades 1 (eight), 2 (four) and 3 with high-grade transformation (HGT) (one). The HGT component was demonstrated as poorly differentiated carcinoma with multifocal necrosis and myoepithelial differentiation. Patients with one of the following factors: longest diameter of the lesion (≥ 1 cm), involvement of subcutaneous fat tissue and widely infiltrative border had a relatively higher rate of local recurrence, distant metastasis and death. Five of six cases were confirmed to have MYB translocation, while nuclear staining for MYB proto-oncogene, transcription factor (MYB) protein was found in four cases. During the follow-up (median = 64 months), two patients experienced local recurrences. One patient, who was classified as grade III PCACC with HGT, developed multiple metastases and died of disease. Another patient was alive with multiple metastases.

CONCLUSIONS

This is the largest single-institution study, to our knowledge, of PCACC in an Asian population. We describe the first case of scalp PCACC with HGT, which is the only death case in our series. PCACC tends to recur locally and has metastatic potential. PCACC with HGT has a poor prognosis.

Predictors of Distant Metastasis and Survival in Adenoid Cystic Carcinoma of the External Auditory Canal

OBJECTIVE

To analyze the predictors of both distant metastasis and survival in patients with adenoid cystic carcinoma of the external auditory canal.

STUDY DESIGN

Retrospective patient review.

SETTING

A single university hospital.

PATIENTS

Eighty-two cases with adenoid cystic carcinoma of the external auditory canal were referred to our institution between 2004 and 2016.

MAIN OUTCOME MEASURES

Distant metastasis was detected by lung computed tomography, proton emission tomography computed tomography, or histopathologic examination of tissue samples. Distant metastasis predictors were analyzed using Student's t tests and χ tests. The log-rank tests of Kaplan-Meier survival curves were used to evaluate survival differences.

RESULTS

During a median follow-up of 36 months (range, 6-162 mo), distant metastasis developed in 25 patients. The occurrence of distant metastasis was significantly associated with histopathologic subtype, T classification, and local recurrence (p < 0.05). The 1-, 10-, 20-, and 25-year cumulative survival rates in the patents with DM were 95.7, 95.7, 71.7, and 0%, respectively, and all survival rates were 100% for the 57 patients without distant metastasis (p = 0.115). Median survival time after occurrence of distant metastasis was 13 months (range, 1-120 mo). Prognosis was better with solely lung metastasis than with metastases to other visceral organs or bone (p < 0.05).

CONCLUSIONS

Distant metastasis appeared to result in a poorer prognosis, occurrence of distant metastasis was significantly associated with local recurrence, extensive surgery is recommended to achieve local control and reduce distant metastasis risk. Routine follow-up investigations for detecting distant metastasis are warranted for patients with an increased risk for distant metastasis.

High podoplanin and low E-cadherin levels correlate with better prognosis in adenoid cystic carcinoma

Objectives

As tumour spread is a complicating event for malignant salivary gland tumours, we decided to study factors related to cell adhesion and lymph vessel formation in two of the three most common malignant salivary gland tumours, mucoepidermoid carcinoma (MEC) and adenoid cystic carcinoma (ACC), to clarify the clinical relevance and potential usefulness of these factors. We also included a group of polymorphous adenocarcinoma (PAC) as this tumour, in common with ACC often shows perineural growth, but in contrast to ACC has an overall good prognosis.

Material and methods

Eighteen patients with ACC, 15 with MEC, and six with PAC were included. Protein expression of podoplanin and E-cadherin was evaluated as percentage of cells expressing the protein and intensity of expression. Ki-67 expression was included in the study as a marker of proliferative activity.

Results

Looking at podoplanin, significantly more ACCs were high expressing compared with both MECs (P = .001) and PACs (P = .028). Also when looking at Ki-67 expression, significantly more ACCs were high expressing compared with MECs (P = .003). Significantly better survival was also seen for ACCs with high podoplanin (P = .022) and low E-cadherin expression (P = .021), respectively.

Conclusions

Our findings show that ACCs express significantly higher levels of podoplanin compared with both MECs and PACs and that high levels are correlated to better survival. Even though the group of PACs analysed was small, these tumours, despite their tendency to perineural spread, which they have in common with ACC, differ from ACCs concerning expression of factors with a known connection to tumour spread.

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

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

Adenoid cystic carcinoma of the larynx in a 70-year-old patient: A case report

Adenoid cystic carcinoma (ACC) is a relatively rare tumor that accounts for <1% of all head and neck malignancies. Laryngeal localization of ACC, which is most commonly hypoglottic, is relatively rare, occurring in 0.07-0.25% of all laryngeal tumors. ACC is characterized as a slow-growing tumor with a high recurrence rate, which often causes dyspnea and hoarseness. ACC exhibits a propensity for perineural invasion and thus, patients may experience pain as a late symptom of the disease. Distant metastasis occurs in 35-50% of cases and the lungs are the most common site of metastasis. Tumors are usually diagnosed by physical examination with fiberoscopy and computed tomography of the neck and chest, due to the high rate of lung metastases. The standard therapy for ACC is surgery followed by radiotherapy. In this study, a 70-year-old patient presented with laryngeal ACC, who underwent total laryngectomy with bilateral neck dissection and adjuvant radiotherapy, is presented. Follow-up examination performed 2 years after surgery revealed no evidence of locoregional recurrence or distant metastases. Previously published literature regarding ACC of the larynx was also reviewed.

