Preoperative diagnostic of parotid gland neoplasms: fine-needle aspiration cytology or core needle biopsy?

CT-guided core needle biopsies of head and neck tumors: a comprehensive monocenter analysis of safety and outcomes

BACKGROUND

Although core needle biopsy is an important tool in minimally invasive tissue sampling and diagnostics for head and neck masses, comprehensive data about safety and outcomes is lacking.

PURPOSE

To retrospectively evaluate the diagnostic performance and safety of computed tomography (CT)-guided percutaneous core needle biopsy of head and neck masses.

MATERIAL AND METHODS

This retrospective single-center study included patients from 04/2007 to 12/2021, and a total of 156 core needle biopsies were evaluated. The initial histopathological results were compared with the long-term final diagnosis to evaluate the diagnostic yield of CT-guided core needle biopsies. The patients' age, sex, and history of malignancy, as well as procedural complications and radiation exposure were collected.

RESULTS

A total of 156 biopsies of 150 patients (mean age 56 years ± 17; 89 men) were evaluated. 57.3% (86/150) of patients had a history of malignancy. 55.1% (86/156) of the lesions were accessed by an infrahyoid needle approach. 92.9% (145/156) of biopsies yielded conclusive results. There were no false positives and 4 false negatives, resulting in a total false negative rate of 2.7% (4/145) and a total diagnostic yield of 90.4% (141/156). There were nine puncture-related complications (9/156-5.7%). None of the complications required further reintervention. The average dose length product was 311.3 mGy × cm.

CONCLUSION

CT-guided core needle biopsies of head and neck masses showed excellent results with high diagnostic yield and clinical safety.

CLINICAL RELEVANCE STATEMENT

General anesthesia for open biopsy carries a higher risk for elderly patients, and fine needle aspiration has a poor reputation in terms of its diagnostic yield. This study focuses on safety and diagnostic yield of CT-guided core needle biopsies.

KEY POINTS

• CT-guided core needle biopsy in head and neck tumors was a reliable and safe procedure. • The most common cause for an inconclusive biopsy result was a shortage of tissue collected during the biopsy. • During our study period of nearly 15 years, the radiation exposure of head and neck biopsies decreased.

Ultrasound-Enhanced Fine-Needle Biopsy Improves Yield in Human Epithelial and Lymphoid Tissue

OBJECTIVE

Needle biopsy is a common technique used to obtain cell and tissue samples for diagnostics. Currently, two biopsy methods are widely used: (i) fine-needle aspiration biopsy (FNAB) and (ii) core needle biopsy (CNB). However, these methods have limitations. Recently, we developed ultrasound-enhanced fine-needle aspiration biopsy (USeFNAB), which employs a needle that flexurally oscillates at an ultrasonic frequency of ∼32 kHz. The needle motion contributes to increased tissue collection while preserving cells and tissue constructs for pathological assessment. Previously, USeFNAB has been investigated only in ex vivo animal tissue. The present study was aimed at determining the feasibility of using USeFNAB in human epithelial and lymphoid tissue.

METHODS

Needle biopsy samples were acquired using FNAB, CNB and USeFNAB on ex vivo human tonsils (N = 10). The tissue yield and quality were quantified by weight measurement and blinded pathologists' assessments. The biopsy methods were then compared.

RESULTS

The results revealed sample mass increases of, on average, 2.3- and 5.4-fold with USeFNAB compared with the state-of-the-art FNAB and CNB, respectively. The quality of tissue fragments collected by USeFNAB was equivalent to that collected by the state-of-the-art methods in terms of morphology and immunohistochemical stainings made from cell blocks as judged by pathologists.

CONCLUSION

Our study indicates that USeFNAB is a promising method that could improve tissue yield to ensure sufficient material for ancillary histochemical and molecular studies for diagnostic pathology, thereby potentially increasing diagnostic accuracy.

Insights Into Pediatric Secretory Carcinoma of the Salivary Gland: A Case Report

Secretory carcinoma of the salivary gland (SCSG) is a rare head and neck tumor in adults and exceptional at the pediatric age. Its varied histological subtypes and distinct clinical presentation pose diagnostic and therapeutic challenges. Therefore, standardized guidelines are of utmost importance for the care of these patients, especially in children. Here we present an 11-year-old male presented with a left cheek mass initially diagnosed as lipoma. A wide resection was performed and SCSG was revealed in the histopathologic and immunohistochemistry analysis. The presentation of this case provides valuable information on the diagnostic and therapeutic complexities of SCSG. It emphasizes the need for standardized guidelines and further research to optimize pediatric patient outcomes. Overall, this case report is a crucial resource for clinicians and researchers, highlighting the importance of interdisciplinary collaboration and early intervention in managing SCSG.

Deep learning-assisted diagnosis of benign and malignant parotid tumors based on ultrasound: a retrospective study

BACKGROUND

To develop a deep learning(DL) model utilizing ultrasound images, and evaluate its efficacy in distinguishing between benign and malignant parotid tumors (PTs), as well as its practicality in assisting clinicians with accurate diagnosis.

METHODS

A total of 2211 ultrasound images of 980 pathologically confirmed PTs (Training set: n = 721; Validation set: n = 82; Internal-test set: n = 89; External-test set: n = 88) from 907 patients were retrospectively included in this study. The optimal model was selected and the diagnostic performance evaluation is conducted by utilizing the area under curve (AUC) of the receiver-operating characteristic(ROC) based on five different DL networks constructed at varying depths. Furthermore, a comparison of different seniority radiologists was made in the presence of the optimal auxiliary diagnosis model. Additionally, the diagnostic confusion matrix of the optimal model was calculated, and an analysis and summary of misjudged cases' characteristics were conducted.

