Multivariate prediction of the probability of recurrence in patients with carcinoma of the parotid gland

Recurrence after primary salivary gland carcinoma: Frequency, survival, and risk factors

BACKGROUND

Primary salivary gland carcinomas (SGC) are rare neoplasms that present therapeutic challenges especially in recurrent tumors. The aim of this study was to investigate the incidence and distribution of tumor recurrence, associated risk factors, and survival.

METHODS

This analysis includes data from 318 patients treated for SGC between 1992 and 2020. Survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate analyses were used to identify risk factors associated with recurrence.

RESULTS

21.7% of the patients developed recurrent disease after a mean of 38.2 months. In multivariate analysis, positive-resection margins, vascular invasion, and tumor localization in the submandibular gland and small salivary glands were independent factors for recurrence. The 5-year overall survival was 67%, the 5-year disease-free survival was 54%.

CONCLUSION

Tumor recurrence in SGC occurred in one out of five patients. In highly aggressive entities and patients with risk factors, treatment intensification should be considered.

Intraparotid node metastasis affects the long-term survival of patients with resectable recurrent parotid gland carcinoma

PURPOSE

The recurrence rate of parotid gland cancer is high, but research on the prognosis of recurrent parotid gland cancer (RPC) is relatively limited. We aim to determine the potential prognosis factors of RPC.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Tertiary cancer center.

METHODS

We conducted a retrospective review from 2012 to 2021 on RPC patients treated at the China National Cancer Center (CNCC). To analyze the impact of various variables on overall survival (OS) after recurrence, a univariate and multivariate Cox proportional hazard model was employed.

RESULTS

A total of 50/218 (23.0%) patients diagnosed with RPC and underwent surgery. The 5-year OS of all RPC patients in this cohort was 61.9%. 5 of 50 patients (10%) exhibited intraparotid node (IPN) metastasis. By univariate and multivariate analyses, we found that IPN metastasis was one of the prognostic factors of OS (p = 0.039) in RPC patients. The presence of IPN metastasis was also related to poor survival in individuals with negative cervical lymph nodes (CN0) (p = 0.011). In terms of the influence of surgical margins on prognosis, our findings revealed that RPC patients with negative margins exhibited a higher survival result than those with positive margins (p = 0.002).

CONCLUSION

According to this study, IPN metastasis indicate a high incidence of mortality in recurrent parotid cancer patients. Particularly, in CN0 patients, the presence of IPN metastasis was associated with poor survival in CN0 patients.

Prognostic Assessment and Risk Stratification in Patients With Postoperative Major Salivary Acinar Cell Carcinoma

OBJECTIVE

To investigate the clinicopathological features and prognosis of postoperative major salivary acinar cell carcinoma (MSACC) and develop a prognostic model.

STUDY DESIGN

Retrospective cohort analysis of a public database.

SETTING

Patients with MSACC were identified from the Surveillance, Epidemiology, and End Results database (1975-2019).

METHODS

Overall survival (OS) was evaluated using Kaplan-Meier curves and a log-rank test. Univariate and multivariate Cox analyses were performed to explore independent prognostic factors. The prognostic model was constructed using screened variables and further visualized with a nomogram and web calculator, and assessed by concordance index, the area under the curve, calibration curve, and decision-making curve analysis.

RESULTS

An upward trend in the incidence of MSACC was observed throughout the study period. A total of 1398 patients were enrolled (training cohort: 978; validation cohort: 420), and the 5- and 10-year OS rates were 97.7% and 81.6%, respectively. Age, marital status, sex, histological grade, T stage, and lymph node status were identified as prognostic factors for OS. A novel nomogram was developed and showed excellent discrimination and clinical applicability. Additionally, a web calculator was designed to dynamically predict patient survival. Based on the nomogram-based score, a risk stratification system was constructed to distinguish patients with different risks. The OS of high-risk patients was significantly lower than that of the low-risk subgroup.

CONCLUSION

Long-term survival in postoperative MSACC was influenced by 6 prognostic factors. The proposed model enables individualized survival prediction and risk stratification, prompting us to be vigilant in high-risk subgroups and consider timely adjustment of subsequent treatment.

Role of Intra-Parotid Lymph Node Metastasis in Primary Parotid Carcinoma

The parotid gland contains intra-glandular lymph nodes, the distribution of which is crucial for understanding the pathogenesis of intra-parotid lymph node metastases of parotid carcinoma and other head and neck carcinomas. Positive intra-parotid lymph node metastasis predicts the risk of positive cervical nodal metastasis. It is important to establish whether prophylactic neck dissection, including intra-parotid lymph nodes, contributes to treatment outcomes. The presence or absence of intra-parotid lymph nodes or metastasis-positive lymph nodes warrants further study. A preoperative diagnosis by imaging and fine-needle aspiration cytology of intra-parotid lymph nodes is difficult. Although intraoperative frozen section biopsy is performed during surgery, it is challenging to identify intra-parotid lymph nodes. The number of lymph nodes was the largest (47%) in the lower half of the superficial lobe, with 35% of nodes being concentrated in the inferior part of the cervicofacial branch, i.e., the lower pole of the parotid gland. Therefore, superficial parotidectomy and lower pole lobectomy need to be performed in cases in which a malignant tumor localizes to the superficial lobe or a lower pole. When intra-parotid lymph node metastases are detected during surgery, selective neck dissection (at least levels II and III) needs to be simultaneously performed.

Survival Outcome of Salivary Gland Carcinoma: A 50-Year Retrospective Study With Long-Term Follow-up

PURPOSE

Salivary gland carcinomas (SGCs) can be classified into more than 20 subtypes with various clinical behaviors. The present study aimed to analyze the clinical and pathological features of SGCs and evaluate their long-term prognosis.

METHODS

A retrospective cohort study was performed. This study investigated cases of histologically confirmed SGC at the authors' institution from January 1963 to December 2014. Data on sex, age, site, histopathological diagnosis, tumor-node-metastasis classification, postoperative radiotherapy and/or chemotherapy, local and regional recurrence, and distant metastasis (DM) were collected as covariates. The overall survival (OS) rate was analyzed as the outcome. Kaplan-Meier survival analysis and Cox multivariate analysis were used for survival analysis. The cohort was divided into 2 groups-before and after 1989. The clinicopathological characteristics of the 2 groups were compared using the χ² test.

RESULTS

The cohort included 1,637 patients who met the admission criteria and had a male-to-female ratio of 0.9:1. The median age was 47 years (range, 8 months to 86 years). The median follow-up time was 54 months (range, 1-432 months). The majority of the tumors occurred in the parotid gland (35.3%), followed by the palate gland (25.2%). Adenoid cystic carcinoma was the most common tumor type (34.3%), and mucoepidermoid carcinoma (29%) was the second most common type. In the 1,637 patients, the neck lymph node metastasis rate was 8.7% at the first surgery, and the overall DM rate was 14.1%. The 5-, 10-, and 15-year OS rates of the 1,637 cases were 93.1%, 87.2%, and 79.3%, respectively. Comparative analysis before and after 1989 showed statistically significant differences in sex, site, histologic subtype, T classification, local and regional recurrence rate, and radiotherapy (P < .05), while no significant differences were found in age, N classification, M staging, DM, or chemotherapy.