Correlation between the pathology and clinical presentations in patients with adenoid cystic carcinoma of the external auditory canal

BACKGROUND

The purpose of this study was to analyze the correlation between the pathology and clinical presentations in patients with adenoid cystic carcinoma (ACC) of the external auditory canal.

METHODS

Twenty-nine patients with ACC of the external auditory canal who underwent surgery were retrospectively reviewed.

RESULTS

Fifty percent of patients with solid pattern disease had recurrences, followed by those with cribriform (33%) and tubular (0%) pattern. Perineural invasion was common (55%), and occurred most frequently in the solid subtype (67%). The rate of otalgia was less in patients with perineural invasion (31% vs 46%). Most tumors (59%) involved the parotid gland, but it was not seen on preoperative MRI (35%).

CONCLUSION

The solid subtype presents the worst prognosis, and is prone to perineural invasion. Despite frequently occurring in ACC of the external auditory canal, perineural invasion may not be associated with otalgia. In ACC of the external auditory canal, high rates of occult parotid involvement support adjunctive superficial parotidectomy.

Adenoid Cystic Carcinoma of the Oral Cavity: Radiology-Pathology Correlation

Adenoid cystic carcinoma in the oral cavity is an uncommon salivary gland malignancy that has a propensity for perineural spread. A high-grade variant is evidenced by an abundance of pleomorphic cells, loss of the classic biphasic epithelial-myoepithelial growth pattern, and comedonecrosis, as well as elevated Ki-67. CT and MRI can both be useful for demonstrating the extent of invasion in oral cavity-associated adenoid cystic carcinoma, which can attain the inferior alveolar nerve for perineural spread by direct invasion through the mandible. Reflecting the aggressive nature of this high-grade malignancy, ¹⁸FDG-PET can demonstrate hypermetabolism and can be useful for staging. These features are exemplified in this sine qua non radiology-pathology correlation article.

Resection of upper lip adenoid cystic carcinoma and reconstruction with reverse Yu flap: Report of three cases and a literature review

The present study aimed to describe the techniques that were used, and the results obtained, with the reverse Yu flap to reconstruct medium-sized upper lip defects following resection for adenoid cystic carcinoma (ACC). Data concerning the clinical and pathological characteristics of tumours, the size and location of the defects, surgical resection and the reconstructive procedure used were evaluated in three patients, as well as postoperative complications and outcomes. In all cases, a complete surgical removal of ACC was achieved with clear margins of at least 1 cm. Histopathological features revealed two cases with a predominant solid growth pattern, and one case of cribriform. Following tumour excision, the average size of the upper lip defect was 35.7×30 mm. The reverse Yu flap was raised simultaneously with tumour resection in all cases. No flap failed, and both excellent aesthetic and functional results were obtained. All the patients had a satisfactory oral competence, without microstomia, after a median of 20 months follow-up (range, 12-30 months). Adjuvant radiation therapy was not necessary in any case. On the basis of the present case study and literature review, reverse Yu flap is revealed to be a simple and reliable technique for the reconstruction of defects ranging from one-third to two-thirds of the total upper lip length, involving the commissure, nasolabial fold and philtrum, with minimal donor morbidity and a good functional and aesthetic outcome. This flap appears to be a valid surgical option for reconstruction of medium-sized upper lip defects, which may be considered following radical excision of ACC.

Pretreatment maximum standardized uptake value of (18)F-fluorodeoxyglucose positron emission tomography as a predictor of distant metastasis in adenoid cystic carcinoma of the head and neck

BACKGROUND

The purpose of this study was to determine whether the maximum standardized uptake value (SUVmax) of the primary tumor on pretreatment (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) has prognostic significance in patients with adenoid cystic carcinoma (ACC) of the head and neck.

METHODS

A retrospective review was carried out on 34 patients with ACC of the head and neck who underwent pretreatment (18)F-FDG PET imaging from June 2005 through July 2009. All patients underwent surgery with curative intent, and 26 of them received adjuvant radiotherapy (RT).

RESULTS

When subjects were stratified into 2 groups according to a cutoff value for SUVmax of 4.15, the risk of distant metastasis was significantly high in patients with high SUVmax (p = .014). Multivariate analysis showed that high SUVmax and histologic grade 3 were independent poor prognostic factors for distant metastasis-free and disease-free survival.

CONCLUSION

Pretreatment SUVmax of the primary tumor is an independent prognostic factor in patients with ACC of the head and neck.