RESULTS

The Resnet18 demonstrated superior diagnostic performance, with an AUC value of 0.947, accuracy of 88.5%, sensitivity of 78.2%, and specificity of 92.7% in internal-test set, and with an AUC value of 0.925, accuracy of 89.8%, sensitivity of 83.3%, and specificity of 90.6% in external-test set. The PTs were subjectively assessed twice by six radiologists, both with and without the assisted of the model. With the assisted of the model, both junior and senior radiologists demonstrated enhanced diagnostic performance. In the internal-test set, there was an increase in AUC values by 0.062 and 0.082 for junior radiologists respectively, while senior radiologists experienced an improvement of 0.066 and 0.106 in their respective AUC values.

CONCLUSIONS

The DL model based on ultrasound images demonstrates exceptional capability in distinguishing between benign and malignant PTs, thereby assisting radiologists of varying expertise levels to achieve heightened diagnostic performance, and serve as a noninvasive imaging adjunct diagnostic method for clinical purposes.

Current management and future challenges in salivary glands cancer

Salivary gland cancers (SGCs) are rare, accounting for less than 5% of all malignancies of the head and neck region, and are morphologically heterogeneous. The diagnosis is mainly based on histology, with the complementary aid of molecular profiling, which is helpful in recognizing some poorly differentiated, borderline, or atypical lesions. Instrumental imaging defines the diagnosis, representing a remarkable tool in the treatment plan. Ultrasound and magnetic resonance are the most common procedures used to describe the primary tumour. The treatment of SGCs is multimodal and consists of surgery, radiotherapy, and systemic therapy; each treatment plan is, however, featured on the patient and disease's characteristics. On 24 June 2022, in the meeting "Current management and future challenges in salivary gland cancers" many experts in this field discussed the state of the art of SGCs research, the future challenges and developments. After the meeting, the same pool of experts maintained close contact to keep these data further updated in the conference proceedings presented here. This review collects the insights and suggestions that emerged from the discussion during and after the meeting per se.

Salivary gland neoplasms in small biopsies and fine needle aspirations

Salivary gland neoplasms are rare and represent a diverse group of head and neck tumors. Their diagnosis in limited cellularity specimens can be challenging as many of these have overlapping clinical, radiological presentation, and pathologic features. Fine needle aspiration and/or core biopsies are more of a norm than rarity to be performed preoperatively to provide invaluable information that can guide clinical management including surgery. Even though these limited specimens may not always provide a definitive diagnosis; they have high sensitivity in confirming primary neoplasia, assessing the tumor grade, and ruling out non-surgical disease. An algorithmic pattern based approach can help narrow the differential diagnosis; leading to a definitive diagnosis with the help of specific ancillary studies.

Deep learning-assisted diagnosis of benign and malignant parotid tumors based on contrast-enhanced CT: a multicenter study

OBJECTIVES

To develop deep learning-assisted diagnosis models based on CT images to facilitate radiologists in differentiating benign and malignant parotid tumors.

METHODS

Data from 573 patients with histopathologically confirmed parotid tumors from center 1 (training set: n = 269; internal-testing set: n = 116) and center 2 (external-testing set: n = 188) were retrospectively collected. Six deep learning models (MobileNet V3, ShuffleNet V2, Inception V3, DenseNet 121, ResNet 50, and VGG 19) based on arterial-phase CT images, and a baseline support vector machine (SVM) model integrating clinical-radiological features with handcrafted radiomics signatures were constructed. The performance of senior and junior radiologists with and without optimal model assistance was compared. The net reclassification index (NRI) and integrated discrimination improvement (IDI) were calculated to evaluate the clinical benefit of using the optimal model.

RESULTS

MobileNet V3 had the best predictive performance, with sensitivity increases of 0.111 and 0.207 (p < 0.05) in the internal- and external-testing sets, respectively, relative to the SVM model. Clinical benefit and overall efficiency of junior radiologist were significantly improved with model assistance; for the internal- and external-testing sets, respectively, the AUCs improved by 0.128 and 0.102 (p < 0.05), the sensitivity improved by 0.194 and 0.120 (p < 0.05), the NRIs were 0.257 and 0.205 (p < 0.001), and the IDIs were 0.316 and 0.252 (p < 0.001).

CONCLUSIONS

The developed deep learning models can assist radiologists in achieving higher diagnostic performance and hopefully provide more valuable information for clinical decision-making in patients with parotid tumors.

KEY POINTS

• The developed deep learning models outperformed the traditional SVM model in predicting benign and malignant parotid tumors. • Junior radiologist can obtain greater clinical benefits with assistance from the optimal deep learning model. • The clinical decision-making process can be accelerated in patients with parotid tumors using the established deep learning model.

Evaluation of Fine Needle Aspiration Cytopathology in Salivary Gland Tumors under Milan System: Challenges, Misdiagnosis Rates, and Clinical Recommendations

(1) Background: Salivary gland tumors are rare in the head and neck. To determine the need and extent of surgical intervention, fine needle aspiration (FNA) is a widely accepted tool to approach salivary gland lesions. However, the FNA cytology varies between entities, while the lack of uniform terminology makes diagnosis more challenging. Since establishing the Milan system for reporting salivary gland cytopathology (MSRSGC) has become an increasingly accepted reporting standard, further examination and detailed recommendations were needed. (2) Methods: Between April 2013 and October 2021, 375 cases with FNA and salivary gland resection were retrospectively collected. All FNA specimens were reclassified according to the criteria of MSRSGC. After surgical excision, the FNA data were compared with the histological diagnosis to estimate the risk of malignancy (ROM), the risk of neoplasm (RON), and the diagnostic accuracy for each diagnostic category. (3) Results: Our cohort's distribution of ROM and RON was similar to the MSRSGC's recommendation. Carcinoma ex pleomorphic adenoma (CXPA) has the highest rate (66.7%) of misdiagnosed as a nonneoplastic lesion or benign salivary gland tumor. Pleomorphic adenoma (PA) and Warthin's tumor were the most common benign salivary gland tumors, while the cytology diagnosis of Warthin's tumor seems more challenging than PAs. (4) Conclusions: Despite the convenience and effectiveness of MSRSGC, we suggest close follow-up, re-biopsy, or surgical removal for salivary lesions even in Milan IVA-Benign for possibly missing FNA of malignancy, mixed lesions, or prevention of malignant transformation.