CONCLUSIONS

The OS rates of SGC have improved significantly over the past 30 years. This is attributable to an increase in the proportion of patients diagnosed at the early stage and receiving radiotherapy, as this has led to a reduction in the local and regional recurrence rate and, consequently, an improvement in the survival rates.

Estimating survival after salvage surgery for recurrent salivary gland cancers: Systematic review

Recurrent salivary gland carcinomas (RSCs) are poorly characterized and their clinical features and treatment options have not yet been fully described. The goal of this study was to analyze the therapeutic strategies and oncological outcomes of RSC patients through a literature review analysis. This systematic review was performed according to the PRISMA statements. Inclusion criteria for the systematic review were based on the population, intervention, comparison, and outcomes according to (PICO) framework. Two thousand seven hundred and four records were selected and 1817 recurrences were studied. Three hundred and sixty-five patients underwent salvage surgery (20.1%) and their 5-year mortality rate, overall survival and disease-free survival were 35%, 70%, and 42%, respectively. RSCs are aggressive neoplasms with a high rate of distant metastases (28.9%). Salvage surgery can be considered in patients with limited local and/or regional recurrences, even in case of single distant relapse, appearing within the first 3 years of follow-up.

[Surgery for parotid gland cancer-controversial and proven aspects]

BACKGROUND

Due to the rarity of primary parotid malignancies, there are currently only limited clinical study data on the optimal surgical therapy. Parotid malignancies encompass a broad spectrum of more than 20 different histological subtypes with varying biology, which thus represents a challenge for even experienced pathologists and head and neck surgeons with proven expertise in salivary gland surgery.

OBJECTIVE

The aim of this review article is to provide an overview of the current literature on surgical therapy of the primary tumor and the cN0 neck as well as treatment of the facial nerve, and to shed light on the various controversial aspects of this topic.

RESULTS

In salivary gland oncology there is a trend towards safe (R0) but more conservative surgery. Currently, less-invasive surgical approaches could potentially be applied in a small subgroup with carefully selected caudally located and R0-resected "low-grade tumors" in stages T1-T2 and cN0 in relatively young patients with high compliance and more in the context of structured clinical studies. Elective neck dissection in the case of cN0 status should be carried out if risk factors for occult cervical lymph node metastasis (T3-T4a, "high-grade subtypes," advanced age, lymphangitic carcinomatosis) are present. In cases of small "low-grade parotid carcinomas," narrow resection margins or even microscopic tumor residues on the facial nerve can potentially be adequately compensated with adjuvant radiation therapy. However, due to the lack of solid data, the significance of the actual effect of the radiation in this situation should be viewed with great caution.

The role of total parotidectomy in high-grade parotid malignancy: A multisurgeon retrospective review

PURPOSE

Determine rates of intra-parotid and neck nodal metastasis, identify risk factors for recurrence, and report outcomes in patients with primary high-grade parotid malignancy who undergo total parotidectomy and neck dissection.

MATERIALS & METHODS

Retrospective review of patients undergoing total parotidectomy and neck dissection for high-grade parotid malignancy between 2005 and 2015. The presence and number of parotid lymph nodes, superficial and deep, as well as cervical lymph nodes involved with metastatic disease were assessed. Risk factors associated with metastatic spread to the parotid deep lobe were identified and recurrence rates reported.

RESULTS

75 patients with median follow-up time of 47 months. 35 patients (46.7%) had parotid lymph node metastasis. Seven patients (9.3%) had deep lobe nodal metastasis without metastasis to the superficial lobe nodes. Nine patients (12%) had positive intra-parotid nodes without positive cervical nodes. Cervical nodal disease was identified in 49.3% patients (37/75). Local, parotid-bed recurrence rate was 5.3% (4/75). Regional lymph node recurrence rate was also 5.3% (4/75). Rate of distant metastasis was 30.6% (23/75). The overall disease free survival rate for all patients at 2 and 5 years were 71% and 60% respectively.

CONCLUSION

Parotid lymph node metastasis occurred at a similar rate to cervical lymph node metastasis (46.7% and 49.3%, respectively). Deep lobe parotid nodal metastasis occurred in nearly a quarter of patients and can occur without superficial parotid nodal metastasis. Rate of recurrence in the parotid bed, which may represent local or regional recurrence, was similar to regional cervical lymph node recurrence. Total parotidectomy and neck dissection should be considered high-grade parotid malignancy regardless of clinical nodal status.

Is Revision Surgery Necessary for Patients With High Risk of Recurrence After Parotidectomy? A Multicenter Retrospective Study

OBJECTIVES

Close margin is a frequent situation after parotidectomy. The need for systematic prophylactic revision surgery is a question that arises regularly for malignant tumors, as it exposes to a high risk of facial palsy, while oncological benefits are unclear.

STUDY DESIGN

retrospective study.

SETTING

Multicentric.

SUBJECTS AND METHODS

We included all patients operated for systematic revision surgery in case of close margins after parotidectomy for a malignant tumor and analyzed the rate of tumor residue and its risk factors.

RESULTS

A tumor residue was identified in 43.5% of 23 cases, but none in case of initial complete excision with supra-millimetric margins. Invaded lymph nodes were identified in 6 cases, but none in case of low-grade tumors.

CONCLUSIONS

Systematic revision seems mandatory in case of infra-millimetric margins and high-grade tumors or positive lymph node; further studies are needed to confirm whether it can be spared for T1-T2/N0 low-grade tumors, with close margins but complete initial excision.

Prognostic scoring models in parotid gland carcinoma

BACKGROUND

The aim was to identify prognostic factors and test three prognostic scoring models that predicted the risk of recurrence in patients with parotid gland carcinoma.

METHODS

All Danish patients with parotid gland carcinoma, treated with curative intent, from 1990 to 2015 (n = 726) were included. Potential prognostic factors were evaluated using Cox regression and competing risk analyses. The concordance of each prognostic model was estimated using Harrel's C index.

RESULTS

The study population consisted of 344 men and 382 women, with a median age of 63 years. Age above 60 years, high grade histology, T3/T4 tumor, regional lymph node metastases, and involved surgical margins were all associated with a significant reduction in recurrence-free survival. The prognostic model that agreed best with actual outcomes had a C-index of 0.76.

CONCLUSION

Prognostic scoring models may improve individualized follow-up strategies after curatively intended treatment for patients with parotid gland carcinoma.

Prediction of Minor Salivary Gland Carcinoma: A Novel Nomogram and Risk Classification System for Overall Survival and Cancer-Specific Survival

OBJECTIVE

Minor salivary gland carcinoma (MiSGC) is rare, and the understanding of this disease is insufficient. This study aimed to identify independent risk factors and develop a nomogram for evaluating the overall survival (OS) and cancer-specific survival (CSS) of patients with MiSGC.

STUDY DESIGN

Retrospective cohort study.