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

OBJECTIVES

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

STUDY DESIGN

Case series.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4.

Review and Updates of Immunohistochemistry in Selected Salivary Gland and Head and Neck Tumors

Context

Immunohistochemistry is a useful tool for diagnosing salivary gland and head and neck tumors.

Objective

To review immunohistochemical markers, which can aid in the diagnosis of selected salivary gland and head and neck tumors.

Data Sources

Literature review and authors' personal practice experience.

Conclusions

Salivary gland and head and neck tumors include a large diverse group of tumors with complex and overlapping histologic features. Immunohistochemistry plays an important role in resolving the differential diagnosis of some salivary gland and head and neck tumors and can provide information for the prognosis of certain tumors.

Adenoid cystic carcinoma presenting as an ulcer on the floor of the mouth: a rare case report

Adenoid cystic carcinoma is a rare epithelial tumour, and comprises about 1% of all malignant tumours of the oral and maxillofacial region. It is a malignant tumour which may develop in the trachea, bronchus, lungs or mammary glands, in addition to the head and neck region. Occurrences in the head and neck are mostly detected in the major salivary gland, oral cavity, pharynx and paranasal sinus where it presents as a slow growing firm nodular swelling. The aim of the article is to highlight the unique presentation of adenoid cystic carcinoma as a solitary ulcer on the floor of the mouth.

Treatment of c-kit positive adenoid cystic carcinoma of the tongue: A case report

Adenoid cystic carcinoma (ACC) or ‘cylindroma’ is a malignant tumor that often occurs in the areas of the head and neck, affecting the secretory glands and the major and minor salivary glands. The present study describes a case of a patient who presented with a posterior tongue lesion. The case is of a 71-year-old female with an asymptomatic volume growth of the posterior left tongue perceived 8 months prior, and neoplastic cells positive for c-kit. A computed tomography of the head and neck showed asymmetry of the base of the tongue, which was enlarged in the left portion. A physical examination revealed a nodule on the posterior left tongue of ~3 cm in diameter, while the cervical lymph node chain had a normal size and consistency. Surgical exeresis of the tongue lesion and cervical lymph node dissection were performed. Subsequent to surgical removal of the cancer cells and adjuvant radiotherapy, the patient showed excellent health, although the follow-up remains in progress. ACC, one of the most biologically destructive tumors of the head and neck, is locally aggressive and gives rise to distant metastases. The tongue is the place of origin in 3.4–17.1% of cases. The treatment for ACC consists of primary surgical resection with adjuvant radiotherapy. To prevent the risk for distant metastasis, it is necessary to remove the first echelon nodes and monitor the patient with a long-term follow-up.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Resection and Reconstruction of Maxillary Class IIIc Defect in a Case of Adenoid Cystic Carcinoma: Cost-Sensitive Technique without Microvascular Grafts

ACC is a rare malignant tumor that affects most commonly the major and minor salivary glands and rarely the paranasal sinuses, lacrimal gland, larynx, ear, vulva, and so forth. The maxillary sinus when affected is considered having a poor prognosis due to delayed diagnosis and delayed treatment credited to its slow spread, late symptoms, and complex anatomy which hampers surgical resection. The expressions of tumor markers too have a significant role in determining the prognosis. The treatment of choice consists of wide radical resection of the tumor followed by radiotherapy. Rehabilitation options in cases with huge maxillary defects still need further exploration.

Adenoid cystic carcinoma of buccal mucosa

Adenoid cystic carcinoma is a malignant neoplasm most commonly originating in the salivary glands of head and neck region. The clinical and pathological findings typical of this tumour include slow growth, perineural invasion and potential local recurrence. Up to 50% of these tumours occur in the intraoral minor salivary glands usually in the hard palate. We present a case report of a 26-year-old woman who was diagnosed with adenoid cystic carcinoma of the right buccal mucosa. The peculiarity of the lesion and the approach we made is the key factor in the presentation.

Adenoid cystic carcinoma of the head and neck

PURPOSE

To report our experience using radiotherapy alone or combined with surgery to treat adenoid cystic carcinoma of the head and neck.

MATERIALS AND METHODS

Radiotherapy alone or combined with surgery was used to treat 120 previously untreated patients with adenoid cystic carcinoma (ACC) of the head and neck from August 1966 to March 2008. Patients were treated with curative intent. American Joint Committee on Cancer stage distribution was,T0 (n = 1), T1 (n = 26), T2 (n = 25), T3 (n = 14), T4 (n = 54), N0 (n = 113), N1 (n = 2), N2a (n = 1), N2b (n = 2), and N2c (n = 2). Treatment included surgery with postoperative radiotherapy (n = 71), radiotherapy alone (n = 46), and preoperative radiotherapy and surgery (n = 3). Incidental and clinical perineural invasion was found in 41 (34%) and 35 (29%) patients, respectively. Median follow-up was 8.6 and 11.6 years overall and among living patients, respectively.