[Indications for fine-needle aspiration and core needle biopsy for diagnosis of salivary gland tumors]

BACKGROUND

Salivary gland malignancies are rare neoplasms of the head and neck area. Preoperative clinical and imaging assessment of salivary gland masses is challenging. However, preoperative identification of malignancy is crucial for further treatment and for the course of the disease.

OBJECTIVE

This article presents the advantages and disadvantages of fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB). Additionally, the sensitivity and specificity of both methods for predicting malignancy were analyzed. Furthermore, it is discussed which procedure is suitable for the diagnostic work-up of salivary gland tumors.

MATERIALS AND METHODS

This current article summarizes important and recent studies in the field of the diagnostic work-up for salivary gland lesions, with discussion of original articles, metanalyses, and systematic reviews concerning FNAC and CNB.

RESULTS

The sensitivity and specificity of the predictive ability of FNAC for malignancy is described at between 70.0-80.0% and 87.5-97.9%. The pooled sensitivity and specificity for CNB were 92.0-98.0% and 95.0-100.0%, respectively. Tumor cell seeding or facial nerve palsy are very rare complications of both procedures.

CONCLUSION

If malignancy is suspected based on clinical examination or imaging, FNAC or CNB should be performed. FNAC is easy to perform; however, an onsite cytologist is necessary. CNB has a higher sensitivity for routine diagnosis of malignancy; tumor typing and grading is facilitated by preserving the histological architecture. In conclusion, CNB is the procedure of choice in the diagnostic work-up for suspected malignant salivary gland tumors.

Post-operative Diagnosis of Primary Parotid Tuberculosis in a Patient Initially Diagnosed as Benign Pleomorphic Adenoma

Primary parotid tuberculosis is a well-known but extremely rare entity even in endemic countries. Most of the cases are diagnosed late in the course of illness when the parotid shows features of cold abscess leading to facial disfigurement. Early diagnosis is a clinical challenge due to lack of clinical suspicion as well as absence of clinical or radiological tests suggestive of the disease. Fine needle aspiration cytology features of early tuberculosis can easily be confused with a pleomorphic adenoma. When ultrasound examination of a parotid lesion is atypical, image guided core needle biopsy can be helpful in differentiating these kinds of rare diseases from more common parotid pathologies.

Current Salivary Glands Biopsy Techniques: A Comprehensive Review

Biopsy is a surgical procedure performed to collect a portion of tissue or organ for diagnostic studies. The aim of the present manuscript is to describe state-of-the-art major and minor salivary gland biopsy techniques and assess the indications and complications of other salivary gland biopsy techniques. A search was performed using the following MeSH terms: biopsy, fine-needle biopsies, image-guided biopsies, frozen sections, and salivary glands disease. A current overview of major and minor salivary glands biopsy techniques was provided. In the oncological field, a comparison was made between the most widely used biopsy method, ultrasound-guided fine-needle aspiration biopsy (US-FNAB), and an alternative method, ultrasound-guided core needle biopsy (US-guided CNB), highlighting the advantages and disadvantages of each. Finally, intra-operative frozen sections (IOFSs) were presented as an additional intraoperative diagnostic method. Minor salivary gland biopsy (MSGB) is the simplest diagnostic method used by clinicians in the diagnosis of inflammatory and autoimmune diseases. In neoplastic lesions, US-FNAB represents the most performed method; however, due to its low diagnostic accuracy for non-neoplastic specimens, US-guided CNB has been introduced as an alternative method.

AN INTEGRATED APPROACH TO THE MORPHOLOGICAL DIAGNOSIS OF DIFFERENT TYPES OF PLEOMORPHIC ADENOMAS OF THE SALIVARY GLAND: LONG-TERM RESEARCH RESULTS

OBJECTIVE

The aim: To describe an integrated approach to the morphological diagnosis of different types of pleomorphic adenomas of the salivary gland.

PATIENTS AND METHODS

Materials and methods: Surgical and biopsy material from 30 patients with pleomorphic adenomas of epithelial, mixed and mesenchymal variants was studied using histological, immunohistochemical, genetic, morphometric and statistical methods.

RESULTS

Results: The results of research allowed us to identify methods for determination the pleomorphic adenomas types. The first method requires an immunohistochemical reaction with a monoclonal antibody to human papillomavirus type 16, followed by counting the percentage of positively stained cells in the tumor. Thus, the mesenchymal variant of the tumor is diagnosed when the percentage of positively stained cells is < 40%. In the mixed variant, this indicator is ≥ 40%, but ≤ 70%, and in epithelial variant - > 70%. The second method was based on the multivariate discriminant analysis. Three formulae were derived to determine the tumor types (Fmesenchymal = - 41.03 + 4.96Х1 + 1.11Х2, Fepithelial = - 22.27 + 3.46Х1 + 0.85Х2, Fmixed = - 122.25 + 5.63Х1 + 3.2Х2, here Х1 - number of vessels, Х2 - specific volume of parenchyma).

CONCLUSION

Conclusions: The authors identified several methods for determining the histological variants of pleomorphic adenomas. These methods will improve the morphological diagnosis of pleomorphic adenomas variants in the preoperative and postoperative periods.

Primary non-Hodgkin lymphoma of the parotid gland: a case report

Most malignant lymphomas of the head and neck region are non-Hodgkin lymphomas (NHL), and diffuse large B-cell lymphoma is the most common subtype. The prevalence of malignant lymphoma among parotid tumors is low, approximately 1% to 4%. The most common symptom of parotid lymphoma is a unilateral, non-tender, firm mass that slowly grows in size over time. As its clinical manifestations are non-specific, a comprehensive assessment is required for an accurate diagnosis. The initial work-up includes imaging tools, such as computed tomography and magnetic resonance imaging. However, NHL of the parotid gland is difficult to distinguish from other types of benign tumors prior to biopsy; histopathological evaluation and subsequent immunohistochemical staining are needed for the final diagnosis. Once a definitive diagnosis is established, patients should be referred to an oncologist for staging. Treatment is mainly based on systemic chemotherapy, whereas radiotherapy is indicated for certain cases. Here, we report the case of a 53-year-old man who presented with a progressively enlarging mass in the right parotid area, which was later diagnosed as malignant lymphoma of the parotid gland after superficial parotidectomy.