SETTING

SEER database (Surveillance, Epidemiology, and End Results).

SUBJECTS AND METHODS

We collected data from patients diagnosed with MiSGC between 2004 and 2015 from the SEER database. According to patient registration, all patients were randomly allocated to training sets and validation sets (2:1). Then, Kaplan-Meier product limit curves and Cox proportional hazard regressions were performed to estimate the prognostic effect of variables. Nomograms based on Cox proportional hazard regressions were established to estimate 3- and 5-year OS and CSS. Finally, the nomogram was developed by the training set, and validation was performed with the concordance index, calibration curves, and decision curve analyses.

RESULTS

In total, 1787 MiSGC cases were registered in SEER. The concordance index for internal validation of OS and CSS prediction was 0.842 and 0.816; that of external validation was 0.871 and 0.831. The calibration plots showed good consistency between nomogram prediction and actual survival. The decision curve analysis showed substantial net benefits of the new predictive model.

CONCLUSIONS

We constructed nomograms and a corresponding risk classification system predicting the OS and CSS of patients with MiSGC. These tools can generate simple-to-use clinical risk grouping and determine the relationship between adjuvant therapy and active surveillance.

The Benefits of Adjuvant Trastuzumab for HER-2-Positive Salivary Gland Cancers

BACKGROUND

Although high-grade salivary gland cancers (SGCs) often express androgen receptor (AR) and/or HER-2/neu, therapeutically targeting these receptors in SGC remains investigational. We investigated the prevalence of receptor expression and the benefit of adjuvant HER-2 directed therapy in the high-risk postoperative setting and explored the clinical utility of sequentially targeting these receptors in the setting of advanced disease.

MATERIALS AND METHODS

We clinically annotated 95 patients with SGC (excluding adenoid cystic carcinoma) treated at our institution from 2002 to 2019 and recorded AR, HER-2/neu status, and tumor genomic profiling results when available. Clinicopathologic information was then integrated with outcomes.

RESULTS

Of 95 patients, most had high-risk histologies, with salivary duct carcinoma (SDC) as the most frequent diagnosis (43, 45%). Thirty-five (37%) experienced recurrence (51% SDC). HER-2/neu was positive (1-3+) by immunostaining in 34 of 52 (65%) evaluable cases. There was no difference in survival based on HER-2/neu or AR expression. Nine of 17 (53%) patients with HER-2+ SDC received adjuvant chemoradiation with trastuzumab. Median disease-free survival (DFS) and overall survival (OS) were longer among patients with HER-2/neu 3+ staining tumors who received adjuvant trastuzumab versus those who did not (DFS, 117 vs. 9 months; p = .02; OS, 74 vs. 43 months; p = .02), with no difference among other HER-2/neu subgroups (0-2+). Two of nine (22%) patients treated with adjuvant trastuzumab demonstrated recurrence, both with low HER-2/neu staining intensity (1+). Longer time to recurrence (hazard ratio, 0.94; p = .01) predicted improved outcomes. Both androgen deprivation and HER-2-directed therapies had clinical benefit beyond the first-line metastatic setting, with partial response observed beyond second-line use.

CONCLUSION

Although prospective data are lacking, the use of adjuvant trastuzumab in high-risk patients with SGC appears beneficial, particularly among patients with tumors exhibiting HER-2/neu 3+ immunostaining.

IMPLICATIONS FOR PRACTICE

Results of this study showed an improved disease-free and overall survival in patients treated with adjuvant trastuzumab for high-risk salivary gland cancers with strong HER-2/neu staining intensity. Following recurrence or metastatic spread, sequential HER-2, and androgen-directed therapies may benefit certain patients with salivary gland cancer.

Surgical extent and role of adjuvant radiotherapy of surgically resectable, low-grade parotid cancer

BACKGROUND

Due to the rarity of low-grade parotid gland cancer and the diversity of histologic subtype, its optimal treatment modalities and prognostic factors have not been established yet. In this study, we aimed to identify the prognostic factors and adequate treatment modalities for patients with low-grade parotid gland cancer.

METHODS

We retrospectively analyzed clinico-pathologic data from 287 patients with low-grade parotid gland cancer from 1999 to 2018.

RESULTS

Recurrence-free survival, disease-specific survival, and overall survival rates at 10 years were 80.6%, 93.9%, and 84.4%, respectively. Among all patients, 56.1% received surgery alone, and the remaining 43.9% received surgery with adjuvant radiotherapy. Resection margin status and TNM stage were significant unfavorable prognostic factors. In patients with T1-2 tumor, surgical extent (total vs. less-than-total) did not show any significant effect on disease recurrence and patients' survival, and the disease was controlled well if a negative surgical margin was obtained after surgery, even with microscopic clear margin of<1 mm. In patients with adverse pathologic features (positive margin, lymphovascular invasion, perineural invasion, extracapsular nodal spread, T3-4, and N1-3), adjuvant radiotherapy significantly decreased loco-regional recurrence.

CONCLUSIONS

Oncological outcomes were good in patients with low-grade parotid gland cancer with surgery and radiotherapy. In patients with T1-2 low-grade parotid gland cancer, surgery alone showed good local control rate regardless of the extent of surgery, if a negative surgical margin was obtained after surgery. Adjuvant radiotherapy played a significant role in controlling loco-regional recurrence in patients with adverse pathologic features.

Major and minor salivary gland tumours

Salivary glands carcinomas are very rare epithelial malignant tumors. In 2013 in Europe, 7800 new diagnoses were estimated, 8.5 % of all head and neck cancer. The last WHO classification (2017) counts more than 20 malignant histotypes, this variety as well as the rarity of some of them needs a skilled pathologist for diagnosis. Surgery remains the mainstay of management followed by radiation in high-grade and high-risk pathological features cases. The intensity modulated radiotherapy (IMRT) should be preferred over conformational radiotherapy techniques as adjuvant and exclusive treatment in advanced cases. Particle radiotherapy (i.e. protons, carbon ions) can have a role in advanced/unresectable disease since it was proved to have better results over photons in loco-regional control both in adenoid cystic carcinoma and in other histotypes. Although chemotherapy is still the most frequent treatment for metastatic patients, several new compounds (i.e. anti-angiogenic agents, tailored agents, checkpoint inhibitors) are under investigation.

Outcomes and prognostic factors in parotid gland malignancies: A 10-year single center experience

OBJECTIVES

To describe a 10-year single center experience with parotid gland malignancies and to determine factors affecting outcomes.

STUDY DESIGN

Retrospective review.

METHODS

The institutional cancer registry was used to identify patients treated surgically for malignancies of the parotid gland between January 2005 and December 2014. Clinical and pathologic data were collected retrospectively from patient charts and analyzed for their association with overall survival (OS) and disease-free survival (DFS).