RESULTS

The 10-year overall, cause-specific, and distant metastasis-free survival rates, respectively, were as follows: radiotherapy alone, 37%, 46%, and 76%; surgery and radiotherapy, 57%, 71%, and 62%; and overall, 50%. The 10-year local control rates were as follows: radiotherapy alone, 36%; surgery and radiotherapy, 84%; and overall, 65%. The 10-year neck control rates were as follows: elective nodal irradiation (ENI), 98%; no ENI, 89%; and overall, 95%.

CONCLUSIONS

Surgery and adjuvant radiotherapy offer the best chance for cure for patients with resectable adenoid cystic carcinomas of the head and neck. Some patients with advanced, incompletely resectable disease can be cured with radiotherapy alone. ENI should be considered for primary sites located in lymphatic-rich regions.

Prognostic significance of Ki-67 in salivary gland carcinomas

BACKGROUND

Salivary gland carcinomas are a heterogeneous group of tumors with varying malignant potential. In this study, we evaluated the proliferative marker Ki-67 in salivary gland carcinomas and related the Ki-67 index to clinical data.

METHODS

A total of 176 salivary gland carcinomas of 13 different subtypes were stained immunohistochemically for Ki-67. The number of Ki-67 positive cells was counted and the Ki-67 index was calculated as the percentage of positive tumor cells.

RESULTS

The Ki-67 median value was 26 (range 1-99). The median follow-up time was 6.9 years (range 0-19 years). The 5- and 10-year crude survival was 70% and 59%, respectively. In univariate analysis, Ki-67 index, stage, vascular invasion and tumor grade were significantly related to crude survival, but in multivariate analysis only Ki-67 index, age, and stage were independent prognostic factors.

CONCLUSION

We showed that irrespective of subtyping, grading or morphological appearance of tumor, the Ki-67 index is an important and independent prognosticator. Clinical and histo-pathological data must be considered, when planning the treatment of the individual patient. We have shown that besides stage and age of the patient, Ki-67 is a strong, independent prognostic factor.

Clinicopathological features of salivary and non-salivary adenoid cystic carcinomas

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

Adenoid cystic carcinoma

Adenoid cystic carcinoma is a malignant tumor with a deceptively benign histologic appearance characterized by indolent, locally invasive growth with high propensity for local recurrence and distant metastasis. The tumor is composed of basaloid cells with small, angulated, and hyperchromatic nuclei and scant cytoplasm arranged into 3 prognostically significant patterns: cribriform, tubular, and solid. Some tumors undergo dedifferentiation into a high-grade form. Numerous studies have attempted to elucidate accurate histologic prognostic features but have often yielded conflicting results. Microarray analysis and gene expression profiling have provided new potential diagnostic and prognostic markers. However, tumor grade, stage, lymph node metastasis, invasion of major nerves, and margin status remain the most consistent predictors of prognosis. The combination of surgery and postoperative radiation therapy has improved locoregional control of the disease. Despite this achievement, late local recurrence and distant metastasis rates remain high and may occur decades after initial diagnosis.

Unique presentation of adenoid cystic carcinoma in postcricoid region: a case report and review of the literature

Malignant tumors of minor salivary glands are uncommon, representing only 2-4% of all head and neck malignancies. In the larynx, minor salivary gland tumors rarely occur and constitute less than 1% of laryngeal tumors. Most of the minor salivary gland tumors arise in the subglottis; however, they can also occur in the supraglottis in the false vocal cords, aryepiglottic folds, and caudal aspect of the epiglottis. The most common type of malignant minor salivary gland tumor is adenoid cystic carcinoma. In the last 20 years, only 40 cases of adenoid cystic carcinoma arising in variable locations of the larynx have been reported in the English language literature. We present a case of adenoid cystic carcinoma of the larynx arising in the inter-arytenoid and postcricoid region in a 54-year-old woman. To our knowledge, this is the first case of adenoid cystic carcinoma arising in this particular region of the larynx.

Adenoid cystic carcinoma: a rare clinical entity and literature review

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

Prognostic significance of nuclear survivin expression in resected adenoid cystic carcinoma of the head and neck

OBJECTIVES

The expression of survivin, an inhibitor of apoptosis, in tumor cells is associated with poor clinical outcome for various cancers. We conducted this study to determine survivin expression in patients with adenoid cystic carcinoma (ACC) of the head and neck and to identify its clinical significance as a prognostic factor.

MATERIALS AND METHODS

We performed immunohistochemical staining for survivin, p53, bcl-2 protein, and Ki-67 in formalin fixed, paraffin-embedded blocks from 37 cases of head and neck ACC. We also reviewed the patients' clinical records to determine the association of staining with clinical course.