Calcification in Salivary Gland Cancer Mimicking Sialolithiasis-A Diagnostic Pitfall on Imaging: Report of Two Cases and Brief Review of the Literature

Objectives: Sialolithiasis is the most common cause of calcifications detected with ultrasound in patients with chronic inflammatory symptoms and swellings of the salivary glands. Other differential diagnoses of calcifications are extremely rare and mostly benign. Methods: Case report and literature review. Results: Two rare cases of malignant parotid gland tumors with calcifications in a localization typical for sialolithiasis, which were mistaken for salivary calculi based on image findings, are presented. Conclusions: This report intends to highlight the pitfalls in the imaging of parotid gland diseases. Even if malignant tumors of the parotid gland with calcifications are extremely rare, in ambiguous cases, differential diagnoses should be considered carefully. A high suspicion index of the need for further diagnostics in cases with calcifications is practical and could include missing periprandial symptoms, no obstruction signs in the proximal duct, and missing evidence of sialolithiasis in sialendoscopy.

Preoperative Magnetic Resonance Image and Computerized Tomography Findings Predictive of Facial Nerve Invasion in Patients with Parotid Cancer without Preoperative Facial Weakness-A Retrospective Observational Study

Simple Summary

Facial nerve invasion in parotid cancer affects survival outcomes as well as functional outcomes after surgery-based treatment. Normal facial muscle function before surgery does not always exclude the possibility of involvement of the facial nerve by a tumor. Especially in patients without facial palsy, accurate evaluation of invasion before surgery is necessary to plan optimal facial nerve resection and reconstruction. Various findings are obtained from preoperative radiological findings, such as CT and MRI. We evaluated the role of these radiological findings in predicting nerve invasion. Large tumor, spiculated margin, and anterolateral location may suggest a high risk of nerve involvement even in patients with normal preoperative facial function. These findings may help surgeons to avoid unexpected facial nerve invasion and to make adequate surgical plans to get optimal oncological and functional outcomes.

Abstract

(1) Background: Facial nerve resection with reconstruction helps achieve optimal outcomes in the treatment of facial nerve invasion (FNI) of parotid cancer. Preoperative imaging is crucial to predict facial nerve reconstruction. The radiological findings of CT or MRI may predict FNI in the parotid cancer even without facial paralysis. Methods: We retrospectively reviewed the records of 151 patients without facial nerve paralysis before surgery who had undergone tumor resection. Previously untreated parotid cancers were included. (2) Results: The median follow-up duration was 62 months (range: 24–120 months). The FNI (+) group (n = 30) showed a significantly worse 5-year overall survival compared with the FNI (−) group (75.5 vs. 93.9%; hazard ratio = 4.19; 95% confidence interval: 1.74–10.08; p = 0.001). The tumor margin, tumor size, presence in the anterolateral parotid region (area 3), retromandibular vein involvement, distance from the stylomastoid foramen to the upper tumor margin, and a high tumor grade were significant factors related to FNI in the univariate analysis. A spiculated tumor margin, the tumor size (2.2 cm), and presence in area 3 were factors predicting FNI in the logistic regression model (p = 0.020, 0.005, and 0.050, respectively; odds ratio: 4.02, 6.40, and 8.16, respectively). (3) Conclusions: The tumor size (≥2.2 cm), spiculated margin, and presence in area 3 as presented in CT and MRI may help clinicians preoperatively predict FNI in patients with parotid cancer and establish an appropriate surgical plan.

Diagnostic Accuracy and Post-Procedural Complications Associated with Ultrasound-Guided Core Needle Biopsy in the Preoperative Evaluation of Parotid Tumors

Correct diagnosis of a parotid neoplasm based on histology preoperatively is of utmost importance in order to guide patient management. The aim of this study was to evaluate the diagnostic accuracy of an ultrasound-guided core needle biopsy of a parotid lesion and to describe associated post-procedural complications. A retrospective study was conducted between January 2015 and March 2021 of all patients who were referred to a tertiary care center for evaluation of a parotid lesion and who underwent core needle biopsy due to high-risk features or when malignancy was suspected on clinical examination or ultrasonography. Patient characteristics, histological findings, and post-procedural complications were recorded and evaluated. Among 890 patients referred for evaluation of a parotid lesion, in 138 patients a core needle biopsy was undertaken. On the basis of core needle biopsy findings, 11 lymphomas and 82 non-lymphoma malignancies were diagnosed in the parotid gland. The sensitivity of the core needle biopsy predicting the accurate tumor type was 97.56% (95% CI 91.47-99.70%) and the specificity 94.64% (95% CI 85.13-98.88%). The accuracy for the correct histopathological diagnosis was 93.48% (95% CI 87.98-96.97%). Post-procedural minor complications occurred in 19 patients (13.8%). In conclusion, a core needle biopsy can identify malignancy in the parotid gland with high sensitivity and specificity in a safe manner and therefore guide surgical treatment.

Adenoid cystic carcinoma. An indolent but aggressive tumour. Part A: from aetiopathogenesis to diagnosis

Adenoid cystic carcinoma (ACC) is a relatively rare tumour of the minor and major salivary glands. It is uncommon in the parotid gland while it is much more frequent in the submandibular gland and in minor salivary and mucinous glands (oral cavity, oropharynx, and paranasal sinuses). ACC may also arise in secretory glands located in other tissues, such as in the tracheobronchial tree, oesophagus, breast, lungs, prostate, uterine cervix, lachrymal and Bartholin’s glands, and skin. The natural history of ACC is characterised by an indolent growth rate, a relatively low probability of regional lymph node metastases and a high likelihood of haematogenous dissemination. ACC has been traditionally subdivided into three histological groups (cribriform, tubular, and solid) based on solid components of the tumour. Some studies have shown that tumours with a solid growth component have a rapid fatal course, compared to tumours without a solid growth component, but other studies have failed to correlate growth patterns with clinical course. The purpose of this review is to analyse the very large number of studies (sometimes contradictory) on ACC. In this first part, the aetiology, epidemiology, histopathology, clinical behaviour and diagnostic workup are examined.