RESULTS

Two hundred patients were identified. Mean age at surgery was 57.8 years, and mean follow-up time was 52 months. One hundred two patients underwent total parotidectomy, while 77 underwent superficial parotidectomy, and 21 underwent deep lobe resection. Seventy patients (35%) required facial nerve (FN) sacrifice. Acinic cell carcinoma was the most common histologic type (22%), followed by mucoepidermoid carcinoma (21.5%) and adenoid cystic carcinoma (12.5%). Twenty-nine patients (14.5%) experienced recurrences, with mean time to recurrence of 23.6 months (range: 1-82 months). Five- and 10-year OS were 81% and 73%, respectively. Five- and 10-year DFS were 80% and 73%, respectively. In univariate analyses, age > 60, histologic type, positive margins, high grade, T-stage, node positivity, perineural invasion, and FN involvement were predictors of OS and DFS. In the multivariate analysis, histology, positive margins, node positivity, and FN involvement were independent predictors of OS and DFS.

CONCLUSIONS

Our single-center experience of 200 patients suggests that histology, positive margins, node positivity, and FN involvement are independently associated with outcomes in parotid malignancies.

LEVEL OF EVIDENCE

4.

Intermediate-grade carcinoma of the parotid and the impact of adjuvant radiation

PURPOSE

To determine the influence of adjuvant radiotherapy on survival in surgically-managed early stage intermediate-grade mucoepidermoid and acinic cell carcinoma of the parotid.

MATERIALS AND METHODS

The National Cancer Database was reviewed between 2004 and 2015 to identify patients with intermediate-grade, early T-stage, node-negative parotid carcinoma who underwent parotidectomy ± radiotherapy.

RESULTS

There were 744 patients identified of which 81% had mucoepidermoid carcinoma and 19% had acinic cell carcinoma. Positive surgical margins were identified in 21% and adjuvant radiotherapy was administered in 38% of cases. Of the 159 patients with positive margins, 113 (71%) received adjuvant radiotherapy. Of the 585 patients with negative margins, 173 (30%) underwent adjuvant radiotherapy. In multivariable analysis, age (over 52 years: HR 5.19, 95%CI 2.33-11.57), insurance status (private insurance: HR 0.24 95%CI 0.13-0.43), and extent of parotidectomy (total parotidectomy: HR 2.02 95%CI 1.23-3.31) were significantly associated with overall survival, while adjuvant radiotherapy was not a significant predictive factor (HR 0.81, 95%CI 0.49-1.36). In patients with positive margin resections, however, adjuvant radiation was an independent predictor of improved survival when adjusted for age, insurance status, and extent of parotidectomy (HR 0.34, 95%CI 0.13-0.88). Conversely, in patients with negative margin resections, adjuvant radiation did not influence survival outcomes when adjusted for these covariates (HR 1.02, 95%CI 0.53-1.93).

CONCLUSIONS AND RELEVANCE

In patients with early stage intermediate-grade parotid carcinoma, adjuvant radiotherapy significantly and independently improves survival in those with post-operative positive margins. Adjuvant therapy, however, does not appear to improve survival outcomes in those with negative margin resections.

Nomograms predictive for oncological outcomes in malignant parotid tumours: recurrence and mortality rates of 228 patients from a single institution

PURPOSE

Malignant parotid tumours are rare and multiple prognostic factors exist.

METHODS

Through a retrospective study we aimed to identify nomograms predicting recurrence and mortality rates in 228 primary parotid cancers. Patients clinical, treatment and tumour characteristics were retrospectively collected between 1980 and 2005 at our Institution. Factors predictive of disease-free-specific-survival (DSS) and overall survival (OS) were calculated by univariate and multivariate analysis. Nomograms were then constructed.

RESULTS

The 5- and 10-year DSS rates were 73% and 71.4%, and nomogram was drawn based on five parameters where perineural invasion showed the most significant predicting influence (p < 0.001). The median follow-up was of 95 months and the 5- and 10-year OS rates were 68.7% and 53.1%; six predictive variables (age, histological grade, perineural invasion, pathological lymph node status, resection margins and distant metastasis) were used to create nomogram.

CONCLUSIONS

Our nomograms provide a tailored outcome to a patient affected by malignant parotid tumour and give him/her a risk assessment for recurrence and mortality based on individual factors by a concordance index > 0.8.

Validation of nomograms for overall survival, cancer-specific survival, and recurrence in carcinoma of the major salivary glands

BACKGROUND

The purpose of this study was to investigate the performance of the Memorial Sloan Kettering Cancer Center salivary carcinoma nomograms predicting overall survival, cancer-specific survival, and recurrence with an external validation dataset.

METHODS

The validation dataset comprised 123 patients treated between 2010 and 2015 at our institution. They were evaluated by assessing discrimination (concordance index [C-index]) and calibration (plotting predicted vs actual probabilities for quintiles).

RESULTS

The validation cohort (n = 123) showed some differences to the original cohort (n = 301). The validation cohort had less high-grade cancers (P = .006), less lymphovascular invasion (LVI; P < .001) and shorter follow-up of 19 months versus 45.6 months. Validation showed a C-index of 0.833 (95% confidence interval [CI] 0.758-0.908), 0.807 (95% CI 0.717-0.898), and 0.844 (95% CI 0.768-0.920) for overall survival, cancer-specific survival, and recurrence, respectively.

CONCLUSION

The 3 salivary gland nomograms performed well using a contemporary validation dataset, despite limitations related to sample size, follow-up, and differences in clinical and pathology characteristics between the original and validation cohorts.

Surgery and Radiotherapy in the Treatment of Malignant Parotid Tumors: A Retrospective Multicenter Study

Aims and background

Major salivary gland cancers are rare, with many histologic types and subtypes. The low incidence and heterogeneity of primary parotid carcinomas makes their outcome difficult to evaluate. Treatment remains primarily surgical, but optimal therapeutic regimens have yet to be fully realized. The present study reviews the experience of three Italian institutions in the treatment of primary parotid carcinomas in order to describe the clinicopathological presentation and treatment options with emphasis on radiotherapy and to analyze the factors influencing survival.

Methods and study design

The records of 110 patients with primary parotid neoplastic lesions treated at three Italian institutions from 1993 to 2004 were retrospectively reviewed. Six patients were excluded from the study: 3 received surgery alone and 3 were not assessable, for a total of 104 assessable patients. Acute and late toxicity of radiotherapy was quantified following the recommendations of the RTOG/EORTC. Survival was analyzed by the actuarial Kaplan-Meier product-limit method. The influence of selected factors on 10-year disease-specific survival was analyzed.

Results

The 104 assessable patients were treated as follows: 11 patients received radiotherapy as their only treatment (3 with a palliative purpose) and 93 had postoperative radiotherapy. Thirty-two patients underwent neck dissection: neck lymph node metastases were found in all them. Their mean age was 60 years (range, 14–92). According to the UICC/2002 TNM Classification, 8 patients were stage I, 19 stage II, 34 stage III, 25 stage IVA, 5 stage IVB, 3 recurrent and 10 not assessable (Tx). The most frequent histologies were adenoid cystic carcinoma (n = 16), mucoepidermoid carcinoma (n = 15), and acinic cell carcinoma (n = 15). Twenty-three patients had recurrences: 10 had local recurrences, 3 neck recurrences, 9 distant metastases, and 1 patient had both local recurrence and distant metastases. No factors were observed that would negatively influence the prognosis. Actuarial 10-year disease-specific survival was 71% and actuarial 10-year local control 82%.