RESULTS

Of the 37 cases of head and neck ACC, 31 (83.8%) were positive for cytoplasmic survivin expression, and 23 (62.2%) were positive for nuclear survivin expression. There was a significant association between nuclear survivin expression and bcl-2 (P = 0.031). A larger tumor was more commonly a survivin-positive tumor (cytoplasmic survivin, P = 0.043; nuclear survivin, P = 0.057). Median overall survival (OS) was significantly longer in patients not expressing nuclear survivin (P = 0.035). A multivariate analysis revealed that nuclear survivin expression significantly impacted OS (hazard ratio 8.567, P = 0.018) in addition to lymph node involvement (hazard ratio 7.704, P = 0.016).

CONCLUSIONS

The immunohistochemical expression of nuclear survivin has a prognostic impact in patients with head and neck ACC. These results suggest that nuclear survivin expression may be a useful biomarker for predicting prognosis in patients with head and neck ACC who were treated with surgical resection.

Prognostic value of a three-grade classification in primary epithelial parotid carcinoma: result of a histological review from a 20-year experience of total parotidectomy with neck dissection in a single institution

BACKGROUND

The tumour grading of primary parotid cancers (PPCs) remains controversial.

METHODS

A 20-year standardised single centre treatment has been assessed retrospectively. The histological review of 155 consecutively treated parotid malignancies identified 96 suitable cases for univariate and multivariate survival analyses.

RESULTS

Treatment involved total parotidectomy, neck dissection and post-operative radiotherapy in, respectively, 91.7%, 83.3% and 70.4% of cases. The 5-year overall survival, disease-specific and recurrence-free survival rates were 79.4%, 83.5% and 70.8%, respectively. Univariate analysis confirmed the classical prognostic factors, i.e. age>60 years, male gender, facial palsy, hardness of the tumour, clinical stage, tumour grade, facial nerve invasion and lymph node metastases. Multivariate analysis identified a three-grade classification just after the clinical stage as the most important prognostic factor.

CONCLUSION

This study identifies the prognostic significance of intermediate grade tumours.

Cutaneous adenoid cystic carcinoma with perineural invasion treated by mohs micrographic surgery-a case report with literature review

We report a 58-year-old woman with cutaneous adenoid cystic carcinoma arising on the chest treated with Mohs micrographic surgery. The patient remained tumor-free at 24-month follow-up. To date, only six other cases of cutaneous adenoid cystic carcinoma were reportedly managed by Mohs surgery. Cutaneous adenoid cystic carcinoma has low potential for distant metastasis but is notorious for its aggressive infiltrative growth pattern, frequent perineural invasion, and high risk of local recurrence after excision. We propose that Mohs surgery is an ideal method to achieve margin-free removal of cutaneous adenoid cystic carcinoma. A brief literature review is provided.

Prognostic value of quantitative p63 immunostaining in adenoid cystic carcinoma of salivary gland assessed by computerized image analysis

BACKGROUND

In a long-term retrospective immunohistochemical study of adenoid cystic carcinoma (ACC) of salivary gland, we investigated the relation of p63 immunodetection to prognosis. Although it is generally agreed that the solid pattern is the most aggressive pattern of growth, ACCs with predominantly cribriform or tubular patterns have an unpredictable clinical course, with a relatively favorable 5-year survival but a low 20-year survival.

METHODS

Formalin-fixed paraffin sections from 35 cases of ACC showing a predominantly better differentiated histopathology, ie, cribriform or tubular patterns of growth, were immunostained for p63. Automated image analysis was used to quantify p63 positivity, using a modification of a previously developed algorithm.

RESULTS

Patients alive for more than 10 years had a lower extent of p63 expression than those who died of disease. Kaplan-Meier analysis revealed that separation of patients with morbidity and mortality from those alive with no evidence of disease, could be achieved at a cutoff of 35% p63 positivity (P = .0031, log-rank test). Multivariate analysis using the Cox proportional hazard model revealed p63 and tumor stage to be independent predictors of survival (P = .012 and P = .0003, respectively).

CONCLUSIONS

To our knowledge, the present study is the first to report prognostic significance of p63 in salivary gland ACC and the first report of a robust and well-studied immunohistochemical stain performable on routinely fixed and processed tissue with prognostic utility.

Differential expression of topoisomerase IIalpha protein in salivary gland carcinomas: histogenetic and prognostic implications

Background

Salivary gland carcinomas are relatively uncommon heterogeneous malignancies characterized by locoregional invasion and distant metastasis. Topoisomerase IIα (topoIIα), located at chromosome 17q21-22, is considered a major mediator of cell proliferation and DNA replication. The purpose of this study was to evaluate the expression of topoIIα in various types of salivary gland tumors and its biological significance.

Methods

The protein expression of topoIIα was evaluated immunohistochemically in formalin-fixed, paraffin-embedded tissue from 54 salivary gland carcinomas and 20 benign tumors (10 pleomorphic adenomas and 10 Warthin's tumors). The primary salivary gland carcinoma specimens consisted of 17 adenoid cystic carcinomas, 7 adenocarcinomas not otherwise specified, 7 mucoepidermoid carcinomas, 6 salivary duct carcinomas, 3 acinic cell carcinomas, 3 carcinomas ex pleomorphic adenomas, 3 epithelial-myoepithelial carcinomas, 2 carcinosarcomas, 2 lymphoepithelial carcinomas, 2 myoepithelial carcinomas, 1 oncocytic carcinoma, and 1 squamous cell carcinoma. The associations between clinicopathological factors and outcome were analyzed.