Correlations between DW-MRI and 18 F-FDG PET/CT parameters in head and neck squamous cell carcinoma following definitive chemo-radiotherapy

BACKGROUND

Posttreatment diffusion-weighted magnetic resonance imaging (DW-MRI) and 18F-fluorodeoxygluocose (18 F-FDG) positron emission tomography (PET) with computed tomography (PET/CT) have potential prognostic value following chemo-radiotherapy (CRT) for head and neck squamous cell carcinoma (HNSCC). Correlations between these PET/CT (standardized uptake value or SUV) and DW-MRI (apparent diffusion coefficient or ADC) parameters have only been previously explored in the pretreatment setting.

AIM

To evaluate stage III and IV HNSCC at 12-weeks post-CRT for the correlation between SUVmax and ADC values and their interval changes from pretreatment imaging.

METHODS

Fifty-six patients (45 male, 11 female, mean age 59.9 + - 7.38) with stage 3 and 4 HNSCC patients underwent 12-week posttreatment DW-MRI and 18 F-FDG PET/CT studies in this prospective study. There were 41/56 patients in the cohort with human papilloma virus-related oropharyngeal cancer (HPV OPC). DW-MRI (ADCmax and ADCmin) and 18 F-FDG PET/CT (SUVmax and SUVmax ratio to liver) parameters were measured at the site of primary tumors (n = 48) and the largest lymph nodes (n = 52). Kendall's tau evaluated the correlation between DW-MRI and 18 F-FDG PET/CT parameters. Mann-Whitney test compared the post-CRT PET/CT and DW-MRI parameters between those participants with and without 2-year disease-free survival (DFS).

RESULTS

There was no correlation between DW-MRI and 18 F-FDG PET/CT parameters on 12-week posttreatment imaging (P = .455-.794; tau = -0.075-0.25) or their interval changes from pretreatment to 12-week posttreatment imaging (P = .1-.946; tau = -0.194-0.044). The primary tumor ADCmean (P = .03) and the interval change in nodal ADCmin (P = .05) predicted 2-year DFS but none of the 18 F-FDG PET/CT parameters were associated with 2-year DFS.

CONCLUSIONS

There is no correlation between the quantitative DWI-MRI and 18 F-FDG PET/CT parameters derived from 12-week post-CRT studies. These parameters may be independent biomarkers however in this HPV OPC dominant cohort, only selected ADC parameters demonstrated prognostic significance. Study was prospectively registered at http://www.controlled-trials.com/ISRCTN58327080.

Comparison of preoperative diagnostic accuracy of fine needle aspiration and core needle biopsy in parotid gland neoplasms

BACKGROUND

Fine needle aspiration (FNA) and core needle biopsy (CNB) are two commonly used approaches for the diagnosis of suspected neoplastic parotid gland lesions. We aimed to compare the diagnostic efficiency of FNA and CNB performed with ultrasound guidance preoperatively for the diagnosis of parotid neoplasms.

METHODS

We retrospectively analysed the preoperative specimens of 113 patients (66 FNA, 47 CNB) who underwent surgical excision at our institute between 2014 and 2017. Patient selection was based on lesion type and dimension, preliminary and final pathology, imaging characteristics, clinical course, and treatment data for accurate statistical analysis. The final diagnosis was based on surgery in all of the patients. We compared the diagnostic accuracy of FNA and CNB regarding the correct tissue-specific diagnosis of benign and malignant tumours. The recurrence and complication rates were analysed to determine the safety of each technique.

RESULTS

Among the 113 patients, the average follow-up period was 65.4 (50-88) months. Seventy-one patients (62.8%) were males, and the median age was 50 years. The most common type of surgery was superficial parotidectomy (83.2%), and the median tumour size was 30.0 mm. Pleomorphic adenoma was the most frequent neoplasm. The diagnostic rates of preoperative pathological evaluation of FNA and CNB samples were 68.2% and 91.5%, respectively. The sensitivity, specificity, and positive predictive value of FNA for detecting malignant lesions were 40, 100, and 100%, respectively, and those of CNB were 100, 100, and 100%, respectively. Only one complication occurred (haematoma) in the biopsy area after CNB. No recurrences were seen after CNB and FNA during the follow-up period.

CONCLUSION

Our findings suggest that the diagnostic ability, sensitivity, and specificity of CNB are excellent compared with those of FNA. The only disadvantage of CNB is the need for experienced staff and good-quality equipment. The complication rates of each technique are very low, and the risk of tumour tract seeding is controversial. CNB should be considered the technique of choice when a nodule is detected in the parotid glands.

Salivary gland carcinoma in children and adolescents: The EXPeRT/PARTNER diagnosis and treatment recommendations

Salivary gland carcinomas (SGCs) are rare during childhood and adolescence. Consequently, no standardized recommendations for the diagnosis and therapeutic management of pediatric SGC are available, and pediatric oncologists and surgeons generally follow adult guidelines. Complete surgical resection with adequate margins constitutes the cornerstone of treatment. However, the indications and modalities of adjuvant therapy remain controversial and may be challenging in view of the potential long-term toxicities in the pediatric population. This paper presents the consensus recommendations for the diagnosis and treatment of children and adolescents with SGCs, established by the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) within the EU-funded PARTNER project (Paediatric Rare Tumours Network - European Registry).

Can Ultrasound in Combination with Virtual Touch Imaging Quantification Predict the Dignity of a Parotid Tumor?