Conclusions

The treatment of salivary gland malignancies remains primarily surgical. Our study confirms the results of the literature with surgery and adjunctive radiotherapy in patients with advanced-stage disease. No variables were observed to influence the prognosis.

The Prognostic Significance of Facial Nerve Involvement in Carcinomas of the Parotid Gland

IMPORTANCE AND BACKGROUND

Facial nerve (FN) palsy and perineural invasion (PNI) are adverse features in carcinomas of the parotid gland. FN sacrifice at the time of surgery is associated with significant morbidity. The role of adjuvant radiotherapy in patients with high-risk features, including FN involvement, remains unclear.

OBJECTIVE

Analyze the disease-free survival (DFS) and overall survival (OS) and the impact of tumor characteristics, including FN involvement, for patients treated with surgical resection for carcinoma of the parotid gland.

DESIGN

This is a retrospective chart review.

SETTING

University of Utah and Intermountain Healthcare, Utah.

PARTICIPANTS

A total of 129 patients who were treated with primary surgery for nonmetastatic primary malignancies of the parotid gland from 1988 to 2006.

INTERVENTIONS

Parotidectomy with or without adjuvant therapy.

MAIN OUTCOME(S) AND MEASURES

Kaplan-Meier analysis was used to obtain 5-year estimates of DFS and OS. Recurrence risk factors, particularly the impact of FN involvement, were analyzed.

RESULTS

Five-year DFS and OS rates were 79% and 78%, respectively. Thirty-two (28%) patients developed recurrent disease. Disease recurrence occurred in 64% of patients with both FN palsy and PNI, in 43% with FN palsy without PNI, in 27% with only PNI, and in 16% without either feature.

CONCLUSIONS AND RELEVANCE

FN involvement, particularly FN palsy, is a predictor of increased risk of recurrence and death. Radiotherapy cannot substitute for FN sacrifice in high-risk patients.

Develop and validation a nomogram to predict the recurrent probability in patients with major salivary gland cancer

Objectives: Prediction of recurrent risk in patients with major salivary gland carcinoma (MSGC) after surgical treatment is an important but difficult task because of a broad spectrum of tumor histological subtypes and diverse clinical behaviors. This study aimed to develop and validate a nomogram to predict the recurrent probability in patients with MSGC.

Methods: A total of 231 consecutive patients with MSGC received curative-intend surgery between 2002 and 2014 from one medical center were selected as the training set. Clinicopathologic variables with the most significant values in the multivariate Cox regression were selected to build into a nomogram to estimate the recurrence probability. An independent validation set of 139 patients treated at the same period from 3 other hospitals were selected for external validation and calibration.

Results: The nomogram was developed on six significant predictive factors, including the smoking history, tumor grade, perineural invasion, lymphatic invasion, pathologic T- and N-classification, of tumor recurrence retained in the multivariate Cox model. The nomogram had a highly predictive performance, with a bootstrapped corrected concordance index of 0.82 for the training set and 0.78 for the validation set. The nomogram showed good calibration in predict 2-year and 5-year recurrence probability both in the training and validation set.

Conclusions: We developed and externally validated an accurate nomogram for prediction the tumor recurrence probability of patients with MSGC after surgical treatment. This nomogram may be used to assist clinician and patient in elaborating the recurrent risk and making decision for appropriate adjuvant treatment.

Multidisciplinary Management of Salivary Gland Cancers

BACKGROUND

Salivary carcinomas are a rare group of biologically diverse neoplasms affecting the head and neck. The wide array of different histological entities and clinical presentations has historically limited attempts to establish well-defined treatment algorithms. In general, low-risk lesions can be managed with a single treatment modality, whereas advanced lesions require a more complex, multidisciplinary approach.

METHODS

The relevant literature was reviewed, focusing on diagnostic and treatment algorithms for salivary malignancies.

RESULTS

Salivary carcinomas with high-risk features require an aggressive treatment approach with complete surgical resection, neck dissection to appropriate cervical lymph-node basins, and postoperative radiotherapy.

CONCLUSIONS

The heterogeneity of salivary neoplasms represents a unique clinical challenge. Despite the multidisciplinary management paradigm detailed in this review, outcomes for advanced disease are unsatisfactory. Future progress will likely require the addition of novel systemic therapeutic strategies.

Complementary role of the Memorial Sloan Kettering Cancer Center nomogram to the American Joint Committee on Cancer system for the prediction of relapse of major salivary gland carcinoma after surgery

BACKGROUND

The purpose of this study was to test the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram in predicting recurrence risk of major salivary gland carcinoma in an Asian cohort.

METHODS

We retrospectively enrolled 149 patients who had undergone intended curative resections for major salivary gland carcinoma between 2007 and 2012. The performance of the MSKCC nomogram and the American Joint Committee on Cancer (AJCC) seventh staging system in predicting recurrence risk was compared.

RESULTS

The MSKCC nomogram and the AJCC staging system both accurately predicted the 5-year recurrence probabilities, with the concordance index (c-index = 0.82; 95% confidence interval [CI], 0.75-0.89 vs c-index, 0.77; 95% CI, 0.68-0.87; p = .45) in patients with major salivary gland carcinomas after curative surgeries. Comparing to the actual observed events, the calibration plot indicated that the MSKCC nomogram accurately estimated the recurrence in low-risk groups but tended to overestimate in high-risk groups. When using the MSKCC nomogram to predict the 5-year recurrence-free probability in each AJCC stage, the prediction was very good for patients with AJCC stages I and II disease (c-index = 0.92 and 0.90, respectively) and modest for those of AJCC stages III and IVa (c-index = 0.51 and 0.62, respectively).

CONCLUSION

The MSKCC nomogram and the AJCC staging system each had its value in predicting recurrence of major salivary gland cancers. When using the MSKCC nomogram to predict the 5-year recurrence-free probability in each AJCC stage, the MSKCC nomogram was more accurate in predicting recurrence risks in those patients with AJCC stage I and II diseases than those with late-stage diseases. © 2017 Wiley Periodicals, Inc. Head Neck 39: 860-867, 2017.

Validation and Comparison of the 7th Edition of the American Joint Committee on Cancer Staging System and Other Prognostic Models to Predict Relapse-Free Survival in Asian Patients with Parotid Cancer

Purpose: Parotid cancer is a rare malignancy characterized by a heterogeneous histologic subtype and distinct biologic behavior. The present study aimed to externally validate and compare the performances of the American Joint Committee on Cancer (AJCC) staging system (7^th Edition), Carrillo score, and Vander Poorten score in the prediction of tumor relapse probability in a large cohort of Asian parotid cancer patients. Methods: In total, 261 patients who underwent primary surgery for localized parotid cancer between 2002 and 2014 at the four affiliated hospitals of Chang Gung Memorial Hospital were identified. All patients were categorized into different prognostic groups defined by these three models for the comparison of associated relapse-free survival (RFS) rates. Results: The 5-year overall survival, cancer-specific survival, and RFS rates were 82.9%, 86.2%, and 77.5%, respectively. All three models were significantly powerful in discriminating between the tumors of patients in the lowest and highest risk groups. The c-statistic for predicting the 5-year RFS was 0.74 for the AJCC staging, 0.74 for the Vander Poorten score, and 0.62 for the Carrillo score. The AJCC staging and Vander Poorten score gave significantly high c-statistic values compared to the Carrillo score. Conclusion: Our data validated that all three models are significantly powerful in discriminating tumor relapse between patients in lowest and highest risk groups. The AJCC system and Vander Poorten score proved superior to the Carrillo score, and showed similar performances in discriminating between the 5-year RFS probabilities of low and high-risk Asian parotid cancer patients.