Results

Of the 54 primary salivary gland carcinomas, 38 (70%) showed positive expression (≥10%) of topoIIα protein, and 16 carcinomas (30%) and all benign tumors were negative (p < 0.001). Expression of topoIIα was more frequently observed in salivary duct carcinoma, carcinoma ex pleomorphic adenoma, adenocarcinoma, and adenoid cystic carcinoma, solid type, and it was associated with advanced stage and shortened survival.

Conclusion

The results of the present study suggest that topoIIα expression is associated with histologically aggressive subtypes and shortened survival. Furthermore, it may provide useful prognostic information and suggests the potential efficacy of topoIIα-targeting therapy in patients with salivary gland carcinoma.

Effects of silencing Id-1 in cell culture of human adenoid cystic carcinoma

Adenoid cystic carcinoma (ACC) is a slow growing but highly invasive cancer with a high recurrence rate. Id (inhibitor of DNA binding) proteins are dominant regulators of basic helix-loop-helix transcription factors that control malignant cell behavior in many different tissues. This study aimed to identify the potential role of inhibiting DNA binding-1 (Id-1) in human salivary adenoid cystic carcinoma (SACC) progression. First, we compared the Id-1 protein expression in a human salivary adenoid cystic carcinoma cell line (ACCM) against three other cell lines and found that Id-1 protein expression in ACCM to be significantly higher. Then we measured Id-1 mRNA and protein expression in ACCM before and after RNA interference (RNAi), which showed successful inhibition of Id-1. Further studies then demonstrated that the proliferation and invasiveness of ACCM cells were dramatically down-regulated, and increased numbers of apoptotic cells were detected after Id-1 silencing. Consequently, our data suggest that Id-1 is a potential target in the treatment of human salivary adenoid cystic carcinoma.

Expression of RUNX3 in salivary adenoid cystic carcinoma: implications for tumor progression and prognosis

Runt-related transcription factor-3 (RUNX3), being a tumor suppressor gene in gastric cancer, plays an important role in inhibiting cellular growth by participating in the transforming growth factor-beta-dependent apoptosis. The aim of this study was to determine the expression of RUNX3 in normal salivary glands and adenoid cystic carcinomas (ACCs), comparing the results with clinicopathological factors and patient survival. The quantitative reverse transcription-polymerase chain reaction (RT-PCR) analysis and Western blot analysis revealed the expression of RUNX3 both in normal salivary glands and ACCs. Nuclear and cytoplasmic immunoreactivities against RUNX3 in ductal luminal cells and acinous cells, but immunonegative in myoepithelial cells, were detected in normal salivary glands. In ACC, the RUNX3 immunostaining was shown in the cytoplasm of tumor cells; however, no nuclear location of RUNX3 was found. Lower RUNX3 expression showed significant correlation to distant metastasis and histological growth pattern (P = 0.009 and P = 0.025, respectively). On univariate analysis, low level of RUNX3 immunolabeling (P = 0.012), stage T4 (P = 0.017), lymph node involvement (P = 0.007), and distant metastasis (P < 0.001) were significantly associated with decreased overall survival. Multivariate analysis showed only distant metastasis had an independent prognostic effect on overall survival (P = 0.043). Our results demonstrate the expression of RUNX3 in normal salivary glands and salivary ACCs. The low level of RUNX3 protein in salivary ACCs might play a pivotal role in tumor progression and have prognostic values in ACCs.

Salivary gland cancers: current treatments, molecular characteristics and new therapies

Salivary gland cancers are relatively rare and quite diverse. Current therapy relies on local ablation. There are few large clinical trials or randomized trials to guide treatment, especially for metastatic disease. This article reviews the epidemiology, staging, molecular characteristics, and treatment evidence for the most common types of salivary cancers and suggests potential future diagnostic and treatment directions. Progress in understanding the molecular and cell biology of salivary gland cancers may lead to the development of targeted therapies in these rare tumors. Multidisciplinary and multi-institutional collaborative studies are needed to help improve survival in salivary gland cancers.