Pre-operative evaluation of a parotid gland tumor is crucial in guiding treatment. This study evaluates the diagnostic performance of B-mode ultrasound in combination with Virtual Touch imaging quantification (VTIQ) in the assessment of parotid lesions. A prospective study of 268 patients with parotid lesions was conducted. Pre-operative ultrasound findings and VTIQ data were compared against histologic results. Ill-defined margins on ultrasound were associated with a significantly higher risk of malignancy (odds ratio [OR] = 1224.0, 95 % confidence interval [CI]: 151.8-9872.7). Faster mean shear waves on VTIQ (OR = 1.81, 95% CI: 1.47-2.23, per 1 m/s increase) and an area with shear wave velocity >6.0 m/s involving >70 % of the lesion (OR = 19.80, 95 % CI: 6.22-63.07) were associated with higher risk of malignancy. Addition of VTIQ to routine pre-operative B-mode ultrasound can provide supplemental information on the dignity of a parotid tumor, allowing for peri-operative procedural optimization.

Carcinoma Ex-Pleomorphic Adenoma Diagnosis During Global Health Engagement Operations

INTRODUCTION

In global health engagement settings, performance of oncologic surgery is evaluated by understanding the host nation healthcare capacity to include inpatient care support and the available postoperative adjunctive therapy to include chemotherapy and radiation therapy.

MATERIALS AND METHODS

We present a case during Pacific Partnership 2018 of a patientwith a malignant facial mass diagnosed postoperatively. A literature review was conducted, searching specifically for cases related to pleomorphic adenoma (PA), carcinoma ex-PA, cases of misdiagnosis, and global health engagement operations.

RESULTS

The patient presented without constitutional symptoms, clinical lymphadenopathy, or cranial nerve VII weakness with a preoperative host nation diagnosis of a benign salivary neoplasm (PA). Postoperatively, a gross total resection of the mass was diagnosed as high-grade adenocarcinoma-a carcinoma ex-PA of the parotid gland. Oncologic staging was noted to be advanced at T3N0, and the patient was referred back to the host nation surgeons for radiation oncology consultation and clinical surveillance to follow.

DISCUSSION

Diagnosis of carcinoma ex-PA-a rare form of salivary gland malignancy-is not always straightforward because of its high degree of cellular heterogeneity, leading to inconsistencies in preoperative sampling results. This case addresses the preoperative diagnostic challenges associated with this type of malignancy, different types of possible treatment modalities aimed at reducing postoperative morbidity, and the preoperative and postoperative challenges that are critical to address during health engagement operations.

Familial bilateral nodular oncocytic hyperplasia of the parotid gland in mother and son

This case series reports familial cases of nodular oncocytic hyperplasia (NOH) diagnosed in a mother and her son, 15 years apart. A 39-year-old man presented in 2003 with a lump below his left ear. Magnetic resonance imaging (MRI) performed showed multifocal parotid nodules and a diagnosis of NOH was histopathologically confirmed following left total parotidectomy. Two years later, he represented with similar symptoms on the right side. NOH was diagnosed following excision of his right parotid gland. In 2018, his 73-year-old mother presented with left ear pain and a lump below her left ear. An MRI scan showed multiple lesions within both parotid glands and bilateral NOH was once again diagnosed following a left superficial parotidectomy and right total parotidectomy. We believe that this is the first reported case of bilateral familial NOH.

Magnetic resonance imaging of salivary gland tumours: Key findings for imaging characterisation

Salivary gland tumours are rare, representing only 3% of all head and neck neoplasms, with the parotid gland being the most common site (80 %). The risk of malignancy is inversely proportional to the size of the gland: lesions arising in the sublingual or minor salivary glands are more likely to be malignant, whereas parotid gland neoplasms are mostly benign. Fine needle aspiration cytology and core needle biopsy are considered the most accurate modalities for the diagnosis of a salivary gland neoplasm; however, they are not always conclusive due to procedural sampling errors and for the presence of a cytological / histological overlap between benign and malignant tumours. Moreover, they cannot be easily performed for parotid deep portion localisation. The role of magnetic resonance imaging (MRI) is growing and advanced techniques (diffusion-weighted and dynamic contrast-enhanced perfusion-weighted imaging) can provide useful additional information for the assessment of salivary gland neoplasms. The aim of this review is to present the main MRI and clinical features of salivary gland tumours to improve their comprehensive evaluation and characterisation.

Diagnostic performance of Milan system for reporting salivary gland cytopathology: A prospective study

BACKGROUND

Fine-needle aspiration (FNA) is a well-established modality for diagnosing salivary gland pathologies. The Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) provides a standardized uniform framework leading to an evidence-based risk of malignancy (ROM). Based on the current literature, ROM in the 6-tier MSRSGC ranges from <5% for neoplasm-benign to >90% for the malignant category. Here, we report our institutional experience adopting MSRSGC.

METHODS

The cytopathology group at our institution implemented MSRSGC at the end of 2018. Through a query of our laboratory information system, we identified all salivary gland FNA cases from 27 November 2018 to 26 October 2020. The pertinent surgical pathology follow-up was also extracted. After manual curation, data was analyzed in Rv4.0.2.

RESULTS

Our cohort comprised of 315 patients undergoing 343 salivary gland FNA biopsies, predominantly on the parotid (90%), 162 with a surgical pathology follow-up. The risk of malignancy ranged from 3.2% in neoplasm-benign (IVA) to 100% in suspicious for malignancy (V) and malignant (VI) categories. ROM in the other categories was: 12.5% for non-diagnostic, 0 for non-neoplastic, 33.3% for atypia of undetermined significance, and 41.9% for salivary gland neoplasm of uncertain malignant potential (SUMP). Most SUMP cases had a basaloid or oncocytoid cytomorphology with similar ROM. In distinguishing benign and malignant salivary gland lesions, FNA had adequacy of 93.6%, a diagnostic yield of 62.2%, a sensitivity of 93.1% and a specificity of 100%.

CONCLUSIONS

MSRSGC was successfully adopted by our cytology group and clinicians, with overall diagnostic performance similar to previous studies.