Outcomes and prognostic factors for surgery followed by modern radiation therapy in parotid gland carcinomas

OBJECTIVE

To evaluate the outcomes and prognostic factors in patients with parotid gland cancers treated with adjuvant radiotherapy with or without chemotherapy.

METHODS

Eighty-five patients with parotid gland cancers were identified between October 2001 and September 2011. The median radiation dose was 66 Gy (range, 9-76 Gy). The outcomes assessment included overall survival, locoregional control, distant metastasis-free survival and disease-free survival.

RESULTS

The stage distribution was 20 patients  (23.5%) in stage I, 28 (32.9%) stage II, 14 (16.5%) stage III and 23 (27.1%) stage IV. Fifty-five patients (64.7%) had positive margins and 23 patients (27.1%) had close margins (<0.5 cm). Lymph node extracapsular spreading occurred in nine patients. The adjuvant therapy included radiotherapy alone in 47 patients (55.3%) and concurrent chemoradiotherapy in 38 patients (44.7%). With a median follow-up of 4.5 years (range, 0.4-11 years), the 5-year overall survival, locoregional control, distant metastasis-free survival and disease-free survival were 82.0, 88.4, 82.4 and 77.5%, respectively. Based on multivariate analysis, N1/N2 was a significant negative prognostic factor for distant metastasis-free survival, disease-free survival and overall survival. Perineural invasion was a significant negative prognostic factor for locoregional control, distant metastasis-free survival and disease-free survival. Patients 50 years or older had significantly worse distant metastasis-free survival, disease-free survival and overall survival.

CONCLUSIONS

Surgery and radiotherapy treatment could achieve excellent outcomes in a modern cohort. However, N1/N2, perineural invasion and age ≥50 years, but not positive margins, are significant factors associated with a worse prognosis.

[Predictors of malignancy in the management of parotid tumors: about 76 cases]

La pathologie tumorale de la glande parotide est complexe et pose un problème diagnostique et thérapeutique. Une bonne analyse des facteurs prédictifs de malignité de ces tumeurs parotidiennes semble actuellement nécessaire en vue d'une meilleure planification thérapeutique. Le but de ce travail est d’étudier les facteurs prédictifs de malignité dans les tumeurs parotidiennes à travers une étude rétrospective sur 76 cas de tumeurs de la parotide traités au service d'Oto-Rhino-Laryngologie et de Chirurgie Cervico-Faciale de l'hôpital militaire Avicenne de Marrakech entre janvier 2000 et décembre 2012. Il s'agit de 40 femmes et 36 hommes. L’âge moyen était de 44 ans pour les tumeurs bénignes alors qu'il était de 50 ans pour les tumeurs malignes. Le délai moyen de consultation était de 24 mois pour les tumeurs bénignes et de 16 mois pour les tumeurs malignes. La tuméfaction de la région parotidienne a été un signe révélateur constant chez tous les malades. La malignité est évoquée cliniquement devant la douleur, la paralysie faciale, la fixité par rapport au plan superficiel ou profond et la présence d'adénopathie. L'IRM constitue désormais l'examen de choix dans l'exploration des masses tumorales parotidiennes avec une bonne valeur diagnostique de malignité ou de bénignité. La cytoponction à l'aiguille fine n'a pas de valeur que si elle est positive. La parotidectomie exploratrice avec examen anatomopathologique extemporané demeure la clé du diagnostic positif. Les tumeurs parotidiennes bénignes représentent l'entité la plus fréquente (80%) et l'adénome pléomorphe demeure le type histologique prédominant (61%). Quant aux tumeurs malignes, elles sont plutôt rares, dominées essentiellement par les carcinomes muco épidermoides (6,5%). Le traitement chirurgical est l'option de choix souvent associée à un curage ganglionnaire et une radiothérapie pour les tumeurs malignes. La paralysie faciale est la complication la plus fréquente de la chirurgie parotidienne.

Clinicopathologic factors associated with recurrence in low- and high-grade parotid cancers

BACKGROUND

The purpose of this study was to determine clinicopathological correlates of outcome among patients with parotid gland cancer.

METHODS

The medical records of 126 patients treated by surgery for localized parotid cancer were retrospectively reviewed to identify the clinicopathologic correlates of recurrence-free survival (RFS) according to histologic grade.

RESULTS

Multivariate analysis revealed that age and lymphovascular invasion were significant factors for recurrence in patients with low-grade cancer (p = .049 and p = .019, respectively), whereas perineural invasion was the only significant factor in patients with high-grade cancer (p = .001). The most frequent recurrence site tends to be different according to histologic grade: local recurrence at low-grade cancer (8.3%) and distant at high-grade cancer (13.6%). The duration of RFS was significantly longer in low-grade cancer than high-grade cancer in regional and distant recurrence (p = .044 and p = .016, respectively).

CONCLUSION

Consideration of different factors may be required for individual low-grade and high-grade parotid cancers when predicting the risk of recurrence. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1788-E1793, 2016.

Outcome analysis of 215 patients with parotid gland tumors: a retrospective cohort analysis

Background

To identify prognostic factors in patients with parotid gland carcinomas who were treated at the Princess Margaret Hospital.

Methods

Clinical outcome of two hundred fifteen patients with malignancies of the parotid gland was evaluated over a 16-year period.

Results

Two-hundred-fifteen patients with adenoid cystic carcinoma (n = 20), adenocarcinoma (n = 19), acinic cell carcinoma (n = 62), basal cell adenocarcinoma (n = 7), carcinoma-ex-pleomorphic adenoma (n = 18), mucoepidermoid carcinoma (n = 70) and salivary duct carcinoma (n = 19) have been included. The 5- and 10-year overall and disease-free survivals were 80.62 %/69.48 % and 74.37 %/62.42 %, respectively. Multivariable analysis showed that age greater than 60 years, advanced pN classification, histopathological grade and the presence of lymphovascular invasion significantly worsened overall and disease-free survival. Univariable analysis revealed periparotid lymph node involvement was associated with decreased overall (p < 0.0001) and disease-free survival (p < 0.0001).

Conclusions

In addition to age, pN classification, histopathological grade, perineural invasion, and lymphovascular involvement, periparotid lymph node metastasis appears to be an important prognosticator in parotid gland malignancy.