Utility of high molecular weight cytokeratins, but not p63, in the differential diagnosis of neuroendocrine and basaloid carcinomas of the head and neck

High-grade neuroendocrine carcinomas of the head and neck overlap significantly in morphology with both basaloid squamous and solid-type adenoid cystic carcinomas. High-grade neuroendocrine carcinomas have sheets of small cells with scant cytoplasm, granular chromatin, and inconspicuous nucleoli. Basaloid squamous and adenoid cystic carcinomas are aggressive variants of their respective tumor types which both have nests of basaloid tumor cells with round nuclei, little cytoplasm, and inconspicuous nucleoli. As the management and prognosis of these tumors are very different, it is important to differentiate them. We performed high molecular weight cytokeratin (CK) and p63 immunohistochemistry on 19 neuroendocrine carcinomas, 18 basaloid squamous carcinomas, and 11 solid-type adenoid cystic carcinomas. All tumors were immunostained for p63, CK 34betaE12, CK 5/6, synaptophysin, chromogranin-A, S-100, and smooth muscle actin. All basaloid squamous and adenoid cystic carcinomas were positive for CK 5/6 and 34betaE12. Only 4 and 5 of the 19 neuroendocrine carcinomas, respectively, were positive for these markers. Staining was focal in the neuroendocrine cases when positive, whereas almost all basaloid squamous and adenoid cystic carcinomas showed strong staining. Almost all tumors of each type were positive for p63, including neuroendocrine carcinomas, but with different staining patterns. Basaloid squamous carcinomas were diffusely positive, neuroendocrine carcinomas were diffusely positive, but with weak staining, and adenoid cystic carcinomas showed a distinct pattern with staining at the periphery of the cell nests only. We conclude that high molecular weight cytokeratin immunostaining is helpful in distinguishing high-grade neuroendocrine carcinomas from similar tumor types.

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

Background

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

Case presentation

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

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

Conclusion

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

Expression of thymidylate synthase and dihydropyrimidine dehydrogenase in adenoid cystic carcinoma of the head and neck: Correlation with clinical outcome

The purpose of this study was to estimate the possibility of using thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD), and p53 as predictive values of clinical outcome in adenoid cystic carcinoma (ACC). The expressions of TS, DPD, and p53 were examined with immunohistochemistry in 27 ACC patients, and the association with clinicopathological factors was determined. Cases with high DPD expression had significantly higher distant metastasis rates compared to those with low DPD expression (p=0.001), whereas neither TS nor p53 expression showed any significant correlation to clinicopathological factors. Interestingly, six of 14 early-stage patients had distant metastases and all of their tumors showed high DPD expression. Kaplan-Meier analysis revealed that a solid histological pattern and distant metastasis correlated with a poor prognosis. In early-stage patients, whose tumor was completely resected, those with high TS or DPD expression had a worse prognosis compared to those with low expression, but the difference did not reach statistical significance (TS, p=0.178; DPD, p=0.251). Our results suggest that assessment of DPD expression in ACC may be a useful tool in determining the mode of treatment as well as evaluating clinical outcome.

Overexpression of cyclin D1 and cortactin is primarily independent of gene amplification in salivary gland adenoid cystic carcinoma

Adenoid cystic carcinoma (ACC) of the salivary glands exhibits persistent growth, invasion and metastasis. Chromosome 11q13 amplification is a frequent event associated with tumor progression in a number of carcinomas and is associated with poor prognosis. Two genes within the 11q13 amplicon that are overexpressed as a result of 11q13 amplification are the cell cycle regulatory protein cyclin D1 (CCND1) and cortactin (CTTN), a protein involved cell motility and invasion. To determine the expression and gene status of cyclin D1 and cortactin in ACC, we evaluated 39 ACC cases by immunohistochemistry (IHC) for cyclin D1 and cortactin expression. Amplification of CCND1 and CTTN was determined by fluorescent in situ hybridization (FISH). Cyclin D1 overexpression was present in 90% (35/39) and cortactin expression in 62% (24/39) of evaluated cases, although CCND1 and CTTN levels were elevated in only two cases (5%) as determined by FISH. Our results indicate that chromosome 11q13 amplification is uncommon in ACC, but that cyclin D1 and cortactin are frequently overexpressed and may therefore contribute to the growth and invasive potential of ACC.

Salivary gland adenoid cystic carcinoma: A review of chemotherapy and molecular therapies

Adenoid cystic carcinoma (ACC) accounts for about 1% of all head and neck malignancies. It has a tendency for a prolonged clinical course, with local recurrences and distant metastases sometimes occurring many years after presentation. Standard treatment for salivary gland ACC is surgery and post-operative radiotherapy. The aim of this review was to examine the reported efficacy of various chemotherapy regimens and molecular therapies on recurrent/metastatic salivary gland ACC. One hundred and fourteen publications were reviewed on chemotherapy as well as possible molecular targets of therapy, including KIT, epidermal growth factor receptor (EGFR), human epidermal growth receptor-2 (HER-2), oestrogen and progesterone receptors, proliferating cell nuclear antigen (PCNA), Ki-67 and the p53, bcl-2 and SOX-4 genes. Reported response rates to combination chemotherapy are low and response duration generally short lived. The response to molecular therapies is low also. More research into novel molecular targets is needed.