The current value of quantitative shear wave sonoelastography in parotid gland tumors

Background

The preoperative differentiation between salivary gland tumor entities using computed tomography, magnetic resonance imaging (MRI) and ultrasound (US) is still limited. Biopsies are often regarded as indispensable for properly characterizing these various lesions. The aim of this study was to analyze the value of acoustic radiation force impulse (ARFI) sonoelastography as an US differentiation tool when examining parotid gland (PG) lesions.

Methods

We included 104 patients with PG masses in this study, employing two different US devices using quantitative ARFI-sonoelastography (Siemens Acuson-S3000, n=59; Siemens Acuson-Sequoia, n=45). The ability of sonoelastographic measurements to differentiate between different neoplasms was compared and analyzed for both US machines.

Results

Quantitative shear wave sonoelastography is limited in its ability to reliably differentiate between tumor entities of the PG as a stand-alone parameter. Measurement results were unsystematically distributed and not transferable between the two US devices. A significant differentiation of benign and malignant lesions was not possible with either US machine (S3000: P=0.770, Sequoia: P=0.382). A differentiation between pleomorphic adenomas (PA) and Warthin tumors was only possible with the Acuson S3000 system (P=0.001, Spearman-Rho =0.492, sensitivity 73.9%, specificity 65.0%).

Conclusions

A reliable identification and differentiation of PG tumors as well as clinical treatment decisions cannot be made with the sole use of ARFI-sonoelastography. The results emphasize the device-dependence and high error-proneness of this US technique when examining lesions of the PG.

Diagnostic value of maximum signal intensity on T1-weighted MRI images for differentiating parotid gland tumours along with pathological correlation

AIM

To investigate the efficacy of the maximum signal intensity of tumour on T1-weighted magnetic resonance imaging (MRI) images for differentiating Warthin's tumours (WTs) from pleomorphic adenomas (PAs) and malignant tumours (MTs).

MATERIALS AND METHODS

One hundred and fifty-four histopathologically confirmed parotid tumours, including 76 PAs, 45 WTs, and 33 MTs, were analysed. MRI results were compared with pathological findings. The maximum signal intensity of tumour and the average signal intensity of spinal cord were measured on T1-weighted images, then the tumour-to-spinal cord signal intensity ratio (T1-max-SIR) was calculated. The distribution of T1-max-SIRs among the three groups of tumours was analysed using the Mann-Whitney U-test. Receiver operating characteristic curves were generated to assess the ability of T1-max-SIRs to differentiate parotid tumours. In addition, the interobserver agreement between readers was assessed using interclass correlation coefficient (ICC).

RESULTS

T1-max-SIRs were higher in WTs than in PAs (p<0.001) and MTs (p<0.001), and no significant difference was found between PAs and MTs (p=0.151). The area under the curve (AUC) of T1-max-SIRs for differentiating WTs from PAs was 0.901, with a sensitivity of 91.1% and a specificity of 82.9%. The AUC of T1-max-SIRs for differentiating WTs from MTs was 0.851, with a sensitivity of 88.9% and a specificity of 78.8%. Readers had excellent interobserver agreement on T1-max-SIRs (ICC = 0.989; 95% confidence interval, 0.985-0.992).

CONCLUSIONS

T1-max-SIRs can be useful for differentiating WTs from PAs and MTs with high diagnostic efficiency.

Cross-sectional imaging and cytologic investigations in the preoperative diagnosis of parotid gland tumors - An updated literature review

An accurate preoperative diagnosis of parotid tumors is essential for the selection and planning of surgical treatment. Various modern cross-sectional imaging and cytologic investigations can support the differential diagnosis of parotid tumors. The aim of this study was to achieve a comprehensive and updated review of modern imaging and cytologic investigations used in parotid tumor diagnosis, based on the latest literature data. This literature review could serve as a guide for clinicians in selecting different types of investigations for the preoperative differential diagnosis of parotid tumors. Magnetic resonance imaging (MRI) with its dynamic and advanced sequences is the first-line imaging investigation used in differentiating parotid tumors. Computed tomography (CT) and positron emission tomography (PET)-CT provide limited indications in differentiating parotid tumors. Fine needle aspiration biopsy and core needle biopsy can contribute with satisfactory results to the cytological diagnosis of parotid tumors. Dynamic MRI with its dynamic contrast-enhanced and diffusion-weighted sequences provides the best accuracy for the preoperative differential diagnosis of parotid tumors. CT allows the best evaluation of bone invasion, being useful when MRI cannot be performed, and PET-CT has value in the follow-up of cancer patients. The dual cytological and imaging approach is the safest method for an accurate differential diagnosis of parotid tumors.

Preoperative evaluation and treatment consideration of parotid gland tumors

BACKGROUND

The nature of parotid tumors often remains unknown preoperatively and final histopathology may reveal unexpected malignancy. Still, the use of fine-needle aspiration cytology (FNAC) and imaging varies in the management of these tumors.

METHODS

We evaluated the preoperative examinations and management of all 195 parotid gland tumors diagnosed within our catchment area of 1.6 million people during 2015.

RESULTS

Altogether 171 (88%) tumors were classified as true salivary gland neoplasms. FNAC showed no false malignant findings, but it was false benign in 5 (2.6%) cases. Preoperative MRI was utilized in 48 patients (25%). Twenty (10%) malignancies included 16 salivary gland carcinomas. Pleomorphic adenomas accounted for 52% of all adenomas. For 24 (40%) Warthin tumors, surgery was omitted.

CONCLUSION

The proportion of malignancies was lower than generally presented. Our proposed guidelines include ultrasound-guided FNAC with certain limitations. MRI is warranted in selected cases, but seems unnecessary routinely.

Diagnostic value of preoperative fine needle aspiration cytology in parotid gland tumors

BACKGROUND

Salivary gland masses constitute a broad spectrum of lesions ranging from non-neoplastic to benign and malignant lesions. Parotid is the largest salivary gland and constitutes 75% to 80% of all salivary gland areas. 80% of parotid lesions are benign and 20% are malignant.