Prognostic Factors and Treatment Outcomes of Parotid Gland Cancer

Objective

To investigate the treatment outcomes of parotid gland cancer at a single center over a 10-year period and to evaluate the prognostic significance of maximum standardized uptake value.

Study Design

Retrospective case series with chart review.

Setting

Academic care center.

Subjects and Methods

Ninety-eight patients with primary parotid gland cancer who were surgically treated at Yonsei University Head & Neck Cancer Clinic between January 1999 and December 2008 were analyzed. Patient data were collected retrospectively from medical charts. The investigators analyzed the association of clinicopathological factors and maximum standardized uptake value on 18F-fluorodeoxyglucose positron emission tomography–computed tomography scan with disease-specific survival.

Results

Mean patient age was 49.7 years. Mean follow-up was 48.8 months. Thirty-three, 40, 30, and 23 patients had stage I, II, III, and IVA disease, respectively. Mucoepidermoid carcinoma was the most common histologic type (34.7%), followed by acinic cell carcinoma (27.6%). Eighteen patients (18.4%) experienced recurrences (mean recurrence gap, 20.6 months; range, 2-87 months). Five- and 10-year disease-specific survival rates were 93.6% and 81.8%, respectively. In the univariate analysis, pathologic T stage, pathologic lymph node status, resection margin, external parenchymal extension, and maximum standardized uptake value were significantly associated with disease-specific survival. Pathologic lymph node status and maximum standardized uptake value were independent prognostic factors in the multivariate analysis.

Conclusion

Our single-center experience with parotid gland cancer treatment is consistent with the literature. Cervical lymph node metastasis and high maximum standardized uptake value are associated with poor survival in parotid gland cancer.

[A retrospective study on parotid carcinoma]

We retrospectively analyzed the clinicopathological factors affecting survival in patients with previously untreated parotid carcinoma. The subjects were 50 patients treated in our department from 1987 through 2011. The T stage was T1, T2, T3, and T4 in 4 patients, 11 patients, 9 patients, and 26 patients, respectively. The N stage was N0, N1, and N2 in 36 patients, 3 patients, and 11 patients, respectively. The clinical stage was I, II, III, and IV in 4 patients, 10 patients, 7 patients, and 29 patients, respectively. Histopathologically, eleven tumor types were observed; mucoepidermoid carcinoma was the most common. The overall 5-year survival rate was 72.1%, and the disease-specific 5-year survival rate was 74.0% in 42 patients who received radical surgery. Twelve patients relapsed; the site of relapse was the primary site alone in 2, in the neck alone in 3 patients, in the neck with distant metastases in 2 patients, and in distant metastatic site (s) alone in 5 patients. Univariate analysis showed that significant prognostic factors for overall survival rates were the T stage, cervical lymph node metastasis, clinical stage, grade, facial nerve palsy, and tumor size. We concluded that patients at high risk of recurrence should receive adjuvant therapy to improve the therapeutic outcomes.

Site-wise Differences in Adequacy of the Surgical resection Margins in Head and Neck Cancers

Adequacy of surgical resection decided by the margin status is important in attaining a good local control and better survival in Head and neck Cancers. Conventionally, a measured distance between the tumor edge and the cut edge of the specimen is taken as the margin. A margin more than 5  millimeter (mm) is considered clear, less than 5 mm is close and less than one mm is denoted as involved. The concept of this adequacy varies between the different sites and subsites in head and neck. The purpose of this paper is to review the current evidence that describes the adequacy of surgical margin status and their variability among the sites and sub-sites in the head and neck.

Effect of clinical symptoms on the indication for selective neck dissection for N0 carcinomas of the parotid gland

Lymph node metastasis is a major prognostic factor in parotid carcinoma, however, the pre-operative diagnosis of occult nodal metastasis is difficult in clinical N0 (cN0) parotid cancer patients. In addition, the indication of neck dissection in T1-3 cN0 patients is controversial. The current study investigated 17 patients with clinical T1-3 cN0 parotid cancer, and analyzed the correlation between patient symptoms/findings and pathological N status/tumor histological grade. In the statistical analysis, pain was found to significantly correlate with neck metastasis. Furthermore, cN0-staged patients without pain exhibited no neck metastasis. However, no significant correlation was identified between patient symptoms or findings and histological grade. These results indicate the possibility that selective neck dissection can be omitted for T1-3 cN0-staged patients without pain.

Clinical outcome of patients with carcinoma ex pleomorphic adenoma of the parotid gland: a comparative study from a single tertiary center

BACKGROUND

Carcinoma ex pleomorphic adenoma (CXPA) of the parotid gland is a high-grade cancer and the prognosis of this cancer has not been compared with non-CXPA high-grade primary parotid cancer.

METHODS

Retrospective medical chart review of patients with surgically treated high-grade primary parotid cancer (21 CXPA and 52 non-CXPA) was performed with correlation with disease-specific survival, locoregional recurrence, and distant recurrence.

RESULTS

Despite having similar stage of cancer and extent of surgical resection, patients with CXPA had a lower disease-specific survival compared to non-CXPA high-grade primary parotid cancer (p = .02). Salivary duct cancer (SDC) was the commonest histologic variant in both cohorts and around 40% of patients with SDC died of distant recurrence that occurred within 3 years from diagnosis.

CONCLUSION

CXPA of the parotid gland is a more aggressive cancer compared to non-CXPA high-grade primary parotid cancer. SDC was associated with a high chance of delayed distant recurrence, which contributed directly to the mortality of this cancer.

Clinicopathological features of mucoepidermoid carcinoma

OBJECTIVE

We aimed to examine the clinical usefulness of a new World Health Organization classification scheme for salivary gland mucoepidermoid carcinoma, and to identify the factors most strongly associated with prognosis and outcome.

METHODS

The clinicopathological features of 45 patients who received treatment for mucoepidermoid carcinoma between 1986 and 2010 were retrospectively investigated.

RESULTS

The overall disease-specific 5-year survival rate was 81.8 per cent. The rate for patients with low-grade tumours (92.5 per cent) was significantly higher than that for patients with intermediate or high-grade tumours (52.2 per cent). Univariate analysis revealed that five factors were significantly associated with five-year survival: age, tumour stage classification, lymph node status, histological grade and treatment method. Four factors were significant in multivariate analysis: age, sex, tumour stage classification and lymph node status.

CONCLUSION

The new World Health Organization classification was useful in predicting disease progression in patients with mucoepidermoid carcinoma. Patients with high-grade tumours or other prognostic factors positively associated with disease progression should be carefully evaluated and monitored.

[Survival analysis and immunohistochemical study of HER-2 and AR (androgen receptor) expression in salivary duct carcinoma]

BACKGROUND

Because of its low incidence, the clinical characteristics of the salivary duct carcinoma (SDC) based on a statistical analysis with a large number of patients remain to be elucidated, and thus it has been impossible to standardize the optimal treatments of SDC including adjuvant systemic therapy.

AIMS

The present study aimed to determine the prognostic factors along with the clinical outcomes of patients with SDC and to evaluate the expression of several receptor molecules as treatment targets.