Genes associated with early development, apoptosis and cell cycle regulation define a gene expression profile of adenoid cystic carcinoma

Adenoid cystic carcinoma (ACC) is an uncommon salivary gland malignancy characterized by indolent yet relentless growth that exhibits inherent resistance to systemic chemotherapy, surgical salvage and conventional radiotherapy. We used microarray analysis to characterize gene expression changes associated with ACC. Eight ACC patient specimens were compared with normal parotid gland tissue and the ACC3 cell line. Differentially expressed genes were identified (512 total) using supervised analysis methods and functional categories assigned using OntoExpress. Genes associated with morphogenesis, neurogenesis, proliferation and apoptosis characterized ACC tumors. Genes associated with saliva production and immune response characterized normal parotid tissues while the ACC3 cell line expressed genes primarily associated with proliferation, chromosome maintenance and the cell cycle. These results demonstrate that ACC tumors express genes associated with early developmental processes including morphogenesis and neurogenesis implicating oncogenic events that result in dedifferentiation of normal salivary glands.

Prognostic factors in head and neck adenoid cystic carcinoma

The aim of this study was to analyse the clinical, histological and immunohistochemical prognostic factors of a large series of adenoid cystic carcinoma, using univariate and multivariate survival analyses. All cases of head and neck ACC (n = 129) treated in a single institution in Brazil, between 1955 and 1997, were selected for the study. Univariate survival analysis revealed that age older than 45 years (p = 0.04), period of complaints inferior to 18 months (p = 0.007), presence of paresthesia (p = 0.04), T stage (p = 0.01), N stage (p = 0.04), M stage (p < 0.001), clinical stage (p = 0.003), solid histological type ( p< 0.001), presence of residual tumor (p < 0.001) and expression of p53 (p = 0.08) correlated with a poor prognosis. In the multivariate survival analyses, clinical stage, solid histological subtype and increased expression of p53 were independent significant prognostic factors. According to our findings, clinical stage, solid growth pattern and expression of p53 were the most important prognostic factors in patients with ACC.

p53, bcl-2 and Ki-67 expression in adenoid cystic carcinoma of the palate. A clinico-pathologic study of 21 cases with long-term follow-up

Adenoid cystic carcinoma (ACC) is an indolent tumor that pursues a protracted clinical course with recurrences and late metastases. The aim of this study was to investigate immunohistochemically the expression of p53, bcl-2 protein, and Ki-67 in 21 cases of ACC of the palate, all with a minimum of 10 years and a maximum of 22 years of clinical follow-up. These results were also analyzed with regard to different clinical prognoses of the histologic subtypes of ACC. High expression of p53 and bcl-2 was noted in 19 out of 21 ACC cases (90%), in which most tumor cells (from 66% to 99%) proved to be immunopositive. A relation to the histologic types, clinical staging, and survival was not found. Therefore, the high immunoreactivity against these oncoproteins in the same tumor cells suggests that these two oncogenes may be involved since the early stage of carcinogenesis. Loss of function of the p53 protein combined with bcl-2 upregulation might give the tumor cells a double growth advantage, because uncontrolled proliferation is combined with a reduced cell death rate. The interaction with other oncogenes may then trigger a multistep process able to promote tumor progression. The low labeling index Ki-67 was detected in nine out of 21 cases (42%), with a low percentage of tumor cells (from 3% to 15%) being positive, whereas the remaining 12 cases were negative. We found no relation to the histologic types, clinical staging, and survival; however, the low proliferation rate could explain the natural course of tumor.

Radiotherapy alone or combined with surgery for adenoid cystic carcinoma of the head and neck

BACKGROUND

The purpose of this study was to analyze the results of radiotherapy (RT) alone or combined with surgery for adenoid cystic carcinoma.

METHODS

Between September 1966 and November 2001, 101 previously untreated patients were treated with curative intent with RT alone or combined with surgery. Follow-up ranged from 0.4 to 30.6 years (median, 6.6 years). All living patients had follow-up for at least 1 year.

RESULTS

The 5- and 10-year rates of local control were as follows: RT alone, 56% and 43%; surgery and RT, 94% and 91%; and overall, 77% and 69%. Multivariate analysis of local control revealed that T stage (p=.0101) and treatment group (p=.0008) significantly influenced this endpoint. The 5- and 10-year rates of distant metastases-free survival were 80% and 73%. The 5- and 10-year absolute survival rates were as follows: RT alone, 57% and 42%; surgery and RT, 77% and 55%; and overall, 68% and 49%. Multivariate analysis of absolute survival revealed that T stage (p=.0043) and clinical nerve invasion (p=.0011) significantly influenced this endpoint. The 5- and 10-year cause-specific survival rates were as follows: RT alone, 65% and 48%; surgery and RT, 81% and 71%; and overall, 74% and 61%. Multivariate analysis revealed that T stage (p=.0008) and clinical nerve invasion (p=.0005) significantly influenced cause-specific survival.

CONCLUSIONS

The optimal treatment for patients with adenoid cystic carcinoma is surgery and adjuvant RT. A significant proportion of patients with incompletely resectable disease are cured after RT alone. Improvements in locoregional control are offset, in part, by the relatively high incidence of distant metastases.