METHODS

Two-hundred and eight-six patients who underwent aspiration cytology in the pathology laboratory between January 1995 and January 2019, evaluated with a sufficient sample and diagnosed, and subsequently underwent surgical treatment were included in the study.

RESULTS

47.9% (137) of the patients were female and 52.1% (149) were male. The mean age was 58 years (range: 38-84 years). 13 (4.54%) of the cases were evaluated as non-diagnostic, 12 (4.1%) as atypia of undetermined significance, 196 (68.5%) as benign neoplasm, 43 (15%) as suspicious for malignancy, and 22 (7.86%) were evaluated as malignant. In the histopathological examination of the samples prepared from surgical specimens of 13 non-diagnostic cases, seven (53.8%) cases were reported as Warthin tumors, four (30.7%) as pleomorphic adenomas, and two (15.5%) were reported as lymph nodes with intraparotid localization.

CONCLUSION

The diagnosis of Fine needle aspiration cytology (FNAC) in the parotid gland is difficult due to the rarity of malignant salivary gland neoplasms, the diversity of carcinoma types, and the similarity of cytologic findings of benign tumors and low-grade carcinomas. The diagnostic accuracy of preoperative FNAC is high for benign tumors and low for malignant tumors.

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

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

Challenges with preoperative diagnosis of low/intermediate-grade carcinoma of the parotid gland: single-center study of 112 patients

BACKGROUND

The malignancy of parotid carcinoma varies, and accurate preoperative assessment of malignancy is important for selecting the appropriate treatment. However, the preoperative diagnosis of low/intermediate-grade carcinoma is difficult, and surgery may sometimes be performed without any prior knowledge of malignancy.

METHODS

The results of fine-needle aspiration cytology (FNA), imaging studies (MRI and US), physical examination, and frozen section biopsy (FSB) were evaluated in 112 patients with low/intermediate-grade parotid carcinoma.

RESULTS

The result of FNA was benign/inadequate specimen in 44.6% of the patients. In addition, the tumor was diagnosed as benign by MRI/US in 21.4% of the patients and 37.5% had no symptoms/signs of malignancy on physical examination. The rate of misdiagnosis as benign decreased when FNA was combined with imaging and physical findings. However, malignancy could not be diagnosed by FNA and FSB in 12.5% of the patients who were only found to have malignant tumors by the final pathological examination.

CONCLUSION

FNA shows a high misdiagnosis rate of malignancy in patients with low/intermediate-grade cancer. Therefore, it is necessary to carefully evaluate the findings of imaging studies and physical examination, and FSB should be conducted if such findings suggest the possibility of malignancy.

The role of fine-needle aspiration biopsy (FNAB) in the diagnostic management of parotid gland masses with emphasis on potential pitfalls

PURPOSE

The treatment strategy of parotid gland tumours depends mainly on the histopathological type of the lesion. Fine-needle aspiration biopsy (FNAB) is recommended in preoperative diagnostics. The aim of the study was to evaluate the FNAB standing in the diagnostic algorithm of parotid gland lesions and to correlate FNAB results in relation to the definitive histopathological diagnosis.

MATERIAL AND METHODS

The retrospective analyses of 651 examined and consequently surgically treated parotid gland lesions at the Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Charles University in Prague between 2006 and 2016 were used. Preoperative cytological results were consequently evaluated in relation to the definitive histopathological diagnosis.

RESULTS

The cohort consisted of 367 women and 284 men (average age 58 years). FNAB was diagnostic in 604 (92.8%) patients and non-diagnostic in 47 (7.2%) patients. The result of FNAB was positive (suspicious for malignant tumour) in 89 (14.7%) patients and negative (benign) in 515 (85.3%) patients. Sensitivity of the examination was 80.00%, specificity was 93.82%, PPV 62.92%, NPV 97.28%, and LR + and LR- were 12.95 and 0.21, respectively, with an accuracy of 92.22%.

CONCLUSION

Our results confirm the significant role of FNAB in the diagnostic algorithm of parotid gland lesions.

An evidence-based analysis of the management of N0 neck in patients with cancer of the parotid gland

Introduction: Management of clinically negative neck (cN0) in patients with parotid gland cancer is controversial. Treatment options can include observation, elective neck dissection or elective radiotherapy. Areas covered: We addressed the treatment options for cN0 patients with parotid gland cancer. A literature review was undertaken to determine the optimal management of this group of patients. Expert opinion: Patients with parotid carcinoma and clinically negative neck have various options for their management. The analysis of tumor stage, histology and grade is essential to better define patients at risk for occult lymph node metastasis. These patients can be managed by surgery, radiotherapy or their combination, depending on the presence of risk factors, the moment at which such risk factors are detected, patient-related clinical conditions, medical provider expertise and institutional facilities.

Non-primary salivary malignancies: A 22-year retrospective study

PURPOSE

Most salivary gland malignancies are primary tumors, but in our medical center one of six is non-primary. The relative scarcity of such reports justifies studying them.

SUBJECTS & METHODS

We studied patients' demographic and clinical parameters, salivary tumors/metastasis, diagnosis and treatment, and survival rates.

RESULTS

Of all our salivary malignancy patients over the last 22 years, 15% (18/119) had non-primary malignant tumors, all located in the parotid glands. Of these, nine had skin cancer (SCC), 3 malignant solid tumors and 6 hematological systemic malignancies. Four had concomitant second malignancy. Mean age was 70.2 ± 13.8 years, 66.7% of the patients were males, 27.8% were smokers, none reported alcohol use. The most prevalent diagnostic tools used were CT (16 patients), FNA (13) and PET-CT (12). Eleven of 18 patients died from the disease despite receiving therapy: 6 SCC patients, 2 CLL patients and all 3 with solid tumors. All four lymphoma patients survived as did another three SCC patients.

CONCLUSIONS

Chemotherapy and radiotherapy for systemic disease prolonged life rather than surgery. Patients with poor prognosis non-primary salivary tumors should be treated conservatively; surgery should be for those without widespread metastases or systemic disease. Sometimes a palliative patient may benefit from tumor debulking.