METHODS

We performed a statistical analysis and immunohistochemical examination of 16 patients with SDC who had undergone initial treatment in the Department of Otorhinolaryngology, Head and Neck Surgery, Keio University School of Medicine from 1996 to 2010.

RESULTS

The 3-year disease-free survival (DFS) and cause-specific survival (CSS) rates were 29.2% and 72.7%, respectively. At the time of the analysis, 6 patients are alive without the disease, 2 patients are alive with distant metastasis, whereas 7 patients had died of distant metastasis, and 1 patient had died of another cause (pulmonary embolism). We examined the prognostic value of the clinico-pathological factors such as age, sex, T classification, N classification, clinical stage, primary site, histological pre-existence of pleomorphic adenoma. A univariate analysis revealed that DFS was significantly correlated with age (p = 0.049), T classification (p = 0.018), and clinical stage (p = 0.029), whereas no factor was found to be correlated with CSS. A multivariate analysis demonstrated that age (> or = 61 vs. < or = 60, risk ratio (RR) = 5.423, p = 0.042) and T classification (3, 4 vs. 1, 2, RR = 1.087, p = 0.020) were the independent prognostic factors for DFS. Positive expressions of HER2, ER (estrogen receptor), PR (progesterone receptor), AR (androgen receptor), and MIB-1 (index > 20%) were found in 50%, 6%, 13%, 100%, and 69%, respectively. However, none of them showed significant correlation with survival.

CONCLUSION

Frequent expressions of HER-2 and AR in SDC suggest that these receptors can be suitable molecular targets of systemic therapy for patients with SDC in which distant metastasis seems to be the largest obstacle to improving survival. In order to assess the efficacy of anti-HER-2 therapy and anti-androgen therapy for each receptor-positive SDC, a multi-institutional joint research system should be organized.

Salivary gland carcinomas

INTRODUCTION

Salivary gland carcinomas are rare tumours of heterogeneous morphology that require distinctive surgical and adjuvant therapy.

METHODS

Relevant studies were electronically searched in PubMed and reviewed for innovative and important information.

RESULTS

Recent insights in genetic alterations like chromosomal aberrations, expression of receptor tyrosine kinases, malfunction of tumour suppressor genes or DNA promoter methylations increased the knowledge about aetiology and pathogenesis. New histological subtypes are recognised, and a three-tiered grading system seems reasonable. Ultrasound remains the basic diagnostic imaging procedure. New developments comprise the diffusion-weighed magnetic resonance imaging, while fluorodeoxyglucose positron emission tomography/computed tomography shows good diagnostic accuracy in detecting distant metastases and local recurrence. Fine-needle aspiration cytology helps in differentiating a neoplasia from a non-neoplastic lesion while being unreliable in recognising malignancy. In contrast, additional core needle biopsy and/or intraoperative frozen section diagnosis increase the accuracy in diagnosing a malignant lesion. Conservative parotid surgery with nerve monitoring remains state-of-the-art. Free flaps or musculoaponeurotic flaps are proposed for prevention of Frey's syndrome. As parotid cancer often shows skip metastases, complete ipsilateral neck dissection (level I-V) is indicated particularly in high-grade lesions. Adjuvant radio(chemo)therapy increases local tumour control, whereas overall survival is not necessarily improved. Current results of systemic chemotherapy or targeted therapy in advanced tumour stages are disappointing.

CONCLUSION

Despite several developments, salivary gland carcinomas remain a heterogeneous group of tumours challenging both pathologists and clinicians.

Signs and symptoms of parotid gland carcinoma and their prognostic value

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

Management of malignant parotid tumors

INTRODUCTION

The aims of this study were to review our experience in the treatment of malignant parotid tumors in material from one center over a 12-year period and to assess treatment outcome and particularly survival.

MATERIALS AND METHODS

Thirty-one patients treated primarily by surgery were included in the study. Complete data regarding the demographic details of the patients, tumor stage, presence of regional/distant metastases, treatment, tumor histology, grade, and follow up were compiled. With reference to the extent of tissue removed, partial superficial parotidectomy was performed in 11 patients, superficial parotidectomy, in 14 patients, and total radical parotidectomy, in six patients.

RESULTS

The median time of follow-up was 64 months, ranging from 8 to 144 months. Eight patients developed recurrences. Six patients died within the follow-up time. The overall survival rates at 5 and 10 years were 82.2% and 76.7%, respectively. The 5- and 10-year disease-free survival rates were 74.8% and 69.8%, respectively.

DISCUSSION

For patients with malignant parotid tumors, the treatment should be individualized according to the findings of each specific case, and regarding surgery, particular care and attention should be paid to maintaining all or part of the facial nerve whenever possible.

Metastatic cutaneous squamous cell carcinoma to parotid nodes: the role of bolus with adjuvant radiotherapy

INTRODUCTION

Information regarding the addition of tissue equivalent bolus to adjuvant radiotherapy (RT) for intra-parotid metastatic head and neck cutaneous squamous cell carcinoma is lacking. This study aimed to evaluate the effect of bolus versus no bolus on the patterns of regional and distant recurrence, regional control (RC), cancer-specific survival (CSS), overall survival, RT toxicity and RT interruption.

METHODS

A retrospective study was performed on consecutive patients diagnosed between 1994 and 2008 with metastatic head and neck cutaneous squamous cell carcinoma who were treated with parotidectomy ± selective neck dissection and adjuvant RT ± parotid bolus.

RESULTS

Seventy-five patients were identified: 64 males and 11 females, with median age of 79 years (range 40-96) of which 39 had bolus during RT. Median follow up was 48 months (range 4-177). There were 23 regional recurrences - 14 dermal, six dermal + nodal and three isolated nodal - and only two systemic recurrences. Nine patients had RT interruption >6 days due to acute skin toxicity. Bolus was associated with increased grade ≥3 radiation dermatitis (P = 0.02). RT interruption >6 days was significantly associated with inferior RC and hazard ratio, 2.83 (95% confidence interval: 1.04-7.71, P = 0.042). Lympho-vascular space invasion, positive margins and nodes >2 cm were adversely significant on CSS multivariate analysis. RC, CSS and overall survival at 5 years were 67, 66 and 52%, respectively.

CONCLUSIONS

Dermal involvement dominated the pattern of regional recurrence. Bolus was associated with significantly worse skin reaction. Bolus use was not associated with a significant overall benefit on RC. This analysis does not support the use of bolus as applied in this cohort.

Mucoepidermoid carcinoma - unknown primary and late distant metastasis: an unusual course of the disease

The authors report the case to understand this unusual presentation and prognosis of mucoepidermoid carcinoma following treatment. We present a case of mucoepidermoid carcinoma in a 67-year-old man. The cancer was diagnosed in the right side of his neck but the primary tumor remained unknown despite attempts at staging. The neck was treated successfully and followed up for 2 years. Metastasis of the primary lesion to the left triceps was diagnosed following a swelling noticed by the patient during the 2-year follow up period. Mucoepidermoid carcinoma can be a low, intermediate or high-grade malignancy and can metastasize to different parts of the body. However, this is the first case report of a metastasis to the triceps muscle.